QUALITATIVE EPIDEMIOLOGIC METHODS
Qualitative Epidemiologic Methods Can Improve Local Prevention Programming among Adolescents Raminta Daniulaityte, Harvey A. Siegal, Robert G. Carlson, and Deric R. Kenne Wright State University School of Medicine
Sanford Starr, and Brad DeCamp Ohio Department of Alcohol and Drug Addiction Services
Abstract The Ohio Substance Abuse MonitoringNetwork (OSAM) is designed to provide accurate, timely, qualitatively-oriented epidemiologic descriptions of substance abuse trends and emerg,ngproblems in the state's major urban and rural areas. Use of qualitative methods in identifying and assessing substance abuse practices in local communities is one of the main assets of OSAM Network. Qualitative methods are sensitive to local contextual variability, flexible enough to capture emergent trends, and can be implemented with limitedfinancial resources. This paper describes how qualitative epidemiolo^c methods, like those used by the OSAM Network, could be applied to inform substance abuse prevention activities, particularly those directed at adolescents.
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Introduction
S
ubstance abuse is a highly dynamic phenomenon. Across the United States and within local communities, "the popularity of any one drug waxes and wanes, a drug's availability fluctuates, the forms and modes of ingesdon of drugs change, new drugs are introduced, and people vary in their willingness to try and continue using various types of drugs" (Ouellet, Wiebel, & Jiminez, 1995, 182). Substance abuse is also a highly local phenomenon that is shaped by socio-economic, cultural, and law enforcement practices. For example, research has found significant differences exist in teen drug use practices among different school districts in the Dayton, Ohio, area. Lifetime marijuana use among ninth graders {n — 3,016) varied from 22% to 36% among school districts, and Ufetime inhalant use varied from 11% to 20% (Falck, Wang, Carlson, & Siegal, 2002). This locally-situated nature of substance use and abuse patterns has been long overlooked by prevention programming that has relied heavily on nationally standardized programs focusing on education and intervention strategies informed by generalized, theoretically driven models. One of the chief lessons of prevention research is the need for a comprehensive approach, one that not only targets the specific educational needs of individuals but also addresses meaningful risk and protective factors operating at the family, community, and public policy levels (NIDA, 1999). This kind of comprehensive approach places a much greater emphasis on the importance of locally specific knowledge of substance abuse trends and issues. The dynamic and locally situated nature of substance abuse phenomena has important implications for treatment and prevention planning. It requires a real-time approach to needs assessment that is flexible enough to capture emerging substance abuse trends while being sensitive to local contextual variability. The Ohio Substance Abuse Monitoring (OSAM) Network, a statewide substance
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abuse surveillance system, was designed to meet these real-time data needs and provide public health officials, especially in the substance abuse treatment area, and policy makers with the data they need to plan and carry out strategies to address existing and emerging substance abuse problems. The purpose of this brief article is to suggest how qualitative epidemiologic methods like those used by the OSAM Network could be applied to inform substance abuse prevention activities, particularly those directed at adolescents. The OSAM Network Supported by the Ohio Department of Alcohol and Drug Addiction Services (ODADAS), the OSAM Network is designed to provide accurate, timely, qualitatively-oriented epidemiologic descriptions of substance abuse trends and emerging problems in Ohio's major urban and rural areas (for a more detailed description of the OSAM Network see Siegal, Carlson, Kenne, Starr, & Stephens, 2000). The OSAM Network is modeled after the Community Epidemiology Work Group, a national substance abuse surveillance system established by the National Institute on Drug Abuse in 1976 (NIDA, 1998a). The OSAM Network consists of eight regional epidemiologists located in major urban areas and several rural areas throughout the state who conduct focus-groups and individual qualitative interviews with active and recovering drug abusers, treatment providers, and law enforcement officials to produce epidemiologic descriptions of local substance use and abuse trends every six months. Participants' statements are evaluated for their accuracy paying specific attention to each individual's knowledge and experience with various drugs. Methodological triangulation is used to enhance the credibility of qualitative findings and increase validity of identified trends in drug use and abuse (Patton, 1999). For example, qualitative findings are supplemented with statistical data on things such as medical examiner reports, drug abuse treatment admissions, rates of drug use and abuse among arrestees and probationers, and regional crime laboratory data. The mass media sources, including local newspaper and
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TV reports, are also monitored for indications about patterns of drug use and abuse. Regional epidemiologists meet twice yearly to share their findings, and then prepare written reports that are available on the Internet (http://www.odadas.state.oh.us).* The OSAM Network also conducts Rapid Response studies that can address specific emerging substance abuse issues or policy concerns. For example, since 2001, the OSAM Network began reporting significant increases in prescription opioid abuse in several areas around the state. In January 2003, regional epidemiologists began conducting qualitative interviews with individuals who abused prescription opioids. This Rapid Response initiative examined patterns of opioid abuse, initiation practices, perceived health risks, and perceived need for treatment. Regional epidemiologists interviewed 43 individuals, between ages 19 and 51, with a recent history of prescription opioid abuse. All of the participants believed that the fastest growing population of users consisted of white individuals in their later teens and early 20s. The interviews revealed that the majority of younger participants used prescription opioids in combination with alcohol and marijuana to enhance intoxicating effects. Typically, they considered that this type of occasional use has low risks and insignificant health effects. This Rapid Response study provided the Ohio single state agency with data about prescription opioid abuse that could be used to inform prevention programming.
