Summary
Cross-sector cooperation, working from evidence and sustainable implementation are central challenges for municipal health promotion. The international prevention system Communities That Care (CTC) addresses all three. With a systemic, multi-level strategy it aims to prevent alcohol and drug misuse, violence, delinquency, school dropout and depressive symptoms among adolescents. Developed in the United States, the system has been shown there to be effective and cost-effective, and it has since been transferred to a number of European countries.
CTC is grounded in theory and empirical evidence and follows a five-phase process model. Essential for acceptance and for evidence-based delivery is the formation of a cross-sector coalition whose members receive advice and training over several years. Local actors are enabled to deploy a model of system change at municipal level and to implement it for the long term. The aim is to select evidence-based measures on the basis of data and need, and to implement them with regard to local conditions, in order to reduce , strengthen and so improve the health of young people. Validated instruments – the CTC youth survey and a register of evidence-based programmes – support the process.
As a systemic intervention, CTC integrates existing local structures and organisations and binds them into the whole process through new decision-making and development bodies. In this way the potential in a municipality can be used as fully as possible, resources pooled, energies released and transparency created.
Introduction: three challenges
The mental health of children and young people, and the systematic prevention of mental health problems in the first phase of life, feature in the health goals of most European countries, and health promotion at municipal level is increasingly written into national strategies. Delivery on the ground, however, is often uncoordinated: existing planning aids go unused, and the evidence base for many local approaches has substantial gaps. Multi-level strategies and systemic transformations have the potential to strengthen skills, embed measures in everyday settings and pool resources. Complex interventions of this kind require careful planning and coordinated implementation if the many structural, professional and methodological challenges are to be met.
Challenge 1: crossing sector boundaries
The mental health of adolescents – with its symptoms of school avoidance, experience of violence, depression and anxiety, and addiction – touches health, social services and education as much as it touches crime prevention. Despite the many overlaps in goals and methods, cooperation at municipal level is usually partial at best, held back by differences in professional understanding, by legal frameworks and by structures that have grown up separately.
Cross-sector networking and the involvement of a wide range of key actors are regarded as success factors for opening up fields of action, local data and resources. A cross-sector network is a dynamic system, subject to a longer process that aims at transforming organisational cultures and practices, and also the understanding of health and how it is promoted. Essential for successful, long-term cross-sector cooperation is capacity building: a shared mission, participation, model- and theory-guided strategies and transparent communication (Walter et al., 2019).
Challenge 2: working from evidence
Working from evidence is regarded as central if prevention and health promotion are to be established permanently as a strong pillar of the health system. So far, this potential is largely untapped in most countries. In practice there is limited knowledge of the benefit of an evidence base and of the national and international findings that already exist; the relevance of evidence-based recommendations is often still contested, and is perceived as colliding with fundamental principles of health promotion such as participation. To foster evidence-based – or better, evidence-informed – decisions, findings on the origins of (mental) health, theories of change and the available evidence must be prepared in a form that practice and policy can use. A database of systematically appraised evidence of effectiveness is the recognised way to support local actors in choosing programmes; the evidence registers page describes the European and national registers that exist for this purpose.
Numerous evaluated programmes, most of them focused on individual behaviour, now exist in Germany and other European countries; in the German-language evidence, as expected, the effects of universal programmes lie in the small to moderate range (Beelmann et al., 2014). For their effectiveness, the quality of implementation is especially important. Pragmatic changes made in passing, which are common, should be avoided; reflective, culturally sensitive adaptation is more effective (Sundell et al., 2016).
Challenge 3: anchoring for the long term
If prevention and health promotion are to become a strong pillar of the health system, they must also be anchored systemically in the municipality, and the measures taken must undergo continuous quality development. That requires not only a consensus among everyone involved but also their training and instrumental support.
Communities That Care, developed in the United States and now in use on several continents – at the time of writing, the authors listed the United States, Canada, Germany, Sweden, Switzerland, the Netherlands, the United Kingdom, Cyprus, Croatia, Australia, Colombia and Chile – addresses all three challenges. It starts from the municipality as the umbrella setting and draws in the other settings of daily life and the service systems. (The Europe page on this site tracks where the system is active today.)
