The “Alcohol, Know Your Limits” PSAs and Binge Drinking: Helping People to Know Their Limits or Just Some Funny Commercials? – Jennifer Burda

Binge drinking is a popular topic in the public health world and on college campuses. However, the magnitude of this public health problem is not just concentrated in American college campuses. Many young people around the globe binge drink. This is also the case in the United Kingdom. Binge drinking is defined as excessive alcohol consumption which usually results in a blood alcohol concentration (BAC) of .08 grams percent or above. A BAC this high is often achieved during a short period of time, such as a woman consuming four drinks over the course of two hours (1). There are numerous health problems associated with binge drinking including unintentional injuries, alcohol poisoning, liver disease, and neurological damage (2). The European School Survey Project on Alcohol and Other Drugs shows 54% of youth in United Kingdom schools have had heavy episodic drinking within a 30 day period (3). The United Kingdom Home Office developed a public health ad campaign called “Alcohol, know your limits” in an attempt to curb binge drinking among young people within the country.
The “Alcohol, know your limits” campaign released several Public Service Announcements (PSAs) to convince youth to not overindulge on alcohol. One PSA features a young woman getting ready for a night out. In the process of getting ready, she rips her tights and top, vomits in the sink with her hair in the way, smudges her eye make-up, pours wine on a chair, breaks the heel off of her shoe, then leaves her home. The PSA ends with “You wouldn’t start a night like this so why end it this way?” (4). This PSA has a similar counterpart. In another PSA, a young man puts on clothes and rips them, goes to the refrigerator and wipes food on his shirt, urinates on the floor next to the toilet, puts an earring in and tears his ear, bangs his head against the door, then leaves his house with a bloody nose. The PSA ends with the same tagline “You wouldn’t start a night like this so why end it this way?” (5). The PSAs attempt to portray the characters as drunk before departing for the evening. The PSAs also demonstrate somewhat extreme examples of binge drinking behavior. However, these PSAs have not proven very successful and these campaign ads are overall flawed for three central reasons. These PSAs have not helped the campaign’s success because they do not take psychological reactance into account, do not address the social norms and culture surrounding binge drinking, and lastly fail because they assume people are rational and will choose to not binge drink because of the consequences.
No consideration for psychological reactance
To put it simply, the message of the “Alcohol, know your limits” PSAs is to not binge drink and portrays binge drinkers in a negative light. These PSAs assume young people will be turned off to binge drinking because of how the people are portrayed in the PSAs. However, the PSAs can have an opposite effect on the youthful targeted audience and cause them to revolt against this suggested restriction of freedom (ie being told not to binge drink) instead of embrace the message being sent.
Psychological reactance theory explains how people have an emotional reaction to threatened freedoms or attempts to control their behavior (6). If individuals perceive they are being manipulated, they will often react opposite to the persuader’s intent and reject doing the suggested activity (7). Psychological reactance occurs in four stages – first there is an understanding of the perceived freedom (in this case, ability to drink as much as one wants), then the perceived threat to freedom (being told not to over drink). This leads to a reactance (binge drinking) which thus ultimately restores the freedom in question (freedom to drink as much as one wants).
These particular PSAs were posted on YouTube which provides a comments field for people to remark on a clip. The following comment was posted by YouTube user Pwnagemonkey1 underneath the PSA portraying the girl getting ready for a night out:
fair enough, but dont try and tell people not to drink. People should be allowed to do whatever they want to themselves as long as its what they want, no matter the consequences. its a part of life, there would be no enjoying life if all you did was take no risks and be boring and sh** (4).
This comment demonstrates how this PSA resulted in psychological reactance. Instead of this YouTube user being inspired to not binge drink, he argues that people should have the freedom to do what they want regardless of the consequences.
Similar comments were posted under the YouTube PSA featuring the boy preparing to leave his apartment. One user wrote “This advert never fails to make me wanna go out and get sh**-faced.” Another user replied with “Yeah it just makes me want to go out on the trash! He really does look better at the end, no?!” (5). These comments explicitly demonstrate reactance and how people revolt and do the opposite of the intended message. The “Alcohol, know your limits” PSAs do not have the desired effect of persuading youth to not binge drink and in some cases, actually indirectly encourage them to binge because of psychological reactance.
A study was done examining the reactance of college students to messaging about flossing compared to binge drinking. Students behaved with rational planned behavior to the flossing message; they understood the healthful purpose of flossing which did not have any perceived infringements on their freedom. Binge drinking messaging was perceived very differently because there are social and commercial factors that promote binge drinking among young people. Therefore, the anti-binging message acts as a threat to perceived norms which causes a reactance (8). The “Alcohol, know your limits” PSAs experience a similar negative attitude and revolt since this message is also going against perceived social norms which young adults particularly value as they try to fit in with their peers. Youth negatively view messages that threaten their freedom or ability to fit in. If this ad campaign had taken psychological reactance into consideration, it would have been more successful.
Social norms and culture of binge drinking not addressed
As mentioned above in the discussion on psychological reactance, binge drinking is a social norm among youth and is not only accepted but expected. Norms are defined as patterns of beliefs and behaviors expected in certain situations and shared by a social group. Norms regulate social behavior (13). Social norms play a particularly important role among youth because they feel added pressure to fit in while they go through the stages of adolescence into adulthood. The “Alcohol, know your limits” PSAs do not address or use social norms or context. They only present negative examples of binge drinking instead of searching to change why or how binge drinking has become a social norm.
There are several socially based reasons for binge drinking which have helped it become normalized. Youth and young adults in the 15-17 age range in the United Kingdom drink because it allows them to express their views more easily, develop trust with friends, and explore sexual relations in what they perceive to be a less threatening context. Because of these reasons, alcohol is perceived as relaxing, an excuse for behavior, and provides an opportunity for bonding (14). These socially based reasons for binge drinking are perpetuated into social norms with the help of the media. Movies, television, and music display these supposed advantages to binge drinking. The media acts as a socialization tool and teaches people what to expect in certain situations (15). For example, the film “Animal House” has helped incoming college freshmen expect crazy fraternity parties with alcohol, as depicted in the movie.
The PSAs have not worked to change the social norms around drinking or address them. The campaign would have been much more successful if it had gone to the core of understanding why youth choose to drink and addressed those issues instead of simply presenting binge drinking in a negative light. The problem of binge drinking will not be solved if the root of the problem just continues to be masked – social norms and culture.
A study was done in South Wales which found the local community around the school embodied a culture of heavy drinking. This even impacted non-drinkers because many conversational topics revolved around alcohol (14). In addition to the results found in the South Wales community, the United Kingdom as a whole has been labeled for having a culture that embraces heavy drinking. Brits are known for their fond appreciation for pubs. Getting to the causal reason for binge drinking in the United Kingdom is key for a successful campaign. A study at Leeds University in the United Kingdom found that social context, beliefs, and morals should be considered when tailoring health promotions to hit a targeted young group (16). A much larger picture and framework needs to be considered for the public health campaign to be successful.
People see the consequences therefore do the behavior – not the case
The PSAs have a loose basis on the Health Belief Model (HBM) which is antiquated and has added to the PSAs’ flawed nature. HBM states people will take action against a disease (or in this case, follow the suggested protocol – not to binge drink) if they feel they have a high susceptibility to the disease/behavior (binge drinking), feel the effects of the disease/behavior are at least moderately severe, and taking action will reduce their susceptibility and the severity of the disease/behavior, and in general, be beneficial. People will choose to act if they do not have to overcome barriers, such as cost or pain (9). In other words, if the benefits outweigh the barriers, people will have an intention to take action and thus change their behavior (10).