Qualitative Methodologies The use of qualitative methodologies is one of the main assets of the OSAM Network's applied research capability. The value of qualitative methods in substance abuse research and public health in general has been widely accepted, although qualitative methodologies continue to be underutili2ed in applied research. Much of the knowledge about drug use and abuse trends has traditionally been derived from large-scale quantitative studies such as National Household Survey on *To date, the OSAM Network has focused on monitoring substance abuse trends among adult populations.
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Drug Abuse (NHSDA) (NIDA, 1998b), or Monitoring the Future Project 0ohnston, O'Malley, & Bachman, 1991). These and other epidemiological data sets provide valuable information on drug use and abuse prevalence and incidence. However, qualitative methods can add new insights into drug-using behavior and provide local knowledge that is not accessible to survey methodologies in a relatively short period of time and at a comparatively lower cost. Qualitative methodologies can reveal insider perspectives, knowledge and norms about substance abuse behaviors. For example, since June 2001, the OSAM Network began receiving reports that MDMA/ Ecstasy abuse was increasing in popularity among ethnic minorities (Ohio Substance Abuse Monitoring Network, 2001, June). Further interviews with young club drug users in the Dayton area suggested that Ecstasy use outside its traditional venues may have different meaning and purpose. "Typical" Ecstasy users continue to be suburban youth and young advilts who get initiated to the drug at ravetype parties and dance clubs. Usually, they take Ecstasy to "have fun," and experience a feeling of connectedness with other partygoers. Among inner-city youth, on the other hand. Ecstasy is often referred to as a "sex drug" and is sometimes used to enhance sexual experiences (Ohio Substance Abuse Monitoring Network, 2003, June). These different meanings of Ecstasy use could not have been as readily captured by conventional survey research, but they may signify different use patterns and have implications for prevention programming among different populations. Certainly, prevention messages can be quickly tailored with such findings available. Qualitative methodologies are also particularly useful in detecting emergent drug-use patterns and relationships before they become apparent to treatment providers or are identified using survey approaches. For example, since January 2003, the OSTVM Network began receiving consistent reports about significant increases in the abuse of powdered cocaine. One of the fastest growing user groups was described as high school age youth. Focus groups with active club drug users suggested that this growing popularity of powdered cocaine was fueled by increasing availability, lower prices and grow-
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ing social acceptability of the drug (Ohio Substance Abuse Monitoring Network, 2003, January). However, these increases have not yet been reported by the latest school survey results. For example, according to the Dayton Area Drug Survey conducted in 2002, about 8% of the area's 12th graders (« = 2,406) reported having used powdered cocaine at least once in their lifetime, which is a slight decrease compared to 8.5% in 2000 (« = 2,012) and 9.5% in 1998 (« = 1,934) (Wright State University, School of Medicine, 2002). In addition, adolescent treatment providers began reporting some increases in powdered cocaine abuse almost one year after initial reports from the focus groups with active and recovering abusers. Finally, compared to survey approaches, qualitative methods can be implemented with limited resources and can provide findings in a relatively short period of time. This is an important asset for the policy makers and prevention specialists who are often limited by diminishing financial resources and time constraints.
Needs Assessment and Prevention Programming More than two decades of substance abuse prevention research indicate that for prevention programs to be effective, they have to be based on an objective assessment of substance abuse patterns in local communities (NIDA, 1999). In 1998, the new guidelines referred to as "Principles of Effectiveness" became established for the Safe and Drug-Free Schools and Communities Act (SDFSCA) Program, which is the nation's largest school-based program for promoting school safety and preventing substance abuse among youth. These new guidelines require prevention programs to be based on a thorough assessment of objective data about drug abuse and violence in the schools and communities served. In 1998, the U.S. Department of Education initiated a study designed to evaluate how local school districts nationwide plan, implement and evaluate SDFSCA and other prevention programs (Hantman & Crosse, 2000). The majority of the school districts used incident reports or conducted small schoolbased surveys about alcohol, tobacco, and illicit drug abuse among students to assess substance abuse problems and prevention needs.
