Exploring family based immigrant youth substance use prevention programmes: a scoping review protocol

Abstract

Introduction

Canada has one of the highest rates of problematic opiate and alcohol use in the world. Globally, Canada was the second country that legalized marijuana for non-medical use. As Canada is an immigrant-receiving country, newcomers and immigrants contend with a substance use landscape that was likely absent in their countries of origin. Although immigrants have lower rates of substance use than the host population, the risk of substance use, especially among youth, increases with acculturation and peer pressure. While parents are best placed to mitigate the risks for substance use among their youth, immigrant parents often do not have the knowledge and skills to do so. Therefore, culturally adaptable family based interventions need be explored to build immigrant parents’ capacities to mitigate substance use risks.

Aim and purpose

The aim of this scoping review is to explore family based substance use prevention interventions for immigrant youth, which will be guided by two questions:

1. What is known about family based interventions for preventing immigrant adolescents’ substance use?

2. What are the features and study results of these intervention protocols?

Methods and analysis

We will apply Arksey and O’Malley’s procedure for reporting scoping review and report study findings based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews.

Discussion

We hope that the knowledge translation emanating from this review will increase immigrant parents’ knowledge of substance use and enable them to effectively intervene to prevent substance use among their youth. We also hope that this work can inform policy development on best practices for substance use prevention and for the creation of culturally sensitive programmes and services for immigrant youth.

Strengths and limitations of this study.

• This study will provide insights into family focused substance use prevention interventions for immigrant youth that can be adapted and applied to a local setting.

• This study will help reorient the role of families in substance use prevention and identify strategies that may help families play that role.

• The scoping review is limited to family based, immigrant-focused substance use interventions that are published in English.

• The exclusion of interventions that do not target immigrants may limit the research by excluding relevant programmes that may be applicable to the population of interest.

Background

Substance and addiction landscape in Canada

The use of both licit and illicit substances is a growing problem in Canada.¹ Canada has the second-highest consumption of prescription opioids in the world due to overprescription and non-medical use of these strong analgesics.^1–3 The use of opioids for non-medical purposes for both licit and illicit drugs is a serious public health problem causing opioid use disorder, a problematic pattern of opioid use that leads to clinically significant issues, and significantly impacts people’s qualities of life, occupations and relationships.^2–4 In Canada, more and more youth has the issue of opioid overdoses, which requires hospitalization.⁵ Alcohol use among children in grades 7–12 is high, with 44% reporting alcohol consumption in 2018.⁶ In Ontario, about 14% of teens have reported using prescription opioids for extra-medical use.⁷ In Canada, about 55% of vehicle accidents that involve youth are caused by alcohol or drugs, and car accidents are the main factor which causes youth death.⁸

In 2018, Canada became the second country to legalise cannabis,⁹ which is the second-most used substance in Canada.¹⁰ In the third quarter of 2019, about 26% of adolescents and young adults (aged 15–24 years) reported having used cannabis,¹¹ while 18% of students (about 374,000) in grades 7–12 reported using cannabis in 2018–2019.⁶ Adolescents’ cannabis use is associated with an increased risk of mental health illnesses, poor academic outcomes and personal disadvantages.¹² Methamphetamine use is also prevalent among youth and young adults, with 1.2% of Canadian students in grades 7–12 reporting using it in 2015.¹³ In 2017–2018, 23 580 hospitalisations among youth were caused by substance misuse.¹⁴ Among these youth, about 17% of them had more than one hospitalisation in the same year and about two-thirds of them had concurrent mental health issues.¹⁴

Immigrants and attitude towards substance use

Canada is a popular destination for international migration, and immigrants have become an important driver of population and economic growth. The 2016 Census showed that immigrants accounted for 21.9% of the Canadian population.¹⁵ In 2017–2018, 80% of Canada’s population growth was driven by immigrants, and in 2019, 313 580 new immigrants landed in Canada.^{16 17} Although Canada pursues a multicultural policy, immigrants to Canada, especially the youth acculture at a higher rate than adults.^{18 19} The prevailing sociocultural climate of the destination country, that is, Canada, impacts how immigrants and newcomers acculturate.²⁰ One of the realities that immigrants are confronted with is the perversity of substance use that differs from their countries of origin.²¹ Yet, although new immigrant youth are less likely to experiment with substances, their risk of substance use increases with their length of stay.²² In so doing, they embrace the host nations’ culture and behaviors that their parents may deem risky or unsafe.^{20 23}

