Investigating Facilitators and Barriers for Active Breaks among Secondary School Students: Formative Evaluation of Teachers and Students

Physical activity in the form of "active breaks" can be combined with academic instruction in primary school. However, few studies have examined the feasibility of conducting active breaks in secondary school. To address this gap, we conducted focus groups (FGs) regarding the implementation of an active breaks (ABs) protocol with 20 teachers and 10 secondary school students. Barriers/facilitators toward the implementation of ABs were classified using grounded theory inductive methods framed by the socio-ecological model. Individual-level factors were instrumental for both teachers and students. Teachers highlighted personal fears and concerns regarding using ABs, while students reported fears related to peer behaviour during the activity. Both teachers and students agreed that ABs can improve cognitive skills and time-on-task behaviour. Teachers articulated concerns related to student behaviour during ABs including possible social exclusion and injury. Students felt that ABs might affect classroom management and interfere with maintaining students' academic focus. Teachers underscored that ABs required social support from the administration and colleagues. Students felt that ABs could support teachers' instructional focus and provide them with an energy respite. Collectively, the FGs suggested that environmental limitations could hinder the implementation of ABs. Involving teacher and student feedback during the codesign phase can rationally inform the design of school-based ABs.

Association of Socioeconomic Factors and Physical Activity with Health-Related Quality of Life in Italian Middle School Children: An Exploratory Cross-Sectional Study

Health-related quality of life (HRQoL) provides a broad assessment of an individual's well-being and can serve as a good prognosticator of life's outcomes later for children and adolescents. Understanding the factors associated with HRQoL is crucial for promoting better health and life satisfaction. This study investigated the cross-sectional association of socioeconomic status, cardio fitness, and physical activity levels with HRQoL in 224 Italian early adolescents attending secondary school in the Emilia-Romagna region located in Northern Italy. In a multivariate path regression model, younger students and females reported a higher quality of life (β = -0.139, p = 0.015, 95% CI: -0.254--0.023 and β = 0.142, p = 0.019, 95% CI: 0.011-0.273, respectively). Having both parents employed and having a higher familiar educational status were also associated with a higher quality of life (β = 0.142, p = 0.013, 95% CI 0.027-0.257 and β = 0.133, p = 0.017, 95% CI 0.022-0.244, respectively). Greater engagement in routine physical activity levels from moderate to vigorous intensity was positively associated with quality of life (β = 0.429, p < 0.001, 95% CI: 0.304-0.554). Endurance (speed) was positively associated with quality of life (β = 0.221, p = 0.001, 95% CI: 0.087-0.355), and students with longer times on the shuttle run reported less quality of life (β = -0.207, p = 0.002, 95% CI: -0.337--0.077). These relations remained intact even when controlling for socioeconomic factors. The current findings reinforce the importance of promoting regular physical activity among younger children and also addressing socioeconomic status disparities to improve children's well-being. Future studies may want to consider expanding the array of measures used to assess physical activity and include additional measures assessing nutrition, cultural factors, and family functioning, all of which can influence a child's willingness to engage in physical activity and their well-being. The emphasis on fitness and physical activity and their contribution to a child's well-being should be the prime focus for stakeholders who work in the education, public health, and health policy sectors.

Influence of prior authorization requirements on provider clinical decision-making

OBJECTIVES

Prior authorization (PA) aims to promote the safe and effective use of medications and to control costs. However, PA-related administrative tasks can contribute to burden on health care providers. This study examines how such tasks affect treatment decisions.

STUDY DESIGN

Cross-sectional, online survey.

METHODS

We conducted an online survey of US medical providers in 2020 based on a convenience sample of 100,000 providers. Multivariate path analysis was used to examine associations among provider practice characteristics, step therapy and other health plan requirements, perceived burdens of PA, communication issues with insurers, and prescribing behaviors (prescribing a different medication than planned, avoiding prescribing of newer medications even if evidence-based guideline recommendations are met, and modifying a diagnosis). Weighted analyses were conducted to assess nonresponse bias.

RESULTS

A total of 1173 respondents (1.2% response rate) provided 1147 usable surveys. Step therapy requirements had the largest effect on clinical decision-making. Other significant effects on clinical decision-making included perceived PA likelihood, communication issues, and health plan requirements (eg, clinical documentation). Weighted analyses showed that the study conclusions were unlikely to have been biased by nonresponse.

CONCLUSIONS

Respondents report that they may alter clinical decisions to avoid PA requirements and related burdens, even in cases in which use of the PA medication was clinically appropriate. Processes that reduce the administrative burden of PA through improved communication and transparency as well as standardized documentation may help ensure that PA more seamlessly achieves its goals of safe and effective use of medications.

Cross-Sectional Analysis of Family Factors Associated with Lifestyle Habits in a Sample of Italian Primary School Children: The I-MOVE Project

The acquisition of healthy dietary and exercise habits during childhood is essential for maintaining these behaviors during adulthood. In early childhood, parents have a profound influence on a child's lifestyle pursuits, serving as both role models and decision-makers. The present study examines family factors as potential contributors to healthy lifestyle habits and their child's overall diet quality among a sample of primary school children. A secondary aim is to evaluate several aspects of diet quality using the Mediterranean adaptation of the Diet Quality Index-International (DQI-I). This cross-sectional study involved 106 children enrolled in a primary school located in Imola, Italy. Data were collected from October to December 2019 using an interactive tool used to assess parent characteristics, children's lifestyle, food frequency (ZOOM-8 questionnaire), and actigraph accelerometers to capture children's physical activity and sedentary behavior. Adherence to the Mediterranean Diet (expressed by KIDMED Index) was positively associated with fathers' educational level, parental sport participation, and the parent's overall nutritional knowledge. Higher mothers' educational level was inversely associated with children's leisure screen time. Parents' nutritional knowledge was positively related to children's average daily minutes of organized sport activities. The better score for DQI-I was for consumption adequacy, followed by variety and moderation. The lowest score was for overall balance. The present study reinforces the importance of family factors in young children's lifestyle choices, particularly their dietary, leisure time, and exercise habits.

Mediterranean diet, physical activity, and family characteristics associated with cognitive performance in Italian primary school children: analysis of the I-MOVE project

Working memory (WM) is a multicomponent system that supports cognitive functioning. It has been linked to a wide variety of outcomes including academic success and general well-being. The present study examined the relations between adherence to the Mediterranean diet (MD) and WM among Italian children, adjusting for important parent characteristics and children's lifestyle habits. Data for this study was obtained from 106 children attending primary school in Imola (Italy) who were part of the I-MOVE study emphasizing school-based physical activity. Children's adherence to the MD was calculated using the KIDMED index (KI) based on the ZOOM-8 questionnaire. Physical activity (PA) levels were assessed using an actigraph accelerometer and WM using the backward digit span test. Univariate regression was used to select significant child-level and family measures associated with WM, which were then tested in a single multivariate regression model. Older age is positively associated with higher WM (β = 0.36; 95% CI 0.25, 0.47). Dietary adherence (KI) (β = 0.07; 95% CI 0.01, 0.14) and engagement in organized PA outside school hours (β = 0.58; 95% CI 0.09, 1.10) are positively related to WM. Among the family measures, father's education was positively associated with WM for high school education and for university vs. middle school or lower, respectively.

CONCLUSION

Adherence to the MD was associated with better WM capacity in primary school children. These findings can be used to guide policymakers in designing health promotion programs and instituting policies emphasizing healthy nutrition to improve physical health and boost cognitive functioning.

