Abstract
This study examined the efficacy of a healthy lifestyle family-based intervention in reducing substance use and sexual risk behaviors compared with prevention as usual over 24 months in Hispanic adolescents. Participants were overweight/obese Hispanic adolescents (N = 280; M age 13.01; SD = .82) in the 7th/8th grade and their primary caregivers. Participants were randomized to either the healthy lifestyle family-based intervention or to the control condition (i.e., referral to community services offered for overweight and/or obese adolescents and their families). Outcomes included adolescent substance use and sexual risk behaviors among adolescents. Intervention effects were found for adolescent alcohol (b = − 0.37, 95% CI = [− 0.49, − 0.26]), marijuana (b = − 1.00, CI = [− 1.22, − 0.78]), and non-prescription drug use (b = − 3.77, CI = [− 6.49, − 1.05]) over 24 months. No significant intervention effects were found for adolescent sexual risk behaviors. Findings suggest that Familias Unidas for Health and Wellness reduces adolescent alcohol, marijuana, and non-prescription drug use across time. ClinicalTrials.gov Identifier: NCT03943628
Keywords: Family-based intervention, Obesity, Substance use, Sexual risk behaviors, Adolescents
Introduction
Substance use and sexual risk behaviors disproportionately affect Hispanic adolescents in the United States (US) compared with their non-Hispanic White counterparts (Kann et al., 2018). For example, Hispanic adolescents have greater lifetime alcohol use, marijuana use, and prescription drug use without doctor approval, and report having more multiple sex partners compared with non-Hispanic White adolescents (Abma & Martinez, 2017; Centers for Disease Control and Prevention [CDC], 2019). Previous research has shown that substance use and sexual risk behaviors intersect with overweight/obesity. Specifically, studies have shown that obese adolescents reported higher levels of substance use behaviors when compared with non-obese adolescents (Zeller et al., 2016). Additionally, overweight status has also been associated with not using a condom at last intercourse for sexually active high school students (Akers et al., 2016; Lowry et al., 2014). Therefore, it is possible that interventions aimed at reducing overweight/obesity may also prevent substance use and sexual risk behaviors among Hispanic adolescents.
Familias Unidas for Health and Wellness (FUHW) is a healthy lifestyle family-based intervention designed to improve physical activity and dietary behaviors (i.e., reduce intake of added sugars and sugar sweetened beverages, and improve intake of fruits and vegetables) to reduce overweight and obesity among Hispanic adolescents and their primary caregivers (St. George et al., 2018). This intervention was found to be efficacious in improving dietary intake and reducing body mass index in Hispanic primary caregivers and improving family functioning behaviors in Hispanic adolescents (Prado et al. 2020). FUHW was adapted from an evidence-based family intervention (Familias Unidas) originally designed to reduce or prevent conduct problems, substance use, and sexual risk behaviors with Hispanic adolescents (Estrada et al., 2017; Prado & Pantin, 2011; Prado et al., 2007). As an adapted intervention, FUHW not only abridged some of the original Familias Unidas content related to substance use and sexual risk behavior but also included new content on physical activity and dietary behaviors to reduce overweight and obesity in Hispanic adolescents and their primary caregivers. Family functioning, which has previously been shown to be negatively associated substance use behaviors and sexual risk-taking behaviors (Cano et al., 2016; Wagner et al., 2010), was the primary mechanism of change in the original Familias Unidas intervention and was included in FUHW.
Therefore, the aims of the current study were to examine the efficacy of Familias Unidas for Health and Wellness (FUHW) in reducing substance use and sexual risk behaviors among Hispanic youth who were overweight/obese. We hypothesized that (1) the adapted FUHW intervention would retain the effects on substance use and sexual risk behaviors and (2) adolescents participating in FUHW would report lower levels of substance use and sexual risk behaviors compared with those in prevention as usual.
Method
Participants
Participants included for the purpose of this study were 280 (FUHW n = 140, control condition n = 140) overweight and obese Hispanic adolescents in the 7th and 8th grade. Of the Hispanic adolescents, 45.1% were overweight (85th to 95th percentile), 42.1% were obese (95th to 98th percentile), and 12.8% were severely obese (≥ 99th percentile). The mean adolescent age was 13.01 years old (SD = 0.83). Parents were on average 41.88 years old (SD = 6.50). Approximately half of adolescents (52.1%) and a majority of parents (88.2%) were female. Most parents (91.1%, n = 255) were born outside of the US, whereas a majority of adolescents were born in the US (64.3%, n = 180). Participating families were low income; 62.1% reported a household income less than $30,000 per year. Demographics for study participants are presented in Table 1.
