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Impact of drug abuse on academic performance and physical health: a cross-sectional comparative study among university students in Bangladesh

• Original Article
• Published: 07 January 2021
• Volume 31 , pages 65–71, ( 2023 )

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• Md. Safaet Hossain Sujan 1 ,
• Rafia Tasnim 1 ,
• Sahadat Hossain   ORCID: orcid.org/0000-0001-9433-202X 1 ,
• Md. Tajuddin Sikder 1 &
• M. Tasdik Hasan 2  

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Introduction

Drug abuse, the driver of human self-destruction, is rapidly increasing among university students and is emerging as a global health concern. Students who abuse drugs are lagging in respect of academic performance, achievement, and other co-curricular activities. This study aims to investigate the differences in academic performance between drug abusers and non-abusers, and the factors associated with drug abuse among university students in Bangladesh.

The study was a cross-sectional survey among the students of five public and semi-public universities in Bangladesh. The sample size was drawn by using the snowball sampling technique. Face-to-face interviews were used to collect data, and the data were analyzed using SPSS 25.0.

Of the 436 participants, 54.59% ( n  = 238) were drug abusers. Male students (68.43%) were found to be significantly ( p  < 0.01) more into drug abuse. Sociodemographic factors including residence status, academic year in university, father’s occupation, and personal income were significantly associated with drug abuse. There was a negative correlation between drug abuse and academic performance, academic achievement, and maintaining good health.

The findings of this study reported a high prevalence and magnitude of psychoactive drug abuse among the university students in Bangladesh, and stress the negative impact of drugs on the abuser’s academic life and physical well-being. Therefore, adequate campus-based initiatives should be extended for the prevention and treatment of drug abuse.

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Acknowledgements

We are very thankful to Md. Estiar Rahman and Mohosina Akhter from the Department of Public Health & Informatics, Jahangirnagar University; Saima Alam from the Military Institute of Science and Technology; Naznin Akter from the Govt. Titumir College; Amjad Hossen Hridoy from Dhaka University and Ariful Islam from Jagannath University for providing support in data collection. We also express our gratitude to all the participants in the study.

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Department of Public Health and Informatics, Jahangirnagar University, Savar, Dhaka, 1342, Bangladesh

Md. Safaet Hossain Sujan, Rafia Tasnim, Sahadat Hossain & Md. Tajuddin Sikder

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Correspondence to Sahadat Hossain .

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All procedures performed in this study involving human participants were in accordance with the ethical standards of the Department of Public Health & Informatics, Jahangirnagar University, Bangladesh and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This manuscript does not contain any studies with animals performed by any of the authors. Informed consent was obtained from all individual participants included in the study.

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Sujan, M.S.H., Tasnim, R., Hossain, S. et al. Impact of drug abuse on academic performance and physical health: a cross-sectional comparative study among university students in Bangladesh. J Public Health (Berl.) 31 , 65–71 (2023). https://doi.org/10.1007/s10389-020-01428-3

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Received : 13 June 2020

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Published : 07 January 2021

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DOI : https://doi.org/10.1007/s10389-020-01428-3

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School-based harm reduction with adolescents: a pilot study

• Nina Rose Fischer 1  

Substance Abuse Treatment, Prevention, and Policy volume  17 , Article number:  79 ( 2022 ) Cite this article

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A pilot study of Safety First: Real Drug Education for Teens showed significant results pre to post curriculum with high school freshmen. Negative outcomes of drug education are linked to a failure to engage students because of developmentally inappropriate materials that include activities that have no relevance to real experiences of young people. The few harm reduction studies showed increased student drug related knowledge. Students were less likely to consume substances, and less likely to consume to harmful levels. More studies are necessary to evidence harm reduction efficacy in the classroom. The goal of this study was to measure harm reduction knowledge and behaviors, including drug policy advocacy, before and after Safety First. Data were analyzed using McNemar’s test, ANOVA, linear regression, t -tests and thematic coding. Survey results, corroborated by the qualitative findings, showed a significant increase ( p  < .05) in high school freshmen harm reduction knowledge and behaviors in relationship to substance use pre to post Safety First. This increase related to a decrease in overall substance use. Harm reduction is often perceived as a controversial approach to substance use. These findings have implications for further study of what could be a promising harm reduction-based substance use intervention with teens.

Research has shown that common reasons drug education programs for youth have failed were lack of student interest because they were not developmentally appropriate, or because activities did not relate to their actual lives [ 1 , 2 ]. A review of school-based drug education studies [ 1 ] showed that for substance use education programs to be effective they should be based on the real experiences of young people, a harm reduction principle [ 1 , 2 , 3 ]. The study of Drug Policy Alliance’s (DPA) Safety First: Real Drug Education for Teens (hyperlinked) drug education curriculum for health education classes is grounded in harm reduction theory. The objective of the curriculum is to teach substance use harm reduction to support positive outcomes for young people.

Harm reduction theory

Harm reduction theory includes pragmatic strategies aimed at reducing dangers related to substance use. The theory emerged with the discovery of AIDS in 1981. Harm reduction was important for reducing transmission of blood-borne infections and for addressing drug use. Evidence has shown that harm reduction approaches greatly reduce morbidity and mortality associated with risky substance use behaviors [ 4 , 5 , 6 ] but has rarely been used to inform drug education curriculum for teenagers.

Harm reduction is an ecological systems approach, addressing drug use from the micro level, individuals, families and communities to the macro level, local, state, and federal policies and norms [ 3 , 7 , 8 , 9 ]. The theory promotes social justice with an emphasis on users’ rights, health, social and economic development, as opposed to the demonization of drug consumption [ 10 ]. Critical to the practice of harm reduction is recognizing that realities of poverty, class, racism, social isolation, past trauma, sex and gender-based discrimination and other social inequalities affect people’s capacity to address drug-related harm. Aims of this study were to measure student ability to understand and advocate for socially just harm reduction policy pre and post Safety First.

Harm reduction interventions vary according to dynamic needs of individuals and communities. The goals are to meet substance users “where they’re at,” incorporating a spectrum of strategies from abstinence, to managing use, to addressing conditions of use along with use itself. The theory adopts tenets of the trans theoretical stages of change model [ 11 , 12 ] and motivational counseling [ 13 ]. This non-judgmental, amoral approach encourages people to embark on incremental, harm-reducing goals. A harm reduction approach is congruent with what is known about adolescent development and decision-making. However, the most prevalent drug education for teens has been abstinence based, attaching stigma and moral judgment to substance use and users, instead of learning the effects and how to make informed, healthy decisions about use [ 14 , 15 ].

School based harm reduction programs have rarely received the attention of researchers. Limited studies exist about harm reduction drug education with adolescents in the US [ 1 ]. Only a few studies, from Canada, Australia and the UK showed positive results [ 1 , 2 , 16 , 17 ]. Classroom based harm reduction approaches are limited but are gaining traction in school settings because of the mixed or ineffective results from prevention and abstinence-based programs that failed to meet the real needs of youth [ 2 , 18 ]. The small pool of studies showed increase in drug related knowledge. Students were less likely to consume substances and were less likely to consume to harmful levels with themselves and peers [ 1 , 2 , 16 , 17 ]. Harm reduction can potentially address the shortfalls of prevention programs but remains contentious in the context of youth substance use, thus has not been widely studied within this population [ 2 ].

Dr. Marsha Rosenbaum, the founder of Drug Policy Alliance (DPA) developed a pamphlet for parents about harm reduction and teens in 1999 where she defined principles for school drug education and ultimately for the Safety First curriculum, “Parents and teachers are responsible for engaging students, providing them with credible information [to] make responsible decisions, avoid drug abuse, and stay safe. Curricula should be age-specific, emphasize student participation, and provide science-based educational materials.” Harm reduction principles require a non-judgmental, motivational, culturally relevant, actively engaging environment that puts student experience at the center of the curriculum [ 2 ]. Safety first includes these elements.

Safety First teaches students about different types of drugs including the short and long-term effects. Students learn how to identify viable research about drugs and discuss and present their findings in the classroom. Drug beliefs are discussed, myths are dispelled, and facts are validated. Behaviors associated with substance use are studied and discussed to inform student’s future decision making. These key principles make up the operational definition of harm reduction reflected in the Safety First curriculum and measured in the study.

The Safety First curriculum developers trained teachers that participated in the pilot studies for three, 8 hours sessions and coached them weekly for at least an hour in the content and modalities of the curriculum. The developers provided technical assistance for curriculum implementation. All teachers delivered the curriculum one to two times per week, depending on the schedule of their health classes, in each of the schools. The class lasted one semester, up to 14 sessions, at 55 minutes per class. The materials necessary for each class were all easily accessible through free downloads online and physically from the DPA curriculum developer/trainers. “How the curriculum was taught” was the variable that had the most effect on the efficacy of the curriculum and is analyzed below.

The overall goal of the study was to measure harm reduction knowledge and behaviors before and after Safety First. Diverse urban public schools were the foci for the pilots in New York City and San Francisco. Outcomes showed change from pre to post Safety First ( p  < .05) in knowledge and behaviors related to substance use. The results corroborated the findings from the few other similar studies [ 1 , 2 , 16 , 17 , 19 ]. This study evidenced need for further implementation of harm reduction based substance use curriculum as part of health education in high schools and for more research to measure the effects of the curriculum with various populations and locales.

The hypotheses of this study were related to the aims of the Safety First: Real Drug Education for Teens curriculum. The curriculum developers hoped to educate freshmen high school students about harm reduction knowledge and behavior. Students will 1) Acquire critical thinking skills to access and evaluate information about alcohol and other drugs [knowledge and behavior]; 2) Understand decision-making and goal setting skills that help students make healthy choices related to substance use [knowledge and behavior]; 3) Develop personal and social strategies to manage the risks, benefits and harms of alcohol and other drug use [behavior]; 4) Know the impact of drug policies on personal and community health [knowledge]; and 5) Learn to advocate for health-oriented drug policies [behaviors]. Thus student knowledge and behavior related to substance use and harm reduction were measured before and after Safety First as part of required health education classes to determine the efficacy of the curriculum.

Data collection

Hypotheses were tested through the collection of data from validated pre/post quantitative surveys (Additional file 1 : Appendix A in the data portal: Appendices A-D can be found in the Data Portal linked here) with items that measured substance use and harm reduction knowledge and behaviors [ 20 , 21 , 22 ] pre/post qualitative focus groups and one on one interviews with semi-structured field-tested guides; and field observation, on a weekly basis in each class with a field tested template. The 14-session (55 minutes/class) curriculum was implemented and studied in four freshmen health education classes at a public school in New York City and five public schools, four classes each, in San Francisco, CA. Researchers committed to different class periods and conducted field observation on different class days weekly to ensure inter-rater reliability [ 23 ].

Demographics (Table 1 )

Participants.

Students were recruited through both purposive and random sampling methods. Drug Police Alliance (DPA) built purposeful relationships with health teachers that wanted to implement Safety First as part of their required substance use unit in New York City. Relationships were built between DPA and San Francisco health teachers through the Adolescent Health Group- a Department of Education arm that oversaw health education curriculum. Students that participated in the pre/post focus groups and interviews were chosen randomly by alternating names on the class rosters.

The total number of freshmen surveyed in the overall pool was 701. Some students did not answer demographic questions which accounted for reduced “ n ” (Table 1 ). The items “What is the definition of abstinence” and “What is the definition of harm reduction” write in examples, were added to the San Francisco survey based on the findings from the initial New York City study. Thus the “ n ” for those items is less. Prior to Safety First most students had not received any drug education (96%). Students were 14 (62%) and 15 years old (31%). Outliers included 13, 16, 17, 18 & 19 years old (7%). Students were males (54%), and female (45.6%). In New York City two identified as “Other” and one as gender non-conforming (0.4%). The largest total ethnic/racial group was Asian (43%), then Latinx (22%), mixed race (12%), white (12%), Black (9%), Middle Eastern (1.8%) and Native American (.02%). In New York City white students were the largest ethnic/racial group, however youth of color made up the majority of the student population. In San Francisco Asian students were the majority student population, then Latinx. Black and white students were next with the same representation. Most New York City students resided in Brooklyn and Manhattan while other students were closely split between Queens and the Bronx. Most San Francisco students lived in Visitacion Valley and Excelsior district. Central Richmond, Outer Sunset and the Mission district vied for second. A small number of students in both cities reported police contact, arrest and/or suspension (Table 1 ). Youth reported substance use as a reason for police involvement.

Sample comparability

The total sample included three higher and three lower achieving schools, all public. The New York City school was unique because students applied and interviewed to be accepted. Pupils were high achieving coming in, average grades were “A’s” and “B’s.” All students planned to attend college and graduate school. Two out of the five San Francisco public schools were like the New York City site in grades and graduation rates but were not admissions based. The remaining three schools had students with lower grade point averages, with more of a range when asked about future plans. All were in politically progressive US coastal cities. All were ethnically diverse, and to an extent reflective of their city’s populations. All schools consisted of students from diverse economic backgrounds. Thus, this body of research from a sample of 701 students in New York City and San Francisco could possibly be extrapolated to students in similar locales with diverse achievement levels, racial and class demographics (Table 1 ).

Data analysis

McNemar’s test was applied to analyze if the harm reduction knowledge and behavior change from before to after Safety First was significant on four critical items (Table 2 ). One-way ANOVA tests were conducted to determine if there was an effect by demographics on substance use knowledge and behavior survey responses (Additional file 1 : Appendix B-D). Linear regression was employed to determine if race or gender were predictive of responses. Qualitative responses were aggregated using thematic codes based on the emergent themes from the “write in” responses on the pre/post surveys, and the interview and focus group transcription and were transformed into quantitative codes to count and compare student responses (Table 2 below, and items 40–44 in Additional file 1 : Appendix A and Appendix B in data portal). Outcomes showed that students learned critical thinking, decision-making and harm reduction strategies. Items that did not show remarkable results, or were null, also informed future implications for Safety First.

The purpose of this pilot study was to determine if DPA’s newly rolled out Safety First: Real Drug education for Teens potentially increased harm reduction knowledge and behaviors for high school freshmen. The findings from the pre and post survey, fortified by the qualitative data, showed a likely increase in student harm reduction knowledge about drug contents and effects, drug research, positive behaviors related to substance use, and drug policies. The results demonstrated that the curriculum most likely influenced overall student substance use knowledge and behavior.

Students showed change in knowledge about, and behaviors related to harm reduction, abstinence, how to detect an opioid overdose, school specific drug policies, and how to advocate for harm reduction based drug policy after Safety First ( p  < .001) (Table 2 ). Students were more involved with advocacy activities after Safety First than before ( p  < .001). It is likely that learning about activism and advocacy as part of the curriculum contributed to this increase in advocacy activities ( p  < .001). More youth advocated for less punitive drug policies after Safety First ( p  < .001).

Themes about drug policy advocacy that emerged from the qualitative data collected from the students after the class pointed to “creating systems of support,” “reducing stigma,” and “lessening punishments.” When before Safety First the themes were advocacy for suspension and jail time. Students mentioned passing along what they learned to fellow classmates, family members, and school administrators after the class to help them improve decision-making about drugs and create fairer drug policies.

ANOVA tests revealed that the most influential effect on student response was from the school they attended, indicating that how a specific teacher taught the curriculum most likely mattered (see below and Appendices B-D). Students from specific schools post Safety First showed more understanding of drug policies, how to advocate for harm reduction based initiatives, and how to respond to an opioid overdose (Table 2 ). However, there was remarkable change across all student comprehension despite differences in how the curriculum was taught.

Likert scale pre to post

Paired t- tests were conducted to determine if there was a significant difference between students’ scores on 20 Likert Scale items after the drug education course. The scale was one strongly agree and five strongly disagree. Seventeen were significant from pre to post Safety First ( p  < .001) (Additional file 1 : Appendix C). Two of the three items that had no statistical significance, “People do not become dependent upon marijuana,” and “If you overdose on a drug you will die,” still showed a shift towards disagree, the harm reduction response, through means comparison. The item “It is better not to drink water while using MDMA (“molly”)” did not show a significant change. The students agreed more with this statement after Safety First. The harm reduction answer was strongly disagree. More students also agreed that “Alcohol helps you deal with uncomfortable feelings” which showed a significant change from pre to post ( p  < .037), producing a null hypothesis. This outcome provides valuable feedback to the Safety First developers. They need to review how Safety First addresses harm reduction related to MDMA and alcohol.