The PSAs make it look like most young people are susceptible to binge drinking (ie the disease/negative health behavior in HBM) by choosing a seemingly normal young woman and man to represent society. The effects of binge drinking in the ads are moderately severe given the destructive nature of the two main characters. Their behavior indicates binge drinking leads to destruction of clothes and other personal items as well as poor judgment which can lead to pouring wine on a chair or urinating besides the toilet. The benefit to choosing not to binge drink is to avoid embarrassment by not doing these destructive behaviors. The PSAs do not highlight any specific barriers that need to be overcome in order to not binge drink. However as mentioned earlier, these PSAs are loosely based on HBM so they do not necessarily have all of its characteristics. Overall, the PSAs insinuate that because the severity and susceptibility of binge drinking is strong, people watching the PSAs should intend to want to and thus change their behavior, ie not binge drink.
HBM assumes people are rational and weigh their choices and options. However, this is not the case. The PSAs express this key characteristic of HBM. Even if the PSAs did experience some success in convincing people the binge drinking consequences are severe enough to not binge drink, this education does not automatically translate over to people changing their behavior. This is because humans are irrational (11). Weighing of costs and benefits and having an obvious logical outcome does not mean people will automatically do the suggested behavior.
There are two key reasons why people are irrational and are arguably predictably irrational in this case of binge drinking. People are irrational because of ownership – they put a high value on what they own. This does not just apply to physical items but to behavior as well. Habits, which include binge drinking, are particularly hard to change because people assume ownership of the habit. People focus on what they will lose as opposed to what they will gain. With binge drinking, people see the loss of having fun with friends and do not see the gain of living a safer lifestyle. People are also irrational because they lack self-control. They are lazy, procrastinate, and overall have less control over their actions than they think (12). Even though they may want to change their behavior, follow through is low because people lack will power.
The PSAs are faulty because they assume people will choose to change their behavior because of the negative effects of binge drinking portrayed in the PSA. However, this is not the case because people are not rational and do not make changes easily. If these points were considered in the “Alcohol, know your limits” PSAs, the campaign would have been more successful.
Conclusion
Binge drinking is a major public health problem in the United Kingdom and the country has developed a campaign to address the issue. However, its “Alcohol, know your limits” PSAs have not been very successful. Although the PSAs possess a degree of attraction for youth because of the humor in the PSAs, they are still largely flawed because they do not take certain social and behavioral science principles into account. The PSAs do not consider the possibility of psychological reactance to the messaging, nor do they highlight and address the social norms or context surrounding binge drinking. The PSAs also assume that because negative aspects of binge drinking are highlighted, people will be rational and not binge because of the consequences shown. Psychological reactance is the most important issue that needs to be immediately addressed since it can encourage binge drinking. The other two flaws simply make the PSAs ineffective. There is much room for improvement for these PSAs. By taking the social and behavioral science principles into account, the PSAs would be more successful and help curb binge drinking in the United Kingdom.
A new intervention
The “Alcohol, know your limits” campaign has room for improvement. In order for the Public Service Announcements (PSAs) associated with the campaign to be successful, they need to address psychological reactance, social norms and culture, as well as people’s irrational behavior. Incorporating these points into a new PSA will result in a stronger public health intervention to curb binge drinking in the United Kingdom.
The new PSA intervention is markedly different from the PSAs currently used in the “Alcohol, know your limits” campaign which depict a boy and girl getting ready for a night out but with insinuations that they binge drank before preparing for the evening and leaving their house. (4, 5) The new PSA does not use footage of young people who have already made the decision to drink and giving the message to not behave like them. Instead, it contains a happy, young, attractive couple spending their evening going out to dinner, sharing an inside joke, and enjoying themselves without binge drinking. The woman (Sarah) later that night reports to a friend how she had the opportunity to get to know her date and had fun versus her experiences meeting other men in bars in the past. Sarah then says she and her date are going rock climbing in the morning and a group of people should go and her friend agrees. The PSA then shows five people in a convertible on a beautiful, sunny morning on the open road heading towards the mountains. Once they arrive at their destination, they enjoy themselves and belay each other as they climb. They eventually reach the mountain’s peak, then sit down to enjoy lunch and admire the view. It ends with the tag line, “Don’t let alcohol give you limits.”
As seen in the new intervention described above, it advertises freedom and success as alternatives to binge drinking as suggested by the images of driving down the open road and reaching the summit of a mountain. The PSA is improved and addresses the “Alcohol, know your limits” campaign’s earlier problems because it contains positive role models, includes advertising theory which encompasses social context and beliefs, and has a replacement value for binge drinking.
Psychological Reactance – no longer an issue
Psychological reactance is a key concern in the original “Alcohol, know your limits” PSAs because they can actually cause more people to binge drink instead of prevent binge drinking. This is because people can have an emotional reaction when they feel they are being controlled or their freedom is in jeopardy (6). The original PSAs instruct the public to not binge drink, which could cause reactance. The new “Don’t let alcohol give you limits” PSA does not explicitly say to not binge drink, nor gives the impression the government is giving orders. Rather, the PSA provides positive role models who do not binge drink. Youth can aspire to become these models as they are happy, young, attractive, and enjoy life. Because binge drinking is not portrayed in an overtly negative light, the four stages of reactance cannot be completed. The second stage of reactance, which is the perceived threat to freedom, does not occur in the new PSA. The original PSAs’ YouTube comments indicate the viewers are more inclined to go out and binge drink after seeing the commercial - the new PSA avoids that because it does not contain a trigger to spark reactance.
The “Don’t let alcohol give you limits” PSA also does not go against perceived social norms of binge drinking per say by stating not to binge drink. Rather, it provides an alternative. The new PSA offers a sense of freedom by presenting a different lifestyle choice instead of restricting freedom and telling youth to not binge drink. Thereby this reduces the risk of reactance (6). However, the new PSA does contain characteristics to address the social norms and culture of binge drinking which not only have a role in addressing psychological reactance but also help get to the root of the binge drinking problem.
Advertising Theory – a Way to Address Social Norms and Culture of Binge Drinking
Binge drinking is often considered a normal social behavior for youth. The original PSAs do not address the social norms or context surrounding binge drinking in youth. Rather, they simply paint binge drinking in a negative light. Studies on British youth found youth binge drink for a variety of reasons which include the ability to express their views more easily, bond, and build trust with friends (14). These are core reasons why youth choose to binge drink. The “Don’t let alcohol give you limits” PSA addresses these particular reasons and tackles their context.
The new PSA shows the couple getting to know each other and being open without the assistance of alcohol. This is then reconfirmed when Sarah speaks to her friend about her preference to “really get to know someone” as opposed to the men she had met in bars. Being drunk is a fleeting state and not permanent – what matters is who a person is at all times, with and without alcohol. Sarah also bonded with her date as they laughed over dinner and shared an inside joke, which show that it is possible to be intimate with someone sans alcohol. The PSA demonstrates the motivating factors for youth binge drinking do not have to apply. People can build relationships without being intoxicated.
The new PSA also addresses the issue of building trust as seen in the clip of the friends belaying on the mountain. One must have total trust in your belay partner because your life is literally in his or her hands. Belaying is not an activity one can do while intoxicated. The friends in the new PSA build trust without the assistance of alcohol. Moreover, the PSA presents a different social norm – young, happy, attractive individuals having fun and enjoying life without alcohol. The PSA uses advertising theory to help perpetuate this norm.
