Audit of school-based substance abuse prevention programmes in Cape Town
Neo Morojele; Raymond Knott, Hans Myburg, Nathan Finkelstein
Medical Research Council, Department of Education, University of the
Western Cape, Health Care Management Services

Background
The misuse of substances among school-going youth is a cause of much concern. Research and other sources note such involvement among high school students in the Western Cape,1 and an increase in the prevalence of dagga use and binge drinking among them between 1990 and 1997.2 The need for comprehensive and effective prevention programmes for adolescents and youth within the whole region of the Western Cape cannot be overstated. Despite the presence of a range of isparate prevention programmes operating in schools in the Western Cape, there is no clarity on the number of such programmes, their approaches and activities, the extent of their coverage of all areas of need, and their potential appropriateness and effectiveness. Substance-abuse prevention is on the agenda of the Western Cape’s Education Department which seeks better co-ordination of programmes being implemented in schools.

A sub-committee of the Western Cape Alcohol and Drug Abuse Forum (Education and Prevention Committee) was formed to assess school-based substance-abuse prevention programmes based in the Western Cape. The two overall aims were to determine:

1. The appropriateness of each of the programmes being implemented in schools.
   Assessment of activities of each individual programme was guided by the prevention principles for school-based programmes of the National Institute on Drug Abuse.3 Those principles have their basis in years of research on effective approaches to substance-abuse prevention among children and adolescents.
2. The extent of coverage of prevention activities in schools within the Western Cape.
   In particular, the assessment sought to determine whether, taken as a whole, there is sufficient coverage by the prevention programmes of all areas of the Western Cape.

Method
Participating programmes
Eight programmes participated in the assessment by returning completed assessment questionnaires. Those organisations previously involved in the assessment but from which questionnaire data were not available were Ace Theatre, Christelik-Maatskaplike Raad, and the Young Caring Community. Completed questionnaires were received from the following programmes:

1. Bridges High School Programmes (Sarah Fisher)
2. Head Start Chemical Dependence Programs (Steve Wood)
3. Lion’s Quest Skills for Adolescence (Salome Daries)
4. Poppets (SANCA)
5. Schools Prevention and Education Programme (South African Narcotics Bureau)
6. Schools Prevention and Education Programme (Cape Town Drug Counselling Centre)
7. TADA (SANCA)
8. Western Cape Education Department (Raymond Knott)

Questionnaire
Participating programme providers completed a 9-page questionnaire which requested programme particulars and contact details, and included eight sections covering the following aspects of programmes: (i) background, (ii) structure, (iii) target audience, (iv) teaching methods, (v) social competencies, (vi) goals and outcomes, (vii) evaluation, and (viii) additional features not covered in previous sections of the questionnaire. Questionnaires were accompanied by a guidelines sheet for questionnaire completion.

Results
Content and thematic analysis of questionnaire responses

Background
Programme philosophy and goals
The main assumptions and philosophy underlying the various programmes are captured in Table 1.

Activities/methods
The key activities/methods employed by the programmes include: (a) provision of drug information, e.g. talks, slide shows to display drugs; (b) discussion groups; (c) referrals and interventions; (d) provision to schools of written policy framework; (e) training courses for teachers, youth; (f) multiple teaching methods - e.g. case studies, experiential learning, role plays, structured workbook, group works, and community projects; (g) inclusion of teachers and parents as well as students as target recipients; (h) parental and community participation; (i) use of puppetry among younger age groups; (j) provision of healthy alternatives to drug use.

Programme goals for the provider
This section sought details on how programme providers benefitted from programme implementation. However, most responses referred to the goals of the programme, or intended outcomes for programme recipients, and duplicated responses given in the previous section.

Table 1: Programme assumptions and philosophy

Programme structure
Number of sessions per group
There is some variation in the number of sessions provided per group as shown in Fig. 1. Two programmes provide only one or two talks per group of students while the remaining programmes were more extensive involving 7,8, 9,10 and more than 10 sessions in two instances. The latter programmes provide weekly sessions for students during the entire school year.

Figure 1: Number of sessions per group

Time span
The time span of the programmes varies. Programmes involving more than one or two sessions last for between 7 weeks and the entire school year. One programme is ongoing for 2 years.

