Advances in Substance Abuse Prevention Practice and Science for Hispanic/Latinos

The problem of substance abuse impacts the Hispanic/Latino youth population. In some cases, subpopulations of the Hispanic/Latino population suffer higher rates of substance use than do other groups. While the science of prevention in the general population and the rigorous study of substances abuse prevention programs have flourished over the past few decades, there continues to be a limited body of knowledge regarding substance abuse prevention that is culturally specific or tailored to Hispanic/Latinos. One promising area is the study of risk and protective factors which finds that acculturation stress, among others, plays a key role in the development of substance use and other behavioral problems among youth. Stress experiences related to discrimination, immigration, parent–child cultural differences all play a role in disrupting normative development and subsequent risk-taking behavior. Culturally focused prevention models such as Familia Adelante show promise in helping reduce acculturation-based risk and increasing individual and family resilience. This chapter will address many of the aforementioned issues and will provide direction for future prevention research for Hispanic/Latinos.


Introduction
This chapter will provide an overview of substance use prevention for Hispanic/ Latino youth. Based on US Census Bureau data Hispanics are the youngest major racial or ethnic group in the United States [1]. About one-third or 17.9 million of the nation's Hispanic population is younger than 18 and about a quarter or 14.6 million of all Hispanics are millennials (ages 18-33 in 2014). Researchers and practitioners alike recognize the advantages of implementing prevention programming that averts the need for more intensive and costly drug treatments. Advances in prevention science have been highlighted in reports from the Institute of Medicine and National Institute on Drug Abuse (NIDA) among others. The question is whether such advances in scientifically based prevention efforts can also extend to Hispanic/ Latino youth including those who are immigrants or non-English speaking. A second question is whether theoretical models used to develop and study drug prevention programs are adequate in terms of addressing core cultural values beliefs and traditions among Hispanic/Latinos. Have prominent and widely used prevention interventions been adapted studied and proven effective with Hispanic/Latino youth? Are culturally tailored evidence-based programs available?
According to the review of literature conducted by Cuijpers [2], prevention programs have different goals, including the following: (a) increasing knowledge about drugs, (b) reducing the use, (c) delaying the onset of first use, (d) reducing abuse, and (e) minimizing the harm caused by the use. Prevention can be understood as any activity designed to avoid substance abuse and reduce its health and social consequences. This broad term can include actions aimed to reduce supply (e.g., based on the principle that the decreased availability of substances reduces the opportunities for abuse and dependence) and actions aimed to reduce demand (i.e., health promotion and disease prevention). In addition, the National Institute on Drug Abuse (NIDA), based on a growing body of prevention science, offers principles concerning prevention which range from the importance of addressing risk and protective factors to implementing and enforcing family and community policies prohibiting substance use [3]. Unfortunately, the NIDA principles do not specifically address the importance of cultural risk or protective factors that may impact substance use among Hispanics. Principle 12 does offer some broad recommendation regarding culture, citing that when communities adapt programs to match their needs, they should still do their best to maintain as close to the original intervention as possible and maintain high fidelity, although this principle is related to program adaptation.

Scope of the problem for Hispanic/Latino youth
Hispanic adolescents experience health disparities related to substance use, emotional problems, and high-risk sexual behavior. By the 12th grade, Latino students report the highest rates of 30-day use of marijuana, inhalants, ecstasy, cocaine, crack, salvia, Vicodin, methamphetamine, crystal methamphetamine, over-thecounter cough medicines, and tobacco through use of hookah [4]. Additionally, over one-quarter of Latino adolescents report alcohol use in the last 30 days as well as reports of the highest rates of binge and heavy drinking [5]. Suicide ideation is elevated among Latino adolescents as 1 in 7 (16.7%) Latino adolescents report suicidal ideation and 1in 10 (10.2%) report having attempted suicide [6]. In 2012, Latina adolescents had higher rates of teenage pregnancy than any other racial and ethnic minority, with 43.6 births per 1000 females, ages 15-19 years old [7].
The fastest-growing drug problem in the United States is prescription drugs, and it is profoundly affecting the lives of teenagers. According to NIDA DrugFacts, prescription drug misuse and abuse is when someone takes a medication inappropriately (e.g., without a prescription). According to National Survey on Drug Use and Health (NSDUH) data on youth and young adults, more than 5700 youth in 2014 reported using prescription pain relievers without a doctor's guidance for the first time.
A common misperception is that prescription drugs are safer or less harmful to one's body than other kinds of drugs. However, there are a range of short-and long-term health consequences for each type of prescription drugs used inappropriately. When concerning opioids, which act on the same parts of the brain as heroin, the consequences of inappropriate use can cause drowsiness, nausea, constipation, and depending on the amount taken, slowed breathing and even respiratory failure [8]. In terms of trends in tobacco use and electronic cigarettes among youth, older students, Hispanics, and Whites are more likely to use e-cigarettes than younger students and Blacks. In the young adult population, males, Hispanics, Whites, and those with lower education are more likely to use e-cigarettes than females, Blacks, and those with higher levels of education [9]. Flavored products marketed as e-cigarettes have gained popularity among youth and adults, while health consequence data continues to highlight the negative health impact of these products.

