The effectiveness of prevention and early intervention to promote health
outcomes for young people
Ann Hagell and Emma Rigby
Association for Young People’s Health
Paper prepared for Public Health England annual conference
16/17 September 2014
Warwick University
Correspondence address:
Dr Ann Hagell, Research Lead
Association for Young People’s Health
32-36 Loman Street, London SE1 0EH
ann@youngpeopleshealth.org.uk
1
Introduction
Adolescence is the fastest changing period of development after infancy,1 and as such
represents a crossroads in life and an opportunity for intervention. Young peoples’
particular health needs are distinct from those of younger children and adults,2 and the
consequences of poor health in adolescence last a lifetime and cost us all in the short and
long term. 3 4
But there is good evidence that it is possible to intervene in adolescence to stop health
issues from developing and to encourage best management of long-term conditions.5 In this
paper we review what is distinctive about prevention & early intervention with the 10-20
age group, and highlight some examples illustrating what can work.
What is prevention & early intervention?
Prevention programmes are designed to (a) prevent the onset or (b) prevent the escalation
of mental or behavioural health problems. Primary or universal prevention programmes are
usually aimed at individuals who are relatively healthy and active, and are focused on
relatively high prevalence issues. These might include smoking cessation, immunisation, or
exercise promotion programmes. Secondary or targeted prevention is aimed at individuals
who are at higher risk of specific conditions or events, or where there are some signs of
emerging difficulties. This is more likely to be used for low prevalence and non-normative
2
events such as eating disorders or self-harm, in groups such as young people being brought
up in local authority care, or in youth custody. Finally, tertiary prevention is aimed at
minimising disability or deterioration from established illnesses. The main function of this
level of prevention is to delay inevitable deterioration. This is less common in adolescence
and is not a focus of this paper.
There is a conceptual overlap between prevention and early intervention. For example,
some universal early interventions are given to everyone in a designated population, such as
all school children, and are intended to prevent problems arising. They are thus both
prevention and intervention. But interventions can also be treatment (distinct from
prevention). We’ve taken a fairly broad definition of prevention and early intervention and
have not drawn firm lines between them, but have looked for evidence on any programmes
particularly intended to tackle the early stages of health issues that tend to emerge between
10 and 20.
Two other issues are worth pointing out at the outset. First, there is often a communality in
risk factors – the same set of risk factors can predict a range of health outcomes. Tackling
these shared underlying risk factors makes sense in prevention as efforts may impact on
several different health outcomes. This sometimes means that the outcomes from
prevention programmes are not quite as expected. Second, there is a distinction between
population level and individual level interventions. Universal prevention is directed at whole
populations – some individuals will benefit, some will not. Targeted interventions are more
likely to be aimed at individuals – the ones we know are more at risk and thus may be more
likely to benefit.
3
What is critical/different/special about prevention in adolescence?
We often ignore the role of prevention and early intervention in the adolescent years, as
these concepts tend to get conflated with ‘early years’. For example, the term ‘early
intervention’ is increasingly used in policy as referring to the first five years of life. But the
teenage years are actually a key time for prevention & early intervention, for several
important reasons, including:
(i)
Many mental illnesses emerge during adolescence & young adulthood – teenagers are
particularly susceptible to developing mental illness due to rapid development, brain
growth, and newly manifesting genetic risk factors. Rates of depression rise
significantly as young people enter adolescence.6 By the age of 19, between a fifth
and a quarter of young people have suffered from a depressive disorder. Depression is
predicted to be the second cause of disability in the world by the year 2020.7 Yet a
very small proportion of adolescents are reached by publically funded mental health
programmes. We do not have good statistics on this in the UK, but the proportion has
been estimated to be as low as 2% in, for example, California. A recent UK based study
has suggested that only five per cent of adolescents in secondary schools reporting
self-harm have seen specialist CAMHS in the previous 6 months.8
(ii)
The origins of several of the key threats to lifetime physical health arise in
adolescence. For example, 99% of adults who smoke started before they were 26, and
4
8/10 before they were 18. Tobacco is still the UK’s biggest public health issue, causing
100,000 deaths per year.9 The vast majority of these smokers start at around 13-15.10
The potential levers for prevention & early intervention in the teenage years may be
different, due to the special characteristics of pubertal physical and social development,
including:
(i)
the possibilities of capitalising on the behavioural flexibility that characterises the
teenage years – habits are not fully formed, yet minds are open, behaviours can be
influenced and may change fast. We would not necessarily say the same of a group of
50 year olds.
