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Substance abuse programs that reduce violence in a youth population: a systematic review.

Dear Editor,

Youth violence is an emerging priority area in global public health (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Violence involving young people, defined according to the World report on violence and health as being between 10 and 29 years old, contribute significantly to the cost of health and welfare services, decrease property value, reduce productivity and disrupt a range of essential services (Krug, Dahlberg, et ah, 2002). For this review, violence was included for both being a victim of violence and/or a perpetrator. Interpersonal violence and illegal drug use are public health challenges that have strong links. Illegal drug use can increase the risks of being both a victim and/or perpetrator of violence. Risk factors at the individual, relationship, community and societal level have been identified that increase an individual's risk of experiencing violence related to illegal drug use. This review formed part of a series of reviews commissioned by the World Health Organization (WHO) which contributed to a forthcoming publication 'Preventing youth violence: Taking action and generating evidence', which includes separate reviews for alcohol and other drugs. Two recent reviews associate restricted availability of alcohol with a decrease in consumption by young people (Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2003) especially over the longer term (>3 years (National Drug Research Institute, 2007). However, alcohol is traded as a legal but restricted commodity in most countries and the same intervention approaches are not necessarily applicable for illegal drugs. For this review, we have excluded intervention programs directed at addressing alcohol.

Adolescents and young adults are the main victims and perpetrators of violence, with homicide and non-fatal assaults involving young people contributing greatly to the global burden of premature death, injury and disability (Krug, Mercy, Dahlberg, & Zwi, 2002). Interpersonal violence is among the top three causes of death in youths, particularly in young men, with an estimated 199,000 youth homicides (9.2 per 100,000 population) occurring globally in the year 2000 (Krug, Dahlberg, et al., 2002).

Previous reviews of the evidence and guidelines on prevention of youth violence focus on well-resourced settings and are not accessible to low and middle income countries (Limbos et al., 2007). Furthermore, little research has been conducted to demonstrate the integration of risk factor control when addressing youth violence. A previous review of youth violence prevention strategies reported on the effectiveness of programs in addressing one or more risk factors for juvenile delinquency and violence (Kellerman AL, Fuqua-Whitley DS, Rivara FP, 1998); however, the effectiveness of the program in specifically preventing or reducing violent behaviour in youth was not addressed.

This review examines the effectiveness of youth violence prevention interventions and differs from previous reviews; first, by performing a systematic review of the literature on youth violence and substance abuse using different inclusion and exclusion criteria that limited this review to the most current and scientifically rigorous research conducted; second, by examining the effectiveness of interventions in specifically preventing both violent behaviour and substance abuse; and finally, by using quantitative methods to summarise the evaluation evidence for these specific variables.

Of the 471 potentially relevant unique citations from all literature searches, five studies met the inclusion criteria. Three studies were conducted in North America with one study taking place in Ireland and one in the United Kingdom. All studies were published after 1990 and only one study was a randomised controlled trial.

Intervention methods included development and monitoring of career goals, mentoring, peer-to-peer goal monitoring and reinforcement (Griffin, Holliday, Frazier, & Braithwaite, 2009); cognitive-behavioral skills for problem-solving and decision-making, resisting media influences, managing stress and anxiety (Botvin, Griffin, & Nichols, 2006); a student and family skills training program that include combined classes (Kumpfer et al., 2012); methadone maintenance and methadone reduction programmes (Gossop, Trakada, Stewart, & Witton, 2005) ; and finally the 'Pulling levers' program which focused on identifying key offenders within high-density violent crime areas, bringing them into the social service and community outreach-run programme.

Post-intervention surveys were the standard instrument of measurement and ranged from a follow up period of four months (Kumpfer et ah, 2012) to one year (Griffin et ah, 2009) (Botvin et ah, 2006). The Gossop et al study follow up period extended to 5 years post intervention whilst the Corsaro et al study had an 11-year follow up period from 1998-2008. The cohort participant sizes ranged from 178 (Griffin et ah, 2009), 1,075 (Gossop et ah, 2005), 4,858 (Botvin et ah, 2006), 250 high risk families in the Kumpfer study. The Corsaro et al study used 1,705 census house blocks to delineate the study site.

