NHSGGC Alcohol and Drug Prevention and Education Model (2012)

A working definition for Prevention and Education is defined as

‘being largely concerned with encouraging and developing ways to support and empower individuals, families and communities in the acquisition of knowledge, attitudes and skills with which to avoid or reduce the development of alcohol problems, drug misuse and alcohol and drug related harm.’

It was hoped that the Prevention and Education Model would create an overarching commissioning framework for alcohol and drug prevention and education provision across the NHS Greater Glasgow and Clyde area that gives clear guidance on what constitutes good practice. This would then inform the future planning and delivery of alcohol and drug prevention and education work, in turn, providing the opportunity for partners to facilitate a move towards developing prevention and education structures fit for purpose that can address issues around equity of provision, cost effectiveness and accountability.

Since the ratification and distribution of the model in 2008, there has been growing evidence of dedicated central and local structures and services with a focus on prevention and education being developed and then maintained. There has also been positive reporting of a flurry of co-ordinated activity that directly links to the 12 core elements in the model being delivered in the alcohol and drug prevention and education field through outcome focused action plans and budgets co-ordinated by these dedicated prevention and education structures.

The five key aims of the NHS Greater Glasgow and Clyde Alcohol and Drug Prevention and Education (2012) Model is

1. To continue to promote consistent practice and standards, in relation to prevention and education practice across all CH(C)P’s in Greater Glasgow and Clyde.
2. To encourage prevention and education practitioners to agree on, and then take ownership of a baseline definition for prevention and education that will then inform universal working in the field.
3. To raise the profile of prevention and education as a range of interventions worthwhile investing in at a local and area wide level by strengthening planning and partnership working across all Tiers and Core Elements.
4. To raise awareness of the updated NHS Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model which includes a working definition for prevention and education, prevention and education tiered model, 12 evidenced based core elements and support functions.
5. To create a more strategic, outcome-focused, co-ordinated, cohesive, sustainable and planned approach to best practice. This will focus on the longer term structural development for prevention and education built on evidenced based approaches and a performance management framework.

The Prevention and Education Model is not meant as a definitive prescriptive guide but instead aims to stimulate discussion and debate amongst strategic planners and practitioners of prevention and education approaches. This therefore creates a vehicle of opportunity in which to explore, understand and respond to the capacity, funding difficulties and constraints inherent in translating theories of good practice into workable and achievable objectives. In doing so, this will help identify appropriate ways forward for the future planning and delivery of prevention and education in localities and across the NHS Greater Glasgow and Clyde wide area.

1. Resilience and protective factors
2. Environmental measures
3. Community involvement
4. Diversionary approaches
5. Brief Intervention approaches
6. Education
7. Training
8. Parenting programmes
9. Social marketing
10. Workplace alcohol and drug policies
11. Harm reduction – alcohol
12. Harm reduction  – drugs

In 2008, the Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model was widely distributed following ratification from the then Greater Glasgow and Clyde Alcohol Action Team / Drug Action Team.

The five key aims of the Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model are

1. To continue to promote consistent practice and standards, in relation to prevention and education practice across all CH(C)P’s in Greater Glasgow and Clyde.
2. To encourage prevention and education practitioners to agree on, and then take ownership of a baseline definition for prevention and education that will then inform universal working in the field.
3. To raise the profile of prevention and education as a range of interventions worthwhile investing in at a local and area wide level by strengthening planning and partnership working across all Tiers and Core Elements.
4. To raise awareness of the updated Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model which includes a working definition for prevention and education, prevention and education tiered model, 12 evidenced based core elements and support functions.
5. To create a more strategic, outcome-focused, co-ordinated, cohesive, sustainable and planned approach to best practice. This will focus on the longer term structural development for prevention and education built on evidenced based approaches and a performance management framework.

It was hoped that the Prevention and Education Model would create an overarching commissioning framework for alcohol and drug prevention and education provision across the Greater Glasgow and Clyde area that gives  clear guidance on what constitutes good practice. This would then inform the future planning and delivery of alcohol and drug prevention and education work, in turn, providing the opportunity for partners to facilitate a move towards developing prevention and education structures fit for purpose that can address issues around equity of provision, cost effectiveness and accountability.

