Cost-effectiveness of a combined classroom curriculum and parental intervention: economic evaluation of data from the Steps Towards Alcohol Misuse Prevention Programme cluster randomised controlled trial

Disentangling the temporal relationship between alcohol-related attitudes and heavy episodic drinking in adolescents within a randomized controlled trial

BACKGROUND AND AIMS

Within many alcohol prevention interventions, changes in alcohol-related attitudes (ARA) are often proposed as precursors to changes in drinking behaviour. This study aimed to measure the longitudinal relationship between ARA and behaviour during the implementation of a large-scale prevention trial.

DESIGN AND SETTING

This study was a two-arm school-based clustered randomized controlled trial. A total of 105 schools in Northern Ireland and Scotland participated in the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) Trial.

PARTICIPANTS

A sample of 12 738 pupils (50% female; mean age = 12.5 years at baseline) self-completed questionnaires on four occasions (T1-T4). The final data sweep (T4) was 33 months post baseline.

MEASUREMENTS

Individual assessments of ARA and heavy episodic drinking (HED) were made at each time-point. Additional covariates included location, school type, school socio-economic status and intervention arm. Estimated models examined the within-individual autoregressive and cross-lagged effects between ARA and HED across the four time-points (Bayes estimator).

FINDINGS

All autoregressive effects were statistically significant for both ARA and HED across all time-points. Past ARA predicted future ARA [e.g. ARAT1 → ARAT2 = 0.071, credibility interval (CI) = 0.043-0.099, P < 0.001, one-tailed]. Similarly, past HED predicated future HED (e.g. HEDT1 → HEDT2 = 0.303, CI = 0.222-0.382, P < 0.001, one-tailed). Autoregressive effects for HED were larger than those for ARA at all time-points. In the cross-lagged effects, past HED statistically significantly predicted more positive ARA in the future (e.g. HEDT2 → ARAT3 = 0.125, CI = 0.078-0.173, P < 0.001, one tailed) except for the initial T1-T2 path. In contrast, past ARA did not predict future HED across any time-points.

CONCLUSIONS

Changes in alcohol-related attitudes were not a precursor to changes in heavy episodic drinking within the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) Trial in Scotland and Northern Ireland. Rather, alcohol-related attitudes were more likely to reflect prior drinking status than predict future status. Heavy episodic drinking status appears to have a greater impact on future alcohol attitudes than attitudes do on future heavy episodic drinking.

Interventions to prevent alcohol use: systematic review of economic evaluations

BACKGROUND

Alcohol use is a leading risk factor for death and disability worldwide.

AIMS

We conducted a systematic review on the cost-effectiveness evidence for interventions to prevent alcohol use across the lifespan.

METHOD

Electronic databases (EMBASE, Medline, PsycINFO, CINAHL and EconLit) were searched for full economic evaluations and return-on-investment studies of alcohol prevention interventions published up to May 2021. The methods and results of included studies were evaluated with narrative synthesis, and study quality was assessed by the Drummond ten-point checklist.

RESULTS

A total of 69 studies met the inclusion criteria for a full economic evaluation or return-on-investment study. Most studies targeted adults or a combination of age groups, seven studies comprised children/adolescents and one involved older adults. Half of the studies found that alcohol prevention interventions are cost-saving (i.e. more effective and less costly than the comparator). This was especially true for universal prevention interventions designed to restrict exposure to alcohol through taxation or advertising bans; and selective/indicated prevention interventions, which involve screening with or without brief intervention for at-risk adults. School-based interventions combined with parent/carer interventions were cost-effective in preventing alcohol use among those aged under 18 years. No interventions were cost-effective for preventing alcohol use in older adults.

CONCLUSIONS

Alcohol prevention interventions show promising evidence of cost-effectiveness. Further economic analyses are needed to facilitate policy-making in low- and middle-income countries, and among child, adolescent and older adult populations.

The Good Behaviour Game intervention to improve behavioural and other outcomes for children aged 7–8 years: a cluster RCT

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.

Trial registration

This trial is registered as ISRCTN64152096.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT

BACKGROUND

Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population.

OBJECTIVES

To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective).

DESIGN

A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations.

SETTING

Paediatric intensive care units in the UK.

PARTICIPANTS

Invasively mechanically ventilated children (aged < 16 years).

INTERVENTIONS

The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded.

MAIN OUTCOME MEASURES

The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days.

RESULTS

The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03).

LIMITATIONS

The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined.

CONCLUSIONS

The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain.

FUTURE WORK

Future work should explore intervention sustainability and effects of the intervention in other paediatric populations.

TRIAL REGISTRATION

This trial is registered as ISRCTN16998143.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.

An Examination of the Longer-Term Impact of a Combined Classroom and Parental Intervention on Alcohol-Related Harms and Heavy Episodic Drinking

Although fewer adolescents are consuming alcohol than was the case in previous decades, those who are consuming alcohol are still exposed to alcohol-related harms. While the evidence for the effectiveness of universal, school-based interventions is limited, a recent cluster randomised controlled trial (The STAMPP Trial) reported a significant effect at 10 months post-intervention of a combined classroom/parental intervention on heavy episodic drinking (HED) in the previous 30 days, but no significant effect on the number of self-reported alcohol-related harms (ARH) experienced in the previous 6 months. This follow-up study sought to examine intervention effects 24 months after delivery of the intervention (+ 57 months from baseline, or + 34 months post-intervention). Participants were 5029 high school students in STAMPP (38% of 12,738 pupils originally randomised into the trial), from 87 schools (82.3% of schools recruited in the original STAMPP trial). Outcomes were assessed using two-level random intercepts models (logistic regression for HED and negative binomial for number of ARH). Results of the present study show that the intervention effect for HED deteriorated over the following 2 years (OR declined from 0.60 to 0.97), and there was still no difference in ARH. This was due to an increase in the prevalence of intervention students' HED rather than a reduction in prevalence in control students. Results are discussed in the context of prevention initiatives.