1
Schools, Public Health and Drugs
The Research Evidence Underlying a Strategic and Systems-Oriented Review
of FPT Capacity to Prevent Problem Substance Use/Addictions through
School-based and School Linked Policies, Programs, Services and Practices
Mary M. Shannon, Douglas S. McCall
March 2004
Prepared for the Office of Alcohol and Drug Policy
Health Canada
2
Contents
A Introduction
1. Purposes
2. Methodology
3. Organization of Report
B Summary of Findings
1. Impact of School Environment
2. Prevention/Promotion Role of School
3. Promising Approaches
4. Promising and Non-Promising Interventions
5. Organizational Capacity of Ministries
6. Conclusions
C. Findings
1. Select Relevant Determinants & Vulnerable Populations
2. Balance Perspectives on Issues-Populations and Settings
3. Understand Impact and Prevention Role of School Environment
4. Select population/sub-populations
5. Integrate with other Health Issues
6. Select the Issue/Aspect and Approach
7. Coordinate Systems and Interventions
8. Re-orient Systems towards Prevention, Improvement, Climate
9. Involve, Empower Individuals and Groups
10. Focus on Public Policy and Cost Benefits
11. Build Resilience & Behaviours within Individuals
12. Surveil Outcomes, Monitor Programs
D. Conclusions
E. References
F. Appendix One – Theories & Questions Underlying this Review of Research
3
A Introduction
1. Purposes
This review of the research has been commissioned as part of a strategic assessment of the
organizational capacities of education and health ministries to prevent substance abuse by
encouraging, requiring and supporting their respective school, public health and addiction
systems to implement evidence-based policies, programs and practices.
The general purpose of this review is to identify the pertinent questions that should be asked in
assessing the organization capacities of provincial/territorial ministries, as well as to answer the
following questions:
Does the social and physical environment of the school play a significant role in
enabling or preventing substance abuse?
Can the school, working with parents, public health and addiction agencies and
the broader community, implement sustainable school-based and school-linked
policies, programs and practices that prevent substance abuse and promote mental
health as well as healthy child/adolescent development?
What are the best or promising overall approaches in enhancing that
prevention/promotion role for schools and relevant agencies/systems? What are
the best or promising, cost-effective and cost-beneficial interventions? How can
these interventions be best organized, coordinated, delivered, sustained and
evaluated?
How can the organizational capacity of provincial/territorial education and health
ministries be strengthened to encourage, require or support their health, addictions
and education systems to prevent substance abuse?
For the purposes of this review, ―substance abuse‖, ―problem use‖, ―addictions‖, and other
addictive behaviours are treated as being synonymous.
School-based and school-linked policies, programs and practices are grouped under general
terms such as ―comprehensive school health‖ or ―healthy schools‖. We use these terms to
capture the many community-based programs that, in fact, rely on schools as a central
component of their strategies and interventions. Many so-called ―community‖ programs are
dependent on schools for delivery of programs to children and youth, recruitment of children and
youth, facilities and for reaching parents about their programs.
―Prevention‖ is used in a general way and often encompasses promotion of overall health and
supportive conditions, preventing overuse or delaying onset of use of alcohol and drugs as well
as inappropriate use of medications and assisting or re-integrating individuals who are under
treatment or counselling.
2. Methodology
This review included a search of the relevant Canadian, ERIC, CINAHL, Medline and PsychInfo
databases as well as a complete search of all records on the Canadian Centre on Substance Abuse
4
database. As well, several records and references from the web site of the National Institute of
Drug Abuse (NIDA) were tracked down and reviewed.
Government web sites such as Health Canada were also searched for relevant studies and
publications. Given the context noted above, we not only assessed the evidence base for school-
based or school-linked interventions but also looking at what researchers can tell us about
effecting real change through systems-based strategies.
As well, the Google search engine was used to locate specific items on the Internet and that often
led to related materials.
A variety of search words and combinations of search words were used in our searches including
schools, prevention, addictions, drug abuse, problem use, school health, alcohol, and others.
The breadth of this review made it impossible to delve into the related sub-topics too deeply, so
we sought to locate more recent references, Canadian references and meta-analyses or major
reports whenever possible.
Many of the topics touched upon in this review are worthy of separate investigations in and of
themselves, but this is beyond the scope of this inquiry.
We focused our searching by:
1. using an ecological and systems-based analytical framework that is emerging in the
research literature about schools and other environments to ensure that we are indeed
asking the right questions in this review
2. identifying evidence-based interventions that are within the recommended scope of
population health and comprehensive school health approaches as defined in the research
literature. We then described those interventions very briefly and tried to summarize the
research evidence indicating that these interventions are worthy of being promoted by
governments.
3. examining how government ministries can encourage, require or support those
interventions in their respective education, public health and addictions systems by first
identifying the organizational capacities that ministries would need to do this effectively,
and then searching the literature to see if these capacities are being used, documented and
discussed.
In this review, there were several systems that come under scrutiny, including schools, the public
health systems and, to the degree that they are separate from public health, the systems that
deliver professional services or addictions prevention workers as well as mental health services
and police officers who work with local communities and schools.
To that end, we used a series of conceptual frameworks that including:
A population health approach that identifies relevant populations or sub-populations,
relevant determinants of health for that population, the settings that reach those
populations and the issues (or aspects of those issues) of most significant impact for that
population. The principles used in this analysis are:
o Focusing on Determinants, Identifying Vulnerable Populations
o Balancing Perspectives on Issues, Populations and Settings
o Understanding the Impact and Prevention Role of Environments
o Selecting a population or sub-population
5
o Integrating with other health issues
o Selecting an Issue or aspect of the issue
o Coordinating multiple interventions across systems
o Re-orienting systems to support prevention/promotion
o Involving/empowering individuals (youth), parents, groups and communities
o Focusing on public policy and cost-benefits
o Building resilience, behaviours, skills, attitudes/beliefs knowledge in individuals
o Maintaining surveillance of health outcomes, system outputs and system capacity
A comprehensive approach to school-based and school linked health promotion
(often called Comprehensive School Health, Coordinated School Health or Health
Promoting Schools) that can be used to integrate the approach to multiple health issues as
well as frame, list and coordinate the many different interventions that can be delivered
by educators, public health professionals, nutritionists/dieticians and others. These
interventions are grouped under five headings:
o Policy and leadership
o Instructional strategies
o Reoriented, Preventive Health Services
o Social support from staff, parents, students and the community
o Physical environment and economic or other practical resources
An environmental/ecological analysis that helps to explain the multiple, linked micro-
environments of the school setting and environments that can be influenced by school-
based interventions and a systems theory orientation that suggests that sustainable
intervention s need to be rooted in the systems named above in order to be effective and
therefore we need to examine the nature of these ―open‖, ―loosely-coupled‖ and
―professional bureaucracies‖ (which school, public health and addictions systems are) as
well as related concepts such as:
o organizational capacity (which we have defined in this project in a certain way
based on the World Health Organization model (2003) and which is similar but
different than community capacity),
o organizational change, diffusion theory, educational change
o how knowledge is transferred to and used (or not) by policy makers,
o how policy is made, implemented and evaluated,
o how professional concerns about innovations and the characteristics of the change
being proposed affect their adoption and
o how formal and informal decisions are actually negotiated within systems.
The developing knowledge about organizational capacity as exemplified in the World
Health Organization (2003) Rapid Assessment and Action Planning Program. That set of
criteria included
o Explicit policy and managerial support for coordination of school
o Adequate staffing/infrastructure at the provincial and local/regional levels
o Formal and informal mechanisms to support coordination
o Adequate time/resources to gather, analyze and disseminate knowledge
o Ongoing and adequate pre-service and inservice activities as well as work place
health programs
o Timely, reliable and usable surveillance ongoing monitoring of the policies,
programs, practices
o Early identification and appropriate management of emerging issues
Concepts and activities related to strategic thinking and planning, including
6
o Scanning the internal and external environment
o Anticipates and manages emerging issues
o Analyzes potential partnerships
o Worries constantly about cost-effects and cost-benefits
o Analyzes the positioning the issues and organizations.
There is an overlap between these conceptual frameworks that is captured in the chart on the next
page. Our findings have been tabulated and described to address these overlaps in a way that is
less repetitive to read. We also developed our instruments in a manner consistent with this chart.
There are additional theories and conceptual frameworks within the chart below that are related
to implementation and diffusion of these approaches and programs within the school and other
settings. These include conceptual frameworks that describe system and organizational change,
educational reform and innovation, how decisions are made by individuals within organizations,
the process and politics of policy-making and implementation, stages of change within
individuals when they adopt new health behaviours and others. However, given that the focus of
this assessment is only on organizational capacity at the provincial/territorial ministry level, we
have not elaborated on these concepts in this report. They are, however, listed briefly in the chart
below.
7
Implementation/
Population Health Comprehensive School Health Ecological/Systems Theory Organization Capacity Strategic Thinking Systems Change
Social Change
1. Focus on determinants 4e. Physical Environment & Resources Social Change
(poverty, gender, culture) to Theories
identify vulnerable
populations
2. Perspectives on issues-
populations – settings
3. Understand 2. Understand limits of school setting, Examine micro- 1. Interaction between 1. Scan environments
environments/settings environments within school individual and environments regularly.
2. Interactions with other
environments 3. Multiple
dimensions of environments
4. Select population or sub- 5. Adapt programs for special needs. Ensure youth friendly.
population
5. Integrate with other health 1. Holistic view of health. Integrate health issues. Managers protect systems 7. Identify, manage emerging issues 2. Anticipate, manage
issues from disturbances issues strategically.
6. Select your issue and 5. Position issue and
approach. your organization.
7. Coordinate multiple 3. Coordinate school-based and school-linked 5. Systems are loosely 1. Explicit policy/manager support for 3. Analyze partnerships Diffusion/ Education
interventions across systems interventions. coupled coordination for risk, benefits, Change/
at all levels investments. Organizational
2. Staff time/ infrastructure for Change Theories
coordination
3. Formal, informal mechanisms for
coordination
8. Reorient health system 4c. Provide health, social services in or linked to schools as 6. Change in professional 4. Knowledge Transfer (Best Practices Policy-making
towards prevention, improve well as work place health programs 4d. Improve bureaucracies occurs through Guidelines Theory
school system, both systems psychosocial environment through peer, parent, whole shared vision, knowledge,
to focus on social/physical school, volunteers programs. 4e. Physical Environment & skills 5. Workforce Development
environment Resources
9. Involve/empower 4d. Involve parents and youth in decisions
individuals or groups
10. Focus on public policy 4a. Develop, implement, evaluate school and PH policies 4. Systems are open to 4. Knowledge Transfer to Decision-
influences at all levels makers
11. Build resilience/ 4b. Establish curriculum, support instruction Stages of Change
behaviours in individuals Theories
12. Maintain surveillance of 6. Describe realistic outputs for SH programs and monitor 7. System Managers often 6. Timely, reliable, PT and local data for 4. Assess cost-effect, Knowledge about
child/youth health outcomes school/public health/other policies &programs focus on boundaries. surveillance and monitoring cost-benefit. valid Indicator
and monitor policies, systems
programs and capacity
3. Organization of Report
This lengthy review of the published research literature essentially follows the chart on the previous
page.
The overlapping concepts of population health and comprehensive school health promotion have been
used as the organizing categories for the references and records located in our searches of databases
and other published works.
We begin with a brief summary of our findings, walk through the various categories outlined above and
then conclude briefly.
Each section contains some selected specific questions, derived from those guiding frameworks that
helped to focus our inquiries.
By necessity, this review covers a lot of ground. Each of the sub-sections could have been the focus for
a more detailed search of the literature. However, our purpose was to substantiate our consideration of
the various elements and questions that will be sued in the other activities of this overall assessment
project. Once we had located sufficient evidence that the specific question or sub-topic was worthy of
examining, we moved on to the next potential sub-topic.
Each sub-section begins with a brief explanation of the concepts being discussed and a very brief
overview of our findings in that sub-section.
An Appendix to this report presents the framework we have used for this investigation in a more
convenient format.
Given the nature of this subject, there is overlap among some of the sub-sections and there are other
ways to organize this significant amount of material. However, it did serve to organize our findings in a
way that validated our use of the organizational capacities that we are seeking to investigate in the
overall assessment project. Having done this review, those organizational capacities seem all the more
important to us.
9
B Summary of Findings
1. Impact of School Environment
Recent Canadian surveys such as the Ontario Drug Use Survey (2003) indicate that substance use by
young people has stabilized at relatively high levels that developed during the 1990’s. While smoking is
declining, alcohol, cannabis and ecstasy are basically unchanged in recent years. Adolescents now first
use cigarettes at a later age, but their first use of alcohol and cannabis is stable at about age 14. About
one-third of Canadian youth report that they have used an illicit drug. With possible decriminalization
of marijuana use, expanded sales of alcohol in private outlets and general realization that moderate use
of alcohol in not necessarily bad for health all marking a plateau being reached in Canadian efforts to
control supply, it is timely for Canadian policy-makers to consider increased efforts in prevention
efforts to reduce demand. Schools should be part of this demand side strategy.
This increased effort would be timely for other reasons, including a general public interest in health
overall, increased attention and capacity being considered for public health programs and a potential
agreement among senior health and education officials to establish new mechanisms for school-based
and school health promotion, this review of the research evidence supporting such efforts is both
timely and relevant.
―Schools could do more than perhaps any other single institution in society to help young people, and
the adults they become, to live healthier, longer, more satisfying and more productive lives.‖
(Carnegie Council on Adolescent Development, 1989)
The school has been called a crucible in the development of children and youth. For most, it is a
launching pad for the rest of their lives. For many, it can be a turning point, towards alienation,
discouragement and substance use or towards reconciliation, renewal and healthier choices and
conditions.
A leading researcher (Flay, 2002) has summarized research to show that the school environment is
linked and is possibly inseparable from the homes of the families and the community that it serves.
Research has shown that individual characteristics of the child/youth interact with that of the school
and are mediated by the practices and nature of the family environment.
The Alberta Alcohol and Drug Abuse Commission (2003) has summarized the research literature on
factors that influence youth substance use and noted that the school environment can either increase
risk or help to protect young people. Not only is the ―connection‖ to schooling critical to health, this
review identifies many specific factors, both within individual students, the family and the local
community that can be influenced by school-based and school-linked programs. These include:
social skills deficits
skills to manage aggression and hostility
problem solving skills
positive bonding with adults
parenting skills
media literacy skills
negative, disorderly school environments/caring school environments
inappropriate school policies on drug use and punishment
academic failure or lack of basic literacy skills
high expectations from teachers
involvement in positive peer groups and activities
access or referral to preventive health and addiction services
9
10
Other researchers have noted that the school can influence mediating individual and environmental
factors such as:
Social skills and competencies (Griffen et al, 2001; Epstein et al, 2000)
Normative beliefs about substance use (Kumar et al, 2002)
Parent-child communications (Komro et al, 2001)
Handling crises and transitions (National Institute on Drug Abuse, 2003)
As well, a renewed interest in health ―literacy‖ reflects the growing understanding that functional
knowledge about a health topic may be a pre-requisite for behavioural change, although such
knowledge is not necessarily sufficient in and of itself. (Further clarification of the essential,
functional knowledge is still required.) As well, research (Roberts at al, 2001) on how young people
perceive and use substances as part of their transition can guide school-based and school-linked
programs more effectively.
We may be at a critical point in our understanding of the complex nature of the school environment
and its linkages with homes, community and other agencies in the community. Many researchers
(Flay, 2000) have noted that there is growing evidence of ―clusters‖ of negative and positive
behaviours and conditions. This review has found that substance use is increasingly being linked
with mental health, social skills and social and emotional learning.
Other researchers have noted the newly understood significance of the psycho-social environment
of the school (Parcel et al, 2003; DeWitt et al, 2002; Hawe et al, 2001a, 2001b; Janosz et al, 1998)
While there is a consensus that these clusters and the overall school environment need to be
addressed by comprehensive programs (Perry, 2003; WHO Expert Committee, 1997; Kumpfer et al,
2002; Flay, 2000) that integrate our approach to several health issues and that coordinate multiple
interventions, researchers and program developers are struggling to sort out the best mix, duration
and type of interventions and how they can be sustained (Scheier et al, 2002; WHO Expert
Committee on School Health, 1997; Allensworth et al, 1997).
New ecological and systems-based understandings (McCall, 2004, Flay, 2002, Stokols, 1992;
Graham, 2003; Weicjk, 1982) about the school environment are emerging that may lead us to
answering some of those questions about mix and coordination of interventions, implementation,
cost –effectiveness, and sustainability.
2. Prevention/Promotion Role of School
The research evidence on the effectiveness of school-based and school-linked health promotion is
clearly established for several health issues for several years. This has been confirmed by major
reviews and reports from Canada (Stewart, 2001) and internationally (WHO Expert Committee on
School Health, 1997; Centers for Disease Control, 2003; Allensworth et al, 1997, St. Leger and
Nutbeam 2000)
The same solid case has been made for substance abuse where instructional programs based on
social skills development (Flay, 2000; Thomas et al , 1999, Caulkins et al, 2002) and programs
using coordinated multiple interventions within the school setting have been demonstrably effective
(Poulin & Elliott, 1997; Botvin et al, 1998; Gottfredson & Wilson, 2003; Cocking, 2002.)
However, the case for having schools prevent substance abuse/addictions has emerged relatively
recently, as programs moved beyond information/knowledge and specific resistance skills training
10
11
approaches to embrace life skills, mental health and whole school approaches. (Ellickson,
2003;Cuijpers et al, 2002)
In the late eighties the value of providing ‗the facts and the risks' about drugs was largely and
rightfully questioned. Young people looked around and found that despite the dire warnings about
alcohol and marijuana, their parents, friends and the media seemed to be unconcerned and largely
unaffected by occasional use of these substances.
The important work of Brian Flay (1986, 1989, 2000) on social influences and life skills emerged.
As well the coordination of instructional programs with accessible support services, school and
agency policies and modifications to the school social environment offered the proof of even more
effectiveness (Parcel et al, 2003, Leija et al, 2003; Sussman et al, 2002; Abbey et al, 2000). As well,
Botvin et al (1998) have described the evolution of different approaches to school-based substance
abuse prevention. These approaches include:
Information Dissemination approaches which proved to be largely ineffective.
Affective Education approaches which also proved to be problematic.
Social Influence approaches that included orrecting Normative Expectations., Psychological
Inoculation.and Resistance Skills Training that do show considerablesuccess.
Integrated Social Influence/Competence Enhancement Approaches that show consistent
success in the short term and even up to six years after.
Life skills training has re-emerged as a basis for prevention programs and appears to be gaining
credibility with recent evaluations noted in this review. In education, this is reflected in a renewed
concern for ―social-emotional learning‖, ―character education‖ and ―caring, respectful‖ schools etc
More recently, this social skills/social development approach has been extended into a approach
that promotes a safe and caring school environment with researchers such as DeWitt et al (2002),
Janosz et al 1998, Hawe 2001a, 2001b) in Canada. This is closely related to the promotion of a
comprehensive approach to mental health as promoted by researchers such as Weist et al (2001). It
is also related to the recent calls for ―youth development agenda‖(Catalano et al 2002)
As noted above, the evidence is emerging from leading researchers such as Flay (2002), Perry
(2003), Kumpfer et al (2002) and Spoth et al (2002) that shows that it is a combination of
instructional, school social environment, school policy, family involvement and peer support
programs and mental health services interventions that is m ost effective in prevention.
As well, more recently researchers have begun the evidence underlying the messages we are trying
to communicate about substance use. Although this development of a ―harm reduction‖ approach is
still relatively untested, it holds the promise of more measurable and realistic outcomes such as a
reduction in drinking and driving among young people, awareness of drugs being used in date rape
etc rather than an unrealistic attempt to have all young people abstain from experimenting with or
moderate use of alcohol (Riley, 1993; Nova Scotia Department of Health, 2003; McBride et al,
2004, Bonomo & Bowes, 2001).
The evidence of short-term, positive effects of school-based and school-linked interventions is very
clear and is noted several times above and throughout this review. However, most random,
controlled studies are short term, measuring effects only a year or two after the intervention. In
regard to the life long effect of school-based interventions, this review did, however, locate a
powerful cost-benefit analysis (Caulkins et al, 2002) that used conservative estimates and
calculations to estimate that for every per cent short term impact of a successful prevention
11
12
program, there will be a 0.15% life long impact. Since most high quality programs report 4-5%
impact in the short term, this would mean a significant impact. That calculation estimates that for
every $150.00 per participant in school instructional programs, $840.00 is saved in health care,
economic and social costs. Most of these savings would come from reduced tobacco and alcohol
consumption rather then illicit drugs. And, these calculations were done with single intervention
programs such as instruction in social skills, whereas the impact of combined and coordinated
interventions could be much higher. This review found similar, less extensive cost-benefit estimates
from others such as Stephens et al (2001), Wang et al (2000) and Chatterji et al, 2001)
However, there are several specific questions that have not been adequately addressed in the
research done on addictions and schools. These issues include topics such as:
clarifying which approaches and which interventions are most effective for
which sub-populations of youth
determining the ―critical mass‖ required of a comprehensive approach that
addresses many different needs with many different interventions and
combinations of interventions while being realistic about the capacity of schools
and local agencies to sustain those interventions
effective coordination of interventions
sustainability of interventions and coordination of programs
being able to replicate effective programs through system change and ministry
leadership.
strengthening the evidence that school-based programs have a lifelong effect
As well, there is a significant absence of knowledge on the impact of government policy, including
its implementation in school systems, public health/addictions and mental health systems. We know
little about the levers that must be used to sustain programs, services and policies at the
school/neighbourhood and regional authority/school board level.
Based on this need, this research review goes beyond the obvious frameworks of population health
and comprehensive school health, to examine the insights gained from ecological approaches
(Stokols, 1996) and open systems theory (Weicjk, 1982; Flay, 2002; Perry, 2003, McCall et al,
1999, McDowell, nd; Graham, 2003). In particular, we look at the organizational capacity of
professional bureaucracies to require, encourage, support and evaluate programs, services and
practices (World Health Organization, 2003; Rappaport, 1977, Kloos et al, 1997Perry et al, 1996) .
Implementation may be a big issue for alcohol and drug education in Canadian schools. American
and other studies (Dusenbury et al, 2003; Wehrman et al, 2002; Pentz, 2003) indicate that curricula,
comprehensiveness and the underlying approach (eg emphasis on social influences and skills) may
not be followed in school-based programs. No Canadian study has been done, but (Roberts et al
(2001) noted that the popular but ineffective DARE program was widely used in Canadian schools.
Canada has no comparable on-going study such as the School Health Polices and Programs Study
(Grunbaum et al, 2000).
The use of systems theory may explain this, as we learned from this review that teachers have
difficulty moving from a knowledge-based approach (to a social influences/normative/skills
approach) and that traditional teacher inservice training in the program was not sufficient to change
their underlying professional beliefs Rohrbach et al, 1993; Kealy et al,2000) . (We also learned that
programs such as DARE have significant parental support and this may also affect the decision to
go with these simplistic programs.)
12
13
Another emerging idea in this and other school health promotion sectors is that in order to be
successful in persuading educators to adopt health promotion policies and programs, we must first
recognize that the primary mission of schools is educational. This revolutionary thought then leads
us to connect and integrate our wish for ―healthy schools‖ with what educators describe as
―effective schools‖ and ―school improvement‖ St.Leger & Nutbeam (2000) have articulated this
concept in describing the dominant paradigms that influence educators and public health
professionals.
Consequently, by using systems theory, and understanding that in ―professional bureaucracies‖
where such professional norms will have an enormous impact on the fate of innovations and
programs, we can then understand how programs such as drug education programs are implemented
or not.
3. Promising Approaches
Indeed, this review found a considerable consensus on the approach and elements that should
characterize a school-based and school-linked prevention strategy. This would include seeing
harmful substance use within the context of
normal adolescent development, where risk-taking and experimentation is a
healthy developmental task (Carr, 19965; Paglia, 1998, Centre on Addictions and
Mental Health, 1999))
other related risk behaviours such as smoking, sexual risk-taking, aggression and
sensation-seeking activities (Jessor & Jessor, 1997, Flay, 2000)
antecedent and underlying developmental factors such as social development,
mental health and self-awareness and control (Alberta Alcohol & Drug Abuse
Commission, 2003)
an interaction between the person‘s individual characteristics, that of his/her
parents/home, the connection to the school and the connection to other adults in
the community (Flay, 2000)
prevailing social norms, community characteristics and media influences
(Alberta Alcohol & Drug Abuse Commission, 2003)
This approach would include multiple school-based and school-lined program elements:
instruction that emphasizes a combination of life skills and social competencies
(Flay, 2002; Thomas et al , 1999, Caulkins et al, 2002) including ―innoculation‖
against social influences, correcting normative beliefs about substance use and
enhancing social skills and also provides a basic ―literacy‖ or ―functional
knowledge‖ about alcohol and other drugs and where to access relevant services.
instruction, co-curricular and whole school practices that encourage social-
emotional learning (Elias & Weissberg, 2000; Elias, 2003; Zins et al, 2003;
Payton et al, 2003) that includes self-knowledge, character development,
learning how to care for and respect others, knowing how to act in social
13
14
situations and how to build relationships.
greater attention to the psycho-social environment of the school (DeWitt et al,
2002; Janosz et al, 1998; Hawe et al, 2001a, 2001b, Konu & Rimpela, 2002) ,
including youth participation in school policy-making, active programs to
engage students in extra-curricular and co-curricular activities, peer programs,
leadership programs, community service as well as parental involvement and
mentoring programs
provision of a comprehensive range of mental health services (Center for Mental
Health Services, 2000; School Mental Health Project, 2001; Rones &
Hoagwood, 2001; Bond et al, 2004, Haynes, 2002) school-based prevention
activities organized by addictions workers, promotion activities by public health
nurses, liaison programs with police and interventions from school
psychologists, social workers and guidance counsellors
Research also indicates that if these interventions are coordinated the impact will be even greater. Perry
et al, 1996, 2003; WHO Expert Committee, 1997; Kumpfer et al, 2002; Flay, 2002)
4. Promising and Non-Promising Interventions
In addition to the evidence supporting the general strategies of instruction, social support and mental
health/addictions services described above, this review has identified several school-based or school-
linked interventions that have been evaluated as being effective or ineffective in reducing harmful
substance use among youth. These include:
Comprehensive, non-punitive school-related policies and practices adopted by school
boards, police services, regional health authorities and addictions agencies and youth
serving professionals, when implemented in coordination withy other interventions
such as instruction, social support and health services can alter behaviour. Policies by
themselves, or narrow policies such as drug testing appear to not influence
behaviours.(Alcohol Policy Network, 2004; Nova Scotia Department of Health, 2002;
Goodstadt, 1989; Yamaguchi et al, 2003; Goldberg et al, 2003, Gliksman et al, 1995;
Grebow et al, 2000)
Narrowly-focused instructional programs such as ―informational approaches‖ or
―abstinence‖ or ―resistance skills‖ or ―affective education‖ have been proved by be
ineffective (Flay, 2000).
Traditional school-based and school-linked social support programs have been
demonstrated to have an effect on drug use; including peer helper programs,
mentoring programs, extra-curricular programs, community service programs and
others (Centre of Excellence for Youth Engagement, 2003; Ciliska at al, 1999; Black
et al, 1998; Collingwood et al, 2000; Mellanby et al, 2000)
Parent-child communications and parenting practices have been strongly linked to
substance use and parenting education and support programs have been shown to
influence that communication and parenting effectiveness (Werch et al, 1991; 2003,
White et al, 1991, Kumpfer et al, 2003, Dishion et al, 2002)). However, the research
on whether representative parental involvement in prevention through parent groups
14
15
and advisory committees has an effect on behaviour and learning is unclear.
School-based or school-linked delivery of addictions, student assistance and
preventive health services, particularly through school-based health clinics (SBHC‘s)
have been reported in case studies to have an effect on substance use behaviours
(Dryfoos et al, 1996; Costello-Wells, 2003, American Association of Psychologists,
2001; Pastore & Techow, 2004, Lowe et al, 2001; Kaplan et al, 1998) but more
research and meta analyses are required.
There were a considerable number of references (Neylon, 1993; Bradley, 1997) to
the role of the public health nurse in schools playing a coordinating role in school
health promotion as well as addictions, but a Canadian study (McCall, 1999) shows
that on average, schools receive about five hours of nurse time per month, so it is
unlikely that such a role would be possible in most schools.
Police officers being assigned as ―resource officers‖ to schools is an apparently
wide-spread practice in Canada (Ryan & Mathews, 1995) but this review did not
locate many controlled case studies or any meta-analyses of their impact on anti-
social behaviors of substance use (Stark et al, 2000; White et al, 2001; Staff et al,
1998). Similarly, the role of school-based addictions workers requires further study
and research (McDonald & Green, 2001; King et al, 2001)
5. Organizational Capacity of Ministries
This review is part of a strategic assessment of provincial/territorial organizational capacity and has
consequently used a definition of such capacity (World Health Organization, 2003) that has these
elements:
1. Explicit policy and managerial support for inter-ministry, interagency and inter-disciplinary
coordination and cooperation
2. Use of formal and informal mechanisms for such coordination and cooperation such as
joint committees, job procedures, written policy statements, joint inservice programs, joint
planning, shared budget allocations, joint vision development and consensus building etc
3. Assigned staff (infrastructure) at the ministry and agency level to facilitate and support
coordination and cooperation.
4. Mechanisms and processes to transfer knowledge to decision-makers and practitioners and
to promote best practices
5. Explicit and sustained programs and processes to develop the capacity of the ministry and
local agency workforce, including studies of current professional practices, guidance and
support for the development of university and college pre-service preparation programs and
development of guidelines, models and materials for sustained staff development programs.
6. Explicit and agreed upon procedures and processes to identify emerging issues and plan
responses accordingly.
7. Regular surveillance of the health status, knowledge, attitudes and behaviours, as well as the
social behaviours and connections to schooling of children and youth as well as monitoring
of local agency policies, programs and capacities.
Very few studies used any of the organizational capacities as a basis for studying implementation
processes and problems. Some exceptions were noted however, including Simpson (2002), Valois &
Hoyle (2000) and Brener et al (2003)
15
16
This review found that many studies (Ennett, et al, 2003; Simpson, 2002; Brown, 2001; Wenter et al,
2002; Ringwalt et al, 2002) that indicate that many, if not most, school-based and school-linked alcohol
and drug programs are not based on the current evidence available about program design and
implementation. Very few studies of this type have been done in Canada. The most prominent example
of this is the DARE program, which is wide-spread in Canada. Obviously, knowledge transfer is a
significant issue for many jurisdictions.
Most studies of implementation are based on top-down thinking (Allison et al, 1991; Giles et al, 2001,
Hahn et al, 2002), where the focus was on the teacher to follow the curriculum designed by experts
(Hallfors & Godette, 2002, Rohrback et al, 2002).
Few studies examined the practical concerns of teachers, nor of their current practices and capacities.
Most studies fidelity in externally funded and supported programs. Some studies noted the immediate
fall-off in fidelity, once those external supports were removed. A few studies of approaches based on
adult learning, professional concerns and perceptions and teacher development were located (Santi et
al, 1992; Flannery & Torquaiti, 1993; Jourdain et al, 2002, MacKinnon et al, 1992; Peterson et al, 2001,
Dusenbury et al, 2003, but more work needs to be done in this area. This is despite the long-standing
work of leading researchers such as Fullan, 1991; Hall & Hord, 1987; Leviinson-Gingiss & Hamilton,
1989).
This review located some studies on the role of personnel other than teachers, but the focus was mostly
on teachers and the classroom. McClanahan et al (1998) reports on school counsellors, King et al
(2001) on addictions workers, Barnett et al(1999) on physicians, Hootman et al (2002) on school
nurses, Berkovitz & Sinclair (2001) on psychiatrists were among the case studies located in this review.
The role and preparation of all of these categories of personnel deserve further study.
Research (Gingiss, 1992) indicates that systems change and adoption of new professional practices
usually takes about three years to be adopted. Few implementation studies have examined timelines
such as this.
Several Canadian reviews (Finlay, 2004; McCall, 2002; McCall et al, 1999; Shannon & McCall, 2001,
2002; Woodward e al, 2004) as well as international reviews (Allensworth et al, 1997, Nutbean & St.
Leger, 1997, WHO Expert Committee on School Health, 1997) have called for regular information on
professional and agency practices in public health and school health as well as on health status,
knowledge and behaviours of children and youth. This study did locate, but did not examine, the semi-
regular studies done on alcohol and drugs in the Atlantic provinces, Ontario and Alberta as well as the
youth health risk surveys done in British Columbia and Quebec.
5. Conclusions
This review of the published research literature has been undertaken to guide a strategic assessment of
the organizational capacities of provincial/territorial ministries of health (including addictions agencies)
and of education to encourage, require and support local agencies to prevent harmful substance use by
children and youth through school-based and school-linked programs, polices and practices.
This review has found that the social and physical environment of the school, acting in concert with the
home and the local community, can either increase or decrease the risk for youth. This review has
found substantial evidence that educators, working with addictions, health police and other agencies
can successfully and significantly intervene with solid evidence showing short term results of up to six
years and some intriguing evidence that, for a portion of young people, with life long effects that can
lead to impressive cost-benefits to society and the individuals concerned.
16
17
This review has found that drug education have evolved into programs that emphasize life skills and
social competencies and that this can be integrated with teaching aimed at social development overall.
This instruction can be coordinated with several interventions that can enhance the social environment
of the school as well as a range of preventive and mental health services offered in schools and nearby
in the community.
This review indicates that implementation of evidence-based programs is an urgent matter for
consideration by decision-makers, as most international studies report that most school-based programs
are not using current knowledge of program effectiveness. In Canada, there are no recent studies of
current practices, policies and programs that were located in this search.
The emerging lenses of ecological approaches to physical and social environments, as well as systems
theory offer many significant insights to policy-makers and practitioners. However, this review
identified only a few studies that have used such conceptual and analytical frameworks in their studies
of the current situation.
Further, this review located very few studies that examined the organizational capacities of ministries or
local agencies to promote, encourage, require or support local professionals and volunteers to do the
right things in preventing harmful substance use among our young people.
17
18
C. Findings
A population health approach is one that seeks to influence the health status of populations either through
interventions to enable them to practice healthy behaviours or to modify the environments in which they live,
learn, work or play. Health promotion strategies, policies and programs used to implement a population
health approach often have to make choices among
the populations or sub-populations to be reached,
the messages to be conveyed (general promotion, harm/risk reduction, prevention of specific
behaviours of conditions etc)
the settings to be used to reach the population or
the interventions (legislation/policy, education, services, social support, changes to physical
environments) to be used to convey those messages
Chomik (2001) has listed and described the elements of a population health approach for Health Canada that
has led us to ask several basic questions during this review. This framework has been adapted for this review.
1. Select Relevant Determinants & Vulnerable Populations
This section examines the application of the population health principle (PH) of considering
relevant determinants and addressing vulnerable populations and the Comprehensive School
Health (CSH) elements addressing the social and of the physical environment of the school
being used to alleviate the impact of some of those determinants on vulnerable sub-
populations of children and youth.
Our general finding for this sub-section of the report is that the school environment can
clearly influence several individual, family, school and community factors that either
increase risk or protect children and youth from harmful substance use. This conclusion is
based on two major overviews of the research and several small-scale studies.
Trends in Youth Substance Use
The most commonly used substances among youth are alcohol, tobacco and cannabis (marijuana,
hash, hash oil). Ontario's Addiction Research Foundation (now the Centre for Addiction and Mental
Health) has sponsored the longest ongoing Canadian survey of youth substance use. Due to the
limitations of this review, the findings of the most recent report of the Ontario Drug Use Survey
(2003) are used here to summarize patterns,of use among young people. Similar results can be
found in
Provincial Student Drug Use Survey of the Atlantic Provinces 2002
Alberta Alcohol and Drug Abuse Commission (AADAC) 2002
British Columbia / 2003 Adolescent Health Survey III
The escalating trend in drug use, which began in the early 1990s, has generally subsided. Between
2001 and 2003, the past year use of 5 measures significantly decreased:
Cigarettes: from 23.1% to 19.2%
Ecstasy: from 6.0% to 4.1%
LSD: from 4.8% to 2.9%
Barbiturates: from 4.0% to 2.5%
The use of any illicit drug, excluding cannabis, also declined, from 18% to 15%.
18
19
According to the Ontario Drug Use Survey (2003) report, there are five general patterns that
describe the long-term trends in drug use between 1977 and 2003:
1) Decreased in the 1980s, Increased in the 1990s, Currently Stable, but Elevated:
Alcohol
Binge Drinking
Inhalants
Cannabis
Ecstasy
Hallucinogens
2) Decreased in the 1980s, Increased in the 1990s, Currently on a Downward Trend:
Cigarettes
LSD
3) Decreased during the 1980s, Upward movement during the 1990s:
Cocaine
Crack
4) Decreased during the 1980s, Stable during the 1990s:
Stimulants
Tranquillizers
Barbiturates
5) Low and Stable:
Heroin
PCP
Methamphetamines
Other Patterns of Use
About two-thirds (68%) of students have not used any illicit drug, including cannabis, in the
past year. Conversely, 32% of students have used an illicit drug, including cannabis.
About one-third (30%) of students do not consume any substance, including alcohol or
tobacco, and another third (31%) consume only alcohol.
One-in-ten (10%) students report using alcohol, tobacco, cannabis and at least one illicit
drug.
The percentage reporting first-time drug use during the past year is as follows: 19% for
alcohol, 10% for cannabis, 9% for cigarettes, and 5% for illicit drugs other than cannabis.
Age of First Use
The average age at which students smoke their first whole cigarette is currently about
age 13. This average age has increased since the early 1980s, when it was age 11.
The average age of first alcohol use is about age 13, and has not showed any major
fluctuations over the past two decades.
The average age of first cannabis use is currently about 14. Historically, this onset
age increased throughout the 1980s and early 1990s, and then decreased again in
recent years.
19
20
Risk and Protective Factors
The Alberta Alcohol & Drug Abuse Commission (2002) has prepared several papers on risk and
protective factors associated with adolescent substance use. These papers provided an overview of
findings of key government documents, journal articles and reports from leading addiction agencies.
Based on these reviews, key risk and protective factors were included in the The Alberta Youth
Experience Survey, 2002.
Risk factors are life events or experiences that are associated with an increase in problematic
behaviours such as alcohol and other drug use.1 Protective factors are life events or experiences that
reduce or moderate the effect of exposure to risk factors.2 The most effective prevention and
intervention projects focus on risk and protective factors within five major life domains: individual,
family, peer, school and community. While much research remains to be done, several risk and
protective factors have been identified (Please refer to the chart on the next page.).
Based on the Alberta Youth Experience Survey, 2002, the most important risk factors for harmful
use of substances and gambling are:
age of user,
peer risk behavior,
family history of substance abuse,
family discord and
poor connections to school life.
The most important protective factors for harmful use of substances and gambling by Alberta youth
are:
parental monitoring,
good social skills,
availability of and participation in pro-social activities,
high school marks and
good connections to school life.
In the past, the emphasis of adolescent addictions research has been on risk factors associated with
adolescent substance use. Recent research indicates the need for a broader perspective
encompassing both risk factors and protective factors. Protective factors function as a buffer
highlighting the interplay between risk and protective factors.
The severity, frequency, and duration of both risk and protective factors affect the adolescent‘s
ability to remain resilient against substance abuse and gambling.
Continued research examining the most relevant risk and protective factors will aid youth initiatives
to develop innovative and improved program solutions for this population.
The following chart is taken from Alberta Alcohol & Drugs Abuse Commission (2001) Youth Risk
and Protective Factors - May 2003, Edmonton, AB, Author
20
21
Risk and Protective Factors Within Major Life Domains
Individual Domain
Risk Factors Protective Factors
- social skill deficits -social skills and responsiveness
- genetic predisposition - emotional stability
- positive attitude about use - positive sense of self
- impulsivity - problem solving skills
- hostility and aggression - flexibility
- alienation - resilience
- rebelliousness
- learning difficulties
- behavioural problems
- temperament
- physical trauma
- early age of onset
Family Domain
Risk Factors Protective Factors
- parental abuse of alcohol, drugs, and/or gambling - positive bonding
- remaining in an abusive or conflict ridden family
- low parental support - emotional support and absence of severe criticism
- low parental monitoring - a sense of basic trust
- poor family management, discipline, and - high parental expectations
problem solving - clear rules and expectations
- favourable attitudes toward teen alcohol, other drug - parental monitoring
use and gambling
- parents‘ mental illness
- ineffective parenting skills, especially for children with
learning disabilities or behavioural problems
School Domain
Risk Factors Protective Factors
- academic failure - caring and supportive school environment
- negative, disorderly, and unsafe school climate - high expectations
- low teacher expectations - clear standards and rules for appropriate behaviour
- lack of clear school policies regarding drug use - youth participation, involvement, and responsibility in
- lack of commitment to school school tasks and decisions
- withdrawn/aggressive classroom behaviour
Peers Domain
Risk Factors Protective Factors
- involvement with peers who use and have - involvement with positive peer group activities and
favorable attitudes towards alcohol, other drugs, and norms
gamble • social competencies such as decision making skills,
- involvement with peers who engage in other problem assertiveness, and interpersonal communication
behaviours
- peer rejections
- poor social skills
Community Domain
Risk Factors Protective Factors
- community norms that promote or permit substance - caring and supportive community
use and gambling - high expectations of youth
- living in impoverished neighbourhoods characterized - being media literate
by high crime rates and alienation - counter-advertising messages (youth educated about
- high rates of transition/mobility advertising)
- cultural disenfranchisement - religious based activities
- community sponsored activities
Note: the factors that can be affected by schools are highlighted in italics and red font.
21
22
Becker (1997) has summarized various models for predicting substance use and abuse that could be
used a basis for determining the realistic outputs for school-based programs.
MODELS OF THE ROLES OF RISK FACTORS IN SUBSTANCE ABUSE
Models of the roles of risk and protective factors in substance abuse are implicit in the narrative review by
Hawkins and colleagues (1992). Figure 2 shows one possible model that incorporates contextual factors and
many of the individual and interpersonal factors described in the review.1 The model shown in figure 2 has 11
broad predictors of substance use and abuse outcome for a total of 12 components. Table 1 lists those
components.
Five components represent contextual factors, while the rest are interpersonal (parent and peer) and
individual factors. The outcome itself is broadly defined, and leads to a good example of how such process
models can be further delineated. For example, one could refine the model in figure 2 by focusing on drug
abuse or on alcohol abuse. Some predictive factors may be more relevant for one outcome than another;
factors that are irrelevant to a particular outcome could be omitted from the refined model for that outcome.
Younoszai (1999) found that involvement in problem behaviors was identified as the most salient
risk factor for drug use, while having a member of a non-using peer group was the most salient
protective factor.
Li et al; (2002) examined whether parents act as gatekeepers by testing the moderator effects of
parents' substance use on the relationships of friends' substance use to adolescent substance use
(cigarettes, alcohol and marijuana) in a longitudinal school-based trial for prevention of substance
use in adolescents. As part of a large substance use prevention trial, entering middle school over
1800 students from 57 schools were surveyed at baseline, 6 months and 18 months (n = 1807 from
57 schools). Results of logistic regression analyses and multiple group structural equation modeling
showed that increasing numbers of parents and friends using substances were associated with
22
23
greater risk of adolescent substance use, as were more substance offers and lower levels of refusal
self-efficacy. Additionally, refusal self-efficacy mediated the effects of baseline use and substance
offers on subsequent use. Non-using parents had a buffering effect on friends' influences to use
substances, such that friends' use did not affect adolescent use when parents were non-users, and the
effects of substance offers on refusal self-efficacy were weaker. The findings suggest that parent
substance use should be addressed in adolescent substance use prevention programs, and that
continuing non-use by parents should be reinforced.
School Influence on Mediating Factors
This review located several records indicating that several of these factors/determinants/ can be influenced
by the school environment, especially when the school works with municipal, police, public health policies,
mental health and addictions programs, services and practices in a sustainable way?
Griffin et al (2001) describe the protective role of personal competence skills in adolescent
substance use: psychological well-being as a mediating factor. Adolescents who use a variety of
cognitive and behavioral self-management strategies have been shown to report reduced rates of
early-stage substance use, but little is known about how these personal competence skills may be
protective. In a series of structural equation models, this study examined the association between
competence skills and substance use over a 3-year period among 849 suburban junior high school
students, and whether psychological distress, well-being, or both mediated this relation. Findings
indicated that well-being fully mediated the relation between early competence and later substance
use, but distress did not. Youth with good competence skills reported greater subsequent well-being,
which in turn predicted less later substance use. Findings suggest that competence skills protect
youth by enhancing well-being and that prevention programs should aim to enhance competence in
order to promote resilience.
Griffin et al (2002) note that several previous studies have investigated the relationship between
psychological distress and substance use among youth. However, less research has investigated the
potentially protective role of psychological well being on adolescent substance use, and the extent
to which personal competence skills may promote well-being. They examined personal competence
skills, psychological distress and well-being, and adolescent substance use over a 3-year period in a
predominantly minority sample of urban students (N = 1,184) attending 13 junior high schools in
New York City. Structural equation modeling indicated that greater competence skills predicted less
distress and greater well-being over time. Although psychological well-being was associated with
less subsequent substance use, distress did not predict later substance use. Findings indicate that
competence skills promote resilience against early stage substance use in part by enhancing
psychological well being, and suggest that school-based prevention programs should include
competence enhancement components in order to promote resilience.
An earlier study (Epstein et al , 2000) done in New York City found much the same thing. Social
competency skills can be a protective factor for substance abuse and these can be taught
successfully in school.
An even earlier study (MacKinnon et al, 1991) found similar results in how a social influences
program can influence mediating attitudes about substance use. . They describes (a) the effects of a
social-influences-based drug prevention program (the Midwestern Prevention Project) on the
mediating variables it was designed to change and (b) the process by which the effects on mediating
variables changed use of drugs (tobacco, alcohol, and marijuana). Students in 42 middle schools and
junior high schools in Kansas City, Missouri, and Kansas City, Kansas, were measured in the fall of
23
24
1984 (N = 5,065) and again 1 year later (N = 5,008) after 24 of the schools had been through the
program. Compared to students in control schools, students in program schools became less likely
to express belief in the positive consequences of drug use, less likely to indicate that they would use
such drugs in the future, more likely to report that their friends were less tolerant of drug use, and
more likely to believe that they were better able to communicate with their friends about drug or
school problems. Change in perceptions of friends' tolerance of drug use was the most substantial
mediator of program effects on drug use. There was evidence that intentions to use and beliefs about
the positive consequences of use may also mediate program effects on drug use.
Kumar et al (2002) examine the relationship between school norms of substance use disapproval
(disapproval by the student body) and students' use of cigarettes, alcohol, and marijuana. Data came
from nationally representative samples of 8th (N = 16,051), 10th (N = 13,251), and 12th (N =
8,797) grade students, attending 150, 140, and 142 schools, respectively. These students
participated in the Monitoring the Future Project in 1999. Measures of school norms of disapproval
of substance use were obtained by aggregating students' personal disapproval of daily cigarette use,
heavy drinking, and marijuana use within each school. Analysis using logistic nonlinear hierarchical
models indicated that in general, school-level disapproval lowered the probability of students' use of
these substances, controlling for their own disapproval and for student and school demographic
characteristics. The beneficial effect of school-level disapproval of cigarette and marijuana use on
8th-grade students' probability of daily cigarette use and marijuana use was significantly higher than
it was for the 12th-grade students. The effect of school-level disapproval of heavy drinking on the
probability of students' drinking was not significantly different across the three grades. Further, a
school environment of disapproval was also found to create a protective environment for those
students in the 8th and 10th grades who were themselves not disapproving of daily cigarette use.
These results argue for prevention programs that include creation of an overarching environment of
disapproval of substance use in schools.
A Canadian study, (Smart & Stoduto, 1997) suggests that Drug education may give students the
knowledge and confidence to intervene in friends' drug use. This study investigated self-reported
interventions by students in the alcohol, tobacco, illicit drug use, and drinking-driving of their
friends. The data came from a study of 1184 students in Ontario schools in grades 7, 9, 11, and 13.
We found that about a third of students intervened in friends' illegal drug use and drinking-driving
but about half intervened about smoking. Students who intervened were more likely to be older and
spend fewer nights at home. They were less likely to use cannabis, but had more friends using
cannabis and illegal drugs. Also, they had more exposure to drug education and were more
disapproving of drug use.
Palmer et al (1998) also found that interventions establishing conservative drug use norms in
classrooms may be an effective strategy in reducing substance use onset among adolescents. They
examined the effectiveness of a social pressure resistance training and a normative education
(NORM) intervention against an information-only control group. RESULTS: The NORM condition
revealed 1-year program effects for cigarette and marijuana use with individuals as the unit of
analysis and only marginal effects with classroom as the unit of analysis. No program effects were
found using school as the analysis unit. A multilevel strategy revealed program effects for cigarettes
and marijuana with both class and school as grouping levels. The effect for alcohol use was
significant at the 2-year follow-up.
Komro et al (2001) analyze the impact of Project Northland on mediating variables. At the end of 3
years of intervention, significantly fewer students in the intervention school districts reported
alcohol use than students in the reference districts. Mediation analyses were conducted to
24
25
investigate if the intervention's effects on mediating variables could explain the reduction in alcohol
use. Important mediators of Project Northland's effect on alcohol use were: (1) peer influence to
use, including normative estimates, (2) functional meanings of alcohol use, (3) attitudes and
behaviors associated with alcohol and drug problems like stimulus seeking, rule violations and bad
judgement, and (4) parent-child alcohol-related communication around alcohol use. In addition,
among those who did not use alcohol at baseline, self-efficacy to refuse offers of alcohol was a
significant mediator.
Donaldson et al (1994) also examine the mediating variables that are affected by programs based
social influence that often prevent the onset of adolescent drug use. Analyses based on a total of
3077 fifth graders participating in the Adolescent Alcohol Prevention Trial revealed that both
normative education and resistance training activated the causal processes they targeted. While
beliefs about prevalence and acceptability significantly mediated the effects of normative education
on subsequent adolescent drug use, resistance skills did not significantly predict subsequent drug
use. More impressively, this pattern of results was virtually the same across sex, ethnicity, context
(public versus private school students), drugs (alcohol, cigarettes, and marijuana) and levels of risk
and was durable across time. These findings strongly suggest that successful social influence-based
prevention programs may be driven primarily by their ability to foster social norms that reduce an
adolescent's social motivation to begin using alcohol, cigarettes, and marijuana.
Puskar et al (2003) report that a Teaching Kids to Cope (TKC) program can have positive effects on
outcomes of depression and coping among rural adolescents. Results indicated improvement in
depressive symptomatology and certain coping skills. Students in the intervention reported a higher
use of cognitive problem-solving coping strategies.
2. Balance Perspectives on Issues-Populations and Settings
In applying population health principles, public health agencies and professionals are often
driven to respond to specific health problems, particularly as they affect more vulnerable
populations. Educators, on the other hand, are driven to provide equitable educational
opportunity to all children, including challenging successful people to achieve their best. This
sub-section examines the implications of policy-makers selecting the school as a setting to
respond to health issues.
It is obvious that schools can help all children and youth in maintaining their own health and
developing skills, knowledge, attitudes and other attributes to help them avoid or reduce the
impact of several, if not all, health and social problems. However, it is suggested here that
research should also be helping systems to identify exactly which parts of health problems are
best addressed by other settings and systems, to determine if intervening with school-age
children and youth has a life-long effect or if is it sufficient to affect their childhood and
adolescent development alone, and to determine if the school setting is a more appropriate
venue for delivering certain messages that are more credible in this setting.
A Shared Concern for Kids, Differing Perspectives, Overlap and Contradictions
It is obvious that health and education professionals and decision-makers share a common concern for
children and youth, easily see relationship between health and learning and see the school as a venue for
promoting health, social development and learning. However, we should look under that agreement to
discover important differences of perspective as well as some underlying contradictions or tensions.
25
26
St. Leger and Nutbeam (2000) have presented a model for mapping the linkages between health and
education agencies. They point out the difficulties inherent in a perspective that sees the school only as
a convenient venue in which to implement or indeed, simply send, packages of health information for
the classroom or sets of instructions (disguised as manuals) to teachers and educators to do more about
health problems. They also describe how a more of a “comprehensive”, “coordinated”, “health
promoting”, “whole school” or “school-community” approach that takes the burden off the
classroom/educators and distributes it to other parts of the school such as cafeterias, health services,
parental involvement, guidance services and that also requires specified actions and services from
health, social services and other agencies and professionals. This “institutional “ approach also
considers the underlying values and social climate of the school.
St. Leger and Nutbeam go on to describe the primary mission of the school as being that of an
“educational institution” and then map out two sets of perspectives, one education and the other,
health, on different but similar long term goals, school related outcomes, school-based interventions
and inputs into the two systems. Their discussion reveals some important differences in perspectives.
For example, they suggest that health tends to be “top-down” or expert-driven, seeking changes in
behaviour and is often focused on the classroom, while education is often more process oriented and
more open to hearing the perspectives from all sides, including those that may not have an expertise.
This type of analysis showing the overlaps and differences between the two sectors has been done
before. For example, the attributes of “effective schools” as defined in the education research is quite
similar to that of “healthy schools”.
The Ontario Task Force on Effective Schools defined these attributes of effective schools:
There are high expectations for all students
The teaching is top quality
The learning environment is positive
Teachers have a comprehensive knowledge of the curriculum
School days are organized to provide the maximum amount of learning time
Parents are involved in their child‘s learning
Teachers plan for improvement
Performance improvement goals are set and achieved
Progress in student performance is closely monitored and regularly communicated
Success is celebrated
The World Health Organization (nd) (has defined the attributes of a “health promoting schools” as
institutions that constantly strengthens their capacity as a healthy setting for living, learning and
working.
A health promoting school:
Fosters health and learning with all the measures at its disposal.
Engages health and education officials, teachers, teachers' unions, students, parents, health
providers and community leaders in efforts to make the school a healthy place.
Strives to provide a healthy environment, school health education, and school health
services along with school/community projects and outreach, health promotion programmes
for staff, nutrition and food safety programmes, opportunities for physical education and
recreation, and programmes for counselling, social support and mental health promotion.
26
27
Implements policies and practices that respect an individual's well being and dignity,
provide multiple opportunities for success, and acknowledge good efforts and intentions as
well as personal achievements.
Strives to improve the health of school personnel, families and community members as well
as pupils; and works with community leaders to help them understand how the community
contributes to, or undermines, health and education.
Health promoting schools focus on:
Caring for oneself and others
Making healthy decisions and taking control over life's circumstances
Creating conditions that are conducive to health (through policies, services, physical / social
conditions)
Building capacities for peace, shelter, education, food, income, a stable ecosystem, equity,
social justice, sustainable development.
Preventing leading causes of death, disease and disability: helminths, tobacco use,
HIV/AIDS/STDs, sedentary lifestyle, drugs and alcohol, violence and injuries, unhealthy
nutrition.
Influencing health-related behaviours: knowledge, beliefs, skills, attitudes, values, support.
As one can see, the effective schools movement and the healthy schools movement share a concern for
a healthy, safe, orderly school environment and high expectations for all students.
Similarly, one can see similarities in standards, well-recognized statements or summaries of the essential
functions of public health (Frank et al, 2003) and public schooling (Shannon & McCall Consulting
Ltd. (1993).
Public Health Functions Schooling Functions
1. Assess the health of the population through 1. Regular reporting on academic achievement
regular needs, health status and system at all levels, participation in schooling and
reports. training, other related factors and propose
remedies and actions.
2. Regular surveillance of health, through 2. Prepare reports on activities and effectiveness
periodic health surveys and advice to system of education systems, accessibility of education
of increasing threat, what they need to look and equity and system efficiency.
for, and intervention required.
3. Promote health through inter-sectorial 3. Promote intellectual development,
partnerships, advocacy for healthy public educational attainment and lifelong learning in
policies; improving personal skills; language arts, mathematics, science, technology,
encouraging healthy behaviours, creating social studies, a second language and the arts as
physical and social environments to support well as health, family life, physical education
health,.
4 Prepare students for vocational purposes,
4. Disease prevention through immunizations; including competitive and innovative aptitudes
investigation and outbreak control; early and values early in school, counselling, career
detection linking and referring to health explorations and career planning in secondary
services and treatment facilities etc.. and vocational training in later years.
5.Socialize young people into the explicit and
27
28
implicit values and norms of society including
personal and character development, civic
participation, respect for others & diversity,
global awareness, social responsibility and other
values as well as valuing health and wellness.
5. Protect health through inspections of 6 Assure safe custody and health of children
facilities, water, air, land use and other factors. and youth during the school day.
7 Sort and select students for future academic
and vocational endeavours by certifying their
skills and knowledge.
Even a brief glimpse at the above chart reveals potential tensions and contradictions between the two
systems. The crowded nature of the three functions relating to what students will learn is immediately
apparent. As well, the often unrecognized and little discussed function of the school in sorting and
selecting students for future places in society may cause conflict with health goals to provide supportive
environments. For example, in schools, tests are designed to fail a certain proportion of students lest
they be accused of reduced standards and rigour. Experiencing failure in school can be a cause for
students to leave school early, thereby increasing potential health risks.
Norland et al (1996) indicates that a positive social climate may not be as simple as it sounds,
because schools perform the function of sorting and selecting people for later places in life. This
means that some people will recognize that they are being sorted and may respond through
substance use and other anti-social behaviours. They suggest that evaluations of school curricular
drug control efforts show they are only modestly successful because they are based on an inaccurate
theory of drug taking. Social control theory is suggested as a better model of drug taking and drug
resistance. Building strong bonds to school acts to decrease the likelihood of interaction with
delinquent peers and thereby decrease delinquency and drug use. Yet schools are sites of
stratification and competition, and strong bonds may be related to one's place in the school
hierarchy. If schools are unable to produce sufficient positions in the hierarchy, those with low
levels of academic success or commitment may turn to the drug subculture to find status and
rewards. A number of future research questions are suggested.
As well, Allison (1992) reports on a simple, yet significant, characteristic of school organization
that could be used to guide programming. He examined the relationship between academic stream
and cigarette, alcohol, and cannabis use among 2,543 high school students as part of the Ontario
Student Drug Survey (1987). Students in basic and general academic streams were found to have
significantly higher levels of cigarette, alcohol, and cannabis use compared to advanced level
students. The effects of academic stream remain significant (except for alcohol use) when gender,
grade average, drug education lessons, and pressure to use these substances are included in multiple
regression analysis. The findings indicate that the process of academic streaming needs to be further
examined as a possible precipitating factor in drug use.
The preceding discussion of similarities and differences in perspectives between educators and health
promoters would suggest that we need to be careful and focused in approaching collaboration between
the two systems, lest we end up promoting actions that actually run counter to existing professional and
social norms that dominate one system or the other.
28
29
Long Term Impact with Children and Youth
Does the research evidence indicate that school-based interventions will have a life time
effect on substance use?
This review found some evidence that suggests that interventions aimed at the population of school-
aged children and youth will result in changes to substance use patterns that lead long-term health
outcomes. However, as noted below, the few longitudinal studies available to be reviewed are not
conclusive enough and further research is recommended.
The most extensive analysis located in this review comes from Caulkin et al (2002) in a publication
for the RAND Corporation. Some of their analysis is reproduced here.
In Chapter Four, we estimated the effects of school-based prevention on adolescent use of marijuana,
alcohol, and tobacco as of the end of the first evaluation follow-up, which we envision as happening in
eighth grade in our hypothetical model program. Unfortunately, with only one possible exception
among the programs we studied (the Lifeskills program), observed differences between treatment and
control groups had disappeared by the end of high school.
At some point, the delay in drug use caused by prevention comes to an end. However, this does not
render moot the question of effect on lifetime consumption. Not only is consumption reduced during
middle and high school, but there is reason to believe that people who use drugs less extensively as
youths will also use drugs less extensively as adults, even if they have tried drugs before leaving high
school (Everingham and Rydell, 1994; Kandel and Yamaguchi, 1993; Kandel, 1975). Still, it is
important to account quantitatively for this decay in observed effects and delay of initiation. The reason
it is important to account for decay and delay is that (as shown later in this chapter) we estimate, for
each drug, age-specific initiation rates, with and without prevention, and associate those rates
(through National Household Survey on Drug Abuse [NHSDA] data) with percentage changes in
lifetime consumption. Decay of the initiation effect thus impinges on estimated lifetime consumption.
It is important throughout this chapter to distinguish between effects on the predictor variables, which
we discuss in the first two sections, and effects on lifetime consumption, which we discuss in the last
section. The final calculation in this chapter divides the percentage differences in lifetime consumption
by the estimates of program effectiveness(shown in Table 4.5) to arrive at Factor 5, the percentage
reduction in lifetime consumption for each percentage-point reduction in prevalence at the end of the
program.
In reviewing the percentages shown in Table 5.2, several observations emerge:
First, one should not extrapolate reductions observed at the end of the program to lifetime reductions.
With the conservative initiation scenario (our preferred scenario), lifetime reductions are only one-sixth
as great as end-of-program initiation reductions for alcohol, tobacco, and marijuana. The
29
30
corresponding value for cocaine is noticeably larger (a bit above one-quarter), but still much less than
one.
Second, the results are quite sensitive to the initiation delay assumption, but in different ways for
different substances. More optimistic scenarios increase estimated effects on marijuana quite
markedly and steadily because people who do not try marijuana until older ages are much less likely
to use marijuana heavily than those who start early. For tobacco, the optimistic scenario yields only
modestly larger Factor 5 values than does the conservative scenario. However, there is a huge jump
when one moves to the very optimistic scenario because under that scenario, many of those whose
initiation is deferred through high school never initiate at all. In terms of reducing lifetime cigarette
consumption, the key is not delaying initiation but eliminating it altogether because those who start
smoking late end up smoking almost as much as those who start early. The trend for cocaine use is
similar. Those who initiate marijuana use between ages 19 and 21 historically have used almost as
much cocaine as those who initiated marijuana at age 17 or 18, so there is little projected gain in terms
of cocaine prevention in moving from the conservative to the optimistic scenario.
Third, focusing on the conservative initiation scenario (our preferred scenario), one can make a simple
but powerful generalization. Roughly speaking, for every 1 percent reduction in use observed at
the end of a prevention program, one can anticipate a 0.15 percent reduction in lifetime use of
the same substance; or, equivalently, 10 percent reductions at the end of the program suggest 1.5
percent reductions in lifetime use. For cocaine, there is about a 0.25–0.30 percent reduction in lifetime
use for every 1 percent observed reduction in marijuana use. Those with a more optimistic view of
initiation delay would bump up these reduction percentages somewhat for tobacco (to about 0.23:1—
i.e., 0.23 percent lifetime reduction per 1.0 percent reduction at program completion) and dramatically
increase the percentages for marijuana (to 0.35:1), but not increase them as much for cocaine or
alcohol (drunkenness). And those who are very optimistic about permanence would use even higher
factors (roughly 0.50:1 for cocaine and marijuana, 0.44:1 for tobacco, and 0.32:1 for alcohol
[drunkenness]).
Skara & Sussman (2003) examined the longer-term impact of prevention programs based on the
psycho-social approach. Although the initial effectiveness of psychosocial strategies programming
in preventing smoking and other drug abuse among adolescents has been well established through
literature reviews and meta-analyses, much less evidence exists for the long-term follow-up success
of these interventions. The primary goal of this paper, therefore, is to summarize the effectiveness
of published program evaluation studies that have followed adolescents across the transitional
period between junior high and high school for a period of at least 2 years. Studies for inclusion in
this review were accessed primarily through a computerized search of Medline, Healthstar, and
PsychINFO databases. Intervention studies that met five core criteria were retained for review. Two
authors independently abstracted data on study characteristics, methodology, and program
outcomes. Search results yielded 25 studies suitable for examination. The majority of these studies
reported significant program effects for long-term smoking, alcohol, and marijuana outcomes, while
indicating a fairly consistent magnitude of program effects. This review provides long-term
empirical evidence of the effectiveness of social influences programs in preventing or reducing
substance use for up to 15 years after completion of programming. However, this conclusion is still
somewhat tenuous given the lack of significant program effects reported in several studies and the
great variability that existed in the level of internal and external validity across all studies.
Shope et al (1998) evaluated the continuing impact of a grade six and seven instructional program
that developed social pressures resistance skills. This program showed short-term positive effects.
