Thursday, May 9, 2013

Generation Rx:Writing a New Prescription for Approaching the Abuse of Prescription Drugs on College Campuses – Sascha Garrey

College!  The best days of our lives!  Or so goes the cliché.  Quintessential to the college experience is coming of age moments, frat parties, pranks and, of course, cramming.  Time management has consistently been a struggle for many college students spanning decades.  The attempt to balance the tension between academics and life involves choice substances for many college students.  In the 90s, exemplified by Chandler, Phoebe, Monica and the gang’s proclivity for java, the energy booster of choice was caffeine.  The 2000s saw a rise in popularity of energy drinks, endorsed by the likes of popular rappers like ‘Lil John’s Crunk and Nelly’s Pimp Juice.  Though the tendency to over-caffeinate or tweak-out on Red Bull is not out of style, students are jumping on an even risker bandwagon to help ease the pressures of college: prescription medication.  A recent National Survey on Drug Use and Health study shows that the misuse of the prescription meds is on the rise amongst youth, and that college age kids are overwhelmingly susceptible to this behavior
According to data from the National Survey on Drug Use and Health 1 in 3 college students have abused or misused prescription medication.  “Abuse” or “misuse” is classified as taking prescription medication that is not prescribed to the user or, having a prescription, but regularly taking higher doses than suggested by the prescribing physician.  Prescription drugs that are most frequently abused by college students are opioids such as Dilaudid or Percocet and stimulants used to treat ADHD symptoms such as Adderall or Vyvanse.  According to the CDC, though this is still a burgeoning issue on the health promotion horizon, the misuse of prescription medication is considered to be a public health crisis.
The misuse of prescription medication amongst college students is a relatively new concern of the Public Health Community.  Though prominent news outlets have covered the issue significantly, major intervention campaigns have yet to be released by prominent Public Health communications entities.  The National Council on Patient Information and Education (NICPIE), a patient safety advocacy group, have taken a first stab at changing the undesired behavior with the 2010 release of their College Campus Prescription Drug Abuse Prevention Resource KitThe kit consists of 14 documents.  Five of the documents offer information in various forms on the facts and dangers of prescription drug misuse on college campuses.  Three of the documents offer advice in the form of “tips” or “what you can do” if a student or someone he knows is engaging in this behavior.  The rest of the documents offer advice about how to craft messages to their target audience.  This includes templates for radio PSAs, press releases and social-media posts.  The identified purpose of this campaign is to, “educate college students about the growing problem and danger of prescription drug abuse, warning signs to watch for and resources for treatment, (and) to help build skills so that students can take action against it”.  This effort is to be realized through “student leaders” or prominent peers on college campuses such as residence dons, fraternity brothers or student health educators.
A recent report released by the White House Office of National Drug Control Policy indicates a slight decrease in the prevalence of prescription drug abuse on college campuses.  This suggests that campaigns that target this behavior have been moderately successful in their efforts.  But, is that good enough?  What is dampening the success of interventions like NCPIE’s so that they are only able to produce modest results?  Though this intervention engages some promising forces of behavioral change, like peer-education, all together, this campaign is fundamentally flawed. The NCIPE intervention could benefit from a complete make-over, but this paper focuses on three major weaknesses that are the most likely sources of hindrance in this campaigns’ quest to put an end to college students’ abuse of prescription medication.  The triumph-averting culprits of the NCPIE’s Taking Action to Prevent & Address Prescription Drug Abuse are all embedded in this intervention’s persuasive message design.  The three flaws discussed here are that their messages are crafted using the reductive Health Belief Model, are designed in a way that is guaranteed to increase psychological reactance and are framed in a way that is not meaningful to the intervention’s target audience. 
This intervention will not be successful in augmenting the behaviors of college prescription drug abusers unless these deficiencies are addressed.  The final section of this paper offers an alternative intervention design for this issue.  It is designed to shore-up the communicative short-comings of the NCPIE’s Taking Action to Prevent & Address Prescription Drug Abuse intervention.

