Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence

Whole-school interventions promoting student commitment to school to prevent substance use and violence, and improve educational attainment: a systematic review

Background

Whole-school interventions modify the school environment to promote health. A subset of these interventions promotes student commitment to school to prevent substance (tobacco, alcohol, other drugs) use and/or violence. A previous review identified the theory of human functioning and school organisation as a comprehensive theory of such interventions, and found evidence that these interventions reduce substance use and/or violence.

Objectives

The objectives were to search for, appraise and synthesise evidence to address the following questions: (1) What whole-school interventions promoting student commitment to school to prevent substance use and/or violence have been evaluated, what intervention subtypes are apparent and how closely do these align with the theory of human functioning and school organisation? (2) What factors relating to setting, population and intervention affect implementation? (3) What are the effects on student substance use, violence and educational attainment? (4) What is the cost-effectiveness of such interventions? (5) Are intervention effects mediated by student commitment to school or moderated by setting or population?

Data sources

A total of 56 information sources were searched (in January 2020), then an updated search of 48 of these was carried out (in May 2021). Reference lists were also searched and experts were contacted.

Review methods

Eligible studies were process/outcome evaluations of whole-school interventions to reduce student violence or substance use among students aged 5-18 years attending schools, via actions aligning with the theory of human functioning and school organisation: modifying teaching to increase engagement, enhancing student-staff relationships, revising school policies, encouraging volunteering or increasing parental involvement. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised qualitatively. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Searches retrieved 63 eligible reports on 27 studies of 22 interventions. We identified four intervention subtypes focused on student participation in school-wide decisions, improving staff-student relationships, increasing engagement in learning and involving parents. The theories of change of most intervention subtypes aligned closely with the theory of human functioning and school organisation, and informed refinement of an intervention theory of change. Theories of change for interventions increasing learning engagement did not align with this theory, aiming instead to increase school commitment primarily via social skills curricula. Factors influencing the implementation included whether or not interventions were tailorable, workable and well explained. Interventions with action groups comprising staff/students, etc. and providing local data were well implemented. Implementation was also affected by whether or not schools accepted the need for change and staff had the resources for delivery. Meta-analyses suggest small, but significant, intervention effects in preventing violence victimisation and perpetration, and substance use. There was sparse and inconsistent evidence of moderation and some evidence of mediation by student commitment to school. Two economic evaluations suggested that there is the potential for the interventions to be cost-effective.

Limitations

The quality of the studies was variable and the economic synthesis was limited to two studies.

Conclusions

Whole-school interventions aiming to promote student commitment to school share similar theories of change and factors affecting implementation. They have the potential to contribute to preventing violence and substance use among young people. Future trials should aim to optimise intervention effectiveness by better theorisation, and assess implementation and effect moderators and mediators.

Study registration

This study is registered as PROSPERO CRD42019154334.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/151/05) and is published in full in Public Health Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Does poor health influence residential selection? Understanding mobility among low-income housing voucher recipients in the Moving to Opportunity Study

Housing mobility programs and housing choice vouchers provide low-income families with a potentially-transformative opportunity to move to low-poverty neighborhoods. However, families often face barriers to attaining upward residential mobility; poor health may be one important barrier, although few studies have examined this hypothesis. We used the experimental Moving to Opportunity (MTO) Study, constructed residential trajectories, and linked neighborhood opportunity measures to over 14,000 addresses of 3526 families across 7 years. We used latent growth curve longitudinal models to test how baseline health modified effects of MTO housing voucher treatment on neighborhood opportunity trajectories. Results show that poor baseline health adversely influenced how the voucher induced upward mobility. Voucher receipt strongly promoted residential mobility if families were healthy; moreover the low-poverty neighborhood voucher plus counseling treatment promoted higher opportunity neighborhood attainment compared to controls, regardless of the baseline health of the family. However families with health vulnerabilities did not retain the same initial neighborhood gains conferred by the housing choice voucher treatment, as families without health vulnerabilities. These results suggest that housing counseling may be one necessary element to expand neighborhood choice into higher opportunity neighborhoods for families with health challenges. Providing housing vouchers alone are insufficient to promote low-income family high opportunity moves, for families who have disabilities or special needs. The implications of these results point to scaling up housing mobility programs, to provide tailored support for low-income families to use housing choice vouchers to make high opportunity moves, which is particularly necessary for families with health challenges.

The Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile ("Mi Mejor Plan") for substance use prevention among early adolescents: study protocol for a randomized controlled trial

BACKGROUND

Substance use is highly prevalent among children and adolescents in Chile, and it is known how it impacts their health and social adjustment. The call for effective prevention of substance use among children adolescents has resulted in numerous school-based programs, and particularly, the Social Competence Promotion Program among Young Adolescents (SCPP-YA) has been proved to be successful for promoting social and problem-solving skills in addition to preventing substance abuse in the US population. The purpose of this study is to test the effectiveness of the Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile ("Mi Mejor Plan").

METHODS

This is a cluster randomized controlled trial, parallel-group type, where "Mi Mejor Plan" is compared to standard school preventive curricula in control schools. A total of 10 schools and 600 adolescents are expected to be recruited and randomized with 1:1 allocation. During formative work, the SCPP-YA program was culturally adapted to Chile. The effectiveness of this program will be assessed using the European Drug Addiction Prevention Trial Questionnaire (EU-Dap), measuring substance use prevalence and risk and protective factors in baseline, post-intervention, and 4 months after the end of the intervention.

DISCUSSION

The proposed study will be the first to test the effectiveness of the Social Competence Promotion Program among Young Adolescents (SCPP-YA) in Chile in a cluster randomized control trial and also the first study evaluating this program in Spanish-speaking Latin America. SCPP-YA has been implemented successfully in the USA. Thus, if the effects of the program are positive, wide implementation in Chile and Latin American countries is possible soon.

TRIAL REGISTRATION

Clinical Trials NCT04236947 . Registered on January 22, 2020.

Alcohol use disorder and non-fatal suicide attempt: findings from a Swedish National Cohort Study

BACKGROUND AND AIMS

Alcohol use disorder (AUD) is associated with increased risk of non-fatal suicide attempt. We aimed to measure the strength and mechanistic nature of the association between AUD and increased suicide attempt and determine any causal pathways and/or shared risk factors.

DESIGN

We used Cox proportional hazards models in population-level and co-relative analyses to evaluate the risk of first non-fatal suicide attempt as a function of previous AUD.

SETTING AND PARTICIPANTS

We used continuously updated longitudinal nationwide Swedish registry data on native Swedes born from 1950 to 1970 (n = 2 229 619) and followed from age 15 until 2012.

MEASUREMENTS

AUD and suicide attempt were identified using International Classification of Diseases (ICD)-8, ICD-9, and ICD-10 codes. AUD was also identified using pharmacy and criminal records. Genetic and family environmental risks were derived based on relatedness via the Multi-Generation Register and shared residency via the Population and Housing Census and the Total Population Register.

FINDINGS

AUD was robustly associated with suicide attempt in crude models (hazard ratio [HR] = 15.24 [95% CI: 14.92, 15.56]). In models adjusted for sociodemographic factors and psychiatric comorbidity, the association was attenuated: for women, HRs declined gradually across time, ranging from 5.55 (3.72, 8.29) during the observation period that ranged from age 15 to 19 years to 1.77 (1.65, 1.90) at age 40 or older. For men, the corresponding figures were 6.12 (4.07, 9.19) and 1.83 (1.72, 1.94); in contrast to women, risk of suicide attempt among men increased from age 15 to 29 before declining. In co-relative models, a residual association remained, consistent with a causal path from AUD to suicide attempt.

