PROSPER delivery of universal preventive interventions with young adolescents: long-term effects on emerging adult substance misuse and associated risk behaviors.

BACKGROUND: Substance misuse and associated health-risking behaviors are prevalent in emerging adulthood. There is a knowledge gap concerning the post-high school effects of community-based delivery systems for universal preventive interventions implemented during young adolescence. This study reports effects of the PROSPER delivery system through age 19, 7.5 years past baseline. METHODS: A cohort sequential design included 28 public school districts randomly assigned to the PROSPER partnership delivery system or usual-programming conditions. PROSPER community teams implemented a family-focused intervention in 6th grade and a school-based intervention in 7th grade. Outcomes for the age 19, post-high school report included lifetime, current, and frequency of substance misuse, as well as antisocial and health-risking sexual behaviors. Intent-to-treat, multi-level analyses of covariance of point-in-time outcomes were conducted, along with analyses of risk-related moderation of intervention effects. RESULTS: Results showed emerging adults from PROSPER communities reported significantly lower substance misuse across a range of types of substances, with relative reduction rates of up to 41.0%. No significant findings were observed for associated antisocial and health-risking sexual behavior indices; or for lifetime rates of sexually transmitted infections. Risk-related moderation effects were non-significant, suggesting generally comparable outcomes across higher- and lower-risk subgroups of emerging adults. CONCLUSIONS: The PROSPER delivery system for brief universal preventive interventions has potential for public health impact by reducing long-term substance misuse, with positive results extending beyond high school.

Reducing adolescents' aggressive and hostile behaviors: randomized trial effects of a brief family intervention 4 years past baseline.

OBJECTIVE: To examine the long-term effects of a brief family intervention on aggressive and hostile behaviors of adolescents in the general population. DESIGN: Randomized trial including 22 public schools assigned to the Iowa Strengthening Families Program or a control condition. Analyses supported sample representativeness and failed to show differential attrition effects 4 years after baseline. INTERVENTION: Seven-session intervention for parents and their sixth-grade children. MEASURES: The multi-informant, multimethod measures included independent observer ratings of adolescent aggressive and hostile behaviors in adolescent-parent interactions, family-member report of aggressive and hostile behaviors in those interactions, and adolescent self-report of aggressive and destructive conduct across settings. Data were collected during the 6th (preintervention and postintervention), 7th, 8th, and 10th grades. RESULTS: All measures showed a generally positive trend in intervention-control group differences over time. During 10th grade, significant intervention-control differences were found for adolescent self-report of aggressive and destructive conduct (P =. 01), with relative reduction rates ranging from 31.7% to 77.0%. Significant differences were shown for observer-rated aggressive and hostile behaviors in adolescent-parent interactions (P =.01); differences in family member reports of those behaviors were not significant. Supplemental analyses of both interactional behavior measures, specific to parent sex, indicated significant experimental group differences in interactions with mothers (P =.04 for both measures) but not with fathers. CONCLUSIONS: Brief family competency-training interventions designed for general populations can reduce aggressive and hostile behaviors in adolescents' interactions with parents and adolescent aggressive behaviors outside of the home setting. Thus, this type of intervention has important public health implications. Arch Pediatr Adolesc Med. 2000;154:1248-1257.

Direct and indirect latent-variable parenting outcomes of two universal family-focused preventive interventions: extending a public health-oriented research base.

Recent literature underscores the need for studies of family-based preventive interventions oriented toward public health objectives. This article illustrates a program evaluation approach for the study of family intervention outcomes in general populations. Thirty-three rural schools were randomly assigned to 1 of 3 conditions: the Preparing for the Drug-Free Years Program (PDFY), the Iowa Strengthening Families Program (ISFP), and a minimal-contact control group. Self-report and observational data collected from 523 families were used to develop measurement models of 3 latent parenting constructs that included measurement method effects. Analyses were conducted to ensure initial and attrition-related group equivalencies and to assess school effects. Structural equation models of the hypothesized sequence of direct and indirect effects for both PDFY and ISFP were then fit to the data. All hypothesized effects were significant for both interventions. The discussion addresses the potential public health benefits of evaluation research on universal preventive interventions.

Engaging families in longitudinal preventive intervention research: discrete-time survival analysis of socioeconomic and social-emotional risk factors.

