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© 2008 American Public Health Association
DOI: 10.2105/AJPH.2007.112524
RESEARCH AND PRACTICE |
Duane C. McBride and Curtis J. VanderWaal are with the Institute for Prevention of Addictions, Andrews University, Berrien Springs, Mich. Yvonne M. Terry-McElrath is with the Institute for Social Research, University of Michigan, Ann Arbor. At the time of the study, Jamie F. Chriqui was with the MayaTech Corporation, Silver Spring, Md. At the time of the study, Jana Myllyluoma was with the Battelle Corporation, Baltimore, Md.
Correspondence: Requests for reprints should be sent to Duane C. McBride, PhD, Institute for Prevention of Addictions, Andrews University, 10211 IPA Rd, Berrien Springs, MI 49104-0211 (e-mail: mcbride{at}andrews.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Objectives. We examined local public health agencies’ involvement in community illicit drug policy advocacy and provision related to youths to determine the extent to which public health agencies were involved in local drug policy activities and could potentially provide an infrastructure for policy alternatives.
Methods. We conducted telephone interviews from 1999 to 2003 with 1793 US public health agencies in 804 communities surrounding schools participating in the Monitoring the Future study. Respondents reported public health agency planning, priorities, and involvement in alternative drug policy advocacy and prevention activities. We examined results for variance by site sociodemographic characteristics.
Results. Most students lived where public health agencies provided resources for community- and school-based drug use prevention. More than one third resided where public health agencies advocated for drug policy alternatives and more than one quarter where public health agencies were involved in juvenile drug court programs. Such activities were significantly higher in urban communities, in the West, and in sites where the proportion of African Americans was above the national average.
Conclusions. Although local public health agencies could increase participation levels in drug policy alternatives, current involvement suggests that agencies may provide a base for supporting the development of public health alternatives to deterrence-based drug policies. Such a base may be more likely in communities with the highest need for such policies and services.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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US illicit drug policy varies significantly by state and substance.1 However, deterrence approaches predominate. Health researchers have called for a public health policy focus that uses prevention and treatment in lieu of incarceration.2–4 Whether a public health approach would better address US drug use than would deterrence is the subject of other articles. However, when considering policy approaches involving public health–related components, it would be helpful to know what role US public health agencies already play in drug policy and practice.
A 1988 Institute of Medicine (IOM) report seriously questioned the ability of state and local health agencies to address immediate crises and enduring public health problems, including substance abuse.5 The IOM found that public health system capabilities were inadequate and called for public health "to serve as leader and catalyst of private efforts as well as performing those health functions that only government can perform."5(p31) Twelve years later, in a 2000 editorial in the Journal, Des Jarlais6 called for a public health approach to drug policy, including prevention, treatment alternatives to incarceration, and programs to reduce health consequences of drug abuse. Des Jarlais concluded that a major challenge for public health would be to incorporate scientific drug use research into public policies to reduce harms associated with use.
Recent research has shown that state public health agencies are increasing participation in health policy formation and development7 and are helping to bridge gaps between adolescent drug treatment service need and provision.8 However, little is known about public health agency involvement in local-level alternative drug policy advocacy. Most drug arrests and policy applications occur at state and local levels.1,9 Furthermore, federal drug control spending recently has moved away from treatment and prevention and toward supply reduction. From 2001 to 2007, federal drug control spending for treatment and prevention steadily decreased from 47% of the total budget to 37%, whereas proportional spending on supply reduction increased from 53% to 63%.10 Thus, the understanding of local public health agency activity relative to drug policy and related local-level services would help provide greater knowledge of the ability to meet the public’s need for substance abuse services.
The ideal—but highly costly—method of investigating public health agency drug policy–related activity participation would involve conducting a random sample of all state and local public health agencies. We were positioned to survey public health agencies surrounding a nationally representative sample of middle and high schools. Substance use etiology indicates that drug use initiation occurs primarily during the middle and high school years; thus, it may be important to examine public health agency policies in communities surrounding such schools.11,12 secondary-school youths are affected by public health agency advocacy for alternative public health drug policies and prevention activities? (2) What percentage of youths are affected by actual public health agency involvement in such alternatives? (3) Is there evidence for site sociodemographic variance in reported advocacy and involvement?
