NIHR Signal Intervention delivered in Northern Irish and Scottish schools reduces binge drinking

Published on 18 July 2017

An alcohol misuse prevention programme reduced the number of 12 to 14-year-old school pupils reporting “binge” drinking 33 months after the course. The difference was 9% compared with usual education (26% vs 17%).

The NIHR-funded Steps Towards Alcohol Misuse Prevention Programme (STAMPP) was tested in a large trial in 105 schools in Northern Ireland and Scotland. It involved around 14 lessons spread over two years and a presentation evening with parents to reinforce the school lessons. Parental uptake of the presentation evening was so low that this part probably had no impact on the main findings.

Overall, pupils receiving STAMPP were 40% less likely to self-report drinking 6.5 or more units in a single episode for boys, or 4.5 units or more for girls, in the last 30 days.

No differences were found for self-reported behaviours like getting in trouble with the police or A&E attendance, nullifying anticipated societal cost savings. Qualitative research showed that teachers found it easy to deliver and students liked the content. The intervention was relatively cheap at £15 per pupil.

STAMPP, or an adapted version, could be considered by local services as an option to reduce binge drinking.

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Why was this study needed?

In England in 2015, 38% of 11 to 15-year-olds had tried alcohol, while in Scotland in 2014, the figures were 32% of 13-year-olds and 70% for 15-year-olds.

National surveys show underage drinking is declining across the UK but remains high in some parts of Scotland and Northern Ireland.

UK teenagers are also among the most likely in Europe to report frequently drinking heavily and being drunk. This can damage their health, school attainment and general wellbeing immediately and in the future.

Research from 2014 showed a school-based alcohol misuse prevention programme, called SHAHRP, had been effective in Australia.

This large trial adapted SHAHRP by adding a brief parental intervention and aimed to evaluate whether it worked in Scotland and Northern Ireland.

What did this study do?

This cluster randomised controlled trial randomised 105 schools in Northern Ireland and Glasgow/Inverclyde Education Authority areas.

Half the schools (52 schools, 6,379 pupils) received the STAMPP alcohol prevention programme and the rest received education as normal (53 schools, 6,359 pupils). Pupils were 12 to 14 years old.

The STAMPP involves school-based learning and skills development in alcohol harm reduction in 14 to 15 sessions over two years and a brief parental presentation evening aiming to ensure consistency at home and school. The classroom component was delivered by trained teachers in two phases over two years, and the parental component was a presentation delivered by a facilitator at specially arranged parent evenings on school premises. This was followed up a few weeks later by a posted information leaflet. The trial also looked at the costs and cost-effectiveness of the programme.

The trial was large and likely to be reliable. However, it may have under-estimated drinking related outcomes as it relied on pupils accurately self-reporting illegal under-age drinking and socially undesirable behaviours, like fighting.

What did it find?

  • Uptake of the school-based component of STAMPP was high and well-received by pupils and teachers. By contrast, the parental-component had such low uptake that the implementation was deemed to have failed. The results predominately reflect the school-based competent of STAMPP only.
  • Self-reported heavy episodic drinking in the last 30 days (classed as male students consuming 6 units or more and female students 4.5 units or more of alcohol in a single episode) was 9% lower in those receiving the STAMPP compared with those receiving education as normal at 33-month follow-up (26% vs 17%, p<0.001). Eleven students need to receive the intervention for one to report no binges in the previous month.
  • This meant at almost 3 years pupils receiving the STAMPP were 40% less likely to report a heavy drinking episode in the last 30 days compared with those receiving their usual education (odds ratio 0.60, 95% confidence interval 0.49 to 0.73).
  • There were no differences in self-reported harms caused by pupils’ own drinking, such as getting into fights after drinking, poorer school performance and trouble with friends and family (mean average 1.3 incidents in the intervention group versus 1.4 in the control group). As nearly two-thirds of participants reported no harms, the study authors commented that this may not have been an adequately sensitive measure for 12 to 14-year-olds.  
  • Average cost of the STAMPP was £818 per school and £15 per pupil. As no lowering in self-reported harms from alcohol were observed, there were no savings to the wider public sector, such as in policing or hospital A&E. Average cost of just the school-based component was £692 per school and £13 per pupil.

