April 5, 2020
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Hallman Lecture – Alfgeir Kristjansson

to extend a special and warm welcome to
our Hallman Lecturer Professor Alfgeir Kristjansson and Kelly will introduce Dr. Kristjansson
more explicitly in a few minutes. It’s so fitting to have Dr. Kristjansson
with us as here in the Faculty of Applied Health Sciences or AHS we’re
concerned with understanding and finding solutions to complex problems related to
health and well-being of individuals and communities and populations and those
that are faced every day. This year as we continue to celebrate our 50th
anniversary we’re really cognizant that we’re not only celebrating that 50 years
of achievement but looking forward to the next 50 years of teaching and
research and service contributions in the fields of health and well-being
emphasizing three main principles: partnerships; leveraging technology and
innovation to maximize the impact of our work; and building our international
reputation. So in that context, we’re especially pleased to welcome Dr.
Kristjansson to speak about this very important topic today. Our faculty
recently released the News to You magazine which gives you some insight
into our work that changes the lives of Canadians. And it’s under the theme of
leading a new conversation, and that extends our last year’s theme which was
relationships and health. The feature story in this year’s News to You looks back to the roots of the Faculty of Applied Health Sciences and traces the
story of the Faculty’s impact over the past 50 years, demonstrating our
pioneering research by early faculty members and the seeds that laid the foundation for much of the research that is happening today. If you’d like to receive a copy or more information about this, I see that Wanda
Deschamps, the Director of Advancement from Applied Health Sciences is right
there, if you put your hand up, there she is. She’d be happy to assist you pass on
this information or a copy of the News to You. One of the seeds of the
foundation of our work here was recognizing the significance of global
health, now one of the pillars of the School of Public Health and Health
Systems. So we look forward to Dr. Kristjansson’s perspective on pressing
global health problems, especially related to the subject
of adolescent substance use and abuse. The topic of substance use is top of
mind in Canada for a number of reasons, and very timely right now. Some of those
reasons include the federal government’s upcoming legalization of recreational
cannibal – cannabis, not cannibal use. That’s a whole other
issue. I don’t know if you’re prepared to speak to that today or not.
Cannabis use effective July maybe July 1st 2018. And at a local level, the time
is also now for innovative thinking in the realm of health and well-being
because we’re like many other parts of the country also facing issues with the
rise in opioid abuse in the region and many other challenges in this same theme.
So it’s imperative, obviously, that the University, and AHS in particular, are
involved in addressing these areas that are characterized as wicked problems of
Public Health given that we do have a particular knowledge and expertise in
these areas, including along the lines of effective programs and how that could
look when applied to the region. However, of course, these aren’t matters just for
universities to address alone. It’s necessary and critical to engage the
broader community and so it’s really nice to have this format where the
community and members of the university can interact to discuss this, this
crucial topic. In keeping with being engaged, one of the tangible ways that
AHS demonstrates our commitment to promoting health and well-being is
through this lecture series which is called the Hallman Lecture Series. We
started the lecture series, as Alfgeir and I were talking about before the talk
today, by bringing in the Honorable Anne McClelland who was Deputy Prime Minister
of Canada and a former Health Minister and she delivered the inaugural Hallman
Lecture for the 50th anniversary year on the legalization and regulation of
cannabis. Today we’re happy to continue the conversation by presenting this Hallman
Lecture which was made possible through a legacy that was created by a
generous and visionary philanthropist who I’d just like to tell you a little
bit about at this time. So Lyle Hallman was a
developer and contractor and philanthropist in the KW area and he was
the recipient of many awards including the Order of Canada and an Honorary
Doctorate from the University of Waterloo making him an alum of
the Faculty of Applied Health Sciences. Generous donations that were made by
Lyle and his wife Wendy to the Faculty of Applied Health Sciences created a
number of endowments to expand and sustain health promotion activities
within the Faculty. These endowments have had a significant impact on health and
well-being of our community through research activities and the spread of
knowledge related to health promotion through many outlets including sessions
like we’re going to experience today. So I’d just like to take the opportunity to
thank the Hallman family for their generosity. Through their giving
we’ve been afforded the opportunity to look at some of the crucial issues
related to health and well-being and explore controversies and challenges and
opportunities inherent to public health and research policy. So many other alumni
in addition to Mr. Hallman contribute to the success of the Faculty
of Applied Health Sciences and the health and well-being of our broader
society, and AHS likes to recognize significant achievements of such
valuable contributions through two awards – our alumni achievement awards.
So we have an Alumni Achievement Award and a Young Alumni Award. It so
happens that the nomination window for those awards opens today and goes
through April 30th and again, if you have ideas of good candidates only criteria is
they have to be AHS alumni. Please bring those forward again through Wanda or
through communicating with any member of the Faculty of Health Sciences. On this
note I just like to thank our partners at the Waterloo Crime Prevention Council
for their collaborative efforts in upstream prevention and acknowledge
their ongoing leadership on drug related issues so thank you very much and thank
you for joining us today. And I’d also like to thank the lead organizer of the
event today from UW Kelly Anthony from the School of Public Health and Health
Systems and invite Kelly to come forward to introduce our speaker more explicitly.
(Kelly) Thanks Jim, thank you so much again Jim, not only for those words but for helping
to make this happen through allowing us to access Hallman funds. Thank you to the
Hallman family, thank you so much. And of course, our co-sponsoring departments are
Recreation and Leisure and Troy Glover is the chair of that department and
Craig Janes, who I’m not sure if he is here yet. It’s cool, there he is.
