A Review of Effective Youth Engagement Strategies for Mental Health and Substance Use Interventions

Journal of Adolescent Health xxx (2016) 1e26

www.jahonline.org Review article

A Review of Effective Youth Engagement Strategies for Mental Health and Substance Use Interventions Tom Dunne, M.D. a, Lisa Bishop, Pharm.D. a, b, *, Susan Avery, M.D. a, and Stephen Darcy, M.A., M.D. a a b

Discipline of Family Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, Canada School of Pharmacy, Memorial University of Newfoundland, St. John’s, NL, Canada

Article history: Received June 10, 2016; Accepted November 17, 2016 Keywords: Youth engagement; Substance use; Mental health; Interventions; Youth; Community-based interventions

A B S T R A C T

The majority of adult mental health and substance use (MH&SU) conditions emerge in adolescence. Prevention, diagnosis, and treatment programs targeting this age group have a unique opportunity to significantly impact the well-being of the future generation of adults. At the same time, youth are reluctant to seek treatment and have high rates of dropout from interventions. An emphasis on youth engagement in prevention and treatment interventions for MH&SU results in better health outcomes for those youth. This literature review was undertaken to evaluate opportunities to improve youth engagement in MH&SU programs. The intent was to determine best practices in the field that combined community-level improvement in clinical outcomes with proven strategies in engagement enhancement to inform program development at a local level. The results discuss 40 studies, reviews, and program reports demonstrating effective youth engagement. These have been grouped into six themes based on the underlying engagement mechanism: youth participation in program development, parental relationships, technology, the health clinic, school, and social marketing. A broad range of tools are discussed that intervention developers can leverage to improve youth engagement in prevention or treatment programs. Ó 2016 Society for Adolescent Health and Medicine. All rights reserved.

Youth are an important target population for both prevention and treatment interventions for mental health and substance use (MH&SU) conditions [1]. The special needs of youth are only now coming into focus in terms of global health and policy, despite the recognition of their rights in the statements of the Geneva Convention of 1924 and the subsequent UN declarations of 1959 and 1990 [1,2]. Population studies have shown that the majority of adult MH&SU disorders emerge in teenage years with half of

Conflicts of Interest: The authors declare no conflicts of interests, including any financial, personal, or other relationships with other people or organizations, which could inappropriately influence or be perceived to influence this work. * Address correspondence to: Lisa Bishop, Pharm.D., School of Pharmacy, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John’s, NL A1B 3V6, Canada. E-mail address: [email protected] (L. Bishop). 1054-139X/Ó 2016 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2016.11.019

IMPLICATIONS AND CONTRIBUTION

This review was developed to aid youth mental health and substance use program developers seeking a library of practical, proven solutions that can be implemented to suit local populations and organizations. The strategies discussed will give researchers and policy developers a selection of evidence-based approaches on how to effectively engage with youth.

all life-time cases presenting by age 14 years and three-quarters by age 24 years [3]. Early prevention, detection, and intervention are critical in this target population if one is to lessen the burden of mental illness in later years [1,3]. Less than half of all adults with MH&SU disorders seek help for their problems, and youth are of no exception to this [4]. Youth are reluctant to seek help for a number of reasons: lack of knowledge regarding the signs of mental illness; lack of awareness on how to access the system; fear of breaches in confidentiality; a belief that they can handle their own problems; stigma surrounding mental illness; and previous bad experiences [5e7]. Treatment programs must be cognizant of this as they seek to increase youth “buy in” and participation in interventions. Programming strategies that prioritize youth engagement builds relevance for youth and can overcome many of the obstacles perceived by youth to access such programs [8]. Once engaged, youth involved in

2

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

interventions show a decrease in rates of substance use and overall morbidity and mortality [9,10]. A number of limiting factors may impede engagement in programs designed to promote youth mental health and wellbeing. In many countries, youth are struggling to survive the effects of war and poverty, and engagement in health-related activities is of lower priority [8]. The rights of children and youth in such circumstances have been the focus of the UN Convention on the Rights of the Child [2]. Advocacy for the health of adolescents has long been the focus of the WHO’s program on maternal, newborn, child, and adolescent health [11]. Further, simple challenges of everyday life can interfere with program uptake, including the difficulty in getting groups organized, work commitments of parents, and school commitments of youth [11]. Gulliver et al. [7] identified entrenched barriers that intervention developers need to ponder: public and self-stigmas about mental health, perceived issues of confidentiality, inability to identify symptoms, self-reliance for correcting problems, awareness of MH&SU services, and lack of accessibility. Drop out rates as high as 22% are seen in many programs aimed at youth mental health, particularly when the issue is substance use [12,13]. Integration of services for comorbid MH&SU conditions in the form of increased collaboration among providers has been shown to improve patient engagement in prevention and treatment programs through increased retention [14]. Collaborative care increases the opportunities for earlier detection of mental health and addiction problems, and the physical health conditions with high rates of comorbidity of these conditions [15]. Overall, youth engagement in health interventions is related to improved, targeted outcomes of treatment programs [16,17]. There are multiple definitions of “youth engagement” in the literature, some restricting engagement to strictly behavioral measures of intervention initiation and attendance, and some taking a broader perspective [18]. For the purposes of this review, youth engagement is defined as an increased amount of observable behaviors (i.e., enrollment, attendance) and a positive change in attitude toward the reported interventions. The purpose of this review is to identify successful youth engagement strategies that are associated with positive mental health or substance use outcomes and offer a categorization of engagement enhancing interventions for program developers. It was completed to inform the development of a communitywellness plan in a unique, urban neighborhood in an Atlantic Canadian city. MH&SU conditions have been considered together in this review. These strategies can be subsumed under six broad categories. By integrating the broad scope of opportunities for increasing youth engagement, this review seeks to offer developers of MH&SU a broader range of potential interventions [10]. Methods Inclusion criteria The authors chose qualitative and quantitative studies, reviews, and reports of interventions that showed positive substance use or mental health outcomes in conjunction with a description of the specific youth engagement strategies that contributed to these outcomes. Targeted populations for interventions were between the ages of 11 and 29 years, which is based on the definition of youth/young people as proposed by the United Nations [19].

An initial search was conducted in August 2014 of PubMed, Cochrane, PsychInfo, and Google Scholar for scholarly articles published within the last 10 years using the search terms (youth OR adoles* OR young person OR student OR child*) AND (engage* OR participat*) paired with each of (mental health OR mental illness) AND (substance OR drug OR alcohol) þ (use þ misuse þ abuse). Details from intervention programs, position papers, and intervention guidelines from national and international substance use and mental health and addictions agencies were searched through Google and Bing. Publications were also identified through a review of the reference lists of papers identified through the primary search. Papers were screened for duplication, adherence to the target population criteria, intervention for substance use and/or mental health, and a discussion of the role of youth engagement in intervention efficacy. Exclusion criteria Articles published prior to 2004 and publications not originally published in the English language were excluded. The search was conducted in 2014. A 10-year review period was selected for the review by the authors in part because of the role of social media was radically transformed in the year 2004 due to the launch of Facebook. Results A total of 40 papers were included in this review. The various strategies of engagement were analyzed and thematically grouped by touchpoint of engagement into six overarching categories. These categories are as follows: (1) youth empowerment through participation in program development; (2) engagement through parental relations; (3) engagement through technology; (4) engagement through the medical or mental health clinic; (5) engagement through school; and (6) engagement through social marketing. Youth empowerment through participation in program development Youth participation in program development is the most direct form of youth engagement identified in the literature. It can range from “light-touch” participation such as comment boxes or evaluation surveys in clinics, all the way to primary decision-making authority at every stage of program design, implementation, and evaluation [20]. Youth participation can be top-down with youth sitting on boards and committees formalized within the organizational hierarchy or bottom-up where youth participate as peer-support workers or researchers [21]. Interventions describing youth participation in program development at a variety of depths are highlighted in Table 1. Engagement through participation in service development, delivery, and evaluation appears to improve maintenance of a recovery focus, the development of coping skills, and development of professional skills [21]. Participation in program design at a clinic level can improve patient relationships with clinicians which in turn improves participation in mental health programs and services [22]. An American study utilizing substance-using youth as “experts” to adapt national programs for local youth had a twofold effect: (1) youth who participated in program adaptation established a dissonance between their behavior in using substances and their prevention role adopted through

Table 1 Relevant literature on youth participation in program development References

