Reducing Risky Behaviors Associated with 21st Birthdays

1. 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 Prevention University of Virginia

2. 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

3. Funding sources

4. 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.

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

6. Prior U.Va. 21st Birthday Interventions • 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

9. 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.

10. Youth-Nex grant funding - August 2011The Personalized Birthday Report (PBR) • Development phase 1: August 2011 - January 2012 • Implementation phase 1: January – May 2012 • Data analysis: May – August 2012 • Development phase 2: August – February 2013 • Implementation phase 2: current 10

11. Enhancements to 21st Birthday Card 3 key elements • Electronic delivery • Social norms approach • Brief motivational enhancement interventions

12. 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).

14. If you push… people just naturally push back.

15. 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 BACcompared 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.

16. Specific Aims For 21st Birthday Web-based intervention (personalized birthday report) • Feedback will decrease the number of drinks consumedduring 21st birthday celebrations. • Feedback will decrease estimated Blood Alcohol Content during 21st birthday celebrations. • Feedback will positively impact the accuracy of perceptionsof 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.

18. 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

19. 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

20. Plan Protective Behaviors Perceptions

21. Student plan Quantity and perception

22. Planned drinks and perceptions of drinking “You plan to have 8drinks on your 21st birthday.” “You plan to have 8drinks on your 21st birthday. On average, U.Va. women report having 5 drinks on their 21st birthdayswhich is fewer than you thought.” Accurate perceptions or underestimate Overestimate

23. Protective behaviors Strategies to reduce risk 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: • 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

24. Negative consequences Avoiding alcohol related problems • 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

26. Post-Birthday Survey Negative Consequences Benefits

27. 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)

28. Dependent variables • Self-Reported 21st Birthday Drinks • 21stBirthday eBAC • Perceived 21st Birthday Drinks (by same-sex) • Self-reported Protective Behaviors • Self-reported Negative Consequences

29. Data Analysis All 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

30. Response Rates Pre-birthday Post-birthday

31. 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 Status Males 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. Email message 21st Birthday Survey

42. Enhanced standard drink guide

44. Changes in feedback for students who planned to drink 3 or 4 drinks and overestimated others’ drinking Female Feedback 2012 Sex-neutral feedback - 2013 Male Feedback 2012