Abstract
Keywords
Introduction
Globally and in Canada, there are a multitude of escalating threats to youth wellbeing, including climate change, predatory commerce and expanding inequalities (Clark et al., 2020). Correspondingly, youth mental health has been in decline over the last 15–20 years (McGorry & Mei, 2023; Sutcliffe et al., 2023; Thorisdottir et al., 2020; Wiens et al., 2020). In Canada, young people also face a mounting opioid crisis, with over 40,000 apparent opioid deaths between 2016 and 2023 (Public Health Agency of Canada, 2022) and young adults carrying the greatest burden of mortality (Gomes et al., 2021; Ledlie et al., 2024). Both the opioid and youth mental health crises accelerated during the pandemic (Ledlie et al., 2024; Madigan et al., 2023a, 2023b).
There is an urgent need to address these issues through prevention and population-level interventions along with complementary interventions (Chief Public Health Officer, 2018; Madigan et al., 2023a, 2023b; McGorry & Mei, 2023; Sutcliffe et al., 2023). The Icelandic Prevention Model (IPM) represents a promising practice that has been implemented in Iceland over the past 25 years and is now being scaled internationally. The model supports community-driven responses to influence risk and protective factors that are associated with substance use behaviours and mental health. Since the model is designed to create healthy developmental contexts, it may have the potential to enhance mental health and wellbeing, along with decreased substance use (Halsall et al., 2020, 2022a).
Typically, the implementation of the IPM has been led by adult stakeholders (Halsall et al., 2020). However, young people can make important contributions both to the design and evaluation of the IPM through the critical insight developed from their lived experience of current issues affecting them. Lanark County was the first community in Canada to adopt the IPM and has been establishing a youth engagement approach to support the implementation. This paper describes the early efforts and findings related to the youth-led participatory evaluation focused on examining youth perspectives on community needs and substance use issues. The paper provides a detailed description of how young people were engaged in and influenced the design and implementation of the research (youth advisors and asset-mapping members) as well as findings from broader youth consultations that explored the experiences of young people in Lanark County and their perspectives on how to implement the IPM.
Icelandic Prevention Model
The IPM was developed as a response to a growing population-level challenge related to youth substance use behaviours in Iceland (Sigfusdottir et al., 2008). The model is premised on the notion that social norms influence substance use behaviours and that changing social norms (e.g. through structured leisure time, strengthened family-community connections and increased opportunities to participate in high-quality extra-curricular activities) can reduce substance use behaviours at a population level (Kristjansson et al., 2021). The intent of preventing or delaying substance use behaviour in youth is to reduce related harms (Carver et al., 2021; Kelly et al., 2023; Kristjansson et al., 2022).
Five Guiding Principles and Ten Core Steps of the Icelandic Prevention Model.
The IPM has been operating in Iceland for almost three decades and over this time period, there has been a significant reduction in youth substance use behaviours. The Icelandic model is now being implemented abroad and there is a need to understand how it can be adapted to new international contexts and whether it will be effective.
Youth Engagement and Participatory Research with Young People
Youth engagement is the “meaningful participation and sustained involvement of a young person in an activity that has a focus outside himself or herself” (Pancer et al., 2002, p. 49). Youth engagement originated in part as a response to the UN Convention on the Rights of the Child (United Nations, 1989) and has been applied within a range of disciplines to enhance youth outcomes. One of the most well-known frameworks, Hart’s ladder, describes the varying degrees of child and youth involvement with the lower three levels representing non-participation and the higher five describing approaches with increasing levels of involvement (Hart, 1992). Pereira (2007) adapted Hart’s ladder to delineate practices that are representative of meaningful youth engagement, including assigned but informed, consulted and informed, adult-initiated with shared decision-making, youth-initiated and directed and youth-adult partnerships. From among this range of approaches, youth-adult partnership has been the most successful (Pereira, 2007). Youth participatory research and evaluation is a related set of practices that involve the inclusion of youth voice to enhance research practice and outcomes (see Checkoway & Richards-Schuster, 2003; Sabo-Flores, 2008; Zeldin et al., 2012). Ideally, in this approach young people are involved in identifying the direction of the research, methods for data collection and application of the findings (Checkoway & Richards-Schuster, 2003). Youth engagement in research is an effective approach for learning about social issues and anti-oppression (Heberle et al., 2020).
Asset Mapping
Often used at the outset of an evaluation, needs assessments are designed to identify existing conditions and to learn what changes are needed in order to improve them (Scriven & Roth, 1978). As a form of needs assessment that moves away from a deficit perspective, asset mapping identifies existing resources to inform strategic planning (Fuller et al., 2002). Within the IPM approach, many communities begin their implementation with an asset mapping exercise to identify community needs and inventory existing programs and services that might be beneficial to build on within their prevention strategy (see Kristjansson et al., 2015; Planet Youth, 2021).
Asset mapping has also been applied to address issues affecting young people and several examples use participatory strategies (see Agdal et al., 2019; Amsden & VanWynsberghe, 2005; DyckFehderau et al., 2013; Santo et al., 2010). The inclusion of youth perspectives can support a more comprehensive assessment of existing assets (Mosavel et al., 2018). It can also enhance impacts, strengthen relationships among adult partners and enhance broader civic participation (Benenson et al., 2015). In terms of youth representation within asset mapping, it can be challenging to reach equity-deserving groups and measures should be taken to ensure their perspectives are included (Hosseinpoor et al., 2018).
