Health Education Research, Vol. 14, No. 1, 7-14,
February 1999
© 1999 Oxford University Press
Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns
School of Journalism and Mass Communication, University of Minnesota, Minneapolis, MN 55455,
1 Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN 55454-1015 and
2 Wake Forest University School of Medicine, Winston-Salem, NC 27157-1063, USA
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Abstract |
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 Top Abstract Introduction and backgroundMethodsResultsDiscussionReferences |
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The study assessed leaders' perceptions of adolescent alcohol use as a public health issue in 28 small communities in northern Minnesota, as part of formative evaluation for a community-based intervention to reduce adolescent alcohol access and consumption. One hundred and eighteen leaders from five key community sectors were interviewed about their perceptions of social, health and alcohol-related problems in their communities. Analyses indicated that school representatives and police chiefs perceived adolescent alcohol use and related problems to be serious; newspaper editors mentioned other social problems more often; and mayors and business representatives did not perceive adolescent alcohol problems to be as serious. In relation to efforts to affect local policy, the study suggested government and business sectors in these communities may need to be educated about the problem to build its importance on the community agenda of health issues. Thus community leaders in some sectors may comprise a key target audience for intervention.
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Introduction and background |
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TopAbstractIntroduction and backgroundMethodsResultsDiscussionReferences |
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Recognizing the role of social and environmental factors in adolescent drinking and other behavior, recent prevention efforts have increasingly emphasized the role of public policy to influence behavior change (Mosher and Jernigan, 1989; Anderson, 1993
). Public policy is one mechanism by which communities establish and legitimize behavioral norms. This recognition occurs in part as a natural evolution of thinking about prevention that recognizes the need to integrate policy and population educational approaches (Perry et al., 1993). However, public policy approaches require a more thorough understanding of communities, power and leadership, and how they combine to affect social change. While traditional educational approaches often seek voluntary behavior change in populations, policy approaches often seek collective action that will result in laws, statutes or rules binding community members, or the renewed enforcement of existing policies.
Community leaders play a key role in the public policy process by virtue of their influence on institutional and political change. Their actions may raise or lower the importance of public issues and thereby strongly influence the community agenda (Hilgartner and Bosk, 1988). Because the public and advocacy groups often play an influential role in forming leaders' judgments about important public issues, leaders themselves compose a key audience for policy-related intervention. Understanding leaders' beliefs and perceptions about health issues, therefore, offers insight into the status of particular issues on the community agenda and related problem-solution implications for the issues. It also functions as formative analysis guiding development of social change strategies where the object of change may be community leaders' own perceptions.
This study sought to examine these issues among leaders of 28 communities in northern Minnesota. The study posed two questions to assess the place of adolescent alcohol use on the community agenda of public health issues:
- How do community leaders perceive adolescent alcohol issues in their communities?
- What are the implications for involving community sectors and leaders in collective action to provide solutions to adolescent alcohol problems?
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Methods |
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TopAbstractIntroduction and backgroundMethodsResultsDiscussionReferences |
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Sample and data collection
Data for this study were gathered from a survey of leaders in 28 communities in northern Minnesota selected for Project Northland, a federally funded study to prevent the onset of alcohol use among young adolescents (Perry et al., 1993
). The communities, ranging in population from about 350 to 18 000, are located in an area that is prone to higher alcohol-related mortality. An interview questionnaire was developed and pre-tested in two non-project communities.1 The pre-test was used both to clarify questions, and to develop and refine coding categories for open-ended responses. Trained staff then conducted structured in-person interviews lasting for an average of 1 h each with leaders from each project community.2
Leaders were selected for interview from five primary sectors usually involved in community decision making (Nix and Seerly, 1971). Wherever possible, the senior leader of the community sector was interviewed. Thus sectors and their leaders included: (1) city government (mayors), (2) law enforcement (police chiefs), (3) education (school principals or senior teachers), (4) business (Chamber of Commerce or other representative business groups) and (5) mass media (local newspaper editors). Some smaller communities had fewer than five of the identified sector leaders.
