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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
HEALTH PROMOTION PLANNING "I find this book to be an invaluable resource, offering a comprehensive guide for assessing and addressing public health issues. Its unique blend of theoretical insights and real-world narratives provides a nuanced understanding of interventions in practical contexts. This book is an essential tool for both current and aspiring professionals in the public health sector." --DANE MINNICK, Indiana Division of Mental Health and Addiction Real stories, real solutions--a unique textbook that embeds definitions and descriptions of program planning principles within the story of one town grappling with the opioid crisis In Health Promotion Planning: Learning from the Accounts of Public Health Practitioners, you will embark on a journey through the heart of a small midwestern city, where a community grapples with the daunting challenges of the opioid epidemic. The book uses narratives in a creative and engaging way, weaving together the real-life accounts of over 100 public health practitioners. As you follow the saga of the town, you will see program planning principles in action. Through the intricacies of substance use and opioid-related challenges, this book sheds light on the interconnected efforts of diverse programs, including needs assessment, health education curriculum, health communication campaigns, environmental change strategies, peer support initiatives, and community organizing. Students and practitioners will uncover the principles and processes of building health promotion programs. Discussion questions and activities at the end of each chapter stimulate reflection and exploration, offering a valuable resource for instructors and individual learners. Health Promotion Planning is a powerful glimpse into public health practice, inspiring future generations to take up the mantle in addressing societal challenges. Learners will witness health promotion in action as they follow the compelling stories inside--where lessons are learned, lives are changed, and hope emerges from the frontlines of a devastating epidemic.
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Seitenzahl: 377
Veröffentlichungsjahr: 2024
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Table of Contents
COVER
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT PAGE
DEDICATION PAGE
NOTE TO INSTRUCTORS
FOREWORD
ACKNOWLEDGMENTS
INTRODUCTION
WHY TALK ABOUT SUBSTANCE USE?
IS THE PROBLEM PREVENTABLE?
WHAT IS THE MAGNITUDE OF THE PROBLEM?
WHAT ARE THE COSTS ASSOCIATED WITH THE PROBLEM?
WHAT DO WE KNOW ABOUT OPIOIDS AND FAMILIES?
HOW DO SOCIAL CONTEXTS INFLUENCE PROBLEMATIC BEHAVIOR SUCH AS SUBSTANCE MISUSE?
HOW CAN PROGRAM PLANNING HELP SOLVE PUBLIC HEALTH PROBLEMS?
HOW WILL THIS BOOK BE STRUCTURED?
CHAPTER GUIDE
DISCUSSION QUESTIONS
REFERENCES
CHAPTER 1: COMMUNITY HEALTH NEEDS ASSESSMENT
FOCUS GROUPS AS A MEANS OF DATA COLLECTION
SURVEYS AS A MEANS OF DATA COLLECTION
MOVING FROM DATA COLLECTION TO ANALYSIS AND ACTION
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 2: FATALITY REVIEW BOARD
USING FATALITY REVIEW BOARDS TO ASSESS NEEDS
SELF‐CARE IS NEEDED IN PUBLIC HEALTH WORK
MAPPING A LIFE AND A DEATH THROUGH MULTIPLE SOURCES OF DATA
ANALYZING PATTERNS TO IDENTIFY FUTURE OPPORTUNITIES FOR INTERVENTION
DISCUSSION QUESTIONS
ACTIVITY
REFERENCES
CHAPTER 3: MATERNAL TREATMENT PROGRAM
USING THE SOCIAL‐ECOLOGICAL FRAMEWORK TO UNDERSTAND BARRIERS AND FACILITATORS TO BEHAVIOR CHANGE
A WAY FORWARD BASED ON CONSUMER PREFERENCES
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 4: RECOVERY RIDE AND RALLY
DIVERSE SOURCES OF FUNDING ARE CRITICAL TO THE SUSTAINABILITY OF THE EVENT
THE SUCCESS OF THE EVENT REQUIRES CAREFUL PLANNING AND COLLABORATION WITH PARTNERS
SPREADING THE MESSAGE OF RECOVERY THROUGH DIFFUSION THEORY
MEASURING THE SUCCESS OF THE EVENT THROUGH EVALUATION
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 5: RED RIBBON WEEK
DIVERSE SOURCES OF BUDGETARY SUPPORT
AWARENESS‐RAISING AS A COMMUNITY‐WIDE INTERVENTION
PLANNING INTERVENTIONS TO PROMOTE AND REINFORCE BEHAVIORAL CHANGE
REVIEWING THE EVENT TO IMPROVE FUTURE PLANNING
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 6: THE WISE PROGRAM
THE BENEFITS OF USING A CANNED PROGRAM FOR HEALTH EDUCATION
USING THE FOUR P'S OF SOCIAL MARKETING TO DO FORMATIVE RESEARCH
