The Comparative Effectiveness of Group and Individual Brief Alcohol Screening and Intervention for College Students (BASICS) Suzanne Zeman, M. S. , R. N. The Pennsylvania State University Health Services John Hustad, Ph. D. Penn State University - College of Medicine Milton S. Hershey Medical Center Linda La. Salle, Ph. D. Rachel Urwin, Ph. D. The Pennsylvania State University Health Services
Outline Brief background on alcohol use by college students nationally and at Penn State Summarize empirically supported techniques for college students Discuss the BASICS program at Penn State Outcome data Summarize our findings Future directions
Objectives Describe the components of group and individual BASICS Identify key behavior outcomes that are relevant to assessing the efficacy of group and individual BASICS Discuss the differences in effectiveness between group and individual delivery mode of BASICS Discuss the implications for college health professionals and campus administrators
Background • Alcohol use is the greatest single contributor to college student morbidity and mortality (e. g. , Hingson et al. , 2009). • Individual (one-on-one) motivational interviewing (MI) is efficacious (e. g. , NIAAA, 2004). • Group-delivered MI has limited evidence of efficacy (La. Chance et al. , 2009) and can be delivered at a lower cost than one-on-one interventions. • Group-delivered MI has yet to be compared to a one-onone MI for alcohol use.
Alcohol Use by College Students 59. 8% of college students reported using alcohol in the last 3 o days according to the ACHA-NCHA Fall 2010 assessment
Snapshot of Annual High-Risk College Drinking Consequences Death: 1, 825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor vehicle crashes. Injury: 599, 000 students between the ages of 18 and 24 are unintentionally injured under the influence of alcohol. Assault: 696, 000 students between the ages of 18 and 24 are assaulted by another student who has been drinking. Sexual Abuse: 97, 000 students between the ages of 18 and 24 are victims of alcohol-related sexual assault or date rape. Source: Hingson et al. , 2009
Consequences Continued Academic Problems: About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall (Engs et al. , 1996; Presley et al. , 1996 a, 1996 b; Wechsler et al. , 2002). Health Problems/Suicide Attempts: More than 150, 000 students develop an alcohol-related health problem (Hingson et al. , 2002), and between 1. 2 and 1. 5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use (Presley et al. , 1998).
Alcohol Abuse and Dependence In the past 12 months, according to questionnaire based self-reports about their drinking: 31 percent of college students met criteria for a diagnosis of alcohol abuse 6 percent of college students met criteria for a diagnosis of alcohol dependence Source: Knight et al. , 2002
Penn State Student Drinking Data From the Student Affairs Research and Assessment, PULSE Student Drinking Report 2011
High Risk Drinking at Penn State Pulse Student Drinking 2011 Data: 47. 5 % of students are high-risk drinkers 18. 6% of students are frequent high risk drinkers Male high risk drinking 52. 6% of high risk drinkers were male Female high risk drinking 42. 5% of high risk drinkers were female Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Alcohol Related Consequences Within the past 12 months as a consequence of drinking… Alcohol Related Consequence ACHANCHA Fall 2010 Data Penn State Pulse Student Drinking Report 2011 Did something they later regretted 32. 4% 29. 8% Forgot where they were/what they did 29. 7% 43% Physically injured themselves 15. 1% 12. 3% Source: American College Health Association, 2010 Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Nightly Self Reported Alcohol Use During a Typical Week-Penn State 2011 Variable Wednesday Thursday Friday Saturday % of Students Drinking 14% 40% 70% 69% Average # Drinks 0. 42 1. 69 3. 86 3. 95 Average # Hours Drinking 0. 32 1. 21 2. 75 2. 81 Average BAC 0. 