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Efficacy of a mobile phone-based life-skills training program for substance use prevention among adolescents: study protocol of a cluster-randomised controlled trial

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Background: Life-skills trainings conducted within the school curriculum are effective in preventing the onset and escalation of substance use among adolescents. However, their dissemination is impeded due to their large resource requirements. Life-skills training provided via mobile phones might represent a more economic and scalable approach. The main objective of the planned study is to test the efficacy of a mobile phone-based life-skills training to prevent substance use among adolescents within a controlled trial. Methods/design: The efficacy of a mobile phone-based life-skills training to prevent substance use among adolescents will be tested in comparison to an assessment only control group, within a cluster-randomised controlled trial with two follow-up assessments after 6 and 18 months. The fully automated program is based on social cognitive theory and addresses self-management skills, social skills, and substance use resistance skills. Participants of the intervention group will receive up to 4 weekly text messages over 6 months in order to stimulate (1) positive outcome expectations, e.g., on using self-management skills to cope with stress, (2) self-efficacy, e.g., to resist social pressure, (3) observational learning, e.g. of interpersonal competences, (4) facilitation, e.g., of strategies to cope with negative emotions, and (5) self-regulation, e.g., by self-monitoring of stress and emotions. Active program engagement will be stimulated by interactive features such as quiz questions, message- and picture-contests, and integration of a friendly competition with prizes in which program users collect credits with each interaction. Study participants will be 1312 students between the ages of 14 and 16 years from approximately 100 secondary school classes. Primary outcome criteria will be problem drinking according to the short form of the Alcohol Use Disorders Identification Test and cigarette smoking within the last 30 days preceding the follow-up assessment at month 18. Discussion: This is the first study testing the efficacy of a mobile phone-based life-skills training for substance use prevention among adolescents within a controlled trial. Given that this intervention approach proves to be effective, it could be easily implemented in various settings and would reach large numbers of young people in a cost-effective way. Trial registration: ISRCTN41347061 (registration date: 21/07/2018).
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S T U D Y P R O T O C O L Open Access
Efficacy of a mobile phone-based life-skills
training program for substance use
prevention among adolescents: study
protocol of a cluster-randomised controlled
trial
Severin Haug
*
, Raquel Paz Castro, Andreas Wenger and Michael P. Schaub
Abstract
Background: Life-skills trainings conducted within the school curriculum are effective in preventing the onset and
escalation of substance use among adolescents. However, their dissemination is impeded due to their large
resource requirements. Life-skills training provided via mobile phones might represent a more economic and
scalable approach. The main objective of the planned study is to test the efficacy of a mobile phone-based life-skills
training to prevent substance use among adolescents within a controlled trial.
Methods/design: The efficacy of a mobile phone-based life-skills training to prevent substance use among
adolescents will be tested in comparison to an assessment only control group, within a cluster-randomised controlled
trial with two follow-up assessments after 6 and 18 months. The fully automated program is based on social cognitive
theory and addresses self-management skills, social skills, and substance use resistance skills. Participants of the
intervention group will receive up to 4 weekly text messages over 6 months in order to stimulate (1) positive outcome
expectations, e.g., on using self-management skills to cope with stress, (2) self-efficacy, e.g., to resist social pressure, (3)
observational learning, e.g. of interpersonal competences, (4) facilitation, e.g., of strategies to cope with negative
emotions, and (5) self-regulation, e.g., by self-monitoring of stress and emotions. Active program engagement will be
stimulated by interactive features such as quiz questions, message- and picture-contests, and integration of a friendly
competition with prizes in which program users collect credits with each interaction. Study participants will be 1312
students between the ages of 14 and 16 years from approximately 100 secondary school classes. Primary outcome
criteria will be problem drinking according to the short form of the Alcohol Use Disorders Identification Test and
cigarette smoking within the last 30 days preceding the follow-up assessment at month 18.
Discussion: This is the first study testing the efficacy of a mobile phone-based life-skills training for substance use
prevention among adolescents within a controlled trial. Given that this intervention approach proves to be effective, it
could be easily implemented in various settings and would reach large numbers of young people in a cost-effective
way.
Trial registration: ISRCTN41347061 (registration date: 21/07/2018).
Keywords: Life-skills, Substance use, Prevention, Adolescents, Mobile phone
* Correspondence: severin.haug@isgf.uzh.ch
Swiss Research Institute for Public Health and Addiction, Zurich University,
Konradstrasse 32, 8005 Zurich, Switzerland
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Haug et al. BMC Public Health (2018) 18:1102
https://doi.org/10.1186/s12889-018-5969-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Several biological, psychological, and social transitions
that occur during adolescence are essential for a young
persons later-life trajectory [1,2]. These transitions offer
opportunities for them to gain skills to achieve greater au-
tonomy from adults, build social connections with peers,
develop a positive body image, and form a sense of iden-
tity. However, these transitions also facilitate exploration
and risk taking at a stage when cognitive functions of the
brain are not yet fully developed [3]. Shifts of emotional
regulations and increased risky behaviours result in vul-
nerabilities for mental and substance use disorders, which
constitute the biggest contributors to the health burden of
10- to 24-year-old individuals [4]. Substance use and the
development of substance use disorders often first emerge
during adolescence and co-occur with mental disorders
[1]. The Swiss data of the Health Behaviour in
School-aged Children (HBSC) study [5] showed noticeably
increases in the lifetime prevalence of alcohol, tobacco
and cannabis consumption over the age groups of
11-to-15-year-olds. The prevalence of regular cigarette
smoking (weekly or daily) increased from 2% among
13-year old boys to 12% among 15-year-old boys and from
2% in 13-year old girls to 9% in 15-year old girls. The
prevalence of binge drinking increased from 19% in
14-year old boys to 27% in 15-year old boys and from 14%
in 14-year old girls to 23% in 15-year old girls.
A systematic review of studies assessing the effectiveness
of prevention, early intervention, and harm reduction in
young people for tobacco, alcohol, and illicit drugs demon-
strated the effectiveness of taxation, public consumption
bans, advertising restrictions, and minimum legal age, as
well as the potential effectiveness of preventative interven-
tions that deliver life-skills training in educational settings
[6]. Schools are particularly suitable settings to reach ado-
lescents with preventative interventions because of the ease
of delivery and access to young people within compulsory
secondary education. A Cochrane Review on school-based
programs for the prevention of tobacco smoking [7]con-
cluded that combined social competence and social influ-
ence interventions had a significant effect at 1 year and at
longest follow-up (OR 0.49, 95% CI 0.28 to 0.87), whereas a
social influences program on its own, multimodal
community-wide initiatives, and information-only interven-
tions were found to be ineffective. Another Cochrane re-
view on school-based prevention programs for alcohol
misuse in young people [8] concluded that certain generic
psychosocial and developmental prevention programs can
be effective. However, the methodological quality of the tri-
als included in the analysis was poor, and this did not allow
for any quantitative pooling of data.
