Does Narrative Quality Matter During Implementation of a School-Based Prevention Intervention? A Test of Narrative Engagement Theory.

Narratives play a powerful role in sharing meaning and making sense of experiences. Specifically, health narratives convey storylines, characters, and messages about health-related behaviors and provide audiences with models for healthy behaviors, prompting audiences' health-related reflections and decision-making. Narrative engagement theory (NET) explains how personal narratives can be integrated into interventions to promote health. This study utilizes NET to test direct and indirect effects of teachers' narrative quality on adolescent outcomes during a school-based substance use prevention intervention that includes narrative pedagogy and an implementation strategy. Observational coding of teacher narratives in video-recorded lessons along with self-report student surveys (N = 1,683) were subjected to path analysis. Findings showed significant direct effects of narrative quality on student engagement, norms (i.e. personal, best-friend injunctive, and descriptive norms), and substance use behavior. The analysis also yielded support for indirect effects of narrative quality on adolescent substance use behavior via student engagement, personal norms, and descriptive norms. Findings highlight important issues related to teacher-student interaction during implementation and contributes implications for adolescent substance use prevention research.

Testing Narrative Persuasion of a Culturally Grounded, School-Based "Dale Se REAL" Entertainment-Education Intervention and Peer Communication on Nicaraguan Adolescent Substance Use.

Guided by narrative engagement theory and social cognitive theory, the present study investigates effects of narrative persuasion and peer communication on Nicaraguan adolescent substance use. Eighth-grade students in Nicaragua were recruited to participate in the culturally grounded, school-based prevention intervention Dale se REAL and to watch five entertainment-education intervention videos that teach drug refusal communication strategies. Using the cross-sectional survey (N = 224), a path analysis was run to examine the mediated moderation effects of narrative engagement (e.g., interest, realism, and identification with main characters) and peer communication about the intervention videos (e.g., frequency and valence of communication) on adolescent refusal self-efficacy and substance use behaviors. Results revealed that realism was significantly related to adolescent refusal self-efficacy and frequent peer communication moderated the association between refusal self-efficacy and the past 30-day marijuana use. Findings suggest that health communication scholars should take into consideration social factors and cultural contexts for adolescent substance use prevention research.

Communication about Suicide, Perceived Social Support, and Suicidal Intention in Korean Adults.

The present study investigates indirect effects of communication about suicide in interpersonal relationships and patient-provider relationships on suicidal intention via attitude, descriptive norm, injunctive norm, and self-efficacy in committing suicide among Korean adults, using longitudinal survey data. Moderation effects of perceived social support are also tested. As a result of path analysis (N = 984), communication about suicide with family, friends, and coworkers is significantly related to pro-suicide descriptive norm and pro-suicide injunctive norm. Positive attitude toward suicide, pro-suicide injunctive norm, and high self-efficacy in committing suicide are significantly related to suicidal intention. Interpersonal communication is positively related to pro-suicide injunctive norm, which in turn links to suicidal intention. Communication about suicide with healthcare professionals, however, did not show significant direct and indirect effects. Moderation effects of perceived social support are detected between interpersonal communication and pro-suicide attitude and pro-suicide injunctive norm, as well as between patient-provider communication and pro-suicide attitude.

Narrative Engagement and Interpersonal Communication about Substance Use on Adolescent Substance Use Behaviors: A Case Study of keepin' it REAL.

The present study examined direct and indirect effects of adolescent narrative engagement on substance use behaviors via refusal self-efficacy. This study also tested moderation effects of communication about substance use with parents, siblings, and friends on substance use behaviors. Students in 8th grade (N = 225) participated in surveys at two different time points. Path analyses revealed a positive association between identification with main characters and refusal self-efficacy as well as negative associations between refusal self-efficacy and the past 30-days substance use. Communication with parents and friends significantly moderated the relationship between refusal self-efficacy and the past 30-days substance use.

Relationships Between Relative Ankle Muscle Ratios, Severity of Symptoms, and Radiologic Parameters in Adolescent Patients With Symptomatic Flexible Flat Feet.

