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Journal of Evidence-Based Social Work
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Culturally Sensitive Treatment for Underrepresented Adolescents with Substance Use: A Systematic Review
Maria Eugenia Contreras-Perez, Staci Morris, Michelle Hospital & Eric Wagner
To cite this article: Maria Eugenia Contreras-Perez, Staci Morris, Michelle Hospital & Eric Wagner (2023) Culturally Sensitive Treatment for Underrepresented Adolescents with Substance Use: A Systematic Review, Journal of Evidence-Based Social Work, 20:3, 404-424, DOI: 10.1080/26408066.2023.2168507
To link to this article: https://doi.org/10.1080/26408066.2023.2168507
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Culturally Sensitive Treatment for Underrepresented Adolescents with Substance Use: A Systematic Review Maria Eugenia Contreras-Perez a,b,c, Staci Morris a,b,c, Michelle Hospital a,b,d, and Eric Wagner a,b,c
aCommunity-Based Research Institute, Florida International University, Miami, FL, USA; bResearch Center in a Minority Institution, Florida International University, Miami, FL, USA; cRobert Stempel School of Social Work, Florida International University, Miami, FL, USA; dDepartment of Biostatistics, Florida International University, Miami. FL . USA
ABSTRACT Purpose: This article presents a systematic review of culturally adapted interventions targeting substance use disorders among underrepresented adolescents. Method: The systematic review included Randomized Controlled Trials conducted with adolescents with substance use-related pro- blems, implemented in the U.S. between January 2017 and February 2022; interventions not tailored explicitly for underserved populations were excluded from this review. The studies were ana- lyzed using the Cochrane Risk of Bias Assessment Tool. Also, the effect size reported for each outcome measurement was included, or if not reported, was calculated using the Psychometrika effect size calculator. Results: The search yielded seven studies, and culturally adapted interventions performed significantly better than comparison condi- tions. Cultural adaptation appears to enhance the effectiveness of treatments for underserved adolescent populations with substance use problems. Discussion: Results are discussed regarding the approaches to cultural adaptation, the social implications of alcohol use among Hispanic/ Latine adolescents, cigarette use, incorporating family components in treatment, and other co-occurring risky behaviors
KEYWORDS Underserved populations; adolescents; substance use problems; culturally adapted treatment
Substance use disorder [SUD] treatments have been widely studied, particularly among adult populations (Boumparis et al., 2017; Magill et al., 2019; Malaguti et al., 2020). An overview of systematic reviews that were conducted to find evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problematic drug use in young adults found that taxation, public use bans, advertising restrictions, minimum legal age, skills training, roadside drug testing, and interventions to reduce injection-related harm are effective strategies for treating substance use and supporting risk reduction (Stockings et al., 2016).
The systematic review also highlights the gaps in substance use treatment, including that taxation, public bans, and advertising restrictions are not available for illegal drugs; information provision without skills training is often ineffective, brief interventions do not have strong
CONTACT Maria Eugenia Contreras-Perez [email protected] Florida International University, 11200 S.W. 8th Street, AHC5, 539B, Miami, Florida 33199
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 2023, VOL. 20, NO. 3, 404–424 https://doi.org/10.1080/26408066.2023.2168507
© 2023 Taylor & Francis
evidence of effectiveness, and the evidence they analyzed comes from high-income countries and majority White population, which could have an impact on the effectiveness of the strategies for other countries, cultures, age groups, and underrepresented populations (Stockings et al., 2016).
Considering that adolescence is the developmental period where most people experiment with substance use for the first time (Das et al., 2016), this paper will focus on interventions designed for adolescents with substance use problems. When providing treatment for adolescents, it is crucial to consider the characteristics of this developmental period. The biological, social, and psychological factors that may influence substance use behavior in adolescents will be briefly described in the following sections.
Biological factors
Biologically, the adolescent brain is still under development. Lower sensorimotor regions are mature in this stage, but some of the higher-order cognitive functioning areas of the brain are still developing and will continue developing through young adulthood (Cousijn et al., 2018; Gray & Squeglia, 2018).
Gray and Squeglia (2018) reported data supporting the fact that ongoing brain development implies an immature dopaminergic system that accentuates the limitations of the inhibitory control system, therefore potentially increasing the presence of high-risk behaviors to com- pensate for the lack of dopamine in the brain. Cousijn et al. (2018) agreed with this idea and added that the dopaminergic system experiences extensive modifications during adolescence; additionally, the executive network is also developing. The executive network is a brain structure that ultimately plays an essential role in reward systems and decision-making; therefore, the underdevelopment of this structure may represent a risk factor for substance use.
Despite the risk factors related to underdeveloped brain structures, recent studies have analyzed a phenomenon called “maturing out of addiction” (Argyriou et al., 2018; Cousijn et al., 2018; Luthar et al., 2018). Research shows that about half of the adolescents engaging in heavy substance use experience a natural use reduction when they reach early adulthood (Cousijn et al., 2018). A possible explanation for this phenomenon is that those risk factors that make adolescents prone to initiate and escalate substance use naturally develop through time; impulsive decision-making decreases in early adulthood and emotional control improves, providing protective factors that may create a natural desist from substance use for some adolescents (Cousijn et al., 2018).
