Introduction
The problem of drug use and abuse attracted great public concern, which resulted in a national clamor for influential prevention and intervention programs. These programs should also prevent progression of the problem from abuse to addiction, and center on the problems associated with substance use and abuse whether behavioral, criminal, psychological, or health problems. Various programs ranging from simple one time intervention (in a single area locality) to nationwide network programs developed to address these objectives. These programs’ arrays of any range share the lack comprehensive and reliable evidence that they work effectively. In addition, the lack of information on epidemiology and etiology of substance abuse in rural and frontiers areas holds back informed decision making about intervention strategies (Robertson, 1997).
In an extended review, D’Onofrio (1997, in Robertson et al [editors] pp. 250-346) inferred the pattern of alcohol use among adolescents is similar across different areas considering population density. Further D’Onofrio (1997) studied the limited literature of adolescent substance use in rural areas and suggested that various risk factors like personality characteristics, peers and family influence, and age of initiation are similar to those in urban areas. Despite the likenesses in epidemiology and etiology of adolescent substance use across different areas there is no or little evidence that universally designed prevention programs can be applied to different areas’ setting with success. Thus, there are two conflicting viewpoints; one argues that such programs can be applied with success if proper procedural methods are followed. Another outlook states that community tailored prevention programs should be adopted according to the risk and protective factors of that community (D’Onofrio, 1997).
In 2003, Johnston and colleagues (NIH publication number 03-5374) analyzed data from the 2002 Monitoring the Future Study about adolescents substance use. They inferred that overall pattern of drug use of eighth to 12th graders is nearly the same across areas, and the trend remains consistent in elder adolescents. The data also confirmed that adolescents remain a high risk group for drug use. They recognized a major criticism to universal prevention programs is the lack of focus on community and environmental characteristics. They finally suggested the basic principle to success is to integrate multifaceted prevention-intervention programs with specific community settings.
In a previous work the researcher displayed personal experience working on Botvin’s Life Skills training program for prevention of adolescent substance use in a frontier community (Lake County, Oregon). The aim of this dissertation is to further expand the research about the scope of adolescent substance use providing a brief outlook on various societal dimensions and different strategies for prevention and control of adolescent substance use. Then to provide a detailed analysis of the work done in Lake County and interpret these results to examine the applicability of Botvin’s Life Skills in a frontier community.
Dimensions of community
A community is a construct (a structure or a model) and it is not just the people living in. Defining a community in sociological terms, it is a social model where its members have a common array of shared interactions, and behaviors, which have a common meaning and prospects. Communities are dynamic builds since interactions, and mobilization link communities irrespective of size, facilities, or economic differences. In urban areas, there are multiple communities based on two main factors, first is the ethnic, linguistic, or religious heterogenicity of the population, second is the mobilization from rural and suburban communities for better economic, or technological opportunities. The factors may account for the sociological differences between urban, rural and frontiers communities. The use of the word dimension instead of parts (for example) implies that we look at analytical categories and not observable parts of the community. One method of analysis is to look at differences or diversities that break a community into categories (Bartle, 2007).
Cultural diversity and adolescent substance use prevention
Adolescent substance use prevention is a message and like any other message it has to adapt to situation, audience, other communicators, context and topic. Since effectiveness remains the main objective of any prevention program, there are two arguments about the way to impose such programs. First is to set up a universal program, but most researchers; however, favor imposing programs with the potential of modification to suit local communities’ culture assuming this provides maximum program effects (Hecht and Krieger, 2006).
Schools are the natural primary site to deliver adolescent substance use prevention programs. In elementary and middle schools most children and adolescents can be reached whereas in high schools dropout is an obstacle to reaching target audience. Therefore, preventive programs have to acknowledge that schools reflect the cultural as well as other facets of diversity in the US (Hecht and Krieger, 2006).
Elliot and Mihalic (2004) reported most teachers consider cultural diversity a limitation in applying most substance use prevention programs, and hold themselves responsible for adapting the programs to meet the students’ diversity. Thus culture base of a prevention program is the foundation of a successful prevention message. However, standardization of the type and extent of modifying the prevention program are important considerations to look at.
The communication accommodation theory provides a theoretical viewpoint to support cultural adaptation of prevention programs. The theory explains how diversity works in an interpersonal background and argues that interpersonal cultural diversity influence interaction among people. The theory puts forward three possible mechanisms for cultural adaptation, first is maintenance where communicators observe the difference and maintain its level. Second mechanism is divergence, which occurs on rejection others’ identities then the communication pattern has to change. Third is convergence, where modification pattern may result in under or over modification either is a relevant issue of the effectiveness of the prevention message (Gallois and others, 2005).
Resnicow and colleagues (2000) defined cultural sensitivity of a prevention message as the level cultural characteristics of a target population are integrated in a prevention program. They defined cultural competency as the ability of individual (mainly practitioners) to practice interpersonal cultural sensitivity. Culturally designed preventions and intervention are those adapted to the cultural characteristics of the community, and culturally based prevention programs are those using cultural characteristics to stimulate behavioral changes (Resnicow and others, 2000).
Generational diversity and adolescent substance use
Addressing the needs and differences of age groups is important to harvest the benefits of whatever policy, prevention program or organizational performance. Research pointed to age as an important deciding factor for needs, values and extent of accepting sociocultural norms and that members of each group have separate arrays of values, attitudes, and behaviors (Columbia, 2005).
Adolescent represent a vulnerable age group because of the rapid biological changes, remarkable individual variation, and growing to developmental and cognitive maturity. Other distinctive features are lack of feeling of authority, and dependence on adults for taking informed decisions. Thus, the principle of (one size fits all) is not suitable when planning healthcare or prevention for adolescents. On the other hand, adults (researchers, family, or communicators) must be aware and responsible and share decision making with adolescents (Turner, 2005). Researcher recognized two phases of adolescence early and late, the limiting age varies as the classification depends on the rate of developmental and cognitive growth. The differences between the two phases are the degree of attention to adults, parent-adolescent relationship, the cognitive processes leading to decision making, degree of attention to reciprocal relationships. It is noticeable that media particularly television use is greater in early adolescence (Gullotta et al, 2005).
The first question should prevention programs be designed specifically or modified to meet the characteristics of younger or elder adolescents. Williams and colleagues (2002) argued that a theoretically reliable and effective health psychology research for prevention or treatment should be based on a developmental outline. They inferred that adolescent’s prevention intervention programs must be specifically designed, highlighting that in this stage adolescent establish their life long configuration of self-management and adjustment. They suggested a three steps prevention programs design for adolescents, primary prevention aiming at modifying risk factors before the onset of the disorder. Secondary prevention should aim at early identification and intervention to abort the problem before progressing to a major one, in terms of substance use, secondary prevention should prevent the progression to abuse or addiction. Tertiary prevention centers on preventing conditions that may result in lasting or irreversible damage as moving to illicit drugs or associated health hazards to substance use (Williams and others, 2002). About intervention, Kaminer (2005) showed that group intervention particularly if including adolescent with problem behavior can produce iatrogenic effects on all participants because of heterogenicity. Kaminer (2005) inferred that to enhance group intervention an attention to preventing, reducing, and controlling such iatrogenic effects in heterogeneous groups should be made.