Gender and race

For San Francisco, an Independent Sample t -test showed “Gender” mattered on two items. More males strongly disagreed that “Marijuana is safe because it is all natural,” than females ( p  < .001). More females moved to strongly agreeing that “You can die from drinking too much alcohol at one time” after Safety First than males ( p  < .001). An independent t -test was administered to measure if gender had an impact on students’ scores on the Likert Scale items. There was a significant difference between males and females on two items in New York City (Additional file 1 : Appendix C). Females were less likely to agree than males that, “People do not become dependent on marijuana,” ( p  < .05). Females were also less likely than males to agree that zero tolerance drug policies make schools safer ( p  < .05). A linear regression demonstrated that race and gender ( p  > .05) were not predictive of significantly different test scores in either city. In San Francisco more males strongly disagreed than females about the item “Marijuana is safe because it is all natural” ( p  < .001). On the item “You can die from drinking too much alcohol at one time” females more strongly agreed than males ( p  < .001).

An ANOVA test showed that race and religion had an effect on student responses. Asian students were more likely to move towards disagreeing with the statement “Marijuana is safe because it is all natural” which was the harm reduction response, in comparison to Latinx and Black students ( p  < .001). Muslim students were more likely to move towards disagreeing with the statement “People do not become dependent upon marijuana,” in comparison to Jewish students ( p  = .020). ANOVA tests showed school site had the most influence on student responses to the Likert Scale items from pre to post (Additional file 1 : Appendix C).

Pre to post: substance use behaviors

On the pre/post survey there were questions about amount and likelihood of specific substance use: 1) to understand prevalence of substance use amongst the population; and 2) to see if learning about harm reduction influenced students’ behaviors/decision making. The majority of students did not report smoking or vaping tobacco but the few students that did, smoked a significant amount, this did not change from pre to post. For marijuana, students reported decreased use from pre to post ( p  < .001) (see below and Additional file 1 : Appendix D). Marijuana use with a date showed remarkable change from “I would probably not use” to almost completely “I would definitely not use marijuana” ( p  < .001). There was a decrease in alcohol use from pre to post ( p  < .001). There was also an overall decrease in students reporting prescription drug use ( p  < .001) (Additional file 1 : Appendix D).

ANOVA tests were administered to see if the demographic factors had an effect on the substance use behavior outcomes from pre to post Safety First (Additional file 1 : Appendix D). A one-way AVOVA yielded that Asian students were more likely to move towards “I would definitely not take/smoke weed with family” than Black students ( p  = .002). An independent sample t -test evidenced that young men were more likely than young women to use prescription drugs with friends ( p  = .020). Results evidenced that students learned about harm reduction strategies. Prevalence of substance use amongst the population became clearer; harm reduction influenced students’ substance use behaviors/decision making from pre to post especially in relationship to marijuana and prescription drugs (Additional file 1 : Appendix D).

More students believed that their classmates were using substances after Safety First than before. This change indicated that the class could have made the students more aware of substance use prevalence. This reported prevalence reflected national numbers for this age group [ 24 ]. In 2016 SAMSHA’s comprehensive report on drug abuse and health showed that 7.3 million youth between 12 and 20 reported alcohol use. About 1 in 5 drank alcohol in the past month. An estimated 855,000 adolescents aged 12 to 17 smoked cigarettes in the past month [ 24 ]. An approximated 24.0 million 12 or older in 2016 were current users of marijuana and approximately 1.6 million adolescents used marijuana in the past month. The national study spoke to the prevalence of drug use by 14- and 15-year-old young people shown in the study [ 24 ]. Student receptivity to harm reduction strategies, substantiated collaterally through the overall reduction in student use, validated the potential relevance of this approach with high school students, starting with freshmen.

Overall harm reduction knowledge and behavior change

Thematic qualitative coding was used to identify the most emergent themes in this data. A code was assigned to prevalent themes and counted and compared to determine outcomes (Additional file 1 : Appendix B). Young people demonstrated an understanding of key harm reduction thought processes and strategies solidifying successful aspects of the Safety First curriculum [ 3 ]. Students made change in their ability to describe specific harm reduction strategies possibly due to Safety First ( p  < .001). In response to “What would you do to make substance use safer?” More youth responded “1” “Realize and plan for set/setting and limits around goal setting related to substance use,” or understand the “Contents, dose, and dosage” than narrowly, “reduce harm” [ 3 ] after the class (Additional file 1 : Appendix B).

Neighborhood, class and race

Interviews unearthed themes related to a difference in student perceptions about substances based on neighborhood, class and race. Students that lived in lower income neighborhoods that were predominantly black and brown consistently believed that one should not do drugs because of the consequences observed in the community. For example, when asked, “What happens in your community when someone is under the influence of drugs or is found with drugs on them?” A 14-year-old African American young woman from Brownsville Brooklyn responded in the pre and post interview, “Arrest. People get shot. People go to the hospital. People go to jail.”

When asked the same question before the class, a white female student that lived in the Upper Westside of Manhattan stated,

I have to admit that I live in a privileged neighborhood. So the use of drugs actually wouldn’t be that bad. Because it’s not like there’s the strongest police force patrolling my neighborhood, which is a huge part of it, like a part that I have to admit.

When asked the same question after Safety First she answered, “… there’s such a low risk for me to be put in a position where I’m...criminalized. So I don’t have to worry walking down the street if I have weed with me or something.”

When asked, “Are different groups of people treated differently if they have or are using drugs? If so, how?” the same African American young woman above explained the neighborhood, class and race differences:

If you seem like a person from a rich up town neighborhood or family using them [drugs], you would immediately think that they got them from somebody else. And then you will look to someone from a poor community who has them [drugs] and blame them, which is a stereotype that I really hate. I think that most of the times if someone from a rich family gets caught with drugs, they’re not gonna get nothing more than a warning. If someone from a poor community or an African or the Hispanic race gets caught, they are going to jail.

A young white woman from an affluent neighborhood’s pre response corroborated her response through her answer to the same question,

At my middle school there was a situation where a guy, mixed race black and white, bought weed for his friend, a white girl. Then she was high in school with that weed. She didn’t even get into as much trouble as the kid who bought it. Everyone in the school was pointing out, he’s biracial, so he’s black. He had a two-week out of school suspension for buying her the weed off campus and she had nothing.

Her post response to the question, “Are different groups of people treated differently if they have or are using drugs? If so, how?” was informed by the drug policy race and class session,

For sure. Low-income groups, African American communities, people of color in general, are so much quicker to be criminalized and prosecuted for having drugs, especially marijuana. I know now that there’s a disproportionate incarceration rate for men of color caught with marijuana.

Themes from student interviews, focus groups, and “write in” answers about the unequal treatment of people using or selling substances because of race, class and neighborhood reflected class lessons from Safety First about inequality in drug policy implementation. The findings indicated that the class increased student knowledge about critical social justice topics. Social justice is key to the harm reduction approach [ 25 ].

Student evaluation of safety first

The majority of students had a positive evaluation of Safety First. Fifty-five percent ( n  = 389) of students reported that they would recommend Safety First. Thirty-nine percent ( n  = 274) stated they would recommend Safety First with some changes. Six percent ( n  = 45) relayed they would not recommend Safety First. Thus 94% of the students believed Safety First was a worthwhile experience. Quantitative coding of the most prevalent themes from the qualitative data sources informed what the students liked best about Safety First.

Direct quotes exemplified the coded themes: Code “1” learning about harm reduction strategies, including what to do in an overdose, a non-judgmental approach to teaching drug education, and I liked ‘everything’: “I actually learned a lot and didn’t feel like I was just being told that drugs were awful, and trying them makes you an awful person,” “I learned how to be safe and smart;” “High schoolers are more prepared for anything involving drug usage and overdose;” “It was not one of those ‘DARE’ abstinence only curriculums where they try to convince you that weed is a gateway to heroine and you will die if you try molly. I actually felt like I learned something that wasn’t fear based;” and “You seem to have tried really hard to make this curriculum great and it shows.” Code “2” learning about different substances: “I like learning about the different effects different drugs can do to your brain and body.” Code “3” the interactive/engaging activities and liking how the teacher taught the class overall, “I liked the different activities that we did that demonstrated different scenarios and substances, also the teacher explained it very well” and “I liked the part where we drank the Koolaid for a party experiment.” Code “4” videos and mixed media, “The videos including the ASAP science videos,” and “I absolutely love that youtube channel,” “I liked the videos, they were informative.” Code “5” was “Nothing” or “I Don’t Know.” “Learning about specific substances” ( n  = 216, 40%) was what the majority of students liked about Safety First. Students wrote “Nothing” or Didn’t Know second ( n  = 137, 25%); the interactive and engaging activities third ( n  = 87, 16%); learning harm reduction strategies fourth ( n  = 81, 15%) and videos were the least mentioned ( n  = 18, 3.3%).

“No Judgement,” “Harm Reduction Skills,” and “Real Drug Education” were other themes that emerged in the post evaluation of the curriculum: “I liked that it wasn’t very judgmental and understood that the chance of kids trying drugs is likely. I also liked the harm reduction strategies,” “I liked how the curriculum went in depth about the side effects of drugs and taught us how to research and find correct information about a drug. It was well organized, and I got so much out of it,” and “It did not look down on people who used! Safety First stated facts and was looking out for our well beings; no biased opinions.”

The data illustrated that youth learned about both harm reduction skills and knowledge, appreciated the non-judgmental element of the approach and enjoyed when it was taught using dynamic, interactive teaching modalities with mixed media.

The results demonstrated that after Safety First student harm reduction knowledge and behavior changed after Safety First ( p  < .05). Prevalence of substance use amongst this student population became clearer. The issue of prevalence, as described above, is quite critical. Regardless of their moral beliefs parents, teachers, administrators, policy makers and a continuum of social services need to know that 14- and 15-year old’s are using substances, and for some, a remarkable amount daily and weekly (see below and Additional file 1 : Appendix D). Entrenched beliefs by policy makers and institutions that “abstinence-based drug education is more effective” persist even with the preponderance of evidence to expose their inefficacy and actual harm [ 14 , 15 ].

The goals of the Safety First developers did not expressly include reducing substance use. True harm reduction does not stigmatize substance use or assume that it is inevitably “wrong” or “dangerous.” [ 3 ] As a researcher I was curious about whether there would be a collateral effect from the curriculum on student drug use, since institutions that promote drug education often see reduced use and abstinence as a goal. Collateral findings did show a significant relationship ( p  < .05) between increased knowledge and skills with reduced substance use over the course of the semester. Teaching students harm reduction influenced students’ substance use behaviors/decision making from pre to post especially in relationship to marijuana and prescription drugs (below and Additional file 1 : Appendix D).

Likert scale items

Seventeen of the Likert scale items on the pre/post survey were significant from pre to post Safety First because students’ answers demonstrated an increase in harm reduction knowledge and behaviors ( p  < .001) (Additional file 1 : Appendix C). The item “It is better not to drink water while using MDMA (“molly”)” did not show a significant change. The students agreed more with this statement after Safety First. The harm reduction answer was to “strongly disagree.” More students also agreed that “Alcohol helps you deal with uncomfortable feelings” which showed a significant change from pre to post ( p  = .037), producing a null hypothesis. The harm reduction answer was to “strongly disagree.” This outcome provided valuable feedback to the Safety First developers. They need to review how Safety First addresses harm reduction related to MDMA and alcohol.

The teaching effect

ANOVA tests revealed that the most influential effect on student knowledge and behavior change was from the school they attended. How the curriculum was taught was the most influential variable. Teachers need training and coaching about how to implement Safety First. Technical assistance must be available from the purveyor or other trained experts to ensure fidelity. Importantly, there was still remarkable change across all student comprehension despite differences in how the curriculum was taught.

Study limitations with recommendations

The recommendations that stem from the “Discussion” are to include more curricula about MDMA and alcohol; provide coaching, training and technical assistance for teachers to adhere to fidelity of Safety First and to use dynamic, interactive, engaging pedagogical modalities in the classroom.

Abundance of data

An abundance of data points were collected for this study. More explication and discussion of fidelity issues, classroom observations and teacher evaluations are rich fodder for future manuscripts. Further discussion and recommendations could be mined from additional analysis. An article that dives more deeply into solely the qualitative data would give nuanced texture to the unique narrative of the Safety First classroom experience. Ethnography and phenomenology could both be used for the data analysis of interviews, focus groups, field observations and “write in” survey data to produce additional, compelling literature.

Sustainability

Although there have been no longitudinal studies of a high school substance use harm reduction curriculum, research of drug prevention programs over time showed that positive effects last throughout high school but taper off after [ 26 ]. Most schools only require one semester of health. This pilot study showed that in 14 classes students learned advocacy skills to promote creative harm reduction oriented policies. A sustainability recommendation is for drug policy organizations to spearhead advocacy groups on school campuses so students can sustain the harm reduction messages throughout and after high school. Longitudinal studies to measure student behavior and knowledge over time are key to the sustainability of Safety First.

Transportability

Results from public schools in two urban coastal cities showed a remarkable change from pre to post Safety First. This study tested student response across literacy, class and achievement levels. The study population were an integrated, multicultural cohort of 14- and 15-year old’s in urban areas, and these discrete demographic groups- Asian (296), Latinx (141), male (381) and female (311) exceeded 100. A sample must be over 100 to be considered generalizable [ 27 ]. Thus, in order to expand the transportability of the results it is integral to see how Safety First works in suburban, rural or small predominantly white locales; or with predominantly Black youth in smaller towns or large cities [ 23 ]. Lesbian, Bisexual, Trans, Non-Binary and Gay youth should be study participants. Youth in “last chance” schools, on probation, in detention or elite private schools should also be identified. Can Safety First be implemented successfully in a different type of institution? A drug treatment facility or a community-based organization? Does the curriculum work with middle school youth or older teens/young adults? Future research should serve youth of different ages, across similar and new demographic factors, and in environments outside the purview of this study.

Randomized control groups

The scope and scale of this study did not allow for the randomized control groups. These would have allowed a direct comparison of the outcomes for young people that either did not have a substance use component in their health class or had been exposed to a prevention and/or abstinence-based curriculum. Future studies should include randomized control groups across various populations of youth. Albeit, this pre/post study design did show baseline student knowledge and behaviors and the effects of Safety first on students after the curriculum.

The Safety First: Real Drug Education for Teens curriculum had significant effect on a diverse population of freshmen from six public high schools in the United States. Students acquired critical thinking skills to access and evaluate information about alcohol and other drugs; they had a better understanding of decision-making and goal setting skills that increased healthy choices related to substance use; they developed personal and social strategies to manage the risks, benefits and harms of alcohol and other drug use; they knew the impact of drug policies on personal and community health; and students learned to advocate for health-oriented drug policies. Outcomes inform future research. The implications of the results were that Safety First should be tested at comparable and new school sites. Further study should include randomized survey samples and control groups. The generalizability of the results should be measured with similar and different populations, as well as test the same students overtime to show the endurance of the effects.

The results are timely. Student knowledge increase related to the detection and response to an opioid overdose is particularly relevant because of national prevalence [ 28 ]. Student interviews about unequal treatment of people using or selling drugs based on race, class, gender and neighborhood illustrated the importance of understanding the intersection particularly between drug policy, race and class. There are a dearth of studies about harm reduction in the classroom [ 2 , 16 , 19 ]. These pilot findings are seed for future research to support harm reduction education for youth.

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The Drug Police Alliance awarded funding for this study through the Research Foundation of the City University of New York.

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Nina Rose Fischer

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This author developed the data collection tools, analyzed the data and wrote up the findings. The author(s) read and approved the final manuscript.

