AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022

Health Promoting Schools: A framework for responding to drug-related issues
Jill Grove, National Centre for Education and Training on Addiction (NCETA)

Summary
Introduction
Survey
Health Promoting Schools
National Education Strategy
Conclusion and References

Summary

The costs to Australian society arising from the harms associated with drug use have been a powerful rationale for National, State and local community responses aimed at reducing these harms. These costs and in particular the use of drugs by young people has been the impetus for school-based responses. As theories and models have changed and developed in relation to drug use so have school-based approaches, moving from the early information only approaches and now towards a Health Promoting Schools approach. Multi-modal strategies within the Health Promoting School framework have the potential to be more effective than single approaches. The objectives of the National School Drug Education Strategy reflect the Health Promoting Schools framework
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Introduction

The term "drug", as used in this paper, is based on the World Health Organisation definition which defined a drug as "any chemical entity or mixture of entities, other than those required for the maintenance of normal health, the administration of which alters biological function and possibly structure. They may be used for the treatment or alleviation of disease, or for non-therapeutic purposes" [1]. Using this definition, drugs include substances such as medications, caffeine, alcohol, tobacco and the illicit drugs. The term "drug" may have a different meaning in other settings or in other sources of information.

The impact of harmful alcohol, tobacco and other drug use on Australian society has been well documented and is a major cause of concern. Illness and disease; injury, violence and crime, disruption of family and other relationships, problems in the workplace and the economic costs are significant areas of drug-related harm. In economic terms, the estimated cost to the Australian community, in 1992, was $18 845 million with tobacco accounting for 67.3% of this cost, followed by alcohol (23.8%) and illicit substances (8.9%) [2]. The impact of drugs on the individual and the community has been a powerful rationale for schools to provide "drug education" as a response to reduce drug-related harm. As drug use behaviour is a complex issue, for the school community, as with the national and state approaches, multiple strategies are likely to be more effective than single ones. "Drug education" is only one of these strategies. This paper will describe the past and present approaches to drug issues within the schooling sector, an outline of the current National School Drug Education Strategy and a brief overview of the currently available national data on drug use by Australian school students.
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School Student Drug Use: Results from the 1996 Survey

In 1996 a national survey on school students’ drug use was conducted, which for the first time included illicit drugs and some over-the-counter and drugs. Of the substances surveyed, the three most commonly reported substances used were all licit drugs. Analgesics (e.g. Panadol and Dispirin) were the most commonly used class of drugs, followed by alcohol and then tobacco. [3]. By the age of 17 years, only 3% of boys and 4% of girls reported they had never consumed alcohol and 56% of boys and 50% of girls were classed as current drinkers [4]. Also by the age of 17 years, 26 % of boys and 25% of girls had never used tobacco, with 28% of boys and 34% of girls being classed as current smokers [5].

Cannabis was the fourth most commonly used drug and the most widely reported illicit drug used [3]. At age 17 years, 56.6% of boys and 54.2% of girls reported that they had ever used cannabis and 20.1% of boys and 13.0% of girls had used it in the last week. Fewer students (aged 12-17 years) reported any use of the other illicit drugs or drug groups: hallucinogens (8.6%), amphetamines (6.1%), opiates (3.7%), ecstasy (3.6%), cocaine (3.6%), and steroids (1.8%) [6]. Lynskey et al [6] commented that many of the students who had ever used illicit drugs had done so only infrequently and had not used them recently.

Drug Education

The early school-based response to drug-related issues was to provide "drug education" to the students. As theories have been tested and changed so have the school-based responses. Many of the earlier school-based drug education programs were based on a primary prevention approach – that is preventing the initiation into drug use[7, 8]. As the term ‘drug’ includes medicines, caffeine, and alcohol as well as the illegal drugs, this approach was considered to be unrealistic given the widespread use of drugs in Australia. This was recognised in the South Australian Education Department’s 1977 Health Education curriculum document.

‘Individuals should understand the roles of drugs, their effects, and the reasons people use them. After all, drugs have been significant in many cultures for a very long time, and it would not seem realistic or desirable to expect community abstinence from them.’ [9]

The following is a brief overview of significant changes that have occurred since the first school-based drug education programmes commenced, in Australia, in the 1970’s.
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The Information-Based Model.

One of the early approaches to drug education was based on the concept that if young people were informed of the harmful effects of drugs then they would not use them. Some of the strategies used in this model included shock or scare tactics, talks by ex-users and "experts" with pharmacological and medical knowledge. Although these programs led to an increase in knowledge, they failed to reduce substance use and in some cases there were reports that the programs led to increased use [10].