PLANNING FOR A SUMMATIVE PROGRAM EVALUATION IN THE FUTURE
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 7: PEER‐RUN WARMLINE
BEHAVIORAL CHANGE CONCEPTS UNDERPIN WARMLINE IMPLEMENTATION
GETTING THE WORD OUT ABOUT SERVICES
RECRUITING STAFF AND VOLUNTEERS TO OPERATE THE WARMLINE
TRAINING WARMLINE OPERATORS AS A PATH TO PROGRAM FIDELITY
EVALUATING PROGRAM SUCCESS WITH THE HELP OF A LOGIC MODEL
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 8: AN INTERPROFESSIONAL SYMPOSIUM
ASSEMBLING A PLANNING COMMITTEE
PLANNING COMMITTEE IN ACTION
KEEPING AN EYE ON THE MISSION, GOALS, AND OBJECTIVES
THE FRUITS OF PLANNING
USING TECHNOLOGY TO GATHER FEEDBACK FROM EVENT PARTICIPANTS
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 9: RECOVERY CAFÉ
PROGRAM PLANNING STARTS WITH A VISION
DEVELOPING, MAINTAINING, AND SUSTAINING A PROGRAM
FINDING A PHYSICAL LOCATION THAT MEETS PROGRAM NEEDS AND GOALS
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 10: GRASSROOTS COMMUNITY ORGANIZING
JOINING FORCES WITH LOCAL LEADERS
STRENGTHENING RELATIONSHIPS THROUGH GRASSROOTS ORGANIZING
BUILDING CONSENSUS AND WORKING TOGETHER
COLLABORATING ACROSS INSTITUTIONAL BOUNDARIES
FUNDING THE PROJECT
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 11: TRAUMA‐INFORMED CARE
PLANNING WITHIN GRANT PARAMETERS
THE INTERSECTION OF SUBSTANCE USE DISORDER AND TRAUMA
STIGMA AS A BARRIER TO TRAUMA‐INFORMED CARE
HELPING THOSE WHO HELP
DISCUSSION QUESTIONS
ACTIVITIES
REFERENCES
CHAPTER 12: WORKING WITH EXTERNAL VENDORS
SCREENING THE VENDOR
EVALUATING THE WORK OF AN EXTERNAL VENDOR
DISCUSSION QUESTIONS
ACTIVITY
REFERENCES
CHAPTER 13: WORKING WITH VOLUNTEERS
COORDINATING VOLUNTEER EFFORTS
TRAINING VOLUNTEERS
DISCUSSION QUESTIONS
ACTIVITY
REFERENCES
CHAPTER 14: WORKING ACROSS INSTITUTIONS
BUILDING STRONG, PERSON‐CENTERED RELATIONSHIPS
FIGHTING STIGMA AS A PART OF PROGRAM PLANNING
DISCUSSION QUESTIONS
ACTIVITY
REFERENCES
INDEX
END USER LICENSE AGREEMENT
Guide
COVER PAGE
TABLE OF CONTENTS
TITLE PAGE
COPYRIGHT PAGE
DEDICATION PAGE
NOTE TO INSTRUCTORS
FOREWORD
ACKNOWLEDGMENTS
BEGIN READING
INDEX
WILEY END USER LICENSE AGREEMENT
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HEALTH PROMOTION PLANNING
Learning from the Accounts of Public Health Practitioners
JEAN MARIE S. PLACE
JONEL THALLER
SCOTT S. HALL
Copyright © 2024 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
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Library of Congress Cataloging‐in‐Publication Data Applied for:
Paperback ISBN: 9781119686187
Cover Design: WileyCover Image: © Thomas H. Mitchell/500px/Getty Images
To my mentors, for introducing me to a profession I am passionate about.
To my Muncie community, for teaching me.
To Obed, Allie, and Ava, for your incredible love.
Jean Marie S. Place
NOTE TO INSTRUCTORS
This book includes multiple stories of how a community addresses the opioid crisis. The stories are based on interviews that we, the authors, conducted. We spoke with many public health practitioners, seeking to learn more about the programs they manage, wanting to understand how these programs work to mitigate the opioid epidemic. We include true stories in this book for the purpose of providing instructional examples, but we do not reveal the county where this work takes place, and we use pseudonyms to protect the practitioners who shared their stories with us. In some stories, small elements in the storyline or sequencing of events have been fictionalized.
In this book, we approach program planning through the lens of a specific health problem so that students can see how multiple programs work together to affect a public health issue. Although we recognize that many public health issues are interconnected, we chose to take a closer look at substance use – and specifically opioid use disorder – to explore how public health practitioners are implementing programs to address this devastating social problem. The opioid crisis is an especially salient societal challenge of which students and instructors are likely to have some basic knowledge or interest. Considering the wide range of this issue, they may even have a personal connection. Consequently, we chose to highlight key principles of program planning by describing programmatic efforts related to addressing substance use and opioid‐related problems. In this way, students can learn more about program planning while, at the same time, learning more about substance use.