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NDr. Nina Rose Fischer is an Associate Professor at City University of New York John Jay College of Criminal Justice in Interdisciplinary Studies where she develops courses about social justice. She is the Co-Director of the prestigious Vera Fellows Program for social justice. She has 25 years experience in harm reduction and youth justice as an organizer, therapist, administrator, policy analyst and researcher. She is currently Principal Investigator on three original research projects 1) youth and police relations; 2) substance use harm reduction; and 3) arrest diversion. She published an article: Interdependent fates: Youth and police—Can they make peace? Peace and Conflict: Journal of Peace Psychology : https://doi.org/10.1037/pac0000466 and a book called The Case for Youth Police Initiative: Interdependent Fates and the Power of Peace, an ethnographic exploration of young people and police relations; as well as recommendations for how law enforcement can benefit from social welfare infrastructure. She is working on creative avenues to disseminate her findings including a docuseries about young people and police in hostile environments envisioning what safety really means. Critical race, class and gender analyses are central to her work as an activist scholar.

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Supplementary Information

Additional file 1., summary pre and post substance use behaviors.

Tobacco use showed no significant change form pre to post. On average, youth reported being with youth that used tobacco or that they used tobacco themselves monthly or never (3.70) before and after Safety First. On average, youth reported being with youth that used alcohol, or using alcohol themselves monthly or never (3.70) before and after Safety First. Tobacco and alcohol showed no significant change from pre to post. Marijuana was a different story. Students believed that fewer peers used marijuana on average (31%) after Safety First than before the harm reduction unit (43%). Students reported spending more time with students that used marijuana on average from monthly or never (Mean-μ = 3.29) closer to monthly (μ = 3.15). Youth reported marijuana use was monthly or never (μ = 3.80) pre to post.

Marijuana use showed a significant change from “I would probably not use” to almost completely “I would definitely not use” if “...your date is using marijuana” after Safety First. Prescription drug use and alcohol use showed no significant change from pre to post, staying an average between “I would probably not use” to “I would definitely not use.”

Students made a remarkable change from pre to post in their ability to describe specific harm reduction strategies in response to “What would you do to make substance use safer? ” Average youth response moved from “2” just reduce harm (μ = 2.25) to “1” Realize and plan for set/setting and limits around goal setting related to substance use, or Contents, Dose, Dosage including reduction of use (μ = 1.60).

An ANOVA was administered to see if any of the demographic factors had an effect on the substance use behavior outcomes from pre to post Safety First. Race and gender had the only effects. A one-way AVOVA yielded that Asian students were more likely to move towards “I would definitely not take/smoke weed with family” than black students [F(6, 556) = 3.50, p  = .002]. An independent sample t -test evidenced that young men were more likely than young women to use prescription drugs with friends (Mean-μ = −.92) to (μ = − 1.31), t(111) = 2.35, p  = .020.

The above results evidenced that the curriculum taught the students about harm reduction strategies. Prevalence of substance use amongst the population became more clear; harm reduction seemed to influence students’ substance use behaviors/decision making from pre to post Safety First, especially in relationship to marijuana and prescription drugs; and students clearly demonstrated an increase in knowledge of harm reduction strategies.

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Fischer, N.R. School-based harm reduction with adolescents: a pilot study. Subst Abuse Treat Prev Policy 17 , 79 (2022). https://doi.org/10.1186/s13011-022-00502-1

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Prevalence and factors associated with substance use among university students in South Africa: implications for prevention

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Substance use is an important public health concern in many countries across the globe. Among the general public, institutions of higher learning have developed a reputation for inducing new substance use among students. In addition to socio-demographic factors, substance use and abuse among university students often appear to be related to psychological stressors typically related to the demand to adapt to the new environment and the pressures associated with academia. The purpose of this study was to identify the prevalence of, and factors associated with substance use among university students.

This quantitative study employed convenience sampling to recruit university students who were 18 years and older from a university in the Western Cape. The study made use of self-administered online questionnaires, which participants completed via SurveyMonkey. The sample consisted of 2915 students. Descriptive statistics were used to describe and provide the prevalence and overview of the demographic characteristics of the respondents. Associations between variables were explored using Chi-square and Mann–Whitney U tests.

The main findings revealed a substance use prevalence rate of 62.7%. The most prominent substances used by students were alcohol (80.6%), cannabis (46%), and ecstasy (5.3%). The study further  revealed clear associations between students’ substance use and mental health. Students who reported substance use at university reported higher depression and anxiety scores than those who did not. However, findings reveal no significant association ( p  = 0.233) between being a substance user and a nonsubstance user and students' respective self-perceived stress scores.

Results show the majority of sampled students had started using substances (both alcohol and other substances) only after entering university. The results call into question seminal findings relating to substance use and the university environment. The novel findings of this study could serve as a baseline input to inform policymakers, programme developers, service providers, parents, and other stakeholders who are involved in the design and implementation of more effective awareness, prevention and, needs-based intervention services.

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Substance use is an important public health concern in many countries across the globe. Among the general public, institutions of higher learning have developed a reputation for inducing new substance use among students [ 1 , 2 , 3 ]. In addition to reporting novice use, studies have also found that students who had prior exposure to substance use increased their frequency once exposed to the university environment [ 4 , 5 ]. A growing body of research has also shown that university students reported using a number of substances at a greater rate than their non-student peers [ 1 , 6 , 7 , 8 , 9 ]. Findings of such studies show that the use of alcohol, particularly getting drunk and binge drinking [ 1 , 6 ], marijuana [ 1 ] and non-prescription amphetamine, were considerably higher among university students when compared with their non-university attending peers [ 1 , 7 , 8 , 9 ].

Research suggests that there could exist some conditions within the environment of higher education settings that makes students more susceptible to the use and/or abuse substances [ 4 , 10 , 11 , 12 ]. The term "substance use" refers to the use of alcohol, tobacco, illicit drugs, prescription and over-the-counter medications [ 13 ]. “Substance abuse” refers to the continued misuse of drugs, alcohol, tobacco and other psychoactive drugs even though the individual has knowledge that their usage of these substances may cause several debilitating problems and may eventually lead to some form of addiction [ 14 ].

Although much is known about students’ substance use rates on a global scale, very few representative studies have been conducted in South Africa (see e.g., [ 15 , 16 , 17 , 18 , 19 ]). Among the few studies carried out in South Africa, very high rates of student alcohol use have been reported [ 16 , 17 , 19 ]. For example, Young and De Klerk [ 17 ] found alcohol prevalence rates of almost 50% at Rhodes University. At the same South African university, 2 years later, Young and Mayson [ 19 ] found that 57.9% of the sample reported hazardous alcohol consumption, i.e., four or more drinks at a time on at least three separate days in the previous three months.

Similarly, another South African study carried out by Kyei and Ramagona [ 15 ], at the University of Venda, found that while over 65% of the students surveyed use alcohol, 49% of those students abuse it. A more recent study conducted by Du Preez and colleagues [ 2 ], which focused on the drinking behaviour of students at Stellenbosch University reported that 71% of males and 54% of females reported hazardous drinking patterns. In addition, the study also found that 13% of the sample indicated harmful drinking behaviour.

The concern of such findings lies in the potential short- and long-term adverse effects associated with the use of substances on students’ overall health and well-being. As substance use has been associated with an increased risk of contracting communicable diseases such as HIV/AIDS and TB [ 20 ]; non-communicable diseases such as mental illnesses; maternal and child maternal and child morbidity and mortality [ 21 ]; as well as injury and trauma. The previously noted consequences of substance use and abuse notwithstanding, it has also been recognised to contribute to epidemics of crime and violence, high university dropout rates, unemployment, and high levels of poverty and crime [ 22 ].

Research has shown that to intervene effectively and prevent the negative consequences of substance use, it is important to identify socio-demographic [ 18 , 23 , 24 ], environmental and psychological factors [ 25 , 26 , 27 ] contributing to the use and misuse of substances. According to Becker et al. [ 25 ] and NIDA [ 27 ], mental conditions such as stress, anxiety, and depression are important factors predisposing students to use and subsequently abuse substances [ 25 , 26 ]. The present study, therefore, aimed to establish the prevalence and associated factors of substance use among students at a historically disadvantaged university in the Western Cape, South Africa.

The study attempted to answer the following questions: (1) What is the prevalence rate of substance use amongst students at the University? (2) What types of substances do the students commonly use? (3) What are the factors associated with substance use among university students?

Design and context

This quantitative study employed convenience sampling to recruit university students who were 18 years and older from one of 26 public universities situated in South Africa. The university consists of seven faculties and four schools. Faculties are made up of Arts, Community and Health Sciences, Dentistry, Economic and Management Sciences, Education, Law and Natural Science. The schools include Pharmacy, Government, Nursing and Science and Mathematics. The study was primarily borne out of the realisation that very little was known about the current prevalence and factors associated with substance use and abuse at universities in the Western Cape, even though it is situated in the region where alcohol and drug use is reported to be four times higher than the national average in South Africa [ 28 ].

Procedure and ethics

The study was approved by the university and its ethics committee (BM18/9/1). After receiving a list of all registered students (N = 25,226) from the Registrar of the university, we sent out emails (as well as reminders) to all the student email addresses. The email included the description of the study and the link to the questionnaire. The questionnaire was administered online using SurveyMonkey for a period of two months (31 July to 30 September 2019). A link to the questionnaire was sent to students' university email addresses. Upon accessing the questionnaire, participants were provided with an information sheet and consent form which outlined the purpose, aims and, objectives of this study, the rights and responsibilities of the participants, as well as what it is that would be expected from them should they agree to take part in the research. Through the information sheet and consent forms, participants were also assured that their identity would remain confidential, and their responses used for research purposes only. This was ensured by not requiring any identifiable information from participants, thus maintaining their anonymity. The participants in this study were provided with referral pathways, should the need for counselling services or emergency intervention arise as a result of their participation in this study. Should students have required any additional referrals for social or mental health support, they were provided with telephone and email contact details of possible referrals. The researcher’s contact information was also available should they not have been successful on their own.

Participants

After excluding incomplete and missing data, 2915 questionnaires were deemed valid for analysis (11.6% response rate). Participants with two missing values on either the AUDIT or the DUDIT as well as corresponding missing values for their demographic information, which would have resulted in biased calculations, were removed. See Table 1 for the demographic characteristics of the population under study.

The final sample consisted of 34% men, 64% women and 1.7% who presented as “other” in terms of ‘gender’. Participants’ ages were captured categorically, ranging from 18–24 years to 75 years and older. The majority of the sample fell into the two youngest categories, i.e. [18–24 years (n = 2164 (63.9%)] and 25–34-year-old category (17%) respectively. With reference to the sample’s level of study, a large proportion of the participants were 1st year (28.8%), 2nd year (25.7%) and 3rd year (22.9%), undergraduate students. Most of the sample (34.8%) was from the faculty of Economic and Management Sciences. This statistic was succeeded by the second largest grouping 22% of students in the faculty of Arts and Humanities.

The substance use questionnaire consisted of five different instruments namely, the demographic section (please see Additional file 1 for a copy of the demographic section of this questionnaire), the Alcohol Use Disorders Identification Test [ 29 ], The Drug Use Disorders Identification Test [ 30 ], The Perceived Stress Scale [ 31 ] and The Self-Reporting Questionnaire [ 32 ].

Demographic section

A demographic section was developed in order to ascertain demographic information relevant to the current study’s aims and objectives. Questions regarding the students’ substance use, age, gender, education level, year level, marital status and onset of substance.

The Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test (AUDIT) was employed to help screen, categorise and diagnose the incidence of safe, hazardous, harmful and dependent drinking among students. The AUDIT is a brief 10-item, 5-point Linkert scale, self-administered questionnaire, with responses ranging from 0 (never) to 4 (4 + times per week) [ 33 ]. The AUDIT has demonstrated a high degree of internal consistency, yielding a Cronbach’s Alpha score of 0.83, with a range of 0.75–0.97 [ 34 ]. For the current sample, Cronbach’s alpha was 0.82.

The Drug Use Disorders Identification Test (DUDIT)

The DUDIT was employed in order to determine the extent of drug use among students. The DUDIT was developed to assist in the screening, diagnosing and categorising the severity of use of substances other than alcohol [ 30 ]. This self-report questionnaire uses a 5-point Likert scale which categorises individuals into three broad categories of drug use, namely, “no drug related problems”, “harmful use or dependence” and “heavily dependent on drugs”. The DUDIT was found to be a psychometrically sound instrument with high convergent validity (r = 0.85) when compared to 44 similar measures such as the DAST-10 and has a Cronbach's alpha of 0.94 [ 35 ]. For the current sample, the Cronbach’s alpha was 0.88.

The Perceived Stress Scale (PSS-10)

The PSS-10 is one of the most extensively used instruments for measuring self-perceived stress on a scale from 0 (never) to 4 (very often) [ 36 ]. Tallied PSS scores are used to detect three categories of stress. An individual is considered to be experiencing low stress is their respective scores ranges from 0 to 13. Scores ranging from 14–26 suggests moderate stress while scores ranging from 27 to 40 would suggest high perceived stress [ 31 ]. The PSS-10 has shown to have good internal and test–retest reliability (α = 0.84–0.86) and it has demonstrated convergent validity with measures of anxiety, depression, and health, and divergent validity with measures of sensations-seeking, religious faith, and aggression among university students [ 37 , 38 ]. For the current sample, Cronbach’s alpha was 0.58.

The Self-Reporting Questionnaire (SRQ-20)

Developed by the World Health Organization (WHO), this questionnaire is a self-rating scale specifically designed to screen for psychological discomfort among individuals, particularly in developing countries. The SRQ-20 was therefore employed to assess the frequency and severity of 20 symptoms related to depression and anxiety among students. The SRQ has proven to be a valid (Cronbach’s α = 0.85) [ 39 ] and reasonably stable instrument in a several studies in different cultural contexts [ 40 , 41 ]. Both the PSS-10 and SRQ-20 are two of the most widely used instrument to measure perceived stress [ 36 , 37 , 38 ] and psychological distress among populations in several different cultural contexts in and around South Africa [ 40 , 41 ]. For the current sample, Cronbach’s alpha was 0.89.

Data analysis

Data were entered into an Excel spreadsheet, and analysis was conducted using the IBM Statistical Package for Social Sciences Version SPSS 26.0 software. Percentages and frequencies were used to report categorical variables. Descriptive statistics was used to summarise the participants’ socio-demographic characteristics and bivariate analysis to examine the associations between background characteristics and alcohol and drug use. The Chi-square test for independence (using α = 0.05) was used to determine whether there were significant differences between student’s substance use before and after their university enrolment. A chi-square test is commonly used when analysing two categorical variables from a single population [ 42 ]. Because scores were not normally distributed, Mann–Whitney U-tests were used to determine the association between students’ self-reported mental health and their use of substances. A p value of less than 0.05 was determined to be statistically significant.

Prevalence of substance use amongst students

The prevalence rates of substance use among the sampled students are presented in the table below (Table 2 ). The prevalence results presented were based on the results obtained questions in the demographic questionnaire. For students to have been labelled as a “substance user” students had to have responded ‘yes’ to the question, which read, “Are you still using any of the substances mentioned above?”. In order to be considered a “non-substance user”, students had to have indicated ‘no’ substance use with respect to this question. Respondents were labelled “unsure” if they indicated ‘yes’ to this question but had not selected any of the substances listed in the question which followed on the survey.

The findings presented in Table 2 show that the majority of respondents reported using substances after they enrolled at the university (62.7%). In this dataset, chi-square analysis indicated a narrow interval span of 60.89–64.43% can be observed among students with an odds ratio of 0.5, and a 95% confidence level. This is indicative of the chances of using substances after being exposed to the university environment is 50%.

Types of substances used

Table 3 (below) displays a list of the substances reported to have been used by the participants after their enrolment at university. Alcohol was the most used substance among students (80.6%) ( n  = 1472). The second-most used substance reported by respondents is cannabis, which is commonly known in the Western Cape as ‘dagga’ or weed. The percentage of students reporting cannabis use amounts to 46% ( n  = 841) of the sampled respondents. The third largest proportion of students (96 students) indicated that they used ecstasy.

Table 3 further reveals that 8% of the students reported using substances that were not explicitly listed in the questionnaire. These substances were listed by participants as: Ritalin ( n  = 33), Poppers ( n  = 32), Ketamine ( n  = 31), Mescaline ( n  = 30), other over-the-counter-medicine ( n  = 28), Dimethyltryptamine (DMT or N) ( n  = 27), Xanax ( n  = 26), Vape ( n  = 25) Traditional beer ( n  = 24), Pethidine ( n  = 21) Tramadol ( n  = 20), Rock ( n  = 19), Hookah ( n  = 18), Flakka ( n  = 17), CAT ( n  = 16) MD (n = 15), MDMA ( n  = 14), Acid ( n  = 10) LSD ( n  = 12) Mushrooms ( n  = 13) and Cocaine ( n  = 11).

