Underage drinking is common on college campuses throughout the United States. This article discusses some of the highrisk alcohol behaviors that students engage in and the consequences of such behaviors. It also reviews some of the interventions for this activity, with an emphasis on peer-facilitated, problembased learning.
HIGH-RISK ALCOHOL BEHAVIORS
Minor in Possession
In the state of Michigan, a minor in possession (MIP) is defined as anyone younger than 21 years who is in possession of alcoholic liquor or a beverage containing alcoholic liquor (as defined in the Michigan Liquor Control Code of 1998) or who has a blood alcohol content of 0.015%. A first offense carries a fine of not more than $100, possible participation in substance abuse prevention or substance abuse treatment and rehabilitation services, possible community service, and possible substance abuse screening and assessment at the individual's own expense. Many of the individuals who violate this law are college students.
Approximately 750 to 1,000 Michigan State University students are cited as first-time MIPs each year. According to the East Lansing police, at least half of the average 1,000 annual MIP citations in East Lansing (not including citations on the Michigan State University campus) involve Michigan State University students. The Michigan State University police document student status only on football weekends, but estimate that 60% of the 600 annual on-campus MLP citations involve Michigan State University students.
Alcohol consumption on campus is a major concern not only at Michigan State University, but also at colleges and universities throughout the United States.1"4 The central problem is that a significant portion of the alcohol is being consumed by students who are younger than the legal drinking age of 21.
A study was conducted at a large Midwestern university to investigate underage drinking and to identify correlations among age, sex, and alcohol consumption.5 A survey instrument that was a modified version of the Student Alcohol Questionnaire was used. It was adrninistered to 270 students during the fall 1990-91 school year at the first meeting of an introductory health class. The respondents included 86 males and 141 females whose ages ranged from 17 to 44 years (median age = 20).
The gender-by-age analyses of variance of the data revealed that there was no statistically significant difference in the total amount of alcohol consumed when comparing underage drinkers (55 males and 104 females) with those of legal drinking age (31 males and 33 females). The results also indicated that males of legal drinking age consumed more alcohol (mean number of drinks per week = 23.9) than did males who were underage (mean number of drinks per week = 21.2). However, underage females consumed more alcohol (mean number of drinks per week = 13.5) than did females of legal drinking age (mean number of drinks per week = 7.5).
During the past several years, the media has brought the problem of binge cLrinking to the attention of the public. However, binge drinking continues as a normal behavior among many college students.
In 1993, the Harvard School of Public Health conducted a survey of students at a representative sample of 4-year U.S. colleges to determine the extent of binge drinking and the resulting negative health and behavior outcomes.6 The survey indicated that most of the students drank alcohol in the past year and that only approximately 16% were nondrinkers. Approximately 40% of the students drank alcohol, but were not binge drinkers. Approximately 44% of the students reported themselves to be binge drinkers, defined as consumption of at least 5 drinks in a row for males or 4 drinks in a row for females during the 2 weeks before the survey. Approximately 20% of the students were frequent binge drinkers, defined as bingeing 3 or more times during the 2 weeks before the survey. The students in the predominant age group (age range 17 to 23 years) had much higher rates of binge drinking than did the older students. However, within the predominant age group, those younger than 21 did not differ from those 21 to 23.
Binge drinking was associated with substantial and broad adverse consequences. Frequent binge drinkers were 7 to 10 times more likely than non-binge drinkers to engage in unprotected and unplanned sexual activities, damage property, be injured or harmed, and get into trouble with campus police. Similar strong relationships were found when comparing infrequent binge drinkers with non-binge drinkers. Binge drinkers reported significantly higher frequencies of dangerous driving behaviors than did non-binge drinkers (P < .001 )?9
In 1997, the Harvard School of Public Health repeated this survey with the purpose of determining whether any changes had occurred between 1993 and 1997.10 One hundred thirty (93%) of the previous 140 colleges participated. The rates of binge drinking among the 10 excluded colleges were found to be virtually identical to those of these 130 colleges.
The 1997 results were almost identical to the 1993 results. In 1997, approximately 19% of the respondents were classified as abstainers. The analysis also revealed that approximately 38% of the students were non-binge drinkers. Approximately 43% of the students surveyed reported themselves to be binge drinkers. Approximately 21% of the students were frequent binge drinkers. Additionally, of the students who drank any alcohol during the school year, more than half (53%) were binge drinkers. The two surveys demonstrated the same risky behaviors and negative outcomes, along with an increased risk of secondhand effects for non-binge drinkers.
The Core Alcohol and Drug Survey has reported findings similar to these. Its most notable finding was that all levels of binge drinking are greater among individuals who are underage.11
INTERVENTIONS FOR HIGH-RISK ALCOHOL BEHAVIORS
Voluntary Versus Coerced Treatment
Studies have indicated that coerced treatment is at least as effective as voluntary treatment (ie, when individuals recognize that they have a problem and self-refer into a treatment program).12-13 Coercion occurs when treatment is offered as an alternative to standard legal or regulatory consequences. It has been found that individuals who are coerced into treatment to maintain their employment status or custody of their children actually do better than those who enter treatment voluntarily.14 Alcoholics, criminals, and individuals receiving public aid who are ordered into treatment by the courts have all been shown to do as well as those who voluntarily enter treatment.14 According to one report, individuals who had been cited for driving under the influence and chose treatment to mitigate their sentences demonstrated a twofold reduction in rearrest for drunk driving compared with those who did not opt for treatment.14 A study conducted in the workplace demonstrated that compliance rates among employees coerced into treatment for addiction exceeded those of employees who voluntarily sought treatment.15 Although these studies do not deal specifically with college populations, the uniformly positive results suggest that mandated interventions for college students who exhibit high-risk alcohol behaviors could prove successful.
