Abstract

The aim of this study was to identify the main characteristics of school-based drug prevention programs in Brazil and verify whether these interventions apply the prevention principles suggested by the National Institute on Drug Abuse (NIDA). A cross-sectional study was conducted using a random national sample of 1,151 public and private school managers. The data were collected using an online questionnaire. Poisson regression was used to identify factors associated with the application of a greater number of prevention principles in the programs. The findings showed that programs were generally sporadic, had an average duration of one semester, incorporated different program models, and primarily directed at students. The most active organization in the delivery of programs was the Military Police. Private schools were shown to be 14% more likely to apply more good practice principles than public schools. Furthermore, programs delivered by school staff, health institutions, or departments of education were more likely to apply more prevention principles. Efforts are needed to improve drug prevention practice in Brazilian schools. Our findings show that, overall, school-based drug prevention programs do not apply the NIDA prevention principles.

Key words
Prevention; Drugs; Programs; School Health

Introduction

Prevention programs focusing on specific risk and protective factors have been found to be effective strategies for preventing school drug use¹1 Zavela KJ. Developing effective school-based drug abuse prevention programs. Am J Health Behav 2002; 26(4):252-265. aiming to create new protective factors and reduce the risk factors of school-age students²2 Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P. School-based prevention for illicit drugs use: A systematic review. Prev Med 2008; 46(5):385-396.^,33 Hale DR, Fitzgerald-Yau N, Viner RM. A systematic review of effective interventions for reducing multiple health risk behaviors in adolescence. Am J Public Health 2014; 104(5):e19-41.. Although many studies have shown the effectiveness of school-based programs in reducing or delaying the onset of alcohol and drug use⁴4 Foxcroft DR, Tsertsvadze A. Universal school-based prevention programs for alcohol misuse in young people. Cochrane Database Syst Rev 2011; 5:CD009113.^,55 LeNoue SR, Riggs PD. Substance Abuse Prevention. Child Adolesc Psychiatr Clin N Am 2016; 25(2):297-305., others have documented iatrogenic program effects⁶6 Werch CE, Owen DM. Iatrogenic effects of alcohol and drug prevention programs. J Stud Alcohol 2002; 63(5):581-590..

Studies in the field of prevention suggest that school-based drug prevention interventions should be research-based. That is, their effectiveness should have been demonstrated by evaluation studies, thus avoiding the waste of human and financial resources associated with actions that have little or no effect²2 Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P. School-based prevention for illicit drugs use: A systematic review. Prev Med 2008; 46(5):385-396.^,44 Foxcroft DR, Tsertsvadze A. Universal school-based prevention programs for alcohol misuse in young people. Cochrane Database Syst Rev 2011; 5:CD009113.^,77 Sloboda Z, Pyakuryal A, Stephens PC, Teasdale B, Forrest D, Stephens RC, Grey SF. Reports of substance abuse prevention programming available in schools. Prev Sci 2008; 9(4):276-287.. However, the implementation of research-based programs poses a challenge in various countries⁸8 Thom B. Good practice in school based alcohol education programmes. Patient Educ Couns 2017; 100 (Supl. 1):S17-S23..

Systematic reviews of the characteristics of drug prevention programs that produced positive outcomes identified the following effective elements: the use of interactive methods; adequate session length, number, and spacing; well-trained staff; and interventions that provide opportunities to practice and learn personal and social skills and address multiple domains such as family and community⁹9 Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane E, Davino K. What works in prevention: Principles of effective prevention programs. Am Psychol 2003; 58(6-7):449.^,1010 Peters LW, Kok G, Ten Dam GT, Buijs GJ, Paulussen TG. Effective elements of school health promotion across behavioral domains: a systematic review of reviews. BMC Public Health 2009; 9:182..

Based on the common elements of effective prevention programs, the National Institute on Drug Abuse (NIDA)¹¹11 National Institute on Drug Abuse (NIDA). Preventing drug use among children and adolescents: A research-based guide for parents, educators, and community leaders. North Bethesda: Diane Publishing; 2003. suggests a number of prevention principles that favor positive outcomes; that is, reductions in drug use among participants. It is suggested that prevention practitioners should be guided by recommendations on good practices based on the common characteristics of effective programs in order to increase the chances of success of preventions actions¹²12 United Nations Office on Drugs and Crime (UNODC). International Standards on drug Use Prevention. Viena: UNODC; 2013..

