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Articles related to both HIV/AIDS and Substance Prevention

AIDS is now the fourth leading cause of death among women of childbearing age in the United States. Substance abuse compounds the risk of AIDS for women, especially for women who are injecting drug users and who share drug paraphernalia, because HIV/AIDS often is transmitted through shared needles or syringes. In addition, under the influence of illicit drugs and alcohol, women may engage in unprotected sex, which also increases their risk for contracting or transmitting HIV/AIDS.
Amaro, H., Raj, A., Vega, R.R., Mangione, T.W., Norville Perez, L. (2001). Racial/ethnic
disparities in the HIV and Substance Abuse epidemics: Communities responding to the need. Public Health Reports, 116: 434-448.

The report states how little research has been done that evaluates programs addressing both substance abuse and HIV in minority women and adolescents. The majority of HIV prevention studies focus on adult males and injection drug users, and these programs ignore the fact that women and adolescents use non-injection drugs (such as alcohol, crack and cocaine) more frequently. There is also a severe lack of research regarding HIV prevention for minority adolescent males. It is important for prevention efforts to be focused on males in early adolescence, because at this age, adolescent females have a higher AIDS incidence. However, this trend is reversed in adulthood when adult males have a higher incidence of AIDS than adult females. The report also covers a brief review of relevant evaluation research. The review results show that effective HIV prevention programs for minority women and adolescents offer safer sex education and behavioral skills training. The effective programs aimed at adolescents are often multi-sessioned, mixed-gender, and school-based. These programs have only been modestly effective, and the authors suggest that effectiveness could be further improved if the intervention addressed such issues as violence against women, the family environment and related risk-taking behaviors, such as substance abuse. Many studies of HIV and substance abuse prevention programs found a decrease in drug-related risk behaviors following the intervention, but no decrease in sexually risky behaviors. For example, O'Neill, Baker, Cooke, Collins, Heather & Wodak (1996), conducted a study on a program for pregnant injection drug users on methodone maintenance treatment. They found that a multisessioned cognitive skill-building intervention led to a decrease in the use of unclean needles, but had no effect on sexual risk-behaviors. Nyamathi, Flaskerud, Keenan, & Leake (1998) also found that an integrated HIV & substance abuse intervention with homeless and drug-addicted women reduced the amount of substance use but not the amount of sexual risks taken. But some integrated programs have shown some success. For example, Eldridge, Lawrence, Little, Shelby, Brasfield, Service & Sly (1997) studied women entering inpatient drug treatment. They had three experimental groups: education only, behavioral skill-building only, and safer sex behavioral skill-building. Participants in the first two groups showed decreases in drug use, but only participants in the third group reported increased use of condoms following the intervention. But little has been accomplished in serving adolescents need for integrated HIV and substance abuse prevention interventions. This report only managed to identify one study of a program intended to address both of these issues in adolescents. St. Lawrence, Jefferson, Banks, Cline, Alleyne & Brasfield (1994), studied the effectiveness of a program that included behavioral skill-training with drug treatment. Participants reported that by the end of the program they had decreased rates of engagement in unwanted sex, sex trade, sex under the influence, and sex with a risky partner. However, there was no comparison group and it is impossible to determine if these effects were due to the behavioral skill-training component or the drug treatment.

Blake, S.M., Ledsky, R., Lehman, T., Goodenow, C., Sawyer, R., & Hack, T. (2001).
Preventing sexual risk behaviors among gay, lesbian, and bisexual adolescents: The benefits of gay-sensitive HIV instruction in schools. American Journal of Public Health, 91 (6), 940-946.