Risk and protective factors
Factors that drive the substance use behaviors of Hispanic youth may be quite similar to those found in the general population of youth, yet there are unique challenges, stressors, and other risk factors that play a role in the development of substance use among Hispanic/Latino youth [10]. Cultural values and language shifts, pre-and post-migration trauma, ethnic identified problems, and parent-child "acculturation gaps" are implicated in the onset of substance use in this growing population. A body of research on family stress, adaptation, and resilience by McCubbin and colleagues has established that stressors that impact minority groups, including Hispanics, can negatively impact and disrupt the family system [11]. In turn, how the family actively deals with their stressful conditions can strengthen family members, their relationships, and the family unit. Highly stressful conditions can overwhelm family functioning.
Acculturative stressors are a class of adverse conditions that can generate interpersonal, cultural and familial challenges. For example, cultural conflict following immigration can reverberate across generations. Such stressors may comprise chronic adversity that includes clashes between personal and family goals; an increase in individualistic views; a reduced sense of the importance of religion; increased intra-family conflicts; gender role conflict; and increased marital conflict. Families with more acculturative stress and who lack a strong social support system or resilience (i.e., family and friends, spiritual resources, access to public social services) or personal resources (i.e., self-esteem) can show a greater decline in family cohesion.

Immigration and acculturation-related hardships confronted by Hispanic/Latino youth
The physical and emotional demands of immigrating to the United States are well documented [12]. New data shows a 117% increase in unaccompanied children ages 12 and under caught at the US-Mexico border in fiscal year 2014 compared to fiscal year 2013. By comparison, the number of apprehensions of children 13-17 years old has by increased 12% in the past year [13]. Parental deportation is an increasingly common hardship experienced by the Hispanic youth. Nearly 33,000 noncitizen youth are in DHS custody each day, representing an over 50% increase from 2001. Chaudry and colleagues found most children of deported undocumented workers remained in the United States with their other parent or relative [14]. The negative consequences of forced family separation because of deportation on child well-being are documented [15][16][17][18]. Children most at risk for negative behavioral or psychological changes are those who witnessed their parents' arrest; children separated from their parents longer than 30 days; and children whose primary caregiver was deported [19].
The term acculturative stress refers to the distress that individuals experience as a result of tension between maintaining the behaviors and characteristics of their country of origin and concurrently adopting those from the majority culture [20]. Acculturative stressors are not unique to Latino populations and may include pressure from learning a new language, balancing differences in cultural values, and adjusting to new employment expectations [21,22]. Stress itself is conceptualized as a behavioral and emotional reaction to acute or chronic life-changing events and occurs when the demands of the events exceed the individuals' perceived personal and social resources to deal with these changes [23]. The stress-illness paradigm offers one way to conceptualize the relationship between social stress and health [24,25].
Research studies on acculturation and health status have been mixed, with some studies showing a positive relation between acculturation and health, while others demonstrate an inverse effect on health outcomes [26]. Furthermore, there is often considerable variation in these outcomes depending on factors such as country of origin, age, gender, years lived in the United States, education, and income [27]. For example, some research shows differences in health outcomes across a number of Latino/a subpopulations, with some subgroups experiencing higher morbidity and mortality rates, diabetes and hypertension, psychiatric disorders, and substance use disorders [27][28][29][30][31][32]. One potential factor driving these different outcomes is experiences of acculturative stress.
Recent work by the authors suggests that acculturation "gaps" between adolescents and their parents can impact healthy emotional development. An additional adversity often faced by Hispanic families involves family member separations due to immigration, such as when parents come to the United States first and children are separated for years. The reunification process can be stressful and painful rather than smooth and joyous. The work by Perreira and colleagues emphasizes how adversity and resilient responses are embedded in social contexts. From an adversities' perspective, this involves loss of social position and class status, loss of vital extended family resources, loss of peer networks and community support, and economic and social segregation and marginalization. Unfamiliar social contexts, language barriers, and humiliation when confronted by racism and discrimination can further erode individual and family coping and resilience.