Advertising theory is a key social and behavioral sciences model. It predicts how an intervention can reach and change a large group of people at the same time by using a universal appeal instead of addressing individual factors. Advertising theory is therefore comprised of attitude change theories as well (17). In advertising theory, people change their behavior or choose to follow the recommendation being given provided the ad has 4 key qualities: the ad makes a promise to the consumer, the concept being advertised has certain benefits, the benefits reinforce a core value the consumer holds dear, and the ad provides support to back up the claim being made.
In the “Don’t let alcohol give you limits” PSA, the promise being made in the ad is the ability to have fun without binge drinking. The subtle benefits to this include being able to get up early to rock climb (or participate in a different activity) and not have to worry about a hangover. Freedom and success are the core values addressed in the PSA. These core values are supported with visual images. For example, the convertible on the road with the top down is symbolic of freedom. The friends are successful because they reach the summit of the mountain and generally give off successful vibes given their happiness and attractiveness. The last scene of the PSA panning the view from the mountain also symbolizes freedom. The PSA presents youth with these two important core values which are achieved by not binge drinking and encourages the culture to not embrace heavy drinking.
In addition to the new PSA using advertising theory as a way to effectively address, understand, and change culture norms surrounding binge drinking, a partnership needs to be developed with the media. The media is responsible for educating the public on what to expect in certain social situations and is thus a socialization tool (15). Music, movies, and television show binge drinking as a common social norm. Partnering with the media and having an agreement to not actively promote binge drinking culture will reduce its normative appearance.
Consequences Do Not Necessarily Lead to Behavior - Embracing Irrationality
The “Alcohol, know your limits” PSAs’ loose basis on the Health Belief Model (HBM) adds to the campaign’s failure. The PSAs assume that because the susceptibility and severity of binge drinking were both portrayed as high in the ads, people will choose not to binge drink. However, desire to change does not necessarily lead to behavioral change. This is because people are irrational and do not follow linear, decision making processes (18). The PSAs also do not work because people lack self control and feel ownership over their habits. Habits are hard to break and people have risk aversion. In terms of changing behaviors, people will focus on what they will lose versus what they gain. Therefore, in order to solve this problem, the public needs to be presented with an alternative to binge drinking that seems worth the risk in order to break their habit. Risk aversion theory helps explain how this can work.
Risk aversion theory explains people will not gamble (whether it be their health, money, habit etc) if they feel the payoff or risk is not attractive (19). Therefore, when working to change people’s habits, the loss of the habit and/or payoff needs to be worth it for the individual. Successful behavioral interventions provide people with a large gain in place of their lost habit. A core value, like freedom, is an example of a worthy replacement of a lost habit. Advertising theory works particularly well to initiate this because it provides a big promise (in this case, freedom) to the audience and works to fill a void.
The new PSA uses advertising theory to tell people that they can attain freedom and success by not binge drinking. Not only does advertising assist with addressing social norms, but it helps with people’s irrational behavior as well. Freedom is the replacement value for the loss people experience by changing their habit. Instead of trying to scare people into changing their behavior and to not binge drink like in the old PSAs, the new PSA understands people are irrational and presents them with an alternative to their loss – freedom.
Conclusion
The proposed new PSA, “Don’t let alcohol give you limits” incorporates advertising theory and addresses where the “Alcohol, know your limits” PSAs fell short – particularly in addressing psychological reactance, social norms and culture, and irrational behavior. The new PSA creates the beginning for improved communication and binge drinking intervention among youth. More needs to be done to truly address binge drinking among youth in the United Kingdom, but the new PSA opens the door for developing more intricate interventions.
References
(1) National Institute of Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking. NIAAA Newsletter 2004; 3. http://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.pdf.
(2) Centers for Disease Control and Prevention. Quick Stats Binge Drinking. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/alcohol/quickstats/binge_drinking.htm
(3) Andersson et tal. Alcohol and Drug Use Among European 17-18 Year Old Students. Data from the ESPAD Project. Stolkhom, Sweden: The Swedish Council for Information on Alcohol and Other Drugs (CAN) and the Pompidou Group at the Council of Europe, 2007. http://www.espad.org/keyresult-generator
(4) Alcohol Know Your Limits. Alcohol Know Your Limits – Binge Drinking Girl. June 16 2008. Online video clip. YouTube. http://www.youtube.com/watch?v=3jftfU30xJg.
(5) Alcohol You’re your Limts. Alcohol You’re your Limits – Binge Drinking Boy. June 16 2008. Online video clip. YouTube. http://www.youtube.com/watch?v=EuowE1SXNkA&feature=PlayList&p=38E9C4FB0390E743&playnext=1&playnext_from=PL&index=1.
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(9) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
(10) Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett, 2007.
(11) Stein E. Can We Be Justified in Believing that Humans Are Irrational? Philosophy and Phenomenological Research 1997; 57:545-565.
(12) Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.
(13) Caboni et tal. Toward an Empirical Delineation of a Normative Structure for College Students. The Journal of Higher Education 2005; 76:519-544.
(14) Honess T, Seymour L, Webster R. The Social Contexts of Underage Drinking. London, England: Home Office. http://www.homeoffice.gov.uk/rds/pdfs/occ-drink.pdf
(15) DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
(16) Carpenter et tal. After 'Unit 1421': An Exploratory Study Into Female Students' Attitudes and Behaviours Towards Binge Drinking at Leeds University. Journal of Public Health 2008; 30:8-13.
(17) Nan X, Faber R. Advertising Theory: Reconceptualizing the Building Blocks. Marketing Theory 2004; 4:7-30.
(18) Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett, 2007.
(19) O’Neill B. Risk Aversion in International Relations Theory. International Studies Quarterly 2001;45 617-640.

Successful Miscommunication: A Critical Review of the Peace of Mind Campaign -Matthew Hanlon

Introduction
In an effort to combat high rates of unhealthy sexual behaviors and negative outcomes of those behaviors the Health Promotion Agency, a public health organization in Ireland, launched a campaign in Northern Ireland. This initiative named "The Peace of Mind Campaign," focused on increasing knowledge of existing sexual health issues facing the Northern Ireland population aged between eighteen and thirty years. The campaign began its efforts in 1993, with a poster campaign that was received very well, but not directly followed up upon. It was not until 1997 that a new poster campaign was launched. These posters were targeted primarily university students at first, as they were used as a test group. Advertisements addressing transmission of chlamydia, getting regular STD tests and to a lesser extent condom use were placed in and around university campuses and surrounding pubs. Studies were then conducted in order to measure awareness of the poster advertisements in the target population. It was found that approximately two thirds of the population was aware of the advertisements and their message.
Based on the findings of the awareness study the in December of 2000 the intervention was expanded to include information leaflets, fact sheets and other forms of print media as well as other locations not directly associated with university students. However, it is important to note that the target age group was not expanded at this time. As the campaign progressed posters were changed regularly with about one year between new iterations. By 2004 fourteen different posters had been created and used in the campaign. Keeping in line with the strategy of varying how the safe sex message was delivered in April of 2007 the Health Promotion Agency began launching radio and television advertisements in Northern Ireland as well (10).