WHAT IS KNOWN

• The development of working memory involves the entire childhood with a rapid spurt between 2 and 8 years of age. • Working memory plays a critical role in children's learning and academic performance and underlies higher-order cognitive abilities.

WHAT IS NEW

• Adherence to the Mediterranean Diet was associated with higher working memory capacity in primary school children. • Health promotion interventions based on PA and sound nutrition involving children benefit not only physical and mental health, but also cognitive health.

Long-term behavioral effects of a school-based prevention program on illicit drug use among young adults

Most universal drug abuse prevention efforts target early adolescents with the goal of delaying or preventing the onset of substance use. The present study examined long-term follow-up data from a large-scale randomized trial of a school-based prevention program that used cognitive-behavioral skills-training techniques to enhance social and personal competence skills and drug refusal skills. The preventive intervention was implemented in junior high schools, and pretest data were collected from students in the classroom. Approximately 13 years later, follow-up data were collected by mail from 2042 young adults. Rates of overall lifetime illicit drug use, as well as lifetime marijuana use, marijuana intoxication, and lifetime non-medical pill use, were lower among students who received the prevention program (Life Skills Training) during junior high school compared to control group participants. These findings support the hypothesis that comprehensive, universal school-based prevention programs can produce long-term effects on illicit drug use behavior.

Trust in science, medicine and medical providers and its relations to vaccine beliefs: A latent class analysis

Aim:

People may differ in their vaccine-related beliefs (i.e. efficacy, safety, purpose), with a host of factors influencing these differences. This can produce homogeneous groups of individuals who share certain beliefs, attitudes and opinions not only towards vaccines but science and medicine in general. This study aims to characterise distinct subgroups and identify ideal targets for tailored public health interventions to reinforce favourable vaccine beliefs.

Methods:

Latent class analysis was used to derive unique profiles using the 2019 Gallup survey of 140 countries. We modelled a composite of vaccine beliefs and regressed this on class membership and relevant covariates.

Results:

Patterns of item endorsement indicated a well-fitting five-class model, with classes distinguished based on whether individuals sought personal knowledge about science, medicine and health; trusted science and scientists; and reported confidence in the health care system. The lowest levels of vaccine beliefs were reported by a class lacking trust and confidence and the highest levels were reported by a class endorsing trust, confidence and desiring medical and scientific knowledge. Country-level income was moderately related to class membership, and vaccine beliefs were higher in lower-income countries.

Conclusions:

Findings suggest that public health campaigns can focus on improving trust in science and medical providers. Efforts to improve vaccination rates can only be achieved when individuals trust science, view the work of scientists as beneficial and hold favourable views towards health care providers. Individuals will then accrue the necessary wisdom to make good health care decisions that affect not only themselves but also their fellow citizens.

Trust and its relations to vaccine beliefs: a latent class analysis on 140,000 individuals worldwide

Background

Research shows that vaccine-related beliefs (i.e., about efficacy, safety, purpose) may reflect a host of within-person and contextual factors yielding homogeneous subgroups of individuals. This study aims to characterize distinct subgroups of people and identify ideal targets for tailored public health interventions to increase vaccine adherence.

Methods

Latent class analysis was used to derive subgroups based on unique response profiles using the 2019 Gallup survey of 140 countries (&gt;140,000 individuals). We modeled a composite of vaccine beliefs as a distal outcome examining differences for the obtained classes, with and without covariates in the model.

Results

A 5-class model fit best with classes distinguished primarily on whether individuals possessed or sought personal knowledge about science, medicine, and health, whether they trusted science, scientists and have confidence in the healthcare system. The lowest levels of vaccine beliefs were reported by a class not endorsing any of these indicators and the highest levels by a class endorsing all the indicators (p &lt; 0.001). Age class showed a U-shaped relation with vaccine beliefs, while higher educational level (p = 0.025), higher subjective income (p = 0.006) and employment (p &lt; 0.001) were related to higher vaccine beliefs. Country-level income was moderately related to class membership and vaccine beliefs were higher in lower-income countries (p &lt; 0.001).

Conclusions

Our findings suggest that more work is needed to improve trust in science and medical providers. Tailored interventions grounded in a community-based and empowering approach with the collaboration of multiple stakeholders seems to be needed to improve vaccination rates. This can only be achieved when individuals trust science, scientists and healthcare providers and accrue the necessary wisdom to make good healthcare decisions that affect not only themselves but their fellow citizens.

Key messages

• Efforts to alter vaccine beliefs should touch on where people access information on science and health, the processes that build trust, and their belief whether science improves well-being.

• Public health interventions should focus on reassuring individuals that science and health workers are benevolent. An essential first step in the health worker-patient relations is building trust.

Designing active breaks in secondary school, results from focus group with teachers: the brave study

Background

Many adolescents are unable to accomplish the daily 60 minutes of moderate to vigorous physical activity (PA) recommended by WHO. Secondary school is a critical period for developing healthy habits and PA interventions have the potential to promote healthy development. Active Breaks (ABs) are a school-based intervention consisting of short bursts (5-15 minutes) of PA made part of the academic routine. Primary school has been ABs main setting, while secondary school interventions received less attention. The aim of the BRAVE Study is to investigate teachers’ opinion about the feasibility of ABs in Italian secondary school.

Methods

In November 2020 20 teachers from two secondary schools located in Bologna province (Italy) were enrolled in two focus groups (FGs). FGs were held online, recorded, and transcribed. Questions were asked about the role of PA in the school routine and related experiences, perceived barriers and facilitators of the intervention, suggestions regarding the intervention design. Final expectations were then discussed.

Results

Despite limited experience with PA interventions, participants felt ABs would improve psycho-physical well-being for both students and teachers. Lack of time and space and a wary attitude towards ABs were listed as barriers. Program flexibility regarding content, administration time frames and implementation mode was listed as a great facilitator: program should be adaptable to participants’ needs, favoring easy and quick exercises. Overall, expectations emphasized improving classroom behavior and promoting healthy habits.

Conclusions

Teachers felt that inclusion of ABs in secondary school was promising and could lead to many health benefits. ABs were deemed feasible given their short duration and adaptability, since the program can be implemented with current personnel resources and space configurations. Co-design is essential to overcome personal barriers and create an effective and sustainable intervention.

Key messages

• According to secondary school teachers, PA interventions have the potential to improve psycho-physical well-being and classroom environment, promoting healthy habits among students.

• ABs are deemed as a feasible and sustainable PA intervention thanks to program flexibility regarding contents, administration time frames and implementation mode.

The Brave study: promoting active breaks in secondary school from students’ point of view

Background

According to the WHO recommendations, children and adolescents should perform at least 60 minutes per day of moderate to vigorous physical activity (PA). Active Breaks (ABs) interventions, short physical activity breaks of 5-15 minutes during school hours, have been examined in primary school children as a potential strategy to counteract a sedentary lifestyle, with minimal disruption to school learning activities. The aim of the BRAVE STUDY is to investigate the feasibility of ABs in a secondary school setting from the students’ point of view.

Methods

In December 2020, 10 students (age 12-13, 6 females and 4 males) attending the second and third grade of secondary schools located in Bologna province (Italy) were involved in a focus group (FG). The FG was conducted online because of COVID-19 and the answers transcribed for a later analysis. Students’ opinions were probed on the role of PA in school and possible facilitators/barriers to implementation of ABs in the school.

