Transcript Diapositiva 1

EU-Dap/Unplugged:
an effective school-based program
for drug use prevention among adolescents
Federica Vigna-Taglianti
EU-Dap study
Piedmont Centre for Drug Addiction Epidemiology
OED Piemonte, Torino
A.Avogadro University, Novara
Vilnius National Conference for Drug Control, 5 November 2009
Substance use among adolescents
Country
Alcohol use last
12 months %
Drunk last 12
months %
Smoking past
30-days %
Cannabis
lifetime %
Any drug but
cannabis %
Austria
Belgium
Czech Rep.
Denmark
Finland
France
Germany
Greece
Italy
Netherlands
Norway
Poland
Portugal
Sweden
UK
93
86
95
95
80
80
93
91
82
85
76
85
74
77
91
69
47
68
82
64
29
61
37
37
46
54
48
28
55
68
49
32
43
30
38
33
45
28
38
31
28
31
28
23
29
21
32
44
23
11
38
27
6
27
28
9
18
15
7
38
8
8
12
6
3
7
10
3
8
6
3
7
7
3
9
Table: Selected indicators of youth substance use in some European countries
ESPAD 2007 Lituania 87%
43%
34%
18%
1
7%
one of the most important causes of death and
poor health among young people
1From
the ESPAD survey 2003 (www.espad.org)
Prevention
Prevention interventions are a good public
health strategy to reduce the burden of
disease due to substance addiction
Prevention strategies:
1. universal prevention
targeted to general population as well as to specific
unselected populations (schools, family, community)
2. selective prevention
targeted to subsets of the population identified as having a
higher risk of drug use than average
3. indicated prevention
which targets those who have already taken drugs and are
considered to be at risk of becoming addicted
Effective Prevention
However,
•
the effectiveness of interventions is
scarcely evaluated
•
only few interventions are effective
No clear evidence is available on effective selective
and indicated interventions (ok: family interventions)
There are evidences that some interventions can
make harm (information only, mass-media for drugs)
Among universal interventions, school-based
comprehensive social influence programs are effective
Negative results: “US Media Campaign”
In the US, the effectiveness evaluation of a recent big
mass-media campaign "National Youth Anti-Drug
Media Campaign" (with messages on TV, radio, and
newspapers, and internet banners), targeted to 12-18
years old youngs and their parents, showed clear
“boomerang” effects:
- 3% increase in marijuana use in 14-16 years old
youngs
- increase of positive attitudes, intentions to use and
first users of marijuana among youngs more exposed to
messages (Jacobsohn)
- boomerang effect on peers marijuana use
Why effective programs
Why is that important to apply effective programs
1. Primary prevention intervention:
• the target population is healthy, our aim is to
prevent a risk behaviour (use of drugs) in a
population where most people are non-users
• the target population did not ask for an
intervention
2. Adolescents are involved (<18 years)
We are responsible for adolescents who start using
drugs because of the intervention
CSI approach
Development of
personal and
social skills
Social skills
Knowledge on risks
and consequences of
use
Knowledge
Normative
education
Modification of
wrong perception of
peers and adults
substance use and
social acceptability
Comprehensive Social
Influence (CSI) Approach
Effective programs in Europe?