Hi Craig, School of Public Health and Health Systems. So this is also
co-sponsorship between those two departments as part of our Faculty and
with the Crime Prevention Council. I’m gonna say a few words and then get us
going with Alfgeir. Some of you know me, I am NOT a researcher. Oftentimes
people who bring Hallman speakers here are important serious researchers. I’m a
teaching professor as some of you know. This is the intersection, this is the
most exciting intersection of my avocation and my vocation of my career.
This is the, this is the manifestation of what I do in class with my students to
connect them with the community and try to encourage them to be change makers on the ground. And the research that, that Waterloo is famous for by many of my
colleagues who are kindly here today. I, a couple of years ago, saw this terrific
assertive little organization called the Crime Prevention Council and asked if I
could sit on their board. I cannot believe I begged to give the time that I
give them and I suppose I again have to thank Craig Janes and Jim Rush for
letting me give that time. And since then I have become increasingly more involved
with the Crime Prevention Council. This was the ideal discussion to have with
our community, and by our community I mean Waterloo, University of Waterloo, but
also the Waterloo Region. We are so enthusiastic to have Alfgeir here.
When we first started reading about the work done in Iceland some of us said,
“Is there a possibility this could happen in our region?” So we started making
comparisons. Well we’re not exactly a, we’re socialist leaning, yeah, and we’re
fairly well, we’re a fairly well-off region, and we started making size
comparisons because the Waterloo Region looks a little bit like Iceland in terms
of size, so we thought maybe we could pull this off. Now we have dreams
that we could, this could be the beginnings of conversations about what
is possible in our community to protect our kids even more than we do. So I won’t
say any more than that, other than that we are so delighted to have Alfgeir
Kristjansson here and I’m going to give you a little bit of a bio. I’m not as
polished as my Dean, but I do have this part written down thanks to Alfgeir.
Dr. Kristjansson is from Iceland. The adorable bio in his West Virginia
University says that Iceland is in Europe in one, is one of the Nordic
countries, which I thought was so cute. I crossed that out, I’m assuming you know
that. He’s been at West Virginia University since 2012. He, prior to going
to WVU, studied in Iceland and in UK at the University of Edinburgh and at
the Karolinska Institute in Sweden where he earned his doctorate in social
medicine. He completed postdoc training in
Colombia. I imagine you know where that is. And Dr. Kristjansson is the senior
data coordinator and analyst of the life course study which is a large registry
database cohort study in Iceland funded by the EU which is a birth cohort of
children followed from the age of 12 onwards and then some retrospective data
to allow them to look at multiple data banks pre-birth through age 12.
He’s also the co-PI on a primary prevention initiative in West Virginia.
And I won’t tell you too much about West Virginia. But you probably have some idea,
that the move from Iceland to West Virginia was a big one. That’s entitled,
“The Integrated Community Engagement Collaborative” (ICE acronym) to promote
adolescent health and positive development in West Virginia – no mean
feat. Dr. Kristjansson also serves as the PI and CI on a number of federally
funded evaluation projects in West Virginia. Finally, Dr. Kristjansson is the
senior data coordinator for the youth in Europe study, a large, a large
cross-sectional health and behavior survey of 15 to 16 year old youth across
15 cities in Europe. And he’s actively involved in child and youth research
with scholars from his home country, and the UK, Sweden, and the US. Without further ado, Alfgeir Kristjansson. (Alfgeir Kristjansson) Hello, you can hear me? Yeah? Good
afternoon, thank you all for coming. Thank you for having me. Thanks to Kelly and
Jim and everybody, it’s been a terrific experience so far. I want to tell you
right away that I’m not a native English speaker so you know I may stumble on a
few words or have to sort of think before I remember. I still sometimes have
to translate before it comes down to my mouth especially in a setting like this.
And you know for a foreigner this is a little bit of a kind of an intimidating
kind of setup you know, there’s this big wall of people you know, and I’m just
standing here. But usually, you know, I can, I can make myself understandable. So what
I’d like to do is to tell you as much as I can about what we’ve done in Iceland
to change a culture really. We were, we were drowning in alcohol really,
and along with that we were way too liberal on drugs. We were indifferent
really, about what our kids were doing. And although we all believed that
Iceland was, and it certainly is comparatively, a very safe country with
low crime rates and homogeneous population we were basically caught with
our pants down in the mid 90s and I want to tell you, so the story of how we were
able to change those trends by focusing on a holistic cultural shift. So before
we go there I want to show you a couple things. So this is the local hike, this is
Reykjavik City and this is Mountain Air Show – it’s a sort of a nice kind of local
hike. So if you ever go to Reykjavik there are flights from, direct flights
from Toronto. They’re pretty affordable too. I don’t get any percentages or
anything, but it’s some nice thing to do. It’s about 800 meters, it’s pretty
steep, so it’s, it’s kind of a good kind of hour,
hour-and-a-half walk and I would, I would recommend it. I try to do it every
time I go home which is actually pretty frequently. This is me and my little guy
Amir. I have three boys. He is the smallest or youngest of the three. He’s
born in in the US and is gonna run for President one day so we will have
President Alfgeirson because in, in iceland we go by first name and then our
children go by the father’s first name followed with a son if it’s a boy and a
daughter if it’s a girl. So my boys are Alfgeirson which means that they’re
my boys, and he’s gonna be President Alfgeirson. So now you know a little bit
about me a little bit about Iceland. Iceland is one of the Nordic countries
which is Norway, Sweden, Finland, Denmark, Iceland, and then we count typically all
the islands which is part of Sweden and the Faroe Islands which is a part of
Denmark and Greenland is sometimes counted to be part of the Nordic countries,
even though it really isn’t. It’s about not as cold as Greenland. People in the
US always tell me isn’t Iceland green and Greenland ice? Isn’t that how it is?