HBM and the Peace of Mind Campaign
This intervention, as has been stated previously, is an educational campaign based on the dissemination of information and subsequent awareness of sexual health issues faced by the population being targeted. It is worth noting that content of the print media contained within this campaign can be divide into two main classes. The first class is information aimed at increasing the population's view of benefits derived from safe sex behaviors. This is achieved by enlarging the population's view of its susceptibility to and the severity of the negative health outcomes associated with sexual behaviors, such as unwanted pregnancy, chlamydia, HIV or other STDs. The second class of information deals with providing specific knowledge about sexual health clinics or where to get further information on sexual health issues. This type of information can be seen as material aimed at reducing the perceived barriers to gaining information about and practicing health conscious sexual behaviors. These two factors, perceived susceptibility and perceived barriers are major components of a popular model for public health interventions known as the Health Belief Model (HBM). The HBM asserts that perceived benefits and perceived barriers are in opposition of each other, and that in order for someone to develop an intention to perform a health behavior the perceived benefits must overcome the perceived barriers (3).
The HBM can be very useful at the beginning stages of a public health intervention. It provides direction and focal points for disseminating information to the target population. There are a number of people that do and will respond to the strategy outlined by the HBM early on in the intervention. Often times there can be a change in a significant portion of the population when a campaign based on the HBM is instituted. However, it is important to note that the entire population does not respond the same way as this smaller group that is fast to develop safe sex habits. There are a few explanations for this occurrence. One is that the people who are fast to pick up condom use and other safe sex habits are different from the rest of the population regarding health conscious behaviors. Due to variables not shared by the rest of the population this group of people readily makes behavior changes when they are given health information they did not previously have. The second explanation is that the educational information presented in the intervention are more salient with the first group and have simply not reached the others who have yet to develop the safe sex habits being promoted. Each of these explanations results in a very different view of the HBM's impact as an intervention model.
Failure of the HBM
When viewing "The Peace of Mind Campaign" through the lens of the HBM it seems to be a rousing success when 67% of subjects in the study evaluating awareness of the campaign responded they knew of the posters and that they recalled the message(10). This is especially true if it is believed that the reason the HBM may be unsuccessful is not because of different groups' response to health information, but whether or not they retained the information given to them. However, this is also based on the assumption that health behaviors in general and, more specifically, sexual health behaviors do follow the HBM, which has been shown to not be the case. In a study where the predictive powers of the HBM was compared to other health behavior models it was shown that the HBM accounted for less variance in diet, exercise and smoking behaviors than did the theory of reasoned action or theory or planned behavior (5). In addition, a later study based on a quantitative review of many preexisting studies it was shown that the HBM was lacking in predictive powers, which was then attributed to its focusing only on factors predisposing people to a behavior (4). Because of these studies it can then be concluded that the HBM functions through the first explanation given for why the HBM does not reach an entire population: there are different groups within a population with different dispositions towards adopting a health behavior. As such this entire campaign is fundamentally flawed because it is based on faulty assumptions made by the HBM and how it is applied to target populations.
Lack of Aim in Addressing Relevant Populations
Another major flaw with this campaign is the target population for the intervention. This intervention was an educational campaign focused on creating awareness of sexual health so that people would then subsequently change their behaviors to conform with their new knowledge. In addition, as stated earlier "The Peace of Mind Campaign" targeted adults of ages eighteen to thirty years. Although there is nothing inherently wrong with targeting a safe sex intervention to that age group, it was a mistake in this particular intervention to place that specific age restriction on the campaign. There is reasoning based on both psychological theories and empirical data collected directly in relation to this campaign that gives credence to an age restriction of eighteen to thirty years being a mistake.
As stated earlier, interventions of this type do have an effect on some members of the population, but there still remains a large proportion that does not change their preexisting behaviors. One possible explanation for this occurrence comes from an extension of the endowment effect. The endowment effect states that people will place higher value upon an item that they have ownership of in comparison to a similar item that they do not own (7). This can be interpreted to mean that owning something has an inherent value to a person and that value is substantially higher than the innate value of that item. It is therefore very easy to infer that people who do not readily change their behaviors to safe sex practices as prescribed by "The Peace of Mind Campaign" feel ownership of their preexisting behaviors. Also, the value members of the target population place on that sense of ownership is substantially higher than what they feel the will receive in return for ceasing their current behaviors.
In order to effectively change the sexual behaviors of those living in Northern Ireland the sense of ownership stemming from the endowment effect must be circumvented. Classical conditioning theory shows that behaviors become more ingrained over time and repetition. The more often, longer duration and amount of reinforcement received from a behavior performed the more ingrained that behavior becomes (6). Thus in order to circumvent that sense of ownership that develops from an ingrained behavior it would be ideal to create a change before or in the early stages of behavior conditioning. Research done by the Health Promotion Agency, the same organization responsible for "The Peace of Mind Campaign," shows that approximately 90% of females and 80% of males between the ages of twelve and fifteen years old are sexually active. Based on this research the target audience of the intervention should have used age twelve as the lower bound for the target population. By educating the population early on it is easier to effect change as behaviors are not yet ingrained and individuals do not possess a sense of ownership yet. Also, it is considerably more likely that by targeting a younger population that early sexual behaviors will be health conscious and will continue into the future due to the processes described by conditioning theory and the endowment effect.
Breakdown in Communication
Borrowing from the endowment effect again another issue can be raised with "The Peace of Mind Campaign." In this instance the issue is not with the delivery of the message, but rather the message itself. The posters used in the promotion of health information this intervention is based around may actually be counterproductive to the end goal. A specific example is one poster used in May of 2004 to educate that chlamydia may not present with any noticeable symptoms. The poster reads "You could be looking at someone with chlamydia." This message is written upon a mirrored background so that whoever is reading it should see their own reflection. This one poster is sending the wrong message, according to three different theories explaining behavior. The first, as was mentioned, is the endowment effect. This poster goes against what you would expect to see if the endowment effect was considered because the poster is threatening a person's sense of ownership of health. People place value on being healthy and this poster in a sense attempts to purchase that belief in exchange for either proof of health or proof of illness. This is not an exchange that would seem worthwhile to a person who believes that he is in fact healthy.
The second theory this poster seems counter to is psychological reactance theory. The basics of reactance theory can be explained as follows. When people perceive a threat to their freedom they will often overexercise that freedom in order to prove that they still hold control over the situation. This can manifest in one or both of two possible ways: behavior or attitude. When a person perceives a behavioral freedom is threatened reactance to threat will motivate the person to further participate in that behavior. Also, if a person feels a particular attitude is being forcible impressed upon them he will most likely take up the opposite attitude in order to assert his freedom (2). This outcome can occur in this situation, as there is a threat being made to a person's freedom from illness and his sexual freedom. A behavioral reaction predicted by this theory would be that a person would not get tested. By making a conscious choice not to get tested a person can reassert their control over being healthy or sick and maintain their sexual freedom. Having an asymptomatic illness allows this choice as the only way to "become" ill is to actually get tested, thus allowing a person to create their own state of health or illness.
Creation of categories based on the physical status of a person leads to the third theory that this poster opposes: labeling theory. This theory asserts that when an individual is labeled as part of a group they will begin to conform to what that label would expect of them (1). There are two different ways under labeling theory that this poster is counterproductive to the goal of promoting safe sex. The first is that poster labels all people, regardless of their true situation, as being at risk for chlamydia. This is a dangerous label to apply to both those at risk and those not at risk as for either group it promotes sexual risk taking in regards for chlamydia. As per labeling theory people or either risk group may be given motivation, they would not have had otherwise, to attempt to live up to the label of being at risk for chlamydia by participating in risky sexual behaviors such as intercourse without condoms. This increases the the level of risk for those already at risk for chlamydia or other negative outcomes of unsafe sexual behavior, and creates risk for those that had a minimal amount beforehand.