Our emphasis on the real‐life accounts of public health professionals is intended to help students see and discuss program planning principles in action. As you will see, public health professionals can include social workers, case managers, therapists, program evaluators, program administrators, and medical specialists, among others. Ultimately, we want students to feel like the people they meet in this text are relatable and the projects they discuss are achievable, thus furthering an investment in becoming public health professionals themselves. We hope, foremost, that students come away with a better understanding of the principles and processes of building health promotion programs, especially for substance use prevention, treatment, and recovery. A deeper knowledge of the opioid epidemic is an added, beneficial outcome.
This textbook does not necessarily depict comprehensive program planning, nor does it detail in‐depth explanations of the opioid epidemic, but it does provide honest, real‐world information from the frontlines to help bring these topics to life. You might find it useful to supplement its content with select articles or other textbooks such as Green and Kreuter’s (2005) Health Program Planning: An Educational and Ecological Approach or McKenzie, Neiger, and Thackeray’s (2017) Planning, Implementing, and Evaluating Health Promotion Programs. In our book, program planning concepts emerge in the course of accounts – or stories – revolving around a person or organization in a given context; the information is driven primarily by the organizations and events we were able to witness and investigate further and, thus, they may lack some elements of inclusivity.
Each chapter will end with discussion questions and activities that can be used by an instructor to spark conversations among students about principles of health promotion planning. These resources can also be used as individual or group assignments, as adapted by instructors. We hope that you will find these tools helpful as you embark on your learning journey.
FOREWORD
Prescription painkillers – ostensibly harmless, even helpful, tablets offered by physicians and stored in medicine cabinets above our bathroom sinks – hit our unsuspecting synapses with the pleasure‐packed thrill of leaping out of an airplane. Many intravenous heroin users can trace their addiction back to misusing painkillers, in some cases legitimately prescribed. These pills, and their opioid‐derived counterparts such as heroin, fentanyl, and carfentanyl, kill approximately 130 Americans per day, driving down our nation’s average life expectancy and mercilessly bringing people who were previously at the prime of their lives into an early grave.
The undergraduate students I teach in my public health course knew nothing about these statistics. Many were not familiar with the word “opioid,” although Schedule II narcotics are responsible for the biggest public health crisis of our time. It was staggering to realize that what my students knew about opioids might be limited to Percocet prescriptions for wisdom teeth or a handful of pills pharmed out at parties.
As I came into my own awareness of this community crisis, I did an about‐face in my syllabus design, reexamining whether definition‐heavy textbooks with piecemeal examples from a range of A to Z topics were packing the punch necessary to help students learn about the public health issues that plague us. As an experiment, I tried teaching a semester‐long, health promotion planning course through an in‐depth examination of one relevant, pressing area – opioid misuse. Didactically, the question was whether a high‐resolution lens focused intensely on one issue could reveal more to my students about public health principles than a series of quick, cursory glances across the landscape.
In this class, we turned the camera to opioids. The master syllabus remained the same – I still had to teach about the major components of planning, implementing, and evaluating health promotion programs – but as we zeroed in on the opioid epidemic, paradoxically, we began to see a more panoramic view. We talked details about medication‐assisted treatment (MAT), post‐incarceration support, prescription monitoring, syringe exchanges, and supervised consumption spaces. Like individual trees in the proverbial forest, these successful health promotion programs marked the path to a vista where we could see a wide‐angle view. We talked more broadly about concepts like health promotion planning models, theories, and strategies. These concepts emerged organically and in context, tied as they were to the programs we discussed. My students began to see the myriad of ways that public health concepts interact when mitigating a specific threat to public health. They saw the forest for the trees.
That semester my students and I walked away with a bargain. We understood the principles and processes of building health promotion programs and had a deeper knowledge of the opioid epidemic. I knew I wanted to teach this way again. I began envisioning a book that could accompany this “high resolution” way of teaching. It should provide definitions and descriptions of program planning, but also anchor them to one specific public health topic and embed them in a story.
The vision has come to fruition in this collection of accounts – or real‐world stories of public health professionals. Our goal is to facilitate practical understanding and application of these concepts by sharing stories of real people in a real community using concepts and models from health promotion planning. Our job was to draw lessons from what our local public health practitioners shared with us, pointing out the principles of health promotion planning behind the outcomes. We hope that familiar people, places, and events will come to mind as you read these stories, providing a visual illustration of concepts that we sometimes only talk about in a detached and overly simplistic way. We hope this book will be beneficial to instructors and students because it is both readable and relevant.
