The 1ournal of PrimaryPrevention, VoL 1~ No. 3, 1996
DAYS La Famflia Community Drug and Alcohol Prevention Program: Family-Centered Model for Working with Inner-City Hispanic Families Lawrence P. Hernandez, Ph.D., 1,3 and Ed Lucero, B.A. 2
Substance abuse among Hispanics is on the increase despite national efforts toward reducing it. Researchers and service providers have recognized the specific need for better prevention models that address the issues of poor Hispanics. La Familia is a community-based ATOD prevention program that targets Hispanic families with high-risk youth from 6 to 11 years old, and attempts to reduce identified risk factors while building on culturally relevant protective factors. During the 2 years, the program has enrolled 219 youth and their families utilizing existing community networks and aggressive outreactt The program resulted in a 92% retention rate and over 80% attendance per session. As a result of the program, families became more willing to discuss ATOD issues openly and made positive steps toward empowerment. KEY WORDS: prevention; Hispanics; protective factors; substance abuse; family-centered; high risk families.
INTRODUCTION The growth of alcohol, tobacco, and other drug (ATOD) addictions and related social problems among the rapidly increasing Hispanic population has seriously challenged service providers. Thus, the need for sound prevention and intervention models effective with this group has become imperative. IUniversity of Southern Colorado, Pueblo, Colorado. 3Regional Prevention Center, Denver Region, Denver, Colorado. Address correspondence to LawrenceP. Hernandez, Universityof Southern Colorado, 2200 Bonforte Boulevard, Pueblo, CO 81001. 255 O 1996 Human Sc~ao~s Prcs~ Inc.
256
Hernandcg and Lucr
The efforts of the Denver Area Youth Services (DAYS) model program, La Fami!'_,a Community Drug and Alcohol Prevention Program was designed with this challenge in mind. This family-centered prevention strategy targets the families of high-risk youth from 6 to 11 years, and attempts to reduce identified risk factors while simultaneously increasing culturally relevant protective factors. La Familia serves the North and West inner-city communities of Denver, Colorado, which are made up of predominantly Hispanic and low-income families. Families ill this area encounter serious barriers to effective participation in any type of prevention program as they are faced with a multitude of stressors. 75 percent of the households in these areas are headed by single women. These neighborhoods are confronted with a multiplicity of problems including high rates of ATOD abuse, massive under/unemployment, gang violence, teen pregnancy, high rates of HIV infection, homelessness, the highest school drop-out rates in the State, and a history marked by distrust of community agencies.
REVIEW O F THE LITERATURE Defining the Population When considering potential prevention strategies that may be effective with Hispanics, the importance of understanding the variations of subgroups within this population cannot be over-emphasized. Puerto Ricans and Cuban-Americans, for example, although considered to be Hispanic, do not necessarily share the same traditions and beliefs that Hondurans or Colombians hold, or necessarily even speak the same language. In fact, one of the most consistent findings in ATOD addiction research is that people's attitudes, beliefs, and behaviors with respect to their use of alcohol, tobacco, and other drugs differ across socio-economic status, ethnic subcultures, and generational groups (Greely, McCreedy, & Theisen, 1980; Heath, 1986). Thus, it is essential that service providers understand and appreciate that when working with Hispanics, or other ethnic populations, they must be cognizant of these differences in all efforts to develop culturally relevant programs. Deficit ]~adition Historically, traditional "deficit" model program~ for drug and alcohol prevention targeting inner-city Hispanics have been primarily focused on addressing variables that place them "at risk" for social problems. These
I.a Famllla
257
programs have ignored the role of culture and families' potential strengths, and as a result, have been ineffective. This deficit tradition assumes that Hispanic children bring to their environments a cultural capital which is impoverished and antithetical to healthy development (Hernandez, 1993). Embedded in this assumption is the idea that impoverished Hispanic parents use ineffective teaching strategies, do not care about their children's future, and generally do not foster their children's academic and social development (Hess & Shipman, 1965; McGowan & Johnson, 1984; for summary see Walker, 1987). In addition, deficit modeled programs are typically individually centered, overlooking the important contributions of Hispanic families and communities in socializing children and impacting their self-esteem and coping skills. Only recently, interventionists have begun to consider the enhancement of personal and environmental protective factors as the key to building resistance to social problems among high-risk families and children (Jessor, 1993). In fact, the enhancement of protective factors by rebuilding family social capital, drawing on cultural strengths, and re-creating supportive networks, may hold the greatest promise for constructing effective prevention and intervention strategies (Comer, 1991). Assessing Specific Risk Factors
One of the goals of La Familia is to target early risk factors such as family disruption and disunity, mental health problems, deviant behavior, negative peer influences, early use of drugs, and strong and favorable attitudes towards the use of alcohol and drugs that are highly predictive of later adolescent and adult ATOD problems. But rather than merely attempting to address risk factors, La Familia helps families to build on already existing individual, familial, and community resources that can protect them from the effects of specific risk factors. To effectively reduce these factors and others, a family-centered program must carefully assess whether the effect of so-called "risk" is equal for all particular individuals involved in a given program. We know from medicine, for example, that the heterozygote status for Sickle Cell Anemia places African Americans at substantial risk for morbidity. Yet, the same condition in the sub-tropic regions of Africa actually protects Africans from contracting life-threatening malaria. It is logical that a similar situation arises with psycho-social risk factors for ATOD abuse (Rutter, 1991). Thus, risk can be assessed at three specific levels of impact for each child and family: (1) Individual Risk, the most direct and specific level of risk (e.g., a child born with a hard-to-detect learning disability or addiction
2.58
Hemand~ and Lucern
to crack-cocaine); (2) Familial Risk, (e.g., a child being raised in a chaotic or alcoholic family) and (3) Community Risk, which descn'bes a community which has a high degree of social disruption in the surrounding area as manifested through such conditions as high levels of crime, abandoned and dilapidated housing, and youth violence. Family-centered program.~ should build in strategies to encourage each family to identify and reduce their own risk factors with specific strategies that tap into familial and o t h e r local resources (e.g. cultural values, extended families, and churches).
