Risk, Protection, and Intervention

Sexual Risk Behavior: a Multi-System Model of Risk and Protective Factors in South African Adolescents Abstract Adolescent sexual risk behavior has typically been studied within singular, isolated systems. Using a multi-system approach, this study examined a combination of individual, proximal, and distal factors in relation to sexual risk behavior among adolescents. A large cross-sectional sample of 2561 adolescent (Mage = 14.92, SDage = 1.70) males (n = 1282) and females in Grades 8 (n = 1225) and 10 completed a range of self-report measures. Hierarchical ordinal logistic regression results supported a multi-system perspective of adolescent sexual risk behavior. Although individual and peer levels were identified as the primary contributors to the final model, a range of factors at varying levels of proximity to the individual were associated with sexual risk behavior. Specifically, being male, black, attaining increased age, greater alcohol use (individual level), parent risk behavior (family/home level), and peer risk behavior, feeling more pressure from peers to have sex (peer level), and lower social cohesion (community level) were associated with increased sexual risk behavior. These findings suggest multiple individual, proximal, and distal factors are salient to understanding sexual risk behavior among adolescents. Implications of the findings for interventions targeting the prevention of adolescent sexual risk behavior are discussed.

Building a Culture of Intimate Partner Violence Prevention in Alberta, Canada Through the Promotion of Healthy Youth Relationships Abstract This article explores the design and implementation of the Alberta Healthy Youth Relationships (AHYR) Strategy. The AHYR is a province-wide practice and policy change initiative in Alberta, Canada, that aims to prevent intimate partner violence by promoting service provider and systems capacity to support healthy relationships in adolescence and beyond. Developed in 2012 within a broader initiative called Shift: The Project to End Domestic Violence, the design of the AHYR began with work with provincial policy-makers, in order to create a policy climate that championed primary prevention practice. This policy climate subsequently supported the province-wide implementation of three evidence-based/evidence-informed programs that focus on building the skills and capacities required for healthy youth relationships. Through these programs, the AHYR has reached over 62,000 youth in grades 7–9, 900 teachers, 850 parents, and 1300 adults that work with youth across the province. In addition to these three programs, the AHYR also works with larger systems (e.g., policymakers, local funders, post-secondary institutions) to advance primary prevention practice. In this paper, we describe how the AHYR contributed to a culture of intimate partner violence prevention practice in the province by improving the readiness of funders and system leaders, community organizations, and practitioners to support healthy relationships best practices. We also describe how we used process evaluation to explore the potential for practice change and to inform the design of the next iteration of the AHYR. The article concludes with implications for other researchers and practitioners aiming to build a culture of intimate partner violence prevention practice within their province or state.

Relationship between Bullying, Substance Use, Psychiatric Disorders, and Social Problems in a Sample of Kenyan Secondary Schools Abstract We aimed to investigate how direct bullying and victimization relate with substance use, the presence of psychiatric disorders, poor school performance, disruptive behaviors, and social problems among secondary school students. A cross-sectional study was conducted in 20 randomly selected mixed-day secondary school students in forms one to three in Machakos County, equivalent to students in grades 1 to 11. From a random starting point, every sixth student in the class was invited to participate. The Drug Use Screening Inventory (revised) (DUSI-R) and the Olweus Bully/Victim Questionnaire (OBVQ) were administered in a classroom-setting by trained research assistants with experience in data collection. Four categories, i.e., bully only, bully-victim, victim only, and neither bully nor victims (neutrals) were developed and problem density scores computed. Descriptive statistics, bivariate, and multinomial logistic regression analysis summarized the findings. Of the 471 students, 13.6% had not experienced bullying problems. Bully-victim was the most prevalent form of bullying. No significant gender differences were reported across categories. Bully-victims reported significant higher problem density scores in eight out of the nine problem domains, and effect sizes of the differences in problem scores between neutrals and bully-victims were larger compared with other categories. Behavioral and family system problem scores retained a significant relationship with bully-victim category (p < 0.001). A high prevalence of bullying problems was documented in both genders. However, bully-victims had a higher risk of multiple negative individual and environmental and social problems. Assessment of bullying problems is an indirect route to identifying significant youth problems. Bullying interventions should be multifaceted to address psycho-socio-behavioral problems.

