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What works in tackling health inequalities?Pathways, policies and practice through the lifecourse$

Sheena Asthana

Print publication date: 2006

Print ISBN-13: 9781861346742

Published to Policy Press Scholarship Online: March 2012

DOI: 10.1332/policypress/9781861346742.001.0001

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Inequalities in the health behaviour of children and youth: policy and practice

Inequalities in the health behaviour of children and youth: policy and practice

Chapter:
(p.323) Nine Inequalities in the health behaviour of children and youth: policy and practice
Source:
What works in tackling health inequalities?
Author(s):

Sheena Asthana

Joyce Halliday

Publisher:
Policy Press
DOI:10.1332/policypress/9781861346742.003.0009

Abstract and Keywords

This chapter focuses on three significant areas where health behaviour is markedly unequal in children and youth: diet and nutrition, substance abuse, sexual health, together with education and employment. It discusses the evidence base of interventions targeting these areas and recent developments in policy and practice. It suggests that the growing interest in the relationship between childhood disadvantage and adult health has quite rightly addressed the neglect of early life influences in a literature previously dominated by a concentration on adult risk factors for chronic adulthood disease.

Keywords:   health behaviour, children, youth, diet and nutrition, substance abuse, sexual health, education, employment, childhood disadvantage, adult health

Introduction

Normal childhood and adolescent development is arguably characterised first by immature and then by inconsistent behaviour, compounded by a sense of invulnerability, experimentation, and a limited concern for future health. This scenario is complicated by two quite different imperatives. On the one hand, young people now face earlier and more intensive exposure to high-risk behaviour, with social and media attitudes encouraging them to look and act older than their years (NSNR, 2000). On the other hand, as Chapter Six has established, there is an increasing delay before the vast majority of adolescents achieve financial and domestic independence. There is thus an extended period post-adolescence where one can no longer assume a requirement to conform and where conspicuous consumption may be an important motivation (Parker et al, 1998).

Social variations are manifest in these risk behaviours and, as Chapter Eight demonstrated, childhood and adolescence, long-held as a period of relative equality in health, is now increasingly perceived as a period of extreme inequality in terms of health behaviour and attendant risk with both immediate and long-term implications. The risk-taking behaviours that can be described as problematic in childhood and youth, such as smoking, drinking, other drug use, early sexual activity and poor eating habits, are all associated with one another (Tyas and Pederson, 1998). The recent attention given to the so-called obesity epidemic has helped extend the profile of social concern to still younger children, albeit with a more explicit focus on health.

The complex relational web between risk factors and detrimental outcomes militates against compartmentalisation. It demands that the connections are made, challenging the preoccupation with symptoms rather than causes and pointing to the need to address the whole person, not just one or two risk factors (Millward et al, 2004). This chapter focuses on three significant areas where health behaviour is markedly unequal, that is: diet and nutrition; substance abuse; and sexual health; together with education and employment.

(p.324) Diet and nutrition

Poor diet in childhood, as Chapter Eight has shown, is associated with both poor child and later adult health. Interventions fall under two related heads. First, there have been long-standing efforts to improve nutritional status, by both food supplementation (ranging from the school-based provision of milk and school meals to the current focus on fruit and vegetables) and efforts to address food poverty. Second, there has been a more recent emphasis on weight-related disorders, primarily obesity. The incidence of dental caries is a further corollary of poor nutritional status, with less than half of all children disease-free on starting school (Walker et al, 2000), a reflection of the frequency and amount of sugar being consumed.

Food supplementation: food poverty and modern malnutrition

It has been suggested that the government’s National Diet and Nutrition Survey (NDNS) exposes a pattern of modern malnutrition, especially in low-income families (Gregory et al, 2000). Chapter Eight has shown how such dietary deficiencies show a social class and income gradient, with households in the lowest income brackets consuming less fresh fruit and vegetables, skimmed milk, fish, fruit juices and breakfast cereals than average, despite spending a greater proportion of their income on food than those in better-off households.

One contributory factor is believed to be food poverty, with those living in the poorest areas having reduced access (although the reasons for this are debated) to good-quality affordable food. Despite suggestions that adults in poverty protect their children’s diets at the expense of their own (Dowler and Calvert, 1995), it has been suggested that one in 50 children do not get three meals a day (Dowler et al, 2001). Social and cultural norms, knowledge and health motivation are important in this equation. Skipping breakfast, for example, is particularly common among adolescent girls, while one in ten girls aged 15–18 report being either a vegan or vegetarian, and those under 25 typically eat half as many fruit and vegetables as those in the 55–64 age group (Gregory et al, 2000). Interventions that address food poverty have the potential to reduce inequalities in diet and expenditure among the poorest families and have formed an important component of the government’s Neighbourhood Renewal Strategy (see Chapter Eleven), while interventions that aim to improve nutritional status have the potential to reduce health inequalities if they are targeted at those in greatest need.

Weight-related disorders

Since the 1980s the prevalence of obesity has increased so dramatically that by 1998 the World Health Organization (WHO) declared it a global epidemic. In the UK it has similarly become a public health priority, with incidence of obesity (p.325) trebling between 1980 and 2001. As Chapter Eight demonstrated, the prevalence of overweight and obesity among children of all ages is increasing as part of this trend, with national statistics suggesting upwards of one fifth of all children are now either overweight or obese, and local studies producing much higher proportions (Bundred et al, 2001; Rudolf et al, 2001). Pertinently, although the risk factors for a range of health disorders increase with weight, many of the problems for overweight/obese children are deferred to later life, leading some to suggest that “the most important long-term consequence of childhood obesity is persistence into adulthood” (Mulvihill and Quigley, 2003, p 14). This too is a risk that increases with the age of the child and the severity of the obesity. The yearly cost has been estimated as £0.5 billion in terms of treatment costs to the National Health Service (NHS) and more than £2 billion in terms of the impact on the wider economy (NAO, 2001). As with adults, it is an area where socioeconomic, ethnic and national inequalities exist. The causes, as we have already noted, include not just an increasingly sedentary lifestyle, reliance on the car and changing eating habits (reflecting, for example, longer working hours and less food preparation at home) (NAO, 2001), but also genetic factors. Many are areas that health professionals are unable to change in isolation.

The increased prevalence of obesity has largely overshadowed other weight-related disorders such as anorexia nervosa and bulimia nervosa which, as Chapter Six has shown, are both comparatively rare and higher among higher social classes. The literature is equivocal about the relationship between the prevalence of such eating disorders and the prevention of obesity but emphatic about the high incidence of dieting and shape/weight-related concerns among older children and teenagers, factors that are not captured by such statistics. The difficulty is determining when these constitute abnormal eating attitudes and behaviour carrying a high degree of risk and when they are part of the natural course of adolescence (Pratt and Woolfenden, 2004). There is a strong argument, therefore, for considering the range of weight-related disorders under one public health umbrella.

What works? Evidence and practice

In considering the efficacy of key interventions attention is focused on three salient areas: breakfast clubs (which aim to improve nutritional status within a specific context), healthy eating initiatives (which take a more broad-based approach to nutritional status) and efforts to prevent and treat obesity.

Breakfast clubs

Children who have no breakfast may be at risk from adverse health effects in the long term, and adverse educational and social effects in the short term as a consequence of poor concentration and behaviour in school, together with poor (p.326) socialisation, bullying and erratic attendance (Street, 1998). An overview of breakfast clubs (Ani and Grantham-McGregor, 1998) suggests they may confer corresponding short-term benefits on classroom behaviour (including active class participation and peer interaction), cognition, academic outcomes and school attendance, with such effects more noticeable in poorly nourished children. They can also provide a safe place for children to meet their friends before school (Lucas, 2003). However, the findings reviewed were largely from outside either Europe or North America. Beneficiaries were thus not only more likely to be undernourished than children in the UK but also less likely to attend school regularly. Those studied also tended to fall into the 9- to 12-year-old age group, whereas in countries such as the UK it may be adolescents who are most at risk of skipping meals and least likely to take part in breakfast schemes (Lucas, 2003).

The Department of Health (DH) established a pilot in 1999/2000 to develop school-based breakfast clubs, with the aim of developing preferences for healthy eating and establishing a positive start to the school day by providing breakfast for those who would otherwise start the school day hungry. Funds were allocated to 253 clubs, with approximately two thirds of these based in primary schools, and were focused on the more deprived areas targeted already by, for example, Health Action Zones (HAZs), Education Action Zones (EAZs) or Sure Start. A national evaluation of this pilot found only modest benefits with respect to social, nutritional, educational and psychological well-being. However, children and parents alike regarded “school breakfast clubs as capable of precipitating at least a degree of positive change across a broad spectrum of outcomes”, including dietary behaviour, social relations and reductions in family stress at the start of the day (Shemilt et al, 2003, p 110). Meanwhile, three quarters of the surveyed clubs felt they had improved attendance (see also Shemilt et al, 2004) and punctuality, with four fifths claiming improvements in concentration and half an improvement in academic performance during morning lessons.

Similar positive outcomes were revealed by a previous sample of 35 clubs in the UK, with organisers reporting a calmer start to the day, better parent/teacher dialogue, improved social cohesion among pupils and less disruptive behaviour (Street and Kenway, 1999). However, there was still concern over early arrivals, children not taking breakfast (including those who spent breakfast club money on snacks before arriving at school) and an inability to reach those with the greatest problems of punctuality, attendance or need (Lucas, 2003). Nevertheless, a recent survey of award-winning clubs by the New Policy Institute suggested that most of these clubs were attracting a disproportionate number of children claiming free school meals (FSM), a group that is less likely to eat breakfast at home (Harrop and Palmer, 2002). The evaluation of the national DH pilot (set up in areas with some degree of multidimensional adversity) similarly suggested they were capable of “reaching families likely to be most in need of support including some families at risk of or experiencing social exclusion” (University of East Anglia, 2002, p 8). Use here was greatest among families where a parent (p.327) was experiencing marked levels of emotional stress or where children had high levels of overall difficulties. A randomised controlled trial (RCT) also found a higher proportion of breakfast club attendees had borderline or abnormal conduct and a higher total difficulties score (Shemilt et al, 2004).

Healthy eating initiatives

A systematic review of interventions designed to promote healthy eating (Roe et al, 1997) suggests the key is similarly behavioural change, with the intervention matched to the population characteristics, as opposed to the more traditional provision of information. Effective interventions include a supportive family, social and structural environment, a personal approach with contact sustained over time, multiple strategies that address barriers to change and influence the local environment, and training for those involved in the delivery and support of such programmes. Interestingly, such interventions appear to be more successful in reducing fat intake and blood cholesterol than in supplementing intake of starchy foods or fruit and vegetables (Roe et al, 1997). However, even such targeted interventions are only producing reductions in total fat intake as a proportion of dietary energy in line with the UK population target set by The health of the nation (DH, 1992) (–3%), while the parallel aim was to increase the consumption of fruit and vegetables and starchy foods by at least 50%.