The second question would be do age differences between parents or teachers and adolescents minimize their role on prevention so to give peers a leadership role than adults. Cuijpers (2002) responded to the hypothesis that peer led substance abuse prevention programs are more successful than adult led school drug prevention programs conducting a meta analysis of the studies compared results of both categories. Cuijpers (2002) noticed that results differ variably from minimal to significant differences; however, the author concluded that this variation of results is because leadership constitutes one factor among other factors that determine prevention program effectiveness. Wood and colleagues (2004) examined the peer variables (alcohol offers, modeling, and perceived norms) compared to parents’ (monitoring, values, and attitudes) in a group of (556) late adolescents on alcohol use. Stratified regression analysis of questionnaires results showed that both peers and parents influence alcohol use, however, higher levels of parent-adolescent involvement link to weaker peer influence. They inferred that parents can still exercise an influential role in late adolescents drinking behavior.
Gender diversity and adolescent substance use
Over the past few years, research showed there are differences between male and female substance use and abuse. Spooner (1999) suggested the age of initiation of alcohol use in males is less than that in females, further; males tend to drink heavier and experience more alcohol related problems than females. The National Institute on Drug Abuse suggested these differences have an impact on drug abuse and progression to dependence; moreover, the differences should have an impact on prevention programs and intervention modalities (NIDA, 2000). The explanation was that males have a greater opportunity to use drugs; however, NIDA research showed that tendency differs, whereas males are abusers to alcohol and marijuana, females are more abusers to sedatives. Other social factors that contribute to this difference were females’ increased rates of education drop out and lesser employment rates (NIDA, 2000). Thus, the problem of drug abuse in females can be looked upon separately as female adolescent substance abuse syndrome (Dakof, 2000). In addition, Dakof (2000) inferred males and females referred to treatment present different clinical features of drug abuse. Lynch and colleagues (2002) looked into the biological basis of male and females tendency differences of drug abuse and inferred that evidence suggests there are differences in biological response to drugs, long-term effects, causes, and correlates of drug abuse.
Low enforcement as a diverse culture
Many adolescent substance prevention programs include law enforcement concept, thus under standing low enforcement as a culture may highlight evaluation of different programs. Shusta and colleagues (2008) recognized lack of trust between police and society as a whole as a community sub culture. They identified the attitude of some police officers as a cause of encouragement for this distrust; further because of distrust, police members look to each other for primary support. Shusta and colleagues (2008) suggested that police officers tend to develop their own culture affected by the work stresses and anxiety. Adding this to their tendency to interpret behavior, motivation, and illegal activity from their cultural point of view creates controversial viewpoints about interpretation of law and its enforcement. In the lights of the diversity of the society, this creates a challenge in law enforcement (Shusta et al, 2008).
Dent and colleagues (2005) examined the level of availability of alcohol in 92 Oregon state communities in relation to enforcement laws as predictors of adolescent alcohol use. Thus, they examined the link between strategies of restricting access and enforcement of possession laws on adolescents alcohol use. There were four outcome measures examined, frequency of alcohol use within 30 days of the study, use of alcohol at school, binge drinking, and drinking and driving. Their results displayed a correlation between all four outcome measures and the rate of illegal alcohol sales. Besides, the level of enforcement of possession influenced significantly the rate of expansion or contraction of using different sources of alcohol sales in a community. Although they recognized that data are epidemiological in nature based on observation from questionnaire sheets subjected to individual and societal variation, yet, they inferred there is experiential support for efforts to control alcohol under age sales and possession enforcement.
Summary on social epidemiology of adolescent substance use
Adolescent substance use is in the center of interest of any academic specialties (sociology, epidemiology, psychology and public health); research suggested that no single discipline can explain the causes, risk behavior, or outcomes of the problem. Social epidemiology focuses on the social factors that characterize the population distribution of substance use behavior. Socio-epidemiological research is defective in evaluating the link between background variables like neighborhood socio-economic conditions, isolation, discrimination and adolescent substance use. In addition research suggests that endogenous factors (genetic or biological) alone can not be held responsible for causing the problem. It is the combination between exogenous (social, economic, or educational) and the endogenous factors that shape adolescents’ risk behavior for substance use and abuse (Galea et al, 2005).
Volume of the problem
Brain Institute, University of Florida (2007) reported that in 2001, 1.9 million adolescents between 12-17 years were heavy drinkers (<14 drinks a week or 4-5 drinks per setting for males, and 7 drinks a week or 2-3 drinks per setting). Binge drinkers (< 5drinks a setting) in the same age group were 4.4 millions and underage alcohol users are 20% of alcohol consumers across the US. Among 9th To 12th grade adolescents, 75% had at least one drink in the last month. In 2003 the National Survey on drug use and health reported that binge drinking rates were 0.9% among adolescents at age 12 years. At 13 years, it was 2.2% at, 7.1% at 14 years and escalating to reach almost one fourth of adolescents at 17 years. In 2004, the Future Monitoring Survey reported that rate of alcohol among adolescents nationwide did not change from the previous survey in 2003 (Evelyn and McKnight 2007).
In 2008, the National Survey on Drug Use and Health (2007) reported that tobacco use among adolescents decreased compared to 2002 results regarding cigarette smoking, but smokeless tobacco rate increased in the same period. In 2007, 1.8% of adolescents between 12 to 13 years were cigarette smokers, between 14 and 15 years, 8.4% of adolescents were cigarette smokers, the rate escalate to reach 18.9% of adolescents between 16 and 17 years. In the same report, the rate of illicit drug use among adolescents aged 12 to 13 years was 3.3% rising to 8.9% at 14 to 15 years, and 16% among 16 to 17 years adolescents. The report shows that the ratio of those whose first illicit drug used was a tranquilizer increased from 2.4% (in 2002) to 6.5% in 2007 (Office of Applied Studies, 2008).
The US frontier community extends over half the land area of the US with population less than 4% of the total US population. Despite that, frontier population is poorer (the poorest 50 US counties are frontiers), depending more on agriculture, and less medically insured. Frontiers adolescents are subjected to the same stresses and temptations as their counterparts in urban areas. The US Census bureau uses the term metropolitan and non-metropolitan areas, however, many researchers use other terms to define frontiers (like population density less than 1000/ square mile) (Frontier Education Center, 2003). Data collected by the American Drug and Alcohol survey and Prevention planning survey on 7th, 8th, 11th, and 12th grade adolescent in nine rural communities showed adolescents living in frontier area to small cities are equally influenced by alcohol and other substances. Exogenous risk factors like family conflicts, having friends who are drug users (peer effect) appear to influence rural and frontier adolescents in these areas and are positively correlated to alcohol use. In addition, economic uncertainty and changes in social patterns and community interconnection were important factors. Among the relevant endogenous factors poor adjustment to school, and depression and the need for excitement (for females) were the most common (Frontier Education Center, 2003). However, the report acknowledged that generalization on rural and frontier adolescents’ trends of substance use can not be drawn from these results as the rates differ among individual rural or frontier communities (Frontier Education Center, 2003).
