Strategies and Interventions Used to Prevent Violence Against Sex Workers in the United States: A Scoping Review Using the Social-Ecological Model

Structural factors in the United States, such as criminalization, contribute to disproportionate rates of violence against sex workers and subsequent risk of adverse health outcomes. There is a clear need for systemic interventions and risk reduction strategies to reduce violence in this population. To inform next steps in prevention, this scoping review provides an overview of the literature on violence prevention efforts targeting sex workers in the United States, mapped out according to the social-ecological model (SEM). A comprehensive search of peer-reviewed literature across five databases with no limit on publication date yielded 2,372 documents. Studies were eligible for inclusion if they focused on the U.S. population of sex workers and had a clearly defined aim or purpose of exploring, describing, or evaluating sex work violence prevention interventions or risk reduction strategies. Twelve studies met all eligibility criteria and were selected. Only two of the studies evaluated sexual violence prevention interventions, while the remaining 10 explored strategies sex workers use to minimize the risk of violence. Most research focused on female sex workers, violence from paying clients, and prevention at the individual level of the SEM. Our findings suggest a need for additional violence prevention interventions tailored for diverse groups of sex workers and cognizant of the overlapping forms of violence they face. This scoping review contributes to the limited body of research on the prevention of violence against sex workers in the United States by providing future directions for research and program development that span across the SEM.

Alcohol's Role in Campus Sexual Assault Bystander Behavior: A Systematic Review

Between 50% and 70% of campus sexual assaults (SA) involve alcohol and campuses frequently promote bystander intervention strategies to prevent SA in student party contexts. This systematic review evaluates the measurement and outcomes of quantitative studies on how alcohol affects campus SA bystander outcomes. Using four search strategies and rigorous systematic review methods, we conducted a review of 36 studies. We included studies published after 2,000 conducted with college students in the United States, its territories, and Canada which contained information on alcohol use and SA bystander outcomes (behaviors and upstream proxies). Only a third of included studies measured bystander behavior directly, the majority measured upstream proxies (e.g., intentions, self-efficacy). Most studies considered the influence of victim intoxication on bystander outcomes. No studies assessed the pharmacological or physiological effects of alcohol on bystander outcomes. A single study examined hypothetical bystander responses when intoxicated, one-third examined bystander's typical alcohol use in relation to bystander outcomes. Many findings are contradictory, including fundamental details such as how often students encounter SA involving alcohol or whether bystanders' alcohol use predicts outcomes. Findings suggest that students are less likely help intoxicated victims compared to sober victims, but there are clear moderating factors. Perpetrator intoxication was not studied in relation to bystander behavior and did not influence any upstream proxies. Evaluations of interventions on alcohol and bystander topics are promising yet more research is required. This review illuminates key gaps in the literature, including the need for validated measures and scenarios, event-level studies, and alcohol administration trials.

Spending Time in Nature Serves as a Protective Factor against Problematic Alcohol Use: A Structural Equation Modeling Approach

Alcohol use in the U.S. continues to be a prevalent behavior with the potential for far-reaching personal and public health consequences. Risk factors for problematic drinking include negative affect and impulsive decision-making. Research suggests exposure to nature reduces negative affect, increases positive affect, and reduces impulsive choice. The purpose of the current study was to explore the relationships between exposure to nature (actively going out to nature and the level of greenness around the participant's daily life), affect, impulsive decision-making, and alcohol use, using structural equation modeling. Cross-sectional data (N = 340) collected online on Amazon MTurk were used to test the hypothesized relationships separately for alcohol consumption and alcohol-related problems. Actively spending time in nature was associated with lower negative affect and higher positive affect, while passive exposure to nature was only associated with higher positive affect. In turn, negative affect was positively related to both alcohol measures, while positive affect was related to increased alcohol consumption, but not alcohol-related problems. Impulsive decision-making was not related to nature or alcohol measures. Findings suggest that intentionally spending time in nature may protect against problematic alcohol use by reducing negative affect. These results warrant further research on nature as an adjunct treatment for reducing alcohol and substance-related harms and carry implications for public education and increasing accessibility to natural spaces.