To support inclusive youth participation in asset mapping, a safe space needs to be created to maintain open-ness to new ideas and the communication of clear objectives (Amsden & VanWynsberghe, 2005). Adult allies familiar with an understanding of youth culture, the potential benefits of youth participation and positive youth development principles can facilitate this process (Handy et al., 2011).
Purpose
There is a need for additional participatory research that examines youth substance use prevention initiatives (Valdez et al., 2020) and researchers have identified that it would be valuable to include young people in the implementation and research related to the IPM (Carver et al., 2021). This research is focused on the initial stages of a youth-led participatory evaluation of the IPM implementation within Lanark County. Specifically, we describe the approach used to involve young people in co-design, community asset mapping and initial consultation. We address the research questions: 1) What are Lanark County youth perspectives on community needs and substance use issues? And how can young people be meaningfully involved in the IPM?
Methods
Context
This research took place in Lanark County. This is a community that is located in the southeast region of Ontario, Canada, characterized by rural areas and some higher-density populations within nine municipalities. The IPM efforts were guided by a partnership with Planet Youth, an organization located in Iceland that offers a guidance program designed to support the implementation of the IPM internationally. The local effort is called Planet Youth Lanark County and is led by a steering committee that includes volunteers and leaders from a range of local organizations. Major contributors to this work include, Open Doors for Lanark Children & Youth (the administrative backbone organization), the Leeds, Grenville & Lanark District Health Unit and the Upper Canada District School Board, among others.
Youth Participation
This research was a component of a larger study examining the full implementation of the IPM in Lanark County (Halsall et al., 2020). Applying the framework developed by Pereira (2007), we utilized three levels of youth involvement (see Figure 1). This included levels described as (1) youth-adult-partnership, (2) adult-initiated and shared decision-making, and (3) consulted and informed. Accordingly, there was a lead youth advisor who was closely involved in decision-making and leading different aspects of the research. There were three youth advisors engaged over the period of the research project (Mahmoud, Tayal, Dixon). Second, there was a group of young people and adult allies that supported the development of an asset map that contributed to this research. Third, consultation interviews were conducted with young people from across Lanark County. The contributions of the youth advisors and the young people involved in the asset-mapping are described in the methods section. Perspectives from the youth consultations are described in the results section. Perspectives from all young people have informed future directions related to research and IPM strategies. See Figure 2 for the timeline of the research. Overview of the Youth Engagement Approach. Adapted from: Pereira (2007). Ready... Set... Engage! Building Effective Youth/Adult Partnerships for a Stronger Child and Youth Mental Health System. Toronto: Children’s Mental Health Ontario & Ottawa: The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO. Timeline of the Research Study.
Within this study, Mahmoud was engaged as the founding youth advisor and member of the Steering Committee from February 2021–April 2022, She supported data analysis, the co-design and facilitation of an initial youth consultation, selection of her successor and co-authorship of the first four publications of the research (see Halsall et al., 2022a, 2023). She grew up in Lanark County and was completing an undergraduate degree in Ottawa. She was recruited through her role on another participatory research project and came with some initial experience in research. She was trained in qualitative data collection and analysis by Halsall.
Her participation coincided with the first couple of years of the pandemic, so schools were often closed, public health units were preoccupied with COVID responsibilities rather than substance use prevention and there were many public health restrictions on the community. This created significant challenges moving the project forward and reaching young people. She participated in Steering Committee meetings during her tenure and provided her perspective to planning conversations and decision-making with respect to the implementation of the IPM as well as the research. Importantly, she was from the community and was able to shape the findings from earlier data collections in critical ways, by highlighting social norms related to rural identity, substance use and sport participation.
Tayal assumed the position from April 2022–December 2022 and was involved in the co-design and implementation of the asset mapping. Tayal also grew up in Lanark County and had previous experience in advocacy work within the mental health and substance use system. Tayal took the lead in designing the visual report for the asset mapping (see Halsall, Khanna, & The Students Commission of Canada, 2022). Dixon became the youth advisor in February 2023 and has extensive leadership experience in system-level youth advocacy within youth mental health and substance use initiatives (see Dixon et al., 2022). Dixon took a lead role in the conceptualization of the ongoing research in Lanark County and contributed to the development of a governance model to inform youth engagement processes going forward. Dixon supported data analysis and drafting of this manuscript.
In the spring of 2022, an asset mapping working group was formed that engaged young people from across Canada, along with young people who grew up in Lanark County (the first youth advisors, Jan and Holmgren). This group was created through a partnership with The Students Commission of Canada (SCC; see Halsall, Khanna, & The Students Commission of Canada, 2022). The project was commissioned by Open Doors for Lanark Children and Youth to support the implementation of the IPM in Lanark County and was intended to focus on the services being provided by the five Youth Centres in the community. Youth members were recruited by inviting young people from the SCC Facilitator Roster. This is a team of young people who often become introduced to the SCC through the annual #CanadaWeWant conference and show a stronger interest in the organization and engagement with the work. These young people are trained in facilitation skills and support the implementation of projects from across the SCC.