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Sample and Data Collection
We collected data through the Robert Wood Johnson Foundation–supported ImpacTeen project.13,14 On the basis of existing illicit drug policy dimensions,15 analyses focused on harm reduction and public health approaches involving prevention, incarceration alternatives, and risk reduction approaches such as needle exchange.
Site selection. ImpacTeen’s sampling frame was based on the Monitoring the Future (MTF) study (supported by the National Institute on Drug Abuse), which conducts nationally representative, yearly cross-sectional surveys of 8th-, 10th-, and 12th-grade students in the continental United States.11,16 From 1999 to 2003, ImpacTeen conducted interviews with public health agencies in sites surrounding schools in their second year of MTF study participation. ImpacTeen used MTF schools so that the proportion of US youths in jurisdictions of public health agencies involved in drug policy advocacy and related activities could be investigated. Site boundaries were defined as the area from which each MTF school drew at least 80% of its student population.8 A total of 966 sites were identified.
Respondent identification and selection. A list of public health agencies with jurisdiction over part or all of each site was developed through Internet and directory searches. Public health agency–related duties can be distributed differently between jurisdictional offices; municipal offices may not be involved in all or some drug-related activities if county or regional offices provide such services. Thus, if relevant, we contacted multiple agencies per site. Trained interviewers made screening calls to identify respondents knowledgeable about the agency’s drug-related activities. Each respondent was asked if his or her agency had jurisdiction over part or all of the site(s) involved and if he or she was knowledgeable about youth substance-related issues in his or her jurisdiction. If a jurisdiction was not appropriate or the respondent indicated that he or she would not be the best informant, then he or she was asked to provide contact information for an appropriate alternative agency or respondent.
Interviews. Computer-assisted telephone interviews were attempted with respondents from all agencies with jurisdiction over some or all of the sites surrounding each MTF school. A total of 1966 interviews were completed in 804 of the 963 possible MTF sites (representing 83.5% site coverage; missing sites were because of nonresponse). In 8.5% of the sites, interviews were completed with multiple respondents for the same site–community–agency combination. For these cases, we selected the final respondent by (1) sorting by degree of knowledge about drug-related items (respondents reporting a substantially higher number of "don’t knows" were removed) and then (2) randomly selecting the final respondent. A total of 1793 interviews were available for final analyses in 804 sites, with an average of 1.3 agencies per community within each site (range = 1–4). Jurisdictions of the included agencies were 61% county; 17% region; 11% city, town, or township; and 11% state.
Respondent weights. Because most sites had more than 1 relevant public health agency, we took steps to identify public health agency jurisdictional boundaries and the proportion of surveyed youths in each specified jurisdiction. MTF personnel assisted in specifying the distribution of surveyed youths per site, which was then used to (1) develop community-specific weights within sites and (2) match with agency-specific jurisdictional boundaries.
To examine the percentage of US youths potentially affected by public health agency involvement in drug policy advocacy and programmatic involvement, we conducted analyses at the site level.
Dependent Measures
We collected 17 dependent measures based on the issues raised by the IOM and Des Jarlais. Measures varied over the 5 years of interviews and focused on 3 categories: (1) alternative drug policy involvement (10 measures); (2) assessment, planning, and priorities (3 measures); and (3) prevention and education (4 measures). All measures were either originally yes-or-no dichotomous measures or recoded into dichotomous measures. Table 1
provides a listing of all outcomes.
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Outcomes were aggregated to the site level as yes-or-no dichotomies indicating whether at least 50% of the students surveyed in the relevant MTF school were in the jurisdiction of at least 1 public health agency participating in the specified drug policy–related activity. Sites with at least 50% of the students in the jurisdiction of a participating public health agency were coded as "1" for each outcome, and sites with fewer than 50% were coded as "0."
