Efficacy of a Brief Intervention to Reduce Substance Use and Human Immunodeficiency Virus Infection Risk Among Latino Youth

Pilot Implementation of Guiando Buenas Decisiones, an Evidence-Based Parenting Program for Spanish-Speaking Families, in Pediatric Primary Care in a Large, U.S. Health System: A Qualitative Interview Study

Adolescent substance use is a significant public health problem in the United States and Hispanic youth engage in substance use services at lower rates than other groups. For this under-served group, prevention services delivered in non-stigmatized, non-specialty care settings may increase access to the services. We describe findings from a feasibility pilot of the implementation of a virtual version of Guiando Buenas Decisiones (GBD), a universal, group-based substance use prevention program for parents. It was conducted with Spanish-speaking families and delivered, virtually, in pediatric primary care in a large healthcare system in the U.S. Through qualitative interviews with pediatricians (n =7)  and parents (n = 26), we explored potential barriers and facilitators of GBD enrollment and engagement. Parents and pediatricians alike noted the dearth of universal prevention programming in Spanish and that GBD could help address the need for linguistically appropriate programming. Parents liked the curriculum content, materials and videos; they felt the focus on strengthening family bonds, setting clear expectations and guidelines, the use of family meetings, and the positive tools provided for navigating family conflict were well-aligned with their cultural and family values. Feedback from parents was helpful for informing more personalized and attentive approaches to program outreach and recruitment methods, and for adaptation of recruitment fliers and letters. In this pediatric primary care context serving an underserved population, we found virtual GBD feasible to implement, acceptable and appealing to parents, and judged by pediatricians as a promising, much-needed addition to their prevention armamentarium.

Interventions Promoting Condom Use Among Youth: A Systematic Review

In many European and other high-income, Western countries, condom use has been decreasing among youth. A variety of promotional strategies to increase condom use exists. Our systematic review aimed to identify effective elements in interventions aimed at increasing condom use in youth. We searched databases (2010-2021) for intervention studies promoting condom use among youth in Western, high-income countries. The primary outcome was condom use; the secondary outcome was sexually transmitted infection (STI) diagnoses. Effectiveness per intervention was defined based on the percentage of comparisons that showed significant increases in condom use and significant decreases in STIs. We compared the effectiveness of interventions for different participant-, intervention- and methodological characteristics. We included 74 papers describing 85 interventions in the review. Overall, the median intervention effectiveness was 33.3% (interquartile range = 0%-66.7%) for condom use and 0% (interquartile range = 0%-100%) for STI diagnoses. Intervention effectiveness for condom use was significantly higher in interventions tailored towards females and males specifically, compared with interventions applied to both sexes combined. Our findings show the difficulty in designing effective interventions to increase condom use among youth. Interventions aimed at either females or males were more effective in increasing condom use.

iVY: protocol for a randomised clinical trial to test the effect of a technology-based intervention to improve virological suppression among young adults with HIV in the USA

INTRODUCTION

Young adults with HIV (YWH) experience worse clinical outcomes than adults and have high rates of substance use (SU) and mental illness that impact their engagement in care and adherence to antiretroviral therapy (ART). The intervention for Virologic Suppression in Youth (iVY) aims to address treatment engagement/adherence, mental health (MH) and SU in a tailored manner using a differentiated care approach that is youth friendly. Findings will provide information about the impact of iVY on HIV virological suppression, MH and SU among YWH who are disproportionately impacted by HIV and at elevated risk for poor health outcomes.

METHODS AND ANALYSIS

The iVY study will test the effect of a technology-based intervention with differing levels of resource requirements (ie, financial and personnel time) in a randomised clinical trial with an adaptive treatment strategy among 200 YWH (18-29 years old). The primary outcome is HIV virological suppression measured via dried blood spot. This piloted and protocolised intervention combines: (1) brief weekly sessions with a counsellor via a video-chat platform (video-counselling) to discuss MH, SU, HIV care engagement/adherence and other barriers to care; and (2) a mobile health app to address barriers such as ART forgetfulness, and social isolation. iVY has the potential to address important, distinct and changing barriers to HIV care engagement (eg, MH, SU) to increase virological suppression among YWH at elevated risk for poor health outcomes.

ETHICS AND DISSEMINATION

This study and its protocols have been approved by the University of California, San Francisco Institutional Review Board. Study staff will work with a Youth Advisory Panel to disseminate results to YWH, participants and the academic community.