An Ecological Momentary Assessment of College Women's Decisions to Use Protective Behavioral Strategies

Protective behavioral strategies (PBS) have been associated with reduced risk for sexual assault victimization in college women. Sexual assault risk reduction programs have had limited success increasing PBS use, particularly among heavy drinkers, suggesting a need for additional research on the malleable predictors of PBS use. Whereas longitudinal studies show women's decisions to use PBS can be both planned and reactive, little is known about the decision-making processes that affect PBS use on drinking days, when sexual assault risk may be elevated. The current study used ecological momentary assessment to examine variability in the associations between decision-making and PBS use within and across drinking days in first-semester college women. Participants (56 female drinkers) completed a 14-day protocol with three daily measures of intentions and willingness to use PBS, and once-daily diaries of PBS use. Multilevel models examined between-day and within-day effects of intentions and willingness to use PBS with regards to sexual assault PBS (e.g., communicating sexual boundaries) and drinking PBS (e.g., limiting alcohol consumption), respectively. On days when sexual assault PBS willingness increased throughout the day, women tended to use more sexual assault PBS. This association was strongest among women who were typically less willing to use these PBS. Among women who were the least willing to use drinking PBS, their drinking PBS use decreased on days when they reported increased willingness to use them. Decisions to use sexual assault and drinking PBS on drinking days were qualified by women's typical levels of willingness to use the different PBS. This suggests the need for a multi-faceted intervention strategy that targets both typical and event-level risk. Individual-level alcohol and sexual assault risk reduction approaches could be enhanced with event-level PBS messaging and evaluation.

A Latent Class Analysis of Prevention Approaches Used to Reduce Community-Level Prescription Drug Misuse in Adolescents and Young Adults

The Substance Abuse and Mental Health Services Administration's Strategic Prevention Framework Partnerships for Success (PFS) program supports community-based organizations (CBOs) across the United States in implementing evidence-based prevention interventions to reduce substance use in adolescents and young adults. Little attention has been paid to how CBOs combine interventions to create comprehensive community-specific prevention approaches, or whether different approaches achieve similar community-level effects on prescription drug misuse (PDM). We used PFS evaluation data to address these gaps. Over 200 CBOs reported their prevention intervention characteristics, including strategy type (e.g., prevention education, environmental strategies) and number of unique interventions. Evaluation staff coded whether each intervention was an evidence-based program, practice, or policy (EBPPP). Latent Class Analysis of seven characteristics (use of each of five strategy types, use of one or more EBPPP, and number of interventions implemented) identified six prevention approach profiles: High Implementation EBPPP, Media Campaigns, Environmental EBPPP, High Implementation Non-EBPPP, Prevention Education, and Other Information Dissemination. All approaches except Media Campaigns and Other Information Dissemination were associated with significant reductions in community-level PDM. These approaches may need to be paired with other, more direct, prevention activities to effectively reduce PDM at the community level. However, similar rates of change in PDM across all 6 prevention approaches suggests only weak evidence favoring use of the other four approaches. Community-based evaluations that account for variability in implemented prevention approaches may provide a more nuanced understanding of community-level effects. Additional work is needed to help CBOs identify the most appropriate approach to use based on their target communities' characteristics and resources.

Examining the Relationship between Social Connection and Opioid Misuse: A Systematic Review

METHODS

We used a Boolean search strategy of PubMed, PsycINFO, and Embase to identify eligible publications from January 1990 to March 2020 and narrative analysis to synthesize the evidence.

RESULTS

The database search identified 1267 independent citations; 29 publications met inclusion criteria. Nearly all the studies demonstrated high risk of bias, most often due to selection and confounding bias. Most of the studies in the review (k = 20, 69%) found at least one significant association between social connection and opioid outcomes. Although no two studies included the same measures of social connection or opioid misuse, and social connection was both positively and negatively associated with opioid misuse, results support that social connection is an important correlate of opioid misuse.

