Professor David Foxcroft

Background.
Universal, school-based behaviour management interventions can produce meaningful improvements in children’s behaviour and other outcomes. However, the UK evidence base for these remains limited.

Objective.
The objective of this trial was to investigate the impact, value for money and longer-term outcomes of the Good Behaviour Game. Study hypotheses centred on immediate impact (hypothesis 1); subgroup effects (at-risk boys, hypothesis 2); implementation effects (dosage, hypothesis 3); maintenance/sleeper effects (12- and 24-month post-intervention follow-ups, hypothesis 4); the temporal association between mental health and academic attainment (hypothesis 5); and the health economic impact of the Good Behaviour Game (hypothesis 6).

Design.
This was a two-group, parallel, cluster-randomised controlled trial. Primary schools (n = 77) were randomly assigned to implement the Good Behaviour Game for 2 years or continue their usual practice, after which there was a 2-year follow-up period.

Setting.
The trial was set in primary schools across 23 local authorities in England.

Participants.
Participants were children (n = 3084) aged 7–8 years attending participating schools.

Intervention.
The Good Behaviour Game is a universal behaviour management intervention. Its core components are classroom rules, team membership, monitoring behaviour and positive reinforcement. It is played alongside a normal classroom activity for a set time, during which children work in teams to win the game to access the agreed rewards. The Good Behaviour Game is a manualised intervention delivered by teachers who receive initial training and ongoing coaching.

Main outcome measures.
The measures were conduct problems (primary outcome; teacher-rated Strengths and Difficulties Questionnaire scores); emotional symptoms (teacher-rated Strengths and Difficulties Questionnaire scores); psychological well-being, peer and social support, bullying (i.e. social acceptance) and school environment (self-report Kidscreen survey results); and school absence and exclusion from school (measured using National Pupil Database records). Measures of academic attainment (reading, standardised tests), disruptive behaviour, concentration problems and prosocial behaviour (Teacher Observation of Child Adaptation Checklist scores) were also collected during the 2-year follow-up period.

Results.
There was no evidence that the Good Behaviour Game improved any outcomes (hypothesis 1). The only significant subgroup moderator effect identified was contrary to expectations: at-risk boys in Good Behaviour Game schools reported higher rates of bullying (hypothesis 2). The moderating effect of the amount of time spent playing the Good Behaviour Game was unclear; in the context of both moderate (≥ 1030 minutes over 2 years) and high (≥ 1348 minutes over 2 years) intervention compliance, there were significant reductions in children’s psychological well-being, but also significant reductions in their school absence (hypothesis 3). The only medium-term intervention effect was for peer and social support at 24 months, but this was in a negative direction (hypothesis 4). After disaggregating within- and between-individual effects, we found no temporal within-individual associations between children’s mental health and their academic attainment (hypothesis 5). Last, our cost–consequences analysis indicated that the Good Behaviour Game does not provide value for money (hypothesis 6).

Limitations.
Limitations included the post-test-only design for several secondary outcomes; suboptimal implementation dosage (mitigated by complier-average causal effect estimation); and moderate child-level attrition (18.5% for the primary outcome analysis), particularly in the post-trial follow-up period (mitigated by the use of full information maximum likelihood procedures).

Future work.
Questions remain regarding programme differentiation (e.g. how distinct is the Good Behaviour Game from existing behaviour management practices, and does this makes a difference in terms of its impact?) and if the Good Behaviour Game is impactful when combined with a complementary preventative intervention (as has been the case in several earlier trials).

Conclusion.
The Good Behaviour Game cannot be recommended based on the findings reported here.

Aims: The aim of this paper was to explore responses to alcohol health information labels from a cross sectional survey of people who drink alcohol from 29 countries.

Design: This paper draws on findings from the Global Drug Survey (GDS) – an annual cross sectional online survey.

Participants: 75,969 (64.3% male) respondents from 29 countries were included in the study.

Measures: Respondents were shown seven health information labels (topics were heart disease, liver, cancer, calories, violence, taking two days off and myth of benefits of moderate drinking). They were asked if the information was new, believable, personally relevant, and if it would change their drinking. A multivariate multilevel Bayesian logistic regression model was used to estimate predicted probabilities for newness, believability, relevance and if messages would change drinking behaviour by country and information label.

Findings: Predicted probabilities showed substantial variability in responses across countries. Respondents from Colombia, Brazil and Mexico were more likely to consider drinking less as well as have lower levels of previous awareness. Those from Denmark and Switzerland were not as likely to say the labels would make them consider drinking less.  The cancer message was consistently the newest and most likely to make people consider drinking less across countries.

Conclusions: Country differences in responses to messages can be used to create targeted harm reduction measures as well as inform what should be on labels.  The provision of such health information on alcohol product labels may play a role in raising awareness of the risk of drinking.

Objectives The Strengthening Families Programme 10–14 (SFP10-14) is a USA-developed universal group-based intervention aiming to prevent substance misuse by strengthening protective factors within the family. This study evaluated a proportionate universal implementation of the adapted UK version (SFP10-14UK) which brought together families identified as likely/not likely to experience/present challenges within a group setting.

Design Pragmatic cluster-randomised controlled effectiveness trial, with families as the unit of randomisation and embedded process and economic evaluations.

Setting The study took place in seven counties of Wales, UK.

Participants 715 families (919 parents/carers, 931 young people) were randomised.

Interventions Families randomised to the intervention arm received the SFP10-14 comprising seven weekly sessions. Families in intervention and control arms received existing services as normal.

Outcome measures Primary outcomes were the number of occasions young people reported drinking alcohol in the last 30 days; and drunkenness during the same period, dichotomised as ‘never’ and ‘1–2 times or more’. Secondary outcomes examined alcohol/tobacco/substance behaviours including: cannabis use; weekly smoking (validated by salivary cotinine measures); age of alcohol initiation; frequency of drinking >5 drinks in a row; frequency of different types of alcoholic drinks; alcohol-related problems. Retention: primary analysis included 746 young people (80.1%) (alcohol consumption) and 732 young people (78.6%) (drunkenness).

Results There was no evidence of statistically significant between-group differences 2 years after randomisation for primary outcomes (young people’s alcohol consumption in the last 30 days adjusted OR=1.11, 95% CI 0.72 to 1.71, p=0.646; drunkenness in the last 30 days adjusted OR=1.46, 95% CI 0.83 to 2.55, p=0.185). There were no statistically significant between-group differences for other substance use outcomes, or those relating to well-being/stress, and emotional/behavioural problems.

Conclusions Previous evidence of effectiveness was not replicated. Findings highlight the importance of evaluating interventions when they are adapted for new settings.

Introduction: The effect of socioeconomic status on adolescent substance abuse may be mediated by family socialization practices. However, traditional mediation analysis using a product or difference method is susceptible to bias when assumptions are not addressed. We aimed to use a potential outcomes framework to assess assumptions of exposure‐mediator interaction and of no confounding of the results.

Method: We revisited a traditional mediation analysis with a multiple mediator causal mediation approach using data from 17,761 Norwegian young people (13–18 years), 51% female. Data were collected through a print questionnaire. Socioeconomic status was operationalized as parental education and employment status (employed or receiving welfare); drinking behavior as the frequency of alcohol consumption and frequency of intoxication in the past year; and socialization practices as general parenting measures, alcohol‐related parental permissiveness, and parent drinking behavior.

Results: There was no consistent evidence of exposure‐mediator interaction. Formal sensitivity analysis of mediator‐outcome confounding was not possible in the multiple mediator model, and this analysis supported the hypothesis that socioeconomic status effects on adolescent substance abuse are fully mediated by family socialization practices, with apparently stronger effects in younger age groups observed in plots.

Conclusion: We found that the effect of socioeconomic status on adolescent substance abuse was fully mediated by family socialization practices. While our analysis provides more rigorous support for causal inferences than past work, we could not completely rule out the possibility of unmeasured confounding.

Aim: Rising mortality and disease prevalence in the homeless have been largely attributed to addiction disorders. This review aimed to assess whether Motivational Interviewing (MI) is effective in changing substance misuse behaviours in the homeless, specifically: 1. reducing substance misuse; 2. increasing addiction treatment linkage; and 3. whether MI effectiveness varied according to the different levels of social disadvantage within homeless populations.

Method: Electronic databases and other sources were searched (to July 2021) for relevant randomized trials and comparative studies. Risk of bias in included studies was evaluated using the Cochrane Risk of Bias tool. A Narrative Synthesis framework was applied to included studies. Moderator variables subgroup analyses were planned a priori. PROSPERO study protocol registration: CRD42019134312

Results: The searches found 1885 records; after application of inclusion criteria n=11 studies from 30 articles were included in the review, all from the United States. There was a paucity of research regarding MI effectiveness for substance misuse outcomes in homeless populations, with a focus on short-term rather than long-term impacts. Risk of bias was generally low but was high for detection bias in most studies. MI appeared to be more effective overall amongst adult homeless persons, yielding consistently small effects, and alcohol use behaviours seemed to be more amenable to change as a result of MI/MET (Motivational Enhancement Therapy) interventions than drug use ones. Limited evidence with high risk of bias indicated that social gradient may attenuate MI effectiveness within the young homeless population, with no impact in the most disadvantaged.

Conclusions: The review’s mixed findings discourage the use of MI as a stand-alone substance use intervention in homeless populations. Although the review findings did not identify MI effectiveness for substance use according to the external level of social disadvantage faced by homeless persons, this should be a focus for further research.

Background. Reducing the alcohol content of drinks has the potential to reduce alcohol consumption. Aims: (1) test the feasibility of a randomised controlled trial (RCT) to assess the effect of alcohol strength on alcohol consumption within licensed premises in the United Kingdom (UK), (2) provide data to estimate key parameters for a RCT. 

Methods. Double-blind randomised controlled cross-over pilot trial based within four licensed premises in the UK. Participants (n=36) purchased and consumed ad libitum a 3.5% lager and a 4.8% lager during two separate study sessions. Descriptive statistics reported the efficacy and efficiency of the study processes, and the rates of licensed premises recruitment, and participant recruitment and attrition. Mean and the 95% confidence interval (CI) compared alcohol consumption between conditions. The mean, standard deviation (SD) and CI of UK units of alcohol consumed were used to calculate a sample size for a RCT. Responses to participant questionnaires and duration of participation in study sessions between conditions were analysed.