Repeated measures analyses of variance demonstrated that significant effects evident at seventh
grade for alcohol use and misuse, as well as cigarette, cocaine, and other drug use were generally
not maintained through twelfth grade. This result may be a result of two hypotheses, the first is that
it is too long a time between the intervention and the measurement almost six years later and that
repeated doses or maintenance of the intervention is required. Or, an alternative explanation is that
developing specific social pressure resistance skills at a certain age is effective for the
30
31
experimentation stage of drug use or that age group, but other skills, knowledge, attitudes/beliefs
need to be taught to affect decisions at later stages in life.
An American longitudinal study (Botvin et al , 2000) found that the students who participated in a
Life Skills Training program showed positive effects six years after the intervention. They
examined long-term follow-up data from a large-scale randomized prevention trial to determine the
extent to which participation in a cognitive-behavioral skills-training prevention program led to less
illicit drug use than for untreated controls. Data were collected by mail from 447 individuals who
were contacted after the end of the 12th grade, 6.5 years after the initial pretest. Results indicated
that students who received the prevention program (Life Skills Training) during junior high school
reported less use of illicit drugs than controls. These results also support the hypothesis that illicit
drug use can be prevented by targeting the use of gateway drugs such as tobacco and alcohol.
Cuijpers et al, (2002) describe the impact of a widely used school-based program in Holland and
conclude that the Healthy School and Drugs project as implemented in Holland may have some
effect on drug use in the children exposed to it. This quasi-experimental study in which students of
nine experimental (N = 1156) schools were compared with students of three control schools (N =
774). The groups were compared before the intervention, 1 year later, 2 years later and 3 years later.
Self-report measures of tobacco, alcohol and marijuana use, attitudes towards substance use,
knowledge about substances and self-efficacy. Some effects on the use of tobacco, alcohol and
cannabis were found. Two years after the intervention, significant effects could still be shown on
alcohol use. Effects of the intervention were also found on knowledge, but there was no clear
evidence for any effects on attitude towards substance use and on self-efficacy.
Flay (2000) reports on several interventions and concludes that many studies have reported positive
effects on behaviours for up to three years. However, data from several long term studies indicate
that effects gradually decay over time, suggesting the need for ―booster‖ sessions. However, Flay
also notes that little is known about the impact of such ―booster‖ sessions. He also notes that there
have been very few longitudinal studies on substances other than tobacco.
Flay (2000) also refers to long-term follow-up data from a large-scale randomized trial involving
students from 56 schools in New York State found reductions in smoking, alcohol, and marijuana
use 6 years after the initial baseline assessment (Botvin et al. 1995a). The magnitude of these
reductions ranged up to 44 percent in drug use and 66 percent in polydrug use (defined as
adolescents who used all three gateway substances during the past week). Results of studies
utilizing generic skills training approaches such as the LST program have also demonstrated an
impact on other forms of drug use. Several studies have demonstrated an impact on the use of
alcohol (Botvin et al. 1984a, b, 1990a, 1994b) and marijuana (Botvin et al. 1984a, b, 1990b, 1995a,
b). These reductions have generally been of a magnitude equal to that found with cigarette smoking.
In concluding this particular discussion, logic and intuition might suggest that the questions about
long-term effects should be more precise in such studies. For example, one question might be asked
to determine if universal programs are able to delay experimentation with alcohol and tobacco until
a later age, when more young people would be better equipped to decide about use. Another
question about long-term impact might ask specifically about harm reduction strategies such as
drinking and driving and whether school programs were a factor in reduced driving under the
influence.
31
32
Does the research describe which of the sub-populations or which of the specific
addictions/substance messages that can be reached or conveyed through school-based or
school-linked programs? How many children/youth of school age are truly not present in
school during the day?
This review found a few studies that tested the use of “universal” prevention programs on students
who are “indicating” problem use. Other studies were noted that seemed to indicate that middle school
programs might be the best age for school-based educational programs. However, none of the studies
located in this review were definitive.
Which alcohol/drug messages are more credible coming from teachers, counsellors, peer helpers,
coaches, parent volunteers, principals etc. Which are more credible if they come from parents?
From public health nurses? etc
This review did not locate any records that sought to apply such communications analysis to school-
based prevention programs on alcohol and drugs. We also did not locate any studies that asked
youth about their current sources of information and knowledge about alcohol and other drugs. This
type of question has often been asked on other surveys on other health topics such as sexual health
(Boyce et al 2004) that found that schools were the primary and most reliable source of information
oh sexual health, when compared with sources such as parents, friends and the Internet.
Another aspect of this question would be to verify which sources are more or less effective in
communicating with youth who are at higher risk of harmful use. This writer has questioned the
assumption that “street youth” are not reachable through schools. In fact, there are very few youth who
actually live on the street. Most are “curb-siders” who go to school during the day, sometimes because
they have to do so for their parole requirements. Traditional school methods and norms will not likely
reach these young people, but it may be that the physical environment of the school is one of the few
environments in which these young people can be contacted.
A review done in preparation for Health Canada’s Compendium of best practices in youth prevention
(Roberts et al, 2001) described the ways to communicate with youth about drugs and which messages
might be more effective. The following suggestions have been derived from this analysis of the
youth population and their perceptions of substance use. Behavioral and other messages to be
delivered within prevention programs and services should be developed and implemented using
these five basic suggestions:
a) Understand and segment the youth population before selecting your messages.
b) Select messages that will be credible to your sub-population and local context
c) Ensure that the sources used and styles of delivery are congruent with the content of your
selected messages
d) Develop a grater understanding of the perceptions and practices of the immediate adult
intermediaries who live and work daily with youth. Develop prevention programs and
services that will help them to be more effective in communicating with youth about
substance use and abuse.
e) Consider how to involve youth more directly in decisions about which messages you will
include in your prevention programs and services.
32
33
People change their behaviours because of perceived risks and benefits. For young people and
others, the perceived level of risk will be significantly affected by their observations of others. If
they regularly see adults misusing alcohol, tobacco and other drugs, they are less likely to perceive
significant risk. If they see friends using drugs such as marijuana socially without dire
consequences, they are less likely to accept abstinence messages.
The perceived benefits of substance use for youth are the same as and different from those often
perceived by adults. People use alcohol, for example, to relieve stress, escape boredom and heighten
enjoyment. Youth, however, also may use alcohol for their own developmental purposes, such as
entry into adulthood, as a means to join a peer group, and as a way to experiment with different
lifestyles.
These youthful perceptions of risk and benefits in substance use are a major challenge in prevention
programming and policy-making. They serve as a reminder of why we need to consider carefully
how we can successfully communicate with youth about substance use and abuse.
Understanding Younger People
There are several factors that make youth a unique population in regard to substance abuse
prevention program planning and policy-making. These include being young, developmental needs
related to adolescent development, key transitions and life events and popular youth subcultures. All
of these factors lead to current levels of youth knowledge, perceptions and beliefs about substance
use which are briefly discussed here.
Being young
The exuberance of youth, their idealism, their lack of independence and their lack of experience all
create specific characteristics that need to be addressed in programs. Young people are generally
less able to see long term consequences (Paglia, 1998), so messages need to emphasize short term
benefits or risks. They are less bonded with conventional norms and customs Paetsch & Bertrand,
1999; Simons-Morton et al, 1999; Jenkins 1996), so messages need to help them form those
linkages. At the same time, they are controlled in almost very aspect of their daily lives due to a
lack of independent resources. So messages that promote autonomous decision-making have greater
appeal (Kim et al, 1998; Wallerstein & Bernstien, 1998). Young people are more likely to take
risks, positive or negative. So messages need to offer positive risks and challenges.
Youth today are optimistic, idealistic, self-reliant, activist and seeking authenticity (Health Canada,
nd). So messages need to be positive, point to personal goal attainment, issue calls for moral or
spiritual action, show youth in meaningful activities and be authentic in their meaning (Center for
Substance Abuse Prevention, 1999).
Child and Youth Development
Children and youth reach different stages at different ages; with each stage being accompanied by
important developmental tasks that need to be recognized and built into prevention strategies. These
stages and developmental tasks need to be addressed in prevention messages. These developmental
needs include recognition, the development of competencies, independence,
intimacy/interdependence with others, identify formation and social interaction and
experimentation. Council on Social Poilicy Renewal, 1999; Carr, 1996; Amos et al, 1997; Banwell
& Young, 1993; Wilks, 1992, Room, 1994, Center on Addictions and Mental Health, 1999). Risk
33
34
taking is an essential tool for youth to use in achieving these developmental tasks. (Irwin &
Millstein, 1986; Jessor, 1982)
The young person‘s need to create an identity separate from their parents leads to experimentation
with a variety of lifestyles. Consequently, youth sometimes choose to use drugs like they choose
clothes or music, as a means to build their new identities (Paglia, 1998). Perhaps we should not
overreact to experimentation with substances, in that such exploratory behaviour usually subsides
after age 20 (Paglia, 1998). The need to develop competence and for recognition can lead to
negative risk taking, unless there are other outlets. The need to form interdependent and intimate
relationships with peers will prompt young people to form or join groups as a way of finding those
relationships. Some of these groups may have norms that permit or encourage substance use. So
the use of drugs can facilitate entry into that group, or to gain social status within the group. Finally,
the physical changes associated with puberty can encourage youth to seek sensations to alleviate
those pressures. Thus, substance use can have a symbolic and functional benefit for youth.
Another major need in the development of children and youth is the acquisition of approp[riate
social skills or competencies. Without those interpersonal, coping and decision-making skills, an
adolescent is at higher risk from several health and social problems. Consequently, it is not
surprising that many prevention programs seek to instill these skills (Flay, 1985; Rooney & Murray,
1996).
Transitions and Events Can Heighten Vulnerability
Several key transitions in the development of the young person, as well as life events such as
bereavement, moving to a new neighbourhood, family crisis or parent unemployment can create
times of greater risk (Rutter, 1989).
Alcohol use during pregnancy can have serious effects. Up to age five, children learn about
expected behaviors and consequences through family interactions and play with others. The
transition from home to school at age five can be difficult, leading to antisocial behaviours.
Children aged six to 12 can learn incrementally about substances, and develop social and decision-
making skills that will later be applied to substance use. The transition into high school can be
difficult for many, particularly girls. Later in school, boys become more vulnerable, suffering more
from school dropout, violence and less participation in post-secondary education or training. The
transition to college, university or to a new job often creates opportunities to abuse substances in
less controlled environments, with many youth becoming susceptible for at least a period of time.
Throughout childhood and adolescence, youth can become more vulnerable to risk due to
bereavement, divorce, moving to another neighbourhood, working too much at a part time job or
from other life events.
Problematic use of substances is often linked with other risk behaviours and conditions. As
researchers such as Jessor and Jessor (1977) have explained, such problems are often presented in
clusters of negative behaviours and situations.
Selected messages and programs need to be available for youth as they encounter these transitions
and situations. .
Youth Subculture Can Be an Intermediary to Health Messages to Youth
34
35
Popular youth subculture can create social norms that are different from those of adults. While the
passage through this subculture may be transitory for most young people, their impact are no less
real than other social influences. Consequently, the youth sub-culture should be seen as an
intermediary in communicating with youth (Center for Substance Abuse Prevention, 1999).
Popular youth culture cuts across racial, ethnic, geographic and other boundaries. This culture is
very prominent and are promoted quickly in the mass media and through other new technologies.
While the fashions and language in this subculture change quickly, there are some core features
such as nonlinear thinking, rapid change, low respect for prescribed authority, and disrespect for
secondhand adult attempts to be ―cool‖. These features need to be recognized when choosing
sources and styles of message delivery (Health Canada , 1999).
Youth Knowledge, Perceptions and Beliefs about Substance use
Youth knowledge about substances and their impact on health appears to be consistently high. But
young people, like adults, continue to use and abuse substances, so we need to dig deeper in our
analysis.
One important factor are the youth normative beliefs about alcohol, tobacco and other drugs. If they
believe that most or many people use these substances, then they are less likely to abstain from use
or be worried about regular use. Consequently, messages need to be developed and delivered for a
variety of youth sub-populations and programs to convey the message that most don‘t smoke, most
don‘t misuse legal drugs and most don‘t use illicit drugs.
A second important factor is the personalization of risk (McCallum, 1995). Young people, like
adults, are aware of the risks of substance use, but are less able to calculate the consequences, have
a poor sense of the time frames or believe they can control the consequences (Holtgrave et al, 1995;
Paglia, 1998). Since the personalization of the risk is essential to behaviour change, this presents a
major challenge for prevention program planners.
Canadian Studies of Youth Knowledge and Beliefs about Substances
Health Canada (1996) studies tracking youth attitudes/beliefs toward substance use as well as other
studies comparing the drug-related beliefs of all youth population and ―out of the mainstream
youth‖ (OMY) should inform message development. These attitudes or beliefs about substances are
reliable predictors of substance use.
That same 1996 Health Canada study found that youth attitudes towards drug use were becoming
more liberal between 1996 and 1993. These included items such as a party needs drugs, doing drugs
is cool, some drugs are all right, marijuana to teens is like alcohol to adults and mist drugs are not
harmful if not used too much.
The Health Canada comparisons between all youth and OMY youth should also inform message
development. They found that:
neither OMY youth or all youth believe that it is necessary to drink alcohol to be accepted
more OMY youth believe a party needs drinking
more OMY youth believe that their peer group drinks
more OMY youth find it difficult to talk with their parents about alcohol and drugs
more OMY youth are surrounded by friends and family that smoke
fewer OMY youth believe their parents would tell them to stop smoking
35
36
fewer OMY youth believe their best friend would care if they smoked
the same proportion of OMY youth and all youth were asked to stop smoking last year
Segmenting the Youth Population
Identifying sub-populations of youth that can be served through prevention programs and services is
essential to effectiveness. This can be done in a variety of ways, including grouping by level of
substance abuse or the different stages of adoption or change, by age, gender, race/culture, local
community or family context or even by psycho graphic profiles.
Grouping youth by their levels of substance use
This is a popular and traditional way to organize prevention programs. Primary, secondary and
tertiary prevention programs have been developed in the past. More recently, such programs have
come to be called Universal, Selective and Indicated Programs. This compendium has adopted this
categorization of programs.
Stages of Adoption or Cessation
Similarly, prevention messages can be aimed at different the individual‘s various stages of
adoption/cessation of substance use. (See the earlier discussion of how young people experiment
with drug use and how they may become regular or heavy users.) Studies have shown how these
levels of involvement with drugs can be used to develop specific messages for different youth.
Experimentation with substances can be viewed as normal, but it can have harmful unintended
consequences such as car accidents and unplanned pregnancies. As well, earlier experimentation is
associated with higher risk of abuse. So onset should be delayed as long as possible. Research
(Paglia, 1998; Blaze-Temple & Low, 1992; Mackesi-Amito et al, 1997) has debunked the myth of
so-called gateway drugs that lead to heavy, harder drug use, so messages should not focus on
specific substances. Specific risks associated with regular use, such as binge drinking (De Wit et al,
1997; Clapper & Lipsitt, 1992), drinking and driving and substance use while deciding about sex,
should be addressed with specific messages within prevention programs. Heavy drug users should
benefit from specific messages encouraging reduced harm and risk, such as using drugs in a safe
environment, clean needles and limiting use as much as possible. Specific messages should also be
tied to different stages in rehabilitation particularly when risks of recidivism are highest.
Stages of Change
Prevention messages can also be organized to move youth along a stages of change continuum
related to substance use and behaviour change (McGuire, 1989; NiMurcho et al,1997; Prochaska et
al, 1994, 1994a; Migneault et al, 1997). Messages first raise awareness and knowledge, then modify
perceptions of risk and benefits as well as attitudes and beliefs, then develop relevant coping skills
and then provide awareness of and access to sources of support from peers, parents, educators and
agencies. Messages aimed at only one part of this continuum (eg. only knowledge, or only
resistance skills) have proved to be limited in their effect. Consequently, programs and services
need to deliver a variety of messages along this stages of change continuum (Werch & Anzalone,
1995; Werch et al, 1993; Werch & DiClemente, 1994).
Different Age Groups
36
37
Differentiating the youth sub-populations by age is often done. The key to success here is to identify
the relevant stages of childhood and adolescent development and address those developmental
needs with specific messages, in age appropriate ways. As well, the content of the messages needs
to be age appropriate, building a scope and sequence to their learning about substances.
Differentiating by Gender
Grouping messages by gender may also be useful. Boys appear to be at greater risk of substance
abuse. They have lower perceptions of risk, are more prone to sensation seeking, and tend to be
more peer oriented in their decision-making Cunningham-Burley, 1999; Paglia, 1998). Different or
more messages may be appropriate for this male sub-population. Girls appear to be more influenced
by social consequences, attractiveness issues and appearances that relate to maturity.
Race, culture, language and spiritual beliefs
All of these cultural and ethnic beliefs can have an influence. Consequently, the sources and styles
of messages should be adapted for these factors. For example, aboriginal youth can benefit from
programs that include messages about traditional ways that are interwoven with prevention
messages.
Local Community Context, Family Situation, Economic Circumstance
Local community norms re substance use as well as the family‘s practices should also be taken into
account in tailoring the messages to specific groups of youth (Hawkins et al, 1992; Vertinsky &
Mangham, 1992). Young people living in rural communities or inner cities may have differing
perceptions of substance use. The children of alcoholic parents have specific needs that need to be
addressed with specific messages of support. Economic disadvantage is obviously part of this
contextual analysis (Frhalick, nd).
Psycho graphic Profiles/Segmentation
More recently, psycho graphic profiling (grouping youth by clusters of strongly held and
interrelated perceptions and beliefs) has been applied to drug abuse prevention for youth. Using this
technique, a Health Canada project (Adrian, 1995; Mintz & Laporte, 1995) found that ―TGIF‘ers
(gregarious youth) and ―Luddites‖ (passive loners) as being at higher risk of substance abuse. This
technique is often used by marketing agencies to sell commercial products.
Street Youth
Canadian studies (Caputo et al, 1997; Adrian, 1995) have described the lives and norms of street-
involved youth. This sub population is composed of hard-core street-entrenched youth as well as
many who are ―curb-siders‖ who stay at home but who spend most of their free time on the street.
Programs for street-entrenched youth should focus first on meeting their practical, urgent, daily
needs rather than being too focused on substance use. Programs for ―curb-siders‖ should aim more
at reintegrating the young people into stable environments such as the school, revised home
situation or foster care (Caputo, 1997).
Credible and Non-Credible Messages
37
38
If a prevention program is based on or includes a behavioral or other message that is not credible
with youth, then it is less likely to succeed. In this part of the discussion we address issues such as
abstinence-only and cold turkey messages, fear and social consequences messages and truly
understanding the influence of peer groups.:
―Abstinence-only‖ messages
At a certain point abstinence-only messages with older youth become less credible. Cognitive
dissonance occurs, when youth observe adult substance consumption patterns and are subjected to
media influences promoting such consumption. As well, other studies show that youth may
establish their own common sense rules about use of drugs such as marijuana based on their own
use or observations of their peers who use the drug socially without dire consequences (Brown et al,
1997). This reality negates any attempts to treat this drug as the same as other more addictive drugs.
As well, the previously discussed youth predisposition to experiment, a factor caused by adolescent
development, may make this abstinence-only message inappropriate for many youth. Such factors
interfere significantly with the credibility of a abstinence only message. Similarly, ―cold-turkey‖
messages may often be ineffective with regular or heavy users. A harm reduction message may be
more effective in many circumstances with this group of youth.
Fear-based messages
Fear-based messages when they are accompanied by nonfactual presentations of information or
presented without realistic avoidance strategies, may be more harmful than good (Paglia, 1998).
Scare tactics generally prove to be ineffective, unless they are based on factual presentations and
credible presenters (such as former addicts). Realistic alternatives and steps to avoid risky situations
need to be presented.
Social Consequences
Messages that emphasize immediate social consequences such as bad breath or looking stupid may
be very effective (McLennan et al, 1998). Similarly, novel presentations (eg a child simulating a
hung-over adult bragging about being drunk), may point out the false value of other social
consequences in a powerful way.
Social Justice Messages
Youth have a greater sense of moral outrage and sense of justice. Consequently, messages that show
how tobacco and alcohol companies market their products can be credible with youth (Center for
Substance Abuse Prevention, 1999).
Peer Group Membership, Not Peer Group Pressure
Misunderstanding the influence of the peer group may lead to inappropriate messages. For example,
there may be little direct pressure from peer group members to use drugs or alcohol (Banwell &
Young, 1993). On the other hand, there is intense pressure on youth to join or form a peer group
Oetting & Beauvais, 1987; Kinsmen et al, 1998) . Alcohol or tobacco use is an easy way for youth
to be seen to join a peer group. On the other hand, the role of a close friend may be very influential
(Smart. 1997; Urberg et al, 1997).
Relating to Other Dominant Youth Concerns
38
39
Marketing and health experts (Witte, 1995) often suggest that messages relate to other high priority
concerns of the target audience. Some of the dominant current concerns of today's youth are: getting
ahead in tough economic times, managing relationships, fitting in, health issues, especially those
that relate to attractiveness and managing stress. Messages that connect substance use reduction to
those concerns are more likely to succeed.
Blanket Messages or Slogans
Short slogans might look good on ads, but they are often ineffective with youth (Paglia, 1998). For
example, the public message, ―AIDS is everyone‘s problem‖ will have little resonance with most
people who have little personal contact with anyone with AIDS. Saying no to drugs is more
complicated than ―Just Say No‖ and all kids know it. So we should not try to fool them or pretend.
Effective Delivery of Messages
Selecting the sources (medium) as well as the style of delivery (pace/tone, spokespersons, images,
language) is also critical in delivering health messages to youth. If they are not congruent with the
content of the message, they will reduce its impact. These include understanding how youth
communicate today, choosing the source of the message, the pace and tone of the message as well
as the spokesperson, symbols and images and language used to convey the message.
Understanding How Youth Communicate
Before discussing aspects directly related to youth substance abuse prevention, let‘s examine how
young people are communicating in today‘s society. Media is a big factor in their lives (Health
Canada, nd). They appreciate words that capture the latest trends, but it is very difficult to use those
words in prevention messages because they change very quickly. They are very fashion conscious
and will reject messages if the person is wearing out of date clothes. Youth resent falseness, so
don‘t try to hide the fact that you are delivering a prevention message.
Youth today are also using the Internet as an alternative to television. They use it from home and
primarily for entertainment and social interaction. Advertisers have already recognized this reality.
As a consequence, youth are more likely to be comfortable with nonlinear forms of communication
and using multiple forms of communications simultaneously (Health Canada, nd).
Selecting Your Source Carefully
Choosing the source or the medium to deliver the message within a prevention program needs to be
done carefully. Parents can deliver (and receive) many messages to their children but may not be
credible on some drug related topics. Schools can teach certain things and provide support to all
students as well as help some at-risk students but they may not be able to address some topics or
help some youth at all. Recreational programs can provide alternatives to all youth and be aimed at
high risk youth as well, but are not universal. Street programs can reach some youth at some times
in certain ways, but are at the wrong end of the continuum of use.
But not all sources of prevention messages can do everything. Young people will and should
consider the source of the message and will judge its credibility accordingly. Prevention planning
needs to take this into account.
39
40
Pace and Tone of the Messages
The pace of the message will be a factor in the youth‘s perception of the message. Novel content or
presentation is often attractive to youth (Louis & Sutton, 1991). Messages that relate to the human
senses will be attractive to boys and messages that revolve around relationships will be attractive to
girls (Donahew et al, 1991).
Spokespersons
The spokespersons used to deliver the message will have an impact on its perceived credibility
(McKenzie, 1999) . For example, teachers are not likely to be seen as being credible as former
addicts on the impact of drug use. But they are seen to be credible helpers in avoiding conflict with
other teachers at school or in improving their grades.
However, a California study (Brown et al, 1997) indicates that youth want more than a simple
presentation from a former addict. They already know that drugs are ―bad‖. They want to be able to
relate that person‘s experience with their own lives and values, to explore and discuss the
relationships and experiences that might lead to drug abuse.
Symbols, Images, Language
The symbols, images and language used to deliver messages will influence their acceptance.
However, it is difficult for programs to stay current with the fast-changing language and fashions of
the youth subculture.
Communicating with Adults to Prevent Youth Substance Abuse
The perceptions, attitudes/beliefs and behaviours of adults working and living with youth will have
an impact on the effective delivery of health messages.
Unrealistic Understanding of Youth Substance Use
Some studies (Fromme & Ruela, 1994; DiLorenzo et al, 1991) show that parents and school
personnel tend to underestimate the level of substance use among youth. This lack of understanding
may lead to not actively discussing drugs in the home and to poor or sporadic delivery of school-
based programs.
Involving Youth in Decisions about Message Development and Delivery
Involving selected youth in decisions about which messages and how they will be delivered in prevention
programs is a relatively new phenomenon. There is a growing research base that suggest autonomy-based
learning can be effective (Kim et al, 1998; Labonte, 1994). Consequently, the decision to consult youth about
the messages to be included in prevention programs is often linked to an empowerment approach to health
promotion.
There is considerable promise from this approach that programs may become more relevant to youth,
particularly if the youth involved as decision-makers are truly from the intended youth sub-population and
have a meaningful way to consult them prior to deciding things.
40
41
However, reviews of such youth empowerment practices is at its infancy stage. It may well be that we are
empowering only a minority of youth (those with more personal resources) to influence and deliver programs
that are no more effective than those developed by sensitive and dedicated.
For example, a Health Canada project (Described in Shannon & McCall, 1999) that used a contest
to involve youth in deciding on tobacco prevention messages led to ads that were as successful in
raising youth awareness as other advertising themes selected by professionals. No worse, but also
no better.
If youth are to be involved in decision-making about prevention messages, there are several general
and specific conditions that need to be met for this to be successful (Center for Substance Abuse
Prevention, 1997). Timelines will need to be more flexible, trust will have to be nurtured, messages
will need to be in sync with youth values and norms and youth will need to have primary control
over the direction of the communications. The Health Canada study (Shannon & McCall, 1999)
examined youth involvement in other forms of public decision-making. Several specific criteria
were developed that can be applied to prevention program development.
3. Understand Impact and Prevention Role of School Environment
This sub-section of the report examines the impact of the social and physical environment of
the school on substance use and the role and effectiveness of school-bazsed and school-linked
programs in preventing harmful use. In this discussion, we examine the population health
principle of examining various settings or contexts for health. We examine the elements of
Comprehensive School Health promotion insofar as understanding the potential and the limits
the school setting. Ecological theory tells us to look for interactions between the individual and
the environments and among the environments that play a significant role in the lives of
children and youth. Strategic thinking tells us to scan these environments regularly/
Our key findings here are:
o research and several recognized behavioural theories confirm that the
environment of the school setting interacts with the characteristics of the child
and the family, as well as other systems and the community to influence the use
of substance by children and youth
o school-based and school-linked interventions and programs can positively
influence the substance use choices made by all young people, especially if they
are based on a social influences/social environment/mental health services
approach that coordinates multiple interventions and links substance use with
mental health, life skills and adolescent development.
o Well-founded theories, conceptual frameworks and new insights for explaining
the impact of the school environment and its linkages with the related
environment of home and community are emerging but several areas require
extensive study and research
o the knowledge about school-based and school-based programs and
interventions relating to alcohol and drugs is similar to that related to other
health issues; a coordinated approach using multiple interventions from a variety
of agencies is more effective but even a single intervention such as instruction
of parent involvement can have a limited but significant effect.
o There is considerable knowledge available from which a defensible program
model or logic could be constructed to guide the development of relevant and
meaningful Indicators. However, this model would have considerable gaps,
including the extent to which program effect could be sustained over time, the
41
42
degree to which and methods for interventions can be coordinated and
appropriate end points or outputs for health, social and learning outputs at the
time of graduation from high school (as opposed to longer term life related
outcomes.)
Diez-Roux (2002) notes that there is a growing body of research in epidemiology and public health
has examined how characteristics of the places where people live are related to a variety of health
outcomes, including health-related behaviors, prevalence and incidence of disease, and mortality.
In Canada, researchers have also described the importance of a settings-based approach (Poland,
Green & Rootman, 2000). Further, senior policy-makers have expressed interest in the use of
settings to coordinate and consolidate prevention efforts in the Healthy Living Strategy (Health
Canada, 2003) and in a preceding paper prepared for the Advisory Committee on Population Health
and Health Security (2002).
As well, the Canadian Institutes for Health Research (CIHR) have funded several projects on the
impact of environments on health, including the SHRN and other grant recipients represented at the
Vancouver workshop
The importance of the school environment on the development and maintenance of youth health
generally is established in the research literature (Allensworth et al, 1997, Mackie & Oickle, 1996;
Nutbeam & St. Leger, 1996, World Health Organization, 1991; World Health Organization Expert
Committee on Comprehensive School Health, 1997; Parcel et al, 2000; Perry, 2000; St. Leger,
1999; Whitman et al, 2000, Ronson, 2003, Miller, 2003, Cuijpers et al, 2002).
The importance of the school setting is felt in these ways (WHO Expert Committee on
Comprehensive School Health Education and Promotion, 1997, pp.1-2):
a) Health Status Affects the Capacity to Learn
Health is a key factor in school entry. Nutritional deficiencies, physical and mental
disabilities and problems associated with premature sexual activity, tobacco/alcohol/drug
use, injury, bullying and violence and other health/social issues can inhibit or prevent
academic success.
b) Educational Attainment Affects Health Status
A lack of basic academic, literacy and numeracy skills prevents a person‘s capacity to
participate fully in personal, family and community life. Formal academic status is directly
liked to economic status.
c) Purposeful interventions using the school as the delivery system can influence short-term
and long-term health status as well as improve educational achievement.
Does the evidence suggest that the social and physical environment of the school
setting of the school has an impact in enabling or preventing substance abuse?
Does the research indicate that school-based and school-linked programs are based on
recognized behavioural and environmental/determinants theories and approaches?
42
43
A New Way of Understanding the School Role
There are a variety of terms used to describe school-based and school-linked health promotion,
including ―Comprehensive School Health‖ (the Canadian term), a ―Health-Promoting School (the
European term) or ―Coordinated School Health‖ (the American term). In England, the term used in
policy documents is simply ―Healthy Schools‖. In Quebec, the term that has developed is ―Ecole et
milieu en sante‖. Similar terms such as the ―community school‖, a ―full service school‖ and ―cities
in schools‖ are also used for local promotion and prevention programs and approaches.
In addition to the different terms, there is also some confusion with the concept (Who Expert
Committee, 1997). Is it an outcome (a ―healthy‖ school), an approach (emphasis on different
agencies working together), a set of values (based on a holistic view of health and well-being), an
issue specific program (coordinated interventions to prevent one problem) or coordinated set of
programs and services (to address several health problems or to promote health in general)? To be
inclusive, we are saying that ―school health‖ includes all of those ideas.
We should also try to be both specific and inclusive in describing what we mean by the ―school‖. In
fact, we mean the students, volunteers and staff of the school, the parents served b y the school, the
surrounding neighbourhood, the professionals, agencies and that work with the school, the school
system and other systems that have mandates to work with the school.
Using this notion, we can define the potential roles of the school in promoting health as including:
o instruction to transmit coping skills, attitudes/beliefs, access to social support, awareness of
health services as well as health knowledge or information
o informal awareness and learning through extra-curricular, co-curricular and other school
activities
o empowering and engaging activities to enhance the young peoples‘ capacity to determine
their own futures and to influence their own environments
o creating peer-led health promotion activities, programs as well as using peer-helper
programs to enhance youth access to available preventive services and counseling/treatment
o delivery and re-orienting preventive and curative health (and other services) in a youth-
friendly, convenient and accessible manner\
o informing, involving and supporting parents to engage them in their child‘s schooling, lives
and neighbourhood life
o involving and supporting community and voluntary organizations to help them reach and
engage children, youth or their parents
o modifying the physical environment, equipment, facilities to enhance health, safety and
security
o compensating for a lack of economic resources among families by providing palliative
services such as school meals, access to toys and technology and specialized transportation
services.
We should also make it clear that ―the school‖ is not simply the classroom. There are many other
physical places within the school other than the classroom, there are many other formal and
informal activities in the school other than instruction and there are many linked activities and
systems that influence what happens in schools.
43
44
We have attempted to capture this inclusiveness and complexity in a diagram that follows this
discussion below. This diagram portrays some of the complexities and the messiness of the school
environment. We are trying to show that the same school can offer a different set of experiences for
different students or even the same student on different days or even the same student on the same
day. What happens in the hallway can be very different than what happens in the classroom, the
gymnasium or on the way to school.
In fact, our understanding of the nature and role of the school has evolved in the past two decades.
Nutbeam & St. Leger (1997, 7-16) have described the history of research in school-based or school-
linked health promotion.
“Early attempts at health education were driven mainly by the medical fraternity,
with exhortations to children about the dangers …. . This authoritarian,
instructionalist approach was superseded by a behavioural approach whose
interventions were shaped largely by social and cognitive behaviour themes.”
In 1988, a national conference sponsored by Health Canada led to a national consensus statement on
Comprehensive School Health (Canadian Association for School Health, 1990). This statement
was endorsed by over 25 national education and health organizations. It described many elements
and components of a comprehensive approach into four areas: instruction, social support, physical
environment and support services, rather than the traditional three.
The Canadian statement also noted that CSH is operationalized at several levels, including the
school/neighbourhood, school board/agencies, province/territory and nationally. There are several
purposes in using this framework, including promotion of school health, prevention of specific
diseases or problems, support for these experiencing poor health and treatment of illness/disorders.
Thus the Canadian contributions to the school health concept were the notion of
comprehensiveness, in integrating our approaches to various health issues as well as
coordinating multiple interventions through various levels in several different systems. Many
of the terms used in the Canadian statement would be found a year later in the World Health
Organization (1991) guidelines for comprehensive school health.
Meanwhile, a similar movement to a coordinated approach (going beyond education to include
health services and a healthy environment) was also underway in the United States. Diane
Allensworth, then Executive Director of the American School Health Association, who had assisted
in the development of the Canadian consensus statement, led discussions that resulted in changes in
the ASHA terminology and the development of an eight-part school health model in the United
States. In 1990, the Centers for Disease Control began its program to support ―coordinated school
health‖ in the United States. In 1997, the United States government commissioned a panel of
experts (Allensworth et al., 1997) to report on comprehensive school health that is a landmark in
our knowledge about school health programs.
Another important feature emerged in the discussions about the Canadian statement, equity of
effort and shared responsibility for school health. Traditionally, people and experts in the health
sector have articulated the roles, skills and content of the tasks that educators need to play in school
health. The traditional demands for more curriculum time and better teaching have been
supplemented by more demands on teachers to coordinate things for children with other agencies, to
engage youth in decision-making, to perform basic health services such as administering medicines
and responding to outbreaks of head lice, to have kids eat better in school than when they are in
their homes or the neighbourhood etc.
44
45
As well, health professionals have also recognized the impact of basic literacy, hence basic school
achievement as one of the determinants of health. Consequently, schools are now seen as a target
for the ―health literacy‖ movement, with greater attention being paid to school retention and
attention being paid once again to basic health knowledge. Consequently, school health proponents
need to learn more about educational paradigms such as ―effective schools‖ and ―school
improvement‖. We need to connect to landmark research about school dropouts from sources such
as Whelage & Rutter (1989). A Canadian review (Morris et al, 1991) has described this basic
research that describes the interaction between individual, family and school characteristics that can
lead to students dropping out or being ―pushed out‖.
As noted in the earlier section, Nutbeam & St. Leger (1997,) and St. Leger and Nutbeam (2000)
have called for a greater understanding of the constraints and pressures that schools face, but we
need to delve more deeply if we are to have health programs embedded into the fabric of schools.
While there is obvious synergy between the socialization and custodial functions of schools and
health promotion, there is also competition between health and the sorting/selection, academic and
vocational functions of schooling.
Even within the socialization function, there is a potential difference of perspective, where
educators see physical ―health‖ within the greater context of personal and social development.
Many traditional health professionals see health as avoiding a number of diseases and problems.
For example, our society has undergone a shift where we see many young people left looking to
their peers for the guidance that their parents used to provide. We also see that the media, political
leaders and business leaders are often providing the moral guidance (or lack thereof) that churches
and parents used to provide. So schools are struggling to provide ―character education‖. And, at the
same time as parenting skills and family life skills are may be waning, we see the elimination of
family studies from many schools. So, educators may see character, moral and parenting education
as more urgent than ―health‖ education.
The Europeans may be ahead of North American conceptions of school health on this question of
values and beliefs as the key elements of school health. The pioneers of the European Health
Promoting Schools Network met in 1990, where a few schools from the Czech Republic, Hungary,
Poland and Slovakia meeting to discuss their efforts. This was the beginning of the Health
Promoting School movement in Europe. Over the years, the European HPS Network has grown
and in 1997, their international conference resolution (Burger et al., 1999) captured and described
the HPS concept in several languages. This statement injected a new aspect to the discussion of
school health promotion. The European statement articulates ten principles of a comprehensive
approach that are more explicit about the social outcomes and values of the process. These include
concepts such as democracy, equity, empowerment, measuring success, collaboration, communities
and sustainability as well as a more traditional approach of defining elements such as school
environment, curriculum and teacher training.
In 1995, 27 countries in the Western Pacific responded to a WHO invitation to collaborate in the
development of health promoting schools. Guidelines for the development of HPS (World Health
Organization, 1995) identified six major elements of the framework including: school health policy,
physical environment, social environment, community, relationships, personal health skills and
health services. This South Pacific approach reflects the common characteristic of all attempts to
define school health promotion by listing some of the essential; ―components‖ that need to make up
the approach.
45
46
More recently, a Report of the 2000 Joint Committee on Health Education and Promotion
Terminology defined Coordinated School Health programs as:
―An organized set of policies, procedures and activities designed to protect, promote, and
improve the health and well-being of students and staff, thus improving a student‘s ability to
learn. It includes but is not limited to comprehensive school health education; school health
services; a healthy school environment; school counselling; psychological and social
services; physical education, school nutrition services; family and community involvement
in school health; and school site health promotion for staff.‖
In Canada, the concept of comprehensiveness and coordination was reinforced with the emergence
of the ―Population Health‖ approach (Health Canada, 1994; 1996). The comprehensive school
health approach was now understood as an application of the population health principles.
A Proposed Addition to the Theory Base for School Health Knowledge
The School Health Research Network (McCall, 2004, Miller, 2003) is attempting to develop a more
―ecological‖ and ―systems-based‖ approach to understanding how school health programs evolve.
Ecological Perspective
While the theory of ecological models has evolved over a long period of time, the application for
health promotion programming has been a recent development and Stokols has become a leader in
developing ecological models for health promotion. The ecological perspective, according to
Stokols (1992), is distinguished by four assumptions:
Assumption One: The health status of individuals and groups "is influenced not only by
environmental factors but also by a variety of personal attributes, including genetic heritage,
psychological dispositions, and behavioral patterns‖. Consequently, health promotion should
focus on the dynamic interplay among diverse environmental and personal factors as
opposed to a framework that focuses "exclusively on environmental, biological, or
behavioral factors.
Assumption Two: The relative scale and complexity of environments may be characterized
in terms of a number of components such as, physical and social components, objective
(actual) or subjective (perceived) qualities, and scale or immediacy to individuals and
groups.
Assumption Three: The effectiveness of an intervention can be enhanced significantly
through the coordination of individuals and groups acting at different levels.
Assumption Four: The interdependencies that exist among immediate and more distant
environments, and the dynamic interrelations between people and their environments need
to be recognized. ―People-environment transactions are characterized by cycles of mutual
influence, whereby the physical and social features of settings directly influence their
occupants' health."‖ Concurrently the participants in settings modify the healthfulness of
their surroundings through their individual and collective actions.‖ In health promotion,
for example, state and national ordinances aimed at promoting environmental quality and
46
47
protecting public health directly influence the occupational safety and health of community
work settings.
Stokols (1996) addressed the challenge of translating social ecological theory into guidelines for community
health programs.
1. Environmental settings have multiple dimensions such as social cohesion, emotional well
being, development maturation, and physical health status.
2. Environmental factors may affect people differently depending on such factors as
personality, health practices, perceptions of the controllability of the environment, and
financial resources.
3. Understanding the dynamic interaction between people and their environment requires the
application of such principles from systems theory as interdependence, deviation
amplification, homeostasis, and negative feedback.
4. This principle recognizes the importance of the interconnections between multiple settings
and life domains, and the close interlinkage between the social and physical facets of those
settings.
5. Social ecology analyses emphasize the integration of multiple levels of analysis (for
example macro level preventive strategies of public health and epidemiology with micro
level individual strategies from medicine) with diverse methodologies (epidemiological
analyses, environmental recordings, medical examinations, questionnaires, and behavioral
observations).
The diagram that follows illustrates this ecological and systems-based understanding of the school
environment. This environment is multi-faceted, interacts with home and the surrounding
community, is influenced by a variety of agencies who are part of professional and semi-
autonomous systems and interacts with the personal characteristics of the child in a variety of ways
that are not uniform for all children or even for the same child in the same day. For interventions
that promote health to be successful in this complex and multi-layered environment, they must be
sustained, coordinated and comprehensive.
47
48
48
49
Does the research indicate that certain characteristics of the school environment
(ie practices, staff, organization, programs and services etc) interact with
characteristics of the families (eg substance use practices, parenting practices,
socio-economic status, race, religion, etc) and communities (eg. resources,
norms, services/programs) and with characteristics of the child (eg genetics,
intelligence, skills, etc) in ways that promote or discourage substance abuse?
This work being done by the School Health Research Network is similar to the work being done by
Brian Flay in ―triadic influences‖ on behaviour.
Flay (2002) presents the thesis that all behaviors have common causes. Generally agreed-upon
categories consist of individual (biological, personality, character traits, prior behaviors), social
(including family, school, peers, and neighborhood) and broader social environmental influences
(economic, political, religious, etc). Thus, reviews of the predictors of tobacco use, substance use
more generally, violence, sexual behavior, and mental health all propose similar categories of causes
of these behaviors.
He suggests that the more proximal the cause to the behavior, the more likely it is to be specific to a
behavior. For example, attitudes toward substance use will be predictive of substance use, but less
predictive of violence or mental health. More distal influences, on the other hand, are likely to have
more generalizable effects.
49
50
Thus, school/home environment and parental involvement are associated with various factors affecting
children‘s mental and physical well-being. A positive school environment both reduces the risk of
substance use and delinquency and improves academic achievement Parental involvement is also
very important to a child‘s overall behavior in school, motivation to learn, grades and test scores, and
long term success.
Flay also suggests that the school and home environments should not be viewed separately
Some researchers have found that lower income, less educated parents are less involved in their
child‘s school, whereas others have found that SES does not impact parent involvement. However,
family structure does predict parent involvement; single parents are less likely to actively participate in
their child‘s school. Parental school involvement is also affected by parenting style and enthusiasm.
Consequently, the institutions of school and family should not be viewed separately; when teachers
and parents interact more, students perform better in school, but to increase parental involvement, a
school‘s organizational structure and staff attitudes must be positive.
Flay (2002) further suggests that health-compromising behaviors seem to be a "patterned response"
to disadvantaged social contexts.
Those in disadvantaged situations are less likely to "mature out" of problem behaviors as they
approach adulthood than are those from more advantaged social contexts. To the degree that poverty
serves to impair general skills, poor children may grow up with compromised social and economic
skills. The lack of educational opportunities in earlier years may place children of poverty at additional
disadvantage. Effects of poverty on academic achievement and children‘s risk for school dropout are
well documented. African Americans drop out of high school at disproportionately high rates (47%),
finding higher education increasingly inaccessible. Although African-Americans and Latinos currently
compose the bottom of the educational and economic ladder, by the year 2000, they are expected to
represent one third of all work-age youth. Dropouts can expect a life of chronic unemployment or low-
status, low-paying employment and disenfranchisement from society and its institutions. The resulting
depressed self-esteem, dissatisfaction, and alienation experienced by many dropouts can escalate to
disordered, aggressive behaviors and a greater probability of crime.
Flay (2002) argues that it is commonly accepted that levels of involvement in risk behaviors vary by
age.
For example, risk behaviors are rare among preadolescents, peak in mid- or late adolescence, and
decline in young adulthood. However, there are clear variations across behaviors in the age of peak
behavior and the age and extent of decline. Some studies have also reported variations in the
relationships between risk behaviors and demographic factors such as race/ethnicity and age.
Flay (2002) also notes that many theories of youth risky behaviors have been proposed over the
years.
Some of these theories are very focused on proximal cognitive-affective factors such as the Theory of
Reasoned Action and the Theory Planned Behavior. Many theories focus on social factors such as the
social learning theories of Akers and Bandura and broader versions of them such as social cognitive
theory, the multistage social learning model, social control theory, the social development model, and
the social ecology model. Other theories have attempted to be more comprehensive. Some of these
such as the domain model of Huba and Bentler are quite atheoretical, attempting just to accommodate
the many predictors of behavior. Some are more theoretical, the most influential example being Jessor
and Jessor‘s8 problem behavior theory.
If research on youth problem and positive behavior is to advance, our theories need to be integrated
with each other. Fortunately, a rapprochement among multivariate theories is possible because they
are largely complementary, and where one theory is weak, another is usually strong. For instance,
bonding theories can describe why adolescents become involved with deviant peers, social learning
theories can describe how involvement with deviant peers affects an adolescent‘s beliefs about a
50
51
particular behavior, and the cognitive theories describe how attitudes toward the specific behavior can
affect the likelihood of the behavior. The one theory that comes closest to integrating all of the above
theories, and that comprehensively accounts for the multiple empirical findings reviewed above, is the
theory of triadic influence.
Flay and others have reviewed existing theories and showed how these theories could be arranged
into a two-dimensional matrix.
The first dimension represents three types of influence: (a) cultural/attitudinal factors (eg, media
depictions of behavior), (b) interpersonal factors (eg parental warmth), and (c) intrapersonal factors
(eg, low self-concept). The second dimension represents different levels of influence: (a) ultimate
factors that, although beyond the easy control of adolescents, indirectly put adolescents at risk for
problem behavior; (b) distal factors that are one or more steps from causing problem behavior; and (c)
proximal factors that affect problem behavior fairly directly. We then used this matrix to develop the
theory of triadic influence (TTI).
In its simplest form, TTI asserts that the various causes of problem behavior fall into 3 distinct
"streams" of influence: sociocultural factors that affect attitudes toward problem behavior,
interpersonal factors that affect the social pressure adolescents feel to engage in problem behavior,
and intrapersonal factors that affect problem behavior-related self-efficacy or related avoidance skills
(Figure 2). Within each stream of influence, there are 2 substreams, representing control/affective (eg,
values/evaluations, bonding/-motivation to comply) and identity/cognitive (eg, expectancies, normative
beliefs, social skills) elements. TTI then asserts that each stream flows through 7 tiers of influence,
ranging from a few proximal variables that affect problem behavior fairly directly (eg, smoking-related
intentions) to a variety of more distal variables that might affect problem behavior only indirectly (eg
parental divorce). Consistent with cognitive social psychologists, we propose that all influences are
mediated by the cognitive construct of intentions.
Flay also further posits that each instance of a behavior has a feedback influence on its predictors.
Thus, an adolescent‘s experimentation with smoking might change her relationships with peers and
family, her own perceptions of the physiological effects of smoking, and her "knowledge" about the
personal and social effects of use. These changes might occur toward the top of streams of influence
and then filter down just as original causes did. However, they might also occur at the proximal level
— that is, smoking alters one‘s expectancies about and attitudes toward smoking, one‘s expectations
of reinforcement from others, and one‘s self-efficacy for refusing offers to smoke.
In its more complete form (Figure 3), TTI is the most comprehensive model of behavior to date, in that
it provides a single, unifying framework that organizes the constructs from many other theories,
including theories of social control and social bonding, social development, peer clustering,
personality, cognitive-affective predictors, social/cognitive learning, biological vulnerability, and other
integrative theories. Further, TTI also provides dozens of testable hypotheses about causal processes,
including mediation, moderation, and reciprocal effects. Thus, TTI provides the framework for
generating hypotheses and integrating results concerning direct and indirect effects, interactions
among predictors, and feedback effects that represent the immediate and long-term consequences of
prior behavior, including ongoing changes in problem behavior and its predictors. Indeed, the theory
can be applied to all of the behaviors under consideration in this paper (Figure 4). Note, however, that
the more distal/ultimate the predictors, the more commonality they have with the multiple behaviors,
and the more proximal the predictors, the more specific to the behavior they must be.
51
52
Flay concludes that all behaviors have the same causes, especially at the distal/ultimate levels.
Social influences — the social ecology — are particularly important during adolescence. These include
the influences of families, schools, peers, and neighborhoods/communities. All are amenable to
prevention and health promotion efforts. Thus, future prevention and health promotion programs need
to involve whole schools, families, and communities in an integrated and coherent way. Classroom
curriculum can teach content and social skills. To be most effective, curricula must be school-wide,
encompassing every grade level in a carefully scoped and sequenced (developmentally appropriate)
way. Cultural appropriateness may also be important. School-wide climate change can provide a safe
learning environment and provide a common language and consistent reinforcement of positive
behaviors, as can integrated family and community programs. Family programs can also teach
improved parenting skills in a way consistent with a coherent program, and community components
can strengthen school and community links and provide opportunities for students to observe and
engage in community service.
Scheier et al (2002) examine how ―clustering‖ occurs within the school social environment and then
correlate those clusters to drug use. They seek to determine if students nested within schools may
show some resemblance based on common (peer) selection or school climate factors (i.e.,
disciplinary practices, group norms, or rules). Appropriate analyses of any treatment effects must be
statistically correct for the magnitude of clustering within these intact social units (i.e., intraclass
correlation coefficient [ICC]). There is little reported evidence, however, of variation in ICCs that
might occur with studies of racially or geographically diverse populations. The purpose of this study
was to generate estimates of intragroup dependence for drug use and psychosocial measures
(hypothesized mediators) from three separate drug abuse prevention trials. Clustering for the drug
52
53
use measures averaged .02 across study and age-groups (range = .002 to .053) and was equivalently
small for the psychosocial measures (averaging .03 across studies and age-groups; range = .001 to
.149). With few exceptions and across different samples, clustering decreased in magnitude over
time. Clustering was largest for peer smoking and drinking norms among white, suburban youth and
smallest for alcohol expectancies among urban black youth.
Does the evidence suggest that the setting of the school is an effective place to
deliver education, preventive health services, social support and a protective,
healthy built environment that prevent addictions?
Trevor Hancock, in a review undertaken for the BC Ministry of Health planning found that there is
strong evidence of the impact of school health programs.
Healthy Schools (The Independent Inquiry, 1998) focused a lot of attention on the need to develop
health-promoting schools, in line with the World Health Organization's definition of such schools.
They concluded, based on recent evaluations, that such schools can "lead to gains in people's
knowledge, attitudes, self-esteem and health behaviours, particularly in primary schools". They paid
particular attention to the promotion of life management skills, substance misuse and sex education,
all of which had been evaluated and shown to be generally effective, particularly when they focused
on early education, a broad approach to wider influences on health-related behaviour, a supportive
school setting, quality programs and a comprehensive approach linked to broad life management
skills. They conclude that successful health promotion at school should increase "life skills" with
resultant improvements in many aspects of physical, mental and social health".
In the IUHPE review carried out for the European Union, St. Leger and Nutbeam (2000) state that
school-based interventions would be more effective if:
the focus is on cognitive and social outcomes as a joint priority with behaviour change
programs are comprehensive and 'holistic', linking the school with agencies and sectors
dealing with health
the intervention is substantial, over several school years, and relevant to changes in young
people's social and cognitive development
adequate attention is given to capacity building through teacher training, and provision of
resources.
They also note that the school environment is a major factor in school health promotion, including
the physical environment, the psychosocial environment and the organizational structure of the
school. Unusually - and very usefully - they point to some approaches to health promotion in
schools that have been shown to be ineffective and should not be used, including:
programs which are developed in response to a perceived crisis (especially if accompanied
by scare tactics and preaching)
broader school involvement which was spasmodic and uncoordinated
programs based largely on external speakers and resources with little involvement of school
staff
little or no investment in teacher training, and provision of support resources.
Finally, they point out that although integrated, comprehensive school health promotion programs
are needed; much of the research has concentrated on achieving specific behavioural outcomes. The
evidence shows that:
nutritional practices can be improved, particularly through multifaceted (skill development,
policy supported) programs
53
54
positive changes in physical activity can be achieved if the intervention is comprehensive
and integrated, uses properly trained personnel, ensures adequate time (60-80 minutes per
week), provides quality facilities and resources and occurs regularly during the week
even well designed and implemented health promotion programs aimed at tobacco, alcohol
and drug use have "only a modest effect on behavioural goals", and then only if they meet
the same criteria as for nutrition and physical activity programs.
In a chapter on school health programs in its report on promising practices in chronic disease
prevention (Centers for Disease Control and Prevention, 2003), the authors note that "rigorous
studies in the 1990's showed that health education in schools can reduce the prevalence of health-
risk behaviors among young people", including smoking, obesity, alcohol and marijuana use. A set
of promising practices for school health incorporate four key concepts:
the coordination of multiple components and the use
of multiple strategies
the coordination of health and education agencies and other organizations
the implementation of CDC's school health guidelines, and
the use of a program planning process to achieve health promotion goals.
A systematic review of 18 strong quality published reviews on the topic of using school-based
programs to reduce adolescent risk behaviour (eight related to smoking/drug use prevention, six
related to sexual risk behaviour prevention, and four related to emotional/behavioural problem
prevention –(Stewart, 2001) found that
Knowledge based didactic programs have no effect on behaviour.
Interactive programs are more effective than non-interactive ones.
Interactive programs based on social learning theory, including developmental, social norms
and social reinforcement are most effective.
Results are modest.
Some programs work for some subgroups of youth (e.g. programs focused on delaying
initiation of sexual activity among the uninitiated).
Finally, a review of 12 primary studies regarding the health promoting schools approach and 32
reviews of studies on the effectiveness of school health promotion (Stewart, 2001) found that
"Although the evidence supporting the health promoting schools approach is limited, this approach
is demonstrated to have an impact on the social and physical school environment in areas of staff
development, school lunch program, exercise, and social context. In some studies, this approach had
a positive impact on nutrition, physical activity, and mental and social well-being.‖ and the
reviewers concluded that:
"Health promotion interventions are most effective when they entail a multifaceted
approach.
Classroom education should be implemented in combination with changes to the school
environment and/or family/community participation.
When initiating the health promoting schools approach, it is important to implement all
components inherent to this approach."
Does the research indicate that certain characteristics of the school environment
(eg. practices, staff, programs and services) interact with the characteristics of the
families (eg. Substance use habits, parenting practices, socio-economic status,
race, religion etc), communities (resources, norms, services/programs) or
children (genetics, intelligence, skills etc) in ways that promote or discourage
substance use?
54
55
General Report and Meta-Analyses on Effectiveness
A review of Australian programs (Midford et al, 2002) identified the conceptual underpinnings of
effective school-based drug education practice in light of contemporary research evidence and the
practical experience of a broad range of drug education stakeholders. The research included a
review of the literature, a national survey of 210 Australian teachers and others involved in drug
education, and structured interviews with 22 key Australian drug education policy stakeholders. The
findings from this research are presented as a list of 16 principles that underpin effective drug
education. In broad terms, drug education should be evidence-based, developmentally appropriate,
sequential, and contextual. Programs should be initiated before drug use commences. Strategies
should be linked to goals and should incorporate harm minimization. Teaching should be interactive
and use peer leaders. The role of the classroom teacher is central. Certain program content is
important, as is social and resistance skills training. Community values, the social context of use,
and the nature of drug harm have to be addressed. Coverage needs to be adequate and supported by
follow-up.
Cuijpers (2002) working in the Netherlands, presents a similar list of ―ingredients‖ for effective
programs. He reviewed three types of studies; meta-analyses (3 studies were included), studies
examining mediating variables of interventions (6 studies), and studies directly comparing
prevention programs with or without specific characteristics (4 studies on boosters, 12 on peer-
versus adult-led programs, and 5 on adding community interventions to school programs). Seven
evidence-based quality criteria were formulated: the effects of a program should have been proven;
interactive delivery methods are superior; the "social influence model" is the best we have; focus on
norms, commitment not to use, and intentions not to use; adding community interventions increases
effects; the use of peer leaders is better; and adding life skills to programs may strengthen effects.
A random control trial conducted by Furr-Holden et al (2004) suggest that developmentally
appropriate programs that combine instruction with family involvement can be effective with
reducing experimentation with illicit drugs.
Ellickson et al, 2003, have reported on a large scale, random controlled trial in Dakota that reported
that a grade 7 and 8 program of 14 lessons can have an impact on cigarette and marijuana use
initiation, current and regular cigarette use, and alcohol misuse. Reductions ranged from 19% to
39%. Program effects were not significant for initial and current drinking or for current and regular
marijuana use.
Bruvold (1990) found in a non-quantitative meta analysis that, at that time, different programs had
different effects on knowledge or attitude/beliefs. He noted that recent meta-analytic reviews
indicate that information-focused interventions have more impact upon knowledge but less upon
attitudes and behavior whereas alternative interventions have less impact upon knowledge but more
upon attitudes and behavior. Bruvold replicated these meta-analyses on eight risk-reduction
programs meeting six standard methodological requirements for evaluation research in use at that
time in California..
Cuijpers P (2002) reviewed and compared peer-led and adult led prevention programs. They report
that several studies have suggested that peer-led drug prevention programs are more effective than
adult-led programs, but the evidence is not conclusive. Cuijpers presents a meta-analysis of studies
that compare drug prevention programs led by peers to the same programs led by adults. Twelve
studies were identified in a systematic literature search. The quality of these studies was not
55
56
optimal, and the interventions and target groups differed considerably among studies. Overall, peer-
led programs were found to be somewhat more effective than adult-led programs (standardized
difference d: 0.24). Large differences between studies were found, with some studies indicating
greater effects for peer-led programs and other studies showing greater effects for adult-led
programs. It is concluded that the effectiveness of a prevention program is determined by several
characteristics of the programs. The leader may constitute one of those characteristics.
McBride (2003) provides a systematic review of the school drug education literature to June 2001
and identifies components that have the potential for creating effective drug education programmes
in schools. The review adopts a well-defined search methodology, specific selection criteria, and
has made a series of recommendations based on the findings of past reviews and recent primary
studies that met the selection criteria. The review is inclusive of reviews and recent primary studies
that involved young people in school settings that encompassed a classroom intervention, included
drug-related behavioural measures and had a positive impact on students' drug-related behaviours.
The review identifies several areas that should be the focus of future programmes. These include
timing and programming issues, content and delivery issues, teacher training, and dissemination.
There is much refinement that can occur in school drug education implementation and research. The
way forward is to continue to create and test interventions that bring together all components of the
development, implementation and evaluation of school drug education that are effective in creating
behaviour change, and that are practical to the school setting.
Nation et al (2003) have identified a number of prevention principles that should be respected in
any program design. Using a review-of-reviews approach across 4 areas (substance abuse, risky
sexual behavior, school failure, and juvenile delinquency and violence), the authors identified 9
characteristics that were consistently associated with effective prevention programs: Programs were
comprehensive, included varied teaching methods, provided sufficient dosage, were theory driven,
provided opportunities for positive relationships, were appropriately timed, were socio-culturally
relevant, included outcome evaluation, and involved well-trained staff. This synthesis can inform
the planning and implementation of problem-specific prevention interventions, provide a rationale
for multi-problem prevention programs, and serve as a basis for further research.
This list of principles is similar to a Canadian compendium of best practices (Roberts et al, 2001)
The list of principles that they recommend areas follows:
Build a Strong Framework
Address protective factors, risk factors and resiliency:
Focus on the factors that most directly promote resiliency or, conversely, contribute to
substance use problems in the population of interest.
Seek comprehensiveness:
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.
Ensure sufficient program duration and intensity:
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.
Strive for Accountability
Base program on accurate information:
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 clear and realistic goals:
Set goals, objectives and activities that address local circumstances, are linked logically and
are measurable and time-limited.
56
57
Monitor and evaluate the program:
Evaluate the process and impact of efforts and ensure that costs are in line with program
benefits.
Address program sustainability from the beginning:
From the outset, work toward long-term sustainability and integration of the program into the
core activities of the relevant organization in the community.
Understand and Involve Young People
Account for the implications of adolescent psychosocial development:
See substance use issues within the context of the stages of adolescent development in
order to respond most effectively.
Recognize youth perceptions of substance use:
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.
Involve youth in program design and implementation:
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.
Create an Effective Process
Develop credible messages:
Both the explicit and implied messages delivered in a program need to be viewed as realistic
and credible by participants.
Combine knowledge and skill development:
Skill development needs to be a central element in programs and it needs to be
accompanied by accurate, objective information.
Use an interactive group process:
Engage and involve participants in skill development activities and discussions.
Give attention to teacher or leader qualities and training:
Select and train leaders or teachers who demonstrate competence, empathy and an ability
to promote the involvement and interaction of young people
The National Institute on Drug Abuse in the United States has published a similar list of prevention
principles thatr are based on research evidence. They are also summarized below:
Lessons from Prevention Research*
The principles listed below are the result of long-term research studies on the origins of drug abuse
behaviors and the common elements of effective prevention programs. These principles were
developed to help prevention practitioners use the results of prevention research to address drug use
among children and adolescents in communities across the country. Parents, educators, and
community leaders can use these principles to help guide their thinking, planning, selection, and
delivery of drug abuse prevention programs at the community level.
Prevention programs are generally designed for use in a particular setting, such as at home, at school,
or within the community, but can be adapted for use in several settings. In addition, programs are also
designed with the intended audience in mind: for everyone in the population, for those at greater risk,
and for those already involved with drugs or other problem behaviors. Some programs can be geared
for more than one audience.
Principle 1 - Prevention programs should enhance protective factors and reverse or reduce risk
factors (Hawkins et al. 2002).
The risk of becoming a drug abuser involves the relationship among the number and type of
risk factors (e.g., deviant attitudes and behaviors) and protective factors (e.g., parental
support) (Wills et al. 1996).
The potential impact of specific risk and protective factors changes with age. For example,
risk factors within the family have greater impact on a younger child, while association with
57
58
drug-abusing peers may be a more significant risk factor for an adolescent (Gerstein and
Green 1993; Dishion et al. 1999).
Early intervention with risk factors (e.g., aggressive behavior and poor self-control) often has
a greater impact than later intervention by changing a child‘s life path (trajectory) away from
problems and toward positive behaviors (Ialongo et al. 2001).
While risk and protective factors can affect people of all groups, these factors can have a
different effect depending on a person‘s age, gender, ethnicity, culture, and environment
(Beauvais et al. 1996; Moon et al. 1999).
Principle 2 - Prevention programs should address all forms of drug abuse, alone or in combination,
including the underage use of legal drugs (e.g., tobacco or alcohol); the use of illegal drugs (e.g.,
marijuana or heroin); and the inappropriate use of legally obtained substances (e.g., inhalants),
prescription medications, or over-the-counter drugs (Johnston et al. 2002).
Principle 3 - Prevention programs should address the type of drug abuse problem in the local
community, target modifiable risk factors, and strengthen identified protective factors (Hawkins et al.
2002).
Principle 4 - Prevention programs should be tailored to address risks specific to population or
audience characteristics, such as age, gender, and ethnicity, to improve program effectiveness
(Oetting et al. 1997).
Principle 5 - Family-based prevention programs should enhance family bonding and relationships and
include parenting skills; practice in developing, discussing, and enforcing family policies on substance
abuse; and training in drug education and information (Ashery et al. 1998).
Family bonding is the bedrock of the relationship between parents and children. Bonding can be
strengthened through skills training on parent supportiveness of children, parent-child communication,
and parental involvement (Kosterman et al. 1997).
Parental monitoring and supervision are critical for drug abuse prevention. These skills
can be enhanced with training on rule-setting; techniques for monitoring activities; praise
for appropriate behavior; and moderate, consistent discipline that enforces defined family
rules (Kosterman et al. 2001).
Drug education and information for parents or caregivers reinforces what children are
learning about the harmful effects of drugs and opens opportunities for family discussions
about the abuse of legal and illegal substances (Bauman et al. 2001).
Brief, family-focused interventions for the general population can positively change
specific parenting behavior that can reduce later risks of drug abuse (Spoth et al. 2002b).
Principle 6 - Prevention programs can be designed to intervene as early as preschool to address risk
factors for drug abuse, such as aggressive behavior, poor social skills, and academic difficulties
(Webster-Stratton 1998; Webster-Stratton et al. 2001).
Principle 7 - Prevention programs for elementary school children should target improving academic
and social-emotional learning to address risk factors for drug abuse, such as early aggression,
academic failure, and school dropout. Education should focus on the following skills (Conduct
Problems Prevention Research Group 2002; Ialongo et al. 2001):
self-control;
emotional awareness;
communication;
social problem-solving; and
academic support, especially in reading.
