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Athletes Training and Learning to Avoid Steroids (ATLAS)

Blueprints Program Rating: Promising

A drug prevention and health promotion program that deters substance use among high school adolescents in school sponsored athletics by educating youth on the harms of anabolic steroids, alcohol, and other drug use and by promoting sports nutrition and exercise.

  • Linn Goldberg, M.D., F.A.C.S.M.
  • Oregon Health Sciences University
  • Division of Health Promotion and Sports Medicine
  • 3181 S.W. Sam Jackson Park Road, CR110
  • Portland, OR 97201-3098
  • (503) 494-8051
  • (503) 494-1310
  • hpsm@ohsu.edu
  • www.atlasprogram.com
  • Alcohol
  • Illicit Drug Use
  • Physical Health and Well-Being

    Program Type

    • After School
    • Skills Training

    Program Setting

    • School

    Continuum of Intervention

    • Universal Prevention (Entire Population)

    A drug prevention and health promotion program that deters substance use among high school adolescents in school sponsored athletics by educating youth on the harms of anabolic steroids, alcohol, and other drug use and by promoting sports nutrition and exercise.

      Population Demographics

      ATLAS is designed to target adolescent male athletes participating in school sponsored athletics, particularly those involved in strength-oriented sports where steroid use is prevalent, such as football.

      Age

      • Late Adolescence (15-18) - High School

      Gender

      • Male only

      Race/Ethnicity

      • White

      Race/Ethnicity/Gender Details

      ATLAS was implemented with a largely white, middle-class population. No data is currently available regarding the program's effectiveness with other more racially and socioeconomically diverse groups.

      • Individual
      • Peer
      Risk Factors
      • Individual: Favorable attitudes towards drug use*, Substance use*
      • Peer: Peer substance use
      Protective Factors
      • Individual: Perceived risk of drug use*, Refusal skills*

      *Risk/Protective Factor was significantly impacted by the program.

      Athletes Training and Learning to Avoid Steroids (ATLAS) is a drug prevention and health promotion program for adolescent high school athletes that emphasizes the negative impact of anabolic steroids, alcohol, and other drugs on immediate sports performance. The program is integrated into team practice sessions and consists of a seven-session classroom curriculum and seven weight room skill training sessions. Coaching staff or surrogates administer the classroom curriculum which includes subjects such as risk factors of steroid use, strength training and sports nutrition, as well as skills to refuse steroids and other substances. In addition, nutritional recommendations and false claims of over the counter supplements are discussed. Parents attend a single evening meeting centered on program goals.

      ATLAS is a drug prevention and health promotion program for high school athletes. It is integrated into team practice sessions and consists of a classroom curriculum and weight room skill training sessions. Coaching staff and peer educators administer the classroom curriculum consisting of seven classroom sessions delivered to subjects over seven weeks of the football season. Program staff administer seven weight room sessions during the same period. Additionally, the ATLAS staff deliver a single evening session to parents describing the program and its goals, and answering questions. The classroom curriculum covers subjects such as risk factors of steroid use, strength training and sports nutrition as well as skills to refuse steroids and other substances. In addition, nutritional recommendations and false claims of over the counter supplements are discussed. A pocket-sized sports nutrition guide and a weight-training booklet are distributed to all student participants. The weight room sessions provide demonstrations of different weight-lifting techniques, while reinforcing other elements of the classroom curriculum. The parent session consists of a one evening informational session about the program as well as ways in which parents can help reinforce the knowledge gained by the youth in the classroom curriculum.

      ATLAS is based on a person-environment social learning theory. ATLAS assumes that anabolic androgenic steroid (AAS) use is a learned, goal-directed action, reinforced by individual, peer, family, and community or school influences. Individuals are influenced by biologic mediators; their knowledge, skills, attitudes regarding AAS risks and benefits; and psychosocial characteristics.