Independent Measures
We obtained age, race, and income variables from the 2000 US Census by zip code. Statistical findings were not affected by use of dichotomous versus continuous forms of the measures; however, model stability was enhanced with dichotomous measures. Thus, the following variables were retained:
- Age: older than national average population aged 12 to 17 years (> 8.6%)
- Race: greater than national average (based on the US census; hereafter referred to as "above average") percentage of African Americans (>12.8%) and above-average percentage of Whites (>82.2%)
- Ethnicity: above-average percentage of Hispanics (> 11.9%)
- Income: higher than national average site median household income (> $40 816)
Variables also included degree of urbanization (obtained from the National Center for Education Statistics) and US census region. In analyses, the South was used as the referent category because of its larger geographic size as well as research showing higher penalty severity in this region for many adult substance-related offenses (possibly indicating an orientation toward traditional prohibition or deterrence policy).1
Analyses
After we removed the sites with missing data on control or weighting variables, 801 sites remained for analyses. When we compared the retained sites with the 159 excluded sites (3 sites could not be included because of missing control data), we did not see any significant differences for region, community population, age, or race. Analyses did show a slightly lower-than-average percentage of Hispanics in the population of included sites (b = –0.045; P < .05). We conducted multivariate logistic regression analyses with SAS version 9.12 (SAS Institute Inc, Cary, NC) and included weights to account for MTF school-selection sampling procedures. Weighted outcomes indicated the percentage of US middle and high school students served by public health agencies with involvement in specified drug policy alternatives and related practices. We ran separate multivariate models for the site-level racial variables of above-average proportions of Whites and above-average proportions of African Americans. All models simultaneously controlled for region and year, as well as site-level ethnicity, income, urbanicity, and population aged 12 to 17 years.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Sites were located in 47 states and the District of Columbia. Most of the youths were represented in urban or suburban rather than town or rural areas (65% vs 35%, respectively), with expected regional variation (20% West, 27% Midwest, 36% South, and 17% Northeast). Regarding race/ethnicity, 54% of the students represented were in sites with above-average proportions of Whites, 28% were in sites with above-average proportions of African Americans, and 24% were in sites with above-average proportions of Hispanics. Given the student-based sample, it is not surprising that 61% of the students represented were in sites with above-average proportions of those aged 12 to 17 years. Approximately half (55%) of the students were represented by sites with above-average median household income.
Table 1
presents the weighted dependent variable distributions by category of agency involvement in illicit drug use policy and practice. More than one third of the youths were served by public health agencies advocating for alternatives to incarceration for youth drug offenders. In addition, more than one quarter of the youths lived in sites served by public health agencies providing some type of direct service for adult or juvenile drug courts (assessment, referral, treatment, or monitoring). Although 24% of the youths resided where public health agencies reported advocating for needle-exchange programming, only 11% lived in jurisdictions where public health agencies provided needle exchange, and only 7% lived where public health agencies reported that such services were available for youths. Virtually no public health agencies reported involvement in medical marijuana programs.
A primary public health role is assessing, prioritizing, and planning for community health needs. The data show that 34% of the youths resided where public health agency assessment plans included youth drug abuse prevention; 23% of the youths lived in sites where the assessment plan included youth drug abuse treatment. Notably, more than one quarter of the youths resided in sites where public health agencies defined their activities focusing on illicit drugs as somewhat or much more important than other public health activities.
Finally, Table 1 shows that a majority of the youths lived in sites where public health agencies provided resources in funds or personnel for community and school drug use prevention. In addition, more than one third of the students lived in areas where local public health agencies participated in school health clinics that included drug use prevention education. More than one quarter of the youths resided in the jurisdictions of public health agencies that sponsored youth-led antidrug organizations.
Because data collection occurred over a period of 5 years (during which changes occurred in local, state, and federal governmental administrations), all outcomes were examined for evidence of time trends. No significant trends were found, indicating that at least during the period studied, levels of public health agency involvement in illicit drug use policy and practice remained relatively stable.