TRIAL REGISTRATION NUMBER

NCT05877729.

Screening for Adolescent Risk Behaviors: Preliminary Evidence for a Family Functioning Tool

BACKGROUND

Family functioning is associated with adolescent drug use, alcohol use, cigarette use, and sexual risk behaviors. Assessing adolescents for family functioning, commonly associated with multiple risk behaviors, may help identify adolescents at risk for adverse health outcomes. This study examined whether a latent family functioning construct, encompassing multiple dimensions of family functioning, was associated with adolescents' substance use and sexual risk behaviors.

METHOD

This study used data harmonization with three intervention trials, including data from 1451 adolescents (M = 13.6, SD = 1.0), to perform a full-information item bifactor analysis on 46 family functioning items from five pre-existing family functioning measures. Regression analysis was used to examine the association between the identified subset of items and the following outcomes: cigarette use, alcohol use, drug use, and condom use.

RESULTS

Bifactor analysis identified a 26-item latent family functioning construct. Regression analysis indicated that a 26-item latent family functioning construct was associated negatively with lifetime and past 90-day cigarette use, alcohol use, and drug use.

CONCLUSION

In sum, the multi-dimensional latent family functioning construct may target specific barriers to risk screening in adolescent populations, including time constraint, hesitancy in discussing sensitive health topics, and use culturally appropriate and age-appropriate assessments.

Family Interventions to improve mental, emotional, and behavioral health outcomes among Latinx youth: A systematic review

Background

The Latinx population is the largest and fastest-growing segment of the U.S. While the vast majority of Latinx children are U.S.-born, over half are growing up in a family where they live with at least one foreign-born parent. Despite research showing that Latinx immigrants are less likely to experience mental, emotional, and behavioral (MEB) health issues (e.g., depression, conduct disorder, substance misuse), their children have one of the country's highest rates of MEB disorders. To address the MEB health of Latinx children and their caregivers, culturally grounded interventions have been developed, implemented, and tested to promote MEB health. The purpose of this systematic review is to identify these interventions and summarize their findings.

Methods

We searched PubMed, PsycINFO, ERIC, Cochrane Library, Scopus, HAPI, ProQuest, and ScienceDirect databases from 1980 through January 2020 as part of a registered protocol (PROSPERO) following PRISMA guidelines. Our inclusion criteria were randomized controlled trials of family interventions among a predominantly Latinx sample. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias Tool.

Findings

Initially, we identified 8,461 articles. After going through the inclusion criteria, 23 studies were included in the review. We found a total of 10 interventions, with Familias Unidas and Bridges/Puentes having the most information available. Overall, 96% of studies demonstrated their effectiveness in addressing MEB health, namely substance use, alcohol and tobacco use, risky sexual behaviors, conduct disorder, and internalizing symptoms among Latinx youths. Most interventions focused on improving parent-child relationships as the main mechanism to improve MEB health among Latinx youths.

Discussion

Our findings show that family interventions can be effective for Latinx youths and their families. It is likely that including cultural values such as familismo and issues related to the Latinx experience such as immigration and acculturation can help the long-term goal of improving MEB health in Latinx communities. Future studies investigating the different cultural components that may influence the acceptability and effectiveness of the interventions are warranted.

Family Functioning in Hispanic Parents of Adolescents: Who Benefits Most from a Family-Based HIV and Substance Use Preventive Intervention?

To understand which families are likely to benefit most from resource-intensive family-based, evidence-based interventions (EBIs), we must examine the key, modifiable determinant of family functioning. The purpose of this study was to (1) identify whether there are subgroups of Hispanic parents that differ meaningfully based on their family functioning at baseline, (2) test whether the Familias Unidas preventive intervention was differentially effective across the baseline family functioning subgroups, and (3) understand the mechanisms of intervention effectiveness within each baseline family functioning subgroup. On a pooled data set of 4 completed efficacy and effectiveness trials of Familias Unidas (n = 1445 low-income, Hispanic immigrant origin, parents and their adolescent between the ages of 12-17), we conducted a series of secondary data analyses. Latent profile analyses revealed four significantly different profiles: (1) low family functioning (n = 210, 14.55%), (2) low-to-moderate family functioning (n = 554, 38.39%), (3) moderate-to-high family functioning (n = 490, 33.96%), and (4) high family functioning (n = 189, 13.10%). A structural equation modeling approach found there were significant differences in intervention effectiveness between the subgroups. The low family functioning subgroup experienced gains in family functioning, and in turn, lower levels of adolescent substance use, internalizing, and externalizing symptoms. The high family functioning subgroup showed significant direct effects of the intervention on adolescent substance use, internalizing, and externalizing symptoms, but no indirect effects through improvements in family functioning. Implications for screening, targeting, and adapting interventions are discussed.