An overlook on risk and protective factors
An understanding of the changes that occur during adolescence and the theories of adolescent substance use should explain risk and protective factors specific to this age group. Behavioral changes in response to re-adjustment, new stresses and anxieties characterize adolescence; it is a period when identity is established in preparation to practice new roles in life. During this stage, practicing adults’ behavior shifts from play to actual behavior and dependence on parents decreases while reliance on peers increases. Another characteristic of adolescence is the increased tendency to take risks either for experimentation or excitation. There are two theories that may explain adolescent substance use (Langrod and others, 2004).
Social Learning theory
The basic elements of this theory are adolescents learn through sensationalist observation of role models behavior and the outcome of this behavior. Thus, role models help adolescents to shape their beliefs about what is normal, popular, or acceptable behavior. However, personal factors like knowledge, personality, skills, and aims may alter adolescents’ vulnerability to role models effects. The theory, therefore, highlight the importance of self-regulatory mechanisms to alter role model effects. Role models can be parents, peers, or siblings where elder peers and siblings play a more important role and are high-status role models (Langrod and others, 2004).
Problem behavior theory
This theory recognizes that behaviors acceptable for adults as age specific but prohibited for adolescents are considered as signs of shifting to maturity. Such a behavior may help adolescents to achieve certain aims like impressing their peers or coping anxiety or failure. Thus according to this theory, substance use is functional or is an instrument to achieve certain objectives. The main problem is if such a behavior succeeds in achieving an aim (as impressing peers); it is difficult to put it out without finding an alternative (Langrod and others, 2004). Kim and others (1995) inferred that unless adolescents learn alternative ways to achieve their aims, substance use may be impossible to modify results of intervention prevention programs. Looking at both theories, there is noticeable complex multiplicity of risk factors contributing to adolescents’ substance use problem, and that they can change through stages of adolescent development. Besides, it is difficult to decide the mechanism of interaction of risk factors ending up with substance use problem (Beman, 1995).
Social identity theory
This theory provides a slightly different viewpoint on social influences that centers on the adolescent’s self-conception as a member of a group and the classification of different social groups. Based on this theory, an adolescent self-conception is a mixture of various self-images that follow a scale of images from (as an example I drink beer) to (I am a member or belong to a group that drink alcohol). The degree where an adolescent social identity takes the priority in a given situation is decisive in shaping the risk behavior. Further, adolescents integrate their social identity to the group’s identity (Kobus, 2003).
Adolescents substance use risk factors
Adolescent substance use risk factors are four main groupings. First are cognitive and personal attitudinal risk factors, which are centered on awareness of the negative outcomes of substance use, they link to personal capabilities and decision making competency (Griffin and others, 2001). Second is personality factors, Sussman and colleagues (2000) reported many personality disorders correlated to adolescents’ substance use like low self-esteem, low social and self-confidence. These adolescents are characteristically impetuous, insubordinate, and more anxious; however there is common characteristic personality pattern to describe them (Sussman et al, 2000). Further, many research studies link personality and psychiatric morbidity to substance use and establish a significant link between the development of conduct behavioral disorders and substance use (Langrod and others, 2004). Third are sociocultural factors, family attitudes, behavior, and management style are strong influential factors that correlate positively to adolescents substance use. Parents’ attitudes (tolerance) to substance use, the quality of parents-adolescent relationship, lack of involvement in adolescents, activities, and use of guilt feeling as a motivation are all blamed for substance use. Many researchers believe that peer effect is stronger especially at the adolescent stage of development, specifically in initiating experimentation, and providing support for use particularly if adolescents are involved in social networks. Other social factors to consider are socioeconomic level and work involvement during school study (Langrod and others, 2004). Since cultural values are reflected in family and community consistency, supervision, and monitoring of adolescent behavior and relationships, thus, they affect initiation and the course of adolescent substance use. The society look to ethnic diversity has a considerable effect on the risk of minority adolescent substance use (Langrod and others, 2004). Genetic influence on adolescent substance use is evident from studies on monozygotic, dizygotic, and adopted twins. Also studies shows that adolescent with positive family history of substance use are at higher risk to develop substance use. Biological markers associated with high risk include alcohol dehydrogenase deficiency (common in Asians), and reduced amplitude of certain waves (P3 wave) in evoked response neurological testing (Langrod and others, 2004).
Adolescents substance use protective factors
Research on protective factors received less research attention, family religious culture mediated to adolescent represent a strong protective factor. In addition, emotional support to adolescents through open parent-adolescent communication style, and flexible monitoring of peer activities are protective techniques. Involvement in organized school activities and school academic achievements are also protective factors (Langrod and others, 2004).
As indicated in the report of the Frontier Education Center (2003), there is scarcity of research on risk and protective factors influencing frontiers adolescents. And most research studies focus on American Indians and Alaska natives who have particular sociocultural environment. Thus, conclusions about adolescents’ risk and protective factors made from these studies are not applicable to all frontiers adolescent (Hawkins and others, 2004).
Factors affecting relapse of substance users
Relapse to substance use or abuse is the event of returning to drug abuse and is a process that takes place over a period of time. It is more common with drug addiction or dependence than with drug use, and it is the result of failed intervention or treatment. Thus, relapse rates depend on the type of intervention or treatment directed to an adolescent, the method of detecting relapse. The main causes are genetic and biological, persistence of stressful socioeconomic factors, unhealthy peer effect, or failure of protective family environment. Theoretical explanation of relapse can be in both social learning theory, and problem behavior theories (Tims and Leukefeld, 1986).
Relapse prevention is currently based on the cognitive behavioral hypothesis, which is in the domain of psychologists (Witkiewitz and Marlatt, 2004). However, since relapse is an individual’s return to substance use it is different in that further research needs to focus on the impact of socioeconomic factors on a particular adolescent trait more prone to relapse. Besides, the mechanism of interaction between sociocultural factors and genetic or biological factors needs further study (Galea and others, 2004).
Prevention and interventions adolescent substance use programs: strategies and approaches
The terms intervention, prevention and treatment are often used interchangeably, despite similarities in strategies and approaches, yet, there are differences in concepts and methods. Intervention refers to a range of actions aiming to reduce or improve a specific problem behavior as substance use. These actions vary in invasiveness from repeated short conversations between an adolescent and a concerned related person (parent, teacher, or a physician). More formal actions include early intervention programs having the objective of intervening before substance use develops to more problematic behavior (abuse, dependence or addiction). They also include intensive treatment programs targeted to stop current substance use and maintain self-restraint. Prevention programs aim to stop substance use at the onset (initiation), thus, contextually; prevention is one form of intervention (Winters, 1999).
