REDUCING RISKY BEHAVIORS ASSOCIATED WITH 21ST BIRTHDAYSTHE PERSONALIZED BIRTHDAY REPORT (PBR)

Ellen Bass, Ph.D.Professor,College of Information Science and Technology College of Nursing and Health Professions Drexel University

Susie Bruce, M.Ed.Director, Gordie Center for Substance Abuse PreventionUniversity of Virginia

THANK YOU! Alcohol & Drug Abuse Prevention Team (ADAPT) peer educators Systems & Information Engineering Capstone Team University of Virginia colleagues & students

Reid Bailey, Ph.D. Kim Brantley, M.S. Sue Calhoun, M.E. Holly Foster, M.Ed. Erik Gunderson, M.D. Adrienne Keller, Ph.D. Sarah Keller, Gordie Center graduate assistant Doug Lee, Ph.D. Marisa Mutty, M.S. Frances Russell, ADAPT intern

Steve Clarke, Ph.D., Virginia Tech Dennis Martell, M.A., Michigan State University

2

FUNDING SOURCES

CELEBRATORY DRINKING “Holidays, campus or personal events in which a greater proportion

of students drink hazardously.” Hazardous or “binge” drinking is defined by the National Institutes

of Health (2004) as blood alcohol concentration (BAC) of 0.08 gram percent or above.

4

5

21ST BIRTHDAY CELEBRATIONS College students drink more during 21st birthday celebrations than at

other times (Lewis, Neighbors, Lee & Oster-Aaland, 2008; Lewis, Lindgren, Fossos, Neighbors & Oster-Aaland, 2009; Wechsler, Kuo & Lee, 1999)

Up to 90% of 21st birthday celebrants consume alcohol 61% reach BAC levels above the legal driving limit of .08 23% reach BAC levels above 0.25 (Neighbors, Lee, Lewis, Fossos & Walter, 2009).

Some students consume 21 drinks during 21st birthday celebrations (Hembroff, Atkin, Martell, McCue & Greenamyer, 2007

Brad McCue: died on 11-5-98 – his 21st birthday 21st birthday card program began at Michigan State and

expanded nationally U.S. Department of Education grant

Mailed card program begun in December 2000 Coordinated by ADAPT peer educators Funding from U.Va. Parents Committee Quantitative survey data collected monthly Focus groups

Mailed card program ended in May 2010 Up to 1/4 of cards returned as undeliverable Time and expense

PRIOR U.VA. 21ST BIRTHDAY INTERVENTIONS

6

U.VA. 21ST BIRTHDAY MAILED CARD RESULTS

Online survey sent to 2,380 students in the 2009-10 academic year. Timed to arrive in the month following their 21st birthdays.

Students reported drinking more during their 21st birthday celebrations than on a typical weekend night.

Men consumed more drinks, reached higher eBACs, and tended to experience more negative consequences.

Students who overestimated their peers’ 21st birthday drinking consumed more drinks and experienced more negative consequences than students whose perceptions were accurate or underestimates.

Students who received the card before their birthday tended to drink less and experience fewer negative consequences during their birthday compared to those who received the card late or not at all.

9

YOUTH-NEX GRANT FUNDING - AUGUST 2011THE PERSONALIZED BIRTHDAY REPORT (PBR)

Development phase 1: August 2011 - January 2012Implementation phase 1: January – May 2012Data analysis: May – August 2012Development phase 2: August – February 2013Implementation phase 2: current

10

10

ENHANCEMENTS TO 21ST BIRTHDAY CARD

3 key elements1. Electronic delivery2. Social norms approach3. Brief motivational enhancement

interventions

11

SOCIAL NORMS APPROACH Students OVER estimate unhealthy behaviors

Students UNDER estimate healthy behaviors

If you think everyone else behaves a certain way, it can influence your behaviors. (Berkowitz 1997; Guha, Bass & Bruce, 2007; Kypri & Langley 2003; Perkins 2002; Perkins & Wechsler 1996; Sher, Bartholow & Nanda, 2001; White et al., 2008).

When we correct misperceptions, healthy behaviors increase. (Haines 1996; Perkins, Linkenbach, Lewis & Neighbors, 2010; Turner, Perkins & Bauerle, 2008). 12

IF YOU PUSH…

people just naturally push back.

BRIEF MOTIVATIONAL ENHANCEMENT INTERVENTIONS (MI)

An NIAAA “Tier 1” strategy to effectively reduce college drinking and negative consequences

Provides tailored, normative feedback to affiliation groups or individuals (Baer et al., 2001; Baer et al., 1992; Borsari and Carey 2000; Dimeff et al., 1999; Marlatt et al., 1998; Murphy et al., 2001; O’Leary et al., 2002; Roberts et al., 2000)

Web-based, personalized feedback has been shown to be more effective in reducing estimated BAC compared to general or static information only (Neighbors et al., 2009).