The Prevention and Education Model is not meant as a definitive prescriptive guide but instead aims to stimulate discussion and debate amongst strategic planners and practitioners of prevention and education approaches. This therefore creates a vehicle of opportunity in which to explore, understand and respond to the capacity, funding difficulties and constraints inherent in translating theories of good practice into workable and achievable objectives. In doing so, this will help identify appropriate ways forward for the future planning and delivery of prevention and education in localities and across the Greater Glasgow and Clyde wide area.

Since the ratification and distribution of the model in 2008, there has been growing evidence of dedicated central and local structures and services with a focus on prevention and education being developed and then maintained. There has also been positive reporting of a flurry of co-ordinated activity that directly links to the 12 core elements in the model being delivered in the alcohol and drug prevention and education field through outcome focused action plans and budgets co-ordinated by these dedicated prevention and education structures.

In 2011 a multi-disciplinary reference group was formed to support the review of the existing evidence base and further progress the model. The following document further introduces this review.

Adolescence is a period of transition when children are at higher risk for a number of behaviours including substance use. Alcohol use and misuse by adolescents and young adults is a major public health issue. A number of factors have been identified that protect adolescents or, alternatively, put them at risk for alcohol and drug use. These factors are concerned with different personal and environmental factors, e.g. the community, the school setting, family, peer group and individual characteristics.

Protective behavioural strategies (PBS) for drinking are behaviours that individuals engage in to reduce or limit alcohol consumption and related negative consequences, such as alternating alcoholic and non-alcoholic drinks. An emerging body of literature indicates that individuals who routinely engage in behaviours such as setting limits, pacing drinks, diluting beverages, and taking social precautions (e.g., walking home with friends) are at a lower risk of experiencing alcohol-related consequences

The rationale for identifying risk factors for alcohol and drug use among adolescents is to promote effective preventive interventions. These interventions should be aimed at reducing or eliminating risk factors and increasing protective factors. Using a risk and protective factor approach is one way of increasing awareness of the need for preventive efforts targeting adolescents and young adults. It provides public health planners and other key stakeholders with information about which aspects of youth development in young people to target with preventive efforts.

Resilience theory provides another approach to preventing initiation of substance use through improving adolescent mental well-being and resilience. There is much variation in the definition of resilience although, it is generally agreed that both the individual as well as environmental characteristics contribute to an individual’s resilience and are critical for positive youth development and the avoidance of risk behaviours.

educing alcohol-related harm in young people is a major priority across Europe. Perceived availability is commonly associated with adolescent alcohol use. Environmental strategies to prevent the misuse of alcohol among young people such as policies restricting access to alcohol have been shown to reduce underage drinking. Much alcohol use and associated harm in young people occurs in public drinking environments. These environments, including bars, nightclubs and their surrounding areas are associated with high levels of acute alcohol-related harms.

Legislation on alcohol-related harm and disorder typically focuses on environmental preventive measures, such as opening hours regulation, staff training, enforcing the refusal of service to intoxicated patrons, and the replacement of drinking glasses and bottles with plastic alternatives. Such approaches require input and support from stakeholders including police, local authority licensing staff and health professionals.

Considerable research has demonstrated that substance use during early adolescence can have long-term negative health consequences. As these behaviours cross levels and contexts, community approaches have been suggested as an important component in the prevention of youth health and behaviour problems. Community approaches comprise a range of interventions and activities including community involvement, community engagement and community mobilisation which are aimed at a range of individuals from different age groups and with different characteristics, thus applying a whole population approach.

Brazg et al (2011) maintained that the successful development and implementation of prevention curricula requires seeking strategies that combine the strengths of researchers and community members. Thus, community coalitions have been suggested as mechanisms to build capacity to mount effective prevention initiatives in communities. For example, Koleck et al (2009) conducted a qualitative study on community and primary health care involvement on alcohol and tobacco actions in seven European countries. They concluded that in order to manage tobacco-and alcohol-related problems, a comprehensive community-based approach, that also includes primary health care teams and policymakers is required. A benefit of community-based prevention campaigns which involve tailored multi-faceted campaigns involving collaboration from various agencies and organisations, is that they can target and give advice to people who do not actively contact health care but may have alcohol and drug issues.

However, community projects and coalitions face significant challenges in focusing efforts and resources towards those interventions which are likely to have optimum impact and lead to change. Thus, reorienting and enhancing the efforts of existing services is a crucial issue for communities with limited resources.

