Report from a Norwegian national project 2010/2011 using the HKH method – Rapid assessment and response
Cannabis use and responses a rapid assessment intervention in three Norwegian cities The Competence Centre at the Bergen Clinics Foundation
Kompetansesenteret arbeider på oppdrag fra helsedirektoratet ISBN: 978-82-8224-034-5 1
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
Kompetansesenter Rus - region vest Bergen er ett av syv regionale kompetansesentra innen rusfeltet i Norge, med regionalt ansvar for Hordaland og Sogn og Fjordane. Arbeidsområder er innen forebygging, tidlig intervensjon og styrking av kompetanse i arbeid med rusmiddelavhengige. Kompetansesenteret bistår med råd og veiledning, kurs/konferanser, seminar, erfaringsutveksling og prosjektutvikling. Stiftelsen Bergensklinikkene er en uavhengig, livssynsnøytral ideell non-profit og selveiende stiftelse for «mestring av rusproblemer, helse, livsstil og avhengighet» gjennom behandling, forebygging, forskning og undervisning.
Heftets tittel: Cannabis use and responses, a rapid assessment intervention in three Norwegian cities Report from a Norwegian national project 2010/2011 using the HKH method – Rapid assessment and response Forfatter: Else Kristin Utne Berg © Stiftelsen Bergensklinikkene ISBN: 978-82-8224-034-5
Rapporten kan bestilles hos:
Kompetansesenter Rus - region vest Bergen Stiftelsen Bergensklinikkene Vestre Torggate 11, 5015 Bergen. Tlf 55 90 86 00 Område: Hordaland, Sogn og Fjordane. Hjemmeside: www.bergensklinikkene.no Spisskompetanse: «Kjønn og rus» og «Foreldrerollen i rusforebyggende arbeid» Helsedirektoratet er oppdragsgiver for kompetansesenterets virksomhet. Layout: Camilla Holcroft
Else Kristin Utne Berg
Cannabis use and responses a rapid assessment intervention in three Norwegian cities Report from a Norwegian national project 2010/2011 using the HKH method – Rapid assessment and response
The Competence Centre at the Bergen Clinics Foundation
In March 2010, the Competence Centre at the Bergen Clinics Foundation established a national project to train key staff working in the Norwegian drug field in a community rapid assessment and response methodology known as HKH (Hurtig Kartlegging og Handling). Project funding was provided by the Norwegian Directorate of Health via the Drug and Alcohol Early Intervention Programme (Helsedirektoratet 2010).
The HKH method is a manualised early identification and intervention approach (Mounteney and Leirvaag, 2007) based on Rapid Assessment & Response (RAR), a tool developed by the World Health Organization (Mounteney and Berg 2008). The method can be used to identify and prioritize community level problems and design appropriate evidence based responses with the involvement of local actors. The Bergen Clinics Foundation have developed, piloted and evaluated the tool to suit Norwegian conditions, in cooperation with Bergen Outreach and Detached Service (Berg, 2011). A key characteristic of the HKH approach is that community level problems are explored simultaneously with the existing responses to these problems, using a wide range of largely qualitative social research methods. Analysis is based on a systematic triangulation of results and the assessment process results in a short summary report and action plan.
The training course was attended by HKH teams from four cities in Norway (Bergen, Stavanger, Kristiansand, and Drammen) supported by supervisors from three regional Competence Centres. Each HKH team identified a particular local health or social problem to serve as a focus for their intervention. As a result, three of the assessments dealt with cannabis related issues and responses, and these will be briefly summarized here. The fourth assessment focused on prostitution amongst men1. The three teams choosing to undertake assessments on cannabis had slightly different objectives and used a variety of methods to collect data, including interviews, document analysis, focus groups and surveys. The following table provides an overview of the aims and key themes in the three studies2:
1 https://www.bergen.kommune.no/bk/multimedia/archive/00113/Menn_som_selger_sek_113962a.pdf 2 A full review is to be found in the three HKH reports from Drammen, Kristiansand and Stavanger, see reference list.