Results. Components of the study protocol were effective and efficient. The venue recruitment rate was less than anticipated. The participant recruitment rate was greater than anticipated. The rate of attrition was 23% and varied by less than 1% according to the arm of the trial. There was a reduction of alcohol consumed under the intervention conditions. Estimated mean difference, and 95% CI (UK units): -3.76 (-5.01 to -2.52). The sample size required for a RCT is 53. Participants did not find one lager more pleasant in taste: (on a scale of one to 10) -0.95 (-2.11 to 0.21). Participants found the reduced-strength lager less enjoyable: (on a scale of one to 10) -1.44 (-2.64 to -0.24) and they perceived themselves to be less intoxicated after consuming it: (on a scale of one to 10) -1.00 (-1.61 to -0.40).

Conclusion. A RCT is feasible with minor alterations to the study protocol and scoping work to establish different brands of alcohol that are more alike and more enjoyable than the products used in the pilot trial. 

Objectives. To explore UK clinicians’ beliefs and behaviours around recommending e-cigarettes as a smoking cessation aid for patients with cancer.

Design. Cross-sectional online survey.

Setting. England, Wales, Scotland and Northern Ireland.

Participants. Clinicians involved in the care of patients with cancer.

Primary and secondary outcomes. Behavioural Change Wheel capability, opportunity and motivation to perform a behaviour, knowledge, beliefs, current practice around e-cigarettes and other smoking cessation practices.

Method. Clinicians (n=506) completed an online survey to assess beliefs and behaviours around e-cigarettes and other smoking cessation practices for patients with cancer. Behavioural factors associated with recommending e-cigarettes in practice were assessed.

Results. 29% of clinicians would not recommend e-cigarettes to patients with cancer who continue to smoke. Factors associated with recommendation include smoking cessation knowledge (OR 1.56, 95% CI 1.01 to 2.44) and e-cigarette knowledge (OR 1.64, 95% CI 1.06 to 2.55), engagement with patients regarding smoking cessation (OR 2.12, 95% CI 1.12 to 4.03), belief in the effectiveness of e-cigarettes (OR 2.36 95% CI 1.61 to 3.47) and belief in sufficient evidence on e-cigarettes (OR 2.08 95% CI 1.10 to 4.00) and how comfortable they felt discussing e-cigarettes with patients (OR 1.57 95% CI 1.04 to 2.36).

Conclusion. Many clinicians providing cancer care to patients who smoke do not recommend e-cigarettes as a smoking cessation aid and were unaware of national guidance supporting recommendation of e-cigarettes as a smoking cessation aid.

Substance abuse and violence are among the primary health concerns regarding Brazilian adolescents. This study sought to explore the short-term effects of the Strengthening Families Program (SFP 10-14), a preventive program for families with adolescents, adapted to Brazil. A pre-experimental design was used, with a pretest and 10-12-month follow-up evaluation. A qualitative study was carried out using in-depth interviews held one to three months after the intervention to examine the use of skills learned. The sample included 126
adolescents (pre-test and follow-up comparison) and 23 adolescents (interviews) between 10 and 14 years of age from low-income families residing in northeastern Brazil. The comparison between pretest and follow-up showed an increase in learning self-efficacy and school absence without parental permission. Null effects were found on the consumption of alcohol in the last month; episodes of binge drinking in the last month; antisocial behavior; parenting practices regarding emotional support factors, intrusiveness, and behavior supervision; future time perspective; doing homework; grade repetition; school grades; school dropout; and satisfaction with one's relationship with school. The majority of the interviewed adolescents reported
applying the learned skills during family interaction and with friends. Future studies should examine the contexts and mechanisms linked to such mixed results.

Background and purpose. Women's health behaviours during pregnancy can affect their children's lifetime outcomes. Inactivity, poor diet, alcohol, and smoking during pregnancy are linked to maternal stress and distress. Mindfulness-based interventions can improve health behaviours and mental health. The purpose of the study was to develop and evaluate the feasibility of a mindfulness-based maternal behaviour change intervention. Materials and methods. The eight-week ‘Mind the Bump’ intervention integrated mindfulness training with behaviour change techniques. It aimed to improve mindfulness, mental health, and adherence to UK maternal health behaviour guidance. Acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects, and equity were evaluated from baseline to post-course and follow-up. Results. Mindfulness, positive affect, and wellbeing improved. Stress, negative affect, depression, anxiety, and adherence to guidance did not improve. The intervention was practicable and safe, but the other implementability criteria were not satisfied. Conclusion. The intervention was not fully feasible; recommendations to address its limitations are discussed.

Purpose. The consequences of problematic alcohol consumption fall heavily on Australian adolescents, with this population at increased risk of death, serious injury and other harm. Research regarding whether gender, socioeconomic status (SES) or locality play a role in young people’s alcohol consumption and related harm is limited in Australia. This study aimed to determine whether Victorian students’ patterns of alcohol uptake, consumption, and related harm differed between gender, SES and locality. Design/methodology/approach. The study involved secondary analysis of student data from the Drug Education in Victorian Schools (DEVS) harm minimization drug education program, undertaken in 21 Victorian government schools over three years The initial cohort of 1752 students was followed during years eight, nine and ten, when their average age would have respectively been 13, 14 and 15 years. Findings. There were no gender differences in drinking uptake, consumption or harm. Students with low SES were more likely to have consumed a full drink of alcohol and also experienced more alcohol related harm. Students living in a Regional/Rural area were more likely to have engaged in high alcohol consumption. Originality/value. The findings of this study highlighted that different student demographics have an impact on patterns of alcohol consumption, vulnerability and harm. Students with low SES, living in a Regional/Rural area, are more at risk than students with higher SES living in a Fringe Metro/Major Regional or Metro area. Future harm minimization drug education programs delivered in schools need toshould consider the needs of students with demographics that make them more susceptible to higher consumption and harm. 

The second edition of Drug Policy and the Public Good presents up-to-date evidence relating to the development of drug policy at local, national, and international levels.  The book explores both illicit drug use and nonmedical use of prescription medications from a public health perspective.  The core of the book is a critical review of the scientific evidence in five areas of drug policy: 1) primary prevention programs in schools and other settings; 2) treatment interventions and harm reduction approaches; 3) attempts to control the supply of illicit drugs, including drug interdiction and law enforcement; 4) penal approaches, decriminalization and other alternatives; and 5) control of the legal market through prescription drug regimes.  It also discusses the trend toward legalization of some psychoactive substances in some countries and the need for a new approach to drug policy that is evidence-based, realistic, and coordinated.  The accumulated evidence provides important information about effective and ineffective policies.  Shifting the emphasis toward a public health approach should reduce the extent of illicit drug use, prevent the escalation of new epidemics, and avoid the unintended consequences arising from the marginalization of drug users through severe criminal penalties.

Objectives. To assess the cost-effectiveness of the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) compared with education as normal (EAN) in reducing self-reported heavy episodic drinking in adolescents. Design. A cost-effectiveness analysis from a public sector perspective conducted as part of a cluster randomised trial. Setting. 105 High schools in Northern Ireland (NI) and in Scotland. Participants. Students in school year 8/S1 (aged 11-12) at baseline. Interventions. A classroom-based alcohol education curricula, combined with a brief alcohol intervention for parents/carers. Outcome measures. Cost per young person experiencing heavy episodic drinking avoided due to STAMPP at 33 months from baseline. Results. The total cost of STAMPP was £85,900, equivalent to £818 per school and £15 per pupil. Due to very low uptake of the parental component, we calculated costs of £692 per school and £13 per pupil without this element. Costs per pupil were reduced further to £426 per school and £8 per pupil when it was assumed there were no additional costs of classroom delivery if STAMPP was delivered as part of activities such as Personal, social, health and economic education (PSHE). STAMPP was associated with a significantly greater proportion of pupils experiencing a heavy drinking episode avoided (0.08/8%) and slightly lower public sector costs (mean difference -£17.19). At a notional willingness-to-pay threshold of £15 (reflecting the cost of STAMPP) the probability of STAMPP being cost-effective was 56%. This level of uncertainty reflected the substantial variability in the cost differences between groups. Conclusions. STAMPP was relatively low-cost and reduced heavy episodic drinking. STAMPP was not associated with any clear public sector cost-savings, but neither did it increase them or lead to any cost-shifting within the public sector categories. Further research is required to establish if the cost-effectiveness of STAMPP is sustained in the long-term.

The aim of this study was to examine the extent of recanting (inconsistencies in reporting of lifetime alcohol use) and its impact on the assessment of primary outcomes within a large-scale alcohol prevention trial. One hundred and five post-primary schools in were randomised to receive either the intervention or education as normal. Participants (N = 12,738) were secondary school students in year 8/S1 (mean age 12.5) at baseline. Self-report questionnaires were administered at baseline (T0) and at T1 (+ 12 months post-baseline), T2 (+ 24 months) and T3 (+ 33 months). The primary outcomes were (i) heavy episodic drinking (consumption of ≥ 6 units in a single episode in the previous 30 days for males and ≥ 4.5 units for females) assessed at T3 and (ii) the number of alcohol-related harms experienced in the last 6 months assessed at T3. Recanting was defined as a negative report of lifetime alcohol consumption that contradicted a prior positive report. Between T1 and T3, 9.9% of students recanted earlier alcohol consumption. Recanting ranged from 4.5 to 5.3% across individual data sweeps. While recanting was significantly associated (negatively) with both primary outcomes, the difference in the rate of recanting across trial arms was small, and adjusting for recanting within the primary outcome models did not impact on the primary outcome effects. Males were observed to recant at a greater rate than females, with a borderline small-sized effect (V = .09). While differential rates of recanting have the potential to undermine the analysis of prevention trial outcomes, recanting is easy to identify and control for within trial primary outcome analyses. Adjusting for recanting should be considered as an additional sensitivity test within prevention trials.

Background: Effective interventions are required to reduce alcohol consumption and its associated harms at the population level. Reducing the alcohol content of beverages has the potential to reduce alcohol consumption through non-conscious processes. Before implementing a randomised controlled trial (RCT) to assess the effect of alcohol strength on alcohol consumption its feasibility needs to established. This study aims to pilot a RCT and obtain data to estimate key parameters required when designing a RCT. These key parameters include the direction and size of the intervention effect, the efficacy and efficiency of the study processes, and the rates of licensed premises recruitment, participant recruitment and attrition. 

