Evidence based primary prevention The Icelandic Model Gothenburg │Förebygg.nu November 2013

Jón Sigfússon ©ICSRA / Reykjavik University 2013 ICSRA │ Reykjavik University

What if these were corporate results? 50 45

42

40

35

35

32

33

30 %

25

26

10 5 0

26

23

25

22 19

20 15

28

16 17

18 15

14

14

15 12

11

12

12

11

12

19

14

10 10

13 9

9

9 7

6

7 6 5 3

9

7 3

5 2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013

2013 ICSRA │ Reykjavik University

What if these were corporate results? 50 45

42

40

35

35

32

33

30 %

25

26

10 5 0

26

23

25

22 19

20 15

28

16 17

18 15

14

14

15 12

11

12

12

11

12

19

14

10 10

13 9

9

9 7

6

7 6 5 3

9

7 3

5 2

1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013

2013 ICSRA │ Reykjavik University

Substance use decrease amongst 15-16 year old adolescents

%

50 45 40 35 30 25 20 15 10 5 0

Drunk last 30 days

42 35

Daily smoking

32

33 26

23 19 17

15

28

Hashish once or more

26 22

16 12

25 18

15 11

14

12

14 12 13 9

11 9

12 9

10 7

19 10 6

14 9 7 6 3

7 3

5 3

1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013

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How has this been achieved? • Research as a basis for policy and actions on the local and national level • An evidence based bottom up approach – not top down

• Prevention work has been focused on risk and protective factors in the lives of youth • Managed to keep a constant dialogue between all those who are responsible for prevention in the close community of the children 2013 ICSRA │ Reykjavik University

Structure of presentation 1. The role of research in prevention work 2. Background of the prevention model 3. Methodology, characteristics and emphasis 4. Actions in regard to primary prevention

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The role of research 2013 ICSRA │ Reykjavik University

ICSRA background • A governmental Youth Research Institution

from 1992 focusing on education and upbringing of youth • ICSRA established 1998 with a broad focus on all aspects of youth research

• Lead Youth Research Institution since 1998

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ICSRA specialization • 10 to 13 year old in Primary school: •

2000-2013 – Bi-annually (Prognostic factors)

• 14 to 16 year old in Primary school: •

1992-2013 – Annually (Status and development)

• 16 to 20 year old in High school/Junior college: •

1992-2013 – Every third year

• Dropout students 2013 ICSRA │ Reykjavik University

Indicators Health status indicators, anxiety, depressive symptoms, physical health status, lifestyle and leisure time activities, local community networks,

negative life events and strain, parents and family, peer group economic and psychological issues,

studies and school, substance use, values and attitudes, violence and delinquency, and more…

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The twofold use of research 1. Scientific 2. Practical

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The scientific role of research 1.

In depth analysis of the data

2.

50 peer reviewed papers past 5 years

3.

Publications in journals in Europe and USA

4.

Science forms the platform for practice

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Collaborators • Karolinska Institutet, Sweden • Kings College, London • University of Ireland, Galway • Reykjavik University • University of California, Irvine • Columbia University, NY • University of Iceland • Penn State University 2013 ICSRA │ Reykjavik University

The practical role of research 1.

Population data collection on substance use

every year (no samples, always population). 2.

Practical descriptive reports within 2-3 months of

each data collection to the municipalities 3.

School reports to the schools

4.

Local information INTO all levels of prevention work is a key issue 2013 ICSRA │ Reykjavik University

Importance of frequent measuring • Every school, every parent, every prevention worker can see the current situation in their close community and can act accordingly. •

Not 2-3 years later but almost immediately

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Childrens rights •

Children have the right to have a say about what they want, what they do and how they feel.

•

We have the obligation to make good use of what they tell us, react and constantly try to make their lives better.

•

People agree on this today 2013 ICSRA │ Reykjavik University

Prevention approach Background 2013 ICSRA │ Reykjavik University

In the year 1992 • Governmental decision to start collecting

data from 15-16 year old students. •

Aim: To see if and how information collected could benefit policymaking and decisions for actions in youth matters in general.

• Several data collections until 1998

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Upward trend 1992 – 1998 30 Have tried hashish

Smoke daily

25

22,8 20,7

20 17,4 % 15

15,1

10 9,6 5

7,2

0 1992

1993

1994

1995

1996

1997

1998

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1998 • At this point of time research already showed

us that certain circumstances and behavior in the lives of adolescents was strongly connected with use. • We tried to establish the risk and protective factors.

