The potential of coaching as a strategy to improve the effectiveness of school-based substance use prevention curricula

How can adolescent aggression be reduced? A multi-level meta-analysis

Aggressive behaviour among adolescents has significant social and economic costs. Numerous attempts have been made to intervene to reduce aggression in adolescents. However, little is known about what factors enhance or diminish intervention effectiveness. The present systematic review and meta-analysis, therefore, seeks to quantify the effectiveness of interventions to reduce aggressive behaviour in adolescents and to identify when and for whom such interventions work best. Sixteen databases were searched for randomised controlled trials that assessed interventions to reduce aggression among adolescents. After screening 9795 records, 95 studies were included. A multi-level meta-analysis found a significant overall small-to-medium effect size (d = 0.28; 95% CI [0.17, 0.39]). More effective interventions were of shorter duration, were conducted in the Middle East, were targeted at adolescents with higher levels of risk, and were facilitated by intervention professionals. Potentially active ingredients were classified using the Behaviour Change Technique Taxonomy. Behavioural practice and problem solving were components of more effective interventions targeted at the general population. Overall the findings indicate that psychosocial interventions are effective in reducing adolescent aggression. Future trials need to assess the effect of individual techniques and their combination to identify the key components that can reduce aggression in adolescents.

Perceived Ease of Access and Age Attenuate the Association Between Marijuana Ad Exposure and Marijuana Use in Adolescents

This study theorizes and tests moderators (perceived availability of marijuana and age-group) of the association between adolescents' frequency of marijuana ad exposure and past-year marijuana use. To test this model, I analyzed national survey data from 9,024 American adolescents with hierarchical regression techniques. Results showed that being a male (95% confidence interval [CI] for unstandardized regression coefficient [0.06, 0.16]) and peer pressure (95% CI [0.04, 0.14]) were positively associated with past-year marijuana use, and father education (95% CI [-0.11, -0.06]) was negatively associated with it. Perceived ease of access (95% CI [0.18, 0.22]), ad exposure (95% CI [0.03, 0.14]), and age (95% CI [0.16, 0.27]) were positively associated with past-year marijuana use. Importantly, the associations of perceived ease of access and age with past-year marijuana use were significantly larger than that of ad exposure. Age (95% CI [0.00, 0.15]) and perceived ease of access (95% CI [0.01, 0.07]) independently strengthened the ad exposure to use association. There was a significant three-way interaction (95% CI [0.01, 0.12]) showing that age increases the positive influence of perceived ease of access on the marijuana ad exposure to past-year marijuana use association. An exploratory analysis further revealed that male adolescents are more strongly influenced by perceived ease of access compared to females. Based on the findings, I suggest that approaches for reducing perceived marijuana availability and for implementing age-specific interventions are promising avenues for prevention programs aimed at decreasing marijuana use in adolescents.

Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum

This study examined how cultural adaptation and delivery quality of the school-based intervention keepin' it REAL (kiR) influenced adolescent substance use. The goal of the study was to compare the effectiveness of the multi-cultural, urban (non-adapted) kiR intervention, a re-grounded (adapted) rural version of the kiR intervention and control condition in a new, rural setting. A total of 39 middle schools in rural communities of two states in the USA were randomly assigned to one of three conditions (i.e., control, non-adapted urban kiR, and adapted rural kiR). Data included adolescent self-reported lifetime substance use and observers' ratings of delivery quality from video recordings of lessons. Ratings of delivery quality were used to create four comparison groups (i.e., low/high delivery quality in non-adapted/urban kiR condition and low/high quality in adapted/rural kiR condition). Controlling for substance use in the 7th grade, findings compared 9th graders' (N = 2781) lifetime alcohol, cigarette, marijuana, and chewing tobacco use. Mixed model analyses revealed that rural youth receiving the culturally adapted/rural curriculum reported significantly less cigarette use than rural youth in the control condition regardless of delivery quality. In the non-adapted/urban condition, youth receiving high delivery quality delivery reported less marijuana use than those receiving low delivery quality condition. However, substance use outcomes of youth receiving high and low delivery quality in the non-adapted intervention did not differ significantly from those the control group. Findings support the effectiveness of the culturally adapted/rural keepin' it REAL curriculum for rural youth.