The second aspect of labeling theory this poster is set against has to do with stigmatization. Because chlamydia can be asymptomatic the only way to be certain of a person's infection status would by medical testing. However, those who get tested can be labeled quite negatively as being at high risk or even worse actually having the disease. This creates a stigma that is associated with the act of being tested(8). People, regardless of their actual risk or infection status, fear being labeled as having the disease simply because they do get tested. This stigma in turn discourages people from seeking medical tests to determine their infection status. A public health intervention should seed to discourage stigmas around being tested instead of promoting them. This poster unfortunately promotes stigmatization of those seeking medical tests and in fact goes against its own goal.
Evaluation of The Peace of Mind Campaign's Effectiveness
Although as stated earlier the Health Promotion Agency cited a study in which 67% of respondents were aware of their campaign, it was by no means a massive success. What this study of the effects of the intervention showed was that people were aware of the intervention's message. In terms of getting the message and information "The Peace of Mind Campaign" was presenting to the public the intervention was moderately successful. Reaching two thirds of the target population is a very large step in the correct direction for a public health intervention. However, reaching the target population in itself does not mean that the message received was effective.
There may have been a portion of the population, as earlier stated, that responded to the health education approach used by this intervention. However, it is highly unlikely that this intervention had any appreciable effect on increasing sexual health behaviors and subsequently decreasing infection rates of sexually transmitted disease beyond those that were reached easily and early on in the intervention. Incidence data for sexually transmitted disease collected by genitourinary medicine clinics in the United Kingdom support this claim. Between the years of 1998 and 2007 chlamydia rates have increased 2.5 times and total diagnoses of any sexually transmitted disease has increased 1.63 times. This data shows it is absolutely vital that public health interventions be rethought. There is a vast body of research that exists and can be applied to campaigns promoting any number of health behaviors, that is not being used to its fullest potential. By tapping into resources not traditionally used by public health agencies interventions can become massively more effective. If new approaches are not used there will just be more interventions like "The Peace of Mind Campaign" that span decades, but only accomplish wasting funding and effort.
Possibilities for Future Interventions
The "Peace of Mind Campaign" instituted in Northern Ireland by the Health Promotion Agency in order to improve the rate of safe sex behaviors was not nearly as effective as it could have been, due to a number of flaws in its design (10). Some flaws existed in the very foundation of the intervention others came about later on and were introduced at a later stage. Regardless of where these flaws were found they detracted from the overall effectiveness of the "Peace of Mind Campaign," which is an unfortunate occurrence as promotion of safe sex behaviors is an important public health goal. However, the "Peace of Mind Campaign" was not a total loss as in addition to its flaws it had some effective strategies as well and because of this can be used as a comparison point for future plans for safe sex interventions. By judging what was effective and what was not about the "Peace of Mind Campaign" an intervention that is significantly more effective as a whole can be designed.
Choosing the Proper Model
The first flaw with the "Peace of Mind Campaign" that was discussed was its reliance on an ineffective behavior model, the Health Belief Model. Therefore, a new intervention would have to diverge from using this model as a basis for planning the intervention. One possible approach would be to create an intervention based on a combination of social expectations theory (SET) and social network theory (SNT). Social Expectations Theory explains behavior which may at first seem to be an individual choice, like condom use, is in fact a social behavior (11). As such, safe sex practices are largely a result of conformity to the expectations of the larger group of which a person is a member. Social network theory also deals with people as being influenced largely by their peers. Under SNT people do not exist as individuals but rather as part of a great social amalgam. Because of this view SNT asserts that behavior change does not occur on the individual level, but rather on the group level and that in order to affect behavior change it must be group focused rather than individually focused (12).
By using group level models instead of the HBM the issue of individual differences between people influencing the effectiveness of the intervention is decreased. Whereas there may exist a strong degree of heterogeneity between individuals, there is much higher degree of homogeneity between groups. This is an important concept for a number of reasons. The first reason, it allows a more focused campaign in terms of how the intervention appeals to an individual. Rather than making hundreds of posters that are designed to appeal individually to people, only a few posters need to be made provided they are designed to appeal on a group level. Another reason is that within a population there are those with different levels of safe sex behaviors. By using a group centric approach this difference does not matter, as changing the group dynamic will reinforce behaviors in people that already practice safe sex, and cause a shift towards safe sex behaviors for people that are not yet there. Therefore, by targeting groups, instead of individuals, it is much more likely that an intervention will be effective for a large proportion of the population rather than a small subsection.
Individual Behaviors Change on a Group Level
Also, using a group centric model as the base for this intervention helps in addressing the second major flaw of the original "Peace of Mind Campaign": its failure to address problems facing the intervention stemming from endowment theory and classical conditioning. As stated earlier, when these two theories are applied to sexual behaviors they show that people are unwilling to make changes because of the intrinsic value of ownership and the level of conditioning they have with respect to that behavior. By using a model that promotes group change for the basis of the intervention it helps alleviate both of these issues. People are more likely to change a behavior they value if they believe they will gain something of equal or greater value. A group level model directly effects this exchange. As the social group a person belongs to shifts, they will be forced to alter their behavior in order to maintain their place in the social hierarchy. In a sense people are exchanging individual behaviors for a sense of social belonging (7). Also, affecting a change in a social network helps to lessen conditioning people have towards sexual behaviors. Changes in social networks result in a break down of cues for the conditioned response a person has towards a behavior (6). If a large enough change can be created then there will be removal of many, if not all, of the social cues that trigger unsafe sexual behavior.
Focusing on the Message
The issues addressed so far have only dealt with the general concepts of a public health intervention without going into the specifics, such as the method of interacting with the public. The "Peace of Mind Campaign" used mainly print media, such as posters and leaflets to reach the target population. This proved to be effective in just terms of exposure in that 60% of people interviewed in a study by the HPA recalled the content of the posters (10). Therefore it seems print was a good media for gaining exposure in the target population. However, the "Peace of Mind Campaign" had problems, not in exposure, but rather in terms of the content of the posters it presented.
One such poster with lackluster content was already discussed in great detail. The major issues with this poster being that it went against what would be expected from an intervention that consulted endowment theory, psychological reactance theory or labeling theory. Therefore it would make sense to design a poster that incorporated the major tenets of these theories rather than disregarding them. The first concept to be included in this poster would come from endowment theory: the poster should somehow offer something of equal or greater value than the behavior being targeted. Psychological reactance theory states that the poster should not threaten the sense of freedom a person possesses, otherwise they will rebel against the message presented (2). Labeling theory states people will conform to a label placed upon them, so the poster should place a positive label on people.
One example of a poster that meets these requirements is as follows: The main picture on the poster is of a couple sitting at the bar talking. The people in the poster are fairly representative of the target population. There is a main caption that reads "It's not about getting lucky tonight, it's about being prepared for the night. Know where you're going, and bring a condom with you." In this poster an exchange is being offered, for a change in sexual behaviors. The message implies that by using a condom it will make a person more sexually attractive because it's "not about getting lucky." This is an exchange that gives a person something of value for giving up their previous behavior. Also, by using a couple representative of the target population it creates a sense of identification for the recipient of the message which limits psychological reactance to threatened freedoms (2). Finally this poster creates a positive label for condom users, without the co-creation of a negative one for non-condom users. "Know where you're going" implies a sense of purpose, direction and confidence. These are all positive traits that people will aspire to have that according the poster condom users have. Therefore if the poster is salient enough people will attempt to take on the label of being a condom user in order to gain these traits that come with it (1).
