The following principles are recommendations for effective programming to prevent and reduce substance use harm among youth. The principles represent a consensus by the project team and steering committee on the basis of evidence from the scientific literature. In our opinion, the more fully they are reflected in a program, the more likely the program will be effective.
Sponsors thinking of adopting a "packaged" program may benefit from using the principles to gauge the program's potential effectiveness, rather than blindly adopting the program. Those developing a program to address local circumstances should use the principles to guide their work. Finally, the principles may be useful in reviewing and strengthening an existing locally devised program. The principles and their categories are:
Focus on the factors that most directly promote resiliency or, conversely, contribute to substance use problems in the population of interest.
Tie activities to complementary efforts by others in the community for a holistic approach, and seek support through agency policy and municipal and other government regulation.
Make certain there is sufficient contact time with participants; age appropriate coverage needs to occur through childhood and adolescence and needs to be intensified as the risk of participants increases.
Base program aims on reliable and, ideally, local information on the nature and extent of youth substance use, problems associated with use and user characteristics.
Set goals, objectives and activities that address local circumstances, are linked logically and are measurable and time-limited.
Evaluate the process and impact of efforts and ensure that costs are in line with program benefits.
From the outset, work toward long-term sustainability and integration of the program into the core activities of the relevant organization in the community.
See substance use issues within the context of the stages of adolescent development in order to respond most effectively.
In order to be credible with participants, programs need to take account of the way young people view the benefits and the risks associated with substance use.
Young people need to see themselves, and to be seen by others, as their own best resource for minimizing any harm associated with substance use.
Both the explicit and implied messages delivered in a program need to be viewed as realistic and credible by participants.
Skill development needs to be a central element in programs and it needs to be accompanied by accurate, objective information.
Engage and involve participants in skill development activities and discussions.
Select and train leaders or teachers who demonstrate competence, empathy and an ability to promote the involvement and interaction of young people.
Focus on the factors that most directly promote health or, conversely, contribute to substance use problems in the population of interest.
In the past, we've acted on the assumption that young people used substances because they didn't know any better. While lack of good information can be an issue, the reason why young people use substances is more complicated. In addition to using for some of the same reasons that adults use (e.g., to relieve stress and to escape emotional pain), young people may try using substances for a variety of other reasons, including, to show independence, signal entry into a peer group and to satisfy curiosity.
The reason why some youth experience problems in relation to their use of substances is also more complicated. Substance use problems usually arise from a combination of individual-, family-, school- and community-related factors. The terms "protective" and "risk factors" are often used to identify aspects of a person and his or her environment that make the development of a given problem less (i.e., protective factor) or more likely (i.e., risk factor). Risk factors, protective factors and resiliency are interrelated concepts that are important considerations in understanding the target population and in designing a program.
A body of international research indicates that the general health status of a society is heavily influenced by the social, economic and physical circumstances of its people (i.e., employment, income, and educational levels, working conditions, social status, the degree of social support experienced, and early childhood nourishment and care).1 From a population health perspective, these factors can be viewed as overarching factors or determinants of health that can be influenced by economic and social policy and may affect the use of substances.
Substance use-specific research shows that societal and community-level factors include the prevailing social norms and attitudes toward substance use, the prevalence of crime in a neighbourhood, the price and availability of various substances, and economic conditions. Factors arising from the family environment include a history of substance use problems, the effectiveness of family management, structure and coping strategies, the level of parent-child attachment, the nature of rules and parental expectations, and the strength of the extended family network.
At the level of the individual, persons may be predisposed to substance use problems due to genetic and/or environmental factors, but neither set of factors will, in and of themselves, determine the outcome. It is very important that a child experience stable support and care from a parent or other adult from an early age. The quality of a child's school experience is a very significant factor for substance use problems and a number of other problems. Influences on the school experience include academic success, reading skills, problem-solving abilities, feeling a part of the school scene (as opposed to feeling alienated) and participation in extracurricular activities.
As a child enters adolescence, the selection of peers and nature of peer support become more important. Anti-social behaviour, such as violence and gang membership, is a risk factor, as is having friends who use substances. Transitions or significant changes in one's environment (e.g., moving to a new neighbourhood or school, bereavement, parental separation) can be a significant point of vulnerability for young people.2 General personal and social competence is critically important. It is reflected in the feeling of control over one's life, feeling optimistic about the future, being able to detach from conflict in the home or neighbourhood, and being willing to seek support from outside the immediate family (e.g., from an outreach worker or drop-in centre). 3
The more risks that a child or youth experiences, the more likely that substance use and related problems may occur. These risks are dynamic and interplay with the strengths and assets available to a person. Resiliency is a concept that helps in understanding this interplay. It has been observed that some people growing up in difficult circumstances fare better than others, and it has been suggested that they are more resilient.4
Resiliency is the ability to cope with adversity or a situation that is not readily amenable to change (e.g., living with an alcohol-dependent parent). The crucial feature of resiliency is the ability to cope, which, in part, is innate, but can be enabled or strengthened through appropriate social support. This capability changes over time, is enhanced by protective factors in the individual and the environment, and contributes to the maintenance and enhancement of health. When risks are greater than the individual's protective factors, then even individuals who have been resilient in the past may experience problems. The balance is not determined solely on the basis of the number of protective and risk factors present in the life of an individual, but on their respective frequency, duration and intensity, as well as the developmental stage at which they occur.
These same attributes have been extended to describe resilient families and communities. For example, resilient communities have been shown to adapt and come together in a mutually supportive way in the face of an adversity such as the collapse of the local economy. 5 Promoting resiliency and strengthening protective factors in people is seen by many as preferable to focusing on their deficits and problems. 6 ,7 However, focusing on promoting resiliency in children so that they can cope with various adversities may cause people to neglect the important work of reforming unhealthy environments.