CONCLUSIONS

In Sweden, alcohol use disorder appears to be an important predictor of suicide attempt even in the context of other psychiatric disorders. The observed association is likely the result of features that jointly impact risk of alcohol use disorder and suicide attempts (genetic liability, psychiatric illness, and childhood stressors) and a potentially causal pathway, acting independently or in conjunction with one another.

A scoping review of whole-of-community interventions on six modifiable cancer prevention risk factors in youth: A systems typology

Whole-of-community interventions delivered across entire geospatial areas show promise for improving population health for youth cancer prevention. The aims of this scoping review were to synthesize the whole-of-community intervention literature on six modifiable risk factors in youth for cancer prevention (alcohol use, diet, obesity, physical activity, sun exposure, tobacco use) and to develop and apply a typology describing the inclusion of fundamental control system functional characteristics. A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus for studies published to the end of 2019. Eligible studies included a geospatially defined whole-of-community intervention; youth 0-18 years; and at least one of the six cancer risk factor outcomes. An iterative process was undertaken to create a typology describing the functions for whole-of-community interventions guided by systems theory, and the typology was used to code the included interventions. A total of 41 interventions were included. Most interventions (43.9%) assessed multiple cancer risk factors. Few interventions provided fundamental functions necessary for community system coordination: sensor, controller, effector. Although communities are a patchwork quilt of microsystems where individuals interact in geographically bounded places nested within larger whole systems of influence, a control systems approach has not been used to frame the literature. Whole-of-community interventions can be characterized by the fundamental system functions necessary for coordinating population health improvement. Future whole-of-community intervention efforts should draw on fundamental knowledge of how systems operate and test whether adoption of the key functions is necessary for whole-of-community population health improvement.

A Component Evaluation of a Randomised Control Community Intervention to Reduce Adolescent Alcohol Use in Australia

Despite a decline in Australian adolescents reporting to have consumed alcohol, a high proportion of the adolescent population still consumes alcohol. Community-led prevention interventions that systematically and strategically implement evidence-based programs have been shown to be effective in producing population-behaviour change related to youth alcohol and drug use. This study evaluated the post-intervention effects of a multi-component community intervention in Australia. It comprised social marketing targeting adolescents and parents, and a community intervention to reduce underage alcohol sales. Structural equation modelling was used to examine direct and indirect effects of community intervention components on intention and consumption. Self-report surveys (N = 3377) and community sales data (27 communities) were analysed to evaluate the effect of the intervention components on intention and consumption before the age of 18. The intervention reduced alcohol sales to minors (OR = .82). Exposure to the social marketing was significantly associated with household no-alcohol rules (OR = 2.24) and parents not supplying alcohol (OR = .72). The intervention predicted intention not to consume alcohol before age 18; intention was associated with not consuming alcohol (OR = 5.70). Total indirect effects from the intervention through to intention were significant. However, parents setting a rule and not supplying alcohol were the only significant direct effects to intention. Parents setting a rule was directly associated with lower consumption. Overall, the intervention logic was supported by the data modelling. The study extends prior knowledge of community-based interventions to prevent adolescent alcohol use by identifying critical intervention components and effect mechanisms. ClinicalTrials.gov Identifier: ACTRN12612000384853.

Community Awareness of Outreach Efforts to Reduce Underage Drinking on California Indian Reservations

We report an evaluation of a combined individual- and community-level treatment and prevention effort to reduce underage drinking by American Indian (AI) youths on rural California Indian reservations. The interventions included: brief motivational interviewing and psychoeducation for Tribal youths, restricting alcohol sales to minors in alcohol sales outlets, and community mobilization and awareness activities. Surveys were collected from 120 adults and 74 teens to evaluate the awareness and effectiveness of the interventions. A high proportion of adult (93%) and youth (96%) respondents endorsed being aware of one or more of the intervention activities, and 88% of adults and 71% of youth felt the program impacted the community in a positive way. Eighty-four percent of adults and 63% of youth agreed that as a result of the activities that they decided to take action to reduce teen drinking in their community. Being aware of more of the intervention activities significantly increased the odds of taking action to change drinking behaviors. This study documents that a significant proportion of the community was aware of the intervention efforts and that awareness caused them to take action to reduce underage drinking. Such efforts may benefit other AI/AN communities seeking to reduce underage drinking.

Understanding the spread of prevention and cessation messages on social media for substance use in youth

Purpose

Engagement is a critical metric to the effectiveness of online health messages. This paper explores how people engage in youth-generated prevention messages in social media.

Design/methodology/approach

The data sample consisted of engagement measures of 82 youth-generated messages hosted in a social media channel and a follow-up survey on content creators' motivation for promoting their messages and their dissemination strategies. A comparative analysis of engagement metrics along with qualitative analysis of the message types was performed.

Findings

Two types of messages were considered: stop messages and prevent messages. Our analyses found that people interacted with stop messages on social media more frequently than prevent messages. On analyzing the youth's motivation and promotion strategies, no significant difference was observed between stop message creators and prevent message creators.

Social implications

This work has implications for programs promoting prevention and health information in social media.

Originality/value

This is the first study in social media-based prevention programs the authors are aware of that differentiated between the strategies of youth-produced prevention messages.

Effective school-based preventive interventions for alcohol use in Africa: a systematic review

Background

Despite recognition of the risks of alcohol use and importance of prevention from an early age, the effectiveness of school-based interventions in Africa has not been clarified.

Objective

We aimed to identify effective school-based alcohol use prevention interventions in Africa.

Methods

We searched eight databases for peer-reviewed articles published until February 3, 2019 that reported on randomized controlled trials, cluster randomized controlled trials, controlled clinical trials, pre-post quasi-experimental studies, cohort studies, and case-control studies. The full-texts of relevant studies were searched.

Results

Four of 2797 papers met our eligibility criteria. All reported interventions targeted secondary school students in South Africa and were incorporated in the school curriculum. The interventions comprised multi-component activities with participatory and peer educational methods, and applied modified programs originally developed in the US. However, intervention effects were inconsistent among studies, although the interventions tended to have a positive effect on non-drinkers at baseline, with stronger effects in girls.

Conclusion

interventions had positive effects on students that were non-drinkers at baseline, especially girls. Although we could not find robust evidence that school-based interventions changed attitudes, frequency/quantity of drinking, and intentions to use alcohol, one intervention showed an increase in students' alcohol refusal self-efficacy.

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.

Evaluating Neighborhood, Social, and Genetic Influences on Precursors of Alcohol Use Risk Behavior in African American Adolescents

Background: Using a socioecological framework, we examined neighborhood and social stressors in concert with genetic risk for alcohol dependence in relation to externalizing behaviors, important precursors to alcohol-related problems. Methods: We used data from African American adolescents and their caregivers in the Gene, Environment, and Neighborhood Initiative, a subsample of the Mobile Youth and Poverty Study. Participants for the current analyses included 112 adolescents who reported ever having at least one full drink of alcohol. Empirical Bayes scores were used to estimate neighborhood-level violence and transitions. Multivariate models tested main effects and then interactions of family stressors, discrimination, and genetic risk with the neighborhood variables. Results: In the main effects model, adolescent externalizing behaviors were positively associated with greater family stressors, more racial discrimination experiences, and genetic liability, while neighborhood variables were nonsignificant. We found three significant interactions. Specifically, the joint effects of neighborhood violence and transitions and between these neighborhood variables and family stressors were significantly associated with externalizing behaviors. Conclusions: Our findings suggest genetic liability and complex interactions between neighborhood context and social stressors are important contributors that should be considered in the development of early prevention programs for adolescents who live in economically disadvantaged areas.