Study type

Study design

Sample size

Age

Jurisdiction

Intervention under study Measured outcomes

Findings

x

Australia

x

x

Australia

x

x

Australia

Interview-based study of 1. Incidence of services Programs implemented a wide range of youth providing consumer drug treatment service participation participation providers and current interventions. opportunities consumers of these Awareness of 2. Enumeration of services regarding opportunities to consumer participation consumer participate was opportunities provided participation in service inversely associated by services decision-making with the depth of 3. Consumer awareness involvement of the of service decisionprogram: making participation Program (incidence%/ opportunities awareness %) Patient charter of rights (85.9%/70.9%) Survey (64.1%/37.3%) Consumer council/forum (43.8%/19%) Consumers involved in resource development (31.3%/13.9%) Consumers involved on decision-making committees (20.3%/0.0%) Complaints process (95.3%/54.2%) 1. Anecdotal evidence 1. Describe the Case description of the suggests improved multimodal model of experiences of an early maintenance of consumer participation intervention youth recovery focus, develemployed in a youth mental health service opment of coping mental health service utilizing youth skills, and develop2. Outline the anecdotal participation in ment of professional experience of conprogram development, skills. sumers and service delivery and 2. More quantitative provider in youth evaluation. The evidence is required to participation in program has designed describe the decision-making participation effectiveness of youth opportunities from a participation on youth top-down managerial perception of perspective and “empowerment” and bottom-up peeron mental health support programs. outcomes. Roles for youth Outline the mechanisms Overview of formalized participation in the developed by leading mechanisms for youth design, delivery, and Australian mental involvement in mental evaluation of mental health services to health services in health services: encourage youth Australia ranging from Advisory and participation in the children to adolescents ambassadorial roles mental health services and including parents Participation in program at a variety of and carers management, organizational levels

11e14 15e19 20e29 Quantitative Cross-sectional study

64 service providers 179 health service consumers

Monson and Thurley, 2011. [21]

Qualitative

Program description

Orygen Youth Health

James, 2007. [5]

Qualitative

Description of the activities of headspacedNational Youth Mental Health Foundation of Australia

N/A

x

3

(continued on next page)

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Bryant et al., 2008. [20]

References

4

Table 1 Continued Study type

Study design

Sample size

Age

Jurisdiction

Intervention under study Measured outcomes

Findings

11e14 15e19 20e29

Qualitative

Cohort focus group study/peer-to-peer/ consumerto-consumer interviews

122 consumers of an Australia mental health service in a 2-week period (36 completed the process)

Steiker et al., 2011. [23]

Qualitative

Pilot communityebased participatory research focus group study

169 youth

x

x

Australia

Austrial qualitative study of adult and youth participation in mental health service provision in the context of a 3-year period of state funding to improve youth participation in services. Trained youth consumers interview other existing youth consumers of mental health services to measure their perceptions and experiences with participation initiatives.

United States Use substance using youth clinically defined as not ready for treatment as “experts” to adapt national preventions to a local context in an effort to create dissonance in the “experts” and prepare them for substance use cessation. Evaluated using focus groups, naturalistic process

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Tobin et al., 2002. [22]

oversight, and while identifying evaluation challenges experienced Peer-counselor roles to date Experts for adaptation of national programs to local contexts Challenges in creating effective youth empowerment through participation: Avoid tokenism Setting realistic expectations for participants Acknowledgment that youth are not a homogenous group The rapport between To measure the “level, clinician and patient extant, and quality” of appears to be consumer participation positively associated with patients’ feelings of being able to participate in decisionmaking related to their own treatment. Patient identified barriers to participation were: Perceived lack of opportunity Personal barriers such as shyness Transportation difficulties Hearing difficulties Lack of interest or motivation 1. Evaluate process Effects on “expert” youth of youth using were: substances Better able to recognize participation in the consequences of program adaptation substance use for 2. Mechanisms youth targeted by the of adaptation intervention and for 3. Behavioral themselves changes from Significant dissonance participating in the between participation in program process development and their own substance-using behaviors

Table 1 Continued References

Study type

Study design

Sample size

Age

Jurisdiction

Intervention under study Measured outcomes

Findings

11e14 15e19 20e29 evaluation, and quantitative surveys.

Steiker, 2008. [24] Quantitative Randomized control trial

Qualitative

Literature review

x

NA

x

x

5

(continued on next page)

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Paterson and Panessa, 2008 [25]

5 high schools, 4 youth groups, youth advocacy group

Identified intervention programs based on personal experience as more appealing than “evidence-based” interventions Participating in program United States Use substance using adaptation results in youth as “experts” to statistically significant adapt national lowered consumption prevention programs (p < .05) of alcohol, to a local context. marijuana, and other Evaluated using focus drugs. groups, naturalistic Utilizing an adaption process evaluation, model of participation and quantitative engages youth who surveys. typically oppose involvement in prevention initiatives Youth receiving training based on adapted curricula report reduced consumption of all substances, but in comparison to unadapted curricula show even more reduction in consumption of alcohol. A review of literature of 1. Overview of NA Literature review of youth engagement in engagement models participation models of harm reduction used in programs at-risk youth in mental initiatives reveals: targeting at-risk youth health service in prevention of illicit Greatest benefit comes provision when youth share drug use power and voice with 2. Evaluate success adults in the design, of youth engagement implementation, and in the context of an assessment of ethical imperative to interventions, rather engage youth in drug than superficial use reduction engagement programs Positive outcomes of engagement are stronger for at-risk youth than low-risk youth Youth are more likely to engage in programs that focus on youth resilience rather than

References

6

Table 1 Continued Study type

Study design

Sample size

Age

Jurisdiction

Intervention under study Measured outcomes

Findings

11e14 15e19 20e29

Stockburger Qualitative et al., 2005. [26]

Participatory, youth-driven cross-sectional focus group study

x

Canada

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

NA ¼ not available; N/A ¼ not applicable.

21 youth 15e19 years

addressing vulnerabilities Youth generated 1. Youth perceptions Youth-led participatory treatment program of substances and research project recommendations for substance use involving four focus engagement: groups of youth under 2. Reasons for youth Establish a friendly, substance use 20 years old regarding welcoming, and substance use and the 3. Perceptions of existing nonjudgmental programs and services factors that affect environment in the local community substance use. Use staff with similar life and desired future experiences as programs for youth targeted youth Allow participating youth to influence the program and to express opinions on the program Have community youth working for youth Program flexibility in terms of age limit restrictions, hours of operation, and specific requirements of youth Prevention program recommendations for engagement were: Early initiation of prevention programs (primary school age) Parenting skill development for substance use conversations Realistic and relevant videos included in curriculum Free recreation programs for youth

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

program participation [23] and (2) youth who participated as consumers of the adapted program were able to better identify with the content, resulting in statistically significant reductions in the use of substances [24]. A review of engagement models for youth programming revealed a consensus that the greatest benefits are achieved by adopting full participatory models that include youth in program initiation and decision-making. Factors that improve rates of engagement in program development include the following: focusing on resilience rather than vulnerabilities [25]; creating a welcoming and nonjudgmental environment; using staff with life experiences similar to targeted youth; having participating youth work directly with targeted youth; and having flexibility in terms of eligible age groups, hours of operation, and the mandatory requirements of youth [26]. Finally, the offer of participation must be genuine and not simply tokenism [5]. Even in an intensive participatory model of youth engagement, challenges in implementation persist. In an Australian review of youth, increased participation in substance use programs did not prevent youth participants from remaining largely unaware of opportunities to engage in program management [20]. Other barriers to participation included a lack of opportunity or information, shyness, transportation difficulties, hearing difficulties, and a lack of interest [22]. Intervention developers seeking to engage youth through participation in program management must ensure youth are aware of all the opportunities and consider options to reduce or eliminate barriers to participation. Engagement through parental relationships Active parental involvement in the education of their children has been identified by substance-using youth as a critical piece in the youth prevention puzzle [26]. A selection of interventions is highlighted in Table 2. A 2006 study of 4,746 middle school and high school students in Minnesota demonstrated a strong relationship between parent-child connectedness and the absence of serious behavioral and emotional risk behaviors [27]. Engagement of substance users in treatment can be substantially improved by recruiting others, such as parents, to advocate for their care. This approach lead two thirds of nontreatment seeking substance users to engage in treatment programs [28]. The most effective model of parental support is characterized by high levels of contact, support, trust, and warmth [29]. In a 2005 review, family empowerment had a positive effect on both youth participation rates and overall mental health [30]. Canadian drug use intervention developers, Parent Action on Drugs, recommend using multiple communication channels to recruit families to programs at the same time each year to build awareness, legitimacy, and demand. In an effort to improve retention of families, they recommend eliminating participation barriers by providing transportation, meals, and a safe neutral venue; encouraging youth participation in program management; and providing incentives and activities not normally available to targeted families (e.g., a family photograph project) [31]. Family-targeted interventions have been shown to work well with at-risk populations and has the long-term effect of reducing use of tobacco (12 average uses per month in control vs. 1 in intervention group), alcohol (3.5 uses per month in control vs. 1.2 in intervention), and marijuana (7 uses per month in control vs. 1 in intervention) [32]. Family checkup (FCU) is an American, school-based, family intervention focused on improving parental positive behavior