Culturally enhancing a group-based motivational interviewing substance use prevention program for Latine youth

Background

Group Motivational Interviewing for Teens (GMIT) has been effective in reducing youth substance use in diverse communities, yet more research is needed to determine its efficacy in reducing tobacco and alternative tobacco products (ATP) use among Latine adolescents. This study modified GMIT to include a focus on ATPs (GMIT-ATP). GMIT was also linguistically translated so it could be offered in English and Spanish, culturally enhanced, and parent sessions were added (GMIT-ATP + P).

Methods

The study's aims were to 1) Develop a model of how cultural context, family relationships, and adolescent tobacco-related skills/beliefs are associated with smoking and ATP use; 2) Examine the impact of the GMIT-ATP intervention on adolescent tobacco use; 3) Examine whether the GMIT-ATP + P intervention improves family/parenting factors associated with reduced adolescent tobacco use; 4) Examine whether GMIT-ATP + P is more effective than GMIT-ATP in improving adolescent tobacco use; 5) Explore whether essential components of our behavior change model mediate the impact on tobacco use, and 6) Explore whether cultural factors influence the impacts of our intervention. Latine adolescents (ages 10-16) and their parents/guardians were recruited throughout Virginia. Parents and adolescents completed three surveys: before and immediately after the program ends and at 3-months post-intervention. Families attended 3 GMIT-ATP or GMIT-ATP + P sessions.

Conclusion

Findings from this study will be disseminated in Latine communities and with providers working with Latine youth and can serve as a community-based model to reduce substance and tobacco use (e.g., ATP) in these Latine communities.

Parent-based interventions to improve multiple lifestyle risk behaviors among adolescents: A systematic review and meta-analysis

Lifestyle risk behaviors often co-occur and are prevalent among adolescents. Parent-based interventions addressing risk behaviors concurrently have the potential to improve youth and parent outcomes. This systematic review evaluated the efficacy of parent-based interventions targeting multiple lifestyle risk behaviors among adolescents and parents. MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), Scopus, CINAHL, the Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 2010-May 2021. Eligible studies were randomised controlled trials (RCTs) of parent-based interventions addressing 2+ risk behaviors: alcohol use, smoking, poor diet, physical inactivity, sedentary behaviors, and poor sleep. Studies directly targeting parents, and that assessed adolescent outcomes (11-18 years) were eligible. Where possible, random-effects meta-analysis was conducted. From 11,975 identified records, 46 publications of 36 RCTs (n = 28,322 youth, n = 7385 parents) were eligible. Parent-based interventions were associated with improved adolescent moderate-to-vigorous physical activity (MVPA) [Odds Ratio (OR) = 1.82, 95% CI = 1.18, 2.81; p = 0.007], and reduced screen time (SMD = -0.39, 95% CI = -0.62, -0.16, p = 0.0009) and discretionary food intake (SMD = -0.18; 95% CI = -0.30, -0.06; p = 0.002) compared to controls. However, there was some evidence that interventions increased the odds of ever using tobacco in the medium-term (OR = 1.47, 95% CI = 0.99, 2.18, p = 0.06) and of past month tobacco use in the long-term (OR = 1.46, 95% CI = 1.12, 1.90; p = 0.005). Overall, the quality of evidence was moderate. Parent-based interventions targeting multiple risk behaviors improved adolescent MVPA, and reduced screen time discretionary food intake. Further research is needed to address sleep problems and increase intervention efficacy, particularly for alcohol and tobacco use.