Methods: A double blind randomised controlled cross-over pilot trial comparing the number of units of reduced strength lager consumed and the number of units of regular strength lager consumed in a single drinking occasion within licensed premises in the UK. Descriptive statistics will report the efficacy and efficiency of the study processes, and the rates of licensed premises recruitment, participant recruitment and attrition. Mean and 95% confidence intervals will be used to compare the consumption of alcohol, and the duration of participation in study sessions, between the intervention arm and the control arm. The mean and standard deviation of UK units of alcohol consumed will be used to calculate a sample size for a definitive RCT. 

Discussion: This is the first naturalistic experimental study to assess the effect of alcohol strength on alcohol consumption in a single drinking occasion within licensed premises. Results from this pilot study will establish the feasibility of, and inform key data parameters for, a larger-scale study. 

With alcohol misuse one of the leading causes of disability among young Australians, determination of potential predictors of risky drinking trajectories of young people is crucial. This study aimed to identify risky drinking trajectories from early to mid-adolescence and to determine if membership of a harm minimization intervention, alcohol knowledge, attitudes towards alcohol and prevalence of alcohol harms would predict trajectory group membership. Longitudinal data from 1,746 students were used to identify alcohol consumption trajectory groups for both intervention and control students. Higher baseline knowledge predicted a higher, increasing, consumption trajectory for controls, whereas, safer attitudes at baseline was not associated with a higher, increasing trajectory. All other alcohol harms at baseline were strongly associated with higher consumption trajectories. The intervention group had fewer increasing trajectories and a lower level of consumption at the end of the program, suggesting the drug education program reduced the number of students who substantially increased their consumption over time, while at the same time reducing their level of consumption in relative terms. The consistency of better intervention student outcomes across all trajectories provides evidence that the drug education program was influential with all types of student drinkers and is suitable for universal delivery

Objectives. To assess the effectiveness of a combined classroom curriculum and parental intervention (the Steps Towards Alcohol Misuse Prevention Programme (STAMPP)), compared with alcohol education as normal (EAN), in reducing self-reported heavy episodic drinking (HED) and alcohol-related harms (ARHs) in adolescents. Setting. 105 high schools in Northern Ireland (NI) and in Scotland. Participants. Schools were stratified by free school meal provision. Schools in NI were also stratified by school type (male/female/coeducational). Eligible students were in school year 8/S1 (aged 11–12 years) at baseline (June 2012). Intervention. A classroom-based alcohol education intervention, coupled with a brief alcohol intervention for parents/carers. Primary outcomes. (1) The prevalence of self-reported HED in the previous 30 days and (2) the number of self-reported ARHs in the previous 6 months. Outcomes were assessed using two-level random intercepts models (logistic regression for HED and negative binomial for number of ARHs). Results. At 33 months, data were available for 5160 intervention and 5073 control students (HED outcome), and 5234 and 5146 students (ARH outcome), respectively. Of those who completed a questionnaire at either baseline or 12 months (n=12 738), 10 405 also completed the questionnaire at 33 months (81.7%). Fewer students in the intervention group reported HED compared with EAN (17%vs26%; OR=0.60, 95% CI 0.49 to 0.73), with no significant difference in the number of self-reported ARHs (incident rate ratio=0.92, 95% CI 0.78 to 1.05). Although the classroom component was largely delivered as intended, there was low uptake of the parental component. There were no reported adverse effects. Conclusions. Results suggest that STAMPP could be an effective programme to reduce HED prevalence. While there was no significant reduction in ARH, it is plausible that effects on harms would manifest later.

Trial registration number: ISRCTN47028486: post results.

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.

Process evaluations generate important data on the extent to which interventions are delivered as intended. However, the tendency to focus only on assessment of pre-specified structural aspects of fidelity has been criticised for paying insufficient attention to implementation processes and how intervention-context interactions influence programme delivery. This paper reports findings from a process evaluation nested within a randomised controlled trial of the Strengthening Families Programme 10–14 (SFP 10–14) in Wales, UK. It uses Extended Normalisation Process Theory to theorise how interaction between SFP 10–14 and local delivery systems - particularly practitioner commitment/capability and organisational capacity - influenced delivery of intended programme activities: fidelity (adherence to SFP 10–14 content and implementation requirements); dose delivered; dose received (participant engagement); participant recruitment and reach (intervention attendance).

Methods

A mixed methods design was utilised. Fidelity assessment sheets (completed by practitioners), structured observation by researchers, and routine data were used to assess: adherence to programme content; staffing numbers and consistency; recruitment/retention; and group size and composition. Interviews with practitioners explored implementation processes and context.

Results

Adherence to programme content was high - with some variation, linked to practitioner commitment to, and understanding of, the intervention’s content and mechanisms. Variation in adherence rates was associated with the extent to which multi-agency delivery team planning meetings were held. Recruitment challenges meant that targets for group size/composition were not always met, but did not affect adherence levels or family engagement. Targets for staffing numbers and consistency were achieved, though capacity within multi-agency networks reduced over time.

Conclusions

Extended Normalisation Process Theory provided a useful framework for assessing implementation and explaining variation by examining intervention-context interactions. Findings highlight the need for process evaluations to consider both the structural and process components of implementation to explain whether programme activities are delivered as intended and why.

Design: The study involved a cross-sectional design. The sample included 501 participants from the United Kingdom (Mean age 18.92; range 11-51; 63% female); 230 school pupils and 271 university students.
 

Methods: Participants completed explicit measures of alcohol prototype perceptions, willingness, drunkenness, harms, and intentions.  They also completed an implicit measure of alcohol attitudes, using the Implicit Association Test.
 

Results: Implicit alcohol attitudes were only weakly related to the explicit measures. When looking at the whole sample, implicit alcohol attitudes did not add to the prediction of willingness over and above prototype perceptions. However, for university students implicit attitudes added to the prediction of behaviour, over and above intentions and willingness.  For school pupils, willingness was a stronger predictor of behaviour than intentions or implicit attitudes. 

Conclusions: Adding implicit measures to the PWM may contribute to our understanding of the development of alcohol behaviours in young people.  Further research could explore how implicit attitudes develop alongside the shift from reactive to planned behaviour.  

Background: The Strengthening Families Programme for youth aged 10-14 and parents/carers (SFP10-14) is a family-based prevention intervention with positive results in trials in the United States. We assessed the effectiveness of SFP10-14 for preventing substance misuse in Poland.

Methods: Cluster randomized controlled trial with 20 communities (511 families; 614 young people) were allocated to SFP10-14 or a control arms. Primary outcomes were alcohol, smoking and other drug use. Secondary outcomes included parenting practices, parent–child relations, and child problem behaviour. Interview-based questionnaires were administered at baseline and at 12- and 24-months post-baseline, with respective 70.4% and 54.4% follow-up rates.

Results: In Bayesian regression models with complete case data we found no effects of SFP10-14 for any of the primary or secondary outcomes at either follow-up. For example at 24-months, posterior odds ratios and 95% credible intervals for past year alcohol use, past month binge drinking, past year smoking, and past year other drug use, were 0.83 (0.44-1.56), 0.83 (0.27-2.65), 1.94 (0.76-5.38), and 0.74 (0.15-3.58), respectively. Although moderate to high attrition rates, together with some evidence of systematic attrition bias according to parent education and family disposable income, could have biased the results, the results were supported in further analyses with propensity score matched data and 40 multiple imputed datasets.

Conclusion: We found no evidence for the effectiveness of SFP10-14 on the prevention of alcohol or tobacco use, parenting behaviour, parent-child relations or 4 child problem behaviour at 12- or 24-month follow-up in a large cluster randomised controlled trial in Poland. 

Findings:  64% of participants experienced ARC harm, including 50% of non-drinkers.  In logistic regression analysis, ARC harms were associated with being female (OR=1.62, 95% CI 1.01-2.62) family members who drank every day (OR=2.65, 95% CI 1.49-4.69) being influenced by others’ drinking (OR=2.03, 95% CI 1.32-3.10) being older (OR=2.61 95% CI 1.57-4.34).  No significant associations were found with high or low self-reported levels of alcohol consumption. Using qualitative descriptors, the ARC harms reported were classified into a novel taxonomy comprising eight categories: Nuisance/frustration/exasperation, Tolerance/adjustment/accommodation, Pressure into unwanted situations, Unsought/inappropriate responsibility, Psychological harm; Physical harm/acute risk of physical harm, Relationship harm, and Undisclosed harm.
 

Conclusions: A high level of ARC harm was reported and experience of ARC harm was linked to several predictors.  Further work is required to validate the proposed taxonomy, and to promote consideration of the phenomenon of ARC harm in alcohol policy.

Alcohol misuse in young people is cause of concern for health services, policy makers, prevention workers, criminal justice system, youth workers, teachers, parents. This is one of three reviews examining the effectiveness of (1) school-based, (2) family-based, and (3) multi-component prevention programs.

Objectives

To review evidence on the effectiveness of universal school-based prevention programs in preventing alcohol misuse in school-aged children up to 18 years of age.

Search methods

Background

Alcohol use and misuse in young people is a major risk behaviour for mortality and morbidity. Motivational interviewing (MI) is a popular technique for addressing excessive drinking in young adults.

Objectives

To assess the effects of motivational interviewing (MI) interventions for preventing alcohol misuse and alcohol-related problems in young adults.

Search methods

We identified relevant evidence from the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12), MEDLINE (January 1966 to July 2015), EMBASE (January 1988 to July 2015), and PsycINFO (1985 to July 2015). We also searched clinical trial registers and handsearched references of topic-related systematic reviews and the included studies.

Selection criteria

We included randomised controlled trials in young adults up to the age of 25 years comparing MIs for prevention of alcohol misuse and alcohol-related problems with no intervention, assessment only or alternative interventions for preventing alcohol misuse and alcohol-related problems.

Data collection and analysis

We used the standard methodological procedures expected by Cochrane.

Main results

We included a total of 84 trials (22,872 participants), with 70/84 studies reporting interventions in higher risk individuals or settings. Studies with follow-up periods of at least four months were of more interest in assessing the sustainability of intervention effects and were also less susceptible to short-term reporting or publication bias. Overall, the risk of bias assessment showed that these studies provided moderate or low quality evidence.

