J. DRUG EDUCATION, Vol. 43(4) 331-351, 2013

PUBLIC COMMITMENT, RESISTANCE TO ADVERTISING, AND LEISURE PROMOTION IN A SCHOOL-BASED DRUG ABUSE PREVENTION PROGRAM: A COMPONENT DISMANTLING STUDY

OLGA HERNÁNDEZ-SERRANO EUSES–University of Girona KENNETH W. GRIFFIN Weill Cornell Medical College JOSÉ MANUEL GARCÍA-FERNÁNDEZ University of Alicante MIREIA ORGILÉS JOSÉ P. ESPADA Miguel Hernández University

ABSTRACT

The objective of the present study was to examine the contribution of three intervention components (public commitment, resistance to advertising, and leisure promotion) on alcohol and protective variables in a school-based substance use prevention program. Participants included 480 Spanish students aged from 14 to 16 who received the Saluda prevention program in one of the following five experimental conditions: complete program, program minus public commitment, program minus resistance to advertising, program minus leisure promotion, and a waiting-list control. The students completed selfreport surveys at pretest, posttest, and 6-month follow-up assessments. When excluding the healthy leisure promotion component, the Saluda program showed no loss of efficacy neither on alcohol use nor on other substancerelated variables, while public commitment and resistance to advertising improved the aforementioned program’s efficacy.

331 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/DE.43.4.c http://baywood.com

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INTRODUCTION Substance use among adolescents is a major concern. In Spain, recent national survey data indicate that the most consumed drugs amongst secondary school students aged from 14 to 18 years old are alcohol, tobacco, and cannabis. Around 75% of the sample reported lifetime alcohol use, whilst lifetime tobacco and cannabis use was reported by 39% and 33% of participants, respectively. Abuse of so-called designer drugs, such as ecstasy or speed, was much more infrequent, with between just 1% and 3.9% of students admitting to consumption at least once in their lifetime. From 2002 to 2010, the most important consumption reduction involved tobacco, cannabis, and cocaine. Nevertheless, though the situation has experienced a global improvement in recent years, the rate still remains high in relation to overall consumption (Spanish Observatory on Drugs and Drug Addiction, 2011). School-based interventions are effective tools in reducing substance use (Faggiano, Vigna-Taglianti, Versino, Zambon, Borraccino, & Lemme, 2008; Karki, Pietila, Lansimies-Antikainen, Vajoranta, Pirskanen, & Laukanen, 2012). However, the impact provided by many of the programs is limited, and some of their effectiveness determinants remain unexplored (Gázquez, Garcia, & Espada, 2009). A crucial aspect in the evaluation of program effectiveness refers to the specific components that are related to success. Efforts to identify the core components of school-based drug abuse prevention programs have been channeled by means of meta-analyses (e.g., Tobler, Roona, Ochshorn, Marshall, Streke, & Stackpole, 2000) and systematic reviews (e.g., Karki et al., 2012). Some of the most important elements that must be present in a good preventive program are: transmission of knowledge, general-skills training, promotion of healthy leisure, public commitment to not participating in drug use, and resistance to advertising (Tobler et al., 2000). In relation to the transmission of knowledge, systematic reviews on schoolbased prevention conclude that, in addition to providing information on the causes and consequences of consumption, drug prevention programs should also work in developing other contents, such as life training skills, the influence of psychosocial processes, or supplementary strategies associated with consumption (Lemstra, Bennett, Nannapaneni, Neudorf, Warren, Dershaw, et al., 2010; Valverde, Delgado, Rodriguez, Lara, Iglesias, Garcia, et al., 2010). Some systematic reviews indicate that the most effective programs include general-skills training, leading to an increase in social and personal competences (Hopfer, Davis, Kam, Shin, Elek, & Hecht, 2010). Within the framework of the social influence model, programs developing resistance skills and those based on the improvement of personal skills should be highlighted. Several studies highlight the fact that socially skilled adolescents are less likely to present risk behaviors concerning either legal or illegal drugs consumption (Lemstra et al., 2010). Other studies deal with interpersonal behavior styles, distinguishing between