CONCLUSIONS

This review highlights the importance of social connection as a correlate to opioid misuse. However, the extensive variability among research studies points to a need for standardization of measurement and larger studies with diverse populations to allow for consequential recommendations for prevention or treatment of opioid misuse. Evidence regarding the associations between social connection and opioid misuse or disorder is sparse. We provide suggestions for advancing this research, including clarification of the complex influences between social connections and opioid misuse.

Examining protocol compliance and self-report congruence between daily diaries and event-contingent ecological momentary assessments of college student drinking

BACKGROUND

Daily diaries and ecological momentary assessments (EMA) are frequently used to assess event-level college student drinking. While both methods have advantages, they also raise questions about data validity, particularly in regard to alcohol's impact on protocol compliance. The current study examined congruence in drinking behaviors reported via retrospective daily diaries and event-contingent drinking logs, protocol compliance with each method, and the extent to which alcohol consumption impacted compliance.

METHODS

Participants were first-semester college women (n = 69) who reported 4+ drinks during an occasion at least once in the past month. Participants reported the number of drinks consumed and subjective intoxication using a 14-day EMA protocol. Event-contingent drinking logs (via self-initiated EMA) assessed behavior immediately after each drinking event; daily diaries assessed behaviors from the previous day. Pairwise correlations examined congruence between drinking logs and corresponding daily dairies; protocol compliance was examined through descriptive analysis of data missingness; and multilevel regression models assessed the associations between protocol compliance, alcohol consumption, and subjective intoxication.

RESULTS

Drinking log and daily diary reports were highly correlated (r's = 0.70 to 0.93). On drinking days, diary reports had higher protocol compliance (96.0%) compared to momentary drinking logs (41.4%). Drinking log missingness was associated with greater alcohol use and subjective intoxication reported in the corresponding daily diary (p's < 0.05).

CONCLUSIONS

Similarities in reports of alcohol consumption and subjective intoxication, coupled with higher missingness of momentary assessments suggest daily diaries may have methodological advantages and unique utility in supplementing momentary assessments.

Alcohol Consumption and Use of Sexual Assault and Drinking Protective Behavioral Strategies: A Diary Study

Heavy drinking is a risk factor for sexual assault. Although protective behavioral strategies (PBS) tend to be associated with reduced alcohol consumption, there are studies showing differential benefits for using these strategies. The current study extended the research on PBS and drinking by examining daily associations between alcohol consumption and sexual assault PBS (e.g., letting others know one's whereabouts) versus stopping or limiting drinking PBS (e.g., planning to stop drinking at a predetermined time) and manner of drinking PBS (e.g., avoiding mixing alcohol types). Women who are heavy episodic drinkers attending a northeastern university (N = 69) completed 14 daily reports of alcohol consumption and PBS use. Using multilevel modeling, we examined associations between alcohol consumption and PBS types across days and PBS users. Alcohol consumption increased with greater use of sexual assault PBS and decreased with greater use of stopping or limiting drinking and manner of drinking PBS. Findings suggest differential benefits for specific PBS. Clinicians, teachers, and parents can provide a menu of options for reducing sexual assault risk by encouraging women to use sexual assault and drinking PBS together.

A Web-Based Intervention to Reduce Indoor Tanning Motivations in Adolescents: a Randomized Controlled Trial

Youthful indoor tanning as few as ten sessions can increase the risk of melanoma by two to four times with each additional session adding another 2 % to the risk. Recent research estimates that indoor tanning can be linked to approximately 450,000 cases of skin cancer annually in the USA, Europe, and Australia. Despite these risks, indoor tanning remains popular with adolescents. This study tested the efficacy of a web-based skin cancer prevention intervention designed to reduce indoor tanning motivations in adolescent females. A nationally representative sample of 443 female teens was enrolled from an online panel into a two-arm, parallel group design, randomized controlled trial. Treatment participants received an appearance-focused intervention grounded in established health behavior change models. Controls viewed a teen alcohol prevention website. Outcome variables included willingness and intentions to indoor tan, willingness to sunless tan, and measures of indoor tanning attitudes and beliefs. The intervention decreased willingness and intentions to indoor tan and increased sunless tanning willingness relative to controls. We also examined indirect mechanisms of change through intervening variables (e.g., indoor tanning attitudes, norms, positive and negative expectancies) using the product of coefficient approach. The web-based intervention demonstrated efficacy in changing adolescent indoor tanning motivations and improving their orientation toward healthier alternatives. Results from the intervening variable analyses give guidance to future adolescent skin cancer prevention interventions.