At four or more months follow-up, we found effects in favour of MI for the quantity of alcohol consumed (standardised mean difference (SMD) −0.11, 95% confidence interval (CI) −0.15 to −0.06 or a reduction from 13.7 drinks/week to 12.5 drinks/week; moderate quality evidence); frequency of alcohol consumption (SMD −0.14, 95% CI −0.21 to −0.07 or a reduction in the number of days/week alcohol was consumed from 2.74 days to 2.52 days; moderate quality evidence); and peak blood alcohol concentration, or BAC (SMD −0.12, 95% CI −0.20 to 0.05, or a reduction from 0.144% to 0.131%; moderate quality evidence).

We found a marginal effect in favour of MI for alcohol problems (SMD −0.08, 95% CI −0.17 to 0.00 or a reduction in an alcohol problems scale score from 8.91 to 8.18; low quality evidence) and no effects for binge drinking (SMD −0.04, 95% CI −0.09 to 0.02, moderate quality evidence) or for average BAC (SMD −0.05, 95% CI −0.18 to 0.08; moderate quality evidence). We also considered other alcohol-related behavioural outcomes, and at four or more months follow-up, we found no effects on drink-driving (SMD −0.13, 95% CI −0.36 to 0.10; moderate quality of evidence) or other alcohol-related risky behaviour (SMD −0.15, 95% CI −0.31 to 0.01; moderate quality evidence).

Further analyses showed that there was no clear relationship between the duration of the MI intervention (in minutes) and effect size. Subgroup analyses revealed no clear subgroup effects for longer-term outcomes (four or more months) for assessment only versus alternative intervention controls; for university/college vs other settings; or for higher risk vs all/low risk participants.

None of the studies reported harms related to MI.

Authors' conclusions

The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for preventing alcohol use, misuse or alcohol-related problems. Although we found some statistically significant effects, the effect sizes were too small, given the measurement scales used in the included studies, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, and the quality of evidence is not strong, implying that any effects could be inflated by risk of bias.

Methods: Randomly selected school questionnaire survey representing four regions in Goa, India, with students (n = 773) aged 16–17.

Results: Most students (67%) were unaware of the problem of antibiotic resistance, with around half (49%) mistakenly thinking that bacteria cause cold or flu. Around one-fifth (19%) said they frequently self-medicate with antibiotics, 57% would discontinue antibiotics when symptoms alleviated and 24% stored unused antibiotics at home. Generalised linear mixed models (GLMM) showed that females consistently had poorer antibiotic knowledge than males. Especially notable were the higher odds in females for reporting incorrectly that antibiotics kill harmful viruses (odds ratio (OR) = 1.93; 99.5% confidence interval (CI) = 1.09–3.41) and for reporting incorrectly that antibiotics do not kill harmless bacteria (OR = 2.02; 99.5% CI = 1.16–3.51). Poor antibiotic practice was not clearly differentiated between males and females. In terms of poor antibiotic practice, one model showed notable results for educational stream: both arts and commerce students were more likely than science students to say they would discontinue antibiotics when symptoms alleviated and before the antibiotic course of treatment was finished (arts: OR = 2.76; 99.5% CI = 1.58–4.82 and commerce: OR = 1.79; 99.5% CI = 1.06–3.04).

Conclusion: Young adults in India had poor antibiotic knowledge and practice. Efforts to improve antibiotic health knowledge and safe practice are required to help prevent the spread of antibiotic resistance.

Purpose of the paper: The purpose of this paper is to report on the use of the Delphi method to gain expert feedback on the identification of behaviour change techniques (BCTs) and development of a novel intervention to reduce adolescent alcohol misuse, based on the Prototype Willingness Model (PWM) of health risk behaviour.

Methodology:  Four BCTs based on the PWM were identified and incorporated into a draft intervention that aimed to change alcohol prototypes and enable adolescents to deal with social pressure.  Using the Delphi process, successive questionnaires were distributed to 20 international experts to build consensus on the theoretical validity of the intervention.

Findings: Fifteen experts completed round one and eleven completed round two of the Delphi study.  A high level of consensus was achieved.   Four priority areas were identified to improve the intervention: 1) incorporating extra techniques to address social pressure, 2) increasing intensity, 3) providing incentives, and 4) addressing credibility.

Limitations:  The sample of experts was self-selected and four participants were lost between the first and second round of the study.

Implications: The effectiveness of the identified BCTs will be evaluated within an intervention to reduce alcohol misuse in adolescents.  Further work should build towards a more unified approach to developing interventions based on the PWM.  The Delphi method is likely to be particularly useful when there is no existing consensus about which BCTs to use that reflect certain theoretical constructs or that best target a specific population or behaviour.

Originality/ value: This paper is the first to address the identification of specific BCTs based on the PWM and thus makes an important contribution to the application of this model to interventions.  This novel application of the Delphi method also makes a useful addition to the growing field of intervention development and design.   

Using the Prototype Willingness Model (PWM) as a framework, this study sought to explore the relationship between prototype perceptions, willingness and alcohol consumption in a sample of adolescents in the United Kingdom.  Adolescents aged 11-17 were asked about their alcohol prototype perceptions, willingness to drink, intentions, alcohol consumption, drunkenness and harms using a cross sectional online survey.  Participants were recruited through opportunity sampling via schools and parents.  The survey was completed by 178 respondents (51% female; 91 aged 11-15, 87 aged 16-17).  Multivariate analysis revealed significant differences between participants aged 11-15 and 16-17 on PWM measures, even when experience with drinking was accounted for (pppp

Background: The Prototype Willingness Model (PWM) may offer an appropriate basis for explaining and preventing adolescent alcohol misuse.  An intervention was developed using a co-production approach, and consisted of an online quiz featuring 10 questions linked to PWM.

Objectives: This study sought to determine the acceptability and relevance of the intervention content to young people, in order to incorporate their feedback into a final version.

Methods: A qualitative think aloud study with follow up semi-structured interviews was undertaken with 16 young people aged 11-15 (50% female), Transcripts were analysed using thematic analysis.

Results: Three main themes relating the acceptability of the intervention were identified; ‘challenging expectations of alcohol education’; ‘motivations for drinking or not drinking’ and ‘the inevitability of drinking’.  Participants found the intervention appealing because it was counter to their expectations.  The content appeared to reflect their experiences of social pressure and drinking encounters.  There was evidence that a focus on drinker/non-drinker prototypes was too narrow and that because adolescents perceived drinking as inevitable, it would be challenging to enact any plans to resist pressure to drink. 

Conclusions: An online intervention based on the PWM has the potential to engage and interest adolescents.  A wide range of alcohol prototypes should be targeted and a focus on short term harms should ensure that the intervention is credible to young people.  

Background

Drinking is influenced by youth (mis)perceptions of how their peers drink. If misperceptions can be corrected, young people may drink less.

Objectives

To determine whether social norms interventions reduce alcohol-related negative consequences, alcohol misuse or alcohol consumption when compared with a control (ranging from assessment only/no intervention to other educational or psychosocial interventions) among university and college students.

Search methods

The following electronic databases were searched up to May 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (only to March 2008). Reference lists of included studies and review articles were manually searched.

Selection criteria

Randomised controlled trials or cluster-randomised controlled trials that compared a social normative intervention versus no intervention, alcohol education leaflet or other 'non-normative feedback' alcohol intervention and reported on alcohol consumption or alcohol-related problems in university or college students.

Data collection and analysis

We used standard methodological procedures as expected by The Cochrane Collaboration. Each outcome was analysed by mode of delivery: mailed normative feedback (MF); Web/computer normative feedback (WF); individual face-to-face normative feedback (IFF); group face-to-face normative feedback (GFF); and normative marketing campaign (MC).

Main results

A total of 66 studies (43,125 participants) were included in the review, and 59 studies (40,951 participants) in the meta-analyses. Outcomes at 4+ months post intervention were of particular interest to assess when effects were sustained beyond the immediate short term. We have reported pooled effects across delivery modes only for those analyses for which heterogeneity across delivery modes is not substantial (I2 < 50%).

Alcohol-related problems at 4+ months: IFF standardised mean difference (SMD) -0.16, 95% confidence interval (CI) -0.31 to -0.01 (participants = 1065; studies = 7; moderate quality of evidence), equivalent to a decrease of 1.5 points in the 69-point alcohol problems scale score. No effects were found for WF or MF.

Binge drinking at 4+ months: results pooled across delivery modes: SMD -0.06, 95% CI -0.11 to -0.02 (participants = 11,292; studies = 16; moderate quality of evidence), equivalent to 2.7% fewer binge drinkers if 30-day prevalence is 43.9%.

Drinking quantity at 4+ months: results pooled across delivery modes: SMD -0.08, 95% CI -0.12 to -0.05 (participants = 20,696; studies = 33; moderate quality of evidence), equivalent to a reduction of 0.9 drinks consumed each week, from a baseline of 13.7 drinks per week.

Drinking frequency at 4+ months: WF SMD -0.12, 95% CI -0.18 to -0.05 (participants = 9456; studies = 9; moderate quality of evidence), equivalent to a decrease of 0.19 drinking days/wk, from a baseline of 2.74 days/wk; IFF SMD -0.21, 95% CI -0.31 to -0.10 (participants = 1464; studies = 8; moderate quality of evidence), equivalent to a decrease of 0.32 drinking days/wk, from a baseline of 2.74 days/wk. No effects were found for GFF or MC.

Estimated blood alcohol concentration (BAC) at 4+ months: peak BAC results pooled across delivery modes: SMD -0.08, 95% CI -0.17 to 0.00 (participants = 7198; studies = 13; low quality of evidence), equivalent to a reduction in peak PAC from an average of 0.144% to 0.135%. No effects were found for typical BAC with IFF.

Authors' conclusions

The results of this review indicate that no substantive meaningful benefits are associated with social norms interventions for prevention of alcohol misuse among college/university students. Although some significant effects were found, we interpret the effect sizes as too small, given the measurement scales used in the studies included in this review, to be of relevance for policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, heterogeneity was a problem in some analyses and bias cannot be discounted as a potential cause of these findings.

Background

Prevention of alcohol, drug and tobacco misuse by young people is a key public health priority. There is a need to develop the evidence base through rigorous evaluations of innovative approaches to substance misuse prevention. The Strengthening Families Programme 10–14 is a universal family-based alcohol, drugs and tobacco prevention programme, which has achieved promising results in US trials, and which now requires cross-cultural assessment. This paper therefore describes the protocol for a randomised controlled trial of the UK version of the Strengthening Families Programme 10–14 (SFP 10–14 UK).

