Feasibility and Acceptability of a Novel Substance Use Prevention Intervention

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To address the needs of this group, this pilot study assessed the feasibility of participant recruitment and retention, as well as the acceptability of a novel substance use prevention intervention, Better Together, for Black youth exposed to household challenges. Methods Participants were recruited using school and community presentations, digital flyers, and referrals. Eighty-nine students from two schools were screened. Participant enrollment, session attendance, and assessment completion were used to determine feasibility. Quantitative and qualitative data were collected after each session; responses were used to assess intervention acceptability. Demographic and substance use data were collected at baseline, post-test, and one-month follow-up. Results Fifty-nine (96%) youth were eligible, returned their parental permission forms, and enrolled. Completion rates for assessments were above 90% for all three assessments. Nearly 90% of participants attended at least five sessions; the average attendance was 6.5 sessions across conditions. Session feedback forms showed that most students were happy after each session (61%-85%). Qualitative feedback suggests that students were engaged in discussing the key messages using their own words. There were no significant changes in substance use knowledge or intentions over time or by condition. However, there was a small yet significant increase in substance use behaviors over time. Conclusions Better Together may be a promising intervention to prevent substance use among Black youth exposed to household challenges. Findings suggest that recruiting, retaining, and engaging participants in the eight-session intervention is possible. Findings will inform plans to implement a full-scale study to evaluate the efficacy and contextual factors that impact effective program implementation. Trial registration: Clinicaltrials.gov: [ID BLINDED FOR REVIEW]. Registered [DATE BLINDED FOR REVIEW] - Retrospectively registered, [LINK BLINDED FOR REVIEW] substance use intervention adverse childhood experiences Figures Figure 1 Key messages regarding feasibility What uncertainties existed regarding feasibility? Better Together is a newly developed 8-session intervention designed to prevent substance use among Black youth (ages 11-13) exposed to household challenges. It was unclear if we could recruit and retain youth from our priority population to participate in the intervention and complete all related assessments. We were also still determining whether participants would find the intervention components acceptable. What are the key feasibility findings? Recruiting and retaining youth exposed to household challenges in the intervention is possible. Of the 57 participants enrolled, over 90% completed all assessments. The average attendance was 6.5 sessions, indicating high dosage across conditions. Session feedback forms showed that most students were happy after each session (61%-85%). What are the implications of the feasibility findings for the design of the main study? Better Together may be a promising intervention to prevent substance use among Black youth exposed to household challenges. However, a larger trial with a larger sample will be needed to determine the intervention’s efficacy and effectiveness in preventing substance use. Introduction Adolescent substance use is a significant public health issue with costly consequences. 1 It is associated with sexual risk behavior, relationship violence, and mental health problems. 2 – 7 Although rates of adolescent substance use are declining nationwide, adolescent substance use continues to be associated with adverse outcomes later in life, including substance abuse, low educational attainment, and incarceration. 8 – 10 Disparities also persist by demographic characteristics, with Black students more likely than Asian, Latino, and White students to report current marijuana use . 11 Adolescent-onset cannabis use is associated with opioid misuse in young adulthood among urban Black young adults. 12 Drug addiction and substance abuse cost the United States (US) more than $ 500 billion each year. 13 Delaying the initiation of substance use is one strategy to prevent later problem use, negative consequences, and costly treatment. Youth exposed to household challenges are more likely to use substances than those who are unexposed. 17 – 21 In addition, exposure to household challenges can increase children’s risk of early substance use (i.e., alcohol or drug use before the age of 13). 22 , 23 Unfortunately, children in the US experience household challenges (e.g., parental substance use, parental incarceration, and parental mental health challenges) at alarming rates. For example, nearly nine million children in the US have a parent suffering from a substance use disorder, 14 almost three million have a parent who is incarcerated, 16 and an estimated 68% of women and 57% of men with mental health problems are parents. In Baltimore, Maryland, where this research was conducted, 79% of youth are Black. Among them, 28% have a parent with a mental illness, 25% have a parent with unhealthy substance use, and 46% have had a family member go to prison or jail. 42 Baltimore youth who reported one household challenge were 80% more likely to report alcohol use, 78% more likely to report marijuana use, 137% more likely to report heroin use, and 231% more likely to report non-medical use of prescription opioids. 43 Selective prevention programs are needed to prevent substance use among Black youth exposed to household challenges. 24 Selective interventions can concentrate resources on those most at risk for problem behaviors. 25 Youth living in contexts with easier access to substances and more accepting norms around substance use may require different strategies or more intensive interventions than youth at lower risk. 26 Despite the need, the number of recently developed effective selective prevention programs for Black youth exposed to household challenges is small. 27 – 29 Having a menu of options for substance use prevention that considers and reflects young people’s lived experiences may help us prevent substance use and the related negative consequences that can occur. The Better Together (BT) intervention is a promising selective prevention intervention for Black youth exposed to household challenges for four primary reasons. First, it prioritizes Black youth during early adolescence, a critical and ideal period for skill-building, identity development, and substance use prevention. Second, it is designed to be delivered after school, when juvenile delinquency peaks 30 , and there is a high need for age-appropriate, after-school programs to enhance children’s development and reduce the chance of maladaptive behaviors. 31 Third, it takes a multilevel approach to substance use prevention for Black youth exposed to household challenges. Finally, it builds on our expertise of using a partnered approach to recruit and retain adolescents exposed to household challenges. 