7

support strategies to increase youth engagement. In a randomized control trial, FCU delivered a significant reduction in the growth of self-reported tobacco, alcohol, and marijuana use which persisted for 2 years [33]. There was also a reduction in the rate of family conflict, antisocial behavior, and alcohol use [34]. Resistance to parental participation has been observed, which can be countered in part by increased clinician efforts to engage families. Strategies include ongoing coaching and support of clinicians by implementation leaders, holding regular meetings to discuss efforts with noncompliant families, and physical resources such as posters and handouts [35]. This is based primarily on studies involving children and adolescents as there is limited literature on the young adult population. Engagement through technology Canadian youth are highly connected. Ninety-nine percent of youth grades 4e11 have access to an Internet connection outside of school, 68% through a mobile computer (laptop or tablet), and 45% through a smartphone. As youth age, technology access increases. By grade 11, over 70% access a mobile computer and smartphone [36]. Technology-based interventions are outlined in Table 3. The two most powerful forms for engagement via technology are (1) video sources and (2) social media [37]. While content presented in a social media context is highly relatable, youth still want to validate the information for accuracy using strategies such as looking for trusted URLs (e.g., .gov or .org), logos from official sources, and the production value and language used on sources [37]. Leveraging a strategy to target change in mental health attitudes and literacy by the use of social media, in particular, may create a long-term opportunity for success [38]. In a systematic review of the literature on web-based interventions for mood disorders, Davies et al. [39] found good evidence that computer-delivered interventions can result in positive effects for treatment and symptom reduction of anxiety and stress. In this study, no differences were observed in comparison to active controls, suggesting the computer-based interventions are as effective as offline interventions. In a scoping review by Boydell et al. [40], additional positive effects for treatment and symptom reduction via Internet-based cognitive behavioral therapy were found for post-traumatic stress, first episode psychosis, and eating disorders. Support for the efficacy of electronically delivered cognitive behavioral therapy was found in a systematic review of e-therapies for children and young adults in the UK for depression and anxiety [41]. Inclusive in this review was a discussion of focus groups of youth identifying engaging software as a key factor for success, and the authors recommendation that online therapies should be evaluated by targeted consumers for software “acceptability and ‘customer orientation’” [41]. Online interventions offer several benefits for improving access to hard-to-reach youth, such as those not attending school, adolescent males, and those experiencing symptoms of mental illness. They can also promote social inclusion of marginalized and geographically isolated youth [42]. The medium has near universal reach, 24-hour access, little or no cost of access, confidentiality or anonymity, ease of updating of materials, interactivity, and linkability [43]. The anonymous environment also serves to reduce the stigma associated with seeking treatment [40]. A study of males at a U.S. college showed that as self-reported psychological distress increases,

References

Study type

Study design

8

Table 2 Relevant literature on parental relationships Sample size Age

Jurisdiction

Intervention under study

Measured outcomes

Findings

11e14 15e19 20e29 Ackard et al., 2006 [27]

Quantitative Cross-sectional survey of students and parents

x

x

2,617

x

x

Parents were identified by Minnesota, School-based survey of teenage 1. Teenager perceptions of 60.3% of males and 71.7% of mother-child and fatherUnited States students measuring the females as the first point of child relationships effect of parental contact for health care behavioral decisions making connectedness on MH and information. including substance use and SU behaviors and outcomes Perceiving low parental overall emotional health communication was 2. Measuring teenager positively associated with valuation of parental substance use, suicide opinions and influence on attempts, depression, and behavioral decision-making low self-esteem. Maternal including substance use and and paternal connectedness overall emotional health both had statistically 3. Measuring teenager significant effects on youth perception of parental health behaviors and communication and caring outcomes. and influence on behavior Among boys, feeling unable to and emotional health talk to mothers about problems was associated with increased substance use (p < .001), suicide attempts (p < .001), and depression (p < .001). Being unable to speak with father about programs was associated with increased substance use (p < .001), suicide attempts (p < .001), and depression (p < .001). Among girls, feeling unable to talk to mothers about problems was associated with increased substance use (p < .001), suicide attempts (p < .001), and depression (p < .001). Being unable to speak with father about programs was associated with increased substance use (p < .001), suicide attempts (p < .05), and depression (p < .001). The authors found a recency 1. Influence of rural North Carolina, Measurement of whether effect from parental adolescents’ perception of United States current and prior year parent behaviors on childhood parental relationship on influences youth mental mental health, suggesting adolescent mental health health in rural communities that interventions to provide positive parenting skills can impact youth mental health outcomes even with a poor family history of parenting behavior. In-year parenting was significantly associated

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Smokowski Quantitative Longitudinal et al., 2014 [29] study of students

4,746

Table 2 Continued References

Study type

Study design

Sample size Age

Jurisdiction

Intervention under study

Measured outcomes

Findings

11e14 15e19 20e29

Qualitative

Systematic review

41 studies

Parent Action on Drugs, 2012 [31]

Qualitative

Evidence-based d best practices

x

x

x

x

d

Description of literature on family-based services in children’s mental health

Canada

Engagement strategies for whole family and youthspecific interventions

N/A

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Hoagwood, 2005 [30]

(p < .001) with anxiety (F ¼ 52.29), depression (F ¼ 96.99), aggression (F ¼ 60.50), self-esteem (F ¼ 52.67), and future optimism (F ¼ 35.47). Encouragingly, receiving parental counseling was associated with improved youth mental health outcomes in the second year of the study. One caveat is that previous parent-child conflict overrode any improvements in parenting to relieve negative child aggression behaviors. Hoagwood’s review found that the relationship parent and therapist improved treatment engagement; however, this was not true of child-therapist relationships. Further, parental attitudes and beliefs about the available mental health services were predictive of engagement. Family empowerment was found to not only improve treatment engagement, but also mental health outcomes. Finally, perceived familial barriers to accessing or participating in treatment decreased both engagement and mental health outcomes. Overall engagement strategies include:  Destigmatize programs, present them as “normal” for families struggling to deal with the challenges of life, not just substance issues  Make the program inclusive for all families in the community, not just families at risk Recruitment strategies include:  Community flyers and posters (continued on next page)

9

10

Table 2 Continued References

Study type

Study design

Sample size Age

Jurisdiction

Intervention under study

Measured outcomes

Findings

11e14 15e19 20e29

Quantitative RCT

998

x

x

United States

Randomized control trial of the 1. Longitudinal reporting of monthly participation in family check-up schoolsubstance use and antisocial based family intervention for behaviors reported annually substance use in grade 6 from ages 11e17 years students 2. Influence on these behaviors of: presence of father; deviant peer involvement in 6th grade; family conflict in

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Connell et al., 2007 [32]

 Service organization and clinician referrals  Web site and social media promotion of events  Repeat promotion of programs frequently  Maintain consistent annual timing of the programs  Maintain waitlists for families that are interested but miss program start deadlines Retention and in-program engagement strategies include:  Eliminate barriers to family participation: provide a family meal at sessions, provide transportation, host events in a safe, neutral venue  Provide incentives to participation in the form of family-centered gifts for attendance milestones (i.e., a family board game), hold prize draws  Create a sense of empowerment for participating youth  Give youth a sense of having an individual and collective voice  Involve youth in program and session management  Ask youth to participate in greeting and welcoming families to sessions  Create opportunities for participation in activities not normally available to these families (i.e., a family photograph project) Engagement with the FCU intervention was positively predicted by risk factors associated with family conflict, deviant behavior and substance use namely: absence of a biological father at home, teacher reported problem behavior, and

Table 2 Continued References

Study type

Study design

Sample size Age

Jurisdiction

Intervention under study

Measured outcomes

Findings

11e14 15e19 20e29 elevated family conflict. Engagement in familytargeted interventions is shown to attract at-risk populations to intervention. The FCU intervention was found to have a long-term effect (up to age 17 years) of reducing use of tobacco, alcohol, and marijuana among youth who became engaged in the intervention. Intervention groups showed an 1. Three-year incidence Randomized control trial of increase in effortful control of antisocial behavior, family check-up in intention-to-treat involvement with deviant school-based family analysis. A statistically peers and cigarette, alcohol, intervention for substance significant reduction in the and marijuana use use and socially deviant growth of use of tobacco 2. Self-reported performance behavior of 6th grade (b ¼ .30), alcohol in effortful control students followed through 8th grade with data collected (b ¼ .22), and marijuana through annual survey (b ¼ .39) was reported through grade 8, 2 years after the intervention (p < .05) Randomized control trial of the 1. Incidence of family conflict, Families who were both randomized to the antisocial behavior, deviant family check-up schoolintervention and engaged peer involvement and based family intervention for with the FCU intervention alcohol use in high school substance use and socially saw statistically significant years influenced by a grade deviant behavior in 6th slower growth in rates of 6 intervention and engagethrough 9th grade youth antisocial behavior ment in the intervention (p < .05), alcohol use (p < .05), and family conflict (p ¼ .052). The researchers propose that the familybased nature of FCU might have improved engagement and retention among youth of at-risk families. 6th grade; randomization to intervention; and engagement in intervention

Quantitative RCT

Van Ryzin Quantitative Longitudinal et al., 2012 [34] RCT

593

x

United States

593

x

United States

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Fosco et al., 2013 [33]

FCU ¼ family checkup; N/A ¼ not applicable; RCT ¼ randomized control trial.