What does current guidance say on this issue?

NICE has a pathway on preventing alcohol-use disorders that includes school-based interventions. 

This provides relevant guidance on education programmes, advice on what to do for pupils thought to be drinking harmful amounts of alcohol and achieving local partnerships such as with children’s services and the police.

The pathway recommendations are based on studies from NICE’s Effective Interventions Library, which includes reference to the original SHAHRP study from Australia, among others.

NICE are currently in the process of producing new guidelines on alcohol interventions in schools but have not yet specified an expected publication date.

What are the implications?

The STAMPP intervention, as implemented in this trial, appears promising for those seeking to reduce heavy drinking in pupils aged 12 to 14 with a modest cost. It is not clear whether this reduction is carried through into later adolescence or adulthood.

NICE have already incorporated the Australian SHAHRP study into their current guidelines, and the partial implementation of STAMPP in this trial means it more closely resembled the original SHAHRP intervention than planned.  

Trialling this intervention in areas of the UK with high under-age drinking, might be a useful next step and could help to better quantify the potential impact on UK health or societal costs.

Citation and Funding

Sumnall H, Agus A, Cole J, et al. Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial. Public Health Res. 2017;5(2).

This project was funded by the National Institute for Health Research Public Health Research programme (project number 10/3002/09). The Public Health Agency of Northern Ireland and Education Boards of Glasgow/Inverclyde provided some intervention costs. Diageo – “a global leader in beverage alcohol” - provided funds to print some workbooks. The remaining intervention costs were internally funded.

Bibliography

Drinkaware. Your child or teenagers health. London: Drinkaware; 2017.

IAS. Prevalence of underage drinking. London: The Institute of Alcohol Studies; 2017.

McBride N, Farringdon F, Midford R, et al. Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction. 2004; 99(3):278–91.

NICE. Alcohol interventions in schools. Public Health Guideline in development. GID-NG10030. London: National Institute for Health and Care Excellence; 2017.

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

NICE. Prevention alcohol use disorders: School-based interventions. NICE pathway. London: National Institute for Health and Care Excellence; 2017.

Why was this study needed?

In England in 2015, 38% of 11 to 15-year-olds had tried alcohol, while in Scotland in 2014, the figures were 32% of 13-year-olds and 70% for 15-year-olds.

National surveys show underage drinking is declining across the UK but remains high in some parts of Scotland and Northern Ireland.

UK teenagers are also among the most likely in Europe to report frequently drinking heavily and being drunk. This can damage their health, school attainment and general wellbeing immediately and in the future.

Research from 2014 showed a school-based alcohol misuse prevention programme, called SHAHRP, had been effective in Australia.

This large trial adapted SHAHRP by adding a brief parental intervention and aimed to evaluate whether it worked in Scotland and Northern Ireland.

What did this study do?

This cluster randomised controlled trial randomised 105 schools in Northern Ireland and Glasgow/Inverclyde Education Authority areas.

Half the schools (52 schools, 6,379 pupils) received the STAMPP alcohol prevention programme and the rest received education as normal (53 schools, 6,359 pupils). Pupils were 12 to 14 years old.

The STAMPP involves school-based learning and skills development in alcohol harm reduction in 14 to 15 sessions over two years and a brief parental presentation evening aiming to ensure consistency at home and school. The classroom component was delivered by trained teachers in two phases over two years, and the parental component was a presentation delivered by a facilitator at specially arranged parent evenings on school premises. This was followed up a few weeks later by a posted information leaflet. The trial also looked at the costs and cost-effectiveness of the programme.

The trial was large and likely to be reliable. However, it may have under-estimated drinking related outcomes as it relied on pupils accurately self-reporting illegal under-age drinking and socially undesirable behaviours, like fighting.

What did it find?

