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Koutakis N., Stattin H., Kerr M.
Addiction: 2008, 103, p. 1629–1637.
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In Sweden routine parent-school meetings incorporating parenting advice and encouraging commitment to take a strong stand against underage drinking had a remarkable impact on adolescent drunkenness – but would this simple, low-cost tactic work as well in the UK?
Summary The Örebro Prevention Programme built on the fact that Swedish schools start each term with a parent information meeting. A survey of pupils in the final grade of compulsory schooling (roughly age 16) in the county of Örebro in central Sweden was used to select schools for the project in communities typified as inner cities, public housing areas, or small towns. Within each type of community, And in small towns, within each town. pairs of matched Matched on the size of the school and pupil alcohol use and delinquency. schools were selected, one of which carried on as normal, the other of which was assigned to test the prevention programme. None of the schools refused to participate in the study.
The programme was implemented across the final three years (grades seven to nine) of compulsory schooling when pupils were aged 13 to 16. Before the programme started, a survey of pupils in grade seven formed the baseline against which to assess impacts in this and the following two years. In each succeeding year the next higher grade was surveyed, meaning that largely the same pupils were followed up each year. In each year roughly 900 pupils Of whom about 90% agreed, were given permission by their parents, and completed the classroom surveys. In different sets of schools and years, from 68% to 84% of parents also agreed to be surveyed by post at home. evenly split between both sets of schools were asked to participate in the study.
Rather than through classroom lessons, the programme worked via the parents. At a seventh-grade parent information meeting, project staff gave a presentation describing the programme and advising parents to maintain a zero-tolerance stance towards youth drinking and to communicate clear rules to their children. This was reinforced by inviting attending parents to sign agreements about their positions on (among other issues) youth drinking; most did so. The agreement was mailed to all parents including those who had not been at the meeting. In each of the next two years project staff attended two further parent meetings to emphasise the key message of strict rules. Reports on the meetings were one of at least three mailings each term to parents. Mailings included letters (most co-signed by project workers and teachers) which stressed the importance of communicating family rules against alcohol and drug use and of promoting organised leisure activities. Based on information from local clubs and organisations, also mailed were catalogues describing leisure activities in the community which parents were asked to read through with their children.
The key question in the pupil surveys asked how often pupils had been drunk in the past four weeks. From virtually no times at age 13, in the control schools not participating in the programme the average rose to nearly once in four weeks at age 16 chart. From a similar starting point, it rose just half as much in programme schools, a medium to large programme impact as represented by the effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. the most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. metric. Also the proportion of pupils who had been drunk more than once during this period was twice as high (27% versus 13%) in non-programme schools.
At age 13 just under a fifth of the pupils said they had already been drunk. Among these high risk pupils the programme was just as, if not more, effective, halving the increase in the frequency of drunkenness; by age 16, without the programme these children were getting drunk on average twice a month compared to less than once a month in programme schools chart. On all these measures for both full and high risk samples, there were statistically significant differences between programme and non-programme schools, and no indication that the programme was any less effective with boys than with girls or vice versa.
Pupils were also asked how often they had committed criminal or antisocial acts Such as breaking into stores or cars, hurting someone with a weapon, painting graffiti, shoplifting, stealing a bike, or vandalism. over the past year. Though the intervention had focused on drinking, here too there were statistically significant and medium to large programme benefits In the form of smaller increases and lower levels of delinquency. across the entire samples and among pupils in the top fifth of delinquency before the programme started. In respect both of drunkenness and delinquency, the there were no major differences between the three types of communities in the effectiveness of the programme.
One mechanism underlying these benefits was expected to be an extension of the parents' strict anti-drinking norms in respect of their 13-year-old children to older ages. Based on the parents' own accounts, the programme did significantly maintain these norms. However, there was no evidence from the children that involvement in adult-led organised group activities – another supposed means by which the programme would affect drinking – had in fact been enhanced by the intervention.
For the authors their study demonstrated that the parent programme had successfully influenced parental attitudes against underage drinking, resulting in (compared to most other prevention programmes) relatively large reductions three years later in drunkenness and delinquency across both boys and girls, among high risk pupils as well as the entire school year, and in different types of communities. It achieved these impacts despite being easily administered through existing parent–teacher meetings, costing very little to implement, and requiring just a two-day course for the people delivering the programme, who need not be specialist professionals. In the Swedish context they believed these attributes meant the programme could be implemented widely and largely within existing resources.
commentary In the Swedish context this was a convincing demonstration of the power of harnessing the parent involvement mechanisms and influence of the school to reinforce parental responsibility in respect of their children's drinking. It is also a testimony to the potential power of unambiguous and simple messages congruent with the culture and to the strong influence exerted by parental attitudes and behaviours on when and then how young people drink.
Though not clear in the featured report, it seems that parents at the initial meeting jointly develop an agreement concerning their stance on youth drinking, possibly adding group solidarity and continuing parent-to-parent reinforcement to the mix of influences leading to impacts As a measure of its impact, in programme schools, children who had already been drunk by age 13 ended up getting drunk on average no more often than the general run of pupils in schools without the parent programme; stiffening the stance of their parents averted a developmental trajectory which would have seen these high risk youngsters drinking regularly to intoxication at age 16. several times greater and more consistent than typical of alcohol prevention programmes applied universally to the entire youth population. This is the case even in respect of programmes recognised as effective and usually far more costly and difficult to implement. Confidence in the validity of these findings is weakened slightly by methodological issues; in particular, the failure to account for the grouping of children and parents within schools could have falsely magnified the apparent impacts. More in background notes.