4
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
HKH city
Objectives
Key topics
Drammen Outreach and detached service
What knowledge do youth, Examine the attitudes to, and explore the use of cannabis among parents and services have about cannabis? What attitudes do young young people in Drammen. people in Drammen have to cannabis use? Prevalence and availability of cannabis in Drammen. How does recruitment to cannabis milieus happen and how can we prevent further recruitment?
Kristiansand Social and prevention service
Levels and patterns of use of Explore the situation regarding cannabis among 17-18 year olds in cannabis among pupils in year 2 in secondary school in Kristiansand. Kristiansand. How to prioritize efforts to reduce debut age and level of use? Identification of risk groups. Which actions are taken to prevent cannabis use, where are the gaps and what improvements are needed?
Stavanger Outreach and detached service
5
Cannabis use among youth aged 12-15 years. The characteristics, levels of use, availability and responses.
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
What are the characteristics of youth, aged 12-15, who use cannabis? Focus on school performance/dropout, family situation, friends/leisure, contact with services, mental health, crime, use of tobacco and alcohol, housing, gender and ethnicity. Identify the responses to be implemented and look at how appropriate and effective these are. Assess the need for new responses or other interventions.
Findings from Kristiansand Kristiansand conducts regular surveys of drug use by 10th grade pupils, and they wanted to use the HKH assessment to increase their knowledge of the student situation. The rapid assessment in Kristiansand found that just under 20% of 17-18 year olds have tried cannabis, while around 5% smoke regularly. There is a general perception among key informants that cannabis use is on the increases, but the HKH found no evidence for this. Cannabis is relatively easy for young people to obtain, and they are most likely to be introduced to the drug by friends and acquaintances. No correlation between ethnicity and cannabis use was found, however the assessment found that young cannabis users were likely to have social and mental health problems. Over half of those who had tried cannabis, first did so between 13 and 16 years (secondary school age), and those who debut early are more likely to drop out of school, are more involved in crime, etc. Otherwise, the HKH found the following: -
Transition phases are clear at risk situations, in particular the transition from school to college and the transition from childcare services to adult Social Services.
-
Services and adults in general rarely communicate their concerns around young people’s cannabis use, and there is a need for more expertise on substance abuse in general and cannabis in particular, so that use can be detected earlier.
-
Informants report that there is a need for a low-threshold service focusing on early identification and intervention.
-
There is a need for increased awareness and knowledge about each other’s services and increased cooperation and coordination of services.
Kristiansand HKH resulted in a multidisciplinary action plan, incorporating a combination of universal, selective and indicative prevention measures. The universal prevention measures include an increased focus on information and education. In addition there are plans for improving networking and the establishment of new structures for interagency work, both at the whole school and class level. The selective prevention measures focus on increasing competence and recruiting at risk youth into cannabis treatment. The indicative level will include the incorporation of questions about substance abuse in an individual assessment tool that is used with at risk students moving from junior to secondary school, as well as strengthening the services on offer for reducing and stopping cannabis use.
6
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
Findings from Drammen Drammen HKH also identified availability of cannabis and that friends are often the source of drugs. A survey amongst secondary school students aged 18 to 19, found that 13.6% have tried cannabis at some point in their lives, while 5.7% have used it in the last 3 months. While young people report that cannabis use is common, the survey shows that few actually use it. Those who reported using cannabis say they had an experience of being different in their childhood, a feeling of being misunderstood, of being angry, frustrated and bored. The vulnerable young people start smoking earlier, and those who start smoking early, smoke more than those who start later. There seems to be two separate cannabis smoking environments that are independent of each other, an ethnic Norwegian milieu linked to relaxing, music and watching movies, and a minority ethnic milieu where cannabis smoking is more linked with physical activity and the need to find something to do. Otherwise, the HKH in Drammen found: -
Teachers, services and young people know little about cannabis and the consequences of use
-
Sport, commitments, aspirations and future plans seem to be protective factors
-
Transitions in life (e.g. between schools) are vulnerable periods
-
There is a need for better information and improved service availability. A lack of awareness about substance abuse and mental health, and a high threshold for accessing mental health services were noted.
-
The communication between services and knowledge about each other is not good enough.
