Between Care and Supervision: Ethical Dilemmas, Institutional Gaps, and Stigma Dynamics in School-Based Substance Use Interventions

Between Care and Supervision: Ethical Dilemmas, Institutional Gaps, and Stigma Dynamics in School-Based Substance Use Interventions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Between Care and Supervision: Ethical Dilemmas, Institutional Gaps, and Stigma Dynamics in School-Based Substance Use Interventions Mehmet Seyman Önder This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9105573/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Substance use in adolescents is not merely an individual risk behavior; it is a multifaceted social problem shaped by school, family, and institutional structures. This qualitative research aims to uncover the ethical and institutional dimensions of school-based interventions by examining the experiences of teachers, counselors, and school administrators who intervene with middle school students who use substances. The study is interpreted within the framework of Ecological Systems Theory, Stigma Theory, Care Ethics, and Institutional Theory. Data were collected through semi-structured in-depth interviews with 70 educators and analyzed using thematic analysis. The findings focus on five main themes: lack of information and experience, procedural ambiguity, institutional ethical breaches, concerns about school stigma, and parental anxiety. The results show that intervention processes are often hampered by legal concerns, pressure on institutional reputation, and fear of social stigma. The research conceptualizes school-based interventions not as a technical implementation process, but as a tension zone between care-oriented ethical responsibilities and bureaucratic control mechanisms. In this respect, the study offers a unique contribution by highlighting the need for structural reform among policymakers and practitioners. 1 Introduction Individuals experience rapid biological, psychological, and social changes during adolescence. Adolescence is a critical period of intense stress. Risk-taking behaviors and vulnerability to environmental influences increase further during this period. Substance use during adolescence goes beyond being an individual problem and becomes a significant public health issue with negative consequences for the education system and social structure (Avcı, 2025 ; P. Das et al., 2023 ; Nath et al., 2022 ). Studies in this area show that the age at which high school students begin substance use is steadily decreasing. Consequently, the risk of exposure to substance use among school-aged individuals is also increasing (Kessy et al., 2025 ; Lopez-Soto et al., 2025 ; Myhr et al., 2024 ; Ninkron et al., 2021 ; Obadeji et al., 2020 ). Therefore, it is of great importance that protective and preventive interventions within the scope of substance abuse begin in schools. Schools, which hold a central position in adolescents' lives, are the institutional structures where behavioral changes in students are first observed. Therefore, teachers, psychological counselors, and school administrators play a crucial role in the early identification, referral, and intervention of students who use substances or are at risk. School-based interventions are of great importance in maintaining students' academic success, supporting their psychosocial well-being, and preventing students from becoming substance abusers (Fisher, 2019 ; Maduka, 2016 ; Poonam, 2025 ). However, in the literature, these interventions are mostly evaluated with statistical data. Scientific studies do not adequately address educators' experiences, the ethical dilemmas they face, and the institutional obstacles they encounter. Furthermore, school-based studies on substance use are largely student-centered; The experience of educators appears to be of secondary importance (Kessy et al., 2025 ; Lopez-Soto et al., 2025 ; McCabe et al., 2016 ; Myhr et al., 2024 ; Ninkron et al., 2021 ; Obadeji et al., 2020 ; Semwal et al., 2025 ; Senanayake et al., 2018 ). Because educators are often viewed solely as observers or guides, the fact that they are also professionals who must navigate legal responsibilities, ethical obligations, institutional procedures, and societal pressures is largely overlooked. They face significant dilemmas, particularly when dealing with a student who uses substances. Educators sometimes find themselves caught between "protecting the student" and "making a legal report," "ethical responsibility" and "institutional reputation," or "professional duty" and "personal safety." These kinds of conflicts naturally make intervention processes complex and fragile. In the Turkish context, socioeconomic inequalities, regional risk factors, and cultural dynamics are among the factors that trigger substance use among adolescents. However, more intense and complex cases may be encountered in schools in regions where substance production and accessibility are higher. In this framework, Bingöl, located in Eastern Türkiye, where cannabis production is widespread and access is relatively easy (Anadolu Ajansı, 2022 ; Bingöl İl Jandarma Komutanlığı, 2024 ; T.C.Bingöl Valiliği, 2021 ), offers a unique research area for understanding how school-based interventions are shaped. In such small settlements, the intertwined nature of social relationships, the strength of family ties, and the fear of stigma directly influence educators' intervention processes. Processes related to students using substances are conducted on an individual basis. However, in substance abuse intervention processes, institutional and systemic problems arise in addition to individual problems. Insufficient knowledge or procedural ambiguity regarding legal processes among educators (Fisher, 2019 ), lack of inter-institutional coordination (Harris et al., 2016 ), and, in some cases, ethical violations (Mushamiri, 2021 ) can make it difficult for students to access the social and psychological support mechanisms they need. Furthermore, concerns about stigma surrounding the school or the child among school administrators and parents (Gronholm et al., 2018 ) can lead to cases being ignored or delayed. This situation poses serious risks to the protection and rehabilitation of students using substances. The main objective of this study is to examine in depth the experiences of educators who intervene with high school students who use substances across the identification, intervention, and follow-up processes. This will reveal knowledge gaps, ethical dilemmas, institutional barriers, and stigma encountered in intervention processes. To highlight the multi-actor nature of school-based interventions, this study aims to examine the experiences and approaches of classroom teachers, psychological counselors, and school administrators together. The research also aims to shed light on the interactions among the education system, legal, health, and safety institutions, and individual practices in the context of substance abuse intervention processes. In this context, the research seeks to answer the following questions: What kinds of experiences have educators had when encountering students who use substances? How do institutional procedures and legal obligations affect educators' intervention processes with students who use substances? What role do fear of stigma and family pressure play in educators' decision-making processes? It is hoped that the data obtained in this study will contribute to strengthening school-based interventions, developing ethical and protective practices, and providing policymakers with insights. 2 Theoretical Framework Understanding school-based interventions for adolescents who use substances requires more than focusing solely on individual behaviors. A broader perspective is needed that considers the multifaceted social, institutional, and cultural contexts in which students are situated. This study employs multiple complementary theoretical approaches rather than adhering to a single theoretical perspective when interpreting educators' experiences. In this context, the research draws upon the frameworks of Ecological Systems Theory, Stigma Theory, Care Ethics, and Institutional Theory. 2.1 Ecological Systems Theory and School-Based Interventions Ecological Systems Theory argues that it is incorrect to explain an individual's development solely in terms of personal characteristics. In this context, it advocates a holistic approach that considers all environmental systems with which the individual interacts in order to explain the individual. According to this theory, an individual's behavior is influenced by the reciprocal interactions among systems at the micro, meso, exo, and macro levels in which the individual is situated (Crawford, 2020 ; Neal & Neal, 2013 ). It is insufficient to evaluate substance use in adolescents solely as pathological or to explain it as individual choice. According to this theory, substance use is a phenomenon that must be considered alongside family relationships, the school environment, peer groups, the structure of local communities, and societal norms (El Kazdouh et al., 2018 ; Leahy et al., 2015 ). Schools are among the microsystems that play a crucial role in a student's development and change (Leahy et al., 2015 ). Educators spend as much time with students as parents do and have the opportunity to closely observe students' behavioral and emotional changes (Allen et al., 2016 ). However, other systems also influence this micro-system. These include: at the meso level, family-school interaction; at the exo level, health, judicial, and security institutions; and at the macro level, cultural values, laws, and social norms. Interventions concerning students who use substances are not limited to school-based practices. Inter-institutional relationships and societal expectations also influence the method and success of interventions. Therefore, in some cases, educators may need to consider not only students' needs but also family reactions, concerns about the school's reputation, legal obligations, and social relationships in the intervention process. In this context, ecological systems theory provides a functional framework for understanding the multifaceted pressures and decision-making processes educators face. 2.2 Stigma Theory and Substance-Using Students Stigma theory focuses on the marginalization and labeling of individuals by groups, communities, or societies due to certain behaviors or characteristics, and attempts to explain the negative effects of this labeling on both the individual and the relationship between the individual and society (Crewe & Guyot-Diangone, 2016 ). Adolescents who use substances face the risk of stigmatization. This is because substance use is seen as both a health-related risky behavior and a deviant behavior that violates societal moral and legal norms. Therefore, students who use substances are often labeled as "criminals," "dangerous," or "problematic" individuals by both their social and academic environments. These labels negatively impact students' academic careers, social relationships, and future prospects (Demir et al., 2025 ; Topkaya et al., 2021 ). Stigma in schools typically manifests in stages such as primary deviance and secondary deviance (Lemert, 1972 ). This process transforms schools into institutional spaces where stigma is produced. It accelerates the spread of a student's substance use behavior among teachers, school administrators, peers, and family, increasing the risk of exclusion. This situation places educators in an ethically contradictory position. Educators, who have a responsibility to support and protect students, may worry that a formal report of a student's substance use will stigmatize the student or the school. Because of this concern, intervention processes may be delayed, or the student's behavior may be ignored (Caballero et al., 2025 ; Kipkurui et al., 2023 ). The themes of "concern about school stigma" and "parental concern about damage to family reputation" that emerged in this study demonstrate that stigma is not solely an individual phenomenon. It can also be experienced in layered ways at the institutional and societal levels. In this case, some educators may prioritize protecting the school's or family's image over the student's well-being. 2.3 Care Ethics and Ethical Dilemmas for Educators Care ethics focuses on empathy, responsibility, sensitivity, and interdependence in interpersonal relationships. According to this approach, ethical decisions cannot be based solely on abstract principles; these decisions must be shaped by relational contexts and the concrete needs of individuals. From this perspective, the relationships that teachers and other school staff establish with students should not be based solely on rules and procedures. Attitudes and behaviors towards students should be shaped by a holistic approach that considers the student's academic, psychological, and social well-being (Chen & Shih, 2025 ). Within this framework, educators become not only providers of academic knowledge but also actors with ethical sensitivity to students' vulnerabilities. When dealing with students who use substances, educators often face a tension stemming from the dilemma between care ethics and legal and institutional obligations. Educators who wish to protect the student, keep them away from stigmatizing and punitive processes, and provide a supportive environment are also confronted with mandatory reporting, disciplinary regulations, and institutional responsibilities. Caught in an ethical impasse, educators are torn between acting on care-based values and complying with regulations (Erdogan & Sezgin, 2020 ; Geiderman & Marco, 2020 ). In some cases, they may even have to assume professional and legal risks while prioritizing the student's well-being. Ethical violations don't stem solely from individual insensitivity or professional incompetence. Inadequate institutional support for care ethics makes ethical violations visible. Educators' fear of "getting into trouble," family pressures, and procedural uncertainties weaken the continuity of care-based interventions, making ethical decision-making processes even more fragile. 