In specific terms, intervention aims to identify current or potential problems of substance use then to motivate those at high risk to change their behavior problem. Treatment aims to provide specific interventions, which address specific needs of adolescents showing problems associated with substance use (Henry-Edwards and others 2005).
Prevention is an active process centered on generating conditions that promote and support well-being. It uses evidence-based approaches, skills, and outlined strategies to reduce risk factors, in simple terms it means to prevent conditions leading to substance use from occurring or influencing adolescents (Carboni, 2007). Prevention can take many forms, universal prevention designed to get to an entire population (adolescents) with neither consideration nor prior assessment to individual risk factors. Substance abuse educational program targeting all school children in a district is an example to universal prevention programs. Selective prevention targets a subpopulation group known to be at higher or have specific risk factors of substance use, skills training prevention program is an example to this category. Indicated prevention programs are directed to individuals showing early signs of early substance use but did not reach the stage of clinical diagnosis. Such programs include some intervention concepts as changing a problem behavior associated with substance use (Carboni 2007).
Toumbourou and colleagues (2007) performed a systematic literature review on intervention prevention strategies aiming to reduce the harm produced by substance use. The general concept of intervention prevention strategies is to reduce substance demand and supply to adolescents.
Intervention strategies and approaches
There are three basic intervention strategies; regulatory, aiming at supply reduction, it uses low enforcement, and policing to reduce and control substance supply to adolescents. Developmental intervention strategies aim at improving the surrounding environment to achieve healthy adolescent development. Early screening and brief intervention strategy targeting high risk adolescent substance users in the form of brief interventions motivating them to stop substance use (Toumbourou and other 2007).
The Substance Abuse and Mental Health Administration identified three intervention approaches for adolescent substance use and abuse (SAMHA, 2002). Brief interventions centered on addressing and developing motivation to change problem behavior and provide skills to meet these aims. Two techniques are commonly in use; first is cognitive behavioral therapy based on social learning theory, and second is motivational interviewing. Family-based therapies with multidimensional family therapy, brief strategic family therapy and multisystem therapy being the most researched three techniques. The third approach is community-based interventions, which provide mental health services within the normal environment of adolescents (school or neighborhood settings). Examples to this intervention approach are adolescents’ community reinforcement approach, and student assistance program (SAMHA 2002).
Prevention strategies and approaches
The fundamental strategy of adolescent substance use prevention programs is to manage driving risk and protective factors whether modifiable or not aiming to change one or more of these factors. The factor (s) a prevention program aims to change is the program content (Hansen and colleagues, 2007).
Effective prevention approaches of adolescents substance use should aim at adolescents, their families, neighborhood, and schools and incorporate strategies targeting these influences. First approach is to improve adolescents’ social and critical thinking skills, second is encouraging safe and supervised recreational, enrichment, and leisure activities especially for adolescents at risk. Third is early identification and referral of adolescents at high risk, which is primarily an activity of teachers, school nurses or attendants. In the school or classroom domain, the principal prevention approaches are school community contribution to the design and delivery of a prevention program. There should clear school policies deterring substance abuse, and school communication campaigns to support behavior norms about substance use. Finally, improvement of school management techniques and instruction methods to promote student engagement in the learning process and improve their academic performance is a fruitful prevention approach (Dash and others, 2003).
In 2007, Hansen and colleagues examined substance use prevention programs available on the national registry of effective programs from 2003. They identified a variety of content elements with no content field included in all programs, and that most programs include different approaches in a combined mixture. Based on this finding, they suggested that most programs are not theory based rather they are fitting theoretical ideas of the program developer. Therefore, program evaluation studies do not support theory or come up with acceptable theory modification. Some may suggest there is a need for rational theories to explain substance use and prevention strategy. However, the challenge is the variability of risk and etiologic factors that cannot be included comprehensively in such a theory. They inferred the real need is to cross the gap between theory and practice.
Revisiting Botvin Life Skills Training
Based on research on human development theories, Mangrulkar and colleagues (2001) categorized key life skills into three groupings. First are social skills, which include communication, negotiation, assertiveness, interpersonal, and cooperation skills. Emotional coping skills include managing stress and feeling (including anger), self-management and self-monitoring skills. Cognitive skills include decision making, problem solving skills, which are represented in determining alternative solutions, analyzing external influences (as peers and media), and understanding the consequences of an action. Mangrulkar and colleagues (2001) inferred these skills are not static and made use of separately; however, they should be put to practice together as they complementary, integrative and enforce each other.
Theories of adolescent development, learning and behavior contribute to the development of life skills approach and form its theoretical background. Mangrulkar and colleagues (2001) suggested that each theory provides a part of the foundation of life skills and no single theory can justify skills development nor can it provide a perspective on why these skills are imperative. Table (1) (appendix 1) summarizes the inference of each theory on developing life skills (Mangrulkar and others 2001). Thus, the theoretical core of life skills approach is a way for adolescents to contribute in constructing norms by teaching them how to think instead of what to think, and providing them with the needed tools (Mangrulkar and others 2001).
Life skills program providers and settings
The challenging nature of methods used to apply life skill training needs professional and personal skills which may be present in program providers or need training to develop. Program providers may be social workers, teachers, parents, or health care providers. Peer leaders have the advantage of not having the authoritarian and educational approaches; however they have to be successful models to covey a credible message. Therefore, they can be successful assistants to adult program providers (Mangrulkar and others 2001). Mangrulkar and colleagues (2001) summarized the characteristics of successful life training program providers; they have to have competence in group processes like enhancing interactions and skills to direct group members. They have to have guiding rather than dominating attitudes, respect adolescent freedom to express opinion and encourage self-esteem, and they have to be enthusiastic and supportive.
Figure (1) (appendix1) represents a model of skills development (adapted from Mangrulkar and others 2001).
Life skills training (LST) program description
LST program has three principle components; first is to deliver an array of general self-management skills, second is to provide adolescents with general social skills. Thus these components focus to enhance the overall adolescent competence and reduce vulnerability to social influences. Third LST component includes specific information and skills linked to drug use and support drug resistance and anti-drug attitudes. This is scheduled in 15 to 17 class periods (each is 45 minutes) targeting mainly middle school students. Ten booster sessions are given in grade eight and five more in grade nine Curriculum materials for the program are teachers’ manual and a student guide (Botvin and Griffin 2001).
Effectiveness of Botvin life skills training prevention program
Over the past 25 years, studies evaluating LST program whether small scale or large scale studies confirmed that LST results in positive outcomes about smoking, alcohol and other substances use behavioral changes especially in middle school adolescents. Studies showed that main barriers to successful implementation were lack of teachers training and program material, low funding and lack of guidance from school district personnel were major barriers (Botvin and Griffin, 2004).