Research shows that sexually active gay, lesbian and bisexual (GLB) adolescents in Massachusetts are significantly more likely than non-GLB adolescents to engage in substance abuse and risky sexual behaviors, such as earlier age at first intercourse, higher number of sexual partners, higher use of alcohol or drugs before last sex and increased pregnancy rates. However, the survey results from a random sample of high school students and HIV-education teachers (demographics not reported) indicated that GLB adolescents in schools with "gay-sensitive" instruction reported fewer sexual partners, less recent sex and less substance use before last sex than GLB youths in schools without gay-sensitive instruction. Furthermore, the survey found that GLB youths in schools without gay-sensitive instruction were at the highest risk for HIV infection, among other things. However, the reliability and validity of these results is questionable. Among the study's limitations is that no out of school youths were assessed and teachers were not asked to specify how their curricula was "gay-sensitive."

Coyle, K., Basen-Enquist, K., Kirby, D., Parcel, G., Banspach, S., Collins, J., Baumler, E.,
Carvajal, S., Harrist, R. (2001). Safer Choices: Reducing teen pregnancy, HIV and STDs. Public Health Reports, 116 (S1), 82-93.

The effectiveness of Safer Choices, a two year school based curriculum aimed at HIV, STD and pregnancy prevention was tested in 20 urban public schools in California and Texas. CDC has named Safer Choices as a "program that works." It is based on social cognitive theory, social influence theory, and models of school change. The aim of the program is to reduce the number of students engaging in unprotected sexual behavior by delaying the number of adolescents who become sexually active in highschool and by increasing condom use. The program also aims to change certain behaviors related to engagement in sexual risk behaviors such as: knowledge about HIV and other STDs, attitudes about sexual behaviors and condom use, normative beliefs regarding sexual intercourse and condom use, and students' belief in their ability to refuse sexual intercourse or unprotected sexual intercourse. It involves 10 sessions each in the 9th and 10th grade, along with school-wide activities, parent education, and school-community linkages. The intervention was implemented at 10 schools in California and 10 in Texas, with half at each site being intervention schools and half being control schools. At the control schools, students received the standard, knowledge based HIV prevention curriculum. The total sample consisted of 3,869 ninth-grade students. In the intervention group, 19.6% were African-American, 13.7% were Asian, 28.7% were Hispanic, and 28.7% were white. After the baseline interview, students were given self-report questionnaires at 7 months, 19 months, and 31 months (approximately 1 year after intervention completion). At the 31-month follow up, most of the results were in the desired direction and several were significant. Sexually experienced participants at the intervention schools decreases instances of sexual intercourse without a condom by a third in the past three months in comparison to the sexually experienced students at the control schools. Students who received the Safer Choices intervention also reported reducing the number of partners with whom they had sexual intercourse without a condom during the past 3 months by one-fourth in comparison to students at control schools. Of those students who had reported having intercourse during the past 3 months, intervention participants were 1.68 times more likely to have used condoms during last sexual intercourse than control participants. Intervention participants also reported more positive attitudes about condoms, greater condom-use self-efficacy, fewer barriers to condom use, and higher levels of perceived risk for HIV and STDs than control participants. Data from the 7-month follow up demonstrated even stronger effects, showing that the effects of the intervention, while still positive, had waned slightly over time. Safer Choices indicates that interventions that are multi-component, theory- and school-based with a clear message can be effective ways of increasing adolescent's self efficacy and reducing sexual risk behaviors.

Levy, S.R., Perhats, C., Weeks, K., Handler, A.S., Zhu, C., Flay, B.R. (1995). Impact of a
school-based AIDS prevention program on risk and protective behavior for newly sexually active teens. Journal of School Health, 65 (4): 145-151.

