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 . 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 . 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 . 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 . 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”  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 .
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.