Family-based prevention programmes for alcohol use in young people

BACKGROUND

Alcohol use in young people is a risk factor for a range of short- and long-term harms and is a cause of concern for health services, policy-makers, youth workers, teachers, and parents.

OBJECTIVES

To assess the effectiveness of universal, selective, and indicated family-based prevention programmes in preventing alcohol use or problem drinking in school-aged children (up to 18 years of age).Specifically, on these outcomes, the review aimed:• to assess the effectiveness of universal family-based prevention programmes for all children up to 18 years ('universal interventions');• to assess the effectiveness of selective family-based prevention programmes for children up to 18 years at elevated risk of alcohol use or problem drinking ('selective interventions'); and• to assess the effectiveness of indicated family-based prevention programmes for children up to 18 years who are currently consuming alcohol, or who have initiated use or regular use ('indicated interventions').

SEARCH METHODS

We identified relevant evidence from the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, MEDLINE (Ovid 1966 to June 2018), Embase (1988 to June 2018), Education Resource Information Center (ERIC; EBSCOhost; 1966 to June 2018), PsycINFO (Ovid 1806 to June 2018), and Google Scholar. We also searched clinical trial registers and handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster RCTs (C-RCTs) involving the parents of school-aged children who were part of the general population with no known risk factors (universal interventions), were at elevated risk of alcohol use or problem drinking (selective interventions), or were already consuming alcohol (indicated interventions). Psychosocial or educational interventions involving parents with or without involvement of children were compared with no intervention, or with alternate (e.g. child only) interventions, allowing experimental isolation of parent components.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 46 studies (39,822 participants), with 27 classified as universal, 12 as selective, and seven as indicated. We performed meta-analyses according to outcome, including studies reporting on the prevalence, frequency, or volume of alcohol use. The overall quality of evidence was low or very low, and there was high, unexplained heterogeneity.Upon comparing any family intervention to no intervention/standard care, we found no intervention effect on the prevalence (standardised mean difference (SMD) 0.00, 95% confidence interval (CI) -0.08 to 0.08; studies = 12; participants = 7490; I² = 57%; low-quality evidence) or frequency (SMD -0.31, 95% CI -0.83 to 0.21; studies = 8; participants = 1835; I² = 96%; very low-quality evidence) of alcohol use in comparison with no intervention/standard care. The effect of any parent/family interventions on alcohol consumption volume compared with no intervention/standard care was very small (SMD -0.14, 95% CI -0.27 to 0.00; studies = 5; participants = 1825; I² = 42%; low-quality evidence).When comparing parent/family and adolescent interventions versus interventions with young people alone, we found no difference in alcohol use prevalence (SMD -0.39, 95% CI -0.91 to 0.14; studies = 4; participants = 5640; I² = 99%; very low-quality evidence) or frequency (SMD -0.16, 95% CI -0.42 to 0.09; studies = 4; participants = 915; I² = 73%; very low-quality evidence). For this comparison, no trials reporting on the volume of alcohol use could be pooled in meta-analysis.In general, the results remained consistent in separate subgroup analyses of universal, selective, and indicated interventions. No adverse effects were reported.

AUTHORS' CONCLUSIONS

The results of this review indicate that there are no clear benefits of family-based programmes for alcohol use among young people. Patterns differ slightly across outcomes, but overall, the variation, heterogeneity, and number of analyses performed preclude any conclusions about intervention effects. Additional independent studies are required to strengthen the evidence and clarify the marginal effects observed.

Whole-of-community interventions to reduce population-level harms arising from alcohol and other drug use: a systematic review and meta-analysis

BACKGROUND AND AIMS

Whole-of-community interventions aim to reduce alcohol and other drug (AOD) use and harms by mobilizing community leaders, organizations and policy-makers to respond effectively to AOD use. The aim of this review is to estimate the effectiveness of whole-of-community interventions in reducing population-level harms arising from AOD use.

DESIGN

A systematic review of electronic databases CENTRAL, Embase, Medline, Medline in Process and PsycINFO was conducted from database inception to August 2017. Eligible trials had a parallel comparison group, implemented interventions in two or more community settings, and reported data on AOD use or harms.

SETTING

Intervention settings included schools, sporting clubs, police and law enforcement agencies, community centres, local media and retail premises.

PARTICIPANTS

Twenty-four trials from 63 publications were included (n = 249 125 participants).

MEASUREMENTS

Outcomes from AOD consumption (quantity and frequency), AOD-related crime and AOD-related accidents, injuries and hospital admissions. Data were pooled using random-effects inverse variance meta-analysis in Review Manager version 5.3.

FINDINGS

Risk of bias was mostly high, due to lack of random allocation, selective reporting and significant attrition. Meta-analyses indicated significant reductions in risky drinking [Alcohol Use Disorders Identification Scale (AUDIT) > 8; three trials (7 data points), relative risk (RR) = 0.78, 95% confidence interval (CI) = 0.62-0.99)], but found no impact on past-month alcohol use (five trials, RR = 0.95, 95% CI = 0.89-1.02), binge drinking (five trials, RR = 0.97, 95% CI = 0.89-1.06) or 12-month marijuana use (two trials, RR = 0.98, 95% CI = 0.86-1.11). Narrative synthesis indicated some reductions in AOD-related assault rates and arrests, but were equivocal for quantity of alcohol consumed, 12-month illicit drug use, assault or abuse, motor vehicle accidents and hospital admissions.

CONCLUSIONS

Interventions to reduce alcohol and other drug use and harms applied to whole communities have resulted so far in small reductions in risky alcohol consumption, but have had little impact upon past month alcohol use, binge drinking or 12-month marijuana use and the studies have been subject to high risk of bias.

Differential intervention effectiveness of a universal school-based resilience intervention in reducing adolescent substance use within student subgroups: exploratory assessment within a cluster-randomised controlled trial

OBJECTIVES

Interventions addressing the individual and environmental protective factors of adolescents are suggested to have potential for reducing adolescent substance use. While universally delivered school-based substance use prevention interventions are common, previous studies have suggested variable effectiveness by subgroups of students. An exploratory study was undertaken to examine the differential effectiveness of a universal school-based resilience intervention on adolescent substance use and protective factors according to their sociodemographic and previous substance use.

DESIGN

Secondary analysis of data from a cluster-randomised controlled trial.

SETTING

32 Australian secondary schools.

PARTICIPANTS

Cohort of grade 7 students (n=3155) followed up in grade 10 (aged 15-16 years; 2014; n=2105).

INTERVENTION

Three-year universal school-based intervention implemented by school staff that targeted a range of student resilience protective factors (2012-2014).

MEASUREMENTS

Primary outcomes included: tobacco (recent, number of cigarettes) and alcohol (recent, 'risk' and number of drinks) use, and secondary outcomes included: marijuana (recent) and other illicit substance (recent) use, and aggregate individual and environmental protective factor scores. Generalised and linear mixed models examined interactions between treatment and student subgroups (gender; socioeconomic disadvantage (low/high); geographic location (major city/inner regional/outer regional-remote); and previous substance use (non-user/user)) at follow-up (36 models).

RESULTS

Analysis of student follow-up data showed no differential intervention effect for any substance use or protective factor outcome for any subgroup, with the exception of one differential effect found by socioeconomic status for the outcome of mean number of cigarettes smoked by recent smokers (p=0.003). There was no evidence of an intervention effect within the low (mean difference (MD) -12.89, 95% CI -26.00 to 0.23) or high (MD 16.36, 95% CI -1.03 to 33.76) socioeconomic subgroups.

CONCLUSIONS

No evidence of an intervention effect on substance use and protective factors was found according to student subgroups defined by sociodemographic characteristics or previous substance use.

