Prevention of alcohol and drug problems among adolescents : evaluating a Swedish version of the Strengthening families program

Alcohol and other drug use among adolescents is a persistent public health problem. Several methods have been developed and studied with the aim to prevent underage substance use. Strategies involving parents in preventive interventions have been promising, and one program in particular has been high-lighted; the Strengthening Families Program 10–14 (SFP 10-14). A culturally adapted version of the SFP to Swedish conditions was developed. The program was named Steg-för-Steg, and a randomized controlled trial was conducted to evaluate the effects of the program on adolescent alcohol and other drug use. This thesis is built around the planning, implementation and outcomes of this RCT with the aim to explore the role of parental programs in reducing problems with alcohol and other drug use among adolescents.

This thesis is based on four papers. The first paper is a descriptive study of the planning, and development of the Steg-för-Steg program. In addition, a pilot study involving two 6th grade classes from two schools in Stockholm is presented. The three additional papers are based on a randomized controlled trial including 707 students and parents in 19 schools in Stockholm. Youth participation in the study required an active consent from their parents, hence the final study population consisted of 587 students, and all parents independent of their child’s participation or not. In paper II predictors of parental participation and retention in the Steg-för-Steg program is examined with multiple logistic regression analyses. The data is based on 441 parents of 6th graders from the intervention arm in the RCT. Paper III analyzes the effects of the Steg-för-Steg program on adolescent use of alcohol and other drugs. General Linear Model is used to examine being drunk lifetime, and norm-breaking behaviours in 587 students during four time points. In paper IV the effects of the Steg-för-Steg program on predictors of adolescent use of alcohol and other drugs is studied with univariate and multiple logistic regression analyses. Data is obtained from 587 students and their parents. Predictor variables were obtained in grade 7, and outcome variables in grade 9.

The results from paper I show that it is possible to transport a family-based program from one country to another, especially if care is taken to adapt the program to local conditions without loosing program fidelity. Paper II shows that parents with a lower level of emotional warmth participated to a greater extent in the Steg-för-Steg program than those with higher level of warmth. In addition, a restrictive attitude towards youth and alcohol was related to participation. Retention in the program was associated with being born in Sweden, and having a low score on the warmth scale. In paper III results from the RCT shows that no effects of the Swedish version of the Strengthening Families Program were found on adolescent use of alcohol, tobacco, and illicit drugs.

Finally, paper IV reveals that high parental knowledge, parents with a restrictive attitude towards youth and alcohol, and adolescents reporting a positive school climate were associated with a lower risk of alcohol and other drug use. Furthermore, youth with high norm-breaking behaviours, youth attending a school in an area with high socioeconomic status, and youth with parents born in Sweden were more likely to have used alcohol and other drugs. There was no association or impact from parental participation in the Swedish version of the Strengthening Families Program on risk or protective factors for adolescent substance use.

Conclusion: While it is possible to transport a family program like the Strengthening Families Program from its American original to Sweden, and also that many parents can be recruited to participate in the program, no effects were found for the program, neither on substance use among the adolescents, nor on the risk and protective factors that the program aims to affect.

List of scientific papers

I. Skärstrand E., Larsson J., and Andréasson S. (2008). Cultural adaptation of the Strengthening Families Programme to a Swedish setting. Health Education. 108(4):287-300.
https://doi.org/10.1108/09654280810884179

II. Skärstrand E., Bränström R., Sundell K., Källmén H., and Andréasson S. (2009). Parental participation and retention in an alcohol preventive family-focused programme. Health Education. 109(5):384-395.
https://doi.org/10.1108/09654280910984807

III. Skärstrand E., Sundell K., and Andréasson S. Evaluation of a Swedish version of the Strengthening Families Programme: Three-year outcome of a cluster randomized trial. [Submitted]

IV. Skärstrand E., Sundell K., and Andréasson S. Effects of a family-focused preventive program on predictors of adolescent use of alcohol and other drugs. [Manuscript]