Studies also indicate that US-born and more acculturated Mexican origin youth exhibit higher rates of externalizing behavior when compared to their less acculturated, Mexican-born peers. Markers of acculturation are consistently associated with externalizing outcomes like conduct problems, juvenile arrest, and substance use. US-born youth report less investment in education and lower academic aspirations than their Mexican-born peers [33]. Among immigrants, greater length of residence in the United States is associated with lowered academic motivation [34,35]. Despite the stressful period of adjustment to a new set of cultural and linguistic changes, immigrants show resilience and better behavioral health compared to US-born Latino youth. The immigrant paradox primarily results from the progressive loss of traditional culture and associated negative health consequences associated with increasing generations or time in the United States [36].
Research examining the effects of both acculturation and stress find that stress partially mediates the relationship between acculturation and negative health behaviors. Stress impedes health by limiting access to salutogenic health behaviors and through maladaptive coping [37]. Hispanics under elevated stressor exposure are more likely to deny the stressor or to use maladaptive coping behaviors such as risky sex and substance abuse [38,39].
Among youth, immigration, and acculturation-related stressors have also been found to predict greater drug use and risky sexual behavior [40,41]. Recently, Cervantes and colleagues identified eight culturally based stress risk domains commonly experienced by Latino adolescents, ranging from acculturation gaps to family immigration-related stress [42]. Higher scores of cultural stress in these life domains were significantly related to both internalizing and externalizing behavioral health problems in Latino adolescents including polysubstance use [10,42]. Effective interventions targeting immigration-related stress among Hispanics must promote healthy coping strategies for acculturation-and immigration-based stressors [43].
The implications of immigration and acculturation stressors are likely accentuated in new Hispanic settlement communities. New settlement areas are often hostile towards immigrants, creating a culture of fear where there is a heightened sense of anxiety that likely underlies social interaction and exaggerates possible stressor exposure. Birman and colleagues provide evidence that these hostile contextual conditions can affect the acculturation process and point to contextual factors such as immigrant density, acceptance of cultural diversity, and presence of social capital as core contextual issues [44].

Protective effects of family and social support
Protective factors are those personal and environmental conditions and experiences that can counteract risk factors for substance use. For example, emphasis on family life is a central core value to most Hispanics and essential for their resilience in achieving normative life aims in the face of adverse social and environmental barriers. The concept of familismo/familism is a core value and belief in the centrality of family in the life of Hispanics. It highlights family loyalty, interdependence over independence, and cooperation over competition. Hispanic cultural values (i.e., familismo, simpatia, power distance, personal space, present time orientation, traditional gender roles) may impact health outcomes and diminish during the acculturation process. Embracing familism as a value contributes to a familial stability, which is linked to better physical health behaviors,

Discrimination
• Maintaining a strong sense of identity and self-confidence higher likelihood of seeking medical help, better psychological health, and lower perceived burden of stress. Familism and the highly involved parenting practices that often come with familism have been linked to fewer behavior problems in children. The work by Perreira and colleagues has pointed to specific resiliency strategies utilized by Hispanic immigrant parents. These include (1) emphasizing with and respecting adolescents/children (i.e., developing a deep understanding of what they are going through in an unfamiliar context and admiring the strength shown by children in that difficult context); (2) seeking help and fostering social support (i.e., connecting to other Hispanics and building community); (3) developing bicultural coping skills (including teaching children about their heritage and American culture); and (4) improving communication with their children (e.g., speaking honestly about difficult situations and being attentive to the child's needs). Familismo, the orientation towards putting the needs of the family above that of the individual, family cohesiveness, reciprocity, and honor is a core value in Hispanic/Latino culture [45][46][47][48][49]. Most studies of psychosocial outcomes related to familismo find favorable psychosocial results for Hispanic children and adolescents [50][51][52][53][54][55]. Incorporating Hispanic/ Latino family values into early intervention and prevention programs can buffer the impact of weakening connection to traditional family protective factors [56].
Other forms of resilience can be found among Hispanic/Latino youth and families. These resources can be "mobilized" as part of any culturally focused prevention strategy. In one qualitative study of family resilience, Cervantes and Santisteban [57] reported specific, contextual resilience strategies mentioned by Hispanic/ Latino families in confronting acculturation stressors ( Table 1).