In Brazil, little is known about the characteristics of school-based drug prevention programs and whether such interventions incorporate the core elements of good prevention practices. It is therefore vital to identify and obtain a better understanding of these initiatives to support the safe implementation of effective programs in Brazilian schools.

The aim of the present study is therefore to identify the main characteristics of school-based drug prevention programs in Brazil and verify whether these interventions apply the prevention principles suggested by NIDA.

Method

Using a probability sample design, we conducted a cross-sectional study with a sample of managers of public and private schools located across Brazil’s five regions (South, Southeast, North, Northeast, and Center-West).

Sample

The target audience of this study were the managers of public and private middle schools and high schools located in urban areas and included in the national registry of basic education schools based on the 2012 School Census provided by the National Institute for Educational Studies and Research. A random sample was generated using Excel’s RAND function. The sample size of each region was directly proportional to the overall population of schools in the region by type (public and private), thus resulting in a self-weighted sample.

Sample size was calculated considering the finite population of schools (n = 52,065), a 95% confidence interval, absolute error of 3%, and response distribution of 50% (due to the lack of previous data on the prevalence of school-based prevention programs in Brazil), resulting in a sample of 1,046 schools. Considering that Web-based surveys have been shown to produce a lower response rate than traditional surveys¹³13 Granello DH, Wheaton JE. Online data collection: Strategies for research. J Counseling Development 2004; 82(4):387-393.^,1414 Andrews D, Nonnecke B, Preece J. Electronic survey methodology: A case study in reaching hard-to-involve Internet users. Int J Human-Computer Interaction 2003; 16(2):185-210., we opted for a final sample of 2,090 schools to account for potential non-responses.

A total of 1,151 valid questionnaires were received, 580 (51.1%) of which affirmed that the school had a drug prevention program (Figure 1).

Data collection

The managers were initially invited to participate in the study by a message sent to the school’s email using the online survey software SurveyMonkey. The respondents that failed to answer the survey after sending four emails were then contacted by telephone. The data were collected in the 2014 school year.

Instruments and variables

We used a self-administered anonymous survey with 45 closed-ended questions assessing the following: respondent characteristics; school characteristics; health education at the school; and respondent training in drug education and NIDA’s prevention principles. Some of the questions were taken from a questionnaire developed by Ringwalt et al.¹⁵15 Ringwalt CL, Ennett S, Vincus A, Thorne J, Rohrbach LA, Simons-Rudolph A. The prevalence of effective substance use prevention curricula in U.S. middle schools. Prev Sci 2002; 3(4):257-265.. The other questions were formulated by the authors to gain an understanding of characteristics specific to school-based prevention programs in Brazil. The understanding of these questions was tested by a previous study conducted in São Paulo¹⁶16 Pereira AP, Paes Â, Sanchez ZM. Factors associated with the implementation of programs for drug abuse prevention in schools. Rev Saude Publica 2016; 50:44..

The respondent characteristics assessed by this study were sex, age, education level, position at the school, and training in drug education. The school characteristics were school type (public or private), region, location, and school size. With regard to school prevention programs, we assessed the annual frequency of activities, duration, target audience, school grades targeted by the program, organizations conducting the programs, program model, and type of activities developed at the school addressing drug issues.

Finally, we assessed the adoption of good prevention practices based on 15 of the principles suggested by NIDA¹¹11 National Institute on Drug Abuse (NIDA). Preventing drug use among children and adolescents: A research-based guide for parents, educators, and community leaders. North Bethesda: Diane Publishing; 2003., in which programs should: enhance protective factors and reverse or reduce risk factors; address all types of drugs; address the type of drug abuse problems in the school; be tailored to the age and characteristics of the students; focus on family participation; focus on community participation; develop activities as early as preschool to address risk factors such as aggressive behavior, poor social skills, and academic difficulties; for elementary school children, focus on training skills such as self-control, emotional awareness, communication, social problem-solving, and academic support; for high school students, focus on study habits and academic support, communication, peer relationships, self-efficacy and assertiveness, drug resistance skills, and reinforcement of antidrug attitudes; reinforce the program at key transition points, such as the transition from middle school to high school and the last year of high school; combine two or more domains of prevention, involving school, family, and community-based programs; be adapted from research-based interventions; be continuous and long-term, reaching different grades at different times throughout the year; include teacher training on good classroom management practices; and employ interactive techniques, such as workshops, talking circles, role-playing, and group activities.

