International

Longitudinal assessment of the SHAHRP program (Australian)

Formative development

Fundamental to intervention research is a formative phase of development to ensure that the intervention is attune with consumer needs and activities. During the development of the SHAHRP intervention, particular attention was given to ensuring the intervention was based on the latest evidence by incorporating results from a systematic literature review of school drug education, was appropriate and relevant to young people by incorporating realistic scenarios and situations based on focus groups conducted with young people, and was tested with teachers and students in the school setting and incorporated modifications to make the program workable in schools and to enhance the potential for success.

Focus Groups

To ensure that the SHAHRP intervention was sensitive to the concerns of the young people it sought to influence, the SHAHRP researchers conducted a series of focus groups with 80 Western Australian teenagers. Young people were allocated to the focus groups based on gender as it was felt that different issues could be raised. The focus groups aimed to identify various issues including young people's alcohol use experiences, alcohol related harms of particular concern to young people, harm reduction strategies adopted by young people, and educational approaches likely to be effective with young people.

The young people were generally keen to express their opinions about alcohol and issues associated with its use. There was consistency in the issues that young people raised in the focus groups.

Piloting Intervention Program

Pre-testing of the SHAHRP intervention played an important role in refining the activities and materials by incorporating teacher and student responses, while maintaining the integrity of the evidence-based components. Three Western Australian secondary schools were recruited to pilot the SHAHRP intervention. SHAHRP was implemented in six year eight classes (12 - 13-year-olds) involving approximately 200 students and six teachers. Before implementation, pilot teachers attended a two-day training workshop based on interactive modelling of intervention activities. Pilot teachers provided written and verbal evaluation of this workshop.

Process evaluation, fidelity of implementation and other monitoring procedures were also piloted during this initial formative stage of the study. Pilot teachers were asked to complete a process evaluation form for each activity immediately after conducting the lesson. The process evaluation forms required comment on level of completion, student response, teacher response and suggestions to retain or modify each activity. Teachers sent these forms to the research team immediately after completion of each lesson. This information provided an ongoing list of suggested modifications and impressions that were used to revise the SHAHRP intervention before the main study.

Evaluation Workshop

An evaluation workshop was conducted at the conclusion of the pilot to further refine the SHAHRP intervention. The workshop was attended by the pilot teachers, the primary writer of the intervention, and the SHAHRP research team. A triangulation of measures was adopted to assess the intervention including teacher and student monitoring. Each activity was discussed and assessed by the pilot teachers, according to intention, content, methods, relevance to age, timing and training. The process evaluation forms, which required comment on level of activity completion, student response, teacher response and suggestions to retain or modify for each activity, were reviewed. Each teacher also provided written student comments about what the young people liked and disliked about the intervention and recommendations for improvements.

These recommendations were incorporated into the SHAHRP intervention prior to longitudinal assessment of the program. One of the most valuable aspects of the pilot process was ‘testing the SHAHRP intervention in the real world' of the classroom, thereby gaining insight into the potential effectiveness of the harm reduction program that incorporated evidence within the school setting.

Study Design

The SHAHRP Randomised Controlled Trial was an efficacy study based on a quasi-experimental, intervention research design. The study explored the effects of a student focused, secondary school, alcohol curriculum program on young people’s alcohol-related knowledge, attitudes, patterns and context of alcohol use and alcohol related harm. The study reflects the Australian National Drug Strategy by adopting a harm minimisation approach; in this case, aiming to reduce the level of alcohol-related harm in young people who drink alcohol, and to reduce the harm experienced by those young people who do not drink alcohol, but socialise with others who do drink. Figure 1 provides an overview of the study design including phases of intervention and data collection.

Sampling: The study sample was selected using cluster sampling, with stratification by socio-economic area. The baseline sample size of 2300 young people considers the design effect created by cluster sampling. The fourteen schools involved in the SHAHRP study represent approximately 23% of government, secondary schools in the Perth metropolitan area. Random allocation to intervention and control conditions occurred by school.