Level of Alcohol and Drug Use among University Students (AUDIT and DUDIT)

The AUDIT and DUDIT were used to determine the amount of alcohol and drug use among the sample of students who stated that they were current substance users in order to supplement the results from the prevalence findings presented above. The results of the Alcohol Use Disorder Identification Test (AUDIT) and the Drug Use Disorder Identification Test (DUDIT) are presented in Table 4 below. In order to determine the extent of substance use by those who identified as using substances, the analysis was conducted on the 1827 participants who reported using substances after enrolling at university.

A total of 1164 (63.7%) of the 1827 students labelled as ‘substance users’ completed the AUDIT. Although the majority of that cohort indicated ‘low-risk drinking’, a total of 349 students indicated ‘hazardous’, ‘harmful’ drinking patterns and ‘alcohol dependence’.

Most respondents (87.2%) who completed the DUDIT reported, what the DUDIT defines as, ‘no drug-related problems’ while 184 students reported ‘harmful/dependence’ and ‘heavily dependent’ use.

Factors associated with substance use

Self-report questionnaire-20.

A cut off score of 7/8 is used to indicate the presence of depression and anxiety [ 41 ] or as Harpham et al. [ 43 ] reports, ‘mental ill health’. Thomas [ 44 ] used a cut-off score of 7/8’s in a study in Durban, South Africa. The table below (Table 5 ) indicates that 32.5% of the total sample, or 45.1% who completed the SRQ-20 presented with a possible case of mental ill health. This indicates the prevalence of mental health distress as reported within this sample.

A Mann–Whitney U Test was conducted in order to test the significance of the association between those who used substances, those who did not and their associated SRQ score. The results are presented in Table 6 below.

The results found in Table 6 and Figs.  1 and 2 reveals a significant association ( p  < 0.01) between being a substance user and non-substance user and students’ respective SRQ scores. The results indicated that students who scored higher in the SRQ-20 (possibly indicating depression and anxiety symptoms) were students who reported substance use at university.

SRQ-25 × Substance Use Histogram

SRQ-25 ×Substance Use Independent-Samples Mann-Whitney U test

A further cross tabulation presented in Table 7 above highlights that those students who reported hazardous, harmful drinking and alcohol dependence also report higher levels of mental health concerns (SRQ-20). Table 8 , below, also indicates that those who report hazardous, harmful drinking and alcohol dependence also report higher levels of perceived stress as compared to those with lower levels of stress. It is interesting to note that all everyone who reported moderate to high perceived stress participated in hazardous or harmful drinking. This speaks to other protective factors which might buffer alcohol use.

Perceived stress scale-10 results

To ascertain the levels of stress students’ experience during their time at university, the PSS-10 was administered and analysed. The PSS-10 measures the level at which respondents appraise life events as being unpredictable, overwhelming, or challenging. Individual scores on the PSS range from 0 to 40, with higher scores indicating higher perceived stress between 0 and 13 are perceived to have low stress. Scores ranging from 14 to 26 would indicate those whose scores are considered as having moderate stress. The final category of scores, i.e. ranging from 27 to 40 would be indicative of individuals having high perceived stress. It is within this context that respondents were scored, and findings were analysed.

Table 9 indicates that substance users have a higher level of perceived stress versus those who do not use substances. The table below indicates whether this difference was significant using a Mann–Whitney U Test (Table  10 ).

The results in Table 8 above and Figs.  3 and 4 below show that there is no significant association ( p  > 0.05) between being a substance user and nonsubstance user post university enrolment and students respective PSS-10 scores. The levels of perceived stress appear to be similar for both cohorts.

PSS-10 × Substance Use Independent-Samples Mann-Whitney U test

PSS-10 × Substance Use Histogram

Table 11 above, is a cross tabulation of the drug use categories according to the DUDIT and the SRQ. According to the table, those who displayed harmful use or are heavily dependent on substances also report the presence of more mental ill health symptoms. Interestingly, 749 of the 1744 students who reported mental ill health challenges did not indicate drug-related problems.

A similar cross tabulation (Table 12 ) was conducted on the DUDIT categories and students’ perceived levels of stress. Although many students indicated a moderate to high level of perceived stress (n = 1608 and 125 respectively), these students did not report problems with drug use. However, a larger number of students reported moderate to high perceived stress who were also using substances in a harmful or dependent manner.

Prevalence of substance use

The aim of this study was to determine the prevalence of, or patterns, of substance abuse among university students as well as mental health factors that may be influencing this use. The term substances refer to both alcohol and drug use. Results from the study show that 62.7% of sampled students indicated, not only that they used substances but that this use (both alcohol and other substances) started after enrolling at the university. The prevalence rates found in this study appear to align with key findings which, similarly, found high substance use rates after students had enrolled at their respective university/college [ 1 , 4 , 10 , 11 , 12 ].

The extent of alcohol and drug use was evaluated using the AUDIT and DUDIT. These results are particularly interesting as it revealed that the majority of students in the sample reported ‘low-risk drinking' (70.4%) and ‘no drug-related problems’ (87.2%). These results are in direct contrast with similar studies in the field which report relatively high prevalence of substance abuse among university students, particularly in South Africa [ 2 , 15 , 19 ]. The substance use rates reported could be due to a variety of reasons, one of which concerns social desirability bias, which refers to the tendency respondents have to present and align themselves and their reality with what they believe to be socially acceptable. However, each questionnaire was self-report and could be completed alone, without the presence of an interviewer or someone known to the student. The majority use notwithstanding, both the AUDIT and DUDIT revealed a number of students who should be considered for either brief or intensive interventions for substance use.

Types of substances used by students

The three most commonly used substances reported were alcohol (80.6%), cannabis (46%) and ecstasy (5.3%) amongst those who used substances after university enrolment. Interestingly, ecstasy use was found to be higher than methamphetamine use among students in the Western Cape, an area well-known for its increased methamphetamine use [ 45 ]. “Other” substances accounted for 8% of the sample, important to note here is that the number of “other” substances evidently surpasses commonly well-known and well-documented substances such as ecstasy (n = 96), methamphetamine (n = 14), buttons (n = 6) and unga (n = 1). This noteworthy and rather unanticipated finding could be indicative of a shift in the types of substances commonly reported/used by university students at this point in time. Although the sample is not representative, this finding is important as it provides an opportunity for researchers and healthcare practitioners to be mindful of the types of substances being used by individuals of a certain age range in the Western Cape.

Mental health of students

The results of this study revealed a significant association ( p  < 0.01) between students’ substance use and their respective SRQ scores. These results appear to be in consensus with much of the available literature which interchangeably associates some aspect of mental health with substance among university students [ 25 , 27 , 46 ]. However, although valuable, the results presented are likewise unable to support or refute the three main hypotheses offered in the literature review which varied from conclusions relating to whether substance use leads to mental health problems [ 47 ]; whether mental health problems cause substance [ 48 ] or whether these concepts are so closely related that it could not be studied in isolation [ 49 ]. It is likewise unfortunate that results were unable to answer the question as to whether students who already present mental health problems prior to attending universities are at an even higher risk of experimenting with substances, as the new environment could exacerbate their already existing symptoms [ 50 ]. What it does however show, is that there appears to be a significant difference between the two groups in terms of their mental health and use of substances, i.e., students who identified as non-users reported fewer symptoms of anxiety and depression (according to the SRQ-20) than students who indicated that they were substances users. Which is indicative of there being some validity to the claims concerning the complex relationship between substance use and mental health, particularly among university students.

This study used the PSS-10 to measure psychological stress among students mainly because it defines stress as an interaction between environmental demands and the individual’s capacity to cope [ 31 ]. Results demonstrate that there is no significant association ( p  > 0.05) between being a substance user and a nonsubstance user post university enrolment and students' respective PSS-10 scores. Figures  1 and 2 furthermore support and expand on the results found in Table 9 by showing how scores cluster around the 19/20 mark in both groups. In terms of students’ level of stress, the results from Figs.  1 and 2 furthermore indicate that the majority of students in both groups fall within the moderate stress levels as per PSS-10. These results found above are in contrast with a body of literature that found significant associations between respondents who suffered from psychological distress and their use of substance use. Substance use was commonly reported as being used by distressed respondents to cope with academic pressures and demands [ 50 , 51 ]. Interestingly, even though we did not account for risk and protective factors, based on the results of the AUDIT/DUDIT category cross tabulation with the SRQ and PSS, protective factors could be moderating or mediating the relationship between stress/mental ill health and students’ either using substances or not. Such factors could account for those with high stress and mental health challenges and not having a substance use problem per se. Considering the scarcity of knowledge about the risk and protective factors of substance abuse among university students, a follow-up study to investigate such factors should be prioritised.

Implications of the study

The insights to be gained from this study could serve several purposes and contribute towards the prevention and reduction of substance use and/or abuse among university students in several ways. In its entirety, the study contributes to the overall scarcity of existing knowledge on substance use and abuse among university students in South Africa. The study sheds light on the current prevalence and the extent to which students’ use and/or abuse substances in a previously underexplored population in the Western Cape. Although it does show that the large majority do not necessarily have harmful or hazardous substance use patterns, it is noteworthy that a minimum of 184 to a maximum of 359 students reported harmful/hazardous/dependent use. Therefore, awareness campaigns and varying degrees of referrals and interventions should be made available to students.

In addition to reporting on the “conventionally” well-documented substances, such as alcohol, marijuana, methamphetamine and heroin in South Africa, this study also provided a platform where students could disclose their use and/or abuse of other types of substance use. This information could prove useful for any future attempts to tailor, inform and/or contextualise research endeavours of a similar nature. The unanticipated findings relating to the assortment of substances could be indicative of a gradual paradigm shift in the types of substances commonly reported/used by students. The novel findings of this study could serve as a baseline input to inform policy makers, programme developers, service providers, parents, and other stakeholders who are involved in the design and implementation of more effective awareness, prevention and needs-based intervention services; and the findings of this study could also serve as a feature map for future research relating to substance use in and around South Africa.

Conclusions

Limitations.

The results produced in this research study, although valuable, reflects a single, purposefully selected university in the Western Cape. Since the prevalence and nature of substance abuse among university students in the Western Cape may vary depending on the environments where the universities are found, the generalisation of the current study’s findings should be done with caution. A general limitation of a correlational study is that it can determine the association between variables but cannot predict causation. Another limitation of inherent is such studies is the ability of respondents to accurately recall past events. In this case, the time intervals for which respondents were asked to report their substance use were not specific, i.e., no reference periods were used to restrict and specify the time intervals for which respondents reported their use of substances. This oversight may have produced unclear assumptions regarding the prevalence of substances among students. In addition, tobacco use was not classified as a problematic substance in this study. This is perhaps something to consider in future studies of this nature.

It is also essential to mention here that the questionnaire was disseminated in only one of the three official languages within the Western Cape, i.e., English. This was done in order to align with the University’s primary medium of teaching and of examination, which is, English. This being said, the official language policy of the Western Cape Government (Western Cape Government 2019) encourages the promotion and use of all of the three official languages of the Western Cape, namely Afrikaans, isiXhosa and English where possible. It is thus recommended that future research carried out in different provinces and or countries consider the official languages of the population under study and strive to provide the respondent with an equal opportunity to interpret and answer questions in their mother tongues.

The social desirability bias, inherent in the self-report measures on substance use, may have resulted in students providing socially acceptable rather than honest answers. Apart from the social desirability bias, it is important to bear in mind that students received the online link via their university student email addresses within a specific timeframe, from 29 July to 27 September 2019. The implications here are that students who were absent, or who did not have access to the necessary resource to complete the questionnaire could have been excluded. Although useful, the cross-sectional design has been criticised for only examining aspects of individual’s beliefs and behaviours without paying concerted consideration to the context in which these beliefs and behaviours occur, which could account for misinterpretation of meanings of the beliefs and/or behaviour recorded. As such, it is necessary to exercise caution when interpreting the results of this study.

Recommendations of the study

Taking the aforesaid findings into consideration, it is hoped that the current study’s results would call upon researchers to further investigate the association of factors in relation to an array of substances other than alcohol. This might be essential in the identification of an increase and/or decrease of many substances, and the identification of newly introduced substances, which is vital for the creatiion of awareness-, and prevention- campaigns as well as intervention strategies aimed at the population under study.

A conclusion of the limitations and recommendations of this study cannot be complete without calling for more comprehensive efforts (multidisciplinary) when investigating the use and abuse amongst individuals in our society. Since this research is observational, experimental research is recommended to identify effective intervention options for mitigating the burden of substance abuse among university students.

Discovering these influencing factors (both risk- and protective) would decrease the probability of an individual using drugs, and would once again pinpoint areas one could focus on with interventions, which would empower those in need of intervention, as opposed to educating only. A determination should also be done on evidence-based “best practices” for primary prevention, as well as the treatment of substance abuse among adolescents in South Africa.

In attempts to promote and adhere to the ethicical principles of avoiding harm, giving respect and protecting participants’ integrity, the author's advocacy plea is to cultivate more inclusivity in future research endeavours, especially in the social sciences. Such efforts could begin by exploring social constructs such as gender on a non-binary spectrum. In addition to this, more culturally sensitive, multi-wave longitudinal research needs to be carried out in order to improve on and expand the understanding of substance use and abuse among young people in South Africa, particularly those transitioning from childhood to adolescence to young adulthood, during which pervasive individual and contextual change is the bedrock of these developmental transitions.

The overall aim of the study was to explore the prevalence and factors associated with substance among university students in South Africa in order to provide baseline information that could inform the development and/or tailoring of any awareness and or prevention campaigns designed to reduce substance use and abuse among students in South Africa. Perhaps more importantly, it is hoped that the results, implications, limitation, and recommendation of the present study invokes increased focus and ignites novel or innovative thinking when undertaking research of similar nature.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Alpha (level of significance)

Equals the size of the population

Equals the sample size

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Additional file 1.

. Demographic Section. A demographic section was developed in order to ascertain demographic information relevant to the current study’s aims and objectives. Questions regarding the students’ substance use, age, gender, education level, year level, marital status and onset of substance.

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Blows, S., Isaacs, S. Prevalence and factors associated with substance use among university students in South Africa: implications for prevention. BMC Psychol 10 , 309 (2022). https://doi.org/10.1186/s40359-022-00987-2

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• Substance use
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Risk and protective factors of drug abuse among adolescents: a systematic review

• Azmawati Mohammed Nawi 1 ,
• Rozmi Ismail 2 ,
• Fauziah Ibrahim 2 ,
• Mohd Rohaizat Hassan 1 ,
• Mohd Rizal Abdul Manaf 1 ,
• Noh Amit 3 ,
• Norhayati Ibrahim 3 &
• Nurul Shafini Shafurdin 2  

BMC Public Health volume  21 , Article number:  2088 ( 2021 ) Cite this article

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Drug abuse is detrimental, and excessive drug usage is a worldwide problem. Drug usage typically begins during adolescence. Factors for drug abuse include a variety of protective and risk factors. Hence, this systematic review aimed to determine the risk and protective factors of drug abuse among adolescents worldwide.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted for the review which utilized three main journal databases, namely PubMed, EBSCOhost, and Web of Science. Tobacco addiction and alcohol abuse were excluded in this review. Retrieved citations were screened, and the data were extracted based on strict inclusion and exclusion criteria. Inclusion criteria include the article being full text, published from the year 2016 until 2020 and provided via open access resource or subscribed to by the institution. Quality assessment was done using Mixed Methods Appraisal Tools (MMAT) version 2018 to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken.