11

12

Table 3 Relevant literature on technology-based interventions References

Study type

Study design

Sample size

Age 11e14 15e19

Fergie et al., 2013 [37]

Qualitative

Focus group study

34 students in 9 x focus groups

x

Jurisdiction Intervention under study

Measured outcomes

Findings

Scotland

Youth reported that Youth perceptions and information presented in a experiences with online social media context is health-related content highly relatable, but there were concerns over whether the information could be trusted. Video sources were also perceived to be more engaging and reliable due to the additional production effort required. Social media sources of information were viewed as complimentary to official online sources of information, contextualizing information in peer experience. Youth also reported that the online environment provided a good opportunity for peer support. The environment allows for rich interaction while still affording the ability to remain anonymous. Youth highlighted the ability for people who were suffering to identify others with similar symptoms and experiences and know that they were “not alone.” In evaluating online content to assess validity, youth reported looking for a trusted URL (government, or .org), logos from official sources, production value, and design of content, language, and style (professional, grammar, spelling). Contrived efforts to make Web sites appeal to youth were described as “cringe-worthy.” Youth have a sensitive radar for authenticity. Participants also reported using objective measures to evaluate online content, in particular considering the “likes” and “dislikes” from other users.

20e29 Use of online sources for health information

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Table 3 Continued References

Study type

Study design

Sample size

Qualitative

Broad literature review

Davies et al., 2014 [39]

Quantitative

Systematic review 17 trials (1,795 and meta-analysis pooled participants)

Boydell et al., 2014 [40]

Qualitative

Literature review

d

126 original studies

Jurisdiction Intervention under study

11e14 15e19

20e29

x

x

N/A

x

N/A

x

N/A

x

x

x

Measured outcomes

Findings

Generation Y (born 1982e2001) Summarizes findings in are more likely to participate three areas:(1) social in social networking and media audiences and blogging for health preferences; (2) using information compared to social media to influence other online health resources. knowledge, behavior, Overall, web-based and outcomes; and (3) interventions show efficacy evaluating the effects of in improving patient social media empowerment in terms of self-efficacy and mastery. Effective interventions with strong user engagement reflect dynamic, frequently updated content. Social media has been effective in achieving behavior change when patients can contact an advisor to request advice or receive tailored prompts promoting positive behavior. In trials comparing inactive Primary outcomes Computer-delivered controls to computerevaluated levels of interventions to improve delivered interventions, the psychological distress; depression, anxiety, and computer interventions were stress; symptoms of mental health supported in the meta-analysis anxiety and depression, with statistically significant and general improvements in anxiety psychological well(pooled standardized mean being. Secondary difference [SMD] .56; 95% outcomes included: CI .77 to .35, p < .001), help-seeking behavior; depression (pooled SMD .43; mental health service 95% CI .63 to .22, p < .001), utilization; diagnosis of and stress (pooled SMD .73; mental disorder and 95% CI 1.27 to .19, p ¼ .008). participant attrition The authors’ find evidence for The review sought to Diverse range of the efficacy of Internet-based answer three questions: technology-based interventions for mental (1) the evidence for using delivered mental health health, positive effects for technology to deliver services for children treatment and symptom mental health services to reduction for anxiety, youth; (2) the impact of depression, post-traumatic such delivery; and (3) stress, recovery in the first the knowledge gaps episode psychosis, and remaining reduction in symptoms of eating disorders. Engagement in terms of active participation, compliance with session schedules and formation of a therapeutic alliance was Social media use in health promotion

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Korda and Itani, 2013 [38]

Age

(continued on next page) 13

References

14

Table 3 Continued Study type

Study design

Sample size

Age

Jurisdiction Intervention under study

11e14 15e19

Qualitative

Literature review

Ellis et al., 2013 [43]

Qualitative and Mixed methods: quantitative national survey and focus group study

e

Survey: 486 males 17 focus groups: 118 males

x

Findings

x

x

N/A

Review of literature for information communication technology delivered mental health interventions

x

x

Australia

N/A

found to be present in Internet-based CBT therapy. Three recent studies of mobile phone applications show efficacy in real-time symptom monitoring allowing personalized intervention and reduction of relapses. High school students express a preference for technologybased intervention, noting the privacy afforded and the feeling of being “spoken to, rather than at.” Youth report online assessments to be more readable and easier to understand than paperand-pencil. There is a higher level of program compliance, and youth report a feeling of flexibility, control, interest, engagement, stimulation, and learning from online interventions. Internet-based strategies for Analyzes information youth engagement in mental communication health interventions technologies in terms of promote social inclusion of their (1) relevance to marginalized and youth with mental geographically isolated health issues and (2) populations. Interactive capabilities for offering interventions, which include mental health services games, social media initiatives, and assistive technologies, can be tailored in content and style to meet the needs to individuals or special populations. Internet-based mental health Participants in the survey interventions offer several were asked about: (1) benefits for improving use of various engagement in hard-totechnologies; (2) reach, vulnerable attitudes and behaviors populations including: wide with regard to mental reach, 24-hours access, little health issues; (3) to no cost of access, preferences for receiving confidentiality, ease of mental health updating materials, information and interactivity, and linkability. support; (4) The medium also facilitates demographics. Focus independence and group questions were

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Stephens-Reicher et al., 2011 [42]

Measured outcomes

20e29

Table 3 Continued References

Study type

Study design

Sample size

Age

Jurisdiction Intervention under study

11e14 15e19

Measured outcomes

Findings

20e29 self-treatment frequently sought by youth. Male survey respondents indicated that 40.6% would recommend a Web site as a source of help for mental health problems. In indicating their preference for mental health information and services through a Web site, respondents indicated they would look for: informationbased Web site only (48.1%), Web site with an online clinic (38.5%), Web site with information and multimedia content (29.6%), and Web site with Q&A function by text message or email (28.8%). The 2-way text-messaging To see if the SMS Two-way text-messaging intervention connecting the technology would intervention for existing therapist and patient outside encourage youth to “stay mental health patients of normal appointments was in touch” with health best suited for young people care providers and requiring travel to an thereby improve the outpatient clinic for relationship with treatment. The service hospital staff. encouraged more frequently contact between patient and clinicians and helped improve that relationship. Measured: (1) help-seeking Elite young athletes have been Three fully automated identified as a population attitudes and (2) Internet-based mental particularly unlikely to seek attitudes; intentions and health help-seeking help for mental health behavior interventions in elite conditions. In an RCT of athletes:(1) mental Internet-based mental heath; (2) feedback; and health help-seeking (3) help-seeking list; intervention, the target population showed increased depression and anxiety literacy with decreased depression and anxiety stigma which persisted 3 months after a mental health literacy/ destigmatization Internetbased intervention compared to controls. The trial did not show around the themes of: (1) interests and technology use; (2) knowledge of and attitudes toward help seeking and mental health; (3) brainstorming solutions to identified problems

Qualitative

Preliminary experiences from operational intervention

d

Gulliver et al., 2012 [45]

Quantitative

RCT  not blinded 4 arms  3 treatment þ control

59

Adolescents

Finland

x

Australia

15

(continued on next page)

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Mäkelä et al., 2010 [44]

References

16

Table 3 Continued Study type

Study design

Sample size

Age

Jurisdiction Intervention under study

11e14 15e19

Norman and Skinner, 2007 [46]

Quantitative with qualitative component

Intervention study

223

x

Findings

x

Canada

x

Australia

improvement in helpseeking attitudes, intention, or behavior. Various refinements of the Prevention and/or cessation Demonstrated effective of smoking reduction of cigarette use “smoking zine” weband intention to use in based program nonsmokers. No effect demonstrated in existing smokers, but researchers recommend that a longer engagement period is required in a using population to impact a complex addictive behavior. Researchers recommend extending the online/ classroom integration of their intervention into health clinics, community groups, and other health service providers. Additionally, they recommend an iterative development process that allows adjustment in content once in field based on user participation and feedback. Also, they recommend functionality within the intervention to allow social media integration from users to allow peer-to-peer information sharing and influence. Researchers highlight the need for youth involvement in program design, delivery, and evaluation to maximize engagement in the broader youth population. Both girls (p < .001) and boys Game on: know alcohol 6 Looking for change in (p < .05) perceived drinking attitude and behavior step alcohol intervention to excess more negatively with respect to alcohol with online and offline after the intervention. Girls usage components also showed a positive change on behavioral intention to drink (p < .05), while no effect was observed

