Prof Harry SumnallMentor UK Seminar Liverpool, March 2016

REFLECTIONS ON TARGETED AND INDICATED PREVENTION

SOCIOECOLOGICAL MODEL OF PUBLIC HEALTH

Institute of Medicine, 2003

A model of health that emphasises the linkages and relationships among multiple factors (or determinants) affecting health.

Campbell, 2010

IOM, 1994

DIFFERENCES BETWEEN SELECTIVE/INDICATED PREVENTION AND TREATMENT

Treatment is based on responding to a clinical diagnosis and quickly provides benefits including symptom reduction.

Indicated prevention refers to high r isk individuals who are identif ied as having minimal but detectable signs or symptoms of factors that predict drug use but who do not meet clinically relevant levels at the current time .

Selective interventions are targeted to individuals or a subgroup of the population whose risk of drug use is significantly higher than average .

The risk may be imminent or it may be a li fetime risk.

Both are probabilist ic interventions – a harder sell

Treatment Selective/indicated prevention

https://www.nice.org.uk/guidance/indevelopment/gid-phg90

Drug prevention GuidelinesExpected publication February 2017

• A variety of evidence based interventions are offered across the EU

• Extent of provision and quality of implementation differs between countries

• Difference between highly research manualised programmes and informal adaptations and ‘kernels’

COMMON LIABILITY MODEL

9

Common liabil ity (CL) to substance use disorders involves mechanisms and biobehavioural characteristics that pertain to the entire course of development of the disorder and changes in the risk.

Problematic drug use/drug dependence can be located on the same dimension as premorbid (and even pre-drug-use) behaviours that are indicators of a highly heritable latent trait variably referred to as dysregulation, disinhibition, behaviour undercontrol or externalising behaviour, including risks for disruptive behaviour disorders.

CLA, a behavioural/psychological trait, manifests in a range of “gateway” behaviours grounded in the mechanisms of socialisation and affective/cognitive regulation with deep evolutionary roots

In simple terms drug use is a manifestation/indicator of an underlying behavioural trait

Vanyukov et al., 2012

MULTIPLE RISK BEHAVIOURS

In accordance with common liabil ity model of behaviour, there is a clustering of risk behaviours in YP

Multiple risk behaviours are associated with effects beyond the cumulative effects of individual health risk behaviour, including poorer emotional wellbeing, psychological distress, and injury

Associated with inequalitiesThere is early evidence for the cost-effectiveness of interventions for multiple

risk behaviours suggesting that they constitute a more cost-efficient means of preventing risk behaviours in adolescence

Hale and Viner, 2012

Bramley et al., 2015

Mental health problems

Behavioral disordersViolenceAlcohol

problems

D R U G U S E I S J U S T O N EP O S S I B L E P R E D I C TO R F O R

P R O B L E M S

13 Million

in last month

Cannabis users

Early intervention

Indicated prevention

70 Million Europeans

ever used (LTP) 3 Million daily

Problem escalation

Slide courtesy of G.Burkhart

Nuffield Council, 2007 - Intervention Ladder

HOW HAS OUR CURRENT UNDERSTANDING OF PREVENTION BEEN ‘CONSTRUCTED’

Drug prevention has been suggested to be an ideological ‘litmus test’ (Edman, 2012)

Drugs [and prevention] re-constructed as a problem to be handled by ‘experts’ rather than politics (Roumeliotis, 2013)

Drug prevention is connected with specific ways of governing society and problems (and ‘problem people’), therefore specific kinds of knowledge are used to construct and represent these problems

• In general public health, respecting autonomy involves not just attention to the protection of individual choice, but also the creation of a social/economic/polit ical environment that affords the conditions necessary to support and nurture such choices – does this hold true for il legal drug use?

• Individuals may have ‘forward looking’ relative to ‘backward looking’ responsibilit ies (responsibilities for certain already-existing behaviours) , but autonomy and capability are essential

• Some targeted populations are perhaps il l equipped for change

• Those who are already better resources are positioned better to benefit from universal and health promotion approaches.

