Background
There are significant physical, mental and social consequences that can result from underage drinking, such as impaired memory and brain functioning, accidents, injuries, violence, risky sexual behaviour and self-harm [
1‐
3]. Childhood (6–12 years of age) is a critical period when alcohol expectancies begin to form [
4], and children are most cognitively vulnerable to the persuasive appeals of advertising. Research has demonstrated a strong correlation between children’s exposure to alcohol advertising, positive alcohol expectancies, drinker identity and future drinking [
5‐
7]. A presumably simple solution to reducing children’s future drinking would be to reduce their exposure to alcohol advertising. Yet this solution becomes highly improbable given the current alcohol marketing landscape, with limited and ineffective regulation in countries such as Australia, New Zealand, Canada and the UK [
8,
9]. Children are exposed, and receptive, to high levels of advertising through avenues such as television [
10,
11], movies [
12], branded merchandise [
7,
13] and, more recently, social media [
14].
Media literacy education, which involves students accessing, analysing, evaluating, and creating media in a variety of forms [
15,
16], is gaining momentum as an approach to substance abuse prevention in schools [
17]. A number of alcohol media literacy (AML) programs have been developed to challenge potentially harmful media messages and subsequently influence health behaviours and attitudes [
18‐
24]. These programs have demonstrated positive outcomes on a range of measures including a decreased preference for alcohol branded merchandise (a precursor to drinking behaviour), increased media deconstruction skills, and lowered drinking intentions [
25].
While AML programs have made a valuable contribution to the alcohol prevention field [
18‐
25], the majority have been developed in the US and are therefore relevant to that specific context. There is a need for AML programs to be developed for other contexts, with specific attention to jurisdiction-specific alcohol marketing regulation and cultural nuances [
25]. This is particularly important given that youth are more likely to drink the specific alcohol brands to whose advertising they are most exposed [
26]. The critical importance of cultural considerations was demonstrated by the alcohol prevention programme Project Northland [
27] which was highly successful with predominantly white, lower-middle class to middle-class youth [
28], but unsuccessful when implemented with urban, low-income and multi-ethnic youth [
29]. Similarly, another study [
30] highlighted the unique context of Northern Mexico when implementing a set of drug-resistance strategies that had been initially developed for US adolescents. The study concluded that prevention programs are more likely to be effective when they have been adapted to be relevant to the specific context.
The Australian advertising scene is replete with depictions of Australian cultural stereotypes such as the ‘larrikin’ male sharing a beer with mates at the beach or over a BBQ [
31,
32]. For example, a content analysis of alcohol advertisements aired over 2 months in major Australian cities [
33] found that approximately half of the advertisements featured the themes of humour (56.7%) or friendship/mateship (41.5%). Portrayals of friendship/mateship often included instances of belittlement, such as a series of advertisements for Victoria Bitter beer where friends ‘saved’ each other by stopping them from engaging in unmanly behaviours including using hand cream and getting a fake tan. Numerous advertisements also linked alcohol to sport such as Australian football. Similarly, female-targeted advertising increasingly portrays drinking as a way for women to bond with their friends and demonstrate their independence from men [
34].
Existing AML programs have also focused solely or primarily on print advertisements, rather than teaching students skills in analysing the broad range of multimodal alcohol advertisements to which they are exposed in Australia and elsewhere [
25]. Multimodal advertisements utilise more than one mode, such as television advertisements which combine visual, audio, spatial and gestural information to be processed [
35].
Given these gaps in the evidence base, Media in the Spotlight, an AML program for Australian children, was developed. While there are cultural differences within the Australian ‘context’, this study sought, as a preliminary step, to tailor the program to the broader Australian context. The program was contextually tailored through inclusion, analysis and critique of Australian alcohol advertisements, Australia media clips, and the values promoted through these advertisements, such as associating alcohol with mateship, sport and larrikinism. Unlike US based AML programs [
18‐
24], the program did not include tobacco advertisements given that advertising for tobacco is completely banned in Australia. Therefore, students’ only exposure to tobacco advertising would be through the program.
Findings from a quasi-experimental trial of the ten-lesson interactive program demonstrated positive results on a range of measures including an increase in media deconstruction skills, decreased perception of social norms for teen drinking and decreased alcohol expectancies [
36]. These scales were all derived from existing scales with acceptable levels of reliability and validity. There were a few minor changes to the language used in the scales to ensure contextual relevance. For example, in some instances the word ‘beer’ was replaced with the more general word ‘alcohol’ and a statement assessing social norms was worded ‘Australians drink alcohol’ (see [
36] for details on the measures used and quantitative evaluation).
