Health Promotion International, Vol. 16, No. 2, 107-110,
June 2001
© Oxford University Press 2001
EDITORIAL |
Illicit drugs: effective prevention requires a health promotion approach
Editor in Chief All countries now face a major crisis in illicit drug use, both directly and indirectly. Emotions run wild when the issue is debated publicly and, understandably, all would wish the problem to go away. But good policy cannot be based on feelings and hearsay—evidence drawn from practice and theory should be the basis for both intervention and prevention strategies.
For too long, illicit drug prevention programmes have been short term, uncoordinated, and have concentrated too much on simple information provision. They have usually operated in isolation from broader health promotion initiatives, and have not been linked to other drug control responses. They have also lacked sustained community-based approaches, which are required to achieve real and long-term benefits. A broader-based health promotion approach is urgently needed.
People have lived in drug-using societies for centuries. Drugs perform many functions—they can treat disease and control pain, and they can relax, remove inhibitions and alter sensations. But they can also do great harm at both the individual and community levels; in many developed countries, for example, deaths due to drug overdoses now exceed those due to road accidents.
One of the most significant developments in the last decade has been the massive increase in availability, purity, potency and cheapness of illicit drugs such as cannabis, amphetamines and heroin. From trends monitored by the United Nations Office for Drug Control and Crime Prevention (UNODCCP, 1999), it appears that overall, strategies to reduce cultivation of opium and cocoa, and to seize products before they reach markets are having only a limited effect. At the same time, production of synthetic drugs such as ecstasy is booming. In Australia, for example, the amount of heroin that can be purchased for the same amount of money increased four-fold between 1997 and 1999, and is now as available and simple as ordering a pizza.
If supply-side strategies are inadequate and failing, then demand-side strategies to reduce and modify uptake are even more important. There is no simple answer to the question of why young people become involved in drugs; the reasons are many and varied. Fortunately, over the last decade our knowledge base has become stronger, and is moving us towards a more socio-ecological framework for intervention than a medical and legal one.
Researchers such as Resnick, Brooks, Jessor, Hawkins, Catalano and Patton have investigated the factors that put young people at risk of developing problem behaviour, and they appear to be protective (Jessor, 1991
; Hawkins et al., 1992; Brooks, 1994; Resnick et al., 1997; Bond et al., 2000). Two key themes emerge for improving and maintaining well-being: connectedness and resilience. Connectedness refers to a sense of belonging, and having strong and meaningful connections to family, school, peers and the community. Resilience refers to the quality that helps people deal with the problems and demands that may confront them, and to respond well to a range of life events. In both these areas, parental support and assistance are very important.
In Victoria, Australia, the State Government's Drug Policy Expert Committee (VDPEC, 2000) has recently released a major report on drug control strategies. Drawing on a range of international research, a useful framework, covering of a range of risk and protective factors for community, school, family and individual/peer levels of intervention, has been presented (Table 1).
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There is an emerging evidence base for interventions that tackle particular risk and protective factors. In the USA, for example, the Midwestern Prevention Project, conducted by Pentz and co-workers, examined the effectiveness and replicability of a multi-component, community-based drug misuse prevention programme (Anderson et al., 1990
). The study looked at the effectiveness of school interventions in the context of broader community mobilization strategies. Significant reductions in tobacco and cannabis use occurred amongst students followed up at Years 9 and 10. However, training for community leaders and the use of mass media was less effective when not teamed with school-based and parenting programmes.
Another US study, Project Northland, led by Perry and colleagues, used similar school- and community-based approaches to reduce alcohol and other drug use in North West Minnesota (Perry, 1996). The research found statistically significant reductions in drug use, changed peer norms and improved parent–child communication. The case can be made from both of these studies for whole-community approaches that complement individual-focused interventions.
The Gatehouse project in Australia aims to reduce the rates of depression and self-harm amongst young people (Centre for Adolescent Health, 2000). This school-based programme emphasizes the importance of positive connectedness between the individual and both teachers and peers. It has identified three priority areas for action: (i) building a sense of security and trust; (ii) enhancing skills and opportunities for good communication; and (iii) building a sense of positive regard through valued participation in aspects of school life. Drawing on the Ottawa Charter framework, the project aims to create a healthy environment rather than concentrating on individuals. Although still at an early stage, the project has already demonstrated a reduction in the rate of smoking in intervention schools compared with non-intervention schools.
When people become socially disconnected they may seek comfort and a sense of security through drug use, and find support and ready acceptance from other drug users. In the UK, particular emphasis has been placed on structural issues that exacerbate this problem, such as poor housing, low income, unemployment, poor education and high crime environments. Prime Minister Tony Blair has set up a Social Exclusion Unit within the Cabinet Office to focus on key points of transition when young people are at greatest risk of becoming excluded and marginalized. Action is centred on truancy, homelessness, neighbourhood renewal, teenage pregnancy, and opportunities for young people not in education, employment or training. Such ‘joined up solutions to joined up problems’ are very much at the centre of the Ottawa Charter's healthy public policy domain.