This article aims (1) to give an overview of the CTC prevention system and its central elements, (2) to set out the existing evidence and (3) to describe, with one European country as the example, how the system is adapted when it crosses a border.
The prevention system
Development in the United States
The CTC concept, developed in the United States by an interdisciplinary research group, dates back to the early 1980s (Hawkins, 1999; Hawkins & Catalano, 2005). The initial aim was to design, on a sound theoretical and empirical footing, an effective approach to preventing substance misuse, violence and delinquency among adolescents (Harachi et al., 1996). From the late 1980s the development of the CTC system merged with the ideas of health promotion, above all (Fagan et al., 2019): (1) the combination of interventions aimed at individual behaviour with interventions aimed at conditions, (2) a focus on risk and protective factors, and (3) the empowerment of communities to identify their local need for prevention and health promotion objectively and to influence it effectively. In the 1990s CTC was developed further in a participatory process with 472 communities in the United States and tested at more than 500 sites (Fagan et al., 2019). During this phase the evidence grew that the health effect of community-based health promotion depends on addressing specific local needs and on the preventive measures being owned by the community (Harachi Manger et al., 1992).
At the core of CTC’s further development was the attempt to overcome two widespread problems (Hawkins et al., 2008a): (1) the use of measures without sufficient scientific evidence and (2) the inadequate implementation of measures that had been shown to be effective. Many studies had also shown that participatory community networks for prevention and health promotion do not by themselves lead to effective community-based health promotion (Hawkins et al., 2008a).
The developers of CTC therefore built into the system the factors regarded as prerequisites for effective cross-sector cooperation at local level, the community coalition (Hawkins et al., 2008a): (1) clearly defined, measurable goals and outcomes, (2) the establishment of high-quality data sources and a monitoring system, (3) the use of evidence-based programmes combined with monitoring and quality management, and (4) evaluation of the implemented programmes against meaningful outcomes.
The core of the CTC prevention system (Hawkins et al., 2008a; Gloppen et al., 2016) is the bringing together and training of municipal decision-makers and the building or extension of a municipal cooperation network for prevention and health promotion. This systemic intervention (described below) rests on five phases, each with its own benchmarks and milestones, which help the community to monitor and steer its implementation progress (for details see Quinby et al., 2008).
The theoretical and empirical basis
From the outset CTC has rested on theoretical concepts and empirical findings, which are outlined here.
The concept of risk and protective factors is the central foundation. Burdens and resources in childhood and adolescence substantially shape the development of young people, the formation of health-related behaviour and their (mental) health. Individual resilience is closely bound up with contextual factors in the family, the peer group, the school and the (Bengel et al., 2009; Rönnau-Böse & Fröhlich-Gildhoff, 2015). The factors overlap considerably in their effects; they act across a wide range of psychosocial problems and behaviours (O’Connell et al., 2009; Hawkins et al., 2004), and risk profiles differ at small scale between towns, districts and neighbourhoods (Monahan et al., 2014). This makes it possible to address the particular burdens of one place, to strengthen its resources, and to prevent in several problem areas at once.
The (SDM), the developmental theory behind the CTC approach, builds on the protective factors (Hawkins & Weis, 1985; Catalano & Hawkins, 1996). Strengthening them in the settings named above – through participation, the fostering of skills and a culture of recognition – supports the goal of promoting healthy behaviour in children and young people. This happens through stronger bonds to the people and settings that serve as models for behaviour. The original article renders the model as an ascending sequence: individual characteristics are taken into account; families, schools, neighbourhoods and peer groups provide opportunities for participation, foster skills and give recognition; from these grow personal and structural bonds to those settings; the settings transmit social norms, values and clear standards; and the outcome is the positive development of children and young people (after Hawkins, 1999).
The CTC theory of change maps the whole prevention system, together with the short-, medium- and long-term results to be expected at the macro, meso and micro levels, in a logic model. Systemic interventions such as cross-sector cooperation thereby become an approach to prevention and health promotion in their own right at the macro and meso levels, in order to achieve change at the meso and micro levels in particular. The logic model, extended from Hawkins et al. (2008a), runs in six steps:
- Input: advice, training, instruments and services.
- Throughput (from 12 months): a functioning team and a coalition able to act.
