Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, May 7, 2009

D.A.R.E. to Know the Truth: The Ineffectiveness of DARE Due to an Inability in Addressing Context and Reality – Danielle Tuft

Adolescent drug use has been a continuous problem that the U.S has had to face and one which has yet to be controlled. In response to this, preventions focused on youth have become a larger focus with hopes that kids will learn to avoid negative peer pressure and recognize the damaging consequences of drug use. School-based drug use prevention programs have been a fundamental part of the US anti drug campaign since the 1970s (1). These programs allow for early prevention opportunities as well as include an already existing structured environment useful for the introduction of important and potentially unknown information.
Of the anti drug campaigns that have been used in the U.S., project DARE (Drug Abuse Resistance Education) has become the most widely disseminated school-based prevention program (2). DARE was created in 1983 as a product of a collaboration between the Los Angeles Police Department and the Los Angeles School District to teach drug use prevention curriculum primarily in elementary schools, though it grew to include middle schools and high schools. Its curriculum, taught by police officers, focuses on providing information about drugs, decision making skills, building self-esteem, and finding alternatives to drugs (1). According to the DARE website, the program benefits children in more than 300,000 classrooms and in all 50 states, as well as millions of children in other countries (3).
Over the past 25 years, many studies have found that the DARE program to be ineffective (1,4). A 5 year longitudinal evaluation of the effectiveness of DARE concluded in 1996 that “no statistically significant impacts of the intervention were observed with respect to the cigarette, alcohol, or marijuana use” (2). Beyond individual reports of the ineffectiveness of the DARE program, the federal government has also recognized this conclusion. The Department of Education prohibits schools from using federally allocated funds on the program as they have determined it ineffective and in 2001, the U.S. Surgeon General put DARE into the group of “ineffective programs”. It is estimated that DARE costs $1-1.3 billion dollars each year, yet it is still widely used regardless of the fact that many studies and organizations have found the program to be ineffective (5).
Failure to Recognize the Importance of Cultural Context
The curriculum of DARE is set up in such a way that it addresses large numbers of school children at one time. While there are some opportunities to focus on the individual, most of the curriculum is addressed to an entire class, or in some situations, an entire school. The program lacks the structure to allow for the exploration of individual students’ different social, economic, or cultural backgrounds and their behavior in response to those contexts.
It has been shown that students respond more favorably to drug prevention programs when the programs visibly incorporate their culture and allow students to be represented (6). It makes sense that a program which directly addresses cultural situations for a specific person or group of people would resonate more with that person. Many anti drug programs have failed to consider the importance of ethnicity and culture and instead have opted for a standardized curriculum assuming it to be effective for all (6). This is the case with DARE as it does not incorporate cultural situations into their curriculum but instead uses role playing focused on simple peer pressure situations, such as “What would you do if your friend offered you drugs?”. There is no exploration into the possibility that the reaction to this question may differ depending in what cultural situation it is asked. Even more, DARE is used throughout the country in cities with many different resources and demographics, yet the same classes and topics are taught with the same methods. It has been argued that standardized prevention messages can and do enforce “dominant cultural values that do not validate or utilize minority children’s cultural experiences” (6).
DARE does not account for the diversity found in many schools and the structured curriculum limits the program’s ability to use different communication techniques or introduce other possible cultural values when dealing with different students from different backgrounds. Minority youth may be underrepresented if prevention materials are constructed from middle class, white culture (6). One book, in discussing a student approved approach regarding the relationship between the officers and students, quoted a student who said that “They need to get to know the kids personally and find out why they’re using drugs or whatever. You need to know the kids and find out why they’re doing something before you can do anything about it” (7). It cannot be assumed that every person sees drug use in the same way, especially considering that many religions use alcohol in a positive manner during rituals or that a child with parents that smoke may perceive cigarettes different from a child who has grown up in a smoke free home. It may be much more difficult for a student to “just say no” when they live in a community where drug related issues are constant or where trafficking drugs is a prevalent option for youth. With this in mind, it is easy to argue that since DARE does not allow for cultural and ethnic differences, many children may feel that the program does not apply to them.
