Towards a model for the provision of comprehensive services for non‐English speaking communities

Drug and Alcohol Review (r99I) ~to, r37-r49

Towards a model for the provision of comprehensive services for non-English speaking communities

CHRIS RISSEL & LOUISE ROWLING

University of Sydney, Sydney, Australia Abstract

People from non-English speaking backgrounds (NESB) tend to utilize Australian health and welfare services less than those people born in Australia. There is also evidence that migrants to Australia tend to increase their consumption of alcohol and other drugs once they have settled. Therefore, NESB people should be a priority focus for the provision of comprehensive services for the prevention and treatment of alcohol and other drug-related problems. To date there has not been a co-ordinated approach to the provision of alcohol and other drug services to NESB communities. This paper proposes a model for the provision of such services, and uses the Sydney Arabic-speaking Lebanese community as an example. This model draws upon available literature and incorporates strategies of community development, namely networking and dissemination of information, and directs efforts at three levels of intervention. [Rissel C, Rowling L. Towards a model for the provision of comprehensive services for non-English speaking communities. Drug,dlcohol Rev I99i; Io: I37-149 ]

Key words: substance use; psychoactive drugs; prevention; community development.

Introduction

Migrating to a new country involves many trau- mas, including dealing with the health and welfare services of the host country. Differences in language, customs, attitudes and beliefs work together to create effective barriers to people of non-English speaking backgrounds (NESB) using these health and welfare services.

Since r988 the Health Education Unit at the University of Sydney has been working on developing ethno-specific drug education resources for Greek parents Ix]. The needs assessment phase of this project highlighted a number of problems: the Greek parents' lack of awareness of alcohol and other drug issues, and services, their reluc-

tance to use these existing services and the non- existence of counsellors with knowledge of the Greek culture and family patterns. When other ethnic communities were examined it soon be- came apparent that these problems were not unique to this NESB community and that a model to plan comprehensive interventions for ethnic communities was necessary.

Ethnic communities have been identified by the Ministerial Council on Drug Strategy (MCDS) [2] as a priority target group for alcohol and other drugs intervention and education. This priority was established both because of the high proportion of the Austalian population from non-English Speaking Backgrounds (NESB) and the relative

Chris Rissel, MPH, Lecturer, School of Community Health, Cumberland College of Health Sciences, University of Sydney, East Street, Lidcombe NSW 2141, Australia, and Louise Rowling, Lecturer, Health Education Unit, University of Sydney, Sydney, Australia. Correspondence and requests for reprints to Mr Rissel.

r37

x38 Chris Rissel 8~ Louise Rowlino~

neglect of these people as foci for Drug Offensive campaigns. The Drug Offensive has also recommended that community-based programmes should be conducted in preference to focusing primarily on the provision of treatment services.

This paper will be presented in two parts. The first part will review the issues and problems of NESB people and describe the theoretical under- pinnings of the model for service provision described herein. The second part will apply this knowledge to a hypothetical case study of the provision and evaluation of comprehensive alcohol and other drug services to a NESB community.

Issues in developing community-based services for NESB people

There is little published material that discusses the problems and issues of preventing or reducing alcohol and other drug problems in NESB communities. Information about the use of substances of dependence, particularly the iUegal drugs by the young, is sparse.

Yet, there is considerable literature on alcohol and other drug prevention and services for the general population, as well as literature concerning community development strategies, and behaviour changing health promotion programmes. It is noteworthy that the more recent alcohol and other drug programmes are using the lessons learned from the health promotion demonstration programmes of the last xo-x 5 years. In particular, there is increasing recognition of the need for community support, involvement and participation in planning and implementing programmes, for the programmes to succeed in both the short and long-term [3-7]"

Multiculturalism

In the sparse multicultural alcohol and other drug literature, it is rare not to find some comment about the need for 'cultural sensitivity' when working with NESB clients. Much of the discus- sion has focused on treatment [8] where it has been recognized that family/couple therapy or group therapy are the modalities of preference [9,io]. Family-based approaches to adolescent alcohol and other drug-related problems are also recommended [ix]. This recommendation fits neatly with the family orientation of many NESB

cultures, a factor identified by a Victorian study into drugs and the Italio-Australian family [I2].

However, Capoccia [9] reported that many alcohol treatment directors felt that there was 'no difference in the effectiveness of services designed specifically for minorities from services designed for the general public (p. i22). This statement reveals that even within the treatment paradigm cultural sensitivity has not been incorporated into the mainstream workers' perceptions and skills of how to deal with NESB clients. Capoccia does go on to report that many staff recognized that the employment of bilingnal/bicultural staff, and the provision of cultural training to staff would improve services. The limited work that has occurred in Australia in relation to provision and utilization of services, suggests that it is a complex area that needs careful planning if appropriate interventions are to be developed [I,I2].

Cultural sensitivity is also the cornerstone for prevention in multicultural health education. Mac- Donald, Thompson and De Souza [i3] define multicultural health education as:

learning opportunities designed with sensitivity to cultural values, beliefs and practices; carried out in relevant languages; developed in and implemented with the active participation of members that are truly reflective of the 'target' group~ and taking into account the participating group's definition of health and its cultural diversity (p. i2).