Out-of-the mainstream youth is a term used to refer to those who are either homeless or have only a tenuous home connection, and often adopt a high-risk lifestyle that includes heavy drug use and other health risk behaviours. One Canadian study found that 60% of female and 47% of male out-of-the-mainstream youth left home to escape a family situation characterized by conflict, abuse or parental alcohol or other drug problems.8 Many school dropouts experience alienation in the school system even though they may have satisfactory academic records.9 The tendency of schools to expel students involved in drug-related incidents can contribute to social exclusion and increase the risk of more severe drug problems. Often, participation in illegal activities is driven by the need to meet basic needs and support a drug habit. 10,11
A clear advantage of the protective/risk factor approach is the understanding that many social and health problems are linked by the same root factors - an understanding that can lead to better integration of strategies and economizing of resources. However, because a factor is linked to substance use problems does not necessarily mean that it causes such problems. Consequently, the actual preventive effect of addressing one or another of the protective or risk factors is not very clear and no doubt varies between the factors.12 Nevertheless, it appears that addressing protective or risk factors in several domains of a young person's life (i.e., individual, school, family and community) can lead to positive outcomes.
Tie activities to complementary efforts by others in the community, and seek support through agency policy and municipal and other government regulation.
Research indicates that comprehensive programs (i.e., those involving multiple components and domains) are much more likely to be effective than single-focused activities. Because of the range of factors that can contribute to substance use problems, it is important that communities or programs identify and address relevant factors through a number of activities that are well coordinated. Families and schools are critically important domains in youth substance use problem prevention. It is better still when others complement their efforts at the community level, including the media, youth agencies, sports and arts groups, communities of faith and municipal governments.
Community coalitions or other planning bodies need to consider a range of complementary policies and services targeting youth. The coordination of different interventions can be accomplished in a number of settings or within a single organization or agency. For example, schools can combine classroom instruction, peer helper programs, parent education, school policies and mentoring for at-risk students. Municipalities can coordinate recreation programs, community policing and neighbourhood support programs. Joint planning in community coalitions will avoid duplication of services and increase the resources that can be brought to an initiative.
Comprehensiveness also means giving attention to organizational policies (e.g., school board or youth agency) to ensure they reinforce program aims.13,14 A recent review did not find evidence of added effect from policies intended to influence the environment (many of the studies reviewed did not attempt to single out any positive effect of the various elements, such as media, and parent training).15 However, the current consensus among experts is that policies need to reinforce programming. At the broader level, legal and regulatory measures (e.g., price increases, server training programs that give attention to underage drinkers, enforcement of minimum purchase age laws) need to be considered as they have demonstrated effectiveness in reducing youthful alcohol-related harm.16
Comprehensiveness challenges programmers to see their prevention initiatives as contributing to a series of interventions that present developmentally appropriate messages throughout childhood and adolescence. For example, school prevention efforts need to be ongoing from kindergarten to secondary school, allowing messages to be repeated and reinforced.
Comprehensiveness in a community also means ensuring that the various parts of the youth population - from lower risk to higher risk - are being served (see the next section on target populations).
Programs for higher risk youth may be situated in multi-service centres or other settings, such as emergency wards in hospitals, health clinics (e.g., for expectant adolescent women), and in shopping malls and on the street. Police and the courts have an opportunity to intervene and divert young people to prevention or treatment programs in the community. A comprehensive approach to programming for higher risk youth may call for the attention and collaboration of some who haven't traditionally played a role in preventing substance use problems, such as urban planners, housing authorities, shopping mall management and employment policy makers. 17
Street youth indicate that they have important basic needs. Food and stable housing are basic requirements for getting off the street; job training, educational upgrading and personal counselling are also important. 18,19 The needs of youth involved with injection drug use may be greater still. 20 Young injection drug users are often involved in multiple drug use, with their daily activities revolving around the acquisition and use of drugs. Involvement in illegal activities is often a means of meeting the financial demands of their drug use, often to the detriment of basic subsistence needs. These realities necessitate a comprehensive prevention and harm reduction approach that gives attention to the environment in which unsafe behaviour occurs, and to the provision of basic needs.
At a broader level, the protective and risk factors associated with substance use problems may also be factors linked to other problem behaviours. For example, in some communities, poverty, particularly if associated with a dysfunctional lifestyle, has been shown to be a risk factor not only for substance use problems, but also for pregnancy and violence among young people. Similarly, difficulties in school are associated with a number of social problems among youth, including substance use problems.21,22 Prevention efforts that address broad risk factors are a means of supporting and integrating with other strategies that aim to improve the lives of people and communities.23 On this basis, a substance use problem prevention plan or strategy might be embedded within a larger crime prevention, safety or health promotion initiative.
Make certain there is sufficient contact time with participants; coverage needs to occur through childhood and adolescence and needs to be intensified as the risk of participants increases.
The general level of use, particularly problematic use, is an important consideration in determining the overall level of the preventive effort required in a community. In Ontario, the only Canadian jurisdiction with long-term trend data, the current levels of substance use and problematic use are close to the levels seen in the late 1970s, which were the highest in the past 20 years.24 Also, most evaluations show that as time passes, program effects erode and need to be replenished.25 Given this, preventive efforts need to provide coverage through childhood and adolescence or at least be coordinated with others to create this effect.
As well as an understanding of the nature and extent of youth substance use locally, it is important for prevention planners to account for local protective and risk factors to clarify their targets and to more precisely gauge program intensity and duration. As a rule, the higher the risk for a group or sector of the population, the greater the needed intensity in the preventive effort.26 In North America, target groups for preventive initiatives are increasingly being classified according to risk level (i.e., universal, selective and indicated targets), a framework that is seen as more discriminating than the terms primary and secondary prevention. Program focus, intensity and duration need to vary according to these target groups.