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Rundle-Thiele et al., Quantitative: 2013 [47] presurvey and postsurvey

Report of experiences RCT 1: 118 RCT 2: 1,402 of an operational intervention, including two RCTs

Measured outcomes

20e29

Table 3 Continued References

Study type

Study design

Sample size

Age

Jurisdiction Intervention under study

11e14 15e19

Qualitative

Systematic review and focus group

63 studies and two focus groups with a total of 15 youth participants

Norman and Yip, 2012 [49]

Qualitative

Report of experiences d of operational interventions of Youth Voices Research Group (YVRG) http:// www.youthvoices .ca/

x

x

Findings

x

UK

x

Canada

for boys on behavioral intention. Strongest evidence is for Mental health outcomes Any e-mediated therapy computer-delivered CBT for aligned with the that involved either depression in young people condition targeted by the remote therapist with depression intervention interaction with patients Similar evidence for computerSecondary mental health or computer or smart delivered CBT for anxiety in outcome not directly phone applicatione young people and weaker targeted by the delivered therapy evidence for anxiety in intervention children Weaker, but positive, evidence for computerized interventions for cognitive training in attention deficit hyperactivity disorder, parent training in conduct disorder, and substance use Overall existing evidence is weak Focus groups of targeted users suggest that interventions must be engaging and up-to-date to encourage uptake Promotion of youth health A case study of an online Information technologye intervention to promote and to assist in research based interventions for youth health system in youth health youth health promotion: navigation skills is reviewed e.g., interactive blogging; by the authors. Findings are photographic elicitation; qualitative in nature but offer video documentaries; in strong insight into social combination with social media campaign action projects development, maintenance and adjustment to facilitate ongoing user engagement in youth audiences. Relevant learnings from the case study include:  Recruitment into online communities can be facilitated by offline referrals from health care professionals  Content should be designed to easily flow across multiple social media channels. The objectives of design need to include shareability and community building in diverse platforms

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Loucas et al., 2014 [41]

Measured outcomes

20e29

(continued on next page) 17

References

18

Table 3 Continued Study type

Study design

Sample size

Age 11e14 15e19

Jurisdiction Intervention under study

Measured outcomes

Findings

20e29

CBT ¼ cognitive behavioral therapy; CI ¼ confidence interval; N/A ¼ not applicable.

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

 Content should refer users back to a core platform (Web site) regardless of where the content is consumed online by the user. The core platform can serve as a reliable, verifiable source of information and a home for the community.  Twitter allows for real-time interaction with youth and the establishment of a playful but professional personality  Social media is a time and human resource intensive initiative. Content must be created, validated, and scheduled. Participant requests for interaction need to be monitored and responded to. Participant activity peaked on evenings and weekendsdoutside normal clinical hours. Responsiveness requires staffing flexibility and availability when program participants are available for interaction.  Recognition of user participation, even through mechanisms as similar as acknowledgment in program content channels, reinforces relationships, and encourages further participation.  Online engagement paired with face-to-face interactions fosters deeper and more personal interactions.

Table 4 Relevant literature on medical or mental health clinic engagement References

Study type

Study design

Sample size

Age

Jurisdiction

Intervention under study

11e14 15e19 20e29 Anderson and Lowen, 2010 [51]

Range of studies including literature reviews; surveys; and focus groups/ interviews

Kim et al., 2014 [53]

Youth are less likely to have an established GP relationship and are less likely to consult a physician or even family for symptoms of these conditions. “Only 5%e6% of youth surveyed reported consulting their family physicians for alcohol or drug abuse, suspected sexually transmitted infections, or help for personal problems.” A “GP in schools” program in Australia was a physician-led, school-based program to introduce family practice norms to adolescents. The program resulted in increases in intention to seek help, actually seeking help, and decreases in perceived barriers to seeking help. In-school, medical clinics are utilized by 50%e70% of students and are the mostly likely site for students to seek advice for personal and alcohol-related problems. To define domains Researchers identified eight relevant indictors of adolescent-friendly care. Of and indicators of these, five are suggestive of the need for youth-friendly strong youth engagement at the clinic care level: (1) accessibility of health care (location, affordability), (2) staff attitude (respectful, supportive, honest, trustworthy), (3) communication (clarity and provision of information, active listening, tone), (4) age-appropriate environment (flexibility of hours, separate physical space, continuity of care, privacy), (5) involvement in health care. Youth want clinicians who treat them in a friendly manner, in a setting designed with young people in mind. They want to be involved in their care and in decision-making about their health. They want to be respected and have access to confidential care. The structure of mental health services (i) How positively influences the rate of youth organizationengagement in treatment on the level following factors: characteristics  Location and proximity to population influence served service engagement by  Staff perception of organizational support and trust in their service delivery youth; (ii) How organiza-  Increased types of services offered by a practice tional culture  Smaller case loads for staff influences the relationship

Systematic review

240 articles selected 23 English articles that fell into evidence levels 1e3

x

x

x

Papers from countries with health care models similar to Canada

To identify models Accessible models of health care of youth-friendly that supported care delivery youth access to health and mental health care

Systematic review

22 studies based on x the initial search of 1,044. Selection chart given

x

x

Papers published in English and French

Young people’s perspective on health care delivery

270 mental health practitioners and 27 mental health service organizations

x

x

United States

Relationship between service providers and service engagement

Cross-sectional Quantitative survey measure (Service Engagement Scale [SES])

Findings

19

(continued on next page)

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Ambresin et al., Mix of qualitative 2013 [52] (6) and quantitative (15) studies

Measured outcomes

Qualitative Faulkner et al., 2009 [54]

Post-trial analyses of audio recordings

106 of 112 participants of the advice arm of the previous trial (2008)

x

City of London, England

between the professionals and the youth

Measured outcomes Intervention under study Jurisdiction 11e14 15e19 20e29

Age Sample size Study design Study type References

Table 4 Continued

 Staff perception of a low number of barriers to service access  Inclusion of family in treatment decision-making Practitioners can optimize patient Analyses of “advice Ananlysis of how engagement in a counseling session by advice is given to arm” of a applying key information sharing and determine what two-arm RCT communication practices when the practitioner involving MI providing guidance to youth. The did that versus advice for practitioner should have a good mastery promoted young cannabis of the subject area and be able to manage interaction users the flow of information to a patient in an (McCambridge interactive orientation. Advice should be 2008) personalized to the patient, with the practitioner being attentive to the patient’s interest, expressed needs, and preferences.

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Findings

20

respondents are more likely to use online interventions, whereas they are less likely to seek traditionally available care [43]. The strengths of the various online media should be evaluated based on the goals of the planned intervention. Telephone counseling through Kids Help Phone successfully reduced distress in young people, with a single session more effective than online therapy [40]. Text-messaging interventions that connect clinicians to patients between appointments increase treatment plan adherence and improve the clinical relationship [44]. Internet-based educational interventions can reduce stigma associated with help seeking for MH&SU conditions and reduce cigarette use and intention to use [45,46]. Norman and Skinner [46] highlight the need for youth involvement in program design, delivery, and evaluation to maximize engagement in youth populations via these interventions. Social media can change attitudes toward using substances and can provide a space where good peer support is possible, with youth highlighting the ability to identify others with similar symptoms and experiences [37,47]. A Canadian intervention, Strongest Families, uses trained coaches to provide call centerebased services to youth with diagnosed attention-deficit hypersensitivity disorder, oppositional defiance disorder, and anxiety disorders. Family-centered strategies are offered to parents guided by a handbook, weekly telephone consultations, and instructional videos. Notable was the absence of face-to-face intervention with the families minimizing barriers present in most offline interventions. Statistically significant decreases in diagnoses for all three conditions were found after 1 year (odds ratio, 2.75; confidence interval 95% 1.61e4.71). Program adherence rates ranged from 80% for skill implementation completion to 95% for telephone sessions [48]. Online interventions may be more effective when paired with face-to-face interactions. In a qualitative case study of an online intervention to promote youth health system navigation skills, Norman and Yip [49] reported that when paired with face-toface interactions, youth formed deeper and more personal interactions. Social media was found to be more effective in achieving behavior change when patients can contact a realworld advisor to request advice or receive tailored prompts promoting positive behavior [38]. Engagement through the medical or mental health clinic Youth are less likely to have an established relationship with a family physician, and only 5%e6% of youth report consulting a family physician for substance use, sexually transmitted infections, or for personal problems [50]. Creating a youth-friendly practice is an ongoing task which requires youth participation and feedback on the part of the clinicians [51]. Clinic-based interventions are reviewed in Table 4. Factors that increase the likelihood of successful youth engagement with health care professionals include the following list: convenience of location; a welcoming staff attitude; effective and appropriate communication skills with youth; ageappropriate space; flexible hours; continuity of care; perceived privacy; diversity of services offered; reduced staff caseloads; and inclusion of family in treatment decision-making [52,53]. To optimize youth patient engagement, practitioners should also consider personalizing counseling to the patient and be attentive to the patient’s interests, expressed needs, and preferences [54]. The GPs in Schools program in Australia was a physician-led, school-based program designed to introduce family practice

Table 5 Relevant literature on school-based interventions References

Study type

Study design

Sample size

Age 11e14

15e19

Jurisdiction

Intervention under study

Measured outcomes

Findings

School connectedness has a strong association with prosocial behavior (.07, p < .0001) and a strong negative association with having “tried smoking” (.36, p < .05) and antisocial behavior (.11, p < .0001). Low mental fitness was also associated with elevated rates of trial of smoking (p < .05). Teacher support is protective for tobacco, alcohol, and marijuana use initiation and escalation from occasional to habitual use (p < .001). Interestingly, it was found that social belonging mediated this protective factor, increasing the likelihood of occasional smoking (p < .01) and alcohol consumption (p < .05). Teacher support is also protective of suicide attempts (p < .05).

