Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Web Based Interventions to Reduce College Student’s Binge Drinking. Is That The Best Answer in 2009? – Mauricio Garcia-Jacques

Alcohol abuse and dependence are well known problems in the United States of America. Among adults, 23% of the population has been reported as being involved in hazardous alcohol use[1]. Within the drinking population, a subset engages in binge drinking (also known as risk drinking), defined as more than five standard drinks at a time for men or more than four for women[2]. This group of consumers experiences various types of harm associated proportionally to the quantity of drinks per time and frequency of risk drinking. The most reported effect is liver disease but injuries, sexual misconduct, illegal substance abuse, social problems (e.g., divorce, poor work/school performance), obesity and overweight have also been associated[2].
College students are a population with a very high proportion of binge drinking; Reilly and Wood found that 40% of students reported engaging in risk drinking at least once during the previous two weeks. Reported data indicates that alcohol is involved in 1,700 student deaths, 500,000 injuries and 600,000 assaults per year [3] . Teenagers are at risk for particular hazards of binge drinking, aside from those previously mentioned; first, surveys indicate that when alcohol is involved in a health problem, teenagers are hesitant to access health care for fear of repercussion by the law or their parents. Second, the impact that heavy drinking presents on the teenager’s brain is different from that of adults. Studies have shown that binge drinking delays development of important areas of the brain as well as executive functions. [4]
Institutions of higher education have been approaching this issue by designing interventions based on the following models of behavior modification: the Health Belief Model (HBM), the Social Norms Theory (SN) and Brief Motivational Intervention with personalized feedback [3-6]. A novel way of delivering interventions to maximize participation and decrease cost is being developed through the internet. This delivery method for the individual level interventions is suggested to schools and colleges by the National Institute of Alcohol Abuse and Alcoholism (NIAAA) based on a variety of studies on college population suggesting equivalent efficacy to in-person interventions[7]. Even though there is no current data reporting the proportion of educational institutions using this tool, evidence suggests there is a trend towards its use, and according to Croom et al., “they are perceived to be ‘best practice’…” in the collegiate context[8-11] Noteworthy, Butler and Correia reported similar results between personalized feedback interventions delivered face-to-face or computer based, but also commented on seven very insightful limitations to their study [12].
This paper will first present a brief description of what a current commercial computer model intervention looks like, followed by three arguments and a discussion of the fundamental flaws of the available web-based interventions aimed to reduce binge drinking. This paper will lightly discuss why the available, albeit limited, data supporting the use of electronic vs. in-person interventions might be faulted, but further insight on the matter is beyond the scope of this review.
Three interventions that have published results indexed in Medline are:, and “college alc”, which report using the social norms theory, amongst other models. It is not surprising that educational institutions are relying on these tools. The three interventions present a vast amount of research reports supporting their methods, and two of them are funded by the NIAAA. As an example of these commercial models and the electronic information delivered on freely available web sites, the author will discuss the experience of using MyStudentBody® Alcohol[13]. This site is a web-based course developed by Inflexxion, Inc, a multimedia company that specializes in healthcare solutions. According to their reported data, the intervention is based on the Brief Alcohol Screening and Intervention for College Students (BASICS), work attributed to Dimeff et al[14].
Author’s experience:
After going through the process of Log In and entering the specific alcohol tag (the site offers various links to interventions on other risk behaviors for this age group), it is obvious that the intervention targets students, and it appears as if it was designed by students (this is a very positive attribute of the site). Soon after I finished looking at the pictures, graphics and layout, I was overwhelmed by the vast amount of links on the homepage. There are many options the student can click on; each one will take you either to another page with more links or to a page with information to read through (with one exception, discussed below). The vast amount of information available is concise and contains well-supported data and numbers.
The interactive link is labeled “RATE MYSELF”. It connects the user to a series of surveys that offer personalized feedback to your answers. Even though, the feedback is divided in two depending on level of risk (green or red zone) and some of the information given is very similar, the user actually gets the sense of a personalized response, an approach that so far has provided evidence of being significantly more effective than providing information alone[4, 12, 15].
The overall experience is satisfactory; it is evident that the webpage uses several models for behavior change, including the most popular ones as mentioned: the HBM, SN, Social Expectations, and Brief Motivation. It is well supported, has a friendly layout and offers a presentation with which the college aged user can easily identify.