Preventive activities can target a broad or "universal" population (e.g., all students in Grades 5 and 6) with the aim of promoting the health of the population, or preventing or delaying the onset of substance use. Children and youth are often the focus of universal preventive efforts intended to address risk factors and practices relating to traffic crashes and other trauma, unwanted pregnancies, suicide, and other short or long-term health and social problems. Parents and families are another priority for universal prevention, largely due to their role in supporting the healthy development of children and the challenges many experience in balancing family and work commitments. Measures often associated with universal prevention include awareness campaigns, school drug education programs, multi-component community initiatives, and, in the case of alcohol and tobacco, various measures to control their availability and price.
Schools are a strong setting for universal programming for youth and should provide appropriate programming in all grades. Given that a significant number of children have initiated use by age 12, primary preventive efforts need to give particular attention to 9-and 10- year-olds before use begins. For Universal youth programs, a minimum level of intensity is usually one 45 to 60-minute contact a week for at least 10 weeks. 27 Programs that provide "booster" sessions in subsequent years to reinforce earlier lessons have been shown to be more effective.
While parents should be encouraged to become involved in broad preventive efforts, they, of course, have a crucial part to play in preventing substance use problems through their role as parents. Parental monitoring of children's behaviour and strong parent-child relationships are also positively correlated with decreased drug use among students.28 Parenting programs can support this role, by addressing such issues as: clarifying and explaining values to their children, modeling healthy behaviours, understanding children's needs and self-concept, communicating effectively with their children, developing problem-solving skills, providing appropriate reinforcement and consequences, use of behavioural contracts, and fostering a democratic environment in the family.29 Parents also need to acquire accurate information on the various substances of abuse and their effects, so they can discuss them knowledgeably with their children.
Parenting programs typically have difficulty attracting parents. It has been suggested that parent information, education and support need to be "normalized" by making them widely available through media, information lines, and work site and school programs.30 It has also been suggested that programs be entrenched in a neighbourhood and available over the course of a number of years rather than the more typical "one-off" sessions. Parents are more likely to be engaged in a parenting program if it is perceived as being established and having a good track record. Many parents may benefit from help on communications, coping and disciplinary skills in a brief one- or two-session program.31
These broad, lower-intensity efforts aimed at the population in general can serve to "till the soil" by creating greater awareness of the issue and acceptance of the need for more targeted programs.32 Similarly, they can lead some individuals to contemplate changing risk behaviours and to present themselves for more intensive programming.33
Some youth and their families experience particular challenges due to academic problems, family dysfunction, poverty, and family history of substance use problems (that may include genetic predisposition). It makes sense to "select" such persons or families for more intensive programming on the basis of these risk factors. Selective prevention aims to generally reduce the influence of these risks and to prevent or reduce substance use problems by building on strengths such as coping strategies (a personal resiliency attribute) and other life skills. Children in difficult environments clearly benefit from selective prevention interventions at the pre-school and early school years. Early childhood education programs that involve and support parents in nurturing their children, and that include home visits, have shown evidence of effectiveness in preventing substance use and other later problems.34 ,35 Adolescent males are currently more likely to use substances in risky ways than females. Prevention settings that have the opportunity to direct attention to males particularly need to be alert to those opportunities.
Family-based approaches appear to hold particular promise for higher-risk children and youth. These approaches are generally designed to improve family functioning and reduce various anti-social behaviours, including the risk of problematic youth substance use. As mentioned above, recruitment and retention are typically challenging with family-based programs. Such groups as Children's Aid Societies and Boys and Girls Clubs may provide contacts for parents of higher risk children. Facilitating development of bonds among parent participants has been suggested as a promising way to retain parents in these programs.36
Although selective programs tend to be more efficient than universal programs in effecting change among at-risk youth, there are important disadvantages that need to be considered; for example, the possibility of labelling and stigmatizing, difficulties with screening, and not enough attention on the community-wide social context as a focus of change.37
Some young people who are using substances regularly will not as yet have met the criteria for dependency, but are at high risk of doing so. These youth usually experience an array of other health and social problems and benefit from indicated prevention programming that is typically more intensive still. Indicated prevention often involves an outreach component to identify, engage and work with these youth to minimize the harm associated with their lifestyle.
A small percentage of students experience a number of significant problems, including those stemming from substance use. For these young people, counselling or more intensive treatment based on sound assessment is important. A range of other services (including intervention, case management and referral to address various issues) is often necessary for these students and needs to be available from schools or community agencies.
With higher risk families, family therapy has been shown to be an effective component of a comprehensive strategy. Family therapy helps family members develop interpersonal skills and improve communication, family dynamics, and interpersonal behaviour. It can be used to help family members improve their perceptions of one another, decrease negative behaviour, and create skills for healthy family interaction. Therapy can also help to enhance parenting skills and reduce inappropriate parental control over children.38
Out-of-the-mainstream youth that are using substances in risky ways need support in a number of areas of their lives, other than substance use. The focus of activity needs to be in minimizing harm in the context of the day-to-day challenges facing these young people. Street youth indicate that having a decent place to live is, by far, the most important factor in getting off the street. 39 Opportunities for leisure, recreation, community service or alternative schooling have been found to be helpful with some higher risk youth. Termed the "alternatives approach", these opportunities may be most appropriate for youth who cannot be accessed through schools, and those who do not have adequate adult supervision or access to a variety of activities. 40 Some of these young people may be characterized as sensation-seekers and may respond well to alternative programs that offer excitement and adventure.41 This experience may motivate some to participate in counselling or other forms of treatment based on sound assessment.