Self-Reported Engagement in a Drug Prevention Program: Individual and Classroom Effects on Proximal and Behavioral Outcomes

Numerous studies emphasize the role of student engagement in academic learning and performance. Less known is whether engagement plays a role in drug prevention program outcomes. We examined a self-report measure of engagement as part of the All Stars Core drug prevention program evaluation, assessing its impact on target risk mechanisms and behavioral outcomes. Students completed pretests just prior to and posttests just after completing the intervention. Surveys assessed demographics, proximal intervening measures (i.e., commitments to avoid substance use and antisocial behavior, perceived lifestyle incongruence with substance use and antisocial behavior, normative beliefs about substance use and antisocial behavior, and parental attentiveness), and distal outcome measures of alcohol, cigarette use, and antisocial behaviors. A brief 6-item posttest measure including items tapping the students' perspective on the quality of teaching the program material and their level of engagement with the program was internally consistent (α = .79). Multi-level analyses positing engagement effects at both the classroom- and individual-level indicated that classroom average engagement was significantly associated with all the targeted risk mechanisms, and outcomes of antisocial behavior and alcohol use, controlling for pretest measures and classroom size. Individual student engagement relative to classroom peers was significantly associated with all posttest target risk mechanisms and behavioral outcomes. The current findings suggest that students should routinely provide assessments of engagement and perceived quality of teaching, which would improve our understanding of how prevention programs work. Teachers can improve engagement by paying attention to students when they speak in class, making the program enjoyable to participants, encouraging students to share opinions, stimulating attentiveness, being well prepared to deliver the intervention, and helping students think broadly about implications of drug prevention as it affects their lives. This type of support will ultimately engage students in ways that will enhance the likelihood that these programs will have their desired effects.

Strategies for enhancing the implementation of school-based policies or practices targeting risk factors for chronic disease

BACKGROUND

A number of school-based policies or practices have been found to be effective in improving child diet and physical activity, and preventing excessive weight gain, tobacco or harmful alcohol use. Schools, however, frequently fail to implement such evidence-based interventions.

OBJECTIVES

The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices to address child diet, physical activity, obesity, tobacco or alcohol use.Secondary objectives of the review are to: Examine the effectiveness of implementation strategies on health behaviour (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of school staff involved in implementing health-promoting policies, programs or practices; describe the cost or cost-effectiveness of such strategies; and describe any unintended adverse effects of strategies on schools, school staff or children.

SEARCH METHODS

All electronic databases were searched on 16 July 2017 for studies published up to 31 August 2016. We searched the following electronic databases: Cochrane Library including the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase Classic and Embase; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); Dissertations and Theses; and SCOPUS. We screened reference lists of all included trials for citations of other potentially relevant trials. We handsearched all publications between 2011 and 2016 in two specialty journals (Implementation Science and Journal of Translational Behavioral Medicine) and conducted searches of the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) as well as the US National Institutes of Health registry (https://clinicaltrials.gov). We consulted with experts in the field to identify other relevant research.

SELECTION CRITERIA

'Implementation' was defined as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any trial (randomised or non-randomised) conducted at any scale, with a parallel control group that compared a strategy to implement policies or practices to address diet, physical activity, overweight or obesity, tobacco or alcohol use by school staff to 'no intervention', 'usual' practice or a different implementation strategy.