Country
Programme name
Age group
Outcome Evaluation
(any kind)
Germany, Sweden, others
Lions’ Quest
10-15
Yes
Finland, Sweden
Greece, Ireland
Italy
Uskalla/Våga
On my own two feet
Nuove tecnologie della comunicazione
Folkeaksjonen mot Narkotika's
12-13
12-13
15-19
10-12
13-18
12-16
No
No
No
No
No
Yes
Norway
Portugal
Spain
O atelier de prevenção
Ordago
Table: Examples of school-based programmes against substance use implemented in European countries based on a CSI model
Characteristics of the EU-Dap trial
Experimental study:
- Cluster Randomized Controlled trial
Funded by the European Community
- Public Health Program
Involving 9 centers in 7 European Countries
Conceived by an international expert group
Supported by EMCDDA
Main aims:
• to build a School-based European Prevention Program
(“Unplugged”)
• to evaluate the efficacy of the program
GERMANY / Kiel
IFT-Nord
SWEDEN / Stockholm
Centre for Tobacco
Prevention
BELGIUM / Gent
De Sleutel
AUSTRIA / Wien
ISG
SPAIN / Bilbao
EDEX
ITALY / L’Aquila
University
GREECE / Thessaloniki
REITOX/PYXIDA
EMCDDA
ITALY / Turin
Piedmont Centre
for Drug
Addiction
Epidemiology
ITALY / Novara
Avogadro University
“Unplugged”
• the program is based on a Comprehensive Social
Influence approach
• It includes the following components
– Social skills
– Personal skills
– Knowledge
– Normative education
– (resistance education, indirectly)
• It is administered by teachers trained in a 3-days course
• It is made by 12 units, 1 hour each
• It is designed for 12-14 years old students
The 12 units
Unit
Title
Goals
1
Opening ”Unplugged”
Introduction to the programme, setting of rules for
the lessons, reflecting on knowledge on drugs
2
To be or not to be in a
group
Clarification of group influences and group
expectations
3
Alcohol
Information on different factors influencing drug use
4
Reality check
5
Smoking the cigarette
drug
Fostering critical evaluation of information, reflection
on differences between own opinion and actual data,
correction of norms
Information on effects of smoking, differentiation of
expected vs. real effects and short-term vs. longterm effects
6
Express yourself
Adequate communication of emotions, distinguishing
between verbal and nonverbal communication
7
“Get up, stand up”
Fostering assertiveness and respect for others
8
“Party tiger”
Recognition and appreciation of positive qualities,
acceptance of positive feedback, practising and
reflection on getting into contact with others
9
Drugs-get informed
Information on positive and negative effects of drug
use
10
Coping competences
Expression of negative feelings, coping with
weaknesses
11
Problem solving and
decision making
Structured problem solving, fostering creative
thinking and self control
12
Goal setting and
closure
Distinguishing long term and short term objectives,
feedback on the programme and the process during
the programme
Evaluation: enrollment
• 7079 students participated in the baseline survey
(November 2004)
• The program (“Unplugged") was administerd
between November 2004 and February 2005 in the
intervention arms
• 6604 (93%) students participated in the first followup survey (May 2005), 3 months (at least) after the
end of the program
• 5812 (82%) students participated in the second
follow-up survey (May 2006), 15 months (at least)
after the end of the program
Procedures for the surveys
Self completed anonymous questionnaire on use of
substances, attitudes, knowledge…
– most items retrieved from EDDRA data bank
– identical for all countries
