Sunday, May 5, 2013

AlcoholEdu: An Insufficient Approach to Curbing Collegiate Binge Drinking – Dominick Morrill

                 Among colleges large and small across the United States, few activities are as ubiquitous to the common experience as binge drinking.  This rapid intake of alcohol not only affects those who choose to partake, but also those individuals who choose not to imbibe so aggressively or at all, as they must endure the degeneracy, violence, and general destruction that their binge drinking classmates tend to visit upon the campus. 
            In a national study conducted between 1999-2005, the prevalence of past-30-day binge drinking among college students increased from 42% to 45% (1).  These figures indicate a significant frequency of this dangerous behavior.  For the purposes of this discussion, we will use the National Institute on Alcohol Abuse and Alcoholism definition of binge drinking that states, “For the typical adult, [binge drinking] corresponds to consuming five or more drinks for men, or four or more drinks for women, in about 2 hours” (2).  For the individual who chooses to engage in binge drinking, the effects on health, personal relationships, and academic performance can be substantial.  Binge drinking can have a detrimental effect on heart, liver, and neurological function, as well as putting the individual at an increased risk for dangerous behavior, injuries, and death (3).  In a study completed in 2009, researchers found that for college students age 18-24, alcohol annually caused: 1,825 deaths, 599,000 unintentional injuries, 696,000 incidents of assault, and 97,000 cases of rape or sexual abuse (4).   For college administrators, parents, and students, these are not trivial statistics.  It is for these enumerated reasons, and a bevy of others that binge drinking is considered a significant public health concern on college campuses.
                 Many public health interventions have been attempted in the past to combat this unhealthy and dangerous behavior, with varying levels of success and efficacy.  This critique will consider one in particular, AlcoholEdu, on the basis of its failure to consider a number of social and behavioral principles and theories.  Following a brief introduction to AlcoholEdu, these failures will be made apparent in the subsequent three sections.  Following these sections, an alternative approach to combating rampant binge drinking will be proposed.


                 AlcoholEdu is a web-based intervention intended for all members of an incoming freshmen class just prior to enrollment at a college or university. The course “extends traditional educational approaches to prevent alcohol misuse by including normative feedback to correct student misperceptions about the acceptability and level of heavy drinking on campus, interactive exercises to challenge alcohol expectancies, and recommendations for strategies to reduce the likelihood of heavy drinking and related consequences (e.g., avoiding drinking games)” (1).  An increasing number of academic institutions are utilizing this web-based program because it represents a broad-reach approach and is relatively cost effective (5).  This course consists of Part I, which contains four distinct learning modules, and Part II, which includes the fifth and final learning module.  Part I typically takes 2-3 hours and must be completed prior to moving on to campus.  Part II occurs approximately 30-45 days later and primarily consists of a content review and brief survey to gauge student experience during the first few weeks on campus (1).  After completing Part I and Part II, students have no further interaction with the AlcoholEdu program. 
                 On a positive note for AlcoholEdu, some studies revealed a reduced frequency of past-30-day alcohol use and binge drinking among first year students (in intervention schools as opposed to control schools) immediately following the intervention.  Unfortunately, however, “these effects did not persist in the subsequent spring semester, regardless of the level of student participation. Additionally, no significant effects were observed, in either of the two follow-up periods, for either the average number of drinks students consumed per occasion or the prevalence of binge drinking” (1).  These results indicate that while AlcoholEdu might be on the correct path towards positively influencing rates of binge drinking on college campuses, this intervention carries with it too many flaws and does not sufficiently address issues caused by environment or social interactions.

Critique of Intervention 1 – Reliance on the Health Belief Model and Failure to Acknowledge Environmental Pressure

                 The first thing that a student realizes when they sit down to complete AlcoholEdu is brazenly expressed to them in the title of this intervention: “you are about to be educated about alcohol”.  This didactic approach is indicative of a longstanding effort in public health to educate individuals in the hopes of impelling a healthful behavior, and is often expressed using the Health Belief Model.  The Health Belief model instructs us that an individual will choose to prevent or avoid an unhealthy behavior if the six constructs provided are satisfied. First, the individual must (1*) perceive their susceptibility to the bad outcome, (2*) perceive the severity of the behavior, (3*) believe taking action would reduce their susceptibility, and (4*) believe the benefits outweigh the costs of taking the action.  Furthermore, the individual (5*) must be exposed to cues or factors that prompt action, and (6*) they must be confident in their ability to successfully perform an action (7). 
                 Unfortunately, this approach is often ineffective in the effort to influence behavior change, but especially so in this particular case, because it does not account for social or environmental factors. To the point of the second construct (2*), students who engage in aggressive drinking might perceive the severity of the behavior, or the detrimental health outcomes, but this is often lost when caught up in social situations and especially when alcohol has been ingested.  Furthermore, when a student sees friends, teammates, or other college students engaging in aggressive drinking, in essence normalizing that behavior, then the perceived severity of that action is often lessened.  Additionally, and most importantly in the issue of college drinking, is the failure of construct (4*).  Many college students believe that drinking and peer acceptance, or social prowess, are inexorably linked.  In fact, “some groups such as fraternities and sororities may actually have a stake in maintaining a normative perception among students of high alcohol use, as it may also connect to other perceived norms and beliefs about social group popularity” (8).  So, in this case, the cost of limiting alcohol consumption, and thus potentially reducing popularity amongst peer groups, is a cost that often outweighs the health benefits of that same action.  This shortsighted attitude of invincibility and adherence to perceived group norms is especially prevalent among male student-athletes and members of the Greek (fraternities and sororities) community (7).