Asset based approaches advocate the concept of assets as the collective resources which individuals and communities have that both protect against negative health outcomes and promote positive well being. Such approaches value the skills and capabilities of a community, focus on identifying the protective factors that support health and wellbeing, and attempt to redress the balance between meeting needs and nurturing the strengths and resources of people and communities. However, such approaches are not a replacement for investing in service improvement, with it being suggested that the move to such approaches forming an integral part of mainstream service delivery will require a change in both individual and organisational attitudes, values and practice (Glasgow Centre for Population Health, 2011).Another crucial issue is ensuring that those interventions implemented are based on sound evidence, as many communities continue to use prevention strategies that have not been shown to be effective.

Gilligan et al (2011) emphasised the need for evidence based methodologically rigorous intervention research to guide alcohol harm reduction programmes at the population, system or community level.

They present suggestions (which were supported by a survey of researchers) of the most important factors in relation to producing high-quality intervention research. Routine collection of relevant data, publication of negative results and reconsideration of funding priorities were ranked highest in terms of their importance in increasing intervention research.

A further issue is ensuring that such interventions are effectively tailored to both the community setting and target group. Holleran Steiker (2008) highlighted the value of involving youth in the cultural adaptation of evidence based drug prevention curricula and recommended that community settings adapt curricula to meet their youths’ unique needs in order to be effective, particularly those communities with diverse cultures. She outlined that many drug prevention curricula often fail to be relevant and engaging to the youth who receive them, and so adaptation can be critical in situations where the culture of the audience is unique, ethnically, socially, organisationally, or economically.

The link between exercise and sports participation and substance use.

There is conflicting evidence in the literature as to whether exercise and sports participation is linked positively or negatively to substance use.

To illustrate, research has indicated that exercise and sports/leisure activity participation is associated with substance use, and as such that leisure may be an important context of substance use prevention. For example, Moore and Werch (2008) examined self-reported exercise frequency and substance use among first year college students who self-identified as drinkers (n = 391) and found that frequent exercisers drank significantly more often and a significantly greater quantity than did infrequent exercisers.

Huurree et al (2010) found that among adolescent Finnish males, leisure-time spent daily among friends (among other factors including parental divorce) was a strong predictor of excessive alcohol use in adulthood. Tibbits et al (2009) examined the association between leisure activity participation and substance use among South African 8th graders (n = 3,497) and found that leisure activity profiles were significantly associated with past-month alcohol, tobacco, and marijuana use. Peck et al (2008) reported that childhood problem behaviour and adolescent sport participation can, but do not necessarily, predict heavy drinking in adulthood. They analysed data from four waves of the Michigan Study of Adolescent Life Transitions which provided data on participants aged 12 to approximately 28 years. They found that the relationship between adolescent sport activity and heavy alcohol use in later life was obtained primarily for sport participants who were also using more than the average amount of alcohol and other drugs at age 18. Similarly, children who were characterised by relatively high levels of sport participation, aggression and other problem behaviour at age 12 were more likely to become sport participants who used more than the average amount of alcohol and other drugs at age 18.

Mays et al (2010) investigated the relationship between school-based sports participation and alcohol-related behaviours using data from the National Longitudinal Study of Adolescent Health collected between 1994 and 2001 (n=8,271). The results indicated that greater involvement in sports during adolescence was associated with faster average acceleration in problem alcohol use over time among youths who only took part in sports, indicating that the relationship between sports participation and problem alcohol use depends on participation in sports in combination with other activities. They concluded that sports may represent an important context for alcohol interventions among adolescents.

Finlay et al (2012) conducted surveys with first year college students (n = 717) examining the relationship between day-to-day activities (volunteering, spiritual activities, media use, socialising, entertainment/campus events and clubs, athletics, classes, working for pay) and alcohol use. Findings indicated that alcohol use was higher among individuals who spent more time involved in athletics and socialising and lower among students who spent more time in spiritual and volunteering activities.

However, other studies have shown a positive relationship between participation in sports and exercise and substance use.

Taliaferro et al (2010) highlighted that the ways in which adolescents spend their out-of-school time is an important factor for predicting positive youth development. They examined relationships between sport participation and numerous health risk behaviours among high school students. Data from the Youth Risk Behaviour Surveys (from 1999 through 2007) was analysed. They found that among white students, sport participation related to multiple positive health behaviours. Conversely, ethnic minority athletes showed fewer positive health behaviours and some negative behaviours. Martha et al (2009) examined the relationship between sports and alcohol consumption among French students (n = 1,356). Results indicated that engaging in physical activity (whether or not it takes place within an institution) and practising martial art were negatively related to heavy episodic drinking.