This study examined whether family risk factors predicted attrition in a prevention research project that incorporated procedures to increase retention in assessment and intervention activities. Analyses used data from 667 rural families collected over 4 waves and consisted of (a) young adolescent and parent reports of internalizing and externalizing problems, (b) observer ratings of distress in parent-child interactions, and (c) family socioeconomic status (SES). Analyses failed to identify any risk factors as significant predictors of intervention participation. Only SES was found to be significant as a predictor of assessment attrition. This SES result appeared to reflect an association between lower educational attainment and an increased likelihood of attrition.

Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline.

This study examined the long-term substance use outcomes of 2 brief interventions designed for general population families of young adolescents. Thirty-three public schools were randomly assigned to 3 conditions: the 5-session Preparing for the Drug Free Years Program, the 7-session Iowa Strengthening Families Program, and a minimal contact control condition. The pretest involved 667 6th graders and their families. Assessments included multiple measures of initiation and current use of alcohol, tobacco, and marijuana. Pretest data were collected in the 6th grade and the reported follow-up data were collected in the 10th grade. Significant intervention-control differences in initiation and current use were found for both interventions. It is concluded that brief family skills-training interventions designed for general populations have the potential to reduce adolescent substance use and thus have important public health implications.

Assessing a public health approach to delay onset and progression of adolescent substance use: latent transition and log-linear analyses of longitudinal family preventive intervention outcomes.

This study examined the effects of the Iowa Strengthening Families Program (ISFP) and the Preparing for the Drug-Free Years program (PDFY) on young adolescent transitions from nonuse of substances to initiation and progression of substance use. Analyses incorporated 3 waves of data collected over a 2.5-year period from 329 rural young adolescents. Outcomes were analyzed by using log-linear models that incorporated substance use status frequencies derived from latent transition analyses. Effects on delayed substance use initiation were shown for both the ISFP and the PDFY at a 2-year follow-up. Also at this follow-up, the PDFY showed effects on delayed progression of use among those previously reporting initiation.

Modeling long-term parent outcomes of two universal family-focused preventive interventions: one-year follow-up results.

The present investigation extended prior work by R. Spoth, C. Redmond, and C. Shin (1998). These researchers reported findings that 2 universal family-focused preventive intervention programs each had direct effects on a proximal parenting outcome (intervention-targeted parenting behaviors) and indirect effects on 2 global and distal outcomes (parent-child affective quality and general child management) at posttesting. A replication of the previously tested parenting outcome model was conducted with 1-year follow-up data and procedures identical to those used in the earlier study. Results of the present study (N = 404 families) indicate that statistically significant effects on parenting outcomes were sustained through a 1-year period following the posttest.

Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study.

OBJECTIVE: This article summarizes the literature on alcohol initiation outcomes of universal family interventions and examines the long-term effects of the Iowa Strengthening Families Program (ISFP) on these outcomes. METHOD: A longitudinal, controlled efficacy study of the ISFP was conducted with 446 families from 22 rural school districts in a Midwestern state. Alcohol initiation behaviors were measured by a four-item index (Alcohol Initiation Index [AII]), with low scores representing a lower level of alcohol initiation. The AII was examined using mixed-model analyses of covariance. Relative reduction rates for individual initiation behaviors and initiation differences among higher- and lower-dosage intervention groups were calculated. RESULTS: AII scores were significantly lower among intervention group adolescents than among control group adolescents at 1- and 2-year follow-up assessments. Relative-reduction rate differences between intervention and control groups on specific alcohol initiation behaviors (e.g., onset of drinking without parental permission, onset of drunkenness) ranged from approximately 30% to 60%. Dosage-related initiation differences were evident only at the 1-year follow-up. CONCLUSIONS: Studies indicating the public health benefits of universal interventions that delay the initiation of alcohol use also underscore the importance of the current line of investigation. All effect sizes and relative reduction rates of specific alcohol initiation behaviors suggest the practical significance of the findings. The gap in the prevention outcome knowledge base in this area of investigation could be filled with more rigorous universal family-focused intervention studies that address a wide range of implementation and methodological issues.

Formative research on smoking cessation program attributes preferred by smokers.

