Challenging Dogma - Fall 2009

Tuesday, December 15, 2009

A DARE-ing Attempt To Create A Better Program To Keep Youth Off Drugs- Justin Schreiber

In the health care field, doctors are being highly criticized for not following evidence-based medicine. In fact, many of the current health care proposals call for an increased use of research in health care decisions. What does not make sense is that we allow for some public health programs such as Drugs Abuse Resistance Education (DARE), to continue to operate and expand, even with no evidence showing the program’s effectiveness. DARE’s reliance on ineffective models such as the Health Belief Model and its breech of the rules of Market Theory and Psychological Reaction Theory has led to a program that has a very strong brand name, but does little to stop youth from using illegal drugs. In fact, some of the program’s practices can lead to an increase in children using drugs. Just because, DARE is the largest anti-drug program in the nation’s schools does not mean there is not room for a new and improved program. A more effective program could be creased using relevant theories such as the Community Coalition Action Theory and Social Norms Theory as well as ideas from other successful campaigns, such as the TRUTH campaign.

A brief history of DARE

DARE started in 1983 by Chief Darryl Gates of the Los Angeles Police Department. He believed that “uniformed police officers were the best equipped to deliver the message that drug use has adverse effects (1).” Police officers were sent to the classroom to teach mostly 5th and 6th grade students about the dangers of drug abuse and how to say “no.” It was using the US Zero Tolerance Policy to drugs as a model (2). Since its inception, DARE has grown to encompass 80% of all school districts in the U.S. and costs around $1.34 billion per year (3-4). Due to criticism of the effectiveness of the program, the “New DARE” program was released in 2004 using “brain imagery” and “mock courtroom exercises” along with new technology to show “tangible proof of how substances diminish mental activity” and the “legal consequences of drug use (5).”

The Health Belief Model and DARE: A failing model for a failing program

DARE was created without the use of theory or research, instead it is considered to be “largely intuitive in its approach (6).” It may not have been the intention, but as DARE developed it began to mirror the Health Belief Model. The Health Belief Model works by exposing people to the severity and susceptibility of the consequences of an action, which they must weigh against the potential benefits of the action. Once they weigh the positives and negatives of each one they might intend to do an action and then follow through with it. The DARE program focuses on the individual level, claiming to give “kids the skills and information they need to make good life choices (5).” A police officer teaches the program emphasizing the connection to the legal consequences related to drug use. The use of imagery and mock exercises add to the potential severity and suitability of drug use. The program provides praise and merchandise for the participants that demonstrate qualities of someone who is drug free.

Research has shown that the Health Belief Model is not an effective way to influence decisions related to choices such as drug use. Nearly “two-thirds” of the studied cases of the Health Belief Model and similar models “reported that at least one of the variables did not predict the outcome variable being studied (7).” This model does not work because it completely ignores the influence of the group and assumes the legal and health consequences are more important than the peer and community pressures, which exist to use drugs. It is impossible for DARE to be effective without proper research into why youth start using drugs in the first place.

The Health Belief Model and DARE’s reliance on the assumption that children will act rationally regarding drug use is a huge failure of the program. Research has shown that adults do not act rational at all; they in fact act predictably irrational (8). If it does not work for adults who have the intellectual maturity and experiences to think through a decision, then how could DARE be naïve enough to assume it would work for children? There is also an assumption that this rational decision can be made no matter the situation a child is in. The classroom environment in which DARE is presented is not an accurate reflection of a real life experience in which a child may be offered drugs. For example, if a child is being pressured to use drugs by their peers, than the need for acceptance might surpass anything taught in a DARE class.

The Health Belief Model, which the DARE program follows assumes decisions are static. The education provided for the DARE program is during the 5th or 6th grade of elementary education. Research shows it is crucial to start targeting children at an early age, but most children do not start experimenting with drugs until the age of 19 (9). A twelve year old 6th grader will go through many changes in the way they think through the experiences they have by the time they are nineteen years old. During these seven years of development, the Health Belief Model would expect that a youth’s decisions would remain unchanged because they are already aware of the severity of the consequences and the benefits to not using drugs. This belief is false because there are other significant factors, such as seeing a friend use drugs, enjoy the experience and not have any consequences, which could make their decision change. Also, these students will have less exposure to drugs at twelve, so the chance of being asked if they want to do drugs is much less than if they were nineteen. DARE is not able to answer questions about drug use that youth may have as they get older and more intellectually competent. Oftentimes, the messages given to children at the age of twelve may seem childish to a nineteen year old. People are not static, especially at a very young age when the focus is on their education, development and socialization. Therefore it is irresponsible to believe a decision made at the age of twelve will stay constant through the age of nineteen.