TARGETED PREVENTION AND AUTONOMY

Wardrope, 2015

CAREFUL WITH HIGH-RISK RECIPIENTS

Drug use and risk is functional in some networks – ‘bonding capital’ in Social Capital research

People consider messages contradicting their opinion as unfair and propagandistic

Strong persuasive intent leads to reactance:Logical deconstruction of the argumentDerogation of the message source

‘FUNCTIONAL’ RISK TAKING

Impulsive, Risk seeking,

Affective intensive, Peer-oriented

Social Primacy

It makes sense: Mating success, social statusFast adaptation to hostile & unstable environmentsPleasure and learning opportunities

Slide courtesy of G.Burkhart

The shared rituals of smoking are a valued means of expressing group identity and belonging (over and above acute pharmacological effects), and smoking helps forge and maintain group solidarity

Important for socially excluded groups and individualsPrevention programmes that do not consider the social meanings of

health behaviours into their approach may struggle to engage target groups

Illegal drugs? Identity and synthetic cannabinoid receptor agonists (SCRA); ketamine?

EXAMPLE OF SMOKING

Voigt, 2010

Social inequalit ies are differences in income, resources, power and status within and between societies, and are maintained via institutions and social processes.

Health inequalities are differences in health between people or groups due to social, geographical, biological or other factors.

Some factors are fixed, whereas others are dynamic In public health, tend to be a focus on socio-economic differentiationClosely linked to social exclusionSubstance use is also a symbolic behaviour and is generally stigmatised, and this

is also another source of inequality

WHAT ARE INEQUALITIES?

CSEW (2015):Use of any drug (mostly cannabis) was highest for those living in the areas

defined to be the most deprived (10.2%), and lowest for those living in areas defined to be the least deprived (6.9%).

However, use of any Class A drug does not vary with Indices of Deprivation, with similar levels of use in all areas (3.1% in the most deprived areas, 3.3% in middle areas, and 2.9% in the least deprived areas).

DRUG USE IS RELATIVELY EQUALLY DISTRIBUTED ACROSS UK SOCIETY

Individuals at risk of mental health disorder more likely to experience problems with substances

Adverse outcomes from drug (and alcohol) use are more strongly related to socio-economic status (SES) than patterns of substance use

Deprivation associated with lower age of first use, progression to dependence, injecting drug use, risky use, health and social morbidity and criminal involvement.

Resilience factors (e.g. strong social support, employment) negated by patterns of deprivation

Inequalities may mediate level of drug involvement

…BUT ADVERSE OUTCOMES ARE NOT EQUALLY DISTRIBUTED

e.g. Bergen et al., 2008; Galea and Vlahov, 2002; Jones et al., 2015; Williams and Latkin, 2007

Effectiveness may be determined by factors such as intervention efficacy, service provision, uptake and compliance

Individuals and subpopulations have differential access to personal and structural ‘resources’ which determine compliance and uptake

Universal and poorly implemented individual level programmes may therefore lead to inequalities

Interventions and actions that do not rely as much on access to resources may reduce inequalities – upstream/population level interventions E.g. Alcohol MUP, tobacco control – for drugs??

PREVENTION AS A SOURCE OF INEQUALITIES

After McGill et al., 2014

CHALLENGES FOR TARGETED PREVENTION AS A RESPONSE TO INEQUALITIES

e.g. ACMD, 2015; Faggiano et al., 2008; Brotherhood and Sumnall, 2013

• Prevention programmes that are best evidenced are targeted at (universal) populations

• Mixed evidence for individualised approaches, e.g. MI, and MET• In UK, often informal adaptation of prevention ‘principles’ and ‘pall iative

approaches’• Targeted at a narrowly defined ‘problem’ – ‘drug use’• Research rarely includes ‘meaningful’ prevention outcomes• Rarely address determinants of inequality, which are often also determinants of

substance use

25

Professor Harry SumnallCentre for Public Health

Liverpool UK

h.sumnall@ljmu.ac.uk@profhrs@euspr

CONTACT