Project success' effects on substance use-related attitudes and behaviors: a randomized controlled trial in alternative high schools

Substance Use Prevention Programming for Adolescents and Young Adults: A Mixed-Method Examination of Substance Use Perceptions and Use of Prevention Services

Although substance use problems are highly prevalent among adolescents and emerging adults, this population does not regularly receive substance use prevention programming in their communities. Low perceived risk of substance use, which is linked to actual behavior, may contribute to low rates of engagement in community prevention efforts for substance use. To examine this, the current study used a mixed methods approach to: (1) examine the relationship between engagement in prevention education and substance use; and, (2) analyze qualitative data on education programs offered in the community to help identify strengths and gaps in prevention resources. Method: Quantitative and qualitative data were collected from adolescents (age 13-18) and young adults (age 19-25) living in the Southeast, recruited from local schools and community events to participate in a preventive intervention focused on prevention of HIV, substance use, and other risky behaviors. Prior to engagement in this intervention, self-report questionnaires were completed by adolescents assessing: substance use, perceived risk, and engagement in substance use education classes. Focus groups were also conducted with adolescents recruited from a local high school and young adults recruited from local colleges to obtain additional information about engagement in education programs. Results: Regarding perceived risk, 71.8% of adolescents reported moderate to great risk in having five or more drinks once or twice a week and 43% of adolescents reported moderate to great risk in smoking cannabis once or twice a week. Forty-four percent of adolescents had talked to one of their parents about the dangers of tobacco, alcohol, or drug use in the past year. Further, 18% of adolescents had been to a class or program on prevention of alcohol and other drug abuse in the past month and 50.7% had heard, read, or watched an advertisement about prevention of substance use in the past year. Qualitative results Eight overarching themes, each with its own sub-themes, emerged from the participant's responses during the focus groups. Each is described below with representative quotes provided throughout for illustrative purposes. Conclusions: Findings revealed several gaps in resources identified by adolescents and young adults that are needed to adequately address substance use, which provide important next steps for substance use prevention among youth.

Personal agency and alcohol abstinence self-efficacy among incarcerated women

Incarcerated women with alcohol use disorders (AUDs) have unique treatment needs. Behavior change models emphasize self-efficacy in making changes to alcohol use, but have not been tested in samples of incarcerated women. Personal agency in several domains was examined as a correlate of alcohol abstinence self-efficacy in a sample of 173 incarcerated women with AUDs. Lower alcohol cravings (β = -0.19, p = .029), greater self-care (β = 0.17, p = .012), and less engagement in transactional sex (β = -0.48, p = .007) were associated with greater self-efficacy. Intrapersonal and interpersonal agency influence incarcerated women's self-efficacy.

Effectiveness of a complex intervention on smoking in adolescents: A cluster-randomized controlled trial

Tobacco smoking is a major preventable cause of death, and a significant public health problem worldwide. Most smokers begin in adolescence, age at which they are more susceptible to nicotine addiction. The prevalence of smoking in adolescence is considerable. Therefore, it would be convenient to incorporate smoking prevention programs in the school environment. It is necessary to provide evidence of its effectiveness. The primary objective of the study was to evaluate the effectiveness of a teacher-delivered school-based intervention on the initiation of smoking in adolescents (ITACA smoking prevention education program). A multi-center cluster randomized trial was designed. Twenty-two secondary schools from Spain were enrolled in 2 successive cohorts, from 2010 to 2011. The intervention consisted in the application of the ITACA smoking prevention education program. A 4-year cognitive-behavioral intervention that is based on the social-influences model and is integrated into schools' regular curricular activities. A total of 1055 students were surveyed before the intervention (age: 12-13 years-old), and at the third year of the intervention (age: 14-15 years-old) of a 4-year education program. The outcome measures were daily and weekly use of cigarettes, and initiation of smoking. There was no evidence that the intervention impacted the incidence of regular smoking (OR = 1.08; 95% CI: 0.50-2.33) or the initiation of smoking (OR = 1.09; 95% CI: 0.56-1.72). This trial provides evidence supporting the non-effectiveness of a complex educational smoking prevention program at 3 years after the intervention.

TRIAL REGISTRATION NUMBER

Current Controlled Trials: NCT01602796.

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.

A Systematic Review of School-Based Alcohol and other Drug Prevention Programs

BACKGROUND

Alcohol use in adolescents constitutes a major public health concern. Europe is the heaviest drinking region of the world. Several school-based alcohol prevention programs have been developed but it is not clear whether they are really effective. The present study was aimed at identifying the typology with the best evidence of effectiveness in European studies.

METHODS

A systematic search of meta-analyses and/or randomized controlled trials (RCTs) on interventions school-based prevention programs aimed at preventing alcohol consumption or changing the attitudes to consume alcohol.

RESULTS

A meta-analysis published in 2011 and 12 RCTs more recently published were identified. The meta-analysis evaluated 53 RCTs but only 11.3% of them were conducted in Europe. Globally, 23 RCTs (43.4%) showed some evidence of effectiveness, and 30 RCTs (56.6%) did not find significant difference between the groups. According to the conclusions of the meta-analysis, the Unplugged program should be considered as a practice option in Europe. Among the other 12 RCTs, 42% were conducted in Europe. Globally, 7 studies (58.3%) achieved positive results, and 5 studies (41.7%) did not find significant differences or produced a mixed pattern of results. Three of the 5 European trials (60%) used the Unplugged program with positive results.

CONCLUSION

Even if further studies should be conducted to confirm these results, Unplugged appears to be the prevention project with the best evidence of effectiveness in European studies.

Universal school-based prevention for illicit drug use

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Alcohol, tobacco, and other drug misuse prevention and cessation programming for alternative high school youth: a review

BACKGROUND

Relative to youth in regular high schools, alternative high school (AHS) youth are at high risk for alcohol, tobacco, and other drug (ATOD) misuse. Prevention and cessation efforts are needed for this population.

METHODS

A systematic, exhaustive literature search was completed to identify ATOD misuse prevention and cessation research studies with AHS youth.

RESULTS

For the AHS population, 23 ATOD misuse prevention or cessation program evaluations were located. This review indicated that successful efforts have focused on instruction in motivation enhancement, life coping skills, and decision making.

CONCLUSIONS

Alcohol, tobacco, and other drug misuse prevention and cessation programming for AHSs is effective, delivered in the classroom or as a school-based clinic. There is little evidence, though, that this programming is effective when delivered through other modalities such as via computer or bridging beyond the school setting. More research and application of evidence-based programming are recommended for youth in AHS settings.

School-based programmes for preventing smoking

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Mental health and the school environment: secondary schools, promotion and pathways to care

PURPOSE OF REVIEW

Addressing youth mental health in secondary schools has received greater attention globally in the past decade. It is essential that educators, mental health experts, researchers, and other related service providers understand the most current research findings to inform policy making, and identify priority areas for the development of future interventions and research strategies. This review describes literature during the past year on school-based mental health programs addressing mental health promotion, prevention, early identification and intervention/treatment.

RECENT FINDINGS

In contrast to the abundance of school-based mental health programs, the evidence of program effectiveness, safety and cost-effectiveness in this area is somewhat insufficient, mostly due to the lack of rigorous research designs, the heterogeneity of school environments, and the complexities of interventions that require multisector collaboration.

SUMMARY

Although the opportunity in school mental health is substantial, much yet needs to be done to develop and evaluate interventions that can be proven to be effective, safe and cost-effective. Mental health literacy may be an appropriate start that will help to set the foundation for mental health promotion, prevention and intervention.