Power calculations suggested that recruitment of a minimum of 800 students was required to achieve statistical power greater than 0.9 to detect an effect size of 0.15 with a coefficient variation of 25% through simple random sampling. The SHAHRP sample of 2343 students (intervention n=1111, control group n=1232) considered the design effect created by cluster sampling (design effect = 1.48; minimum sample required = 1184) and allowed scope for an expected attrition rate of fifteen percent per year.

Retention: The retention rate of study students was 75.9% over 32 months.

The SHAHRP survey instrument was purposely developed and tested to measure young people's knowledge, attitudes, patterns of use, context of use, harm associated with the young people own use of alcohol and harm associated with other people’s use of alcohol. The conceptual basis of the measures included in the SHAHRP survey draws on several studies, interventions and student generated data. In addition, several measures of harm were identified and defined by young people during focus groups conducted in the formative year of SHAHRP.

The anonymous, self-completion surveys were completed by study students under the guidance of trained researchers who instructed students and responded to questions following a set procedure. In addition, the survey protocol involved providing a verbal summary of the study and its design to both intervention and control students and teachers. In line with local Education Department policy classroom teachers were in attendance, however, they were requested to refrain from moving about the room to limit any possible influence on student’s responses.

Parametric assessment – validity and reliability

Extensive pre-testing of the SHAHRP questionnaire was undertaken during the formative period of the study. Validity measures included the assessment of face and content validity, using expert review, target group review (young people and teachers) and statistical review of the survey. Internal consistency and test-retest procedures were used to determine the reliability of the SHAHRP survey. The test-retest procedure was conducted with four classes of year nine students (approx. 120, 14-year-old students) from the pilot schools. These students completed the survey on two occasions, separated by two weeks. If the test-retest analysis indicated that an individual item was likely to be unreliable, then that item was excluded from the analysis and was not reported in the results. However, these items were maintained; as scale or index items such as face validity, content validity and internal consistency would be compromised with their exclusion.

Data analysis: Four scales/indices were developed to assess overall change. These were: knowledge index (19 items; internal consistency: 0.73); attitude scale (six items; internal consistency: 0.64); harm associated with own use of alcohol index (17 items; internal consistency: 0.9); and harm associated with others’ use of alcohol index (six items; internal consistency: 0.70). The knowledge index represents actual number of correct answers to knowledge questions; the attitude scale was a sum of the six attitude variables with lower scores representing safer alcohol related attitudes; and the harm indices measure number of harms experienced. Consumption was measured using two variables related to how often alcohol was consumed and how much alcohol was consumed per occasion. Risky drinking was also assessed. Context of use was measured using six variables related to situation of use to define non-drinkers, supervised drinkers and unsupervised drinkers. Multilevel modelling procedures were used to analyse the results of the study.

Citation

Details of and citation for the SHAHRP survey and parametric testing details (https://www.springer.com/us/book/9789811010095). University libraries will have free downloads of the book and chapter.

McBride, N. (2016). Assessment phase of the Intervention Research Framework: The measurement instrument and data collection (129-147). In: Intervention Research. A practical guide for developing evidence-based school prevention programmes. Springer: Singapore.

The results of the primary randomised controlled trial of the SHAHRP intervention showed significant knowledge, attitude, and behavioural effects early in the study, some of which were maintained for the duration of the study.

The intervention group had significantly greater knowledge during both intervention phases, and significantly safer alcohol-related attitudes to final follow-up. During First and Second phases of SHAHRP, intervention students consumed 31.4% and 31.7% less alcohol. Intervention students were 25.7% and 33.8% less likely to drink to risky levels after each intervention phase. The intervention reduced the harm that young people reported associated with their own use of alcohol, with intervention students experiencing 32.7%, 16.7% and 22.9% less harm from first follow-up onwards.

