The Application of the Rapid Assessment and ...

Accepted Manuscript Title: The Application of the Rapid Assessment and Response Methodology for Cannabis Prevention Research among Youth in the Netherlands Author: Hans B. Dupont Charles D. Kaplan Richard V. Braam Hans T. Verbraeck Nanne K. de Vries PII: DOI: Reference:

S0955-3959(14)00307-7 http://dx.doi.org/doi:10.1016/j.drugpo.2014.11.003 DRUPOL 1485

To appear in:

International Journal of Drug Policy

Received date: Revised date: Accepted date:

15-9-2014 30-10-2014 5-11-2014

Please cite this article as: Dupont, H. B., Kaplan, C. D., Braam, R. V., Verbraeck, H. T., and de Vries, N. K.,The Application of the Rapid Assessment and Response Methodology for Cannabis Prevention Research among Youth in the Netherlands, International Journal of Drug Policy (2014), http://dx.doi.org/10.1016/j.drugpo.2014.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Highlights (for review)

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RAR was found to provide a powerful methodology for implementation and adaptation in cannabis prevention.

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The cumulative past-month use in the target group (N=391) was 48%.

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Differences in the normative structure emerged as the focal point in designing a customized response. A tailored, low-threshold, effective, individual brief intervention for youth

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problematic cannabis use is needed.

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*Manuscript ASSESSING AND ADRESSING ADOLESCENT CANNABIS USE

The Application of the Rapid Assessment and Response Methodology for Cannabis Prevention Research among Youth in the Netherlands

Hans B. Dupont (MSc),1 Charles D. Kaplan (PhD),2 Richard V. Braam (MSc),3 Hans T.

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Verbraeck (MSc), 3 Nanne K. de Vries (PhD)4

Head of Addiction Prevention Department Mondriaan, Sittard, The Netherlands, Research project Coordinator Maastricht University/CAPHRI, The Netherlands Corresponding author: Hans Dupont, Waldeck Pyrmontsraat 53, 6224 LM, Maastricht, The Netherlands, [email protected], 0031-6-12704243, 0031-43-6011134 2 Research Professor and Associate Dean of Research Hamovitch Center for Science in the Human Services, School of Social Work,University of Southern California, Los Angeles, USA 3 Director, CVO, Research and Consultancy, Utrecht, The Netherlands 4 Senior researcher, CVO, Research and Consultancy, Utrecht, The Netherlands 5

Professor of CAPHRI, School for Public Health, Maastricht University, The Netherlands

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ASSESSING AND ADRESSING ADOLESCENT CANNABIS USE

Abstract Background Drug prevention methods tailored to specific target groups have become increasingly important. There is a growing need to find ways to rapidly assess and situate target groups in their particular contexts. This need is associated with the implementation of evidence-based

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interventions (EBIs) for these specific target groups.

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Method

This article describes the application of Rapid Assessment and Response (RAR) as a

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necessary first step in designing and implementing a prevention intervention plan for problematic cannabis use among “loitering” youth in the South of the Netherlands. Seven

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RAR studies were conducted using an innovative stepwise model in which the prevention field worker is central.

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Results

The normative structure for the use of cannabis was found to vary across the neighborhoods

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of the RAR studies and emerged as the focal point in designing a suitable response. The RAR studies also identified the need in the prevention toolbox for a tailored, low-threshold,

Conclusion

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effective, individual brief intervention for youth problematic cannabis use.

The RAR was found to provide a powerful methodology for detecting target groups and generating contextual and normative data that enable the prevention field worker to select and

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adapt from the spectrum of existing Evidence based Interventions (EBIs) or develop the most promising model for implementation with the specific target group. Keywords: Rapid Assessment and Response, cannabis, targeted addiction prevention, implementation, context, norms

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Introduction Limburg is the most southern Dutch province. It has 1.1 million inhabitants in an area of 2200 square kilometers. Unlike most other Dutch citizens, the majority of Limburgians has a catholic religious background. Furthermore, Limburg distinguishes itself from the rest of the

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Netherlands by a hilly landscape. The geographical situation of Limburg, being a Dutch wedge between Belgium and Germany, results in a large amount of drug tourism where

neighboring country cannabis users visit Limburg in order to purchase and consume cannabis.

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Nuisance caused by drug tourism stimulated the provincial government to finance research

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with the goal of producing a cost-effective assessment of the situation of loitering cannabisusing youth in two major towns (Venlo and Heerlen). These grants stimulated successive grant applications from other Limburgian municipalities to study these youth on their own

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streets.

