School-Based Substance Use Interventions: An Overview of Systematic Reviews and Meta-analysis

Substance use among young people is a global public health challenge with a high burden in African countries, including Ghana. Behavioural interventions implemented in schools can be effective in preventing substance use among young people in Ghana; however, these interventions are currently lacking. Evidence-based frameworks can contribute to the design and implementation of behavioural school-based substance use prevention interventions; however, to be useful, it is important that they reflect the culture and context in which the interventions will be implemented. The goal of the study was to co-develop a framework to guide the design and adaptation of school-based substance use prevention interventions in Ghana. A multi-method approach to develop the framework was implemented in five steps: 1) definition of scope and objectives of the proposed framework, 2) evidence review and synthesis of existing school-based substance use prevention interventions, 3) a mixed methods study of young people's social networks in schools and its association with their substance use behaviour, 4) interest holder consultation (deliberative dialogue with 12 interest holders in Berekum, Ghana) to garner their recommendations for a school-based substance use prevention intervention in Ghana, and 5) framework iteration and its final visualization. The framework specifies what an ideal school-based substance use prevention should entail, components of the intervention, agents that can deliver the intervention, key interest holders to engage in intervention, and the application of theories, models, and frameworks in intervention design and adaptation. The SSUP framework provides a practical and flexible tool to guide the design and adaptation of school-based substance use prevention interventions in Ghana and similar contexts. It supports context-specific planning, interest holder engagement, and integration into existing school health promotion structure. Future research should explore its feasibility and effectiveness across diverse school settings. The framework offers a foundation for advancing locally grounded, prevention efforts across Africa.

BackgroundEarly-onset substance use is a risk factor for continued use, dependency, and poor long-term health outcomes. Indigenous youth are more likely to engage in early-onset substance use than their non-Indigenous counterparts. In Canada, culturally appropriate prevention programs are needed for Indigenous youth in elementary schools. Therefore, this scoping review aims to explore the published, international literature examining school-based substance use prevention programs for Indigenous children aged 7–13.Main textMethods: This scoping review followed a six-step approach: 1) identifying the research questions, 2) identifying relevant studies, 3) selecting the studies, 4) charting the data, 5) collating, summarizing, and reporting the results, and 6) consulting with experts. The review was reported using guidelines from Preferred Reporting Items for Systematic reviews and Meta-Analyses extensions for Scoping Reviews (PRISMA-ScR). Results: Eleven articles (3 Canadian; 7 American and; 1 Australian) were included in the review. The prevention programs they studied were based on existing research or were adapted from existing interventions. The programs were tailored to each communities’ culture by including Indigenous stakeholders in developing or adapting prevention programs to be culturally safe and responsive. The articles evaluated the programs’ Effectiveness in changing student knowledge, attitudes, and behaviors using pre- and post-intervention surveys, randomized control trials, longitudinally designed analysis, and mixed methods. Mixed quantitative findings and qualitative findings highlighted the programs’ value in building community capacity and fostering cultural revitalization.ConclusionThis review highlights best practices for developing school-based substance use prevention programs for Indigenous youth. Findings suggest that prevention programs should be culturally responsive and provide students with the knowledge and skills to prevent and manage substance use in real-life situations. Making Indigenous beliefs, values, languages, images, and worldviews central to the prevention curriculum enhanced the Effectiveness, appropriateness, and sustainability of prevention programs. Indigenous communities are best positioned to facilitate cultural tailoring without compromising the fidelity of evidence-based prevention programs.

Peers play an important role in the initiation and progression of substance use during adolescence. Consideration of peer influences is therefore a necessary factor to be included in prevention programs that aim to delay onset or minimise substance use amongst young people. The aim of this review was to examine how peer influences have been addressed by modern school-based substance use prevention programs. School-based interventions have addressed the role of peers in a variety of ways. These include designing programs based on social influence models, which target peer influence, peer pressure, and social norms, as well as including peers in the delivery of the intervention. More recently, informal peer-led interventions have been developed that utilise naturally occurring processes of information sharing between young people. Interventions that take a social influence approach, particularly those that are peer-led, appear to be an effective means of preventing adolescent substance use. Future research should continue to explore the benefits of informal peer-led programs, as well as developing secondary and tertiary programs that intervene to reduce risky use and promote help-seeking for existing substance-related problems.

ObjectiveThis study examined the associations between public health engagement (PHE) in school-based substance use prevention programs and student substance use. For the purposes of this study, PHE refers to any form of collaboration between the local government public health agency and the school to promote the physical and mental health of students.MethodsData for this study were collected from the Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking and Sedentary behaviour (COMPASS) study during the 2018/2019 data collection year. Multilevel logistic regression was used to analyze the associations between PHE and student substance use.ResultsData from 84 schools and 42,149 students were included; 70% of schools had PHE in substance use prevention programs. PHE in substance use prevention appears to have had no significant impact on student substance use in our models. When PHE was divided into five methods of engagement, it was found that when public health solved problems jointly with schools, the odds of a student using alcohol or cannabis significantly increased. When schools were split into low- and high-use schools for each substance measured, some methods of PHE significantly decreased the odds of cannabis and cigarette use in high-use schools and significantly increased the odds of alcohol and cannabis use in low-use schools.ConclusionThis study highlights the need to develop better partnerships and collaborations between public health and schools, and the importance of ensuring that school-based substance use prevention programs are evidence-based and tailored to the specific needs of schools and students.

