What works in prevention: education and awareness

1. What works in prevention:
education and awareness

2. What is prevention?
• People often think of prevention as stopping someone from using
substances, or they may think of it as stopping people from developing
problematic or excessive use of substances.
• Prevention work is important at every level of substance use.
• It is often thought to be about education and awareness designed to
reduce, or avoid completely, the risks of people using substances
problematically.

3. What is prevention (cont.)
• Education and awareness has a role to play but increasingly
evidence shows that this alone has no effect on preventing harm
or, for example, stopping young people from using.
• Prevention work includes education and awareness of different
types but it still needs to be part of a coherent approach to
working with substance problems. This includes both harm reduction
goals and specialist treatment.

4. • In sum, prevention can work towards preventing the onset of
problematic use, but it is also about reducing problematic use once it
develops, or supporting someone to prevent further harm, through
specialist interventions, when their use has already resulted in
health and social harms to themselves and/or others.
• In the following film clip, Professor Harry Sumnall from Liverpool
John Moore’s University discusses what constitutes harm reduction
and prevention .
What is prevention (cont.)

5. Why is prevention needed?
• 24% of men and 18% of women aged 16 and over drink more than the
recommended levels of alcohol weekly – increasing risks to their
health and well-being.
• While drug use is declining overall, young people aged 16-24
have double the rates of illicit drug use than older age groups.
However, there has been a large increase in drug-related
deaths in England among men and women, with men
aged 30-39 then 40-49 most at risk. The biggest
increase according to age group were the
20-29 yr olds (ONS 2014).
• Problematic substance use – be it alcohol or other drugs – is also
linked to a number of serious health conditions, e.g. several types of
cancers, neurological and gastrointestinal problems, heart and
respiratory disease/ failure.

6. Why is prevention needed (cont.)
• Problematic substance use can have a negative impact on social
and family functioning leading to family breakdown, stress and
trauma, social isolation, insecure housing and economic hardship.
• Thus prevention efforts focus on trying to prevent harmful patterns of
substance use and the cost this has to individuals, their families,
communities and society.

7. Who needs prevention work?
• Young people have tended to be the main targets for prevention
work.
• However, prevention work is not just about young people – it is
about adults too, particularly as evidence shows patterns of
substance use changing within different age groups.
• Recent evidence in the UK has identified high risk alcohol
consumption among middle-aged, middle class people – a group
who are often overlooked (Iparraguirre 2015).
• So prevention is also about targeting groups or individuals who are
at particular risk through their substance use, and focussing more
attention on developing specific initiatives for those groups.

8. Institute of Medicine (IoM) 1994 –
Model of Prevention
• The IoM model (1994) sets our different types of prevention:
universal, selective, indicated.
1. Universal prevention – general population,
2. Selective prevention – targets groups or sub groups that are more
at risk
3. Indicated prevention – targeted at individuals as being at risk
(Institute of Medicine 1994)
• In this film clip, Harry Sumnall, takes us through one model of
prevention.

9. IoM model (cont.)

10. IoM model (cont.)
• The IoM model sets these different levels of prevention within a
segmented continuum of treatment and maintenance.
• It could be criticised for not showing that prevention
can occur at different stages of the treatment and
maintenance journeys as well as at the start of the
process.
• For example, preventing someone from returning to problematic
levels of substance use during the maintenance phase is prevention
work; preventing someone’s substance use from getting worse
during an intervention is prevention work.

11. Universal prevention
• Universal prevention is delivered to the whole population regardless of
risk. It focuses on delaying the onset of drug use or preventing it
completely, limiting frequency of drug use or limiting progression of
drug use
• In the following film clip, Harry Sumnall talks about the evidence for
prevention
• Evidence is often based on school or community samples. It shows:
– Mass media or information only approaches don’t work – indeed,
they can make things worse!
– However, combined with school and community-based
programmes, mass media approaches can work.
– Developing a person’s skills and self-efficacy, particularly for
younger people learning to help themselves is the key to behaviour
change.

12. Selective prevention
Selective prevention is:
• Delivered to individuals or groups who have a higher risk of harmful
substance use because they face more “biopsychological,
behavioural or social risk factors” than the general population, e.g.
Looked After Children, Older People.
• Delivered to people whose use is already problematic with the goal
of stopping it progressing further, e.g. brief Interventions to dance
club drug users.
(ACMD 2015: 13)

13. Indicated prevention
• Targets individuals who have been screened or otherwise identified
and being at greater risk of harmful substance use.
• Examples may include people presenting to hospital Accident and
Emergency departments as a result of their substance use, or
families of people with substance problems.
(ACMD 2015)

14. Functional perspectives
• Foxcroft (2013) suggests the IOM model above is extended to
include functional perspectives.
• In addition to the three levels of prevention, interventions would also
be categorised as being:
– Environmental, e.g. System wide policies and restrictions
– Developmental, e.g. Skills development
– Informational, e.g. Increase knowledge and awareness

15. Prevention in context
• Foxcroft’s ‘environmental’ level is an important one to consider in
prevention efforts.
• People do not live in voids nor make decisions about substance use
unaffected by a cultural and societal context.
• Ecological systems theory helpfully presents this context as a nested
set of ‘systems’ with the individual at the centre. This nested system
comprises:
– Micro-systems: immediate setting of an individual e.g. home,
school, work
– Meso-system: interactions between micro systems
– Exo-system: settings that influence individual development but are
not directly involved, e.g. management committee of youth club
– Macro-system: cultural and societal environments, e.g. political
contexts. This level envelopes all other systems.