TRIAL REGISTRATION NUMBER

ACTRN12611000606987.

Private troubles to public issue: empowering communities to reduce alcohol-related harm in Sabah, Malaysia

Summary

Alcohol is the number three contributor to the burden of disease worldwide so must remain a priority health promotion issue internationally. Malaysia is a Muslim country and alcohol-related harm was not seen as a priority until recently, because it only affects a minority of the population. Sabah has more than 30 different ethnic groups, and alcohol has a traditional role in the cultural practices of many of these groups. In 2009, the Intervention Group for Alcohol Misuse (IGAM) was formed, under the umbrella of Mercy Malaysia by a group of healthcare workers, academics, members of the Clergy and people who were previously alcohol-dependent concerned about the harmful effects of excessive alcohol consumption. IGAM in collaboration with other bodies have organized public seminars, visited villages and schools, encouraged the formation of a support group and trained healthcare professionals in health promotion intervention. The focus later changed to empowering communities to find solutions to alcohol-related harm in their community in a way which is sensitive to their culture. A standard tool-kit was developed using WHO materials as a guide. Village committees were formed and adapted the toolkit according to their needs. This strategy has been shown to be effective, in that 90% of the 20 committees formed are actively and successfully involved in health promotion to reduce alcohol-related harm in their communities.

Effects of Alcohol Interventions on Other Drug Use in the Cherokee Nation

OBJECTIVES

To evaluate effects of 2 alcohol prevention interventions-Communities Mobilizing for Change on Alcohol (CMCA), a community organizing intervention designed to reduce youth alcohol access, and CONNECT, an individual-level screening and brief intervention approach-on other drug use outcomes.

METHODS

We conducted a community intervention trial with quarterly surveys over 3 years (2012-2015) of high school students living within the jurisdictional service area of the Cherokee Nation in Oklahoma. We used generalized estimating equations and linear probability models to examine intervention spillover effects on other drug use.

RESULTS

We found significant reductions in drug use other than alcohol attributable to CMCA and CONNECT. CMCA was associated with a 35% reduction in chewing tobacco use, a 39% reduction in marijuana use, and a 48% reduction in prescription drug misuse. CONNECT was associated with a 26% reduction in marijuana use and a 31% reduction in prescription drug misuse.

CONCLUSIONS

Nonalcohol drug use was consistently reduced as a result of 2 theoretically and operationally distinct alcohol prevention strategies. Evaluations of alcohol prevention efforts should continue to include other drug use to understand the broader effects of such interventions.

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.

Timing of First Alcohol Use and First Sex in Male and Female Adolescents

PURPOSE

We examined associations between timing of first alcohol use and first sexual intercourse in adolescent males and potential differences in observed associations between males and females.

METHODS

Data were drawn from 4,079 male and 4,059 female participants of the National Longitudinal Study of Youth 1997, aged 12-16 years at the first assessment. Cox proportional hazards regression models were estimated predicting age at first sexual intercourse from age at first alcohol use, without and with adjustment for correlated sociodemographic and individual- and family-level risk factors. Analyses were conducted separately for males and females, with interactions between alcohol use and respondent sex (female vs. male) modeled in subsidiary analyses.

RESULTS

Onset of first drink was strongly predictive of earlier sexual intercourse for both males and females, with effects of drinking most pronounced for females during early adolescence.

CONCLUSIONS

Results highlight age at first alcohol use as an important predictor of sexual onset in male as well as female adolescents and suggest that effective prevention efforts focusing on delay of sexual intercourse might also focus on delay on alcohol use.

Effectiveness of a pragmatic school-based universal resilience intervention in reducing tobacco, alcohol and illicit substance use in a population of adolescents: cluster-randomised controlled trial

OBJECTIVES

Initiation of tobacco, alcohol and illicit substance use typically occurs during adolescence, with the school setting recommended to reduce adolescent substance use. Strengthening individual (eg, problem solving) and environmental (eg, caring relationships at school) resilience protective factors of adolescents has been suggested as a strategy for reducing substance use by adolescents; however, few studies have examined this potential. A study was conducted to investigate the effectiveness of a pragmatic school-based universal 'resilience' intervention in reducing the prevalence of tobacco, alcohol and illicit substance use, and increasing the individual and environmental protective factors of students.

DESIGN

A cluster-randomised controlled trial.

SETTING

Thirty-two Australian secondary schools (20 intervention; 12 control).

PARTICIPANTS

Cohort of grade 7 students followed-up in grade 10 (2014; aged 15-16 years).

INTERVENTION

A pragmatic intervention involving school staff selection and implementation of available programmes and resources targeting individual and environmental 'resilience' protective factors for all grade 7-10 students was implemented in schools (2012-2014). School staff were provided implementation support.

MEASUREMENTS

An online survey collected baseline and follow-up data for primary outcomes: tobacco (ever, recent) and alcohol (ever, recent, 'risk') use, and secondary outcomes: marijuana and other illicit substance use, and individual (six-factor subscales, aggregate) and environmental (three-factor subscales, aggregate) protective factor scores. Generalised and linear mixed models examined follow-up differences between groups.

RESULTS

Follow-up data from 2105 students (intervention=1261; control=844; 69% of baseline cohort) were analysed. No significant differences were found between intervention and control students for any primary (ever tobacco: OR 1.25, 95% CI 0.92 to 1.68, p=0.14; recent tobacco: OR 1.39, 95% CI 0.84 to 2.31, p=0.19; recent ever alcohol: OR 1.11, 95% CI 0.83 to 1.48, p=0.46; alcohol: OR 1.13, 95% CI 0.78 to 1.62, p=0.51; 'risk' alcohol: OR 0.98, 95% CI 0.70 to 1.36, p=0.89) or secondary outcomes (marijuana: OR 1.12, 95% CI 0.74 to 1.68, p=0.57; other illicit substance: OR 1.19, 95% CI 0.67 to 2.10, p=0.54; individual protective factors: MD=0, 95% CI -0.07 to 0.06, p=0.89; environmental protective factors: MD: -0.02, 95% CI -0.09 to 0.06, p=0.65).

CONCLUSIONS

The universally implemented pragmatic school-based intervention was not effective in reducing the prevalence of tobacco, alcohol or illicit substance use, or in increasing the protective factors of students.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register reference: ACTRN12611000606987.

25 Years of Complex Intervention Trials: Reflections on Lived and Scientific Experiences

For the past 25 years, I have led multiple group-randomized trials, each focused on a specific underserved population of youth and each one evaluated health effects of complex interventions designed to prevent high-risk behaviors. I share my reflections on issues of intervention and research design, as well as how research results fostered my evolution toward addressing fundamental social determinants of health and well-being. Reflections related to intervention design emphasize the importance of careful consideration of theory of causes and theory of change, theoretical comprehensiveness versus fundamental determinants of population health, how high to reach, and health in all policies. Flowing from these intervention design issues are reflections on implications for research design, including the importance of matching the unit of intervention to the unit of assignment, the emerging field of public health law research, and consideration of design options and design elements beyond and in combination with random assignment.