Dependent measures
Beliefs about community health and alcohol problems
As a first step toward understanding the place of adolescent alcohol problems on the community issues agenda, leaders were asked to name the social and health problems facing their communities (open-ended). Respondents were asked about the major social problems facing people in their community and, similarly, what they identified as major health problems. Responses to perceived social problems were coded as health (alcohol, drugs, chemical dependency), the community economy, community services, and social problems such as aging, youth, crime, cultural conflict and the family. Responses to perceived health problems were coded as substance abuse-related, disease-related, sexually transmitted diseases (STDs) and health care-related issues. Additionally, leaders were asked to rate `a series of social problems concerning teenagers' in their communities on a five-point scale ranging from `not at all serious' (one) to `very serious' (five). These adolescent problems included crime, pregnancy, STDs among adolescents, suicide, tobacco use, alcohol use, drinking and driving, and illegal drug use. Leaders were also asked to list what they believed to be three or four main reasons for teenage drinking. These were coded as family influences, social and cultural influences, community infrastructure (lack of employment or recreational opportunities), peer-relations (peer pressure, low self-esteem), schools and the law, and mass media influences.
Alcohol and drug programs and decision makers
To obtain a picture of groups leaders perceived to be active and experienced in alcohol-related community decision making, and to understand to what extent community sectors were actually involved in providing solutions to adolescent alcohol problems, leaders were first asked to name four decisions or programs that had occurred in their communities during the preceding 5 years. Programs identified were coded as education/action/awareness programs, school/law programs and community group-sponsored programs. Leaders were also asked to name persons, agencies or organizations responsible for making decisions about these programs. Program decision makers included a variety of state, regional and county bodies such as county social service agencies, local government and law enforcement (city council, mayor, mental health advisory board), local school administrations (school board, PTO), the local business community, and local private groups such as civic organizations, churches, the United Way, Alcoholics Anonymous, etc.
Perceptions of adolescent alcohol access and viable policy alternatives
This group of items addressed more directly leaders' awareness and concern about adolescent alcohol issues in their communities. The fundamental questions of how easy it would be for teens to gain access to alcohol and how receptive leaders thought the community might be to potential policies addressing teen alcohol access were considered. Two groups of items were included for analysis in this section. The first was leaders' perceptions of teens' ease of obtaining alcohol. The second was their perception of the community's favor toward certain teen alcohol policies. `Access' questions included items on teens buying alcohol at a store; asking an older sibling or person to buy alcohol; ordering a drink in a bar; obtaining alcohol at a friend's home; or finding a party at which they could drink. These were drawn from previous surveys indicating common sources of alcohol accessed by underaged persons. All items were constructed on five-point scales from `no difficulty at all' in gaining access to alcohol (1) to `extreme difficulty in gaining access' (5). An `access' index (Cronbach's 
= 0.70) was developed with these items.
Policy questions included perceived community support for school-based programs to prevent underage drinking; community education programs; degrees of strictness in law enforcement for teen drinking (warning, fining, jailing teens or business proprietors); banning alcohol advertising and banning alcohol beverage companies' sponsorship of sports activities. All items were five-point scales ranging from `most would oppose' the policy (1) to `most would favor' (5). These items constituted the `policy' index (Cronbach's = 0.72).
Independent measures
To compare differences in leaders' responses, we used several independent measures. First, size of community population was used to examine whether leaders' perceptions varied in larger and smaller towns (Finnegan et al., 1993).3 Second, leaders' length of residence in the communities was used to compare perceptions of the adolescent alcohol issue (Viswanath et al, 1990).4 Third, we also compared leaders' perceptions according to the rate of community liquor licenses per 1000 population.5 Finally, we compared leaders' perceptions of the teen alcohol issue based on how well leaders believed their communities to function in general. This involved two scales: (1) systemic functioning (how well communities were perceived by leaders to function on several related characteristics)6 and (2) systemic provision (how communities were perceived by leaders to function in providing for residents' basic needs).7
Analyses
Because we expected differences among leaders' perceptions of the adolescent alcohol problem based on their sector representation, we used the SAS General Linear Modeling (GLM) package to compare leaders' responses (SAS, 1990).8 The models controlled for three independent variables: leaders' gender, educational attainment and duration of residence in their communities. Where significant F-values were obtained in the models, we performed Bonferroni (Dunn) follow-up tests to examine pair-wise comparisons between leaders representing the different sectors. Interaction effects due to gender or educational attainment (two levels) were also analyzed.