This problem is well illustrated by a cluster randomised trial of 43 primary schools in South Wales and the South West of England, where the introduction of fruit tuck shops was found to have only limited impact on pupils’ fruit consumption and to produce no significant difference between intervention and control schools in pupils’ intake of fruit or other snacks. Indeed, only 70,000 fruits were sold in the 23 intervention schools over the year, equating to just 0.046 fruits per pupil per day, and four schools had closed their fruit tuck shops by the end of the intervention year (Moore et al, 2000; Moore, 2001). A whole school intervention that increased the provision of fruits and vegetables in school (via tuck shops and school lunches), as well as providing information for parents, children and teachers, together with tasting opportunities and practical food preparation, found little more success. Evaluation found that children in the intervention schools increased their fruit intake more than those in the control school, and their knowledge about fruits and vegetables was also greater, but the changes were only modest (Anderson, 2001).

Food Dudes (see Box 9.1) represents a further step towards adopting a comprehensive approach to altering eating behaviour, introducing peer group example and a reward system. The programme has been conducted with incremental changes to context, age group, socio-economic profile of the children, and administration (moving from programme staff to school staff). It has now been rolled out in parts of Scotland, Wales, England and Ireland and is the subject of ongoing evaluation. (p.328)

Obesity: prevention and treatment

A recent systematic review of interventions for the prevention of obesity in children found “the mismatch between the prevalence and significance of the condition and the knowledge base from which to inform preventative activity” to be “remarkable and an outstanding feature of this review” (Campbell et al, 2002, p 12). Others stress the limitations of review-level evidence itself for decision making about policy and practice in such a complex and relational field, an area that is impossible to capture in quantitative outcomes alone (Mulvihill and Quigley, 2003).

As far as prevention goes, the strongest evidence of effectiveness focuses on multifaceted school-based programmes, that is, programmes that promote physical (p.329) activity, the modification of dietary intake and the targeting of sedentary behaviours (Mulvihill and Quigley, 2003). Such interventions have been found to be particularly effective for girls. Planet Health, for example, was a multifaceted behavioural intervention that targeted 11- to 13-year-olds in the three areas just described, but with a strong emphasis on reducing television viewing (Gortmaker et al, 1999). Two years later it found reduced prevalence of obesity among girls in the intervention schools and fewer obese girls in the intervention group but no significant differences for boys. Two possible reasons were the more pronounced reduction in television viewing among the girls and a greater increase in their fruit and vegetable consumption, resulting in a smaller daily increment in total energy intake.

The one UK study included within the systematic reviews (see Box 9.2) found, however, that positive changes in attitudes and environment were accompanied by few significant changes in behaviour, and suggested that the prevailing social and environmental forces require much larger public health control measures (Sahota et al, 2001a). A more recent UK school-based preventative programme similarly found no clear intervention effect and stressed the need for reinforcement beyond the school setting (Warren et al, 2003). Such community-based interventions, by definition, do not focus just on children and adolescents and (p.330) are considered more generally in Chapter Eleven. With respect specifically to young people the limited data available make it difficult to conclude that one strategy or combination of strategies is more important than others in the prevention of childhood obesity (Campbell et al, 2002).

There is even less evidence for the preventative effectiveness of school-based health promotion interventions (focusing on the classroom curriculum to reduce sedentary behaviours such as television and video games), and a lack of evidence as to the effectiveness of school-based physical activity on a standalone basis (NHS CRD, 2002). However, Campbell et al (2002) suggest that the most promising interventions focus on simple reductions in sedentary behaviours with lifestyle activities sustainable across the lifecycle (such as walking and cycling) likely to be the most effective. There is also evidence that there are different issues affecting primary and secondary schools, with a sharp drop off in sports uptake in the upward transition and an increase in canteen, tuck shop and vending machine access to food.

Family-based behavioural modification programmes that involve parents via family therapy and target these same three areas (dietary education, physical activity and a reduction in sedentary behaviours), together with regular visits to a paediatrician, also lack the same weight of evidence as multifaceted school-based interventions, but do show limited evidence of effectiveness. In contrast, there is a lack of evidence to support family-based health promotion programmes as a preventative measure (despite the fact that these too include a strong focus on dietary and health education, increased activity and sustained contact with children and parents) (Mulvihill and Quigley, 2003). This suggests the potential importance of the behavioural modification/family therapy element.

With respect to the treatment of obesity, Summerbell et al (2004) synthesised the results of 18 RCTs that focused on lifestyle interventions (all having some form of dietary input, physical activity and behavioural therapy), and that observed participants for a minimum of six months. Most were, however, based in hospital settings and focused on small, homogenous, motivated groups. As a result their review, as with the issue of prevention, found little generalisable evidence of what works. Indeed, none of the studies were conducted in the UK although all were undertaken in societies where there is a similar “unrelenting progression towards weight gain”, militating against the maintenance of weight loss (Summerbell et al, 2004, p 7).

It is the family as opposed to the school that tends to be the locus for successful interventions at the treatment stage, most specifically family-based interventions involving at least one parent alongside the child, and combining physical activity and health promotion with the targeting of sedentary behaviour (Mulvihill and Quigley, 2003). For primary school children evidence supports multifaceted family behaviour modification programmes, where the parent acts as the agent of change (and components include parenting, communications skills training and child management alongside diet, exercise and reductions in sedentary (p.331) behaviour). The value of the parental influence may, however, vary with the age of the child, providing more benefits to younger (more compliant) children. Evaluation of effectiveness is also compromised by the disparate nature of the interventions (and an inability to isolate the effective components of any such programme), so that overall there remains insufficient evidence to recommend family-based behaviour modification programmes as an effective treatment (NHS CRD, 2002). There is, nevertheless, limited evidence for behaviour modification programmes that lack parental involvement, suggesting the support of parents is important to the process and that treatments need to be individualised.

Story (1999) draws on a non-systematic literature review of 12 school-based interventions targeted at overweight children (the large majority with a no-treatment control and based on physical activity and nutritional education). Eleven out of twelve found a reduction in the percentage of children classified as overweight in the intervention group, with an average decline in individual body weight of 10%. Interventions again tended to be more effective where children were younger and weight problems the most intense. However, Story (1999) also highlights the stigma potentially attaching to school-based treatments, with the possibility of psychosocial damage; few studies of school-based treatments have thus been conducted since 1985 with the school acting instead as a potentially powerful preventative arena.

LeMura and Maziekas (2002), drawing on a meta-analysis of laboratory-based exercise programmes, also demonstrate the effectiveness of exercise treatment programmes, the three most favoured interventions being low-intensity, long-duration exercise; aerobic exercise with high repetition resistance training; and exercise programmes in conjunction with behaviour modification. The translation of effective laboratory-based strategies to a non-clinical setting is often, however, problematic. The results from a series of small trials in the US (Epstein et al, 1985, reviewed in Summerbell et al, 2004) suggest again that while lifestyle exercise (such as walking or running), aerobics and callisthenics may all produce significant reductions in weight, it is the former that is the most likely to produce sustained change. Finally, while the National Institute for Clinical Excellence (NICE) has approved the use of two drugs in the management of adult obesity, orlistat and sibutramine, neither are currently recommended for use with younger age groups (NICE, 2001).

The evidence for sustained effective weight loss treatments is thus small, partly because to have any effect interventions need to be complex and partly because such interventions do not alter the context of the obese child’s environment external to the family. Additionally, as Summerbell et al (2004) point out, a problem of epidemic proportions requires commensurate resources in prevention and treatment in order to achieve change. Successful strategies require action to create environments that support prevention and maintenance (that is, upstream rather than individual interventions), and need to address the range of obesogenic factors (sports and leisure, family, high-energy foods, education and information) (p.332) (Blair et al, 2003). Encouragingly, however, it has been suggested that lifestyle behaviours that contribute to and sustain obesity in adults are less well-established in children and may be more amenable to change (Edmunds et al, 2001).

Other weight-related disorders

Pratt and Woolfenden (2004), considering interventions for preventing eating disorders in children and adolescents, were similarly unable to draw any firm conclusion about the effectiveness of eating disorder programmes in childhood and adolescents. Again, a variety of approaches (encompassing the acquisition of knowledge, the modification of eating and risk behaviours and efforts to increase social well-being), a diversity of target groups and a paucity of admissible RCTs, limited the evidence base. However, the correlation between such eating disorders and overweight status, low self-esteem, depression, suicidal ideation and substance misuse, indicates the need again to take a holistic approach to the identification and amelioration of risk factors, together with the identification of protective factors.

Limitations to the evidence base

The limitations to the available evidence base are emerging as a dominant subtext within this book. Here the diversity of the studies (with numerous intervention components), their methodological quality (including recruitment base), size, and duration, limits the generalisability and reproducibility of the findings concerning obesity, as does the US focus and the concentration on children aged 7–12. This is compounded by difficulties in the measurement of childhood obesity, measures of diet and physical activity (which are often weak estimates of actual behaviour) and a limited understanding of the interface between an individual’s behaviour and their environment. Several studies that effected change in the short term found these changes were not maintained at subsequent follow-ups, suggesting (as indicated by the behavioural change literature) the need for sustained rather than time-limited interventions.

Roe et al (1997), considering healthy eating interventions, found a similar reliance on findings from the US and a neglect of the adolescent population. They suggest there are too few well-evaluated studies to identify the most effective outcomes for any given target group. There is also a marked neglect of patient-related variables, including gender, ethnicity, socio-economic status and psychological status, reflecting the general dearth of evidence in relation to public health interventions that address health inequality issues (Mulvihill and Quigley, 2003), together with a neglect of the characteristics of those lost from follow-up.

(p.333) Policy

The issues of diet and obesity have been on the political agenda since the 1990s, albeit with a primary emphasis on the adult population. The health of the nation (DH, 1992) introduced targets in these areas and this was reinforced by both the Independent Inquiry into Inequalities in Health (Acheson, 1998), which recommended increasing the availability and accessibility of foodstuffs to reduce health inequalities throughout life, and Saving lives: Our healthier nation (DH, 1999). This emphasis has been maintained by the Public Health White Paper, Choosing health (HM Government and DH, 2004), which took reducing obesity and improving diet and nutrition as one of its six overarching priorities. It is also supported by the 2004 Spending Review Objectives, where one of the joint targets for the DH, Department for Education and Skills (DfES) and the Department for Culture, Media and Sport (DCMS) is to halt the year-on-year rise in obesity among children under the age of 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole (DfES, 2004a).