The majority of the generic programmes addressing
social competences and social influences which were in-
cluded in the above-cited reviews can be described as
life-skills trainings and primarily rely on Banduras social
learning theory [9] which hypothesizes that children and
adolescents learn substance use by modelling, imitation,
and reinforcement, influenced by individual cognitions,
attitudes. Furthermore, based on the social influences
approach, [10] substance use susceptibility is increased
by poor personal and social skills and young people initi-
ate drug use as a result of pressure from peers, family
and the media.
Generic life skills programs to prevent substance use,
like the IPSY program, developed in Germany [11]orthe
ALERT [12] or Life Skills Training [13] programs devel-
oped in the US, typically combine training in
self-management skills (e.g., coping with stress, emotional
self-regulation, goal setting), social skills (e.g., assertiveness,
communication skills) and substance use resistance skills
(e.g. resisting peer pressure to drink alcohol, recognizing
and resisting media influences promoting cigarette smok-
ing, normative expectations about substance use).
Although these life-skills training programs were effective
at preventing the onset of specific substances [7,11,14]o
r
at decreasing problematic substance use [8], their imple-
mentationanddisseminationinschoolspresentserious
challenges [15]. First, teachers and other professionals need
the time, motivation, knowledge and skills to deliver the
program. Second, extensive resources, in terms of
personnel, money, and time allocated to deliver substance
use prevention, are required to prepare and administer such
programs.
Electronically-delivered interventions (e.g. via com-
puter, Internet or mobile phone) have the potential to
overcome the above-mentioned obstacles that hinder
successful program implementation and larger-scale dis-
semination of life-skills training in schools.
Electronically-delivered interventions have a wide reach
at a low cost, and offer the opportunity to automatically
deliver individually-tailored contents that can be
accessed at any time and in any place [16]. Furthermore,
electronically-delivered interventions might be more ap-
pealing for adolescents, because they can better ensure
privacy and tailor contents to their needs.
A recent systematic review of alcohol and other drug
prevention programs facilitated by computers or the
Internet [17] identified nine trials of online prevention
programs, of which six demonstrated significant, but
modest effects for alcohol and/or other drug use out-
comes. The programs were delivered in the US,
Australia and the Netherlands and provided between 1
and 12 online curriculum-based standard lessons or tai-
lored feedback. All programs were universal, i.e., deliv-
ered interventions to all students regardless of their level
of risk, and were primarily based on principles of the so-
cial learning theory [9], the social influences approach
[10] and the social cognitive theory [18,19].
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Beyond traditional personal computers, a promising
means of delivering prevention programs is to do so re-
motely through the use of mobile technologies. In
Switzerland, as in most other developed countries, almost
all (98%) adolescents between the ages of 12 and 19 own a
mobile phone, and 97% of these phones are smartphones
[20]. Most adolescents are familiar with how to use mobile
phones and typically use them on a daily basis for texting,
taking pictures, playing games etc. Mobile phone-based
interventions can provide almost constant support to
users, in comparison to interventions that can only be
accessed at specific times or locations and they provide a
discrete and confidential means of intervention delivery
[21]. Particularly mobile phone text messaging is a suitable
means of delivering individually tailored messages via mo-
bile phone. This interactive service allows cost-effective,
instantaneous, direct delivery of messages to individuals.
Several recent reviews underline the potential and efficacy
of text messaging-based interventions in various health
domains (e.g., diabetes self-management, weight loss,
physical activity, smoking cessation, and medication ad-
herence) and for different target groups, including adoles-
cents and young adults [2225].
Within a pre-post study in Switzerland, the acceptance
and potential effectiveness of a mobile phone-based
life-skills training program for substance use prevention
among non-smoking vocational school students was
tested [26]. This program was based on social cognitive
theory and addressed self-management skills, social
skills, and substance use resistance skills. Program par-
ticipants received up to 3 weekly text messages over
6 months. Active program engagement was stimulated
by interactive features such as quiz questions, message
and picture-contests, and integration of a friendly com-
petition with prizes in which program users collected
credits with each interaction. A total of 1067 vocational
students who owned a mobile phone and were not regu-
lar cigarette smokers were invited to participate in the
program. Of these, 877 (82.2%) participated in the pro-
gram and the associated study. Pre-post comparisons re-
vealed decreased perceived stress and increases in
several life skills addressed between baseline and the
follow-up assessment. The proportion of adolescents
with at-risk alcohol use significantly declined from
20.2% at baseline to 15.5% at follow-up.
Based on these results, showing high-level acceptance
and promising effectiveness of a mobile phone-delivered
life-skills training program among vocational school stu-
dents, a reasonable next step is to test the efficacy of this
interventional approach within a controlled trial. How-
ever, as the age of onset of substance use is strongly in-
creasing between the ages of 14 and 16 [5], it might be
even more appropriate to test this universal prevention
approach among secondary school students.
Within this study protocol, we describe a cluster rando-
mised controlled trial testing the efficacy of a similar mo-
bile phone-based life-skills training program to prevent
substance use among secondary school students.
Methods/design
Design and hypotheses
A two-arm cluster-randomised controlled trial will be
conducted to test the efficacy of the SmartCoach, a mo-
bile phone-based life-skills training program to prevent
substance use among secondary school students. The ef-
ficacy of the intervention will be tested in comparison to
an assessment only control group. The study partici-
pants will be assessed at baseline and at 6- and
18-months follow-up (Fig. 1). Our main hypothesis is
that the individually tailored intervention program with
a duration of 6 months will be more effective than as-
sessment only, to prevent the onset and escalation of
problematic alcohol and tobacco use at 18-months
follow-up.
Participants, setting and procedure
We will test the intervention in secondary school stu-
dents aged between 14 and 16 (grades 8 and 9). In this
age group the prevalence of experimental and regular
use of alcohol, tobacco and cannabis is increasing no-
ticeably [5]. However, only a minority has established
problematic or disordered substance use [5,27]. Further-
more, nearly all adolescents at this age are familiar with
how to use mobile phones and typically use them on a
daily basis. According to the latest representative survey
on media use in adolescents in Switzerland, 98% of the
adolescents aged 14 and 15 years own a mobile phone
and 98% use a mobile phone daily or several times per
week [20]. Secondary schools in the German speaking
part of Switzerland will be invited to participate in the
study by cooperating regional centres for addiction
prevention.
Employees of the above-mentioned centres for addic-
tion prevention will arrange information sessions with a
duration of 60 min in participating secondary school
classes during regular school lessons reserved for health
education. These information sessions will be led by jun-
ior scientist from the Swiss Research Institute for Public
Health and Addiction, who are experienced in the work
with young people, the provision of preventive interven-
tions and trained on the study and on the program to be
delivered.
The parents of the secondary school students in par-
ticipating classes will be informed at least 1 week in ad-
vance of this session. They will receive a letter including
information about the study and the intervention pro-
gram and the parents are asked to give written informed
consent to their childs participation in the study.
