'What Works' in Drug Education and Prevention?
This literature review examines the evidence of effectiveness of different types of drug prevention and education for children and young people.
3. Effectiveness of Drug Prevention Beyond Schools
Broader findings on the effectiveness of education and prevention of drug use
Below is a table drawn from the ACMD report (2015) which summarises the findings from one piece of research on the evidence of effectiveness for a wide range of policies and interventions designed to address young people's addictive behaviours (Brotherhood et. al, 2013). This is included here because it contains further evidence beyond that on schools-based prevention on 'what works' in substance use prevention (including alcohol and tobacco). The findings on schools are consistent with those in Chapter 2. Pre-school family programmes, multi-sector programmes with multiple components (including school and the community) and some skills development based programmes (similar to the social competence and social influence approach described above) are promising and likely to be beneficial, if implemented correctly. The evidence is summarised in the table below, and the approaches in bold are those that deal specifically with illicit drug use (it should be noted that the table may not be comprehensive) ( ACMD, 2015).
Table 1 - 'What works' in substance use prevention for young people - a summary of Brotherhood et al., 2013
| Beneficial Interventions and approaches which showed robust evidence for positive effects on addictive behaviours. Research evidence for the intervention or approach is likely to be transferable to young people in other geographies. |
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| Likely to be beneficial Interventions and approaches for which there was some, but limited, evidence for positive effects on addictive behaviours. Research evidence for the intervention or approach was likely to be transferable to young people in other geographies but caution is warranted and adaptation studies are recommended. |
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| Mixed evidence Interventions and approaches for which there was some evidence of positive effects in favour of the intervention, but which also showed some limitations or unintended effects that would need to be assessed before implementing them further. |
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Interventions that do not have substance use outcomes and may not focus on drugs at all, but rather on children and young people's attachment to and behaviour at school, can be effective at reducing substance use, e.g. The Good Behaviour Game (see chapter 4). Similarly, there may be interventions whose focus is on drug use/misuse but which may also help reduce other, different risk taking behaviours. The EDPQS, former UKDPC and ACMD (amongst others) promote a more generic approach, which target multiple risk behaviours, of which drug use is only one (see Chapter 6).
Peer-led interventions do not appear in the table by Brotherhood et. al. (2013) above, but the EMCDDA lists these in a section headed 'likely to work' [10] , and so are included here. Peer education can be described as 'the teaching or sharing of health information, values and behaviours between individuals with shared characteristics' (MacArthur et al., 2015). This can involve all or part of the delivery of an intervention by peers the same age or older in formal or informal settings, and have been used to target substance use, sexual risk behaviour, HIV prevention and psychosocial wellbeing among young people (MacArthur et al., 2015). The rationale for this approach is that young people learn from each other and have greater credibility, sensitivity and understanding than adults when discussing health behaviour, and can act as positive role models to reinforce these messages.
A review of 29 reviews found evidence in favour of the effectiveness of peer educators in school-based drug prevention programmes in reducing all substances use at post-test, but this relative effectiveness did not extend to 1 or 2 year follow-ups (McGrath et al., 2006). More recently, MacArthur et. al. (2015) conducted a systematic review to investigate and quantify the effect of peer-led interventions that sought to reduce tobacco, alcohol and/or drug use among people aged 11-21 years. Most of the studies reviewed were on tobacco and alcohol use, and only 3 of the studies (all from the US) focussed on cannabis use (no studies were found that examined other drug use), but the findings tentatively suggest that peer-led interventions may possibly be effective in preventing cannabis use among young people (MacArthur et al., 2015).
ASSIST (A Stop Smoking In Schools Trial) is a peer-led, licensed programme, developed in Wales and England, which has shown reductions in adolescent smoking prevalence (Campbell et. al., 2008 in MacArthur et. al., 2015). ASSIST is different to other peer-led prevention interventions in that the peers are selected by the pupils, rather than the teachers and so a different type of peer is selected from the 'usual suspects'. ASSIST programme is currently being trialled in Scotland by the Scottish Government [11] , and an approach which combines ASSIST and FRANK [12] is being tested in England [13] which will produce findings for drug and tobacco prevention. The results of the trial in England, which include drugs, will be of interest.
Interventions for high risk/vulnerable young people
As well as understanding 'what works' and does not in universal prevention, it is also important to consider the differential effects of programmes in population subgroups - 'what works' for whom ( ACMD, 2015). Of particular importance are high-risk groups, those young people who are at an increased risk of involvement in drug/substance misuse, or who are already using substances.
The National Institute for Health and Care Excellence ( NICE) Public health guideline [ PH4] on Substance misuse interventions for vulnerable under 25s (2007) [14] , states that vulnerable and disadvantaged children and young people aged under 25 who are at particular risk of misusing substances include: "those who are - or who have been - looked after by local authorities, fostered or homeless, or who move frequently, those whose parents or other family members misuse substances, those from marginalised and disadvantaged communities, including some black and minority ethnic groups, those with behavioural conduct disorders and/or mental health problems, those excluded from school and truants, young offenders (including those who are incarcerated), those involved in commercial sex work, those with other health, education or social problems at home, school and elsewhere and those who are already misusing substances".
Understanding the 'differential prevention impact' of programmes on vulnerable young people/high risk groups is important, as it allows for better targeting and refinement of programmes and importantly may reduce the possibility of interventions reinforcing health and social inequalities ( ACMD, 2015). The evidence is mixed, and while some studies show that there is no difference in intervention effectiveness across sub-groups, others show prevention programmes to be effective only in the higher risk groups, while others show the opposite, with stronger effects in the lower-risk groups ( ACMD, 2015).
While the evidence suggests that drug prevention is better embedded in more holistic strategies that promote healthy development and wellbeing, there is a case for maintaining drug-specific prevention interventions for those young people most at risk of harm, or already misusing drugs. NICE, as highlighted above, provide guidance on substance misuse interventions for under 25s [15] and has recently consulted on draft guidelines for this group for 2017 [16] . However, the evidence also suggests that young people considered at greater risk will also benefit from universal approaches, and so tailored approaches may not always be required (Spoth et al., 2006, in ACMD, 2015).
One universal programme with benefits for higher risk young people is the School Health and Alcohol Harm Reduction Project ( SHAHRP). SHAHRP is an interactive universal school based programme with a psychosocial and developmental approach, focussing on harm reduction philosophy with skills training, education and activities with the aim of bringing about behaviour change. Although focussed on alcohol, the findings from Australia, and from the adapted SHAHRP programme in Northern Ireland are worth highlighting. In both evaluations, the results demonstrate that this approach shows evidence of effectiveness amongst the higher risk young people, who some may argue are the group where risk reduction is most important [17] . Findings from the Northern Ireland evaluation showed that SHAHRP was viewed positively, seen as enjoyable and worthwhile by the recipients and engaging and relevant to the young people's experiences of alcohol use (Harvey et al., 2016). This compared to "alcohol education as usual", which was viewed negatively as unstructured, boring, repetitive and unrealistic. The authors conclude that one reason alcohol education is not generally effective may be due to the failure to engage young people (Harvey et al., 2016).
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