This hypothesis must be read with caution. Even when half of the adolescents with heavy substance use seem to mature out of it when they reach adulthood, adolescents under specific circumstances, such as those who initiated use in preadolescence or those who attend college social gatherings where substance use is normalized as a desirable practice, may experience a substance use increase in young adulthood (Luthar et al., 2018). Research has yet to show a definitive explanation for the “maturing out of addiction” phenomenon. Therefore, it is crucial to consider that not only biological factors are involved in substance use initiation and escalation, but social and psychological factors are implicated as well.
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 405
Social implications
Family context and peer group are two social elements that substantially affect adolescents’ substance use behavior. Recent studies have shown two salient risk factors related to family context. First, adolescents with a family history of substance use disorders are more likely to develop substance-related problems (Gray & Squeglia, 2018). Second, it seems that adoles- cents from a permissive family environment with low levels of behavioral control are at increased vulnerability to engage in substance use (Moreno & Palomar, 2017; Piedra et al., 2020). Family context also can have protective implications for substance use. Specifically, family cohesion seems to be a protective factor with multiple benefits; in cohesive families, 1) parents may have more knowledge of the adolescent’s behavior, therefore can monitor safety more closely; 2) parental support may increase the effectiveness of other parenting practices including behavioral control; 3) adolescents are more prone to turn to family members for guidance and support; 4) parents serve as healthy models of relation- ships, providing the adolescent with tools to have healthy relationships themselves; 5) parents can engage in open communication about risk and safe behavior (Goodrum et al., 2020).
Regarding peer group influence, various studies suggest that the patterns of substance use of an adolescent’s closest peer group can exert a significant impact on the age of onset and escalation of substance use; the proportion of substance-using immediate peers is often used as a predictor in the decision to engage in substance use when analyzing adolescent’s behavior (Cousijn et al., 2018; Rial Boubeta et al., 2018).
A recent systematic review examined how substance use is associated with peer selection and socialization (Henneberger et al., 2021). The article analyzed 40 studies that supported the idea that peer selection and socialization are associated with substance use; peer selection showed effects on alcohol and tobacco use, and socialization was related to alcohol use. These results indicate that adolescents who use substances are more likely to add and retain friends that use substances, and that friendships are more common among adoles- cents with similar substance use levels. The authors theorized that this outcome can be explained because adolescents seek social acceptance; therefore, aligning with peers with similar behavior can help increase conformity to group norms, lowering the cognitive dissonance that may arise when they associate with peers that are dissimilar to them (Henneberger et al., 2021).
Conversely, having a social network of non-using peers can serve as a protective factor. Some research has shown that interventions that increase the amount of non-using peers can effectively reduce substance use among adolescents (Valente et al., 2007). For example, Toward No Drug Abuse [TND] is a curriculum that focuses on motivation, skills, and decision-making to reduce substance use in adolescents. Valente et al., 2007) adapted this curriculum to include group activities and created small groups to increase the social network of non-using peers of the adolescent during the sessions. The results of this study showed that adolescents with existing networks of substance-using peers increased their substance use in the one-year follow-up, while adolescents who restructured their social networks or increased the number of non-using peers showed a substance use reduction, clearly supporting the power of peer influence on positive and negative treatment outcomes.
406 M. E. CONTRERAS-PEREZ ET AL.
Psychological implications
The psychological factors associated with substance use also can have risk and protective implications. For example, several psychological risk factors have been identified, such as 1) difficulties with emotional awareness (the ability to identify and overcome negative emo- tions) have been linked with increased cannabis use after receiving treatment (Micalizzi et al., 2020); 2) adolescents with characteristics of hopelessness personality, defined as the constant expectation that negative things may happen, usually have an impaired ability to define problems, generate, select, implement, and evaluate solutions. This decreased pro- blem-solving ability has been linked to an increase in alcohol and marijuana use (Jaffee & D’Zurilla, 2009); 3) the presence of personality disorders such as antisocial, borderline, and paranoid behavior have been positively and significantly associated with substance use disorders (Habersaat et al., 2018); 4) early experiences of homelessness can trigger Post Traumatic Stress Disorder [PTSD] symptoms and higher levels of substance use that ultimately can lead to more days of homelessness (Davis et al., 2019); 5) anxiety sensitivity, which can be defined as the fear of experiencing anxiety symptoms, has been associated with a greater likelihood of using alcohol, cigarettes, and electronic nicotine delivery systems (Guillot et al., 2020; Knapp et al., 2021); and 6) time perspective (feeling and orientations toward the past, present, and future), specifically having negative feelings about time or a direction toward the past over the present and future have been positively associated with higher substance use (Assylkhan et al., 2021).