DATA COLLECTION AND ANALYSIS

Citation screening, data extraction and assessment of risk of bias was performed by review authors in pairs. Disagreements between review authors were resolved via consensus, or if required, by a third author. Considerable trial heterogeneity precluded meta-analysis. We narratively synthesised trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We included 27 trials, 18 of which were conducted in the USA. Nineteen studies employed randomised controlled trial (RCT) designs. Fifteen trials tested strategies to implement healthy eating policies, practice or programs; six trials tested strategies targeting physical activity policies or practices; and three trials targeted tobacco policies or practices. Three trials targeted a combination of risk factors. None of the included trials sought to increase the implementation of interventions to delay initiation or reduce the consumption of alcohol. All trials examined multi-strategic implementation strategies and no two trials examined the same combinations of implementation strategies. The most common implementation strategies included educational materials, educational outreach and educational meetings. For all outcomes, the overall quality of evidence was very low and the risk of bias was high for the majority of trials for detection and performance bias.Among 13 trials reporting dichotomous implementation outcomes-the proportion of schools or school staff (e.g. classes) implementing a targeted policy or practice-the median unadjusted (improvement) effect sizes ranged from 8.5% to 66.6%. Of seven trials reporting the percentage of a practice, program or policy that had been implemented, the median unadjusted effect (improvement), relative to the control ranged from -8% to 43%. The effect, relative to control, reported in two trials assessing the impact of implementation strategies on the time per week teachers spent delivering targeted policies or practices ranged from 26.6 to 54.9 minutes per week. Among trials reporting other continuous implementation outcomes, findings were mixed. Four trials were conducted of strategies that sought to achieve implementation 'at scale', that is, across samples of at least 50 schools, of which improvements in implementation were reported in three trials.The impact of interventions on student health behaviour or weight status were mixed. Three of the eight trials with physical activity outcomes reported no significant improvements. Two trials reported reductions in tobacco use among intervention relative to control. Seven of nine trials reported no between-group differences on student overweight, obesity or adiposity. Positive improvements in child dietary intake were generally reported among trials reporting these outcomes. Three trials assessed the impact of implementation strategies on the attitudes of school staff and found mixed effects. Two trials specified in the study methods an assessment of potential unintended adverse effects, of which, they reported none. One trial reported implementation support did not significantly increase school revenue or expenses and another, conducted a formal economic evaluation, reporting the intervention to be cost-effective. Trial heterogeneity, and the lack of consistent terminology describing implementation strategies, were important limitations of the review.

AUTHORS' CONCLUSIONS

Given the very low quality of the available evidence, it is uncertain whether the strategies tested improve implementation of the targeted school-based policies or practices, student health behaviours, or the knowledge or attitudes of school staff. It is also uncertain if strategies to improve implementation are cost-effective or if they result in unintended adverse consequences. Further research is required to guide efforts to facilitate the translation of evidence into practice in this setting.

The power of a collaborative relationship between technical assistance providers and community prevention teams: A correlational and longitudinal study

BACKGROUND

Historically, effectiveness of community collaborative prevention efforts has been mixed. Consequently, research has been undertaken to better understand the factors that support their effectiveness; theory and some related empirical research suggests that the provision of technical assistance is one important supporting factor. The current study examines one aspect of technical assistance that may be important in supporting coalition effectiveness, the collaborative relationship between the technical assistance provider and site lead implementer.

METHODS

Four and one-half years of data were collected from technical assistance providers and prevention team members from the 14 community prevention teams involved in the PROSPER project.

RESULTS

Spearman correlation analyses with longitudinal data show that the levels of the collaborative relationship during one phase of collaborative team functioning associated with characteristics of internal team functioning in future phases.

CONCLUSIONS

Results suggest that community collaborative prevention work should consider the collaborative nature of the technical assistance provider - prevention community team relationship when designing and conducting technical assistance activities, and it may be important to continually assess these dynamics to support high quality implementation.

Universal school-based prevention for illicit drug use

BACKGROUND

Drug addiction is a chronic, relapsing disease. Primary interventions should aim to reduce first use or to prevent the transition from experimental use to addiction. School is the appropriate setting for preventive interventions.