Part I: Three Main Failures of the NCPIE Prescription Drug Abuse Intervention
The Health Belief Model Irrationally Assume Rationality
Implicit to the NCPIE’s campaign is that the more information students receive about the dangers of prescription drug misuse, the less likely they are to engage in that behavior.  The underlying assumption in this approach is that, once educated, college students will tap into a rational cerebral process and use this new knowledge to make the decision to not consume prescription medication inappropriately when the opportunity arises.  This logic comes from the Health Belief Model (HBM), a proposed and widely favored framework for modeling human behavior in health-related situations.  Though it is a classic approach to Public Health Communications interventions, it is not known to produce consistently substantial, behavior-changing results.  
The Health Belief model is the Economist’s cost-benefit analysis theory of behavior applied to health decision-making. According to this model, an individual’s behavior is the result of weighing the pros and cons associated by a fundamental decision: to act or not act (Edberg, 2007).  The HBM assumes individuals privy to an intervention are isolated entities, subjected to a rational mind-frame as they take the steps to coming to the decision that will motivate their behavior.  The assumption that individuals are rational underlies the majority of scientific disciplines (Ariely, 2008).  The rational decision maker has the ability to engage in perfect reasoning when choosing between behaviors.  He will use the resources available to him at the moment of choice, to choose the path that will produce the greatest personal pay-off (Frank, 2002).  In the case of the HBM, the resources available to the rational decision maker are the perceived benefits and costs that precede an individual’s motivation to act.  Costs and benefits of the implied action are consider to be functions of the decision maker’s existing health beliefs, perceived susceptibility to an outcome implied by the action (or inaction) and the perceived severity of that outcome (Edberg, 2007).  Once this tension is resolved, the course of action whose benefits outweigh its costs informs the individual decision maker’s intention to act and the appropriate behavior is to follow.  
The designers of the NCPIE’s intervention believe the unhealthy behavior of college students who are abusing prescription medication will be changed if they are given information, mostly in the form of statistics and expert opinions, about the downside to their actions.  Given that this campaign uses the HBM to inform most of its communications strategy, the designers have predicted that the dissemination of potentially alarming information will be relevant to their target audience at the initiation of the thought process that leads to behavior.  This is the point at which, in the HBM, implied costs and benefits of abusing prescription medication are pitted against each other.  Actors under an HBM lens are rational and are motivated to maximize their utility or wellbeing.  Thus, the rational actor, now informed by the NCPIE’s messages of the potential dangers of prescription drug, will opt to minimize their personal costs and act in a way that maximizes their personal health benefits: they will say “no” to prescription drug misuse!
Despite its popularity, the Health Belief Model is considered by many behavioral psychologists to be too simplistic to be useful theoretical predictor of behavior (Ogden, 2003).  It is well documented that human behavior, despite the accepted Positivist paradigm in mainstream science, is most often irrational (Ariely, 2003, Tomas, 1995).  Studies have shown, and we know this by our own intuition and experience, that human behavior is motivated by a complex web of forces, regardless of their relevance to the specific act under decisional scrutiny.  Unlike the college students whose psyches are radically reduced in the NCPIE’s approach to changing their behavior, human beings are not isolated entities who are readily able to the tap into their relevant knowledge base about the health costs and benefits.  However, even if they, were, these are never the sole forces that seep into motivational reasoning for behavior (Ariely, 2003).  Individuals are subject to a whole host of factors: their environmental context, their personal history, their peers, emotions, desires, perceived social norms and more.  Put differently, “the focus of the (HBM) is the current subjective state of the individual, not one’s history or experience” (Thomas, 1995). 
The HBM explicitly ignores the irrational behavioral tendencies of individuals, particularly stressed out college students on their own for the first time with pressures, distractions and misconceptions thundering throughout their campuses.  The designers of this intervention have put a great deal of emphasis on the belief that once an individual college student is privy to the information in their kit, the costs of choosing to misuse prescription drugs will be more greatly perceived and will thus outweigh the benefits of following through with the unhealthy behavior.  Then gradually, equipped with more information, college students will rationally opt-out of behavior that they now see is more costly to them than beneficial.  To increase the likelihood of successfully changing the behavior favoring the abuse of prescription drugs on college campuses, the NCPIE will have to re-think putting so much stock in the predictive powers of the HBM.    