The effectiveness of the Youth AIDS Prevention Project (YAPP) was tested on 1,669 African American middle schoolers in 15 high risk Chicago metropolitan school districts. YAPP is a school-based, multiple risk reduction program designed to prevent STD's, HIV/AIDS and substance abuse among African American middle schoolers. Five districts comprised the control group of the study and these students received the standard AIDS state mandated education. The other ten districts comprised the treatment condition. Originally they were broken down into two separate treatment conditions: parent interactive and parent noninteractive. In the parent noninteractive condition, the parent was simply asked to attend a YAPP orientation meeting. In the parent interactive condition, the parents were asked to attend several meetings, were required to assist their children with YAPP homework assignments, and were asked to get involved in other ways. However, the two groups were analyzed together as the effort to get parents more involved was unsuccessful (aside from the homework assistance) and there were no statistical differences between the two groups. The YAPP classroom is an integrated approach to multiple risk reduction and prevention and relies upon knowledge transfer, active learning and skills-building techniques to influence student knowledge, attitudes, intentions and behavior. Activities included lectures, class discussions, videos, small group exercises, brainstorming, role plays, educational competitions and discussion of student's anonymously submitted questions. The program lasted for 2 weeks with one session per day in the 7th grade, and for five weeks in the eighth grade with one session per week. Effectiveness was tested through the administration of a pre and post intervention questionnaire. Unfortunately, this study only examined whether the intervention influenced the participants level of sexual activity, the use of protective behaviors (condoms or condoms and foam) in the sexually active, and the participants intentions to be sexually active in the next 12 months and their intentions to use condoms or condoms and foam during this time period. This study did not report any of the results related to substance abuse. One-third of the participants were sexually active when the program began, and 19% became sexually active between 7th and 8th grades. Approximately one-half remained abstinent throughout the program. For sexually active students in the treatment and control conditions, those in the treatment program were significantly more likely to report ever using condoms with foam and were marginally less likely to have been sexually active in the past 30 days. Those treatment participants who had been sexually active in the past 30 days were more likely to have used protective methods. Participants in the treatment program were also significantly more likely to report intending to use condoms with foam if they had sexual intercourse in the next 12 months. This program shows the importance of early interventions and their potential for success.

Rotheram-Borus, M.J., Lee, M.B., Murphy, D.A., Futterman, D., Duan, N., ET AL.
(2001). Efficacy of a preventive intervention for youths living with HIV. American Journal of Public Health, 91 (3), 400-405.

310 HIV infected youths aged 13-24 years (27% African-American, 37% Latino) were assigned to the intervention or control group. The intervention further divided the participants into approximately 15 person small groups, and consisted of 2 modules: "Stay Healthy" and "Act Safe." "Stay Healthy" consisted of 12 sessions and promoted healthy behaviors of individuals living with AIDS. "Act Safe" consisted of 11 sessions and aimed to reduce incidences of HIV youth putting others at risk for transmission of the disease (for example, reducing substance abuse and increasing condom use and disclosure of HIV status). The underlying theory of the intervention is the Social Action model, which focuses on improving coping, negotiation skills and self-efficacy. Following the "Stay Healthy" module, female intervention attendees had significantly more positive lifestyle changes than intervention non-attendees and control subjects did. Female intervention attendees also had a significantly higher positive action coping subscale score. Both male and female intervention attendees had a significantly higher social support coping scale than control subjects and intervention non-attendees. Following the "Act Safe" module, intervention attendees reported 45% fewer sexual partners, 82% fewer unprotected sexual acts, 50% fewer HIV-negative sexual partners, and 31% less substance abuse (on a weighted index) than those in the control condition. However, 27% of the youth did not even attend one intervention session, so it is recommended that alternative methods (for example, individual sessions, telephone groups or Internet-based interventions) be explored.

Rowden, D.W., Dorsey, P.E., Bullman, S., Lestina, R.P., Han, C., & Herrell, J.M. (1999).
HIV outreach for hard to reach populations: a cross-site perspective. Evaluation and Program Planning, 22, 251-258.

