BackgroundConcern is growing regarding frequent and excessive misuse of alcohol by young people. The average age at which young people in Europe start to drink is twelve and a half, and during the last decade, the quantity of alcohol consumed by younger adolescents in the UK has increased. Families are known to play an important role in shaping young people's alcohol misuse, although family risk and protective factors associated with misuse in a UK context are in need of further investigation.MethodsThe study used a cross-sectional design, involving secondary analyses of self-completion questionnaire responses from 6,628 secondary school children (i.e. aged 11-16 years), from 12 schools within an urban location in Wales. Items relating to family functioning and perceived parental attitudes were first subjected to factor analysis. Associations of family closeness and conflict, parental monitoring and attitudes and family history of substance misuse with children's self reported alcohol consumption were examined using logistic regression analyses.ResultsApproximately three quarters of respondents reported having tried alcohol, most of whom had first tried alcohol aged 12 or under. Parental monitoring and family closeness were positively correlated with one another and were both associated with significantly lower levels of drinking behaviours. Family violence and conflict, more liberal parental attitudes towards substance use and towards alcohol and petty crime, and family history of substance misuse were positively correlated with one another and with higher levels of drinking behaviours. Parental monitoring was identified as the family functioning factor most consistently associated with drinking behaviour in multivariate analyses.ConclusionsSignificant relationships were found between young people's drinking behaviours and perceptions of risk and protective factors in the family environment. Parental monitoring was strongly associated with family closeness and appeared to form one part of a parenting style of more general communication and regulation of children's behaviour. Findings support the need for alcohol misuse prevention interventions which address risk and protective factors within the family setting. Timing of such prevention work should be related both to the development of family relationships and the age at which young people begin drinking alcohol.

PurposeProcess 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).MethodsA 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.ResultsAdherence 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.ConclusionsExtended 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.

Purpose -The purpose of this paper is to assess the implementation of the Welsh Network of Healthy School Schemes (WNHSS) at national, local and school levels, using a systems approach drawing on the Ottawa Charter. Design/methodology/approach -The approach takes the form of a single-case study using data from a documentary analysis, interviews with Healthy Schools Co-ordinators (n ¼ 23) and stakeholder (n , 93) discussion of interim findings at three regional workshops. Findings -There was almost universal adherence to a national framework based on Ottawa Charter principles. Substantial progress had been made with advocacy and mediation, although the framework provided less specific guidance regarding enablement. All-Wales training for co-ordinators, the commitment of co-ordinators to working across administrative and professional boundaries, and support from local education and health partnerships, were important determinants of healthy school schemes' growth and efficiency. Primary schools were more successful than secondary schools in embedding health-related changes. Research limitations/implications -Although findings are largely based on indirect evidence, the use of a social-ecological model of evaluation provided valuable insights into implementation processes at multiple levels. Findings suggest that strong national support benefits programme development and dissemination and should include effective monitoring of local performance. The national strategic environment was influential at all levels of programme implementation. Priorities for further research include application of the social-ecological model and organisational theory to investigate indicators of sustainability and influences on inequalities in health in school health promotion programmes. Originality/value -The review illustrates the importance of evaluating health promotion programmes at multiple levels using a systems approach.

BackgroundInvolvement of parents/carers may increase the effectiveness of primary school-based alcohol-misuse prevention projects. However, few interventions have been designed for pre-adolescent children, or specifically involve parents/carers. The Kids, Adults Together (KAT) programme in primary schools aimed to reduce alcohol misuse through such an approach.ObjectiveTo determine the value and feasibility of conducting an effectiveness trial of KAT.DesignParallel-group cluster randomised exploratory trial with an embedded process evaluation. Schools were the unit of randomisation.SettingPrimary schools (n = 9) in south Wales, UK.ParticipantsPupils in Year 5/6 (aged 9–11 years) and their parents/carers; school staff.InterventionThe Kids, Adults Together programme consisted of (1) classwork addressing the effects of alcohol; (2) a family event for children and parents/carers; and (3) a ‘goody bag’ containing fun items, including a digital versatile disc (DVD) for families to watch together. The intervention comprised KAT plus existing alcohol-related activities and lessons. Control-group schools continued with existing alcohol-related lessons and activities.Main outcome measuresKey outcomes related to the progression criteria for a potential future effectiveness trial. These included the acceptability, participation equity, feasibility and implementation of KAT; the recruitment and retention of research participants; and the acceptability and feasibility of research processes, including data collection methods and outcome measures.ResultsNine schools (free school meal entitlement ranging from 1% to 37.2%) participated. Two of five intervention schools withdrew but all four control schools were retained, and these seven schools facilitated all research data collections. Programme acceptability and participation rates were high in all three intervention schools (parent/carer participation rates ranged from 45.1% to 65.7%), although implementation quality varied. At baseline, approximately 75% of eligible children (n = 418) provided data, of whom 257 also provided data at follow-up. Only 27 parents/carers (estimated response rate 6.5%) completed interviews. Most children were willing to complete questionnaires but measures were not appropriate for this age group. Measures of alcohol consumption produced inconsistent responses. Intermediate outcomes on family communication showed no evidence of intervention effectiveness.ConclusionsIn the three schools that received the KAT intervention, it was found to be acceptable to schools and pupils and there were good levels of participation from parents/carers from across a range of socioeconomic groups. However, two intervention schools withdrew from the trial. Findings from intermediate outcomes on family communication did not support programme theory. In addition, the study highlighted challenges in identifying suitable outcome measures for children aged 9–11 years and the feasibility of long-term follow-up via secondary schools.Future workIt would not be appropriate to proceed to an effectiveness trial of KAT. There are doubts/uncertainties about the potential effects of KAT; suitability of measures; the large number of schools which would be required for an effectiveness trial of KAT, and the cost of this; feasibility of follow-up in secondary schools; and programme implementation and theory. There is a need to develop and validate measures for children aged 9–11 years; to test the feasibility of follow-up data collection methods in secondary schools; and to further consider sample size requirements and feasibility.Trial registrationCurrent Controlled Trials ISRCTN80672127.FundingThe exploratory trial of this project was funded by the National Institute for Health Research Public Health Research programme and the process evaluation was funded by the Economic and Social Research Council. The work was undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. This project will be published in full inPublic Health Research; Vol. 3, No. 15. See the NIHR Journals Library website for further project information.