A first theme, and one that reflects the evidence base, has been the increased emphasis on a ‘settings’ approach to health promotion, in which schools and communities are identified as the locus for multiple and reinforcing health-promoting actions. The concept of the healthy school was developed by the WHO in the early 1980s in order to encourage a whole school approach to personal and community health (see, for example, Lister-Sharp et al, 1999). It recognises, for example, that classroom education on nutrition is undermined if healthy food choices are not available in school meals and in school tuck shops. This produced a raft of health-promoting school programmes across the UK, which were consolidated and extended by the Healthy Schools Programme, a joint DH and Department for Education and Employment (DfEE) initiative launched in England in 1998. This aims to improve standards of health and education and to tackle health inequalities by making children, teachers, parents and local communities more aware of the opportunities that exist in schools for improving health. The focus on the school may be of particular importance in rural areas where young people do not have easy access to health and other services.

An important part of the Programme is the National Healthy School Standard (NHSS), a national guidance and accreditation process to support the development of healthy schools, which includes the requirement to promote healthier food within schools and to provide education about healthy eating. The standard is now increasingly focused on achievements at school level and concerned to target the most disadvantaged. Schools themselves are expected, for example, to demonstrate how they are contributing to targets around health inequalities, social inclusion and raising achievements, while those schools where FSM eligibility is 20% or more are expected to implement the standard most closely, achieving NHSS Level Three by March 2006 (DH and DfES, 2003a). A review (p.334) of the NHSS suggested it has been instrumental in providing a structure for health promotion work and curriculum development and increasing motivation to act. Related improvements in pilot schools included improvements in attendance, bullying, self-esteem and the school environment, that is, areas beyond academic achievement, with the standard felt to mirror the broad view that young people take of health (Rivers et al, 2000). Success is, however, highly dependent on the standard being accorded a high profile at senior level in local health and education authorities, having a similarly high level of support at school level and being backed by adequate human and financial resources, including the ability to renegotiate external catering contracts. There have also been problems involving young people systematically, and little evidence to date of any real difference between schools according to level reached (Warwick et al, 2004).

Within this holistic context many would argue that the role of school meals has long been neglected. School lunches were once considered a means of enabling needy and undernourished children to benefit from school education. Their contribution to the health of children had been tentatively recognised by the reintroduction after 20 years of national minimum nutritional standards for schools in 2001. This was, however, set against the growth of commercial sponsorship in school meals and catering contracts awarded to firms who had but a weak commitment to providing nutritious meals. It was also set against the low FSM uptake, thought to be caused in part by the stigma and bullying associated with targeting (Riley, 2005). Both act to constrain the potential of school meals to confer nutritional advantage.

There has also been a lack of any serious challenge to advertising or attention to the power of marketing to make healthier choices more attractive, alongside a lack of research into the negative effects of junk food. Meanwhile, the food industry continues to offer a range of incentives to schools to allow the sale of their produce on school sites, or indeed commands a contractual presence by virtue of the Private Finance Initiative (where they operate in tandem with the construction companies to secure a range of catering and vending contracts). Given the time it took to ban tobacco, despite conclusive evidence as to its adverse impact on health, the task of redefining where, when and how unhealthy foods may be marketed in the interest of public health, is likely to be major challenge. Choosing health has signalled the intention to start to address the issue, albeit in the future, with a strategy to restrict the advertising and promotion to children (including sponsorship, vending machines and packaging) of foods and drinks that are high in fat, salt or sugar (HM Government and DH, 2004).

Similar plans to consider the introduction of nutrient-based standards for school meals were given a much needed impetus by a television series presented by celebrity chef Jamie Oliver. This raised the profile of school lunches dramatically, stressing not only the limited per capita spend and the wide-ranging consequences of poor diet but also the endemic resistance to healthy eating among many school children and their parents. The government consequently pledged £280 (p.335) million (over three years from September 2005) to improve school meals, with per capita spend rising from 37p to (the still very low figure of) 50p per child in primary schools and 60p in secondary schools. This will be reinforced by accredited training qualifications for school caterers, new statutory requirements (from 2006) for nutrient-based primary and secondary standards and revised school meal standards to cover the whole school day (thus including, for example, vending machine sales). Significantly, this reinforces moves already made by the Scottish Executive and Welsh Assembly to introduce and resource higher standards, suggesting, as with a number of other aspects of the health inequalities agenda, a more progressive approach outside England. However, criticism continues to focus on the available resources (given, for instance, the dismantling of the kitchen infrastructure) and the lack of a curriculum in schools to teach children to purchase, prepare and cook healthy food. More pervasively, the Child Poverty Action Group (CPAG) suggests universal provision of school meals is fundamental to ensuring increased uptake from low-income homes (Riley, 2005).

Other components of the Healthy Schools Programme include the National Healthy Schools Network, Wired for Health, Cooking for Kids and Safer Travel to School (which focuses on strategies to reduce car journeys to school where safer, healthier alternatives exist). A series of related initiatives build on this school focus and the integrated approach between education and health. The proportion of young people spending two hours or more in physical education lessons at school fell, for example, from 46% in 1994 to 33% in 1999 (CYPU, 2001), with nearly one fifth of school children spending less than one hour per week on physical education (Nessa and Gallagher, 2004), half the NHSS standard. The government’s plan for sport (DCMS, 2000) therefore included a focus both on young people and the educational infrastructure. This incorporated a health inequalities dimension with lottery-funded school sports coordinators to be established initially in the 600 communities in the greatest need and lottery resources channelled, via Sport England, to disadvantaged areas: areas with Sports Action Zone, EAZ or Excellence in Cities funding. It also established specialist sports colleges. This was reinforced in 2002 by the Physical Education, School Sports and Club Links Strategy, which aims to build on the emerging network of specialist sports colleges to develop 400 school sport partnerships by 2006, supported by teachers released to act as secondary school sports coordinators and primary/special school link teachers (DfES and DCMS, 2003). Funding of £459 million was dedicated to the strategy in 2002 with a further £519 million identified in 2004 for the period 2006–08. Further support has been given by a Public Service Agreement (PSA) target that aims to increase the percentage of 5- to 16-year-olds who spend a minimum of two hours each week on high-quality Physical Education (PE) and school sport within and beyond the curriculum from 25% in 2002 to 75% by 2006 (DfES, 2004a). By 2003–04 62% of pupils in school within a school sport partnership were reported to have met this target, although as yet only 6,500 of England’s 12,000 schools fall into this category.

(p.336) Breakfast clubs can similarly be seen as a response to a number of key public policy drivers: childcare, education, nutrition and social inclusion, although their status remains ambiguous and insecure, in part probably because of this breadth of remit (Harrop and Palmer, 2002). Adequate coverage is also a real problem for so many of these targeted initiatives. The New Policy Institute (Street and Kenway, 1999) estimated that there were some 400–600 breakfast clubs in 1999, catering for perhaps 0.5% of primary school-aged children, a figure that contrasts markedly with the suggestion that one third of all children may start the day without breakfast. Breakfast clubs in more deprived areas are also highly dependent on external funding since it is unlikely that they will ever be able to charge enough to cover their costs. As with childcare, the political emphasis on new starts and the provision of start-up funding has also left many clubs in financial difficulty (while the task of securing ongoing funding is a disincentive to establishment, particularly in primary schools, which have higher staffing ratios and lower rates of attendance). Staffing is a further critical barrier because of the early start and the restricted hours. However, the holistic emphasis is gradually encouraging more schools to view such clubs as part of their mainstream activities rather than an additional service, with concurrent opportunities to provide staffing, for example, from school budgets (Harrop and Palmer, 2002).

Given the increasing evidence of a link between nutrition and school performance and behaviour many would argue that this is a wise investment of educational resources but, paradoxically, these clubs do not always offer a nutritious and well-balanced meal. A survey of award-winning breakfast clubs by the New Policy Institute found most had adopted a ‘give them what they want philosophy’ in order to ensure good take-up of breakfast or sometimes to restrict costs (Harrop and Palmer, 2002, p 25). Fresh foods are thus cut back with the club focusing (as in resource-constrained households) on popular foods that they know the children will eat. As a consequence health and nutrition and access for families on a low income are both frequent casualties – suggesting the need for increased emphasis on the importance of breakfast, the involvement of health professionals and increased subsidies for those who cannot afford to participate (Street and Kenway, 1999).

Another relatively high-profile response has been the Five-a-Day Programme in England. Established by The NHS Plan, where it was linked to The NHS Cancer Plan (DH, 2000) and the National Service Framework for Coronary Heart Disease (NSF for CHD), it aims to increase people’s awareness of the importance of having access to, and eating, at least five portions of vegetables and fruit a day. Key elements are the National School Fruit Scheme, which entitles children aged between four and six to a free piece of fruit each day at school, and community initiatives developed by primary care organisations and their partners for people living in disadvantaged areas, together with work with the food industry, including growers and caterers, to improve the general public’s access to fruit and vegetables. The National Audit Office (NAO) has also suggested that the (p.337) DH and DfES should consider a performance target for fruit and vegetables in schools, while the Children’s NSF also directs attention to the broader issues of healthy diet and physical activity.

Effective political strategies against weight-related disorders are similarly recognised as those that (drawing on the albeit tentative evidence base) work at a number of levels (individual, group and community), and address both circumstantial barriers to change (such as affordability and access) and attitudinal barriers (such as dietary perceptions, health-related knowledge, cooking skills and peer pressure) (HDA, 2002). Within the NHS, primary and community health professionals such as general practitioners (GPs), health visitors and school nurses, offer the greatest contact with overweight/obese children. Research conducted by the NAO in 1999 found, however, that while 83% of health authorities had identified obesity as a public health issue in their Health Improvement Programme, only 28% had actually taken action to address this and plans tended to address the issue via cancer and CHD strategies, rather than a dedicated obesity strategy, suggesting a corresponding neglect of childhood and adolescence (NAO, 2001). Key staff have long been subject to a number of competing priorities. School nurses, for instance, are significantly bound up in child protection as well as immunisation work, which limits their ability to work on prevention or increase their public health role, despite the rhetoric of both Choosing health (HM Government and DH, 2004) and the NSF for Children and Young People.

Substance abuse

Cigarette smoking is the major preventable cause of premature mortality in industrialised countries. Reducing its prevalence among adults is thus central to policies to improve health and to reduce socio-economic inequalities. Given that most smokers start smoking in their teenage years, and that heavy smoking in adolescence is associated with a higher risk of smoking long term, childhood and early youth would be expected to be key periods for primary prevention. Indeed, with 16% of 11-year-olds in England having already experimented with smoking, it has been suggested that programmes may have to target children as young as four to eight years of age if they are to intervene before behavioural patterns become established (NHS CRD, 1999). The proportion of young people smoking on a regular, weekly basis has remained relatively stable across the 1990s with, as Chapter Eight has shown, 20% of boys and 26% of girls aged 15 smoking at least one cigarette a week.

