Midford R., Cahill H., Lester L. et al.
Drugs: Education, Prevention and Policy: 2018, 25(1), p. 88–96.
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Strong argument for harm reduction to be the basis of standard drug education within schools from this large-scale Australian trial. Alcohol-related findings 15 months after the two-year programme ended showed its residual effectiveness in reducing pupils’ alcohol consumption and related harm.
Summary Australia’s 2010–2015 drug strategy explicitly endorsed a harm reduction approach, giving scope for school drug education to provide practical knowledge and skills about alcohol and illicit drugs and in turn enabling pupils to make safer decisions about substance use.
The Drug Education in Victorian Schools programme delivered harm reduction and skills-focused substance use education to secondary school pupils over a two-year period.
The featured study evaluated the programme’s residual effectiveness a year after pupils stopped receiving lessons through this programme.
Between baseline and the follow-up there were several statistically significant findings, including a greater increase in knowledge about drugs among intervention pupils, less of an increase in alcohol consumption, a decrease in alcohol-related harm, and fewer risky drinkers.
As alcohol is the drug that causes the most harm to young people, it was given the greatest emphasis in the Drug Education in Victorian Schools programme – a harm reduction and drug education programme delivered over a two-year period (and 18 lessons) to a cohort of secondary school pupils. Lessons on alcohol were integrated with lessons on other drugs, and the programme as a whole explored the connection between substance use and issues such as mental health, gender norms, violence, antisocial behaviour, and sexual vulnerability.
Alcohol-related findings from the first and second years of the Drug Education in Victorian Schools programme have been reported in previous papers (1 2). The central finding in both was that while pupils receiving the intervention were no less likely to have tried alcohol, their alcohol consumption and related harm increased less steeply than that of pupils receiving usual drug education.
The aim of the featured paper was to evaluate the ongoing effectiveness of the programme by examining outcomes at the three-year follow-up when pupils were no longer receiving these drug education lessons. The researchers predicted that 15 months after the programme ended it would continue to have an influence on pupils in the intervention group (versus those in the control group) by them:
• consuming less alcohol;
• consuming alcohol in a less risky manner;
• experiencing less harm associated with drinking.
Twenty-one government secondary schools in the Australian state of Victoria were recruited to the study on a voluntary basis at the beginning of 2010, with 1752 pupils consenting to participate out of 2700 eligible pupils. Schools were categorised according to location and socioeconomic status, and schools within each group were then randomly allocated to either the intervention group or the control group, with twice the number allocated to the intervention group to allow more precise statements about the effects of the Drug Education in Victorian Schools programme.
Pupils were in year 8 (aged 13–14) when they started the programme. Those in schools assigned to the intervention received 10 lessons in year one and eight lessons in year two. In control group schools, pupils received a minimum of 10 hours’ drug education in each of these years, though the content varied from school to school based on available curriculum resources. In the third year, no lessons from the Drug Education in Victorian Schools programme were provided and both intervention and control group pupils received the usual drug education provided by their school.
Between baseline and the three-year follow-up trends were generally similar to the evaluations at the end of the first and second years of the programme.
There were a number of statistically significant differences between the schools delivering the intervention and schools delivering drug education as usual, indicating residual effects of the Drug Education in Victorian Schools programme:
• Pupils’ knowledge increased by 36% (seven correct answers) in the intervention group but by just 25% (five correct answers) in the control group.
• Among pupils who drank, alcohol consumption increased much less steeply in intervention than in control schools – 84% versus 331%.
• The proportion of pupils who tended to drink in a manner that risked alcohol-related harm increased from 19% to 39% in the intervention group, but by much more (19% to 51%) among pupils in the control group. Intervention pupils were less likely to be risky drinkers at the three-year follow-up.
• At the three-year follow-up, intervention group pupils who usually drank in a risky way decreased their consumption by 10%, compared with control group pupils who increased their consumption by 107%.
• Alcohol-related harm experienced by pupils who drank during the previous 12 months decreased by 28% from baseline to the three-year follow-up in the intervention group but increased by 38% in the control group.
• Three years later, pupils who usually drank in a manner that risked acute harm decreased their level of harm by 36% in the intervention group compared with pupils in the control group who increased their level of harm by 60%.
There were also a number of areas where the intervention group did not show an advantage to a statistically significant degree:
• Pupils in both groups exhibited ‘highly responsible’ attitudes towards drinking at baseline, with an average score of 18.6 out of a possible 25. Three years later, attitude scores increased by 11% for intervention pupils and 10% for control pupils.