Table 1.
Participant characteristics at baseline (N = 280)
| Characteristic | Total (N = 280) n (%) or mean (SD) | FUHW (n = 140) n (%) or mean (SD) | Control (n = 140) n (%) or mean (SD) | p-value |
|---|---|---|---|---|
|
| ||||
| Adolescent | ||||
| Age, mean (SD) | 13.01 (0.83) | 13.04 (0.87) | 12.99 (0.79) | 0.61 |
| Gender | 146 (52.3) | 69 (49.3) | 77 (55.0) | 0.37 |
| Female, n (%) | ||||
| Country of origin | 100 (35.7) | 55 (39.3) | 32.1 | 0.19 |
| Foreign born, n (%) | 180 (64.3) | 85 (60.7) | 67.9 | |
| US born, n (%) | ||||
| Number of years in the USA | 24 (8.6) | 11 (7.9) | 13 (9.3) | 0.62 |
| Less than 1 year, n (%) | 69 (24.6) | 38 (27.1) | 31 (22.1) | |
| 1–9 years, n (%) | 185 (66.1) | 91 (65.0) | 94 (67.1) | |
| More than 9 years, n (%) | ||||
| No response, n (%) | 2 (0.07) | 0 (0.0) | 2 (1.5) | |
| BMI | 0.51 | |||
| Overweight (85th-95th percentile), n (%) | 123 (45.1) | 57 (41.6) | 66 (48.5) | |
| Obese (95th to 98th percentile), n (%) | 115 (42.1) | 61 (44.5) | 54 (39.7) | |
| Severely obese (≥ 99th percentile), n (%) | 35 (12.8) | 19 (13.9) | 16 (11.8) | |
| Primary caregiver | ||||
| Age, mean (SD) | 41.88 (6.50) | 42.09 (6.30) | 41.66 (6.70) | 0.58 |
| Gender | 247 (88.2) | 122 (87.1) | 125 (89.3) | 0.58 |
| Female, n (%) | ||||
| Country of origin | 255 (91.1) | 126 (90.0) | 129 (92.1) | 0.53 |
| Foreign born, n (%) | 25 (8.9) | 14 (10.0) | 11 (7.9) | |
| US born, n (%) | ||||
| Marital status | 0.47 | |||
| Married, n (%) | 162 (57.9) | 80 (57.1) | 82 (58.6) | |
| Living with someone, n (%) | 28 (10.0) | 14 (10.0) | 14 (10.0) | |
| Separated, n (%) | 28 (10.0) | 18 (12.9) | 10 (7.1) | |
| Divorced, n (%) | 36 (12.9) | 17 (12.1) | 19 (13.6) | |
| Widowed, n (%) | 2 (0.7) | 0 (0.0) | 2 (1.4) | |
| Never married and not living with someone, n (%) | 24 (8.6) | 11 (7.9) | 13 (9.3) | |
| Income | ||||
| Less than $25,000 | 151 (53.9) | 73 (52.1) | 78 (55.7) | 0.45 |
| $25,000 or more | 115 (41.1) | 61 (43.6) | 54 (38.6) | |
Study Design
This study consists of data analysis of a randomized-controlled trial to determine the efficacy of FUHW, compared with the control condition, on adolescent substance use and sexual risk behaviors. Adolescents were assessed at baseline and 6, 12, and 24 months post-baseline for a variety of behaviors including, but not limited to, physical activity, body mass index, dietary behaviors, and family functioning. One adolescent per family and their primary caregiver were eligible to participate in the study if the Hispanic adolescent was a student in the 7th/8th grade, had a BMI ≥ 85th percentile adjusted for age and sex, lived with an adult primary caregiver willing to participate in the 2-year study, and had plans to remain a resident of the geographic study catchment area during the study period. FUHW is a 12-week preventive intervention delivered through 8 group sessions and 4 family sessions, each taking place once a week. During the first 1.5 h of the group sessions, facilitators led parent-only group sessions in discussing healthy lifestyle behaviors, risky behaviors, and positive-parenting behaviors (Prado et al., 2020). The adolescent was not present during the parent group sessions and instead participated in outdoor physical activities. During the second hour of the group sessions, parent and adolescent participated together in nutritional and physical activities (e.g., cooking classes, yoga). During family sessions, facilitators guided parent and adolescent in practicing the skills parents learned through the parent-only group sessions (e.g., role-playing activities). FUHW was adapted to contain the core components of Familias Unidas while increasing content related to physical activity and dietary behaviors. To adapt FUHW, while staying consistent with the number of sessions in Familias Unidas, a large portion of the substance use and sexual risk behavior related content was condensed or removed. Specifically, while parent homework assignment in the original Familias Unidas was focused on substance use and sexual risk behaviors, the parent homework assignments in FUHW were focused on physical activity and healthy dietary behaviors. Additional details regarding recruitment, randomization, and intervention design can be found elsewhere (St. George et al., 2018; Prado et al., 2020). The average overall intervention attendance, including group and family sessions, was 8.46 (SD = 3.90) out of a possible 12 sessions. Families who were randomized to the control condition (no active intervention from study staff) were referred to the local health department resources for physical activity and nutrition information. All study procedures were approved by the University of Miami’s social and behavioral sciences institutional review board.