BACKGROUND: This article reports formative research procedures used to identify smoking cessation program attributes preferred by smokers. A theoretical rationale and a program development framework are presented. METHODS: Findings from a series of qualitative and small sample quantitative studies were used to evaluate smoker response to specific program materials, and to identify a comprehensive set of preferred smoking cessation program attributes. These findings guided the development of a telephone survey administered to a random sample of 205 smokers interested in quitting. RESULTS: The 205 smokers completing telephone interviews frequently indicated preferences for program features having little to do with specific cessation methods used. Low demand on time, endorsements by medical authorities, relaxation instructions, weight control techniques, and a substantial research base were often cited as being most preferred. Overall, chi-square analyses provided minimal support for significant relationships between preferences and sociodemographic or smoking history variables. DISCUSSION: The benefits of combining qualitative and quantitative research methods in cessation program development efforts are noted. Implications for further research are discussed, particularly those concerning multiattribute analysis of consumer preferences.

Identifying program preferences through conjoint analysis: illustrative results from a parent sample.

PURPOSE: The purpose of this article is to illustrate the application of conjoint analysis, a consumer research technique, using data from a survey of parents' preferences for prevention programs. DESIGN: This study utilized a one-time, cross-sectional telephone survey. SETTING: Data were collected from subjects living in economically disadvantaged rural midwestern counties. SUBJECTS: Subjects were 202 randomly selected parents with preadolescents who indicated interest in family-focused prevention programs. MEASURES: Conjoint analysis software was employed in computer-assisted telephone interviews to evaluate relative preferences for 39 individual features of family-focused prevention programs falling under 11 categories (e.g., program meeting time, facilitator background). The software also guided computer simulations of parent choices among four types of programs. RESULTS: Findings indicated that meeting time was the most important category of program features. Strongly preferred individual features included meetings scheduled on weekday evenings, instruction by child development specialists, and programs based on extensive research. Two multiple-session programs evaluated via computer simulations incorporated several preferred features and received higher ratings than did single-session programs. Estimated variance z-tests indicated limited differences in perceived importance of program feature categories across sociodemographic subgroups. CONCLUSIONS: Findings highlight a) differences in the relative value parents place on various features of prevention programs in the surveyed population and b) the importance of practical aspects of program delivery.

Simulating smokers' acceptance of modifications in a cessation program.

Recent research has underscored the importance of assessing barriers to smokers' acceptance of cessation programs. This paper illustrates the use of computer simulations to gauge smokers' response to program modifications which may produce barriers to participation. It also highlights methodological issues encountered in conducting this work. Computer simulations were based on conjoint analysis, a consumer research method which enables measurement of smokers' relative preference for various modifications of cessation programs. Results from two studies are presented in this paper. The primary study used a randomly selected sample of 218 adult smokers who participated in a computer-assisted phone interview. Initially, the study assessed smokers' relative utility rating of 30 features of cessation programs. Utility data were used in computer-simulated comparisons of a low-cost, self-help oriented program under development and five other existing programs. A baseline version of the program under development and two modifications (for example, use of a support group with a higher level of cost) were simulated. Both the baseline version and modifications received a favorable response vis-à-vis comparison programs. Modifications requiring higher program costs were, however, associated with moderately reduced levels of favorable consumer response. The second study used a sample of 70 smokers who responded to an expanded set of smoking cessation program features focusing on program packaging. This secondary study incorporate in-person, computer-assisted interviews at a shopping mall, with smokers viewing an artist's mock-up of various program options on display. A similar pattern of responses to simulated program modifications emerged, with monetary cost apparently playing a key role. The significance of conjoint-based computer simulation as a tool in program development or dissemination, salient methodological issues, and implications for further research are discussed.

Smoking cessation program preferences associated with stage of quitting.

The purpose of this article is to report results from three exploratory studies which examined smoker preferences for cessation program attributes associated with stage of quitting. Study 1 was a telephone survey of 205 randomly selected smokers, in "precontemplative," "contemplative," and "ready-for-action" stages of quitting, who were queried about their preference for a wide variety of cessation program attributes. Study 2 entailed a computer-assisted telephone interview of 218 smokers in the same three stages of quitting. Interview data were used for multiattribute utility analysis of (a) preference for specific program attributes, selected partially on the basis of Study 1 results; and (b) preference for six different types of cessation programs, evaluated through computer simulations. Study 3 replicated Study 2 procedures using a smaller mall intercept sample which allowed in-person interviews and the use of display materials. Results suggested that there are limited but potentially significant differences among smokers in the three stages concerning program attribute preferences (e.g., use of self-help vs. facilitator-led programs, inclusion of relaxation techniques, quitting cold turkey, strategies for gaining social support). Nonetheless, there were no statistically significant differences among the three subgroups in level of preference for the six types of programs evaluated. Implications of these preliminary results are discussed.