Terry-McElrath and O’Malley (2011) investigated the relationship between participation in sports, athletics or exercising and substance use in early adulthood using longitudinal data (n = 11,741). Results indicated that increased participation in sports, athletics or exercising was related to significantly lower substance use frequency at age 18 and through significantly and negatively correlated growth trajectories through early adulthood. Thus, they concluded that encouraging exercise among young people may relate to lower substance use levels throughout early adulthood. However, additional research by Terry-McElrath et al (2011) highlighted an important difference between exercise and team sport participation in relation to adolescent substance use. Using longitudinal data, they found that higher levels of exercise were associated with lower levels of alcohol, cigarette, and marijuana use but that higher levels of athletic team participation were associated with higher levels of high school alcohol use.

Other research has indicated mixed results for different types of substance use, generally indicating that sport is negatively associated with alcohol but positively associated with tobacco and cannabis use. For example, Lisha and Sussman (2010) reviewed studies on high school and college sports involvement and drug use and found that participation in sport was related to higher levels of alcohol consumption, but lower levels of both cigarette smoking and illegal drug use. Wichstrom and Wichstrom (2009) conducted surveys among Norweigan high school students between 1992 and 2006 (n = 3,251). They found that those involved initially in team sports had greater growth in alcohol consumption, but lower growth in tobacco use and cannabis use, during the adolescent and early adult years compared to those involved in technical or strength sports. However, taking part in endurance sports, as opposed to technical or strength sports, predicted reduced growth in alcohol intoxication and tobacco use. Thus, they concluded that sports participation in adolescence, and participation in team sports in particular, may increase the growth in alcohol intoxication during late adolescent and early adult years, whereas participation in team sports and endurance sports may reduce later increase in tobacco and cannabis use.

Weinstock (2010) highlighted how substance use often occurs at the expense of other, substance-free, activities. They proposed exercise as an intervention for hazardous drinking and substance use disorders due to its numerous physical and mental health benefits. It was also posited that offering interventions for heavy drinking that do not stigmatise or require an individual to see a mental health professional may increase the utility and acceptability of the intervention and ultimately increase the number of individuals effectively treated.

Alcohol use has been identified by the World Health Organisation as the second greatest risk to public health in developed countries. Brief Interventions (BIs) are one preventative approach to address this issue. In fact, Graham and Mackinnon (2010) described Scotland’s programme to deliver alcohol BIs for hazardous drinkers as a ‘key plank’ of the wider strategy to reduce population alcohol consumption.

BIs can generally be described as short-term preventive consultations to detect problematic alcohol use in an early stage and to motivate nontreatment-seeking heavy drinkers to change their behaviour or seek treatment. BIs may involve 1 to 5 sessions of 5 to 60 minutes of structured information and advice giving, or counselling based approaches such as brief motivational interviewing (BMI), wherein patients’ own motivations are empathetically explored and guided toward change.

BMI incorporate principles of motivational interviewing (MI), such as empathetic and reflective listening and commonly include the provision of individualised feedback. Feedback typically consists of information about the individual’s alcohol use, peer and environmental influences on drinking, and reflects the individual’s beliefs about alcohol. BMI present normative information on drinking to correct an individuals’ inflated perceptions of the amount of alcohol that peers typically consume (i.e., descriptive norms). This tailored approach is seen to perhaps be more effective than the delivery of a more general prevention message, due to the fact that the individual is more likely to identify with and pay more attention to personally relevant information than to general information.

Alcohol misuse in young people is a cause of concern for health services, policy makers, prevention workers, the criminal justice system, youth workers, teachers, and parents. Much of the prevention work in relation to alcohol and drugs has been conducted in schools or educational establishments, with school-based drug and alcohol prevention curricula arguably constituting the nation’s primary strategy for preventing adolescent drug use. Key reasons for intervention work concern the prevalence of substance use in the general population, with its social, health, and economic consequences, and the influence of factors originating in school environments on substance use. Schools are considered an ideal setting for programmes aimed at decreasing the prevalence of health risk behaviours as: they provide access to young people at a time when they are vulnerable to emotional problems and risk taking behaviour; young people spend half their waking hours at school; and the quality of experiences with teachers and peers can have a positive impact on young people’s health and emotional well-being.

