Monday, May 20, 2013

Talk. They Hear You. Or Do They?: Analyzing the Public Health Approach To Underage Drinking –Kelly Mitchell


            Alcohol consumption among adolescents is a major public health problem in the United States. Despite the fact that alcohol consumption under the age of 21 is illegal, people age 12 to 20 years drink 11% of all alcohol consumed and account for 189,000 emergency room visits for conditions related to alcohol each year. (1) While the underage drinking rates have been steadily declining, the statistics still remain at an alarming level and continue to cause senseless injuries and even death among adolescents. Despite many efforts to reduce this behavior, the question of why adolescents choose to drink alcohol remains at the forefront of public health debates across the nation.
            In an effort to decrease the prevalence of underage drinking, the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Prevention (CSAP) recently launched its Underage Drinking Prevention National Media campaign entitled “Talk. They Hear You.” (2) This intervention aims to reduce underage drinking among youth by providing parents and caregivers with resources they need to understand the risk factors involved with alcohol and then address the issue with their children at an early age. Through increasing parents’ awareness of the prevalence and risks of underage drinking; equipping parents with the knowledge, skills, and confidence to prevent underage drinking; and increasing parents’ actions to prevent underage drinking, (2) the campaign aims to decrease the prevalence of alcohol use among adolescents. The foundation of this intervention is to educate parents about alcohol abuse among teenagers who will then use this knowledge to influence their children’s decisions about alcohol consumption in the future. (3)
Overview of the Critique
            The strength of the “Talk. They Hear You.” intervention is inadequate based on the social and behavioral theories and principles that contradict the components of the campaign. SAMHSA’s approach is flawed in several aspects and will likely be unsuccessful in reducing alcohol use among adolescents. First, the campaign does not take into account the fact that social and environmental factors highly influence the behavior of adolescents according to the Social Cognitive Theory. Since teenagers spend the majority of their time in school with their peers, social influence will play a higher role than parents when it comes to decision-making. Additionally, the effects of psychological reactance will cause adolescents to feel robbed of their autonomy and will therefore counteract the intervention. They will feel the urge to rebel against their parents by doing the exact opposite of what is asked of them. The final flaw is that the intervention incorrectly utilizes the traditional Health Belief Model by assuming that adolescents will rationally weigh the cost and benefits of alcohol consumption even if fully explained by their parents. Furthermore, the campaign falsely assumes that the parents themselves will think rationally about the issue and fully understand the risks of alcohol consumption. 
Flaw #1: The Impact of Social Learning and Modeling on Adolescents

            The main focus of the “Talk. They Hear You.” campaign is to target parents and caregivers by offering the necessary educational tools and resources to enable parents to confidently talk to their children about alcohol. Parents will then present this knowledge by speaking to their children about the risks of alcohol use. One of the main goals of the intervention is “to reinforce the importance of talking with children about the dangers of alcohol use.” (4) This value of the intervention does not take into consideration the fact that their children’s environment, social scene, and media exposure significantly influence their ability to make reasonable decisions. Children and adolescents are swayed by these factors for various reasons; in fact, most studies have shown that many teenagers report using alcohol because all of the “cool” kids drink. (5) This perception of “cool” is not something that parents can change since it is rooted in the social and environmental components of an adolescents’ life. The intervention overlooks the vital impact of social models on the fragile adolescent lifestyle—which does not always include parents and guardians in the mind of an adolescent.
            This parental approach to teaching children about the dangers of alcohol use aims at the individual for a change in behavior. According to the Social Learning Theory, individual behavior is part of a triangle—an interaction between an individual, their behaviors, and the environment. (6) The social and environmental factors that influence teenager’s behavior are so strong that parental intervention is often unsuccessful in overruling this notion. In fact, studies have hypothesized that alcohol use behaviors are largely the result of cognitive processes through which people anticipate the consequences associated with their actions and act accordingly, consistent with the social learning approach. (7) In other words, one’s personal beliefs about drinking are at the forefront of their decisions, and those values stem from examples of others’ behavior. It only makes sense that these examples must include people that teenagers respect and admire.
The concept of “observational learning” or “modeling” complements this idea as it refers to the “process whereby people learn through the experiences of credible others, rather than through their own experience.” (8) This supports the notion that adolescents learn a specific behavior by following a model. The “Talk. They Listen.” campaign uses parents as models, which might work in some cases. However, since most adolescents look to their peers as models for behavior, this campaign lacks credibility. Therefore, when creating a campaign targeting adolescent behavior, it is imperative to take into account the impact of social models and ensure that the models themselves are chosen wisely.
Flaw #2: The Effects of Psychological Reactance

