These CBIs typically mentioned use of a specific theoretical construct without reference to a broader theory, or intervention technique. In addition, sometimes a specific construct or intervention technique can be associated with more than one theory. For example, several of these CBIs mentioned that the goal of the intervention was to improve “self-efficacy”, a specific construct that is most often associated with Social Cognitive Theory, but is also incorporated within other theories such as the Theory of Reasoned Action. We applied the same classification system to these CBIs with regard to mention, application and measure for the construct and/or techniques. For each CBI listed in Tables 1 and 2, the use of the theory or construct/technique are classified as mentioned, applied, or measured .As noted above, a CBI was classified as “applied” if any one of the associated articles provided some description of how the theory/construct was used in the CBI. Of the 21 CBIs that mentioned use of a broad theory, all provided at least some information about how the theory was applied to the intervention . However, the quality of the description explaining how the theory was applied varied considerably across the CBIs. Tables 1 provides a brief summary of how the articles, associated with each CBI, applied theory. There were a number of articles that provided a strong description of how the theory was applied to the intervention . Another intervention, the Life Skills Training CD-ROM, was derived from an evidence-based comprehensive in-person curriculum with a strong basis in Social Learning/Cognitive Theory. The Life Skills Training CD-ROM, like the original face-to face curriculum, contains a number of modules that articulate the specific linkages between theory and intervention approaches. Other articles described how one or two aspects of the theory were applied to the CBI, but not the overall theoretical pathway that would inform behavior change In contrast, the majority of articles lacked sufficient information to understand how theory informed the development of the intervention. For the CBIs listed that did not mention use of a broad theory , but mentioned using a specific construct or technique,vertical grow system all provided a description of how it was applied in the intervention ; however the amount and quality of information provided about the application of the construct/techniques varied considerable across this group of CBIs.Of the 21 CBIs that mentioned use/application of theory , all but two included at least one measure of a construct associated with the theory.

If a CBI mentioned use of a theory, it was more likely to include a measure of specific constructs associated with the theory compared to CBIs that did not mention use of a broad theory. Specifically, of the CBIs, that did not explicitly mention use of a theory, but did include a specific construct, only five included corresponding measures of the theoretical construct . Tables 1 and 2 lists the classification of each CBI and provides a list of the measure associated with the theory, construct or intervention technique.The measures listed in Table 3 and 4 are primary outcome measures and, in many cases, are different from those listed in Tables 1 and 2 which lists the measures of theoretical constructs which were often secondary rather than primary outcomes. For the outcomes listed in Tables 3 and 4, an asterisk denotes statistical significance indicating that the intervention showed more favorable results than the comparator Of the 42 CBIs, all but one demonstrated improvements in alcohol knowledge and/or attitudes. In addition to these knowledge or attitude outcomes, the majority of the CBIs showed significant reductions in alcohol related behaviors. The proportion of CBIs reporting significant behavioral outcomes was greater among those that used a broad theoretical framework compared to those that targeted a specific theoretical construct and/or intervention technique .This study identified 100 unique articles covering 42 unique computer-based interventions aimed at preventing or reducing alcohol use among adolescents and young adults.Thus, this review includes a total of 21 new CBIs and 43 new articles. This review is the first to provide an in-depth examination of how CBI’s integrate theories of behavior change to address alcohol use among adolescents and young adults. While theories of behavior change are a critical component of effective interventions that have been developed and evaluated over the past several decades, attention to the application of theory in CBIs has been limited. We utilized a simple classification system to examine if theories were mentioned, applied or measured in any of the publications that corresponded with the CBIs. Only half of the CBIs reviewed mentioned use of an overarching, established theory of behavior change. The other half mentioned used of a single construct and/or intervention technique but did not state use of a broader theory. CBIs that were based on a broad theoretical framework were more likely to include measures of constructs associated with the theory than those that used a discrete construct or intervention technique.

