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Screening and Brief Intervention With Low-Income Youth in Community-Based Settings

      Abstract

      Purpose

      We described screening, brief intervention, and referral to treatment (SBIRT) results and assessed whether SBIRT is associated with positive changes in substance use, risky use, and educational/employment outcomes for youth in community-based settings that are not healthcare focused.

      Methods

      YouthBuild USA serves youth of ages 16–24 who are neither in school nor employed. In an SBIRT intervention, youth completed substance use surveys and Alcohol Use Disorders Identification Test and Drug Abuse Screening Test screenings at entry and program completion. Staff reported on services provided in response to screening scores. Regression models compared changes in youth screening results and substance use from intake to follow-up and, with aggregate program-level data, youth outcomes across programs with and without the SBIRT intervention.

      Results

      Youth significantly reduced Alcohol Use Disorders Identification Test (3.1 vs. 2.3, p < .001) and Drug Abuse Screening Test (1.9 vs. 1.4, p < .001) scores, positive screens (64% vs. 54%, p < .001), and need for referrals to treatment (48% vs. 37%, p < .001), indicating less risky substance use, although self-reports of substance use in the past 30 days did not decrease. Proportionately more youth in SBIRT programs attained a high school diploma or equivalent (49% vs. 42%, p = .01) and were still in educational/job placements 3 months after program completion (67% vs. 59%, p = .02), compared to youth in non-SBIRT programs.

      Discussion

      These findings suggest that community-based SBIRT is associated with positive outcomes–both reduced risky substance use and improved education and employment–that relate to longer-term positive development for youth. SBIRT appears to be an evidence-based approach to intervene and help youth.

