an integrated approach to preventing substance use in adolescents: 24-month … · champion 1., n....

An integrated approach to preventing substance use in adolescents: 24-month outcomes from the

CAP (Climate and Preventure) intervention in Australian schools

N.C. Newton1., M. Teesson1., P. Conrod2., T. Slade1., K. Champion1., N. Nair1., E. Kelly1., N. Carragher1., E. Barrett1.

1. NHMRC Centre for Research Excellence in Mental Health

and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales

2. Sainte-Justine University Hospital Center, Universite de Montreal, Canada

Why prevent? • Harms from alcohol misuse are substantial • Early, persistent or binge drinking in adolescence can

have long-term consequences • Even modest reductions in risky drinking could have

large societal impacts

Types of prevention 1. Universal: delivered to entire population regardless of

level of risk 2. Selective: targeted to groups at greatest risk of

developing problems

Is universal prevention effective? • A recent review identified some evidence of positive

effects from universal prevention programs: – EU-DAP/Unplugged (Faggiano, 2010)

– Life Skills Training Program (Botvin et al, 2001)

– Good Behaviour Game (van Lier, 2009)

• However, program content and delivery context were identified as potential barriers to effective prevention

‘Climate Schools’ program • Overcomes conceptual and implementation difficulties:

– Social influence approach – Harm-minimisation goal – Internet-based delivery – Embedded in school curriculum – Interactive and engaging storyboards

• Shown to be effective in: – Increasing alcohol knowledge; reducing average weekly alcohol

use, frequency of drinking to excess and alcohol harms (Newton et al., 2009a; 2009b, 2010)

Aim of the current study • To further test the efficacy of the ‘Climate Schools’

universal prevention program in: – Increasing alcohol knowledge – Reducing alcohol use – Reducing binge drinking – Reducing alcohol-related harms

Criticisms of universal prevention • Magnitude of the effect is small (effect sizes ≈ 0.3) • Effects may be short-lived • Programs may be less effective in “high-risk”

adolescents

Can we improve prevention efforts by supplementing a universal prevention program with a selective prevention program for “high-risk” adolescents?

Personality and substance use

Negative Thinking

Anxiety Sensitivity

Sensation Seeking Impulsivity

• Earlier onset drinking

• Greater drinking to cope

• Greater binge drinking

• More alcohol-related harms

• Later onset drinking • More responsive to

anxiolytic effects of alcohol

• Earlier onset drinking • Associated with other

high-risk behaviours

Conrod et al., 2000; Comreau et al., 2001; Woicik et al., 2009

Substance Use Risk Profile Scale

Preventure* • Personality-targeted prevention program (13-14 yr olds) • Aims to increase coping skills in “high-risk” adolescents • Effective in:

– reducing quantity of alcohol use – reducing frequency of alcohol use – reducing binge drinking – reducing personality domain-specific outcomes, e.g. depression

in high-risk negative thinking and panic symptoms in high-risk anxiety sensitivity

* Castellanos et al., 2006; Conrod et al., 2006 ; 2008, 2010; 2011

Can we improve prevention efforts by supplementing a universal prevention program with a selective personality-

targeted prevention program for “high-risk” adolescents?

‘Climate Schools’ – content • Two modules for Year 8 students (13-14 years old) • Each module consists of 6 lessons (20 mins online and

20 mins teacher led activities) covering: – Alcohol guidelines and laws – Normative use – Short and long term risks – Influence of media / peers – Drug refusal and minimisation skills – Staying safe and first aid

Preventure - content • All adolescents screened using the SURPS • “High-risk” adolescents take part in two 90-minute coping

skills workshops: – manualised – facilitator-led – content differs depending on personality – based on motivational interviewing (MI)

and cognitive behaviour therapy (CBT) principles

• First time Preventure trialled in Australia

Climate and Preventure (CAP) trial*

* Newton N, Teesson M, Barrett E, Slade T, Conrod P CAP study, evaluation of integrated universal and selective prevention strategies for youth alcohol misuse: Study protocol of a cluster randomized controlled trial BMC Psychiatry (2012) 12 118

+ =

CAP trial design • Four group cluster RCT with schools randomised to:

Control – education as usual Climate alone – universal prevention (for all) Preventure alone – selective prevention (for “high-risk”) CAP – universal prevention (for all) + selective

prevention (for “high-risk”)