Somehow for some reason people have learned that and yes that’s more or less
true East Greenland is an ice shell and Iceland has glacier but it’s mostly not
ice shell. Population about 300 thousand which is obviously not a lot.
Reykjavik Capital area is here and on this corner we have about 65 to 70
percent of the population. So all these areas around the shore are small towns
and villages. Language Icelandic. We have one of the smallest serving currencies
in the world which means that we are really fragile for inflation and
high interest rates and so on, and you know we can talk about that at another
time. And then most people in Iceland believe in elves so if you, I’m not
saying that they worship elves, but they do believe elves exist, and there are
good reasons for that. So if you ever go there you’ll sort of
see that in the landscape. Probably the original reason why I’m here is because
of this article that appeared in the British newspaper The Independent in
January of 2017. It was written by a reporter called
Emma Young and it was subsequently distributed in most like science, The
Huffington Post, The Atlantic, in several places. And it’s been drowning us
basically with requests since this came out. And I really don’t know why this
happened now because we’ve been doing this work for 20 years. But
subsequently the BBC made a short video of what was happening in Iceland that
you can find on YouTube if you’re interested. It’s about seven minutes, and it’s pretty well done. And they chased some, some people around and tried to figure out,
put it into like a footage format. This is a sort of a news type, news story
briefing of what was what was done over there. So let me take you back to try to
understand the context. How were things really, when they were really, really bad.
So this picture is taken in downtown Reykjavik in the mid 90’s around 4:00
a.m. on a Friday or a Saturday night. I know it’s pretty bright, but you know in
the mid-summer in Iceland it really doesn’t get dark at all. In December, it’s
dark all the time. So we have these sort of extreme shifts. And this
basically shows the atmosphere in midtown Reykjavik at 4:00 a.m. on a
weekend. Pretty typical, packed with people, everybody drinking, a lot of young
people, and a lot of underage drinking. And this was, people knew about this, you
know, they were fully aware of the situation. It was sort of accepted, you
know, that’s just how things are. But when our comparative statistics started
showing where we were compared to other countries, people really got alarmed. And
in the beginning we came to realize that even on a European
scale our shape was pretty bad. This is from the European SBOT study. You guys
know the monitoring the future study? This is the longest-serving drug serve,
drug, adolescent drug use survey in, I think the world. It has been going on since
1975. The SBOT study is basically a pan-European survey of a very similar
kind. It tracks adolescent drug, alcohol and tobacco use, today in about 40 countries.
They started off in ’95 with 20 countries. This survey showed us in a pretty bad
light. We’re number 5 there of 20 countries and these are rates of a
proportion of girls and boys that have been drunk 10 times or more often in the
last 12 months. At the same time our comparative statistics on drunkenness
for the first time at the age of 13 or younger were also very high. So
basically our, I mean I got a 12 year old boy, and the fact that he’s one year from
becoming drunk compared to, you know, what these numbers show is just absolutely
mind-blowing. And so that was another typical indicator. Overall in the SBOT
studies we were near the top or at the top in many different categories. So let
me begin with telling you three things that I want you to know before I get any
further. Oftentimes when we talk about what happens in, what was happening, and
has been done in Iceland, people tend to wait for the one golden standard. What
was the one really, you know, sort of major shifting thing you did. If you are
waiting for that answer, I’m not gonna be able to give it to you, because it wasn’t
just one golden thing. It’s changing a culture, it takes time and need, and
requires a lot of moving parts. So the Icelandic model is not a program. It’s a
community building system for the long haul. The individual elements of what we do and what we have done are not new. Most
of this is in some way available in countries with advanced infrastructure
and as far as I know they’re all available here as well. We probably just
put them together slightly differently. And collabor, if there is one thing which
is critical, then it is collaboration. And at the same time that collaboration is
key, it is also the realization that in the absence of collaboration not much is
going to happen. In other words, if we do community building, I as a researcher am
always going to be an external to people in communities. In other words, I can’t
walk into a community and just tell people what to do. That’s not how it
works. Nobody wants to be told what to do in the first place, and I don’t have
access to people in that way. So collaboration is key. In a nutshell, what
we are trying to do, and have been able to do in many ways, is to integrate the
process of research, policy and practice. We have lots of students here. We are led
to believe that research informs policy that then will lead into practice. That’s
sort of how we like to believe this thing works. Scholars like me do research,
we write our research papers, and we have this one paragraph in the discussion
section where we say that this groundbreaking study and these fantastic
findings will inform new intervention programs, bla, bla, bla, bla, bla.
This happens almost never, almost never. And this process is not linear and clear
as this suggests; it almost never is. If you have ever worked with people at the
municipal, area, district, province, or policy level, generally they do not have
the means or the time to really consult with the peer-reviewed literature.