OBJECTIVES

To evaluate the effectiveness of universal school-based interventions in reducing drug use compared to usual curricular activities or no intervention.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group's Trials Register (September 2013), the Cochrane Central Register of Controlled Trials (2013, Issue 9), PubMed (1966 to September 2013), EMBASE (1988 to September 2013) and other databases. We also contacted researchers in the field and checked reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCT) evaluating school-based interventions designed to prevent illicit drugs use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 51 studies, with 127,146 participants. Programmes were mainly delivered in sixth and seventh grade pupils. Most of the trials were conducted in the USA. Social competence approach versus usual curricula or no intervention Marijuana use at < 12 months follow-up: the results favoured the social competence intervention (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.81 to 1.01, four studies, 9456 participants, moderate quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a positive significant effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one found a trend in favour of the control group.Marijuana use at 12+ months: the results favoured the social competence intervention (RR 0.86; 95% CI 0.74 to 1.00, one study, 2678 participants, high quality evidence). Seven studies assessed this outcome (no data for meta-analysis): two showed a significant positive effect of intervention, three showed a non-significant effect, one found a significant effect in favour of the control group and one a trend in favour of the control group.Hard drug use at < 12 months: we found no difference (RR 0.69; 95% CI 0.40 to 1.18, one study, 2090 participants, moderate quality evidence). Two studies assessed this outcome (no data for meta-analysis): one showed comparable results for the intervention and control group; one found a statistically non-significant trend in favour of the social competence approach.Hard drug use at 12+ months: we found no difference (mean difference (MD) -0.01; 95% CI -0.06 to 0.04), one study, 1075 participants, high quality evidence). One study with no data for meta-analysis showed comparable results for the intervention and control group.Any drug use at < 12 months: the results favoured social competence interventions (RR 0.27; 95% CI 0.14 to 0.51, two studies, 2512 participants, moderate quality evidence). One study with 1566 participants provided continuous data showing no difference (MD 0.02; 95% CI -0.05 to 0.09, moderate quality evidence). Social influence approach versus usual curricula or no intervention Marijuana use at < 12 months: we found a nearly statistically significant effect in favour of the social influence approach (RR 0.88; 95% CI 0.72 to 1.07, three studies, 10,716 participants, moderate quality evidence). One study with 764 participants provided continuous data showing results that favoured the social influence intervention (MD -0.26; 95% CI -0.48 to -0.04).Marijuana use at 12+ months: we found no difference (RR 0.95; 95% CI 0.81 to 1.13, one study, 5862 participants, moderate quality evidence). One study with 764 participants provided continuous data and showed nearly statistically significant results in favour of the social influence intervention (MD -0.22; 95% CI -0.46 to 0.02). Of the four studies not providing data for meta-analysis a statistically significant protective effect was only found by one study.Hard drug use at 12+ months: one study not providing data for meta-analysis found a significant protective effect of the social influence approach.Any drug use: no studies assessed this outcome. Combined approach versus usual curricula or no intervention Marijuana use at < 12 months: there was a trend in favour of intervention (RR 0.79; 95% CI 0.59 to 1.05, three studies, 8701 participants, moderate quality evidence). One study with 693 participants provided continuous data and showed no difference (MD -1.90; 95% CI -5.83 to 2.03).Marijuana use at 12+ months: the results favoured combined intervention (RR 0.83; 95% CI 0.69 to 0.99, six studies, 26,910 participants, moderate quality evidence). One study with 690 participants provided continuous data and showed no difference (MD -0.80; 95% CI -4.39 to 2.79). Two studies not providing data for meta-analysis did not find a significant effect.Hard drug use at < 12 months: one study with 693 participants provided both dichotomous and continuous data and showed conflicting results: no difference for dichotomous outcomes (RR 0.85; 95% CI 0.63 to 1.14), but results in favour of the combined intervention for the continuous outcome (MD -3.10; 95% CI -5.90 to -0.30). The quality of evidence was high.Hard drug use at 12+ months: we found no difference (RR 0.86; 95% CI 0.39 to 1.90, two studies, 1066 participants, high quality evidence). One study with 690 participants provided continuous data and showed no difference (MD 0.30; 95% CI -1.36 to 1.96). Two studies not providing data for meta-analysis showed a significant effect of treatment.Any drug use at < 12 months: the results favoured combined intervention (RR 0.76; 95% CI 0.64 to 0.89, one study, 6362 participants).Only one study assessed the effect of a knowledge-focused intervention on drug use and found no effect. The types of comparisons and the programmes assessed in the other two groups of studies were very heterogeneous and difficult to synthesise.