Incorrect Choice in Leaders
The Communications Theory is a widely used theory within public health and one which touches upon the importance of “who says what to whom in what channel with what effect” (8). This theory clearly points to the importance of recognizing the person who is conveying the message and what effects may be brought about by that choice.
Since its inception, DARE has relied upon police officers to be the “teachers” of anti drug information. DARE explains that there are multiple benefits to the use of police officers, such as the fact that it “humanizes” the officers and allows youth to relate to them as people or that it removes police from the enforcement role and allows students to see them in a different one (3). While to some effect, there may be a “hero” factor attributed to police by young people, the police officer’s authoritative position is still kept. They come dressed in uniform and as a special guest, separating themselves from the youth. Even more, in many situations the officers may lecture, thus once again putting themselves above the youth and in an authoritative position as the person who has the answers.
It is also very possible that the perceptions students have of officers may differ greatly. It is unlikely that a student who comes from a neighborhood with high crime rates and constant police action will be able to recognize a police officer as credible or to see them in a positive manner. DARE is a program that lasts about one hour a week for between 10 to 17 weeks. The officers with whom students are to bond with are not considered to be normal members of the educational community and it could be argued that their infrequent interaction with the youth make it difficult for the youth to cement positive relationships with them.
It has been found that peer led programs have been better at reducing substance abuse than programs without a peer component, yet DARE has continuously used police officers as the main person to disperse anti drug information (9). Children cannot relate to them and are even more likely to disregard the advice they may receive from them. Early adolescence is a period in which children shift from being primarily influenced by their parents to being primarily influenced by their peers (6). With this in mind, it does not make sense that DARE would choose adults, especially ones with no previous relationship with the youth, to attempt to influence the ideas and behaviors of early adolescents.
Unrealistic Goals and Failure to Look Past the Individual
The DARE program uses an abstinence approach, telling students that they should never do drugs at all rather than recognizing that many students at some point experiment. It has been hypothesized that this approach may actually be damaging to prevention efforts as it may provoke rebellious behavior from students already experimenting (10). It is unlikely that a student will never experiment, and in the case of alcohol, DARE does not provide methods in which to avoid actual alcohol abuse once a student reaches the legal age to drink. In the case of adolescents who have experience with substances, advocating no use may actually lead to an increase in drug use, as they may reject the intervention (10). DARE does not address students who are already experimenting and the curriculum gives them no reason to stop because the program no longer relates to them as they have not abstained from drug use. A person like this may feel that they have no place within the current program. Even youth who have not experimented may recognize the program to be unrealistic and view it as ineffective or not applicable to current youth.
It is clear to see the unrealistic expectations of the DARE program simply within its well known slogan of “Just Say No”. The simplistic nature of the statement seems to allude to a mistaken idea that turning down drugs is as easy as saying a couple words. DARE, like many other public health programs, focuses solely on the individual level, and fails to look at reasons beyond individual control for unhealthy behaviors. This approach focuses on providing individuals the tools they need, such as education and skills, to say no; however this clearly is not enough as approximately 6,000 youth try a cigarette per day (11). Similar to looking at cultural backgrounds as reasons for behavioral choices, it is necessary to look at the larger reasons beyond a person themselves as to why a student may say “yes” instead.
The U.S. has recognized for years that adolescent drug use is a huge problem and has encouraged the use of school based prevention programs to combat it. Although many of these programs have been created, none have been as prevalent as the DARE program. However, DARE’s ineffectiveness in reducing adolescent drug use behavior clearly contrasts its popularity and prevalence (1). Aspects of the program’s ineffectiveness could be attributed to its inability to account for certain ideas found within social theories.