Critique of Intervention 2 – Inspiring Reactance

                 Psychological Reactance Theory instructs us that when a social influence seeks to repeal, infringe, or threaten an individual’s freedom, that person will often experience reactance, or “a motivational state aimed at restoring the threatened freedom” (5).  For American adolescents, few life events conjure the same level of perceived freedom as the move away from home and on to a college campus.  It is in the state of a nearly frenzied excitement about this impending freedom that AlcoholEdu requires the incoming freshman to sit diligently at a computer for upwards of three hours and receive a lecture on healthy behavior regarding alcohol consumption.  As outlined in the above section, this is often not the best way to attempt a public health intervention, but this approach seems especially ineffective within the context of nearly unprecedented freedom for many incoming freshmen.
                 AlcoholEdu further incites resistance to its important message by ignoring the substantial role that similarity can play in deflecting reactance.  As noted in the study by Paul J. Silvia, “When the communicator was highly similar to the participant, people agreed strongly, regardless of threat.  Similarity increased the force toward persuasion by increasing liking, and it decreased the force toward resistance by making the message seem less threatening” (9).  AlcoholEdu does little to deflect this reactance on two primary fronts, which will be outlined in the following paragraphs.            
First, the length of the required course inspires feelings of being lectured, an interaction rarely enjoyed or practiced by members of a similar group.  While there are some interactive aspects of AlcoholEdu that allow students to become engaged in the learning process (such as interactive activities to enter body mass and number of drinks to determine potential Blood Alcohol Content), the majority of the course requires the student to absorb oft-repeated or common sense facts about alcohol (1).  For example, one section of AlcoholEdu instructs the accepted measurement of one drink: 12 oz. of beer, 5 oz. of wine, or 1.5 oz. of hard liquor.  Now while this may be informative to some members of the population, I would argue that most 18-19 year old adolescents would be insulted that they are required to rehear the same commonly accepted facts that have been instilled in them throughout lower level and secondary education.  Although there may exist useful facts and information within the program, the presence of these obvious facts may cause some members of the community to mentally disengage from the learning process.  The benefits of educating a small portion of the population are outweighed by the cost of losing the attentiveness of the majority.  Not properly engaging students can inspire dislike and thus exacerbate negative reactance.
                 Secondly, an inherent flaw in a broad based approach like AlcoholEdu is the inability to target subjects with a similar instructor.  The presence of a similar instructor in public health interventions has the very positive effect of increasing “liking” and as a result decreasing reactance.  Silvia continues, “As expected, people in the high-similarity group expressed more liking for the communicator and did people in the low similarity group”.  Furthermore, “When similarity was low, threatening attitudinal freedom led to less agreement.  When the similarity was high, however, threatening the freedom had no effect: People strongly agreed with the communicator regardless of the level of threat” (8).  While there is obviously some effort in AlcoholEdu to use college age actors and instructors in their program, it is simply impossible to connect with every distinct group of students using such a broad approach.