The 1993 Harvard School of Public Health survey found that fewer than 1% of those students who considered themselves to be binge drinkers believed that they had a drinking problem or ever sought treatment.6 These individuals could be coerced into treatment if they were cited as MLPs. The incentive in their entering treatment would be the removal of the alcohol-related offense from their police record.
Previous, Research-Based Interventions
An experimental study of three different interventions was conducted to determine the best approach for reducing high-risk alcohol behavior among young adults.16 Volunteers who were college students were solicited for the study and randomly assigned to one of the three interventions. The most in-depth intervention involved a total of six 90-minute classroom meetings and discussion groups, one per week, during 6 weeks. There was a self-help intervention in which students were given six reading assignments to complete during the same 6-week period as the classroom intervention. Another intervention involved completing a 1-hour feedback and advice session with a member of the professional staff.
The study revealed that self-reported rates of drinking were reduced by 40% overall following the intervention phase and were maintained during a 2-year follow-up period. The classroom intervention and the 1-hour intervention yielded comparable results, whereas the self-help intervention was slightly less effective. When the students were given an opportunity to evaluate the three interventions, the classroom and the 1-hour interventions received the most favorable ratings and the self-help intervention the least favorable ratings.
Mariait conducted a randomized, controlled trial to evaluate the efficacy of a brief intervention for college students with high-risk alcohol behaviors.17 This intervention, when used for at-risk students during their freshman year, led to significant reductions in the rates of drinking and the harmful consequences associated with drinking. Over time, the high-risk alcohol behaviors of all of the participants tended to decrease, but those who received the brief intervention experienced a significantly greater and faster reduction.
Although multi-target and multi-strategy community-based interventions arising out of cooperation between city governments and colleges/universities have not yet been tested, most of the data indicate that they could be successful in reducing high-risk alcohol behaviors among students. However, the following would be required: (1) development of a community-college/university task force made up of officials, citizens, faculty, and students; (2) assessment of drinking on campus and in the community; (3) development of strategies to reduce alcohol use and related problems within the community and on campus; (4) availability of referral services for those in greater need; (5) development of a plan to evaluate the intervention; and (6) development of plans to institutionalize the intervention from the beginning.
Problem- Based Learning Interventions
The proposed peer-facilitated, problem-based learning (PBL) intervention program for MIPs at Michigan State University is based on the method of established PBL programs. It is a modification of the Patient-Oriented Problem Solving (POPS), which has been used to teach students of the health professions about the health risks of alcohol and other drugs.18 In PBL, students have an interactive educational experience in small groups. Students receive printed materials that reveal only part of a problem to them. They must work together, exchanging and providing information, to solve the problem.
The POPS program has been employed in an interdisciplinary setting of medical, dental, veterinary, nursing, and pharmacy students to teach them about the negative effects of alcohol and drug use. The program involves the completion of three phases. The initial phase (phase I) consists of a pretest, cognitive-behavioral assessment, and homework. The next phase (phase ?) involves breaking up into groups of five, with each student having one-fifth of the problem, and discussing the answers to the pretest, the homework, and problem scenarios during the two phases (I and II). The final phase (phase HJ) involves spending a day teaching middle school students about the negative effects of alcohol and drug use through videotaped scenarios, visual aids, and interactive group discussion. Hence, the POPS program combines both an educational component and a community service component.
PBL programs such as the POPS program can be used as either an intervention or a prevention instrument for high-risk alcohol behaviors among underage drinkers. The efficacy of this methodology has been consistently supported by experience and feedback from participants.19"23 It is anticipated that this program will be successful in reducing alcohol consumption and recidivism among MIPs.
Previous Studies on Peer-Facilitated and Cooperative Learning
Numerous studies have verified the effectiveness of peer-group activities in helping students learn, particularly regarding sensitive topics such as alcohol use in younger populations.24,25 However, these activities must be appropriately structured to ensure that all students are active participants with equal contributions and gains. In traditional unstructured group work, students receive a problem or an activity and are required to present an answer. The burden of the work generally falls to a few of the students, with the others exerting minimal effort. However, all of the students in the group receive the same grade.
In contrast, cooperative learning requires that all of the students in a group work together to find the answers. Students in these groups must provide instruction to their peers so that they all learn the material and the group reaches appropriate conclusions. Such teaching and explaining of material to others is strongly associated with learning gains.25
Cooperative learning motivates students to be active and responsible for their learning26 and results in more favorable attitudes toward learning than do instructor-led sessions.27 It carries with it the additional benefits of improved selfesteem and better interpersonal relations.28 Cooperative learning has also been found to reduce learner anxiety.29-30 The assignment of students to groups is not an issue because successful learning does not depend on the members of a group liking each other.31
Learning activities that are problem based have been found to change learners' knowledge about and attitudes toward the subject being studied.32-33 The presentation of information in the context of the real world increases learners' ability to apply knowledge appropriately.34 Also, peer-group learning is cost-effective because fewer professional teachers or experts in the subject matter are required to obtain positive results. In fact, in one study the presence of an expert tutor in a PBL group was not found to significantly affect students' learning, the learning process, or students' satisfaction with the process.35
Underage drinking occurs frequently on college campuses throughout the United States and is accompanied by adverse consequences. Participation in a peer-facilitated, problem-based learning program is an alternative to sentencing for these students. Such a program can result in changes in college students' knowledge about, attitudes toward, and behaviors regarding alcohol.
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