Post on 22-Jan-2016
description
Caroline Jackson, Rosemary Geddes, Sally Haw and John Frank
Scottish Collaboration for Public HealthResearch and Policy
A systematic review of interventions to prevent or
reduce substance use and sexual risk behaviour in adolescents
Introduction
• Experiences in the formative years impact on health and wellbeing in later years
• Drinking, smoking, illicit drug use and risky sexual behaviour are among the major health problems affecting young people in high-income countries, especially the UK
• Growing evidence that risk behaviours in young people tend to cluster together to some extent
• This clustering, and the recognition that many risk behaviours share similar underlying risk and protective factors has led to the proposal that interventions should target multiple (or generic) risk behaviours
Summary table of child well-being in 21 high-income countries*
*Child Poverty in Perspective: an overview of child well-being in rich countries, UNICEF
Review methods
• Electronic search strategy conducted to identify interventions that reported on substance (alcohol, illicit drug or tobacco) use and sexual risk behaviour outcomes
• Inclusion criteria:o Experimental or quasi-experimental studies reporting on the above outcomes during adolescence or young adulthood (11-25 years)o Implemented in young people aged about 5 (i.e. Having started school)o Minimum 6 month follow-up
Exclusion criteria:o Secondary prevention studies (e.g. Interventions targeting existing drug abusers)o Clinical intervention studieso Studies of selected populations at high-risk of risk behaviours (e.g. only children from drug-using families etc.)
• 2 authors independently reviewed and selected studies identified in the search and independently assessed study quality, using the Quality Assessment Tool for Quantitative Studies
Review methods
• Extracted relevant information on study characteristics
• Extracted odds ratios for outcomes, or, when not presented in the paper, calculated odds ratios from raw data, where possible
• Meta-analysis was not performed, since the substantial between-study heterogeneity (in intervention programme, outcomes, setting and study population) would have given meaningless summary effect estimates with little practical value
Primary literature review of studies reporting multiple risk behaviour outcomes
1433 articles from database search
1129 titles and abstracts screened (after de-duplication)
8 articles identified through other sources
45 full-text articles assessed for eligibility
Excluded 5 articles• 3 with follow-up < 6 months• 2 with insufficient information on outcome definition/effect 18 studies, after accounting for multiple articles
from the same study
33 articles potentially eligible assessed against inclusion criteria
Excluded 5 studies rated weak from synthesis of results
Results from 13 studies rated as methodologically strong or moderate were synthesised
Results – Study characteristicsStudy design Setting
Results – Study characteristicsStudy design Setting
Duration of follow-up Loss to follow-up
Results - Effectiveness of interventions
Results were generally mixed, with studies having:• an impact on some behaviours but not others• having a different effect across different measures of a particular risk behaviour• differential effects by gender• short-term effects only
• Studies reported on a range of substance use and sexual risk behaviour measures
• One study was rated as strong, 12 moderate and 5 weak
Results - Effectiveness of interventions
Effect on ≥ 1 smoking measure
Effect on ≥ 1 alcohol measure
Effect on ≥ 1 illicit drug measure
Effect on ≥ 1 sexual risk behaviour measure
Effect on ≥ 1 substance use and ≥ 1 sexual risk behaviour measure
No significant effect Significant effect
0 2 4 6 8 10 12 14
Number of Studies
4 5
2 9
3 7
5 8
3
Sexual intercourse
0.1 10
Sex partners
STDs
Pregnancy/birth
Condom use
1
Odds ratio
Better outcome Worse outcome (except for condom use)
Sexual intercourse
0.1 10
Sex partners
STDs
Pregnancy/birth
Condom use
1
Odds ratio
Better outcome Worse outcome (except for condom use)
Sexual intercourse
0.1 10
Condom use
Sex partners
STDs
Pregnancy/birth
1
Odds ratio
Better outcome Worse outcome (except for condom use)
Sexual intercourse
0.1 10
Condom use
Sex partners
STDs
Pregnancy/birth
Seattle Social Development Project
Aban Aya Youth Project
Focus on Kids & InformedParents and childrentogether
1
Odds ratio
Better outcome Worse outcome (except for condom use)