Methods/Design

The trial comprises a pragmatic cluster randomised controlled effectiveness trial with families as the unit of randomisation, with embedded process and economic evaluations. Participating families will be randomised to one of two treatment groups - usual care with full access to existing services (control group), or usual care plus SFP 10–14 UK (intervention group). The trial has two primary outcomes - the number of occasions that young people report having drunk alcohol in the last 30 days, and drunkenness during the last 30 days, both dichotomised as ‘never’ and ‘1-2 times or more’. The main follow-up is at 2 years past baseline, and short-term and intermediate outcomes are also measured at 9 and 15 months.

Discussion

The results from this trial will provide evidence on the effectiveness and cost-effectiveness of an innovative universal family-based substance misuse prevention programme in a UK context.

This is the protocol for a review. The objectives are as follows: To compare the diagnostic accuracy of one brief alcohol questionnaires with another for identifying risk, harmful or hazardous drinking, or alcohol dependence in primary care. We will investigate the following factors as potential sources of heterogeneity: sex, age and ethnicity.

Design and Methods: A cluster randomised controlled trial of the 18 lesson Drug Education in Victorian Schools (DEVS) drug education programme was undertaken with students during years eight and nine (13 and 14 years of age respectively), with follow up in year ten (15 years of age). The programme covered all drugs, employed a harm minimisation approach that used participatory, critical thinking and skills based teaching methods, and engaged parental influence through home activities. Twenty-one secondary schools in Victoria, Australia, were randomly allocated to receive the DEVS programme (14 schools) or the drug education usually provided by their schools (7 schools). In relation to cannabis, communication with parents, lessons remembered, responsible attitudes, whether used, frequency of use and associated harms were measured.

Results: In comparison to controls, there was a significantly greater increase in the intervention students’ communication with parents about cannabis recall of cannabis lessons received, and responsible attitudes towards cannabis. While there were no significant differences between the two study groups in relation to the proportion of cannabis users, the increase in level of use by intervention students was significantly less and they experienced a lesser increase in associated harms.

Conclusion: A harm minimisation focused school drug education programme reduced the level of cannabis use and associated harm. This supports harm minimisation education as an effective prevention strategy for school students.

Universal, selective and indicated forms of prevention have been adopted as improvements on previous notions of primary and secondary prevention. However, some conceptual confusion remains concerning the placing of environmental, community-based or mass media preventive interventions within this typology. It is suggested that a new dimension of functional types of prevention, namely environmental, developmental and informational prevention should be specified alongside the forms of prevention in a taxonomy matrix. The main advantage of this new taxonomy is that a matrix combining the form and function dimensions of prevention can be used to identify and map out prevention strategies, to consider where research evidence is present and where more is needed, and to evaluate the relative effectiveness of different categories and components of prevention for specific health and social issues. Such evaluations would provide empirical evidence as to whether the different categories of prevention are related to outcomes or processes of prevention in ways that suggest the value of the taxonomy for understanding and increasing the impact of prevention science. This new prevention taxonomy has been useful for conceptualising and planning prevention activities in a case study involving the Swedish National Institute for Public Health. Future work should assess (1) the robustness of this new taxonomy and (2) the theoretical and empirical basis for profiling prevention investments across the various forms and functions of prevention.

Primary research objective

To assess the effects of interventions at the individual, family and school level that aim to target multiple substance use behaviours (two or more from alcohol, tobacco, cannabis, other substance use) for the primary or secondary prevention of substance use and related harms in individuals aged 8 to 25.

Secondary research objectives

-To explore whether the effects of the intervention differ within and between population subgroups.

-To explore whether the effects of the intervention differ by risk behaviour and by outcomes.

-To explore the influence of the setting of the intervention on the design, delivery and outcomes of the interventions.

-To explore the relationship between the number and/or types of component(s) of an intervention, duration, and effects of the interventions.

-To explore whether the impact(s) of interventions differ according to whether behaviours are addressed simultaneously or sequentially and/or whether behaviours are addressed in a particular order.

-To explore the cost-effectiveness of interventions.

-To identify the implications of the review findings for further research, policy and practice.

BACKGROUND:

Globally, harmful use of alcohol results in approximately 2.5 million deaths each year. About 9% of these deaths are young people between the ages of 15 and 29 years (WHO 2011), mainly resulting from motor vehicle accidents, homicides, suicides and drownings. Hazardous drinking levels for men (consuming over 40 g/day alcohol on average, that is 5 units) double the risk of liver disease, raised blood pressure, some cancers and violent death (because some people who have this average alcohol consumption drink heavily on some days). For women, over 24 g/day average alcohol consumption (3 units) increases the risk for developing liver disease and breast cancer. Motivational interviewing (MI) is a popular technique for addressing excessive drinking in young adults but its effectiveness has not previously been examined in a Cochrane review.

OBJECTIVES:

The specific objectives were:(1) to summarise current evidence about the effects of MI intended to address alcohol and alcohol-related problems in young adults, compared with no intervention or a different intervention, on alcohol consumption and other substantive outcome measures;(2) to investigate whether the effects of MI are modified by the length of the intervention.

SEARCH METHODS:

Relevant evidence was identified from (1) Cochrane Central Register of Controlled Trials (CENTRAL) (October 2013), (2) MEDLINE (January 1966 to October 2013), (3) EMBASE (January 1988 to October 2013), and (4) PsycINFO (1985 to October 2013). References of topic-related systematic reviews and the included studies were handsearched.

SELECTION CRITERIA:

Randomised controlled trials and cluster randomised controlled trials of young people up to the age of 25 years in college and non-college settings comparing MIs with no intervention or a different intervention for prevention of alcohol misuse and alcohol-related problems were included.

DATA COLLECTION AND ANALYSIS:

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS:

A total of 66 randomised trials (17,901 participants) were included four of which were cluster randomised. Studies with longer-term follow-up (four plus months) were of more interest when considering the sustainability of intervention effects.At four or more months follow-up, effects were found for the quantity of alcohol consumed (standardised mean difference (SMD) -0.14; 95% confidence interval (CI) -0.20 to -0.08 or a reduction from 13.7 drinks/week to 12.2 drinks/week), moderate quality of evidence; frequency of alcohol consumption (SMD -0.11; 95% CI -0.19 to -0.03 or a reduction in the number of days/week alcohol was consumed from 2.74 days to 2.57 days), moderate quality of evidence; and peak blood alcohol concentration (BAC) (SMD -0.14; 95% CI -0.23 to -0.05 or a decrease in peak BAC from 0.144% to 0.129%), moderate quality of evidence. A marginal effect was found for alcohol problems (SMD -0.08; 95% CI -0.15 to 0.00 or a reduction in an alcohol problems scale score from 8.91 to 8.18), low quality of evidence. No effects were found for binge drinking (SMD -0.05; 95% CI -0.12 to 0.01), moderate quality of evidence; or average BAC (SMD -0.08; 95% CI -0.22 to 0.06), moderate quality of evidence. We also considered other outcomes and at four or more months follow-up we found no effects on drink-driving (SMD -0.11; 95% CI -0.31 to 0.09), moderate quality of evidence; or other alcohol-related risky behaviour (SMD -0.14; 95% CI -0.30 to 0.02), moderate quality of evidence.Further analyses showed that the type of control comparison (assessment only versus alternative intervention) did not predict the outcome in a clear or straightforward way; and there was no consistent relationship between the duration of the MI intervention (in minutes) and effect size.

AUTHORS' CONCLUSIONS:

The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for the prevention of alcohol misuse. Although some significant effects were found, we interpret the effect sizes as being too small, given the measurement scales used in the studies included in the review, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, heterogeneity was a problem in some analyses and bias cannot be discounted as a potential cause of these findings.

In Australia, the burden of alcohol-attributable harm falls most heavily on young people. Prevention is important, and schools have long been seen as appropriate settings for pre-emptive interventions with this high risk group. This paper evaluates the effectiveness, in relation to alcohol harm prevention, of the Drug Education in Victorian Schools (DEVS) programme, nine months after implementation. This intervention dealt with both licit and illicit drugs, employed a harm minimisation approach that incorporated interactive, skill based, teaching methods and capitalised on parental influence through home activities.

METHODS:

A cluster randomised, controlled trial of the first ten lessons of the DEVS drug education programme was conducted with year eight students, aged 13-14 years. Twenty-one secondary schools in Victoria, Australia were randomly allocated to receive the DEVS programme (14 schools, n=1163) or the drug education usually provided by their schools (7 schools, n=589). Self-reported changes were measured in relation to: knowledge and attitudes, communication with parents, drug education lessons remembered, proportion of drinkers, alcohol consumption (quantity multiplied by frequency), proportion of student drinkers engaging in risky consumption, and the number of harms experienced as a result of alcohol consumption.

RESULTS:

In comparison to the controls, there was a significantly greater increase in the intervention students' knowledge about drugs, including alcohol (p≤0.001); there was a significant change in their level of communication with parents about alcohol (p=0.037); they recalled receiving significantly more alcohol education (p<0.001); their alcohol consumption increased significantly less (p=0.011); and they experienced a lesser increase in harms associated with their drinking (p≤0.001). There were no significant differences between the two study groups in relation to changes in attitudes towards alcohol or in the proportion of drinkers or risky drinkers. There was, however, a notable trend of less consumption by risky drinkers in the intervention group.

CONCLUSIONS:

A comprehensive, harm minimisation focused school drug education programme is effective in increasing general drug knowledge, and reducing alcohol consumption and harm.

Nutrition may be a risk factor for unipolar depression. We aimed to review the association between dietary variables and the risk of depression.

Methods

Fifteen databases were searched up to May 2010. Only longitudinal studies for which outcomes were unipolar depression and/or depressive symptoms in adults were eligible for inclusion. Eleven studies were included and critically evaluated. Participants were in the age range 18–97 years and the study sample size was in the range 526–27 111. Follow-up ranged from 2 to 13 years. The diversity of dietary variables and nonlinear associations precluded formal meta-analysis and so a narrative analysis was undertaken.

Results

Variables inversely associated with depression risk were the consumption of nutrients such as folate, omega-3 fatty acids and monounsaturated fatty acids; foods such as olive oil and fish; and a diet rich in fruits, vegetables, nuts and legumes. Some of these associations varied by sex and some showed a nonlinear association.

Conclusions

At the study level, weaknesses in the assessment of exposure and outcome may have introduced bias. Most studies investigated a cohort subgroup that may have resulted in selection bias. At the review level, there is a risk of publication bias and, in addition, narrative analyses are more prone to subjectivities than meta-analyses. Diet may potentially influence the risk of depression, although the evidence is not yet conclusive. Strengthening healthy-eating patterns at the public health level may have a potential benefit. Robust prospective cohort studies specially designed to study the association between diet and depression risk are needed.