042 0. 064 0. 083 0. 085 Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Drinks Consumed/Hour During Peak Drinking by Penn State Students Number of Drinks >0 to ≤ 1 drinks % of Students 21% >1 to ≤ 2 drinks 43% > 2 to ≤ 3 drinks 22% > 3 drinks 14% Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Self Reported Alcohol Consequences Direct Consequences: Physical % of Students Had a hangover/headache the morning after drinking 60. 5% Felt sick to your stomach or thrown up 45. 1% Been unable to remember a part of the previous evening 43. 1% Been hurt or injured 12. 3% Gotten into a physical fight 5. 8% Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Self Reported Alcohol Consequences Direct Consequences: Academic Missed class % of Students 25. 2% Gotten behind in schoolwork 22% Had difficulty concentrating in class 9. 8% Performed poorly on an assignment or test 2. 6% Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
Self Reported Alcohol Consequences Direct Consequences: Interpersonal % of Students Done something you later regretted 29. 8% Become rude, obnoxious or insulting 28. 5% Felt guilty about your drinking 22. 8% Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011
The NIAAA Report on College Drinking What Colleges Need to Know Now An Update on College Drinking Research. (2007) www. collegedrinkingprevention. gov
4 Tiers of Effectiveness Task Force members placed prevention strategies in descending tiers on the basis on the evidence available to support or refute them. Tier 1: Evidence of effectiveness among college students. BASICS fits here which is why we are using it at Penn State in University Health Services. Tier 2: Evidence of success with general populations that could be applied to college environments. Tier 3: Evidence of logical and theoretical promise, but require more comprehensive evaluation. Tier 4: Evidence of ineffectiveness. Source: “A Call to Action: Changing the Culture of Drinking at U. S. Colleges, ” NIAAA Task Force.
Nationally Recognized Program National Institutes of Health One of the most promising interventions for college students regarding alcohol use Substance Abuse and Mental Health Services Administration (SAMHSA) Model Program BASICS is a tier 1 strategy which is why we are using it at Penn State in University Health Services (Source: http: //www. samhsa. gov )
BASICS Implementation at Penn State Alcohol intervention programs have been offered at UHS since the mid -1980’s; components of BASICS have been used ~5 years now (AIP I & II and PAUSE Blue & White) Expansion of BASICS has been a collaborative SA effort between UHS, Judicial Affairs, Residence Life, CAPS and the VP of SA 5 FT health educators were hired to facilitate the program in addition to a PT graduate assistant 1 new FT Addiction Specialist was also hired in CAPS to facilitate referrals from BASICS Dr. John Hustad was hired to do a comprehensive evaluation of the BASICS program National experts on BASICS and Motivational Interviewing were brought in to do staff training
Policy Changes Affecting Referral to BASICS Effective fall 2010: all students who have a first time alcohol violation (underage possession or use, DUI, public drunkenness, supplying to minors, party host, etc. ) that occurs on or off campus have a mandated referral to BASICS all students who go to Mt. Nittany Medical Center (local hospital) or alcohol-related treatment have a mandated referral to BASICS students complete 2 or 4 mandated sessions based on their screenings and experiences with alcohol program fee is $200 We’ve seen ~ 1500 students so far in BASICS since August 2011
Referral Sources Judicial Affairs Residence Life Emergency Department (Mt. Nittany Medical Center) Types of policy or legal violations: Underage drinking/ underage possession or use DUI Public Drunkenness/ excessive consumption Alcohol-related emergency department treatment Furnishing to minors