Synthesizing an Effective Approach
After analysis of the shortcomings of "Peace of Mind Campaign" and their comparison to other approaches described a general understanding of what an effective public health intervention would require can be reached. The first step in an effective intervention is to choose a model that works to base the intervention upon. Group level models have distinct advantages over individual level ones that make them much more useful in this setting. By using a group level model it allows interventions to focus on the issue at hand in a homogeneous population rather than getting bogged down by trying to determine how best to influence a conglomeration of heterogeneous individuals. Also, group level models confer the added advantage of creating a new set of social norms. This is aids in the second step of creating a successful intervention: people must feel they are benefiting from making the behavior change proscribed by the intervention. Changing social norms is an advantage in reaching this second step. People will exchange their negative behavior for these new norms because they gain a sense of group belonging as replacement for their lost behavior. The third step is to make sure the message of the intervention is salient and coercive to the public. Three cognitive theories were used in creating the poster in described as a replacement for the one that came from the "Peace of Mind Campaign." However, there are countless useful cognitive theories that can be applied as well. It falls to public health officials to carefully design interventions so that they meet these criteria. If this is done, there will be more successful interventions that occur.

References
1. Becker, H.S. Outsiders: Studies in the Sociology of Deviance. Simon and Schuster 1966
2. Brehm, S. S., Brehm, J. W. Psychological Reactance: A Theory of Freedom and Control. New York, 1966
3. Glanz, K. Health Behavior and Health Education: Theory, Research, and Practice. Jossey-Bass, 2002
4. Harrison, J. A.; Mullen, P. D.; and Green, L. W. A Meta-Analysis of Studies of the Health Belief Model. Health Education Research 1992; 7:107–116.
5. Mullen, P. D., Hersey, J., Iverson, D. C . Health Behavior Models Compared. Social Science and Medicine 1987; 24: 973–981.
6. Pavlov, I. P. Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. London: Oxford University Press, 1927.
7. Shogren, J. F., Shin, S. Y., Hayes, D.J., Kliebenstein, J.B. Resolving Differences in Willingness to Pay and Willingness to Accept. The American Economic Review March, 1994; 84:255-270
8. Wright, E.R., Gronfein, W.P., Owens, T.J. Deinstitutionalization, Social Rejection, and the Self-Esteem of Former Mental Patients. Journal of Health and Social Behavior, March, 2000; 41:68-90
9. All new episodes seen at GUM clinics: 1998-2007. United Kingdom and country specific tables. Health Protection Agency, July 2008
http://www.avert.org/stdstatisticuk.htm
10. The Peace of Mind Campaign:
http://www.healthpromotionagency.org.uk/Work/Sexualhealth/campaign.htm
11. Hornic, R. Alternative Models of Behavior Change Working Paper. Annenburg School for Communication, 1990; 131: 5-6
12. Meyer, G.W. Social information processing and social networks: A test of social influence mechanisms. Human Relations, 1994; 47: 1013-1048.

The Road to D.A.R.E Was Paved With Good Intentions: A Critique of the D.A.R.E. Program in the U.S. – Jinné N. Richards

Part 1:Introduction
Experimentation with alcohol and drugs is so common among today’s young people that it is unfortunately often considered normative. Yet, in 1983 the Drug Abuse Resistance Education (D.A.R.E.) program was developed by the Los Angeles Police Department and the Los Angeles School District in response to the growing incidence of drug use among high school students. Soon after, the program became the basis for drug education curricula across the United States. This program’s major objective was to bring uniformed police officers into the elementary school classrooms for about one hour per week for one semester to lecture the students mostly on information about drugs and the consequences of their use. Following the didactic session was a question and answer section. Additionally, the students were given homework assignments for completion for the following session (1).
However, since its inception, a growing body of evidence has shown that the D.A.R.E program is ineffective in preventing drug use among adolescents. Specifically, students who were exposed to D.A.R.E. fared no better than students without D.A.R.E. (1). Proposed reasons for the program’s lack of effectiveness ranged from the claim that the program inadvertently glamorized drugs by providing information about the various classes and methods of use to sending mixed messages about drug use. In actuality, not all drug use results in life-long addiction, a concept that was inherent to the D.A.R.E. curriculum. Upon review of the program, it is evident that several of the causes for this program’s failure were rooted in flaws with the program’s curriculum as well as the instructors themselves. Therefore the purpose of this paper is to provide three theories explaining why the D.A.R.E. program does not succeed in decreasing adolescent drug use. These theories include: the use of the labeling theory, the curriculum’s disregard for the importance of peer influence on an individual’s behavior, and lastly, the effect instructor interaction may have on an individual’s trust and retention of the presented material.
Argument 1: The Labeling Theory
The first reason the D.A.R.E. program fails to reduce adolescent drug use is due to how the instructors label using drugs as a socially deviant behavior. The labeling theory concerns how self-identity and/or behavior of an individual may be determined or influenced by the terms used to describe or classify him or her (2). Part of the D.A.R.E. curriculum involves labeling drug use as being associated with socially deviant individuals and behavior, and this concept is emphasized and reinforced by program lecturers. Thus, according to Gunnar-Bernbug et al, when “… an act of deviance is publicly announced and defined as immoral… the immoral character of the actor is highlighted …[which then illuminates]… the [similarities] shared by [stigmatized youths] while also differentiating them from those who are not labeled (Gunnar-Bernbug 69-70).” Those who are contemplating drug use, or who are already using drugs, are highlighted and stigmatized by their peers. As a direct result of this program’s stigmatization, the labeled youth may “… withdraw from interaction with conventional peers …[and subsequently the conventional peers may] avoid publicly known deviants, ‘fearing the social stigma may rub off’ (Gunnar-Bernbug 71).” Thus, as a direct result of this stigmatization, the labeled youth may isolate his or herself for fear of rejection, or be shunned by his or her peers, and excluded from social networks within his or her environment.
As a result of being stigmatized, and subsequently isolated by their peers, individuals may then go on to seek acceptance by peers who are in similarly isolated situations. Stigmatized youths tend to seek out “…deviant groups in order to be with those who are in a similarly disadvantaged social position [and]… share their deviant self-concepts and attitudes (Gunnar-Bernbug 70).” They may be drawn to these groups not only because the members are in similarly isolated situations, but also because they may share the same attitudes and behaviors. Moreover, these groups provide isolated youths with a sense of social support…[and] social shelter from those who react negatively towards their…status (Gunnar-Bernbug 70)”. Thus, once an individual has been isolated socially from his or her peers based on his or her behaviors or actions, it is likely that he or she will seek out others who have been similarly isolated, and form groups in which they can receive support, camaraderie, and, at times, protection from those who have declared them outcasts.