      Keywords

      Implications and Contribution
      This study uniquely evaluated whether screening, brief intervention and referral to treatment (SBIRT) is associated with improved outcomes in community-based settings. Youth in SBIRT programs reduced risky substance use and were more likely to attain high school diplomas/equivalents and stay in educational/job placements longer–key areas for longer-term positive development.
      Youth use substances at high rates and face consequences due to their risky use [
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health.
      ]. Risky substance use affects more than just health, including educational consequences with missed days at school, poor academic performance, and higher rates of dropping out [
      • Staff J.
      • Patrick M.E.
      • Loken E.
      • et al.
      Teenage alcohol use and educational attainment.
      ,
      • Gutierrez A.
      • Sher L.
      Alcohol and drug use among adolescents: An educational overview.
      ]. In turn, youth who drop out of high school are at heightened risk of more serious substance use problems [
      • Henry K.L.
      • Knight K.E.
      • Thornberry T.P.
      School disengagement as a predictor of dropout, delinquency, and problem substance use during adolescence and early adulthood.
      ]. For the workplace, risky use can lead to loss of job for failed drug screens or poor performance [
      • Henkel D.
      Unemployment and substance use: A review of the literature (1990-2010).
      ]. These effects compound for youth, ultimately impacting earnings potential and quality of life.
      The screening, brief intervention, and referral to treatment (SBIRT) approach identifies and addresses problems early and helps both youth and adults [
      • Tanner-Smith E.E.
      • Lipsey M.W.
      Brief alcohol interventions for adolescents and young adults: A systematic review and meta-analysis.
      ,
      • Martin G.
      • Copeland J.
      • Swift W.
      The adolescent cannabis check-up: Feasibility of a brief intervention for young cannabis users.
      ,
      • Mitchell S.G.
      • Gryczynski J.
      • O'Grady K.E.
      • et al.
      SBIRT for adolescent drug and alcohol use: Current status and future directions.
      ,
      • Harris S.K.
      • Louis-Jacques J.
      • Knight J.R.
      Screening and brief intervention for alcohol and other abuse.
      ,
      • Tanner-Smith E.E.
      • Steinka-Fry K.T.
      • Hennessy E.A.
      • et al.
      Can brief alcohol interventions for youth also address concurrent illicit drug use? Results from a meta-analysis.
      ]. To date, SBIRT has been primarily implemented in primary care and emergency room settings [
      • Thoele K.
      • Moffat L.
      • Konicek S.
      • et al.
      Strategies to promote the implementation of screening, brief intervention, and referral to treatment (SBIRT) in healthcare settings: A scoping review.
      ]. While most youth ages 12–17 had a doctor's visit in the past year (94.1%) [
      National Center for Health Statistics
      Percentage of having a doctor visit for any reason in the past 12 months for children under age 18 years, United States, 2019.
      ], this occurred for only 77.1% of people aged 18–34 [
      National Center for Health Statistics
      Percentage of having a doctor visit for any reason in the past 12 months for adults aged 18 and over, United States, 2019.
      ]. If SBIRT is only provided in medical settings, we likely miss opportunities to intervene early with youth.
      Several studies have reported favorably on the feasibility of implementing SBIRT in schools [
      • Curtis B.L.
      • McLellan A.T.
      • Gabellini B.N.
      Translating SBIRT to public school settings: An initial test of feasibility.
      ,
      • Grenard J.L.
      • Ames S.L.
      • Wiers R.W.
      • et al.
      Brief intervention for substance use among at-risk adolescents: A pilot study.
      ,
      • Maslowsky J.
      • Whelan Capell J.
      • Moberg D.P.
      • Brown R.L.
      Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility.
      ]. In addition, school-based SBIRT studies have reported increased intentions to reduce or delay substance use [
      • Maslowsky J.
      • Whelan Capell J.
      • Moberg D.P.
      • Brown R.L.
      Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility.
      ]; increased discussions of and counseling for alcohol and marijuana use and more motivation to decrease marijuana use, but without substantive changes in frequency of alcohol or marijuana use [
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • et al.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the Check Yourself tool.
      ]; decreased self-reported days of drinking to intoxication and self-reported drug use, but not alcohol use [
      • Mitchell S.G.
      • Gryczynski J.
      • Gonzales A.
      • et al.
      Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program: Services and outcomes.
      ]; and reduced alcohol use and heavy episodic drinking [
      • Komro K.A.
      • Livingston M.D.
      • Wagenaar A.C.
      • et al.
      Multilevel prevention trial of alcohol use among American Indian and white high school students in the Cherokee nation.
      ] related to SBIRT interventions. No studies were identified that report on SBIRT with youth in community settings other than schools. For youth, particularly those at higher risk, community-based interventions outside of school settings may better support them to identify and reduce risky substance use.
      This study examined whether SBIRT is associated with improved outcomes in community-based settings that are not healthcare focused. YouthBuild works with youth aged 16–24 who are neither enrolled in school nor employed, to help them reach educational goals, prepare for future careers, and grow into community leaders. Youth participate in a 9-to-12-month program that provides educational and on-the-job training. YouthBuild USA offers training and coaching to local YouthBuild programs and has built a robust network of over 230 programs in 46 states and territories. Local YouthBuild programs are independently run and sponsored and managed by community-based nonprofits, community colleges, and public agencies.
      With funding from the Conrad N. Hilton Foundation, YouthBuild USA partnered with 130 programs over 3 years to test the feasibility of delivering SBIRT services to youth in its programs, with coaching provided by YouthBuild USA. Early in the SBIRT implementation, they also contracted with external researchers to conduct a prospective evaluation of its community-based SBIRT approach. Here, we present findings from this evaluation, which focuses on substance use and screening outcomes for youth participating in year 3 of the SBIRT initiative, and educational and employment outcomes for youth across all 3 years of the initiative compared to youth in non-SBIRT YouthBuild programs. Our primary goal was to determine if risky substance use changed, and if there were any additional effects on educational and employment outcomes. In addition, we report on services received relative to screening results.

      Methods

      Program selection and training

      The YouthBuild SBIRT initiative ran from 2014 to 2017. YouthBuild USA released an annual request for proposals to ensure that local YouthBuild programs understood the commitment to implementing SBIRT and participating in coaching sessions. Few programs were excluded, those that were required funding to participate or had no youth or staff available (e.g., a new program with no current services). Over the 3-year effort, 130 programs participated to varying degrees. Programs received training and coaching on SBIRT but no implementation funds. Staff attended initial and annual booster trainings covering SBIRT and motivational interviewing in depth, as well as quarterly webinars on motivational interviewing and SBIRT implementation. Staff were also trained to train other staff in their programs in case of staff turnover. Monthly and ad hoc coaching sessions helped programs implement SBIRT and motivational interviewing. In addition, staff received a 10-step implementation plan, training materials, and an SBIRT Adolescent Learners' Guide [
      NORC at the University of Chicago
      Guide to adolescent screening, brief intervention and referral to treatment (SBIRT).
      ]. Coaches and YouthBuild USA staff monitored implementation through quarterly reports submitted by programs. To encourage data submission, programs received small honorary payments.