AUTHORS' CONCLUSIONS

School programmes based on a combination of social competence and social influence approaches showed, on average, small but consistent protective effects in preventing drug use, even if some outcomes did not show statistical significance. Some programmes based on the social competence approach also showed protective effects for some outcomes.Since the effects of school-based programmes are small, they should form part of more comprehensive strategies for drug use prevention in order to achieve a population-level impact.

Factors facilitating and constraining the delivery of effective teacher training to promote health and well-being in schools: a survey of current practice and systematic review

Background

Schools are an important setting for health promotion and teachers have an integral role to play in promoting children and young people’s health and well-being. Adequate initial teacher training (ITT) and continuing professional development in health is therefore important.

Objectives

To conduct a survey of initial teacher training providers in England and a systematic review of effectiveness to assess how health and well-being is covered on courses, and to identify barriers and facilitators to effective training.

Methods

Methods included an online questionnaire survey with a sample of 220 ITT course managers in England; interviews with a purposive sample of 19 of the course managers responding to the questionnaire; and a two-stage systematic review comprising a descriptive map of the characteristics of international research studies of health teacher training and a detailed synthesis of a subset of studies specifically on pre-service training. Databases (including MEDLINE, EMBASE, The Campbell Library and PsycINFO) were searched from the period of database inception up to May 2011.

Results

The overall response rate for the survey was 34%. The majority (89%) of respondents agreed that it was either important or very important to cover health within the ITT curriculum. The most commonly covered topics on courses wereEvery Child Matters(100%), child protection (100%), emotional health (99%) and antibullying (97%). Fewer course managers reported covering healthy eating (63%), sex and relationships (62%), drugs (56%), alcohol (41%) and smoking (34%). Many interviewees expressed a holistic view of education and believed that health was important in the ITT curriculum. However, there was variability in how health was addressed across and within institutions. Trainee teachers' experience of addressing child health on school placement was also variable. Facilitators to covering health included interests and backgrounds of ITT staff; staff health-related professional experience; availability of health expertise from external agencies; supportive government policy frameworks; and interprofessional and interdepartmental working. The main barriers were limited curriculum time; health being perceived to be a lower priority than other aspects of training; health no longer a high government priority in education; and lack of funding. A total of 170 studies met the eligibility criteria for the descriptive map. The majority covered teacher training in relation to sexual and reproductive health, drugs and alcohol or mental and emotional health. A total of 21 publications (20 studies) were prioritised for the synthesis. All were evaluations of health training for pre-service teachers, and just under half were from the UK. Twelve studies reported outcomes (impact of training on teachers, but not pupils), many of which were single cohort before-and-after studies. Sixteen studies reported processes. Following training there were some increases in trainee teachers' factual knowledge of health and a general increase in their confidence to address health issues. In general, training was acceptable and well received by trainees. Evidence suggested that effective training should include practical experience and skills and be personally relevant and take into account individual needs. Barriers to health training identified from the studies included lack of time, balancing breadth and depth, and variation in training provision.

Conclusions

Among those surveyed there appears to be general support for health and well-being in ITT. However, further research on the longer-term impact of ITT around health and well-being is needed, particularly in the early career period. The main limitation of this research was the low response rate (34%) to the survey.

Study registration

PROSPERO number CRD42012001977.

Funding

The National Institute for Health Research Public Health Research programme.

How prevention curricula are taught under real-world conditions: Types of and reasons for teacher curriculum adaptations

PURPOSE

As interventions are disseminated widely, issues of fidelity and adaptation become increasingly critical to understand. This study aims to describe the types of adaptations made by teachers delivering a school-based substance use prevention curriculum and their reasons for adapting program content.

DESIGN/METHODOLOGY/APPROACH

To determine the degree to which implementers adhere to a prevention curriculum, naturally adapt the curriculum, and the reasons implementers give for making adaptations, the study examined lesson adaptations made by the 31 teachers who implemented the keepin' it REAL drug prevention curriculum in 7th grade classrooms (n = 25 schools). Data were collected from teacher self-reports after each lesson and observer coding of videotaped lessons. From the total sample, 276 lesson videos were randomly selected for observational analysis.