58
59
Principle 8 - Prevention programs for middle or junior high and high school students should increase
academic and social competence with the following skills (Botvin et al. 1995; Scheier et al. 1999):
study habits and academic support;
communication;
peer relationships;
self-efficacy and assertiveness;
drug resistance skills;
reinforcement of anti-drug attitudes; and
strengthening of personal commitments against drug abuse.
Principle 9 - Prevention programs aimed at general populations at key transition points, such as the
transition to middle school, can produce beneficial effects even among high-risk families and children.
Such interventions do not single out risk populations and, therefore, reduce labeling and promote
bonding to school and community (Botvin et al. 1995; Dishion et al. 2002).
Principle 10 - Community prevention programs that combine two or more effective programs, such as
family-based and school-based programs, can be more effective than a single program alone
(Battistich et al. 1997).
Principle 11 - Community prevention programs reaching populations in multiple settings—for
example, schools, clubs, faith-based organizations, and the media—are most effective when they
present consistent, community-wide messages in each setting (Chou et al. 1998).
Principle 12 - When communities adapt programs to match their needs, community norms, or differing
cultural requirements, they should retain core elements of the original research-based intervention
(Spoth et al. 2002b), which include:
Structure (how the program is organized and constructed);
Content (the information, skills, and strategies of the program); and
Delivery (how the program is adapted, implemented, and evaluated).
Principle 13 - Prevention programs should be long-term with repeated interventions (i.e., booster
programs) to reinforce the original prevention goals. Research shows that the benefits from middle
school prevention programs diminish without followup programs in high school (Scheier et al. 1999).
Principle 14 - Prevention programs should include teacher training on good classroom management
practices, such as rewarding appropriate student behavior. Such techniques help to foster students‘
positive behavior, achievement, academic motivation, and school bonding (Lalongo et al. 2001).
Principle 15 - Prevention programs are most effective when they employ interactive techniques, such
as peer discussion groups and parent role-playing, that allow for active involvement in learning about
drug abuse and reinforcing skills (Botvin et al. 1995).
Principle 16 - Research-based prevention programs can be cost-effective. Similar to earlier research,
recent research shows that for each dollar invested in prevention, a savings of up to $10 in treatment
for alcohol or other substance abuse can be seen (Aos et al. 2001; Hawkins et al. 1999; Pentz 1998;
Spoth et al. 2002a).
* Information for this InfoFacts was taken directly from the publication, Preventing Drug Use among
Children and Adolescents, A Research-Based Guide for Parents, Educators, and Community Leaders,
Second Edition, National Institute on Drug Abuse, 2003.
In an article published in Spanish, Fernandez et al (2002) describe the impact and associated
characteristics of preventive programs addressing consumption of tobacco, alcohol and illegal drugs
is a major public health problem in developed countries. The aim of the study is to describe the
59
60
impact and associated characteristics of preventive programs addressed at those problems in the
school setting. Meta-analysis focusing on evaluations of programs focusing on smoking, alcohol
and/or cannabis at the school setting are reviewed. The search was done at Cochrane Library and
Medline databases of articles published between 1993 and 1999, and including as keywords
programs, education, drugs prevention, prevention, smoking, alcohol, school, adolescence,
teenagers, young people, evaluation, health education, effectiveness, review, meta-analysis. We
found 5 meta-analysis of programs summarizing the effect of preventive programs, most of them
dealing with legal and illegal drugs. However, most of the interventions reporting changes in
behavior measured only smoking. More effective interventions addressed social influences, used
active methodology and were implemented by teachers or peers. The importance of booster
sessions, the quality of implementation and thorough evaluation is stressed. Overall, meta-analysis
of evaluated programs shows a small effect, although the population impact may be relevant..
4. Select population/sub-populations
This sub-section discusses the application of the population health principle of selecting a
population or sub-population for the health-promoting interventions as well as the element of a
comprehensive approach to school-based health promotion that suggests that programs should
be adapted to meet the needs of sub-populations as well as adapted to ensure that delivery of
health and other services is “friendly” to children and youth so that they will be encouraged to
access those services.
Are findings in this sub-section are:
o the research evidence is not clear as to whether programs should seek to include
a wide range of audiences or focus on those children who are at higher risk.
There is some evidence that suggests that universal programs should target
middle school students.
o Several studies show that programs and services can be adapted to meet special
needs based on culture, age and disadvantage. Research also indicates that
“universal” programs may have some positive effect on “indicated” populations
and that “indicated” programs can have an impact on a wider audience.
Does the evidence suggest that there are sub-populations within the children/youth
population that would benefit more from school-based or school-linked policies,
programs and services?
Universal vs Indicated Approach
A question often debated in respect to school-based programs is whether schools should focus
solely on ―universal‖ messages about delaying onset or experimentation with alcohol and drugs or
whether they should also focus on the needs of students who are ―indicating‖ that they may be
abusing substances.
Poulin & Elliott (1997) call for a comprehensive approach to school and community prevention that
incorporates a variety of interventions for a variety of sub-populations. They use the Atlantic Drug
Use Survey to characterize adolescent drug use in terms of a risk continuum and to explore the
rationale for harm reduction as a potential approach for school-based drug prevention. The risk
continuum was also used as a policy framework. They conclude that there is a need for integrated
school- and community-based drug prevention programs, with goals, strategies and outcome
measures capturing the full spectrum of patterns of use and levels of risk among subgroups of the
adolescent student population
60
61
The prevention principles recommended by the National Institute on Drug Abuse (2003) quotes
several sources to suggest that programs should address all forms of harmful substance use
(Johnson, 2001) whilw tailoring their messages to specific drug problems in the local community
(Harkins et al, 2002)as well as to specific risks or local sub-population characteristics (oetting et al,
1999)..For most local prevention program managers implementing these three principles would be a
formidable task each year, so it is suggested here that further research is needed into the critical
mass, conditions and stable content of local; programs that can be sustained.
Griffen et al (2003), in a random controlled trial on the impact of a ―universal‖ prevention program on high
risk children may have spiked a myth about the inappropriateness of such programs for youth who are in
higher risk situations. The effectiveness of a universal drug abuse preventive intervention was
examined among youth from 29 inner-city middle schools participating in a randomized, controlled
prevention trial. A subsample of youth (21% of full sample) was identified as being at high risk for
substance use initiation based on exposure to substance-using peers and poor academic performance
in school. The prevention program taught drug refusal skills, antidrug norms, personal self-
management skills, and general social skills. RESULTS: Findings indicated that youth at high risk
who received the program (n = 426) reported less smoking, drinking, inhalant use, and polydrug use
at the one-year follow-up assessment compared to youth at high risk in the control condition that
did not receive the intervention (n = 332). Results indicate that a universal drug abuse prevention
program is effective for minority, economically disadvantaged, inner-city youth who are at higher
than average risk for substance use initiation.
Thompson et al (1997) examined the net effects of refining a high school-based indicated drug
prevention program. The Personal Growth Class (PGC), tailored to meet the needs of high-risk
youth, was designed to increase control of drug use, school performance, and emotional well-being.
The program integrates social support and life-skills training. Process evaluation revealed the need
for program enhancements that led to greater impacts of the program. The results support arguments
that effective indicated prevention programs should target specific high-risk youth employing
strategies to counteract the multifaceted risk factors they experience and enhance needed protective
factors.
An earlier review (Lamarine, 1993) reflected the discussion of the times when she suggested that
school programs should focus on children and youth who show (indicate) signs of more
susceptibility to substance abuse. She suggests that identification could be done as early as early
childhood.
Dent et al (2001) found that a successful classroom-based prevention program developed for youth
at alternative high schools (high risk) to youth at general high schools. A replication of a previously
tested prevention program in a general high school population was conducted with 1-year follow-up
data. Classrooms within each of three schools were randomly assigned to two conditions, classroom
education or standard care control. Statistically significant effects on alcohol and illicit drug use
were achieved in this population through a 1-year period following the program, although effects
were not achieved on cigarette smoking and marijuana use. These results suggest that this program
(Project Towards No Drug Abuse) has applicability to a wide range of older teens.
Gottfredson & Wilson (2003) using meta-analytic techniques, summarize the results from 94 studies
of school-based prevention activities that examined alcohol or other drug use outcomes. They set
out to determine what features of school-based substance abuse prevention programs are related to
variability in the size of program effects, It asked (1) Which populations (e.g., high risk vs. general
61
62
population) should be targeted for prevention services? (2) What is the best age or developmental
stage for prevention programming? (3) Does program duration matter? and (4) Does the role of the
person delivering the service (e.g., teacher, law enforcement officer, peer) matter? The results
suggest that targeting middle school aged children and designing programs that can be delivered
primarily by peer leaders will increase the effectiveness of school-based substance use prevention
programs. The results also imply that such programs need not be lengthy. The evidence related to
the targeting issue is sparse, but suggests that, at least for programs teaching social competency
skills, targeting higher risk youths may yield stronger effects than targeting the general population.
Suggestions for future research are offered.
Lisnov et al (1998) reported that students who participated in the DARE and Captain Clean
programs felt that school-based programs were far more effective in prevention than television ads,
testimonials by famous people, billboards, and print ads displayed on public transportation. Students
perceived the two school-based programs, Project DARE (a national program conducted through
local police departments) and Captain Clean (an intense live theater program coordinated with
student participation), as being equally effective overall, although the interactive theater program
was rated as significantly better at encouraging students to talk about their feelings concerning
substance abuse issues and at relating to the students' ethnic/racial backgrounds. When students
were categorized according to frequency of alcohol use, nonusers, infrequent users, and frequent
users differed significantly in their ratings of the school-based programs.
Snow et al (1997) use an amenability to treatment model that stipulates that interventions may be
differentially effective for subgroups of individuals with similar characteristics. Using such a
model, they tested the impact of two social-cognitive interventions implemented in the sixth
(Intervention I) and eighth/ninth (Intervention II) grades on students' skill acquisition and on their
ninth and tenth grade substance use. A randomized factorial design was used to examine main and
interaction effects within the context of student family household status and gender. Positive
program effects were found for Intervention II on skill acquisition and overall drug involvement.
Interaction effects of Intervention II x Family Household Status provided support for the
amenability to treatment model, but no support for the model was observed based on student
gender. Possible explanations for the study findings are presented and future research directions are
proposed to address why differences emerge in amenability to intervention and why such
differences occur for specific subgroups.
Has the research described special programs that were able to influence the substance use of
various groups who may be at higher risk of problem substance use of addictions?
Are there comprehensive models that address specific addiction issues such as FASD,
children of alcoholics, drinking and driving, experimentation with illicit drugs, abuse of
prescription or medications etc?
Marlatt et al (2003) have described how substance abuse prevention programs can be successfuly
adapted to fit with cultural traditions of aboriginal students. Similarly, Botvin et al (2001) reported
on how a program originally designed for a white middle class population can be adopted for a
minority, disadvantaged and inner city popultation.
Hecht ET AL (2003) report on the evaluation of a culturally grounded prevention intervention
targeting substance use among urban middle-school students. The curriculum consists of 10 lessons
promoting antidrug norms and teaching resistance and other social skills, reinforced by booster
activities and a media campaign. Three versions were delivered: Mexican American, combined
African American and European American, and Multicultural. Thirty-five middle schools were
randomly assigned to 1 of the 3 versions or the control. Students completed baseline and follow-up
62
63
questionnaires over a 2-year period (total 6,035 respondents). Analyses utilizing a generalized
estimating equations approach assessed the overall effectiveness of cultural grounding and the
cultural matching hypothesis. Support was found for the intervention's overall effectiveness, with
statistically significant effects on gateway drug use as well as norms, attitudes, and resistance
strategies but with little support for the cultural matching hypothesis. Specific contrasts found the
Mexican American and Multicultural versions impacted the most outcomes.
Horn & Kolbo (2000) have developed a conceptual model for developing programs for children of
addicts. A Cumulative Strategies Model posits four basic principals for effective prevention for high
risk children and guides prevention program design. Representing a Cumulative Strategies Model,
described herein is a multicomponent prevention program that is theory-driven, risk-based, and
targets children affected by familial alcohol abuse. Three components of this program and specific
methods of implementing each component are discussed, and field reactions are reviewed.
Emshoff & Price (1999) report on a literature search including both published and unpublished
descriptions and evaluations of interventions with Children of Alcoholic (COAs). The scope and
nature of the problems of growing up in an alcoholic home are presented. The risk and protective
factors associated with this population have been used as a foundation for preventive and treatment
interventions. The most common modality of prevention and intervention programs is the short-
term small group format. Programs for COAs should include the basic components of information,
problem- and emotion-focused coping skills, and social and emotional support. Physicians are in a
unique position to identify and provide basic services and referrals for Children of Alcoholics
(COA‘s). School settings are the most common intervention sites, but family and broad-based
community programs also have shown promise in alcohol and other drug prevention. They report
that several COA interventions have demonstrated positive results with respect to a variety of
measures including knowledge of program content, social support, coping skills, and emotional
functioning. But they also suggest that rigorous studies are needed to understand better the complex
ways children deal with parental alcoholism.
Zapert et al (2002) have described six different sub-groups of adolescents and their escalating or
stable use of substances. Six distinct clusters of substance users emerged-2 groups representing
relatively stable patterns of substance use from early through late adolescence (ie., nonusers and
alcohol experimenters), and 4 groups of users showing escalating patterns of substance use (i.e., low
escalators, early starters, late starters, and high escalators). Their work demonstrates the usefulness
of studying patterns of use across multiple substances, and underscores the importance of building
classification schemes based on repeated measurements of substance use to reflect changes over
time.
63
64
5. Integrate with other Health Issues
This sub-section address the population health principle that, whenever possible, prevention
and promotion efforts in regards to one health problem should be integrated with efforts to
address another health problem, where the research shows that the etiology of the behaviours
suggests that root causes are similar or the same and where, systems theory and strategic
analysis suggests that such integration is possible. One of the elements of a comprehensive
approach to school health promotion suggests that we view children and youth in a holistic way
and do not try to categorize them by their health or social problems, particularly during their
turbulent, changeable growing periods. An important learning from systems based theory is that
managers of “profession al bureaucracies” tend to protect their systems from external
disturbances. Consequently,, it makes sense to present “new” health problems in a way that
links them to what the system is already doing on another problem or within the context of an
established program. Our model of organizational capacity suggests that systems need to
identify and anticipate emerging health issues in advance, lest they force their way into the
system through a crisis or external public pressure. Strategic thinking also suggests that we need
to consider the impact of combining and identifying health issues through the lens of how
profile, human resources, funding, control and influence will be re-distributed so that we can
anticipate resistance or early adoption.
Our findings in this sub-section are closely related to the next, where we conclude that a
combination of instruction in social skills/competence as well as character education or “social,
emotional learning” with far greater attention to the psychosocial climate of the school and a
comprehensive approach to mental health services and promotion. Based on this review, we
believe that this combination of issues and approaches holds the most promise. On a more
specific level, the research clearly indicates that tobacco use, alcohol/drug use and other social
behavioral problems are closely related and could be addressed efficiently in comprehensive
programs.
Does combining the prevention of substance abuse/addictions with other health issues
such as social skills, life skills, mental health, tobacco or within a risk/social behaviour
framework lead to enhanced intervention outcomes on addictions or on overall health?
Does the research evidence truly suggest that taking a holistic view of the child,
recognizing that substance abuse is usually part of a larger health, social or
developmental problem is more effective?
Research on school health promotion (WHO School Health Working Group, 1996, Allensworth et
al, 1997) has often told us that there are ―clusters‖ of ―health-reducing‖ and ―health enhancing‖
behaviours and conditions. But we don‘t know which single or coordinated set of interventions can
best influence those behavioural and environmental clusters. The research cited here and in the next
sub-section may indicate that some of the linkages are beginning to become clearer, at least in
respect to social behaviours such as alcohol, drug and tobacco use.
Flay (2002) presents the thesis that all behaviors have common causes.
Generally agreed-upon categories consist of individual (biological, personality, character traits, prior
behaviors), social (including family, school, peers, and neighborhood) and broader social
environmental influences (economic, political, religious, etc). Thus, reviews of the predictors of
tobacco use, substance use more generally, violence, sexual behavior,and mental health all propose
similar categories of causes of these behaviors.He suggests that all behaviors, not just problem
64
65
behaviors, are related to each other. They are correlated, and they also cause each other. That is,
whatever one occurs first will be predictive of others.
He also shows the strong linkages between alcohol /drug use and other risk behaviours.
About a third of youths committing serious crimes consume alcohol just before the offense. More than
70% of teen suicides involve frequent use of alcohol or drugs. Nearly 40% of drownings involve use of
alcohol. Alcohol and drug use are the best predictors of early sexual activity and are associated with
more unplanned pregnancies, more sexually transmitted diseases, more HIV infection, and greater
school dropout than any other causal factor.
Flay concludes that all behaviors have the same causes, especially at the distal/ultimate levels.
Social influences — the social ecology — are particularly important during adolescence. These include
the influences of families, schools, peers, and neighborhoods/communities. All are amenable to
prevention and health promotion efforts. Thus, future prevention and health promotion programs need
to involve whole schools, families, and communities in an integrated and coherent way. Classroom
curriculum can teach content and social skills. To be most effective, curricula must be schoolwide,
encompassing every grade level in a carefully scoped and sequenced (developmentally appropriate)
way. Cultural appropriateness may also be important. School-wide climate change can provide a safe
learning environment and provide a common language and consistent reinforcement of positive
behaviors, as can integrated family and community programs. Family programs can also teach
improved parenting skills in a way consistent with a coherent program, and community components
can strengthen school and community links and provide opportunities for students to observe and
engage in community service.
65
66
Flay also suggests that although evidence for relationships among behaviors is strong, the direction
of the relationships is often unclear.
Does poor academic achievement lead to increased disruptive behavior, violence, and/or substance
use, or vice versa? He concludes that modern theories of behavioral development would suggest that
these relationships are, in fact, bidirectional, with one causal direction being dominant at some
developmental stages and the other direction at other developmental stages. For example, it is quite
reasonable to expect initiation of any of the problem behaviors to be predicted by prior mental health
or school performance, but for continued problem behavior to, in turn, influence future mental health or
school performance. He concludes that because all adolescent behaviors are interrelated, future
prevention and health promotion programs should address all youth behavioral development in a
comprehensive and coherent way.
Botvin et al (1998) have reviewed several studies concerning the etiology of tobacco, alcohol, and
drug use indicate that a variety of cognitive, attitudinal, social, personality, pharmacological, and
developmental factors promote and help maintain drug use (Baumrind and Moselle 1985; Blum and
Richards 1979; Jessor and Jessor 1977; Jones and Battjes 1985; Kandel 1978; Meyer and Mirin
1979; Newcomb and Bentler 1988; Wechsler 1976). They suggest that it ―seems logical to conclude
that the most effective prevention strategy would be one that is comprehensive, targeting a broad
array of etiologic determinants. They go on to say that ―research has been conducted over more than
15 years with broader based prevention approaches that emphasize the teaching of generic personal
and social skills either alone (Caplan et al. 1992) or in combination with components from the
social influence model (Botvin et al. 1980, 1983, 1984a, b, 1990b; Gilchrist and Schinke 1983;
Schinke and Gilchrist 1983, 1984). This type of prevention strategy is more comprehensive than
traditional cognitive/affective approaches or social influence training approaches. Moreover, unlike
affective education approaches, which rely on experiential classroom activities, these approaches
emphasize the use of proven cognitive behavioral skills training methods.‖
Cunningham & Henggeler (2001) suggest that combining drug abuse prevention with anti-bullying
may be effective. They describe the implementation of a collaborative preventive intervention
project (Healthy Schools) designed to reduce levels of bullying and related antisocial behaviors in
children attending two urban middle schools serving primarily African American students. These
schools have high rates of juvenile violence, as reflected by suspensions and expulsions for
behavioral problems. Using a quasi-experimental design, empirically based drug and violence
prevention programs, Bullying Prevention and Project ALERT, are being implemented at each
middle school. In addition, an intensive evidence-based intervention, multisystemic therapy, is
being used to target students at high risk of expulsion and court referral. Hence, the proposed
project integrates both universal approaches to prevention and a model that focuses on indicated
cases. Targeted outcomes, by which the effectiveness of this comprehensive school-based program
will be measured, are reduced youth violence, reduced drug use, and improved psychosocial
functioning of participating youth.
Flay et al (2001) report on the effectiveness of an integrated comprehensive school model for
character development, problem behavior prevention, and academic achievement enhancement. The
Positive Action program consists of a school curriculum, together with schoolwide climate, family,
and community components. As evaluated here, the yearly K-6 curriculum consists of over 140
fifteen-to-twenty-minute lessons per year delivered in school classrooms on an almost daily basis.
The program is based on theories of self-concept, learning, behavior, and school ecology. We use a
matched control design and school-level achievement and disciplinary data to evaluate program
effects on student performance and behavior in two separate school districts. The program improved
achievement by 16% in one district and 52% in another, and reduced disciplinary referrals by 78%
66
67
in one district and 85% in the other. We discuss implications of these replicated findings for the
prevention of substance abuse and violence, the improvement of school performance, and the
reform of American schools.
The next sub-section of this report examines how instructional and other approaches to preventing
harmful substance use have evolved from a focus on providing information on drugs, to developing
values and specific skills to a more general approach to developing social skills and competencies. In
that section we will suggest that attention also be paid to the “social and emotional learning” of
children, which is a new trend in education to focus on issues such as character education and to their
overall mental health. As part of that broader approach the trend in health promotion circles to focus
on “youth development” would appear to be part of that emerging strategy.
Does the research describe how systems can identify and act upon emerging issues related to
addictions, children/youth and schools? Are there planned or regular ways that the systems,
ministries and agencies? Are there examples of systems, ministries that have consciously
chosen to focus on an aspect of addictions and children and youth for a defined strategic
reason rather than just convenience, urgency or external funding? Are there studies that
show how alcohol/drugs can successfully compete or cooperate with other health issues
being addressed by the school system?
This review did not locate any records addressing these questions derived from systems and strategic
thinking. More searching was beyond the scope of this inquiry but such further work is recommended. This
research should examine the bi-directional nature of the influences between and among negative of positive
behaviours to determine the timing and best approach for emphasizing one or the other in the development of
children and youth.
6. Select the Issue/Aspect and Approach
This sub-section continues the discussion from the previous, with a lengthy analysis of
approaches to drug education that have been taken in the past. (Much of this analysis is
provided by Botvin et al, 1998) and has been quoted or summarized here.) However, this
section also extends that analysis to suggest that the “integrated social influences/social
competence enhancement” approach recommended by Botvin et al is coordinated with an
emerging trend in education to teach students about character, caring and respect, as well as
with a focus on the overall mental health of students and on improving the psycho-social
environment of the school. Fortunately, in Canada, there are several research projects exploring
these new strategies that can and should be linked in with any activities undertaken in response
to this review.
Our findings here are two fold:
a combination of social skills development, emotional and social learning, attention to
the psycho-social climate in the school and the provision of comprehensive mental
health services and programs offers the most solid evidence base that such an approach
would reduce harmful substance use
the “harm reduction” approach is promising insofar as it helps to focus and clarify the
health messages being delivered to youth but this approach still needs further testing
and evaluation.
Are there different impacts for programs based on different approaches (eg delay
of experimentation, abstinence, moderation or harm reduction) for all school-
aged children/youth or sub-populations within the children/youth population?
67
68
Does an approach based on life skills/social skills/social influences work more
effectively?
Does an approach based on specific resistance skills have an impact?
Should programs focus on so-called ―gateway drugs‖ such as tobacco or
marijuana?
Should a program focus on addictive behaviours? alcohol? all drugs? Illicit
drugs? Emerging drugs that youth may not know about?
Botvin et al (1998) have described the evolution of different approaches to school-based substance
abuse prevention. These approaches include:
Information Dissemination Approaches
Affective Education Approaches
Social Influence Approaches
o Correcting Normative Expectations.
o Psychological Inoculation.
o Resistance Skills Training.
Integrated Social Influence/Competence Enhancement Approaches
Information Dissemination Approaches
Botvin et al (1998) describe this approach.
Growing out of an educational tradition, the most common approach to drug abuse prevention found in most
schools has had a singular focus, that is, providing information about drugs and the consequences of drug
abuse. The focus of tobacco, alcohol, and drug education programs (as they are frequently called by school
personnel) involves factual information about the adverse health, social, and legal consequences of drug
use without providing any skill training relevant to drug prevention. Fear arousal strategies are frequently
incorporated into these programs in an effort to dramatize the deleterious effects of drug use and motivate
(i.e., scare) adolescents into remaining abstinent. Other topics usually covered in informational programs
include patterns of drug use, the pharmacology of various drugs of abuse, and methods of using drugs.
While most programs have a distinctly antidrug use orientation, some programs endeavor to present the
facts in a balanced and neutral manner. Such approaches to the problem of drug abuse rest on an implicit
assumption that drug use and even drug abuse are the end result of a logical decision-making process. It is
further assumed that if adolescents were better informed about the dangers of using drugs they would make
a rational and informed decision to remain drug free.
According to previous reviews of the drug abuse prevention literature (Botvin and Botvin 1992;
Dielman 1994; Dryfoos 1993; Ellickson 1993) and the results of meta-analytic studies (e.g., Bangert-
Drowns 1988; Tobler 1986), evaluation studies have consistently shown that prevention approaches
that rely exclusively or primarily on the information dissemination model do not prevent, reduce, or
deter drug use. Although virtually all information-based prevention programs are able to demonstrate
an increase in knowledge, and some studies have demonstrated an impact on attitudes in a direction
consistent with nondrug use, there is little evidence indicating that they can have any meaningful
impact on drug use behavior. The results of these studies should not be taken to mean that knowledge
or information does not have a role in prevention programs. Rather, they underscore the fact that there
are multiple factors promoting adolescent drug use and that prevention approaches based on more
complex models of drug initiation are required in order for prevention efforts to be effective.
Affective Education Approaches
Botvin et al describe this approach:
During the 1970s, the nature of drug education began to change in some quarters. This change grew
out of a dissatisfaction with the information approach and a recognition that some individuals were
more likely to become involved with drugs than others. While drug education efforts based on teaching
68
69
facts focused largely on drugs and their effects, affective education involved a change in perspective
and focus from drugs to the psychosocial needs of the individual. Implicit in the affective education
model of drug initiation was the underlying belief that individuals with a certain constellation of
characteristics were at risk for becoming drug users and that the solution was to be found in programs
promoting affective development. In contrast to information-based approaches, affective education
emphasizes personal and social development in order to either overcome personal deficiencies
believed to increase risk for using drugs or provide individuals with characteristics hypothesized to be
associated with decreased risk of using drugs such as high self-esteem, personal insight, and self-
awareness. Thus, the emphasis is on the affective rather than the cognitive.
An interesting feature of affective education is that it was more comprehensive than information
dissemination approaches and recognized the role of psychosocial factors in the etiology of drug
abuse. It also foreshadowed the expanded social skills training approach to drug abuse prevention,
which has demonstrated significant reductions in both the incidence and prevalence of drug use. For
example, components of affective education approaches that are used in some of the most successful
prevention programs include decisionmaking, effective communication, and assertiveness. However,
studies evaluating the effectiveness of affective education have produced disappointing results. Some
affective education approaches have demonstrated an impact on one or more of the correlates of drug
use, while others have not produced the expected effects on drug-related variables. More important,
they have not demonstrated an impact on drug use itself (Kearney and Hines 1980; Kim 1988).
Despite several strengths (i.e., emphasis on psychosocial variables and a more comprehensive
intervention approach), the affective education model has several major weaknesses. These include a
focus on a narrow and incomplete set of etiologic determinants, the use of ineffective methods to
achieve their stated program goals (such as the use of experiential games and classroom activities
rather than skills training methods), a lack of domain-specific information related to drug abuse, and
the inclusion of ―responsible use‖ norm-setting messages that may be counterproductive (Botvin
1995a, b).‖
Social Influence Approaches
Botvin et al go on to describe the development of the social influences approach.
In response to the disappointing findings of studies testing the effectiveness of information
dissemination and affective education approaches to prevention, researchers began testing a
prevention model based in social psychology. From this perspective, adolescent cigarette smoking, for
example, was conceptualized as being the result of social influences (persuasive messages) from
peers and the media in the form of peer offers to smoke cigarettes, of advertising appeals, or of
exposure to smokers who may serve as role models for these students.
The prevention approaches based on this model have typically contained two or more of the following
components: psychological inoculation, correcting normative expectations, and resistance skills
training. Early research with approaches based on this model emphasized psychological inoculation
and modifying normative expectations. More recent approaches have tested variations on this model,
emphasizing resistance skills training. Some approaches have added other components such as
having students make a public commitment not to use drugs. For the most part, the various
permutations of the social influence model are similar in that they are based on social cognitive theory
(Bandura 1977) and a conceptual model that stresses the fundamental importance of social factors in
promoting the initiation of adolescent drug use. Although this model includes social influences coming
from the family, peers, and the media, the focus of most preventive interventions is on the last two of
these, with the primary emphasis being placed on peer influences.
Psychological Inoculation.
Social psychological research in persuasive communications (McGuire 1964, 1968) led prevention
researchers (Evans 1976; Evans et al. 1978) to attempt to prevent cigarette smoking by
―psychologically inoculating‖ adolescents against prosmoking messages coming from their social
environment. These messages were conceptualized as the equivalent of ―germs‖ with the potential for
69
70
infecting adolescents with pro-smoking attitudes. In order to build up resistance to these germs,
adolescents were exposed initially to weaker forms of these messages and then to gradually stronger
pro-smoking messages. Adolescents were trained in critical techniques to refute these pro-smoking
messages. These techniques included recognizing a persuasive pro-smoking message, analyzing the
message and its source, and developing tactics for coping with these situations. For example,
adolescents are taught skills for dealing with situations involving an offer by a peer to smoke
cigarettes. It was hypothesized that, by being prepared for the situation and having a counterargument
ready before the offer is made, the adolescent would be better able to resist the pressure to try a
cigarette. Although this foreshadowed the use of refusal skills, it focused more on cognitions and
attitudes with little or no focus on skills training. Thus, the primary goal of this prevention approach
was to prepare adolescents for eventual exposure to persuasive pro-smoking influences from peers
and/or the media.
Correcting Normative Expectations.
A second component of social influence approaches to drug abuse prevention was based on a social
psychological principle called the ―false consensus effect‖ (Ross et al. 1977). The false consensus
effect helps explain the observation that adolescents who believe that cigarette smoking is a behavior
that nearly everyone engages in are more likely to smoke cigarettes. Providing students with accurate
information about the actual smoking rates or having them conduct their own survey to discover the
information themselves alters their perceptions of smoking norms.‖
Botvin (2000), in a different article, reports that a normative approach that targets individual level
etiologic factors can be effective. The most promising prevention approaches target individuals
during the beginning of adolescence and teach drug resistance skills and norm setting either alone or
in combination with general personal and social skills. Evaluation studies testing these approaches
show that they can significantly reduce adolescent tobacco, alcohol, and marijuana use. While some
studies show that these effects may decrease over time, booster interventions have been found to
maintain and in some instances even enhance prevention effects. The results of one large-scale
evaluation study shows that it is possible to produce reductions in drug use that last until the end of
high school. Available evidence suggests that these approaches may be effective when taught by
different kinds of teachers and with different populations. The current paper provides a brief review
of school-based prevention approaches targeting individual-level etiologic factors, evidence
supporting their effectiveness, and a discussion of potential mediating mechanisms.
Another early study (Hansen et al, 1991) reported that a normative approach was effective in
reducing in substance use behaviours while a resistance skills approach was not effective with the
same sample of California students.
Donaldson et al (2000) assessed the effects of normative education, arguably the most successful
component of social influence based prevention programs, on alcohol and cigarette consumption
using both self- and reciprocal best friend reports of substance use. Analyses of subsamples of data
from 11,995 students participating in the Adolescent Alcohol Prevention Trial revealed that
normative education significantly delayed the onset of alcohol use across the eighth, ninth, and
tenth grades among public school students. A similar but somewhat less robust pattern was found
for cigarette use. Further, a ―best friend methodology eas used to overcome any problems
assocxiated with self-reporting substsance abuse. These results suggest that self-report bias does not
account for previous findings and demonstrate rather convincingly that normative education is an
effective drug prevention strategy for public school settings.
Resistance Skills Training.
70
71
Botvin et al (1998) describe the third major component of social influence approaches, resistance
skill training,
Resistance Skill training, which has become a central feature of such approaches over the past
decade, is to provide adolescents with the skills needed to identify and resist common social
influences to use drugs—influences coming from the media and especially influences from peers.
They suggest ― However, an important difference in these approaches is the focus on teaching
students the skills needed to resist these influences. The resistance skills dealing with the media are
intended to make students aware of the media influences they will be exposed to, with a particular
emphasis on the techniques used by advertisers to influence consumer behavior. Students are taught
to recognize advertising appeals designed to sell tobacco products or alcoholic beverages as well as
how to formulate counterarguments to those appeals. Resistance skills are also taught to combat both
subtle and more direct (and at times coercive) pressure from peers to smoke, drink, or use illicit drugs.
These skills typically include refusal skills, which are a subset of general assertive skills. Using
behavioral training techniques, skills for refusing offers to use drugs are modeled and practiced in the
classroom. Students are taught to identify high-risk situations (such as parties or hanging around after
school) where they are the most likely to experience peer pressure to smoke cigarettes, drink, or use
illicit drugs. They are shown how to handle these situations through a repertoire of verbal (refusal)
responses. They are also taught how to use these verbal responses in an effective (assertive) manner
(i.e., with an appropriate tone of voice, making eye contact, using ―I‖ statements, maintaining an
assertive body position, speaking clearly and confidently).
The target population for most of the research conducted with resistance skills training approaches
has been middle school or junior high school students (grades six to nine). Some studies have
targeted younger populations, such as fourth or fifth graders (Flynn et al. 1992). The length of
prevention approaches based on the resistance skills training model has ranged from as few as 3 or 4
sessions to as many as 11 or 12 sessions conducted over a 2-year period. Different types of program
providers have also been used in various research studies. Some programs have been implemented
by research staff members, others have been implemented by regular classroom teachers. Many
prevention programs teaching resistance skills have done so with the assistance of peer leaders
serving as program providers.‖
Palmer et al (1998) examined the effectiveness of a social pressure resistance training and a
normative education (NORM) intervention against an information-only control group. The NORM
condition revealed 1-year program effects for cigarette and marijuana use with individuals as the
unit of analysis and only marginal effects with classroom as the unit of analysis. No program effects
were found using school as the analysis unit. A multilevel strategy revealed program effects for
cigarettes and marijuana with both class and school as grouping levels. The effect for alcohol use
was significant at the 2-year follow-up. Interventions establishing conservative drug use norms in
classrooms may be an effective strategy in reducing substance use onset among adolescents.
These students are either older (e.g., 7th graders may be taught by 9th or 10th graders) or the same
age as the students participating in the prevention program. A common argument for using peer
leaders as program providers is that they have greater credibility with junior high school age
students with respect to lifestyle issues than do adults, since adolescence is a time characterized by
some degree of rebellion against parents and other adult authority figures. In addition to providing
students with information concerning rates of drug use and skills for resisting offers to use drugs, a
potentially powerful benefit of peer leader programs is that they may help alter school norms
regarding drug use and its social acceptability. To the extent that peer leaders are viewed by
students as being credible sources of information and influential role models who do not regard
drug use as being socially acceptable, peer-led prevention programs may have an important impact
on normative beliefs supportive of nondrug use. ―
Botvin et al (1998) conclude:
71
72
After more than 15 years, there is an impressive literature of studies testing interventions based on the
social influence approach. These studies have been published in high-quality peer-reviewed journals
and have documented its effectiveness in both small- and large-scale studies (Arkin et al. 1981;
Donaldson et al. 1994; Ellickson and Bell 1990; Hurd et al. 1980; Luepker et al. 1983; Pentz et al.
1989a, b; Perry et al. 1983; Snow et al. 1992; Sussman et al. 1993; Telch et al. 1982). The focus of
most of these studies has been on smoking prevention with some studies reporting results in terms of
smoking onset (preventing the transition from nonsmoking to smoking), others reporting results in
terms of overall smoking prevalence, and still others reporting results with respect to an index
measure or scale of smoking involvement.
Although there is considerable variability across studies in terms of methods and the magnitude of
effects, these studies have generally indicated that this type of prevention approach is capable of
reducing drug use by 30 to 50 percent after the initial intervention (based on a comparison of the
proportion of smokers in the experimental group with the proportion of smokers in the control group).
Studies reporting results in terms of smoking incidence have shown reductions ranging from
approximately 30 to 40 percent (comparing the proportion of new smokers in the experimental group
with the proportion of new smokers in the control group). Several studies have demonstrated
reductions in the overall prevalence of cigarette smoking in terms of both occasional smoking (one or
more cigarettes per month) and/or regular smoking (one or more cigarettes per week). Those
reductions have ranged from approximately 40 to 50 percent. Although there are fewer studies
assessing the impact of social influence approaches to substances other than tobacco, such as for
alcohol or marijuana use (Donaldson et al. 1994; Ellickson and Bell 1990; McAlister et al. 1980; Pentz
et al. 1989a; Shope et al. 1992), the magnitude of the reductions reported has generally been similar
to that found for smoking.
Over the years, several follow-up studies have been published that report positive behavior effects
lasting for up to 3 years (Luepker et al. 1983; MacKinnon et al. 1991; McAlister et al. 1980; Pentz et al.
1989b; Shope et al. 1992; Sussman et al. 1993; Telch et al. 1982). However, data from several longer
term followup studies have shown that these effects gradually decay over time (Bell et al. 1993;
Ellickson et al. 1993; Flay et al. 1989; Murray et al. 1988), suggesting the need for ongoing
intervention or booster sessions. Because little is known about the nature and timing of booster
interventions, additional research is needed. Also, because relatively little research has been
conducted with substances other than tobacco, data concerning the durability of prevention effects on
other substances are not available. The studies testing social influence approaches have been similar
in most respects. There are, nonetheless, some differences. In order to gain a better understanding of
the underlying mechanism of these programs, and to develop more effective interventions, the various
intervention components of these programs deserve closer scrutiny.
A common component of several resistance skills training approaches has been a procedure through
which individuals make a public commitment not to smoke, drink, or use drugs. However, a study by
Hurd and colleagues (Hurd et al. 1980) suggests that this component may not contribute to any
observed prevention effects. Another common component is the use of videotaped or filmed
prevention materials similar to those utilized by Evans and colleagues (Evans et al. 1978). Still, it is not
yet clear what type of media material is the most effective or the extent to which it is a necessary
component of these prevention programs. Similarly, little is known about the optimal time of
intervention (age or grade level), program length, program structure, type of provider, type of booster
intervention and its timing, or the characteristics of the individuals who are the most affected by these
interventions. Finally, nearly all of the studies testing resistance skills training approaches have used
peer leaders. Moreover, some studies have attempted to determine the effectiveness of peer leaders
relative to other program providers. By and large, the existing evidence supports the use of peer
leaders for this type of prevention approach (Arkin et al. 1981; Perry et al. 1983). Yet it is not
altogether clear from the available evidence that peer leaders are either necessary or better than other
providers. Mor work is necessary to determine the most appropriate kind of program provider and the
optimal mix of responsibilities between adult and peer providers.‖
Integrated Social Influence/Competence Enhancement Approaches
Botvin et al (1998) suggest that ―the underlying conceptual framework for social approaches is that
adolescents begin to smoke, drink, or use drugs either because they succumb to the persuasive
72
73
messages targeted at them or because they lack the necessary skills to resist social influences to use
drugs.
Although social influence approaches are important because they recognize the role social factors
play in the etiology of drug abuse, they have been criticized because they do not pay sufficient
attention to the intrapersonal factors involved in the etiology of drug use and abuse (Botvin and Botvin
1992). More comprehensive than either informational or affective education approaches, they still may
be based on an understanding of drug abuse etiology that is too narrow and fails to fully appreciate
the array of etiologic factors not subsumed under the social influence model. These approaches also
largely ignore the fact that there may be multiple developmental pathways leading to drug abuse.
While it may be the case that social influences may be the most potent factors promoting drug use for
some individuals, intrapersonal factors may be more important for others. For example, using drugs
may not be a simple matter of yielding to peer pressure for some adolescents, but it may be
instrumental in helping them deal with anxiety, low self-esteem, or a lack of comfort in social
situations. To the extent that this is correct, prevention approaches need to go beyond the social
influences model to interventions, which are broader based and more comprehensive.
The theoretical foundation for these approaches is Bandura‘s social cognitive theory (Bandura 1977)
and Jessor‘s problem behavior theory (Jessor and Jessor 1977). Drug abuse is conceptualized as a
socially learned and functional behavior, which is the result of the interplay between social
(interpersonal) and personal (intrapersonal) factors. Drug use behavior is learned through a process of
modeling/imitation and reinforcement and is influenced by an adolescent‘s cognitions, attitudes, and
beliefs.
Although these approaches have several features that they share with social influence approaches, a
distinctive feature of these approaches is an emphasis on the teaching of generic personal self-
management skills and social skills. These skills are taught in a systematic fashion using a
combination of instruction and demonstration, feedback, reinforcement, behavioral rehearsal (in-class
practice) and extended (out-of-class) practice through behavioral homework assignments. Examples
of the skills typically included in this prevention approach are decision-making and problem-solving
skills, cognitive skills for resisting interpersonal and media influences, skills for enhancing self-esteem
(goal setting and self-directed behavior change techniques), adaptive coping strategies for dealing
with stress and anxiety, general social skills (complimenting, conversational skills, and skills for
forming new friendships), and general assertive skills (requests and refusals). Most variations on this
prevention approach teach generic skills along with their application to situations related directly to
tobacco, alcohol, or drug use. An added benefit of this type of program is that it teaches students a
repertoire of generic skills that can be used to deal with many of the challenges confronting
adolescents in their everyday lives.
The purpose of programs based on this model is to provide students with the kind of generic skills for
coping with life that will have broad application. This contrasts markedly with social influence
approaches that focus exclusively on information and skills relating to the problem of drug abuse.
Although the problem-specific social influence approaches are most easily contrasted with the generic
skills training model, the most effective approaches appear to be ones that integrate features of both.
In fact, there is some evidence to suggest that generic skills training or competence enhancement
approaches are not effective unless they also contain domain-specific material (Caplan et al. 1992).
The target population for most of the studies conducted with the personal and social skills training
approach has been middle school and junior high school students. The vast majority of published
studies have involved students who were in the seventh grade during the first year of intervention.
Multiyear studies and followup studies have involved students during the 8th and 9th grades, and
some more recent studies have followed students up to the 12th grade (Botvin et al. 1995a, b). On the
other end of the age spectrum, very little work has been done with younger populations, although
some studies have been conducted with sixth graders (Kreutter et al. 1991). The reason for this is that
researchers have generally avoided younger populations because of the difficulty in demonstrating
statistically significant behavioral effects because the base rates of drug use are too low. Most of the
studies conducted with approaches that emphasize the teaching of personal self-management skills
and generic social skills have been implemented with adults as the primary program provider. In many
cases these adults were regular classroom teachers; in some cases they were outside health
73
74
professionals (i.e., members of the research project staff). Some studies used college students as
program providers, while others used either same age or older peer leaders. Peer leaders, when used,
frequently had clearly delineated responsibilities and worked under the direction and supervision of an
adult primary provider. Some studies have actually used peer leaders who had sole responsibility for
conducting these interventions and who did so on their own and without the help of adult providers.
Studies testing this prevention strategy have shown that it can be successfully implemented by peer
leaders, outside health professionals, and teachers.
The effectiveness of the expanded social influence/competence enhancement approaches has been
tested in a number of research studies, from small studies involving a few schools to large-scale,
randomized clinical trials. These studies have consistently demonstrated behavioral effects as well as
effects on hypothesized mediating variables. Importantly, the magnitude of reported effects of these
approaches has typically been relatively large. These studies have generally produced 40 to 80
percent reductions in drug use behavior. One criticism of contemporary prevention programs is that
even though they have been able to demonstrate impressive reductions in the incidence and
prevalence of drug use behavior, these reductions have generally occurred with respect to
experimental or occasional use. Although it is important to demonstrate reductions in the early stages
of drug use, critics argue that what matters most is demonstrating reductions in more frequent levels of
use—i.e., the kind of regular use that eventuates in addictive or compulsive patterns of use. Data from
two studies of a prevention program called Life Skills Training (LST) deal directly with this issue by
demonstrating reductions of 56 to 67 percent in the proportion of pretest nonsmokers becoming
regular smokers 1 year after the conclusion of the prevention program without any additional booster
sessions (Botvin and Eng 1982; Botvin et al. 1983). For those students receiving booster sessions,
these reductions have been as high as 87 percent (Botvin et al. 1983). Equally important is the finding
from several studies that produced initial reductions of 50 percent or more for regular cigarette
smoking (Botvin and Eng 1982; Botvin et al. 1983, 1990b).‖
The conclusions of Botvin et al (1998) are not always clearly accepted by everyone. A Canadian
study (Hundert et al, 1999) reflects the mixed pattern of evaluation studies that have examined the
impact of social skills training and education programs. This report describes program effects of the
Tri-Ministry Study a school-based, longitudinal trial carried out over a 5-year period to assess the
effectiveness of classwide social skills training (SS), partner reading (RE), and a combination of
both (SS & RE) to reduce maladjustment among children in the primary division (up to grade 3) of
Ontario schools. It also places these effects in the context of other school-based prevention studies
and discusses them in view of important methodological and programmatic issues. The incremental
effects attributable to the intervention programs were small and sporadic. There were statistically
significant increases in prosocial behaviour observed in the playgrounds of intervention schools
with no differentiation by program type. Furthermore, there was some evidence--a reduction in
teacher and parent-rated externalising problems--that the combination of SS & RE and SS alone
may have had modest beneficial effects. A review of nine other school-based studies, which
evaluated universally delivered mental health prevention programs in general populations of
students, revealed similar mixed results. There are both methodologic and programmatic issues
implicated in the weak findings that have been reported to date. These issues need to be addressed
to advance knowledge about the potential impact of mental-health prevention initiatives delivered
universally through school-based programs. A companion paper gives the specific details on the
programs, randomisation of schools, selection of subjects, measurements, and analysis.
Botvin et al , (2000) , in a later case study, illustrate more of the sometimes contradictory findings,
as the students who participated in a Life Skills Training program showed positive effects six years
after the intervention. The present study examined long-term follow-up data from a large-scale
randomized prevention trial to determine the extent to which participation in a cognitive-behavioral
skills-training prevention program led to less illicit drug use than for untreated controls. Data were
collected by mail from 447 individuals who were contacted after the end of the 12th grade, 6.5 years
after the initial pretest. Results indicated that students who received the prevention program (Life
74
75
Skills Training) during junior high school reported less use of illicit drugs than controls. These
results also support the hypothesis that illicit drug use can be prevented by targeting the use of
gateway drugs such as tobacco and alcohol.
Eise et al (2002) report on an evaluation of a life skills program (Lions Quest Skills for Adolesence)
and found a mixed set of results. In comparision to a random control group, there were some
positive impacts on substanhce related behaviours after one year for Hoispanics, but not for others.
There were also some improvements pre-test to post test for the experimental group.
Hansen WB. (1992) reviewed research on programs published between 1980 and 1990 and found
that ―comprehensive‖ and ―social influence‖ programs are found to be most successful in
preventing the onset of substance use.
Gorman (1998) argues that the social influences approach to drug prevention has not been proved.
Eisen et al (2003) evaluated the popular Skills for Adolescence (SFA) of Lions Quest, a widely used
comprehensive life skills training curriculum with a dedicated drug education unit, to determine if it
is more effective than standard care in deterring and delaying substance use through middle school.
Two-year posttest (1-year post-intervention) data were collected from 5691 eighth graders (77% of
those who completed the sixth-grade survey and 87% of those who completed the seventh-grade
survey). Lifetime and recent (last 30 days) use of five substances or combinations of substances was
compared using mixed-model regression to control for school clustering. There were two significant
treatment main effects at the end of the eighth grade: lifetime (P=.05) and recent (P3 visits) users of SBHC
services. Mental health problems among all participants included depression in 31%, use of alcohol
1 time or more per month in 21%, use of alcohol daily in 5%, suicidal ideation in 16%, history of a
suicide attempt in 10%, knowing someone who had been murdered in 50%, and being in at least 1
fight at school in 26%. Frequent users, average users, and nonusers did not differ by age, grade,
race, or any of the measured mental health problems. Among the 472 students who completed the
survey section on SBHC perceptions, 305 described health center use: 92% were satisfied with
health center services, 79% were comfortable being seen in the SBHC, 74% believed visits were
kept confidential, 61% told their parents about each visit, and 51% considered the SBHC their
regular health care source. The health center was used for mental health services by 34% and
sexuality-related care by 15%. The 167 students who described reasons for not using the SBHC
most frequently reported that they already had a physician (60%), did not need it (50%), prefer
continuing previous health care (45%), did not get around to it (30%), parents were opposed (20%),
were not comfortable (19%), did not know about the service (19%), and did not want problems
known (19%). they conclude that, in this urban high school, (1) average users, frequent users, and
nonusers did not differ in the mental health problems measured in this study; (2) those who used the
SBHC indicated strong satisfaction with the care received; and (3) those who did not use the SBHC
chose to stay away for a variety of reasons, most commonly the availability of other care or the
perception of lack of need.
Joost et al (1993) suggest that disproportionate use of school health rooms can be predicted on the
basis of product health diseases such as obesity. They found that such students are more likely to
use school-based health clinics This implies that such centers may be a means of reaching such
high-risk groups. Keyl et al (1996) found that school-based health clinics need to be actively
promoted to make their operation and services known to students and their parents.
Young & Ireson (2003) suggest that a combination of telehealth and school health clinics can help
rural schools and communities gain access to convenient care. This study evaluated the quality and
cost effectiveness of health care provided in urban and rural elementary school-based telehealth
centers, using plain old telephone system (POTS) technology. A telehealth school-based model was
developed that used a full-time school nurse, half-time mental-health consultant, linked pediatric
practice, and linked child psychiatrist via POTS with an electronic stethoscope; ears, nose, and
131
132
throat endoscope; and otoscope. One rural and 1 urban center were evaluated. Providers, nurses,
children, and parents completed satisfaction questionnaires. Providers and nurses also evaluated
how well telemedicine supported their clinical decision-making. Parents were asked how use of the
center affected them financially and at work. Of the combined 3461 visits to school nurses at both
centers, 4.3% resulted in 150 telehealth consultations referrals; 142 (95%) were completed during
the 2-year project. The most common teleconsult diagnoses were otitis media, pharyngitis,
dermatitis, and upper respiratory infections. Provider, nurse, child, and parent satisfaction all were
high. Providers' and nurses' decision confidence scores ranged from a low of 4 to a high of 4.8 on a
5-point scale. Average family savings per encounter were 3.4 hours of work time (43 dollars) and
177 dollars in emergency department or 54 dollars in physician costs. Including travel, savings for
families ranged from 101 dollars to 224 dollars per encounter. Thirteen children received
telepsychiatric evaluations resulting in diagnoses of depression and attention-deficit/hyperactivity,
anxiety, and conduct disorders. Telehealth technology was effective in delivering pediatric acute
care to children in these schools. Pediatric providers, nurses, parents, and children reported primary
care school-based telehealth as an acceptable alternative to traditional health care delivery systems.
The POTS-based technology helps to make this telehealth service a cost-effective alternative for
improving access to primary and psychiatric health care for underserved children.
Best Practices and Sustainability of School School-based Health Centers
The general principles and advisable program format appears to be well discussed
The School Health Committee of the American Academy of Pediatrics (2001) offers guidelines on
the integration of expanded school health services, including school-based and school-linked health
centers, into community-based health care systems. The AAP suggests that expanded school health
services should be integrated so that they enhance accessibility, provide high-quality health care,
link children to a medical home, are financially sustainable, and address both long- and short-term
needs of children and adolescents.
These guidelines are consistent with professional guidelines published on the web site of the
Canadian Association of School Psychologists (New Brunswick Department of Education, 2001).
Sustainability and long term funding have been noted in much of the research on school-based
clinics.
Swider &Valukas (2004) discuss a variety of funding sources for SBHC‘s based on the American
experience. Obviously, not all of these sources will apply to Canadian jurisdictions. Promising
sources of funds include private grants, federal grants, and state funding. Using a variety of funding
sources will enable ongoing provision of health care to students. They suggest that SBHCs should
consider infrastructure development that allows a variety of funding options, including formalizing
existing partnership commitments, engaging in a needs assessment and strategic planning process,
developing the infrastructure for potential government grants and implementing a billing system for
client services. (In Canada, this could be to the local health unit or school board.)
Summers et al (2003) suggest that SBHC‘s need to use a variety of client-driven, community-based
and strategic approaches to ensure that their programs are well supported by local communities and
schools. They suggest a community-based model would aim programs and intervention at high-risk
adolescents identified as needing treatment. Community-Oriented Primary Care (COPC) bridges the
gap between primary care and public health to evaluate and improve the delivery of health care to
identified populations. The COPC model was used to develop and implement an adolescent school-
132
133
based health center in a southwestern border community. The four process steps based on the COPC
model include: identifying the community of interest, identifying the health problem, developing
and implementing intervention(s), and conducting ongoing evaluation. Key stakeholders from the
medical, educational, and consumer groups were invited to participate in the first and second steps.
Representatives of various school adolescent subcultures formed a group of promotores (health
promoters) to monitor, advise, and contribute to the process. The Dartmouth COOP survey was
selected to identify health concerns and risks of the targeted high school. The promotores prepared
and administered the survey to 1,116 students. Results were used to design the initial health center
program components using an interdisciplinary team to implement interventions aimed at the major
health concerns and risks identified by the COOP. A short feedback loop contributed to program
refinements, and ongoing evaluation continues to shape the practice of health care providers in the
school-based health care center.
Guernsey & Pastore (1996) present a similar analysis of the need for SBHC‘s to be closely tied to
their communities and schools with their mprograms, needs assessments and outreach. They discuss
the steps necessary to assess student needs and build community support, develop the plan for
delivery of school-based primary care, implement the school-based health center model, and
evaluate the health center program.
Roles of Public Health, Mental Health Personnel in SBHC‘s.
The roles of various health care and school personnel in SBHC‘s also appears to be well-discussed.
Gall (2002) suggests that Nurse practitioners are the primary clinician in the majority of SBHCs in
the United States. To help move the field of school-based health care from innovation to
mainstream, nurse practitioners need to continue to be part of the development of conceptual
frameworks, appropriate methods, and evaluation of the process and outcomes. Educational
achievement, access to care and reimbursement, and reduction of adolescent morbidity are
indicators that have great significance in policy development. The extent to which nurse
practitioners in SBHCs can provide evidence of making a difference will determine the success of
this important health care venue for adolescents and demonstrate their own professional excellence.
Hacker & Wessel (1998) have also described the collaboration necessary between SBHC‘s staff and
school nurses. Partnerships between school-based health centers and school nurses are critical for
the success of school-based health centers, and partnerships will enhance and expand roles for
school nurses. This paper clarifies the role of each in three areas: collaboration, communication, and
cooperation. In addition, obstacles to partnerships are examined. The goal of this collaboration is a
shared vision for the continuum of school health services in which school nurse and school health
center serve integral roles. Elements for successful collaboration between nurse and health center
are reviewed, including clarifying roles, shared leadership and program ownership, cooperative
training and continuing education, negotiating conflict, and most importantly, maintaining mutual
support and respect.
Kubiszyn T. (1999) reviews recent trends, developments and empirical support for the expansion of
psychological practice to include school-based treatment and management of serious and chronic
medical conditions, including somatization, in collaboration with primary health care providers.
Trends and developments reviewed include (a) the expansion and integration of health, mental
health, social and community services in schools, (b) the rapid growth of school-based health
centers (SBHCs), (c) psychology's increased involvement in the collaborative treatment of chronic
and serious medical disorders, (d) recent federal and state legislative initiatives, and (e) cost-driven
133
134
marketplace changes. Lack of empirical data specific to collaborative psychologist-health care
provider collaboration in schools and SBHCs, particularly around somatization, is discussed.
Ethical and legal, professional, and reimbursement issues that must be addressed if psychologists
are to practice in this emergent arena are identified. This article calls for research to document both
the clinical effectiveness and cost-efficacy of collaborative psychologist-primary care provider
intervention in schools and SBHCs.
Work Place Health, Wellness and Assistance Programs
Beyers (2001) review two meta-analyses (Peersimmian et al, 1998; France-Dawson et al, 1994) for the
Effective Public Health Practice Program in Ontario and found that most evaluations of workplace
health programs were methodologically flawed due to the absence of a control group in the studies.
Nevertheless, they suggest that comprehensive programs that include screening, risk assessment and
choice of treatment and education options by participants to be most promising.
(More To be added)
School Reform/Improvement and Health
A major Canadian research project on the relationship between student performance and student
engagement (Smith et al, 2001) can form the basis of this discussion. This study includes several
case studies and leading educational researchers in Canada.
They defined student engagement as being a multi-faceted concept
They used a framework based on an ―inside out‖ approach
They suggest that the student engagement is best understood as a series of “nested layers”, starting with
the student and reaching outward to the classroom, sxchool, family and community.
More To be added. Discuss Effective schooling, School improvement and Social/Emotional
Learning
Education and Health Systems Improving the Social and Physical Environment of the School
Does re-orienting schools to focus on the psychosocial climate (including school
improvement and effective schooling) have an impact on health and social behaviours as
well as learning?
Schools provide a number of opportunities for engaging youth in meaningful ways. These include
instructional strategies such as self-directed and cooperative learning strategies, project-based
learning, student webquests and other online learning, formal student leadership programs and
obligatory community service programs. There are also many ways that schools can empower and
engage youth through school-based peer helper and mentoring programs, voluntary student activity
programs, clubs and other extra-curricular activities. The policy, procedures and practices of the
school can emphasize student involvement, fairness and assumption of responsibilities by young
people. Further, the decision-making processes of the school can be modified to enhance student
engagement, including formal roles for the Student Council, efforts to manage a wide range of
students and the frequent use of formal needs assessments and student surveys.
134
135
Youth engagement is the meaningful participation and sustained involvement of a young person in
an activity that has a focus outside of himself or herself. Youth can be engaged in many things, and
in many different ways. It may involve doing volunteer work, participating in a youth organization,
playing in a band or a school orchestra, working for a political party or a non-governmental
organization, or taking part in the activities of one‘s church, mosque or synagogue, among many
other things. Some youth will take a leadership role in these activities, helping to organize other
youth in their efforts, while other youth will be satisfied to be participants in the activity or
organization.
Research collected by the Centre of Excellence on Youth Engagement (2003) indicates that
activities and programs to engage youth can:
make youth more aware of those in society who are disadvantaged
help youth cope with stressful life situations
provide youth with supportive social networks
enhance their social skills
increase their sense of what kind of work or occupation they might enjoy
increase their sense of competence
increase their self-esteem
give them a better sense of what is right and wrong
decrease problem behaviours
increase their academic performance and their likelihood of going on to higher education
enhance their life skills in areas such as public speaking
make them feel empowered, valued and important
help them get along better with adults
increase their leadership abilities
increase their sense of social responsibility
reduce drug use, teen pregnancy and aggression
The knowledge about school health programs has identified several interventions that can be used to generate
increased social support and youth engagement in the school setting:
f. Social Support
a) Whole school programs to improve the school climate
b) Peer helper programs for early identification and referrals
c) Student leadership and community service programs for student involvement and
participation in school policy development, awareness activities and other
activities such as dry grads, etc
d) Parent involvement, education and support programs
e) Cooperation with local community programs, services and campaigns
f) Specialized out reach to local merchants and stores to cooperate in restricting
access of minors to alcohol, prescription drugs and other substances near schools
Note: Please note that youth participation in decision-making is more fully discussed in a subsequent sub-section.
Whole School Programs to Improve the Psychosocial Climate of the School
Parcel et al (2003) report on the Child and Adolescent Trial for Cardiovascular Health (CATCH)
study provided an opportunity to study how aspects of school climate are associated with continued
implementation of the CATCH program. Nutrient analysis of menus, observations of physical
education (PE) classes, and teacher and staff self-reports were used to measure CATCH program
components. Results of this study indicate that aspects of school climate were associated with
135
136
continued implementation of the CATCH classroom component but not the CATCH food service or
PE components. These findings have implications for how we plan for the progression of innovative
school health promotion programs from the initial trial stage to institutionalization. Measures of
school climate may be useful in determining a school's readiness to adopt and implement an
innovative health promotion curriculum.
Dewitt et al (2002) have conceptualized the role that the school culture and climate can play in
influencing school achievement and health outcomes. They have developed a ―schools as
communities‖ framework based on the work of others such as Whelage and Rutter. They suggest
that the student‘s perceptions of the school environment are influenced by the formal aspects of
―school climate‖ such as rules, size of school, organization of the school etc as well as by informal
aspects of the school such as interpersonal relationships, emphasis on learning and goals, positive
student behaviours and attitudes etc.
This framework has been discussed earlier in this paper. Similalry, the work of Michel Janosz and
Penny Hawe has also been presented and discussed ewarlier in this paper. All of these Canadian
researchers have indicated that the psycho-social climate of the school can have an important
impact on health, social behaviours and learning.
However, an earlier analysis by Norland et al (1996) indicates that a positive social climate may not
be as simple as it sounds, because schools perform the function of sorting and selecting people for
later places in life. This means that some people will recognize that they are being sorted and may
respond through substance use and other anti-social behaviours. They suggest that evaluations of
school curricular drug control efforts show they are only modestly successful because they are
based on an inaccurate theory of drug taking. Social control theory is suggested as a better model of
drug taking and drug resistance. Building strong bonds to school acts to decrease the likelihood of
interaction with delinquent peers and thereby decrease delinquency and drug use. Yet schools are
sites of stratification and competition, and strong bonds may be related to one's place in the school
hierarchy. If schools are unable to produce sufficient positions in the hierarchy, those with low
levels of academic success or commitment may turn to the drug subculture to find status and
rewards. A number of future research questions are suggested.
Konu & Rimpela (2002) present a conceptual model for well-being in schools. They suggest that a
theoretically grounded model based on the sociological concept of well-being is needed for
planning and evaluation of school development programmes. The School Well-being Model is
based on Allardt's sociological theory of welfare and assesses well-being as an entity in school
setting. Well-being is connected with teaching and education, and with learning and achievements.
Indicators of well-being are divided into four categories: school conditions (having), social
relationships (loving), means for self-fulfilment (being) and health status. 'Means for self-fulfilment'
encompasses possibilities for each pupil to study according to his/her own resources and
capabilities. 'Health status' is seen through pupils' symptoms, diseases and illnesses. Each well-
being category contains several aspects of pupils' life in school. The model takes into account the
important impact of pupils' homes and the surrounding community. Compared with others, The
School Well-being Model's main differences are the use of the well-being concept, the definition of
health and the subcategory means for self-fulfilment. Making the outline of the well-being concept
facilitates the development of theoretically grounded subjective and objective well-being indicators.
Greenberg et al (2003) suggest that a comprehensive mission for schools is to educate students to be
knowledgeable, responsible, socially skilled, healthy, caring, and contributing citizens. This mission
is supported by the growing number of school-based prevention and youth development programs.
136
137
Yet, the current impact of these programs is limited because of insufficient coordination with other
components of school operations and inattention to implementation and evaluation factors necessary
for strong program impact and sustainability. Widespread implementation of beneficial prevention
programming requires further development of research-based, comprehensive school reform models
that improve social, health, and academic outcomes; educational policies that demand
accountability for fostering children's full development; professional development that prepares and
supports educators to implement programs effectively; and systematic monitoring and evaluation to
guide school improvement.
Wyn J et al (2000) describe an Australian mental health program Mind Matters that is an example
of such coordination of social, emotional and academic learning within a mental health framework
The program provides a framework for mental health promotion in widely differing school settings.
The teacher professional development dimension of the program is central to enhancing the role of
schools in broad population mental health promotion.
Durlak & Wells (1997) used meta-analysis to review 177 primary prevention programs designed to
prevent behavioral and social problems in children and adolescents. Findings provide empirical
support for further research and practice in primary prevention. Most categories of programs
produced outcomes similar to or higher in magnitude than those obtained by many other established
preventive and treatment interventions in the social sciences and medicine. Programs modifying the
school environment, individually focused mental health promotion efforts, and attempts to help
children negotiate stressful transitions yield significant mean effects ranging from 0.24 to 0.93. In
practical terms, the average participant in a primary prevention program surpasses the performance
of between 59% to 82% of those in a control group, and outcomes reflect an 8% to 46% difference
in success rates favoring prevention groups. Most categories of programs had the dual benefit of
significantly reducing problems and significantly increasing competencies. Priorities for future
research include clearer specification of intervention procedures and program goals, assessment of
program implementation, more follow-up studies, and determining how characteristics of the
intervention and participants relate to different outcomes.
