SPORT Prevention Plus Wellness

Study 1

Summary

Werch et al. (2005) and Moore & Werch (2009) conducted a randomized controllws trial in a high school in northeast Florida. Students (n=604) were randomized in equal proportions to the intervention (n=302) and control (n=302) groups. The baseline assessment took place during the fall semester of 2002. Post-intervention data were collected three months after the implementation of the program during the mid-spring semester of 2003 and again 12 months after the baseline data collection during the fall semester of 2003. An 18-month follow-up was also conducted, consisting of 346 students, 179 in the treatment group and 167 in the control group.

Werch et. al. (2005) and Moore & Werch (2009) found the following:

• At three months post-intervention, the students in SPORT reported more reduction in alcohol consumption, initiation, alcohol use risk, and drug use behaviors (30 day cigarette frequency) than those in the control group, as well as increased exercise habits.
• At 12 months post-baseline, SPORT resulted in positive effects on the frequency of cigarette smoking and cigarette smoking initiation.
• Short-term effects were found favoring previous substance users receiving SPORT on alcohol consumption, drug use, and drug initiation, while long-term effects were found on drug consumption and improved physical activity.
• Alcohol use risk and protective factors at 12 months post-baseline
• At 18 months, no significant effects were found in the full sample.
• Among drug-using adolescents, those in SPORT had significantly lower scores on four substance measures: alcohol frequency, quantity, heavy use, and marijuana frequency.

Evaluation Methodology

Design:

Werch et. al., 2005: The study was a randomized controlled trial conducted in a suburban high school in the northeast Florida region. In the fall of 2002, a total of 604 participants, 335 ninth and 269 eleventh-grade students were randomly assigned within grade levels by computer to either the intervention or control group. Baseline data were collected at the beginning of the fall semester 2002, and post-intervention data were collected 3-months after the implementation of the program during mid-spring semester 2003 and again 12-months after the baseline data collecting during the fall semester 2003. All outcome data were collected from participants, assembled by classroom in the school auditorium, by trained project staff following a standardized protocol. At the three month follow-up, 584 of the original 604 students participated, representing an attrition rate of 3.3%. At the twelve-month follow-up, 514 of the original 604 students participated, representing an attrition rate of 15%.

Those in the control group received two commercially prepared generic alcohol prevention and health promotion print materials. The first was a booklet titled: "What Everyone Should Know About Wellness", which included information about wellness, smoking, alcohol, exercise, nutrition, and stress management. The 15-page booklet with illustrations was administered in a private, secured setting within the participating school. The control intervention was administered simultaneously with fitness consultations. The process involved providing control participants with the reading material, seating them in a quiet place, and providing instruction to carefully read the material at their own pace. One week after participants were given the control booklets, and corresponding to the mailing of the intervention flyer, control subjects were sent a generic health and fitness pamphlet. The six-panel pamphlet titled "For Teens Only: Staying Healthy and Fit" included information about fitness, nutrition, stress management, alcohol and drugs, and changing unhealthy habits.

Moore & Werch, 2009: Students who were originally randomized to receive the experimental intervention received a booster in the fall of 2003, consisting of an iterative consultation (n=179) while those who received the minimal intervention control again received a commercially published health brochure. The key difference in the re-intervention was that the consult was iterative and provided feedback based on one's prior screen responses. Data were collected 18 months after the initial study baseline. Outcome data were collected from participants, assembled by classroom in the school auditorium, by trained project staff following a standardized protocol. The 346 students who participated at the 18-month follow-up (of an original 604 students in the sample) represent an attrition rate of 42.72%.

Sample:

Werch et. al., 2005: The initial sample consisted of 604 participants, 302 in the treatment group and 302 in the control group. 335 were in the ninth grade and 269 were in the 11th grade. 51.0% were White, 21.5% were African-American, and the remaining 27.5% were all other ethnic groups combined. 56% of participants were female and 44% were male. 12.7% of participating students were enrolled in the free or reduced cost lunch program. 38.7% reported having a family member with an alcohol or drug problem, and a majority of fathers (60.3%) and mothers (53.0%) drank alcohol at least a few times a year. 60.9% reported some alcohol or drug education within the last year. A greater proportion of control adolescents (42.7%) reported a family alcohol or drug problem than intervention adolescents (34.9%). No other differences were found between the two groups at baseline.

