Blueprint for Action: Preventing substance-related harms among youth through a Comprehensive School Health approach

Overview

This resource sets out action plans and strategies at various levels of the Canadian education system to prevent substance-related harms among youth.

Table of Contents

• Introduction
• Purpose
• Who this resource is for
• Overview of the Blueprint for Action
• How this resource was developed
• Section 1: Key messages
• Section 2: The Blueprint for Action intervention model
  • Overview of the model
  • Comprehensive School Health approach
  • Substance use prevention approaches
    • Upstream prevention approaches
    • Harm reduction approaches
    • Stigma reduction initiatives
    • Equity-oriented approaches
  • Combining the intervention approaches
  • Strengths of the Blueprint for Action model
• Section 3: Putting the Blueprint for Action into practice
  • Barriers and Enables to implementing the Blueprint model
  • Principles for Action
• Conclusion
• Appendices
  • Appendix 1. The Blueprint for Action model "in practice"
  • Appendix 2. Additional resources and research articles

Introduction

Schools are an important environment for youth.^{Footnote 1} They are a setting for learning, personal and community development, socialization and the promotion of health and well-being. The COVID-19 pandemic has highlighted the significance of school communities in the lives of young people and their families, as well as their central place in our society. In recent years, there has also been greater attention on the role of schools in addressing substance use and substance-related harms among youth.

At the same time, there have been major advancements in our understanding of substance use topics, due to growing evidence on the factors that contribute to substance-related harms and promising practices for intervention,^{Footnote 2} including those designed for and by youth. This evidence is being used to shape interventions in various settings. However, there are opportunities to better integrate evidence-based approaches to preventing substance-related harms in the context of school communities.

Purpose

We developed this resource with three main purposes:

1. To inform strategies that prevent substance-related harms in youth at various levels of the Canadian education system

   The main purpose of this resource is to inform comprehensive and concrete action plans and strategies at various levels of the Canadian education system (individual schools, school boards, school health organizations, among others) to prevent substance-related harms among youth. Specifically, this resource sets out a Comprehensive School Health approach that reflects the diverse realities and needs of students, the various factors associated with substance use and substance-related harms, and the many areas in which schools can take action.

2. To call for school communities to think differently about how they approach youth substance use

   In light of resource limitations, it is in school communities' best interest to invest in school health initiatives that are both effective and equitable. This means shifting away from outdated approaches and exploring options that are supported by evidence. It also means recognizing that "one-size-fits-all" models do not resonate with, and often exclude many youth, and that models that reflect youths' diverse needs, identities and situations are needed. Likewise, school-based efforts to prevent substance-related harms must reflect school communities' unique needs, resources, culture and values.

3. To support school stakeholders in engaging their networks, communities and governments for increased attention, buy-in and resources for comprehensive approaches, that are planned, integrated and holistic, for preventing substance-related harms among youth

   School-based efforts to prevent substance-related harms among youth are not just ideal to have; these efforts work to protect and promote the rights of youth, in accordance with various international treaties (for example, the United Nations Convention on the Rights of the Child). However, as outlined in the accompanying policy paper on youth substance use, substance-related harms are incredibly complex and a public health problem that cannot be addressed through quick fixes. This is why this Blueprint sets out an approach for immediate and ongoing action.

Who this resource is for

The primary audience for this resource is members of Canadian school communities. This includes those working within the education system, for example:

• administrators
• school board officials and other decision-makers
• teachers
• guidance counsellors
• health professionals who work in school communities
• community organizations that support youth

Along with students and their families, these groups are essential to planning, implementing and sustaining efforts to prevent substance-related harms.

The secondary audience for this resource is the broader array of Canadian school stakeholders. This includes:

• government officials and researchers working in substance use and school health
• school and public health organizations and organizations representing populations of youth experiencing inequities and their allies (for example, Indigenous and LGBTQ2+ [lesbian, gay, bisexual, transgender, queer and two-Spirit] youth)

These stakeholders can directly or indirectly advocate for and support equitable, evidence-based initiatives to prevent substance-related harms, within both school communities and other settings.

Overview of the Blueprint for Action

This resource includes three sections.

Section 1: outlines four key messages that inform application of the Blueprint.

Section 2: presents a new model, which integrates the Comprehensive School Health framework with four evidence-based approaches for addressing substance use issues. The section also exams how the components fit together and the value of integrating various approaches within prevention efforts.

Section 3: describes the application of the model, including facilitators and barriers and concludes with cross-cutting principles for action.

How this resource was developed

This resource was developed through engagement with Canadian school stakeholders. Much of the content reflects discussions and activities that took place during School Matters: Building a Blueprint for Action for School Communities to Help Prevent Substance Use Harms, a two-day forum convening over fifty diverse school stakeholders in February 2020 in Toronto, Ontario. Participants included youth/students, administrators, researchers, government officials, school health professionals, teachers, members of community organizations, parents and Indigenous peoples from across Canada. The Public Health Agency of Canada (PHAC) co-hosted the forum with three other national organizations: the Canadian Centre on Substance Use and Addiction, Canadian Students for Sensible Drug Policy and Joint Consortium for School Health. The forum focused primarily on secondary school contexts, although many forum participants underscored the need for complementary interventions at other school levels.

Throughout the forum, participants shared their knowledge, ideas and perspectives on youth substance use, various intervention approaches and school health. These contributions greatly shaped this resource, as well as an accompanying policy paper. Participants were also invited to provide input on both of these publications. We are grateful for their ongoing engagement in this work.

Section 1: Key messages

This section describes four key messages that are essential to apply the Blueprint.

1. Evidence-based substance use education is only one component of a comprehensive approach for preventing substance-related harms among youth.

   Equitable school policies, positive social and physical environments and supportive partnerships and services for youth are other important components that school communities can integrate into their intervention planning. These components are discussed in detail in Section 2.

2. The best prevention measures often have nothing to do with substance use at all.

   Efforts to improve youths' overall health and well-being and reduce social and health inequities can go a long way in minimizing youths' risk of substance-related harms.

3. Efforts to prevent substance-related harms among youth must reflect school communities' unique needs, values, preferences and environments.

   A key part of this is active, meaningful engagement with various school community members, including teachers, families, school health nurses, other school staff, and most importantly youth themselves.