Assessing Specific Protective Factors
Protective factors have been shown to counteract the potentially harmful effects of powerful individual, familial, and community risk factors influencing ATOD problems. As Compas (1987) points out, the modest to moderate correlations typically found between individual stressful life events and various maladaptive problems and disorders of childhood and adolescence suggest that personal and environmental protective factors are important for healthy coping and moderating the effects of stress-producing risk factors. Eaton (1978) has also shown that the lack of appropriate "buffers" (particularly social support) while experiencing life stressors can result in increased psychological disturbance. Specifically, a protective factor is defined as a personal or environmental resource which mitigates the effect of stress from the environment and/or internal sources, and assists an individual in developing effective coping strategies for dealing with a particular context (Hernandez, 1993). Given this definition, no particular characteristics are always protective. However, researchers have summarized four basic processes by which protective factors operate: (1) those that reduce the risk or impact of the effects of stress by virtue of acting on the riskiness itself or through alteration of exposure to, or involvement in, the risk; (2) those that reduce the likelihood of negative chain reactions stemming from the risk encounter; (3) those that promote self-esteem and self-efficacy through the availability of secure and supportive personal relationships or successes in task accomplishment; and (4) those that open up opportunities of a positive kind (Rutter, 1991, 1987, 1985). Thus, programs utilizing a family-centered philosophy should emphasize complete assessment in identifying specific protective factors of children, parents, and communities that can be enhanced and capitalized upon for ATOD abuse prevention.
La Yamilia
259
Building Social Capital In La Familia, ATOD problems are viewed as a product of a dysfunctional system that includes the family and community in which the individual is immersed. In turn, one of the most important efforts of La Familia's family-centered philosophy of prevention is to help families build protective environments by jointly engaging multiple families and their children in the process of learning healthy lifestyles and the creation of social capital. Social capital is viewed as the most important component in the development of resilience and success of a particular child, family or community. It represents the time and energy that adults have to invest in each other, in children, and in community institutions--such as schools, congregations, community groups, worker associations, and so forth (Dickerson, 1991; Guydish & Sanstad, 1992; Lee, 1991; McGraw, 1992). Social capital fuels a learning process in which adults and children teach each other to take control of their lives and to think creatively about ways to help their families and neighborhoods. Building social capital involves teaching families to re-create positive family environments that stimulate them to discuss, debate, reshape, and test out new parenting skills, communication techniques, and coping strategies. La Familia staff work to create "mini-universities" in communities by working with groups of youth and families and providing them with the opportunity to become life-long learners and community partners in the success of all children. Most importantly, the process of developing social capital leads to new relationships among high-risk Hispanic families and youth and thus re-creates historically supportive social networks. Impoverished Hispanic communities have historically relied on the extended-family structure (as opposed to the nuclear family) and strong religions and community values tied to tradition as the main source of support and assistance with child rearing. These strong community networks among Hispanics encourage community members to view children as members of a larger community family. Such networks--coined as the "tortilla trail" by Mothers of East Los Angeles (MELA), a highly successful grass-roots organization to prevent violence and drug use--are based on reciprocal relationships among families. In MELA, mothers join forces to keep track of each other's children, educate themselves about drug, alcohol, violence, and gang prevention, teach and support each other in their children's development, model resilient behavior, effective coping and communication skills for neighborhood youth, and plan and develop intervention for broader community development. These new internal and external resources which families and communities develop serve as protective factors against the risk of ATOD abuse.
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Hernandez and Lucero
DESIGN
Defining Tasks of the Program La Familia was created around a set of eight key defining tasks for building youth, family, and community strengths:
1) Utilize existing community relationships, networks, and leadership for outreach and recruitment. 2) Let every child/family/community identify their own priorities and goals. 3) Help build trusting relationships between family members and other families by encouraging them to support and learn from one another. 4) Teach parents and other community members to be "prevention minded." 5) Help children, parents, families, and communities implement new skills and focus on "doable" and "wirmable" target behaviors. Help parents, children, and communities achieve "little victories" while striving toward long-term goals. 6) Teach parents and other community members to organize and build supportive relationships with groups and individuals that have the resources and willingness to help them achieve their goals. 7) "II'ain as many community-based prevention specialists, parent organizers, and peer counselors as possible in such skills as outreach and recruitment, evaluation and assessment of clients for various programs, in delivering prevention strategies, and in community resource development. 8) Encourage greater independent action of children and families early to avoid dependence on the program. Program Overview La Familia specifically incorporates into its services a strong element of respect and honor for the Hispanic culture. All program efforts are geared towards addressing specific needs of the locally identified Hispanic communities using specially developed and adapted curricula that maintains an emphasis on honoring cultural integrity. Each component of the program serves to enhance the other through a connected culturally relevant family-centered philosophy and strategies. These strategies build on positive cultural traditions, values, and beliefs. The three components to this program include the Family Strengths Pro-
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261
gram (FSP), the Basic Prevention Program (BPP) and the Follow-Along Program (FAP). Each is designed to meet the particular developmental needs of individuals and families through active participation of children, other family members, and staff. The program involves multi-family interventions (assessment, training, counseling, and family bonding activities) that take place where the participants live (in public housing developments that donated units to the project) or where the children attend school. All components are bilingual/bicultural. Project staff not only speak Spanish, but also grew up in similar inner-city Hispanic communities. The staff have also shown an ability to relate to families in the program and gain their trust and confidence. Each component of the program also encourages children and other family members to learn from one another and utilize new skills and knowledge on a daily basis. Participant youth and families are recruited through referrals from school staff and existing community networks. Families with children 6 to 11 years old are targeted. For each child involved in the program, at least one parent, and preferably the entire family including extended family members, are asked to participate in program activities. However, children who have been referred to the program are not restricted from the program even if a parent does not commit to fully participating, but the parent must give consent for each child's participation. All program activities are designed to address both the needs of youth who have participating families and for those who do not. However, ongoing efforts are made by staff to fully involve family members of every child in the program. Arrangements are made with the schools to provide incentives for improved performance of youth involved in the program. Youth are awarded $25 for successful completion of prevention programming, as are participating parents. Youth also have an opportunity to earn points for cash awards for successful school performance (e.g., good grades, good attendance, and homework completion). In addition, staff serve as advocates for families dealing with other systems such as Social Services, Housing Authority, etc. and collaborate with other agencies in the delivery of some services. All program activities are coordinated through the DAYS office. Family Strengths Program (FSP) The 14 week FSP addresses identified risk factors by focusing on improvement of: parenting skills; positive family environment; communication among family members; children's social skills; social support structures, and reducing children's intent to use alcohol and other drugs. As a central focus of this component, existing strengths of parents and children are iden-
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tiffed and built upon. Families are involved in two to three informal meetings or events (e.g. poflucks, open house, etc.) before participation in the actual program be~n~. The first few informal meetings are key to developing an atmosphere of mutual respect and trust. Participants are also involved in both single and multiple family sessions, cultural excursions, recreation sessions, groups with peers, and program planning sessions. FSP has five interwoven focus areas: Introduction and Group Bonding--These exercises target relationships between family members and bonding with other families and begin with a "conocimiento," or a process of getting to know each other on an individual and familial basis. The FSP then moves forward to explore issues of risk, self-esteem, and behavior. Other exercises used assist the youth participants in understanding themselves in the context of culture and family. Identifying what constitutes both positive and negative behavior also takes a strong focus; however, the motivation of this new understanding rests in the goal of re-focusing the negative behavior into a more positive one. "Cuentos," or storytelling, and cultural history are used to further promote family and community cultural identity. Eventually, participants explore and test out individual, familial, and cultural protective factors and culturally relevant ways to change negative behaviors.