Results

Students reported they wanted to be more active as a consequence of time spent in class sitting at a desk. Students also reported that an organized activity like ABs conducted in the classroom setting provides an excellent opportunity to improve social relations with classmates. Students also highlighted the possible psycho-physical well-being benefits arising from PA. Among the potentially negative aspects reported, students underlined the possible confusion that would be created in classroom and the time subtracted from academic learning activities.

Conclusions

The FG represents an ideal mean to obtain in-depth information on how people feel about a pending program or a change in their routine. The current FG reinforces positive outcomes from exposure to a PA program that can be intertwined with their daily classroom activities. ABs programs can help to reconcile the needs of students that arise during the day with the PA objectives recommended by the WHO.

Key messages

• ABs can be a zero-cost intervention strategy to achieve WHO recommendations and would create conditions for a greater psycho-physical benefits in classrooms.

• A qualitative approach, such as FGs, provides a mean to collect information not obtainable with quantitative methods, that could be useful to co-design interventions for children and adolescents.

Perceptions of prior authorization by use of electronic prior authorization software: A survey of providers in the United States

BACKGROUND: Given provider, patient, and health plan administrative burden, there is consensus that the medication prior authorization (PA) process needs to be streamlined and standardized. This includes broader adoption of electronic PA (ePA) solutions, including real-time clinical benefit determination. Insight into provider experiences with ePA will help health plans and pharmacy benefit managers (PBMs) prioritize efforts and investments in PA process improvement. OBJECTIVE: To identify provider experiences with PA by their use of ePA technology in a national sample of providers from the United States. METHODS: An online, nationwide survey was sent to licensed providers in 2020. The survey obtained information on provider experiences with PA, including PA workload, time to the communication of a PA decision, and other PA-related interactions with plans/PBMs. Provider characteristics and survey responses by provider use of ePA were compared using analysis of variance tests for items based on ordinal scales and a chi-square test statistic for nominal variables. Multivariable regression analyses identified associations between ePA use and PA experience variables, controlling for provider characteristics. RESULTS: Of 1,147 providers submitting usable surveys, 58% reported personally using ePA for at least some of their PA submissions, 88% submit at least 1 PA in a typical week, and most (82%) spend up to 5 hours a week on PA submissions. A majority (58.5%) reported that manual PA is often required. Those using ePA submitted a higher volume of PAs (P < 0.001) and spent more time on PA submissions (P = 0.003) than providers not using ePA software, but the duration of time from start to finish for a PA submission did not differ (P = 0.211). Providers who use ePA reported more difficulty identifying step therapy requirements (P = 0.005) and more frequently needing to submit additional documentation (P = 0.022). PA-related communication failures did not differ. Those using ePA reported a shorter time to PA decision (P = 0.004) than those not using ePA. Univariate descriptive findings were supported by multivariable analyses. CONCLUSIONS: This large, nationwide survey identified that a provider's use of ePA was not associated with less provider time or fewer challenges in preparing and submitting PA requests. However, the use of ePA was associated with a reported shorter PA decision time. Efforts to standardize PA requirements, support of real-time benefits check functionality, and better integration of ePA processes into provider workflows may help reduce PA burden and treatment delays. DISCLOSURES: Funding provided by the National Institutes of Health (NIMH #1R41MH124600-01).

Developmental cascades in studies of adolescent and young adult substance use etiology: A systematic review

•

Systematic reviews of developmental cascade studies in drug etiology are lacking.

•

Reviews can highlight important design concerns that promote better science.

•

Cascade studies articulate important risk mechanisms that are prevention targets.

•

Few cascade studies find support for intricate risk mechanisms involving parents.

Introduction

Frequently, developmental cascade models are used to examine causal linkages between early family risk and substance use etiology. When framed with longitudinal data, cascade models contribute to understanding developmental etiology by parsing stability from change in multiple domains of influence. This systematic review examines the research methods used in cascade studies of substance use etiology.

Method

A systematic literature review involved four electronic literature databases (i.e., PsycINFO, MEDLINE, EMBASE, Web of Science). Specific terms referenced substance use etiology and developmental cascade effects. Inclusion requirements included cross-domain effects and repeated measures. Studies were eliminated based on including interventions or growth modeling that failed to differentiate time-specific effects. A risk assessment indicated adequate inter-rater reliability for the 18 studies included.

Results

Conceptually, there was little evidence supporting hypothesized cascade effects that involved cross-domain risk mechanisms linking early parental socialization with later substance use. Methodologically, studies were characterized by modest sample sizes, lack of power, and relatively small effect sizes (ESavg. = 0.05 [SD = 0.046], range 0.003 - 0.19). Only half of the studies conducted formal statistical tests of indirect effects linking early socialization with later substance use.

Conclusion

This review highlights there is very little evidence for developmental cascade effects involving early parental socialization and substance use etiology. Methodological and conceptual limitations may hamper detection of developmental cascade effects and further undermine our understanding of substance use etiology. Future studies may want to follow larger samples, over extended time frames and specify intermediate mechanism that contribute to vulnerability.

Typologies of stress appraisal and problem-focused coping: associations with compliance with public health recommendations during the COVID-19 pandemic

BACKGROUND

Given prior research finding that young adults are less likely to engage in recommended public health behaviors (PHBs) than older adults, understanding who is and is not likely to engage in PHBs among young adults is crucial to mitigating the effects of the COVID-19 pandemic. Drawing on the Transactional Theory of Stress and Coping, this study examined how typologies of stress appraisal (SA) and problem-focused coping (PFC) among young adults were associated with compliance with public health recommendations during the pandemic.

METHODS

An online sample of young adults in the United States, ages 18-35, was recruited during the early phase of the pandemic (April-May 2020). Participants reported their appraisals of how central, threatening, and uncontrollable the pandemic was, their tendencies to engage in instrumental, problem-focused coping strategies, and how frequently they engaged in three recommended PHBs (social distancing, mask wearing, and hand washing).

RESULTS

Using latent class analysis, we identified three classes of individuals: Low-SA/Low-PFC, Low-SA/High-PFC, and High-SA/High-PFC. Demographics did not efficiently distinguish membership in the three classes. The former two classes reported less compliance with public health recommendations than did the latter class. Tests of measurement invariance for gender indicated trivial differences in the composition of class membership and relations to compliance.

CONCLUSIONS

This research uncovered three qualitatively distinct classes of people who differed in their appraisal of the pandemic and their tendency to engage in PFC. Individuals who view the pandemic as central and threatening and engage in problem-focused coping were more likely than their peers to comply with guidelines recommending social distancing, mask wearing, and hand washing. These results contribute to our understanding of why people do and do not comply with public health guidelines and highlight the importance of attending to psychological variables in public health research. Understanding what drives poor compliance with public health recommendations can contribute to efforts promoting better compliance, and ultimately better health outcomes.

Assessing the Role of Trust in Information Sources, Adoption of Preventive Practices, Volunteering and Degree of Training on Biological Risk Prevention, on Perceived Risk of Infection and Usage of Personal Protective Equipment Among Italian Medical Students During the SARS-CoV-2 Pandemic

Background: During the initial phase of the COVID-19 pandemic, the University of Bologna Medical School surveyed medical students to learn more about their preparation to confront challenges posed by the pandemic and whether it affects perceptions of viral infection risk. This information could help design risk-reduction interventions with training to mitigate possible viral exposure. Method: A cross-sectional online survey examining students' characteristics, volunteer status, adoption of evidence-based preventive measures, trust in information sources used, infectious disease training, and knowledge of PPE usage in relation to perceived risk of infection from SARS-CoV-2 in daily living, academic, and healthcare activities. A multivariate path model estimated the simultaneous influences of all exogenous factors on perceived risk. A Poisson regression model assessed the same multivariate effects on knowledge of PPE usage. Results: The analysis sample included 537 respondents. Perceived risk of infection was highest in hospital activities. On average, students were able to use only four out of seven types of PPE albeit they adopted most of the evidence-based preventive measures. Adoption of preventive measures was positively associated with perceived risk of COVID infection. Conversely, training on PPE usage and volunteer work were associated with lower perceived risk in healthcare setting and higher PPE knowledge. Conclusion: Implementing early safety-based educational programs remedy students' lack of knowledge in infectious disease prevention and mitigate their risk of infection. Voluntary work should be encouraged with potential benefit for both their continued medical training and strengthening the healthcare system's response to public health emergencies.