In order for DARE to become more effective it must recognize the problems it currently has and reformat its curriculum. The program must look past the individual level and attempt to find reasons for unhealthy behavior within the cultural context of its students as well as welcome the different views and perceptions student have on drugs. DARE must also realize that while there may be some uses for police officers in the program, they cannot be the main distributor of information as many students may not see them in a positive light. Lastly, it is important that DARE adjust its goals and realize that it is unlikely to end all adolescent drug use but to instead focus on how to control it or how to offer other options to students who already are or have the potential of experimenting with drugs.
Recognizing problems in the structure and implementation of the DARE program allows for an opportunity to address possible changes and a new intervention that uses different health behavior theories and correct those issues found in DARE. While a completely new intervention is not absolutely necessary, a revamp of the traditional DARE program is needed. Studies have continued to show DARE to be ineffective in the long term and a new anti-drug intervention which takes cultural theory, social network theory, and harm reduction into account must be put into action (1,4).
The intervention would address the three main faults discussed in regards to the current DARE program, those being its failure to recognize cultural context, employing ineffective leaders, and putting forth unrealistic goals. The revamped program would be much more comprehensive and look at possible social and cultural contexts in regards to drug use. It would also be designed in a way so that it could be reworked to fit a particular geographic setting or demographic.
First, the program would make use of the Cultural Theory and recognize the need for different techniques for different groups of people based on their cultural background and understandings of health and addiction. The program would include discussions that are targeted and tailored to specific groups, particularly different ethnic groups, in an attempt to be more effective after recognizing the differences in drug use rates among different ethnicities and cultures. The intervention would also be created with the use of focus groups, employing a specific cultures view on alcohol use, smoking, and illicit drug use so as to use a group of people’s own views on drug use to influence their health behaviors.
Second, it would be a long-term program starting in elementary school and continuing through middle and high school, with discussions and seminars happening at least 50% of the weeks in an academic school year. The intervention would take into account the Social Network Theory and the importance of peers and their influence. The discussions would be led by older peer leaders who share commonalities beyond simply age with the targeted age group, such as middle school students leading discussions for elementary students and high school students leading for middle school students. This intervention would still use police officers but rather than lead discussions in an authoritative manner, they would join discussion groups as participants in order to allow for a more even relationship between themselves and the students. This would allow police officers to still form positive relationships with students without “scaring” students or exacerbating the negative impression some students may have of the police force. The program would also employ a buddy system between younger peers and responsible older peers with similar cultural and social backgrounds, in order to provide a positive role model and to show actual alternatives to drug use.
Lastly, the program would be designed in such a way to meet the changing attitudes and social contexts that come with growing up. This revamped intervention would take into account the changing attitudes of alcohol and marijuana within the American public, such as the increasing push to legalize marijuana. The program would integrate use reduction goals with harm reduction goals, in an attempt to include all students as well as to teach students how to be safe or how to handle situations such as a friend who is drunk and needs help. Harm reduction goals would also give a student the skills needed to be safe once they reach the legal age to drink alcohol or smoke cigarettes. The integration would move from a heavier focus on use reduction to a heavier focus on harm reduction as the students get older. For example, the elementary based program would be more focused on use reduction, though may find in certain communities that harm reduction is necessary while, the high school program would still promote abstinence while recognizing the growing need to rely more heavily on harm reduction.
Using the Cultural Theory and Recognizing the Cultural Context
When youth are able to see themselves in presented situations, they are more likely to relate to and support the prevention messages (6). The Cultural Theory recognizes that a behavior related to health is influenced by a person’s understanding about its meaning or is a result from a lifestyle built around meanings, symbols and values, as they are connected to a larger social structure (8). Through this theory, which asks questions such as “what does it mean to be healthy?” this new intervention is able to account for different students varying understandings of drug use (8). Its use in creating the discussions and program topics, allow the intervention to change methods depending on how one group may view alcohol in a larger context or the fact that students who live in neighborhoods with heavy drug use may see dealing or using as inevitable. The targeted nature of this intervention also allows for the opportunity to do this rather than approach a larger group with multiple backgrounds using only one view of drug use.
