Youth alcohol consumption is associated with many short- and long-term physical and social harms. Youth who drink alcohol are more likely to experience alcohol-related motor vehicle crashes,1 engage in self-harm or suicidal behaviors,2,3 participate in physical fights,1,4 report risky sexual behavior5 and sustain physical injuries,6,7 in comparison to their non-drinking counterparts. The National Drug Strategy Household Survey, a nationally representative survey of Australians, found that participants aged 12 to 14 years self-reported a higher ratio of delinquent behavior (e.g. causing damage to property, stealing, physically abusing someone) per standard drink than any other age group.8 Similarly, a nationally representative sample of youth aged 18 to 20 years in the United States found that alcohol consumption was positively related to delinquency and criminal activity (e.g. vandalizing, stealing, engaging in risky or dangerous behavior).9 Furthermore, longitudinal studies have found that lifetime prevalence of alcohol dependence increased steeply as the age of onset of drinking decreased.10-12 In turn, youth alcohol use is not only associated with immediate physical and social harms, but can also contribute to the risk of alcohol-related harm over a lifetime, such as diseases that are related to the accumulative effects of alcohol (e.g. cardiovascular disease, cancers, liver disease, nutrition related conditions).3,13
Due to the harms associated with youth alcohol consumption, many government organizations advise against young people drinking. For example, Australia's National Health and Medical Research Council advise that people under 18 years of age should abstain from alcohol use, while United States Dietary Guidelines recommend not consuming alcohol prior to 21 years of age.3,14 Many countries also classify drinking five or more standard drinks on one occasion as “risky” or “binge” drinking.3,15 Despite these recommendations, 66% of Australian school students aged 12 to 17 years report drinking alcohol, and people aged 18 to 24 years constitute the age group most likely to consume alcohol at levels deemed risky (i.e. > 5 standard drinks on a single occasion) and very risky (i.e. > 11 standard drinks on a single occasion).16 Risky drinking is also common among youth in the United States; within a sample of high school seniors, 20% reported drinking five or more drinks on one occasion within the past two weeks.7 Similarly, the European School Survey Project on Alcohol and Other Drugs (a survey of 96,046 students from 35 European countries) found one in 12 students aged 16 years who were surveyed in 2015 reported drinking alcohol to the point of intoxication at the age of 13 or younger.17
Youth living in rural and remote areas are more likely to drink alcohol and are at higher risk of experiencing alcohol-related harms than youth living in urban locations. For example, an analysis of the National Drug Strategy Household Survey found that 42% of people aged 12 to 17 years who lived in rural areas reported alcohol use in the past year, compared to 28% in major cities.18 The Victorian Youth Alcohol and Drug Survey also demonstrated that very high-risk drinking (i.e. more than 20 drinks at least 12 times a year for males and more than 11 drinks at least 12 times a year for females) among youth aged 16 to 24 years old increased with remoteness: 19.8% of the sample in metropolitan areas reported very high risk drinking, compared to 24.6% within inner regional and 26.5% within outer regional/remote areas.19 Similar to the aforementioned Australian data, youth in non-urban areas of the United States report higher alcohol consumption compared to their urban counterparts.20 It also appears that risk-taking while drinking is more common among youth who live in rural compared to urban locations. Studies in the United States and Australia have shown that youth who live in rural areas are more likely than youth living in urban areas to drive a motor vehicle while under the influence of alcohol.21,22 This more prevalent and riskier alcohol use translates into greater alcohol-related harms among youth in rural and remote areas compared to youth in urban areas. For example, in Australia, alcohol-attributed deaths occur at a rate approximately 1.7 times higher among youth living in non-urban compared to urban areas.23
Given the prevalence of youth alcohol use and related harms, there has been a range of interventions developed to reduce youth alcohol consumption and the associated negative consequences. These interventions can be broadly grouped into categories: school-based drug education (e.g. alcohol risk awareness and peer resistance strategies), mass media campaigns, community strengthening, selective prevention (i.e. targeting “at risk” populations), guidelines and information (e.g. alcohol warning labels and safe drinking guidelines), alcohol and other drug treatment (e.g. residential rehabilitation programs and counseling), and regulations restricting availability (e.g. higher alcohol prices and minimum age laws). A report by the Australian National Council on Drugs reviewed the available international evidence pertaining to these interventions and found that all of the aforementioned intervention types had acceptable evidence of effectiveness among youth, with the exception of mass media campaigns, guidelines and health warnings, which either lacked youth-based evidence or had evidence of limited impact.24 While reviews of the effectiveness of youth alcohol interventions are a vital step toward implementing and further developing effective youth alcohol intervention strategies, they predominantly rely on evidence from interventions implemented in urban environments.