Data analysis

The qualitative variables were described using absolute frequencies, prevalence, and 95% confidence intervals. The numerical variable (number of prevention principles) was presented using means, minimum/maximum, and standard deviation. Inferential analysis was performed using Poisson regression to identify factors associated with a greater number of prevention principles, where the dependent variable (outcome) was the sum of prevention principles applied, ranging from zero to 15.

The independent (explanatory) variables were school characteristics (public or private, region, school size, and location) and the organizations conducting the drug prevention programs. A first model was applied including all variables that obtained p < 0.20 in the univariate analysis. Non-significant variables were then excluded in a step-by-step manner up to the final model, adopting a significance level of 5%. The results from the Poisson regression are presented as incidence rate ratios (IRR) and 95% confidence intervals (95% CI). All analyses were performed using the statistical software program Stata 13. Weighting adjustment was not applied because the sample was self-weighted. Non-responses were proportional across regions.

Ethical approval

This study was approved by the Research Ethics Committee at the Federal University of São Paulo. All respondents signed an informed consent form.

Results

Table 1 shows the characteristics of the respondents and schools. The results show that the majority of the schools were public, small, located in the Southeast region and in non-capital cities. The majority of respondents were school principals, women, aged between 40 and 49 years, and educated to postgraduate level.

Over half of the respondents (51.1%) reported that their school had a drug prevention program and were therefore asked to answer the questions regarding program characteristics (Table 2). In the majority of schools, the frequency of activities was irregular and the average duration of interventions was one trimester. Almost all the programs were directed at students and less than half involved the family and community. The data show that the majority of programs were directed at middle school students (sixth to ninth grade). Around 40% of the schools implemented programs delivered by school staff, while 30% reported that the programs were provided by health institutions. The most active organization conducting programs in the schools was the Military Police, delivering programs in 70% of schools. In this respect, 35.7% of the overall sample (411/1151) reported that they participated in PROERD, a national drug and violence resistance program implemented by the Military Police.

Table 2 also shows that the schools combined one or more program models. In this regard, more than 80% of the schools reported that they applied programs that focused on health education, affective education, and scientific knowledge, while 45% used scare tactics.

Almost 90% of the schools provided presentations with invited guests and around 40% used presentations with former drug users. Films and school assignments about drugs were also common drug prevention activities developed in the schools (Table 2).

Table 3 shows the prevention principles applied by the schools in drug prevention programs. The findings show that the majority of schools dealt with risk and protective factors and addressed all drugs and that programs were tailored to the age of the participants.

The average number of prevention principles applied was 8.3, ranging from 0 (the minimum) to 15 (the maximum) (standard deviation = 3.3; results not shown).

Table 4 shows the factors associated with the application of a greater number of prevention principles by programs. The results of the final model show that private schools were 14% more likely to apply more prevention principles than public schools. Furthermore, that fact that programs were delivered by school staff, a health institution, or the department of education led to an increase in the number of prevention principles applied by programs.

Discussion

The data presented suggest that school-based drug prevention programs are sporadic, directed primarily at middle school students (sixth to ninth grades), delivered mainly by the Military Police, have an average duration of one trimester, and incorporate different program models. The factors associated with the application of a greater number of prevention principles were: being a private school and the fact that programs were delivered by school staff, a health institution, or the department of education.

Some of the characteristics of drug prevention programs identified by this study are similar to those reported by a study involving 79 schools conducted in São Paulo in the 1980s by Carlini-Cotrim and Rosemberg¹⁷17 Carlini-Cotrim B, Rosemberg F. Drogas: prevenção no cotidiano escolar. Cad Pesquisa 1990; (74):40-46.. These authors reported that programs were sporadic, implemented by non-educational entities, and directed primarily at students. This finding suggests that little progress has been made towards the implementation of research-based drug prevention curricula over the last three decades.

Studies of school-based drug prevention programs in the United States showed that progress toward the implementation of evidence-based drug prevention curricula was slow⁵5 LeNoue SR, Riggs PD. Substance Abuse Prevention. Child Adolesc Psychiatr Clin N Am 2016; 25(2):297-305.^,1818 Hallfors D, Godette D. Will the Principles of Effectiveness' improve prevention practice? Early findings from a diffusion study. Health Educ Res 2002; 17(4):461-470.

19 Ringwalt C, Hanley S, Vincus AA, Ennett ST, Rohrbach LA, Bowling JM. The prevalence of effective substance use prevention curricula in the nation's high schools. J Prim Prev 2008; 29(6):479-488.