(ii)
the possibilities both for interventions that include the whole family, but also for
reaching young people on their own outside the family and capitalising on the fact that
they are starting to carve independent lives – this is a particularly strong argument if
used in combination with the possibilities posed by the behavioural flexibility
mentioned above.
(iii) the opportunities offered by the growing importance of the peer group and the role of
social norms in shaping behaviour. (Eg, Steinberg’s driving experiments – adolescent
drivers much more affected by the behaviour of their peers in the car than adult
drivers.)11
5
(iv) the evidence for different behavioural responses to some cues in teenagers, known as
developmental differences in reward processing.12 For example, with smoking, there
is evidence that young people are more price sensitive than adults,13 so interventions
to make cigarettes particularly expensive to them may work better than with adults.
(v)
the fact that, because of the way the adolescent brain is developing, it might work
better if we focus on changing the risk context (their environments and the
opportunities presented to them) rather than trying to impart facts and improve
decision making.14 Grey brain matter volume, after increasing at earlier ages, begins
to thin starting around puberty. This change correlates with advancing cognitive
abilities. Scientists believe this process reflects greater organization of the brain as it
prunes redundant connections and enhances transmission of brain messages. This
process is not complete until the early 20s.
(vi) the particular importance of the educational context. Young people spend a
significant amount of time in school, further and higher education, and many may be
reached at the same time if efforts are directed at the educational setting. This
means more emphasis on school and community-based interventions for this age
group, and raises the potential to address the whole-school ethos. Traditionally
educational interventions tend to focus on providing information, through lectures or
fact sheets. But there’s a growing interest in using the educational context to deliver a
change in how people think – wellbeing, CBT etc in the group, school context.
6
(vii) a particular need to address partnerships between services when trying to help this
age group. Prevention/early intervention often delivered in convenient places where
young people go for other routine activities. We need more of a ‘catch them while
you can’ (sometimes called the “no wrong door”) approach with this age group. This
means emphasising the critical importance of partnerships, schools, youth justice,
primary care, social services, and community groups, and in providing appropriate
training about adolescent development for all professionals coming into contact with
young people.
Effective/promising prevention programmes
The kinds of health issues that have been targeted for prevention and early intervention in
adolescence have included substance misuse, violence, anxiety and self-harm, pregnancy
and sexually transmitted infections, road traffic accidents, eating disorders, and also
promotion of positive health behaviours including building resilience and coping strategies.
We do not have space to provide a full overview, but instead we present some examples of
interventions that have been demonstrated to work with this age group, selected to show
the range of ways in which we can intervene that may be particularly appropriate to this age
group.
