What is prevention?
“Prevention can be defined broadly as policies, programmes and practices designed to reduce the incidence and prevalence of drug use (including alcohol, tobacco, illegal drugs) and associated health, behavioural and social problems.” (Advisory Council on the Misuse of Drugs, UK, 2015)
Defining drug prevention and education
There is no commonly accepted definition of „drug prevention‟ in Europe. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) define this as any policy, programme, or activity that is directly or indirectly aimed at preventing, delaying or reducing drug use, and/or its negative consequences such as health and social harm, or the development of problematic drug use (EMCDDA, 2011). This applies to all psychoactive substances, both legal and illegal. Drug prevention activities can target whole populations, subpopulations, or individuals and may address common factors that reduce vulnerability to drug use or which promote healthy development in general. (Warren, 2016)
Prevention of drug use, particularly among young people, is usually a central goal in national policies on illicit drugs, as well as in international declarations and resolutions on drug control. Political leaders and the public usually strongly support drug prevention as a drug policy pillar. Governments and non-governmental organizations in many countries have invested in a wide range of prevention strategies and programs. (Prevention of Drug Use and Problematic Use pg.2)
National Drug and Alcohol Strategy 2017-2025
Reducing harm, supporting recovery (2017) is the first ‘integrated’ drug and alcohol strategy in Ireland. The strategy aims to provide an integrated public health approach to substance misuse. Substance misuse means the harmful or hazardous use of psychoactive substances, including alcohol, illegal drugs and the abuse of prescription medicines. The public consultation, which informed the strategy, highlighted changing attitudes towards people who use drugs, with calls for drug use to be treated first and foremost as a health issue. (pg.7)
The strategy’s vision is for a healthier and safer Ireland, where public health and safety is protected and the harms caused to individual, families and communities by substance misuse are reduced and every person affected by substance use is empowered to improve their health and wellbeing and quality of life.( pg.8)
Goals of the drugs strategy
- Promote and protect health and wellbeing.
- Minimise the harms caused by the use and misuse of substances and promote rehabilitation and recovery.
- Address the harms of drug markets and reduce access to drugs for harmful use.
- Support participation of individuals, families and communities.
- Develop sound and comprehensive evidence-informed policies and actions.(pg.18)
Models of prevention
The EMCDDA classifies prevention types according to a scheme developed by Mrazek and Haggerty (1994). The categories are complementary to one another and replace the previously used categorisation of primary, secondary, and tertiary. This categorisation based on the overall vulnerability of the people addressed – the known level of vulnerability for developing substance use problems distinguishes between the categories, rather than how much or whether people are actually using substances. (Warren, 2016) Universal prevention: Addresses a population at large and targets the development of skills and values, norm perception and interaction with peers and social life. Focus on raising awareness and drug education.
Some of the advantages of the programme:
- No labelling or stigmatisation
- Middle class insists that the program be well run
- Provides the possibility for focusing on community-wide contextual factors.
Some of the disadvantages:
- Small benefit to the individual
- May have the greatest effect in those at lowest risk
- Unnecessarily expensive
- Community initiatives may be undermined
- Hard to detect an overall effect
Selective or targeted prevention: Addresses vulnerable groups where substance use is often concentrated and focuses on improving their opportunities in difficult living and social conditions, e.g. Strengthening Families Programme.
- Potential of addressing problems early on
- Potentially efficient
- Resources not wasted on low risk young people
- May allow earlier intervention
- At risk individuals are more likely engage in more serve substance
- Possibilities of labelling and stigmatization
- Difficulties with screening- cost and commitment, the difficulty of targeting accurately, boundary problems
- High-risk group contributes many fewer cases than the low-risk group
- Tends to ignore the social context as a focus of intervention
Indicated prevention: Addresses vulnerable individuals and helps them in dealing and coping with the individual personality traits, which make them more vulnerable to escalating drug use. There is also interest more recently in environmental prevention, interventions that do not use persuasion to change people’s attitudes and behaviour, but instead use interventions that try to limit the availability of opportunities to use drugs, through national policies, restrictions and actions that affect social and cultural norms, e.g. drug driving policies (EMCDDA, 2011; ACMD, 2015).
Environmental prevention: Addresses societies or social environments and targets social norms including market regulations.
Risk and Protective Factors
Studies over the past two decades have tried to determine the origins and pathways of drug abuse and addiction – how the problem starts and how it progresses. Many factors have been identified that help differentiates those more likely to abuse drugs from those less vulnerable to drug abuse. Factors associated with greater potential for drug abuse are called “risk” factors, while those associated with reduced potential for abuse are called “protective” factors. However, most individuals at risk for drug abuse do not start using drugs or become addicted. Risk and protective factors can affect children in a developmental risk trajectory, or path. For example, early risks, such as out-of-control aggressive behaviour, may be seen in a very young child. If not addressed through positive parental actions, this behaviour can lead to additional risks when the child enters school. In focusing on the risk path, research-based prevention programs can intervene early in a child’s development to strengthen protective factors and reduce risks long before problem behaviours develop. (NIDA, 2003)
Some important issues concerning the risk factors young people face. (Hawkins et al, 1992)
- Risk exists in multiple domains, across family, community, school and the individual
- The more risk factors present, the greater the risk. Risk factors have a predictive and multiplying feature
- Many of the risk factors identified for alcohol, tobacco and other drug use are also predictive of other problem behaviours among youth, including teen pregnancy, school dropout crime and mental health issues.