20 Ringwalt C, Vincus AA, Hanley S, Ennett ST, Bowling JM, Haws S. The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2008. Prev Sci 2011; 12(1):63-69.^-2121 Hanley SM, Ringwalt C, Ennett ST, Vincus AA, Bowling JM, Haws SW, Rohrbach LA. The prevalence of evidence-based substance use prevention curricula in the nation's elementary schools. J Drug Educ 2010; 40(1):51-60.. The findings showed that gradual progress was made in terms of investment and the development of consistent policy measures and the National Registry of Effective Programs and Practices¹⁹19 Ringwalt C, Hanley S, Vincus AA, Ennett ST, Rohrbach LA, Bowling JM. The prevalence of effective substance use prevention curricula in the nation's high schools. J Prim Prev 2008; 29(6):479-488.^,2020 Ringwalt C, Vincus AA, Hanley S, Ennett ST, Bowling JM, Haws S. The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2008. Prev Sci 2011; 12(1):63-69.. In Brazil, drug use prevention is one of the components of country’s national school health program (Programa Saúde na Escola - PSE), a partnership between the health and education ministries, the program is implemented in public schools with the support of primary healthcare centers²²22 Brasil. Decreto nº 6.286, de 5 de dezembro de 2007. Institui o Programa Saúde na Escola-PSE, e dá outras providências. Diário Oficial da União; 2007., in addition to being part of chapter 4 of the National Drug Policy²³23 Brasil. Resolução nº 03/GSIPR/CH/CONAD, de 27 de outubro de 2005. Aprova a Política Nacional sobre Drogas. Diário Oficial da União; 2005..

Our findings show that the primary target audience of programs are students (94.0%) and families have only limited involvement. This suggests that the majority of programs are not integrated with the community and family, one of the key elements of effective interventions for preventing substance use in adolescents²⁴24 Das JK, Salam RA, Arshad A, Finkelstein Y, Bhutta ZA. Interventions for Adolescent Substance Abuse: An Overview of Systematic Reviews. J Adolesc Health 2016; 59(4S):S61-S75.

25 Kuntsche S, Kuntsche E. Parent-based interventions for preventing or reducing adolescent substance use - A systematic literature review. Clin Psychol Rev 2016; 45:89-101.

26 Foxcroft DR, Tsertsvadze A. Universal family-based prevention programs for alcohol misuse in young people. Cochrane Database Syst Rev 2011; 9.^-2727 Griffin KW, Botvin GJ. Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am 2010; 19(3):505-526..

The average duration of interventions was one trimester. This time period may be considered adequate depending on program content⁹9 Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane E, Davino K. What works in prevention: Principles of effective prevention programs. Am Psychol 2003; 58(6-7):449.. The literature recommends that programs should consist of a series of 10 to 15 structured sessions to achieve positive prevention outcomes¹²12 United Nations Office on Drugs and Crime (UNODC). International Standards on drug Use Prevention. Viena: UNODC; 2013.. Thus, considering that sessions are delivered once a week, this would require a program duration of between 3 and 4 months.

The findings also show that the Military Police was the most active organization in the delivery of programs. At the time of the study, PROERD was based on the Drug Abuse Resistance Education (DARE) program developed by the Los Angeles Police Department²⁸28 Shamblen SR, Courser MW, Abadi MH, Johnson KW, Young L, Browne TJ. An international evaluation of DARE in São Paulo, Brazil. Drugs Educ Prev Policy 2014; 21(2):110-119.. An evaluation of the DARE program in the United States showed that the program was not effective in preventing drug use among adolescentes²⁹29 Pan W, Bai H. A multivariate approach to a meta-analytic review of the effectiveness of the DARE program. Int J Environ Res Public Health 2009; 6(1):267-277.

30 Vincus AA, Ringwalt C, Harris MS, Shamblen SR. A short-term, quasi-experimental evaluation of DARE's revised elementary school curriculum. J Drug Educ 2010; 40(1):37-49.

31 West SL, O'Neal KK. Project DARE outcome effectiveness revisited. Am J Public Health 2004; 94(6):1027-1029.^-3232 Perry CL, Komro KA, Veblen-Mortenson S, Bosma LM, Farbakhsh K, Munson KA, Stigler MH, Lytle LA. A randomized controlled trial of the middle and junior high school DARE and DARE Plus programs. Arch Pediatr Adolesc Med 2003; 157(2):178-184..