Efficacy of a Family-Based Intervention for HIV Prevention with Hispanic Adolescents with Same Gender Sexual Behaviors

Despite the availability of efficacious and effective family-based interventions, such interventions are scarce for sexual minority adolescents, particularly among ethnic/racial minorities. Prior to creating an entirely new intervention, a prudent first step may be to determine if existing interventions are efficacious in reducing risk behaviors in sexual minority adolescents. This study assesses the relative efficacy of a general, family-based intervention (Familias Unidas) on improving substance and condom use outcomes among Hispanic adolescents with same gender sexual behaviors (HASGB). Data across five distinct trials of Familias Unidas were synthesized. HASGB were randomized either to an intervention (n = 94) or control condition (n = 100). Mediation analyses tested for intervention efficacy on past 90-day substance (cigarette/alcohol/illicit drug) use and condomless sex at last intercourse in HASGB participants and whether family functioning indicators-parent-adolescent communication, positive parenting, and parental monitoring of peers-mediated the effects. Post hoc analyses explored the moderating role of study target population based on prior risk. Familias Unidas did not impact substance use but significantly reduced condomless sex postintervention relative to the control condition. Hypothesized mediators did not explain this effect. Post hoc analyses indicated that the effect was significant in studies that recruited based on prior risk but not studies that recruited universal samples. Our results suggest that a general, family-based intervention may have positive effects on condom use in HASGB, particularly those with prior indicated risk. Identifying intervention components that drive this effect in addition to developing tailored content for HASGB is needed.

Vital Voices: HIV Prevention and Care Interventions Developed for Disproportionately Affected Communities by Historically Underrepresented, Early-Career Scientists

BACKGROUND

HIV prevention interventions which support engagement in care and increased awareness of biomedical options, including pre-exposure prophylaxis (PrEP), are highly desired for disproportionately affected Black/African American, Hispanic/Latinx and gay, bisexual, and other men who have sex with men (GBMSM) populations in the United States (US). However, in almost 40 years of HIV research, few interventions have been developed directly by and for these priority populations in domestic counties most at risk. We submit that interventions developed by early-career scientists who identify with and work directly with affected subgroups, and which include social and structural determinants of health, are vital as culturally tailored HIV prevention and care tools.

METHODS

We reviewed and summarized interventions developed from 2007 to 2020 by historically underrepresented early-career HIV prevention scientists in a federally funded research mentoring program. We mapped these interventions to determine which were in jurisdictions deemed as high priority (based on HIV burden) by national prevention strategies.

RESULTS

We summarized 11 HIV interventions; 10 (91%) of the 11 interventions are in geographic areas where HIV disparities are most concentrated and where new HIV prevention and care activities are focused. Each intervention addresses critical social and structural determinants of health disparities, and successfully reaches priority populations.

CONCLUSION

Focused funding that supports historically underrepresented scientists and their HIV prevention and care intervention research can help facilitate reaching national goals to reduce HIV-related disparities and end the HIV epidemic. Maintaining these funding streams should remain a priority as one of the tools for national HIV prevention.

Effects of a School-Based Drug Prevention Program on Sexual Risk Behavior Among Adolescents in Brazilian Schools

Sexual risk behaviors are closely related to the use of alcohol, tobacco, and other illicit drugs as well as teen dating violence. School-based drug prevention programs that teach social and personal skills could potentially also reduce sexual risk behaviors. We examined the effects of the #Tamojunto program on youth sexual risk behaviors. A randomized controlled trial was conducted with 6391 7th and 8th grade students in 72 public schools in six Brazilian cities. Baseline data were collected prior to program implementation. Two waves of follow-up assessments occurred after 9 and 21 months. Analyses were performed taking into account the multilevel structure of the data. We used intention-to-treat to evaluate changes in the prevalence of sexual risk behaviors over time and between groups. Adolescent age ranged from 11 to 15 years, with a mean of 12.6 ± 0.8 years, and 51.0% were female. Among all participants, receipt of #Tamojunto was associated with higher risk of lifetime sex at 21 months follow-up (OR 1.27, 95% CI [1.03, 1.56]). Among girls, at 9 months follow-up, the program was associated with higher likelihood of having engaged in sex in the last month (OR 1.76, 95% CI [1.13, 2.74]). At 21 months follow-up, girls receiving the program were more likely to report engaging in condomless sex in the last month (OR 1.64, 95% CI [1.07, 2.50]). #Tamojunto may be ineffective and possibly harmful for preventing sexual risk behaviors, especially among girls. We suggest further investigation of the possible mediating role of life skills intervention components on girl's sexual behaviors.