Systematic review of universal school-based 'resilience' interventions targeting adolescent tobacco, alcohol or illicit substance use: A meta-analysis

Universal school-based interventions that address adolescent 'resilience' may represent a means of reducing adolescent substance use, however previous systematic reviews have not examined the effectiveness of such an intervention approach. A systematic review was undertaken to 1) assess whether universal school-based 'resilience' interventions are effective in reducing the prevalence of tobacco, alcohol or illicit substance use by adolescents, and 2) describe such effectiveness per intervention characteristic subgroups. Eligible studies were peer-reviewed reports (1994-2015) of randomised controlled trials including participants aged 5-18years that reported adolescent tobacco, alcohol or illicit substance use, and implemented a universal school-based 'resilience' intervention (i.e. those addressing both individual (e.g. self-esteem) and environmental (e.g. school connectedness) protective factors of resilience). Trial effects for binary outcomes were synthesised via meta-analyses and effect sizes reported as odds ratios. Subgroup (by intervention type, prevention approach, setting, intervention duration, follow-up length) and sensitivity analyses (excluding studies at high risk of bias) were conducted. Nineteen eligible studies were identified from 16,619 records (tobacco: n=15, alcohol: n=17, illicit: n=11). An overall intervention effect was found for binary measures of illicit substance use (n=10; OR: 0.78, 95%CI: 0.6-0.93, p=0.007,Tau²=0.0, I²=0%), but not tobacco or alcohol use. A similar result was found when studies assessed as high risk of bias were excluded. Overall intervention effects were evident for illicit substance use within multiple intervention characteristic subgroups, but not tobacco and alcohol. Such results support the implementation of universal school-based interventions that address 'resilience' protective factors to reduce adolescent illicit substance use, however suggest alternate approaches are required for tobacco and alcohol use. PROSPERO registration: CRD42014004906.

The Living the Example Social Media Substance Use Prevention Program: A Pilot Evaluation

BACKGROUND

Adolescent substance use rates in rural areas of the United States, such as upstate New York, have risen substantially in recent years, calling for new intervention approaches in response to this trend. The Mentor Foundation USA conducts the Living the Example (LTE) campaign to engage youth in prevention using an experiential approach. As part of LTE, youth create their own prevention messages following a training curriculum in techniques for effective messaging and then share them via social media. This paper reports on a pilot evaluation of the LTE program.

OBJECTIVE

To conduct a pilot test of LTE in two rural high schools in upstate New York. We hypothesized that positive antidrug brand representations could be promoted using social media strategies to complement the Shattering the Myths (STM) in-person, event-based approach (hypothesis 1, H1), and that youth would respond positively and engage with prevention messages disseminated by their peers. We also hypothesized that exposure to the social media prevention messages would be associated with more positive substance use avoidance attitudes and beliefs, reductions in future use intentions, and decreased substance use at posttest (hypothesis 2, H2).

METHODS

We adapted a previously published curriculum created by the authors that focuses on branding, messaging, and social media for prevention. The curriculum consisted of five, one-hour sessions. It was delivered to participating youth in five sequential weeks after school at the two high schools in late October and early November 2016. We designed a pre- and posttest pilot implementation study to evaluate the effects of LTE on student uptake of the intervention and short-term substance use and related outcomes. Working at two high schools in upstate New York, we conducted a pilot feasibility evaluation of LTE with 9th-grade students (ie, freshmen) at these high schools. We administered a 125-item questionnaire online to capture data on media use; attitudes toward social media; next 30-day personal drug use intentions; personal reasons to use drugs; reasons participants believe their peers would use drugs; self-reported exposure to the LTE program; and receptivity to the LTE program, among those reporting exposure. We constructed multivariable logistic regression models to analyze the relationship between program receptivity and outcomes. First, in a cross-sectional logistic regression model, we regressed self-reported LTE message receipt on drug use intent and actions related to LTE messaging. Then, for analysis of participants with matched pre- and posttest responses, we used multilevel generalized estimating equation (GEE) techniques to model changes in behavior from baseline to follow-up.

RESULTS

Youth reported increased intentions to use marijuana (odds ratio [OR] 2.134, P=.02) between pre- and posttest. However, youth who reported exposure and receptivity to LTE reported a significant decrease in intentions (OR 0.239, P=.008). We observed a similar pattern for sedatives/sleeping pills-an increase in intentions overall (OR 1.886, P=.07), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.210, P=.02). We saw the same pattern for use of any drug-an increase in reported intentions overall (OR 2.141, P=.02), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.111, P=.004).

CONCLUSIONS

We observed some evidence of significant LTE program effects. Social media may be an effective strategy for peer-to-peer substance use prevention in the future. These findings point both to the potential of LTE and the social media diffusion model and to the need for more research on a larger scale with an expanded youth population in the future.

Friends' Alcohol-Related Social Networking Site Activity Predicts Escalations in Adolescent Drinking: Mediation by Peer Norms

PURPOSE

Adolescents' increased use of social networking sites (SNS) coincides with a developmental period of heightened risk for alcohol use initiation. However, little is known regarding associations between adolescents' SNS use and drinking initiation nor the mechanisms of this association. This study examined longitudinal associations among adolescents' exposure to friends' alcohol-related SNS postings, alcohol-favorable peer injunctive norms, and initiation of drinking behaviors.

METHODS

Participants were 658 high-school students who reported on posting of alcohol-related SNS content by self and friends, alcohol-related injunctive norms, and other developmental risk factors for alcohol use at two time points, 1 year apart. Participants also reported on initiation of three drinking behaviors: consuming a full drink, becoming drunk, and heavy episodic drinking (three or more drinks per occasion). Probit regression analyses were used to predict initiation of drinking behaviors from exposure to alcohol-related SNS content. Path analyses examined mediation of this association by peer injunctive norms.

RESULTS

Exposure to friends' alcohol-related SNS content predicted adolescents' initiation of drinking and heavy episodic drinking 1 year later, controlling for demographic and known developmental risk factors for alcohol use (i.e., parental monitoring and peer orientation). In addition, alcohol-favorable peer injunctive norms statistically mediated the relationship between alcohol-related SNS exposure and each drinking milestone.

CONCLUSIONS

Results suggest that social media plays a unique role in contributing to peer influence processes surrounding alcohol use and highlight the need for future investigative and preventive efforts to account for adolescents' changing social environments.

Natural Peer Leaders as Substance Use Prevention Agents: the Teens' Life Choice Project

In adolescent social groups, natural peer leaders have been found to engage in more frequent experimentation with substance use and to possess disproportionate power to affect the behavior and social choices of their associated peer followers. In the current exploratory study, we used sociometrics and social cognitive mapping to identify natural leaders of cliques in a seventh grade population and invited the leaders to develop anti-drug presentations for an audience of younger peers. The program employed social-psychological approaches directed at having leaders proceed from extrinsic inducements to intrinsic identification with their persuasive products in the context of the group intervention process. The goals of the intervention were to induce substance resistant self-persuasion in the leaders and to produce a spread of this resistance effect to their peer followers. To test the intervention, we compared the substance use behaviors of the selected leaders and their peers to a control cohort. The study found preliminary support that the intervention produced changes in the substance use behavior among the leaders who participated in the intervention, but did not detect a spread to non-leader peers in the short term. This descriptive study speaks to the plausibility of employing self-persuasion paradigms to bring about change in high-risk behaviors among highly central adolescents. In addition, it highlights the viability of applying social psychological principles to prevention work and calls for more research in this area.

Alcohol, tobacco and local control: A comparison of several community-based prevention trials

In North America there are significant similarities and differences in attitudes with regard to alcohol and tobacco on several dimensions, including the view taken of producers, suppliers and retailers, the products, and in the patterns of use. There are also contrasting as well as overlapping tendencies with regard to perceived problems associated with alcohol versus tobacco consumption, intervention initiatives and the resources available. These secular developments and forces provide a context for examining 10 community-based prevention trials which have sought to reduce harm from alcohol or tobacco using a range of strategies. The strategies have included education and information campaigns, media advocacy, counter-advertising and health promotion, controls on selling and consumption venues and other regulations reduced access to alcohol or tobacco, enhanced law enforcement and surveillance, and community organizing and coalition development. The paper outlines the challenges of undertaking community-based trials and interpreting their findings. It notes that interventions which show promise are those that pay particular attention to controls on access, include the environmental contexts of where the products are sold and distributed, and involve enforcement of public health polices. Controlling tobacco use may be made somewhat easier, than is the case for alcohol, with the vilification of the tobacco industry and marginalization and victimization of smokers. Nevertheless, the community trial provides opportunities for reducing harm related to alcohol and tobacco, particularly if resources are oriented in a coordinated way to those control measures and policies with the widest scope and greatest effectiveness.