Lake County Botvin Life Skills Training Program: Methods
Botvin’s life skills training program was introduced to Lake County, Oregon schools for 3-year period (1998-2000). This was work was done during the period of October 1998 to February 2000 as an informal evaluation of the Botvin prevention approach targeting 6th and 7th grade adolescents being the common time frame for substance use initiation (D’Onofri0 1997).
Participants
This study included 133 adolescents of 6 th grades and 99 adolescents of 7 th grades attending three middle schools. Daly Middle School in Lakeview, Paisley Middle School grades nearly 50 miles away and North Lake middle school students 100 miles away from Lakeview. They were asked to fill self-report Life Skills Training Student Survey booklets.
Apparatuses
The Survey included 11 questions chosen from sections C and D of the survey prepared by Cornell University (appendix 2). The questions chosen intended to measure the student’s past and present licit or illicit substance use (question 1). Student perception of drug use among peers and adults (questions 2 and 3), drug refusal skills (questions 4 and 5), and decision making skills (question 6). Other measures included were media effect (questions 7, 8, and 9), question 10 intended to measure anxiety reduction mechanisms among adolescents examined, and question 11 measured communication skills (appendix 3).
Procedure
The procedure selected was the pretest-post test evaluation, in which participants answer the same questionnaire before and after LST program implementation. This should highlight the program effect on selected objectives. The survey was administered twice; in October 1998 (before program implementation) and in February 2000 (after program implementation). Administering the survey passed into stages to ensure consistency in data collection; first, each student was given an ID number, then 2 copies were made for the same student one for the pretest and the second for the pos test. Second, survey administration and collection was done by the researcher or an assistant other than the classroom teacher to ensure honest students’ self-expression in answering the questions. No scoring to answers of the questions as reported in the Life Skills Training Questionnaire Middle School Version Instruction Guid. This was because the questions in this survey were selections from the original questionnaire dealing with substance use as a whole (tobacco, alcohol, and other drugs). Statistical analysis was done using Stats software version 1.1 from Decision Analyst, Inc.
Limitations
This study did not include a control group from any other frontier area. All efforts taken to seek cooperating of school principals of comparable student populations immediately outside Lake County such as in Modoc County, California and Harney, Oregon were unsuccessful. Thus, results of this study come only from comparing the self-reported data collected before and after the instruction period in the same population of students.
Second is the inconsistency in the total numbers of participants’ response for the pre test and post- test. This is partly because of demographic factors as the survey was administered twice (18 months apart), and was performed in three schools 50 to 100 miles apart. Therefore, the total number of students completed the pre and post-test was occasionally different because of mobilization or absence from school. Further, in other occasions, some students’ answers were inconsistent in an overlook on both booklets with occasionally ambiguous contradicting answers. These students’ complete survey results or responses (answers) to specific questions were not included and the students were considered no respondents either to the whole test or to a particular question.
Lake County Botvin Life Skills Training Program: Results
Results of this study show that substance use among 6th grade Lake County adolescents was 20.3% in 1998. In 2000 (post test) the rate was 10.8% in the same age group. Comparing self-reported substance use before and after applying Botvin life skills among 6th and 7th graders showed significant differences pretest with probability of 99.9%, z-value of 5.4429 and P value less than 0.01. Post test results were also similar in significance pointing to early age of initiation among Lake County adolescents.
Tables 2 to 12 show the pre and post test responses of 6th grades and 7th grades students to the different question groups, which are graphically, represented in figures 2 to 12.
Statistical analysis of research-retrieved data aims confirming the data obtained were not because of chance (testing the null hypothesis). In the context, significance tests estimate the evidence that data obtained provide an argument they are applicable to a population (Connolly and Sluckin 1971). Many researchers use t-test, and when normality fails they use Wilcoxon rank sum test, for non-parametric data, chi-square test, bootstrap, and Fischer randomization tests are in common use. In this work data are two groups to compare, the total sample size of each group is known, and the proportions for each group that falls within a single category is also known. Therefore, the researcher compared proportions using the z-test (Smucker and others 2007). The P value is the probability of being wrong in concluding that there is a true difference in the two groups (the probability of rejecting the null hypothesis, or Type I error). Traditionally, one can conclude there is a significant difference when P < 0.05. In this work, the researcher used z-test (difference between two independent proportions) to calculate the probability of significant difference. The researcher then estimated z-value, critical z-score is taken from z tables (appendix in many statistics textbooks), P is calculated as [1 – critical z-score] (Dekking and others, 2005).
For question 1 (self-report of substance use), the probability of pre test to post test significant change in 6th grade daily substance users was 95.8%, z-value was 2.0332, critical z-score was 0.97882. Thus, P-value equals 0.02 (< 0.05) pointing to statistically significant reduction in Lake County 6th grade adolescent daily substance users. For 7th grade adolescents, there were no statistically significant differences between pre test and post test patterns of substance use. For question 2 and 3 (perception of substance use among peers and adults), sixth graders thought of half their peers are substance users (pre test to post test), z-value was 1.8643. P-value was 0.03 pointing to a significant change of concept of substance use among peers. For 7th graders, P-value was less than 0.01 for the same category pointing to a more significant change of concept.
Sixth graders change of concept about adult substance use showed significant changes in concepts about none of adults were substance users, half, and all adults are substance users. The probability of pre test to post test significant change ranged from 99.97% and 83.36%, z-value ranged from 3.6130 to 1.38383, and P value was below 0.05 for all observations. Seventh graders response on the same question showed no significant change of pre test and post test concepts.
Pre test and post test drug refusal skills (questions 4 and 5) for six graders showed significant change in who may say (no) (question 4) where probability was 99.8%, z-value was 3.1672 and P was <0.001. There was also a significant change about those who will not say (no) to the negative side pointing to the impulse of experimentation, where probability was 99.5% and P was <0.001. Sixth graders who confirmed saying (no) both pre and post test did not show significant difference. Response of 6th graders on what excuse to say did not show significant differences pre and post test. Response of 7th graders to question 4 showed no significant differences to drug refusal skills, as did their responses to question 5 shows.
About decision making skills, showed decision making skills improved among 6th grade adolescent where the probability of improvement was 97.75%, z-value was 2.2818 and P was <0.01. Among 7th grade adolescent, marked improvement in decision making skills was achieved where probability was 99.97%, z-value was 3.648, and P was <0.01.
Results on media influence were consistent among 6th graders about truthful advertisement messages (question 7) and there was no statistically significant pre to pos test result. For 7th graders, the change about the possibility that advertisement message may not be truthful was significant with a probability of 90.63%, z-value was 1.6761, and P was <0.05. For question 8, response to cigarettes advertisement (whether make the person any better). A significant change of concept among 6th graders that cigarettes never makes (me) better occurred where probability was 99.9%, z-value was 5.1186, and P value was <0.01. In 7th graders however, significant changes occurred in all responses with P always <0.05. Question 9 measured responses on alcohol advertisement, did not show significant changes in all responses of 6th and 7th graders.
