A Randomized Controlled Trial of a Parent-Centered Intervention in Preventing Substance Use and HIV Risk Behaivors in Hispanic Adolescents

Journal of Consulting and Clinical Psychology
2007, Vol. 75, No. 6, 914 –926

Copyright 2007 by the American Psychological Association
0022-006X/07/$12.00 DOI: 10.1037/0022-006X.75.6.914

A Randomized Controlled Trial of a Parent-Centered Intervention in
Preventing Substance Use and HIV Risk Behaviors in Hispanic
Adolescents
Guillermo Prado and Hilda Pantin

Ervin Briones

University of Miami

University of Tennessee at Martin

Seth J. Schwartz, Daniel Feaster, Shi Huang, Summer Sullivan, Maria I. Tapia, Eduardo Sabillon,
Barbara Lopez, and Jose´ Szapocznik
University of Miami
The present study evaluated the efficacy of Familias Unidas ⫹ Parent–Preadolescent Training for HIV
Prevention (PATH), a Hispanic-specific, parent-centered intervention, in preventing adolescent substance
use and unsafe sexual behavior. Two hundred sixty-six 8th-grade Hispanic adolescents and their primary
caregivers were randomly assigned to 1 of 3 conditions: Familias Unidas ⫹ PATH, English for Speakers
of Other Languages (ESOL) ⫹ PATH, and ESOL ⫹ HeartPower! for Hispanics (HEART). Participants
were assessed at baseline and at 6, 12, 24, and 36 months postbaseline. Results showed that (a) Familias
Unidas ⫹ PATH was efficacious in preventing and reducing cigarette use relative to both control
conditions; (b) Familias Unidas ⫹ PATH was efficacious, relative to ESOL ⫹ HEART, in reducing illicit
drug use; and (c) Familias Unidas ⫹ PATH was efficacious, relative to ESOL ⫹ PATH, in reducing
unsafe sexual behavior. The effects of Familias Unidas ⫹ PATH on these distal outcomes were partially
mediated by improvements in family functioning. These findings suggest that strengthening the family
system, rather than targeting specific health behaviors, may be most efficacious in preventing and/or
reducing cigarette smoking, illicit drug use, and unsafe sex in Hispanic adolescents.
Keywords: prevention, HIV, drugs, smoking, Hispanic

Early substance use and sexual behavior, along with the outcomes with which these behaviors are associated, such as substance abuse and dependence (Gil, Wagner, & Tubman, 2004) and
HIV infection (Prado et al., 2006), are not evenly distributed across
ethnic groups. Hispanic adolescents report higher use across all
drug categories (with the exception of amphetamines; Johnston et
al., 2007) and also engage in higher rates of unprotected sexual
intercourse than do non-Hispanic White and African American
adolescents (Centers for Disease Control and Prevention, 2006b).2
Compared with non-Hispanic Whites, Hispanics are also disproportionately represented among HIV/AIDS cases, accounting for
18% of all such cases in the United States in 2004 (Centers for
Disease Control and Prevention, 2006a).
These disparities are especially disconcerting because Hispanics
are the largest and fastest growing minority group in the United
States (Ramirez & de la Cruz, 2003), representing 14% of the
population. Moreover, Hispanics accounted for approximately half
of all U.S. population growth between 2000 and 2006 (Bernstein,
2007). Hispanics are also a youthful population, with more than
one third under the age of 18 (Marotta & Garcia, 2003). Preventing

Substance use and HIV/AIDS represent major public health
problems facing America’s youths (Centers for Disease Control
and Prevention, 2006a; Johnston, O’Malley, Bachman, & Schulenberg, 2007).1 Both substance use and sexual behavior are often
initiated in adolescence (Guo et al., 2002) and are associated with
compromised developmental outcomes, including unplanned pregnancy, sexually transmitted diseases (including HIV), and school
dropout (Rosenthal, Biro, Succop, Baker, & Stanberry, 1994;
Smith, 1997).

Guillermo Prado, Hilda Pantin, Seth J. Schwartz, Daniel Feaster, Shi
Huang, Summer Sullivan, Maria I. Tapia, Eduardo Sabillon, Barbara
Lopez, and Jose´ Szapocznik, Center for Family Studies, Miller School of
Medicine, University of Miami; Ervin Briones, Department of Psychology,
University of Tennessee at Martin.
This research was supported by National Institute of Mental Health
Grant MH63402 awarded to Jose´ Szapocznik and by National Institute on
Drug Abuse Grant 19101 awarded to Guillermo Prado. We would like to
acknowledge Omar Cardentey for his administrative support. We would
also like to thank assessors Mercedes Prado, Norma Aguilar, Alba Alfonso,
Leslia Pineda, and Julia Andı´on as well as adherence raters Mike Robbins,
Gonzalo Perez, and Lola Arellano. Finally, we would like to thank the
families who participated in this study.
Correspondence concerning this article should be addressed to
Guillermo Prado, Center for Family Studies, Miller School of Medicine,
University of Miami, 1425 Northwest 10th Street, Miami, FL 33136.
E-mail: [email protected]

1

Substance use refers to the use of tobacco, alcohol, and illicit drugs.
The term Hispanic is used to be consistent with the terminology used
by the U.S. Census Bureau. However, it is intended to include individuals
living in the United States from a vast variety of backgrounds, some of
whom may identify themselves as Latinos/Latinas or Chicanos/Chicanas.
2

914

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

these problems in Hispanic adolescents is therefore of vital importance.
Despite the facts that (a) unsafe sexual behavior and substance
use are so prominent among Hispanic adolescents and (b) both of
these behaviors are directly associated with HIV contraction, few
substance use (see Szapocznik, Prado, Burlew, Williams, & Santisteban, 2007) and HIV (see Prado et al., 2006) preventive interventions have been developed and tested specifically for Hispanic
adolescents. The purpose of the present study was to evaluate the
efficacy of a Hispanic-specific intervention designed to prevent
substance use and unsafe sexual behavior in Hispanic adolescents.
Culturally specific interventions are those that are tailored toward
a specific ethnic group and that integrate culture into one or more
of the intervention components (Prado, Szapocznik, Schwartz,
Maldonado-Molina, & Pantin, in press). Scant research has examined the degree to which cultural specification might improve the
impact of empirically supported interventions, and more research
is clearly needed in this area (Nagayama Hall, 2005).

915

In the present study, we evaluated the combination of Familias
Unidas and Parent Preadolescent Training for HIV Prevention
(PATH; Krauss et al., 2000) in preventing both substance use and
unsafe sex in Hispanic adolescents. Whereas Familias Unidas
focuses on improving family functioning, PATH focuses specifically on increasing parent–adolescent communication about sex
and HIV risks (Krauss et al., 2000). PATH, however, does not
target positive parenting or communication skills, which may be a
necessary prerequisite to initiating parent–adolescent discussions
about sexuality and HIV. Given Hispanic cultural taboos against
discussing sexuality and HIV (Gomez & Marin, 1996), it may be
important to strengthen the family system before addressing sexuality and HIV. It was therefore important to test whether the
efficacy of PATH in preventing substance use and unsafe sex in
Hispanic adolescents depends on whether it is embedded within a
family-strengthening intervention (i.e., Familias Unidas).

The Current Study
Risk and Protective Factors for Adolescent Substance Use
and Unsafe Sexual Behavior
Many of the most powerful protective mechanisms against
adolescent substance use and unsafe sexual behavior are within the
family. These include parental involvement (Vakalahi, 2002), positive parenting (e.g., positive reinforcement for good behavior;
Ellickson & Morton, 1999), family support (Henrich, Brookmeyer,
Shrier, & Shahar, 2006), and parent–adolescent communication
(Meschke, Bartholomae, & Zentall, 2000). It is not surprising that
family-based interventions are especially efficacious in reducing
risk and increasing protection against substance use and HIV risks
(e.g., Pantin et al., 2003; Tobler et al., 2000). Family is especially
important among Hispanics (Santisteban, Muir-Malcolm, Mitrani,
& Szapocznik, 2002), for whom familism (e.g., use of family as a
source of emotional support) is an integral part of the culture. As
a result, preventive interventions for Hispanics should be family
based.