Table 2 presents site-level racial distribution differences in the percentage of youths served by public health agencies involved with drug policy–related issues. Generally, youths who lived in sites with above-average proportions of Whites were significantly less likely than youths living in sites that did not have above-average proportions of Whites to be served by public health agencies that (1) advocated for treatment alternatives to incarceration for youth drug law violations, (2) had any involvement in adult drug courts, (3) promoted juvenile drug court programs, or (4) were involved with needle exchange. Conversely, youths who lived in sites with above-average proportions of African Americans were significantly more likely than youths living in sites that did not have above-average proportions of African Americans to be served by public health agencies involved in alternative drug policies and practices, including (1) advocating for treatment alternatives to incarceration for youths, (2) having any involvement in adult drug courts, (3) promoting juvenile drug court programs, and (4) providing or supporting needle-exchange programs. A similar pattern was observed for having a community diagnosis plan that included youth drug use prevention. Again, the odds of youths residing in the jurisdiction of a public health agency reporting this activity were significantly lower in sites with above-average proportions of Whites and significantly higher in sites with above-average proportions of African Americans compared with other sites. For prevention and education variables, public health agency participation in school health clinics was significantly higher for MTF youths in sites with above-average proportions of African Americans.
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Although ethnicity was included as an independent variable in all models (defined as sites with above-average proportions of Hispanics), only 4 outcomes showed significance for this predictor (data not shown). In models that controlled for above-average proportions of Whites, youths who lived in sites with above-average proportions of Hispanics were significantly less likely than youths who lived in sites with below-average proportions of His-panics to be served by public health agencies (1) advocating for treatment alternatives to incarceration (odd ratio [OR]=0.30; 95% confidence interval [CI]=0.10, 0.93; P<.05); (2) promoting juvenile drug court programs (OR=0.45; 95% CI=0.22, 0.92; P<.05); or (3) participating in school health clinic prevention education for youth drug use (OR=0.31; 95% CI=0.10, 0.93; P<.05). In models with both above-average proportions of Whites and above-average proportions of African Americans, youths in sites with above-average proportions of Hispanics were less likely than youths who lived in sites with below-average proportions of Hispanics to be served by public health agencies reporting needle-exchange programming availability for youths (OR=0.27; 95% CI=0.10, 0.72; P<.01).
Table 3 shows relations with income, urbanicity, and age. Few significant differences were observed. The data indicate that youths in sites with above-average median household income were more likely than youths who did not live in sites with above-average median income to be served by public health agencies involved in or promoting juvenile drug court programs but less likely to be served by agencies citing illicit drug activities as more important than other agency activities. Youths living in urban areas were significantly more likely than youths not living in urban areas to have local public health agencies advocating for, providing, or promoting needle-exchange programs. Youths living in sites with an above-average proportion of 12- to 17-year-olds were significantly more likely than youths who did not live in sites with above-average proportion of 12- to 17-year-olds to be served by public health agencies that provided resources for community illicit drug use prevention activities.
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Table 4
examines regional differences. Youths in the West were significantly more likely than those in the South to reside where public health agencies advocated for and provided drug policy alternatives. In fact, only 1 of the policy variables examined—any involvement in juvenile drug court programs—was not significantly more likely for youths in the West than in the South. Three of the policy variables were also more likely for Midwestern and Northeastern than for Southern students: any involvement in and promotion of adult drug court programs and promotion of juvenile drug court programs. Furthermore, public health agency advocacy for and promotion of needle exchange was significantly more likely for Northeastern than for Southern youths. Youths residing in the West and Northeast were significantly more likely than those in the South to live where the local public health agency defined their illicit drug activities as more important than their other responsibilities. Non-Southern youths were significantly more likely than their Southern counterparts to have local public health agencies that sponsored youth-led antidrug organizations. Interestingly, youths in the West were less likely than were youths in the South to be in the jurisdiction of public health agencies providing resources to schools for illicit drug use prevention activities.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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As calls for a public health–based drug policy increase in US society, it is important to examine the interest, importance, roles, and capacity of currently existing local public health agency systems to participate in such efforts. Our study was subject to limitations. Data were not obtained from a random selection of public health agencies in the United States and represent self-reported agency involvement versus actual observed public health agency activity. Because the data were collected via telephone surveys asking participants to report recent agency practices, results were subject to recall bias. Furthermore, outcomes were modified over the data collection period; results may not be generalizable beyond the period studied. Public health agencies exist within political, social, and budgetary environments that may affect agency priorities at any given time. Furthermore, no attempt has been made to link levels of drug-related service need and reported public health agency activities. However, this study provided an opportunity to interview a national sample of public health agency representatives to better understand overall agency involvement in drug policy–related issues and the potential effect of such efforts on policy alternative development.