Prevention of Alcohol- and Tobacco-Related Harms

Based on a definition of comprehensive prevention, the author submits prevention actions in alcohol and tobacco related problems to the question: “Education or control, must we choose?” After reviewing the history, the author describes the current panorama of health education actions and control before discussing some methodological and ethical questions concerning the methods and the actors of prevention. He tries to define “prevention ideal” – which must be distinguished from “ideal prevention” and its totalitarian abuse – to introduce the second part of his text which deals with the question of evaluation of the effectiveness of alcohol- and tobacco-related problems prevention.

The author confirms the efficacy of control measures, but also shows that education has a certain degree of efficacy, despite the dominant trends in Anglo-Saxons countries. He also shows that education is necessary in the context of many European countries. After discussing the issue of cost-effectiveness ratio, the author emphasise the need for global prevention taking into account cultural and political elements to ensure efficient as well as effective prevention and social acceptance of this prevention.

Effectiveness of Positive Youth Development Interventions: A Meta-Analysis of Randomized Controlled Trials

Positive youth development is thought to be essential to the prevention of adolescent risk behavior and the promotion of thriving. This meta-analysis examined the effects of positive youth development interventions in promoting positive outcomes and reducing risk behavior. Ten databases and grey literature were scanned using a predefined search strategy. We included studies that focused on young people aged 10-19 years, implemented a positive youth development intervention, were outside school hours, and utilized a randomized controlled design. Twenty-four studies, involving 23,258 participants, met the inclusion criteria and were included in the analysis. The impact of the interventions on outcomes including behavioral problems, sexual risk behavior, academic achievement, prosocial behavior and psychological adjustment were assessed. Positive youth development interventions had a small but significant effect on academic achievement and psychological adjustment. No significant effects were found for sexual risk behaviors, problem behavior or positive social behaviors. Intervention effects were independent of program characteristics and participant age. Low-risk young people derived more benefit from positive youth development interventions than high-risk youth. The studies examined had several methodological flaws, which weakened the ability to draw conclusions. Substantial progress has been made in the theoretical understanding of youth development in the past two decades. This progress needs to be matched in the intervention literature, through the use of high-quality evaluation research of positive youth development programs.

Qualitative process evaluation of an Australian alcohol media literacy study: recommendations for designing culturally responsive school-based programs

Background

Alcohol media literacy programs seek to mitigate the potentially harmful effects of alcohol advertising on children’s drinking intentions and behaviours through equipping them with skills to challenge media messages. In order for such programs to be effective, the teaching and learning experiences must be tailored to their specific cultural context. Media in the Spotlight is an alcohol media literacy program aimed at 9 to 12 year old Australian children. This study evaluates the process and implementation of the program, outlining the factors that facilitated and inhibited implementation. From this evaluation, a pedagogical framework has been developed for health professionals implementing culturally responsive programs in school settings.

Methods

Process measures included: semi-structured interviews with teachers before and after the program was implemented (n = 11 interviews), program evaluation questionnaires completed by children (n = 166), lesson observations completed by teachers (n = 35 observations), and reflective journal entries completed by the researcher (n = 44 entries). A thematic analysis approach was used to analyse all of the data sets using NVivo. Inductive coding was used, whereby the findings were derived from the research objectives and multiple readings and interpretations of the data.

Results

Five key pedagogical considerations were identified that facilitated implementation. These were: connecting to the students’ life worlds to achieve cultural significance; empowering students with real-world skills to ensure relevance; ensuring programs are well structured with strong connections to the school curriculum; creating developmentally appropriate activities while providing a range of assessment opportunities; and including hands-on and interactive activities to promote student engagement. Three potential inhibitors to implementing the alcohol media literacy program in upper-elementary school classrooms were identified. These included topic sensitivities, classroom management challenges, and fitting new programs into already busy school schedules.

Conclusion

Overall, the program content and individual lessons were well received by the teachers and students. The lessons learned from the development, implementation and evaluation of this program can provide health professionals with key pedagogical strategies for designing culturally responsive educational programs. Culturally responsive programs are critical for ensuring interventions are effective for their specific context.

Adolescent Smoking Cessation: Development of a School Nurse Intervention

The purpose of this study was to examine the feasibility of a range of strategies to engage and to enhance secondary school nurse involvement in teenage smoking prevention and cessation. School nurses were willing to assist students to quit smoking, but they felt unprepared. Information provided by nurses involved in a three-stage review, pilot-testing, and trial design resulted in the development of a resource for nurses. This resource comprised individual student approaches (brief intervention based on motivational interviewing and written activities designed to help students examine their smoking behavior), approaches to assist parents (letter of support for parents of students who smoke), and school newsletter items. Each component of the resource was found by school nurses to be appropriate, useful, and complementary to their other school-wide approaches to assist adolescents to quit smoking. Nurses also reported an interest to expand or to enhance their smoking cessation role in the school.

The Health Promoting Schools Framework: Known Unknowns and an Agenda for Future Research

The World Health Organization’s Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools’ “core business” by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children’s basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools.

Development and evaluation of an intervention providing insight into the tobacco industry to prevent smoking uptake: a mixed-methods study

Background

Smokers who start smoking at an early age are less likely to quit and more likely to die from their habit. Evidence from the USTruth®campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing smoking uptake.

Objectives

In an exploratory study, to develop, pilot and provide preliminary evidence of the acceptability and effectiveness of Operation Smoke Storm, a school-based intervention based on the premise of theTruth®campaign, to prevent smoking uptake.

Design

Mixed-methods, non-randomised controlled study. Component 1 was delivered to Year 7 students, and student focus groups and teacher interviews were conducted to refine the lessons and to develop components 2 and 3. The revised Year 7 lessons and accompanying family booklet were delivered to new Year 7 students 1 year later in one school only; Year 8 students in both schools received the booster session.

Setting and participants

Students in Years 7–8 (aged 11–13 years) in two UK schools.

Intervention

A three-component intervention comprising (1) three 50-minute classroom-based sessions in Year 7 in which students acted as secret agents to uncover industry practices through videos, quizzes, discussions and presentations; (2) an accompanying family booklet containing activities designed to stimulate discussions about smoking between parents and students; and (3) a 1-hour interactive classroom-based booster session for Year 8 students, in which students learnt about tobacco marketing strategies from the perspectives of an industry executive, a marketing company and a health campaigner.

Main outcome measures

Odds ratios to compare the self-reported prevalence of ever smoking and susceptibility to smoking in Year 8 students after the delivery of the booster session in study schools compared with students in local control schools. Qualitative data on acceptability of the intervention.

Results

The combined prevalence of ever smoking and susceptibility increased from 18.2% in Year 7 to 33.8% in Year 8. After adjusting for confounders there was no significant difference in the odds of a Year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls [adjusted odds ratio (aOR) 1.28, 95% confidence interval (CI) 0.83 to 1.97;p = 0.263] and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58;p = 0.549). Students mostly enjoyed the intervention and acquired new knowledge that appeared to strengthen their aversion to smoking. Teachers liked the ‘off-the-shelf’ nature of the resource, although they highlighted differences by academic ability in the extent to which students understood the messages being presented. Use of the family component was low but it was received positively by those parents who did engage with it.

