In October 2018, the Cannabis Act (Bill C-45) came into effect. This act federally legalized the recreational use of cannabis for adults in Canada (Government of Canada, 2018). Lawmakers proposed certain benefits to legalized cannabis, which included the potential for decreased criminal activity through governmental regulation and oversight, the opportunity to generate tax revenues, and a reduction in government expenditures on law enforcement that addressed illegal cannabis consumption (Hajizadeh, 2016). Yet, opponents of cannabis legalization argued that legalized recreational use posed societal risks. The increased access to legal cannabis may potentiate harms in vulnerable populations—pregnant women, children, individuals with low socioeconomic status, or mental illness—increasing both prevalence and consequence of acute and long-term health and behavioral effects of cannabis use (McGinty et al., 2017; Windle et al., 2019).
In children, the risks of cannabis use are well documented. Long-term frequent cannabis use during brain development may permanently affect attention, memory, and learning centers of the brain (McInnis & Porath-Waller, 2016). Early initiation of cannabis use (i.e., use before the age of 16 years) is more likely to be associated with serious mental health conditions, including psychotic symptoms, schizophrenia, and depression, as well as the risk of suicide (George & Vaccarino, 2015; Gobbi et al., 2019; Silins et al., 2014; Volkow et al., 2016). Cannabis use before the age of 25 years may lead to poor academic performance, a higher likelihood of driving while intoxicated, and an increased risk of dependency (George & Vaccarino, 2015; Melchior et al., 2017; Silins et al., 2014).
The prevalence of cannabis use in youth has been consistently high in Canada. Compared with their peers in other developed countries, Canadian adolescents are among the highest rates of cannabis use (United Nations Office on Drugs and Crime, 2019). Notably, youth between the ages of 15 and 24 years have reported usage rates that are more than double that of adults (Statistics Canada, 2015). Research suggests the younger generation perceives cannabis use to be widespread and often feels indifferent to its potential risks (Porath-Waller et al., 2013). Such behaviors and attitudes suggest a need for credible, evidence-based information to allow youth to make confident and informed decisions about cannabis consumption (Canadian Public Health Association, 2017).
Traditional didactic educational strategies that focus on abstinence often do not resonate with the experiences of youth (Hyshka, 2013; Ripley, 2005; Watson et al., 2019). In Saskatchewan, the school curriculum combines the topic of cannabis with education on illegal substances, yet the traditional message of “just avoid it” now has little relevance in the current context of legalized recreational cannabis. Recognizing this gap in education, we developed REACH (Real Education About Cannabis and Health), a toolkit and curriculum resource for teachers to use within the classroom to educate youth about cannabis. Young people have a right to access accurate, nonjudgmental, evidence-based health information (Canadian Students for Sensible Drug Policy, 2018). Through REACH, youth have the opportunity to develop the knowledge, skills, and attitudes to understand and manage themselves in the changing world of cannabis legalization and regulation.
This innovative educational program was developed through a multidisciplinary collaboration of nursing and pharmacy students, middle school and high school students, university faculty, and middle school and high school teachers. This partnership was intentionally formed because collaboration is considered a best practice for addressing a variety of health issues, including health promotion (Addiction and Mental Health Collaborative Project Steering Committee, 2014). Credible and authentic prevention efforts in youth is best achieved by involving youth in the creation of educational materials (Grills et al., 2018). Community health nurses and pharmacists brought further credibility to development of the REACH resource as these professions are well-respected frontline health care providers widely recognized for their knowledge and roles in health prevention, promotion and education (Community Health Nurses of Canada, 2019; Canadian Pharmacists Association, 2001).
The Multidisciplinary Team
The multidisciplinary team consisted of two faculty from the College of Nursing (P.K.,J.K.), two pharmacy faculty from the College of Pharmacy and Nutrition (H.M. and K.M.), twelve 4th year nursing students and one 4th year pharmacy student from their respective colleges at the University of Saskatchewan. The participating nursing students were undergoing a community practice placement to fulfill clinical hours as a requirement for their nursing degree. These placements were through the College of Nursing Safe School Health Improvement Project and School Health Initiatvie (SHIP) or School Health Initiatvie with Nursing Education (SHINE) Programs. The SHIP and SHINE programs are community-based partnerships between the College of Nursing and two elementary schools and two high schools in Saskatoon. These programs provide an opportunity for nursing students to work within the schools to fulfill clinical hours in the area of community partnership, capacity building, and community development. The participating pharmacy student was completing a Specialty Structured Practices Experiential Program as a requirement for the pharmacy degree. The association of the pharmacy student with the nursing team provided a novel opportunity for the pharmacy student to practice in a nontraditional setting, and for multidisciplinary collaboration among the students. Each nursing student spent 260 hours in the community practice placement, while the pharmacist student dedicated 200 hours to this project.