Question 10 measured adolescents’ response to anxiety. Results show statistically significant difference among 6th graders who would take a health attitude to decrease anxiety, where the probability was 98.25%, z-value was 2.3754, and P value was <0.05. Among 7th graders a significant change occurred among adolescents who will never go for health behavior as their numbers significantly decreased in post test results. Probability of change was 94.69%, z-value was 1.9345, and P was <0.05.
Question 11 measured communication skills, 6th graders showed significant improvement in post test response where probability was 99.9%, z-value was 5.0277, and P was <0.05. While 7th graders showed no significant changes between pre and pos test responses.
Outcomes of the study
The self-reported data gathered from the students before and after the period of Life Skills Training, instruction in Lake County suggests an overall positive affect in reducing substance use by the 6th grade student population more than 7th graders. The difference between the before and after survey measures of knowledge, and various related skills, showed increased awareness of what substance use in relation to peers and adults for 6th graders but less with 7th graders. Change in refusal skills after Botvin Life Skills training of adolescents in Lake County showed significant changes in saying (no) for six graders, yet, the impulse for experimentation was still greater. Seventh grade adolescents did not show any significant changes. Life Skills training showed significant improvement in decision making for both 6th and 7th graders of Lake County. The media influence on adolescents showed significant improvements in some areas but not all, and best results were noticed in relation to cigarettes advertisement. Adolescents’ behavior in response to anxiety was improved after life skills training for both 6th and 7th Lake County graders. However, improvement in communication skills was more significant in 6th graders than in 7th graders.
The overall analysis suggests than 6th graders are more responsive to life skills training and the need to a multifactor prevention approach considering specific risk and protective factors in Lake County. The data also suggest the potential of interactive approach in preventing substance use in young adolescents.
Discussion
Donovan (2007) recognized there is little attention paid to alcohol and substance use in adolescent around 12 years old (6th graders), therefore reviewed National and state surveys for alcohol use among 6th graders. The Youth risk behavior survey in 2005 (after Donovan, 2007) reports that 33.9% of 9th grade adolescents reported drinking alcohol before they were 13 years old. Donovan (2007) noticed that survey results varied because of many factors, first is the level of substance use involvement asked about in the survey (last year, last month, a sip, daily drinking…). Survey results also vary as a function of gender, age, ethnicity, and the year in which the survey was conducted. A characteristic of Lake County, Oregon population is the age group below 17 years represents nearly 25% of the population (7500), this displays the importance the importance of targeting this population in substance use prevention programs (DHS, 2002).
In 1997-1998 and 1999-2000 school years, the school adolescent population of Lake County was surveyed for alcohol and other substances use; however 6th grade adolescents were not included. Results showed that in 1998, the prevalence of Alcohol and substance use among 8th graders was 27.1% and in 2000 the rate decreased to 18.9%. The rates were significantly different from Oregon state prevalence rates (26% and 26.4% respectively) (DHS 2002). The Department of Human Services, Oregon Government issued a report on Lake County substance use based on data from 2000 to 2006 (DHS, 2008). The report showed that 34 adolescents (12-17 years) in Lake County are alcohol dependent or abusers. Adolescents included reported alcohol use before reaching 13 years old, 36% of 8th graders reported drinking alcohol in the past month, and 15% reported binge drinking. The rate of tobacco use in Lake County teens is almost double that of their counterparts in Oregon state (smoking, 13% compared to 9% for Oregon teen) smokeless tobacco use rate was 37% compare to 12% for Oregon teens. Results of this study, although concerned with younger age, confirm the high prevalence of substance use among Lake County adolescents.
Adolescents’ decision of substance use is the outcome of many risk factors including social acceptability, family influence, peer and media (use promotion) effects, and substance availability (National Center on Addiction and Substance Use at Columbia University, 2005).
Community influences
The 2003 report of the Frontiers Education Center points to the following key issues about specific risk and protective factor for substance use in frontiers’ adolescents. First, there is lack of literature researching high risk behavior in frontier adolescents. Research also overlooks specific issues of risk and protective factors to drug use in this population. The report acknowledges lack of data on frontiers adolescents, and points to the relationship between poverty and serious emotional disturbances among frontier’s adolescents which may lead to substance abuse. The report also points to the lack of trust of frontier’s adolescents in health professionals to discuss their problems and assigned this to frequent turnover of health professionals in these communities.
Frontier communities’ poverty and behavioral health (psychological comorbidity) problems reflect on the problem of substance use (Frontier Education Center, 2003).
Based on Lake County data book (DHS, 2002), more than 10% of the population needs treatment for substance use of which nearly 13% are adolescents between 10 to 17 years. Further, 8% of the population needs mental health treatment services, of which 18.8% are adolescents between 10 to 17 years. Knowing that Lake County population represents 3.2% of the Eastern Oregon Region (EOHSC) population, one can appreciate how large the Lake County figures are important. As regard poverty, the report indicates that 59% of the County population is living below 200% Federal poverty level. Armstrong and Costello (2005) reviewed community studies of adolescents’ substance use and psychiatric comorbidity and inferred that comorbidity of substance use with depression was 23.8% with alcohol and slightly higher (24.1%) with illicit drugs. Association rates of substance use and mood disorders were similar to depression with one study reported 8.3% rate of association in Oregon adolescents. Anxiety and substance use comorbidity median rates ranged between 16.2 and 18.2%. In this study, Botvin Life Skills training was successful in modifying 6th grade adolescents response to anxiety. Armstrong and Costello (2005) also inferred that the single most important factor in progression from use to abuse and dependence is the early age of initiation. DHS report (2008) infers that age of initiation among Lake County Adolescent is before 13 years, this is confirmed in this study because of the significant differences in self-reported substance use between 6th grade adolescents and 7th graders. Barnes and colleagues (2007) examined adolescents’ time use in relation to problem behavior and inferred that time spent indoors caring for siblings or watching TV is a modest risk factor, also involvement in extracurricular activities is a modest protective factor. They also inferred that working teens drink heavily and lack of activities to spend time links to spending more time with peers, which is a risk factor to all behavior problems including substance use. This factor is of relevance to frontiers adolescence because of poverty and lack of facilities.
Peers and family influences
Kobus (2003) recognized the research evidence that peers’ association is an important risk factor for adolescent substance use particularly smoking. However, the mechanisms of peer influences are not investigated properly with respect to their importance in designing successful substance use prevention intervention programs. Kobus (2003) suggested that social learning, problem behavior, and social network theory provide an understanding to peers influences mechanisms (the first two theories are of importance in frontiers). The author inferred that in the same peers’ influence in promoting substance use, and providing the social example for substance use, it can be used for deterring substance use. Kobus (2003) identified that peers influence is not without opposing forces, family relationships, and media can neutralize peers effect on adolescents for substance use.