An Examination of the Relationship Between Consequence-Specific Normative Belief Patterns and Alcohol-Related Consequences Among College Students

BACKGROUND

Research has previously identified a high-risk subgroup of college students who experience high levels of multiple and repeated alcohol-related consequences (MRC group). The purpose of this study was to examine the association between consequence-specific normative influences and experiencing multiple and repeated drinking-related consequences using a person-centered approach. Normative subgroups were identified using latent profile analysis (LPA), which were then used to predict MRC group status at 6-month follow-up.

METHODS

First-year college student drinkers (N = 2,024) at a large northeastern university completed online surveys during the fall and spring semesters of their freshman year. Retention was high with 92% of invited participants completing T2, of which the MRC group accounted for 27%.

RESULTS

Three student profiles were identified from LPA on T1 data: Nonpermissive Parents (77%), Positive Peer and Parent Norms (21%), and Permissive Parents (3%). Logistic regression revealed that both the Positive Peer and Parent Norms and Permissive Parents profiles had significantly higher odds of MRC group membership at follow-up (1.81 and 2.78 times greater, respectively).

CONCLUSIONS

The results suggest value in prevention efforts that include normative beliefs about alcohol-related consequences. Further, parental norms in particular have the potential to enhance interventions, especially through direct communication of disapproval for experiencing consequences.

A Dual-Process Examination of Alcohol-Related Consequences Among First-Year College Students

OBJECTIVE

Despite showing reductions in college student drinking, interventions have shown some inconsistency in their ability to successfully decrease consequences. With the goal of improving prevention efforts, the purpose of this study was to examine the role of consequence-specific constructs, in addition to drinking, that influence students' experiences with alcohol-related problems. The study examined how drinking and protective behaviors mediated the relationships between students' willingness to experience consequences, intentions to avoid them, and four categories of alcohol-related problems (physiological, social, sexual, and academic).

METHOD

First-year college student drinkers (n = 2,024) at a large northeastern university completed surveys during the fall and spring of their freshman year.

RESULTS

As expected, different patterns of associations emerged for physiological and nonphysiological consequences. When physiological consequences (e.g., hangover, vomiting) were examined, drinking significantly mediated the effect of willingness on the consequences. Drinking-specific protective behaviors indirectly influenced consequences through drinking behaviors whereas general protective behaviors did not. When nonphysiological (e.g., social, sexual, academic) consequences were examined, drinking and general protective behaviors emerged as significant mediators of the effects of willingness and intentions on the consequences, whereas drinking-specific protective behaviors did not.

CONCLUSIONS

The results suggest that prevention efforts (e.g., personalized feedback) could be tailored to address specific types of protective behaviors as well as specific types of consequences frequently experienced by college students.

Examining the effects of drinking and interpersonal protective behaviors on unwanted sexual experiences in college women

INTRODUCTION

Recent evidence suggests interpersonal protective behaviors (IPBs) may be more effective than alcohol-based strategies at decreasing alcohol-related sexual consequences. However, no studies have examined individual IPBs to assess their unique influences on specific sexual consequences. The current study used a longitudinal design to examine the direct effects of typical weekly drinking and specific IPBs on unwanted sex. IPBs were also examined as moderators of the relationship between drinking and unwanted sex.

METHODS

Randomly sampled female drinkers attending a northeastern university (N=191) completed a baseline survey measuring typical weekly drinking and IPBs and a six-month follow-up assessing unwanted sex. Bootstrapped regression examined the effects.