Aim: This study aimed to explore constructs in the prototype willingness model (PWM) to establish if it provides a basis for understanding and preventing alcohol misuse in teenagers in the UK.

Methods: Four focus groups were carried out with 11–13 and 16–17 year olds. There were 13 males and 14 females. Transcripts of the focus groups were analysed using thematic analysis in NVivo.

Findings: Three PWM relevant themes were identified. The first theme brought together the alcohol prototypes described by participants. The second theme addressed drinking contexts and contrasts evidence that suggests that some drinking is planned and some is unplanned. The final theme looks at attitudes and norms including participants’ attitudes towards alcohol education.

Conclusions: The findings from this study show that young people in this sample held clear prototypes in relation to alcohol. The evident difference between ‘planned’ and ‘unplanned’ drinking contexts suggests that the PWM provides a more satisfactory explanation of young people's drinking than a decisional model based on intentions alone. Drinking alcohol was reported by the participants as a normative teenage behaviour. Implications for an intervention programme targeting alcohol prototypes and future research are discussed.

The Strengthening Families Programme 10–14 (SFP10–14; UK) is a seven-session DVD-based family skills training programme. While the programme has been extensively evaluated in the United States, no randomized controlled trial (RCT) of the SFP10–14 has been conducted in the United Kingdom. This exploratory Phase II study was an evaluation of a universally delivered prevention programme using a mixed-methods design study blending both quantitative and qualitative data. It aimed to examine intervention versus control differences in young person's substance use, aggressive behaviours and school absence, parenting behaviour and measures of family life. All parents/carers (n = 53) with a young person aged 10–14 years (n = 69) attending three schools in different locations in England were invited to complete self-report questionnaires pre- and post-intervention, and at 3 months after completion of the SFP10–14 (UK). A purposive sample of parents/caregivers (n = 16) and young people (n = 14) provided qualitative feedback from participating families. Participant recruitment to the study was slow and many families were reluctant to be randomly allocated, instead indicating a preference for the SFP10–14 (UK) group. Rather than abandoning the trial, a decision was made to proceed as a quasi-experimental study, that is, without randomization.


Read More: http://informahealthcare.com/doi/abs/10.3109/09687637.2012.658889

AIMS:

To assess external validity characteristics of studies from two Cochrane Systematic Reviews of the effectiveness of universal family-based prevention of alcohol misuse in young people.

METHODS:

Two reviewers used an a priori developed external validity rating form and independently assessed three external validity dimensions of generalizability, applicability and predictability (GAP) in randomized controlled trials.

RESULTS:

The majority (69%) of the included 29 studies were rated 'unclear' on the reporting of sufficient information for judging generalizability from sample to study population. Ten studies (35%) were rated 'unclear' on the reporting of sufficient information for judging applicability to other populations and settings. No study provided an assessment of the validity of the trial end-point measures for subsequent mortality, morbidity, quality of life or other economic or social outcomes. Similarly, no study reported on the validity of surrogate measures using established criteria for assessing surrogate end-points.

CONCLUSIONS:

Studies evaluating the benefits of family-based prevention of alcohol misuse in young people are generally inadequate at reporting information relevant to generalizability of the findings or implications for health or social outcomes. Researchers, study authors, peer reviewers, journal editors and scientific societies should take steps to improve the reporting of information relevant to external validity in prevention trials.

Background: This study seeks to extend earlier Australian school drug education research by developing and measuring the effectiveness of a comprehensive, evidence-based, harm reduction focused school drug education program for junior secondary students aged 13 to 15 years. The intervention draws on the recent literature as to the common elements in effective school curriculum. It seeks to incorporate the social influence of parents through home activities. It also emphasises the use of appropriate pedagogy in the delivery of classroom lessons. Methods/Design: A cluster randomised school drug education trial will be conducted with 1746 junior high school students in 21 Victorian secondary schools over a period of three years. Both the schools and students have actively consented to participate in the study. The education program comprises ten lessons in year eight (13-14 year olds) and eight in year nine (14-15 year olds) that address issues around the use of alcohol, tobacco, cannabis and other illicit drugs. Control students will receive the drug education normally provided in their schools. Students will be tested at baseline, at the end of each intervention year and also at the end of year ten. A self completion questionnaire will be used to collect information on knowledge, patterns and context of use, attitudes and harms experienced in relation to alcohol, tobacco, cannabis and other illicit drug use. Multi-level modelling will be the method of analysis because it can best accommodate hierarchically structured data. All analyses will be conducted on an Intent-to-Treat basis. In addition, focus groups will be conducted with teachers and students in five of the 14 intervention schools, subsequent to delivery of the year eight and nine programs. This will provide qualitative data about the effectiveness of the lessons and the relevance of the materials. Discussion: The benefits of this drug education study derive both from the knowledge gained by trialling an optimum combination of innovative, harm reduction approaches with a large, student sample, and the resultant product. The research will provide better understanding of what benefits can be achieved by harm reduction education. It will also produce an intervention, dealing with both licit and illicit drug use that has been thoroughly evaluated in terms of its efficacy, and informed by teacher and student feedback. This makes available to schools a comprehensive drug education package with prevention characteristics and useability that are well understood.

Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence. Fortunately, evidence-based interventions are increasingly being identified that are capable of making drugs less available, reducing violence in drug markets, lessening misuse of legal pharmaceuticals, preventing drug use initiation in young people, and reducing drug use and its consequences in established drug users. We review relevant evidence and outline the likely effects of fuller implementation of existing interventions. The reasoning behind the final decisions for action might be of a non-scientific nature, focused more on what the public and policy-makers deem of value. Nevertheless, important opportunities exist for science to inform these deliberations and guide the selection of policies that maximise the public good.

Background Nurses and midwives form the bulk of the clinical health workforce and play a central role in all health service delivery. There is potential to improve health care quality if nurses routinely use the best available evidence in their clinical practice. Since many of the factors perceived by nurses as barriers to the implementation of evidence-based practice (EBP) lie at the organisational level, it is of interest to devise and assess the effectiveness of organisational infrastructures designed to promote EBP among nurses. Objectives To assess the effectiveness of organisational infrastructures in promoting evidence-based nursing. Search methods We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, BIREME, IBECS, NHS Economic Evaluations Database, Social Science Citation Index, Science Citation Index and Conference Proceedings Citation Indexes up to 9 March 2011. We developed a new search strategy for this update as the strategy published in 2003 omitted key terms. Additional search methods included: screening reference lists of relevant studies, contacting authors of relevant papers regarding any further published or unpublished work, and searching websites of selected research groups and organisations. Selection criteria We considered randomised controlled trials, controlled clinical trials, interrupted times series (ITSs) and controlled before and after studies of an entire or identified component of an organisational infrastructure intervention aimed at promoting EBP in nursing. The participants were all healthcare organisations comprising nurses, midwives and health visitors. Data collection and analysis Two authors independently extracted data and assessed risk of bias. For the ITS analysis, we reported the change in the slopes of the regression lines, and the change in the level effect of the outcome at 3, 6, 12 and 24 months follow-up. Main results We included one study from the USA (re-analysed as an ITS) involving one hospital and an unknown number of nurses and patients. The study evaluated the effects of a standardised evidence-based nursing procedure on nursing care for patients at risk of developing healthcare-acquired pressure ulcers (HAPUs). If a patient's admission Braden score was below or equal to 18 (i.e. indicating a high risk of developing pressure ulcers), nurses were authorised to initiate a pressure ulcer prevention bundle (i.e. a set of evidence-based clinical interventions) without waiting for a physician order. Re-analysis of data as a time series showed that against a background trend of decreasing HAPU rates, if that trend was assumed to be real, there was no evidence of an intervention effect at three months (mean rate per quarter 0.7%; 95% confidence interval (CI) 1.7 to 3.3; P = 0.457). Given the small percentages post intervention it was not statistically possible to extrapolate effects beyond three months. Authors' conclusions Despite extensive searching of published and unpublished research we identified only one low-quality study; we excluded many studies due to non-eligible study design. If policy-makers and healthcare organisations wish to promote evidence-based nursing successfully at an organisational level, they must ensure the funding and conduct of well-designed studies to generate evidence to guide policy

Alcohol and other drug use and misuse is a significant problem amongst Polish youth. The SFP10-14 is a family-based prevention intervention that has positive results in US trials, but questions remain about the generalizability of these results to other countries and settings.

Methods/Design

A cluster randomized controlled trial in community settings across Poland. Communities will be randomized to a SFP10-14 trial arm or to a control arm. Recruitment and consent of families, and delivery of the SFP10-14, will be undertaken by community workers. The primary outcomes are alcohol and other drug use and misuse. Secondary (or intermediate) outcomes include parenting practices, parent–child relations, and child problem behaviour. Interview-based questionnaires will be administered at baseline, 12 and 24 months.

Discussion

The trial will provide information about the effectiveness of the SFP10-14 in Poland.

Trial registration

International Standard Randomised Controlled Trial Number: ISRCTN89673828

Selection criteria

Randomized trials evaluating universal school-based prevention programs and reporting outcomes for alcohol use in students 18 years of age or younger were included. Two reviewers screened titles/abstracts and full text of identified records.

Data collection and analysis

Two reviewers extracted relevant data independently using an a priori defined extraction form. Risk of bias was assessed.

Main results

53 trials were included, most of which were cluster-randomised. The reporting quality of trials was poor, only 3.8% of them reporting adequate method of randomisation and program allocation concealment. Incomplete data was adequately addressed in 23% of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarized only qualitatively.

Six of the 11 trials evaluating alcohol-specific interventions showed some evidence of effectiveness compared to a standard curriculum. In 14 of the 39 trials evaluating generic interventions, the program interventions demonstrated significantly greater reductions in alcohol use either through a main or subgroup effect. Gender, baseline alcohol use, and ethnicity modified the effects of interventions. Results from the remaining 3 trials with interventions targeting cannabis, alcohol, and/or tobacco were inconsistent.

Authors' conclusions

This review identified studies that showed no effects of preventive interventions, as well as studies that demonstrated statistically significant effects. There was no easily discernible pattern in characteristics that would distinguish trials with positive results from those with no effects. Most commonly observed positive effects across programs were for drunkenness and binge drinking. Current evidence suggests that certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options. These include the Life Skills Training Program, the Unplugged program, and the Good Behaviour Game. A stronger focus of future research on intervention program content and delivery context is warranted.