Research on behavioral intervention strategies for Hispanic/Latino youth
Evidence-based drug prevention programming for Hispanic/Latinos does exist, although the number or programs is small. Familias Unidas, Familia Adelante, Strengthening the Bonds of Chicano Youth, and other similar programs will be highlighted here. The Familias Unidas intervention research has been undertaken with various Hispanic/Latino population groups including a study of predominantly Cuban (39%), Central and South Americans (29 and 17%, respectively), and a small proportion of Puerto Rican/Dominican (5%) participants [58]. A more recent study of Familias Unidas included adolescent participants who were predominantly US-born (56.1%) as well as adolescent immigrants from Honduras (26.9%), Cuba (20.4%), and Nicaragua (16.1%) [59]. A study of Strengthening the Bonds of Chicano Youth (El Proyecto de Nuestra Juventud) included 450 high-risk youth in an established, nonimmigrant community setting [60]. Results were generally positive in reducing risk factors for substance use.
Familias Preparando la Nueva Generación (FPNG) is a synchronized culturally grounded parenting component program which involves Latino youth substance abuse prevention [61]. FPNG serves as an addition to the already proven efficacious classroom-based drug abuse prevention intervention, Keepin' it Real (KIR). One study showed that anti-drug norms were stronger in participants who were enrolled in KIR whose parents also participated in FPNG than in participants who were enrolled in KIR alone. Along with these stronger anti-drug norms, participants whose parents were in FPNG also showed reduced use of cigarettes and alcohol. The findings have shown that adolescent normative beliefs and related behaviors can be changed through synchronized culturally grounded parent and youth interventions.
REAL Groups is a small-group intervention designed to complement the schoolbased Keepin' it Real (KIR) prevention program [62]. REAL Groups intervention is the result of a partnership with predominantly Mexican-American schools located in the central city neighborhoods of a southwestern US metropolitan area. The REAL Groups approach was designed as a companion to the larger KIR intervention and takes place over 10 weeks specifically targeting Latino, Hispanic, and Mexican-American children that appear to be more vulnerable to using drugs before entering adolescence. However, the outcomes of the REAL Groups intervention have been mixed and inconclusive, mainly due to the participants of the study being in the fifth grade with low drug use rates.
The mother/daughter intervention (MDI) approach is another program that involves substance abuse prevention strategies for youth [63]. This approach consists of 10 sessions via the internet which are to be completed at a rate of one session per week. In one study the MDI targeted young Black and Latina girls between the ages of 10 and 13 and their mothers. The outcome of the MDI showed that the girls who received the intervention reported lower levels of depression and higher levels of self-efficacy about their ability to avoid cigarette smoking, alcohol consumption, and drug use.
Substance abuse treatment and prevention interventions also exist to address intrafamilial stress in Hispanic families, such as brief strategic family therapy (BSFT) and more recently culturally informed family therapy for adolescents (CIFTA) [64,65]. Again, these studies have included predominately Cuban or other Caribbean Latino samples yet may prove beneficial when applied to other Hispanic/ Latino groups.

Integrating acculturation stress into prevention efforts
As an example of the expanding set of innovative research-based prevention programs for Hispanic/Latino youth, Familia Adelante will be will be discussed in some detail to exemplify one recently developed, culturally focused program. Familia Adelante is a drug prevention program that incorporates promotores as facilitators for this curriculum-based drug prevention program. The first iteration of the Familia Adelante (FA) curriculum showed reductions in family stress School-related stress Identify the stressors related to school, cultural, and ethnic differences and how this stress affects youth; help youth identify trusted adults to share stressful experiences and youth behavior problems, enhancing academic and psychosocial coping and decreasing substance use patterns in Latino youth [66]. FA was also tested through in the SAMHSA-funded Blythe Street Prevention Project (BSPP) with youth and their parents, and that study found significant improvements in drug knowledge and drug resistance skills in both youth and parents [67]. FA was then evaluated in 2006 with six cohorts of families in a school-based setting. Findings were positive showing that family and peer communication improved and perceptions of substance use harm increased while social norms around sexual behavior and past-30-day use of marijuana and illegal drugs were reduced [68]. The developers also conducted NIH-supported work to infuse the FA curriculum with reproductive health education and HIV prevention messaging. Based on focus group data, new content was identified by participating youth that was not included in the original FA curriculum (i.e., content on eating disorders) ( Table 2).