2.4 Institutional Theory and Bureaucratic Obstacles Institutional theory is an approach that explains individuals' behavior within a professional group by considering the group's organizational structure, institutionalized norms, legal regulations, and established practices. According to this approach, institutions not only shape individual behavior through legal regulations but also provide a cognitive and normative framework for what should and should not be done. In this context, it is stated that institutions generally serve to restrict and direct individuals' scope of action (Farashahi et al., 2005 ; Forgues et al., 2012 ; Sandhu, 2018 ). Schools, ministries of education, health institutions, law enforcement agencies, and judicial mechanisms should coordinate their efforts in school-based interventions for students who use substances. The lack of clearly defined authorities and responsibilities among these institutions leads to confusion in interventions, ultimately rendering them ineffective. Theoretically, this situation is referred to as an "institutional void." In institutional gaps, individuals are unsure which rules and norms to follow or which procedures to apply. This uncertainty leads individuals to develop solutions through informal and personal initiatives (Webb et al., 2019 ). This lack of coordination between institutions and the misguided actions of officials create risks for both the protection and professional and legal security of students. This risk undermines the trust that both students and some officials have in institutional structures, leading officials to exhibit behaviors such as "avoiding responsibility," "ignoring the issue," or "delaying the process." 3 Method 3.1 Research Model This study was designed as a qualitative study to examine the experiences, perceptions, and procedural and structural problems encountered by educators intervening with students who use substances. Thematic analysis was used to extract meaningful themes and patterns from the participants' narratives. The reason for choosing this method is that it enables a deeper understanding of participants' experiences and perceptions by systematically identifying themes and patterns in the data. This method is considered effective for revealing themes and for facilitating clear communication of the study's main findings and conclusions (Caballero et al., 2025 ). This study was conducted within the interpretive paradigm. According to the interpretive approach, social reality is constructed not only as an objective, singular construct but also through the experiences and meaning-making processes of individuals (Pulla & Carter, 2018 ). In this context, the study aimed to understand how educators perceive situations when encountering students who use substances and how they assign meaning to these experiences. 3.2 Research Context The research was conducted in Bingöl province, located in the Eastern Anatolia Region of Türkiye, which is considered one of the socio-economically disadvantaged regions. Bingöl is known as one of the provinces where cannabis production and access to the substance are relatively more widespread and easier due to its geographical location and the prevalence of rural areas. This situation increases the risk factors for substance use, especially for adolescents. Bingöl's social structure is characterized by strong intra-family ties in small settlements, a high level of social control, and widespread fear of stigma. This context leads educators to conduct intervention processes with students using substances under not only professional but also social and cultural pressures. Therefore, Bingöl offers a unique research environment for examining the institutional and ethical dimensions of school-based interventions. 3.3 Participants The study participants were 70 educators working in 14 high schools in Bingöl province's city center. The study group comprised three professional groups: 28 classroom teachers, 28 psychological counselors, and 14 school administrators. Participants were selected using criterion sampling, a purposive sampling method. The participation criterion was that participants had directly encountered a student in their school who was using or at risk of using substances. This criterion aimed to ensure that participants had experience relevant to the research topic and to enrich the data. Participants' professional experience ranged from 5 to 25 years. This provided an opportunity to compare educators' perspectives at different seniority levels regarding intervention processes related to student substance use. 3.4 Data Collection In this study, semi-structured in-depth interview forms, specifically designed for each occupational group, were used as data collection tools. In preparing the interview questions, the relevant literature was reviewed, including studies on substance use, school-based interventions, ethical dilemmas, and institutional processes. During the development of the interview forms, opinions were sought from three academics who are experts in the field, and the questions were revised based on the feedback received. Subsequently, pilot interviews were conducted with a classroom teacher, a school counselor, and a school administrator. As a result of the pilot interviews, the clarity, scope, and depth of the questions were evaluated; necessary adjustments were made, and the interview forms were finalized. Interviews were conducted in quiet environments at the schools where the participants worked, ensuring the confidentiality of the interviews. Interview durations averaged 25–40 minutes. 3.5 Ethical Principles Ethical principles were strictly adhered to throughout the research process. Ethical approval was obtained from the Bingöl University Ethics Committee before the start of the study; furthermore, the necessary permissions were obtained from the Provincial Directorate of National Education. Before the interviews, the research purpose, process, and principles of voluntary participation were explained in detail to the participants; written informed consent was obtained from those who agreed to participate in the study. To protect participants' anonymity, all participants were given pseudonyms; age and occupation information were presented in general terms. Direct quotations in the research report do not contain any information that could lead to the identification of participants. 3.6 Data Analysis The data obtained in the research were analyzed using thematic analysis. In the analysis process, the systematic steps of thematic analysis were followed. In the first stage, all interview recordings were read repeatedly to become familiar with the data and record initial impressions. In the second stage, the data were coded into meaningful units, and open codes were created. In the third stage, similar codes were grouped together to create potential themes. In the fourth stage, the themes were reviewed; their compatibility with the entire dataset was evaluated, and a thematic map was created. In the final stage, the themes were identified, named, and reported. To increase the reliability of the analysis, the coding and theme-generation process was reviewed multiple times, and care was taken to support the themes with direct citations. 3.7 Thematic Map This study includes 3 groups, and data were collected separately from each group. Themes were created from the collected data and distributed according to the groups. 5 themes were obtained from school administrators, 4 from school counselors, and 3 from classroom teachers, and these were compiled into a map. The map is shown below. 4 Findings Data from in-depth interviews conducted as part of this study were analyzed and grouped into five main themes that highlight the multifaceted challenges educators face when intervening with students who use substances. These themes emphasize the commonalities and differences in the experiences of teachers, counselors, and school administrators. The findings demonstrate that intervention processes are not limited to individual knowledge and experience; they are also shaped by systemic factors such as institutional structures, ethical dilemmas, fear of stigma, and family pressure. Theme 1: Lack of Knowledge and Experience Participants' statements reveal that some classroom teachers, school counselors, and administrators lack sufficient knowledge and experience in identifying and intervening with students using substances. This lack of knowledge and experience can make it difficult to implement appropriate interventions and prevent students from receiving the necessary support when substance use is detected. In particular, it has been observed that classroom teachers and some school administrators frequently interpret changes in students as 'adolescent problems,' 'discipline problems,' or 'academic failure.' This hinders the early diagnosis of substance use. “Teachers don’t pay attention to students’ behavior. Therefore, they don’t realize whether a student is using drugs because they don’t notice any changes in the student. Even if they do notice, they don’t know the reason and don’t question it.” (Ali, 40, Manager) “Teachers can’t tell which students are using drugs because they don’t know what symptoms drug users exhibit.” (Mustafa, 38, Counselor) The Ministry of National Education has prepared training modules for teachers on topics such as substance abuse and exploitation. However, some teachers tend to avoid these trainings. “The Ministry of National Education has prepared numerous training modules for educators, primarily on substance abuse and exploitation. Participation in these trainings is mandatory for teachers and administrators. However, many find ways to avoid them.” (Özkan, 31 Counselor) Some teachers who encounter a student using drugs may not know what to do and may try to find an appropriate solution on their own. This can prevent correct and effective interventions and lead to the problem escalating. “Teachers and administrators who encounter a student using drugs, because they don't know what to do, try to implement what they think is the most appropriate solution.” (Birgül, 29, Counselor) Students in university psychology departments receive training in crisis intervention. Many universities include how to intervene with individuals using substances in their curricula or provide specialized training on this topic. However, some psychological counselors may neglect this training or be inadequate in putting theoretical knowledge into practice. “As guidance counselors, we don’t frequently encounter students using substances. Therefore, we don’t have much experience in what we should do.” (Kaan, 36, Counselor) “They taught us crisis intervention in our undergraduate education, but they didn’t provide any specific training on how to intervene with students using substances.” (Bahri, 34, Counselor) Theme 2: Procedural Complexity Teachers have an obligation to report students who use substances. However, some participants noted that there is no clear roadmap for when reporting should be done, leading to procedural complexity and thus preventing them from effectively addressing students' problems. The fact that two different school guidance counselors working at two different schools indicated different centers where the official notification should be made suggests confusion in the procedure. “When we identify a child using drugs, we have to report it to the Child Monitoring Center. We cannot initiate any action without their knowledge.” (Burcu, 32, Counselor) “When we encounter such a case, we first go to the Guidance and Research Center affiliated with the Provincial Directorate of National Education.” (Deniz, 37, Counselor) School administrators, while aware of their legal responsibilities, have indicated that a lack of knowledge about regulations poses serious risks. There is widespread concern that taking the wrong step could have irreversible consequences for both students and themselves. “What is the official aspect of the matter? That is, our knowledge of the laws is insufficient, but our responsibility is great…” (Muharrem, 48, administrator) In this climate of uncertainty, some administrators have been observed to interpret disciplinary rules as tools rather than a protective framework. This not only makes it difficult for students to access support mechanisms but also leads to their expulsion from school. “When you learn that a child is using drugs, you cannot keep that child in school. To protect the other students, the child who uses drugs must be expelled from school according to the Disciplinary Regulations.” (Süha, 39, administrator) Theme 3: Ethical Violations Committed by Institutions and Individuals One of the striking findings of this study is the identification of unethical practices commonly observed in some institutions during intervention processes. These violations are not limited to individual errors. The violations lead to ethical problems in the functioning of institutional structures. One ethical violation in educational institutions is the failure to implement institutional regulations and procedures. Regulations are created to govern the institution's operations