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Fleming, M.F., Balousek S., Grossberg P.M. et al.
Journal of Studies on Alcohol and Drugs: 2010, 71, p. 23–31.
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Can college health clinics do widespread screening and brief alcohol advice? Yes they can, is one conclusion of this first large-scale test conducted at five North American universities. The other main conclusion – that by doing so they make worthwhile reductions in drinking and related harm – is weakened by the small size of the impacts.
Summary Brief advice from doctors in health care settings can reduce alcohol use, harm, mortality, and related costs among adult patients, but there is limited information on whether it is also effective for young patients, especially college students.
To address this issue the featured study was conducted at the health services of five diverse universities in the USA and Canada, where over a full-day interactive workshop plus booster sessions, 13 primary care physicians (in the event they conducted 91% of the interventions), three nurse practitioners, and one physician assistant were trained to deliver a brief intervention to heavy-drinking students. It was the first large alcohol screening and brief intervention trial conducted in a college health setting where primary care providers delivered the brief counselling protocol.
At the universities all students 18 and over were asked to complete a screening survey including questions on drinking as well as other health topics as they arrived for regularly scheduled appointments Except at one of the sites, where initial screening was conducted in a college health class. to see their primary care doctors. Over 85% were screened (12,900 students) of whom about a third screened positive Over 14 US standard drinks (each 1.75 UK units) a week for men, 11 for women; over five drinks more than four times in the previous 28 days; and/or two or more positive answers to the CAGE questions about feeling the need to drink less, being annoyed by criticism of one's drinking, feeling guilty, or needing a drink first thing. for at-risk drinking. Of these 4512 positive-screen students, 46% or 2090 agreed to join the study and were interviewed face-to-face by researchers to determine whether they met the trial's criteria. Over a 1000 were eliminated because over the past four weeks they had not drunk heavily according to the study's criteria, For men over 50 US standard drinks (each 1.75 UK units) or eight or more heavy drinking episodes (five or more drinks); for women, over 40 drinks or six or more heavy drinking episodes (four or more drinks). leaving (after other exclusions) 986 enrolled in the trial.
The researchers gave all enrolled students a booklet on general health issues. For a randomly selected half (the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group) this was the sole 'intervention', and rather than focusing on drinking, they were told the trial included drinking along with other health-related behaviours, questions about which were included in all the assessments. They saw the same doctors as the other patients allocated to the brief intervention, but medical staff were not told they were part of the trial.
The other half of the students were allocated to the brief intervention. Appointments were made for them to see their doctors for two 15-minute consultations (the second to reinforce the first) a month apart, and each was phoned between the sessions and a month later to check progress and offer encouragement. The sessions were guided by a manual which instructed the clinician to offer or discuss with the student: how their drinking compared to other young adults; a list of alcohol's adverse consequences relevant to college students; lists of personal likes and dislikes about drinking; worksheets on drinking cues; a blood alcohol level calculator; the impact of their drinking on achieving their goals; agreement to reduce alcohol-related risks in the form of a prescription signed by the student; and drinking diary cards.
Students were paid a total of $200 if they completed the required procedures. Editor's note: which for the intervention students appeared to include attending the brief intervention sessions; the manual says students should be invited to ask about health issues other than alcohol for which another visit would be scheduled, but students should be warned "You would not be paid for that visit, however." All but 12% of the intervention students completed all four intervention phases. Of the total sample, 96% were interviewed over the phone six and 12 months later by a researcher unaware of to which group they had been allocated. Drinking patterns and other data What the relatively few students who did not complete the follow-ups might have said was estimated from their earlier responses. gathered by these interviews were compared with the pre-intervention data to assess whether intervention students had reduced their drinking and related risks more than the control students.
From each drinking about 70 US standard drinks (about 123 UK units) over four weeks before the intervention, a year later both sets of students had cut down to around 53 drinks (about 93 UK units). However, the reduction (by 27% v. 21%) was greater among students allocated to the brief intervention, and during the 12 months the extra reduction was statistically significant. Similarly, both sets of students reported substantial reductions in the number of days they drank heavily, Five or more US standard drinks for men and four for women. a reduction which was on average slightly greater among intervention students (26% v. 23%), but this time not to a statistically significant degree. This was also narrowly the case in respect of the extra reduction (15.4% v. 12.6%) among intervention students in the number of days they drank at all.