The youth addiction prevention field in the Netherlands offers a comprehensive landscape,

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varying from school based programs (Cuijpers, Jonkers, de Weerdt & de Jong 2002) to more targeted interventions e.g. for children of substance abusers (Van Deursen, Salemink,

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Lammers & Wiers, 2010). A national consortium of 13 Institutes invested in inventorizing the basic existing addiction prevention supply of interventions for the youth in the Netherlands (Spits, Dupont, & Oudejans, 2014). In this stock a wide range of public health problems is

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addressed that are conceived as inextricably related to addiction such as family dysfunctions and deviant behavior. In order to obtain critical background knowledge for the implementation of the best preventive package of tools for problematic cannabis use among these youth, the funded municipalities established a coordinated program of 7 Rapid

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Assessments and Response (RAR) studies conducted by our prevention research group over 7 years (Vandekerckhove & Dupont, 2003, Dupont, Kaplan, Verbraeck, Braam, & van de Wijngaart, 2005, Braam, Verbraeck & Trautmann, 2004). The project set out to answer a set of questions, such as: What would be the necessary and sufficient supply addiction prevention interventions for the youth in the assessed areas? What prevention tools are readily available from the basic supply? Are there any lacks in the supply? What combination of tools from the basic supply and eventually new investments will make sense in this regard and can they be implemented?

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This article summarizes the most important methodological and substantive results and lessons learned from these studies (Hollands, Custers, Vinken, & Dupont, 2005, Romans, 2005, Geenen & Erens, 2006, Kramer & Dupont, 2006, Alders, Kramer, van Erp & Dupont, 2008, Peerbooms, 2009, Hernaus & Van der Pol 2010). In the Netherlands and other European countries, epidemiological research into the use of

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cannabis as well as other drugs is conducted on a regular basis (EMCDDA, 2011, Van Laar, Cruts, van Ooyen-Houben, Meijer, & Brunt, 2013). Although the cannabis use of Dutch

adults is about the European average (4% users in the last month, 2009), the prevalence of

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15% of monthly use among 15- to 16-year-olds is high in comparison with other European

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countries (Van Laar et al., 2013, Lamberts, 2010). Because of these relatively high rates of current use among this adolescent age-graded group, cannabis became an important issue for public health prevention in the Netherlands. Reinforcing this interest in young adolescent

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cannabis use, the results of a number of studies appeared documenting the risks associated with cannabis use including lags in cognitive and respiratory development, psychosis and

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dependence (Fischer, Rehm & Hall, 2009, Van Os, Kenis &, Rutten, 2010, Solowij 2010, Henry, 2010). The incidence of these cannabis-related problems has been found to be higher with earlier onset, a higher frequency or a longer duration of use. Early onset of cannabis use

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has been found to be associated with decreased school performance (Horwood et al. 2010, Pope et al., 2003). In addition, the early onset of use is considered as the critical risk factor for

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future addiction problems and for addiction prevention in general (Hingson & Zha, 2009). Moreover, the problematic use of cannabis has also been found to occur more frequently among truants, early school drop-outs, special education students, “fringe-group” and mentally restricted youth, and children of parents with addiction or other psychiatric problems

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(Van Laar et al. 2013, 2011, Pope et al., 2003, Henry 2010). The accumulation of risk factors appears to increase the susceptibility for addiction in problematic cannabis users. Within the framework of a coherent public health prevention policy, priority has been given in the Netherlands not only to the monitoring of cannabis use among young populations, but also to the screening for addiction risk behavior in cannabis-using youth in appropriate settings. Effective prevention interventions must be designed based on screening assessments that are tightly fitted not only to the individual characteristics of the problematic cannabisuser members of the target group, but also to the context and normative structure of the community conditioning the screening process. In the Netherlands, like most countries, epidemiological research using nation-wide data still remain the basis for macro-policy 4

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decision-making on public health priorities. Nevertheless, the applicability of these methodologies for developing prevention EBIs and their implementation has been recognized as limited. One of the causes of this problem is that cannabis as well as other drug use scenes and the settings are volatile in their dynamics with changes occurring very rapidly needing vigilant surveillance on emerging trends (Stimson, Fitch, Rhodes & Ball, 1999, Trautmann & Burrows, 2000). As a consequence, interventions are often very poorly tailored to individual

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characteristics of the specific target group embedded in a particular context and normative

structure. Additionally, interventions may often be deployed too late when the problematic

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cannabis use has developed into addiction patterns involving poly-drug use. Therefore,

understanding developed in the Netherlands of a research need for professional prevention

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workers in the field, already equipped with the tools of effective interventions and best practices, to gain fundamental background knowledge of the interaction between the behavior

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patterns of multiple substance use, individual characteristics of individual cannabis users and characteristics of use settings that include contextual and normative factors. This background knowledge was seen in the Netherlands and supported by the international literature as

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necessary for the implementation of interventions quickly and effectively (Rotheram-Borus, Swendeman & Chorpita, 2012, http://www.loketgezondleven.nl/i-database Rhodes, Stimson,

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Fitch, Ball & Renton, 1999, Stimson et al., 1999).

