Community readiness in the system pilot of "Communities That Care" in BrazilAbstract
Community readiness involves the perspective of leadership on the need for changes within the territory, combined with the local capacity to promote them. "Communities That Care" is a prevention system being adapted in Brazil. This study aimed to assess community readiness with 34 community leaders from São Paulo and 36 from Florianópolis. The study employed a quantitative, descriptive, and cross-sectional methodology. Results indicated difficulties in driving change and structural differences between the communities; however, there was cohesion in leaders’ opinions. It was unanimously recognized that drug use is a risk behavior, but that drugs are easily accessible in these communities. There is a perceived urgency to implement preventive programs, although such programs are not well-known. The study concludes that investing in readiness assessment can be crucial to supporting community interventions.
Keywords:
Communities That Care; community readiness; prevention system; process evaluation; drug abuse prevention; cultural change
Resumo
Prontidão comunitária envolve a perspectiva de lideranças sobre a necessidade de mudanças no território, aliada à capacidade local para promovê-las. “Comunidades que Cuidam” é um sistema de prevenção em adaptação no Brasil. Objetivou-se avaliar a prontidão comunitária com 34 líderes da comunidade de São Paulo e 36 de Florianópolis. Este estudo possui metodologia quantitativa e descritiva, de recorte transversal. Resultados demonstraram dificuldades para produzir mudanças e diferenças estruturais entre as comunidades; entretanto, houve coesão de opiniões entre lideranças. É unânime que usar drogas é comportamento de risco, mas de fácil acesso nas comunidades. Há percepção de urgência para aplicar programas preventivos, ainda que muito pouco conhecidos. Conclui-se que investir na avaliação da prontidão pode ser importante para subsidiar intervenções comunitárias.
Palavras-chave:
Comunidades Que Cuidam; prontidão comunitária; sistema de prevenção; avaliação de processo; prevenção do abuso de drogas; mudança cultural
Community readiness is a broad concept that encompasses the perceptions of community leaders regarding the necessity of implementing changes within their territory, combined with the local capacity to develop actions that enable preventive transformations in response to significant community issues (Castañeda et al., 2012). The degree of readiness or preparation is specific to each community demand and is multifaceted in its structure. There is an ongoing discussion about its importance as a crucial element to be considered when organizing a community prevention action plan (Castañeda et al., 2012; Kostadinov et al., 2015).
Community readiness can be developed through a continuous training process, where the community gradually acquires fundamental knowledge of prevention science. This includes learning to analyze and produce data that help identify the community's real needs, recognizing and utilizing its own resources, and seeking new ones to enable preventive actions (Castañeda et al., 2012). Assessing readiness provides an overview of key outcomes related to changes in organizational processes and community norms, the quality of local leadership support, and other relevant aspects. This, in turn, fosters greater confidence in implementing training, strategies, and preventive programs (Kostadinov et al., 2015).
For preventive interventions to be successful, they must include multiple components and a variety of methods, along with systematic planning and a collaborative approach. Over the past decade, Brazil has implemented a series of school- and community-based prevention programs adapted to address alcohol and other drug use (Abreu et al., 2021). At this stage of the country's prevention science, the focus is on social mobilization through the strengthening of socio-community networks as permanent mechanisms for designing, developing, and implementing programs and actions. The goal is to ensure that preventive actions are planned and executed with the population to foster autonomy, rather than for the population, which could reinforce alienation (Paiva et al., 2012).
Communities That Care (CTC) is an evidence-based prevention system originating in the United States, currently undergoing a pilot cultural adaptation in Brazil under the name Comunidades que Cuidam (CQC)1 (Frandoloso, 2023). This prevention system aims to foster the organization and training of community leaders (Hawkins et al., 2008; Brown et al., 2011). Grounded in a public health approach, it employs a participatory and territory-based structure, enabling the development of tailored preventive planning based on the specific community profile (Hawkins et al., 2014).
The primary prevention outcomes targeted by the CTC system include reducing risk factors and promoting protective factors associated with alcohol, tobacco, and other drug use, as well as antisocial behavior and violence (Rhew et al., 2013). Studies indicate that the CTC system is associated with a 32% lower likelihood of participating youth engaging in alcohol abuse and a 25% lower chance of involvement in legal conflicts compared to a control group of youth not participating in the intervention. With a 30-year history, high-quality empirical studies, and adaptation in over 600 communities, CTC is recognized as one of the most widely implemented and evaluated prevention systems in the world (Brown, 2015).
