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Although personalised feedback interventions (PFIs) for alcohol misuse among college students have demonstrated reliable efficacy, effect sizes are modest and little improvement in efficacy has been observed in the last 15 years. More systematic and explicit application of theory may enhance our understanding of PFI mechanisms and lead to incremental improvements in efficacy. The current review identified intervention trials of PFIs (N = 93), the theoretical frameworks (N = 20) on which they were based, the extent to which theory was utilised in development and evaluation of the intervention, and the principles of behaviour change implicated in each of those theories. Though the majority of studies identified a theoretical framework for interventions, theory is not being tested uniformly across current studies of PFIs. A review of the most commonly cited theories resulted in identification of 11 theoretical principles of behaviour change: alternatives to behaviour, autonomy, commitment, expectancies, goals/change plan, interpersonal discrepancy, intrapersonal discrepancy, awareness of contingent outcomes, self-efficacy, skills necessary to overcome barriers and therapeutic relationship. Potential applications of these theoretical principles in PFI development and testing are discussed.
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ISSN: 1606-6359 (print), 1476-7392 (electronic)
Addict Res Theory, Early Online: 1–14
!2015 Informa UK Ltd. DOI: 10.3109/16066359.2014.1001840
REVIEW ARTICLE
Theories of behaviour change and personalised feedback interventions
for college student drinking
Mary Beth Miller, Ellen Meier, Nathaniel Lombardi, and Thad R. Leffingwell
Department of Psychology, Oklahoma State University, Stillwater, OK, USA
Abstract
Although personalised feedback interventions (PFIs) for alcohol misuse among college students
have demonstrated reliable efficacy, effect sizes are modest and little improvement in efficacy
has been observed in the last 15 years. More systematic and explicit application of theory may
enhance our understanding of PFI mechanisms and lead to incremental improvements in
efficacy. The current review identified intervention trials of PFIs (N¼93), the theoretical
frameworks (N¼20) on which they were based, the extent to which theory was utilised in
development and evaluation of the intervention, and the principles of behaviour change
implicated in each of those theories. Though the majority of studies identified a theoretical
framework for interventions, theory is not being tested uniformly across current studies of PFIs.
A review of the most commonly cited theories resulted in identification of 11 theoretical
principles of behaviour change: alternatives to behaviour, autonomy, commitment, expectan-
cies, goals/change plan, interpersonal discrepancy, intrapersonal discrepancy, awareness of
contingent outcomes, self-efficacy, skills necessary to overcome barriers and therapeutic
relationship. Potential applications of these theoretical principles in PFI development and
testing are discussed.
Keywords
Alcohol, college students, drinking,
motivational interviewing, personalised
feedback, theory
History
Received 31 December 2013
Revised 20 September 2014
Accepted 17 December 2014
Published online 14 January 2015
Introduction
Excessive alcohol consumption is one of the largest barriers to
physical and mental health in our nation, costing the US
approximately $223 billion per year (CDC, 2012). It is
especially prevalent on college campuses, where approxi-
mately 40% of students report engaging in heavy episodic
drinking (Wechsler & Nelson, 2008). Personalised feedback
interventions (PFIs), which aim to increase the salience of
normative and personal standards in order to promote
thoughtful consideration of future alcohol use, have been
some of the most widely utilised and successful interventions
to date. They have been reliably effective in reducing alcohol
use and related problems among college students (Carey, Scott-
Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011)
and have demonstrated at least short-term promise among
underage (Spijkerman et al., 2010) and general population
drinkers (Riper et al., 2009). However, the content of such
interventions varies widely across studies (Miller et al., 2013),
and effect sizes range from 0.01 to 0.44 (Riper et al., 2009).
Although the efficacy of PFIs has been demonstrated consist-
ently, significant enhancement of PFI efficacy has not been
observed in over 15 years of study.
One potential reason for the variable content and efficacy
of PFIs may be that theories are not always easily translated
to intervention development or testing and may not explicitly
identify theory-based mechanisms of change (Michie,
Johnston, Francis, Hardeman, & Eccles, 2008). Historically,
intervention researchers have used multifaceted interventions
derived from a number of psychological theories to make
broad impacts on populations such as college students (Miller,
Toscova, Miller, & Sanchez, 2000). Though this approach has
been effective (Cronce & Larimer, 2011), the variability
within these interventions renders them difficult to compare
and obscures which components may drive intervention
efficacy (Miller et al., 2013). Refined understanding and
application of theory, then, may be used to advance what is
known in research and practice to ensure that interventions
target mechanisms of behaviour change. Comparative trials of
new, theoretically derived PFI content may aid in identifying
the most robust theoretical frameworks and abandoning those
that fail to enhance understanding or efficacy. Such applica-
tions would not only guide the development of interventions
for different populations and behaviours but also facilitate the
development of better theory (Michie et al., 2008).
To evaluate the use of theory in PFI development
and testing, we reviewed the PFI literature with the aim of
(a) identifying theories currently cited in studies of college
alcohol PFIs, (b) reviewing the principles of behaviour
change acknowledged in those theoretical frameworks and
Correspondence: Ms Mary Beth Miller, MS, Department of Psychology,
Oklahoma State University, 116 North Murray, Stillwater, OK 74078,
USA. E-mail: marybeth.miller@okstate.edu
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(c) discussing how such principles may be translated to the
content of interventions. The current review identifies inter-
vention trials of PFIs, the theoretical frameworks on which they
were based, the extent to which theory was utilised in
development and evaluation of the intervention and the
principles of behaviour change implicated in each of those
theories. Discussion focuses primarily on the potential appli-
cations of theoretical principles in future PFI trials.
Understanding the current and potential uses of theory in this
way is expected to advance conceptualisation of PFI mechan-
isms of change and enhance the effectiveness of interventions
for college alcohol misuse.
Methods
Search strategy and selection
Articles published through May of 2013 were identified using
PsycINFO and Web of Science databases. The Boolean search
strategy included keywords (brief intervention OR feedback)
AND (alcohol OR drinking) AND (college students).After
deleting duplicate references (n¼47), a total of 391 articles
were identified. ‘‘Personalised feedback’’ was defined as any
information regarding one’s personal use of alcohol or
associated consequences that were provided to the student
following an assessment. This definition includes brief
motivational interventions (BMIs), which characteristically
incorporate personalised feedback (Dimeff, Baer, Kivlahan, &
Marlatt, 1999). Articles were excluded from the review if they
comprised: (a) unpublished theses or dissertations (n¼15);
(b) review articles, book chapters or other non-experimental
studies (n¼62); (c) non-college student samples (n¼44); (d)
non-intervention studies (n¼119); (e) interventions that did
not include personalised alcohol feedback (n¼41); (f)
outcomes that did not target alcohol use or related conse-
quences (n¼13); or (g) preliminary reports of a subsequent
study (n¼12). Secondary analyses of data (n¼14), which
typically focused on mediation or moderation of original
outcomes, were coded in conjunction with primary outcome
reports. Reference sections of systematic reviews were also
examined to identify relevant articles (n¼22). Thus, a total of
93 studies were included in the final review (refer Figure 1 for
a flow chart of study selection).
Coding and reliability
Three advanced graduate student raters coded each study
utilising a modified version of Michie and Prestwich’s (2010)
coding scheme (refer Table 1 for coding criteria). After
baseline inter-ratter reliability of 95% was achieved, each
rater independently coded a pre-assigned number of articles
(Figure 1). Each study was coded for reference of a theory or
model of behaviour, assessment of theory-relevant constructs,
randomisation of participants, intervention outcomes, use of
mediation or moderation analyses and discussion and refine-
ment of theory based on findings. Coding scheme items
regarding the use of theory in developing intervention
techniques were excluded from analyses based on previous
acknowledgements that published reporting of such standards
likely underestimates actual practice (Prestwich et al., 2014).
