Community epidemiology of risk and adolescent substance use: practical questions for enhancing prevention

Community utilization of risk and protective factor data for prevention planning in Chile and Colombia

Many effective community health service delivery systems implemented in the USA assess risk and protective factors (RPFs) for youth problem behaviors in a community, and report these data back to local coalitions for prevention planning. This study examined whether community prevention coalitions in Chile and Colombia perceived these reports of RPFs-based on the results of the Communities That Care Youth Survey-to be understandable, valid, useful, and worth disseminating. Thematic content analysis was used to analyze qualitative data collected from 7 focus groups with 75 coalition members. Results indicated heterogeneity between and within coalitions in terms of participants' understanding of RPFs. However, most participants found reports of RPFs to be easy to understand, thorough, 'true' to their communities, and useful for diagnosing and prioritizing needs, action planning, and mobilizing others in their communities. Findings suggest the viability of preventive systems that rely on community-level RPF data, for use in Latin America.

Protocol for a hybrid type 3 cluster randomized trial of a technical assistance system supporting coalitions and evidence-based drug prevention programs

BACKGROUND

Over 5000 community anti-drug coalitions operating in the USA serve as a cornerstone of federal drug prevention. These coalitions, however, have demonstrated effectiveness in preventing substance use only when they use technical assistance (TA) and implement evidence-based programs (EBPs). The absence of TA and EBP implementation by coalitions is a key research-to-practice gap. The Coalition Check-Up TA system is designed to fill this gap by supporting community coalition implementation of EBPs. Existing TA models for evidence-based coalition approaches are resource intensive and coalition model specific. The Coalition Check-Up is a lower cost strategy that works with a variety of types of coalitions to support sustainable implementation of EBPs. This study protocol describes a hybrid type 3 effectiveness-implementation trial applying Wandersman's Interactive Systems Framework to test the effects of the Coalition Check-Up on coalition EBP implementation capacity and outcomes. The Interactive Systems Framework outlines how the prevention support system-especially TA-bolsters EBP dissemination and implementation.

METHODS

Using a cluster randomized controlled design, this trial will test the overall effectiveness of the Coalition Check-Up, including how it contributes to EBP implementation and prevention of youth substance use. The first aim is to estimate the impact of the Coalition Check-Up on coalitions' capacity to do their work. We will recruit 68 anti-drug coalitions for random assignment to the Coalition Check-Up or "TA as usual" condition. We will evaluate whether the Coalition Check-Up improves coalition capacity using measures of coalition member responses about team processes, coalition network composition, and collaborative structure. Our second aim is to estimate the impact of the Coalition Check-Up on implementation of EBPs, and our third aim is to estimate the impact of the Coalition Check-Up on youth substance use.

DISCUSSION

This project will clarify how the Coalition Check-Up, a scalable approach to TA due to its low cost, affects coalition capacity to support EBP implementation. Analyses also provide insight into causal pathways from the prevention support system to the prevention delivery system outlined by the Interactive Systems Framework. Results will build the evidence-base for how to support community coalitions' sustainable implementation of evidence-based prevention programs and policies.

TRIAL REGISTRATION

Clinicaltrials.gov registration number NCT04592120 . Registered on October 19, 2020.

A Comparison of Cut Points for Measuring Risk Factors for Adolescent Substance Use and Antisocial Behaviors in the U.S. and Colombia

As the identification and targeting of salient risk factors for adolescent substance use become more widely used globally, an essential question arises as to whether U.S.-based cut points in the distributions of these risk factors that identify "high" risk can be used validly in other countries as well. This study examined proportions of youth at "high" risk using different empirically derived cut points in the distributions of 18 measured risk factors. Data were obtained from large-scale samples of adolescents in Colombia and the United States. Results indicated that significant (p < 0.05) differences in the proportions of "high" risk youth were found in 38.9% of risk factors for 6th graders, 61.1% for 8th graders, and 66.6% for 10th graders. Colombian-based cut points for determining the proportion of Colombian youth at "high" risk were preferable to U.S.-based cut points in almost all comparisons that exhibited a significant difference. Our findings suggest that observed differences were related to the type of risk factor (e.g., drug specific vs. non-drug specific). Findings from this study demonstrate the need for collecting large-scale national data on risk factors for adolescent substance use and developing country-specific cut points based on the distributions of these measures to avoid misidentification of youth at "high" risk.