Caution must be exercised in working with high-risk youth, as bringing them together into new groups can in some cases increase substance use. It has been speculated that participants in these groups may tend to validate and legitimize the anti-social behaviour of other group members.42
Injection drug use poses several serious risks (i.e., overdose, HIV and hepatitis C infection) and warrants intensive preventive efforts. Young people may be particularly susceptible because of relative inexperience, faulty knowledge and pressure from older users of injection drugs. Conventional approaches for reaching youth and providing prevention programming may not be appropriate for this population. Rather, creative outreach approaches, involving peers, offer more success. Also, research suggests that increasing access to new, sterile injection equipment may eliminate one of the more significant contributors to injection drug use risk and needs to be a program priority.43,44 Safe injecting facilities may reduce overdose deaths while reducing transmission of blood-borne infections and minimizing public nuisance. While some centres outside Canada have implemented these types of measures, and others are investigating their potential for reducing risk of overdose and other health problems, they remain controversial and their cost effectiveness is at this time largely speculative.45 ,46
While indicated programs are clearly required to address more advanced substance use problems, they also tend to be the most costly to develop and implement (though efficient in reaching the appropriate target group). Challenges in recruitment and retention are not uncommon. Ideally, a combination of universal, selective and indicated programs will be available in a given community and will vary with the community.47
Base aims on reliable and, ideally, local information on the nature of youth substance use and problems associated with it.
Accurate information on the nature and extent of substance use and associated problems is a critically important basis for prevention program development (see Section 2). Data can help determine the point at which a significant portion of a population has begun to use occasionally, or regularly, and can indicate the substances of greatest concern. To be most effective, youth preventive programs need to match their goals, activities and messages to these specific circumstances. For instance, if a significant portion of a youth population is currently using alcohol frequently and heavily, a program based on reducing the harm associated with this risky use of alcohol makes most sense.
Large prevalence studies, conducted at regular intervals within a jurisdiction, are very useful in estimating the nature of substance use in that jurisdiction. Information of particular value to programmers is: age of first use of a significant portion of the population, age and gender differences, age of peak use for most youth, and problems reported. Prevention programmers also need to seek out more local indications of the nature and extent of substance use in their community (e.g., police and emergency room data). The Canadian Community Epidemiology Network on Drug Use (CCENDU) supports a number of Canadian communities in developing a profile of drug use in their communities. Each community in the network brings together local experts (e.g., public health, emergency ward, police, and treatment specialists) to contribute quantitative and qualitative information that is relevant to local needs and easily updated.48 Prevention and health promotion workers are also learning from First Nations peoples and using structured narratives or story telling to gather qualitative information on what is occurring within a community.49
Regular ongoing reviews of the nature and extent of substance use among the population of interest will help to evaluate program efforts and lead to adjustment of aims and activities accordingly.
Set goals, objectives and activities that address local circumstances, are linked logically, and are measurable and time-limited.
Clear and realistic goals that logically link program activities to the problems and factors found in a community are necessary to guide implementation. Clear and measurable goals will permit evaluation to determine whether the program achieved its objectives. Goals will vary with the community and the circumstances; however, important considerations for all programs are the points at which use and problematic use of different substances generally begin. Drawn from youth survey findings, this information allows preventive efforts to be more precise with both goals and messages.
Program efforts aiming to prevent or delay the age of initial use need to be timed to occur before any significant percentage of youth have tried the substance. Although circumstances may vary in particular communities, various Canadian studies (see Section 2) suggest the appropriate timing for efforts to prevent or delay the onset of use is currently as follows:
Intensive preventive efforts need to be focused during these years, prior to the transition to secondary school.
Program efforts aiming to minimize the harmful effects associated with heavy or risky substance use need to occur before significant numbers of youth use substances in this way, which currently in this country is generally as follows:
A "stages of change" model, originally developed as a strategy for guiding treatment processes, can also help to conceptualize prevention goals based on particular characteristics of the target population. 50, 51, 52 This model, as it applies to prevention, proposes that individuals pass through several stages in deciding to use a particular substance:
Pre-contemplation: not considering use
Contemplation: thinking about initiating use
Preparation: intending to use
Action: initiating use
Maintenance: continuing to use
Accordingly, for youth who are not yet using (i.e., either not considering use or thinking about use) the program aim would be primary prevention. Programs working with a population largely consisting of youth who have initiated use and continue to use, a secondary prevention or harm reduction aim makes most sense. Each of these aims logically lead to particular activities and messages (e.g., use of more intensive approaches with those using or preparing to use).
Goals can be refined and better evaluated by regularly polling youth participants on their "stage of change" for each substance of concern. For example, determining the percentage of youth no longer considering use (i.e., moving from contemplation to pre-contemplation) would be an appropriate focus for program goals and evaluation measures.
It is important to involve key groups, particularly youth participants, in the process of developing program goals.
Evaluate the process and outcome of efforts, and ensure that costs are in line with program benefits.
It is difficult to demonstrate effectiveness in prevention programming. Research shows that the effects of many current programs are quite small - when they show any effect at all. Programs demonstrating evidence as a result of rigorous, controlled research need to be replicated with different sub-populations (i.e., different ethno-cultural groups) in various settings. While the need for prevention program evaluation has been noted for years, many preventive efforts remain unevaluated. Scientific evaluation is a specialized task requiring knowledge of experimental design and statistics, expertise that most preventive programs lack. This expertise tends to be expensive and most preventive organizations cannot afford the associated costs. Moreover, fears that the evaluation will put a program in a poor light or that it will divert attention and resources from the intervention are common. These barriers can be overcome if governments and other funding bodies give evaluation greater priority by highlighting the benefits of evaluation in continuously improving a program, and, most importantly, by offering technical and financial support (which is generally agreed to amount to at least 10% of other costs) for evaluation.53
Even without technical assistance, programs can document and evaluate their efforts. Two general forms of evaluation are process and outcome evaluations. Questions to be answered by a process evaluation are "How many people are coming? Are we reaching our target audience?" A mid-program focus group or questionnaire could determine satisfaction with the program. In this way, changes can be made early to meet the needs of the group and reach the desired outcomes of the program. The aim of outcome evaluations is to answer the question, "Did the program achieve what was expected?"