Regarding protective factors related to psychological variables, adolescents better able to acknowledge their own and other people’s emotions are at substantially lower risk for substance use problems; this is especially true if they are capable of understanding and resolving their negative emotional states and can moderate those emotions (González- Yubero et al., 2021); in general, adolescents who do not engage in substance use tend to be better psychosocially adjusted and report a greater life satisfaction (Aguilar & Fátima, 2020).
Up to this point, the biological, social, and psychological factors involved in adolescent substance use have been presented. It is relevant to consider those factors when providing treatment. Additionally, when working with adolescents from underrepresented popula- tions, it is also important to consider their background when designing and delivering the intervention. This idea will be further elaborated in the following sections.
Cultural adaptation of evidence-based interventions
Culturally adapted treatment has shown to be an effective way to address substance use problems in adolescents (Hernandez Robles et al., 2016; Marsiglia, Ayers et al., 2019); it is also essential for ensuring the social validity, cultural relevance, acceptability, and, ulti- mately, the clinical effectiveness of evidence-based treatment applied with underrepre- sented populations (Bernal & Adames, 2017; Sarche et al., 2011).
According to the National Institutes of Health, an underrepresented population is defined as “a subgroup of the population whose representation is disproportionately low relative to their numbers in the general population, or the case of clinical trials or patient registries, disease population. The subgroup may be identified by race, ethnicity, age, sex, gender, socioeconomic status, etc.” (National Institutes of Health, n.d.)
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 407
A treatment adapted for underrepresented populations should combine scientific meth- ods with individualized and community-based service interventions (Bhatti-Sinclair, 2015). Lau et al. (2016) presented two conditions under which a cultural adaptation must be implemented: 1) the implementation of an evidence-based intervention is not being effec- tive for the population, and 2) the minority group is experiencing unique clinical problems.
Cultural adaptations can include modifications to how, when, and where the interven- tion is delivered to meet the client’s cultural preferences; they often include a translation of the materials to the client’s native language and the use of culturally appropriate designs and examples (Hernandez Robles et al., 2016). Bernal and Adames (2017) describe three levels at which the adaptations might be implemented: 1) the propositional model, which involves the theoretical framework that is used; 2) the procedural model, which includes the steps, stages, and procedures used; and 3) the philosophical model underlying the treatment.
Prior reviews of culturally adapted interventions for underrepresented adolescents with substance use
Two previous reviews have examined the effectiveness of culturally sensitive interventions for underrepresented adolescents who engage in substance use. In 2017, a meta-analytic study compared seven culturally sensitive treatment conditions with seven alternative treatment modalities. This study found a significantly greater reduction in post-treatment substance use levels when implementing culturally sensitive interventions (Steinka-Fry et al., 2017). However, this review only included studies until 2012, therefore there is a need for a review of findings from more recent studies.
A second systematic review that analyzed the effectiveness of culturally sensitive inter- ventions for underrepresented adolescents with substance use included ten studies with Latine adolescents (Hernandez Robles et al., 2016). The authors found better outcomes when implementing culturally sensitive programs. However, it only included information from interventions with Latine adolescents such as Sembrando Salud (Elder et al., 2002), Project FLAVOR (Johnson et al., 2005), and Keepin’ it REAL (Marsiglia et al., 2012), which leaves a gap for studies that are tailored for other underserved populations.
The current review aims to assess the reported effectiveness of culturally sensitive inter- ventions implemented with underserved adolescents with substance use-related problems.
Method
Search strategy
To conduct this systematic review, a computer-based search was performed using ProQuest, PubMed, and PsycINFO, which are specialized databases that include papers on health and social sciences. Titles, keywords, and abstracts were searched for key con- cepts. The keywords used were concepts related to the objective of this paper. Used separately or in different combinations, the keywords used were: intervention, therapy, treatment, program; culturally sensitive, cultural adaptation, culturally adapted; minority, underserved, ethnic minority, racial minority; youth, adolescents, underage; alcohol and other drugs, substance misuse, and substance abuse.
408 M. E. CONTRERAS-PEREZ ET AL.
Inclusion and exclusion criteria
For this systematic review, papers were included if: 1) they were published in the last five years (January 01, 2017, to February 28, 2022); 2) they included the adolescents (ages 12 to 18) as participants; 3) the publication included the implementation of an intervention for substance misuse related issues; 4) the intervention was clinical, meaning the components intended to cause an effect over substance use and/or related variables; 5) the article presented the results of a Randomized Control Trial [RCT]; 6) the paper was written in English; 7) the intervention was implemented with minority populations in the U.S. Articles were also included when they analyzed other variables besides substance use; when they analyzed individual or group interventions; when included a parent component; and when they were implemented in school-based or clinical settings.
Studies were excluded from the review if they were: 1) published before 2017; 2) not implemented with underserved populations; 3) published in a journal that did not include a peer review process; 4) implemented with adults or children; 5) implementing universal prevention strategies only; 6) focused on substance use addiction, 7) not an RCT; 8) implemented outside the U.S.; 7) the article was not written in English.