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prosocial and antisocial behavior (Inglés, Martínez-González, García-Fernández, Torregrosa, & Ruíz-Esteban, 2012). Prosocial behavior is often related to the establishment of voluntary and empathetic behaviors with the aim of promoting benefits for other individuals (Eisenberg, Fabes, & Spinrad, 2006) by several actions such as, for instance, helping another classmate with his or her homework or listening to someone’s problems. Antisocial behavior is usually linked to the desire to break social laws and taking actions against others. An ex post facto study concluded that tobacco and alcohol consumption were positively and significantly related to elevated antisocial behavior scores (Inglés, Delgado, Bautista, Torregrasa, Espada, García-Fernández, et al., 2007). The model of lifestyle and risk-factors and protection for drug use is related to the comprehensive theories (Calafat, Amengual, Farrés, Mejías, & Borrás, 1992). This model highlights the paramount importance of the use of free time to prevent drug use. Some studies have shown that the promotion of healthy leisure activities can be an effective component in prevention programming, particularly when implemented in an intensive and structured way, when combined with other contents (such as social resistance skills training), or when delivered outside of the classroom (Bruvold, 1993; Hansen, 1995). Concerning the stated subject, studies stemming from the 2001 HealthWise Project deserve special mention. The aforementioned program consisted of lessons for learners from different grades, and the aim was basically to reduce Sexually Transmitted Infections (STI’s), Acquired Immunodeficiency Syndrome (AIDS) in particular, as well as to reduce substance abuse and to increase a positive use of leisure time (Caldwell, Smith, Wegner, Vergnani, Mpofu, Flisher, et al., 2004). Tibbits, Smith, Caldwell, and Flisher (2011) found that HealthWise was effective at both restraining the onset of frequent polydrug use (at pretest evaluation) and decreasing polydrug use. A dissertation reviewed and approved by founding members of the project suggested that adolescent leisure experiences predicted pretest evaluation substance use and that changes in leisure experiences predicted changes in substance use behaviors over time (Sharp, Coffman, Caldwell, Smith, Wegner, Vergnani, et al., 2011). This conclusion is reinforced by the findings described in another dissertation (Tibbits, 2009), in which the author suggests that, concerning leisure activities, both amotivation and boredom might be two factors playing a capital role concerning health-risk behaviors, even if, surrounding this subject, further longitudinal research is strongly recommended. A recent study indicated that sports participation did demonstrate positive effects against marijuana use (Dever, Schulenberg, Dworkin, O’Malley, Kloska, & Blachman, 2012). The commitment to not participating in drug use is often included amongst other components designed to alter the motivation to use drugs (Hansen, Derzon, Dusenbury, Bishop, Campbell, & Alford, 2009). Making a public commitment to abstain from substance use in the future is believed to have the potential to strengthen links between intention and behavior (Hansen, 1992). Several studies have underlined the effectiveness of public commitment as a prevention strategy

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(Hansen, Dusenbury, Bishop, & Derzon, 2007). Recently, well designed programs that focused on building commitments had larger effects than did those not including this component. Overall, helping participants to develop strong commitments to avoid substance use was positively correlated with substance use outcomes (Hansen et al., 2009). A study reviewed by Giles et al. (2010) suggested that encouraging decision-making was associated with commitments to not use substances amongst students whose teachers displayed greater interactive teaching. According to the social learning theory (Bandura, 1977), behaviors are learned in a social context, through a triple process of observation, modeling and reinforcement. Drug use is often initiated and maintained when friends, family and/or media negatively influence a young person’s behavior through social learning processes. When adolescents lack the ability to develop the skills to resist negative messages promoting substance use from both the media and their peers, they are more likely to initiate use (Botvin, 2000). Thus, many prevention programs include social-resistance skills training, as well as instruction to ease the resistance against any media-promoter of substance use (Kulis, Dustman, Brown, & Martínez, 2013; Singh, Jimerson, Renshaw, Saeki, Hart, Earhart, et al., 2011). Media resistance components aim to change attitudes of adolescents misleading drug-related advertisements (Gonzalez, Gomez-Duran, & Garcia, 2000). Another approach that can be used to examine how specific program components or modules affect intervention outcomes is to experimentally manipulate the components provided to participants (Sussman, 2001). In Spain, within the last years, there is a clear trend to inquire into the active factors responsible for program effects: to replicate an effective intervention through componentdismantling studies might be a meaningful example. Within this framework, the Saluda program (Espada & Méndez, 2003) was partially dismantled in 2012 with the aim of analyzing, among Spanish students, the main behavioral trainingrelated components: social-skills training and problem-solving training. Results from the aforementioned study evidenced higher levels of effectiveness when the Saluda program included both components; furthermore, a summation effect was stated (Espada, Griffin, Pereira, Orgilés, & Garcia-Fernandez, 2012). The present study has been conceived as a continuation of the previous one; once the paramount importance of both components was established, the next step was to focus on the contribution of the other components. Youthful experimentation with substances (alcohol in particular) is marked by society and culture within the framework of Mediterranean countries, and deeply-grounded in the Spanish culture as a tool for interaction associated with recreational culture groups. For these reasons, we considered it important to channel our study in this direction. The objective of this study is to evaluate the contribution of three components of the school-based substance abuse prevention program Saluda: (a) leisure promotion; (b) public commitment; and (c) resistance to advertising. Determining the specific contribution of each one of these components may improve the efficiency of interventions and might concurrently increase their cost-effectiveness. Thus,