This definition includes the key concept of active participation in development and planning. By including this concept MacDonald et al. have drawn on a central element of community development theory, that long-term solutions are only possible if those people affected by the proposed changes are actively involved in determining the solutions. Participation by representatives of the NESB 'target' group is central to the multicultural models of alcohol and other drug-related problem prevention proposed by Orlandi [I4] and Griswold-Ezekoye [i5] as well as the major demonstration heart disease prevention programme conducted in the USA and North Karelia,

The major heart disease prevention programmes at Stanford [3,4], Pawtucket [5], Minne- sota [6] and North Karelia [7] all used participation of local people and community development strategies to some degree. All attribute some

success of their programme to community involvement and community organization. Lessons from the heart disease prevention projects indicate that potentially the greatest effects of alcohol and other drug problem prevention will occur through small changes in consumption and attitude in the general community rather than the concentration on only high risk individuals [i6,x7].

This has also been recognised in the alcohol and other drugs field [rS] with the National Campaign Against Drug Abuse (NCADA) Task Force on Evaluation commenting that 'community-based interventions are at the heart of the NCADA strategy' [i9]. Johnson and Solis 12o] recommended that 'sustained, highly integrated multi-component programmes should be prefer- able to single component programmes or campaigns' (p. 77). They went on to recommend the optimal prevention programmes, targeted at adolescents, would 'utilize not only school systems for delivery, but also, families, mass media and community organization' (p. 78).

While recognizing several practical differences between the prevention of heart disease and the prevention of alcohol and other drug-related problems, Johnson and Solis 1.2o] list five reasons why the lessons from community heart disease prevention are relevant to drug abuse prevention.

(i) Many of the behavioural objectives are the same.

(2) Problems of community organization are similar.

(3) The same genera] strategies for community stratification and assignment to experimental conditions are appropriate to both kinds of programmes.

(4) Many of the measurement problems and their solutions are the same.

(5) The scope of both types of programmes is similarly large and demanding in terms of organizational requirements (p. 78).

Rather than review the major heart disease prevention programme strategies and the theories

Sewoices for non-English communities r39

upon which they are based, it is enough to say that in a variety of settings, community-based interventions have been successful [2i~. Essential components of a community-based intervention are that members of the community must be involved in the planning and implementation of the programme, they must have a sense of ownership of the programme, and they must identify the problems to be addressed as relevant and a priority for their community [22]. Community development approaches. Within the broad framework of community work outlined above there are a number of approaches. For example, Rothman [23] identified three approaches; locality development, social planning and social action. Locality development involves 'broad participation of a wide spectrum of people at the local community level in goal determination and action' (p. 26), social planning emphasizes a 'technical process of problem solving.., rational, deliberately planned and controlled change has a central place in this model' (p. 27) and social action which involves 'disadvantaged segments of the larger population that need to be organised, perhaps in alliance with others, in order to make adequate demands for more resources' (p. 27).

Jackson, Mitchell and Wright [24] have built upon this model and developed a continuum of community development, from developmental casework to social movements (See Fig. I). According to Jackson et al. [231 developmental casework involves building self-esteem and confi- dence of clients to enable them to move towards control over their own lives. Mutual support involves developing self-help groups and building and expanding social networks. Networks are fundamental to all other stages of community development. Interaction between people in existing networks, whether they be social, professional, religious, leisure, family, race or traditional networks, are the basic process or mechanism by which information and innovations diffuse through communities 1251. Therefore, expanding

Developmental Mutual Issue Participation casework support identification control of

and campaigns services

Figure i. Community development continuum proposed by Iackson et al. [~3].

Social movement

I4o (Sfir'is Rissel ~ Louise Ro~olino~

and developing networks is of vital importance in community interventions. Issue identification and campaigns may occur when there is a coincidence of interests of various networks. It assumes some networks or organizations already exist and are capable of attempting tasks. This may be the case with the well-established communities.

Participation in service delivery and control over services is an important way for people to learn skills which they may then be able to transfer to other situations. It is also fundamental to the successful implementation of programmes [3-7]. Members of the community must be involved in the planning and implementation of programmes and services, not only to encourage a sense of ownership and longer term continuity, but to increase the credibility of drug or alcohol mes- sages, and increase the appropriateness of sources and mediums of communication [26].

Social movement may occur when there is a strong commitment by a large network of people. A social movement within ethnic communities towards the decrease of alcohol and other drug- related problems would be highly desirable and is the agenda of the National Campaign Against Drug Abuse.

Community development strate~es. When working within a community development approach, particular strategies are often used. These include dissemination of information, building and expanding networks and relationships, consciousness and awareness raising, and the provision of resources [27,28 ] .