Attrition analyses showed that at 12-month follow-up, 85% of the sample was successfully maintained (n=514), with comparable numbers of missing adolescents equally distributed across the intervention (n=42) and control (n=48) groups. A comparison of participants who dropped from the study in each group at 12-months was conducted using baseline data. No differences were found between dropouts in the two groups on any of the alcohol and drug consumption measures, or exercise behavior measures. Also, no differences were found between dropouts by group on any of the socio-demographic measures with one exception. A greater percentage of participants who dropped from the control group had mothers who reported drinking at least a few times a year (71.7%) than were among those who dropped from the intervention group (47.4%).

Moore & Werch, 2009: The sample for the reintervention consisted of 346 students, 179 in the treatment group and 167 in the control group. 51.7% were White, 22.3% were African-American, and 26.0% were all other ethnic groups combined. 63.3% were female and 36.7% were male. 9.8% of participating students were enrolled in the free or reduced lunch program. 38% reported someone in their family having an alcohol or drug problem. The sample participating in the re-intervention consisted of 67% of the original sample.

To determine differences between the original sample and the sample for this study, comparison of those who participated with those who did not using original baseline data was conducted. There were four differences on socio-demographic variables. A greater percentage of the initial sample who dropped out were males (51.9% vs. 35.6% of females), in the free/reduced lunch program (57.1% vs. 40.5% not in the program), frequently absent from school (60.6% dropped vs. 44.5% of those who reported never being absent, 37.8% rarely, and 49.3% 1-2 per month), and not living with both parents (50.8% living with their mother only dropped, as did 44.2% living with father, 66.7% living with other vs. 36.1% living with both parents). No differences were found between the initial sample and the current sample on any of the alcohol and drug consumption measures or exercise behavior measures.

Measures:

Werch et. al., 2005: The Youth Alcohol and Health Survey was used to collect data on alcohol and drug consumption, risk, and protective factors associated with alcohol use, and exercise habits. Alcohol consumption was measured by items adapted from previous substance abuse prevention research. Measures used for this study's analysis included items assessing 30-day frequency and quantity of alcohol use; heavy alcohol use, defined as consuming five or more drinks in a row during the last 30 days; 13 items measuring negative consequences (problems) experienced during drinking; and length of time using alcohol (ranging from "I do not drink" and "30 days or less," to "6 months or more."). In addition, a measure of the stage of initiation of alcohol use was taken, adopted from previous stage research and theory. This item had seven response categories, reflecting recent advances in staging the initiation of alcohol consumption, ranging from strong pre-contemplation stage (will never try alcohol) to a maintenance stage (drinking for longer than six months).

Drug use behaviors measured included 30-day frequency of cigarette smoking and marijuana use, paralleling the alcohol frequency measure. Similarly, measures of cigarette and marijuana stage were taken, which also corresponded to the measure of alcohol use initiation. Measures of moderate and vigorous physical activity were collected, adopted from the Youth Risk Behavior Survey. These items measured 7-day participation in vigorous physical activity (at least 20 minutes with sweating and breathing hard) and moderate physical activity (at least 30 minutes with no sweating or breathing hard).

Cognitive, social, and environmental risk and protective factors found to mediate alcohol consumption were also measured. Measures of alcohol use risk factors (targeted for reduction) included positive expectancy beliefs (pros), perceived peer prevalence of alcohol use, influenceability, social norms, intention to use alcohol, and attitudes. Measures of alcohol use protective factors (targeted for increase) included negative expectancy beliefs (cons), behavioral capability, resistance self-efficacy, self-control, perceived susceptibility, parental monitoring, parent/child communication, positive parent/child relationship, and value incompatibility.

Moore & Werch, 2009, used the Youth Alcohol and Health Survey to collect data on alcohol and drug use, alcohol use-related risk and protective factors, and exercise habits.

Analysis:

Werch et. al., 2005: Descriptive statistics including frequencies, percentages, means, and standard deviations were generated to describe the sample. Baseline measures were compared by experimental group using chi-square tests for categorical data and independent t-tests for continuous scores. MANCOVAs were used to test the primary objective of examining the efficacy of the intervention at both 3 and 12-month follow-ups, with baseline scores serving as covariates, first analyzing alcohol consumption, then risk/protective factors for alcohol use, and lastly, drug use and exercise behaviors. MANCOVA was used due to the multiple health behaviors addressed by the intervention, and because the dependent variables were not perfectly correlated.

Repeated measures MANCOVAs were then used to examine temporal effects across baseline, 3-month and 12-month data collections, again examining alcohol consumption, followed by alcohol/risk protective factors, and then other drug use and exercise habits. Lastly, factorial MANCOVAs were conducted to test the secondary objective of examining possible interaction effects of prior drug use (past 30-day marijuana and/or cigarette use) and intervention exposure on alcohol use, drug consumption, and exercise behavior measures.