Modeling Behavior as Dynamic Sequential States: Introduction to the Special Issue

This special issue of Evaluation and The Health Professions focuses on applications and extensions of latent transition analysis (LTA), a longitudinal parameterization of the latent class (LC) model. LTA is a model of discrete or qualitative change over time among potentially complex states (e.g., patterns of recent drug use or abuse experiences), commonly referred to as latent classes, latent profiles, or latent statuses. Frequently, researchers will distinguish the term "classes" for cross-sectional studies and with LTA use "statuses" to indicate the concept of "dynamic change" with individuals shifting in their response patterns and associated statuses over time. It goes without saying that LTA models are underutilized, although quite flexible. This special issue showcases articles that apply LTA and extend the capabilities of this approach to modeling discrete change in new ways.

Typologies of coping in young adults in the context of the COVID-19 pandemic

The COVID-19 pandemic has created major upheavals in the lives of people worldwide. The virus has mostly affected elderly populations, but there may be corollary effects on young adults' psychosocial adjustment due to educational, economic, and occupational disruptions. Using latent class analysis, we examined unique typologies of coping in response to the pandemic among young adults. We used an expanded set of indicators including traditional measures of problem- and emotion-focused coping as well as measures of resilience and coping flexibility. We also examined whether class membership could be predicted by demographics, stress appraisal, and psychosocial characteristics including catastrophic thinking and impulsivity. The sample of 1,391 young adults (ages 18-35) was recruited via Amazon's Mechanical Turk (MTurk) and snowball methods from late-April to early-May 2020. Six classes were identified: (1) Resilient Flexible Problem-Focused Copers, (2) Resilient Inflexible Problem-Focused Copers, (3) Non-Resilient Flexible Problem-Focused Venters, (4) Non-Resilient Flexible Problem-Focused Copers, (5) Non-Resilient Flexible Non-Copers, and (6) Non-Resilient Inflexible Non-Copers. Using Class 1 as the reference class, we found perceived centrality and uncontrollability of the pandemic as well as catastrophic thinking and impulsivity were significant predictors of class membership. The mean levels of stress appraisal and psychosocial characteristics varied significantly between the classes, reinforcing the structural validity of these classes. The findings suggest the importance of training young adults to develop resilience and flexibility as well as specific coping skills that can help offset the psychological effects of dramatic lifestyle changes that may result from pandemics or other health crises in the future.

Adolescent Transitions in Self-Management Strategies and Young Adult Alcohol Use

Individuals use a variety of strategies to manage their thoughts, emotions, and behaviors across the lifespan. In this study, we used latent class analysis to derive distinct subtypes of self-management skills in early adolescence and latent transition analysis to examine whether movement between different classes was associated with later young adult alcohol use. Assessments of behavioral self-control, affective self-regulation, and cognitive self-reinforcement were obtained in the seventh and 10th grades from students participating in two independent drug prevention trials (control group participants only, N = 3,939). Assessment of alcohol use was obtained when participants were young adults (23–26). A model distinguishing four subtypes of self-management skills fit best for both the seventh and 10th grades. While findings indicated modest stability in class structure over time, maintaining class membership characterized by high cognitive self-reinforcement and high affective self-regulation was consistently protective in terms of young adult alcohol use relative to movement from this to other classes. Transitions in class membership involving an expansion of self-management strategies were protective and associated with lower levels of young adult alcohol use and transitions involving a contraction of self-management strategies associated with higher young adult alcohol use. This study illustrates the important use of person-centered techniques to exemplify how typologies of self-management during adolescence can play a protective role in young adult alcohol use.

Are E-cigarette Users a Unique Group of Smokers? Latent Class Analysis of the National Youth Tobacco Survey

We used data from the 2014 National Youth Tobacco Survey to examine patterns of cigarette smoking behavior and tobacco use. In light of the recent upsurge in e-cigarette use, we modeled current use and future intentions to use vape products along with combustible cigarette smoking and other tobacco products (i.e., cigars, cigarillos, chew, snuff, and dip). Latent class analyses indicated four discrete classes of smokers including a nominally involved class with very modest levels of tobacco product use, a class blending e-cigarette and cigars, a class of youth who predominantly use combustible cigarettes, and a group reporting indiscriminate use of almost all tobacco products excluding chew. Tests of invariance in item response probabilities and latent class proportions showed little variation across race and gender, albeit a new class of combustible cigarette and e-cigarette users emerged when examined by grade. Members of the heavy smoking and tobacco use class were more likely to be male, White, and older. Predictors of class membership included expectancies (perceived benefits of use), perceived harm (risk), media exposure, tobacco dependence, and the desire to quit. Findings are discussed in terms of characterizing risk among already smoking youth and how actionable prevention measures can be incorporated into existing universal and indicated programs that target reducing tobacco use and smoking behaviors.

Youth marijuana use: a review of causes and consequences

The legalization of medical and recreational marijuana has raised concerns about a potential increase in the availability and illegal use of marijuana by adolescent minors. To better understand the etiology, patterns, and consequences of adolescent marijuana use, this article reviews high quality, methodologically rigorous, longitudinal studies that focus on the role of personality factors such as sensation-seeking in the etiology of use, developmental trajectories of use and the effects of chronic use, potential gateway effects of marijuana on other illicit drugs, and its role in the onset of psychiatric disorders in adolescents and young adults. Implications are discussed in terms of mechanisms that account for initial and continued use of marijuana by adolescents, how use is associated with key developmental milestones and adult role socialization, and the potential of marijuana use during adolescence in furthering later drug involvement.

Frailty Phenotypes and Relations With Surgical Outcomes: A Latent Class Analysis

BACKGROUND

Frailty is an important concept in the care of older adults although controversy remains regarding its defining features and clinical utility. Both the Fried phenotype and the Rockwood deficit accumulation approaches cast frailty as a "burden" without exploring the relative salience of its cardinal markers and their relevance to the patient. New multifactorial perspectives require a reliable assessment of frailty that can validly predict postoperative health outcomes.

METHODS

In a retrospective study of 2828 unselected surgical patients, we used item response theory to examine the ability of 32 heterogeneous markers capturing limitations in physical, functional, emotional, and social activity domains to indicate severity of frailty as a latent continuum. Eighteen markers efficiently indicated frailty severity and were then subject to latent class analysis to derive discrete phenotypes. Next, we validated the obtained frailty phenotypes against patient-reported 30-day postoperative outcomes using multivariable logistic regression. Models were adjusted for demographics, comorbidity, type and duration of surgery, and cigarette and alcohol consumption.