Davis (2003) describes the appalling young-adult outcomes of youth with serious emotional
disturbance who are served in public systems and suggests that they demonstrate a failure of
standard services to address the unique needs of these youths during their transition from
adolescence to adulthood. He discusses the needs of this population and the current ability of mental
health and other relevant agencies to meet those needs. The contrast between needs and system
status is presented through a framework of contrasting developmental and institutional transitions.
This article reviews the barriers to effective system reform, and the recommendations for changes
made by national panels focused on transition and applied research.
Patton et al (2000) outline the conceptual background and strategy of intervention for a systematic
and sustainable approach to mental health promotion in secondary schools through the study of The
Gatehouse Project in Australia. The conceptual origins of the Gatehouse Project are described in
terms of the epidemiology of adolescent mental health problems, attachment theory, education
reform research and health promotional theory and practice. The elements of health promotional
work are described in terms of structural change and priority setting; implementation at multiple
levels within the participating schools is described. The conceptual framework of the Gatehouse
Project emphasises healthy attachments with peers and teachers through the promotion of a sense of
security and trust, effective communication and a sense of positive self-regard based on
participation in varied aspects of school and community life. A school social climate profile is
derived from a questionnaire survey of students. An adolescent health team uses this information to
137
138
set priorities for change within the school. Interventions may focus on the promotion of a positive
social climate of the whole school or in the classroom. Curriculum-based health education is also
used and based on materials that are relevant to the normal developmental experiences of teenagers.
These are integrated into the mainstream curriculum and incorporate a strong component of teacher
professional development. Lastly, the intervention promotes linkage between the school and broader
community with a particular emphasis on the needs of young people at high risk of school drop-out.
They note that educational environments are complex systems undergoing continuous and
simultaneous changes. The Gatehouse Project will provide unique information on the relationship
between the social environment and the emotional wellbeing of young people. More importantly it
outlines a sustainable process for building the capacity of schools to promote the social and
emotional development of young people.
Noam GG, Hermann CA. (2002) introduces a school-based prevention and intervention method for
young adolescents called Responsive Advocacy for Life and Learning in Youth (RALLY).
Prevention practitioners, a new role developed by the program, work in classrooms and after-school
settings to provide nonstigmatizing support to students. Using a three-tiered prevention model,
practitioners integrate a mental health and educational focus to foster students' academic, social, and
emotional success. The intervention involves all children of an age cohort in middle schools. The
practitioners are developmental specialists who create relationships with youth, teachers, and
families in high-risk environments and serve triage functions to existing community and health care
institutions. The RALLY intervention builds on normative developmental and developmental
psychopathology theory, especially a risk and resilience framework. The paper describes the
principles behind the practice and how the work in this field has created innovations in theory and a
new impetus for research.
Rudd & Walsh (1993) ask if schools as healthful environments are a prerequisite to comprehensive
school health programs. They suggest that the development of healthy schools to support and nature
the well-being of students, teachers, and staff is proposed as a first step toward the goal of
comprehensive health education. A focus on healthy schools incorporates elements of an expanded
concept of comprehensive health education that demands careful consideration of the physical,
psychological, and social environment of the schools as a worksite to students, teachers, and staff.
The active participation of all stakeholders in environmental assessments, health and safety audits,
and restructuring of schools is an essential part of the school reform movement. A healthy worksite
concept supports the transformation of the school environment to increase "productivity" by
enhancing the ability of teachers, staff, and students to function well.
Hootman et al (2002) describe a program to educate school nurses about mental health
interventions. An educational program was designed to assist school nurses in the identification of
potential mental health problems. In addition, information about appropriate interventions for
students at risk for aggression, violence, and other mental health pathology was presented. The
program involved education on mental health assessment and intervention, as well as expert
psychiatric clinical support for the development of student support groups. School nurses were then
challenged to develop practice improvement projects incorporating this knowledge for a group of
students in their work setting.
Weissberg et al (2003) suggest that the most beneficial preventive interventions for young people
involve coordinated, systemic efforts to enhance their social-emotional competence and health.
They propose standards for empirically supported programming worthy of dissemination and steps
to integrate prevention science with practice. They highlight key research findings and common
principles for effective programming across family, school, community, health care, and policy
138
139
interventions and discuss their implications for practice. Recent advances in prevention research and
growing support for evidence-based practice are encouraging developments that will increase the
number of children and youth who succeed and contribute in school and life.
A Canadian study (Rye et al, 2001) also suggests that school climate and relationships with parents
is essential to program effectiveness. Parents, students, and program leaders involved in an in-
school drug prevention program called Opening Doors were assessed for their perceptions of the
efficacy of the program. In general, the feedback indicated a very high program satisfaction level
from respondents with parents indicating the highest level satisfaction (92%). Areas for
improvement ranged from: parent attendance, invitation process, increased support from schools,
and increasing awareness of scheduling and time involvement by leaders and school administration
based on program leader feedback as well as invitation process and program duration from the
parents (e.g., 37% thought the program was too short). Student satisfaction may be predicted from
the perceived impact of the program on significant relationships (e.g., with peers and family) as
well as affective reactions to the program (e.g., enjoyment of the program). Finally, a school-level
analysis indicated that the application of the Opening Doors Program in different schools was
provided uniformly.
School-based Peer Programs
There is a considerable body of evidence on impact of school-based peer helper programs, the
magnitude of which is beyond the scope of this paper. The Canadian Association of School
administrators (1992) has summarized the research on such peer programs. Quoting Rey Carr from
the BC Peer Resource Center, this document has summarized the functions of such peer helpers as:
students learn about school services
ut their concerns
The summary document also described the essential elements of a peer helper program:
1.The program must be led and supervised by an adult who is trained and experienced in
peer helping.
2.The program consists of training sessions, a tested curriculum-based on student needs.
3.The training environment encourages enjoyment, involvement and skill development.
4.Students selected as trainees must feel the training is special and trainees must represent
the social composition of the community in which they will be working.
5.The training methods must emphasize interactive components and feature applied
activities.
6.The training program and the roles of the peer helpers must have a broad base of support
from teachers, administrators, parents and other students.
7.The trainees must have ongoing supervision and learning opportunities.
139
140
This CASA summary, although somewhat dated, provides a review of the research. It shows the
impact of peer helper programs use in a variety of settings within the school towards a variety of
purposes and program goals.
A more recent Canadian review (Ciliska, 2001) has summartized the meta analysis of Harden et al,
1999) and reported that peer helper programs can be effective in reducing tobacco and drug use,
especially for high risk youth.
Mobilizing Social Support
The presence of an active social network is one of the determinants that can affect and individual‘s
health behavior. Such social support can be enhanced or created through a variety of programs
including:
-help groups
rtners/family members in the home setting.
The paper done for Health Canada on youth-led health promotion (McCall, 1995) prepared an
inventory of community and school-based programs. Working from a lengthy list of potential sites
within both the community and school settings, the findings relevant to this paper were:
programs aimed at youth out of the mainstream
effective in communicating with youth about health issues
had a health impact
no impact evaluation data was available.
Black et al (1998) have conducted a meta-analysis of peer programs related to substance abuse.
Their review focuses on the following: a) results of a 120-study meta-analysis of school-based drug
prevention programs and positive program features; b) considerations for falsely concluding that
peer programs are ineffective; c) features of two model or stellar programs that compared
interactive (peer leadership) to teacher/researcher-led (non-interactive) programs that followed
National Peer Helpers Association (NPHA) Programmatic Standards; and d) suggestions for
designing and implementing high-quality, peer-led programs. They conclude that interactive peer
interventions for middle school students are statistically superior to non-interactive didactic, lecture
programs led by teachers/researchers. Programs implemented according to NPHA Programmatic
Standards may eliminate Type II (false negative) and III ("implementation failure" or ineffectively
designed and implemented program) errors. Opportunities for prudent application of well-designed
peer programs appropriately implemented and evaluated must remain a salient priority.
Sussman et al (1997) described two studies that were conducted at high schools whose students are
at high risk for drug abuse. Twenty-one schools were randomly assigned to one of three conditions:
(a) standard care, (b) classroom drug abuse education only, or (c) classroom plus school-as-
community. Results of the first study indicated that the school-as-community component--which
140
141
involved weekly meetings and periodic events at seven schools--was implemented as planned, drug
abused focused, and perceived as productive in discouraging drug abuse. In the second study, staff
in the classroom plus school-as-community condition self-reported involvement in the greatest
number of community activities across the school year, compared with staff from the other two
conditions. These two studies support the feasibility of formalized groups of high-risk youth to
promote drug-free events.
Mellanby et al (2000) reviewed evaluations that compared the effects of peers or adults delivering
the same material. The identified studies indicated that peer leaders were at least as, or more,
effective than adults. However, they suggest that although their review uggests that peer-led
programmes can be effective, methodological difficulties and analytical problems indicate that this
is not an easy area to investigate, and research so far has not provided a definitive answer
Winkleby et al (2001) report on the impact of a peer advocacy program. Teen Activists for
Community Change and Leadership Education is designed to engage high school students living in
low-income neighborhoods in community advocacy efforts to transform their schools and
communities so they do not reinforce use of alcohol, tobacco, and other drugs. This nine month
intervention for 116 freshmen and sophomores in and near San Jose, California consisted of 30-90
minute meetings. Social cognitive constructs of sense of community, perceived self-efficacy,
outcome expectancies, incentive value, policy control, and leadership competence guided the
program. No changes in individual use of alcohol, tobacco, and other drugs were observed by the
end of the program, but improvements in community involvement and self-perception of many of
the constructs were observed.
Extra-Curricular Activities
The Centre for Excellence on Youth Engagement (2003) has described the research on the health
impacts of student engagement/participation in school activities: These impacts include direct
reference to substance use, social and emotional difficulties and overall risk behaviours. .
Youth Engagement and Alcohol Use
Eccles and Barber (1999) used data from the Michigan Study of Adolescent Life
Transitions (MSALT) to examine the relationship between youth engagement and
involvement in behaviours that might place their health at risk, such as alcohol and drug
use. Youth in the MSALT project were followed through 8 waves of data collection,
beginning when they were in the 6th grade (1983-84), and continuing into 1996-97, when
most were 25 or 26 years of age. The analyses presented in the Eccles and Barber (1999)
report include data from 1,259 respondents who had completed survey items about
activity involvement in the grade 10 wave of data collection (in 1988-89), and for whom
outcome data were available at wave 6 (in 1990-91, when most were in grade 12) and in
wave 7, two years later (in 1992-93). Information was collected on the adolescents'
involvement in a wide variety of activities while they were in the 10th grade, by presenting
them with a list of 16 sports and 30 school and community clubs and organizations, and
asking them to check off all activities in which they participated. An index was created to
indicate the level of involvement of each student in each of five major activities: prosocial
activities (e.g., volunteering and community service), performance activities (e.g., school
band, drama), team sports (e.g., basketball team), school involvement (e.g., student
government), and academic clubs (e.g., math club). Health risk behaviours were assessed
in the 10th and 12th grades by asking students to indicate on a scale from 1 (none) to 7
(21 or more times) how frequently over the previous 6 months they had engaged in a
number of risky behaviours, including drinking alcohol and getting drunk.
141
142
Results showed that individuals involved in prosocial activities such as volunteer work
when they were in grade 10 drank alcohol and got drunk at much lower rates than did
those who did not engage in these kinds of activities, when these behaviours were
measured two years later, in grade 12. The relationship between involvement in prosocial
activities and drinking remained, even after controlling for gender, mother's educational
level, intelligence, and even 10th grade drinking. This is consistent with a possible causal
relationship between prosocial activities and a reduction in drinking, in that prosocial
activity in grade 10 predicted changes in drinking behaviour from grade 10 to grade 12.
Similar effects were obtained for involvement in the performing arts, with adolescents who
were involved in these kinds of activities in grade 10 showing lower levels of alcohol
consumption in grade 12. Participation in school involvement activities and academic
clubs in grade 10 was not related to drinking in grade 12. Team sport involvement
assessed in grade 10, on the other hand, was related to increases in alcohol consumption
in grade 12.
Another study using a different sample from the MSALT data (Barber, Eccles & Stone,
2001) also examined the relationship between extracurricular involvements and alcohol
consumption. This study included approximately 900 of the MSALT participants, for whom
data were available during the 10th grade (wave 5), 12th grade (wave 6), and 2 (wave7)
and 6 (wave 8) years after high school. Engagement or involvement was measured in the
10th grade, as described above; adolescents were asked to check activities in which they
participated from a list provided to them. The activities were grouped into four categories:
prosocial activities, team sports, performing arts, and school involvement. Information on
drinking was collected at waves 5, 6, 7 and 8 for the previous 6 months, on a scale
ranging from 1=none to 7=21 or more times. The results indicated that those who had
participated in prosocial activities in Grade 10 drank significantly less frequently than
those who had not been involved in these kinds of activities across all time periods.
Indeed, participation in prosocial activities in the 10th grade predicted lower levels of
alcohol use up to 8 years later, 6 years after the individuals had completed high school.
Involvement in other kinds of activities &endash; sports, the performing arts and school,
showed a different relationship with drinking: sports team participation was associated
with higher levels of drinking, as was participation in the performing arts.
Vicary, Smith, Caldwell & Swisher (1998) utilized data collected as part of the Rural
Adolescent Development Study (RAD) to assess the relationship between involvement in
positive leisure activities and use of alcohol. The RAD study involved giving annual
surveys to students, originally in grade 7, 8 or 9, from a rural school in northeastern
Appalachia. This area was populated by families with low- to middle-income levels, with
two thirds of the adult population having a high school education or less. Involvement in
three kinds of activities was assessed in the survey: Personal Development Activities
(e.g., church attendance, volunteer activities); Social Activities (e.g., attending parties,
hanging out with friends); and School-Related Activities (e.g., after-school extracurricular
activities, school sports). Alcohol use was assessed by means of a subscale of the
Primary Prevention Awareness, Attitudes and Use Scale (PPAAUS; Swisher, Shute &
Bibeau, 1984), which asked respondents to indicate the frequency with which they
consumed alcohol, on a 6-point scale ("never" (1) to "many times daily" (6)). The data
from 460 respondents who had participated for at least two sequential years in the study,
and who had no history of drinking as assessed at time 1 were included in the data
analyses. The results indicated that decreases in sports, hobbies and crafts, and church
involvement preceded increased alcohol use for girls, but not for boys.
Komro et al. (1996) assessed the effects of adolescent participation in the planning and
promotion of alcohol-free social activities on drinking. This research was part of Project
142
143
Northland, a program based in northeastern Minnesota, which was designed to prevent or
reduce alcohol abuse among young adolescents using a "multi-level community wide"
approach (Komro et al, 1996, p. 328). The project has been implemented in 24 school
districts in the state since 1991. One component of the project is the "peer participation
program", in which seventh grade students in the intervention schools were recruited to
participate in the planning and promotion of alcohol-free activities, such as dances, ski
trips and movie nights, for their fellow students. Students who were involved in the
planning of the program activities (planners) were compared with students who attended
the peer-planned events, but were not involved in planning them (attenders), and students
who neither planned nor attended any of the events (nonparticipants), with regard to their
use of alcohol. All students involved in the study completed self-report surveys at three
points in time &endash; at the beginning and end of grade 6 (fall of 1991 and spring of
1992), before the program began, and after the program had been implemented, at the
end of grade 7 (spring 1993). In addition to items assessing demographic and background
characteristics contained in the earlier surveys, all surveys included questions assessing
alcohol use ("On how many occasions have you had alcoholic beverages to drink (during
the past 12 months, 30 days, and 7 days)?").
The study cohort consisted of 1,028 students, 166 of them who were "planners", 335 who
were "attenders" and 527 who were "nonparticipants". Analysis of covariance was used to
compare the drinking levels of the three groups as assessed on the grade 7 survey, with
baseline drinking levels and background variables from the grade 6 surveys as covariates.
These analyses showed a significant difference in alcohol consumption among the three
groups. The planners consumed significantly less alcohol than did the attenders and
nonparticipants. Moreover, the greatest impact of the peer participation program was on
planners who had reported alcohol use in the baseline surveys administered in grade 6.
Shannon & McCall Consulting Ltd (1996, 1998), in two reviews done for Health Canada found
differential effects for the youth organizers of youth activities as distinct from the youth
participants in such activities. While the experience of young people in leadership positions
appears to offer several benefits, the evidence on the impact of youth organized vs adult
organized activities seems less clear.
Nevertheless, the review done by the Centre of Excellence for Youth Engagement (2003) has
identified other sources that indicate that participation in such extr0currciuylar activities creates
health benefits.
Similarly, Jenkins (1996) found that extracurricular involvement was significantly and
negatively correlated with high school students' use of both gateway (cigarettes,
marijuana, beer, wine cooler, and liquor) and hard drugs (e.g., inhalants, LSD,
amphetamines, cocaine, heroin), independent of both academic performance and
affiliation with peers who used drugs. Their sample consisted of 2229 randomly selected
high school students from Grades 8, 10 and 12 from 17 school districts in Ohio.
Engagement was measured as a single-item self-report measure, in which students were
asked if they were involved in "any enjoyable extracurricular activities".
Youth Engagement and Smoking
Chung and Elias (1996) administered surveys to 556 adolescents (274 males and 282
females) in grades 9 to 12 who attended high school in New Jersey. The surveys included
self-report measures of seven "problem" behaviours: delinquent behaviour (e.g., hitting
someone, stealing), smoking, drinking alcoholic beverages such as beer and wine,
drinking hard liquor, use of inhalants, taking pills such as uppers and downers, and using
hard drugs. The survey also included a measure of the amount and quality of youths'
143
144
participation in a variety of non-academic activities such as sports. Using cluster analysis,
the investigators identified four groupings of the youth who exhibited similar patterns of
problem behaviour. One of the clusters they identified (comprising 22.7% of their sample)
was made up of youth who showed much higher levels of smoking than the youth in the
other three clusters that were identified. These "smokers" had significantly lower levels of
participation in various non-academic activities than did individuals in clusters that were
characterized by lower levels of smoking.
Youth Engagement and Overall Risk Behaviours.
In response to a perceived need to measure youth assets, Oman and his colleagues
(Oman, Vesely, McLeroy, Harris-Wyatt, Aspy, Rodine & Marshall, 2002) developed the
Youth Asset Scale. On the basis of a review of extant literature and extensive community
consultations, including interviews with 100 youth and adult "key informants", a list of
potential assets was identified. Factor analyses of these items resulted in six
developmental asset factors, which included the engagement-related variables of
"community involvement", "constructive use of time in groups and sports", and
"constructive use of time in religious activities or groups". Oman et al. assessed the
validity of their asset variables by examining the relation between risk behaviours and the
absence of each of the assets. Risk behaviours were obtained by youth self-report and
included drug and alcohol use, smoking, fighting, carrying a weapon, truancy, sexual
activity, and being arrested or picked up by the police. Participants included 1350 youth
with an average age of 15.4 years. Youth were identified as having an asset if they
indicated that they participated in the behaviours associated with that asset
"usually/almost always", that asset-related behaviours were "very/extremely important to
you", or that participation was "mostly/very much like you". Logistical regression indicated
that youth who reported an absence of each of the three engagement assets were
significant more likely to engage in between three and seven more risk behaviours than
youth who had the assets.
Youth Engagement and Socio-emotional Difficulties
McHale, Crouter, and Tucker (2001) examined the relation between engagement and
several indices of adjustment as part of a larger study of gender development. The
children were assessed at 10 years of age at baseline and again two years later.
Adjustment measures included depression, school grades, and conduct problems.
Participation in each of seven categories of free-time activities (e.g., hobbies, sports,
reading, hanging out) was measured at each time point, as well as demographic
information. They found that time spent in hobbies and sports at baseline was inversely
related to depression at 12 years of age. Time spent in unstructured activities (hanging
out and outdoor play) at baseline predicted adjustment difficulties two years later.
Mahoney, Schweder and Stattin (2002) surveyed 703 grade 8 adolescents (351 boys and
352 girls), from six communities in central Sweden. They also sent questionnaires to the
parents of the children who were surveyed. Analyses were performed on the 537
adolescents (281 girls and 256 boys) whose parents completed a survey. The survey
contained measures of involvement in structured after-school community-based activities,
such as sports, music, theatre and fine arts, scouting, church organizations and politics.
The adolescent respondents also completed a standardized 6-item scale used to assess
depressed mood (Diekstra, 1995). The scale included such items as: "How often do you
feel as if you don't want to live any more?" (1=almost never; 5=very often). The results
indicated that adolescents who participated in structured after-school activities had
significantly lower levels of depression than did those who did not participate in such
activities. The relationship between involvement and depression was especially strong for
144
145
young people who were "detached" from their parents, in that the parents had little
knowledge of their children's activities. The individuals with detached parents showed low
levels of depression if they were involved in structured activities, but high levels if they
were not.
The researchers at the Centre for Excellence on Youth Engagement identify several issues for further
research in relation to youth engagement or participation.
Causation and Correlation: Much of the research evidence, however, has been
correlational and concurrent in nature, in which both engagement and health variables
were measured at the same point in time. Youth engagement researchers have long
recognized problems in making causal inferences from such data. Second, correlational
links between engagement and health may be a function of a shared connection to a third
variable (e.g., both engagement and a sense of self-efficacy may be the result of financial
resources). Finally, connections between engagement and health may be a function of
selection effects, which are potential confounds in studies in which youth determine their
own level of engagement. Youth who are engaged may differ from their nonengaged
peers in a number of important ways even before they become engaged. Further,
healthier youth may be more likely to maintain their engagement over time than less
healthy youth and thus possibly amplify pre-existing differences
Mediating Processes: a convincing argument for a causal role for engagement also
requires understanding how engagement influences well being. These explanatory
processes, which specify the mechanisms through which engagement operates, are
known as mediating variables. For example, if engagement leads to reduced marijuana
use because engaged youth make friends in an activity with other youth who believe
drug use is wrong, than the relation between engagement and drug use is said to be
"mediated" by friends' values. Similarly, Adult activity leaders can serve as role models
and mentors, as well as providing social, emotional and instrumental support (Eccles &
Barber, 1999; Larson, 1994). Relationships with adults outside the family may help
adolescents establish the autonomy necessary for a successful transition to adulthood. In
addition, engagement activities may facilitate adolescents' social integration into the
larger community, since such activities frequently provide connections to adult
community leaders, promote community values and a sense of social responsibility, and
introduce youth to community organizations and how they function.
Moderating Variables: The type of activity appears to be an important moderator of the
relation between engagement and outcome. Another potentially important moderator is
the extent to which the engagement activity is structured or unstructured. In a relatively
early study, Agnew and Peterson (1989) concluded that participation in organized
activities was associated with reduced delinquency, while time spent in unstructured
"hanging out" predicted increased difficulty. Mahoney and Stattin (2000) recently
reported a similar finding. High school youth who were involved in structured activities
showed lower antisocial behaviours, compared with peers who spent relatively large
amounts of time in unstructured activities. Further, in a separate study, time spent in
unsupervised peer contexts was associated with subsequent adjustment problems in a
longitudinal study of early adolescence, while leisure time spent with parents and
nonparental adults predicted positive outcomes (McHale et al., 2001).
Giles et al (2001) found that effective teaching engaged students in learning about alcohol and drugs
and was positively correlated with beneficial health outcomes in a comprehensive drug education
145
146
program. They examined the relationship between students' perceptions of a problem behavior
prevention program, All Stars, and changes in the program variables. Three factors--Program
Enjoyment, Student Engagement, and Teacher Relationship--were used to predict changes in the
four variables targeted by the All Stars program. Student Engagement was related to greater
changes in student idealism, commitment, and bonding. Program Enjoyment was related to positive
changes in student idealism and normative beliefs. Teacher Relationship had little impact on the
program variables
Collingwood et al (2000) use program evaluation data from school and community applications of a
physical fitness drug prevention program to report on extra-curricular activities as an alternative to
substance use. A train-the-trainer methology was applied to install the program in twenty-two
settings within the state of Illinois. The physical training program consisted of exercise and
educational modules delivered over a twelve-week time period that focused on learning values and
life skills through exercise. Complete pre-post data were obtained on 329 participating youth at six
school and community based sites. Significant increases were demonstrated in physical activity and
physical fitness (cardiovascular endurance, strength, and flexibility). Youth self-report data
indicated significant decreases in risk factors such as low self-concept, poor school attendance,
anxiety, depression, and number of friends who use alcohol and drugs. There were significant
reductions in the percentage of youth who used cigarettes, smokeless tobacco, and alcohol. It was
concluded that a strong relationship was demonstrated for increased fitness leading to lowered risk
factors and usage patterns. Likewise, the train-the-trainer model was shown to be an effective
installation approach to expand fitness programming within prevention settings.
Carlini-Cotrim & de Carvalho (1993) describe data obtained among 16,117 high-school students in
fifteen Brazilian cities, involving participation in a number of extracurricular activities and
consumption of drugs and alcohol. In the great majority of cases, no association was found between
attendance of artistic-, community-, or sports-related activities and the use of these substances. On
the other hand, a weak but constant negative association was found involving alcohol/drug
consumption and attendance of religious activities.
The Centre for Excellence in Youth Engagement (2003) Larson's (1994) longitudinal investigation
of the impact of extracurricular involvement on delinquency (described above) is a good example of
this research strategy. Path analyses were conducted separately for each of the categories of
engagement (sports, arts and hobbies, and youth group activities) for two cohorts of youth (Grades
5/6 and Grades 7/8 at baseline), who were reassessed 2 and 4 years later. Controlling for baseline
levels of each variable, path analyses were conducted to determine the influence of Time 2
engagement on Time 3 delinquency, as well as the influence of Time 2 delinquency on engagement
at Time 3. Overall, Larson's (1994) results provide good evidence that involvement in arts and
hobbies, as well as participation in youth group activities, may reduce later delinquency. There was
no evidence for the hypothesis that delinquency affected subsequent engagement in either youth
group activities or arts and hobbies. Sports involvement, however, did not appear to influence later
delinquency. In fact, the significant inverse correlation between sports at Time 2 and Time 3
delinquency was better explained by the impact of delinquency on sports participation than the
effect of sports participation on delinquency.
In a similarly designed study, McHale, Crouter, and Tucker (2001) investigated relations between
free time activities and adjustment in middle childhood and early adolescence. They wanted to test
the hypothesis that youth select themselves into activities on the basis of pre-existing background
factors or personal attributes. McHale and her colleagues tested whether adjustment at 10 years of
age predicted activities at 12 years of age better than age 10 activities predicted age 12 adjustment.
146
147
They concluded that there was more support for the hypothesis that adjustment predicted activities
than the reverse pattern, although they concluded that associations between activities and
adjustment over time were probably reciprocal. Similar to Larson's (1994) findings, they found the
relation depended on the specific activity and adjustment measure. In addition, the measures of
activity participation showed lower longitudinal stability than the adjustment measures and this
differential stability may have affected the results.
School-based Mentoring Programs
McLaughlin et al (1993) report on a small case study of a teacher-mentor program that was
successful in reducing drug use in the short term. A Teachers as Facilitators (TAF) Program used
classroom teachers as leaders of small groups that promoted social, emotional, and academic
development of children at high risk of adopting potentially destructive substance abuse patterns.
The program was intended to increase participating students' positive socialization experiences and
academic achievement by successfully integrating these students into the school's social system. A
longer-range goal was to increase students' sense of worth as it affects their attitudes toward
relationships with other people and academic demands. Program results were: 1) school personnel
were found capable of accurately identifying and referring to the TAF Program children who were
at risk of substance usage and in need of assistance; 2) the TAF Program was effective in improving
at-risk students' perceived academic self-concept, but was less effective in increasing students'
perceived sense of social support; and 3) the program was endorsed by participating teachers,
counselors, and administrators.
Sipe (2002) provides a meta-analysis of mentoring programs for adolescents. He reviews the
research conducted on youth mentoring programs from the mid-1980s through the late 1990s. A
number of studies have documented the varied benefits youth derive through participation in
programmatic mentoring ranging from improved relationships to a reduction in the initiation of drug
and alcohol use. Not all mentors or mentoring programs, however, are equally effective. Strategies
that mentors use to foster the development of positive relationships and effective program practices,
related to screening, training, and ongoing support are also discussed. Finally, some questions that
remain to be addressed by the mentoring field are presented.
Community Service Learning
The Centre for Excellence on Youth Engagement (2003) has cited a well-controlled intervention
study, O'Donnell and her colleagues (O'Donnell et al., 1999), which showed that community service
involvement led to reduced violence . Details of the study are described above in the section on the
relation between engagement and violent/delinquent behaviours. There are several specific design
aspects of this study, however, that are particularly important for determining the potential causal
role of engagement on health outcomes. First, students were randomly assigned to experimental and
control group, through their classrooms. This means that groups were likely to be equal in
background and personal attributes before the engagement intervention. It also eliminates selection
effects as a possible explanation for the results. Second, the authors included pre- and post-test
measures, as well as a 6-month follow-up to assess long term effects. There is clearly a need for
similarly designed experimental studies to clarify the causal role of engagement in promoting
healthy youth.
As well the Centre for Excellence on Youth Engagement (2003) has cited an assessment of the
"Youth Volunteer" projects by Hamilton and Fenzel (1988) showed that, overall, participants in the
program showed modest but enduring gains in social responsibility over the project duration. Youth
147
148
in community service activities made greater gains sense of social responsibility than participants in
engaged in child care activities. These results were based on a sample of 44 adolescents, ranging in
age from 11 to 17 years of age. Conclusions from this study are limited, however, due to its
relatively small sample size and lack of a control group. The study by Jones and Offord (1989),
described earlier, provides support for engagement or participation as the causal factor. A primary
component of their preventive intervention was the opportunity for youth to participate in various
community activities, directed by highly skilled adults. They found that a community that offered
young people opportunities for participation had lower rates of youth crime than did a matched
control community that did not offer such opportunities. Allen, Philliber, Herling & Gabriel (1997)
found that adolescents who were randomly assigned to participate in a community service program
showed significantly better long-term adjustment than youth who were assigned to a control
condition in which they were not given the opportunity to participate in community service.
The Centre of Excellence on Youth Engagement (2003) has reviewed other evidence on
community service learning.
Youniss, Yates and Su (1997) used data from an ongoing survey of high school seniors
conducted annually by the Institute for Social Research at the University of Michigan to
look at the relationship between student activities and drug use. The survey is
administered each spring in about 125 public and private high schools representing a
cross section of high schools across the United States. Included in the survey were
measures of students' school involvements (e.g., working on school publications), creative
activities (e.g., creative writing), sports (e.g., playing sports either inside or outside
school), and partying (e.g., going to bars, parties). They grouped students into five
orientations based on their level of involvement in each of these activities: (1) a school
orientation; (2) a party orientation; (3) an all-around orientation (students who were high in
all four kinds of activities); (4) an average orientation (students who were average on all
activities); and (5) a disengaged orientation (students who were low in all activities). Also
measured on the survey was students' involvement in community service and marijuana
use. The results indicated that the more students were involved in community service, the
less frequently they used marijuana. This relationship between community service
involvement and marijuana use was found for all the orientations except for the "all-
around" orientation.
The relationship between marijuana use and community service involvement was
confirmed in another study by Youniss, McLellan, Su and Yates (1999), using a different
sample of adolescents from the annual survey conducted by the Institute for Social
Research. For this study, the authors utilized data collected from nearly 17,000 high
school seniors between 1988 and 1993. Participation in community service activities was
assessed by a survey item asking respondents to indicate the extent to which they had
participated in community service or civic affairs in the previous year Once again,
participation was significantly related to the frequency with which the students reported
having used marijuana in the previous 12 months. The more frequent their participation in
community service or civic affairs, the less frequently they used marijuana.
The relationship between community service and marijuana use was also found in the
studies using data from the Michigan Study of Adolescent Life Transitions (Eccles &
Barber, 1999; Barber, Eccles and Stone, 2001). Both these investigations found that
individuals who reported participating in community service and volunteer activities when
they were in grade 10 were less likely to use marijuana both in their later teenage years,
and into young adulthood. In addition to looking at marijuana use, the Eccles and Barber
(1999) study assessed use of hard drugs, using the same kind of scale that they had used
in assessing marijuana use (i.e., frequency of use in the previous six months, on a 7 point
148
149
scale ranging from "none" (1) to "21 or more times" (7)). They found that individuals who
participated in prosocial activities such as volunteering in grade 10 reported using hard
drugs less frequently when assessed two years later, in grade 12.
The Centre for Excellence (2003) identifies these implications for future research in youth
engagement through school and community social activities.
1. Research is needed in which 'pathways' to engagement are examined in the context of health
outcomes, for example, through the naturalistic, longitudinal study of youth (Farrow & Saewyc,
2002)
2. Each of the issues discussed above in relation to moderating, mediating, and causal factors
have important implications for future research. For example, little is know about the process by
which engagement is linked to outcomes (mediating processes).
3. We need to better understand how and why engagement is linked to health outcomes,
depending on the nature of the engagement, the type of outcome, and the particular persons
involved (moderating processes). This will require longitudinal studies involving large sample
sizes of youth, including highly involved and highly non-engaged youth from various
backgrounds. Such studies will also require measurement of a variety of health-related
outcomes and types of engagement.
This research agenda is similar to the one published by Calvert et al (2002).
Parent Involvement Programs
Not all parents have the time or resources to be fully involved in school activities. Consequently,
there needs to be a variety of specific ways that parents can become involved. Individual parent
involvement in school-related health promotion can occur in these ways.
being regularly informed of their child's academic progress in health instruction, as well
as, their human, social and healthy development
receiving additional, regular reports when their child is experiencing difficulty
being informed of health or social problems relevant to their community
receiving information on the goals of the school's health programs and relevant
community health services
being involved in home-based learning activities that support the health curriculum and
classroom instruction
responding to surveys on school health issues and programs
being educated or trained in parenting skills or strategies on specific health problems
being a parent volunteer for school activities relating to health
electing parents to school advisory committees or councils that take an interest in health
issues
Collectively, parents can be involved in these ways:
organizing a parent information meeting, workshop, parenting course or parent resource
center in the school
serving on a parent committee or subcommittee on health
fundraising for health materials, resources or equipment for the school
forming a group to advocate for school or community health policies, programs or
services
advocating for policy from the municipality, school board or board of health
forming or joining a voluntary or self-help group
149
150
Inform, Educate, Involve and Empower
Based on the review of the research, it is suggested that schools can develop four different types of
approaches to programs to engaging parents in school-related health promotion. They are
informing, educating, involving and empowering.
Informing parents about health issues, programs and policies. This is the type of approach
most often used by schools and health agencies. The strategy is to raise general awareness
within the population using the school as a site to transmit information.
Educating or training parents in health-related knowledge or skills. There are several
programs addressing single health issues, as well as, general parent effectiveness programs that
illustrate this type of approach. Often an external agency partners with a school to offer this type
of program. At-risk families are often seen as the client for such programs.
Involving parents with their children's learning or in school/community decision-making about
health education, prevention and promotion. This type of program seeks to change the way
programs, services and policies are developed and implemented within the school, district,
health agency or community.
Empowering parents to influence public policy decisions. The goal of these activities is to
share the decision-making process with parents so that self-help or advocacy groups are
supported and new or different programs, services or policies are introduced that support
parental participation.
Parent Involvement In Prevention
A Health Canada review (Whitehead & Gliksman, 1984) of parenting programs has identified
several messages that can be delivered to parents, including how to (1) clarify and explain values,
(2) model behaviours, (3) understand children‘s needs and self-concept, (4) develop
communications skills and engage in reflective listening, (5) problem-solve, (6) use appropriate
reinforcement techniques, (7) present natural consequences, (8) use behavioural contracts, (9) foster
a democratic milieu within the family and (10) understand different parenting styles.
Research on the effectiveness of parent programs to prevent health and social problems is at an
early stage. Although the rationale for involving parents is solid (Mangham, 1992), several
reviewers (Dembo et al, 1985; White et al, 1992; Tobler, 1986; Bangert-Drowns, 1988) have
concluded that the results are inconclusive. This may be because of poor design of parent programs
resulting in the exclusion of at-risk parents; not coordinating parent education programs with other
health, social, employment training and housing services; and poor implementation of programs
(CASH, 1992).
Powell (1990) reviewed the research on parent education and support programs as well. Positive
effects of intensive, early childhood education programs included enhanced child competence,
maternal behaviours and several family characteristics. The success of these programs depended
upon the number of contacts with families and the range of services offered to the families.
Successful programs were characterized by collegial relationships between parents and staff, a
balanced focus on the needs of the child and the parent to create supportive social networks,
tailoring programs to specific groups of parents and allocating significant program time to open-
ended discussion.
150
151
Researchers are now reporting case studies of parental involvement in prevention programs. They
are also beginning to construct theories to explain why parents become involved or choose not to
participate.
Hahn et al (1996) used the Health Belief Model (HBM) to guide their examination of parent
involvement in a school-related drug prevention program for very young children. HBM suggests
that people will take action to prevent health probl
demographic, socio-psychological and structural situation.
They concluded that parents become involved when certain cues are received. These are: their
children's enthusiasm, transportation, child care and other incentives, positive attitudes from school
personnel, a combination of communications strategies and having multiple channels for their
participation.
Brock & Beazley (1995) also use the Health Belief Model (HBM) to explain parents‘ decisions to
participate in at-home learning activities in a grade nine AIDS/HIV and sexuality education
program. They found that 44% of the 100 parents who responded to the survey reported that they
were either moderately or highly involved in the five at-home activities. The authors noted that 20%
of the parents never received a guide from their children. They recommend a variety of
communication strategies to ensure that parents are informed of the existence of the activities
including direct mail, adaptation of materials to lower literacy levels, use of local media,
cooperation with parent councils and a covering letter from the principal.
Hearn et al (1992) reported that 75% of parents of 4th grade students participated in at-home
learning activities relating to cardiovascular health. Parents reported positive changes in some
nutrition habits, physical activity and role modeling as a result of the combined at-home and
classroom program. Parents with lower socio-economic status did not participate or benefit as
much, thereby requiring specific attention in programming.
Werch et al (1991) reported on the effects of a take-home drug prevention program using at-home
correspondence and other activities. 90% of mothers reported helping their children complete at
least one-fourth of the materials. Parent-child communications had no apparent impact of children's
intent to experiment with drugs. The authors recommended changes in program messages and
content.
Perry et al (1990) studied parental involvement in a smoking prevention program for students in
grades four to six. 95% of the parents participated in the program, with the child initiating the
activity in the vast majority of cases. Behavioural impacts were restricted to parents who were
smokers reporting that they intended to quit. Family discussions about smoking definitely increased
as a result of the program.
Perry et al, (1989) and Crockett et al (1989) have examined the behavioral impact of involving
parents of third grade students in at-home learning activities that complemented the classroom
instruction. The students that had home-based activities were compared to those with just the
classroom instruction. The results showed that home-based learning with instruction had a
significant effect on nutrition habits.
151
152
Perry et al, (19--), assessed the impact of a home learning activity program for the parents of pre-
adolescents. The program created an opportunity for parents to discuss smoking with their children.
Brannon et al, (1989) report that a combination of parent, TV and classroom instruction was able to
involve students in discussions with their parents and to gain wide participant acceptance.
Simons-Morton et al, (1984) reported that a combined instruction, parent and media program was
able to influence the snack choices of third and fourth grade students, at least for period of up to
eight weeks. However, the effect of the combined interventions declined after that time period.
Meininger (2000) found that studies combining behaviourally focused interventions with students
with efforts to change the social environment of the school by involving families and community
had little effect
Good et al (1997) describe an approach to neighbourhood-based consultation that emphasizes
collaboration with advocacy for local citizens. The primary goal is to facilitate involvement of
families and other citizens in collective action. It illustrates the assessment, collaboration, and
organizing activities dictated by an open-system, ecologically oriented community approach. The
authors define an open system as one that is understood to be part of its local context. In this case,
school boundaries are assumed to extend into the neighbourhood, and vice versa. Considered
within the school boundaries are families of the school children, neighbours, local businesses,
churches, and other community resources. Similarly, the school is viewed as a potential resource
for each of these. Practice involves assessment of direct interests as defined by participants,
development of bridge-building activities between school and citizens, small wins over time, and
long-range commitment to creation of organizational structures that connect the culture of the
school and the interests of the neighbourhood. Three types of participation structures were
identified: (a) settings and opportunities for families to have two-way communication with the
school; (b) settings and opportunities that promote communication among families; and (c) active
parent organizations that participate in decision making and planning, allowing for families to
communicate their interests as a group of stakeholders. Bridging activities include special event
and program planning along with spontaneous "moments of opportunity" that express family and
neighbourhood interests. The entry, assessment, and development of bridging activities in search
for more permanent structures is described in the context of the school district and its historical
relation to the neighbourhood. Questions addressed in the article included: 1) How can low-income
families be involved in schools in ways that benefit both their own empowerment and the well-
being of their children? 2) Where do barriers exist for meaningful participation of families in
schools?, and 3) What are the characteristics of meaningful family involvement?
Kumpfer et al (2002) tested the effectiveness of a multicomponent prevention program, Project
SAFE (Strengthening America's Families and Environment), with 655 1st graders from 12 rural
schools. This sample was randomly assigned to receive the I Can Problem Solve (ICPS) program
(M. B. Shure & G. Spivack, 1979), alone or combined with the Strengthening Families (SF)
program (K. L. Kumpfer, J. P. DeMarsh, & W. Child, 1989), or SF parent training only. Nine-
month change scores revealed significantly larger improvements and effect sizes (0.35 to 1.26) on
all outcome variables (school bonding, parenting skills, family relationships, social competency,
and behavioral self-regulation) for the combined ICPS and SF program compared with ICPS-only
or no-treatment controls. Adding parenting-only improved social competency and self-regulations
more but negatively impacted family relationships, whereas adding SF improved family
relationships, parenting, and school bonding more.
152
153
Weeks et al (1997) tested the effectiveness of involving parents in school-based AIDS education
with respect to altering AIDS-related knowledge, attitudes, behavioral intentions, communications
patterns, and behavior of students. Fifteen high risk school districts (pre-test N = 2,392) were
randomly assigned to one of three conditions: parent-interactive (classroom curricula + parent-
interactive component); parent non-interactive (classroom curricula only); control (basic AIDS
education ordinarily provided by the school). Students were tested over time in grades 7, 8 and 9.
Results indicate that both treatment conditions (parent-interactive and non-interactive) had a strong
positive impact in enhancing student's knowledge, attitudes, communication patterns and behavioral
intentions. However, results also indicate that there were no behavioral outcome differences
between the treatment groups and the control condition. Results demonstrate few outcome
differences between the two experimental conditions.
In the two treatment groups (parent-interactive and parent non-interactive), the program effects
appear to be the result of school-based curricula and of student self-determined intentions and
behaviors, rather than the presence or absence of planned parental involvement. Whether or not
structured or planned parental involvement becomes part of a school-based educational activity
should perhaps be determined by (a) the existing level of parent-school interaction based on the
nature of the community, (b) the amount of money readily available to follow through on a program
of parent involvement without compromising on student programs, (c) the age of the child and the
sensitivity of the issue, and (d) the ability of the parent/family to be involved effectively without
extraordinary expense or sacrifice by either parent or school.
Hahn et al (1998) studied the effects of a school and home-based drug prevention program on risk
factors for subsequent alcohol, tobacco, and other drug (ATOD) use among children were studied.
Data on parent and child risk factors for ATOD use were collected from fifty-six low-income
parents and their children, ages four to six years, using a pretest-posttest design. The parent-child
intervention was conducted over a two-month period. The intervention had no effect on parent or
child risk factors. However, the program was favorably received by parents and children.
Kumpfer et al (2003 examined the impact of a family-based drug education program. Because
"substance abuse" is a "family disease" of lifestyle, including both genetic and family
environmental causes, effective family strengthening prevention programs should be included in all
comprehensive substance abuse prevention activities. This article presents reviews of causal models
of substance use and evidence-based practices. National searches by the authors suggest that there is
sufficient research evidence to support broad dissemination of five highly effective family
strengthening approaches (e.g., behavioral parent training, family skills training, in-home family
support, brief family therapy, and family education). Additionally, family approaches have average
effect sizes two to nine time larger than child-only prevention approaches. Comprehensive
prevention programs combining both approaches produced much larger effect sizes. The
Strengthening Families Program (SFP) is the only one of these programs that has been replicated
with positive results by independent researchers with different cultural groups and with different
ages of children. Few research-based programs have been adopted by practitioners, partly because
of technology transfer issues. Overall, research on ways to improve dissemination, marketing,
training, and funding is needed to improve adoption of effective prevention programs.
Werch et al (2003) examined the one-year follow-up effects of the STARS (Start Taking Alcohol
Risks Seriously) for Families program, a 2-year preventive intervention based on a stage of
acquisition model, and consisting of nurse consultations and parent materials. A randomized
controlled trial was conducted, with participants receiving either the intervention or a minimal
intervention control. Participants included a cohort of 650 sixth-grade students from two urban
153
154
middle schools-one magnet (bused) and one neighborhood. For the magnet school sample,
significantly fewer intervention students (5%) were planning to drink in the next 6 months than
control students (18%), chi2 = 11.53, 1 d.f., P = 0.001. Magnet school intervention students also had
less intentions to drink in the future, greater motivation to avoid drinking and less total alcohol risk
than control students, Ps 70%
wanted to become involved or more involved and needed information on how they may be able to
participate. Only 25% believed they were adequately prepared. Two thirds believed school-based
clinics were one of the best ways to reach underserved children and adolescents and should include
preteens. They concluded that AAP pediatricians want to become more involved with
comprehensive school health programs. The ways in which they want to participate vary
substantially. Most pediatricians thought they needed additional education.
Epling et al (2003) present the rationale and describe how to develop and implement Case-based
teaching in preventive medicine. They suggest that the importance of prevention teaching is
165
166
increasingly recognized in medical education, but its implementation in medical school curricula is
hampered by its cross-specialty nature, lack of curricular time, and perception as a topic of less
importance than the traditional basic and clinical sciences. The Case-Based Series in Population-
Oriented Prevention (C-POP) was developed to address national objectives for prevention education
in a format that recognizes the students' abilities and preferences for case-based learning. This series
uses small-group discussion cases that can be adapted to a variety of settings and instructor
capabilities. These cases guide the learners from a specific clinical problem to the broader clinical
and population-based prevention issues for the topic. The cases were developed with the use of
local health department scenarios and data and have been taught and refined in a number of settings.
As part of the curriculum development project, evaluation tools that examined prevention skills and
orientation were developed and tested. With its emphasis on small-group learning, clinical
relevance, and adaptability to a variety of learner and instructor needs, the C-POP project
effectively integrates prevention concepts into medical education.
Berkovitz & Sinclair E.(2001) discuss the need to train psychiatrists in school consultation and
suggest that it is important to approach mental health and psychosocial concerns from the broad
perspective of addressing barriers to learning and promoting healthy development. There is a major
national impetus to improve academic achievement and literacy, which can be amplified by
addressing the social, emotional, and mental health needs of children and youth. Training in school
consultation allows the psychiatrist to better understand a critical institution in each child's life and
also provides technical assistance and training to school personnel, which facilitates networking
between programs and individuals involved in or interested in school mental health.
Hootman et al (2002) describe a program to educate school nurses about mental health
interventions. An educational program was designed to assist school nurses in the identification of
potential mental health problems. In addition, information about appropriate interventions for
students at risk for aggression, violence, and other mental health pathology was presented. The
program involved education on mental health assessment and intervention, as well as expert
psychiatric clinical support for the development of student support groups. School nurses were then
challenged to develop practice improvement projects incorporating this knowledge for a group of
students in their work setting.
Nader et al (2003) report on two national surveys on pediatric training and activities in school
health: 1991 and 2001 in the US. to determine whether training/education during residency
influences doing school health later in practice, and whether the amount or nature of residency
training in school health (as reported by practicing pediatricians) increased over time, as
recommended by various task forces. When resident education in school health is offered during
residency, it is associated with a higher likelihood of pediatricians' doing school health later in
practice. Recent trainees report having more residency training in school health, yet fewer recent
trainees report doing school health compared with their older colleagues. The gap between those
who do school health and have received education in school health during residency has continued
over at least a 10-year period. Recommendations include specification of school health and
community pediatrics competencies for the effective practice of pediatrics in the future.
Bullock et al (2002) used a survey to determine if attendance at specific continuing education
programs increased the perceived competence of school nurses who enrolled and completed the
programs. Respondents were queried about the general content of six courses offered by the
Missouri Department of Health and Senior Services in conjunction with the University of Missouri-
Columbia Sinclair School of Nursing. Specific content areas were mental health concerns, suicide
prevention, diabetes management, asthma management, seizure disorders, and developing clinical
166
167
skills as they pertained to school-age children. Comparing a sample of school nurses who had
attended the programs with a group whom had not, a statistically significant difference was found in
the participant group who reported higher self-perceived competence than the nonparticipant group
in all content areas. Results of the study suggest that school nurses who attend specific continuing
education programs feel more competent in practice than nurses who do not attend.
Burger & Spickard (1991) have described an attempt to integrate substance abuse into the
curriculum of a traditionally organized medical school. Faculty selection, determination of the skills
and knowledge needed, and methods for enriching the curriculum to include substance abuse are
discussed. Problems encountered during the project, benefits of implementing the curriculum
changes, and recommendations for other medical schools choosing to implement such a program
also are provided.
Power et al (2003) discuss Preparing psychologists to link systems of care in managing and
preventing children's health problems. They describe multiple pathways for the preparation of child-
oriented psychologists to link health, educational, and family systems, in keeping with the National
Institute of Mental Health guidelines for preparing professionals in child and adolescent
psychology. These pathways include training embedded in graduate programs specializing in
clinical child, pediatric, school, community, and family psychology. This article highlights a
training initiative for preparing child-oriented psychologists based in a school psychology program.
Interdisciplinary Training
Lia-Hoagberg et al (1997) reported on the value of creating inter-disciplinary teams of health and
education professionals. They describe an interdisciplinary health team training program for school-
based clinic staff in Minnesota. The project sought to improve team functioning, level of practice,
and health care services at the school sites. Participants were interdisciplinary staff members from
clinics in senior high, middle, and elementary schools. The program consisted of further
development in team training knowledge and skills and educational sessions on issues identified by
participants. Evaluations indicated participants reported greater knowledge and improved team
functioning experiences from the team training. Gains also were shown in knowledge and skills in
specific school topic areas such as violence, resiliency, working with resistant families, and self-
care. The program could serve as a model for other interdisciplinary school health team training
Mason & Wood (2000) found similar results with training of education and mental health workers.
A model is presented to illustrate a clinical mental health training program within a
multidisciplinary School-Based Health Clinic (SBHC). In collaboration with schools of education,
medicine, nursing, and social work, a multidisciplinary training and treatment program was
established that provided unique opportunities for clinical training. An ecological/public health
model was utilized as the conceptual framework for clinical mental health training, treatment, and
research. Preliminary clinical outcome data suggest that out of a sample of 381 patients, 15% of
those utilizing the SBHC's mental health services were being treated for substance abuse disorders.
This finding supports current research that has demonstrated that the SBHCs are providing access to
students who are in the most serious need to mental health services. Process data suggest that the
SBHC is an effective site for multidisciplinary clinical mental health training
Training/Staff Development & Technology
Findings indicate that more active innovation ands collaboration in the use of technology would
provide additional training for current staff .
167
168
Farel et al (2001) describe the effect of an online analytic skills training course on professional
development and practice and discusses recommendations for using this training modality in the
public health workforce. The Enhancing Data Utilization Skills Through Information Technology
initiative trained professionals in maternal and child health from 13 Southerntier state and local
health departments to collect, analyze, and interpret data via a year-long Web-based course. The
evaluation of this initiative was based on a model of change for health professionals that holds that
training influences behavior by increasing knowledge, influencing beliefs related to the behavior,
enhancing self-efficacy, and improving skills. Participants' knowledge, beliefs, and self-efficacy all
increased significantly during the course. Participants' self-assessed skill levels increased
significantly for each of 12 selected skills and overall for all skills combined. Distance learning is
potentially an effective means for professionals to advance their skills while continuing to fulfill
their work-related responsibilities.
An early study of computerized information for professional develoment purposes (Bosworth &,
Yoast, 1991) found that school staff used the information in their program planning. The computer
system, DIADS, provided access to a cost-effective planning resource that has information to
programs about alcohol, other drugs, and prevention, helps the school assess the effectiveness of its
current prevention efforts using an expert-generated school assessment model containing fourteen
factors. Feedback from the assessment provides suggestions for improvements in current prevention
programs. DIADS guides the selection of future activities and helps in program planning. Pilot test
of DIADS at several sites indicates school personnel find the information on DIADS helpful, timely
and easy to access
Bynum et al (2002) report on differential responses to distance education/training (telehealth)
programs. Socioeconomic and demographic factors can affect the impact of telehealth education
programs that use interactive compressed video technology. This study assessed program
satisfaction among participants in the University of Arkansas for Medical Sciences' School
Telehealth Education Program delivered by interactive compressed video. Variables in the one-
group posttest study were age, gender, ethnicity, education, community size, and program topics for
years 1997-1999. The convenience sample included 3,319 participants in junior high and high
schools. The School Telehealth Education Program provided information about health risks, disease
prevention, health promotion, personal growth, and health sciences. Adolescents reported medium
to high levels of satisfaction regarding program interest and quality. Significantly higher satisfaction
was expressed for programs on muscular dystrophy, anatomy of the heart, and tobacco addiction (p
< 0.001 to p = 0.003). Females, African Americans, and junior high school students reported
significantly greater satisfaction (p < 0.001 to p = 0.005). High school students reported
significantly greater satisfaction than junior high school students regarding the interactive video
equipment (p = 0.011). White females (p = 0.025) and African American males (p = 0.004) in
smaller, rural communities reported higher satisfaction than White males. The School Telehealth
Education Program, delivered by interactive compressed video, promoted program satisfaction
among rural and minority populations and among junior high and high school students. Effective
program methods included an emphasis on participants' learning needs, increasing access in rural
areas among ethnic groups, speaker communication, and clarity of the program presentation.
Basen-Engquist et al (1994) did a similar study on the impact of video-based vs workshop training
of teachers in tobacco education. This study examined the implementation phase of a four-year
research project to test the effectiveness of strategies to increase diffusion of Smart Choices, a
school-based tobacco prevention program. The impact on curriculum implementation of two
approaches to teacher training are compared. School districts were randomly assigned to a live
168
169
workshop training or video training condition. The outcome of the evaluation was teachers'
implementation of Smart Choices. Results show a lower proportion of video-trained teachers
implemented the curriculum, but overall completeness and fidelity of implementation for those
teachers who did teach the curriculum were comparable for the two groups. Video-trained teachers,
however, were less likely to use brainstorming and student presentations/role plays, two of the
methods prescribed by the curriculum. Implications of the results for teacher training are discussed.
169
170
9. Involve, Empower Individuals and Groups
This sub-section examines the population health principle that health promotion programs are
more effective if individuals, groups and communities are involved and empowered in the
decisions affecting their health. In the school setting, this plays out through the involvement of
students, parents, volunteers and staff in classroom/school decision-making as well as decisions
about youth programs delivered by public health, addictions and other agencies.
Our findings in this sub-section can be summarized as follows:
there is considerable research evidence showing correlations between youth/student
engagement and health as well as risk behaviours such as drug use. However, the
cause effect relationship is not clearly established and there needs to be more critical
examination of which youth (leaders vs participants) actually benefit. Very few
studies examine the impact of youth participation in decision-making on the
participants or recipients of the youth driven decisions.
There is considerable research to show that parent involvement in their children’s
education and their values and expectations about schooling have a important
impact on achievement and health. However, collective parental involvement in
school decision-health care, or other agencies making is yet to be strongly
correlated, let alone seen as a cause, of either improved school performance or
healthier student outcomes
The European definition of “health promoting schools” emphasizes “democratic
participation” more strongly than North American or other models. This is similar
to the emergence of calls for “democratic” schooling.
School systems are using several formal means to involve and engage its clients in
decision-making, including student councils and consultations, obligatory student
community service learning, student leadership programs, parent councils,
mandatory report cards for parents and satisfaction surveys, school goal-setting,
school report cards, extensive use of Indicators as well as informal means such as
“active learning”, “styles of learning” and school climate enhancement to improve
levels of involvement and engagement. These multiple measures are far greater in
scope than those used by systems such as recreation, public health, or other youth-
serving agencies. Whether all of these measures are sufficient to counteract other
competing pressures on schools to measure, standardize and improve academic
results in selected academic subjects as well as overcome an underlying function to
transmit dominant values, norms and to exercise social control is another question.
Indeed, the built-in “inertia” of loosely coupled systems and professional
bureaucracies may actually safeguard schools and students from governments
wishing to exert too direct control over their direction.
Engaging, Empowering Youth in Decision-Making
Please note that this sub-section examines youth participation in decision-making of schools and
public health agencies. Other forms of engagement, such as peer programs, extra-curricular
activities, student leadership, and community service learning are discussed in the sub-section
above on involving and empowering individuals and groups.
The World Youth Report (Lansdowne, 2003) has summarized the evidence supporting a youth
engagement/development agenda:
170
171
―Participation promotes the well-being and development of young people. It is by questioning,
expressing their views and having their opinions taken seriously that young people develop
skills, build competencies, acquire confidence and form aspirations. It is a virtuous circle. The
more opportunities a young person has for meaningful participation, the more experienced
and competent he or she becomes. This allows more effective participation, which in turn
enhances development.‖
An expert on youth participation (Roger Hart) has described such involvement in an eight step
Ladder, described below in reverse order. The bottom three rungs describe youth involvement that
is not true participation whereas the top five rungs describe true participation.
8. Youth-initiated, shared decisions with adults is when projects or
programs are initiated by youth and decision-making is shared among
youth and adults. These project empower youth while enabling them to
learn from experience and the expertise of adults.
7. Youth-initiated and directed is when young people initiate and direct a
project or program
Adults are involved only in a supportive role.
6. Adult-initiated, shared decisions with youth is when projects or
programs are initiated by adults but the decision-making is shared with
the young people.
5. Consulted and informed is when youth give advice on projects or
programs designed and run by adults. The youth are informed about
how their input will be used and the outcomes of the decisions made by
adults.
4. Assigned but informed is where youth are assigned a specific role and
informed about how and why they are being involved.
3. Tokenism is where young people appear to be given a voice, but in fact
have little or no choice about what they do or how they participate.
2. Decoration is where young people are used to help or "bolster" a cause
in a relatively indirect way, although adults do not pretend that the
cause is inspired by youth.
1. Manipulation is where adults use youth to support causes and
pretend that the causes are inspired by youth
This review did not identify many studies indicating that youth participation in the decision-making of
adult agencies or programs has an impact of their health and well-being. As well, it is likely that the
distinction in the impact of the experience between the youth representative and youth in general would
need to be made here as well. However, the limits of this review prevented an in-depth examination of
this sub-topic.
Involving Parents in Decision-Making
Again, please note that this sub-section is addressing the impact of parental involvement in
decision-making of the school and public health programs through mechanisms such as formal
consultations, parent councils and other processes. Please see the more detailed discussion of parent
involvement in the section above on creating social support within a comprehensive approach to
school health promotion. That previous section covers the programs and policies promoting
involvement of individual parents in the health and learning of their children.
As in the case of youth, the evidence that individual parent participation in the health, development
and education of their children is quite strong. However, this review did not locate much evidence
171
172
that formal participation of parents in school or agency program decision-making had a significant
impact.
Rothwell (1992) examined the different forms of parental involvement. Her review indicates that
properly planned programs result in greater student achievement and more support for schools. She
also concluded that parental involvement can help to compensate for socioeconomic differences and
that school personnel can assist parents to be more effective in supporting their child.
Valpy (1995) has suggested that one of the best recommendations of the recent Ontario Royal
Commission on learning was the creation of school-community councils. He suggests that such
councils could become the "village educating the child", thereby providing a variety of resources
and support services. However, we did not locate any study that examined the impact of involving
such councils in prevention.
Add studies of parental involvement in decision-making that show little correlation to academic
achievement or health outcomes. OPSOA, etc
Involving Empowering Volunteers
Involving, Empowering Staff
Involving Empowering Community
Health Canada (199_ ) has developed a position paper and other materials which address one of the
primary determinants of heart health; the physical environment and economic resources available to
populations to follow heart healthy behaviors. The position paper, Promoting Heart Health in
Canada: Focus on Heart Health Inequalities presents the rationale and a fully explained process for
use of community development and advocacy strategies to increase the physical resources and
economic capacity of communities to improve their health. The paper shows that there is an
interaction between the risk conditions associated with poverty [occupation stress, polluted
environment, discrimination] and psychosocial risk factors [isolation, low self-esteem, low
perceived power] and behavioral risk factors [smoking, poor nutrition, physical inactivity]. The risk
conditions, psychosocial risk factors and behavioral risk factors eventually create greater risk to
cardiovascular disease.
This paper then presents a continuum for community health development.
Personal Small Group Community Coalition Political Aaction
Empowerment Development Organization Advocacy
practicing improving social developing local lobbying for supporting broad-
develop- support actions on healthier public based social
ment case work commu- policies movements
nity defined health
issues
enhancing promoting engaging in achieving creating a vision
personal personal behavior critical strategic of a sustainable,
perceptions of change community/pro- consensus pre- ferred future,
172
173
control and power fessional dialogue en- hancing
partici- patory
democracy
providing support raising conflict to collaborating and
for lifestyle the conscious conducting conflict
choices level resolution
Community Development
Health Canada has also published (199 ) a guide to mobilizing communities for heart health action.
This document identifies for key phases, each of which must be successful, for the intervention to
succeed. Phase One is community entry, enabling health promoters to find sustainable linkages to
the community being mobilized. Phase Two requires that the mechanisms for change be identified.
These will be specific to each community. Phase Three, activating the process, also will evolve
differently in different communities. Phase Four, implementing concrete plans, is perhaps the most
obvious and perhaps the easiest of the four stages. The document also suggests training and
technical systems for both health professionals and citizens/community leaders.
A public health effectiveness project undertaken by the Hamilton Teaching Health Unit Hayward et
al, 1993) discussed an empowerment-based approach to working with clients and communities.
This report links a community development approach to public health practice and provides a clear
role and rationale for public health nurses to follow.
Add more from Community School research here, examining the school as a hub for
community development.
173
174
10. Focus on Public Policy and Cost Benefits
This sub-section addresses the population health principle that public policy must actively
promote health. In the comprehensive school health framework, this policy element plays out
in four ways; there needs to be effective “policy” (that includes implementation and evaluation
cycles), there needs to be explicit policy supporting a comprehensive (integrated issues and
coordinated interventions), there needs to be specific and comprehensive policies on a variety
of health problems, and there needs to be a constant search for cost –effectiveness, cost-
benefits and sustainability. From systems theory, we know that schools, public health and other
systems that work with schools are open to external influences and pressures. This makes
effective policy-making more difficult.
Our findings in this sub-section are:
o this search found few studies that analyzed macro-policies and policy-making
processes exercised by governments aimed at ensuring that policy development
is multi-sectorial, supported, implemented and evaluated regularly
o most school health policy studies focused on the school system, especially
individual schools and appear to not recognize the policy-making process of
school systems nor show any interest in school health policies adopted by
regional health authorities, addictions agencies, social service agencies or police
services
o a small number of case studies were identified in this search that reported
different or little impacts on ATOD behaviours. A combination of policy,
instructional, service an environmental interventions is more effective and
recommended.
o a 1995 Ontario study indicates that most school board policies on alcohol/drugs
are comprehensive in nature. There are several publications on the appropriate
content nature of these comprehensive policies.
o zero tolerance and school-based drug searches have emerged as a controversial
policy topic.
o several cost-benefit studies on different health issues were located in this search.
However, there were none identified that addressed alcohol and drugs. Studies
on tobacco show that cost-benefits are significant. Further study into alcohol
and drugs is suggested.