Familias Unidas
Familias Unidas (United Families; Pantin et al., 2003; Pantin,
Schwartz, Sullivan, Prado, & Szapocznik, 2004) is one of the few
interventions (see Szapocznik et al., 2007, for a review) that are
efficacious in increasing parental involvement, positive parenting,
and family support in Hispanic families. Familias Unidas proceeds
from the assumption that parental involvement, positive parenting,
parent–adolescent communication, and family support are essential to promoting positive adolescent development and to preventing substance use and unsafe sex (Pantin et al., 2004). Familias
Unidas is a parent-centered intervention, in which the vast majority
of components are delivered directly to parents. Consistent with
Hispanic cultural expectations, Familias Unidas places parents in
positions of leadership and expertise and builds on pan-Hispanic
values, such as primacy of family, sanctity of parental authority,
and roles of parents as the family’s leaders and educators (Santisteban et al., 2002). Hispanic-specific cultural issues are integrated in all aspects of the intervention, from the underlying
theoretical model to the specific content of the intervention to the
format of the intervention activities.

The purpose of the current study was twofold. The first aim was
to investigate whether Familias Unidas ⫹ PATH would be efficacious relative to two control conditions in (a) preventing substance
use and unsafe sexual behavior in Hispanic adolescents and (b)
improving family functioning (parental involvement, parent–
adolescent communication, positive parenting, and family support). The second aim was to examine whether and to what extent
improvements in family functioning would mediate the effects of
intervention condition on substance use and unsafe sexual behavior. In both control conditions, English for Speakers of Other
Languages (ESOL) was used as an attention control for Familias
Unidas. In the second control condition, HeartPower! for Hispanics (HEART; American Heart Association, 1996) was used as an
attention control for PATH. The term attention control is used to
refer to a module intended to provide equivalent amounts of
dosage and participant–facilitator contact. The randomized controlled trial therefore consisted of the following three conditions:
(a) Familias Unidas ⫹ PATH, (b) ESOL ⫹ PATH, and (c)
ESOL ⫹ HEART.
Four study hypotheses were advanced. Consistent with Sandler,
Ayers, and Wolchik (2003), hypotheses pertaining to family functioning, the proximal outcome targeted in Familias Unidas, were
examined in terms of change trajectories within the 1-year active
intervention period. Distal outcomes—adolescent cigarette, alcohol, and illicit drug use and unsafe sexual behavior—were examined in terms of change trajectories from baseline to 2 years
postintervention.
Hypothesis 1: Over time, adolescents randomized to Familias
Unidas ⫹ PATH will be less likely to report (a) alcohol use,
(b) cigarette use, and (c) illicit drug use during the 90 days
prior to each assessment point compared with adolescents
randomized to ESOL ⫹ PATH or ESOL ⫹ HEART.
Hypothesis 2: Over time, adolescents randomized to Familias
Unidas ⫹ PATH will be less likely to engage in unprotected
sex during the 90 days prior to each assessment point compared with adolescents randomized to either ESOL ⫹ PATH
or ESOL ⫹ HEART.

PRADO ET AL.

916

Hypothesis 3: Parents randomized to Familias Unidas ⫹
PATH will report greater improvements in family functioning
(comprising parental involvement, parent–adolescent communication, positive parenting, and family support) between
baseline and postintervention than will parents randomized to
either ESOL ⫹ PATH or ESOL ⫹ HEART.

The study was conducted from September 2000 through August
2005. It was approved by the University of Miami social and
behavioral sciences institutional review board and by the research
committee of the Miami–Dade County School Board.3

randomized to one of the three interventions (see Figure 1). Families who satisfied eligibility criteria and who consented (i.e.,
parents) and assented (i.e., adolescents) completed the baseline
assessments.
Participants in the present study were 128 boys and 138 girls
(mean age ⫽ 13.4 years, SD ⫽ 0.68) and their primary caregivers
(34 men, 232 women; mean age ⫽ 40.9 years, SD ⫽ 6.2). Only
18.6% of the families reported household income greater than
$30,000 per year. Forty percent of the adolescents were born in the
United States. Immigrant adolescents (n ⫽ 159) and their parents
were born in Cuba (40%), Nicaragua (25%), Honduras (9%),
Colombia (4%), and other Hispanic countries (22%). Of foreignborn adolescents, exactly half had been living in the United States
for less than 3 years, whereas the other half had been living in the
United States either between 3 and 10 years (n ⫽ 54; 34%) or more
than 10 years (n ⫽ 25; 16%). Parents of U.S.-born adolescents
were born primarily in Nicaragua (33%), Cuba (20%), and Honduras (12%).

Participants

Study Design

Hypothesis 4: Improvements in family functioning during the
intervention will mediate the effects of intervention condition
on alcohol, cigarette, and illicit drug use and unprotected sex
over time.

Method

Adolescents and their families participated in the study in two
cohorts: May 2001–July 2004 and May 2002–July 2005. Recruitment took place during April through June of the adolescents’
seventh-grade year. During recruitment, on several occasions,
study staff visited all seventh-grade homerooms in the three participating middle schools to distribute recruitment flyers to students. The flyer briefly described the study and the potential
benefits associated with participation. Adolescents were asked to
return the letter signed by their parents indicating whether the
parents were interested in learning about the study. Parents who
were interested in learning more about the study were contacted by
project staff. Provided that parents were still interested after speaking with project staff, they and their adolescents were screened for
eligibility. Students entering the eighth grade were selected for two
reasons. First, the transition to ninth grade and high school is a
time of increased risk (Schulenberg, Maggs, & Hurrelmann, 1997)
for substance use and unsafe sexual behavior. Second, the base
rates for these behaviors increase during high school (cf. Johnston
et al., 2007), thus maximizing the likelihood of detecting intervention effects.
Families were eligible to participate provided that (a) at least
one parent was born in a Spanish-speaking country in the Americas, (b) the adolescent was attending one of the three participating
middle schools, (c) the adolescent would advance to the eighth
grade in the next school year, (d) neither the adolescent nor the
primary parent had ever been hospitalized for psychiatric reasons,
(e) the family was not planning to move out of the Miami area
during the 1st year of participation or out of the South Florida area
during the 3 years of the study, (f) the adolescent was living with
an adult primary caregiver who was willing to participate in the
study, and (g) a primary caregiver was available on weekday
evenings to attend weekly meetings. It should be noted that the
mobility rate for these schools was approximately 40%, and approximately 26% of potential participants were ineligible to participate because they were planning to move out of the catchment
area. One parent from each family participated in the study with
the adolescent. Of the 649 potential families, 70 refused to participate. Of the remaining 579, 266 met inclusion criteria and were

The present study used a 3 (condition) ⫻ 5 (time) randomized
controlled design. Participants were assessed at baseline, randomized, and reassessed at 6, 12 (postintervention), 24, and 36 months
postbaseline. The study used an intent-to-treat design, such that
participants continued to be assessed at each timepoint, whether or
not they had dropped out of the intervention. The research coordinator randomized participants to one of three conditions using an
urn randomization (Wei & Lachin, 1988) computer program that
balanced on the following adolescent characteristics: gender; years
in the United States (i.e., 0 –3, 3–10, or more than 10); having
initiated substance use (yes, no); and having initiated (yes, no)
oral, vaginal, or anal sex.

Intervention
The active intervention phase constituted most of the 1st year of
participation. Each condition consisted of two modules. The first
condition consisted of Familias Unidas ⫹ PATH, the second
condition consisted of ESOL ⫹ PATH, and the third condition
consisted of ESOL ⫹ HEART. In each of the three conditions,
families participated in the first module between September and
December and in the second module between January and April.
All intervention conditions were parent centered, with adolescents’
participation in intervention activities limited to a small number of
family visits and parent–adolescent discussion circles in the Familias Unidas and PATH modules. In these family visits, facilitators met separately with each parent and adolescent dyad and
conducted exercises to help the parent enact with the adolescent
the skills learned in the group sessions. Adolescents also participated in parent–adolescent discussion circles. In these parent–
adolescent discussion circles, facilitators met jointly with all of the
parent and adolescent dyads in multifamily group sessions.
All three conditions were designed to deliver an equivalent
dosage of 49 hr, although the number and type of sessions varied.
3
Two serious adverse events were reported to the University of Miami’s
institutional review board. The board concluded that the adverse events
“did not appear to be related to the study.”

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

917

649 potential participants

70 refused to
participate
579 participants were screened

266 Adolescents and their Primary
Caregivers completed baseline
assessment and were randomized

44 were not promoted to the
8th grade
26 were not living within the
catchment area of the three
participating middle schools
163 primary caregivers were
not available to meet at least
once per week
80 families were planning to
move outside of the

catchment area of one of the
three participating middle
schools

91 randomized to Familias
Unidas + PATH

84 randomized to ESOL +
PATH

91 randomized to ESOL +
HEART

80 completed 6-month post
baseline assessment

78 completed 6-month post
baseline assessment

84 completed 6-month post
baseline assessment

75 completed 12-month post
baseline assessment

74 completed 12-month post
baseline assessment

76 completed 24-month post
baseline assessment

71 completed 24-month post
baseline assessment

70 completed 24-month post
baseline assessment

71 completed 36-month post
baseline assessment

70 completed 36-month post
baseline assessment

70 completed 36-month post
baseline assessment

79 completed 12-month post
baseline assessment

Figure 1. Flow of study participants. PATH ⫽ Parent–Preadolescent Training for HIV Prevention; ESOL ⫽
English for Speakers of Other Languages; HEART ⫽ HeartPower! for Hispanics.

