Suzanne Zeman, M.S., R.N. The Pennsylvania State University University Health Services

1. 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 University Health Services John Hustad, Ph.D. Penn State University - College of Medicine Milton S. Hershey Medical Center Linda LaSalle, Ph.D. Rachel Urwin, Ph.D. The Pennsylvania State University University Health Services

2. 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

3. 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

4. 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 (LaChance 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-on-one MI for alcohol use.

5. Alcohol Use by College Students • 59.8% of college students reported using alcohol in the last 3o days according to the ACHA-NCHA Fall 2010 assessment

6. 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

7. 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., 1996a, 1996b;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).

8. 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

9. Penn State Student Drinking Data From the Student Affairs Research and Assessment, PULSE Student Drinking Report 2011

10. High Risk Drinking at Penn State • 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

11. Alcohol Related Consequences Within the past 12 months as a consequence of drinking… Source: American College Health Association, 2010 Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

12. Nightly Self Reported Alcohol Use During a Typical Week-Penn State 2011 Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

13. Drinks Consumed/Hour During Peak Drinking by Penn State Students Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

14. Self Reported Alcohol Consequences Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

15. Self Reported Alcohol Consequences Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

16. Self Reported Alcohol Consequences Source: Penn State Student Affairs Research and Assessment, Student Drinking Report 2011

17. The NIAAA Report on College Drinking What Colleges Need to Know Now An Update on College Drinking Research. (2007) www.collegedrinkingprevention.gov/

18. 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.

19. 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 )

20. 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

21. 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

22. 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

23. BASICS Components

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Sample PNF sheet for an Actual Student

31. 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

32. 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

33. Key Behavior Outcomes Relevant to Assessing the Efficacy of Group and Individual BASICS

34. Behavior Outcomes of BASICS • Decreased typical BAC • Decreased peak BAC • Decreased negative consequences associated with alcohol • Increased use of protective behaviors while drinking

35. 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 one-on-one delivery of BASICS (Larimer, et. al., 2007) • Recent research suggests that group delivered BASICS is promising and cost-effective (LaChance, 2009). • To date, no research has been conducted comparing the efficacy of group delivered BASICS to individually delivered BASICS.

36. 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.

37. 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

38. Study Procedure and Design A= Assessment R= Randomization BMI= Brief Motivational Intervention Follow up Assessment at 1, 3, 6 Months BMI A R Group BMI Excluded High Risk Students

39. BASICS Components-Group Condition

40. 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

41. BASICS Components-Group Condition

42. 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

43. 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)

44. Participant Flow

45. 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.

46. Sample Characteristics

47. Sample Characteristics

48. Raw Means of Key Outcome Variables Across Assessments

49. Raw Means of Key Outcome Variables Across Assessments for Participants

50. Participant Self Reported Alcohol Related Consequences