Moore & Werch, 2009: Descriptive statistics including frequencies, percentages, means, and standard deviations were used to describe the sample. Baseline equivalence and attrition analysis were conducted using chi-square tests for categorical data and independent sample t-tests for continuous scores. MANCOVAs were used to the primary objective of examining the efficacy of the re-intervention at an 18-month follow-up, first analyzing alcohol consumption, then drug use, exercise behaviors, and risk and protective factors for alcohol use. Baseline data were used as covariates. Lastly, factorial MANCOVAs were conducted to test the secondary objective of examining possible interaction effects of prior drug use (past 30-day marijuana, cigarette and/or heavy alcohol use at baseline) and re-intervention exposure on alcohol consumption, then drug use, exercise behaviors, and risk and protective factors for alcohol use, again using baseline data as covariates.

Outcomes

Werch et. al., 2005: Overall MANCOVA tests at 3-months post-intervention were significant for alcohol consumption and initiation factors, drug use behaviors, and exercise habits, with positive effects for those exposed to Project SPORT. Only drug use initiation was not significant 3-month follow-up. Univariate analyses showed that among alcohol consumption behaviors, significantly less 30-day frequency, 30-day quantity, and 30-day heavy use was found for those receiving Project SPORT compared to those receiving the control treatment. Significantly less alcohol use initiation was seen for adolescents exposed to Project SPORT compared to those exposed to the minimal intervention control, on measures of both state of alcohol initiation and length of alcohol use. SPORT youth also displayed significantly more protection from alcohol use than control youth on measures of negative expectancy beliefs, behavioral capability, perceived susceptibility, parental monitoring, and parent/child communication. SPORT participants also showed less risk for alcohol use compared to control participants on measures of intention to drink in the future, alcohol attitudes, and influenceability. Lastly, youth exposed to the SPORT intervention engaged in more moderate physical activity and smoked cigarettes less frequently than those exposed to the minimal intervention control.

At the 12-month follow-up, significant overall MANCOVAs were found for alcohol use risk and protective factors, drug behaviors, and drug use initiation, with positive effects for those exposed to Project SPORT. The overall MANCOVA for alcohol initiation was not significant, however the univariate analysis for length of alcohol use was significant, with intervention adolescents using alcohol for a briefer period of time than control adolescents. Project SPORT provided more alcohol use protection than the minimal intervention control on parent/child communication and positive parent/child relationship, but less protection on perceived susceptibility. Intervention participants had less alcohol risk than control participants, as measured on intentions to drink in the next six months. Youth receiving the treatment also smoked cigarettes less frequently than control youth and were less advanced in their stage of initiation cigarette smoking than control students.

When testing the temporal effects of the intervention, significant overall MANCOVA interaction effects were found for alcohol consumption and initiation, alcohol risk and protective factors, and drug initiation, with positive effects over time for those exposed to Project SPORT. Univariate ANOVAs were significant for 30-day alcohol quantity, length of alcohol use, and stage of alcohol initiation, with trends indicating intervention youth measures decreasing at 3-months and increasing at 12-months and control youth measures increasing at both 3 and 12-months. Univariate analyses showed significant interactions on 30-day cigarette frequency and cigarette stage of initiation, with intervention youth showing less use at 3-months and somewhat of an increase at 12-months, whereas control youth showing increases at 3-months and greater increases at 12-months.

When testing the secondary objective of examining interaction effects between prior marijuana and/or cigarette use and intervention exposure, overall factorial MANCOVA interaction effects at 3-months postintervention were significant for alcohol consumption behaviors, drug use behaviors, and drug initiation, with more positive effects for drug using adolescents who received Project SPORT. Univariate analyses showed that at 3-month follow-up, drug users who received the intervention had significantly less 30-day alcohol frequency, 30-day quantity, and 30-day heavy use than drug users receiving the minimal intervention control. Likewise, drug users exposed to Project SPORT had less 30-day cigarette frequency of consumption and 30-day marijuana frequency.

At 12-months follow-up, significant overall factorial MANCOVA interactions were found for drug use behaviors, drug initiation, and exercise habits, with more positive effects for drug using adolescents receiving Project SPORT. The univariate analysis for 30-day heavy alcohol use was significant, with drug using youth exposed to the intervention drinking heavily less frequently than drug using control youth. Drug users receiving Project SPORT also used cigarettes less frequently in the past 30-days and marijuana less frequently in the past month than drug users receiving the minimal intervention control. Similarly, findings were seen for cigarette and marijuana initiation, with drug using adolescents given the intervention having less advanced drug use initiation than drug using adolescents given the control. Lastly, adolescents using drugs and exposed to Project SPORT engaged in more frequent vigorous physical activity and moderate physical activity than those adolescents exposed to the minimal intervention control.

