C 2006) The Journal of Primary Prevention, Vol. 27, No. 2, March 2006 ( DOI: 10.1007/s10935-005-0029-1
Cross-Cultural Adaptation and Evaluation of a Home-Based Program for Alcohol Use Prevention among Urban Youth: The “Slick Tracy Home Team Program” Kelli A. Komro,1,3 Cheryl L. Perry,2 Sara Veblen-Mortenson,2 Kian Farbakhsh,2 Kari C. Kugler,2 Karen A. Alfano,2 Bonnie S. Dudovitz,2 Carolyn L. Williams,2 and Rhonda Jones-Webb2 Published online: 24 February 2006
The current study describes the extensive cross-cultural adaptation of a brief home-based alcohol prevention program for racially and ethnically diverse sixth grade students and their families, using a randomized controlled trial design involving 60 public schools in the city of Chicago (N = 3,623 students). The adapted program achieved high participation levels (73%) overall, as well as in single parent families, non-English homes, and low-income students, among other at risk groups. Lower levels of factors associated with the onset of alcohol use (i.e., normative expectations and outcome expectations) were achieved in the intervention group compared to the control group. However, no differences were observed for several other protective factors or alcohol use. Editors’ Strategic Implications: The experimental design, large sample, and specific adaptation of the program for an ethnically diverse urban population of children and their families provide a model for culturally appropriate prevention efforts. Further, the attitudinal results (and dose-response findings) of the Slick Tracy alcohol prevention program are promising. KEY WORDS: family; prevention; alcohol use; young adolescents; randomized trial.
1 Department of Epidemiology & Health Policy, University of Florida, College of Medicine, Florida. 2 University of Minnesota, School of Public Health, Minnesota. 3 Address correspondence to Kelli A. Komro, Ph.D., Department of Epidemiology & Health Policy
Research and Institute for Child Health Policy, University of Florida, College of Medicine, 1329 SW 16th Street, Room 5130, P.O. Box 100177, Gainesville, Florida 32610-0177; e-mail:
[email protected]. 135 C 2006 Springer Science+Business Media, Inc. 0278-095X/06/0300-0135/1
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INTRODUCTION Recent research in the area of family strategies to prevent alcohol and other drug use among general populations of adolescents supports the efficacy of familybased approaches, with some important questions remaining regarding achievable participation levels, level of intensity for behavior change to occur, and generalizability of findings to diverse racial and ethnic populations (Bauman, Foshee, et al., 2001; Drug Strategies, 1996; Dusenbury & Falco, 1995; Komro & Toomey, 2002; National Institute on Drug Abuse, 1997; Spoth, Redmond, & Shin, 2001). Two promising approaches to engaging parents in prevention include groupbased family-skills training programs (Brody et al., 2004; Kumpfer, Molgaard, & Spoth, 1996; National Institute on Drug Abuse, 1997; Spoth et al., 2001; Spoth, Guyll, Chao, & Molgaard, 2003) and home-based parent-child structured activities (Bauman, Foshee, et al., 2001; Werch et al., 2003; Williams, Perry, et al., 1995). The most rigorous evaluation of a group-based family training program was conducted in a rural setting of a Midwestern state with 33 participating schools and nearly all White participants (Spoth et al., 2001). Schools were randomly assigned to one of three experimental conditions: (1) seven-session Iowa Strengthening Families Program, (2) five-session Preparing for the Drug-Free Years, or (3) control. The two family programs included either five or seven weekly 2-hr group sessions for parents, with some sessions attended by young adolescents for structured parent-child interactions to take place. Typically, 8–10 families participated in each group session. Sessions were conducted by trained group leaders. Fifty-one percent of families participated in the pretest, and of those, close to 50% agreed to participate in the family skills training workshops. Thus, only 27% of eligible families agreed to participate in the family programs. There was nearly full attendance by 90% and complete attendance by 60% of those families (Spoth et al., 2001). Therefore, nearly full participation was achieved by 24% of eligible families. The programs were implemented when the students were in sixth grade and the students were assessed through tenth grade. Findings showed evidence of delayed initiation and lower alcohol and tobacco use among the intervention groups compared with the control group, with more significant differences among the more-intensive Iowa Strengthening Families Program. Spoth and colleagues (2003) adapted the Strengthening Families Program for African American families and conducted an exploratory study of its effectiveness. Changes to the program included surface structure changes with depiction of African American families and artwork, with the content of the program remaining the same. A random selection of 200 families who had completed a first wave of assessments for a longitudinal study was recruited to participate in the evaluation of the program. Of the 200 families, 151 could be contacted, 110 participated in the intervention study, and 85 families provided data sufficient for