- Short-term outcomes (from 24 months): adoption of a science-based approach; cooperation and support for prevention; shared normative orientations; a social development strategy.
- Output (from 24 months): selection and introduction of suitable, effective prevention programmes.
- Intermediate outcomes (from 36 months): reduction of risk factors and strengthening of protective factors.
- Long-term outcomes (from 60 months): less problem behaviour and better health.
The first steps belong to the macro level of the municipality, the middle ones to the meso level of settings such as schools, and the last to the micro level of the individual. The model assumes that (1) the educational measures – training and process consultation – strengthen the skills of those involved and their cooperation, and support the building of structures and resources (coalition capacity); (2) the coalitions thus built bring about a system transformation in the municipality (more science-based practice and inter-organisational cooperation, a change in health-related norms, the establishment of a social development strategy); (3) the municipalities address their empirically identified local needs with evidence-based measures and steer this process under quality assurance; and (4) among children and young people, contextual risk factors are reduced and protective factors increased, problem behaviour gives way to healthier behaviour, and ultimately the (mental) health of adolescents improves.
Effectiveness
The (CYDS) in the United States examined the effectiveness and cost-effectiveness of CTC and continues to do so in a long-term study. This randomised controlled trial includes 24 communities in seven US states (Hawkins et al., 2008a). Numerous publications on the short-, medium- and long-term effects at different levels are now available, each following the logic model above.
At the macro level, the degree of science-based prevention and health promotion rose markedly. The odds of reaching the highest level of the adoption score – the degree to which a science-based approach to prevention has been taken up – were more than five times higher for CTC communities than for control communities (odds ratio [OR] = 5.37; Brown et al., 2011). The effect was still detectable five years later (OR = 4.0; 95 % confidence interval [CI] 2.51–5.49; Quinby et al., 2008). It depends on the success of coalition capacity building (Shapiro et al., 2015) and is mediated by the acquisition of new prevention skills and by inter-organisational networking. The already high quality of implementation of the evidence-based measures was maintained over years and was still evident two years after the study ended (Fagan et al., 2012).
At the meso level, first effects were visible just under three years, and in some cases 1.67 years, after the evidence-based measures had been targeted at identified needs (Hawkins et al., 2008b). In a multivariate model, the risk factors each CTC community had prioritised fell slightly on average – for example low commitment to school, friends who engage in problem behaviour, family conflict, rebellious attitudes, and community norms that condone adolescent alcohol and drug use.
At the micro level, children and young people outside CTC communities showed, compared with those inside them, higher incidences of first alcohol use (OR = 1.60; p < 0.05), first cigarette smoking (OR = 1.79; p < 0.05), first delinquent behaviour (OR = 1.41; p < 0.05) and first use of smokeless tobacco (OR = 2.34; p < 0.01; Hawkins et al., 2009). Adolescents outside CTC communities also showed higher prevalences of alcohol use (OR = 1.25; 95 % CI 1.04–1.52), smokeless tobacco use (OR = 1.79; 95 % CI 1.23–2.62), binge drinking (OR = 1.40; 95 % CI 1.07–1.84) and delinquent behaviour (OR = 1.34; 95 % CI 1.20–1.49; Hawkins et al., 2009). Long-term effects were still evident when the cohort of fifth-graders had reached the age of 21 (Fagan et al., 2019).
Alongside PROSPER, an intervention used only in the United States (Spoth et al., 2013), CTC is thus the only approach for which randomised trials show effects at community level. According to a mediation analysis, 96 % of the lower prevalence of problem behaviour among pupils in CTC communities is attributable to their stronger adoption of a science-based approach to prevention (Brown et al., 2014).
Economic evaluations show that CTC is also a good investment in monetary terms. With implementation costs of 556 US dollars per adolescent, the net benefit after five years was 3,920 dollars per adolescent, a benefit-cost ratio of 8.22 to 1 (Kuklinski et al., 2015). Long-term analyses twelve years after baseline, when the participants were 23, show a benefit-cost ratio of 12.88 to 1 for the primary outcomes (alcohol, drugs, antisocial behaviour); if secondary outcomes such as school completion are included, the ratio rises to 30.62 to 1 (Kuklinski et al., 2021).