16. Bronfenbrenner’s ecological
system of human development
(Jack and Jack 2000)
Societal influence
Macro-system
Exo-system
Meso-system
Micro-systems
HOME
Micro-systems
SCHOOL
Micro-systems
NEIGHBOURHOOD

17. Prevention in context (cont.)
Jack and Jack (2000) state the interactions between systems that
individuals live in can be split into two:
1. Cumulative, e.g. multiple environmental risk factors increase
potential harm to human development
2. Moderating or mediating, i.e. effect of factor A on factor C depends
on characteristics of intermediate factor B.

18. Prevention in context (cont.)
• In other words, if a young person is struggling at school, has little
support at home from substance using parents, if the local youth club
closes and the young person is living in an area with a gang culture, the
risks are likely to be cumulative.
• However, if the young person is struggling at school but the school and
substance using parents are actively communicating and supporting the
young person at home, ensuring they have other non-using people and
positive activities in their lives, the outcome is more likely to be different.
• Therefore an important part of your work is to identify the risks and
protective factors and to support the development of protective
factors.
• Go to the resources, working with young people and how to talk about
substance use for further information on identifying and asking about
substance use.

19. Prevention: examples of risk and
protective factors
Risk factors Protective factors
Parents who use alcohol or
other drugs
Good parental bonding and
supervision of/ disapproval of
substance use
Child abuse and maltreatment
and sexual exploitation
Good social skills - including
problem solving, self-efficacy
Inadequate parental supervision External support system which
reinforces/strengthens child’s
coping
Young offenders Attendance at community clubs or
groups including faith groups
School exclusion or lack of
economic opportunities
Commitment to school attendance
Living in neighbourhood poverty
or homelessness
Policies/laws limiting availability of
substances

20. What works in prevention
• Clear messages about prevention work can be drawn from the
evidence:
– Information/education alone doesn’t work.
– Collaborative approaches do – these include
education and awareness combined with
individual, intra-individual, community and
society level collaboration, e.g. education and
awareness as part of school-based life skills
curriculum, reinforced by parents, community
initiatives and support enforcement through legal
and wider policy measures.

21. Key messages for all professionals
In the following film clip, Harry Sumnall provides some key messages
for professionals about how to work in a preventative way. These are
summarised below:
1. Access and understand the evidence base, eg. NICE guidance,
Public Health England
2. Understand what doesn’t work, e.g. Information only approaches –
doesn’t change behaviour; needs to be combined with other
activities
3. Don’t worry too much about drug use – drug use may not be the
issue for young people. Focus on potential problems and harms
associated with it.
4. Important to consider activities that are age and audience
appropriate; be realist about outcomes at universal level.

22. Advice to health and social care
professionals
• In this final clip, Harry Sumnall gives advice to health and social care
professionals in particular.
• Increasingly health and social care workers are getting involved in
prevention work:
– It may not be drug focussed but activities that keep young people
safe, improve socialisation, reduce risk, keep them in school, teach
them good behaviours about health and well-being.
– In other words, preventative work is not just about asking about
substance use. If you are supporting people in other areas of their
lives this is hugely important prevention work activity.
• Professionals need to understand how drug use fits in to people’s wider
biographies and to understand how activities are interlinked.
• Professionals need to view prevention work holistically and not in
isolation, e.g. a lack of educational engagement may increase the risk of
drug use, mental health issues may increase the risk of drug use.

23. References
• Advisory Council on the Misuse of Drugs (2015) Prevention of drug and alcohol
dependence. Briefing by the Recovery Committee. Available online at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/406926/AC
MD_RC_Prevention_briefing_250215.pdf
• Institute of Medicine Committee on prevention of Mental Disorders (1994) Reducing
Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Available
online at: http://www.ncbi.nlm.nih.gov/books/NBK236319/
• Foxcroft D (2013) ‘Can Prevention Classification be Improved by Considering the
Function of Prevention?’ Prevention Science DOI 10.1007/s11121-013-0435-1
• Iparraguirre, J. (2015) ‘Socioeconomic determinants of risk of harmful alcohol drinking
among people aged 50 or over in England.’ BMJ Open, 5:e007684.
doi:10.1136/bmjopen-2015-007684
• Jack, G. and Jack, D. (2000) ‘Ecological Social Work: The Application of a Systems
Model of Development in Context.’ In: Stepney, P. and Ford, D. (eds.) Social Work
Models, Methods and Theories. Lyme Regis, Dorset: Russell House