and ensure that everyone is treated fairly. In some cases, personal relationships, family ties, or individual interests can override regulations. “Our behavior doesn’t align with the regulations. In small towns, family relationships override regulations. Instead of calling the police first, as is the procedure, we call the parents first.” (Muharrem – administrator – 48) Ethical issues can also arise in the student guidance and counseling process. Teachers or counselors may shirk responsibility instead of helping students. “When I identified students having problems in the classroom, I used to refer them to the guidance counselor. But I don’t do that anymore. Because the guidance counselor’s approach is: ‘Don’t cause me any problems!’” (Dilara, 40, teacher) One of the institutions where ethical violations are most common is the police force. Police are obligated to consider students' rights and privacy and to avoid practices that negatively impact them. According to regulations, police officers should not draw attention to themselves or endanger students when removing them from school. However, instead of protecting students, the police may focus on finding criminals. Thus, by overlooking certain details, they endanger students and stigmatize them. Some participants noted that security forces associate students with crime instead of protecting them, and that some students have been mistreated by certain security personnel. “Security forces are trying to use these students as informants for drug traffickers.” (Sergen, 33, counselor) “When we report a child to the police, police teams come to the school in official vehicles and uniforms and start walking around the school corridors with their radios, which attracts the attention of all the students. Then the children wonder why the police are at the school. Later, the students tell their families, and their families also start questioning why the police are at the school. Thus, the child in question is exposed.” (Batuhan, 35, counselor) “A narcotics police officer explained the effects and methods of drug use to our students to raise awareness. That year, there was an increase in drug use rates at our school. Later, we heard that this police officer was arrested for drug trafficking.” (Tahsin, 46, teacher) Healthcare professionals are legally obligated to report cases they encounter to the relevant authorities. However, sometimes, even with good intentions, such as protecting the child, healthcare professionals fail to follow procedures that prioritize the child's best interests. “I took a student who had fainted to the hospital. After the doctor did a blood test, he said, ‘There’s something I need to tell you, but I don’t want you to report it right away. The child has been using drugs.’ So we had to call his family.” (Tahsin, 46, teacher) Theme 4: Concerns About School Stigma It is important for teachers to relay information they receive from students to the school administration to ensure student needs are met and a safe learning environment is created. However, in some cases, school administrators prioritize the school's reputation over concerns about school stigma. This leads to students' well-being being relegated to second place. For example, a teacher reporting a serious problem, such as a student's substance abuse, might be met with advice like, "Close the subject, they'll graduate anyway." This can lead educators to hesitate to act ethically and sacrifice the possibility of saving the child from substance abuse for the sake of the school's reputation. “A female student came to me and confessed that she used drugs. I reported it to the school administration. The girl was a senior. The school administrator told me, ‘Close the subject, they’re graduating this year anyway.’ I was shocked to hear that from the school administrator.” (Dilara, 40, teacher) “There’s a fear that a problem at school becoming public will damage the school. They say, ‘Oh, let no one know, the school will be harmed.’” (Özkan, 31, counselor) School administrators, concerned about significant issues like substance abuse among students becoming public knowledge at the school, may pressure families to withdraw their children. “The school administration, fearing the spread of substance abuse and the stigma surrounding the school, forced the family to withdraw the child. In doing so, they essentially sacrificed the child who was using substances.” (Ali, 36, counselor) The idea that school administrators shouldn't be concerned with students' behavior outside of school is also ethically debatable. School administrators who focus solely on students' behavior inside school may hinder the fulfillment of students' complementary needs. Students' lives outside of school can also affect the educational process. However, some school administrators have explicitly stated that they are not concerned with students' lives outside of school. “What matters to us is whether the child is using or selling something at school. We are not concerned with the child's life outside of school. If the child exhibits these behaviors at school, then we will do whatever is necessary.” (Tolga, 34, Counselor) Theme 5: Parents' Concerns The final theme reveals the intense concerns and resistance of parents to intervention processes. Creating a healthy environment for students' education and development in educational institutions is a shared responsibility of educators and families. However, as seen in the statements below, some parents' concerns regarding educational institutions emerge. Regarding child protection, families may worry that school administrations are not sufficiently sensitive. They fear that teachers' and administrators' insensitivity will lead to the stigmatization of students. “When we informed the family that the student was using drugs, they reacted as if we were declaring their child guilty.” (Metin, 36, Counselor) “In some cases, we see that the family is aware of the child's addiction. But they still keep it a secret because they don't want the child to be stigmatized by relatives and neighbors.” (Tolga, 34, administrator) “Even a small rumor about the child greatly disturbs the family. Because they think that both the child and they themselves will be stigmatized and therefore ostracized from society. They put a lot of pressure on us to cover up the incident.” (Mehmet, 42, administrator) Families' concern that their children will be reported to official institutions by the school administration stems from the fear that this will negatively affect their children's criminal records. Some families prefer to resolve matters privately, believing that official notifications could harm their children. “The school and its administrators are in a more vulnerable position. The family should know that procedural processes are the responsibility of the school administration. The family doesn't want anyone to know about their child's situation; they think they can handle it internally.” (Muharrem, 48, administrator) “We first contact the family. Because families say, ‘If the information is given to official institutions, we will say that our child has been slandered.’ The family knows that any official notification will be recorded on the child's criminal record.” (Sergen, 33, counselor) It has been reported that some families, despite being aware of their children's substance use, try to conceal the situation and even pressure school administration to cover up cases. In more serious cases, risks such as threats and hostility arise. “When we submit a legal report, our names are also included in court records, and when the child's family sees the file, they perceive us as those who reported the child, hold us responsible, and harbor hostility towards us. Therefore, teachers don't report cases to avoid taking risks.” (Kazım, 33, administrator) “Some children's families threaten us and the school administration. In such cases, we report the family to the police.” (Eda, 35, teacher) These findings demonstrate that school-based interventions for students using substances are too complex to be solved by individual efforts. Lack of information, institutional uncertainty, ethical issues, fear of stigma, and family pressure create interconnected structures that hinder the intervention process. 5 Discussion The findings of this study reveal that school-based interventions for high school students who use substances are too complex to be evaluated solely within the framework of individual professional competencies. Multifaceted factors, including educators' experiences, lack of knowledge and experience, ambiguity in institutional procedures, ethical violations, fear of stigma, and parental resistance, directly shape intervention processes. When considered alongside the ecological systems, stigma, care ethics, and institutional theory frameworks presented at the beginning of the study, these findings offer important clues as to why school-based interventions are often ineffective. Firstly, the lack of knowledge and experience among educators in identifying and intervening with students using substances aligns with a problem frequently highlighted in the literature. International studies show that teachers and school administrators are not adequately equipped to recognize the signs of substance use, leading to missed opportunities for early intervention (Fisher, 2019 ; Godley, 2006 ). Similarly, this study shows that behavioral changes in students are often normalized by associating them with adolescence. From an ecological systems theory perspective, this indicates a weakened capacity of the school micro-system to recognize and transform risky student behaviors. Psychological counselors' statements indicate that the theoretical knowledge acquired during professional training is insufficient to address complex, multifaceted cases in the field. This finding parallels studies showing that substance use is generally treated as a secondary topic in teacher and counselor training (S. Das & Roberts, 2016 ). The ineffectiveness of mandatory training modules in practice indicates that institutional structures keep professional development at a formal level rather than supporting it. One of the study's striking findings is that the ambiguity and complexity of institutional procedures hinder intervention processes. Educators reported being unsure when and what steps to take when encountering a student using substances. From an institutional theory perspective, this uncertainty leads individuals to resort to informal and personal solutions. Due to the lack of a clear roadmap, educators either shirk responsibility or make decisions whose legal consequences they cannot foresee. This demonstrates that the system is focused on maintaining its own functioning rather than protecting students. The theme of ethical violations reveals that not only individual errors but also institutional structures create ethical problems in intervention processes. Experiences across law enforcement and healthcare institutions show that students' rights and privacy are not adequately protected. When evaluated within the context of stigma theory, public shaming of students in the school environment leads to them being labeled as "substance abusers," and this label becomes permanent. This is a serious problem that can lead to students disengaging from the educational process and reinforcing risky behaviors (Blyth et al., 2023 ). The perspective of care ethics offers an important framework for understanding educators' ethical dilemmas (Henrich et al., 2010 ). Educators, while wanting to protect and support their students, are caught between legal reporting obligations, family pressure, and concerns about personal safety. This tension indicates that care-based approaches are not adequately supported at the institutional level. The reluctance of educators to report cases for fear of "getting into trouble" shows that care ethics remain at the individual level and are not adopted by the system. Concerns about school stigma are one of the most striking findings of this study. The prioritization of institutional reputation over student needs by school administrations demonstrates that stigma is not only an individual-level process but also an institutional one. This finding is consistent with studies conducted in different countries (Stahl et al., 2023 ). The social pressure created by associating the school's name with substance abuse leads administrators to downplay the problems. This weakens the school's protective and preventive role, making students more vulnerable. Parental resistance to intervention processes is also an important finding that needs to be addressed within the framework of ecological systems theory. Families may avoid cooperating with schools and other institutions for fear that their children will be stigmatized and that official records will negatively affect their future. This leads to dysfunction in the family-school mesosystem and limits the student's access to support mechanisms. Furthermore, pressure and threats from families on educators push the professional boundaries of teachers and administrators, further complicating intervention processes. 