The original objective was to include interventions designed for racial, ethnic, and sexual minorities. Unfortunately, the search did not yield any interventions specifically designed for sexual and gender minority adolescents that met the inclusion and exclusion criteria of this review.
Analytic strategy
As a first step, all titles and abstracts of the retrieved articles were reviewed considering the inclusion and exclusion criteria. Full texts of the relevant articles were examined to analyze the pertinence of their inclusion in this paper based on the inclusion and exclusion criteria. As a final step, relevant articles were selected to be included in the data extraction process.
Data extraction process
The quality of each study was assessed using the Cochrane Risk of Bias Assessment tool (Sterne et al., 2019), which is specific for RCTs. This strategy assigns “low,” “some concerns,” or “high” as the risk of bias level. The analyzed categories were randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcomes, bias in selecting the reported results, and overall bias.
To analyze the magnitude of the experimental effect in each study, Cohen’s d (Cohen, 1988) was used to obtain effect sizes for substance use; the effect sizes were taken directly from the original manuscript if the authors reported it. If the authors did not report effect size, it was calculated with pooled standard deviations (Faraone, 2008) using the Psychometrica online calculator (Lenhard & Lenhard, 2016). In the studies that reported several measures, the effect size was calculated for the statistically significant result in the study.
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 409
Results
As represented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] flow diagram included in Figure 1, the initial search yielded 2924 articles; 317 studies were excluded as duplications; therefore, 2607 studies were screened at the abstract review stage, from which 2571 were categorized as irrelevant using the inclusion and exclusion criteria. The 36 articles remaining were analyzed in the full-text screening; at this stage, 29 were excluded due to one of several reasons: 1) the research design was not an RCT; 2) it was the wrong type of study, meaning that the authors were not applying an intervention; 3) the study was not applied in the U.S.; 4) the article did not report treatment results; 5) the intervention was not tailored for minority populations; 6) it was the wrong kind of intervention, meaning reducing substance misuse was not the treatment objective; or 7) the study was implemented with adults.
Seven studies were included in this systematic review; the articles were published from 2017 to 2021 and, as broken down in Table 1, included Latine, American Indian, and Hispanic adolescents. The adolescents’ ages varied from 12.4 years (Kulis et al., 2017) to
Figure 1. Preferred reporting items for systematic reviews and meta-analyses flow chart representing the selection process of the articles analyzed in this study.
410 M. E. CONTRERAS-PEREZ ET AL.
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JOURNAL OF EVIDENCE-BASED SOCIAL WORK 411
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412 M. E. CONTRERAS-PEREZ ET AL.
17.9 years (Gonzales et al., 2018); most of the studies included the adolescent’s parents or primary caregivers (Estrada et al., 2019; Fernandez et al., 2021; Gonzales et al., 2018; Marsiglia, Ayers et al., 2019) and the rest were implemented with the adolescent only. Most of the adolescents who received the interventions in the seven analyzed studies were male. Two studies reported fidelity of the implementation or program adherence (Gonzales et al., 2018; Kulis et al., 2017). In Gonzales et al. (2018), independent raters assessed adherence through video recordings of the sessions, finding high rates of fidelity (91% with adolescents and 88% with parent components). In Kulis et al. (2017), the research team observed several sessions scoring fidelity on a scale from 1 (not at all) to 4 (completely), finding that the mean fidelity ranged from 3.1 to 3.4, indicating that the teachers mostly adhered to the intervention.
As presented in Table 1, one of the interventions was internet-based (Estrada et al., 2019), one was applied in a clinical context with patients mostly referred to mandated therapy (Burrow-Sánchez & Hops, 2019), and the rest were school-based interventions. Three of the studies used the Keepin’ it REAL [kiR] treatment (Marsiglia, Ayers et al., 2019) or an adapted version of kiR (Hecht et al., 2018; Kulis et al., 2017), and most of them implemented three follow-up measurements at different time points.
As represented in Table 2, all the articles analyzed presented an overall low risk of bias according to the Cochrane Risk of Bias Assessment tool (Sterne et al., 2019). All the studies had a low risk of bias in all the measured categories except for one (Fernandez et al., 2021).
Table 3 presents the effect size reported by the authors or calculated using the Psychometrica effect size calculator (Lenhard & Lenhard, 2016). Table 3 also shows the article’s key findings. The results are diverse; however, all the studies found differences when comparing experimental conditions to control groups, showing positive evidence toward culturally adapted treatments.
Review of the interventions
In the first analyzed paper, Kulis et al. (2017) analyzed the efficacy of Living in 2 Worlds, an adapted version of kiR redesigned for urban American Indian [UAI] adolescents. The authors developed the adaptation through community-based participatory research, using the expert knowledge of UAI adolescents, parents, professionals, and prevention
Table 2. Risk of Bias for Randomized Controlled Trials.
Study Randomization
process
Deviation from intended
intervention
Missing outcome
data Measurement of
the outcome Selection of the reported result
Overall bias
Kulis et al. (2017) Low Low Low Low Low Low Gonzales et al.