Lions Quest Skills for Adolescence Program as a School Intervention to Prevent Substance Use—a Pilot Study Across Three South East European Countries Abstract Development of personal and social skills in a classroom prevents later drug use and alcohol abuse, and influence-related risk factors. However, clinical trials on the potential impact of such programs from low- or middle-income countries remain limited. Lions Quest Skills for Adolescence (LQSFA), a school-based prevention intervention supporting life skills, was implemented in three South East European countries. This was a collaboration between the United Nations Office on Drugs and Crime, the Lions Clubs International Foundation, and the Ministries of Education of Serbia, the Former Yugoslav Republic of Macedonia and Montenegro. The pilot was a multisite non-randomized trial. A total of 2964 elementary school students received the intervention through 232 instructors trained by the same internationally certified trainer. These were compared to 2232 students following the regular curriculum, which does not include LQFSA, in the same elementary schools. The assessment was done at the beginning and at the end of the same academic year (period of 10 months). Despite limited fluctuations, the overall results indicated an encouraging outcome on the current use of substances (alcohol, cigarettes, and marijuana) as well as intention to using these substances in the next 3 months among current users. This study attempts to address this aforementioned gap in literature and contributes to the body of research demonstrating the value, feasibility, and transferability of life skills programs in achieving prevention outcomes in South East Europe. Moreover, it paves the way to a future randomized clinical trial to further corroborate the results, overcoming limitation in current study design.

Income Inequality, HIV Stigma, and Preventing HIV Disease Progression in Rural Communities Abstract Antiretroviral therapies (ART) suppress HIV replication, thereby preventing HIV disease progression and potentially preventing HIV transmission. However, there remain significant health disparities among people living with HIV, particularly for women living in impoverished rural areas. A significant contributing factor to HIV-related disparities is a stigma. And yet, the relative contributions of stigma, gender, socio-economics, and geography in relation to health outcomes are understudied. We examined the associations of internalized stigma and enacted stigma with community-level income inequality and HIV viral suppression—the hallmark of successful ART—among 124 men and 74 women receiving care from a publicly funded HIV clinic serving rural areas with high-HIV prevalence in the southeastern US. Participants provided informed consent, completed computerized interviews, and provided access to their medical records. Gini index was collected at the census tract level to estimate community-level income inequality. Individual-level and multilevel models controlled for point distance that patients lived from the clinic and quality of life, and included participant gender as a moderator. We found that for women, income inequality, internalized stigma, and enacted stigma were significantly associated with HIV suppression. For men, there were no significant associations between viral suppression and model variables. The null findings for men are consistent with gender-based health disparities and suggest the need for gender-tailored prevention interventions to improve the health of people living with HIV in rural areas. Results confirm and help to explain previous research on the impact of HIV stigma and income inequality among people living with HIV in rural settings.

A Cross-National Comparison of the Development of Adolescent Problem Behavior: a 1-Year Longitudinal Study in India, the Netherlands, the USA, and Australia Abstract The world youth population is the largest ever and the levels of problem behavior will influence future global health. Recognition of these issues raises questions as to whether adolescent development knowledge can be internationally applied. To date, most research examining adolescent problem behavior has been completed in the United States (USA) and there has been neglected analysis of health inequalities. The aim of the present study was to compare the structure and predictors of problem behavior in representative samples from the USA, Australia, India, and the Netherlands. Two timepoints of longitudinal data were analyzed from the International Youth Development Study that originally recruited state-representative student cohorts in 2002 in Washington State, USA (analytic sample N = 1942) and Victoria, Australia (N = 1957). Similar aged samples were recruited in Mumbai, India, in 2010 (N = 3.923) and the Netherlands in 2008 (N = 682). Surveys were matched and follow-up occurred over 1-year (average baseline ages 12 to 13). CFA identified a latent problem behavior construct comprised of substance use and antisocial behavior indicators. There were cross-national differences in the indicators for this construct. Factor loadings and items were similar between Australia and the USA; however, different items loaded on the construct for the Indian and Netherlands sample. SEM identified that problem behavior at time 2 was predicted by time 1 behavior, with cross-national differences evident. Low parent education was predictive in the USA and India. The number of risk factors present was predictive of problem behavior in all four nations. The findings suggest that evaluated preventative strategies to reduce adolescent problem behavior may have international applications. The analysis of cross-nationally matched longitudinal data appears feasible for identifying prevalence and predictor differences that may signify policy and cultural contexts, to be considered in adapting prevention programs.