In the Familias Unidas ⫹ PATH condition, there were 15 group
sessions, 8 family visits, and 2 parent–adolescent circles. In the
ESOL ⫹ PATH condition, there were 8 ESOL classes, 6 group
sessions, and 2 family visits. In the ESOL ⫹ HEART condition,
there were 8 ESOL classes and 7 group sessions. Each of the four
modules that composed each of the three conditions is described
below.
Familias Unidas. Familias Unidas is a Hispanic-specific,
family-based preventive intervention designed to reduce risk for
and increase protection against substance use and sexual risk
behaviors in Hispanic adolescents. Hispanic-specific cultural is-

sues are integrated in all aspects of the intervention, from the
underlying theoretical model to the specific content of the intervention to the format of the intervention activities (Pantin et al.,
2003, 2004). Familias Unidas is guided by ecodevelopmental
theory (Szapocznik & Coatsworth, 1999). Ecodevelopmental theory borrows from and extends Bronfenbrenner’s (1986; Szapocznik & Coatsworth, 1999) social ecological framework. Consistent
with ecodevelopmental theory, Familias Unidas aims to prevent
substance use and sexual risk behaviors by (a) increasing parental
involvement in the adolescent’s life, (b) increasing family support
for the adolescent, (c) promoting positive parenting, and (d) im-

918

PRADO ET AL.

proving parent–adolescent communication (see Pantin et al., 2004,
for more details on the intervention).
PATH. PATH (Krauss et al., 2000) is a theoretically based
HIV prevention curriculum designed to promote responsible sexual behavior by training parents to become effective HIV educators for their children. PATH is designed to increase parents’ and
adolescents’ knowledge about HIV and to promote parent–
adolescent communication about HIV risks. PATH was originally
designed for a multicultural sample that included Hispanics and
was later adapted specifically for use with a Hispanic sample. One
example of a cultural adaptation is the use of an induction video.
This induction video used a Spanish telenovela, the equivalent of
an American soap opera, to address the cultural taboos regarding
discussing sexuality or HIV.
HEART. HEART is designed to reduce adolescents’ risk for
cardiovascular disease and to promote adolescent cardiovascular
health by (a) increasing awareness of cardiovascular risk factors,
such as cigarette use, and (b) improving attitudes toward exercise
and nutrition. HEART encourages parents to be involved in their
adolescents’ cardiovascular health, but it is not specifically designed to reduce risk for adolescent illicit drug use or unsafe sexual
behavior.
ESOL. The ESOL classes aimed to help parents communicate
more effectively in English. It was expected that parents would be
interested in this module because the majority of them were
monolingual and had no working knowledge of English.
Combinations of modules for the interventions. The experimental intervention consisted of the Familias Unidas and PATH
modules. The first control condition consisted of the ESOL and
PATH modules. The inclusion of ESOL in the first control condition (ESOL ⫹ PATH) controlled for the dosage and participant
contact in Familias Unidas. This condition was designed to evaluate whether parent–adolescent discussions about sexuality are
best facilitated after promotion of general family communication
and other positive family processes (e.g., positive parenting). In
the second control condition, participants received both the ESOL
and the HEART modules. HEART was chosen as a control for
PATH because it does not target HIV risks directly and controls
for the dosage and participant contact in PATH. As a result, the
third control condition served as an attention control for both
Familias Unidas and PATH. The Familias Unidas, PATH, and
HEART modules were all delivered in Spanish. Because ESOL
was designed to teach English skills, it was delivered in both
languages.

Facilitators and Training of Facilitators
Three Hispanic facilitators (two master’s and one doctoral level)
conducted the intervention sessions in Familias Unidas, PATH,
and HEART. Prior to conducting intervention activities, facilitators had an average of 5 years’ clinical experience working with
urban, low-income Hispanic immigrant families. Facilitators were
trained and certified in Familias Unidas and PATH by the treatment developers, Dr. Hilda Pantin in Familias Unidas and Dr.
Beatrice Krauss in PATH, for 3 months using the respective
intervention manuals (Krauss et al., 2000; Pantin et al., 2004).
Facilitators were trained in HEART using an intervention manual
developed by the American Heart Association (1996). ESOL
classes were conducted by certified ESOL instructors from the

local public school system to ensure that it was delivered by
individuals with considerable expertise in language instruction.
ESOL instructors did not receive any training or certification from
the staff affiliated with the present study.
Familias Unidas, PATH, and HEART facilitators also received
training in general group processes (e.g., promoting group cohesiveness). After completing their training, facilitators conducted
pilot groups and pilot family visits with 54 families, 18 each for
Familias Unidas, PATH, and HEART. These pilot families were
recruited from the same schools and on the basis of the same
inclusion and exclusion criteria as those recruited for the primary
study. Facilitators needed to achieve a minimum of 80% adherence
to be certified in the respective intervention module. The 54 pilot
cases were not among the families randomized to condition or on
whom outcome data are reported. Families participating in the
pilot study were asked to provide feedback as to the cultural
appropriateness of each of the intervention modules. Families
characterized all intervention modules as culturally appropriate.

Adherence and Fidelity
All intervention sessions in the Familias Unidas, PATH, and
HEART modules were videotaped with participants’ consent. To
assess adherence to the modules, independent raters, blind to
condition, rated all of the videotaped group sessions and parent–
adolescent discussion circles in each condition as well as 25% of
the individualized family visits. Observational adherence measures
were developed to identify key (prescribed) facilitator behaviors
that were planned for each session in each of the intervention
modules. For example, in one of the PATH group sessions, examples of prescribed facilitator behaviors included “guiding group in
developing a plan for talking with children about HIV/AIDS,”
“introducing and leading activities to demonstrate and practice
safety skills,” and “reviewing and updating new information about
HIV/AIDS.” Additionally, because the PATH intervention module
was group-process oriented (as were Familias Unidas and
HEART), key facilitator prescribed behaviors also included “joins
all members of the groups” and “establishes group member alliances.” All facilitator prescribed behaviors were rated on an extensiveness/quality rating ranging from 0 ⫽ not at all/very poor to
6 ⫽ extensively/excellent. The average extensiveness/quality rating
for all three intervention modules was considerably/good. The
average adherence ratings were 3.72 (SD ⫽ 0.48) for Familias
Unidas, 3.64 (SD ⫽ 0.31) for PATH, and 3.70 (SD ⫽ 0.45) for
HEART. There were no significant differences in adherence ratings by intervention module, F(2, 154) ⫽ 0.73, p ⫽ .49. Interrater
reliability for the adherence measures was satisfactory (␬ ⫽ .75)

Procedures
Adolescent measures were completed on laptop computers with
the audio computer-assisted self-interview system (Turner, Rogers, Lindberg, Pleck, & Sonenstein, 1998). The content of each
questionnaire item, along with the response choices, was read to
the adolescent through a set of headphones connected to a laptop
computer. The adolescent indicated her or his response using the
keyboard or mouse. Parent assessments were completed in interview form with a trained Hispanic interviewer. To minimize potential interviewer bias, interviewers were blind to condition. Dif-

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

ferent methods were used for adolescent versus parent assessments
because, during the pilot phase, many parents expressed considerable discomfort about completing their assessments on computer.
Families were compensated $20, $25, $30, $35, and $40 for
completing the baseline, 6-, 12-, 24-, and 36-month postbaseline
assessments, respectively. Families were also eligible for transportation reimbursements (maximum $30 per assessment) to complete
the assessments in our offices. All payments were given to the
parents.