(2018) Low Low Low Low Low Low
Hecht et al. (2018) Low Low Low Low Low Low Estrada et al. (2019) Low Low Low Low Low Low Burrow-Sánchez
and Hops (2019) Low Low Low Low Low Low
Marsiglia et al., (2019)
Low Low Low Low Low Low
Fernandez et al. (2021)
Low Low Some concerns
Low Low Low
Note. Risk of bias ratings based on the Cochrane Risk of Bias Assessment Tool (Sterne et al., 2019)
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 413
curriculum specialists, including among them the last the original designers of kiR. The article had a low risk of bias in all the categories and reported a small effect size (−0.194). The fact that the effect size was negative indicates that substance use increased after treatment, which is normal considering that the intervention intended to reduce the escalation of substance use in adolescents, not to reduce substance use below the original baseline.
The youth receiving the experimental condition reported less increase in cigarette use in the posttest. For other substance use behaviors, the outcomes were in a relatively more positive direction for Living in 2 Worlds without reaching significant results, suggesting that culturally tailored prevention programs can delay initiation and slow increase in substance use, particularly cigarette use. The study also measured the last 30-day frequency
Table 3. Outcome findings and effect sizes.
Study Effect Size Key findings
Kulis et al. (2017) −0.194* Adolescents treated with Living in 2 Worlds, compared to control, reported significantly less growth in cigarette use from pretest to posttest. Regarding alcohol and marijuana use, the program showed a relatively more positive direction than the control group without reaching significant results. The effect size was reported for cigarette use since that is the statistically significant result of the study.
Gonzales et al. (2018) 0.43* The intervention Bridges/Puentes significantly reduced the frequency of alcohol use, drunkenness, and the likelihood of having a substance use disorder. These results were found in adolescents who reported previous substance use at baseline.
Hecht et al. (2018) 0.29 Adolescents’ who received the culturally adapted keepin’ it REAL curriculum for rural population reported significantly less cigarette use than those in the control condition, regardless of delivery quality. All the other effects of a high-quality adapted curriculum showed decreased substance use, but it was not statistically significant. The effect size was reported for cigarette use since that is the statistically significant result of the study.
Estrada et al. (2019) 0.10* eHealth Familias Unidas reduced overall drug use from baseline to 12 months post measurement, compared to prevention as usual. Marijuana use decreased across time for the experimental condition while increasing for the control group. Inhalant use showed a maintained quantity in the experimental condition and an increase in the control group. The experimental condition reduced prescription drug use compared to prevention as usual. There were no intervention effects on alcohol.
Burrow-Sánchez and Hops (2019)
0.92* This study confirms that Accommodated Cognitive-Behavioral Treatment can provide a differential benefit when compared with a non-accommodated version with the same treatment components, with results extending up to 12 months posttreatment.
Marsiglia et al., (2019) 0.210* Adolescents who received control showed a significantly higher probability of using any substance at the last follow-up; on the contrary, families who received the Parent Only condition showed an initial significant increase in the predicted probabilities between waves 1 and 2, but then a significant decrease between follow-ups 2 and 4; there was no significant change over time for the adolescents in the Parent Youth condition. The effect size was reported for a significant decrease in the Parent Only condition.
Fernandez et al. (2021) 0.106 The treatment did not generate significant differences in reducing substance use; however, the effects of the intervention compared with control (who received prevention as usual) showed significantly better results for alcohol, marijuana, and non-prescription drug use. The effect size was reported for the decrease in non-prescription drug use since this was the substance that adolescents reported using the most.
Note: If the authors did not report effect size, it was calculated using the Psychometrica effect size calculator (Lenhard & Lenhard, 2016).
* Effect size as reported in the original study.
414 M. E. CONTRERAS-PEREZ ET AL.
of engaging in risky behaviors such as fighting, stealing, carrying a weapon, skipping school, or doing something dangerous on a dare. The results did not present a reduction or a significant change in this variable. However, the item had relatively better changes in the experimental condition when compared to the control (Kulis et al., 2017).
Gonzales et al. (2018) study aimed to test the effectiveness of the Bridges/Puentes intervention to reduce the frequency of alcohol misuse and rates of alcohol disorder five years after implementation with Mexican American adolescents. In this study, they used the sample used in a previous RCT that included three annual cohorts of families. The study was punctuated with a low risk of bias in all the analyzed categories. According to the author’s calculations, the results were reported with an effect size of 0.43, representing a medium effect.
The authors reported that, five years after participating in the intervention, the treatment significantly reduced the likelihood of having a substance use disorder and significantly reduced alcohol use and drunkenness episodes; these results were observed with youth who reported substance use at baseline, but not with abstainers. The treatment was not statis- tically effective in reducing past-year binge drinking among participants (Gonzales et al., 2018).