Briefly, extending networks means increasing the number of linkages between people, and the density of the network. The rationale is that people need other people; that if they are interacting with others then there is more chance of them gaining support or assistance from each other. Working with networks is particularly appropriate with NESB communities where tradi- tions encourage strong community ties. This allows information dissemination or training to occur through existing social structures, rather than by creating new systems. Kelly [29] suggests that existing progressive organizations, self-help groups, adult education groups, voluntary associa- tions, schools, churches, and the many informal social settings where people interact, may be particularly valuable settings to work with net-

works. There is considerable literature detailing the health benefits of social networks and support (for example work by Cohen and Syme [3o], Minkler [3 x] and Crawford [32]), so this will not be reviewed here.

The provision and learning of information is another important strategy. Information in conjunction with other strategies can be very power- fill. Alone, it is unlikely to change behaviours, but is a starting point for learning new behaviours. Casswell [33] reported that the use of data describing alcohol-related harm can be an important component of educational initiatives, and can be used with particular effect to influence key individuals, policy makers or politicians. An important aspect of the Planned Approach To Community Health (PATCH) programme [34] is the use of data obtained from a specific community to raise awareness of a problem in that community.

Intervention models

Several models have been proposed for working with whole communities [x4,I5,34-37 ]. Most follow the procedural framework described by Henderson and Thomas [38]. They listed nine stages of community work.

(i) Entering the community. (u) Getting to know the community. (3) What next? Needs, goals and roles, (4) Making contacts and bringing people to-

gether. (5) Forming and building organizations. (6) Helping to clarify goals and priorities. (7) Keeping the organization going. (8) Dealing with friends and enemies. (9) Leavings and endings.

(These Stages are not sequential and are often interconnected. Various stages are more important at different times during a project.)

For example Elder, McGraw and Abrams [36 ] commenced the first phase of their programme with an assessment of the community, and then contact with gatekeepers and key individuals. They then encouraged these people to contact their respective members of their networks to join the programme and then to form organizations to plan and implement programmes. These smaller groups set goals and designed programmes to

Services for non-English communities 14I

change behaviours, as well as to change environmental conditions.

All the models proposed or the programmes based on them included a stage of forming at least one initial interest group, and then other working groups. The degree of formality of the groups varies from model to model (for example, the P A T C H model is very structured where Crowley's model [35] is much less so), but a common element is membership by representatives of the community. The initial group may be called an 'Advisory Board' [x5,36] or a 'Core Group' [34]. Working groups may have many different titles, but these groups are responsible for specific project planning. Training is often necessary, and may be provided (again with varying degrees of formality) by the Advisory Board or an external health department or university group. The P A T C H programme, for example, has an exten- sive and elaborate training programme which is run over six workshops [34].

Different working groups, depending on interests, motivation and resources, may choose to work with various target groups--adolescents, adults, shopkeepers, e tc . - -or different organiza- t ions-schools , workplaces or community settings - - o r with different mediums of communica- t i o n - m a s s media to face-to-face interpersonal interaction. The approach of using local events and activities to support mass media campaigns has been used successfully by the Drug Offensive

[39]-

Facto. influencing service provi, ion for ZCESB communities

Many elements of a community need to be considered prior to implementation of a comprehensive intervention for NESB communities, as they may affect the ease and application of the model. The Sydney Lebanese community will be used as a means of exemplifying the factors. (Unless otherwise specified the following data is taken from the documents Overseas born Austra- lians z988 [4o], and A¢ Statistical Profile of Ethnic Communities in NSIV [4x].)

Population size. The size of the NESB community will directly affect the level of staffing necessary for any intervention. Smaller communities may be able to manage with one or two staff members

who share roles specified in the model. Larger communities may require at least one staff member at each level of intervention in t h e proposed model. The Lebanese community is one of the largest NESB groups (o.8% of the NSW population). It is also increasing in size (through migration and birth rate), whereas some more established communities are decreasing in size and have a lower birth rate.

Financial resources. Financial constraints have a direct effect on service provision. If financial resources are limited, the proposed model can still provide insight into the possible levels at which intervention work can be done. The initial focus of the intervention would be determined by the needs of the community, but could still be viewed within an overall programme similar to the model proposed. The time-frame for implementing the full model would have to be lengthened.

Language spoken at home. The extent to which NESB people speak their native tongue at home tends to reflect the degree to which that community retains its original culture, and how much it has assimilated with the norms of Australian-born people. It is also generally known that people with little or no English tend to use services much less than those people with good English [42]. Lebanese is the third most commonly spoken language at home in NSW (IO.Z%), after Italian (I4.3%) and Greek (ma%). A survey of Arabic- speaking people in Marrickville found that a very high proportion of Arabic-speaking people had poor English language ability [43].

Geographical location. Communication and dissemination of information between members of the community is easier when they live geo- graphically close to each other. (Although work by Tranter [44] found that dense and crowded housing actually increased isolation of residents.) Of the Lebanese in Australia almost 75 % live in NSW (about 20% in Victoria); and of those who live in NSW over 95 % live in Sydney. Thus, there is a particularly high concentration of Lebanese in Sydney. Even within Sydney there ~.re particular municipalities where there are concentrated clus- ters of Lebanese people. More than 55% of the Lebanese community in Sydney can be found in

142 Chris Rissel ~ Louise Rowling

7 0 -

6 0 -

5 0 -

40-

.~ 30-

2 0 -

UK and

.Ch ina Ireland . .Greece

• India ~(ugoslavia Egypt South . S d Lanka "Cyprus

Philippines Hong Africa United Turkey • • te z • , . States

r, ong = New = Lebanon • = • Zealand Canada

Vietnam = Malaysia

• USSR

• Poland • Hungary

• Italy

A u s t r i a ~ Netherlands M~lta • Germany

1 0 -

0 0 1'o •s ~o ~s ' 29 and

Median period of residence (years) over

Figure 2. Median age by median period of residemy in Australia of overseas-born Australians (Source: Census of Population and Housing, 1986 ).

five local government areas, with a further r7% in the next five local government areas.