32 – 34 However, critical questions about feasibility remained. Thus, the current study provides evidence for the feasibility and acceptability of the Better Together intervention. Methods Study Design This study occurred from September 2023 through April 2024 in Baltimore, Maryland, USA. We partnered with two schools to assess the feasibility and acceptability of the BT intervention in a small, randomized trial. We compared the outcomes of Black youth (ages 11–13) exposed to household challenges who received the intervention (n = 32) with a time-matched control group of youth exposed to household challenges (n = 27). An online random number generator was used to randomize participants to either the control or intervention group. Randomization occurred at the family level, which allowed all eligible youth from a single family to be in the same condition and minimized the potential for contamination of intervention effects. Participants completed electronic assessments three times: baseline (one week before the start of the intervention), post-test (one week after the intervention), and a 1-month follow-up (one month after the post-test). The trial ended after implementation in two schools at the end of the school year. We obtained Institutional Review Board approval from [BLINDED FOR REVIEW]. The trial was registered at ClinicalTrials.gov [BLINDED FOR REVIEW]. Recruitment and Enrollment Youth enrollment occurred one month before the start of the intervention. To be eligible, participants had to be between 11 and 13 years old, identify as Black or African American, and have been exposed to one or more household challenges. Direct youth recruitment occurred with study team members inviting families to participate via presentations at each organization. Participants were also recruited indirectly through referrals from organizational staff and enrolled participants. Recruitment materials and presentations did not include information about household challenges as an eligibility criterion to prevent the risk of stigma associated with participating. Interested youth were required to complete a participant interest form that included their name, as well as their caregiver’s name and contact information. A study team member contacted the caregiver to inform them of the study and assist the caregiver in completing a screener to determine the youth’s eligibility. A study team member reviewed the purpose and procedures of the study as outlined on the parental permission form. The permission form was emailed and texted to caregivers via Qualtrics to obtain signatures. Once permission was granted, all eligible youth in the family were assigned a participant ID. Oral assent was obtained from all youth before they completed the baseline survey. Curriculum Delivery and Content Both intervention and control group sessions occurred twice a week, in person, during non-school hours for four weeks. At most, 15 youth were allowed to participate in each group. Sessions were co-facilitated by two study team members. Participants were compensated $ 25 for each session they attended and each assessment they completed. Better Together. Better Together (BT) is an age-appropriate, culturally relevant prevention intervention to prevent substance use among Black youth experiencing household challenges (ages 11–13) by addressing the multilevel influences of substance use. Specifically, BT aims to prevent substance use by enhancing self-management skills and positive racial identity, increasing social connections, and improving community asset awareness. Its eight sessions are divided into three sections (i.e., All About Me, All Around Me, and All About the Future), each bookended by Introduction and Closing sessions. Each session is 90 minutes in duration. Except for the closing, all sessions begin with an overview of the objectives, after which participants watch a brief animated video of a continuing story that aligns with the topics discussed in the session. Sessions 2–7 present three didactic learning components and two interactive activities reinforcing learning and allowing participants to have guided discussions and practice skills. Each session includes a guided practice of the BEST decision-making model (i.e., ‘Breathe,’ ‘Educate yourself,’ ‘Select the best option for you,’ ‘Take action’). Each session closes with a private written reflection activity, a review of the main points, a session-related activity to practice with a trusted adult, and an affirmation reminding youth of their and the group’s strengths. The final closing session includes a jeopardy-type review game and a presentation by youth to their invited trusted adults. Youth in the Media. Control group participants participated in a Youth in the Media (YM) program. Delivered in eight in-person, 90-minute sessions concurrently with BT sessions, the YM program was designed to (1) increase participants’ awareness of and access to the different types of media and free resources available at their local libraries, (2) discuss different types of media that center stories and experiences of Black youth, and (3) expose participants to careers in media. Sessions covered a range of media types, including sportscasting, spoken word, marketing, blogging, and comic books. Each session opened with a theme-related icebreaker and closed with a review of the key points and a lesson-related activity to practice. There was no caregiver component for the YM program. Measures Primary Outcomes: Feasibility and Acceptability Feasibility. Process measures were assessed through interest forms and screening logs. We defined recruitment success as the ability to recruit at least 20 youths per cycle (10 per condition). Retention was evaluated in two ways. First, we assessed retention by the number of sessions the participant attended (dosage). We defined dosage success as youth participating in five or more sessions. Second, retention was assessed by the proportion of youth who completed the post-test and 1-month follow-up. We defined retention success as more than 80% of the sample was retained at all assessments. Acceptability . A three-item questionnaire was distributed after each session to assess intervention acceptability. The questionnaires asked participants to choose how they felt (i.e., happy, sad, tired, confused, or other). If they replied ‘other’, they were prompted to include a feeling. Participants were also asked to share their favorite aspect of the session (i.e., activities, information, or videos). We defined high acceptability as more than half of the participants feeling happy after sessions and ranking activities as the most favorable. Finally, participants were required to respond to an open-ended question, sharing one takeaway from the session (engagement). High acceptability was defined as more than half of the participants listing one of the key messages as a takeaway from the session. Secondary Outcomes: Substance Use Knowledge, Intentions, and Behaviors Knowledge. Three true/false items were used to assess substance use knowledge: (1) alcohol is considered a drug, (2) drinking alcohol or using drugs leads to poor judgment and decision-making, and (3) it is against the law for children and teenagers to use drugs. Correct responses were summed to create a scale ranging from 0 to 3. with higher scores indicating more knowledge. Cronbach’s alpha for the scale was .51 (baseline), .44 (post-test), and .78 (1-month). Intentions. Three items were used to assess intentions. Participants were asked if they would (1) smoke marijuana, (2) use tobacco products, or (3) drink alcohol in the next six months. Responses were ‘0 – no’, ‘1 – maybe” and ‘2 – yes’. Responses were averaged to create a scale score, with scores closer to zero indicating lower intentions to use substances. Cronbach’s alpha for the scale was .73 (baseline), .29 (post-test) and .88 (1-month). Behaviors. One item was used to assess substance use behaviors: Have you ever had a drink of alcohol (more than a few sips) or tried any drug (i.e., marijuana, cigarette, prescription pills, ecstasy, cocaine, etc.)? Participants responded, ‘yes’ or ‘no’. Participants Fifty-four adolescents in Baltimore, Maryland, participated in this randomized control trial. The average age of our sample was 11.6 years old. There were more female participants (50%) than male participants (46%) or those who identified by other gender identities (4%). Having an incarcerated parent was the most common household challenge (54%), followed by having a parent with a history of substance use (20%) and having a parent with mental illness (19%). Over a quarter of participants (26%) reported lifetime substance use at baseline. Table 1 presents the details on the characteristics of the sample at baseline. Table 1 – Baseline Characteristics (N = 54) Variable Total (N = 54) Control (N = 26) Intervention (N = 28) Age (mean, SD) 11.6 (0.66) 11.5 (0.71) 11.6 (0.63) Attendance 6.5 6.3 6.7 Gender (n, %) Female 27 (50) 12 (46) 15 (54) Male 25 (46) 12 (46) 13 (46) Other 2 (4) 2 (8) 0 Household Challenges* (n, %) Substance use 11 (20) 5 (19) 6 (21) Incarceration 29 (54) 13 (50) 16 (57) Mental Illness 10 (19) 7 (27) 3 (11) Lifetime Substance Use (n, %) Yes 14 (26) 10 (38) 4 (14) No 40 (74) 16 (62) 24 (86) *indicates missing values [Insert Table 1 here] Data Analysis Descriptive