However, a later Swedish trial failed to replicate these findings. It tested the programme's effectiveness in a study conducted by independent researchers not involved in its development, and using the current (in Sweden) widely disseminated version of the programme presented by experienced Örebro presenters. Though the programme was fairly fully implemented, it had no reliable effects on regular drinking or on drunkenness, and the apparent impacts on parental attitudes and behaviour may have been due to parents and children exposed to the Örebro programme being more likely to give the responses 'approved' by the programme. Even in Sweden it seems that routinising the programme diluted its impact compared to the featured trial, when the schools and the presenters were participating in a trailblazing project led by the programme's
Editor's note: A reference is being made here to the 'researcher allegiance' effect. In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers. Such overlaps between developers and researchers are endemic2 in drug prevention research.
1. See articles at the following web addresses:
2. See article at the following web address:
http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004 who can be expected to be both expert on its implementation and enthusiastic about its potential.
Accepting these initial results as an indication of the programme's potential, the question remains whether it would have the same potential in drinking cultures like that of the UK. A trial in the Netherlands of a Dutch version of the Örebro programme may be a better pointer to how it would perform in Britain. If so, it suggests that it would be an effective addition to alcohol use prevention lessons, but not the standalone success it was at first in Sweden. Ease of implementation, low cost, the fact that no classroom time is involved, and the potential for extra impacts, may be seen as making it worth a try alongside whole school programmes, the promotion of activities which give young people a sense of achievement and belonging, and perhaps above all, cultural change which makes parents more willing and able to control drinking among underage children.
Efforts to involve parents have generally been more elaborate but less successful than the one trialled in the featured study. A meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. combining findings from randomised studies of parent-focused substance use prevention programmes found modest effects in the form of fewer adolescent children starting to drink and a lower frequency of drinking. This was particularly the case when whole schools were engaged in the intervention, offering an opportunity for pupils and parents who participated in the programme to influence those who did not. However, the findings were undermined by a general failure to account for families which were unable to be followed up.
A common practical problem is getting parents to participate in face-to-face substance use prevention programmes. Typically in Britain (see for example 1 2 3) and elsewhere in Europe, attendance is very low, especially among parents most in need of parenting support and with lenient attitudes to substance use. Generally in these studies the attempt was to encourage attendance at special add-on events. On this count the featured study's strategy of incorporating prevention in to the school's core parent involvement programme has a distinct advantage. The downside is that at these events schools have a limited time in which communicate with parents; educational and other social issues (such as knife-carrying, guns, bullying, illegal drugs, teenage pregnancy) are likely to be seen as higher priorities both by the school and by the parents. Other solutions tried in Australia and the USA involve mailings to parents from the school or parent-child homework assignments; more in background notes.
An obvious risk of encouraging parents to make their strictness about underage drinking known to their children, is that the children will respond by hiding their drinking, depriving parents of awareness and the opportunity to intervene. In Sweden but perhaps less so in Britain, voluntary self-disclosure is an important way parents learn about their children's leisure-time activities. More in background notes.
As the authors acknowledged, the main question mark for readers outside Sweden will be the programme's applicability to their cultures. Rather than having to create this, it merely had to extend the strict On a scale of 1 (lenient) to 4 (strict), from the start these attitudes averaged 3.8. anti-underage drinking norms held by parents and communicated to their children when they were 13 years of age to later ages, when legal purchase was still many years away for their children. Such attitudes reflect national policy. For a European nation, Sweden has unusually restrictive alcohol laws, allowing legal purchase only at age 20 and confining the sale of anything other than low-content beverages to state-run stores, restrictions which make it clear that drinking is not mainstream and accepted.
As in Sweden, in Britain too parents seem influential in their children's drinking, but as much in the direction of condoning as outright opposition. It would be a far bigger task to persuade the majority of British parents to harden their attitudes and keep them hardened as their child approaches the lower legal alcohol purchase age in the UK, where full-strength drinks are available in virtually every supermarket. In drinking cultures like Britain, advice originating from the school about the parent's responsibility to communicate an unambiguous stance on drinking risks being seen as unwelcome meddling, especially by the heavy drinking parents whose children could most benefit from stronger parenting. See background notes for some relevant studies. A trial in the Netherlands of a Dutch version of the Örebro programme may be a better pointer to how it would perform in a drinking culture more like that of the UK. If so, it suggests that it would be a worthwhile addition to alcohol use prevention lessons, but not the standalone success it was at first in Sweden.
Attempts are being made in Britain to harden parental attitudes to youth drinking. Aided perhaps by media coverage highlighting the risks of youth drinking, the relevant English national policy aims to develop a national consensus on young people and drinking. At the sharp end of the policy are court orders requiring parents whose children persistently drink in public to exercise greater control. Further down the scale are support for parents whose children are at risk of problems such as drinking, and the attempt to establish a partnership with parents based on a clear understanding of acceptable and unacceptable levels and patterns of youth drinking. So far however the message received by parents from other aspects of alcohol policy – alcohol's mainstream position in society, and particularly the recent extension of opening hours – is that the government is not taking a stand to manage the issue of alcohol in society, undermining the credibility of calls for parents themselves to shoulder that responsibility.
Thanks for their comments on this entry in draft to Richard Velleman of the Mental Health Research & Development Unit of the Avon & Wiltshire Mental Health Partnership NHS Trust and the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 13 August 2011
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