      YouthBuild program and SBIRT implementation

      Generally, YouthBuild programs recruit new cohorts of youth for each 9-to-12-month program. Eligible youth must be (1) 16–24 years old on enrollment date; (2) a member of a low-income family, a child of incarcerated parents, in foster care, a youth offender, disabled, or a migrant; and (3) a school dropout or previously a school dropout who has subsequently re-enrolled. Prospective participants go through a formal intake process that includes face-to-face interviews, eligibility verification, and a 1-to-3-week multi-faceted orientation. This orientation exposes the youth to the overall YouthBuild program and approach and ensures that youth are ready for the program structure and activities. Youth who successfully complete orientation formally enroll into the program.
      Once formally enrolled, youth completed screenings using the validated Alcohol Use Disorders Identification Test (AUDIT) [
      • Knight J.R.
      • Sherritt L.
      • Harris S.K.
      • et al.
      Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT.
      ,
      • Reinert D.F.
      • Allen J.P.
      The alcohol use disorders identification test: An update of research findings.
      ] and Drug and Alcohol Screening Test (DAST-10) [
      • French M.T.
      • Roebuck M.C.
      • McGeary K.A.
      • et al.
      Using the drug abuse screening test (DAST-10) to analyze health services utilization and cost for substance users in a community-based setting.
      ,
      • McCabe S.E.
      • Boyd C.J.
      • Cranford J.A.
      • et al.
      A modified version of the Drug Abuse Screening Test among undergraduate students.
      ]. AUDIT scores range from 0 to 40 [
      Scoring the AUDIT.
      ] and DAST-10 scores from 0 to 10 [
      Instrument: Drug abuse screening test (DAST-10) | NIDA CTN common data elements.
      ]. For the AUDIT, program staff were trained to provide a brief intervention for youth ages 16–17 with a score of 2, for women 18 and older with a score of 4–14, and for men 18 and older with a score of 8–14; and referrals to treatment for scores higher than these respective cut-points [
      • Knight J.R.
      • Sherritt L.
      • Harris S.K.
      • et al.
      Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT, CAGE, and CRAFFT.
      ,
      • Reinert D.F.
      • Allen J.P.
      The alcohol use disorders identification test: An update of research findings.
      ]. For the DAST-10, program staff were trained to provide brief interventions for scores of 2 and referrals to treatment for scores 3 or higher for all youth [
      • Reinert D.F.
      • Allen J.P.
      The alcohol use disorders identification test: An update of research findings.
      ]. For the brief interventions, staff provided feedback on the youth's screening score, discussed levels of use relative to national averages, shared concerns about use in terms of health and employment, assessed readiness for change, and used motivational interviewing to help the youth make plans to cut back or stop use of substances. They used this same approach and motivational interviewing when making referrals to treatment. YouthBuild programs with SBIRT were encouraged to adopt progressive sanctions for substance use, rather than zero-tolerance policies, to support youth to answer the surveys and engage in discussion honestly.

      Study data

      Study data came from two sources. First, substance use, screening and services were reported by youth and YouthBuild staff for youth taking part in year 3 of the SBIRT intervention. Due to the time needed to establish rigorous data collection processes, we only report these data from year 3 SBIRT programs. Second, aggregated program-level educational and employment outcomes were analyzed for youth in the SBIRT programs across the three implementation years and compared to youth in non-SBIRT programs for those same 3 years.