The university team members partnered with youth and staff in two middle schools (St. Luke and North Park Wilson) and two high schools (Bishop James Mahoney High School and Tommy Douglas Collegiate). Geographically, these schools provided student representation from both the public and separate school divisions and represented a broad range of socioeconomic demographics. The participating students ranged from grades 7 to 10.
The REACH program consists of two modules, which differ in their content and context based on student age. Module 1 is intended for middle school, and Module 2 is geared toward high school students. Each module consists of four lesson plans which have been mapped to the Saskatchewan Ministry of Education's curricular outcomes and indicators for health education in the seventh and ninth grades, respectively. The four lessons are (a) an introduction to cannabis, (b) the science of cannabis, (c) social science implications, and (d) peer pressure, decision making, and harm reduction. Each lesson lasts approximately 40 to 55 minutes. The modules are adaptable to accommodate a tighter schedule. The REACH program is a curriculum resource that accompanies the modules to help prepare the teacher for a real education about cannabis and health for Saskatchewan youth. The resource includes comprehensive learning outcomes, a list of required resources and materials, directions and lesson outlines, suggested activities, lesson checklists, evaluations, and research highlights. Each module also includes supplementary videos, wherein the participating youth collaborated to share their previous misconceptions and perceptions about cannabis, and why they choose not to use it. Finally, a resource section is provided for teachers to access more information about cannabis to enhance their preparation for the lessons. That appendix includes general information about cannabis, how and why conversations need to take place with youth, cannabis risk reduction strategies, and how to access supports for kids and families. The REACH program used the constructivist approach, embracing and acknowledging the circumstances of both the teacher and learner and encouraging student-centered learning in collaboration with the youth and their peers (Dennick, 2016). The REACH curriculum resource was designed to increase student knowledge about cannabis; nurture protective factors and capacity building in decision making; challenge contextual adaptation skills, confidence, and efficacy in handling future adversities; and encourage the reduction of risks of consumption and social harms. The accompanying illustrations throughout the resources were created by youth within the participating schools. Although the resources were created locally in Saskatchewan, they are sufficiently generic to be shared widely across the country.
The project was funded by the Cannabinoid Research Initiative of Saskatchewan (CRIS), an interdisciplinary research team that aims to obtain scientific evidence about the application of cannabinoids and cannabis derivatives to humans and animals for health, disease, and disorders (CRIS, 2020). Although CRIS is primarily recognized for its research, the group's knowledge translation pillar is committed to improving public awareness about the potential risks and benefits of safe cannabis use, both medical and recreational (CRIS, 2020).
REACH's development consisted of four main stages: (a) project planning, (b) content development, (c) program review, and (d) dissemination and evaluation (Figure 1). Project planning involved a series of meetings with faculty and teachers, obtaining funding for the project, and logistical development of a framework and time line.
Development of REACH (Real Education About Cannabis and Health).
The content development phase commenced in January 2019 and lasted for 12 weeks during the university students' practical placements. Prior to their interaction with youth in the participating schools, nursing and pharmacy students first developed a fundamental understanding of cannabis, learned best practices for teaching, and developed readiness to answer questions related to cannabis. This required a 2-week immersion into topics such as science and regulations associated with cannabis use; risk and harm reduction; health public policy; promotion, advocacy, and health literacy; developmental theory with a particular emphasis on school-aged children and parents; social competence and peer pressure; decision making and choices; learner and youth engagement; social marketing; and community health nursing standards. The university students consulted with experts to share knowledge and used a collaborative learning model (Lie, 2002). In the next phase, the university students formed relationships with the teachers and their classes. Consent forms were distributed to the parents, and 195 of 281 consent forms were returned, granting permission for their child to participate. Two separate modules were created to acknowledge differences in cognitive, social, and emotional development among adolescents of various ages (Keating, 2004; Wigfield et al., 2005). One module was used for middle school classrooms (grades 7 and 8), and the other for high school students (grades 9 and 10).