Awareness and mentoring are important preconditions to family influences on prevention of adolescents’ substance use. McGillicddy and colleagues (2007) examined and inferred about parents awareness of substance use incidence, 82% of parents accurately reported their teens are smoking, 86% accurately reported their teens are drinking alcohol, whereas only 72% reported their teens are using illicit drugs. However, about teens’ frequency of substance use, parents considerably underestimate or overestimate their teens’ frequency of substance use, and the difference was larger with younger age teens. About parental mentoring, the younger the teen the less parental mentoring, and parental mentoring is at minimum on weekends, with lesser awareness of frequency, after school hours, or if parents are stressed with own problems. McGillicddy and colleagues (2007) suggested involving parents in prevention-intervention especially in cases of uncooperative teen or absent preprogram parental report.
Avenevoli and Merikangas (2003) stated that current research on the family role in adolescents substance use focuses on genetic epidemiologic studies and familial risk factors. They reviewed the literature on the association between parents, siblings smoking and adolescents’ tobacco use. Their findings showed inconsistent association between parents smoking and adolescents’ tobacco use, however the effects of siblings (probably as peers) was greater. They suggested families’ integration in the prevention studies.
In the present study, 6th grade adolescents’ perception that less peers are smoking (after life skills training) was associated with significant reduction in their self-reported rate of substance use, confirming Kobus’s results.
Media influences
Media has an influential impact on adolescents’ health and behavior, Ellickson and others (2005) studied a sample of more than 3000 middle schools adolescents. Results showed that 90% of the sample saw beer ads in television, sports or concert events, 80% looked at magazines displaying alcohol ads. Further 13% of in depth internet viewers (more than two pages) to alcohol websites were underage. Garfield and others (2003) showed that self-reported reading of magazines with alcohol ads in public settings were more than 7 million underage adolescents. Choi and others (2002) showed that tobacco advertising was a leading cause to adolescents’ change of status from experimentation to established smoking.
Strasburger and Donnerstein (1999) stated that although television is the predominant medium; yet, radio, magazines, and movies are influential media. They stated that content analysis of prime time networks drama, showed that 70% display tobacco, alcohol, or illicit drugs use, and more than half the musical videos contained substance use. Further, they inferred that for every prevention message as just say no, teen will view 25 beer or wine ads (in average). They examined correlational studies of consumption and exposure to ads and found a positive relationship.
Wakefield and others (2003) examined how media affects cigarette smoking about advertising, promotion, antismoking messages, and product placement. They inferred that media effects are complex and multifaceted, first media not only shape but also reflect social values about smoking, and media convey smoking promotion message directly to audiences. Media as a social learning mean provide and impress adolescents with attractive social models; media promotes and influences discussions on smoking. Besides, smoking media messages influence prevention intervention efforts, and strongly oppose antismoking messages.
Sargent (2005) stated that there is weak evidence to support the movies’ influence on behaviors for which movies are rated and television and video games have a stronger influence on adolescents. Sargent (2005) explained the strong media influence in that among social influences (peers, families, and media) peer and family effects are reciprocal with teens that is they influence each other with varying degrees. However, with media the influence is only in one direction that media affect teens convey whatever message convincingly and attractively.
The media influence on adolescents’ substance use is shown in the present study as indicated by the modest change in opinion about how true media messages are and the response to smoking and alcohol message in the media.
Substance refusal and social skills
Scheier and colleagues (1999) examined assertiveness, substance refusal, and personal competence as social skills included in training prevention programs. Their findings suggested that lower refusal correlates with poor academic performance, and poor competence, on the other hand, poor refusal links to high risk taking and increased substance use. They inferred that results of social skills training programs are modest regarding developing refusal skills. Scheier and colleagues (1999) identified that during the course of adolescents’ development, there is an interaction of social instructional skills; therefore, it can be difficult to recognize the role of refusal skills separate from other essential program skills.
In the current study, although communication and decision making skills showed significant improvement after life skills training; yet, refusal skills pattern showed slight change in saying no to drugs. However, there was no change in the reason of saying no. These somewhat unclear results point to the complexity of assessing refusal skills separately in agreement with Scheier et al (1999).
Botvin’s life skill evaluation
Botvin Life Skills is an interactive approach to substance use prevention, which centers on interpersonal interactions. The approach features small group participatory interactions lead by a peer. Therefore, peer training is important for adolescents’ acquisition and practice of skills developed. Of equal importance is to integrate proper beliefs and processes into the everyday adolescent activities (Tobler, 1986).
Buhler and others (2007) examined 442 fifth grade adolescents involved in life skills training for substance use prevention. Their results showed students’ increased knowledge of life skills met students’ refrain from substance use, further a significant number of smoking adolescents stopped and none of the experimental smoker or non smokers turned to smoking. Buhler et al (2007) concluded that life skills training is , as research shows, the most effective single school based substance use prevention program. Botvin and others (2003) examined the effectiveness of life skills training on children and adolescents of third to 6th grades. Results showed that annual smoking prevalence rate was reduced by 61% and the same rate for alcohol use was reduced by 25%. They suggested that life skills training program is successful in substance use prevention for middle and elementary schools.
Elliot and Mihalic (2004) looked into the process of replication of a successful prevention program as the main cause of variability of results. Their argument focused on five areas where replication defects may occur, first is selection of the site where the program to be implemented. They identified five elements for site selection, a suitable site is one connected to a respected local champion, a site with influential supporting administration, a site with organizational commitment and staff stability. Other conditions of site selection are; a site with needed resources, a site where the credibility of the chosen program is appreciated by the local community, and a site that has the potential for making the program a routine practice. The second area for problematic replication is staff (program leaders) training; they acknowledged the main obstacle in achieving this is staff turnover. Program staff should possess eligibility requirements, and administration should be encouraged to attend the training to ensure a cooperative path between administrators and program staff, which is on factor ensuring sustainability. Third is technical assistance to program staff by the program developers to overcome application difficulties. Of importance is their observation that technical assistance from program providers tend to decline over time even during the initial two years supported program implementation. In addition, technical assistance support teams are occasionally hard to find which leads to either delay or defect in program replication. Fourth is program sustainability, which depends on affording all previous condition in addition to financial funding after the period granted (usually two years). Finally is the issue of program fidelity that is applying the core components of the program without modifications or what is known as fidelity adaptation balance.
Community tailored versus National prevention-intervention programs
Adopting national substance use prevention intervention programs achieves three important objectives; first as the problem is a nationwide problem, there is a need for a national strategy to face. Second is the development of a national strategic prevention network and third is to ensure scientific-based prevention strategy (science to service) (Curie, 2005).