Goals and Objectives--In this focus area, parents and youth are given the opportunity to share the expectations they have of each other as well as discuss various expectations of the school and home environment and how the two can merge to become mutually supportive. The importance of education, self-worth, and career opportunities are also stressed throughout this section. Communication--As part of this focus area, messages communicated between youth and parents are explored. The differences between 'T' and "You" messages and the ways in which families share thoughts and feelings of criticism and praise are also examined. Alcoho~ Drugs, and Families--This focus area emphasizes the understanding of the impact of ATOD on individuals, families, and communities. Discussions are focused on recognizing how substance abuse can infiltrate customs and traditions and become the norm within various cultural and ethnic groups. Participants also examine the available resources in their communities. Problem Solving--The development of skills including listening and giving clear, concise directions between parents and youth are explored and
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tested out during this focus area. Sharing of emotions and feelings are encouraged to assist in jointly resolving problems between family members. Choices and consequences as well as empowerment efforts are also emphasized.
Basic Prevention Program (BPP) In the second stage of the program, families and youth become involved in the BPP, which lasts from 10 to 12 weeks. The BPP emphasizes applied prevention and intervention principles that are crucial to a familycentered approach. This component focuses on increasing social capital by exploring the areas of drug use attitudes and awareness, family bonding and communication, self-esteem and the community, personal and community efficacy, developing positive peer influences, responsible behavior in the community, and positive attitudes toward improved performance in school. The focus areas, which are integrated throughout the entire program, are highlighted below:
Alcoho~ Tobacco, and Other Drugs--This focus area attempts to teach coping skills that are essential to the avoidance of legal and illegal drugs. The format used is generally open discussion. Some objectives of this section are to provide education about ATOD issues and effects, change attitudes toward drug use and abuse, and to develop healthy attitudes toward self and others. Exercises to improve communication such as role playing, puppet shows, and excursions are a few examples of how objectives are met. Community and Respons/b///ty--Objectives of this section are to build social capital by increasing responsible behavior toward authority, laws, community and family rules and mores and by exploring attitudes towards gang involvement. Basic themes are reviewed including family strengths, school performance, peer influence, and cultural values. Various speakers discuss such topics as storytelling, rituals, generational issues, and Latino culture and community. Family members are assisted in becoming involved politically in their schools and community organizations. A review of available resources that could be helpful in increasing and promoting broad-based community involvement is conducted by all participants. Follow-Along Program (FAP)
Due to limited resources, the FAP is offered to only half of families who complete the FSP and BPP. FAP is an adjunct strategy that is designed
Hermmdez and Lucero
to reinforce what has been learned through the other two prevention program~ tO link participants with community resources, and to continue positive peer and adult influences. FAP utiliTes bi-weekly groups and regular contacts with Hispanic role model mentors and peer counselors that have suc.ce.s~lly completed other DAYS programs. Upon completion of each component of the La Fam!!!a program, graduation ceremonies, which involve the entire community, are conducted.
EVALUATION DESIGN
Overall Program Evaluation The comprehensive program evaluation includes both outcome components and assessment of progress simultaneously on an individual, familial, and program level and is one of the most important aspects of the program. Process Evaluation
To examine implementation of various aspects of the program and the delivery of services, several methods of process evaluation are employed. Monthly progress notes are recorded in each client's case management file to monitor client participation and progress. The Program Involvement Form records daily client attendance and the involvement of various family members in program activities. The Program Assessment Prof'de (PAP) which addresses issues of program delivery such as overall session ratings, completion of material covered, leader delivery, and usefulness of materials and topics is completed by clients and staff. The results of the PAP are reviewed weekly by the program evaluator and staff. Videotaping of programs is used for staff training and client feedback. Staff also participate in weekly meetings with evaluators. Outcome Evaluation Using a pre-test and post-test design, several measures are employed to measure the effect of various interventions on youth and family behavior. Youths and participating family members are asked to complete several assessments upon entry into the program; parallel forms of these assessments are re-administered at completion of the FSP, at 6-months, 12 months, and 18 months thereafter: (1) The Intake and Admission Form (IAF) includes a rating of risk areas, and staff's rating of client's self-help
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265
skills; (2) The Child Self-Assessment Profile (CSAP) (Wanberg, 1993) contains 17 sub-scales which examine the child's involvement in various activities, current problems in school and at home, and exposure, attitudes, expectations, and behaviors around drug use; (3) The Parent Assessment Profile (PAP) comprised of Child Aggression, Depression and Conduct Diso r d e r Scales (from the Achenbach Child Behavior Checklist, see McConaughy, Stanger, and Achenbach, 1992), and Family Cohesion, Conflict, Organization and Expression Scales (from the Family Environment Scale, Moos and Moos, 1982) is also used. The Child Follow-up Assessment Questionnaire (CFAQ) and the Parent Follow-up Assessment Questionnaire (PFAQ) are used as parallel follow-up measures to the CSAP and PAP.. The IAF is re-administered at each follow-up measurement.