      • Person - Environment
      • Social Learning

      ATLAS was evaluated in a randomized controlled trial involving 31 high school football teams in the Portland, OR area. Thirty-four schools were matched in pairs based on demographic parameters (school size, family socioeconomic status, school attendance, student participation in free lunch program, number of students attending college, and the football team's win-loss record from the prior season). Following randomization, three schools dropped out resulting in 15 experimental schools and 16 control schools. Self-report data was collected at pretest, posttest, and a 9 or 12-month follow-up. The evaluation focused on whether the program was able to influence knowledge and attitudes concerning anabolic androgenic steroid (AAS) use, sports nutrition and exercise knowledge and behaviors, and intentions to use AAS.

      At the end of the season and at one-year follow-up, ATLAS students reported an increase in knowledge of and beliefs in the potential negative effects of using AAS and other substances, an increase in sports nutrition knowledge and behaviors, enhanced strength-training self-efficacy, and greater ability to refuse drug offers from peers. In addition, experimental students were less likely to actually use steroids at the end of the season and the one-year follow-up (19 new users from baseline in the control group and 9 in the experimental group). Experimental students were less likely to report illicit drug use (individual and school-level) and new occurrences of drinking and driving (individual level only) at the one-year follow-up. It should be noted that at the end of the season, illicit drug use was higher in the experimental group.

      Drug Use Intentions and Behaviors

      • Decreased likelihood of lifetime steroid use at posttest and one-year follow-up, but differences not significant.
      • Decreased likelihood of alcohol and other drug use at the one-year follow-up.
      • Decreased likelihood of new occurrences of drinking and driving at one-year follow-up.

      Health Promotion Behaviors found at posttest and one-year follow-up:

      • Heightened perception of coach intolerance to drug use.
      • Improved nutrition knowledge and behaviors.
      • Enhanced strength training self-efficacy.
      • Less likely to believe advertisements for sports supplements and positive steroid use images.
      • Reduction in sport supplement use at one-year follow-up.

      Significant Program Effects on Risk and Protective Factors:

      • Greater self-reported ability to refuse drug offers from peers.
      • Greater knowledge of the effects of steroids and alcohol.
      • Stronger beliefs about the harmful effects of anabolic steroid use and perceived greater susceptibility to their effects.

      ATLAS was designed to target adolescent male high school athletes participating in strength-related sports. To date, the evaluations have been conducted in predominantly white middle- to working-class schools in urban areas. There is no information available regarding the effectiveness of the program in rural areas or among racially or ethnically diverse schools.

      In the randomized study of ATLAS, the attrition rate was high at the 9-12 month follow-up. There was no analysis of differential attrition. There were a number of significant differences between the treatment and control groups at baseline. All tests were one-tailed, but results reported in this writeup adjusted for that.

      In addition, while the content of the program remained constant from the first study that included only Cohort 1 to the second study which included three cohorts, the curriculum time was altered for the second study. Cohorts 2 and 3 received eight sessions (five classroom and three weight room sessions), while Cohort 1 received seven classroom and seven weight room sessions.

      The pilot cannot be considered a replication as the evaluation only occurred in two schools, the number of students was small with poor retention rates in the control group, one-tailed tests, failure to analyze differential attrition, and no measures of actual behavior change.

      Additionally, all outcomes are based on self-reports, and there is no test of theory. Most problematic is that the primary outcome, lifetime steroid use, is not affected by the program.

      In a personal correspondence with Linn Goldberg, we asked for and received data on drug effects that had not been analyzed for the paper. Findings demonstrated that short-term illicit drug use, which included marijuana, amphetamines, and narcotics, was significantly reduced. When alcohol and illicit drugs were combined, the effect was still present. This effect was not, however, significant for the first cohort at the one-year follow-up.

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      Goldberg, L., Elliot, D., Clarke, G. N., MacKinnon, D. P., Moe, E., Zoref, L., ... Lapin, A. (1996). Effects of a multidimensional anabolic steroid prevention intervention: The Adolescents Training and Learning to Avoid Steroids (ATLAS) Program. JAMA, 276(19), 1555-1562.

      Goldberg, L., MacKinnon, D. P., Elliot, D. L., Moe, E. L., Clarke, G., & Cheong, J. (2000). The Adolescents Training and Learning to Avoid Steroids Program: Preventing drug use and promoting health behaviors. Archives of Pediatrics and Adolescent Medicine, 154(4), 332-338.