FINDINGS

Teachers self-reported adapting more than 68 percent of prevention lessons, while independent observers reported more than 97 percent of the observed lessons were adapted in some way. Types of adaptations included: altering the delivery of the lesson by revising the delivery timetable or delivery context; changing content of the lesson by removing, partially covering, revising, or adding content; and altering the designated format of the lesson (such as assigning small group activities to students as individual work). Reasons for adaptation included responding to constraints (time, institutional, personal, and technical), and responding to student needs (students' abilities to process curriculum content, to enhance student engagement with material).

RESEARCH LIMITATIONS/IMPLICATIONS

The study sample was limited to rural schools in the US mid-Atlantic; however, the results suggest that if programs are to be effectively implemented, program developers need a better understanding of the types of adaptations and reasons implementers provide for adapting curricula.

PRACTICAL IMPLICATIONS

These descriptive data suggest that prevention curricula be developed in shorter teaching modules, developers reconsider the usefulness of homework, and implementer training and ongoing support might benefit from more attention to different implementation styles.

ORIGINALITY/VALUE

With nearly half of US public schools implementing some form of evidence-based substance use prevention program, issues of implementation fidelity and adaptation have become paramount in the field of prevention. The findings from this study reveal the complexity of the types of adaptations teachers make naturally in the classroom to evidence-based curricula and provide reasons for these adaptations. This information should prove useful for prevention researchers, program developers, and health educators alike.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

The role of teacher communicator style in the delivery of a middle school substance use prevention program

We examine whether teachers' communicator style relates to student engagement, teacher-student relationships, student perceptions of teacher immediacy, as well as observer ratings of delivery skills during the implementation of All Stars, a middle school-based substance use prevention program. Data from 48 teachers who taught All Stars up to 3 consecutive years and their respective seventh-grade students (n = 2,240) indicate that having an authoritative communication style is negatively related to student engagement with the curriculum and the quality of the student-teacher relationship, while having an expressive communicator style improves teachers' immediacy to student needs. Adaptations made by a subsample of teachers (n = 27) reveal that those who were more expressive asked students more questions, used more motivational techniques, and introduced more new concepts than authoritarian teachers.

Mentoring adolescents to prevent drug and alcohol use

BACKGROUND

Many adolescents receive mentoring. There is no systematic review if mentoring prevents alcohol and drug use.

OBJECTIVES

Assess effectiveness of mentoring to prevent adolescent alcohol/drug use.

SEARCH METHODS

Cochrane CENTRAL (issue 4), MEDLINE (1950-to July 2011), EMBASE (1980-to July 2011), 5 other electronic and 11 Grey literature electronic databases, 10 websites, reference lists, experts in addictions and mentoring.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mentoring in adolescents to prevent alcohol/drug use.

DATA COLLECTION AND ANALYSIS

We identified 2,113 abstracts, independently assessed 233 full-text articles, 4 RCTs met inclusion criteria. Two reviewers independently extracted data and assessed risks of bias. We contacted investigators for missing information.

MAIN RESULTS

We identified 4 RCTs (1,194 adolescents). No RCT reported enough detail to assess whether a strong randomisation method was used or allocation was concealed. Blinding was not possible as the intervention was mentoring. Three RCTs provided complete data. No selective reporting.Three RCTs provided evidence about mentoring and preventing alcohol use. We pooled two RCTs (RR for mentoring compared to no intervention = 0.71 (95% CI = 0.57 to 0.90, P value = 0.005). A third RCT found no significant differences.Three RCTs provided evidence about mentoring and preventing drug use, but could not be pooled. One found significantly less use of "illegal" drugs," one did not, and one assessed only marijuana use and found no significant differences.One RCT measured "substance use" without separating alcohol and drugs, and found no difference for mentoring.

AUTHORS' CONCLUSIONS

All four RCTs were in the US, and included "deprived" and mostly minority adolescents. Participants were young (in two studies age 12, and in two others 9-16). All students at baseline were non-users of alcohol and drugs. Two RCTs found mentoring reduced the rate of initiation of alcohol, and one of drug usage. The ability of the interventions to be effective was limited by the low rates of commencing alcohol and drug use during the intervention period in two studies (the use of marijuana in one study increased to 1% in the experimental and to 1.6% in the control group, and in another study drug usage rose to 6% in the experimental and 11% in the control group). However, in a third study there was scope for the intervention to have an effect as alcohol use rose to 19% in the experimental and 27% in the control group. The studies assessed structured programmes and not informal mentors.