Another problem with the Health Belief Model is it is built off “of Eurocentric middle-class male ideologies, values and beliefs” where women and people of color are viewed as deviations rather than variations (10).” For a program, which is so widespread, it would seem essential to use a theory that has shown success through many cultures, beliefs and socio-economic backgrounds. DARE assumes the message need not be changed for different communities in order for it to be effective. Each DARE officer gets about 80 hours of training, but they “are instructed not to deviate in any substantive fashion from the curriculum (11).” Each community, no matter their thoughts on police or drugs, receive the same lecture developed from a law enforcement, Zero Tolerance framework. This approach ignores any of the other community factors, which may lead to someone making the decision to use drugs. This failure could lead to a boomerang effect resulting in increased drug use.

DARE may never have intended to follow the Health Belief Model when it was created, but when evaluating the program the organizers should have realized how close it mirrored the theory. Failure to recognize this has lead the program to follow a flawed theory that has helped to lead to its ineffectiveness.

DARE ignores the importance of Psychological Reactions Theory

The Psychological Reactions Theory states that people will “adopt an attitude opposite of what was intended due to a perceived threat to freedom (12).” The way DARE promotes its message ignores the importance of this concept. In many communities, police are viewed as a group, which has the power to take away freedom. Many children have seen a family member or friend taken away by the police. The zero tolerance message of DARE only exacerbates this threat to freedom. DARE does very little to bring in other stakeholders which might be viewed by youth as someone who they can relate with. When researching the effects of DARE “few coordinators reported that ‘youth groups’ were involved” and “parents tend to be rather detached (11).” By excluding those who youth are most likely to trust increases this threat to freedom. Conflicting messages to exist between peers and family and this will only increase the resistance youth will have for the DARE message.

It is surprising, considering the effectiveness of interventions such as the Truth campaign, that when DARE came out with new DARE program in 2004 there was no attempt to change their model to take into account the Psychological Reactions Theory (5). The largest study of the DARE program since its inception noted that with police officers as facilitators, “effectiveness may be less than other possible program providers (11).” The creators of the drug prevention program that DARE was modeled after refused to work with DARE because they “had problems with police in the classroom (13).” Part of the problem is the way DARE was created. It was started by the police and continues to be run by them, so having someone else taking over this role is seen as a threat to the organization.

For a long time, anti-smoking campaigns used adults in their ads and they were not effective. However, the Truth campaign brought together a “500 person youth summit to gain insight into where youth felt the [anti-smoking] effort should head (14).” They emphasized rebellion as one of their top three. Police officers represent the anti-thesis of rebellion, and this is why there is such a backlash to having them give the message. If the DARE campaign had spent the time to research their audience than either the police would not be leading the discussion or there would be a larger attempt to re-frame the role of the police in the community. Until one of these two needs are met than program will be always destined to fail.

DARE’s Failure to Live Up to it’s Promises

The success of Marketing Theory can be seen everywhere around us through successful advertisements. What makes these advertisements so successful is that they offer a promise for something people want, which they figure out through extensive research (15). They also make sure to live up to their promises so people keep coming back to using their product. DARE completely disregarded both of these rules by selling kids something they don’t necessarily want and not living up to the promises offered.

Instead of researching what youth actually want, DARE created a program, which forced their message to an uninterested audience. The program promises students who avoid drugs will not be punished, will gain approval from the police and won’t have harmful health effects. As mentioned earlier, the Truth campaign did market testing and found “tobacco was a tool of rebellion” and they did not like anti-tobacco messages “pass[ing] judgment on tobacco users (14).” Along with drug use DARE tries to stop youth smoking as well, yet their messaging does nothing to address the desire for rebellion. Though the Truth campaign targets an older audience it is able to speak to its audience, whereas the DARE campaign has no idea if it is promising something that is significant to youth.

DARE uses teaching skills that promise to students that the choice to saying “no” to drugs is easy, but once these youth enter a real world situation it does not do what was taught. DARE offers to students “accurate information about drugs, alcohol and tobacco,” skills for “how to recognize and resist peer pressure [and] ideas for positive alternatives to drug use” and “good decision making skills (16). The problem lies in the way that they do this. A real life drug use experience generally involves a peer or family member trying to pressure the youth into using the drug. It could occur in a situation where the youth feels uncomfortable saying no due to ridicule or even fear of abuse. The scenarios that DARE uses involved students “turning down drags from uniformed policemen (13).” This scenario promises to these students that turning down drugs in real life is an easy as turning it down from a uniformed police officer in the safety of their classroom. When the real situation does not match this promise the anger and betrayal that result can lead to not only a rejection of the information taught by DARE but the “’boomerang’ effect . . . encourage[ing] some children to fiddle with drugs (13).” To be able to provide an effective message there needs to be a focus on scenarios that are more realistic and peer based.