OBJECTIVE: To investigate differences in the relative sizes of the ankle-stabilizing muscles in individuals with versus without flexible flat feet and to determine predictors of symptom severity. METHODS: This cross-sectional study included 30 patients with symptomatic flexible flat feet and 24 normal controls. The following were evaluated: foot posture index, resting calcaneal stance position angle, radiographic findings (calcaneal pitch, Meary's angle, talocalcaneal angle, talonavicular coverage angle [TNCA]), foot function index (FFI), and cross-sectional areas (CSA) of the tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) upon ultrasonographic examination. To address morphometric differences among participants, individual muscle measurements were normalized to proportions of total muscle CSA. Between-group differences were evaluated with independent t-tests. Correlations between muscle ratios, radiographic parameters, and FFI scores were investigated. Logistic regression analysis was performed to determine which parameters predicted severe symptoms. RESULTS: The relative size of the TP was significantly greater and those of the TA and PL were significantly smaller in patients with flat feet than in normal controls. Correlations were found among relative muscle CSA ratios, radiographic parameters, and FFI score. Linear regression analysis confirmed that the TNCA and the relative CSA of the PL were independent predictors of symptom severity. CONCLUSION: This study found significant differences in the relative CSAs of the ankle muscles in patients with flexible flat feet versus individuals without flat feet; these differences were significantly correlated with anatomic abnormalities. Symptoms were more severe in patients with relatively greater forefoot abduction and relatively smaller PL.

Application of the theory of planned behavior to predict smoking intentions: cross-cultural comparison of Kenyan and American young adults.

Despite well-established research on the applications of the theory of planned behavior (TPB) in the American culture, TPB has not been fully tested in the Kenyan culture. This study compared the applications of TPB in predicting smoking intentions (i.e., future and weekend smoking intentions) of Kenyan and American young adults. Data were collected from 252 Kenyans and 227 Americans. The Kenyan participants consisted of 41.7% females with a mean age of 25 years (SD = 4.81). The American participants (49.3% females) had an average age of 19 years (SD = 1.30). Multi-group path analysis was performed to test the equivalence of a TPB-based mediation model in Kenyans and Americans. Significant differences of TPB application were detected. In the American model, smoking consequence beliefs were indirectly associated with smoking intentions through attitudes whereas neither direct nor indirect effects of smoking consequence beliefs were detected in the Kenyan model. Instead, normative beliefs indirectly associated with future and weekend smoking intentions through attitudes and subjective norms in the Kenyan model. Despite some overlapping paths, there were cultural variations on specific associations among TPB constructs between Kenyans and Americans. Cultural adaptations may be needed when applying TPB in the Kenyan cultural context.

How Does Family Communication Relate to Adolescent Dating Violence and Externalizing Behaviors? The Role of Parent-Adolescent Risk Communication and Attitudes toward Violence in a Nicaraguan Sample.

Family plays a critical role for adolescent socialization. Parents in particular can promote either adolescent prosocial or problem behaviors. The purpose of the present study is two-fold. The first is to investigate the main and interaction effects of family communication (i.e., verbal hostility and expressiveness) on adolescent risk behaviors (i.e., dating violence and externalizing behaviors). The second is to test whether family communication is indirectly associated with adolescent risk behaviors through parent-adolescent risk communication and adolescent attitudes toward violence. Nicaraguan 7th and 8th graders were recruited to participate in paper-pencil surveys (N = 1,651). Path analysis identified significant main effects of verbal hostility for adolescent dating violence and externalizing behaviors. Although expressiveness did not show a significant main effect, interaction effects with verbal hostility were identified for both dating violence and externalizing behaviors. When verbal hostility was low, expressiveness was negatively related to adolescent dating violence and externalizing behaviors whereas when verbal hostility was high, expressiveness was positively associated with these behaviors. Significant indirect effects were detected only via adolescent attitudes toward violence. Prevention efforts that promote positive family environments and especially that eliminate verbal hostility are suggested.

Is Parent-Adolescent Drug Talk Always Protective? Testing A New Scale of Drug Talk Styles in Relation to Adolescent Personal Norms, Parental Injunctive Norms, Substance Use Intentions, and Behaviors.