One-year follow-up evaluation of the Project Towards No Drug Abuse (TND) dissemination trial

OBJECTIVE

The aims of this trial, conducted 2004-2008, were to examine (1) the effectiveness of Project Towards No Drug Abuse (TND) at the one-year follow-up when implemented on a large scale; and (2) the relative effectiveness of two training approaches for program implementers.

METHOD

A total of 65 high schools from 14 school districts across the United States were randomized to one of three conditions: regular workshop training, comprehensive implementation support, or standard care control. Physical education and health teachers delivered the program to students (n=2538). Program effectiveness was assessed with dichotomous measures of 30-day substance use at baseline and one-year follow-up.

RESULTS

When the program conditions were considered in aggregate and compared to controls, the program showed a marginally significant effect in lowering marijuana use from baseline to the one-year follow-up. Significant program effects on hard drug use were achieved for baseline non-users only. There were no differences in the effects of the two program conditions.

CONCLUSION

Positive outcomes may be achieved by trained teachers when they implement Project TND in real-world high school environments; however, program effects are likely to be weaker than those achieved in efficacy trials. Training workshops may be adequate to build capacity for successful program implementation.

The Project Towards No Drug Abuse (TND) dissemination trial: implementation fidelity and immediate outcomes

One of the important research issues in the emerging area of research on dissemination of prevention programs relates to the type and extent of training needed by program providers to prepare them to implement effective programs with fidelity. The present paper describes the immediate outcomes of a dissemination and implementation trial of Project Toward No Drug Abuse, an evidence-based prevention program for high school students. A total of 65 high schools in 14 school districts across the USA were recruited and randomly assigned to one of three experimental conditions: comprehensive implementation support for teachers, regular workshop training only, or standard care control. The comprehensive intervention was comprised of on-site coaching, web-based support, and technical assistance, in addition to the regular workshop. Students (n = 2,983) completed self-report surveys before and immediately after program implementation. Fidelity of implementation was assessed with a classroom observation procedure that focused on program process. Results indicated that relative to the controls, both intervention conditions produced effects on hypothesized program mediators, including greater gains in program-related knowledge; greater reductions in cigarette, marijuana and hard drug use intentions; and more positive changes in drug-related beliefs. There were stronger effects on implementation fidelity in the comprehensive, relative to the regular, training condition. However, seven of the ten immediate student outcome measures showed no significant differences between the two training conditions. The implications of these findings for dissemination research and practice are discussed.

Three-year trajectory of teachers' fidelity to a drug prevention curriculum

Little is known about the trajectories over time of classroom teachers' fidelity to drug prevention curricula. Using the "Concerns-Based Adoption Model" (C-BAM) as a theoretical framework, we hypothesized that teachers' fidelity would improve with repetition. Participants comprised 23 middle school teachers who videotaped their administration of three entire iterations of the All Stars curriculum. Investigators coded two key curriculum lessons, specifically assessing the proportion of activities of each lesson teachers attempted and whether they omitted, added, or changed prescribed content, or delivered it using new methods. Study findings provided only partial support for the C-BAM model. Considerable variability in teachers' performance over time was noted, suggesting that their progression over time may be nonlinear and dynamic, and quite possibly a function of their classroom and school contexts. There was also evidence that, by their third iteration of All Stars, teachers tended to regress toward the baseline mean. That is, the implementation quality of those that started out with high levels of fidelity tended to degrade, while those that started out with very low fidelity to the curriculum tended to improve. Study findings suggest the need for ongoing training and technical assistance, as well as "just in time" messages delivered electronically; but it is also possible that some prevention curricula may impose unrealistic expectations or burdens on teachers' abilities and classroom time.