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Within the first half of the information sessions in the
school classes, the junior scientist will raise awareness on
theimportanceoflifeskillstoeffectivelycopewiththede-
mands and challenges of everyday life. For this purpose,
they will use video sequences demonstrating typical
stressors and demands for this age group (e.g., search for
an apprenticeship, exam stress, peer pressure for substance
use) and different strategies to cope with them. The import-
ance of emotional regulation skills and social competences
to effectively cope with these stressors will be discussed
based on case vignettes. Subsequently, the students will be
informed about and invited to participate in a study testing
innovative channels for the provision of life-skills trainings.
To ensure sufficient participation and, thus, representative-
nessofthesample[28], a reward of 10 Swiss Francs for
participation in each of the two follow-up assessments will
be announced.
Students (1) with minimum age 14, (2) who own a mo-
bile phone and (3) providing parental informed consent
will be invited to participate in the study. Using their own
or a provided mobile phone, informed consent will be ob-
tained online from the study participants. Subsequently,
they will be invited to choose a username, to provide their
mobile phone number and to fill in the baseline assess-
ment directly on the mobile phone.
Participants of the intervention group will receive add-
itional questions which are necessary for the tailoring of
the intervention content. Furthermore, for participants of
the intervention group, the mobile phone-based interven-
tion program and its association with a friendly competi-
tion will be described in detail. Subsequently, participants
of the intervention group will receive an individually tai-
lored web-feedback directly on their mobile phone (see
also section intervention). During the subsequent 6 months,
participants of the intervention group will receive the indi-
vidually tailored mobile phone-based life-skills training.
Participants of the assessment only control group will
be thanked for their study participation, they will be
Introduction in secondary school classes
Cluster randomisation
by school class
Assessment of inclusion criteria
Follow-up assessment month 6
Intervention group
Indiviudalised mobile
phone-based program
for 6 months
Minimum age 14, possession of a
mobile phone and informed consent
for study participation (students and
parents)
Assessment only
control group
Follow-up assessment month 18
Fig. 1 Study design
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informed about their group assignment and their reward
for participation in the follow-up assessment.
Follow-up assessments after 6 and 18 months will be
conducted by a research assistant, within the participat-
ing school classes, during regular school lessons and
using tablet computers. Computer-assisted telephone in-
terviews will be conducted by a research assistant when
assessments cannot take place during a school lesson be-
cause of vacations, class resolution, or study participants
absence from class.
Ethical review
The study protocol was approved by the Ethics Commit-
tee of the Faculty of Arts and Sciences at the University
of Zurich (approval number 18.6.5; date of approval
June, 21st, 2018). The trial will be executed in compli-
ance with the Helsinki Declaration.
Randomisation and allocation concealment
To avoid spill-over effects within school classes, we will
conduct a cluster-randomised controlled trial using
school class as a randomisation unit. Due to the hetero-
geneity of students in the different secondary schools,
we will use a separate randomisation list for each school
(stratified randomisation). Furthermore, to approximate
equality of sample sizes in the study groups, we will use
block randomisation with computer generated randomly
permuted blocks of 4 cases [29].
Junior scientists supervising the baseline assessment
will be blinded to the group allocation of school classes.
In addition, group allocation will not be revealed to par-
ticipants until they had provided their informed consent,
username, mobile phone number, and baseline data. Fur-
thermore, the research assistants who perform the
computer-assisted follow up assessments for primary
and secondary outcomes will be blinded to the group
allocation.
Sample size calculation
As this is the first study on the efficacy of a mobile
phone-based life-skills training for substance use preven-
tion, we could not rely our calculations on conclusive re-
sults of similar studies. Instead, our calculations were
based on the effect sizes of traditional face-to-face deliv-
ered life skills training programs in educational settings.
However, to account for the longer duration and higher
intensity of traditional life-skills trainings compared to
our mobile phone-based training, these estimates based
on the effect sizes of traditional face-to-face delivered
life skills training programs were revised downwards,
resulting in a more conservative estimation.
An estimation of the expectable effect sizes was based
on the results of a Cochrane Review on school-based pro-
grammes for preventing smoking [7] and on the efficacy
of a program for the prevention of binge drinking in ado-
lescents based on the Life Skills Training [30]. The
Cochrane Review revealed a statistically significant effect
in preventing the onset of smoking for combined social
competence and social influences curricula (six RCTs)
with an Odds Ratio of 0.49 (95% CI 0.280.87). The pro-
gram for the prevention of binge drinking in adolescence
based on the Life Skills Training revealed an intervention
effect on problem drinking at the 1-year follow-up, with
an odds ratio (OR) of 0.41 (95% CI 0.180.93), and at the
2-year follow-up with an OR of 0.40 (95% CI 0.220.74).
Based on these studies, and a slight downward correction,
an OR of 0.60 was expected for the main outcome
measures.
Based on an estimated OR of 0.60 and an expected
30-days-prevalence of problem drinking in 16 year-old
adolescents of 25% in the control group at the 18-month
follow-up (mean of prevalence in 15-year olds derived
from HBSC study [5] and in 17-year olds derived from
Addiction Monitoring [31]), a sample size of n=370 in
each study group would be required to have 80% power
for a χ
2
-test (α= 5%, 2-sided) in order to detect this dif-
ference based on a calculation using G-Power.
Based on an estimated OR of 0.60 and an expected
30-days prevalence of tobacco smoking in 16 year-old
adolescents of 22% in the control group at the 18-month
follow-up (mean of prevalence in 15-year olds derived
from HBSC study [5] and in 17-year olds derived from
Addiction Monitoring [31]), a sample size of n=410 in
each study group would be required to have 80% power
for a χ
2
-test (α= 5%, 2-sided) in order to detect this
difference.
As secondary school students are nested within school
classes, we additionally need to consider a potential de-
sign effect for the calculation of the sample size for our
study. Based on [26,32], an average cluster size of 13
study participants per school class and an intra-cluster
correlation coefficient of 0.05 could be expected. This
would result in a design effect of 1.60. Multiplying this
design effect by the required size for an unnested sample
(n= 410) results in a required sample size of n= 656 per
study group and a total of n= 1312 study participants.
Thus, based on the participation rates of the previous
MobileCoach studies [32,33] and the pre-post study on
a mobile phone-based life- skills training, approximately
100 secondary school classes are required to reach this
sample size.
Intervention program
Theoretical background and intervention contents
The intervention elements of the program will be based
on the Social Cognitive Theory [18,19]. This theory re-
lies on the Social Learning Theory, as it was founded on
principles of learning within the human social context
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[9], though it has also integrated several concepts from
cognitive psychology. Key concepts of this theory, which
will be addressed within the mobile phone-based pro-
gram are (1) outcome expectations (i.e., beliefs about the
likelihood and impact of the consequences of behav-
ioural choices), (2) self-efficacy (i.e., beliefs about ones
personal ability to perform a desired behaviour which
could be stimulated, for example, by mastery, experience
or persuasion); (3) observational learning (i.e., learning
new behaviours via exposure to them through interper-
sonal or media displays; e.g., through peer modelling);
(4) facilitation (i.e., providing strategies, tools, and re-
sources that make new behaviours easier to perform);
and (5) self-regulation (i.e., controlling oneself via moni-
toring, goal-setting, feedback, and self-instruction).