May have more positive effects for the heaviest drinkers (Murphy et al., 2001).

Only two published studies on Web- or email delivered normative messages to address 21st birthday celebrations (Glassman et al., 2008; Neighbors et al., 2009), invariably integrated personalized feedback did not assess change in normative alcohol consumption perceptions limited by participation bias found mixed results on post-intervention alcohol consumption.

15

SPECIFIC AIMS FOR 21ST BIRTHDAY WEB-BASED INTERVENTION (PERSONALIZED BIRTHDAY REPORT)

Feedback will decrease the number of drinks consumed during 21st birthday celebrations.

Feedback will decrease estimated Blood Alcohol Content during 21st birthday celebrations.

Feedback will positively impact the accuracy of perceptions of average drink consumption during 21st birthday celebrations.

Feedback will increase the protective behaviors associated with drinking during 21st birthday celebrations.

Feedback will decrease the negative consequences associated with alcohol consumption during 21st birthday celebrations.

16

Personalized Birthday Report TimelineSummer 2011 Complete literature review of 21st birthday interventions

Fall 2011 Finalize data analysis of previous 21st birthday interventionsCreate campaign messages, theme and email scriptUse focus groups for feedback on ‘script’ and messagesRevise messages and script as needed

Spring 2012 Program/code online interventionUse focus groups for feedback on intervention presentation/designImplement interventionConduct intervention evaluationUse focus groups for feedback on intervention presentation/design

Summer 2012 Preliminary data analysisFall 2012 Revise campaign messages and feedback scripts

Prepare and submit manuscript for publicationSpring 2013 Program/code online intervention

Implement interventionConduct intervention evaluation 17

STUDY DESIGN Pre-birthday survey to PBR (feedback) and Plan-only (no

feedback) groups Plan-only survey on SurveyMonkey Custom survey for PBR group If birthday already passed, survey not administered

Post-birthday survey to Control, Plan-only & PBR groups All surveys on SurveyMonkey If person did not participate in the pre-birthday survey,

added to Control Group

18

PROCEDURE Invitations for pre-birthday surveys (PBR and Plan-only)

sent to email address 7 days prior to birthdate. No reminder emails

Invitations for post-birthday surveys sent to email address 7 days after birthdate. 1st reminder email 4 days after the initial invitation 2nd reminder email 4 days after the first reminder

Incentives Pre-birthday: Arch’s Frozen Yogurt coupon Post-birthday: 6 drawings for $100 bookstore gift certificate

19

Plan

Protective Behaviors

Perceptions

Quantity and perception

Student plan

PLANNED DRINKS AND PERCEPTIONS OF DRINKING

22

“You plan to have 8 drinks on your 21st birthday. On average, U.Va. women report

having 5 drinks on their 21st birthdays which is fewer than you thought.”

“You plan to have 8 drinks on your 21st birthday.”

Accurate perceptions or underestimate Overestimate

PROTECTIVE BEHAVIORS

Congratulations! You are significantly lowering your risk of alcohol-related problems by planning to use 4 protective strategies during your 21st birthday celebration. Among U.Va. women who drink, 91% report using at least 3 protective strategies.Here are some additional actions students use:

23

•Alternate alcoholic with non-alcoholic beverages•Ask a friend to let me know when I’ve had enough•Determine, in advance, not to exceed a set number of drinks•Eat before and/or during drinking•Keep track of how many drinks I’m having

List includes any protective behaviors not selected on the survey

Strategies to reduce risk

NEGATIVE CONSEQUENCES

24

The less U.Va. men drink during their 21st birthday celebration, the less likely they are to experience alcohol-related problems. You can reduce your risk by drinking 4 or fewer drinks on your 21st birthday

Avoiding alcohol related problems

POST-BIRTHDAY SURVEY

Negative Consequences

Benefits

INDEPENDENT VARIABLES Sex Intervention Group (Control, Plan-only, PBR/feedback) Fraternity/sorority affiliation (Greek or non-Greek; IFC or ISC) Perception Status

Underestimate: estimated 2 or more drinks fewer than the actual same-sex median

Accurate: within 1 drink of the actual same-sex median Overestimate: estimated 2 or more drinks greater than the actual

same-sex median Drinking Risk Level

Low (eBAC < 0.08) Moderate (0.08 ≤ eBAC ≤ 0.12) High (eBAC > 0.12)

