Opinion

There has been growing interest in the Australian community about alcohol and especially its negative effects and problems associated with violence, injury, traffic crashes, unwanted sexual encounters, ‘sexting’, as well as potential long term consequences.  Growing concern has resulted in increased emphasis on the need for interventions and prevention strategies that work. In this context, it is important to consider what role schools might effectively play.

Over several decades, a diverse range of school-based prevention and intervention programs have been developed to circumvent alcohol-related risks.  Mostly they have originated from the United States.

Traditionally, school-based programs were didactic with a knowledge-deficit curriculum-based focus. Early approaches assumed that if young people had more knowledge about the effects of alcohol that this would avert problems. Later programs addressed affective or personality deficits (e.g. low self-esteem, poor communication and interpersonal skills) (Kuntsche, Knibbe et al. 2006), and then social skills (Gorman 1996, Botvin and Griffin 2002). More recently, interventions extended beyond the classroom-based to include parents, the social and physical environment, school policies, informal curriculum and links with community (Parsons, Stears et al. 1996, International Union of Health Promotion and Education 2009, Lee 2009, Tang, Nutbeam et al. 2009).

However, until very recently, there was little solid evidence of the efficacy of school-based programs.  A recent Cochrane review (Foxcroft and Tsertsvadze 2011, Foxcroft and Tsertsvadze 2012) found evidence to be poor, with a wide range of outcomes, and many programs showing no effect at all. Given this, NCETA undertook a wider systematic review[1] to examine the evidence of what works and give clear guidance about constitutes ‘best buys’. The review expanded on the Cochrane review to examine the full array of school-based alcohol interventions available.

Methodological approach

A modified NHMRC methodological approach was used to appraise, classify and grade evidence (NHMRC 1999, NHMRC 2007, NHMRC 2009). Relevant programs were identified through a detailed search process and assessed for 1) level of evidence, 2) consistency of findings, 3) ‘clinical’ impact, 4) generalisability of findings and 5) applicability of findings, then graded as: A (evidence trusted to guide practice), B (evidence trusted to guide practice in most situations), C (evidence provides some support), or D (evidence is weak).

A user-friendly 1, 2 or 3 Star rating system was then used to reflect overall effectiveness, grade of evidence and outcomes. To receive a 3 Star rating (‘Good evidence of effect’), a study needed to be well conducted and show consistent positive outcomes. 2 Star programs had ‘Some evidence of positive effect’ from well conducted studies. 1 Star programs were inconclusive because either the research overall was poorly conducted (Grade C or D body of evidence is weak and recommendation must be applied with caution) and/or the research inconsistently showed good outcomes. Zero star rating (‘No evidence of effect’) were well conducted studies (Grade A or B) that showed no positive outcomes. Programs that were well conducted (Grade A or B) that showed negative outcomes, such as increases in risky drinking behaviours, were rated ‘X’.

Findings

A total of 70 studies were reviewed that involved 40 different school-based programs. The programs were mainly from North America (n=22) and Australia (n=10), with the remaining 8 from Germany, Canada, Sweden, Netherlands, Norway, and Europe.

Of the 40 programs reviewed only three had strong evidence of a positive effect. Seven showed some evidence of positive effect, 19 were inconclusive, nine had no evidence of effect and two resulted in negative outcomes, such as increases in alcohol use.

Encouragingly, of the three programs that demonstrated the strongest efficacy (i.e,  the 3 Star Programs), one was Australia’s Climate Schools program developed by NDARC (the other two were American programs). And, among the seven programs that received a 2 Star rating, one was Australia’s SHAHRP program developed by NDRI.

Take home message:

1. There is increasingly good evidence of which school-based programs are effective and that schools might employ to best advantage to address alcohol
2. Evidence of effective programs is limited to a relatively small number of programs
3. Of the programs that received a 3 Star rating, one was NDARC’s Climate Schools, and of 2 Star programs one was NDRI’s SHAHRP program.

We are now better placed to effectively address alcohol issues through the school sector than ever before and are able to use Australian-based programs to do so. Importantly, any exhortations for schools to be proactively involved in addressing alcohol issues can now rely on evidence based programs of demonstrated efficacy rather than operate on good will alone.