RESULTS

The 18 markers provided psychometric evidence of a single reliable continuum of frailty severity. Latent class analyses produced 3 distinct subtypes, based on patients' endorsement probabilities of the frailty indicators: not frail (49.7%), moderately frail (33.5%), and severely frail (16.7%). Unlike the moderate class, severely frail endorsed emotional health problems in addition to physical burdens and functional limitations. Models adjusting for age, sex, type of anesthesia, and intraoperative factors indicated that severely frail (odds ratio, 1.89; 95% confidence interval, 1.42-2.50) and moderately frail patients (odds ratio, 1.31; 95% confidence interval, 1.03-1.67) both had higher odds of experiencing postoperative complications compared to not frail patients. In a 3-way comparison, a higher proportion of severely frail patients (10.7%) reported poorer quality of life after surgery compared to moderately frail (9.2%) and not frail (8.3%) patients (P < .001). There was no significant difference among these groups in proportions reporting hospital readmission (5.6%, 5.1%, and 3.8%, respectively; P = .067).

CONCLUSIONS

Self-report frailty items can accurately discern 3 distinct phenotypes differing in composition and their relations with surgical outcomes. Systematically assessing a wider set of domains including limitations in functional, emotional, and social activities can inform clinicians on what precipitates loss of physiological reserve and profoundly influences patients' lives. This information can help guide the current discussion on frailty and add meaningful clinical tools to the surgical practice.

Specialized Smartphone Intervention Apps: Review of 2014 to 2018 NIH Funded Grants

Background

The widespread adoption of smartphones provides researchers with expanded opportunities for developing, testing and implementing interventions. National Institutes of Health (NIH) funds competitive, investigator-initiated grant applications. Funded grants represent the state of the science and therefore are expected to anticipate the progression of research in the near future.

Objective

The objective of this paper is to provide an analysis of the kinds of smartphone-based intervention apps funded in NIH research grants during the five-year period between 2014 and 2018.

Methods

We queried NIH Reporter to identify candidate funded grants that addressed mHealth and the use of smartphones. From 1524 potential grants, we identified 397 that met the requisites of including an intervention app. Each grant’s abstract was analyzed to understand the focus of intervention. The year of funding, type of activity (eg, R01, R34, and so on) and funding were noted.

Results

We identified 13 categories of strategies employed in funded smartphone intervention apps. Most grants included either one (35.0%) or two (39.0%) intervention approaches. These included artificial intelligence (57 apps), bionic adaptation (33 apps), cognitive and behavioral therapies (68 apps), contingency management (24 apps), education and information (85 apps), enhanced motivation (50 apps), facilitating, reminding and referring (60 apps), gaming and gamification (52 apps), mindfulness training (18 apps), monitoring and feedback (192 apps), norm setting (7 apps), skills training (85 apps) and social support and social networking (59 apps). The most frequently observed grant types included Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) grants (40.8%) and Research Project Grants (R01s) (26.2%). The number of grants funded increased through the five-year period from 60 in 2014 to 112 in 2018.

Conclusions

Smartphone intervention apps are increasingly competitive for NIH funding. They reflect a wide diversity of approaches that have significant potential for use in applied settings.

Comparison of Cardiovascular Health Between US Army and Civilians

Background

Cardiovascular conditions are common in US Army and civilian populations. The recently developed concept of ideal cardiovascular health provides a new approach to evaluating population cardiovascular status.

Methods and Results

We defined a cohort of 263 430 active duty Army personnel, aged 17 to 64 years, who completed a 2012 physical examination and a corresponding subset of the noninstitutionalized, civilian US population, who participated in the National Health and Nutrition Examination Survey (NHANES) 2011 to 2012 cycle. We compared 4 cardiovascular health metrics (current smoking, body mass index, blood pressure, and diabetic status) between Army and civilian groups overall, and separately by sex, race/ethnicity, and age. The Army population was younger, was less often women or Hispanic, and had less post–high school education than the NHANES population. Smoking rates were ≈20% in the Army and NHANES groups, but <15% among Army women and Hispanics. Overall, one third of the Army and NHANES groups and NHANES women, but nearly half of Army women, demonstrated ideal body mass index. Ideal blood pressure was strikingly less prevalent in the Army than NHANES participants (30% versus 55%). Diabetes mellitus was rare in both groups.

Conclusions

Ideal cardiovascular health was less prevalent in the Army than NHANES group, despite exclusion of the least healthy recruits. Prevalence of ideal body mass index and blood pressure was low in both the Army and NHANES groups, even at early adult ages. This finding reveals the need for policy changes to promote, preserve, and improve ideal cardiovascular health in both the Army and the US population as a whole.

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

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

Challenges Facing Evidence-Based Prevention: Incorporating an Abductive Theory of Method

Current systems used to determine whether prevention programs are "evidence-based" rely on the logic of deductive reasoning. This reliance has fostered implementation of strategies with explicitly stated evaluation criteria used to gauge program validity and suitability for dissemination. Frequently, investigators resort to the randomized controlled trial (RCT) combined with null hypothesis significance testing (NHST) as a means to rule out competing hypotheses and determine whether an intervention works. The RCT design has achieved success across numerous disciplines but is not without limitations. We outline several issues that question allegiance to the RCT, NHST, and the hypothetico-deductive method of scientific inquiry. We also discuss three challenges to the status of program evaluation including reproducibility, generalizability, and credibility of findings. As an alternative, we posit that extending current program evaluation criteria with principles drawn from an abductive theory of method (ATOM) can strengthen our ability to address these challenges and advance studies of drug prevention. Abductive reasoning involves working from observed phenomena to the generation of alternative explanations for the phenomena and comparing the alternatives to select the best possible explanation. We conclude that an ATOM can help increase the influence and impact of evidence-based prevention for population benefit.

Strategies to Avoid Replication Failure With Evidence-Based Prevention Interventions: Case Examples From the Strengthening Families Program

Research has found disturbing long-term effects of poor parenting on children's behavioral health including addiction, delinquency, depression/anxiety, and poorer health as adults. Poor parenting practices thus contribute substantially to the health crisis in America. However, skilled, nurturing parents, or caretakers can help youth avoid these developmental problems. A number of family and parenting evidence-based interventions (EBIs) that teach parenting skills are now available for dissemination. Unfortunately, replications of EBIs do not always produce the original positive results. Organizations that seek to use family EBIs to improve parenting and family skills need to avoid practices that create replication failure. We examine several possible factors that contribute to replication failure using examples from five replications of the EBI "Iowa Strengthening Families Program for ages 10-14." We then share six strategies conducive to avoid replication failures including (1) choosing the right program and implementation strategy for the population, (2) administering the right "dosage," (3) choosing and properly training implementers, (4) maintaining program integrity and adherence, (5) ensuring cultural sensitivity, and (6) ensuring accurate and complete reporting of evaluation results. These guidelines can advance prevention science to meet the demands of a growing public health agenda.

Protective Effects of Psychological Strengths Against Psychiatric Disorders Among Soldiers

This study prospectively examined psychological strengths targeted in U.S. Army training programs as predictors of psychiatric diagnosis in active duty soldiers. At baseline, the cohort (140,584 soldiers) was without psychiatric disorder. Soldiers were then followed for 2 yr and classified as healthy, or acquiring a psychiatric diagnosis (adjustment disorder, anxiety disorder, depression, or post-traumatic stress disorder), or being prescribed psychotropic medication without a psychiatric diagnosis. Soldiers who remained healthy reported significantly higher strengths scores at baseline, compared with soldiers who were diagnosed with a psychiatric disorder. In addition, soldiers in the worst strengths decile were twice as likely to develop a psychiatric disorder, compared with soldiers in the top 50% on baseline strengths. Strengths afforded the greatest protection against depression. Offering tailored resilience training programs could help the Army steel vulnerable soldiers against the challenges of life, military training, and combat.

