The impact of an educational program based on self-regulation theory on reducing alcohol consumption among adolescents: a randomized controlled trial

Abstract

Background

Alcohol abuse leads to numerous physical and mental health issues, as well as an increased risk of infectious and chronic diseases. Additionally, it contributes significantly to mortality and disability rates within the population. This study aims to assess the effectiveness of an educational intervention based on self-regulation theory (SRT) in reducing alcohol consumption among Iranian adolescents.

Methods

This analysis was conducted as a before-and-after experimental study involving 430 high school students in the southern Kerman province from 2023 to 2024. The study employed a cluster sampling approach, encompassing 14 educational classes, with seven classes randomly assigned to the intervention group and seven classes to the control group. Data were collected using a researcher-made questionnaire based on SRT, and its validity (with a CVR and CVI above 90%) and reliability (with a Cronbach’s alpha coefficient of more than 0.9 for the entire questionnaire) were rigorously assessed and confirmed. The data were analyzed using SPSS version 21, applying independent t-tests, paired t-tests, and chi-square tests. A p-value of less than 0.05 was considered statistically significant.

Results

The mean age of the adolescents was 15.32 ± 0.8 years. In intervention group, the mean score of the behavioral inhibition and working memory increased from 34.43 ± 7.83 and 31.59 ± 5.20 before the intervention to 37.33 ± 7.69 and 32.67 ± 5.83 after the intervention. Also, the mean score of internalization of speech, motivational evaluation system and behavioral reconstitution increased respectively from 30.37 ± 6.27, 24.88 ± 4.80 and 45.29 ± 6.30 before the intervention to 32.42 ± 6.14, 26.74 ± 4.70 and after the intervention. Following the educational intervention, the average scores for the constructs of behavioral inhibition (p = 0.03), working memory (p = 0.001), internalization of speech (p = 0.02), motivational evaluation system (p = 0.04), and behavioral reconstitution (p = 0.001) demonstrated a significant increase in the intervention group compared to the control group.

Conclusions

Interventions based on SRT can significantly decrease the likelihood of alcohol use among adolescents. Continuous training rooted in this theory within school settings is beneficial for preventing risky behaviors in adolescents.

Introduction

Alcohol consumption is recognized as a risk factor for various infectious and chronic diseases. In addition to causing severe physical and psychological issues, it contributes significantly to the global burden of mortality and disability [1–3]. According to international statistics from 2019, approximately 400 million individuals aged 15 and older are affected by alcohol use disorders, while 209 million are grappling with alcohol dependence [4]. Alcohol consumption is recognized as the primary risk factor contributing to disease burden among individuals aged 15 to 49. Moreover, those in the younger age range of 20 to 39 are especially susceptible, as demonstrated by the statistic that 13% of alcohol-related deaths occurred within this demographic in 2019 [4, 5]. Additionally, alcohol use is significantly common among adolescents, who are classified as a high-risk group. Research indicates that over 50% of 15-year-olds have consumed alcohol at least once, with 37% reporting consumption in the past month [6]. Furthermore, findings from a global survey reveal that the overall rate of alcohol consumption among adolescents is 25.2%, with reported figures of 28.3% for boys and 22.4% for girls, respectively [7]. Despite the potential underreporting of alcohol consumption in Iran due to legal restrictions and religious influences, a study conducted on Iranian adolescents aged 15 to 18 found that 15.1% had engaged in alcohol consumption. Notably, this behavior was significantly more prevalent among boys, with a rate of 21.9%, compared to 8.4% among girls [8]. Additionally, another study indicated that the rate of alcohol consumption among Iranian adolescents was 16.6% [9]. The results of a study in Kerman show that the prevalence of alcohol consumption, especially among young people, is higher than in other provinces of the country, with the prevalence of alcohol consumption in lifetime, past year, and past month being 41.15%, 37.61%, and 15.91%, respectively [10]. The prevalence of alcohol consumption in Kermanian students in grades 10 to 12 revealed that 12.9% [11]. In addition, the findings of another study on pre-university students in Kerman found that the prevalence of alcohol consumption was 16.2% among boys and 4.5% among girls [12].