Critique of Intervention 3 – Limited Interaction with Students and the Failure to Counter Negative Modeling
The third and final critique of AlcoholEdu rests on the assertion that the amount of time spent trying to influence behavior regarding student alcohol use is plainly insufficient.  As noted in the description of AlcoholEdu earlier in this critique, this intervention simply did not have a negligible effect after the first semester.  It is generally accepted that the first six weeks of a student’s college career are an important time to intervene, as that is the time when social pressures and student expectations are at their zenith (10), but to only intervene at that time is welcoming the short-lived success of that intervention.  Once the student has settled into college life, expectations from peers, modeling behavior, and the acceptance of perceived social norms can have a far greater formative effect than a one-time intervention could ever hope to counter.
                 Modeling and social learning can have a dramatic effect on how a student chooses to engage in alcohol use and to interact socially, regardless of their prior knowledge or perceptions of alcohol.  Defleur and Ball-Rokeach explain in their Theories of Mass Communication, “if a particular pattern of behavior is performed by a model, and if that pattern is identified as problem-solving, rewarding, or in some other way desirable in its consequences, the probability that it will be adopted by an observer is increased” (11).  As an example, if a young male student sees an older male student, a sports team or fraternity leader for instance, engage in excessive drinking and then enjoy the reward of popularity or social success, then the eventual success (popularity) will be attributed to the perceived impetus (aggressive drinking).  If the young student engages in said behavior and enjoys a similar result of increased popularity, it is then likely that the particular pattern will become a more permanent fixture of that individual’s behavior (11).
                 While AlcoholEdu is noble in purpose and earnest in effort, it will simply not be effective among the cohorts of heaviest drinkers because it does not sufficiently counter for the social development of behavior.  As a result of a national collegiate survey completed in 1995, researchers noted, “measures reflecting intensive peer exposure—having five or more close student friends, socializing with friends more than 2 hours per day and living in a fraternity or sorority—predicted significantly higher levels of heavy drinking…” (12).  If these factors are indicators of the heaviest drinkers on campus, then any effort to influence behavior with alcohol related knowledge, applied only during the first weeks of college, will be virtually ineffective.  Once an individual is established in those social groups, his or her previous perceptions of alcohol and appropriate behavior might be swept away (8).       

New Intervention Proposal – Increase face-to-face Interactions and Branding Positive Behavior

                 For an intervention to achieve a measurable amount of success in altering the incidence of collegiate binge drinking, it must present a more comprehensive approach to altering perceptions and influencing behavior.  This intervention will be conducted, not by a web-based, impersonal survey or instructional video, but by targeted instructors who will be best suited to deflect reactance for that particular group.  For example, targeting high-risk drinkers like male student-athletes, with an older and noticeably “successful” (academically, socially, or athletically) male student-athlete could yield positive results. Furthermore, this intervention will not only take place during the first weeks of freshman year, but throughout the year, thus increasing the likelihood that the formation of social groups will not altogether negate the effects of the intervention. 
In fact, by encouraging those who imbibe responsibly to maintain a positive and noticeable presence in social situations, others might be inspired to emulate that behavior.  This might impel the formation of a distinct identity along the lines of safe and healthful drinking behavior.  “Branding” of responsible individuals can help to inspire other people to adopt that behavior as well.  Although this intervention is not as economical or as easily applied as a program like AlcoholEdu, the positive, long-term effects of reducing the incidence of destructive binge drinking on a college campus will return the investment many times over. 
Defense of Intervention 1 – Deflecting Reactance
Psychological reactance represents possibly the greatest impediment to the success of an intervention regarding collegiate binge drinking.  The newfound and unprecedented freedom experienced by college freshmen is likely to produce an exceptionally strong feeling of reactance when that freedom is threatened by an intervention.  The key to deflecting that reactance, I believe, can be found in increasing the feelings of similarity, and by that measure, increasing the compliance through “liking”.  As Hovland, Janis, and Kelley stated:
An individual is likely to feel that persons with status, values, interests, and needs similar to his own see things as he does and judge them from the same point of view.  Because of this, their assertions about matters of which the individual is ignorant but where he feels the viewpoint makes a difference… will tend to carry special credibility (9).
Individuals are likely to absorb the anecdotes, heed the warnings, and acknowledge or adopt the alternative behavior if an individual who is similarly situated expresses it to them. 
                  Although this may seem like an intervention that will be difficult to implement, it can be easily achieved by recruiting positive models on a small scale. For example, the college or university might charge an athletics coach with recruiting an older team member with a record of responsible behavior to speak with freshmen teammates once every few weeks after practice.  The individuals recruited to speak with their teammates do not need any formal training, just a willingness to have a frank and open discussion about social interactions and behavior regarding alcohol.  These informal meetings will give an opportunity to discuss good and bad interactions with alcohol without inciting the negative reactance response. 
Defense of Intervention 2 – Face-to-Face Interactions
                 While computer-based interventions, like AlcoholEdu, have gained popularity due to their broad reach and low cost, one must question whether these efforts produce long-term benefits that can begin to compare to more personal interactions.  The results of a study completed in 2011 would indicate that the answer is unequivocally negative.  Researchers from Brown University and others concluded:
FTFI (face-to-face intervention) participants drank less, drank less frequently, and reported fewer problems at short-term follow-up; they continued to consume lower quantities at intermediate and long-term follow-ups {as compared to the control group}”.  Meanwhile, “Compared to controls, CDI (computer delivered intervention) participants reported lower quantities, frequency, and peak intoxication at short-term follow-up, but these effects were not maintained. Direct comparisons between FTFI and CDIs were infrequent, but these trials favored the FTFIs on both quantity and problem measures (13). 
Even though computer delivered interventions are certainly easier to present to a greater number of people, is it really worthwhile if results do not last beyond the first few months of school?  Furthermore, if less than 50% of students engage in binge drinking (as noted in the statistics above), it would seem to make more sense to choose an intervention that more specifically targets those individuals and is more effective.  While the results of face-to-face interactions are not as easily achieved, the eventual benefits of such interventions seem to far outweigh the costs. 