statistics were calculated for demographics, recruitment and retention feasibility, intervention acceptability, and substance use knowledge, intentions, and attitudes. A mixed ANOVA was used to test whether the intervention influenced changes in substance use knowledge and intentions over time. Chi-squared and t- tests assessed behavior changes across time and by group assignment. All statistical analyses were conducted using STATA version 18.0. We conducted a content analysis of the qualitative responses. Results Feasibility and Acceptability Figure 1 displays the participant flowchart for this study. Over 100 youth completed an interest form to be screened for eligibility (n = 127). Fifty-two percent of interested youth were ineligible (n = 66). Among those eligible, 3% did not return their parental permission forms after at least five attempts from the study team (n = 2). Fifty-nine Black youth (ages 11–13) exposed to household challenges were enrolled in the study and randomized to a condition. Before the intervention began, two students shared conflicts that prohibited them from participating. Three additional students completed the baseline assessment but did not attend a session. Thus, 54 enrolled youth completed all three assessments (92%). Eighty-seven percent of participants attended at least five sessions (n = 47). Across conditions, youth participated in an average of 6.5 sessions, with 93% of intervention and 81% of control group participants attending five or more sessions (n = 26 and 21, respectively). [Insert Fig. 1 here] Session feedback forms showed that most students were happy after each session (60%- 85%). Session 1 (We Are Better Together) had the highest ratings, and Session 3 (Having Boundaries) had the lowest (60%). Of note, Session 3 also had the highest percentage of youth who reported that they were ‘tired’ after the session (23%), implying other factors may have contributed to the perception of the session. Activities were ranked as the most favorable aspect of the intervention for all sessions. Qualitative feedback suggests that students were engaged in discussing the key messages using their own words. For example, in Session 2 (Managing Emotions), when asked about the biggest takeaway messages, youth comments aligned with the takeaways for the session: I learned that we need to learn how to control our emotions and not get upset. You always have a choice in things even when you don’t think so. I can express my emotions in a good way. Similarly, in Session 5 (Staying Connected), youth corrected identified messages about the importance of help-seeking and effective communication: Ask for help when you need it. The big takeaway I learned was how people get connected in the community and the other way late to communicate and get connected. One takeaway that I learned was that you can’t not always win everything and do stuff by yourself always ask for help and don’t give up. Substance Use Knowledge, Intentions, and Behaviors There were no significant changes in knowledge (η 2 = 0.016, F = 0.70, df = 2) or intentions (η 2 = 0.012, F = 0.58, df = 2) over time or by condition. However, trends showed that compared to the control group, participants in the intervention group reported higher anti-drug attitudes and substance use knowledge at each assessment (see Table 2 ). At baseline, participants in the control group, on average, scored lower than those in the intervention on the knowledge assessment (M diff =-0.30, 95% CI: (-0.73, 0.14)). Following the program, the control group continued to show less knowledge about substances than those in the intervention (M diff =-0.31, 95% CI: (-0.69, 0.06)). Similarly, participants in the control group showed higher intentions to use drugs at the 1-month follow-up compared to those in the intervention (M diff =0.18, 95% CI: (-0.06, 0.41). During post ad hoc analysis, we observed significant behavior changes over time only (F = 7.09, df = 2, p = 0.0013). However, the effect size of the change was small (< 0.20). Despite this significance, there were still fewer intervention group youth (n = 9) who reported lifetime substance use at 1-month follow-up compared to control group youth (n = 13). Table 2 Descriptive Statistics for Substance Use Knowledge Intentions Time Point Knowledge (mean, SD) Intentions (mean, SD) N Combined Con Int Mean difference (95% CI) N Combined Con Int Mean difference (95% CI) Baseline 51 2.16 (0.78) 2.00 (0.78) 2.30 (0.78) -0.30 (-0.73, 0.14) 54 0.10 (0.31) 0.15 (0.36) 0.06 (0.26) 0.09 (-0.07, 0.26) Posttest 51 2.33 (0.68) 2.17 (0.76) 2.48 (0.58) -0.31 (-0.69, 0.06) 51 0.14 (0.38) 0.15 (0.34) 0.13 (0.42) 0.02 (-0.20, 0.24) 1-month 44 2.16 (0.75) 2.14 (0.71) 2.18 (0.80) -0.04 (-0.50, 0.41) 47 0.17 (0.40) 0.26 (0.51) 0.08 (0.25) 0.18 (-0.06, 0.41) [Insert Table 2 here] Discussion This study aimed to assess the feasibility and participant satisfaction of Better Together, a novel prevention intervention for Black youth exposed to household challenges. We recruited over 20 youth per cycle, with most attending nearly all sessions. In addition, their responses to the after-session feedback questionnaires suggested they were satisfied and engaged with the materials. Conversely, the increase in lifetime substance use for intervention, but not control participants, was unexpected. We discuss possible explanations for this finding below. Having school staff as paid partners in our research was crucial to our successful recruitment and retention efforts. Common barriers to research recruitment and retention of youth living in challenging settings include concerns about safety, fear of re-traumatization, logistical issues, housing instability, and limited utility and relevance of content. 35 – 38 However, strategies such as working with community partners, using social media, and training staff to be personable have been proposed as effective methods to recruit better and retain vulnerable youth in prevention research. 39 – 44 Using these strategies enabled our team to be viewed as an asset rather than a burden to families. In addition, offering partner compensation communicated our value that equity in research relationships included equitable compensation for all research team members, not only those affiliated with the university. Future researchers should also consider using community-engaged strategies to improve their recruitment and retention efforts with youth and families with household challenges who may have additional barriers to and concerns about research participation. It is unclear how to interpret the lack of findings for substance use knowledge and intentions. These findings may reflect limitations in our measures, survey fatigue, or sample size. Alternatively, despite the quantitative and qualitative data suggesting participants were engaged during the sessions, the content may have needed to be more compelling to be retained. Similarly, the increase in substance use behavior over time for the intervention group may be a function of time rather than the intervention. The number of youth who reported lifetime substance use increased for both groups, confirming the heightened susceptibility of substance use for youth exposed to adversity during early adolescence. 45 , 46 Although the rate of increase was accelerated for the intervention group, the number of youth reporting substance use was lower for those who participated in the intervention compared to the control at all assessments. A longer follow-up and additional contextual data are needed to assess how much the intervention slows the rate of substance use initiation. Such findings help researchers determine how to enhance the intervention to be more absorbent and effective. Methodological limitations of this pilot study include small sample size, limited measures, and no long-term follow-ups. Study groups did not differ by most demographic factors or initial scores on outcome measures. Thus, more research is needed. Despite these limitations, study findings suggest that participant recruitment and retention are possible for this novel substance use prevention intervention. In addition, youth were satisfied and engaged with the intervention materials. This intervention responds to the research demonstrating the value of tailoring interventions to support population health and extend the impact of evidence-based interventions. 