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we hypothesized that the four intervention conditions (the Saluda program plus three partial versions described below) would be more effective than no intervention, and that the program with all its components would be more effective than the other partial-intervention conditions. Finally, we conservatively hypothesized that the components effectiveness would be equal among all of them as, to present, no conclusive evidence concerning the superiority of any of the components has been described. METHOD Participants The sample was recruited from five public schools of Secondary Education in the region of Alicante (Spain). Students were Spanish native speakers, from a middle-class socioeconomic level. Nineteen students (3.95%) were excluded due to lack of information or failure to submit the informed consent of parents. The final sample consisted of 480 students with ages ranging from 14 to 16 years (M = 14.9, SD = .74): amongst them, 225 (47%) were boys. A total number of 266 (55.4%) participants were students of 9th grade and 214 (44.6%) pertained to 10th grade. There were no significant differences in these demographic variables across conditions at the pretest assessment. The fieldwork was conducted during the 2011-2012 school year. Retention of participants in the study was high. There were three subjects (two in the “complete program condition” and the other one in the “program minus public commitment condition”) who did not attended one treatment session due to illness. All participants completed the pretest, posttest, and 6-month follow-up. Measures Substance Use Questionnaire (Espada, Méndez, & Hidalgo, 2003)

Items assessed the frequency and intensity of substance use: alcohol, cannabis, and other illegal substances (e.g., ecstasy or hallucinogens). Questions referred to the last month and lifetime frequency of consumption, using a scale of six response alternatives (never, daily, 2/3 times a week, once a week, once a month, and less than once a month). Intention of Substance Consumption Questionnaire (Espada et al., 2003)

Seven items were used to assess intention to use alcohol and other drugs. Items had a dichotomous (yes/no) response format.

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Leisure Activities Questionnaire (Espada et al., 2003)

This part of the survey consisted of eight items assessing healthy leisure activities such as reading, engaging in sports, outdoor activities or volunteering, as well as other activities, such as watching TV, chatting, playing video games, or going out with friends. Response options were recorded to reflect the practice (yes/no) of each one of the activities. Knowledge about Drugs Questionnaire (Espada et al., 2003)

A scale consisting of 20 questions assessed general knowledge about substances along with the consequences of substance use, perceived risks of drug use, and normative perceptions about the prevalence of alcohol and illicit drug use by peers of the same age. Knowledge questions had the following response options: “true,” “false,” and “I don’t know.” Based on psychometric testing, two subscales were established: a 10-item scale for alcohol use and another 10-item scale for illicit drugs. The Cronbach alpha coefficient of internal consistency scored 0.50 and 0.74, for alcohol use and illicit drugs scales, respectively. Teenage Inventory of Social Skills (TISS; Inderbitzen & Foster, 1992; adaptation of Ingles, Hidalgo, Mendez, & Inderbitzen, 2003)

This scale assesses the social competence of adolescents with regards to their relationships with peers. It consists of 40 items with a 6-point scale (from 1 = “does not describe me at all” to 6 = “describes me completely”). It encompasses two subscales: prosocial behavior, which assesses behaviors that generate positive peer acceptance; and antisocial behavior, which assesses negative behaviors that generate rejection by peers. Scores for the two subscales are obtained by summing the relevant items, and higher scores indicate a greater behavioral involvement. The internal consistency coefficient was 0.89 for the prosocial behavior scale and 0.84 for the scale of antisocial behavior. Procedure Prior to the intervention, a meeting with the school board (school principals and guidance counselors) was held in order to explain the aims of the investigation, describe the prevention program, explain the proposed study procedures, and answer questions with a view to facilitating participation and collaboration. Once the recruitment was successfully completed, we held a meeting with parents of participating students to explain the study, to answer questions, and to obtain informed consent. The assessment and intervention were conducted in the school context. A pretest evaluation was conducted during September 2011. One week later, the beginning of the intervention took place. The program-providers and research staff were composed of psychology graduate students who were unaware of the study hypotheses. Program providers received specific training appropriate

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to the experimental condition to which they were assigned. The program was implemented once a week during school hours, in classrooms of 20 to 30 students. One week after the completion of the intervention program, during December 2011, the post-test assessment was carried out, whilst the follow-up assessment took place 6 months later in June 2012. The study was approved by an Ethics Committee for Experimental Research. Intervention Dismantling Strategy The Saluda program consists of 10 sessions (1 hour per session) with the following contents: a) information on alcohol and illicit drugs, and their effects; b) information on causal factors (motivations) for drinking and taking pills among adolescents; c) advertising analysis; d) social skills and assertiveness skills; e) information on healthy leisure offers existing in the city, and incorporating healthy activities in the weekly schedule; f) abilities in problem solving and decision making; and g) public commitment to non-abuse of alcohol and synthetic drugs. In the present study, schools were assigned to one of the five different experimental condition-based groups assuming a treatment dismantling strategy used in previous substance use studies (e.g., Espada et al., 2012; Walters, Vader, Harris, Field, & Jouriles, 2009). Conditions and components are shown in Table 1 and included: 1. the complete Saluda program (SC) which comprised 127 subjects; 2. the Saluda program minus the public commitment component (S-PC), with 91 subjects; 3. the Saluda program minus the resistance to advertising component (S-AR), with a total of 79 participants; 4. the Saluda program minus the healthy leisure promotion component (S-LP), which had 94 subjects; and 5. a waiting list control group (WL) with 89 subjects. Each school was randomly assigned to one of the five conditions. In order to standardize the length of intervention time, the groups receiving incomplete versions of the program held discussion sessions and participated in dynamic group activities without any specific skills training content. Data Analysis Plan The hypotheses were examined by means of univariate analyses of variance, where the independent variable or factor (type of treatment) had five levels (complete Saluda program, Saluda program minus the public commitment component, Saluda program minus the resistance to advertising component, Saluda program minus the healthy leisure promotion component, and a waiting-list control group) and the protective variables (perceived norm, knowledge, substance use intention, and social skills) were quantitative variables. Also, P2 test was performed to