6 Conclusion This study reveals that school-based interventions for middle school students using substances represent a complex, multifaceted, and structural problem that cannot be explained solely by individual professional competencies. The findings demonstrate that educators face interconnected problem areas in intervention processes, including a lack of knowledge and experience, procedural ambiguity, institutional ethical breaches, fear of stigma, and parental pressure. This underscores that the school is not merely a place of education but also a critical institutional space where care, supervision, law, health, and social norms intersect. The research shows that educators are often caught between care-based ethical responsibilities that prioritize the student's well-being and concerns about legislation, discipline, institutional reputation, and personal safety. Stigma, particularly in smaller communities, has been found to become a collective pressure mechanism encompassing not only the student but also the family and the school. Consequently, effective school-based interventions require more than just awareness training; they necessitate clear procedures, inter-agency coordination, ethical safeguards, confidentiality practices, and trust-based collaboration with families. In this context, the study strongly argues that school-based policies on substance use should be restructured to adopt an inclusive, protective, and care-oriented approach rather than a punitive one. Limitations and Suggestions for Further Research This study has several limitations that should be considered when interpreting the findings. First, the research was conducted in a single province (Bingöl), which may limit the generalizability of the results to other regions with different socio-cultural and institutional contexts. The unique characteristics of the research setting, including strong social ties and stigma dynamics, may have influenced participants’ responses and experiences. Second, the study is based on qualitative data obtained through self-reports of participants. Therefore, the findings may be affected by recall bias, social desirability bias, or participants’ selective reporting of experiences. Some participants may have refrained from fully disclosing sensitive information due to the ethical and institutional nature of the topic. Third, the study focuses solely on the perspectives of educators, including teachers, psychological counselors, and school administrators. The absence of student and parent perspectives limits a more comprehensive understanding of the phenomenon and the interaction between different actors involved in the intervention process. Although thematic analysis allowed for an in-depth exploration of participants’ experiences, the findings are inherently interpretive and context-dependent. Future studies may benefit from combining qualitative and quantitative approaches or conducting comparative research across different regions and school types to enhance the robustness and transferability of the findings. Declarations a. Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval certificate number 33117789/044/88964 was obtained from the Bingöl University Ethics Committee on 03.01.2023, and the governorship approval number E-48605746-44-69567660 was obtained from the Provincial Directorate of National Education on 31.03.2023. Written informed consent was obtained from all participants prior to data collection. Furthermore, all participants explicitly consented to the publication of direct quotations, provided that their identities remain confidential. In the findings section, the names of the interviewees have been changed for ethical reasons to avoid disclosing their identities and genders when using their data. b. Consent for publication Participants are reluctant to share their data because they are concerned about their identities being revealed. c. Data Accessibility The datasets created and/or analyzed in this study are not publicly available. Participants, all public employees, agreed to participate in the interviews on the condition that their data would not be shared with anyone for reasons of professional and personal safety. However, data may be obtained from the relevant author upon reasonable request. d. Competing interests The authors declare that they have no conflict of interest. e. Funding The authors have not received any financial support for the research, authorship, and/or publication of this article. f. Authors' contributions The author solely conceived the study, designed the research, conducted data collection and analysis, and wrote and approved the final version of the manuscript. g. Clinical Study Number Not applicable. References Allen, K.-A., Vella-Brodrick, D., & Waters, L. (2016). Fostering School Belonging in Secondary Schools Using a Socio-Ecological Framework. The Educational and Developmental Psychologist , 33 (1), 97–121. https://doi.org/10.1017/edp.2016.5 Anadolu Ajansı. (2022). Bingöl’de 1 milyon 45 bin 720 kök Hint keneviri ele geçirildi . Anadolu Ajansı. https://www.aa.com.tr/tr/gundem/bingolde-1-milyon-45-bin-720-kok-hint-keneviri-ele-gecirildi/2659339 Avcı, M. (2025). Adolescents’ experiences with substance use: Risks, protective factors and interventions. 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H., Tinkasimile, A., Mapendo, F., Anthony, W., Irema, I., Lyatuu, I. W., Sando, D., Nyundo, A., Ismail, A., Mtenga, J. E., Mwaitete, N. L., Marero, A., Hussein, A., Tibenderana, J. R., Mchome, A. S., … Fawzi, W. (2025). Determinants of substance use among adolescents aged 10-19 years in Tanga Region, Eastern Tanzania: A cross-sectional analysis. PLOS Global Public Health , 5 (7), e0004150. https://doi.org/10.1371/journal.pgph.0004150 Kipkurui, N., Owidi, E., Ayieko, J., Owuor, G., Mugenya, I., Agot, K., & Roxby, A. C. (2023). Navigating antiretroviral adherence in boarding secondary schools in Nairobi, Kenya: A qualitative study of adolescents living with HIV, their caregivers and school nurses. PLOS Global Public Health , 3 (9), e0002418. https://doi.org/10.1371/journal.pgph.0002418 Leahy, D., Schaffalitzky, E., Armstrong, C., Latham, L., McNicholas, F., Meagher, D., Nathan, Y., O’Connor, R., O’Keane, V., Ryan, P., Smyth, B. P., Swan, D., & Cullen, W. (2015). How social context impacts on the development, identification and treatment of mental and substance use disorders among young people—A qualitative study of health care workers. Irish Journal of Psychological Medicine , 32 (1), 117–128. https://doi.org/10.1017/ipm.2014.70 Lemert, E. M. (with Internet Archive). (1972). Human deviance, social problems, and social control . Englewood Cliffs, N.J., Prentice-Hall. http://archive.org/details/humandeviancesoc0000leme Lopez-Soto, A., Ramirez, E., Cordoba, J., & Montero-Zamora, P. (2025). Substance use risk screening and associated factors among Costa Rican secondary students: A nationally representative analysis. Frontiers in Public Health , 13 , 1652601. https://doi.org/10.3389/fpubh.2025.1652601 Maduka, N. (2016). Benefits of Early Intervention in the Prevention of Substance Abuse: The Case Study of In–School Awareness Programmes in Enugu State. Science Journal of Public Health , 4 (5), 1–6. https://doi.org/10.11648/j.sjph.s.2016040501.11 McCabe, S. E., Veliz, P., & Boyd, C. J. (2016). Early Exposure to Stimulant Medications and Substance-Related Problems: The Role of Medical and Nonmedical Contexts. Drug and Alcohol Dependence , 163 , 55–63. https://doi.org/10.1016/j.drugalcdep.2016.03.019 Mushamiri, S. P. (2021). Teachers’ knowledge on drug policy within secondary schools in Johannesburg, South Africa [Master of Arts (MA), University of Johannesburg]. https://ujcontent.uj.ac.za/esploro/outputs/graduate/Teachers-knowledge-on-drug-policy-within/9910971007691 Myhr, A., Vesterbekkmo, R. K., Samarawickrema, I., & Sund, E. R. (2024). Trends in Norwegian adolescents’ substance use between 2014 and 2022: Socioeconomic and gender differences. BMC Public Health , 24 , 2482. https://doi.org/10.1186/s12889-024-19983-9 Nath, A., Choudhari, S. G., Dakhode, S. U., Rannaware, A., & Gaidhane, A. M. (2022). Substance Abuse Amongst Adolescents: An Issue of Public Health Significance. Cureus , 14 (11), e31193. https://doi.org/10.7759/cureus.31193 Neal, J. W., & Neal, Z. P. (2013). Nested or Networked? Future Directions for Ecological Systems Theory. Social Development , 22 (4), 722–737. https://doi.org/10.1111/sode.12018 Ninkron, P., Yau, S., Khuntiterakul, P., & Nakamadee, B. (2021). Substance use and related risk behaviors among junior high school students in Nakhon Pathom province, Thailand. Journal of Health Research , 36 (2), 345–353. https://doi.org/10.1108/JHR-05-2020-0137 Obadeji, A., Kumolalo, B. F., Oluwole, L. O., Ajiboye, A. S., Dada, M. U., & Ebeyi, R. C. (2020). Substance Use among Adolescent High School Students in Nigeria and Its Relationship with Psychosocial Factors. Journal of Research in Health Sciences , 20 (2), e00480. https://doi.org/10.34172/jrhs.2020.15 Poonam, P. (2025). The role of Education in Preventing Substance Abuse During Adolescence. International Journal of Physical Education & Sports Sciences , 20 (1), 13–17. https://doi.org/10.29070/6fwen390 Pulla, V., & Carter, E. (2018). Employing Interpretivism in Social Work Research. International Journal of Social Work and Human Services Practice , 6 , 9–14. https://doi.org/10.13189/ijrh.2018.060102 Sandhu, S. (2018). Neo-Institutional Theory. In The International Encyclopedia of Strategic Communication (pp. 1–15). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781119010722.iesc0116 Semwal, J., Deepshikha, Vallabh, V., Uniyal, A., Shrivastava, A., Bijalwan, R., & Nagrath, D. (2025). Substance abuse among Adolescents and Youth (10–24 years): Assessing the prevalence and risk assessment in the suburban areas of Dehradun District, Uttarakhand. Journal of Family Medicine and Primary Care , 14 (3), 954–962. https://doi.org/10.4103/jfmpc.jfmpc_1260_24 Senanayake, S., Gunawardena, S., Kumbukage, M., Wickramasnghe, C., Gunawardena, N., Lokubalasooriya, A., & Peiris, R. (2018). Smoking, Alcohol Consumption, and Illegal Substance Abuse among Adolescents in Sri Lanka: Results from Sri Lankan Global School-Based Health Survey 2016. Advances in Public Health , 2018 (1), 9724176. https://doi.org/10.1155/2018/9724176 Stahl, G., Baak, M., Schulz, S., & Peterson, A. (2023). A cautionary tale: CVE policy actors managing risk in Australian schools. Current Sociology , 71 (5), 905–923. https://doi.org/10.1177/00113921211028631 T.C.Bingöl Valiliği. (2021). Genç İlçesi Kırsalında 225 Bin Kök Kenevir Bitkisi ve 95 Kg Kubar Esrar Ele Geçirildi . https://www.bingol.gov.tr/genc-ilcesi-kirsalinda-225-bin-kok-kenevir-bitkisi-ve-95-kg-kubar-esrar-ele-gecirildi Topkaya, N., Şahin, E., Krettmann, A. K., & Essau, C. A. (2021). Stigmatization of people with alcohol and drug addiction among Turkish undergraduate students. Addictive Behaviors Reports , 14 , 100386. https://doi.org/10.1016/j.abrep.2021.100386 Webb, J., Khoury, T., & Hitt, M. (2019). The Influence of Formal and Informal Institutional Voids on Entrepreneurship. Entrepreneurship Theory and Practice . https://doi.org/10.1177/1042258719830310 Additional Declarations No competing interests reported. Supplementary Files InterviewForms.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 24 Mar, 2026 Submission checks completed at journal 23 Mar, 2026 First submitted to journal 23 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9105573","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626329703,"identity":"79b3eaa7-18ae-46ff-99ed-75d99fa97a7e","order_by":0,"name":"Mehmet Seyman Önder","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYHACAxiD8QGQ4OEjRQsziMXDRooWNgkwSUg9v3TzxscVf2wS17afPVb5NcdOho2B+eGjG3i0SM45Vmx4ti0tcduZvLTbstuSgQ5jMzbOweeqGzlmko0NhxO3Hcgxuy25jRmohYdNmoAW858Nf/4nbjv/xqxYcls9UVrMGBvYDiRuAzE+bjtMWIvkjLRiyca2ZONtN94YSzNuO87DxkzAL/wSyRs/Nvyxk912Psfw489t1fb87M0PH+PTAgOODUCCmQfEZCZCOQjYgwjGH0SqHgWjYBSMgpEFAEuNSblcvWvzAAAAAElFTkSuQmCC","orcid":"","institution":"Bingöl University","correspondingAuthor":true,"prefix":"","firstName":"Mehmet","middleName":"Seyman","lastName":"Önder","suffix":""}],"badges":[],"createdAt":"2026-03-12 13:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9105573/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9105573/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107869319,"identity":"f180117e-457d-41fd-bf19-1753a155eaa3","added_by":"auto","created_at":"2026-04-27 07:36:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":307867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9105573/v1/18ee680f-b035-4145-9a08-711764fbe869.pdf"},{"id":107558983,"identity":"894778a0-82be-4542-a7f1-40fc936915d1","added_by":"auto","created_at":"2026-04-22 15:37:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15962,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewForms.docx","url":"https://assets-eu.researchsquare.com/files/rs-9105573/v1/d6cf939d65e0cb0537e58196.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Between Care and Supervision: Ethical Dilemmas, Institutional Gaps, and Stigma Dynamics in School-Based Substance Use Interventions","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eIndividuals experience rapid biological, psychological, and social changes during adolescence. Adolescence is a critical period of intense stress. Risk-taking behaviors and vulnerability to environmental influences increase further during this period. Substance use during adolescence goes beyond being an individual problem and becomes a significant public health issue with negative consequences for the education system and social structure (Avcı, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; P. Das et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Nath et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies in this area show that the age at which high school students begin substance use is steadily decreasing. Consequently, the risk of exposure to substance use among school-aged individuals is also increasing (Kessy et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lopez-Soto et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Myhr et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ninkron et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Obadeji et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Therefore, it is of great importance that protective and preventive interventions within the scope of substance abuse begin in schools.