Caroline Jackson, Rosemary Geddes, Sally Haw and John Frank Scottish Collaboration for Public Health Research 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 studies o 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 characteristics Study design Setting

Results – Study characteristics Study 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 effectSignificant effect Number of Studies

Sexual intercourse Sex partners STDs Pregnancy/birth Condom use 1 Odds ratio Better outcomeWorse outcome (except for condom use)

Sexual intercourse Sex partners STDs Pregnancy/birth Condom use 1 Odds ratio Better outcomeWorse outcome (except for condom use)

Sexual intercourse Condom use Sex partners STDs Pregnancy/birth 1 Odds ratio Better outcomeWorse outcome (except for condom use)

Sexual intercourse Condom use Sex partners STDs Pregnancy/birth Seattle Social Development Project Aban Aya Youth Project Focus on Kids & Informed Parents and children together 1 Odds ratio Better outcomeWorse 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 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:

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