Limitations

Logistical difficulties meant that students’ responses in Year 7 and Year 8 could not be linked; however, baseline smoking behaviours differed little between intervention and control schools, and analyses were adjusted for confounders measured at follow-up.

Conclusions

Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education but it does not appear to have reduced smoking and susceptibility.

Future work

The lack of a strong signal for potential effectiveness, considered alongside logistical difficulties in recruiting and working with schools, suggests that a fully powered cluster randomised trial of the intervention is not warranted.

Funding

The National Institute for Health Research (NIHR) Public Health Research programme.

Effectiveness of Positive Youth Development Interventions: A Meta-Analysis of Randomized Controlled Trials

Positive youth development is thought to be essential to the prevention of adolescent risk behavior and the promotion of thriving. This meta-analysis examined the effects of positive youth development interventions in promoting positive outcomes and reducing risk behavior. Ten databases and grey literature were scanned using a predefined search strategy. We included studies that focused on young people aged 10-19 years, implemented a positive youth development intervention, were outside school hours, and utilized a randomized controlled design. Twenty-four studies, involving 23,258 participants, met the inclusion criteria and were included in the analysis. The impact of the interventions on outcomes including behavioral problems, sexual risk behavior, academic achievement, prosocial behavior and psychological adjustment were assessed. Positive youth development interventions had a small but significant effect on academic achievement and psychological adjustment. No significant effects were found for sexual risk behaviors, problem behavior or positive social behaviors. Intervention effects were independent of program characteristics and participant age. Low-risk young people derived more benefit from positive youth development interventions than high-risk youth. The studies examined had several methodological flaws, which weakened the ability to draw conclusions. Substantial progress has been made in the theoretical understanding of youth development in the past two decades. This progress needs to be matched in the intervention literature, through the use of high-quality evaluation research of positive youth development programs.

The Effect of Enforcement on Merchant Compliance with the Minimum Legal Drinking Age Law

The aim of this paper is to evaluate the effectiveness of an intervention to deter underage alcohol sales by targeting alcohol retailers instead of underage youth. A quasi-experiment using a repeated-intervention design was conducted for a random sample (n=143) of off-sale alcohol outlets from across New Orleans. Compliance checks of off-sale outlets were conducted at baseline, two months after the intervention, and eight months after the intervention. At baseline, only 11.2% (16/143) of outlets were compliant. Following the intervention, compliance increased to 39.9% (p<.001). The increase in compliance was greatest among outlets receiving citations for non compliance (23/45, 51.1%; p<.001); however, a significant increase in compliance (34/98, 34.7%; p<.001) was also observed among outlets that did not receive a citation but were only exposed to the media coverage of the issuing of citations. A small residual effect of the intervention persisted at eight months post intervention among the outlets receiving citations for non-compliance. The study demonstrates that a deterrence strategy composed of compliance checks and the threat of compliance checks was effective in increasing alcohol retailer compliance with the minimum legal drinking age law. Given the limited effectiveness of general deterrence strategies in targeting other illegal alcohol use behaviors, these findings suggest general deterrence strategies are less effective when the behavior targeted is influenced by physiologic and social externalities, as is the case for underage alcohol consumers, rather than by costs and benefits, as is the case for alcohol retailers.

Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review

CONTEXT

Parenting interventions may prevent adolescent substance use; however, questions remain regarding the effectiveness of interventions across substances and delivery qualities contributing to successful intervention outcomes.

OBJECTIVE

To describe the effectiveness of parent-focused interventions in reducing or preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal intervention targeted participants, dosage, settings, and delivery methods.

DATA SOURCES

PubMed, PsycINFO, ERIC, and CINAHL.

STUDY SELECTION

Randomized controlled trials reporting adolescent substance use outcomes, focusing on imparting parenting knowledge, skills, practices, or behaviors.

DATA EXTRACTION

Trained researchers extracted data from each article using a standardized, prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest plots was used to summarize findings.

RESULTS

A total of 42 studies represented by 66 articles met inclusion criteria. Results indicate that parenting interventions are effective at preventing and decreasing adolescent tobacco, alcohol, and illicit substance use over the short and long term. The majority of effective interventions required ≤12 contact hours and were implemented through in-person sessions including parents and youth. Evidence for computer-based delivery was strong only for alcohol use prevention. Few interventions were delivered outside of school or home settings.

LIMITATIONS

Overall risk of bias is high.

CONCLUSIONS

This review suggests that relatively low-intensity group parenting interventions are effective at reducing or preventing adolescent substance use and that protection may persist for multiple years. There is a need for additional evidence in clinical and other community settings using an expanded set of delivery methods.

Violence-Related Outcomes of the D.A.R.E. Plus Project

The objectives of this study were to examine outcomes of the Minnesota D.A.R.E. Plus Project on violence-related behaviors among middle school students and mediation analyses that test how the intervention was effective in reducing physical and verbal violence. Twenty-four schools were randomly assigned to the D.A.R.E. middle school curriculum, the D.A.R.E. Plus multicomponent intervention, or control. The study cohort completed a self-report questionnaire at baseline and two follow-ups. The results showed that boys had higher rates of violence and victimization than girls. The D.A.R.E. Plus program was more effective in preventing violence among boys than among girls. It appears that the small behavioral effect that D.A.R.E. Plus did demonstrate on physical and verbal violence among boys was entirely mediated by a decrease of norms that support violence, an increase in outcome expectancies about being violence-free, and an increase in parental consequences for fighting.

Modifying Pro-Drug Risk Factors in Adolescents: Results From Project ALERT

The objective of this study was to evaluate the impact of a revised state-of-the-art drug prevention program, Project ALERT, on risk factors for drug use in mostly rural midwestern schools and communities. Fifty-five middle schools from South Dakota were randomly assigned to treatment or control conditions. Treatment-group students received 11 lessons in Grade 7 and 3 more in Grade 8. Effects for 4,276 eighth graders were assessed 18 months after baseline. Results indicate that Project ALERT had statistically significant effects on all the targeted risk factors associated with cigarette and marijuana use and more modest gains with the pro-alcoholrisk factors. The program helped adolescents at low, moderate, and high risk for future use, with the effect sizes typically stronger for the low- and moderate-risk groups. Thus, school-based drug prevention programs can lower risk factors that correlate with drug use, help low- to high-risk adolescents, and be effective in diverse school environments.

Prevention and Counseling Psychology

This article advocates the need for a much stronger emphasis on and commitment to the science and practice of prevention in counseling psychology. Historical and recent developments in the profession are highlighted, as are the changing U.S. demographics and societal needs that mandate an enhanced prevention focus for the field. A prevention-based agenda of four fundamental goals for counseling psychology is articulated. The goals include eight training domains and objectives as well as skills needed to support a prevention agenda for counseling psychology. Barriers and adjustments needed to give renewed vitality toward prevention are discussed. Prevention resources and funding opportunities are presented.

Best Practice Guidelines on Prevention Practice, Research, Training, and Social Advocacy for Psychologists

Preventive interventions have been shown to successfully aid the development of children, youths, and adults and avert maladjustment in individuals at risk for negative outcomes. Continued scientific advancement of preventive interventions is crucial to further the health of U.S. children, youths, and families. This article presents 15 best practice guidelines on prevention practice, research, training, and social advocacy for psychology. These guidelines articulate clear standards and a framework for moving the profession toward improving the well-being of a greater number of individuals and communities. The guidelines are intended to assist psychologists in evaluating their preparation for engaging in prevention work and in furthering their understanding through increased knowledge, skills, and experience in prevention.