The paper presented by Hecht et al. (2018) had the goal of comparing the effectiveness of the multi-cultural, urban, non-adapted keepin’ it REAL [kiR] intervention to an adapted rural version; the adaptation of the curriculum was conducted using studies articulating the adolescent perspective on substance use, and with cultural narratives through participatory action research. The study was evaluated with a low risk of bias, and the effect size was calculated using the cigarette used measurement, which showed a small effect (0.29).
Since school teachers implemented the intervention, the videotaped kiR lessons were coded by three trained coders and categorized in four conditions: low/high quality in non- adapted kiR and low/high quality in rural adapted kiR. The adapted curriculum proved effective in significantly reducing cigarette use, and non-significant reductions in alcohol, marijuana, and chewing tobacco were also reported. The reduction in cigarette use was found regardless of delivery quality, which the authors hypothesize this might have been because culturally adapted components are more powerful predictors of prevention out- comes, masking any delivery effects (Hecht et al., 2018).
The article written by Estrada et al. (2019) aimed to evaluate the efficacy of the eHealth Familias Unidas intervention when adapted for internet implementation. This intervention includes family components and is specifically tailored for Hispanic adolescents. Overall, the study was evaluated with a low risk of bias, and the author’s reported that their results had an effect size of 0.10, representing a small effect size.
The study included the training of school mental health personnel and community mental health professionals so they could implement the intervention; as the main results, this study found that the intervention was significantly more effective than treatment as usual; specifically, the treatment decreased marijuana use, maintained baseline levels of inhalant use while the control group increased use levels; reduced prescription drug use, and reduced cigarette use. There were no intervention effects on alcohol use, which they argued was due to the high acceptance of using this substance among the Hispanic population (Estrada et al., 2019).
The authors also measured two alternative variables. First, they wanted to know if family functioning mediated changes in substance use. Their findings did not support this
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 415
hypothesis even though the intervention had a positive impact on family functioning. Second, they asked the adolescents if they were engaging in condomless sex as a predictor of risky sexual behavior; they found that in the posttest, adolescents engaged less in this behavior (Estrada et al., 2019).
Burrow-Sánchez and Hops (2019) article’s objective was to test a standard group-based version of a cognitive-behavioral treatment against the culturally accommodated version of the same program for Latine adolescents with substance use disorder. Additionally, the authors evaluated the cultural variables of ethnic identity, acculturation, and familism as potential moderators of treatment outcomes. The study had a low risk of bias, and the effect size of the measured results the authors reported was 0.92, which corresponds to a large effect.
The author’s found a significant reduction in substance use at 12-months posttreatment when comparing their results with the adolescents who received standard treatment. As to their secondary analysis, they found that familism was a moderating variable: adolescents whose parents endorsed lower levels of familism in the culturally adapted version reported significantly lower substance use at follow-up when comparing them with their low parental familism counterparts in the standard condition, but also when comparing them to those with high parental familism in the standard condition (Burrow-Sánchez & Hops, 2019).
Marsiglia, Ayers et al. (2019) wanted to assess the combined effects of a parenting intervention and kiR to suggest what works best for adolescent substance use prevention: adolescent-parent or parent-only interventions. The article focused on analyzing the differ- ences between the parent-youth and the parent-only conditions, but they also applied a comparison control condition. The report had an overall low risk of bias, and the result for the parent-only condition showed an effect size of 0.210, which can be interpreted as a small effect. When the authors analyzed overall substance use patterns, they found a significant decrease in substance use in the parent-only condition; when analyzing substances individually, they found that this same group significantly reduced any sub- stance use 16 months after the intervention. In comparison, the control condition showed a significant overall increase in substance use. The parent-youth condition did not show either a decrease or an increase in general substance use; alcohol use analyzed alone did show an increase in this condition. The authors argue that recent immigrant Latine parents engage in prevention related behaviors particularly when they know their children’s tea- chers are not involved (Marsiglia, Ayers et al., 2019).
Fernandez et al. (2021) examined the efficacy of a healthy lifestyle family-based inter- vention for Hispanic adolescents, compared with prevention as usual. The program was tailored to increase other healthy behaviors, and this explains why the participants were overweight or obese adolescents referred to community services offered for overweight adolescents and their families. The article showed an overall low risk of bias but was punctuated with some concerns regarding missing outcome data since they did not present the flow of participants within the study; therefore, it was impossible to calculate attrition. The effect size was calculated with their results and resulted in 0.106, which represents a small effect. The overall results of this intervention showed that at the 6-month follow-up, alcohol, marijuana, and non-prescription drug use were not significantly different; however, the effect of the experimental condition was significantly different compared to control conditions for all the measured substances, since adolescents in the experimental condition were using significantly less. It is relevant to add that the researchers removed parts of the
416 M. E. CONTRERAS-PEREZ ET AL.
original substance use components to adapt this intervention to target obesity; since they still found significant results for substance use, they argue that this points to crossover effects of the strategies on multiple health behaviors (Fernandez et al., 2021).