Linkage between pre- and post-test by a self generated
code based on fixed data (some letters from name of
parents, date of birth..)
the reliability was tested in a pilot study
(Galanti 2006, Preventive Medicine)
Individual code
The questionnaire
Gender differences: cigarettes
I smoked at least one cigarette in the last 30 days
100,0
Ragazzi
90,0
Ragazze
80,0
70,0
60,0
%
50,0
40,0
30,0
34,0
27,3
28,9
22,7
25,6
24,4
20,0
10,0
0,0
Torino/Italia
Bilbao/Spagna
Novara/Italia
Ragazzi n= 841, Ragazze n= 807 Ragazzi n= 205, Ragazze n= 195 Ragazzi n= 275, Ragazze n= 238
Drunkenness episodes
I've been drunk at least ONCE in the last 30 days
100,0
Ragazzi
Ragazze
90,0
80,0
70,0
60,0
% 50,0
40,0
30,0
20,0
10,0
11,9
17,3
18,4
10,5
7,6
10,9
0,0
Torino/Italia
Bilbao/Spagna
Novara/Italia
Ragazzi n= 841, Ragazze n= Ragazzi n= 205, Ragazze n= Ragazzi n= 275, Ragazze n=
807
195
238
Smoking cannabis
I smoked cannabis at least ONCE in the last 30 days
100,0
90,0
80,0
70,0
60,0
% 50,0
40,0
30,0
20,0
10,0
0,0
Ragazzi
Ragazze
17,7
10,3
5,2
Torino/Italia
10,6
Bilbao/Spagna
5,1
4,6
Novara/Italia
Ragazzi n= 841, Ragazze n= Ragazzi n= 205, Ragazze n= Ragazzi n= 275, Ragazze n=
807
195
238
Program effect: ALO smoking
% 22,0
21,0
21,0
20,0
19,0
18,0
17,2
17,1
17,0
16,0
15,5
15,0
[0] CONTROL
14,0
14,1
[1] BASIC
[2] PARENT
13,0
12,9
[3] PEER
12,5
12,2
[1+2+3] INTERV
12,0
%Yes BAS
%Yes FU1
t
Daily smoking
% 10,0
9,6
9,0
8,0
7,2
7,0
6,5
6,0
6,1
5,7
5,0
6,1
6,0
4,8
[0] CONTROL
4,6
[1] BASIC
[2] PARENT
4,0
[3] PEER
3,3
[1+2+3] INTERV
3,0
%Yes BAS
%Yes FU1
t
ALO drunkenness
% 12,0
11,7
11,0
10,0
9,4
9,0
8,5
8,4
8,0
7,4
7,0
[0] CONTROL
6,6
[1] BASIC
[2] PARENT
6,0
5,0
5,5
5,4
5,3
%Yes BAS
[3] PEER
[1+2+3] INTERV
%Yes FU1
t
ALO cannabis
% 8,0
7,3
7,0
6,0
5,5
5,3
5,0
4,9
4,0
3,9
4,1
[0] CONTROL
3,0
[1] BASIC
3,0
[2] PARENT
2,8
2,7
2,4
[3] PEER
[1+2+3] INTERV
2,0
%Yes BAS
%Yes FU1
t
Adjusted statistical analysis
• A Multi-Level model was used to:
– Adjust for the cluster effect (cluster RCT: the unit
of the randomization is the class, but the unit of
the analysis is the student)
– Take into account the differences in the
prevalence of use among centers
– Take into account the differences in the
prevalence of use among arms (the controls
show higher prevalences of use at the baseline)
Results: post-test
all interventions vs control group
3 months after the end of the program
BAS vs FUP1
Controls Interventions
n/N
n/N
Adjusted
POR (95%CI)
Reduction
ALO smoking
605/2968
496/2979
0.88 (0.71-1.08)
-12%
Regular smoking 387/2968
297/2979
0.86 (0.67-1.10)
-14%
277/2968
193/2979
0.70 (0.52-0.94)
-30%
353/3054
253/3083
0.72 (0.58-0.90)
-28%
120/3054
76/3083
0.69 (0.48-0.99)
-31%
225/3130
152/3150
0.77 (0.60-1.00)
-23%
Regular cannabis 137/3130
88/3150
0.76 (0.53-1.09)
-24%
222/3185
0.89 (0.69-1.15)
-11%
Daily smoking
ALO
drunkenness
Regular
drunkenness
ALO cannabis
ALO drugs
293/3156
Transition among stages: smoking
POST-TEST SURVEY
Intensity of use
BASELINE
no use
sporadic
frequent
daily
No use
%
90.2
95%CI
89.0-91.3
BASELINE
frequent
daily
total (n)
total (n)
4.9-6.8
1.8
2.2
2516
1.3-2.4
1.7-2.9
%
38.0
28.6
13.4
19.9
31.1-45.5
22.4-35.8
9.1-19.4
14.6-26.5
%
16.2
19.2
26.3
38.4
95%CI
10.2-24.6
12.6-28.0
18.6-35.7
29.4-48.2
171
99
%
7.1
2.2
8.8
81.9
95%CI
4.2-11.8
0.9-5.5
5.5-13.8
75.6-86.8
2363
218
110
277
2968
1.8
1.5
2597
1.3-2.3
1.1-2.0
%
95%CI
sporadic
daily
frequent
95%CI
total (n)
no use
sporadic
Control arm
5.8
Pooled intervention arms
91.4
5.4
90.2-92.4
4.6-6.3
%
49.1
26.0
16.6
8.3
95%CI
41.7-56.6