The contents of the mobile phone-based program will
rely on proven and widely-disseminated life-skills pro-
grams, like IPSY [11], ALERT [12] and Life Skills Train-
ing [13]. The program addresses (1) self-management
skills, (2) social skills, and (3) substance use resistance
skills. The program will be structured according to these
major contents with the individually tailored web-based
feedback and the mobile phone text messages in weeks
19 focusing on self-management skills, the messages in
weeks 1015 focusing on social skills, and the messages
in weeks 1620 focusing on substance use resistance
skills. Boosters for each of the components will be pro-
vided in weeks 2224.
Technological background
The intervention program will be developed using the
MobileCoach system. Technical details of the system are
described elsewhere [34,35]. The MobileCoach system
is available as an open source project on http://www.mo-
bile-coach.eu. Password protection and Secure Sockets
Layer (SSL) encoding are used to ensure the privacy and
safety of data transfer.
Individually tailored feedback
The individual tailored web-based feedback will be given
to study participants of the intervention group immedi-
ately after completion of the online baseline assessment
within the school classes. This feedback comprises 45
screens, including textual and graphical feedback on
stress in general, the individual level of stress in various
domains compared to an age- and gender-specific refer-
ence group, and individual applied and suggested coping
strategies. The feedback will use individual data gathered
at the baseline assessment on perceived stress in differ-
ent domains (school, leisure time, friends, family, and
social media) and on individual strategies for coping
with stress. Instruments for the assessment of stress and
coping strategies will be derived from the study Juvenir
4.0, a national survey on stress in adolescents with more
than 1500 participants [36]. Data of this survey will also
be used to provide an age- and gender-specific feedback
on the individual stress level.
Text messages
For a period of 6 months, program participants will re-
ceive between two and four individualized text messages
per week on their mobile phone. These messages will be
generated and sent by the fully-automated system.
Within the first 9 weeks, the messages will focus on
self-management skills; e.g., coping with stress, emo-
tional self-regulation or management of feelings of anger
and frustration. In weeks 1015, the messages will focus
on social skills; e.g., making requests, refusing unreason-
able requests, meeting new people. In weeks 1620, the
text messages will focus on substance use resistance
skills; e.g., recognizing and resisting media influences,
social norms of substance use or the associations of
self-management skills and social skills with substance
use. Boosters for each of the components will be pro-
vided in weeks 2224. The messages will be tailored ac-
cording to the individual data from the baseline
assessment and on text messaging assessments during
program runtime; e.g., on substance use or the individ-
uals emotional state.
To exploit the full potential of current mobile phones,
several interactive features, like quiz questions, tasks to
create individually-tailored if-then behaviour plans based
on implementation intentions, and message contests,
will be implemented within the program. Due to the
wide dissemination of smartphones in adolescents [20],
several messages will also include hyperlinks to audio
files (e.g., audio testimonials, motivational podcasts), as
well as to thematically-appropriate video clips, pictures
and related websites.
Tabl e 1shows a selection of the planned intervention el-
ements, which are based on concepts derived from social
cognitive theory [18,19] and the major contents of
widely-disseminated life-skills programs [1113]:
self-management skills, social skills, and substance use re-
sistance skills.
Prize draw
To stimulate active program engagement, program
use will be associated with a friendly competition,
which will allow program users to collect credits for
each interaction (e.g., answering monitoring text mes-
sages, participating in quizzes, creating messages or
pictures within contests, accessing video links inte-
grated in text messages). The more credits partici-
pants will collect, the higher their chances will be of
winning one of several attractive prizes which will be
part of a prize draw (10 prizes with the sum of 500
Swiss Francs) after program completion. Participants
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will be able to retrieve their number of credits com-
pared to the number of credits of other program par-
ticipantsof their group (similar starting date) at any
time from an individual profile page.
Assessments and outcomes
At baseline, demographic variables (age, sex, migra-
tion background), data on mobile phone use as well
as characteristics of the schools (location, type of
school) and school classes (level, size, number of stu-
dents present) will be assessed.
Baseline- and follow-up assessments will include
(1) Problem drinking in the preceding 30 days,
assessed by the short form of the Alcohol Use
Disorders Identification Test, the AUDIT-C [37].
This test comprises 3 items on (1) frequency of
alcohol consumption, (2) quantity of alcohol con-
sumption, and (3) binge drinking. Pictures will be
used to illustrate the quantity of a standard
drink, which corresponded to 1214 g of pure al-
cohol. Based on a validation study of a large Ger-
man sample, a cut-off of 5 will be used [38].
(2) 30-days point prevalence rate for smoking
abstinence (not having smoked a puffwithin
the past 30 days according to the criteria of the
Society for Nicotine and Tobacco Research [39]).
(3) Quantity of cigarettes smoked in the preceding
30 days by assessing the number of smoking days
and the typical number of cigarettes smoked per
smoking day.
(4) Cannabis use in the preceding 30 days assessed by
an item of the HBSC study [5] addressing the
number of cannabis consumption days.
(5) Perceived stress assessed by a four-item version [40]
of the Perceived Stress Scale [41]. This scale mea-
sures the degree to which students appraised situa-
tions as stressful over the preceding month.
(6) Interpersonal competences, assessed by the brief
version of the Interpersonal Competence
Questionnaire [42], addressing the following
domains of social competence: (1) initiation of
relationships, (2) negative assertion, (3) disclosure
of personal information, (4) emotional support, and
(5) conflict management.
The primary outcomes of the planned study are (1)
prevalence of problem drinking in the preceding 30 days
according to the AUDIT-C and (2) prevalence of
cigarette smoking in the preceding 30 days (having
smoked at least a puff according to the criteria of the
Society for Nictotine and Tobacco Research [39]).
Secondary outcomes are
Prevalence of cannabis use in the preceding 30 days
(having used cannabis at least once)
Quantity of alcohol use in the preceding 30 days
Quantity of cigarettes smoked in the previous
30 days
Table 1 Exemplary intervention elements of the mobile phone-based life-skills training
Concept
derived from
social
cognitive
theory
Content category
Self-management skills Social skills Substance use resistance skills
Outcome
expectations
Individually tailored information on pros of using self-management
skills to cope with stress.
Tailored information on the
pros of applying social skills,
e.g., making requests.
Information on pros of
resisting alcohol, including
social norms within an age-
and gender-specific reference
group.
Self-efficacy Videos demonstrating easily applicable strategies to cope with
negative emotions.
Contest on creating a bubble
text on refusing an
unreasonable request within a
given situation presented on a
picture.
Creation of if-then-plan for
resisting invitation for smok-
ing marijuana
Observational
learning
Interactive message contest on stress regulation strategies. Video showing exemplary
behaviour on individually
poorly developed social skills.
Video podcast showing peer
models who successfully
refused cigarette smoking.
Facilitation Creation of if-then-plans for coping with the currently most severely
affecting stress situation.