It is critical to understand the factors that can increase uptake of such programs in schools and strengthen their sustainability. Previous evaluation research in this area has focussed primarily on quantifying the effectiveness of programs, with limited attention given to the implementation process [
25]. Process evaluations can help to explain why a program was or was not effective in a real world setting [
37‐
40], thereby informing the improvement and sustainability of innovative programs in schools [
37]. The purpose of this paper is to examine and reflect upon the implementation process of Media in the Spotlight, and through this provide a pedagogical framework for health professionals seeking to design and implement culturally responsive programs in educational settings.
Discussion
This study evaluated the process and implementation of Media in the Spotlight, an interactive AML program created for a specific cultural context. The study aimed to provide a pedagogical framework for health professionals implementing culturally responsive programs in school settings. In a time of significant curriculum change and competing demands for elementary school teachers [
46], it is valuable to understand what teachers consider to be important in a health program, to increase program uptake and sustainability in schools. In drug and alcohol education especially, it is critical for programs to be created in a way that is culturally responsive, to ensure program relevance and effectiveness [
25].
Overall, the program was well received by the teachers and feedback suggested that they were open to a cross disciplinary approach to alcohol prevention in schools. The teachers did not report any significant inhibitors to implementation apart from classroom management issues and the time constraints imposed by an overcrowded curriculum. The issue of time constraints in an “overcrowded curriculum” is commonly cited as a problem for teachers [
47,
48]. However, teacher uptake and sustainability of programs can be increased through developing a structured program that is easy to follow, has clear and strong connections to the school curriculum, embeds assessment opportunities within the lessons and includes achievable outcomes.
The teachers also expressed confidence in being able to implement the program themselves due to the program’s structured and comprehensive nature. A well-structured program that is achievable, interactive and relevant for students will also keep students engaged and reduce the likelihood of classroom management issues [
49,
50]. Given the demanding nature of the teaching profession, teachers value having all necessary resources included within programs so that they do not have to spend time sourcing information.
The qualitative data sources indicated that the program was enjoyable and acceptable to the students, with the hands-on activities identified as a key strength of the program. This finding is supported by education learning theories such as constructivism which posits that students learn through constructing knowledge and meaning from their experiences [
51]. Further, hands-on and interactive activities that engage students in the topic, and enable them to demonstrate and apply their knowledge, are more likely to sustain student interest [
51]. The inclusion of hands-on activities are particularly important for drug and alcohol education, as the most effective programs go beyond transmitting knowledge to teaching skills and building coping strategies [
52]. Future programs could consider including related extension activities for students that grasp the concepts quickly. This may be more feasible to achieve when the regular classroom teacher is implementing the program, as they would have an understanding of the needs and capabilities of individual students in the class.
Using culturally bound advertisements as an entry point to learning about alcohol proved powerful, as it connected to the students’ life worlds [
53] through use of authentic text from contexts they were familiar with. The media plays a significant role in young people’s lives and can therefore be an effective way of creating relevance and motivation in lessons [
54]. The media literacy skills acquired can also enable students to resist the emotional messages presented through ads and positively influence behaviour change [
21,
55,
56]. Meta-analyses of school-based drug prevention programs found that skills rather than knowledge are powerful for changing behaviour [
57]. This principle, of drawing upon students’ lifeworlds and empowering them with practical skills, can be applied to other sensitive health areas such as sexual health [
58] and body image [
59]. Of critical importance is ensuring that the stimuli selected is developmentally appropriate and specific to the children’s cultural context.
There are several limitations that should be considered when interpreting the results of this study. The teacher process evaluation data was collected from six teachers in four schools and therefore may not be representative of the wider teaching population, although opinions do represent a range of teaching experiences from early career to highly experienced teachers. Additionally, there may have been a bias against negative disclosure as the interviewer was also the intervention creator and deliverer. However this may have also helped disclosure as the interviewer had developed a rapport with the teachers. Cultural considerations may need to be more narrowly defined to specific regions within a country. Media in the Spotlight was developed, implemented and evaluated in an area with a high percentage of white Anglo-Saxon Australians. In other areas of Australia with more diverse ethnicities, the cultural considerations may differ. Nonetheless, the principles from the pedagogical framework can be applied to other contexts.
Acknowledgements
We thank the teachers and students in the school study sites for assistance with this project.