The working group was launched with an initial workshop that provided background on upstream prevention in substance use, the IPM and the overall mandate of the project. Using a reading club and group reflection approach, the team began by conducting a literature review focused on youth engagement, youth substance use prevention, asset-mapping, community development for health equity and youth-led social enterprise. Next, the team collaborated to develop an interview guide and to facilitate consultations with local Youth Centre staff and young people. The working group applied an experiential learning approach, whereby each planning phase was accomplished through working meetings so that young people and adult allies could reflect on the learning together and build on each other’s ideas. Articles that were read, were discussed in the group and key ideas were shared and explored together. Analysis of the interviews was completed in breakout rooms during virtual meetings so that group members could mentor each other in thematic analysis techniques, and come to consensus on codes and themes. This process supports both observational and experiential learning and fosters reinforcement through connections formed within the group (Cadigan & Bellefeuille, 2022).
Youth compensation varied depending on the stage of the project. The first youth advisor was initially paid with an honorarium and provided invoices for the hours worked. As the youth engagement processes became more formalized, successive youth advisors were hired at the research assistant level at the first authors affiliate hospital and were paid hourly wages. Their job descriptions highlighted both research and advocacy responsibilities. The young people supporting the asset mapping were hired under short-term contracts through the SCC. Finally, young people participating in interviews were compensated with digital gift cards for their time.
Semi-structured Interviews
To ensure diverse and representative youth were included, participants were recruited through existing community resources (i.e. the Youth Centres) as well as through schools. The Planet Youth Lanark County Youth Engagement Lead (Shams) had strong relationships with Youth Centre administrations. An email was sent to each Centre describing the IPM and the related research and inclusion criteria (youth had to be age 16 or over to participate based on REB approval). Youth Centres shared the information with their staff and members to identify who would be interested in participating and to organize a date for the researchers and Shams to visit or to organize a call. Semi-structured individual interviews (n = 5) and one focus group (n = 5) were conducted between Winter 2022 and Spring 2023 with 10 young people. All interviews were completed by the lead author over the phone, in person or via Zoom. On average, interviews lasted about 38 min (range: 21–53 min). As described above, the interview guide was developed through the asset mapping working group and focused on youth experience of substance use issues in the community, barriers affecting young people and changes they would like to see in their community. The interview guide is included in Appendix A and available in Halsall, Khanna, & The Students Commission of Canada (2022).
Interviews were audio-recorded and transcribed using the Otter.ai software with the exception of one interview whereby handwritten notes were taken during the interview. Halsall, Dixon and Jan were involved in the transcription and coding of the qualitative interview data and a thematic analysis was applied (see Braun & Clarke, 2006, 2014) using NVivo software. This process involves (1) familiarization with the interview transcripts, (2) the development of initial codes, (3) refinement of codes into themes, (4) revision of themes, (5) creation of definitions for themes and (6) drafting the report which involves combining the findings into a compelling argument and demonstration of themes through the extraction of data to include in the report. Dixon and Jan completed the initial coding. In a second round, codes were reviewed and revised by Halsall. Dixon and Halsall met in bi-weekly working meetings to review and clarify codes, and reached consensus on the final themes. This research received approval from the Royal Ottawa Health Care Group Research Ethics Board (#2020011) and informed consent was received from all participants. All participants who agreed to be included on the Planet Youth Lanark County mailing list have been provided with project updates, including opportunities to be involved with future Planet Youth Lanark County work. We have included only consultation interview data in the results section because those were the young people who consented to participate in the research. The other young people participated more as co-researchers and we did not complete an informed consent process with them.
In addition to the formal interviews conducted and recorded for this research, larger groups of youth ranging in age from 10 to 18 years participated in informal focus groups and were asked similar questions within schools and other youth centres (n = 297). The results of those conversations, which closely mirrored the formal interview results (see PY ACHIEVE, 2024), were summarized and presented to the PYLC Steering Committee and to the community. Some of the youth who participated in those focus groups helped to present the summarized data, share their personal perspectives, and are now working on the PYLC Youth Advisory Committee. This committee is currently involved in shaping the research questions to be used in the next round of consultations that will follow the 2024 population-level school survey data release (step 4 of the IPM).
Results from the Youth Consultations
Participant ages ranged from 17 to 24 (M = 18.8). Gender identities were reported as six girls/women, one boy/man, two gender non-conforming and one trans girl/woman. Most were White, English-speaking and born in Canada. Three identified as having a disability, while two preferred not to answer. A minority of participants reported experiencing some level of economic hardship. Thematic analyses resulted in four themes related to substance use issues, a lack of activities, intersectional discrimination and recommendations for community changes.