4. Many traditional approaches to addressing youth substance use (for example, zero tolerance policies, abstinence-only education) have limited effectiveness and can produce unintended negative consequences.

   It is important that school communities use the best available evidence to inform their efforts to prevent substance-related harms and evaluate these initiatives on an ongoing basis, instead of simply accepting and repeating the status quo.

Section 2: The Blueprint for Action intervention model

In this section

• Overview of the model
• Comprehensive School Health approach
• Substance use prevention approaches
• Upstream prevention approaches
• Harm reduction approaches
• Stigma reduction initiatives
• Equity-oriented approaches
• Combining the intervention approaches
• Strengths of the Blueprint for Action model

Overview of the model

The Blueprint model is meant to support school community members in planning and carrying out a wide range of strategies for preventing substance-related harms among youth that:

• are grounded in evidence (including practice-based evidence^{Footnote 3}),
• reflect students' diverse needs and environments, and
• maximize the levers^{Footnote 4} school communities can use to support health and well-being.

The Blueprint for Action model brings together the Comprehensive School Health framework, an effective and well-established model for informing action on school health matters, and four evidence-based approaches to preventing substance-related harms:

• upstream prevention
• harm reduction
• stigma reduction
• equity-oriented approaches

These approaches and the Comprehensive School Health framework are defined and unpacked later in this section. The Blueprint for Action model includes a tool for planning and implementing comprehensive school-based interventions to prevent substance-related harms (see Appendix 1). The image below shows an example of how school communities can use the Blueprint for Action tool to plot out various intervention strategies to bring together (for instance, in a school action plan) as a part of a school community's comprehensive approach to preventing substance-related harms.

Table 1.

no data	Substance use intervention approach: Upstream prevention	Substance use intervention approach: Harm reduction	Substance use intervention approach: Stigma reduction	Substance use intervention approach: Equity-oriented
Comprehensive School Health framework component: Teaching and learning				Offering diversity and inclusivity training for students and staff to increase knowledge of the diverse identities and situations that contribute to an individual's unique lived experience.
Comprehensive School Health framework component: Social and physical environment	Providing resources, encouragement and space to students who are keen to start a new club or student group, organize events.
Comprehensive School Health framework component: Policy		Establishing school-board level policies that require schools to have naloxone kits available and accessible in the event of a suspected opioid poisoning.
Comprehensive School Health framework component: Partnerships and services			Working with local substance use counsellors to facilitate access to specialized support to students who use substances.

Much of the available literature and resources on school-based initiatives related to youth substance use focus solely on a particular intervention approach and lever. For example, several publications describe best practices for harm reduction and drug education, and in doing so, provide evidence on a particular approach (harm reduction) and lever (education). However, these publications provide a relatively narrow perspective on the range of actions school communities can take to address youth substance use and rarely acknowledge how education can be used as part of a more comprehensive and coordinated approach to preventing substance-related harms.

Taking these limitations into account, the Blueprint model was designed to include several evidence-based approaches, outline the many ways they can be carried out within school communities and describe how initiatives can fit together to support youths' well-being and prevent substance-related harms.

Comprehensive School Health approach

Comprehensive School Health is an internationally recognized approach to building healthy school communities. The approach can be used to guide the planning, implementation and evaluation of school initiatives related to various aspects of health.

Comprehensive School Health has been widely adopted in Canada and in various formats, ranging from local school action plans to provincial/territorial school health strategies. Evaluations of the approach demonstrate its effectiveness in improving youths' health, social and educational outcomes and reducing health inequities, and that these benefits can be long lasting.

The pan-Canadian Joint Consortium for School Health developed a framework to represent the Comprehensive School Health approach (Figure 1). The framework encourages school communities to act across four inter-related components that compose the whole school environment when assessing or implementing an intervention:

1. Social and physical environments, including the relationships among and between staff and students; school culture; buildings, grounds and recreation space in and around the school; and spaces designated to promote student safety and connectedness
2. Teaching and learning, including formal and informal curricula and resources; professional development opportunities for staff related to health and well-being; student and staffs' knowledge, and understanding and skills related to health and well-being
3. Policy, including policies, guidelines and practices that promote and support students' health, well-being and achievement and foster a respectful, welcoming and caring school environment for all members of the school community
4. Partnerships and services, including connections between school staff and students' families; supportive working relationships among and between schools and community organizations; partnerships between health and education sectors; and community and school-based services that support and promote student and staff health and well-being

Figure 1 - Text description

A four circle Venn diagram showing the intersection between the social and physical environment, teaching and learning, policy, and partnerships and services.

The Comprehensive School Health framework can be used to guide and strengthen efforts within school communities related to substance use. By design, the framework is not prescriptive to allow school communities to adjust their plans as contexts and needs change (for example, as they did when many Canadian school communities shifted to online spaces during the COVID-19 pandemic).

Canadian resources on addressing youth substance use using Comprehensive School Health

In 2009, the Joint Consortium for School Health and the Canadian Institute for Substance Use Research released a resource series called Addressing Substance Use in Canadian Schools. The series centres on Comprehensive School Health and features topics on substance use policy and education, school-family-community partnerships and responding to the needs of marginalized youth. The series emphasizes reducing substance-related harms (rather than promoting abstinence), the importance of social-emotional learning and the need to use a range of levers (not just substance use education) to address substance use.

In 2014, the Canadian Centre on Substance Use and Addiction developed the Canadian Standards for Youth Substance Abuse Prevention, which includes guides for community, family and school contexts. Among these, the guide entitled Building on our Strengths: Standards for Prevention in Schools, focuses on prevention initiatives and acknowledges the need for a Comprehensive School Health approach. The guide describes the importance of meeting youth "where they are at" through prevention efforts. It also includes guidance regarding sustainability, evaluations and other considerations for designing school substance use initiatives.

Substance use prevention approaches

Upstream prevention approaches

Upstream prevention focuses on addressing root causes of a health issue and has recently gained ground in school communities (see Box 1 for detail on the origins of the term "upstream"). Upstream prevention is closely related to health promotion since it can enhance protective factors, such as positive social and health outcomes (such as social connectedness and autonomy, among others), as well as minimize risk factors and associated negative outcomes (for example, substance-related harms).