Podcasts introducing
conversational skills or
strategies for making requests.
Contest on creating a bubble
text on refusing an alcoholic
drink at a party presented on
a given picture.
Self-regulation Monitoring of and feedback on individual emotions. Monitoring of and feedback on
progress of individual social
skills.
Monitoring of and feedback
on individual alcohol use.
Haug et al. BMC Public Health (2018) 18:1102 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Frequency of cannabis use in the preceding 30 days
Perceived stress
Interpersonal competences
Data analyses
Generalized Linear Mixed Models will be used to test
intervention effects for binary outcomes and linear
mixed models for continuous outcomes [43,44]. These
models account for both fixed and random effects and
are particularly useful in analysing longitudinal and
nested data (e.g., time within students, students within
school classes). To test the efficacy of the intervention,
we will test the variables study group,timeand their
interaction study group x timeas predictors of the out-
come criteria assessed at follow-up. If necessary, we will
control for baseline differences by adding additional
baseline variables as covariates to the models. We will
conduct both (1) intention to treat analyses and (2)
complete case analyses considering all study participants
with available follow-up data. For ITT analyses, we will
use multiple imputation procedures as described else-
where [45].
Discussion
Substance use in adolescents and later adulthood and its
related consequences represent a serious public health
problem [27]. Although life-skills trainings were effective
in preventing the onset and escalation of both problem-
atic alcohol and tobacco use [7,11,30], the implementa-
tion and dissemination of the existing programs in
schools represent serious challenges as they require large
resources in terms of money and time [15]. In contrast
to comprehensive school-based curricula, training and
counselling via mobile phone is more economic and
matches with the lifestyle and communication habits of
the target group. Most adolescents are familiar with how
to use mobile phones and typically use them on a daily
basis for texting, taking photos, playing games etc. This
is the first study testing the efficacy of a mobile
phone-delivered life-skills training for substance use pre-
vention among adolescents within a controlled trial.
Given that this program proves to be effective, it could
be disseminated to various groups of adolescents, e.g. in
schools or leisure time settings. A translation of the
intervention content into other languages would easily
enable program dissemination to adolescents in other
regions and countries.
Abbreviation
AUDIT-C: Short form of the alcohol use disorders identification test
Acknowledgements
We would like to thank Andreas Filler and Tobias Kowatsch for their
technical assistance in using the MobileCoach platform for this project.
Funding
Funding for this study is provided by the Swiss National Science Foundation
(No. 10001C_179222/1). The funder has no role in study design, data
collection and analysis, decision to publish, or preparation of manuscripts.
Availability of data and materials
Not applicable.
Authorscontributions
SH and RPC were responsible for the study design. SH, RPC, MPS, and AW
designed the mobile phone-based intervention program. SH and RPC are re-
sponsible for the data collection. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
The study protocol was approved by the the Ethics Committee of the
Faculty of Arts and Sciences at the University of Zurich (approval number
18.6.5; date of approval June, 21st, 2018).
The parents of the secondary school students in participating classes are
asked to give written informed consent to their childs participation in the
study. Students providing parental informed consent will be invited to
participate in the study. Using their own or a provided mobile phone,
informed consent will be obtained online from the study participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 3 August 2018 Accepted: 14 August 2018
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... However, early interventions that incorporate skills trainings have also shown promising effectiveness [4]. Evidence for this effectiveness primarily stems from life skills trainings embedded in school curricula [5][6][7][8][9][10][11], whereas life skills trainings to promote mental health and prevent substance use in young adolescents are only recently being adapted to digital interventions as well as being tested [12][13][14][15][16][17][18]. This trend is mainly fostered by the difficulties that schools encounter when trying to implement life skills trainings in their curricula [9] and the personnel and financial resources that such programs require [19]. ...
... Data for this study were extracted from a 2-arm, parallel-group, cluster randomized controlled trial that used school class as the randomization unit, as detailed elsewhere [14,18]. ...
... The SmartCoach program combined (1) tailored web-based feedback to reduce the individual level of stress, which was delivered directly after completion of the baseline assessment, and (2) tailored mobile phone SMS text messages to promote self-management skills (block 1), social skills (block 2), and substance use resistance skills (block 3) over 6 months. The theoretical backgrounds of these intervention components are described elsewhere [14,18]. ...
Preprint
BACKGROUND Mobile phone–delivered life skills programs are an emerging and promising way to promote mental health and prevent substance use among adolescents, but little is known about how adolescents actually use them. OBJECTIVE The aim of this study is to determine engagement with a mobile phone–based life skills program and its different components, as well as the associations of engagement with adolescent characteristics and intended substance use and mental health outcomes. METHODS We performed secondary data analysis on data from the intervention group (n=750) from a study that compared a mobile phone–based life skills intervention for adolescents recruited in secondary and upper secondary school classes with an assessment-only control group. Throughout the 6-month intervention, participants received 1 SMS text message prompt per week that introduced a life skills topic or encouraged participation in a quiz or individual life skills training or stimulated sharing messages with other program participants through a friendly contest. Decision trees were used to identify predictors of engagement (use and subjective experience). The stability of these decision trees was assessed using a resampling method and by graphical representation. Finally, associations between engagement and intended substance use and mental health outcomes were examined using logistic and linear regression analyses. RESULTS The adolescents took part in half of the 50 interactions (mean 23.6, SD 15.9) prompted by the program, with SMS text messages being the most used and contests being the least used components. Adolescents who did not drink in a problematic manner and attended an upper secondary school were the ones to use the program the most. Regarding associations between engagement and intended outcomes, adolescents who used the contests more frequently were more likely to be nonsmokers at follow-up than those who did not (odds ratio 0.86, 95% CI 0.76-0.98; P =.02). In addition, adolescents who read the SMS text messages more attentively were less likely to drink in a problematic manner at follow-up (odds ratio 0.43, 95% CI 1.29-3.41; P =.003). Finally, participants who used the program the most and least were more likely to increase their well-being from baseline to 6-month follow-up compared with those with average engagement ( βs =.39; t<sub>586</sub>=2.66; P =.008; R<sup>2</sup> =0.24). CONCLUSIONS Most of the adolescents participating in a digital life skills program that aimed to prevent substance use and promote mental health engaged with the intervention. However, measures to increase engagement in problem drinkers should be considered. Furthermore, efforts must be made to ensure that interventions are engaging and powerful across different educational levels. First results indicate that higher engagement with digital life skills programs could be associated with intended outcomes. Future studies should apply further measures to improve the reach of lower-engaged participants at follow-up to establish such associations with certainty.
... Free, online interventions may overcome the aforementioned shortcomings, as they can reach larger and more diverse populations relatively easily, compared to traditional treatments, as was demonstrated in previous studies (Baumgartner et al., 2019;Haug, Castro, Wenger, & Schaub, 2018;Herrero et al., 2019;Weisel et al., 2018). Online interventions may also reduce other treatment barriers that can be present in offline interventions, such as unaffordability of traditional therapies, stigma, or feelings of shame for seeking help for PPU (Dhuffar & Griffiths, 2016). ...