The prevention model of Rapid Assessment and Response for youth problematic

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cannabis use

As mentioned in the Introduction, nation-wide epidemiological methods offer a sound basis to chart the broad outlines of public health policies in the field of alcohol and drug abuse. The meaning of addiction prevention in the Netherlands is not solely restricted to drug

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dependence behaviors, but also includes risks and consequences of compulsive cannabis use In this regard what is called « addiction prevention » in the Netherlands is not solely preventing addiction, but also aimed at a wide range of other public health problems. However, two issues remain unsettled by the single reliance on these methods to provide the necessary background knowledge in order to implement EBIs. First, detailed knowledge of the dynamics of location where risk behavior occurs both in the physical and social sense is needed in order to plan prevention operations. Second, once these located dynamics are understood, deciding the way the specifically defined target groups can be reached with suitable prevention programs can be highly problematic. To fashion an effective outreach strategy that is socially and culturally relevant for the specific target group, a detailed 5

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description of the drug subculture that includes the existing normative structure related to cannabis use as well as the social and community context of cannabis use are essential preconditions. In order to be both relevant and valid, this description must be centered on the perspective of the cannabis users (Kaplan, 2010, Rhodes et al. 1999, Stimson, Fitch, & Rhodes, 1998. Stimson et al., 1999, Fitch, Stimson, Rhodes & Poznyak, 2004, Grund,

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Kaplan, Adriaans, Blanken & Huisman, 1990, Boys, Marsden. & Stang, 2001). Qualitative research methodologies are the essential component in RAR (Stimson et al.,

1999). These methodologies allow for collection of data that would otherwise be unavailable

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to answer fundamental research questions about specific target groups. The drug market, the

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subculture music and the cannabis use patterns are all subject to rapid change. In the 1990s RARs, that previously had been used in other areas (Manderson & Aaby, 1992, Solomon & Seegers, 1996), were adapted for research into HIV and drugs. In the latest decade, RARs

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have been deployed extensively throughout the world (Vandekerckhove & Dupont, 2003, Braam et al., 2004, Braam & Januleviciene, 2008, Kikas, Pendin, Murašin, Braam &

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Trautmann, 2006, Needle, Trotter, Goosby, Bates & Von Zinkernagel, 2000, Bouwman 2010).

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Due to a growing number of studies on effectiveness of prevention interventions in the past decade, national data bases with EBIs are increasingly well-documented (http://www.loketgezondleven.nl/i-database). The effectiveness of alcohol and drug

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prevention can be improved by shifting the focus towards vulnerable groups. Following the recent paradigm shift in prevention methods where the specific characteristics of the target group are of primary importance (Conrod et al., 2000), an urgent need has arisen in the field to find ways to chart vulnerable groups rapidly. Prevention work becomes more personal, and

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with that the professionalism of the prevention worker also takes up a more prominent position. In the academic reflection on the implementation of innovation, there is a parallel shift in focus from the characteristics of the innovative intervention towards the personal characteristics of the prevention worker of the intended user and the context in which they should place the innovation (Paulussen, Wiefferink & Mesters, 2007, Bovens, 2010). In this respect, prevention worker professionalism could be described as knowledge of evidencebased interventions and the possibility to adapt these quickly to the context of vulnerable groups.

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This prevention worker’s knowledge of evidence based interventions and professional skills, combined with a number of inductive methodologies (Rhodes et al. 1999 Stimson et al. 1998, 1999, 2001, Fitch et al., 2004) generate a large amount of data. This proportionate effort makes the RAR method cost- effective. It also creates the possibility of a rapid feed-back to stakeholders, which adds to their commitment to help in the collective search for effective preventive solutions. The research data are tailored to the actual practice. A basic principle of

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RAR is that validity is enhanced by triangulation that arises from an approach combining qualitative and quantitative methodologies and different respondents. By means of RAR,

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information is generated that tells a good deal about little. Beside triangulation “the funneling of information” is also an important basic principle of RAR. From the obtained information,

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hypotheses can be induced about the nature of the subject being investigated. These hypotheses can be cross checked. This illustrates the importance of triangulation once again.

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In order to penetrate more deeply into the core of the answer to the research question, the order of the methodologies and the elimination of superfluous data are relevant (Braam et al.

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2004).