As previously mentioned, MyStudentBody® Alcohol (MSB), is used as an example of what a thorough web-based intervention addressing alcohol abuse by college students looks like at present day. The following arguments and critiques address the flaws shared by the web-based education/intervention programs, keeping in mind that most of the freely available sites contain less circumferential approaches than the example presented.
Argument #1: The misuse and abuse of the Health Belief Model.
The four basic components of the Health Belief Model (HBM) are: 1) Perceived susceptibility 2) Perceived severity 3) Perceived benefits of taking action 4) Perceived barriers to taking action. When the subject has identified these components, the person weighs them, and if the perceived severity, susceptibility and benefits outweigh the barriers, a behavioral change, according to the theoretical model, should occur [16]. Two additional components have been added to the model since it was first developed. Researchers found that a Cue to action, understood as an external motivation, gives the individual a thrust to change behavior. They also found that self-efficacy or the self-perceived ability to make such change is essential to perform an action. [17]
While there are six variables in the HBM, it appears that the single most explored component on the websites is perceived severity. MSB is heavily loaded with messages about possible severe drinking-related outcomes such as death, rape, injuries and the less severe like poor academic performance, pregnancy, etc. There is a link to a page where students share stories about their negative experiences with drinking (e.g., a diabetic friend who continuously ended up unconscious due to poor glycemic control after heavy drinking). ads are focused on mocking the more common outcomes such as vomiting, hangovers, poor academic performance etc, but approached from the point of view of the innocent victims, kind of the “second hand smoke” damages of drinking[18]. has a student tab with links to information of how the body is damaged by alcohol, a “snapshot” of alcohol-related statistics and many others offering vast amount of information, mostly focusing on severe consequences[19].
To the author’s knowledge, the only indexed article supporting perceived severity as the most important variable as motivation for safe alcohol use was performed by Bardsley and Beckman in 1988. This was a retrospective study in which subjects in treatment for alcoholism were asked about their reason for entering treatment. Not surprisingly, the number one answer was related to the severity of impact the disease was having on their lives, followed by cues to action [20]. There is no need to discuss the differences between the subjects in this study and college students in general to realize that the knowledge obtained from the study cannot be extrapolated to design preventive interventions for all college students. Other than Bradley’s work, there is no strong evidence to reduce teenage binge drinking using perceived severity as the main message.
On the other hand, Janz and Becker published an analysis on 46 interventions modeled on the HBM finding that perceived barriers and perceived susceptibility ranked highest as predictors of preventive behavior, while perceived severity was only “weakly associated”[21]. More supportive evidence to use other variables of the HBM in this age group was given by Von et. al, who analyzed five health related behaviors, including alcohol use. The authors found that the only variable that was significant in promoting all of the safe behaviors was self-efficacy followed by perceived barriers in the alcohol use sub-analysis[22].
ARGUMENT # 2: Applying the Social Norms Theory: Whose norms do college students actually care about?
A recent release by the NIAAA states that Social Norms Theory (SNT) is the most widely used to change the perception of alcohol use by students’ peers. Through surveys, the NIAAA found that almost 50% of colleges in the sample (n=747) had implemented a social norms campaign in 2002[7]. Following report of the survey results are comments on the mixed effectiveness of the social norms approach based on available publications. Available studies reporting positively on the approach present a short-term follow-up and most of them comment on this as a limitation. Studies that follow subjects for one year report a loss of difference between the evaluated groups after one year. Few studies use a control group and those that do, base the control intervention on the now obsolete educational approach consistently found to be ineffective[3, 4, 9, 11, 12, 14]. Even though the information learned is useful, by using the educational approach as control, results will be biased towards a positive finding. When the studies do not use a control group authors report a comparison of self-reported data on pre and post surveys or compare with statistics on alcohol related problems from previous years. Limitations to these methods are noted [4-6, 8, 14, 23-25]. Therefore researchers need to come up with more effective control interventions or comparison groups. Despite no strong evidence supporting SNT as an effective means of reducing risk drinking, it has a high potential to support behavior change as long as it is optimized by field research giving that college students are susceptible to social norms.