Age. The age structure of a population is important because different drug or alcohol problems are relevant at different ages. The age structure of the Lebanese community shows a median age of 33 years and a greater number of males age I4-44 than females. This is older than the median age of the Australian community (27. 5 years). The Lebanese community also has a higher birth rate, with women aged 4o-49 having had an average of 4.2 children compared to the average Australian issue of 2. 9 children. Thus, there may be considerable room for prevention of alcohol and other drug-related problems with the children.

immigrants from many Asian countries. In fact, Lebanese-born people fit neatly in the middle of the major waves of migration to Australia (see Fig. 2).

Culture. Each culture has its own unique elements, some of which influence beliefs about health and alcohol or other drug consumption. It is essential that these elements are known and understood. For example, informal discussions with Arabic speaking health and welfare workers in the Sydney Metropolitan region suggest that the following issues are important: non-usage of services, lack of knowledge of alcohol and other drug issues, lack of trained counsellors, and a high degree of respect for doctors.

Period of residency. Immediate settlement and migration issues are often more urgent than prevention of alcohol or other drug problems that are not yet evident, and which the community does not recognize as a significant problem. Therefore, the length of residency needs to be considered. Basser [45] provides support for the thesis that the time spent in Australia correlates with the number and type of contacts with community health staff: the less time in Australia the more single (often crisis) contacts.

Overseas-born Lebanese have lived in Australia for a shorter period than, for example, overseas- born Greeks, but are not as new to Australia as

DruEproblems. While it is notoriously difficult to find data on drug usage in ethnic communities there is some indication that the Lebanese community has more than its fair share of problems. Lebanese were enormously over-repre- sented in the figures for the number of New South Wales higher court convictions for drug offences compared to all other ethnic groups [46]. They were also the largest numbers of any ethnic group registered at Bourke Street Drug and Alcohol Service [46], twice as many as the next ethnic group. Trimboli and Ridoutt [47] found that Arabic-speaking people smoked tobacco and drank coffee more than the Australian population.

Services for non-English communities I43

Community readiness. Interviews with Arabic- speaking workers and welfare agency representatives indicate that there is a community concern about drugs. It is important that concern exists to avoid the imposition of an unwanted project. Arabic-speaking workers recognized that there are few (or no) services to which they could refer 'at risk' or 'in need' clients, and that a comprehensive intervention project would be well received (source: personal communications with Arabic- speaking workers in Sydney). They have identified that alcohol and other drug-related issues are a priority and some have already initiated steps to increase their own skills and awareness [48,49]. This action clearly indicates readiness of key community members.

Use of services. Despite gaps and a lack of recency of service utilization data, it appears that the Arabic-speaking Lebanese community uses services less than would be expected on the basis of NSW demographic information of the number of Arabic-speaking peoples. Alcohol and other drug- related problems are not mentioned as the reason for the service utilization as frequently as for the Australian-born population. Yet when this is examined more closely, it is often the case that alcohol or other drugs are actually an underlying cause, of whatever problem is stated as the reason for presentation at the service (source: personal communication with Newtown Community Health Centre Drug and Alcohol psychologist).

A response to the provision of community-based services for a NESB community

The remainder of this paper describes a model of comprehensive alcohol and other drug service provision for a NESB community. This comprehensive service provision model includes three different levels. Primary prevention, in this case, involves the prevention of alcohol and other drug- related problems. The next level, early intervention, involves the early detection, assessment and referral of newly-developed or developing alcohol and other drug-related problems before they worsen. Treatment, the third level, involves counselling and treatment, to provide help with existing problems and prevent, as much as possible, further problems that may be caused by the alcohol or other drug problem. This model, of

the proposed service provision, is shown diagrammatically in the Appendix. It can also be used for planning the provision of comprehensive alcohol and other drug services for different ethnic communities.

To operationalize the model an implementation plan (see Fig. 3) has been developed, which incorporates the proposed model and utilizes community development strategies, the planning strategies from major heart disease prevention programmes and continued evaluative feedback.