School-based interventions for young people with emotional/mental health problems are often provided by external practitioners and their relationship with host schools is a key influence on implementation. Poor integration within school systems, schools' tendency to define interventions around pupils' behaviour and teachers' control over access, may undermine therapeutic relationships. This study examines how one school-based intervention—Bounceback—addressed these challenges. Methods comprised interviews with programme staff, school staff and service users. Bounceback sought to develop therapeutic relationships through creating a safe, welcoming place and maximising pupils' choice about how they engaged with it. To ensure Bounceback was delivered as intended, staff developed five conditions which schools were asked to meet: adhering to referral criteria, ensuring that attendance was voluntary, appropriate completion of referral forms, mechanisms for contacting pupils and private accommodation to maintain confidentiality. Pupils reported high levels of acceptability and described relationships of trust with Bounceback staff. Although pupils had choice about most aspects of Bounceback, teachers controlled access to it, partly in order to manage demand. The study highlights the need for external agencies to communicate their aims and needs clearly to schools and the importance of peripatetic practitioners being well integrated within their parent organisations.

The results re-emphasize the inadequacies of existing cessation provision for meeting adolescent preferences and suggest that developing more adolescent-appropriate support requires a reconceptualization of existing interventions, with service users situated at the core of intervention design. The study highlights a number of service development points for intervention planners including: rethinking the timing and location of provision; placing more emphasis on the selection of facilitators; harnessing support from friends and family; and rooting these developments in broader tobacco control strategies.

BackgroundAlcohol misuse by young people is an important public health issue, and has led to the development of a range of prevention interventions. Evidence concerning the most effective approaches to intervention design and implementation is limited. Parental involvement in school-based interventions is important, but many programmes fail to recruit large numbers of parents. This paper reports findings from an exploratory evaluation of a new alcohol misuse prevention programme - Kids, Adults Together (KAT), which comprised a classroom component, engagement with parents through a fun evening for families with children aged 9-11 years, and a DVD. The evaluation aimed to establish the programme's theoretical basis, explore implementation processes and acceptability, and identify plausible precursors of the intended long-term outcomes.MethodsDocumentary analysis and interviews with key personnel examined the programme's development. Classroom preparation and KAT family events in two schools were observed. Focus groups with children, and interviews with parents who attended KAT family events were held immediately after programme delivery, and again after three months. Interviews with head teachers and with teachers who delivered the classroom preparation were conducted. Follow-up interviews with programme personnel were undertaken. Questionnaires were sent to parents of all children involved in classroom preparation.ResultsKAT achieved high levels of acceptability and involvement among both children and parents. Main perceived impacts of the programme were increased pro-social communication within families (including discussions about harmful parental alcohol consumption), heightened knowledge and awareness of the effects of alcohol consumption and key legal and health issues, and changes in parental drinking behaviours.ConclusionsKAT demonstrated promise as a prevention intervention, primarily through its impact on knowledge and communication processes within families, and its ability to engage with large numbers of parents. A key programme mechanism was the classroom preparation's facilitation of parental involvement in the family fun evening. The programme also incorporated features identified in the literature as likely to increase effectiveness, including a focus on harm reduction, interactive delivery, and targeting primary-school-age children. Further research is needed to test and develop programme theory through implementation in different school contexts, and to examine potential longer-term impacts, and the feasibility of large scale delivery.

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