The evidence page on this site places these findings alongside the Australian replication, the German evaluation and the more cautious 2025 verdict of the UK Youth Endowment Fund.
The instruments
Needs analysis and evaluation: the CTC youth survey
An essential component of the CTC system is the youth survey. The online questionnaire covers the fields of violence, delinquency, alcohol and drug misuse, school dropout, teenage pregnancy, depressive symptoms and wellbeing. It also records risk and protective factors in four domains, illustrated here with examples from the German adaptation (Groeger-Roth et al., 2015):
- Family (risk: poor family management, parental approval of antisocial behaviour; protection: family cohesion, family opportunities for prosocial involvement);
- School (risk: falling behind academically, lack of commitment to school; protection: school opportunities and recognition for prosocial involvement);
- Children and young people (risk: alienation and rebelliousness, friends who show antisocial behaviour or use substances; protection: moral beliefs and clear norms, interaction with prosocial peers);
- Neighbourhood (risk: social disorganisation and lack of attachment to the neighbourhood, perceived availability of alcohol, tobacco, drugs and weapons; protection: opportunities and recognition for prosocial involvement).
When CTC crosses a border, the survey is translated, adapted and re-validated. The German version, for instance, was tested on a representative sample and proved transferable in practice, with methodological modifications (Groeger-Roth et al., 2015). Reference values matter too: where a region runs a periodic survey of its own – Lower Saxony has surveyed a representative sample of pupils every two years since 2013 (Soellner et al., 2018) – a municipality can read its profile against that benchmark and say something precise about its local need. The youth survey page describes the instrument and its European adaptations in more detail.
Evidence-based measures: a register
The fourth phase of CTC asks a community to match its prioritised factors to programmes with demonstrated effect. That requires a register of programmes reviewed against explicit standards of evidence. The US original is Blueprints for Healthy Youth Development; several European countries have since built their own, and the European Xchange register lists interventions evaluated in Europe. Where no register existed, CTC has been the reason to build one: the German register was set up in 2011 specifically to support the CTC process and is now known well beyond it (Groeger-Roth, 2015; Brender et al., 2024). The evidence registers page sets out the options for a European community.
The systemic intervention at municipal level
The CTC prevention system consists of five phases, which correspond to the public health action cycle (problem definition, strategy formulation, implementation, assessment) and to the plan-do-check-act cycle. Over the whole period, which can exceed two years, those involved are trained in five training units and accompanied by process consultants. Specific instruments with defined goals, milestones and benchmarks serve quality assurance and quality development and support the process.
On the basis of the materials, training, surveys and consultancy provided, local actors are enabled to deploy a theoretically and empirically grounded model of system change at municipal level and to implement it for the long term. The aim is to select evidence-based measures on the basis of data and need, and to implement them with regard to local conditions, so as to reduce risk factors, strengthen protective factors and thereby improve the health of young people. As a systemic intervention, CTC integrates existing local structures and organisations and binds them – and residents – into the whole process through new decision-making and development bodies. In this way the potential in a municipality can be used as fully as possible, resources pooled, energies released and transparency created.
Phase 1: preparing for CTC
First, the structural and staffing prerequisites for establishing CTC in the municipality are created. These include forming a core group of decision-makers from the central institutions, identifying a key person to champion the overall process in the municipality, and settling who will coordinate CTC. Existing networks can be used and, where necessary, extended. The necessary framework conditions must also be clarified and agreed.
Phase 2: introducing CTC and building support
A survey of children and young people is conducted and analysed externally to establish the baseline and the prevention needs (elevated risk factors, weak protective factors; see phase 3). A steering group is founded, chaired by an influential person – as a rule the mayor or the head of the county administration. A , to be founded at the same time, should include the most important local institutions and experts in child and adolescent health and in prevention and health promotion.
Phase 3: creating a community profile
At the centre stands the identification and prioritisation of the central risk and protective factors and problem behaviours. Alongside the youth survey, the profile draws on regional health-reporting data, on administrative data such as child-welfare caseloads and indicators of social deprivation, and on police crime statistics. Existing prevention and health-promotion services are also analysed, in order to use existing structures and expertise, close gaps and avoid duplication.