Evaluation sugKestions

An integral part of any implementation plan is evaluation. Community development is notoriously difficuk to evaluate. One of the .reasons for this is that in 'pure' community development, the outcomes are never pre-determined by the community worker. In this proposed intervention however, it is the strategies of community development that are being used to achieve stated objectives. Process sub-objectives are stated and their attainment would assist in the assessment of whether the community development strategies were implemented correctly. The following sug- gestions could be used in the evaluation of the proposed intervention. The terminology used in this research plan is based on health promotion evaluation terminology as defined by Green and Lewis [5 o] and Windsor et al. [5i]. They use the term outcome evaluation to refer to the long-term effects of the project. Frequently used outcome evaluation measures include changes in the rates of relevant health problems, e.g. cirrhosis of the liver, or criminal offences, or incidences relating to alcohol or other drug use. Impact evaluation is the term used to refer to the short-term changes that result from the project and are usually measured in terms of behavioural or environmental changes, or changes in knowledge, attidues or certain skills. Process evaluation is synonymous with formative evaluation and considers the quality of the implementation of the programme [5o-52].

Impact evaluation. Long-term health improve- ments might not be detectable over the life of this project because its aims are to increase knowledge of alcohol and other drug issues and increase the utilization of mainstream services, that is, short- term aims. It is not realistic to evaluate for long- term effects.

I44 Chris Rissel ~ Louise Rowling

Stage I

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

Stage 7

Implementation plan

I Form Advisory Body ]

Recruitment, orientation and team building ] t

1 identify and contact key people

Inform and educate about the project

l Baseline survey of D & A knowledge, attitudes and practices, knowledge of

services, and use of services etc.

1 Community awareness campaign,

(using results of survey where appropriate) • Dissemination of information

• Use of networks to form work parties

] Working parties/ I groups formed 4

Training groups about D & A issues and services available; 'What to do . . . '

Community goal setting i

$

Education programs within existing networks, referral to Arabic speaking treatment services and

mainstream services, and provision of Arabic speaking counsellor

Follow-up survey of knowledge, attitudes, I m

practices, use of s~rvices etc. ." I 4

Figure 3. Implementation plan.

Groups include: Mainstream workers

Ethnic workers Adults Priests

Youth groups

~ e ~ a ~

Therefore, there is a quasi-experimental situation of having a baseline level of service utilization, and knowledge of alcohol and other drug issues, followed by an intervention consisting of counselling and information giving and awareness-raising through various networks, followed by another assessment of service utilization and knowledge levels. There are several studies which provide examples of sampling and survey techniques with NESB communities [46,53-55 ]. The effects of the

components of the intervention should also be evaluated: education, use of networks, awareness- raising and the work of the bi-lingual counsellor.

To improve the internal validity of the overall intervention a non-equivalent group design could be used [56]. Other NESB communities might be monitored in their use of services during the study period as a control group for the Lebanese community. It could then be argued that the intervention caused the increase in service utiliza-

Services for non-English communities I45

tion rather than some other factor. It would be ideal if knowledge of alcohol and other drug issues could be assessed in all NESB communities both before and after the study, but this would be very expensive. It is not considered feasible and, indeed, is the antithesis of an intervention approach which is based on the use of existing networks, to use a randomized controlled trial study design.

Is the programme reaching the target group? It is important that a large proportion of the community be involved in the project. It is also important that a large proportion of Arabic-speaking Leb- anese people who speak little or no English are involved, as well as those people who have adopted the Australian culture and specific sub-groups (e.g parents).

Does the community accept the project and its activities? It is almost unnecessary to say that in this project the community needs to accept the project. The project is orientated so as to maximize acceptance, relevance and satisfaction with the project by including members of the community in the planning from its inception.

Is the programme being implemented as intended? Because this is an innovative and new project it will not be possible to rigidly compare the project's implementation with its plan. While there is a plan and process that will be followed, all the details and circumstances cannot be predicted. Therefore, documentation of what actually hap- pens, and recording of the sequence of events and activities, will be invaluable for explaining the results of the project. It will provide the basis for a model of comprehensive services for ethnic communities.

Are the programme components adequate? If the Arabic-speaking Lebanese community is actually being reached (participating), is satisfied with the programme and the programme is following the implementation plan, then are the programme components and strategies adequate to achieve stated objectives at impact evaluation? The answer to this question is yes, as the project is based on literature on community development strategies, heart disease prevention programmes and treatment issues with ethnic communities. It is an

innovative and comprehensive approach, one which there is every reason to suggest will achieve its objectives.

Implementation plan

The implementation involves seven stages and covers a somewhat arbitrary 2-year period. It is first shown diagrammatically (see Fig. 3), then discussed in relation to some examples of specific sub-objectives of the plan. Overall project objectives might be:

(i) to increase the knowledge of the Arabic- speaking Lebanese community about alcohol and other drug issues~

(2) to increase the utilization of existing mainstream services by the Arabic-speaking Leb- anese community.

Subobjectives. To achieve the project objectives and operationalize the plan it is useful to consider subobjectives and their achievement as stepping stones [57]. The following subobjectives are examples only, and are not comprehensive.

Stage z: an Advisory Group should be formed to advise the Project staff about specific cultural factors, and assist in the recruitment and orientation of project staff.

It is essential that the community and its key members support the project. One of the methods that could increase the involvement of the most enthusiastic key community members early in the project, is for these key individuals to assist in the selection and orientation of the project staff. The specific and. detailed information about cultural issues provided thereby, is invaluable.