The Affective Model

The next model has been referred to as either the affective model or the personality deficit model [11, 12]. This model assumed that young people used drugs because of low self esteem, poor communication and interpersonal skills. Strategies focussed on affective issues such as self esteem building and communication skills. Programs also avoided inclusion of any drug information [11]. Evaluation of these programs showed that they were not significantly effective in reducing the use of drugs. However some of the studies did not differentiate between experimental, social and problematic use. Also it has been show that having a high self esteem does not preclude drug use [13].

The Psycho-Social Model

This model was based on a blend of a number of theories including social learning theory [14]. The others were problem behaviour theory and social inoculation theory [11,15]. The psycho-social approach used a number of strategies including; providing students with relevant and accurate information, media analysis, role modelling, peer resistance and peer refusal skill rehearsal. The belief that peer influence was a prominent determinant of adolescent drug use led to a number of programs being developed that had a major focus on refusal skills, the "Just Say No To Drugs" programmes. It has now been suggested that peer influence is less important than has been commonly believed [16,17].

Ecological or Interactive Model

The psychosocial model ignored the influence the environment may have on the reasons for using a drug and also the possible consequences of that use. The ecological or interactive model has built on the psycho-social model [12]. This model recognises the complex interaction between the individual (e.g. gender, age, health, mood, and expectations), the drug (e.g. chemical properties, strength, and frequency of dose, method of use, and use with other drugs) and the environment (e.g place, time of day, other people and culture – community or group).

The Interactive Model

It has also been shown that teaching about drug-related issues is best conducted within an ongoing, comprehensive, developmentally appropriate health education curriculum [18].

From Health Education to Health Promoting Schools

A curriculum focus is only one approach that can be used to respond to drug-related issues. A number of essential elements have been identified to achieve the best education and health outcomes from school health programmes. These include:

• replacing the health education model with a health promotion model that uses multiple strategies,
• being comprehensive in concept (e.g. having policies which impact on the physical and psychosocial environment of the school, developing links with the wider community, including parents and health-related services),

• being comprehensive in content (not focus just on health problems but also include elements of personal and social development, life skills relevant to the students needs and the positive aspect of health as a resource for life), and
• be based on partnerships (e.g. between teachers, students and parents, and the school community with health practitioners and relevant agencies) [19, 20].

The health promoting school concept provides a framework for schools to develop a potentially more effective response to drug and other health-related issues, in line with the Interactive Model of drug use. While definitions of a health promoting school may vary the World Health Organisation [21] suggests a Health Promoting School can be characterized as a school that is constantly strengthening its capacity as a healthy setting for living, learning and working. The health promoting school aims to create an environment that promotes and enhances the health and well being of students, teachers and other school staff. It is an approach that develops and strengthens collaboration between members of the school community and the broader community.

Broadly there are three aspects to the health promoting school:

• Curiculum, teaching and learning,
• School organisation, ethos and environment, and
• Partnerships and services

This will be explored in more detail later.
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Three Interlocking Elements of a Health Promoting School [19]

Drug Issues Within the Health Promoting School Framework

In developing any responses to drug-related issues, a knowledge and understanding of a number of factors is required including the factors that underlay drug use. The National Drug Strategic Framework provides an overview of some of these factors, which include:

• social and cultural factors such as parental drug use, cultural norms within a particular group or setting,
• psychological factors such as stress, anxiety and depression,
• health factors such as chronic pain,
• market factors such as the promotion and availability of alcoholic beverages and medications, and
• economic and geographic factors such as income and levels of employment, lack of access to recreational and health services [22].

Many of the early responses to alcohol, tobacco and illicit drug use did not acknowledge that drug use is functional, that it is often has immediate benefits and mostly is experienced as pleasurable, and for some users it has been a rational choice [13, 16, 23]. However any drug use, including the legitimate use of medications is not risk free and for some people the non-use of their medication can carry a significant risk for themselves and, at times, may impact on others.

There are different levels of use from non-use, experimental, occasional and regular use through to dependent use. Use at a lower level does not mean that there will be progression to a higher level of use. Depending on the cost or benefits (real or perceived) that may be obtained from the use of any drug there may be movement in either direction. There are potential risks with any drug use. Movement to higher levels increases the potential risks to which the individual may be exposed. Different risks may be associated with intoxication, regular excessive use and with dependence [24]. For example, for school students using alcohol the majority of risks are more likely to be associated with intoxication but for students smoking tobacco the potential risks would be associated with dependence and regular use. Movement towards the higher levels of use may be associated with other problems in the individual’s life, for example, adolescents with mental health problems have reported a higher rate of other health-risk behaviours, including smoking, drinking and other drug use [25].