MyStudentBody® Alcohol, along with the freely available information on the web, provide by default information on the reported social norms nation wide. The commercial website offers school administrators the option of designing surveys for their campus and modeling a local norm, upgrading the intervention to be directly targeted to the particular college community. This approach is more effective as evidence suggests that the closer the reference norm the stronger the intervention[15, 26]. On the other hand, evidence also indicates that students are less likely to misperceive their close friends drinking pattern[26, 27]. Therefore, if a survey is too specific to a group, chances are that results show students are within the “socially acceptable” range, resulting in a harmful intervention. The term “socially acceptable”, exploded by the social norms model in this context, does not equal safe alcohol use. National surveys place the norm (MEAN) between 4-6 drinks per week[13, 28]. Considering the environment in college, where the greatest amounts of alcohol use take place during weekends, a possible accurate interpretation would be: Up to 50% of students drink more than 4-6 drinks per weekend. Is this a message that should be promoted?
ARGUMENT # 3: Lack of Altitude!
If solely relying on computerized intervention models to attempt to reduce binge drinking, educational institutions would fail to address the other two levels of intervention suggested by the NIAAA: the student body as a whole and the community and surrounding environment[29]. An individual intervention approach in modern social theory is viewed as a lower level intervention. The level is defined not by the degree of efficacy, but by the level of expected impact. Individual and small group interventions are labeled in the hierarchy as lower level while progressing towards community, environmental, and policy interventions increases the expected impact. As with every hierarchical model the interdependence of the levels is inevitable requiring a circumferential approach in the design of behavioral modification interventions. It is not a novel idea that social/environmental conditions are important as determinants of health and health behavior. Amusing and insightful reviews by Mcginnis (“Actual Causes of Death in the US”) and Link (“Social Conditions as Fundamental Causes of Disease”) illustrate the concept far better than this report can attempt[30, 31].
Even though the NIAAA suggests broadening the levels of intervention, schools, according to DeJong (2002)[32] are failing to implement basic infrastructure in order to develop environmental interventions. A related finding was that colleges were not increasing their non-governmental budget spent on substance abuse prevention, facts that can be interpreted as if this issue was of low priority to school administrations. (More recent data is warranted given the implementation of the NIAAA’s “Rapid Response Program” in 2003.[7]) It is beyond this report to provide data on how many colleges (if any) are developing environmental interventions, and the author assumes, as cited before, increasing attention and resources to web-based interventions[8, 10, 12]. Therefore, by failing to go beyond the lower levels, the interventions will produce only limited and temporary effects if successful.
Computer models like MSB have a lot of potential with little cost. However, during this developmental stage several modifications of the websites are needed to improve effectiveness. More importantly, further linkage to efforts in the community and other levels are essential. It is interesting to note that MyStudentBody® Alcohol provides an extensive list of past interventions at individual, community and policy levels, although, there are very few higher level interventions in tier 2 and none in tier 1 (by NIAAA’s definition [19]) reflecting the lack of data and the need of research and implementation of higher-level interventions. With this script, I would like to propose that future interventions to reduce binge drinking in the college setting should be based on the PRECEDE-PROCEED model to apply the social science theories. This model will benefit from the co-utilization of electronic resources like MSB or other available internet based systems. The PRECEDE-PROCEED model is not an intervention itself; in contrast, it provides a scheme for the evaluation of a problem and the evaluation of interventions based on novel social theory [33]. The PRECEDE section was first published in 1980 by Green, Kreuter and others, it stands for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis [34]. Ten years later the PROCEED section was added to complement and evaluate interventions becoming a comprehensive model rather than solely evaluating problems. PROCEED is the acronym for Policy, Regulatory, and Organizational Constructs in Education and Environmental Development [35].
A simplified description of this model will be presented but it is recommended that further information be sought in the revised version of this model by Green and Kreuter before attempting its implementation [36]. PRECEDE-PROCEED can be divided in eight phases of evolution distributed equally among the two.
The first half is the pre-evaluation section, where each phase represents a different hierarchical level that has an influence on behavior. Phase one asks for a social assessment and allows for multiple methods of data gathering, including surveys, observations, interviews with leaders, etc. All looking for variables such as readiness to change, need to change, attitude towards the problem etc. Phase two asks for an epidemiological, behavioral and environmental assessment. It attempts to define the determinants of behavior at different levels (individual to community) and to identify health outcomes related to the behavior in question in the population being evaluated. Phase three asks for an educational and ecological assessment. Finally phase four dictates for an administrative and policy assessment. All four phases should seek for predisposing, reinforcing or enabling factors that influence behavior, needless to say, identifying these factors is an essential first step towards behavior modification [36].