General information Risk factor information Cognitive misperceptions Media pressure Leisure activities enhancement Social skills training-general skills Social skills training-substance use skills Problem solving training-general skills Problem solving training-substance use skills Maintenance strategies 6. Public commitment

5. Problem-solving training

4. Social-skills training

2. Resistance to advertising 3. Healthy leisure promotion

1. Information and normative education

Components & & & &

& & & & & & & & & & & & & & &

S-LP (n = 94)

SC (n = 127) & & & & & & & & &

S-PC (n = 91)

& & & & & &

& & &

S-AR (n = 79)

WL (n = 89)

Note: SC = Saluda Complete program; S-PC = Saluda program minus the Public Commitment component; S-AR = Saluda program minus the Resistance to Advertising component; S-LP = Saluda program minus the healthy Leisure Promotion component; WL = Waiting-List control group.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Sessions

Table 1. Program Components and Sessions Taught in Each Experimental Condition

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determine if any statistical relationship existed between the factor (type of treatment) and the two qualitative variables: substance use and performing leisure activities. Post-hoc analyses were conducted using the Scheffé adjustment for multiple comparisons. We calculated effect sizes for each assessment point of the evaluation. The effect size was calculated using the index d (standardized mean difference) proposed by Cohen (1988), considering values as follows: 0.20 (small effect size), 0.50 (medium effect size), and 0.80 (large effect size). Furthermore, classrooms were defined as the units of randomization (participants were clustered within classrooms). To address this analytically, variance component estimates were computed, using Restricted Maximum Likelihood (REML). This was done to estimate the components of variance attributable to the random factor (classroom) amongst the dependent variables, and to test whether those differed significantly from zero. For each dependent variable, the Wald Z statistic was examined to determine the population variance factor due to the classrooms. All analyses were conducted using the SPSS 19.0 statistical software assuming an alpha level of .05. RESULTS When analyzing pretest differences, we found that there were no baseline differences between groups in any of the outcome or demographic variables included in this study. The Wald Z statistic revealed that the population variance factor was similar by classroom in each version of the program (SC = 1.04, p = .29; S-LP = 0.80, p = .42; S-PC = 0.59, p = .55, S-AR = 0.22, p = .82, and group WL = 0.38, p = .70); it indicates that all classroom clustering effects were negligible and not statistically significant across all the variables. Effects on Alcohol and Other Illicit Substances Post-hoc tests indicated that alcohol use was significantly lower in the complete Saluda program compared to the Saluda program minus public commitment and the Saluda program minus resistance to advertising at the posttest assessment. The largest difference was found when comparing the complete Saluda program to the control group (d = 0.30). However, the post-hoc test found no statistically significant differences between the complete Saluda program and Saluda minus leisure promotion at the posttest and follow-up (Table 2). As the use of other illicit substances was under 1% at all assessment points, we did not analyze intervention effects on these behaviors, although we did examine effects on drunkenness. Compared to the intervention conditions (Table 2), a higher proportion of participants in the waiting list group (WL) reported more episodes of drunkenness with moderate and lower effect sizes at posttest (SC d = 0.34, S-LP d = 0.20, S-PC d = 0.23, S-AR d = 0.50) and with moderate and high effect sizes at follow-up (SC d = 0.73, S-LP d = 0.73, S-PC d = 0.84, S-AR d = 0.76).

47 2 4 22 14 38 27 58 1 4 19 18 27 20 38 0 0 43 20 26 8

Never Daily 2/3 times a week Once a week Once a month Less than once a month Drunkenness

Never Daily 2/3 times a week Once a week Once a month Less than once a month Drunkenness

Never Daily 2/3 times a week Once a week Once a month Less than once a month Drunkenness

POST-TEST

FOLLOW-UP

N

(29.92) (.0) (.0) (33.85) (15.75) (20.47) (11.3)

(45.7) (.8) (3.1) (15.0) (14.2) (21.3) (15.7)

(37.0) (1.6) (3.1) (17.3) (11.0) (29.9) (21.3)