Criteria for Effective Macro-Policy on Policy-making, Implementation and Monitoring
Policy-making is emerging as a key, overarching concern for school health approaches and
programs. The basics of effective policy-making (macro-policy) would include these criteria
(McCall et al, 1999)
1. Written, comprehensive policies define and describe the expectations of the system and
professionals working in those systems. Required actions from subordinate agencies are
described as well. (Canadian Association of School Administrators, 1990; National School
Boards‘ Association, 1981; Health Canada, 1994; Canadian Public Health Association,
1993)
2. There are explicit, written action plans to implement, monitor and evaluate the policies.
(World Health Organization, 1991; Canadian Public Health Association, 1993; Crichton,
1987)
3. The priorities of the system are explicit. (Broadfoot et al, 1994; Crighton, 1987)
4. Relevant research is monitored and disseminated regularly. (MacLean, 1996; World Health
Organization, 1997; Saskatchewan Education, 1996)
174
175
5. There are appropriate administrative structures and staff assignments. (Odden, 1991;
Macbeth, 1980; World Health Organization, 1997; Health Canada, 1994)
6. Resources, in the form of funding, staffing or materials are linked to policy directions.
(Funk, 1991; Consortium for Policy Research in Education, 1996; Canadian Public Health
Association, 1993; Health Canada, 1994)
7. Systematic staff development and training occurs regularly. (MacKinnon et al, 1994; Health
Canada, 1994; Canadian Public Health Association, 1993)
8. Cooperation among the systems that serve youth is encouraged, supported and facilitated.
(Fisher, 1990; Allensworth et al, 1997; Canadian Association for School Health, 1994a;
Capper et al, 1996)
9. There are mechanisms in place to monitor the activity and impact of the systems.
(Granaheim et al, 1990; Mutchler & Pollard, 1994; Allensworth et al 1997)
10. Regular written reports are issued that describe the performance of the systems. (Funk,
1991; Health Canada, 1994; Allensworth et al, 1997)
11. Policy-makers communicate with their publics about the progress of the system and
relevant issues. (Canadian Association of School Administrators, 1990, Allensworth et al,
1997)
The seven strategies outlined by Taylor et al., (2000) and used throughout Sweden move from
policy development to program development and include: 1. policy development happening at
different societal levels (national, local), 2.laws and regulations (affecting public health),
3.reorienting organizations (aims at obtaining sustainable development in organizations to support
public health), 4. advocacy for improved health (encourages actions for improved health at different
societal levels preceded by activities responding to health needs), 5. building alliances and creating
awareness (new alliances between different partners in different settings), 6. enabling (providing
basic prerequisites to support people to follow health conducive behaviour such as product
development), and 7. mobilizing/empowering
Many other researchers have concluded that schools need to have health policies (Nutbeam et al.,
1987; Smith et al., 1992; Tones and Tilford, 1994) and that such policies should be aimed at
students, teachers and support staff (Smith et al., 1992). Policies should also include the need for
enhanced community links (Smith, 1992), in-service training and involvement for non-teaching
staff, parents and other adults (National Foundation for Educational Research, 1993). It was also
recommended that young people have a role in the decision-making procedures in all matters
relating to health (WHO, 1993; Miller, 1993, 1997).
Schmid et al (1995) has described the evolution of policy/advocacy efforts to prevent cardiovascular
disease. The Policy Approach is divided into two areas: legislation/regulation and organizational
policy. Environmental strategies, influenced by policy and advocacy measures, can alter or control
the physical or social department. Policy strategies aimed at organizational change can help
government health agencies establish a new focus on prevention and promotion. This can include
advocacy to shift resources to prevention and health promotion activities.
The Canadian Association of Principals (McCall, 2004) has prepared a set of principles that should
guide the development of all school health policies.
What
1. ―School Health Policies‖ are adopted and implemented by schools, school boards, education
ministries, public health units, health ministries, social service agencies, social service ministries and
other sectors to guide, develop and support the actions of educators, public health staff and other
175
176
publicly funded professions and agencies that work with or within schools.
2. Policy-making should be seen and understood as happening within mandated, publicly accountable
systems, not individual school buildings. Consequently, education ministries and school board
policies and procedures should set the stage and encourage appropriate policies, procedures and
practices adopted at the school level. Further, School Health Policies are not only adopted by
educational authorities, they are equally the responsibility of health, social and other youth serving
agencies.
3. School Health Policies are part of a comprehensive and coordinated approach to using the school as
a setting within the community to promote health. Other elements in this comprehensive approach
include sustained instruction in health, personal and social development, family studies and physical
education, preventive health services, changes to the physical environment/facilities, encouraging
social support through parental involvement, youth engagement, specific efforts to reduce inequities
and coordination with community-based agencies.
4. School Health Policies should cover a number of health-related topics, including tobacco use, injury
prevention, drug/alcohol use and other addictions, premature and risky sexual behaviour, nutrition,
hygiene, physical activity, mental health, safe water and sanitation, anti-social behaviour/bullying,
citizenship and character development, social equity and basic educational achievement for all.
5. Other School Health Policies should define minimum levels of service and required mandates for
agencies, schools and professionals. For example, policies should stipulate a recommended or
minimum time for health instruction, for pupil-nurse and pupil-counsellor staffing ratios, for minimum
services to special education and chronically ill students etc.
6. School Health Policies should also require specific professionals, agencies and ministries to
coordinate their efforts in response to specific health issues, setting standards for information
sharing, procedures for referrals, communications among professionals and with parents etc. These
policies should cover ministry, agency and school responsibilities to coordinate their efforts, to
involve parents, to engage youth, to conduct regular assessments of student health and health
determinants that their institutions can reasonably influence, etc.
Why
1. There are research studies showing that specific policies, when implemented within a
comprehensive prevention approach, can have a significant impact on health behaviours and
outcomes. Other policies such as guaranteeing convenient youth friendly services, implementing
parent resource centres or a minimum instructional time of 50 hours of health instruction per year
have been shown to have very positive effects. For example, a policy of implementing a mandatory
anti-smoking program in all schools would save 15 dollars in health care and other costs for every
dollar invested in the instructional program.
2. Evidence is emerging that comprehensive policies requiring schools and other agencies to be
―health-promoting‖ can lead to improved academic outcomes, even for disadvantaged schools. As
well, other studies have shown that increasing and improving physical education time in schools can
lead to improved student achievement in academic subjects.
How
1. Policy-making should be seen as a springboard for action, that the process is equally important to
the words that end up on paper, because through the process of consultation and adoption the
school personnel, volunteers and community/parents become engaged and committed to the
implementation of the policy.
2. Policies should be adopted with clear and specific references to the human and financial resources
required to implement them. Policies should identify the qualifications and training required for their
implementation. Any changes in job descriptions or professional roles should be the subject of
consultations or negotiations with relevant associations or unions.
176
177
3. The policy-making process should be cyclical in nature, including adequate provisions to identify
emerging health issues, appropriate consultations and surveys, transparency in public decision-
making, stipulated reporting procedures and evaluation criteria and opportunities to review and
enhance the written policies.
4. Policy development should include staff representation, parental involvement, youth involvement and
representation from appropriate health and social agencies or professions. Wherever possible,
policies should be based upon and should refer to available scientific evidence supporting the
proposed interventions.
5. School Health Policies should be comprehensive in nature and encourage coordinated interventions
that include instructional, environmental and services elements. For example, a school tobacco
policy would include no smoking rules and enforcement steps, critical outcomes for curriculum and
instruction, minimum instructional time, adequate guaranteed access to information, adequate
access to cessation services, encouraging student peer helper programs, stipulating procedures for
parental involvement etc.
The content of school and public health and addiction agency policies relative to addictions and
substance abuse should include the following elements:
h) School Policies, Practices, Organization
1. Description of Board Approach (Complexity, Punitive-Supportive,
Harm Reduction, Addictive Behaviours vs Substances etc)
2. Integration with policies on student development & health
3. Relationship to Relevant Laws, Regulations
4. Overall policies on school climate/culture/relationships in school
5. School Discipline and Suspension Policies
6. School Search & Seizure Policies
7. Procedures on Records, Exchange of Information with Other
Agencies
8. Expected Outputs of Curriculum, Early Identification,
Guidance/Counselling/Assistance Programs
9. Description of Staff, Volunteer and Student Rights and
Responsibilities
10. Process for Staff, Volunteer Development
11. Support for Student, Community Groups
12. Alcohol Use at Student Graduation, Field Trips
13. Alcohol Use at Adult Functions in Schools, Adults on Field Trips
14. Related Policies on Substance Abuse by Employees/Assistance
Programs
15. Procedures for Evaluation, Reporting on Policy
There are several guides and manuals that have described such policies in detail, including the
publications from Nova Scotia (NS Department of Health, 2002), British Columbia (McCall, 1990)
and Ontario (Addictions Research Foundation, 1991; Alcohol Policy Network, 2004)
Does the research indicate that legislation/regulation interventions can be used
effectively generally in society as well as with schools/children to be effective in
influencing behaviour or conditions that determine substance use? Does the
research also describe how proponents can successfully advocate for such
policies?
177
178
Does the research indicate that relevant school health policies will have an
impact on behaviours or conditions relating to substance abuse?
Goodstadt (1989) suggests that schools that are attempting to reduce substance abuse by
implementing policies related to use of alcohol and other drugs in schools should recognize that
studies indicate that: 1) neither educational nor school policy strategies by themselves are likely to
effectively prevent use and abuse; 2) to be effective, education and policies must acknowledge and
incorporate clear statements of community norms about alcohol and drug use; 3) to be effective,
educational and policy strategies must complement and reinforce each other; and 4) education and
policies must acknowledge and reinforce the positive behavior of the large number of students who
do not use or abuse alcohol and other drugs.
Yamaguchi et al (2003) have described the relationship between student illicit drug use and school
drug-testing policies. Their report provides information about drug testing by American secondary
schools, based on results from national surveys. The study provides descriptive information on
drug-testing practices by schools from 1998 to 2001, and examines the association between drug
testing by schools and reported drug use by students. School-level data on drug testing were
obtained through the Youth, Education, and Society study, and student-level survey data were
obtained from the same schools participating in the Monitoring the Future study. A relatively small
percentage of schools (about 18%) reported testing students for drug use, with more high schools
than middle schools reporting drug testing. Drug testing was not associated with students' reported
illicit drug use, or with rate of use among experienced marijuana users. Drug testing of athletes was
not associated with illicit drug use among male high school athletes.
Goldberg et al (2003) report the results of a study on Drug testing athletes to prevent substance
abuse: Two high schools, one with mandatory drug testing (DT) consent before sports participation,
and a control school (C), without DT, were assessed during the 1999-2000 school year. The past 30-
day index of illicit drugs (4-fold difference) and athletic enhancing substances (3-fold difference)
were lower (p < .05) among DT athletes at follow-up without difference in alcohol use. However,
most drug use risk factors, including norms of use, belief in lower risk of drugs, and poorer attitudes
toward the school, increased among DT athletes (p < .05). Although a reduction in the illicit drug
use index was present among nonathletes at the DT school, at the end of the school year, it did not
achieve statistical significance (p < .10). The authors conclude that random drug testing (DT) may
have reduced substance use among athletes. However, worsening of risk factors and small sample
size suggests caution to this drug prevention approach.
The Nova Scotia Department of Health (2001), in a manual on school board drug policies sates that
Zero Tolerance generally refers to school policies regarding alcohol, tobacco, other drugs, and
violence that emphasize punitive actions such as suspension, expulsion, or notification of the police.
Very little has been done to evaluate the effectiveness of zero-tolerance policies;10 however, research
suggests that such policies can have negative effects, such as:
Alienating students at risk of harmful involvement, and further alienating students who may
already be on the perimeter of the school community;9,11
Placing the student at risk for dropping out of school – being suspended from school is a
strong predictor of dropping out;10
Placing the student in an environment where use is more likely – suspension and expulsion
may place the student ‗on the street‘;10
Criminalizing users;5
Reinforcing the adult status of certain activities, such as drinking, which may serve to
increase curiosity and desire to use;9 and
Discouraging and preventing students from self-reporting substance use problems and
seeking help for themselves or their friends.5,9,11
178
179
Suspension, expulsion, and/or police intervention may be necessary in more extreme
cases,12 such as continuous infractions or students caught trafficking drugs. However, harm
minimization policy alternatives are less punitive, and may be more helpful to the student by
minimizing harm or preventing further use.
The Department advocates a harm minimization approach to school policies that would aim to
promote health and well-being, and reduce the risk and severity of the adverse consequences of
substance use. Such policies take into consideration the impact that zero-tolerance may have on a
student. Policies may vary depending on the type or severity of the student offense. For instance,
trafficking may be dealt with differently than possession (see Legal Issues, p. 10), or when the
substance is cocaine versus cannabis.
Does the research indicate the ―school health policies‖ (ie policies adopted by
education ministries, school boards, or schools, health ministries, regional health
authorities or local health authorities) are actually implemented, evaluated and
enforced?
Are there studies that describe whether appropriate policy-making (that includes
managerial support, consensus development for implementation, adequate
resources, implementation, timelines and reporting requirements are being
employed?
Gliksman et al (1995) examined the development and implementation of School Drug Policy in
Ontario Boards of Education, the components of these policies, and the composition of policy
development committees. Data from 125 Boards of Education were obtained from responses to a
questionnaire administered in the Fall of 1991. Findings from the study indicate that school drug
policies are increasingly comprehensive-including not only disciplinary measures, but also a
preventive curriculum and early intervention component. The composition of policy development
working groups normally consisted of such groups as board personnel, teachers, and practitioners
from other fields. Students were not often included in the process of policy development. Thus, the
development and implementation of school drug policy in Ontario indicates a "top down" rather
than "bottom up" approach.
Scott DM, Friedli D (2002) report on the nature and implementation of school policies on
absenteeism, drug use and violence in Nebraska schools. For "using drugs other than alcohol or
tobacco at school" in both areas, disciplinary procedures included parent contact and short-term
suspension. For "using drugs other than alcohol or tobacco at school," for a second time offense was
long-term suspension and semester expulsion for a third-time offense. Some of the discrepancies in
disciplinary actions, however, suggest the need for consistent enforcement and communication of
policies for both urban and rural schools
Grebow et al., (2000) state that students learn best in a school that promotes their physical and
psychosocial health as a matter of established policy. Policies which support a healthy physical
environment carry the message that students are valued, that adults respect them and give them a
connectedness and sense of well-being related to school. If the emphasis on the physical
environment becomes policy it is not susceptible to budget cuts. Policies that address the needs of
the people in the building of their relationship to one another make up the psychosocial
environment. When academic and extracurricular opportunities are open to everyone, students are
free from harassment and discrimination; and they receive the support services they need, students
are free to learn.
179
180
Grebow et al., (2000) also suggest that a thoughtful policy analysis will consider the various needs
and cultures within the school, with attention to input from youth. In addition, although teachers
and administrators try to meets the needs of staff and students, policy goes a long way in ensuring
protections and supports for everyone. Valuing teachers and creating policy that commits the
district to ensuring professional treatment for all teachers, regardless of changes in schools or
administration, seems to be important as well. They describe teachers as the keystone of efforts to
strengthen student achievement and valued and supported teachers are more likely to model positive
strategies for communication and conflict resolution. Creating policy to institutionalize family and
community engagement as part of every day school life is another consideration. Also community
members volunteer in schools and attend cultural events and athletics, where they view the school
in a positive light. In addition, policy is essential for the coordination of a school health program –
for the integration of a healthy school with a school‘s other health-related goals that helps it become
an institutionalized part of the school culture. The authors suggest linking school environmental
health issues to the district‘s mission, goals, and budget and its stated priorities. For instance,
national attention to standardized testing has led to local school boards focused on increasing
academic achievement. Therefore, if hiring a social worker or beginning a family outreach program
is the goal for the healthier school environment, then emphasize the potential for strengthening
student achievement. Finding community advocates who share the goal for improving the school
environment can help support school health policies. Consider possible challenges to the
recommendations and also ways to implement in small steps. Incrementally, working through
advisory boards and committees also garners support and working through appropriate channels
expedites getting the information to the right people and conveys authority. Finally, the authors say
that it is important to understand limitations of protocol and that not all efforts will succeed on the
first try.
Tubman & Soza Vento (2001) examine the key role of enforcement in school policies. This study
describes anti-tobacco policies implemented by middle and high schools in Florida. All schools had
in place formal anti-tobacco policies but implementation of those policies was more rigorous at the
middle school level. Principals and health education teachers reported the formal and informal
strategies used to enforce their school's anti-tobacco policies. Punitive enforcement strategies were
more commonly reported than non-punitive strategies. Enforcement strategies were significantly
associated with several features of school settings including number of supports for teachers' efforts,
teachers' perceptions of program success, and training opportunities for teachers. Middle school
staff reported using significantly more enforcement strategies than high school staff, and their
strategies were more likely to be associated with school context variables.
Does the research indicate if certain school health interventions or combinations of
such interventions are more effective, cost effective, cost-beneficial?
Plotnick (1994) presents the basic ideas of benefit-cost analysis and its closely related tool, cost-
effectiveness analysis. It then sketches a "blueprint" for a benefit-cost analysis of an experimental
drug use prevention program intended to prevent relapse into drug use by parents receiving
methadone maintenance and to lower the risk that the children of these parents will become
substance users. The blueprint can help structure evaluations of other prevention programs.
Caulkins et al (2002) in a report to the RAND Corporation, have calculated the social and economic
benefits of school-based drug prevention. Their work is factual, objective and powerful. It also
shows that the majority of social and economic benefits accrue from the prevention of tobacco and
alcohol use rather than illicit drugs.
180
181
Our report shows that school-based drug prevention programs are a good investment from the benefit-
cost standpoint. The best estimate of social costs saved per prevention program participant ($840)
greatly exceeds the program cost per participant ($150), and that dollar-figure difference is highly
robust with respect to uncertainty about various parameter values.
It should also be noted that the $840 in savings does not entirely or even primarily take the form of
increased revenue accruing to the government. That is, we are not arguing that funding school-based
prevention programs is a good way to balance the budget, even in the long run. On the other hand, a
favorable social benefit-to-cost ratio is an important factor in the decision to invest in a wide range of
public programs, from highway improvements to flood control. School-based drug prevention is a good
social investment in that sense.
Thus, school-based drug prevention‘s benefits do not stem primarily from reduction in the use of illicit
drugs. The same cannot be said of the benefits from locking up drug dealers or some forms of drug
treatment (such as methadone maintenance not accompanied by associated social services). Other
forms of treatment are as much about helping addicts acquire job skills, resolve interpersonal conflicts,
get help from social services, and improve their general health and welfare as they are about reducing
drug use. School-based drug prevention is more akin to the other forms of treatment than it is to drug
law enforcement or methadone maintenance in this regard. Although
school-based drug prevention is not primarily about preventing illicit drug use, it nevertheless appears
to have a favorable benefit-cost ratio on the basis of its impact on illicit drug use alone.
However, viewing school-based drug prevention in so narrow a light unfairly penalizes prevention,
relative to other programs for which reductions in drug use are in fact the primary benefit, because
prevention‘s benefits
with regard to licit drug use are in that case disregarded. Some readers might infer from this
discussion that school-based prevention should be viewed as a public health intervention, and not a
criminal justice intervention, and thus it should be funded out of health dollars rather than criminal
justice (or education) dollars.
An interesting implication of the trade-off between drug prevention programs and traditional classroom
instruction is that the programs should be evaluated not only in terms of their behavioral effects but
also in terms of the educational value, if any, they provide. Suppose a prevention program teaches
critical thinking, analysis, and writing or math skills almost as effectively as the conventional academic
instruction it displaces. Such a program could be much more cost effective in a real economic sense
than another prevention program that offered no such academic benefits, even if the second program
were more effective at reducing drug use. Currently, drug prevention programs are rarely evaluated in
terms of their contribution to educational outcomes (which are quite distinct from mere knowledge
about drugs and their effects).
Our findings may also have implications for the level of support of drug prevention programs within
schools. School administrators and teachers do not always feel comfortable with their unsought-after
responsibility for helping to prevent the use of illicit drugs (Reuter and Timpane, 2001). Tying the
program to a broader range of public health benefits might serve to pique their interest.
Finally, an implication of our program effectiveness findings (see the ―Other Results of Interest‖
section), is that prevention programs, even the cutting-edge ones, should not be viewed as ―vaccines‖
that inoculate those in the program against drug use. There is very strong empirical support for the
belief that these programs reduce drug use, but there is even stronger support for the belief that they
leave an even greater proportion of baseline users unaffected. Prevention may be cost effective, but it
cannot be expected to single-handedly address concerns about substance abuse, at least in its
present form and as far as we currently understand prevention‘s effectiveness.
As a final note in that regard, one contribution that a systems analysis, such as this one, can make is
to highlight those parameters for which the evidence is thinnest. In this analysis, the evidence is
clearly the thinnest on the decay function. Therefore, we suggest that future evaluations of school-
based drug prevention programs should plan for more frequent and sustained follow-up data collection
and that researchers who have unpublished follow-up data from past evaluations should publish their
results now.
181
182
A Canadian study (Stephens et al, 2001) cited in the recent Romanow report, examined the
economic benefit of classroom programs to reduce tobacco use. This study compared the costs of
developing and delivering an effective school-based smoking prevention program with the savings
to be expected from reducing the prevalence of smoking in the Canadian population over time. A
smoking prevention program that meets published criteria for effectiveness, implemented nationally
in Canada, would cost $67 per student (1996 dollars). Assuming such a program would reduce
smoking by 6% initially and 4% indefinitely, lifetime savings on health care would be $3,400 per
person and on productivity, almost $14,000. The benefit-cost ratio would be 15.4 and the net
savings $619 million annually. Sensitivity analyses reveal that considerable economic benefits
could accrue from an effective smoking prevention program under a wide range of conditions.
Wang et al (2001) examine the Cost-effectiveness of a school-based tobacco-use prevention
program. Using data from the previously reported 2-year efficacy study of the Project Toward No
Tobacco Use (TNT), we conducted a decision analysis to determine the cost-effectiveness of TNT.
The benefits measured were life years (LYs) saved, quality-adjusted life years (QALYs) saved, and
medical care costs saved, discounted at 3%. The costs measured were program costs. We quantified
TNT's cost-effectiveness as cost per LY saved and cost per QALY saved. INTERVENTION: A 10-
lesson curriculum designed to counteract social influences and misconceptions that lead to tobacco
use was delivered by trained health educators to a cohort of 1234 seventh-grade students in 8 junior
high schools. A 2-lesson booster session was delivered to the eighth-grade students in the second
year. The efficacy evaluation was based on 770 ninth-grade students who participated in the
program in the seventh and eighth grades and in both the baseline and the 2-year follow-up survey.
RESULTS: Under base case assumptions, at an intervention cost of $16 403, TNT prevented an
estimated 34.9 students from becoming established smokers. As a result, we could expect a saving
of $13 316 per LY saved and a saving of $8482 per QALY saved. Results showed TNT to be cost
saving over a reasonable range of model parameter estimates. CONCLUSIONS: The TNT is highly
cost-effective compared with other widely accepted prevention interventions. School-based
prevention programs of this type warrant careful consideration by policy makers and program
planners.
Wang and another group of researchers (Wang et al, 2000) have done an economic evaluation of
Safer Choices: a school-based human immunodeficiency virus, other sexually transmitted diseases,
and pregnancy prevention program. The baseline cost-effectiveness and cost benefit were derived in
4 steps: (1) estimation of intervention costs; (2) adaptation of the Bernoulli model to translate
increases in condom use into cases of human immunodeficiency virus and other sexually
transmitted diseases averted, and development of a model to translate increases in contraceptive use
into cases of pregnancy averted; (3) translation of cases averted into medical costs and social costs
averted; and (4) calculation of the net benefit of the program. Multivariable sensitivity analysis was
performed to determine the robustness of the base-case results. RESULTS: Under base-case
assumptions, at an intervention cost of $105,243, Safer Choices achieved a 15% increase in condom
use and an 11% increase in contraceptive use within 1 year among 345 sexually active students. An
estimated 0.12 cases of human immunodeficiency virus, 24.37 cases of chlamydia, 2.77 cases of
gonorrhea, 5.86 cases of pelvic inflammatory disease, and 18.5 pregnancies were prevented. For
every dollar invested in the program, $2.65 in total medical and social costs were saved. Results of
most of the scenarios remained cost saving under a wide range of model variable estimates.
CONCLUSIONS: The Safer Choices program is cost-effective and cost saving in most scenarios
considered. School-based prevention programs of this type warrant careful consideration by policy
makers and program planners. Program cost data should be routinely collected in evaluations of
adolescent prevention programs.
182
183
A third study led by Wang (Wang et al, 2003) has done an economic analysis of a school-based
obesity prevention program. To assess the cost-effectiveness and cost-benefit of Planet Health, a
school-based intervention designed to reduce obesity in youth of middle-school age children.
Standard cost-effectiveness analysis methods and a societal perspective were used in this study.
Three categories of costs were measured: intervention costs, medical care costs associated with
adulthood overweight, and costs of productivity loss associated with adulthood overweight. Health
outcome was measured as cases of adulthood overweight prevented and quality-adjusted life years
(QALYs) saved. Cost-effectiveness ratio was measured as the ratio of net intervention costs to the
total number of QALYs saved, and net-benefit was measured as costs averted by the intervention
minus program costs. Under base-case assumptions, at an intervention cost of $33,677 or $14 US
dollars per student per year, the program would prevent an estimated 1.9% of the female students
(5.8 of 310) from becoming overweight adults. As a result, an estimated 4.1 QALYs would be
saved by the program, and society could expect to save an estimated $15,887 USD in medical care
costs and $25,104 USD in loss of productivity costs. These findings translated to a cost of $4305
USD per QALY saved and a net saving of $7313 USD to society. Results remained cost-effective
under all scenarios considered and remained cost-saving under most scenarios. The Planet Health
program is cost-effective and cost-saving as implemented. School-based prevention programs of
this type are likely to be cost-effective uses of public funds and warrant careful consideration by
policy makers and program planners.
Young & Ireson (2003) suggest that a combination of telehealth and school health clinics can help
rural schools and communities gain access to convenient care and save health care costs. This study
evaluated the cost effectiveness of health care provided in urban and rural elementary school-based
telehealth centers, using plain old telephone system (POTS) technology. A telehealth school-based
model was developed that used a full-time school nurse, half-time mental-health consultant, linked
pediatric practice, and linked child psychiatrist via POTS with an electronic stethoscope; ears, nose,
and throat endoscope; and otoscope. Average family savings per encounter were 3.4 hours of work
time (43 dollars) and 177 dollars in emergency department or 54 dollars in physician costs.
Including travel, savings for families ranged from 101 dollars to 224 dollars per encounter. Thirteen
children received telepsychiatric evaluations resulting in diagnoses of depression and attention-
deficit/hyperactivity, anxiety, and conduct disorders. Telehealth technology was effective in
delivering pediatric acute care to children in these schools. Pediatric providers, nurses, parents, and
children reported primary care school-based telehealth as an acceptable alternative to traditional
health care delivery systems. The POTS-based technology helps to make this telehealth service a
cost-effective alternative for improving access to primary and psychiatric health care for
underserved children.
Chatterji et al (2001) outline economic cost analysis methods and demonstrate their applicability to
school-based prevention programs. As an example, the paper focuses on estimating the economic
cost of ALPHA, an intensive school-based substance use prevention program..
Guay et al (2003) examined the relative costs of immunization in school and clinical delivery
points. In 1994, immunization against hepatitis B was implemented in schools in Quebec, targeting
grade 4 students. In 1996-1997 and 1997-1998, one Local Community Service Centre (CLSC)
replaced the school-based program in its district with vaccination offered in community clinics after
school hours. The aim of the current study was to compare the effectiveness and costs of school-
based and clinic-based programs. Vaccination coverage data were collected in the CLSC with the
clinic-based program (CBP), and in three matched CLSCs with a school-based program (SBP),
from 1994 to 2000. Surveys were conducted to estimate costs to parents, to schools and to CLSCs in
183
184
1997-1998. With the implementation of the CBP, the vaccination coverage fell to 73%, compared
with over 90% in the SBPs. Coverage increased to 90% when the CBP was abandoned. Costs to the
CLSC were not much lower in the CBP. Societal costs were $63 per student vaccinated in the CBP,
and < or = $40 in the SBPs. Results demonstrate the advantage of a SBP over a CBP for the
immunization of schoolchildren.
A similar Canadian study (Sadoway et al, 1990) showed that labour costs for delivering
immunization to young children (0-4 years) were 2.9 times higher in Ontario, where private
physicians were used as compared to Alberta, where public health nurses were used.
11. Build Resilience & Behaviours within Individuals
This sub-section discusses another principle of the population health approlach, that education
and information programs and health services should help to build individual resilience in the
forms of basic health literacy, knowledge, skills, attitudes/beliefs, awareness of health services,
ability to access social support and willingness to help others and the development of
personalized action plans or behavioral intentions. Within the school health promotion context,
these attributes are developed primarily by instructional or health education strategies. This can
be broken down into sub-elements such as curriculum design, teaching and learning methods
and providing other supports for teaching.
Our findings in this section can be summarized as follows
o instructional design could be based on readily available and proven theories of
how individuals learn about health, but they are not necessarily designed that
way
o further research is required into the specific learning outcomes, scope and
sequence that is most effective for preventing harmful substance use
o further research should be done into combining curricular and instructional
approaches that promote social skills/competence, mental health, social and
emotional learning and yet still retain sufficient functional knowledge about
drugs and alcohol
o more research should be done into how instruction in these areas described
above could be successfully linked to enhancements to the psycho-social climate
of the school and comprehensive addictions and mental health services
Has the research applied and described programs that are based on stages of change
theories and behavioural theories? Has the research described the key individual
resilience characteristics and coping skills needed? Functional knowledge needed?
Attitudes and Beliefs Needed? Self-knowledge Needed? General Skills and Specific
Skills Needed? Awareness and Use of Health Services Needed? Awareness and
Skills needed to Access to Social Support from friends, parents, others?
The population health approach/health determinants theory is well founded on knowledge of
research about behavior and behavior change. Similarly, Parcel (1984) has reviewed several of these
theories about behavior change, including psychosocial influences, social learning and reasoned
action that support the use of school-based and school-linked health promotion strategies.
Several models of health promotion have been developed from the understanding of behavioral
change, including the Health Belief Model, the reduction or elimination of risk conditions/factors
184
185
and the PRECEDE Model. These models explain how individual health behaviors and
environmental influences are linked in influencing health status. For a summary of these behavior
change theories, visit the following WebSite
www.commint.com/power_point/change_theories/index.htm
The Health Belief Model suggests that there are two major factors that influence the likelihood that
a person will adopt a recommended preventive health action. First, they must feel personally
threatened by the disease (i.e., they must feel personally susceptible to a disease with serious or
severe consequences) and second, they must believe that the benefits of taking the preventive action
outweigh the perceived barriers to (and/or costs of ) preventive action. This model is essential to
understanding the effectiveness of interventions aimed at the individual. In the past, the strategy
used to influence health beliefs was education and the focus was on preventing particular
behaviours. Gradually, as knowledge of health promotion increased, the focus has broadened to
include attention to social support and the impact of the entire environment.
The reduction or elimination of risk conditions or external factors (Catania et al, 1990) has been the
focus of more recent health promoting strategies. Social, economic or biological status can be
influenced by advocating for economic changes, better housing or more reoriented health services.
The PRECEDE model, (Green & Kreuter, 1991) explains the interactions between individual and
the environment.
More recently, health promotion experts have been trying to identify the specific environmental
factors or internal beliefs (or combinations thereof) that create resilience (Mangahm et al, 1994)
within a person despite unhealthy or harsh environmental conditions.
Stages of Change in Individuals
There are several theories about the stages of change that individuals undergo when they are
adopting healthy behaviours also need to take into account. These include:
1.Becoming aware of the issue or problem (usually through social marketing and media
campaigns.)
2.Becoming informed about the issue and having access to good information (usually
through printed materials, telephone services, or electronic means).
3.Developing relevant knowledge, skills, understanding and attitudes (usually through
education programs).
4.Having an opportunity to practice their new skills (usually as part of education programs).
185
186
5.Being motivated and supported in their new behaviours by others or with new resources
(usually through new forms of social support, changes in service delivery or in advocacy/
policy or funding to create better conditions).
Use of Theory in Program Design
McCallum (1995) also reviewed some of the theories and models underpinning effective
communication practice. The following checklists provides a guide to program planners
munication planning and pretesting
terials with the target audience
to them
audiences likely to see them when public service air time is available
rengths
reinforce the change
-term communication objectives
component over the long-term, one shot campaigns
are unlikely to have a lasting effect.
Comprehensive school health theory and knowledge has described these elements of school-based
instruction to build resilience, literacy and skills:
i) Instruction
1. Instruction to convey functional knowledge and awareness of
addictions, drugs and risks etc
2. Instruction on specific skills such as refusal skills, resistance to peer
pressure etc
3. Instruction in more general skills such as media literacy, social skills,
decision-making, problem solving
4. Instruction to address self-knowledge, self worth, common challenges
associated with puberty etc
5. Instruction to increase awareness of local and other sources of
addictions information, advice, counselling and crisis interventions
6. Features of successful curriculum design
7. Features of effective teaching methods and strategies
8. Features of successful implementation and professional development
strategies for teachers in implementing the curriculum
9. Features for effective involvement of students as peer leaders in
instruction.
10. Features for effective involvement of parents in take home learning
associated with the school curriculum.
186
187
11. Effective adaptations of programs for specific message such as
drinking & driving, for sub-populations such as the children of
alcoholics, for aboriginal students, for ethno-cultural minority
students, for rural students etc.
The following questions are pertinent to drug education and most other issues within a broad health
education programs:
Does the literature adequately describe the types and breadth of outputs (ie going beyond
facts to define ―functional knowledge‖ that is important, the specific behaviours to promote,
to describe general or specific social and problem solving skills, to describe what attitudes
and beliefs etc that can be transmitted by school programs?
Does the literature describe a minimum and optimum set of health-related learning outputs
related to alcohol/drugs education that can be achieved by schools?
In the past we falsely equated health knowledge as a proxy for health behaviour, then we learned
that often knowledge alone often did not affect behaviour, then some of us have rejected school
health education programs as being ineffective (again falsely) It may be time that we reviewed
again the evidence of the SHEE large scale evaluation of health education (Connell & Turner, 1985)
showed a positive cumulative effect of 50 hours of health instruction. Also, it may be time that we
seek a new understanding about health knowledge or health literacy, as being the skills, aptitudes,
awareness and ability to plan and use functional knowledge about health to improve our health and
well-being.
(Allensworth et al, 1997, p. 286, Nutbeam & St. Leger, p.10) suggest that we need to clarify what
learning about health is essential (knowledge, skills, attitudes, beliefs, values, personal goal-setting,
problem-solving/decision-making, media literacy, awareness of health services, career and life
aspirations etc). We also need to describe exactly how curricula and teaching practice can be
organized and delivered to achieve those essential outputs.
The National Institute on Drug Abuse (2003) has identified research evidence that suggests that
instructional programs should be geared to age-appropriate outcomes. Pre-school programs should
address risk factors such as aggressive behaviours, poor social skills and learning difficulties.
(Webster-Stratton et al, 2001). Elementary programs should focus on basic academic outcomes,
social-emotional learning and skills such as self-control, self-awareness, social skills, problem
solving and reading skills(Coordinated Problem Behaviours Group, 2002; Lalong et al, 2002).
Junior High programs should increase academic and social skills (Botvin et al, 1998; Scheir et al,
1999) such as study habits, communication, peer relationships, self-efficacy, assertiveness skills,
resistance skills and personal action plans. .NIDA also suggests that instructional programs should
help students at key transition points in their lives such as entry into secondary school (Dishion et
al, 2002)
Dusenbury L, Falco (1995) were among the first to identify potential components of effective drug
abuse prevention curricula. A review of school-based drug abuse prevention programs was
conducted for 1989-1994. In addition to a comprehensive literature review, interviews were
conducted with a panel of 15 leading experts in prevention research. Key elements of promising
prevention curricula were identified. Effective prevention programs were found to be based on a
sound theoretical or research foundation. They included developmentally appropriate information
about drugs, social resistance skills training, and normative education. Broader based personal and
187
188
social skills training appeared to enhance program effects. Effective programs used interactive
teaching techniques and teacher training, and provided adequate coverage and sufficient follow-up.
Cultural sensitivity to the target population was found to be critical to program success. Additional
program components were expected to enhance curriculum effectiveness. Finally, experts agreed
that adequate evaluation of prevention curricula was critical. Unfortunately, despite information
about the types of curricula that are effective, the most promising prevention curricula are not
widely disseminated. Reasons for under-utilization are explored, and recommendations made for
correcting the situation.
Sancho nd), in a summary of effective health education, suggests that cultural factors need to be
infused into the health curriculum. Pikes & Banoub-Baddour (1991) report that a cardiovascular
health education program facilitated by the public health nurse was successful in changing health
knowledge of adolescents. Schall (1994) reports that studies have shown that school-based health
education programs that start early and continue for several grades provide significant and sustained
effects on health knowledge, attitudes and behaviors.
Implementation of Instructional Programs
The studies reviewed for this paper noted that implementation was a key factor to success.
Grunbaum (1998) noted that the characteristics of successful health education programs often
centered on the training provided to teachers. A similar finding Renaud, 1997) comes from a heart
health project in Montreal. The characteristics of the teachers and the program explained the level
of implementation of the heart health curriculum. Hausman & Ruzek (1995) suggest that
implementation of school health education should focus on teacher concerns.
Three Canadian associations (Canadian Association of Principals et al, 1996) have also described
strategies and conditions for effective health education. These criteria for effectiveness include:
Supports for Success
h other parts of a comprehensive approach having learning
outcomes associated with skill development, attitudes/beliefs, as well as knowledge about
nutrition.
-prepared teachers, active parent
involvement and at-home activities, peer-based informal learning to supplement the
curriculum, coordination of classroom teaching with community awareness programs and
community expertise
Goals/Content
emphasizing generic skills
-making taught through
role playing]
health messages to all youth with specific messages to high-risk youth
units
Methods/Techniques
188
189
nal techniques
A Canadian study, (Ross et al, 1998) which showed null effect on knowledge, skills and self
efficacy underlines the need for high quality, well-implemented instructional programs to be
effective.
Our review found some references showing that peer and parental involvement improved the
chances of classroom instruction effect. Hern et al (1998) reported that high school biology
students can be educated by older peers drawn from undergraduate nursing students. Johnson &
Johnson (1987) report that when cooperative learning is implemented effectively in peer-based
learning, long-term modifications of nutrition knowledge, attitudes and behavior result. A report on
the Chicago Heart Health Curriculum (Petchers et al, 1987) reported that the parent participation
component had no effect on student knowledge or behavior with regard to cardiovascular disease
prevention. However, Gordon & Haynes (1982) report that parental involvement with homework in
nutrition education at the elementary grade level was successful.
In a three year trial, Botvin et al (1990) found that a cognitive-behavioral approach to substance
abuse prevention had significant prevention effects were found for cigarette smoking, marijuana
use, and immoderate alcohol use. Prevention effects were also found for normative expectations and
knowledge concerning substance use, interpersonal skills, and communication skills. In a
randomized block design, schools were assigned to receive (a) the prevention program with formal
provider training and implementation feedback, (b) the prevention program with videotaped
provider training and no feedback, or (c) no treatment. After pretest equivalence and comparability
of conditions with respect to attrition were established, students who received at least 60% of the
prevention program (N = 3,684) were included in analyses of program effectiveness.
Park (2000) reported on a study that examined the effects of parental involvement in instruction.
Preparing for the Drug-Free Years (PDFY) is a curriculum designed to help parents learn skills to
consistently communicate clear norms against adolescent substance use, effectively and proactively
manage their families, reduce family conflict, and help their children learn skills to resist antisocial
peer influences. This study examined the effects of PDFY on the trajectories of these factors, as
well as on the trajectory of alcohol use from early to mid adolescence. The sample consisted of 424
rural families of sixth graders from schools randomly assigned to an intervention or a control
condition. Data were collected from both parents and students at pretest, posttest, and 1-, 2- and 3
1/2-year follow-ups. Latent growth models were examined. PDFY significantly reduced the growth
of alcohol use and improved parent norms regarding adolescent alcohol use over time. Implications
for prevention and evaluation are discussed.
Ambtman et al (1999), in a study done for the Alcoholism Foundation of Manitoba, evaluated the
effectiveness of a province-wide chemical abuse prevention education program for grades two
through six. Two separate studies were conducted. Study 1 measured pre- and post-scores on a test
with 1101 experimental and 991 control subjects in a quasi-experimental design. Study 2 surveyed
500 elementary school teachers on their opinions and practices regarding drug education, and on the
prevalence of the program in schools. The study found that: 1) students had a high initial knowledge
level; 2) students showed modest but statistically significant knowledge gains for urban schools and
189
190
grades three, four, and five of rural schools; 3) the program was most effective with students with a
low base knowledge; 4) an estimated 20 to 30 percent of Manitoba elementary teachers had been in-
serviced and/or were using the program across the province; and 5) the program was received well
among teachers.
Ramirez et al (1999) evaluated Mirame!/Look at Me!, a substance abuse prevention program for
low-income Mexican-American youth aged 9-13 years. The theory-driven curriculum, developed
for mass distribution via a satellite television network, features social models who demonstrate
cognitive-behavioral skills and display conservative norms regarding substance abuse. An 18-
session curriculum contains 5-min videos that are assigned to be followed by discussion and social
reinforcement from a teacher or volunteer. This case study reports the program development
process and experiences in the initial dissemination of the program through national networks for
schools and cable television subscribers.
Finke et al (2002) in a small scale study found that children with a plan to resist the use of drugs
were more likely not to use drugs.
Sussman et al (1997) found that direct instruction by teachers was more effective than self-
instruction for students in alternative high schools, despite the fact that such self instruction was the
primary means of learning in such schools.
Abbey et al (2000) report on a family-based program that was aimed at family communications and
substance abuse was effective in beliefs about delaying experimentation with alchol. A family-
based substance abuse prevention program was evaluated which emphasizes family cohesion,
school and peer attachment, self-esteem, and attitudes about adolescent use of alcohol and tobacco.
The program was implemented in rural communities and targeted families with students entering
middle or junior high school. Baseline surveys were conducted with students and parents in four
schools and were readministered one year later. Because the program was voluntary, a quasi-
experimental design was used to compare participants (29 students and 28 parents) and
nonparticipants (268 students and 134 parents). Analyses of covariance indicated that student
participants, as compared to nonparticipants, had higher family cohesion, less family fighting,
greater school attachment, higher self-esteem, and believed that alcohol should be consumed at an
older age at the one year follow-up. There were fewer significant results for parent participants.
Strategies for involving parents in prevention programs are discussed.
Lilja et al (2003), based on the results from meta-analyses of outcome studies of school-based
programs, conclude that interactive programs tend to be more effective than not only those mainly
intended to increase factual knowledge about tobacco, alcohol, and illegal drugs, but also those
initiatives aimed at influencing adolescents' attitudes toward those substances. The interactive
strategy corresponds to problem-based learning or the interactive educational approach, now widely
popular in educational circles. These outcome studies have provided us with important knowledge.
However, there are relatively few evaluation investigations that analyze in substantive detail the
process by which adolescents change their alcohol, tobacco, and illegal drug-use behavior, and alter
their perceptions about these substances.
Ellickson et al (2003) report on Project Alert, an instructional program. Fifty-five South Dakota
middle schools were randomly assigned to program or control conditions. Treatment group students
received 11 lessons in 7th grade and 3 more in 8th grade. Program effects for 4276 8th-graders were
assessed 18 months after baseline. The revised Project ALERT curriculum curbed cigarette and
marijuana use initiation, current and regular cigarette use, and alcohol misuse. Reductions ranged
190
191
from 19% to 39%. Program effects were not significant for initial and current drinking or for current
and regular marijuana use. School-based drug prevention programs can prevent occasional and
more serious drug use, help low- to high-risk adolescents, and be effective in diverse school
environments.
Midford et al (2002) describe the conceptual underpinnings of effective school-based drug
education practice in light of contemporary research evidence and the practical experience of a
broad range of drug education stakeholders. The research involved a review of the literature, a
national survey of 210 Australian teachers and others involved in drug education, and structured
interviews with 22 key Australian drug education policy stakeholders. The findings from this
research have been distilled and presented as a list of 16 principles that underpin effective drug
education. In broad terms, drug education should be evidence-based, developmentally appropriate,
sequential, and contextual. Programs should be initiated before drug use commences. Strategies
should be linked to goals and should incorporate harm minimization. Teaching should be interactive
and use peer leaders. The role of the classroom teacher is central. Certain program content is
important, as is social and resistance skills training. Community values, the social context of use,
and the nature of drug harm have to be addressed. Coverage needs to be adequate and supported by
follow-up. It is envisaged that these principles will provide all those involved in the drug education
field with a set of up-to-date, research-based guidelines against which to reference decisions on
program design, selection, implementation, and evaluation.
Sussman et al (2003) report on a RCT that shows that direct instruction in health education for
youth indicating substance abuse is more effective than self-instruction. After two years, the self-
instruction program produced no behavioral effects relative to the standard care control condition.
The results indicated maintenance of program effects on cigarette smoking and hard drug use in the
health educator-led version.
Cloetta & Bisegger (2000) focused on the contribution of student characteristics and of teaching
quality to the gain in knowledge about drugs. 165 8th- and 9th-graders in eight classes answered a
questionnaire three times: before, immediately after and five months after the intervention. There
was a significant increase in knowledge immediately after the intervention (mean m = 6.2) and after
five months (m = 6.1) compared to the score before (m = 4.5). Furthermore, non-German speaking
students of the "Sekundarschule" (higher level) learned the most, non-German speaking students of
the "Realschule" (lower level) learned nothing at all. We found a positive association between
teaching quality as assessed by each class and knowledge gain in the same class. Multiple linear
regression analysis showed that five months after the intervention student characteristics explained
an important part of the variance in knowledge gain (25% of the total variance), while teaching
quality explained another 5%. Consequently, these characteristics can serve as predictors of
knowledge gain in such programmes.
Ellickson et al, (1993) found that school-based programs are able to affect knowledge and some
attitudes and beliefs but were not able to influence underlying attitudes about alcohol use. Evaluated
with over 4,000 students in an experimental test that included 30 diverse California and Oregon
schools, the curriculum seeks to help young people develop both the motivation to avoid drugs and
the skills they need to resist pro-drug pressures. Using regression analyses, we examine the
program's impact on the intervening (cognitive) variables hypothesized to affect actual use:
adolescent beliefs in their ability to resist, perceived consequences of use, normative perceptions
about peer use and tolerance of drugs, and expectations of future use. The analysis depicts program
effects for perceptions linked to each target substance (alcohol, cigarettes, and marijuana), across all
students and for those at different levels of risk for future use. Results show that the curriculum
191
192
successfully dampened cognitive risk factors from each of the above categories for both cigarettes
and marijuana, indicating that social influence programs can mitigate a broad range of beliefs
associated with the propensity to use drugs. However, it had a limited impact on beliefs about
alcohol, the most widely used and socially accepted of the three drugs.
192
193
12. Surveil Outcomes, Monitor Programs
This sub-section addresses the population health principle that health promotion efforts should
be based on regular health assessments and should be evaluated by relevant and meaningful
health surveillance outcomes and local program, policies and practices. For school health
promotion, this principle has three important aspects; one, the measures used to monitor
“system outputs” (for school systems and other systems) should not be confused with long
term health outcomes, two, the responsibility for accomplishing these health outputs and
outcomes is shared and is still only a piece of the puzzle in terms of overall health status and
three, it is more relevant to monitor health status and behaviours, social behaviours and selected
learning outcomes simultaneously. From systems theory, we know that system managers will be
concerned about “system boundaries” so this clarity of desirable outputs and sharing of
responsibility for health outcomes is very important if we hope to secure their cooperation.
Finally, from our overview of organizational capacity, we are looking for reports on effective
ways and means that systems can regularly surveil health, social and learning outputs/outcomes
and local policy/programs and practices.
Our findings in this sub-section are:
o the current indicators used to monitor child/youth health need revision, as they
are often based on deficit models, do not measure the influence of physical and
social environments
o the current indicators used to measure health, social behaviors and learning do
not clearly establish end points based on realistic program logic models and
these need to be clarified
o the current surveys used to monitor child and youth development in Canada are
inadequate in thst they are irregular, limited to national samples, and not timely
enough for program planning at the provincial/territorial or local levels
This sub-section looked for research that would answer these questions. Our review did not locate
many studies, particularly studies describing or explaining Canadian systems if surveillance and
monitoring. (These explanations may be available but not published, as the rationales and as part of the
regular Alcohol and Drug and youth risk surveys undertaken by several provinces in Canada.)
Does the research tell us how relevant determinants can be described and monitored
through a system of reliable Indicators related to the school environment that can be
used to measure health, social and educational outcomes as well as the context, inputs,
processes and outputs of school and public health systems? Are there such Indicator
systems currently being used or contemplated?
What is currently being monitored in alcohol and drug surveys in Canada? Is the impact
of the school environment and the status of programs and policies being monitored? Are
youth assets as well as deficits being reported? Is there adequate data on psycho-social
factors?
Does the research tell us to what extent are current policies, programs, services and
practices in the two systems based on research evidence? Can we identify and describe
ministries or agencies that have consciously made decisions about major school-based or
school-linked programs or services based on such evidence?
Does the research indicate that school systems, public health and addictions
systems have established appropriate Indicators of system performance that
include defensible program logic, contextual, input, process and output indicators
as well as appropriate outcomes data that are truly related to the program logic
model?
193
194
Does the research indicate the nature of a minimum number of the most
appropriate measures to surveil and monitor substance use and related health
status, FPT policy and program status and local agency/community capacity that
can be used to report on system accountability?
Are there studies that describe systems that have established evidence-based surveillance
and monitoring systems relative to health, addiction behaviours of children and youth?
Similar to the principle of a population health approach that suggests we describe and monitor
expected inputs, processes and outputs, an important element of a school health promotion program
is to describe realistic roles and outputs for each of the systems involved. This leads to questions
such as the following:
Does the research describe the roles of the three primary systems responsible for preventing
problem substance use through schools (ie education, public health and addictions agencies?
Has the research describe realistic outputs for school-based and school-linked addictions
prevention programs that can be monitored over time? How do these outputs (appropriate
adolescent knowledge, skills, attitudes, changes to school environment, access to services
etc) relate to long-term health outcomes related to substance use? Does the research clearly
delineate the two (outputs after 12 years of schooling vs life long outcomes)?
Wyrick et al (2001) examined ten secondary health education state curriculum frameworks in the
US were reviewed for their inclusion of 12 topics/mediators commonly used to prevent adolescent
substance use. Beliefs about consequences, decision-making skills, and stress management skills
were identified most often while commitment, lifestyle incongruence, and normative beliefs were
identified least often. Among states that included Alcohol, Tobacco and Other Drugs, beliefs about
consequences and resistance skills were the most commonly identified mediators. Commitment,
goal setting, and normative beliefs were not identified in any ATOD sections.
Finlay (2004), in an unpublished review prepared for the BC Ministry of Health Services and
planning identified several gaps in the surveillance data relating to the health of children and youth.
―To determine the Canada-wide applicability of the recommendations of the BC Provincial Health
Officer, the data presented in his Report were compared with similar data for the other provincial and
territorial jurisdictions. This examination of and search for comparable data on the health status and
behaviours of school age children in Canada resulted in the following observations.
There is an abundance of data on the health status and health behaviours of school age children in
Canada (at the provincial and territorial level, as well as on a national basis). There are good sources
of comparable data on a number of health indicators that provide provincially comparable data on
school-age children and youth. Examples of these sources include the Physical Activity Monitor of the
Canada Fitness and Lifestyle Research Institute, the Canadian Community Health Survey, Health
Canada – Notifiiable Diseases; Health Canada: Injury Surveillance and various surveys of Statistics
Canada.
Notwithstanding these sources, there are significant difficulties in finding data, based on regularly
conducted surveys that are comparable on a province-by-province (or territory) basis.
For example, data are available from a number of studies that have been done for an individual
province of territory. While data from these studies and reports are valuable, they present challenges
in term of comparability as many of these studies have been done as ―one-off‖ studies that address a
specific question or concern that is of interest at a particular time within one province. Therefore, the
replication of these studies or surveys over a period of years is not necessarily carried out. Nor are
similar studies carried out in the other provincial and territorial jurisdictions.
Further challenges to data comparability occurs in the following instances:
194
195
1. Where similar studies or surveys are carried out, the findings vary somewhat. (E.g. Health
Canada’s Canadian Tobacco Use Monitoring Survey versus Statistics Canada Survey of
% of Smokers in the Population)
2. Where similar surveys have been undertaken in more than one jurisdiction, the
methodologies or the presentation of the data often varies (e.g. slightly differing age
groupings, attempted suicide versus suicide mortality rates), thus making the
comparability of findings between jurisdictions difficult and open to debate.
As well, some surveys or studies report national data based on a sample sizes that are too small to
produce statistically significant data for an individual province or territory. Thus, these studies are of
little value with regard to providing data that are comparable on a province-by-province basis.‖
The findings of this recent review by Finlay are similar to other reviews prepared for the Council of
Ministers of Education, Canada, the Canadian Education Statistics Council and Justice Canada
(McCall, 2002; Shannon & McCall, 2000; 2001).
The review undertaken for Justice Canada, the Council of Ministers of Education, Canada and the
Canadian Association of Principals (Shannon & McCall Consulting, 2001) is still pertinent to this
discussion, although there are new surveys such as the CTCUMS that have been launched since the
writing of the paper from which excerpts are reproduced below:
What Kind of Information and Why?
We begin this discussion with a reminder that regular, reliable and timely (Indicators) data should be
collected to monitor the conditions of children and youth, their environments and the status of relevant
policies and programs. Such data is sometimes used to confirm or duplicate empirical, controlled
studies that show a specific condition or intervention has an impact but this should not be the primary
purpose of collecting the data. Collecting and analyzing regular, reliable data should alert policy-
makers and practitioners that something is working, or not working in their various public systems.
Positive and Negative Behaviours and Factors
Before discussing the scientific feasibility of collecting reliable data on the social behaviours, social
environments and relevant public policies and programs, we would like to raise one important principle
that should underline our approach to these issues and to lay to rest some of the legitimate concerns
raised by educators and others about the misuse of statistical data in the form of Indicators.
First, we should not be collecting information only on the negative behaviours of children and youth.
Obviously, positive and negative behaviours are important to having a complete picture of the situation
and so we need to collect both kinds of information. Consequently, in the conceptualization of the
rationale for collecting such data, we need to consider items that go beyond ―deficits‖ thinking about
children and youth. For example, Claudet & Ellett (1999) suggest a conceptual scheme that goes
beyond negative or deficit only thinking. They suggested three scales: 1) student achievement; 2)
perceived organizational effectiveness; 3) school holding power. Other similar work on communities,
such as that of Robert Samson of the University of Chicago, has turned from monitoring community
safety to monitoring community ―efficacy‖.
Our thinking on this important principle has also been influenced by the work of a scientific panel
convened by the U.S. Department of Education (Special Study Panel on Education Indicators, 1991).
This panel proposed a set of positive and negative features of the school environment so that we can
know that that school environment is purposeful, caring and ordered.
Valid, Proper Use of Statistics
Second, we need to collect data that can be used within a valid, defensible Indicators system. This
means a number of things. One, we need to select data sources or items that are meaningful
195
196
reflections of the reality of the situation. Two, we need a number of reliable data sources to provide a
comprehensive picture. Three, those data sources need to report on more than simply outcomes.
Early mistakes with the development of education Indicators in Canada have led to resistance to their
use. The misuse of statistical data by the media and a tendency among some policy-makers to create
―rankings‖ of schools has led many in the front-line to resist collecting data about their systems.
Most Indicators systems related to Canadian school systems developed piece-meal, with ad-hoc data
reported in isolated and infrequent reports. As well, output and outcomes data were often reported
without having contextual and process (programs and resources) data. Consequently, many education
and other practitioners have become cynical or wary about reporting and monitoring systems that do
not present an accurate and complete picture. In some instances, this has hardened into resistance to
all Indicators.
Secondly, there is an unfortunate tendency of the media and some authorities to present single-issue
data (such as test results) in a way that encourages the ―ranking‖ of schools. Lists of ―good‖ and ―bad‖
schools are published in newspapers, without background information and without including other
pertinent, contextual, policy/program and community information. School boards and
provinces/territories also suffer periodically with these types of simplistic rankings.
Ironically, this ranking tendency is best countered by reliable, regular and comprehensive data that
allows schools and school systems to report progress over time. They are able to present context,
input, process and output data simultaneously and they are able to compare their progress with their
own previous results. Consequently, meaningful reports and discussion emerge more frequently.
In order to be valid, Indicator systems should:
a) be directly related to the goals for the system,
b) collect data relating to the social and economic context as well as the family and community
characteristics,
c) measure inputs to the system,
d) describe throughputs or processes within the system,
e) report on outputs directly attributable to the system and
f) record long-term outcomes or impacts of the system.
The Scientific Feasibility
We need to be reasonably confident that researchers and policymakers have developed a stable,
albeit evolving, consensus on what needs to be measured and monitored. We need to know that those
items are based on sound conceptual models that have been tested through research and practice.
We need to know that the items being measured and monitored present a reliable picture.
In this project we are asking about the feasibility of measuring three basic things: the social behaviours
of youth, the social environments in which they live, learn and play and the school and agency policies
and programs that seek to support them.
In this brief discussion, we hope to identify:
a. where there is agreement on what items should be measured and monitored;
b. issues raised in previous consultations or in published sources about the reliability of
methods or items.
The Social Behaviours of Youth
There is a significant amount of research, theory and knowledge development that is relevant to the
discussion of the social behaviour of children and youth. Our understanding of health determinants,
resilience, (National Crime Prevention Council, nd), behaviour change models (National Crime
Prevention Council, nd) and the developmental stages and tasks of children and adolescents (National
Crime Prevention Council, 1996; 1997) need not be repeated here. However, this ever-widening and
deepening pool of knowledge should form a backdrop to our understanding of how behaviour is
developed.
196
197
There appears to be a consensus in the research literature that we should be monitoring a variety of
youth social behaviours. For the purposes of this paper, we have categorized such behaviours as
follows:
Pro-social behaviours such as participating in extracurricular activities.
Volunteering/community service is seen to be important in character and career
development by many.
Avoiding higher risk situations such as being unsupervised after school or going to
dangerous places in community or school is also monitored in some studies.
Health risk behaviours such as smoking, drinking or early sexual activity have been
associated with anti-social behaviours.
Anti-social behaviours such as bullying and delinquency are emerging as a consistent
topic in studies.
Criminal behaviours ranging from small property crimes to serious crimes and threats
against people have been reported in several studies.
While there appears to be some discussion in the research literature (Education Testing Service,
1999; Gaustad, 1991) as to whether these behaviours can be placed on a continuum or whether they
can be clustered into non-serious and serious groupings, there appears to be a consensus on their
relevance.
Staying with the individual, there also appears to be a consensus in the research that selected
attitudes, beliefs, perceptions and values. For the purposes of this brief overview, we have grouped
these items as follows:
respect for others
good character
having positive life goals
having a positive self-image/esteem
being confident, not stressed (mental health)
having an attachment to school (including detentions, suspensions, expulsion).
Researchers and policymakers have also developed a consensus that certain knowledge and skills
are important factors to individual social behaviours. These include:
social skills
decision-making/coping/problem-solving skills
conflict resolution skills
media literacy about violence on TV, games
having basic academic skills and school success
acquiring job-related skills
There is also a consensus that social support, in a variety of forms, is also be a factor worthy of
monitoring and measuring, including:
trust, positive relationship with parents
trust, able to confide in at least one adult
trust, positive leadership with teachers or other caregivers
trust, able to confide in a friend
trust, able to relate to positive peer group
successful initial job experiences
access to technology.
Researchers and policy-makers have agreed that preventive, treatment and rehabilitation services will
have a direct impact on social behaviours. Youth access and use of the following services should be
monitored:
access, use of supervised after-school programs
access to youth friendly personal, academic, pastoral, health and career counseling
appropriate access to remedial or alternative schooling
appropriate, adapted special education services and programs
therapeutic services
appropriate temporary or long-term custody institutions
alternative/diversion programs and services
victim support services
197
198
rehabilitation services
Finally, we have prepared a list of youth behavioural outcomes. These are the statistics that are most
often cited in the media and include:
youth crime status
youth health status
youth employment status
youth academic status (drop-outs, high school graduates, training programs and post-
secondary education).
The summary above describes the items relating to youth social behaviours which are most often cited
in research evidence and various studies and surveys. Together, they provide a meaningful,
composite portrait of the individual factors that influence behaviours.
However, there are some important issues that have been raised in previous consultations about
measuring and monitoring youth behaviours.
a) Can we measure anti-social behaviour in an adequate manner?
Bonita & Hanson (1994) review the difficulties associated with using administrative data (inaccurate,
misleading) victimization/perception surveys (missing ―victimless‖ crime such as prostitution or
vandalism, subjective) and self-reported behaviours (uncertain results). MacDonald & da Costa, 1996;
1996) have expressed similar concerns about underreporting of incidents by students. Definitions and
terminology can also be a factor when asking people to report on subjective issues such as ―hate
crimes‖ (Canadian Heritage, 1998).
Our rudimentary review of the published research done in preparing this paper located some
responses to these concerns. For example, the U.S. Department of Education (1996) has defined the
elements of a good administrative data collection strategy. As well, the Nation Center on Education
Statistics (nd) resolved many of the definition and terminology issues through the work of an expert
task force.
b) Who Should Be Surveyed?
Another potential problem in monitoring social behaviours and social climate is associated with who
should be surveyed. An example of this can be found in two U.S. reports on school safety (National
Center for Education Statistics, 1998), one which surveyed school principals and another which
surveyed students.
The obvious answer to this difficulty is to have more than one type of respondent from each social
environment, but is this scientifically and technically feasible?
c) Are people desensitized or over sensitive in victimization/perception surveys?
This is an issue raised in previous consultations on these issues? Can respondent bias, if any, be
controlled through scientific study design?
d) Can Reliable Administrative Data be collected from Administrators
A survey done as part of the CMEC paper on school safety data showed that most schools in Canada
are required to report serious incidents, such as violent incidents, criminal acts or serious property
crimes to their school boards. However, that survey also showed that most schools are not keeping
records on other, less serious antisocial behaviours, nor on their actions to deal with those incidents.
Consequently, some have raised concern about the reliability of existing administrative records from
schools.
Todd et al (1996) shows us some of these risks in their analysis of the data collection practices at
several Georgia schools. Respondents felt such data collection was worthwhile but they lacked
reliable baseline or comparative data, displayed a poor understanding of indicator items and, often,
respondents from the same school reported widely different estimates of incidents.
198
199
This issue has been discussed in both the published research literature. Researchers have reported
on a case study that shows how local school administrators can use good administrative record
keeping to improve their practices in helping students in difficulty. Further, there is considerable
experience being developed in Canadian and American schools in the collection and use of
administrative and student data as part of the Effective Behaviour Support (EBS) program, originating
out of Oregon. This holistic school safety program teaches school-based administrators how to collect
and use reliable and meaningful data through maintaining confidential, individual records. These
student case records can be aggregated to provide accurate, practical and meaningful information to
schools in the form of administrative data.
For more comprehensive advice on the nature of appropriate administrative data from schools, we can
turn to a task force established by the National Center for Education Statistics (Crime, Violence and
Discipline Reporting Task Force, 1996). This report had very detailed recommendations on the nature
of administrative data that should be collected from schools.
The Social Environments Related to Youth
In this section we discuss the social environments related to youth. They include, for the purposes of
this brief overview, the home, the school, public recreation/other programs, and public places in the
community.
The Home/Family
There appears to be considerable consensus among researchers and policy-makers about the
characteristics of the home and family that are relevant to the social behaviours and achievement.
They include:
socio-economic status
employment status, aspirations of parents
ethnocultural factors
marital status and history
social and cultural capital
parental involvement and parenting style
The School
The concern for the social environment of the school as an important factor in public view with studies
relating to school dropouts (Rutter, et al, 1979; Janosz & Lecler, 1993). The concept of the ―quality of
school life‖ evolved into ―school climate‖ and eventually into ―school culture‖ and has become as a
well-defined and understood part of the research literature on ―effective schools‖. More recently,
researchers and policy-makers have reexamined the school‘s social environment in relation to
violence and have reviewed concepts such as school discipline/codes of conduct.
In the rudimentary literature search undertaken in preparation of this summary, we located several
conceptual frameworks to explain the influences of the school‘s social environment (Jason et al, 1998;
Lighthouse, 1999; Macintosh, 1991; Applied Research Branch, 2000; Office of Educational Research
and Improvement, 2001; National Center for Education Statistics, 1991). There are many, many more
sources.
The elements of an effective, positive school culture have been generally seen to include:
shared responsibility and decision-making
parental involvement
high teacher expectations
recognizing cultural differences
relevant learning
research-based instructional practices
sense of personal responsibility
safe orderly learning environments
focus on learning
teacher encouragement
199
200
frequent monitoring of progress
Public Funded Recreation, Day-care and Other Programs
Although there is a consensus in the preliminary collection of published works identified in the
preparation of this paper that the status and nature of well-organized, publicly funded recreation, day-
care, arts and other programs should be measured and monitored, our rudimentary search did not
locate documents providing the depth and detail as that for homes and schools.