- Risk factors show a great deal of consistency in their effects across different races, cultures and social classes.
When risk factors are reduced across family, school, community and for the individual and protective factors enhanced, young people are less likely to develop problems across a range of areas including substance misuse, teenage pregnancy, crime and mental health issues. (Hawkins et al, 1992) Schools are in a strong position to build protective processes.
Life skills are one of the protective factors. Teaching life skills in the classroom has been shown to substantially reduce tobacco, alcohol, and illicit drug use. Life skills work is recommended for all pupils. When aimed at the whole school population, universal programmes will also engage pupils with identified risks.
The Add Health project, a longitudinal study on adolescent health and development found that young people who feel connected to school have better mental health and are less likely to engage in risky behaviours including the use of alcohol and illegal drugs, early sexual activity and violence (Blum et al, 1997). Other researchers have found that pupils respond to efforts to improve academic performance when the feel connected to school.
The risk and resiliency literature emphasise that schools are critical environments for young people to develop strengths and the capacity to adjust to pressure, bounce back from adversity and develop social, academic and vocational competencies necessary to do well in life. Milstein and Henry (2000) specified the protective factors that build resilience and that can be developed within the school setting; positive bonding, clear and consistent boundaries, life skills, caring and support, high expectations and meaningful participation.
A comparative study carried out by the NACD of early school leavers and school-attending students looking at the Risk and Protection Factors for substance use among young people. The study was undertaken in line with Action 98 of the National Drugs Strategy 2001-2008. The study is based on information collected in 2008 during face-to-face interviews with 991 people between 15 and 18 years of age. The target population comprised school-attending students and young people who, having left school, were attending either a Youth reach or
Community Training Centre.
The main findings from the study are hugely important from a policy perspective highlighting as they do the following:
- Substance use among the early school-leavers in this study is significantly higher than among the school-attending students, implying that estimates based on school- attending students alone underestimate the prevalence rates for people in the 15-18 year age group.
- Parental involvement and concern constitute protective factors against substance use, while the provision of information on substance use to parents within educational settings also reduces the risk of substance use among early school leavers.
- Substance use by other family members constitutes a significant risk factor for young people. A positive school experience (including good relationships with teachers) has a huge effect in terms of reducing the risk of drinking alcohol, and using cannabis or other drugs. This indicates a substantial overlap between the factors that increase the risk of early school leaving and those, which encourage substance use among young people.
- Friends can represent a major risk factor for substance use. If friends use substances, the young person is at a considerably greater risk of using the same substances: conversely, friends can also constitute a major protective factor.
- Early substance use is a precursor to more serious forms of use. Early substance use involving alcohol and cigarettes, in particular, signals a considerable additional risk of progressing later to “illicit drugs”.
- Living in a Drugs Task Force area has a measurable, statistically significant positive effect on drug use among early school leavers. (Haase et al, 2010)
Evidence-based prevention programmes
The main goal of any alcohol, tobacco, or drug use prevention program for youth should be to reduce levels of harm, both to the user and to others. The means to this end may be preventing the use of the substance altogether, or limiting or shaping it, or insulating the use from harm. Whatever means the program adopts, the program should be designed based on an assessment of the dimensions of harm related to the substance use in the target population, and measurement of changes in the attributable harm should be included in the evaluation. (Room, 2012)
Several model preventive intervention programs are reviewed, including universal, selected, and indicated programs for schools and families, along with a comprehensive community- based prevention programs (Griffin et al, 2011). Descriptions of the model programs, including information on their primary goals, target audiences, implementation methods, program components, provider training, and evidence of effectiveness, which adapted in part from the SAMHSA Model Program Fact Sheets and the SAMHSA National Registry of Evidence-Based Programs and Policies (NREPP) review of the effectiveness of these model programs are focused on intervention effects on substance use behaviours.
School Based Prevention programs
The three programs represent different tiers of prevention: Life Skills Training is a universal program designed for all students in a particular setting; Project Towards No Drug Abuse is a selective program designed for students attending alternative or continuation high schools; and Brief Alcohol Screening and Intervention for College Students is an indicated program designed for college students who are heavy drinkers.
Universal-for everyone in population: Life Skills Training (LST)
- Target Population: Middle or junior high school students, additional programs available for elementary and high school students.
- Providers: Classroom teachers, peer leaders, or health professionals.
- Goals: Prevent alcohol, tobacco, marijuana, other drug use, and violence by targeting multiple risk and protective factors and providing skills training in drug resistance skills, personal self-management, and social competence skills in order to build resilience and help youth navigate developmental task.