  • Uptake of the school-based component of STAMPP was high and well-received by pupils and teachers. By contrast, the parental-component had such low uptake that the implementation was deemed to have failed. The results predominately reflect the school-based competent of STAMPP only.
  • Self-reported heavy episodic drinking in the last 30 days (classed as male students consuming 6 units or more and female students 4.5 units or more of alcohol in a single episode) was 9% lower in those receiving the STAMPP compared with those receiving education as normal at 33-month follow-up (26% vs 17%, p<0.001). Eleven students need to receive the intervention for one to report no binges in the previous month.
  • This meant at almost 3 years pupils receiving the STAMPP were 40% less likely to report a heavy drinking episode in the last 30 days compared with those receiving their usual education (odds ratio 0.60, 95% confidence interval 0.49 to 0.73).
  • There were no differences in self-reported harms caused by pupils’ own drinking, such as getting into fights after drinking, poorer school performance and trouble with friends and family (mean average 1.3 incidents in the intervention group versus 1.4 in the control group). As nearly two-thirds of participants reported no harms, the study authors commented that this may not have been an adequately sensitive measure for 12 to 14-year-olds.  
  • Average cost of the STAMPP was £818 per school and £15 per pupil. As no lowering in self-reported harms from alcohol were observed, there were no savings to the wider public sector, such as in policing or hospital A&E. Average cost of just the school-based component was £692 per school and £13 per pupil.

What does current guidance say on this issue?

NICE has a pathway on preventing alcohol-use disorders that includes school-based interventions. 

This provides relevant guidance on education programmes, advice on what to do for pupils thought to be drinking harmful amounts of alcohol and achieving local partnerships such as with children’s services and the police.

The pathway recommendations are based on studies from NICE’s Effective Interventions Library, which includes reference to the original SHAHRP study from Australia, among others.

NICE are currently in the process of producing new guidelines on alcohol interventions in schools but have not yet specified an expected publication date.

What are the implications?

The STAMPP intervention, as implemented in this trial, appears promising for those seeking to reduce heavy drinking in pupils aged 12 to 14 with a modest cost. It is not clear whether this reduction is carried through into later adolescence or adulthood.

NICE have already incorporated the Australian SHAHRP study into their current guidelines, and the partial implementation of STAMPP in this trial means it more closely resembled the original SHAHRP intervention than planned.  

Trialling this intervention in areas of the UK with high under-age drinking, might be a useful next step and could help to better quantify the potential impact on UK health or societal costs.

Citation and Funding

Sumnall H, Agus A, Cole J, et al. Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial. Public Health Res. 2017;5(2).

This project was funded by the National Institute for Health Research Public Health Research programme (project number 10/3002/09). The Public Health Agency of Northern Ireland and Education Boards of Glasgow/Inverclyde provided some intervention costs. Diageo – “a global leader in beverage alcohol” - provided funds to print some workbooks. The remaining intervention costs were internally funded.

Bibliography

Drinkaware. Your child or teenagers health. London: Drinkaware; 2017.

IAS. Prevalence of underage drinking. London: The Institute of Alcohol Studies; 2017.

McBride N, Farringdon F, Midford R, et al. Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction. 2004; 99(3):278–91.

NICE. Alcohol interventions in schools. Public Health Guideline in development. GID-NG10030. London: National Institute for Health and Care Excellence; 2017.

NICE. Alcohol: school-based interventions. PH7. London: National Institute for Health and Care Excellence; 2007.

NICE. Prevention alcohol use disorders: School-based interventions. NICE pathway. London: National Institute for Health and Care Excellence; 2017.

Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial

Published on 12 April 2017

Sumnall H, Agus A, Cole J, Doherty P, Foxcroft D, Harvey S, McKay M, Murphy L & Percy A.