      Youth surveys, AUDIT and DAST-10 scores, and services

      Youth surveys included demographics (gender, age group, ethnicity, and race) and substance use (number of days in past 30 days of binge alcohol, marijuana, and other drug use). YouthBuild USA created the survey internally for staff to use when talking with youth about substance use. Staff screened youth using the AUDIT and DAST-10 at the beginning and end of the program, and asked youth to complete the survey. Staff submitted surveys directly to the research team and provided an Excel table detailing AUDIT and DAST-10 scores and services provided for each youth.
      Overall, 62 programs implemented SBIRT in year 3 with 1,406 youth. However, only 32 programs serving 500 youth submitted screening data, and serve as our analytic sample. Furthermore, some programs did not administer the youth survey, so substance use data were available for only 228 youth. Non-response analyses for the year 3 sample indicated missing surveys were related to program (i.e., YouthBuild site, p < .001) but not to individual AUDIT or DAST-10 scores or positive screening status at intake. Missing follow-up screening data varied by demographics: youth in the 16–17 age group (p = .01) and African-American youth (p = .04) were more likely to having missing follow-up screening, while White youth were more likely to have follow-up screening present (p = .02).
      Youth were assigned a non-identifying code used to link surveys collected at intake and follow-up. All data provided to the research team were deidentified and not linked to subjects. SBIRT was integrated into the normal workflow of the YouthBuild programs so the university Instituitional Review Board deemed the study did not qualify as human subjects research and neither required Instituitional Review Board approval nor consent.

      Aggregate data on educational and employment outcomes

      Data on outcomes related to retention in the YouthBuild program, educational gains, and educational/employment placements came from YouthBuild USA's data reporting system, which includes data from SBIRT and non-SBIRT programs for all three program years. Before sharing with the researchers, YouthBuild USA aggregated the youth results to the program level.

      Outcome variables

      For youth-level data, we analyzed changes in AUDIT and DAST-10 scores; positive screening status calculated across the AUDIT and DAST-10; and self-reported binge alcohol use, marijuana use, and drug use other than marijuana in the past 30 days. For both screening tools, a positive screen was calculated as a score of two or higher because we did not have data on age and gender for the full sample to mimic the more detailed cut-points used by program staff. For aggregate data we analyzed percentages of youth completing the program, who entered the program without a high school diploma or equivalent who then earned one in the program, placed in a job or education program at program completion, and retained in their job or educational placement 3 months post-completion.

      Analyses

      We conducted univariate and bivariate analyses. We also conducted multilevel regressions, controlling for program, to assess change in youth outcomes from intake to follow-up. As a sensitivity analysis, a second set of regressions included youth demographics, which did not change the main effect for time, yet had a smaller sample; thus, these results are not reported.
      For aggregate data on educational and employment outcomes, we conducted regressions to assess program-level outcomes by SBIRT participation, controlling for program-level demographics (gender, mean age at entry, race, and ethnicity), program size, mean length of stay, cohort year and program. Regression results report the estimated marginal means (EMM), holding any covariates at their means. Analyses were conducted with IBM SPSS Statistics v.28.0.0.0.