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The four main risk and protective factors Family factors

Extracurricular activities, sports

Peer group effect

General well being

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And analyzing deeper

Family factors

Organized activities vs. unorganized Extracurricular activities

Time spent with parents Support Monitoring Control

Peer group

Positive and negative effects. How we as parents approach the peer group Staying outside late

General well being Inside and outside of school, at home, bullying e.t.c.

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1998 Drug-free Iceland • Based on these findings a research based action plan was initiated by the government with the aim to try out a totally new methodology in substance use prevention. • Obviously, what had been done before, was not

working.

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Organizations promoting drug free areas in 2013 • Common phrases in declarations/mission statements: •

Fight against drugs, Attack or Combat drugs

•

Intensify police measures, Offensive actions against drugs, School action plans against drugs

•

… and a lot of handshakes and resolutions …

• Very little on evidence-based work, role of parents, addressing risk factors in the close community and

informal social control 2013 ICSRA │ Reykjavik University

Aim of Drug free Iceland • To change the actual behavior of youth and

not only their attitudes

• Change the life-style environment of our children so that they would be in lesser risk of substance use

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The methodology 2013 ICSRA │ Reykjavik University

Our focus is primary prevention •Primary prevention, preventing the development of

substance use before it starts

•Secondary prevention, that refers to measures that detect substance use

•Tertiary prevention efforts that focus on people already abusing substances 2013 ICSRA │ Reykjavik University

Substance use follows cohorts Sigfusdottir et al. 2011, Global Health Promotion

Lifetime drunkenness

57

60 50 40 % 30

41

41 32 20

25

22

20 10 0

10

8 6

13

14

14

16 15

Cohort 1984

4 1 13

21

12

11 6 14

15

Cohort 1991 2013 ICSRA │ Reykjavik University

Substance use follows cohorts Sigfusdottir et al. 2011, Global Health Promotion

Lifetime drunkenness

60

57

50

40

41

40 % 30 20

25 20 10

10

0 13

14

15

Cohort 1984

13

14

15

Cohort 1991 2013 ICSRA │ Reykjavik University

What else could we tell the policymakers? 2013 ICSRA │ Reykjavik University

Percentage of girls in 9th and 10th grade who have become drunk in the last 30 days depending on how much time they spend with parents 100 90

Almost never

Seldom

Sometimes

Often

Almost always

80 70 60

% 50

42,0

40 30

20

27,8

17,6 12,0

10,4

10 0

Girls who have become drunk last 30 days 2013 ICSRA │ Reykjavik University

Percentage of students in 9th and 10th grade who have become drunk in the last 30 days depending on if their friends become drunk once pr. month.

100

None or few

A few

Many

Almost all

90

80 68,2

70 60

49,3

% 50 40

30

23,3

20 10

4,6

0 Boys who have become drunk past 30 days 2013 ICSRA │ Reykjavik University

Percentage of students in 9th and 10th grade who smoke daily depending on if they practice sports

50 Almost never

Up to 3 times pr. week

4 times or more often

40

30

24,9

%

20 12,5

10

10,4

9,9 4,0

3,5

0 Boys who smoke daily

Girls who smoke daily

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Main actions Based on the research findings 2013 ICSRA │ Reykjavik University

Local actions – examples: • Research as a basis in policymaking and actions

• Strengthen parent organizations and cooperation • Support extra – curricular activities / sports

• Support active NGOs´ • Support Young people at risk inside schools • Form co-operative work groups against drugs • Anti smoking/drinking campains • Strengthen social capital

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National actions – examples: • Legal age of adulthood raised from 16 to 18 years • Age limits to buy tobacco and alcohol (18 and 20) • Strict regulations for sellers of tobacco • A total advertising ban of tobacco and alcohol • Restricted access to buying alcohol and tobacco • Total visibility ban of tobacco and alcohol • Rules on outside hours for adolecents 2013 ICSRA │ Reykjavik University

Visibility ban of tobacco

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Outside hours reminder

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Rules on outside hours • Why? Risk factor to “hang out” late with peers • Addressed to parents to encourage sleep of children • Stickers on every refrigerator • Under 12 year old 20:00 from 1st of May to 1st of September (summer) and until 22 in winter.

• 13 to 16 year old until midnight in summer and 22:00 in winter.