Studies in the United States, Australia, and Europe have indicated that early onset of alcohol use is a predictor of substance abuse and alcohol dependence in adulthood. The implementation of effective prevention programmes is a potential powerful tool to lower the prevalence of substance use in early adolescents and to delay the age of onset of substance use. Research has shown that a developmental window of opportunity exists to intervene with adolescents who have not yet initiated or have recently initiated substance use; substantial public health benefits might be gained if appropriately-timed interventions are applied to delay onset or, following initiation, to delay transition to more serious use (Anthony, 2003).

In the past, many school-based prevention programmes have been developed and implemented. In general, three major types of school-based interventions have been used :

1. Knowledge programmes aim to enhance students’ knowledge on biological and psychological aspects of substance use in order to accomplish a more negative attitude towards substance use, which will deter actual use.
2. Cognitive-affective programmes argue that psychological factors place students in vulnerable positions and therefore aim to improve students’ self-confidence and self-awareness.
3. Social influence programmes aim to improve social and/or life skills in order to prevent peer pressure leading to substance use.

There is general consensus in the literature that social influence programmes seem to be most effective, in that they more often show positive effects compared to knowledge and affective programmes (Paglia and Room, 1999).

Despite schools theoretically being an ideal setting for accessing adolescents and preventing initiation of substance use, there is limited evidence of effective interventions in this setting. Stigler et al (2011) concluded that school interventions that are most effective are theory driven, address social norms around alcohol use, build personal and social skills helping students resist pressure to use alcohol, involve interactive teaching approaches, use peer leaders, integrate other segments of the population into the programme, be delivered over several sessions and years, provide training and support to facilitators, and be culturally and developmentally appropriate.

The current chapter discusses the role of training and support for staff when working with those with alcohol or drug issues, or when providing related programmes or interventions.

It should be noted that much of the research is undertaken with respondents working in primary care, and so the generalisability of findings to non-primary care staff working in prevention and education is questionable. However, there are common themes indicating the need for staff to be provided with training and support that is tailored to their needs. This does highlight a gap in the research, in relation to the training needs of other staff and professional groups.

Adolescent alcohol use is common and has serious immediate and longterm ramifications. The average age at which young people in Europe start to drink is twelve and a half, and during the last decade, the quantity of alcohol consumed by younger adolescents in the UK has increased. Among 13-15 year olds in Greater Glasgow and Clyde who drank alcohol, the average age for alcohol onset was 12 years old and among those who had used drugs, the average age for drug use initiation was 13 years old (Scottish Schools Adolescent Lifestyles and Substance Use Survey, 2010). While social factors other than those associated with parenting play a role in determining a child’s risk for initiation of substance misuse, parents can have a significant influence on their children’s decisions about these issues. Thus, of the many risk and protective factors associated with alcohol and drug misuse among young people, psychosocial factors within the family are particularly important.

Longitudinal studies investigating factors associated with adolescent alcohol use have identified a number of parenting variables as influential in delaying adolescent alcohol initiation and reducing consequent alcohol use. These include :

• parental modelling
• provision of alcohol specific communication
• parental disapproval of drinking
• consistent parental discipline, with parents employing an authoritative parenting style characterised by warmth and support combined with rules and control
• provision of positive parental reinforcementparental monitoring (reflecting a knowledge about their child’s whereabouts and social connections)
• the quality of the parent-child relationship (including the level of conflict between the parent and the child, parental support, parental involvement, amount of time parents spend with their children, and the level and quality of communication between the parent and the child).

The timing of prevention programmes is commonly discussed in the literature. Given the likelihood of engaging in these behaviours during teenage years, pre-adolescence is seen to be a critical time to implement prevention programmes. Matriculation from high school to college/university is also typified by an increase in alcohol use and related harm for many students. Therefore, this transition period is an ideal time for preventive interventions to target alcohol use and related problems. Given the harm associated with alcohol misuse, there is a consensus that adolescents should avoid drinking for as long as possible. For this recommendation to be adopted, parents and guardians of adolescents require information about strategies that they can employ to prevent or reduce their adolescent’s alcohol use that are supported by evidence.