There are several findings from this review that relate to key issues facing the science of school and community-based intervention programs. These include the heterogeneity of approaches and implementation activities of the intervention programs, the relatively small number of evaluations conducted, the marked variation among different communities in the observed effect of violence outcomes and the methodological limitations inherent to community and school based evaluations.

In the Corsaro et al study, there was a short duration between baseline and follow up data collection periods, meaning that the violence outcome measures calculated for these periods may not have truly represented measures before and after program implementation. The failure to take pre-existing trends in violence outcome measures into account is a limitation of this study. The possibility of contamination between intervention and control groups was present in some cases, whereby students attending the same school may have been exposed to elements of the intervention. If contamination did occur, however, the effect of the intervention is likely to be under-estimated and not over-estimated.

This review found only four studies that satisfied the criteria of an intervention that addressed illegal drug use by youth and whether they reduced violence. No studies were found for an intervention that addressed violence used as an economic compulsive or violence used to access drugs. Only one study was found of an intervention to address violence inherent to illegal drug markets (Corsaro, Hunt, Hippie, & McGarrell, 2012). Kumpfer et al demonstrated beneficial effect with regard to reducing youth violence but its replicability to larger cohorts was limited by cost, the training requirements for group leaders and the need for involvement of high risk adolescents and their families to reap a beneficial effect (Kumpfer, Xie, & O'Driscoll, 2012). This study also represented a weak study design. The Griffin et al study showed no overall effect for reducing violent behavior (Griffin et al., 2009). The Botvin et al study represented the strongest study design with beneficial effect demonstrated with violence indicators (Botvin et al., 2006) and proved to be a cost effective and appropriate school based intervention.

The findings of this review are important as it highlights the shortage of intervention programs for youth that address multiple risk factors for violence, the limited generalizability of youth substance abuse programs due to methodological design limitations and the absence of consistency of rigor in evaluation of intervention programs.

Whilst there are an extensive number of substance abuse intervention programs globally, many of these programs are poorly designed, with few randomized controlled trials, difficulties in assessing intervention components and the lack of medium to long term follow up and evaluation of program participants. These factors limited the number of studies included in this review.

Of the five studies cited in this review, three are North American-based whilst two are European-based which reflects the scarcity of substance abuse prevention research being conducted in low and middle income countries and suggests a bias in the literature. The review also favours more downstream programmatic interventions as these are more conducive to evaluation research. For example, in the case of Kumpfer et al, the heterogeneous changing nature of the drug markets, offenders and overall neighbourhood contexts makes it difficult to attribute the modest, yet significant, impact to the intervention.

The restriction of this review to illegal drug use intervention programs meant that several intervention programs that addressed alcohol and illegal drug use control, could not be included. As highlighted earlier, this review formed part of a series of reviews conducted for the WHO focusing on youth violence. A systematic review of intervention programs that addressed alcohol abuse and violence was commissioned as an entire separate review. Only English studies were included, although the initial search strategy did not exclude non-English studies.

Our findings provided limited evidence to support the hypothesis that interventions that reduce illegal drug use in persons may also decrease violence. This is consistent with previous research which found that programs designed to address multiple risk factors for youth violence have shown efficacy (Tibbits, Smith, Caldwell, & Flisher, 2011). Programs to strengthen families, enhance life skills training and provide drug abuse treatment, which aim to reduce illegal drug use have also been shown to decrease violence and achieve statistically significant reductions in violence and/or criminal behavior (Gossop et al., 2005) (Kumpfer et al., 2012). The 2008 Faggiano Cochrane review found that skills-based programs are effective in reducing illegal drug use however, these findings were limited to primary and secondary intervention programs. Tertiary prevention programs, i.e., targeting those already involved in violence, are most effective when treating drug misusers' substance dependence first and on a voluntary basis prior to any further intervention (Gossop et al., 2005).

Our review suggests that schools are the most appropriate settings for primary (targeting the general population) and secondary (targeting those at risk) intervention programs. Knowledge, attitude and subsequent behavior regarding illegal drug use, are established as young children and adolescents. Schools offer a base for broad implementation of substance abuse educational policies and offer a long period of follow up to assess program evaluation. In terms of cost and training, it would be cost-effective to have teachers and other dedicated staffs carry out the interventions, as these are generally people who stay in the location over many years so the skills do not need to be retrained. Because of their daily interaction with youth, there would also be a propensity for established trust.

