The short version of the Sexual Distress Scale (SDS-3): Measurement invariance across countries, gender identities, and sexual orientations.

Background: The three-item Sexual Distress Scale (SDS-3) has been frequently used to assess distress related to sexuality in public health surveys and research on sexual wellbeing. However, its psychometric properties and measurement invariance across cultural, gender and sexual subgroups have not yet been examined. This multinational study aimed to validate the SDS-3 and test its psychometric properties, including measurement invariance across language, country, gender identity, and sexual orientation groups. Methods: We used global survey data from 82,243 individuals (Mean age=32.39 years; 40.3 % men, 57.0 % women, 2.8 % non-binary, and 0.6 % other genders) participating in the International Sexual Survey (ISS; https://internationalsexsurvey.org/) across 42 countries and 26 languages. Participants completed the SDS-3, as well as questions regarding sociodemographic characteristics, including gender identity and sexual orientation. Results: Confirmatory factor analysis (CFA) supported a unidimensional factor structure for the SDS-3, and multi-group CFA (MGCFA) suggested that this factor structure was invariant across countries, languages, gender identities, and sexual orientations. Cronbach's α for the unidimensional score was 0.83 (range between 0.76 and 0.89), and McDonald's ω was 0.84 (range between 0.76 and 0.90). Participants who did not experience sexual problems had significantly lower SDS-3 total scores (M = 2.99; SD=2.54) compared to those who reported sexual problems (M = 5.60; SD=3.00), with a large effect size (Cohen's d = 1.01 [95 % CI=-1.03, -0.98]; p < 0.001). Conclusion: The SDS-3 has a unidimensional factor structure and appears to be valid and reliable for measuring sexual distress among individuals from different countries, gender identities, and sexual orientations.

Cross-cultural validation and measurement invariance of anxiety and depression symptoms: A study of the Brief Symptom Inventory (BSI) in 42 countries.

BACKGROUND: Depression and anxiety are among the most prevalent mental health issues experienced worldwide. However, whereas cross-cultural studies utilize psychometrically valid and reliable scales, fewer can meaningfully compare these conditions across different groups. To address this gap, the current study aimed to psychometrically assess the Brief Symptomatology Index (BSI) in 42 countries. METHODS: Using data from the International Sex Survey (N = 82,243; Mage = 32.39; SDage = 12.52; women: n = 46,874; 57 %), we examined the reliability of depression and anxiety symptom scores of the BSI-18, as well as evaluated evidence of construct, invariance, and criterion-related validity in predicting clinically relevant variables across countries, languages, genders, and sexual orientations. RESULTS: Results corroborated an invariant, two-factor structure across all groups tested, exhibiting excellent reliability estimates for both subscales. The 'caseness' criterion effectively discriminated among those at low and high risk of depression and anxiety, yielding differential effects on the clinical criteria examined. LIMITATIONS: The predictive validation was not made against a clinical diagnosis, and the full BSI-18 scale was not examined (excluding the somatization sub-dimension), limiting the validation scope of the BSI-18. Finally, the study was conducted online, mainly by advertisements through social media, ultimately skewing our sample towards women, younger, and highly educated populations. CONCLUSIONS: The results support that the BSI-12 is a valid and reliable assessment tool for assessing depression and anxiety symptoms across countries, languages, genders, and sexual orientations. Further, its caseness criterion can discriminate well between participants at high and low risk of depression and anxiety.

Cross-Cultural Adult ADHD Assessment in 42 Countries Using the Adult ADHD Self-Report Scale Screener.