\u003c/p\u003e \u003cp\u003eSchools, which hold a central position in adolescents' lives, are the institutional structures where behavioral changes in students are first observed. Therefore, teachers, psychological counselors, and school administrators play a crucial role in the early identification, referral, and intervention of students who use substances or are at risk. School-based interventions are of great importance in maintaining students' academic success, supporting their psychosocial well-being, and preventing students from becoming substance abusers (Fisher, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Maduka, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Poonam, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, in the literature, these interventions are mostly evaluated with statistical data. Scientific studies do not adequately address educators' experiences, the ethical dilemmas they face, and the institutional obstacles they encounter. Furthermore, school-based studies on substance use are largely student-centered; The experience of educators appears to be of secondary importance (Kessy et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lopez-Soto et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; McCabe et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Myhr et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ninkron et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Obadeji et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Semwal et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Senanayake et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Because educators are often viewed solely as observers or guides, the fact that they are also professionals who must navigate legal responsibilities, ethical obligations, institutional procedures, and societal pressures is largely overlooked. They face significant dilemmas, particularly when dealing with a student who uses substances. Educators sometimes find themselves caught between \"protecting the student\" and \"making a legal report,\" \"ethical responsibility\" and \"institutional reputation,\" or \"professional duty\" and \"personal safety.\" These kinds of conflicts naturally make intervention processes complex and fragile.\u003c/p\u003e \u003cp\u003eIn the Turkish context, socioeconomic inequalities, regional risk factors, and cultural dynamics are among the factors that trigger substance use among adolescents. However, more intense and complex cases may be encountered in schools in regions where substance production and accessibility are higher. In this framework, Bing\u0026ouml;l, located in Eastern T\u0026uuml;rkiye, where cannabis production is widespread and access is relatively easy (Anadolu Ajansı, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bing\u0026ouml;l İl Jandarma Komutanlığı, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; T.C.Bing\u0026ouml;l Valiliği, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), offers a unique research area for understanding how school-based interventions are shaped. In such small settlements, the intertwined nature of social relationships, the strength of family ties, and the fear of stigma directly influence educators' intervention processes.\u003c/p\u003e \u003cp\u003eProcesses related to students using substances are conducted on an individual basis. However, in substance abuse intervention processes, institutional and systemic problems arise in addition to individual problems. Insufficient knowledge or procedural ambiguity regarding legal processes among educators (Fisher, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), lack of inter-institutional coordination (Harris et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), and, in some cases, ethical violations (Mushamiri, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) can make it difficult for students to access the social and psychological support mechanisms they need. Furthermore, concerns about stigma surrounding the school or the child among school administrators and parents (Gronholm et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) can lead to cases being ignored or delayed. This situation poses serious risks to the protection and rehabilitation of students using substances.\u003c/p\u003e \u003cp\u003eThe main objective of this study is to examine in depth the experiences of educators who intervene with high school students who use substances across the identification, intervention, and follow-up processes. This will reveal knowledge gaps, ethical dilemmas, institutional barriers, and stigma encountered in intervention processes.\u003c/p\u003e \u003cp\u003eTo highlight the multi-actor nature of school-based interventions, this study aims to examine the experiences and approaches of classroom teachers, psychological counselors, and school administrators together. The research also aims to shed light on the interactions among the education system, legal, health, and safety institutions, and individual practices in the context of substance abuse intervention processes.\u003c/p\u003e \u003cp\u003eIn this context, the research seeks to answer the following questions:\u003c/p\u003e \u003cp\u003eWhat kinds of experiences have educators had when encountering students who use substances?\u003c/p\u003e \u003cp\u003eHow do institutional procedures and legal obligations affect educators' intervention processes with students who use substances?\u003c/p\u003e \u003cp\u003eWhat role do fear of stigma and family pressure play in educators' decision-making processes?\u003c/p\u003e \u003cp\u003eIt is hoped that the data obtained in this study will contribute to strengthening school-based interventions, developing ethical and protective practices, and providing policymakers with insights.\u003c/p\u003e"},{"header":"2 Theoretical Framework","content":"\u003cp\u003eUnderstanding school-based interventions for adolescents who use substances requires more than focusing solely on individual behaviors. A broader perspective is needed that considers the multifaceted social, institutional, and cultural contexts in which students are situated. This study employs multiple complementary theoretical approaches rather than adhering to a single theoretical perspective when interpreting educators' experiences. In this context, the research draws upon the frameworks of Ecological Systems Theory, Stigma Theory, Care Ethics, and Institutional Theory.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Ecological Systems Theory and School-Based Interventions\u003c/h2\u003e \u003cp\u003eEcological Systems Theory argues that it is incorrect to explain an individual's development solely in terms of personal characteristics. In this context, it advocates a holistic approach that considers all environmental systems with which the individual interacts in order to explain the individual. According to this theory, an individual's behavior is influenced by the reciprocal interactions among systems at the micro, meso, exo, and macro levels in which the individual is situated (Crawford, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Neal \u0026amp; Neal, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). It is insufficient to evaluate substance use in adolescents solely as pathological or to explain it as individual choice. According to this theory, substance use is a phenomenon that must be considered alongside family relationships, the school environment, peer groups, the structure of local communities, and societal norms (El Kazdouh et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Leahy et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSchools are among the microsystems that play a crucial role in a student's development and change (Leahy et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Educators spend as much time with students as parents do and have the opportunity to closely observe students' behavioral and emotional changes (Allen et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, other systems also influence this micro-system. These include: at the meso level, family-school interaction; at the exo level, health, judicial, and security institutions; and at the macro level, cultural values, laws, and social norms.\u003c/p\u003e \u003cp\u003eInterventions concerning students who use substances are not limited to school-based practices. Inter-institutional relationships and societal expectations also influence the method and success of interventions. Therefore, in some cases, educators may need to consider not only students' needs but also family reactions, concerns about the school's reputation, legal obligations, and social relationships in the intervention process. In this context, ecological systems theory provides a functional framework for understanding the multifaceted pressures and decision-making processes educators face.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Stigma Theory and Substance-Using Students\u003c/h2\u003e \u003cp\u003eStigma theory focuses on the marginalization and labeling of individuals by groups, communities, or societies due to certain behaviors or characteristics, and attempts to explain the negative effects of this labeling on both the individual and the relationship between the individual and society (Crewe \u0026amp; Guyot-Diangone, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdolescents who use substances face the risk of stigmatization. This is because substance use is seen as both a health-related risky behavior and a deviant behavior that violates societal moral and legal norms. Therefore, students who use substances are often labeled as \"criminals,\" \"dangerous,\" or \"problematic\" individuals by both their social and academic environments. These labels negatively impact students' academic careers, social relationships, and future prospects (Demir et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Topkaya et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStigma in schools typically manifests in stages such as primary deviance and secondary deviance (Lemert, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1972\u003c/span\u003e). This process transforms schools into institutional spaces where stigma is produced. It accelerates the spread of a student's substance use behavior among teachers, school administrators, peers, and family, increasing the risk of exclusion.\u003c/p\u003e \u003cp\u003eThis situation places educators in an ethically contradictory position. Educators, who have a responsibility to support and protect students, may worry that a formal report of a student's substance use will stigmatize the student or the school. Because of this concern, intervention processes may be delayed, or the student's behavior may be ignored (Caballero et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Kipkurui et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe themes of \"concern about school stigma\" and \"parental concern about damage to family reputation\" that emerged in this study demonstrate that stigma is not solely an individual phenomenon. It can also be experienced in layered ways at the institutional and societal levels. In this case, some educators may prioritize protecting the school's or family's image over the student's well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Care Ethics and Ethical Dilemmas for Educators\u003c/h2\u003e \u003cp\u003eCare ethics focuses on empathy, responsibility, sensitivity, and interdependence in interpersonal relationships. According to this approach, ethical decisions cannot be based solely on abstract principles; these decisions must be shaped by relational contexts and the concrete needs of individuals.\u003c/p\u003e \u003cp\u003eFrom this perspective, the relationships that teachers and other school staff establish with students should not be based solely on rules and procedures. Attitudes and behaviors towards students should be shaped by a holistic approach that considers the student's academic, psychological, and social well-being (Chen \u0026amp; Shih, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Within this framework, educators become not only providers of academic knowledge but also actors with ethical sensitivity to students' vulnerabilities.\u003c/p\u003e \u003cp\u003eWhen dealing with students who use substances, educators often face a tension stemming from the dilemma between care ethics and legal and institutional obligations. Educators who wish to protect the student, keep them away from stigmatizing and punitive processes, and provide a supportive environment are also confronted with mandatory reporting, disciplinary regulations, and institutional responsibilities. Caught in an ethical impasse, educators are torn between acting on care-based values and complying with regulations (Erdogan \u0026amp; Sezgin, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Geiderman \u0026amp; Marco, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In some cases, they may even have to assume professional and legal risks while prioritizing the student's well-being.\u003c/p\u003e \u003cp\u003eEthical violations don't stem solely from individual insensitivity or professional incompetence. Inadequate institutional support for care ethics makes ethical violations visible. Educators' fear of \"getting into trouble,\" family pressures, and procedural uncertainties weaken the continuity of care-based interventions, making ethical decision-making processes even more fragile.