Measures
The measures reported in this article were part of a larger
assessment battery, which ranged from 60 to 90 min for adolescents and 45 to 60 min for parents. Parents and adolescents
completed the battery in the language of their choice (Spanish or
English). All measures were translated into Spanish by integrated
back translation and committee resolution approaches, as recommended by Kurtines and Szapocznik (1995). Fifty-nine percent of
adolescents completed their assessments in English, whereas all
parents completed their assessments in Spanish.
Demographics. Adolescents and parents completed a demographics form on which they provided their date and country of
birth, number of years lived in the United States, and national
origin. Parents were also asked about their marital status and
household income.
Acculturation. The Bicultural Involvement Questionnaire—
Revised (Birman, 1998; Szapocznik & Kurtines, 1980) was used to
assess adolescents’ and parents’ levels of orientation toward
American and Hispanic culture. This measure assesses Americanism and Hispanicism in terms of both (a) comfort and enjoyment
with American and Hispanic cultural practices (e.g., comfort and
use of language, food, and traditions) and (b) how much participants would want or like to utilize American and Hispanic cultural
practices. Twenty of the 21 Americanism and Hispanicism items
(all except language use at work) were used for adolescents, and 20
of the 21 Americanism and Hispanicism items (all except language
use at school) were used for parents. Each item on both the
Americanism and the Hispanicism subscales was rated on a
5-point Likert scale, with higher scores on each of the two subscales representing more of an orientation to the respective culture.
In the present sample, Cronbach’s alpha coefficients for Americanism and Hispanicism scores were .92 and .90, respectively, for
adolescents and .91 and .89, respectively, for parents.
Family functioning. Parent reports of family functioning were
assessed with four indicators: parental involvement, positive parenting, family support, and parent–adolescent communication. Parental involvement (12 items; ␣ ⫽ .78) and positive parenting (6
items; ␣ ⫽ .71) were assessed via the corresponding subscales
from the Parenting Practices Scale (Gorman-Smith, Tolan, Zelli, &
Huesmann, 1996). Family support (6 items; ␣ ⫽ .49) was assessed
via the corresponding subscale from the Family Relations Scale
(Tolan, Gorman-Smith, Huesmann, & Zelli, 1997a).4 Parent–
adolescent communication (20 items; ␣ ⫽ .85) was assessed with
the Parent–Adolescent Communication Scale (Barnes & Olson,
1985). At each timepoint, we computed a Family Functioning
factor score by taking the participant’s standardized score on each
of the family functioning indicators, multiplying this standardized

919

score by the corresponding factor loading for the indicator, and
summing these four weighted indicators.
Substance use. Substance use was assessed with items similar
to those used in the Monitoring the Future Study, a national
epidemiologic study to assess the prevalence of substance use in
the United States (Johnston et al., 2007). At each assessment,
adolescents were asked whether they had ever smoked, drunk
alcohol, or used an illicit drug in their lifetime and in the 90 days
prior to assessment.5 Adolescents who responded “yes” to having
used an illicit drug in the past 90 days were asked about the
frequency of their use of a variety of drugs, including marijuana,
cocaine, amphetamines, methamphetamines, and barbiturates.
Sexual risk behaviors. Sexual risk behaviors were measured
with items from Jemmott et al.’s (1998) Sexual Behavior instrument. At each assessment timepoint, adolescents were asked to
indicate whether they had ever had sex in their lifetime and in the
90 days prior to assessment. Adolescents who reported having had
sex in the past 90 days were asked whether they had engaged in
unprotected sex (i.e., sex without a condom) during that time.
Adolescents who reported ever having sex were also asked
whether they had engaged in unprotected sex at last intercourse,
had consumed alcohol or drugs before their last sexual intercourse,
and had ever contracted a sexually transmitted disease.

Results
Sample Size Calculations
When we estimated 20% attrition over the 36-month follow-up
period and set the Type I error rate at .05 (for a two-tailed test),
with 80% power, 240 participants were required across the three
study conditions to detect an Intervention ⫻ Time effect size
equivalent to d ⫽ 0.28 (Cohen, 1988).

Data Analytic Strategy
Mplus Version 3.12 (Muthe´n & Muthe´n, 2005) was used to test
the study hypotheses.
Hypotheses 1, 2, and 3. Tests of Hypotheses 1, 2, and 3 were
conducted via growth curve modeling. Growth curve analyses
were used to estimate individual trajectories of change and to test
for slope differences among the three study conditions over time.
Growth curve modeling is more powerful and versatile than repeated measures analysis of variance because it allows for missing
data, with the assumption that the data are missing at random
(Little & Rubin, 1987). In these analyses, Familias Unidas ⫹
PATH served as the reference group, so that each control condition
(i.e., ESOL ⫹ PATH and ESOL ⫹ HEART) was compared with
Familias Unidas ⫹ PATH. Therefore, the coefficients obtained for
the ESOL ⫹ HEART and ESOL ⫹ PATH conditions indicate the
direction and degree to which each condition differs from the
Familias Unidas ⫹ PATH condition on the outcome in question.
For each of the four distal outcomes, data from all five assessment
4

This low alpha is consistent with the alpha reported in the validation
study of this measure (Tolan, Gorman-Smith, Husemann, & Zelli, 1997b).
5
Past-90-day outcomes are commonly reported in randomized controlled trials involving HIV preventive interventions (e.g., DiClemente et
al., 2004; Jemmott, Jemmott, & Fong, 1998).

PRADO ET AL.

920

Table 1
Baseline Comparisons of Demographic Characteristics and Outcome Variables by Intervention Condition
Familias Unidas ⫹ PATH
(n ⫽ 91)
Variable
Gender
Male
Female
Age
Years in the United States
0–3
3–10
⬎10
Family income
$0–$9,999
$10,000–$19,999
$20,000–$29,999
⬎$30,000
Not reported
Adolescent’s Americanism
Adolescent’s Hispanicism
Parent’s Americanism
Parent’s Hispanicism
Family Functioning factor score
Parent-adolescent communication
Family support
Parental involvement
Positive parenting
Past-90-day cigarette use (binary)
Past-90-day alcohol use (binary)
Past-90-day illicit drug use (binary)
Frequency of past-90-day illicit drug use
Past-90-day unprotected sex (binary)

n (%)

M (SD)

39 (43)
52 (57)

ESOL ⫹ PATH
(n ⫽ 84)
n (%)

M (SD)

42 (50)
42 (50)
13.36 (0.67)

ESOL ⫹ HEART
(n ⫽ 91)
n (%)

M (SD)

47 (52)
44 (48)
13.40 (0.72)

.45
13.49 (0.66)

31 (34)
18 (20)
42 (46)

25 (30)
24 (29)
35 (41)

27 (30)
17 (19)
47 (52)

20 (22)
34 (37)
20 (22)
14 (15)
3(3)

21 (25)
23 (27)
22 (26)
18 (21)

27 (30)
30 (33)
18 (20)
16 (18)

p

.41
.46

.67

73.31 (14.13)
67.30 (12.95)
48.56 (13.41)
81.16 (11.40)
⫺1.0 (1.0)
77.3 (8.4)
18.5 (3.3)
34.3 (4.2)
16.5 (1.6)
3 (3.3)
9 (10.0)
2 (2.2)

73.99 (14.31)
65.73 (13.15)
49.78 (12.42)
79.19 (11.44)
0.04 (1.0)
78.0 (8.9)
19.0 (2.3)
34.7 (3.7)
16.7 (1.8)
1 (1.2)
9 (10.7)
6 (7.1)

0.43 (3.69)
0 (0)

75.12 (13.57)
64.62 (14.64)
51.35 (15.83)
78.89 (12.67)
0.06 (0.9)
77.0 (9.4)
18.8 (3.0)
34.9 (3.1)
16.9 (1.8)
3 (3.3)
8 (8.8)
3 (3.3)

0.16 (0.81)
N/Aa

0.07 (0.54)
1 (50)

.68
.42
.41
.38
.57
.75
.55
.65
.46
.71
.91
.29
.52
1.00

Note. PATH ⫽ Parent-Preadolescent Training for HIV Prevention; ESOL ⫽ English for Speakers of Other Languages; HEART ⫽ HeartPower! for
Hispanics.
a
There were no participants in this condition who reported engaging in past-90-day sexual behavior at baseline, and hence this item does not apply.

points (baseline and 6, 12, 24, and 36 months postbaseline) were
used. Because the substance use outcomes were binary, the categorical option in Mplus, which uses a logit link to analyze binary
data, was used. For family functioning, which was a proximal
outcome and was expected to change primarily during the active
intervention period, analyses focused on changes between baseline
and 12 months postbaseline.
Hypothesis 4. Mediational analyses were planned to examine
whether significant changes in family functioning (if any) might
have mediated the effect of the intervention on any of the four
distal outcomes: past-90-day alcohol use, past-90-day cigarette
use, past-90-day illicit drug use, and past-90-day unprotected sex.
For each outcome for which the effect of condition was statistically significant, a growth curve controlling for the slope of family
functioning was then estimated (Cheong, MacKinnon, & Khoo,
2003). For each outcome, mediation was assumed if the path from
intervention condition to the slope of the outcome variable was
reduced to nonsignificance when the slope of family functioning
was added to the model.

Comparability of Conditions
Chi-square tests and analyses of variance indicated no significant differences by intervention on any of the demographic char-

acteristics; acculturation (Americanism and Hispanicism); family
functioning; or alcohol use, cigarette use, illicit drug use, or
unprotected sex in the 90 days prior to the baseline assessment (see
Table 1).