• 3 studies had a significant positive effect on at least one substance use outcome and one sexual risk behaviour outcome
Promising intervention approaches (1)
(1) Aban Aya Youth Project:
• Significantly reduced substance use and recent sexual intercourse among males only, with no effect on females
• significantly reduced past-month cigarette smoking and reduced pregnancy and non-significantly increased condom use
(2) Focus on Kids plus Improving Parents and Children Together (FOK plus ImPACT):
• Included individual, school, parent and community components
• Included individual and parenting components
(3) Seattle Social Development Project (now called Raising Healthy Children)
Promising intervention approaches (2)
• Significantly reduced heavy drinking, lifetime sexual activity and a history of multiple partners at age 18• Increased age at first sexual intercourse
At age 21:• increased condom use at last intercourse (among single people)• reduced pregnancy and childbirth among women• reduced the prevalence of having multiple partners
• Included individual, school and parenting components
• Although these three studies have a number of limitations, the findings do suggest that complex multi-domain approaches might be the most effective in addressing multiple risk behaviour
• Although these three studies have a number of limitations, the findings do suggest that complex multi-domain approaches might be the most effective in addressing multiple risk behaviour
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5805
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Source: Aos S, Lieb R, Mayfield J et al (2004). Washington State institute for Public Policy
Economic benefits
School curriculum-based programmes
Limitations of review
• Our search strategy did not include terms for other health behaviour outcomes (e.g. Delinquency, mental health etc.). However, our review focused on “risk-taking” behaviours rather than health behaviour in general
• A limitation of quality assessment tools is that some elements may be rated as weak due to poor reporting of study methodology rather than actual weak methodology
• Our review focused on identifying intervention programmes that reported on both substance use and sexual risk behaviour outcomes. However, some studies that have currently only been evaluated for their effect on substance use might similarly have an effect on sexual risk behaviour and vice-versa (e.g. Strengthening Families for Parents and Youth 10-14)
Conclusions
• We found few experimental or quasi-experimental studies of interventions to reduce risky behaviour where substance use and risk behaviour outcomes have been reported
• Identified studies reported mixed results, with just three studies reporting significant effects on at least one substance use and one sexual risk behaviour outcome
• These programmes were complex interventions, addressing more than one domain of risk/protective factors
• Future studies should, where possible, collect and report on multiple risk behaviour outcomes, and assessments of effects by gender and SES are needed
• There is some evidence that intervening in mid-childhood can impact on later risk behaviour, and this should be investigated further
Jackson C, Frank J, Haw S;2010 available at: www.scphrp.ac.uk
Extra slides
Characteristics of identified studies
• 14 interventions were RCTs and 4 were controlled trials
• The majority were implemented (at least in part) in secondary or middle schools, with one implemented in primary school• Follow-up ranged from 1 year - 21 years, with just 4 studies following participants for >3 years
• Attrition rates were generally high, with 13 studies reporting rates above 20%
• Studies reported on a range of substance use and sexual risk behaviour measures
• One study was rated as strong, 12 moderate and 5 weak
Marijuana, alcohol & tobacco use
School connectedness
Family-parent connectedness
Academic achievement
Sexual risk behaviour
Parental presence
Household access to substances
Self-esteem
Appears older than most
Average daily school attendance
Perceived parent disapproval of adolescent sex
Parental-adolescent activities
Community norms favourable Towards drug use
Perceived availability of drugs
Family history of substance use
Favourable attitudes towards antisocial behaviour
Family history of problem behaviour
Availability of drugs
Sensation seeking
Low income & poor housing
Experience of authority care
Low parental aspirations
Low school attendance/truancy
Antisocial behaviour
Overlap in the risk and protective factors for sexual risk behaviour and substance use