OBJECTIVE: We analyzed adult ADHD symptoms in a cross-cultural context, including investigating the occurrence and potential correlates of adult ADHD and psychometric examination of the Adult ADHD Self-Report Scale (ASRS) Screener. METHOD: Our analysis is based on a large-scale research project involving 42 countries (International Sex Survey, N=72,627, 57% women, Mage=32.84; SDage=12.57). RESULTS: The ASRS Screener demonstrated good reliability and validity, along with partial invariance across different languages, countries, and genders. The occurrence of being at risk for adult ADHD was relatively high (21.4% for women, 18.1% for men). The highest scores were obtained in the US, Canada, and other English-speaking Western countries, with significantly lower scores among East Asian and non-English-speaking European countries. Moreover, ADHD symptom severity and occurrence were especially high among gender-diverse individuals. Significant associations between adult ADHD symptoms and age, mental and sexual health, and socioeconomic status were observed. CONCLUSIONS: Present results show significant cross-cultural variability in adult ADHD occurrence as well as highlight important factors related to adult ADHD. Moreover, the importance of further research on adult ADHD in previously understudied populations (non-Western countries) and minority groups (gender-diverse individuals) is stressed. Lastly, the present analysis is consistent with previous evidence showing low specificity of adult ADHD screening instruments and contributes to the current discussion on accurate adult ADHD screening and diagnosis.

Psychometric properties of the Alcohol Use Disorders Identification Test (AUDIT) across cross-cultural subgroups, genders, and sexual orientations: Findings from the International Sex Survey (ISS).

INTRODUCTION: Despite being a widely used screening questionnaire, there is no consensus on the most appropriate measurement model for the Alcohol Use Disorders Identification Test (AUDIT). Furthermore, there have been limited studies on its measurement invariance across cross-cultural subgroups, genders, and sexual orientations. AIMS: The present study aimed to examine the fit of different measurement models for the AUDIT and its measurement invariance across a wide range of subgroups by country, language, gender, and sexual orientation. METHODS: Responses concerning past-year alcohol use from the participants of the cross-sectional International Sex Survey were considered (N = 62,943; Mage: 32.73; SD = 12.59). Confirmatory factor analysis, as well as measurement invariance tests were performed for 21 countries, 14 languages, three genders, and four sexual-orientation subgroups that met the minimum sample size requirement for inclusion in these analyses. RESULTS: A two-factor model with factors describing 'alcohol use' (items 1-3) and 'alcohol problems' (items 4-10) showed the best model fit across countries, languages, genders, and sexual orientations. For the former two, scalar and latent mean levels of invariance were reached considering different criteria. For gender and sexual orientation, a latent mean level of invariance was reached. CONCLUSIONS: In line with the two-factor model, the calculation of separate alcohol-use and alcohol-problem scores is recommended when using the AUDIT. The high levels of measurement invariance achieved for the AUDIT support its use in cross-cultural research, capable also of meaningful comparisons among genders and sexual orientations.

The eleven-item Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-11): Cross-cultural psychometric evaluation across 42 countries.

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is an instrument to screen substance-use-related health risks. However, little is known whether the ASSIST could be further shortened while remaining psychometrically sound across different countries, languages, gender identities, and sexual-orientation-based groups. The study aimed to validate a shortened 11-item ASSIST (ASSIST-11). Using the International Sex Survey data, 82,243 participants (M age = 32.39 years) across 42 countries and 26 languages completed questions from the ASSIST-11 regarding gender identity, sexual orientation, and other information. Confirmatory factor analysis (CFA) and multigroup CFA (MGCFA) evaluated the ASSIST-11's structure and tested measurement invariance across groups. Cronbach's α and McDonald's ω were used to examine the internal consistency. Cohen's d and independent t-tests were used to examine known-group validity. The ASSIST-11 was unidimensional across countries, languages, age groups, gender identities (i.e., men, women, and gender-diverse individuals), and sexual orientations (i.e., heterosexual and sexual minority individuals). Cronbach's α was 0.63 and McDonald's ω was 0.68 for the ASSIST-11. Known-group validity was supported by Cohen's d (range between 0.23 and 0.40) with significant differences (p-values<0.001). The ASSIST-11 is a modified instrument with a unidimensional factor structure across different languages, age groups, countries, gender identities, and sexual orientations. The low internal consistency of the ASSIST-11 might be acceptable as it assesses a broad concept (i.e., use of several different substances). Healthcare providers and researchers may use the ASSIST-11 to quickly assess substance-use information from general populations and evaluate the need to follow up with more detailed questions about substance use.

Compulsive sexual behavior disorder in 42 countries: Insights from the International Sex Survey and introduction of standardized assessment tools.

