Schools

Alcohol and harm in young people

Within a period of about 10 years, young people change from individuals who have never had an alcoholic drink to individuals who, as an age group, are a heavy drinking section of the population.

The teen years are a vulnerable stage in young people’s development, due in part to increased exposure to and use of alcohol and other drugs. Young Australians aged 12-17 years are over four times more likely to have consumed alcohol than any form of illicit drug. The harm experienced by young people in alcohol use situations is associated with their own consumption of alcohol and other people's consumption of alcohol, and tends to occur with single occasion use (acute) rather than from long term use (chronic). Over a fifth of young people who consume alcohol are at risk of an injury or harm for each single drinking occasion. Some of these harms, like sexual assault and violence, can have a lifelong impact.

Alcohol is also associated with the three leading causes of mortality among young people (unintentional injuries, homicide and suicide) and is a leading risk factor for premature death and disability for secondary school youth aged 15-18 years old.

Why provide a school program?

The success of the SHAHRP program in modifying alcohol-related behaviours is an important program impact, as alcohol use and risk of harm is high. The short- and long-term harms associated with alcohol use in young people are considerable as alcohol also acts as a precursor to other health and lifestyle problems experienced by young people that can negatively impact their future. Alcohol consumption is a risk factor for unsafe sexual practices, violence and injury, adverse behavioural problems, academic failure, mental illness and social problems. In addition, early age of onset and feeling drunk during initial drinking experiences increases probability of a problem drinking in adulthood.

In summary

Young people generally have little experience in alcohol use situations and therefore have relatively limited capacity to predict factors that will impact on the event and potential outcomes. Young people also have lower tolerance to the effects of alcohol which makes the loss of physical, cognitive and emotional functions more immediate. In Australia, the age of first alcohol use remains stable , however, alcohol is still estimated to be responsible for 65% of the burden of disease in Australia compared to 19% for tobacco and 16% for illicit drugs, respectively. To reduce this burden, effective early intervention and prevention strategies, such as SHAHRP, play an important part in reducing the burden of alcohol.

The SHAHRP intervention is comprised of 13 harm minimisation classroom lessons, over a two-year period. The SHAHRP lessons assist young people by enhancing their ability to identify and use strategies that will reduce the potential for harm in drinking situations and that will assist in reducing the impact of harm once it has occurred.

Teacher training

Teacher training is ideally conducted before each phase of the SHAHRP intervention. During Phase One, teachers are provided with two days of training that provides an overview of the study behaviour outcomes, evidence-based components, and interactive modelling of each Phase One activity. Phase Two training is conducted over two days for teachers new to SHAHRP. On the first day of training, these teachers are briefed on the research aspects of SHAHRP and Phase One intervention activities. On day two, all teachers participate in interactive modelling of Phase Two activities. Teachers who are experienced in interactive techniques are recommended as SHAHRP teachers.

Teacher manual

The SHAHRP Teacher Manual provides specific written guidance for teachers. The manual included detailed and structured lesson plans for eight 60-minute lessons in the First Phase and five 50-minute lessons in the Second Phase. Each lesson plan includes sample questions to help facilitate discussion and processing of activities and to focus on activity intention, coaching points to aid in the management of the activities, and background information about alcohol-related issues. Additional coaching points have been included in the teacher manual and are based on feedback from teachers who have previously taught the program.

Student workbooks

The SHAHRP program is largely activity based, however, student workbooks are available for each phase to stimulate and engage students’ interest, provide information, encourage young people to further explore issues and to record what they have learned to consolidate practical activities. Qualitative results from the SHAHRP study show that young people and teachers think the books are appealing and great to use as reinforcement to the interactive activities.

Trigger Visual

A Trigger Visual is used in Phase Two of SHAHRP. The video features scenarios that young people may experience in alcohol use situations to prompt discussion about how to minimise the harms associated with alcohol use.

The SHAHRP Intervention Components may be downloaded from the Resources page.