According to parent-offspring drug talk (PODT) model, the specificity of drug talk styles is identified by the timing and directness of communication about substance use between parent and adolescent (e.g., situated direct, ongoing direct, situated indirect, and ongoing indirect talk style). Given the limitation of the original, single item measure for drug talk styles with a categorical response option, the current study proposed a new scale of drug talk styles and tested its concurrent validity. Using cross-sectional survey data (N = 2,035), confirmatory factor analysis was conducted to test the factor structure of the scale. Consistent with PODT model, the analysis yielded support for a four-factor structure for the drug talk styles. Next, a path analysis was employed to validate the scale. The findings suggested that situated direct talk was positively related to personal anti-substance-use norms and parental anti-substance-use injunctive norms but negatively related to smoking intention, as well as alcohol use in the past 30 days. Ongoing direct talk, however, was found to be positively associated with alcohol and marijuana use in the past 30 days. Research implications and future directions are discussed.

Differential Effects of Parental "drug talk" Styles and Family Communication Environments on Adolescent Substance Use.

The current study examines the relationships among adolescent reports of parent-adolescent drug talk styles, family communication environments (e.g., expressiveness, structural traditionalism, and conflict avoidance), and adolescent substance use. ANCOVAs revealed that the 9th grade adolescents (N = 718) engaged in four styles of "drug talks" with parents (e.g., situated direct, ongoing direct, situated indirect, and ongoing indirect style) and these styles differed in their effect on adolescent substance use. Multiple regression analyses showed that expressiveness and structural traditionalism were negatively related to adolescent substance use, whereas conflict avoidance was positively associated with substance use. When controlling for family communication environments and gender, adolescents with an ongoing indirect style reported the lowest use of substance. The findings suggest implications and future directions for theory and practice.

Trends of Parent-Adolescent Drug Talk Styles in Early Adolescence.

The present study seeks to understand how parents as prevention agents approach substance use prevention messages during the period of early adolescence. Students (N = 410) in a drug prevention trial completed surveys from 7th to 9th grade. Using longitudinal data, a series of latent transition analyses was conducted to identify major trends of parent-adolescent drug talk styles (i.e., never talked, situated direct, ongoing direct, situated indirect, and ongoing indirect) in control and treatment conditions. Findings demonstrate a developmental trend in drug talk styles toward a situated style of talk as youth transitioned from 7th grade to 9th grade. Findings also show that even though the drug prevention trial did not specifically target parental communication, parents in the treatment condition provide more ongoing substance use prevention messages to their adolescent children than do parents in the control condition. The present study discusses relevant developmental issues, potential intervention effects, and future research directions for communication research in substance use prevention.

Designed Cultural Adaptation and Delivery Quality in Rural Substance Use Prevention: an Effectiveness Trial for the Keepin' it REAL Curriculum.

This study examined how cultural adaptation and delivery quality of the school-based intervention keepin' it REAL (kiR) influenced adolescent substance use. The goal of the study was to compare the effectiveness of the multi-cultural, urban (non-adapted) kiR intervention, a re-grounded (adapted) rural version of the kiR intervention and control condition in a new, rural setting. A total of 39 middle schools in rural communities of two states in the USA were randomly assigned to one of three conditions (i.e., control, non-adapted urban kiR, and adapted rural kiR). Data included adolescent self-reported lifetime substance use and observers' ratings of delivery quality from video recordings of lessons. Ratings of delivery quality were used to create four comparison groups (i.e., low/high delivery quality in non-adapted/urban kiR condition and low/high quality in adapted/rural kiR condition). Controlling for substance use in the 7th grade, findings compared 9th graders' (N = 2781) lifetime alcohol, cigarette, marijuana, and chewing tobacco use. Mixed model analyses revealed that rural youth receiving the culturally adapted/rural curriculum reported significantly less cigarette use than rural youth in the control condition regardless of delivery quality. In the non-adapted/urban condition, youth receiving high delivery quality delivery reported less marijuana use than those receiving low delivery quality condition. However, substance use outcomes of youth receiving high and low delivery quality in the non-adapted intervention did not differ significantly from those the control group. Findings support the effectiveness of the culturally adapted/rural keepin' it REAL curriculum for rural youth.