20 0 2 29 17 27 7

39 2 4 20 14 18 18

42 0 2 14 20 23 13

N

(21.28) (.0) (2.13) (30.85) (18.09) (27.66) (11.3)

(41.49) (2.1) (4.3) (21.3) (14.9) (19.1) (19.1)

(44.7) (.0) (2.1) (14.9) (21.3) (24.5) (13.8)

%

S-LP (n = 94)

34 0 1 19 13 24 3

33 0 1 17 18 22 10

38 0 2 11 21 19 12

N

(36.26) (.0) (1.1) (21.98) (14.29) (26.37) (4.7)

(36.3) (.0) (1.1) (18.7) (19.8) (24.2) (7.6)

(41.8) (.0) (2.2) (12.1) (23.1) (20.9) (13.2)

%

S-PC (n = 91)

24 1 1 15 19 19 6

30 0 1 14 12 19 6

32 5 2 5 6 28 17

N

%

(30.38) (1.27) (1.27) (18.99) (24.05) (24.05) (9.5)

(38.0) (.0) (1.3) (17.7) (15.2) (24.1) (11.0)

(40.5) (6.3) (2.5) (6.3) (7.6) (35.4) (21.5)

S-AR (n =79)

24 0 5 35 10 15 24

29 1 3 32 12 12 26

30 1 5 17 10 17 28

N

(26.97) (.0) (5.62) (39.33) (11.24) (16.85) (45.3)

(32.6) (1.1) (3.4) (36.0) (13.5) (13.5) (29.2)

(33.7) (1.1) 5.6) (19.1) (11.2) (19.1) (31.5)

%

WL (n = 89)

n.s. n.s. n.s. n.s. n.s. n.s. 28.45*

14.14* n.s. n.s. n.s. n.s. n.s. 16.00*

n.s. n.s. n.s. n.s. n.s. n.s. n.s.

X2

Note: SC = Saluda Complete program; S-PC = Saluda program minus the Public Commitment component; S-AR = Saluda program minus the Advertising Resistance component; S-LP - Saluda program minus the Leisure Promotion component; WL = Waiting-List control group. *p < .001; **p = .0.

PRE-TEST

%

SC (n = 127)

Table 2. Proportion of Participants Reporting the Use of Alcohol and Drunkenness

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Drunkenness was significantly lower in the PS-CP compared to PS-AP at the posttest assessment (d = 0.31). Effects on Protective Variables Table 3 includes the scores on perceived norms, level of knowledge, substance use intention, and social skills. Perceived norms regarding alcohol consumption were significantly lower in the four intervention conditions compared to the control group (F (4.312) = 10.73, p < .001) at the posttest (S-LP d = –0.91, S-AR d = –0.94, SC d = –0.67, SC-PC d = –0.71) and the follow-up (F (4.312) = 3.47, p < .001, S-LP d = –0.64) assessments. We also found significant differences between condition S-LP versus S-PC and SC, finding lower scores on perceived norms among participants in the S-LP condition (d = 0.24 and d = –0.22, respectively). The scores on perceived norms regarding drunkenness were significantly lower in the four intervention conditions compared to the control group at the posttest and follow-up assessments. The largest mean difference across conditions concerned WL versus both S-LP (d = –0.76) at follow-up. Participants in the S-LP group at posttest and follow-up and subjects from the S-AR intervention group at follow-up, showed greater increases in the level of knowledge about alcohol than the waiting-list (WL) condition. However, the largest mean difference across conditions concerned S-LP versus WL (d= 0.86) at follow-up, in which the level of knowledge for the S-LP group was substantially higher than the level from the control group. Also, participants in the S-LP condition had higher levels of knowledge about alcohol compared to those in the SC and S-PC condition, with moderate effects sizes (SC posttest d = –0.73 and follow-up d = –0.65; S-PC posttest d = 0.53). Participants in the S-LP, S-PC, and S-AR conditions had greater increases in knowledge about illicit drugs than the waiting-list (WL) condition (S-LP posttest d = 0.51 and follow-up d = 0.87; S-AR follow-up d = 0.80; S-PC follow-up d = 0.76). Also, participants in the S-LP condition showed higher levels of knowledge about illicit drugs in comparison to those in the SC condition (posttest d = –0.42 and follow-up d = –0.26). Drug use intention was significantly lower in the four conditions compared to the waiting-list (WL) at the posttest (SC d = 0.44; S-LP d = 0.30; S-PC d = 0.46; S-AR d = 0.14) and follow-up (SC d = –0.58; S-LP d = 0.63; S-PC d = 0.64; S-AR d = 0.30) assessments. At the same time, the differences among the four intervention conditions were statistically non-significant neither at posttest nor at follow-up. Students who received PS-LP and PS-AP conditions significantly increased their social skills compared to the SC group at posttest. The largest mean difference across conditions was between the PS-LP and the SC conditions (d = 0.72). With respect to participation in leisure activities, significant differences were observed across experimental conditions at follow-up (see Table 4). Participation entailed both volunteer activities (P2 = 18.611, p < .001) and reading (P2 = 12.087,