The use of the Cultural Theory would also allow for cultural tailoring, defined as the “process of creating culturally sensitive interventions” (12). As part of this intervention there would be a focus on both the surface structure and deep structure, two dimensions of cultural sensitivity. It is explained that surface structure looks to match intervention materials and methods to the observable characteristics of a population, such as music, food, preferred clothing, and language. Deep structure on the other hand involves incorporating outside forces, such as culture, history, and environment in an effort to influence behaviors (12). The employment of these methods would most likely be more effective in reducing drug use both because students would understand drug use in a context familiar to them and the influences that are more problematic to a specific group can be addressed rather than spending time on issues that one cultural group hold to be insignificant.
In order for the intervention to be effective, focus groups must be a major part of the development. Focus groups have been found to be effective in creating culturally sensitive intervention message (6,12). Youth from the targeted groups must be involved in order to understand the realities of the social and cultural context as well as in an attempt to avoid stereotyping.
The Social Network Theory and Choosing Effective Leaders
This revamped intervention pairs up younger students to older students who serve as positive role models and creates a support system that is outside the student’s normal environment or friend base. The intervention does so in accordance with Social Network Theory which recognizes that “relationships between and among individuals are important, as is how the nature of those relationships influences beliefs and behavior” and that these relationships play an important role as to whether a person partakes in risky health behavior or not (8). More specifically related to drug use, the Social Network Theory means that students are heavily influenced by the drug use habits of their family, community, or friends. With this in mind, it is important that young students are able to see positive role models and identify how responsible youth avoid drug use.
Unlike the traditional DARE program, this intervention uses peers to lead discussions and interactive activities and places police officers in a more even level with students. As addressed in the previous critique, it has been found that peer-led programs are more effective at drug use reduction than prevention programs that lack a peer component (9). Using youth that students can relate to is important in attempting to change behavioral norms. Peers are more effective as leaders in that they seem more credible to students, which encourages those students to actually support the anti-drug information discussed, and that norms created through use of a discussion group are more likely to continue outside of school (9). As part of this intervention, using middle school students to help lead discussions for elementary students, provides role models who do not partake in drugs and may impart to the youth that drinking and drug use is not a norm and that it is not necessary to be “cool”. Particularly, using youth who have avoided drug use in an area where it may be prevalent may show students that it is not inevitable and that there are people who they can go to that will help them keep healthy behaviors.
Integrating Harm Reduction Approach with Use Reduction Approach
There has been a growing movement in creating a framework for a harm reduction approach in public health intervention, which is rooted in the awareness of adolescent psychosocial development where curiosity and a willingness to experiment are prevalent (13). Today, youth are seeing states continued interest in legalizing marijuana for both medical and leisure or their parents drinking a glass of wine at dinner. Even more, students eventually reach an age where it is legal to consume alcohol or smoke cigarettes, yet the traditional DARE program disregards this and does not provide students with the skills needed to partake in alcohol use safely. It has been argued that “school based prevention programs cannot be effective because they are inconsistent with the messages that adolescents receive from the larger social environment” (13)
With this in mind, this new intervention includes a harm reduction approach, primarily aimed at older youth. The approach focuses on the principles of harm reduction and uses them pragmatically, offering information about drugs rather than solely against them (13). It is unrealistic to assume that youth will abstain completely from drugs and it is important to offer safe options and teach moderation skills. In addition to promoting safer use, this approach allows the program to reach out to students who may have already experimented or are currently use drugs.
This revamped intervention corrects the faults found in the traditional DARE program though the use of the Social Network Theory and the Cultural Theory. It provides a program that is better at dealing with growing multiculturalism and is accessible to many more students than the original program. It also moves away from the abstinence only approach and accepts the need to educate students on safe use. Overall, an intervention like this may be much more effective and positive to students.
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