Independent measures were used to assess their possible influence on leaders' perceptions of the adolescent alcohol issue. A nested design was created within the GLM procedure using `access' as the outcome variable. For statistical comparisons, leaders in the five sectors were nested within population groupings; residence in community categories; liquor licenses per 1000 population; and high and low scores on the systemic function and systemic provision scales, respectively.
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Results |
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TopAbstractIntroduction and backgroundMethodsResultsDiscussionReferences |
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A total of 119 leaders were identified and contacted; all but one was interviewed (N = 118). Mayors composed 24% (n = 28) of the sample; police chiefs, 17% (n = 21); school representatives, 23% (n = 27); business representatives, 19% (n = 22); and newspaper editors, 17% (n = 20). Of the 28 communities, 71% (n = 20) had their own community newspapers and 75% (n = 21) had their own police departments. Mayors, police chiefs and school officials were predominantly male; while business and media leaders were about evenly split by gender. About 51% of the leaders had attained a college degree and 28% had resided in their communities for more than 33 years.
Beliefs about community health and alcohol problems
In the analysis of leaders' perceptions of community social problems, health-related issues such as alcohol, drug and chemical dependency and abuse problems were perceived to contribute significantly to social problems (F [4, 117] = 4.20, P = 0.003). The differences apparent in the least-squared means indicated that school representatives and police chiefs perceived health-related issues to contribute significantly more to community social problems when compared with business representatives' perceptions (LS means = 0.57, 0.59 and 0.11, respectively). Problems such as aging, youth, crime and lack of social activities (Table I) were also perceived to contribute significantly to social problems (F [4, 117] = 7.30, P = 0.0001).
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Business representatives and editors mentioned social problems significantly more often than school representatives and police chiefs (LS means = 0.78, 0.81, and 0.29, 0.17, respectively). Perceptions of other issues such as the community economy, community services or family-related problems were not perceived as significant social problems. In the broad category of health problems, substance abuse-related, disease-related, chronic diseases-related and health care-related problems, though mentioned, were not perceived to contribute significantly to community health problems.
Analysis showed that alcohol problems were perceived to be significant more as `social problems' than as individual `health problems' (such as substance abuse) in the communities.
Leaders perceived a variety of factors such as family, society, peers, community opportunities, schools and the media as contributing to underage drinking, but did not focus significantly on any single cause.
From the leaders' responses on items relating to adolescent social and health concerns, drinking and driving (F [4, 114] = 3.14, P = 0.02) was also perceived to be a major issue. A significant difference between school representatives and mayors (LS means = 4.06 and 3.01, respectively) was apparent in this perception. However, teen alcohol use overall did not emerge as a significant concern. Additionally, teen crime (F [4, 116] = 3.10, P = 0.02) was perceived to be a major problem by police chiefs significantly more than by mayors (LS means = 2.53 and 1.83, respectively). Teen suicide also emerged as a major adolescent social and health concern. School representatives and editors perceived this problem to be significant compared with police chiefs and business representatives (LS Means = 2.04, 2.47 and 1.46, 1.58, respectively). Leaders in each sector did not differ significantly on concerns such as teen pregnancy, tobacco use and illegal drug use.
Alcohol and drug use programs and decision makers
Leaders were asked to name community programs and decisions, and decision makers whom they perceived to be active in alcohol-related decision making. Education, action and awareness programs emerged as significantly active categories in dealing with adolescent alcohol problems (F [1. 101] = 4.84, P = 0.03). A leader–educational attainment interaction was apparent: leaders with an educational background of `college degree or more' mentioned this category significantly more often than leaders with an educational background of `some college or less' (LS means = 0.80 and 0.53, respectively). Leaders also cited programs sponsored by schools and law enforcement agencies (F [4, 102] = 3.25, P = 0.02). More school representatives than editors mentioned programs sponsored by schools and law enforcement agencies (LS means = 0.90 and 0.32, respectively). Programs sponsored by private or civic community groups did not receive significant mention. See Table II.
