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Meta-Analysis
. 2018 Oct 5;10(10):CD009927.
doi: 10.1002/14651858.CD009927.pub2.

Individual-, Family-, and School-Level Interventions Targeting Multiple Risk Behaviours in Young People

Affiliations
Free PMC article
Meta-Analysis

Individual-, Family-, and School-Level Interventions Targeting Multiple Risk Behaviours in Young People

Georgina MacArthur et al. Cochrane Database Syst Rev. .
Free PMC article

Abstract

Background: Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

Objectives: To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

Search methods: We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

Selection criteria: We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

Data collection and analysis: We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

Main results: We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

Authors' conclusions: Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Conflict of interest statement

RC is a scientific advisor for DECIPHer Impact, a not‐for‐profit company wholly owned by the Universities of Cardiff and Bristol, which licences, quality‐assures, and supports the delivery of evidence‐based public health promotion interventions. RC receives payment for this work.

JW has been the recipient of research funding from the National Institute for Health Research (NIHR), UK, and the National Institute for Social Care and Health Research (NISCHR), Wales.

DG has been the recipient of research funding from the NIHR, Ambulance Service and Medical Research Council (MRC), UK, and is a trustee for The Samaritans.

MH has been the recipient of research funding from the MRC and Economic and Social Research Council, UK, and has received payment for unrelated activity from Gilead Sciences Inc, Bristol‐Myers Squibb, and Janssen, UK.

GJM, DMC, JR, SHW, RK, CC, RL, VE, RL, and KEP ‐ no known interests.

Figures

1
1
Logic Model: interventions to prevent multiple risk behaviours in individuals aged 8 to 25 years.
2
2
Study flow diagram (searches conducted in 2012, 2015, and 2016).
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
5
5
Funnel plot. Outcome 7: antisocial behaviour and offending (short‐term): universal school‐based interventions.
6
6
Funnel plot of comparison. Outcome 7: antisocial behaviour and offending. Outcome 7.1: antisocial behaviour and offending ‐ any (short‐term).
7
7
Funnel plot of comparison. Outcome 7: antisocial behaviour and offending. Outcome 7.2: violent offences (short‐term).
8
8
Funnel plot of comparison. Outcome 7: antisocial behaviour and offending. Outcome 7.3: school or general delinquency (short‐term).
9
9
Funnel plot of comparison. Outcome 1: tobacco. Outcome 1.1: tobacco use (short‐term).
10
10
Funnel plot of comparison. Outcome 2: alcohol. Outcome 2.1: alcohol use (short‐term).
11
11
Funnel plot of comparison. Outcome 4: cannabis use. Outcome 4.1: cannabis use (short‐term).
12
12
Funnel plot of comparison. Outcome 5: illicit drug use. Outcome 5.1: Illicit drug use (short‐term).
13
13
Funnel plot of comparison. Outcome 9: sexual risk behaviours. Outcome 9.1: sexual risk behaviour (short‐term).
1.1
1.1. Analysis
Comparison 1 Tobacco, Outcome 1 Tobacco Use (short‐term).
1.2
1.2. Analysis
Comparison 1 Tobacco, Outcome 2 Tobacco Use (long‐term).
2.1
2.1. Analysis
Comparison 2 Alcohol, Outcome 1 Alcohol Use (short‐term).
2.2
2.2. Analysis
Comparison 2 Alcohol, Outcome 2 Alcohol Use (long‐term).
3.1
3.1. Analysis
Comparison 3 Binge drinking, Outcome 1 Drunkenness or Excess Drinking (short‐term).
3.2
3.2. Analysis
Comparison 3 Binge drinking, Outcome 2 Drunkenness or Excess Drinking (long‐term).
4.1
4.1. Analysis
Comparison 4 Illicit drug use, Outcome 1 Illicit drug use (short‐term).
4.2
4.2. Analysis
Comparison 4 Illicit drug use, Outcome 2 Illicit drug use (long‐term).
5.1
5.1. Analysis
Comparison 5 Cannabis use, Outcome 1 Cannabis Use (short‐term).
5.2
5.2. Analysis
Comparison 5 Cannabis use, Outcome 2 Cannabis Use (long‐term).
6.1
6.1. Analysis
Comparison 6 Alcohol, tobacco, and/or drug use, Outcome 1 Composite Substance Use (short‐term).
6.2
6.2. Analysis
Comparison 6 Alcohol, tobacco, and/or drug use, Outcome 2 Composite Substance Use (long‐term).
7.1
7.1. Analysis
Comparison 7 Antisocial behaviour and offending, Outcome 1 Antisocial Behaviour and Offending ‐ Any (short‐term).
7.2
7.2. Analysis
Comparison 7 Antisocial behaviour and offending, Outcome 2 Violent Offences.
7.3
7.3. Analysis
Comparison 7 Antisocial behaviour and offending, Outcome 3 School or General Delinquency.
7.4
7.4. Analysis
Comparison 7 Antisocial behaviour and offending, Outcome 4 Antisocial Behaviour and Offending ‐ Any (long term).
8.1
8.1. Analysis
Comparison 8 Vehicle‐related risk behaviours, Outcome 1 Driving Under the Influence of Alcohol and/or Drugs.
9.1
9.1. Analysis
Comparison 9 Sexual risk behaviours, Outcome 1 Sexual Risk Behaviour (short‐term).
9.2
9.2. Analysis
Comparison 9 Sexual risk behaviours, Outcome 2 Sexual Risk Behaviour (long‐term).
10.1
10.1. Analysis
Comparison 10 Physical activity, Outcome 1 Physical Activity.
11.1
11.1. Analysis
Comparison 11 Mental health, Outcome 1 Depressive Symptoms (short‐term).
11.2
11.2. Analysis
Comparison 11 Mental health, Outcome 2 Depressive Symptoms (long‐term).
12.1
12.1. Analysis
Comparison 12 Unhealthy diet, Outcome 1 BMI.
12.2
12.2. Analysis
Comparison 12 Unhealthy diet, Outcome 2 Unhealthy Diet.
13.1
13.1. Analysis
Comparison 13 School‐related outcomes, Outcome 1 Academic Performance (short‐term).

Update of

  • Cochrane Database Syst Rev. doi: 10.1002/14651858.CD009927

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