Parental Messages about Substance Use in Early Adolescence: Extending a Model of Drug-Talk Styles.

This study extends a typology of parent-offspring drug talk styles to early adolescents and investigates associations with adolescent substance use. Data come from a self-report survey associated with a school-based, 7th grade drug prevention curriculum. Mixed methods were used to collect data across four measurement occasions spanning 30 months. Findings highlight the frequencies of various drug-talk styles over time (i.e., situated direct, ongoing direct, situated indirect, ongoing indirect, never talked), messages adolescents hear from parents, and comparisons of alcohol, cigarette, and marijuana use by drug-talk style. This study advances an understanding of parent-adolescent communication about substances and holds practical implications for drug prevention efforts.

Entertainment-Education Videos as a Persuasive Tool in the Substance Use Prevention Intervention "keepin' it REAL".

Based on social cognitive theory and narrative engagement theory, the current study examined hypothesized indirect effects of engagement with keepin' it REAL (kiR) curriculum entertainment-education (E-E) videos on youth alcohol use via youth drug offer refusal efficacy. Students in 7th grade (N = 1,464) at 25 public schools in two Midwestern states were randomly assigned to one of the two versions of the kiR curriculum, the kiR urban version and the kiR rural version. Each version had their own set of five culturally-grounded E-E videos depicting communicative skills to refuse drug offers. Differential effects for engagement components were expected depending on the degree of cultural matching. Pre/post surveys were administered at the beginning and the end of 7th grade. Structural equation modeling analysis resulted in partial support for the research hypotheses. Rural youth receiving the urban curriculum who reported higher interest in the E-E videos were more likely to report having higher refusal efficacy, and in turn, less likely to use alcohol. Rural youth receiving the rural curriculum who identified with the E-E video main characters were more likely to report having higher refusal efficacy, and in turn, less likely to use alcohol. Implications for E-E health promotion are discussed.

Parent Prevention Communication Profiles and Adolescent Substance Use: A Latent Profile Analysis and Growth Curve Model.

This current study identifies distinct parent prevention communication profiles and examines whether youth with different parental communication profiles have varying substance use trajectories over time. Eleven schools in two rural school districts in the Midwestern United States were selected, and 784 students were surveyed at three time points from the beginning of 7th grade to the end of 8th grade. A series of latent profile analyses were performed to identify discrete profiles/subgroups of substance-specific prevention communication (SSPC). The results revealed a 4-profile model of SSPC: Active-Open, Passive-Open, Active-Silent, and Passive-Silent. A growth curve model revealed different rates of lifetime substance use depending on the youth's SSPC profile. These findings have implications for parenting interventions and tailoring messages for parents to fit specific SSPC profiles.

Segmentation of Mexican-Heritage Immigrants: Acculturation Typology and Language Preference in Health Information Seeking.

With the fast growing number of Mexican immigrants in the United States, more attention is needed to understand the relationship between acculturation and language preference in health information seeking. Latent class analysis provides one useful approach to understanding the diversity in sample of Mexican immigrants (N = 238). Based on 13 linguistic, psychological and behavioral indicators for acculturation, four discrete subgroups were characterized: (1) Less acculturated, (2) Moderately acculturated, (3) Highly acculturated, (4) Selectively bicultural. A Chi-square test revealed that three sub-groups were significantly different in language preference when seeking health information. Less acculturated and moderately acculturated groups sought health information in Spanish, whereas the highly acculturated group preferred English for health information. Selectively bicultural group preferred bilingual health information. Implications for health campaign strategies using audience segmentation are discussed.

A Longitudinal Study of Parental Anti-Substance-Use Socialization for Early Adolescents' Substance-Use Behaviors.

The present study examines the role of communication in shaping norms and behaviors with significant personal and societal consequences. Based on primary socialization theory and the general theory of family communication, parental anti-substance-use socialization processes were hypothesized to influence early adolescents' substance use norms and behaviors. Using longitudinal data (N =1,059), the results revealed that parent-adolescent prevention communication about substance use in the media and parental anti-substance-use injunctive norms were positively associated with early adolescents' personal anti-substance-use norms, which, in turn, led to decreases in recent alcohol, cigarette, and marijuana use. It was also found that family expressiveness and structural traditionalism positively related to the hypothesized association between parental socialization processes and early adolescents' norms and behaviors.