Alcohol consumption adversely affects not only the health of the individual drinker but also threatens the welfare and health of their family and the broader community. In terms of personal health risks, alcohol intake significantly increases the risk of HIV infection and is associated with poor treatment outcomes, as well as a heightened risk of tuberculosis and pneumonia [1]. Furthermore, research indicates a correlation between alcohol consumption and the development of various chronic diseases in adulthood, including cardiovascular diseases, diabetes, digestive disorders, and certain types of cancer [2]. Alcohol use among adolescents can lead to a variety of health issues and risky behaviors, including drug abuse, the onset of mental disorders, suicidal tendencies, teenage pregnancy, and increased school absenteeism [13]. In addition to these health consequences, prolonged alcohol abuse can result in numerous social problems, such as difficulties in the workplace, family conflicts, relationship breakdowns, financial struggles, and unemployment [4].

Alcohol consumption among adolescents is increasingly recognized as a significant public health concern. Research indicates a pressing need for preventive initiatives aimed at reducing consumption or delaying the onset of alcohol use [14]. The school environment plays a crucial role in educating adolescents about healthy behaviors and promoting health-oriented lifestyles. It provides an opportunity to engage many students simultaneously, and interventions conducted within schools are often cost-effective. Various studies on the social costs of early alcohol consumption suggest that school-based programs focused on alcohol prevention for adolescents represent a significant investment in improving the health of this age group [15, 16]. However, only a few studies have successfully designed and implemented alcohol prevention education programs grounded in a theoretical framework. These theoretical models provide a coherent and appropriate structure for various phases of research, including data collection, the design of needs-focused programs, and the development of relevant educational content aimed at promoting health-related behaviors and preventing risky behaviors. By establishing a solid foundation for evaluating health programs, theoretical frameworks ultimately enhance program effectiveness [17].

Theoretical framework

Self-regulation has been linked to alcohol use in some studies on alcohol prevention in adolescents and recommended that this theory be utilized in educational interventions [18]. Quinn et al. suggest that the protective effects of high self-regulation in the context of some high-risk behaviors, such as alcohol drinking and risky sexual behavior, could make it a promising target for effective interventions [19].

Self-Regulation Theory (SRT) encompasses a goal-directed approach to achieving and maintaining personal objectives. This framework enables individuals to adjust their behaviors accordingly. In 1997, Barclay identified five essential executive factors for self-regulation: (1) “Behavioral Inhibition”: The ability to suppress immediate reactions and delay gratification; (2) “Working Memory”: The skill of storing and retrieving relevant information necessary for effective problem-solving; (3) “Internalization of Speech”: The capacity for self-reflective dialogue; (4) “Motivational Evaluation System”: The process of assessing the emotional and motivational aspects of past experiences to envision potential futures and adjust behaviors accordingly; and (5) “Behavioral Reconstitution”: The ability to develop complex and innovative behaviors, evaluate and recognize previous behavioral patterns, and integrate them to create new behaviors characterized by unique arrangements and sequences. Figure 1 illustrates the cyclical model of SRT [20]. There is a body of evidence indicating that self-regulation is crucial for the development and preservation of health and well-being across the lifespan. In contrast, inadequate self-regulation has been associated with adverse outcomes, including health risk behaviors like early alcohol consumption. This importance has led the development of various interventions aimed at enhancing self-regulation skills during childhood and adolescence [21, 22]. Currently, studies that have used SRT in relation to alcohol consumption in adolescents are limited. Also, there is lack of knowledge about the psychological factors associated with alcohol use in high school students especially in Muslim countries such as Iran. Although early interventions can be very useful in reducing risky behaviors in adolescents, school-based alcohol prevention interventions based on SRT are still very limited worldwide. Therefore, the current research aims to evaluate the effectiveness of an educational program based on SRT in reducing alcohol consumption among Iranian adolescents.

Fig. 1.