... Online interventions may also reduce other treatment barriers that can be present in offline interventions, such as unaffordability of traditional therapies, stigma, or feelings of shame for seeking help for PPU (Dhuffar & Griffiths, 2016). In addition, online interventions have already demonstrated their abilities to reduce other individual and social treatment barriers, given that they can be used any time privately the treatment-seeking individual feels the need for help, they are cost-effective or free, and easy-to-use (Baumgartner et al., 2019;Haug et al., 2018;Herrero et al., 2019;Weisel et al., 2018). Despite recent calls for randomized controlled trials to examine the effectiveness of interventions for PPU (Griffin et al., 2021;Grubbs et al., 2020) and the advantages of online interventions, compared to traditional interventions, no prior study examined the efficacy of online interventions for PPU. ...
... Participants evaluated the intervention positively concerning its usefulness, understandability, appearance, and length, illustrating the acceptability of the intervention (Bowen et al., 2009). These findings corroborated the results of previous online interventions, suggesting that evidencebased, online self-help materials may reduce treatment barriers and provide free and easy-to-use tools to reduce problematic behaviors (Baumgartner et al., 2019;Haug et al., 2018;Herrero et al., 2019;Weisel et al., 2018). Still, based on participants' feedback, some changes in study design and content of intervention are suggested for future research. ...
Article
Full-text available
Background and Aims Despite problematic pornography use (PPU) being prevalent, no previous study has examined the effectiveness of evidence-based interventions for PPU, using rigorous methods. Using a two-armed randomized controlled trial study design, we examined the feasibility and initial effectiveness of a six-week online PPU intervention. Methods We recruited 264 participants (3.8% women, M age = 33.2, SD = 10.6) who were randomized and assigned to either the self-help intervention ( n = 123) or waitlist control condition ( n = 141), and completed self-report questionnaires at baseline and after the end of the intervention (six-week follow-up). Multivariable linear regression models were generated and tested on a complete case basis to investigate possible treatment effects. Participants provided quantitative and qualitative feedback regarding the intervention’s content and appearance. Results Participants evaluated all modules positively in the intervention in general. There were differential dropout rates (89.4% in intervention vs. 44.7% in control group) with an overall follow-up rate of 34.5%. The intervention group reported significantly lower levels of PPU ( P < 0.001, d = 1.32) at the six-week follow-up. Moreover, they reported lower pornography use frequency ( P < 0.001, d = 1.65), self-perceived pornography addiction ( P = 0.01, d = 0.85), pornography craving ( P = 0.02, d = 0.40), and higher pornography avoidance self-efficacy ( P = 0.001, d = 0.87) at the six-week follow-up. Discussion and Conclusions The present study was only a first step in rigorous treatment studies for PPU, but the findings are promising and suggest that online interventions for PPU might help reduce PPU in some cases, even without the guidance of therapists, by reducing treatment barriers.
... However, early interventions that incorporate skills trainings have also shown promising effectiveness [4]. Evidence for this effectiveness primarily stems from life skills trainings embedded in school curricula [5][6][7][8][9][10][11], whereas life skills trainings to promote mental health and prevent substance use in young adolescents are only recently being adapted to digital interventions as well as being tested [12][13][14][15][16][17][18]. This trend is mainly fostered by the difficulties that schools encounter when trying to implement life skills trainings in their curricula [9] and the personnel and financial resources that such programs require [19]. ...
... Data for this study were extracted from a 2-arm, parallel-group, cluster randomized controlled trial that used school class as the randomization unit, as detailed elsewhere [14,18]. ...
... The SmartCoach program combined (1) tailored web-based feedback to reduce the individual level of stress, which was delivered directly after completion of the baseline assessment, and (2) tailored mobile phone SMS text messages to promote self-management skills (block 1), social skills (block 2), and substance use resistance skills (block 3) over 6 months. The theoretical backgrounds of these intervention components are described elsewhere [14,18]. ...
Article
Full-text available
Background: Mobile phone–delivered life skills programs are an emerging and promising way to promote mental health and prevent substance use among adolescents, but little is known about how adolescents actually use them. Objective: The aim of this study is to determine engagement with a mobile phone–based life skills program and its different components, as well as the associations of engagement with adolescent characteristics and intended substance use and mental health outcomes. Methods: We performed secondary data analysis on data from the intervention group (n=750) from a study that compared a mobile phone–based life skills intervention for adolescents recruited in secondary and upper secondary school classes with an assessment-only control group. Throughout the 6-month intervention, participants received 1 SMS text message prompt per week that introduced a life skills topic or encouraged participation in a quiz or individual life skills training or stimulated sharing messages with other program participants through a friendly contest. Decision trees were used to identify predictors of engagement (use and subjective experience). The stability of these decision trees was assessed using a resampling method and by graphical representation. Finally, associations between engagement and intended substance use and mental health outcomes were examined using logistic and linear regression analyses. Results: The adolescents took part in half of the 50 interactions (mean 23.6, SD 15.9) prompted by the program, with SMS text messages being the most used and contests being the least used components. Adolescents who did not drink in a problematic manner and attended an upper secondary school were the ones to use the program the most. Regarding associations between engagement and intended outcomes, adolescents who used the contests more frequently were more likely to be nonsmokers at follow-up than those who did not (odds ratio 0.86, 95% CI 0.76-0.98; P=.02). In addition, adolescents who read the SMS text messages more attentively were less likely to drink in a problematic manner at follow-up (odds ratio 0.43, 95% CI 1.29-3.41; P=.003). Finally, participants who used the program the most and least were more likely to increase their well-being from baseline to 6-month follow-up compared with those with average engagement (βs=.39; t586=2.66; P=.008; R2=0.24). Conclusions: Most of the adolescents participating in a digital life skills program that aimed to prevent substance use and promote mental health engaged with the intervention. However, measures to increase engagement in problem drinkers should be considered. Furthermore, efforts must be made to ensure that interventions are engaging and powerful across different educational levels. First results indicate that higher engagement with digital life skills programs could be associated with intended outcomes. Future studies should apply further measures to improve the reach of lower-engaged participants at follow-up to establish such associations with certainty.
... Mobile training programs can be applied to provide training to parents [25]. The use of mobile training programs can make the learning process easier to access [26]. Speed in providing access, convenience, and timeliness in delivering learning materials can be a vital component of the training program to continue to grow [27]. ...
... The mobile training program is currently a trend used to provide training [26]. This convenience can be felt related to the provision of education and learning that makes access easy [59]. ...
... With its various potentials and advantages, the mobile training program is expected to be an alternative learning source that can increase the efficiency and effectiveness of the training process and results carried out [26]. Successful training is judged by the implementation carried out by the trainees [65]. ...
