Background
Adolescence is characterized by a strong increase in alcohol use: In 2009, approximately 40% of all Dutch 12-year olds reported lifetime alcohol use, which increases to 70% among 14-year olds and 85% among 16-year olds [
1]. Of the Dutch 12-year olds, 9.7% even reported to have been drinking in the last month [
1]. Starting to drink at an early age puts youth at serious risk of developing many alcohol-related problems, such as heavy episodic drinking, alcoholism, and cognitive impairments (e.g., [
2,
3]). These consequences of early onset of alcohol use stress the need to postpone the age of onset. Most school-based alcohol prevention in the Netherlands is conducted at the secondary educational level among 12-15-year olds, while at this age many children have already started to experiment with alcohol. Since many Dutch youth start to drink in early adolescence, prevention programs targeting elementary schoolchildren are needed. However, theory-driven alcohol prevention programs for elementary schoolchildren are lacking.
Socialization theory [
4] posits that parents are the main socializing agents in their children's development, especially when it comes to health issues, which has been supported by a wide range of studies [
5,
6]. Recent studies in the Netherlands showed that through e.g., setting strict rules about alcohol, communicating constructively about alcohol issues, and monitoring daily activities, parents can delay the onset of alcohol use [
7‐
10]. Another reason why parents are important in preventing adolescent alcohol use is that elementary schoolchildren live at home and are still very susceptible to their parents' influences, while peers become more important during mid-adolescence and in some domains parental influence declines [
9,
11]. Moreover, most children get their first glass of alcohol from their parents [
12]. By making parents aware of their role in introducing alcohol to their child, the age of alcohol onset can be delayed (e.g., [
8]).
Parental drinking affects adolescent alcohol use through norm-setting and modeling [
9,
13]. Further, drinking parents tend to engage less in alcohol-specific socialization practices [
7,
14], probably because they do not consider themselves being credible in prohibiting their children from drinking. However, alcohol-specific socialization strategies like setting rules, monitoring and communicating constructively are also effective when parents are (heavy) drinkers themselves (e.g., [
7,
15]). Therefore, it is important to empower this specific group of parents to enhance the confidence alcohol-drinking parents have in the effectiveness of their alcohol-specific parenting strategies. The current program addresses this issue by increasing parents' comfort level in communicating with their children about (their own) alcohol use.
Thus, although there is substantial empirical evidence that parents can prevent early onset of drinking by engaging in alcohol-specific parenting, no effective prevention program for parents and primary school children has been implemented in the Netherlands. The prevention program "In control: No alcohol!", which approach is based on a smoking prevention program called "Smoke-free Kids" [
16], aims to fill this gap. It is a home-based program, which provides many opportunities to engage in structured interactions for the parents and children. Parents and children can go through the program on their own, when they have time, and are not obliged to engage in a complex, time-consuming program. A pilot study conducted over a period of 6 months has provided some insight into the effective components of the "In control: No alcohol!" program [
17]. Specifically, exposure to the program increased the likelihood that mothers make a rule with their children about not drinking before a certain age, that mothers monitor their children, and for mothers that drink alcohol more than average, it increased the quality of alcohol-specific communication.
Aim and hypotheses
The main aim of this project is to conduct a Randomized Controlled Trial (RCT) to evaluate a recently developed home-based alcohol prevention program, entitled "In control: No alcohol!" The program focuses on alcohol-specific parenting as a tool in delaying the age of alcohol onset in children. Onset of alcohol use is defined as the intake of the first glass of alcohol. With this RCT, including an experimental and a control group, we test whether fewer children have their first drink at an earlier age when included in the program. The second aim is to determine whether the program increases maternal use of several alcohol-specific parenting practices according to mothers and their offspring. The third aim is to test whether the prevention program differs between families varying on parental own drinking.
More specifically, we expect that a) a significant lower percentage of children who followed the program will have had their first glass of alcohol at the last follow-up compared to children who did not follow the program. b) mothers who followed the program are significantly more likely to engage in alcohol-specific parenting than mothers who did not follow the program. We expect that mothers involved in the program (as compared to controls) will set and keep stricter rules about alcohol, are more involved in constructive communication on alcohol-related topics, have more confidence in discussing alcohol matters, reduce children's access to alcohol beverages, make a rule with their children about not drinking before a certain age and are more likely to monitor children's activities. c) Above average drinking mothers that follow the program are more likely to increase their alcohol-specific parenting as compared to below average drinking mothers that follow the program.
Discussion
The present study protocol presents the design of an RCT evaluating the effectiveness of the "In control: No alcohol!" program for 6 grade children. This universal prevention program aims to delay the age of alcohol onset for Dutch children. It is hypothesized that mothers in the prevention condition will employ more alcohol socialization practices, and that children in the prevention condition will be less likely to have their first glass of alcohol, compared to the control condition.
Strengths and limitations
An important strength of the program "In control: No alcohol!" is that it is theory driven. The underlying structure of the program is based on the Social Cognitive Learning Theory [
4], and the Elaboration Likelihood Model [
25], while the content is based on recent alcohol-specific parenting research [
7‐
10,
26]. Second, the program reaches children during the pre-initiation stage of alcohol use, aiming to prevent them from drinking their first alcoholic beverage, and thereby lowering the odds of heavy drinking [
2,
3]. Third, parents can complete the program with their children at home at a time of their choice. This creates the opportunity to include parents in the study, who are normally more difficult to reach for alcohol prevention, like parents who drink alcohol.
A strength of the study design is that it also includes long-term follow-ups at 12 and 18 months, in addition to the immediate follow-up at 6 months. This will create more opportunity to find an effect on actual alcohol use of the children, as well as mediating effects through alcohol-specific parenting practices. Further, if the "In control: No alcohol!" program turns out to be effective, it can easily be implemented on a large scale via primary schools. A limitation of the study is that only mothers can participate. While there are several good reasons for this choice (e.g. mothers are more likely to spend time with their children and to enroll in health-related programs), previous research has shown differences in alcohol-specific socialization between mothers and fathers; For example, mothers communicate more often about alcohol [
7,
38] and are more understanding towards their children [
39] compared to fathers. In future research, the effect of the program, when targeted at fathers, should be investigated.
Implications for practice
If the "In control: No alcohol!" program turns out to be effective, it can be implemented on a large scale in a reasonable amount of time. The program's modular, self-help format allows flexibility as regards where, when, and how it is implemented. Although the proposed study will measure effects on individual children after delivering the modules to households, in the future, the program could also be self-administered on a website that provides sequential access to the prevention modules. This is one of the main reasons that the Trimbos Institute (the Netherlands Institute for Mental Health and Addiction) is actively involved in this project. Collaboration with the Trimbos Institute guarantees that the program will be widespread and will reach large populations. Another advantage of the close collaboration with Trimbos Institute is that the results of this study can be transferred to practice immediately hardly without delay.
Competing interests
Jacqueline Verdurmen and Ingrid Schulten work for the Trimbos Institute, which is the institute that co-developed the "In control: No alcohol!" program, together with Haske van der Vorst and Rutger Engels. The other authors declare that they have no competing interests.
Authors' contributions
SM is responsible for the data collection, data analysis and for reporting the study results. All other authors are supervisors and grant applicators. All authors read and approved the final manuscript.