Cyclical model of SRT [20]

Methods

Study design and participants

This study utilized a before-and-after experimental design and was conducted with 430 high school students in southern Kerman Province, Iran, between 2023 and 2024. The statistical population for the study comprised all second-grade male high school students from seven cities under the jurisdiction of Jiroft University of Medical Sciences in southern Kerman. The study utilized a cluster sampling method for data collection. In the initial phase, all seven cities affiliated with the university were designated as research locations. Each city was divided into four distinct geographical regions as clusters (north, south, west, and east), and one regions were randomly selected in each cluster. In the third stage, one high school was randomly identified from each selected cluster. Subsequently, two classes were randomly chosen from each selected high school. In each high school, one class was randomly designated as the experimental group, while another was assigned as the control group. Ultimately, seven classes were classified as experimental and seven as control groups. Consequently, 430 students from these seven high schools were randomly allocated to either the intervention group (n = 215) or the control group (n = 215), based on the established inclusion criteria. The inclusion criteria for this study consisted of individuals of Iranian nationality, male participants enrolled in a second-grade high school, and native residents. Conversely, the exclusion criteria included individuals who did not consistently attend training sessions and those who failed to complete the questionnaire during the post-test phase. In addition, students who were alcohol dependent or had mental disorders were excluded from the study. The sample size was calculated using a confidence level of 95%, with Zα = 1.96, Zβ = 0.84, an effect size (d) of 1.1, and a standard deviation of 4.07, which was obtained derived from a pilot study involving 30 students. The formula utilized for estimating the sample size is as follows:

Measurements

• A)Demographic characteristics of the participants: This section included 12 questions regarding age, parental education levels, parental occupations, family income, body mass index, regular physical activity, history of smoking and alcohol consumption, family history of alcohol use, and the presence of conflict within the family.
• B)Constructs of SRT: This section of the questionnaire comprised 50 items on the constructs of SRT. The “Behavioral Inhibition” is articulated through 10 items (For instance, I refrain from engaging in activities that promote the consumption of alcoholic beverages), with the “Working Memory” similarly featuring 10 items (For example, in situations where problems emerge, I depend on my memory to guide me in addressing them). The “Internalization of Speech” is represented by 9 items (For instance, I can successfully abstain from drinking alcohol by maintaining a positive dialogue with myself), the “Motivational Evaluation System” consists of 7 items (For example, I regularly monitor my progress in achieving my health objectives and in abstaining from alcohol consumption), and the “Behavioral Reconstitution” is detailed with 14 items (For instance, to avoid alcohol, I make a concerted effort to prevent boredom and explore various avenues for achieving success). All items were developed using a 5-point Likert scale, ranging from complete disagreement (score of 1) to complete agreement (score of 5).
• C)Validity and reliability of the questionnaire: The reliability of the questionnaire was analyzed using Cronbach’s alpha method, which yielded a score greater than 0.9 for entire questionnaire. Cronbach’s alpha for each construct, respectively, was 0.78 for the behavioral inhibition; 0.79 for the working memory; 0.7 for internalization of speech; 0.77 for motivational evaluation system; and 0.83 for behavioral reconstitution.

The validity of the questionnaire was assessed through two approaches: face validity and content validity. During this phase, the questionnaire was distributed to a panel of ten experts in psychology and health education, who suggested revisions to improve its content. Ultimately, the content validity rate (CVR) and content validity index (CVI) were calculated, resulting in values of 0.92 and 0.90, respectively, for the entire questionnaire.

The intervention

The research commenced after receiving permission from the General Directorate of Education of Kerman Province. Following this approval, the intervention for the experimental group was carried out in collaboration with city education directors and school principals. Participation in the study was entirely voluntary and all students were informed that they had the right not to answer any of the questions in the questionnaire. Also, the confidentiality of the information provided by the participants was fully respected in this research. All methods were performed in accordance with the relevant guidelines and regulations.