Background and aims: Despite its inclusion in the 11th revision of the International Classification of Diseases, there is a virtual paucity of high-quality scientific evidence about compulsive sexual behavior disorder (CSBD), especially in underrepresented and underserved populations. Therefore, we comprehensively examined CSBD across 42 countries, genders, and sexual orientations, and validated the original (CSBD-19) and short (CSBD-7) versions of the Compulsive Sexual Behavior Disorder Scale to provide standardized, state-of-the-art screening tools for research and clinical practice. Method: Using data from the International Sex Survey (N = 82,243; Mage = 32.39 years, SD = 12.52), we evaluated the psychometric properties of the CSBD-19 and CSBD-7 and compared CSBD across 42 countries, three genders, eight sexual orientations, and individuals with low vs. high risk of experiencing CSBD. Results: A total of 4.8% of the participants were at high risk of experiencing CSBD. Country- and gender-based differences were observed, while no sexual-orientation-based differences were present in CSBD levels. Only 14% of individuals with CSBD have ever sought treatment for this disorder, with an additional 33% not having sought treatment because of various reasons. Both versions of the scale demonstrated excellent validity and reliability. Discussion and conclusions: This study contributes to a better understanding of CSBD in underrepresented and underserved populations and facilitates its identification in diverse populations by providing freely accessible ICD-11-based screening tools in 26 languages. The findings may also serve as a crucial building block to stimulate research into evidence-based, culturally sensitive prevention and intervention strategies for CSBD that are currently missing from the literature.

Negative Consequences of Substance Use in European University Students: Results from Project SNIPE.

BACKGROUND: University students are a risk group for heavy substance use and the experience of various potentially severe negative substance use consequences which may impact on their health, social, and academic functioning. Whilst the experience of negative consequences of substance use is well understood in North American student samples, there is little data on these experiences in European students. In order to develop effective harm prevention and reduction interventions for students' substance use, there needs to be an understanding of the types of consequences experienced in European student samples. OBJECTIVES: The aim of the study was to investigate the prevalence and predictors of the experience of negative substance use-related consequences amongst university students in 7 European countries. METHODS: University students (n = 4,482) in Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the UK completed an online survey of their substance use behaviours and the experience of associated negative consequences. RESULTS: European students reported that experiencing a hangover or illness, missing class, being short of money, and experiencing memory loss were the most commonly experienced negative consequences of substance use. Not living with other students and using alcohol, cannabis, sedatives, and cocaine were also associated with higher odds of experiencing these negative consequences. CONCLUSIONS: In contrast to North American data, European university students tended to experience consequences that are associated with lower level health risks rather than more severe consequences (e.g., drink-driving and physical injury). Harm prevention and reduction interventions for students should be targeted towards those consequences that are most salient to the target group to ensure feedback is relevant and potentially more effective in changing students' substance use behaviours.

Personal and perceived peer use and attitudes towards use of non-prescribed prescription sedatives and sleeping pills among university students in seven European countries.

INTRODUCTION: The use of non-prescribed prescription sedatives and sleeping pills (NPPSSP) among university students has been described as an important public health issue. However, the impact of perceived social norms on students' use and attitudes towards use of NPPSSP is still unclear. Our aim was to investigate whether perceptions of peer use and approval of use are associated with students' personal use and approval of NPPSSP use. METHODS: Cross-sectional data from the Social Norms Intervention for the prevention of Polydrug Use (SNIPE) project containing 4482 university students from seven European countries were analyzed to investigate self-other discrepancies regarding personal use and attitudes towards NPPSSP use. Associations between personal and perceived peer use and between personal and perceived approval of use were examined using multivariable logistic regression. RESULTS: The majority (51.0%) of students perceived their peers' NPPSSP use to be higher than their personal use. 92.6% of students perceived their peers' approval of NPPSSP use to be identical or higher than their personal approval. Students perceiving that the majority of peers had used NPPSSP at least once displayed higher odds for personal lifetime use (OR: 1.95, 95% CI: 1.49-2.55). Perceived peer approval of NPPSSP use was associated with higher odds for personal approval (OR: 5.49, 95% CI: 4.63-6.51). CONCLUSIONS: Among European university students, perceiving NPPSSP use and approval of use to be the norm was positively associated with students' personal NPPSSP use and approval of use, respectively. Interventions addressing perceived social norms may prevent or reduce NPPSSP use among university students. Final trial registration number: DRKS00004375 on the 'German Clinical Trials Register'.

