Caroline Jackson, Rosemary Geddes, Sally Haw and John Frank

1. A systematic review of interventions to prevent or reduce substance use and sexual risk behaviour in adolescents Caroline Jackson, Rosemary Geddes, Sally Haw and John Frank Scottish Collaboration for Public Health Research and Policy

2. 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

3. 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

4. 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: • Experimental or quasi-experimental studies reporting on the above outcomes • during adolescence or young adulthood (11-25 years) • Implemented in young people aged about 5 (i.e. Having started school) • Minimum 6 month follow-up • Exclusion criteria: • Secondary prevention studies (e.g. Interventions targeting existing drug • abusers) • Clinical intervention studies • Studies of selected populations at high-risk of risk behaviours (e.g. only • children from drug-using families etc.)

5. Review methods • 2 authors independently reviewed and selected studies identified in the • search and independently assessed study quality, using the Quality Assessment • Tool for Quantitative Studies • 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

6. Primary literature review of studies reporting multiple risk behaviour outcomes 8 articles identified through other sources 1433 articles from database search 1129 titles and abstracts screened (after de-duplication) 45 full-text articles assessed for eligibility • Excluded 5 articles • 3 with follow-up < 6 months • 2 with insufficient information on outcome definition/effect 33 articles potentially eligible assessed against inclusion criteria 18 studies, after accounting for multiple articles from the same study Results from 13 studies rated as methodologically strong or moderate were synthesised Excluded 5 studies rated weak from synthesis of results

7. Results – Study characteristics Setting Study design

8. Results – Study characteristics Setting Study design Duration of follow-up Loss to follow-up

9. Results - Effectiveness of interventions • 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 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

10. Results - Effectiveness of interventions Effect on ≥ 1 smoking measure 5 4 Effect on ≥ 1 alcohol measure 2 9 3 7 Effect on ≥ 1 illicit drug measure Effect on ≥ 1 sexual risk behaviour measure 8 5 Effect on ≥ 1 substance use and ≥ 1 sexual risk behaviour measure 3 0 2 4 6 8 10 12 14 Number of Studies No significant effect Significant effect

11. Odds ratio Sexual intercourse Condom use Sex partners Pregnancy/birth STDs 0.1 10 1 Better outcome Worse outcome (except for condom use)

12. Odds ratio Sexual intercourse Condom use Sex partners Pregnancy/birth STDs 0.1 10 1 Better outcome Worse outcome (except for condom use)

13. Odds ratio Sexual intercourse Condom use Sex partners Pregnancy/birth STDs 1 0.1 10 Better outcome Worse outcome (except for condom use)

14. Odds ratio AbanAya Youth Project Sexual intercourse Seattle Social Development Project Condom use Focus on Kids & Informed Parents and children together Sex partners Pregnancy/birth STDs 1 0.1 10 Better outcome Worse outcome (except for condom use)

15. Promising intervention approaches (1) • 3 studies had a significant positive effect on at least one substance • use outcome and one sexual risk behaviour outcome (1) Aban Aya Youth Project: • Included individual, school, parent and community components • Significantly reduced substance use and recent sexual intercourse • among males only, with no effect on females (2) Focus on Kids plus Improving Parents and Children Together (FOK plus ImPACT): • Included individual and parenting components • significantly reduced past-month cigarette smoking and reduced • pregnancy and non-significantly increased condom use

16. Promising intervention approaches (2) (3) Seattle Social Development Project (now called Raising Healthy Children) • Included individual, school and parenting components • 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

17. 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

18. 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 Economic benefits 9837 5805 School curriculum-based programmes 717 54 Source: Aos S, Lieb R, Mayfield J et al (2004). Washington State institute for Public Policy

19. 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)

20. 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

21. Jackson C, Frank J, Haw S; 2010 available at: www.scphrp.ac.uk

22. Extra slides

23. 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

24. Overlap in the risk and protective factors for sexual risk behaviour and substance use Marijuana, alcohol & tobacco use Sexual risk behaviour Parental presence School connectedness Family history of substance use Academic achievement Family-parent connectedness Low school attendance/truancy Household access to substances Family history of problem behaviour Community norms favourable Towards drug use Average daily school attendance Low income & poor housing Perceived parent disapproval of adolescent sex Perceived availability of drugs Availability of drugs Self-esteem Antisocial behaviour Parental-adolescent activities Sensation seeking Experience of authority care Favourable attitudes towards antisocial behaviour Appears older than most Low parental aspirations