The intervention process consisted of four stages. In the initial phase, data on alcohol prevention was collected according to the principles of SRT, encompassing both the intervention and control groups during the pre-test stage. After the pre-test was administered, the initial outcomes were evaluated, and a needs assessment meeting was conducted using the initial data and the viewpoints of representatives from executive directors, teachers, and students to establish the number and approach for the training sessions. In the second phase, an educational program was developed that incorporated the principles of SRT, utilizing the findings from the pre-test stage across six sessions. This sessions of sessions were deemed sufficient by the trainers to cover the educational content and objectives related to all the SRT constructs. During the third phase, the educational intervention was exclusively administered to the students in the intervention group, while the control group did not participate in any training. All training sessions were conducted by a mental health specialist in collaboration with an expert in health education. All educational intervention sessions were implemented similarly according to a specific guideline and in full coordination with all school executives. In the final phase, the intervention and control groups completed the questionnaires again after one month after the training sessions, enabling an assessment of the training program’s effectiveness. Considering the research, a one-month follow-up after school-based interventions for alcohol prevention can be effective in assessing the initial impact and identifying any necessary adjustments [16, 23].

Table 1 presents the details of the educational program. The initiative was developed and executed through six training sessions, each lasting between 45 and 60 min, held over two and a half months. The post-test was performed one month after the ending training sessions.

Table 1.

Intervention content

Sessions	Educational content	Educational strategies
First session	Students’ awareness and skills regarding behavioral inhibition were enhanced through a series of lectures and interactive question-and-answer sessions that examined the issues and negative consequences of alcohol consumption.	- Use of printed educational materials - Teaching how to say no to peer pressure - Individual and group counseling
Second session	Adolescents were supported in resisting internal and peer pressure by enhancing their self-confidence through the development of self-efficacy and skill performance. Through two theses sessions, behavioral inhibition was effectively addressed.	-Use of brief educational videos - Organization of an exhibition - Invitation of a guest speaker who had previously abstained from alcohol as “A rol model”
Third session	Individuals’ capacity for storage and recall was enhanced through the implementation of a self-report and the presentation of a specific project or topic. In this approach, individuals are required to continuously engage their memory by recalling previous memories or events. Throughout this session, it is essential to consistently encourage adolescents to develop their memory skills. During this phase, groups of 6 to 8 individuals utilized the problem-solving process to improve the storage and retrieval of information.	-Teaching memory enhancement strategies through segmenting information for recall, using mnemonic tools, visualizing memories through mental imagery - Teaching group and individual problem-solving skills - Stress management technique
Fourth session	This session included an internal dialogue that allowed the adolescents to express their emotions and feelings, thereby increasing their awareness of their current circumstances and aspirations for the future. Additionally, the speaker-listener technique was employed. At this stage, the questions posed were: What is my current status? What factors contribute to this situation?	- Using speaker-listener technique -Teaching the technique of thinking aloud and encouraging students to express their thought processes verbally -Using positive thinking techniques -Encouraging students to actively participate in expressing their inner feelings
Fifth session	The session focused on sharing information about the specific conditions under which adolescents abstained from alcohol consumption, even when encouraged by their peers. An exhibition aimed at preventing alcohol abuse was organized with the participation of students and teachers. During this session, parents were invited to engage in activities designed to enhance their support for adolescents.	- Organization of an exhibition at school -Creating a support network with family and teachers
Sixth session	The following three methods were employed in behavioral reconstitution: 1- Self-efficacy: The strategies implemented included practical demonstrations, group discussions with 6 to 8 members, group problem-solving exercises, and the enhancement of self-efficacy and self-monitoring skills. The self-monitoring framework comprised three components: (a) assessing emotional well-being and promoting purposeful, enjoyable, and rational activities while mitigating alcohol consumption; (b) establishing goals and applying an outcome measurement method; and (c) recording personal motivations. During the mood monitoring phase, participants were provided with a daily diary at the beginning of the study and were asked to use the diary to document the factors that influenced their alcohol consumption. Supportive feedback was also utilized to promote behavioral reconstitution and self-monitoring. In the goal-setting and outcome methods section, individuals were invited to identify sub-goals and specify the desired outcomes for their objectives. In the section on documenting personal motivation, both at the initial phase and during follow-up evaluations, participants were encouraged to revise their motivations to align with their sub-goals. 2- Feedback: The second important aspect of behavioral reconstitution is feedback. This feedback enables individuals to guide, control, and adjust their efforts as they work toward their desired outcomes. 3- Forecasting the time required to achieve the objective: In this context, short-term objectives were employed to facilitate the attainment of the goal.	- Practical demonstrations and Individual and group counseling to overcome obstacles to increasing self-efficacy - Use a daily diary to record healthy lifestyle goals, motivations, and their desired outcomes to increasing self-monitoring - The technique of setting and prioritizing short-term objectives - Provide frequent feedback by educators on how the selected goals relate to how students are making behavioral changes -Use timelines for each sub-goal

Data analysis

The data were analyzed using SPSS version 21 software, employing independent t-tests, paired t-tests, and chi-square tests. A p-value of less than 0.05 was considered significant. Assessors were blinded to group allocation to reduce bias.