Stage 2: all key community members should be identified and contacted, and informed about the project.

Again, it is essential that influential community members are involved in the planning and implementation of the project from the very beginning. They need information and education about the project, and may need education themselves about alcohol and other drug issues. The credibility and viability of the project to a large extent depends on the acceptance of the project by these influential community members.

I46 Chris Rissel ~ Louise Rowling

Stage 3: a survey of knowledge, attitudes and practices of the Arabic-speaking Leban- ese community should be conducted in the early stages of the project.

Baseline information is needed both for the evaluation of the project as well as for the planning of programmes. The data would provide information about which programmes are a priority or are most feasible. The results would also play a valuable role in the next stage (community awareness) by making the 'drug problem' relevant and something which belongs to the community.

Stage 4: a campaign should be mounted to raise the awareness of the Arabic-speaking Lebanese community and disseminate information about alcohol and other drug topics.

The awareness-raising campaign is an important 'official' beginning to the project. Different as- pects should be directed to particular existing networks, such as parents, youth groups, priests, elderly and women, as well as the Arabic-speaking workers and mainstream workers. Referral to the project counsellor and encouraging use of certain mainstream treatment services could also be a feature of this campaign.

One likely consequence of this campaign is the formation of new Arabic-speaking Lebanese working groups or special interest groups. These new networks would bring together members of existing networks who would participate in developing particular ways, methods or programmes toincrease the amount of accurate information about alcohol and other drugs, and knowledge about what services are available for people who need them. Project staff would need to work closely with these different networks, so that not only do these community members learn new skills and information concerning alcohol and other drugs, but also the participants of these groups, 'early adopters' [25] would be able to communicate the information to their respective family members, friends and various associates. Existing groups would, of course, receive the close attention of project staff. Stage 5: appropriate information needs to be

provided to the Arabic-speaking Leb- anese community through meetings and various networks, and would need to include what to do and where to go if a 'problem' is identified.

It is important that educative work done with the community groups is sensitive to both the Arabic- speaking culture, as well as the particular sub- culture of that group. It is most likely that more homogenous groups, i.e. youth, parents, adult females, and elderly men would present a better learning situation than less homogenous groups. It is also more likely that in a supportive homogenous environment, initiatives to change alcohol or other drug-related behaviours would be more forthcoming and would be better able to be maintained, once initiated. Accurate assessment of unfulfilled needs would be able to be undertaken in these forums. Knowledge about available services would also be a major part of the education programmes. Stage 6: programmes need to be planned by

community members in conjunction with project staff. The latter would implement the programmes in community settings where the project has penetrated least or where community members have identified the greatest need.

To maximize the project's potential, project staff would work with community groups to develop programmes to access the typically hard to reach sub-groups. Insights and local knowledge brought to bear on planning and making programmes appropriate and relevant, should prove beneficial.

To some extent it is difficult to anticipate exactly what programmes would he implemented. This depends on what particular issues are relevant and appropriate to the community, as well as what are the best ways to tackle these problems. The need for this degree of flexibility was pointed out quite saliently in a report by the (then) NSW Drug and Alcohol Authority (NSWDAA) [581 on a drug and alcohol awareness campaign for people of non-English speakifig backgrounds. The report stated that intensive ongoing dissemination of information through ethnic media (up to 3 or 4 months prior to extending invitations) is a pre- requisite for participation in seminars delivered for ethnic communities.

With regard to the development and implementation of educational strategies, the NSWDAA report [58 ] stated that intensive consultations needs to take place with appropriate representatives of targeted communities, and that 'unless such liaison is given due emphasis the possible

success of the strategy will be seriously affected' (p. 21). Total resistance from a communities' members may be the result of inappropriate strategies on delicate issues (e.g. alcohol and other drug- related problems).

8rage 7: a repeat of the first survey would need to be conducted to provide evaluation data on the effects of the project and feedback to the community about the activities that have been conducted.

Feedback of the results of activities can be a powerful motivating factor. It is important that community members see that 'something can be done' about alcohol and other drug-related problems. This perceived ability to tackle problems could influence the community's preparedness to address other health problems.

Conclusions

It is necessary to develop a comprehensive response to alcohol and other drug-related problems for NESB communities. To develop thi s response, meet the needs of the community and to maximize measurable outcomes, information from diverse areas of intervention development research literature [I4] needs to be utilized. The model described in this paper attempts to operationalize the currently accepted principles of programme design in the health fidd.

Acknowledgements

The development of this model of service provision was made possible by a grant from the National Campaign Against Drug Abuse. We gratefully acknolwedge the support of the NSW Directorate of the Drug Offensive.

References

[1] Carless A. Developing a drug education program for Non-English speaking Greek parents--a report on the process. Sydney: Health Education Unit, 1989 .

[2] National Campaign Against Drug Abuse. The National Campaign Against Drug Abuse 1985-88. Evaluation and Future Directions, Monograph Series No 12. Canberra: Australian Government Publishing Service, 1989.

[3] Farquhar JW, et al. Community education for cardiovascular health. Lancet, i977;i:1192- 5.