Although it has rarely been undertaken to date, it is also important to give consideration to program costs in relation to outcomes. In considering costs, an important issue is deciding what costs to include. One investigation distinguished between low, medium and high cost definitions for school drug education: 54
In investigating program costs, it is also important to consider who is bearing the cost. One source distinguishes among those costs borne by the primary sponsor, the partner agencies, and the participants:55
Program research and evaluation costs need to be included in a full accounting.56 Readiness of the community or target population may be seen as a variable - if the group to whom a program is directed is not engaged and motivated, participant recruitment will consume more effort and materials than if this was not the case. Several months of promotion may be required to give the program visibility and to encourage participation by young people.
There are early signs that prevention programs for youth can show modest cost effectiveness. 57 Beyond that, it may be that the broad application of several prevention programs in a population may have a cumulative positive effect that is less apparent in the evaluation of any of the specific programs. 58
From the outset, work toward long-term sustainability, integrating the program into core activities of relevant organizations in the community.
Too often programs are developed without a commitment of continued funding or without sufficient thought given to long-term viability. As noted above, program duration is a key factor in achieving sustained effects over time. Before any preventive initiative is started, planners need to determine the long-term implications. A formal work plan, time table and budget that include defined responsibilities and long-term funding need to be developed at the outset. According to Rogers' theory of diffusion of innovation, sustainability issues should be addressed in the first stage (innovation development) before proceeding to the other stages of dissemination, adoption, implementation and maintenance.59
According to one model, sustainability requires continuous attention to four aspects of community work: the issue (putting a specific issue on the agenda for the public, the decision-makers, and the community partners); the program (that is being implemented in the community); behaviour changes (that may have resulted from the program); and the partnership (that was involved in and supports the program).60
An important first step toward program sustainability is the development of a program or service that the community wants or needs and the formation of partnerships to support it. Programs initiated by an individual agency or small group can be strengthened and supported by seeking additional partnerships at the outset. Partnerships can be built around specific issues of common concern, and may involve all levels of government, non-government agencies, volunteer groups and the corporate community as well. Steps to developing relevant partnerships can include: focusing on a specific community issue/concern, identifying partners who might be interested in working on the issue, identifying benefits for them to become involved, and developing a communications plan for the project and a strategy for involving new agencies and individuals.61
Other specific issues related to program sustainability that need to be addressed include availability of staffing, staff training, materials required, space needs, agency mandates, and time requirements.
These types of issues become barriers to adoption and to permanence if not adequately addressed in the early stages.62 For example, program developers and planners are more likely to achieve success by ensuring that a prevention program is integrated fully into a school or community organization (or both). This means that "core" staffing would be assigned to implement the program, material costs would be included in annual budgets, and equipment and space needs would be allocated on a long-term basis. Within the school setting, substance abuse preventive programs must fit within the formal curriculum and structure of the school.
Once school or community agency personnel are assigned to implement the program, adequate ongoing training of the required staff will ensure that the expertise lies within the organization (as opposed to an external sponsor of the program). Because of the need to train new staff, to give refresher training to existing staff, and to train for program modifications, training must be seen as ongoing. Beyond that, even the provision of the training itself needs to be integrated into existing structures and organizations (e.g., appropriate teacher training can be integrated into pre-service curricula in university Faculty of Education programs).
Sustainability of an "issue" such as substance abuse can also serve to support program sustainability. For example, if the issue remains on the agenda of the public and key decision-makers, there is a greater likelihood of attracting longer-term funding, and maintaining long-term commitment of community partners. Activities such as communication campaigns, advocacy and awareness-raising activities can help to sustain the "issue". 63 In the substance abuse field, it is particularly important to educate the public with accurate data on trends and issues. If the public responds to perceived "crises", the response may be strong, but short-lived. In order to maintain long-term support for their own program and for preventive efforts generally, sponsors need to both promote their own program, and also support messages emphasizing that substance use problems are not a one-time crisis, but rather an integral part of our society.
See substance use issues within the context of child and adolescent psychosocial development in order to respond most effectively.
An understanding of late childhood psychosocial development and the stages of adolescent development are important to consider when developing prevention programs. A major challenge in child and adolescent development is identity formation.64 The extent of successful identity formation in childhood years has an important bearing on how well this process is achieved in adolescence.
Personal identity is a self-recognition that takes in one's attributes, desires and personal orientations and determines how people think, feel and behave. Self-concept and personal identity are inextricably linked, and a sense of being in control (i.e., one's self-esteem) depends on how well identity formation is proceeding.
Erikson and others have referred to the last phase of childhood identity formation as the "industry versus inferiority" stage. By the end of this stage, children should, through "industry", have acquired confidence in their ability to learn and become diligent in acquiring new knowledge and skills. Success in achieving these attributes through middle and late childhood will provide a good foundation for successful identity formation in adolescence. In this last childhood phase, achievement should lead to acquiring self-esteem and impulse control, and to learning to accept social conventions and respect legitimate authority.
If these various attributes are not achieved during this middle and late childhood period, a sense of "inferiority" may develop. This sense may inhibit efforts to learn new things and acquire new competencies. At the same time, there is likely to be low self-esteem, anxiety and maladjustment. In addition, the failure to develop self-control can lead to impulsive behaviour and instigating such behaviour in others. If "inferiority" rather than "industry" is the overall outcome of the last phase of childhood psychosocial development, the prognosis for adequate identity formation in adolescence is poorer.