20e29

Quantitative

Cross-sectional survey

10,632

x

Canada

Mental fitness survey of Gr 7e12 students to investigate the association of school connectedness with mental fitness, pro- and antisocial behavior and trial of smoking.

1. Self-reported perceptions of three elements of mental fitness: autonomy, competence, and relatedness to school 2. Self-reported prosocial behavior, antisocial behaviors, and history of trial of tobacco smoking

McNeely and Falci, 2004 [57]

Quantitative

Cross-sectional analysis of survey data

13,750

x

United States

Stratified sample of 80 high schools from the National Longitudinal Study of Adolescent Health to measure teacher support as a protective, delaying engagement in health-risk behavior

Bond et al., 2007 [58]

Quantitative

RCT

2,678

x

x

Australia

Gatehouse Project school-based intervention to promote emotional well-being through increased school connectedness measured through longitudinal schoolbased survey administered a three intervals (13e14 years old, 16 years old, and 18 years old)

1. School connectedness measured through a three-question panel of questions scaled into a single score 2. Perceived teach support measured through a three-question panel of questions scaled into a single score 3. Cigarette smoking in the last 30 days 4. Alcohol use in the last 12 months 5. Marijuana use in the last 30 days 6. Suicidal ideation/attempt in the last 12 months 7. Sexual intercourse in the last 12 months 8. Weapon-related violence participation in the last 12 months 1. Mental health status per the Clinical Interview ScheduledRevised 2. Alcohol, tobacco, and marijuana use 3. Completion of high school 4. University entrance score 5. Scale measurement of social connectedness, interpersonal conflict, and school connectedness

Systematic review

22 studies

x

x

d

Experimental whole-school drug intervention programs with longitudinal surveys of

Fletcher et al., 2008 [59]

1. Drug use and influence of intervention and school connectedness

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Murnaghan et al., 2014 [55]

The intervention was associated with reducing smoking (p ¼ .029) and regular smoking (p ¼ .037) compared to controls. Students with low school connectedness but good social connectedness were at increased risk for anxiety and depressive symptoms (p < .05), and regular consumption of tobacco, alcohol, and marijuana (p ¼ .001). Interventions that target improvements in student participation, relationships, 21

(continued on next page)

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

References

Table 5 Continued

Study type

Study design

Sample size

11e14

Age

15e19

20e29

Jurisdiction

Intervention under study

school-level and individual-level school connectedness and drug use

Measured outcomes

2. Smoking, drinking and “problem behaviors,” and influence of intervention and school connectedness

Findings

school ethos have a causal relationship in reducing drug use and other risk behaviors, especially for boys. Program targeting early substance use experiences appear most effective (D.A.R.E. plus and Aban Aya). In a review of observation studies, the authors conclude that the process of disengagement that leads to increased substance use risk may an environment with few formal extracurricular opportunities for engagement.

22

norms to adolescents. The program resulted in increased help seeking by youth. These in-school medical clinics are utilized by 50%e70% of students and are the mostly likely site for students to seek advice for personal and alcohol-related problems [50]. This illustrates that changing the structure of the delivery of care from the clinic to the school setting can positively influence a change in targeted behaviors related to MH&SU. Engagement through school There appears to be an established relationship between school connectedness and mental fitness in adolescents [55], school-based interventions are discussed in Table 5. School engagement was associated with lower emotional distress (Gr. 7e8: 43%, p < .001; Gr. 9e12: 36%, p < .001); suicidal involvement (Gr. 7e8: 17%, p < .001; Gr. 9e12: 18%, p < .001); and reduced cigarette, marijuana, and alcohol use [56]. Connectedness to teachers also offers a protective effect for students progressing from no use to regular use for tobacco (relative risk ratio [RRR] .84, p < .001), marijuana use (RRR .88, p < .001), drinking to the point of drunkenness (RRR .86, p < .001), and suicidal ideation or attempt (RRR .90, p < .05) [57]. Conversely, students with low levels of school engagement are at elevated risk of anxiety and depression (odds ratio, 1.3; confidence interval, 1.0e1.76) and substance use [58,59]. School is, therefore, a logical setting to target broad youth audiences through formal and informal curricula. Screening at schools can identify at-risk youth earlier and further engage them in prevention and treatment interventions. In a trial of a voluntary mental health screening tool compared to usual school-based referrals, students receiving the screen were 20-times more likely to receive a referral for mental health services and were more likely to uptake school-based interventions. The absolute numbers of students pursuing community-based interventions were higher in the screening group [60]. Engagement through social marketing Social marketing is not solely restricted to advertising campaigns, but is inclusive of any commercial marketing technique intended to achieve a population-level behavior change [61,62]. Marketing theory programs conceptualize target populations as “audiences” and create strategic plans that promote a desired behavior (e.g., nonedrug use) in “competition” with the benefits of the negative behavior (e.g., glamor of drug use, “high” achieved from drug use) [61]. A selection of social marketing interventions are reviewed in Table 6. Social marketing campaigns have been effective in improving student alcohol-related beliefs and skills in alcohol harm reduction (80% felt more confident in safe drinking behavior); reducing community stigmas of mental illness (53.4% of campaign participants report improved attitudes and behaviors); and preventing youth smoking, alcohol use, and illicit drug use [61,63,64]. Evaluation of a U.S. national campaign targeting reduction in marijuana use in the early 2000s shows limited effectiveness of advertising efforts in isolation. Findings from the campaign were mixed, with advertising alone possibly leading to overall paradoxical increase in marijuana use in youth by increasing the perceived incidence of drug consumption in the general population [65]. This study also highlighted the fact that similar social marketing campaigns can have different effects on various age groups due to factors such as “meta-messaging” and its effect on

Table 6 Relevant literature on social marketing Study type

Thompson et al., 2013 [63]

Kirkwood and Hudnall, 2006 [64]

Study design

Sample Age Jurisdiction size 11e14 15e19 20e29

Intervention under study

Quantitative Cross-sectional survey

1,910

Before one more alcoholrelated risk and harm reduction social media campaign for college campuses

Qualitative

d

Best practices and case reports

x

x

United States

x

Idaho, United States

Measured outcomes

Findings

1. Campaign effectiveness is An integrated social media campaign is successful in directing students to generating traffic to the the alcoholdrisk reduction campaign Web site intervention Web site, with 2. Impact on student reported particular success from four beliefs related to alcohol use campaign elements: a Facebook page 3. Impact on student reported (3.1 times increase in likelihood to alcohol use behaviors visit, p ¼ .000), campaign video (p ¼ .000), t-shirts (2.6 times more likely, p < .001), and blood alcohol concentration card (2.3 times more likely, p ¼ .003). The Web site targeted attitudinal and behavioral changes to alcohol consumption. Of Web site visitors, 66.1% reported thinking more about their drinking choices, 67.6% were more aware of and avoiding risky situations while drinking, and 44.3% reported thinking of changing the way they drink. The Web site also significantly improved visitors knowledge of alcohol consumption, its effects, and related risks. In terms of actual behavioral changes 62% reported avoiding risky behaviors, 28.8% reduced the amount they drinks, with 30.8% reducing the number of drinking occasions. Mental health stakeholders, including Social marketing interventions 1. Identification of best youth and patients, collaborated to practices in developing for stigma reduction develop a community-based social community-led social developed, implemented, marketing campaign to reduce public marketing initiatives and evaluated by members stigma related to mental health. The of stigmatized groups (in this 2. Effectiveness of social campaign in isolation reported no marketing campaigns in case those with mental significant changes in attitudes in the changing attitudes in target illness) with utilization of community is relatively small to audiences regarding professional services as achieve significant effects. When stigmatized groups required. supplemented with a communitydevelopment project, the campaign did reflect attitude and behavior changes. “The empowerment component of the campaign development achieved its two goals: (1) that people with mental illness and disabilities controlled the process of developing the campaign and (2) that consumers envisioned the outcome of the

