Dr Hannah Carver is a Lecturer in Substance Use in the Faculty of Social Sciences at the University of Services and Co-Director of the Salvation Army Centre for Addiction Service and Research. She is the co-lead for the SSA funded Youth in Iceland Model (also known as the Icelandic Model) project. The team recently published a qualitative study about adapting the Icelandic model. The SSA caught up with Hannah to find out more
SSA: Your study is about the Youth in Iceland Model of drug and alcohol prevention. What does that involve?
Dr Carver: “The Icelandic model is a prevention approach developed in Iceland in the 1990s as a way of preventing young people’s drug, alcohol and tobacco use. There was a recognition that these were problems in Iceland at that time. So, the government, researchers, parents and practitioners all thought ‘we need to do something about this’.
The Icelandic model is a community-based approach. Schools do an annual survey to monitor young people’s substance use, and to identify other risk and protective factors. The survey asks about recreational activities that children are interested in and will then support provision of those recreational activities.
In Iceland, teenagers will get a stipend of a few hundred euros that they can use to pay for those activities. And they are quite often straight after school. I guess the whole point of that is that if they’re doing that, they’re not out drinking or using drugs.
There’s also the recognition that when parents and kids spend a lot of time together, it kind of reduces risk factors around substance use. So, the model involves parental pledges where parents and kids pledge to spend time together. There’s also a curfew for certain age groups to be home by a particular time.
Prevention is the poor sister of drug and alcohol research. Prevention research is kind of limited, and nobody seems to care too much about it despite there being an evidence base that if we prevent substance use, we will save money in the long term.
It ultimately aims to reduce and delay substance use but also to reduce other risk factors. It’s now expanded to include things like sleep, mental health, social media and internet use by identifying risk factors and fitting interventions in that will reduce these risk factors and that will improve protective factors.”
SSA: You mention that there are high levels drinking and drug use in Scotland and that this is increasing. Why is this more acute in Scotland?
“I think Scotland has a complex relationship with alcohol and drug use. Young people are growing up in a culture where alcohol use is normalised, and many people don’t see it as an issue. Drug use is less common, but it’s also quite normalised.
Some countries have much stricter rules about alcohol and drug use than Scotland does, particularly alcohol use. In the UK or Scotland, you can buy alcohol almost everywhere, whereas in countries like Iceland you go to a specific alcohol shop which means it’s less accessible. Also, taxation, if it is very expensive, young people are less likely to drink. Whereas in Scotland and the UK it’s pretty cheap even with minimum unit pricing. Also, alcohol is advertised freely in Scotland whereas in some other European countries there are bans on advertising.”
The Icelandic model works across communities and has many different elements. How do you go about researching an intervention that is that complex?
“This study was a small qualitative study exploring whether people thought the model could be implemented and why. So, it’s pre-implementation.
We used a theoretical framework that helps you consider how complex interventions like this are implemented and therefore how to evaluate them. It gives you a good understanding of the types of things you would look for when implementing a particular intervention. But also, how you would measure the impact of it, how you would focus on particular issues within implementation.
That’s the kind of 5- to 10-year cycle required, whereas the political cycle could be much shorter than that. The current government might buy into this and fund it, but then another government or politician could be interested and then they’re no longer in post. It needs cross-party support and can’t be driven by one political party.
Evaluating complex interventions like this takes big teams, and a lot of time and funding. Also, prevention is the poor sister of drug and alcohol research. Prevention research is kind of limited, and nobody seems to care too much about it despite there being an evidence base that if we prevent substance use, we will save money in the long term. So, there’s that challenge where you’re working in a complex intervention and this side of prevention. It means it’s a bit neglected compared with treatment research. All of that together means that to evaluate it properly would take a lot of money to do.”
Part of the Icelandic model’s effectiveness is that it involves getting buy-in from lots of different people in the community. What did you find from your research that helped improve that buy-in?
“Initially it came from people, it wasn’t just academics or government saying ‘let’s do this’. It was very much partnership working and that came up in our research. People highlighted partnership working as a particularly important aspect, but also as something that could be challenging because there tends to be competition around resources. Telling people that it wouldn’t just benefit schools, it would benefit the wider community, policing, health resources, youth clubs etc. could make buy-in easier.
One thing that participants also talked about that made a difference, was that the model has a strong evidence base from Iceland over the past 20 to 30 years showing that it has contributed to improvements in substance use. In Iceland, when the model started, it was the norm for people aged 14 or 15 to drink and use drugs, but now it’s almost unheard of, with most young people starting to drink and use drugs at 18 or older.”
You said that there were challenges with getting political and financial backing for this. Why was it difficult to get political support for this model?
“This is a long-term solution; it’s not a one-year intervention. It would have to be something that would be implemented for years for there to be an effect. It also takes a lot of time to do the data collection through the surveys, to implement interventions based on the results and then to evaluate them.
That’s the kind of 5- to 10-year cycle required, whereas the political cycle could be much shorter than that. The current government might buy into this and fund it, but then another government or politician could be interested and then they’re no longer in post. It needs cross-party support and can’t be driven by one political party.”
The model means that interventions are based on local needs. How would these needs differ in Scotland from in Iceland?
“Every time you mention the word curfew, people in Scotland go ‘oh no that would never work here, you can’t roam the streets and tell kids to get home’. But when you kind of draw that out, a lot of people then reflect and say, ‘well I had a curfew and actually my friend’s mum told me to go home’. I think when you call it a curfew people think it’s very authoritarian.
Our SSA funded project focused on Dundee and there’s a lot in Dundee around sports but also other recreational activities. For example, art is obviously a big thing so it’s important to make sure there are activities that are acceptable for children who don’t want to do sport.”
In your paper you talk about the challenges of getting honest answers from children. The model relies on getting a good understanding of what children need in the response to the survey – is that a challenge?
“If we are doing surveys in schools, we might miss out a whole cohort of young people who don’t engage in school for various reasons. Some of those are children who may already be affected by substance use. So, you need to consider that this is universal prevention and about all young people, but we also need to think about how to target young people who are much more vulnerable.
Within the survey, if young people are already using substances, they might be concerned about reporting it. Some might also be concerned about their parents using substances. Even though the survey is confidential, young people might not believe that and might put what they think is acceptable. There are also issues around social desirability in that some children will answer what they think is the right answer rather than the truth about their own experiences.
I think the Planet Youth team have a lot of experience of doing that in Iceland. But I think it’s about understanding how, in Scotland, kids might answer things differently. How they answer that in a way that is honest, because this survey essentially, it’s the thing that will then inform what’s implemented.
The survey is now being piloted across five areas of Scotland, lead by Winning Scotland, so it will be really interesting to see what comes out of the surveys and then what interventions are provided as a result.”
Dr Hannah Carver was interviewed by Rob Calder
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