Assessment Baseline

Survey

Climate Schools program

Preventure program (high-risk

students only)

Post-test survey

12 month F/U

survey

24 month F/U

survey

36 month F/U

survey

Timing Term 1-2 Feb-April

2012

Terms 1&3 Feb-Sept

2012

Terms 1-3 Feb-Sept

2012

Term 3-4 July-Dec

2012

Term 1 Feb-April

2013

Term 1 Feb-April

2014

Term 1 Feb-April

2015

Grade Year 8 Year 8 Year 8 Year 8 Year 9 Year 10 Year 11

CONTROL ✔ ✔ ✔ ✔ ✔ CLIMATE ✔ ✔ ✔ ✔ ✔ ✔ PREVENTURE ✔ ✔ ✔ ✔ ✔ ✔ CAP ✔ ✔ ✔ ✔ ✔ ✔ ✔

Measures • Alcohol knowledge • Alcohol use (in the previous 6 months):

– any standard drink – binge drinking (5+ drinks) – average total consumption (quantity x frequency)*

• Alcohol related harms: – abbreviated version of the Rutgers Alcohol Problems Index

(RAPI)* • Other drug use, mental health, motivations, aggression, bullying, psychotic-like experiences…

* Log transformed due to skewness

Control

CAP (Universal + Selective)

Preventure (Selective)

Climate (Universal)

Hypotheses – total sample

Control Climate (Universal)

1. Climate > Control

This would be a replication of previous findings

Control


2. CAP > Control


Climate (Universal)

3. CAP > Climate


Hypotheses – “high-risk” sample

Climate (Universal)


Control High risk

High risk

High risk

High risk

4. Preventure > Control


Control High risk

High risk

This would be a replication of previous findings


5. CAP > Climate

Climate (Universal)

High risk

High risk

Schools recruited 27 schools (18 private, 9 public)

Total students: 3,361

Parental consent/return 2,608 students (77.6%)

CONTROL 7 schools

Students: 612

CLIMATE 6 schools*

Students: 708

PREVENTURE 7 schools

Students: 615

CAP 6 schools

Students: 673

Student consent / present at baseline

2,190 students

No consent / return No consent: 94 (2.8%) No return: 659 (19.6%)

* One school dropped out due to insufficient time and was not included in the intention to treat sample

Recruitment/Consent

CONTROL 7 schools

Students: 527

CLIMATE 6 schools

Students: 576


Students: 478

CAP 6 schools

Students: 609

Low risk

57.7% (n=276)

High risk

42.3% (n=202)

Low risk

55.8% (n=340)

High risk

44.2% (n=269)

High risk

44.8% (n=236)

Low risk

58.3% (n=336)

High risk

41.7% (n=240)

Low risk

55.2% (n=291)

Preventure

Usual education Climate Climate

Preventure

Usual education

Screening

CONTROL 7 schools

N=527

CLIMATE 6 schools

N=576


N=478

CAP 6 schools

N=609

84.4% (N=445)

75.5% (N=435)

65.9% (N=315)

77.8% (N=474)

89.6% (N=472)

83.3% (N=480)

73.0% (N=349)

84.9% (N=517)

85.4% (N=450)

78.8% (N=454)

70.5% (N=337)

80.6% (N=491)

76.2% (N=1669)

83.0% (N=1818)

79.1% (N=1732)

Post-intervention

Baseline

24 months post-baseline

12 months post-baseline

Follow-up rates

Baseline characteristics Total Sample

(N=2190) “High-risk”

Sample (N=947)

% male 57.4% 57.4%

% Independent/Catholic school 74.7% 74.2%

Mean (SD) age 13.3 (0.5) 13.3 (0.5)

Mean (SD) alcohol knowledge^ 7.8 (2.8) 7.8 (2.9)

% any standard drink* 10.3% 15.7%

% any binge drinking* 5.0% 7.5%

Mean (Range) total consumption# 1.5 (1-46) 2.1 (1-46)

Mean (SD) alcohol harms 5.1 (5.4) 6.2 (6.3)

^ Scale range 1-15 * In the previous 6 months # Number of standard drinks per month in the past 6 months (based on quantity x frequency)

Outcomes – knowledge (total sample) 7

89

1011

Mea

n sc

ore

on k

now

legd

e sc

ale

Baseline Post 12M F/U 24M F/U

Control ClimateCAP Preventure

*N=2189

Alcohol knowledge - total sample*

Adolescents in the Climate and CAP groups significantly increased their knowledge about alcohol

Based on GEE analyses with exchangeable working correlation matrix, modeling time as a continuous variable, centred at post-intervention. All analyses carried out in Stata v12.