Raters agreed on 90% of coding criteria, and inconsistencies
were resolved via group discussion.
Results
Theoretical frameworks
A total of 20 theoretical frameworks were identified in the
review of 93 PFI trials, the most commonly cited theories
being motivational interviewing (MI; Miller & Rollnick,
1991; 74.2%)
1
and social norms theory (Perkins, 2002; 49.5%;
refer Table 2 for outline of studies’ theoretical frameworks.
Any other single framework was cited in 1.1–15.1% of studies
(Table 2). Of the 93 articles, 64.5% referenced a combination
of theories, 59.1% referenced a theory other than MI and
14.0% referenced no framework at all. Approximately 69.0%
of studies reported measuring a theoretically relevant con-
struct, such as descriptive norms or readiness to change;
however, 26.6% of those failed to cite the theory from which
the construct was derived. Only about one in three studies
(33.3%) reported assessing for mediators of effect, though
over half (55.9%) included moderators. Finally, only 41.9%
discussed applications to theory, and none attempted to refine
theory by adding or removing constructs or specifying
how the relationships between constructs may be changed
(Table 1).
Principles of behaviour change
Theories cited in more than 3.0% of studies (n¼10) were
further reviewed for theoretical determinants of behaviour
change. Cognitive dissonance theory (Festinger, 1957),
Rogers’ (1957) ideal conditions for change and self-perception
theory (Bem, 1972) were also included due to their influences
391 studies identified
294 studies eligible
127 studies obtained
93 studies included
(14 secondary analyses coded
collectively with original works)
97 title exclusions
189 abstract exclusions
34 article exclusions
(14 of which were secondary
analyses of original reports)
127 studies reviewed by Coder A
67 studies reviewed
by Coder B
67 studies reviewed
by Coder C
22 studies gleaned from reviews
Figure 1. Flow chart of study selection.
1
Most studies referenced MI, but none referenced the specific theory
(Miller & Rose, 2009); thus, data were coded including and excluding
MI as a theory (Table 1).
2M. B. Miller et al. Addict Res Theory, Early Online: 1–14
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on MI (Miller & Rose, 2009). Eleven primary principles of
behaviour change were identified (refer Tables 2 and 3 for
corresponding theories and applications): alternatives to
behaviour, which may be influenced by social support and
peer approval, autonomy, awareness of contingent outcomes,
commitment to behaviour change, expectations for behaviour
change, goals or change plan, interpersonal or normative
discrepancy, which may be moderated by the similarity and
importance of the normative referent (also referred to as
subjective norms); self-efficacy, skills necessary to overcome
barriers to change and the therapeutic relationship, which may
be influenced by therapist skill and training.
Discussion
Translation of theoretical principles to PFIs
Alternatives to behaviour
Addiction science is clear that drug use decreases as a
function of decreased availability of substances and increased
Table 1. Use of theory in PFIs for college alcohol misuse (N¼93) as specified by the modified theory coding scheme.
Item
n(%) Yes Including
MI as Theory
n(%) Yes Excluding
MI as theory
a
1. Theory/model of behaviour mentioned 80 (86.0%) 55 (59.1%)
2. Single theory referenced 33 (35.5%) 25 (26.9%)
Number of theories referenced: M(SD) 2 (1.53) 1.25 (1.43)
3. Participants selected based on theory-relevant construct (e.g. stage of change) 1 (1.1%) 1 (1.1%)
4. Theory/predictors used to tailor intervention techniques to recipients 47 (50.5%) 47 (50.5%)
5. Theory-relevant constructs measured as outcomes 64 (68.8%) 64 (68.8%)
6. Theory-relevant constructs matched at least one theory referenced
b
47 (50.5%) 47 (50.5%)
7. Participants randomised to conditions 84 (90.3%) 84 (90.3%)
8. Intervention leads to changes in at least one theory-relevant construct in favour of intervention
b
42 (45.2%) 42 (45.2%)
9. Mediation analyses conducted 31 (33.3%) 31 (33.3%)
10. Moderation analyses conducted 52 (55.9%) 52 (55.9%)
11. Theory mentioned in discussion 39 (41.9%) 29 (31.2%)
12. Results used to refine theory 0 (0.0%) 0 (0.0%)
a
Most studies referenced MI, but none referenced the specific theory (Miller & Rose, 2009); thus, data were coded including and excluding MI as
a theory.
b
Data from all studies, not only those measuring theory-relevant constructs.
Table 2. Summary of theories cited in PFIs for college alcohol misuse as well as corresponding principles of change.
Theory or framework
No. of studies citing
theory (N¼93) Corresponding principles of change
Alcohol expectancy theory 13 (14.0%) Expectancies
Cognitive dissonance theory
a
1 (1.1%) Autonomy/Discrepancy/Negative consequences (contingent
outcomes)
Health belief model 4 (4.3%) Awareness, benefits of change, negative consequences and cues to
action (contingent outcomes)/Skills to overcome barriers/
Expectancies/Social support or approval/Self-efficacy
Motivational interviewing 69 (74.2%) Commitment to change/Change talk/Therapeutic relationship
(empathy, MI spirit, training, use of MI-adherent behaviours)
Rogers’ (1957) interpersonal conditions for change
a
0 (0.0%) Discrepancy/Therapeutic relationship (contact, genuineness, con-
gruence, unconditional positive regard, accurate empathy, client
perception of being understood)
Self-determination theory 4 (4.3%) Autonomy/Competence (self-efficacy)/Relatedness (social
support)
Self-perception theory
a
0 (0.0%) Autonomy/Current behaviour
Self-regulation theory 8 (8.6%) Awareness, reasons for change and reinforcement (contingent
outcomes)/Commitment/Discrepancy/Goals-Change Plan/
Expectancies/Self-efficacy
Social cognitive [learning] theory 6 (6.5%) Skills to overcome barriers/Benefits of change, knowledge-
awareness and negative consequences (contingent outcomes)/
Goals/Expectations/Self-efficacy
Social comparison theory 6 (6.5%) Discrepancy/Referent’s abilities and opinions as related to target/
Similarity to referent
Social impact theory 4 (4.3%) Social support or approval
Social norms theory 46 (49.5%) Discrepancy
Transtheoretical model 14 (15.1%) Awareness, negative consequences and reinforcement
(contingent outcomes)/Change plan/Commitment/Discrepancy/
Environment (alternatives)/Social support
a
Theories included based on their influence on MI. Behavioural theories of choice (n¼3), decision-making theory (n¼1), the precaution adoption
process model (n¼1), problem behaviour theory (n¼1), role theory (n¼1), self-categorisation theory (n¼2), self-concept discrepancy theory
(n¼2), social identity theory (n¼3) and the theory of planned behaviour (n¼3) were not cited in more than 3% of studies and, therefore, were
excluded from the review. Constructs related to awareness of the consequences of substance use and benefits of change were characterised collectively
as ‘‘contingent outcomes.’’ References used in identifying principles of change are available upon request.
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access to alternative reinforcers that are somewhat immediate,
as delayed rewards tend to be discounted in value (Miller &
Carroll, 2006; Vuchinich & Tucker, 2003). Consistent with
theory, college students who reduced drinking following a PFI
reported decreased reinforcement from drinking and increased
reinforcement from school-related activities (Murphy, Correia,
Colby, & Vuchinich, 2005). Moreover, a 50-min individual
session targeting substance-free activities has been found to
enhance the effects of a BMI, decreasing alcohol-related
problems among college students and heavy drinking among
those who derive the majority of positive reinforcement from
substance-related activities (Murphy et al., 2012). Future
interventions, then, may benefit from identifying (either via
checklist, writing or conversation) alternative, enjoyable
activities available in the area [see Correia, Carey, Simons,
& Borsari (2003) for list of reinforcing activities].