The pattern of alcohol consumption, the first and most widely consumed recreational drug used by young people, has similarly shown no obvious trend when measured by frequency over the 1990s, with approximately one fifth of 11- to 15-year-olds drinking in the past week. However, the average weekly consumption of alcohol among young people has increased substantially (Rowan, (p.338) 2004), and the UK heads the European league table in terms of the prevalence of binge drinking and youthful intoxication. Contributory factors include increasingly sophisticated subsector marketing and increases in the alcoholic content of the drinks sold.

Alcohol dependence is surprisingly common even at this early stage in the lifecourse, with misuse carrying a range of immediate risks of harm both to the young person and to others. In Europe one in four deaths of young men aged 15–29 is attributable to alcohol, while in the UK 18,000 young people are estimated to be scarred for life each year as a result of drunken assaults (Foxcroft et al, 2003). The age of initiation is linked to the lifetime alcohol dependency rate (although use does not track as strongly into adulthood as cigarette smoking) (Graham and Power, 2004). As Chapter Eight has shown, research also suggests that alcohol may act as a gatekeeper to other drug use, with exclusive use of either cigarettes or illegal drugs being negligible. Changes to its normative status might thus influence a range of substance use, as well risky and premature sexual behaviour. It is estimated that the cost of alcohol misuse approaches £20 billion a year, including crime and antisocial behaviour and lost productivity as well as damage to health (Cabinet Office, 2004).

The situation with respect to other drugs is more complex, reflecting both the range of available substances and the patterns of consumption. Not only does the UK have the highest rates of drug use in Europe, comparable to those found in the US, but research also suggests that official statistics underestimate both experimentation and usage. As Chapter Eight has shown, two fifths of young people aged 15 have tried one or more street drugs, most commonly cannabis. Until recently, however, it was suggested that there had been a de facto bifurcation of recreational and hard drug use, with 99% of the cost of drug misuse in England and Wales attributed to the 250,000 Class A drug users of all ages, 100,000 of whom are possibly young people (Drugs Strategy Directorate, 2002). The related socio-economic costs are nevertheless immense (estimated at between £10 and £17 billion a year) for Class A drug use alone (not least because of the existence of strong links with crime), with recreational use by young people estimated to cost a further £28 million a year (Canning et al, 2004). This is reflected in the annual drugs-related expenditure which, at £1.5 billion for 2005/06, dwarfs that seen for any other intervention discussed in this book. Meanwhile, the increasing use of heroin and cocaine by adolescents and young adults within recreational settings, poly-drug use and the mixing of drugs and alcohol provide a further challenge for policy and practice. Perceptions of substance use as recreational can also act as a barrier to accessing help (Wincup et al, 2003). Each year it is estimated that 20,000 young people become adult problem drug users (DfES, 2005), and problems cluster among the most vulnerable.

(p.339) What works? Evidence and practice

While interventions often target a range of drugs, they appear to be more common with respect to tobacco and other drug use than with respect to alcohol. This is probably a response to social attitudes, with a general acceptance of sensible alcohol use as opposed to a concern for abstinence. Most, reflecting the stage of lifecourse, also focus on primary prevention, with some secondary prevention to address substance misuse and limited interventions around the issue of dependence. The acceptance of links to social exclusion also means substance misuse is increasingly seen as an integral part of the larger youth agenda, particularly in neighbourhood renewal areas and in conjunction with vulnerable groups such as the homeless, care leavers and youth offenders (Home Office, nd).

Both adolescent nicotine dependence and social circumstances influence adult smoking (Jefferis et al, 2003). Interventions seeking to reduce nicotine dependence in isolation are, therefore, unlikely to be effective in reducing the socio-economic gradients in smoking. Rather, they need to address both the pharmacological and social pathways into adult smoking. This has meant both an increasing emphasis on social influences within educational programmes and the introduction of community interventions that address the decision to smoke within a broad social context.

Thomas (2002), while acknowledging the key influence of culture on smoking, presents a typically US-centric view of behavioural interventions in schools designed to prevent children from starting smoking. As in many other areas, he finds little evidence to support the provision of information alone, and only equivocal evidence to support interventions based on social learning theory/ social influence, including, for example, discussions around the incidence of smoking, its social consequences, peer, family and media influences on smoking and tobacco refusal skills. One reason is likely to be (as in Box 9.3) the focus on the school environment alone without recourse to the wider social and cultural context. The same class of programmes was also found to be the most effective by earlier meta-analyses. Rooney and Murray (1996), for example, suggested social influence programmes could reduce smoking by between 5% and 30%.

Outcomes, it has been suggested, might also be improved by supplementation with interventions designed to increase generic social competence (improving social skills, reducing stress and increasing self-esteem in the classroom, for example, without a specific anti-smoking emphasis). However, a key limiting factor for any school-based educational programmes for early youth is the degree to which different groups participate in school life and identify with the institution. Kobus (2003), in reviewing peer group influences, found that by their early teens disenfranchised groups related to activities outside school and to age-heterogeneous groups in the larger community. This potentially limits the impact of school-based educational programmes to their more pro-social peers, while other vulnerable groups such as truants and the excluded are, by definition, unable to participate and require a more targeted approach. Regular smokers, for (p.340) example, are twice as likely to be absent from school as non-smokers (Charlton and Blair, 1989). Breeze et al (2001), focusing on drugs prevention discourses, also suggest that the emphasis on resistance and risk sits uneasily with what they describe as a cost-benefit consumerist hedonistic perspective, wherein young people are comfortable with their drug use and lack significant guilt but still have inadequacies in their knowledge base.

Another limitation is the intensity and duration of the intervention. Most schools teach health education as part of personal health and social education (PHSE). However, it has been suggested that 20–30 lessons during adolescence may be required to influence smoking behaviour (Prochaska, 2000; Tobler et al, 2000). This is a major demand on the curriculum alongside potentially similar claims from other PHSE targets, and contrasts markedly with the limited time allocated within many of the reviewed interventions. MacKintosh et al (2000), (p.341) describing a multicomponent drugs intervention programme that still amounted to only 11–25 hours for the majority of students, emphasised the need not only to consider the time available but also the degree to which social influence is capable of forming the basis of harm reduction as opposed to primary prevention interventions, and the degree to which it can be effective with older adolescents.

An alternative is to ally school-based interventions with actions in the community, such as parent education, work with youth organisations, and campaigns ranging from those aiming to reduce cigarette sales to minors to those aiming to reduce cardiovascular diseases across the age range (see Box 9.4). Like those designed to improve generic social competence, such programmes have not been rigorously evaluated (Thomas, 2002), and little support has been found for their effectiveness. Where positive results have been found, the interventions have again been informed by social learning theory, emphasising the importance of creating negative attitudes towards smoking and reducing the intention to smoke (Sowden et al, 2004). An authoritative positive parenting (p.342) style has also been found to be protective, in contrast to a permissive, distracted family environment (Tyas and Pederson, 1998), findings that reinforce the emphasis placed on parenting in early life. Indeed, a comprehensive review of child and adolescent mental health treatments found that family therapy was “superior to other treatment modalities” in reducing substance misuse (Fonagy et al, 2002, p 324).

The literature suggests that mass media campaigns can have a significant and cost-effective impact in this area, reducing cigarette consumption and denormalising smoking, particularly if their focus is on the industry’s manipulation of youth and the negative effects of second-hand smoke (Lantz et al, 2000). However, only a limited number of studies have employed a controlled design to this end and these do not provide strong evidence of effectiveness. Sowden and Arblaster (1999) found only two. Both were intensive programmes, repeated across three or four years and based on social learning theory (including, for example, refusal skills and resistance to advertising pressures). Both had an effect on intermediate outcomes such as attitudes towards smoking and intentions to smoke in the future as well as smoking rates. In both cases, too, the successful interventions utilised a mass media programme in conjunction with school-based education (as opposed to no intervention or school-based intervention only), suggesting the increased potency of broad-based interventions.

In contrast, the enforcement of the law relating to cigarette sales to underage youth appears to have a limited impact on smoking behaviour. In a synthesis of interventions aimed at preventing the sale of tobacco to minors, few communities achieved sustained levels of high compliance, and there was little consequent effect on youth perceptions of access to tobacco or on the prevalence of smoking. However, it has been suggested that there is a threshold level of compliance, above which access can be reduced, and that if such compliance can reduce consumption by 5% it would be as cost-effective as any other prevention activities (Stead and Lancaster, 2004).

A recent meta review confirmed that the main focus for the primary prevention of drug use is adolescents in schools. It also reported that primary prevention programmes are unlikely to have a major impact on drug use or drug problems, that the impact of drug prevention programmes tends to be confined to the gateway drugs of alcohol, tobacco and cannabis rather than illicit drugs, and that most British interventions are not properly evaluated (Canning et al, 2004). The challenge of tackling health inequalities in this manner was further highlighted by the fact that school-based initiatives were found to be more effective with non-users (where they may delay start) and lower-risk adolescents (where they may raise awareness and challenge normative beliefs) rather than with those at a high risk. High-risk families are also less likely to be involved with parent-orientated programmes. There was, however, some support for interactive programmes, with those led by peers that addressed the social influences of substance use being the most effective (Tobler et al, 2000). Additional features of (p.343) effective programmes were intensity (more than 10 sessions) and reinforcement via booster sessions (Canning et al, 2004). A distinction may also be made between peer delivery (which appears to have limited ability to make users stop but may reinforce abstinence and limit drug-using repertoires) and peer development programmes. The latter provide a basis for working with more vulnerable young people and appear able to foster the educators’ self-esteem and maturity and change their existing patterns of drug use (Shiner, 2000). The young person who is delivering the programme thus tends to benefit the most. Interestingly, a consideration of peer-led sexual health programmes suggests, however, that it may be not the inclusion of a peer per se but rather the ability of the provider to facilitate learning and their comfort with the subject matter, that may be important (Ellis and Grey, 2004).