Throughout its extensive implementation history, the CTC system has recognized the importance of considering the dimension of community readiness for change and incorporated this principle into its initial phase through the "Community Key Informant Survey" (CKIS) questionnaire (Oliveira Corrêa et al., 2020). Assessing the community's level of preparedness to implement CTC has become an essential first step in the prevention system. In the initial phase, implementers are tasked with interviewing and administering the questionnaire to key leaders to determine the community's readiness. In subsequent phases, the system leverages the strengths identified in this evaluation and develops strategies to address local barriers, encouraging openness to change through targeted actions (Parker et al., 2018).
The CTC system is regarded as an extremely promising preventive approach for Latin American countries such as Colombia, Chile, and Mexico (Thurow, 2020), particularly due to its potential to empower communities by fostering the development of higher readiness levels (Pérez-Gómez & Mejía-Trujillo, 2015). In Colombia, the system has been implemented in various communities, and the CKIS instrument was cross-culturally adapted. This experience reaffirmed the relevance of the questionnaire for diagnostic processes in assessing different levels of readiness across multiple profiles and areas of intervention (Oliveira Corrêa et al., 2020).
The adaptations of the CTC system for Latin America are relatively recent compared to its global implementation history, as are studies focusing on community readiness itself. Scientific production on community readiness is predominantly concentrated in developed countries (Chilenski et al., 2007; Feinberg et al., 2004; Hawkins et al., 2008) or in a few initiatives in Latin American countries, where research remains in its early stages (Oliveira Corrêa et al., 2020; Pérez-Gómez & Mejía-Trujillo, 2015; Thurow, 2020).
Despite Brazil's well-established history of community interventions-such as initiatives in favelas, low-income neighborhoods, grassroots ecclesial communities, and the robust development of community social psychology (Freitas Campos, 2015)-there is a noticeable lack of articles, books, and high-quality scientific publications addressing the dimension of community readiness in the context of implementing community strategies in Brazil. Notably, these community actions have yet to be specifically directed toward the preventive field. To address this gap, the present article aims to describe the initial process of assessing community readiness in the two participating territories, the preliminary evidence of the scale’s reliability, and its implications for the ongoing pilot implementation in Brazil.
Method
This study is characterized as quantitative, descriptive, and cross-sectional. In the field of prevention research, it represents an investigation within the implementation science of the Comunidades que Cuidam (CQC) Prevention System, undergoing a pilot cultural adaptation. The study took place between November 2020 and June 2023 in two Brazilian communities. It is part of a multicenter project titled “Pilot Study for the Cultural Adaptation of the Communities That Care Prevention System in Brazil,” involving the Federal University of Santa Catarina (UFSC), the Federal University of São Paulo (UNIFESP), and the University of Miami. The study was approved by the Ethics Committee for Research with Human Subjects (CEPSH/UFSC) under CAAE number 50477321.3.0000.0121 and opinion number 5.087.043, as well as by the Ethics Committee of UNIFESP under CAAE number 54755921.6.0000.5505 and opinion number 5.780.949.
Context
Communities with defined territorial boundaries and collaborative leadership interested in implementing prevention projects were selected-one in the Southern region and the other in the Southeastern region of Brazil. These locations must not have implemented preventive strategies for drug use or violence in the past two years.
In São Paulo, the selected community is the city's second-largest district by land area, although one of the least populated, covering 153 km² with 202,321 residents (Instituto Brasileiro de Geografia e Estatística | IBGE, n.d.). It is considered one of São Paulo’s communities with high social vulnerability. Like other outskirts of this Brazilian metropolis, it has some of the city's lowest urbanization indices. The community has a long history of struggles for land regularization and housing conditions, faces difficulties accessing public services, and is distant from the city center. However, it benefits from better preservation of the local environment, with remnants of the Atlantic Forest and Indigenous villages that protect their cultural heritage. As a result, the community was officially designated as São Paulo’s ecotourism hub, offering potential economic opportunities for this impoverished region (Subprefeitura de Parelheiros Cidade de São Paulo, 2024).
The community located in the capital of Santa Catarina spans an area of 22.45 km² and has a population of 7,378. It is one of the oldest communities in Florianópolis, with a cultural heritage rooted in Azorean colonization. Economically, the region has developed as a hub for mariculture and artisanal fishing, as well as a gastronomic and tourism center in the city (Instituto Brasileiro de Geografia e Estatística | IBGE, n.d.). It is considered an upper-middle-class neighborhood, with some of the most expensive real estate in the municipality. However, the population faces significant environmental challenges, such as inadequate sewage treatment. Approximately 20.9% of residents use irregular connections to dispose of wastewater, leading to the contamination of rivers, seas, and the degradation of the local environment (Sartorato, 2020).