47–50 Study findings also provide additional evidence of the difficulty of preventing substance use in families where substance use may be a lower priority in the presence of other household challenges. Thus, further research is needed to understand what will work, for whom, and under what circumstances to prevent substance use among Black youth exposed to household challenges. Declarations Ethics approval and consent to participate The Institutional Review Board at the Johns Hopkins Bloomberg School of Public (IRB: 25611) provided research ethics approval, including consent procedures. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The Bloomberg American Health Initiative supported this work. The funders had no role in the review or approval of this manuscript for publication. Authors’ contributions TWP was involved in obtaining funding, designing the study, developing the protocol, and drafting the manuscript. BSB analyzed the quantitative and qualitative data. WT supported implementation. All authors read, edited and approved the final manuscript. 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Adaptation of an HIV prevention curriculum for use with older African American women. JANAC: Journal of the Association of Nurses in AIDS Care . 2008;19(1):16–27. Supplementary Files CONSORTChecklist.doc Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 23 Oct, 2025 Reviewers invited by journal 17 Jan, 2025 Editor assigned by journal 27 Nov, 2024 First submitted to journal 26 Nov, 2024 Editorial decision: Minor revision 22 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5105000","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":403684837,"identity":"ba90fd9e-5191-4678-8924-0f6581d6d61f","order_by":0,"name":"Terrinieka Powell","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYLCCBDDJ3HjgA88BEMsAr2oehBbGhoMziNbCANVymIeBCC327L3PPjxguCNncLyx4bCNzJ3EBvbmbRJ4beE5bjwjgeGZscGZgw2Hc3ieJTbwHCvDr0UijRnol8OJ224kgrQcTmyQyDHDr0X+GVTL/YcNhy1AWuTfENAiwQazBeh9BrAtPAS0nAE5zOCZsf2ZxIaDPTyHjdt40oot8Glhbz/GzPij4o6cZPvhgw9+9hyW7Wc/vPEGPi0QYHAAQjP2MDCwEVYOBlAtDD+IVD8KRsEoGAUjCgAACaFOBPpTu1wAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3254-059X","institution":"Johns Hopkins University Bloomberg School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Terrinieka","middleName":"","lastName":"Powell","suffix":""},{"id":403684838,"identity":"9d1ee094-337b-42b3-9159-21955b0195c6","order_by":1,"name":"Bianca Smith-Black","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health: Johns Hopkins University Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Bianca","middleName":"","lastName":"Smith-Black","suffix":""},{"id":403684839,"identity":"4bc04f7b-e6f4-4857-b815-de8af4c66576","order_by":2,"name":"Wubishet Taye","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health: Johns Hopkins University Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Wubishet","middleName":"","lastName":"Taye","suffix":""}],"badges":[],"createdAt":"2024-09-17 17:39:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5105000/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5105000/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74295428,"identity":"53ff14f7-b6cb-4d1b-90ce-2d91b962d9f7","added_by":"auto","created_at":"2025-01-20 17:58:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":415728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant Flowchart in Pilot Study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5105000/v1/875350acf8acd9a231a24989.png"},{"id":74295667,"identity":"2e83c496-9e95-454b-be9a-6038c2580dbf","added_by":"auto","created_at":"2025-01-20 18:06:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1233646,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5105000/v1/6e8939e0-3a17-48f4-8e39-5bbe0b1d36f4.pdf"},{"id":74294906,"identity":"1c1b0b55-1c87-4751-9174-0258a04997e4","added_by":"auto","created_at":"2025-01-20 17:50:27","extension":"doc","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":224256,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORTChecklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-5105000/v1/8a493fe00a6cd381e7844aee.doc"}],"financialInterests":"","formattedTitle":"Feasibility and Acceptability of a Novel Substance Use Prevention Intervention","fulltext":[{"header":"Key messages regarding feasibility","content":"\u003cul\u003e\n \u003cli\u003e\u003cem\u003eWhat uncertainties existed regarding feasibility?\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBetter Together is a newly developed 8-session intervention designed to prevent substance use among Black youth (ages 11-13) exposed to household challenges. It was unclear if we could recruit and retain youth from our priority population to participate in the intervention and complete all related assessments. We were also still determining whether participants would find the intervention components acceptable.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eWhat are the key feasibility findings?\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRecruiting and retaining youth exposed to household challenges in the intervention is possible. Of the 57 participants enrolled, over 90% completed all assessments. The average attendance was 6.5 sessions, indicating high dosage across conditions. Session feedback forms showed that most students were happy after each session (61%-85%).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eWhat are the implications of the feasibility findings for the design of the main study?\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBetter Together may be a promising intervention to prevent substance use among Black youth exposed to household challenges. However, a larger trial with a larger sample will be needed to determine the intervention’s efficacy and effectiveness in preventing substance use.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAdolescent substance use is a significant public health issue with costly consequences.\u003csup\u003e \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e \u003c/sup\u003e It is associated with sexual risk behavior, relationship violence, and mental health problems.\u003csup\u003e \u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e \u003c/sup\u003e Although rates of adolescent substance use are declining nationwide, adolescent substance use continues to be associated with adverse outcomes later in life, including substance abuse, low educational attainment, and incarceration.\u003csup\u003e \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e \u003c/sup\u003e Disparities also persist by demographic characteristics, with \u003cem\u003eBlack students more likely than Asian, Latino, and White students to report current marijuana use\u003c/em\u003e.\u003csup\u003e \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e \u003c/sup\u003e Adolescent-onset cannabis use is associated with opioid misuse in young adulthood among urban Black young adults.\u003csup\u003e \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e \u003c/sup\u003e Drug addiction and substance abuse cost the United States (US) more than \u003cspan\u003e$\u003c/span\u003e500\u0026nbsp;billion each year.\u003csup\u003e \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e \u003c/sup\u003e Delaying the initiation of substance use is one strategy to prevent later problem use, negative consequences, and costly treatment.\u003c/p\u003e \u003cp\u003eYouth exposed to household challenges are more likely to use substances than those who are unexposed.\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In addition, exposure to household challenges can increase children\u0026rsquo;s risk of early substance use (i.e., alcohol or drug use before the age of 13).