RESULTS La Familia was initially funded in May 1992 and completed its first 2 year funding cycle in June, 1994. Overall, the project has exceeded goals and expectations and has been well received in the target communities. All staff, parent organizers, peer counselors, and mentors have received extensive training in utilizing the family-centered philosophy and the FSP curriculum. Through the second year of the program, La Familia received 240 individual child referrals, completed 224 intakes, and enrolled 219 youth and 61 families (some families had more than one child participating in the program while families of other children did not fully participate and were not counted in the data). Almost all the families served by the project were low-income, indigent (average monthly family income, $569), and faced extraordinary challenges to their participation in the program. However, by utilizing existing community networks, aggressive community outreach, and the incentive program, La Familia achieved a 92% retention rate and over 80% attendance per session for participating youth and families. Participation of fathers during the second year has also dramatically increased from only I father to nearly 24. The previous year, virtually no fathers of young children were involved. To address this issue, the project assigned a male prevention specialist and a parent organizer to aggressively recruit. This strategy proved highly successful. "l~ble 1 summarizes youth involvement across cohorts. The project has had a 97% completion rate of the initial evaluation forms. Completing 6-month, 12-month, and 18-month follow-up forms has proved to be a great challenge for program staff, primarily due to the nature of the issues facing this population. As one example, almost all the participants live in some form of public housing. In the North Lincoln com-
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germmdez and Lueere
Table 1. Youth Participation and Retention Rates Acrc~ Cohorts
All Cohort 1 Sept92
Cohort 2 MarchJune 93
Cohort 3 SeptDec. 93
Cohort 4 MarchJune 94
Cohorts Sept. 92June 94
Total number or referrals Completed intakes % of referrals
61 56 92%
59 59 100%
60 60 100%
60 49 82%
240 224 93%
Youth starting program % of referrals % of intakes
53 87% 95%
57 97% 97%
60 100% 100%
49 82% 100%
219 91% 98%
Youth % of % of % of
49 80% 88% 92%
50 85% 85% 88%
58 97% 97% 97%
45 75% 92% 92%
292 84% 90% 92%
completing program referrals intakes youth starting
Note: This table makes no distinction between BPP and SFP youth; nor does it include parent
participants.
munity, a major Denver housing project was closed with short notice and a large portion of the families who participated in the program were dispersed throughout the city. Most left no forwarding addresses. Nevertheless, initial and anecdotal data provide some important insights into addressing the needs of various impoverished Hispanic communities. "I~ble 2 provides a summary of drug use across 12 drug type categories for all youth clients admitted to La Familia. In general, there was low exposure to opportunities for ATOD use among the population, except for exposure to cigarettes (14.3%), beer (20.6%), and wine (11.9%). 8.8% reported using beer 1-10 times and 1.6% smoked 1-5 cigarettes a day. In the follow-up assessment, reports of opportunities for drug use and actual use were up consistently, approaching significance. However, staff and clients both attribute this change to the client's greater willingness to discuss drug use rather than actual increases, a hypothesis which is supported by current research (Rhodes, 1993). Figure 1 indicates drug exposure and use by age cohort at the end of the FSP. Even though, overall, drug use and exposure among all youth cohorts is low, results indicate a monotonic increase across age. Most noteworthy is that exposure and use was at peak for 9- and 10-year-olds, and significantly lower for l l-year-olds. Although various interpretations can be attached to this result, anecdotal evidence suggests that 9- and 10-yearolds are particularly vulnerable to ATOD use and exposure. The primary goal of the project over the next 5 months will be to complete follow-up measures and do a comprehensive analysis on data col-
194 194 194 194 193 194 194 201 201 201 201
Beer Wine Spirits Marijuana Cocaine Amphetamines Acid Glue Gasoline Paint White.Out
, .
85.7
%
154 171 177 181 188 192 193 197 198 198 197
N
79.4 88.1 91.2 93.3 97,4 99.0 99.5 98.0 98.5 98.5 98.9
%
Never Had Chance to Use
162
N
Never Had Chance to Use
12.7
%
23 21 14 13 5 2 1 3 1 1 4
N
11.9 10.8 7.2 6.7 2.6 1.0 _5 1_5 -5 .5 2.0
%
Had Chance But Did Not Use
25
N
17 2 3 0 0 0 0 1 2 2 0
N
3
N
Used 1-10 Tunes
8.8 L0 1.5 0.0 0.0 0.0 0.0 0.5 1.0 L0 0.0
%
1.6
%
Smoked 1-5 a Day
Categories of Use Had Chance But Did Not Use
Note: The median age was 7.2. The youth were equally divided by sex: 49% were male and 51% were female. *The number of respondents doesn't always add up to 201 as a result of raissing data.