Thank you for joining us in this journey,
Jean Marie S. Place, PhD, MPH, MSWJune 22, 2023
ACKNOWLEDGMENTS
We want to thank the many public health practitioners who shared their stories with us, invited us into their organizations, and revealed the ups and downs of program planning. Thank you!
INTRODUCTION
WHY TALK ABOUT SUBSTANCE USE?
Before you begin this section, ask yourself if you believe substance misuse is a public health problem. If you affirmed that substance misuse is a public health problem, can you describe why you believe so? In this introduction, we want to encourage you to think broadly about substance misuse – specifically opioid misuse – and how it has affected individuals, families, and communities. Consider how program planning principles can help public health practitioners address serious issues, such as the opioid epidemic.
Substance misuse (including addiction) is one of the major health challenges of our day. Societal‐wide problems have accelerated swiftly and savagely – the result of a storm of social, economic, and political forces that contributed to the easy availability of opioids and other illicit substances in the United States. Public health professionals have spent countless hours planning and implementing programs to battle the effects of this major challenge.
How big of a problem are we talking about? In 2022, nearly 110,000 American lives were lost to drug overdose. Drug deaths had steadily increased over 2020 and 2021, with a 17% and 30% increase, respectively (Centers for Disease Control [CDC], 2023). Most of these deaths are attributed to opioids (Scholl et al., 2019), with synthetic opioids like fentanyl contributing to roughly 75% of the deaths. On any given day, roughly 130 Americans die because of the misuse of an opioid (National Center for Drug Abuse Statistics, 2023).1
The US Department of Health and Human Services declared a national public health emergency in 2017 due to unprecedented, nationwide opioid abuse. Former director of the Centers for Disease Control Robert Redfield called it “the public health issue of our time.” What does that mean for you as an aspiring professional? How might the challenges of addiction affect those you interact with in your career? How might your career be shaped by the challenging, urgent threat of substance misuse, specifically opioid misuse, even if you do not directly work with a population that uses these substances?
Before we discuss the wide array of programmatic efforts aimed at addressing something like opioid misuse, we want to provide context on opioids to firmly establish the substance use epidemic as a matter of public health. The information provided below is intended to make clear how the opioid epidemic affects the public, and why students who are trained to develop prevention and treatment programs for an individual, family, or community unit are a vital workforce. Take a look at this brief overview on how opioid use disorder (OUD) fits the criteria for being a public health problem.
IS THE PROBLEM PREVENTABLE?
Substance misuse, including misuse of opioids, is a preventable problem. Much of what puts people at risk for substance misuse can be minimized – and efforts to prevent opioid misuse and overdose can save and improve many lives. For example, the CDC (
2021
) offered several methods for reducing opioid overdose deaths. First, medical professionals can improve how and when opioids are prescribed to patients. Overall exposure to opioids can be reduced when medical professionals and other practitioners promote alternative pain treatment, including emotional and cognitive pain management skills. Further, education and public awareness of opioid misuse and its consequences can be improved and expanded, and best practices of treating those with OUD can be made more abundant and accessible. Other approaches may become more apparent as you continue reading about the causes and effects of opioid‐related problems.
WHAT IS THE MAGNITUDE OF THE PROBLEM?
As is apparent in the statistics already mentioned, the magnitude of substance‐misuse‐related deaths is staggering. Furthermore, upwards of 930,000 people in the United States died of a drug overdose from 1999 to 2020, with opioid‐related deaths increasing more than eight times in the past two decades (National Center for Health Statistics,
2021
). More than two out of every three drug overdoses involve opioids (Hedegaard et al.,
2021
). Aside from overdoses, close to one million people received medication‐assisted treatments to manage their OUD in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022). Moreover, nearly 5 million individuals ages 12 and older reported having misused prescription pain relievers (SAMHSA, 2022). Consider how many lives are affected by this problem when including those who love, care for, and depend on people struggling with substance use disorder.
The opioid misuse problem has gotten worse over time. While data from 2022 suggests that a staggering increase in overdose deaths has begun to level off, in earlier years the United States faced an astronomic rise in such deaths. From 2019 to 2020, there was an age‐adjusted 31% increase in overdose deaths, with some states seeing upwards of a 50% increase in overdose deaths within one year (CDC,
2021
). From 2013 to 2017, the average annual increase of drug overdose deaths due to synthetic opioids was 75% per year, slowing but still increasing 9% per year from 2017 through 2019 (Hedegaard et al.,
2020
). In recent years, opioids accounted for over 68,000 deaths in 2020 – a dramatic increase from just under 48,000 such deaths in 2017 (CDC,
2022
).
WHAT ARE THE COSTS ASSOCIATED WITH THE PROBLEM?