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inclusion in the study. Of those, 34 were in the intervention group and 51 were in the waitlist-control group. These numbers, again, attest to the difficulty of recruiting families to attend group sessions. Of the eight proximal outcome variables tested, two significantly increased in the intervention compared with the control group after the program implementation: child participation in family meetings and intervention-targeted child behaviors. Alcohol-related peer resistance, alcohol refusal, and general peer resistance did not change significantly in either group. Further cultural adaptations were conducted on the Strengthening Families Program for rural African American families and it was, therefore, renamed Strong African American Families Program (Brody et al., 2004). Eight county-units were randomly assigned to intervention or control condition. Schools in these counties provided lists of 11-year-old students and 521 were selected randomly to be recruited for participation in this study. The recruitment rate was 64% and similar across intervention and control counties; 150 families in the control counties participated in the pretest and 172 families in the intervention counties participated in the pretest, with high retention for the posttest (96–97%). Among the 172 families in the intervention condition, 21 did not attend any prevention activities. Approximately 65% of the pretested families (approximately 41% of eligible families) took part in five of seven sessions, 44% (approximately 28% of eligible families) attended all seven sessions. As hypothesized, the families in the intervention condition had significantly higher communicative parenting practices and youth protective factors than families in the control condition three months after the intervention. In addition, there was evidence that the intervention induced changes in parenting practices that promoted the development of youth protective factors. The participation rates were higher than reported in the previous studies, and suggest the importance of cultural adaptations to appeal to various populations. Because of the difficulty in recruiting and retaining families to participate in group-based family skills training programs, home-based approaches have been developed to achieve more favorable participation. These types of programs can be implemented at times and places convenient to each family. However, these types of programs are generally less intensive and are often reinforced with other school and community strategies in order to create behavior change on adolescent alcohol and other drug use (Perry et al., 1996; Werch et al., 2003; Williams, Perry, et al., 1995). Home-based activities have been implemented through schools with participation rates over 70% (Werch et al., 2003; Williams, Perry, et al., 1995) and independent of schools with a participation rate just under 50% (Bauman, Foshee, et al., 2001). Bauman, Foshee, and colleagues (2001) designed and implemented a foursession home-based program that was completely independent from school programs. Adolescents aged 12 to 14 and their families were identified by
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random-digit dialing throughout the contiguous United States. The program included four mailed booklets and telephone contacts by health educators. Of the eligible families, 55% completed a baseline survey and were randomly assigned to intervention or control condition. Among the intervention group who completed the baseline survey, 84% started the program and 74% completed it. Among the eligible families, therefore, 46% began the program and 34% completed it. Follow-up interviews were conducted 3 and 12 months after program completion. Smoking onset was reduced by 16% among the entire sample and by 25% among non-Hispanic whites. No differences were found between the intervention and control group for onset of alcohol or smokeless tobacco use. Another randomized trial evaluated a home-based program that was associated with school components. Werch and colleagues (2003) implemented and evaluated a two-year intervention, which included prevention postcards and four family take-home lessons, as well as two brief one-on-one consultations between each student and a nurse about why and how the child should avoid alcohol. Two schools in Jacksonville, Florida were included in the study and students within schools were randomly assigned to the intervention or control condition. Of participating students, 58% were African American students and 34% were white, and over half were in the free lunch program. No information was provided regarding the participation and completion of the family lessons. However, it was reported that between 94 and 98% of parents talked with their child about