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Jackson C.A., Henderson M., Frank J.W. et al.
Journal of Public Health: 2012, 34(S1), p. i31–i40.
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Different youth 'problem' behaviours overlap and share common causes, so it should make sense to implement programmes which affect several at once. That was the thesis of this Scottish review, which looked at studies reporting on both substance use and risky or underage sex. The literature was scarce but did give some reasons for optimism.
Summary Substance (alcohol, tobacco and illicit drug) use and sexual risk behaviour share some common underlying determinants. This 'rapid review' sought to synthesise the international evidence on 'what works' to prevent these overlapping risk behaviours, focusing largely on the 'microenvironment' rather than broader social and legal issues, and on universal approaches addressing whole youth populations rather than selected 'high-risk' groups or individuals.
The reviewers found no previous reviews of intervention studies which had reported multiple risk-behaviour outcomes, so instead they identified reviews focused on single risk-behaviours, and also looked for individual evaluation studies which reported both substance use and sexual risk behaviour outcomes. The latter had to be based on the young people's behaviour at age 11 to 25 and the impacts of interventions implemented between the ages of about five and 25.
The featured article reported its findings separately based on its 'review of reviews' (broken down by type of intervention, eg, school-based versus parenting) and on its analysis of individual multi-outcome studies. It also included substantial consideration of the influences on risk behaviour beyond the type of specific interventions it reviewed. This account is based on the article's summary conclusions.
Reviews of studies addressing single risk behaviours indicated that evidence for the effectiveness of most approaches was mixed or limited due to few studies. Policy interventions and mass-media approaches, such as those which have focused on smoking, have had some success. School-based curriculum-focused programmes appear insufficient on their own to prevent risk behaviour, but whole-school approaches which also address the school's ethos and environment show some promise. Family/parenting programmes have also had mixed success, with the most promising intervention being the Strengthening Families Program for Parents and Youth 10–14 [Editor's note: described in this Findings review]. Maintaining family connectedness into the adolescent years, an aim of this programme, may help to reinforce and strengthen some of the protective factors needed to prevent risk behaviour. Multi-domain interventions have also had some success in reducing risk behaviour, though again, evidence is mixed.
The review of individual studies found that the common feature of interventions which affected both substance use and sexual risk behaviour was their multi-component nature, addressing influences on risk behaviour at individual, school and family and community levels [Editor's note: see for example this review of the impact of such interventions on drinking]. This pattern is consistent with the findings of the review of reviews, suggesting that complex interventions may be more effective than more traditional curriculum-only school programmes. [Editor's note: the same authors have produced a more extended analysis of the same studies.]
On the evidence to date, the most promising interventions for reducing several risk behaviours simultaneously are those which address multiple domains of risk and protective factors, perhaps because they match the multi-faceted nature of the causes of risk behaviour. Such interventions largely aim to bolster young people's resilience, supported by promoting positive parental/family influences and/or healthy school environments which foster positive social and emotional development.
Timing is likely to be very important, particularly in relation to periods of transition in young people's lives. Programmes were commonly implemented at ages 11–12, during transition into adolescence, or at ages 13–14, when risk behaviours, or experimentation with them, may already have started. The Seattle Social Development Project was the only identified programme implemented in the pre-adolescent early years of primary school. Its success, especially in reducing sexual risk behaviour, suggests that intervening in early mid-childhood can have an impact on later risk behaviour. It may not be too late to intervene during teenage years, but addressing underlying determinants of risk behaviour early in childhood may have a greater impact than only intervening in adolescence.
Although substance use and sexual risk behaviour share common underlying determinants, the contribution of these factors varies. For example, a survey of a sample of Scottish schools found that differences between schools in the prevalence of smoking was related to school-level characteristics such as the school's focus on caring and inclusiveness, while underage sex was related to individual and neighbourhood socioeconomic factors. Such findings provide further support for a holistic approach to preventing several risk behaviours at once.
The main limitation of our review of reviews was that it depended on what has previously been reviewed and the way those reviews classified interventions. This hampered the identification of common features (such as duration or use of booster sessions) which might characterise successful interventions for different risk behaviours.
Methodological differences between individual studies also made it difficult to identify elements of successful interventions. The studies also tended to suffer from methodological limitations and short follow-ups. They also were rarely replicated in other populations or countries and often did not assess whether the intervention was equally effective for both sexes and for people at different socioeconomic levels. In turn this made it difficult to determine the interventions' impacts on health inequality. However, it seems likely that health equality considerations will mandate a combination of universal approaches and those targeted at higher risk groups.
As well as appropriate intervention programmes, steps are needed to reduce the exposure of young people to negative influences, and to increase opportunities for engaging in activities that nurture positive development. Policymakers should be act on the evidence that broader social change is needed to reduce negative societal influences and marginalisation, social exclusion and the vulnerability of young people during periods of transition in their lives. Further consideration below.
Among these broader influences are those exerted during very early childhood, which affect health and wellbeing throughout the life course, influencing literacy and numeracy, mental health, heart disease, criminality, and social participation. Although pre-school interventions can improve child development and life success, they are not always effective in preventing risk behaviour in young people [Editor's note: see this Findings hot topic on early years interventions].
Regulatory and legislative measures that increase price and impose marketing restrictions can help to reduce smoking by young people may also reduce drinking. However, these measures may be circumvented, so should be considered part of a larger package of preventive measures and thoroughly evaluated. Media ads and portrayals also affect a variety of health behaviours. The media industry could take more responsibility for the role they play, and parents need to be more aware of the role of media in their children's development and how to minimise it. Other dimensions of the social context also play a role, including cultural norms, access to attractive leisure and social facilities, and opportunities for engaging in health-enhancing activities.
Early childhood through to young adulthood includes various transition periods, each with the potential for increasing young people's vulnerability. Recent studies of young people in transition to adulthood highlighted the importance of social mobility, education, personal competence and resilience, as well as gender, neighbourhood deprivation and family support.
Last revised 18 July 2013. First uploaded 18 July 2013
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