Upstream protective factors that promote overall health and well-being include:

• healthy relationships
• a strong sense of self
• access to high quality education
• a safe environment
• school and community connectedness

These protective factors can prevent individuals from "falling into the river"; thereby avoiding the negative impact of risk factors, such as poverty, food insecurity, social isolation and experiences of trauma, abuse, stigma and discrimination. By preventing these risk factors, individuals have a decreased likelihood of experiencing substance-related harms. Enhancing protective factors, particularly during early life, can have a significant positive impact on health and well-being in the long-term.

The river parable shows the importance of these upstream efforts. Fortunately, there are many powerful protective factors within school communities. These include healthy, supportive relationships between students and adults within the school and a high degree of school connectedness. These and other protective factors can be strengthened by actions big and small within schools. Even relatively simple things, like creating safe, inclusive spaces for youth and demonstrating a genuine interest in students' interests and goals, can help reduce their likelihood of experiencing substance-related harms.

One emerging best practice, the Icelandic Model of Adolescence Substance Use Prevention, is an internationally recognized upstream prevention model, applied in communities in over 30 countries, including Canada. The Model outlines a process for identifying and addressing a community's unique risk and protective factors, often times through interventions that are not specifically related to substance use.

Positive youth development programs are one example of upstream prevention school-based programming, which have been implemented widely in Canada and elsewhere. These programs view youth as individuals with inherent strengths and immeasurable potential, as opposed to individuals with problems that need to be solved. Positive youth development programs provide teachers with training, guidance and strategies to enhance students' well-being, socio-emotional skills and positive mental health. By boosting these, positive youth development programs can help reduce the likelihood of substance-related harms, as well as poor mental health, bullying, violence and other negative factors.

Effective upstream prevention can look different from one school community to the next, depending on the unique needs and the resources available. These differences will have implications for what school communities prioritize and act to address. For example, a school community in an urban centre may prioritize increasing opportunities for healthy recreation and leisure for students by building partnerships with local organizations, while a school community in a rural and remote community may prioritize programming that shares information on and celebrates Indigenous culture.

As these examples demonstrate, upstream efforts often seem unrelated to substance use, as opposed to specific substance use policies or education. Indeed, proponents of the upstream approach to addressing youth substance use say, "the best prevention measures often have nothing do with substance use at all".

Outlined below are examples of specific school community-based upstream prevention initiatives, across the four components of the Comprehensive School Health framework. For more on upstream prevention efforts in school communities, please refer to PHAC's resource series Preventing problematic substance use by enhancing student well-being.

Upstream prevention and the principles of Comprehensive School Health

Teaching and learning

• Weaving social-emotional learning into curricula to enhance students' skills related to self-awareness, empathy, communication, self-regulation and conflict resolution.
• Prioritizing health education through course allocations and scheduling to enhance students' knowledge, attitudes and skills related to a healthy lifestyle (for example, sleep, nutrition, stress management, positive mental health, physical activity, consent).
• Adapting curricula to improve students' health literacy skills (including mental health), and enhance their ability to find, appraise and understand health information.
• Establishing a universal school food program that encourages staff and students to come together in a welcoming, inclusive environment to socialize and share a meal or a snack.

Social and physical environment

• Promoting and expanding the range of extra-curricular programming available to students (for example, intramurals, events and clubs) to reflect students' diverse interests and identities.
• Enabling students to create and decorate safe, inviting and inclusive communal spaces within the school for their use during breaks or after school activities.
• Facilitating opportunities for adults within the school community to serve as formal or informal mentors, providing youth with guidance, social and emotional support.

Policy

• Assessing existing school policies, including the school's vision and mission statement, to identify whether these policies facilitate students' overall health and well-being and decrease risk factors and enhance protective factors.
• Developing and enforcing policies that foster a safe and inclusive school climate for all, while discouraging bullying, harassment, stigma and discrimination in its various forms.
• Outlining in policy expectations that youth are compensated, through financial or other means, for their time leading and contributing to school initiatives such as research, program design and facilitation.

Partnerships and Services

• Facilitating and promoting diverse part-time work and volunteer opportunities for students within community organizations or events (for example, local food banks, community bicycle co-ops, arts and culture festivals, code-a-thons).
• Developing partnerships between schools and community athletics and recreation centres to increase access to programming for youth (for example, by offering reduced rate workshops, hosting an open house for students and their families).
• Inviting local partners into the school for various events, such as a wellness activity or art performance for the students.

Harm reduction approaches

As one of four pillars of the Canadian Drugs and Substances Strategy, harm reduction is an evidence-based approach that respects and promotes human rights and is a key ingredient of effective efforts to address youth substance use. Harm reduction efforts aim to reduce the potential social and health harms related to substance use. This is in contrast to approaches that require non-use, which reflect the belief that avoiding substance use entirely is the only acceptable and safe option for individuals, such as the "just say no" campaigns. These initiatives have been evaluated extensively and show limited effectiveness. Harm reduction and approaches requiring complete avoidance of substance use differ in how they measure success and the range of choices individuals can exercise when it comes to their substance use (see example in Box 2).

Central to harm reduction, is the understanding that individuals vary in their experience with substance use and with their openness to supports or change. Because of this, harm reduction takes an inclusive and pragmatic approach to preventing substance-related harms among youth.

Given these realities, harm reduction initiatives:

• present people with options that enable better health, while still reflecting their unique wants, needs and values at a given time
• support healthy behaviours without "forcing" them and celebrate even the smallest positive behaviour changes, recognizing that each is a step towards improved health and well-being
• respond to the needs of all people by meeting individuals where they are at, including those who do not use substances, use substances occasionally or frequently, or have a substance use disorder

A growing number of school communities in Canada and abroad are implementing harm reduction initiatives; such as, drug education focused on practical and effective strategies for reducing potential health effects associated with using certain substances. School-based harm reduction initiatives can have positive impacts on students' knowledge, attitudes and behaviours related to substance use, and can promote less harmful substance use. These outcomes may be explained by students' receptiveness to harm reduction messaging. Research shows that youth perceive harm reduction drug education as more helpful and practical than approaches focused on non-use, since many youth have used or will use substances to some extent and already apply harm reduction strategies in their own lives. Additionally, many studies prove that harm reduction efforts do not encourage youth to experiment with substance use.