Social Norms and Accessibility as Influences in Youth Substance Use Behaviours
The young people that we interviewed described substance use as a widespread behaviour among youth. They described the influences of peer and family norms that promoted substance use, as well as general ease of access through friend connections, social media networks or their parents. Some youth also shared conflicting thoughts on the availability of substances. For example: It's just so available. Like everywhere you look, somebody's either gonna be smoking a cigarette, like, with a group of people and there's a vape around or there's somebody you know, that smokes weed. It's just, I think it's just too available… I know people that if you were going to get that stuff, you could just message somebody on Instagram and within 20 minutes you'd have what you want. (Y1)
Many of the young people communicated that accessing substances from parents or caregivers was relatively common. One participant also shared that the rationale behind her parents’ choice to provide substances to her was to reduce the risk of exposure to potentially harmful supplies. So, I know a lot of people get it from like older people. I get it from my parents. They buy me it just because they want me to use safe stuff. And like, my mom… she gets me the stuff because she wants me to get it from like a safe place instead of a not safe place, I guess. (Y6)
Another issue that was raised, was the normalization of certain substance use behaviours, and in particular, the consumption of nicotine through vaping. Youth described that middle school-aged youth were being drawn to vaping as they find the flavours appealing: I feel like vaping is really normalized now. Like, it was initially conceived as a way to prevent smoking, and get people off of smoking. But it has largely caused more [smoking] because of the flavors being like candy. And so children are more interested in them and teenagers. And like, if you go to talk to a seventh grader in my high school, they've probably hauled off a vape. (Y9)
Substance use among youth was also influenced by peer behaviours and participants described the mechanism of exposure through peers and how escalation can occur through initial positive experiences, and rationalization of risk. …when you start growing up, you're hanging out with your friends and you try stuff. And then like, it just goes from there. Like you try something like say, you try cannabis, and you're like, ‘Oh, I like this.’ And then you go and get more. And then they're like, ‘Oh, we also have this' and you're like, ‘I could be down to try that'. And then it just spirals from there. Because I think a lot, a lot of people think like, ‘Oh, if I only try it, like, what's the worst that can happen? Like if I try it?’ And then it just leads on from there. (Y1)
Beyond peer norms, young people also identified that some youth used substances as a coping mechanism to deal with stress related to parental conflict and abuse, and mental health concerns. Most of it is either peer pressure, their parents being terrible people, or their parents giving it to them. Either their parents being abusive or whatever and that's their way of coping with the abuse and stuff like that. [And] depression, anxiety. Like, you know... coping with mental health. (Y10)
These descriptions of social contexts that normalize and promote substance use behaviours are reflective of the critical challenges that these young people experience in navigating substance use in their community. In addition, it highlights the importance of applying population-level approaches. These norms will not change if interventions can only impact a small sub-group within the community.
Lack of Activities
Our participants felt that substance use in the region was partially driven by boredom and a lack of activities for young people. Youth proposed that having more activities would be a potential strategy to reduce substance use in the community. They also felt that there was a need for more programming that is targeted to youth interests. “If there was even a cheap art program, I’d be willing to sign up for it. It’s just... we have art class at school, it’s just not the same as like getting art classes, you know?” (Y10)
Overall, young people highlighted a significant lack of youth-centred amenities and infrastructure, in particular, for entertainment. I actually think it's not the worst idea [having a movie theatre in town] because it would give young people somewhere to go. Instead of just hanging around, like, doing bad stuff. Well, not that everyone does. But just instead of not having that option, and like, ‘We're bored.' ‘We have nothing to do. Let's do drugs.’ ‘We have nothing to do. Oh, well, how about we go see a movie?’ (Y3)
The lack of activities is further complicated by the dispersed nature of the region and lack of public transportation, limiting opportunities to connect with others outside of school. This was especially challenging for youth who lived outside of town centres and those without an independent mode of transportation (i.e. a driver’s license and access to a vehicle). [Lack of transportation is a barrier] because there's like no transportation in our community. There's no buses other than school. There's no taxis. There's nothing like that…. Unless you're lucky enough to live like directly in town. (Y10)
Young people are entering a stage of their life where they are becoming more independent and exploring new avenues that challenge their skills and abilities. Providing opportunities for stimulation and engagement within healthy supportive contexts is an important way to help young people transition, while learning to manage their growing independence.
Intersectional Discrimination
Discrimination and racism was a widespread issue and major concern for the young people. In particular, race, income, disability, sexual-orientation and gender identity-based discrimination was consistently described among participants, with descriptions of numerous personal experiences of discrimination. “… from my experience [and] the youth that I've talked to, money is a big barrier. Racism, homophobia…” (Y3) Many of these experiences of harassment occurred during school time. Participants also described their experiences of educator responses having a lack of impact on their current situation: Like the most teachers can do is really just tell them not to, but that's not gonna get you anywhere. [While participant was administering an in-school survey to younger students] one of the kids wrote the R slur at the bottom, which I found very offensive. So, I showed the teacher and she just said ‘Don't do that' and crumpled it and threw it out. Which, I mean, what else are you gonna do? (Y1)
Several young people shared that these behaviours were often perpetrated by certain groups, such as younger adolescent boys and young people from more rural areas. At least I've found it's mostly dumb, pre-pubescent teenage boys who don't know shit and are getting away with whatever they want because it makes them look cool in front of their friends. And there was a case, lots of cases actually a year or two ago of these guys would bark at girls, bark at them! (Y9) Definitely a lot of discrimination. I mean, a lot of the, like, a lot of the youth in this area, they're very, like, country and stuff. So they're very, like, old school, I guess. And some of the things I've heard, just even walking down the school hallways, it like makes me sick. [This discriminatory behaviour was directed towards]… Like disabilities, low income, or like sex and gender, sexual orientation. (Y1)
One participant described their awareness of the broader social context of discrimination youth face, identifying early socialization of children and how they are constrained to match the societal expectations of their assigned sex at birth. This contributed to the discrimination they experience in current contexts. I think it was also the fact that I was raised as female, is also a thing. Because mental health concerns for people assigned female at birth … and the way different neurotypical, and neurodivergent cases present in people raised femininely are very different than people raised as boys. And one of the best cases I've ever heard is, we raise girls to be perfect, and we raise boys to be brave. Girls are conditioned to be perfect. (Y9)
This knowledge influenced their perspective and interest in social justice. It's hard to not be [interested in human rights issues] when it's your debate, your rights they're debating. Losing interest in human rights in rights issues is a privilege that I sometimes don't have. And I like to acknowledge that it's a privilege. (Y9)
Some of the negative attitudes that were described by the participants extended to programs and services that were available in the community. One youth shared that certain opportunities that were available to youth, carried a stigma, placing youth who accessed them at risk for discrimination from peers: I live in [town]. So, the lack of access to things to do, like the stereotypes behind the things to do, like you can go to the library, but you're looked down upon for going to the library. Like, you're a nerd or whatever. (Y3)
These attitudes also applied to Youth Centres and youth felt that it was related to their philosophy of welcoming and creating safe spaces for all, “There's just a lot of stigma around youth centres.” (Y1) At the Youth Centre… we have like, people of all kinds come in, work there, everything, volunteer. And we don't exclude or anything. So, I think it's a really nice safe spot. But, I've also heard people talk bad about it because of the same reasons. (Y3)
Again, these experiences highlight the need for interventions that can impact social norms. They describe social learning and multiple contexts where young people experience discrimination. Multi-level strategies will be needed to change behaviours across these levels. This includes strategies that target structural inequities. Building on these challenges that young people experience, youth expressed their thoughts on possible directions that could improve their communities as described in the following section.