Social support/peer approval
Strong interpersonal relationships have been established as an
important factor in preventing heavy drinking (Miller,
Andrews, Wilbourne, & Bennett, 1998), and social drinking
motives have been found to moderate PFI outcomes
(Neighbors, Larimer, & Lewis, 2004). As substance use is a
prevalent part of social activities in college, social support is
important to consider when generating alternative activities
for college students (Murphy, Barnett, & Colby, 2006).
Increased social support may be facilitated by providing
individuals with a list of either (a) campus organisations that
provide access to individuals who do not drink heavily or (b)
social activities that are reinforcing in the absence of
drinking.
Autonomy
Individuals who enter treatment for autonomous reasons
report greater intention to persist in therapy than those who
enter for extrinsic reasons (Pelletier, Tuson, & Haddad, 1997).
From an MI perspective, autonomy is established by explicitly
stating that the individual is the one who decides if, when, and
how to change and by providing individuals with a variety of
options for self-designated change (Miller & Rollnick, 2013).
In the context of interventions, this may be most easily
conceptualised as choice. When provided with their choice of
alcohol intervention, heavy-drinking college students have
been found to select more intense and effective interventions
and to report greater satisfaction with the intervention,
although choice itself did not predict changes in drinking or
consequences (Carey, DeMartini, Prince, Luteran, & Carey,
2013). Participation in alcohol-related goal setting has also
been found to increase college students’ commitment to and
self-efficacy for that goal (Lozano & Stephens, 2010). Based
on these studies, as well as findings that college students may
prefer a variety of different intervention components (Miller
& Leffingwell, 2013), autonomy may be facilitated in future
PFIs by providing as many opportunities as possible for
individuals to assert choice.
Awareness of contingent outcomes
Together, cognitive dissonance theory and social cognitive
theory suggest that people change when one behaviour results
in an unequal and foreseeable distribution of negative rather
than positive consequences, while an alternative behaviour
results in an unequal and foreseeable distribution of positive
rather than negative consequences (Bandura, 1998; Cooper,
2012). Awareness of personal risk is often elicited in current
interventions via feedback on negative consequences of
behaviour; however, it may also be facilitated via self-
monitoring (Brown, 1998), education on misguided beliefs or
feedback on underestimations of consequence severity (like-
lihood of outcomes such as arrest or suspension). Negative
drinking consequences have been found to predict changes in
drinking behaviour (Merrill, Read, & Barnett, 2013) and to
moderate intervention effects (Mun, White, & Morgan, 2009;
Palfai, Zisseron, & Saitz, 2011). However, Mallett, Bachrach
and Turrisi (2008) have noted that college students do not
perceive all intuitively ‘‘negative consequences’’ of drinking
as negative. Rather, students rate some consequences (waking
up in another’s bed, skipping meals) as relatively positive.
Moreover, students may believe that the alternative to drinking
(e.g. not going out with friends, friends’ perceiving behaviour
as boring or dull) is even more negative than the consequences
they are experiencing. Most BASICS-derived interventions
seem to address these issues via decisional balance exercises,
measures of substance-free reinforcement (Murphy et al.,
2012) and assessments of comprehensive effects of alcohol
(Fromme, Stroot, & Kaplan, 1993). However, interventions
may also benefit from quantitatively assessing not only the
frequency but also the valence (positive/negative) of drinking
outcomes (referred to in Table 3 as the ‘‘outcome valence’’).
This cumulative, quantitative value may be an ideal pre-
dictor of behaviour change in future studies. Similarly, it may
be useful to incorporate self-generated expectancies into
assessments and feedback, as students may expect negative
consequences that are not captured in current assessments
(Peterson, Borsari, Mastroleo, Read, & Carey, 2013). Self-
identified negative consequences, rather than researcher-
defined negative consequences, could then be explicitly
listed in future PFIs as benefits of change; and any ‘‘negative’’
consequences experienced on lighter-drinking nights could
be explored.
Assuming the outcomes of decreased alcohol use lead to
attitudes in favour of change, positive reinforcement may be
elicited in future interventions by providing feedback on
positive outcomes of change (you saved xamount of money
this month) or tracking progress toward goals. Self-reinforce-
ment and social support may also sustain change efforts
(Bandura, 2004; Brown, 1998), in which case individuals
could identify rewards for success that could be provided via
self or others. Incentives for non-substance-related activities
on campus or in the community may also be provided in
certain contexts (i.e. for mandated students).
Interestingly, one study has also found that students may
change behaviours based on likely – rather than already
experienced – consequences. Specifically, a PFI including
normative information, protective behavioural strategies and
information regarding intended BAC effects for 21st birthday
drinking was more effective than assessment only in reducing
BAC for college students, particularly those who intended to
reach higher levels of drinking that night (Neighbors,
Lee, Lewis, Fossos, & Walter, 2009). Therefore, feedback
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Table 3. Theoretical principles of behaviour change and implications for content of interventions.
Principle of behaviour change Theory Implications for intervention content
Alternatives to current behaviour
(environmental context and
resources
a
)
SCgT/TTM Identify (via checklist, writing or conversation) enjoyable, substance-
free activities in the area (intramurals, game nights, concerts,
bowling, dancing, TV, massage)
Provide incentives for alternative activities, contingent on reduced
drug use
Targeted constructs: substance-free reinforcement
Social support/peer approval (social
influences
a
; social
support, acquiescence
b
)
HBM/SDT/SImT/TTM Identify (via checklist, writing or conversation) positive peer groups
(clubs, organisations)
Promote identification with positive peer groups (similarities,
leadership opportunities)
Identify social, substance-free activities that are reinforcing
(intramurals, biking, hiking, Big Brothers/Sisters, local jobs)
Social skills training
Targeted constructs: attention to social comparison, social drinking
motives, social identity, campus affiliations
Autonomy (personal responsibility
3
) CDT/SDT/SPT/TTM Explicitly state that change is the individual’s decision
Provide menu of options for change (realistically or hypothetically)
Provide choice whenever possible (mode/content/location of
intervention)
Targeted constructs: choice, controlled orientation
Awareness of contingent outcomes
(beliefs about consequences,
knowledge
a
; feedback
b,c
)
CDT/HBM/SCgT/SRT/TTM Assess for frequency (or likelihood), positivity/negativity and
importance of drinking versus change outcomes (decisional
balance)
Feedback on negative substance use outcomes
Education regarding misguided beliefs/underestimations of severity
and likely outcomes of change
Reframe negative outcomes of substance use as benefits of change
Problem solve negative outcomes of change
Feedback on positive outcomes of change (you saved $Xthis month)
and progress toward goals
Identify (via checklist, writing or conversation) potential rewards for
successive goals
Targeted constructs: alcohol-related problems/risk, consideration of
future consequences, perceived costs, perceived benefits, serious-
ness of referral incident, recognition of problems, retention of
feedback information (outcome valence)
Commitment to behaviour change
(motivation
a,b
; implementation
intentions
b
)
MI/TTM Assess commitment to change and tailor follow-up questions to
provide strategies or additional assessment
Identify (via checklist, writing or conversation) individual’s reasons
and strategies for change, either realistically or hypothetically
(decisional balance)
Allow highly motivated individuals to leave comments regarding
feedback
Targeted constructs: behavioural intentions, change talk, commitment,
readiness to change, sustain talk, use of coping strategies, use of
protective behaviours
Expectancies for behaviour change AET/HBM/SCgT/SRT Education regarding misguided positive expectancies for
substance use
Behavioural tests of positive expectancies for substance use
Identify substance-free activities that also elicit the positive
expectancies for substance use
Reframe negative expectancies for substance use as benefits of change
Targeted constructs: beliefs about drinking, outcome expectancies
(valence and value)
Goals/change plan (goals, behavioural
regulation
a
; menu of options
c
)
SCgT/SRT/TTM Identify (via checklist, writing or conversation) realistic, specific,
time-limited goal
Identify progressive, concrete strategies for goal attainment
Identify barriers to change (cognitive, behavioural, social)
Weigh costs and benefits of each strategy/plan
Identify supportive others who will help individual reach goals
Targeted constructs: (short-term and long-term change goals)
Interpersonal (normative) discrepancy
(subjective norms
b
)
CDT/SNT/SRT/SCmT Descriptive normative comparisons (estimation of peer behaviour,
personal behaviour and actual peer behaviour; percentile rankings)
Injunctive normative comparisons (estimation and actual peer
approval of behaviours)
Reflective normative comparisons (estimation and actual opposite
sex peers’ approval)
(continued )
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on intended behaviours and likely outcomes may also be
effective in preventing high-risk behaviours.