The series of seminal meta-analytic studies of school-based substance use prevention program studies conducted by the late Nancy S. Tobler and colleagues concluded that programs with content focused on social influences' knowledge, drug refusal skills, and generic competency skills and that use participatory or interactive teaching strategies were more effective than programs focused on knowledge and attitudes and favoring traditional didactic instruction. The present study compared current school practice against evidence-based standards for "effective content" and "effective delivery," derived from the Tobler findings. Respondents were the lead staff who taught substance use prevention in the 1998-1999 school year in a national sample of public and private schools that included middle school grades (N = 1,795). Results indicate that most providers (62.25%) taught effective content, but few used effective delivery (17.44%), and fewer still used both effective content and delivery (14.23%). Those who taught an evidence-based program (e.g., Life Skills Training, Project ALERT), however, were more likely to implement both effective content and delivery, as were those teachers who were recently trained in substance use prevention and were comfortable using interactive teaching methods. The findings indicate that the transfer to practice of research knowledge about school-based substance use prevention programming has been limited.

Enhancing the delivery quality of school-based, evidence-based prevention programs is one key to ensuring uniform program effects on student outcomes. Program evaluations often focus on content dosage when implementing prevention curricula, however, less is known about implementation quality of prevention content, especially among teachers who may or may not have a prevention background. The goal of the current study is to add to the scholarly literature on implementation quality for a school-based substance use prevention intervention. Twenty-five schools in Ohio and Pennsylvania implemented the original keepin' REAL (kiR) substance use prevention curriculum. Each of the 10, 40-45 min lessons of the kiR curriculum was video recorded. Coders observed and rated a random sample of 276 videos reflecting 78 classes taught by 31 teachers. Codes included teachers' delivery techniques (e.g., lecture, discussion, demonstration and role play) and engagement with students (e.g. attentiveness, enthusiasm and positivity). Based on the video ratings, a latent profile analysis was run to identify typology of delivery quality. Five profiles were identified: holistic approach, attentive teacher-orientated approach, enthusiastic lecture approach, engaged interactive learning approach and skill practice-only approach. This study provides a descriptive typology of delivery quality while implementing a school-based substance use prevention intervention.

Addressing Common Risk and Protective Factors Can Prevent a Wide Range of Adolescent Risk Behaviors

Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online intervention

Objectives: Evaluate the association between school-based treatment of substance use disorders and academic outcomes by developing a system of simple and easily tracked academic performance metrics coinciding with an established substance use treatment program. Methods: This study provided treatment to 75 high school students enrolled without exclusion who voluntarily sought care for substance use disorders. Participants were enrolled in a 12-week program of individual motivational interviewing, acceptance and commitment therapy, family sessions, case management, contingency management, and psychiatric consultation at school-based health centers. We tracked distinct metrics of substance use treatment, including urine drug screens and self-reported use, along with three key metrics of academic performance referred to as the ABCs: attendance (No. of missed classes and percentage of days attended), behavior (No. of behavioral incidents per semester), and credits (grade-point average). Results: Participants in the study attended an average of 6.4 sessions and nearly 50% attained a negative urine drug screen. Participants demonstrated a significant reduction in behavioral incidents with an average decrease from 1.2 to 0.41 incidents per semester (p < 0.01). In addition, there was a reduction in the mean number of missed classes from 148 per semester to 127 (p = 0.001). Conclusions: School-based substance use treatment appears to be associated with a reduction in behavioral incidents and improved class attendance. This study provides the foundation for development of a robust school-based substance treatment program that can be rigorously evaluated against a control group for students with substance use disorders.

Background: Adolescent substance use is highly prevalent and problematic; it has been reported as one of the most pertinent leading health concerns in the United States. The current longitudinal study examined the presence of peer and parental interpersonal relationship consequences (IP) as a motivating factor in activating coping skills to decrease the frequency of adolescent substance use, while further evaluating the role of impulsivity within that process. Objectives: Two main hypotheses were proposed: (1) IP will decrease substance use frequency mediated by increases in motivation and temptation coping; and (2) impulsivity will moderate the link between coping and substance use frequency. Participants included 343 adolescents between the ages of 13-19 (M = 16.23) referred to Project READY, a school-based substance use intervention. Assessments were completed during Sessions 1 and 4 of the intervention. Results: Serial mediation analyses indicated temptation coping, baseline alcohol use, and Time 2 marijuana use were the only statistically significant predictors of Time 2 alcohol use. Temptation coping and baseline marijuana use were the only statistically significant predictors of Time 2 marijuana use. Conclusions: Once adolescents’ baseline and concurrent substance use were incorporated into the model, there was no statistical significance of the indirect effects. Results provided a stronger examination of the factors related to long-term substance use among adolescents. Knowing that temptation coping and baseline substance use levels were significant predictors of time 2 substance use independent of interpersonal consequences and motivation to change provides a structural frame and highlights need for early intervention.