In addition to the isolated groups providing social shelter from stigma, these groups also encourage the same socially deviant behavior for which the individual is being stigmatized. These social groups provide the individual with “…collective rationalizations, definitions, peer pressure, and opportunities that encourage and facilitate deviant behavior (Gunnar-Bernbug 82).” Once the individual has entered into the group, the latter will dictate his or her behavior, and will encourage him or her to part-take of any deviant behavior. Likewise, this deviant behavior is not limited to one period of time, for which the individual is likely to out-grow this behavior. Studies have shown that “…deviant labeling during adolescence may be a consequential event for the life course, pushing or leading youths on a pathway of blocked structured opportunities and delinquency [well into] young adulthood (Gunnar-Bernbug 83).” Therefore, adolescence is not the only age group who is vulnerable to the effects of socially deviant behavior, but this behavior can carry over into young adulthood, and may dictate the individual’s entire life-course.
Argument 2: Peer Groups
The second reason that the D.A.R.E. program failed its goals involves the fact that this does not prioritize the effect that one’s peers may have on influencing the initiation of drug behavior. Studies have shown “ … the most potent proximal influence on pattern of drug use in adolescence [are their] peers (Steinberg 1060).” Elementary children are exposed to the effects of drug use during this time period via the D.A.R.E program, but by the time they are in their adolescence, they may have likely forgotten the majority of the program’s teachings. Yet the most predictive factor of whether or not an individual chooses to begin engaging in drug use and/or socially deviant behavior is whether they have peers who engage in the same behavior. In addition to dictating the initiation of drug use, once the group an individual associates with has started using drugs and/or participating in a socially deviant behavior, he or she “…[is] more likely … to make the transition into heavier substance use [as a group] (Steinberg 1063).” So, once the individual has made the decision to remain in the group, and to initiate socially deviant behavior, it is likely that, as a group, they will make a collective decision to not only continue the behavior, but to progress on to harsher and more dangerous substances.
By underestimating peer influence on an individual’s decision to do drugs, The D.A.R.E. program has ignored a potentially significant source of peer influence and/or peer pressure. Studies on teen addictive behavior and substance use have concluded, “If an individual is involved with peers who do not engage in the use of drugs and alcohol, he or she will … be less likely to begin involvement (Steinberg 1063).” If individuals who have been socially isolated in groups based on deviant behavior are more likely to participate in deviant behavior, then it stands to reason that individuals who are in groups that do not participate in deviant behavior are less likely to participate in socially deviant behavior. Moreover, if an individual with a socially deviant behavior is in a group that does not participate in his or her behavior, the same individual may feel compelled to discontinue the behavior because he or she “…may be encouraged [by his or her peers] to reduce already present levels of substance use (Steinberg 1063).” So, if, by chance, a teen has entered a group where the majority does not mirror his or her behavior, the young person may modify his or her behavior more because of the group dynamic and less because of the information he or she has acquired about the hazards of that behavior.
Argument 3: Lack of Trust
Lastly, one of the most difficult tasks that the D.A.R.E program tries to accomplish is attempting to modify behaviors with very strong developmental components via a curriculum that is least conducive to behavior modification. D.A.R.E. utilizes a series of lectures on drug use followed by a question and answer session, which ultimately limits the amount of interaction the students have with their instructor. This approach is thought to be counter-productive particularly in this age group because “Interactive programs tend to emphasize developing drug-specific social skills [necessary for resisting drug use,] and more social competencies [useful for recognizing risky behaviors] (Ennett 1398).” Thus, if these programs were more interactive and comprised less of lectures, the participants would be more apt to acquire skills for recognizing and resisting drug use as a result of peer influence. These skills would be carried over into the subsequent developmental phase of adolescence, and would be less likely to be forgotten.
Moreover, there are seldom opportunities for the participant to develop any rapport and/or trust with the instructors given the lack of direct participant-instructor interaction. Trust of the instructor is most likely to be achieved through “…everyday interactions [or]… by the way the teacher [interacts] with her or him in their continuing contacts with each other (Woolen 95).” Since the D.A.R.E. program is taught through a series of lectures by police officers for a one hour per week during one semester of their elementary school years, and there is limited interaction, there is both a lack of continuity and a lack of communication between the participants and the instructors, which will most likely result in a loss of rapport/trust between them. Thus, it is quite evident that the instructors are unaware that they “…not only provide facts and information, but also [impact] how students perceive them as [resources] (Banfield 65).” Therefore, the instructors might be unaware that they are responsible for more than just delivering the information to the students. They are also responsible for establishing a rapport with their students to ensure maximum acceptance, and thus retention of the information.
Because the participants do not trust their instructors, they are unlikely to accept as true any information that they obtain from their instructors. Research has shown that “… if the teacher is able to increase the affect of their students… then positive instructional outcomes are likely to occur (Banfield 65).” Thus, there is a direct positive correlation between a student’s trust for his or her instructor and whether or not he or she is likely to not only believe the presented information, but whether he or she is likely to retain and utilize it. In direct contrast to this concept, if the instructor is perceived to be less than truthful and/or reliable, then their “…students’ affect for them will likely be reduced and negative instructional outcomes will result (Banfield 65)”. Hence, it is this perception of the instructors that dictates whether or not the information they present will be viewed as factual and, thus, remembered, or whether it will be viewed with skepticism and then quickly forgotten.
Part 1 Conclusion
The D.A.R.E. Program was created to deter youths from experimenting with drugs or to discontinue its use once they have already started. But it failed to reach these goals because its creators were unable to incorporate a basic understanding of the sub-culture of the population it was suppose to serve. They were unable to reach their goals because they failed to understand how labeling deviant behavior could glamorized drug use, and subsequently appeal to many adolescents if the group they identify with approves of such behavior. Additionally, the creators did not have a basic understanding of the importance of the instructor-student relationship as it pertains to the faith and subsequent retention of the material being presented. Failure to recognize and understand the power of peer pressure on adolescent behavior led to the rapid subsequent discontinuation of the program by many school districts across the United States. A careful and through study of the population is imperative if the program is going to be relevant and consequently, beneficial. D.A.R.E. was created with good intentions, but it takes more than that to execute a successful drug free program.
Part 2 Proposed Intervention: The New D.A.R.E. Program
The new proposed D.A.R.E. program will involve many of the basic fundamentals that the original program held. For example, the program will be taught to elementary school children (fifth graders) for the entire academic school year, and will focus on the dissemination of information pertaining to illegal drugs, their use as well as abuse. However, the program will utilize active participation of the students instead of a series of lectures by outside instructors.
The new program will differ from the original by being taught by the students’ own fifth grade teachers in the school, whom they already know and trust, rather than trained police officers in the community. These classroom teachers will receive formal training regarding drugs use and abuse, effective methods for conveying information, as well as words and phrases to avoid when interacting with students. The trained fifth grade teachers will then conduct a series of classroom interactive lectures and activities, as well as inviting members of the community who work to combat drug and alcohol prevention and addiction to give guest lectures. The teachers will also be encouraged to allow guest lecturers who were formerly addicted to drugs to speak to their students regarding their personal experiences with drugs and the devastating impact they had on their lives. Lastly, trained offices, some of whom may have participated in the original D.A.R.E. program, will be encouraged to give guest lectures to the fifth graders in order to supplement the lectures provided by their teachers regarding the different categories of illicit drugs.