Shifting to a harm reduction approach can also help prevent social harms related to substance use. For example, harm reduction-oriented school policies seek to connect students to various supports (including counselling, harm reduction or treatment services) to help manage their substance use or address underlying causes, with the goal of facilitating health and well-being. On the other hand, school policies requiring non-use, most often encourage punishment (such as suspension or expulsion) of students who use substances, which can push them further from support, opportunity and their larger community. These punitive actions can have long-lasting and avoidable negative social consequences.

Outlined below are examples of school-based harm reduction initiatives, across the four components of the Comprehensive School Health framework.

Harm reduction approaches and the principles of Comprehensive School Health

Teaching and learning

• Sharing youth-specific recommendations within Canada's Low-Risk Alcohol Drinking Guidelines and Lower-Risk Cannabis Use Guidelines through posters, class discussions and pamphlets.
• Using a "train-the-trainer" model to equip youth to facilitate safe, non-stigmatizing peer-to-peer discussions on harm reduction strategies that students have used or seen in their own lives.
• Hosting school community information sessions on the Good Samaritan Act, emphasizing its central public health and safety objectives.

Social and physical environment

• Displaying print materials designed by students (for example, meme posters) that feature harm reduction messaging in common spaces within the school.
• Installing safe disposal containers that school community members can access to safely dispose of needles, razors, broken glass or other "sharps".

Policy

• Reviewing school policies to identify which ones align with and can help implement harm reduction-oriented initiatives and objectives within the school community.
• Creating school-level Good Samaritan policies that prevent the punishment of students or other members of the school community who call for emergency help in response to a potential substance use poisoning or overdose on school property.
• Empowering teachers to create their own harm reduction-oriented policies for their classroom, such as a policy that encourages students to speak with their teacher before or after class if they are struggling with their substance use and without fear of reprisal or punishment.

Partnerships and services

• Inviting local pharmacists into the school to give a presentation on how to effectively recognize and respond to a suspected opioid poisoning and about naloxone kits (for example, what these kits are, how to use them, where to get them in the local community).
• Partnering with local public health nurses working in harm reduction service centres (for example, supervised consumption sites and managed alcohol programs) to increase youths' awareness and understanding of these services that exist in their community.

Stigma reduction initiatives

Many health experts and advocates agree that stigma reduction must be a core objective in any plan or strategy to prevent substance-related harms. Stigma begins with the negative stereotyping of people, creating separations (such as "us" versus "them"). These separations may relate to parts of people's identities, like their age, ethnicity, nationality, culture, gender or LGBTQ2+ identity. Certain behaviours, like substance use, are also stigmatized in society, as are many health conditions, including substance use disorders and mental illness. People can also experience intersecting stigmas, which is when several aspects of one's identity are stigmatized (for example, in the case of a racialized trans youth living with a mental illness).

Stigma prevents us from seeing people as full, complex human beings, and treating them as such. Stigma gets in the way of people accessing important resources, building and sustaining healthy relationships and, ultimately, reaching their full potential. In this way, stigma negatively impacts individuals, their communities and society more broadly.

The Chief Public Health Officer's 2019 Report on the State of Public Health in Canada outlines how stigma is a pressing public health and social justice concern, and one that demands a widespread response across sectors and segments of the population. The report also describes substance use stigma, its root causes and impact on substance-related harms and other negative consequences. Box 3 summarizes the many forms of substance use stigma.

Stigma reduction efforts are highly relevant and beneficial in school environments. These efforts can undo the divisions and dehumanization that often come with the various forms of stigma.

Stigma reduction efforts:

• make space for open, informed and non-judgmental conversations about substance use, as well as other stigmatized behaviours, health conditions or identities
• create opportunities for school community members to exchange credible, practical information and advice about substance use, which can facilitate more informed or lower-risk behaviour
• help to enhance important socio-emotional assets and skills, such as empathy, sensitivity and compassion

It is natural and even expected for youth to have questions about substance use. Unfortunately, these conversations remain taboo in some school communities (for example due to staff's discomfort with the subject matter or students' fear of punishment). For this reason, many youth seek other sources of information, such as social media and the internet, and sometimes without knowing how to assess which information is credible.

Creating safe, stigma-free spaces can encourage individuals to ask for help and to access available harm reduction or treatment supports. Stigma is a major barrier to seeking help, and efforts to reduce stigma can begin to bring these barriers down.

Shown below are various examples of stigma reduction initiatives, across the four components of the Comprehensive School Health framework.

Stigma reduction initiatives and the principles of Comprehensive School Health

Teaching and learning

• Enhancing school health curricula to include classroom activities that counter common misconceptions about substance use and about people who use drugs.
• Teaching students about the importance of person-first language (for example, "person who uses drugs" vs. "drug user") and other strategies for reducing stigmatizing language, and challenging students to practice these strategies through various class assessments.
• Facilitating access to anti-racism, anti-homophobia/transphobia and anti-oppression and implicit/unconscious bias training for school staff and volunteers, given the intersections between substance use stigma and other forms of stigma.
• Providing by-stander training to students to support them in safely intervening in situations of abusive, isolating, or stigmatizing behaviour online and in "real-life" contexts.

Social and physical environment

• Ensuring print materials and other media used or displayed within the school (for example, posters and videos) do not portray stereotypes about substance use or people who use substances.
• Designating "safe zones" in school communities where youth can ask questions and seek support for substance use-related issues without fear of reprisal or judgement, and identify these spaces with a poster or sticker (for example, similar to the rainbow flag for LGBTQ2+ allies).

Policy

• Identifying existing school policies that aim to connect students and other members of the school community with supports related to substance use, mental health or other aspects of their health and well-being.
• Reforming existing school policies that may perpetuate systemic substance use stigma, including punitive "zero-tolerance" policies and those that promote fear and shame.
• Developing and promoting protocols to identify members of the school community who show signs of a substance use disorder or may be at risk of substance-related harms and facilitating access to supports.

Partnerships and services

• Inviting people (for example, young adults who recently were in school) with lived or living experience of substance use to give a presentation to students on their experiences and coping strategies related to stigma, and to offer social support and mentorship to students.
• Offering accessible workshops and learning opportunities for parents/families designed to increase understanding of substance use topics, mitigate stigma and help prepare them for discussing substance use with their children.