Commitment
Both MI (Miller & Rollnick, 2013) and the transtheoretical
model (DiClemente & Prochaska, 1998) suggest that com-
mitment is integral to behaviour change. Within an MI
framework, commitment is conceptualised separately from
intention or readiness to change (RTC), in that intention/
readiness represents implied but not explicit commitment
(Miller & Rollnick, 2013). As these variables may operate on
a continuum, though, we will discuss them collectively.
RTC has received mixed support as a mediator or
moderator of PFI outcomes, with some studies demonstrating
that higher RTC differentially affects outcomes (Amaro et al.,
2010; Carey, Henson, Carey, & Maisto, 2007; Tomaka,
Palacios, Morales-Monks, & Davis, 2012) and some reporting
Table 3. Continued
Principle of behaviour change Theory Implications for intervention content
Subjective normative comparisons (estimation and actual important
others’ approval)
Assess importance of target behaviour
Targeted constructs: descriptive and injunctive norms (reflective and
subjective norms)
Similarity and importance of nor-
mative referent (subjective norms
b
)
SCmT Assess for similarity to/motivation to comply with referent
Emphasise way in which client relates to referent group (shared
hobbies, goals, experiences)
Reference relevant out-group (rival campus/organisation)
Targeted constructs: gender identity, gender-specific versus gender-
neutral referents
Intrapersonal discrepancy CDT/Rogers/SRT/TTM Feedback regarding impact of substance use on important values,
behaviours or goals
Ranked importance of substance use in comparison to other life
values/goals
Targeted constructs: actual-/self-ideal discrepancy (importance-con-
sistency discrepancy)
Self-efficacy (beliefs about capabil-
ities
a
; self-efficacy
b,c
)
HBM/SCgT/SDT/SRT Identify (via checklist, writing or conversation) previous examples of
successful change
Build mastery via role play, cue exposure or in vivo practice
Elicit vicarious experience via examples of similar, well-liked others
engaging in behaviour change goal
Identify situations in which change is less difficult
Skills training (distress tolerance, deep breathing, relaxation) to cope
with negative physiological and/or affective states
Feedback regarding the impact of substance use on general sense of
self-efficacy
Targeted constructs: alcohol coping, consequence avoidance, drinking
refusal self-efficacy
Skills necessary to overcome barriers
to behaviour change (emotion
a,b
;
skills
a
; ego depletion, task
demands
b
)
HBM/SCgT Assess for perceived barriers of change (intensity and likelihood of
negative expectancies for change, social support, high-risk
situations)
Skills training (drink refusal, harm reduction, desensitisation,
cognitive restructuring, communication, assertiveness, emotion
regulation, distress tolerance, deep breathing, relaxation, problem-
solving, anger management)
Behavioural tests of negative expectancies for change
Coping skills training specific to withdrawal
Targeted constructs: anxiety, coping strategies, delay discounting,
depression, impulsivity, negative effect, novelty-/sensation-seek-
ing, protective behavioural strategies, self-regulation
Therapeutic relationship (empathy,
advice to change
c
)
MI/Rogers Identify an interventionist
Tailor content to individual’s point of view (readiness, preference,
perception of outcomes)
Targeted constructs: MI spirit (client ratings of therapist)
Therapist skill/training MI Targeted constructs: MI-consistent behaviours, MI-inconsistent
behaviours, therapist use of specific techniques
a
Construct identified by Michie et al. (2005).
b
Construct identified by Webb & Sheeran (2005).
c
Construct identified by Bien, Miller, & Tonigan (1993); AET, Alcohol expectancy theory; AUDIT, alcohol use disorders identification test; CDT,
cognitive dissonance theory; HBM, health belief model; MI, motivational interviewing; Rogers, Rogers’ (1957) model of necessary and sufficient
conditions for change; SCgT, social cognitive theory; SCmT, social comparison theory; SDT, self-determination theory; SImT, social impact theory;
SNT, social norms theory; SPT, self-perception theory; SRT, self-regulation theory; TTM, transtheoretical model. Targeted constructs in parentheses
represent those that were discussed or proposed in the current review but have not been tested.
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non-significant effects (Barnett, Murphy, Colby, & Monti,
2007; Carey, Henson, Carey, & Maisto, 2009; Walters, Vader,
Harris, Field, & Jouriles, 2009). Change talk has also received
mixed support as a predictor of drinking outcomes among
college students (appearing more prognostic for voluntary, as
opposed to mandated, students), while sustain talk has been
consistent in predicting worse drinking outcomes (Apodaca
et al., 2014; Vader, Walters, Prabhu, Houck, & Field, 2010).
However, a recent finding that self-exploration, rather than
change talk, mediates intervention outcomes seems to suggest
that the integrated MI process may be more influential in
eliciting behaviour change than specific client utterances
(Borsari et al., 2014).
Commitment is currently elicited most often within the
context of a therapeutic conversation, in which individuals
discuss their personal or hypothetical reasons for change
(Miller & Rollnick, 2013). Similar strategies, such as
decisional balance exercises, have been employed in written
interventions (Wagener et al., 2012) to increase motivation to
change, though their unique efficacy is unclear (Collins &
Carey, 2005; LaBrie, Pedersen, Earleywine, & Olsen, 2006).
Current strategies could potentially be enhanced in future
interventions by having individuals indicate which reasons
and strategies for change they would endorse if they decided
to change in the future or how they would convince a friend
who had alcohol problems to seek treatment or change. Along
the same lines, individuals reporting strong reasons and
ability to change may benefit from leaving comments
regarding their reactions to feedback (a strategy that may
not be effective for individuals low in motivation, as they may
use the opportunity to verbalise sustain talk). Interventions
may also elicit commitment by asking for it, perhaps via
tailored scaled questions. If commitment is strong, feedback
on strategies could be provided; if not, follow-up questions
could elicit what it would take to increase commitment
(Miller & Rollnick, 2013).