The data also show that the drug prevention programs combined one or more program models. In this regard, evidence shows that programs that combine various prevention models were considerably more effective than those based on only one model²³23 Brasil. Resolução nº 03/GSIPR/CH/CONAD, de 27 de outubro de 2005. Aprova a Política Nacional sobre Drogas. Diário Oficial da União; 2005.^,3333 Foxcroft DR, Tsertsvadze A. Universal multi-component prevention programs for alcohol misuse in young people. Cochrane Database Syst Rev 2011; (9):CD009307..

Although the majority of schools included models suggested by the literature, 45% still used scare tactics models, which have been shown to be ineffective in preventing drug use in adolescents¹⁰10 Peters LW, Kok G, Ten Dam GT, Buijs GJ, Paulussen TG. Effective elements of school health promotion across behavioral domains: a systematic review of reviews. BMC Public Health 2009; 9:182.. Around 40% of the schools reported the use of presentations by former drug users. Given that research has shown that this technique is ineffective and in some cases can result in negative outcomes, this finding suggests that these schools are not adopting evidence-based prevention practices¹²12 United Nations Office on Drugs and Crime (UNODC). International Standards on drug Use Prevention. Viena: UNODC; 2013.^,2727 Griffin KW, Botvin GJ. Evidence-based interventions for preventing substance use disorders in adolescents. Child Adolesc Psychiatr Clin N Am 2010; 19(3):505-526..

The findings also show that the majority of schools used presentations by invited guests, school assignments, films about drugs, and group activities, provided educational material, and held special events. However, it is not clear whether these actions were isolated one-of activities or integrated into the programs. School programs based on good prevention practices provide participants with practical experiences, in contrast to those that offer only information and discussion, enabling students to develop and practice new skills through interactive activities⁸8 Thom B. Good practice in school based alcohol education programmes. Patient Educ Couns 2017; 100 (Supl. 1):S17-S23..

The average number of prevention principles reported by the respondents was 8.3. The programs addressed risk and protective factors, provided information on the main types of drugs, focused on skills training for elementary school children, and employed interactive techniques. However, more than 60% of the programs were not adapted from research-based interventions, did not involve teacher training, and did not reinforce the program at key transition points, suggesting failings in important aspects of good prevention practices¹²12 United Nations Office on Drugs and Crime (UNODC). International Standards on drug Use Prevention. Viena: UNODC; 2013..

The number of prevention principles tended to be greater in private schools, which may be due to the greater availability of financial resources for training and the purchase of materials. In this regard, a study of factors associated with the implementation of drug prevention programs involving 263 principals from schools in São Paulo reported that lack of resources was a major obstacle to the implementation of effective drug prevention programs in public schools¹⁶16 Pereira AP, Paes Â, Sanchez ZM. Factors associated with the implementation of programs for drug abuse prevention in schools. Rev Saude Publica 2016; 50:44..

Finally, our results show that programs delivered by school staff, health institutions, and departments of education are more likely to apply more prevention principles. This finding highlights the importance of involving school staff and departments of education for the development of activities based on the prevention principles outlined in this study. Thus, it is evident that the expansion of the PSE³⁴34 Sousa MC, Esperidião MA, Medina MG. Intersectorality in the 'Health in Schools' Program: an evaluation of the political-management process and working practices. Cien Saude Colet 2017; 22(6):1781-1790. could help speed up progress in the adoption of evidence-based drug prevention practices in Brazilian schools.

Study limitations include the fact that it was not possible to contact 25% of the schools in the sample, thus hindering the generalization of our findings. Another limitation is the use of a self-administered questionnaire with closed-ended questions, which prevented a more detailed investigation of the programs and the respondents’ exact understanding of the questions. Ideally, we should have visited the schools to observe the prevention programs in practice; however, these methods were outside the scope of this study. Despite these limitations, it is important to stress that, to the best of our knowledge, this is the first attempt to assess the characteristics of drug prevention programs using a random national sample of Brazilian schools.

Conclusion

Efforts are needed to improve drug prevention practice in Brazilian schools. Our findings show that, overall, the activities developed in school-based prevention programs in Brazil do not apply the NIDA prevention principles. It is vital that those responsible for delivering school-based prevention programs are guided by evidence-based good practices. The provision of adequate training to prevention practitioners, development of national good prevention practice guidelines, and the formulation and implementation of evidence-based policies are just some of the actions needed to ensure the implementation of effective school-based drug use prevention programs and the integration of these interventions into school education plans. Future research should evaluate the efficiency and effectiveness of school-based programs in order to help school managers decide on the adoption cost-effective programs.

References

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