European University Students' Experiences and Attitudes toward Campus Alcohol Policy: A Qualitative Study.

BACKGROUND: Many studies indicate that a substantial part of the student population drinks excessively, yet most European universities do not have an alcohol policy. In the absence of an alcohol guideline at universities and the easy access to alcohol sold at the student cafeteria, for instance, this has the potential to place students at risk of overconsumption, which has adverse health consequences. OBJECTIVES: Therefore, our study objectives were to explore and compare university students' experiences and attitudes toward alcohol policy on their campus using a qualitative approach. METHODS: 29 focus group discussions (FGDs) were conducted among students from universities in five European countries: Belgium (4 FGDs), Denmark (6 FGDs), France (5 FGDs), Hungary (6 FGDs), and the Slovak Republic (8 FGDs), with a total number of 189 participants. RESULTS: Across the five European countries, students recognized that alcohol was a big problem on their campuses yet they knew very little, if any, about the rules concerning alcohol on their campus. CONCLUSIONS: Students will not support an on campus alcohol restriction and a policy should therefore focus on prevention initiatives.

Normative Perceptions of Cannabis Use Among European University Students: Associations of Perceived Peer Use and Peer Attitudes With Personal Use and Attitudes.

OBJECTIVE: Perceptions of peer behavior and attitudes exert considerable social pressure on young adults to use substances. This study investigated whether European students perceive their peers' cannabis use and approval of cannabis use to be higher than their own personal behaviors and attitudes, and whether estimations of peer use and attitudes are associated with personal use and attitudes. METHOD: University students (n = 4,131) from Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the United Kingdom completed an online survey as part of the Social Norms Intervention for Polysubstance usE in students (SNIPE) Project, a feasibility study of a web-based normative feedback intervention for substance use. The survey assessed students' (a) personal substance use and attitudes and (b) perceptions of their peers' cannabis use (descriptive norms) and attitudes (injunctive norms). RESULTS: Although most respondents (92%) did not personally use cannabis in the past 2 months, the majority of students thought that the majority of their peers were using cannabis and that their peers had more permissive attitudes toward cannabis than they did. When we controlled for students' age, sex, study year, and religious beliefs, perceived peer descriptive norms were associated with personal cannabis use (odds ratio [OR] = 1.42; 95% CI [1.22, 1.64]) and perceived injunctive norms were associated with personal attitudes toward cannabis use (OR = 1.46; 95% CI [1.09, 1.94]). CONCLUSIONS: European students appear to possess similar discrepancies between personal and perceived peer norms for cannabis use and attitudes as found in North American students. Interventions that address such discrepancies may be effective in reducing cannabis use.

Personal and Perceived Peer Use of and Attitudes Toward Alcohol Among University and College Students in Seven EU Countries: Project SNIPE.

OBJECTIVE: The objective of this study was to explore perceptions of peer substance use and related attitudes among European students. Challenging perceptions about peer substance use has become the basis of a form of prevention and intervention known as the social norms approach, which can be delivered using personalized online feedback. This article reports baseline alcohol use and attitudes data for university students across Europe collected as part of the Social Norms Intervention for the prevention of Polydrug usE project (Project SNIPE). METHOD: Students from universities in Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the United Kingdom were recruited to take part in an online survey by the use of email invitations, social media, classroom announcements, flyers, and stalls in social areas, such as in cafeterias and bars on campus. A total of 4,482 students agreed to participate. RESULTS: Overall, respondents reported both perceived alcohol use and perceived acceptance of alcohol use among their peers that were higher than their own use or acceptance. Perceived peers' behaviors and attitudes were found to be predictive of personal behaviors and attitudes, with some variation across countries and by sex. CONCLUSIONS: The results suggest that students at the participating institutions across selected European countries exhibit overall similar patterns of perceptions as have been found on American college campuses. In conjunction with the finding that the perceived norm is predictive of personal behavior and attitudes, this research provides support to the view that the social norms approach may be a viable method to reduce alcohol consumption among students at European universities.