Out of 425 articles identified, 22 quantitative articles and one qualitative article were included in the final review. Both the risk and protective factors obtained were categorized into three main domains: individual, family, and community factors. The individual risk factors identified were traits of high impulsivity; rebelliousness; emotional regulation impairment, low religious, pain catastrophic, homework completeness, total screen time and alexithymia; the experience of maltreatment or a negative upbringing; having psychiatric disorders such as conduct problems and major depressive disorder; previous e-cigarette exposure; behavioral addiction; low-perceived risk; high-perceived drug accessibility; and high-attitude to use synthetic drugs. The familial risk factors were prenatal maternal smoking; poor maternal psychological control; low parental education; negligence; poor supervision; uncontrolled pocket money; and the presence of substance-using family members. One community risk factor reported was having peers who abuse drugs. The protective factors determined were individual traits of optimism; a high level of mindfulness; having social phobia; having strong beliefs against substance abuse; the desire to maintain one’s health; high paternal awareness of drug abuse; school connectedness; structured activity and having strong religious beliefs.

The outcomes of this review suggest a complex interaction between a multitude of factors influencing adolescent drug abuse. Therefore, successful adolescent drug abuse prevention programs will require extensive work at all levels of domains.

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Introduction

Drug abuse is a global problem; 5.6% of the global population aged 15–64 years used drugs at least once during 2016 [ 1 ]. The usage of drugs among younger people has been shown to be higher than that among older people for most drugs. Drug abuse is also on the rise in many ASEAN (Association of Southeast Asian Nations) countries, especially among young males between 15 and 30 years of age. The increased burden due to drug abuse among adolescents and young adults was shown by the Global Burden of Disease (GBD) study in 2013 [ 2 ]. About 14% of the total health burden in young men is caused by alcohol and drug abuse. Younger people are also more likely to die from substance use disorders [ 3 ], and cannabis is the drug of choice among such users [ 4 ].

Adolescents are the group of people most prone to addiction [ 5 ]. The critical age of initiation of drug use begins during the adolescent period, and the maximum usage of drugs occurs among young people aged 18–25 years old [ 1 ]. During this period, adolescents have a strong inclination toward experimentation, curiosity, susceptibility to peer pressure, rebellion against authority, and poor self-worth, which makes such individuals vulnerable to drug abuse [ 2 ]. During adolescence, the basic development process generally involves changing relations between the individual and the multiple levels of the context within which the young person is accustomed. Variation in the substance and timing of these relations promotes diversity in adolescence and represents sources of risk or protective factors across this life period [ 6 ]. All these factors are crucial to helping young people develop their full potential and attain the best health in the transition to adulthood. Abusing drugs impairs the successful transition to adulthood by impairing the development of critical thinking and the learning of crucial cognitive skills [ 7 ]. Adolescents who abuse drugs are also reported to have higher rates of physical and mental illness and reduced overall health and well-being [ 8 ].

The absence of protective factors and the presence of risk factors predispose adolescents to drug abuse. Some of the risk factors are the presence of early mental and behavioral health problems, peer pressure, poorly equipped schools, poverty, poor parental supervision and relationships, a poor family structure, a lack of opportunities, isolation, gender, and accessibility to drugs [ 9 ]. The protective factors include high self-esteem, religiosity, grit, peer factors, self-control, parental monitoring, academic competence, anti-drug use policies, and strong neighborhood attachment [ 10 , 11 , 12 , 13 , 14 , 15 ].

The majority of previous systematic reviews done worldwide on drug usage focused on the mental, psychological, or social consequences of substance abuse [ 16 , 17 , 18 ], while some focused only on risk and protective factors for the non-medical use of prescription drugs among youths [ 19 ]. A few studies focused only on the risk factors of single drug usage among adolescents [ 20 ]. Therefore, the development of the current systematic review is based on the main research question: What is the current risk and protective factors among adolescent on the involvement with drug abuse? To the best of our knowledge, there is limited evidence from systematic reviews that explores the risk and protective factors among the adolescent population involved in drug abuse. Especially among developing countries, such as those in South East Asia, such research on the risk and protective factors for drug abuse is scarce. Furthermore, this review will shed light on the recent trends of risk and protective factors and provide insight into the main focus factors for prevention and control activities program. Additionally, this review will provide information on how these risk and protective factors change throughout various developmental stages. Therefore, the objective of this systematic review was to determine the risk and protective factors of drug abuse among adolescents worldwide. This paper thus fills in the gaps of previous studies and adds to the existing body of knowledge. In addition, this review may benefit certain parties in developing countries like Malaysia, where the national response to drugs is developing in terms of harm reduction, prison sentences, drug treatments, law enforcement responses, and civil society participation.

This systematic review was conducted using three databases, PubMed, EBSCOhost, and Web of Science, considering the easy access and wide coverage of reliable journals, focusing on the risk and protective factors of drug abuse among adolescents from 2016 until December 2020. The search was limited to the last 5 years to focus only on the most recent findings related to risk and protective factors. The search strategy employed was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) checklist.

A preliminary search was conducted to identify appropriate keywords and determine whether this review was feasible. Subsequently, the related keywords were searched using online thesauruses, online dictionaries, and online encyclopedias. These keywords were verified and validated by an academic professor at the National University of Malaysia. The keywords used as shown in Table  1 .

Selection criteria

The systematic review process for searching the articles was carried out via the steps shown in Fig.  1 . Firstly, screening was done to remove duplicate articles from the selected search engines. A total of 240 articles were removed in this stage. Titles and abstracts were screened based on the relevancy of the titles to the inclusion and exclusion criteria and the objectives. The inclusion criteria were full text original articles, open access articles or articles subscribed to by the institution, observation and intervention study design and English language articles. The exclusion criteria in this search were (a) case study articles, (b) systematic and narrative review paper articles, (c) non-adolescent-based analyses, (d) non-English articles, and (e) articles focusing on smoking (nicotine) and alcohol-related issues only. A total of 130 articles were excluded after title and abstract screening, leaving 55 articles to be assessed for eligibility. The full text of each article was obtained, and each full article was checked thoroughly to determine if it would fulfil the inclusion criteria and objectives of this study. Each of the authors compared their list of potentially relevant articles and discussed their selections until a final agreement was obtained. A total of 22 articles were accepted to be included in this review. Most of the excluded articles were excluded because the population was not of the target age range—i.e., featuring subjects with an age > 18 years, a cohort born in 1965–1975, or undergraduate college students; the subject matter was not related to the study objective—i.e., assessing the effects on premature mortality, violent behavior, psychiatric illness, individual traits, and personality; type of article such as narrative review and neuropsychiatry review; and because of our inability to obtain the full article—e.g., forthcoming work in 2021. One qualitative article was added to explain the domain related to risk and the protective factors among the adolescents.

PRISMA flow diagram showing the selection of studies on risk and protective factors for drug abuse among adolescents.2.2. Operational Definition

Drug-related substances in this context refer to narcotics, opioids, psychoactive substances, amphetamines, cannabis, ecstasy, heroin, cocaine, hallucinogens, depressants, and stimulants. Drugs of abuse can be either off-label drugs or drugs that are medically prescribed. The two most commonly abused substances not included in this review are nicotine (tobacco) and alcohol. Accordingly, e-cigarettes and nicotine vape were also not included. Further, “adolescence” in this study refers to members of the population aged between 10 to 18 years [ 21 ].

Data extraction tool

All researchers independently extracted information for each article into an Excel spreadsheet. The data were then customized based on their (a) number; (b) year; (c) author and country; (d) titles; (e) study design; (f) type of substance abuse; (g) results—risks and protective factors; and (h) conclusions. A second reviewer crossed-checked the articles assigned to them and provided comments in the table.

Quality assessment tool

By using the Mixed Method Assessment Tool (MMAT version 2018), all articles were critically appraised for their quality by two independent reviewers. This tool has been shown to be useful in systematic reviews encompassing different study designs [ 22 ]. Articles were only selected if both reviewers agreed upon the articles’ quality. Any disagreement between the assigned reviewers was managed by employing a third independent reviewer. All included studies received a rating of “yes” for the questions in the respective domains of the MMAT checklists. Therefore, none of the articles were removed from this review due to poor quality. The Cohen’s kappa (agreement) between the two reviewers was 0.77, indicating moderate agreement [ 23 ].

The initial search found 425 studies for review, but after removing duplicates and applying the criteria listed above, we narrowed the pool to 22 articles, all of which are quantitative in their study design. The studies include three prospective cohort studies [ 24 , 25 , 26 ], one community trial [ 27 ], one case-control study [ 28 ], and nine cross-sectional studies [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. After careful discussion, all reviewer panels agreed to add one qualitative study [ 46 ] to help provide reasoning for the quantitative results. The selected qualitative paper was chosen because it discussed almost all domains on the risk and protective factors found in this review.

A summary of all 23 articles is listed in Table  2 . A majority of the studies (13 articles) were from the United States of America (USA) [ 25 , 26 , 27 , 29 , 30 , 31 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], three studies were from the Asia region [ 32 , 33 , 38 ], four studies were from Europe [ 24 , 28 , 40 , 44 ], and one study was from Latin America [ 35 ], Africa [ 43 ] and Mediterranean [ 45 ]. The number of sample participants varied widely between the studies, ranging from 70 samples (minimum) to 700,178 samples (maximum), while the qualitative paper utilized a total of 100 interviewees. There were a wide range of drugs assessed in the quantitative articles, with marijuana being mentioned in 11 studies, cannabis in five studies, and opioid (six studies). There was also large heterogeneity in terms of the study design, type of drug abused, measurements of outcomes, and analysis techniques used. Therefore, the data were presented descriptively.

After thorough discussion and evaluation, all the findings (both risk and protective factors) from the review were categorized into three main domains: individual factors, family factors, and community factors. The conceptual framework is summarized in Fig.  2 .

Conceptual framework of risk and protective factors related to adolescent drug abuse

DOMAIN: individual factor

Risk factors.

Almost all the articles highlighted significant findings of individual risk factors for adolescent drug abuse. Therefore, our findings for this domain were further broken down into five more sub-domains consisting of personal/individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance history, comorbidity and an individual’s attitude and perception.

Personal/individual traits

Chuang et al. [ 29 ] found that adolescents with high impulsivity traits had a significant positive association with drug addiction. This study also showed that the impulsivity trait alone was an independent risk factor that increased the odds between two to four times for using any drug compared to the non-impulsive group. Another longitudinal study by Guttmannova et al. showed that rebellious traits are positively associated with marijuana drug abuse [ 27 ]. The authors argued that measures of rebelliousness are a good proxy for a youth’s propensity to engage in risky behavior. Nevertheless, Wilson et al. [ 37 ], in a study involving 112 youths undergoing detoxification treatment for opioid abuse, found that a majority of the affected respondents had difficulty in regulating their emotions. The authors found that those with emotional regulation impairment traits became opioid dependent at an earlier age. Apart from that, a case-control study among outpatient youths found that adolescents involved in cannabis abuse had significant alexithymia traits compared to the control population [ 28 ]. Those adolescents scored high in the dimension of Difficulty in Identifying Emotion (DIF), which is one of the key definitions of diagnosing alexithymia. Overall, the adjusted Odds Ratio for DIF in cannabis abuse was 1.11 (95% CI, 1.03–1.20).

Significant negative growth exposure

A history of maltreatment in the past was also shown to have a positive association with adolescent drug abuse. A study found that a history of physical abuse in the past is associated with adolescent drug abuse through a Path Analysis, despite evidence being limited to the female gender [ 25 ]. However, evidence from another study focusing at foster care concluded that any type of maltreatment might result in a prevalence as high as 85.7% for the lifetime use of cannabis and as high as 31.7% for the prevalence of cannabis use within the last 3-months [ 30 ]. The study also found significant latent variables that accounted for drug abuse outcomes, which were chronic physical maltreatment (factor loading of 0.858) and chronic psychological maltreatment (factor loading of 0.825), with an r 2 of 73.6 and 68.1%, respectively. Another study shed light on those living in child welfare service (CWS) [ 35 ]. It was observed through longitudinal measurements that proportions of marijuana usage increased from 9 to 18% after 36 months in CWS. Hence, there is evidence of the possibility of a negative upbringing at such shelters.

Personal psychiatric diagnosis

The robust studies conducted in the USA have deduced that adolescents diagnosed with a conduct problem (CP) have a positive association with marijuana abuse (OR = 1.75 [1.56, 1.96], p  < 0.0001). Furthermore, those with a diagnosis of Major Depressive Disorder (MDD) showed a significant positive association with marijuana abuse.

Previous substance and addiction history

Another study found that exposure to e-cigarettes within the past 30 days is related to an increase in the prevalence of marijuana use and prescription drug use by at least four times in the 8th and 10th grades and by at least three times in the 12th grade [ 34 ]. An association between other behavioral addictions and the development of drug abuse was also studied [ 29 ]. Using a 12-item index to assess potential addictive behaviors [ 39 ], significant associations between drug abuse and the groups with two behavioral addictions (OR = 3.19, 95% CI 1.25,9.77) and three behavioral addictions (OR = 3.46, 95% CI 1.25,9.58) were reported.

Comorbidity

The paper by Dash et al. (2020) highlight adolescent with a disease who needs routine medical pain treatment have higher risk of opioid misuse [ 38 ]. The adolescents who have disorder symptoms may have a risk for opioid misuse despite for the pain intensity.

Individual’s attitudes and perceptions

In a study conducted in three Latin America countries (Argentina, Chile, and Uruguay), it was shown that adolescents with low or no perceived risk of taking marijuana had a higher risk of abuse (OR = 8.22 times, 95% CI 7.56, 10.30) [ 35 ]. This finding is in line with another study that investigated 2002 adolescents and concluded that perceiving the drug as harmless was an independent risk factor that could prospectively predict future marijuana abuse [ 27 ]. Moreover, some youth interviewed perceived that they gained benefits from substance use [ 38 ]. The focus group discussion summarized that the youth felt positive personal motivation and could escape from a negative state by taking drugs. Apart from that, adolescents who had high-perceived availability of drugs in their neighborhoods were more likely to increase their usage of marijuana over time (OR = 11.00, 95% CI 9.11, 13.27) [ 35 ]. A cheap price of the substance and the availability of drug dealers around schools were factors for youth accessibility [ 38 ]. Perceived drug accessibility has also been linked with the authorities’ enforcement programs. The youth perception of a lax community enforcement of laws regarding drug use at all-time points predicted an increase in marijuana use in the subsequent assessment period [ 27 ]. Besides perception, a study examining the attitudes towards synthetic drugs based on 8076 probabilistic samples of Macau students found that the odds of the lifetime use of marijuana was almost three times higher among those with a strong attitude towards the use of synthetic drugs [ 32 ]. In addition, total screen time among the adolescent increase the likelihood of frequent cannabis use. Those who reported daily cannabis use have a mean of 12.56 h of total screen time, compared to a mean of 6.93 h among those who reported no cannabis use. Adolescent with more time on internet use, messaging, playing video games and watching TV/movies were significantly associated with more frequent cannabis use [ 44 ].

Protective factors

Individual traits.

Some individual traits have been determined to protect adolescents from developing drug abuse habits. A study by Marin et al. found that youth with an optimistic trait were less likely to become drug dependent [ 33 ]. In this study involving 1104 Iranian students, it was concluded that a higher optimism score (measured using the Children Attributional Style Questionnaire, CASQ) was a protective factor against illicit drug use (OR = 0.90, 95% CI: 0.85–0.95). Another study found that high levels of mindfulness, measured using the 25-item Child Acceptance and Mindfulness Measure, CAMM, lead to a slower progression toward injectable drug abuse among youth with opioid addiction (1.67 years, p  = .041) [ 37 ]. In addition, the social phobia trait was found to have a negative association with marijuana use (OR = 0.87, 95% CI 0.77–0.97), as suggested [ 31 ].

According to El Kazdouh et al., individuals with a strong belief against substance use and those with a strong desire to maintain their health were more likely to be protected from involvement in drug abuse [ 46 ].

DOMAIN: family factors

The biological factors underlying drug abuse in adolescents have been reported in several studies. Epigenetic studies are considered important, as they can provide a good outline of the potential pre-natal factors that can be targeted at an earlier stage. Expecting mothers who smoke tobacco and alcohol have an indirect link with adolescent substance abuse in later life [ 24 , 39 ]. Moreover, the dynamic relationship between parents and their children may have some profound effects on the child’s growth. Luk et al. examined the mediator effects between parenting style and substance abuse and found the maternal psychological control dimension to be a significant variable [ 26 ]. The mother’s psychological control was two times higher in influencing her children to be involved in substance abuse compared to the other dimension. Conversely, an indirect risk factor towards youth drug abuse was elaborated in a study in which low parental educational level predicted a greater risk of future drug abuse by reducing the youth’s perception of harm [ 27 , 43 ]. Negligence from a parental perspective could also contribute to this problem. According to El Kazdouh et al. [ 46 ], a lack of parental supervision, uncontrolled pocket money spending among children, and the presence of substance-using family members were the most common negligence factors.