Don’t Use the Word “Don’t”: Psychological Reactance Theory
Key tools for behavioral modification offered in the NCPIE’s prescription drug abuse resource kit are message templates.  The templates propose language that the intervention designers believe is effective in getting their messages to resonate with their target audience. Different message templates are offered for different communication mediums.  The following is a selection of the message templates included in the Taking Action to Prevent & Address Prescription Drug Abuse kit:
Sample Campus Radio Public Service Announcement:
Using stimulants to “get in the zone” and focus is not only dangerous, experts say doing so won’t improve your grades over time.  But you will put your future at risk.  Your best bet for good grades?  Don’t procrastinate or skip sleep.

Sample Sponsorship Spot for an Athletic Game:

Planning on cutting loose during (the) big game? Don’t add prescription drug abuse to your party plans.

Sample Post for Display on a Social Networking Platform:
Peer pressure is real, but don’t give in to the temptation to fit in.
Overwhelmingly, the suggested design for crafting the messages of this campaign tells college students what not to do.  The linguistic choice used in the NCPIE’s communication design will induce psychological reactance. 
According to Psychological Reactance Theory, when people receive a message that they perceive as threatening to their behavioral freedom, they are psychologically triggered to behave in a way that restores that freedom (Deatrick, et al., 2007).   For instance: “Don’t screw up your life”, “Don’t add prescription drugs to your party plans”, “Don’t procrastinate or skip sleep”, preach to the message receiver how he or she should be.  This alienates them from their own ability to make choices about how they think they should be.  Messages that threaten the receiver’s freedom can result in the “boomerang” effect, or the provocation of the opposite behavior the messenger intends to promote (Silvia, 2005).  A prominent study examining the reaction of youth to pro and anti smoking messages showed that subjecting youth to “overtly persuasive” messages, the youth under study were less likely to conform to the behavior suggested in the directive.  Youth subjected to an explicitly anti-smoking message were more likely to smoke and youth subjected to an explicitly pro-smoking message were more likely to not smoke (Grandpre et. al., 2003).  Further, researchers who evaluated the effectiveness of Congress’ National Youth Anti-Drug Media Campaign that ran from 1998 and 2004 found that the effort was largely unsuccessful and attributed the increased drug-use amongst targeted youth in part to reactance (Hornik, 2008). 
Reactance is of particular concern in health campaigns aimed at youth in the midst of a transitional life stage (Detrick, et al., 2007).  What are the college years if not one giant transitional stage of teenagers emerging as young adults?  The persuasive messages included as linguistic templates the NCPIE prescription drug abuse prevention campaign are specifically intended for college students.  The use of directive language that very obviously impinges on students’ capacity for free self-determination (i.e. the consistent use of the word “don’t”) is problematic in light of this group’s tendency to reactance.  Significant documentation supports the behavioral predictions of Psychological Reactance Theory, suggesting that campaigns designed for social influence more effectively modify behavior using communication strategies that keep perceived freedom invasion to a minimum (Silvia, 317).   
It all Comes Down to the Frame
All persuasive language is shaped/motivated by an implicit frame (Tannen).  “A frame is a way of packaging and positioning an issue so that it conveys a certain meaning” (Menashe, et. al., 1998).  Framing an issue means to place value or significance on a particular aspect of the issue in a way that is definitional to that issue.  It is the packaging of certain aspects of an issue in a way that gives is meaning and defines what the issue truly represents.  The purpose of a frame in a communications strategy is to influence peoples’ decisions by appealing to their values and priorities.  Framing an issue in a particular way also implies a solution to that issue.  When two frames are pit against each other, the successful frame will be the one that is most in sync with the values and beliefs of those who the framers seek to persuade (Menashe, et. al., 1998). 