PERCEIVED NORMS

KNOWLEDGE

FOLLOW-UP

POSTTEST

PRETEST

FOLLOW-UP

POSTTEST

PRETEST

Illicit drugs

Alcohol

Illicit drugs

Alcohol

Illicit drugs

Alcohol

Drunkenness

Alcohol

Drunkenness

Alcohol

Drunkenness

Alcohol

M (SD) 70.76 (18.50) 62.78 (23.36) 59.49 (20.28) 51.08 (23.07) 67.30 (20.23) 57.22 (25.47) 6.47 (1.80) 3.00 (1.82) 6.85 (1.87) 5.00 (1.96) 6.90 (1.55) 4.63 (1.82)

M (SD) 70.27 (24.09) 63.13 (26.14) 63.70 (20.44) 57.40 (23.86) 62.42 (17.68) 49.52 (20.52) 6.03 (1.80) 3.52 (1.89) 6.63 (1.99) 4.66 (1.98) 6.69 (1.73) 4.59 (1.90)

M (SD) 75.21 (15.02) 68.09 (21.24) 59.09 (22.05) 53.62 (24.78) 61.03 (22.22) 51.94 (22.89) 6.87 (1.64) 3.63 (1.91) 7.67 (1.95) 6.24 (7.96) 7.55 (1.72) 4.71 (1.76)

69.96 (18.90) 62.72 (23.22) 64.29 (20.62) 61.00 (22.43) 66.41 (21.65) 55.46 (21.93) 6.31 (2.04) 3.76 (2.10) 6.02 (2.35) 3.98 (2.01) 6.37 (1.89) 4.27 (1.63)

S-AR (n = 79)

M (SD)

S-PC (n = 91)

S-LP (n = 94)

SC (n = 127)

6.65 (1.93) 3.42 (1.90) 6.61 (1.98) 3.27 (1.79) 5.64 (2.63) 3.25 (1.61)

78.31 (16.42) 69.07 (22.13) 77.51 (18.30) 68.91 (23.95) 73.58 (16.59) 68.96 (21.71)

M (SD)

WL (n =89)

6.66*

7.73*

7.63*

8.79*

n.s.

n.s.

6.24*

3.47*

7.70*

10.73*

n.s.

n.s.

F

Table 3. Means and Standard Deviations in Perceived Norms, Knowledge, Substance Use Intention and Social Skills

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INTENTION USE

FOLLOW-UP

POSTTEST

PRETEST

FOLLOW-UP

POSTTEST

Prosocial

Antisocial

Prosocial

Antisocial

Prosocial

Antisocial

1.32 (1.14) 1.00 (1.05) 1.05 (1.00)

48.18 (13.23) 84.40 (15.00) 49.68 (13.27) 84.59 (14.62) 47.71 (13.36) 87.24 (12.79)

1.24 (1.28) 1.20 (1.23) 1.11 (1.24)

50.36 (14.96) 78.32 (15.96) 50.45 (14.59) 76.20 (17.00) 48.93 (14.56) 83.01 (12.80) 50.81 (12.32) 80.08 (15.54) 53.32 (15.00) 80.54 (16.23) 47.64 (11.33) 84.27 (15.38)

.96 (1.06) 1.16 (1.22) 1.05 (1.11)

50.34 (12.06) 82.14 (12.71) 53.06 (13.20) 84.81 (11.72) 53.10 (12.20) 84.16 (11.74)

1.71 (1.49) 1.58 (1.31) 1.40 (1.43)

48.40 (13.59) 82.37 (15.93) 50.25 (13.65) 83.64 (14.89) 50.43 (13.82) 80.85 (15.97)

1.45 (1.39) 1.78 (1.45) 2.13 (2.11)

n.s.

n.s.

4.17*

n.s.

n.s.

n.s.

6.87*

3.14**

n.s.

Note: SC = Saluda Complete program; S-PC = Saluda program minus the Public Commitment component; S-AR = Saluda program minus the Resistance to Advertising component; S-LP = Saluda program minus the healthy Leisure Promotion component; WL = Waiting-List control group. *p < .001; **p = .01.

SOCIAL SKILLS

PRETEST

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% (74.2) (93.7) (97.8) (73.0) (83.1) (75.3) (51.7) (9.0) (67.4) (85.4) (97.8) (77.5) (78.7) (85.4) (74.2) (9.0) (71.7) (88.7) (92.5) (67.9) (75.5) (88.7) (50.9) (3.8)

N 66 74 87 65 74 67 46 8 60 76 87 69 70 76 66 8 38 47 49 36 40 47 27 2

% (86.1) (79.1) (98.7) (58.2) (59.5) (84.8) (58.2) (1.3) (81.0) (92.4) (97.5) (69.6) (65.8) (84.8) (84.8) (1.3) (73.0) (90.5) (95.2) (76.2) (66.7) (93.7) (57.1) (3.2)