While the maternal factors above were shown to be risk factors, the opposite effect was seen when the paternal figure equipped himself with sufficient knowledge. A study found that fathers with good information and awareness were more likely to protect their adolescent children from drug abuse [ 26 ]. El Kazdouh et al. noted that support and advice could be some of the protective factors in this area [ 46 ].

DOMAIN: community factors

• Risk factor

A study in 2017 showed a positive association between adolescent drug abuse and peers who abuse drugs [ 32 , 39 ]. It was estimated that the odds of becoming a lifetime marijuana user was significantly increased by a factor of 2.5 ( p  < 0.001) among peer groups who were taking synthetic drugs. This factor served as peer pressure for youth, who subconsciously had desire to be like the others [ 38 ]. The impact of availability and engagement in structured and unstructured activities also play a role in marijuana use. The findings from Spillane (2000) found that the availability of unstructured activities was associated with increased likelihood of marijuana use [ 42 ].

• Protective factor

Strong religious beliefs integrated into society serve as a crucial protective factor that can prevent adolescents from engaging in drug abuse [ 38 , 45 ]. In addition, the school connectedness and adult support also play a major contribution in the drug use [ 40 ].

The goal of this review was to identify and classify the risks and protective factors that lead adolescents to drug abuse across the three important domains of the individual, family, and community. No findings conflicted with each other, as each of them had their own arguments and justifications. The findings from our review showed that individual factors were the most commonly highlighted. These factors include individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance and addiction history, and an individual’s attitude and perception as risk factors.

Within the individual factor domain, nine articles were found to contribute to the subdomain of personal/ individual traits [ 27 , 28 , 29 , 37 , 38 , 39 , 40 , 43 , 44 ]. Despite the heterogeneity of the study designs and the substances under investigation, all of the papers found statistically significant results for the possible risk factors of adolescent drug abuse. The traits of high impulsivity, rebelliousness, difficulty in regulating emotions, and alexithymia can be considered negative characteristic traits. These adolescents suffer from the inability to self-regulate their emotions, so they tend to externalize their behaviors as a way to avoid or suppress the negative feelings that they are experiencing [ 41 , 47 , 48 ]. On the other hand, engaging in such behaviors could plausibly provide a greater sense of positive emotions and make them feel good [ 49 ]. Apart from that, evidence from a neurophysiological point of view also suggests that the compulsive drive toward drug use is complemented by deficits in impulse control and decision making (impulsive trait) [ 50 ]. A person’s ability in self-control will seriously impaired with continuous drug use and will lead to the hallmark of addiction [ 51 ].

On the other hand, there are articles that reported some individual traits to be protective for adolescents from engaging in drug abuse. Youth with the optimistic trait, a high level of mindfulness, and social phobia were less likely to become drug dependent [ 31 , 33 , 37 ]. All of these articles used different psychometric instruments to classify each individual trait and were mutually exclusive. Therefore, each trait measured the chance of engaging in drug abuse on its own and did not reflect the chance at the end of the spectrum. These findings show that individual traits can be either protective or risk factors for the drugs used among adolescents. Therefore, any adolescent with negative personality traits should be monitored closely by providing health education, motivation, counselling, and emotional support since it can be concluded that negative personality traits are correlated with high risk behaviours such as drug abuse [ 52 ].

Our study also found that a history of maltreatment has a positive association with adolescent drug abuse. Those adolescents with episodes of maltreatment were considered to have negative growth exposure, as their childhoods were negatively affected by traumatic events. Some significant associations were found between maltreatment and adolescent drug abuse, although the former factor was limited to the female gender [ 25 , 30 , 36 ]. One possible reason for the contrasting results between genders is the different sample populations, which only covered child welfare centers [ 36 ] and foster care [ 30 ]. Regardless of the place, maltreatment can happen anywhere depending on the presence of the perpetrators. To date, evidence that concretely links maltreatment and substance abuse remains limited. However, a plausible explanation for this link could be the indirect effects of posttraumatic stress (i.e., a history of maltreatment) leading to substance use [ 53 , 54 ]. These findings highlight the importance of continuous monitoring and follow-ups with adolescents who have a history of maltreatment and who have ever attended a welfare center.

Addiction sometimes leads to another addiction, as described by the findings of several studies [ 29 , 34 ]. An initial study focused on the effects of e-cigarettes in the development of other substance abuse disorders, particularly those related to marijuana, alcohol, and commonly prescribed medications [ 34 ]. The authors found that the use of e-cigarettes can lead to more severe substance addiction [ 55 ], possibly through normalization of the behavior. On the other hand, Chuang et al.’s extensive study in 2017 analyzed the combined effects of either multiple addictions alone or a combination of multiple addictions together with the impulsivity trait [ 29 ]. The outcomes reported were intriguing and provide the opportunity for targeted intervention. The synergistic effects of impulsiveness and three other substance addictions (marijuana, tobacco, and alcohol) substantially increased the likelihood for drug abuse from 3.46 (95%CI 1.25, 9.58) to 10.13 (95% CI 3.95, 25.95). Therefore, proper rehabilitation is an important strategy to ensure that one addiction will not lead to another addiction.

The likelihood for drug abuse increases as the population perceives little or no harmful risks associated with the drugs. On the opposite side of the coin, a greater perceived risk remains a protective factor for marijuana abuse [ 56 ]. However, another study noted that a stronger determinant for adolescent drug abuse was the perceived availability of the drug [ 35 , 57 ]. Looking at the bigger picture, both perceptions corroborate each other and may inform drug use. Another study, on the other hand, reported that there was a decreasing trend of perceived drug risk in conjunction with the increasing usage of drugs [ 58 ]. As more people do drugs, youth may inevitably perceive those drugs as an acceptable norm without any harmful consequences [ 59 ].

In addition, the total spent for screen time also contribute to drug abuse among adolescent [ 43 ]. This scenario has been proven by many researchers on the effect of screen time on the mental health [ 60 ] that leads to the substance use among the adolescent due to the ubiquity of pro-substance use content on the internet. Adolescent with comorbidity who needs medical pain management by opioids also tend to misuse in future. A qualitative exploration on the perspectives among general practitioners concerning the risk of opioid misuse in people with pain, showed pain management by opioids is a default treatment and misuse is not a main problem for the them [ 61 ]. A careful decision on the use of opioids as a pain management should be consider among the adolescents and their understanding is needed.

Within the family factor domain, family structures were found to have both positive and negative associations with drug abuse among adolescents. As described in one study, paternal knowledge was consistently found to be a protective factor against substance abuse [ 26 ]. With sufficient knowledge, the father can serve as the guardian of his family to monitor and protect his children from negative influences [ 62 ]. The work by Luk et al. also reported a positive association of maternal psychological association towards drug abuse (IRR 2.41, p  < 0.05) [ 26 ]. The authors also observed the same effect of paternal psychological control, although it was statistically insignificant. This construct relates to parenting style, and the authors argued that parenting style might have a profound effect on the outcomes under study. While an earlier literature review [ 63 ] also reported such a relationship, a recent study showed a lesser impact [ 64 ] with regards to neglectful parenting styles leading to poorer substance abuse outcomes. Nevertheless, it was highlighted in another study that the adolescents’ perception of a neglectful parenting style increased their odds (OR 2.14, p  = 0.012) of developing alcohol abuse, not the parenting style itself [ 65 ]. Altogether, families play vital roles in adolescents’ risk for engaging in substance abuse [ 66 ]. Therefore, any intervention to impede the initiation of substance use or curb existing substance use among adolescents needs to include parents—especially improving parent–child communication and ensuring that parents monitor their children’s activities.

Finally, the community also contributes to drug abuse among adolescents. As shown by Li et al. [ 32 ] and El Kazdouh et al. [ 46 ], peers exert a certain influence on other teenagers by making them subconsciously want to fit into the group. Peer selection and peer socialization processes might explain why peer pressure serves as a risk factor for drug-abuse among adolescents [ 67 ]. Another study reported that strong religious beliefs integrated into society play a crucial role in preventing adolescents from engaging in drug abuse [ 46 ]. Most religions devalue any actions that can cause harmful health effects, such as substance abuse [ 68 ]. Hence, spiritual beliefs may help protect adolescents. This theme has been well established in many studies [ 60 , 69 , 70 , 71 , 72 ] and, therefore, could be implemented by religious societies as part of interventions to curb the issue of adolescent drug abuse. The connection with school and structured activity did reduce the risk as a study in USA found exposure to media anti-drug messages had an indirect negative effect on substances abuse through school-related activity and social activity [ 73 ]. The school activity should highlight on the importance of developmental perspective when designing and offering school-based prevention programs [75].

Limitations

We adopted a review approach that synthesized existing evidence on the risk and protective factors of adolescents engaging in drug abuse. Although this systematic review builds on the conclusion of a rigorous review of studies in different settings, there are some potential limitations to this work. We may have missed some other important factors, as we only included English articles, and article extraction was only done from the three search engines mentioned. Nonetheless, this review focused on worldwide drug abuse studies, rather than the broader context of substance abuse including alcohol and cigarettes, thereby making this paper more focused.

Conclusions

This review has addressed some recent knowledge related to the individual, familial, and community risk and preventive factors for adolescent drug use. We suggest that more attention should be given to individual factors since most findings were discussed in relation to such factors. With the increasing trend of drug abuse, it will be critical to focus research specifically on this area. Localized studies, especially those related to demographic factors, may be more effective in generating results that are specific to particular areas and thus may be more useful in generating and assessing local control and prevention efforts. Interventions using different theory-based psychotherapies and a recognition of the unique developmental milestones specific to adolescents are among examples that can be used. Relevant holistic approaches should be strengthened not only by relevant government agencies but also by the private sector and non-governmental organizations by promoting protective factors while reducing risk factors in programs involving adolescents from primary school up to adulthood to prevent and control drug abuse. Finally, legal legislation and enforcement against drug abuse should be engaged with regularly as part of our commitment to combat this public health burden.

Data availability and materials

All data generated or analysed during this study are included in this published article.

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The authors acknowledge The Ministry of Higher Education Malaysia and The Universiti Kebangsaan Malaysia, (UKM) for funding this study under the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). We also thank the team for their commitment and tireless efforts in ensuring that manuscript was well executed.

Financial support for this study was obtained from the Ministry of Higher Education, Malaysia through the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Nawi, A.M., Ismail, R., Ibrahim, F. et al. Risk and protective factors of drug abuse among adolescents: a systematic review. BMC Public Health 21 , 2088 (2021). https://doi.org/10.1186/s12889-021-11906-2

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Youth Participatory Action Research for Youth Substance Use Prevention: A Systematic Review

Elizabeth salerno valdez.

University of Arizona, Health Promotion Sciences. 1295 N Martin Ave, Tucson, AZ 85724

Luis Valdez

University of Massachusetts-Amherst, School of Public Health and Health Sciences, Arnold House, Amherst, MA 01003

David O Garcia

Josephine korchmaros.

University of Arizona, Southwest Institute for Research on Women. 181 S. Tucson Blvd. 101 Tucson, AZ 85716

Sally Stevens

Samantha sabo.

Northern Arizona University, Center for Health Equity Research. PO Box 4064, Northern Arizona University, Flagstaff, AZ 86011-4065

Scott Carvajal

A growing body of research points to the efficacy of participatory methods in decreasing rates of alcohol, tobacco, and other drug use and other risky behaviors among youth. However, to date, no systematic review of the literature has been conducted on Youth Participatory Action Research (YPAR) for youth substance use prevention. This review draws on the peer-reviewed literature on YPAR in the context of youth substance use prevention published from January 1, 1998 through April 30, 2018. We summarize (1) the published evidence regarding YPAR for youth substance use prevention; (2) the level of youth engagement in the research process; (3) the methodologies used in YPAR studies for youth substance use prevention; and (4) where more research is needed. In all, we identified 15 unduplicated peer-reviewed, English-language articles that referenced YPAR, Community Based Participatory Research, youth, and substance use prevention. We used Reliability-Tested Guidelines for Assessing Participatory Research Projects to assess the level of youth engagement in the research process. Our findings indicated that youth participation in research and social action resulted in increased community awareness of substance use and related solutions. This supports the premise of youth participation as an agent of community change by producing community-specific substance use data and prevention materials. Identified weaknesses include inconsistent levels of youth engagement throughout the research process, a lack of formalized agreements between youth and researchers with regard to project and data management, and a lack of outcome evaluation measures for assessing YPAR for youth substance use prevention.

Youth substance use and misuse continues to be a public health concern of epidemic proportions ( Mack, 2012 ). Early initiation of substance use is associated with negative health, social, and behavioral outcomes later in life, including physical and behavioral health problems ( Mack, 2012 ; Newcomb & Locke, 2005 ). According to the Monitoring the Future Survey (MTF), in 2017, annual marijuana prevalence among 8 th , 10 th , and 12 th graders increased significantly by 1.3 percentage points to 23.9% ( Johnston et al., 2018 ). Further, lifetime prevalence, annual prevalence, 30-day prevalence, and daily prevalence of alcohol use showed little or no change ( Johnston et al., 2018 ). Alarmingly, this is the first year that no decrease in prevalence was demonstrated, and may herald the end of the long-term decline in youth alcohol use ( Johnston et al., 2018 ). Similarly, prevalence of use of any illicit drug other than marijuana remained steady in 2017 ( Johnston et al., 2018 ).

These findings point to a need for innovative approaches for prevention, including youth engagement in research and public health programming ( Ozer, 2017 ). Youth participatory action research (YPAR) has received growing attention in public health and related fields for its potential in augmenting prevention efforts related to alcohol, tobacco, or other drug (ATOD) use. Ozer describes YPAR as an innovative, equity-focused approach for promoting adolescent health and well-being that draws on the expertise of youth as they conduct research and improve conditions that support healthy development ( Ozer, 2017 ).

With roots in the pedagogy of Brazilian-born education reformer Paulo Freire ( Freire, 1996 ), YPAR is a form of participatory action research (PAR) that provides youth with the opportunity to study social problems affecting their lives and to determine actions to solve these problems ( Cammarota & Fine, 2008 ). PAR is an approach that engages researchers and participants in collective, self-reflective inquiry so they can understand themselves and the world around them, and improve upon their circumstances (Livingston, 2017). Livingston describes PAR as combining two separate research concepts: participation – active involvement of “subjects” in the research process; and action – defining social problems and solving them (Livingston, 2017). Further, PAR recognizes the social, political, and structural origins of health and the disproportionate impact of substance use and related problems on disenfranchised groups ( Freire, 1996 ; Trask, 1987 ).

YPAR also is similar in to youth-led community-based participatory research (CBPR). CBPR most closely resembles the tenants of PAR while emphasizing the scientific rigor of conventional research ( Israel, Schulz, Parker, & Becker, 1998 ). According to Israel and colleagues, CBPR is a collaborative partnership approach to research that equitably involves community members, organizational representatives, and researchers in all aspects of the research process ( Israel et al., 1998 ). The research process is defined as inception of the research question, data collection and analysis, dissemination and/or application of the results ( Israel et al., 1998 ). Partners contribute their expertise and share responsibilities and ownership of the research. This collaborative process thus increases the understanding of a given phenomenon, which can be incorporated into action to enhance the health and well-being of community members ( Israel et al., 1998 ).

YPAR is distinct from PAR and CBPR in that it is youth-led, as opposed to being adult-led with or about youth ( Cammarota & Fine, 2008 ). Youth learn how to conduct research (using surveys, focus groups, and photovoice, among other methods), effectively becoming youth researchers and advocates for change ( Jason & Glenwick, 2016 ). Further, YPAR emphasizes the development and strengthening of collective efficacy (or collective empowerment) among youth involved in the research, which enables them to engage in social action for change. Youth advocate for change based on evidence from their research, and engage in social action in their schools, communities, and at the policy level, which in turn influences their attitudes and behaviors ( Cammarota & Fine, 2008 ).