Adapting evidence-based programs
Given the lack of prevention programs that have used a grounded cultural theory or that have incorporated culturally relevant risk and protective factors, there is oftentimes a need to use other evidence-based prevention practices and approaches and to adapt those to the needs of local Hispanic/Latino community. In one literature review comparing cultural adaptations to either no treatment or unadapted treatments, researchers found that cultural adaptations can be more effective than either of these other conditions, especially for clients with a diagnosed mental health disorder [69]. When examined as a whole, the scientific literature on cultural adaptations shows treatment effects to be significant and moderate in size on average [69][70][71][72][73][74][75]. Still, researchers caution that conclusions about the need for cultural adaptations should be reserved until more studies that directly compare adapted and unadapted EBPPs are conducted.
Adapted interventions that address the powerful, everyday stressors experienced by Hispanic/Latino clients are likely to be perceived as more relevant and attractive to clients. Enhancing content of existing EBPPs to reflect the values (e.g.,  family, religion) and world views of Latino clients will also increase the cultural relevance of the intervention [69,76]. Finally, there are a number of agency-and provider-level characteristics that must be considered before a decision to adapt an EBP is made. First and foremost is the capacity of a provider organization to systematically undertake an adaptation. Agency capacity refers to the financial and human capital resources, skills, knowledge, and in-kind support that are needed to take on each step of the adaptation process (outlined below). For example, an initial needs assessment may include conducting consumer, staff, and other stakeholder interviews or focus groups. Thus, an agency should be prepared to cover costs related to staffing of these additional activities, paying incentives for participants, offering childcare, providing food and providing transportation for participants, transcription of focus group data, data management, data analysis, and reporting.

Conclusions and recommendations for future research
Drug prevention science and practice continues to expand, and to some extent the field has made positive impact in the Hispanic/Latino community. Based on the research to date, sufficient evidence exists about culturally specific risk and protective factors associated with the onset of substance use [3,42]. Additionally, the momentum is gathering for the development and study of culturally focused prevention interventions. Acculturation and related stressors have been shown to precipitate behavioral health problems, and the body of research on acculturation stress can serve as theoretical underpinnings for the development of additional contemporary, culturally sensitive programming. As prevention programming and the evidence base for Hispanic/Latino practices continues to expand, core theoretical considerations will drive effective prevention programming. Latino and other scholars agree that concepts of acculturation, acculturation stress, familismo, respeto, and comunidad (community) must be inherent components, if not core components of prevention strategies for this growing population. Reinforcing positive family and youth identity that incorporates, embraces, and honors cultural history and traditions appears to have most promise.
In addition, there is growing evidence that factors such as acculturation stress, parent-child acculturation gaps, and prolonged discrimination (measured by allostatic load) may all play a role in the development of SUD among Hispanic/Latino youth. Programs such as Familia Adelante, which can be considered a culturally grounded model, address many of the acculturation and stress-related issues that resonate with many Hispanic/Latino youth. The development of prevention service approaches that include family and parent involvement is necessary, not only for the purpose of recruiting and retaining families but also as a way to promote and reinforce familismo. Future research on the impact of immigration policy and enforcement is needed particularly related to how family separations, childhood trauma associated with immigration, and deportation experiences lead to the development of behavioral health problems. The testing of prevention programs that are specific to new immigrants and refugee populations will be needed to address the uncertainties that these youth and families experience and that may not be addressed in existing prevention models.
Finally, we have outlined issues related to adapting existing EPBs for use in Hispanic/Latino communities. Research is fairly conclusive that adapting an EBP to the language and cultural characteristics of a particular ethnic community is better than not doing the adaption. Yet, the skills, capacity, and resources available to do good program adaptation must be in place. More specific research on program adaptations of generic prevention programs for Hispanic/Latino communities is needed.