Current Knowledge in Prevention of Alcohol and Other Drug Abuse
"There is nothing quite so practical as good theory and nothing so good for theory-making as direct involvement with practice."
-Nevitt Sanford
Background
Most alcohol and other drug education efforts in institutions of higher education are being conducted by student affairs professionals (Sandeen 1988). Since the 1960s, most student affairs programs have been based on theories of student development, which focus on enriching the individual (Widick, Knefelkamp & Parker 1980). However, to find guidance for developing alcohol and other drug education programs, program designers in higher education have primarily reviewed literature on alcohol and drug abuse rather than student development theory.
This drug abuse literature contains numerous theories. In a monograph on contemporary theories of drug abuse (Lettieri, Sayers & Pearson 1980), 43 theories are covered. To add to the complexity, the theories span the disciplines of social, behavioral, and biological sciences. Deciding which of these theories is most effective is difficult because the data have not been empirically tested for most of the current theories (Galizio & Maisto 1985). Thus, research in this field is not as rigorous as it could be.
In addition, few of the existing, workable theories have been applied to the field of drug abuse prevention and education. Alcohol and other drug education programs in colleges (and in elementary and high schools) have been developed in an atheoretical manner. That is, they have been based on educational judgments that are not supported in the research literature (Braucht & Braucht 1984; Bukoski 1986; Schaps, DiBartolo, Moskowitz, Palley & Churgin 1980). Failure to base program development on theory is especially characteristic of alcohol and drug education programs on college campuses (Gonzalez 1988a; Saltz & Elandt 1986), where such programs have proliferated rapidly in recent years (Gadaleto & Anderson 1986). The lack of theoretical frameworks for college efforts has made it difficult to conduct program evaluation and has led to increasing demands from college administrators for information on "what works" to prevent alcohol and other drug-related problems (Magner 1988). The purpose of this section is to review the most influential concepts in the prevention field and to identify models that may be applicable to alcohol and other drug education on the college campus.
Dominant Theoretical Models
Sociocultural Model of Prevention and Distribution-of-Consumption Theory
Although several theoretical models relevant to alcohol and drug education have been proposed (Amatetti 1987), few prevention and education programs, particularly on college campuses, have been developed based on these models. Most of these programs are based on the sociocultural model of prevention. An assumption made in the sociocultural model is that change in knowledge will lead to a change in social norms. Applied primarily to alcohol education, this model suggests that social norms about drinking must be changed to reduce alcohol problems. The prevention goal focuses on establishing new social norms that will promote safe, responsible drinking (Nirenberg & Miller 1984). According to Nirenberg & Miller (1984, p. 10), "This would be achieved by (1) clearly distinguishing between responsible drinking and alcohol abuse, (2) establishing a "safe" drinking level in terms of quantity and frequency, (3) reducing the social importance and mystique of drinking, and (4) emphasizing the use of alcohol in a social-recreational context rather than solitary drinking for the purpose of intoxication." The sociocultural model of prevention assumes that if people are provided with information about alcohol (or other drugs) and their effects, people's knowledge about these substances will increase. Increased knowledge will then lead to positive attitude changes, which will be followed by less use or abuse. Goodstadt (1978) examined the assumptions made under this knowledge-attitude-behavior framework and found them to be seriously flawed. Nevertheless, such assumptions have dominated the thinking of college prevention practitioners since the mid-1960s.
Perhaps the most important factor in the rapid proliferation of alcohol education programs in American colleges and universities during the 1970s and 1980s was the 50 Plus 12 Project sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (Kraft 1976; Gadaleto & Anderson 1986). The goals of this sociocultural model-based project were (1) to gather information regarding drinking practices and activities on campus; (2) to disseminate information about alcohol, alcohol use, and alcohol abuse; and (3) to encourage universities to develop alcohol-related educational programs. As part of this effort, the Whole College Catalog About Drinking (Hewitt 1976) was disseminated to every college and university in the United States. This publication endorsed the development of responsible attitudes toward alcohol as the overriding goal of alcohol education and prevention on the college campus.