Equity-oriented approaches

Certain populations are disproportionately impacted by substance-related harms and other negative social and health outcomes, making equity an important focus for effective interventions. Supporting health equity, means creating conditions that give everyone the opportunity to reach their full health potential and ensure no one is systematically disadvantaged from achieving this potential.

Equity is related to equality, although the two are distinct. The goal of equity is to understand and give people what they need to enjoy healthy, fulfilling lives. In contrast, the goal of equality is to ensure that everyone gets the same things to enjoy healthy, fulfilling lives. Both aim for fairness and justice, but equity acknowledges that we all start from a different place and have different needs.

Equity-oriented interventions seek to make institutions and systems more accessible, responsive, compassionate and safer for all people. This could be achieved by developing policies, programs and other interventions that reflect individuals' diverse needs. Box 4 describes cultural safety and trauma- and violence-informed (TVI) practice, which are two examples of equity-based intervention approaches.

Equity-oriented interventions can:

• help prevent stigma, discrimination and substance-related harms in various settings and environments;
• yield unique social and learning benefits within school communities
• for example, teachers and other school community members can help students of all cultural backgrounds reach their academic potential when they foster culturally safe learning and social environments. This involves understanding how culture can shape many aspects of one's life (in ways of seeing, knowing and doing) and validating individuals' experiences and identities;
• promote the shift in thinking to focus on "what happened to you?" from the TVI practice, to help adults within the school community better understand the complex factors that shape youths' behaviour. An equity lens can help adults understand students' needs, rather than simply labelling them as a "bad kid".

All school communities, no matter the demographics, can strive to be more equity-oriented. Both cultural safety and TVI practice do not require formal training or specialized knowledge to implement, and both models can involve relatively simple strategies. These can include person-centred communication (for example, asking students what can be done to make them more comfortable or support their learning) and efforts to make the school environment calmer and more inviting.

Outlined below are examples of specific equity-oriented initiatives, particularly those related to TVI and cultural safety, across the four components of the Comprehensive School Health framework.

Equity-oriented approaches and the principles of Comprehensive School Health

Teaching and learning

• Educating students on Indigenous history, including the multigenerational impacts of colonization and colonialism and the resilience of Indigenous peoples in Canada, reflecting and building on school curricula in these areas.
• Educating the school community on the impact adverse childhood experiences and trauma have on an individual's brain development, learning and social interactions, through use of the Brain Story toolkit and other evidence-based resources.
• Providing workshops or resources to deepen understanding of the many cultural groups represented in the school and how to provide culturally safe care/education.
• Ensuring educators are familiar with students' unique backgrounds to provide education based on needs (for example, being familiar with a student's Individualized Education Plan, speaking with school counsellor or social worker).

Social and physical environment

• Ensuring all students have a work environment that is conducive to their unique needs (for example, quiet areas, music, lighting, and other elements of a sensory-friendly environment).
• Cultivating physical environments that invite students of all genders, races, sexual orientations, cultural groups, abilities and social classes to feel safe and welcome (for example, Gay-Straight Alliance clubs).
• Ensuring the school and surrounding area is accessible to all students (for example, through installing ramps and elevators, giving students extra time to get to class or activities).

Policy

• Identifying existing school policies that support equity and help to address inequities related to health or social matters.
• Designing policies that integrate the unique and diverse views and needs of students so they are expected and respected (for example, some students may celebrate different holidays or have different ways to celebrate, such as fasting, silence and praying).
• Adapting policies to be more equity-oriented (for example, removing disciplinary policies that may re-traumatize students, allowing different styles of learning and testing).
• Applying a Gender-Based Analysis (GBA) + approach to policy development and review.
• Increasing diversity of staff within the school community.

Partnerships and services

• Supporting students and other school community members to participate in the KAIROS Blanket Exercise program, which seeks to foster truth, understanding, respect and reconciliation among Indigenous and non-Indigenous peoples.
• Partnering with private sector organizations offering extracurricular activities that otherwise could only be accessed by more privileged groups in the school.
• Facilitating school trips, in collaboration with local Indigenous groups that enable student to attend Indigenous pow-wows, ceremonies, feasts among other activities.
• Engaging with local Indigenous Friendship Centres for land-based education opportunities with local leaders.

Combining the intervention approaches

Each of the four intervention approaches – upstream prevention, harm reduction, stigma reduction initiatives and equity-oriented approaches – has numerous benefits and is supported by evidence. Each can be operationalized in many ways within Canadian school communities, including through application of the Comprehensive School Health framework.

School Matters Forum participants highlighted that the approaches are sometimes pitted against another. For example, participants noted the perception that it is impossible to implement both upstream prevention and harm reduction initiatives concurrently within school contexts. It is important to note that the four approaches are not mutually exclusive.

The four approaches have much in common; they share values of compassion, equity and responsiveness to individuals' needs to reach their full potential. The approaches may even look the same in practice. At the School Matters Forum, after learning about each approach, participants were asked to brainstorm how each approach could be put into practice across the four components of the Comprehensive School Health framework. Frequently, there was overlap in the types of initiatives identified across the approaches. This reinforces that all four approaches are complementary.

The inter-relation between the approaches is emphasized in the model. The cells of the model are also meant to represent building blocks that can form a strong and holistic strategy for preventing substance-related harms within school communities by having a broad range of approaches represented (refer to Appendix 1).

When planning and combining these approaches (for example, within a school community action plan or school board-level strategy), it is critical that the interventions are tailored to reflect the unique values, needs and resources of the school communities for which they are intended. This can be supported by actively engaging with members of the school community to ensure that initiatives are practical, relevant and sustainable. This is described more in the "Principles for Action" outlined in Section 3. There is also a variety of practical tools available to help school communities identify and assess their unique needs and plan school health initiatives accordingly (see Appendix 2).