Participants
The study included 70 key leaders, with 34 from São Paulo and 36 from Florianópolis. These representatives from both communities were of both genders, and most had lived in their respective communities for 11 to 30 years (38.2%, n = 13 in São Paulo; 50.0%, n = 18 in Florianópolis). In São Paulo, 47.6% (n = 10) of participants were aged between 41 and 50 years. In contrast, the largest age group in Florianópolis was between 61 and 70 years, representing 26.6% (n = 9) of the sample. Regarding education levels, 47.6% (n = 10) of participants in São Paulo held a university degree, while in Florianópolis, 52.9% (n = 18) had completed postgraduate studies.
These key leaders were involved in neighborhood associations or community councils (22.6%, n = 14 in São Paulo and 25.9%, n = 15 in Florianópolis); educational institutions (4.8%, n = 3 in São Paulo and 17.2%, n = 10 in Florianópolis); churches or religious centers of various denominations (12.9%, n = 8 in São Paulo and 12.1%, n = 7 in Florianópolis); non-governmental organizations (NGOs) or cultural foundations (11.3%, n = 7 in São Paulo and 6.9%, n = 4 in Florianópolis); commerce and service sectors (8.6%, n = 5 in both São Paulo and Florianópolis); security sectors (4.8%, n = 3 in São Paulo and 8.6%, n = 5 in Florianópolis); or were unaffiliated participants who joined independently (16.1%, n = 10 in São Paulo and 13.8%, n = 8 in Florianópolis). Representatives from public health institutions were reported only in the São Paulo community (6.5%, n = 4). This variability in the profile of leaders and the sectors represented by the participants is highly positive, as it provides a multifaceted perspective on the responses to the community readiness questionnaire.
Instrument
The Community Key Informant Survey (CKIS; Arthur et al., 2002) was used to evaluate indicators of community readiness for change. The original U.S. version of the instrument contains approximately 150 items. However, an adapted version for the Latin American context, previously applied in Colombia and Chile, was utilized. This version includes 16 dimensions, 32 items, and primarily uses a 4-point response scale: 1 - Strongly Agree, 2 - Agree, 3 - Disagree, 4 - Strongly Disagree (Oliveira Corrêa et al., 2020).
The Spanish-language version was translated into Brazilian Portuguese by four bilingual researchers who are leaders in the field of prevention in Brazil. The final version used in this study represents a consensus among the translators. Psychometric validation processes for the Escala de Prontidão Comunitária para Líderes-chave are ongoing and will be presented in future publications.
Oliveira Corrêa et al. (2020) conducted a latent profile analysis with 211 community leaders from 16 communities in Colombia, utilizing some of the dimensions mentioned above. Their study assessed the internal consistencies of the following dimensions: Norms regarding drug use (α = 0.80), Support for prevention (α = 0.63), Openness to change (α = 0.62), Community cohesion (α = 0.80), Conflict resolution (α = 0.60), Effective leadership (α = 0.86), and Accountability (α = 0.65).
Data collection procedure
The Escala de Prontidão Comunitária para Líderes-chave (Brazilian translation of the CKIS) was administered online through an interface created on the RedCap platform. The questionnaire link was emailed in August 2021 to participants registered for the first training session (Key Leader Orientation - KLO) before its commencement. At the end of the training, the link was resent along with the training evaluation form. Additionally, the questionnaire was shared via WhatsApp with other community leaders who expressed interest in the CQC system but were unable to attend the training due to scheduling conflicts.
Data analysis procedure
The statistical analyses conducted included descriptive analysis of item response frequencies and inferential analysis through internal reliability testing of the dimensions using the Statistical Package for the Social Sciences (SPSS, version 21.0). Reliability analysis was assessed using Cronbach's Alpha coefficient (α) (Souza, Alexandre, & Guirardello, 2017). The analyses focused on examining reliability indices for each of the 16 dimensions within each community.
The calculation of item scores was also conducted separately for each community and involved computing the arithmetic mean of the averages of responses provided for each item on a Likert scale. For most dimensions, the score calculation (M) included only data from participants who had completed all items. However, for dimensions with a Cronbach's alpha coefficient greater than 0.73, the inclusion of some incomplete responses (i.e., data from participants who did not answer all items) was permitted. The average standard deviation (SD) was calculated based on the mean scores derived from the entire sample (i.e., both communities).
The authors chose to detail the discussions of each score by analyzing the disagreements and agreements among leaders regarding the characteristics of their communities. This approach aimed to facilitate comparisons between the territories and assess their impacts on the community readiness dimension with a focus on prevention. Accordingly, item responses were categorically grouped as "disagree" and "agree" for most 4-point scales (disagree and strongly disagree X agree and strongly agree), and into three options for 5-point scales. Results that stood out in each community, encompassing at least 75% or more of responses (one-fourth of the sample), are presented as frequencies in the following section.