Youth Suggestions for Strategies to Enhance the Community
When prompted to consider potential strategies to improve the experiences of youth in the region, themes of active listening and more enhanced training for adults in positions of authority (teachers, community workers, emergency services) were brought forward. “I just want adults to listen half the time… teachers, doctors, generally people in authority because, half the time, I feel like I'm being gas-lit.” (Y9) Positive experiences with adult authority figures were specific to those adults who had prior training in topics of importance identified by youth. I do like my teacher, but she's been trained to deal with mental health issues too… So there's a couple teachers I really like at the school. But then again… Every teacher deserves to know how to deal with things properly... I think we should have, like, more training, like for mental health… [For] staff at facilities and, like, pretty much anywhere. Like anyone with like a job that's basically in the community. (Y10)
Anti-oppressive, anti-racist and anti homophobic/transphobic education was of clear importance to the youth interviewed. Recognizing that youth perceptions of equity issues are often formed by the adults they interact with during their early years, participants communicated that schools could be a potential venue for this perceptual shift. They felt that early anti-oppressive education offered strong potential for building safer spaces for youth as they grow up in the community: [Young people] could be educated about [equity issues, sexual, gender, racial identity] more in school, I think… I'd say like, at a younger age too like, not too young, but like, when they're teaching sex ed or something. Just explain that we exist, you know, or something like that. Because, like, they need to learn from a young age that people like this exist, otherwise, they're not going to understand it when they grow up. And then they're gonna be like, “hey, this person is different, let's pick on them”. (Y10)
Along with education, school contexts would need to demonstrate that acceptance is practiced and valued. This would have to be communicated within representation of staff, general attitudes and policy change.
Other solutions included increased access to public transportation as a potential facilitator to youth involvement in their communities: I can't drive yet... Just… I'm not confident enough and I'm anxious and stuff. And it feels like you can't get many places... And I mean, I guess, ideally, we wouldn't have like public transportation from here to there kind of thing, because that wouldn't be very practical. But like, if we could have a train to Ottawa, something I don't know, to connect it to a greater urban area. Because I think it's becoming a greater urban area. But it doesn't have all the benefits that a greater urban area does. (Y9)
Meaningful extracurricular activities were named as being very influential for young people who participated. In particular, extracurricular opportunities with a strong focus on leadership, mentorship, and skill-building. One barrier (and potential solution) was the lack of adults in the community available to facilitate this programming. We don’t have a lot of like, older mentors for the younger people or the younger group… Other than like, the youth center or like after school programs, there's nothing really where people could just go and do something. Like when I was younger, [I participated in a leadership and citizenship program that included outdoor sport and expeditions]. And we'd go and, like, just hanging out with a bunch of people. And there's adults there. And we learned a bunch of stuff… which I think was really cool…. it's not for everybody. But I was saying, like, have more, like, after school programs and stuff for, like the older youth that they would be interested in. (Y1)
Discussion
This paper describes the initial stages of youth engagement processes that were being integrated into the Planet Youth Lanark County strategy and evaluation. We provide an in-depth account of how the processes were developed as well as an overview of findings from the initial consultations, including local youth perspectives on factors that influence substance use, challenges that they are experiencing and reflections on community changes that would improve the quality of life for young people.
In terms of contextual issues that influence substance use, young people felt that many substances, such as cannabis and e-cigarettes, were easily accessible. Other regions of the world that are engaged in implementing the IPM have similarly found that substances were easily available to young people (Sepulveda et al., 2023), including through parents (Kelly et al., 2023; Sepulveda et al., 2023), and that substance use was seen as socially acceptable (Carver et al., 2021). In addition, these findings confirm what the data from the school survey captured, as 20% of the survey participants identified that they receive alcohol from their parents and 21% identified that they drink at home (Planet Youth Lanark County, 2024).