Expectancies
Expectancies have been addressed most commonly in alcohol
interventions via alcohol expectancy challenges. Though these
exercises have been effective in altering expectancies and
decreasing drinking across studies, effects do not seem to last
more than four weeks (Scott-Sheldon, Terry, Carey, Garey, &
Carey, 2012) and seem to favour male students (Labbe &
Maisto, 2011). Moreover, the expectancy challenge does not
seem to improve outcomes when used in conjunction with a
brief intervention (Wood, Capone, Laforge, Erickson, &
Brand, 2007), and alcohol expectancies do not seem to be
influential mediators or moderators of PFI effects (Borsari &
Carey, 2000; Kulesza, McVay, Larimer, & Copeland, 2013;
White, Mun, Pugh, & Morgan, 2007). However, researchers
have suggested that the valence (positive or negative) and
weighted value of expected outcomes rather than the
probability of the outcome itself – may be amenable to
intervention and related to decreases in consumption (Fromme,
Kivlahan, & Marlatt, 1986). Therefore, in future interventions,
the valence and value of some expectations (I would feel more
attractive) could be altered using corrective feedback on social
norms (Xpercent of students find sober peers more attractive
than drunk peers), while others (I would enjoy sex more; I
would be funnier) could be altered via education or behavioural
tests (asking peers if s/he is funnier after drinking). Positive
alcohol expectancies may also be addressed by identifying
non-drinking strategies that also elicit those outcomes (e.g.
conversation skills for those expecting increased sociability;
relaxation training for those expecting increased relaxation;
Jones & McMahon, 1998). Conversely, negative alcohol
expectancies may be reframed as benefits of change.
Goals/change plan
Several theories emphasise the importance of setting realistic
change goals and planning how to achieve them. Self-
regulation theory, for example, specifically recommends
setting progressive and concrete goals (Brown, 1998).
DiClemente and Prochaska (1998) also recommend planning
to move only one stage of change (e.g. from pre-contemplation
to contemplation) to promote willingness to engage in
treatment and continue progress after termination. Though
the importance of goal setting has received little empirical
attention within the PFI literature (Curtin, Stephens, &
Bonenberger, 2001), setting and committing to either self-
selected or prescribed goals has been associated with more
positive drinking outcomes (Lozano & Stephens, 2010). Thus,
consistent with theory, providing individuals with the oppor-
tunity to set long-term and progressive short-term goals that
are realistic and time-limited is likely to enhance treatment
outcomes.
Interpersonal discrepancy
Research has found consistently that high-risk drinkers over-
estimate others’ alcohol consumption, that overestimations are
positively correlated with actual drinking behaviours
(Neighbors, Lee, Lewis, Fossos, & Larimer, 2007; Perkins,
Haines, & Rice, 2005), and that correcting misperceptions
leads to reductions in drinking that are often mediated by
changes in normative beliefs (Borsari & Carey, 2000;
Doumas, McKinley, & Book, 2009; Kulesza et al., 2013;
Neighbors et al., 2004). Misperception of others’ approval of
drinking behaviours also influences future behaviour (LaBrie,
Cail, Hummer, Lac, & Neighbors, 2009; Larimer, Turner,
Mallett, & Geisner, 2004), and correcting these misperceptions
has been found to mediate outcomes in some (Turrisi et al.,
2009) but not all (Carey, Henson, Carey, & Maisto, 2010)
experimental studies. Thus, providing feedback that cor-
rects students’ misperceptions of their peers’ drinking behav-
iours as well as peers’, significant others’ or important
others’ approval of drinking behaviours seems to be important
in PFIs.
Both theory and research suggest that the level of discrep-
ancy impacts intervention outcomes, such that interventions
are more effective when referencing similar, important peers
and targeting inaccurate (discrepant) perceptions (LaBrie,
Hummer, Neighbors, & Pederson, 2008). Thus, the behaviour
and group to which the individual is being compared is of
utmost importance. Though multiple behaviours have been
targeted in previous research (drinking quantity, drinking
frequency, frequency of heavy episodic drinking, frequency of
negative consequences, frequency of socialising without
drinking or drinking moderately, prevalence of use of protect-
ive behavioural strategies; refer Miller et al., 2013 for a
DOI: 10.3109/16066359.2014.1001840 Theory and personalised feedback interventions 7
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review), the differential efficacy of their inclusion has not been
examined. Similarly, although interventions could also utilise
an unlimited number of social referents, the additive value of
such comparisons is unclear. It may be interesting in future
studies to determine if ethnicity- or culture-based references
are more effective among subgroups of students who strongly
identify with certain cultures or if comparisons to professionals
in one’s target career are beneficial for older students preparing
to enter the job market. Perceived importance of the behaviour
and motivation to comply with each referent is also expected to
be important in motivating behaviour change (Cooper, 2012;
Fishbein & Ajzen, 1975). Identification with referent groups
may be bolstered by referencing an out-group (another campus
or organisation) or reminding individuals of their similarity to,
emotional involvement with or leadership for the referent
(Tajfel, 1982).
Intrapersonal discrepancy
Several theories (Festinger, 1957; Miller & Brown, 1991;
Rogers, 1957) also emphasise the importance of creating
discrepancy between current behaviour and personal standards
or goals. Interventions may elicit such discrepancies by
providing feedback on how alcohol impacts one’s values
(being a role model, intelligent, healthy), behaviours (exercis-
ing, earning ideal grades) or goals (graduating, becoming a
lawyer). This is already done in a number of interventions via
feedback on monetary or physical costs of drinking and has
been included via personal strivings assessment (Neal & Carey,
2004). Self-ideal discrepancy has also been assessed as a
mediator of outcomes among college students (Murphy,
Dennhardt, Skidmore, Martens, & McDevitt-Murphy, 2010).
However, the perceived importance of ideals is often not
assessed. Measures similar to the valued living questionnaire
(Wilson, Sandoz, Kitchens, & Roberts, 2010) could be used to
enhance the efforts made in previous studies (Neal & Carey,
2004). If individuals report strongly valuing family, for
example, feedback could depict how often they call family
members, do nice things for them, or spend time with them
and how their current drinking pattern impacts those behav-
iours. It may also be useful to have individuals rank the
importance of drinking in relation to other values, as this may
imitate the utility of asking, ‘‘And how does drinking fit in?’’
(Miller, 1998).
Self-efficacy
Self-efficacy has been implicated as important in predicting
and reducing heavy drinking (Collins & Carey, 2007;
LaChance, Feldstein Ewing, Bryan, & Hutchison, 2009;
Norman & Conner, 2006) but has received less explicit
empirical attention within the PFI literature. Though it was
measured in two of the PFI studies reviewed, it was not a
significant mediator of effect in the one study in which it was
tested (Kulesza et al., 2013). Theoretically, self-efficacy
increases as a function of (a) mastery experience, (b) vicarious
experience (modelling), (c) verbal or social persuasion and
(d) decreased physiological arousal/affective states that would
otherwise be interpreted as vulnerability (Bandura, 1998).
Each of these mechanisms could be targeted in interventions in
order to increase self-efficacy. Mastery experience, for
example, is commonly targeted in MI interventions by eliciting
previous examples of successful behaviour change (Walters &
Baer, 2006). Theoretically, mastery experiences may also be
elicited via role play, cue exposure or in vivo practice.
Similarly, vicarious experience may be evoked by reframing
friends who do not drink heavily as models of drinking
behaviour. Verbal persuasions may comprise either direct
encouragement or discussions of situations in which
change is less difficult. Finally, physiological and affective
states that may undermine self-efficacy could be prevented by
incorporating relaxation or deep breathing training modules
into interventions. Because the effectiveness of such strategies
in enhancing the efficacy of PFIs has not been tested
empirically, however, the utility of such interventions is
unknown.
Skills
Individuals must feel capable of overcoming any physical,
social or self-evaluative barriers to change, which likely
overlap with negative expectancies for change (Bandura,
2004). It is important, then, to assess for such barriers, which
may then be targeted using skills training, education or
cognitive restructuring. Behavioural skills training are a
strongly supported treatment strategy for individuals with
alcohol problems (Miller et al., 1998). Though this may
include training on skills specific to avoiding substance misuse
(drink refusal, harm reduction, desensitisation), Miller et al.