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

References

(continued on next page)

23

References

24

Table 6 Continued Study type

Study design

Sample Age Jurisdiction size 11e14 15e19 20e29

Quantitative Cross-sectional survey

2,515

Longshore et al., 2006 [66]

Quantitative RCT and longitudinal survey

4,689

x

Measured outcomes

1. Measure campaign awareSerial surveys of adolescents ness among adolescents regarding National Youth 2. Self-reported youth alcohol Anti-Drug Media Campaign and drug (cigarettes, awareness and the marijuana) use relationship to substance use 3. Analysis of effect of awareness on substance use behaviors by age

x

United States

x

South Dakota, Synergistic effect of National United States Youth Anti-Drug Media Campaign and school-based ALERT plus intervention

1. Marijuana use in the last month 2. Self-reported exposure of National Youth Anti-Drug Media campaign 3. Randomization to control (campaign þ ALERT program) or intervention (campaign þ ALERT plus program)

Findings

campaign by designing the social marketing campaign themselves.” Researchers found that campaign awareness was strongest and grew most quickly among early adolescents, showing PSAs and video ads have strong traction in vulnerable early adolescents. As youth aged their consumption of television and radio decreased which marked a significant reduction in message exposure. This media consumption pattern is consistent with an overall downward trajectory in campaign awareness in older adolescents, with the exception of specific campaign videos which had increased awareness. This divide in media consumption across adolescence should inform media selection in campaign development. In later adolescence campaign, awareness was associated with diminished use of alcohol and tobacco, although not marijuana despite it being the focus of the campaign. The study also revealed some reverse iatrogenic effects of the campaign, suggesting that in young adolescents that campaign awareness is associated with increase alcohol, tobacco, and marijuana use. One theory is that the presence of this campaign contributes to a normalization of drug use, increasing the perception that drug use is more pervasive in a population than is the reality. In a randomized trial, grade 9 students who experienced a school-based intervention from grades 7 to 10 regarding marijuana use and who reported at least weekly exposure to a national antimarijuana advertising campaign had significantly less marijuana use in the last month (b ¼ .62, p ¼ .03). The campaign alone showed no significant reduction in marijuana use (b ¼ .18, p ¼ .09); however, the two interventions had a synergistic effective on reduction in marijuana use.

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

Schierer and Grenard, 2010 [65]

Intervention under study

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

perceived norms of behavior [65]. Another study found that when combined with school-level interventions, a synergistic effect occurred and marijuana use was reduced [66]. The evidence, therefore, for the efficacy of a pure advertising approach to improving MH&SU outcomes is inconsistent. However, when included as part of an integrated intervention strategy utilizing diverse modalities for prevention and treatment, social marketing may provide an important avenue to engage targeted populations to reduce stigma for conditions, improve awareness of symptoms and help seeking for mental illness, and prevent or reduce substance use [39,40,60,63]. Discussion This review highlights the considerable research that has been done on youth engagement over the past decade. The goal of this review is to give those participating in research and program development an overview of the scope of effective approaches to youth engagement as seen in the literature. It is limited by the inclusion of literature from the period of 2004e2014. This period was chosen primarily because of the role of social media changed in 2004. The breadth of modalities available to MH&SU intervention developers to improve youth engagement necessitated a broad selection criteria for studies for inclusion. In a field still in development, this has required inclusion of qualitative, quantitative, and descriptive papers that have addressed a broad range of MH&SU outcomes, which can be viewed as a limitation in the current review and an opportunity for further development of the science in this area. By nature of this review article, the description of each study intervention is limited and readers are encouraged to consult individual papers for a more in-depth description of the interventions. It is also important to note that engaging youth in an intervention does not always equate to a change in their MH&SU behavior. The recent Lancet Commission on Adolescent Health and Wellbeing reinforces the importance of meaningful youth participation and engagement in improving youth’s health and well-being, which supports the findings from this present review [1]. An emphasis on youth engagement in prevention and treatment interventions for MH&SU can positively influence health outcomes. The six distinct approaches to youth engagement discussed in this review reveal a wide array of mechanisms for MH&SU intervention developers to utilize, including engagement through youth participation in program development, parental relationships, technology, health clinic, school, and social marketing. This review highlights two important points: (1) that there is no single “most effective” way to engage youth when designing an MH&SU program and (2) that the best recipe for success may involve a combination of approaches based on the local needs, desires, and resources available. While there has been much research across the broad scope of approaches to MH&SU prevention and treatment, there has been little in the way of research to investigate the synergistic possibilities of using multiple modalities to achieve stronger youth engagement and improve overall outcomes. More research is required to further refine the optimal mix of interventions to best engage youth and achieve the best possible treatment options for young people. The tables presented give a detailed description of the evidence. These descriptions can provide a helpful tool to the potential researchers and/or program developers. As programs and policies are developed, the essential ingredient remains the

25

active and full participation of those most affected by them, that is, the youth themselves [58]. Meaningful youth engagement will ultimately lead to more effective programming and healthier youth. Our youth are our future; we cannot afford to leave them disaffected or disengaged. Acknowledgments The authors would like to thank all the members of the community boarddin particular Melissa Earles-Drukendwho supported this project as well as the support from Memorial University of Newfoundland, in particular the Discipline of Family Medicine and the School of Pharmacy. Thank you for the support of other research team members: Dr. Norah Duggan, Dr. Amanda Pendergast, and Mr. Rob Sinnott. The authors would also like to acknowledge student research assistant, Mr. Christopher Singleton, who contributed to the project. Funding for student research assistants was provided by Memorial University Summer Undergraduate Research Awards. Funding Sources Work performed by T.D. for this manuscript was funded by a Summer Undergraduate Research Award from the Faculty of Medicine, Memorial University of Newfoundland. The funder had no involvement in: study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication. References [1] Patton G, Sawyer S, Santelli J, et al. Our future: A Lancet commission on adolescent health and wellbeing. Lancet 2016;387:2423e78. [2] Convention on the rights of the child. New York, NY: UNICEF; 2016. Available at: https://www.unicef.org/crc/. Accessed November 13, 2016. [3] Kessler R, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-iv disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593. [4] Urbanoski K, Rush B, Wild T, et al. Use of mental health care services by Canadians with co-occurring substance dependence and mental disorders. Psychiatr Serv 2007;58:962e9. [5] James AM. Principles of youth participation in mental health services. Med J Aust 2007;187(7 Suppl.):S57e60. [6] Rickwood D, Deane F, Wilson C. When and how do young people seek professional help for mental health problems. Med J Aust 2007; 187(7 Suppl.):S35e9. [7] Gulliver A, Griffiths K, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review. BMC Psychiatry 2010;10:113. [8] Sawyer S, Afifi R, Bearinger L, et al. Adolescence: A foundation for future health. Lancet 2012;379:1630e40. [9] McConnell M, Memetovic J, Richardson C. Coping style and substance use intention and behavior patterns in a cohort of BC adolescents. Addict Behav 2014;39:1394e7. [10] Catalano R, Fagan A, Gavin L, et al. Worldwide application of prevention science in adolescent health. Lancet 2012;379:1653e64. [11] Maternal, newborn, child and adolescent health. New York, NY: World Health Organization; 2016. Available at: http://www.who.int/maternal_ child_adolescent/en/. Accessed November 13, 2016. [12] Edlund M, Wang P, Berglund P, et al. Dropping out of mental health treatment: Patterns and predictors among epidemiological survey respondents in the United States and Ontario. Am J Psychiatry 2002;159: 845e51. doi:10.1176/appi.ajp.159.5.845. [13] Olfson M, Mojtabai R, Sampson N, et al. Dropout from outpatient mental health care in the United States. Psychiatr Serv 2009;60. [14] Richardson L, Ludman E, McCauley E, et al. Collaborative care for adolescents with depression in primary care. JAMA 2014;312:809. [15] Servili C. An International Perspective on Youth Mental Health: The role of primary health care and collaborative care models. J Can Acad Child Adolesc Psychiatry 2012;21:127e9.