... Given social and individual barriers of traditional (off-line, face-to-face) treatment approaches for problematic cybersexual activities, such as feelings of shame and stigma or unaffordable costs (Dhuffar & Griffiths, 2016), scalable, science-based online interventions may be considered as an alternative for traditional interventions. Online self-help interventions may reduce traditional treatment barriers by providing a free and easy-to-use tool with high anonymity, privacy, flexibility, and short or no waiting time; and supporting participants' autonomy and self-efficacy, as it was demonstrated, for example, in the case of substance use and problematic gambling (Baumgartner et al., 2019;Haug, Castro, Wenger, & Schaub, 2018;Herrero et al., 2019;Weisel et al., 2018). However, online interventions have their disadvantages as well, such as high dropout rates (Rooke, Copeland, Norberg, Hine, & McCambridge, 2013;Schaub et al., 2015), or lower levels of adherence due to the "distant" nature of the interventions (e.g., lack of personal relationships, or limited individualization options) (Amann et al., 2018;Haug et al., 2018;Schaub et al., 2016). ...
... Online self-help interventions may reduce traditional treatment barriers by providing a free and easy-to-use tool with high anonymity, privacy, flexibility, and short or no waiting time; and supporting participants' autonomy and self-efficacy, as it was demonstrated, for example, in the case of substance use and problematic gambling (Baumgartner et al., 2019;Haug, Castro, Wenger, & Schaub, 2018;Herrero et al., 2019;Weisel et al., 2018). However, online interventions have their disadvantages as well, such as high dropout rates (Rooke, Copeland, Norberg, Hine, & McCambridge, 2013;Schaub et al., 2015), or lower levels of adherence due to the "distant" nature of the interventions (e.g., lack of personal relationships, or limited individualization options) (Amann et al., 2018;Haug et al., 2018;Schaub et al., 2016). Thus, online interventions should not be considered as replacements for traditional, face-to-face therapies but as an additional method that may provide treatment for those people who are hesitant or cannot afford to seek traditional treatment. ...
Chapter
The present chapter addresses the many faces of cybersex and describes the mental health challenges of various sexual activities using new technologies. This includes a range of sexual behaviors, from Internet use to sex with robots. In many cases, cybersex use is not problematic and not associated with personal distress or functional impairment. However, in those cases where people lose control over their cybersexual behavior or harm others we discuss diagnostic criteria as well as differential diagnoses and ways to evaluate the given behavior. The chapter also addresses the current state of research regarding the psychobiology as well as pharmacological and psychotherapeutic treatment options of cybersexual behaviors that are associated with mental health issues.
... Life skills are considered as the abilities for adaptive and positive behavior which enable individuals to deal with the demands and challenges of everyday life effectively [25]. Life skills training has preventive goals for controlling and managing problems, and is appropriate for group and individual interventions as an educational strategy [26]. These skills play a role in having a healthier life, communicating with others better, having higher decision-making power, solving problems in life, and providing good mental and social health [27]. ...
Article
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Objectives Suburbanization is associated with an individual's health. This study aimed to investigate the effect of life skills training on the hope and health of women referred to comprehensive health service centers in the suburbs of Khoy city. Study design quasi-experimental study (Pre-test/Post-test with a control group) Methods in this study, out of 5 comprehensive health service centers, two centers were selected as intervention and comparison groups, and from each center, 37 women were randomly selected. At first, both groups completed the Goldberg general health questionnaire and the Miller hope questionnaire, and the intervention group was taught life skills. At the end of the training, both groups were re-evaluated. Descriptive statistics such as frequency distribution and dispersion indices were used in data analysis. Mann-Whitney and Wilcoxon Signed Ranks Tests were used in inferential statistics. Results Group training in life skills did not significantly affect hope (P.value = 0.972) and various aspects of health (P.value = 0.421). Conclusions It seems that only interventions such as life skills training will not improve suburban women's hope and health. Perhaps improving social infrastructure and comprehensive living conditions in suburban areas will promote hope and health.
... To address this issue, youth prevention programs have been developed that focus on knowledge, skills, and behaviors predictive of substance use, guided by theory and prior research [25]. For example, existing prevention programs have targeted skills such as social resistance, self-management, communication, and decision making (e.g., [12,27,28,46]. Recently, scholars have examined the role of information in substance use decision processes. ...
Article
Objective This study explored the feasibility and effects of a game-based phone application for training health care workers to use personal protective equipment. Method A single-blind randomized controlled trial was conducted. All participants in the experimental group (n = 123) and the control group (n = 125) received 75 minutes of training and were provided with a video and a paper copy of the procedures. Participants in the experimental group used an additional game-based phone application to simulate the procedures. Results Participants in the experimental group practiced a median of 15 times (range, 14-19 times). The learning curve indicated that they needed at least 12 repetitions to master the skill. Score improvements (Z = -2.257, p = .024) in the experimental group were significantly superior to those in the control group, as were the incidences of procedural errors of hand hygiene (χ2 = 4.085, p = .043) and protective clothing (χ2 = 5.394, p = .02). Conclusion The game-based phone application simulation guided participants to practice enough times to master the skill, enhance their skill performance, and reduce the incidence of procedural errors. [J Contin Educ Nurs. 2022;53(5):212-220.].
Article
Background Digital technologies are increasingly integrating into people’s daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings. Objective This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps. Methods The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting–based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace. Results From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting–based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention. Conclusions The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings.
Article
Objective: Driving after drinking is a major concern among college students. The present study examined the association between interventionist use of positively valenced words and intervention outcomes in the context of a text-messaging based intervention aimed at reducing drinking after driving behaviors among college students. Method: Data analyzed in this manuscript come from a previously published randomized controlled trial of a brief intervention aimed at reducing alcohol-impaired driving. Participants were 25 college students who reported driving after drinking 2 or more drinks at least twice in the past three months. After completing baseline measures, participants were provided a brief personalized driving after drinking feedback intervention via text-messaging. Results: A moderation analysis revealed that the relationship between the number of drinks consumed prior to driving at baseline and the number of drinks consumed prior to driving at 3-month follow-up was moderated by the interventionist's use of positively valenced words during the intervention. Conclusions: These findings provide evidence that the use of positively valenced words by an interventionist during a text message-based intervention moderates intervention outcomes.