(1998) suggest that effective treatment often targets general
skills (communication, assertiveness) and active, rather than
avoidant, coping strategies. Within the PFI literature, protect-
ive behavioural strategies seem to be the most commonly
assessed skill set, with three (Amaro et al., 2010; Barnett et al.,
2007; Larimer et al., 2007) of five studies (Neighbors et al.,
2009; Wood et al., 2010) indicating that it is a significant
mediator of effect. Self-regulation has also been identified as
an indicator of skill but has also received mixed evidence of
importance (Carey et al., 2007; Neal & Carey, 2004; Wood
et al., 2007). Only one study reviewed (Kulesza et al., 2013)
tested the mediating effects of coping strategies; however, they
did find the predicted outcomes.
A number of skills training components could be
incorporated into future PFIs. Training in emotion regulation,
distress tolerance, deep breathing, relaxation, problem-
solving and anger management may facilitate progress in
this area (Blume & Marlatt, 2009). Interventions may also
offer social skills training to enhance ability and self-efficacy
to interact effectively in social situations without alcohol (e.g.
conversation skills, assertiveness). Cognitive barriers to
change may be addressed by assessing the intensity and
likelihood of negative expectancies for change, conducting
behavioural tests of outcomes (e.g. did they quit talking to you
when you quit drinking), or providing specific coping
strategies for negative expectancies of change (relaxation,
conversation; Dobson & Hamilton, 2009; Rohsenow, Smith,
& Johnston, 1985). If physical barriers to change are a
concern, individuals may be provided with information on
ways to cope with withdrawal. Such training could be tailored
based on baseline assessments or included as optional
segments of interventions.
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Therapeutic relationship
Both theory (Miller & Rollnick, 2013; Rogers, 1957) and
research support the importance of therapist factors in
eliciting change talk and positive client outcomes, with
reflective listening, directiveness and emotion focus demon-
strating particularly important roles in evoking behaviour
change (Longabaugh et al., 2005). These conditions translate
more easily to therapy style than to the content of an
intervention. However, the need for a therapeutic relationship
suggests that it may be beneficial, even in written interven-
tions, to identify an interventionist. To be client-centred, it
may also be important to provide feedback from the
individual’s point of view and tailor intervention content to
readiness. For example, if individuals do not view unplanned
sex as negative, interventions may focus on outcomes that
they do see as negative, such as increased risk of sexually
transmitted diseases or unplanned pregnancy; if individuals
report no interest in change, interventions may discuss change
hypothetically (Walters & Baer, 2006).
Conclusion
The current review moves the literature on PFI development
and testing forward in four primary ways. First, it provides
evidence that PFIs for college alcohol misuse are derived from
a variety of theoretical perspectives, many of which are not
tested uniformly across intervention trials (Table 1). Second, it
simplifies the theoretical constructs relevant to behaviour
change that may be incorporated in research as mediators/
moderators of change (Table 3). Third, it clearly illustrates the
way in which theory may be implemented in interventions for
alcohol misuse (refer ‘‘Translation of Theoretical Principles to
PFIs’’ section as well as Table 3). Finally, it outlines a number
of theoretically based intervention strategies that may be
applicable to a variety of addictive behaviours, client samples
and modes of intervention delivery.
Theory is not being tested uniformly across current studies
of PFIs. Almost a third of studies fail to report measurement of
theory-relevant constructs, a quarter of those fail to reference
the theory from which those constructs were derived and a
third fail to report assessment of mediators/moderators of
effect. Collectively, it seems that certain forms of discrepancy
(i.e. descriptive norms) and commitment (RTC) have been
tested consistently, while the importance of principles such as
autonomy, intrapersonal discrepancy and self-efficacy have
received less empirical attention. Investigation of causal
processes is critical for the advancement of both interventions
and evidence-based practice (Longabaugh et al., 2005). Thus,
theory may be useful in determining which principles of
change to target in future research and incorporate in future
interventions, as many current interventions yield small to
moderate effects on drinking (Riper et al., 2009).
It would also be ideal to operationalise and standardise
measurement of the constructs reviewed. A number of
theories cite overlapping constructs that may not represent
unique determinants of change (Bandura, 1998). SDT’s
conceptualisation of competence (Ryan & Deci, 2000), for
example, and the theory of planned behaviour (TPB)’s
perceived behavioural control (Ajzen, 1991) may not differ
meaningfully from social cognitive theory’s self-efficacy
(Bandura, 1997). Likewise, positive and negative alcohol
expectancies have been conceptualised as drinking motives
and motivation to change, respectively (Jones & McMahon,
1998); and readiness to change was measured in 15 different
studies with nine different scales. Negative consequences are
also measured in a variety of ways (Mallett et al., 2013),
whether utilised as outcomes or components of a decisional
balance. Research regarding the practical importance of
differentiating between these constructs and how they are
measured may facilitate understanding and integration of
findings.
While useful in developing and testing interventions for
alcohol misuse, the current review was limited by several
factors. First, it included studies of PFIs specifically targeting
college student drinking. Though the current search resulted
in identification of 20 theoretical frameworks and a list of
behaviour change principles that overlap considerably
with other reviews (Table 3), a number of additional theories
and constructs may be relevant to addictive behaviours.
Specifically, Michie et al. (2005) suggest that social/profes-
sional identity; memory, attention and decision processes; and
the nature of the behaviour (e.g. routine versus automatic)
may be important domains for health behaviour change. Bien,
Miller and Tonigan (1993) also found that advice to change
and a menu of options, which may broach aspects of the
therapeutic relationship, were common elements of effective
interventions. Similarly, though backward searches of identi-
fied articles were conducted, the use of specific search terms
may have led to oversight of relevant articles. A second
limitation of the current study is the comprehensive review of
only 13 theoretical frameworks. More fine-grained review of
excluded theories (e.g. TPB) as well as theories that have not
been commonly incorporated into PFIs may elicit additional
constructs and strategies for change (e.g. attentional bias
modification; see Cox, Fadardi, Intriligator, & Klinger, 2014).
Finally, we suspect that the brevity of publications may have
limited authors’ abilities to explicitly cite and expand on the
theories from which they were operating. However, secondary
mediator/moderator analyses of original studies were included
in the current review, so vigorous tests of theory are not likely
underestimated.
Both clinicians and researchers benefit from the use of
treatment strategies that directly target mechanisms of
change. Theory contributes to our understanding of health
behaviours and offers guidance in determining intervention
content, construct measurement, outcome interpretation and
study application. The current review provides the field with a
number of theoretically based principles of and strategies for
change. Future studies examining which of these principles
and strategies are most effective in eliciting positive outcomes
is warranted. Continued application of these principles in
research will provide us the opportunity not only to refine and
improve treatment strategies but also to incorporate new and
innovative components into current interventions.
Declaration of interest
The authors report no conflicts of interest. The
authors alone are responsible for the content and writing of
the article.
DOI: 10.3109/16066359.2014.1001840 Theory and personalised feedback interventions 9
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... Despite their widespread use and current status as the most effective available resource, small effect sizes have led researchers to highlight the "need for the development of more effective intervention strategies" . A review of interventions for college student drinking noted that "significant enhancement of personalized feedback intervention efficacy has not been observed in over 15 years of study" (Miller et al., 2015). Newer directions of study include the application of behavioral economic theory to addressing college substance use (Murphy et al., 2019(Murphy et al., , 2012(Murphy et al., , 2015, as well as the use of pharmacotherapy (DeMartini et al., 2016;O'Malley et al., 2015), both of which have been demonstrated to enhance reductions in substance use associated with BMIs. ...