Consequently, we will ask the questions of others at the Ottawa meeting. Is there a consensus in the
research and current practice that would make it feasible to identify specific items to measure and
monitor.
Public Places in the Community for Youth
Our rudimentary review of the published literature did identify several, disparate sources that measure
and monitor perceived and reported levels of safety, crime and social behaviours in public places in
the community. For example, the Federation of Canadian Municipalities (2001) and the Canadian
Institute for Health Information (1995) include safety information in their Indicators programs. As well,
composite reports or detailed analysis of various surveys, such as The Progress of Canada‘s Children
(Canadian Council on Social Development, 2001) or Income and Well-being (Canadian Council on
Social Development, 1999) have used NLSCY data on issues such as recreation user fees and
problem neighbourhoods. However, most studies of community safety issues such as the CCSD
Personal Security Index (Canadian Council on Social Development, 2001) do not have detailed data
or analyses on how youth perceive and behave in public places such as streets, shopping malls and
other locales. Our search located several, similar reports that had not isolated youth data in Calgary
(nd), Toronto (nd), Albuquerque (2000), Trans Country (nd), King County (nd) and San Mateo (2000).
The Office of Juvenile Justice and Delinquency Prevention (1999) has noted that anti-social and
criminal behaviours peak in the after school hours or in the evening on non-school days. The U.S.
Federal Interagency Forum on Child and Family Statistics (2001) has reported that a broader set of
Indicators of youth sexual behaviours and social environments is needed. They call for positive
indicators of youth behaviour in the community and on neighbourhood environments.
Consequently, one of the means within our discussion of scientific feasibility should be if and how we
can measure and monitor the impact of social environments in the community. This discussion should
not only include issues of safety but also overall community social support or ―efficacy‖. At the meeting
some of our expert participants will be able to expand on these concepts.
The Status of Relevant Policies, Programs and Practices
This is an area of activity that is often overlooked within Indicator programs. We need reliable, regular
and family information on the status of policies, programs and practices that are relevant to youth
social behaviours and social environments. We need to be able to determine if appropriate policies are
in place, whether those programs are being implemented and whether these policies and programs
are having the desired impact on professional practice.
We should be able to measure and monitor the relevant policies, programs and practices of:
schools and school systems
police services
public health
social services/child welfare agencies
youth courts
custody agencies
employment agencies
recreation departments
municipalities.
200
201
We should also be able to determine the availability and programs/practices of relevant community-
based agencies, including:
youth serving organization
diversions/alternative programs
arts/cultural organizations
sports organizations
religious organizations
business organizations.
It is not feasible, nor necessary, to provide detailed descriptions of the appropriate policies, programs
and practices of these public and voluntary agencies within this discussion paper. At the meeting in
Ottawa, we need only to determine if it is feasible to collect reliable, regular and timely data on these
topics. However, it may be useful to present just one example of one agency to illustrate the type of
information needed. Once again, the school appears to be the agency that has been most studied in
the published research literature.
There is a considerable agreement on the policy and program elements that make up a safe, orderly
school environment. These have been summarized in a research-based Canadian consensus
statement. (Canadian Association of Principals, 2000):
inclusive curriculum
fair and consistently applied codes of behaviour
problem-solving, not punitive approach
natural justice approach
leadership and teacher training
pro-social leadership
coordination of services delivery to children and youth
police-school partnerships and protocol
whole school approach
focus on specific issues, including bullying, attendance, incidents, student attachment
engaging youth in after school programs, peer mediation, community service learning,
school watch and school court programs
instruction in social skills, conflict resolution, law-related education, drug prevention,
decision-making, anger management, character development, media literacy
clear, positive behaviour expectations
parent, agency and community involvement and support
appropriate security precautions
well designed, maintained facilities
police, health, employment, social and community services coordinated with school
youth friendly alternatives to suspension
alternate schooling arrangements
restorative justice programs.
This section of the discussion paper has briefly reviewed some of the questions pertaining to the
scientific feasibility of measuring and monitoring youth social behaviours, social environments and the
relevant policies, programs and practices. Our discussion has been based on a rudimentary review of
some of the published research literature.
Based on these sources, it seems scientifically feasible to identify measures and statistical sources
that can be monitored over time to report regularly, reliably and in a timely fashion. This finding is open
for discussion at the meeting in Hull.
If Data Were Gathered, Is it Needed? Would it Be Used?
The survey of local school districts that was done for the CMEC report has underlined the need for
reliable information. This survey was administered to 50 school districts selected on a random basis.
The results were as follows:
About half of the school districts in the small random sample were using external,
published studies and surveys on school safety to review and improve programs.
201
202
Less than half of the school districts are collecting data on the attachment their
students have to their schools and, when they do, this is usually in the form of
monitoring school dropout rates.
Two thirds of school districts do not monitor factors such as student perceptions of the
school climate.
Just over half of the school districts monitor serious incidents such as criminal
behaviours in their schools. Less serious incidents such as vandalism, bullying or
harassment are not monitored by two-thirds of the school districts.
Three-quarters of the school districts said they are not required to report such data to
their respective education ministries.
Half of the school districts require reports from their schools on the policies and
programs being implemented to improve school safety.
The vast majority (over 85%) of school district administrators said that it was important or very
important to have regular, reliable information on youth antisocial behaviours that take place in schools
and the community.
Administrators wanted such information to be practical, comparable and analyzed so that policy and
program implications are clearly identified. An open-ended question in the survey prompted several
suggestions that the burden of data collection in schools should not be onerous.
Do We Have that Information Now?
Increasing Concern, Several Studies, Incomplete Picture
Canadians are increasingly concerned about the safety of youth in schools and in the community.
Media reports about violent crimes in schools as well as increased worries about the devastating
consequences of antisocial behaviours such as bullying and harassment have heightened these
concerns. This has led to the development of several studies and one-time surveys in Canada. As
well, some ongoing surveys have included more questions on specific issues and topics.
Unfortunately, these studies tend to be measuring only one aspect and many are not necessarily
going to be repeated. As well, some of these studies are narrow in scope, reporting only on the
negative behaviours of youth and/or risk factors without any data on the pro-social behaviours and
factors that can reinforce resilience and social attachment. It is perhaps not surprising, therefore, to
find that the findings of these reports vary. For example, the prevalence of bullying behaviours varies
from five to 45% among the various studies.
Further, most of these studies are based on surveys of only one population such as youth, parents,
teachers or administrators. They often do not report adequately on the social, economic and family
contexts, or on the status and delivery of programs and policies to prevent antisocial behaviours.
Large scale, ongoing surveys (such as the General Social Survey) that are done at the national level,
often do not have sufficient specificity to report adequately on the impact of school and community
social environments on safety and learning. Other, more specific surveys such as the Health
Behaviours of School-age Children (HBSC) have a better selection of questions, but the Canadian
sample size is very limited.
The National Longitudinal Survey on Children and Youth (NLSCY) has multiple respondents and a
good selection of questions, but is largely inaccessible to local decision-makers, does not have
provincial/territorial data for children/youth over age five and has a lengthy lag time (over five years)
between data collection and publication of results, thereby making it problematic for use by
policymakers seeking to monitor their systems. As well, we understand that the most recent cycle of
data collection has not been able to collect a sufficient number of schools participating and that this
part of the NLSCY may be discarded.
There have been some recent studies (that may become ongoing surveys) undertaken by education
ministries that have asked questions about school climate. However, they tend to be part of larger
scope surveys of school graduates and academic-oriented school report cards and, consequently, do
202
203
not provide in depth coverage of school climate and school safety issues. These surveys also do not
report on context or on the status of relevant policies and programs.
At the national level, the interest in youth antisocial behaviours is reflected in the introduction or
expansion of items in surveys done by HRDC, Health Canada, Justice Canada and Statistics Canada.
However, these surveys are often difficult to access, ask a limited number of questions or are
sampling only at a national level.
Very few of the surveys done to date in the provinces/territories or at the national level have asked
questions about the status of prevention programs and policies in schools, other agencies or the
community. Consequently, we have little information on whether such policies and programs are being
implemented. These strengths and weaknesses in all of these studies and surveys are examined in
more detail in the analysis of current and recent surveys presented later in this report.
Therefore, this paper suggests that there is an urgent need for education, justice and other authorities
to consider how regular, reliable information about school and community safety can be collected and
made easily accessible to education, justice, law enforcement, health, social service and other
professionals and agencies.
Content Analysis of Existing Surveys and Recent Studies
A general content analysis was undertaken of the existing national and provincial/territorial surveys
and recent one-time studies relating to youth social behaviours, environments and programs. It should
be noted that this analysis is only of their general nature. The framework used to analyze their
questions is based on the preceding discussion of what should be monitored and measured.
The brief summary below is based on a general content analysis of the surveys listed. The purpose of
this preliminary analysis is to indicate the types of questions being asked in regular Canadian surveys
and recent one-time studies. Several gaps in our knowledge of the social behaviours, environments
and relevant public policies/programs are noted after the presentation of the results. Appendix One of
this paper contains a description of these studies and the content analysis for each survey or study.
If collaboration in the collection and sharing of these data is deemed to be feasible, further specific
examination of these studies would be required.
The following regular surveys and recent one-time studies were examined.
(Note: In some cases, some of the recent studies or reports within a province are grouped together in
this report.)
Regular National Surveys
National Longitudinal Survey of Chidren and Youth (NLSCY)
Health Behaviours of School-age Children (HBSC)
General Social Survey (GSS) (Victimization and Activities Components)
Uniform Crime Reporting Survey (UCR)
Youth Custody and Court Survey (YCCS)
Youth Court Survey (YCS)
Canadian Community Health Survey (CCHS)
National Population Health Survey (NPHS)
Youth in Transition Survey (PISA/YITS)
School Achievement Indicators Program (SAIP)
Regular Provincial/Territorial Surveys
New Brunswick Positive Learning Environments
Newfoundland School Report Card/Quality of Student Life/School Activities
Survey
Quebec NCPC Project Survey/Previous Studies/Superior Council on Education
Recommendation
Ontario Suspensions & Incidents Data/School Report Card Development
BC School Report Card/McCreary Adolescent Health Survey/Auditor-General
Recommendations
203
204
Nunavut Community Profile
Personal Education Number (BC, AB, MB, SK, QC, NF)
One time National and Provincial/Territorial Studies
Teacher Federation Surveys (Several reviewed, please see Appendix for details)
Family Characteristics of Problem Kids
Profile of Youth Justice in Canada
Alternative Measures in Canada/Alternative Measures Survey
Community Involvement/ Youth Volunteering on Rise
Survey of School Board Polices on Violence (Day et al, 1995)
School Violence and the Zero Tolerance Alternative (Gabor, 1995)
Truancy and the Social Context of Schooling Frank & Lipps, 1997)
Bullying and Victimization among Canadian Children (Craig et al, 1998)
Weapons Use in Canadian Schools (Walker, 1995)
Exemplary Police-School Programs (Ryab & Mathews, 1995)
Nova Scotia School Code of Conduct: Report to the Minister (2001)
Manitoba Longitudinal Survey of Recent Graduates (1999)
BC Auditor-General Report (2000)
Alberta Centre on the Law and the Family (Gomes et al, 2000)
Northwest Territories School Relationships Study (1996)
Alberta Tri-University Qualitative Reports on Disruptive Behaviours (1996-98)
Education Quality and Accountability Office of Ontario Survey (2001)
NLSCY Analysis Participation in Activities (2001)
The timeliness of the data as well as the sample size (national results only, provincial/territorial results,
local results). The gaps in the coverage of these data sources are discussed after the table
summarizing the results. One-time studies are not reported in this summary, but are examined in the
Appendix.
The following summary indicates clearly that we rarely have a regular, reliable data source from
among the surveys and studies reviewed in preparation of this paper for most of the topics listed here.
In some cases, for some age groups, we have data from some surveys with a national only sample. In
other cases, we have good data from one or two provinces, but not from the rest.
In some cases, we have identified a national survey with a few questions on a few related topics.
Other times, we found national surveys with many questions on several topics, but it covered only one
age group.
Further, we need to be cautious about the practical value of national data sources to provincial and
local policy-makers and practitioners. Since most major public systems are administered provincially,
those policy-makers will, more often than not, need provincial/territorial results for them to decide on
new directions. Local agencies are the ones that are often required to make decisions about the use of
scarce resources, and they need to be persuaded to collect data and use existing data.
Summary of Content Analysis of Canadian Surveys and One-time Studies
204
Type of Indicator
Context Data
Economic Conditions – the general national or provincial economic conditions are usually not sought or
reported with the survey results GSS
Social Conditions- these data are usually not sought, nor reported with the survey results GSS
Media Influences – none
Other Data - none reported
Input Data
Family Characteristics- major surveys include questions, best data available every five years from a national
sample only for under 15 years old (NLSCY), PISA/YITS has one time p/t data on 15 yrs.old
Community Characteristics – major surveys include these questions, best data every five years from a national
sample under 15 years old (NLSCY)
Local Employment Rates-questions rarely asked
Other Data
Funding, resources, characteristics of schools, agencies, police etc-characteristics of schools asked in several
studies, questions rarely asked about other community agencies
Process Data
Administrative data from:
o Schools- questions from 3 p/t surveys, 3 other p/t developing systems, no national data source
o Police Services- regular data from UCR, crimes only
o Courts- regular data from YCS, crimes and probation only
o Custody Agencies- some from YCCS (not sure if this is an ongoing survey)
o Recreation Dep’t’s – no survey or study reviewed had admin data from this source
o Youth Serving Organizations- no survey or study reviewed had admin data from this source
o Employment Agencies – no survey or study had admin data from this source
Perceptions/Victimization Surveys of schools (S), home (H) Community (C ), recreation programs (R)
o Youth – 3 p/t surveys have questions, best national data is every 3 yrs (HBSC), some p/t data from
PISA/YITS, (data is on schools mostly, some on community or homes)
o Parents – NLSCY has best data every five years in national sample every five years
o Teachers – NLSCY has best national data, NB, QC, have data.
o Principals – NLSCY has best national data every five years,
o Caregivers – no survey had questions from other caregivers
o Police Officers- no survey had questions from police officers
o Citizens/General Public – few questions in NPHS (national), CCHS (local/provincial)
Impact. Awareness of Social Influences
o Parent behaviours, practices – best national data from NLSCY(5 yrs), HBSC (every 3 years), 3 p/t
surveys have questions
o Peer behaviours, practices – best national data from NLSCY, HBSC, 3 p/t surveys have some questions
Status of Policies/ Programs/Practices
o Schools – best national data from NLSCY (5 yrs), two p/t surveys have data
o Recreation Dept’s – some data from NLSCY
o Police- some data from NLSCY
o Youth Courts - some data from YCS
o Public Health – some data from NLSCY every 5 years
o Social Service/Child Welfare – some data from NLSCY every five years
o Employment – no data source available
o Arts/Cultural Organizations – no data available
o Youth Serving Organizations – no data available
o Religious Organizations – no data available
o Diversion/Alternatives Programs –no data available
o Other – no other type reported
Output Data
Youth Behaviours -
o Pro-social Behaviours – NLSCY, HBSC, YITS, BC, NF, QC
o Community Service/Volunteering – YITS, BC
o Risk Situations (eg home alone) – HBSC
o Health Risk Behaviours – NLSCY, HBSC, BC
o Anti-social Behaviours – NLSCY, HBSC, GSS, BC, QC, NB,
o Criminal Behaviours – UCR, YCS, NLSCY
206
Youth Attitudes/Beliefs -
o Respect for Others – Canadian Heritage is initiating survey with Stats Canada
o Character/Values - CCHS (Optional), NLSCY, YITS, QC
o Personal Life Goals – NLSCY, YITS, HBSC, NB, QC, BC
o Self-Image – NLSCY, HBSC, NB, QC, BC
o Confidence, Mental Health, Stress, Anxiety – NLSCY, HBSC, CCHS (Option), NPHS, NB, QC, BC
o Attachment to school – NLSCY, HBSC, YITS, NF, QC, BC, BC, Student Numbers
Youth Knowledge/Skills -
o Social Skills – YITS (15+), NF, QC, BC, MB
o Decision-making Skills, Problem solving skills – YITS (15+)
o Conflict resolution Skills – none
o Knowledge of Legal Responsibilities/ Rights – none
o Media Literacy Skills – none
o Basic Academic Skills – SAIP, NLSCY
o Job-related skills – NLSCY, YITS, MB
Access to Social Support -
o Trust in Parents – NLSCY, YITS, HBSC, BC, QC,
o Trust in at least one adult – NLSCY, BC
o Trust in teachers, service providers – NLSCY, YITS, HBSC, NB, NF, QC
o Trust in friend – NLSCY
o Trust in friends, peer group –NLSCY, HBSC, BC
o Initial Job Experiences – YITS, MB
o Access to technology – YITS (Option), NF
Access, Use of Preventive/ Emergency Services -
Preventive/Protective Services -
o After School, Recreation ,Programs etc – NLSCY, YITS, HBSC, GSS, CCHS (option), NF, QC, BC
o Personal, pastoral, health, career counseling –NLSCY, HBSC, CCHS, YITS, NPHS, MB
o Remedial/alternative schooling – NLSCY, YITS, NB, NF, Student Number?
o Adapted Sp. Ed Programs – QC, Student Number?
Treatment/Rehabilitation Services –
o Therapeutic Services – NPHS, NB
o Custodial Institutions - YCCS, YCS
o Alternative Programs – YCCS
o Victim Support Services – none
o Rehabilitation Services – none
Outcomes Data
Youth Health Status – NPHS (12+), CCHS, GSS (15+)
Youth Crime Status – UCR, YCS
Youth Employment Status – Unemployment data
High School Dropout/Grad Rates/Training/PSE Status – SAIP
In addition to the general gaps and difficulties identified prior to the presentation of the table
above, this general contents analysis identified a n umber of specific gaps in our knowledge,
including:
a) There were very few surveys that were able to correlate contextual and input data with outputs
and with process data.
b) Most national surveys have very little administrative data from schools. The administrative data
from other agencies such as recreation departments, public health, child welfare agencies and
other agencies is not collected in any of these surveys. Administrative data from police services is
not necessarily representative and even when combined with the available youth court crime
stats, these surveys do not offer explanations or warning signs about antisocial behaviours For
example, bullying is not monitored in these surveys, yet it is a major problem, with severe
consequences.
c). Almost all of these surveys and studies collect very little input data that describes the
characteristics of institutions and agencies that are supposed to support youth. Where it is done,
it is usually done only for schools.
d) Perception/victimization surveys, that can go deeper than administrative data to catch
unreported crimes or behaviours, are not used in common way in many ofd the surveys and
206
207
studies. As well, when these perceptions and victimization surveys are used, they often do not
use multiple respondents in order to capture the variations in perceptions.
e) Most surveys and studies do not collect information on the status or reach of prevention or
promotion programs. We need to know if such programs are actually being delivered to children
and youth, if they are of high quality and if they are actually used by an appropriate number of
youth or by the appropriate sub-populations of youth.
f) Overall, when one looks at all of the surveys and studies, there is a wide, good range of pro and
antisocial behaviours being measured at different times, for different ages of youth or for different
jurisdictions. However, this wide range of behaviours is not often captured within one survey or for more
than one age group, or they are monitored infrequently or only at national level.
g) We can gather very little knowledge about the relevant attitudes/beliefs and values of youth
from the existing number of surveys and studies.
h) The survey and studies provide very little information about the related knowledge and coping
skills of youth, despite the fact that we know these types of programs can reduce violence and
improve pro-social behaviours.
i) There is a wide range of questions about youth access to various forms of social support, but
these data sources are not regular, reliable, timely, nor are they available with provincial/territorial
results.
j) These surveys and studies provide very little information on how many kids are participating in
preventive, protective and treatment services such as career counseling, health services,
treatment services, diversion programs etc.
k) In these surveys and studies, outcomes data is often presented and measured without having
information on the other factors such as context, inputs and process. Consequently, these results
do not inform decision-makers adequately, confuse the public, and move us no closer to better
policies or programs. .
l) The NLSCY has the best set of instruments, but its cohort sample is only national after age 5,
the data is not timely, and the schools surveys are being dropped because of lack of
respondents.
m) The optional nature of several components of the HBSC and CCHS surveys may make
comparative analysis with other countries or among communities difficult.
n) Some of the surveys examine school climate and home climate, but few surveys examine
other public places within the community that serve youth. It is not clear if general surveys about
the community safety and social climate currently differentiate the responses from youth about
those youth-specific places.
o) Five provinces now developing school report cards that include data on antisocial behaviours
data (NF, ON, ON, AB, QC).
p) Several school boards are developing local tracking systems using administrative data such as
that recommended in the Oregon EBS program.
Wenter et al (2002) assessed how current practice in US middle school substance use
prevention programs compares with seven recommended guidelines adapted from the Centers
for Disease Control and Prevention guidelines for school-based tobacco use prevention
programs. An estimated 64.2% of schools met four or more of the recommendations for school-
based substance use prevention practice; 4.0% met all seven recommendations. Schools were
most likely to report having and enforcing substance use prevention policies (84.3%) and least
likely to report training teachers in substance use prevention (17.9%). More recommendations
were implemented in schools that were public and had larger enrollments, greater perceived
availability of resources, greater school board and parental support for substance use
207
208
prevention, and had hired a school substance use prevention coordinator. The authors
concluded that the low prevalence of comprehensive substance use prevention programs in U.S.
middle schools may limit the potential impact of school programs on the prevalence of youth
substance use.
A similar study on US schools and curricula (Ringwalt et al, 2002) found that 26.8% of all
schools, including 34.6% of public schools and 12.6% of private schools, used at least 1 of the
10 effective curricula specified. Few school or respondent characteristics were related to
program implementation. Over two thirds of schools reported using more than 1 curriculum,
and almost half reported using 3 or more. Results demonstrate the considerable gap between
our understanding of effective curricula and current school practice.
McCall, (1997); Allensworth et al, (1997, p. 287) and Nutbeam & St. Leger, (1997) suggest in
their reviews of the research on school health that we need a clearer understanding of the
potential and the realistic, sustainable limits of school-based and school-linked interventions to
prevent specific health problems. In other words, knowing what is achievable for the school in
relation to several health issues, including which, if any, issues are more easily influenced by
school health programs and which are essential for the school to address for which age groups
of youth at what stages of their development. (For example, the US has identified six health
issues for school-aged children based on their health impact. Is anyone studying whether some
issues are not modifiable through school health programs?)
These same research reviews have suggested that we need better and more frequent monitoring
of the status of policies, programs and services available in the school and the community
through the development of Indicators (Nutbeam & St. Leger, 1996, 1997; Allensworth et al,
1997, McCall, 1997, WHO Working Group, 1996, WHO Expert Committee 1997)
Finally, these international reviews suggest that a set of Indicators to monitor the "health" of
schools, school systems and related systems such as public health, social services, recreation,
police and youth employment services be developed. These Indicators need to be more
meaningful ion measuring factors such as the resiliency within children, the capacity of systems
to respond rather than simply deficits and negative incidents or treatment statistics. The
tendency in health promotion and education is to focus on the concepts that are most easily
operationalized and measured. There is an urgent need for more meaningful indicators that
report on a comprehensive set of indicators that cover context, inputs and processes at all levels
as well as immediate outputs and long-term outcomes.
A survey of ministry and school board practices (McCall et al, 1999) in monitoring school
health and HIV/sexual health policies and programs would suggest that ongoing monitoring
might be a problem within Canada.
Education ministries and school districts were asked how they reported student achievement in
health education. Respondents were asked to indicate which of several following reporting
procedures were used. Less than 20% of education respondents reported that they reported
student health achievement scores or indicators in annual reports, or that they assess the
effectiveness of the health education program in respect to learning outcomes. As well, very
few education respondents were tracking the number of students who were opting to take
health, physical education or family studies courses in senior high school grades.
Health ministries and public health units were asked abut their reporting requirements on the
prevention aspects of their inter-ministry (all ministries) action plan on AIDS/HIV. Very few
health ministries nor public health units reported that there were regular mechanisms for
evaluating progress.
208
209
Very few health or education ministries or local agencies regularly monitored public opinions
about health issues, nor did they monitor client satisfaction with prevention programs. Very fe
ministries or agencies monitored participation rates in various optional programs such as health
education or preventive health services.
209
210
D. Conclusions
This literature review has identified substantial evidence that supports the use of the school setting
to influence substance use by children and youth.
Can the school, working with parents, public health and addiction agencies and
the broader community, implement sustainable school-based and school-linked
policies, programs and practices that prevent substance abuse and promote
mental health as well as healthy child/adolescent development?
What are the best or promising overall approaches in enhancing that
prevention/promotion role for schools and relevant agencies/systems? What are
the best or promising, cost-effective and cost-beneficial interventions? How can
these interventions be best organized, coordinated, delivered, sustained and
evaluated?
How can the organizational capacity of provincial/territorial education and health ministries be
strengthened to encourage, require or support their health, addictions and education systems to
prevent substance abuse?
The sources identified in this wide-ranging review show that the social and physical environment
of the school has an impact on the nature of such use by adolescents. Further, some prominent
researchers are suggesting that the school environment is linked directly to the environments of the
home and the local community, so interventions in the school setting may have an impact on those
other contexts.
The research identifies the mediating factors related to risk and protection from harmful substance
use that can be influenced within the school setting. New understanding about the use of alcohol,
tobacco and other drugs by youth, as well as new insights into adolescent development make the
evidence base about suitable and effective approaches to school-based and school-linked
prevention more understandable and clear. A better balance between harm reduction and
abstinence messages might well be achievable.
As well, this review has identified new ways of understanding the ecological nature of the multiple
micro-environments within the school, as well as systems theory that can explain how programs
can be made more sustainable.
A considerable consensus now exists on the nature of effective instructional programs that are
based on social skills development. This review has also described bow that effective instruction
about drugs and alcohol can be linked to broader instruction in social and emotional learning,
whole school approaches to enhance the social environment within the school and comprehensive
mental health services.
This review has also briefly reviewed some of the research on specific interventions that are part of
population health and comprehensive school health approaches, but further research into many of
these principles and elements is strongly suggested.
The organizational capacity of health, education and other ministries to promote this new
understanding, these new approaches and these multiple, coordinated interventions would appear
to be urgent. This review found that many systems fail to make use of research evidence.
The capacity of health and education ministries to coordinate policy, promote cooperation,
210
211
transfer knowledge, develop their work forces, monitor and report on outputs and systems and
manage emerging issues will be a critical factor in sustainability, coordination and ultimately
harmful use of substances by youth.
This review identified and described these capacities, located some sources indicating their
importance and relevance and showed why they should be used in other parts of this strategic
assessment project. However, we did not locate many studies, especially Canadian studies, that
used this type of systems thinking to assess the current status of programs and policies.
Consequently, it is important further assessment be done into the next levels of the systems, the
local school boards, regional health authorities, addictions agencies, police and mental health
agencies.
As well, it is important that the many points of further inquiry that can be done by more in-depth
research reviews or further research that have been identified in this report be considered through
the development of a research agenda on the role of the school setting in preventing harmful
substance use.
211
212
E. References
Aas J, Klepp KI. (1992). Adolescents‘ alcohol use related to perceived norms. Scandinas
Journal of Psychology. 33(4):315-25.
Aos, S.; Phipps, P.; Barnoski, R.; and Lieb, R. The Comparative Costs and Benefits of
Programs to Reduce Crime. Vol. 4 (1-05-1201). Olympia, WA: Washington State Institute for
Public Policy, May 2001.
Abbey A, Pilgrim C, Hendrickson P, Buresh S. (2000). Evaluation of a family-based substance
abuse prevention program targeted for the middle school years. J Drug Educ. 30(2):213-28.
Abt Associates Inc., Eggert Leona L, Kumpfer Karol L. (1997). Drug abuse prevention for at-
risk individuals. (NIDA Drug Abuse Research Dissemination and Applications (RDA)
Materials ; NIH Publication No. 97-4115) Rockville: National Institute on Drug Abuse. Office
of Science Policy and Communications. Public Information Branch. v, 165 p. (ADAI bk) HV
5825 A224 1997 .
Addiction Research Foundation. (1990). Suggested drug education curriculum content areas for
each grade division. Notebook. Toronto, ON: Centre on Addiction and Mental Health.
Addiction Research Foundation. (1991). Alcohol and Drug Policies: A Guide for School
Boards. (2nd ed.). Toronto, ON: Author.
Adelman HS, Taylor L. (2000). Moving prevention from the fringes into
the fabric of school improvement. Journal of Education and Psychological Consultation. vol.
11, no. 1, p. 7–36.
Adrian M, Layne N, Williams R. (1995). Canadian Youth and Drugs: A Health Promotion and
Social Marketing Resource Guide. Ottawa, ON: Health Canada.
Advisory Committee on Population Health. 2000. The Opportunity of Adolescence. Ottawa,
ON: The Health Sector Contribution, Health Canada.
Advisory Committee on Population Health. 2002. Advancing Integrated Prevention Strategies
in Canada: An Approach to Reducing the Burden of Chronic Disease, Ottawa, ON: Health
Canada
Ajzen I, Fishbein M. (1980). Understanding Attitudes and Predicting Behavior. Englewood
Cliffs, NJ: Prentice-Hall.
Ajzenstat J, Gentiles L. (1988). Sex Education in Canada: A Survey of Policies and Programs.
Toronto, Ontario: Human Life Research Institute.
Alberta Alcohol & Drugs Abuse Commission. (2001) Youth Risk and Protective Factors - May
2003. Edmonton, AB: Author.
Alberta Alcohol & Drug Abuse Commission. (2002). An Overview of Risk and Protective
Factors The Alberta Youth Experience Survey 2002. Edmonton, AB: Author.
Alcohol and Public Health Research Unit. (nd). Alcohol Advertising.
http://www.aphru.ac.nz/projects/Alcohol/advertising.htm#children.
212
213
Alcohol Policy Network. (2004). Let‘s Take Action on Alcohol Problems in Schools, Colleges
and Universities: A Practical Guide to Policy Development for Administrators, Educators,
Students and Others Concerned about Health, Safety, and Liability. Toronto, ON: Ontario
Public Health Association.
Allensworth DD, Lawson E, Nicholson I , Wyche J, eds. (1997). Schools & Health. Our
Nation's Investment, Washington, DC: Institute of Medicine. National Academy Press.
Allensworth DD. (1993). Health education. The state of the art, Journal of School Health,
63(1):14-20.
Allensworth DD. (1994). The research base for innovative practices in school health education
at the secondary level. Journal of School Health, 64(5):180-7.
Allison KR. (1992). Academic stream and tobacco, alcohol, and cannabis use among Ontario
high school students. Int J Addict. May;27(5):561-70.
Allison KR, Silverman G, Dignam C. (1990). Effects on students of teacher training in use of a
drug education curriculum. J Drug Educ. 20(1):31-46.
Allott R, Paxton R, Leonard R. (1999). Drug education: a review of British Government policy
and evidence on effectiveness. Health Educ Res. Aug;14(4):491-505.
Ambtman R, Madak P, Koss D, Strople MJ. (1999). Evaluation of a comprehensive elementary
school curriculum-based drug education program. J Drug Educ. 20(3):199-225.
American Academy of Pediatrics. Committee on School Health. (2001). School health centers
and other integrated school health services. Committee on School Health. Pediatrics.
Jan;107(1):198-201.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders. (4 ed.) Washington, DC: American Psychiatric Association.
Ames A, Gray D, Currie C, Elton R. (1997). Healthy or druggy? Self-image, ideal image and
smoking behavior among young people. Social Science and Medicine, 45:847-858.
Andreasen AR. (1995). Marketing Social Change: Changing Behaviour to Promote Health,
Social Development and the Environment. San Francisco, CA: Jossey-Bass.
Anthony JC, Petronis KR. (1995). Early onset drug use and risk of later drug problems. Drug
and Alcohol Dependency, 40(1):9-15.
Armbruster P. (2002). The administration of school-based mental health services. Child
Adolesc Psychiatr Clin N Am. Jan;11(1):23-41.
Arnett J. (1992). Reckless behavior in adolescence. A developmental perspective.
Developmental Review. 12:339-373.
Ashery, R.S.; Robertson, E.B.; and Kumpfer, K.L.; eds. Drug Abuse Prevention Through
Family Interventions. NIDA Research Monograph No. 177. Washington, DC: U.S.
Government Printing Office, 1998.
Auditor General of British Columbia. (2001). Fostering a Safe Learning Environment:
213
214
How the British Columbia School System Is Doing, Government of British Columbia.
Austin, Gregory. (1992). School failure and alcohol and other drug abuse. (Children at Risk)
Madison, WI : Wisconsin Clearinghouse, i, 57 p. (ADAI bk) HV 5824 Y68 A87 1992.
Bandura A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall.
Bangert-Drowns J (1988), "The Effects of School-based Substance Abuse Education: A Meta-
Analysis", Journal of Drug Education, 18(3).
Banks C. (1993). Restructuring schools for equity: What we have learned in two decades. Phi
Delta Kappan. 75, 42-48.
Banwell CL, Young D. (1993). Rites of passage: Smoking and the construction of social
identity. Drug and Alcohol Review, 12:377-385.
Barnett S, Niebuhr V, Baldwin C. (1998). Principles for developing interdisciplinary school-
based primary care centers. J Sch Health. Mar;68(3):99-105.
Barnett S, Duncan P, O'Connor KG. (1999). Pediatricians' response to the demand for school
health programming. Pediatrics. Apr;103(4):e45.
Barrett M. (1994). Sexuality education in Canadian schools: An overview in 1994. Canadian
Journal of Human Sexuality, 3(3):199-208.
Basen-Engquist K, O'Hara-Tompkins N, Lovato CY, Lewis MJ, Parcel GS, Gingiss P. (1994).
The effect of two types of teacher training on implementation of Smart Choices: a tobacco
prevention curriculum. J Sch Health. Oct;64(8):334-9.
Battistich V, Hom A, (1997). The relationship between students' Sense of their School as a
community and their involvement in problem behaviors, American Journal of Public Health,
87(12):1997-2001.
Battistich, V.; Solomon, D.; Watson, M.; and Schaps, E. Caring school communities.
Educational Psychologist 32(3):137–151, 1997.
Bauman, K.E.; Foshee, V.A.; Ennett, S.T.; Pemberton, M.; Hicks, K.A.; King, T.S.; and Koch,
G.G. The influence of a family program on adolescent tobacco and alcohol. American Journal
of Public Health 91(4):604–610, 2001.
BC Ministry of Education, (1996), Investing In All Our Children: A Handbook of Social Equity
Programs, Victoria, BC.
Beauvais F. (2001). Do school-based drug and alcohol abuse prevention programs work in
American Indian communities? In: Trimble JE ; Beauvais F (eds.). Health Promotion ad
Substance Abuse revention Among American Indian and Alaska Native Communities: Issues
In Cultural Competence. (CSAP Cultural Competence Series 9.) Rockville: Center for
Substance Abuse Prevention, pp. 203-214. (ADAI bk) HV 5824 E85 O44 v.9.
Beauvais, F.; Chavez, E.; Oetting, E.; Deffenbacher, J.; and Cornell, G. Drug use, violence, and
victimization among White American, Mexican American, and American Indian dropouts,
students with academic problems, and students in good academic standing. Journal of
Counseling Psychology 43:292–299, 1996.
214
215
Beck J. (1998). 100 years of "just say no" versus "just say know". Reevaluating drug education
goals for the coming century. Eval Rev. Feb;22(1):15-45.
Becker BJ. (1997). Meta-analysis and models of substance abuse prevention, Found in William
J. Bukoski, Meta-Analysis of Drug Abuse Prevention Programs NIDA Research Monograph
170. U.S. Department of Health and Human Services. National Institutes of Health, National
Institute on Drug Abuse.
Becker MH. (1974). The health belief model and personal health behavior. Health Education
Monographs, 2:324-473.
Bell B, Joly K. (1997). Health Promotion in Canada: A Case Study, Ottawa. Ottawa, ON:
Health Canada.
Bell RM, Ellickson PL, Harrison ER. (1993). Do drug prevention effects persist into high
school? How project ALERT did with ninth graders. Prev Med, 22:463-483. (ADAI rp 06228) .
Bellis MA, Hughes K, Lowey H. (2002). Healthy nightclubs and recreational substance use.
From a harm minimisation to a healthy settings approach. Addict Behav. Nov-Dec;27(6):1025-
35.
Benard, Bonnie. (1991). Fostering resiliency in kids : Protective Factors in the Family, School,
and Community. Portland, OR : Northwest Regional Educational Laboratory, August. 27 p.
[BF 723 R46 B4 1991].
Berkovitz IH, Sinclair E. (2001). Training programs in school consultation. Child Adolesc
Psychiatr Clin N Am. 2001 Jan;10(1):83-92.
Berman S. (1997). Children‘s social consciousness and the development
of social responsibility. (SUNY series: Democracy and education). Albany, NY: State
University of New York.
Beyers J (2001) The effectiveness of health promotion interventions in the workplace.
Hamilton, ON, Effective Public Health Practice Program.
Billig S. (2000). The impact of service learning on youth, schools, and communities: research
on K-12 school-based service learning, 1990-1999. Available
from:http://www.learningindeed.org/research/slreseaerch/slrschsy.html.
Birch DA, Duplaga C, Seabert DM, Wilbur KM. (2001). What do master teachers consider
important in professional preparation for school health education. J Sch Health. Feb;71(2):56-
60.
Black DR, Tobler NS, Sciacca JP. (1998). Peer helping/involvement: an efficacious way to
meet the challenge of reducing alcohol, tobacco, and other drug use among youth? J Sch
Health. Mar;68(3):87-93.
Blaze-Temple D, Lo SK. (1992). Stages of drug use. A community survey of Perth teenagers.
British Journal of Addictions, 87(2):215-25.
Blum RW, Beuhring T, Wunderlich M, Resnick MD, (1996), Don't ask, They won't well: The
215
216
quality of adolescent health screening in five practice settings. American Journal of Public
Health, 86(12):1767-1772.
Bodgen JF. (2003). How Schools Work and How to Work with Schools. A Primer for
Professionals Who Serve Children and Youth. Alexandria, VA:National Association of State
Boards of Education. http://www.nasbe.org.
Bond L, Thomas L, Coffey C, Glover S, Butler H, Carlin JB, Patton G. (2004). Long-term
impact of the Gatehouse Project on cannabis use of 16-year-olds in Australia. J Sch Health.
Jan;74(1):23-9.
Bond L, Glover S, Godfrey C, Butler H, Patton GC. (2001). Building capacity for system-level
change in schools: Lessons from the Gatehouse Project. Health Education & Behavior, 28(3).
Bonomo Y, Bowes G. (2001). Putting harm reduction into an adolescent context. J Paediatr
Child Health. Feb;37(1):5-8.
Bosker & Scheerens. (1994). Alternative models of school effectiveness put to the test.
International Journal of Educational Research. 21, 159-180.
Bosworth K, Yoast R. (1991). DIADS: computer-based system for development of school drug
prevention programs. J Drug Educ. 21(3):231-45. (ADAI jl).
Bosworth K. (1998). Assessment of drug abuse prevention curricula developed at the local
level. J Drug Educ. 28(4):307-25.
Botvin GJ, Botvin EM. (1992). School-based and community-based prevention approaches. In:
Lowinson JH, Ruiz P, Millman RB, Langrod JG. (eds.) Substance Abuse: A Comprehensive
Textbook. (2nd edition) Baltimore : Williams & Wilkins, pp.910-927. (ADAI bk) RC 564 S826
1992 [REF HAND]
Botvin GJ, Botvin EM Ruchlin H (1998) School-Based Approaches to Drug Abuse Prevention:
Evidence for Effectiveness and Suggestions for Determining Cost-Effectiveness. Cost-
Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implications for Programming
and Policy NIDA Research Monograph, Number 176
Botvin GJ, Epstein Jam, Baker E, Diaz T, Ifill-Williams M. (1997). School-based drug abuse
prevention with inner-city minority youth. J Child Adolesc Subst Abuse 6(1):5-19. (ADAI jl).
Botvin GJ, Baker E, Dusenbury L, Tortu S, Botvin EM (1990). Preventing adolescent drug
abuse through a multimodal cognitive-behavioral approach: results of a 3-year study. J Consult
Clin Psychol. Aug;58(4):437-46.
Botvin GJ, Botvin EM, Ruchlin H. (1998). School-based approaches to drug abuse prevention:
evidence for effectiveness and suggestions for determining cost-effectiveness, found in William
J. Bukoski, Ph.D.,Richard I. Evans, Ph.D. (Eds). Cost-Benefit/Cost-Effectiveness Research of
Drug Abuse Prevention: Implications for Programming and Policy, NIDA Research
Monograph 176. U.S. Department of Health and Human Services, National Institutes of Health.
Botvin GJ, Griffin KW, Diaz T, Ifill-Williams M. (2001). Drug abuse prevention among
minority adolescents: post-test and one-year follow-up of a school-based preventive
intervention. Prev Sci. Mar;2(1):1-13.
216
217
Botvin GJ, Griffin KW, Diaz T, Ifill-Williams M. (2001). Preventing binge drinking during
early adolescence: one- and two-year follow-up of a school-based preventive intervention.
Psychol Addict Behav Dec;15(4):360-5. (ADAI jl).
Botvin GJ, Griffin KW, Diaz T, Scheier LM, Williams C, Epstein JA. (2000). Preventing illicit
drug use in adolescents: long-term follow-up data from a randomized control trial of a school
population. Addict Behav. Sep-Oct;25(5):769-74.
Botvin GJ, Griffin KW. (2002). Life skills training as a primary prevention approach for
adolescent drug abuse and other problem behaviors. Int J Emerg Ment Health. Winter;4(1):41-
7.
Botvin GJ, Schinke SP, Orlandi MA. (1989). Psychosocial approaches to substance abuse
prevention: theoretical foundations and empirical findings Crisis. Apr;10(1):62-77.
Botvin GJ. (1995). Drug abuse prevention in school settings. In: Botvin GJ, Schinke SP,
Orlandi MA. (eds.) Drug Abuse Prevention with Multiethnic Youth. Thousand Oaks, CA:
SAGE Publications, pp. 169-192. (ADAI bk) HV 5824 Y68 D7713 1995.
Botvin GJ. (2000). Preventing drug abuse in schools: social and competence enhancement
approaches targeting individual-level etiologic factors. Addict Behav. Nov-Dec;25(6):887-97.
Botvin GJ.(1996). Preventing drug abuse through the schools: Intervention programs that work.
In: National Conference on Drug Abuse Prevention Research, September 19-20, Washington
DC.
Botvin, G.; Baker, E.; Dusenbury, L.; Botvin, E.; and Diaz, T. Long-term follow-up results of a
randomized drug-abuse prevention trial in a white middle class population. Journal of the
American Medical Association 273:1106–1112, 1995.
Boyce W, Doherty M, Fortin C, MacKinnon D. (2004.) Canadian Youth, Sexual
Health and HIV/AIDS Study. Toronto, ON: Council of Ministers of Education,
Canada.
Bradley BJ. (1997). The school nurse as health educator. J Sch Health. Jan;67(1):3-8.
Brener ND, Everett Jones S, Kann L, McManus T. (2003). Variation in school health policies
and programs by demographic characteristics of US schools. J Sch Health. Apr;73(4):143-9.
Brenman AJ. (1989). The Influence of Health Belief on Eating Behaviour in Children and
Adolscents, Harvard University Press.
Broadfoot P. (1994). Teachers and educational reforms: Teachers' response to policy changes in
England and France, Paper presented to the Annual Meeting of the British Educational
Research Association. Oxford, England, Sept 8-11,1994, ED380463.
Brock GC, Beazley RP. (1995). Using the health belief model to explain parents‘ participation
in adolescent at-home sexuality education activities. Journal of School Health, 65(4):124-126.
Brown JH. (2001). Youth, drugs and resilience education. J Drug Educ. 31(1):83-122.
Brown JH, D‘Emedio-Caston M, Pollard J. (1997). Students and substances: Social power in
drug education, Educational Evaluation and 217Policy Analysis, 19 (1): 65-82.
218
Bruvold WH. (1990). A meta-analysis of the California school-based risk reduction program. J
Drug Educ. 20(2):139-52.
Bullock LF, Libbus MK, Lewis S, Gayer D. (2002). Continuing education: improving
perceived competence in school nurses. J Sch Nurs. Dec;18(6):360-3.
Burger MC, Spickard WA. (1991). Integrating substance abuse education in the medical
student curriculum. Am J Med Sci. Sep;302(3):181-4.
Bynum AB, Cranford CO, Irwin CA, Denny GS. (2002). Participant satisfaction with a school
telehealth education program using interactive compressed video delivery methods in rural
Arkansas. J Sch Health. Aug;72(6):235-42.
Calvert M, Zeldin S, Weisenbach A. (2002). Youth Involvement for Community,
Organizational and Youth Development: Directions for Research, Evaluation and Practice 2002
University of Wisconsin-Madison and Innovation Center for Community and Youth
Development/Tides Center.
http://www.atthetable.org/images/Details/04260214593275_At%20the%20Table%20Research
%20Agenda%20-%20FINAL.pdf
Cameron R, Brown KS, Best JA, Pelkman CL, Madill CL, Manske SR, Payne ME. (1999).
Effectiveness of a social influences smoking prevention program as a function of provider type,
training method, and school risk. Am J Public Health Dec;89(12):1827-31. (ADAI jl).
Camiletti, Y, Huffman, MC. (1998). Research utilization: evaluation of initiatives in a public
health nursing division. Canadian Journal of Nursing Administration, 11, 59-77.
Canadian Association for School Health, (1995). Selected Case Studies of Youth Involvement
in Public Decision-Making. Final Report, Surrey, BC.
Canadian Association for School Health. (1996). Reducing Tobacco Use, Promoting Health:
Informing, Educating, Involving and Empowering Parents Through Schools. Surrey, BC:
Author.
Canadian Association for School Health. (1991). Comprehensive School Health: A National
Consensus Statement. Surrey, BC: Author.
Canadian Association for School Health. (1992). Making the Connections: Comprehensive
School Health. Surry, BC: Author.
Canadian Association for School Health (1992), Working With Parents: Training, Supporting
and Empowering. Some Evidence and Issues, Canadian Association for School Health, Surrey,
BC.
Canadian Association for School Health. (1997). Food for thought: Schools and nutrition. The
CAP Journal, 7(1), 11-14.
Canadian Association of Principals, Canadian Association of School Administrators, Canadian
Association for School Health, (1996), Reducing Tobacco Use, Promoting Health. Teaching
Strategies and Resources. Surrey, BC: Canadian Association for School Health.
Canadian Association of School Administrators. (1992), Peer Helper
218
219
Programs. Surrey, BC: Shannon & McCall Consulting.
Canadian Association of School Administrators. (1990). AIDS/ HIV Education: Developing
Policies and School-community Partnerships. Oakville, ON: Canadian Association of School
Administrators.
Canadian Cancer Society. (1995). A Comprehensive School and Community Approach to
Preventing and Reducing Tobacco Use Among Youth: Strategic Project Planning Guide,
Toronto, ON.
Canadian Public Health Association. (1990). Community Health - Public Health Nursing in
Canada. Preparation & Practice. Ottawa, ON.
Capper SA, Duncan WJ, Ginter PM, Barganier C, Blough N, Cleaveland P. (1996). Translating
public health research into public health practice outcomes and characteristics of successful
collaborations. American Journal of Preventive Medicine, 12(4 Suppl):67-70.
Caputo T, Weiler R, Anderson J. (1997). The Street Lifestyle Study. Ottawa, ON: Office of
Alcohol, Drugs and Dependency Issues, Health Canada.
Caputo T, Weiler R, Green L. (1996). Peer Helper Initiatives For Out of the Mainstreaming
Youth. Ottawa, ON: Health Canada.
Carlini-Cotrim B, de Carvalho VA. (1993). Extracurricular activities: are they an effective
strategy against drug consumption? J Drug Educ. 23(1):97-104.
Carnegie Corporation on Adolescent Development, (1992). Task Force on Youth Development
and Community Programs, New York, NY:Carnegie Council on Adolescent Development
.
Carnegie Council on Adolescent Development. (1989). Turning Points: Preparing American
Youth for the 21st Century, report of the Task Force on Education of Youth Adolescents.
Carr R. (1996). Mobilizing Peer Resources to Assist in Tobacco Reduction. Ottawa, ON:
Tobacco Reduction Program, Health Canada.
Carroll JJ. (2000). Counseling students' conceptions of substance dependence and related initial
interventions. J Addict Offender Counseling 20(2):84-92. (ADAI jl).
Cassidy CA. (1997). Facilitating behavior change. Use of the trans-theoretical model in the
occupational health setting. AAOHN Journal, 45(5):239-46.
Catalano RF, Hawkins JD, Berglund ML, Pollard JA, Arthur MW. (2002). Prevention science
and positive youth development: competitive or cooperative frameworks? J Adolesc Health.
Dec;31(6 Suppl):230-9.
Catania JA et al. (1990). Towards an understanding of risk behaviour: An AIDS risk reduction
model. Health Education Quarterly; 17(1): 53-72.
Caulkins J, Pacula J, Paddock S, Chiesa JR (2002) School-Based Drug Prevention: What Kind
of Drug Use Does It Prevent? Santa Monica, CA, RAND Corporation,
http://www.rand.org/publications/MR/MR1459/index.html
Caulkins Jonathan P, Rydell C Peter, Everingham Susan S, Chiesa James,
219
220
Bushway Shawn. (1999), An Ounce of prevention, a pound of uncertainty : The cost-
effectiveness of school-based drug prevention programs. (MR-923-RWJ) Santa Monica, CA :
RAND Drug Policy Research Center, xxxiii, 194 p. [HV 5824 Y68 C22 1999].
Center for Media Education. (1998). Alcohol Advertising Targeted At Youth on the Internet:
An Update. Author. http://tap.epn.org/cem/981218/alcrep.html.
Center for Mental Health Services. (2000). Addressing Barriers to Student Learning &
Promoting Healthy Development: A Usable Research-Base. November. Substance Abuse and
Mental Health Services Administration.
Center for Substance Abuse Prevention. (1997). Division of Knowledge Development and
Evaluation. Selected Findings in Prevention: A Decade of Results from the Center for
Substance Abuse Prevention (CSAP). (DHHS Publication No. (SMA) 97-3143) [Rockville]:
Center for Substance Abuse Prevention, ix, 63 p. [HV 5825 C39 1997].
Center for Substance Abuse Prevention. (1999). Youth popular culture: What we need to know.
Technical Assistance Bulletin. Washington, DC: Substance Abuse and Mental Health Services
Administration, US Department of Health and Human Services.
Center for Substance Abuse Prevention. (nd). Integrating Knowledge About Youth Popular
Culture Into Substance Abuse Prevention Communications. Washington, DC: Author.
Centers for Disease Control. (1994). Guidelines for school health programs to prevent tobacco
use and addiction. J School Health 64(9):353-360. (ADAI rp 06862).
Centre for Addiction and Mental Health. (1999). Alcohol and Drug Prevention Programs for
Youth: What Works? Toronto, ON: Author.
Centers for Disease Control. (2001). School Health Policies and Programs Study 2000. Journal
of School Health Supplement. volume 71, number 7, September.
Centers for Disease Control and Prevention. (2003). Promising Practices in Chronic Disease
Prevention and Control. Atlanta GA: CDCP.
Centers for Disease Control. (2003). Building a Healthier Future through School Health
Programs. Atlanta, GA: Author,
http://www.cdc.gov/nccdphp/promising_practices/pdfs/SchoolHealth.pdf.
Centre for Health Promotion. (1998). Overview of Health Communication Campaigns, 104.
Toronto, ON: University of Toronto.
Centre of Excellence for Youth Engagement. (2003). Youth Engagement and Health
Outcomes: Is There A Link? Review of Research Literature Linking Youth Engagement and
Health Outcomes. http://www.engagementcentre.ca/litrev2.htm.
Centre on Addictions and Mental Health. (1999). Alcohol and drug prevention programs for
youth: What works? Best Advice. Toronto, ON: Author.
Chatterji P, Caffray CM, Jones AS, Lillie-Blanton M, Werthamer L. (2001). Applying cost
analysis methods to school-based prevention programs. Prev Sci. Mar;2(1):45-55.
Chen K, Kendal DB. (1995). The natural history of drug use from adolescence to the mid-
thirties in a general population sample. American Journal of Public Health, 85:41-47.
220
221
Chen WW. (1991). A comparison of self-reported health education competencies among
selected school health educators in the United States and Taiwan, R.O.C. J Sch Health.
Mar;61(3):127-30.
Chomik TA. (2001). The Population Health Template: Key Elements and Actions That Define
A Population Health Approach, Strategic Policy Directorate, Population and Public Health
Branch, Health Canada http://www.hc-sc.gc.ca/hppb/phdd/pdf/discussion_paper.pdf.
Chou SP, Pickering RP, (1992). Early onset of drinking as a risk factor for lifetime alcohol-
related problems. British Journal of Addictions, 87(8):1199-1204.
Chou, C.; Montgomery, S.; Pentz, M.; Rohrbach, L.; Johnson, C.; Flay, B.; and Mackinnon, D.
Effects of a community-based prevention program in decreasing drug use in high-risk
adolescents. American Journal of Public Health 88:944–948, 1998.
Christenson CL. Havsy LH.( 2003). Family-school-peer relationships: significance for social,
emotional, and academic learning. In: Zins JE, et al., eds. Building School Success on Social
and Emotional Learning. New York, NY: Teachers College Press.
Cliska D (2001) Peer Health Promotion Interventions for Youth Hamilton, ON, Effective
Public Health Practice Program.
Ciliska D, Hayward S, Dobbins M, Brunton G, & Underwood J. (1999). Transferring public
health nursing research to health system planning: assessing the relevance and accessibility of
systematic reviews. Canadian Journal of Public Health, 31, 23-36.
Clapper RL, Lipsitt LP. (1992). Young heavy drinkers and their drinking experience. Predictors
of later alcohol use. International Journal on Addictions, 27(10):1211-21.
Cloetta B, Bisegger C. (2000). Differential learning effects in preventive drug education by
peer group members Soz. Praventivmed. 45(1):52-9.
Cochrane Reviewers Handbook 4.1.4. (2001). In M.Clarke & A. D. Oxman (Eds.), The
Cochrane Library. Oxford: Update Software.
Cocking L (2002) The effectiveness of school social work from a risk and resilience
perspective, Hamilton, ON, Effective Public Health Practice Program.
Cohen J., ed. (1999). Educating Minds and Hearts: Social Emotional Learning and the Passage
into Adolescence. New York, NY: Teachers College Press.
Coleman J. (1990). Foundations of social theory, Cambridge, MA: Harvard University Press.
Coleman P, Collinge J, Tabin Y. (1995). The coproduction of learning: Improving schools from
the inside out. In B. Levin, W.J. Fowler & H.L. Walberg (Eds.), Advances in Educational
Productivity: Vol. 5: Organizational Influences on Educational Productivity (pp. 141-174).
Greenwich CT: JAI Press.
Collaborative for Academic, Social, and Emotional Learning. (2002). Safe and Sound: An
Educational Leader‘s Guide to Evidence Based Social and Emotional Learning Programs.
Chicago, I: Author.
221
222
Comer J P., et al., eds. (1999). Child by Child: the Comer Process for Change in Education.
New York, NY: Teachers College Press.
Conduct Problems Prevention Research Group. Predictor variables associated with positive
Fast Track outcomes at the end of third grade. Journal of Abnormal Child Psychology
30(1):37–52, 2002.
Connell DB., et al. (1986). School health education evaluation. International Journal of
Educational Research. vol. 10, p. 245–345. Tarrytown, NY.
Cooke, D. (2001) It‘s All About Improvement Ontario Task Force on Effective Schools,
http://www.saee.bc.ca/2002_1_3.html.
Coleman EA, Honeycutt G, Ogden B, McMillan DE, O'Sullivan PS, Light K, Wingfield W.
(1997). Assessing substance abuse among health care students and the efficacy of educational
interventions. J Prof Nurs 13:28-37. (ADAI rp 07462).
Collingwood TR, Sunderlin J, Reynolds R, Kohl HW 3rd. (2000). Physical training as a
substance abuse prevention intervention for youth. J Drug Educ. 30(4):435-51.
Collins D, Cellucci T. (1991). Effects of a school-based alcohol education program with a
media prevention component. Psychol Rep 69:191-7. (ADAI rp 05004).
Connell D et al. (1985). Summary of findings of the school health education evaluation: Health
promotion effectiveness, implementation and costs. Journal of School Health, 55(8).
Connell DB, Turner RR. (1985). School health education evaluation. The impact of
instructional experience and the effects of cumulative instruction. J Sch Health. Oct;55(8):324-
31.
Consortium for Policy Research in Education. (1996). Public Policy and School Reform: A
Research Summary, ERIC Clearinghouse in Assessment and Evaluation, ED399625.
Contento IR. (1991), Skiss, and attitudes: Measurement issues", Journal of School Health,
61(5):208-211.
Corvo K, Persse L. (1998). An evaluation of a pre-school based prevention program:
longitudinal effects on children's alcohol-related expectancies. J Alcohol Drug Educ 43(2):36-
47. (ADAI jl).
Costa FM, Jessor R, Turbin MS. (1999). Transition into adolescent problem drinking. The role
of psychological risk and protective factors. Journal of Studies on Alcohol, 60(4):480-90.
Costello-Wells B, McFarland L, Reed J, Walton K. (2003). School-based mental health clinics.
J Child Adolesc Psychiatr Nurs. Apr-Jun;16(2):60-70.
Covello Vincent. (1995), Risk perception and communication. Canadian Journal of Public
Health, 86(2):78-9.
Crichton A. (1981). Health policy-making: Fundamental issues in the US, Canada, Great
Britain, and Australia, Ann Arbor, MI: Health Administration Press.
222
223
Crighton JV. (1987). School district policy guide, Vancouver, BC: British Columbia School
Trustees‘ Association.
Crockett SJ, Mullis RM, Perry CL. (1987). Parent nutrition education: A conceptual model.
Journal of School Health,58(2):53-57.
Cuijpers P. (2002). Effective ingredients of school-based drug prevention programs. A
systematic review. Addict Behav. Nov-Dec;27(6):1009-23.
Cuijpers P. (2002). Peer-led and adult-led school drug prevention: a meta-analytic comparison.
J Drug Educ. 32(2):107-19.
Cuijpers P, Jonkers R, de WI, de JA. (2002). The effects of drug abuse prevention at school:
The 'Healthy School and Drugs' project. Addiction. Jan;97(1):67-73.
Cuijpers P. (2002) Peer-led and adult-led school drug prevention: a meta-analytic comparison. J
Drug Educ. 32(2):107-19. (ADAI jl).
Cuijpers P, Jonkers R, de WI, de JA. (2002). The effects of drug abuse prevention at school: the
'Healthy School and Drugs' project. Addiction. Jan;97(1):67-73.
Cunningham PB, Henggeler SW. (2001). Implementation of an empirically based drug and
violence prevention and intervention program in public school settings. J Clin Child Psychol.
Jun;30(2):221-32.
D‘Emidio-Caston M, Brown JH. (1998). The other side of the story. Student narratives on the
California drug, alcohol and tobacco education programs. Evaluation Review, 22(1):95-117.
Davis M. (2003). Addressing the needs of youth in transition to adulthood. Adm Policy Ment
Health. Jul;30(6):495-509.
Day D. (1990). Young Women in Nova Scotia: A Study of Attitudes, Behaviour and
Aspirations. Halifax, Nova Scotia: Advisory Council on the Status of Women.
Dembra R, Pilaro L, Burgos W, DesJarlais DC, Schmeidler J. (1979). Self-concept and drug
involvement among urban junior high school youths. International Journal of Addiction,
14(8):1125-44.
Dembo MH et al (1985), "An Evaluation of Group Parent Education: Behavioural, PET and
Adlerian Programs", Review of Education Research, 55(2), 155-200.
Dent CW, Sussman S, Hennesy M, Galaif ER, Stacy AW, Moss M, Craig S. (1998).
Implementation and process evaluation of a school-based drug abuse prevention program:
Project towards no drug abuse. J Drug Educ. 28(4):361-75. (ADAI jl).
Dent CW, Sussman S, Stacy AW. (2001). Project towards no drug abuse: Generalizability to a
general high school sample. Prev Med. Jun;32(6):514-20.
Derzon JH, Wilson SJ, Cunningham CA. (2002). The Effectiveness of School-based
Interventions for Preventing and Reducing Violence. Center for Evaluation Research and
Methodology, Vanderbilt University 1999; 182 p. http://harmfish.org/pub/arss99sd.pdf.
DeVries H, Backbier E, Dijkstra M, VanBreukelen G, Parcel G, Kok G. (1994). A
223
224
Dutch social influence smoking prevention approach for vocational school students. Health
Educ Res 9(3):365-374. (ADAI rp 06667).
Dewalf MW. (1992). The Relationship Between Youth Group Paarticipation and the Use of
Tobacco and Drugs. Paper presented at the Annual Meeting of the American Educational
Research Association. San Francisco, CA. April 20-24.
Dewit D, Akst L, Braun K, Lefebrve L, McKee C, Rye BJ, Shain M, (2002). Sense of School
Membership: A Mediating Mechanism Linking Student Perceptions of School Culture with
Academic and Behavioural Functioning, Toronto, ON: Centre for Addiction and Mental
Health.
DeWit D, Offord DR, Wong M. (1997). Patterns of onset and cessation of drug use over the
early part of the life course. Health Education and Behaviour, 24:746-758.
DeWit DJ, Braunk, Steep B, Ellis K, Rye BJ, Silverman G, Smythe C, Stevens-Lavigne A.
(1997). Evaluation of an In-School Drug Prevention Program for At-Risk Youth. Toronto, ON:
Centre on Addications and Mental Health.
Dielman TE, Kloska DD, Leech SL, Schulenberg JE, Shope JT. (1992). Susceptibility to peer
pressure as an explanatory variable for the differential effectiveness of an alcohol misuse
prevention program in elementary schools. J Sch Health. 62(6):233-237. (ADAI rp 05562).
Diez Roux AV. (2002). Invited commentary: Places, people, and health. American Journal of
Epidemiology, Vol. 155, No. 6, 516.
Dignan M, Block G, Skeckler A, Howard G, Cosby M. (1986). Locus of control and smokeless
tobacco use among adolescents. Adolescence, 21(8):388-81.
Dijkstra M, DeVries H, Parcel GS. (1993). The linkage approach applied to a school-based
smoking prevention program in the Netherlands. J School Health. 63(8):339-342. (ADAI rp
06668).
DiLorenzo TM, WeltonGL, McCalla TL, Finer WW, Brownson RC, Van Tuinen M. (1991).
Underestimates of student substance use by school personnel: A cause for concern? Journal of
Behavioral Medicine, 14(4):397-407.
Dishion TJ, Kavanagh K, Schneiger A, Nelson S, Kaufman NK. (2002).Preventing early
adolescent substance use: a family-centered strategy for the public middle school. Prev Sci.
Sep;3(3):191-201.
Dishion TJ, Kavanagh K. (2000). A multilevel approach to family-centered prevention in
schools: process and outcome. Addict Behav. Nov-Dec;25(6):899-911. (ADAI jl).
Dishion, T.; McCord, J.; and Poulin, F. When interventions harm: Peer groups and problem
behavior. American Psychologist 54:755-764, 1999.
Dobbins M, Lockett D, Michel I, Beyers J, Feldman L, Vobra J, Micucci S. (2001). The
Effectiveness of School-based Interventions in Promoting Physical Activity and Fitness Among
Children and Youth. A Systematic Review, Effective Public Health Practive Project, Public
Health Research, Education and Development Program. Hamilton, ON.
Donahew L, Lorch E, Palmgreen P. (1991). Sensation seeking and targeting of televised
224
225
anti-drug PSA‘s . In L. Donahew, HE Sypher & WJ Bukeski, eds., Persuasive Communications
and Drug Abuse Prevention, 209-226. Hillside, NJ: Erlbaum.
Donaldson SI, Graham JW, Hansen WB. (1994). Testing the generalizability of intervening
mechanism theories: understanding the effects of adolescent drug use prevention interventions.
J Behav Med. Apr;17(2):195-216.
Donaldson SI, Thomas CW, Graham JW, Au JG, Hansen WB. (2000). Verifying drug abuse
prevention program effects using reciprocal best friend reports. J Behav Med. Dec;23(6):585-
601.
Donnermeyer JF. (2000) Parents' perceptions of a school-based prevention education program.
J Drug Educ. 30(3):325-42.
Dryfoos JG, Brindis C, Kaplan DW. (1996). Research and evaluation in school-based health
care. Adolesc Med. Jun;7(2):207-220.