Many of the young people described personal experiences of discrimination that had a considerable negative impact. Further, this finding was not unique to our participants as 33% of the survey respondents reported that they did not feel safe at school (Planet Youth Lanark County, 2024). These findings are a reflection of the broader atmosphere in Canada, in that over a quarter of 11–15 year olds report that they have experienced bullying two-three times or more over the last 2 months (UNICEF Canada, 2019). Canada ranks among the higher scores when compared with other wealthy countries with respect to percentage of young people who report being bullied (UNICEF Canada, 2017; UNICEF Canada, 2020). This is in contrast to Icelandic youth who report some of the lowest scores. In a national survey, 21% of Canadian students reported being bullied, with transgender youth experiencing the highest rate at 41% (Health Canada, 2024). Young people who were involved in bullying (both victims and perpetrators) reported higher rates of substance use than their peers who were not involved in bullying.
Participants expressed that youth experienced boredom related to a lack of access to extra-curricular opportunities and transportation infrastructure to support access, and that this contributed to substance use among young people. These insights were reported by adult partners involved in PYLC (Halsall et al., 2023) and also somewhat reflected in the survey findings, whereby only 25% of students report participating in sport three or more times per week (Planet Youth Lanark County, 2024). The 2024 report card on physical activity for children and youth (ParticipACTION, 2024) reported that around 67% of youth age 12–17 participated in some form of physical activity, however, the rates range from 86% for youth from high-income families to 55% from low-income families. Youth Centres and other youth programs represent important partner organizations that are often involved in IPM efforts. These partners can be involved in strengthening local efforts to increase participation in constructive out-of-school activities. Our participants also highlight that there is a stigma around youth centre programming. This is an important consideration when planning how to scale programs to a population-level. These programs are often supporting equity-deserving populations who are not able to access other services. As such, other families may not consider these program offerings as a viable option. Organizations may need to modify existing program offerings in order for them to increase their reach and potential to affect population-level norms within a community.
Recommendations
There were three main recommendations offered by the young people: (1) increased training for responsible adults so that they can better support young people, (2) broader education focused on anti-oppression, anti-racism and anti- homophobic/transphobia principles and (3) supporting access to extra-curricular opportunities. Planet Youth Lanark County facilitated a goal setting exercise in June of 2023 and identified the development of safe spaces as one of the community priorities. This goal aligns with the priorities highlighted by the young people in this consultation: access to safe spaces, both in and out of school.
It is important to begin conversations about discrimination early; children absorb ambient messages about race, gender, sexuality, ability and other axes of identity at early ages (e.g., Baron & Banaji, 2006). Anti-discrimination principles need to be supported and embedded in the contexts that youth access; schools and other spaces are influential in prompting inclusive anti-oppressive behavior (Heberle et al., 2020). For example, messaging in school and other spaces that acknowledges the reality of systemic discrimination predicts youth anti-racist action (Bañales et al., 2019). Conversely, environments that are systemically discriminatory reinforce exclusion and disconnection (McPherson, 2022). Classroom-based tools, such as the Developing Inclusive Youth program (for children as young as 8) have been effective for promoting attitudes of (interracial) inclusion, associating positive traits to - and playing with - children from different backgrounds (Killen et al., 2022).
The WITS Program, designed for children from Kindergarten to grade three is well-known and beneficial. In a large-scale longitudinal evaluation in rural Canadian schools, children in intervention schools were more likely to report bullying or discrimination, and experienced a faster decline in aggression and emotional problems when compared to children in control schools (Leadbeater et al., 2022). In Ontario, schools and school boards are mandated to have bullying policies that include protocols for prevention, intervention plans and progressive discipline that provides for inclusive and equitable education (Ontario, 2024). Many schools in the region are already implementing the WITS program (see Ottawa-Carleton District School Board, 2024; Upper Canada District School Board, 2024), yet issues related to bullying appear to be persisting. Consistent monitoring and evaluation of these programs may improve effectiveness. Further research should examine implementation and impact of bullying programs within applied contexts.
Exposure to 2SLGBTQ + people and their stories is especially important in smaller communities where there is not a critical mass of visible queer community and raising awareness may be effective. Out in Schools is a BC film-based program to reduce homophobia, biphobia and transphobia. The program is facilitated by 2SLGBTQIA + people who present 2SLGBTQIA + youth-centred film screenings and facilitate group dialogues discussing themes of gender, sexuality, lived experiences, discrimination and ways to be inclusive. The workshops are aimed at grades 5–12. This program has been associated with reduced odds of LGB students experiencing discrimination, reduced odds of LGB and hetero girls reporting bullying or considering suicide, and increased levels of school connectedness (Burk et al., 2018). The Canadian Centre for Gender and Sexual Diversity provides educational programs in Ontario for classrooms and youth groups related to intersectionality and diversity, comprehensive sexuality education, and queer history (see https://ccgsd-ccdgs.org/).
Youth who have the opportunity to participate in youth-focused interventions, particularly programs involving community service, are more likely to think critically about social issues (Heberle et al., 2020). This cross-cutting nature of youth community engagement aligns with young people’s recommendation for additional extracurricular opportunities and programs. Since the issues of bullying and discrimination have been identified as a priority for youth, peer interventions might be a critical opportunity to explore. Bystander intervention trainings (e.g., Right to Be, Green Dot, Bringing in the Bystander) have demonstrated some evidence that they are effective at improving attitudes and behaviors in relation to identifying discrimination and harassment and responsibility to address it (see Kettrey & Marx, 2021; Mujal et al., 2019). Increasingly, bystander intervention trainings are designed for adolescents, and focus on specific kinds of discrimination (e.g., anti-Asian harassment, anti-trans harassment). Right to Be offers free online training. The Influence in Action program developed by the SCC is designed to engage influential students in training in motivational interviewing and substance use prevention to develop a healthy peer social context (see https://archives.studentscommission.ca/drugbuzz/index.php). Another peer model that may be useful to create healthy and supportive school contexts is the Recess Project (McNamara, Gibson, Lakman, Spadafora, Lodewyk, & Walker, 2018). This intervention provides training for ‘Junior Recess Leaders’ to support more inclusive play spaces at recess and integrates a range of play options and opportunities to build relationships.