Public Health Involvement in Drug Policy, Planning, and Prevention
Prevention is and has been a core public health role.17 True to this history, most US youths lived where public health agencies provided resources for school and community drug abuse prevention. Furthermore, approximately one third of the youths were in the jurisdiction of public health agencies directly involved in school drug prevention education activities or community diagnosis plans including youth illicit drug use prevention. These findings suggest that drug use prevention is seen as a fundamental task for public health agencies. Recent research literature suggests that although considerable progress has been made in defining effective prevention program standards,18 recent years have seen significant declines in states’ abilities to provide technical assistance to schools to implement such programs.19 The current data indicate that most local public health agencies are already prevention partners in communities and schools and may be able to play an important role in this increasingly resource-limited era. Although most of the youths lived in communities where public health agencies were involved in traditional services such as drug abuse prevention, the proportion of youths declined to about 29% when public health agencies were involved in providing alternative drug policies.
Drug treatment as an alternative to incarceration is one of the most widely accepted tenets of a harm reduction and public health approach to drug law violations. Research suggests that even prosecutors generally prefer treatment diversion to incarceration for youth marijuana violations.20 In our study, about 35% of the youths were served by public health agencies involved in alternative advocacy. This was higher than actual program participation or provision. Actual participation in treatment-based alternatives requires the existence of such programs, so perhaps it is not surprising that advocacy was more prevalent than participation.
Local public health agencies have many responsibilities competing for limited resources.21 More than one quarter of the youths in the MTF survey lived where public health agencies saw their work in drug abuse prevention, policy, or service provision as more important than their work in other areas. Even though the data did indicate significant regional effects, perhaps a local support base could be used to build a more comprehensive national public health approach to drug abuse policy.
Differences by Community Sociodemographic Characteristics and Region
Race/ethnicity has long been an important variable in public health policy and practice.22 A recent report showed that more than 70% of state health agencies considered minority health one of their areas of responsibilities.7 Our analyses consistently indicated significantly different odds of youths being served by public health agencies involved in drug policy alternatives by site racial composition. Youths who lived in sites that had above-average proportions of African Americans were generally more than twice as likely as those who lived in sites that had above-average proportions of Whites to be served by public health agencies advocating for and involved in treatment alternatives to incarceration as well as other alternative policy and practice activities. The criminalization of drug use has had a disproportional effect on the African American community, resulting in significant disparities in drug-related incarceration rates.23,24 Our findings suggest that local public health agencies may be able to provide a key role in moving toward drug treatment alternatives for African American communities.
Our findings also suggest that public health agencies may respond to fiscal realities and local community needs in decisions to participate in illicit drug policy issues. Increased site-level median household income was significantly associated with increased involvement in juvenile drug court programs. This may reflect budget realities; juvenile drug courts may be less prevalent in communities with fewer available resources. However, youths in wealthier sites were less likely to be served by public health agencies placing high importance on illicit drug activities than were youths in poorer sites. Whether this stems from lower population drug use rates or from other factors is unknown.
Our findings on urbanicity provided additional evidence suggesting that public health agencies are more likely to be active in advocating for and implementing a public health approach to drug use in higher-risk communities. Although national differences between rural and urban drug use tend to be relatively small,11 research does indicate that urban areas are more likely to have higher rates of injection drug use.11,25 The data presented show that compared with youths living in rural areas, urban youths were more than twice as likely to be served by public health agencies advocating for or involved in needle exchange.
The major regional differences observed in the data may reflect a general innovative trend for the West relative to drug policy.20 The West might provide an important base for increasing local public health agency involvement in drug policy and related services. Conversely, results showed that Southern public health agencies appeared to have the lowest likelihood of alternative drug policy involvement, possibly indicating either significant differences in public health agency roles or limited cultural support of alternative approaches to illicit drug use prevention.
