Evidence-based programmes in schools: are they a realistic solution for drug and alcohol prevention?

On 26 March, Mentor will be hosting a seminar: ‘What works’ in supporting young people’s development – making evidence useful for schools and practitioners. Mentor is very supportive of the use of evidence-based programmes, but to say that their use in the UK for drug and alcohol prevention has been limited is an understatement.

There are different types of evidence (see the presentation below) but some of the strongest comes from randomised controlled trials (RCTs). Allocating randomly between the intervention and control groups makes it more likely that any improvement is due to the intervention and not some other factor. Continue reading

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EUSPR – Krakow

EUSPR - KrakowPaul and I spent two days in Krakow last week at the European Society for Prevention Research (EUSPR).  As with the two previous conferences that the society has held the agenda was packed and there’s a lot to digest.

The theme of this year’s meeting was the common risk and protective factors for multiple risk behaviours and saw speakers from both Europe and North America try to make sense of some quite complex data.

For example, Judith Prochaska from Stanford University took us through a lot of US attempts to work out how to affect a number of interrelated risks – cancer, substance misuse, obesity, and diet – and seemed to conclude that not only do you need to think about the risks you’re trying to effect, but the combination of interventions you use, and the order in which you run them.  So for example if you’re trying to work on smoking with those trying to treat their drug use, then waiting for a couple of weeks before doing smoking cessation seems critical to better outcomes.

Dr Dan Hale from UCL presented an analysis that he has been involved in looking the common factors that are associated with a range of risk behaviours.  He said that substance use, sexual health and violence are partially explicable due to common risk but associations decrease with age – these include bullying and poor school attachment.  The exception being alcohol misuse where they found that the predictors for heavy drinking at age 19 are getting on well at school and having good grades – which he thought could be to do with the norms around university’s drinking cultures.

Another of the keynote speakers was Fabrizio Faggiano, who argued that we need to think about putting in place a regulatory system for prevention interventions, similar to the ones that regulate medicines.  He suggested that too often when prevention interventions are proven to be ineffective we think it is okay to tinker with the content, but in his view if an intervention is showing an iatrogenic effect (making things worse), we should decommission it.

EUSPR - posterAs well as being able to draw on the expertise of the keynote speakers we were able to present the work we did with Street Talk both as a poster (right) and during one of the parallel sessions.

Both were very well received.

Of particular interest was the use we made of an ‘app’ for smart phones and tablets to help our practitioners screen and gather data from the 2,000 young people who were seen during the project.

I was also pleased that there was an appetite to try to replicate the Street Talk approach from researchers in a number of countries.  I will be making another presentation on Street Talk at a meeting of experts in brief interventions with young people at the EMCDDA in Lisbon in January.

Another excellent presentation by Nik Koutakis explained how the Effekt programme, which offers a brief intervention with parents which has led to reductions in drunkenness by their teenage children, worked and how it had been brought to scale in Sweden.

Judy Hutchings from Bangor University explained how she had researched and then introduced the Incredible Years programme to Wales.  Judy was clear about the amount of work that she’d done to ensure that the programme was delivered with fidelity and the proper levels of support for practitioners, which she saw as critical to the successes she and her team have been able to measure.

Alongside all of the presentations we also held a members meeting – at which I presented a report on behalf of the Supervisory Board – where one of the issues that was discussed was the need to attract more practitioners to become involved in the society.  I can see huge benefits in this, both to practitioners but also to the research community.

The Deciding Time

The latest report from the Early Action Task Force, The Deciding Time, says:

It’s hard to imagine that we’d ever stop immunising children against TB or polio because we could not afford it. Or only operate for cancer after a nine-week minimum waiting period because earlier detection and swift treatment is thought too expensive. Yet in other, less well chartered areas of public policy that is exactly what is happening now; delaying or cutting entirely the earlier action, and, very shortly, paying the price.

The report itself makes the case for fundamentally changing the priorities for government funding with a much clearer focus on early action.  They point out that the Youth Justice Board spent something less than 7% of its money on preventing young people coming into the criminal justice system, while (as we know) only 4% of the NHS budget goes on items that are designated as prevention.

Settling Disputes In Research

One of the key influences on young people’s behaviour is the boundaries and values that parents express.

Parenting that is too laissez-faire (“I can’t tell you how to live your life, do what you think is best”), or too authoritarian (“Do as I say or else!”), tends not to be as effective as authoritative parenting (“I want to know where you are and who you are with”, “I don’t want you to drink at the party”).

We also know that the attitudes and behaviours of the parents of young people’s friends also plays a part in protecting or raising the risks around substance misuse.