Immigrants’ attitudes towards substances may be informed by availability and acceptability of these substances at home and in their host country. For instance, immigrants who come from countries where plant products are commonly used are more likely to accept cannabis than those who do not.^{24 25} Also, since alcohol and marijuana are easily accessible and socially acceptable substances in Canada, immigrants without prior exposure to them may be inclined to start using them for recreation purposes.²⁶ Moreover, immigrants’ risk for substance use might be aggravated by immigration-related stress, which increases the risk of developing mental health illnesses.²⁷ Thus, new immigrants may use substances as a maladaptive coping mechanism to deal with stress induced by immigration and resettlement processes.

Immigrant youth and risk of substance use

Generally, new immigrant youth in Canada have a significantly lower level of substance use than their Canadian counterparts. For instance, a study by Hamilton et al on subjective social status, immigration generations and substance use among youth,²⁸ 13.9% of first-generation immigrant youth in Ontario reported using cannabis before, while 9.8% drink alcohol regularly. In the same research, 22.6% of second-generation immigrant adolescents reported having used cannabis, and 16.8% consumed alcohol regularly.²⁸ The acculturation process has been cited as a risk factor for the initiation of substance use among immigrant youth.^{24 29} Thus, immigrant youth may feel pressured to conform to the practices of their receiving country and feel the need to belong with their peers who may be using substances.^{24 29 30}

To mitigate the risks of substance use for immigrants, family based substance use prevention programmes are needed. Such programmes must be culturally safe and empowering to parents with effective strategies to help youth navigate these risks.^{31 32} Cultural safety is underpinned by principles of social justice and is grounded in critical theoretical perspectives, and draws attention to the impact of racialisation, culturalisation, discrimination and disparities in health and access to healthcare among marginalised communities.^{33 34} Family based substance use prevention programmes can be implemented in group settings with active family participation through role-plays, curriculum-based approaches, videos and youth–parent collaborative activities.^33–36

Due to the increased risk of substance use among immigrant youth in Canada, the research team, majority of whom are first-generation immigrants with diverse lived experiences, together with stakeholders involved in settlement programmes identified a need to equip parents, guardians and caregivers with skills to mitigate this risk. This scoping review is guided by principles of community-based research, and as such, the research focus was informed by community partners. Any intervention that will emanate from this review will also be selected by the community partners. Community consultation is essential in grounding this review to foster ownership of the process and the outcome.³⁷ Therefore, this consultation yielded the following objectives that guide the scoping review: (a) to understand substance use trends and the risks that their kids may encounter; (b) to detect early signs of substance use among youth and (c) identify resources to mitigate the risks for immigrant youth substance use and to build capacity for families to intervene to delay or prevent substance use initiation. Although the definition of youth varies, for the purpose of this review, youth will be referred to those who range between 12 years and 17 years of age.

Studies suggest that parents are important resources for substance use prevention among immigrant youth. Effective parenting, characterised by parental warmth and close supervision of children, can delay or prevent substance use initiation.^{30 38 39} In addition, parents’ zero tolerance of and clear rules about substance use can prevent substance use initiation.^{38 40 41} A good family based substance use prevention programme for immigrant youth need to consider skills and behavioural and cultural factors when developing or adapting it.³⁷ These include understanding language limitations, the acculturation process and the available support systems. It also needs to highlight family’s role in protecting and supporting youth in the acculturation process.⁴²

Aim and purpose

The aim of this review is to explore the types and characteristics of family based substance use prevention interventions for immigrant youth. The purpose of this project is to identify and describe family based substance use prevention interventions that could potentially be adapted to support immigrant families in mitigating the risk of substance use initiation facing youth.