Defense of Intervention 3 – Branding Positive Behavior

                 One of the more successful public health interventions in recent memory was achieved by the “truth” campaign, an anti-smoking initiative that adopted a novel approach to combating teenage tobacco use.  The “truth” campaign was novel, not only in its success against a rather imposing foe (the tobacco industry), but also in its adoption of marketing theory and branding to achieve that goal (14).  Although this campaign was directed at middle and high school age adolescents, I believe that the same principles can also be successfully applied to a slightly older cohort. 
                 An important facet of the “truth” campaign was to replace one identity with another.  As Hicks notes in his essay, “If we were to turn the tables on tobacco we surmised that we could not take away their tool of rebellion without giving them an alternative” (14).  Although college drinking is not directly analogous to the “rebellious” tone of adolescent tobacco use, one might replace the perceived “popularity” associated with college binge drinking by highlighting those individuals who choose not to drink so aggressively; “branding” more responsible individuals and encouraging them to engage fully in the social drinking events could achieve this.  A way to “brand” these individuals would be to give them brightly colored shirts and instruct them to attend parties in a highly visible fashion; that is, interact with others frequently and positively.  By providing conspicuous examples of people who can have fun while maintaining sobriety, this might inspire others, especially those with initial, bad experiences with college drinking, to adopt that brand.  As Hicks describes, the more people who adopt this brand, the greater the level of “accumulated awareness” (14).  Success will hopefully breed more success with this intervention.  
Conclusion –
                 The health and safety concerns associated with rampant binge drinking on college campuses are not trivial or insignificant; these concerns deserve the full and focused attention of parents, administrators, and students alike.  Unfortunately, interventions like AlcoholEdu are simply an insufficient approach to what amounts to a very serious public health concern.  By engaging students on a more personal and comprehensive level, taking steps to avoid reactance, and providing positive alternatives to that behavior, I fully believe that great strides can be made in reducing the very detrimental health, social, and academic effects associated with binge drinking. 

(1)      Paschall M., et al. Evaluation of Internet-Based Alcohol Misuse Prevention Course for College Freshmen. American Journal of Preventative Medicine 2011;41(3):300 –308.
(2)      National Institute on Alcohol Abuse and Alcoholism. Moderate & Binge Drinking. Washington DC: National Institute on Alcohol Abuse and Alcoholism. 
(3)      Centers for Disease Control and Prevention. Fact Sheets – Binge Drinking. Atlanta, Georgia: CDC.
(4)      Hingson RW., et al. Magnitude of and trends in alcohol-related mortality and morbidity among U.S. college students ages 18-24, 1998-2005. Journal of Studies on Alcohol and Drugs, July (Suppl 16): 12-20, 2009.
(5)      Hustad J., et al. Web-based alcohol prevention for incoming college students: A randomized controlled trial. Addictive Behaviors 2010; 35: 183-189.
(6)      Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27(3) 277-284.
(7)      Smedley BD. Promoting Health: Strategies from Social and Behavioral Research. Institute of Medicine 2000; (In coursepack: 215-226)
(8)      Perkins HW. Social Norms and the Prevention of Alcohol Misuse in Collegiate Contexts. Department of Anthropology and Sociology, Hobart and William Smith Colleges, Geneva, New York 14456.
(9)      (see (6))
(10)    National Institute on Alcohol Abuse and Alcoholism. College Fact Sheet. Washington DC:
(11)    Defleur & Ball-Rokeach, Socialization and Theories of Indirect Influence (307-319). In: Defleur & Ball-Rokeach, (5)ed. Theories of Mass Communication. White Plains, NY: Longman Inc. 1989
(12)    Wechsler, H., Dowdall, G.W., Davenport, A. and Castillo, S. Correlates of college student binge drinking. American Journal of Public Health 85: 921- 926, 1995.
(13)    Carey K., et al., Face-to-face versus computer-delivered alcohol interventions for college drinkers: A meta-analytic review, 1998 to 2010. Clinical Psychology Review 2012; 32, 8: 690-703
(14)    Hicks J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5

No comments:

Post a Comment