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On the issue of program decision makers, a leader–gender interaction was observed for the category of local school administration (school board, PTA). Male leaders perceived local school administrations as decision makers for such programs significantly more than did female leaders (F [1, 99] = 4.02, P = 0.05; LS means = 0.78 and 0.57, respectively). All other decision-maker categories including local government and law enforcement agencies, state, regional, county agencies, the business community, and other private groups did not emerge as significant contributors to alcohol and drug-related programs, in the leaders' perceptions.
Perceptions of adolescent alcohol access and viable policy alternatives
Perceptions of the ease of adolescent access to alcohol emerged as a significant outcome (F [4, 107] = 4.7, P = 0.002) among the leaders, but there were significant differences by sector. Editors and school representatives perceived adolescent access to alcohol as being easy (LS means = 17.67 and 16.40, respectively) when compared to mayors and business representatives (LS means = 20.71 and 19.30, respectively). The policy index (for viable policy alternatives) was not significantly different among the sector leaders.
Community characteristics and leaders' perceptions of access
Leaders' perceptions did not vary significantly by community characteristics including population size, duration of community residence, liquor licenses per 1000 population, and the scales of systemic functioning and systemic provision.
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Discussion |
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TopAbstractIntroduction and backgroundMethodsResultsDiscussionReferences |
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Because leaders have a major impact on the formation of the community issues agenda, it is important to understand their perceptions of problems and solutions prior to engaging communities in public health campaigns. Within the limitations imposed by the sample size in this study, it is clear that even in small towns, leaders are not homogeneous in their concern about the issue of adolescent alcohol access and use. Sector leaders' perceptual differences are important in part because they may indicate the extent of community `readiness' to approach a public health problem such as adolescent alcohol access through improved enforcement of existing policies or development of new policy measures.
In this study, mayors perceived adolescent access to alcohol to be fairly difficult, especially when compared with the perceptions of school representatives and editors. These results suggested that this key decision maker may not be as concerned about adolescent alcohol problems as some other leaders. School representatives seemed to be especially aware of health-related social problems (alcohol, drugs and chemical dependency), drinking and driving problems among teens, and teen suicide. Additionally, this group also perceived teen access to alcohol to be fairly easy, when compared with mayors and business representatives. For alcohol and drug-use programs and decision makers, school programs for adolescents were cited more by school representatives than by other sector leaders. However, school representatives did not view broad social problems (such as aging, youth, crime or cultural conflict) as important. Since their professional role involves dealing extensively with children and adolescents, a fairly high degree of awareness of adolescent problems among school representatives might be expected.
Business representatives perceived broad social issues as contributing to social problems, but did not perceive adolescent and alcohol problems to be important. Also, along with mayors, they perceived adolescent access to alcohol to be relatively difficult when compared with editors and school representatives. It is possible that the nature of business in this geographic region (tourism and recreation) combined with long-standing social traditions about alcohol use may have predisposed them not to consider adolescent alcohol access as of major import. Business leaders appeared to resemble mayors in their perceptions of adolescent alcohol problems and issues. The results indicated that both mayors and business representatives may require education about the issue to build its place among the most important community public health issues.
Editors perceived broad social issues such as aging, youth, crime and sexual harassment to contribute to social problems significantly more than the school representatives or police chiefs. They perceived teen suicide to be a major community adolescent health concern and thought it relatively easy for teens to gain access to alcohol. Given that one of the roles of the newspaper is to serve as a community news and information source, editors may be more sensitive to broad social issues including teen suicide and adolescent access to alcohol. However, very few editors perceived school and law enforcement agency programs as contributing significantly toward solving adolescent alcohol problems.
Police chiefs perceived teen crime to be a major contributing factor to adolescent concerns, but mentioned teen suicide as a problem significantly less than school representatives and editors. Health-related problems such as alcohol, drugs and chemical abuse were mentioned significantly more often by police chiefs when compared with business representatives. Again, the role of police chiefs in a community could explain their sensitivity primarily to crime-related issues (which also arise from health-related problems listed above).
