Evidence-based practice in school substance use prevention: fidelity of implementation under real-world conditions.

Fidelity of program implementation under real-world conditions is a critical issue in the dissemination of evidence-based school substance use prevention curricula. Program effects are diminished when programs are implemented with poor fidelity. We assessed five domains of fidelity--adherence, exposure (dosage), quality of delivery, participant responsiveness and program differentiation (lack of contamination from other programs)--in a subset of respondents (N = 342) from a national random sample of public schools with middle school grades (N = 1721). Respondents taught 1 of 10 evidence-based universal substance use prevention programs as their primary program during the 2004-05 school year. Their responses to survey questions about their recent implementation practices indicated that fidelity was high for quality of delivery and participant responsiveness, low for program differentiation and modest for adherence and exposure--the two core domains of fidelity. Results suggest the need for continued emphasis on fidelity in program materials, trainings and on-going technical support. Particular attention should be paid to supporting use of interactive delivery strategies.

Association of MDMA/ecstasy and other substance use with self-reported sexually transmitted diseases among college-aged adults: a national study.

OBJECTIVES: MDMA/ecstasy use among college students has increased and reportedly leads to risky sexual behaviours. However, little is known about its association with sexually transmitted diseases (STDs). To evaluate this public health concern, this study examined the association between substance use (particularly MDMA) and self-reported STDs (chlamydia, gonorrhoea, herpes and syphilis) among college students and non-students aged 18-22 years (n=20,858). STUDY DESIGN: A cross-sectional data analysis of a national survey. METHODS: Data were drawn from the 2005-2006 National Surveys on Drug Use and Health; a nationally representative survey of non-institutionalized Americans. Self-reported STDs and substance use were assessed by the audio computer-assisted self-interviewing method. The association between MDMA use and STDs was determined while taking into account young adults' use of other substances, healthcare utilization and sociodemographic characteristics. RESULTS: Overall, 2.1% of college students and 2.5% of non-students reported contracting an STD in the past year. MDMA use in the past year was not associated with STDs. Among non-students, onset of MDMA use before 18 years of age increased the odds of past-year STDs. In both groups, alcohol use, marijuana use, female gender and African American race increased the odds of both past-year and lifetime STDs. Additional analyses indicated that, regardless of college-attending status, greater odds of past-year STDs were noted among users of alcohol and drugs, and users of alcohol alone, but not among users of drugs alone. CONCLUSIONS: Alcohol use is a robust correlate of STDs. Irrespective of college-attending status, young women and African Americans have a higher rate of STDs than young men and Whites.

Supporting Adolescents with Guidance and Employment (SAGE).

Supporting Adolescents with Guidance and Employment (SAGE) is a multifaceted, community-based violence-prevention program. Its target is African-American male adolescents in Durham, North Carolina. Public health professionals, county government officials, and local businessmen collaborated in its development and implementation. The program is based on the paradigm of risk and protective factors, in which various risk factors for youth violence are buffered by modifiable, protective psychosocial processes. SAGE includes an eight-month African-American Rites of Passage program (adult mentoring, African-American culture and history lessons, and manhood and conflict-resolution training), a six-week summer employment component, and a 12-week entrepreneurial experience. Of the 260 youth recruited, 88 were randomly assigned to receive all three program components, 85 were assigned to the summer employment and entrepreneurial components only, and 87 were assigned to a delayed program or control condition. We compared these three groups' psychosocial and behavioral outcomes using survey data and archival records. Program implementation data include attendance records; mentor-youth activity logs pre- and postprogram focus group discussions; and telephone interviews with parents, program staff, and participants. The mean age of the adolescents recruited into the program was 14. Half reported receiving free lunches at school; half were not living with a father; and one quarter reported that their mothers had not completed high school. During the previous year, many had engaged in various violence-related behaviors, including fighting (49%) and carrying a gun (22%). Youths in each program condition were similar with respect to key demographic and behavioral characteristics. The key components of the SAGE program represent increasingly popular but untested approaches. Preliminary results reveal that these youths are involved in violent behavior both as perpetrators and as victims.