However, greater attention to what theory was used, articulating how theory informed the intervention and including measures of the theoretical constructs is critical to assess and understand the causal pathways between intervention components/mechanisms and behavioral outcomes . When mentioning the use of a theory or construct, almost all provided at least some description of how it informed the CBI; however, the amount and quality of information about how the theory was applied to the intervention varied considerably. Greater attention to what is inside the “black box” is critical in order to improve our understanding of not only what works, but why it works. While a few articles provided detailed information about the application of theory, the majority included limited information to examine the pathway between intervention approach and outcomes. There are a number of reasons why there may be limited information on the use of theory in CBIs. Some researchers/intervention developers may not fully appreciate how theory can be used to inform intervention approaches. There is an emphasis on outcomes/effectiveness of interventions and less attention is placed on their development. In addition, to our knowledge, there are no publication guidelines/standards for describing the use of theoretical frameworks in intervention studies and the inclusion of this information is often up to individual authors and reviewers. Given the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed in publications. The classification system used in this review provided some form of personalized normative feedback and applied it relatively consistently across the CBIs. Personalized normative feedback is designed to correct misperceptions about the frequency and acceptability of alcohol use among peers. It typically involves an assessment of a youth’s perceptions of peer norms around alcohol attitudes and use followed by tailored information about actual norms. In addition, some interventions have recently incorporated personal feedback to address individual’s motivations to change through assessing and providing feedback on drinking motives or in decisional balance exercises. The widespread use of personalized normative feedback in CBIs may be because it has been widely documented as an effective strategy and because it lends itself readily to an interactive, personalized computer-based intervention. Motivational interviewing was also used in several of the CBIs and is an effective face-to-face counseling technique. In contrast, this technique was applied to CBIs in a number of different ways, such as exercises designed to clarify goals and values, making both the description of how it was applied even more essential to examine differential effectiveness across various CBIs. This study builds on the growing evidence supporting the use of CBIs as a promising intervention approach. We found most of the CBIs improved knowledge, attitudes and reduced alcohol use among adolescents and young adults. In addition, this study suggests CBIs that use overarching theories more frequently reported significant behavioral outcomes than those that use just one specific construct or intervention technique . This finding is consistent with prior studies examining the use of theory in face to-face interventions targeting alcohol use in adolescents.

However, it is important to acknowledge the wide variation across the CBIs not only in their use of theory, but in scope, the targeted populations,mobile grow systems duration/dosage, and measured outcomes. It is encouraging that even brief/targeted CBIs demonstrated some effectiveness and thus can play an important role in improving knowledge and attitudes, which are important contributors to changes in behavior. There are limitations to this study. As discussed previously, many articles did not explicitly describe how theory was applied in the CBI. It is therefore possible that the theoretical pathways for the intervention were further developed than we have noted, and possibly included in other documents, such as logic models and/or funding applications; however, such information is not readily accessible and was outside the scope of this review. Thus, lack of mention of the name of a theory or construct or its application does not mean that the intervention did not integrate the theory in the intervention, only that the article did not provide information about its application. Thus, due to variations in the described use of theory along with the wide range of CBIs, it was not possible to draw comparisons about the relative effectiveness of CBIs according to the theory used. The ability to make such comparisons is further limited by the wide time frame in which CBIs were developed. This review spanned articles published between 1995 and 2014. During this period, CBIs to address health issues have been rapidly evolving due to major advancements in technological innovations . These advancements coupled with greater interest and investments from federal agencies and philanthropic foundations. Over time one would expect these factors to further contribute to the effectiveness of CBIs.Marijuana use is common among persons living with HIV as studies have reported prevalence rates of current marijuana use between 24 and 56 % as compared to approximately 7 % in the general United States population. Men who have sex with men report higher rates of current and past-year marijuana use than their heterosexual counterparts. Several studies report that persons living with HIV use marijuana to alleviate stress, anxiety, depression, HIV-related symptoms and side effects of antiretroviral therapy. In one recent study, among HIV-seropositive persons who inject drugs and who recently seroconverted, heavy cannabis use was associated with lower plasma viral load levels. The therapeutic effects of marijuana are proposed to be mediated via the actions of active cannabinoid chemicals in marijuana—cannabidiol—at specific receptor sites: cannabinoid receptors located mainly on cells and tissues of the immune system. In contrast the primary psychoactive cannabinoid in marijuana: tetrahydrocannabidiol binds to and activates another receptor site: cannabinoid receptor located mainly in areas of the brain to produce the euphoric and cognitive impairing effects of marijuana. Accordingly, there are concerns that marijuana use may be associated with poorer HIV treatment outcomes. Previous studies have found marijuana use to be associated with decreased cognitive function as well as reduced ART adherence, which is crucial for persons living with HIV as optimal adherence to ART medications is required for long-term viral suppression. Effective prevention strategies to reduce unhealthy or harmful marijuana use require an in depth understanding of subgroups with different patterns of use. Despite the published evidence that marijuana use is common among HIV+ individuals and MSM and the potential adverse health outcomes associated with its use in these populations, very little is known about the patterns of marijuana use or how patterns of marijuana use may change over time in these populations. Developmental research suggests different rather than similar pathways via which individuals initiate and progress to unhealthy or problem substance use over the life course. For instance, individuals who start using substances at an early age have increased risk of progressing to problem use and developing use disorders. Among HIV+ women, depressive symptoms and the presence of hepatitis C infection was associated with a pattern of persistent heavy drinking over time. Another study found that low income and concurrent substance use were factors that predicted consistent hazardous drinking among HIV + MSM. Therefore, understanding the natural history of marijuana use and the identification of different trajectories of use over time is important in order for intervention programs to be most effective. For instance, the identification of different patterns of marijuana use over time can help characterize subgroups of individuals with the greatest risk of progressing to heavy patterns of marijuana use and reveal unique predictors of such patterns of use which can be used to inform targeted intervention programs.