Differential application of cue-controlled relaxation in the reduction of general anxiety.

This exploratory study investigated the effectiveness of cue-controlled relaxation in the multiple-outcome reduction of general anxiety. Additionally, it examined the effects of matching the technique's presentation with trainee conceptual level. Results suggested that the technique significantly reduced general anxiety. Multivariate analysis of covariance also indicated that the training was differentially effective relative to trainee conceptual level, but not relative to the type of technique presentation.

Consumer-focused data collection in prevention program evaluation. Rationale and illustrations.

This article presents a rationale for consumer-focused data collection at multiple points in the process of prevention program evaluation. Recommended procedures include data collection on consumer responses to various recruitment strategies and consumer preferences for specific program delivery features. Following the general rationale for use of these procedures, a summary description of their relationship with existing approaches to program evaluation is presented. Finally, illustrations of consumer-focused data collection procedures applied during several phases of an ongoing program evaluation project are provided.

Applying readily accessible graphical techniques to assess curvilinear relationships and detect outliers. The case of protective family processes.

The purpose of this article is to use data from a study of protective family processes to illustrate how readily accessible graphical techniques can supplement correlation and regression analyses. Graphical techniques can help to (a) better understand family process data from a descriptive standpoint, (b) minimize erroneous statistical conclusions, and (c) clarify theoretically important relationships among variables. Following a brief description of the substantive area selected for illustration of the graphical techniques, data from a study employing multimethod measurement procedures (N = 146) are employed to illustrate two graphical technique applications in the analysis of a predictor (marital quality) of a study outcome variable (parent-child affective quality). Instructions for the application of relevant procedures in SAS and SPSS statistical packages are provided.

Coronary heart disease risk scales and reactivity in a prevention program assessment: failure to show positive relationships.

This study was designed to evaluate relationships among the Jenkins Activity Survey, the Cook-Medley Hostility Scale, and cardiovascular reactivity measured during a semistructured interview in a hospital setting. Subjects were 201 business persons participating in a cardiovascular risk assessment interview component of a fitness program. Correlation analysis showed little evidence of significant positive relationships between self-report scores and reactivity in the total sample and among subjects with high resting blood pressures. Graphic analysis of total sample bivariate distributions, however, demonstrated patterns suggestive of nonlinear relationships. Evaluation of scatterplots and residual plots in conjunction with nonlinear and weighted least squares regression analyses nonetheless failed to reveal significant nonlinear relationships. The authors discuss implications of these findings.

Risk moderation of parent and child outcomes in a preventive intervention: a test and replication.

Family risk-related variations in proximal parent and young adolescent outcomes of a universal family-focused preventive intervention were examined using a cumulative index of risk incorporating sociodemographic characteristics and social-emotional adjustment measures. Results of an initial investigation involving 209 families of young adolescents suggested that intervention efficacy was largely unrelated to cumulative family risk. These findings were replicated with a second sample of 428 families. Implications for future intervention applications and outcome research are discussed.

Comprehensive behavioral medicine in community mental health. A needs assessment that needs assessment.

It is suggested that the massive costs incurred nationally in health care are in large part a fitting concern of Community Mental Health (CMH). There is considerable data available to suggest that as much as half of the variance in common health disorders is associated with behavioral factors. There is a rapidly growing movement to provide interventions geared toward these behavioral components in health disorders, but much of this has occurred outside of the traditional mental health environment. There are arguments to suggest that CMH should be more involved in the development of comprehensive behavioral medicine services, both in terms of the expertise and resources that it can bring to bear upon these problems, and its potential to reach segments of the population which are otherwise likely to be underserved, if served at all. Implications for CMH planning and financing are discussed, drawing upon a selective literature review and clinical illustrations.