It’s just not how things tend to work. Obviously, we would like for that to be
the case, but it requires much more than just to conduct a review of the
literature. There’s a whole translation piece that is really, really complicated,
and we as researchers, we tend to study smaller, smaller, and tinier, and more
significant niches in order to advance it and pull it and, and move the needle a
little bit more in knowledge-making. So just to underline, this process is not
linear. So unfortunately, what tends to happen always, often, is that the
researcher is sort of looking ahead, she in this instance, publishes papers under
the university and research scholarship system that we operate, and most of them
just fly by the policymaker. And that’s just, that’s just a fact, you know, this is
just how it works very often. As a result the policymaker is trying to communicate
with the practitioners. They’re blindfolded because they really don’t
have good directions. We’d like to believe that everybody is doing their
best, that’s you know, I’m not going to talk down on people working in policy or
practice, I believe that those people are absolutely and we are all trying to do
our best. What I’m trying to underline is that these three sections are siloed, and
they’re very kind of separate, in especially when it comes to immediate
collaboration. What we would like to do is to get those major pillars to talk
with one another; get people in research not only to talk with people in policy, I
would like to see the researchers talk directly with practitioners, and I would
like to see the practitioners come back to the researcher, to talk about what we
have observed as practice-oriented knowledge. And there is such a thing;
there’s practice-oriented knowledge as separate from academic knowledge. If all
those entities can really work closely together we have a much better chance of
creating change in the lives of real people. And essentially, that’s been what we believe Iceland has been pretty
successful at. So let me move to the model. And I don’t have any time. I’m good;
all right, all right. I’ve got a lot of slides so I’m gonna, I’m gonna maybe
start talking faster. So essentially… oh, first this. In 2010 Tom
Frieden – who’s Tom Frieden? Head of the Centers for Disease Control, well former
head of the Centers for Disease Control/ He wrote this paper and published in the
American Journal of Public Health titled, “A framework for public health action: The
health impact pyramid.” And basically, what this paper concerns is to try to
demonstrate through this diagram how increasing individual effort is needed
to provide more individual level services or intervention services with
subsequent decrease in population impact. Do you follow me?
So really the approach that we are most commonly used to in prevention is to
turn our focus on this area to basically work on a one-to-one setting. This is
where our hospital system is, for example. We wait for people to get really sick, we
treat them individually, it costs an enormous amount of resources – money,
manpower, time, and so on, but we spend much less emphasis on the lower parts of
the triangle which really concern prevention of the primary end of things.
So he says personal life style is socially
conditioned. By the way, if you’re from sociology, we knew this in the seventies.
Individuals are unlikely to eat very differently from the rest of their
families and social circles. It makes little sense to expect individuals to
behave differently than their peers. It’s more appropriate to seek a general
change in behavioral norms and in the circumstances which facilitate their
adoption. And the Iceland system has been about this.
It’s been about changing the context so that individual default choices and
decisions are healthy. That’s really where it’s been about. In a figurative
manner this is really what we do in many ways, how it works. We view individuals
inside school communities as social products. So children are environmental
products. That’s our central theoretical viewpoint. They are products of four
major domains that are located within local school community. And we say local
school community not to point the finger at the schools, which is so commonly done, but to underline that schools are organized by geographical districts,
right? So children that go to a given school, they are also likely to live
around that school. They’re also likely to have parents that live in the area
around that school. So basically the school is like a central unit where
people in the area have children that go to the same school. So if it was a
different institution we could just, you know, substitute it for the other. So the
school is just there because it’s, it’s helpful as a moving unit. We then work
with well-defined risk and protective factors in these four major domains:
parents and family, leisure time, peer group, and school and the school
environment. Children spend about 90% of their time in their school community. But
obviously, and in Iceland the municipalities, which is the next circle
around, they both fund the schools and they fund
most of the recreation or extracurricular activities that are
available to children. So if we are going to get any kind of buy-in of the
community level we have to work with municipalities too. And in fact, just to, just speed things up a little bit, the municipalities are our
primary funders. They fund this program moving forward and they are in charge of
the school communities. The national government, which you know the country’s
government, is then around the entire thing. They fund a tiny little portion
of it, but we make sure to nurture that relationship carefully and make sure
that they are on par with everything that’s going on, particularly the Ministry of
Education. So back to the notion of children being social attributes, or
social products. In short, a child that is in very good standing in those four
major domains, is well supported by their family, well monitored, has good
friends, interesting things to do, participate in organized leisure time
activities, has good access to that, and is happy in school – doesn’t have to be an
A student, just happy in school, children with that profile are very unlikely to
initiate drug use. We all know that. Everybody knows that, almost. Okay, if we
all know that, what is it that we have to do? What we have tried to do is to drive
down risk factors and strengthen protective factors within those four
major domains. This primarily originated in literature from the US, so it’s not
specific to Iceland. In fact, if we look at risk and protective factors at the
basic level in these four major domains they’re very similar across different
places. We know these things pretty well and have known them for a long time.