The SHAHRP results indicate that an intervention developed to reduce the alcohol-related harm that young people experience, can have an immediate effect in achieving this aim with a series of classroom-based lessons. Over the period of the study (from baseline to final follow-up 32 months later), young people who participated in the SHAHRP intervention had a 10% greater alcohol related knowledge, consumed 20% less alcohol, were 19.5% less likely to drink to harmful or hazardous levels, experienced 33% less harm associated with their own use of alcohol and 10% less harm associated with other people’s use of alcohol than did the control group. These results indicate that a relatively brief classroom alcohol intervention, that is evidence-based, can lead to behaviour change in young people’s alcohol use, particularly in risky use and the harm associated with their own use of alcohol.

The SHAHRP intervention was particularly successful with early risky drinkers, with early unsupervised drinkers from the intervention group significantly less likely to experience harm associated with their own use of alcohol, compared to the control group. Unsupervised drinkers experienced 18.4% less alcohol-related harm after participating in both phases of the SHAHRP intervention and this difference was maintained (19.4% difference) 17 months after the completion of SHAHRP.

The following summary of results provides a brief, simplified version of multilevel modelling analysis of the SHAHRP study data. There are several peer-reviewed journal publications which provide scientific analysis and discussion of the results.

X significant statistical difference between control and SHAHRP students in favour of the SHAHRP program. The summary of results is based on analysis using multilevel modelling.

SHAHRP has demonstrated a strong history of translational impact on policy and practice nationally and internationally, exemplified in the history of the SHAHRP program adoption into core activity by external health, education, youth and research organisations worldwide. Since 2011, when recording of these impacts was first initiated, over 2500 organisations from 54 countries and a diverse range of sectors have incorporated SHAHRP research into their practice and/or service provision.

Sectors implementing SHAHRP include secondary and tertiary education; drug and alcohol services; public health and health promotion services; youth and family services; juvenile justice and diversion services; defence forces and many others.

SHAHRP has been adopted in over 80 policies (25 times in Australian policy and 55 times in internationally).

Enablers for Behavioural, Policy and Practice Impact

The formative development of the SHAHRP intervention was critical to behavioural success. A review of the enablers of behavioural success include:

• Primacy of a harm reduction approach
  The primacy of a harm reduction approach is in the intervention and evaluation. This paradigm accepts alcohol use, and/or exposure to use as part of young people’s life experience thereby broadening the scope to impact on alcohol use and situation of use through acknowledgment of a greater range of alcohol-related experiences to which young people may be exposed and allowing intervention professionals to use a greater range of harm prevention and harm reduction strategies. A harm reduction approach also gives attention to young people who do drink and who choose to continue to drink, a group largely ignored in abstinence-based programs.

   

• Involvement of the target group
  The involvement of the target group/s was used to develop the intervention. The SHAHRP intervention was based on the needs and experiences of young people; as young people play a critical part in the formation, piloting and ongoing review of the intervention. By embedding the experiences of the target group into intervention development, SHAHRP has inherent relevance to the target group. This acceptance was acknowledged in the SHAHRP study, by teaching staff who note that young people are ‘switched on’ to this style of alcohol education and it was much easier to teach as a result in the increased level of student interest.
• ‘Best fit’
  ‘Best fit’ within schools by piloting and modifying the intervention based on teacher review, with a particular emphasis on functionality in the setting. Notably, two of the SHAHRP researchers had experience in the secondary school system as teachers and this ‘insider’ involvement was beneficial understanding various organisational barriers and enablers.
• Early intent
  An early intent to make the intervention readily available to schools at low or no cost. Access to evidence-based effective programs has been reported as a limitation to the development of the field. The history of external policy and practice access to and use of the SHAHRP intervention shows that formal dissemination of research is critical to uptake.

Awards

• Winner of the 2013 National Drug and Alcohol Award for excellence in Prevention and Community Education.
• Winner of the 2004 Excellence in research category of the National Drug and Alcohol Awards.