Duncan DF, Nicholson T, Clifford P, Hawkins W, Petosa R. (1994). Harm reduction: an
emerging new paradigm for drug education. J Drug Educ. 24(4):281-90.
DuPont RL. (1998). Addiction. A new paradigm. Bulletin of the Menniger Clinic, 62(2):231-
42. Rockville, MD: Institute for Behavior and Health.
Durlak JA, Wells AM. (1997). Primary prevention mental health programs for children and
adolescents: a meta-analytic review. Am J Community Psychol. Apr;25(2):115-52.
Dusenburg L, Botvin GJ. (1992). Substance abuse prevention. Competence enhancement and
the development of positive life options. Journal of Addictions and Disorder, 11(3):29-45.
Dusenbury L, Brannigan R, Falco M, Hansen WB. (2003). A review of research on fidelity of
implementation: implications for drug abuse prevention in school settings. Health Educ Res.
Apr;18(2):237-56.
Dusenbury L, Falco M, Lake A. (1997). A review of the evaluation of 47 drug abuse prevention
curricula available nationally. J Sch Health. Apr;67(4):127-32.
Dusenbury L, Falco M. (1995). Eleven components of effective drug abuse prevention
curricula. J Sch Health. Dec;65(10):420-5.
Dusenbury LA, Hansen WB, Giles SM. (2003). Teacher training in norm setting approaches to
drug education: a pilot study comparing standard and video-enhanced methods. J Drug Educ.
33(3):325-36.
Early TJ, Vonk ME (2001) Effectiveness of School Social Work from a Risk and Resilience
Perspective. Social Work in Education, 23(1): 9-31
Edmundson E, Parcel GS, Feldman HA, Elder J, Perry CL, Johnson CC, Williston BJ, Stone
EJ, Yang M, Lytle L, Webber L. (1996). The effects of the Child and Adolescent Trial for
Cardiovascular Health upon psychosocial determinants of diet and physical activity behavior.
Journal of Preventive Medicine, Jul-Aug;25(4):442-54.
Effective Public Health Practice Project. (2001). The Effectiveness of the Health Promoting
225
226
Schools Approach and School-based Health Promotion Interventions Public Health Research
Education, Hamilton, ON.
Effective Public Health Practice Project (2001) The Effectiveness of the Health Promoting
Schools Approach and School-based Health Promotion Interventions Public Health Research
Education, Hamilton, ON.
Effective Public Health Practice Project (2003).
http://www.hamilton.ca/PHCS/EPHPP/default.asp.
Eggert IL, Herting JR, Thompson EA. (1996). The drug involvement scale for adolescents
(DISA). Journal of Drug Education, 26(2):101-30.
Eise M, Zellman GL, Massett HA, Murray DM. (2002). Evaluating the Lions-Quest "Skills for
Adolescence" drug education program: first-year behavior outcomes. Addict Behav. Jul-
Aug;27(4):619-32.
Eisen M, Zellman GL, Murray DM. (2003). Evaluating the Lions-Quest "Skills for
Adolescence" drug education program. Second-year behavior outcomes. Addict Behav.
Jul;28(5):883-97.
Elias MJ. (2003). Academic and Social-Emotional Learning. Educational Practices Series.
Geneva, Switzerland: International Bureau of Education, Publications Unit.
http://www.ibe.unesco.org/International/Publications/EducationalPractices/EducationalPractice
sSeriesPdf/prac11e.pdf.
Elias MJ, et al. (1997). Promoting Social and Emotional Learning: Guidelines for Educators.
Alexandria, VA: Association for Supervision and Curriculum Development.
Elias MJ, Gara MA, Schuyler TF, Branden-Muller LR, Sayette MA. (1991). The promotion of
social competence: longitudinal study of a preventive school-based program. Am J
Orthopsychiatry. Jul;61(3):409-17.
Elias MJ, Kress JS, Gager PJ, Hancock ME. (1994). Adolescent health promotion and risk
reduction: cementing the social contract between pediatricians and the schools. Bull N Y Acad
Med. 1994 Summer;71(1):87-110.
Elias MJ, Tobias SE. (1996). Social Problem Solving Interventions in the Schools: curriculum
materials for educators. Distributed by National Professional Resources: www.nprinc.com.
Elias MJ, Tobias SE, Friedlander BS. (2000). Emotionally Intelligent Parenting: How to Raise
a Self-disciplined, Responsible, Socially Skilled Child. New York, NY: Random House/Three
Rivers Press.
Elias MJ, Weissberg RP. (2000). Primary prevention: educational approaches to enhance social
and emotional learning. J Sch Health. May;70(5):186-90.
Ellickson PL, Bell RM, Harrison ER (1993). Changing adolescent propensities to use drugs:
results from Project ALERT. Health Educ Q. Summer;20(2):227-42.
Ellickson PL, McCaffrey DF, Ghosh-Dastidar B, Longshore DL. (2003). New inroads in
preventing adolescent drug use: results from a large-scale trial of project ALERT in middle
schools. Am J Public Health. Nov;93(11):1830-6.
Emshoff JG, Price AW. (1999). Prevention and intervention strategies with children of
226
227
alcoholics. Pediatrics. May;103(5 Pt 2):1112-21.
Ennett ST, Ringwalt CL, Thorne J, Rohrbach LA, Vincus A, Simons-Rudolph A, Jones S.
(2003). A comparison of current practice in school-based substance use prevention programs
with meta-analysis findings. Prev Sci. Mar;4(1):1-14.
Ennett ST, Tobler NS, Ringwalt CL, Flewelling RL. (1994). How effective is drug abuse
resistance education? A meta-analysis of Project DARE outcome evaluations. Am J Public
Health. Sep;84(9):1394-401.
Epling JW, Morrow CB, Sutphen SM, Novick LF. (2003). Case-based teaching in preventive
medicine: rationale, development, and implementation. Am J Prev Med. May;24(4 Suppl):85-9.
Epstein JL. (2001). School, Family, and Community Partnerships: Preparing Educators and
Improving Schools. Boulder, CO: Westview Press.
Epstein JA, Griffin KW, Botvin GJ. (2000). Role of general and specific competence skills in
protecting inner-city adolescents from alcohol use. J Stud Alcohol. May;61(3):379-86.
Erickson PG. (1999). Introduction: the three phases of harm reduction. An examination of
emerging concepts, methodologies, and critiques. Subst Use Misuse. Jan;34(1):1-7.
Erickson F, Schultz J. (1992). Students‘ experience of the curriculum. In P. Jackson (Ed.),
Handbook of Research on Curriculum (pp. 465-485). New York: Macmillan.
Farel A, Umble K, Polhamus B. (2001). Impact of an online analytic skills course. Eval Health
Prof. Dec;24(4):446-59.
Federal-Provincial-Territorial Council on Social Policy Renewal. (1999). Appendix b:
Developmental stages and environmental influences. A National Children‘s Agenda:
Developing a Shared Vision. Ottawa, ON: Government of Canada.
Feldman L, Harvey B, Holowatz P, Shortt L. (1999). Alcohol beliefs and behaviours among
high school students. Journal of Adolescent Health, 24(1):48-58.
Fernandez S, Nebot M, Jane M. (2002). The evaluation of effectiveness of scholastic programs
in the prevention of consumption of tobacco, alcohol and cannabis: what do meta-analyses tell
us? Rev Esp Salud Publica. May-Jun;76(3):175-87.
Fertman CI, Fichter C, Schlesinger J, Tarasevich S, Wald H, Zhang X. (2001). Evaluating the
effectiveness of student assistance programs in Pennsylvania. J Drug Educ. 31(4):353-66.
Fetro et al. (1989). Formative evaluation of classroom implementation and immediate impact of
AIDS education. Paper presented to 65th Annula Conference of the American School Health
Association.
Fetterman DM, Kaftarian SJ, Wandersman A. (1996). Empowerment evaluation: knowledge
and tools for self-assessment and accountability. Newbury Park, CA: Sage.
Finke L, Williams J, Ritter M, Kemper D, Kersey S, Nightenhauser J, Autry K, Going C,
Wulfman G, Hail A. (2002). Survival against drugs: education for school-age children. J Child
Adolesc Psychiatr Nurs. Oct-Dec;15(4):163-9.
227
228
Finlay J. (2004). Healthy Schools: The Need for a Pan-Canadian School Health Strategy.
Victoria, BC: BC Ministry of Health Services and Planning.
Fisher WA. (1990). All together now: An integrated approach to preventing adolescent
pregnancy and STD/HIV infection. Part III: Healthy adolescent and sexual development.
SIECUS Report. 18(4):1-11.
Flannery DJ, Torquati J. (1993). An elementary school substance abuse prevention program:
teacher and administrator perspectives. J Drug Educ. 23(4):387-97.
Flay BR. (2002). Positive Youth Development Requires Comprehensive Health Promotion
Programs Newsletter of the American Academy of Health Behaviour. Prepared for acceptance
of the Research Laureate Medallion from the American Academy of Health Behavior, Annual
Conference, Napa, California, March 25th, 2002.
Flay BR ; Koepke D ; Thomson SJ ; Santi S ; Best JA ; Brown KS. (1989). Six-year follow-up
of the first Waterloo school smoking prevention trial. Am J Public Health 79:1371-1376.
(ADAI rp 03845).
Flay BR, Allred CG, Ordway N. (2001). Effects of the Positive Action program on
achievement and discipline: two matched-control comparisons. Prev Sci. Jun;2(2):71-89.
Flay BR. (1985). Psychosocial approaches to smoking prevention. A review of findings. Health
Psychology, 4:449-488.
Flay BR. (1986). Mass media linkages with school-based programs for drug abuse prevention. J
School Health 56(9):402-06. (ADAI bk) HV 5825 C644 1986.
Flay BR. (2000). Approaches to substance use prevention utilizing school curriculum plus
social environment change. Addict Behav. Nov-Dec;25(6):861-85.
Flisher AJ ; Brawn A ; Mukoma W. (2002). Intervening through the school system. In: Miller
WR ; Weisner CM (eds.). Changing Substance Abuse Through Health and Social Systems.
New York : Kluwer Academic / Plenum Publishers, 2002, pp.171-182. (ADAI bk) RC 564
C470 2002.
Flynn BS, Worden JK, Secker-Walker RH, Badger GJ, Geller BM, Costanza MC. (1992).
Prevention of cigarette smoking through mass media intervention and school programs. Am J
Public Health, 82(6):827-834. (ADAI rp 05385).
Fralick PC. (nd). Summary of Youth, Substance Abuse and the Determinants of Health. What
Determines Health? Ottawa, ON: National Forum on Health.
www.nfh.hwc.ca/publicat/execsumm/fralick.htm.
Fromme K, Ruela K. (1994). Mediators and moderators of young adults‘ drinking. Addiction,
89(1):63-71.
France-Dawson M, Holland J, Fullerton D, Kelly P, Arnols S, Oakley A (1994) Review of
effectiveness of workplace health promotion interventions London, GB, Social Science
Research Unit
Frank J, Di Ruggiero E, Moloughney B. (2003). The Future of Public Health in Canada:
Developing a Public Health System for the 21st Century, Institute of Population and
228
229
Public Health, Canadian Institutes of Health Research.
http://www.cpha.ca/coalition/future_e.pdf Accessed on March 7, 2004
Fullan M. (1991). The New Meaning of Educational Change, Toronto, ON: OISE University
Press.
Fullan MJ. (1991). The New Meaning of Education Change. Toronto, ON: OISE Press,
University of Toronto.
Funk RS. (1991). A policymakers checklist. The American School Board Journal, July.
Furr-Holden CD, Ialongo NS, Anthony JC, Petras H, Kellam SG. (2004). Developmentally
inspired drug prevention: middle school outcomes in a school-based randomized prevention
trial. Drug Alcohol Depend. Feb 7;73(2):149-58.
Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. (2000). Utility of psychosocial
screening at a school-based health center. J Sch Health. Sep;70(7):292-8.
Gall GB. (2002). Comprehensive risk assessment for adolescents in school-based health
centers. Nurs Clin North Am. Sep;37(3):553-64.
Gardner H. (2000). Intelligence Reframed: Multiple Intelligences for the21st Century. New
York, NY: Basic Books.
Gatehouse Project. (nd). Project Web Site
http://www.rch.org.au/gatehouseproject/project/theprogram/index.cfm?doc_id=397 .
Geiger BF, Petri CJ, Myers O, Lan J, Binkley D, Aldige CR, Berdebes J. (2002). Using
technology to teach health: a collaborative pilot project in Alabama. J Sch Health.
Dec;72(10):401-7.
Gerstein, D.R.; and Green, L.W., eds.; Preventing Drug Abuse: What Do We Know?
Washington, DC: National Academy Press, 1993.
Giles SM, Harrington NG, Fearnow-Kenney M. (2001). Evaluation of the All Stars Program:
student and teacher factors that influence mediators of substance use. J Drug Educ. 31(4):385-
97.
Gilham SA, Lucas WL, Sivewright D. (1997). The impact of drug education and prevention
programs. Disparity between impressionistic and empirical assessments. Eval Rev.
Oct;21(5):589-613.
Gillmore MR, Wells EA, Simpson EE, Morrison DM, Hoppe MJ, Wilsdon A. (1998).
Children‘s beliefs about drinking. American Journal on Drug and Alcohol Abuse, 24(1):131-
51.
Gingiss PL. (1992). Enhancing program implementation and maintenance through a multiphase
approach to peer-based staff development. J Sch Health. May;62(5):161-6.
Giroux HA. (1997). Channel surfing: Race talk and the destruction of today‘s youth. New
York: St. Martin‘s.
Gliksman L, Allison K, Adlaf E, Newton- Taylor B. (1995). Toward comprehensive
229
230
school drug policy in Ontario. J Drug Educ. 25(2):129-38.
Glynn TJ. (1989). Essential elements of school-based smoking prevention programs. J Sch
Health 59(5):181-8. (ADAI rp 03679).
Goldberg L, Elliot DL, MacKinnon DP, Moe E, Kuehl KS, Nohre L, Lockwood CM. (2003).
Drug testing athletes to prevent substance abuse: background and pilot study results of the
SATURN (Student Athlete Testing Using Random Notification) study. J Adolesc Health.
Jan;32(1):16-25.
Goleman D. (1995). Emotional Intelligence: Why It Can Matter More Than IQ. New York,
NY: Bantam Books.
Golub A, Johnson BD. (1994). The shifting importance of alcohol and marijuana as gateway
substances among serious drug abusers. Journal of Studies on Alcohol, 55:607-14.
Good TL, Wiley AR, Thomas RE, Stweart E, McCoy J, Kloos B, Hunt G.D, Moore T,
Rappaport J. (1997). Bridging the gap between schools and community: Organizing for family
involvement in a low-income neighborhood. Journal of Educational and Psychological
Consultation, 8(3).
Goodlad J. (1984). A Place Called School. New York: McGraw-Hill.
Goodstadt MS, Cook G. Magids S, Gruson V. (1978). The Drug Attitudes Scale (DAS): Its
development and evaluation. International Journal on Addictions, 13(8):1307-17.
Goodstadt MS. (1989). Substance abuse curricula vs. school drug policies. J Sch Health.
Aug;59(6):246-50.
Gordon LV, Haynes DK, (1982). Parental participation in nutrition education homework.
Journal of American Dietetic Association, Oct;81(4):445-8.
Gorman DM. (1995). Are school-based resistance skills training programs effective in
preventing alcohol misuse? J Alcohol Drug Educ 41(1):74-98. (ADAI jl).
Gorman DM. (1995). On the difference between statistical and practical significance in school-
based drug abuse prevention. Drugs Educ Prev Policy. 2(3):275-283. (ADAI jl).
Gorman DM. (1996). Do school-based social skills training programs prevent alcohol use
among young people? Addict Res. 4(2):191-210. (ADAI jl).
Gorman DM. (1998). The irrelevance of evidence in the development of school-based drug
prevention policy, 1986-1996. Eval Rev. Feb;22(1):118-46.
Gosin MN, Dustman PA, Drapeau AE, Harthun ML (2003). Participatory Action Research:
creating an effective prevention curriculum for adolescents in the Southwestern US. Health
Educ Res. Jun;18(3):363-79.
Gottfredson DC, Wilson DB. (2003). Characteristics of effective school-based substance abuse
prevention Prev Sci. Mar;4(1):27-38.
Graham A (2003). Organizations-theory and definitions, SPS 809AB – 2003, School of Policy
Studies, Queens University.
230
231
Granheim M, Kogan M, Leithwood K. (1990). Evaluation as policy making: Introducing
evaluation into a national, decentralized school System, London, UK: Jessica Kingsley.
Grebow PM, Greene BZ, Harvey J, Head CJ. (2000). Shaping health policies. Educational
Leadership, 57(6).
Green LW, Kreuter AW. (1991). Health Promotion Planning: An Education and Environment
Approach. Mountain View, CA: Mayfield Publishing.
Greenberg MT, Weissberg RP, O'Brien MU, Zins JE, Fredericks L, Resnik H, Elias MJ.
(2003). Enhancing school-based prevention and youth development through coordinated social,
emotional, and academic learning. Am Psychol. Jun-Jul;58(6-7):466-74.
Griffin KW, Botvin GJ, Nichols TR, Doyle MM. (2003). Effectiveness of a universal drug
abuse prevention approach for youth at high risk for substance use initiation. Prev Med.
Jan;36(1):1-7.
Griffin KW, Botvin GJ, Scheier LM, Epstein JA, Doyle MM. (2002). Personal competence
skills, distress, and well-being as determinants of substance use in a predominantly minority
urban adolescent sample. Prev Sci. Mar;3(1):23-33.
Griffin KW, Scheier LM, Botvin GJ, Diaz T. (2001). Protective role of personal competence
skills in adolescent substance use: psychological well-being as a mediating factor. Psychol
Addict Behav. Sep;15(3):194-203.
Grossman DC, Neckerman HJ, Koepsell TD, Liu PY, Asher KN, Beland K, Frey K, Rivara FP.
(1997). Effectiveness of a violence prevention curriculum among children in elementary
school. JAMA. 277:1605-1611. (ADAI rp 07681).
Gruber E, DiClemente RJ, Anderson MM, Lodico M. (1996). Early drinking onset and its
association with alcohol use and problem behavior in late adolescence. Preventive Medicine,
25(3):293-300.
Grunbaum JA, Kann L, Williams BI, Kinchen SA, Collins JL, Baumler ER, Kolbe LJ. (2000).
Surveillance for characteristics of health education among secondary schools--school health
education profiles, 1998 MMWR CDC Surveill Summ. Aug 18;49(8):iv-41.
Grunbaum JA, Kann L, Williams BI, Kinchen SA, Collins JL, Kolbe LJ. (1998).
Characteristics of health education among secondary schools--School Health Education
Profiles, 1996. Mor Mortal Weekly Rep CED Surveill Summ, Sep 11;47(4):1-31.
Guay M, Clouatre AM, Blackburn M, Baron G, De Wals P, Roy C, Desrochers J, Milord F.
(2003). Effectiveness and cost comparison of two strategies for hepatitis B vaccination of
schoolchildren. Can J Public Health. 2003 Jan-Feb;94(1):64-7.
Guernsey BP, Pastore DR. (1996). Comprehensive School-Based Health Centers:
Implementing the Model. Adolesc Med. Jun;7(2):181-196.
Gunja F, Cox A, Rosenbaum M, Appel J, (2004). Making Sense of Student Drug Testing Why
Educators are Saying No American Civil Liberties Union, New Haven, CT
http://www.drugpolicy.org/docUploads/drug_testing_booklet.pdf.
Hacker K, Wessel GL. (1998). School-based health centers and school nurses: cementing
231
232
the collaboration. J Sch Health. Dec;68(10):409-14.
Hahn EJ et al. (1996). Cues to parent involvement in drug prevention and school activities.
Journal of School Health, 66(5):165-70.
Hahn EJ, Hall LA, Simpson MR. (1998). Drug prevention with high risk families and young
children. J Drug Educ. 28(4):327-45.
Hahn EJ, Noland MP, Rayens MK, Christie DM. (2002). Efficacy of training and fidelity of
implementation of the life skills training program. J Sch Health. Sep;72(7):282-7.
Hall GE, Hord SM. (1987). Change in school. Facilitating the process. State University of New
York, Albany.
Hallfors D, Godette D. (2002). Will the 'principles of effectiveness' improve prevention
practice? Early findings from a diffusion study. Health Educ Res. Aug;17(4):461-70.
Hansen WB. (1992). School-based substance abuse prevention: a review of the state of the art
in curriculum, 1980-1990. Health Educ Res. Sep;7(3):403-30.
Hansen WB, Graham JW. (1991). Preventing alcohol, marijuana, and cigarette use among
adolescents: peer pressure resistance training versus establishing conservative norms. Prev
Med. May;20(3):414-30.
Hansen WB, McNeal RB Jr. (1999). Drug education practice: Results of an observational
study. Health Educ Res. Feb;14(1):85-97.
Hansen WB, O‘Malley PM. (1996). Drug use. In Diclemente RJ, Hansen WB, Ponton LE,
Handbook of Adolescent Health Risk Behavior. New York, NY: Plenum Press.
Hansen WB. (1992). School-based substance abuse prevention: a review of the state of the art
in curriculum, 1980-1990. Health Educ Res 7(3):403-430. (ADAI rp 05629).
Hansen WB. (1993). School-based alcohol prevention programs. Alcohol Health Res World.
17(1):54-60. (ADAI jl).
Harden A, Oakley A, Peersman G (1999) A review of the effectiveness and appropriateness of
peer-delivered health promotion interventions for young people. London, UK, Social EPI-
CENTRE, Science research Unit, Institute of Education
Harrington NG, Giles SM, Hoyle RH, Feeney GJ, Yungbluth SC. (2001). Evaluation of the All
Stars character education and problem behavior prevention program: Effects on mediator and
outcome variables for middle school students. Health Educ Behav. Oct;28(5):533-46.
Harvey-Berino Jean, Weing JF, Flynn B, Wick JR. (1998). Statewide dissemination of a
nutrition program: Show the way to 5-a-day, Journal of Nutrition Education, 30(1):29-36.
Harvard Graduate School of Education. (2003). The Evaluation Exchange.
Cambridge, MA:www.gse.harvard.edu/hfrp/eval/archives.html.
Hausman AJ, Ruzek SB, (1995). Implementation of comprehensive school health education in
elementary schools: focus on teacher concerns, Journal of School Health, Mar;65(3):81-6.
232
233
Hawe P. (1998). Making sense of context-level influences on health. Health Educ Res.
Dec;13(4):i-iv .
Hawe P, Wise M, Nutbeam D. (2001a). Policy- and system-level approaches to health
promotion in Australia. Health Educ Behav. 2001 Jun;28(3):267-73.
Hawe P, Riley T, Shiel E. (2001b). Understanding programs within their context: use of inter-
organisational network analysis within a community intervention trial. International Union for
Health Education and Health Promotion Conference . Paris, 16th-20th July
Hawkins JD, Catalano FR, Miller JY. (1992). Factors for alcohol and other drug problems in
adolescence and early childhood: Implications for substance abuse prevention. Psychological
Bulletin, 112:64-105.
Hawkins JD, Graham JW, Maguin E, Abbott R, Hill KG, Catalano RF. (1997). Exploring the
effects of age of alcohol use initiation and psychological risk factors on subsequent alcohol
misuse. Journal of Studies on Alcohol, 58(3):280-90.
Hawkins, J.D.; Catalano, R.F.; Kosterman, R.; Abbott, R.; and Hill, K.G. Preventing adolescent
health-risk behaviors by strengthening protection during childhood. Archives of Pediatric and
Adolescent Medicine 153:226–234, 1999.
Hawkins, J.D.; Catalano, R.F.; and Arthur, M. Promoting science-based prevention in
communities. Addictive Behaviors 90(5):1–26, 2002.
Hay DI, (2002). A Literature Review of the Effectiveness of School-Based Services School-
Based Program Review Ministry of Children and Family Development, Victoria, BC.
Haynes NM. (2002). Addressing students' social and emotional needs: the role of mental health
teams in schools. J Health Soc Policy. 16(1-2):109-23.
Hays RD, Stacy AW, DiMatteo MR. (1987). Problem behaviour theory and adolescent alcohol
use. Addictive Behaviors, 12(2):189-93.
Hayward S, Ciliska D, Mitchell-DiCenso A, Thomas H, Underwood J, Rafael A. Public Health
Nursing and Health Promotion: background paper,
http://hiru.mcmaster.ca/ohcen/groups/hthu/93-2.htm.
Health & Welfare Canada. (1986). Achieving Health for All: A Framework for Health
Promotion. Ottawa, ON: Health and Welfare Canada.
Health and Welfare Canada, Enhancing Prevention in the Practice of Health Professionals.
Strategies for Today and Tomorrow, Ottawa, ON.
Health Canada (199 ) Heart Health, Heart Health Equality. Mobilizing Communities for
Action, http://www.hc-sc.gc.ca/hppb/ahi/hearthealth/pubs/equal/eqa01.htm.
Health Canada. (1997). Health promotion interventions to promote healthy eating in the general
population - a review, Health promotion effectiveness reviews Summary bulletin 6-1997,
http://www.hea.org.uk/research/download/ereview6.html.
Health Canada. (2003). Taking Action on Healthy Living: Background Information on the
Integrated Pan-Canadian Healthy Living Strategy. Ottawa, ON.
233
234
Health Canada. (1996). Towards a Common Understanding: Clarifying the Core Concepts of
Population Health, Ottawa, ON, Author.
Health Canada. (1993). Selected attitudes among youth aged 11-17 concerning
smoking/alcohol and drug use. Canadian Youth and Drugs. A Health Promotion and Social
Marketing Resource Guide. Ottawa, ON: Health Canada.
Health Canada. (1996). Other Drugs & Alcohol. Executive Summary. Ottawa, ON: Author.
Health Canada. (1996). Out of the Mainstream Youth. Executive Summary. Ottawa, ON:
Author.
Health Canada. (1999). Communicating with Canada‘s Youth. A paper presented to a
conference in Ottawa, March 30, 1999. Ottawa, ON: Program Promotion Division, Health
Canada.
Health Canada. (nd). Still Making A Difference: Interim Report: The Impact of the Health
Promotion Directorate‘s Social Marketing Campaign 1992-93. Ottawa, ON: Program
Promotion Division, Health Promotion Directorate.
Health Canada. (nd). Youth Public Opinion Research Study: Secondary Analysis of Current
Market Research on Youth Ages 7-19. Ottawa, ON: Author.
Health Canada. (1994). Strategies for Population Health Investing in the Health of Canada's
Advisory Committee on Population Health. Ottawa, ON, Author.
Hearn MD et al (1992), "Involving Families in Cardiovascular Health Promotion: The CATCH
Feasibility Study", Journal of Health Education, 23(1), p.22-31.
Hecht ML, Marsiglia FF, Elek E, Wagstaff DA, Kulis S, Dustman P, Miller-Day M. (2003).
Culturally grounded substance use prevention: an evaluation of the keepin' it R.E.A.L.
curriculum. Prev Sci. Dec;4(4):233-48.
Hern MJ, Gates D, Amulung S, McCabe P, (1998). Linking learning with health behaviours of
high school adolescents. Pediatric Nursing, Mar-Apr;24(2):127-32.
Hirischi T. (1969). Courses of Deliquency. Berkely, CA: University of California Press.
Holtgrave DR, Tinsley BJ, Kay LS. (1995). Encouraging risk reduction: A decision-making
approach to message design. In E Maibach & RL Parrot, eds., Designing Health Messages:
Approaches from Communication Theory and Public Health Practice. Thousand Oaks, CA:
Sage.
Hootman J, Houck GM, King MC. (2002). A program to educate school nurses about mental
health interventions. J Sch Nurs. Aug;18(4):191-5.
Hopper CA, Gruber MB, Munoz KD, Herb RA, (1992). Effect of including parents in a school-
based exercise and nutrition program for children, Res Q Exerc Sport, Sep;63(3):315-21.
Hord SM, Rutherford WL, Huling AL, Hall GE. (1988). Taking charge of change. Alexandria,
VA: Association for Supervision and Curriculum Development.
234
235
Horn K, Kolbo JR. (2000). Application of a cumulative strategies model for drug abuse
prevention: exploring choices for high risk children. J Drug Educ. 30(3):291-312.
http://www.nida.nih.gov/pdf/monographs/monograph170/096-119_Becker.pdf.
Huang L, Gibbs J. (1992). Partners or adversaries? Home-school collaboration across culture,
race, and ethnicity. In:Christenson, S; Close Conoley, J., eds. Home-school Collaboration:
Enhancing Children‘s Academic and Social Competence, p. 81–110. Silver Spring, MD:
National Association of School Psychologists.
Hundert J, Boyle MH, Cunningham CE, Duku E, Heale J, McDonald J, Offord DR, Racine Y.
(1999). Helping children adjust--a Tri-Ministry Study: II. Program effects. J Child Psychol
Psychiatry. Oct;40(7):1061-73.
Hyndman, B., Libstug, A., Giesbrecht, N., Hershfield, L., & Rootman, I. (1993). The Use of
Social Science Theory to Develop Health Promotion Programs (Rep. No. 4). Toronto: Centre
for Health Promotion, University of Toronto.
Ialongo, N.; Poduska, J.; Werthamer, L.; and Kellam, S. The distal impact of two first-grade
preventive interventions on conduct problems and disorder in early adolescence. Journal of
Emotional and Behavioral Disorders 9:146–160, 2001.
Igra V, Irwin CE Jr, (1996). Theories of adolescent risk-taking behaviour, Handbook of
Adolescent Health Risk Behavior, New York, NY: Plenum Press.
Independent Inquiry Into Inequalities in Health. (1998). Chapter on Education, London:
National Health Service. http://www.archive.official-
documents.co.uk/document/doh/ih/part2b.htm
Ionnotti RJ, Bush PJ, Weinfort KP. (1996). Perceptions of friend‘s use of alcohol, cigarettes
and marijuana among urban school children. A longitudinal study. Health Educatin and
Behavior, 24(3):287-99.
Irwin CE Jr, Igra V, Eyre S, Millstein S, (1997). Risk-taking behavior in adolescents: the
paradigm, Ann NY Acad Sci, May 28:817-35.
Irwin CE, Millstein SG. (1986). Biopsychosocial correlates of risk-taking behaviors during
adolescence. Journal of Adolescent Health Care, 7:825-965.
Irwin CE. (1987). Adolescent social behavior and health. New Directions for Child
Development, 37:1-12.
Israel BA, Checkoway B, Schultz A, Zimmerman M. (1994). Health education and community
empowerment: Conceptualizing and measuring perceptions of individual, organizational and
community control. Health Education Quarterly, 21(2):149-70.
Jackson C, Henriksen L, Dickinson D, Levine DW. (1997). The early use of alcohol and
tobacco. Its relation to children‘s competence and parents‘ behavior. American Journal of
Public Health, 87(3):359-64.
James WH, Wabaunsee R. (1995). At-risk students : Drug prevention through
afterschool/latchkey programs? Drugs Educ Prev Policy 2(1):65-75. (ADAI jl).
Janosz M, Georges P, Parent S. (1998). L'environnement éducatif à l'école secondaire
235
236
: un modèle théorique pour guider l'évaluation du milieu. Revue Canadienne de Psycho-
Éducation, 27(2), 285-306.
Janz WK, Becker (1984). MH. The Health Belief Model: A Decade Later, Health Education
Quarterly 11: 1-47.
Jenkins JE, (1996). The influence of peer affiliation and student activities on adolescent drug
involvement. Adolescence. 31(122):297-306.
Jennings J, Pearson G, Harris M. (2000). Implementing and maintaining school-based mental
health services in a large, urban school district. J Sch Health. May;70(5):201-5.
Jepson L, Juszczak L, Fisher M. (1998). Mental health care in a high school based health
service. Adolescence. Spring;33(129):1-15.
Jessor R. (1993). Successful adolescent development among youth in high-risk settings.
American Psychologist. vol. 48, p. 177–216. Washington, DC..
Jessor R, Jessor R. (1977). Problem Behavior and Psychosocial Development. New York, NY:
Academic Press.
Johnson DW, Johnson RT. (1994). Learning Together and Alone: Cooperative, Competitive,
and Individualistic Learning. .Needham Heights, MA: Allyn & Bacon.
Johnston, L.D.; O‘Malley, P.M.; and Bachman, J.G. Monitoring the Future National Survey
Results on Drug Use, 1975–2002. Volume 1: Secondary School Students. Bethesda, MD:
National Institute on Drug Abuse, 2002.
Jones ME, Clark D. (1993). What school nurses really do--a study of school nurse utilization,
Journal of School of Nursing, Apr;9(2):10-17.
Joost JC, Grossman LS, McCarter RJ, Verhulst SJ, Winsted-Hall D, Mehl R, (1993). Predictors
of frequent middle school health room use. Journal of Developmental Behavior Pediatric,
Aug;14(4):259-63.
Jourdan D, Piec I, Aublet-Cuvelier B, Berger D, Lejeune ML, Laquet-Riffaud A, Geneix C,
Glanddier PY. (2002). School health education: practices and representations of primary school
teachers Sante Publique. Dec;14(4):403-23.
Joyce BR, Showers B. (1988). Student Achievement through Staff Development. Longman,
New York.
Kalafat J, Illback RJ, A qualitative evaluation of school-based family resource and youth
service centers. American Journal of Community Psychology, Aug;26(4):573-604.
Kam CM, Greenberg MT, Walls CT. (2003). Examining the role of implementation quality in
school-based prevention using the PATHS curriculum. Promoting Alternative Thinking Skills
Curriculum. Prev Sci. Mar;4(1):55-63.
Kandel DB, Logan JA. (1984). Patterns of drug use from adolescence to young adulthood.
Periods of risk for initiation, continued use and discontinuation. American Journal of Public
Health, 74:660-666.
236
237
Kandel DB, Yamaguchi K, Chen K. (1992). Stages of progression in drug involvement from
adolescence to adulthood. Further evidence of the gateway theory. Journal of School Health,
53:447-457.
Kantor GK, Caudill BD, Ungerleider S. (1992). Project Impact: teaching the teachers to
intervene in student substance abuse problems. J Alcohol Drug Educ. 38(1):11-29.
Kaplan DW, Brindis C, Naylor KE, Phibbs SL, Ahlstrand KR, Melinkovich P. (1998).
Elementary school-based health center use. Pediatrics. Jun;101(6):E12.
Kealey KA, Peterson AV Jr, Gaul MA, Dinh KT. (2000). Teacher training as a behavior change
process: principles and results from a longitudinal study. Health Educ Behav. Feb;27(1):64-81.
Keefe K. (1994). Perceptions of normative social pressure and attitudes toward alcohol use,
changes during adolescence. Journal of Studies on Alcohol, 55(1):46-54.
Kelsey KS, Campbell MK, Vanata DF, (1998). Parent and adolescent girls' preferences for
parental involvement in adolescent health promotion programs. Journal of American Dietetic
Association, Aug;98(9):906-7.
Keyl PM, Hurtado MP, Barber MM, Borton J, (1996). School-based health centers. Students'
access, knowledge, and use of services., Arch Pediatr Adolesc Med. Feb; 150(2):175-80.
Kessler R. (2000). The Soul of Education: Helping Students Find Connection,
Compassion, and Character at School. Alexandria, VA: Association for Supervision and
Curriculum Development.
Kim S, Crutchfield C, Williams C, Hepler N. (1998). Toward a new paradigm in substance
abuse and other problem behavior prevention for youth. Youth development and empowerment
approach. Journal of Drug Education, 28(1):1-17.
King KA, Wagner DI, Hedrick B. (2001). Safe and drug-free school coordinators' perceived
needs to improve violence and drug prevention programs. J Sch Health. Aug;71(6):236-41.
Kinsman SB, Romer D, Furstenberg FF, Schwartz DF. (1998). Early sexual initiation: The role
of peer norms. Pediatrics, 102(5):1188-92.
Kolbe LJ, Iverson DC. (1981). Implementing comprehensive health education, educational
innovations and social change. Health Education Quarterly. 8(1).
Kolbe LJ, Kann L, Brener N.D. (2001). Overview and summary of findings: School health
policies and programs study 2000. Journal of School Health, 71(7), 253-259.
Komro KA, Perry CL, Williams CL, Stigler MH, Farbakhsh K, Veblen-Mortenson S. (2001).
How did Project Northland reduce alcohol use among young adolescents? Analysis of
mediating variables. Health Educ Res. Feb;16(1):59-70.
Komro KA, Toomey TL. (2002). Strategies to prevent underage drinking. Alcohol Res Health.
26(1):5-14.
Konu A, Rimpela M. (2002). Well-being in schools: a conceptual model. Health Promot Int.
Mar;17(1):79-87.
Kosterman, R.; Hawkins, J.D.; Spoth, R.; Haggerty, K.P.; and Zhu, K. Effects of a
237
238
preventive parent-training intervention on observed family interactions: Proximal outcomes
from Preparing for the Drug Free Years. Journal of Community Psychology 25(4):337–352,
1997.
Kosterman, R.; Hawkins, J.D.; Haggerty, K.P.; Spoth, R.; and Redmond, C. Preparing for the
Drug Free Years: Session-specific effects of a universal parent-training intervention with rural
families. Journal of Drug Education 31(1):47–68, 2001.
Kozolanka K. (1993). Beyond Integrated Curriculum Student Voice & the Nature of
Engagement. Unpublished master‘s thesis Kingston, ON: Queen‘s University.
Kriete R, Bechtel L.( 2002). The Morning Meeting Book. Greenfield, MA:
Northeast Foundation for Children.
Kubiszyn T. (1999.) Integrating health and mental health services in schools: psychologists
collaborating with primary care providers. Clin Psychol Rev. Mar;19(2):179-98.
Kumar R, O'Malley PM, Johnston LD, Schulenberg JE, Bachman JG. (2002). Effects of
school-level norms on student substance use. Prev Sci. Jun;3(2):105-24.
Kumpfer K et al. (1991). A Community Change Model for School Health Promotion", Journal
of Health Education, 22 (2).
Kumpfer KL, Alvarado R, Tait C, Turner C. (2002). Effectiveness of school-based family and
children's skills training for substance abuse prevention among 6-8-year-old rural children.
Psychol Addict Behav. Dec;16(4 Suppl):S65-71.
Kumpfer KL, Alvarado R, Whiteside HO. (2003). Family-based interventions for substance use
and misuse prevention. Subst Use Misuse. Sep-Nov;38(11-13):1759-87.
Labonte R. (1994). Health promotion and empowerment: Reflections on professional practice.
Health Education Quarterly, 21(2):253-68.
Ladd GW, Mize J. (1983). A cognitive social-learning model of social skill training.
Psychological Review. vol. 90, p. 127–57. Washington, DC.
Lamarine RJ. (1993). School drug education programming: in search of a new direction. J Drug
Educ. 23(4):325-31.
Lambert NM, McCombs BL, eds. (1998). How Students Learn: Reforming Schools Through
Learner-centered Education. Washington, DC: American Psychological Association.
Lancman H, Pastore DR, Steed N, Maresca A. (2000). Adolescent Hepatitis B vaccination:
comparison among 2 high school-based health centers and an adolescent clinic. Arch Pediatr
Adolesc Med. Nov;154(11):1085-8.
Lansdowne G. (2003). Youth Participation in Decision Making - Chapter 10 of the World
Youth Report 2003 The global situation of young people United Nations Publications.
http://www.un.org/esa/socdev/unyin/wyr/documents/ch10.pdf
Langer JH. (1976). Guidelines for school-police cooperation in drug abuse policy department. J
Sch Health. Apr;46(4):197-9.
238
239
Lantieri L, ed. (2001). Schools with Spirit: Nurturing the Inner Lives of Children and Teachers.
Boston, MA: Beacon Press.
La Table Provinciale de Concertation sur la Violence, les Jeunes et le Milieu Scolaire. (2000).
La Présence Policière dans les Établissements Scolaires.
http://www.wl.csvdc.qc.ca/Sitepolice/default.html.
Lazebnik R, Grey SF, Ferguson C. (2001). Integrating substance abuse content into an HIV
risk-reduction intervention: A pilot study with middle school-aged Hispanic students. Subst
Abuse. 22(2):105-117. (ADAI jl).
Levinson-Gingiss P, Hamilton R. (1989). Evaluation of training effects on teacher attitudes and
concerns prior to implementing a human sexuality education program. Journal of School
Health, vol 59, 156-160.
Li C, Pentz MA, Chou CP. (2002). Parental substance use as a modifier of adolescent substance
use risk. Addiction. Dec;97(12):1537-50.
Lia-Hoagberg B, Nelson P, Chase RA. (1997). An interdisciplinary health team training
program for school staff in Minnesota. J Sch Health. Mar;67(3):94-7.
Leiberman A. (1995). Practices that support teacher development. Phi Delta Kappan vol. 76, p.
591–96. Bloomington, IN,
Lewis CC, Schaps E, Watson MS. (1996). The caring classroom‘s academic edge. Educational
leadership. vol. 54, p. 16–21. Alexandria, VA.
Lilja J, Wilhelmsen BU, Larsson S, Hamilton D. (2003). Evaluation of drug use prevention
programs directed at adolescents. Subst Use Misuse. Sep-Nov;38(11-13):1831-63.
Liontos LB. (1991). Involving the Families of At-Risk Youth in the Educational Process.
Eugene, OR: ERIC Clearinghouse on Educational Management.
Lisnov L, Harding CG, Safer LA, Kavanagh J. (1998). Adolescents' perceptions of substance
abuse prevention strategies. Adolescence. Summer;33(130):301-11.
Lister-Sharp, D., Chapman, S., Stewart-Brown, S., & Sowden, A. (1999). Heatlh promoting
schools and health promotion in schools: two systematic reviews. Health Technolog
Assessment, 3, 1-6.
Louis MR & Sutton RI. (1991). Shifting cognitive gears: From habits of mind to active
thinking. Human Relations, 44:55-76.
Lowe JM, Knapp ML, Meyer MA, Gall GB, Hampton JG, Dillman JA, Roover ML. (2001.)
School-based health centers as a locus for community health improvement. Qual Manag Health
Care. Summer;9(4):24-32.
Luepker RV, Murray DM, Jacobs DR Jr, Mittelmark MB, Bracht N, Carlaw R, Crow R, Elmer
P, Finnegan J, Folson AR, et al, (1994), Community education for cardiovascular disease
prevention: Risk factor changes in the Minnesota Heart Health Program. American Journal of
Public Health, Sep;84(9):1383-93.
239
240
Lupton D. (1994). Consumerism, commodity culture and health promotion. Health Promotion
International, 9:111-118.
Lytle LA, Ward J, Nader PR, Pedersen S, Williston BJ. (2003). Maintenance of a health
promotion program in elementary schools: Results from the CATCH-ON study key informant
interviews. Health Educ Behav. Aug;30(4):503-18.
Macbeth A. (1980). School boards: From purpose to practice, Edinburgh, Scotland: Scottish
Academic Press.
McCallum DB. (1995). Risk communication: A tool for behaviour change. Research
Monographs, 155:65-89. Washington, DC: National Institute on Drug Abuse.
Maccoby N. (1990). Communication and health education research. Potential sources for
education for prevention of drug abuse. Research Monograph, 93:1-23. Washington, DC:
National Institute on Drug Abuse.
MacDonald MA, Green LW. (2001). Reconciling concept and context: the dilemma of
implementation in school-based health promotion. Health Educ Behav. Dec;28(6):749-68.
MacDougall C. (2004). School Health Committees. Perceptions of Public Health Staff.
Doctorial Thesis. Toronto, ON: Ontario Institute for Studies in Education, University of
Toronto.
MacKesy-Amiti ME, Fendrich M, Goldstein PJ. (1997). Sequence of drug use among serious
drug users. Typical vs atypical progression. Drug and Alcohol Dependence, 45:185-196.
Mackie W, Oickle P. (1996). Comprehensive school health: The physician as advocate. Journal
of the Canadian Medical Association, 156: 1301-5.
MacKinnon DP, Johnson CA, Pentz MA, Dwyer JH, Hansen WB, Flay BR, Wang EY. (1991).
Mediating mechanisms in a school-based drug prevention program: first-year effects of the
Midwestern Prevention Project. Health Psychol. 10(3):164-72.
MacLean Dr. (1996). Positioning dissemination in public policy. Canadian Journal of Public
Health, 87-(Suppl.2)540-43.
Mangham C (1992), Family Empowerment as an Approach in Substance Abuse Prevention, A
paper prepared for the Alcohol and Drug Unit, Health Promotion Directorate, Health and
Welfare Canada.
Mangham C et al. (1994), Resiliency in Health Promotion: Annotated Bibliography, Detailed
Analysis, Ottawa, ON: Health Canada.
Mangham C. (1995). Resiliency: Relevance to Health Promotion. Discussion Paper. Ottawa,
ON: Alcohol and Drug Program, Health Canada.
Marbach E, Holtgren DR. (1995). Advances in public health communication. Annual Review
of Public Health, 16:219-38.
Marlatt GA, Larimer ME, Mail PD, Hawkins EH, Cummins LH, Blume AW, Lonczak HS,
Burns KM, Chan KK, Cronce JM, La Marr CJ, Radin S, Forquera R, Gonzales R, Tetrick C,
Gallion. (2003). Journeys of the Circle: a culturally congruent life skills intervention
240
241
for adolescent Indian drinking. Alcohol Clin Exp Res. Aug;27(8):1327-9.
Mason MJ, Wood TA. (2000). Clinical mental health training within a multidisciplinary
school-based health clinic. J Health Soc Policy. 11(3):45-65.
McBride N. (2003). A systematic review of school drug education. Health Educ Res.
Dec;18(6):729-42.
McBride N, Farringdon F, Midford R, Meuleners L, Phillips M. (2004) Harm minimization in
school drug education: final results of the School Health and Alcohol Harm Reduction Project
(SHAHRP). Addiction. Mar;99(3):278-91.
McBride N, Midford R, Cameron I. (1998). An empirical model for school health promotion:
The Western Australian School Health Project model. Health Promotion International, 14, (1),
pp. 17-25. [RJ214].
McCall D, Beazley R, Doherty-Poirier, Lovato C, MacKinnon, Otis J, Shannon M. (1999).
Schools, Public Health, Sexuality and HIV: A Status Report. Toronto, ON: Council of
Ministers of Education, Canada.
McCall D. (1990). Substance Abuse Prevention: Policies and programs for School Boards,
Colleges and Universities, BC Council for Leadership in Education and Administration.
Alcohol and Drugs Program, Ministry of Labour and Consumer Services, Brtistish Columbia.
McCall DS, (1995). Youth-Led Health Promotion: A Framework for Investigating
Effectiveness and Creating an Inventory of Tobacco and Other Program, Canadian Association
for School Health.
McCall D. (1997). A Research Agenda on Community and School Health. Surrey, BC: Centre
on Community and School Health, Canadian Association for School Health.
McCall DS. (2002). Understanding and Monitoring Youth Social Behaviours, Social
Environments and Relevant School, Agency and Community Policies, Programs and Practices
A Report on a Meeting of Experts, Officials and Practitioners, Analysis of Existing Ongoing
Surveys and Recent Studies And Suggested Collaborative Actions to Collect and Share Data.
Council of Ministers of Education, Canada, Justice Canada, Canadian Association of
Principals.
McCall DS. (2004) Developing a Research Agenda, Program and Network on School-based or
School-linked Health Promotion, Paper to the Joint Workshop on School Health, Vancouver,
BC, February 12-14.
McCallum DB. (1995). Risk communication: A tool for behaviour change. Research
Monographs, 155:65-89. Washington, DC: National Institute on Drug Abuse.
McCannell. (2000). Too many laps? Try this approach and they‘ll be back for more! Strategies,
14(2), 16-18.
McClanahan KK, McLaughlin RJ, Loos VE, Holcomb JD, Gibbins AD, Smith QW. (1998).
Training school counselors in substance abuse risk reduction techniques for use with children
and adolescents. J Drug Educ. 28(1):39-51.
McCord MT, Klein JD, Foy JM, Fotergill Km. (1993). School-based clinic use and
241
242
school performance. Journal of Adolescent Health, Mar;14(2):91-8.
McCormick LK, Steckler AB, McLeroy KR. (1995). Diffusion of innovations in schools: A
study of adoption and implementation of school-based tobacco prevention curricula. Am J
Health Promotion. 9(3):210-219. (ADAI rp 08260).
McCracken G. (1992). Got a Smoke? A Cultural Account of Tobacco in the Lives of
Contemporary Teens. Toronto, ON: Ontario Ministry of Health.
McDonald L, Sayger TV. (1998). Impact of a family and school based prevention program on
protective factors for high risk youth. Drugs Society. 12(1/2):61-85. (ADAI jl).
McDowell I. (nd). Scientific Paradigms in Population Health. Ottawa, ON: University of
Ottawa.
McGuire W. (1972). Social psychology. In PC Dodwell, ed., New Horizons in Psychology.
Middlesex, England: Penguin Books.
McGuire W. (1981). Theoretical foundation of campaigns. In Rice RE and Paisley WE, eds.,
Public Communication Campaigns, 41-70. Beverly Hills, CA: Sage Publications.
McGuire WJ. (1985). Attitude and attitude change. In G. Lindzey & E Arenson, eds., Public
Communities Campaigns (2nd edition), 43-65. Newbury Park, CA: Sage.
McGuire WJ. (1989). Theoretical foundations of campaigns. In RE Rice and CK Atkin, eds.,
Public Communications Campaigns (2nd edition), 43-65. Newbury Park, CA: Sage.
McKenna, M.L. (2003). Implementing school nutrition policies. Canadian Journal of Dietetic
Practice and Research, 64(4), 208-213.
McKenzie D. (1999). Under the Influence. The Impact of Alcohol Advertising on Youth.
Toronto, ON: Association to Reduce Alcohol Promotion in Ontario.
McLaren P, Leonardo Z, Perez X. (2000). Commentary on the school as a setting for health
promotion in Poland BD, Green LW, Rootman I, Settings for Health Promotion. Linking
Theory and Practice. Thousand Oaks, CA: Sage Publications Ltd.
McLaughlin RJ, McClanahan KK, Holcomb JD, Gibbins AD, Smith QW, Vlasak JW, Kingery
PM. (1993). Reducing substance abuse risk factors among children through a teacher as
facilitator program. J Drug Educ. 23(2):137-50.
McLennan JD, Shaw E, Shema SJ, Garnder WP, Pope SK, Kelleher KJ. (1998). Adolescents‘
insight into heavy drinking. Journal of Adolescent Health, 22(5):409-16.
Mellanby AR, Rees JB, Tripp JH. (2000). Peer-led and adult-led school health education: a
critical review of available comparative research. Health Educ Res. Oct;15(5):533-45.
Merini C, de Peretti C. (2002). External partnerships and prevention relative to psychoactive
substances: what should be the position of the school and its partners? Sante Publique.
Jun;14(2):147-64.
Micucci S, Thomas H, Vobra J. (2002). The Effectivenss of School-based Strategies for the
Primary Prevention of Obesity and for Promoting Physical Activity and/or Nutrition,
242
243
the Major Risk Factors for Type 2 Diabetes. A Review of Reviews. Toronto, ON: Ontario
Public Health Association.
Midford R, Munro G, McBride N, Snow P, Ladzinski U (2002). Principles that underpin
effective school-based drug education. J Drug Educ. 32(4):363-86.
Migneault JP, Palloneu VE, Velior WF. (1997). Decisional balance and stage of change for
adolescent thinking. Addiction and Behavior, 22(3):339-51.
Ministry of Health of Ontario Public Health Branch. (1997). Mandatory Health Program and
Services Guidelines Toronto, Ontario: Queen's Printer for Ontario.
Ministry of Health Ontario. (1996). Healthy Lifestyles Model Program. Public Health &
Epidemiology Report Ontario, Special Issue 96-1.
Mintz J, Laporte J. Really me social marketing case study. In S. Shapiro, WD Perrault, EJ
McCarthy, eds., Basic Marketing: A Global Managerial Approach. http://www.hc-
sc.gc.ca/hppb/socialmarketing/publications/reallyme.htm.
Mintz J. (1989). Social marketing. New weapon in an old struggle. Health Promotion,
Winter:6-12.
Moon, D.; Hecht, M.; Jackson, K.; and Spellers, R. Ethnic and gender differences and
similarities in adolescent drug use and refusals of drug offers. Substance Use and Misuse
34(8):1059–1083, 1999.
Morgan M, Hibell B, Andersson B, Bjarnason T, Kokkevi A, Narusk A. (1999). The ESPAD
Study: Implications for prevention [European Schools Project on Alcohol and Other Drugs].
Drugs Educ Prev Policy. 6(2):243-256. (ADAI jl).
Morris S et al. (1991). Evaluating the Effectiveness of School Drop-out Prevention Strategies,
Some Suggestions for Future Research. Toronto, ON: Canadian Education Association.
Murray DM, Short B. (1996). Intraclass correlation among measures related to alcohol use by
school aged adolescents: estimates, correlates and applications in intervention studies. J Drug
Educ. 26(3):207-30. (ADAI jl).
Mutchler SE, Pollard JS. (1994). Linkages among education, health and social services systems
that are creating new governance structures. Paper presented to the American Education
Research Association Annual Meeting, April 4-8. New Orleans, LA.
Myers-Clack SA, Christopher SE. (2001) Effectiveness of a health course at influencing
preservice teachers' attitudes toward teaching health. J Sch Health. Nov;71(9):462-6.
Nader PR, Broyles SL, Brennan J, Taras H. (2003). Two national surveys on pediatric training
and activities in school health: 1991 and 2001. Pediatrics. Apr;111(4 Pt 1):730-4.
Nader PR, Sellers DE, Johnson CC, Perry CL, Stone EJ, Cook KC, Bebchuk J, Luepker RV.
(1996). The effect of adult participation in a school-based family intervention to improve
Children's diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health.
Journal of Preventive Medicine, Jul-Aug;25(4):455-64.
Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane E,
243
244
Davino K. (2003). What works in prevention. Principles of effective prevention programs. Am
Psychol. Jun-Jul;58(6-7):449-56.
National Commission on Drug-Free Schools. (1990) Toward a drug-free generation : a nation's
responsibility, final report, September 1990. Washington DC: National Commission on Drug-
Free Schools, 1990. xiii, 98 p.
National Commission on Service Learning. 2002. The Power of Service
Learning. Newton, MA: NCSL.
National Institute on Drug Abuse (2003) Preventing Drug Use among Children and
Adolescents, A Research-Based Guide for Parents, Educators, and Community Leaders,
Second Edition, National Institute on Drug Abuse, 2003.
National Research Council. (1989). Improving Risk Communication: National Research
Council Committee on Risk Perception and Communication. Washington, DC: National
Academy Press.
National School Boards Association. (1981). The School Board and the Instructional
Program, Washington, DC: National School Boards Association.
New Brunswick Department of Education. (2001). Guidelines for Professional Practice for
School Psychologists, Fredericton, NB: Author.
Newfoundland Department of Education. (2000). Student Activity Survey: Grade 12. St.
Johns, NF: Author.
Newmann FM. (1986). Priorities for the future: Toward a
common agenda. Social Education, 50, 240-250.
Newmann FM (1989). Student engagement and high school reform. Educational Leadership,
46(5), 34-36.
Newmann FM, Wehlage GG, Lamborn SD.(1992). The significance and sources of student
engagement. In Newmann, F.M. (Ed.), Student Engagement and Achievement in American
Schools (pp 11-39). New York: Teachers College Press.
Neylon J. (1993). School nursing: health promotion for school children, Nurs Stand, Apr;14-
20;7(30):37-40.
Ni Mhurchu C, Margetts BM, Speller VM. (1997). Applying the stages-of-change model to
dietary change. Nutrition Review, 55(1):10-16.
Noam GG, Hermann CA. (2002). Where education and mental health meet: Developmental
prevention and early intervention in schools. Dev Psychopathol. Fall;14(4):861-75.
Noddings N. (1992). The Challenge to Care in Schools: An Alternative Approach to Education.
New York, NY: Teachers College Press.
Norland S, Eichar D, DiChiara A. (1996). Curricula, competition and conventional bonds: the
educational role in drug control. J Drug Educ. 26(3):231-42.
Nova Scotia Department of Health. (2002). When Drugs Come to School. s
244
245
Novick B, Kress J, Elias MJ. (2002). Building Learning Communities
with Character: How to Integrate Academic, Social, and Emotional Learning. Alexandria, VA,
ASCD.
Nutbeam D, St Leger L. (1996). Effective Health Promotion: Towards Health Promoting
Schools, National Health and Medical Research Council.
Nutbeam D, St. Leger L. (1997). Priorities for Research into Health Promoting Schools in
Australia. University of Australia, Australia Health Promoting Schools Association
O‘Callaghan FV, Chang DC, Call VJ, Baglioni A. (1997). Models of alcohol use by young
adults: An examination of various attitude-behaviour theories. Journal of Studies on Alcohol,
58(5):502-7.
Odden AR. (1991). Education policy implementation, Albany, NY: State University of New
York, Albany NY.
O'Donnell J, Hawkins JD, Catalano RF, Abbott RD, Day LE. (1995). Preventing school failure,
drug use, and delinquency among low-income children: Long-term intervention in elementary
schools. Am J Orthopsychiatry. 65(1):87-100. (ADAI rp 06876).
Oetting, E.; Edwards, R.; Kelly, K.; and Beauvais, F. Risk and protective factors for drug use
among rural American youth. In: Robertson, E.B.; Sloboda, Z.; Boyd, G.M.; Beatty, L.; and
Kozel, N.J., eds. Rural Substance Abuse: State of Knowledge and Issues. NIDA Research
Monograph No. 168. Washington, DC: U.S. Government Printing Office, pp. 90–130, 1997.
Oetting ER, Beauvais F. (1987). Peer cluster theory, socialization characteristics and adolescent
drug use: A path analysis. Journal of counseling Psychology, 34:205-213.
O‘Neil J. (1997). Building schools as communities: a conversation with James Comer.
Educational Leadership. vol. 54, p. 6–10.
Ontario Ministry of Health and Long-Term Care. (1997). Mandatory health program and
services guidelines. Toronto, Ontario: Queen's Printer for Ontario.
Osganian SK, Parcel GS, Stone EJ. (2003). Institutionalization of a school health promotion
program: background and rationale of the CATCH-ON study. Health Educ Behav.
Aug;30(4):410-7.
Osterman KF. (2000). Students‘ need for belonging in the school
community. Review of Educational Research.vol. 70, p. 323–67.
Paetsch JJ, Bertrand LD. (1997). The relationship between peer, social and school factors and
deliquency among youth. Journal of School Health, 67(1):27-32.
Paglia A. (1998). Tobacco Risk Communication Strategy for Youth: A Review. Ottawa, ON:
Tobacco Reduction Division, Health Canada.
Palinkas LA, Atkins CJ, Miller C, Ferreira D. (1996). Social skills training for drug prevention
in high-risk female adolescents. Prev Med. Nov-Dec;25(6):692-701.
Palmer RF, Graham JW, White EL, Hansen WB. (1998). Applying multilevel analytic
245
246
strategies in adolescent substance use prevention research. Prev Med. 1998 May-Jun;27(3):328-
36.
Palmer RF, Graham JW, White EL, Hansen WB. (1998). Applying multilevel analytic
strategies in adolescent substance use prevention research. Prev Med. May-Jun;27(3):328-36.
Parcel GS (1984), Theoretical models for application in school health education research.
Health Education, 15 (4).
Parcel GS, Kelder SH, Basen-Enquist K. (2000). The school as a setting for health promotion
in Poland BD, Green LW, Rootman I, Settings for Health Promotion. Linking Theory and
Practice. Thousand Oaks, CA: Sage Publications Ltd.
Parcel GS, Perry CL, Kelder SH, Elder JP, Mitchell PD, Lytle LA, Johnson CC, Stone EJ.
(2003). School climate and the institutionalization of the CATCH program. Health Educ
Behav. Aug;30(4):489-502.
Parcel GS, Simons-Morton B, O'Hara NM, Baranowski T, Wilson B, (1989). School promotion
of healthful diet and physical activity: impact on learning outcomes and self-reported behavior.
Health Education Quarterly, Summer;16(2):181-99.
Parcel, G.S., Perry, C.L., Kelder, S.H., Elder, J.P., Mitchell, P.D., Lytle, L. A., Johnson, C.C.,
and Stone, E.J. (2003). School climate and the institutionalization of the CATCH Program.
Health Education and Behavior, 30 (4), August.
Park J, Kosterman R, Hawkins JD, Haggerty KP, Duncan TE, Duncan SC, Spoth R. (2000).
Effects of the "Preparing for the Drug Free Years" curriculum on growth in alcohol use and risk
for alcohol use in early adolescence. Prev Sci. Sep;1(3):125-38.
Pasi R. (2001). Higher Expectations: Promoting Social Emotional Learning and Academic
Achievement in Your School. New York, NY: Teachers College Press.
Pastore DR, Juszczak L, Fisher MM, Friedman SB. (1998). School-based health center
utilization: a survey of users and nonusers. Arch Pediatr Adolesc Med. Aug;152(8):763-7.
Pastore DR, Techow B. (2004). Adolescent school-based health care: a description of two sites
in their 20th year of service. Mt Sinai J Med. May;71(3):191-6.
Pateman, B. (2003). Healthier students, better learners. Educational Leadership, 61(4).
Patton GC, Glover S, Bond L, Butler H, Godfrey C, Di Pietro G, Bowes G. (2000). The
Gatehouse Project: A systematic approach to mental health promotion in secondary schools.
Aust N Z J Psychiatry. Aug;34(4):586-93.
Pavis S, Cunningham-Burley S. (1999). Male youth street culture: Understanding the context of
health-related behaviors. Health Education Research, 14(5):583-96.
Payton JW, Wardlaw DM, Graczyk PA, Bloodworth MR, Tompsett CJ, Weissberg RP. (2000).
Social and emotional learning: a framework for promoting mental health and reducing risk
behavior in children and youth. J Sch Health. May;70(5):179-85.
Peele S, Brodsky A. (1997). Gateway to nowhere. How alcohol come to be scapegoated for
drug abuse. Addiction Research, 5:419-426.
246
247
Peele S. (1985). The Meaning of Addiction: Compulsive Experience and its Interpretation.
Toronto, ON: Lexington Books.
Peersman G, Harden A, Oliver S (1998) Effectiveness of of health promotion interventions in
the workplace.A Review. London, GB, Health Education Authority
Peleg A, Neumann L, Friger M, Peleg R, Sperber AD (2001). Outcomes of a brief alcohol
abuse prevention program for Israeli high school students. J Adolesc Health. Apr;28(4):263-9.
Pentz MA. (1998). Costs, Benefits, and Cost-Effectiveness of Comprehensive Drug Abuse
Prevention found in William J. Bukoski, Ph.D.Richard I. Evans, Ph.D. (Eds) Cost-
Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implications for Programming
and Policy, NIDA Research Monograph 176 1998 U.S. Department of Health and Human
Services, National Institutes of Health.
Pentz MA. (2003). Evidence-based prevention: characteristics, impact, and future direction. J
Psychoactive Drugs. May;35 Suppl 1:143-52.
Perkins HW, Berkowitz AD. (1986). Perceiving the community norms of alcohol use among
students. Some research implications for campus alcohol education programming. International
Journal on Addictions, 21(9-10):961-76.
Perkins HW, Merlman PW, Leichliter JS, Cashin JR, Presley CA. (1999). Misperceptions of
the norms for the frequency of alcohol and other drug use on college campuses. Journal of
American College Health. 47(6):253-8.
Perry CL et al. (1989). Parent involvement with children's health promotion: A one year
follow-up of the Minnesota Home Team. Health Education Quarterly, 16(2):171-180:171-180.
Perry CL, Jessor R. (1985). The concept of health promotion and the prevention of adolescent
drug abuse. Health Education Quarterly. vol. 12, p. 169–84.
Perry CL et al (1990), "Parent Involvement in Cigarette Smoking Prevention: Two Pilot
Evaluators of the Unpuffable Program", Journal of School Health, 60(9), 443-447.
Perry CL, Komro KA, Veblen-Mortenson S, Bosma LM, Farbakhsh K, Munson KA, Stigler
MH, Lytle LA. (2003). A randomized controlled trial of the middle and junior high school
D.A.R.E. and D.A.R.E. Plus programs. Arch Pediatr Adolesc Med. Feb;157(2):178-84.
Perry CL, Williams CL, Veblen-Mortenson S, Toomey TL, Komro KA, Anstine PS, McGovern
PG, Finnegan JR, Forster JL, Wagenaar AC, Wolfson M. (1996). Project Northland: outcomes
of a communitywide alcohol use prevention program during early adolescence. Am J Public
Health. Jul;86(7):956-65.