N 68 72 78 46 47 67 46 1 64 73 77 55 52 67 67 1 46 57 60 48 42 59 36 2

% (67.0) (79.1) (93.4) (58.2) (69.2) (86.8) (51.6) (1.1) (65.9) (91.2) (93.4) (81.3) (76.9) (85.7) (73.6) (2.2) (87.5) (92.2) (96.9) (81.3) (67.2) (81.3) (54.7) (3.1)

N 61 72 85 53 63 79 47 1 60 83 85 74 70 78 67 2 56 59 62 52 43 52 35 2

(73.4) (81.9) (94.7) (64.9) (64.9) (73.4) (48.9) (7.4) (70.2) (88.3) (96.8) (66.0) (64.9) (75.5) (78.7) (9.6) (88.7) (85.5) (95.2) (69.4) (66.1) (83.9) (59.7) (11.3)

69 77 89 61 61 69 46 7 66 83 91 62 61 71 74 9 55 53 59 43 41 52 37 7

(80.3) (86.6) (92.1) (68.5) (78.7) (81.1) (47.2) (3.9) (70.9) (87.4) (94.5) (67.7) (74.6) (79.5) (71.3) (6.3) (94.4) (85.9) (87.3) (70.4) (67.6) (80.3) (50.7) (15.5)

102 110 117 87 100 103 60 5 90 111 120 86 91 97 87 8 67 61 62 50 48 56 36 11

Reading Sport TV Disco-bar Console Chat Outdoor Volunteer

Reading Sport TV Disco-bar Console Chat Outdoor Volunteer

Reading Sport TV Disco-bar Console Chat Outdoor Volunteer

WL

%

S-AR

N

S-PC

%

S-LP

N

SC

Table 4. Distribution of Participants Performing Leisure Activities

POST-TEST

FOLLOW-UP

PRE-TEST

Note: SC = Saluda Complete program; S-PC = Saluda program minus the Public Commitment component; S-AR = Saluda program minus the Resistance to Advertising component; S-LP = Saluda program minus the healthy Leisure Promotion component; WL = Waiting List control group.

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345

p < .01). A higher proportion of participants in the waiting-list group (WL) reported no reading compared to those in the SC and S-LP conditions (d = 0.70 and d = 0.46 respectively). The proportion of participants who read was significantly lower in the S-AR group compared to the SC, S-PC, and S-LP groups (d = 0.64, d = .37 and d = 0.41 respectively). On the other hand, participation in volunteer activities was significantly higher in the S-LP group compared to the waiting-list group (d = 0.33). Also, the proportion of participants in volunteer activities was higher among SC participants compared to those in the S-PC and S-AR groups, with low effect sizes. The largest mean difference across conditions was found when comparing the SC and S-PC conditions (d = 0.36). No significant differences were found between the SC and S-LP condition. DISCUSSION The main objective of this study was to examine the contribution of three components (public commitment, resistance to advertising, and leisure promotion) from a prevention program, in order to ascertain their specific effects on outcomes and, in addition, to determine if certain components could be removed with the aim of improving cost-effectiveness. By means of an intervention dismantling strategy, the efficacy of the different conditions (complete program, program minus public commitment, program minus resistance to advertising, program minus leisure promotion, and a waiting-list control group) was tested. We compared each condition with both the other conditions and with a waiting-list control group on substance use—alcohol and illicit drugs—and on protective variables— knowledge, social skills, leisure promotion, substance use intention, and perceived norms. In general, the findings indicated that the four prevention conditions were significantly more effective than the waiting-list control condition in reducing the number of drunkenness episodes at posttest and follow-up. The complete program condition was significantly more effective than the waiting-list control condition in alcohol use at posttest, although they did not significantly reduce the frequency of alcohol use at 6-month follow-up. A plausible explanation for this finding may be that a follow-up period of 6 months is insufficient to observe significant changes in regular consumption. Behavioral effects from prevention programs are not always immediately evident but tend to be revealed over time, after a certain period of time since the intervention has elapsed (Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995; Pentz, 1994). Furthermore, the four prevention conditions were significantly more effective than the waiting-list control concerning the majority of the protective variables included in the study design. The contribution of the program minus leisure promotion with respect to the waiting-list control is especially remarkable, regarding the improvement within the following variables: perceived norm about alcohol and drunkenness, level of knowledge about alcohol and illicit drugs, drug use

