How Iceland uses research to see problems ahead

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Youth in Iceland, the ongoing longitudinal research project surveying secondary school students, is credited with reducing cigarette smoking, drinking and cannabis use among the country’s young people since 1997.

Though some of its content has developed over the years, the priorities have remained broadly the same: to advance and distribute knowledge on the social factors determining the health, wellbeing and behaviour of young people; to enhance the quality of life of young people; and to create a venue for collaboration of scholars, specifically for the education and training of young scholars.

As well as functioning as continuous monitoring tools to help local communities direct their work on young people’s positive development, the surveys are also shining a light on the new risk and protective factors that have emerged over time. 

The latest survey, for instance, found that the use of e-cigarettes in Iceland has been rising steeply, although there has not been a reversal in tobacco use, which remains low. The 2017 data showed ‘current’ use (within the past 30 days) of e-cigarettes to be at 15% – and use of combustible cigarettes at 4% – among 10th graders ( 15- to 16-year-olds).

The data has shown that adolescents who initiate e-cigarette use are more likely to initiate the use of alcohol and other types of drugs than those who do not smoke.

Álfgeir Kristjánsson, assistant professor at West Virginia University’s School of Public Health, and a collaborator on the Icelandic prevention approach and Youth in Iceland study series, says this has implications for primary prevention. “There is something that is appealing about smoking e-cigarettes. Kids are seeing it as ‘fake smoking’ but it looks the same as real smoking; it has the same behaviours attached. The same drag of air into the lungs – it looks daring and risky. 

“That is really the issue we need to tackle from a primary prevention point of view. Studies from other countries have shown that use of e-cigarettes leads to combustible tobacco, so – although e-cigarettes are less harmful than tobacco – they lead into it.”

The study also found that levels of anxiety are on the rise among teenagers, particularly girls. Although there are indications that this trend is fuelled by screen use and social media, Kristjánsson says: “I cannot confirm it, but our primary hypothesis is that the social system of peer groups has shifted quite a bit – social media is in their face all the time.” The researchers are working towards a longitudinal analysis of the relationship between screen use and anxiety.

The primary prevention approach of Youth in Iceland – an upstream idea of preventing problems from being initiated or developing into an addiction – differs from a ‘therapy approach’ of waiting for problems to become severe enough for clinical interventions. 

To this end, achieving the programme’s aim of long-term change means the model is reliant on collaboration between its various entities.

“The collaboration has to be between the boots on the ground – the researchers, the municipalities and the policy-makers,” says Kristjánsson. “We’re looking at a paradigm shift in the population and that’s something you can’t rely on a band-aid method for – they have been shown, time and again, not to work for preventative methods.”

Once data is produced, it is shared with the various stakeholders – the “layers of the cake”. Municipality leaders receive a report for their area to help them diagnose and track their position against other areas and nationally. It can also be used as a tool for determining how resources are deployed. Additionally, a copy is sent to each member of parliament. The most important layer, however, is that of local communities, says Kristjánsson. 

One of the researchers’ biggest challenges is making sure data matches the local communities and that they can see how they compare. “It is very common to get generalised reports/samples – this is not helpful at a local level,” he says.

The model offers a set of recommended interventions, but it is up to communities to decide what they do with the data – a process that is most effective when there is strong collaboration involving parent organisations at a grassroots level. The idea of researchers coming into a town and telling local communities what to do based on the results, for instance, is ineffective, says Kristjánsson.

The survey’s planning processes are centred on the researchers’ goals of high-quality data and high response rates. Though technology has evolved since the studies began, they have found that the best approach is still good old-fashioned pencil and paper. 

“While computerised surveys may often be easier to come by for the research team [no shipment of paper, data processing directly into computerised format, and so on], the schools that assist us in collecting the data are best geared towards the organisation and distribution of paper and pencil surveys,” says Kristjánsson. 

This is because almost none of the schools have computer laboratories that are large enough to accommodate all the students taking the survey at the same time, so coordination of students becomes difficult for the schools. The use of computer-based surveys also increases the risk of sample biases and means the researchers are, in effect, outsourcing data quality to the schools. 

Key to the continued success of the model is the trust between local communities and the researchers, says Kristjánsson. “Often, people who have ties to the battleground feed us information about trends that might not have shown up for two years in the survey. This bottom-up collaboration has created dialogue and trust, but also an understanding that these entities don’t work on their own.” 

This article was first published in Issue 21 of Impact.