Results
Initially, the study sought to evaluate the reliability of the community readiness measure undergoing cultural adaptation for Brazil. The results indicated that most dimensions demonstrated acceptable reliability patterns for both target communities. A significant portion of the reliability values were satisfactory (approximately 0.70), high (approximately 0.80), or very high (approximately 0.90) across most constructs (Gliem & Gliem, 2003), suggesting good performance of the questionnaire and its potential applicability in the Brazilian context. Table 1 presents the number of responses for each dimension, along with the arithmetic means (scores), average standard deviations, and Cronbach's alpha values for each community.
Results of Internal Consistency and Community Readiness for Change Scores in the Communities of São Paulo (São Paulo) and Florianópolis (Santa Catarina)
Some exceptions emerged in certain dimensions that required exclusion or modification. The primary adjustment involved the dimension Norms about adolescent drug use. Upon inspecting correlations and indices of change, the items appeared to cluster into two distinct dimensions: Normalization of drug use and Perception of the risk level of drug use. This decision aligns with a prior publication that suggested the need to separate this dimension into two during the instrument's adaptation for a Latin American context (Oliveira Corrêa et al., 2020).
The dimension Conflict resolution showed extremely low internal consistency in the Florianópolis sample (α = 0.25), while the dimension Support for prevention exhibited very low internal consistency in the São Paulo sample (α = 0.31) and a borderline value for Florianópolis (α = 0.50). As a result, these dimensions were excluded from the score analyses for the communities. The details of the instrument's psychometric validation will be published in a separate article currently under submission to a scientific journal.
Table 2 displays the average percentages of total responses from key leaders in São Paulo and Florianópolis for the readiness-for-change dimensions of the instrument. Below, the most significant data for each community are presented, subdivided according to the proximity of the instrument's dimensions: (a) Structural issues in communities; (b) How communities are organized; and (c) Beliefs about drugs and the prevention agenda.
Average Percentages of Total Responses from Key Leaders in São Paulo and Florianópolis for the Dimensions of Readiness for Change
Structural issues in communities
The majority of leaders agreed that residents are experiencing economic hardships (95.2% in São Paulo and 84.1% in Florianópolis). In São Paulo, all key leaders who responded to the questionnaire (n = 21) agreed that people are facing financial difficulties and that many are unemployed. In Florianópolis, 93.1% (n = 27) agreed regarding financial struggles, and 70.4% (n = 19) acknowledged unemployment as an issue.
Regarding available jobs, 85.7% (n = 18) in São Paulo and 88.9% (n = 24) in Florianópolis agreed that salaries offered are undervalued and insufficient. When asked about the presence of impoverished individuals in the community, São Paulo leaders unanimously recognized this issue (100%, n = 21), while in Florianópolis, the poverty index was reported at 67.7% (n = 23). These indicators highlight notable differences in the socioeconomic conditions of the two communities targeted in this pilot study.
Regarding social indicators, there is a general perception that the vulnerability conditions in the São Paulo community are very severe, with 91.8% of its leaders in agreement. In the Florianópolis community, 72.1% of leaders perceived social indicators as severe. A detailed analysis of the items reveals that in São Paulo, 100.0% (n = 21) of leaders considered adolescent alcohol and drug use in the community to be very severe. In contrast, leaders in Florianópolis considered alcohol use to be very severe at a rate of 81.8% (n = 27) and drug use at 84.9% (n= 28).
Regarding conflicts with the law and violence, 95.2% (n = 20) of leaders in São Paulo considered these issues very severe, compared to 81.3% (n = 26) in Florianópolis. For teenage pregnancy, 95.0% (n = 19) in São Paulo considered it very severe, while in Florianópolis, the rate was lower, though still significant, at 76.7% (n = 23). São Paulo also showed elevated perceptions of the presence of gangs or factions (94.4%, n = 17), child prostitution (88.9%, n = 16), and low-quality education (95.2%, n = 20). Mental health issues such as depression and suicide were also highly reported, with 95.0% (n = 19) of leaders recognizing these as severe problems. In contrast, all these indicators in Florianópolis were reported at rates below 72%.
Economic vulnerabilities, perceptions of community members' involvement in violence, and other psychosocial issues are perceived by leaders as more severe in the São Paulo community. This aligns with certain social indicators identified by the researchers and highlights the potential impact on needs assessment and the design of specific interventions essential for prevention in each local context. Nonetheless, the leadership in both communities acknowledges the presence of significant problems, even though the data reveal some structural differences between the two communities.