Assessing Community Readiness for Preventing Youth Substance Use in Colombia: A Latent Profile Analysis

The growing use of evidence-based preventive interventions for youth substance use in Latin American countries has prompted governments, researchers, and practitioners to ask if communities are ready for implementing these interventions, especially in light of the elevated costs and long-term commitment necessary for successful implementation. This study explores the construct validity of a measure of community readiness for prevention, using confirmatory factor and latent profile analyses of 7 measures theorized to be indicators of community readiness for implementing preventive interventions for youth substance use. Data were obtained from 211 community leaders in 16 communities in Colombia. Results indicate that community readiness can be represented as a unidimensional construct with multiple profiles of varying levels of readiness. Findings suggest community readiness can be measured adequately as a latent construct and that its indicators can be used diagnostically to assess areas where readiness could be improved for better implementation of evidence-based preventive interventions.

Ready, willing, and able: the role of cannabis use opportunities in understanding adolescent cannabis use

AIMS

To examine adolescent cannabis use-both at national and individual levels-by deconstructing it into its necessary conditions of realistic use opportunities and willingness to use the drug given such opportunities.

DESIGN

Nationally representative, repeated cross-sectional survey.

SETTING

Norway.

PARTICIPANTS

A total of 8818 16-year-olds who participated in the European School Survey Project on Alcohol and Other Drugs (ESPAD) in 2007, 2011, and 2015.

MEASUREMENTS

Adolescent reports concerning their life-time 'cannabis use' and 'possibilities to use cannabis' were used to assess: (a) overall cannabis use, (b) exposure to realistic cannabis use opportunities, and (c) cannabis use among those exposed to use opportunities. Logistic regression models were used to estimate national trends since 2007 in these indicators, and to identify individual-level factors associated with cannabis use versus non-use among youth exposed to concrete use opportunities.

FINDINGS

Prevalence of life-time cannabis use remained stably low, averaging 6.4% across the three surveys. Life-time exposure to cannabis use opportunities decreased [odds ratio (OR)_{ESPAD assessment}  = 0.90, 95% confidence interval (CI) = 0.84-0.97, P = 0.006], yet cannabis use among adolescents with such opportunities increased significantly (OR_{ESPAD assessment}  = 1.17, 95% CI = 1.03-1.34, P = 0.02) since 2007. After controlling for a range of other risk factors, abstinence from alcohol intoxication and cigarette use, as well as the perceptions of even minimal cannabis use as risky remained the factors most robustly associated with lower likelihood of cannabis use among youth with realistic use opportunities.

CONCLUSIONS

Approaches accounting for realistic use opportunities proved critical in our understanding of underage cannabis use, both at the national and individual level, and may be informative for development of prevention strategies in the era of cannabis liberalization. In addition, delineation of realistic opportunities from behaviours conditioned upon such opportunities is generalizable to a range of public health issues.

Risk and Protective Factors for Early Substance Use Initiation: A Longitudinal Study of Mexican-Origin Youth

Substance use initiation in adolescence is a critical issue, given its association with substance dependency and associated problems in adulthood. However, due to the dearth of fine-grained, longitudinal studies, the factors associated with early initiation are poorly understood, especially in minority youth. The present study examined substance use initiation in a sample of Mexican-origin youth (N=674) assessed annually from age 10 to 16. Using discrete-time survival analyses, we found that initiation escalated rapidly from late childhood to adolescence, and we identified a wide range of factors, from the individual to the cultural level of analysis, that significantly increased or decreased risk for early initiation. These findings have important implications for programs aimed at preventing early substance use by Mexican-origin youth.