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Institutional Theory and Bureaucratic Obstacles\u003c/h2\u003e \u003cp\u003eInstitutional theory is an approach that explains individuals' behavior within a professional group by considering the group's organizational structure, institutionalized norms, legal regulations, and established practices. According to this approach, institutions not only shape individual behavior through legal regulations but also provide a cognitive and normative framework for what should and should not be done. In this context, it is stated that institutions generally serve to restrict and direct individuals' scope of action (Farashahi et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Forgues et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Sandhu, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSchools, ministries of education, health institutions, law enforcement agencies, and judicial mechanisms should coordinate their efforts in school-based interventions for students who use substances. The lack of clearly defined authorities and responsibilities among these institutions leads to confusion in interventions, ultimately rendering them ineffective. Theoretically, this situation is referred to as an \"institutional void.\" In institutional gaps, individuals are unsure which rules and norms to follow or which procedures to apply. This uncertainty leads individuals to develop solutions through informal and personal initiatives (Webb et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis lack of coordination between institutions and the misguided actions of officials create risks for both the protection and professional and legal security of students. This risk undermines the trust that both students and some officials have in institutional structures, leading officials to exhibit behaviors such as \"avoiding responsibility,\" \"ignoring the issue,\" or \"delaying the process.\"\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Method","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Research Model\u003c/h2\u003e \u003cp\u003eThis study was designed as a qualitative study to examine the experiences, perceptions, and procedural and structural problems encountered by educators intervening with students who use substances. Thematic analysis was used to extract meaningful themes and patterns from the participants' narratives. The reason for choosing this method is that it enables a deeper understanding of participants' experiences and perceptions by systematically identifying themes and patterns in the data. This method is considered effective for revealing themes and for facilitating clear communication of the study's main findings and conclusions (Caballero et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study was conducted within the interpretive paradigm. According to the interpretive approach, social reality is constructed not only as an objective, singular construct but also through the experiences and meaning-making processes of individuals (Pulla \u0026amp; Carter, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In this context, the study aimed to understand how educators perceive situations when encountering students who use substances and how they assign meaning to these experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Research Context\u003c/h2\u003e \u003cp\u003eThe research was conducted in Bing\u0026ouml;l province, located in the Eastern Anatolia Region of T\u0026uuml;rkiye, which is considered one of the socio-economically disadvantaged regions. Bing\u0026ouml;l is known as one of the provinces where cannabis production and access to the substance are relatively more widespread and easier due to its geographical location and the prevalence of rural areas. This situation increases the risk factors for substance use, especially for adolescents.\u003c/p\u003e \u003cp\u003eBing\u0026ouml;l's social structure is characterized by strong intra-family ties in small settlements, a high level of social control, and widespread fear of stigma. This context leads educators to conduct intervention processes with students using substances under not only professional but also social and cultural pressures. Therefore, Bing\u0026ouml;l offers a unique research environment for examining the institutional and ethical dimensions of school-based interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Participants\u003c/h2\u003e \u003cp\u003e The study participants were 70 educators working in 14 high schools in Bing\u0026ouml;l province's city center. The study group comprised three professional groups: 28 classroom teachers, 28 psychological counselors, and 14 school administrators.\u003c/p\u003e \u003cp\u003eParticipants were selected using criterion sampling, a purposive sampling method. The participation criterion was that participants had directly encountered a student in their school who was using or at risk of using substances. This criterion aimed to ensure that participants had experience relevant to the research topic and to enrich the data. Participants' professional experience ranged from 5 to 25 years. This provided an opportunity to compare educators' perspectives at different seniority levels regarding intervention processes related to student substance use.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Data Collection\u003c/h2\u003e \u003cp\u003eIn this study, semi-structured in-depth interview forms, specifically designed for each occupational group, were used as data collection tools. In preparing the interview questions, the relevant literature was reviewed, including studies on substance use, school-based interventions, ethical dilemmas, and institutional processes.\u003c/p\u003e \u003cp\u003eDuring the development of the interview forms, opinions were sought from three academics who are experts in the field, and the questions were revised based on the feedback received. Subsequently, pilot interviews were conducted with a classroom teacher, a school counselor, and a school administrator. As a result of the pilot interviews, the clarity, scope, and depth of the questions were evaluated; necessary adjustments were made, and the interview forms were finalized.\u003c/p\u003e \u003cp\u003e Interviews were conducted in quiet environments at the schools where the participants worked, ensuring the confidentiality of the interviews. Interview durations averaged 25\u0026ndash;40 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Ethical Principles\u003c/h2\u003e \u003cp\u003e Ethical principles were strictly adhered to throughout the research process. Ethical approval was obtained from the Bing\u0026ouml;l University Ethics Committee before the start of the study; furthermore, the necessary permissions were obtained from the Provincial Directorate of National Education. Before the interviews, the research purpose, process, and principles of voluntary participation were explained in detail to the participants; written informed consent was obtained from those who agreed to participate in the study.\u003c/p\u003e \u003cp\u003eTo protect participants' anonymity, all participants were given pseudonyms; age and occupation information were presented in general terms. Direct quotations in the research report do not contain any information that could lead to the identification of participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data Analysis\u003c/h2\u003e \u003cp\u003eThe data obtained in the research were analyzed using thematic analysis. In the analysis process, the systematic steps of thematic analysis were followed. In the first stage, all interview recordings were read repeatedly to become familiar with the data and record initial impressions. In the second stage, the data were coded into meaningful units, and open codes were created. In the third stage, similar codes were grouped together to create potential themes. In the fourth stage, the themes were reviewed; their compatibility with the entire dataset was evaluated, and a thematic map was created. In the final stage, the themes were identified, named, and reported.\u003c/p\u003e \u003cp\u003e To increase the reliability of the analysis, the coding and theme-generation process was reviewed multiple times, and care was taken to support the themes with direct citations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Thematic Map\u003c/h2\u003e \u003cp\u003eThis study includes 3 groups, and data were collected separately from each group. Themes were created from the collected data and distributed according to the groups. 5 themes were obtained from school administrators, 4 from school counselors, and 3 from classroom teachers, and these were compiled into a map. The map is shown below.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Findings","content":"\u003cp\u003eData from in-depth interviews conducted as part of this study were analyzed and grouped into five main themes that highlight the multifaceted challenges educators face when intervening with students who use substances. These themes emphasize the commonalities and differences in the experiences of teachers, counselors, and school administrators. The findings demonstrate that intervention processes are not limited to individual knowledge and experience; they are also shaped by systemic factors such as institutional structures, ethical dilemmas, fear of stigma, and family pressure.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Lack of Knowledge and Experience\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants' statements reveal that some classroom teachers, school counselors, and administrators lack sufficient knowledge and experience in identifying and intervening with students using substances. This lack of knowledge and experience can make it difficult to implement appropriate interventions and prevent students from receiving the necessary support when substance use is detected.\u003c/p\u003e \u003cp\u003eIn particular, it has been observed that classroom teachers and some school administrators frequently interpret changes in students as 'adolescent problems,' 'discipline problems,' or 'academic failure.' This hinders the early diagnosis of substance use.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Teachers don\u0026rsquo;t pay attention to students\u0026rsquo; behavior. Therefore, they don\u0026rsquo;t realize whether a student is using drugs because they don\u0026rsquo;t notice any changes in the student. Even if they do notice, they don\u0026rsquo;t know the reason and don\u0026rsquo;t question it.\u0026rdquo; (Ali, 40, Manager)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Teachers can\u0026rsquo;t tell which students are using drugs because they don\u0026rsquo;t know what symptoms drug users exhibit.\u0026rdquo; (Mustafa, 38, Counselor)\u003c/p\u003e \u003cp\u003eThe Ministry of National Education has prepared training modules for teachers on topics such as substance abuse and exploitation. However, some teachers tend to avoid these trainings.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The Ministry of National Education has prepared numerous training modules for educators, primarily on substance abuse and exploitation. Participation in these trainings is mandatory for teachers and administrators. However, many find ways to avoid them.\u0026rdquo; (\u0026Ouml;zkan, 31 Counselor)\u003c/p\u003e \u003cp\u003eSome teachers who encounter a student using drugs may not know what to do and may try to find an appropriate solution on their own. This can prevent correct and effective interventions and lead to the problem escalating.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Teachers and administrators who encounter a student using drugs, because they don't know what to do, try to implement what they think is the most appropriate solution.\u0026rdquo; (Birg\u0026uuml;l, 29, Counselor)\u003c/p\u003e \u003cp\u003eStudents in university psychology departments receive training in crisis intervention. Many universities include how to intervene with individuals using substances in their curricula or provide specialized training on this topic. However, some psychological counselors may neglect this training or be inadequate in putting theoretical knowledge into practice.\u003c/p\u003e \u003cp\u003e\u0026ldquo;As guidance counselors, we don\u0026rsquo;t frequently encounter students using substances. Therefore, we don\u0026rsquo;t have much experience in what we should do.\u0026rdquo; (Kaan, 36, Counselor)\u003c/p\u003e \u003cp\u003e\u0026ldquo;They taught us crisis intervention in our undergraduate education, but they didn\u0026rsquo;t provide any specific training on how to intervene with students using substances.\u0026rdquo; (Bahri, 34, Counselor)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Procedural Complexity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTeachers have an obligation to report students who use substances. However, some participants noted that there is no clear roadmap for when reporting should be done, leading to procedural complexity and thus preventing them from effectively addressing students' problems.\u003c/p\u003e \u003cp\u003eThe fact that two different school guidance counselors working at two different schools indicated different centers where the official notification should be made suggests confusion in the procedure.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When we identify a child using drugs, we have to report it to the Child Monitoring Center. We cannot initiate any action without their knowledge.