... In addition to assessing whether expanded personalized feedback is an effective means of preventing or reducing risky substance use, as this literature grows it will also be important to assess how personalized feedback programs impact behavior change. Despite the prevalence of brief alcohol interventions, the mechanisms by which these programs lead to behavior change remains largely unknown, with many theoretical frameworks specified, and measurement of intermediary mechanisms in college intervention studies often inconsistent or absent (Miller et al., 2015). The emerging literature on personalized prevention has also thus far largely failed to specify mechanisms of change (Conrod et al., 2011. ...
... We hypothesize that increased knowledge of one's underlying risk for substance use problems will enhance motivation to engage in healthier behaviors and increase readiness to change behavior among those already engaging in risky drinking. Readiness to change is believed to be a central target for BMI effectiveness (Miller et al., 2015). ...
Article
Objective: Risky substance use among college students is widespread, and associated with numerous adverse consequences. Current interventions focus primarily on students' current substance use; we hypothesize that shifting focus from current use to underlying risk factors is a complementary approach that may improve effectiveness of prevention/intervention programming. This approach aligns with the personalized medicine movement, which aims to harness knowledge about underlying etiological factors to provide individuals with specific information about their unique risk profiles and personalized recommendations, to motivate and enable individuals to better self-regulate their health. Method: Our group is building and evaluating an online Personalized Feedback Program (PFP) for college students that provides feedback about the individual's underlying genetically influenced externalizing and internalizing risk factors for substance use, along with personalized recommendations/resources. The project capitalizes on work from a university-wide research project (Spit for Science; S4S), in which > 12,000 students (˜70% of 5 years of incoming freshmen) are being followed longitudinally to assess substance use and related factors across the college years. In this article, we describe our foundational work to develop the PFP. Results: From the S4S data, we have identified risk factors across four domains (Sensation Seeking, Impulsivity, Extraversion, and Neuroticism) that are correlated with college students' substance use. We developed an online self-guided PFP, in collaboration with professionals from student affairs, and using feedback from students, with the ultimate goal of conducting a randomized clinical trial. Conclusion: The provision of personalized risk information represents a novel approach to complement and extend existing college substance use programming. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Personalized normative feedback (PNF) interventions can be considered as a subset of personalized feedback interventions (PFIs). Personalized feedback interventions (PFIs) aim to 'increase the salience of normative and personal standards in order to promote thoughtful consideration' about one's own behavior [35]. Personalized normative feedback interventions (PNF) make use of injunctive and/or descriptive normative information to elicit behavior change. ...
Article
Full-text available
Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.
... Understanding the mechanisms of change Reid and Carey (2015) have argued that improvements in intervention efficacy are most likely to be achieved by investigating mechanisms of change, rather than just testing efficacy alone (see also Miller et al. 2015). In addition, there have been calls for research to adopt factorial designs (e.g. ...
Article
Full-text available
Objectives: To test the effects of exposure to a campaign to discourage drinking alcohol drinks down in one gulp (‘bolting’). Method: Laboratory experiments assessed the effects of exposure to (1) the campaign (Pilot Study; N = 48), (2) the campaign combined with an injunctive norm message of explicit peer disapproval of bolting (Study 1; N = 78), and (3) the campaign and a descriptive norm message of low prevalence of bolting (Study 2; N = 96) on both normative perceptions of bolting and bolting intentions. Results: The Pilot Study showed that the campaign had no effect on norm perceptions or bolting intentions. In Study 1, the campaign was associated with higher, not lower, intentions to bolt drinks, an effect exacerbated by the injunctive norm information. Bootstrapping analyzes of the indirect effects showed that participants perceived that bolting was more common when exposed to the campaign combined with the injunctive norm, and these negative descriptive norm perceptions were associated with stronger bolting intentions. In contrast, Study 2 showed that addition of the descriptive norm (i.e. low prevalence information) enhanced the effectiveness of the campaign. Conclusions: The results highlight the potentially harmful effects of exposure to an injunctive norm message of disapproval information and distinguish them from the beneficial impact of exposure to a descriptive norm message of low prevalence. The importance of pre-testing campaigns and providing process evaluations is discussed.
Article
The primary aim of the current study is to determine the incremental efficacy of adding a novel values component to a personalized feedback intervention for young adult drinking. Undergraduate students (N = 254) were randomized to receive either traditional, traditional with values assessment, or values enhanced feedback. Results showed significant decreases in drinks per week (p < .01) and alcohol-related consequences (p < .05) across all feedback conditions. Further research is needed to determine whether using values-based feedback could enhance intervention effects and how best to incorporate feedback in a way that is feasible and acceptable to recipients.
Article
The Behavior Change Technique Taxonomy version one (BCTTv1) was used to identify behavior change techniques (BCTs) to understand the current state of science of binge drinking interventions targeting college students. Thirteen studies were reviewed and 32 different BCTs were identified, with the most frequently coded BCTs being Feedback on behavior (2.2) and Social comparison (6.2). There was no apparent reason for how many BCTs were used in each intervention. Binge drinking interventions must use more diverse methods and focus on using several BCT categories like Regulation (11), which develops skills for behavioral maintenance, to create more effective prevention efforts.
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Assessment and personalised feedback are important components of brief interventions (BIs) for cannabis use. A key outcome is to increase motivation to change during this short interaction. The diversity of available assessments and time burden scoring them pose a challenge for routine use in clinical practice. An instant assessment and feedback (iAx) system was developed to administer assessments informed by bioSocial Cognitive Theory, that were instantly scored and benchmarked against clinical norms, to provide patient feedback and guide treatment planning. This study evaluated the feasibility and additive effectiveness of the iAx on motivation to change cannabis use, when compared to treatment as usual (TAU), in a single-session BI. A randomised controlled trial was conducted in a public hospital alcohol and drug outpatient clinic. Eighty-seven cannabis users (Mage = 26.41; 66% male) were assigned to the BI utilising the iAx (iAx; n = 44) or to the standard BI (TAU; n = 43). Patients completed pre- and post-BI assessments of motivation to change and a post-BI measure of treatment satisfaction. Practitioners completed a feedback survey. Patients receiving iAx reported a significantly greater increase in motivation to change from pre- to post-BI compared to patients receiving TAU (d = 0.49, p = .03). Treatment satisfaction was high across both conditions, with no significant difference between groups (p = .57). Practitioners also reported a high level of satisfaction with the iAx system. In summary, findings support the feasibility and additive effectiveness of the iAx to enhance patient motivation during cannabis BI.
Article
Objective Adverse consequences of binge drinking episodes are well-established, but fewer studies have investigated how incremental changes in daily alcohol use relate to well-being. We examined within- and between-person associations in alcohol use and next-day valued living to enhance our understanding of the impact of alcohol use on following-day outcomes in college students. Participants. During November 2018, 73 undergraduate participants (65.7% female) completed surveys through Qualtrics. Method: Using daily diary methodology, participants completed nightly surveys (N = 784) on their cellular devices over a two-week period. Results: Within-participant variations in evening alcohol use demonstrated a negative linear association with next-day valued living, controlling for relevant variables. Conclusions: Findings supplement other studies demonstrating the impact of individual variability in alcohol use on engagement in valued behaviors. Knowledge of the hazards of alcohol use within the context of valued living has the potential to inform alcohol use prevention and intervention programs.
Article
Given the equivocal literature on the relationship between internalizing symptoms and early adolescent alcohol use (AU) and AU disorder (AUD), the present study took a developmental perspective to understand how internalizing and externalizing symptoms may operate together in the etiology of AU and AUD. We pit the delayed onset and rapid escalation hypothesis (Hussong et al., 2011) against a synthesis of the dual failure model and the stable co-occurring hypothesis (Capaldi, 1992; Colder et al., 2013, 2018) to test competing developmental pathways to adolescent AU and AUD involving problem behavior, peer delinquency, and early initiation of AU. A latent transactional and mediational framework was used to test pathways to AUD spanning developmental periods before AU initiation ( Mage = 11) to early and high risk for AUD ( Mage = 14–15 and Mage = 17–18). The results supported three pathways to AUD. The first started with “pure” externalizing symptoms in early childhood and involved multiple mediators, including the subsequent development of co-occurring symptoms and peer delinquency. The second pathway involved stable co-occurring symptoms. Interestingly, chronically elevated pure internalizing symptoms did not figure prominently in pathways to AUD. Selection and socialization effects between early AU and peer delinquency constituted a third pathway.