[4] Farquhar JW, et al. The Stanford Five City

Services f o r non-English communities r47

project: an overview. In: MatatazzoJD, Weiss SM, Herd JA, Miller NE, Weiss SM (eds). Behavioural health--a handbook of health enhancement and disease prevention. NY: John Wiley, 1984;1154-65.

[5] Laseter T, Abrams D, Artz L. Lay volunteer delivery of a community-based cardiovascular risk factor change program: the Pawtucket experi- ment. In: Matatazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM (eds). Behavioural health--a handbook of health enhancement and disease prevention. NY: John Wiley, 1984;1166-78.

[6] Mitdemark MB, et al. Community-wide prevention of cardiovascular disease: education strategies of the Minnesota Heart Health Program. Preven- tive Med 1986;i5:1-17.

[7] Puska P. Community-based prevention of cardiovascular disease: The North Karelia project. In: Matatazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM (eds). Behavioural health--a handbook of health enhancement and disease prevention. NY: John Wiley, 2984;114o-47.

[8] Chapman RJ. Cultural bias in alcoholism counselling. Ale Treat Q 1988;5:1o5-13.

[9] Capoccia VA. Providing alcoholism services to minority populations: If we have the will do we have the way? Ale Treat Q 1984;1:115-24.

[1o] Glynn TJ (ed.). Drugs and the family. NIDA Research Issues 29: US DHEW, 1981.

[ii] Bry BH. Empirical foundations of family-based approaches to adolescent substance abuse. In: Glynn: TJ, Leukefeld CG, Ludford JP (eds). Preventing adolescent drug abuse--intervention strategies. NIDA Research Monograph 47: DHHS, 1983;154-71.

[x2] Gucciardo T. Breaking the silence: drugs and the Italo-Australian Family. Bulleen, Victoria: Italian Catholic Federation, 1989 .

[13] MacDonald JL, Thompson PR, De Souza H. Multicultural health education: an emerging reality in Canada. Hygie 1988;7:12-16.

[I4] Orlandi MA. Community-based substance abuse prevention: a multicultural perspective. J School Hlth 1986;56:394-4Ol.

[15] Griswold-Ezekoye S. The multicultural model in chemical abuse prevention and intervention. In: Griswold-Ezekoye S, Kumpfer KL, Bukoski wJ (eds). Childhood and chemical abuse--prevention and intervention. NY: Haworth Press, 1986.

[i6] Rose G. Sick individuals and sick populations. Int J Epidemiol i985;i4:32-8.

[17] Kottke TE, Puska P, Salonen JT, Tuomilehto J, Nissinen A. Projected effects of high-risk versus population based prevention strategies in coronary heart disease. Am J Epidemiol 1985;121:697-7o 4.

[18] Nathan PE. Alcohol dependency prevention and early intervention. Publ Hlth Pep 1988;lO3:683- 9.

148 Chris Rissel & Louise Rowling

[i9] McDonald D, Brown H, Hamilton M, Miller M, Stephenson E. Australian drug policies i988 and beyond--a drugs campaign evaluation. Aust Drug Alc Rev 1988;7:499-5o 5.

[2o] Johnson CA, Solis J. Comprehensive community programs for drug abuse prevention: implications of the community heart disease prevention programs for future reesearch. In: Glynn TJ, Leuke- feld CG, Ludford JP (eds). Preventing adolescent drug abuse--intervention strategies. NIDA Re- search Monograph 47: DHSS, i983;76-i14.

[21] Winklestein W, Marmot M. Primary prevention of ischaemic heart disease: evaluation of commu- nit'/ interventions. Ann Rev Publ Hlth I98I;2:253-76.

[22] Wakefield MA, Wilson DH. Community organ;- sat;on for health promotion. Comm Hlth Stud I986;IO:444-5I.

[23] Rothman J. Three models of community organ;- sat;on practice, their mixing and phasing. In: Cox FM, Erlich JL, Rothman J, Tropman JE (eds). Strategies of community organization--a book of readings, 3rd ed. Illinois: Peacock Publishers, I97O;25-42.

[24] Jackson T, Mitchell S, Wright M. The community development continuum. Comm Hlth Stud I989;13:66-73.

[25] Rogers EM. Diffusions of innovations (3rd edn). NY: Free Press, 1983.

[26] McGuire WJ. Theoretical foundations of campaigns. In: Rice R, Paisely W (eds), Public communication campaigns. Beverly Hills: Sage, 198I~4I-7O.

[27] Benn C. Attacking poverty through participation. Melbourne: PIT Publishing, i981.

[281 Community Development in Health Project. Working Paper. Melbourne: Community Devel- opment in Health Project, i988.

[29] Kelly JG. A guide to conducting prevention research in the community--first steps. NY: Haworth Press, i988.

[3 o] Cohen S, Syme SL. Social support and health. Florida: Academic Press, I985.

[31] Minlder M. Building support networks from social isolation. Generations, r986 , Summer: 46- 9.

[32] Crawford G. Support networks and health-related change in the elderly: theory-based nursing strategies. Family Comm Hlth i987;io:39-48.