Universal family-focused preventive intervention efforts have focused primarily on teaching parenting skills such as parental monitoring and the use of appropriate discipline techniques that have been demonstrated to be related to adaptive adolescent outcomes such as delayed initiation of substance use (Kumpfer and Alvarado, 2003). In the UK most efforts to prevent alcohol misuse depend on schools as a means of reaching large numbers of young people and, potentially, their families (Velleman, 2009) with classroom-based education for children as an established part of the curriculum. The incorporation of activities or materials for parents or the engagement of parents and children in joint activities has been identified as an important aspect of school-based prevention interventions, driven by the recognition that the family environment plays an important role in shaping young people’s attitudes and behaviour towards alcohol, as well as influencing a range of both protective and risk factors (Velleman et al, 2005). The UK Government provides strong strategic support for school-based substance misuse education and for prevention initiatives which involve external agencies and children’s families, with all governments now expecting schools to engage with the wider community. Additionally, most schools in the UK have made a commitment to becoming health promoting schools, which involves linking participation to health.

A number of features have been identified which are likely to increase the effectiveness of the interventions. These include a focus on harm reduction rather than abstinence; interactive activities and delivery; targeting children at primary school, when they are less likely to have experimented with alcohol or other substances; and involving parents as well as children directly in the interventions.

Yap et al (2011) highlighted that despite substantial evidence demonstrating the important influence that parents have on adolescent drinking, evidence based preventative interventions that help parents to reduce the risk that their child will develop later alcohol use problems are lacking. Thus, other than general guidance on parenting styles that are influential in reducing adolescent alcohol use, existing interventions do not clearly describe specific parenting strategies that can be readily put into practice. For this literature to be informative for parents, the parenting styles identified need to be made more explicit as individual, actionable parenting strategies. An additional  issue is that parental participation in parenting interventions is generally low.

Social marketing is the use of commercial marketing techniques to help in the acquisition of a behaviour that is beneficial for the health of a target population (Weinreich, 1999). Although there is no universally agreed definition of social marketing, it is generally accepted that it is more than mass media or public education campaigns. While overlapping with public health, social marketing differs in that it involves the strategic use of marketing principles and practices. Below is a generally accepted definition:

The application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programmes designed to influence the voluntary or involuntary behaviour of target audiences in order to improve the welfare of individuals and society. (Donovan and Henley, 2003)

Social marketing applies some of the same principles used in commercial marketing for the analysis, planning, execution, and evaluation of programmes designed to motivate voluntary behavioural change. However, the difference is that social marketing promotes products, ideas or services for a voluntary behaviour change among its target audience whereas in commercial marketing, a product or a service is traded for economic gains without any concern for healthy behaviour change in the target audience. Social marketing uses a range of techniques and approaches, commonly known as a ‘marketing mix’, to help change people’s behaviour in a clearly defined and positive way. The main aims of alcohol social marketing are to encourage people who are drinking at increasing and higher risk levels to reduce their consumption and to provide the necessary support and information to help them to do so.

All social marketing activity needs to be evaluated at some level to identify how relevant, effective and efficient it is in meeting objectives. The benefits of evaluation include: more effective marketing interventions; more experimentation; improved efficiency by investing in the things that work best; better informed budgeting processes; more accurate forecasting of outcomes; more effective management of expectations about results; increased consumer knowledge and insight; and enhanced credibility of social marketing (Alcohol Learning Centre, 2010).

Throughout the literature, a number of authors have discussed the features, theoretical principles and concepts of social marketing campaigns. These are :

• A consumer orientation – Individuals are active participants in the social marketing process. Campaigns need to be aware of and responsive to their needs and aspirations.
• The concept of exchange – For exchange to occur, valuable benefits must be offered to individuals who must give up something valuable to gain these benefits.
• The use of market segmentation – This breaks a population of interest into groups based on lifestyle, demographic and attitudinal similarities. Groups are selected and campaigns developed to respond to the needs of different audience segments.
• Competition – This comes from the behaviours that targeted audiences prefer over the behaviours that social marketers seek to promote.
• Environmental influences – These are factors outside the control of campaign designers and include sociocultural forces and demographic trends.
• Research and evaluation – Formative research is needed to underpin a campaign’s design.

Social marketing approaches have been shown to be successful in reaching population groups and improving behavioural outcomes across a range of public health areas (although failure is also not uncommon), particularly if they are multi-modal and carefully designed to engage particular groups.

