REDUCING RISKY BEHAVIORS
ASSOCIATED WITH 21ST BIRTHDAYS
THE 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
THANK YOU!
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Alcohol & Drug Abuse Prevention Team (ADAPT) peer educators
Systems & Information Engineering Capstone Team
University of Virginia colleagues & students
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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
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FUNDING SOURCES
CELEBRATORY DRINKING
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“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.
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21ST BIRTHDAY CELEBRATIONS
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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)
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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).
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Some students consume 21 drinks during 21st
birthday celebrations (Hembroff, Atkin, Martell, McCue & Greenamyer, 2007
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Brad McCue: died on 11-5-98 – his 21st birthday
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21st birthday card program began at Michigan State and
expanded nationally
U.S. Department of Education grant
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PRIOR U.VA. 21ST BIRTHDAY INTERVENTIONS
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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
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Mailed card program ended in May 2010
Up to 1/4 of cards returned as undeliverable
 Time and expense
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U.VA. 21ST BIRTHDAY MAILED CARD RESULTS
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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.
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YOUTH-NEX GRANT FUNDING - AUGUST 2011
THE PERSONALIZED BIRTHDAY REPORT (PBR)
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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
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ENHANCEMENTS TO 21ST BIRTHDAY CARD
3 key elements
1. Electronic delivery
2. Social norms approach
3. Brief motivational enhancement
interventions
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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).
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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)
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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)
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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).
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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.
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SPECIFIC AIMS FOR 21ST BIRTHDAY WEB-BASED
INTERVENTION (PERSONALIZED BIRTHDAY REPORT)
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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.
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Personalized Birthday Report Timeline
Summer 2011 Complete literature review of 21st birthday interventions
Fall 2011
Finalize data analysis of previous 21st birthday interventions
Create campaign messages, theme and email script
Use focus groups for feedback on ‘script’ and messages
Revise messages and script as needed
Spring 2012 Program/code online intervention
Use focus groups for feedback on intervention
presentation/design
Implement intervention
Conduct intervention evaluation
Use focus groups for feedback on intervention
presentation/design
Summer 2012 Preliminary data analysis
Fall 2012
Revise campaign messages and feedback scripts
Spring 2013
Prepare and submit manuscript for publication
Program/code online intervention
Implement intervention
Conduct intervention evaluation
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STUDY DESIGN
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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
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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
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PROCEDURE
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Invitations for pre-birthday surveys (PBR and Plan-only)
sent to email address 7 days prior to birthdate.
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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
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Incentives
Pre-birthday: Arch’s Frozen Yogurt coupon
 Post-birthday: 6 drawings for $100 bookstore gift certificate
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Plan
Protective
Behaviors
Perceptions
Student
plan
Quantity and
perception
PLANNED DRINKS AND PERCEPTIONS OF DRINKING
“You plan to have 8 drinks on
your 21st birthday.”
“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.”
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Accurate perceptions or underestimate
Overestimate
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
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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
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POST-BIRTHDAY SURVEY
Negative
Consequences
Benefits
INDEPENDENT VARIABLES
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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
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Drinking Risk Level
Low (eBAC < 0.08)
 Moderate (0.08 ≤ eBAC ≤ 0.12)
 High (eBAC > 0.12)
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DEPENDENT VARIABLES
o
o
o
o
o
Self-Reported 21st Birthday Drinks
21st Birthday eBAC
Perceived 21st Birthday Drinks (by same-sex)
Self-reported Protective Behaviors
Self-reported Negative Consequences
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DATA ANALYSIS
All analyses completed using R.
 ANOVA models include Sex, Greek Affiliation, and Intervention Group
and all interactions
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Also included Perception Status to analyze the number of drinks consumed
Drinking Risk Level used in analysis of negative consequences
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RESPONSE RATES
PRE-BIRTHDAY
Plan
Feedback
Invited Valid
Female
Drinker Grk drinker
Invited
Valid
Drinker Grk drinker
137
91
85
40
164
91
86
45
Male
84
37
36
13
135
36
35
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Total
221
128
121
53
299
127
121
63
57.9%
43.8%
42.5%
52.1%
POST-BIRTHDAY
Control
Control Total
Invited Valid
(added back)
Female
122
67
123
Male
88
33
71
Total
210
100
47.6%
194
Plan
Feedback
Invited Valid
Drinker Grk drinker Invited
Valid
Drinker Grk drinker
91
63
59
22
91
61
57
26
37
27
25
12
36
25
22
12
128
90
70.3%
84
34
40.5%
127
86
67.7%
79
38
48.1%
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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)
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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
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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)
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Females in the Feedback Group had significantly lower perceptions than those in the Planonly group (p = 0.0218) and in the Control group (p = 0.006)
PERCEPTION STATUS
Males
Females
100%
100%
80%
80%
60%
Under
40%
Over
Accurate
20%
60%
Under
40%
Over
Accurate
20%
0%
0%
Post
Control
Pre
Post
Plan
Pre
Post
Feedback
Post
Control
Pre
Post
Plan
Pre
Post
Feedback
No significant differences for feedback group between pre-birthday and
post-birthday surveys
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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).
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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).
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SELF-REPORTED NEGATIVE CONSEQUENCES
Greeks self-report more negative consequences
(F1,322 = 14.04, p < 0.001)
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SELF-REPORTED NEGATIVE CONSEQUENCES (2)
Drinking risk level has an effect on negative consequences
(F2,332 = 38.57, p < 0.001)
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STUDENT PERCEPTIONS OF PERSONALIZED
FEEDBACK REPORT
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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“
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Focus groups conducted in May 2012
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Students liked the personalized feedback component
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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
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PHASE 2 - ENHANCEMENTS
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Concern: Feedback did not impact Greek men as much
as other students
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Similar results seen in previous U.Va. Web-based normative
feedback program
Response: Changed feedback from sex-specific to sexneutral
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
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Improved/enhanced email and survey appearance
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21st Birthday Survey
Enhanced
standard drink
guide
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