      Goldberg, L., Elliot, D. L., Clarke, G. N., MacKinnon, D. P., Zoref, L., Moe, E., ... Wolf, S. (1996). The Adolescents Training and Learning to Avoid Steroids (ATLAS) Prevention Program. Archives of Pediatric Adolescent Medicine, 150, 713-721.

      Center for Health Promotion Research
      Oregon Health & Science University
      3181 S.W. Sam Jackson Park Road, CR110
      Portland, OR 97201-3098
      Phone: (503) 494-8051
      Email: chpr@ohsu.edu
      www.atlasprogram.com

      Study 1

      Goldberg, L., Elliot, D., Clarke, G. N., MacKinnon, D. P., Moe, E., Zoref, L., ... Lapin, A. (1996). Effects of a multidimensional anabolic steroid prevention intervention: The Adolescents Training and Learning to Avoid Steroids (ATLAS) Program. JAMA, 276(19), 1555-1562.

      Study 2

      Goldberg, L., MacKinnon, D. P., Elliot, D. L., Moe, E. L., Clarke, G., & Cheong, J. (2000). The Adolescents Training and Learning to Avoid Steroids Program: Preventing drug use and promoting health behaviors. Archives of Pediatrics and Adolescent Medicine, 154(4), 332-338.

      Goldberg, L., Elliot, D., Clarke, G. N., MacKinnon, D. P., Moe, E., Zoref, L., ... Lapin, A. (1996). Effects of a multidimensional anabolic steroid prevention intervention: The Adolescents Training and Learning to Avoid Steroids (ATLAS) Program. JAMA, 276 (19), 1555-1562.

      Evaluation Methodology

      Design: A randomized controlled trial was conducted involving 34 high school football teams in the Portland, OR area during the 1994-1995 school year. The 34 schools were matched in pairs based on demographic parameters such as school size, family socioeconomic status, school attendance, student participation in free lunch programs, number of students attending college, and the football teams’ win-loss record for the season prior to participation. Seventeen schools were randomly selected to be in the experimental group with the remaining 17 assigned to the control group. After randomization, but before student contact, three experimental schools dropped from the study, citing time constraints and curriculum control issues. Two of the unpaired schools were matched on demographics and one was randomized to the experimental condition, resulting in a final sample of 15 schools in the experimental group and 16 in the control group. Participating experimental and control schools were each provided with approximately $3,000 of weight-lifting equipment prior to onset of the prevention program. This was done as a school incentive to participate and to enhance each school’s exercise facility to keep students lifting weights in the school environment, since commercial gyms are a common site for acquiring anabolic androgenic steroids (AAS). Control group students were provided with a commercially produced, anti-AAS pamphlet.

      All football athletes were approached at the schools for study participation with parental consent required. Questionnaires were administered prior to the beginning of the intervention, at the end of intervention (about 10 weeks post-baseline), and at long term follow-up. The follow-up occurred either at the end of the intervention year for graduating seniors or one year from the initial assessment for returning students. Incentives for the students ranged from t-shirts to movie passes for each completed assessment. Research staff administered confidential code-numbered questionnaires in large group sessions at each school.

      Sample: The initial all-male sample consisted of 1,506 youth football players with informed consent completing the pretest questionnaire (n = 702 in the experimental schools and n = 804 in the control schools). Of this initial sample, 1,226 (81.4%) completed the posttest assessment (n = 532 in the experimental and n = 694 in the control schools). A total of 869 youth (57.7%) completed the third, long-term follow-up assessment (n = 407 in the experimental and n = 462 in the control schools). Altogether, 88.2% of all enrolled youth completed the baseline assessment and at least 1 of the 2 remaining follow-up assessments. There was a significant difference in the rate of attrition at posttest (with higher attrition from the experimental group), but no significant difference at the long-term follow-up.

      Differential attrition was not reported, other than a mention in the Comments section of the article that dropouts from the control group had significantly higher baseline intentions to use AAS than dropouts from the experimental group.