There really isn’t much new under the sun with regards to risk factors at the
absolute basic level. So this is, in a nutshell, how it works. Just briefly on the background. The
initial measurement in Iceland began with something called the Educational
Research Institute. They conducted surveys that showed our terrible status
and as well as the SBOT studies. The project called Drug-free Iceland 2002,
which you know barked on a lot of controversy around the title of it – are
you gonna make the country free of drugs in five years, you know? Then again people
came back and said, well are we gonna say almost drug-free Iceland 2002? Is that
better? Obviously it’s not better. We’re gonna aim for, you know, we aim high. They
initiated a… this kind of system. And the original thinkers behind this were
people from sociology and criminology, they were not people from community
health, or people that really had much applied background, that they were micro
sociologists, mostly. And for them they used classical sociological theory,
Durkheimian theory, classic theories, criminology, Hershey’s control theory,
those kinds to really understand that there is a set of commitments that we
can work with in lives of adolescents that really should deter them from
delinquency, including drug use initiation. So prevention work was based
on sociology criminology theories and at this time collaborative efforts among
researchers, policymakers, and practitioners and administrative
leadership begins. The Center for Social Research and Analysis, where I have had
an appointment since 2004, took this over in ’98 and has been working with it until
the present. Our surveys are similar to the “Monitoring the Future” study, but we
include a number of measures also that are more specific to our environment, and
we leave a space for development and change on an annual basis as well. The
focus of our work is on primary prevention, just to make that
distinguishment right away. We do not engage much with drugs. We just focus on
strengthening protective factors, driving down risk factors, and as a result the
belief is that drug use is gonna change. I know that in many, in many areas, there’s this sort of distinction and lack of clarity
between what happens within the primary, secondary, and the tertiary end of
things. We are strong supporters of tertiary prevention. We’re strong
supporters of treatment bed availability, of treatments being offered and
available for free to those that absolutely need them, but that’s not our
area of work. In other words we believe that those should be separate. People
that work in community building should work in that area.
They shouldn’t concern too much what’s happening at the treatment level and I
think there are good reasons for that. Our main focus is on the adolescent
social environment. Substance use is perceived to be a social attribute. It’s
something that happens. Basically the environment produces risk factors. If the
risk factors are too high, the odds of substance use initiation is raised. It is
our job to build environments for children that drives down these risk
factors. In many places we like to point the finger at people and say, well you
just have to be more responsible, or you’re making poor choices. When I am 13
from a poor area with no resources and a broken family, it’s hard to point the
finger at me. We work with well-established protective factors
in the lives of adolescents within the sport domains, no time limit – that’s
another essence that I believe it has been very important to us, that we lay
emphasis on a long term goal or long term change. This is not a sponsored
project for 18 months, it’s not something that takes three years to do, and
unfortunately in our world of short-term grantism where we get grants
to do something, and then we are in a limbo of whether they can continue or
not, it’s something that we have intentionally shied away from. Because
cultural change takes time. We emphasize quick and consistent dissemination and
translation of annual results. Our surveys are annual to all people
involved, both as a diagnostic and monitoring tool, again for everybody –
policymakers, administrative leaders, and practitioners, including parents. So when
I was doing the walk back home at the sort of early time of my career in this
work, I met with parents probably hundreds of times in all communities
around the country and it taught me a lot,
you know. They will ask very different questions than you will ask. They were
right on the money and what’s happening this very minute. What are the latest
risk issues, what are the new modes of using, what are the new modes of
distribution? Many people would ask questions, are looking at sex as well? Is that involved there? Are you looking at sexual risk behavior? And so they will be very kind
of current. And our aim is to create a collaborative dialogue between
researchers, policymakers and practitioners. I want people in practice,
people on the ground, to contact me and ask what the data means. And I want to go
out there and I want to talk to them. And we want our people to be trained to do
this collaboratively. Consistent, annual, repetitive cycle. So how does it work?
Remember: research, policy, practice. The role and responsibilities of researchers.
We define risk and protective factors. We collect process and analyze data. We’re
trained to do that. We write national, municipal, and school community level
reports, and we disseminate them quickly and effectively to all involved. We then
present translated findings to policymakers, including elected officials,
and obviously we would direct our talk differently if you were a roomful of
elected officials. Municipal and school community level, school faculty,
prevention workers, and really everybody else, including parents. And we recommend and make recommendations for interventions
to all these people. That is the role and responsibility of researchers in this
triangle. The role and responsibilities of policymakers and administrative
leaders is primarily, and this is how it’s happened in Iceland, of course, is
to procure funding and make sure that we have protected time paid for, both at the
national and municipal levels, to pay for the research. We do long-term contracts
with them so that we can have access to the schools, we will collect the data
and do the dissemination piece. Local prevention personnel, as I told you
earlier, I can’t have access into local communities. I am NOT a local. I’m not a
local champion. I don’t have the local trust. I don’t have the know-how. People
don’t know me, they don’t know where I’m from, they don’t know what I’m about. If I
can work with people at the local level however, that are rooted in the
communities, they are obviously much better geared to that kind of work. So
the municipalities will fund local prevention personnel. They will fund
organised recreational and extracurricular activities, which we know
are very important for the leisure time piece in the prevention system. They will
also promote and try to make sure that children participate in these kinds of
activities on a very consistent, regular basis. They will often fund other types of
interventions that may be locally tailored and specific to their
environment, because this is not a universal top-down system. There isn’t
one intervention that’s gonna work everywhere. And of course, they fund
NGOs that have specific focus, such as, well two of them are called “home
and school” and “together group.” Its concerned mostly the parental to
school and community collaboration. The municipalities will also facilitate the
population access to the research piece. Everything
follows the data. Everybody follows what’s happening with the day on an
annual, consistent basis. And they will pass laws and set directions for
prevention and health promotion work. Practitioners, that we often call local
champions, they work locally. They are prevention specialists at municipal
district and school levels, they’re youth workers, the faculty and other school
personnel at the local school community level, and most certainly they are
parents. They will organize support parent law organizations and involvement
at the municipal and school community levels. Having a strong parental
community within each school, if there is a golden egg in this system, that is it.