Methods

We will conduct a scoping review of family based substance use prevention programmes for immigrant youth to identify and describe these interventions. A scoping literature review focuses on an under-researched or complicated research area and seeks to summarise key concepts, principles, primary sources and evidence under that topic.⁴³ This scoping review will be guided by community-based research principles, a collaborative, equal partnership between researchers and community members during the research process.^{37 44 45} We will depend on stakeholders within the immigrant community to identify and refine the research problem, develop an appropriate knowledge translation tool and thereafter seek mechanisms for developing a culturally appropriate intervention for immigrant families.⁴⁵ This scoping review started with the consultation with community partners involved in providing settlement and integration services for immigrants. These partners will later be constituted to a community advisory committee (CAC) and will oversee the completion of the scoping review, knowledge translation and development of an intervention suitable for the targeted community. Immigrant youth will be involved in the knowledge event where the research team will present the results. Also, those youth will provide feedback regarding the review’s findings. The scoping review will be guided by Arksey and O’Malley’s⁴⁶ steps of conducting a scoping review, which are outlined below.

Step 1: identify the research question

Through community consultation, the search terms were suggested, which contributed to the formulation of research questions. A search has been conducted on PubMed, Web of Science and PROSPERO to ensure that no such scoping review has been done. The scoping review will be guided by two broad research questions: (a) ‘what is known about family based interventions for preventing immigrant youth’s substance use?’ and (b) ‘what are the features and study results of these intervention protocols?’.

Step 2: identify relevant studies

The research team, with the help of a health sciences librarian, has developed a strategy to search for published articles and the grey literature. A concept map based on the following keywords has been developed to guide the search for relevant publications: ‘family’, ‘prevention’, ‘immigration’, ‘youth’, ‘substance use’ and types of substances. Online supplemental appendix 1 is a prototype of a concept map that will be used to guide the review. A test search on MEDLINE has been conducted to assess its feasibility. Thereafter, the following databases will be searched for relevant studies: Ovid MEDLINE, 1946–present; CINAHL (EBSCO); EMBASE, 1947–present; Web of Science, 1900–present; and APA PsycInfo, 1806–present. This scoping review will include literature published between 2000 and 2020. Limiting publications in the past 20 years is because substance use dynamics and interventions are changing, and interventions implemented more than 20 years ago may not suitable for the current situation.⁴⁷ All relevant studies will be downloaded and saved in Mendeley, a reference-managing software, and all duplicate references will be removed. Besides searching literature in databases, the grey literature will also be included in this scoping review. The research team will search for the grey literature from Canadian organisations related to substance use, including the Canadian Centre on Substance Use and Addiction (CCSA), the Centre for Addiction and Mental Health (CAMH) and the Canadian Agency for Drugs and Technologies in Health (CADTH). Searching for the grey literature will be based on the keywords in the concept map, and specific steps will be adjusted based on the search engines’ results.

Both the CCSA and CAMH are leading Canadian research centres for substance use and addiction, providing guidelines to care, research and education.^{48 49} The CADTH is a non-profit organisation that provides evidence for healthcare decision-makers.⁵⁰ The keywords used to search the electronic databases will be applied for the grey literature search.

Inclusion criteria

To be included in the scoping review, studies must (a) discuss a family focused substance use prevention intervention; (b) empirical studies except reviews; (c) have the immigrant youth (aged 12–17 years) as the intervention target; (d) be published in English and (e) be conducted in Canada, the USA, Europe, Australia or New Zealand, as these regions are key destinations for international migrants. Also, considering the development stage and needs to be supervised by parents, participants’ age in this study will be between 12 years and 17 years.

Exclusion criteria

Interventions that are not family focused, focus on youth older than 17 years or focus on native-born populations will not be included in the study. Also, literature reviews, letters to the editors and opinion pieces will be excluded from the study.

Step 3: study selection

The search results will be exported to a reference management system, Rayyan, and the inclusion and exclusion criteria will be applied. The research team will screen for title/abstract first to determine the suitability of the article to be included in the review. Two reviewers will be involved in the screening process. A third reviewer will be involved as a tie breaker in instances where the two reviewers cannot agree on whether to include or exclude an article.

Step 4: charting the data

The research team will extract information from the articles using a table with the following columns: (a) name(s) of author(s), year of publication and title, (b) characteristics of intervention and (c) outcomes and significant findings.