Control Climate (Universal)

1. Climate > Control in total sample?

Based on GEE analyses with exchangeable working correlation matrix, modeling time as a continuous variable, centred at post-intervention. All analyses carried out in Stata v12. OR=odds ratio (95% CI) diff=mean difference over time between groups (95% CI)

Any drinking: OR=0.62 (0.49-0.77)

Binge drinking: OR=0.59 (0.44-0.77)

Total consumption: diff=-0.08 (-0.13- -0.02)

Alcohol harm: diff=-0.08 (-0.16- -0.01)

This is a replication of previous findings

Control


2. CAP > Control in total sample?

Any drinking: OR=0.71 (0.58-0.87)


✖ Total consumption: diff=-0.02 (-0.08-0.05)




Climate (Universal)

3. CAP > Climate in total sample?

✖ Any drinking: OR=1.15 (0.94-1.41)

✖ Binge drinking: OR=1.10 (0.84-1.42)

✖ Total consumption: diff=0.04 (-0.02-0.09)

✖ Alcohol harm: diff=0.00 (-0.07-0.07)


Binge drinking


0.0

5.1

.15

.2.2

5P

roba

bilit

y of

bin

ge d

rinki

ng


Control ClimateCAP

*N=2189

Binge drinking - total sample*21%

15%

~5%

4. Preventure > Control in “high-risk” sample?


Control High risk

High risk

This is a replication of previous findings

Any drinking: OR=0.72 (0.51-1.00)


✖ Total consumption: diff=-0.08 (-0.19-0.02)


Based on GEE analyses with exchangeable working correlation matrix, modeling time as a continuous variable, centred at post-intervention. All analyses carried out in Stata v12. OR=odds ratio (95% CI) diff=mean difference over time between groups (95% CI). Analyses control for baseline scores


5. CAP > Climate in “high-risk” sample

Climate (Universal)

High risk

High risk

✖ Any drinking: OR=1.30 (0.92-1.84)

✖ Binge drinking: OR=1.11 (0.77-1.60)

✖ Total consumption: diff=0.06 (-0.03-0.15)

✖ Alcohol harm: diff=0.01 (-0.11-0.13)

Based on GEE analyses with exchangeable working correlation matrix, modeling time as a continuous variable, centred at post-intervention. All analyses carried out in Stata v12. OR=odds ratio (95% CI) diff=mean difference over time between groups (95% CI). Analyses control for baseline scores

Binge drinking in “high-risk” sample

0.1

.2.3

.4P

roba

bilit

y of

bin

ge d

rinki

ng


Control ClimateCAP Preventure

*N=947

Binge drinking - 'high risk' subsample*


30%

Conclusions • Universal prevention is effective • Selective (personality-targeted) prevention is effective

amongst high-risk adolescents • Combined universal + selective prevention is effective

when compared to education as usual • Universal alone and combined universal + selective

prevention are equally effective

Why are CAP and Climate equally effective?

• Any prevention is better than no prevention • CAP may be more effective for some personality profiles • CAP may be more effective for other outcomes, e.g. illicit

drug use, depression, anxiety • Schools differ in numbers of students at “high-risk” –

selective prevention might kick-in when the overall “load” of “high-risk” students exceeds a particular threshold

Implications • These results provide a strong rationale to roll out

universal school-based prevention – www.positivechoices.org.au

• Preventure may be warranted in schools with particularly high prevalence of “high-risk” students

• Additional costs associated with selective prevention need to be considered

• Need to continue exploring other agents of change: – Social networks – Parents

Acknowledgements • Participating schools and students • The CAP Study team:

– Emma Barrett, Katrina Champion, Erin Kelly, Julia Rosenfeld, Lucie Swaffield, Natasha Nair, Natacha Carragher

• Funding: – National Health and Medical Research Council (APP1004744)

Website: www.capstudy.org.au

http://www.capstudy.org.au/

an integrated approach to preventing substance use in adolescents: 24-month … · champion 1., n....

Documents