Financially, the total economic burden of the opioid epidemic in the United States is estimated to be about $1,021 billion each year, including costs of OUD at $471 billion and costs associated with fatal opioid overdose estimated at $550 billion (Luo et al.,
2021
). This economic burden includes costs from healthcare, lost productivity, addiction treatment, and criminal justice involvement. On the flipside, for every person that does not develop an OUD, significant financial value is generated. For every person that does not develop an OUD, $2.2 million is generated from a societal perspective, $325,125 from a taxpayer perspective, and $244,030 from a healthcare sector perspective (Murphy,
2021
).
Other costs of opioid‐related problems are more physical in nature. For example, infants born with opioids in their blood suffer withdrawal from the dissipation of the substance, known as neonatal abstinence syndrome (Hirai et al.,
2021
). Opioid misuse can also contribute to the spread of infectious diseases like HIV and Hepatitis C through contaminated needles used to inject the substance (CDC,
2021
). Incarceration rates also increase with greater misuse of opioids, separating those who struggle with OUD even farther from much‐needed prosocial interaction and support (Scott et al.,
2021
).
Estimates suggest that OUD has cost US taxpayers around $93 billion. Such costs include nearly $30 billion for criminal justice system expenses and $63 billion in excessive healthcare expenses. The additional loss of productivity in the workforce due to premature deaths is estimated to be about $65 billion (Murphy, 2021).
This sampling of facts and figures begins to give us an idea of how OUD is considered a public health problem. Finding solutions to this problem can be especially difficult. By the time a person reaches a state of active opioid addiction they have, by definition, become dependent on the substance and can experience extremely painful, and sometimes dangerous, withdrawal symptoms if they quit using. Moreover, in active addiction, the brain has developed an increased tolerance to the drug, needing a progressively higher dose of it to avoid these withdrawal symptoms. Many public health professionals push for preventing misuse before it starts, for example, by working to help people avoid adverse childhood experiences (ACEs) that tend to predict substance use in later life (Leza et al., 2021; Rogers et al., 2022).
Despite the overwhelming nature of this work, addressing public health problems like opioid misuse is essential for the welfare of society. As you will see in the next section, families can play a major role in substance‐related problems. We suspect that many people can relate in some way to the positive and negative impact families can have on an individual’s growth and development, and we invite you to consider the importance of incorporating families into planning and implementing solutions to public health problems.
We will now take a deeper dive into how OUD creates a burden for families.
WHAT DO WE KNOW ABOUT OPIOIDS AND FAMILIES?
Many of us love someone, or know someone who loves someone, who is struggling with addiction. So powerful is the pull of addiction that our loved ones often become unrecognizable to us. In recent years, over 500,000 children were living with an adult with OUD, an increase of 30% since 2002 (Bullinger & Wing, 2019). Children raised in homes with drug abuse are at elevated risks for neglect, abuse, unsanitary living conditions, witnessing domestic violence, and having limited resources (Barnard & McKeganey, 2004; Taplin & Mattick, 2015). Studies show that children who live in a home where there is opioid misuse generally experience psychological distress and reduced family cohesion (Ashrafioun et al., 2011). Adults who misuse opioids often report that they were mistreated as children, and research suggests that opioids are preferred by such adults due to the numbing effects of the substance (Maté, 2010). Opioid prescriptions given to family members increase the likelihood that individuals without opioid prescriptions overdose on opioids, meaning family members can be a key source of access to opioids (Khan et al., 2019).
Parents who have substance use disorder may adversely impact their children in a variety of ways, not withstanding the love they have for their children. Opioid use during pregnancy increases the risk of fetal underdevelopment and babies born suffering from withdrawal symptoms, such as tremors, poor sleep, irritability, and feeding difficulties (Schiff & Patrick, 2017; Wexelblatt et al., 2018). Moreover, sometimes pregnant women with an OUD avoid proper prenatal care due to stigma or fear of child protective services involvement (Schempf & Strobino, 2009). Infants and toddlers may struggle to form healthy attachments to parents who are in active addiction and struggling with OUD, which makes children more vulnerable to stress and emotion dysregulation (Cook et al., 2017).
Parents with OUD can become preoccupied with drug seeking and may engage less often with their young children (Young & Martin, 2012). Opioid dependence can alter a parent’s brain, replacing the natural pleasure‐inducing experience of relationships with drug cravings (Mitsi & Zachariou, 2016). As children age, they continue to be at risk for inadequate parenting. Parents who struggle with OUD frequently engage in more negative parenting behaviors and fewer positive parenting behaviors (Peisch et al., 2018). They have also been found to use harsher and more humiliating punishment (Peisch et al., 2018).