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Explainable AI aims at building intelligent systems that are able to provide a clear, and human understandable, justification of their decisions. This holds for both rule-based and data-driven methods. In management of chronic diseases, the users of such systems are patients that follow strict dietary rules to manage such diseases. After receiving the input of the intake food, the system performs reasoning to understand whether the users follow an unhealthy behavior. Successively, the system has to communicate the results in a clear and effective way, that is, the output message has to persuade users to follow the right dietary rules. In this paper, we address the main challenges to build such systems: i) the natural language generation of messages that explain the reasoner inconsistency; and, ii) the effectiveness of such messages at persuading the users. Results prove that the persuasive explanations are able to reduce the unhealthy users’ behaviors.
Article
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Background Young people’s risky use of alcohol or recreational drugs, such as cannabis, remains a significant public health issue. Many countries have made substantial efforts to minimize the long-term consequences of alcohol and/or cannabis use at multiple levels, ranging from government policy initiatives to primary health care services. In this review, we focused on the effects of brief interventions, provided by electronic devices (computerized brief interventions). A brief intervention is defined as any preventive or therapeutic activity delivered by a health worker, psychologist, social worker, or volunteer worker, and given within a maximum of four structured therapy sessions each lasting between five and ten minutes with a maximum total time of one hour. Brief interventions may work by making the clients think differently about their alcohol/cannabis use, and by providing them with skills to change their behavior if they are motivated to change. A computerized brief intervention, in contrast, is not directly delivered by a human being, but may be delivered through online and offline electronic devices. Such interventions can reach large audiences at a low cost and can simultaneously simulate an ‘interpersonal therapeutic component’ by targeting recipients’ feedback. Objectives To assess the effectiveness of early, computerized brief interventions on alcohol and cannabis use by young people aged 15 to 25 years who are high or risky consumers of either one or both of these substances by synthesizing data from randomized controlled trials. Search methods We searched 11 electronic databases including MEDLINE, PsycINFO, EMBASE, Cinahl and The Cochrane Library in April 2016 for published, unpublished and ongoing studies using adapted subject headings and a comprehensive list of free-text terms. Additionally, we searched the reference lists of the included studies. We also have set up an EBSCO host alert notification (EPAlerts@EPNET.COM) that continuously surveys the Cochrane Library (including CENTRAL), Medline and Embase. We receive updated searches via email. This search is up to date as of May 2016. Selection criteria We included all randomized or quasi-randomized controlled trials of any computerized brief intervention used as a stand-alone treatment aimed at reducing alcohol and/or cannabis consumption. Eligible comparators included no intervention, waiting list control or an alternative brief intervention (computerized or non-computerized). Participants were young people between 15 and 25 years of age who were defined as risky consumers of alcohol or cannabis, or both. Data collection and analysis Two researchers independently screened titles and abstracts against the inclusion criteria. Two researchers independently assessed the full texts of all included articles. We used standard methodological procedures expected by the Campbell Collaboration. Results We included 60 studies that had randomized 33,316 participants in this review. Study characteristics: The studies were mostly from the United States and targeted high and risky alcohol use among university students. Bias/quality assessment: Some of the studies lacked clear descriptions of how the randomization sequence was generated and concealed. Many of the studies did not blind the participants. Some of the studies suffered from high loss to follow-up, and few studies had a pre-registered protocol. Findings: For alcohol, we found moderate quality evidence that multi-dose assessment and feedback was more effective than a single-dose assessment. We found low quality evidence that assessment and feedback might be more effective than no intervention. Assessment and feedback might also be more effective than assessment alone (low quality evidence). Short-term effects (< 6 months) were mostly larger than long-term (≥6 months) effects. For cannabis, we found that assessment and feedback might slightly reduce short-term consumption compared to no intervention. Adding feedback to assessment may have little or no effect on short-term cannabis consumption. Moreover, there may be little or no difference between assessment plus feedback and education on short-term and long-term cannabis consumption. Adverse effects: We did not find evidence of any adverse effects of the interventions. Implications for policy, practice and research Computerized brief interventions are easy to administer, and the evidence from this review indicates that such brief interventions might reduce drinking for several months after the intervention. Additionally, there is no evidence for adverse effects. This means that brief, computerized interventions could be feasible ways of dealing with risky alcohol use among young people. The evidence on cannabis consumption is scarcer, suggesting the need for more research.
Article
This study investigated the clinical significance of previously reported statistically significant mean reductions in drinking and related problems among college students in a randomized trial of a brief indicated preventive intervention (G. A. Marlatt et al., 1998). Data were analyzed over a 2-year follow-up for participants from a high-risk intervention group (n = 153), a high-risk control group (n = 160), and a functional comparison group (n = 77). A risk cutpoint for each dependent measure was based on the functional comparison group distribution. Compared with the high-risk controls, more individuals in the high-risk intervention group improved and fewer worsened, especially on alcohol-related problems and, to a lesser extent, on drinking pattern variables. These data from a prevention context clarify the magnitude and direction of individual change obscured by group means.
Article
Objective: The current study examined the efficacy of mailed personalized normative feedback (PNF) as a brief alcohol intervention for at-risk college drinkers, and investigated discrepancy as a possible mediator of the intervention effect. Method: Participants consisted of 100 at-risk college drinkers who completed an alcohol-use assessment at baseline, 6-week posttest and 6-month follow-up. Measures included number of drinks consumed per heaviest drinking week, frequency of heavy-drinking episodes, peak blood alcohol concentration and number of alcohol-related problems, all for the last month. Participants were randomly assigned to either a mailed brief intervention (MBI; n = 49) or attention-control (C; n = 5 1) group. The MBI group received mailed PNF that was based on baseline responses to the drinking measures; the C group received a psychoeducational brochure about alcohol. Results: Mixed-model, repeated measures ANOVAs were used to examine the effects of time, group and gender on discrepancy and the drinking variables. Following the intervention, the MBI group reported significantly higher perceived discrepancy between self and others' drinking than the C group, The MBI group reported consuming significantly fewer drinks per heaviest drinking week and engaging in heavy episodic drinking less frequently than the C group at the 6-week posttest; however, these differences were no longer evident at the 6-month follow-up. Hierarchical regression analyses did not provide evidence for the hypothesized mediating effect of discrepancy. Conclusions: Mailed PNF may be a cost- and time-efficient means of developing discrepancy and temporarily reducing heavy alcohol consumption among at-risk college drinkers.
Article
Descriptive norms, which are beliefs about the most commonly exhibited behavior in a group, are commonly used in normative interventions to reduce harmful drinking and perceptions about the extent of drinking among peers. The present study examined if interventions utilizing gender personalized normative would decrease subjects ' misperceptions and individual drinking behavior (frequency and quantity) more than both a no feedback control group, and a group receiving standard normative feedback. The sample consisted of 161 female and 85 male participants with an average age of 21. Results demonstrated that feedback decreased misperceptions of others 'alcohol use, however significant differences were not found between gender-specific feedback and gender nonspecific feedback, suggesting that tailoring the feedback by gender may not be particularly beneficial. Also, reductions in drinking among the groups from baseline through 2 month follow-up were not observed. Implications of the results and suggestions for further research that might refine social normative approaches are discussed.