Australian SHAHRP Study (original Randomised Controlled Trial)

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11. McBride, N. (2003). A systematic review of school drug education. Health Education Research Theory and Practice, 18, (6), pp. 729-742. https://doi.org/10.1093/her/cyf050
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Northern Ireland SHAHRP replication study

1. McKay, M., Sumnall, H., McBride, N., and Harvey, S. (2014) The differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences: A multi-level growth modelling analysis. Journal of Adolescence; 37: 1057-1067. https://doi.org/10.1016/j.adolescence.2014.07.014
2. McBride, N., McKay, M. & Sumnall, H. (2013). SHAHRP: School Health and Alcohol Harm Reduction Project – Developments in Australia and the UK. Education and Health, 31, 79-83. http://hdl.handle.net/20.500.11937/20482
3. McKay, M., McBride, N., Sumnall, H. and Cole, J. (2012). Reducing the harm from adolescent alcohol consumption: Results from an adapted version of SHAHRP in Northern Ireland. Journal of Substance Use; 17(2), 98-12 1Early Online: 1-24. ISSN 1465-9891 print/ISSN 1475-9942 online. https://doi.org/10.3109/14659891.2011.615884
4. McKay, M., Cole, J., and Sumnall, H. (2011). Teenage thinking on teenage drinking: 15-16 year olds’ experiences of alcohol in Northern Ireland. Drugs: Education Prevention and Policy; 18(5): 323-332. https://doi.org/10.3109/09687637.2010.507559

United Kingdom SHAHRP replication study

1. Agus, A, McKay, M., Cole, J., Doherty, P., Foxcroft, D., Harvey, S., Murphy, L., Percy, A., and Sumnall, H. (2019). Cost-effectiveness of a combined classroom curriculum and parental intervention: economic evaluation of data from the Steps Towards Alcohol Misuse Prevention Programme cluster randomised controlled trial. BMJ Open; 9:e027951. https://doi.org/10.1136/bmjopen-2018-027951
2. Percy, A., Agus, A., Cole, J., Doherty, P., Foxcroft, D., Harvey, S., McKay, M., Murphy, L., and Sumnall, H. (2019). Recanting of previous reports of alcohol consumption within a large-scale clustered randomised control trial. Prevention Science; https://doi.org/10.1007/s11121-019-0981-2
3. Sumnall, H, Agus, A, Cole, JC, Doherty, P, Foxcroft, D, Harvey, S, McKay, MT, Murphy, L and Percy, A (2017) Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial. Public Health Research, 5 (2). https://doi.org/10.3310/phr05020
4. McKay M, Agus A, Cole J, Doherty, P., Foxcroft, D., Harvey, S., Murphy, L., Percy, A., and Sumnall, H. (2017). Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school-based and community-based cluster randomised controlled trial. BMJ Open 2018;8:e019722. https://doi.org/10.1136/bmjopen-2017-019722
5. McKay, M., Sumnall, H., Harvey, S., and Cole, J. (2017). Perceptions of school-based alcohol education by educational and health stakeholders: ‘Education as usual’ compared to a randomised controlled trial. Drugs: Education, Prevention and Policy; 25 (1): 77-87. https://doi.org/10.1080/09687637.2016.1273316
6. McKay, M., and Harvey, S. (2014). ‘Drink doesn’t mess with your head . . .you only get a hangover’: Adolescents’ views on alcohol and drugs, and implications for Education, Prevention and Intervention. Education and Health; 32 (1): 35-39. https://sheu.org.uk/sheux/EH/eh321mm.pdf

Brazil SHAHRP replication study

1. Amato, T., Opaleye, E., McBride, N. and Noto, A. (2021). Reducing alcohol-related risks among adolescents: a feasibility study of the SHAHRP program in Brazilian school. Ciencia & Saude Coletiva; 26(08): 3005-3018 Aug 2021. https://doi.org/10.1590/1413-81232021268.13472020