In order to assess the effectiveness of the Center for Substance Abuse Treatment's (CSAT) HIV outreach programs for hard-to-reach populations, this study compared the referrals and entry into substance abuse treatment of 1675 members of the HIV Outreach sample and a comparison group of 3,704 participants in CSAT's National Treatment Improvement Evaluation Study (NTIES). The age group assessed in both groups is predominantly in the 19-44 range. There was also significant numbers of women, African-Americans, and Latinos present in both samples. The HIV Outreach programs consisted of encouraging and facilitating entry into substance abuse treatment, interventions to reduce the risk of contracting and transmitting HIV/AIDS, screening for STD's and HIV/AIDS, and linkages to primary medical care, mental health care, and social services. The study found that HIV outreach substantially improved access to hard-to-reach populations, such as females and minorities. Almost 73% of the HIV Outreach clients who entered substance treatment were female, as compared to only 34% of the NTIES sample. 67% of the HIV Outreach clients entering substance abuse treatment were African-American, while 56% of the NTIES participants entering substance abuse treatment were African-American, and there was also a marginal increase in the number of Latino clients entering substance abuse treatment from the HIV Outreach program as compared to the NTIES sample: 17% to 15%. The increased number of women and minorities from the HIV Outreach project entering substance abuse treatment is especially significant in that these individuals had both a higher amount of substance abuse than the NTIES sample (31% had injected drugs in the last 30 days compared to 18% of the NTIES sample) and also reported a higher incidence of shared needles (14% of the HIV Outreach sample as compared to 4% of the NTIES sample). Not only were these individuals engaging in more risky behaviors, but they also were more likely to have never had substance abuse treatment before: this was the first drug treatment for 55.6% of the HIV Outreach sample as compared to 40.1% of the NTIES sample. The study also found that more women in the female-specific HIV Outreach projects than in the mixed gender programs were referred to (83% as compared to 44%) and actually entered substance abuse treatment (93% as compared to 49%). African-American specific projects also provided more referrals (89% of African-Americans in the specific program as compared to 44% of African-Americans in non-specific programs), but there was not a large corresponding increase in entry into substance abuse treatment (80% for specific programs, 77% for non-specific programs). This initial data analysis of CSAT's HIV Outreach programs did not look at data concerning HIV risk reduction. However, it did show that HIV Outreach programs can be effective in increasing the referrals and entry of substance abusing individuals who are at a high-risk for AIDS into substance abuse treatment

Articles related to HIV prevention only:

CDC AIDS Community Demonstration Projects Research Group. (1999). Community-
level intervention in five cities: final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health, 89 (3), 336-345.

15,025 individuals who were high-risk youth, residents in a census tract with high rates of sexually transmitted diseases, injection drug users, female sex partners of IDU's, commercial sex workers, and men who have sex with men were interviewed following a CDC sponsored intervention in their communities. Of these individuals, 54% were African Americans, 19% were Hispanic, and 35% were under the age of 35. The 5 target communities were located in Dallas, Denver, Long Beach, California, New York City and Seattle. The intervention was based on the Transtheoretic Model of Behavior Change and utilized carefully trained volunteers from each community to highlight and promote identification with and acceptance of the intervention message. The intervention consisted of the distribution of role model stories. The stories were developed from real-life experiences of community members and illustrated how these individuals moved from earlier to later stages of change regarding condom and bleach beliefs. The stories were featured in fliers and were distributed along with condoms and bleach kits in street settings, public sex environments, and other community venues by the peer volunteers. In the subsequent interviews, it was demonstrated that those who participated in the intervention (approximately 54% of the target population) intended to use condoms more frequently (percentage in community increased from 30% to 44%), and the percentage of community respondents who always used condoms with their non-main partners increased from 25% to 33%. This intervention was determined to be an effective means of helping hard to reach populations.

Darbes, L.A., Kennedy, G.E., Peersman, G., Zohrabyan, L., & Rutherford, G.W.
(March 2002). Systematic Review of HIV Behavioral Prevention Research in African-American Populations., accessed 6/26/02.