Strengths of the Blueprint for Action model

The Blueprint is relevant, feasible and actionable in the context of Canadian school communities for many reasons, including:

1. The model affords greater reach and relevance with youth compared to "one-size-fits-all" models. Youth differ tremendously in their identities, substance use experience, interests, learning styles and their broader life situation, among other factors. These differences are not appreciated in "one-size-fits-all" models for addressing substance use; various approaches are needed to resonate with and reflect the needs of the student body as a whole.
2. When applied in combination, the model building blocks can support and reinforce each other. Given the similarities across the intervention approaches, when applied together and within the Comprehensive School Health framework, they send a consistent message to students, families, partners and others about the school community's commitment to promoting health and well-being and addressing substance use as an important health issue.
3. The four intervention approaches have broad relevance. The four approaches have a place within any school community and schools have flexibility to tailor them to meet their unique context and needs. In this way, the Blueprint can be a useful tool in schools in rural and remote communities, as well as in large urban centres, and everything in between. Further, the four approaches exist within many school communities to some extent, often without being explicitly linked to the prevention of substance-related harms.
4. The model can contribute to a range of positive outcomes for school communities. Given the intervention approaches' diverse aims, adopting them in combination is likely to yield numerous positive impacts for students and the broader school community, beyond those specific to substance use. These may include greater school connectedness, enhanced resilience and mental well-being among students and improved relationships between students and staff.
5. The model reflects a much-needed shift away from the status quo. The substance use landscape has evolved, as has the evidence of how to best intervene. Our dialogue and actions related to youth substance use must shift in accordance with these developments. The Blueprint model reflects a contemporary, evidence-informed and holistic means of addressing substance use within school communities, and one that compensates for the shortcomings of existing approaches.

School Matters Forum participants noted these and many other potential strengths of the Blueprint model. Some participants also described how the model could serve as a national catalyst for shifting dialogue and action related to youth substance use within school communities, mirroring similar changes in other contexts (such as the health system). While this section focused on the conceptual aspects of the model and its components, Section 3 delves into the practicalities of the model applied within "real-world" school communities, with further insights from School Matters Forum stakeholders.

Section 3: Putting the Blueprint for Action into practice

In this section

• Barriers and Enables to implementing the Blueprint model
  • Resistance to change
  • Partnerships
  • Capacity and information resources and limitations
  • Relevant and impactful substance use initiatives
• Principles for Action

Section 3 reflects key learnings and discussions from the School Matters Forum around various factors that can either support or inhibit school communities as they work to apply the Blueprint model. This section also outlines cross-cutting principles to consider when planning and delivering interventions.

Barriers and enablers to implementing the Blueprint model

Several factors may impact the implementation of comprehensive approaches to preventing substance-related harms. Many of these factors reflect ongoing challenges that school communities face when it comes to planning and carrying out health initiatives in general and the enablers may be factors that school communities have not yet considered exploring for a variety of reasons.

Resistance to change

For various reasons, school communities may be resistant to new ways of addressing youth substance use. These may include:

• limited readiness for change and a lack of political will
• fear of pushback for discussing certain substance use topics with students (for example, lower-risk use)
• a lack of understanding of the different intervention approaches
• thinking that these efforts fall outside of the school's responsibilities

A lack of representation and diversity at decision-making tables can pose additional challenges for introducing and getting support for novel approaches. Other contextual factors such as a lack of social capital, income inequality, limited access to important social resources (such as childcare, secure and safe job opportunities), and other social determinants of health may also interfere with school communities' ability to organize, fund and support these approaches.

The existence and effectiveness of school health and well-being initiatives rely heavily on the champions within the school community who can get these initiatives off the ground and generate buy-in from other members of the school community. Champions may include any adults in the school community, as well as youth. In particular, youth have expertise, energy and ideas to develop and lead health and well-being initiatives. In all cases, it is important that champions have the support of administrators and decision-makers. This support may include training, funding and an openness to new ways of doing.

Partnerships

Various obstacles can get in the way of fruitful partnerships. One major obstacle is a lack of clear, shared objectives and different interpretations of the problem to be addressed around youth substance use. Using other portions of the model, such as "teaching and learning" across the four substance use intervention approaches could help bring a common understanding among key players.

Additional obstacles to forming meaningful partnerships may include:

• limited dedicated resources required to develop these partnerships
• unrealistic expectations for immediate results
• resource limitations that incentivize competition over collaboration
• existing silos across sectors that can get in the way of forming unconventional, but beneficial, partnerships

Managing expectations is essential, as partnerships take time and energy to develop. Strong partnerships are those that draw on the unique expertise, experiences and resources of each party. Partnerships and services are a key component of the Model and include various examples throughout the document. Partnerships can facilitate capacity building, sharing of resources and promising practices and collaboration on shared initiatives.

Capacity and information resources limitations

School communities may also have challenges related to capacity and available information resources. These may stem from high turnover in staff, students, and community partners, limitations in staff training, and numerous competing priorities. In these cases, there may be broader environmental factors that could be leveraged to support school communities in advancing comprehensive approaches to preventing substance-related harms.

These factors may include:

• greater public awareness and dialogue about substance use (framed as a health issue instead of a criminal issue);
• changes in policy and practice at various levels of government that support people who use drugs and reduce stigma;
• existing factors within the school environment such as trusting and supportive relationships between staff and students and invested parents, which can be enough to generate initial momentum and support for advancing the approaches outlined in this Blueprint.

With respect to information resources, various challenges were flagged, including outdated drug education focused on non-use, and relatively few harm reduction education resources for youth audiences. Similar challenges include limited capacity to vet resources, a lack of awareness of resources, and conversely, being overwhelmed by the volume of resources and not knowing where to begin. Likewise, resources on stigma reduction and equity-oriented approaches designed for school contexts are not yet mainstream, making related resources difficult for school communities to find.

To help overcome some of these barriers, schools can start by using existing resources and supports, with examples included in Appendix 2. These resources could include a focus on substance use, as well as related topics, like socio-emotional learning and mental health. Resources are most useful when they align with existing structures and practices (such as provincial curricula); however, they can also be tailored to a school communities' unique context or sourced externally, such as from community partners or public health organizations.

Relevant and impactful substance use initiatives

Challenges in implementing relevant initiatives may include the tendency to pursue "low hanging fruit" which maintain the status quo, rather than making strides towards comprehensive approaches to preventing substance-related harms. There is also the practical issue of staying on top of evolving trends in how youth communicate and substance use patterns. These create challenges for keeping youth-focused initiatives engaging, timely and relevant. Piloting innovative practices on a small-scale and scaling up when they show promise could be one way to overcome the status quo.

Though the specific facilitators and barriers school communities experience may vary, the factors identified above provide helpful considerations for school communities looking to apply the Blueprint.