Descriptive normative beliefs and the self-regulation in alcohol use among Slovak university students.

AIM: This study aims (i) to understand how descriptive normative beliefs (DNB) about typical students' alcohol use and self-regulation (SRG) are related to alcohol use (AU) by exploring the indirect effect of SRG on AU through DNB and (ii) to explore gender differences and the differences between universities in DNB, SRG and AU. SUBJECT AND METHODS: The cross-sectional data were collected online from 817 Slovak university students from four universities (75.22% females; Mage = 19.61; SD = 1.42), who filled in the AUDIT-C items, items measuring the DNB about typical students' AU and SRG. T-tests, one-way Anova and structural equation modelling were used for data analysis. RESULTS: Gender differences in AU and DNB were found with males having higher levels of both AU and DNB. The tested model of AU fits the data well. A significant association was found between DNB and (i) AU (positive) and (ii) SRG (negative). The analysis confirmed the existence of an indirect effect of SRG on AU through DNB. CONCLUSION: The study contributes to research concerning AU by the way in which DNB and SRG are linked to AU among Slovak university students. The research findings can also be used in developing prevention and intervention programs.

Student estimations of peer alcohol consumption: links between the Social Norms Approach and the Health Promoting University concept.

BACKGROUND: The Social Norms Approach, with its focus on positive behaviour and its consensus orientation, is a health promotion intervention of relevance to the context of a Health Promoting University. In particular, the approach could assist with addressing excessive alcohol consumption. AIM: This article aims to discuss the link between the Social Norms Approach and the Health Promoting University, and analyse estimations of peer alcohol consumption among European university students. METHODS: A total of 4392 students from universities in six European countries and Turkey were asked to report their own typical alcohol consumption per day and to estimate the same for their peers of same sex. Students were classified as accurate or inaccurate estimators of peer alcohol consumption. Socio-demographic factors and personal alcohol consumption were examined as predictors for an accurate estimation. RESULTS: 72% of male and 51% of female students were identified as having accurate estimations about the amount of alcoholic drinks consumed per day by their peers. Male students, older students, those studying year 3 and above, and Turkish and Danish students were more likely to accurately estimate their peers' alcohol consumption. Independent from these factors, students' accurate estimation of peers' drinking decreased significantly with increasing personal consumption. CONCLUSIONS: As accurate estimates of peer alcohol consumption appear to affect personal drinking behaviour positively, social norms interventions targeted at correcting possible misperceptions about peer alcohol use among students may be a useful health promotion tool in the context of a health promoting university.

Mother's and father's monitoring is more important than parental social support regarding sexual risk behaviour among 15-year-old adolescents.

BACKGROUND AND OBJECTIVES: There is strong evidence that parental processes such as monitoring and social support play an important role with regard to sexual risk behaviour among adolescents. We wished to explore the influence of both parents' monitoring and support on sexual risk behaviour among adolescent boys and girls. METHODS: Questionnaires concerning sexual risk behaviour, parental support and parental monitoring were administered to 15-year-old students (n = 1343; 628 boys). Crude and adjusted logistic regression models were used to explore the effect of parents' monitoring and support on sexual risk behaviour among adolescent boys and girls. RESULTS: Parental monitoring was more strongly associated with sexual risk behaviour than parental social support. In particular, less monitoring by the father was significantly linked to early first sexual intercourse among girls and to not using a condom during last intercourse among boys. Less monitoring by the mother was associated only with not using a condom at last intercourse among boys. CONCLUSION: Parental monitoring, even more than parental support, may delay the onset of sexual activity and increase the frequency of condom use among adolescents. The effects of mothers' and fathers' parenting processes on sexual risk behaviour of adolescents differ. Paternal monitoring affects condom use among boys, and initiation of sexual activity in girls.