While the idea to talk to children about alcohol before they reach their teenage years is well intentioned and may have some benefits, by the time children become adolescents they reach a point in which their independence and autonomy are of the highest importance to them. Adolescents do not want to be told how to live their life; they want to have experiences and learn from those experiences on their own merit. Parental influence on their teenager’s decision to drink alcohol will likely threaten their individual freedom and trigger psychological reactance. The psychological reactance theory poses that if a person’s behavioral freedom is reduced, he or she will become motivationally aroused to counterforce this loss of freedom. (9)
An applicable example of this theory is an experiment involving 2-year-olds who are placed in a room with several toys. Beside the toys set up for the children to play with, there are additional toys behind a barrier that the children cannot reach. As the theory implies, the children are inclined to play with the unattainable toys—theoretically, because it is out of their control. This experiment exemplifies the concept that it is natural for people want to be in control of their own choices and behavior. As a result, people will often purposely choose to oppose a particular force, rule, or intervention in an attempt to restore their limited freedom.
Another one of the goals of the “Talk. They Hear You” campaign states “to inform parents to start the conversation early—before they are teenagers.” (4) The problem with this method is that when a child enters their teenage years, the effects of psychological reactance will inevitably come into play and directly threaten the teenager’s freedom. In essence, a boomerang effect will occur when teenagers are told not to drink by their parents, and the information they were given as children will become irrelevant when the forces of psychological reactance come into effect. Whether they were told as children how to make decisions, adolescents thrive on testing their parents and bending the rules by maintaining their own sense of self and making their own choices. This inevitable attitude among adolescents will not bode well with this intervention because they will want to make decisions on their own when it comes to alcohol.
Flaw #3: Challenging the Health Belief Model
            The Health Belief Model has been the traditional foundation for public health interventions since the 1950’s and one of the first theories of health behavior. Social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephel Kegels based the mechanism on the understanding that people weigh the scale of perceived benefits of practicing a behavior versus the opposing costs. (10) According to the model, there are six main constructs that influence people’s decisions about whether to take action: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy. (9) While these elements can often be useful in exploring individual behavior, the assumption that individuals rationally evaluate the costs and benefits of a situation is a major flaw of the Health Belief Model as it directing ignores elements of external and social influence. (10) Additionally, the model fails to recognize that there are major disparities in knowledge among individuals. Individuals hold varying levels of understanding which makes it difficult to fully perceive the susceptibility and severity of a threat, recognize the benefits of avoiding that threat, and then make a rational decision to act. This model fails to consider that many individuals are unable to see reality clearly and understand these factors because they do not always have the capacity.   
            With regard to the “Talk. They Hear You.” Campaign, the flaw of the Health Belief Model is two-fold. First, the intervention makes the false assumption that children and adolescents will rationally decide to take their parents’ advice and abide by their rules. The underlying truth is that adolescents have a skewed perception of right and wrong because of social and environmental factors that influence their decision-making skills. They may remember conversations with their parents when they were children regarding alcohol, but they may not take this information into consideration as an adolescent when faced with a decision. Secondly, it is naïve to assume that the parents and caregivers themselves will receive the message of the campaign, have the full capacity to understand the resources, and convey that message to their children. Another weakness in the campaign is that it essentially takes an extra step in reaching the adolescent by connecting the parent directly and the adolescent indirectly. Further, this information might not even resonate with some folks who do not think rationally about alcohol consumption among teenagers. 
The idea of optimistic bias is another major flaw of the campaign among both parents and their children. Optimistic bias stems from the idea that people tend to assume that their susceptibility to an outcome is lower than others, and generally expect positive events to occur in their futures. Alternatively, while individuals underestimate the risk and probability of negative outcomes in their own lives, they often believe that the general population is at a higher risk than themselves. Unfortunately for the “Talk. They Hear You.” campaign, optimistic bias opposes the main function of the intervention. If parents do not believe that their child will develop a drinking habit, then they will not utilize the resources within the intervention or even pay attention to the message conveyed. Parents might presume that the campaign is a great idea for the general population, but if every parent thinks that their child does not need an intervention, then the campaign will not be successful.  
Proposed Alternative Intervention