BASICS Components Assessment Session Structured Interview Self-Monitoring of Drinking Self-Report questionnaire Feedback Session Individualized feedback report (PNF sheet) Referral
Traditional BASICS Delivery Every student spent two 1 hour individual sessions with a health educator Students that screened ≥ 16 on the AUDIT (with an alcohol policy/legal violation) were also mandated to two 1 hour sessions with a clinician in CAPS Students participating in the research had their feedback session audio recorded Non-mandatory referrals were also made for students screening for symptoms of anxiety or depression Satisfaction surveys were also conducted at the end of the second session
BASICS Session One: Assessment Confidentiality Discuss student’s referral event Review standard drinks Explain monitoring activity Screen for anxiety, depression and alcohol dependence Complete a comprehensive computer assessment (typical drinking patterns, negative consequences, perceptions of alcohol use, risk behaviors, etc. ) Refer students to CAPS for anxiety and depression (if applicable) 1 -2 weeks between session one and session two
Anxiety Screening The Overall Anxiety Screening and Impairment Scale (OASIS) is used to screen for anxiety A student scoring ≥ 8 on the screening is given a non-mandatory referral to CAPS for further evaluation
Depression Screening The Patient Health Questionnaire-9 (PHQ-9) is used to screen for depression Any student who screens positive for question #9 (self harm, suicidal ideation) has a phone crisis consultation with a CAPS clinician to determine appropriate course of action Any student who scores ≥ 10 is given a non-mandatory referral to CAPS for further evaluation
Alcohol Abuse Screening The Alcohol Use Disorders Identification Test (AUDIT) from the World Health Organization is used to screen for alcohol abuse Any student who scores a ≥ 16 with an alcohol violation is mandated to two additional sessions in CAPS with one of the Addiction Specialists Any student who scores a ≥ 16 who went to the ED but didn’t have an alcohol violation is given a non-mandatory referral to CAPS for two additional sessions
BASICS Session Two: Feedback Personalized normative feedback (PNF) sheets are given to students based on the computerized assessment they completed Health educators review the PNF sheets with the students and use motivational interviewing techniques to assist with behavior change BAC cards and alcohol poisoning cards are given out Change/action plans are completed (if applicable) Referral to CAPS made for students with AUDIT scores ≥ 16 (if alcohol violation) Satisfaction survey
Sample PNF sheet for an Actual Student
BASICS 3 and 4 Extended BASICS (sessions 3 and 4) occurs in CAPS with the Addiction Specialists BASICS 3 is an intake consultation BASICS 4 is tailored to the student needs
Follow-up Assessment All BASICS participants are required to complete a 1 month follow-up assessment as part of their sanction requirement Research participants were asked to complete additional follow ups
Key Behavior Outcomes Relevant to Assessing the Efficacy of Group and Individual BASICS
Behavior Outcomes of BASICS Decreased typical BAC Decreased peak BAC Decreased negative consequences associated with alcohol Increased use of protective behaviors while drinking
Research Background High risk drinking among college students is well documented (Hingson, 2005; Johnson, et. al. , 2008; Nelson, et. al. , 2009) There is strong empirical evidence supporting the efficacy of oneon-one delivery of BASICS (Larimer, et. al. , 2007) Recent research suggests that group delivered BASICS is promising and cost-effective (La. Chance, 2009). To date, no research has been conducted comparing the efficacy of group delivered BASICS to individually delivered BASICS.
Hypothesis We hypothesized that participants who received individual MI would report drinking at lower levels on a peak drinking occasion and experience reduced levels of alcohol-related problems at follow-up compared to the group MI condition.