Internalizing Symptoms and Externalizing Behaviors in Latinx Adolescents with Same Sex Behaviors in Miami

Sexual minorities report poorer mental health relative to heterosexual counterparts, but this is underexplored in Latinx youth. This study compares internalizing symptoms and externalizing behaviors in Latinx adolescents with Same Sex Behaviors (LASSB) to their Latinx adolescent peers who did not report same sex behaviors (non-LASSB). It also explores the moderating role of biculturalism on the relationship between internalizing symptoms and externalizing behaviors, and same-sex behaviors. Individual-level baseline data (Total N=1,634; LASSB n=195) from five trials of a preventive intervention for Latinx adolescents were synthesized. Normal and clinical levels of internalizing symptoms and externalizing behaviors were determined, and logistic regression models were conducted to determine the odds of LASSB reporting these behaviors relative to non-LASSB. Additional adjusted models tested for the moderating effect of biculturalism. LASSB reported significantly higher odds of normal levels of all externalizing behaviors and clinical levels of anxious/depressed compared to non-LASSB. Biculturalism significantly moderated the association between same-sex behavior and clinical levels of internalizing behaviors; however, in subgroup analyses among LASSB, biculturalism did not significantly predict any of these behaviors. Latinx adolescents exhibited mental health disparities by same-sex behavior. Biculturalism may be an important indicator for describing these disparities in LASSB and should be further explored.

Assessment of Parent-Based Interventions for Adolescent Sexual Health: A Systematic Review and Meta-analysis

IMPORTANCE

Parent-based sexual health interventions have received considerable attention as one factor that can increase safer sexual behavior among youth; however, to our knowledge, the evidence linking parent-based interventions to youth sexual behaviors has not been empirically synthesized.

OBJECTIVE

To examine the association of parent-based sexual health interventions with 3 primary youth outcomes-delayed sexual activity, condom use, and parent-child sexual communication-as well as several secondary outcomes. We also explored potential moderators of intervention effectiveness.

DATA SOURCES

A systematic search was conducted of studies published through March 2018 using MEDLINE, PsycINFO, Communication Source, and CINAHL databases and relevant review articles.

STUDY SELECTION

Studies were included if they: (1) sampled adolescents (mean age, ≤18 years), (2) included parents in a key intervention component, (3) evaluated program effects with experimental/quasi-experimental designs, (4) included an adolescent-reported behavioral outcome, (5) consisted of a US-based sample, and (6) were published in English.

DATA EXTRACTION AND SYNTHESIS

Standardized mean difference (d) and 95% confidence intervals were computed from studies and meta-analyzed using random-effects models. A secondary analysis evaluated potential moderating variables.

MAIN OUTCOMES AND MEASURES

The primary outcomes were delayed sexual activity, condom use, and sexual communication.

RESULTS

Independent findings from 31 articles reporting on 12 464 adolescents (mean age = 12.3 years) were synthesized. Across studies, there was a significant association of parent-based interventions with improved condom use (d = 0.32; 95% CI, 0.13-0.51; P = .001) and parent-child sexual communication (d = 0.27; 95% CI, 0.19-0.35; P = .001). No significant differences between parent-based interventions and control programs were found for delaying sexual activity (d = -0.06; 95% CI, -0.14 to 0.02; P = .16). The associations for condom use were heterogeneous. Moderation analyses revealed larger associations for interventions that focused on younger, compared with older, adolescents; targeted black or Hispanic youth compared with mixed race/ethnicity samples; targeted parents and teens equally compared with emphasizing parents only; and included a program dose of 10 hours or more compared with a lower dose.

CONCLUSIONS AND RELEVANCE

Parent-based sexual health programs can promote safer sex behavior and cognitions in adolescents, although the findings in this analysis were generally modest. Moderation analyses indicated several areas where future programs could place additional attention to improve potential effectiveness.

Predictors of Participation in an eHealth, Family-Based Preventive Intervention for Hispanic Youth

The Familias Unidas intervention is an efficacious family-based preventive intervention for reducing substance use and other health risks among Hispanic youth. A current randomized controlled trial (RCT) is examining this intervention's efficacy when delivered via the Internet (eHealth). eHealth interventions can overcome logistical barriers to participation, yet there is limited information about the feasibility of these interventions, especially among ethnic minorities. This paper examines participation and predictors of participation in the eHealth Familias Unidas intervention in a sample of 113 Hispanic families whose adolescent had behavioral problems. Analyses examined multidimensional ways of characterizing participation, including the following: (1) total intervention participation, (2) initial engagement (participating in at least one of the first three intervention sessions), (3) completing the pre-recorded, eHealth parent group sessions, and (4) participating in the live, facilitator-led, eHealth family sessions. Participation in this eHealth intervention was comparable to, and in most cases higher than, previous, face-to-face Familias Unidas interventions. High levels of baseline family stress were associated with lower initial engagement and lower family session participation. Greater parental Hispanicism was associated with more participation in eHealth parent group sessions and across the total intervention. Higher levels of baseline effective parenting, in other words less intervention need, were significantly associated with lower levels of total intervention participation and lower levels of family session participation. Implications for preventive interventions delivered via Internet are discussed.