In general, parental substance misuse contributes to less parental monitoring and supervision and less parental warmth and support, putting children of any age at risk for developmental and behavioral problems (Barnes et al., 2000). Children are also at risk for becoming parentified – meaning, they are expected to take on the role of a caregiver to a needy parent, which puts excessive pressure on children to behave beyond their capacities (Godsall et al., 2004). Ultimately, parents with OUD are at risk of losing their children to the foster care system, and research suggests that children remain in the system longer and are less likely to be reunited with their parents when opioids are involved, compared to other substances (Grella et al., 2009; Mirick & Steenrod, 2016). This may be due to such mothers having a stronger addiction and especially low financial and housing stability (Grella et al., 2009). Moreover, parents who lose custody of their children are less likely to recover from OUD (Comiskey, 2013).
In some families, children are the opioid users. In recent years, between roughly 12% and 14% of high schoolers in the United States admitted to having misused prescription opioids in the past (CDC, 2021). Adolescents are at risk for poorer judgment due to the neurological gap between their expanding reward system and slowly developing cognitive control functions (Chassin et al., 2013), which can contribute to substance misuse. Furthermore, living in a rural setting seems to correspond with higher adolescent opioid misuse by as much as 35% (Monnat & Rigg, 2016), and adolescent opioid use is strongly linked to depression (Edlunda et al., 2015). Dealing with adolescent substance misuse can be overbearing for parents, some of whom may cope by turning to substances themselves, which in turn can escalate the risks for poorer parenting and subsequent child outcomes (Leonard & Eiden, 2007).
As noted earlier, family dynamics often play key roles in opioid misuse problems. They can also be a contributing factor to other public health challenges and outcomes. Multiple theoretical perspectives help us understand why families and other social contexts can have such a powerful influence on problematic behaviors and societal trends. These perspectives are important to consider when addressing various public health problems.
HOW DO SOCIAL CONTEXTS INFLUENCE PROBLEMATIC BEHAVIOR SUCH AS SUBSTANCE MISUSE?
Public health initiatives hinge on the assumption that people have the capacity to change their behavior and health status. Yet, changing deeply engrained habits of thinking and doing can be extremely difficult – especially when the social environment, or the life circumstances and social interactions that surround and envelope a person, does not support the change.
Systems theory helps us visualize how the social environment influences human behavior. Through this lens, we see that individuals (and groups of individuals) operate as wholly functioning systems that are likewise comprised of functional subsystems. A family system, for example, can contain unique sibling‐to‐sibling or parent‐to‐child subsystems, each with its own dynamic and history.
Systems are functional in that each individual part contributes to the whole in a generally predictable manner. Individual family members often assume, whether consciously or not, a distinct role within the system, such as that of protector, caretaker, scapegoat, cheerleader, or peacekeeper. But, having specific roles does not imply that a system is necessarily promoting health and wellbeing or encouraging an ideal distribution of power among members. Some family systems can be highly dysfunctional, even for long spans of time. While internal or external forces can significantly disrupt a system and warrant a temporary adjustment, the system will naturally seek a return to homeostasis, or its previous state of operation.
Conceptualizing family systems in this way helps to understand why some people continue problematic behavior even when they express a desire to change it. Consider people who say they want to quit misusing drugs because of health issues but have been raised in a family where substance use is encouraged as part of leisure and bonding. Or, consider a person with a substance use disorder who have family members who thrive in caring for and rescuing the individual from their self‐inflicted consequences. For these people, the decision to cease substance misuse, a positive behavior change, impacts the regular functioning of the system by disrupting routine interactions and altering assigned roles. Thus, behavior change is not as simple as one person changing their behavior. The context of their social environment must be taken into consideration.
Urie Bronfenbrenner’s (1979) ecological systems theory2 expands the family systems framework by incorporating an ecological perspective, taking into account multiple layers of influence from the social environment. This theory incorporates multiple layers of external systemic influences: the micro‐, mezzo‐ (or exo‐), and macrosystems. Another level of influence, the mesosystem, recognizes interactions that occur between systems at the mezzo‐/exo‐level. Moreover, the chronosystem refers to the influence of time and human development, such as adolescence, on human behavior.
The microsystem is comprised of all of an individual’s personal characteristics and personality traits, including health and mental health conditions, strengths, challenges, and goals. A person who is struggling with addiction may be also grappling with severe anxiety or depression. They may have experienced sudden abandonment or a painful injury at some point in their life history. They may be young or old, raised in affluence or generational poverty. They may be highly educated or may have dropped out of high school. They may have a genetic disposition to addiction. All of these factors influence their behavior and belief in what is wise and possible.
The mezzosystem, also sometimes referred to as the exo‐system, refers to the small groups, communities, or organizations to which an individual belongs, such as their family, school, neighborhood, workplace, or recreational groups. As with the microsystem, interactions within the mezzosystem can have a significant effect on a person’s capacity for behavior change and ability to thrive. Peer and family systems have a huge impact on individual success in recovery from a substance use disorder. Human beings naturally long to connect with others, and group membership is a crucial component in identity development and maintenance of self‐concept. In the addiction recovery community, the phrase “people, places, and things” is often used to refer to components of a person’s environment that can trigger a return to substance misuse. Some connections provide easy access to substances and normalize their misuse.
