Harry Sumnall's presentation from the March 7 Mentor-ADEPIS seminar 'Targeted prevention interventions and the case of PreVenture'

1. Prof Harry Sumnall
Mentor UK Seminar
Liverpool, March
2016
REFLECTIONS ON TARGETED
AND INDICATED PREVENTION

2. SOCIOECOLOGICAL MODEL OF PUBLIC HEALTH
Institute of Medicine, 2003
A model of health that emphasises the linkages and relationships
among multiple factors (or determinants) affecting health.

3. Campbell, 2010

4. IOM, 1994

5. DIFFERENCES BETWEEN SELECTIVE/INDICATED
PREVENTION AND TREATMENT
 Treatment is based on
responding to a
clinical diagnosis and
quickly provides
benefits including
symptom reduction.
 Indicated prevention refers to high risk
individuals who are identified as
having minimal but detectable signs
or symptoms of factors that predict
drug use but who do not meet clinically
relevant levels at the current time.
 Selective interventions are targeted to
individuals or a subgroup of the
population whose risk of drug use is
significantly higher than average.
 The risk may be imminent or it may be
a lifetime risk.
 Both are probabilistic interventions – a
harder sell
Treatment Selective/indicated
prevention

7. https://www.nice.org.uk/guidance/indevelopment/gid-phg90
Drug prevention Guidelines
Expected publication February 2017

8. • A variety of evidence based
interventions are offered across
the EU
• Extent of provision and quality of
implementation differs between
countries
• Difference between highly
research manualised
programmes and informal
adaptations and ‘kernels’

9. COMMON LIABILITY MODEL
9
 Common liability (CL) to substance use disorders involves mechanisms and
biobehavioural characteristics that pertain to the entire course of development
of the disorder and changes in the risk.
 Problematic drug use/drug dependence can be located on the same dimension as
premorbid (and even pre-drug-use) behaviours that are indicators of a highly
heritable latent trait variably referred to as dysregulation, disinhibition, behaviour
undercontrol or externalising behaviour, including risks for disruptive behaviour
disorders.
 CLA, a behavioural/psychological trait, manifests in a range of “gateway”
behaviours grounded in the mechanisms of socialisation and affective/cognitive
regulation with deep evolutionary roots
 In simple terms drug use is a manifestation/indicator of an underlying
behavioural trait
Vanyukov et al., 2012

10. MULTIPLE RISK BEHAVIOURS
 In accordance with common liability model of behaviour, there is a clustering of
risk behaviours in YP
 Multiple risk behaviours are associated with effects beyond the cumulative effects
of individual health risk behaviour, including poorer emotional wellbeing,
psychological distress, and injury
 Associated with inequalities
 There is early evidence for the cost-effectiveness of interventions for multiple
risk behaviours suggesting that they constitute a more cost-efficient means of
preventing risk behaviours in adolescence
Hale and Viner, 2012

11. Bramley et al., 2015

13. Mental health
problems
Behavioral
disorders
Violence
Alcohol problems
DRUG USE IS JUST
ONE
POSSIBLE
PREDICTOR FOR
PROBLEMS
Cannabis users
Early intervention
Indicated
prevention
70 Million
Europeans
ever used (LTP)
Problem
escalation
Slide courtesy of G.Burkhart

14. Nuffield Council, 2007 - Intervention Ladder

15. HOW HAS OUR CURRENT UNDERSTANDING OF
PREVENTION BEEN ‘CONSTRUCTED’
Drug prevention has been suggested to be an
ideological ‘litmus test’ (Edman, 2012)
Drugs [and prevention] re-constructed as a problem
to be handled by ‘experts’ rather than politics
(Roumeliotis, 2013)
Drug prevention is connected with specific ways of
governing society and problems (and ‘problem
people’), therefore specific kinds of knowledge are
used to construct and represent these problems

16. • In general public health, respecting autonomy involves not just attention to the
protection of individual choice, but also the creation of a social/economic/political
environment that affords the conditions necessary to support and nurture such
choices – does this hold true for illegal drug use?
• Individuals may have ‘forward looking’ relative to ‘backward looking’
responsibilities (responsibilities for certain already-existing behaviours) , but
autonomy and capability are essential
• Some targeted populations are perhaps ill equipped for change
• Those who are already better resources are positioned better to benefit from
universal and health promotion approaches.
TARGETED PREVENTION AND AUTONOMY
Wardrope, 2015