Evaluating construct equivalence of youth depression measures across multiple measures and multiple studies

Construct equivalence of measures across studies is necessary for synthesizing results when combining data in meta-analysis or integrative data analysis. We discuss several assumptions required for construct equivalence, and review methods using individual-level data and item response theory (IRT) analysis for detecting or adjusting for violations of these assumptions. We apply IRT to data from 7 measures of depressive symptoms for 4,283 youth from 16 randomized prevention trials. Findings indicate that these data violate assumptions of conditional independence. Bifactor IRT models find that depression measures contain substantial reporter variance, and indicate that a single common factor model would be substantially biased. Separate analyses of ratings by youth find stronger evidence for construct equivalence, but factor invariance across sex and age does not hold. We conclude that data synthesis studies employing measures of youth depression should analyze results separately by reporter, explore more complex approaches to integrate these different perspectives, and explore methods that adjust for sex and age differences in item functioning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Preventing Youth Internalizing Symptoms Through the Familias Unidas Intervention: Examining Variation in Response

Prevention programs that strengthen parenting and family functioning have been found to reduce poor behavioral outcomes in adolescents, including substance use, HIV risk, externalizing and internalizing problems. However, there is evidence that not all youth benefit similarly from these programs. Familias Unidas is a family-focused intervention designed to prevent substance use and sexual risk among Hispanic youth and has recently demonstrated unanticipated reductions in internalizing symptoms for some youth. This paper examines variation in intervention response for internalizing symptoms using individual-level data pooled across four distinct Familias Unidas trials: (1) 266 eighth grade students recruited from the general school population; (2) 160 ninth grade students from the general school population; (3) 213 adolescents with conduct, aggression, and/or attention problems; and (4) 242 adolescents with a delinquency history. Causal inference growth mixture modeling suggests a three-class model. The two largest classes represent youth with low (60 %) and medium (27 %) internalizing symptoms at baseline, and both intervention and control participants show reductions in internalizing symptoms. The third class (13 %) represents youth with high levels of baseline internalizing symptoms who remain at steady levels of internalizing symptoms when exposed to the intervention, but who experience an increase in symptoms under the control condition. Female gender, low baseline levels of parent-adolescent communication, and older age were associated with membership in the high-risk class. These synthesis analyses involving a large sample of youth with varying initial risk levels represent a further step toward strengthening our knowledge of preventive intervention response and improving preventive interventions.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Use of Web-Based Parent-Adolescent Health Promotion Program Among Puerto Ricans

BACKGROUND

Despite positive attitudes of Latinos using the Internet and the increased availability of health information resources, few studies have been conducted that examine actual use and barriers to web-based health information.

OBJECTIVE

The aim of this study was to examine whether select sociodemographic factors and technology factors (e.g., computer and Internet access) predicted use of a web-based, parent-adolescent sexual communication program or a physical activity program, entitled Cuídalos, among Puerto Rican parents.

METHODS

This study uses data from a randomized controlled trial designed to examine the long-term effectiveness of Cuídalos. Parents were recruited from community-based and school sites throughout Puerto Rico and randomly assigned to a web-based, parent-adolescent sexual communication (n = 245) or a physical activity (n = 247) program. Parents were instructed to complete the two-session program within 1 week and had access to the program for a period of 3 months. Outcomes in this secondary analysis were the number of log-ins and self-reported access during the 3-month period. Reasons for not accessing the program after the 3-month period were assessed.

RESULTS

Self-reported access after completion of the Cuídalos program and the actual number of log-ins over the intervention period were low. There were no statistically significant differences in the number of log-ins between parents who accessed Cuídalos during the 3-month time frame and those who did not (p = .28). Logistic regression analyses demonstrated that the odds of accessing Cuídalos during the 3-month period was 72% higher (OR = 1.72, 95% CI [1.08, 2.75]) among parents with a high school education or less, as compared to parents with a college education (p = .02). Similarly, Poisson regression model results indicated that, with every year increase in age, the expected number of log-ins increased by 1% (RR = 1.01, 95% CI [1.00, 1.02]); compared to those who accessed the program at home, the expected number of log-ins ranged from 10% to 27% lower for parents accessing elsewhere. Reasons for not accessing the program during the 3-month period included not having easy access to a computer (n = 134, 48.6%), or they did not know how to access the program again (n = 56, 20.3%).