190
na
Cigarettes
Name of Drug
i
II
0.0
%
0 0 0 0 0 0 0 0 0 0 0
N
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
%
Used More Than 10 Tunes
0
N
Smoked 6-10 a Day
Table 2, Summary of Drug Use Across Youth Admitted to the Denver Area Youth Services Prevention Programs (N = 201)
i
268
Hernandez and l.,ucero 0.51 /
0.48 1
ttl
0 "a ~ ., ~
0.39 t 0.36o.330.3. 0.~. 0.24. 0.21-
0.18. 0.15 0.12 0.060.03. 1'1 N-~
N-29
-zee (p
DAYS La Famflia Community Drug and Alcohol Prevention Program: Family-Centered Model for Working with Inner-City Hispanic Families Lawrence P. Hernandez, Ph.D., 1,3 and Ed Lucero, B.A. 2
Substance abuse among Hispanics is on the increase despite national efforts toward reducing it. Researchers and service providers have recognized the specific need for better prevention models that address the issues of poor Hispanics. La Familia is a community-based ATOD prevention program that targets Hispanic families with high-risk youth from 6 to 11 years old, and attempts to reduce identified risk factors while building on culturally relevant protective factors. During the 2 years, the program has enrolled 219 youth and their families utilizing existing community networks and aggressive outreactt The program resulted in a 92% retention rate and over 80% attendance per session. As a result of the program, families became more willing to discuss ATOD issues openly and made positive steps toward empowerment. KEY WORDS: prevention; Hispanics; protective factors; substance abuse; family-centered; high risk families.
INTRODUCTION The growth of alcohol, tobacco, and other drug (ATOD) addictions and related social problems among the rapidly increasing Hispanic population has seriously challenged service providers. Thus, the need for sound prevention and intervention models effective with this group has become imperative. IUniversity of Southern Colorado, Pueblo, Colorado. 3Regional Prevention Center, Denver Region, Denver, Colorado. Address correspondence to LawrenceP. Hernandez, Universityof Southern Colorado, 2200 Bonforte Boulevard, Pueblo, CO 81001. 255 O 1996 Human Sc~ao~s Prcs~ Inc.
256
Hernandcg and Lucr
The efforts of the Denver Area Youth Services (DAYS) model program, La Fami!'_,a Community Drug and Alcohol Prevention Program was designed with this challenge in mind. This family-centered prevention strategy targets the families of high-risk youth from 6 to 11 years, and attempts to reduce identified risk factors while simultaneously increasing culturally relevant protective factors. La Familia serves the North and West inner-city communities of Denver, Colorado, which are made up of predominantly Hispanic and low-income families. Families ill this area encounter serious barriers to effective participation in any type of prevention program as they are faced with a multitude of stressors. 75 percent of the households in these areas are headed by single women. These neighborhoods are confronted with a multiplicity of problems including high rates of ATOD abuse, massive under/unemployment, gang violence, teen pregnancy, high rates of HIV infection, homelessness, the highest school drop-out rates in the State, and a history marked by distrust of community agencies.
REVIEW O F THE LITERATURE Defining the Population When considering potential prevention strategies that may be effective with Hispanics, the importance of understanding the variations of subgroups within this population cannot be over-emphasized. Puerto Ricans and Cuban-Americans, for example, although considered to be Hispanic, do not necessarily share the same traditions and beliefs that Hondurans or Colombians hold, or necessarily even speak the same language. In fact, one of the most consistent findings in ATOD addiction research is that people's attitudes, beliefs, and behaviors with respect to their use of alcohol, tobacco, and other drugs differ across socio-economic status, ethnic subcultures, and generational groups (Greely, McCreedy, & Theisen, 1980; Heath, 1986). Thus, it is essential that service providers understand and appreciate that when working with Hispanics, or other ethnic populations, they must be cognizant of these differences in all efforts to develop culturally relevant programs. Deficit ]~adition Historically, traditional "deficit" model program~ for drug and alcohol prevention targeting inner-city Hispanics have been primarily focused on addressing variables that place them "at risk" for social problems. These
I.a Famllla
257
programs have ignored the role of culture and families' potential strengths, and as a result, have been ineffective. This deficit tradition assumes that Hispanic children bring to their environments a cultural capital which is impoverished and antithetical to healthy development (Hernandez, 1993). Embedded in this assumption is the idea that impoverished Hispanic parents use ineffective teaching strategies, do not care about their children's future, and generally do not foster their children's academic and social development (Hess & Shipman, 1965; McGowan & Johnson, 1984; for summary see Walker, 1987). In addition, deficit modeled programs are typically individually centered, overlooking the important contributions of Hispanic families and communities in socializing children and impacting their self-esteem and coping skills. Only recently, interventionists have begun to consider the enhancement of personal and environmental protective factors as the key to building resistance to social problems among high-risk families and children (Jessor, 1993). In fact, the enhancement of protective factors by rebuilding family social capital, drawing on cultural strengths, and re-creating supportive networks, may hold the greatest promise for constructing effective prevention and intervention strategies (Comer, 1991). Assessing Specific Risk Factors
One of the goals of La Familia is to target early risk factors such as family disruption and disunity, mental health problems, deviant behavior, negative peer influences, early use of drugs, and strong and favorable attitudes towards the use of alcohol and drugs that are highly predictive of later adolescent and adult ATOD problems. But rather than merely attempting to address risk factors, La Familia helps families to build on already existing individual, familial, and community resources that can protect them from the effects of specific risk factors. To effectively reduce these factors and others, a family-centered program must carefully assess whether the effect of so-called "risk" is equal for all particular individuals involved in a given program. We know from medicine, for example, that the heterozygote status for Sickle Cell Anemia places African Americans at substantial risk for morbidity. Yet, the same condition in the sub-tropic regions of Africa actually protects Africans from contracting life-threatening malaria. It is logical that a similar situation arises with psycho-social risk factors for ATOD abuse (Rutter, 1991). Thus, risk can be assessed at three specific levels of impact for each child and family: (1) Individual Risk, the most direct and specific level of risk (e.g., a child born with a hard-to-detect learning disability or addiction
2.58
Hemand~ and Lucern
to crack-cocaine); (2) Familial Risk, (e.g., a child being raised in a chaotic or alcoholic family) and (3) Community Risk, which descn'bes a community which has a high degree of social disruption in the surrounding area as manifested through such conditions as high levels of crime, abandoned and dilapidated housing, and youth violence. Family-centered program.~ should build in strategies to encourage each family to identify and reduce their own risk factors with specific strategies that tap into familial and o t h e r local resources (e.g. cultural values, extended families, and churches).