Pregnancy among three national samples of runaway and homeless youth.

PURPOSE: To compare estimates of the prevalence of pregnancy among runaway and homeless youth between the ages of 14 and 17 years in various settings with each other and with youth in the general population. METHODS: Comparisons used three surveys of youth: (a) the first nationally representative survey of runaway and homeless youth residing in federally and nonfederally funded shelters, (b) a multicity survey of street youth, and (c) a nationally representative household survey of youth with and without recent runaway and homeless experiences. RESULTS: Youth living on the streets had the highest lifetime rates of pregnancy (48%), followed by youth residing in shelters (33%) and household youth (<10%). CONCLUSIONS: Shelter and street youth were at much greater risk of having ever been pregnant than were youth in households, regardless of whether they had recent runaway or homeless experiences. Such youth need comprehensive services, including pregnancy prevention, family planning, and prenatal and parenting services.

PIP: This study estimated and compared adolescent pregnancy rates among runaway and homeless adolescents in several settings. Data were obtained through 3 surveys: 1) a 1992 Youth Risk Behavior Survey (YRBS) among a nationally representative sample with recent runaway and homeless youth experiences; 2) the first nationally representative survey among a multistage sample of runaway and homeless youth living in federally and nonfederally funded youth shelters; and 3) the first multi-city survey of street youth. Data were collected among youth aged 14-17 years in 1992. Findings indicate that in all surveys youth were usually pregnant only once, but many street and shelter youth had 2 or more pregnancies. About 10% of both street and shelter youth reported being pregnant at the time of the interview. Significant differences occurred by age among street youth and for length of time away among both street and shelter youth. About 50% of street youth had a pregnancy experience compared to about 33% living in shelters. Less than 10% of household runaway youth had a pregnancy experience. Differences in rates were not statistically significant. The findings are based on self-reports, a purposive street sample, and potentially duplicate reporting among street youth. The high pregnancy rates are attributed, in part, to the prevalence of sexual abuse and other related reasons. 21-60% reported sexual abuse, compared to only 3-12% among the general population. A strong need exists for preventive/prenatal services for runaway and street youth.

HIV-risk behaviors associated with homelessness characteristics in youth.

PURPOSE: To examine characteristics of youth homelessness associated with engaging in risk behaviors for human immunodeficiency virus (HIV). METHODS: The sample included 288 currently homeless or runaway Washington, DC youth aged 14-21 years. Measures were self-reported homelessness characteristics, unsafe sexual behavior, injection drug use, and background characteristics. Bivariate and multivariable analyses of the relationships between homelessness characteristics and HIV risk behaviors were conducted. RESULTS: Both male (n = 140) and female (n = 148) participants reported high rates of unsafe sexual behaviors, but low rates of injection drug use. HIV risk was significantly associated in bivariate analyses with severity of homelessness circumstances (i.e., spending the night in public place or with strangers, going hungry, and participating in the street economy), the duration of homelessness (i.e., greater number of episodes of homelessness, longer time length of current episode), and specific reasons for being homeless (i.e., thrown out). In addition, sexual victimization and older age were associated with increased HIV risk. In multivariable models, a smaller set of these homelessness characteristics remained significant independent correlates and explained a substantial amount of the variation in the HIV risk indices for both males and females. CONCLUSIONS: The results contribute to greater theoretical understanding of the characteristics of homelessness associated with increased risk of HIV infection within this vulnerable population of youth. The associations between homelessness characteristics and HIV risk suggest the need for HIV prevention efforts to focus directly on ameliorating the homelessness circumstances of youth.

Differences between white and black youth who drink heavily.

This study compares the attitudes and beliefs of white and black adolescents who drink heavily. The study's sample comprises 1,533 youth who responded in 1987 to a survey of 10,259 7th to 12th grade students, and reported that they had gotten drunk at least six times within the previous year. The ratio of blacks to whites decreased with drinking severity. Controlling for age, sex, and living situation, a logistic regression revealed that blacks were significantly more likely than whites to believe that getting drunk would lead to health problems and that alcohol is addicting. Blacks were also more concerned than whites about their parents' disapproval of their drinking alcohol, while whites were more concerned than blacks about their friends' disapproval. The study suggests that programs targeted towards black youth who drink heavily should focus less on enhancing peer refusal skills and more on ensuring that black parents and other adults make explicit their negative attitudes towards alcohol use.