Skills basis

The SHAHRP activities incorporate various strategies for interaction including delivery of utility information; skill rehearsal; individual and small group decision making; and discussions based on scenarios suggested by young people, with an emphasis on identifying alcohol-related harm and strategies to reduce harm. Interactive involvement is emphasized, with two-thirds of activities being primarily interactive and another 15% requiring some interaction between young people. Interactive involvement between young people provides important practice in reducing harm associated with alcohol use that is relevant and acceptable to young people, and this is a critical aspect of lessons using an evidence-based approach.

Ages for delivery

The SHAHRP Randomised Controlled Trial indicates that implementation should be based on local prevalence data. Phase One of SHAHRP is designed to be implemented in the year prior to prevalence data indicating that experimentation has started to occur. Phase Two of SHAHRP is designed to be implemented when the prevalence data indicates that young people are starting to experiment with alcohol. In Australia, prevalence data has been consistent overtime and indicates that implementation should occur in year eight (12/13 year’s old) and year nine (13/14 year’s old) of secondary school.

Dose and fidelity of implementation

To maximise effectiveness when using the SHAHRP program, it is important to teach the program as closely as possible to how it is documented in the teacher manual. The student behaviour changes that came during the SHAHRP Randomised Controlled Trial were based on teaching the program to at least 80% as documented. During the SHAHRP Randomised Controlled Trial study teachers also received training in the delivery of the program to students. Two days of training were conducted for Phase One of the SHAHRP program, and one day of training for Phase Two (two days for those new to SHAHRP). The training involved an overview of the research background and program development. In addition, teachers participated in each activity to model how the activity should be taught and allowed teachers to assess implementation and management requirements.

In targeting alcohol, a key issue affecting the health and wellbeing of young people and their communities, the School Health and Alcohol Harm Reduction Project (SHAHRP) fosters knowledge, understanding and skills for decision making and teaches the application of problem-solving techniques to support healthy living.

Many teachers, from a variety of schools in Australia covering a broad socio-economic range, have taught the SHAHRP program. The majority of schools implement the SHAHRP program within the Health and Physical Education learning area, however, teachers from other learning areas have successfully taught the SHAHRP program.

The SHAHRP alcohol education program is appropriate for students in the middle years of schooling (years 6-10). The 15-lesson, 2-phase model is delivered over 2 sequential years of schooling.

Research evidence demonstrates that Phase One has most behavioural impact when it is delivered immediately prior to experimentation (13 years of age), and Phase Two when it is delivered in the year that the majority of students initiate experimentation (14 years of age).

The School Health and Alcohol Harm Reduction Project (SHAHRP) program espouses principles of good practice. The program:

1. Has a strong evidence base and has been evaluated in Australia, Northern Ireland, the UK and Brazil for its behavioural impact on young people.
2. Follows good practice in school alcohol and drug education by:
   • Addressing alcohol at a critical time in youth development (‘inoculation’ pg. 14, SHAHRP Teacher manual) and at a transition time in schooling.
   • Placing the teacher at the centre of an extended learning experience for students.
   • Enabling the teacher or support staff to follow up any issues students may have.
   • Adopting an approach of sequential learning.
   • Encouraging alcohol education embedded in the curriculum.
   • Using interactive pedagogy and student-centred learning strategies.
3. Aligns with and contributes to achieving learning outcomes of the Australian curriculum’s:
   • General capabilities.
   • Health and Physical Education curriculum strand: Personal, social and community health.
4. Adopts a strength-based approach. Participation in the SHAHRP program will strengthen young people’s capacity to make safe, or safer, decisions about alcohol by focusing on age related normative use, harm assessment and prediction, and realistic age-appropriate harm reduction strategies.

To access full details of SHAHRP’s link to the Australian curriculum please see: https://positivechoices.org.au/teachers/shahrp-school-health-and-alcohol-harm-reduction-project

The behavioural findings of SHAHRP have made an important contribution to the science and evidence base in the field, affording the SHAHRP project recognition as world leading in this area. This recognition demonstrated in four replications of the study, repeated identification in Cochrane reviews, and over 2000 citations of the key study publications.