Figure 1 depicts the prevention model of Rapid Assessment and Response for youth problematic cannabis use that was developed in Limburg in order to address the critical issues

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of locating the target group and designing the outreach strategy for the 7 studies in the coordinated provincial prevention research program. The model was an adaptation and

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modification of RAR models that have been designed for drug abuse studies over the past four decades. In our practice, as described above, the role of the prevention worker has proven itself to be crucial. Therefore in our model, the prevention worker provides the axis around which the steps of the RAR revolve. The model shows that the RAR process resembles an

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empirical circle (De Groot, 1969) being applied to a small area. The process proceeds through 4 distinct steps revolving around the practices of the professional prevention worker. At each stage, the prevention worker answers key questions concerning the target group, use of substances, problems, causes, consequences, possible interventions, response plan and implementation and monitoring evaluation. These questions guide the process and are continuously asked and adapted (Braam et al., 2004). The stepwise RAR model was applied in 7 studies in the province of Limburg which focused on cannabis-using loitering youth (Hollands et al., 2005, Romans, 2005, Geenen & Erens, 2006, Kramer & Dupont, 2006, Alders et al., 2008, Peerbooms, 2009, Hernaus & Van der Pol 2010).

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Figure 1 Stepwise Model of RAR Implementation All 7 RARs consisted of studying available data and document sources, a qualitative field observation interview phase, a quantitative phase in which the direct target group was recruited and interviewed with a closed-ended questionnaire and a final phase in which a

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focus group, consisting of target group members and professionals, was conducted in order to check the results and the response plan. Although in each of the individual studies slightly

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different variations in the development of the RAR instrument emerged, their similarities outweigh their differences. Of special interest in collecting the quantitative data was the

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frequency of use of cannabis and other drugs, the onset of their use, the money spent on cannabis and the perception of the norm of cannabis use assessed with the question: “Do you

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think it is normal for somebody your age to smoke cannabis?”.

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RAR studies of cannabis use in loitering youth in Limburg Table 1 presents the 7 RAR studies described in terms of the following key characteristics: most important conclusion of qualitative assessment, cannabis use in the past month, response recommended by respondents, the real response and the most important overall lesson

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learned.In regards to the key epidemiological characteristic of past month’s cannabis use it is important to note that the benchmark: 10-15% is normally found in this age group, (van Laar,

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et al. 2013). In Maastricht two coordinated studies were done; each one in a separate

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neighborhood.

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Table 1

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Overview of 7 RAR studies

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Venlo Venlo is an industrial town with 92,000 inhabitants close to the German border. Several suburbs were included in the RAR study (Hollands et al. 2005). These suburbs contain many multi-story buildings. 20% of Venlo’s inhabitants have either a Turkish or Moroccan background. Markedly, in some neighborhoods, 10% are Germans. Subsidy for this study

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from the city of Venlo was gained within the framework of the Hektor/Achilles project, a coherent approach to fight the nuisance of drug tourism. The province of Limburg co-

financed this study. The RAR team consisted of 3 professional prevention workers and a

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trainee. Qualitative interviews (N=28) and questionnaires were taken with the direct target

group (N=33). Groups of Turkish and Moroccan loiterers were found, but also groups of self-

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declared “white trash” loiterers. Age varied from 12 to 25 years. Cannabis had an early onset (about 14 yrs. on average) and a high past month prevalence (50%). Recommendations were:

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to start earlier (i.e., at the age of 11-12 years) with school-based alcohol and drug education, to appoint a prevention worker with an outreaching assignment and to have more peer

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education. As a response, a field prevention worker was employed, and the national schoolbased education program was implemented for the last year of primary school (also in the rest

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of our catchment area). A peer education program was started. Valkenburg

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Valkenburg (population 16,828) is best described as a tourist town. In summer, large numbers of native Dutch youth visit Valkenburg. With a small subsidy of the village, this RAR was performed (Romans, 2005). A master student trainee was counseled by a professional prevention worker. The study was restricted to loiterers who were also inhabitants of this

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town. Most respondents held tourists as being responsible for all disruptive behavior. Strikingly, 100% of the direct target group members (N=30) were Dutch. Age varied between 14 and 21 years. 33% smoked cannabis the previous month. Recommended were the engagement of drug educators who know what they are talking about, fear arousal in examples and special tourist information. From the village of Valkenburg no subsidy was acquired for the response phase. Regular prevention activities were continued (BAU) in this village; i.e., programs in all secondary schools, consultation for parents and youth workers and interventions for children of addicted parents. Stein