This campaign has misinterpreted the problem at the center of prescription drug misuse amongst college students.  Instead of determining what this population does want, or why this audience truly engages in these unhealthy behaviors, they have devoted their entire communications campaign to spreading the word about what they should not want.  Frame theory and a framing analysis will assist with demonstrating this point.The core values that anchor the frames of the NCPIE’s health promotion messages are health, science, safety and the law.  Using these values as their dominant frames, the designers communicate to their target audience that the problem that warrants intervention is that abusing prescription pills will compromise the futures of the abusers.  The implied solution of these frames is to offer facts about the dangers of this behavior and provide information on what “experts” suggest is appropriate behavior.
Prioritizing these frames will weaken the communication efforts of the NCPIE’s intervention.  Overemphasis on solving the problem of prescription drug abuse on college campuses with facts and figures ignores the very likely situation for the Optimistic Bias to exert its force.  This phenomenon describes the tendency for individuals to demonstrate unrealistic optimism in their predication of their future life occurrences (Weisntein, 1980).  This can translate into people making unhealthy choices in the moment even when they know the facts about downsides to their behavior.  Optimism is influenced depending on if the decision-maker is in a “hot”, or emotional, state or the “cold” state characteristic of the individual’s mind frame when not confronted with the decision (Ariely, 2008).  Let’s say a college student who is prone to abusing prescription drugs finds herself in a situation where she is overwhelmed with the pressures of school and she has the opportunity to use their roommate’s Adderall to pull off yet another all-nighter.  Now armed with the facts from the NCPIE campaign frames, how will she proceed?  If she is desperate (in a “hot” or emotional state), or simply used to misusing Adderall without any severe consequences (fuel for cognitive dissonance), her propensity to succumb to the optimistic bias is heightened.  Further, depending on the context in which the college student must make her decision to abuse or not abuse, she is likely to consider only the facts that support a more favorable or benign future health outcome should she indulge in the Adderall.  This is knows as “cognitive dissonance”.  It is most likely the case that college students will need to be confronted with more compellingly framed messages that resonate with their values before consistent behavioral augmentation is achieved. 
Intervening Prescription Drug Abuse Amongst College Students: A Different Approach
The NCPIE’s intervention attempts to change college student’s behavior through first changing their beliefs and attitudes.  This is an exceptionally hard feat!  Before we proceed any further, let’s consider the likely beliefs and attitudes held by youth who are prone to abusing prescription medication. 
The New York Times recently published an article about this issue.  The author requested that teenagers and college students’ for whom this article’s themes resonated with, write letter about their experiences with prescription drug abuse.
Two forces are at work here.  The first is that students who use prescription meds for ADHD inappropriately do so because the pressure of school and perceived expectations of their performance is overwhelming.  The second is that there is a misconception that it is the norm to abuse these kinds of medication.  Thus, a communications intervention that simultaneously targets the stresses of college and social norms is likely to be more effective in preventing the abuse of prescription drugs.
Interventions that directly target social norms are now considered to be one of the most effective methods of promoting healthy behavior using mass media (Cialdini, 1998).  Social norm targeting health promotion efforts are becoming increasingly popular of US college campuses.  For instance, a number of attempts at curving the drinking problem amongst the student population at Northern Illinois University flat out failed throughout the 1980s.  The school’s first campaign, in the same vein as the NCPIE’s approach, focused on alerting students to the dangers of drinking, warning them not to engage in risky behavior, or, put differently, using scare tactics to deter students from binge drinking.  This failed.  By the end of this rendition of the intervention, the binge-drinking rate was higher than it had initially been at the start of the campaign.  It wasn’t until the school radically shifted their approach from scaring students to simply making them aware of the typical behavior surrounding drinking at their college was.  In reality, typical social drinking consumption at Northern Illinois University was less than 5 drinks.  However, a student survey found that students who typically consume five or more drinks at a party assumed that the majority of students consumed the same amount in similar situations.  Once University prevention efforts went into debunking this misconception, the prevalence of binge drinking dropped from 45 to 38% in the campaign’s first year (Rosenberg, 2013).