      Results

      Demographics and reported substance use

      The analysis of year 3 SBIRT programs with intake screening data included 32 programs with 500 youth. The largest groups of youth were male, in the 18–20 age group, Black/African-American, and not Hispanic/Latino (see Table 1). Seven out of ten (72.4%) were in minoritized race/ethnicity groups.
      Table 1Characteristics of youth receiving SBIRT services and self-reported substance use in past 30 days
      Number
      Data are from the youth intake survey. About half of the youth did not complete the survey (n = 272), thus demographics and substance use are reported for n = 228 youth.
      Percent
      # of Programs32100.0
      # of Youth500100.0
      Demographics
       Gender
      Male16070.2
      Female6829.8
       Age
      16–172511.0
      18–2012554.8
      21–247834.2
       Ethnicity
      Hispanic or Latinx5725.0
      Not Hispanic or Latinx17175.0
       Race (can be >1 race)
      Black or African-American9240.2
      White8537.1
      Native American or Alaskan Native187.9
      Asian or Native Hawaiian/Pacific Islander81.6
      Other5423.6
      Multiple race categories reported2410.5
       Minoritized (Hispanic/Latinx or any non-White)16572.4
      Substance Use Past 30 Days
       Binge drinking (5+ for males, 4+ for females)6529.2
       Marijuana10345.6
       Drugs other than marijuana177.5
      a Data are from the youth intake survey. About half of the youth did not complete the survey (n = 272), thus demographics and substance use are reported for n = 228 youth.
      Substance use was commonly reported on the intake survey (Table 1). Nearly one-third of youth (29.2%) used alcohol at “binge” levels (5 or more drinks at one time for males, four or more for females). Nearly half (45.6%) reported marijuana use in the past month. Only 7.5% reported use of drugs other than marijuana. These rates varied slightly when adjusting for program (Table 2).
      Table 2Intake versus follow-up screening results and self-reported substance use
      Mulitivariate regressions
      EMM = Estimated Marginal means. Model controls for program (random effects).
      NEMM-time 1EMM-time 2Estimate95% CIp-value
      AUDIT Score (mean)4603.1172.310.0870.487, 1.126<.001
      DAST-10 Score (mean)4951.9021.4390.4630.288, 0.638<.001
      Positive Screen (%)
      Positive screen is the percent of youth scoring 2 or higher on either the AUDIT or DAST-10.
      50064.453.910.56.2, 14.9<.001
      Positive BI (%)
      Positive screen is the percent of youth scoring 2 or higher on either the AUDIT or DAST-10.
      50016.917.4−0.5−4.5, 3.5.806
      Positive RT (%)
      Positive screen is the percent of youth scoring 2 or higher on either the AUDIT or DAST-10.
      50048.036.911.26.9, 15.4<.001
      Binge alcohol (%)22625.031.3−6.3−12.7, 0.1.055
      Marijuana use (%)22644.241.82.4−4.3, 9.2.479
      Use of drugs other than marijuana (%)2267.03.83.2−0.8, 7.2.119
      Positive BI is the percent of youth scoring 2 on either the AUDIT or DAST-10, so a brief intervention is indicated.
      Positive RT is the precent of youth scoring 3 or higher on either the AUDIT or DAST-10, so a referral to treatment is indicated.
      a EMM = Estimated Marginal means. Model controls for program (random effects).
      b Positive screen is the percent of youth scoring 2 or higher on either the AUDIT or DAST-10.

      Screening for risky substance use

      Among the 500 youth, 460 were screened with the AUDIT and 495 with the DAST-10 (not mutually exclusive). The mean AUDIT score at intake was 3.1 (standard deviation [SD] 4.58), after controlling for program, indicating unhealthy alcohol use for this population (see Table 2). The mean DAST-10 score at intake was 1.9 (SD 2.26), after controlling for program, indicating low risk. Both the AUDIT and DAST-10 results spanned the range of potential scores. Figure 1 shows screening results for the AUDIT and DAST-10 separately and combined, where youth were placed in the highest risk category across the two screens. Overall, two out of three youth (64.0%) had a positive screen for risky use. Brief intervention was indicated for 16.8% of youth and referral to treatment for 47.2%.
      Figure thumbnail gr1
      Figure 1AUDIT, DAST-10 and combined screening results at intake.

      Services received after screening

      Staff were trained on cut-points for when to provide a brief intervention or referral to treatment based on screening results. Our analyses used the most conservative cut-point of 2 for a brief intervention and 3 for a referral to treatment for all youth as the guidelines varied by age and gender, which were not available for all youth in our data set. As expected, staff provided higher levels of intervention to youth with higher scores (see Figure 2). About half of youth with no risky substance use (48.9%) received no intervention, but 24.7% received a brief intervention and 8.3% received a referral to treatment. For youth scoring 2 on either screen, 59.3% received a brief intervention and 16.0% received a referral to treatment; 24.7% received no intervention. For youth scoring 3 or higher on either screen, half (49.6%) received a referral to treatment, 42.1% received a brief intervention, and 8.3% received no intervention.
      Figure thumbnail gr2
      Figure 2Services received by screening results.

      Pre-post substance use and screening for risky substance use

      At the end of each cohort, programs re-screened youth, and youth were asked to complete an additional survey. In multilevel regression models comparing intake and follow-up screenings, there were significant decreases in both the AUDIT (EMM 3.1 at intake vs. 2.3 at follow-up, p < .001) and DAST-10 (EMM 1.9 vs. 1.4, p < .001) scores, and in the percentage of youth who screened positive (EMM 64.4% vs. 53.9%, p < .001), controlling for program. For the screening result categories of brief intervention or referral to treatment indicated, there was a significant reduction in the percent of youth needing a referral to treatment (EMM 48.0% vs. 36.9%, p < .001), suggesting that the severity of substance use issues reduced over time (see Table 2).
      However, multilevel regression results controlling for program showed little change in the percentage of youth who reported any use of specific substances in the past month. The proportion of youth reporting binge drinking appears to have increased and reported other drug use appears to have decreased, but these changes were not statistically significant.