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The third RAR was carried out in Stein, a rural village with 25,476 inhabitants, of whom a high percentage are part of the lower social class (Geenen & Erens, 2006). Here, a professional prevention worker was assisted by a master student trainee. The fact that a high past-month prevalence (2%, in 16yrs old) of amphetamine use was found in Stein in a 4-year epidemiological survey (Houben, 2006) caused quite a stir in the town council, which eased the process of getting this RAR funded. Of the direct target group (N=55), 9% used

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amphetamines last month (age 12-23 years). Cannabis was also quite prevalent: 54% smoked during the previous month. To the question, “do you regard cannabis smoking a normal thing

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to do for somebody your age?” 93% answered yes. The same question was asked for alcohol (100%, yes) and amphetamine (29%, yes). Recommended were a coherent community

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approach and the assignment of a field prevention worker. Apart from BAU, a community

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response called “Strong in Stein” was developed.

Heerlen

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Heerlen is the largest city (population. 82,754) in an urbanized area bordering Germany. The income is low compared to the Dutch average; there are high levels of unemployment and a relatively large proportion of Moroccan and Turkish inhabitants (7.5%). Heerlen is

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characterized as a small town with metropolitan problems. The province of Limburg and the city of Heerlen co-financed this RAR to assess nuisance caused by loiterers in 8

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neighbourhoods, covering 40% of the town (Kramer & Dupont, 2006). During the process, a quantitative survey (N=106) was carried out with loiterers (12-23 years.) and found a young average onset (14yrs.) of cannabis use. During the previous month, 35% used cannabis. On average, €30, - was spent weekly on purchasing cannabis. Recommended here were screening

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and early detection programs, assignment of a prevention field worker, drug education in primary schools, combining physical activity with drug prevention and an especially targeted prevention program. For 6 years, a field prevention worker has operated in Heerlen, subsidized by the city, and the national school-based education program has been implemented during the last year of primary school. The experiences in Heerlen and later RARs were a starting point for the development of Moti-4, a tailored, low- threshold, effective preventive intervention, for vulnerable adolescents (Dupont, Adriana, van de Mheen, de Vries, 2014, in press). Maastricht

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In Maastricht, the capital of Limburg 2 RARs were performed. In the first RAR, Daalhof (inh. 6.630) and Mariaberg (inh. 4,740) were assessed (Alders et al., 2008). Daalhof is a suburb with multi-story buildings and partly new buildings in the higher segment of the housing market. Mariaberg is a traditional working-class quarter with a strong alcohol culture. The nuisance caused by drug tourism lead the city of Maastricht in the subsidization of the RAR in those 2 suburbs. A research group of 5 people, 3 prevention workers and 2 professional youth

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workers was formed. Recruitment of the loiterers was carried out in the same manner in both suburbs. The group found in Daalhof had an average age of 17.8 years (N=45), and a

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previous-month prevalence of cannabis use of 78%. There was also high involvement in hard drugs like amphetamine and cocaine. The youth in Mariaberg (N=20) on the other hand were

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younger (average age 14.6 years). Here, 15% had smoked cannabis in the previous month. In Mariaberg, early onset of alcohol use seemed to be the biggest public health problem.

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Recommended in both suburbs was the assignment of a field prevention worker. In Mariaberg, an integral project targeted at influencing the alcohol norm was recommended and actually carried out by the assigned field worker. In Daalhof, the recommendation was to

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promote a safe environment. Here, a field worker commenced in a project targeted at deescalating the drug careers of younger loiterers.

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A second Maastricht RAR (Peerbooms, 2009) was performed in Malberg and de Heeg (12,034 inhabitants), both suburbs being comparable with Daalhof. There was no external

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funding; the RAR was being performed by a trainee masters student, advised by a professional prevention worker. The age varied from 12 to 28 years, the average age 17.4 years (N=64). In the previous month, 45% of the youngsters had administered cannabis. Here also, the norm for cannabis varied considerably: in de Heeg, 81% of the respondents regarded

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cannabis smoking as normal behavior for people their age, while in Malberg only 25% had this opinion. Recommended here were the assignment of a field worker and future efforts to keep in contact with these vulnerable youth. No special response was performed since no extra budget was obtained from the city of Maastricht. Sittard Sittard (97,806 inhabitants) is the second largest city in Limburg. Here Ophoven, an upperclass suburb, and Sanderbout, a working-class quarter were assessed (total: 6,210 inhabitants; Hernaus & van der Pol, 2010). This RAR was carried out by 2 trainees, who were advised by a professional prevention worker. In these neighborhoods, 39 loiterers were recruited with an 12