Several replications of the SHAHRP longitudinal study have occurred, including:

• University of Liverpool, Northern Ireland replication of SHAHRP. A non-randomised controlled longitudinal trial.
• Liverpool John Moore’s University, National Institute of Health funding (UK), SHAHRP Alcohol Misuse Prevention Program. School-based cluster randomised controlled trial.
• Universidade Federal de São Paulo, The SHAHRP adaptation and replication conducted in secondary schools in Brazil. A non-randomised controlled trial.

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.

The teacher and student comments below reflect some of the positive experiences with SHAHRP at the school level.

Student comments

‘I liked the way we were able to talk freely about our opinions in groups and then explain it to the class.’

‘It was fun and very progressive.’

‘People don't realise how dangerous and how harmful the consequences are of drinking too much and getting out of control. Maybe this will help some to consider the harm before their actions.’

‘I learnt a bit and also related it to my own previous personal situations and also that of friends. It made me see things a little differently.’

 

Teacher comments

‘I have been teaching for twenty-five years in a very traditional way, but I found it was just what the kids and I needed!’

‘The hands on, practical activities were the highlight for me and the kids. They were easier to manage than I expected because the kids just loved doing them so much and got so much out of them.’

‘Both myself and my class benefited a great deal from being involved in this project and I will definitely be teaching it again.’

‘Fantastic program! Even the reluctant kids participated quite well. I like the variety of activities.’

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.

Figure 1: Overview of Study Design

Month and year	2/97	5/97 8/97	10/97	5/98	10/98	10/99	10/00	10/01
Intervention group	O1	X1	O2	X2	O3	O4	O5	O6
Control group	O1		O2	X	O3	O4	O5	O6

Key:	X: Intervention	X control school regular alcohol education
	O: Observation

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 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.

The Results of the SHAHRP Study to date

	After phase one (13 year olds)	After phase two (14 year olds)	One year after phase two (no lessons) (15 year olds)
Knowledge	X 21.5%	X 9.2%	4.5%
Attitudes	X	X	X
Consumption Total	X 31.4%	X 31.7%	9.2%
Consumption Risky	X 25.7%	X 33.8%	X 4.2%
Context of use	X	X	X
Harm associated with own use	X 32.7%	X 16.7%	X 22.9%
Harm associated with other's use		10%	12.8%

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.

Training is recommended for teachers new to SHAHRP or new to an interactive teaching style. Ideally SHAHRP is taught by teachers in the school who know and have an ongoing relationship with the students. Teachers from both the English and Health Education teaching areas have taught SHAHRP.

Training in SHAHRP is not readily available. As a research institute the National Drug Research Institute does not have the capacity to provide training. However, several Australian educators are registered as SHAHRP training facilitators. The National Drug Research Institute has links to this consortium of trainers who have been trained as SHAHRP facilitators but who work full time elsewhere.

If you are interested in having a trainer conduct a SHAHRP training workshop, please submit your request via the Feedback form. This will be forwarded to the SHAHRP training consortium to see if anyone is available to facilitator your training. Training is provided at cost recovery so this would include airfares and accommodation as well as other cost (venue hire, catering, trainer fee, equipment etc.) Cost items would need to be negotiated with the SHAHRP training consortium staff.

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
12. McBride, N., Farringdon, F., Midford, R., Meuleners, L., and Phillips, M. (2003). Early unsupervised drinking - reducing the risks. The School Health and Alcohol Harm Reduction Project. Drug and Alcohol Review, 22, (3), pp. 263-276. https://doi.org/10.1080/0959523031000154409
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14. McBride, N. (2002). School Health and Alcohol Harm Reduction Project: Reducing Alcohol Related Harms in Young People. PhD thesis. Curtin University: Perth, Western Australia.
15. McBride, N. (2002). Systematic literature review of school drug education. National Drug Research Institute. NDRI Monograph No. 5. Curtin University of Technology, Perth, Western Australia. ISBN: 1 74067 188 0.
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17. Midford, R., Munro, G., McBride, N., Snow, P., and Ladzinski, U. (2002). Principles that underpin effective school-based drug education. Journal of Drug Education; 32, (4): 363-386. https://doi.org/10.2190%2FT66J-YDBX-J256-J8T9
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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