            An alternative intervention can be implemented in order to decrease the prevalence of underage drinking on a national level that promotes independence and freedom rather than parental influence. With that in mind, the new intervention plan will involve a nation-wide initiative that establishes a “peer mentor committee” at every public high school. The committee will be called “#DrugFreeStandUp” and each high school will have its own subcommittee title. For example, the committee at Brighton High School will be called “#BHSStandUp” and a private school like Christian Brothers Academy that might decide to join could be called “#CBAStandUp”. This committee will consist of three boys and three girls in each grade level at the high school, totaling 24 students. These students will commit to a drug and alcohol free lifestyle and will serve as peer mentors to the rest of the student body. The peer mentors will be elected by their classmates each year, so they will be well-respected and have a strong influence on the behavior of their peers.
            To add to the credibility of this intervention among high school students, the nation-wide committee will be endorsed by two popular young celebrities—a male and a female—who will also commit to living a healthy lifestyle and serve as the faces of the committee. This group will not only surround students with healthy choices within their social network, it will give them the illusion of control over their lives and lead to safe choices with regard to alcohol.
Intervention #1: Recognition of the Group as a Whole Versus the Individual

            The “Talk. They Hear You.” campaign failed to utilize the Social Learning Theory because parents were assigned as the main models for teen behavior. #DrugFreeStandUp will properly apply the Social Network Theory—the idea that networks of close family and friends highly influence values and behavior—by assigning peers as models. Social network analysis, which is a set of theories, methods, and techniques used to understand social relationships and how these relationships might influence individual and group behavior (11), has proven that individual substance use and misuse is strongly associated with, and perhaps influenced by, use within one’s social network. (11)
            Based on this theory, the new intervention will have a significant impact on the behavior of students. The nationwide attention that #DrugFreeStandUp will receive whether through the celebrities that endorse it or through word of mouth will encourage adolescents to want to mimic the lifestyles of their peer leaders who will lead by example. This group will represent the new “popular” thing to do, and members will take pride in being elected to a group that is competitive and prestigious in nature. Adolescents crave a sense of belonging in a time that can be physically, emotionally, mentally, and psychologically confusing. It is important that they feel this sense of comfort in their every day lifestyle which begins at school. By promoting their own alcohol-free standpoint, the peer mentors will eliminate any fear of not fitting in among students who choose not to drink.
An intervention that simply encourages parents to speak to their children about alcohol is just not enough. #DrugFreeStandUp will move beyond the traditional Social Learning Theory and aim toward a group level approach. When “mob mentality” occurs, the behavior of a large group cannot be justified by individual decision-making. In other words, an intervention must target the group as a whole in order to make a difference rather than on an individual level. (12) The new intervention will ensure that masses of adolescents are reached at every high school in the nation. This is particularly more effective than focusing on the individual through a parent. The “Talk. They Hear You.” campaign misses a significant factor in the influence of the adolescent lifestyle—social norms and networks. #DrugFreeStandUp will be sure to address these crucial factors.
Intervention #2: Emphasis on the Illusion of Control

            Incorporating the illusion of control to this new intervention will give adolescents the sense of freedom that they are making decisions on their own. According to the illusion of control theory, people overestimate their ability to control events. Through #DrugFreeStandUp, students will be socially drawn to a group that happens to make good decisions with regard to alcohol consumption. In the students’ minds, they are choosing to do the right thing on their own. This is an illusion because in fact, the peer mentor committee is inadvertently influencing the behavior of the students that respect and admire the group.
            The illusion of control aspect of the new intervention is a direct improvement upon the effects of psychological reactance in the “Talk. They Hear You.” campaign. Rather than imposing rules upon adolescents, the new intervention gives them the perception that they invented the rule. This illusion of control avoids the rebellion that often occurs as a result of psychological reactance and translates to voluntary healthy behavior and choices.
Intervention #3: A Focus on the “Big Picture”