In addition to the program being taught to fifth graders, the New D.A.R.E. Program will also be taught to seventh graders for reinforcement. This program for seventh graders will be taught by their health teachers. And much like the fifth grade teachers, these seventh grade health teachers will also need special training, particularly on the importance of avoiding categorizing people who do drugs, drink alcohol, and/or smoke as deviants. The program would be offered for only one semester (the typical length of health classes), and will be more group activity oriented and less lecture oriented. The students will have at least one lecture that will serve as a review of the materials and information covered in the fifth grade. The remaining lectures will provide data on the prevalence of drug, alcohol, and smoking in the U.S. and within their communities. One key change in this curriculum would be the introduction of a project in which each student must participate. The students would have a choice of either working in small groups to conduct research on the prevalence of teen drug use, alcohol use, or smoking/tobacco within their own schools and/or communities and its impact on performance and/or behavior. Or, they could choose to conduct an interview with members of their communities who are committed to mitigating and/or eradicating the impact of drugs within their communities. At the end of the semester, each group would be expected to write a report on their findings and give a 10-minute oral presentation to their entire health class.
Improvement 1: Mitigating the Influences of Peer Groups
Because the original D.A.R.E program underestimated the impact of one’s peers on his or her decision to do drugs, the original program was found to be mildly (if at all) effective in reducing the incidence of drug use among teens. Adolescents generally “… overestimate the prevalence of smoking, drinking, and illicit drug use among other adolescents and adults (Botvin 889)”. As a result of this overestimation, adolescents are much more inclined to believe that their peers are partaking of illicit drugs, and because they adapt the “everybody else is doing it too” attitude, they choose to begin doing drugs so that they do not feel left out (7).
However, the New D.A.R.E. Program will attempt to combat peer influences by using a social approach that provides students with what experts in the field of drug prevention call normative education. Normative education “… attempts to help correct the misperception that most people use drugs and [attempts to establish] anti-drug use norms (Botvin 889)”. By allowing the fifth grade students to attend lectures provided by community leaders regarding the actual prevalence of drug use, students will begin to appreciate the fact that all of their peers are not involved with drug use, and it is in fact a small minority of adolescents who are part-taking of these behaviors. Additionally, this message will be further cemented when the students complete their seventh grade health classes where they will either conduct interviews with community activists, or they will conduct research pertaining to the prevalence of drug use in their schools and/or communities. These activities will enable students to obtain a more realistic perspective on the level of drug use in a way that has both high credibility (because they are doing their own research) and that has meaning to them, because the research is being conducted within their own environments (i.e. their schools and/or communities) (7).
Recently, it has been proposed that normative education, which attempts to correct the overestimation the teens have with regards to the prevalence of drug use, is necessary prior to teaching the skills necessary to resist drug use (7). Preliminary research has shown that resistance skills training may be “… ineffective in the absence of conservative social norms against drug use, since if [adolescents perceive the norm] is to use drugs, [they] will be less likely to resist offers of drugs (Botvin 889).” Therefore, the New D.A.R.E. Program must first focus on correcting the adolescents’ perception of the prevalence of drug use, before it attempts to teach them skills necessary to resist social influences and peer pressure.
Improvement 2: Elimination of Harmful Labeling
This New D.A.R.E Program will improve upon the original program in terms of labeling adolescent behavior because the new program requires that all teachers receive special training on the impact of categorizing those who do drugs as being social deviants. This concept is particularly important in avoiding the further alienation of those who already use drugs or intend to use drugs. The original program attempted to “…separate ‘them’ – the [minority] stigmatized group- from ‘us’ (Link 528)” with “us” being the majority of societal members, who are not using drug (8). By making this distinction of the majority being the non-drug users and the minority being the drug users, the original D.A.R.E. instructors attempted to alter the adolescent participants’ overestimation that the majority of teens are doing drugs, and showing them that, in fact, a very small percentage of teens actually do drugs. Despite their attempts, this labeling only served to further alienate the teens that already were doing drugs.
However, by utilizing the concept of normative education and allowing the participants of the New D.A.R.E. Program to listen to lectures from both their teachers as well as leaders in their community regarding the statistics surrounding teen drug use, as well as to participate in their own research, teens will be able to draw their own conclusions regarding the prevalence of drug use in the community. The students will be able to see that indeed the majority of teens do not do drugs and it is really a small minority of them that do (7). This realization will be accomplished without the teachers pointing it out to them by labeling socially deviant behavior.
Improvement 3: Improving the Students’ Trust in Their Instructors
One particular weakness of the original D.A.R.E. program was that it was conducted as a series of lectures by uniformed police officers in a classroom. Research has found that this method is not effective in conveying information as it “… uses instructional methods that are less interactive…and students [tend to] ‘tune out’ an expected message from an authority figure (Botvin 891).” It is thought that students ignore these messages because they have not established a relationship with the police officers, as they have done with many of their teachers, Thus, the students have no trust for the officers, and, by extension, his or her intended messages (5).
However, the New D.A.R.E. Program will work to decrease the students’ perception of the message being delivered by an authority figure by having the classes taught by their teachers, and having the police officers come in as guest lecturers. Woolen et al suggest that if “…what the teacher says, and the way he or she says it, makes it appear to the student that the teacher has the student’s best interest at heart, the level of trust is most likely to increase (Woolen 95).” This method will be more effective in reducing students ignoring the intended messages, as they will now be coming from a person with whom they will be more inclined to trust (5).
Part 2 Conclusion
The New D.A.R.E. Program will attempt to improve upon the original program by addressing three of the key shortcomings of the original. This new program will attempt to lessen the impact of one’s peers and increase the impact of their instructors on one’s decision to not do drugs. It also attempts to improve a student’s trust in his/her relationship with the instructor by having the message delivered through a person he or she is already likely to trust, the classroom teacher. With these improvements, it is very likely that adolescents will come to the realization that drug users are among society’s minorities, and it is not the norm. Additionally, by doing their own research on drug use and by interviewing members of their communities, they will be informed about the negative impact of drug use from people whom they trust and hopefully, make a decision to say no to drugs.
REFERENCES
1. Birkeland S, Graham-Murphy E, Weiss C. Good Reason for ignoring good evaluation: The case of the drug abuse resistance education (D.A.R.E.) program. Evaluation and Program Planning 2005; 28:247-256.
2. Ennett ST, Tobler NS, Ringwald CL, Flewelling RL. How Effective Is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations. American Journal of Public Health 1994; 84(9): 13941401.
3. Gunnar-Bernburg J, Krohn MD, Rivera CJ. Official Labeling, Criminal Embeddedness, and Subsequent Delinquency: A Longitudinal Test of Labeling Theory. Journal of Research in Crime and Delinquency 2006; 43:67-88.
4. Steinberg L, Fletcher A, Darling N. Parental Monitoring and Peer Influence on Adolescent Substance Use. Pediatrics 1994; 93(6): 1060-1064.
5. Woolen AG, McCroskey JC. Student Trust of Teacher as a Function of Socio-communicative Styles of Teacher and Socio-communicative orientation of Students. Communication Research Reports 1996; 13:94-100.
6. Banfield SR, Richmond VP, McCroskey JC. The Effect of Teacher Misbehaviors on Teacher Credibility and Affect for the Teacher. Communication Education 2006; 55(1):63-72.
7. Botvin gj. Preventing drug abuse in Schools: Social and competence enhancement approaches targeting Individual-Level Etiologic Factors. Addictive Behaviors 2000; 25 (6): 887-897.
8. Link BG, Phelan JC. Stigma and its public health implications. Lancet 2006;367:528-59.

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

Introduction
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: mystudentbody.com, e-chug.com 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). Hadenough.org 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]. CollegeDrinkingPrevention.gov 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.
Counterproposal
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.
Counter-argument #1: REMODELING THE HEALTH BELIEF MODEL
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.
Conclusion:
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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