The multidisciplinary team codeveloped the program with the cohort of middle school and high school students who contributed extensively to the development of resources in the REACH toolkit. However, resource development required the team to educate the school youth about cannabis. The team created a tentative framework for educating the youth with the understanding that lessons would be adapted as needed based on classroom interactions and engagement. Over the next 10 weeks the university students hosted approximately four face-to-face sessions with each cohort (grades 7 and 8 at St. Luke School, n = 82; grades 7 and 8 at North Park Wilson School; n = 28; grade 9 at Bishop James Mahoney High School, n = 66, and grade 10 at Tommy Douglas Collegiate, n = 19). These sessions consisted of interactive activities to stimulate engagement and discussion, as well as didactic components aimed at meeting the learning objectives established a priori. The teach-back method, shown to be effective in improving comprehension and influencing behavior, was used throughout the lessons (Candela et al., 2018; Ha Dinh et al., 2016). After each classroom session, a team debrief—moderated by a nursing faculty member—allowed university students to reflect on what worked well and what could be modified for the next session (Tannenbaum & Cerasoli, 2013). Feedback from students and teachers was encouraged and incorporated throughout the process. A professional videographer recorded the sessions. Given its complexity, an animator was hired to provide a visual depiction of how cannabis works in the body.
The university students repeated each session multiple times with new students. Each session was followed by a debriefing, which allowed continual reflection and opportunity to revise and refine the content. Feedback from students and teachers was also encouraged and incorporated throughout the process. After completion of all classroom encounters, the university students and faculty finalized the lesson plans, videos, and other resources, and formatted them for review. The materials were shared with other stakeholders, including additional parents and educators and representatives from the Ministry of Education. Edits were applied accordingly.
The social context regarding cannabis use in Canada is undergoing considerable change. To help address this change, the REACH program provides a curricular resource to help students navigate conversations about cannabis and health. REACH supports student achievement of curricular outcomes by embracing a comprehensive school community health approach; educating the whole person through holistic learning of body, mind, and spirit; focusing on achieving health literacy and efficacy related to cannabis; building inquiry skills; and responding to and addressing community perceptions, norms, and context (Government of Saskatchewan Ministry of Education, 2010).
Participation in the program's development was an excellent learning experience for the participating youth and teachers and feedback has been positive. One middle school teacher stated:
As a teacher of adolescents, I feel that this program should be brought to all Saskatchewan classrooms. This program covers the emotional, physical, and social aspects of cannabis use and the consequences associated with each. I felt that the presentation of the information was geared towards the student's needs, as cannabis use is a reality among today's youth.
A grade 8 student at one of the participating schools suggested that the program “provided actual, beneficial information to educate adolescents….Nothing was glossed over or sugar-coated…. It taught us many ways to handle peer pressure when it comes to cannabis use.”
Our nursing and pharmacy students had the opportunity to be part of a multidisciplinary team and to collaborate, along with teachers and students from the community. Each discipline discovered what they had to offer in this environment, and the nursing and pharmacy students gained experience in role clarification and collaborative leadership within this context. They learned how to build trust and establish a rapport with the youth creating a safe space for honest discussion. According to the feedback, the experience was worthwhile and the skills developed can be extrapolated to other settings. One nursing student said:
As a nurse in training, it was tremendously valuable for me to apply various methods of youth engagement strategies with adolescents. Observing first-hand how approaches like the teach-back-method sparked interest and created learning opportunities will benefit my professional practice for years to come.
Conclusion and Next Steps
A collaboration between nursing and pharmacy students with youth in grades 7 through 10 resulted in an authentic and relatable educational program about cannabis. The nursing and pharmacy faculty will work diligently to make the toolkit widely available to schools and teachers across the province. A graduate student at the University of Saskatchewan continues development of a generic tool suitable for assessment in youth to assess youth knowledge about cannabis. The effectiveness of the REACH program on cannabis knowledge retention and behavior intention will be evaluated in a cohort of grade 7 and grade 9 students using pre- and postdesign study. To follow our progress, please visit, https://words.usask.ca/cannabised4kids/.
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