Assessing Specific Protective Factors
Protective factors have been shown to counteract the potentially harmful effects of powerful individual, familial, and community risk factors influencing ATOD problems. As Compas (1987) points out, the modest to moderate correlations typically found between individual stressful life events and various maladaptive problems and disorders of childhood and adolescence suggest that personal and environmental protective factors are important for healthy coping and moderating the effects of stress-producing risk factors. Eaton (1978) has also shown that the lack of appropriate "buffers" (particularly social support) while experiencing life stressors can result in increased psychological disturbance. Specifically, a protective factor is defined as a personal or environmental resource which mitigates the effect of stress from the environment and/or internal sources, and assists an individual in developing effective coping strategies for dealing with a particular context (Hernandez, 1993). Given this definition, no particular characteristics are always protective. However, researchers have summarized four basic processes by which protective factors operate: (1) those that reduce the risk or impact of the effects of stress by virtue of acting on the riskiness itself or through alteration of exposure to, or involvement in, the risk; (2) those that reduce the likelihood of negative chain reactions stemming from the risk encounter; (3) those that promote self-esteem and self-efficacy through the availability of secure and supportive personal relationships or successes in task accomplishment; and (4) those that open up opportunities of a positive kind (Rutter, 1991, 1987, 1985). Thus, programs utilizing a family-centered philosophy should emphasize complete assessment in identifying specific protective factors of children, parents, and communities that can be enhanced and capitalized upon for ATOD abuse prevention.
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Building Social Capital In La Familia, ATOD problems are viewed as a product of a dysfunctional system that includes the family and community in which the individual is immersed. In turn, one of the most important efforts of La Familia's family-centered philosophy of prevention is to help families build protective environments by jointly engaging multiple families and their children in the process of learning healthy lifestyles and the creation of social capital. Social capital is viewed as the most important component in the development of resilience and success of a particular child, family or community. It represents the time and energy that adults have to invest in each other, in children, and in community institutions--such as schools, congregations, community groups, worker associations, and so forth (Dickerson, 1991; Guydish & Sanstad, 1992; Lee, 1991; McGraw, 1992). Social capital fuels a learning process in which adults and children teach each other to take control of their lives and to think creatively about ways to help their families and neighborhoods. Building social capital involves teaching families to re-create positive family environments that stimulate them to discuss, debate, reshape, and test out new parenting skills, communication techniques, and coping strategies. La Familia staff work to create "mini-universities" in communities by working with groups of youth and families and providing them with the opportunity to become life-long learners and community partners in the success of all children. Most importantly, the process of developing social capital leads to new relationships among high-risk Hispanic families and youth and thus re-creates historically supportive social networks. Impoverished Hispanic communities have historically relied on the extended-family structure (as opposed to the nuclear family) and strong religions and community values tied to tradition as the main source of support and assistance with child rearing. These strong community networks among Hispanics encourage community members to view children as members of a larger community family. Such networks--coined as the "tortilla trail" by Mothers of East Los Angeles (MELA), a highly successful grass-roots organization to prevent violence and drug use--are based on reciprocal relationships among families. In MELA, mothers join forces to keep track of each other's children, educate themselves about drug, alcohol, violence, and gang prevention, teach and support each other in their children's development, model resilient behavior, effective coping and communication skills for neighborhood youth, and plan and develop intervention for broader community development. These new internal and external resources which families and communities develop serve as protective factors against the risk of ATOD abuse.
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Hernandez and Lucero
DESIGN
Defining Tasks of the Program La Familia was created around a set of eight key defining tasks for building youth, family, and community strengths:
1) Utilize existing community relationships, networks, and leadership for outreach and recruitment. 2) Let every child/family/community identify their own priorities and goals. 3) Help build trusting relationships between family members and other families by encouraging them to support and learn from one another. 4) Teach parents and other community members to be "prevention minded." 5) Help children, parents, families, and communities implement new skills and focus on "doable" and "wirmable" target behaviors. Help parents, children, and communities achieve "little victories" while striving toward long-term goals. 6) Teach parents and other community members to organize and build supportive relationships with groups and individuals that have the resources and willingness to help them achieve their goals. 7) "II'ain as many community-based prevention specialists, parent organizers, and peer counselors as possible in such skills as outreach and recruitment, evaluation and assessment of clients for various programs, in delivering prevention strategies, and in community resource development. 8) Encourage greater independent action of children and families early to avoid dependence on the program. Program Overview La Familia specifically incorporates into its services a strong element of respect and honor for the Hispanic culture. All program efforts are geared towards addressing specific needs of the locally identified Hispanic communities using specially developed and adapted curricula that maintains an emphasis on honoring cultural integrity. Each component of the program serves to enhance the other through a connected culturally relevant family-centered philosophy and strategies. These strategies build on positive cultural traditions, values, and beliefs. The three components to this program include the Family Strengths Pro-
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261
gram (FSP), the Basic Prevention Program (BPP) and the Follow-Along Program (FAP). Each is designed to meet the particular developmental needs of individuals and families through active participation of children, other family members, and staff. The program involves multi-family interventions (assessment, training, counseling, and family bonding activities) that take place where the participants live (in public housing developments that donated units to the project) or where the children attend school. All components are bilingual/bicultural. Project staff not only speak Spanish, but also grew up in similar inner-city Hispanic communities. The staff have also shown an ability to relate to families in the program and gain their trust and confidence. Each component of the program also encourages children and other family members to learn from one another and utilize new skills and knowledge on a daily basis. Participant youth and families are recruited through referrals from school staff and existing community networks. Families with children 6 to 11 years old are targeted. For each child involved in the program, at least one parent, and preferably the entire family including extended family members, are asked to participate in program activities. However, children who have been referred to the program are not restricted from the program even if a parent does not commit to fully participating, but the parent must give consent for each child's participation. All program activities are designed to address both the needs of youth who have participating families and for those who do not. However, ongoing efforts are made by staff to fully involve family members of every child in the program. Arrangements are made with the schools to provide incentives for improved performance of youth involved in the program. Youth are awarded $25 for successful completion of prevention programming, as are participating parents. Youth also have an opportunity to earn points for cash awards for successful school performance (e.g., good grades, good attendance, and homework completion). In addition, staff serve as advocates for families dealing with other systems such as Social Services, Housing Authority, etc. and collaborate with other agencies in the delivery of some services. All program activities are coordinated through the DAYS office. Family Strengths Program (FSP) The 14 week FSP addresses identified risk factors by focusing on improvement of: parenting skills; positive family environment; communication among family members; children's social skills; social support structures, and reducing children's intent to use alcohol and other drugs. As a central focus of this component, existing strengths of parents and children are iden-
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Hermmdez and Lucere
tiffed and built upon. Families are involved in two to three informal meetings or events (e.g. poflucks, open house, etc.) before participation in the actual program be~n~. The first few informal meetings are key to developing an atmosphere of mutual respect and trust. Participants are also involved in both single and multiple family sessions, cultural excursions, recreation sessions, groups with peers, and program planning sessions. FSP has five interwoven focus areas: Introduction and Group Bonding--These exercises target relationships between family members and bonding with other families and begin with a "conocimiento," or a process of getting to know each other on an individual and familial basis. The FSP then moves forward to explore issues of risk, self-esteem, and behavior. Other exercises used assist the youth participants in understanding themselves in the context of culture and family. Identifying what constitutes both positive and negative behavior also takes a strong focus; however, the motivation of this new understanding rests in the goal of re-focusing the negative behavior into a more positive one. "Cuentos," or storytelling, and cultural history are used to further promote family and community cultural identity. Eventually, participants explore and test out individual, familial, and cultural protective factors and culturally relevant ways to change negative behaviors.