Exploring Parental Influence on the Progression of Alcohol Use in Mexican-Heritage Youth: a Latent Transition Analysis.

Mexican-heritage youth are members of the fastest growing minority group and are at particular risk for substance use including alcohol consumption. Youth face numerous risk factors including positive descriptions of substance use on media and peer offers that are potentially ameliorated by parental anti-substance use socialization efforts. Guided by primary socialization theory and the theory of planned behavior, the present study posited eight research questions to identify discrete subgroups/patterns of Mexican-heritage youth alcohol use behavior and parental influence on youth outcomes. Longitudinal survey data (n = 1147) from youth in 29 public schools located in Phoenix, Arizona, were collected over 3 years. Latent class and transition analyses identified four discrete subgroups characterized by response patterns of alcohol use behaviors and perceptions in Mexican-heritage youth: (1) non-drinker, (2) potential drinker, (3) experimenter, and (4) regular drinker. Targeted parent-child communication about alcohol and parental monitoring were found to be significant predictors for youth alcohol use. Research implications and future directions are suggested.

Teacher Narratives and Student Engagement: Testing Narrative Engagement Theory in Drug Prevention Education.

Testing narrative engagement theory, this study examines student engagement and teachers' spontaneous narratives told in a narrative-based drug prevention curriculum. The study describes the extent to which teachers share their own narratives in a narrative-based curriculum, identifies dominant narrative elements, forms and functions, and assesses the relationships among teacher narratives, overall lesson narrative quality, and student engagement. One hundred videotaped lessons of the keepin' it REAL drug prevention curriculum were coded and the results supported the claim that increased narrative quality of a prevention lesson would be associated with increased student engagement. The quality of narrativity, however, varied widely. Implications of these results for narrative-based prevention interventions and narrative pedagogy are discussed.

Typology of delivery quality: latent profile analysis of teacher engagement and delivery techniques in a school-based prevention intervention, keepin' it REAL curriculum.

Enhancing the delivery quality of school-based, evidence-based prevention programs is one key to ensuring uniform program effects on student outcomes. Program evaluations often focus on content dosage when implementing prevention curricula, however, less is known about implementation quality of prevention content, especially among teachers who may or may not have a prevention background. The goal of the current study is to add to the scholarly literature on implementation quality for a school-based substance use prevention intervention. Twenty-five schools in Ohio and Pennsylvania implemented the original keepin' REAL (kiR) substance use prevention curriculum. Each of the 10, 40-45 min lessons of the kiR curriculum was video recorded. Coders observed and rated a random sample of 276 videos reflecting 78 classes taught by 31 teachers. Codes included teachers' delivery techniques (e.g., lecture, discussion, demonstration and role play) and engagement with students (e.g. attentiveness, enthusiasm and positivity). Based on the video ratings, a latent profile analysis was run to identify typology of delivery quality. Five profiles were identified: holistic approach, attentive teacher-orientated approach, enthusiastic lecture approach, engaged interactive learning approach and skill practice-only approach. This study provides a descriptive typology of delivery quality while implementing a school-based substance use prevention intervention.

Does parentification place Mexican-heritage youth at risk for substance use? Identifying the intervening nature of parent-child communication about alcohol.

Past research on parentification suggests that adopting adult responsibilities to the point at which the child plays a parental role places children at risk for poor mental and behavioral health outcomes. Since family relations are particularly important in Mexican culture, two hypotheses were posed to examine the indirect effects of parentification on Mexican-heritage youths' substance use via parent-child communication about alcohol, while examining the moderating effects of parent-child closeness. Mexican-heritage youth (N = 697) from 23 public middle schools in Phoenix, AZ completed surveys at three waves. Structural equation modeling results provided partial support for the hypotheses. Mexican-heritage youth experiencing problem-solving parentification were more likely to talk with a parent about alcohol and, in turn, less likely to use substances. This mediation effect, however, was not found with respect to adult parentification, and parent-child closeness was not a significant moderator. Implications for the beneficial effects of problem-solving parentification are discussed.