Tests of Hypotheses
Hypothesis 1a: Alcohol use. Growth curve analyses showed
no significant differences in past-90-day alcohol use between
Familias Unidas ⫹ PATH and either of the other conditions.6
Hypothesis 1b: Cigarette use. Growth curve analyses indicated significant differences in past-90-day cigarette use between
Familias Unidas ⫹ PATH and ESOL ⫹ PATH (z ⫽ 3.25, p ⬍
.002; d ⫽ 0.54) as well as between Familias Unidas ⫹ PATH and
ESOL ⫹ HEART (z ⫽ 2.66, p ⬍ .008; d ⫽ 0.80). The mean
trajectory of smoking in Familias Unidas ⫹ PATH decreased,
while the mean trajectories of smoking increased in both ESOL ⫹
PATH and ESOL ⫹ HEART. The observed percentages (see
Figure 2) indicate that at the 36-month postbaseline assessment,
6
Growth curve analyses controlling for dosage were estimated and were
virtually identical. The results for all analyses are available from Guillermo
Prado.

Percent Reporting Smoking in the Past 90 Days

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

921

16
14
12

Familias Unidas+PATH

10
ESOL+PATH
8
ESOL+HEART

6
4
2
0
baseline

6

12

24

36

Months Since Baseline

Figure 2. Past-90-days smoking by condition. PATH ⫽ Parent–Preadolescent Training for HIV Prevention;
ESOL ⫽ English for Speakers of Other Languages; HEART ⫽ HeartPower! for Hispanics.

1.4% of the adolescents in Familias Unidas ⫹ PATH reported
smoking in the 90 days prior to assessment, compared to 10% in
ESOL ⫹ PATH and 14.3% in ESOL ⫹ HEART.
Hypothesis 1c: Illicit drug use. Growth curve analyses indicated significant differences in past-90-day illicit drug use between
Familias Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽ 2.02, p ⬍
.05; d ⫽ 0.58). No significant differences were observed between
Familias Unidas ⫹ PATH and ESOL ⫹ PATH (z ⫽ 1.07, p ⫽ .28;
d ⫽ 0.05). The observed mean frequency of illicit drug use
decreased in Familias Unidas ⫹ PATH but increased in ESOL ⫹
HEART between 24 and 36 months postbaseline (see Figure 3).
Hypothesis 2: Unprotected sexual behavior. Growth curve
analyses were not estimated for past-90-day unprotected sex given
the small number of participants engaging in sexual behavior in the
past 90 days. However, Fisher’s exact tests conducted at each
timepoint indicated that there were no significant differences by
condition for this outcome.
Hypothesis 3: Family functioning. Growth curve analyses indicated significant differences in family functioning between Familias Unidas ⫹ PATH and ESOL ⫹ PATH (z ⫽ ⫺2.47, p ⬍ .02;
d ⫽ 0.28) and between Familias Unidas ⫹ PATH and ESOL ⫹
HEART (z ⫽ ⫺3.52, p ⬍ .0005; d ⫽ 0.38). The mean trajectory
of family functioning in Familias Unidas ⫹ PATH increased,
while the mean trajectories of family functioning decreased in both
ESOL ⫹ PATH and ESOL ⫹ HEART (see Figure 4 for observed
means).7
Hypothesis 4. Mediational analyses were conducted to determine whether family functioning mediated the effects of intervention on past-90-day smoking and illicit drug use. Mediational
analyses were not conducted on past-90-day alcohol use or past90-day unprotected sexual intercourse, because there were no
significant intervention effects on these outcomes.
When the slope of family functioning on the growth curve of
smoking was controlled, the results indicated that neither the
growth trajectories between Familias Unidas ⫹ PATH and
ESOL ⫹ PATH (z ⫽ 1.32, ns) nor those between Familias Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽ 1.11, ns) differed
significantly. Thus, changes in family functioning partially mediated the effect of intervention condition on smoking. Similarly,

when the slope of family functioning was controlled, results indicated that differences in the growth trajectories for illicit drug use
between Familias Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽
1.28, p ⫽ .20) were no longer significantly different. Thus,
changes in family functioning partially mediated the effect of
intervention on illicit drug use.

Post Hoc Analyses
Decomposition of family functioning. The significant omnibus
effect of intervention condition on family functioning was then
followed up with post hoc exploratory analyses. Because these
exploratory post hoc analyses were applied only after the overall
omnibus test was significant, Bonferroni corrections were not
applied (Hedeker & Gibbons, 2006). In these analyses, we decomposed the Family Functioning factor score into its four component
indicators (parent involvement, family support, positive parenting,
and parent–adolescent communication) to explore the specific
aspects of family functioning on which Familias Unidas ⫹ PATH
differed significantly from the other conditions. Growth curve
analyses indicated significant differences in positive parenting
between Familias Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽
⫺1.97, p ⬍ .05; d ⫽ 0.12) and between Familias Unidas ⫹ PATH
and ESOL ⫹ PATH (z ⫽ ⫺2.03, p ⬍ .05; d ⫽ 0.21). The mean
trajectory of positive parenting in Familias Unidas ⫹ PATH increased, while the mean trajectories of positive parenting decreased in both ESOL ⫹ PATH and ESOL ⫹ HEART. Significant
differences also emerged for parent–adolescent communication.
The mean trajectory of parent–adolescent communication in Familias Unidas ⫹ PATH increased, while the mean trajectory of
parent–adolescent communication decreased in ESOL ⫹ PATH
(z ⫽ ⫺2.43, p ⬍ .02; d ⫽ 0.26). No significant difference was
observed in the growth trajectories for parent–adolescent commu7
Because of the low reliability in family support, analyses were conducted both with and without the Family Support subscale, and the results
were virtually identical. However, because of the theoretical importance of
family support within ecodevelopmental theory and within Familias Unidas, the subscale was retained in analysis.

PRADO ET AL.
Frequency of Illicit Drug Use in the Past 90 Days

922

1.6
1.4
Familias
Unidas+PATH
ESOL+PATH

1.2
1
0.8
0.6

ESOL+HEART

0.4
0.2
0
baseline

6

12

24

36

Months Since Baseline
Figure 3. Past-90-days illicit drug use by condition. PATH ⫽ Parent–Preadolescent Training for HIV
Prevention; ESOL ⫽ English for Speakers of Other Languages; HEART ⫽ HeartPower! for Hispanics.

nication between Familias Unidas ⫹ PATH and ESOL ⫹ HEART.
Additionally, no significant differences by condition emerged for
parental involvement or family support.
Mediation analysis: Positive parenting and parent–adolescent
communication. We conducted post hoc analyses to determine
whether positive parenting and parent–adolescent communication
mediated the effects of intervention on past-90-day smoking and
illicit drug use. When we controlled for the slope of positive
parenting on the growth curve of smoking, differences in the
growth trajectories between Familias Unidas ⫹ PATH and
ESOL ⫹ PATH (z ⫽ 1.45, p ⫽ .15) and between Familias
Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽ 1.10, p ⫽ .27) were
reduced to nonsignificance. Similarly, when we controlled for the
slope of parent–adolescent communication, the differences in the
growth trajectories for smoking between Familias Unidas ⫹
PATH and ESOL ⫹ PATH (z ⫽ 1.27, p ⫽ .20) were reduced to
nonsignificance. This suggests that changes in positive parenting
and changes in parent–adolescent communication each partially
mediated the intervention effect on smoking.
When we controlled for the slope of positive parenting, differences in the growth trajectories for illicit drug use between Familias Unidas ⫹ PATH and ESOL ⫹ HEART (z ⫽ 1.34, p ⫽ .18)
were reduced to nonsignificance. Analyses to determine whether
parent–adolescent communication mediated the intervention effects on illicit drug use were not conducted because there were no
significant differences between Familias Unidas ⫹ PATH and
ESOL ⫹ HEART on parent–adolescent communication and no
significant differences between Familias Unidas ⫹ PATH and
ESOL ⫹ PATH on illicit drug use (as reported in the test of
Hypothesis 1c).
Substance use initiation. We conducted post hoc analyses to
explore whether rates of substance use initiation (i.e., smoking,
alcohol, and drug use) significantly differed by condition.8 The
results indicated that smoking initiation rates were significantly
different by condition, ␹2(2, N ⫽ 218) ⫽ 6.79, p ⬍ .04 (w ⫽ .18).
Fewer adolescents in Familias Unidas ⫹ PATH (8 out of 74;
10.8%) reported initiating smoking during the course of the study
(i.e., from 6 months to 3 years postbaseline), compared to adolescents in ESOL ⫹ PATH (18 out of 74; 24.3%) and ESOL ⫹
HEART (19 out of 70; 27.1%). No significant differences in
initiation rates were observed for alcohol use or illicit drug use.