Public Health Research Volume 5 Issue 2 , 2017

Background Alcohol use in young people remains a public health concern, with adverse impacts on outcomes such as health, well-being, education and relationships. Objectives To assess the effectiveness and cost-effectiveness of a combined classroom curriculum and parental intervention on self-reported alcohol use [heavy episodic drinking (HED)] and alcohol-related harms (indicators such as getting into fights after drinking, poorer school performance and trouble with friends and family). Design A two-arm, cluster randomised controlled trial with schools as the unit of randomisation. Setting A total of 105 post-primary schools in Northern Ireland (NI) and Glasgow/Inverclyde Educational Authority areas. Participants A total of 12,738 male and female secondary school students (intervention delivered when students were in school year 9 in NI or S2 in Scotland in the academic year 2012–13 and aged 12–13 years) were randomised. Randomisation and baseline (T0) surveys took place when children were in school year 8 or S1. Schools were randomised (1 : 1) by an independent statistician to the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) or to education as normal (EAN). All schools were stratified by free school meal provision. Schools in NI were also stratified by school type (male/female/coeducational). Interventions STAMPP combined a school-based alcohol harm reduction curriculum [an adapted version of the School Health and Alcohol Harm Reduction Project (SHAHRP)] and a brief parental intervention designed to support parents in setting family rules around drinking. The classroom component comprised two phases delivered over 2 years, and the parental component comprised a standardised presentation delivered by a trained facilitator at specially arranged parent evenings on school premises. This was followed up a few weeks later by an information leaflet mailed to all intervention pupils’ parents highlighting the main points of the evening. Main outcome measures (1) Self-reported HED (defined as self-reported consumption of ≥ 6 units in a single episode in the previous 30 days for male students and ≥ 4.5 units for female students) assessed at 33 months from baseline (T3); and (2) the number of self-reported harms (harms caused by own drinking) assessed at T3. Data sources Self-completed pupil questionnaires. Results At final follow-up (T3), data were available for 5160 intervention and 5073 control pupils for the HED outcome, and for 5234 intervention and 5146 control pupils for the self-reported harms outcome. The intervention reduced self-reported HED compared with EAN (p < 0.001), but did not reduce self-reported harms associated with own drinking. The odds ratio for the intervention effect on HED was 0.596 (standard error 0.0596, 95% confidence interval 0.490 to 0.725). The mean cost of delivery per school was £818 and the mean cost per individual was £15. There were no clear cost savings in terms of service utilisation associated with the intervention. The process evaluation showed that the classroom component engaged and was enjoyed by pupils, and was valued by teachers. Schools, students, intervention trainers and delivery staff (teachers) were not blind to study condition. Data collection was undertaken by a team of researchers that included the trial manager and research assistants, some of whom were not blinded to study condition. Data analysis of primary and secondary outcomes was undertaken by the trial statistician, who was blinded to the study condition. Limitations Although the classroom component was largely delivered as intended, there was very low attendance at the parent/carer event; however, all intervention pupils’ parents/carers received an intervention leaflet. Conclusions The results of this trial provide some support for the effectiveness and cost-effectiveness of STAMPP in reducing heavy episodic (binge) drinking, but not in reducing self-reported alcohol-related harms, in young people over a 33-month follow-up period. As there was low uptake of the parental component, it is uncertain whether or not the intervention effect was accounted for by the classroom component alone. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 2. See the NIHR Journals Library website for further project information. The Public Health Agency of NI and Education Boards of Glasgow/Inverclyde provided some intervention costs. Diageo provided funds to print some workbooks. The remaining intervention costs were internally funded.

How was SHARPP planned and delivered?

Phase 1 of the SHAHRP classroom curriculum aimed to consist of six lessons (with 16 activities) delivered to students in school year nine or S2 (aged at least 12 years) by trained teachers. Phase 2 aimed for four lessons (with 10 activities) delivered in school year 10 or S3 (aged 13–14 years) by trained teachers. Actual implementation was spread over more lessons, around eight in phase 1 and six in phase two.

The brief intervention delivered to the parent(s)/carer(s) of children in the intervention comprised a short, standardised presentation delivered by a team of trained facilitators (independent of the trial team) at specially arranged parent evenings on school premises.

Uptake of this was very low. In total, 319 parents/carers attended the intervention nights in Northern Ireland (9% of those eligible), and 63 parents attended in Scotland (2.5% of those eligible).

Expert commentary

Adolescent drunkenness during “binges” is not common everywhere, but such experiences carry risks to the young person drinking, their family and their community. Compared to other nations, British 15 year olds are more likely to get drunk.

School children aged 12 to 14 years old began this experiment, with the frequency of binges and self-reported harms measured, up to age 15 to 16. The reduction in bingeing with a classroom-based intervention is promising. Few adolescents reported harm in either the experimental or control groups. Previous research found harm really takes off between ages 16 to 19. Parents were not successfully engaged in this experiment, which probably reduced its impact.

Woody Caan, Co-Chair, Alcohol Special Interest Group, Faculty of Public Health