The University of California, San Francisco AIDS Research Institute and the Cochrane Collaborative Review Group on HIV/AIDS collaborated to do a systematic review of HIV prevention among four at-risk groups, including youth/adolescents. They identified effective prevention studies and broke these programs down into one of three categories: good, fair, or limited. A study's score determined their category placement, and scores were derived from points in various categories, including randomization, level of attrition, proper methods utilized to prevent contamination of intervention, and information on training or makeup of the facilitators. If a study received 75-100% of the possible points, it was deemed a 'good' study, if it received 50-75% of the possible points it was deemed a 'fair' study, and if it received less than 50% it was deemed a 'limited' study. The review also looked separately at intervention studies with 100% African-American participants, studies that included African-Americans in the sample and ran separate analyses for African-Americans, and studies with at least 80% of the sample comprised of African-Americans.
'Good' Studies with 100% African-American participants:
  1. Stanton & colleagues evaluated an intervention designed to decrease HIV risk behaviors among adolescents. The intervention was based on protection motivation theory, and was delivered through naturally occurring friendship groups. The intervention group received information, risk reduction materials and skills training through peer education. The control group received HIV/AIDS information without the presence of friends and without a theoretical context. For both groups, the program consisted of 8 weekly meetings (seven 90 minute meetings, one full day session). At the 6-month follow up, the intervention group reported increased condom use and increased condom use intentions. However, the significant results had disappeared by the 12-month follow-up. Fang investigated the effect of the friendship groups, and found that at the 6 month follow up, the percentage of groups in which all sexually active members used condoms increased from 33% to 69%, while control group rates remained stable.

  2. St. Lawrence & colleagues conducted an intervention that sought to increase self-efficacy in 246 adolescents recruited from a community health center. The theoretically based intervention consisted of 8 weekly education and behavioral skills sessions that were 90-120 minutes long. Activities included information, skills training, peer education and role-plays. The control group received one 2 hou educational program. At baseline, the men had significantly higher amounts of sexual risk than the females did. At the 1-year follow up, the male intervention participants had decreased the incidence of unprotected sex compared to male control participants. Female intervention participants had maintained their low levels of sexual risk while the level of sexual risk had increased for female control participants. The intervention also resulted in increased condom use for both sexes, and increased communication and negotiation skills.
'Good' studies in which some percentage is African-American and separate analyses are conducted on African-Americans:
  1. Rotheram-Borus and colleagues evaluated an intervention designed to decrease runaway's high levels of HIV risk behavior among a sample of 312 runaways (57% African-American) recruited from New York shelters for runaways. The intervention consisted of counseling, referrals, risk reduction materials and skills training. Two shelters participated in the intervention group, and the maximum number of sessions possible was 10. Two other shelters served as a comparison group. At the two-year follow up, intervention participants reported greater reductions in unprotected sex and less substance abuse than control group. Among ethnicity, African-American youths made greater reductions in substance abuse compared to Whites and Latinos.
From their review of these and other studies, the researchers were able to identify the following common elements of successful HIV/AIDS prevention programs for the African-American population:
  1. Skills training was a component of the intervention

  2. The interventions had been specialized in order to address the unique needs of the African-American population. Many of the facilitators were African-Americans.

  3. Interventions also took into account gender differences. For example, effective interventions for women taught them better communication skills for encouraging their partners to wear condoms. Interventions solely for women were also successful.

  4. Interventions were more successful if they were given over several sessions and/or were longer in duration. At minimum, interventions of 3 to 5 sessions were able to achieve positive effects and remain feasible.
Jemmott, J.B. 3rd, Jemmott, L.S., Fong, G.T., & McCaffree, K. (1999). Reducing HIV
risk-associated sexual behavior among African American adolescents: Testing the generality of intervention effects. American Journal of Community Psychology, 27 (2), 161-187.

Jemmott & colleagues conducted intervention for 659 younger adolescents (6th & 7th graders) in Philadelphia. There were 3 groups: 2 intervention groups and one control group. The theoretical basis was social cognitive theory and theory of reasoned action. The first intervention group focused on abstinence as the proper way to prevent AIDS, and the second intervention group promoted safe sexual practices. The control group received a health promotion intervention on heart disease, diet and exercise. All interventions were delivered in eight 1-hr modules over two consecutive Saturdays, and were delivered by peer and adult facilitators. Follow-ups were completed at 3 months, 6 months and 1 year. At 3 months, adolescents from the abstinence group were significantly less likely to have had sex than the control group and were marginally less likely to have had sex than the safe sex group. The safe sex group practiced more consistent condom use, higher frequency of condom use and was more likely to have protected sex than either of the two other groups. At 12 months, both intervention groups reported more condom use than the control group. But only the safe sex group had significant and positive outcomes on the frequency of unprotected sex. There was no difference found between peer's delivery of the intervention and adult delivery.