The 50 Plus 12 Project was extremely successful in encouraging college representatives to discuss alcohol abuse and to develop programs of education and prevention. Reporting on a follow-up of this federal effort, Kraft (1977) found that the project had stimulated alcohol education programming at 81 percent of the participating universities. The concept of responsible drinking promoted by the project became a dominant theme. However, despite efforts to define "responsible drinking" behaviors (Gonzalez 1978; 1990), the concept has generally remained ambiguous. In a poster distributed nationally by the NIAAA in the mid-1970s, the following caption appeared: "If you need a drink to be social, that's not social drinking." Such definitions have been criticized in the research literature as being too general to prevent alcohol-related problems (Cellucci 1984). As a result, NIAAA prevention efforts have changed their emphasis from promoting responsible drinking to reducing overall per capita consumption of alcohol (NIAAA 1984).
The change in emphasis from promoting responsible drinking to discouraging the use of alcohol results from two related factors. First, the sociocultural model of prevention is being abandoned in favor of a distribution-of- consumption model (Holder & Stoil 1988). The distribution-of-consumption (or single-distribution) model is based on the theory that a direct relationship exists between the amount of alcohol consumed and alcohol problems in a population (Bruun et al. 1975). Those supporting this model seek to reduce the availability of alcohol by increasing its price, reducing the number of hours during which it is sold, and limiting the age at which it can be purchased. They are interested in using public policy to help prevent alcohol and other drug abuse. For illicit drug use, the concepts of "supply reduction" and "user accountability" have become popular in national prevention policy (U.S. Congress 1988). Interest has increased regarding the legal aspects of manipulating public policy in these ways (Gordis 1988; Moore & Gerstein 1981; NIAAA 1987).
The research shows that although availability influences the incidence of alcohol problems (Moskowitz 1986), the relationship between the two is not clear. For example, there is considerable evidence that the minimum legal drinking age affects the number of automobile crashes among affected age groups (Cook & Tauchen 1984; DuMouchel, Williams & Zador 1987; Wagenaar 1983). The effects of the legal drinking age on alcohol consumption in general (Hingson et al. 1983; Vingilis & Smart 1981)-and on alcohol use among college students in particular (Gonzalez 1989b; Hughes & Dodder 1986; Perkins & Berkowitz, in press)-is less clear. In summarizing the effects of regulations on drinking and driving, Moskowitz (1986, p. 34) said, "The extent to which formal controls are effective may depend upon their ability to stimulate or reinforce informal social controls. Hence, formal controls must be congruent with informal controls and must be adequately communicated to be effective." Therefore, efforts made on campus to reduce the availability of alcohol by formulating policies should be carefully designed to fit the campus culture. For example, the campus policy may require parties to have closed bars rather than kegs and have the bar attended by trained students of legal drinking and serving age who could serve as monitors.
The second reason for the change in emphasis from promoting responsible drinking to discouraging the use of alcohol is that no one has been able to demonstrate experimentally the effectiveness of prevention approaches based on the sociocultural model. In an extensive review of the literature on evaluating educational strategies to prevent alcohol problems (most of them conducted with school-age children), Braucht and Braucht (1984) reported that researchers widely agree that information-only strategies do not have much effect on behavior. However, they added, "[S]evere and pervasive methodological flaws in the extant evaluation studies make any conclusions regarding the effectiveness of alcohol/drug-use educational strategies more a matter of reliance on faith than on credible empirical evidence" (p. 262). The same thing can be said of all approaches to the prevention of alcohol problems (Moskowitz 1986) and to health education in general (Lorig & Laurin 1985).
If the sociocultural model (and its focus on the promotion of responsible attitudes about drinking) is to remain viable, educators must demonstrate the effectiveness of such programs for reducing alcohol-related problems. Goodstadt and Caleekal-John (1984) identified 14 studies that have experimentally assessed the impact of campus-based alcohol education programs. The authors concluded that the number of experimental studies is sufficient to begin to assess the potential for such programs even though all of the studies had problems in research design and/or analysis. Kinder, Pape, and Walfish (1980) proposed criteria to be used as minimal requirements for future research projects. Desirable features include (1) adequate descriptions of the target population and educational methods; (2) random assignment to experimental and control groups; (3) collection of follow-up data; (4) appropriate statistical procedures; (5) experimental designs capable of detecting potential interaction effects (e.g., type of educational strategy by type of student); (6) behavioral assessment at different points in time as well as assessment of knowledge, attitudes, and other intermediate variables; and (7) "the greatest need and challenge for all research in the area is the development and use of measures of attitudes, knowledge, and behavior that are psychometrically adequate" (p. 1052). The importance of these and other assessment issues is discussed in more detail by Berkowitz in section VI.