Measures
Adolescent Substance Use
Adolescents’ substance use was assessed with items from a population-based epidemiologic survey, Monitoring the Future (Johnston et al., 2018). Specifically, adolescents reported whether and how many times they had used a particular substance (e.g., “On how many occasions have you taken a prescription drug without a prescription or taken more than what was prescribed, in the past 3 months?”) during the past 90 days at each assessment, including alcohol use, marijuana use, and non-prescription drug use.
Adolescent Sexual Risk Behaviors
Condomless sex was used to assess adolescents sexual risk behaviors (Jemmott III et al., 1998). Adolescents responded to an item taken from the Sexual Behavior Instrument: “In the past 3 months, about how often have you had vaginal or anal sex without using a condom?” Participant responses included 0 = Never, 1 = Less than half of the time, 2 = About half of the time, 3 = Not always, but more than half of the time, and 4 = Always.
Data Analysis Plan
Chi-square tests or independent t-tests were conducted to test for significant differences on baseline demographic characteristics (e.g., age, gender) and outcome variables (i.e., alcohol use, marijuana use, non-prescription drug use, and sexual risk behaviors) by condition. Regression analyses were conducted to examine intervention effects on the adolescent outcomes at 6 months post-baseline. To control for the effects of baseline outcomes, we specified the same outcomes at baseline as covariates in the regression model. To examine intervention effects on trajectories of the study outcomes over 2 years, a series of linear latent growth curve analyses were conducted (Muthén & Muthen, 2017). We included adolescent BMI percentiles (continuous) as a control variable for each model. To account for a non-normal distribution of the count variables (i.e., alcohol, marijuana, and non-prescription drug use), a Poisson distribution was used. To address the relatively small responses of condomless sex across time (baseline = 1.4% of total sample responded at least Less than half of the time; 24 months post-baseline = 5.4% of total sample responded at least Less than half of the time), binary variables were used to estimate trajectories of condomless sex. The condomless sex variable was recoded as 0 = Never and 1 = At least less than half of the time. To account for this categorical variable, the logistic distribution was used. We reported intervention effect sizes by dividing the absolute values of regression coefficients (unstandardized b) by the standard deviation of the residuals of outcomes (Meredith & Tisak, 1990). Additionally, the pooled incidence rate ratio (IRR) was used as intervention effects for count variables and was calculated by taking the exponent of the regression coefficient, i.e., unstandardized b (Spittal et al., 2015). Similarly, for the model with a binary outcome (i.e., condomless sex), odds ratio (OR) was used as an effect size. All analyses are intent-to-treat. We addressed missing data by using full information maximum likelihood (FIML) (Enders, 2011). All analyses were conducted with Mplus version 8.0 (Muthén & Muthen, 2017).
Results
Supplementary Fig. 1 shows the CONSORT flow diagram for this trial. There were no differences in attrition rates between the two study conditions across time (χ21df = 6.05, p = 0.11). Analyses indicated no significant differences at baseline by condition on key demographics and outcomes for adolescents (Table 1). Descriptive statistics of adolescent substance use and sexual risk behaviors across condition and over time are found in Table 2.
Table 2.