There are number of risk and protective factors that can influence drug use and other health and behavioural outcomes in young people [26-32]. Risk factors include: intra and inter-relationship problems, emotional, physical or sexual abuse; family disruption; parents’ or siblings’ problem drug use; education or employment issues; physical or mental health problems. Resnick et al [27] found that parent-family connectedness and perceived school connectedness were protective factors against all the health risk behaviours they measured, except for a history of pregnancy.

As with the level of drug use, the risks and problems associated with student drug use is not spread uniformly throughout the school student population and as there are significant links to other health risk behaviours a range of strategies is needed to respond to these. For schools this can include prevention strategies which may be universal or targeted for specific groups, school-based intervention strategies or referral to community-based intervention or treatment programmes. Whilst not inclusive of all the potential strategies, placing this within the Health Promoting Schools framework could look as follows.
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Curriculum, teaching and learning: Drug-related issues should be part of a planned, sequential health education programme and also integrated into other subjects [18]. The planning and implementation needs to take into consideration,:

• local issues and needs,
• student needs and learning styles.
• student-centered teaching, and

• experiential learning.

The teachers need to be supported with quality resources and professional development.

School organisation, ethos and environment: Many factors contribute to providing a caring and supportive environment for students and teachers. This includes having policies and guidelines for the management of issues such as:

• licit (including medications) and the illicit drug-related issues
• a smoke-free environment,
• harassment and bullying.

It also includes providing

• a range of alternative activities for students (e.g. sporting, drama, musical and community service activities), recognising and celebrating their achievement.
• support services for students and staff (e.g. peer support programs, school-based counsellors, nurses and chaplains).

Partnerships and services: Collaborative partnerships are an integral component of a health promoting school in developing a range of mutli-modal strategies. The partnerships can be between parents, students and teachers or the school community with human services providers in the broader community. These partnerships can support not only teaching and learning but can also contribute to a supportive and caring environment. Examples of this are:

• Encouraging school, parent and student interaction through newsletters, "take-home" activity worksheets, presentations of student learning and involvement in curricula and policy decisions.
• Health agencies and other services providing expert advice in the development of curricula, resources, policies, and school-based services and providing supportive services for students and staff.
• Linking school activities to community, state and national health promotion activities e.g. Quit campaigns, National Alcohol Campaign.
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National School Drug Education Strategy

Under the education component of the National Illicit Drug Strategy, funding has been provided to the Commonwealth Department of Education, Training and Youth Affairs (DETYA) to develop and implement the National School Drug Education Strategy. The goal of this strategy is ‘no illicit drugs in schools, however other drugs such as alcohol and tobacco are included. The objectives of the National School Drug Education Strategy articulate well with the Health Promoting Schools Framework. The objectives of the Strategy are as follows:

  Support the development of safe school environments for Australian students.

1. In conjunction with students, parents, related agencies and the broader school community, develop initiatives, programmes, and guidelines to support and enhance State and Territory drug education strategies.
2. Identify, disseminate and promote the use of good practice models of school drug education policies, programmes, curriculum and resources.
3. Enhance the range of drug education curriculum materials.
4. Enhance the professional practice of teachers and the school support staff and support the training of preservice teachers.
5. In partnership with other stakeholders such as health, inform engage and involve parents about drug related issues.
6. Observing community cultural protocols and in conjunction with students, parents and the broader community, identify areas of particular need and provide strategies for regions and/or targeted groups.
7. Maintain and strengthen the role of research in the development and delivery of school drug education programmes and ensure that school aged children are included in other relevant research under the National Drug Strategy [33].

The "National School Drug Education Strategy" document is supported by a companion document "National Framework for Protocols for Managing the Possession, Use and/or Distribution of Illicit and Other Unsanctioned Drugs in schools". This document also reflects the Health Promoting Schools framework and it recognises that "detachment from schools is an additional risk factor for further involvement in drug use, while involvement is an important protective factor". It is recommended that "strenuous efforts" should be made to retain those involved in drug-related incidents within an education or treatment setting [34]
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Conclusion

As there are a number of common risk and protective factors that underlie drug use behaviour and other health-related problems, agencies can take a more strategic approach by developing partnerships with other agencies and school community members. By working in partnership there is the potential of developing more cost effective multi-modal strategies that diminish the risk factors and enhance the protective factors for young people. This includes identifying what the school and its community members are best suited to manage, what each agency, institution or private provider can best provide and which can be best achieved by collaborative efforts. The Health Promoting Schools concept provides the ideal framework for the development of these partnerships and the strategies to respond to drug-related issues.

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Last Modified: 27-11-2002 10:11:18