[33] Casswell S. Educational initiatives in the prevention of drug related harm. Aust Drug Alc Rev I98817:299-3o3.

[34] Kreuter MW. PATCH: Planned Approach To Community Health--a general overview. Paper presented at i2tb World Conference on Health Education, Dublin, Ireland, September i, i985 .

[35] Crowley JF. Alliance for change--a plan for

community action on adolescent drug abuse. Minnesota: Community Interventions, x984.

[36] Elder JP, et al. Organisational and community approaches to community-wide prevention of heart disease: the first two years of the Pawtucket Heart Health Program. Preventive Med 1986;I5:Io7-17 •

[37] Nelson CF, Krenter MW, Watkins NB, Stoddard RR. A partnership between the community, state and federal government: rhetoric or reality. Hygie I986;5:27-31.

[38] Henderson P, Thomas DN. Skills in neighbour- hood work (2nd edn). London: Allen and Unwin, 1987.

[391 Carroll TE, LoyJG. The drug offensive--a review of its approach and progress from April i986 to September i988. Aust Drug Alc Rev r988~7:487-98.

[4o] Australian Bureau of Statistics. Overseas born Australians 1988--a statistical profile. ABS Cata- logue Number 4112.o, 1988.

[4I] Ethnic Affairs Commission of NSW and Depart- ment of Housing. A statistical profile of ethnic communities in NSW. Sydney: Ethnic Affairs Commission of NSW & Department of Housing, x988.

[42] Hartley R. The social costs of inadequate literacy--a report for International Literacy Year. Canberra: Australian Government Publishing Ser- vice, x989.

[43] Younes A. Needs of the Arabic-speaking community in the Marrickville Municipality. Sydney: Marrickville Community Information Centre, i985.

[44] Tranter P. Residential privacy in disadvantaged areas. Duntroon: Royal Military College (Mono- gaph No. i7) , 1985.

[45] Basset M. Clients of Community Health Centre by country of birth and reason for visit i979-8o. Unpublished report, 198i.

[46] Barton J. Ethnicity and drug use in an opiate treatment setting. Unpublished report, i988.

[47] Trimboli A, Ridoutt L. The drug use patterns of four ethnic communities: a summary. Sydney: CEIDA, i987.

[48] Directorate of the Drug Offensive. Ethnic Affairs Policy Statement--Annual Report i987. Sydney: Directorate of the Drug Offensive, i987.

[49] Egarchos D, McDonald J. Drug and alcohol program for the Arabic-Speaking Committee Against Drug Abuse (ASCADA). Sydney: Direc- torate of the Drug Offensive and the NSW Department of Health, r988.

[5 o] Green LW, Lewis FM. Measurement and evaluation in health education and health promotion. Mayfield: Palo Alto, i986.

[5 I] Windsor RA, Baranowski T, Clark N, Cutter G.

Services for non-English communities z49

Evaluation of health promotion and education programs. Mayfield: Palo Alto, i984.

[52] King JA, Morris LL, Fitz-Gibbon CT. How to assess program implementation. Newbury Park: Sage, i987 .

[53] Bekiaris J, Wise M, Gleeson S. The Good Heart, Good Life project--developing a heart disease prevention project with a migrant community. Paper presented at the Public Health Association of Australia Annual Conference, Health in Multi- cultural Societies, University of Melbourne, Mel- bourne 24-27 September, i989.

[54] Huey-Huey Hage B, Oliver RG, Wahlqvist ML, Powles JW. Telephone directory listings of pre- sumptive Chinese surnames: an appropriate sampling frame for a dispersed population with characteristic surnames. Poster presented at the

Public Health Association of Australia Annual Conference, Health in Multicuhural Societies, University of Melbourne, Melbourne 24-27 Sep- tember, i989 .

[55] Adlaf EM, Smart RG, Tan SH. Ethnicity and drug use: a critical look. Int J Addict x989;24:i-i8.

[56] Campbell DT, Stanley J. Experimental and quasi- experimental designs for research, Chicago: Rand-McNally, 1963.

[57] Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education planning--a diagnostic approach. Maytield: Palo Alto, i98o.

[58] NSW Drug and Alcohol Authorky. Drugs are everybody's problem, you too are affected--Re- port on a drug and alcohol awareness campaign for people of non-English speaking background. Sydney: NSWDAA, 1987.

D & A Community Development Officer (CDO) Arabic speaking

f

Community

t * Prevention --.....

D & A Educator

Arabic speaking

--.... / Early intervention

Assessment and referral

j -.. D & A Workers and .D & A Workers: Health and Welfare Workers • non-Arabic speaking in existing services: - but culturally aware Arabic speaking and interpreters

--.... / Counselling and/or treatment

J \ D & A Counsellor • Mainstream treatment Arabic speaking with . services: culturally family counselling aware and interpreters skills

Community Development

Strategies

L J

I n

f 0

r

m a

t i o n

N e t

W O r k I

n g

D i S S e m

i n a

t i

0 n

Appendix. Proposed model for provision of drug, and alcohol services for the Lebanese Community.

Towards a model for the provision of comprehensive services for non‐English speaking communities

Documents