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average age of 16.3 years. 77% Had used cannabis in the previous month. An early onset and a low threshold to start were found. Recommendations were to re-open a youth centre in Sittard, assign a field worker, carry out more assessments in other neighborhoods and promote collaboration between network partners. No direct response was performed because of budgetary problems. In 2013, however, a field worker could be assigned and another RAR

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was performed in this city. Similarities in problems and response assessment

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Vulnerable youngsters were identified who had greater risk factors for addiction, such as

being a school drop-out, marginalized, truancy, having mentally ill or addicted parents and

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attending special educational programs (Van Laar et al. 2011, Pope et al. 2003, Henry, 2010). Cannabis was found to be easily available and there was a low threshold for the initiation of

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cannabis use. The cumulative past-month use in the target group (average of seven studies, N=391) was 48%. There was an early average onset of first cannabis use (14 yrs.). 16 Years was taken as the cut-off point determining early prevalence (Horwood, et al. 2010). Extreme

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outliers were reported. Users spent €32 (average of five studies, N=320) on cannabis per week. Consequently, these youth were in need of a tailored preventive approach. In answering

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the key questions, a description of set and setting (Zinberg, 1984) of use as well as the respondents’ opinions of existing prevention measures as effective measures to be taken in the near future was made. These data allowed for a specific characterization of who, where, with

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whom and what to do in these neighborhoods with our package of preventive interventions. These findings were combined in a response plan for each neighborhood in which the existing professional knowledge of EBIs and opinion of stakeholders were incorporated. To accomplish the objective of affecting a later onset of cannabis use, information and service

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providers were trained in communication skills for youth, their parents and adult significant others. Early-detection programs were implemented (e.g., in general medical practices) and programs that were a combination of physical activity and prevention (one of the main recommendations in all RARs), were introduced. For vulnerable youth Moti-4, a tailored, low- threshold, effective preventive intervention, has been developed because none of the existing prevention tools on the shelf were acceptable to the target group (Dupont, Adriana, van de Mheen, de Vries, 2014, in press). The experience of the RAR implemented in South Limburg showed that a mechanical approach of using the RAR to simply provide useful background information for applying existing EBIs will likely lead to only partial success at best. Rather the RAR results provided a challenge to develop new 13

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interventions that organically fit with the constellation of the specific cannabis use characteristics of the target group.The goals of Moti-4 are to diminish the use of cannabis among youth and to encourage their motivation to change their behaviour that was shaped by their early onset of cannabis use, the existence of a norm supporting cannabis use and a relatively high amount of money spent each week on cannabis. Intervention Mapping (Bartholomew, Parcel, Kok, Gottlieb, Fernandez, 2011), a systematic approach to develop

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theory- and evidence-based interventions, was used to develop a protocol for the intervention. With Intervention Mapping it was possible to make a productive combination of theory and

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community knowledge. Moti-4 was developed following the six consecutive steps of

Intervention Mapping: Needs Assessment, Behavioral and Learning Outcomes, Selecting

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Change Methods and Translating Methods into Intervention Strategies and Materials, Production of the Program Components and the Program, Program Adoption and

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Implementation, Planning for Program Evaluation. This resulted in the evolvement of a substantial 4 session intervention with a clear manual and training for prevention workers. Though motivational interviewing was the main guiding theoretical principle, moti-4 also

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consists of self-monitoring, social norm and social network excercises, knowledge transfer and strengthening resilience to peer pressure (Dupont et al., 2014). Moti-4 was implemented in

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Limburg and two other provinces. After the effectiveness of this intervention is further

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assessed, moti-4 will be implemented nationwide.

Differences in normative structure

While there were many similarities in the youth that determined the intensity of the

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prevention response that was needed across the seven neighborhoods, the differences in the normative structure emerged as the focal point in designing a suitable and customized response tailored for the specific normative structure of the target population. Although a large proportion of the respondents regarded using cannabis as a normal thing to do for people their age, there were large differences between neighbourhoods. The use of cannabis in the previous month varied from 15% to 78% reflecting these differences in normative structure. Following this, the response to each of the target groups varied considerably based upon these assessments. Besides a qualitative comparison of the normative structure for drug use in several RARs, some quantitative assessments in selected cities and villages were also made. In the 2 neighbourhoods in Maastricht, we asked 65 respondents: “Do you think it is normal 14

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for a person your age to use cannabis?” There was quite a large difference between the 2 neighbourhoods (81% yes in the Heeg; 25% yes in Malberg). Comparable differences were found in earlier RARs. In Heerlen (Kramer & Dupont, 2006) and Maastricht (Alders et al, 2008), this same question was assessed with a 5- point likert scale. No statistically significant change was found in an independent T-test. The norms for cannabis use are fairly consistent across the 2 cities. When comparing these scores the same way between neighbourhoods in

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Maastricht, a significant difference was found between Mariaberg (N=20, M=2.5, SD=0.51) and Daalhof (N=45, M=4.27, SD=0.45). These outcomes proved that Daalhof had a heavy

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scene and the response was adapted. The same independent T-test was done, comparing Malberg (M=2.57, n=21, SD=1.6) and the Heeg (M=4.6; n=30; SD=0.97). Here also a

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significant difference was found implying that a different preventive response was warranted.