(1) Motivational interviewing (including MI brief interventions) Motivational
interviewing is a client-centred counselling style, sometimes called a guided
therapeutic approach. It usually consists of relatively brief sessions that do not try to
7
pass on information or teach skills (and as such is rather different to CBT), but
explore and reinforce the young person’s intrinsic motivation towards health
behaviour while supporting their autonomy. Motivational interviewing consists of
open-ended questions giving reflections & providing affirmation. It presents a good
fit with young people’s needs to exert their independence and make decisions for
themselves – as such it is perfect for adolescents, being non-judgemental, empathic
and collaborative. It can consist of around 1-3 sessions, 20-50 minutes, in a number
of different treatment modalities – as individuals, in a group, one-to-one or on the
telephone. There are now in excess of 80 RCTs providing evidence on effectiveness,
particularly for substance use. It has been tested in a variety of different localities
including primary care, education settings, or community-based. It works well in a
‘catch them while you can’ situation, if young people have presented for another
reason (for example at A&E) and screening suggests they might benefit from some
preventative work to tackle emerging substance use difficulties or anger
management, etc.15 16
(2) Peer led smoking reduction. Smokers who start before the age of 16 are twice as
likely to continue as adults than those starting after 16.17 One example of a
prevention programme here is the ASSIST programme (A Stop Smoking In Schools
Trial).18 This is a peer-led intervention aimed at preventing smoking uptake in
secondary schools. Influential students are trained to act as peer supporters during
informal interactions outside the classroom. Results have shown a 22% reduction in
the odds of being a regular smoker in an intervention school compared with a
control school. The average cost of the intervention is £27 per student.
8
Implemented on a population basis, the ASSIST intervention could lead to a
significant reduction in adolescent smoking prevalence.19 This intervention is
interesting in the light of what we have said about the special characteristics of the
adolescent life stage, as it deliberately sought to exploit informal channels of
information exchange and peer influence outside the classroom.
(3) School based general substance misuse programmes – for example the well
researched Botvin LifeSkills Training. This is designed for people aged 8-18 to avoid
tobacco, alcohol and drug use. High school level programmes include six to ten 45
minute sessions, delivered by trained teachers, counsellors or social workers (ie, not
peer-led). The programme promotes self-management skills, effective
communication and better awareness. Tools are provided to help maintain
implementation fidelity. Evidence established from more than 30 randomised
controlled trials consistently demonstrates reductions in substance misuse.20
(4) School based resilience programmes, for example the UK Penn Resilience
Programme. This is a school based curriculum for promoting psychological wellbeing by building resilience and encouraging positive thinking. It is an American
programme with a longstanding research history, and was imported in to the UK in
the mid-2000s. It consists of a series of either 12 90 minute sessions or 18-24 60
minute sessions delivered by trained facilitators, based on the principles of cognitive
behaviour therapy and development of social problem-solving skills. It includes
assertiveness, negotiation, decision making and relaxation and lessons use role play,
sort stories and discussions to develop skills. There have been a number of
9
controlled studies showing the original programme prevents symptoms of
depression and anxiety. The UK evaluation of implementation in 3 local authorities
with Year 7 pupils concluded that there were significant short-term improvements in
depression symptom scores, school attendance rates and English attainment.21
(5) School level policies, such as those relating to school start times and accident
prevention. Early school start times have been implicated in a number of health
issues including higher rates of accidents among young people, particularly in
relation to young drivers. On average, young people go to sleep and wake up around
two hours later than adults and younger children. In one study where a 1-hour delay
in school start times was introduced there was a 16.5% reduction in crash rates for
teen drivers in the whole county.22 This is a more salient issue in the US and
Australia where more college-aged children drive themselves to school than in the
UK, but with the rise in the school participation age to 18 here, it may become more
of an issue. It also serves to alert us to the need to line up our requirements of
adolescents with their developmental stage, and shows how school policies may
serve a health protection function. Short sleep duration is common in adolescents
and has also been related to rates of depression.23
(6) Legal initiatives such as the Graduated Driver Licence Scheme Bill Nearly a quarter of
all car drivers who died in 2012 were young drivers, despite only accounting for 3-5%
of all car miles driven each year. 17-19 year olds have the highest number of deaths
per 10 million drivers. Overall, in 2011 more than 1,500 young drivers were killed or
seriously injured. In the UK one in five novice drivers has an accident within 6
10
months of passing their test. A Private Member’s Bill was introduced to the House of
Commons in 2013 but has stalled. The key proposal is an intermediary stage
between the learner licence and the full licence. During this period fewer
passengers would be allowed and the alcohol limit would be lower than for other
drivers. It has been estimated that the scheme could substantially reduce casualties,
deaths and costs.24 All 50 American States and the District of Columbia have a threestage graduated driver licensing system. A report by the American AAA Foundation
for Traffic Safety found that states with teen driver safety programmes had a 40%
lower rate of crashes resulting in injury among 16 year olds.