Kamb, M.L., Fishbein, M., Douglas Jr, J.M., Rhodes, F., Rogers, J., Bolan, G.,
Zenilman, J., Hoxworth, T., Malotte, C.K., Iatesta, M., Kent, C., Lentz, A., Graziano, S., Byers, R.H., Peterman, T.A. (1998). Efficacy of risk-reduction counseling to prevent Human Immunodeficiency Virus and Sexually Transmitted Diseases. Journal of the American Medical Association, 280 (13), 1161-1167.

5,758 participants from 5 U.S. cities (Baltimore, Denver, Long Beach, California, Newark, NJ and San Francisco) participated in Project RESPECT, a study which compared the effectiveness of 2 interactive HIV/STD counseling interventions to the didactic prevention messages typically given at HIV/STD clinics. Participants were age 14 and up (median age 25) and were 59% African-American, 19% Hispanic, 16% white, and 6% other races. The participants were randomly put into one of 4 intervention groups: Arm 1 (4 sessions of enhanced counseling based on the theory of reasoned action and social cognitive theory), Arm 2 (2 sessions of interactive risk-reduction counseling), and Arms 3 and 4 (2 brief typical didactic messages). Participants in arms 1, 2, and 3 were asked to schedule follow up appointments at 3, 6, 9 and 12 months. Participants in arm 4 were not asked to schedule any follow up visits, but were contacted at 12 months. All interventions included an HIV and STD test and were presented on an individual basis. The aim of the enhanced counseling intervention was to change the key theoretical elements (self-efficacy, attitudes and perceived norms) regarding condom use. The brief counseling intervention was modeled after CDC's recommended HIV counseling for patients at public clinics and HIV test sites. At both the enhanced counseling and brief counseling interventions, participants made small risk reduction goals that could be accomplished before the next session, and at the final session a long-term risk-reduction plan was agreed upon. Participants in arms 3 and 4 received two brief prevention messages about HIV and STD that were deliberately designed so as to not engage the participant in interactive counseling. The results show that condom use increased substantially for all 3 interventions. At the 3 and 6-month follow-up visits, the increases in condom use were highest for participants in the two counseling interventions. At the 3-month follow up, enhanced counseling participants and brief counseling participants reported significantly more "no unprotected vaginal sex" than the didactic participants (46% and 44% as compared to 38%). At the 6 month visit, these trends continued in the same direction but were no longer significant, and at the 9 month and 12 month visits, any condom use and "no unprotected vaginal sex" were reported more frequently than at enrollment, but there were no significant differences between the 3 interventions. However, it was found that enhanced counseling participants were more likely to report "no unprotected sex" at 12 months than participants in the other interventions. Enhanced counseling participants were more likely to have increased condom use, but brief counseling participants tended to report safe behaviors unrelated to condoms (no new partners or no casual partners) most often, followed by the enhanced counseling group and then the didactic messages group. Through the 12-month visit, 12.7% of the participants had contacted a new STD (gonorrhea, chlamydia, syphilis or HIV). More participants from the didactic messages groups developed STDs compared to either of the two counseling interventions (instances of new STDs through the 12 month visit was 10.4% for the didactic arm, 7.2% in the enhanced counseling arm, and 7.3% in the brief counseling arm). For the two interactive counseling arms, 20% fewer participants had new STDs at the 12 month visits, which is an important decrease and should indicate a corresponding (but not necessarily equivalent) decrease in HIV risk. The study also found that the relative effectiveness of counseling was highest for certain subgroups, including participants aged 20 and younger. This study found that there are comparable risk-reduction benefits from both brief and extended counseling, which is an important find.