If we can have access to parents through strong structures within the school
system, that is really, really a key relationship. Organized municipal level
school community meetings with professionals and parents. So commonly
when we go out there to meet with people at the local level, the best meetings are
if we can meet local professionals, local prevention workers, school faculty and
parents all in the same room, that’s when the light bulb comes on, very often. They
assist in setting strategies and goals for the years ahead, for the next year
ahead, and certainly enforce and support locally tailored interventions that may
be of various different kinds, facilitate a dialogue with the parent community,
really their job is in many ways focused largely on the parenting
community, and promote participation in organized recreational or extra-curricular activities. And we have certain interventions that focus on that
specifically. So I gonna speed it up. In other words, we can learn, all can
learn from another, you know. We are not working separately, we have to try to
integrate. So as a researcher my limit is also that if I’m going to have access to
community I have to have community partners to work with. One thing very important: for us to be
influential, we have to be able to write and disseminate results that are clear
and geared towards the level of implementation. So let’s say that you
guys are a roomful of parents in a given high school. This is a very active
parenting community. And I bring you findings with a random sample from the
province. How are you going to be, how are you going to believe that the findings
attribute to your children? In other words, to achieve the buy-in, the analysis
and dissemination need to fit the level of implementation. So we laid great
emphasis on creating city level reports for city people, community level reports
for community people, and even school community reports for those. A few key intervention activities before I run through a few results. So
consistent annual report dissemination, translation of results to all involved.
This is the public health education piece of it. This is annual, repetitive,
basically spewing of information all the time to all these areas. Efficient
parental groups in school communities increase parental monitoring and co-communication at the school level. And a few things that we’ve done for that are
for example parental walks – this is sort of like a gathering of parents in
communities to get to know one another. And there is an NGO that enforces or
facilitates something called the parenting contracts, which are basically
sort of an agreement that parents in a given school come together, that we are
gonna follow certain rules together. Because all parents, if you ask them, all
parents are tired of being the one with the finger; the one, “No you can’t do this,
no you can’t do that, no you can’t be outside late, no you can’t go to this
party.” Every parent agrees, no no I’m sick and
tired of being in this position. The leisure time card has been something
that has been effective, and is particularly in Reykjavik, which is like a prepaid
check or a voucher basically for kids to participate in organized leisure time
activities. And those are very, very important as a
preventive tool as well, to participate in sports or music or drama or something
else. Absolutely no smoking and alcohol use policy before, during, and after
school related events. This should be a common sense but, absolutely wasn’t in
Iceland then before. And we have a curfew actually on outside hours. And you know
you know the literature on late outside hours is pretty clear. Kids that hang out
late at night outside doing nothing are probably up to nothing very productive.
So a friend of mine I will show this table because a friend of mine at West
Virginia who is actually a US-based scholar and an interventionist, he got
really involved in this, and was very interested in this, and he created this
table to sort of demonstrate a difference between this approach and
many other approaches. And I always show with just a demo so this is sort of the
third eye of somebody that really knows the intervention stuff well. Our
system is long-term instead of short-term, it’s collaborative instead of
prescriptive, we focus on holistic change and a lot of different outcomes, not on
an isolated outcome, which is you know it’s often the preference of funders for
example. We view community as an absolutely central point of intervention.
It’s service intense, we want to provide service, it’s service-oriented research,
and it’s not career and research intense in that sense. We definitely use the data
for our own scientific needs as well, but that’s the secondary aim of the work. And
our idea is to sustain long-term benefits to community partners instead
of just leaving them behind after we have collected data, which is
unfortunately way too common. So Iceland has witnessed an absolute
paradigm shift in rates of standard rates of drug and alcohol use over time.
In 1998 42% of our kids in tenth grade had been drunk in the last 20, in the
last 30 days; that rate is now 5%. 23% were daily cigarette smokers; that rate
is now 3%. And 17% had used cannabis substances; that rate is now 7%. So clearly something absolutely massive has changed. If you looked at our position in the latest SBOT study which is, was conducted in 2015, we are at the
absolute bottom. Thirty five percent have used lifetime use of alcohol, the average
is 80 percent; nine percent, the only country with a single digit number in a
thirty day use of alcohol, and drunkenness has been almost eradicated.
So clearly a lot of things have changed. Sometimes we’re asked, well isn’t these,
aren’t these secular trends? Isn’t this happening everywhere in the Nordic
countries? No, it’s not. There are some things that are definitely happening
there too, but nobody is as excessive in this change than we are. So we are, in terms of binge drinking at 8%, Norway at 19, Sweden at 22, Finland at 23, the Faroe
Islands at 28, and Denmark at 56. So you know, we are definitely far, far ahead of
most of them. This is an interesting figure that also demonstrates well our
aims. Our aim is to push the initiation as far up as we can, it’s to delay the
initiation or prevent them from beginning. There’s countless cost-benefit
analyses and all kinds of research on the fact that if you can delay the onset,
you really have done well. And each of these lines represents an age
distribution in a study we did in 2009 called the Nordic Youth Study, with all
the Nordic countries except Sweden. And it just shows a ratio of kids when they
initiate alcohol use. Every line represents one country, and then it sort
of peaks at a certain time, for example Greenland here peaks at the age of
thirteen and a half. There is one curve that peaks behind all the other ones, and
that is Iceland. Our peak is at the age of sixteen; we are a year, a year and a half
or even more behind the other ones. So clearly, something has changed more in our backyard than it has in these other countries. What about risk and protective
factors? Let’s show you a few results. Parents and children spend more time
together. In 1997, 23% percent of kids said that in ninth
and tenth grade that they almost often or almost always spend time with their
parents during the weekends. Actually, during weekdays, excuse me.