Parker et al (2001) note that young adolescents in the late 1990s, despite having more access to drugs, had slightly lower rates of drug trying and recent drug taking and were less likely to be current smokers and drinkers. However, they suggest this was largely independent of official interventions. They advocate abandoning the search for abstinence solutions in favour of management strategies: a national secondary prevention programme to target adolescent recreational drug triers and users in order to prevent their progression to harder drugs, and initiatives to minimise harm from problematic drug use. Clubbers in their early twenties, for instance, are often poly-drug users who confound the image of the socially excluded criminal who resorts to Class A drugs, yet can face problems with their physical and psychological health and are unlikely to be seen by treatment programmes (Measham et al, 2001). Targeted public health messages for young heroin users have similarly been suggested to harness their contemplation to change, avoid overdosing and prevent the switch from smoking to injecting. In general, however, while the effectiveness of prevention programmes has been demonstrated with respect to the acquisition of knowledge, this does not extend to drug-using behaviour for the most vulnerable groups, as measured by prevention or delay in onset (Millward et al, 2004). A review of the grey literature similarly found evidence of projects that had engaged with young people and produced better services but little evidence that this prevented, delayed or modified risky behaviour. This was attributed in part to the absence of effective evaluation. It did, however, add further support to one of the underlying themes of this book – the movement away from single-issue interventions towards combined interventions that address a cluster of risks (Coomber et al, 2004).

A systematic review of over 50 psychosocial and educational interventions aimed at the primary prevention of alcohol misuse for those aged 25 and under was similarly unable to come to any firm conclusions concerning the nature of effective prevention in the short or medium term. Nearly half of the interventions reviewed proved ineffective, there was little to distinguish effective interventions from the ineffective and the former failed to convince with respect to either pattern or scale of outcomes (Foxcroft et al, 2003). Research based in Australia (p.344) suggests one of the contributory factors may again be the emphasis on abstinence or delayed use. A school-based programme focusing instead on harm reduction goals was able to produce significant changes in consumption (including harmful and hazardous consumption) and the harm associated with consumption, alongside the more normal changes in knowledge and attitudes. These were all sustained to varying degrees across the programme, although diminishing by the final follow-up 17 months after programme delivery (McBride et al, 2004).

The American Strengthening Families Programme, initiated for families where one parent was involved in a methadone maintenance programme or attending a substance misuse outpatient centre, was highlighted as of potential interest. Here the aim was to enhance the quality of parenting and to reduce problem behaviour, with reduced substance use in older children and reduced adolescent drug use at follow-up incidental to a larger improvement in child behaviour and family relationships. Home visits by nurses in the prenatal period and early childhood to high-risk families were similarly found, 15 years later, to be reflected in reduced cigarette and alcohol consumption and behavioural problems related to alcohol and drugs in the by then adolescent children (Olds et al, 1998). This again demonstrates the importance of broad-based parenting programmes beyond their efficacy in early life (see Chapter Five). As with smoking, the more recent emphasis on community-based interventions was also considered to hold promise (Foxcroft et al, 2003). Minimum drinking age laws can also be effective in preventing alcohol-related accidents and injuries with review-level evidence also suggesting that lower blood alcohol concentration laws can similarly reduce accidents involving young and inexperienced drivers (Mulvihill et al, 2005). However, neither of these have been tested in a UK context.

In contrast to the equivocal evidence relating to prevention, there is robust research evidence from the National Treatment Outcome Research Study that treatment for drug dependence is effective, with consequent gains in health, crime reduction and risky behaviours such as injecting and sharing injecting (Edmunds et al, 1999; Gossop et al, 2001; Sondhi et al, 2002). Efficacy, as always, depends on the characteristics of the regimes and very little is known about treatment outcomes for young people (HAS, 2001). The National Treatment Outcome Research Study, for example, covers all those aged 16–58 without reporting separately on effectiveness for young people (although the majority of the clients studied were in their late twenties and early thirties) (Gossop et al, 1998). Across the study group as a whole, however, one third achieved abstinence from illicit opiates in community settings, rising to one half in residential settings after four to five years (Gossop et al, 2001).

A review of adolescent treatment outcomes (Williams et al, 2000) found similar levels of reduction with again an allied improvement in illegal behaviour, together with health and school functioning. Significant relapse rates are, however, also recorded not least because over 90% of adolescents in substance misuse treatment programmes have demonstrated psychiatric comorbidity, which reduces treatment (p.345) compliance and predicts poor long-term outcomes (HAS, 2001). The reported improvements in other domains such as confidence, self-esteem and coping strategies suggest, however, a base for sustained intervention. This is supported by more descriptive studies (see, for example, Crome et al, 1998) that similarly find improvements across a broad range of functions and high levels of retention within the service despite multiple disadvantages.

Limitations to the evidence base

The studies reviewed varied in terms of the location, duration and type of intervention considered, the age range of the participants, base rates of substance use and outcomes measured. Behavioural approaches often seek to address tobacco, alcohol and drug use, and even antisocial behaviour, together. While commonalities suggest this is a sensible approach, it makes it difficult to compare outcomes and community interventions are similarly very difficult to evaluate. The European Smoking Prevention Framework Approach evaluation (see Box 9.3) illustrates well the difficulties of isolating the effective characteristics of such interventions, even within the dictates of a common framework, particularly when the intervention seeks to accommodate local needs and to account for different national baselines (de Vries et al, 2003). The US bias to the available literature also means that potentially important cultural differences are in danger of being ignored, while variations within the target population are often neglected or unreported. There is a lack of attention, for example, to ethnicity (Markham et al, 2001), while the emphasis on school-based primary prevention has tended to exclude those most at risk. The impact on long-term behaviour has also been neglected in favour of changes in attitude, knowledge and the development of resistance skills, with a parallel emphasis on self-reported behaviour at the expense of more objective measures of drug use such as saliva and blood tests (Canning et al, 2004).

Policy

The cultural context for reducing the initiation and incidence of smoking is probably now at its most supportive. In contrast with nutrition there is active market intervention with, for example, bans on tobacco advertisements including the withdrawal of tobacco sponsorship, enforcement of under-age sales, proof of age cards and rules on the location of cigarette vending machines. These, together with widespread restrictions on smoking in public spaces, combine to reduce opportunities for smoking and make it less socially acceptable, while taxation makes it costly. In the UK it is also illegal to sell tobacco to anyone under the age of 16 (although not for them to smoke it), although enforcement and compliance are often problematic.

Within this largely supportive environment, the White Paper Smoking kills (DH, 1998a) (see Chapter Five) identified young people as a priority for the (p.346) smoking cessation strategies introduced from April 1999 and set targets to reduce smoking among children in England from 13% to 9% or less by 2010, with a fall to 11% by 2005. Subsequent surveys of English smoking cessation service coordinators found, however, that the programmes had made little progress either in attracting young people or in developing services for them, and that those suffering from smoking-related illnesses were given a higher priority (Coleman et al, 2002; Pound et al, 2005). Even where services were offered, these were seen to be peripheral to a primarily adult-focused strategy and did not cater for those below the age of 16. Not surprisingly, therefore, the Health Development Agency (HDA) found there was almost “no good evidence of effective smoking cessation interventions for young people, nor much experience in the UK of setting up and running such interventions” (HDA, 2004, p 1). Such findings reinforce the impression of a preoccupation with primary prevention for this age group, irrespective of substance concerned, and illustrate the difficulty in translating a change in policy into practical response. Similarly, there have been few reported trials of cessation programmes and few young people are counselled to quit as a part of a routine medical consultation. In contrast, descriptive studies suggest many teenage smokers are motivated to quit, and that the use of nicotine replacement therapy (NRT) for adolescents should be reconsidered (Lantz et al, 2000).

The UK drugs strategy was formalised in the early 1990s in response to the widespread emergence of problematic heroin use in many poor communities, followed by the unprecedented expansion in young people’s recreational drug trying. Tackling drugs together (HMSO, 1994) has been criticised for being strong on the ‘war on drugs’ rhetoric and weak in all other respects (Parker et al, 2001). A key legacy, however, was the creation of Drug Action Teams (DATs), which brought key players such as the police, probation, health, education, social services, drugs services and voluntary and community organisations together at the local level. This includes a dedicated budget for the treatment of young people (80% of DATs now provide treatment services for young people), together with a sum of money to be spent on support for education in schools (including teacher training and the Healthy Schools Programme) that is directed to the local education authority (LEA).

Tackling drugs to build a better Britain (Cabinet Office, 1998), conceived by New Labour as a 10-year strategy to 2008, similarly employed an essentially UK approach, with almost every health, welfare, care and control and enforcement official expected to play a role in a local multiagency partnership approach to dealing with drugs. The strategy had four key goals (with accompanying targets), one of which was to help young people resist drug misuse, together with the protection of communities from drug-related antisocial and criminal behaviour, the identification of drug-driven or related offending in the criminal (p.347) justice system and the reduction in the availability of drugs on the streets. Significantly, the latter is the least developed and, together with the changes in the criminal justice system and the emphasis on young people, marks a shift away from enforcement in this area towards prevention and treatment. With £250 million of new money in the first five years and an annual expenditure of £1.3 billion per annum, critics have, however, queried the lack of success (Parker et al, 2001).

The strategy was thus further updated in 2002, including a focus on Class A drugs that emphasises education, prevention and treatment, and a further increase in resources, with planned direct annual expenditure rising further to nearly £1.5 billion in 2005/06. Young people are again one of four priority areas for these new resources, including education campaigns focusing on Class A drugs, support for families and increased outreach and community treatment, while changes to the youth justice system include provision for testing and referral for treatment on arrest and as a condition of community sentences. The aim is to support 40,000–50,000 vulnerable young people per annum by 2006, with research suggesting that criminal justice intervention schemes are highly cost-effective in terms of savings to health and welfare as well as the criminal justice system itself (Millward et al, 2004).

One contributory element, expected to accommodate one tenth of this target group, is the Positive Futures Programme. This is a sports-based social inclusion project aimed at 10- to 19-year-olds in the 57 most disadvantaged communities, where sports and arts are being used as part of what is described as a ‘relationship strategy’ to reconnect marginalised young people with local services, to develop skills to resist drugs and reduce offending and, critically, to re-enter education (Positive Futures, 2004). Also key are the Youth Offending Teams (YOTs), juvenile custody (together expected to support 12,000) and the drug treatment agencies (a further 5,000). However, the main mechanism continues to be local health and education services and Connexions, which together are expected to provide nearly 60% of this target provision, a threefold increase on 2002. The Jobcentre Plus Progresss2work Initiative, introduced in 2002, also aims to help drug users find and sustain employment (Drugs Strategy Directorate, 2002).

A further key change has been the reclassification of cannabis as a Class C drug. Previous to January 2004 the processing of young people for cannabis possession dominated policing contact, increasing the friction with young people, potentially making reintegration into the education system or employment difficult and accounting for the equivalent of 500 full-time officers a year (May et al, 2002). These resources could have been more effectively directed towards prevention and treatment. There has also been a relaxation in targets, explicitly acknowledging the difficulty of reducing illicit drug use per se among all under 25-year-olds and the inability to reduce Class A drug use by 50% by 2008. The focus is now on achieving general reductions in Class A and frequent drug use, particularly among the most vulnerable.