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Monitoring/Evaluation

Getting funding for evaluation of the RARs was challenging. In support of the evaluation after the implementation of change, we have conducted 2 “light” RARs in Heerlen and Maastricht,

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in which the same process is completed with considerably less respondents. For this purpose, qualitative interviews were carried out to evaluate the interventions in order to adapt them or

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implement new interventions. In each neighborhood, the range of EBIs was augmented. The work of the outreach prevention workers and their home calls was highly appreciated. Early detection of problems as well as referral to addiction care benefits considerably from this

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approach. The need for targeted measures was further recommended such as Intermediate Vocational Training institutes as well as an expansion of RAR to other towns in the region and sites. Adjustments were made matching these recommendations to the specific conditions

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of implementation. Discussion

Cannabis is easily available in towns and villages in Limburg. In 7 RAR studies cannabis use was found to be an essential element in the environment of loitering youth. A low threshold to the commencement of cannabis use, an early onset of use and a high prevalence rate in the past month’s use was assessed in the direct target group. In each RAR the need for a tailored response for adolescents vulnerable for problematic cannabis use was found. The differences in normative structure in these villages and neighbourhoods were of major importance in the response. As identification with certain subgroups (Verkooijen, de Vries & Nielsen, 2007) and the perception of others’ use (Walker, Neighbors, Rodriguez, Stevens & 15

Page 16 of 28


Roffman, 2011) is associated with high cannabis use, the value of norm-based interventions seems uncontestable (Pedersen, Miles, Hunter, Osilla, Ewing & d’Amico) and is supported by the results of the RAR studies. RAR has proven to be a good method to map the target group for addiction prevention. The response interventions were chosen from the existing prevention toolbox and if any loopholes

ip t

were found, RAR helped to formulate adequate answers. In this way, RAR helped to shape an effective local drug policy. The existing arsenal of best practices and EBIs is likely to improve public health if those interventions can be broadly diffused and sustained over time

cr

(Spits, Dupont, Oudejans, 2014, in press). When formulating adequate answers, we might

us

need to know “disruptive innovations” that synthesize common elements across EBIs and experiment with new delivery formats (Rotheram-Borus et al., 2012).

an

Our adaptation of the RAR method was always to let a professional addiction prevention worker be the pivotal party in the RAR research team. This approach has 3 main advantages: The prevention workers’ knowledge of evidence-based interventions promotes a rapid

M

-

elimination of preventive proposals that are not feasible. -

The interaction the prevention worker has with the RAR team and the target group

ed

respondents during the assessment phase helps to build the network that will be needed to implement the response plan at a later phase. If a gap in the toolbox is found, the prevention worker has the possibility to adapt the

ce pt

-

arsenal of existing EBIs quickly to the context of vulnerable groups.

The RARs accentuated the gap that existed in our prevention toolbox as well as being a useful

Ac

aid in the actual development of a targeted new tool based on theory and practice. This development is exemplified by the general answer to one of the main questions clarified by the RARs: specific risk groups of cannabis-smoking youth vulnerable to mental and physical health problems and problems with school and work are in need of a tailored, low-threshold, effective preventive intervention. The RARs showed that the Moti-4 needed to be developed in South Limburg; an intervention aimed at preventing addiction among problematic cannabis user youth (Dupont, Adriana, van de Mheen, de Vries, 2014, in press). Future intervention research is needed in order to make the findings more robust. The applicability of the RAR as an implementation tool for drug prevention workers should be 16

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further assessed in other Dutch municipalities. This should occur through the comparative assessment of indicators used in the studies described, such as age of onset, current use and the level of the social norm encouraging use. Assessment and comparison of the norm with a validated instrument seems the crux in future research. An intriguing suggestion is that these RAR studies be conducted internationally especially in the neighboring cities and villages in

ip t

Germany and Belgium. An important lesson learned during the process is that much effort needs to be invested in keeping in touch with the target groups and detecting their problems. By employing the same

cr

professionals who performed the assessment in the neighborhood as outreach prevention

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workers to implement the response plan and evaluate it, we have succeeded in doing just that. The RAR experience also proved to be an effective method for stimulating the higher

an

vocationally trained staff to become more research minded and more professional. The stimulation of the staff towards more research mindedness is a bonus of the RAR process (Marlow, 2010). Last but not least, RAR also might be an excellent method to raise more

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money for prevention projects. Our experience is that a sufficient funding for the assessment phase improves the chances to obtain a response phase subsidy. Cognitive dissonance theory

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might be at work here (Festinger, 1957); something that is paid for has to be taken more

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ce pt

serious.