Phase 4: creating an action plan
Those involved define verifiable goals for the problem behaviour to be addressed, the strengthening of protective factors and the reduction of risk factors. To this end, evidence-based programmes are selected from a register according to need, and a concept is drawn up for how existing services can be linked with the newly selected ones. It is essential that the steering group approves the action plan, so that the plan is owned by the municipality and the necessary resources are made available.
Phase 5: implementing the action plan
The selected measures are now implemented and delivered. The organisational structure required is reviewed, further institutions are brought in where necessary and cooperation agreements are concluded. This phase has no time limit. To measure changes at the behavioural level in the risk and protective factors the municipality has prioritised, the youth survey is repeated every two to three years. It also provides the basis for adjusting the action plan.
Municipalities differ greatly in their starting points and framework conditions for a concept such as CTC. One important condition is the size of the municipality, and the complexity of the local landscape of actors that follows from it. In Germany, CTC has been implemented above all in rural counties and smaller municipalities, but there is now positive experience in larger cities too: one large city reported that CTC had, among other things, improved cooperation between the planning departments for youth, schools, urban planning and health within the municipal administration.
Crossing a border: what the German adaptation shows
CTC was adapted to the German context between 2009 and 2012 in an EU-funded pilot led by the Crime Prevention Council of Lower Saxony. The transfer covered (1) the systemic intervention concept at municipal level, (2) the youth survey and (3) an evidence register. After a feasibility study (Schubert et al., 2013), CTC has been implemented as a regular programme in Lower Saxony since 2013 (Groeger-Roth, 2018), and a national transfer office founded in 2018 supports implementation in other federal states. The concept addresses municipalities of different size and structure – counties, cities and city districts – and a resolution of the municipal council is a precondition for taking part, to secure broad local acceptance and readiness. As in the US original, the German CTC system rests on the Social Development Model, the logic model and the five-phase intervention.
The adaptation was above all structural and cultural. Unlike in the United States, CTC in Germany as a rule builds on existing structures and networks and can extend them in staff and structure. While volunteers dominate the community coalitions in the United States, Germany works primarily with the existing professional structures. The accompanying training was adjusted accordingly, and the CTC instruments were adapted linguistically and culturally. Much of this is likely to hold for other European welfare states, where a municipality bringing schools, youth services, health services and police to one table is convening professionals who already exist rather than recruiting volunteers who do not.
Conclusion and outlook
Interventions aimed at conditions, and combined interventions aimed at both behaviour and conditions, are implemented and evaluated less often than their recognised importance would suggest, partly because of their complexity and the lack of adequate study designs. That applies to municipal prevention and health promotion with its systemic steering of cross-sector coalitions as well. Precisely for complex interventions that act over the long term, changes in (mental) health among the ultimate beneficiaries are rarely measured, and the linking of output and outcome parameters, and of primary and secondary data, is often missing.
This is where the CTC prevention system comes in. With careful implementation and intensive support for the municipalities, positive effects appear at every level, and they last.
CTC is an evidence-based intervention strategy that is consistently grounded in theory, incorporates empirical findings and is implemented under quality assurance. Its aim is to enable municipalities to develop a locally tailored strategy for preventing psychosocial problems among adolescents. In doing so, CTC tries to reconcile the demands of evidence and participation, so as to achieve the widest possible acceptance of a science-based approach. Transferred to Germany some fifteen years ago and adapted structurally and with cultural sensitivity, the systemic intervention has since spread across several federal states, and adaptations exist in a number of other European countries.
At the time the original article was written, a federally funded study, CTC-EFF (2020–2023), was examining in a cluster non-randomised controlled trial whether the effects of the original US study can be replicated in Germany, in 22 matched pairs of CTC and comparison municipalities of varying size and social structure in four federal states (Röding et al., 2022, 2026). First, cross-sectional analyses showed clear associations: municipalities with strong prevention cooperation implement science-based prevention far more often (OR 26.05), as do municipalities with strong community power (OR 19.29; Birgel et al., 2023a); and where overall municipal prevention capacity is higher, adolescents use substances less often (OR 0.28; for alcohol OR 0.30, for tobacco OR 0.09; Birgel et al., 2023b). Both papers rest on cross-sectional data and demonstrate associations, not causal effects.
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