Descriptive statistics of adolescent substance use and sexual risk behaviors across condition and over time
| Overall sample (N = 280) |
Familias Unidas for Health and Wellness (n = 140) |
Control condition (n = 140) |
||||
|---|---|---|---|---|---|---|
| M (SD) | Min/max | M (SD) | Min/max | M (SD) | Min/max | |
|
| ||||||
| Past 90-day alcohol use | ||||||
| Timepoint 1 | 0.04 (0.29) | .00–4.00 | 0.05 (0.38) | .00–4.00 | 0.03 (0.17) | .00–1.00 |
| Timepoint 2 | 0.03 (0.33) | .00 5.00 | 0.01 (0.09) | .00–1.00 | 0.05 (0.46) | .00–5.00 |
| Timepoint 3 | 0.48 (4.79) | .00–64.00 | 0.30 (2.45) | .00–24.00 | 0.65 (6.22) | .00–64.00 |
| Timepoint 4 | 0.32 (1.58) | .00–16.00 | 0.22 (1.23) | .00–10.00 | 0.40 (1.82) | .00–16.00 |
| Past 90-day marijuana use | ||||||
| Timepoint 1 | 0.03 (0.30) | .00–4.00 | 0.05 (0.42) | .00–4.00 | 0.01 (0.08) | .00–1.00 |
| Timepoint 2 | 0.27 (4.06) | .00–63.00 | 0.00 (0.00) | .00–.00 | 0.54 (5.68) | .00–63.00 |
| Timepoint 3 | 0.74 (7.20) | .00–99.00 | 0.36 (2.53) | .00–22.00 | 1.09 (9.70) | .00–99.00 |
| Timepoint 4 | 0.59 (3.19) | .00–30.00 | 0.46 (2.83) | .00–24.00 | 0.71 (3.48) | .00–30.00 |
| Past 90-day non-prescription drug use | ||||||
| Timepoint 1 | 0.19 (3.01) | .00–50.00 | 0.38 (4.27) | .00–50.00 | 0.01 (0.08) | .00–1.00 |
| Timepoint 2 | 0.05 (0.66) | .00–10.00 | 0.01 (0.09) | .00–1.00 | 0.10 (0.92) | .00–10.00 |
| Timepoint 3 | 0.55 (7.00) | .00–99.00 | 1.15 (10.15) | .00–99.00 | 0.01 (0.10) | .00–1.00 |
| Timepoint 4 | 0.08 (0.79) | .00–10.00 | 0.11 (1.05) | .00–10.00 | 0.06 (0.51) | .00–5.00 |
| Past 90-day condom use | ||||||
| Timepoint 1 | 0.57 (0.53) | .00–1.00 | 0.50 (0.58) | .00–1.00 | 0.67 (0.58) | .00–1.00 |
| Timepoint 2 | 0.20 (0.44) | .00–1.00 | 0.00 (0.00) | .00–.00 | 0.25 (0.50) | .00–1.00 |
| Timepoint 3 | 0.38 (0.50) | .00–1.00 | 0.33 (0.50) | .00–1.00 | 0.43 (0.53) | .00–1.00 |
| Timepoint 4 | 0.14 (0.35) | .00–1.00 | 0.11 (0.31) | .00–1.00 | 0.19 (0.40) | .00–1.00 |
Timepoint1: Baseline, Timepoint 2: 6 months, Timepoint 3: 12 months, Timepoint 4: 24 months
M mean, SD: standard deviation, Min minimum score, Max maximum score
Intervention Effects on Adolescent Substance Use
At 6 months post-baseline, alcohol, marijuana, and non-prescription drug use were not significantly different by treatment arm. However, the effects of FUHW compared with prevention as usual over time (baseline through 24 months post-follow-up) were significantly different on alcohol use (b = − 0.37, 95% CI = [− 0.49, − 0.26], p < 0.001, IRR = 0.69), marijuana (b = − 1.00, CI = [− 1.22, − 0.78], p < 0.001, IRR = 0.37), and non-prescription drug use (b = − 3.77, CI = [− 6.49, − 1.05], p < 0.001, IRR = 0.02).
Intervention Effects on Adolescent Risky Sexual Behaviors
There was no intervention effect on adolescent reported past 90-day condomless sex between FUHW and the control condition at 6 months post-baseline or the 24-month follow-up assessment (Table 3).
Table 3.
Intervention effects across FUHW and control condition for adolescent outcomes
| Timepoint |
||||||
|---|---|---|---|---|---|---|
| T1-T2 |
T1-T4 |
|||||
| b | 95% CI | p value | b | 95% CI | p value | |
|
| ||||||
| Alcohol use | − 1.06 | [− 3.52, 1.396] | 0.39 | −0.37 | [−0.49, − 0.26] | <0.001 |
| Marijuana use | n.e | n.e | n.e | −1.00 | [− 1.22, − 0.78] | <0.001 |
| Non-prescription drug use | − 3.84 | [− 94.01, 86.32] | 0.93 | − 3.77 | [− 6.49, − 1.05] | <0.01 |
| Sexual risk behaviors | n.e | n.e | n.e | 0.18 | [− 0.10, 0.46] | 0.21 |
n.e.: the model did not estimate coefficient due to insufficient response and variability of the variable
T1 timepoint 1, T2 timepoint 2, T4 timepoint 4; b unstandardized coefficient
Discussion
This study evaluated the efficacy of Familias Unidas for Health and Wellness (FUHW) on substance use and sexual risk behaviors among overweight/obese adolescents. Findings from the current study suggest that the FUHW intervention had a direct effect on trajectories of adolescent substance use behaviors; however, FUHW did not have effects on sexual risk behaviors. These findings indicate that FUHW retained some of the effects of the original Familias Unidas intervention, having crossover effects on substance use behaviors. Despite removing portions of the original substance use and sexual risk behavior content to adapt the original Familias Unidas intervention to target obesity and include obesity related content, there were significant positive impacts on multiple substance use behaviors, suggesting that family-based interventions can have crossover effects on multiple health behaviors (Perrino et al., 2016; Smith et al., 2018; Vidot et al., 2016).