The Updated National Drugs Strategy has in turn been revisited under the auspices of Every child matters (DfES, 2005) in an attempt to ensure an integrated service for vulnerable children with an enhanced preventative element. This also (p.348) introduced a targeted geographical approach with High Focus Areas. These are areas with high levels of local need and inadequate levels of service provision where progress towards the new objectives of reformed delivery, strengthened accountability, increased service and workforce capacity and a focus on the needs of the most vulnerable young people is expected to be more rapid than average (DfES, 2005). This more integrated approach is emphasised by two developments already discussed. The first is the assumption of lead policy responsibility by the DfES (which shares responsibility with the Home Office for target delivery). The second is the assumption of local operational responsibility and target delivery by the Directors of Children’s Services (with the DAT chairs) through the medium of the Children and Young People’s Plans due to be produced in April 2006 (DfES, 2005).

The final part of the triad is represented by the Alcohol Harm Reduction Strategy for England (Cabinet Office, 2004). This focuses on reducing the harm caused by crime and antisocial behaviour (seen as primarily an urban problem) alongside the harm caused to health because of binge and chronic drinking. While youth is not an explicit target, the 5.9 million binge drinkers (technically those who consume above twice the recommended daily guidelines but more commonly considered those who drink to get drunk) are generally aged under 25. One of the key strategies also focuses on changing behaviour and culture via improved education and communication and young people are again the prime target. Ofcom has also reviewed the rules on broadcast advertising of alcohol to ensure that from January 2005 advertisements do not appeal particularly to the under-18s or link alcohol with sexual activity or behavioural attributes such as daring or aggression (HM Government and DH, 2004).

Unlike drugs policy, the relatively large population who have alcohol problems is less likely to have contact with the criminal justice system and this cannot, therefore, be used as a trigger for treatment. Instead, the first port of call is more likely to the health system, particularly Accident and Emergency Departments, together with schools and, for example, mental health assessments or YOTs. Here, both increased training and effective screening procedures are required if such contacts are to act as key entry points for secondary and tertiary interventions. At present, for example, there is little specific reference to drugs or alcohol even in the Framework for the assessment of children in need and their families (DH et al, 2000).

As noted already, school programmes have been seen as attractive vehicles for primary prevention because most schools already teach health education as part of PHSE. The results of school interventions have, however, often been disappointing, with competing priorities among (non-statutory) PHSE targets as well as pressure from the national curriculum. Drugs education (including alcohol and tobacco) is now a planned component of PHSE, with Citizenship a statutory part of the national secondary curriculum since September 2003, and the majority of schools having a drugs education policy. This aims to increase (p.349) pupils’ knowledge about the range of drugs (including the risks attached), examine their attitudes towards drugs and drug users and develop the personal and social skills to communicate, make effective choices and ask for help when needed (DH and DfES, 2003b). It is also one of the NHSS themes, moving away from the school’s role in developing knowledge and skills towards influencing behaviour. The government, reflecting concerns over the requirement for secondary prevention, is also considering how substance misuse education can be provided in post-16 education settings.

The Connexions service, the DfES career and academic planning service for 13- to 19-year-olds, also holds a wider supportive role in secondary and further education. Personal Advisors are trained to address individual and social problems, including the use of drugs and alcohol. Priority is given to young people at risk of disaffection and underachievement and the evidence base would suggest that such an approach might be able to address the paradox that while knowledge about the harmful effects of a behaviour appears not to be protective, it seems to become more relevant when personalised (Tyas and Pederson, 1998).

Despite the political imperative to create coherent strategies with an explicit focus on young people, critical services for young people continue to be absent or under great pressure, particularly with respect to alcohol and drugs misuse. DATs, as the local delivery arm of the drugs policy, have ensured some local treatment is available for young people. However, the Health Advisory Service suggests there is still a lack of understanding that children’s services are not just an extension of adult drug services (HAS, 2001). Meanwhile, the recent introduction of the alcohol harm reduction strategy means the response time in this area has been limited. It has been suggested that there is now an established need for a dedicated, specialist therapeutic social care and health service (covering drugs, alcohol, mental health and sexual health) to back up the operation of the Connexions service. The introduction of Children’s Trusts by 2008 (see Chapter Five) should begin to address these issues.

Sexual health

The sexual health of young people in the UK is poor. As Chapter Eight has noted, there is a high incidence of risky sexual behaviour, allied with high rates of teenage pregnancy and an increase in sexually transmitted infections (STIs), with teenagers and young adults bearing a disproportionate part of the burden (Ellis and Grey, 2004). Together, this forms a considerable cluster of risk that carries significant implications for future health and fertility. It is also a risk that varies considerably with gender, socio-economic background, education, ethnicity and locality (NHS CRD, 1997; Aggleton et al, 1998). Teenage mothers, for example, tend to be disadvantaged at the outset and this is often compounded by the early transition to motherhood which can cause stress on adolescent relationships, compromise antenatal health and further affect educational (p.350) attainment and longer-term opportunities, often resulting in long-term benefit dependency and poverty (Chevalier and Viitanen, 2003; Swann et al, 2003). Consequently, it is increasingly accepted that policy and practice must address not only sexual behaviour and the range of adverse health and social outcomes but also the determinants of risk.

What works? Evidence and practice

Despite arguments for joined-up action and a holistic approach to the needs of young people, evidence as to what works tends to focus on the prevention of teenage pregnancy and effective support for teenage parents and their children. A recent review of the prevention of STIs found, however, that nearly half the included studies focused on young people, with 14 out of 26 looking at sex education programmes in schools (Ellis and Grey, 2004). This found that school-based sex education programmes can be effective in reducing sexually risky behaviour among adolescents and that they are more effective if begun before the onset of sexual activity. By increasing condom use, delaying initiation and reducing the frequency of sex, STI programmes also potentially reduce unintended pregnancy (Kirby, 1999, cited in HDA, 2001). However, a key limitation (as with substance misuse) is that the adolescent population attending school is generally at a low risk and interventions need to be able to target high-risk youth. This is compounded by a lack of evidence as to the effectiveness of interventions designed to reduce inequalities in sexual health. However, a number of studies do emphasise the links between behaviour, education and wider social opportunities, and use the link to suggest attention be paid to socio-political intervention including the improvement of educational and employment opportunities (Ellis and Grey, 2004).

There have been two main approaches to unintended pregnancy: educational (primarily again school-based) interventions and the provision and delivery of contraceptive and counselling services (NHS CRD, 1997). In marked contrast to this focus, it has been argued persuasively that raising expectations of girls from a very young age has a direct effect on the chances of their becoming a teenage mother, and that policy should instead target educational opportunities and aspirations from the pre-primary phase onwards (Cheesbrough et al, 2002).

Education

DiCenso et al (2002), focusing on RCTs alone, suggest there is little if any evidence to support the effectiveness of primary prevention strategies, with the exception of multifaceted approaches to life skills and pregnancy. However, a broader synthesis of systematic reviews and meta-analyses (Swann et al, 2003) suggests there is good evidence to support school-based sex education linked to contraceptive services, alongside the community-based delivery of education, (p.351) development and contraceptive services; youth development programmes; and family outreach (see also Dennison, 2004). These are strategies that focus on early intervention in the lifecourse and acknowledge the need to empower young people within personal relationships, as well as addressing continuing low levels of knowledge and constraints to contraceptive access and use (Wellings, 1998). They improve chances of eventual condom or other contraceptive use without increasing sexual activity (Cheesbrough et al, 2002).

The majority of evaluations of educational approaches are, typically, US-based. These suggest that successful interventions are characterised by a sound theoretical base, intervene before patterns of behaviour are established and take a participatory, personalised age-appropriate approach. They also include practical skills such as improvements in communication (negotiating protected sex and the use of contraception remains problematic) and focus clearly on reducing one or more sexual behaviours that lead to unintended pregnancy or STI infection (Meyrick and Swann, 1998). Additionally, the literature emphasises the need for integration and a broad-based approach, closing the gap between education and health and raising awareness of the range of issues impinging on sexual health (see Box 9.5). Such a collaborative, multiagency approach is considered particularly apposite where the young people concerned fall into the hard-to-reach or vulnerable category (HDA, 2001).

Communication within the family about sex has been found to be significantly associated with rates of teenage pregnancy (Wellings et al, 1998), although an authoritative review finds insufficient evidence to link communication and sexually risky behaviour (Ellis and Grey, 2004). Children whose parents adopt a more realist-humanist approach are likely to learn more from their parents about sexual matters than those who adopt a moralistic one. In the Netherlands, for example, where teenage pregnancy rates are six times lower than they are in (p.352) Britain, and sex is discussed more openly in the home, research suggests young people are both better informed about sexual health and contraception and more sexually competent (using contraception and able to define the role of sex within a relationship). Young people also engage in more mixed-sex out-of-school activities, discuss problems with friends of both sexes and subscribe to weaker gender stereotypes than in Britain, where cultural expectations continue to link successful masculinity to number of sexual encounters and performance (Aggleton et al, 1998). A total of 85% of young people in the Netherlands are estimated to use contraception at first intercourse compared to 66% of 16- to 19-year-olds in the UK and 50% of those aged under 16 (SEU, 1999). It may also be significant that there has been an increase in what has been termed the ‘Double Dutch’ method of combined condom and pill use in an effort to reduce both teenage pregnancy and protect against STIs, which would also increase contraceptive effectiveness among young people. In the US a recent drop in the very high rates of teenage pregnancy have similarly been ascribed to changed contraceptive methods, with increased use of contraceptive injections and implants.

Programmes that offer educational support or improve job prospects may also motivate young people to avoid pregnancy (NHS CRD, 1997). Box 9.6 emphasises the key roles of economy and education.

Few programmes have attempted to tackle the underlying socio-economic and environmental factors associated with an increased risk of pregnancy. Qualitative research suggests, for example, that the most vulnerable and socially disadvantaged (children in care, the homeless, those who have suffered sexual abuse or who (p.353) have mental health problems) often have difficulties forming and maintaining relationships and feel they have little control over their lives, while sex tends to lack any significant meaning or value. They are thus likely to gamble with contraception as part of a broader pattern of risk taking (Hughes et al, 1999). As Chapter Five emphasised, some of the solutions are likely to lie in interventions initiated at a much earlier age. Day care for disadvantaged children, for example, has been shown to lower pregnancy rates among these children as adolescents (Zoritch et al, 2000).