      Baseline Equivalence: Baseline equivalence tests (2-tailed) revealed significant differences on several variables between the experimental and control groups on both demographics and outcomes targeted by ATLAS. Control students were slightly younger by 7 weeks, had a slightly higher mean GPA, had fathers who were slightly more educated, and had higher family incomes. When compared to students in the control schools, students in the experimental schools had poorer nutrition behaviors, lower strength-training self-efficacy, perceived themselves as more athletically competent, were less likely to believe in media advertisements, were less likely to view their peers as a good information source, had greater knowledge of nutritional supplements/exercise, and believed their coaches were less tolerant of AAS use. When assessing baseline equivalence at the school level, there was only one preintervention difference, perception of athletic competence.

      Measures: Data was collected for three cohorts at pretest, posttest, and a 9 or 12-month follow-up over the period 1994 to 1996. The principal assessment instrument was a 168-item, self-report questionnaire developed for this investigation with the use of items employed in earlier studies. The questionnaire assessed AAS and other drug use, attitudes, and behavioral intent to use AAS. Items that evaluated the use of other illicit drugs and alcohol were from ongoing, national surveys of American high school seniors. Other constructs assessed included knowledge of nutrition and exercise and norms of drug use; exercise and dietary patterns; peer tolerance of AAS and other drug use and support of health-promoting behaviors; body image; self-esteem; need for achievement; mood; anger and impulsivity; and subjective satisfaction with the components of the intervention.

      Analysis: The program effects were estimated separately with the conditional regression model at the post-intervention assessment and at the long-term follow-up. The program effect estimate was the difference between experimental and control subjects at posttest adjusted for the pretest levels for each subject. Program effects were also estimated after controlling for age, student GPA, and father's education. The analyses were also conducted at the school-level of analysis. The long-term follow-up data for graduating seniors was combined with long-term follow-up assessment for returning players. Together, these data comprise the long-term follow-up. One-tailed tests of significance were used to report individual-level program effects.

      Outcomes

      Behavioral Intent: When analyzed at the individual level, athletes in the experimental group had less short-term and long-term intent to use AAS than control students. When analyzed at the school level, there was a non-significant short and long-term trend in the predicted direction, both of which were significant when GPA and father's education were held constant. Intent to use AAS for specific rewards was significantly different for the individual level, but not for the school-level analysis at the short term analysis point. This construct was not assessed in the long-term follow-up.

      Behaviors: Compared to the control group, students in the intervention group reported significant improvements in their sports nutrition behaviors and greater use of school gyms versus private gyms. In addition, these findings persisted (and remained statistically significant) throughout the follow-up period. At the posttest, eleven participants reported new use of AAS during the testing period, with 8 of those subjects coming from the control group. At the long-term follow-up, there were an additional four participants from the control group and three from the experimental group that reported lifetime use of AAS. However, total AAS users (current and past) did not achieve a significant difference between the groups at any testing period.

      In personal correspondence with the program designer and subsequent analysis of drug data, it was found that short-term illicit drug use, which included marijuana, amphetamines and narcotics were reduced at short term (p<.05) and when alcohol and illicit drugs were combined, the effect was still present (p<.01). At one year, the effect on the first cohort was not significant.

      Knowledge: Experimental adolescents demonstrated significantly greater knowledge of the consequences of AAS and alcohol usage, improved knowledge about supplements and exercise as compared to control subjects at both posttest and long-term follow-up.

      Non-peer Influences: Compared to control students, athletes in the experimental group demonstrated significant findings on questions related to non-peer influences on their decision making and information receiving about AAS usage. They believed their coaches and parents were less tolerant of AAS use and believed their coach was a reliable source of information about drugs. At the posttest and long-term follow-up, experimental subjects, compared to control subjects, were significantly more skeptical of media influences which promote AAS usage.

      Peer Influences: Athletes in the experimental group yielded significant findings on issues relating to belief in their team and peers as trusted information sources for both follow-up periods. Normative beliefs about AAS use improved at the short-term follow-up for the experimental group, but these findings did not continue for the long-term follow-up. Although no school level differences were observed in perceived friend or peer tolerance of drug use, individual level analyses indicated significantly lower perceived peer tolerance of drug use reported by experimental subjects at the short-term assessment.