RESULTS

Drinking predicted unwanted sex after accounting for IPBs (range of bs=.008-.009, SE=.005, 95% CI [.000, .02]). Vigilance-related IPBs were negatively associated with unwanted sex after controlling for drinking (b=-.052, SE=.025, 95% CI [-.107, -.008]). The IPB "Talking to people who know one's potential dating or sexual partner to find out what s/he is like" significantly moderated the drinking-unwanted sex relationship (b=-.009, SE=.004, 95% CI [-.018, -.003]). At above-average drinking levels, women who used this IPB more frequently reported fewer episodes of unwanted sex.

CONCLUSION

Findings revealed obtaining information about a potential partner significantly reduced the impact of drinking on unwanted sex for heavier drinkers. Future research examining how women implement this IPB may clarify its role in reducing unwanted sex.

Who Will Experience the Most Alcohol Problems in College? The Roles of Middle and High School Drinking Tendencies

BACKGROUND

Previous work examining college drinking tendencies has identified a disproportionately small (20%), but uniquely high-risk group of students who experience nearly 50% of the reported alcohol-related consequences (i.e., the multiple repeated consequences, or MRC, group). With the goal of reducing drinking-related consequences later in college, this study sought to identify potential MRC group members in their first semester by examining: (i) early-risk subgroups based on analysis of early-risk screening constructs (e.g., age of drinking onset, middle school alcohol exposure, high school drinking, and consequences); and (ii) their association with MRC criteria early in the first semester of college.

METHODS

A random sample of 2,021 first-year college student drinkers (56% female) completed a web-based drinking survey in their first semester on campus.

RESULTS

Latent class analysis revealed 4 early-risk subgroups: (i) an early-onset risk group who endorsed early age of drinking onset and engaged in heavy middle and high school drinking (10%); (ii) a late-onset risk group who engaged in weekend drinking and drunkenness and experienced 6 or more unique consequences as seniors in high school (32%); (iii) an early-onset limited risk group who only endorsed early age of onset and middle school drinking (3%); and (iv) a minimal risk group who did not engage in any early-risk behaviors (55%). Members of both the early- and late-onset risk groups had significantly higher odds of MRC membership in their first semester of college (9.85 and 6.79 greater, respectively).

CONCLUSIONS

Results suggest age of onset, middle and high school drinking and drunkenness, and frequency of unique consequences could be particularly useful in brief screening tools. Further, findings support early screening and prevention efforts for MRC membership prior to college matriculation.

Do students use contextual protective behaviors to reduce alcohol-related sexual risk? Examination of a dual-process decision-making model

Recent studies suggest drinking protective behaviors (DPBs) and contextual protective behaviors (CPBs) can uniquely reduce alcohol-related sexual risk in college students. Few studies have examined CPBs independently, and even fewer have utilized theory to examine modifiable psychosocial predictors of students' decisions to use CPBs. The current study used a prospective design to examine (a) rational and reactive pathways and psychosocial constructs predictive of CPB use and (b) how gender might moderate these influences in a sample of college students. Students (n = 508) completed Web-based baseline (mid-Spring semester) and 1- and 6-month follow-up assessments of CPB use; psychosocial constructs (expectancies, normative beliefs, attitudes, and self-concept); and rational and reactive pathways (intentions and willingness). Regression was used to examine rational and reactive influences as proximal predictors of CPB use at the 6-month follow-up. Subsequent path analyses examined the effects of psychosocial constructs, as distal predictors of CPB use, mediated through the rational and reactive pathways. Both rational (intentions to use CPB) and reactive (willingness to use CPB) influences were significantly associated with increased CPB use. The examined distal predictors were found to effect CPB use differentially through the rational and reactive pathways. Gender did not significantly moderate any relationships within in the model. Findings suggest potential entry points for increasing CPB use that include both rational and reactive pathways. Overall, this study demonstrates the mechanisms underlying how to increase the use of CPBs in programs designed to reduce alcohol-related sexual consequences and victimization.