• The average number of times pupils talked to their parents about alcohol increased by 95% in the intervention group, compared with 71% for pupils in the control group.
• There was an increase in the proportion of pupils who consumed a full standard drink, from 23% to 52% in the intervention group and 23% to 55% in the control group.
Part of a larger three-year trial of the Drug Education in Victorian Schools programme, this study found that lessons focusing on building skills and reducing harm can remain effective in reducing pupils’ alcohol consumption and alcohol-related harm, even among risky drinkers, and even after the lessons have finished. This provides evidence that effective school drug education not only offers immediate and mass benefit, but that these benefits can continue past the life of programme delivery.
Australian policy endorses a harm reduction approach to substance use. Findings from this and earlier studies on the alcohol prevention outcomes of the Drug Education in Victorian Schools programme (1 2) provide a strong argument for harm reduction to be the basis of standard drug education within schools.
commentary The Drug Education in Victorian Schools programme is now the recommended drug education programme for year 8 and 9 pupils in the Australian state of Victoria, giving schools the means to impart practical knowledge and skills about alcohol and illicit drugs, which enables their pupils to make safer decisions about substance use.
The Effectiveness Bank previously reported the outcomes at the end of the two-year programme, identifying how the lessons brought about change in three factors likely to influence pupils’ decisions about drinking:
The first of these changes remained statistically significant in the featured paper, the second did not, and the third was not reported.
Harm reduction opens up opportunities for discussions during which young people can be open about drinking. While the earlier findings indicated that it might be possible to involve parents in helping to moderate and/or encourage safer drinking, the later findings did not support this to the same degree. The average number of times pupils talked to their parents about alcohol did increase by a considerable amount in both groups, but being in the intervention group did not confer a significant advantage. The age of pupils may be an important factor in interpreting these findings – they were 15–16-years-old at the time data was collected for this study, and may have been less open to talking to their parents than they were a year or two before, not just about drinking, but other issues too.
Some of the differences observed between pupils in the intervention and control groups in the featured paper were remarkable. However, an important caveat was the smaller number of pupils on which these findings were based – for example, the figures on alcohol consumption showing a relative increase between baseline and the three year follow-up of 84% for intervention group pupils and 331% for control group pupils were derived from 513 pupils (out of the 1,744 who had drunk a full standard alcoholic beverage in the previous 12 months). Drawing from an even smaller pool of risky drinkers, levels of alcohol consumption and related harms shown to decrease among intervention group pupils and increase among control group pupils were based on only 33 pupils.
One of the limitations of the trial was the low proportion of eligible pupils from the schools who were included. The requirement to obtain consent from pupils and parents excluded 35% of eligible pupils, and on top of this the study suffered from a drop-out rate of 45% between baseline and the three-year follow-up. This raises questions over the generalisability of the results to all the pupils who outside the context of a research study would have received all or some of the lessons, and over whether the ‘level playing field’ intended to be assured by randomisation was sustained. For example, if pupils who would have responded least well to harm-reduction education tended to be missing, the results would have been biased in favour of the curriculum. Further limitations pertinent to this study are discussed in the Effectiveness Bank commentary of the two-year outcomes of the Drug Education in Victorian Schools programme.
The curriculum tested in the featured study was based in part on the Australian alcohol harm reduction curriculum School Health and Alcohol Harm Reduction Project (SHAHRP). The most recent evaluation of this adapted to the UK context was published in 2012, and found that it curbed the growth in alcohol-related problems among teenagers in Northern Ireland and also that pupils tended to drink less. Effects were most apparent when the lessons had been taught by voluntary-sector drug and alcohol educators rather than the schools’ own teachers, and among just under half of pupils who before the lessons started at age 13–14 had already drunk ‘unsupervised’ without adults being present.
For the UK the most important guidance on alcohol education was issued in 2007 by the National Institute for Health and Care Excellence (NICE). This endorsed alcohol harm reduction as a goal for substance use education, advising that education “should aim to encourage children not to drink, delay the age at which young people start drinking and reduce the harm it can cause among those who do drink”.
School-based drug education was and for many remains the great hope for preventing unhealthy or illegal substance use and the dominant form of universal prevention applied to all regardless of their risk for developing substance use problems. Across almost an entire age group, it offers a way to divert the development of these forms of substance use before they or their precursors have taken root. Though the promise is clear, the fulfilment has been less so. Read more about why in the Effectiveness Bank hot topic.
Thanks for their comments on this entry in draft to research author Dr Richard Midford of Perth Psychological Services in Australia. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 30 November 2018. First uploaded 29 October 2018