This model does not propose a particular intervention, and phases five to eight in the PROCEED section will be only named in a general way as (5)Implementation, (6)Process evaluation, (7)Impact Evaluation and (8)Outcome evaluation [36]. An important issue to note is that only phase five is used for the implementation of the intervention. The other phases are to evaluate the effectiveness of the intervention. Defining the goals is necessary after the PRECEDE phase during the design of the intervention in order to facilitate the PROCEED phases [33]. This model will quickly identify an ineffective intervention and the required modifications applied as needed. This model is comprehensive, providing those who deliver behavior modification interventions (school administrators, health officials, etc.) with a systematic approach for its development and continuous evaluation of not only behavior outcomes, but of the many factors influencing behavior. Even though using this model provides multiple benefits, I will limit the discussion towards how this model supporting the electronic resources, will improve the flaws discussed previously.
Evidence has been presented that favors the uses of other variables rather than perceived severity as influencing factors for behavior change [15, 20, 21]. The ones found in the literature, such as perceived barriers, perceived susceptibility and self efficacy should be used as an initial model of the educational strategy for any intervention utilizing the HBM in this setting. This would represent a proper improvement for the current distribution of information of MSB and other web based resources. Although, a full investigation following the PRECEDE model of the individual level variables that influence each school community should ensure the optimization of the HBM. I predict that the importance of the variables will vary among different communities. This opinion argues in favor of the utilization of a dynamic survey method such as a computerized model to gather the information because it can be implemented quickly, at low cost and with ongoing results. The utilization of internet based surveys for public health has been validated with promising results, a good argument is the maintenance of anonymity [37, 38]. MSB could offer different lay outs emphasizing the information that will impact the most at an individual level depending on each community’s attitude and expectancies towards a behavior.
Counter-argument #2: Networking! The new norm.
Some problems regarding the evidence supporting the Social Norms Theory have been discussed. By implementing evaluation phases after defining the goals of an intervention will help understand better its effectiveness. The PROCEED phases of the model are ideal to evaluate interventions that lack the strength of evidence to validate them.
Some reports weaken the usefulness of a general Social Norm intervention to modify binge drinking by college students. Specifically, the findings that only closest friends’ norm alters or influences behavior, with some evidence showing that the closer the friend the least likely a student is to misperceive the quantity of alcohol consumed [15, 26]. The second argument is still in question and no studies so far had looked at an intervention using close friends norm. Two separate questions need to be answered; the computer model surveys following the PROCEDE phases are ideal to do so. First, how can we define the close friends? A demographic survey designed to develop a social network model can answer that question. An example of what this model looks like was developed by Christakis (2008) following networks for smoking [39]. The second question is what the norm within those networks is, defined by surveying the networks found. This information will develop a more targeted intervention. It is essential to follow the post-intervention evaluation phases because this is a novel approach that has not been explored widely in the literature.
As a secondary outcome of the surveys, if the networks are followed long term, an analysis could define if there are any differences among the drinking patterns in long term health or social outcomes such as marginalization, income, fulfillment of goals etc. This information could turn out useful if more deleterious effects of binge drinking are found and will help in the development of new norms and role models that discourage binge drinking.
Counter-argument #3: PROCEED to your HIGHNESS
The concepts of interdependence between levels of intervention and the comprehensiveness of the PRECEDE-PROCEED model have been mentioned above. The first four stages urge those designing the intervention to assess multiple levels of behavior influence. It is intuitive that schools cannot rely solely on computer based models to reduce binge drinking in college. To be able to optimize the presented model, a multidisciplinary approach is needed. As described above, an evaluation of the environment, the social factors, the legislation, the community attitudes and expectancies are needed [5, 30, 32] just as much as the involvement of separate groups of people among the student community, families, student leaders, community leaders and school administrators. This “multi-specialty” group can do a better job defining the goals, obtaining the resources and maintaining the innovations than each group alone. To be able to implement such a wide movement, an expert manager would facilitate the roles of each group and provide useful advice. MSB (or equivalent) could offer function as counselors to the administrators of the intervention. They have experts in multiple areas and offering this service would increase significantly the added value of the product and the impact of the outcomes.
No matter how strong is the evidence towards the effectiveness of a particular intervention, no intervention can be generalized. I cannot make enough emphasis on the importance of continuous formative research; which is why I favor the PRECEDE-PROCEED model as the structure for any intervention. The consideration of environmental/ecological factors in the determination of behavior is becoming the standard of delivery and the utilization of new technologies should ease the complexity of this approach.
I want to thank MSB staff team for all the support given during the development of this paper and for granting full access to the system. (Disclosure: No financial relationship or interest is present between the author and the commercial companies discussed.)
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