How communities are organized
The dimension Community organization had the most frequent responses in the categories never and almost never, with 55.4% in São Paulo and 45.6% in Florianópolis. This result indicates a perceived weakness in community organization, particularly regarding the maintenance and cleanliness of the community, shared childcare responsibilities, and the availability of recreational activities in the area.
In the dimension of Accountability, a notable difference emerged between the perspectives of leaders in the two communities. In São Paulo, the majority of responses indicated never or rarely for items related to responsibility (54.3%), whereas in Florianópolis, the predominant responses were frequently and always (65.1%). In São Paulo, 75.0% (n = 15) stated that community members never or rarely fulfill their promises. In contrast, 73.1% (n = 19) of leaders in Florianópolis reported that community members are responsible for honoring their commitments. Despite these differences, leaders in both communities expressed that members are frequently or always willing to take on commitments to improve community life, with 85.7% (n= 18) in São Paulo and 73.5% (n = 25) in Florianópolis affirming this.
For the dimension of Community cohesion, 71.8% of leaders in Florianópolis agreed that the community is in harmony regarding its values and attitudes. In contrast, the perspective in São Paulo is more divided, with 52.3% agreeing and 47.7% disagreeing. In Florianópolis, 77.4% (n= 24) of leaders stated that people in the community can be trusted, and 87.9% (n = 26) said they are willing to help their neighbors. Additionally, 86.7% (n = 26) agreed that people tend to get along well, and 82.9% (n = 29) believed that individuals feel a sense of belonging to the community. For the same items in São Paulo, response rates did not exceed 68%, indicating a developmental need to foster community cohesion.
Regarding Effective leadership, responses in both communities showed a notable split between disagreement and agreement. In São Paulo, 46.9% of leaders disagreed, while 53.1% agreed that the leadership is effective in addressing community demands. Similarly, in Florianópolis, 43.1% disagreed, and 56.9% agreed, reflecting a comparable trend in perceptions of leadership efficacy.
The dimension of Conflict resolution showed a slight predominance of agreement among leaders regarding the community's ability to mediate conflicts, with 56.6% agreeing in São Paulo and 53.5% in Florianópolis. Disagreement rates were 43.4% and 46.6%, respectively. Further psychometric evaluations will be needed to deepen the analysis of this dimension, which consists of only three items and showed differences in internal consistency across the two samples.
Finally, regarding Collective efficacy, leaders largely disagreed that community problems are handled assertively and collectively, with 69.4% in São Paulo and 54.8% in Florianópolis expressing disagreement. Specifically, they disagreed that community groups have resources to address adolescent problems, with 90.5% (n = 19) in São Paulo and 96.6% (n = 28) in Florianópolis, and that residents participate together in decision-making, with 90.5% (n = 19) in São Paulo and 85.7% (n = 24) in Florianópolis. In São Paulo, 79.0% (n = 15) also disagreed that there is planning for what happens in the community. However, 76.7% (n = 23) of leaders in Florianópolis believe the community can solve its problems. Conversely, 79.0% (n= 15) of leaders in São Paulo believe that the community's problems are beyond the capacity of its members to resolve.
Beliefs about drugs and the preventive agenda
Regarding Availability of drugs in the community, the majority of leaders reported that it is easy for youth to access alcohol and other drugs (90.2% in São Paulo and 89.9% in Florianópolis). In Brazil, the most consumed legal drugs are alcohol and tobacco/nicotine, a reality reflected in the investigated communities. In São Paulo, 95.2% (n = 20) of leaders agreed that adolescents can easily access alcohol in the community, while in Florianópolis, 97.0% (n= 32) shared this perception. Similarly, 95.2% (n = 20) in São Paulo and 93.9% (n = 31) in Florianópolis believed it is easy for youth to access tobacco cigarettes.
Although marijuana is illegal in Brazil, it is reportedly easily accessible in these communities, with 90.5% (n = 19) in São Paulo and 90.0% (n = 27) in Florianópolis affirming its availability. For other illegal drugs such as cocaine, crack, and ecstasy, the perceived accessibility is slightly lower, at 80.0% (n = 16) in São Paulo and 78.6% (n = 22) in Florianópolis. These findings underscore a significant challenge regarding drug availability in the communities, even for underage adolescents who are theoretically prohibited from accessing both legal and illegal substances.
Another relevant point in the communities' perspectives on drugs concerns the perception of drug use as a normalized aspect of adolescents' daily lives. Responses to the dimension of Normalization of drug use were somewhat more divided than the previous dimension. However, 79.0% (n = 15) in São Paulo and 87.5% (n = 28) in Florianópolis disagreed with the notion that the use of illegal drugs (cocaine, crack, and ecstasy) is normal and expected during adolescence.