\u0026rdquo; (Burcu, 32, Counselor)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When we encounter such a case, we first go to the Guidance and Research Center affiliated with the Provincial Directorate of National Education.\u0026rdquo; (Deniz, 37, Counselor)\u003c/p\u003e \u003cp\u003eSchool administrators, while aware of their legal responsibilities, have indicated that a lack of knowledge about regulations poses serious risks. There is widespread concern that taking the wrong step could have irreversible consequences for both students and themselves.\u003c/p\u003e \u003cp\u003e\u0026ldquo;What is the official aspect of the matter? That is, our knowledge of the laws is insufficient, but our responsibility is great\u0026hellip;\u0026rdquo; (Muharrem, 48, administrator)\u003c/p\u003e \u003cp\u003eIn this climate of uncertainty, some administrators have been observed to interpret disciplinary rules as tools rather than a protective framework. This not only makes it difficult for students to access support mechanisms but also leads to their expulsion from school.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When you learn that a child is using drugs, you cannot keep that child in school. To protect the other students, the child who uses drugs must be expelled from school according to the Disciplinary Regulations.\u0026rdquo; (S\u0026uuml;ha, 39, administrator)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3: Ethical Violations Committed by Institutions and Individuals\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOne of the striking findings of this study is the identification of unethical practices commonly observed in some institutions during intervention processes. These violations are not limited to individual errors. The violations lead to ethical problems in the functioning of institutional structures.\u003c/p\u003e \u003cp\u003eOne ethical violation in educational institutions is the failure to implement institutional regulations and procedures. Regulations are created to govern the institution's operations and ensure that everyone is treated fairly. In some cases, personal relationships, family ties, or individual interests can override regulations.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Our behavior doesn\u0026rsquo;t align with the regulations. In small towns, family relationships override regulations. Instead of calling the police first, as is the procedure, we call the parents first.\u0026rdquo; (Muharrem \u0026ndash; administrator \u0026ndash; 48)\u003c/p\u003e \u003cp\u003eEthical issues can also arise in the student guidance and counseling process. Teachers or counselors may shirk responsibility instead of helping students.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When I identified students having problems in the classroom, I used to refer them to the guidance counselor. But I don\u0026rsquo;t do that anymore. Because the guidance counselor\u0026rsquo;s approach is: \u0026lsquo;Don\u0026rsquo;t cause me any problems!\u0026rsquo;\u0026rdquo; (Dilara, 40, teacher)\u003c/p\u003e \u003cp\u003eOne of the institutions where ethical violations are most common is the police force. Police are obligated to consider students' rights and privacy and to avoid practices that negatively impact them. According to regulations, police officers should not draw attention to themselves or endanger students when removing them from school. However, instead of protecting students, the police may focus on finding criminals. Thus, by overlooking certain details, they endanger students and stigmatize them. Some participants noted that security forces associate students with crime instead of protecting them, and that some students have been mistreated by certain security personnel.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Security forces are trying to use these students as informants for drug traffickers.\u0026rdquo; (Sergen, 33, counselor)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When we report a child to the police, police teams come to the school in official vehicles and uniforms and start walking around the school corridors with their radios, which attracts the attention of all the students. Then the children wonder why the police are at the school. Later, the students tell their families, and their families also start questioning why the police are at the school. Thus, the child in question is exposed.\u0026rdquo; (Batuhan, 35, counselor)\u003c/p\u003e \u003cp\u003e\u0026ldquo;A narcotics police officer explained the effects and methods of drug use to our students to raise awareness. That year, there was an increase in drug use rates at our school. Later, we heard that this police officer was arrested for drug trafficking.\u0026rdquo; (Tahsin, 46, teacher)\u003c/p\u003e \u003cp\u003eHealthcare professionals are legally obligated to report cases they encounter to the relevant authorities. However, sometimes, even with good intentions, such as protecting the child, healthcare professionals fail to follow procedures that prioritize the child's best interests.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I took a student who had fainted to the hospital. After the doctor did a blood test, he said, \u0026lsquo;There\u0026rsquo;s something I need to tell you, but I don\u0026rsquo;t want you to report it right away. The child has been using drugs.\u0026rsquo; So we had to call his family.\u0026rdquo; (Tahsin, 46, teacher)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4: Concerns About School Stigma\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIt is important for teachers to relay information they receive from students to the school administration to ensure student needs are met and a safe learning environment is created. However, in some cases, school administrators prioritize the school's reputation over concerns about school stigma. This leads to students' well-being being relegated to second place.\u003c/p\u003e \u003cp\u003eFor example, a teacher reporting a serious problem, such as a student's substance abuse, might be met with advice like, \"Close the subject, they'll graduate anyway.\" This can lead educators to hesitate to act ethically and sacrifice the possibility of saving the child from substance abuse for the sake of the school's reputation.\u003c/p\u003e \u003cp\u003e\u0026ldquo;A female student came to me and confessed that she used drugs. I reported it to the school administration. The girl was a senior. The school administrator told me, \u0026lsquo;Close the subject, they\u0026rsquo;re graduating this year anyway.\u0026rsquo; I was shocked to hear that from the school administrator.\u0026rdquo; (Dilara, 40, teacher)\u003c/p\u003e \u003cp\u003e\u0026ldquo;There\u0026rsquo;s a fear that a problem at school becoming public will damage the school. They say, \u0026lsquo;Oh, let no one know, the school will be harmed.\u0026rsquo;\u0026rdquo; (\u0026Ouml;zkan, 31, counselor)\u003c/p\u003e \u003cp\u003eSchool administrators, concerned about significant issues like substance abuse among students becoming public knowledge at the school, may pressure families to withdraw their children.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The school administration, fearing the spread of substance abuse and the stigma surrounding the school, forced the family to withdraw the child. In doing so, they essentially sacrificed the child who was using substances.\u0026rdquo; (Ali, 36, counselor)\u003c/p\u003e \u003cp\u003eThe idea that school administrators shouldn't be concerned with students' behavior outside of school is also ethically debatable. School administrators who focus solely on students' behavior inside school may hinder the fulfillment of students' complementary needs. Students' lives outside of school can also affect the educational process. However, some school administrators have explicitly stated that they are not concerned with students' lives outside of school.\u003c/p\u003e \u003cp\u003e\u0026ldquo;What matters to us is whether the child is using or selling something at school. We are not concerned with the child's life outside of school. If the child exhibits these behaviors at school, then we will do whatever is necessary.\u0026rdquo; (Tolga, 34, Counselor)\u003c/p\u003e \u003cp\u003e\u003cb\u003e Theme 5: Parents' Concerns\u003c/b\u003e\u003c/p\u003e \u003cp\u003e The final theme reveals the intense concerns and resistance of parents to intervention processes.\u003c/p\u003e \u003cp\u003eCreating a healthy environment for students' education and development in educational institutions is a shared responsibility of educators and families. However, as seen in the statements below, some parents' concerns regarding educational institutions emerge. Regarding child protection, families may worry that school administrations are not sufficiently sensitive. They fear that teachers' and administrators' insensitivity will lead to the stigmatization of students.\u003c/p\u003e \u003cp\u003e\u0026ldquo;When we informed the family that the student was using drugs, they reacted as if we were declaring their child guilty.\u0026rdquo; (Metin, 36, Counselor)\u003c/p\u003e \u003cp\u003e\u0026ldquo;In some cases, we see that the family is aware of the child's addiction. But they still keep it a secret because they don't want the child to be stigmatized by relatives and neighbors.\u0026rdquo; (Tolga, 34, administrator)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Even a small rumor about the child greatly disturbs the family. Because they think that both the child and they themselves will be stigmatized and therefore ostracized from society. They put a lot of pressure on us to cover up the incident.\u0026rdquo; (Mehmet, 42, administrator)\u003c/p\u003e \u003cp\u003eFamilies' concern that their children will be reported to official institutions by the school administration stems from the fear that this will negatively affect their children's criminal records. Some families prefer to resolve matters privately, believing that official notifications could harm their children.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The school and its administrators are in a more vulnerable position. The family should know that procedural processes are the responsibility of the school administration. The family doesn't want anyone to know about their child's situation; they think they can handle it internally.\u0026rdquo; (Muharrem, 48, administrator)\u003c/p\u003e \u003cp\u003e\u0026ldquo;We first contact the family. Because families say, \u0026lsquo;If the information is given to official institutions, we will say that our child has been slandered.\u0026rsquo; The family knows that any official notification will be recorded on the child's criminal record.\u0026rdquo; (Sergen, 33, counselor)\u003c/p\u003e \u003cp\u003eIt has been reported that some families, despite being aware of their children's substance use, try to conceal the situation and even pressure school administration to cover up cases. In more serious cases, risks such as threats and hostility arise.\u003c/p\u003e \u003cp\u003e \u0026ldquo;When we submit a legal report, our names are also included in court records, and when the child's family sees the file, they perceive us as those who reported the child, hold us responsible, and harbor hostility towards us. Therefore, teachers don't report cases to avoid taking risks.\u0026rdquo; (Kazım, 33, administrator)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Some children's families threaten us and the school administration. In such cases, we report the family to the police.\u0026rdquo; (Eda, 35, teacher)\u003c/p\u003e \u003cp\u003eThese findings demonstrate that school-based interventions for students using substances are too complex to be solved by individual efforts. Lack of information, institutional uncertainty, ethical issues, fear of stigma, and family pressure create interconnected structures that hinder the intervention process.\u003c/p\u003e"},{"header":"5 Discussion","content":"\u003cp\u003eThe findings of this study reveal that school-based interventions for high school students who use substances are too complex to be evaluated solely within the framework of individual professional competencies. Multifaceted factors, including educators' experiences, lack of knowledge and experience, ambiguity in institutional procedures, ethical violations, fear of stigma, and parental resistance, directly shape intervention processes. When considered alongside the ecological systems, stigma, care ethics, and institutional theory frameworks presented at the beginning of the study, these findings offer important clues as to why school-based interventions are often ineffective.\u003c/p\u003e \u003cp\u003eFirstly, the lack of knowledge and experience among educators in identifying and intervening with students using substances aligns with a problem frequently highlighted in the literature. International studies show that teachers and school administrators are not adequately equipped to recognize the signs of substance use, leading to missed opportunities for early intervention (Fisher, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Godley, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Similarly, this study shows that behavioral changes in students are often normalized by associating them with adolescence. From an ecological systems theory perspective, this indicates a weakened capacity of the school micro-system to recognize and transform risky student behaviors.