Plain Language Summary

Psychosocial and Developmental Alcohol Misuse Prevention in Schools can be effective

We conducted a Cochrane systematic review of 53 well-designed experimental studies that examined the effectiveness of school-based universal programs for the prevention of alcohol misuse in young people. The studies were divided into two major groups based on the nature of the prevention program: 1) programs targeting specifically prevention or reduction of alcohol misuse and 2) generic programs with wider focus for prevention (e.g., other drug use/abuse, antisocial behavior). In the review we found studies that showed no effects of the preventive program, as well as studies that demonstrated statistically significant effects. There was no easily discernible pattern in program characteristics that would distinguish studies with positive results from those with no effects. Most commonly observed positive effects across programs were for drunkenness and binge drinking. In conclusion, current evidence suggests that certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options. These include the Life Skills Training Program, the Unplugged program, and the Good Behaviour Game.

Background Alcohol misuse in young people is a cause of concern for health services, policy makers, prevention workers, and criminal justice system, youth workers, teachers, and parents. Objectives To systematically review evidence on the effectiveness of universal family-based prevention programs in preventing alcohol misuse in school-aged children up to 18 years of age. To update a part of a previously published Cochrane systematic review. Search strategy Relevant evidence ( up to 2002) was selected from the previous Cochrane review. Later studies, to July 2010, were identified from MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Project CORK, and PsycINFO. Selection criteria Randomized trials evaluating universal family-based prevention programs and reporting outcomes for alcohol use in students 18 years of age or younger were included. Two reviewers screened titles/abstracts and full text of identified records. Data collection and analysis Two reviewers extracted relevant data independently using an a priori defined extraction form. Risk of bias was assessed. Main results 12 parallel-group trials were included. The reporting quality of trials was poor, only 20% of them reporting adequate method of randomisation and program allocation concealment. Incomplete data was adequately addressed in about half of the trials and this information was unclear for about 30% of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarized only qualitatively. 9 of the 12 trials showed some evidence of effectiveness compared to a control or other intervention group, with persistence of effects over the medium and longer-term. Four of these effective interventions were gender-specific, focusing on young females. One study with a small sample size showed positive effects that were not statistically significant, and two studies with larger sample sizes reported no significant effects of the family-based intervention for reducing alcohol misuse. Authors' conclusions In conclusion, in this Cochrane systematic review we found that that the effects of family-based prevention interventions are small but generally consistent and also persistent into the medium- to longer-term.

Background Alcohol misuse in young people is cause of concern for health services, policy makers, prevention workers, criminal justice system, youth workers, teachers, parents. This is one of three reviews examining the effectiveness of (1) school-based, (2) family-based, and (3) multi-component prevention programs. Objectives To review evidence on the effectiveness of universal school-based prevention programs in preventing alcohol misuse in school-aged children up to 18 years of age. Search strategy Relevant evidence (up to 2002) was selected from the previous Cochrane review. Later studies, to July 2010, were identified from MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Project CORK, and PsycINFO. Selection criteria Randomized trials evaluating universal school-based prevention programs and reporting outcomes for alcohol use in students 18 years of age or younger were included. Two reviewers screened titles/abstracts and full text of identified records. Data collection and analysis Two reviewers extracted relevant data independently using an a priori defined extraction form. Risk of bias was assessed. Main results 53 trials were included, most of which were cluster-randomised. The reporting quality of trials was poor, only 3.8% of them reporting adequate method of randomisation and program allocation concealment. Incomplete data was adequately addressed in 23% of the trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarized only qualitatively.Six of the 11 trials evaluating alcohol-specific interventions showed some evidence of effectiveness compared to a standard curriculum. In 14 of the 39 trials evaluating generic interventions, the program interventions demonstrated significantly greater reductions in alcohol use either through a main or subgroup effect. Gender, baseline alcohol use, and ethnicity modified the effects of interventions. Results from the remaining 3 trials with interventions targeting cannabis, alcohol, and/or tobacco were inconsistent. Authors' conclusions This review identified studies that showed no effects of preventive interventions, as well as studies that demonstrated statistically significant effects. There was no easily discernible pattern in characteristics that would distinguish trials with positive results from those with no effects. Most commonly observed positive effects across programs were for drunkenness and binge drinking. Current evidence suggests that certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options. These include the Life Skills Training Program, the Unplugged program, and the Good Behaviour Game. A stronger focus of future research on intervention program content and delivery context is warranted. PLAIN LANGUAGE SUMMARY Psychosocial and Development Alcohol Misuse Prevention in Schools can be effective We conducted a Cochrane systematic review of 53 well-designed experimental studies that examined the effectiveness of school-based universal programs for the prevention of alcohol misuse in young people. The studies were divided into two major groups based on the nature of the prevention program: 1) programs targeting specifically prevention or reduction of alcohol misuse and 2) generic programs with wider focus for prevention (e. g., other drug use/abuse, antisocial behavior). In the review we found studies that showed no effects of the preventive program, as well as studies that demonstrated statistically significant effects. There was no easily discernible pattern in program characteristics that would distinguish studies with positive results from those with no effects. Most commonly observed positive effects across programs were for drunkenness and binge drinking. In conclusion, current evidence suggests that certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options. These include the Life Skills Training Program, the Unplugged program, and the Good Behaviour Game.

Aim The aim in this methodological paper is to demonstrate, using Bayes' Theorem, an approach to estimating the difference in prevalence of a disorder in two groups whose test scores are obtained, illustrated with data from a college student trial where 12-month outcomes are reported for the Alcohol Use Disorders Identification Test (AUDIT). Method Using known population prevalence as a background probability and diagnostic accuracy information for the AUDIT scale, we calculated the post-test probability of alcohol abuse or dependence for study participants. The difference in post-test probability between the study intervention and control groups indicates the effectiveness of the intervention to reduce alcohol use disorder rates. Findings In the illustrative analysis, at 12-month follow-up there was a mean AUDIT score difference of 2.2 points between the intervention and control groups: an effect size of unclear policy relevance. Using Bayes' Theorem, the post-test probability mean difference between the two groups was 9% (95% confidence interval 3-14%). Interpreted as a prevalence reduction, this is evaluated more easily by policy makers and clinicians. Conclusion Important information on the probable differences in real world prevalence and impact of prevention and treatment programmes can be produced by applying Bayes' Theorem to studies where diagnostic outcome measures are used. However, the usefulness of this approach relies upon good information on the accuracy of such diagnostic measures for target conditions.

Background Drinking is influenced by youth (mis) perceptions of how their peers drink. If misperceptions can be corrected, young people may drink less. Objectives To determine whether social norms feedback reduces alcohol misuse in university or college students. Search strategy Cochrane Drugs and Alcohol Group Register of Trials; Central; MEDLINE; EMBASE; PsyInfo; CINAHL (up to March 2008). Selection criteria RCT or cluster RCT that evaluate social normative intervention with no intervention, alcohol education leaflet or other non-normative feedback intervention Data collection and analysis 2/3 authors extracted data. Included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. Main results Twenty-two studies were included (7,275 participants). Alcohol related problems: Significant reduction with Web/computer feedback (WF) (SMD-0.31 95% CI-0.59 to -0.02), three studies, 278 participants. No significant effect of mailed feedback (MF), individual face-to-face feedback (IFF) or group face-to-face feedback (GFF). Peak Blood Alcohol Content (BAC) : Significant reduction with WF (SMD-0.77 95% CI-1.25 to -0.28), two studies, 198 participants. No significant effect of MF or IFF. Drinking Frequency: Significant reduction with WF (SMD -0.38 95% CI -0.63 to -0.13), two studies, 243 participants and IFF (SMD -0.39 95% Cl -0.66 to -0.12), two studies, 217 participants. No significant effect of MF. Drinking Quantity: Significant reduction with WF (SMD -0.35 95% Cl -0.51 to -0.18), five studies, 556 participants and GFF (SMD -0.32 95% Cl -0.63 to -0.02) three studies, 173 participants. No significant effect of MF or IF. Binge drinking: Significant reduction with WF (SMD -0.47 95% Cl -0.92 to -0.03) one study, 80 participants, IFF (SMD -0.25 95% Cl -0.49 to -0.02) three studies, 278 participants and and GFF (SMD -0.38 95% Cl -0.62 to -0.14) four studies, 264 participants. No significant effect for MF. BAC: No significant effect of MF and IFF Drinking norms: Significant reduction with WF (SMD -0.75 95% Cl -0.98 to -0.52) three studies, 312 participants. Authors' conclusions WF and IFF are probably effective in reducing alcohol misuse. No direct comparisons of WF against IFF were found, but WF impacted across a broader set of outcomes and is less costly so therefore might be preferred. Significant effects were more apparent for short-term outcomes (up to three months). For mailed and group feedback, and social norms marketing campaigns, the results are on the whole not significant and therefore cannot be recommended.

Background: The effect of alcohol portrayals and advertising on the drinking behaviour of young people is a matter of much debate. We evaluated the relationship between exposure to alcohol advertising, marketing and portrayal on subsequent drinking behaviour in young people by systematic review of cohort (longitudinal) studies. Methods: studies were identified in October 2006 by searches of electronic databases, with no date restriction, supplemented with hand searches of reference lists of retrieved articles. Cohort studies that evaluated exposure to advertising or marketing or alcohol portrayals and drinking at baseline and assessed drinking behaviour at follow-up in young people were selected and reviewed. Results: seven cohort studies that followed up more than 13,000 young people aged 10 to 26 years old were reviewed. The studies evaluated a range of different alcohol advertisement and marketing exposures including print and broadcast media. Two studies measured the hours of TV and music video viewing. All measured drinking behaviour using a variety of outcome measures. Two studies evaluated drinkers and non-drinkers separately. Baseline non-drinkers were significantly more likely to have become a drinker at follow-up with greater exposure to alcohol advertisements. There was little difference in drinking frequency at follow-up in baseline drinkers. In studies that included drinkers and non-drinkers, increased exposure at baseline led to significant increased risk of drinking at follow-up. The strength of the relationship varied between studies but effect sizes were generally modest. All studies controlled for age and gender, however potential confounding factors adjusted for in analyses varied from study to study. Important risk factors such as peer drinking and parental attitudes and behaviour were not adequately accounted for in some studies. Conclusion: data from prospective cohort studies suggest there is an association between exposure to alcohol advertising or promotional activity and subsequent alcohol consumption in young people. Inferences about the modest effect sizes found are limited by the potential influence of residual or unmeasured confounding.