It is inadequate to rely on an urban-centric evidence base to choose effective youth alcohol intervention strategies for rural and remote areas, as strategies shown to be effective in urban environments may not be as, if at all, effective in rural and remote locations. For example, a sexual risk intervention shown to reduce risky sexual behavior among urban youth failed to lead to behavior change in rural youth, even when adjustments were permitted to accommodate the different context.25 By transplanting urban solutions into rural environments, we may also overlook mechanisms for change that are pertinent to rural and remote environments. For example, addressing the social norms associated with alcohol has been suggested as being particularly important in the rural context. A survey of Australian households showed that youth aged 12 to 17 years from rural areas were 1.2 times more likely to obtain their first alcohol from parents compared to those living in major cities.18 Therefore, in order to reduce the comparatively high alcohol use and associated harms among youth in rural and remote areas, a review of the existing strategies that show efficacy within this population is necessary.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or underway systematic reviews on the topic were identified.
The objective of this review is to evaluate the effectiveness of strategies or interventions, versus other or no strategies/interventions, to reduce risky alcohol consumption among youth living in rural or remote areas.
What is the effectiveness of strategies or interventions, versus other or no strategies/interventions, for reducing risky alcohol consumption among youth living in rural or remote areas?
The review will consider studies that include youth living in rural or remote areas. Youth will be defined as people aged 12 to 24 years old, as per the definition used by the Australian Institute of Health and Welfare.26 Rurality will be based on the study identifying participants as from rural, remote, regional, non-urban or non-metropolitan locations.
This review will consider studies that evaluate any type of intervention or strategy with the purpose of reducing or preventing alcohol consumption or alcohol-related harms among youth (aged 12 to 24 years) who live in rural and remote areas. Risky drinking will be defined as consuming five or more standard drinks on one occasion, as per the definition of “risky drinking occasion” provided by National Health Medical and Research Council.3
This review will consider studies that compare the intervention to previous or other interventions, no comparison, or historical controls.
This review will consider studies that include the following primary outcome: frequency of short-term risky alcohol consumption (i.e. five or more standard drinks on one occasion) as measured by self-reported occasions of drinking five or more standard drinks (e.g. how often have you consumed five or more standard drinks on one occasion in the past week/month/year/lifetime?).
Secondary outcomes of interest are: frequency of alcohol consumption measured by self-reported occasions of drinking alcohol (e.g. how often do you usually drink alcohol? How often in the past week/month/year/lifetime have you drunk alcohol?); age of first alcohol consumption measured by self-reported alcohol initiation (e.g. what age were you when you first started drinking, not counting small tastes or sips of alcohol?); frequency of drunkenness as measured by self-reported occasions of drunkenness; age of first drunkenness as measured by self-reported drunkenness initiation; alcohol related harms measured by proportion of deaths primarily attributed to alcohol consumption; proportion of hospitalizations primarily attributed to alcohol consumption; Rutgers Alcohol Problem Index (a self-report measure of adolescent problem drinking);27 and self-report of frequency of risky behaviors while under the influence of alcohol (various measures, usually take the form of a list of behaviors developed for the purpose of the study for participants to rate the frequency of occurrence).
Types of studies
This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical or descriptive cross-sectional studies will be considered for inclusion. Studies published in English will be included. A search of “risky drinking youth” in MEDLINE Trends indicated that 1983 was the first year that studies on this topic were published. However, given drinking behavior is influenced by societal norms,18 studies may lose their contemporary relevance over time. As such, only studies published from 1999 will be included.
The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness.28
The search strategy will aim to locate both published and unpublished studies. An initial limited search of CINAHL via EBSCO was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
The databases to be searched include: MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials.
Sources of unpublished studies and gray literature to be searched include: ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove.
Following the search, all identified citations will be collated and uploaded into EndNote X8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).29 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.29
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using standardized critical appraisal instruments from JBI for experimental, quasi-experimental, descriptive and observational studies.28,30 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise will be resolved through discussion, or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table.
All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). Included studies will be stratified by methodological quality.
Data will be extracted from studies included in the review by two independent reviewers using the standardized data extraction tool in JBI SUMARI.28
The data extracted will include specific details about the populations, study location, study methods, interventions, and outcomes of significance to the review objective, particularly incidents of risky drinking. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI.28 Effect sizes will be expressed as either odds ratios (for dichotomous data) and weighted (or standardized) final post-intervention mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared and I2 tests. Statistical analyses will be performed using random effects using Tufanaru et al.'s decision process.31 Sensitivity analyses will be conducted to test decisions made regarding the inclusion of studies of lower methodological quality in meta-analyses. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate. A funnel plot will be generated using RevMan 5.3.5 (ProQuest LLC, Ann Arbor, USA) to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed, where appropriate. A synthesis of all studies will be presented, as well as a synthesis of studies by region.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for grading the certainty of evidence will be followed and a Summary of Findings (SoF) will be created using GRADEPro GDT software (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcome reported in the SoF will be the frequency of short-term risky alcohol consumption.
The authors acknowledge that they live and work on the lands of the Arrernte people. The authors also acknowledge and thank Josephine McGill (College and Research Services Librarian, Flinders University) for her assistance in developing a comprehensive search strategy.
This review is funded by the Northern Territory Department of Health Harm Minimisation Unit. Aside from outlining a broad review question, the funder had no input into the development of this protocol and will not be involved in any other aspect of the systematic review.
Appendix I: Search strategy for CINAHL via EBSCO
Search conducted 22nd August 2019
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