Step 5: collating, summarising and reporting results

The goal of conducting the scoping review is to map out findings and provide an overview of selected literature.⁴⁶ We will report the research results based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a method for reviewing literature that is useful in reviewing healthcare interventions.^{51 52} Therefore, first, we will provide a basic numerical description of the articles included in the study, including their locations, the interventions studied and the approaches used in the interventions. Second, we will synthesis the data and identify common themes that emanate from the extracted data. A narrative description of these themes will be developed to convey the main findings.

Step 6: sharing the study findings/patient and public involvement

We will present this scoping review’s preliminary findings to the CAC and thereafter to the wider stakeholders involved in providing services to newcomers and immigrants with limited English abilities. During this meeting, we will seek their feedback regarding the presentation, scoping review’s findings and initiate the process of identifying an intervention from the presentation that can be adapted to serve the local immigrant community. Data collected in this phase will inform grant applications for intervention development and implementation.

Discussion

The decision to conduct a scoping review of family based substance use prevention interventions for immigrant youth has been informed by stakeholders, who observed that there is a dearth of literature on substance use interventions and programming that focus on immigrant youth. Moreover, immigrant parents have expressed a desire to build capacity to prevent and mitigate the risks of substance use that the youth face. Parents’ active engagement in preventing their youth’s substance use can help youth realise the consequences of substance use and hopefully help them avoid engaging in these practices.^{38 40 41} The scoping review is, therefore, set in such a manner that it applies the community-based research principles from the conceptualisation of the idea to the eventual implementation of a family-based substance use prevention intervention for immigrant youth. Researchers and community stakeholders are set to work collaboratively in hopes that this partnership will increase parental knowledge of substance use, address critical societal issues related to substance use, contribute to public health and enhance ownership and uptake of the research findings.^{53 54}

This research project is grounded on the understanding that newcomers and immigrants are a vulnerable population. While they may have better health indicators than the native population at the time of immigration, this advantage tends to wane with the increasing length of stay in the host country.⁵⁵ Therefore, supporting newcomers and immigrants navigate one of the imminent risks that they face even before they acclimatise and settle in their new country is needed. This work also takes a social justice lens because of the socioeconomic and health inequalities that newcomers and immigrants face, which make them vulnerable to health conditions. For instance, besides contending with cultural shock, racial issues and a new way of life, most newcomers and immigrants often struggle to secure employment that matches their skills and qualifications.⁵⁶ Hence, most are at a higher risk of living in poverty than the native population.⁵⁷ This low socioeconomic status increases their risks of developing mental illnesses, limits their ability to parent effectively and even increases their risk of engaging in maladaptive behaviours to deal with the ensuing stress.^{27 58}

Immigrant parents are important resources for the youth and can influence their behaviour by transmitting values, beliefs and rules on substance use.³⁸ However, raising children and supporting youth in a foreign country with no social support or extended family may prove to be an additional challenge for many parents who already face cultural and social challenges.^{59 60} Nevertheless, resources for immigrants that would help them avoid substance use are urgently required. Early onset of substance use increases risks for poor educational outcomes, substance use disorders, substance-related death and even suicides.^{61 62} Such resources could help immigrant youth avoid behaviours and practices that would hinder their ability to achieve academic and future success.^{63 64}

This scoping review could contribute to the growing knowledge about immigrants’ substance use, inform policy development on best practices in substance use prevention programmes for immigrant youth and help create culturally sensitive programmes and services for the immigrant population.

Limitations of the review

Limiting the studies included in this review to those published in the English language means that the literature that would have been relevant for our study will be omitted. Also, including only substance use prevention interventions aimed at immigrant youth deprives this study of potentially relevant interventions that could be culturally adapted to support the affected community.

Patient and public involvement

Since this review is guided by the principles of community-based research, CAC will be actively involved in all the phases of the study, including knowledge translation and dissemination and selection of an intervention. The research team will share the findings of the study with the targeted community in the region by organising a 1-day knowledge exchange event. Thereafter, the community will provide feedback on the content and initiate the process of identifying an intervention that can be adapted to address community needs.