      Individual Factors: Students in the experimental group had significantly greater short-term and long-term feelings of athletic competence, confidence in their ability to strength train, ability to refuse AAS and other drugs, and increases in self-esteem. Additionally, experimental students, compared to control students at posttest, reported significant increases in communication with peers and less impulsivity.

      Attitudes: Following the intervention, experimental students, compared to control students, were more likely to believe in the potential severity of AAS use risks, had more unfavorable attitudes towards AAS users and felt more personal vulnerability to the negative effects of AAS. All of these findings demonstrated statistical significance.

      Goldberg, L., MacKinnon, D. P., Elliot, D. L., Moe, E. L., Clarke, G., & Cheong, J. (2000). The Adolescents Training and Learning to Avoid Steroids Program: Preventing drug use and promoting health behaviors. Archives of Pediatrics and Adolescent Medicine, 154 (4), 332-338.

      Expansion of Study 1 with 3 Cohorts - This is a continuation evaluation of the Study 1 sites, with additional students added to the sample (in all, three sequential cohorts assessed before and after each athletic season in 1994, 1995, and 1996). Cohorts 1 and 2 had available data at the one-year follow-up; cohort 3 had not yet reached the one-year follow-up marker, and only had pretest and posttest data available.

      Design: The design is described in Study 1. Data was collected for three cohorts at pretest, posttest, and at 9- or 12-month follow-up over the period 1994 to 1996. The data described above (in Study 1) represents the first cohort of this implementation. Two additional cohorts participated in this study, which occurred over a three-year time period. The content of the program for the second and third cohorts of this implementation were based on the same content as previous implementations. However, the organizational framework was altered to compress the curriculum into eight sessions (five classroom and three weight room sessions).

      Sample: The study was comprised of 3,207 athletes at baseline from the 31 schools. Of those students who were assessed prior to the program implementation, 78.5% (n=2,516) of students from both groups completed the posttest instrument (n = 1,371 in the control group; n = 1,145 in the experimental group). The posttest to one-year follow-up reflected similar retention rates as other school based programming with 68.7% of Cohort 1 and 2 (700 control and 591 experimental) students participating in the follow-up (Cohort 3 had only completed the intervention and posttest at this time period). The attrition rate from pretest to one year was 46%. The attrition rate at the one-year follow-up did not differ between experimental and control groups. There was no analysis of differential attrition.

      All cohorts included athletes from grades 9 through 12; however, cohorts 2 and 3 mostly consisted of 9th and 10th grade students. The experimental group differed significantly from the control group at baseline in that it included more African Americans and fewer Whites and parental education was lower. However, outcomes were not altered when the baseline differences (age, ethnicity, and father's education) were included in the conditional regression models (using individuals and schools as the unit of analysis) as covariates. Individual-level 2-tailed tests also showed that at baseline the experimental group reported greater knowledge of AAS effects, higher normative AAS use, poorer nutrition behavior, and lower strength training self-efficacy, compared with controls.

      Measures: The principal assessment instrument was a 168-item, self-report questionnaire described in Study 1.

      Analysis: Program effects were estimated with the conditional regression model using individuals and schools as units of analyses. All analyses were repeated with age, ethnicity, and father's education used as covariates. One-tailed significance tests were used.

      Outcomes

      Knowledge: Athletes in the experimental group demonstrated significantly improved knowledge of the effect of exercise and sport supplements at the season's end and at the long-term follow-up. Athletes in the experimental group, compared to the control group, also illustrated significantly greater knowledge of AAS, alcohol, and marijuana's effects at both follow-up periods.

      Attitudes/Beliefs: Subjects in the experimental group yielded significantly stronger beliefs that AAS has harmful effects and perceived greater susceptibility to their effects at both follow-up periods. In addition, subjects in the experimental group were significantly less likely to believe advertisements for sport supplements and positive AAS use images at both assessment periods.

      Individual Factors: Experimental students reported significantly higher self-esteem and less impulsivity at season's end, as compared to their control counterparts. In addition, students in the experimental group had greater confidence in their athletic abilities both at the season's end and at the long-term follow-up.