The availability and normalization of drugs could become more concerning if coupled with a perception that downplays the harms of adolescent drug use. However, this does not seem to be the scenario in the communities investigated. The results indicate that, in the dimension of Perception of the risk level of drug use, the communities largely agree that drug use is harmful or detrimental to the healthy development of adolescents (76.6% in São Paulo and 88.7% in Florianópolis).
This percentage varied slightly between communities and depending on the type of drug in question, as in the previous dimension. For alcohol, 81.8% (n = 27) of leaders in Florianópolis consider it harmful, compared to 78.8% (n = 26) for nicotine cigarettes. In São Paulo, these percentages did not exceed 64%, indicating a slight difference in perspective on drugs between the two communities.
However, for marijuana, 84.6% (n = 22) in São Paulo and 94.1% (n = 32) in Florianópolis classified it as harmful. This perception reaches 100.0% (n = 34) in Florianópolis for the most stigmatized illegal drugs, while in São Paulo, it represents 96.2% (n = 25) of responses. In summary, there is a consensus that drugs are available in the communities and their use is seen as common, with the exception of more stigmatized illegal drugs. Nevertheless, drug use is overwhelmingly perceived as a risky and harmful behavior, both for individual health and for the community at large.
Responses regarding Collaboration between members and sectors were similar between the two communities, with a slight majority of 52.9% in São Paulo and 52.8% in Florianópolis disagreeing that there is sufficient collaboration within the community to address its demands. However, organizations and institutions in both communities expressed willingness to play a specific role in implementing a plan to prevent risk behaviors among adolescents. This was agreed upon by 95.7% (n = 22) in São Paulo and 80.0% (n = 24) of leaders in Florianópolis.
Despite this, other areas of disagreement became apparent. In São Paulo, 75.0% (n = 15) of leaders stated that there is no network in place to ensure the well-being of children and adolescents. In Florianópolis, the main challenges reported by the community were related to coordinating simultaneous preventive strategies (79.3%, n = 23) and sharing resources (76.9%, n = 20) to implement initiatives focused on adolescents.
Regarding community members' commitment and participation, a majority of 73.7% in São Paulo and 66.7% in Florianópolis disagreed that there is Community ownership for prevention. Responses indicate that key leaders disagree that residents actively participate in decision-making, with 81.0% (n = 17) in São Paulo and 80.0% (n = 24) in Florianópolis expressing this view. In São Paulo, there was also a notable difficulty in engaging residents in community activities, with 81.5% (n = 22) of leaders highlighting this challenge.
The results for the dimension Openness to change indicated a willingness among community members to test new ideas for solving problems, with 72.0% of key leaders in São Paulo and 87.1% in Florianópolis agreeing. However, openness to change remains a challenge. In São Paulo, 51.9% (n = 14) of leaders perceive the community as resistant to change. Conversely, the majority in Florianópolis, at 57.6% (n = 19), believe the community is open to change.
The dimension of Support for prevention examined the belief in and knowledge of prevention approaches within the community. Results showed that 63.8% in São Paulo and 56.5% in Florianópolis disagreed that there is community support for prevention. In both communities, there was a strong reluctance to pay higher taxes to support prevention programs, with 84.2% (n = 16) in São Paulo and 93.3% (n = 28) in Florianópolis unwilling to do so. Regarding the legitimacy of preventive actions, 75.8% (n = 25) in Florianópolis agreed that it is possible to reduce adolescent problems through prevention programs. In contrast, 76.2% (n = 16) in São Paulo reported being unaware of prevention programs.
Regarding Urgency for prevention, 100.0% of leaders in São Paulo and 95.8% in Florianópolis identified preventive approaches as important for addressing adolescent needs. Both communities stood out positively in recognizing the importance of preventing unhealthy behaviors among youth, such as drug use, crime or legal conflicts, violence, and school dropout. Finally, the results related to prevention highlighted the need to invest in training programs that foster support, engagement, and collaboration among community members and sectors for preventive initiatives, even though their importance is already well understood.
Discussion
Structural issues in communities
The concept of social inscription encompasses two dimensions: the first is integration into the workforce, with its associated conditions, risks, and protections; the second involves proximity relationships, including family, neighborhood, and other social and community connections, which provide individuals with conditions of protection and security (Castel, 1998). In this context, it is important to consider how proximity relationships can create conditions of either risk or protection for individuals, thereby establishing a direct link to the principles underlying preventive actions, such as those focusing on drug use and violence.