      Program, education, and employment outcomes

      Over the 3-year implementation, the aggregated program-level data include 225 SBIRT cohorts and 237 non-SBIRT cohorts (see Table 3). SBIRT programs had larger cohorts, 30.8 youth on average versus 26.5 at non-SBIRT programs (p = .03), and non-SBIRT programs had proportionately more court-involved youth at intake (30.7% vs. 27.4% at SBIRT programs, p = .05).
      Table 3Comparison of SBIRT and non-SBIRT sites by key characteristics and by outcome results
      Bivariate T-tests for key characteristics
      TotalSBIRTNot SBIRTp
      NMeanNMeanNMean
      Site characteristics
       Program size (average # students)46228.622530.823726.5.03
       Length of time in program (average # months)4629.922510.02379.8.29
      Youth Demographics at entry
       Female (%)46234.822535.823733.8.13
       African-American (%)46246.822548.423745.3.17
       White (%)46224.822523.323726.1.15
       Hispanic (%)46227.822528.623727.1.29
       Other race (%)4626.92256.72377.0.41
       Age at entry (years)46219.222519.223719.3.22
       Court-involved (%)43929.121327.422630.7.05
       No high school diploma or equivalent (%)46288.822589.423788.2.24
      Multivariate regressions for outcomes
      EMM = Estimated Marginal Means. Models control for % female, mean age at entry, % white, % African-American, % Hispanic, % Other Race, % court-involved, % entered without high school diploma or equivalent, Size (# students in cohort year), and mean length of stay in program (fixed effects) and program and cohort year (random effects).
      EMM SBIRTEMM No SBIRTEstimate95% CIp-value
      YouthBuild program completion (%)68.868.90.11−5.3 to 5.5.97
      Attained HS diploma or equivalent (%)48.542.0−6.50−11.1 to −1.9.01
      Placement in job or education program (%)52.248.4−3.86−9.2 to 1.5.16
      Retained in placement for 3 mo (%)66.759.4−7.29−13.5 to −1.1.02
      a EMM = Estimated Marginal Means. Models control for % female, mean age at entry, % white, % African-American, % Hispanic, % Other Race, % court-involved, % entered without high school diploma or equivalent, Size (# students in cohort year), and mean length of stay in program (fixed effects) and program and cohort year (random effects).
      Regression models (Table 3) show that being in an SBIRT cohort was associated with improvements in the mean proportion of youth who attained a high school diploma or equivalent and the mean proportion who were retained in job or education placement at 3 months, as compared to non-SBIRT cohorts, controlling for program-level covariates. Most youth (88.8%) entered YouthBuild without a high school diploma or equivalent. Despite no significant difference between SBIRT and non-SBIRT programs at intake, proportionately more youth in SBIRT programs attained their high school diploma or equivalent while in the program compared to youth in non-SBIRT programs (EMM 48.5% for youth in SBIRT programs vs. 42.0% for youth in non-SBIRT programs, p = .01). Similarly, although youth in both types of programs were placed in job or education programs at similar rates on graduation (EMM 52.2% SBIRT and 48.4% non-SBIRT), proportionately more youth in SBIRT programs were retained in their job or educational placements 3 months after graduation compared to youth in non-SBIRT programs (66.7% SBIRT vs. 59.4% non-SBIRT, p = .02).