In Australia, the Centre for Adolescent Health has recently completed a report on evidence-based approaches to promoting adolescent health (Thomborou et al., 2000). The work reviewed 178 research articles and assigned weightings to signify the confidence with which programmes can be implemented. The ‘best buys’ comprise a broad set of health promotion approaches, including health promoting schools, social marketing, peer intervention, parent support and community strengthening. The Victorian government, upon the advice of its Drug Policy Expert Committee, has endorsed these approaches and has announced that substantial funding, representing at least 10% of the total drug budget, will be allocated to prevention. Strategies are likely to include the following elements.
Health promoting schools
- Focus on well-being and cultures that promote resilience.
- Enable sustained life skills development.
- Support vulnerable young people.
- Integrate programmes into the broader curriculum.
- De-emphasize the use of outside presenters.
- Develop school-based health and welfare support services.
Social marketing
- Build on careful research and focus group testing.
- Target specific age groups and drug use patterns.
- Closely integrate with other prevention elements.
- Provide direct non-media information through community involvement.
- Set clear and realistic goals for broad and narrow casting.
- Use sustained and planned approaches to communication.
- Rigorously evaluate intended and unintended effects.
Peer intervention
- Develop as core strategy for disconnected, ‘hard to reach’ groups.
- Use targeted and highly structured approaches.
- Focus on current drug users to reduce harm.
- Draw on current and former drug users.
- Provide information, skills and support.
- Facilitate links to health, welfare and rehabilitation services.
Parent support
- Use telephone and face-to-face parent peer support.
- Offer formal parent education workshops and seminars.
- Provide both reactive and outreach (e.g. home visiting) services.
- Focus on critical transition from primary to secondary school.
- Target socially disadvantaged, culturally and linguistically diverse, and adolescent parents.
- Encourage modelling appropriate behaviour and developing a habit of communication.
Community strengthening
- Build resilient and supportive neighbourhoods and communities of interest.
- Encourage community groups, local businesses and public services to work together.
- Disseminate research, project information, resources and ideas.
- Strengthen local capacity through training, facilitation and coordination.
- Develop local drug strategies involving all relevant sectors and groups.
- Help manage public spaces and support economic development.
- Develop youth-focused and early intervention responses.
Governments should now invest in drug prevention within a health promotion framework with greater confidence, given the knowledge that is now available. Greater priority and investment in terms of time, money and people must be given to prevention in all its forms. Policy development and subsequent action should focus on preventing uptake of use, stopping use becoming dependence, and helping those experiencing problems from continuing use. Budgets should allow the provision of expert advice, information and support to those who will manage or deliver prevention programmes, including those working in local government and the community. Special emphasis needs to be given to hearing the ‘voice of youth’ through surveys, focus groups, youth organizations, etc.
Coordinated multi-dimensional strategies are required that bring together both universal and highly targeted approaches. A prevention framework built on health promotion principles should focus on healthy environments as well as individuals, should give attention to both licit and illicit drugs, should use customized strategies for different stages of the life cycle, and should recognize cultural differences. Wherever possible, investments in drug prevention should integrate and combine with broader-based health promotion approaches for youth. This important principle recognizes that by tackling the underlying social determinants of drugs misuse, which are common to many other issues, positive outcomes should occur in diverse areas such as depression, youth suicide, teenage pregnancy, eating disorders, crime and violence. It is time that drug prevention came in from the cold and warmed up with health promotion.
REFERENCES
Anderson, C., Pentz, M., Weber, M., Dwyer, J., Baer, N. et al. (1990) Relative effectiveness of comprehensive community programming for drug abuse prevention with high-risk and low-risk adolescents. Journal of Consulting and Clinical Psychology, 58, 447.[Web of Science][Medline]
Bond, L., Thomas, L., Patton, G., Thomborou, J. and Catalano, R. (2000) Improving the lives of young Victorians in our community: a survey of risk and protective factors. Centre for Adolescent Health, Melbourne.
Brooks, R. (1994) Children at risk: fostering resilience and hope. American Journal of Orthopsychiatry, 64, 4.
Centre for Adolescent Health (2000) The Gatehouse Project: Promoting emotional wellbeing—a whole school approach. Progress Report. Centre for Adolescent Health, Melbourne.
Hawkins, D., Catalano, R. and Miller, J. (1992) Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychology Bulletin, 112, 64–105.
Jessor, R. (1991) Risk behaviour in adolescents: a psychosocial framework for understanding and action. Journal of Adolescent Health, 12, 597–605.[Web of Science][Medline]
Perry, C. et al. (1996) Project Northland: outcomes of a community-wide alcohol use prevention program during early adolescence. American Journal of Public Health, 86, 956.
Resnick, M., Bearman, P., Blum, R., Bauman, K. et al. (1997) Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. Journal of the American Medical Association, 278, 10.
Thomborou, J., Patton, G., Sawyer, S., Olsson, C., Webb-Pullman, J., Catalano, R. and Godfrey, C. (2000) Evidence–based health promotion: Resources for planning. No. 2 Adolescent health. Public Health Division, Department of Human Services, Melbourne (http://www.dhs.vic.gov.au/phd/0003097).
United Nations Office of Drug Control and Crime Prevention (1999) Global Illicit Drug Trends. UNODCCP, New York.
Victoria Drug Policy Expert Committee (2000) Drugs: Meeting the challenge. Stage Two Report. State Government of Victoria, Melbourne (http://www.dhs.vic.gov.au/phd/dpec/index.htm).
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