Examination of a dual-process model predicting riding with drinking drivers

BACKGROUND

Nearly 1 in 5 of the fatalities in alcohol-related crashes are passengers. Few studies have utilized theory to examine modifiable psychosocial predictors of individuals' tendencies to be a passenger in a vehicle operated by a driver who has consumed alcohol. This study used a prospective design to test a dual-process model featuring reasoned and reactive psychological influences and psychosocial constructs as predictors of riding with drinking drivers (RWDD) in a sample of individuals aged 18 to 21.

METHODS

College students (N = 508) completed web-based questionnaires assessing RWDD, psychosocial constructs (attitudes, expectancies, and norms), and reasoned and reactive influences (intentions and willingness) at baseline (the middle of the spring semester) and again 1 and 6 months later. Regression was used to analyze reasoned and reactive influences as proximal predictors of RWDD at the 6-month follow-up. Subsequent analyses examined the relationship between the psychosocial constructs as distal predictors of RWDD and the mediation effects of reasoned and reactive influences.

RESULTS

Both reasoned and reactive influences predicted RWDD, while only the reactive influence had a significant unique effect. Reactive influences significantly mediated the effects of peer norms, attitudes, and drinking influences on RWDD. Nearly all effects were constant across gender except parental norms (significant for females).

CONCLUSIONS

Findings highlight that the important precursors of RWDD were reactive influences, attitudes, and peer and parent norms. These findings suggest several intervention methods, specifically normative feedback interventions, parent-based interventions, and brief motivational interviewing, may be particularly beneficial in reducing RWDD.

How much does one more drink matter? Examining effects of event-level alcohol use and previous sexual victimization on sex-related consequences

OBJECTIVE

The first semester of college has been associated with increased drinking and sexual risk. However, it remains unclear why some drinking occasions result in experiencing negative sexual consequences whereas others do not. The current study used a diary-based approach to assess the event-level effect of alcohol use and previous adult/adolescent sexual victimization (PSV) on experiencing negative sex-related consequences in first-year college women.

METHOD

Participants (N=120) provided repeated measures of weekend drinking and sex-related consequences on the Friday and Saturday nights of six different weekends over the course of their first semester, resulting in 12 measured drinking occasions. A multilevel model was used to assess both between- and within-person effects of alcohol use and between-person effects of PSV on the likelihood of experiencing negative alcohol-related sexual consequences.

RESULTS

Findings revealed an important within-person association, such that every drink consumed above one's mean was associated with a 13% increase in the likelihood of experiencing negative consequences. In addition, PSV had a significant main effect on experiencing negative sex-related consequences. Individuals with PSV experienced nearly 2.5 times more sexual consequences than individuals without PSV.

CONCLUSIONS

These results yield important implications for prevention, particularly with respect to limiting "above average" alcohol consumption among women with a history of sexual victimization.

Identifying theoretical predictors of risky alcohol use among noncollege emerging adults

OBJECTIVE

Studies show that emerging adults who do not obtain postsecondary education are at greater risk for developing alcohol use disorders later in life relative to their college-attending peers. Research examining constructs amenable to change within this population is necessary to inform intervention efforts. Thus, the current study aimed to identify psychosocial correlates of risky alcohol use for noncollege emerging adults. A secondary goal was to examine whether gender moderated the relationships between the psychosocial constructs and alcohol use.

METHOD

Participants were a nationally representative sample of noncollege emerging adults (18-22 years old) who reported using alcohol in the past year, recruited through an established Internet panel (N = 209; 125 women). A path model was used to examine the relationship between theoretically derived constructs (expectancies, attitudes, normative beliefs) and risky (peak) drinking. A second model examined a multigroup solution to assess moderating effects of gender.

RESULTS

The full-sample model revealed significant associations between attitudes toward drinking and risky drinking. The model assessing gender differences revealed association between normative beliefs and drinking for women but not men, whereas attitudes were significantly associated with risky drinking for both men and women.

CONCLUSIONS

Findings highlight the importance of attitudes and, for women, descriptive norms in the etiology of risky drinking among noncollege emerging adults, which emphasizes their potential utility in the development and adaptation of interventions for this at-risk population.