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Emerald Group Publishing Limited
Copyright © 2009, Emerald Group Publishing Limited
Letter to the Editor
Article Type: Letter to the Editor From: Health Education, Volume 109, Issue 6
Dear Professor Weare,
We welcome the opportunity to respond to Ray Daugherty’s critique of our recent article “Evaluation of an alcohol risk reduction program (PRIME for Life) in young Swedish military conscripts”, published in Health Education, Vol. 109 No. 2, 2009.
Before responding, we believe it is important for readers to be made aware of the source of these comments. Ray Daugherty is the current President of the Prevention Research Institute, a private organisation, which developed the PRIME for Life (PFL) program. The main authors of the article described here are associated with the Karolinska Institute, a public research institute in Sweden, and have no financial or other conflict of interest in this research.
In response to Mr Daugherty’s specific comments, we respond as follows:
Previous evaluations of PFL. The claim that PFL has been evaluated independently and that our findings are “at odds with all other independent evaluations of PFL” is incorrect and misleading. Our article is the first peer reviewed evaluation of the program to appear in a scientific journal. The evaluations referred to by Mr Daugherty were conducted by the Prevention Research Institute and are not independent. It is important to emphasise that our findings are highly consistent with a large volume of research indicating that health education programs, such as PFL, are rarely associated with long term changes in alcohol and drug use behaviour (see, Babor et al., 2003; Loxley et al., 2004; Giesbrecht, 2007). We certainly do not dismiss the positive intention of such programs, and recognise their value as a way to inform the public about important health issues. However, if behaviour change and harm reduction is the goal, then strategies, which affect the price, availability and marketing of alcohol to young people (and adults) have far superior efficacy, and this is now well established.
Program implementation. It will be evident to most informed readers that this was an outcome evaluation, which aimed to determine whether the main program objectives were achieved, and not a process evaluation focussing on implementation issues. These are separate but related methodologies, and it is quite reasonable to conduct evaluations focussing on outcomes alone, particularly as a first step when no independent evaluations of a program have been reported in the scientific literature. Clearly, the way a program is implemented can influence outcomes, and we acknowledge the possibility that this program may not have been implemented optimally. Equally, one cannot assume that the program would have been successful had it been implemented differently. The long list of implementation issues described by Mr Daugherty highlight concerning flaws in the implementation process which was the responsibility of the Prevention Research Institute who managed the PFL program in Sweden. This is problematic given that the program has been running in Sweden for many years, and in 2005 was up to it’s 8th revision (Prime Times, 2008).
Measurement tools. The validity of the alcohol assessment tool used in this study has been questioned. The Alcohol Use Disorders Identification Test (AUDIT) is one of the most widely used questionnaires to assess alcohol consumption among adults and youth, and is currently used to measure alcohol habits in Sweden (Källmén et al., 2007). The psychometric properties of the AUDIT have been reported elsewhere (Bergman and Källmén, 2002). The AUDIT was developed with the ambition that it would be useful in countries with differing alcohol habits and cultures. For the purpose of this study, the cut-off for hazardous or harmful alcohol habits among males was set at the recommended eight points (Saunders et al., 1993), and the cut-off for females was set at six points. Mr Daugherty argues that the AUDIT may be inadequate because it does not detect changes in high risk drinking behaviours. AUDIT measures both the average frequency and the amount of alcohol consumed on a five point scale, ranging from 1-2 standard glasses consumed on a typical drinking occasion, up to 10 or more. Separate analyses were conducted to examine changes in ‘high risk’ alcohol consumption but no significant pre-post program effects were found. Although not reported, separate analyses of the first two AUDIT items, measuring the average frequency and amount of alcohol consumed, also failed to show a significant pre-post intervention effect. The AUDIT measures change in alcohol consumption on a ‘typical drinking occasion’, and this wording could overlook some heavy drinking occasions. These should be detected by the AUDIT ‘binge drinking’ question, which asks respondents how often they drank six or more standard glasses of alcohol during the previous week or month. Nonetheless, we acknowledge the possibility that some heavy drinking ocassions (most likely a small minority) may not have been captured by the questionnaire. The attitude scale used in this study was developed by the STAD alcohol and drug research group in Stockholm, Sweden. The face validity of the questionnaire items were assessed by an independent group of alcohol researchers at STAD. Mr Daugherty correctly notes that the reliability of the instrument was not assessed before the study.
Data analysis. A general concern was raised regarding the data analytic approach – namely that only the total AUDIT score was presented. Separate item analyses were performed using the AUDIT, including the average frequency and amount of alcohol consumed, for both high risk and all subjects, but no program effects were found.
Mats Å. Hallgren Håkan Källmén, Håkan Leifman, Torbjörn Sjölund Sven Andréasson
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Mats Å. Hallgren
Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Stockholm, Sweden (correspondence to: STAD section, Crafoords väg 6, 113 24, Stockholm, Sweden; E-mail: email@example.com)
Håkan Källmén, Håkan Leifman, Torbjörn Sjölund
Dependency section, Stockholm Prevents Alcohol and Drug Problems (STAD), Stockholm, Sweden
National Institute for Public Health, Ostersund, Sweden