Another set of questions asked students about the number of times they had undesirable alcohol-related experiences over the past year, such as causing shame or embarrassment, passing out, having a bad time, or an altercation with a friend. For both sets of students these experiences had become substantially less frequent, but the reduction was significantly steeper among students allocated to the brief intervention.
There were no statistically significant differences in trends in respect of other measures including health care utilisation, injuries, drink driving, depression, or smoking.
This trial provides some of the best evidence to date that spending time talking with students about their alcohol use is worth the time, effort, and resources required to do so, evidenced by the high proportion of students who on health grounds needed to cut down on their drinking, and the extra reductions seen after the brief alcohol advice sessions. The diversity of sites in the study offer reassurance that similar results would be found elsewhere.
One practical implication is that systematic alcohol screening of college students attending health clinics for routine care is feasible using a paper-and-pencil questionnaire; receptionists can distribute the questionnaires, and students are willing to provide information on health habits such as exercise, smoking, weight concerns, and drinking, contradicting concerns that clinic or student resistance means college health clinics have a minimal role to play in campus-wide efforts to identify high-risk students. The study also showed that primary care providers can be trained to conduct and successfully implement brief alcohol interventions; as commonly happens, such work does not have to be diverted to counselling centres and non-clinical settings.
The extra reductions in drinking and harm were less than those seen in similar studies of non-student adult populations, possibly because young people often feel invincible and have limited experience of the serious consequences of drinking, and/or peer pressure and perceived social norms. Though these were greater among students allocated to the brief intervention, the study also found large reductions in drinking and related harms in the control group, perhaps due to natural transitions due to aging or the abating of an atypically high level of drinking, or the impact of being asked about one's drinking and related harms. Of the 4512 students screened positive for risky drinking by the health screening survey, just 22% participated in the trial. It is possible that they differed in salient ways from the students who did not in the end meet the trial's criteria and agree to join it.
commentary The authors make the case for their study justifying resource allocation to alcohol screening and brief advice for college students. One half of the argument – the prevalence of heavy drinking – seems persuasive. But the other half – that the intervention reduced drinking to a degree worth the investment – can be questioned. For example, a year after the intervention the students allocated to it were drinking on average about 23 UK units a week, the other students about one unit more. The difference may seem insufficient to be clinically significant or to warrant the investment. Though this was how they ended up, because the intervention students started at a slightly higher level, they reduced their drinking by about two UK units more a week, a figure which may still seem unconvincing, especially since part may have been due to them knowing the study was really about their drinking and not their general health, a fact hidden from the control group students. This 'social desirability' bias is one of several possible reasons why control groups in brief alcohol intervention studies on average substantially reduce their drinking or at least say they have.
An alternative perspective is that simply asking about drinking and its adverse consequences had an impact which the intervention reinforced, meaning the whole package led to substantial drinking reductions. This can happen, but if it did, the research assessments which may have promoted those reductions would have to be costed in to the package, and also the financial inducement to complete those assessments and to complete (if this also was rewarded) the intervention itself.
Overall offering some alcohol intervention has led to greater reductions in drinking and drink-related problems in college students than simply assessment (with or without a control intervention not intended to reduce drinking). Effects are small, but of the order to be expected from a broad public health measure as opposed to targeted treatment for people actually seeking to curb their drinking.
As well as counselling individual heavy drinkers, an alternative and, it has been argued, the primary strategy, is to change the college environment and culture to make regular and heavy drinking less possible and less attractive. Where these levers are available, college administrators concerned to reduce drinking and its adverse consequences among their students may consider tightening campus rules, more vigorous enforcement of those rules and of general alcohol laws, alcohol-free bars and entertainments, and generally fostering an environment which makes sobriety easier and the opposite harder. Such initiatives are limited by the fact that much drinking occurs off-campus, but have effectively been extended to the local area.
Last revised 31 May 2013. First uploaded 24 May 2013
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