Potential mediators, moderators, or independent effects in the relationship between parents' former and current cigarette use and their children's cigarette use.

Research consistently has shown that cigarette use by adolescents is related to their parents' use and to particular characteristics of the family environment, but few studies have examined the linkages between parents' smoking behavior and other family characteristics to explain adolescents' smoking. In this study, we tested mediator, moderator, and independent models for their ability to characterize the relationship between parents' and their children's smoking. A sample of 719 matched pairs of parent (usually mother) and child was used. Respondents were part of an ongoing randomized evaluation of the Drug Abuse Resistance Education (DARE) Project in Illinois, and the subset of data used in these analyses was collected in 1991, when the youths were in the sixth or seventh grades. Results of logistic regression provided the greatest support for the independent model, which suggests that the effects of parents' smoking and familial characteristics on adolescents' smoking are not linked. Results also supported those found by other researchers by showing that parents' former smoking is associated with adolescents' current smoking. Significant family characteristics were family disunion and parents' awareness of their child's activities. These results suggest, in part, that children at any age may have the capability of storing memories of their parents' smoking, memories that influence their own smoking; also, characteristics of the family environment, independent of parents' smoking behavior, have an effect on adolescents' smoking. Prevention implications and recommendations are also discussed.

Long-term evaluation of drug abuse resistance education.

Project DARE (Drug Abuse Resistance Education) is the most prevalent school-based drug-use prevention program in the United States, but there is little evidence of its effectiveness. Results from a longitudinal evaluation of the program in 36 schools in Illinois provide only limited support for DARE's impact on student's drug use immediately following the intervention, and no support for either continued or emerging impact on drug use 1 or 2 years after receiving DARE instruction. In addition, DARE had only limited positive effects on psychological variables (i.e., self-esteem) and no effect on social variables (e.g., peer resistance skills). Possible substantive and methodological explanations for the relative lack of DARE's effectiveness observed in this study are discussed.

Risk of child abuse or neglect in a cohort of low-income children.

The purposes of this research were to identify risk factors for reported child abuse or neglect and to examine the roles of stress and social support in the etiology of child maltreatment. Mothers of newborn infants with biomedical and sociodemographic risk factors were recruited from community and regional hospitals and local health departments in 42 counties of North and South Carolina selected for geographic distribution and for large numbers of such newborns. For every four such mothers, the next mother to deliver an otherwise normal newborn was sought. Mothers were interviewed shortly after giving birth, and state Central Registries of Child Abuse and Neglect were reviewed when each infant was 1 year of age. Eight hundred forty-two of 1,111 recruited mothers were successfully interviewed in their homes between March 1986 and June 1987. Seven hundred forty-nine North Carolina births who resided in the state more than 6 months were eligible for inclusion in the analysis. Logistic regression with backward elimination procedures was used in the analysis. Maternal education (p < .01), number of other dependent children in the home (p < .01), receipt of Medicaid (p < .01), maternal depression (p < .05), and whether the maternal subject lived with her own mother at age 14 years (p < .05) were the best predictors of a maltreatment report. Further examination revealed an interaction effect between stressful life events, as measured by life event scores, and social well-being (p < .01). For children born at risk for social and/or medical problems, extreme low income (participation in public income support programs), low maternal education, maternal depression, the presence of any other young children in the home, and a mother's separation at age 14 years from her own mother significantly predict child maltreatment reports in the first year of life. In addition, stressful life events, even if perceived positively, may increase or decrease the risk of maltreatment reports, depending upon the presence of social support.

Stress, social support, and substantiated maltreatment in the second and third years of life.