individual take-home lessons. Alcohol intentions and an overall alcohol risk factor scale were significantly lower among the intervention group compared with the control group. Alcohol use was lower among the intervention group, but differences were not statistically significant. Our research team has been involved with the design and evaluation of parent strategies for over 20 years. Perry and colleagues began with the design of “hometeam” approaches for cardiovascular health promotion (Perry, 1986; Perry et al., 1988). The rationale for the design of home-based approaches was to enhance parental involvement and participation by developing non-traditional, non-class based, activity formats to be implemented in the home (Perry, 1986; Perry, Mullis, & Maile, 1985; Perry et al., 1988). A randomized school trial was conducted involving 31 schools and 2,250 predominantly Caucasian and middle class students and their families to compare a school and home-based program with the schoolbased program alone or control condition. The home-based program included five packets that were mailed to each child’s home on a weekly basis. The packets were designed as a family game using a baseball motif and included: (1) an adventure story, which provided role models for healthy eating; (2) games that distinguish between “everyday” and “sometimes” foods, stickers to label household foods as heart healthy, and sodium searches; (3) goal setting; (4) recipes; (5) refrigerator tip sheets; and (6) participation points that were returned to the school. Participation
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in the home program was high; 86% of parents participated and 71% fully completed the five-week course. Students in the home-based program had the most positive outcomes with more behavior change, reduced total fat, saturated fat, and monounsaturated fat in their diets, and more of the encouraged foods on their food shelves. Due to the success of the “home-team” approach with cardiovascular health behaviors, the approach was then incorporated into smoking prevention with a program called the Unpuffables (Perry, Pirie, Holder, Halper, & Dudovitz, 1990) and as part of an alcohol prevention trial (Perry et al., 1993; Williams, Perry, et al., 1995). A home-based prevention program for sixth grade students and their parents was developed and evaluated as part of a multiple component alcohol use preventive intervention called Project Northland. Project Northland is an intervention with school, peer, family and community components. It was originally developed and evaluated in the northeastern region of Minnesota, which includes small, rural communities with primarily a White population. It is an area of the country with high alcohol-related problems. The first year of the intervention included a home-based program called the Slick Tracy Home Team Program (Williams, Perry, et al., 1995). The program consists of four sessions of activity booklets, small group activities to introduce each session in the classroom, and small group projects that students completed in the classroom. Students brought home the activity booklets to read and complete with their parents during four consecutive weeks. A randomized trial was conducted to evaluate Project Northland, with 24 school districts randomly assigned to intervention or delayed program-control group. Evaluation of the Slick Tracy program consisted of school surveys implemented at the beginning (baseline) and end (follow-up) of sixth grade. High levels of participation were obtained overall (76%) and across gender, race/ethnicity, and risk status. Increases in knowledge and family communication about alcohol use were found (Williams, Perry, et al., 1995). After three years of exposure to the full Project Northland multiple component intervention, alcohol use rates were lower among students in the intervention schools compared with the control schools (Perry et al., 1996). The current study documents the cross-cultural adaptation of the Slick Tracy Home Team Program for racially and ethnically diverse youth and their families living in Chicago (Komro, Perry, Veblen-Mortenson, et al., 2004). One main research question was whether the adapted program could achieve overall high participation levels among families in a large urban area, as well as across various subgroups defined by race/ethnicity, family composition, income, and language spoken at home. Another main research question was whether improvements in proximal risk and protective factors related to alcohol use onset would be observed among students eligible for participation in this brief family program compared to students in the control group.
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METHOD Study Design The study design is a randomized controlled trial of schools and surrounding community areas in the city of Chicago (Komro, Perry, Veblen-Mortenson, et al., 2004). From a list of all public schools in Chicago, 122 schools were selected for recruitment that included grades 5 through 8, had relatively low mobility rates (