The macrosystem refers to influence on human behavior at a societal and cultural level. Powerful institutions, such as the criminal justice system, the healthcare system, government, the media, and religion all impact opportunities and norms and trickle down into the decisions people make about their lives. For example, institutional biases against people with addictions, criminalization of certain substances but not others, representations of substance misuse portrayed by the media, and common constructions of race, class, and gender influence public perceptions of substance use. The influence of these macro‐factors may sometimes be difficult for an individual to perceive directly but are nonetheless significant enough to influence behavior.
Any of these systems can be targeted when planning a behavior change strategy. For example, social workers work with individuals and families, but also within larger systems, such as neighborhoods and organizations, to facilitate improvements in health and wellbeing. At a macro‐level, family policy experts advocate for policy change by working closely with legislative bodies. Likewise, public health workers engage in health education that can occur on a micro‐level, with an individual, or on a macro‐level if the goal is to bring about a culture change, establishing new behavioral norms.
External influences of human behavior can also be categorized as social, economic, and political forces. Social forces (Cox, 1981; Callero, 2017) are the core values and beliefs generally in a person’s social environment, determining what behavior is normal and what is taboo, such as whether it is acceptable to use illegal drugs as a leisure activity. Economic forces (Heilbroner & Thurow, 1998; Estola, 2001) determine the availability of resources to individuals and communities, and whether people have access to the resources they need to merely survive or, conversely, whether their access to money, material goods, and special services might enable them to thrive. Political forces (Elkins, 1979; Gonidec, 1981) refer to the distribution of power or, more specifically, who makes the laws and what activities are considered criminal. These forces often work together to shape perceptions and responses to public health concerns. For example, we saw all of these forces converge with the increase in federal funding to support expansion of substance misuse treatment once the problem began to affect a more affluent demographic of users (Hoagland et al., 2019).
Social, economic, and political forces can also be considered social determinants of health – significant factors within the social environment that impact health and wellbeing, as well as overall functioning and quality of life.
Understanding the scope of a public health problem (e.g. the extents of opioid misuse and overdoses) and the roles played by social contexts (e.g. family, economy, culture) that encourage or maintain problematic behaviors help set the stage for addressing the problem. Effective prevention and intervention efforts require significant preparation and planning. Premature implementation of intended solutions can lead to a waste of opportunities and resources and could even make problems worse.
HOW CAN PROGRAM PLANNING HELP SOLVE PUBLIC HEALTH PROBLEMS?
A program is a set of activities organized toward a specific goal, and that goal typically involves influencing human behavior in some manner. Health promotion and social service programs are intended to improve the quality of life for individuals, families, and/or communities, building upon capacity and strengths that are already present to increase positive outcomes and reduce negative ones. In many ways, program planning and implementation is a form of carefully orchestrated problem solving, and it begins with a clear need or problem that should be addressed.
As you will see throughout this book, program planning is foundational to addressing public health problems, including opioid misuse. Public health professionals should be aware of various considerations in their planning efforts. Successful programs often target multiple factors that simultaneously contribute to a given problem. Such a complex approach requires careful, intentional planning. Given our focus on opioid misuse, and the relevance of familial factors for many individuals who struggle with this problem, especially minors, we now provide examples of how program planning can incorporate family‐oriented elements in efforts to address the opioid epidemic.
In the case of opioid misuse prevention efforts, programs that target children should consider involving their parents. Clearly parents have a major influence on their children’s drug‐related decisions and behaviors, and the family environment overall can provide risk and protective factors that predict children’s substance use (Swadi, 1999). Parents also influence children’s attitudes about substances, with more favorable attitudes predicting future substance use (Guo et al., 2001; Messler et al., 2014). Prevention efforts can include educating parents about addiction and opioid misuse and how to reduce the risk of their children getting involved with substance misuse (US Department of Justice – Drug Enforcement Administration & US Department of Education – Office of Safe & Healthy Students, 2017). Parents can help by teaching children healthy coping behaviors and using healthy parenting practices in general (Henderson et al., 2009). Efforts to prevent opioid misuse among parents should also account for the likelihood that such parents also often struggle with depression and anxiety (Martins et al., 2009), face social isolation from the community (Suchman et al., 2006), and may live in high‐conflict and low‐support home environments (Spehr et al., 2017). Helping parents who are dealing with grief, loss, and past or current trauma can decrease the likelihood that they turn to substances (Garrett & Landau, 2007).