Substance use is associated with a range of negative consequences for the workplace, with high-risk alcohol consumption affecting a substantial proportion of workers, particularly in some subgroups. In fact, it has been argued that a large proportion of the estimated alcohol-attributable costs to society are borne by workplaces. Some individuals drink before work, during work hours, or work under the influence of alcohol. The impact of alcohol on the workplace is wide ranging, including a risk of accidents leading to injury, higher rates of poor health and absenteeism, and generally negative effects on the atmosphere in the workplace, leading to increased costs for both employers and employees. Exposure to employee substance use in the workplace is also related to several negative outcomes (poor workplace safety, increased work strain, and decreased morale) among workers who do not use substances at work.

The workplace has been identified as a promising setting for health promotion. Researchers have implemented and evaluated a variety of workplace alcohol prevention efforts in recent years, including programmes focused on health promotion, social health promotion, brief interventions, and changing the work environment. However, it is generally thought that workplace settings remain underutilised for delivering evidenced-based health interventions. For example, previous studies have suggested that the occupational health services (OHS) could be more actively involved in alcohol prevention (Holmqvist et al., 2008).

There are several reasons for workplaces to engage in prevention, early detection and treatment of alcohol and drug related problems. The existing high prevalence and increase in the consumption of alcohol and drugs among active employees in the workforce has created a new challenge for OHS, as the use of alcohol and drugs may affect workplace safety and productivity. Ames and Bennett (2011) highlight the advantage of the workplace as a setting for interventions as they have the potential to reach broad audiences and populations that would otherwise not receive prevention programmes and, thereby, benefit both the employee and employer. In addition, workplaces appear to be appropriate sites for conducting early interventions, because most people spend substantial periods of time at work.

Several studies have highlighted risk and protective factors associated with, in particular, alcohol intake. Protective factors (which have been shown to promote lower levels of alcohol intake) include decision latitude (skill utilisation, decision authority), job control, social support, job pride, stimulation, paid training, job satisfaction, and job gratifications. Risk factors include psychological and physical demands, role overload, working hours, harassment, and job insecurity.

Most of the content in the Prevention and Education Model focuses on harm reduction approaches linked to alcohol and drugs, e.g. community and environmental approaches, consideration of risk and protective factors, education and parenting approaches etc. This chapter focuses on examples of harm reduction alcohol approaches for some of the particularly vulnerable groups living in our society.

This includes those individuals who are particularly vulnerable to the consequences of alcohol related harm, or whose own or another’s alcohol use can make them vulnerable to other negative consequences. For example, individual’s involved in or affected by issues such as youth offending, criminality, homelessness, drink driving, fetal alcohol spectrum disorder and domestic violence.

The current chapter discusses two of these issues in more detail –

1. fetal alcohol spectrum disorder, and
2. the link between alcohol, crime and offending.

Marginalised populations including people who inject drugs are more negatively affected by the gap between health needs and available services. Young people at risk of injecting, or those already experimenting with injecting drugs, find themselves isolated from health and prevention services, which increases the risks for health and social harms (Merkinaite et al, 2010).

The concept of harm reduction means that decreasing drug-related harms is given an even higher priority than reduction of drug consumption (Wodak and McLeod, 2008), meaning that individuals can access needed services, including non-judgmental and low-threshold approaches offered by harm reduction programmes. Rhodes (2009) discusses harm reduction as being contingent upon the social context, comprising interactions between individuals and environments and how this impacts on the production and reduction of drug harms. Wodak and McLeod (2008) maintain that it has been known since the early 1990s that HIV among injecting drug users (IDU) can be effectively, safely and costeffectively controlled by the early implementation of a comprehensive package of harm reduction strategies. Strategies include: explicit and peer-based education about the risk of HIV from sharing injecting equipment; needle syringe programmes (NSP); drug treatment (including opiate substitution treatment (OST)) and community development.

Caulkins et al (2009) discuss how opponents of harm reduction fear that reducing harmfulness might increase use, while opponents of use reduction fear that efforts to reduce use can increase harmfulness. They propose that both strategies have a role in an intervention approach, but at different points depending on where the individual is on their drug use continuum, the particular drug, the social cost structure, and the stage of the drug epidemic.

• Outcomes Logic Models – GGC Alcohol and Drug Prevention and Education Model (2012) – Appendices – Outcomes Logic Models
• P&E References – GGC Alcohol and Drug Prevention and Education Model (2012) – Appendices – P&E References
• Tiered Structure – GGC Alcohol and Drug Prevention and Education Model (2012) – Appendices – Tiered Structure

In 2008, the Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model was widely distributed following ratification from the then Greater Glasgow and Clyde Alcohol and Drug Action Team.