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Conclusions |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONConclusionsReferences |
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Local public health agencies appear to participate strongly in illicit drug use prevention efforts; results indicated that policy advocacy and alternative service provision participation were also noteworthy. Although the overall rate of involvement in any form of public health alternatives to drug policy was only about one third, the odds for advocacy and involvement increased significantly where the need for such involvement may be the greatest. This included urban areas and communities with higher proportions of African American people.26 The data also suggested that Western public health agencies led in local public health agency drug policy alternative involvement. Clearly, there is significant room for increasing local public health agency involvement in policy alternatives. However, the data suggested that local public health agencies may provide a base for building collaborative prevention programs and drug policy reform beginning at the local level.
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Acknowledgments |
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This article was supported by a grant from the Robert Wood Johnson Foundation to the University of Illinois at Chicago (grant 33009) as part of the foundation’s ImpacTeen Initiative.
Note. The views expressed in this article are those of the authors and do not necessarily reflect the views of the Robert Wood Johnson Foundation.
Human Participant Protection
The University of Illinois at Chicago’s Office for the Protection of Research Subjects institutional review board approved the human subject review protocols.
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Footnotes |
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Peer Reviewed
Contributors
D. C. McBride assisted with all stages of the study and led the writing of the article. Y. M. Terry-McElrath led and synthesized statistical analysis, assisted with survey instrument development, and contributed significantly to the writing of the article. C. J. VanderWaal assisted with survey instrument development. J. F. Chriqui assisted in interpretation of the data. J. Myllyluoma directed data collection efforts. All authors helped to interpret findings and review drafts of the article.
Accepted for publication June 30, 2007.
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References |
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1. Illicit Drug Team. Illicit Drug Policies: Selected Laws From the 50 States. Berrien Springs, Mich: Andrews University; 2002. Available at: http://www.impacteen.org/generalarea_PDFs/IDTchartbook032103.pdf. Accessed June 7, 2007.
2. Caulkins JP, Rydell CP, Scwabe WI, Chisea J. Mandatory Minimum Drug Sentences: Throwing Away the Key or the Taxpayers’ Money? RAND Research Brief MR-827-DPRC. Santa Monica, Calif: RAND; 1997. Available at: http://www.rand.org/pubs/monograph_reports/MR827/. Accessed July 1, 2007.
3. McBride DC, VanderWaal CJ, Terry-McElrath YM. The drugs-crime wars: past, present, and future directions in theory, policy, and program interventions. In: Hart SV, ed. Toward a Drugs and Crime Research Agenda for the 21st Century. Washington, DC: National Institute of Justice; 2003:97–161. Available at: http://www.ncjrs.gov/pdffiles1/nij/194616.pdf. Accessed December 15, 2006.
4. Rydell CP, Everingham SS. Controlling Cocaine: Supply Versus Demand Programs. Santa Monica, Calif: RAND; 1994. RAND Monograph/Report MR-331-ONDCP/A/DPRC. Available at: http://www.rand.org/pubs/monograph_reports/MR331/. Accessed July 1, 2007.
5. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.
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12. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Survey Results on Drug Use, 1975–2003: Volume II, College Students and Adults Ages 19–45. Bethesda, Md: National Institute on Drug Abuse, National Institutes of Health; 2006. NIH Publication 06-5884. Available at: http://www.monitoringthefuture.org/pubs/monographs/vol2_2005.pdf. Accessed December 15, 2006.
13. McBride DC, Pacula RL, Chaloupka FJ, VanderWaal CJ, Chriqui JF, Terry-McElrath YM. ImpacTeen: contributing to drug policy development. Connection. 2003; June:4,7. Available at: http://www.academyhealth.org/publications/connection/jun03.pdf. Accessed October 18, 2007.
14. ImpacTeen. ImpacTeen: A Policy Research Partnership for Healthier Youth Behavior Web site. Available at: http://www.impacteen.org. Accessed June 11, 2007.
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