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Walker, D. D., Neighbors, C., Rodriguez, L. M., Stevens R. S. & Roffman R. A. (2011) Social Norms and Self-efficacy in Heavy Using Adolescent Marijuna Smokers. Psychology of addictive behaviors, 25 (4), 727-732. Zinberg, N. (1984). Drug, Set, and Setting The basis for Controlled Intoxicant Use. Yale

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Figure(s)

1. Problem Assessment - What is the problem? Who uses what, where, how much, and from which onset? What is the norm for cannabis use?

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2. Response Assessment - What is being done about prevention? What does work? EBIs “on the shelf”? What are the gaps? Supply?

Funneling Triangulation

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Speed/Promptness

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4. Monitoring Evaluation: Has the problem decreased?”Light RAR”. If too little, go back to 1.

Professionalism Prevention Worker Knowledge evidencebased interventions

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3. Response Plan, Method of Approach -The implementation of a coherent set of preventive measures!

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Table(s)

Village/

Qualitative assessment

Quantitative assessments

Response assessment

Response plan

Important lessons learned

neighborhood

N=33 Health 50% Cannabis education use in past starting at month younger age, outreaching prevention, targeted prevention

Outreach prevention worker, strengthene d business as usual1.

Focus on fewer neighborhood s Employing field prevention worker. After 2008: implementati on of moti-4 Valkenburg (Village) N=21 N=30 Information business as Investment in 16,828 inh. Young Dutch 33% Cannabis transfer by usual, relationship (Romans, 2005) tourists are use in past experts, fear because with subsidy responsible month arousal in village providers for (alcohol health didn’t After 2008: related) education, subsidize implementati disruptive special continuatio on of moti-4 behaviour tourist n education Stein (Village) N=25 N=55 Community business as Continuation 25,476 inh. Amphetamine 54% Cannabis approach usual,“Stro is challenge (Geenen & Erens, use use in past project, ng in Stein” After 2008: 2006) month targeted project implementati prevention on of moti-4

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N=28 Difference between several groups of loiterers

Heerlen (several neighborhoods) 88,754 inh.

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Venlo (several neighborhoods) 92,000 inh. (Hollands et al. 2005)

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(Kramer & Dupont, 2006)

N=36 Small town with big town problems

N=106 More 35% Cannabis school-based use in past prevention, month combination of physical activity and prevention, outreach and targeted prevention

Outreach worker, business as usual targeted prevention, combinatio n with physical activity

Focus on neighborhood s employing field prevention worker Moti-4, start

1

Business as usual consists of EBIs of alcohol and drug education in primary and secondary schools, peer education, training of professional intermediaries and parents, projects with children of addicted parents.

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Village/suburbs

Quantitativ e assessments

Response assessment

N=9 High prevalence of hard drugs, group with anti-social or disruptive behavior N=11 Very low threshold for alcohol

N=45 78% Cannabis use in past month

Outreach, combination with repressive interventions

Response plan

Important lessons learned

Combination with law enforcement, focus on norm

Sittard (neighborhoods: N=11 Ophoven and Sanderbout) High cannabis use 6,210 inh.

Involvement of prevention worker is conditio sine qua non

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Outreachin g prevention worker marginaliz ed group, Maastricht business as (neighborhood: N=20 Integral usual Mariaberg) 15% alcohol norm Moti-4 4,740 inh. Cannabis use project (Alders et al. 2008) in past month Mariaberg Super strengthene d business as usual in project to lift alconorm Maastricht (Malberg & N=10 N=64 Outreach business as de Heeg) Rather average 45% prevention usual, 12,034 inh. as expected Cannabis use worker in because (Peerbooms, 2009) in past month these village suburbs, didn’t efforts to subsidize keep in touch continuatio with these n vulnerable Moti-4 groups

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Maastricht (neighborhood: Daalhof) 6,630 inh.

Qualitative assessment

(Hernaus & van der Pol, 2010)

N=38

Interventions combining 77% life music Cannabis use and in past month education, a centre for the youth

business as usual, because village didn’t subsidize continuatio n Moti-4

Response P R is important, focus on norm, laying down a standard

Involvement of prevention worker is conditio sine qua non

Table 1 Overview of seven RAR studies

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