The five key aims of the Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model are :

1. To continue to promote consistent practice and standards, in relation to prevention and education practice across all CH(C)P’s in Greater Glasgow and Clyde.
2. To encourage prevention and education practitioners to agree on, and then take ownership of, a baseline definition for prevention and education that will then inform universal working in the field.
3. To raise the profile of prevention and education as a range of interventions worthwhile investing in at a local and area-wide level by strengthening planning and partnership working across all Tiers and Core Elements.
4. To raise awareness of the updated Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model which includes a working definition for prevention and education, a prevention and education tiered model, 12 evidence based core elements, and support functions.
5. To create a more strategic, outcome-focused, co-ordinated, cohesive, sustainable and planned approach to best practice. This will focus on the longer term structural development for prevention and education, built on evidenced based approaches and a performance management framework.

Since the ratification and distribution of the model in 2008, there has been growing evidence of dedicated central and local structures and services with a focus on prevention and education being developed and implemented. There has also been positive reporting of a flurry of co-ordinated activity that directly links to the 12 core elements in the model being delivered in the alcohol and drug prevention and education field through outcome focused action plans and budgets co-ordinated by these dedicated prevention and education structures.

In 2011 a multi-disciplinary reference group was formed to support the review of the existing model using the latest available evidence base. To ensure the review was evidence-based and up-to-date, the group commissioned an independent researcher from Dudleston Harkins Social Research Ltd. to carry out an extensive review of the International alcohol and drug prevention and education evidence base. The review generally focused on work undertaken between 2008 and 2012, unless the research was seen to be of particular relevance. Also unless otherwise stated in the chapters, the research mentioned in this document was conducted in the United States.

Key aims of the evidence review were as follows :

1. That it updates the existing Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model by reinforcing the existing evidence base and identifying new evidence in order to inform future practice.
2. That it draws on theoretical models.
3. That the evidence is evaluated in relation to whether the evidence relates to short term or long term outcomes.
4. That the review has a focus on outcome-focused work.
5. That the review considers how outcomes for the Prevention and Education Model should be set including whether the review suggests the need for re-consideration of the core elements.
6. To consider for each piece of work how practice is evidenced, how the work is evaluated, or how the findings are demonstrated.
7. To consider which types and tiers the work falls into (e.g. initiation to risky behaviour, harm reduction, harm minimisation).
8. To consider whether the work has a population or targeted approach.
9. To consider up-to-date and innovative methods including digital techniques used in social marketing.
10. To consider the transferability of evidence and the limitations of the findings.

Given the extent of literature available in this field, the decision was made to focus on academic research using the following stages :

• Stage 1 – The identification of key words to be used in the search
• Stage 2 – Keyword searches of electronic databases and publication search sources
• Stage 3 – A snowballing approach
• Stage 4 – Review and summarising

It is hoped that the Prevention and Education Model will continue to provide an overarching commissioning framework for alcohol and drug prevention and education provision across the Greater Glasgow and Clyde area that gives clear guidance on what constitutes good practice. This will then inform the future planning and delivery of alcohol and drug prevention and education work, in turn, providing the opportunity for partners to facilitate and deliver prevention and education structures fit for purpose that address issues of equity of provision, cost effectiveness and accountability.

The Prevention and Education Model is not meant as a definitive prescriptive guide but instead aims to stimulate discussion and debate amongst strategic planners and practitioners of prevention and education approaches.

This therefore creates a vehicle of opportunity in which to explore, understand and respond to the capacity, funding difficulties and constraints inherent in translating theories of good practice into workable and achievable objectives. In doing so, this will help identify appropriate ways forward for the future planning and delivery of prevention and education, in localities and across the Greater Glasgow and Clyde wide area.

We hope that planners and practitioners alike can now use the evidence base within this document and the updated Greater Glasgow and Clyde Alcohol and Drug Prevention and Education Model to inform and direct their existing work programmes and inspire future practice and initiatives in the alcohol and drug field.

• Linda Malcolm, Health Improvement Lead (Alcohol and Drugs) – GGC
• Dr Catherine Chiang, Public Health Directorate – GGC
• Dr Judith Harkins, Dudleston Harkins Social Research Ltd

(June 2013)