Value Expectancy Theories
Value expectancy theories are a family of theories stating that an individual's behavior can be predicted (Goldman, Brown & Christiansen 1987; Rotter 1954). One such theory widely used in the design of alcohol and other drug education, as well as in general health education, is the health belief model. The health belief model relates theories of decision making to an individual's perceived ability to choose from alternative health behaviors (Rosenstock 1974). The theory underlying the health belief model has been attributed to Lewinian theory of goal setting in the level-of-aspiration situation. Lewin (cited in Maiman & Becker 1974) hypothesized that behavior depends primarily upon two variables: (1) the value placed by an individual on a particular outcome and (2) the individual's estimate of the likelihood that a given action will result in that outcome. In the health belief model, an individual's motivation to act is analyzed as a function of whether or not he or she expects to attain a health-related goal. The health belief model provides a theoretical basis from which health-related behavior might be predicted and altered.
Rosenstock (1974) said that the health belief model is based upon the idea that it is the world as it is perceived that will determine an individual's actions and not the actual physical environment. (This theory is derived from phenomenology, a branch of philosophy.) According to this model, individuals will act to avoid a health problem, but they first need to believe they are personally susceptible to the problem. Second, they need to perceive the severity of the situation before they will take a particular action. Third, the probability that an individual will act to improve his or her health is determined by the individual's perception of the benefits of and barriers to alternative behaviors. A beneficial alternative is one that is likely to reduce the severity of a health problem or one's susceptibility to it. Finally, a "cue to action" such as an internal stimulus (e.g., perception of bodily states) or an external stimulus (e.g., mass media communications, personal knowledge of someone affected by the condition) must occur to trigger the appropriate health behavior.
The health belief model has been used to design individually focused drug education and prevention programs (Albert & Simpson 1985; Iverson 1978; Kaufert, Rabkin, Syrotuik, Boyco & Shane 1986). Kleinot and Rogers (1982) successfully applied this model to an alcohol education program for college students. The program focused on (1) the adverse consequences of excessive drinking, (2) the probability that these consequences would occur, and (3) the effectiveness of abstinence or moderation in preventing these consequences. In their experiment, Kleinot and Rogers systematically examined the effects of this information on students. They found that college student drinkers' intentions to moderate their drinking habits were positively affected by the information.
Portnoy (1980) developed a for-credit alcohol education course for college students incorporating factors of the health belief model and persuasive communication strategies. The results of a multivariate analysis of variance demonstrated the overall effectiveness of the program. Portnoy concluded that the program was effective for college students who were not problem drinkers because it increased their knowledge about alcohol, reinforced desirable attitudes and beliefs, and reduced beer consumption. He suggested that the program could have had greater personal impact if more emphasis had been placed on the subjects' susceptibility to alcohol-related problems, such as difficulties relating to peers and parents or traffic citations for drunk driving. These problems were seen as potentially more relevant than presenting medical and psychological problems, which often seem irrelevant to college students.
In addition to predicting an individual's health-related behavior, the health belief model can help predict an institutional or societywide response to a health problem (Gonzalez 1988a). For example, efforts have been conducted over the last 10 years to encourage college leaders nationwide to discuss the impact of alcohol on their campuses. As a result, alcohol abuse has been recognized as one of the leading social and health threats to college students (Goodale 1986; Ingalls 1982; Sherwood 1987). Similarly, more recent attention by the U.S. Department of Education on the use of illicit drugs on campus is increasing the perception of drugs other than alcohol as major threats to college students. Thus, the first two principles of the health belief model-susceptibility to and severity of the problem-can be seen as driving forces in the development of alcohol and other drug education programs on campus.
