Testing Protection Motivation Theory in Context to Alcohol
Cessation
Purpose of study: The study is targeted at Indians and their understanding and
intentions towards alcohol consumption. The study aims at understanding if Indians are
willing to quit or reduce alcohol consumption.
About the Survey: The survey consists of 8 sections and 32 questions in total. The
questions marked (R) are reverse coded. After the first demographic section, the
questions pose a statement and the respondent is expected to answer on the basis of
how they respond to that statement. This response is collected through a Likert Scale
which consists of the following 5 options:
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
The survey will take approximately 15 minutes to be completed.
Consent: The survey maintains the respondent’s anonymity with no information being
recorded apart from the answers to the survey questions. We are accountable for
maintaining respondent anonymity. The responses to this survey will be used solely for
educational study. The participant ID is not connected to the respondent or their data.
Participation in the survey is completely voluntary and the respondent may withdraw their
consent or close the survey at any time.
By signing this consent, I am allowing my responses to be used for an educational
study under the above constraints.
Participant ID: ____________
Demographic Assessment
1. What age group do you belong to?
● Below 18 years
● 18 - 25 years
● 25 - 35 years
● 35 - 50 years
● 50 - 60 years
● Above 60 years
2. Please self-identify your gender.
● Male
● Female
● Prefer not to say
● Other: _______
3. What is your highest level of education?
● Some level of schooling
● 10th pass
● 12th pass
● Bachelor’s degree
● Master’s degree
● Doctorate or higher
● Prefer not to say
● Other: _______
4. What is your employment status?
● Student
● Unemployed
● Self Employed
● Part Time
● Full Time
● Retired
● Prefer not to say
● Other: _____
5. What is your annual income?
● Less than 1 Lakh
● 1 - 5 Lakhs
● 6 - 12 Lakhs
1
● 12 - 36 Lakhs
● More than 36 Lakhs
● Prefer not to say
6. What is your marital status?
● Single
● Married
● Divorced
● Widow
● Prefer not to say
● Other: _______
7. How often do you consume alcohol?
● Never
● Rarely
● Sometimes
● Often
● Always
Severity
8. The earlier a person starts drinking alcohol, the greater is the harm ●
Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
9. Alcohol consumption can cause some severe health problems
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
10. Alcoholics die earlier than people who don’t consume alcohol
● Strongly Disagree
● Disagree
2
● Neutral
● Agree
3
● Strongly Agree
Vulnerability
11. If I start drinking regularly, I will get addicted
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
12. If I get addicted to alcohol, I will experience severe health problems
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
13. Being an alcoholic won’t make any difference to my mental health (R)
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
14. Once I become an alcoholic, I would not be able to quit
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Intrinsic Reward
15. Drinking alcohol helps to feel more included among peers
● Strongly Disagree
4
● Disagree
● Neutral
● Agree
● Strongly Agree
16. Drinking alcohol helps to take mind off worries
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
17. Drinking alcohol makes one more confident in different social settings
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Extrinsic Reward
18. Drinking alcohol helps in social networking
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
19. Drinking alcohol helps to have fun in parties
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
20. While drinking alcohol, one does not feel relaxed (R)
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
21. Drinking alcohol helps to bond better with colleagues and peers
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Response Efficacy
22. Reducing alcohol consumption will lead to a healthier lifestyle.
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
23. If one stops drinking, they will be less likely to acquire any disease.
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
24. If one stopped drinking alcohol, their mental health will remain unaffected
(R)
● Strongly Disagree
● Disagree
● Neutral
5
● Agree
● Strongly Agree
25.Quitting alcohol leads to a better social life.
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Self Efficacy
26. I can easily refuse a friend or a relative if I do not want to drink alcohol
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
27. I can manage my drinking habits in a healthy manner
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
28.I do not get under peer pressure to drink alcohol when I don’t want to
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Response Cost
29. Quitting alcohol can lead to low energy and depression
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● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
30. Quitting alcohol can lead one being isolated by one’s social circle
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
31. Stopping to drink alcohol leads to no withdrawal symptoms (R)
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
32. Quitting of alcohol consumption will lead to having less fun at parties
● Strongly Disagree
● Disagree
● Neutral
● Agree
● Strongly Agree
Thank you for taking out your time to fill out this survey.
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