20.0-33.1
11.7-22.9
5.0-13.4
%
22.4
17.1
28.9
31.6
95%CI
14.5-32.9
10.3-27.1
20.0-40.0
22.2-42.7
%
7.3
1.5
5.8
85.4
95%CI
4.0-12.9
0.4-5.2
3.0-11.1
78.5-90.3
2483
199
104
193
182
169
76
137
2979
The program works better in preventing the transition
towards regular use more than promoting the cessation
Gender differences
Females
Males
BAS vs FUP1
Adjusted
POR (95%CI)
Change
Adjusted
POR (95%CI)
Change
ALO smoking
0.88 (0.66-1.18)
-12%
0.86 (0.65-1.15)
-14%
Regular smoking 0.68 (0.50-0.93)
-32%
1.07 (0.74-1.55)
+7%
0.49 (0.34-0.71)
-51%
0.99 (0.64-1.52)
-1%
0.64 (0.49-0.85)
-36%
0.86 (0.63-1.18)
-14%
0.68 (0.45-1.04)
-32%
0.66 (0.37-1.18)
-34%
0.62 (0.45-0.85)
-38%
1.05 (0.70-1.58)
+5%
Regular cannabis 0.60 (0.40-0.91)
-40%
1.17 (0.59-2.33)
+17%
0.64 (0.48-0.86)
-36%
1.40 (0.95-2.04)
+40%
Daily smoking
ALO
drunkenness
Regular
drunkenness
ALO cannabis
ALO drugs
among females:
 results are not statistically significant
 no effect is detectable for smoking, cannabis and drugs
Young adolescent girls
Girls
11-12 years
N=781
13-18 years
N=2254
POR (95%CI)
POR (95%CI)
Any smoking
0,78 (0,45-1,34)
0,84 (0,63-1,13)
Frequent smoking
0,52 (0,23-1,21)
1,21 (0,83-1,77)
Daily smoking
0,45 (0,18-1,13)
1,19 (0,77-1,85)
Any drunkenness
0,44 (0,19-1,04)
0,94 (0,68-1,29)
Frequent drunkenness
0,70 (0,16-3,01)
0,65 (0,37-1,16)
Any cannabis
§
1,15 (0,77-1,71)
Frequent cannabis
§
1,19 (0,62-2,27)
1,03 (0,47-2,28)
1,42 (0,98-2,06)
Indicator of use
Any illicit drug
If administered to young adolescents, the program works
also on females
Enrollment by centre at 1 year
[02] FOLLOW-UP 1
% Partecipants/Students Eligible for FUP
through Eudap Surveys
%
100
100
92
90
80
99
93
92
[03] FOLLOW-UP 2
93
87
82
77
95
94
89
88
85
76
93
93
82
77
78
70
60
50
40
30
20
10
TOTAL
[09] ItalyAquila
[08] ItalyNovara
[07] AustriaWien
[06] GreeceThessaloniki
[05] SwedenStockholm
[04] BelgiumGent
[03] GermanyKiel
[02] SpainBilbao
[01] ItalyTurin
0
Results: 1 year follow-up
all interventions vs control group
15 months after the end of the program
BAS vs FUP2
Controls Interventions
n/N
n/N
Adjusted
POR (95%CI)
Reduction
ALO smoking
692/2558
606/2602
0,94 (0,80-1,11)
-6%
Regular smoking
473/2558
392/2602
0,89 (0,72-1,09)
-11%
Daily smoking
333/2558
280/2602
0,92 (0,73-1,16)
-8%
ALO drunkenness
469/2618
374/2698
0,80 (0,67-0,97)
-20%
Regular
drunkenness
168/2618
102/2698
0,62 (0,47-0,81)
-38%
ALO cannabis
255/2699
183/2768
0,83 (0,65-1,05)
-17%
Regular cannabis
158/2699
105/2768
0,74 (0,53-1,01)
-26%
ALO drugs
315/2716
238/2797
0,85 (0,69-1,05)
-15%
Post-test vs 1 year follow-up results
Post-test
15 months follow-up
% reduction
% reduction
ALO smoking
-12%
-6%
Regular smoking
-14%
-11%
Daily smoking
-30%
-8%
ALO drunkenness
-28%
-20%
Regular drunkenness
-31%
-38%
ALO cannabis
-23%
-17%
Regular cannabis
-24%
-26%
ALO drugs
-11%
-15%
Graphical representation of changes
Daily smoking
Any episode of
drunkenness
Any use of cannabis
Conclusions on the effect
The statistical analysis shows that Unplugged is effective
in reducing use of drugs, alcohol and cigarettes at the
post-test
and the results are maintained for alcohol (and
cannabis) at 1 year follow-up
The program works better in preventing the use more
than promoting cessation
Since there are gender differences in the effectiveness,
it is recommended to administer the program to early
adolescents (less than 14 years old)
Implementation of Units
100
% classes
80
60
Partial
Complete
40
20
0
1
2
3
4
5
6
7
8
9
10 11 12
Core Units
Experimental version of the Unplugged program