Discussion
This article’s objective was to present a systematic review of culturally adapted interventions that target substance use disorders among underrepresented minority adolescents. Seven articles met the inclusion criteria of this review, and all of them found significant differences between experimental and control conditions. The specific results were sorted into five different categories: 1) adapting treatment to include cultural components; 2) alcohol use in Hispanic/Latine adolescents; 3) cigarette use and treatment; 4) family components in treatment, and 5) related risky behavior.
Adapting treatment to include cultural components
Two of the articles specifically mentioned that the first step of the process was to adapt an already existing treatment to include cultural components pertinent to the adolescents they wanted to work with (Hecht et al., 2018; Kulis et al., 2017).
The first of these articles used studies that presented the adolescent’s perspective on substance use and Participatory Action Research [PAR] to make the modifications. PAR is a methodology that aims to redistribute power among researchers and participants, allow- ing the latter to actively participate in the design of different components of the study; in this case, they used it so adolescents could have a say in the treatment components (Hecht et al., 2018; Shamrova & Cummings, 2017). Even though PAR has shown benefits when used with adults, the impact of this methodology used with children and youth was less represented in the literature, that is why there was a recent systematic review that analyzed 45 articles with the objective to find evidence of its effectiveness with younger populations. The research showed positive outcomes for the children and youth, the organizations, and the communities involved (Shamrova & Cummings, 2017).
Kulis et al. (2017) is the second article that described the process to generate the adaptation they implemented. In this study, the authors used Community Based Participatory Research [CBPR], which allowed them to include the adolescents, parents, and professionals who would apply the intervention, and even the original designers of the kiR curriculum to obtain feedback from all of them while conducting the modifications. CBPR is a methodology that facilitates increased racial and ethnic minority participation in trials, therefore, obtaining more accurate and valuable information and increasing the likelihood of participation and uptake. This approach includes community involvement of the participants beyond the subject participation and benefits from their engagement as partners that help identify the study questions, develop interventions, recruit participants, collect data, interpret findings, deliver interventions, and even disseminate the obtained results (De Las Nueces et al., 2012).
The PAR and CBPR approaches have slight differences in implementation. PAR aims to implement two components simultaneously, research to understand the problem and action to generate changes. Therefore, PAR provides a way to obtain information regarding a system while attempting to make changes within it. On the other hand, CBPR is applied in
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 417
community settings, inviting members of that setting to help with the design and imple- mentation of a research project, respecting the contributions of the community partners, and holding high the principle of “do no harm” (San Francisco State University, n. d.). Despite these differences, both PAR and CBPR aim to increase the level of engagement of the participants while benefiting from their experience and feedback, providing a space where their participation goes beyond being subjects of the study. The articles analyzed in this study that used both methodologies showed positive results, evidencing their benefits when working with adolescents (Hecht et al., 2018: Kulis et al., 2017).
Alcohol use in Hispanic/Latine adolescents
Two of the reviewed articles worked with Hispanic or Latine adolescents. Their interven- tions had no effects on alcohol use (Estrada et al., 2019), or past year binge drinking (Gonzales et al., 2018). Both studies posited as a possible rationale for the lack of significant findings that acceptance of alcohol use and social norms favoring binge drinking among this population make alcohol use a behavior particularly resistant to change. This is a rationale that needs to be further studied since there doesn’t appear to be research to back it up except for the results of clinical studies that find this outcome. Qualitative studies directly with the Hispanic/Latine population may provide a clearer understanding of what variables are implicated in these results. The intervention Familias Unidas has shown similar effects in previous applications, where adolescents do not change alcohol use after treatment (Prado et al., 2012). However, a recent study conducted with college students had the objective to compare differences in perceived social norms of drug and alcohol use among Hispanics/Latine and non-Hispanic White young adults. This study found that non- Hispanic White students reported more frequent alcohol use than Hispanics/Latine (Edwards et al., 2019); these results obscure the hypothesis that acceptance of use among Hispanics/Latine might be contributing to higher use.
Another way of explaining why adolescents are often resistant to change their alcohol use, may be related to the social factors presented in previous research, indicating that family context and peer interactions play a key role in adolescent substance use; a family with low parental control, negligence, having substance-using parents or other family members (Nawi et al., 2021), or peer interaction factors such as having close friends who engage in substance use and promote this behavior (Cousijn et al., 2018; Rial Boubeta et al., 2018) are elements that could be increasing the adolescents’ resistance to change their alcohol use. These different explanations evidence the need to further study the variables that might be influencing the observed results in the analyzed articles (Estrada et al., 2019; Gonzales et al., 2018).
Cigarette use and treatment
Two studies analyzed in this article presented results related to cigarette use. In both studies, the cigarette was the only substance that gave statistically positive results: Kulis et al. (2017) found that adolescents reported less growth in cigarette use in posttests, which was not found in the rest of the substances analyzed. Hecht et al. (2018) found a similar result, identifying that the curriculum effectively reduced cigarette use significantly while changes in other measured substances were positive yet not statistically significant.