Belonging to a school Gender and Sexuality Alliance (GSA) is associated with lower substance use among LGBTQ+ youth. However, it is unknown whether GSA participation facilitates access to resources for substance use concerns. Using longitudinal data from 38 Massachusetts high schools, we compared sources of support for substance use concerns listed by GSA members (n = 361) and nonmembers (n = 1539). Subsequently, we tested whether GSA membership was associated with comfort, confidence and awareness regarding substance use resources in school and the community. Finally, we assessed whether specific GSA activities and discussions (e.g. social support) were associated with these outcomes. Among students with recent substance use, GSA membership was associated with greater comfort, confidence and awareness regarding school-based substance use resources in the spring semester, adjusted for fall semester levels and non-GSA club involvement. Furthermore, students in GSAs where members reported more advocacy and social support activities reported higher levels of comfort, confidence and awareness regarding community-based substance use resources. These results indicate that among students using alcohol or nicotine products, GSA members may be more receptive to school-based substance use prevention efforts. Furthermore, GSA-based social support and activism experiences may promote access to community-based substance use resources.

We describe the conceptual framework and practitioner-based study outcomes of a school-based substance use prevention intervention focused on strengthening student commitment to their personal vision. This study found increases related to goal clarity and identification of a mentor following the intervention. We suggest implications for future school-based substance use prevention services and future research to evaluate the program.

Social interface model (SIM) explicates the important roles of family, peer, and school microsystems in intervention research. The present study used surveys to explore how Nicaraguan adolescents who participated in a school-based substance use and violence prevention intervention communicated about the intervention with parents, peers, and teachers. Latent class analysis was run to identify distinctive typologies of interfaces characterized by occurrence and importance of conversations. Five latent classes (N = 109) were discovered: optimal transference (21%), neutral transference (17%), limited positive transference (17%), negligible neutral interface (28%), and negligible adverse interface (16%). The optimal transference and neutral transference groups reported having conversations with all three microsystems (i.e. their mother, father, best friend, and teachers) and that those conversations resulted in seeing the curriculum the same way or as more important. The negligible neutral interface and negligible adverse interface groups reported minimal or no conversation across microsystems, which resulted in viewing the curriculum as not important or less important. The limited positive transference group reported selective conversations mostly with their mother and teachers, which was evaluated as important and/or neutral. Findings discuss the application of SIM in prevention research and provide a more nuanced understanding of how intervention messages are recalled and processed post-delivery.

Substance use in adolescence is a significant public health issue, particularly in early-to-mid adolescence, which represents a window of risk in the etiology of substance abuse and dependence. Substance use during this development period often results from affiliation with deviant peers, who model, facilitate, and reinforce use. Existing school-based substance use prevention programs have historically aimed to build adolescent knowledge regarding the dangers of substance use and/or enhance peer refusal skills. Research finds that these programs have had some success in reducing substance use, but meta-analyses report that average effect sizes are small. In a small one-year cluster randomized trial (12 middle and high schools; N = 813 students; ClinicalTrials.gov: NCT04478240), cooperative learning (CL) was implemented with the support of specialized technology and evaluated for its ability to reduce deviant peer affiliation and, in turn, reduce substance use. CL is a structured approach to small-group learning that provides at-risk youth with the opportunity to build friendships with more prosocial youth, interrupting the process of deviant peer clustering. Multi-level modeling revealed intervention effects for deviant peer affiliation and alcohol use across the sample, while tobacco use was significantly reduced among non-White students; intervention effects for marijuana use were only marginally significant. Effects for dosage were found for all outcomes, suggesting that every lesson taught had a significant impact. We conclude that CL, delivered with the aid of specialized technology, represents a viable option for universal substance use prevention. Future research should attempt to combine this approach with evidence-based prevention curricula.

Narratives play a powerful role in sharing meaning and making sense of experiences. Specifically, health narratives convey storylines, characters, and messages about health-related behaviors and provide audiences with models for healthy behaviors, prompting audiences’ health-related reflections and decision-making. Narrative engagement theory (NET) explains how personal narratives can be integrated into interventions to promote health. This study utilizes NET to test direct and indirect effects of teachers’ narrative quality on adolescent outcomes during a school-based substance use prevention intervention that includes narrative pedagogy and an implementation strategy. Observational coding of teacher narratives in video-recorded lessons along with self-report student surveys (N = 1,683) were subjected to path analysis. Findings showed significant direct effects of narrative quality on student engagement, norms (i.e. personal, best-friend injunctive, and descriptive norms), and substance use behavior. The analysis also yielded support for indirect effects of narrative quality on adolescent substance use behavior via student engagement, personal norms, and descriptive norms. Findings highlight important issues related to teacher-student interaction during implementation and contributes implications for adolescent substance use prevention research.