Sexual risk behaviors. We conducted post hoc analyses to
explore differences by intervention condition on incidence of
STDs and two additional HIV risk behaviors measured by the
Youth Risk Behavior Surveillance Survey: (a) unprotected sex at
last sexual intercourse and (b) alcohol or drug use before last
sexual intercourse.9 The incidence of STDs in Familias Unidas ⫹
PATH (0 out of 80; 0%) was significantly lower than that for
adolescents in ESOL ⫹ PATH (1 out of 81; 1.2%) and ESOL ⫹
HEART (5 out of 85; 5.9%), Fisher’s exact p ⫽ .05. Readers
should use caution when interpreting this finding, given the small
number of participants reporting STD contraction. A significant
difference also emerged, ␹2(1, N ⫽ 53) ⫽ 3.87, p ⬍ .05 (w ⫽ .27),
in unsafe sex at last sexual intercourse between Familias Unidas ⫹
PATH and ESOL ⫹ PATH, with 19.2% (or 5 out of 26) of the
adolescents in Familias Unidas ⫹ PATH and 44.4% (or 12 out of
27) in ESOL ⫹ PATH reporting unsafe sexual intercourse. No
other significant differences were found.

Discussion
The purpose of the present study was to evaluate the efficacy of
Familias Unidas ⫹ PATH, a parent-centered, ecodevelopmentally
based intervention, in preventing substance use and unsafe sexual
behavior in Hispanic adolescents. To our knowledge, the present
study is the first to examine the efficacy of a culturally specific
intervention in preventing both substance use and sexual risk
behaviors in this rapidly growing and at-risk population.
Familias Unidas ⫹ PATH was efficacious in preventing smoking initiation and in reducing cigarette and illicit drug use, moderately efficacious in preventing unsafe sexual behavior, and not
efficacious in preventing or reducing alcohol use. The effects of
Familias Unidas ⫹ PATH on cigarette and illicit drug use were
partially mediated by improvements in family functioning.
8

For each of the respective analyses, adolescents were excluded if they
indicated the behavior at baseline. For example, adolescents who reported
having smoked at baseline were excluded from the smoking initiation
analyses.
9
There were no participants in this condition who reported engaging in
past-90-day sexual behavior at baseline, and hence this item does not
apply.

Mean Family Functioning Score

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

0.25
0.2
0.15
0.1
0.05
0
-0.05
-0.1
-0.15
-0.2

923

Familias
Unidas+PATH
ESOL+PATH
ESOL+HEART

baseline

6

12

Months Since Baseline
Figure 4. Family functioning factor score by condition. PATH ⫽ Parent–Preadolescent Training for HIV
Prevention; ESOL ⫽ English for Speakers of Other Languages; HEART ⫽ HeartPower! for Hispanics.

These findings affirm the importance of family functioning in
the prevention of substance use. There is evidence that family
processes are irrevocably intertwined with the development of
substance use (e.g., Sale et al., 2005) and that family-based interventions are among the most efficacious modalities in preventing
adolescent substance use (Tobler et al., 2000). The present results
also suggest important differences among family processes in
protecting Hispanic adolescents from specific negative health outcomes. It is noteworthy that only two of the four family processes
assessed—positive parenting and parent–adolescent communication—were associated with significant differences favoring Familias Unidas ⫹ PATH. Parental involvement and family support,
for which differential efficacy was not found, increased in all three
conditions. All three conditions encouraged parents to be involved
in their adolescents’ lives and to offer them support. However,
only the Familias Unidas module focused specifically on improving positive parenting and parent–adolescent communication. This
suggests that the favorable outcomes evident in Familias Unidas ⫹
PATH, relative to the other two conditions, may be attributable to
Familias Unidas and not PATH. Nevertheless, future research is
needed to support definitive conclusions regarding the efficacy of
Familias Unidas without PATH.
Examining the trajectories of cigarette and illicit drug use across
conditions suggests that the preventive effects of Familias Unidas ⫹ PATH emerged most strongly at the 2-year follow-up. This
finding is consistent with other studies (e.g., Wolchik et al., 2002)
that have found delayed effects of preventive interventions delivered in early adolescence. The present finding, along with the
results reported by Wolchik et al., suggest that effects of preventive interventions may only become apparent after several years
postintervention. Such sleeper effects may be a function of developmental increases in base rates of the target behaviors.
Although Familias Unidas ⫹ PATH was efficacious relative to
the control conditions in preventing cigarette smoking and illicit
drug use, it was not efficacious in preventing alcohol use. With
regard to alcohol use, the results from this study are consistent with
those of Martinez and Eddy (2005), whose Hispanic-specific prevention program was efficacious in decreasing the likelihood of
tobacco, but not alcohol, use in a sample of primarily Mexican
American adolescents. Further research is needed to understand
these results.
Regarding prevention of unsafe sexual behavior, sexually active
adolescents in Familias Unidas ⫹ PATH reported having been

significantly more likely to use a condom at last sexual intercourse
than their counterparts in ESOL ⫹ PATH. Moreover, adolescents
in Familias Unidas ⫹ PATH were significantly less likely to report
having contracted sexually transmitted diseases than were adolescents in the other conditions. Although the PATH module specifically targeted HIV risks, including unprotected sexual behavior,
the present finding suggests that, for Hispanic adolescents, discussions about HIV risks may be most beneficial when delivered
following an intervention that improves family functioning. If
general parent–adolescent communication and other aspects of
positive family functioning are not first targeted, facilitating
parent–adolescent discussions about sexuality and HIV may produce iatrogenic results. However, the condition differences in
condom use at last sexual intercourse must be interpreted with
caution, given that no effects were found for past-90-day unprotected sexual intercourse. It is important to note, however, that this
lack of statistical significance might have been due, at least in part,
to the small number of participants reporting past-90-day unprotected sexual intercourse.
Another important observation from this study is that the Familias Unidas ⫹ PATH intervention produced favorable outcomes
in the adolescents, even though the majority of the intervention
sessions were delivered only to the parents. This finding is consistent with other studies that have found that adolescent behaviors
can be altered even when the majority of intervention sessions are
delivered to parents (e.g., Martinez & Eddy, 2005; Pantin et al.,
2003) and place parents in the change agent role. Moreover, the
consistency of these findings with those using non-Hispanic samples (e.g., Brody et al., 2006; Spoth, Guyll, Chao, & Molgaard,
2003) suggests that the efficacy of parent-based interventions in
preventing adolescent substance use and unsafe sexual behavior
may generalize across ethnic groups.
Finally, it was surprising that the ESOL ⫹ HEART condition, in
which the HEART module was specifically designed to prevent
cardiovascular risk behaviors, such as cigarette smoking, was less
efficacious in preventing smoking than Familias Unidas ⫹ PATH,
in which smoking was not directly addressed. Of similar interest is
the fact that ESOL ⫹ PATH, in which the PATH module was
specifically designed to target HIV risks, was not efficacious in
preventing unsafe sexual intercourse. However, Familias Unidas ⫹ PATH was efficacious in preventing both cigarette smoking
and unsafe sexual behavior at last intercourse. These findings
suggest that targeting specific health behaviors in the context of

924

PRADO ET AL.

strengthening the family system may be most efficacious in preventing or reducing cigarette smoking and unsafe sex in Hispanic
adolescents.