In assessing the community readiness of the two target territories in the pilot study of the Comunidades que Cuidam (CQC) Prevention System in Brazil, it was observed that the conditions of vulnerability, as discussed above (Castel, 1998), are more pronounced in the São Paulo community than in Florianópolis. Nonetheless, the leadership in both territories highlighted the presence of economic challenges and weaknesses in local indicators.
According to the most recent census in 2022, São Paulo retains its position as having the highest GDP in Brazil, while Florianópolis ranks 51st nationally. However, both cities are tied for 10th place in terms of average monthly formal worker earnings, at 4.4 minimum wages (Instituto Brasileiro de Geografia e Estatística | IBGE, n.d.). Regarding key leaders' perceptions of structural issues, the São Paulo community showed a higher percentage of risk across all indices. These included financial problems, unemployment, and low income, as well as severe adolescent alcohol and drug consumption, conflicts with the law, violence, teenage pregnancy, the presence of gangs or factions, child prostitution, low-quality education, and mental health issues such as depression and suicide.
Addressing these structural determinants and compensating for historical injustices requires, on one hand, large-scale policy changes, while, on the other, it necessitates the task of planning practical changes in the social determinants within communities (Brownson et al., 2021). Although preventive actions alone cannot alter macro-level determinants, they must take them into account when planning interventions. Such interventions should aim to address the dialectic between the production of subjectivities and lifestyles that reflect various levels of social determination.
In other words, the CQC cannot change the historical differences that shaped the socioeconomic constitution of these two communities, each with distinct characteristics. However, it can address the processes that exacerbate youth vulnerability by strengthening life skills and empowering young people to confront contextual pressures. Additionally, it can foster critical reflections among families and community leaders on how economic vulnerabilities serve as risk factors for involvement in violence and drug use. Preventive systems like the CQC can support community self-management by creating spaces and conditions for addressing various social problems that require attention. They can also strengthen social bonds and community potential, fostering autonomy in tackling health challenges. In doing so, such systems can positively influence socioeconomic disparities, becoming a protective factor (Paiva et al., 2012).
How communities are organized
It is important to highlight how individuals participate in decisions regarding collective agendas, whether there is cohesion in these efforts to improve the territory, and the perceived effectiveness of community leadership and the necessary coordination for advocating local improvements. In this context, understanding how communities are organized can significantly impact the effectiveness of the preventive plan developed by community coalitions (Castañeda et al., 2012). Improving collective efficacy indices involves fostering a positive vision of the community so that its members recognize it as a powerful force for transformation (Edwards et al., 2000).
The communities of Florianópolis and São Paulo stood out positively for the cohesion of their opinions and ideas regarding the community, its functioning, and attitudes toward prevention. However, both communities demonstrated difficulties in driving changes within their territories. For this reason, fostering the coordination of existing initiatives and leadership, enhancing collective actions, and developing a rationale for integrated care systems could be a crucial step toward changing attitudes and encouraging community engagement for meaningful territorial transformations (Kostadinov et al., 2015).
The adoption of evidence-based preventive strategies is one of the core elements of the CQC system (Frandoloso, 2023). Alongside the implementation phases, knowledge and skills are developed with a focus on scientific prevention approaches and the productive functioning of coalitions, enhancing joint actions and strengthening interpersonal and intersectoral relationships. These changes are essential for achieving long-term outcomes within the prevention system, as they foster shifts in community organization with an emphasis on autonomy, empowerment, and leadership engagement in preventive actions with demonstrated efficacy indicators (Brown, 2015).
Beliefs about drugs and the prevention agenda
The two target communities of the CQC pilot study in Brazil share the perception that drugs are easily accessible within their territories and that their use is considered common among young people and their families. This is especially true for legal substances such as alcohol and tobacco, as well as marijuana, which is illegal in Brazil but already subject to an initial movement toward normalization and legalization. On the other hand, drug use is overwhelmingly understood as a risky and harmful behavior for both individual health and the community environment.
Evaluations of the implementation process of “Communities That Care” (CTC) have shown that strengthening anti-drug norms within communities led to a reduction in youth drug use during both the implementation and sustainability phases of the prevention system (Rhew et al., 2013). These findings align with the CTC theory of change, which posits that high levels of community readiness and engagement, the promotion of positive bonds, clear norms, recognition of prosocial behaviors, and the adoption of an evidence-based perspective can collectively foster healthy behaviors among youth (Brown et al., 2011).