\u003c/p\u003e \u003cp\u003ePsychological counselors' statements indicate that the theoretical knowledge acquired during professional training is insufficient to address complex, multifaceted cases in the field. This finding parallels studies showing that substance use is generally treated as a secondary topic in teacher and counselor training (S. Das \u0026amp; Roberts, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The ineffectiveness of mandatory training modules in practice indicates that institutional structures keep professional development at a formal level rather than supporting it.\u003c/p\u003e \u003cp\u003eOne of the study's striking findings is that the ambiguity and complexity of institutional procedures hinder intervention processes. Educators reported being unsure when and what steps to take when encountering a student using substances. From an institutional theory perspective, this uncertainty leads individuals to resort to informal and personal solutions. Due to the lack of a clear roadmap, educators either shirk responsibility or make decisions whose legal consequences they cannot foresee. This demonstrates that the system is focused on maintaining its own functioning rather than protecting students.\u003c/p\u003e \u003cp\u003eThe theme of ethical violations reveals that not only individual errors but also institutional structures create ethical problems in intervention processes. Experiences across law enforcement and healthcare institutions show that students' rights and privacy are not adequately protected. When evaluated within the context of stigma theory, public shaming of students in the school environment leads to them being labeled as \"substance abusers,\" and this label becomes permanent. This is a serious problem that can lead to students disengaging from the educational process and reinforcing risky behaviors (Blyth et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe perspective of care ethics offers an important framework for understanding educators' ethical dilemmas (Henrich et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Educators, while wanting to protect and support their students, are caught between legal reporting obligations, family pressure, and concerns about personal safety. This tension indicates that care-based approaches are not adequately supported at the institutional level. The reluctance of educators to report cases for fear of \"getting into trouble\" shows that care ethics remain at the individual level and are not adopted by the system.\u003c/p\u003e \u003cp\u003eConcerns about school stigma are one of the most striking findings of this study. The prioritization of institutional reputation over student needs by school administrations demonstrates that stigma is not only an individual-level process but also an institutional one. This finding is consistent with studies conducted in different countries (Stahl et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The social pressure created by associating the school's name with substance abuse leads administrators to downplay the problems. This weakens the school's protective and preventive role, making students more vulnerable.\u003c/p\u003e \u003cp\u003eParental resistance to intervention processes is also an important finding that needs to be addressed within the framework of ecological systems theory. Families may avoid cooperating with schools and other institutions for fear that their children will be stigmatized and that official records will negatively affect their future. This leads to dysfunction in the family-school mesosystem and limits the student's access to support mechanisms. Furthermore, pressure and threats from families on educators push the professional boundaries of teachers and administrators, further complicating intervention processes.\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eThis study reveals that school-based interventions for middle school students using substances represent a complex, multifaceted, and structural problem that cannot be explained solely by individual professional competencies. The findings demonstrate that educators face interconnected problem areas in intervention processes, including a lack of knowledge and experience, procedural ambiguity, institutional ethical breaches, fear of stigma, and parental pressure. This underscores that the school is not merely a place of education but also a critical institutional space where care, supervision, law, health, and social norms intersect. The research shows that educators are often caught between care-based ethical responsibilities that prioritize the student's well-being and concerns about legislation, discipline, institutional reputation, and personal safety. Stigma, particularly in smaller communities, has been found to become a collective pressure mechanism encompassing not only the student but also the family and the school.\u003c/p\u003e \u003cp\u003eConsequently, effective school-based interventions require more than just awareness training; they necessitate clear procedures, inter-agency coordination, ethical safeguards, confidentiality practices, and trust-based collaboration with families. In this context, the study strongly argues that school-based policies on substance use should be restructured to adopt an inclusive, protective, and care-oriented approach rather than a punitive one.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and Suggestions for Further Research\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the research was conducted in a single province (Bing\u0026ouml;l), which may limit the generalizability of the results to other regions with different socio-cultural and institutional contexts. The unique characteristics of the research setting, including strong social ties and stigma dynamics, may have influenced participants\u0026rsquo; responses and experiences.\u003c/p\u003e \u003cp\u003eSecond, the study is based on qualitative data obtained through self-reports of participants. Therefore, the findings may be affected by recall bias, social desirability bias, or participants\u0026rsquo; selective reporting of experiences. Some participants may have refrained from fully disclosing sensitive information due to the ethical and institutional nature of the topic.\u003c/p\u003e \u003cp\u003eThird, the study focuses solely on the perspectives of educators, including teachers, psychological counselors, and school administrators. The absence of student and parent perspectives limits a more comprehensive understanding of the phenomenon and the interaction between different actors involved in the intervention process.\u003c/p\u003e \u003cp\u003eAlthough thematic analysis allowed for an in-depth exploration of participants\u0026rsquo; experiences, the findings are inherently interpretive and context-dependent. Future studies may benefit from combining qualitative and quantitative approaches or conducting comparative research across different regions and school types to enhance the robustness and transferability of the findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ea.\u0026nbsp; \u0026nbsp;Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval certificate number 33117789/044/88964 was obtained from the Bingöl University Ethics Committee on 03.01.2023, and the governorship approval number E-48605746-44-69567660 was obtained from the Provincial Directorate of National Education on 31.03.2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to data collection. Furthermore, all participants explicitly consented to the publication of direct quotations, provided that their identities remain confidential.\u003c/p\u003e\n\u003cp\u003eIn the findings section, the names of the interviewees have been changed for ethical reasons to avoid disclosing their identities and genders when using their data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb.\u0026nbsp; \u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants are reluctant to share their data because they are concerned about their identities being revealed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec.\u0026nbsp; \u0026nbsp;Data Accessibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets created and/or analyzed in this study are not publicly available. Participants, all public employees, agreed to participate in the interviews on the condition that their data would not be shared with anyone for reasons of professional and personal safety. However, data may be obtained from the relevant author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed.\u0026nbsp; \u0026nbsp;Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee.\u0026nbsp; \u0026nbsp;Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have not received any financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ef.\u0026nbsp; \u0026nbsp;\u0026nbsp;Authors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author solely conceived the study, designed the research, conducted data collection and analysis, and wrote and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eg.\u0026nbsp; \u0026nbsp;Clinical Study Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAllen, K.-A., Vella-Brodrick, D., \u0026amp; Waters, L. 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Early Exposure to Stimulant Medications and Substance-Related Problems: The Role of Medical and Nonmedical Contexts. \u003cem\u003eDrug and Alcohol Dependence\u003c/em\u003e, \u003cem\u003e163\u003c/em\u003e, 55\u0026ndash;63. https://doi.org/10.1016/j.drugalcdep.2016.03.019\u003c/li\u003e\n \u003cli\u003eMushamiri, S. P. (2021). \u003cem\u003eTeachers\u0026rsquo; knowledge on drug policy within secondary schools in Johannesburg, South Africa\u003c/em\u003e [Master of Arts (MA), University of Johannesburg]. https://ujcontent.uj.ac.za/esploro/outputs/graduate/Teachers-knowledge-on-drug-policy-within/9910971007691\u003c/li\u003e\n \u003cli\u003eMyhr, A., Vesterbekkmo, R. K., Samarawickrema, I., \u0026amp; Sund, E. R. (2024). Trends in Norwegian adolescents\u0026rsquo; substance use between 2014 and 2022: Socioeconomic and gender differences. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e, 2482. https://doi.org/10.1186/s12889-024-19983-9\u003c/li\u003e\n \u003cli\u003eNath, A., Choudhari, S. G., Dakhode, S. U., Rannaware, A., \u0026amp; Gaidhane, A. M. (2022). Substance Abuse Amongst Adolescents: An Issue of Public Health Significance. \u003cem\u003eCureus\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(11), e31193. https://doi.org/10.7759/cureus.31193\u003c/li\u003e\n \u003cli\u003eNeal, J. W., \u0026amp; Neal, Z. P. (2013). Nested or Networked? Future Directions for Ecological Systems Theory. \u003cem\u003eSocial Development\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(4), 722\u0026ndash;737. https://doi.org/10.1111/sode.12018\u003c/li\u003e\n \u003cli\u003eNinkron, P., Yau, S., Khuntiterakul, P., \u0026amp; Nakamadee, B. (2021). 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The Influence of Formal and Informal Institutional Voids on Entrepreneurship. \u003cem\u003eEntrepreneurship Theory and Practice\u003c/em\u003e. https://doi.org/10.1177/1042258719830310\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9105573/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9105573/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSubstance use in adolescents is not merely an individual risk behavior; it is a multifaceted social problem shaped by school, family, and institutional structures. This qualitative research aims to uncover the ethical and institutional dimensions of school-based interventions by examining the experiences of teachers, counselors, and school administrators who intervene with middle school students who use substances. The study is interpreted within the framework of Ecological Systems Theory, Stigma Theory, Care Ethics, and Institutional Theory. Data were collected through semi-structured in-depth interviews with 70 educators and analyzed using thematic analysis. The findings focus on five main themes: lack of information and experience, procedural ambiguity, institutional ethical breaches, concerns about school stigma, and parental anxiety. The results show that intervention processes are often hampered by legal concerns, pressure on institutional reputation, and fear of social stigma. The research conceptualizes school-based interventions not as a technical implementation process, but as a tension zone between care-oriented ethical responsibilities and bureaucratic control mechanisms. In this respect, the study offers a unique contribution by highlighting the need for structural reform among policymakers and practitioners.\u003c/p\u003e","manuscriptTitle":"Between Care and Supervision: Ethical Dilemmas, Institutional Gaps, and Stigma Dynamics in School-Based Substance Use Interventions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 15:37:06","doi":"10.21203/rs.3.rs-9105573/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-30T20:24:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81147658823769960912341529616852081711","date":"2026-04-22T14:20:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T06:31:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T14:22:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T06:28:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-23T13:57:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-23T10:49:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5a0fa4a2-a513-4a98-8e22-7886d7c093a9","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-04-30T20:24:02+00:00","index":72,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T15:37:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 15:37:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9105573","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9105573","identity":"rs-9105573","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}