Results

The mean age of the students participating in the study was 15.32 ± 0.8 years. Table 2 presents the demographic characteristics of the students by group. Regarding parental education levels, 73.7% of fathers and 76% of mothers achieved a high school diploma or a lower level of education. According to the statistics, 42.1% of fathers were engaged in freelance work, while 78.8% of mothers were dedicated to being housewives. A majority of the students, specifically 52.8%, exhibited a normal body mass index. A total of 58.6% of the participants classified their family’s monthly income as favorable. Only 32.3% of students engage in regular physical activity. Among the participants, 10.5% reported a history of smoking, while 27.2% declared that they had consumed alcohol in the past. It was reported that 17.4% of students have a family member with a history of alcohol consumption. Additionally, 41.4% of students typically witness conflicts and arguments within their family environments. Results from the chi-square test conducted prior to the intervention indicated that there was no significant difference in demographic characteristics and the scores of the constructs of the SRT questionnaire between the two groups (p > 0.05).

Table 2.

Demographic characteristics of participants

Variable		Intervention group N (%)	Control group N (%)	Total N (%)	p-value
Father’s education level	Illiterate	24 (11.2)	23 (10.7)	47 (10.9)	0.95
	≤ 12th grade	159 (74)	158 (73.5)	317 (73.7)
	> 12th grade	32 (14.9)	34 (15.8)	66 (15.3)
Mother’s education level	Illiterate	13 (6)	20 (9.3)	33 (7.7)	0.44
	≤ 12th grade	166 (77.2)	161 (74.9)	327 (76)
	> 12th grade	36 (16.7)	34 (15.8)	70 (16.3)
Occupation of father	Freelance jobs	95 (44.2)	86 (40)	181 (42.1)	0.56
	Employee	37 (17.2)	36 (16.7)	73 (17)
	Farmer	53 (24.7)	66 (30.7)	119 (27.7)
	Casual laborer	30 (14)	27 (12.6)	57 (13.3)
Occupation of mother	Housewife	169 (78.6)	170 (79.1)	339 (78.8)	0.72
	Employee	24 (11.2)	25 (11.6)	49 (11.4)
	Casual laborer	18 (10.2)	20 (7.3)	42 (9.8)
BMI categories	Underweight	82 (38.1)	88 (40.9)	170 (39.5)	0.14
	Normal	111 (51.6)	116 (54)	227 (52.8)
	Overweight	22 (10.2)	11 (5.1)	33 (7.7)
Family economic status	Bad	34 (15.8)	25 (11.6)	59 (13.7)	0.41
	Moderate	60 (27.9)	59 (27.4)	119 (27.7)
	Good	121 (56.3)	131 (60.9)	252 (58.6)
Having regular physical activity	Yes	64 (29.8)	75 (34.9)	139 (32.3)	0.15
	No	151 (70.2)	140 (65.1)	291 (67.7)
Past smoking history	Yes	27 (12.6)	18 (8.4)	45 (10.5)	0.10
	No	188 (87.4)	197 (91.6)	385 (89.5)
Past alcohol history	Yes	57 (26.5)	60 (27.9)	117 (27.2)	0.41
	No	158 (73.5)	155 (72.1)	313 (72.8)
Family alcohol history	Yes	36 (16.7)	39 (18.1)	75 (17.4)	0.40
	No	179 (83.3)	176 (81.9)	355 (82.6)
Conflict and arguments between parents	Yes	94 (43.7)	84 (39.1)	178 (41.4)	0.18
	No	121 (53.6)	131 (60.9)	252 (58.6)

The educational intervention led to a significant increase in the mean scores for the constructs of “Behavioral Inhibition” (p = 0.03), “Working Memory” (p < 0.001), “Internalization of Speech” (p = 0.02), “Motivational Evaluation System” (p = 0.04), and “Behavioral Reconstitution” (p < 0.001) in the intervention group compared to the control group, although effect size for all constructs was less than 0.5 (small effect).