The NCPIE intervention designers belabor the point in their media templates that “1 in 3 college students abuse prescription medication” and then produced to throw out more numbers on why that is problematic to the future health status of those students.  Presenting the statistic in this way highlights the abhorrent behavior.  To target social norms, the communications campaign should flip that around and push the message that 2 out of 3 college students are not abusing prescription medications. 
The intervention I propose uses media that are likely to be seen by college students, posters and social media pages, to set forth the message that prescription drug abuse is not the norm on their college campus.  A poster, which would be translated into a graphic that could be easily posted on social medial websites, would feature a single, high-definition image.  Imposed somewhere near the top, in bold lettering, would be a quick, biting message that targets norms.  This would be followed but smaller text towards the bottom suggesting how the message receiver could act post-interaction with the prevention material.  The images would reflect the frames that students perceived as important.  Information of this nature could be gathered inexpensively via a focus group of students or by doing a frame analysis on the positions given on relevant blogs or responses to online new stories, such as those given for the New York Times article. The language will be clear and the next step for the potential abuser receiving the message will be unambiguous, however overtly directive language will be avoided to get theses messages across.  Peer educators at a University’s health or wellness department could facilitate this intervention and messages could be tailored to promote appropriate services offered at the university.  For instance, stress was a common reason for sited by students in the New York Times article as a reason to abuse prescription stimulants.  A poster/post that address this factor could look like this:
A color photo of a student or group of students doing yoga
In block letters at the top of the image: “2 out of 3 students don’t abuse Adderall”
In smaller print at the bottom, the university-specific message that evokes a call to action: “If you’re stressed out with school, come check out our free yoga classes every Wednesday” 
A color image of a clock whose arms evoke imagery of a scale; on hand is a pill and the other is an agenda
In block letters at the top of the image: “2 out of 3 students don’t abuse Adderall”
In smaller print at the bottom, the university-specific message that evokes a call to action: “If you’re finding that there just aren’t enough hours in the day, why not make an appointment with a time-management specialist at the career center”
Why this Will Work
This communications intervention aimed at college students who are prone to prescription drug misuse will prove more effective than the NCPIE approach for three reasons: it uses frames the issue meaningfully to the target audience, it is designed to minimize reactance and it puts the control, it targets social norms
According to Menashe et. al.“message framing has been shown to influence…individual behavior”.  If the problem of drug misuse is presented to college students in a way that addresses the problem as they see it, compliance to the sought after behavior is more feasible.  Illustrating the problem as a function of college students not having enough scientific information to make the right decision or of the student’s laziness (“don’t procrastinate”) will not induce attitudinal nor behavioral change in the message receiver.  Framing the problem as a function of the rigorous, even unfair, demands on University is more in synch with how the target population views the problem.  This will increase the likelihood that the target college students are swayed by the persuasive language used in the intervention.
According to a study conducted by Dr. Paul Sylvia, reactance is minimized, in part, by interpersonal similarity and by avoiding threatening language.  This intervention will depict images of college-aged students or objects that college students are familiar with.  It is to be administered by peer health educators, which will further increase interpersonal similarity between messenger and message receiver.  Furthermore, the language used is direct, but open.  It avoids explicitly telling the target audience what to do (i.e. moving away from the freedom threatening “don’t screw up your life”) while offering a non-ambiguous course of action. Combined, these two elements will decrease reactance. 
Finally, because injurious behavior is often more apparent than healthy behavior, it can often be mistaken for the norm.  Studies have shown that targeting social norms in an intervention campaign can produce real results (Rosenburg, 2013).  The most prominent message used in the alternative innervation is that it is not the standard practice on college campuses to misuse prescription drugs.  Once the target population is aware that their behavior is abhorrent, their implicit tendency to conform to the group is more likely to come into effect.
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