      Team Influences: Athletes in the experimental group believed that their teammates were more reliable sources for information about drugs, nutrition, and exercise, and that their coaches were less tolerant of AAS usage. In addition, the self-reported ability to reject drug offers from peers was significantly greater for the experimental group than the control group at both testing periods.

      New Sport Supplement Use: New sport supplement use among those in the experimental group was not lower than control subjects at the season's end, but was reduced significantly at the one-year follow-up.

      Intent to Use and New Use: Athletes in the experimental group reported significantly lower intent to use AAS at the season's end as compared to the control group, but this difference is only at the individual level and not at the school level. At posttest, there were significantly more cumulative lifetime AAS users in the control group (n = 18) than in the experimental group (n = 7). One-year follow-up data indicates that a greater number of new users were found in the control group as compared to the experimental group (19 versus 9, respectively). This result was marginally significant (p = .07) with a one-tailed test.

      Alcohol and Other Drug Use: The index score for alcohol and other drug use (marijuana, amphetamines, and narcotics) was not lower for the experimental group as compared to the control group at the end of the season. However, it was lower among the experimental group at the one-year follow-up, with and without alcohol included in the index, and in both individual and school-level analyses.

      Other Health Behaviors: New occurrences of drinking and driving were significantly lower for the experimental group at the one-year follow-up, but only at the individual level and not at the school level. In addition, those in the experimental group reported significantly improved nutrition behaviors and enhanced strength training self-efficacy.

      Outcomes- Brief Bullets

      • Lower reported intent to use and actual AAS use.
      • Reduced illicit drug use at the one-year follow-up.
      • Reduced incidents of drinking and driving.
      • Reduced supplement use.
      • Improved nutrition behaviors.

      Generalizability

      This experiment was conducted as a follow-up to the second implementation of the ATLAS experiment. Although the sample size was increased, the population still consists exclusively of adolescent male football players and it is impossible to predict what effects the program might have on individuals outside of this group.

      Limitations

      As with all of the ATLAS evaluations, it is unknown what effects the ATLAS program might have on populations outside of the specific targeted group (male adolescent football players). In addition, one-tailed rather than two-tailed tests of significance were used. Attrition was high (46%) at follow-up for Cohorts 1 and 2 (Cohort 3 follow-up not available), and there was no analysis of differential attrition.

      Goldberg, L., Elliot, D. L., Clarke, G. N., MacKinnon, D. P., Zoref, L., Moe, E., ... Wolf, S. (1996). The Adolescents Training and Learning to Avoid Steroids (ATLAS) Prevention Program. Archives of Pediatric Adolescent Medicine, 150, 713-721.

      Pilot Study

      Design: Two urban high schools in the Portland, OR area participated in the quasi-experimental study. The schools were matched on various demographic parameters such as school size, family socioeconomic status, average parental education, school attendance, student participation in free lunch programs, number of students attending college, and the football teams' win-loss record for the season prior to participation. One school received the eight-week ATLAS program, while the control school received no intervention. All participants were assessed twice, nine weeks apart: just prior to the first intervention session, and in the week after the final intervention session. Subjects in both conditions were provided with a free movie theater pass each time they completed the questionnaire. Adolescents who participated in the experimental protocol also received T-shirts with the research study logo. Confidential, code numbered questionnaires were administered by research staff in group sessions at schools. Parents, coaches, and other school personnel were not present during the assessment and did not have access to questionnaires or the coding list.

      Sample: A total of 173 male varsity football players at the two high schools were invited to participate in the study. Subjects and parents or guardians signed a letter of informed consent prior to participation. Of the 90 adolescents eligible to participate in the experimental condition, 66 (73.3%) consented, compared with 54 (65.1%) of 83 adolescents attending the control school. Of the 66 experimental subjects, 56 (84.8%) participated in both assessments, and 24 (44.4%) of the 54 control subjects completed both assessments, for an overall retained sample of 80 students. This was a significant difference in participation across conditions. Because the majority of consenting but nonparticipating adolescents failed to complete the baseline questionnaire, it was not possible to examine how they differed from retained subjects.