YPAR can contribute to substance use research as an ideal approach to ensure cultural-grounding and culture-as-intervention in health promotion programs targeting youth, particularly as more public health research and health behavior interventions emphasize culture over individual level strategies to achieve sustainable change resulting in positive health outcomes ( Airhihenbuwa, Ford, & Iwelunmor, 2014 ). Further as youth are embedded in complex environments, participatory methods are ideal for public health researchers and practitioners targeting the ecological contexts in which substance use occurs ( Golden, McLeroy, Green, Earp, & Lieberman, 2015 ). PAR/CBPR/YPAR approaches have been shown to successfully decrease rates of ATOD use and other risky behaviors among at-risk youth ( Kulbok et al., 2015 ; Romero, 2016 ). However, while there is a growing body of research on YPAR ( Cammarota & Fine, 2008 ; Ozer, 2017 ; Shamrova & Cummings, 2017 ), existing research using YPAR for youth substance use prevention has not been systematically evaluated.

The purpose of this review is to identify and describe YPAR studies in the context of youth substance use prevention research. We documented targeted substances, participant descriptions, objectives, overarching participatory approaches, methodologies used, youth outcomes, community outcomes, and reported pit falls. Specifically, we had four overarching objectives: (1) To summarize the published evidence regarding YPAR for youth substance use prevention; (2) To articulate the level of youth engagement in the research process; (3) To summarize the methodologies used in YPAR studies for youth substance use prevention; and (4) To synthesize where more research is needed.

The current study is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), used for the transparent reporting of systematic reviews ( Moher, Liberati, Tetzlaff, & Altman, 2009 ).

Inclusion criteria included peer-reviewed, English-language articles published from January 1, 1998 through April 30, 2018 that referenced YPAR, PAR, CBPR, youth, and substance use prevention. We included articles on YPAR interventions/programs/projects for youth substance use prevention; youth-led PAR or CBPR projects; and studies addressing substance use prevention as a primary or secondary outcome. All included studies described research that was youth-led (versus adult-led or in partnership with adults).

Articles inconsistent with the inclusion criteria or which were editorial, historical or theoretical in nature were excluded. We excluded articles on adult-led interventions with youth collaborators and articles or other publications from non-peer reviewed sources. For example, we excluded articles where youth were used to validate or test an intervention if that intervention was not originally conceived by and developed by youth.

Search Strategy

To identify references we conducted a search across PsycINFO, PubMed, Web of Science, Scopus, EMBASE and Google Scholar online databases, followed by an analysis of the text contained in the title, abstract, and index terms of retrieved articles. Depending on the search engine, we used MeSH heading, keyword, and topic searches. Our search included terms associated with the study population (separated by OR): ‘adolescent’ or ‘adolescence’ or ‘youth’ or ‘teen’, AND terms associated with the approach: ‘youth participatory action research’ or ‘community-based participatory research’ or ‘participatory action research’, AND terms associated with the outcome: ‘substance use’ or ‘substance abuse’ or ‘drug abuse’ or ‘drug prevention’ or ‘drug dependence’ or ‘drug use’ or ‘underage drinking’ or ‘alcohol’ or ‘alcohol use’ or ‘alcohol misuse’ or ‘alcoholism’ or ’marijuana’ or ‘cannabis use’ or ’marijuana use’ or ‘opioid’ or ‘opioid misuse’ or ‘opioid use’ or ‘injection drug use’ or ‘injection drug’ or ‘amphetamine’ or ‘amphetamine use’ or ‘ illicit drug’ or ‘illicit drug use’ or ‘tobacco’ or ‘tobacco use’. We then carefully reviewed reference lists from all articles that met the inclusion criteria for additional studies for potential review.

Study Selection

Two authors (ESV, IS) independently inspected all titles and abstracts according to the inclusion criteria and eliminated duplicates. We recorded author, journal, and year of publication from each manuscript that met inclusion criteria. Where the two authors disagreed, they met to discuss and, if possible, reach a consensus. They met once to resolve eight disagreements and were able to reach consensus on six. Judgment was referred to a third reviewer (LV) for the remaining two studies.

Risk of Bias (Quality Assessment): Level of Youth Engagement

The Reliability-Tested Guidelines for Assessing Participatory Research Projects (Mercer et al., as cited in Minkler & Wallerstein, 2011 ) were adapted to assess the level of youth engagement in each stage of the participatory research process: participants and the nature of their involvement (i.e., participants’ appropriateness for the project); participants’ role in shaping the purpose and scope of the research (i.e., inception of the research question and development of the study design); their role in research implementation and context (i.e., data collection and analysis); and their role in the dissemination of research outcomes (i.e., dissemination/application of the results [social action]). The guidelines define participatory research as systematic inquiry, with the collaboration of those affected by the issue being studied, for the purposes of education and of taking action or effecting change ( Minkler & Wallerstein, 2011 ). The guidelines are meant to assess proposed projects; however, we used them to assess completed projects described in the articles. For the purposes of this review, we adapted the guidelines by assessing whether the article met or did not meet each guideline. We excluded two guidelines within Shaping the Purpose and Scope of the Research from our scoring as they fell out of the scope of the objectives of this literature review and synthesis. Specifically, the eliminated guidelines did not assess engagement in the research process. While further description of the guidelines is outside of the scope of this article, the complete guidelines can be found at Mercer et al., as cited in Minkler & Wallerstein, 2011 ). We searched for the presence of each of the domains in all projects described within selected articles and reported the results of this deductive thematic analysis ( Table 2 ).

Youth Participation in the Research Process

We identified 887 article abstracts and screened them for duplicates ( Figure 1 ). A total of 547 original abstracts were retained and 340 duplicates deleted. Of the retained abstracts, 324 were excluded due to search engine misclassification (i.e., those unrelated to YPAR, CBPR, or substance use prevention). The remaining 223 article abstracts were screened for youth-led CBPR as follows: 14 described community-placed research (i.e., traditional research conducted in/about a community but without community participation); 16 described research that was community-partnered but for which the community did not conduct the research; 30 described research that was CBPR for adults about adults; and 39 articles described research that was CBPR that involved youth but was not youth-led (e.g., adult-led with or about youth). Next, the full texts of the remaining 123 articles were screened for substance use intervention studies involving YPAR, among which 108 were excluded because they were descriptive/review articles on YPAR (i.e., other systematic reviews unrelated to substance use, case studies, and lessons learned articles focused on elements other than interventions of interest). Finally, 15 articles met the inclusion criteria for this review. The projects described in these articles varied considerably with regard to targeted substances, participant descriptions, objectives ,participatory approaches, methods, youth outcomes, community outcomes, and reported pitfalls ( Table 1 ).

Study Selection Flow Chart

YPAR Studies for Substance Use Prevention

Targeted Substance(s)

Seven articles listed tobacco as the targeted substance ( Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Petteway et al., 2018; Pinsker et al., 2017 ; Ross, 2011 ; Tanjasiri et al., 2011 ). Eight articles reportedly targeted general substance use or ATOD ( Ager et al., 2008 ; Berg et al., 2009 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ; Wilson et al., 2008 ).

Participant Descriptions

The projects described in the 15 articles varied with regard to target populations. Fourteen articles involved youth of vulnerable backgrounds (i.e., rural, indigenous, street involved, refugee, conflict survivors) ( Ager, Parquet, & Kreutzinger, 2008 ; Berg, Coman, & Schensul, 2009 ; Diamond et al., 2009 ; Jardine & James, 2012 ; Lee, Lipperman-Kreda, Saephan, & Kirkpatrick, 2013 ; Lee et al., 2017 ; Petteway, Sheikhattari, & Wagner, 2018; Ross, 2011 ; Tanjasiri, Lew, Kuratani, Wong, & Fu, 2011 ; Wilson, M. Minkler, S. Dasho, N. Wallerstein, & A. C. Martin, 2008 ), rural youth ( Helm et al., 2015 ), urban youth ( Ager et al., 2008 ), street-involved youth ( Poland, Tupker, & Breland, 2002 ), LGBTQ youth ( Maglajlić & Tiffany, 2006 ), refugee youth ( Pinsker et al., 2017 ), and survivors of conflict ( Maglajlić & Tiffany, 2006 )). One article did not describe participants as having any kind of vulnerability ( Brazg, Bekemeier, Spigner, & Huebner, 2011 ).

Eleven articles engaged youth of color (e.g., African American ( Ager et al., 2008 ; Berg et al., 2009 ; Diamond et al., 2009 ), Latino ( Berg et al., 2009 ; Diamond et al., 2009 ), Native ( Helm et al., 2015 ; Jardine & James, 2012 ), Southeast Asian ( Lee et al., 2013 ; Lee et al., 2017 ), Somali ( Pinsker et al., 2017 ), Asian American and Pacific Islander ( Tanjasiri et al., 2011 ). Study populations engaged a range of ages (i.e., ages 10–24). Most participants were 10–18 years of age. Only one article studied elementary school children ( Wilson et al., 2008 ). Studies were conducted in the United States, except two were conducted in Canada and one was conducted in Bosnia Herzegovina.

Sample sizes varied greatly across articles. Seven articles had sample sizes of 10 or fewer participants ( Ager et al., 2008 ; Brazg et al., 2011 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2017 ; Poland et al., 2002 ). Three articles had sample sizes between 15–20 participants ( Diamond et al., 2009 ; J. P. Lee et al., 2013 ; Petteway et al., 2018; Ross, 2011 ). Five articles reported projects with multiple cohorts, with total sample sizes ranging from 32–122 participants ( Berg et al., 2009 ; Maglajlić & Tiffany, 2006 ; Pinsker et al., 2017 ; Tanjasiri et al., 2011 ; Wilson et al., 2008 ).

Articles reported varying objectives to achieve their overall goal of youth substance use prevention. Six articles reported aiming to conduct a community assessment of youth substance use ( Brazg et al., 2011 ; Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Ross, 2011 ; Tanjasiri 3t al., 2011 ). Four articles sought to develop an intervention or program for substance use prevention ( Helm et al., 2015 ; Maglajlić & Tiffany, 2006 ; Pinsker et al., 2017 ; Poland et al., 2002 ). Four articles reported goals related to building youth or community capacity ( Ager et al., 2008 ; Diamond et al. 2009 , Petteway et al., 2018; Wilson et a., 2008 ). One article conveyed the objective was to reduce and/or delay onset of substance use in youth ( Berg et al., 2009 ).

Participatory Approaches

A number of different participatory project designs were reported. Salient approaches included PAR (n=7) ( Berg et al., 2009 ; Brazg et al., 2011 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2013 : Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ) CBPR (n=4) (Petteway et al., 2018; Pinsker et al., 2017 ; Tanjasiri et al., 2011 ; Wilson et al., 2008 ), Hart’s Ladder of Participation (n=1) ( Jardine & James, 2012 ), and the participatory intervention model (PIM) ( Diamond et al., 2009 ). One article did not mention a participatory approach ( Ager et al., 2008 ).

Roger Hart’s Ladder of Participation emphasizes meaningful youth participation where youth initiate projects or programs and share decision making with adults. It describes eight escalating degrees of participation, ranging from non-participation at the lowest rungs (e.g., manipulation, decoration, and tokenism) to true participation at the top rungs of the ladder (e.g., provision of information by youth, youth-initiated shared decisions with adults) ( Shier, 2001 ). The participatory intervention model (PIM) is a methodology for grounding interventions in the ongoing life of communities, by involving community stakeholders and targeted populations in each stage of the intervention development process ( Nastasi et al. 2000 ).

There are a number of overlapping elements across participatory approaches, and many articles used more than one approach. For example, three articles reported using Positive Youth Development (PYD) ( Helm et al., 2015 ; Ross, 2011 ; Wilson et al., 2008 ). PYD is an intentional approach that recognizes, utilizes, and enhances young people’s strengths, rather than focusing on correcting, curing, or treating them for maladaptive tendencies or so-called disabilities ( Damon, 2004 ). PYD is a framework that is compatible with PAR/CBPR, but PYD does not require a research component.

Articles described the use of a variety of research methods. All articles reported providing research methods or skills development training followed by a youth-led research project or intervention. Photovoice ( Wang & Burris, 1994 , 1997 ) was the most common method (n=6) ( Brazg et al., 2011 ; Helm et al., 2015 ; Lee et al., 2013 ; Lee et al., 2017 ; Petteway et al., 2018; Tanjasiri et al., 2011 ; Wilson et al., 2007 ). Four articles reported traditional qualitative methods including focus groups, one-on-one interviews, community observations, and community surveys ( Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ). Two articles reported using both Photovoice and traditional qualitative methods ( Lee et al., 2013 ; Lee et al., 2017 ). One article reported mixed methods projects with multiple cohorts ( Berg et al., 2009 ). One article reported a project in which youth counted and documented temporary tobacco advertisements, and analyzed Geographic Information System (GIS) mapping data of tobacco stores in their neighborhood ( Ross, 2011 ).

Three articles reported skills development training for the purposes of developing an intervention. Two articles reported youth-led video development for substance use prevention ( Ager et al., 2008 ; Pinsker et al., 2017 ). One article described the “Leadership and Craft Development Training Program” to train youth to produce original works of art to be either recorded on a compilation CD or displayed at a live “drug free” CD release show ( Diamond et al., 2009 ). All articles described some type of action plan (e.g., reaching policy makers), social action activity (e.g., community presentation), or deliverable (e.g., community-tailored tobacco prevention video) as the culminating element of the participatory project.

Outcomes for Youth

Articles reported a number of positive effects of youth involvement in YPAR projects on substance use indicators. Participating youth increased their knowledge about tobacco ( Lee et al., 2013 ; Lee et al., 2017 ; Petteway et al., 2018; Pinsker et al., 2017 ; Ross, 2011 ; Tanjasiri et al., 2011 ), alcohol, and other substances ( Ager et al., 2008 ; Berg et al., 2009 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ). Ten articles presented results from YPAR projects that identified influential factors for substance use in their communities, thereby increasing their knowledge and awareness of these issues at the community level ( Ager et al., 2008 ; Brazg et al., 2011 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Petteway et al., 2018; Pinsker et al., 2017 ; Ross, 2011 ; Tanjasiri et al., 2011 ). Other outcomes included decreased approval of peer drug use ( Berg et al., 2009 ), increased dialogue between youth and adult community members about youth substance use ( Brazg et al., 2011 ), and decreased alcohol use and frequency of marijuana use over time ( Berg et al., 2009 ).

Articles noted that youth involvement in YPAR encouraged skill development among youth. Youth developed research skills, including photography ( Brazg et al., 2011 ; Helm et al., 2015 ; Lee et al., 2017 ; Petteway et al., 2018; Tanjasiri et al., 2011 ; Wilson et al., 2007 ), qualitative data collection and analysis ( Poland et al., 2002 ), video development, editing, and production ( Ager et al., 2008 ; Pinsker et al., 2017 ), marketing, media, and art design ( Diamond et al., 2009 ), research methods ( Berg et al., 2009 ; Jardine & James, 2012 ; Lee et al., 2013 ; Ross, 2011 ), group-identified action plan development ( Wilson et al., 2008 ), decision making ( Maglajlić & Tiffany, 2006 ), and teamwork ( Ross, 2011 ). Researchers also reported that youth developed their leadership skills through their engagement in YPAR projects. Specifically, their involvement in YPAR provided them with opportunities to interact with decision-makers and thus positioned them as leaders and role models in their communities ( Helm et al., 2015 ; Lee et al., 2017 ; Petteway et al., 2018; Ross, 2011 ; Tanjasiri et al., 2011 ), while also connecting them with public speaking and networking opportunities (e.g., conferences, presentations) ( Berg et al., 2009 ; Helm et al., 2015 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Ross, 2011 ; Tanjasiri et al., 2011 ).

According to the articles, fundamental to the success of YPAR was the development and strengthening of collective efficacy (or collective empowerment) among these groups of youth, which enabled them to engage in social action. All articles reported that youth either contributed to development of action plans or conducted action-oriented activities, which involved raising critical awareness among their peers, schools, adults, and/or communities through social media, workshops, strategic meetings, and community presentations.