Intervention effects on the trajectories of substance use may be attributed to engagement in physical activity behaviors throughout the intervention. There is a large body of literature that suggests the positive psychological and behavioral health effects of physical activity. Existing research suggest that physical activity interventions are related to lower reports of substance use behaviors in adolescents (Simonton et al., 2018). Learning and participating in physical activity behaviors throughout the intervention may have reduced adolescents’ substance use behaviors (Abrantes et al., 2017). For example, yoga, which adolescents participated in during FUHW, has multiple health benefits and has been associated with lower levels of substance use behaviors (Butzer et al., 2017). Additionally, retained intervention effects on the trajectories of substance use could be attributed to improved family functioning behaviors reported by adolescents participating in the intervention. Previous family-based intervention research has shown that improved family functioning acts as a mechanism in reducing substance use (Sandler et al., 2011). Improved levels of family functioning due to participation in the intervention may help adolescents abstain from substance use behaviors over time (Sánchez-Queija et al., 2016; Wagner et al., 2010). Future research should examine the mediating effects of physical activity behaviors and family functioning between intervention and adolescent outcomes.
FUHW did not have an effect on adolescents’ sexual risk behaviors compared with the control condition, despite previous trials of Familias Unidas showing reductions in unprotected sexual behaviors (Estrada et al., 2017; Prado et al., 2007). It may be possible that intervention effects on sexual risk behaviors may have manifested after the 24-month follow-up, such as at 30 months post-intervention or 36 months, consistent with previous studies (Estrada et al., 2017). The mean age of adolescents when they initiated this study was 13 years; thus, the 24 months post-baseline assessment occurred as participants were transitioning into high school. This transition may mark an increased normative influence to engage in sexual behaviors. For example, nationwide, only 3% of adolescent report having sexual intercourse before the age of 13, yet by the 9th grade (approximately age 15), almost 13% report currently engaging in sexual intercourse and by the 10th grade that rate almost doubles to 25% (Abma & Martinez, 2017). Perhaps due to low prevalence of past 90-day sexual behaviors at 6 (n = 5) and 24 months (n = 31) post-intervention, the effect of the intervention on sexual risk behaviors was harder to determine. Relatively, skills, attitudes, and intentions regarding sexual risk may change quickly post-intervention and may be better to assess at shorter-term follow-up assessments and as proxies for future sexual behaviors (Goesling et al., 2014). Further, it may take time for adolescents to internalize and apply learned skills regarding sexual risk behaviors (Hale et al., 2014).
Limitations and Conclusions
The findings from this study should be interpreted while considering some limitations. First, the study participants are Hispanic from one geographical region. Whereas the Hispanic population from this geographical location is heterogenous representing numerous Latin American countries, the generalizability of study findings may still be limited. Participants are not representative of the US population given that foreign-born Hispanics in this study were mostly from Venezuela and Cuba. Second, this study used self-reported adolescent data, which presents a limitation that can allow for social desirability of responses with adolescents. However, previous studies indicate that there is relatively high concordance between adolescent reported data and parent reported data (Fisher et al., 2006). Although some limitations exist, this study extends previous findings related to the FUHW intervention and the additional crossover effects it has on Hispanic adolescent substance use behaviors.
Supplementary Material
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s11121-021-01220-z.
Acknowledgements
This study was funded by the National Institute on Minority Health and Health Disparities (R01 MD007724) to Guillermo Prado, PhD and Sarah Messiah, PhD, MPH.
Funding
This study was funded by the National Institute of Minority Health and Health Disparities R01MD007724 to Guillermo Prado, PhD and Sarah Messiah, PhD, MPH.
Footnotes
Conflict of Interest The authorsdeclare that they have no conflict of interest.
Ethics Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board of the University of Miami (No. 20130195).
Informed Consent Informed consent and assent was obtained from all individuals included in the study.
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