That’s 53% in 2016. The statement, “My parents know where I am in the evenings”: 52% in 2000, 80% in 2016. Rates of students in ninth and tenth grade that participate in sports with a
club or a team four times or more often per week: 23% in 2000, 40% in 2016. Rates of students that have been outside
three times or more often after 10:00 p.m. at night: 53% in 2000, 22% in 2016. Now as you know, this system is about
building community, it’s not so much about drug use. So what other
associated factors can we expect to change if drug use is changing in terms
of risk and protective factors? One of them is bullying. This is numbers of
participants, or a participant that have been a part of a group teasing an
individual, once or more often in the last twelve months: 35%
in ’99, 7.5% in 2016. And subsequent changes in other similar
measures. Same for measures on theft: 32% committed any kind of
theft of five thousand Icelandic króna or or less, it’s about forty Canadian
dollars, in 1997, 13.9% 2016.
What about other places? Is this possible to replicate somewhere? We’ve
been working with a number of communities and one of them is
Riga in Latvia, which is the capital of Latvia. They’ve done really well
over the last ten, twelve years of following this trend as much as possible,
and they’ve shown really, really positive results. I’m running out of time so I
just want to go through briefly evaluation. We did an evaluation study in
2009 which was published in Preventive Medicine – by the way all this is
published, and you know I’m happy to share it with whoever is interested –
where we looked at communities that have been a part of this project
from the start, and those that have never participated. As you know when you do
community work things get kind of messy, you know, sometimes communities
participate for a little bit, then they have changes, political leadership, and
they move out, then they come back in four years later, or they may take only
part in a part of the project. Those things are really kind of unlinear, non-linear.
So we did this study with communities that were a part of this
project for the entire time and those that never did really anything with it.
And to cut a long story short we were able to find intervention effect to the
most extent for smoking, toxication, parental monitoring, participation in
sports, and decrease in party lifestyles. So in some, substances decreased more in
intervention communities than in others and the prevalence of protective
factors did as well. We’ve also monitored our progress through the European SBOT studies carefully and we see that our change has been more excessive than in
other countries. We continue to publish. This is a trend analysis that we
published on risk and protective factors and our situation, and all of this is out
there if you’re, if you’re interested. So what are we doing differently? In short,
we’re not doing anything that many other places aren’t necessarily doing, but it’s
just kind of organizing them in a different way. We’re trying to speed up
the process of collaboration where that is an absolutely central part. We focus
exclusively on primary prevention because we really think that if you
build communities you will have less problems downstream, if you begin well at
that end. We focus there on environmental change and not on individual
responsibility. We don’t want to point the finger at children we want to say
these are people that are our responsibility to produce as community
citizens. I’ve been trying to do this in West Virginia for a few years now and we
are kind of stuck at their level of raising awareness. And the reason is that
we don’t have the community partners, we don’t have the community
links. We’ve done well with data collection, we’ve done well with creating
links with school superintendents offices, and data analysis
dissemination and so on and interestingly the variable relationships
with risk and protective factors are basically the same, you know. As we know,
those are universal more or less. Rural Appalachia, totally different environment,
still more or less the same. So the challenges over there, are that, you
know, there is really no primary prevention infrastructure. We just don’t
have the access to people in the same manner as we have in our home country.
Very weak and usually basically just inactive parental communities at the
school level. So we don’t have the links to the schools. The schools have more
than enough on their plates. They cannot be made responsible for this. The county
and the board and the municipalities have to step in in that direction.
Yes it’s rural, yes we’ve been told that there’s problems of outreach and
transportation and so on, but if you ask people, “Do you come to the football games?” Yes they come to the football games. So can they not come to the prevention
meetings then, too? So you know it’s a matter of also of this creating this kind
of knowledge and interest and obviously in Appalachia there is quite a
bit of kind of limited openness to interference of this kind. People often
say, “You’re not gonna tell me what to do with my children” you know. So it’s a
delicate, very kind of delicate thing, and and they’ll point at me and say, “He’s from
the socialist north, you know, he won’t understand this culture” or whatever. But
generally speaking, you know, the system, there’s no reason to believe that it
wouldn’t work elsewhere. So if you’re interested in publications please get in
touch with me. Thank you very much. Sorry to go over time. (clapping) (Kelly) Thank You Alfgeir, that was terrific.
We’ve got time. I should say, in case some people need to run out, 7 p.m. tonight is
a follow-up. Alfgeir will be talking to our community, the larger community of
the Waterloo Region 7 o’clock at Kitchener Public Library and that will
be live streamed as well as videotaped. This is also being videotaped.
We’ve got time for one or two questions before we go to a reception that did require registration, so I hope those who registered for the reception stay and
join us for a bit. A question for Alfgeir? Yeah? (goes to person asking question) (Alfgeir) Back on? All right, thank you good
question. Question was, how effective do you think this would be potentially in
terms of other behaviors? We see clear patterns of change for some behaviors,
but not for others. So for example I showed you both bullying and, you know,
theft as a measure of delinquency. We know those are are definitely sort of a
byproduct of a stronger community. But I wouldn’t count on it working on for for
everything, you know. People talk about, you know, is it gonna overlap with
obesity and so and so forth. I’m not sure about that, but definitely things that
are related we see that clearly. (audience question) Has there been any research around the sexual initiation, like having sex earlier or later, that kind of connection?
(Alfgeir) Yeah, very good and very common question. No. The reason is mostly that it’s still
too controversial, and especially with regards to the consistency of this, this
is a boat that we cannot rock too much. We leave a space for changes, and you
know obviously things change over 20 years. We now have cigarettes and
excessive caffeine use and all kinds of things that obviously change over time.