\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Unfortunately, children in the US experience household challenges (e.g., parental substance use, parental incarceration, and parental mental health challenges) at alarming rates. For example, nearly nine million children in the US have a parent suffering from a substance use disorder,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e almost three million have a parent who is incarcerated,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and an estimated 68% of women and 57% of men with mental health problems are parents. In Baltimore, Maryland, where this research was conducted, 79% of youth are Black. Among them, 28% have a parent with a mental illness, 25% have a parent with unhealthy substance use, and 46% have had a family member go to prison or jail.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e Baltimore youth who reported one household challenge were 80% more likely to report alcohol use, 78% more likely to report marijuana use, 137% more likely to report heroin use, and 231% more likely to report non-medical use of prescription opioids.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSelective prevention programs are needed to prevent substance use among Black youth exposed to household challenges.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Selective interventions can concentrate resources on those most at risk for problem behaviors.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Youth living in contexts with easier access to substances and more accepting norms around substance use may require different strategies or more intensive interventions than youth at lower risk.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Despite the need, the number of recently developed effective selective prevention programs for Black youth exposed to household challenges is small.\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Having a menu of options for substance use prevention that considers and reflects young people\u0026rsquo;s lived experiences may help us prevent substance use and the related negative consequences that can occur.\u003c/p\u003e \u003cp\u003eThe Better Together (BT) intervention is a promising selective prevention intervention for Black youth exposed to household challenges for four primary reasons. First, it prioritizes Black youth during early adolescence, a critical and ideal period for skill-building, identity development, and substance use prevention. Second, it is designed to be delivered after school, when juvenile delinquency peaks\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003c/sup\u003e and there is a high need for age-appropriate, after-school programs to enhance children\u0026rsquo;s development and reduce the chance of maladaptive behaviors.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Third, it takes a multilevel approach to substance use prevention for Black youth exposed to household challenges. Finally, it builds on our expertise of using a partnered approach to recruit and retain adolescents exposed to household challenges.\u003csup\u003e\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e However, critical questions about feasibility remained. Thus, the current study provides evidence for the feasibility and acceptability of the Better Together intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study occurred from September 2023 through April 2024 in Baltimore, Maryland, USA. We partnered with two schools to assess the feasibility and acceptability of the BT intervention in a small, randomized trial. We compared the outcomes of Black youth (ages 11\u0026ndash;13) exposed to household challenges who received the intervention (n\u0026thinsp;=\u0026thinsp;32) with a time-matched control group of youth exposed to household challenges (n\u0026thinsp;=\u0026thinsp;27). An online random number generator was used to randomize participants to either the control or intervention group. Randomization occurred at the family level, which allowed all eligible youth from a single family to be in the same condition and minimized the potential for contamination of intervention effects. Participants completed electronic assessments three times: baseline (one week before the start of the intervention), post-test (one week after the intervention), and a 1-month follow-up (one month after the post-test). The trial ended after implementation in two schools at the end of the school year. We obtained Institutional Review Board approval from [BLINDED FOR REVIEW]. The trial was registered at ClinicalTrials.gov [BLINDED FOR REVIEW].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecruitment and Enrollment\u003c/h3\u003e\n\u003cp\u003eYouth enrollment occurred one month before the start of the intervention. To be eligible, participants had to be between 11 and 13 years old, identify as Black or African American, and have been exposed to one or more household challenges. Direct youth recruitment occurred with study team members inviting families to participate via presentations at each organization. Participants were also recruited indirectly through referrals from organizational staff and enrolled participants. Recruitment materials and presentations did not include information about household challenges as an eligibility criterion to prevent the risk of stigma associated with participating.\u003c/p\u003e \u003cp\u003eInterested youth were required to complete a participant interest form that included their name, as well as their caregiver\u0026rsquo;s name and contact information. A study team member contacted the caregiver to inform them of the study and assist the caregiver in completing a screener to determine the youth\u0026rsquo;s eligibility. A study team member reviewed the purpose and procedures of the study as outlined on the parental permission form. The permission form was emailed and texted to caregivers via Qualtrics to obtain signatures. Once permission was granted, all eligible youth in the family were assigned a participant ID. Oral assent was obtained from all youth before they completed the baseline survey.\u003c/p\u003e\n\u003ch3\u003eCurriculum Delivery and Content\u003c/h3\u003e\n\u003cp\u003eBoth intervention and control group sessions occurred twice a week, in person, during non-school hours for four weeks. At most, 15 youth were allowed to participate in each group. Sessions were co-facilitated by two study team members. Participants were compensated \u003cspan\u003e$\u003c/span\u003e25 for each session they attended and each assessment they completed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBetter Together.\u003c/b\u003e Better Together (BT) is an age-appropriate, culturally relevant prevention intervention to prevent substance use among Black youth experiencing household challenges (ages 11\u0026ndash;13) by addressing the multilevel influences of substance use. Specifically, BT aims to prevent substance use by enhancing self-management skills and positive racial identity, increasing social connections, and improving community asset awareness. Its eight sessions are divided into three sections (i.e., All About Me, All Around Me, and All About the Future), each bookended by Introduction and Closing sessions. Each session is 90 minutes in duration. Except for the closing, all sessions begin with an overview of the objectives, after which participants watch a brief animated video of a continuing story that aligns with the topics discussed in the session. Sessions 2\u0026ndash;7 present three didactic learning components and two interactive activities reinforcing learning and allowing participants to have guided discussions and practice skills. Each session includes a guided practice of the BEST decision-making model (i.e., \u0026lsquo;Breathe,\u0026rsquo; \u0026lsquo;Educate yourself,\u0026rsquo; \u0026lsquo;Select the best option for you,\u0026rsquo; \u0026lsquo;Take action\u0026rsquo;). Each session closes with a private written reflection activity, a review of the main points, a session-related activity to practice with a trusted adult, and an affirmation reminding youth of their and the group\u0026rsquo;s strengths. The final closing session includes a jeopardy-type review game and a presentation by youth to their invited trusted adults.\u003c/p\u003e \u003cp\u003e\u003cb\u003eYouth in the Media.