What Works in Prevention?

What Works in Prevention?

By David Pere Martínez Oró

In the field of drug dependency, implementing genuinely preventative programmes is an urgent challenge. This text briefly outlines the central aspects that hinder the quality of prevention and presents the basic elements of scientific evidence regarding preventative effectiveness. In other words, what works in prevention?

In Spain, during the 1980s, the devastating effects of the heroin crisis prompted a conceptualisation of drug dependency prevention as a matter of utmost priority. Action was needed before it was too late—when dependency had already become a reality. How could society in general, and young people in particular, be safeguarded against an uncertain and ever-changing social phenomenon? Initially, media campaigns and awareness events (such as concerts and matches “against Drugs”) were used. The aim was to deliver a clear and visceral rejection of anything related to drugs. The harsh reality left no room for half measures. Beyond these broad actions, it became evident that young people were the most affected group. Therefore, specific actions targeted at them were necessary before they had any contact with drugs. School-based prevention was seen as potentially effective. Specialists began visiting schools to explain in detail what drugs were and, above all, their negative consequences. Since then, school prevention programmes have expanded significantly, although it remains common for some Spanish students to finish secondary education without receiving any information about drugs.

Throughout the 1990s and especially in the early 2000s, prevention programmes across various settings (community, family, nightlife, non-formal education, etc.) multiplied. This proliferation and consequent disparity of programmes stem from drug dependency prevention being a devolved and decentralised responsibility. Today, it is implemented by third-sector entities (of varying scales), local councils, regional governments, provincial authorities, and even the central government.

According to the 2018 Report by the National Plan on Drugs (DGPNSD) (2020: 77 ff.), 170 school prevention programmes, 103 family prevention programmes, three university-level initiatives, and numerous actions in alternative and nightlife settings, as well as targeted actions for vulnerable populations, were carried out in Spain. Nearly 300 structured prevention programmes exist alongside countless other structured or ad hoc initiatives. It is not an exaggeration to estimate that 400 prevention programmes, across all forms, are currently being implemented in Spain. Additionally, there are numerous isolated actions labelled as “preventive.” This diversity of programmes, approaches, objectives, target groups, and theoretical frameworks shares a common denominator: the systematic omission of evaluation processes. Without an effectiveness (or impact) evaluation system, it is impossible to determine whether prevention programmes are genuinely preventative. Can we answer the question: Are we delivering preventative prevention? Without data derived from evaluations, it is challenging to provide an empirically robust response. In other words, do the preventive actions we implement achieve the desired effects on the target population, reducing the needs that justify their implementation? Any programme manager should be able to emphatically answer, “Yes.”

Aware of the uncertainty surrounding the preventative capacity of numerous programmes, various institutions have worked tirelessly in recent years to improve the preventative quality of these initiatives. At the European level, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has been working for years to ensure high-quality prevention in programmes. Several EMCDDA publications (2021, 2019a, 2019b, 2018, 2012, 2011, 2010) and its Best Practices portal document progress in prevention quality. Similarly, Spain’s National Strategy on Addictions 2017–2024 strongly emphasises quality prevention in addiction, exemplified by its Best Practices in Addictions portal—a must-consult resource for implementing high-quality, truly preventative programmes. After years of work, we now have sufficient scientific evidence to know with reasonable certainty what works in prevention and what does not. For instance, the summary table on page 13 of a document prepared as part of the Local Plans for Addiction Prevention Improvement Spaces programme by Episteme, commissioned by the Barcelona Provincial Council, provides useful insights. Additionally, the document includes references to scientific evidence for the following key points.

Answering the question, What works in prevention?, requires a complex explanation. This brief text highlights only the most basic aspects.

Evidence shows that the more time spent engaging with target groups in preventative actions, the better the outcomes and preventative effects. For example, one-hour annual school workshops have proven ineffective regardless of content. In contrast, school prevention programmes with good content lasting eight, ten, or even fifteen sessions are effective. Therefore, we must abandon the notion that a one-hour annual workshop has any impact. Resources allocated to such widespread but ineffective actions should be redirected to other preventative measures. For example, reducing coverage to increase the number of sessions would mean fewer young people receive the “annual talk,” but those who do would benefit from preventative effects.

In Spain, there is a tradition of implementing programmes by setting—school, family, community, etc. Scientific evidence confirms that programmes with multiple components are more effective than those addressing each setting in isolation. For instance, a school programme is more effective if families are involved in activities and even more so if the community participates. A concrete example is responsible alcohol dispensing programmes, which have shown limited effectiveness. However, the Swedish STAD programme, which combines enforcement (law application), community work, and responsible alcohol dispensing training, has proven effective in reducing fights, sexual assaults, traffic accidents, and drug- and alcohol-related hospital emergencies.

Community Work: Community-based programmes are the most effective. Among the STAD components, the community aspect is the most impactful. Programmes tailored to community needs, where the community actively participates in design, implementation, and evaluation, are far more effective than those in other settings. The main reason is that they address realities the community is mobilised to change.

Plausible Narratives: Implausible and alarmist narratives do not yield preventative effects. Although the use of such narratives has decreased, abandoning them entirely would be a significant step towards improving prevention quality.

These four points serve as a starting framework for pursuing high-quality prevention. A long journey lies ahead.