The action plan resulting from the Drammen HKH is rooted in the activities of the Centre for alcohol and drug prevention, but also involves other partners. Key measures include: dissemination of information and knowledge to key groups identified by the assessment, prevention work with parents, targeted outreach work in current cannabis using environments, network building with sports and support services, and establishment of user-friendly websites. There are also aims to investigate simpler referral practices and enhanced cooperation between the local authority, specialist health services and schools.
7
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
Findings from Stavanger The Stavanger HKH focused mainly on at risk young people, and also found ready availability of cannabis in the city. It is primarily young people using cannabis that are responsible for selling to other teenagers. Introduction to drugs is common in childcare institutions, and friends and family are primarily responsible for recruitment into the drug using milieu. The extent of cannabis use is related to the adolescents’ total life situation, including: school performance, family situation, friends/leisure, mental health, antisocial behavior, etc. No relationship was identified between ethnicity and use of cannabis. Investigation of the existing service responses for young people and cannabis, found: -
The services provided for the target group rarely relate to concerns about drug use
-
The services have little knowledge about young people’s use of cannabis, while the services working with older drug addicts reported that their clients often started using drugs at the age of 12-13
-
Young people keep their own drug use hidden, or underreport it when in contact with services
-
Services report lack of expertise in and lack of focus on drugs when working with this age group
-
There are few and poor services for this age group, and there are no routines on how to detect substance use among young people
Recommendations from the Health Directorates early intervention manual (Helsedirektoratet 2010) provide a structure for Stavanger’s HKH action plan. The key initiative is to set up a chain of actions that can respond when there is concern about a young person’s drug use. Further, there are specific suggestions on how to monitor and set up procedures regarding school truancy, developing services and professional’s competence regarding drugs, and developing assessment tools on an individual level to identify youth at risk.
8
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
Summary Both European and Norwegian research show stable and partially decreasing trends in the use of most illicit drugs, with cannabis among the substances showing the greatest decline. The three HKH assessments on cannabis use in three cities in Norway confirm this trend. The findings also confirm the picture from other studies that young people are introduced to drugs through family and friends and/or in residential childcare, and that there is a vulnerable group of young people that is particularly exposed to adverse effects associated with cannabis use. Vulnerability is linked to social, psychological and behavioral factors. The assessments in Kristiansand and Drammen problematise what is known as the majority misunderstanding, i.e. that young people have the perception that “everyone” smokes cannabis, while surveys show that there is a minority that actually does it. In communication with young people this issue is important to address. The need for diverse and coordinated services for young cannabis users, as well as identification that existing services know very little about each other, are factors identified in the three cities. Otherwise, it is interesting to note that the use of cannabis is rarely addressed in meetings between young cannabis users and services. Of concern is the fact that knowledge about the harmful effects of cannabis smoking is not only scarce among the young people who smoke, but also within the services.
9
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
References Berg, Else Kristin Utne (2011): Hurtig Kartlegging og Handling. Nasjonalt ptosjekt 2010-2011. Stiftelsen Bergensklinikkene. Bergen kommune, Utekontakten/Stiftelsen Bergensklinikkene (2007): Evaluering av Hurtig Kartlegging og Handling. Drammen kommune, Senter for rusforebygging, Uteteamet (2011): Drammensungdom og deres holdninger til bruk av cannabis. Helsedirektoratet (03/2010): Fra bekymring til handling. En veileder om tidlig intervensjon på rusområdet. Kristiansand kommune, Sosiale og forebyggende tjenester (2011): HKH-rapport 2011. Cannabis blant 17-18 åringer i Kristiansand. Mounteney, Jane og Leirvåg, Siv-Elin (2007): Manual HKH. Stiftelsen Bergensklinikkene. Mounteney, Jane og Berg, Else Kristin Utne (2008): ”Youth, risk and rapid assessment: a new model for community social work assessment?” I European Journal of Social Work, 11:3, 221-236. Stavanger kommune, Uteseksjonen (2011): Hasjbruk blant ungdom. Hasjbruk blant ungdom 12-15 år. Omfang, kjennetegn og tiltak.
10
Cannabis use and responses, a rapid assessment intervention in three Norwegian cities