      Discussion

      Combined AUDIT and DAST-10 screening results for the youth in this study of SBIRT in community settings indicated that 16.8% needed a brief intervention and nearly half (47.2%) needed a referral to treatment. In comparison, a study of middle and high school students in New York found 25% of students screened using the CRAFFT were at moderate risk (brief intervention) and 25% at significant risk (referral to treatment) [
      • Curtis B.L.
      • McLellan A.T.
      • Gabellini B.N.
      Translating SBIRT to public school settings: An initial test of feasibility.
      ]. Note, the CRAFFT is a validated brief screening tool for adolescent substance use. The name is derived from the key letters of the tool's six questions: Car, Relax, Alone, Forget, Friends, and Trouble [
      • Knight J.R.
      • Sherritt L.
      • Shrier L.A.
      • et al.
      Validity of the CRAFFT substance abuse screening test among adolescent clinic patients.
      ]. Another study of undergraduates found 24% of students had AUDIT scores of eight or higher [
      • Lindgren K.P.
      • Ramirez J.J.
      • Namaky N.
      • et al.
      Evaluating the relationship between explicit and implicit drinking identity centrality and hazardous drinking.
      ]. Another study of undergraduates screened with the DAST-10 found 9% needed a brief intervention and 10% needed a referral to treatment [
      • McCabe S.E.
      • Boyd C.J.
      • Cranford J.A.
      • et al.
      A modified version of the Drug Abuse Screening Test among undergraduate students.
      ]. The higher rates of positive screens in the YouthBuild population support the need for community-based interventions with high-risk youth who may not be engaging with professionals in school-based and healthcare settings.
      The pre/post comparison of AUDIT and DAST-10 scores indicates that SBIRT in YouthBuild programs was associated with reduced risky use of substances, although self-reports of any substance use in the past 30 days did not decrease. This combination of findings suggest that youth may have used substances fewer days per month or at lower amounts, or experienced fewer consequences related to use, resulting in less risky use despite continued use. Thus, the SBIRT intervention seems to offer a harm reduction approach to support youth. Future studies with more rigorous methods could further examine this hypothesis, extending this knowledge base in more generalizable samples and with a control group.
      When comparing youth in YouthBuild programs with SBIRT to those in programs without SBIRT, we saw significantly better outcomes in attainment of a high school diploma or equivalent and still being in a job or educational placement 3 months after completing the program. Furthermore, because most of these youth are minoritized, the findings suggest that community-based SBIRT is associated with improved outcomes regarding risky substance use for these youth from minority groups, as found in a systematic review and meta-analysis of a brief alcohol intervention for adolescents and young adults [
      • Tanner-Smith E.E.
      • Lipsey M.W.
      Brief alcohol interventions for adolescents and young adults: A systematic review and meta-analysis.
      ]. Unfortunately, the aggregate data did not allow specific outcome analyses by race or ethnicity, or linkage to specific youth.
      These results are important in three key regards. First, the two substances reported most frequently by youth at the SBIRT programs were alcohol and marijuana. For older youth in particular, alcohol is legal and recreational marijuana use is legal in 24 states and Washington D.C. [
      • Solutions D.G.
      Map of marijuana legality by state.
      ], with more states likely to legalize marijuana in the near future. Programs that work with older youth, particularly those who use alcohol and marijuana at risky levels, need a way to address substance use with their participants. SBIRT, and the motivational interviewing that takes place during the brief intervention, offers an evidence-based way to intervene and help youth reduce risky use. For job development programs in particular, brief interventions can focus on the consequences for a work site and use that as motivation to change participants' substance use behavior.
      Second, the results demonstrated not just an association with risky substance use, as found in other research [
      • Tanner-Smith E.E.
      • Lipsey M.W.
      Brief alcohol interventions for adolescents and young adults: A systematic review and meta-analysis.
      ,
      • Martin G.
      • Copeland J.
      • Swift W.
      The adolescent cannabis check-up: Feasibility of a brief intervention for young cannabis users.
      ,
      • Mitchell S.G.
      • Gryczynski J.
      • O'Grady K.E.
      • et al.
      SBIRT for adolescent drug and alcohol use: Current status and future directions.
      ,
      • Harris S.K.
      • Louis-Jacques J.
      • Knight J.R.
      Screening and brief intervention for alcohol and other abuse.
      ,
      • Tanner-Smith E.E.
      • Steinka-Fry K.T.
      • Hennessy E.A.
      • et al.
      Can brief alcohol interventions for youth also address concurrent illicit drug use? Results from a meta-analysis.
      ,
      • Bien T.H.
      • Miller W.R.
      • Tonigan J.S.
      Brief interventions for alcohol problems: A review.
      ,
      • Stephens R.S.
      • Roffman R.A.
      • Curtin L.