Moore & Werch, 2009: The researchers examined the effects of the re-intervention for all participants using a series of MANCOVAs, and none of the results were significant. When examining the effects of the re-intervention for drug-using versus non-drug using adolescents, the multivariate tests were significant for four of the models: alcohol behaviors, drug behaviors, protective factors, and risk factors. Univariate tests for group by drug user status interaction revealed that drug-using adolescents in the intervention group had significantly lower use/risk than the control group, while the scores for the non-drug users were similar across the two groups on 30-day alcohol frequency, alcohol quantity, heavy alcohol use, and marijuana use. This same significant pattern of lower risk scores for the substance-using youth in the intervention group was found for Protective Factors self-control, lifestyle and value incompatibility, perceived susceptibility, and parent-child communication, as well as the Risk Factor attitude.

Study 2

This study is included as Sport Prevention and Wellness, though the article refers to the intervention under the name Project Active.

Summary

Werch et al. (2011) conducted a randomized controlled trial within two public high schools in northeast Florida during fall of 2008. Students were randomly assigned to a brief 30-minute intervention (n=237) or a standard care (health education booklet) control group (n=242). Assessments were at baseline (fall 2008) and 3 months after the intervention (spring 2009), and measured student health risk and promoting behaviors.

Werch et al. (2011) found that at posttest, relative to students in the control group, those in the intervention group reported significantly:

• Greater reductions in quantity x frequency of alcohol use
• Greater improvements in reduced alcohol use quantity
• Higher likelihood to initiate alcohol use
• Higher likelihood to stop drinking
• Greater nutrition (risk and protective factor), and
• Greater frequency of relaxation activities (risk and protective factor)

Evaluation Methodology

Design:

Recruitment: Students were recruited from two public high schools in northeast Florida during fall 2008. Students in grades 11 and 12 were invited to participate in the study using formal presentations made in school classrooms, cafeterias, auditoriums, and conference rooms. Of the 512 students recruited into the study, 93.6% (n = 479) met grade-eligible inclusion criteria and were present on the day of the baseline assessment. 

Assignment: Within two schools, participants were randomly assigned to a brief 30-minute intervention (n=237) or a standard care (health education booklet) control group (n=242) by computer generated random numbers stratified on baseline drug use (30-day alcohol, cigarette and/or marijuana drug use vs. non-use).

Attrition: Assessments were at baseline (fall 2008) and 3-months after the brief intervention (spring 2009). About 6% of the sample (n=28) was lost to follow-up.

Sample: Participants were an average age of 17 years old, were about 62% female, 53% Black/African American, 27% White, 16% Mixed, 10% Hispanic, and 4% Other. Additionally, 37% of students qualified for free lunch. At baseline, 23% of students used alcohol, 7% used cigarettes, and 10% used marijuana in the past 30-days, and 21% of students reported daily moderate exercise.

Measures: Primary health risk behavior outcomes were three index measures of past 30-day frequency x quantity of alcohol, cigarette, and marijuana use, and one health promoting behavioral summed total score measure of exercise. Outcome measures were based on well-known sources and were self-reported by students. The study also assessed risk and protective factors of nutrition, sleep, and stress management, and mediators of coupling beliefs, peer influenceability, self-efficacy, and self-image. Questions about honesty and a fake drug suggested accurate reporting by student participants.

Analysis: For continuous outcomes, repeated measures ANOVAs were used to test intervention effects from pretest to posttest. Bonferroni corrections were used to adjust for multiple comparisons of risk behavior and health promoting behavior outcome groupings. Logistic regressions were then performed to examine intervention effects on improving, initiating, and stopping alcohol use. Although students were randomized within two schools, the authors conducted preliminary analyses to examine the effect of school on the outcome. They stated that only one significant 3-way interaction (school by condition by time) was found and therefore school setting was excluded as a factor.

Additionally, mediation analyses of intervention outcomes were conducted for only risk factors associated with significant behavioral outcomes that significantly differed between study conditions over time. 

Intent-to-Treat: The study presented a complete case analysis. It followed an intent-to-treat analysis by including all randomized students, if data were available at posttest.

Outcomes

Implementation Fidelity: Not reported.

Baseline Equivalence: The authors stated that there were no differences were found on any of the socio-demographic or target health behavior measures between treatment groups at baseline, though no significance tests were reported. 