Rotheram-Borus, M.J., Gwadz, M., Fernandez, M.I., Srinivasan, S. (1998). Timing of HIV
interventions on reductions in sexual risk among adolescents. American Journal of Community Psychology, 26 (1), 73-96.

151 adolescents between the ages of 13-24 (53% African-American, 39% Hispanic, 8% other ethnicity's) participated in a study examining the influence of the number of sessions on a program's effectiveness. The participants were randomly assigned to one of 3 groups: intervention group consisting of 10.5 hrs of treatment spread over 3 sessions, intervention group consisting of 10.5 hrs of treatment spread over 7 sessions and a no-intervention control condition. The intervention utilized cognitive-behavioral intervention strategies, and addressed knowledge of HIV, social cognitive factors (outcome expectancies, perceived risk of HIV and self-efficacy), negotiation skills in low and high pressure situations, condom use and goal setting. At the 3-month follow up, those participants who were in the seven-session condition had a significantly lower number of sexual partners than the participants in the three-session condition. Youths in the control condition reported on average 7.9 more risk acts than youths attending the three -session intervention and 15.1 more risk acts on average than youths attending the seven-session intervention.

Articles related to Substance Abuse prevention only:

Black, D.R. Tobler, N.S., Sciacca, J.P. (1998). Peer helping/involvement: an efficacious
way to meet the challenge of reducing alcohol, tobacco, and other drug use among youth? Journal of School Health, 68 (3): 87-93.

The authors completed a review of 120 adolescent drug prevention programs that simultaneously addressed use of alcohol, cigarettes, cannabis and other illicit drugs. Most of the participants were in grades 6-8, and the interventions were universally applied to students in these grades. The authors separated the programs into two categories: peer led (interactive) or teacher led (non-interactive). Characteristics of a peer-led intervention is that it involves communication based on face to face peer interactions, and planned activities include role plays, modeling & rehearsal of interpersonal skills. Peers also often provide constructive feedback. Teacher-led programs, on the other hand, are passive. The teacher introduces the program content in a lecture format and interaction primarily occurs between the teacher and a student, rather than between students. The authors found that the interactive programs were statistically superior to non-interactive programs across the different drugs. The study also indicated that peer helpers can deliver the same benefits as more educated teachers as long as they have received adequate training. The most effective programs were those that have the following components in common: 1) they dispel the myth that everyone is doing drugs by showing local statistics, 2) they teach drug refusal skills, and 3) they present the negative consequences (ensuing physical, emotional, social and economical problems) of using drugs. The most effective delivery method emphasized sharing, cooperating and contributing. Small groups and constructive peer feedback regarding refusal skills were also highly valued. 68% of the programs took 6 hours to complete.

The authors also further expand on two model programs. Botvin, Baker, Renick, Filazzola, and Botvin (1984) conducted a 20 session cognitive-behavioral program for substance abuse prevention with 1,311 7th graders in 10 suburban New York middle schools. The program was designed to decrease pressure to smoke, drink excessively or use cannabis, and was delivered through either a peer-led group or a teacher-led group. The study found that peer led programs were statistically superior to teacher-led and control group programs regarding monthly measures of cigarette smoking and cannabis use, and also for weekly measures of cannabis use. Further participants from the peer-led groups had significantly less drunkenness than participants in the teacher led and control groups. Perry & Grant's program also used a teacher-led group and a peer-led group, and was designed solely to reduce alcohol consumption. It was found that students in the peer led group as compared to students in the teacher-led and control group reported significantly less alcohol use, acquired more knowledge of drinking, improved their attitudes regarding drinking, and had fewer friends who drank.

Hser, Y.I., Grella, C.E., Hubbard, R.L., Hsieh, S.C., Fletcher, B.W., Brown, B.S.,
Anglin, M.D. (2001). An evaluation of drug treatments for adolescents in 4 U.S. cities. Archives of General Psychiatry, 58, 689-695.