Contraception and counselling

The next stage is to ensure contraceptive use and protection from STIs at first intercourse and at all subsequent events. Research shows an association between conception rates and the type of contraceptive services available locally, with clinics, particularly youth-orientated clinics, encouraging use and reducing pregnancy rates (Clements et al, 1998). Successful contraceptive services aimed at young people focus on access to a wide variety of settings and consider both physical accessibility (location, for example, on bus routes) and timing (such as availability after school or on a drop-in basis). They also provide trained and selected staff, services targeted specifically at boys and men, and services that are integrated so that contraception is available not only alongside other sexual health services but alongside services that move beyond health. It is also important to utilise key presenting opportunities such as emergency contraception and offer a long-term service that is sensitive to local needs and the characteristics of local high-risk groups, and to ensure that young people are aware of the various options available to them subsequent to unprotected sex or conception.

Less is known about the experiences and sexual health needs of young lesbians and gay men. Indeed, it has been suggested that one of the reasons for poor contraceptive use among young heterosexuals is the tension between health promotion/safe sex messages and cultural and gendered expectations. Girls, who as a group tend to have the most difficulty dealing with condoms, tend to remain the ones expected to negotiate their use (Hillier et al, 1998).

Secondary prevention

Initiatives to prevent adverse health and social outcomes have been divided into four key groups: antenatal care; social support and parenting; preschool education and support; and parental education support. These are all areas that, as Chapter Five demonstrated, are critical to life chances. This established that parenting programmes per se are effective in changing parenting practices and improving behaviour problems in young children (Barlow and Stewart-Brown, 2000) as well as improving aspects of maternal psychosocial health including anxiety, depression and self-esteem (Barlow and Coren, 2003), while early education (p.354) programmes can improve longer-term outcomes for children with disadvantaged backgrounds. Coren and Barlow (2003) also conducted a Cochrane Review of the best evidence relating specifically to parenting programmes aimed at improving outcomes for teenage mothers and their children. The results, while limited by methodological problems, indicate that parenting programmes are similarly effective in improving a range of outcomes for both teenage parents and their infants, including maternal sensitivity, identity, self-confidence and the infants’ responsiveness to their parents. They suggest that, as with the wider class of parenting programmes, group-based interventions may be a more supportive and helpful strategy than individual interventions, while fathers are typically neglected. There are also a number of approaches that allow teenage mothers to continue formal education while increased flexibility concerning educational re-entry is similarly attracting increased political attention.

The pilot Sure Start Plus Programme (see Box 9.7), introduced in 1999, provides a nationally evaluated example of an intervention designed to reduce the risk of (p.355) long-term social exclusion and poverty resulting from teenage pregnancy and teenage parenthood by taking an individually tailored yet broad-based approach to supporting teenage parents.

Limitations to the evidence base

Teenage pregnancy rates remained relatively constant for the three decades from 1969 but fell between 1998–2000 by 6% (Botting et al, 1998), suggesting that policy may be beginning to have an impact. As in many areas reviewed, the evidence base is, however, often insufficient to support particular interventions. Reviews conducted for the Health Education Authority and its successor body the Health Development Agency comment on the poor methodological quality of many of the studies covered and the focus on different outcomes, which makes synthesis difficult. The diversity of approaches also militates against conclusions about the efficacy of universal programmes as opposed to initiatives targeting particularly vulnerable groups such as non-school attendees, looked-after children, the homeless, children of teenage parents and some black and minority ethnic groups. Nevertheless, there is evidence for interventions that increase knowledge and skills (via education and family-based approaches), reduce risk (by increasing service quality and uptake) and prevent adverse health and social outcomes (by increasing access to information, advice, counselling and social support) (Meyrick and Swann, 1998; Swann et al, 2003). Young people are not considered a priority group for HIV prevention initiatives so, in an area where there is very little review-level evidence relating even to the high-risk groups in the UK population and no review-level evidence about addressing inequalities, there is no consideration of interventions to prevent HIV transmission (Ellis et al, 2003).

Policy

As Chapter Eight noted, the teenage birth rate in the UK was similar to that in other Northern European countries in the 1970s but was not subject to the same subsequent decrease. Sexual health (including STIs and unplanned conceptions among young people) was, therefore, one of the five priority areas established by The health of the nation (DH, 1992). This introduced a target of reducing unplanned conceptions to those aged under 16 to 4.8 per 1,000 by 2000 (from a baseline of 9.6 per 1,000 in 1989/91). However, by 1996/98 the rate had only been reduced to 9.0 per 1,000.

It was the Green Paper, Our healthier nation (DH, 1998b) that saw teenage pregnancy for the first time as a social issue related to structural issues. Internationally, a marked correlation had been noted between countries with high rates of live births to teenagers and high levels of relative deprivation, poor educational achievement and family breakdown (SEU, 1999). The significance had also been noted of high levels of income inequality, high proportions of (p.356) teenage parents, and a benefit system that did not require lone parents to work until their children had left school, alongside low levels of contraceptive use. The Teenage Pregnancy Strategy, with a budget of £60 million across the first three years, was thus a product of the Social Exclusion Unit’s interdepartmental remit. It focused on better prevention, aiming to halve the rate of conceptions among those under the age of 18 (and reduce conception rates in those under the age of 16) across a decade. This is now encapsulated in a joint DH/DfES Public Service Agreement (PSA), and an 8.6% improvement has been recorded, the conception rate for 15- to 17-year-olds having fallen from 46.6 per 1,000 in 1998 to 42.6 per 1,000 in 2002.

It also focuses on increased support for teenage parents. The specific target here was to have 60% of teenage mothers learning or in employment by 2010. The strategy also acknowledged the range of related issues such as housing and social support, advocating, for example, that no lone parent under the age of 18 should be placed in a lone tenancy and that teenage pregnancy coordinators be appointed jointly by health and local authorities to pull together local services. Towards this end those aged under 16 are now required to finish their full-time education and receive help with childcare. For lone parents of employable age the New Deal for Lone Parents (NDLP) provides a package of support around preparation for work. Revisions to the scheme mean that it is now available to all, not just those claiming Income Support and with dependent children of school age.

Meanwhile, as noted earlier, the cross-departmental pilot programme, Sure Start Plus, was introduced to reduce the risk of long-term social exclusion and poverty resulting from teenage pregnancy and teenage parenthood. Funded initially for three years to March 2004 under the auspices of the Sure Start Unit it was extended to April 2006 and responsibility transferred to the Teenage Pregnancy Unit, where it too became part of the national Teenage Pregnancy Strategy. Shortly afterwards the Teenage Pregnancy Unit itself was moved from the DH to the new Children, Young People and Families Directorate, DfES. Sure Start provides coordinated support to pregnant teenagers and teenage parents under 18 years via a Personal Advisor who coordinates a tailored support package. It also addresses the health inequalities agenda by being based in 20 HAZs (or former HAZs) in England, selected additionally for having high rates of teenage pregnancy.

There is thus a growing acceptance that education and socio-economic status are two of the strongest factors predicting teenage pregnancy and adverse health outcomes. This is reflected in the growing number of structural solutions: the availability of day care, the concern for increasing numbers in education post-16, the tentative emergence of family policy and demands for the provision of appropriate housing. The body of effort remains, however, focused on primary and secondary prevention (interventions that increase knowledge, enhance social/ relationship skills, improve access to services and other resources and facilitate (p.357) their effective use) rather than offering any serious challenge to socio-economic disadvantage.

The children of teenage mothers also constitute a high-risk group alongside their mothers (Coren et al, 2003). They risk higher infant mortality rates, lower birth weights, developmental and behaviour problems and lower school attainment (Botting et al, 1998), together with an increased likelihood of childhood accidents and hospital admittance. Contributory factors have been examined in the preceding chapters on early life, and include a lack of preconception healthcare, higher than average rates of smoking during pregnancy and postnatal depression, limited breastfeeding, a lack of knowledge of child development and a lack of effective parenting skills. A reduction in teenage pregnancy was therefore also identified as one of the key interventions for the NHS if it was to achieve its health inequalities target in the area of infant mortality. However, there is also an analytical tendency to confuse young mothers with single mothers, unmarried mothers with unsupported mothers and unplanned pregnancies with unwanted pregnancies. Outcomes, as Chapter Eight has stressed, are not universally negative nor attributable necessarily to age (Aggleton et al, 1998).

The Sexual Health and HIV Strategy (DH, 2001) also highlights young people as a target group for specific health information and prevention. It seeks to reduce the transmission of STIs and HIV, as well as reducing the prevalence of undiagnosed infections and unintended pregnancy rates and the stigma associated with STIs and HIV. The initial roll-out of the chlamydia screening programme in England, for example, targets selected groups of women under the age of 25, such as those attending genitourinary medicine (GUM) clinics, women seeking terminations and those having their first cervical smear. However, it is restricted at the outset to just 10 sites. Sex education in schools also now has to include education about HIV/AIDS and other STIs. The system is, however, under disproportionate pressure. Between 1991 and 2001, the number of new episodes dealt with by GUM clinics rose by 143%, reaching 1.3 million in 2001. In some clinics, patients had to wait for up to 28 days for a routine appointment, and in 5% of clinics there was a delay of up to a week for urgent appointments (Munro et al, 2004). This increase in workload and waiting times has implications for the treatment of all populations using these clinics, but particularly for a subpopulation such as adolescents, where embarrassment and stigma along with poor communication skills and poor treatment-seeking behaviour may already be barriers to accessing advice. In Sweden, awareness of sexual health among 16- to 23-year-olds was found to be highest among those who had contact with the healthcare system.

Education and employment

Education has been a pervasive theme within this chapter. We have seen how knowledge about health behaviours remains a key weapon within the primary preventative agenda, albeit one that tends to be most effective in the hands of (p.358) those at lowest risk. We have seen how the school has become a key locus for health promotion interventions, such as improved nutrition and physical activity. We have also noted how the complex relational web between risk factors and detrimental outcomes challenges the preoccupation with symptoms and demands that behavioural interventions make the link to education and wider social opportunities. Chapter Three looked at educational policies across the lifecourse while Chapter Eight looked at the direct role that education plays in determining health inequalities. Here we focus on educational interventions at the community level.

A number of initiatives have been introduced aimed specifically at schools or areas with high levels of social disadvantage and poor educational attainment. The first of these were EAZs. Introduced in two competitive rounds from 1999 EAZs were archetypal new labour partnership projects, predicated on support from business and innovation. They were designed to tackle a range of attainment-related issues, including the quality of teaching, social inclusion and support for pupils and their families, with each of the 73 zones focusing on two or three secondary schools together with their primary feeder schools. McKnight et al (2005), reviewing their contribution, concur with Ofsted in suggesting that they did more to tackle inclusion than standards, establishing homework and breakfast clubs and improving the motivation, attitudes and self-esteem of pupils. However, their impact on standards was largely confined to the youngest pupils.