The majority of leaders in the two Brazilian pilot communities recognized the urgency of addressing prevention issues. Despite this sense of urgency, there is limited knowledge about evidence-based preventive strategies and programs, as leaders reported a degree of local unawareness regarding these initiatives. In both communities, a prevention approach rooted in the outdated and criticized "war on drugs" model still prevails. This model relies on disseminating information through lectures by experts and former drug users, using fear-based tactics and descriptions of substance effects (Abreu et al., 2021; Freitas Campos, 2015).
This is a critical issue to address, as a community’s trust in evidence-based prevention approaches is directly associated with reductions in alcohol and drug use and violence rates (Hawkins et al., 2014). For example, in the United States, a randomized clinical trial revealed greater acceptance of evidence-based preventive strategies among communities implementing the CTC system compared to control communities, following a period of one to four and a half years of implementation (Brown et al., 2011). Leaders in CTC communities continued to report higher stages of adoption of science-based approaches even during the sustainability phase (Rhew et al., 2013). CTC training sessions on "what is evidence-based prevention" have been highlighted by community leaders as highly relevant for promoting this new perspective and fostering openness to prevention science (Gloppen et al., 2016).
Communities being open to change are the starting point for the success of any intervention strategy in a given territory, and the implementation of the CQC system is no exception (Basic, 2015). One of the greatest challenges in this first cultural adaptation of the CQC in Brazil, beyond building knowledge in prevention science, may be the development of tools to improve community readiness levels and effectively prepare communities to become protagonists of significant changes in their territories (Frandoloso, 2023). In this context, CTC interventions that provide continuous training for leaders and members of the community coalition in prevention science may be an essential resource. These efforts can help communities move from a stage of contemplation to one of effective action for change (Gloppen et al., 2016).
Finally, understanding the readiness for change of a community, school, or other institution is a critical step in the implementation of high-quality preventive strategies, grounded in scientific perspectives and with strong adherence rates among the target population. Readiness acts as a measurable moderator of the effectiveness, efficiency, adherence, and feasibility of both the implementation process and outcomes. It also provides indicators of the sustainability of preventive interventions (Basic, 2015; Chilenski et al., 2007).
Final considerations
This research, related to the cultural adaptation of the Comunidades que Cuidam (CQC) Prevention System, highlighted the importance of considering the dimension of readiness to establish a well-structured, community-based preventive plan. Community readiness for change enables the community to take a leading role in the set of activities to be developed, thereby fostering a stronger connection with local values and dynamics, ultimately enhancing the effectiveness of the interventions.
The theme of community readiness remains underdeveloped in Brazil, despite the country's strong tradition of socio-community interventions. Thus, discussing the concepts and theoretical foundations of this construct, as well as adapting or developing instruments to evaluate it, is an important initiative. In addition to contributing to the science of prevention in Brazil, community readiness for change can engage in meaningful dialogue with the well-established field of community social psychology in the country, as well as other community-based initiatives that focus on leveraging the strengths present in local territories.
The CQC, as a preventive system, has shown promise for implementation in Brazil by contributing to the reflection and improvement of community-based interventions. It provides a solid foundation for evidence-based preventive programs targeting alcohol and drug abuse. This study represents a pioneering effort in exploring the concept of community readiness within the context of implementing a preventive system in the country. New studies involving additional communities and other Brazilian regions are now underway to further assess the system's feasibility and effectiveness in strengthening community prevention efforts in Brazil.
The Escala de Prontidão Comunitária para Líderes-chave is currently undergoing cultural adaptation for Brazil and, at this stage of the pilot study, has not yet completed all the necessary phases for full psychometric validation. Additional verifications are needed to confirm the reliability of its results. Consequently, the findings should be interpreted with caution, requiring further studies once the CQC instruments are fully validated for the Brazilian context. Another limitation to note is that this research involved a case study of two communities with highly specific realities, which cannot be generalized. Nevertheless, it provides some insights into the challenges of addressing the construct of community readiness in Brazil, given the country's diverse community realities.
Further investigative activities are needed to continue the process initiated in this pilot study of adapting the CQC to Brazil. Initially, a psychometric study of the Escala de Prontidão Comunitária para Líderes-chave instrument should be conducted. Subsequently, new applications of the instrument should be performed, including comparisons of pre- and post-intervention data from the CQC. These studies are essential to determine whether the system effectively improves community readiness indices regarding drug use prevention, violence, or other topics of public or academic interest.
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1
In this article, we ask readers to pay attention to the terminology used for the preventive system, as both versions will be referenced: the original name, “Communities That Care” (CTC), will be used when referring to descriptions and studies from the United States or other international contexts. When discussing the system's adaptation process in Brazil, it will be referred to as “Comunidades Que Cuidam” (CQC).
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Data Availability Statement
Research data is available on request from the corresponding author.
Research data is available on request from the corresponding author.