Community Prevention Coalition Context and Capacity Assessment: Comparing the United States and Mexico

Effective planning for community health partnerships requires understanding how initial readiness-that is, contextual factors and capacity-influences implementation of activities and programs. This study compares the context and capacity of drug and violence prevention coalitions in Mexico to those in the United States. Measures of coalition context include community problems, community leadership style, and sense of community. Measures of coalition capacity include the existence of collaborative partnerships and coalition champions. The assessment was completed by 195 members of 9 coalitions in Mexico and 139 members of 7 coalitions in the United States. Psychometric analyses indicate the measures have moderate to strong internal consistency, along with good convergent and discriminant validity in both settings. Results indicate that members of Mexican coalitions perceive substantially more serious community problems, especially with respect to education, law enforcement, and access to alcohol and drugs. Compared to respondents in the United States, Mexican respondents perceive sense of community to be weaker and that prevention efforts are not as valued by the population where the coalitions are located. The Mexican coalitions appear to be operating in a substantially more challenging environment for the prevention of violence and substance use. Their ability to manage these challenges will likely play a large role in determining whether they are successful in their prevention efforts. The context and capacity assessment is a valuable tool that coalitions can use in order to identify and address initial barriers to success.

Symptoms with betel nut and betel nut with tobacco among Micronesian youth

Betel nut has been stated to be addictive, but evidence is lacking. This study describes dependence symptoms among adolescents using betel alone or with tobacco. In the first study, participants were 151 9th graders in Saipan. In the second study, participants were 269 9th graders in Pohnpei and Yap. Participants completed a confidential questionnaire adapted from the U.S. National Survey of Drug Use and Health, which measured dependence symptoms. The 15 items were summed to form a scale, with a range of 0-15, where higher scores indicated greater endorsement of dependence symptoms. In the first study, 39.1% had used betel. More than two-thirds of all users (69.5%) used betel in the previous month: 87.8% also used tobacco with the betel. The mean (SD) dependence symptoms scale score among tobacco users was 8.2±4.0 versus 3.4±2.9 among those who used betel alone [t(7)=3.3, p=0.015]. In the second study, 38% from Pohnpei and 85% from Yap had used betel and most of the current users used it in the previous month (67% from Pohnpei, 91% from Yap). Among those who had used betel in the previous month, 90% from Pohnpei and 64% from Yap were using betel with tobacco. The dependence score was positively associated with frequency of tobacco use (e.g., mean (SD)=11.3 (±2.4) among most frequent users versus a mean (SD)=4.8 (±3.5) among the never users [F(3109)=28.8, p<0.001]). Betel nut users who also use tobacco may benefit from tobacco cessation strategies.

The community epidemiology of underage drinking: variation across communities in relations of risk to alcohol use

To test the assumption embedded in state-of-the-art, community assessment and decision-making regarding prevention of underage drinking: that there is minimal variation in the way that risk and protective factors (RPF) are associated with underage drinking across communities. Three large datasets provided the same measures of adolescent alcohol use and RPFs. Multilevel ordered-logistic regression models were carried out separately for each dataset and separately for males and females in 8th and 10th grades, testing random slopes for each RPF index. Predicted school-level coefficients were derived from these models, representing the association between RPFs and alcohol use. The variation in associations between RPFs and alcohol use across schools was greatest for antisocial peer risk and community protection; the lowest variation across schools was found for family cohesion and individual antisocial behavior. Ranges in predicted coefficients indicate large differences across schools for many RPFs. Bivariate correlations indicated that school-level associations vary across RPFs in expected directions. Policy makers should recognize that the magnitude of associations between RPFs and adolescent alcohol use vary considerably across communities, and that such variability is greater for certain RPFs than others. These findings have implications for policies regarding how prevention resources are targeted within and across communities.

Predicting alcohol use across adolescence: relative strength of individual, family, peer, and contextual risk and protective factors

The current study examined developmental changes in the relative influence of risk and protective factors (RPFs) across individual, family, peer, school, and community domains on adolescent alcohol use. Using longitudinal data from two independent samples, multivariate cross-lagged models were used to estimate the unique influence of each RPF on subsequent changes in recent alcohol use between early to late adolescence. The results supported the hypothesis that the influence of Individual Risk would increase during this developmental period. However, less consistent evidence was found concerning developmental changes among the other domains. Whereas the influence arising from Family Protection diminished during adolescence, the influence of Family Risk, School Protection, and Community Protection did not vary. The influence of Peer Risk showed a nonlinear pattern across adolescence, peaking during the middle adolescent years. The results of this study support a developmental approach to adolescent alcohol use and emphasize the need for prevention strategies that account for these developmental changes.