Principles for action

While the Blueprint model can help school communities identify what actions they can take to prevent substance-related harms, the five principles outlined in this section describe how they can effectively work towards this objective; with greater detail included in the accompanying policy paper. The principles are relevant to any initiative designed to prevent substance-related harms among youth.

Five Principles for Action

1. Health equity

   Many sub-groups of Canadian youth are disproportionately and negatively impacted by substance-related harms, as a result of ongoing systemic policies, practices and behaviours that disadvantage some youth. These sub-groups include Indigenous youth, youth in the child welfare system and LGBTQ2+ youth, among others. Applying a health equity lens means not losing sight of these priority populations and designing prevention efforts that reflect an understanding of their unique context and needs. It also means acknowledging and helping to dismantle socially determined barriers to health and well-being, such as those associated with gender, socio-economic status, race, LGBTQ2+ identity and stigma.

2. Compassionate, non-judgemental and strength-based approaches

   Interventions intended to prevent substance-related harms among youth are greatly strengthened by meaningful engagement of youth (a vital player within school communities), including those with lived experience of substance use. School communities should design interventions that leverage youths' many strengths and enhance their resilience, instead of trying to "fix" their shortcomings. They should also explicitly aim to counter and reduce substance use stigma and promote compassion.

3. Harm reduction

   Substance-related harms vary; they can be reduced through harm reduction efforts at individual- and school community-levels. As described in Section 2, harm reduction is a pragmatic and equitable approach to preventing substance-related harms among youth, and can be operationalized through policies, education and services within school communities, among other initiatives.

4. Multi-sectoral partnerships

   Many of the root causes of substance-related harms extend beyond the reach of the education sector or any one sector, underscoring the need for a collective response to help prevent substance-related harms. School communities are encouraged to build and strengthen partnerships across sectors (such as health, public safety, local businesses and academia) and at various levels (including individuals, families, local communities and governments) with the shared goal of promoting health and well-being and preventing substance-related harms. Strong partnerships and ongoing collaboration also increase the likelihood that interventions are comprehensive and sustainable.

5. Evidence-informed practice

   Certain "go-to" approaches for addressing substance use have limited effectiveness and can even produce unintended negative consequences. School communities should ensure that their intervention planning and delivery is grounded in the best available evidence (including practice-based evidence) and regularly evaluate the success of their efforts, instead of merely accepting and repeating the status quo.

Conclusion

School communities have a vested interest in the health and well-being of youth, including their risk of experiencing substance-related harms. This resource presents the Blueprint for Action intervention model - a tool that school communities can use to inform and strengthen their efforts to prevent substance-related harms among youth. Through thoughtful application and evaluation of this model, school stakeholders can help to support positive shifts in how school communities address substance use, and ultimately, their ability to effectively respond to and prevent substance-related harms.

Appendices

Appendix 1. The Blueprint for Action model "in practice"

School communities can use the Blueprint for Action model tool to plot out various intervention strategies to bring together (for instance, in a school action plan) as a part of a school community's comprehensive approach to preventing substance-related harms.

Table 2.

		Substance Use Intervention Approaches
		Upstream prevention	Harm reduction	Stigma reduction	Equity-oriented
Comprehensive School Health Framework Components	Teaching and Learning
	Social and Physical Environment
	Policy
	Partnerships and Services

This table is also available for download as a fillable PDF form.

Appendix 2. Additional resources and research articles

• Public Health Agency of Canada. (2018). The Chief Public Health Officer's Report on the State of Public Health in Canada 2018: Preventing Problematic Substance Use in Youth.
• Public Health Agency of Canada. (2020). Preventing substance-related harms among Canadian youth through action within school communities: A policy paper.
• Joint Consortium for School Health. Healthy School Planner.
• Canadian Centre on Substance Use and Addiction. (2020). Talking pot with youth: A cannabis communication guide for youth allies.

Comprehensive School Health

• Joint Consortium for School Health. (2019). Comprehensive School Health Framework: What is Comprehensive School Health?
• McKay, H. A., Macdonald, H. M., Nettlefold, L., Masse, L. C., Day, M., & Naylor, P. J. (2015). Action Schools! BC implementation: from efficacy to effectiveness to scale-up. British Journal of Sports Medicine, 49(4), 210-218.
• Ofosu, N. N., Ekwaru, J. P., Bastian, K. A., Loehr, S. A., Storey, K., Spence, J. C., & Veugelers, P. J. (2018). Long-term effects of comprehensive school health on health-related knowledge, attitudes, self-efficacy, health behaviours and weight status of adolescents. BMC public health, 18(1), 515.
• Vander Ploeg, K. A., McGavock, J., Maximova, K., & Veugelers, P. J. (2014). School-based health promotion and physical activity during and after school hours. Pediatrics, 133(2), e371-e378.
• Vander Ploeg, K. A., Maximova, K., McGavock, J., Davis, W., & Veugelers, P. (2014). Do school-based physical activity interventions increase or reduce inequalities in health?. Social science & medicine, 112, 80-87.
• Veugelers, P. J., & Fitzgerald, A. L. (2005). Effectiveness of school programs in preventing childhood obesity: a multilevel comparison. American Journal of Public Health, 95(3), 432-435.