Why Research Design and Methods Is So Crucial to Understanding Drug Use/Abuse: Introduction to the Special Issue

The collection of articles in this special issue both raise the bar and inspire new thinking with regard to both design and methodology concerns that influence drug use/abuse research. Thematically speaking, the articles focus on issues related to missing data, response formats, strategies for data harmonization, propensity scoring methods as an alternative to randomized control trials, integrative data analysis, statistical corrections to reduce bias from attrition, challenges faced from conducting large-scale evaluations, and employing abductive theory of method as an alternative to the more traditional hypothetico-deductive reasoning. Collectively, these issues are of paramount importance as they provide specific means to improve our investigative tools and refine the logical framework we employ to examine the problem of drug use/abuse. Each of the authors addresses a specific challenge outlining how it affects our current research efforts and then outlines remedies that can advance the field. To their credit, they have included issues that affect both etiology and prevention, thus broadening our horizons as we learn more about developmental processes causally related to drug use/abuse and intervention strategies that can mitigate developmental vulnerability. This is the essential dialogue required to advance our intellectual tool kit and improve the research skills we bring to bear on the important questions facing the field of drug use/abuse. Ultimately, the goal is to increase our ability to identify the causes and consequences of drug use/abuse and find ways to ameliorate these problems as we engage the public health agenda.

Latent-Variable Confirmatory Factor Analysis of the Adolescent Temperament Questionnaire

Latent-variable confirmatory factor analysis was used to examine the dimensional structure of adolescent temperament from a sample of 436 adolescents. The ninedimensional model proposed by A. Thomas and S. Chess in 1977 was extended by including a bidimensional structure of Mood (including both positive and negative affectivity) and a dimension of Ego Control tapping resiliency and flexibility. All 11 dimensions were statistically reliable and a superiorfit was obtained with a correlated, rather than an orthogonal, model. Results indicated that the factors of Threshold, Intensity, and Distractibility may not be developmentally consistent nor conceptually homogeneous. Moreover, modelfit statistics underscored that a single nomothetic model could not adequately account for the variability underlying the temperamental styles of these adolescents. Separate primary models reflecting temperamental "systems" of Cognitive-Diligence, Sociability/Resilience, and Wgor/Mobility also were tested. Findings suggest that extension of temperament assessment from infancy and childhood to adolescence is developmentally appropriate, although further elucidation of temperamental styles consistent with adult personality is warranted.

The U.S. Army Person-Event Data Environment: A Military-Civilian Big Data Enterprise

This report describes a groundbreaking military-civilian collaboration that benefits from an Army and Department of Defense (DoD) big data business intelligence platform called the Person-Event Data Environment (PDE). The PDE is a consolidated data repository that contains unclassified but sensitive manpower, training, financial, health, and medical records covering U.S. Army personnel (Active Duty, Reserve, and National Guard), civilian contractors, and military dependents. These unique data assets provide a veridical timeline capturing each soldier's military experience from entry to separation from the armed forces. The PDE was designed to afford unprecedented cost-efficiencies by bringing researchers and military scientists to a single computerized repository rather than porting vast data resources to individual laboratories. With funding from the Robert Wood Johnson Foundation, researchers from the University of Pennsylvania Positive Psychology Center joined forces with the U.S. Army Research Facilitation Laboratory, forming the scientific backbone of the military-civilian collaboration. This unparalleled opportunity was necessitated by a growing need to learn more about relations between psychological and health assets and health outcomes, including healthcare utilization and costs-issues of major importance for both military and civilian population health. The PDE represents more than 100 times the population size and many times the number of linked variables covered by the nation's leading sources of population health data (e.g., the National Health and Nutrition Examination Survey). Following extensive Army vetting procedures, civilian researchers can mine the PDE's trove of information using a suite of statistical packages made available in a Citrix Virtual Desktop. A SharePoint collaboration and governance management environment ensures user compliance with federal and DoD regulations concerning human subjects' protections and also provides a secure portal for multisite collaborations. Taking similarities and differences between military and civilian populations into account, PDE studies can provide much more detailed insight into health-related questions of broad societal concern. Finding ways to make the rich repository of digitized information in the PDE available through military-civilian collaboration can help solve critical medical and behavioral issues affecting the health and well-being of our nations' military and civilian populations.

The Person-Event Data Environment: leveraging big data for studies of psychological strengths in soldiers

The Department of Defense (DoD) strives to efficiently manage the large volumes of administrative data collected and repurpose this information for research and analyses with policy implications. This need is especially present in the United States Army, which maintains numerous electronic databases with information on more than one million Active-Duty, Reserve, and National Guard soldiers, their family members, and Army civilian employees. The accumulation of vast amounts of digitized health, military service, and demographic data thus approaches, and may even exceed, traditional benchmarks for Big Data. Given the challenges of disseminating sensitive personal and health information, the Person-Event Data Environment (PDE) was created to unify disparate Army and DoD databases in a secure cloud-based enclave. This electronic repository serves the ultimate goal of achieving cost efficiencies in psychological and healthcare studies and provides a platform for collaboration among diverse scientists. This paper provides an overview of the uses of the PDE to perform command surveillance and policy analysis for Army leadership. The paper highlights the confluence of both economic and behavioral science perspectives elucidating empirically-based studies examining relations between psychological assets, health, and healthcare utilization. Specific examples explore the role of psychological assets in major cost drivers such as medical expenditures both during deployment and stateside, drug use, attrition from basic training, and low reenlistment rates. Through creation of the PDE, the Army and scientific community can now capitalize on the vast amounts of personnel, financial, medical, training and education, deployment, and security systems that influence Army-wide policies and procedures.

Did we get our money's worth? Bridging economic and behavioral measures of program success in adolescent drug prevention

The recent U.S. Congressional mandate for creating drug-free learning environments in elementary and secondary schools stipulates that education reform rely on accountability, parental and community involvement, local decision making, and use of evidence-based drug prevention programs. By necessity, this charge has been paralleled by increased interest in demonstrating that drug prevention programs net tangible benefits to society. One pressing concern is precisely how to integrate traditional scientific methods of program evaluation with economic measures of “cost efficiency”. The languages and methods of each respective discipline don’t necessarily converge on how to establish the true benefits of drug prevention. This article serves as a primer for conducting economic analyses of school-based drug prevention programs. The article provides the reader with a foundation in the relevant principles, methodologies, and benefits related to conducting economic analysis. Discussion revolves around how economists value the potential costs and benefits, both financial and personal, from implementing school-based drug prevention programs targeting youth. Application of heterogeneous costing methods coupled with widely divergent program evaluation findings influences the feasibility of these techniques and may hinder utilization of these practices. Determination of cost-efficiency should undoubtedly become one of several markers of program success and contribute to the ongoing debate over health policy.