Limitations
The present results should be considered in light of several
important limitations. First, the study would have benefited from
the inclusion of an inert control condition. Although attention
control modules were used to control for the effects of dosage and
nonspecific parent group processes, such as social support, these
attention control modules might have inadvertently affected some
of the study variables and might have reduced the power to detect
the efficacy of Familias Unidas ⫹ PATH. At least one module in
each condition encouraged parents to spend time with their adolescents and to teach them specific strategies or behaviors. For
example, in HEART, parents were prompted to be involved in
their adolescents’ physical fitness and health decisions. In PATH,
parents were prompted to educate their adolescents about safe
versus unsafe sexual behavior. Perhaps as a result, improvements
in parental involvement and in family support were observed
across all conditions.
Another limitation is that the present sample was not representative of the U.S. Hispanic population, and hence the results should
not be generalized to all Hispanic adolescents. The U.S. Hispanic
population is composed mostly of Mexican Americans, who represent 65% of all legal U.S. Hispanic residents (Marotta & Garcia,
2003) and a large majority of unauthorized migrants (Bean, Corona, Tuiran, Woodrow-Lafield, & Van Hook, 2001). This subpopulation of Hispanics was not well represented in our study. It
is important, then, to replicate the present results with a representative sample of Hispanic adolescents and their families.
Third, as in all prevention studies, participants were those who
consented and assented to participate in the study. Self-selection
biases may be associated with such samples, in that participants
who enroll in the intervention may have better functioning families
than those who do not enroll (Perrino, Coatsworth, Briones, Pantin, & Szapocznik, 2001). Because informed consent was obtained
only from families who were screened and determined to be
eligible for the study, it was not possible to compare the randomized sample to the screened sample or to the population of students
in the participating schools. Without information about those who
refused to participate and those who were excluded, it is unclear
how much this sample represents even the local population from
which participants were recruited.
A fourth limitation is the reliance on self-report measures.
Self-report measures are vulnerable to social desirability effects.
Direct observations of parent–adolescent interactions and standardized observational ratings of these interactions across all participating families may help to provide a better representation of
the targeted constructs. Self-report measures may also present
problems with regard to drug and alcohol use and to sexually
transmitted diseases. Although self-reports tend to converge reasonably well with biomarkers of drug use in minority adolescents
(Dillon, Turner, Robbins, & Szapocznik, 2005), there is evidence
that some adolescents provide false-negative reports of drug use
(Santisteban et al., 2003). However, prior research (e.g., Metzger
et al., 2000) has found that audio computer-assisted self-interview,
the method of administration used in this study, increases the

veracity of responding. Finally, some adolescents may not be
aware that they have a sexually transmitted disease, and those who
are aware may not be willing to disclose this information.
Fifth, continuous data were not collected for smoking and alcohol use at each timepoint. Although fairly strong effects for cigarette smoking were found favoring Familias Unidas ⫹ PATH, the
collection of dichotomous data on alcohol use substantially limited
the possibility of uncovering intervention effects on this outcome.
It is recommended that future studies include more sensitive measures of alcohol use, consistent with those now conventional in the
adolescent alcohol treatment literature.
Sixth, adolescents were involved, however minimally, in Familias Unidas, PATH, and HEART but not involved at all in the
ESOL module. Because ESOL was included in both control conditions, differential levels of adolescent exposure cannot be ruled
out as having contributed to the findings. However, an alternative
explanation, consistent with ecodevelopmental theory, suggests
that family functioning is the mechanism that produces changes in
adolescent outcomes. The present results support this interpretation, given that changes in family functioning mediated the effects
of intervention condition on adolescent substance use outcomes. It
is possible that the youths’ presence in intervention sessions facilitated improvements in family functioning because the parents
were able to rehearse their newly acquired parenting skills in vivo
(i.e., with the adolescent).

Conclusions and Future Directions
Despite these limitations, the present study may have important
practical implications for clinical practice as well as for research.
For practice, it is clear that working primarily with parents may be
an especially effective strategy for preventing or reducing negative
behaviors among Hispanic adolescents and perhaps among adolescents in general. Improving family functioning— especially
parent–adolescent communication and positive parenting—is critical in preventing substance use and unsafe sex in Hispanic adolescents. Educating parents and adolescents about risks associated
with substance use and with unsafe sex appears to be less effective,
especially without attention to family functioning beforehand.
For research, the present results suggest that Familias Unidas ⫹
PATH is efficacious in preventing cigarette and illicit drug use and
unsafe sex and that the intervention operates, in part, through
improvements in family functioning. There are at least two future
directions that follow from this study. First, given the sharp rise in
rates of substance use in emerging adulthood (Arnett, 2004), it is
important to track the efficacy of Familias Unidas ⫹ PATH and
similar interventions in preventing substance use into emerging
adulthood. Second, it is important to examine the efficacy of
Familias Unidas ⫹ PATH across different subgroups of Hispanic
adolescents. As discussed by Pantin, Prado, Schwartz, and Sullivan (2005) and Prado et al. (2006), Hispanic adolescents differ not
only by nationality and immigrant generation but also by risk and
protective processes, such as positive parenting and parent–
adolescent communication. It is therefore important to identify and
examine subgroups of adolescents for whom Familias Unidas ⫹
PATH is more or less efficacious. This work is currently underway
(Grant DA019101; Guillermo Prado, principal investigator).
In conclusion, the present results suggest that Familias Unidas ⫹ PATH may have the potential to help reduce the disparities

SUBSTANCE USE AND HIV PREVENTION FOR HISPANIC YOUTH

in substance use and HIV rates between Hispanic adolescents and
those from other ethnic groups by preventing and reducing substance use and sexual risk behaviors in Hispanic adolescents.
These results suggest that a culturally specific, parent-centered
intervention may be efficacious in preventing or reducing health
risk behaviors in this rapidly growing and vulnerable population.

References
American Heart Association. (1996). Heartpower: Learn it! Live it! Love
it!: A teacher resource [American Heart Association Schoolsite Program]. Washington, DC: Author.
Arnett, J. J. (2004). Emerging adulthood: The winding road from the late
teens through the twenties. Oxford, England: Oxford University Press.
Barnes, H. L., & Olson, D. H. (1985). Parent-adolescent communication
and the circumplex model. Child Development, 56, 438 – 447.
Bean, F. D., Corona, R., Tuiran, R., Woodrow-Lafield, K. A., & Van Hook,
J. (2001). Circular, invisible, and ambiguous migrants: Components of
difference in estimates of the number of unauthorized Mexican migrants
in the United States. Demography, 38, 411– 422.
Bernstein, R. (2007). Minority population tops 100 million. Retrieved May
17, 2007, from http://www.census.gov/dcmd/www/embargo/popest/
national/pio-nat_stat.html
Birman, D. (1998). Biculturalism and perceived competence of Latino
immigrant adolescents. American Journal of Community Psychology,
26, 335–354.
Brody, G. H., Murry, V. M., Kogan, S. M., Gerrard, M., Gibbons, F. X.,
Molgaard, V., et al. (2006). The Strong African American Families
Program: A cluster-randomized prevention trial of long-term effects and
a mediational model. Journal of Consulting and Clinical Psychology,
74, 356 –366.
Bronfenbrenner, U. (1986). Ecology of the family as a context for human
development. American Psychologist, 32, 513–531.
Centers for Disease Control and Prevention. (2006a). HIV/AIDS surveillance report: Vol. 17. 2005. Atlanta, GA: U.S. Department of Health and
Human Services.
Centers for Disease Control and Prevention. (2006b). Youth Risk Behavior
Surveillance—United States, 2005: Surveillance summaries. Morbidity
and Mortality Weekly Report 2006, 55 (No. SS-5), 1–108.
Cheong, J., MacKinnon, D. P., & Khoo, S. T. (2003). Investigation of
mediational processes using parallel process latent growth curve modeling. Structural Equation Modeling, 10, 238 –262.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences.
Hillsdale, NJ: Erlbaum.
DiClemente, R. J., Wingood, G. M., Harrington, K. F., Lang, D. L., Davies,
S. L., Hook, E. W., et al. (2004). Efficacy of an HIV prevention
intervention for African American adolescent girls: A randomized controlled trial. Journal of the American Medical Association, 292, 171–
179.
Dillon, F. R., Turner, C. W., Robbins, M. S., & Szapocznik, J. (2005).
Concordance among biological, interview, and self-report measures of
drug use among African American and Hispanic adolescents referred for
drug abuse treatment. Psychology of Addictive Behaviors, 19, 404 – 413.
Ellickson, P. L., & Morton, S. C. (1999). Identifying adolescents at risk for
hard drug use: Racial/ethnic variations. Journal of Adolescent Health,
25, 382–395.
Gil, A. G., Wagner, E. F., & Tubman, J. G. (2004). Culturally sensitive
substance abuse intervention for Hispanic and African American adolescents: Empirical examples from the Alcohol Treatment Targeting
Adolescents in Need (ATTAIN) Project. Addiction, 99, 140 –150.
Gomez, C. A., & Marin, B. V. (1996). Gender, culture, and power: Barriers
to HIV prevention strategies for women. Journal of Sex Research, 33,
355–362.
Gorman-Smith, D., Tolan, P., Zelli, A., & Huesmann, L. R. (1996). The