OBJECTIVE: The purpose of this research was to determine whether risk factors for a maltreatment report in the first year of life, especially the interaction of life event stress and social support, persist into the second and third years of life. METHOD: Predominantly low income mothers who had been interviewed shortly after the birth of infants in a longitudinal cohort were re-interviewed around the infants' first birthdays, and reports to North Carolina's Central Registry of Child Abuse and Neglect were tracked for substantiated maltreatment reports. RESULTS: Variables significantly associated with a substantiated maltreatment report in the second or third year of life (p < .01) were first year maltreatment reports and participation in Medicaid. Three interactions between a stressful life event indicator variable and a social support indicator variable were significant predictors of substantiated second or third year reports (p < .05). CONCLUSIONS: Even in the presence of significant risk factors from the first year of life, life event stress can increase the risk of a substantiated maltreatment report in the second or third years of life, but social support may moderate the effect of life events.

Prevalence of alcohol and drug use among North Carolina public school students.

During spring 1987, North Carolina conducted a drug prevalence survey on a randomly selected, stratified cluster sample of 10,259 seventh-12th grade students enrolled in public schools. The survey assisted in development of new drug prevention programs funded by the Drug-Free Schools Act of 1986. Results indicated alcohol, tobacco, and marijuana were the most commonly used drugs; males and whites were more frequent users than females and blacks; and almost 20% of 11th and 12th grade students reported coming to school drunk in the year preceding the survey. Extensive use of wine coolers and smokeless tobacco was noted. The need is discussed for other states to conduct similar surveys to establish a data base from which better programming decisions can be made.

Cocaine and crack users compared.

Because crack use is such a recent phenomenon, little is known about users of this highly addictive drug, the harmful effects of which have been widely publicized. This study hypothesized that crack users would be more depressed and more alienated from family, friends, and school staff than would cocaine users, and would consider as less important reasons not to use crack and cocaine. The authors compared 411 users of cocaine (but not crack) to 156 crack users, all but 22 of whom had also used cocaine. The sample was derived from a larger random survey of 7th- through 12th-grade students in North Carolina. Results indicated that crack users were younger than cocaine users, made poorer grades, were more depressed, and were more likely to be alienated from family and friends. However, cocaine and crack users were equally unlikely to confide in anyone in their school if they had a drinking or drug problem. Further, crack users were more likely to have talked once to a teacher or counselor in the past year about their problems. The implications of these seemingly inconsistent findings are explored. Crack users appear to be a particularly vulnerable population.

Shelters for runaway and homeless youths: capacity and occupancy.

Data from a nationally representative sample of shelters for runaway and homeless youths (N = 160) were analyzed to determine shelter capacity, occupancy, and occupancy ratios. Analysis focused in particular on occupancy ratios by funding status, shelter size, metropolitan statistical area (MSA), season, and day of the week.

Youth and familial substance use's association with suicide attempts among runaway and homeless youth.

This study examined how youth suicide attempts are associated with youth and familial substance use among two samples of runaway and homeless youth (RHY): (a) a nationally representative sample of RHY residing in shelters, and (b) a multicity, purposive sample of RHY found on the street. Data were collected using personal interviews from 640 shelter youth and 600 street youth in 1992. Logistic regression analyses revealed that, after controlling for key demographic characteristics, youth who had used substances (particularly sedatives, hallucinogens, and inhalants) were much more likely than those who had not used substances to have ever attempted suicide. In addition, after controlling for their own substance use, youth with family members who had used substances were twice as likely as those without such family members to have ever attempted suicide. This study suggests the importance of developing and focusing suicide prevention.

Substance use among runaway and homeless youth in three national samples.

OBJECTIVES: Standardized estimates of the prevalence of substance use by runaway and homeless youth between the ages of 12 and 21 in various settings were compared with each other and with estimates for youth in the general population. METHODS: Four surveys were used: (1) a nationally representative survey of runaway and homeless youth residing in federally and non-federally funded shelters; (2) a multicity survey of street youth; (3) a nationally representative household survey of youth with and without recent runaway and homeless experiences; and (4) a nationally representative household survey of youth whose previous runaway/homeless status was unknown. RESULTS: For almost every substance, substance use prevalence was highest among street youth. Shelter youth and household youth with recent runaway/homeless experiences reported similar rates. In the household surveys, substance use rates were lowest and were generally comparable. CONCLUSIONS: Many homeless and runaway youth use tobacco, alcohol, and other drugs at rates substantially higher than nonrunaway and nonhomeless youth, indicating a need for comprehensive and intensive substance abuse prevention and treatment services for these youth.