\u003c/b\u003e Control group participants participated in a Youth in the Media (YM) program. Delivered in eight in-person, 90-minute sessions concurrently with BT sessions, the YM program was designed to (1) increase participants\u0026rsquo; awareness of and access to the different types of media and free resources available at their local libraries, (2) discuss different types of media that center stories and experiences of Black youth, and (3) expose participants to careers in media. Sessions covered a range of media types, including sportscasting, spoken word, marketing, blogging, and comic books. Each session opened with a theme-related icebreaker and closed with a review of the key points and a lesson-related activity to practice. There was no caregiver component for the YM program.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePrimary Outcomes: Feasibility and Acceptability\u003c/h2\u003e \u003cp\u003e \u003cb\u003eFeasibility.\u003c/b\u003e Process measures were assessed through interest forms and screening logs. We defined recruitment success as the ability to recruit at least 20 youths per cycle (10 per condition). Retention was evaluated in two ways. First, we assessed retention by the number of sessions the participant attended (dosage). We defined dosage success as youth participating in five or more sessions. Second, retention was assessed by the proportion of youth who completed the post-test and 1-month follow-up. We defined retention success as more than 80% of the sample was retained at all assessments.\u003c/p\u003e \u003cp\u003e\u003cb\u003eAcceptability\u003c/b\u003e. A three-item questionnaire was distributed after each session to assess intervention acceptability. The questionnaires asked participants to choose how they felt (i.e., happy, sad, tired, confused, or other). If they replied \u0026lsquo;other\u0026rsquo;, they were prompted to include a feeling. Participants were also asked to share their favorite aspect of the session (i.e., activities, information, or videos). We defined high acceptability as more than half of the participants feeling happy after sessions and ranking activities as the most favorable. Finally, participants were required to respond to an open-ended question, sharing one takeaway from the session (engagement). High acceptability was defined as more than half of the participants listing one of the key messages as a takeaway from the session.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSecondary Outcomes: Substance Use Knowledge, Intentions, and Behaviors\u003c/h2\u003e \u003cp\u003e \u003cb\u003eKnowledge.\u003c/b\u003e Three true/false items were used to assess substance use knowledge: (1) alcohol is considered a drug, (2) drinking alcohol or using drugs leads to poor judgment and decision-making, and (3) it is against the law for children and teenagers to use drugs. Correct responses were summed to create a scale ranging from 0 to 3. with higher scores indicating more knowledge. Cronbach\u0026rsquo;s alpha for the scale was .51 (baseline), .44 (post-test), and .78 (1-month).\u003c/p\u003e \u003cp\u003e \u003cb\u003eIntentions.\u003c/b\u003e Three items were used to assess intentions. Participants were asked if they would (1) smoke marijuana, (2) use tobacco products, or (3) drink alcohol in the next six months. Responses were \u0026lsquo;0 \u0026ndash; no\u0026rsquo;, \u0026lsquo;1 \u0026ndash; maybe\u0026rdquo; and \u0026lsquo;2 \u0026ndash; yes\u0026rsquo;. Responses were averaged to create a scale score, with scores closer to zero indicating lower intentions to use substances. Cronbach\u0026rsquo;s alpha for the scale was .73 (baseline), .29 (post-test) and .88 (1-month).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBehaviors.\u003c/b\u003e One item was used to assess substance use behaviors: Have you ever had a drink of alcohol (more than a few sips) or tried any drug (i.e., marijuana, cigarette, prescription pills, ecstasy, cocaine, etc.)? Participants responded, \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eFifty-four adolescents in Baltimore, Maryland, participated in this randomized control trial. The average age of our sample was 11.6 years old. There were more female participants (50%) than male participants (46%) or those who identified by other gender identities (4%). Having an incarcerated parent was the most common household challenge (54%), followed by having a parent with a history of substance use (20%) and having a parent with mental illness (19%). Over a quarter of participants (26%) reported lifetime substance use at baseline. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the details on the characteristics of the sample at baseline.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Baseline Characteristics (N\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.6 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6 (0.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttendance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold Challenges* (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubstance use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncarceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental Illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifetime Substance Use (n, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*indicates missing values\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were calculated for demographics, recruitment and retention feasibility, intervention acceptability, and substance use knowledge, intentions, and attitudes. A mixed ANOVA was used to test whether the intervention influenced changes in substance use knowledge and intentions over time. Chi-squared and \u003cem\u003et-\u003c/em\u003etests assessed behavior changes across time and by group assignment. All statistical analyses were conducted using STATA version 18.0. We conducted a content analysis of the qualitative responses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFeasibility and Acceptability\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the participant flowchart for this study. Over 100 youth completed an interest form to be screened for eligibility (n\u0026thinsp;=\u0026thinsp;127). Fifty-two percent of interested youth were ineligible (n\u0026thinsp;=\u0026thinsp;66). Among those eligible, 3% did not return their parental permission forms after at least five attempts from the study team (n\u0026thinsp;=\u0026thinsp;2). Fifty-nine Black youth (ages 11\u0026ndash;13) exposed to household challenges were enrolled in the study and randomized to a condition. Before the intervention began, two students shared conflicts that prohibited them from participating. Three additional students completed the baseline assessment but did not attend a session. Thus, 54 enrolled youth completed all three assessments (92%). Eighty-seven percent of participants attended at least five sessions (n\u0026thinsp;=\u0026thinsp;47). Across conditions, youth participated in an average of 6.5 sessions, with 93% of intervention and 81% of control group participants attending five or more sessions (n\u0026thinsp;=\u0026thinsp;26 and 21, respectively).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003eSession feedback forms showed that most students were happy after each session (60%- 85%). Session 1 (We Are Better Together) had the highest ratings, and Session 3 (Having Boundaries) had the lowest (60%). Of note, Session 3 also had the highest percentage of youth who reported that they were \u0026lsquo;tired\u0026rsquo; after the session (23%), implying other factors may have contributed to the perception of the session. Activities were ranked as the most favorable aspect of the intervention for all sessions.\u003c/p\u003e \u003cp\u003eQualitative feedback suggests that students were engaged in discussing the key messages using their own words. For example, in Session 2 (Managing Emotions), when asked about the biggest takeaway messages, youth comments aligned with the takeaways for the session:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI learned that we need to learn how to control our emotions and not get upset.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eYou always have a choice in things even when you don\u0026rsquo;t think so.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI can express my emotions in a good way.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSimilarly, in Session 5 (Staying Connected), youth corrected identified messages about the importance of help-seeking and effective communication:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAsk for help when you need it.