DISCUSSION

Despite the availability of web-based and e-health resources, further research is needed to identify how to facilitate greater access and actual use of digital health resources by Latinos. This is an important effort in order to prevent a widening health equity gap caused by a lack of access and use of digital health resources.

Short-Term Effects on Family Communication and Adolescent Conduct Problems: Familias Unidas in Ecuador

Familias Unidas, a Hispanic/Latino-specific, parent-centered intervention, found to be efficacious in improving family functioning and reducing externalizing behaviors among youth in the USA, was recently adapted and tested for use in Ecuador. This study examined the short-term efficacy of Familias Unidas in Ecuador on parent-adolescent communication, parental monitoring of peers, and youth conduct problems. Two hundred thirty-nine youths (ages 12-14 years) and their primary care givers were randomized to either Familias Unidas or Community Practice and assessed pre- and post-intervention. There was a significant difference between Familias Unidas and Community Practice in conduct problems at 3 months (standardized β = -.101, p = .001, effect size = .262). A significant indirect intervention effect was also detected, indicating that Familias Unidas predicted conduct problems at 3 months through parent-adolescent communication at 3 months (standardized β = -.036, p = .016, CI 95% [-.066, -.007], effect size = .265). Familias Unidas was efficacious in reducing conduct problems through improved parent-adolescent communication, relative to Community Practice. Future assessments will determine whether Familias Unidas also has an impact on substance use and sexual risk behaviors at later time points, as demonstrated in past Familias Unidas trials. The short-term effects of the intervention, family engagement, and facilitator skill in the Ecuadorian adaptation of Familias Unidas are promising. This study implies that an intervention developed for Hispanics/Latinos in the USA and culturally adapted and implemented for use by Hispanics/Latinos in a Latin American country can be efficacious in improving family functioning and reducing youth conduct problems.

TRIAL REGISTRATION

MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Ecuador.

Informed consent comprehension among vulnerable populations in Ecuador: video-delivered vs. in-person standard method

The informed consent comprehension process is key to engaging potential research subject participation. The aim of this study is to compare informed consent comprehension between two methods: standard and video-delivered. We compared the in-person and video-delivered informed consent process in the Familias Unidas intervention. We evaluated comprehension using a 7-item true/false questionnaire. There were a total of 152 participants in the control group and 87 in the experimental. General characteristics were similar between both groups (p > 0.05). First-attempt informed consent comprehension was higher in the intervention group but was not statistically significant (80% and 78% respectively p = 0.44). A video-delivered informed consent process did not differ from the standard method of informed consent in a low educational and socioeconomic environment.

Parent-adolescent relationships in Hispanic versus Caucasian families: Associations with alcohol and marijuana use onset

Parent-adolescent relationship (PAR) factors such as social support and negative interactions are associated with initiation of alcohol and marijuana use during adolescence. However, few studies have examined whether the relationship between PAR, especially the paternal role, and substance use onset varies by ethnicity. This is important given that ethnic group differences have been related to alcohol and marijuana use, cultural values and parenting. This study examines whether ethnicity moderates the prospective prediction of substance use onset by PAR factors. The sample comprised 124 adolescents who self-identified as Hispanic and 795 adolescents who self-identified as non-Hispanic Whites, and was drawn from an ongoing longitudinal survey on adolescent substance use. Discrete-time survival modeling was used to prospectively predict age at onset of substance use among participants who were substance-naïve at baseline. Interactions between ethnicity and PAR factors indicated that PAR factors had a larger influence on age of alcohol and marijuana onset for Hispanics than for Caucasians. Among Hispanics, greater social support from and greater negative interactions with the father-figure were more predictive of earlier onset of alcohol, and greater social support from the mother-figure was more predictive of later alcohol onset, compared to Caucasians. Similarly, greater negative interactions with the father-figure were more predictive of earlier onset of marijuana use among Hispanics than among Caucasians. These findings suggest the influence of PAR on alcohol and marijuana use onset may be larger for Hispanics than for Caucasians. Incorporating these parenting factors in substance use prevention programs advances public health in a culturally sensitive manner that is relevant to at-risk Hispanic adolescents.