Moreover, in the intervention group, all SRT constructs demonstrated statistically significant differences from their pre-intervention measurements (p < 0.01). In contrast, the control group did not exhibit any statistically significant differences in the constructs when assessed against their pre-intervention values (p > 0.05), as shown in Table 3.

Table 3.

Comparison of mean scores of constructs of SRT before and after the intervention in two groups

Constructs		Group	Before intervention M ± SD	After intervention M ± SD	Cohen’s d effect size#	p-value
Behavioral inhibition		Intervention	34.43 ± 7.83	37.33 ± 7.69	0.20	< 0.001†
		Control	35.30 ± 7.56	35.80 ± 7.52		0.11
		p-value	0.24	0.03*
Working memory		Intervention	31.59 ± 5.20	32.67 ± 5.83	0.31	0.01†
		Control	30.88 ± 4.64	30.91 ± 5.47		0.92
		p-value	0.13	0.001*
Internalization of speech		Intervention	30.37 ± 6.27	32.42 ± 6.14	0.22	< 0.001†
		Control	30.73 ± 6.90	31.05 ± 6.61		0.34
		p-value>	0.57	0.02*
Motivational evaluation system		Intervention	24.88 ± 4.80	26.74 ± 4.70	0.20	< 0.001†
		Control	25.39 ± 5.01	25.78 ± 4.99		0.10
		p-value	0.28	0.04
Behavioral reconstitution		Intervention	45.29 ± 6.30	47.76 ± 7.15	0.32	< 0.001†
		Control	45.37 ± 6.59	45.37 ± 8.10		0.75
		p-value	0.71	0.001*

The mean values were significantly different from the control group (independent-samples t-test): ^*p < 0.05

The mean values were significantly different from those observed before the intervention (paired t-test): ^†p < 0.05. ^# Cohen’s d after intervention between two groups

Discussion

This study is the first to analyze the impact of an educational model based on SRT in the context of reducing alcohol consumption among adolescents. The findings suggest that implementing an educational intervention grounded in SRT can significantly contribute to preventing alcohol use in this demographic. Various educational initiatives have been implemented worldwide to reduce alcohol consumption among adolescents, with varying degrees of success [16, 24, 25]. Overall, these intervention programs suggest that adolescent education should focus on modifiable risk factors and the enhancement of protective factors. This can be achieved through prevention programs that involve family, school, and community settings. The school environment is an ideal setting for educating students about the prevention of risky behaviors. Research indicates that educational interventions targeting alcohol abuse within school contexts can be effective in the short term; however, it is crucial to ensure the continuity of these training programs [26].

The findings of the current research, one of the few studies addressing adolescent alcohol consumption prevention through SRT, indicate that this theoretical approach can serve as a valuable framework for educational initiatives. The study’s results demonstrate a significant increase in behavioral inhibition among students who participated in the educational program compared to the control group, with an effect size of 0.2. Behavioral inhibition refers to the capacity to control or postpone alcohol consumption. This skill enables individuals to ignore significant internal triggers and external distractions, allowing them to engage in behaviors that are most beneficial for their well-being [27]. In this study, one method employed to enhance behavioral inhibition in adolescents was to improve their understanding and skills related to alcohol use and its consequences. The research conducted by Barroso et al. on seventh-grade adolescents revealed that the educational intervention significantly improved the knowledge of participants in the intervention group regarding alcohol consumption and its associated consequences. In contrast, the control group demonstrated a limited understanding of these issues [28]. Another strategy to promote behavioral inhibition involves enhancing self-efficacy related to alcohol consumption, a method that has been discussed in numerous studies. Feldstein et al., showed compared to participants receiving a standard alcohol and drug education, those receiving motivational interview showed increases in self-efficacy with an effect size of 0.29 for alcohol use [29]. DiBello et al. suggest that strong self-efficacy can effectively assist individuals in managing their alcohol consumption, thereby facilitating a reduction in their drinking habits [30]. Additionally, a study conducted by Tabernero et al. that focused on young adults aged 17 to 26 revealed that individuals who perceived themselves as having a low ability to resist alcohol were more likely to engage in excessive drinking behaviors. In contrast, those with a high level of self-efficacy reported lower alcohol consumption compared to their peers [31].