            The “Talk. They Hear You.” campaign provides valuable material to parents that include the most up to date studies and statistics on underage drinking. As explored earlier, the Health Belief Model falsely assumes that parents will rationally absorb these statistics and educate their children based on facts. #DrugFreeStandUp will be more effective because it takes into account the fact that presenting statistics is not always effective. The law of small numbers and optimistic bias are well-known theories that work to design effective interventions in addressing human irrationality. The law of small numbers states that humans struggle with probability and have a distorted perspective on statistics. Since there is a misconception with regard to risk, it is difficult for people to relate to numbers and therefore are not influenced by statistics. Essentially, “Talk. They Hear You” will not be effective because parents will often be misled by the statistics provided to them and will therefore not convey the “big picture” to their children.
People are more inclined to behave a certain way through single examples and personal stories rather than raw numbers sway their decision. The new intervention will certainly provide opportunities to share real stories about fun ways to avoid situations with alcohol which will be much more effective than reciting data. Through monthly retreats, alcohol-free social events, and community service activities, students will have the opportunity to share personal stories of obstacles they have faced with regard to alcohol and other issues in order to experience first hand the alternative ways to have fun with their peers.

            The “Talk. They Hear You.” campaign fails to meet the social and behavioral theories and concepts that consistently drive the way people think about issues and act on them. While it is certainly important for parents to talk to their children about alcohol and create an open environment at home, the intervention will not solve the serious alcohol issue among adolescents as a whole. Since each flaw in the old intervention has been addressed by theories of social and behavioral science, there is room for success in the near future for adolescents through #DrugFreeStandUp. The new intervention focuses on viewing adolescents as a group rather than as individuals, provides an illusion of control, and allows for the adolescent to see the big picture—concepts that are vital to changing behavior. The core value of freedom is now prevalent as the individual will make their own decisions based on personal stories from their peers and support from leaders in their community.

1) Centers for Disease Control and Prevention. Fact Sheets – Underage Drinking. Atlanta, GA: Centers for Disease Control and Prevention.
2) Greenburg, M., Spoth, R., and Turrisi, R. Preventive Interventions Addressing Underage Drinking: State of the Evidence and Steps Toward Public Health Impact. Journal of the American Academy of Pediatrics. 2008; 121:311-336.
3) Nash, S.G., McQueen, A., and Bray, J.H. Pathways to Adolescent Alcohol Use: Family Environment, Peer Influence, and Parental Expectations. Journal of Adolescent Health. 2005; 37(1): 19–28.
4) Substance Abuse and Mental Health Services Administration. Sample “Talk. They Hear You.” Materials. Rockville, MD: Substance Abuse and Mental Health Services Administration.
5) Klein, J., Schoen, C., and Simantov, E. Health-Compromising Behaviors: Why Do Adolescents Smoke or Drink? JAMA Pediatrics. 2000; 154(10):1025-1033.
6) Siegel, Michael. “Traditional Health Behavior Models.” SB721. Boston University, Boston. 21 Feb. 2013. Lecture.
7) Grube, J., Paschall, M., and Lipperman-Kreda, S. Community Norms, Enforcement Of Minimum Legal Drinking Age Laws, Personal Beliefs And Underage Drinking: An Explanatory Model. NIH Public Access. 2010: 35(3): 249–257.
8) National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute. Part 2. 2005; 13-21.
9) Allen, D., Sprenkle, D., and Vitale, P. Reactance Theory and Alcohol Consumption Laws: Further Confirmation Among Collegiate Alcohol Consumers. Journal of Studies On Alcohol. 1994; 55: 34-40.
10) Edberg, M. Individual Health Behavior Theories. (pp. 35-49). Essential of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
11) Gallagher, P., Mouttapa, M., and Valente, T. Using Social Networks to Understand and Prevent Substance Use: A Transdisciplinary Perspective. Substance Use & Misuse. 2004; 39 (10-12): 1685-1712.
12) Siegel, Michael. “Alternative Models.” SB721. Boston University, Boston. 7 Feb 2013. Lecture.

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