Methods -Procedures • Participants were recruited from a sample of college students (N = 547) who were mandated to receive an alcohol intervention following an alcohol-related offense (e. g. , underage drinking, arrested for driving, emergency department visit, driving under the influence) during the fall semester of the 2010 -2011 academic year • Eligibility criteria: Alcohol Use Disorder Identification Test (AUDIT) score <16, no suicidal ideation, and an undergraduate student between 18 and 22 years old
Study Procedure and Design A= Assessment R= Randomization BMI= Brief Motivational Intervention BMI A R Group BMI Excluded High Risk Students Follow up Assessment at 1, 3, 6 Months
BASICS Components-Group Condition Individual Group Assessment Session Individual BMI 2 nd Session Group BMI 2 nd Session
Group BASICS Condition Session 1 of BASICS was done individually with a health educator Session 2 was conducted in a group setting Group characteristics: 2 -7 students per group Facilitated by a health educator A mixing board was used for recording and all participants had individual microphones for the group sessions All group participants scored < 16 on the AUDIT and did not endorse suicidal ideation on the PHQ-9, question #9
BASICS Components-Group Condition Assessment Session Feedback Session Individual Group Structured Interview Self-Monitoring of Drinking Self-Report questionnaire Individualized feedback report (PNF sheet)
Method Participants and Setting Students who were mandated to receive an intervention. Incentives: $15 gift card for the 30 day follow up survey $20 gift card for the 3 month follow up survey $25 gift card for the 6 month follow up survey Participation in this study fulfilled the campus requirement
Method Demographics Alcohol use (Past month): Typical Drinks and amount of time spent drinking Peak Drinks and amount of time spent drinking Estimated average and peak blood alcohol concentration (e. g. , Hustad & Carey, 2005) Alcohol-related consequences: Young Adult Consequences Questionnaire (YAACQ; Read et al. , 2006; Kahler, Hustad et al. , 2008)
Participant Flow
Sample Characteristics Participants randomized to receive group-delivered BASICS were more likely to be male than participants in the individual BASICS condition There were no other significant differences between the two conditions according to key demographic and baseline characteristics.
Sample Characteristics Variable # Percentage Male 189 69% Female 93 33% Mean= 19. 04 (SD=1. 21) - White 229 81% Asian 15 5% Black/African American 10 4% Hispanic 11 4% Other 27 10% Gender: Age Race:
Sample Characteristics Variable % On-campus 64% Off-campus 29% With parents 0. 7% Fraternity house 3. 2% Sorority floor 1. 42% Residence: Other 1%
Raw Means of Key Outcome Variables Across Assessments Variable Individual (N=133) Group (N=147) Gender: p Value 0. 05 % male 72. 30 61. 19 - % female 27. 70 38. 81 - Ethnicity (% White) 88. 72 82. 31 0. 13 Year (% Freshman) 52. 63 50. 34 0. 92 Residence (% on campus) 64. 66 63. 27 0. 78 Greek status (% non-Greek) 81. 95 80. 27 0. 84
Raw Means of Key Outcome Variables Across Assessments for Participants Variable Individual (N=133) Group (N=147) p Value Age 18. 98 19. 11 0. 39 Drinks/week 11. 14 11. 27 0. 91 Drinks/ drinking day 5. 10 5. 04 0. 85 Heavy drinking frequency 1. 24 1. 18 0. 78 Typical BAC 0. 08 0. 93 Peak BAC 0. 14 0. 13 0. 57 YAACQ total 6. 29 5. 55 0. 23
Participant Self Reported Alcohol Related Consequences I have had a blackout after drinking heavily I often drank more than I originally had planned I often have thought about needing to cut down or to stop drinking I have woken up in an unexpected place after heavy drinking No Yes I have felt badly about myself because of my drinking I have passed out from my drinking I have felt guilty about my drinking 0 50 100 150 200 250 300
Participant Self Reported Alcohol Related Consequences Gotten in trouble with police I have gotten into trouble at work or school because of drinking While drinking, I have said or done embarassing things I have said things while drinking that I later regretted No I have had a hangover (headache, sick to the stomach) the morning after drinking Yes I've not been able to remember large stretches of time while drinking I have felt very sick to my stomach or thrown up after drinking I have taken foolish risks when I have been drinking 0 50 100 150 200 250