The Orebro programme (see here for the CAYT analysis of the programme) was developed in Sweden as a way of trying to help parents to set collective boundaries to reduce alcohol use. It brings together parents of young people who go to the same school and it; raises their awareness of the harms that alcohol can do to young people; why not engaging in early use of alcohol is beneficial to young people; and perhaps most importantly it asks the parents to collectively set boundaries and expectations for their children.

The journal Addiction has been running an interesting debate about the effectiveness of the programme, where a trial of the programme carried out by people independent to the developers found that it does not appear to reduce or delay youth drunkenness.

The authors of the original research wrote back to suggest:

Overall, our conclusions suggest the opposite of what Bodin & Strandberg concluded. The ÖPP programme appears to influence changes in youth drunkenness, which is the aim of the programme. In addition, the effect of the programme is seemingly explained by changes in parental attitudes to youth drinking, providing strong support for the validity of the programme theory.

Which led to a further letter in the journal from Bodin and Strandberg arguing that what they were trying to explore was not whether the programme worked in ‘laboratory’ conditions, but if it could work in the ‘real world’. They rightly point out this is one of the major challenges of current prevention research.

To me this sets out a critical issue for organisations like ours to think about; how do we not only pick the right interventions, but how can we make sure that the implementation of them has the best chance of replicating positive results?

The dangers are clear: delivering a good programme badly damages not only the reputation of the programme, but also the still fragile reputation of the evidence based prevention movement. However, programmes that only work when delivered by the programme developers aren’t of much use to the wider world and have little chance of achieving scale or sustainability.

The Society for Prevention Research – the US big sister organisation to the European Society for Prevention Research that I’m involved with – has set out standards for judging the very best programmes and interventions that include: having been tested at least twice, evaluated in real world conditions, and having clear cost information and monitoring tools.

Drug-related research in Europe: recent developments and future perspectives

Aside

The EMCDDA have published a paper on the research into drugs taking place in Europe.  A couple of quotes stand out.

First on the difference between what nations say is their priority and where they’re investing in research:

Bühringer et al. (2009) found a considerable difference between the identified national research priorities and the number of studies available, particularly in the areas of ‘supply reduction’ and ‘policy’, which seemed to be relatively under-researched, or for which findings were not available. Under ‘demand reduction’, prevention was the least-researched area, although most countries considered it to be a national priority.

The second is around the new societies that are being set up on a pan-European basis, including the European Society for Prevention Research:

[The societies] may prove to be a way forward for overcoming limitations and gaps in drug-related research, further disseminate research findings, and influence priorities and the allocation of funding.

Predictors for Binge Drinking

This piece of German research suggests a number of predictive factors for young people who are more at risk of binge drinking.

Their research was carried out with 44,610 15 year old students and their analysis found eleven relevant risk and protective factors for binge drinking:

  • Suicidal Thoughts (risk)
  • School failure and having to retake a year (risk)
  • Living in a family in receipt of welfare benefits (protective)
  • Being religious (protective)
  • Having a lot of friends (risk)
  • Undertaking other risky behaviours (risk)
  • Parental divorce or separation (risk)
  • School truancy (risk)
  • Having aggressive teachers or being subject to violence at school (risk)

The authors conclusion is that:

Whereas some of the influence factors for binge drinking are not surprising since they are known predictors of substance abuse in general (e.g., risk-taking behavior), there are two points that could be targeted in interventions that should not focus on adolescents alone: 1. training teachers in positive, reassuring behavior and constructive criticism which has also been proofed as effective pedagogic strategy in intervention studies and 2. a focus on high risk students either because they lack coping strategies when in negative mood or because of their low academic achievements and absenteeism from school. An interesting fact is also the protective value of religiosity, which so far has not been the focus of prevention strategies especially not in a country like Germany.

Research in Brief

Headlines from research papers that I’ve seen in recent weeks:

  1. Predicting Resistance to Health Education Messages for Cannabis Use – the most frequent cannabis users are the most likely to be the most resistant to health messages about the drug.
  2. Young age at first intercourse and risk-taking behavioursyoung age at first intercourse is associated with subsequent risk-taking behaviours (such as smoking and binge drinking) according to a survey of 64,659 women aged 18–45.
  3. Examining Explanatory Mechanisms of the Effects of Early Alcohol Use on Young Adult Alcohol Dependence – Prevention efforts from primary school should focus on delaying the onset of alcohol use and reducing substance use in adolescence as well as improving school functioning, reducing adolescent problem behaviors, and targeting adolescent peer networks.
  4. Do Peers’ Parents Matter? A New Link Between Positive Parenting and Adolescent Substance Use – this paper suggests that not only are teenagers own parents important to substance use, but that so are their friends parents.
  5. Parental alcohol-specific rules and alcohol use from early adolescence to young adulthood – although parents become less strict in setting alcohol-specific rules over time, and adolescent alcohol use increases over time, the specific rules parents set remain important in restraining the alcohol use of their adolescent offspring.