Kristjansson and colleagues (2020b) highlight that partners must contribute equally to supporting the implementation of community strategies as schools are already carrying the workload related to data collection. To support substance use prevention, Iceland developed a leisure card program that provides about $400 USD to children between the ages of 6–18 years so that they can participate in out-of-school activities (Meyers et al., 2023). Participating organizations must be approved by municipal sport and recreation bodies and meet professional quality standards to be included in the program. Since this approach is offered in a universal format, it has the potential to shift social norms related to leisure time and change health indicators at the population-level. Further, this approach has the potential to integrate youth employment and mentorship opportunities, further supporting the development of young people. In Iceland, many of the extracurricular facilities are located adjacent to schools, therefore transportation is not necessary. As such, this program also represents a quality aftercare support for families. A leisure card pilot has been implemented in Franklin County, Kentucky and in the first few years of implementation, they have identified increases in extracurricular participation (Meyers et al., 2023). Recognizing that there are greater inequities in Canada than in Iceland, municipalities might consider implementing a progressive taxation scheme to fund leisure card programs. In addition, since some sport cultures may promote substance use (see Asgeirsdottir et al., 2021; Kelly et al., 2023) care should be taken when considering the specific sport context to ensure that substance use behaviours are not exacerbated. Wherever possible, partnerships should be leveraged in order to take advantage of existing infrastructure to increase opportunities and accessibility. Land-based and outdoor recreation may be another beneficial option for communities in rural areas.
Utility of Youth Engagement within the IPM
One of the existing criticisms of the IPM is that the population-level survey will not capture the perspectives of equity-deserving populations that are no longer connected to school (Carver et al., 2021). Involving young people from these groups within youth engagement efforts may mitigate this issue as their perspective and insight can be integrated into the design of community efforts. Our findings validate the survey data as well as findings collected from other local stakeholders (see Halsall et al., 2023; Planet Youth Lanark County, 2024). Additionally, the student surveys that are focused on grade 10 students only, while providing a consistent quantitative measure to help evaluate the efficacy of initiatives over time, do not provide the depth of insight that focus groups or interviews can. Meeting a larger age spectrum of youth at local youth centres and schools helps to broaden the capture of youth perspectives, and expands the narrative around important issues. It also helps to ensure that youth are meaningfully involved in helping solve the issues that affect them.
The IPM captures systematic evidence about four contexts that influence youth development: (1) school, (2) family, (3) peer and (4) leisure time. The school surveys were designed to capture risk and protective factors that are associated with these contexts to inform strategic planning that can change these contexts. However, school survey findings do not offer guidance regarding what to prioritize in terms of community strategies. A youth engagement process can help communities to understand what aspects of community life affect young people most significantly and to identify future directions that should be prioritized. Our findings relate to each of four contexts of focus within the IPM and highlight precursors and interactions that are implicated in the initiation of substance use and highlight processes that might be amenable to change. These findings help us to understand how these phenomena are experienced by young people and in some cases, why they exist. This is important information that can help community leaders and researchers understand mechanisms of influence and design approaches that are better equipped to address them.
This work has been bolstered by the deep expertise and vast networks developed by the SCC. They mobilized a national group of diverse young people to design and implement the asset mapping. Within this process, we utilized collaborative working meetings to support the introduction of key concepts in the literature, orientation to the overall IPM and local contextual issues, and design and implementation of the data collection. Building on this work, the SCC also supported a Youth Summit in Lanark County in August of 2023 and a second summit in the fall of 2024.
The young people who were involved in collaborating on this research made very significant contributions to the findings and enriched the insight developed through this work. First, Mahmoud played a key role in the interpretations of the qualitative findings captured with stakeholder interviews, including enhancing nuance of understanding related to rural youth identity, the nature of social norms related to substance use and the interaction of sport culture and substance use (see Halsall et al., 2025). The young people involved in the asset mapping (Mahmoud, Holmgren, Tayal, Jan) all made significant contributions to the development of interview guide questions to ensure that youth-friendly language was used to discuss existing challenges in the community as well as service use, to highlight social justice issues, and to centre the lived experience of health equity-seeking groups (see Halsall, Khanna, & The Students Commission of Canada, 2022). They also supported the development of creative knowledge mobilization products (see https://planetyouth-lanarkcounty-assetmap.mystrikingly.com/).
Jan created knowledge mobilization visuals for this paper as well as for communications with local young people. Dixon has enhanced the conceptual development of the research, the analysis and interpretation of findings, the governance structure guiding the research study, the engagement of local youth perspectives in shaping future research directions, has recognized local opportunities within integrated youth services structures to improve potential employment opportunities for youth and leveraged existing youth engagement processes to move this research program forward. These contributions strengthen the findings from this research, enhance the relevance of recommendations and will lead to better health outcomes (Halsall et al., 2021, 2022b; Kristjánsson et al., 2020). Building on this work, PYLC has now launched a youth advisory council and is continuing to expand on community consultations.