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The scientific isolation needed to be broken 2013 ICSRA │ Reykjavik University

The researchers “guru“ approach

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We needed to focus on close community • How could an average figure on alcohol use in

Sweden help prevention workers in Gothenburg? • “Average” is the biggest liar!

• Population research / yearly •

Reports to 80% of municipalities

•

School reports to 70% of schools

• Local information within 2-3 months of data collection each year 2013 ICSRA │ Reykjavik University

School

10

Average

20

5,2 5,8 6,6 7,9 8,5 8,8 8,9 9,1 9,2 10,6 11,9 12,0 12,5 12,5 12,6 12,8 12,8 13,2 14,3 14,9 15,5 15,6 16,9 17,1 18,6 19,8 20,9 21,0 23,1 25,5 27,0

31,4

% 30

School

2,3

Local figures for smoking in 33 gymnasiums (16-19)

Every school can see where students stand. 50

40

0

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Local information fuels dialogue •

Dialogue between key stakeholders •

Politicians, municipalities and local authorities

•

Parental groups and family planners

•

School authorities and school workers

•

Health educators, health and social services

•

Leisure time workers, prevention workers

•

Sports and youth institutions

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The way we work now

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Knowing is not enough. How do you act? 2013 ICSRA │ Reykjavik University

One practical example 2013 ICSRA │ Reykjavik University

The Reykjavik City Leisure Card The Leisure Card initiative is to guarantee that all

children up to the age of 18 have the opportunity to engage in leisure activities outside school. The City of Reykjavik allocates approximately EUR 3.000.000-, yearly to the Leisure Card Influencing parents first and foremost 2013 ICSRA │ Reykjavik University

Twofold goal

1. Humanitarian goal • Less substance use

2. Financial goal • Return on investment is multiple 2013 ICSRA │ Reykjavik University

And what is achieved? 2013 ICSRA │ Reykjavik University

Percentage of students in 9th grade that participate in sports in a sports club four times per week or more

50 45

Increased organized sports participation 42,0

40

34,0

35 30 % 25

23,0

20

15 10

5 0

2000

2006

2012

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Percentage of students in 9th and 10th grade who spend time (often/almost always) with their parents during weekdays 50 45

Time spent with parents

40

46,0

33,0

35 30

% 25

23,0

20 15 10 5 0 1997

2006

2012

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Proportion of students in 9th and 10th grade who have been out after 10 pm (3 times or more) in the past week 75

Less late outside hours

65 55

53,0 40,0

45

% 35

29,0

25 15 5 -5

2000

2006

2012

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My parents know where I am in the evenings (applies very or rather well to me) 9th and 10th grade 80 70 60

Increased parental monitoring

67,0

71,0

2006

2012

52,0

50 %

40 30 20 10 0 2000

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And substance use is going down 50

45

Drunk last 30 days

42

Daily smoking

40

35

35

32

33 26

30 %

25

10 5

0

28

26

23

17

25

22 19

20 15

Hashish once or more

16

18

15

14

14

15 12

11

12

12

11

12

19 14

10 10

13

9

9

9 7

6

7 6

9 3

7 3

5 32

1998 1999 2000 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2013 ICSRA │ Reykjavik University

What about evaluation? 2013 ICSRA │ Reykjavik University

Kristjansson et al. 2010, Preventive Medicine

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To conclude 2013 ICSRA │ Reykjavik University

ADPY

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Youth in Europe starts 2005 50 45

Drunk last 30 days

42

40

35

35

32

15 10 5

26

23 19

20 17

15

Hashish once or more

33

30 % 25

Daily smoking

28

Substance use down by 50% in 8 years

26 22

16 12

15

14

14

11

12

13

12

11

9

9

0 1998 1999 2000 2001 2002 2003 2004 2005

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15 – 16 year old who have become drunk past 30 days in some European cities 2013 50

45 40 35 % 30

28,0 24,2

25

19,2

20 15,3 15

12,2 8,6

10 5,4 5 0

9,8

10,3

16,1

16,8

19,7

24,2

15 – 16 year old who have become drunk past 30 days in Reykjavik 2013 and 1998 50 45

42,0

40

35 % 30

28,0

25

23,0 19,2

20 15,3 15 8,6

10

9,8

10,3

16,1

24,2

19,7

16,8

12,2

5,4 5

0 RVK 2013

RVK 1998

What is the commitment?

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Thank you Gothenburg│November 2013

2013 ICSRA │Reykjavik University