- Materials: Teachers manual and student guide for each year, relaxation audiotape, optional multimedia materials for smoking & biofeedback.
- Teaching method: Facilitated discussion, structured small group activities, and role-playing scenarios are used to stimulate participation and promote the acquisition of skills.
- Finding: Three large-scale randomized effectiveness trials have shown reductions in tobacco, alcohol, marijuana and other illicit drug use, and violence/delinquency for a diverse range of adolescents, with duration of effects lasting up to six years, among LST participants compared to controls. (http://www.lifeskillstraining.com) http://www.lifeskillstraining.com/
Selected program- for members of at-risk groups: Project Towards No Drug Abuse (TDN)
- Target Population: Students attending alternative or continuation high schools; has also been tested in students attending traditional high schools.
- Providers: Classroom teachers, health education staff.
- Goals: Prevent tobacco, alcohol, other drug use, violence-related behaviours, and other problem behaviours by addressing motivation factors (i.e., students’ attitudes, beliefs, expectations, and desires regarding drug use); skills (social, self-control, and coping skills); and decision-making (i.e., how to make decisions that lead to health-promoting behaviours).
- Materials: Teacher manual, student workbooks, optional videotape, and board game.
- Teaching method: Program sessions are highly participatory and interactive. The sessions provide opportunities for interactions among students and between students and the teacher.
- Finding: Several randomized trials have been conducted showing reductions in tobacco, alcohol, and marijuana for up to two years; one study demonstrated effects on “hard drug” use four and five years after the intervention among TND participants compared to controls. http://tnd.usc.edu/
Indicated program – for at-risk individuals: Brief Alcohol Screening and Intervention for College Students. (BASIC)
- Targeted population: College students engaging in heavy alcohol use and/or at risk for negative consequences of alcohol use. http://tnd.usc.edu/
- Providers: College counsellor or personnel proficient in motivational interviewing techniques.
- Goals: Motivate students to reduce alcohol use in order to decrease the negative consequences of drinking; reveal discrepancies between the student’s risky, drinking behaviour and his or her goals and values.
- Materials: Program manual, program workbook with sample tools, a training video and personalized assessment and feedback sheets and handouts.
- Teaching method: Based on principles of motivational interviewing, program delivered in an empathetic, non-judgmental one-on-one session by trained counsellor or staff.
- Findings: The programme had significantly greater reductions in drinking frequency and quantity compared to control group students, with the greatest intervention impact observed in the first year after the intervention. http://depts.washington.edu/abrc/basics.htm
Concerns about the evidence base of programs
D.A.R.E. – United States
The D.A.R.E. (Drug Abuse Resistance Education) program was developed at the initiative of the Los Angeles Police Department for police officers to teach in schools to pre-teen students. (Weiss et al). In its original version, the program was heavily centered on teaching children to “say no” to drugs and had sessions on building self-esteem. The goal was to prevent all use of illicit drugs. The programme was generally very well received by parents, politicians, and the public, and by the late 1990s, about 80 percent of school districts in the http://depts.washington.edu/abrc/basics.htm
United States were using D.A.R.E. They spent hundreds of millions of federal dollars for the program, and it was estimated to be used or closely imitated in over 50 countries. However, numerous evaluations of D.A.R.E. indicated that it had little effect on young people’s drug using behaviour or that the small effect it had dissipated quickly over time.
Remarkably, though the program was widely discredited and criticized in the media, it remained in use in many districts and is still quite widely used in 2015 (Kumar et al, 2013). Many drug prevention experts have criticized the inclusion of poorly evaluated programs among those the United States judges to be “evidence-based.”
The scientific literature on drug prevention programs indicates that there remain many methodological challenges to determining the effectiveness of programs, and there are prominent evaluations in the literature that continue to stir controversy. Nonetheless, there is some consensus with regard to both school-based and mass media programs around a few points:
• To achieve public health goals, drug prevention should focus not only on preventing all use of drugs
• It is not effective simply to scare young people with accounts of the dangers of drugs. Reality-based information that can help them prevents drug-related harms throughout their lives.
• Evaluations of prevention programs suggest strongly that the content of educational programs should be based on formative research that clarifies the particular reality of initiation of drug use and factors influencing continued and problematic use.
• Prevention programs should ideally be thoroughly and independently tested before implementation. (Prevention of Drug Use and Problematic Use pg.16)
Most reviews of prevention programs conclude that combined approaches in a coherent multifactorial strategy improving reality-based knowledge of drug use and drug-related harms, ensuring access to counselling and other services, endeavouring to remove risk factors in schools and other places where young people congregate, improving parents’ capacity to have reality-based conversations with young people, etc. are likely to be more effective than only providing information or building skills of young people.
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- Room, R. (2012) Preventing youthful substance use and harm. Between effectiveness and political wishfulness. Substance Use and Misuse, 47, 936–943.
- Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP). Available at: www.nrepp.s-amhsa.gov. [Accessed 28 Jan. 2019].
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