27

DEPENDENT VARIABLESo Self-Reported 21st Birthday Drinks o 21st Birthday eBACo Perceived 21st Birthday Drinks (by same-sex)o Self-reported Protective Behaviorso Self-reported Negative Consequences

28

DATA ANALYSISAll analyses completed using R. ANOVA models include Sex, Greek Affiliation, and Intervention Group

and all interactions Also included Perception Status to analyze the number of drinks consumed Drinking Risk Level used in analysis of negative consequences

29

RESPONSE RATES

  Plan       Feedback      

Invited Valid Drinker Grk drinker Invited Valid Drinker Grk drinker

Female 137 91 85 40 164 91 86 45

Male 84 37 36 13 135 36 35 18

Total 221 128 121 53 299 127 121 63    57.9%  43.8%   42.5%  52.1%

PRE-BIRTHDAY

POST-BIRTHDAYPlan       Feedback      Invited Valid Drinker Grk drinker Invited Valid Drinker Grk drinker

91 63 59 22 91 61 57 2637 27 25 12 36 25 22 12

128 90 84 34 127 86 79 38  70.3%   40.5%   67.7%   48.1%

  Control   Control Total  Invited Valid (added back)Female 122 67 123Male 88 33 71Total 210 100 194

47.6%  

30

SELF-REPORTED 21ST BIRTHDAY DRINKING

Males drink more than females (F1,322 = 38.18, p < 0.001)

Greeks drink more than non-Greeks (F1,322 = 18.82, p < 0.001)

32

21ST BIRTHDAY EBAC

Greeks have higher eBAC (F1,322 = 12.73, p = 0.04)

Greek males in the feedback group have higher eBAC (p=0.033) • Not what we wanted

33

PERCEIVED 21ST BIRTHDAY DRINKS (BY SAME-SEX)

Intervention impacts perceptions of 21st birthday drink consumption (Males: F2,100 = 4.088, p = 0.02; Females: F2,222 = 5.417, p = 0.005 ).

Males in the Feedback Group had significantly lower perceptions of their same sex peers’ 21st birthday drink consumption than in the Control Group (p=0.03)

Females in the Feedback Group had significantly lower perceptions than those in the Plan-only group (p = 0.0218) and in the Control group (p = 0.006)

34

PERCEPTION STATUSMales

Post Pre Post Pre PostControl Plan Feedback

0%

20%

40%

60%

80%

100%

UnderOverAccurate

Post Pre Post Pre PostControl Plan Feedback

0%

20%

40%

60%

80%

100%

UnderOverAccurate

Females

No significant differences for feedback group between pre-birthday and post-birthday surveys

35

PERCEPTION STATUS AND 21ST BIRTHDAY DRINKING

Perception status has an effect on drinking (F1,322 = 20.88, p < 0.001)

Both males and females who overestimate drank significantly more than those with accurate or underestimated perceptions (p < 0.001).

36

SELF-REPORTED PROTECTIVE BEHAVIORS

Females use more protective behaviors than males (F1,323) = 17.73, p < 0.001).

The intervention has an effect on the number of protective behaviors (F2,323) = 3.595, p = 0.029). • Those in the Feedback Group used more protective behaviors than those in the Control

Group (p = 0.039).

37

SELF-REPORTED NEGATIVE CONSEQUENCES

Greeks self-report more negative consequences (F1,322 = 14.04, p < 0.001)

38

SELF-REPORTED NEGATIVE CONSEQUENCES (2)

Drinking risk level has an effect on negative consequences (F2,332 = 38.57, p < 0.001) 39

STUDENT PERCEPTIONS OF PERSONALIZED FEEDBACK REPORT Post-birthday follow-up survey. Overwhelming majority

agreed: "I learned new information“ "I appreciated receiving the personalized feedback" "I believe the birthday email program should be continued“

Focus groups conducted in May 2012 Students liked the personalized feedback component

Many said that was the entire reason they even took the survey. They liked that the emails and surveys came from the ADAPT

peer educators - a familiar resource No technological issues

40

PHASE 2 - ENHANCEMENTS Concern: Feedback did not impact Greek men as much

as other students Similar results seen in previous U.Va. Web-based normative

feedback program Response: Changed feedback from sex-specific to sex-

neutral Based on Bridget Bewick’s normative feedback research at

the University of Leeds Required revision of all feedback scripts Still provided sex-specific low-risk drinking guidelines, but

without mentioning the student’s sex Improved/enhanced email and survey appearance 41

      21st Birthday Survey

Email messa

ge

Enhanced standard drink

guide

Sex-neutral feedback - 2013

Female Feedback 2012

Male Feedback 2012

Changes in feedback for students who planned to drink 3 or 4 drinks and overestimated others’ drinking