"Scaling-out" evidence-based interventions to new populations or new health care delivery systems

BACKGROUND

Implementing treatments and interventions with demonstrated effectiveness is critical for improving patient health outcomes at a reduced cost. When an evidence-based intervention (EBI) is implemented with fidelity in a setting that is very similar to the setting wherein it was previously found to be effective, it is reasonable to anticipate similar benefits of that EBI. However, one goal of implementation science is to expand the use of EBIs as broadly as is feasible and appropriate in order to foster the greatest public health impact. When implementing an EBI in a novel setting, or targeting novel populations, one must consider whether there is sufficient justification that the EBI would have similar benefits to those found in earlier trials.

DISCUSSION

In this paper, we introduce a new concept for implementation called "scaling-out" when EBIs are adapted either to new populations or new delivery systems, or both. Using existing external validity theories and multilevel mediation modeling, we provide a logical framework for determining what new empirical evidence is required for an intervention to retain its evidence-based standard in this new context. The motivating questions are whether scale-out can reasonably be expected to produce population-level effectiveness as found in previous studies, and what additional empirical evaluations would be necessary to test for this short of an entirely new effectiveness trial. We present evaluation options for assessing whether scaling-out results in the ultimate health outcome of interest.

CONCLUSION

In scaling to health or service delivery systems or population/community contexts that are different from the setting where the EBI was originally tested, there are situations where a shorter timeframe of translation is possible. We argue that implementation of an EBI in a moderately different setting or with a different population can sometimes "borrow strength" from evidence of impact in a prior effectiveness trial. The collection of additional empirical data is deemed necessary by the nature and degree of adaptations to the EBI and the context. Our argument in this paper is conceptual, and we propose formal empirical tests of mediational equivalence in a follow-up paper.

Engaging School Mental Health Professionals to Deliver Evidence-Based Interventions to Hispanic Families

Research has demonstrated that a number of evidence-based programs can be effectively implemented in different community settings, such as schools, to target Hispanic youth and their families; however, successful implementation of such programs represents a challenge for practitioners. This article describes experiences and strategies associated with recruiting, training, and supervising school mental health professionals in the school-based implementation of an evidence-based, family-centered prevention program for Hispanic families. School mental health professionals were recruited and given intensive training, weekly supervision for adherence monitoring, and ongoing technical assistance, in addition to intervention manuals and materials. We emphasize how strategies based on the prevention program itself were used to recruit, engage, and train school mental health professionals to deliver a family-based evidence-based program, blending research and practice in a large public school system. Implications of lessons learned are discussed, as well as the specific strategies to overcome challenges when engaging and training community partners in delivering a manualized intervention with rigorous adherence to the program.

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents

BACKGROUND

School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

OBJECTIVES

To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

SEARCH METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmesSix trials evaluated school-based educational interventions.In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendanceTwo trials evaluated incentive-based programmes to promote school attendance.In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmesThe single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

AUTHORS' CONCLUSIONS

There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

Familias Unidas for high risk adolescents: Study design of a cultural adaptation and randomized controlled trial of a U.S. drug and sexual risk behavior intervention in Ecuador

BACKGROUND

Developing, testing and implementing evidence-based prevention interventions are important in decreasing substance use and sexual risk behavior among adolescents. This process requires research expertise, infrastructure, resources and decades of research testing, which might not always be feasible for low resource countries. Adapting and testing interventions proven to be efficacious in similar cultures might circumvent the time and costs of implementing evidence-based interventions in new settings. This paper describes the two-phase study, including training and development of the research infrastructure in the Ecuadorian university necessary to implement a randomized controlled trial.

METHODS/DESIGN

Familias Unidas is a multilevel parent-centered intervention designed in the U.S. to prevent drug use and sexual risk behaviors in Hispanic adolescents. The current study consisted of Phase 1 feasibility study (n=38) which adapted the intervention and study procedures within a single-site school setting in an area with a high prevalence of drug use and unprotected sexual behavior among adolescents in Ecuador, and Phase 2 randomized controlled trial of the adapted intervention in two public high schools with a target population of families with adolescents from 12 to 14 years old.

DISCUSSION

The trial is currently in Phase 2. Study recruitment was completed with 239 parent-youth dyads enrolling. The intervention phase and the first follow-up assessment have been completed. The second and third follow-up assessments will be completed in 2016. This project has the potential of benefitting a large population of families in areas of Ecuador that are disproportionally affected by drug trafficking and its consequences.

TRIAL REGISTRATION

MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Quito, Ecuador.