Identification of risk factors in local settings is important in addressing contextual needs, especially when introducing prevention programs in developing countries. Integration of risk factors contextualised to local settings have shown efficacy, as shown in the impact study by Tibbits et al, with regard to the Healthwise life skill programs' reduction of high risk sexual behaviour and substance abuse amongst students in the Western Cape province of South Africa. As more countries shift away from the criminal justice system and incarceration model of dealing with youth violence and substance abuse, Public health professionals working with key stakeholder agencies have an important role to fulfil.

Interpersonal youth violence may have broad and substantial impacts which range from damaging the individual's health and the cohesion of communities to the drainage of resources from other priority health areas and services. Additionally, interventions to reduce violence in youth are important to arrest the progression to subsequent adult onset violence. Substance abuse and youth violence has become more important and widespread in rapidly urbanising lower and middle income countries. Despite a range of evidence suggesting links between illegal drugs and violent behaviour, there is a paucity of prevention interventions aimed at reducing violence that are specifically drug-related. Further investment and research are required to evaluate the effects of co-ordinated and integrated programmes to prevent and treat both drug use and violent behaviour and to disseminate evidence-based practice.

Within the area of international prevention trends, there has been a growing interest on the parts of governments, municipalities, research centers, civil society, organizations and international organizations in creating observatories or analytical tools for security-related problems including but not limited to school violence, domestic violence, drug use and social and gender violence. The observatory model is additionally proposed on a broader level by the International Scientific and Professional Advisory Council of the United Nations at the Eleventh United Nations Congress on Crime Prevention and Criminal Justice and provides an alternate strategy to conceptualize and measure violence and best research practices.

Ardil Jabar, School of Public Health

University of Cape Town

Western Cape, South Africa

Aramide Lawal, Evidence Based Centre

University of Stellenbosch

Western Cape, South Africa

Zain Mehtar, Faculty of Health Science

University of Cape Town

Western Cape, South Africa


Richard Matzopoulos, School of Public Health

University of Cape Town

Western Cape, South Africa


Botvin, G. J., Griffin, K. W., & Nichols, T. D. (2006). Preventing youth violence and delinquency through a universal school based approach. New York.

Corsaro, N., Hunt, E. D., Hippie, N. K., & McGarrell, E. F. (2012). The Impact of Drug Market Pulling Levers Policing on Neighborhood Violence. Criminology & Public Policy, 11(2), 167-199. http://doi. org/10.1111/j.l745-9133.2012.00798.x

Foxcroft, D. R., Ireland, D., Lister-Sharp, D. J., Lowe, G., & Breen, R. (2003). Longer-term primary prevention for alcohol misuse in young people: a systematic review. Addiction (Abingdon, England), 98(4), 397-411. Retrieved from pubmed/12653810

Gossop, M., Trakada, K., Stewart, D., & Witton, J. (2005). Reductions in criminal convictions after addiction treatment: 5-year follow-up. Drug and Alcohol Dependence, 79(3), 295-302. http://doi. org/10.1016/j.drugalcdep.2005.01.023

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Kumpfer, K. L., Xie, J., & O'Driscoll, R. (2012). Effectiveness of a Culturally Adapted Strengthening Families Program 12-16 Years for High-Risk Irish Families. Child & Youth Care Forum, 41(2), 173-195.

Limbos, M. A., Chan, L. S., Warf, C., Schneir, A., Iverson, E., Shekelle, P., & Kipke, M. D. (2007). Effectiveness of interventions to prevent youth violence a systematic review. American Journal of Preventive Medicine, 33(1), 65-74. http://doi.Org/10.1016/j. amepre.2007.02.045

National Drug Research Institute. (2007). Restrictions on the Sale and Supply of Alcohol: Evidence and Outcomes. (Curtin University of Technology, Ed.). Perth: National Drug Research Institute.

Tibbits, M. K., Smith, E. a, Caldwell, L. L., & Flisher, A. J. (2011). Impact of HealthWise South Africa on polydrug use and high-risk sexual behavior. Health Education Research, 26(4), 653-63. http://
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Author:Jabar, Ardil; Lawal, Aramide; Mehtar, Zain; Matzopoulos, Richard
Publication:Journal of Alcohol & Drug Education
Article Type:Letter to the editor
Geographic Code:6SOUT
Date:Aug 1, 2016
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