925

relation of family functioning to violence among inner-city minority
youth. Journal of Family Psychology, 10, 115–129.
Guo, J., Chung, I. J., Hill, K., Hawkins, J., Catalano, R., & Abbott, R.
(2002). Developmental relationships between adolescent substance use
and risky sexual behavior in young adulthood. Journal of Adolescent
Health, 31, 354 –362.
Hedeker, D., & Gibbons, R. D. (2006). Longitudinal data analysis. New
York: Wiley.
Henrich, C. C., Brookmeyer, K. A., Shrier, L. A., & Shahar, G. (2006).
Supportive relationships and sexual risk behavior in adolescence: An
ecological-transactional approach. Journal of Pediatric Psychology, 31,
286 –297.
Jemmott, J. B., III, Jemmott, L. S., & Fong, G. T. (1998). Abstinence and
safer sex HIV risk-reduction interventions for African American adolescents: A randomized controlled trial. Journal of the American Medical Association, 279, 1529 –1536.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E.
(2007). Monitoring the Future national survey results on drug use,
1975–2006: Vol. 1. Secondary school students (NIH Publication No.
07– 6205). Bethesda, MD: National Institute on Drug Abuse.
Krauss, B. J., Godfrey, C., Yee, D., Goldsamt, L., Tiffany, J., Almeyda, L.,
et al. (2000). Saving our children from a silent epidemic: The PATH
program for parents and preadolescents. In W. Pequegnat & J. Szapocznik (Eds.), Working with families in the era of HIV/AIDS (pp. 89 –112).
Thousand Oaks, CA: Sage.
Kurtines, W. M., & Szapocznik, J. (1995). Cultural competence in assessing Hispanic youths and families: Challenges in the assessment of
treatment needs and treatment evaluation for Hispanic drug-abusing
adolescents. NIDA Research Monographs, 156, 172–189.
Little, R. J. A., & Rubin, D. B. (1987). Statistical analysis with missing
data. New York: Wiley.
Marotta, S. A., & Garcia, J. G. (2003). Latinos in the United States in 2000.
Hispanic Journal of Behavioral Sciences, 25, 13–34.
Martinez, C. R., Jr., & Eddy, J. M. (2005). Effects of culturally adapted
parent management training on Latino youth behavioral health outcomes. Journal of Consulting and Clinical Psychology, 73, 841– 851.
Meschke, L. L., Bartholomae, S., & Zentall, S. R. (2000). Adolescent
sexuality and parent-adolescent processes: Promoting healthy teen
choices. Family Relations, 49, 143–154.
Metzger, D. S., Koblin, B. A., Turner, C., Navalline, H., Valenti, F., Holte,
S., et al. (2000). Randomized controlled trial of audio computer-assisted
self-interviewing: Utility and acceptability in longitudinal studies. American Journal of Epidemiology, 152, 99 –106.
Muthe´n, L. K., & Muthe´n, B. O. (2005). Mplus: Statistical analysis with
latent variables: User’s guide. Los Angeles: Muthe´n & Muthe´n.
Nagayama Hall, G. C. (2005). Introduction to the special section on
multicultural and community psychology: Clinical psychology in context. Journal of Consulting and Clinical Psychology, 73, 787–789.
Pantin, H., Coatsworth, J. D., Feaster, D. J., Newman, F. L., Briones, E.,
Prado, G., et al. (2003). Familias Unidas: The efficacy of an intervention
to promote parental investment in Hispanic immigrant families. Prevention Science, 4, 189 –201.
Pantin, H., Prado, G., Schwartz, S. J., & Sullivan, S. (2005). Methodological challenges in designing efficacious drug abuse and HIV preventive
interventions for Hispanic adolescent subgroups. Journal of Urban
Health, 82, iii92–iii102.
Pantin, H., Schwartz, S. J., Sullivan, S., Prado, G., & Szapocznik, J. (2004).
Ecodevelopmental HIV prevention programs for Hispanic adolescents.
American Journal of Orthopsychiatry, 74, 545–558.
Perrino, T., Coatsworth, J. D., Briones, E., Pantin, H., & Szapocznik, J.
(2001). Initial engagement in parent-centered interventions: A family
systems perspective. Journal of Primary Prevention, 22, 21– 44.
Prado, G., Schwartz, S. J., Pattatucci-Aragon, A., Clatts, M., Pantin, H.,

926

PRADO ET AL.

Amaro, H., et al. (2006). Preventing HIV transmission in Hispanic
adolescents. Drug and Alcohol Dependence, 84S, S43–S53.
Prado, G., Szapocznik, J., Schwartz, S. Maldonado-Molina, M., & Pantin,
H. (in press). Drug abuse prevalence, etiology, prevention, and treatment
in Hispanic adolescents: A cultural perspective. Journal of Drug Issues.
Ramirez, R. R., & de la Cruz, G. P. (2003). The Hispanic population in the
United States: March 2002 (Current Population Report P20 –545).
Washington, DC: U.S. Census Bureau.
Rosenthal, S. L., Biro, F. M., Succop, P. A., Baker, J. G., & Stanberry,
L. R. (1994). Reasons for condom utilization among high-risk adolescent
girls. Clinical Pediatrics, 33, 706 –711.
Sale, E., Sambrano, S., Springer, J. F., Peta, C., Pan, W., & Kasim, R.
(2005). Family protection and prevention of alcohol use among Hispanic
youth at high risk. American Journal of Community Psychology, 36,
195–205.
Sandler, I. N., Ayers, T. S., & Wolchik, S. A. (2003). The Family Bereavement Program: Efficacy evaluation of a theory-based prevention
program for parentally bereaved children and adolescents. Journal of
Consulting and Clinical Psychology, 71, 587– 600.
Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Kurtines, W. M.,
Schwartz, S. J., LaPerriere, A., & Szapocznick, J. (2003). The efficacy
of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use. Journal of Family Psychology, 17,
121–133.
Santisteban, D. A., Muir-Malcolm, J. A., Mitrani, V. B., & Szapocznik, J.
(2002). Integrating the study of ethnic culture and family psychology
intervention science. In H. A. Liddle, D. A. Santisteban, R. F. Levant, &
J. H. Bray (Eds.), Family psychology: Science-based interventions (pp.
331–352). Washington, DC: American Psychological Association.
Schulenberg, J., Maggs, J. L., & Hurrelmann, K. (1997). Health risks and
developmental transitions during adolescence. New York: Cambridge
University Press.
Smith, C. (1997). Factors associated with early sexual activity among
urban adolescents. Social Work, 42, 334 –346.
Spoth, R. L., Guyll, M., Chao, W., & Molgaard, V. (2003). Exploratory
study of a preventive intervention with general population African
American families. Journal of Early Adolescence, 23, 435– 468.
Szapocznik, J., & Coatsworth, J. D. (1999). An ecodevelopmental framework for organizing the influences on drug abuse: A developmental

model of risk and protection. In M. Glantz & C. R. Hartel (Eds.), Drug
abuse: Origins and interventions (pp. 331–366). Washington, DC:
American Psychological Association.
Szapocznik, J., & Kurtines, W. M. (1980). Acculturation, biculturalism,
and adjustment among Cuban Americans. In A. M. Padilla (Ed.), Psychological dimensions on the acculturation process: Theory, models,
and some new findings (pp. 139 –159). Boulder, CO: Westview.
Szapocznik, J., Prado, G., Burlew, K., Williams, R., & Santisteban, D.
(2007). Drug abuse in African American and Hispanic adolescents:
Culture, development, and behavior. Annual Review of Clinical Psychology, 3, 155–183.
Tobler, N. S., Roona, M. R., Ochshorn, P., Marshall, D. G., Streke, A. V.,
& Stackpole, K. M. (2000). School-based adolescent drug prevention
programs: 1998 meta-analysis. Journal of Primary Prevention, 20, 275–
336.
Tolan, P. H., Gorman-Smith, D., Huesmann, L. R., & Zelli, A. (1997a).
Assessing family processes to explain risk for antisocial behavior and
depression among urban youth. Psychological Assessment, 9, 212–223.
Tolan, P. H., Gorman-Smith, D., Huesmann, L. R., & Zelli, A. (1997b).
Assessment of family relationship characteristics: A measure to explain
risk for antisocial behavior and depression among urban youth. Psychological Assessment, 9, 212–223.
Turner, C. F., Rogers, S. M., Lindberg, L. D., Pleck, J. H., & Sonenstein,
F. L. (1998, May 8). Adolescent sexual behavior, drug use, and violence:
Increased reporting with computer survey technology. Science, 280,
867– 873.
Vakalahi, H. F. (2002). Family-based predictors of adolescent substance
use. Journal of Child and Adolescent Substance Abuse, 11(3), 1–15.
Wei, L. J., & Lachin, J. M. (1988). Properties of the urn randomization in
clinical trials. Controlled Clinical Trials, 9, 345–364.
Wolchik, S. A., Sandler, I. N., Millsap, R. E., Plummer, B. A., Greene,
S. M., Anderson, E. R., et al. (2002). Six-year follow-up of preventive
interventions for children of divorce: A randomized controlled trial.
Journal of the American Medical Association, 288, 1874 –1881.

Received September 29, 2006
Revision received August 17, 2007
Accepted August 20, 2007 䡲