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThe big takeaway I learned was how people get connected in the community and the other way late to communicate and get connected.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eOne takeaway that I learned was that you can\u0026rsquo;t not always win everything and do stuff by yourself always ask for help and don\u0026rsquo;t give up.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSubstance Use Knowledge, Intentions, and Behaviors\u003c/h2\u003e \u003cp\u003eThere were no significant changes in knowledge (η\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.016, F\u0026thinsp;=\u0026thinsp;0.70, df\u0026thinsp;=\u0026thinsp;2) or intentions (η\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.012, F\u0026thinsp;=\u0026thinsp;0.58, df\u0026thinsp;=\u0026thinsp;2) over time or by condition. However, trends showed that compared to the control group, participants in the intervention group reported higher anti-drug attitudes and substance use knowledge at each assessment (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). At baseline, participants in the control group, on average, scored lower than those in the intervention on the knowledge assessment (M\u003csub\u003ediff\u003c/sub\u003e=-0.30, 95% CI: (-0.73, 0.14)). Following the program, the control group continued to show less knowledge about substances than those in the intervention (M\u003csub\u003ediff\u003c/sub\u003e=-0.31, 95% CI: (-0.69, 0.06)). Similarly, participants in the control group showed higher intentions to use drugs at the 1-month follow-up compared to those in the intervention (M\u003csub\u003ediff\u003c/sub\u003e=0.18, 95% CI: (-0.06, 0.41). During post ad hoc analysis, we observed significant behavior changes over time only (F\u0026thinsp;=\u0026thinsp;7.09, df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;=\u0026thinsp;0.0013). However, the effect size of the change was small (\u0026lt;\u0026thinsp;0.20). Despite this significance, there were still fewer intervention group youth (n\u0026thinsp;=\u0026thinsp;9) who reported lifetime substance use at 1-month follow-up compared to control group youth (n\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics for Substance Use Knowledge Intentions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003cp\u003e(mean, SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eIntentions\u003c/p\u003e \u003cp\u003e(mean, SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean difference (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCombined\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eInt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMean difference (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.16 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.00 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.30 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.30\u003c/p\u003e \u003cp\u003e(-0.73, 0.14)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.10 (0.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.15 (0.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.06 (0.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003cp\u003e(-0.07, 0.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosttest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.33 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.17 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.48 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.31\u003c/p\u003e \u003cp\u003e(-0.69, 0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.14 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.15 (0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.13 (0.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003cp\u003e(-0.20, 0.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-month\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.16 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.14 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.18 (0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003cp\u003e(-0.50, 0.41)\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.17 (0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.26 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.08 (0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003cp\u003e(-0.06, 0.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to assess the feasibility and participant satisfaction of Better Together, a novel prevention intervention for Black youth exposed to household challenges. We recruited over 20 youth per cycle, with most attending nearly all sessions. In addition, their responses to the after-session feedback questionnaires suggested they were satisfied and engaged with the materials. Conversely, the increase in lifetime substance use for intervention, but not control participants, was unexpected. We discuss possible explanations for this finding below.\u003c/p\u003e \u003cp\u003eHaving school staff as paid partners in our research was crucial to our successful recruitment and retention efforts. Common barriers to research recruitment and retention of youth living in challenging settings include concerns about safety, fear of re-traumatization, logistical issues, housing instability, and limited utility and relevance of content.\u003csup\u003e\u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e However, strategies such as working with community partners, using social media, and training staff to be personable have been proposed as effective methods to recruit better and retain vulnerable youth in prevention research.\u003csup\u003e\u003cspan additionalcitationids=\"CR40 CR41 CR42 CR43\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Using these strategies enabled our team to be viewed as an asset rather than a burden to families. In addition, offering partner compensation communicated our value that equity in research relationships included equitable compensation for all research team members, not only those affiliated with the university. Future researchers should also consider using community-engaged strategies to improve their recruitment and retention efforts with youth and families with household challenges who may have additional barriers to and concerns about research participation.\u003c/p\u003e \u003cp\u003eIt is unclear how to interpret the lack of findings for substance use knowledge and intentions. These findings may reflect limitations in our measures, survey fatigue, or sample size. Alternatively, despite the quantitative and qualitative data suggesting participants were engaged during the sessions, the content may have needed to be more compelling to be retained. Similarly, the increase in substance use behavior over time for the intervention group may be a function of time rather than the intervention. The number of youth who reported lifetime substance use increased for both groups, confirming the heightened susceptibility of substance use for youth exposed to adversity during early adolescence.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e Although the rate of increase was accelerated for the intervention group, the number of youth reporting substance use was lower for those who participated in the intervention compared to the control at all assessments. A longer follow-up and additional contextual data are needed to assess how much the intervention slows the rate of substance use initiation. Such findings help researchers determine how to enhance the intervention to be more absorbent and effective.