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Background: Substance use and misuse often first emerge during adolescence. Generic life skills training that is typically conducted within the school curriculum is effective at preventing the onset and escalation of substance use among adolescents. However, the dissemination of such programs is impeded by their large resource requirements in terms of personnel, money, and time. Life skills training provided via mobile phones might be a more economic and scalable approach, which additionally matches the lifestyle and communication habits of adolescents. Objective: The aim of this study was to test the acceptance and initial effectiveness of an individually tailored mobile phone–based life skills training program in vocational school students. Methods: Thefullyautomatedprogram,namedready4life,isbasedonsocialcognitivetheoryandaddressesself-management skills, social skills, and substance use resistance skills. Program participants received up to 3 weekly text messages (short message service, SMS) over 6 months. Active program engagement was stimulated by interactive features such as quiz questions, message- and picture-contests, and integration of a friendly competition with prizes in which program users collected credits with each interaction. Generalized estimating equation (GEE) analyses were used to investigate for changes between baseline and 6-month follow-up in the following outcomes: perceived stress, self-management skills, social skills, at-risk alcohol use, tobacco smoking, and cannabis use. Results: The program was tested in 118 school classes at 13 vocational schools in Switzerland. A total of 1067 students who owned a mobile phone and were not regular cigarette smokers were invited to participate in the life skills program. Of these, 877 (82.19%, 877/1067; mean age=17.4 years, standard deviation [SD]=2.7; 58.3% females) participated in the program and the associated study. A total of 43 students (4.9%, 43/877) withdrew their program participation during the intervention period. The mean number of interactive program activities that participants engaged in was 15.5 (SD 13.3) out of a total of 39 possible activities. Follow-up assessments were completed by 436 of the 877 (49.7%) participants. GEE analyses revealed decreased perceived stress (odds ratio, OR=0.93; 95% CI 0.87-0.99; P=.03) and increases in several life skills addressed between baseline and the follow-up assessment. The proportion of adolescents with at-risk alcohol use declined from 20.2% at baseline to 15.5% at follow-up (OR 0.70, 95% CI 0.53-0.93; P=.01), whereas no significant changes were obtained for tobacco (OR 0.94, 95% CI 0.65-1.36; P=.76) or cannabis use (OR 0.91, 95% CI 0.67-1.24; P=.54). Conclusions: These results reveal high-level acceptance and promising effectiveness of this interventional approach, which could be easily and economically implemented. A reasonable next step would be to test the efficacy of this program within a controlled trial.
Article
Evidence-based preventive interventions for adolescent substance use, violence, and mental health issues are increasingly being adapted and disseminated internationally. In the present paper, we report the results of an effectiveness study that was part of a comprehensive initiative by a coalition of health promotion organizations in the Lombardy region of Italy to select, culturally adapt, implement, evaluate, and sustain an evidence-based drug abuse prevention program developed in the USA. Findings are presented from a large-scale effectiveness study of the Life Skills Training prevention program among over 3000 students attending 55 middle schools in Italy. The prevention program taught drug refusal skills, antidrug norms, personal self-management skills, and general social skills. Relative to comparison group students, students who received the prevention program were less likely to initiate smoking at the post-test and 2-year follow-up, and less likely to initiate weekly drunkenness at the 1-year follow-up. The program had direct positive effects on several cognitive, attitudinal, and skill variables believed to play a protective role in adolescent substance use. The findings from this study show that a drug abuse prevention program originally designed for adolescents in the USA is effective in a sample of Italian youth when a rigorous and systematic approach to cultural adaptation is followed that incorporates the input of multiple stakeholders.
Article
Objective: To test the efficacy of a combined web- and text messaging-based intervention to reduce problem drinking in young people compared to assessment only. Method: Two-arm, parallel-group, cluster-randomized controlled trial with assessments at baseline and 6-month follow up. The automated intervention included online feedback, based on the social norms approach, and individually tailored text messages addressing social norms, outcome expectations, motivation, self-efficacy, and planning processes, provided over 3 months. The main outcome criterion was the prevalence of risky single-occasion drinking (RSOD, defined as drinking at least 5 standard drinks on a single occasion in men and 4 in women) in the past 30 days. Irrespective of alcohol consumption, 1,355 students from 80 Swiss vocational and upper secondary school classes, all of whom owned a mobile phone, were invited to participate in the study. Of these, 1,041 (76.8%) students participated in the study. Results: Based on intention-to-treat analyses, RSOD prevalence decreased by 5.9% in the intervention group and increased by 2.6% in the control group, relative to that of baseline assessment (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.44-0.87). No significant group differences were observed for the following secondary outcomes: RSOD frequency, quantity of alcohol consumed, estimated peak blood alcohol concentration, and overestimation of peer drinking norms. Conclusions: The intervention program reduced RSOD, which is a major indicator of problem drinking in young people, effectively. (PsycINFO Database Record
Article
Purpose of review: Alcohol and other drug use are major contributors to the global burden of disease. Prevention is critical and evidence is beginning to support the use of online mediums to prevent alcohol and other drug use and harms among adolescents. This study aims to expand the evidence base by conducting a systematic review of recent universal prevention programs delivered by computers and the Internet. Recent findings: A total of 12 papers reporting outcomes from trials of nine universal online prevention programs were identified. Of the identified interventions, five targeted multiple substances, two focused solely on alcohol, one targeted only cannabis and one primarily addressed smoking. The majority of programs were delivered at school; however one was implemented in a primary care setting. Six programs demonstrated significant, but modest, effects for alcohol and/or other drug use outcomes. Summary: Evidence to support the efficacy of computer and Internet-based prevention programs for alcohol and other drug use and related harms among adolescents is rapidly emerging, demonstrating that online prevention is an area of increasing promise. Further replication work, longer-term trials and attempts to increase the impact are required.
Article
During puberty, when young people are completing their education, transitioning into employment, and forming longer-term intimate relationships, a shift in emotional regulation and an increase in risky behaviour, including substance use, is seen. This Series paper considers the potential effects of alcohol, tobacco, and illicit drug use during this period on: social, psychological, and health outcomes in adolescence and young adulthood; role transitions, and later health and social outcomes of regular substance use initiated in adolescence; and the offspring of young people who use substances. We sourced consistent support for causal relations between substance use and outcomes and evidence of biological plausibility from different but complementary research designs. Many adverse health and social outcomes have been associated with different types of substance use. The major challenge lies in deciding which are causal. Furthermore, qualitatively different harms are associated with different substances, differences in life stage when these harms occur, and the quality of evidence for different substances and health outcomes varies substantially. The preponderance of evidence comes from a few high-income countries, thus whether the same social and health outcomes would occur in other countries and cultures is unclear. Nonetheless, the number of harms that are causally related to substance use in young people warrant high-quality research design interventions to prevent or ameliorate these harms.
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Substance use in young people (aged 10-24 years) might disrupt key periods of transition that occur as the adolescent brain undergoes cognitive and emotional development, and key psychosocial transitions are made. Adolescence is the peak time for initiation of substance use, with tobacco and alcohol usually preceding the use of illicit drugs. Substantial variation is noted between countries in the levels, types, and sequences of substance use in young people, indicating that a young person's use of substances depends on their social context, drug availability, and their personal characteristics. The Global Burden of Disease (GBD) 2013 study suggests that the burden attributable to substance use increases substantially in adolescence and young adulthood. In young men aged 20-24 years, alcohol and illicit substance use are responsible for 14% of total health burden. Alcohol causes most health burden in eastern Europe, and illicit drug burden is higher in the USA, Canada, Australia, New Zealand, and western Europe. Large gaps exist in epidemiological data about the extent of drug use worldwide and much of what we know about the natural history of substance use comes from cohort studies in high-income countries undertaken decades ago, which hinders effective global policy responses. In view of the global epidemiological transitions from diseases of poverty to non-communicable diseases, the burden of disease and health risks among adolescents and young adults is likely to change substantially, in ways that will no doubt see substance use playing an increasingly large part.
Article
We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision—which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.