Perry CL. (2000). Commentary on the school as a setting for health promotion in Poland BD,
Green LW, Rootman I, Settings for Health Promotion. Linking Theory and Practice. Thousand
Oaks, CA: Sage Publications Ltd.
Petchers MK, Hirsch EZ, Bloch BA. (1987). The impact of parent participation on the
effectiveness of a heart health curriculum. Health Education Quarterly, Winter;14(4):449-60.
Peterson FL, Cooper RJ, Laird JM. (2001). Enhancing teacher health literacy in school
247
248
health promotion: a vision for the new millennium. J Sch Health. Apr;71(4):138-44.
Phelan P, Davidson AL, Cao H. (1992). Speaking up: Students‘ perspectives on school. Phi
Delta Kappan, 73, 695-704.
Pidwirny MJ. (nd). Introduction to Systems Theory, Ph.D., Department of Geography,
Okanagan University College.
Piran, N. (1995). Prevention: Can early lessons lead to a delineation of an alternative model? A
critical look at prevention with school children. Eating Disorders: The Journal of Treatment &
Prevention, 3, 28-36.
Plotnick RD. (1994). Applying benefit-cost analysis to substance use prevention programs. Int
J Addict. Feb;29(3):339-59
Poland BD, Green LW, Rootman I. (2000). Reflection on settings for health promotion in
Poland BD, Green LW, Rootman I, Settings for Health Promotion. Linking Theory and
Practice. Thousand Oaks, CA: Sage Publications Ltd.
Potvin L, Paradis G, Laurier D, Masson P, Pelletier J, Lessard R. (1992). Intervention
framework of the Quebec Healthy Heart Demonstration Project. Hygie, 11(1):17-23.
Poulin C, Elliott D. (1997). Alcohol, tobacco and cannabis use among Nova Scotia adolescents:
implications for prevention and harm reduction. CMAJ. May 15;156(10):1387-93.
Powell DR (1990), Parent Education and Support Programs, ERIC Clearinghouse on
Elementary and Early Childhood Education, Urbana, ILL.
Power TJ, Shapiro ES, DuPaul GJ. (2003). Preparing psychologists to link systems of care in
managing and preventing children's health problems. J Pediatr Psychol. Mar;28(2):147-55.
Price JH, Yingling F, Dake JA, Telljohann SK. (2003). Adolescent smoking cessation services
of school-based health centers. Health Educ Behav. Apr;30(2):196-208.
Prochaska JO, Redding CA, Harlow LL, Rossi JS, Velicer WF. (1994b). The transtheoretical
model of change and HIV prevention: A review. Health Education Quarterly, 21(4):471-86.
Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Kakowski W. Fiore C,
Harlow LL, Redding CA, Rosenbloom D. (1994a). Stages of change and decisional balance for
12 problem behaviors. Health Psychology, 13(1):39-46.
Prochaska JV, Velicer WF. (1997). The transtheoretical model of behavior change. American
Journal of Health Promotion, 12(1):38-48.
Pruitt BE, Kingery PM, Mirzale E, Heuberger G, Hurley RS. (1991). Peer influence and drug
use among adolescents in rural areas. Journal of Drug Education, 21(1):1-11.
Puskar K, Sereika S, Tusaie-Mumford K. (2003). Effect of the Teaching Kids to Cope (TKC)
program on outcomes of depression and coping among rural adolescents. J Child Adolesc
Psychiatr Nurs. Apr-Jun;16(2):71-80.
Putting Research to Work for the Community: Presentations, Papers and Recommendations.
248
249
(1998). Rockville: National Institute on Drug Abuse, 1998, pp. 43-56. (ADAI bk) HV 5825
N42 1998.
Ramirez AG, Gallion KJ, Espinoza R, McAlister A, Chalela P. (1997). Developing a media-
and school-based program for substance abuse prevention among hispanic youth: A case study
of Mirame!/Look at me! Health Educ Behav. 24(5):603-612. (ADAI rp 07815).
Ramirez AG, Gallion KJ, Espinoza R, Chalela P. (1999). Developing a media- and school-
based program for substance abuse prevention among Hispanic youth: a case study of
Mirame!/Look at Me! Nicotine Tob Res. (1 Suppl 1):S99-104.
Rappaport, J. (1997). Community psychology: Values, research and action. New York: Holt,
Rinehart, and Winston.
Renaud L, Chevalier S, Dufour R, O"Loughlin J, Beaudet N, Bourgeois A, Ouellet D. (1997).
Evaluation of the implementation of an educational curriculum: Optimal intervention for the
adoption of an educational program of health in elementary schools. Canadian Journal of Public
Health, Sep-Oct;88(5):351-3.
Renaud L, O'Loughlin J, Dery V. (2003) The St-Louis du Parc Heart Health Project: A critical
analysis of the reverse effects on smoking. Tob Control. Sep;12(3):302-9.
Resnicow K, Botvin G. (1993). School-based substance use prevention programs: Why do
effects decay? Prev Med. 22:484-490. (ADAI rp 06216).
Resnicow K, Allensworth DD. (1996). Conducting a comprehensive school health program.
Journal of School Health 66(2), 59-63.
Richards-Colocino N, McKenzie P, Newton RR. (1996). Project Success : Comprehensive
intervention services for middle school high-risk youth. J Adolesc Res 11(1):130-163. (ADAI
rp 08092).
Riessma, F. (1988). The next stage in educational reform: The student as consumer. Social
Policy, 18(2), 2.
Riley D. (1993). The Harm Reduction Model: Pragmatic Approaches to Drug Use from the
Area between Intolerance and Neglect, Ottawa, ON: Centre on Substance Abuse,
Ringwalt CL, Ennett S, Vincus A, Thorne J, Rohrbach LA, Simons-Rudolph A. (2002). The
prevalence of effective substance use prevention curricula in U.S. middle schools. Prev Sci.
Dec;3(4):257-65.
Ringwalt CL, Ennett S, Johnson R, Rohrbach LA, Simons-Rudolph A, Vincus A, Thorne J,
(2003). Factors Associated With Fidelity to Substance Use Prevention Curriculum Guides in
the Nation‘s Middle Schools Health Education & Behaviour, Volume 30, Issue 3: June.
Roberts A, Gerber L. (2003). Nursing Perspectives on Public Health Programming in Nunavut,
Department of Health and Human Services,
Roberts G, McCall DS, Stevens-Lavigne A, Anderson J, Paglia A, Bollenbach S, Wiebe J,
Gliksman L. (2001). Preventing Substance Use Problems among Young People - A
Compendium of Best Practices. Ottawa, ON: Health Canada, Office of Canada‘s Drug
Strategy.
249
250
Rohrbach LA, Graham JW, Hansen WB. (1993). Diffusion of a school-based substance abuse
prevention program: predictors of program implementation. Prev Med. 22:237-260. (ADAI rp
06072).
Romano JC. (2001). The complicated task of managing school health programs. J Sch Nurs.
Jun;17(3):126-30.
Romano JL. (1997). School personnel training for the prevention of tobacco, alcohol, and other
drug use: issues and outcomes. J Drug Educ. 27(3):245-58. (ADAI jl).
Romano JL. (1999). Prevention training of paraprofessionals in the schools: an examination of
relevancy and effectiveness. J Drug Educ. 29(4): 373-86. (ADAI jl).
Rones M, Hoagwood K. (2000). School-based mental health services: a research review. Clin
Child Fam Psychol Rev. Dec;3(4):223-41.
Ronson BG, Stanton C, (2003). Active Healthy School Community Models From Around the
World Literature Review. Toronto, ON: Ontario Physical Education and Health Association.
Room R. (1994). Adolescent drinking as a collective behavior and performance. In R Zucker, G
Boyd and J Howard, eds., The Development of Alcohol Problems: Exploring the
Biopsychosocial Matrix ofRisk, NIAAA Research Monograph No. 26. Rockville, MD:
National Institute on Alcohol Abuse and Addictions.
Rooney BL, Murray DM. (1996). A meta-analysis of smoking prevention programs after
adjustment for errors in the unit of analysis. Health Education Quarterly, 23:48-64.
Ross C, Richard L, Potvin L. (1998). One year outcome evaluation of an alcohol and drug
abuse prevention program in a Quebec high school. Canadian J Pub Health 89(3):166-170.
(ADAI rp 08471).
Rudd RE, Walsh DC. (1993). Schools as healthful environments: Prerequisite to
comprehensive school health? Prev Med. Jul;22(4):499-506.
Rudduck J, Chaplain R, Wallace G. (1996a). Reviewing the conditions of learning in school. In
J. Rudduck, R. Chaplain & G. Wallace (Eds.), School improvement: What can pupils tell us?
(pp. 172-178). London: Fulton.
Rudduck J, Chaplain R, Wallace G. (Eds.). (1996b). School Improvement: What Can Pupils
Tell Us? London: Fulton.
Rutter M. (1989). Pathways from Childhood to Adult Life. Paper presented to the Annual
Conference of the Association for Child Psychology and Psychiatry, London, July 1.
Ryan C, Matthews F, (1995). A National Directory of Exemplary School-Based Police
Programs To Combat Youth Violence, Ottawa, ON: Solicitor General of Canada.
Ryder D. (1996). The analysis of policy: understanding the process of policy development.
Addiction. Sep;91(9):1265-70.
Rye BJ, Humpartzoomian R, Steep B. (2001). Feedback from participants and leaders in an
250
251
intervention program: the 1997-1998 opening doors process evaluation. J Drug Educ.
31(2):185-206.
Sadoway DT, Plain RH, Soskoline L (1990. Infant and preschool immunization delivery in
Alberta and Ontario. A particle cost-minimization analysis. Can J of Public Health. 81 (2):
146-51.
Salovey P, Sluyter D. eds. (1997). Emotional Development and Emotional Intelligence:
Educational Implications. New York, NY: Basic Books.
Santi SM, Best JA, Payne ME, Brown KS, Cameron R. (1992). A comparison between
instructional experience and performance of teachers and nurses delivering a smoking
prevention program. Can J Public Health. Nov-Dec;83(6):433-6.
Saskatchewan Education. (1996). Curriculum evaluation report: Health education, 7, 8, & 9.
Regina, SK: Department of Education.
Satcher D, Tudor Bradford M. (2003). Healthy schools, healthy kids. American School Board
Journal, 190(3), 22-25.
Schall E, (1994). School-based health education: what works? American Journal of Preventive
Medicine, May-Jun;10(3 Suppl):30-2.
Scheier LM, Griffin KW, Doyle MM, Botvin GJ. (2002). Estimates of intragroup dependence
for drug use and skill measures in school-based drug abuse prevention trials: an empirical study
of three independent samples. Health Educ Behav. Feb;29(1):85-103.
Scheier, L.; Botvin, G.; Diaz, T.; and Griffin, K. Social skills, competence, and drug refusal
efficacy as predictors of adolescent alcohol use. Journal of Drug Education 29(3):251–278,
1999.
Schmid TL, Pratt M, Howze E. (1995). Policy as intervention: Environmental and policy
approaches to the prevention of cardiovascular disease. American Journal of Public Health,
85:1207-1211.
School Mental Health Project. (2001). Comprehensive & Multifaceted Guidelines for Mental
Health in Schools, Addressing Barriers to Learning. Vol 6, No 4,
Scileppi, J.A. (1984). A systems view of education: A model for change. Lanham, MD:
University Press of America.
Scott DM, Friedli D. (2002). Attendance problems and disciplinary procedures in Nebraska
schools. J Drug Educ. 32(2):149-65.
Seabert DM, Pigg RM Jr, Weiler RM, Behar-Horenstein LS, Miller MD, Varnes JW. (2002).
The influence of preservice instruction in health education methods on the health content taught
by elementary teachers in Indiana. J Sch Health. Dec;72(10):422-8.
Shamai S, Coambs RB. (1992). The relative autonomy of schools and educational interventions
for substance abuse prevention, sex education, and gender stereotyping. Adolescence.
27(108):757-770.
Shannon & McCall Consulting Ltd. (1993). Canada‘s school systems: An overview of
251
252
their potential role in promoting reproductive health and understanding of new reproductive
technologies. New Reproductive Technologies and the Science, Industry, Education and
Social Welfare Systems in Canada, Volume 5, Research Studies. Ottawa, ON: Royal
Commission on New Reproductive Technologies.
Shannon & McCall Consulting Ltd (1996) Youth-led Health Promotion A Framework for
Investigating Effectiveness and Creating an Inventory of Tobacco and Other Programs,
Tobacco reduction Program, Health Canada
Shannon & McCall Consulting Ltd. (1998), Selected Case Studies of Youth Involvement in
Public Decision-Making, Childhood & Youth Division, Ottawa, Health Canada
Shannon & McCall Consulting Ltd. (2000). The Feasibility of Collaboration in Collecting and
Sharing Data on Youth Social Behaviours, Environments and Relevant School & Community
Programs. A Discussion Paper Prepared for a Meeting of Experts, Officials and Practitioners
October 15-16, Hull, Quebec. Council of Ministers of Education, Canada, Justice Canada,
Canadian Association of Principals.
Shannon & McCall Consulting Ltd. (2001). Schools as Safe Places to Learn: Current Practices
in Monitoring the Safety of Schools. A Report to the Canadian Education Statistics Council.
Toronto, ON: Council of Ministers of Education, Canada.
Shannon & McCall Consulting Ltd (2001) The Feasibility of Collaboration in Collecting and
Sharing Data on Youth Social Behaviours, Environments and Relevant School & Community
Programs A Discussion Paper Prepared for a Meeting of Experts, Officials and Practitioners October
15-16, Hull, Quebec. Canadian Association of Principals, Council of Ministers of Education, Canada,
Justice Canada
Shannon DM, James FR. (1992). Academic intervention for at risk students with substance
misusing backgrounds. J Alcohol Drug Educ. 38(1):73-85. (ADAI jl).
Shannon M, McCall DS. (1991). Active & Healthy Living. A Dialogue on Teacher Training.
Ottawa, Health Canada. Fitness Unit.
Shannon MM, McCall DS. (2001). Schools as Safe Places to Learn: Current Practices in
Monitoring the Safety of Schools. A Report to the Canadian Education Statistics Council.
Toronto, ON: Council of Ministers of Education, Canada.
Shannon MM, McCall DS, (2002). The Feasibility of Collaboration in Collecting and Sharing
Data on Youth Social Behaviours, Environments and Relevant School and Community
Programs. Ottawa, ON: Canadian Association of Principals.
Shope JT, Copeland LA, Kamp ME, Lang SW. (1998). Twelfth grade follow-up of the
effectiveness of a middle school-based substance abuse prevention program. J Drug Educ.
28(3):185-97. (ADAI jl).
Shope JT, Elliott MR, Raghunathan TE, Waller PF. (2001). Long-term follow-up of a high
school alcohol misuse prevention program's effect on students' subsequent driving. Alcohol
Clin Exp Res. Mar;25(3):403-10. (ADAI jl).
Silver Gate Group. (2001). Robert Wood Johnson Foundation. Prevention 2000: Moving
effective prevention programs into practice. Princeton, NJ : Robert Wood Johnson Foundation,
September 2001. 30 p. (ADAI bk) HV 5825 S32 2001.
252
253
Simons-Morton BG, Crump AD, Haynie DL, Saylor KE. (1999). Student-school bonding and
adolescent problem behavior. Health Education Research, 14(1):99-107.
Simons-Norton BG, Donahew L, Crump AD. (1997). Health communication in the prevention
of alcohol, tobacco and drug use. Health Education and Behaviors, 24(5):544-54.
Simons-Rudolph AP, Ennett ST, Ringwalt CL, Rohrbach LA, Vincus AA, Johnson RE. (2003).
The principles of effectiveness: early awareness and plans for implementation in a national
sample of public schools and their districts. J Sch Health. May;73(5):181-5.
Simpson DD. (2002). A conceptual framework for transferring research to practice. J Subst
Abuse Treat. Jun;22(4):171-82.
Skara S, Sussman S. (2003). A review of 25 long-term adolescent tobacco and other drug use
prevention program evaluations. Prev Med. Nov;37(5):451-74.
Sleeter C, Grant C. (1991). Mapping terrains of power: Student cultural knowledge versus
classroom knowledge. In C. Sleeter (Ed.). Empowerment Through Multicultural Education.
(pp.49-67). Albany, NY: State University of New York Press.
Smart RG, Stoduto G. (1997). Interventions by students in friends' alcohol, tobacco, and drug
use. J Drug Educ. 27(3):213-22.
Smith WJ, Butler-Kisber L, LaRocque LJ, Portelli JP, Shields CM, Sparkes CS, Vibert AB.
(2001). Student Engagement in Learning and School Life: National Project Report Ed-
LexPublications.
http://ed-lex.law.mcgill.ca/Pub-SE.htm#_Toc324170
Smith WJ, Butler-Kisber L, LaRocque LJ, Portelli J, Shields CM, Sturge Sparkes C, Vibert A.
(1998). Student engagement in learning and school life: National project report. Montréal:
McGill University, Office of Research on Educational Policy.
Smith WJ, Donahue H, Vibert A. (Eds.). (1998a). Student engagement in learning and school
life: Case reports from project schools (Vol. I). Montréal: McGill University, Office of
Research on Educational Policy.
Smith WJ, Donahue H, Vibert A. (Eds.). (1998b). Student engagement in learning and school
life: Case reports from project schools (Vol. II). Montréal: McGill University, Office of
Research on Educational Policy.
Snow DL, Tebes JK, Ayers TS. (1997). Impact of two social-cognitive interventions to prevent
adolescent substance use: test of an amenability to treatment model. J Drug Educ. 27(1):1-17.
Soldana C, Markell G, (1997). Parent involvement in health concerns for youth: the issue of
adolescent immunization. Journal of School Health, Sep;67(7):292-3.
Spoth RL, Redmond C, Trudeau L, Shin C. (2001). Longitudinal substance initiation outcomes
for a universal preventive intervention combining family and school programs. Psychol Addict
Behav. Jun;16(2):129-34. (ADAI jl).
Spoth, R.; Guyull, M.; and Day, S. Universal family-focused interventions in alcohol-use
disorder prevention: Cost effectiveness and cost-benefit analyses of two interventions.
253
254
Journal of Studies on Alcohol 63:219–228, 2002a.
St Leger L, Nutbeam D. (2000). A model for mapping linkages between health and education
agencies to improve school health. J. Sch Health, Feb. 2000, Vol 70, No 2: 45-49.
St. Leger, L, Nutbeam, D. (1996). Settings 2 - Effective School Health Promotion. Towards
Health Promoting Schools. National Health and Medical research Council, NHMRC Health
Advancement Standing Committee. Canberra, Commonwealth of Australia.
St.Leger LH. (1999). The opportunities and effectiveness of the health promoting primary
school in improving child health – a review of the claims and evidence. Health Education
Research, 14, 15-69.
Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. (1998). Can non-
prosecutory enforcement of public health legislation reduce smoking among high school
students? Aust N Z J Public Health. 22(3 Suppl):332-5.
Stanhope M, Lancaster J. (1996). Community health nursing promoting health of aggregates,
families and individuals. (4 ed.) Toronto, ON: Mosby.
Stark C, Gibson H, Travers K, Gardner B. (2000). Drug action team strategies in Scotland.
Health Bull (Edinb). 2000 Jan;58(1):53-7.
Stephens, Thomas, Murray J. Kaiserman, Douglas S. McCall, Carol Sutherland-Brown. (1996).
The Costs and Potential Economic Benefits of School-based Smoking Prevention in CANADA.
Working Paper. Ontario Tobacco Reduction Unit.
Stephens T, Kaiserman MJ, McCall DS, Sutherland-Brown C. (2001). School-based Smoking
Prevention: Economic Costs Versus Benefits , Canadian Journal of Public Health. 92: 89.
Stewart M, Michelin LR, Dunkeley, G. (2003). School Health Benchmarking: General Report,
Public Health Research, Education, Development-Ottawa, Ottawa, ON.
Stokes H, Mukerjee D. (2000). The nature of health service/school links in Australia. Journal of
School Health. 70(6), 255-56.
Stokols D. Establishing and maintaining healthy environments. Toward a social ecology of
health promotion. Am Psychol 1992 Jan;47(1):6-22.
Stokols, D. Translating social ecological theory into guidelines for community health
promotion. Am J Health Promotion 1996; 10: 282-98.
Strong R, Silver H,.Robinson A. (1995). What do students want? Educational Leadership, 53,
8-12.
Sturges & Rogers. (1996). Cited in Paglia A. (1998). Tobacco Risk Communication Strategy
for Youth: A Literature Review. Ottawa, ON: Tobacco Reducation Division, Health Canada.
Summers LC, Williams J, Borges W, Ortiz M, Schaefer S, Liehr P. (2003). School-based health
center viability: application of the COPC model. Issues Compr Pediatr Nurs. Oct-
Dec;26(4):231-51.
Sussman S, Simon TR, Dent CW, Stacy AW, Galaif ER, Moss MA, Craig S, Johnson CA.
254
255
(1997). Immediate impact of thirty-two drug use prevention activities among students at
continuation high schools. Subst Use Misuse. Feb;32(3):265-81. (ADAI jl).
Sussman S, Dent CW, Stacy AW. (2002) Project towards no drug abuse: a review of the
findings and future directions. Am J Health Behav. Sep-Oct;26(5):354-65.
Sussman S, Galaif ER, Newman T, Hennesy M, Pentz MA, Dent CW, Stacy AW, Moss MA,
Craig S, Simon TR. (1997). Implementation and process evaluation of a student "school-as-
community" group. A component of a school-based drug abuse prevention program. Eval Rev.
Feb;21(1):94-123.
Sussman S, Simon TR, Dent CW, Stacy AW, Galaif ER, Moss MA, Craig S, Johnson CA.
(1997). Immediate impact of thirty-two drug use prevention activities among students at
continuation high schools. Subst Use Misuse. Feb;32(3):265-81.
Sussman S, Sun P, McCuller WJ, Dent CW. (2003). Project Towards No Drug Abuse: two-year
outcomes of a trial that compares health educator delivery to self-instruction Prev Med.
Aug;37(2):155-62.
Swider SM, Valukas A. (2004). Options for sustaining school-based health centers. J Sch
Health. Apr;74(4):115-8.
The Alberta Tobacco Reduction Strategy. (2003) Supporting Tobacco-free Schools Creating
Policy for Tobacco-free Schools Edmonton, AB: Alberta Alcohol & Drug Abuse Commission,
Edmonton, AB.
Thomas H, Siracusa L, Ross G, Beath L, Hanna L, Michaud M, Moore P, Partington B,
Voorberg G (1999) Effectiveness of school-based Interventions in reducing adolescent risk
behaviour: A systematic review of reviews. Hamilton, ON, Effective Public Health Practice
Program.
Thombs DL, Wollertt BJ, Farkash LG. (1997). Social context, perceived norms and drinking
behavior in young people. Journal on Substance Abuse, 9:257-67.
Thompson EA, Horn M, Herting JR, Eggert LL. (1997). Enhancing outcomes in an indicated
drug prevention program for high-risk youth. J Drug Educ. 27(1):19-41.
Tobler NS (1986), "Meta-Analysis of 143 Adolescent Drug Prevention Programs: Quantative
Outcome Results of Program Participants Compared To A Control Group or Comparison
Group", Journal of Drug Issues, 16(4), 537-567.
Tobler NS, Lessard T, Marshall D, Ochshorn P, Roona M. (1999). Effectiveness of school-
based drug prevention programs for marijuana use. School Psychol Int 20(1):105-137. (ADAI
rp 08666).
Tobler NS. (1997). Meta-analysis of adolescent drug prevention programs: results of the 1993
meta-analysis. NIDA Res Monogr. 170:5-68.
Tobler NS, Stratton HH (1997) Effectiveness of school-based drug prevention programs. A
meta-analysis of the research. Journal of Primary Prevention. 18(1): 71-129
Topping K. (2000). Tutoring. Geneva, Switzerland: International Bureau
255
256
of Education and the International Academy of Education. [Educational practices series,
booklet no. 5, see: www.ibe.unesco.org].
Topping KJ, Bremner WG. (1998). Promoting Social Competence: Practice and Resources
Guide. Edinburgh, UK: Scottish Office Education and Industry Department.
Tricker R, Davis LG. (1988). Implementing drug education in schools: an analysis of the costs
and teacher perceptions. J Sch Health. May;58(5):181-5.
Tubman JG, Soza Vento R. (2001). Principal and teacher reports of strategies to enforce anti-
tobacco policies in Florida middle and high schools. J Sch Health. Aug;71(6):229-35.
Turner GE, Burciaga C, Sussman S, Klein-Selski E, Craig S, Dent CW, Mason HR, Burton D,
Flay B. (1993). Which lesson components mediate refusal assertion skill improvement in
school-based adolescent tobacco use prevention? Int J Addict. Jun;28(8):749-66. (ADAI jl).
Underwoord J. (2003). The Value of Nurses in the Community. Ottawa, ON: Canadian Nurses
Association.
United States Department of Health and Human Services. (nd). Media Literacy Skills as a
Substance Abuse Prevention Strategy. Washington, DC: Author.
http://www.health.org/medltnew/wklyrd/index.htm.
Urberg KA, Degirmencioglo SM, Pilgrim C. (1997). Close friend and group infleunce on
adolescent cigarette smoking and alcohol use. Developmental Psychology, 33(5):834-44.
Utne O‘Brien M, Weissberg RP, Shriver TP. (2003). Educational leadership for academic,
social, and emotional learning. In: Elias MJ, Arnold H, Hussey C, eds. EQ + IQ = Best
Leadership Practices for Caring and Successful Schools. Thousand Oaks, CA: Corwin Press.
Valois RF, Hoyle TB. (2000). Formative evaluation results from the Mariner Project: a
coordinated school health pilot program. J Sch Health. Mar;70(3):95-103.
Van Nelson C et al. (1991). The Effect of Participation in Activities Outside the School and
Family Structure on Substance Use by Middle and Secondary School Students. Paper presented
to the Annual Meeting of the Midwest Educational Research Association. Chicago, IL. October
17.
Vertinsky PA, Mangham C. (1996). Making It Fit: Matching Substance Abuse Prevention
Strategies. Vancouver, BC: British Columbia School Trustees Association.
Wallerstein N, Sanchez-Merki V. (1994). Freiran praxis in health education: Research results
from an adolescent prevention program. Health Education Research, 9(1):105-18.
Wallerstein N. (1992). Powerlessness empowerment and health: Implications for health
promotion programs. American Journal of Health Promotion, 6(3):197-205.
Wang LY, Crossett LS, Lowry R, Sussman S, Dent CW. (2001). Cost-effectiveness of a
school-based tobacco-use prevention program. Arch Pediatr Adolesc Med. Sep;155(9):1043-
50.
Wang LY, Davis M, Robin L, Collins J, Coyle K, Baumler E. (2000). Economic evaluation of
Safer Choices: A school-based human immunodeficiency virus, other sexually
256
257
transmitted diseases, and pregnancy prevention program. Arch Pediatr Adolesc Med.
Oct;154(10):1017-24.
Wang LY, Yang Q, Lowry R, Wechsler H. (2003), Economic analysis of a school-based
obesity prevention program. Obes Res. Nov;11(11):1275-7.
Wang MC, Haertel GD, Walberg HJ. (1993). Toward a knowledge base for school learning.
Review of Educational Research, 63, 249-294.
Warren CW, Kann L, Small ML, Santelli JS, Collins JL, Kolbe LJ. (1997). Age of initiating
selected health risk behaviors among high school students in the United States. Journal of
Adolescent Health, 21(4):225-31.
Wartella E, Middlestadt S. (1991). The evolution of direct effects limited effects, information
processing, and affect and arousal models. In L. Donahew, HE Sypher & WJ Bukoski, eds.,
Persuasive Communication and Drug Abuse Prevention. Thousand Oaks. CA: Sage.
Webster-Stratton C, Taylor T. (2001). Nipping early risk factors in the bud: preventing
substance abuse, delinquency, and violence in adolescence through interventions targeted at
young children (0-8 years). Prev Sci. Sep;2(3):165-92.
Webster-Stratton, C. Preventing conduct problems in Head Start children: Strengthening
parenting competencies. Journal of Consulting and Clinical Psychology 66:715–730, 1998.
Webster-Stratton, C.; Reid, J.; and Hammond, M. Preventing conduct problems, promoting
social competence: A parent and teacher training partnership in Head Start. Journal of Clinical
Child Psychology 30:282–302, 2001.
Weeks K, Levy SR, Gordon AK, Handler A, Perhats C, Flay BR. (1997). Does parental
involvement make a difference? The impact of parent interactive activities on students in a
school-based AIDS prevention program. AIDS Educ Prev. Feb;9(1 Suppl):90-106.
Wehrmann KC, Shin H, Poertner MS. (2002). Transfer of training: an evaluation study. J
Health Soc Policy. 15(3-4):23-37.
Weijck KJE. 1982. Administering education in loosely-coupled schools. Phi Delta Kappan,
63:673-76.
Weiler RM. (1997). Adolescent perceptions of health concerns. An exploratory study among
rural midwestern youth. Health Education and Behavior, 24(3):287-99.
Weinsten NB, Rothman AJ, Sutton SR. (1998). Stage theories of health behavior. Conceptual
and methodological issues. Health Psychology. 17(3):290-9.
Weissberg RP. et al. eds. (1997). Healthy Children 2010: Establishing Preventive Services:
Issues in Children‘s and Families‘ Lives, Vol. 9. Thousand Oaks, CA: Sage Publications.
Weissberg RP, Kumpfer KL, Seligman ME. (2003). Prevention that works for children and
youth. An introduction. Am Psychol. Jun-Jul;58(6-7):425-32.
Weist MD, Lowie JA, Flaherty LT, Pruitt D. (2001). Collaboration among the education,
mental health, and public health systems to promote youth mental health. Psychiatr Serv.
Oct;52(10):1348-51.
257
258
Weist MD, Nabors LA, Myers CP, Armbruster P. (2000). Evaluation of expanded school
mental health programs. Community Ment Health J. Aug;36(4):395-411.
Weist MD. (2001). Toward a public mental health promotion and intervention system for
youth. J Sch Health. Mar;71(3):101-4.
Wenter DL, Ennett ST, Ribisl KM, Vincus AA, Rohrbach L, Ringwalt CL, Jones SM. (2002).
Comprehensiveness of substance use prevention programs in U.S. middle schools. J Adolesc
Health. Jun;30(6):455-62.
Werch CE, Carlson JM, Pappas DM, DiClemente CC. (1996). Brief nurse consultations for
preventing alcohol use among urban school youth. J School Health. 66(9):335-338. (ADAI rp
07346).
Werch CE, Anzalone D. (1995). Stage theory and research on tobacco, alcohol and other drug
use. Journal of Drug Education, 25(2):81-98.
Werch CE, Diclemente CC. (1994). A multi-component stage model for making drug
prevention strategies and messages to youth stage of use. Health Education Research, 9(1):37-
46.
Werch CE, Meers BW, Farrell J. (1993). Stages of drug use acquisition among college
students. Implications for the prevention of drug abuse. Journal of Drug Education, 23(4):375-
86.
Werch CE, Owen DM, Carlson JM, DiClemente CC, Edgemon P, Moore M. (2003). One-year
follow-up results of the STARS for Families alcohol prevention program. Health Educ Res.
Feb;18(1):74-87.
Werch CE, Young M, Clark M, Garrett C, Hooks S, Kersten C. (1991). Effects of a take-home
drug prevention program on drug-related communication and beliefs of parents and children. J
Sch Health. Oct;61(8):346-50.
Whelage GG, Rutter RA et al. (1989), Reducing the Risk: Schools As Communities of Support,
The Falmer Press, Philadelphia, PA.
White K.R. et al (1992) "Does Research Support Claims About the Benefits of Involving
Parents in Early Intervention Programs", Review of Educational Research, 62(1).
White MD, Fyfe JJ, Campbell SP, Goldkamp JS. (2001). The school-police partnership.
Identifying at-risk youth through a truant recovery program. Eval Rev. Oct;25(5):507-32.
Whitehead PC, Gliksman L. (1984). Parent Education: A Review and Analysis of Drug Abuse
and General Programs. Ottawa, ON: Health Canada.
Whitman CV, Aldinger C, Levinger B, Birdthistle I. (2000). Thematic Study on School Health
and Nutrition. Education Development Center, Collaborating Center, WHO.
WHO Expert Committee on Comprehensive School Health Education and Promotion. (1997).
Promoting Health Through Schools, Geneva, Switzerland: World Health Organization.
Wilks J, Callan VJ, Austin DA. (1989). Parent, peer and personal determinants of
258
259
adolescent drinking. British Journal of Addiction, 84(6):619-30.
Wilks J. (1992). Adolescent views on risky and illegal alcohol use. Drug and Alcohol
Review.11:137-143.
Williams CL, Perry CL, Farbakhsh K, Veblen-Mortenson S. (1999). Project Northland:
comprehensive alcohol use prevention for young adolescents, their parents, schools, peers and
communities. J Stud Alcohol Suppl. Mar;13:112-24. (ADAI jl).
Wills, T.; McNamara, G.; Vaccaro, D.; and Hirky, A. Escalated substance use: A longitudinal
grouping analysis from early to middle adolescence. Journal of Abnormal Psychology
105:166–180, 1996.
Willis E. (2000). School-based/school-linked health centers expanding points of access. WMJ.
2000 Jan-Feb;99(1):44-7.
Wilson E & McCall D, (1996). Comprehensive School Health. Canadian Perspectives,
Canadian Association for School Health, Heart & Stroke Foundation of Canada.
Winkleby MA, Feighery EC, Altman DA, Kole S, Tencati E. (2001). Engaging ethnically
diverse teens in a substance use prevention advocacy program. Am J Health Promot. Jul-
Aug;15(6):433-6, ii.
Witte K. (1995). Fishing for success. Using the persuasive health message framework to
generate effective campaign messages. In E. Mailbach & RL Parrott, eds., Designing Health
Messages: Approaches from Communications Theory and Public Health Practice. Thousand
Oaks, CA: Sage.
Wood RJ, Drolet JC, Fetro JV, Synovitz LB, Wood AR. (2002). Residential adolescent
substance abuse treatment: recommendations for collaboration between school health and
substance abuse treatment personnel. J Sch Health. Nov;72(9):363-7.
Woodward G, Manuel D, Goel V. (2004) Developing a balanced scorecard for public health.
Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, 2004.
World Health Organization. (1997). Expert Committee on Comprehensive School Health
Education and Promotion. Promoting Health Through Schools, Geneva, Switzerland: World
Health Organization.
World Health Organization. (2003). Rapid Assessment and Action Planning Process (RAAPP)
A Method and Tools to Enable Ministries of Education and Health to Assess and Strengthen
Their Capacity to Promote Health through Schools Department of Non-communicable Disease
Prevention and Health Promotion Division of Global School Health Initiative.
World Health Organization . 1991. Comprehensive School Health Education. Suggested
Guidelines for Action. Geneva, Switzerland: World Health Organization.
World Health Organization. (1998). Health Promotion Glossary, Geneva, Switzerland.
World Health Organization. (1997). Improving the performance of health clinics in district
health centres: Report of a WHO Study Group. Geneva, Switzerland: World Health
Organization.
259
260
World Health Organization. (nd). What is a health promoting school?
http://www.who.int/school_youth_health/gshi/hps/en/ Accessed on March 5, 2004
Wyn J, Cahill H, Holdsworth R, Rowling L, Carson S. (2000). MindMatters, a whole-school
approach promoting mental health and wellbeing. Aust N Z J Psychiatry. Aug;34(4):594-601.
Wyrick D, Wyrick CH, Bibeau DL, Fearnow-Kenney M. (2001). Coverage of adolescent
substance use prevention in state frameworks for health education. J Sch Health.
Nov;71(9):437-42.
Yaffe MJ. Developing and supporting school health programs. Role for family physicians.
Canadian Family Physician, Apr;44:821-4, 827-9.
Yamaguchi K, Kandel DB. (1984). Patterns of drug use from adolescence to young adulthood
(II and III). Sequences of progression. American Journal of Public Health, 74:668-681.
Yamaguchi R, Johnston LD, O'Malley PM. (2003). Relationship between student illicit drug
use and school drug-testing policies. J Sch Health. Apr;73(4):159-64.
Young M, Rausch S. (1991). Be a winner: Arkansas' approach to involving law enforcement
officers in drug education. J Drug Educ. 21(2):183-9.
Young TL, Ireson C. (2003) Effectiveness of school-based telehealth care in urban and rural
elementary schools. Pediatrics. 2003 Nov;112(5):1088-94.
Younoszai TM, Lohrmann DK, Seefeldt CA, Greene R. (1999). Trends from 1987 to 1991 in
alcohol, tobacco, and other drug (ATOD) use among adolescents exposed to a school district-
wide prevention intervention. J Drug Educ. 29(1):77-94.
Zapert K, Snow DL, Tebes JK. (2002). Patterns of substance use in early through late
adolescence. Am J Community Psychol. Dec;30(6):835-52.
Zavela KJ. (2002). Developing effective school-based drug abuse prevention programs. Am J
Health Behav. Jul-Aug;26(4):252-65.
Zins JE. et al. eds. (2003). Building School Success on Social and Emotional Learning. New
York, NY: Teachers College Press.
Zollinger TW, Saywell RM Jr, Muegge CM, Wooldridge JS, Cummings SF, Caine VA. (2003).
Impact of the life skills training curriculum on middle school students tobacco use in Marion
County, Indiana, 1997-2000. J Sch Health. Nov;73(9):338-46.
260
261
F. Appendix One – Theories & Questions Underlying this Review of Research
This assessment study is based on the application of evidence-based theory and conceptual frameworks
on population health, comprehensive school health promotion, ecological and systems theory and
organizational capacity. This brief summary describes the elements or principles inherent in such
approaches. These frameworks will guide the development of questions for the focus groups, surveys,
literature reviews, interviews and related work in this assessment.
Population Health Principles
The principles of a population health approach (Chomik, 2001) deemed to be relevant in this assessment
are:
1) Focus on determinants and interactions among them to identify more vulnerable populations.
Determinants such as economic status, educational attainment, gender, culture and genetic
make-up will not be directly modified but can be alleviated through public health and school
health programs. (Other interventions such as tax policy, legislation etc can be used to
modify these determinants but these are outside the scope of school-based or school-linked
health promotion.)
This principle leads to questions such as:
Does the evidence suggest that there are sub-populations within the youth
population that are more vulnerable to problem substance use?
Does the research indicate which of the determinants of health most affect the
substance use patterns habits of children and youth? How do they have those
effects? Are there any combinations of determinants that are demonstrably more
influential, either positively or negatively?
2) Balanced different perspectives when selecting a focus among populations, health issues and
settings.
For the most part, public health programs are driven by urgent health issues and the needs of
at-risk populations while school programs tend to be aimed at equal opportunity for all
school-aged children. Although the school setting is of shared interest to the two sectors and
the educators ―effective school‖ is close to that of the health professionals ―healthy schools‖,
these divergent perspectives between the two systems about the choice to focus on a sub-
population (vs all children), an issue (vs all development challenges faced by children) or a
setting (vs all settings in the community( may be seen as a barrier to sustained cooperation
between the two systems. (See St‘ Leger & Nutbeam (2000) for further discussion of
differing perspectives between the two systems.)
This principle leads to questions such as:
Does the evidence suggest that interventions aimed at the population of school-aged
children and youth will result in changes to substance use patterns that lead long-term
health outcomes? Does the effect last long enough to create a life-long effect?
3) Understand the impact of social and physical environments/settings.
There is growing interest, reflected in Canadian policy development (Advisory
Committee on Population Health and Health Security, 2003), and research funding in
the impact of selected contexts or environments in which people live, learn, work and
play. Obviously, schools are one of these environments. This project portrays the school
environment as a series of micro-environments (classrooms, hallways, cafeterias,
playgrounds, sports teams, etc.) that can offer a discontinuous experience for children,
or even for the same child in the same day. This project also sees these micro-
261
262
environments as interacting with other environments such as the home, recreation and
after school programs, local neighbourhoods, restaurants and stores.
This principle leads to questions such as:
Does the evidence suggest that the setting of the school is an effective place to
deliver education, preventive health services, social support and a protective,
healthy environment that prevent addictions?
Does the research describe which of the sub-populations or which of the specific
addictions/substance messages that can be reached or conveyed through school-
based or school-linked programs? How many children/youth of school age are truly
not present in school during the day? Which messages are more credible coming
from teachers, counsellors, peer helpers, coaches, parent volunteers, principals etc.
Which are more credible if they come from parents? From public health nurses? Etc
Does the research indicate that certain characteristics of the school environment (eg.
practices, staff, programs and services) interact with the characteristics of the
families (eg. Substance use habits, parenting practices, socio-economic status, race,
religion etc), communities (resources, norms, services/programs)or children
(genetics, intelligence, skills etc) in ways that promote or discourage substance use?
Does the research indicate to what extent those determinants can be influenced by
the school environment, as well as school, municipal, police and public health
policies, programs, services and practices in a sustainable way?
4) Select your population or sub-population carefully.
For program effectiveness and clarity of policy outcomes, health promotion programs should
clearly identify the target populations.
This principle leads to questions such as:
Does the evidence suggest that there are sub-populations within the children/youth
population that would benefit more from school-based or school-linked policies,
programs and services?
5) Integrate your approach with other health issues.
The integration of health-promoting messages across various health issues (eg nutrition and
physical activity, addictions and mental health) needs to be carefully considered. Recently in
Canada and in other countries, we have seen a convergence and linking of substance abuse
with life skills and more recently, mental health.
This principle leads to questions such as:
Does combining the prevention of substance abuse/addictions with other health issues
such as social skills, life skills, mental health, tobacco or within a risk/social behaviour
framework lead to enhanced intervention outcomes on addictions or overall health?
6) Select/frame your focus on the health issue – promotion or prevention, holistic or problem-
specific.
Public health programs and strategies need to select a focus that captures the attention of the
target audience and decision-makers, but that focus also needs to be durable and stable over
the long term. For example, the current public concern over marijuana laws can be useful in
promoting a drug prevention in agenda, but if it is perceived to be too narrow in focus, it will
be resisted by educators. As well, attention/funding may be drawn away once public concern
about the issue fades. By not acting with a holistic view of addictions, life skills and mental
health as well as not addressing other problems (tobacco, gambling, misuse of medications.)
and linking those multiple sub- issues to programs in health education overasll, we
262
263
may lose more than we gain.
This principle leads to questions such as:
Are there different impacts for programs based on different approaches (eg delay of
experimentation, abstinence, moderation or harm reduction) for all school-aged
children/youth or sub-populations within the children/youth population?
Does an approach based on life skills/social skills/social influences work more
effectively?
Does an approach based on specific resistance skills have an impact?
Should programs focus on so-called ―gateway drugs‖ such as tobacco or marijuana?
Should a program focus on addictive behavours? alcohol? all drugs? Illicit drugs?
Emerging drugs?
7) Coordinate multiple interventions across systems at all levels.
The premise of this population health principle is that there is a need for mandates, time and
other resources to coordinate school, public health, recreation and other systems. Such
coordination is possible, especially when using the school as a hub, but it is often difficult,
especially if such coordination is overly dependent on a crisis or the individual efforts of a
single agency or charismatic person.
This principle leads to questions such as:
Does the research indicate that a conscious, explicit and sustained effort to use a
wide range of multiple evidence-based interventions (using the school as a hub) to
influence the conditions and behaviours will lead to better health, social and
educational outcomes?
Does the research indicate that active and sustained coordination of these multiple
interventions will be cost-effective and economically beneficial?
Does the research tell us the most effective ways to coordinate across sectors and
systems?
8) Reorient systems towards prevention
For the health system, this re-orientation means a shift of resources from treatment and
emergency responses to prevention and promotion. Within public health, the shift is away
from the medical model of focusing on individual behaviours towards interventions that
affect environments, settings, policies, programs and services. This means more public health
activity in advocacy, coordination, delivery and access to preventive services, empowerment
of youth, parents and others and inspection of physical environments.
For school systems, this means a shift away from a narrow interpretation of the academic
function of schools in order to recognize that health education is a legitimate academic
discipline that leads to satisfying careers.
As well, a re-orientation of the school systems means a broadening of the socialization and
custody functions of schooling. Any such broadening of these two functions will require a
greater contribution from other sectors such as public health and social services or increased
funding to the school systems.
For both systems, this re-orientation means a greater attention should be paid to the psycho-
social environment of the school, as it is this environment that is often linked to health
outcomes, school retention/achievement and social behaviours.
This principle leads to questions such as:
Does the research indicate that a conscious, explicit and
263
264
sustained effort to shift health programming resources ―upstream‖ (i.e. re-
orientation of health services and health professionals to be more preventive) and to
have public health, schools and others to focus more on the psychosocial
environment of the school and several systems to seek improvements in the
physical environment of the school) will prevent specific conditions or behaviours
that most strongly affect the health and substance use of children and youth?
Does re-orienting schools to focus on the psychosocial climate (including school
improvement and effective schooling) have an impact on health and social
behaviours as well as learning?
9) Involve/empower individuals, groups and communities.
For schools and public health, the principle means paying greater attention to parent
involvement, education and support programs/resource centres, youth engagement in
decision-making, peer, leadership, community service and extracurricular programs,
involving volunteers and staff in decisions and better coordination between schools and
community agencies.
This principle leads to questions such as:
Does the research indicate that the involvement of parents, youth and the local
community in school-based and school-linked policies, programs, services and practices
will lead to better health, social and educational outcomes? Does the research describe
how youth, parents and community can be empowered and involved?
Does the research indicate that youth, parent, staff and volunteer involvement in
decision-making have a positive impact on health and learning outcomes?
10) Focus on public policy and advocacy.
This principle suggests that public policy related to school health promotion is required from
health and education ministries, from school boards, from regional health authorities and
from other agencies, from local schools and from professional certification and related
authorities. Those policies should address specific issues as well as require and encourage
coordination and cooperation at all levels in several systems. Effective public policy-making
includes implementation and evaluation as well as a written statement of goals, programs,
procedures and practices.
This principle leads to questions such as:
Does the research indicate that legislation/regulation interventions can be used
effectively generally in society as well as with schools/children to be effective in
influencing g behaviour or conditions that determine substance use? Does the
research also describe how proponents can successfully advocate for such policies?
Does the research indicate the ―school policies‖ (ie policies adopted by education
ministries, school boards, or schools, health ministries, regional health authorities
or local health authorities) are actually implemented, evaluated and enforced?
Are there studies that describe whether appropriate policy-making (that includes
managerial support, consensus development for implementation, adequate
resources, implementation timelines, reporting requirements) are being employed?
11) Build resilience and healthy behaviours in individuals.
Health education (formal and informal) is the primary means for individuals to acquire
functional knowledge about nutrition, substance abuse and overall health, develop coping
and general skills, learn new attitudes/beliefs and self-knowledge, improve their access to
social support, acquire greater awareness and use of health, nutrition and addiction services
and gain experience in developing personal nutrition/health action plans. Awareness,
264
265
information and knowledge may not be sufficient to change behaviours, but these attributes
may well be pre-requisites to behaviour change within individuals.
This principle leads to questions such as:
Has the research described programs that are based on stages of change and behavioural
theories?
Has the research described the key individual resilience characteristics and coping skills
needed? Functional knowledge needed? Attitudes and Beliefs Needed? Self-knowledge
Needed? General Skills and Specific Skills Needed? Awareness and Use of Health
Services Needed? Awareness and Skills needed to Access to Social Support from
friends, parents, others?
12) Develop and use surveillance, monitoring and regular health assessments.
The surveillance of substance use status and behaviours of school-age children and youth,
and an ongoing monitoring of policies and programs is an essential part of a population
health approach. Regular assessments of the national, provincial/territorial and local
situations are a necessity to effective health promotion.
This principle leads to questions such as:
Does the research tell us how relevant determinants can be described and monitored
through a system of reliable Indicators related to the school environment that can be
used to measure health, social and educational outcomes as well as the context,
inputs, processes and outputs of school and public health systems? Are there such
Indicator systems currently being used or contemplated?
Does the research tell us to what extent are current policies, programs, services and
practices in the two systems based on research evidence? Can we identify and
describe ministries or agencies that have consciously made decisions about major
school-based or school-linked programs or services based on such evidence?
Does the research indicate the nature of a minimum number of the most appropriate
measures to surveil and monitor substance use and related behaviours/status, FPT
policy and program status and local agency/community capacity that can be used to
report on system accountability?
This assessment will determine the organization current capacity of education and health ministries to
employ these principles of a population health approach.
265
266
Comprehensive Approach to School Health Promotion
Our knowledge about comprehensive school health promotion (Nutbeam & St. Leger, 1996;
Allensworth et al, 1997; World Health Organization Expert Committee on Comprehensive School
Health, 1997; Effective Public Health Practice Project, 2001; Micucci et al, 2004; Cuijpers et al, 2002 )
suggests that this assessment needs to address the elements of such an approach as described briefly
below:
1) Employs a comprehensive approach that views health in a holistic way, that integrates a wide
range of health and social issues and provides promotion, prevention, protection, assistance
and reintegration policies, programs and services from a variety of agencies.
Consideration of this element leads to questions such as:
Does the research indicate that school-based and school-linked programs are based
on recognized behavioural and environmental/determinants theories and
approaches?
Does the research evidence truly suggest that taking a holistic view of the child,
recognizing that substance abuse is usually part of a larger health, social or
developmental problem is more effective?
2) Describes the capacity of the school, both in terms of its potential and its limits, in working
with public health, addictions and nutrition agencies as well as with parents and youth groups
to influence the health status, behaviours and school-related influential factors/conditions.
Consideration of this element leads to questions such as:
Does the research indicate that school systems, public health and nutrition systems
have established appropriate Indicators of system performance that include
defensible program logic, contextual, input, process and output indicators as well as
appropriate outcomes data that are truly related to the program logic model?
Are there studies that describe systems that have established evidence-based
surveillance and monitoring systems relative to substance use among children and
youth?
3) Coordinates the interventions within the school and those linked to the school from other
agencies and deliver those interventions in sustainable ways and programs.
Consideration of this element leads to questions such as:
Does the research indicate if such coordination and cooperation increases the
impact on health, social and learning outcomes?
Does the research describe how the various interventions can be coordinated in a
sustained manner? Does the research describe effective models of school-
community programs and services that can be used to prevent problem substance
use? Does it describe how these can be developed and sustained in different
contexts?
Does the research describe ―whole school‖ approaches that are effective in
addressing the health, mental health and addictions related behaviours of
children/youth?
Does it describe how these can be developed and sustained in different contexts?
Does the research indicate if certain combinations of such interventions are more
effective, cost effective, cost-beneficial?
4) Implements multiple, effective, cost-effective and sustainable interventions that can be
delivered in the school setting, including:
266
267
a). Policies and practices that regulate or influence health choices.
b) Coordination of interventions in school-based and school-linked programs
c). Curriculum and instruction.
d) Delivery of preventive health, addictions, mental health and police services.
e) Generating social support from parents, adults, peers, local media.
f) Maintenance of a healthy physical environment.
Consideration of these elements leads to questions such as:
Does the research indicate which of the school-based and school-linked multiple
interventions listed below are effective?
Cost-effective? Cost-beneficial?
Does the research describe minimum dosage, duration, intensity, necessary qualities,
training required etc for these interventions?
5. Adapts programs and services to meet special needs and also ensures that the service
delivery is ―youth-friendly‖.
Consideration of this element leads to questions such as:
Has the research described special programs that were able to influence the
substance use of various groups who may be at higher risk of problem substance
use of addictions? Are there comprehensive models that address specific addiction
issues such as FASD, children of alcoholics, drinking and driving, experimentation
with illicit drugs, abuse of prescription or medications etc?
Has the research describe d the extent to which adolescents are aware of and make
use of preventive health and treatment services related to substance use? Does the
research indicate how such services can be made more ―youth friendly‖?
6. Establishes realistic outputs for school health programs and describes essential policies,
programs, practices and conditions.
Consideration of this element leads to questions such as:
Does the research describe the roles of the three or four primary systems responsible for
preventing problem substance use through schools (ie education, public health,
addictions and police agencies)?
Has the research describe realistic outputs for school-based and school-linked addictions
prevention programs that can be monitored over time? How do these outputs
(appropriate adolescent knowledge, skills, attitudes, changes to school environment,
access to services etc) relate to long-term health outcomes related to substance use?
Does the research clearly delineate the two (outputs after 12 years of schooling vs life
long health, social and learning outcomes)?
267
268
Ecological Understanding of Physical and Social Environments
The understanding gained from an ecological perspective on environments suggests that we ask
questions about the interactions between the environment and the individual. There is a dynamic
interplay between individual characteristics/capacities and their physical, social and perceived
environments. The same environment will affect different people in different ways. There is an inter-
play between immediate and more distant environments. Settings have multiple dimensions that include
social cohesion and emotional well-being.
Stokols (1996) addressed the challenge of translating social ecological theory into guidelines for
community health programs.
6. Environmental settings have multiple dimensions such as social cohesion, emotional well
being, development maturation, and physical health status.
7. Environmental factors may affect people differently depending on such factors as personality,
health practices, perceptions of the controllability of the environment, and financial resources.
8. Understanding the dynamic interaction between people and their environment requires the
application of such principles from systems theory as interdependence, deviation amplification,
homeostasis, and negative feedback.
9. This principle recognizes the importance of the interconnections between multiple settings and
life domains, and the close interlinkage between the social and physical facets of those settings.
Social ecology analyses emphasize the integration of multiple levels of analysis (for example macro
level preventive strategies of public health and epidemiology with micro level individual strategies from
medicine) with diverse methodologies (epidemiological analyses, environmental recordings, medical
examinations, questionnaires, and behavioral observations).
This assessment will seek to determine the extent to which current organizational capacity and practices of
education and health ministries take such ecological theory into account in their ministry practices, programs
and policies.
Systems Theory and Change
Systems theory (Weijck, 1982, McCall et al, 1999; Pidwirny, nd, Graham (2003) can and should lead us to ask
questions derived from the characteristics of education, public health, police, mental health and addictions
systems. These characteristics are similar for all these systems.
1) These systems are open to influences at a variety of levels, from the provincial level right
down to the classroom teacher or public health nurse.
2) These systems are loosely-coupled, where decision-makers at the top are dependent upon
workers throughout the system operating from a shared set of values, common vision and
consistent ways of interacting with clients and with each other.
3) These systems are professional bureaucracies where knowledge and information is a valued
commodity and control is exercised through standardization of such knowledge and skills.
Expertise is a source of power in such systems and can be used to counteract authority based
on position.
4) Managers tend to spend time on disturbances to the system and on managing the boundaries
between the system and the outside world.
Further, other knowledge developed about education systems and education change (Fullan, 1991, Hord
et al, 1988) and similar knowledge about public health, nutrition and addictions systems need to be used
in the interpretation of our findings.
268
269
Organizational Capacity
The capacity of key organizations within such systems becomes very important. This is particularly true
of those in leadership positions within such systems (such as provincial/territorial ministries of
education and health).
This analysis will focus on seven different organizational capacities suggested by the World Health
Organization (2003) and by several other sources (McCall, 2004). The capacities that need to be present
within education and health ministries are:
1) Explicit policy and managerial support for coordination of school-based and school-linked
programs and services.
2) Adequate staffing/infrastructure at the provincial and local/regional levels to sustain
coordinated policies, programs and practices.
3) Formal and informal mechanisms to support coordination and inter-ministry, interagency and
interdisciplinary cooperation.
4) Adequate time/resources to gather, analyze and disseminate knowledge and promote the use
of best or promising practices.
5) Ongoing and adequate pre-service and inservice activities as well as work place health
programs to develop the capacities of the work forces in education, public health and
nutrition systems.
6) Timely, reliable and usable surveillance of the nutrition health status, behaviours and
determinants relevant to school-age children and youth and ongoing monitoring of the
policies, programs, practices of local agencies and professionals in order that
federal/provincial/territorial policies and programs are both accountable to and grounded in
the realities of local communities
7) Early identification and appropriate management of emerging issues. Health and education
systems need to have clearly identified priority issues. But they also need to identify
emerging issues and address those issues, otherwise they will go outside the established
process and push their way into the open, loosely coupled system in another way.
In our view, it is the use of ecological/systems theory and organizational capacity that brings a unique
quality to this assessment. Based on research related to population health and school health, we know
quite a few things about evidence-based interventions that work if they have adequate time, funding and
human resources. However, by applying systems theory and by measuring organizational capacity, we
learn much more about what is sustainable in the real world of competing priorities and scarce
resources.
Strategic Thinking
We also add a third unique lens for this assessment; strategic thinking and planning. Through these
types of analysis, we can also anticipate some of the opportunities and barriers that will accompany
every effort to prevent harmful substance use through the school setting. By strategic planning, we do
not mean good operational planning. Strategic thinking looks at the why in order to maximize our
profile, funding recruitment or influence.
Why we do some things (and not others)
Why we select some partners (and not others)
Why we time some interventions and events to maximize their effect or chances of
success
Why we do things in a certain way
Consequently, strategic thinking consistently:
269
270
1. Scans the internal and external environment for strengths, weaknesses, opportunities and
threats.
2. Anticipates and manages emerging issues to maximize benefits to the organization.
3. Analyzes potential partnerships for their risks/benefits and potential two-way investments.
4. Worries constantly about cost-effects and cost-benefits.
5. Analyzes the positioning the issues and organizations.
There are several questions derived from the knowledge described above about the ecology of social
and physical environments, open systems, organizational capacity and strategic thinking. Some of those
questions were used to guide our literature review and are listed below.
1. Has the research identified and applied appropriate knowledge and theories about
organizations and systems to the prevention of addictions through schools? Have the
characteristics of ―open systems‖, ―ecological approaches‖, ―loosely coupled systems‖, and
―professional bureaucracies been applied to this issue?
2. Has the concept of ―organizational capacity‖ been applied to the prevention of addictions
through schools (This capacity would include explicit policy/leadership, adequate staff
infrastructure, formal and informal mechanisms for cooperation, ability to gather,
analyze and disseminate knowledge about best practices, health surveillance and program
monitoring, adequate workforce development and adequate strategic issue identification
and management processes.)
3. Have recognized theories about ―educational change and innovation‖, and ―diffusion‖ of
health promoting practices been applied to this issue? Are there studies that provide
descriptions of local agency roles and responsibilities, minimum and optimal staffing ratios,
health service delivery requirements, minimum instructional time for curriculum, etc? Are
there studies that have described successful or unsuccessful implementation and diffusion
strategies on school alcohol/drug programs?
4. Have theories related to government roles and levers to encourage or require cooperation
and coordination of polices and programs been applied to school alcohol/drug programs?
Have concepts such as shared vision, relationship building, continuum of cooperation,
strategies for promoting interagency cooperation, written protocols and formal committees
been examined? Have there been studies that describe the extent to which interministry,
interagency and interdisciplinary cooperation and coordination is occurring? Are there
examples of how governments have created and employed coalitions and councils to
develop, implement and evaluate programs?
5. Have there been studies on the knowledge, attitudes and perceptions of policy-makers and
decision makers and the ―knowledge transfer‖ process relative to the prevention of problem
substance use through schools? Has there been work on concepts such as ―non-rational
decision-making practices in such systems that affect decisions about alcohol/drugs in
schools? Do we know if systems have adequate mechanisms to collect, analyze and
disseminate knowledge about alcohol/drugs, children/youth and schools in appropriate
formats and through appropriate media? Are there mechanisms for publishing and
promoting best practices and best policies on school alcohol/drug prevention programs?
6. Have there been studies of the current practices, qualifications and job roles as well as the
―concerns‖ of staff in implementing changes related to alcohol/drugs in schools? Have there
been studies that examined appropriate and inappropriate models of staff development?
Have there been studies that have described the status and effectiveness of college and
university programs
270
271
Does the research describe how systems can identify and act upon emerging issues related to addictions,
children/youth and schools? Are there planned or regular ways that the systems, ministries and
agencies? Are there examples of systems, ministries that have consciously chosen to focus on an aspect
of addictions and children and youth for a defined strategic reason rather than just convenience, urgency
or external funding? Are there studies that show how alcohol/drugs can successfully compete or
cooperate with other health issues being addressed by the school system?
Application of these Theories and Concepts in this Assessment
There is an overlap between the several conceptual frameworks described above that is captured in the
chart below. Our findings for this literature review have been tabulated and described to address these
overlaps in a way that is less repetitive to read. We also developed the other instruments for this
assessment in a manner consistent with this chart.
The reader will note that in the chart, there are additional aspects related to implementation and
diffusion of these approaches and programs within the school and other settings. These include
conceptual frameworks that describe system and organizational change, educational reform and
innovation, how decisions are made by individuals within organizations, the process and politics of
policy-making and implementation, stages of change within individuals when they adopt new health
behaviours and others. However, given that the focus of this assessment is only on organizational
capacity at the provincial/territorial ministry level, we have not elaborated on these concepts in this
report. They are, however, listed briefly in the chart on the next page.
As noted in the introduction, this assessment of the organizational capacity of education and health
ministries to promote health, prevent substance abuse and promote healthy eating among children and
youth started with the adaptation of the WHO Rapid Assessment and Action Process tool. As we
considered this tool, we realized that that our research reviews, focus groups, surveys and interviews
needed to be guided by a set of appropriate conceptual frameworks and evidence-based theories.
The practical application of population health and school health frameworks helps us clearly identify
what provincial/territorial ministries ought to be striving to achieve through their policies, programs and
practices. The use of ecological and systems theory illuminates several issues immediately. If we don‘t
understand how open, loosely coupled, professional bureaucracies (such as schools and public health
systems) really function, then we will not be looking at the key elements of the situation.
The clearly stated list of organizational capacities that has adapted the WHO instrument also clarifies
our inquiry. Our introduction of strategic thinking principles (that maximize profile, influence, resource
allocations, effective partnerships, sustainability etc) will also extend the WHO framework.
The other conceptual frameworks such as diffusion and educational change would also be very helpful
in further inquiries into the implementation of ministry polices and programs but are beyond the scope
of this initial assessment.
Together, these frameworks will ensure that this assessment is strategic, evidence-based, focused on
organizational capacity and powerful through its analysis based on ecological and systems thinking.
271
272
Implementation/
Population Health Comprehensive School Health Ecological/Systems Theory Organizational Capacity Strategic Thinking Systems Change
Social Change
1. Focus on determinants (poverty, 4e. Physical Environment & Social Change
gender, culture) to identify Resources Theories
vulnerable populations
2. Balance perspectives on issues-
populations –settings
3. Understand 2. Understand limits of school 1. Interaction between individual 1. Scan environments regularly.
environments/settings setting, Examine micro-environments and environments 2. Interactions
within school with other environments 3. Multiple
dimensions of environments
4. Select population or sub- 5. Adapt programs for special needs.
population Ensure youth friendly.
5. Integrate with other health 1. Holistic view of health. Integrate Managers protect systems from 7. Identify, manage emerging issues 2. Anticipate, manage issues
issues health issues. disturbances strategically.
6. Select your issue. 5. Position issue and your
organization.
7. Coordinate multiple 3. Coordinate school-based and 5. Systems are loosely coupled 1. Explicit policy/manager support for 3. Analyze partnerships for risk, Theories, knowledge
interventions across systems at all school-linked interventions. coordination 2. Staff time/ infrastructure benefits, investments. on cooperation,
levels for coordination 3. Formal, informal coordination, inter-
mechanisms for coordination disciplinary practice
8. Reorient health systems towards 4c. Provide health, social services in 6. Change in professional 4. Knowledge Transfer (Best Practices Diffusion/
prevention, improve/reform school or linked to schools and work place bureaucracies occurs through Guidelines to decision-makers, Education Change/
systems to include health, have health programs. shared vision, knowledge, skills practitioners Organizational
both systems focus on social and Change Theories,
physical environment 4d. Improve psychosocial 5. Workforce Development Adult learning
environment through peer, parent,
whole school.
4e. Physical Environment &
Resources
9. Involve/empower individuals or 4d. Involve students, parents,
groups volunteers and staff in decisions
10. Focus on public policy 4a. Develop, implement, evaluate 4. Systems are open to influences at 4. Knowledge Transfer to Decision- Policy-making
school and PH policies all levels makers Theory
11. Build resilience/ behaviours in 4b. Establish curriculum, support Stages of Change
individuals instruction Theories, Learning
theory
12. Maintain surveillance of 6. Describe realistic outputs for SH 7. System Managers often focus on 6. Timely, reliable, PT and local data for 4. Assess cost-effect, cost-benefit. Knowledge about
child/youth health outcomes and programs and monitor school/public boundaries. surveillance and monitoring valid Indicator
monitor policies, programs and health/other policies &programs systems
272
273
capacity
273
274
274