\u003c/p\u003e \u003cp\u003eMethodological limitations of this pilot study include small sample size, limited measures, and no long-term follow-ups. Study groups did not differ by most demographic factors or initial scores on outcome measures. Thus, more research is needed. Despite these limitations, study findings suggest that participant recruitment and retention are possible for this novel substance use prevention intervention. In addition, youth were satisfied and engaged with the intervention materials. This intervention responds to the research demonstrating the value of tailoring interventions to support population health and extend the impact of evidence-based interventions. \u003csup\u003e47\u0026ndash;50\u003c/sup\u003e Study findings also provide additional evidence of the difficulty of preventing substance use in families where substance use may be a lower priority in the presence of other household challenges. Thus, further research is needed to understand what will work, for whom, and under what circumstances to prevent substance use among Black youth exposed to household challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board at the Johns Hopkins Bloomberg School of Public (IRB: 25611) provided research ethics approval, including consent procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Bloomberg American Health Initiative supported this work. The funders had no role in the review or approval of this manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTWP was involved in obtaining funding, designing the study, developing the protocol, and drafting the manuscript. BSB analyzed the quantitative and qualitative data. WT supported implementation. All authors read, edited and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study team would like to thank the youth and families engaged with the study. We would also like to thank our participating schools and their leadership, especially our school liaisons, Ma Theresa Cabillos and Marissa Puryear. Their contributions to and support of this research were invaluable. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGarofoli M. 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Enhancing recruitment and retention of minority young women in community-based clinical research. \u003cem\u003eJ Pediatr Adolesc Gynecol\u003c/em\u003e. 2005;18(6):403\u0026ndash;407. \u003c/li\u003e\n\u003cli\u003eKealey KA, Ludman EJ, Mann SL, et al. Overcoming barriers to recruitment and retention in adolescent smoking cessation. \u003cem\u003eNicotine Tob Res\u003c/em\u003e. 2007;9(2):257\u0026ndash;270. \u003c/li\u003e\n\u003cli\u003eSeed M, Juarez M, Alnatour R. Improving recruitment and retention rates in preventive longitudinal research with adolescent mother. \u003cem\u003eJ Child Adolesc Psychiatr\u003c/em\u003e. 2009;22(3):150\u0026ndash;153. \u003c/li\u003e\n\u003cli\u003eSeibold-Simpson S, Morrison-Beedy D. Avoiding early study attrition in adolescent girls: Impact of recruitment contextual factors. \u003cem\u003eWest J Nurs Res\u003c/em\u003e. 2010;32(6):761\u0026ndash;778. \u003c/li\u003e\n\u003cli\u003eThrul J, Stemmler M, Goecke M, B\u0026uuml;hler A. Are you in or out? recruitment of adolescent smokers into a behavioral smoking cessation intervention. \u003cem\u003eAddict Behav\u003c/em\u003e. 2015;45:150\u0026ndash;155. \u003c/li\u003e\n\u003cli\u003eVan Doesum KTM, Riebschleger J, Carroll J, et al. Successful recruitment strategies for prevention programs targeting children of parents with mental health challenges: An international study. \u003cem\u003eChild Youth Serv\u003c/em\u003e. 2016;37(2):156\u0026ndash;174. \u003c/li\u003e\n\u003cli\u003eD\u0026apos;Elio MA, O\u0026apos;Brien RW, Iannotti RJ, Bush PJ, Galper DI. Early adolescents\u0026rsquo; substance use and life stress: Concurrent and prospective relationships. \u003cem\u003eSubst Use Misuse\u003c/em\u003e. 1996;31(7):873\u0026ndash;894.\u003c/li\u003e\n\u003cli\u003eEl-Sawy H, Abd Elhay M. Characteristics of substance dependence in adolescents with and without a history of trauma. \u003cem\u003eMiddle East Current Psychiatry\u003c/em\u003e. 2011;18(4):211\u0026ndash;216.\u003c/li\u003e\n\u003cli\u003eMcKleroy VS, Galbraith JS, Cummings B, et al. Adapting evidence-based behavioral interventions for new settings and target populations. \u003cem\u003eAIDS Education \u0026amp; Prevention\u003c/em\u003e. 2006;18(supp):59\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eWingood GM, Diclemente RJ. The ADAPT-ITT model: A novel method of adapting evidence-based HIV interventions. \u003cem\u003eJ Acquir Immune Defic Syndr\u003c/em\u003e. 2008;47(SUPPL. 1):S40\u0026ndash;S46.\u003c/li\u003e\n\u003cli\u003eKachingwe ON, Lewis Q, Offiong A, Smith BD, LoVette A, Powell TW. Using the intervention mapping for adaption framework to adapt an evidence-based sexual health intervention for youth affected by trauma. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2023;23(1):1052.\u003c/li\u003e\n\u003cli\u003eCornelius JB, Moneyham L, LeGrand S. Adaptation of an HIV prevention curriculum for use with older African American women. \u003cem\u003eJANAC: Journal of the Association of Nurses in AIDS Care\u003c/em\u003e. 2008;19(1):16\u0026ndash;27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"substance use, intervention, adverse childhood experiences","lastPublishedDoi":"10.21203/rs.3.rs-5105000/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5105000/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eYouth exposed to household challenges are among the groups most vulnerable to early substance use. To address the needs of this group, this pilot study assessed the feasibility of participant recruitment and retention, as well as the acceptability of a novel substance use prevention intervention, Better Together, for Black youth exposed to household challenges.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eParticipants were recruited using school and community presentations, digital flyers, and referrals. Eighty-nine students from two schools were screened. Participant enrollment, session attendance, and assessment completion were used to determine feasibility. Quantitative and qualitative data were collected after each session; responses were used to assess intervention acceptability. Demographic and substance use data were collected at baseline, post-test, and one-month follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e Fifty-nine (96%) youth were eligible, returned their parental permission forms, and enrolled. Completion rates for assessments were above 90% for all three assessments. Nearly 90% of participants attended at least five sessions; the average attendance was 6.5 sessions across conditions. Session feedback forms showed that most students were happy after each session (61%-85%). Qualitative feedback suggests that students were engaged in discussing the key messages using their own words. There were no significant changes in substance use knowledge or intentions over time or by condition. However, there was a small yet significant increase in substance use behaviors over time.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBetter Together may be a promising intervention to prevent substance use among Black youth exposed to household challenges. Findings suggest that recruiting, retaining, and engaging participants in the eight-session intervention is possible. Findings will inform plans to implement a full-scale study to evaluate the efficacy and contextual factors that impact effective program implementation.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinicaltrials.gov: [ID BLINDED FOR REVIEW]. Registered [DATE BLINDED FOR REVIEW] - Retrospectively registered, [LINK BLINDED FOR REVIEW]\u003c/p\u003e","manuscriptTitle":"Feasibility and Acceptability of a Novel Substance Use Prevention Intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-20 17:50:22","doi":"10.21203/rs.3.rs-5105000/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-10-23T10:58:41+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-17T19:11:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-27T08:02:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pilot and Feasibility Studies","date":"2024-11-26T19:24:49+00:00","index":"","fulltext":""},{"type":"decision","content":"Minor revision","date":"2024-11-22T12:08:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7841ef23-79a1-43da-869c-f83a074cf154","owner":[],"postedDate":"January 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T07:33:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-20 17:50:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5105000","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5105000","identity":"rs-5105000","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}