The study’s findings indicated that, following the completion of the educational intervention, participants in the intervention group scored significantly higher in the working memory construct than their counterparts in the control group with an effect size of 0.31. Consistent with the results of our study, a meta-analysis examining interventions aimed at adolescents’ alcohol consumption, which reported continuous outcomes, revealed that the overall calculations resulted a small and significant effect size of 0.22, in favor of the intervention [16]. Deficits in specific cognitive processing skills, including working memory, inhibition, attention, planning, problem-solving, and cognitive flexibility, recognized as neurocognitive characteristics, may contribute to an increased vulnerability to alcohol and drug abuse among adolescents [32]. Therefore, it is essential to prioritize the enhancement of cognitive abilities within educational programs. An effective strategy for improving working memory in adolescents is to involve them in training that develops their problem-solving skills. This study demonstrated that students who participated in the problem-solving technique attained higher scores on the working memory construct related to alcohol consumption by the conclusion of the intervention. The findings of Sorsdahl et al. suggest that strategies designed to enhance problem-solving skills and provide cognitive tools for individuals to manage their challenges may effectively reduce risky alcohol consumption and drug use. These approaches should be integrated into educational interventions [33]. Botvin et al. also emphasize that alcohol prevention education programs must incorporate training in resistance skills. This training helps adolescents cope with peer pressure and should also concentrate on enhancing personal competencies related to decision-making and problem-solving [34]. The current study demonstrated that the experimental group exhibited a significant improvement in the internalization of speech following the educational intervention, compared to the control group with an effect size of 0.22. This concept is referred to in some research as “private or inner speech” is recognized as an effective mechanism for facilitating behavior change [35] and has been employed in various studies aimed at promoting healthier lifestyles [36] or assisting individuals struggling with addictions [37]. Alderson-Day et al. suggest that private speech can serve as an important resource for self-regulation and motivation, even in adulthood [38]. The findings indicate that employing this technique may be beneficial for interventions aimed at preventing alcohol consumption among adolescents. Tanner-Smith et al., reported Short-term alcohol interventions have been shown to significantly lower alcohol consumption and related problems in adolescents, achieving effect sizes of 0.27 and 0.19, respectively. They conclude that these brief interventions offer beneficial impacts on alcohol-related outcomes for adolescents and young adults, which, although modest, are potentially advantageous considering their brevity and low cost [39].

The findings of the study revealed that the intervention group experienced a significant increase in motivational evaluation with an effect size of 0.20. By engaging in motivational evaluation, adolescents are encouraged to reflect on their past successes in resisting alcohol and choosing healthier leisure activities, which serves to inspire and reinforce their ongoing commitment to healthy living. The research conducted by Reyes-Rodríguez et al. demonstrated that the motivational interviewing program was an effective preventive approach for high school students in Colombia, resulting in a decrease in both the frequency and quantity of alcohol consumption [40]. Another randomized controlled study finding showed that motivational interviews were relatively effective through increases in motivation (with effect size of 0.30) to reduce alcohol consumption 6 months after intervention within a predominantly Hispanic adolescent sample [29]. To mitigate the risk of early reduction in the effectiveness of motivational interventions, it is essential to integrate these programs with other initiatives that support adolescents in maintaining positive behaviors. These measures may include implementing various activities and actions involving family members and teachers, similar to the interventions conducted during the educational sessions of this research. Additionally, introducing further interventions within family, school, and community settings that focus on adolescents and their peers will be beneficial in addressing risk factors. Strong evidence indicates that social influences from key individuals, such as parents, siblings, and peers, along with the impact of social media, are significant factors that can either encourage or deter the initiation and continued use of alcohol [41].

