In the USA primary care nurses have successfully delivered a school-based intervention to prevent under-age drinking based on a brief (average 20 minutes) one-to-one consultation with each pupil. Parents of nearly 90% of sixth grade (age 11–12) pupils at two innercity schools agreed to their children entering the study. One school was for local pupils, at the other 40% of pupils were bussed in from the suburbs. Within each school pupils were randomly assigned to the STARS for Families programme or to act as controls. In the first year the programme consisted of a nurse consultation plus postcards mailed to parents with an alcohol prevention message to discuss with their children. Next year there was a follow-up consultation and four parent-child homework tasks incorporating a ‘contract’ returned to the school which committed the child not to drink and designated a parent to remind them of that pledge. Postcards and homework were endorsed by the lead researcher and a local paediatrician. Control pupils simply read alcohol health promotion and prevention booklets at school.

Then about 14 years old, 78% of the pupils surveyed at baseline were re-surveyed a year after the intervention had ended. All alcohol use measures were lower among STARS for Families pupils, most noticeably at the bussed-in school where intervention pupils were less likely to drink (11% versus 21%), significantly less likely to intend to drink soon (5% versus 18%), and were assessed as at significantly less risk of drinking. The same trends were seen at the local school but only a reduced risk of drinking attained statistical significance. However, at this school there had been significant alcohol use reductions after the first year of the programme.

In context The main puzzle is why significant long-term effects were not seen at the local school. The probable explanation is a combination of the number of pupils who did not complete follow-up surveys and the fact that control and intervention families more often mixed together in the same neighbourhood, potentially spreading any preventive impact to control pupils. Also, an attempt to tailor the intervention to individual risk and protective factors may have overcomplicated it. Earlier studies with short follow-ups minimising attrition, which reduced ‘contamination’ by not involving parents, and which used simpler interventions, reported substantial (but not always statistically significant) intervention effects in local schools in the same area. One also established that primary care nurses produced outcomes as good as or better than those from family doctors. The entire package was much more extensive than the nurse consultations. Home-based activities successfully stimulated parent-child communication about drinking so were potentially an active ingredient, as were the research surveys which provided the data enabling consultations and postcards to be tailored to the pupil.

Practice implications Advantages of the approach are that it does not occupy classroom time and that it is simple and cheap enough for widespread dissemination. It also releases teachers from the bind of objectively teaching about substance use while trying to prevent it, and pupils seem more likely to discuss drug use openly with someone who does not have the disciplinary responsibilities of a teacher. The intervention could be implemented by school counsellors or school nurses, who in Britain are being encouraged to extend their public health role. It can be targeted at at-risk pupils yet avoids dealing with them as a group (perhaps reinforcing deviance) or stigmatising them – they would be ‘Just seeing the nurse’. Alternatively, in institutions with a high risk profile it could be applied across the board. The best format for the sessions and how far they need to be tailored to the pupil are unclear, but quite simple interventions with follow-up sessions seem effective, at least with respect to drinking. Postcards and take-home lessons which involve parents may augment schoolbased activities but are not essential.

Featured studies Werch C.B. et al. “One-year follow-up results of the STARS for Families alcohol prevention program.” Health Education Research: 2003, 18(1), p. 74-87. Copies: apply Alcohol Concern. Contacts Chudley Werch, Center for Research on Substance Use, 4567 St Johns Bluff Road South, Jacksonville, Florida 32224-2645, USA, cwerch@unf.edu