By Iris Smith, PhD
The prevention of substance use disorders is complex. Most prevention strategies involve building awareness and motivating behavior change in individuals and families and creating policy changes within communities and larger jurisdictions. Intervention strategies focused on policy change and dissemination are less frequent.
Research has shown that perceived severity of a problem is not a reliable predictor of behavior change or policy action. The public health challenges associated with the COVID-19 pandemic are a recent example. Dissemination of surveillance data on the incidence and severity of the virus was not always sufficient motivation for behavior change at the individual level and the sociopolitical environment at the time created obstacles to successful adoption and implementation of public health recommendations.
A recent review of studies that examined the policy diffusion process in public health found that sharing scientific evidence with policy makers did not increase the likelihood that policy decisions would be influenced by the “evidence” presented and that policy makers are often influenced by other indicators of “success” such as widespread adoption or political pressure.1 In a now classic study of evaluation use, Weiss et al (2005) determined that even though the original evaluations of D.A.R.E. did not find it to be an effective intervention, many school districts adopted the program because it had received national recognition and had been endorsed by multiple police departments as an effective drug use education/prevention program. Subsequently as media reports of negative evaluation findings became available, many school districts decided to drop the program. The follow up study found that decisions to drop the program were not based solely on the negative evaluation findings but were also influenced by the Department of Education’s Safe and Drug Free Schools requirement that Department grant funds could only be used to adopt programs from their “approved” list of evidence-based programs and D.A.R.E. was not on the list. 2
Policy interventions such as age restrictions, prohibition of use and distribution, price increases or taxation, and limiting availability such as restrictions on the density of alcohol retail stores or bars have been associated with reductions in use.3 Minimum age alcohol policies have resulted in reduced underage and excessive use among youth. Similarly, price increases, interdiction efforts and restrictions on place of sale have also been associated with reductions in use.
However, substance use policy can also have unintentional effects. For example, policies that ban certain substances or limit use to certain settings or use by certain individuals, such as age restrictions or driving while intoxicated policies, can result in reductions in use under those circumstances but may also encourage use in other settings. Policies that prohibit the consumption or distribution of substances can lead to increases in crime and violence. The effectiveness of these types of policy interventions depends on community capacity to enforce them.
Advocacy involves an exchange of information. When policy development or change is the goal, the audiences include community leaders, representatives of government agencies and legislators. How the communication is framed, the language, and images used can also support or detract from the effectiveness of the message. There are few research studies that have examined the effectiveness of different strategies for exchanging information, however collaborative/participatory approaches that engage multiple partners in crafting and disseminating the message appear to be an effective model for advocacy.4 In some cases, the language and images used in presentations can affect how the communication is received. Racial cues such as depicting a perpetrator as Black rather than White or comparing health outcomes by race can undermine levels of support for policies likely to advance racial equity. Research on racial cues suggests that many White respondents respond to depictions of some policy issues (including crime and poverty) in ways that reflect a pattern of racism. But when messaging depicts broader social responsibility for poverty and crime White respondents shift toward greater support for governmental intervention only when White characters are depicted. The use of qualitative techniques such as storytelling can increase empathy and public support for policies that address social determinants of health.5
Advocacy for the adoption of equitable evidence-based prevention strategies is an essential part of prevention practice. The effectiveness of advocacy efforts is influenced by multiple factors including the science, the message, the sociopolitical environment, and the audience.
2 Weiss CH, Murphy-Graham E, Birkeland S. (2005). An Alternate Route to Policy Influence How Evaluations Affect D.A.R.E. American Journal of Evaluation; 26(1), March 2005; pg. 12-20.
3 Paschall MJ, Yau R, Ringwalt CL (2019) Substance Use Policy Interventions: Intended and Unintended Consequences in: Sloboda Z, Petras H, Robertson E, Hingson R (Eds) Prevention of Substance Use; Springer Nature: Cham, Switzerland.
4 Halliday E, Tompson A, McGill E, Egan M, Popay J (2023) Strategies for Knowledge Exchange for Action to Address Place-Based Determinants of Health Inequalities: An Umbrella Review. Journal of Public Health, 45 (3); pg. e467-e477 https://doi.org/10.1093/pubmed/fdac146
5 Niederdeppe J, Liu J, Spruill M, Lewis NA, Moore S, Fowler EF, Gollust SE (2023) Strategic Messaging to Promote Policies that Advance Racial Equity: What Do We Know and What Do We Need to Learn? Milbank Quarterly 101(2), pg. 349-425.