17. CAREFUL WITH HIGH-RISK RECIPIENTS
 Drug use and risk is functional in some networks – ‘bonding
capital’ in Social Capital research
 People consider messages contradicting their opinion as unfair and
propagandistic
 Strong persuasive intent leads to reactance:
Logical deconstruction of the argument
Derogation of the message source

18. ‘FUNCTIONAL’ RISK TAKING
Impulsive,
Risk seeking,
Affective intensive,
Peer-oriented
Social Primacy
It makes sense:
Mating success, social status
Fast adaptation to hostile & unstable
environments
Pleasure and learning opportunities
Slide courtesy of G.Burkhart

19.  The shared rituals of smoking are a valued means of expressing
group identity and belonging (over and above acute pharmacological
effects), and smoking helps forge and maintain group solidarity
 Important for socially excluded groups and individuals
 Prevention programmes that do not consider the social meanings of
health behaviours into their approach may struggle to engage target
groups
 Illegal drugs? Identity and synthetic cannabinoid receptor agonists
(SCRA); ketamine?
EXAMPLE OF SMOKING
Voigt, 2010

20.  Social inequalities are differences in income, resources, power and status within
and between societies, and are maintained via institutions and social processes.
 Health inequalities are differences in health between people or groups due to
social, geographical, biological or other factors.
 Some factors are fixed, whereas others are dynamic
 In public health, tend to be a focus on socio-economic differentiation
 Closely linked to social exclusion
 Substance use is also a symbolic behaviour and is generally stigmatised, and this
is also another source of inequality
WHAT ARE INEQUALITIES?

21. CSEW (2015):
 Use of any drug (mostly cannabis) was highest for those living in the areas
defined to be the most deprived (10.2%), and lowest for those living in areas
defined to be the least deprived (6.9%).
 However, use of any Class A drug does not vary with Indices of Deprivation, with
similar levels of use in all areas (3.1% in the most deprived areas, 3.3% in middle
areas, and 2.9% in the least deprived areas).
DRUG USE IS RELATIVELY EQUALLY DISTRIBUTED
ACROSS UK SOCIETY

22.  Individuals at risk of mental health disorder more likely to experience problems
with substances
 Adverse outcomes from drug (and alcohol) use are more strongly related to socio -
economic status (SES) than patterns of substance use
 Deprivation associated with lower age of first use, progression to dependence,
injecting drug use, risky use, health and social morbidity and criminal
involvement.
 Resilience factors (e.g. strong social support, employment) negated by patterns
of deprivation
 Inequalities may mediate level of drug involvement
…BUT ADVERSE OUTCOMES ARE NOT EQUALLY
DISTRIBUTED
e.g. Bergen et al., 2008; Galea and Vlahov, 2002; Jones et al., 2015; Williams and Latkin, 2007

23.  Effectiveness may be determined by factors such as intervention efficacy,
service provision, uptake and compliance
 Individuals and subpopulations have differential access to personal
and structural ‘resources’ which determine compliance and uptake
 Universal and poorly implemented individual level programmes may
therefore lead to inequalities
 Interventions and actions that do not rely as much on access to resources
may reduce inequalities – upstream/population level interventions
 E.g. Alcohol MUP, tobacco control – for drugs??
PREVENTION AS A SOURCE OF INEQUALITIES
After McGill et al., 2014

24. CHALLENGES FOR TARGETED PREVENTION AS A
RESPONSE TO INEQUALITIES
e.g. ACMD, 2015; Faggiano et al., 2008; Brotherhood and Sumnall, 2013
• Prevention programmes that are best evidenced are targeted at (universal)
populations
• Mixed evidence for individualised approaches, e.g. MI, and MET
• In UK, often informal adaptation of prevention ‘principles’ and ‘palliative
approaches’
• Targeted at a narrowly defined ‘problem’ – ‘drug use’
• Research rarely includes ‘meaningful’ prevention outcomes
• Rarely address determinants of inequality, which are often also determinants of
substance use

25. Professor Harry Sumnall
Centre for Public Health
Liverpool
UK
h.sumnall@ljmu.ac.uk
@profhrs
@euspr
25
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