While identity formation begins in infancy, it does not become a major psychosocial challenge until adolescence. 65 What is distinctive about adolescent psychosocial development is its intensity and its concentration on the particular challenge of establishing a coherent self-identity. This whole developmental process may be characterized as one of "experimentation". In a gradual, hesitant process the adolescent takes on new viewpoints and tries out various behaviours. As time goes on, earlier opinions and ways of behaving may be rejected, modified in some respects or regarded as acceptable.
As parents and educators can attest, adolescent psychosocial development is not always a smooth and ordered process. When a person lacks a coherent outlook on life and a sound framework of thinking to address one's feelings, identity confusion occurs. As a passing and only partially manifested phenomenon, identity confusion is a normal part of development. When it persists and is not resolved, serious problems can arise.
In general there are three recognized stages of adolescent psychosocial development. While individuals may vary a bit in the age they enter or move from a particular stage, these stages are defined as follows: early phase (age 12-14), middle phase (age15-17) and late phase (age 18-22).
Unfortunately some adolescents do not progress satisfactorily through the three successive phases of psychosocial development. These are the persons who are most at risk of substance use-related harm. For these high-risk individuals, identity confusion persists and has the following aspects:
All of these aspects of identity confusion can be risks for initiating and continuing substance use. Those who are obsessed with finding instant gratification can be enticed by the opportunity of feeling the immediate high produced by various drugs. Youth who are caught in a pathological questioning of self-worth can be prone to adopt deviant behaviour (e.g., drug use) out of a feeling that because they are worthless, it does not matter what they do. 66 Feelings of incompetence can heighten questioning of self-worth with the same outcome. Negative experience in social relationships at school (i.e., feeling isolated and not fitting in) poses a particular risk for dropping out and adopting the street lifestyle with its characteristic heavy use of alcohol and other drugs. 67 Youth with no commitment to a belief or values system are not constrained by moral or social behaviour principles.
This is not to suggest that substance use problems cannot arise in the context of "normal" adolescent development. Indeed, the normal incidents of impulsive, reckless behaviour in early adolescence, or a temporary state of identity confusion at any phase of psychosocial development, could be a time of vulnerability for substance use. However, those adolescents experiencing continuing identity confusion are at much greater risk for initiating and later experiencing substance use related harm.
Our knowledge about childhood and adolescent identity formation raises important considerations for substance use problem prevention programming. There is a need for well-designed universal programs in the early phase (age 12-14) of adolescent psychosocial development. These programs need to be timed to address the behaviours that can arise as a result of this intense period of identity development (e.g., a lack of caution in behaviour and the possible rejection of parental values and advice). It also suggests a need for multi-faceted selective programs that address a range of developmental concerns. Such programs need to be directed to at-risk groups that might consist of low achievers and those with low self-worth and poor impulse control at the "industry-inferiority" stage (i.e., middle to late childhood). These programs are needed in addition to, not instead of, the universal prevention programs that all children need to be exposed to at this stage. Selective programs are also needed for those high-risk youth who continue to show signs of identity confusion during adolescence. Finally, multi-faceted indicated programs with a harm reduction perspective are also needed for sub-sets of adolescents where risk factors linked to dysfunctional psychosocial development have already led to the onset and continuation of substance use.
In order to be credible with participants, programs need to be aware of the way young people view the benefits and the risks associated with substance use.
All substance use meets some type of perceived need on the part of the user. While some needs may be met through a drug's effect (e.g., relief of pain, feeling of pleasure), others may be met through symbolism associated with use of a substance (e.g., sense of rebellion, feeling of belonging).
Young people use substances for many of the same reasons as adults (e.g., stress relief); however, there are some perceived needs or benefits that are more pronounced with young people because they satisfy important needs related to adolescent development. These needs include: taking risks, demonstrating autonomy and independence, developing values distinct from parental and societal authority, signalling entry into a peer group, seeking novel and exciting experiences, and satisfying curiosity. 68
A young person's perception of how common or "normative" substance use is can be an important influence on his or her own use of substances. For example, if there is a sense that most of their friends smoke, drink or use other substances, young people are more likely to do so. Some young people may use substances as consumer items such as clothes and music to establish an identity or image for themselves.69 Some youth do not choose substance use per se but rather a lifestyle within which substance use is a part, along with other elements such as alienation, rebellion and seeking what they regard as freedom and friendship. 70
Adolescent attitudes and beliefs regarding substance use and risk tend to change rapidly and become more tolerant with increasing age. More so than adults, youth tend to minimize the risks associated with their own substance use, with young men tending to do so to a greater extent than young women. 71 It has long been acknowledged that young people tend to give less attention to long-term risks associated with substance use than they do the more immediate consequences.72
Perceptions of risk by young people appear linked to rates of use.73 This linkage has held in Canada over the past 10 years with attitudes of Canadian youth generally becoming more tolerant of substance use as rates have increased.74 There is some indication that decreases in perceived risk associated with drug use precede and lead to increases in rates of use. 75 Attitudes of out-of-the-mainstream youth tend to be more tolerant still and are influenced by a need to escape negative emotions and experiences past and present, and in some cases, by simply not caring (i.e., suicide ideation).76
There is some indication that young people distinguish between lower-risk and more problematic use of substances. In one Canadian study of youth attitudes, those perceived to be using substances recreationally were considered popular socially, while daily or lone use was considered deviant and unacceptable. 77 This perception by young people is in line with research that suggests that young people who engage in occasional substance use tend to be better adjusted psychologically than either non-users or heavy users.78
While acknowledging the benefits of substance use perceived by young people, it is important that programs work interactively with participants to weigh perceived benefits against perceived risks in an unbiased manner. With higher-risk youth, this is best achieved through motivational counselling.
Young people need to see themselves, and to be seen by others, as their own best resource for preventing and minimizing harmful effects associated with substance use.