Advances in Statistical Methods for Causal Inference in Prevention Science: Introduction to the Special Section Abstract The board of the Society for Prevention Research noted recently that extant methods for the analysis of causality mechanisms in prevention may still be too rudimentary for detailed and sophisticated analysis of causality hypotheses. This Special Section aims to fill some of the current voids, in particular in the domain of statistical methods of the analysis of causal inference. In the first article, Bray et al. propose a novel methodological approach in which they link propensity score techniques and Latent Class Analysis. In the second article, Kelcey et al. discuss power analysis tools for the study of causal mediation effects in cluster-randomized interventions. Wiedermann et al. present, in the third article, methods of Direction Dependence Analysis for the identification of confounders and for inference concerning the direction of causal effects in mediation models. A more general approach to the identification of causal structures in non-experimental data is presented by Shimizu in the fourth article. This approach is based on linear non-Gaussian acyclic models. Molenaar introduces vector-autoregressive methods for the optimal representation of Granger causality in time-dependent data. The Special Section concludes with a commentary by Musci and Stuart. In this commentary, the contributions of the articles in the Special Section are highlighted from the perspective of the experimental causal research tradition.

Inverse Propensity Score Weighting with a Latent Class Exposure: Estimating the Causal Effect of Reported Reasons for Alcohol Use on Problem Alcohol Use 16 Years Later Abstract Latent class analysis (LCA) has proven to be a useful tool for identifying qualitatively different population subgroups who may be at varying levels of risk for negative outcomes. Recent methodological work has improved techniques for linking latent class membership to distal outcomes; however, these techniques do not adjust for potential confounding variables that may provide alternative explanations for observed relations. Inverse propensity score weighting provides a way to account for many confounders simultaneously, thereby strengthening causal inference of the effects of predictors on outcomes. Although propensity score weighting has been adapted to LCA with covariates, there has been limited work adapting it to LCA with distal outcomes. The current study proposes a step-by-step approach for using inverse propensity score weighting together with the “Bolck, Croon, and Hagenaars” approach to LCA with distal outcomes (i.e., the BCH approach), in order to estimate the causal effects of reasons for alcohol use latent class membership during the year after high school (at age 19) on later problem alcohol use (at age 35) with data from the longitudinal sample in the Monitoring the Future study. A supplementary appendix provides evidence for the accuracy of the proposed approach via a small-scale simulation study, as well as sample programming code to conduct the step-by-step approach.

Evaluating Personalized Feedback Intervention Framing with a Randomized Controlled Trial to Reduce Young Adult Alcohol-Related Sexual Risk Taking Abstract The purpose of this study was to evaluate personalized feedback intervention (PFI) framing with two web-delivered PFIs aimed to reduce young adult alcohol-related risky sexual behavior (RSB). Combined PFIs typically use an additive approach whereby independent components on drinking and components on RSB are presented without the discussion of the influence of alcohol on RSB. In contrast, an integrated PFI highlights the RSB-alcohol connection by presenting integrated alcohol and RSB components that focus on the role of intoxication as a barrier to risk reduction in sexual situations. In a randomized controlled trial, 402 (53.98% female) sexually active young adults aged 18–25 were randomly assigned to a combined PFI, an integrated PFI, or attention control. All assessment and intervention procedures were web-based. At the 1-month follow-up, those randomly assigned to the integrated condition had a lower likelihood of having any casual sex partners compared to those in the control group. At the 6-month follow-up, the combined condition had a lower likelihood of having any casual sex partners compared to those in the control group. When examining alcohol-related RSB, at the 1-month follow-up, both interventions showed a lower likelihood of any drinking prior to sex compared to the control group. When examining alcohol-related sexual consequences, results showed a reduction in the non-zero count of consequences in the integrated condition compared to the control at the 1-month follow-up. For typical drinks per week, those in the combined condition showed a greater reduction in the non-zero count of drinks than those in the control condition at the 1-month follow-up. While there were no significant differences between the two interventions, the current findings highlight the utility of two efficacious web-based alcohol and RSB interventions among a national sample of at-risk young adults.

Expanding Our Horizons: Risk, Protection, and Intervention in Emerging Adulthood Abstract Prevention science research has focused on early childhood and early school years, on the logic that addressing individual and contextual risk factors as early as possible would prevent the compounding of risk downstream. Methodological and technological advances have opened the door to an expanded exploration of risk, health promotion, and intervention in emerging adulthood and throughout the lifespan, but prevention science remains dominated by research on early childhood and adolescence. Articles in this special issue of Prevention Science showcase the use of new technologies to access young adult populations and to develop and deliver interventions as well as strategies to help account for developmental and cultural contexts in designing interventions. The issue represents an important step forward in applying the preventive research cycle to emerging adulthood, and it provides an opportunity to expand our horizons by building theories of development that are not tied solely to age progression.