Currently there are two working prevention schemes, the risk and protective factors frame whose objective is to strengthen protective factors and minimize risk factors. The second is the IOM (Institute of Mental Health) frame, which recognizes there are three approach to choose from, the universal, the selective (for a particular subgroup at high risk), and the indicated approaches (targeting a subgroup with early signs of substance use). Whatever frame chosen it remains essential that a program should suit the targeted population, and includes initiatives to change socioeconomic, environmental, and political circumstances (Nebraska Health and Human Service System, 2004). Adolescents of Lake County, as a frontier, have specific risk factors, besides poverty, comorbidity with psychological problems, the early age of initiation of substance use, which represent a challenge to prevention programs implementation. Elliot and Mihalic (2004) consider no contradiction between fidelity and modifying a program to suite local environment, since fidelity is applying the core components not the whole program as it is. Further, they identified that local environment is ever changing, which calls for continuous monitoring of program implementation, and program modification does not mean controlling the program elements. Finally, they acknowledged that implementing fidelity in prevention programs modified to suite specific communities is a higher level of implementation that needs special training and knowledge.
Botvin and colleagues (1998) examined the effectiveness of school-based prevention approaches and stated, since affective education is superior to information dissemination, psychological factors as etiological elements must be recognized and accounted for in program implementation. They realized that affective education is an essential component in training programs, besides, the social influence approach has three major components, psychological inoculation, resistance skills, and correcting normative expectations. They inferred a comprehensive successful prevention should include all these components (multicomponent strategy).
Botvin and Griffin (2001) stated although the generalizability of life skills training is shown in the literature; yet, they realized that strongest prevention programs stem from approaches specifically designed to suite a particular targeted population. They clarified how to modify life skills training using the core or generic life skills of the program and skills specific to community where the program is applied. They emphasized that such a combination would results in better prevention results.
Sloboda and colleagues (2008) recognize the challenges in applying successful prevention programs to a particular community are to determine the extent of fidelity, examining the content and how well it covers the local community. They also identified the lack of standardized definitions, and measurements of contents (content analysis methodologies).
Conclusion
Alcohol, tobacco, and other substance use are key public health problems that grasped community, educational and health authorities concerns, as it starts during adolescence to produce its bad aftermath in adult life. Prevention intervention programs resulted in minimal effects on drug use patterns and prevalence over the past 20 years. Reviewing the literature shows that multicomponent programs, community based or modified to address specific risk and protective factors of targeted population result in better outcomes. Besides, programs addressing multiple substance use have more impact. Programs designed to address other specifics, as age, ethnicity, and other population characteristics are more favourable. Peers’ and media influences appear to be major risk factors for any targeted population. Lake County as almost all frontier communities has certain characteristics that should be considered in implementing a prevention program. Poverty, early initiation of substance use, and comorbidity with psychological health problems are important characteristics to consider. This study evaluated the effect of Botvin Life Skills Training implemented on 6th and 7th grade adolescents of three Lake County middle schools over two years. Results showed that self-reported drug use is similar or even higher than rates of Oregon State, changes in risk behavior or improve skills change were modest pretest compared to posttest responses. Overall analysis suggests than 6th graders are more responsive to life skills training and the need to a multifactor prevention approach considering specific risk and protective factors. The interaction and complexity of risk factors are significant explanations for these results. The LifeSkills training program (LST) is an interactive key program for adolescent substance abuse nationwide. The program works on reducing the effects of risk factors and supporting the protective factors, more important it teaches skills connected to social resistance and augments personal resilience. The reviewed finding of LST evaluation studies (small groups, large groups), in different adolescent populations display that LST program induces consistent positive behavior outcomes on substance use. The lack of measures to determine the extent of fidelity and content analysis are challenges to overcome. Programs planned for substance abuse prevention should maintain enough time to achieve desirable results; LST was applied for less than two years and this is, perhaps, another cause for the modest results. In addition, suitable duration of program implementation ensures better long-term results, prevents relapses, and of more importance guards against the transition from substance use to abuse and dependence. In the light of numerous references and research on adolescent substance use, the challenge remains how to cross the gap between research and practice. Another challenge is how to replicate and disseminate successful programs, and to appreciate that substance use prevention programs are not health care and produce its effects if applied on a wide scale. Prevention programs’ settings are in the real world where risk factors interact, change from an area to another and from time to time, coping with these variations is an important step to success. Multicomponent interactive community modified prevention programs implemented in schools environment remain the gold standard of prevention.
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Appendix 1
Appendix 2
Appendix 3
Questions included in the study’s self-report Life Skills Training Student Survey:
- About how often (if ever) do you: Smoke cigarettes, drink alcohol, smoke marijuana, sniff inhalants or use other drugs?
- How many people your age do you think: Smoke cigarettes, drink alcohol, smoke marijuana, use cocaine or other hard drugs, and sniff other things to get high?
- How many adults do you think: Smoke cigarettes, drink alcohol, and smoke marijuana, use cocaine or other hard drugs?
- How likely would it be for you to say “No” when someone tries to get you to smoke cigarettes, drink alcohol, smoke marijuana, use cocaine or other hard drugs, or inhale other things to get high?
- If someone asked you to smoke, drink, use marijuana or other drugs, would you:Tell them no, tell them not now, I don’t want to, make up an excuse and leave?
- When I have a problem or need to make an important decision I get more information needed to make the best choice, think of ways to solve the problem, think what will happen for each choice before doing it, make the best choice and then do it.
- When I see or hear an advertisement, I think about whether what the Ad says is true, remind myself that the Ad is trying to get me to buy what they are advertising, tell myself that advertisements are not always truthful.
- When I see or hear a cigarette Ad, I tell myself that smoking cigarettes will not make my life better.
- When I see or hear an alcohol Ad, I tell myself that drinking wine, beer or liquor will not make my life better.
- When I feel anxious, I relax my muscles in my body, imagine myself in a peaceful place, tell myself to feel clam and not worry, breath slowly while I count 4 in and 4 out, practice doing whatever makes me feel nervous until I feel more confident.
- When I want people to understand me, I make sure what I say matches my tone of voice, how I stand, and the expression on y face, talk in a way that is clear and specific.
Appendix 4: Survey results
Table 2: 6th and 7th graders pre test and post test responses to question 1
Occas = Occasional
Table 3: 6th and 7th graders Pre test and post test responses to question 2
Table 4: 6th and 7th graders pre test and post test responses to question 3
Table 5: 6th and 7th graders pre test and post test responses to question 4
Table 6: 6th and 7th graders pre test and post test responses to question 5
Table 7: 6th and 7th graders pre test and post test responses to question 6
Table 8: 6th and 7th graders pre test and post test responses to question 7
Table 9: 6th and 7th graders pre test and post test responses to question 8
Table 10: 6th and 7th graders pre test and post test responses to question 9
Table 11: 6th and 7th graders pre test and post test responses to question 10
Table 12: 6th and 7th graders pre test and post test responses to question 11