Average size of groups
On the whole the groups comprise one school class, and their size ranges between about 20 and 40 students. SANAB facilitators also address groups of between three and 600 participants, and Head Start reported involvement in different group sizes depending on their activities and recipients. That is, there is one session for the entire school, a double session for parents, and five sessions for groups and teachers, respectively.

Student/teacher/community involvement in programme implementation
Fig. 2 shows that in all cases students and teachers are involved in programme implementation. The community is involved in programme implementation in six cases only. Community involvement takes a number of forms and involves different community members. Community involvement includes: (a) use of community resources for intervention and counsellor assessment, (b) parents and parental support groups, (c) other community support groups for students, and (d) community leaders.

Figure 2: Student/teacher/community involvement in programme implementation

Involvement/implementation in historically disadvantaged communities and rural areas
Fig. 3 shows that four programmes reported some involvement in historically disadvantaged communities and the other half reported total involvement in them. Those not extensively involved in them reported that their programmes had not yet been translated for ‘African’ students, and that historically disadvantaged schools were unable to make financial contributions to pay for the programme, although programme providers would attempt to raise funds for such schools.

Five of the programmes reported at least some involvement in rural areas. The reported reasons for no rural involvement are insufficient funding and personnel, that the particular programme has an urban focus, and that rural areas are not applicable to their programmes.

Figure 3: Extent of involvement in HDCs and rural areas

Involvement of other role players
In the case of five programmes other role players also took part in programme activities. The role players included are listed in Table 2.

Table 2: Other role players involved in programmes

Target audience
The organisations target various grade levels as shown in Fig. 4. One programme targets Sub A children, but generally Standard 4 is the lowest standard at which prevention activities begin to occur. Most programmes are geared towards Standards 6 and 7, fewer of them target Standards 8, 9 and 10, and only three run programmes at the tertiary level of education.

Figure 4: Number of programmes involved in levels of school

Teaching methods
The teaching methods used by most programmes are discussions, group feedback and reinforcement (used very often by 7, 6 and 6 of the programmes, respectively, as shown in Fig. 5. The methodsless often used were extended practice (only used in three cases), and modelling and role playing which were only used in 5 cases. Two organisations reported using other methods which involved community participation, critical thinking, and training.

Figure 5: Extent of use of selected teaching methods

Social competencies/skills
The extent of use of four social competencies - communication skills, self-efficacy, assertiveness and drug-resistance skills - was determined. The extent of their use by the eight programmes can be seen in Fig. 6.

Figure 6: Number of programmes teaching selected social skills

Programme goals and outcomes
As shown in Fig. 7, seven out of the eight programmes were reported to promote a sense of belonging to the community, positive peer influence and anti-drug social norms. Five programmes were reported to promote a sense of belonging to the school and emphasise skills training teaching methods.

Figure 7: Programme goals and outcomes

Programme evaluation
Only three of the programmes have undergone any formal evaluation so far. These have involved completion of evaluation forms by students, and/or teachers and parents after participating in a programme, and a "pilot study...using the random sampling method".

Additional information
Programme strengths
The respondents’ perceptions about the strength of their programmes are shown in Table 3.

TABLE 3: Perceived programme strengths

Programme weaknesses, barriers to best implementation
Similar responses were given in sections requesting information about the programme’s weaknesses and barriers to best implementation. All but one of the respondents admitted to weaknesses within their programmes. They all noted barriers to implementing their programmes most beneficially. The perceived weaknesses and barriers are shown in Table 4.

Table 4: Perceived weaknesses/barriers

Desired improvements
Two groups failed to report on desired improvements and a third programme is still being piloted. The desired improvements relate to the perceived weaknesses and strengths and included: (a) availability of more resources/materials for running the programme; (b) greater teacher involvement and commitment; (c) extension of facilitators’ training; (d) more emphasis on parental training; (e) more follow-up contact, and communication with teachers and pupils’ support groups after programme completion.

Discussion
Eight programmes reported on their activities in schools. These programmes are characterised by a range of philosophies and assumptions about the nature of substance-abuse problems and most appropriate methods for preventing them. Most programmes aim to prevent the misuse or use of alcohol and other drugs among school-going youth, while a small number also recognise the reality of drug use and the need for harm minimisation and referrals for those already affected by drug use. Some programmes are uni-faceted and simply provide information about harmful effects of drug use and drug involvement. Others are more comprehensive and supplement information provision with social skills training sessions. There is evidence of the use of varied activities and age-appropriate methods such as the use of puppets for the young Sub A children, and the use of fellow adolescents in facilitating some activities.