Applying Research and Theory in Program Planning: An Example from a Nutrition Education Intervention

Public health practitioners often hear that effective interventions are theory-based and draw from practice and research. However, operationalizing this integration of theory, research, and practice to develop a concrete program that can be delivered in communities is a difficult task that many practitioners feel illequipped to accomplish. This article describes the steps and processes used in designing the Teens Eating for Energy at School (TEENS) study, a school-based nutrition education program. The goal of TEENS is to increase middle and junior high students’ intake of fruits, vegetables, and lower fat foods to reduce their future risk of cancer. In this article, the authors describe a 10-step process of creating health behavior change programs. The authors use examples from the TEENS study to illustrate how a very concrete, community-based intervention is developed from behavioral theory, research, and knowledge of practice and the target audience.

Secondary Effects of an Alcohol Prevention Program Targeting Students and/or Parents

The secondary effects of an alcohol prevention program (PAS) on onset of weekly smoking and monthly cannabis use are examined among >3000 Dutch early adolescents (M age=12.64) randomized over four conditions: 1) parent intervention (PI), 2) student intervention (SI), 3) combined intervention (CI) and 4) control condition (CC). Rules about alcohol, alcohol use, and adolescents' self-control were investigated as possible mediators. PI had a marginal aversive effect, slightly increasing the risk of beginning to smoke at T1, and increased the likelihood of beginning to use cannabis use at T1 and T2. SI delayed the onset of monthly cannabis use at T3. CI increased the risk to use cannabis at T3. No mediational processes were found. In conclusion, though this study show mixed results, negative side effects of the PI were found, particularly at earlier ages. Moreover, these results indicate the need for multi-target interventions.

Adolescent Drinking and Alcohol Policy

Policy approaches to prevention have considerable promise for addressing underage drinking and its associated problems. Based on the available evidence, the most effective policies appear to be (a) taxation or price increases, (b) increases in the minimum drinking age, and (c) graduated licensing or zero tolerance. Random breath testing and sobriety checkpoints also appear promising, although there is little evidence for their effectiveness specifically with young people. Major changes in the conditions of sale (e.g., privatization) may also affect the availability of alcohol to young people and thus underage drinking. The evidence is less convincing, however, for the effects of more modest license restrictions (e.g., limiting outlet density, hours of sale), responsible beverage service, advertising restrictions, warning labels, keg registration, and school policies. It is clear from the available research that no policy can be effective unless it is accompanied by enforcement and by awareness on the part of the intended targets of both the policy and the enforcement efforts.

A component-centered meta-analysis of family-based prevention programs for adolescent substance use

Although research has documented the positive effects of family-based prevention programs, the field lacks specific information regarding why these programs are effective. The current study summarized the effects of family-based programs on adolescent substance use using a component-based approach to meta-analysis in which we decomposed programs into a set of key topics or components that were specifically addressed by program curricula (e.g., parental monitoring/behavior management,problem solving, positive family relations, etc.). Components were coded according to the amount of time spent on program services that targeted youth, parents, and the whole family; we also coded effect sizes across studies for each substance-related outcome. Given the nested nature of the data, we used hierarchical linear modeling to link program components (Level 2) with effect sizes (Level 1). The overall effect size across programs was .31, which did not differ by type of substance. Youth-focused components designed to encourage more positive family relationships and a positive orientation toward the future emerged as key factors predicting larger than average effect sizes. Our results suggest that, within the universe of family-based prevention, where components such as parental monitoring/behavior management are almost universal, adding or expanding certain youth-focused components may be able to enhance program efficacy.

Effectiveness of a Dutch community-based alcohol intervention: Changes in alcohol use of adolescents after 1 and 5 years

BACKGROUND

Underage alcohol drinking is a severe public health problem. The aim of this study was to evaluate the short- and long-term effects of a Dutch community-based alcohol intervention on alcohol use of adolescents in the second and fourth grade of high school.

METHODS

The community intervention integrated health education, regulation, and enforcement in multiple settings, targeting adolescents as well as their environments. In order to evaluate effectiveness, a quasi-experimental pretest posttest design was used based on three independent cross-sectional surveys in 2003, 2007 and 2011, resulting in an analytical sample of approximately 5700 and 3100 adolescents in the intervention and reference region, respectively. For the main analyses, we compared the change in recent alcohol use and binge drinking in the intervention region with the reference region. Linear regression was used to obtain (adjusted) prevalence of alcohol use.

RESULTS

During the study period, there was an overall decline in the prevalence of alcohol use. After 1 year of intervention, the decline was 11% (P<0.01) and 6% (P<0.01) stronger in the intervention region as compared to the reference region, for recent alcohol use and binge drinking respectively. This effect was restricted to the second grade and remained after 5 years of intervention. No clear subgroup effects or confounding were observed for ethnicity, gender or educational level.

CONCLUSIONS

The Dutch community intervention appears to be effective on the short- and long-term in reducing the prevalence of recent alcohol use and binge drinking of (underage) adolescents in the second grade of high school.

The critical role of communications in a multilevel obesity-prevention intervention: Lessons learned for alcohol educators

OBJECTIVE

Multilevel interventions to prevent underage drinking are more effective than individual-level strategies, and messaging campaigns are key to such approaches. Recognizing the benefits of translating best practices across public health domains, this paper details the communications campaign from Shape Up Somerville (SUS), an exemplar for multilevel community-based approaches to address pediatric obesity, highlighting lessons learned for alcohol educators.

METHODS

All elements of SUS, including the communications strategy, were developed collaboratively with local partners. Communication initiatives included community-engaged brand development to unify diverse intervention components; school-based communications to promote new opportunities for healthy eating and physical activity; and media partnerships to promote healthy behaviors community-wide.

RESULTS

The overall SUS intervention was effective in reducing prevalence of overweight/obesity among first- to third-graders in Somerville relative to control communities. Process evaluation showed that communications successfully reached diverse community segments and raised awareness of and receptivity to changes.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Communications campaigns are essential components of multilevel interventions addressing public health challenges including obesity and underage drinking. Such communications should be developed collaboratively with the target audience and stakeholders, designed to engage community members at multiple levels through multiple channels within a systems framework, and sustained through local partnerships.

Prevention trial in the Cherokee Nation: design of a randomized community trial

Despite advances in prevention science and practice in recent decades, the U.S. continues to struggle with significant alcohol-related risks and consequences among youth, especially among vulnerable rural and Native American youth. The Prevention Trial in the Cherokee Nation is a partnership between prevention scientists and Cherokee Nation Behavioral Health to create, implement, and evaluate a new, integrated community-level intervention designed to prevent underage drinking and associated negative consequences among Native American and other youth living in rural high-risk underserved communities. The intervention builds directly on results of multiple previous trials of two conceptually distinct approaches. The first is an updated version of CMCA, an established community environmental change intervention, and the second is CONNECT, our newly developed population-wide intervention based on screening, brief intervention, and referral to treatment (SBIRT) research. CMCA direct-action community organizing is used to engage local citizens to address community norms and practices related to alcohol use and commercial and social access to alcohol among adolescents. The new CONNECT intervention expands traditional SBIRT to be implemented universally within schools. Six key research design elements optimize causal inference and experimental evaluation of intervention effects, including a controlled interrupted time-series design, purposive selection of towns, random assignment to study condition, nested cohorts as well as repeated cross-sectional observations, a factorial design crossing two conceptually distinct interventions, and multiple comparison groups. The purpose of this paper is to describe the strong partnership between prevention scientists and behavioral health leaders within the Cherokee Nation, and the intervention and research design of this new community trial.