In 1999 the programme was succeeded by the Excellence in Cities programme. This covered a far larger geographical area (encompassing one third of local education authorities [LEAs] and schools), involved more substantial funding and was a more prescriptive programme, including learning support units and learning support mentors. The programme also focused primarily on secondary schools, including the introduction of City Learning Centres. It appears to have had a more significant effect on attainment and attendance, with evaluation finding the greatest improvements among those with lower levels of attainment and attributing this to both the focused strategy and the fact that responsibility for implementation lies with the schools themselves. However, in both cases very considerable disadvantages remain and it has again been suggested this may require more radical reforms to mainstream funding rather than just a continuation of targeted initiatives (McKnight et al, 2005).

The role of schools in inclusion has also continued to receive recognition via the Extended Schools’ Strategy. This expects all schools over time to provide a core offer of extended services, including study support, parental support, family learning and improved referral to multiagency support alongside a childcare component as established by the 10-year Childcare Strategy. There is also a new statutory duty on schools, established by the 2000 Education Act, to safeguard children and promote their welfare (DfES, 2004b).

Considerable political emphasis, as Chapter Three noted, has also been placed on participation in higher education. For children aged 16-plus who attend fulltime (p.359) courses at school or college, a means-tested Education Maintenance Allowance (EMA) was introduced on a pilot basis in 1999, with the aim of encouraging children from lower-income families to continue in education. It is now available nationally, with approximately half of all 16-year-olds in England estimated to be eligible and allowances ranging from £10 to £30 per week depending on family income. At the same time young people not in employment are entitled to lower rates of Income Support than those aged 25 or over, with the basic rate for a single person aged 16–17 standing at only £32.50 a week. Entry to employment is thus being deferred. A PSA target aiming to increase participation in higher education towards 50% of those aged 18–30 and to increase fair access (DfES, 2004a) has also been established.

Those aged 18–30 were also the focus of the government’s first welfare-to-work programme – the New Deal for Young People (NDYP). Its aim is to increase employment and long-term employability by a tailored package of support (delivered by a Personal Advisor) that combines advice, training, support (including the identification and resolution of barriers to employment) and other assistance, including work experience. It was introduced into 12 pathfinder areas in January 1998 and then launched, almost immediately, across Britain in April 1998. At that time almost 120,000 young people were long-term unemployed, with a further 15,000–20,000 young people becoming eligible each month (NAO, 2002). Additionally, young rough sleepers were given immediate access to the New Deal gateway (SEU, 1998).

The initial target was to move 250,000 young people off benefits and into work by 2002. This target was actually met by September 2000, with 339,000 participants having ceased claiming Jobseeker’s Allowance by October 2001 and experiencing at least one spell of sustained employment, 240,000 of whom were known to have moved to unsubsidised sustained jobs. However, this needs to be put into the context of the labour market, where youth unemployment was decreasing rapidly. The net effect of the programme has thus been estimated as a reduction in youth unemployment of 35,000 and an increase in youth employment of 15,000 across the first two years of its operation (many having entered education or training). This was achieved at a net cost of about £140 million per annum or between £5 and £8,000 per person of any age brought into employment as a result of the scheme (NAO, 2002). The most dramatic impact was on those registered as unemployed for over a year, where a fall of almost 95% was recorded between April 1997 and April 2002 (from 90,700 to 5,100).

Little is known about the quality of jobs taken by NDYP leavers, but a national survey has suggested high levels of job satisfaction and some evidence of wage progression, with evidence identifying the individualised help from the Personal Advisors as the key element of success (see Finn, 2003). Subsequent patterns of unemployment are also considered to resemble the newly rather than the long-term unemployed. Other assessments have, however, been less favourable, suggesting about one third of those who participated in NDYP returned to (p.360) unemployment and about one in five of those who did obtain a job failed to retain it for 13 weeks (Finn, 2003). An increased emphasis on job entry targets is also thought to be undermining the original focus of the programme.

Subsequent changes to the programme, following the government’s Green Paper, Towards full employment in a modern society (DWP, 2001), have aimed to increase flexibility, the involvement of employers and the focus on barriers to employment. Significantly, however, the unemployment rate for 16- to 17-year-olds who are outside this policy envelope has not fallen, and this younger age group (which is likely to include some of the most disadvantaged) appears neglected by policy makers unless in education or training (Hills and Stewart, 2005). Evaluations of NDLP suggest this is also making a net if modest impact (Finn, 2003). It has been estimated that employment rates among lone parents are approximately five percentage points higher than they would have been in the absence of New Labour’s policies (McKnight, 2005).

Conclusion

In seeking to establish the links between the evidence base, policy and practice as it relates to health behaviours for young people, we have been confounded by the age range subsumed within this stage of the lifecourse. We have been challenged by the difficulties in separating normal behaviour from risky behaviour and the risky from the problematic, and confronted by the lack of evidence as to how to target problematic behaviour at an early stage. Unlike the health inequalities discussed in Chapter Seven, it is not necessarily a shift, in one sense, to prevention that is required in the behavioural realm – the research evidence suggests that preventative strategies are most effective among those at lowest risk. Rather it is a shift to the acceptance and effective management of risky health. However, it is also a shift to elemental prevention that is required – addressing the structural determinants of health inequalities such as education and employment.Table 9.1 summarises those interventions that the evidence base indicates as effective in improving health behaviours at this stage of the lifecourse, together with key areas where the review-level evidence is still lacking.

This chapter has drawn a familiar picture of connections within this realm of risky behaviour, such that problems tend not to occur singly but at least in tandem. The stress on social pathways and links to the social inclusion agenda recognise this interconnectivity, as does the use of adult advisors or mentors to provide social and emotional support and practical signposting across a range of initiatives such as Connexions and Sure Start Plus. Beneath these recent (and often geographically partial introductions), however, critical services for children and youth are often absent or partial, while mainstream services commonly still operate in parallel. There is a recognised need for one-stop services and multiagency provision that are geared towards the holistic needs of young people (Millward et al, 2004), yet organisational barriers continue to prevent effective (p.361) service organisation. The fragmentation of responsibility means costs and benefits are unlikely to fall in the same place and agencies remain unaware that antisocial behaviour in childhood leads to high costs for them (Scott et al, 2001).

It has also become apparent that while interventions often succeed in changing knowledge and attitudes, the link to behavioural change is much more tenuous. Not surprisingly, given the age group under consideration, the school has emerged as a key locus for preventative intervention. The NHSS epitomises the search for multifactorial change that can impact simultaneously on the linked triad of health inequality, social inclusion and education, extend beyond the immediate school community and become embedded in mainstream policy, increasing the chances for sustained and durable intervention. Potentially universal interventions, irrespective of whether we are talking about breakfast clubs, substance abuse or sexual health, tend, however, not to reach those most in need. Area-based initiatives (ABIs), such as HAZs, EAZs and Sure Start, have been employed to target intervention, as have initiatives that target particular hard-to-reach groups, such as arrest referral schemes, community projects that seek the views of ethnic groups and initiatives such as Positive Futures that offer diversionary activities for marginalised young people (Millward et al, 2004).

The role of the family has also received renewed attention not just because of its potentially protective role but also as a necessary locus for treatment. There continues, however, to be less research on the role of statutory agencies, particularly the contribution of welfare agencies (Graham and Power, 2004). As we move to consider adulthood, family structure continues to be critical but the intersection with structural factors such as employment and housing also becomes central. (p.362)

Table 9.1: Interventions during childhood and adolescence: summary of the evidence base relating to health behaviours

Source

NUTRITIONAL STATUS

Obesity

Two key reviews (one on treatment and one on prevention) suggest no direct conclusions can be drawn with confidence

Cochrane Review

There is some evidence that multifaceted school-based programmes that promote physical activity, modify diet and target sedentary behaviour can reduce the prevalence of obesity among school children

Review of reviews

There is less evidence that preventative efficacy attaches to any of these elements alone or to a multifaceted focus on the family

Review of reviews

Multifaceted family behaviour modification programmes can be effective in the targeted treatment of obesity

Review of reviews

Healthy eating

Healthy eating interventions can prompt behavioural change and reduce fat intake and blood cholesterol but such reductions tend to be minimal (approximately –3% total fat intake)

Other review

Breakfast clubs

In developing countries breakfast clubs may improve classroom behaviour, cognition, academic outcomes and school attendance in the short term

Review

Lack of review-level evidence

Information on adolescents

Studies from the UK

Sustainable weight-loss treatments

Interventions for preventing eating disorders

Upstream interventions

DRUGS (INCLUDING ALCOHOL AND TOBACCO)

Smoking

There is a lack of high-quality evidence about the effectiveness of combinations of social influences and social competence approaches in school

Cochrane Review

Enforcement of the law relating to cigarette sales to under-age youth can have an effect on retailer behaviour, but the impact on smoking behaviour is likely to be small

Cochrane Review

There is some support for the effectiveness of community-wide interventions in helping to prevent the uptake of smoking in young people based again on social learning theory/the social influences approach

Cochrane Review

There is some evidence that the mass media can be effective in preventing the uptake of smoking in young people in conjunction with other interventions

Cochrane Review

There is review-level evidence that increasing the price of cigarettes reduces tobacco use among both adolescents and young adults

Review of reviews

Alcohol

No firm conclusions about the effectiveness of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse for those aged under 25 in the short and medium term are possible

Cochrane Review

There is some evidence for effectiveness of peer-led prevention programmes and interactive programmes that foster the development of interpersonal skills. This also applies to smoking

Review of reviews

Minimum legal drinking age laws prevent alcohol-related crashes, supported by lower blood alcohol concentration laws

Review of reviews

Drugs

Very little is known about treatment outcomes for young people

Overview

Family therapy appears to be superior to other treatment modalities in reducing substance misuse

Overview

Lack of review-level evidence

Effectiveness of community programmes

Interventions that focus on youth

Initiatives to prevent progression to harder drugs and minimise harm from problematic drug use

SEXUAL HEALTH

There is good evidence to support school-based sex education; education linked to contraceptive services alongside the community-based delivery of education, development and contraceptive services; youth development programmes; and family outreach (but this is not supported by RCTs)

Review of reviews

STI campaigns increase condom use and can delay initiation and reduce the frequency of sex, potentially reducing unintended pregnancy as well

Overview

Programmes that offer educational support or improve job prospects may motivate young people to avoid pregnancy

Cochrane Review

Parenting programmes and antenatal care programmes may be effective in improving outcomes for both teenage mothers and their infants

Cochrane Review

Lack of review-level evidence

Early fatherhood

Upstream interventions versus poverty and disadvantage

Interventions relating to the UK

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