Sample composition could explain certain interactions between sector leaders and gender, and educational attainment. For example, male leaders cited the local school administration as a key decision maker in alcohol and drug use-related programs significantly more than female leaders. Given that school representatives on the whole scored high on school/law sponsored program mentions and given the composition of school representatives (23 male and four female), the nature of the sample could have accounted for such an interaction. Education, awareness and action programs were mentioned more often by leaders with a college degree or more when compared with leaders with `some college or less'.
Leaders in the different sectors act as `gatekeepers' in the development of important community issues both in symbolic legitimization of the issues and in action to allocate resources to address them. In the case of adolescent alcohol access, this study suggests that decision makers in the government and business sectors of these small communities constitute a key audience for intervention efforts directed at policy change. While school representatives and police chiefs may enforce policy, and the media may serve a surveillance function in the development of policy, it is the government sector that holds a key political power base (Thompson, 1992) to change or modify policy. This is followed closely by (in this study) the business sector that could perhaps best implement many policies aimed at restricting teen alcohol access. In this light, awareness and acceptance of the adolescent alcohol problem, and a commitment to finding adequate solutions by providing a broad social change climate in these communities is needed, particularly among the representatives of the government and business sectors.
Notes
- Questionnaire items were developed based on the `community reconnaissance' method of Nix and Seerly (1971) and Nix (1977). This approach seeks information from a variety of community leaders about important local issues, power, influence and decision making to understand differences in how communities function. As such, it is a hybrid method of community analysis composed of elements of the positional, reputational and decision-making methods well documented in the community organization literature. For a fuller treatment of the method, see Finnegan et al. (1989).
- Interviewers recorded responses on the questionnaires and coded them according to the coding categories developed in the pre-test. An independent coder also coded responses, and discrepancies were then discussed and resolved. In the pre-test phase, we formally tested inter-coder reliability on the open-ended questions using Cohen's
which accounts for the proportion both of observed agreement and by-chance agreement. The on seven open-ended questions averaged 0.85 with a range of 0.73–0.91.
- This was done to examine the potential differences in perceptions of leaders in larger and smaller communities. Larger communities tend to have more pluralistic and differentiated social and leadership structures with several sectors playing significant roles in many spheres of community life (Tichenor et al., 1980).
- Duration of residency in a community may also affect perceptions through deep community ties, on the one hand, or through lack of them, on the other. Both could lead to different perceptions of the importance of an issue to the community.
- A greater number of liquor licenses in a community could be indicative of the greater role and influence of alcohol in the community's economy.
- The scale `systemic functioning' was obtained through factor analysis (varimax rotation) of leaders' responses to questions about their perceptions of the communities' (a) receptivity to change and newcomers, (b) degree of citizen participation in community decision making and (c) opportunities for the emergence of new leaders. Cronbach's on this scale was 0.70. The more leaders perceive their communities to function effectively, the less likely they may perceive a major teen alcohol problem.
- The scale `systemic provision' was also obtained through factor analysis of leaders' responses to questions about community (a) job opportunities, (b) recreational facilities, (c) quality of medical care and (d) ease of recruiting people to run for elective community offices. Cronbach's on this scale was 0.64. The more leaders perceive their communities as providing well for its residents, the less likely they may perceive teen alcohol as a major problem.
- The expectation of differences in leaders' perceptions was based in part on role theory. That is, perceptions are strongly influenced by the roles one plays in communities. Thus to some extent we expected educators and police chiefs to view teen alcohol use as a greater problem than other sector leaders because of their greater exposure to both the problem and the age group in their daily lives.
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Acknowledgments |
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This research was supported by a grant of the National Institute on Alcohol Abuse and Alcoholism (R01-AA08596), National Institutes of Health, Bethesda, MD.
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References |
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TopAbstractIntroduction and backgroundMethodsResultsDiscussionReferences |
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Anderson, P. (1993) Population and high-risk approaches: both necessary to reduce alcohol harm. Addiction, 88, 170–174.[ISI][Medline]
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