Long-term effects of self-control on alcohol use and sexual behavior among urban minority young women

High risk alcohol use and sexual behaviors peak in young adulthood and often occur in the same individuals. Alcohol use has been found to impair decision-making and contribute to high risk sexual activity. However, the association between alcohol use and risky sexual behavior may also reflect enduring individual differences in risk taking, sociability, self-control, and related variables. Both behaviors can serve similar functions related to recreation, interpersonal connection, and the pursuit of excitement or pleasure. The present study examined the extent to which high risk drinking and sexual behavior clustered together in a sample of urban minority young adult women, a demographic group at elevated risk for negative outcomes related to sexual health. We tested whether psychosocial functioning measured at the beginning of high school predicted classes of risk behaviors when girls were tracked longitudinally into young adulthood. Latent class analysis indicated three distinct profiles based on high risk drinking and sexual behavior (i.e., multiple sex partners) in young adulthood. The largest class (73% of the sample) reported low levels of risky drinking and sexual behavior. The next largest class (19%) reported high risk drinking and low risk sexual behavior, and the smallest class (8%) reported high levels of both behaviors. Compared to women from other racial/ethnic groups, black women were more likely to be categorized in the high risk drinking/low risk sex class. Multinomial logistic regression indicated that self-control in adolescence had a broad and enduring protective effect on risk behaviors eight years later and was associated with a greater probability of being in the low risk drinking/low risk sex class. Findings are discussed in terms of understanding the phenotypic expressions of risk behavior as they relate to early psychosocial development and the long-term protective function of self-control in reducing high risk drinking and sexual behaviors.

An empirical assessment of the Above the Influence advertising campaign

This study evaluated the efficacy of Above the Influence (ATI), a national media-based health persuasion campaign to deter youth drug use. The campaign uses public service anti-drug prevention messages and targets youth between the ages of 14 and 16, a period of heightened susceptibility to peer influences. The evaluation utilized mall intercepts from geographically dispersed regions of the country. Theoretical impetus for the campaign combines elements of the theory of reasoned action (TRA), persuasion theory, and the health belief model. A series of structural equation models were tested with four randomly drawn cross-validation samples (N = 3,000). Findings suggest that awareness of ATI is associated with greater anti-drug beliefs, fewer drug use intentions, and less marijuana use. Congruent with the TRA, changes in beliefs and intentions are intermediate steps linking campaign awareness with behavior. This study provides further evidence of positive campaign effects and may strengthen reliance on mass media health persuasion campaigns as a useful adjunct to other programs targeting youth.

The three latent classes of adolescent delinquency and the risk factors for membership in each class

This study used latent class analysis to examine subpopulation membership based on self-reports of delinquent behaviors obtained from Australian youth. Three discrete identifiable classes were derived based on 51 indicators of physical violence, property damage, minor infractions, drug use, and social delinquency. One class of youth engaged in primarily rule breaking and norm violations including underage alcohol use, typical of this age period. A second class was more actively delinquent emphasizing drug use, trespassing, and various forms of disobedience. A third class of highly delinquent youth differed from their counterparts by endorsing drug use, thievery that involved stealing money, goods, and cars, property damage, gambling, precocious sexual experiences, involvement with pornographic materials, and fighting. Multinomial logistic regression predicting class membership indicated highly delinquent youth were more likely to be older males, use venting coping strategies, and be fun or novelty seeking compared with rule breakers. Findings are discussed in terms of refining current taxonomic arguments regarding the structure of delinquency and implications for prevention of early-stage antisocial behavior.

Influence of a nationwide social marketing campaign on adolescent drug use

In this study, we examined whether awareness (recall) of the National Youth Anti-Drug Media Campaign (NYADMC) benefited youth by attenuating their drug use. Data were obtained from the National Survey of Parents and Youth (NSPY), an evaluative survey tool designed to monitor campaign progress over 4 years. A growth modeling strategy was used to examine whether change in message recall or campaign brand awareness was related to declining patterns of drug use. Two distinct growth trajectories were modeled to account for growth among younger (12 to 14) versus older (15 to 18) youth. Growth trajectories indicated steady and positive increases in alcohol, cigarette, and marijuana use over time. During the early portion of adolescence, youth reported more "brand" awareness, remembered more of the video clips depicting campaign messages, recalled more media stories about youth and drugs and more antitobacco ads, and reported more radio listening and less television watching. When they were older, these same youth reported declines in these same awareness categories except for specifically recalling campaign ads and radio listening. Models positing simultaneous growth in drug use and campaign awareness indicated mixed findings for the campaign. Overall early levels of campaign awareness had a limited influence on rates of growth, and in a few cases higher levels were associated with quicker acquisition of drug use behaviors. When they were younger, these youth accelerated their drug use and reported increasing amounts of campaign awareness. When they were older, increasing awareness was associated with declines in binge drinking and cigarette smoking. No effects for marijuana were significant but trended in the direction of increased awareness associated with declining drug use. The findings are discussed in terms of how they depart from previous reports of campaign efficacy and the potential efficacy of social marketing campaigns to reach a large and impressionable youthful audience with strategically placed advertisements.

Tri-city study of Ecstasy use problems: a latent class analysis

This study used latent class analysis to examine distinctive subtypes of Ecstasy users based on 24 abuse and dependence symptoms underlying standard DSM-IV criteria. Data came from a three site, population-based, epidemiological study to examine diagnostic nosology for Ecstasy use. Subject inclusion criteria included lifetime Ecstasy use exceeding five times and once in the past year, with participants ranging in age between 16 and 47 years of age from St. Louis, Miami, U.S. and Sydney, Australia. A satisfactory model typified four latent classes representing clearly differentiated diagnostic clusters including: (1) a group of sub-threshold users endorsing few abuse and dependence symptoms (negatives), (2) a group of 'diagnostic orphans' who had characteristic features of dependence for a select group of symptoms (mild dependent), (3) a 'transitional group' mimicking the orphans with regard to their profile of dependence also but reporting some abuse symptoms (moderate dependent), and (4) a 'severe dependent' group with a distinct profile of abuse and dependence symptoms. A multinomial logistic regression model indicated that certain latent classes showed unique associations with external non-diagnostic markers. Controlling for demographic characteristics and lifetime quantity of Ecstasy pill use, criminal behavior and motivational cues for Ecstasy use were the most efficient predictors of cluster membership. This study reinforces the heuristic utility of DSM-IV criteria applied to Ecstasy but with a different collage of symptoms that produced four distinct classes of Ecstasy users.

Cognitive predictors of alcohol involvement and alcohol consumption-related consequences in a sample of drunk-driving offenders

Motivational theories of alcohol involvement emphasize a wide range of cognitive factors as precursors to "heavy" or high-risk drinking. Central to this consideration has been expectancies, drinking urges, triggers, and situational cues, all of which can synergistically or independently stimulate drinking. Unfortunately, empirical studies have scrutinized low-level or moderate drinkers drawn from the general population, and less is known about the role of cognitive factors as precursors to high-risk drinking. The present study examines the unique contribution of several measures of cognitive motivation to harmful alcohol use in a sample of convicted drunk drivers. Confirmatory factor analysis indicated the psychometric soundness of a model positing four latent predictor constructs assessing drinking urges/triggers, situational cues, positive and negative expectancies and outcome constructs assessing harmful alcohol use and perceived consequences of harmful drinking. A structural equation model indicated that each motivational construct was associated uniquely with both drinking and perceived consequences, with the largest overall effect in both cases associated with situational cues. Results are discussed in terms of identifying prominent cognitive factors that may foster harmful drinking among high-risk populations and their implications for treatment.