Differential Attrition: On page 5, the authors stated that no differences were found in the proportion of those who dropped out between treatment groups (2% in the intervention group and 4% in the control group). The overall attrition rate plus the difference between conditions in attrition rates indicate that the study met both the cautious and optimistic WWC standards. Attrition analyses showed that students who attrited were more likely than non-attritors to drink, smoke cigarettes, skip school, and be absent from school. However, condition by attrition interactions indicated students who attrited from the control group use marijuana more frequently than those who attrited from the intervention group.

Posttest: For continuous outcomes, there were significant condition by time interaction effects on one of four behavioral outcomes. From pretest to posttest, students who received the intervention showed a significant reduction in quantity x frequency of alcohol use (d=.26), compared to those in the control group. There were no significant effects on cigarette use, marijuana use, or exercise. Results of logistic regressions examining improvement, initiation, and cessation showed that students in the intervention group versus control group had significant improvements in reduced alcohol use quantity, were less likely to initiate alcohol use, and were more likely to stop drinking at posttest.  

Analyses of intervention effects on risk and protective factors showed that intervention group participants, compared to those in the control group, increased nutrition and frequency of relaxation activities at posttest. Exploratory mediation analyses found that intervention effects were mediated by changes in peer influenceability for alcohol use, and self-efficacy and self-image for health promoting behaviors.

Long-Term: Not examined.

Study 3

This study evaluated SPORT Prevention Plus Wellness, though the article refers to the program name as the "Behavior-Image Model (BIM)".

Summary

Ihlan & Yildiz (2018) conducted a cluster randomized controlled trial at one public high school in Istanbul in which 8 classes with 214 students were randomized to condition. Data were collected before the brief intervention and at 3 months post-intervention.

Ihlan & Yildiz (2018) found no significant condition differences in risk and protective factors measured at three months post-intervention.Evaluation Methodology

Design:

Recruitment: The sample came from students in grades 10-11 in one Istanbul high school. Recruitment was not discussed. However, the CONSORT diagram presented in Figure 2 (p. 59) shows that 515 students within 8 classes were recruited for the study, and 281 students (55%) within these 4 classes were randomly assigned to condition.

Assignment: There were 8 classes in the 10^th and 11^th grades at the school. The 10^th and 11^th grades were listed and then classes were selected randomly by drawing lots. The first two classes of the 10^th grade were selected for the intervention group and the next two classes were selected for the control group. The same procedure was applied to the 11^th grade. This process resulted in 281 students assigned, 143 within 4 classes in the intervention group and 138 students within 4 classes in the control group. During school hours, a researcher held one-in-one brief intervention sessions with the intervention group students, which could be a potential confound. No information on the control group was provided, other than "subjects in the control group did not participate in the brief interventions" (p. 59).

Assessments/Attrition: Assessments occurred at baseline and three months later. The CONSORT flow diagram (Figure 2, p. 59) suggests no classes dropped out of the study. At the student level, 215 students were included in the analysis sample for an overall attrition rate of 23%.

Sample: No sample description at the school or class level was provided. At the individual level, 53.6% were female (46.4% male) and students were evenly divided between the 10^th and 11^th grade (and between the ages of 15 and 18). Most (83.9%) were rated as "good" on status of academic achievement (6.3% were "good" and 9.8% were "poor") - though it was unclear how this was assessed.

Measures: No behavioral outcomes were assessed. Measures of risk and protective factors included exercise self-efficacy (Cronbach's Alpha: 0.92), health-related quality of life (Cronbach's Alpha=.64-.69), and healthy lifestyle domains, such as health responsibility, physical activity, nutrition, positive life perspective, interpersonal relations, stress management, and spiritual health (Cronbach alpha= 0.88-.90).

Analysis: Two-way repeated-measures ANOVA we conducted using SPSS, version 15.0 but without any adjustment for clustering within classrooms (the unit of assignment).

Intent-to-Treat: Not discussed but it appears from the CONSORT diagram that those who did not receive the intervention were dropped.

Outcomes

Implementation Fidelity: Not reported.

Baseline Equivalence: Baseline equivalence was not reported for the randomized sample. For the analysis sample (n=215), Table 1 (page 63) shows no statistically significant student-level demographic differences between conditions for 5 of 5 variables tested (age, gender, mother's education, academic achievement, time spent at the computer/TV during the day and others). Also, for the analysis sample, Tables 2, 3 and 4 show no statistically significant pretest differences in any of the 12 baseline risk and protective factors.  

Differential Attrition: Not reported for attritors vs. completers, but baseline equivalence for the analysis sample suggests that attrition did not bias the comparisons across conditions.

Posttest: At three months post-intervention, there were no significant differences between groups on any of the 13 risk and protective factors reported in Tables 2, 3 and 4 (according to the F-tests).

Long-Term: Not tested.