Those who plan or sponsor prevention efforts need to involve the young people in programming decisions on an ongoing basis. The most meaningful way to involve young people is through a community development approach that engages them in a process of identifying and working toward solutions to what they perceive to be their own issues. The process itself, regardless of the outcome, can be a powerful experience in building personal and group capacity for change.79
Participating youth who are involved in data gathering, program planning, modification and evaluation are less likely to drop out of the intervention, thereby increasing the possibility of it having the intended effect. 80 They are also more likely to be motivated to actively develop new skills and to be open to accepting new information. In some cases, this may mean having an opportunity to contribute to decisions on the process and pacing of the program. In other cases, it will make sense for the young people to assume primary responsibility for developing program messages and for implementing the program.
Peer-based approaches are being used with mainstream youth to address issues as wide-ranging as reducing impaired driving and promoting safer dancing at raves. 81,82,83 Marginalized young people (including those living in poverty, gay/lesbian persons and those with mental health problems) often have poor experiences with the service delivery system and are often poorly informed about available services and what they do. It is particularly important to engage and involve these young people in programming decisions in a respectful and non-judgmental way. Peers can be very helpful in an outreach capacity with out-of-the-mainstream youth.84 A peer education approach has been used to modify risky behaviours among youth involved in injection drug use. Due to the illicit nature of their lifestyle, these youth are often hidden from the mainstream of health education. Compared to others, peer educators are more likely to reach youth involved in injection drug use, and to be viewed as credible advocates of health-promoting behaviour.85 ,86
Regardless of the sub-group, involving youth means nurturing trust and working cooperatively with and supporting credible representatives of the youth population as they clarify the problems; determine appropriate goals; and design, possibly deliver, and help to evaluate the prevention program or activity. It also means ensuring the supportive involvement of adults to facilitate and supervise program activities and to put youth in touch with other resources.
Both the explicit and implied messages delivered in a program need to be viewed as realistic and credible by participants, and need to be delivered by credible messengers.
Every program communicates a number of messages. Some are explicit (e.g., all drug use is unacceptable), while others are implied (e.g., a didactic approach communicates that youth participants may not have a worthwhile view). A good way to ensure appropriate message development is to involve youth participants in the design process. To illustrate: sponsors of a recent campaign in Florida that has achieved very positive short-term results attribute much of the effect to the fact that young people were involved with devising the message.87
The most important principle for every program, regardless of program goal, is that drug information be scientifically accurate, objective, non-biased and presented without value judgment. Regardless of the age of the intended target group, participants must be provided with accurate information and strategies for developing skills such as communication, decision-making, problem-solving and conflict resolution. Even if younger participants initially accept messages that focus solely on the negative aspects of drug use, once they receive more accurate information, there is a danger that all the messages received earlier will lose credibility.
It is important that programs discuss the reasons people use drugs and present alternatives to drug use. Information needs to address both the dangers and the benefits of using and not using drugs, and focus on short-term effects and consequences. Students will dismiss information that they perceive as contradictory to their own substance use experiences or the experiences of those around them (e.g., parents, older peers, famous individuals).
Fear-arousing messages accompanied by incorrect or exaggerated information are not effective, and can generate skepticism, disrespect and resistance toward any advice on substance use or other risk behaviour. These messages can actually erode motivation to deal with a problem, particularly when there are no accompanying coping strategies presented or if the consequences are presented as unavoidable. 88
Similarly, simplistic messages that young people believe to be unrealistic (e.g., just say "no") or not feasible (e.g., play sports when there are no facilities readily available) will not be seen as credible. Because children and youth are less interested in distant, long-term effects, programs need to give greater attention to concrete "here and now" social consequences that can be avoided, such as being less attractive, smelling of tobacco and doing things that will be regretted afterwards.89 Discussion of these consequences and risks, the benefits of not using, and alternatives to using substances needs to be presented in an accurate and unbiased manner.
As students increase in age, so typically does their drug use. As noted above, by Grade 11, the majority of students are using alcohol. Therefore, in addition to basic information about drug effects, it will be important to integrate new messages with respect to risky behaviours and safe use; for example: (a) identifying dangerous or unhealthy practices, such as driving or playing sports after using, chugging or bingeing, engaging in unplanned sex after using, studying or working after using, and using and sharing needles; (b) raising awareness level of regular and heavy users of the risk of dependence and long-term problems associated with these levels of use; and (c) increasing awareness of resources available for those motivated to reduce or quit use and supporting access to services.
Inclusion of these types of messages can support a harm reduction program goal; that is, not focusing on eliminating alcohol and other drug use, but rather on minimizing the negative impact of drug use for the user, the community and the society. Adopting a harm reduction approach requires: providing factual information; providing resources; teaching skills and strategies; and building on existing capacities, strengths and practices of participants.
While most relevant in developing media messages, it is useful for prevention program developers to pay attention to the norms, values and language of young people and youth culture.90 Some of the dominant concerns of young Canadians include getting ahead in a competitive economic environment, managing relationships, fitting in, and certain health issues such as attractiveness and managing stress.91 Youth today are generally optimistic, self-reliant and in search of authenticity. Many are also idealistic, activist and have a strong sense of social justice. Fashion and language change rapidly, but there are core features to youth culture, such as rapid change, non-linear thinking, low respect for prescribed authority and for second-hand adult attempts to be "cool".92 Messages that connect substance use with these issues, aspirations and values are more likely to be attended to.
For instance, a study of youth involved with injection drug use found that while the social norm was to generally not share needles, sharing with friends or sexual partners was considered acceptable. 93 , 94 Trust was seen as an important part of close relationships, with needle sharing a way of demonstrating that trust. As such, campaigns carrying the message that one should never share needles may have limited impact. It is important that prevention initiatives address the values and beliefs underlying the target behaviour.