The third principle of the health belief model-the perception that alternative behaviors will bring positive benefits-is receiving increased attention among college administrators. Speaking at the First National Conference on Campus Policy Initiatives held in Washington, D.C., Dr. John W. Ryan, president of Indiana University, said, "Effective alcohol education programs and policy initiatives on campus have changed-from something we all wanted but could not afford . . . to something we cannot afford to be without" (Ryan 1986, p. 78). Such pronouncements have helped change the attitudes of campus leaders from benign neglect (Ingalls 1982) to increasing concern for prevention programs (Fischer 1987; Gonzalez 1985). This new level of motivation has been translated into action by the increase in both internal and external stimuli (i.e., "cues to action" in the health belief model) resulting from the changing public attitude toward alcohol use. One particularly strong stimulus has been the growing tendency of the courts to impose third-party liability charges on colleges that permit alcohol-related violations of law or policy that result in injury or death. According to a white paper sponsored by the American Council on Education (1986) and disseminated to college presidents nationwide, "The important point is that every school should appraise its policy in light of the changing temper of public policy toward alcohol abuse" (p. 69). In addition to serving as a strong incentive to action, such liability cases and warnings underscore the severity of the alcohol (and increasingly other drug) problems confronting higher education. Just as the health belief model predicts, colleges are taking numerous steps to protect themselves by implementing educational programs and policy changes (Gadaleto & Anderson 1985; Gonzalez & Broughton 1986; Sherwood 1987).
In a review of health belief model investigations published from 1974 to 1984, as well as from findings of 17 studies conducted before 1974, Janz and Becker (1984) found that the "perceived susceptibility" dimension of the model was particularly important for preventive health behavior. This finding has important implications for using this model to design college alcohol and other drug abuse prevention programs. It suggests that such prevention efforts should emphasize information about personal susceptibility and risks associated with substance abuse. Unless students' perception of personal susceptibility is increased as a result of the programs, the students are not likely to be motivated to take responsibility for using these substances properly. College students tend to be overly optimistic about the probability of being harmed (Weinstein & Lachendro 1982). Yet, such students must be led to realize that they are not invulnerable to physical, psychological, and social harm. They must realize their personal risk from drug use. These realizations are crucial to information-based interventions designed to reduce the use of harmful drugs (Cvetkovich, Earle, Schinke, Gilchrist & Trimble 1987).
In a study to assess the efficacy of health beliefs as predictors of smoking cessation, the researchers found that general health concern and perceived susceptibility were the major predictors (Kaufert et al. 1986). A concept closely related to perceived susceptibility is the risk perceived to be associated with unhealthy practices (Lorig & Laurin 1985). Epidemiological studies have found that perception of increased risk was associated with declines in reported drug use by high school students (Johnston 1985). Using data from 11 annual surveys of high school seniors (1976-1986), Bachman, Johnston, O'Malley, and Humphreys (1988) found that the increased perception of risks associated with marijuana use resulted in a reduction of marijuana use reported by the students. The researchers suggest that the shifting views about risks may have influenced the increases found in the students' own disapproval of drug use, the disapproval they convey to others, and the disapproval others convey to them.
In challenging the "conventional wisdom" about the inability of information to affect behavior, Bachman et al. (1988, p. 109) concluded that "information about risks and consequences of drug use, communicated by a credible source, can be persuasive and can play an important role in reducing demand, which ultimately must be the most effective means of reducing drug use." This conclusion is supported by empirical research regarding the power of the health belief model to prevent unwanted behavior (Janz & Becker 1984). In a multiple regression analysis of variables predictive of alcohol, marijuana, and cocaine use among college students, perception of risk emerged as the strongest predictor (Gonzalez & Haney 1990). Thus, prevention programs that focus on increasing the perception of risk (associated with alcohol and other drug use) are supported in theory as well as in empirical research.
Another expectancy theory that has been receiving increased attention in the alcohol and other drug education and prevention field is the social learning theory (Bandura 1977a, 1977b, 1986). This theory is based on a self-efficacy paradigm. According to the paradigm, behavior change and maintenance are functions of (1) expectations about the outcomes of engaging in a behavior and (2) expectations about one's ability to engage in the behavior. Beliefs about whether a given behavior will lead to a given outcome are termed outcome expectations, and beliefs about how capable one is of performing the behavior that leads to those outcomes are termed efficacy expectations. Social learning theory places more emphasis on environmental influences than does the health belief model. According to social learning theory, alcohol and other drug use is socially learned, purposeful behavior resulting from the interplay between socioenvironmental factors and personal perceptions (Johnson & Solis 1983).