Ultimately, the findings of this study indicated that the intervention group experienced a significant increase in behavioral reconstitution with an effect size of 0.32 compared to the control group. Behavioral reconstitution, a key aspect of self-regulation, enables adolescents to formulate plans and work towards achieving their desired objectives through goal-oriented actions, which may contribute to the modification of their adaptive behaviors. Evidence suggests that self-regulation enhances goal-directed behavior and empowers individuals to resist temptations, thereby aiding them in pursuing their goals [21]. In this section of the current research, the approach employed was self-monitoring. This technique focuses on enhancing behavior by systematically observing and documenting actions in real-world contexts over a specified period. It can be effectively integrated as an intervention component to promote behavior change across various health domains [42, 43]. Wagner et al. showed that compared with adolescents aged 14–18 years-old assigned to standard care (i.e., education/assessment/referral-only), those who received guided self-change program (including weekly self-monitoring, treatment goal advice, brief readings and homework assignments, options, and action plans, motivational strategies and cognitive relapse prevention procedures had significant reductions in total number of alcohol use days with effect size of 0.45 at post-treatment, and 0.20 at 3-months post-treatment [44].

Carpenter et al. suggest that incorporating self-monitoring into alcohol prevention programs can provide valuable insights into when and whether a person requires intervention [43]. Research indicates that health promotion strategies that utilize diverse methods, such as self-monitoring, planning, and self-assessment, tend to lead to improved self-regulation. Consequently, health planners must consider the implementation of these methods to help prevent alcohol use among adolescents [45].

Strengths and limitations of the study

The active participation of adolescents in all stages of the intervention, ranging from needs assessment to implementation and evaluation of the educational program, was a significant strength of this study. Additionally, this research is one of the few educational initiatives worldwide that has utilized a theoretical framework to implement a program designed to prevent alcohol abuse among adolescents. An additional strength of this study is the use of a researcher-developed questionnaire based on SRT, which provides an effective framework for preventing alcohol consumption. The primary limitation of this research is the use of a self-report method, which may allow respondents’ answers to be influenced by their interpretations. In response to this issue, a team of experts has consistently validated the questionnaire to create a comprehensive questionnaire. Also, to reduce social desirability bias, the questionnaires were completed completely anonymously.

Another limitation of the study was that the participants were exclusively male, selected from urban schools, which restricts the applicability of the findings to other demographics (such as females or rural populations). Therefore, it is suggested to develop the educational content tailored to girls and to carry out the study once more with female participants in various settings including rural areas, while considering the cultural norms. Cultural and religious norms especially in Muslim countries can significantly impact study outcomes by influencing how individuals perceive and report health issues. Furthermore, stigma associated with alcohol use can lead to underreporting, making it difficult to generalize findings to populations with different cultural or religious backgrounds. Incorporating qualitative research methods, such as interviews and focus groups, can provide a deeper understanding of cultural and religious influences on health behaviors. Finally, we could only assess the outcomes after a duration of one month. It is essential to conduct long-term follow-ups and implement further interventions to guarantee sustained results.

Conclusions

The results of the current study indicate that educational interventions grounded in SRT can be effective in preventing alcohol consumption among adolescents. Educational interventions in school settings are effective in preventing alcohol use or delaying its onset during adolescence and should be consistently integrated into school health programs. Interventions should be designed to enhance the individual abilities of adolescents while also providing a supportive network that includes parents, teachers, and other community members.

Author contributions

EM proposed the study. AB and MB collected the data and TR, EM, YS performed the statistical analysis. All authors prepared the first draft of the manuscript and read, revised and approved the final manuscript.

Funding

No funding was received for the study.

Data availability

The data sets used and/or analyzed during the current study are not publicly available due to confidentiality of data and subsequent research, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this research has been secured from the ethics committee of Jiroft University of Medical Sciences, designated by the code IR.JMU.REC.1398.071 and IRCT number: IRCT20200923048817N1. Registration date 2020-10-26, Membership number: 48817, Trial Id: 51213.

A written informed consent was obtained from all participants. Also Informed consent was obtained from parents or legal guardians of students under 16 years old. The study was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.