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Even though the survey results indicated that the majority of the school districts had moved in the direction of meeting the reqvdrements of needs assessment, it was nevertheless suggested that the quality of the needs assessment data might require improvement (Hantman & Crosse, 2000). Given the dynamic and locally situated nature of substance use and abuse practices and a growing recognition of qualitative methods in the field of substance abuse research, we would offer that school and community-based prevention programming could benefit from methods like those used by the OSAM Network to develop epidemiologic drug use and abuse trend reports. Such readily implemented community research would help strengthen community planning and response capabilities. OSAM Network's Technical Assistance to the Local Prevention Programs The OSAM Network has developed a training and technical assistance capacity to provide others with the qualitative methods needed to conduct similar assessments. Such methods could be readily adopted by local communities, thereby providing planners with timely assessments focusing on substance abuse and violence among adolescents. In the fall of 2002, the OSAM Network's core scientific unit initiated a series of training sessions for the local vVlcohol, Drug, and Mental Health boards and other policy makers throughout the state. The aim of these training sessions was to share OSAM Network's experience and educate local policy makers about the value, efficiency and applicability of qualitatively based research in addressing local substance abuse treatment and prevention problems. These training sessions were designed to provide policy makers with concrete conceptual and methodological tools to carry out their own needs assessment projects. The OSAM Network's training and technical assistance capability could be further extended to local school and community-based
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prevention program. Qualitative methodologies could provide a credible, cost-effective means to collect information about substance abuse trends among adolescents, meanings and norms in the local community, and new populations of users. Such efforts could contribute to more consistent collaboration between research and practice initiatives and would make a contribution to the development of research-based prevention at the local level. Applying Qualitative Methods to Improve Substance Abuse Prevention Progranuning Among Adolescents: A Community Agenda As previously indicated, needs assessment projects for prevention programming have traditionally relied on quantitative survey-type methodologies. On the basis of our experience using qualitative methods to monitor substance abuse trends through the OSAM Network, we propose that in addition to traditional quantitative approaches, qualitative methods could be used to improve prevention programming, particularly among adolescents. Here we outline what such an initiative might look like. First, those people and organizations in local communities responsible for providing assessments of substance abuse trends among adolescents would establish a community agenda. The agenda would include, among other things, the specific research questions of interest. Qualitative methodologies covdd be used to gather basic epidemiologic data on substance use and abuse trends among adolescents as well as attitudes toward abusing various drugs, including alcohol and tobacco. In addition, qualitative methodologies could be used to focus on substance abuse issues that are specific to the local school districts and communities. The results of such studies could be used to target prevention programming toward specific emerging substance abuse trends while at the same time helping to orient prevention initiatives toward prevalent attitudes among adolescents. A focus group or individual qualitative interview protocol would then be developed.
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The target population would initially include high-school students 18 years of age, school counselors, parents, and perhaps adolescent treatment providers. Conducting research with students at least 18 years of age reduces human subjects' issues that must be considered when minors are involved in research, although over time research could be conducted with adolescents as well.
Conclusion There are several advantages to using qualitative methodologies to improve substance abuse prevention programming among adolescents. First, implementing focus groups and/or individual interviews to collect data on substance use and abuse trends is relatively inexpensive, compared to conducting large-scale epidemiologic surveys. Second, compared to survey approaches, the results of qualitative interviews can be analyzed and reports and recommendations developed more rapidly. Third, qualitative methods can be adapted to address local issues of concern. These issues might include specific focus on particular emerging drug trends, such as the recent increase nationally in MDMA/Ecstasy abuse among adolescents and young adults. Other local issues of interest might include evaluating attitudes toward new prevention programming materials, such as new videos or print media. In this case, qualitative methods could be used to determine the attitudes of both adolescents and parents toward the new prevention programming materials. Qualitative methods can be used successfully with minimal training; such methodologies could be readily adopted by local school boards or agencies to improve prevention programming. Finally, the results from qualitative methods could have more appeal to lay policy makers, because they more readily portray issues related to substance abuse from the perspectives of young people themselves.
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Author Note Raminta Daniulaityte, Harvey A. Siegal, Robert G. Carlson, Deric R. Kenne, Center for Interventions, Treatment & Addictions Research, Wright State University, School of Medicine, Dayton, Ohio; Sanford Starr, and Brad De Camp, Ohio Department of Alcohol and Drug Addiction Services, Columbus, Ohio. Correspondence concerning this article should be addressed to Raminta Daniulaityte, Wright State University School of Medicine, 143 Biological Sciences Building, 3640 Colonel Glenn Highway, Dayton, Ohio. 45435 Tel: (937) 775-2066; Fax: (937) 775-2066; E-mail:
[email protected].