This article reports the drug treatment outcomes for 1167 adolescents from 4 U.S. cities (Pittsburgh, Pa; Minneapolis, Minn.; Chicago and Portland, Ore.). The adolescents participated in residential (RES) programs, outpatient drug-free (ODF) programs, and short-term inpatient (STI) programs, and were assessed at intake and a 1-year follow up interview. The sample was 66.2% white, 18.3% black, 9.3% Hispanic, and 6.3% other ethnic groups. The mean age was 15.7 years. 47.1% of the sample reported that marijuana was their primary problem, while 20.6% named alcohol as their primary problem. They tended to have multiple problems: large numbers of the sample were polydrug users (25% used 3 or more drugs), were dependent on a substance (73%), were diagnosed as having a mental disorder (63%), and 67.2% were criminally "active" (were currently involved with the criminal justice system). The majority of the treatment programs placed an emphasis on family therapy (50% of the RES programs, all but one ODF program, 100% STI programs). RES programs provided frequent group sessions, individual sessions, and education. It was typically planned or recommended that patients stay in treatment for 3-12 months (median: 5 months). ODF programs provided treatment on a regular or intensive level, and included counseling sessions (group and individual), education and skills training. Planned duration of treatment ranged from 1 to 6 months (median: 1.6 months). STI programs provided counseling and 12-step programs within a medically controlled environment. Most had daily group sessions and weekly individual sessions. Planned stay ranged from 5 to 35 days (median: 18 days) and upon discharge, patients were typically referred to outpatient programs. At the 1-year follow up, it was discovered that there were significant improvements in the domains of drug use, psychological adjustment, school performance, and criminal activity in the year following treatment, compared to the year preceding treatment. Weekly or more frequent marijuana use decreased from 80.4% to 43.8%, heavy drinking dropped from 33.8% to 20.3%, the use of other illicit drugs dropped from 48% to 42.2% and criminal activities dropped from 75.6% to 52.8%. Improved psychological adjustment was demonstrated through fewer suicidal thoughts and hostility and increased self-esteem. In the year following treatment, more participants attended school and reported average or better than average grades compared to the year preceding treatment. There were a few exceptions to the improvement trend. For example, patients in ODF programs showed no improvement in their use of hallucinogens and stimulants, and use of illicit drugs besides marijuana increased. Longer time in treatment (including with STI programs) was found to be associated with the highest level of improvement related to any drug or alcohol use and arrest rates.

SAMHSA Model Programs: Project ALERT. (n.d.). Retrieved July 9, 2002, from

Project ALERT is a 2-year, 14 lesson, drug prevention curriculum for middle school students and aims to decrease the onset and regular use of substances. It focuses on the drugs most commonly used by this age group: alcohol, tobacco, marijuana and inhalants. The goals of the program are to establish non-drug using norms and to teach young adolescents the skills needed to resist drugs. The curriculum involves guided classroom discussions, videos, small group activities and role-play. The effectiveness of the program was tested by randomly assigning 30 schools to one of three groups: Control, Teacher-led intervention and Teacher and Teen Leader intervention. The schools were located in a variety of different environments. Nine schools had minority populations of at least 50%, and all schools had a diverse population. A pre- and post-test showed that the program substantially reduced prodrug attitudes and beliefs. Fifteen months after baseline, in comparison to the control groups, marijuana initiation rates were 30% lower for ALERT students, and current marijuana use was 60% lower in the teacher-led program. Among those who had experience with tobacco at baseline, current and occasional use was 20 to 25% lower, and regular and heavy cigarette use was 33 to 55% lower among ALERT students. Many of the enhanced antidrug beliefs persisted into the 10th grade, including: intention to not use substances in the next 6 months, the belief that one can resist drugs, the belief that doing drugs is a harmful activity and is not worth it, the belief that peers respect nonusers, and the perception that few peers do drugs or approve of doing drugs.

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No employee, applicant for employment, or member of the public shall be discriminated against
on the basis of race, color, religion, sex, age, national origin, disability, sexual orientation, or
any other personal characteristic protected by federal, state, or local law.