Program planning often also means preparing intervention efforts that help individuals and families end and recover from opioid misuse. Successful family‐based treatment strategies typically combine home visits with counseling (Barnard & McKeganey, 2004; O’Farrell & Clements, 2012). Planning related to treatment and intervention benefits from a comprehensive, ecological approach that addresses family dynamics and other systems outside of the home, such as schools, aftercare services, community policies, and cultural norms and behaviors (Fischer & Lyness, 2005). Seeking commitments from schools, communities, and leaders to support children and families is critical for wide ranging success (Boyd & Faden, 2002).
When programming focuses on parents’ opioid misuse, program developers should consider the various ways that children fit into the circumstances. For example, some parents avoid seeking treatment because of a lack of childcare options, though having children can also motivate parents to recover from substance misuse (Taplin & Mattick, 2015). Children need help coping with a parent with an OUD and may need a more stable place to live for a time. Even though parental recovery from substance abuse is a positive outcome, it can also be an especially stressful time for the family. Familiar family patterns and routines get disrupted, making the recovery period potentially more challenging for children than before recovery, even if ultimately the family environment improves (Lewis & Allen‐Byrd, 2007). Program planning should account for additional stress during the early recovery period and help ensure that new family patterns form that help prevent relapse and other risk factors that could contribute to children’s substance misuse.
Considering all the influences that may lead a person to misuse opioids for the first, second, and subsequent times, prevention and intervention efforts must cast a wide net. Broadly, problematic human behavior and social trends are complex and often require complex solutions. Throughout this book, we provide a variety of examples of public health professionals working hard to address opioid‐related problems. Such efforts are built from a foundation of program planning and their stories allow a glimpse into important planning processes. These are real‐life examples that typically illustrate a mixture of both ideal and less‐than‐ideal procedures, creating opportunities to critically evaluate lessons that can be applied in the future. In practice, our best intentions do not always translate into the implementation of best practices, but being able to adapt to novel circumstances is also an essential part of program planning.
HOW WILL THIS BOOK BE STRUCTURED?
The content in this book is delivered through professionals’ own accounts of their public health work. We conducted formal and informal interviews with more than 100 people who live and work in a small midwestern city with an Americana feel. In tandem with the interviews, we observed coalition meetings in action, took notes at townhalls, ate with people in active addiction at community‐centered meals, and visited extensively with public health professionals, clinicians, social workers, and elected officials trying to find solutions to an ever‐increasing crisis.
The people named in each of the accounts are real people with fictional names used to mask their identities. Embedded within these stories are key insights into program planning. We have highlighted insights that can serve as stepping stones for each of us as we advance public health practice in our own communities. Interventions should be built on a solid foundation of knowledge, expertise, and evidence, and so we have tried to point out public health principles as they are revealed in the context of a story.
Finally, we provide discussion questions to consider at the end of the chapter. Use these to further reflect on what can be learned and adapted from these professional accounts and applied to other communities.
Please know that our intent is not to provide an exhaustive list of interventions used to address the opioid epidemic. Rather, the chapters in this textbook describe the tools used by one community at one point in time. In this way, the stories are limited in scope and cannot underscore every important learning principle. Nevertheless, we hope readers get a feel for how public health practice is implemented in communities across the United States – imperfect and imprecise, but full of lessons for future generations to absorb as they take up the torch in addressing a devastating national crisis.
CHAPTER GUIDE
In
Chapter 1
, we introduce Flynn Mosi who is in charge of a community‐wide needs assessment. Use this chapter to learn more about the basics of conducting large‐scale needs assessments. We illuminate the difference between primary and secondary data, identify different sources for data collection, and discuss how needs are prioritized for intervention.
In
Chapter 2
, we introduce Fabiola Martin who engages her team in another type of needs assessment, a fatality review board. They look at the untimely deaths of people lost to substance misuse and seek to learn lessons from these deaths to better help those who struggle with OUD. Use this chapter to understand risk factors and levels of prevention.
In
Chapter 3
, we describe a maternal treatment center for women with OUD during pregnancy and in the postpartum period. We introduce a staff member named Kate who wants to help the women but does not have a complete understanding of the barriers women face in treatment. She works with staff to improve their program based on the results of a consumer analysis conducted among women with substance use disorder, particularly OUD. Use this chapter to get a better understanding of the socio‐ecological model and barriers and facilitators that affect health outcomes. We also discuss qualitative and quantitative research in a community setting, and how research results can inform program planning.
In
Chapter 4
, we introduce Juli Kohl who organizes an event to celebrate recovery from substance use disorders. We explore the logistics of event planning, including forming a planning committee, developing financial sources of support, marketing to vendors and participants, and evaluating an event’s success. Use this chapter to learn about implementation management.
In
Chapter 5
, we introduce Darby Montegro who brings a prevention program to schools and an awareness event to the community. In this chapter, we focus on understanding a theoretical model for behavior change, as well as implementation considerations like obtaining sources of support.
In
Chapter 6