(7) National policy initiatives such as the English Teenage Pregnancy Strategy. Between
1998 and 2012 the English under-18 conception rate fell over 40%.25 This is the
result, in part, of the long-term efforts of the Teenage Pregnancy Strategy which was
a very successful government prevention programme running from 2000 to 2010,
and its legacy in the work of local government and frontline practitioners. The key
components are threefold and include the provision of high-quality comprehensive
sex and relationship education in schools and youth settings, open discussion with
parents, and easy access to youth-friendly conception services.26 In February this
year, the PSHE Association, Brook and the Sex Education Forum published guidance
and tools for supporting schools in delivering the sex & relationship education
component.
To explore more examples of prevention with this age group, there are many interventions
to look at on-line at the Early Intervention Foundation (EIF) (www.eif.org.uk/events/early11
intervention-guidebook-launch/) , the Social Research Unit at Dartington
(www.dartington.org.uk/projects/investing-in-children) , and the Mental Health Innovation
Network (www.mhinnovation.net/about). For example, there are 50 programmes in the EIF
guidebook, 36 for young people aged 10-19, and 12 where the strength of evidence is rated
as good (and the criteria are tough).
Challenges
There are four main groups of challenges facing us. First, it is clear that not everything
works, but we do not yet know why – the critical elements of successful programmes still
remain something of a mystery. Prevention programmes that look quite similar can have a
range of different outcomes in different settings, some more successful than others. Nearly
all writers on the theme call for more thorough testing in the UK context.
Second, implementation can be patchy. Some key components may get lost in translation.
For example, the European trial of the US-based Unplugged programme to reduce alcohol
use concluded “This basic curriculum was supplemented either by meetings led by pupils
selected by their classmates, or by workshops for the pupils' parents. While the curriculum
was moderately well implemented, peer-led activities were rarely conducted, few
parents attended the workshops, and an important element – role-play – was generally
omitted.”27 In the US the basic curriculum included these things, but they were not fully
implemented in the European trial.
12
Third, effect sizes may be small – there is so much else going on in young people’s lives, and
the influences on their behaviour are coming from all directions. Universal, preventative
programmes may make some difference but often the differences are quite small. However,
in the scheme of things they are still very important, particularly if they apply across the
population. For example, the successful DECIPher ASSIST smoking cessation programme has
estimated that after delivery to 60,000 Year 8 students, 1,650 young people will not go on to
take up smoking as a result – and we do need to regard this as a significant success.
Fourth, despite the potential usefulness of cost benefit analyses in making the argument for
preventative work with the adolescent age group, we are still short on thorough and
persuasive data that help to make the argument. This is partly because the costs often
stretch over the whole lifespan and accrue under a number of different headings.
Conclusion
Prevention in adolescent presents some unique opportunities. Young people in the second
decade of life share distinctive characteristics that should inform the kinds of prevention and
interventions we chose to deliver. Although they respond less well to fact-based educational
interventions, their focus on their peer groups and the fact that they are breaking free from
their families opens up new ways of shaping their behaviour. Their openness to new ideas,
need for autonomy and hyper-responsiveness to certain kinds of rewards should all inform
how we try to help. In addition, this may be a particularly suitable time of life to use
national, local and school policies to create healthy contexts for them.
13
We have looked at a range of preventative programmes that seek to impact on young people
in different ways. Some of these offer universal support. Others tackle high-risk individuals,
trying to change the way they think and make decisions. Others try to change the ethos of
the environments that they live in, such as schools and colleges. Others shape local and
national policies, enabling them to live healthier lives. What we have presented here is a
very small and illustrative selection of programmes and this paper should not be regarded as
a thorough review of all available interventions. But it offers a starting point in making the
argument for including the adolescent age group in any discussions about prevention and
early intervention.
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