Age
12 years
n/N*
%
13 years
n/N*
%
14 years
n/N*
%
ALO smoking
153/2202
6.9 156/2082 8.5 719/2497 28.8
Regular smoking
85/2202
3.9
85/2082
4.1 477/2497 19.1
Daily smoking
48/2202
2.2
53/2082
2.5 331/2497 13.3
ALO drunkenness
88/2254
3.9
81/2132
3.8 295/2536 11.6
Regular
drunkenness
30/2254
1.3
24/2132
1.1
93/2536
3.7
ALO cannabis
30/2273
1.3
21/2154
1.0 217/2576
8.4
Regular cannabis
16/2273
0.7
9/2154
0.4 136/2576
5.3
ALO drugs
76/2289
3.3
39/2170
1.8 267/2594 10.3
14 years old students have very high level of use
Suggestions for implementation
The Guide is a tool for
a. Policy makers (Chapter 1)
b. Headmasters (Chapter 2)
c. Teachers (Chapter 3)
to disseminate and implement
CSI programs in the schools
Practical tools are provided in
each chapter to choose, plan,
implement and evaluate the
implementation of the
program
Conducting an environment assessment
• Ministry of Education mandate, promote and/or coordinate
• School autonomy to choose to implement a CSI programme
• Regional authorities promote and coordinate
• Schools use consultative processes which involve teachers,
parents & pupils
• Motivated teachers to lead or manage the programme
• Schools have an established tradition of prevention activities
or have set a mission statement or goal to do so
Criteria to consider when
choosing a CSI program
GETTING STARTED
SEE TOOL N. 1
Guide: Chapter 2
Steps to follow
The environment attitude towards tobacco/alcohol and
substance use and towards prevention interventions has
to be considered (post-pone/create)
Steps to follow
• Ensure materials for teachers and students are available.
Tips for raising
funds
• Investigate funds available from the Ministry, Region, School
Budget.
Organize a teacher
training
• Engage parents to support the programme.
SEE TOOL N. 2
Gathering resources to implement a CSI programme
SEE TOOL N. 3
Guide: Chapter 2
IMPLEMENTING
Getting organized to implement a CSI programme
• Schedule and organize the programme’s implementation on
the school calendar.
•Support Teachers’ continuing education in legislation. Allow
teachers to attend training, should it be available, or organize a
training for teachers by allowing those that have taught
prevention programmes to act as trainers.
Steps to follow
• Teachers can adopt the role as trainers.
• Teachers are motivated to accurately implement all sessions
of the programme in the foreseen sequence.
• Parents are interested in the continuation of prevention
activities and ask the school to annually implement them
• Adopt the programme to take place as core curriculum within
one or more subjects.
• Funding by Ministry set aside for implementation.
• Surveil the program’s implementation and suggest how to
improve upon it.
Conduct a quality control
assessment
Maintaining quality in CSI programmes
SEE TOOL N. 4
Guide: Chapter 2
SUSTAINING
Sustaining the implementation of the program across
years is important (inequalities/context/effectiveness)
Ongoing activities
www.eudap.net
In 2006, the EC funded a second phase of the project (EUDap2), aimed to the dissemination of effective prevention
programs
Poland and Czech Republic joined the project as
new implementing countries
the Guide to successful implementation of CSI
curricula in schools has been published
Publications on the effect of the program are now
available on Pubmed/International Journals
New projects are ongoing with the collaboration of
Mentor Foundation
Mentor Lithuania is involved… together with
Russia, Romania, Croatia and Kyrgyzstan