26

T. Dunne et al. / Journal of Adolescent Health xxx (2016) 1e26

[16] Garvey C, Julion W, Fogg L, et al. Measuring participation in a prevention trial with parents of young children. Res Nurs Health 2006;29:212e22. [17] Garnick DW, Lee MT, O’Brien PL, et al. The Washington circle engagement performance measures’ association with adolescent treatment outcomes. Drug Alcohol Depend 2012;124:250e8. [18] Pullmann M, Ague S, Johnson T, et al. Defining engagement in adolescent substance abuse treatment. Am J Community Psychol 2013;52:347e58. [19] United Nations Department of Economic and Social Affairs. Definition of youth. 2013. Available at: http://www.un.org/esa/socdev/documents/ youth/fact-sheets/youth-definition.pdf. Accessed January 18, 2016. [20] Bryant J, Saxton M, Madden A, et al. Consumer participation in the planning and delivery of drug treatment services: The current arrangements. Drug & Alcohol Revs 2008;27:130e7. [21] Monson K, Thurley M. Consumer participation in a youth mental health service. Early Intervention in Psychiatry 2011;5:381e8. [22] Tobin M, Chen L, Leathley C. Consumer participation in mental health services: Who wants it and why? Aust Health Rev 2002;25:91. [23] Steiker L, Powell T, Goldbach J, Hopson L. Dissonance-based interventions for substance using alternative high school youth. Practice 2011;23:235e52. [24] Steiker L. Making drug and alcohol prevention relevant. Fam Community Health 2008;31:S52e60. [25] Paterson B, Panessa C. Engagement as an ethical imperative in harm reduction involving at-risk youth. Int J Drug Policy 2008;19:24e32. [26] Stockburger J, Parsa-Pajouh B, de Leeuw S, Greenwood M. Youth voices on prevention and intervention of youth substance abuse. Centre Excell Child Adolescents Spec needs 2005. Available at: http://www.unbc.ca/assets/ centreca/english/piysa.pdf. Accessed August 15, 2014. [27] Ackard D, Neumark-Sztainer D, Story M, Perry C. Parent-Child connectedness and behavioral and emotional health among adolescents. Am J Prev Med 2006;30:59e66. [28] Meyers R, Miller W, Smith J, Tonigan J. A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. J Consult Clin Psychol 2002;70:1182e5. [29] Smokowski P, Bacallao M, Cotter K, Evans C. The effects of positive and negative parenting practices on adolescent mental health outcomes in a multicultural sample of rural youth. Child Psychiatry Hum Dev 2014;46:333e45. [30] Hoagwood K. Family-based services in children’s mental health: A research review and synthesis. J Child Psychol Psychiatry 2005;46:690e713. [31] Parent Action on Drugs. Family-based approaches to building resiliency in children and youth. 2012. Available at: https://healthnexus.adobe connect.com/_a1137761304/p2zgadmcnp5/?launcher¼false&fcsContent¼ true&pbMode¼normal. Accessed July 14, 2014. [32] Connell A, Dishion T, Yasui M, Kavanagh K. An adaptive approach to family intervention: Linking engagement in family-centered intervention to reductions in adolescent problem behavior. J Consult Clin Psychol 2007;75: 568e79. [33] Fosco G, Frank L, Stormshak E, Dishon T. Opening the “black box”: Family check-up intervention effects on self-regulation that prevents growth in problem behavior and substance use. J Sch Psychol 2013;51:455e68. [34] Van Ryzin M, Stormshak E, Dishion T. Engaging parents in the family check-up in middle School: Longitudinal effects on family conflict and problem behavior through the high school transition. J Adolesc Health 2012;50:627e33. [35] Weist M, Youngstrom E, Stephan S, et al. Challenges and ideas from a research program on high-quality, evidence-based practice in school mental health. J Clin Child Adolesc Psychol 2013;43:244e55. [36] Steeves V. Young Canadians in a wired world. Phase III: Experts or amateurs? Gauging young Canadians’ digital literacy skills: MediaSmarts. 2014. Available at: http://mediasmarts.ca/ycww/experts-or-amateurs-gauging -young-canadians-digital-literacy-skills. Accessed August 1, 2014. [37] Fergie G, Hunt K, Hilton S. What young people want from health-related online resources: A focus group study. J Youth Stud 2013;16:579e96. [38] Korda H, Itani Z. Harnessing social media for health promotion and behavior change. Health Promotion Pract 2011;14:15e23. [39] Davies E, Morriss R, Glazebrook C. Computer-delivered and web-based interventions to improve depression, anxiety, and psychological wellbeing of university students: A systematic review and meta-analysis. J Med Internet Res 2014;16:e130. [40] Boydell K, Hodgins M, Pignatiello A, et al. Using technology to deliver mental health services to children and youth: A scoping review. J Can Acad Child Adolesc Psychiatry 2014;23:87e99. [41] Loucas C, Pennent M, Whittington C, et al. G130 e-therapies for mental health problems in children and young people: A systematic review and focus group investigation. Arch Dis Child 2014;99:A58.

[42] Stephens-Reicher J, Metcalf A, Blanchard M, et al. Reaching the hardto-reach: How information communication technologies can reach young people at greater risk of mental health difficulties. Australas Psychiatry 2011;19(Suppl. 1):S58e61. [43] Ellis L, Collin P, Hurley P, et al. Young men’s attitudes and behaviour in relation to mental health and technology: Implications for the development of online mental health services. BMC Psychiatry 2013; 13:119. [44] Makela K, Paavola T, Stenman M. Development of short message services application for patient-provider communication in clinical psychiatry. Telemed e-Health 2010;16:827e9. [45] Gulliver A, Griffiths K, Christensen H, et al. Internet-based interventions to promote mental health help-seeking in elite athletes: An exploratory randomized controlled trial. J Med Internet Res 2012;14:e69. [46] Norman C, Skinner H. Engaging youth in e-health promotion: Lessons learned from a decade of teen net research. Adolesc Med State Art Rev 2007;18:357e69. [47] Rundle-Thiele S, Russell-Bennett R, Leo C, Dietrich T. Moderating teen drinking. Combining social marketing and education. Health Educ 2013; 113:392e406. [48] McGrath P, Lingley-Pottie P, Thurston C, et al. Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: Randomized trials and overall analysis. J Am Acad Child Adolesc Psychiatry 2011;50:1162e72. [49] Norman C, Yip A. eHealth promotion and social innovation with youth: Using social and visual media to engage diverse communities. Stud Health Technol Inform 2012;172:54e70. [50] Anderson J, Lowen C. Connecting youth with mental health services: Systematic review. Can Fam Physician 2010;56:778e84. [51] Anderson J, Lowen C. Developing a youth friendly family practice. Can Fam Physician 2010;56:737e8. e283e5. [52] Ambresin A, Bennett K, Patton G, et al. Assessment of youth-friendly health care: A systematic review of indicators drawn from young people’s perspectives. J Adolesc Health 2013;52:670e81. [53] Kim H, Tracy E, Biegel D, et al. The effects of organizational culture on mental health engagement of transition youth. J Behav Health Serv Res 2015;42:466e85. [54] Faulkner N, McCambridge J, Slym R, Rollnick S. It ain’t what you do, it’s the way that you do it: A qualitative study of advice for young cannabis users. Drug Alcohol Rev 2009;28:129e34. [55] Murnaghan D, Morrison W, Laurence C, Bell B. Investigating mental fitness and school connectedness in Prince Edward Island and New Brunswick, Canada. J Sch Health 2014;84:444e50. [56] Resnick M, Bearman PS, Blum RW, et al. Protecting adolescents from harm. Findings from the national longitudinal study on adolescent health. JAMA 1997;278:823e32. [57] McNeely C, Falci C. School connectedness and the transition into and out of health-risk behavior among adolescents: A comparison of social belonging and teacher support. J Sch Health 2004;74:284e92. [58] Bond L, Butler H, Thomas L, et al. Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health, and academic outcomes. J Adolesc Health 2007;40: 357.e9e357.e18. [59] Fletcher A, Bonell C, Hargreaves J. School effects on young People’s drug use: A systematic review of intervention and observational studies. J Adolesc Health 2008;42:209e20. [60] Husky M, Kaplan A, McGuire L, et al. Identifying adolescents at risk through voluntary school-based mental health screening. J Adolesc 2011;34: 505e11. [61] Stead M, Gordon R, Angus K, McDermott L. A systematic review of social marketing effectiveness. Health Educ 2007;107:126e91. [62] Andreasen A. Social marketing: Its definition and domain. J Public Policy Marketing 1994;13:108e14. [63] Thompson E, Heley F, Oster-Aaland L, et al. The impact of a student-driven social marketing campaign on college student alcohol-related beliefs and behaviors. Social Marketing Q 2013;19:52e64. [64] Kirkwood A, Stamm B. A social marketing approach to challenging stigma. Prof Psychol Res Pr 2006;37:472e6. [65] Scheier L, Grenard J. Influence of a nationwide social marketing campaign on adolescent drug use. J Health Commun 2010;15:240e71. [66] Longshore D, Ghosh-Dastidar B, Ellickson P. National youth anti-drug media campaign and school-based drug prevention: Evidence for a synergistic effect in ALERT Plus. Addict Behav 2006;31:496e508.