Familial backgrounds and risk behaviors of youth with thrownaway experiences.

Many homeless youth may also be considered "thrownaway" in that they have specifically been told to leave home. In this study, thrownaway experiences among homeless youth are examined in two national samples: (a) a nationally representative sample of youth residing in youth shelters, and (b) a purposive sample of street youth in 10 cities. Prevalence of thrownaway experiences for the total samples and for demographic subgroups is provided, along with comparisons of the familial backgrounds and high-risk behaviors of youth with and without such experiences. In both samples, youth with thrownaway experiences (who constituted nearly half of each sample) were more likely than youth without such experiences to report (a) that they had attempted suicide, used marijuana and other drugs (excluding cocaine), and had been involved in the drug trade and carried hidden weapons; (b) that other family members had used illicit drugs during the 30 days before the youth left home; and (c) that they had spent at least 1 night away from home due to physical and/or emotional abuse or neglect, familial conflict, and familial substance use. Thrownaway youth constitute a particularly vulnerable subpopulation of homeless youth. A greater recognition and understanding of such youth will facilitate design of services that better address their needs.

Prevalence and correlates of survival sex among runaway and homeless youth.

OBJECTIVE: This study examined the prevalence and correlates of survival sex among runaway and homeless youths. METHODS: A nationally representative sample of shelter youths and a multicity sample of street youths were interviewed. RESULTS: Approximately 28% of street youths and 10% of shelter youths reported having participated in survival sex, which was associated with age, days away from home, victimization, criminal behaviors, substance use, suicide attempts, sexually transmitted disease, and pregnancy. CONCLUSIONS: Intensive and ongoing services are needed to provide resources and residential assistance to enable runaway and homeless youths to avoid survival sex, which is associated with many problem behaviors.

How effective is drug abuse resistance education? A meta-analysis of Project DARE outcome evaluations.

OBJECTIVES: Project DARE (Drug Abuse Resistance Education) is the most widely used school-based drug use prevention program in the United States, but the findings of rigorous evaluations of its effectiveness have not been considered collectively. METHODS: We used meta-analytic techniques to review eight methodologically rigorous DARE evaluations. Weighted effect size means for several short-term outcomes also were compared with means reported for other drug use prevention programs. RESULTS: The DARE effect size for drug use behavior ranged from .00 to .11 across the eight studies; the weighted mean for drug use across studies was .06. For all outcomes considered, the DARE effect size means were substantially smaller than those of programs emphasizing social and general competencies and using interactive teaching strategies. CONCLUSIONS: DARE's short-term effectiveness for reducing or preventing drug use behavior is small and is less than for interactive prevention programs.

The prevalence of homelessness among adolescents in the United States.

OBJECTIVES: Homeless adolescents represent one of the nation's most vulnerable populations. This study reports the 12-month prevalence of homeless episodes among US adolescents. METHODS: Personal, audiotaped interviews were conducted in 1992 and 1993 with a representative household sample of 6496 adolescents aged 12 to 17 as part of the Youth Risk behavior Survey sponsored by the Centers for Disease Control and Prevention. Respondents reported whether they had spent the night in any of a variety of locations other than home during the previous 12 months. RESULTS: Altogether, 7.6% of the youths questioned reported that they had spent at least 1 night in youth or adult shelter (3.3%), public place (2.2%), an abandoned building (1.0%), outside 2.2%), underground (0.4%), or with a stranger (1.1%). Boys were much more likely than girls to report having experienced a homeless episode. CONCLUSIONS: This study suggests that homelessness among adolescents is not simply an urban problem and that prevention programs targeting homeless youths should be implemented nationwide. Additional research is needed to assess the frequency and duration of homeless experiences. Future studies of homelessness in the general population should include questions pertinent to adolescents.