Prevention approaches based on social learning theory have emphasized developing social and personal skills in youth and young adults to enable them to resist pro-drug environmental and peer pressures (Botvin 1983). Based on the premise that unhealthy behaviors are maintained through periodic social reinforcement and environmental cues, recent prevention programs based on social learning theory have combined two efforts: those to correct perceptions of social norms and those to individualize instruction on peer refusal and social skills (Botvin & Wills 1985).
In general, these "psychosocial" approaches to alcohol and other drug abuse prevention fall into two general categories: (1) programs that focus primarily on social influences believed to promote alcohol and other drug use and (2) training approaches designed to enhance personal and social competence. The social influences method seeks to increase students' resistance to group social pressures to smoke and use other drugs by making them more aware of these pressures and by helping them develop effective counter-arguments (Hansen 1990). The personal and social competence method helps students develop personal characteristics associated with a low susceptibility to alcohol and other drug abuse. These characteristics include assertiveness skills, effective interpersonal communication skills, and social and decision-making skills. Supporters of this broad-based personal and social competence method (Hawkins, Lishner, Catalano & Howard 1986) have argued that prevention strategies must do more than provide youngsters with the skills necessary to resist pressures to smoke, drink, and use other drugs. Such strategies must also reduce students' motivation to use these substances by increasing their personal and social competence skills and by increasing their perceptions of the risks drugs pose.
Systems Theory
Increasingly, communitywide, comprehensive efforts are being supported for the prevention of alcohol and other drug-related problems. Communitywide prevention refers to applying prevention strategies throughout a community in a sustained, highly integrated approach that simultaneously targets and involves diverse people. The theoretical foundations for this approach are drawn from general systems theory; research methodology; health planning; epidemiology; and to a lesser extent, planned-change concepts (Benard 1990). Various communitywide interventions have been developed for many public health problems, ranging from heart disease prevention to health promotion (Johnson & Solis 1983; Perry 1986). The rationale for applying these models to the prevention of alcohol and other drug abuse assumes that there are multiple causes for drug abuse and that prevention efforts focused on a single system will probably fail (Benard 1990).
Theories and models guiding most current, communitywide prevention efforts tend to emphasize personality and coping variables and the ways these factors interact with the environment to contribute to alcohol and other drug problems (Perry 1986). One of the most influential theories in this multilevel approach to prevention is problem behavior theory (Jessor & Jessor 1977). Problem behavior theory focuses on three major levels of analysis-the level of behavior, the level of personality, and the level of environment. The theory is based on an awareness that efforts to change behavior can be focused at any or all levels. Problem behavior theory provides the foundation for a comprehensive health-promotion approach to drug abuse prevention proposed by Perry and Jessor (1983). Perry and Jessor proposed a health behavior theory that conceptualizes "health" as four interrelated domains: physical, psychological, social, and personal health. Within these domains, health is enhanced by (1) weakening or eliminating behaviors that compromise health and by (2) strengthening or introducing behaviors that enhance health. These two strategies for health promotion can be applied to intrapersonal characteristics, environmental influences, and behavior. In each case, the intervention focuses on weakening or eliminating intrapersonal characteristics, environmental influences, or behaviors that compromise health, while simultaneously introducing or strengthening those that promote health.
Perry and Jessor (1983) underscore the importance of understanding the relationships among behaviors and suggest that research on alcohol and other drug abuse prevention should focus on multiple domains. The intrapersonal domain-composed of attitudes, beliefs, and motivations for health-related behaviors-is seen as an important determinant in the adoption of such behavior. Environmental factors are also thought to affect an individual's health-related behavior. Perry and Jessor's (1983) model proposes two environmental approaches to be used in reducing drug-taking behavior: (1) environmental factors aimed at resisting or avoiding health-compromising behaviors (e.g., reducing the availability of drugs, media campaigns to resist drug use, social and policy sanctions for drug-related activities) and (2) environmental supports for health-enhancing behaviors (e.g., positive peer relations, drug-free activities for students, health/fitness programs). Ideally, each of these components enhances an individual's assessments of his or her personal susceptibility (i.e., taking drugs is serious, dangerous, and potentially lethal), and promotes the viability of alternative behaviors (i.e., I can avoid these problems and be happy doing other things.).