      Comparison of extended versus brief treatments for marijuana use.
      ,
      • Bertholet N.
      • Daeppen J.-B.
      • Wietlisbach V.
      • et al.
      Reduction of alcohol consumption by brief alcohol intervention in primary care: Systematic review and meta-analysis.
      ,
      • Kaner E.F.
      • Beyer F.R.
      • Muirhead C.
      • et al.
      Effectiveness of brief alcohol interventions in primary care populations.
      ], but showed an association with educational and employment outcomes–key areas that relate to longer-term positive development. Similarly, SBIRT can improve health outcomes beyond just reduced substance use [
      • Sterling S.
      • Kline-Simon A.H.
      • Jones A.
      • et al.
      Health care use over 3 years after adolescent SBIRT.
      ]. Further, people who are employed are less likely to engage in risky substance use and less likely to develop substance use disorders [
      • Henkel D.
      Unemployment and substance use: A review of the literature (1990-2010).
      ]. Thus, SBIRT may offer a way that YouthBuild and other youth development programs can help participants with a broad range of outcomes. Ultimately, SBIRT takes a harm reduction approach, aimed at reducing or eliminating risky substance use, but not necessarily requiring abstinence. For YouthBuild in particular, a key aim is to support youth to make good decisions about substance use to support their longer-term development related to education and employment. SBIRT may offer a way to intervene early to help youth engage in healthier behaviors that can impact multiple areas of their lives.
      Finally, the data on types of services provided by screening result showed that community-based providers, with training and coaching, appropriately provided brief interventions and referrals to treatment as needed for most youth. In fact, likely due to the community-based setting and the amount of time YouthBuild staff interact with youth, staff sometimes provided more services than strictly called for under SBIRT guidelines used in healthcare settings.
      This study had several limitations. First, YouthBuild programs were not randomized to the SBIRT and non-SBIRT groups. Thus, other factors could have influenced the results, although by using all other YouthBuild programs operating at the same time as the SBIRT programs and controlling for differences across programs, some of the external influences were minimized. Second, we only collected screening and survey data on youth at the SBIRT programs. The pre/post comparison on changes in AUDIT and DAST-10 scores and substance use, therefore, do not have a comparison group to control for difference. Third, the lack of age and gender data for all sites required us to use conservative cut-off scores that may not have reflected practice. Fourth, the substance use questions were from an internal tool rather than existing validated tools and focused simply on any use in the past month and not frequency or amount, so the sensitivity for measuring change in alcohol and other drug use was limited. Fifth, data were missing or incomplete for reasons related to programs and youth, and which may not have been random. We focused on the third year of the program to reduce the impact of missing data, but these findings may have sample bias. Last, the program-level data are aggregated and were not linkable to the youth data, thus we could not directly assess the outcomes for specific youth. Despite these limitations and their potential impact on generalizability, this study offers insights into how a community-based SBIRT intervention might operate.
      Risky substance use, and dependent use, is often stigmatized in our society. Furthermore, denial about problematic use and lack of conversations regarding use are the norm. By offering community-based SBIRT interventions in programs for youth at higher risk, we can begin to normalize conversations about substance use, risky use, and dependence. Given the limited research on community-based SBIRT interventions and our study's limitations, we recommend further research in this area. Over time, this approach could help youth with risky and problematic use get the care they need earlier in their lives, which could, in turn, reduce the severity of problems and improve the quality of their lives regarding health, education, and employment.

      Acknowledgments

      We would like to acknowledge statistical guidance provided by Grant Ritter, Ph.D., at Brandeis University. We would also like to acknowledge the contributions of the YouthBuild USA coaches in supporting this work. Additionally, we would like to thank staff at YouthBuild USA for their support in providing data. Finally, we would like to thank all the YouthBuild staff and youth who took part in this evaluation. Preliminary findings from this study were presented at the 14th Annual International Network on Brief Interventions for Alcohol and Other Drugs (INEBRIA) Conference.

      Funding Sources

      This work was supported by a grant that YouthBuild USA received from the Conrad N. Hilton Foundation under its Substance Use Prevention Strategic Initiative, grant # 20130288 . YouthBuild USA contracted with researchers at Brandeis University to conduct the evaluation. The Conrad N. Hilton Foundation had no role in the design, analysis, interpretation, writing, review, or decision to submit the manuscript for publication.

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