The programmes are of varied duration and run a varied number of sessions. Most are delivered to one school class per session. Teacher and student involvement in implementing programmes is fairly extensive while community involvement is less extensive. All programmes report involvement including those in historically disadvantaged communities, although not to a great extent, and there is less extensive rural involvement. Most programmes begin activities with Standard 4 students, while Sub B to Standard 3 students are completely under-served, and there is a tapering off of programme activities from Standard 10 onwards.

Teaching methods include mainly discussions, feedback and reinforcement, but here is less of the more intense methods of extended practice, modelling and role playing among the programmes. There is a tendency to teach social skills including assertiveness, drug-resistance skills and, to a slightly lesser extent, self-efficacy and communication.

Most programmes strive towards potentially positive goals and outcomes of the promotion of a sense of belonging to the community, positive peer influence and anti- drug social norms. Although evaluation forms are completed by students, teachers and staff, there is no evidence of programme effectiveness in any of the cases. Some programmes are clearly based on well-tested models evaluated in different settings while other programmes are conceptualised and developed by their current programme providers. The programme providers note numerous programme strengths. They also mention a number of programme weaknesses and barriers to implementation. Programmes all seem to suffer extensively from insufficient personnel and financial resources for implementing activities.

Conclusions/recommendations
The present assessment describes the activities of eight substance abuse prevention programmes within the Western Cape, and helps to clarify the nature of substance- abuse prevention programmes in schools and their extent of involvement in different areas within the Western Cape. However, it is limited due to a failure to access information from all programmes implementing activities in schools, reliance on self- report of activities and possible bias in the sample.

The programmes vary in content and approach. Those that are most likely to be beneficial and should be used as a model for more programmes within the region are those that include key elements of the NIDA prevention principles for school-based programmes which are very structured and include more than one year of ntervention, a focus on more than one age group, focus on interactive teaching methods, education provision, and teaching of social competencies. Shortcomings of some programmes include the use of information and, in some cases, what appear to be shock tactics to discourage drug involvement, a failure to have more sustained implementation of programmes, limited commitment to schools with less resources, and particularly those in communities in which consequences of drug use at the societal level are more in evidence.

Based on the findings of this assessment, and a general understanding of the topic we would recommend that, where possible:

1. Programmes that use simple information approaches should also employ more interactive teaching methods and strive to include social competencies/skills training elements, and avoid the use of ‘shock tactics’.
2. Programmes should be extended to cover the primary school and early secondary school levels.
3. Programmes should be extended to include multiple years of intervention.
4. Programmes should seek to extend levels of community involvement.
5. Programmes should seek to serve historically disadvantaged communities.
6. Programmes should seek to serve rural communities.
7. Programmes should aim to include more intensive teaching methods such as the use of extended practice, role playing and modelling.
8. Programme providers should recognise shortcomings in their approaches, where present, and be open to modifying potentially ineffective aspects.
9. Programmes should be evaluated to determine their consequent outcomes, and the degree to which they are effective in achieving expected outcomes.
10. There is a need for more training of programme facilitators.
11. There is a need for more funding for programmes.
12. There is a need to ensure consistency of programme messages, particularly where programmes are being introduced in similar schools.
13. There is a need to prevent duplication of programme activities within the same school settings.

References

1. Flisher AJ, Ziervogel CF, Chalton DO, Leger PH, Robertson BA. Risk taking behaviour of Cape Peninsula high school students: IV Alcohol Use. SAMJ 1993; 83: 480-482.
2. Flisher AJ, Parry CDH, Evans J, Lombard C, Müller M. Prevalence rates of alcohol, tobacco and other drug (ATOD) use among Cape Town students in Grades 8 and 11. Paper Presented at the 4th Annual Congress of the Psychological Society of South Africa (PSYSSA) - Cape Town, 11 September 1998.
3. National Institute on Drug Abuse. Preventing drug use among children and adolescents. A research-based guide. National Institute of Drug Abuse, 1997.

Acknowledgements
The authors would like to thank the participants of each of the alcohol and other drug prevention programmes for their openness in submitting details about their activities in schools. We would also like to acknowledge the inspiration of Mr Myer Katovsky (Chairman of the Western Cape Alcohol and Drug Abuse Forum’s Education and Prevention Working Group) for initiating this assessment.