Racial/ethnic differences in the protective effects of self-management skills on adolescent substance use

A variety of cognitive and behavioral self-management skills have been posited as protective in terms of adolescent substance use. This study examined whether these skills measured in the 7th grade served a protective function in 9th grade substance use across ethnically diverse samples of adolescents. Participants consisted of Black (n = 461) and Hispanic (n = 320) urban youth and White suburban youth (n = 757). Structural equation modeling indicated that a second order Self-Management Skills latent factor consisting of first order latent factors of Decision-Making, Self-Regulation, and Self-Reinforcement skills was protective for adolescent substance use across racial/ethnic subgroups. However, Self-Management Skills were more strongly protective for suburban White youth and less protective for urban minority youth. These findings are consistent with previous research showing that predictive power of risk and protective factors derived from psychosocial theories varies widely across racial/ethnic subgroups of youth and is weaker among racial/ethnic minority youth compared to White youth. An important next step is to broaden the focus of etiology research from individual-level determinants to studying adolescent substance use behavior in the context of the cultural background and primary social settings of young people, such as family, school, and community environments.

A psycho-economic model of ecstasy consumption and related consequences: a multi-site study with community samples

Becker and Murphy's (1988) theory of rational behavior suggests that economic factors play an influential role in the decision leading to drug consumption and possibly dependence. Psychological models, on the other hand, emphasize internal regulatory cues that motivate drug use and play a contributory role in dependence. Until now, the confluence of both economic and psychological models has not been tested empirically. The present study used latent-variable structural equation modeling (SEM) to examine the influence of both economic (social anomie, unit price, and time spent acquiring drugs) and psychological risk factors (motivation, depression, and sexual risk behaviors) on self-reported ecstasy use. Data were obtained from 612 recreational ecstasy users in the United States and Australia participating in a NIDA-funded epidemiological study examining trends in ecstasy use. The sample was mainly white (61%), male (58%), and young (mean age = 23 yrs [5.25]). All of the hypothesized latent constructs were statistically reliable and correlated in the expected direction. A saturated SEM indicated that monetary and opportunity cost, but not income, significantly predicted ecstasy use. Among the psychological measures, motivational cues were the strongest predictor of both use and dependence. Inclusion of gender, age, race, education, and site variables did not appreciably alter the final model parameters. The implications of incorporating the role of economic factors in shaping a more refined understanding of addiction are discussed. Suggestions for future research and study limitations are also noted.

Low perceived chances for success in life and binge drinking among inner-city minority youth

PURPOSE

To examine the relationship between low perceived chances for success in life and binge drinking in a sample of economically disadvantaged, predominantly minority, urban adolescents.

METHODS

A sample of predominantly black and Hispanic students (N = 774) from 13 inner-city schools completed confidential questionnaires in the 7th, 8th, and 9th grades. Eight items measured students' estimation of achieving certain adaptive life goals. Students who reported that they typically drink five or more drinks per drinking occasion were identified as binge drinkers.

RESULTS

Chi-square proportional analyses indicated that rates of binge drinking increased and perceived life chances decreased for both boys and girls from the 7th to 9th grade. A cross-lagged path analytic model revealed that higher perceived life chances in the 7th grade predicted less binge drinking in the 8th grade, whereas binge drinking in the 8th grade predicted lower perceived life chances in the 9th grade, controlling for change over time in both variables.

CONCLUSIONS

Low perceived chances of success in life appear to play a role in the initiation and escalation of binge drinking during early adolescence, with a reciprocal relationship between the two factors developing over time.

Common predictors of cigarette smoking, alcohol use, aggression, and delinquency among inner-city minority youth

The present study examined the prevalence rates and common predictors of substance use, aggression, and delinquency among inner-city minority youth entering middle school. A survey was administered to sixth grade students (N=5442) from 42 New York City schools. Aggressive behaviors were reported most frequently, followed by delinquent behaviors, alcohol use, and cigarette smoking. Across all behavioral outcomes, social and environmental influences explained the largest proportion of variance, followed by individual characteristics and skills, bonding to conventional institutions, and demographic variables. For the majority of predictor variables, there was substantial overlap in patterns of prediction across outcomes. These findings indicate that several factors that correspond to the predominant psychosocial theories of adolescent development explain variation across different problem behavior outcomes among inner-city minority youth.

Personal competence skills, distress, and well-being as determinants of substance use in a predominantly minority urban adolescent sample

Several previous studies have investigated the relationship between psychological distress and substance use among youth. However, less research has investigated the potentially protective role of psychological well-being on adolescent substance use, and the extent to which personal competence skills may promote well-being. The present study examined personal competence skills, psychological distress and well-being, and adolescent substance use over a 3-year period in a predominantly minority sample of urban students (N = 1,184) attending 13 junior high schools in New York City. Structural equation modeling indicated that greater competence skills predicted less distress and greater well-being over time. Although psychological well-being was associated with less subsequent substance use, distress did not predict later substance use. Findings indicate that competence skills promote resilience against early stage substance use in part by enhancing psychological well-being, and suggest that school-based prevention programs should include competence enhancement components in order to promote resilience.

Estimates of intragroup dependence for drug use and skill measures in school-based drug abuse prevention trials: an empirical study of three independent samples

Group-randomized drug abuse prevention trials customarily designate schools as the unit of assignment to experimental condition; however, students within schools remain the unit of observation. Students nested within schools may show some resemblance based on common (peer) selection or school climate factors (i.e., disciplinary practices, group norms, or rules). Appropriate analyses of any treatment effects must be statistically correct for the magnitude of clustering within these intact social units (i.e., intraclass correlation coefficient [ICC]). There is little reported evidence, however, of variation in ICCs that might occur with studies of racially or geographically diverse populations. The purpose of this study was to generate estimates of intragroup dependence for drug use and psychosocial measures (hypothesized mediators) from three separate drug abuse prevention trials. Clustering for the drug use measures averaged .02 across study and age-groups (range = .002 to .053) and was equivalently small for the psychosocial measures (averaging .03 across studies and age-groups; range = .001 to .149). With few exceptions and across different samples, clustering decreased in magnitude over time. Clustering was largest for peer smoking and drinking norms among white, suburban youth and smallest for alcohol expectancies among urban black youth. Findings are discussed with respect to the influence of social climate factors and group norms in the design and analysis of school-based, drug abuse, prevention programs.

Factors associated with regular marijuana use among high school students: a long-term follow-up study

The present study investigated whether several behavioral and psychosocial factors measured during early adolescence predicted regular marijuana use 6 years later in a sample of high school students. As part of a school-based survey. 7th-grade students (N = 1,132) reported levels of alcohol, tobacco, and marijuana use, and were assessed on several domains of psychosocial functioning potentially relevant in the etiology of marijuana use. When students were followed-up in the 12th-grade, 14% smoked marijuana on a regular basis (once or more per month). Findings indicated that early cigarette smoking, alcohol use, and alcohol intoxication predicted later regular marijuana use. For boys, early marijuana use increased the odds for later regular marijuana use. Cigarette smoking by friends and siblings during early adolescence also increased the likelihood of later monthly marijuana use. The findings suggest that early prevention programs for adolescent alcohol, tobacco, and/or other drug use may have important preventive effects in terms of potentially more serious levels of marijuana involvement later in adolescence and early adulthood.

Protective role of personal competence skills in adolescent substance use: psychological well-being as a mediating factor

Adolescents who use a variety of cognitive and behavioral self-management strategies have been shown to report reduced rates of early-stage substance use, but little is known about how these personal competence skills may be protective. In a series of structural equation models, this study examined the association between competence skills and substance use over a 3-year period among 849 suburban junior high school students, and whether psychological distress, well-being, or both mediated this relation. Findings indicated that well-being fully mediated the relation between early competence and later substance use, but distress did not. Youth with good competence skills reported greater subsequent well-being, which in turn predicted less later substance use. Findings suggest that competence skills protect youth by enhancing well-being and that prevention programs should aim to enhance competence in order to promote resilience.