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intention, and leisure activities (reading and volunteer activities), with high effect sizes concerning the majority of these protective variables. The hypothesis that the complete program would be more effective than the incomplete versions was supported when comparing it to the program minus public-commitment and the program minus resistance to advertising. The importance of public commitment and resistance to advertising is stated, concerning the reduction on alcohol consumption and the increase in participants performing leisure activities (volunteer activities). Future prevention programs should give high priority to the public commitment and resistance to advertising components, as they provide substantial effects on consumption within the Saluda program. The Saluda program minus the leisure promotion condition was significantly more effective than the complete program with reference to the following protective variables: perceived norm about alcohol, level of knowledge about alcohol and illicit drugs, and social skills. However, no significant differences were found between the complete program and the program minus the leisure promotion condition in order to reduce alcohol use, drunkenness, drug intention use, and to increase volunteer activities. Thus, we can conclude that, when excluding the healthy leisure promotion component, outcomes in three of the protective variables (perceived norm about alcohol, level of knowledge about alcohol and illicit drugs, and social skills) are improved. Furthermore, concerning reduction alcohol use, drunkenness, drug intention use and to increase volunteer activities, the Saluda program shows no loss of effectiveness when excluding the leisure promotion component. When we compared the influence of the three components (public commitment, resistance to advertising, and leisure promotion) among themselves, significant differences were observed. The public commitment component was more effective than the leisure promotion component in improving the levels of perceived norms and knowledge about alcohol. This is consistent with several studies supporting the efficacy of the public commitment component (Flay, 2009; Hansen et al., 2009). We only identified differences between public commitment and resistance to advertising in relation to reducing drunkenness and increasing leisure activities (reading). The largest effects concerned resistance to advertising. These findings are consistent with several studies (Botvin, 2000; Gonzalez et al., 2000). The most likely reasons to explain why the healthy leisure component did not have a positive effect might be the following three options: 1. Within the framework of the Saluda Program, the leisure promotion component entails a search for information concerning the leisure opportunities offered within the city. Thus, students participate in the active search for information. However, the most positive results identified within this framework belong to specific alternative programs with an extracurricular application scope within adolescents in general risk or vulnerable groups. Some of these programs are well-known in Spain, as they have been

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thoroughly tested, as in Abierto hasta el amanecer (Fernández & Secades, 2003) or La noche más joven (Martín & Moncada, 2003). 2. The theoretical alternative models are less supported than theoretical models based on competences development, as traditional approaches do not include strategies inspired by the explicative psychological theories and, moreover, they have not proved to have the same effectiveness. 3. Some studies conclude that programs promoting alternative leisure have no impact on the consumption behavior (Schaps, Moscowitz, Malvin, & Schaeffer, 1986). Furthermore, consumption may be encouraged whenever these activities are presented in a non-structured way (Hansen, 1995). On the other hand, the increase in healthy activities practiced within leisure time (e.g., sport) does not necessarily entail that other kinds of activities (such as going to bars or clubs) will not be done additionally (Calafat, Amengual, Mejías, Borrás, & Palmer, 1989). A recent systematic review of 17 longitudinal studies examined the relationship between sports participation and alcohol and drug use in adolescents. Results indicated that participation in sport is associated with alcohol use and it also appears to be related to a certain level of reduction on illicit drugs use (Kwan, Bobko, Faulkner, Donnelly, & Cairney, 2014). It is of paramount importance not only to determine what is effective in a schoolbased drug abuse prevention program, but also to find out what is not effective and why so (Fernandez, Nebot, & Jané, 2002). Our findings indicate that the leisure promotion component could be eliminated from the intervention, which would likely increase the overall cost-benefit for the program by reducing the number of sessions. While the inappropriate use of leisure promotion may be a risk factor for other health-related outcomes such as obesity, in the present study we found that this component had little or no efficacy in terms of the study variables. From a societal perspective, the costs of effective prevention are well worth, at least in developed countries (Flay, 2009). On the other hand, it might be appropriate to deliver the intervention in a modular fashion, identifying in advance the needs of specific groups of students and delivering briefer tailored versions of the program that addresses the largest deficit in each group. Our findings should be interpreted in light of our study’s methodological limitations. First, the nature of the participants (Spanish urban students from medium-high socioeconomic backgrounds) suggests that the results may not be generalizable to populations from different socioeconomic backgrounds. Further research should replicate the present study with a wider range profile of socioeconomic and geographical samples. On another note, the fact that all of our measures were self-reported by students explains another limitation: although it is a commonly accepted method of data collection within the framework of programevaluations, the inclusion of objective behavioral indicators for some constructs would be useful in future studies (Espada et al., 2012). In order to control the

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appropriate application of the protocols, it would be convenient to control and assess the fidelity of implementation of the program, with the aim of determining if it has been applied as stated by its design and evaluation pilot (Dusenbury, Branningan, Falco, & Hansen, 2003), considering that the fidelity of this deployment largely determines the success of a preventive intervention (SánchezMartínez, Ariza, Pérez, Diéguez, López, & Nebot, 2010). We can conclude that, when removing the healthy leisure promotion component, the Saluda program shows no loss of efficacy neither on substance consumption nor on other protective variables, whilst public commitment and resistance to advertising improve the aforementioned program’s efficacy. Therefore, it is possible to improve the cost-benefit intervention balance by implementing the program with the core components plus the secondary components “public commitment” and “resistance to advertising,” and excluding “leisure promotion.”

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