With police officers leading discussions children have been promised help for friends or family and have instead had to watch these people they report get carted off to jail. This promise, more then any other, can shatter the trust in DARE. The police officers that come into the classroom focus on “winning the trust of youngsters” by showing that they “interested in their happiness and welfare (18).” Some youth have tried to utilize this promise by turning in their parents for help, but they have been surprised to watch their parents arrested. One child who reported his parents complained that “they never said [his parents] would be arrested,” he instead thought the “police would come get the drugs and tell them that drugs are wrong (18).” Youth who see this happen will not ever trust the officers of the DARE program are looking out for their best interest, so the promise loses its validity and therefore the program is rejected by youth. DARE officers try to do the impossible of being helpful friend and law enforcement agent, but these two roles can detract from each other leading to the potential for more problems than solutions.

The Real New DARE: Youth Empowered Leadership Promoting (YELP) Drug Prevention

In order to create an effective drug prevention program there needs to be a complete change in the way DARE is run, starting with its name. This new program will be called Youth Empowered Leadership Promoting (YELP) Drug Prevention. This reflects the importance of youth empowerment and leadership in drug use prevention. Using theories that have been shown to work for youth public health campaigns would provide a strong base for a new program. This new intervention would still take advantage of using in-class lectures, but in keeping with the psychological reactions theory, police officers would no longer be the main people leading these discussions. YELP would span from early elementary to near the end of high school and research would be done to find out what students at each of these ages value. The use of Psychological Reactions Theory would be incorporated into the development of these interactive class presentations. Peer-to-peer interaction would be an essential part of the educational structure of this new program, increasing the probability that youth will follow the message. Also the message provided by YELP would scrap the idea of zero tolerance and instead use social norms to better educate youth on the realities of drug use. In order to ensure that the message is retained by youth the Community Coalition Action Theory and Empowerment Theory would be used. These would bring in multiple community entities to develop structural community changes that focus on hitting the real problems behind drug abuse in youth instead of just placing a band-aid on a symptom.

How to Use Psychological Reaction Theory to Help and Not Hurt a Public Health Campaign

The Truth campaign is innovative because its message was youth talking to youth. This is a way to use the Psychological Reaction Theory to create a message that youth are more likely to buy into.

First of all YELP Drug Prevention will use peer-to-peer interaction and peer advisors to promote the message of not using drugs. Studies have shown that “similarity . . . enhances the communicator’s credibility, which further increases the forces toward compliance (19).” Since this program will encompass youth from late elementary until the end of high school, older students will be recruited to be involved in the development and presentation of the message to their younger peers. Similar to what was done in the Truth campaign, these students will help craft a message that reflects the unique issues faced by youth in their community (14). When the message is presented it can reflect the values of the youth of this community in a language that they can relate to. In order for this to work youth need to help deliver the message to their peers. The most comprehensive review of the DARE program recommended, “increasing the involvement of both youth and church groups as a way to reinforce DARE’s message (11).” By switching the creation and implementing of the message from law enforcement to peers, there is a greater chance that participants will not view this message as a threat to their freedom, but instead a strong message to comply with.

Using older peers is important to build commitment to avoiding drug usage. In evaluating drug prevention programs “the variables most strongly associated with future drug use were normative beliefs, values and commitment (6).” If older peers can publicly commit to being drug free their younger peers will agree to the same commitment. DARE also has youth show public commitment, but there is the associated fear that a law enforcement officer is having them do this. Instead having peers ask them to do it, the reasoning switches from complying due to fear of repercussions, to that of agreement with someone they relate to. These public commitments could be a powerful tool to build strength in numbers to resist drug use.

The use of peer-to-peer interactive techniques to reinforce the anti-drug message is the other component that will ensure that the Psychological Reaction Theory is being used for the success of YELP Drug Prevention. As mentioned earlier, having a police officer do a role-play scenario about purchasing drugs with a youth is so far from realistic that the youth will immediately disregard it. Instead a more effective strategy would be a “cooperative or participatory learning approach” that works to “generate discussions and other interactions among students (11).” In YELP students will do peer to peer interactions where they practice resistance skills by practicing saying no to each other. This is an extremely important skill to teach because students are much more likely to agree with what their peers say. It is easy to say “no” to a police officer that you do not relate to, so switching these interactive scenarios to be peer to peer makes them more realistic and relevant.