A feasibility trial to examine the social norms approach for the prevention and reduction of licit and illicit drug use in European University and college students.

BACKGROUND: Incorrect perceptions of high rates of peer alcohol and tobacco use are predictive of increased personal use in student populations. Correcting misperceptions by providing feedback has been shown to be an effective intervention for reducing licit drug use. It is currently unknown if social norms interventions are effective in preventing and reducing illicit drug use in European students. The purpose of this paper is to describe the design of a multi-site cluster controlled trial of a web-based social norms intervention aimed at reducing licit and preventing illicit drug use in European university students. METHODS/DESIGN: An online questionnaire to assess rates of drug use will be developed and translated based on existing social norms surveys. Students from sixteen universities in seven participating European countries will be invited to complete the questionnaire. Both intervention and control sites will be chosen by convenience. In each country, the intervention site will be the university that the local principal investigator is affiliated with. We aim to recruit 1000 students per site (baseline assessment). All participants will complete the online questionnaire at baseline. Baseline data will be used to develop social norms messages that will be included in a web-based intervention. The intervention group will receive individualized social norms feedback. The website will remain online during the following 5 months. After five months, a second survey will be conducted and effects of the intervention on social norms and drug use will be measured in comparison to the control site. DISCUSSION: This project is the first cross-national European collaboration to investigate the feasibility of a social norms intervention to reduce licit and prevent illicit drug use among European university students. FINAL TRIAL REGISTRATION NUMBER: DRKS00004375 on the 'German Clinical Trials Register'.

Psychosocial factors associated with sexual behaviour in early adolescence.

OBJECTIVES: To compare the psychosocial characteristics of sexually inexperienced adolescents with those of youths who had had sex, whether safe or unsafe. METHODS: We gathered information on self-esteem, well-being, social support, family structure, educational aspiration, parental education and sexual behaviour of 2318 adolescents (mean-age 14.3 years) attending elementary school in Slovakia. Those who reported having had first sex after a relationship shorter than one month, who reported sex after alcohol consumption, who had had four or more sexual partners or who inconsistently used a condom were considered to have engaged in unsafe sex. RESULTS: Respondents who were younger, female, reported living in an intact family or having a higher level of social support from family were more likely to still be virgins. Adolescents who had sex, whether safe or unsafe, had similar psychosocial characteristics. Those who reported a higher level of positive self-esteem or social support from friends, but a lower level of well-being, social support from family or educational aspiration were more likely to engage in unsafe sex. CONCLUSION: Psychosocial features of adolescents who reported having had unsafe sex were similar to those of adolescents who had had safe sex but differed from the characteristics of adolescents who reported not to have started sexual activity.

Psychological and behavioural factors associated with sexual risk behaviour among Slovak students.

BACKGROUND: Knowledge about the prevalence of sexual risk behaviour (SRB) in adolescence is needed to prevent unwanted health consequences. Studies on SRB among adolescents in Central Europe are rare and mostly rely on a single indicator for SRB. This study aims to assess the association of behavioural and psychological factors with three types of SRB in adolescents in Central Europe. METHODS: We obtained data on behavioural factors (having been drunk during previous month, smoking during previous week, early sexual initiation), psychological factors (self-esteem, well-being, extroversion, neuroticism, religiousness), and SRB (intercourse under risky conditions, multiple sexual partners, and inconsistent condom use) in 832 Slovak university students (response 94.3%). RESULTS: Among those with sexual experience (62%), inconsistent condom use was the most prevalent risk behaviour (81% in females, 72% in males). With the exception of having been drunk in males, no factor was associated with inconsistent condom use. Regarding the other types of SRB, early sexual initiation was most strongly associated. In addition, other, mostly behavioural, factors were associated, in particular having been drunk. CONCLUSION: Results suggest that behavioural factors are more closely related to SRB than psychological factors. Associations differ by type of SRB and gender but offer few clues to target risk groups for inconsistent condom use. Results show a high need for health-promotion programmes in early adolescence that target SRB in conjunction with other health risk behaviours such as alcohol abuse.