Self Reported Referral Source Judicial Affairs Residence Life Emergency Department District Magistrate Other
Measures Demographics: Gender and weight (in pounds) Alcohol Use Disorder Identification (AUDIT; Saunders et al. , 1993) was used to screen students for alcohol dependence Alcohol use (past month): Self-reported number of peak drinks and amount of time spent drinking. These variables were used to estimate peak blood alcohol concentration (e. BAC) (e. g. , Hustad & Carey, 2005) Alcohol-related consequences (past month): Young Adult Consequences Questionnaire (YAACQ; Read et al. , 2006; Kahler et al. , 2008)
Analysis Plan Investigated differences by group over time using General estimating equations (GEE) Investigated whether gender moderated the effect of the intervention
Primary Outcomes
Baseline Characteristics • Conditions were not statistically different on key demographics and variables • Evaluate differences by group over time using two separate general estimating equations (GEE) models for (1) peak e. BAC and (2) alcohol-related consequences after controlling for gender
Primary Outcomes • The effect for time was significant for peak e. BAC (z = -2. 07, p =. 04) and alcohol-related consequences (z = -2. 79, p =. 005) • There was a main effect for gender where female participants had significantly higher peak e. BACs than male participants (z = 4. 86, p <. 001) • The main effect for gender was not statistically significant for alcohol-related consequences (z = 0. 57, p =. 57) • The condition X time interaction was not statistically significant
Results: Estimated Typical Blood Alcohol Concentration (BAC) 0. 09 0. 08 0. 0780000002 0. 0730000001 0. 0650000001 Mean 0. 0600000001 0. 05 0. 063 0. 0580000001 0. 04 0. 03 0. 02 0. 01 0 Baseline 30 Day Follow up Individual Group 3 Month Follow up
Results: Estimated Peak Blood Alcohol Concentration (BAC) 0. 16 0. 14 0. 12 0. 140 0. 131 0. 101 Mean 0. 1 0. 08 0. 096 0. 095 0. 06 0. 04 0. 02 0 Baseline Individual 30 Day Follow up. Group 3 Month Follow up
Results: Alcohol Problems 7 6. 3 6 Mean 5 5. 6 4. 7 4. 3 4 4 3 3. 1 2 1 0 Baseline Individual 30 Day Follow up Group 3 Month Follow up
Results: Number of Safer Drinking Strategies 60 50 47. 932 47. 007 40 Mean 34. 283 30 33. 027 Individual 28. 38 Group 25. 376 20 10 0 Baseline 30 Day Follow up 3 Month Follow up
Discussion • Participants decreased their alcohol use and associated harms after they received a MI • Group MI was not statistically different than individual MI
Summary of Main Study Outcomes Both Groups demonstrated decreases on key outcome variables No differences between the group versus individual conditions No gender by intervention effects Group motivational interviewing appears to be a cost effective method Participants decreased their alcohol use and related harms after BASICS Despite the lack of a control group, the magnitude of these reductions are similar to similar studies (e. g. , Carey, et. al. , 2006)
Limitations • Results may not generalize to non-mandated students • Lack of an assessment-only control group • Fidelity of the interventionists has not been analyzed
Implications Results suggest that group MI is a cost-efficient intervention strategy
Future Directions Evaluate mechanisms and active ingredients of behavioral change Look at mediators of change such as: alcohol norms, motivation to change, self efficacy, alcohol beliefs and in-session talk Investigate the effect of time on outcomes Our 6 month follow up is in progress and will be finished soon Continue to evaluate the efficacy of BASICS
Thank You to Penn State Staff Involved with BASICS Liz Barton-Staff assistant Alwyn Brittain-BASICS Health Educator Angel Goldian-Staff assistant Rochelle Holmes-BASICS Graudate Assistant John Hustad, Ph. D. -BASICS Researcher Linda La. Salle, Ph. D. -Associate Director of Educational Services David Mallen-BASICS Health Educator Jessica Nabozny-BASICS Health Educator Steve Shephard-BASICS Health Educator Katie Tenny-BASICS Health Educator Rachel Urwin, Ph. D. -Coordinator of Educational Services
THANK YOU
Contact information: Suzanne Zeman, M. S. , R. N. Coordinator of Educational Services The Pennsylvania State University Health Services slb 227@sa. psu. edu (814) 863 -0461
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