      Baseline Differences: Significant baseline differences between participants at the two schools were found for truancy days, anabolic androgenic steroid (AAS) use, beliefs that AASs are not dangerous, knowledge of energy content in foods, peer tolerance of drug use, and norms among friends.

      Measures: The principal assessment instrument was a 299-item, self-report questionnaire, developed for this investigation with the use of items employed in earlier studies. The questionnaire assessed AAS and other drug use, attitudes, and behavioral intent to use AAS. Items that evaluated the use of other illicit drugs and alcohol were from ongoing, national surveys of American high school seniors. Other constructs assessed included knowledge of nutrition and exercise and norms of drug use; exercise and dietary patterns; peer tolerance of AAS and other drug use and support of health-promoting behaviors; body image; self-esteem; need for achievement; mood; anger and impulsivity; and subjective satisfaction with the components of the intervention.

      Analysis: Because of some group differences at baseline, and because subjects were not randomly assigned to treatments, it was important to test program effects under different assumptions about how the schools would change in the absence of program exposure. The program effects were tested under two assumptions about the change in the dependent measure over time if the program had no effect. The first method, the conditional model, tested for effects assuming that the dependent variable in each condition would regress to mean levels. The second method, the unconditional model, tested for effects assuming that group differences would not change over time.

      Outcomes:

      Posttest: All the results reported below use one-tailed tests.

      Knowledge: The program had significant beneficial effects on knowledge of alternatives to AAS use, knowledge of dietary supplements, protein powders, and ergogenic drugs, and knowledge about the effects of steroids. While there were no significant program effects on knowledge of proper exercise techniques or energy intake from food, the pattern of effects was in the positive direction, favoring the students in the intervention group.

      Attitudes: There was evidence of a program effect on attitudes about drugs as a way to solve all problems and drugs as a way to lose weight and others' attitudes about losing.

      Intentions: Program students became less likely to intend to use steroids while control students were more likely to intend to use steroids. The construct "intend to use AASs as a reward" (such as for scholarships or first team positions) was found to be statistically significant with program students less likely to use compared to the control group.

      Body Image: Students who participated in the program were more likely than the control youth to increase their belief that they had a "good" body.

      Norms of AAS/Drug Use: The program students' perception of the number of other persons who use AAS showed a significant positive program effect. The effects for other norms and peer tolerance of drug use were in the desired direction for the program students but not statistically significant.

      Skills: Program effects on resistance skills measures were in the desired direction for program students but were not statistically significant.

      Beliefs: The program had large statistically significant effects on beliefs about the media's influence on steroid use and beliefs about the positive consequences of steroid use. Other beliefs about the negative consequences of AAS use and parental attitudes toward AAS were not statistically significant. However, pretest and posttest scores indicate that these beliefs were well understood by the intervention group prior to their participation in the ATLAS program.

      Long-term effects:

      The initial pilot study did not include a long-term follow-up data collection period.

      Outcomes- Brief Bullets:

      • Reduced interest in trying steroids, even if friends and peers began using.
      • ATLAS participants were less likely to believe steroid use was a good idea.
      • After completion, ATLAS participants believed that steroids were more dangerous.
      • Increased awareness of alternatives to steroid use.
      • Improved body image.
      • Increase in knowledge of diet supplements.
      • Decrease in the belief in dietary supplements as beneficial.

      Generalizability: This outcome trial demonstrates an effective anabolic androgenic steroid prevention program for adolescent male athletes participating in strength-based team sports. It is impossible to estimate the effectiveness of the program to groups outside of this population.

      Limitations: The sample size was extremely small in the pilot study (n = 56 in the experimental group and n = 24 in the control group), making any assumptions about the effectiveness of the program is speculative at best. In addition, the attrition rate was also high, with only 84.8% of the experimental participants and 44.4% of the control participants completing both assessments (n = 80 total participants at post-test), raising questions about self-selection for the program as well as other issues of sample bias. There was no analysis of differential attrition. One-tailed rather than two-tailed tests of significance were used in the analysis. Behaviors were never actually measured, only knowledge, attitudes and intentions.

      Video

      http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/medicine/divisions/hpsm/center-for-health-promotion-research/videos.cfm