Upstream prevention

• Alberta Family Wellness Institute. (2020). Brain story toolkit.
• Black, D. S., Grenard, J. L., Sussman, S., & Rohrbach, L. A. (2010). The influence of school-based natural mentoring relationships on school attachment and subsequent adolescent risk behaviors. Health Education Research, 25(5), 892-902.
• De Pedro, K. T., Esqueda, M. C., & Gilreath, T. D. (2017). School protective factors and substance use among lesbian, gay, and bisexual adolescents in California public schools. LGBT Health, 4(3), 210-216.
• Damon, W. (2004). What is positive youth development?. The Annals of the American Academy of Political and Social Science, 591(1), 13-24.
• Kristjansson, A. L., Mann, M. J., Sigfusson, J., Thorisdottir, I. E., Allegrante, J. P., & Sigfusdottir, I. D. (2020). Development and guiding principles of the Icelandic model for preventing adolescent substance use. Health Promotion Practice, 21(1), 62-69.
• Kristjansson, A. L., Mann, M. J., Sigfusson, J., Thorisdottir, I. E., Allegrante, J. P., & Sigfusdottir, I. D. (2020). Implementing the Icelandic model for preventing adolescent substance use. Health Promotion Practice, 21(1), 70-79.
• McNeely, C., & Falci, C. (2004). School connectedness and the transition into and out of health‐risk behavior among adolescents: A comparison of social belonging and teacher support. Journal of School Health, 74(7), 284-292.
• Public Health Agency of Canada. (2019). Preventing problematic substance use by enhancing student well-being.
• Sigfusdottir, I. D., Soriano, H. E., Mann, M. J., & Kristjansson, A. L. (2020). Prevention is possible: A brief history of the origin and dissemination of the Icelandic prevention model. Health Promotion Practice, 21(1), 58-61.
• Sigfúsdóttir, I. D., Thorlindsson, T., Kristjánsson, Á. L., Roe, K. M., & Allegrante, J. P. (2009). Substance use prevention for adolescents: the Icelandic model. Health Promotion International, 24(1), 16-25.
• Sterrett, E. M., Jones, D. J., McKee, L. G., & Kincaid, C. (2011). Supportive non-parental adults and adolescent psychosocial functioning: Using social support as a theoretical frame- work. American Journal of Community Psychology, 48(3-4), 284-295.
• Weatherson, K. A., O'Neill, M., Lau, E. Y., Qian, W., Leatherdale, S. T., & Faulkner, G. E. (2018). The protective effects of school connectedness on substance use and physical activity. Journal of Adolescent Health, 63(6), 724-731.

Harm reduction

• Butters, J. E. (2004). The impact of peers and social disapproval on high-risk cannabis use: gender differences and implications for drug education. Drugs: Education, Prevention and Policy, 11(5), 381-390.
• Evans‐Whipp, T. J., Bond, L., Toumbourou, J. W., & Catalano, R. F. (2007). School, parent, and student perspectives of school drug policies. Journal of School Health, 77(3), 138-146.
• Evans-Whipp, T. J., Plenty, S. M., Catalano, R. F., Herrenkohl, T. I., & Toumbourou, J. W. (2013). The impact of school alcohol policy on student drinking. Health Education Research, 28(4), 651-662.
• Hamilton, G., Cross, D., Resnicow, K. & Shaw, T. (2007). Does harm minimisation lead to greater experimentation? Results from a school smoking intervention trial. Drug and Alcohol Review, 26(6), 605-613.
• Hawk, M., Coulter, R. W., Egan, J. E., Fisk, S., Friedman, M. R., Tula, M., & Kinsky, S. (2017). Harm reduction principles for healthcare settings. Harm Reduction Journal, 14(1), 70.
• Jenkins, E. K., Slemon, A., & Haines-Saah, R. J. (2017). Developing harm reduction in the context of youth substance use: insights from a multi-site qualitative analysis of young people's harm minimization strategies. Harm Reduction Journal, 14(1), 53.
• McBride, N., Farringdon, F., Midford, R., Meuleners, L., & Phillips, M. (2004). Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction, 99(3), 278-291.
• Midford, R. (2010). Drug prevention programmes for young people: where have we been and where should we be going?. Addiction, 105(10), 1688-1695.
• Newton, N. C., Conrod, P., Teesson, M., & Faggiano, F. (2012). School-based alcohol and other drug prevention. Drug Abuse and Addiction in Medical Illness (pp. 545-560). Springer, New York, NY.
• Vogl, L., Teesson, M., Andrews, G., Bird, K., Steadman, B., & Dillon, P. (2009). A computerized harm minimization prevention program for alcohol misuse and related harms: randomized controlled trial. Addiction, 104(4), 564-575.

Stigma reduction

• Canadian Centre on Substance Use and Addiction. (2019). Overcoming Stigma Through Language: A Primer.
• Canadian Public Health Association. (2019). Language matters: Using respectful language in relation to sexual health, substance use, STBBIs and intersecting sources of stigma.
• Community Addictions Peer Support Association. Stigma ends with me [video gallery].
• Health Canada. (2021). Stigma around drug use.
• Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction, 107(1), 39-50.
• National Academies of Sciences, Engineering, and Medicine. (2016). Ending discrimination against people with mental and substance use disorders: The evidence for stigma change. National Academies Press.
• Public Health Agency of Canada. (2019). The Chief Public Health Officer's Report on the State of Public Health in Canada 2019: Addressing Stigma: Towards a More Inclusive Health System.
• Public Health Agency of Canada. (2020). Communicating about Substance Use in Compassionate, Safe and Non-Stigmatizing Ways.

Equity-oriented

• Covington, S. S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 40(sup5), 377-385.
• Khoury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance use, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. Depression and Anxiety, 27(12), 1077-1086.
• McCormick, R. M. (2000). Aboriginal traditions in the treatment of substance abuse. Canadian Journal of Counselling, 34(1), 25.
• McIvor, O., Napoleon, A., & Dickie, K. M. (2013). Language and culture as protective factors for at-risk communities. International Journal of Indigenous Health, 5(1), 6. doi:10.18357/ijih51200912327
• Prangnell, A., Voon, P., Shulha, H., Nosova, E., Shoveller, J., Milloy, M. J.,... & Hayashi, K. (2019). The relationship between childhood emotional abuse and chronic pain among people who inject drugs in Vancouver, Canada. Child Abuse & Neglect, 93, 119-127.
• Substance Abuse and Mental Health Services Administration. (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.
• Van Ameringen, M., Mancini, C., Patterson, B., & Boyle, M. H. (2008). Post‐Traumatic stress disorder in Canada. CNS Neuroscience & Therapeutics, 14(3), 171-181. doi:10.1111/j.1755-5949.2008.00049.x
• Wah, Y. L., & Nasri, N. B. M. (2019). A systematic review: The effect of culturally responsive pedagogy on student learning and achievement. International Journal of Academic Research in Business and Social Sciences, 9(5) doi:10.6007/IJARBSS/v9-i5/5907
• Williams, R. (1999). Cultural safety — what does it mean for our work practice? Australian and New Zealand Journal of Public Health, 23(2), 213-214. doi:10.1111/j.1467-842X.1999
• Wu, N. S., Schairer, L. C., Dellor, E., & Grella, C. (2010). Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors, 35(1), 68-71.