418 M. E. CONTRERAS-PEREZ ET AL.
The results show that cigarette use was more susceptible to change with treatment, resulting in statistical differences in use in the post measurements. It is interesting to analyze that even though these two studies applied adaptations of the kiR curriculum (Hecht et al., 2018; Kulis et al., 2017), the study that implemented kiR in its original modality did not show a significant difference at any measured point for cigarette use (Marsiglia, Ayers et al., 2019).
A systematic review and meta-analysis searched peer-reviewed journals over 10 years to analyze whether brief interventions targeting alcohol use could effectively change cigarette use. Overall, their results showed that brief alcohol interventions did not differentially reduce cigarette use, therefore concluding that untargeted behaviors are not affected by this kind of intervention (McCambridge & Jenkins, 2008). It is important to note that the ethnicity of the participants was not reported; more recent cigarette use studies acknowl- edge that the implications of race in cigarette use when implementing treatment are yet to be analyzed (Wellman et al., 2016).
Family components in treatment
The majority of the analyzed articles included parent components. The implications of parental participation in substance use treatment with adolescents is a widely studied topic in the literature; a meta-analysis of family-based prevention programs for adolescents with substance use identified that key components predicting more significant effect size in substance use change were encouraging positive family relationships, and positive orienta- tion toward the future; elements such as parental monitoring of the adolescents’ behavior were widely used and highly effective, which shows that some components can enhance the efficacy of the program (Van Ryzin et al., 2016).
Marsiglia, Ayers et al. (2019) most clearly documented parental involvement as critical in substance use reduction. Nonetheless, all the interventions that included a parent or family component had positive results: 1) Estrada et al. (2019) found that treatment affected the overall family functioning positively; 2) Gonzales et al. (2018) implemented the intervention including the adolescents’ parents, and it was effective in reducing alcohol use and drun- kenness episodes; and, 3) Burrow-Sánchez and Hops (2019) analyzed the role of familism as possible moderating variable and found that in fact, adolescents that reported lower levels of familism in parental dynamics also reported lower levels of substance use. The results of the analyzed studies align with the previous literature regarding the positive implications of including parental components in treatment (Van Ryzin et al., 2016), providing strong evidence that adolescents benefit more when the intervention consists of this interaction.
Related risky behaviors
Three studies included in this review analyzed or included components to target related risky behaviors in addition to substance use. One of the studies examined the use of condomless sex reported by the participants, showing positive outcomes in this behavior (Estrada et al., 2019). The second study measured the last 30-day frequency of five risky behaviors other than substance use which included fighting, stealing, carrying a weapon, skipping school, or doing something dangerous on a dare; the results yielded no significant differences in the overall frequency of these behaviors in the posttest, and the authors did
JOURNAL OF EVIDENCE-BASED SOCIAL WORK 419
not discuss the implications of this finding (Kulis et al., 2017), The final article was a little different since it was an adaptation for overweight/obese adolescents; to adapt the treatment to address this behavior the authors removed some of the components tailored for sub- stance use and substituted them with healthy lifestyle components. Since they still found a significant reduction in multiple substance use behaviors, the authors argued that a possible crossover effect occurred, allowing the participants to generalize the provided strategies (Fernandez et al., 2021).
Different risky behaviors have been related in literature to substance use in adolescents. Antisocial behavior such as violence, general delinquency, and status offenses (Jalling et al., 2016) and sexually risky behavior (Oshri et al., 2013) are among the most common, highlighting the relevance of generating treatment that allows participants to receive general strategies that go beyond substance use.
Conclusion
This systematic review presented the findings of seven Randomized Controlled Trials that implemented one or more forms of treatment targeting substance use with underserved adolescents, most of them including parent components. All included articles showed positive outcomes when comparing the adolescents who received treatment with those of the control groups. The findings of this study imply that adolescent substance use is a research field that has Yielded effective strategies to treat this problem, specifically with underrepresented adolescents. The fact that these studies obtained positive results supports the evidence of the effectiveness of cultural adaptations and provides insight regarding the benefits of tailoring treatment to the diverse needs of underrepresented populations.
Substance use is a topic that has been highly addressed in the literature. This systematic review focused on underrepresented adolescents since it’s a less studied population with vulnerabilities toward substance use initiation and escalation. It’s relevant to consider that the interventions had overall good results. However, some still give very general and inaccurate explanations for phenomena such as Hispanic/Latine participants’ vulnerability to alcohol misuse, showing significant gaps in the literature yet to fill. Underrepresented populations deserve to receive the best available treatment we can provide and fill those gaps in the literature is a key step to achieving that goal.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The authors gratefully acknowledge use of the services and facilities supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health Under Award Number NIMHD (U54MD012393), Florida International University Research Center in Minority Institutions. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
420 M. E. CONTRERAS-PEREZ ET AL.
ORCID
Maria Eugenia Contreras-Perez http://orcid.org/0000-0002-2249-3657 Staci Morris http://orcid.org/0000-0003-3271-6188 Michelle Hospital http://orcid.org/0000-0002-9941-9607 Eric Wagner http://orcid.org/0000-0001-9222-085X
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