YPAR projects provided youth opportunities to engage in advocacy and policy change for substance use prevention. For example, Ross (2011) reported that their project provided youth with the opportunity to work with a senator to write a bill to limit the marketing and sale of tobacco to minors. Other articles reported advocacy activities including the development of collective action plans and projects designed to change public norms and promote social advocacy around youth issues at the school, community, organizational, and policy levels ( Berg et al., 2009 ; Wilson et al., 2008 ).

Outcomes for Communities

Communities received substance use-specific data, programs, and materials tailored to their communities by youth living and interacting in these environments. For example, one article reported that their YPAR project developed a community-specific prevention strategy, including the recommendation to develop a nation-wide, school-based participatory peer education program ( Maglajlić & Tiffany, 2006 ). Another article reported that the community received enhanced community-level data needed to develop the foundation of a prevention program from the perspective of rural Hawaiian youth ( Helm et al., 2015 ).

YPAR projects helped to re-shape community perceptions of youth, effectively shifting the discourse from youth as problems to youth as resources and agents of change. For example, Petteway, Sheikhattari, and Wagner (2018) stated that their project led to the development of a youth tobacco advisory council, and was instrumental in establishing a more dynamic and open communication between city agencies, council members, community residents, and members of the tobacco prevention collaborative. Overall, articles commented on the complex interaction between learning, adult support and facilitation, research action and creating, and affirming positive attitudes towards youth involvement in the community.

YPAR projects involved youth in community awareness and educational campaigns for substance use prevention. Articles reported cooperation with the media using talk shows, TV advertisements, billboards, and music ( Diamond et al., 2009 ; Maglajlić & Tiffany, 2006 ). Youth also had the opportunity to disseminate findings to other youth through a peer to-peer education program that resulted from YPAR projects ( Maglajlić & Tiffany, 2006 ), and through workshops and strategic meetings ( Lee et al., 2017 ). Another project reportedly reached several thousands of youth through ads, information booths, a website, promotional items, and friends ( Diamond et al., 2009 ).

Reported Pitfalls

Articles noted a number of pitfalls over the course of the YPAR projects. Pitfalls included youth (Petteway et al., 2018; Wilson et al., 2008 ) and staff turnover (Petteway et al., 2018) and limited time to complete deliverables ( Jardine & James, 2012 ; Wilson et al., 2008 ). Limited resources and budget also posed some challenges for YPAR projects ( Poland et al., 2002 ; Ross, 2011 ). YPAR projects, like most researcher or funder-sponsored projects, often faced challenges related to sustainability and achieving long-term impact (Petteway et al., 2018).

Level of Youth Engagement

According to participatory research scholars, true participatory research involves community members from inception to dissemination ( Minkler & Wallerstein, 2011 ). We determined that the articles varied in the degree researchers engaged youth in the research process ( Table 2 ).

Participants and the nature of their involvement

All articles described the youth to assess their representation in the project. Most articles described provisions to build trust between researchers and youth (n=12) ( Ager et al., 2008 ; Berg et al., 2009 ; Diamond et al., 2009 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Pinsker et al., 2017 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ). Fewer articles described making efforts to address barriers to participation by underrepresented youth (n=8) ( Ager et al., 2008 ; Berg et al., 2009 ; Diamond et al., 2009 ; Lee et al., 2017 ; Petteway et al., 2018; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ), or having a formal/informal agreement regarding management of the project (n=5) ( Diamond et al., 2009 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ).

Shaping the purpose and scope of the research

All articles described providing for mutual learning among youth and researchers. However, researchers were less likely to involve youth in the development of the research question (n=7) ( Berg et al., 2009 ; Diamond et al., 2009 ; Lee et al., 2013 ; Maglajlić & Tiffany, 2006 ; Pinsker et al., 2017 ; Ross, 2011 ; Wilson et al., 2008 ), or consult with them or involve them in the research design (n=7) ( Berg et al., 2009 ; Diamond et al., 2009 ; Maglajlić & Tiffany, 2006 ; Pinsker et al., 2017 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ).

Research implementation and context

All articles described work involving youth in research implementation, providing youth with the opportunity to learn about research, and permitting researchers to learn about youth’s perspectives on the research topic. Nearly all research engaged youth in data analyses and sufficiently involved youth in interpretation of research findings (n=13) ( Ager et al., 2008 ; Berg et al., 2009 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ). Fewer articles described having a formal or informal agreement regarding mutual decision-making about potential changes in research methods or focus (n=8) ( Berg et al., 2009 ; Diamond et al., 2009 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ).

Nature of the research outcomes

All articles reflected commitment to social, individual, and/or cultural action by both the researchers and youth participating in the research process, but fewer described having a formal or informal agreement for acknowledging differences in result interpretation (e.g., youth have a different perspective of the findings than the researcher) (n=9) ( Diamond et al., 2009 ; Helm et al., 2015 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ). All articles described a formal or informal agreement (verbal or written) regarding ownership and sharing of the research data (n=15). Most articles reported providing feedback of research results to youth (n=13) ( Ager et al., 2008 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Pinsker et al., 2017 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ), and involving youth in the dissemination of research findings (n=14) ( Ager et al., 2008 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Jardine & James, 2012 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Pinsker et al., 2017 ; Poland et al., 2002 ; Ross, 2011 ; Tanjasiri et al., 2011 ; Wilson et al., 2008 ). Most articles described plans directed at sustainability in relation to the purpose of the research (e.g., by fostering collaboration between youth and youth-serving agencies, funding sources, policymakers) (n=12) ( Ager et al., 2008 ; Brazg et al., 2011 ; Diamond et al., 2009 ; Helm et al., 2015 ; Lee et al., 2013 ; Lee et al., 2017 ; Maglajlić & Tiffany, 2006 ; Petteway et al., 2018; Pinsker et al., 2017 ; Poland et al., 2002 ; Ross, 2011 ; Wilson et al., 2008 ).

The aim of this study was to review current evidence for YPAR studies in the context of youth substance use prevention research We summarize (1) the published evidence regarding YPAR for youth substance use prevention; (2) the level of youth engagement in the research process; (3) the methodologies used in YPAR studies for youth substance use prevention; and (4) where more research is needed.

We systematically examined the existing YPAR studies aiming to prevent youth substance use, their targeted substances, participant descriptions, objectives, participatory approaches, methodologies, youth outcomes, community outcomes, and pitfalls, as well as the role of youth in the research process. Most projects described in the articles targeted tobacco and ATOD as part of their prevention efforts. We identified articles involving a diverse set of target populations. Almost all articles described studies that engaged vulnerable youth in the participatory process. The literature supports YPAR as an appropriate approach to engage youth of color who may not yet feel comfortable with written/verbal expression ( Anyon, Bender, Kennedy, & Dechants, 2018 ; Cammarota & Fine, 2008 ; Ozer, 2017 ). Articles reported multiple objectives intended to help meet their universal goal of youth substance use prevention, including developing community assessments, building youth and community capacity, and developing interventions/programs. This review identified articles describing the development of substance use prevention interventions using a YPAR approach, as well as articles describing YPAR projects in which the participatory method (e.g., Photovoice) served as the intervention itself. Youth engagement was facilitated by the participatory approaches employed by the studies, including CBPR, PAR, YPAR, PIM, and Hart’s Ladder of Participation.

The 15 studies utilized a variety of research methods and/or skills development, the most frequent of which were photovoice, qualitative methods, and video development. Digital storytelling tools like photovoice and video development in particular are consistent with YPAR and CBPR principles that emphasize empowerment, individual and community strengths, mutual learning, and balancing research and action ( Minkler & Wallerstein, 2011 ). The photovoice process in particular is touted as a means to link youth with their community through culture and leadership ( Helm & Kanoelani Davis, 2017 ). Further, using YPAR, qualitative methods such as interviews and focus groups feature an individual’s or group’s feelings, views, and patterns and minimize control or manipulation from the researcher ( MacDonald, 2012 ). Articles described using the findings from the research methods to develop some type of action plan (e.g., reaching policy makers), social action activity (e.g., community presentation), or deliverable (e.g., tobacco prevention video) as the culminating element of the participatory project.

Youth and communities experienced a number of positive outcomes as a result of their participation in YPAR substance use prevention projects. Youth learned about substance use, developed research skills, developed collective efficacy, and participated in advocacy and policy change. Communities benefitted from YPAR projects in numerous ways, including receipt of community-tailed substance use-specific data, programs and materials, positively shifted community perceptions of youth to resources and agents of change, and increased community awareness through educational substance use prevention campaigns. Our findings coincide with other reviews of participatory research with youth regarding to benefits of YPAR for youth and communities ( Anyon et al., 2018 ; Shamrova & Cummings, 2017 ).

We assessed youth engagement in the research process using the Reliability-Tested Guidelines for Assessing Participatory Research Projects by Mercer et al. ( Minkler & Wallerstein, 2011 ). Articles varied with regard to the level of youth engagement. We found that more than half of studies reported that youth were generally more engaged in later phases of the research (e.g., dissemination of the results). Fidelity to the YPAR approach is such that youth are involved in every step of the research process ( Cammarota & Fine, 2008 ). When a researcher identifies a problem, generates the research question, and develops the study design, this can create power imbalances, misinterpret youth voices, or create a research environment where youth play a trivial role ( Cammarota & Fine, 2008 ; Shier, 2001 ).

Research involving youth from inception to dissemination was able to engage youth in substance use prevention at multiple levels. For example, one study that involved youth in the development of the research question and study design found effects at multiple levels, including individual level behavioral change (i.e., decreased alcohol use and frequency of marijuana use), increased social cohesion among participants, improved peer norms (i.e., youth shifted to believing that fewer peers were using drugs and approval of peer drug use decreased, educational expectations increased), and increased community level self-efficacy (i.e., increase in social action) ( Berg et al., 2009 ). Increased youth engagement also resulted in opportunities for engagement with policy makers.

We also identified areas for improvement. With regard to youth engagement in the research process, programs could have enhanced power sharing and equitable decision-making between researchers and youth. Several studies did not report established formal or informal agreements with youth at varying phases of the YPAR process, including agreements regarding management of the project and its data, or potential changes in research methods. We acknowledge that some of these agreements may have been implicit in nature or simply not reported; however, formalized agreements promote trust and encourage power sharing ( Minkler & Wallerstein, 2011 ). As such, it is critical that researchers balance time and resources to expand the roles of youth beyond their role as solely a data source, and emphasize equitable power distribution, in order to promote the youth voice and enhance project outcomes ( Cammarota & Fine, 2008 ).

Another area for improvement within YPAR for youth substance use prevention is outcome evaluation. All articles identified by this review reported youth substance use prevention as one of their primary or secondary outcomes. However, articles varied widely with regard to their outcome measures, likely due to the wide range of reported objectives (i.e., intervention development, community assessment, capacity building). Most articles did not report if and how outcome data were collected or analyzed, the data limitations, or how other researchers might replicate or confirm these findings. Only one article reported more proximal individual level behavioral outcomes measures for youth involved in the project (i.e., frequency of substance use) ( Berg et al., 2009 ). The majority of articles used more distal measures for evaluating YPAR (versus substance use) including measures for peer norms and collective efficacy (e.g., social action) and community engagement. Many articles reported their outcomes as the deliverables resulting from the projects (e.g., videos, photovoice data, interactions with decision-makers, research skill development). Using more proximal measures for substance use would help to assess how involvement in YPAR changes the substance use behaviors of the youth involved. Further, no articles reported long-term outcomes for youth involved in the projects. We recommend follow-up with youth to determine how involvement in YPAR impacts substance use-related outcomes, including improvements in educational attainment (e.g., high school graduation), health behaviors (e.g., substance use), and interpersonal outcomes (e.g., domestic violence).

Strengths and Limitations

This review has numerous strengths. Importantly, we used PRISMA guidelines to systematically examine YPAR for substance use prevention. We believe this review adds valuable insight to the expanding literature on YPAR and its potential applications. The review is not without limitations. First, the exclusion of articles from non-peer-reviewed sources, book chapters, and masters and doctoral theses may have eliminated some important and influential examples of YPAR for youth substance use prevention. We also limited the search to articles published in English, and may have missed some relevant contributions in other languages. Publication bias poses considerable limitations given that studies with limited or negative findings likely remained unpublished, resulting in a bias toward effective or successful YPAR projects. We identified studies using a comprehensive list of search terms; however, the search terms could have limited the scope of identified articles. We may have missed studies that could be considered YPAR because of the use of specific labels particular to the field, thus limiting the generalizability of findings. Relatedly, the authors acknowledge that a single research program may occur over multiple years and is represented in numerous peer- reviewed articles and other forms of dissemination. A single article may aim to highlight only one phase of the project, rather than all phases of a project. For example, issues like formal and informal agreements may nbnot be addressed in a particular article or dissemination activity. It is possible that these research projects in fact address all of these components, but did not report them in the retained article. As a result, the articles that were identified, screened, and retained in this review are not meant to be comprehensive representations of all aspects of YPAR for youth substance use prevention.

Implications for Research

Research on YPAR for youth substance use prevention remains sparse. Therefore, additional research focused on using YPAR methods in substan ce use research with this population is needed. While several articles included in this review discussed how youth involvement enhanced or informed community-level data collection efforts, additional research should focus on specific community outcomes including practice and policy changes. Several articles reported successful YPAR or CBPR outcomes for curriculum or intervention development. Further research should engage youth in the development and testing of youth substance use prevention programs. This review also found limited use of evaluation measures. Future studies should include evaluation measures for substance use at both the individual/behavioral level and community level as a means to measure impact of YPAR programs.

Conclusions

YPAR provides youth with opportunities to develop research and leadership skills, while fostering consciousness about social issues of concern, including youth substance use. Critical consciousness can propel youth towards action to inform substance use related research, policy change, and intervention development. Future research should prioritize more fully engaging youth in every step of the research process and establish more formalized agreements between youth and researchers with regard to project and data management. The addition of outcome measures for assessing YPAR for youth substance use prevention is also needed. However, there is high promise for YPAR frameworks and methods to enhance youth substance use prevention. Building on collective strength and community assets, these studies show that youth can collaborate with researchers to collect data, develop materials and programs, and promote social change in their communities, schools, and neighborhoods. As youth are embedded in complex environments where identities(s), culture(s) and developmental processes are fluid, YPAR is an ideal approach to ensure cultural-grounding and culture-as-intervention in health promotion programs ( Airhihenbuwa, Ford, & Iwelunmor, 2014 ). Further, with the rapid change of technology, culture and globalism, these methods are ideal for public health researchers and practitioners aiming for responsiveness to the ecological contexts in which substance misuse occurs ( Golden, McLeroy, Green, Earp, & Lieberman, 2015 ).

Acknowledgments

The study described in this manuscript was funded by the Ruth L. Kirschstein National Research Services Award, Individual Predoctoral Fellowship [PA-16–309] by the National Institute of Minority Health and Health Disparities, National Institutes of Health; the Program in Migration and Health – California Endowment, UC Berkeley; and the Center for Border Health Disparities, Arizona Health Sciences, University of Arizona.

Declaration of Interests

The authors report no conflicts of interest

Contributor Information

Elizabeth Salerno Valdez, University of Arizona, Health Promotion Sciences. 1295 N Martin Ave, Tucson, AZ 85724.

Iva Skobic, University of Arizona, Health Promotion Sciences. 1295 N Martin Ave, Tucson, AZ 85724.

Luis Valdez, University of Massachusetts-Amherst, School of Public Health and Health Sciences, Arnold House, Amherst, MA 01003.

David O Garcia, University of Arizona, Health Promotion Sciences. 1295 N Martin Ave, Tucson, AZ 85724.

Josephine Korchmaros, University of Arizona, Southwest Institute for Research on Women. 181 S. Tucson Blvd. 101 Tucson, AZ 85716.

Sally Stevens, University of Arizona, Southwest Institute for Research on Women. 181 S. Tucson Blvd. 101 Tucson, AZ 85716.

Samantha Sabo, Northern Arizona University, Center for Health Equity Research. PO Box 4064, Northern Arizona University, Flagstaff, AZ 86011-4065.

Scott Carvajal, University of Arizona, Health Promotion Sciences. 1295 N Martin Ave, Tucson, AZ 85724.

*Indicates 15 articles included in this review.

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