The aim of this study was to evaluate the Strengthening Families Programme for young people aged ten to 14 and their parents (SFP 10-14) in Barnsley, a northern English city, based on the experience of facilitators and families who had participated in the programme. A mixed methods design blending both quantitative and qualitative data was used in the study carried out in two phases over a nine-month period in 2005. Quantitative data were collected through: the SFP 10-14 Parent/Caregiver Survey Questionnaire, the SFP 10 -14 Young Persons' Survey Questionnaire and the Strengths and Difficulties Questionnaire. Questionnaire data were compared at the beginning of the SFP 10-14 programmes (weeks 1-2) and at the end of the programmes (week 7). In addition, two focus group meetings were held with families who had undertaken the SFP 10-14 programme; and three focus group meetings were conducted with facilitators of SFP 10-14 programmes. Once quantitative and qualitative data had been analysed separately, a synthesis of the main findings from both approaches was then completed. Following the programmes, parents reported significant changes in communication limit setting, emotional management, prosocial behaviour and drugs/alcohol use. Total difficulties scores were also significantly different pre- and post SFP 10-14 programmes. For the young people, communication, and emotional management were improved and their drugs/alcohol use was less. Their total difficulties scores were also significantly different. Qualitative evidence indicated that families who participated in the study found the SFP 10-14 useful in preventing young people's alcohol and drug use in terms of: learning more about alcohol and drugs, using knowledge and skills to reduce behaviours that might lead to alcohol and drug use and, for young people, dealing with peer pressure that might lead to drug and alcohol use. Parents/caregivers and young people reported that the SFP 10-14 had played a part in improving family functioning through strengthening the family unit. The findings from this exploratory study suggest that the SFP 10-14 may be a useful primary prevention intervention in helping to prevent drug and alcohol misuse in young people.

OBJECTIVES: We sought to establish whether the jugular, subclavian, or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis, or infection related to CVA devices. We also sought to determine whether the circumference of a long-term CVA device influences the incidence of venous thrombosis, venous stenosis, or infection related to CVA devices.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in

the field. There were no language restrictions.

SELECTION CRITERIA: We included randomized controlled trials comparing central venous catheter insertion routes. 

DATA COLLECTION AND ANALYSIS: Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g., misplaced catheter, minor bleeding, hematoma).

MAIN RESULTS: We considered 83 studies for inclusion in the review. Six studies appeared eligible, but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled

trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows:

1. Catheter-related infectious complications: Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval [CI]: 1.95–10.71) favoring subclavian over femoral access. Major infectious complications (sepsis with or without bacteremia):

the RR was 3.04 (95% CI: 0.63–14.82) favoring subclavian access. Colonized catheter (�103 colonyforming units/mL of Gram-positive microorganisms): the RR was 3.65 (95% CI: 1.40–9.56) favoring subclavian access. Colonized catheter (more than 103 colony-forming units/mL of Gram-negative microorganisms): the RR was 5.41 (95% CI: 1.61–18.15) favoring subclavian access.

2. Catheter-related mechanical complications: Overall complications (arterial puncture, minor bleeding, hematoma, misplaced catheter): the RR was 0.92 (95% CI: 0.56–1.51) favoring subclavian access.

3. Catheter-related thrombotic complications: Catheterrelated thromboses (fibrin sleeves, major, and complete thrombosis): the RR was 11.53 (95% CI: 2.80–47.52) favoring subclavian access.

REVIEWER’S CONCLUSIONS: Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required.

Central venous access (CVA), in which a large bore catheter is routed through a vein in the neck, upper chest or femoral area, is needed to give drugs that cannot be given by mouth or via a conventional cannula in the arm.

Objectives

To establish whether either the jugular, subclavian or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis or infection related to CVA devices.

To determine whether the circumference of a long-term central venous access device influences the incidence of venous thrombosis, venous stenosis or infection related to CVA devices.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions.

Selection criteria

We included randomized controlled trials comparing central venous catheter insertion routes.

Data collection and analysis

Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g misplaced catheter, minor bleeding, haematoma).

Main results

We considered 83 studies for inclusion in the review. Six studies appeared eligible but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows

1. Catheter-related infectious complications 

Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval (CI) 1.95 to 10.71) favouring subclavian over femoral access. 

Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI 0.63 to 14.82) favouring subclavian access. 

Colonized catheter (greater than 103 colony-forming units/mL of gram positive microorganisms): the RR was 3.65 (95%CI 1.40 to 9.56) favouring subclavian access. 

Colonized catheter (greater than 103 colony-forming units/mL of gram negative microorganisms): the RR was 5.41 (95% CI 1.61 to 18.15) favouring subclavian access.

2. Catheter-related mechanical complications 

Overall complications (arterial puncture, minor bleeding, haematoma, misplaced catheter): the RR was 0.92 (95% 0.56 to 1.51) favouring subclavian access.

3. Catheter-related thrombotic complications 

Catheter-related thromboses (fibrin sleeves, major and complete thrombosis): the RR was 11.53 (95% CI 2.80, to 47.52) favouring subclavian access.

Authors' conclusions

Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required.

Methods  Recent studies were examined on the global burden of alcohol and also those focusing on the links between overall consumption and high-risk drinking, on one hand, and drinking-related damage on the other hand. A synopsis of main findings from reviews and other analysis provides the basis for conclusions about the impacts of education and persuasion interventions.

Results  There is a relative absence of evidence of the effectiveness of education and persuasion in reducing consumption, curtailing high-risk drinking or reducing damage from alcohol. This is in contrast to the rising levels of damage from alcohol, and also to the demonstrated effectiveness of certain alcohol policies and interventions, as summarized in Babor et al.

Conclusions  Given that only a small fraction of education and persuasion interventions have any positive impact, generating ‘more of the same’ is not an impact-effective and cost-efficient approach. Therefore, interventions that have not been shown to be effective need to be phased out and those most effective and of widest scope should receive more attention and enhanced resources. A reframing of the roles and foci of persuasion interventions is advised, including, for example, focusing on informing policy-makers, and stimulating public discussions about the rationale of alcohol policies and the roles that citizens can play in promoting and supporting these policies.

This is the protocol for a review. The objectives are as follows:

(1) - To summarise the current evidence about the effectiveness of interventions delivered in non-school settings intended to prevent or reduce drug use by young people under 25;

(2) - To investigate whether interventions' effects are modified by the type and setting of the intervention, and the age of young people targeted;

(3) - To identify areas where more research is needed.

Over 30 studies reported that early extubation (within eight hours) appears to be safe without an increased incidence of morbidity. A benefit of the practice may be cost savings associated with shorter Intensive Care Unit and hospital length of stays.

Objectives

To assess the effects of early extubation and the impact of the extubating clinician's profession on morbidity, mortality, intensive care unit and hospital length of stay, with a subgroup analysis for extubation within four hours or four to eight hours.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to June 2003), EMBASE (January 1980 to June 2003), CINAHL (January 1982 to December 2002), SIGLE (January 1980 to December 2002). We searched reference lists of articles and contacted researchers in the field.

Selection criteria

Randomized controlled trials and controlled clinical trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement, aortic aneurysm repair).

Data collection and analysis

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. A meta-analysis for most outcomes was conducted.

Main results

Six trials were included in the review. There was no evidence of a difference between early and conventionally extubated patients shown in the relative risk and 95% confidence interval for the following outcomes: mortality in intensive care was 0.8 (0.42 to 1.52); thirty day mortality was 1.2 (0.63 to 2.27); myocardial ischaemia was 0.96 (0.71 to 1.30); reintubation within 24 hours of surgery was 5.93 (0.72 to 49.14). Time spent in intensive care and in hospital were significantly shorter for patients extubated early (7.02 hours (- 7.42 to - 6.61) and 1.08 days ( - 1.35 to - 0.82) respectively).

Authors' conclusions

There is no evidence of a difference in mortality and morbidity rates between the study groups. Early extubation reduces intensive care unit and hospital length of stay. Studies were underpowered and designed to show differences between study groups rather than equivalence between the groups.

Suggested future areas of investigation: establishing the safety and efficacy of immediate extubation compared with early extubation; establishing the most effective means of pain control and reducing anxiety for patients; systematic reviews of the evidence for different parts of the patients journey through a cardiac surgery episode; and the impact of the profession of the clinician making the decision to extubate.

Numerous papers were found that discussed evidence-based nursing and barriers to research utilisation, but no previous work on benchmarking or assessing evidence-based nursing was found. Fourteen 'benchmarking evidence-based nursing' criteria were developed, organised around four key themes for achieving effective practice: Selecting a particular aspect of practice to question or examine; finding out from the literature, professional networks and other sources what is current best practice, and critically appraising the available literature and sources of information; implementing and/or learning how to provide best-known clinical practice; and confirming that you are providing best practice.
 

All six clinical areas were generally poor on all 14 benchmarking criteria. However, there were some positive attributes: nurses with degree level post-registration education had better knowledge of searching for and critically appraising research; some senior clinical specialists were supportive of evidence-based changes; and one ward had stronger communication/dissemination links for relevant evidence with related clinical areas (paediatrics).
 

It was concluded that the benchmarking tool developed in the study was useful in identifying positive and negative aspects of evidence-based nursing practice. The tool may be helpful to other organizations considering how to take forward evidence-based nursing practice.

Thirty recently published research studies, which reported the influence of (clearly identifiable) family socialization variables on (self-reported) adolescent drinking behaviour were selected for analysis. The results of these studies were subjected to meta-analysis using a sorting technique. Variables were sorted along the dimensions of Support and Control, and along a Family Structure dimension, which measured parental intactness.

Results of the meta-analysis indicated a clear negative linear relationship between Support and adolescent drinking. There was also a negative linear relationship between Control and drinking behaviour. Thus low support and lax control were associated with increased drinking. However, there was some evidence of a possible curvilinear relationship between control and adolescent drinking. A negative relationship between Family Structure and adolescent drinking was also found, i.e. adolescents from non-intact families tend to drink more. The results were incorporated into a family systems perspective.

It is suggested that extremes of Support and Control, when measured adequately, may be dysfunctional for adequate socialization into normal drinking behaviour, as defined by social and cultural norms, during adolescence.