Goals and Objectives--In this focus area, parents and youth are given the opportunity to share the expectations they have of each other as well as discuss various expectations of the school and home environment and how the two can merge to become mutually supportive. The importance of education, self-worth, and career opportunities are also stressed throughout this section. Communication--As part of this focus area, messages communicated between youth and parents are explored. The differences between 'T' and "You" messages and the ways in which families share thoughts and feelings of criticism and praise are also examined. Alcoho~ Drugs, and Families--This focus area emphasizes the understanding of the impact of ATOD on individuals, families, and communities. Discussions are focused on recognizing how substance abuse can infiltrate customs and traditions and become the norm within various cultural and ethnic groups. Participants also examine the available resources in their communities. Problem Solving--The development of skills including listening and giving clear, concise directions between parents and youth are explored and
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tested out during this focus area. Sharing of emotions and feelings are encouraged to assist in jointly resolving problems between family members. Choices and consequences as well as empowerment efforts are also emphasized.
Basic Prevention Program (BPP) In the second stage of the program, families and youth become involved in the BPP, which lasts from 10 to 12 weeks. The BPP emphasizes applied prevention and intervention principles that are crucial to a familycentered approach. This component focuses on increasing social capital by exploring the areas of drug use attitudes and awareness, family bonding and communication, self-esteem and the community, personal and community efficacy, developing positive peer influences, responsible behavior in the community, and positive attitudes toward improved performance in school. The focus areas, which are integrated throughout the entire program, are highlighted below:
Alcoho~ Tobacco, and Other Drugs--This focus area attempts to teach coping skills that are essential to the avoidance of legal and illegal drugs. The format used is generally open discussion. Some objectives of this section are to provide education about ATOD issues and effects, change attitudes toward drug use and abuse, and to develop healthy attitudes toward self and others. Exercises to improve communication such as role playing, puppet shows, and excursions are a few examples of how objectives are met. Community and Respons/b///ty--Objectives of this section are to build social capital by increasing responsible behavior toward authority, laws, community and family rules and mores and by exploring attitudes towards gang involvement. Basic themes are reviewed including family strengths, school performance, peer influence, and cultural values. Various speakers discuss such topics as storytelling, rituals, generational issues, and Latino culture and community. Family members are assisted in becoming involved politically in their schools and community organizations. A review of available resources that could be helpful in increasing and promoting broad-based community involvement is conducted by all participants. Follow-Along Program (FAP)
Due to limited resources, the FAP is offered to only half of families who complete the FSP and BPP. FAP is an adjunct strategy that is designed
Hermmdez and Lucero
to reinforce what has been learned through the other two prevention program~ tO link participants with community resources, and to continue positive peer and adult influences. FAP utiliTes bi-weekly groups and regular contacts with Hispanic role model mentors and peer counselors that have suc.ce.s~lly completed other DAYS programs. Upon completion of each component of the La Fam!!!a program, graduation ceremonies, which involve the entire community, are conducted.
EVALUATION DESIGN
Overall Program Evaluation The comprehensive program evaluation includes both outcome components and assessment of progress simultaneously on an individual, familial, and program level and is one of the most important aspects of the program. Process Evaluation
To examine implementation of various aspects of the program and the delivery of services, several methods of process evaluation are employed. Monthly progress notes are recorded in each client's case management file to monitor client participation and progress. The Program Involvement Form records daily client attendance and the involvement of various family members in program activities. The Program Assessment Prof'de (PAP) which addresses issues of program delivery such as overall session ratings, completion of material covered, leader delivery, and usefulness of materials and topics is completed by clients and staff. The results of the PAP are reviewed weekly by the program evaluator and staff. Videotaping of programs is used for staff training and client feedback. Staff also participate in weekly meetings with evaluators. Outcome Evaluation Using a pre-test and post-test design, several measures are employed to measure the effect of various interventions on youth and family behavior. Youths and participating family members are asked to complete several assessments upon entry into the program; parallel forms of these assessments are re-administered at completion of the FSP, at 6-months, 12 months, and 18 months thereafter: (1) The Intake and Admission Form (IAF) includes a rating of risk areas, and staff's rating of client's self-help
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skills; (2) The Child Self-Assessment Profile (CSAP) (Wanberg, 1993) contains 17 sub-scales which examine the child's involvement in various activities, current problems in school and at home, and exposure, attitudes, expectations, and behaviors around drug use; (3) The Parent Assessment Profile (PAP) comprised of Child Aggression, Depression and Conduct Diso r d e r Scales (from the Achenbach Child Behavior Checklist, see McConaughy, Stanger, and Achenbach, 1992), and Family Cohesion, Conflict, Organization and Expression Scales (from the Family Environment Scale, Moos and Moos, 1982) is also used. The Child Follow-up Assessment Questionnaire (CFAQ) and the Parent Follow-up Assessment Questionnaire (PFAQ) are used as parallel follow-up measures to the CSAP and PAP.. The IAF is re-administered at each follow-up measurement.