Implementation Quality: Lessons Learned in the Context of the Head Start REDI Trial

This study uses data collected in the intervention classrooms (N = 22) of Head Start REDI (Research-based, Developmentally Informed), a randomized clinical trial testing the efficacy of a comprehensive preschool curriculum targeting children's social-emotional competence, language, and emergent literacy skills delivered by teachers who received weekly coaching support. Multiple dimensions of implementation (Dosage, Fidelity, Generalization, and Child Engagement) were assessed across curriculum components. Results indicated that REDI Trainers perceived significant growth in teacher implementation quality over time but that patterns differed by implementation dimension. Dosage and Fidelity of all intervention components were high at the beginning of the year and remained so over time while Generalization was low at baseline but increased significantly across the year. Variation in implementation was associated with variation on several child outcome measures in the social-emotional domain but not in the language and literacy domains.

Implementation quality of a family-focused preventive intervention in a community-based dissemination

The aims of this study were to determine (1) the degree to which an evidence-based intervention (EBI) delivered outside the context of a research trial remained faithful to the content and design of the programme as intended and as reported in experimental trials of the same programme, and (2) whether implementation quality affected programme outcomes. We report results of an observational study of 11 sites involved in the statewide dissemination of a popular family-focused prevention programme, the Strengthening Families Programme for Parents and Youth 10-14. We found numerous differences between the community-based implementations we observed and researcher-driven implementations of the same programme, but variability in programme delivery and adherence to content were unrelated to programme outcomes. We conclude that short-term outcomes of well-designed EBIs delivered by well-trained facilitators may be robust to minor changes in delivery and content. However, the effects of implementation quality on longer-term outcomes are unknown.

Teachers' delivery skills and substance use prevention program outcomes: the moderating role of students' need for cognition and impulse decision making

The purpose of this study was to extend the literature in both substance use implementation and persuasive health communication by examining the extent to which students' need for cognition and impulsive decision-making moderated the relationship between teachers' classroom communication behavior and program outcomes in an evidence-based middle school substance use prevention curriculum. Participants included 48 teachers and their respective 7th grade students who participated in a randomized trial testing the effectiveness of personal coaching as a means to improve the quality with which teachers implemented the All Stars curriculum. Need for cognition and impulse decision-making were both associated with positive changes in lifestyle incongruence and commitments to not use substances for students whose teachers displayed greater interactive teaching. Further, need for cognition was associated with lower alcohol use rates while impulse decision making related to lower rates of marijuana use in classes with interactive teaching.

Randomized controlled trial of the ACTION smoking cessation curriculum in tobacco-growing communities

We conducted a group randomized trial of an interactive, games-based, tobacco cessation program (ACTION) designed to help adolescents who live in tobacco-growing communities to stop using tobacco. More than 260 high school students participated in this study, in 14 schools across three states. We collected self-reported measures of cigarette and smokeless tobacco use and conducted biochemical validation of self-reported use at three time points (pre-test, immediate post-test, and 90-day follow-up). We used multi-level modeling to account for intraclass clustering at the school and classroom levels, and we analyzed our results using an intent-to-treat approach and a per protocol approach. Using the per protocol analytic approach, ACTION participants were more likely than comparison participants to achieve abstinence at 90-day follow-up. We found no program effects on our secondary outcomes or mediating factors. This study suggests that ACTION has promise as a relatively effective adolescent cessation program, although the overall limited effectiveness of cessation programs for adolescents must be acknowledged.

The effects of students' curriculum engagement, attitudes toward their teachers, and perception of their teachers' skills on school-based prevention curriculum outcomes

We examined the association between changes in the substances and mediating variables targeted by the All Stars drug prevention curriculum, and students' engagement in and enjoyment of the curriculum, their attitudes toward their teachers, and their perceptions of their teachers' skills. Forty-eight school staff administered at least one All Stars class, for up to three consecutive years, to their seventh grade students in 107 classes in a large Midwestern school district. A sample of 2428 students completed a linked pretest and post-test, for a response rate of 91%. We found that students' engagement in and enjoyment of the curriculum, their attitudes toward their teachers, and their perceptions of their teachers' skill were all associated with positive changes in the curriculum's five mediators, but not with changes in students' substance use per se. Study findings suggest the importance of these three attributes to the achievement of the objectives of prevention curricula.