It is important to bear in mind that youth are not a homogeneous population and that there are a number of youth subgroups or cultures with their own distinct norms and values (e.g., ecstasy use at raves and non-violence among "ravers"). Gender also needs to be considered in preparing appropriate messages for substance use problem prevention. For example, provocative messages that trigger strong affective responses and interpersonal discussions have been found to be effective with young girls. Boys, who are at greater risk of substance use, will likely be influenced more by themes relating to action, competition, bodily sensations and peer group membership. 95
Youth who seek novel and exciting experiences tend to be more likely to engage in substance use.96 So, messages that acknowledge curiosity and the appeal of risk-taking while offering reasonable alternatives to achieve it may be effective with these adolescents. It is crucial that ethno-cultural beliefs of participating youth be understood when developing program messages. For example, messages that integrate with traditional teachings and practices appear most promising with prevention programs for Aboriginal youth. 97,98
Skill development needs to be a central element in programs and it needs to be accompanied by accurate, objective information.
Programs that focus on knowledge only do not bring about change in adolescent substance use behaviours. Affective education approaches focusing on such issues as self-esteem and personal values and beliefs without making specific reference to drugs have been shown to be ineffective when used alone or in combination with a knowledge component.99, 100
Some school programs include components that aim to develop specific resistance skills. However, heavy reliance on resistance training is less likely to be effective, given that "peer pressure" has been exaggerated as a causal factor in risk behaviours.101 Considerable evidence suggests that associating with drug-using peers is often a consequence rather than a cause of substance use.102 That is, young people thinking of using seek out a drug-using group, and while they may not have been pressured into using by peers, they may be pressured not to quit.103
A broader life skills approach may render better results than a narrower focus on refusal or social resistance skills.104 Based on social learning theory, the types of skills covered in a broad life skills program include decision-making, goal setting, stress management, assertiveness, and communication skills and are intended to generalize to various situations and health-related behaviours. Mastery of these skills can enhance the young person's self-confidence in dealing with these situations. Requiring an interactive process, life skills sessions usually include demonstration of the skill, practice and feedback on the use of the skill, discussion on applying it and ongoing modelling of the skill.105
Another type of program challenges common or normative assumptions about the acceptance of substance use in society. The "normative" approach is based on the contention that beliefs of what is normal or accepted are important factors in youthful substance use, in that if a young person believes that most people are using substances, they will perceive less risk and are less likely to abstain from use or be worried about use. These programs seek to undermine popular beliefs that "everyone else" is doing drugs. Student surveys and opinion polls can be used to give students an understanding of actual rates of use and aid them in setting their own norms. The normative approach may make more sense with older students, as life skills appear to be more difficult to affect at this point.
This is not to say there shouldn't be a knowledge component to a prevention program. In all of these various approaches, acknowledgement of the perceived benefits along with information on possible health and social consequences of drug use presented in a factual, balanced fashion can clarify personal risk and support decision-making. 106 As much as possible, it is important that the knowledge component focus on practical rather than theoretical knowledge. 107 For example, street youth are relatively knowledgeable of the health risks associated with the use of various substances and are unlikely to pay attention to information on the negative consequences of drug use.108 However, they may be receptive to a practical, harm reduction message (e.g., try a little first to see how it feels, rather than a regular dose; or where to find help, or how to provide help to others). Participants can often develop this information from their own experiences. In conjunction with the provision of information, preventive strategies directed to street youth need to address the psychosocial factors associated with their use of substances, including a need to escape painful emotions and experiences, depression, low self-esteem, and peer relations.
Engage and involve participants in skill development activities and discussions.
Complementing the psychosocial content, prevention programs that show greatest effect use an interactive group process (interaction in this case means peer to peer, rather than between instructor and youth).109 Interaction appears to be critical in obtaining behavioural goals (non-interactive approaches appear capable of affecting knowledge only). Interactive programs employ role-plays, Socratic questioning, simulations, service-learning projects, brainstorming, cooperative learning and peer-to-peer discussion to promote active participation among youth. These types of "hands-on" activities provide valuable opportunities for youth to clarify their beliefs and to practice helpful skills, such as problem solving, decision-making, and communicating effectively.
Best conducted in small groups, this approach calls on the leader to oversee the activities, establish a supportive environment, keep groups on track and ensure that each adolescent has an opportunity to participate and receive feedback on their use of these skills. For older adolescents, a less structured interactive approach may be most appropriate, with the same aim of encouraging the participation of the full group or class within a supportive atmosphere. The role of the teacher or leader with these approaches is to facilitate and to assume a directive role only when it is necessary to correct a misconception. 110 Interactive programs appear to be effective across drug type (i.e., alcohol, tobacco, marijuana, and other illicit drugs), and across ethnicity. 111
Select and train leaders or teachers who demonstrate competence, empathy and an ability to promote the involvement of young people.
Program messages are more likely to be attended to if the leader or teacher is accepted and respected by the target group. Acceptance is more likely if the leader is comfortable with the program's content and process. Most effective prevention programs require teachers or leaders who are comfortable in a facilitative rather than directive role. Even programs that have been shown to be effective will be seriously hampered by teachers or leaders who are unable to deliver the programs as they were designed to be delivered.112 Mental health professionals have been shown to be effective in this capacity, particularly with high school students.113 Teachers who have been trained for these types of programs can be effective and have the advantage of being available on a daily basis. Training needs to offer demonstration of interactive teaching techniques and ample opportunity to practice these skills. 114 Teachers may be more effective with younger students than with high school students. Young people can serve as leaders or as co-partners with an adult, by, for example, helping to create an appropriate environment and initiating discussion.115 ,116 What appears to matter most is that the teacher or leader demonstrates competence, empathy and an ability to promote the involvement of young participants. Training is often helpful in developing these attributes and ensuring that programs are conducted as they were designed to be delivered. 117 Peer approaches may be particularly useful in working with out-of-the-mainstream youth.118