In advancing youth engagement efforts, we have found that it is important to ensure that young people working in higher decision-making roles be informed about the evidence related to social determinants, risk and protective factors and the nature of primary prevention. In our work, we have applied a multi-level approach, whereby, high capacity youth with backgrounds working in leadership roles within collaborative efforts are involved in higher-level decision-making. These young people bring deep experience working in complex, system-level efforts. Through their work, they develop a range of skills, including facilitation, project management, negotiation, research design and knowledge of related evidence, among others. We have worked with these individuals to support the mentorship and skill-development for larger groups of young people and the outreach and engagement of a broader set of local young people to capture their perspectives of health equity issues.
These components have been important in maintaining the focus of our efforts on upstream approaches. Without these supports, there is a risk that strategies will drift toward educational, individual-focused efforts that may not have the potential to improve population-level health and well-being. “Public views have been shown to also include the idea that ill health is primarily self-inflicted and is dependent on an individual’s unhealthy behaviours” (Berg, 2021, p. 102) and often stakeholder recommendations within IPM projects will support strategic directions focused on education targeted toward individuals (Carroll & Daly Consultants, N. D). Efforts may also been drawn downstream toward harm-reduction or treatment (Halsall et al., 2022a). These challenges are related to lifestyle drift (Popay et al., 2010): the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors. Coupled with this is a move away from action to address the social gradient towards activities targeted at the most disadvantaged. (p. 148)
Although the term lifestyle drift is focused on policy approaches related to social determinants, we have found that the mechanisms of influence and related risks are equivalent when implementing upstream approaches designed to influence population-level changes in health, such as the IPM (Halsall et al.). Integrating young people at multiple-levels of involvement and supporting capacity-building for young people in leadership positions enriches their insight related to research and practice and enhances their meaningful engagement in effective population-level efforts. This is a critical component of supporting quality youth engagement within IPM efforts.
Strengths, Limitations and Future Recommendations
This research was implemented in community and subject to a changing context and dynamic influences. As such, a flexible approach was applied and some components had to be adapted in order to be implemented. Since the community consultations had to be conducted within a short-time frame and community partners wanted to target young people being served by the youth centres, we were not able to interview a very large sample of young people. However, we were able to reach young people who were being served by the youth centres and they were able to share lived experiences of key equity issues. Broader consultations were implemented within local schools and these findings were used to inform community planning. These results align with our data as well as the school survey data.
This is the first research that describes an in-depth approach to engaging young people in the design and evaluation of the IPM. It can be used as a model to support the development of youth engagement processes within the IPM and other upstream prevention initiatives. Importantly, this study represents a rare example of a model to meaningfully involve youth lived experience to inform system-level upstream initiatives. Future research should be conducted to capture the impacts related to participatory approaches to youth substance use prevention, including the examination of changes to practice and policy, the integration of youth perspectives within community strategies and the inclusion of measures that examine contextual and individual outcomes (Valdez et al., 2020). Future initiatives that are integrating youth engagement within the IPM should continue to examine ways that youth can be meaningfully engaged to enhance population-level impacts on youth health and wellbeing.
This project demonstrates credibility through the development of a strong connection with the community and partners, triangulation with informal youth consultation and school survey data, participatory engagement and examination of previous research (see Shenton, 2004). Further, this paper provides in-depth information with respect to the research team, the overall approach and the community context to support opportunities to transfer lessons learned to other communities (transferability, dependability and confirmability). This research meets each of the 21 reporting guidelines from the Standards for Reporting Qualitative Research (O’Brien et al., 2014).
Conclusion
This study represents a novel participatory approach that includes youth in the design of the implementation and evaluation of the IPM. Substance use issues affecting young people are complex and it is important to examine youth perspectives in order to better understand the mechanisms of influence as well as what issues are most important to them. We applied a multi-level approach that involved high-capacity youth within major decision points within the research, as well as other levels of involvement to capture relevant perspectives related to community issues. We argue that this multi-level approach is necessary to integrate meaningful engagement of young people within complex prevention initiatives to create greater population-level health equity. Our findings will contribute to the on-going efforts focused on upstream prevention in Lanark County and serves to inform other IPM initiatives, as well as other upstream prevention initiatives that integrate youth engagement.
Footnotes
Acknowledgments
We would like to acknowledge the efforts of the Planet Youth Lanark County Steering Committee in supporting the implementation of the Planet Youth Lanark County initiative and for facilitating the development of this protocol.
Statements and declarations
Author Contributions
TH was responsible for the conception and design of the work, data collection and analysis, drafted and revised the manuscript, and approved the final submitted version. MD supported analysis, drafted and revised the manuscript, and approved the final submitted version. NK supported design, data collection, revised the manuscript, and approved the final submitted version. RS supported data collection, revised the manuscript, and approved the final submitted version. KM and AH supported conceptualization of methods and substantively revised the manuscript and approved the final submitted version. KM and SNI substantively revised the manuscript and approved the final submitted version.
Funding
This project is funded by the Canadian Institutes of Health Research (CIHR; award # 434257). The funder is providing the salary for the lead author as well as a research allowance for this project.
Declaration of Conflicting Interest
The authors declare that they have no competing interests.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.