And sex is a question that comes up time and time again, I tell you, you know,
especially from parents. So we have designed some sub-studies where we
have done work with that, but it’s not sort of an integrated part of this work.
But, as we know that do prevention, there isn’t one group in alcohol use, and
another group in smoking, and the third group in sexual risk behavior, and the
fourth group in dropout prevention, and the fifth group in violence, it’s all one
and the same group. So you know I wouldn’t, I wouldn’t be too worried that
those things aren’t hold hands, but we haven’t done really any detailed
analysis of that. (audience question) I’d be really interested in hearing how you took the language of researchers and put it into language that policymakers
can understand, parents can understand, that made it real to them. I think that’s
our biggest challenge. For instance, we’ll say “improve mental health”; we don’t say
“improve mental health by…” and so I’d be interested to know how you did that
and, like did you pass it by people or…? (Alfgeir) Yeah, very good question. It’s a skill, there’s no question, you know, it’s a skill. When we report back into the
community we use bar charts and line graphs. We use no Greek symbols. When it
comes to scaling ,we basically provide, you know, means and standard deviations
and so on, but in terms of substance it means much more to people to have
individual questions. It means much more to people to hear what is the frequency
of children that have sleeping problems rather than what is the average of the
bla-bla-bla depression scale for depressive affect, do you follow me. So we
will we will tease out items that we know appeal to people that really are
resembled of the scaling and but, but I understand the question it’s a very good
one. It’s delicate, and it’s a skill, you know, so we keep it simple but they are
definitely the most important pieces and many of these measures are just count
measures. We’re just counting, you know, how often did you do this, or did you do
this at all, and so on. (audience question) Do you have any data about the utilization of the healthcare systems, like mental health systems over the years
of that project? (Alfgeir) I’m sorry can you repeat the…? (audience member) How much the health mental health systems were utilized? Was there any drop in the need for, let’s
say psychotherapy services or psychiatry services? (Alfgeir) Yeah, no we don’t, we don’t have data on the need for the systems, but in our analyses we have
shown that this doesn’t really impact mental health much. In all ways, our
mental health trends do not follow these trends very well. So my sort of, initial
thought on that is that there are other factors at stake, although these may be
important factors that I’m sure many of them are, there are also other factors at
stake. And obviously the problem here is that time goes by;
things aren’t stagnant when there’s time is passing so there may be other things
happening that we just don’t know about. So I would not be comfortable in stating
that yes, you know, it has impact on mental health because I don’t have that
evidence. (audience question) I believe you mentioned something about a parental contract? (Alfgeir) Right. (audience member) I was just wondering if you could explain about it a little bit? (Alfgeir) Sure, sure. So one of the
parts of the system is to fund NGOs that have a specific focus. And one of those
is funded by the municipalities and called “the home and the school” and it’s
about bridging the link and the collaboration between what happens in
schools and what happens in the home. Oftentimes we put parents and schools
sort of up against one another. We put schools out there and they’re
pointed at by parents and vice versa. “The home and the school” is an NGO that really works about bridging those links and one of the things that, one of the principal
things they do, is a parental contract, which basically they assigned
to the parenting community on the class level. They go into every class, and they
talk to parents about the importance of collaboration. And part of that is they
sign a contract agreement between them with, with set sort of common rules about
you know outside hours, homework and so on and so forth. And this is something
that is initiated by the parents. Obviously not everybody participates in
this and so on. But it’s, it’s a mutual kind of agreement
that supports parents in this sort of being the one with the finger, you know,
which really is challenging. And having parents on board, just generally,
in any aspect of this work, is really, really critical. (Troy Glover comes up to thank the speaker) Hi everybody. I’m Troy
Glover. I’m the chair of the Department of Recreation and Leisure Studies. I’ve been tasked with thanking Dr. Kristjansson for his talk today so thank you very
much for the thought-provoking and enlightening presentation on the
transformative and sustainable effects of the Icelandic model, or I guess
community building system as you described it, on youth substance use and
abuse. The impact of the model you presented demonstrates the importance of
the things we hold dear in the Faculty of Applied Health Sciences; things like
preventative health, social determinants of health, evidence informed policy and
programming, research impact, health promotion, prevention, and purposeful
leisure. In a faculty that prides itself on leading new conversations about
health, and a university known for advancing innovation, your remarks sit
well with this audience. No doubt they will inspire meaningful discussions
about what we can do locally to better support youth in our community. On a
personal note your remarks underscore for me the the amazing opportunities for
greater collaboration between my unit, Recreation and Leisure Studies, and the
School of Public Health and Health Systems and other academic and community organizations. As you’ve shown our interests can combine to address complex
social and health problems and engage in culture change. So on behalf of the
Faculty of Applied Health Sciences please accept my sincerest thanks. Thank
you. (Kelly) Thanks Troy, and thanks again Alfgeir, this was terrific beyond what a lot of us imagined was even possible and we had
high hopes. Reminder the Crime Prevention Council event tonight at 7 p.m. at
Kitchener Public Library and I should tell you Alfgeir has one more gig
tomorrow morning. We’ve, for those of you who care about
extra attention to that translation into action, tomorrow morning we have arranged for Alfgeir to sit with our key stakeholders in our community –
mayors, city councilors, etc., and Alfgeir’s going to make the case that something
like this is possible in our region. So stay tuned, and thanks again Alfgeir,
it’s terrific.

David Frank