RESULTS La Familia was initially funded in May 1992 and completed its first 2 year funding cycle in June, 1994. Overall, the project has exceeded goals and expectations and has been well received in the target communities. All staff, parent organizers, peer counselors, and mentors have received extensive training in utilizing the family-centered philosophy and the FSP curriculum. Through the second year of the program, La Familia received 240 individual child referrals, completed 224 intakes, and enrolled 219 youth and 61 families (some families had more than one child participating in the program while families of other children did not fully participate and were not counted in the data). Almost all the families served by the project were low-income, indigent (average monthly family income, $569), and faced extraordinary challenges to their participation in the program. However, by utilizing existing community networks, aggressive community outreach, and the incentive program, La Familia achieved a 92% retention rate and over 80% attendance per session for participating youth and families. Participation of fathers during the second year has also dramatically increased from only I father to nearly 24. The previous year, virtually no fathers of young children were involved. To address this issue, the project assigned a male prevention specialist and a parent organizer to aggressively recruit. This strategy proved highly successful. "l~ble 1 summarizes youth involvement across cohorts. The project has had a 97% completion rate of the initial evaluation forms. Completing 6-month, 12-month, and 18-month follow-up forms has proved to be a great challenge for program staff, primarily due to the nature of the issues facing this population. As one example, almost all the participants live in some form of public housing. In the North Lincoln com-
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Table 1. Youth Participation and Retention Rates Acrc~ Cohorts
All Cohort 1 Sept92
Cohort 2 MarchJune 93
Cohort 3 SeptDec. 93
Cohort 4 MarchJune 94
Cohorts Sept. 92June 94
Total number or referrals Completed intakes % of referrals
61 56 92%
59 59 100%
60 60 100%
60 49 82%
240 224 93%
Youth starting program % of referrals % of intakes
53 87% 95%
57 97% 97%
60 100% 100%
49 82% 100%
219 91% 98%
Youth % of % of % of
49 80% 88% 92%
50 85% 85% 88%
58 97% 97% 97%
45 75% 92% 92%
292 84% 90% 92%
completing program referrals intakes youth starting
Note: This table makes no distinction between BPP and SFP youth; nor does it include parent
participants.
munity, a major Denver housing project was closed with short notice and a large portion of the families who participated in the program were dispersed throughout the city. Most left no forwarding addresses. Nevertheless, initial and anecdotal data provide some important insights into addressing the needs of various impoverished Hispanic communities. "I~ble 2 provides a summary of drug use across 12 drug type categories for all youth clients admitted to La Familia. In general, there was low exposure to opportunities for ATOD use among the population, except for exposure to cigarettes (14.3%), beer (20.6%), and wine (11.9%). 8.8% reported using beer 1-10 times and 1.6% smoked 1-5 cigarettes a day. In the follow-up assessment, reports of opportunities for drug use and actual use were up consistently, approaching significance. However, staff and clients both attribute this change to the client's greater willingness to discuss drug use rather than actual increases, a hypothesis which is supported by current research (Rhodes, 1993). Figure 1 indicates drug exposure and use by age cohort at the end of the FSP. Even though, overall, drug use and exposure among all youth cohorts is low, results indicate a monotonic increase across age. Most noteworthy is that exposure and use was at peak for 9- and 10-year-olds, and significantly lower for l l-year-olds. Although various interpretations can be attached to this result, anecdotal evidence suggests that 9- and 10-yearolds are particularly vulnerable to ATOD use and exposure. The primary goal of the project over the next 5 months will be to complete follow-up measures and do a comprehensive analysis on data col-
194 194 194 194 193 194 194 201 201 201 201
Beer Wine Spirits Marijuana Cocaine Amphetamines Acid Glue Gasoline Paint White.Out
, .
85.7
%
154 171 177 181 188 192 193 197 198 198 197
N
79.4 88.1 91.2 93.3 97,4 99.0 99.5 98.0 98.5 98.5 98.9
%
Never Had Chance to Use
162
N
Never Had Chance to Use
12.7
%
23 21 14 13 5 2 1 3 1 1 4
N
11.9 10.8 7.2 6.7 2.6 1.0 _5 1_5 -5 .5 2.0
%
Had Chance But Did Not Use
25
N
17 2 3 0 0 0 0 1 2 2 0
N
3
N
Used 1-10 Tunes
8.8 L0 1.5 0.0 0.0 0.0 0.0 0.5 1.0 L0 0.0
%
1.6
%
Smoked 1-5 a Day
Categories of Use Had Chance But Did Not Use
Note: The median age was 7.2. The youth were equally divided by sex: 49% were male and 51% were female. *The number of respondents doesn't always add up to 201 as a result of raissing data.
190
na
Cigarettes
Name of Drug
i
II
0.0
%
0 0 0 0 0 0 0 0 0 0 0
N
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
%
Used More Than 10 Tunes
0
N
Smoked 6-10 a Day
Table 2, Summary of Drug Use Across Youth Admitted to the Denver Area Youth Services Prevention Programs (N = 201)
i
268
Hernandez and l.,ucero 0.51 /
0.48 1
ttl
0 "a ~ ., ~
0.39 t 0.36o.330.3. 0.~. 0.24. 0.21-
0.18. 0.15 0.12 0.060.03. 1'1 N-~
N-29
-zee (p