The Power of Social Norms in Keeping Youth off of Drugs

It seems like anytime a TV show or movie comes on with youth in it they are drinking or using drugs. This is why a “vast majority of young people greatly exaggerate in their minds the quantity and frequency of drinking among their peers (20).” This exaggeration leads to youth feeling the need to participate in these behaviors to fit in with their peer group. Social Norms Theory instead works to develop a message that reflects the realities of drug use amongst their peers. DARE’s use of the Health Belief Model ignored social factors that relate to drug abuse, only focusing on the individual. YELP will move towards the incorporation of the group thought process and away from that of the individual for more successful results.

Youth in YELP Drug Prevention will use interactive sessions to think about the number of peers who do not use drugs or alcohol. This will be done through games that require the students to guess, writing projects where they write down all of their friends who haven’t used drugs and various other interactive techniques to get the message across. Once they realize that a significant majority is not using drugs the next step will be to help them establish a community to reinforce the large numbers of youth who do not use drugs. To build momentum behind this community of students “” will be used as an example for YELP. This campaign reminds youth that being part of the 84% percent of youth who don’t smoke is “not just a number, it’s who you are (21).” Using examples of how 91% of eighth graders reported not using marijuana in the last month will be a focus of this new program (22). Then modeling of “,” YELP will use technology as a focus to build this community within and beyond the classroom. DARE prescribes to a flawed theory that decisions are static, but YELP provides a community of peer support for when youth face new challenges to their conviction to stay off of drugs.

Making Youth Drug Prevention a Community Effort

One of the biggest failures of DARE is how it completely ignores the community and the other coalitions that are working on stopping drug abuse for youth. When DARE was studied the recommendation was that “DARE nor any other drug prevention program can or should stand alone in a school district (11).” It also views the issue of drug abuse in a bubble, without considering the factors in the community that lead to the prevalence of drug usage. By using the Community Coalition Action Theory and Empowerment Theory, YELP Drug Prevention will utilize the vast resources that exist in a community by bringing together the key stakeholders that work on youth drug prevention.

In order to effectively evaluate a community for its stakeholders and for the issues that influence drug use a community assessment must be done (24). This community assessment will identify whom the key stakeholders in that specific community that fight to keep kids off of drugs. Parents, teachers, community leaders, employers, law enforcement, and many others all have an interest in this issue and they all have something they can provide to strengthen a program. Teachers will be involved in helping to implement the in-class portion that was discussed before. Parents will assist by continuing the messaging heard at school at home and by serving as strong role models. Community leaders will assist by reaffirming the in-class message through guest presentations and holding community events, in conjunction with law enforcement and employers. These events could bring together drug free communities that youth have formed in their classroom. The exact way YELP will be implemented will be different for each community based on the resources and leadership that were determined by the community assessment. This provides a lot of autonomy to allow people who put on the programs in their school to make it their program. This is done to correct one of the key failures of the DARE campaign, which creates a generic program, that stays the same in all communities.

This community assessment will also help determine what the real issues are that lead to increased drug use in that community. The Empowerment Theory recognizes there are multiple factors that may be more important in a community then any single public health issue, and until those are corrected it is impossible to correct this public health issue. There are two laws that are considered essential for public health programs to succeed the “law of indirect effect” which indicates the need for “changing modifiable risk and protective factors” and the “law of maximum expected potential effect” which recognizes the need to “target and change characteristics that statistically account for drug use (24).” YELP will use this community assessment to figure out what other factors lead to drug abuse in youth and will develop partnerships with organizations that work on those issues. Solving the other community issues will be directly linked to drug prevention. Youth will also be empowered to be a part of these larger community changes, giving them a sense of personal accomplishment and development. This way the focus can be on fixing the problem, which will lead to longer lasting and more complete change.

The 1.34 billion dollar failure

The creators of DARE had great intentions to try and target youth before they started drugs. It also was a very positive step for law enforcement in using education instead of jail time as a way to fix the drug problem. Where DARE went wrong is that it got so blinded by early popularity that it no longer felt the need to justify itself through research or outcomes. Its faults became very apparent, relying on theories that are proven not to work and disregarding others. To create a really effective program to stop youth from using drugs many of the key components really need to be scraped in favor of a new program that focuses on social theories that have shown to be effective in public health campaigns targeting youth, especially around addiction.


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