The implications of Perry and Jessor's (1983) model for alcohol and other drug abuse prevention programs and research are substantial. First, it offers a theory-based health promotion intervention relevant to adolescent drug use. Second, it highlights the importance of preventive interventions that seek to implement, simultaneously, the introduction of (or strengthening of) health-enhancing behavior and the elimination of (or weakening of) health-compromising behavior. Perry and Jessor (1983) suggest that research is needed to specify the relative contribution of each strategy and the interactions among the strategies. A third implication of the model is that interventions need to encompass a wider focus than that of individual behavior alone. More attention should be paid to the larger environment, including the social norms and social supports that regulate the occurrence of behavior. Also, changing personality attributes, such as the value an individual places on fitness and his or her general sense of personal competence, should be considered. Finally, the relationships among various health-compromising behaviors seem to require interventions that focus on multiple behavioral targets and are able to assess multiple behavioral outcomes.
An Integrated Theory for the College Campus
The theories discussed above have rarely been applied to alcohol and other drug abuse prevention on the college campus. The few applications of theory to prevention that exist in the literature apply mostly to school-based programs (Amatetti 1987). College-based prevention programs have often been planned on the assumption that raising awareness of the problem is sufficient to change behavior. (See section III; Oblander 1984). A closer examination shows that awareness of the problem may be only a first step; it is perhaps a necessary, but not a sufficient, condition for behavioral change (Cvetkovich et al. 1987; Engs 1977; Goodstadt 1978).
A meaningful theory of alcohol and other drug abuse prevention for higher education must be comprehensive, practical, and testable. A comprehensive theory must look at (1) the individual and his or her biopsychosocial susceptibilities to alcohol and other drug problems, as well as the individual's knowledge, attitudes, and motivations; and (2) the environment, or the setting in which drinking or other drug use occurs. This includes the campus and community mores that shape usage and policy regulations that govern alcohol or other drug availability and use on campus. Both of these elements-the person and the environment-are interactive and interdependent. The most effective strategies will be those that deal with both elements.
Because of their unique emphasis on intrapersonal, environmental, and person/environment interaction, the health belief model, social learning theory, and problem behavior theory were combined by Gonzalez (1989a) into an integrated theoretical framework for the design of prevention programs and research on the college campus. Each of these theories, as previously discussed, suggests special areas of emphasis which, when combined, can provide a powerful and practical model for program planners and researchers. The Integrated Theoretical Model for Alcohol and Drug Prevention (ITMADP) proposed by Gonzalez (1989a) is the result of such a selective combination and application of principles.
To apply problem behavior theory to alcohol and other drug abuse, one must divide behavior into health-enhancing and health-compromising categories and identify domains for intervention (Perry & Jessor 1985; cited in Amatetti 1987). The two domains emphasized by Gonzalez' ITMADP are person-focused and environmentally focused preventive interventions (e.g., individually oriented skills-building activities, discouragement of health-compromising behaviors through media campaigns).
The health belief model is used to identify personally oriented goals for intervention. The health belief model assumes that an individual's disposition toward abusing alcohol and taking illegal drugs is mediated by three factors: (1) the degree to which individuals believe they are personally susceptible to alcohol and other drug-related problems or dependence, (2) the perceived severity of the consequences of alcohol and other drug abuse, and (3) the degree to which the individuals believe alternative behaviors constitute viable (i.e., perceived benefits outweigh perceived barriers) alternatives to alcohol and other drug abuse. Personally oriented interventions seek to amplify individuals' perceptions of their susceptibility and the severity of alcohol and other drug-related problems in order to discourage health-compromising behaviors; these interventions are also designed to enhance the acceptability of perceived alternative, health-enhancing behaviors.
Before individuals can engage in these behaviors, they need appropriate skills. Needed skills include those for assertiveness, stress management, and interpersonal communication that are necessary to resist environmental pressures effectively and to enhance drug-free participation in activities and relationships. Methods to enhance behavioral skills in these domains are included in the ITMADP to promote an individual's ability to mediate between his or her health beliefs and the external pressures related to alcohol and other drug use. The acquisition of these skills subsequently enhances an individual's efficacy expectations, which, according to social learning theory, are necessary for practicing these skills. Thus, an individual's efforts are combined with alterations to the surrounding environment to support the student's use of these skills and discourage any health-compromising behaviors.
According to the ITMADP, environmental interventions should include the motivation to protect oneself as proposed in the health belief model. For example, a media campaign could inform students that alcohol and other drug abuse problems can be severe; that even young, healthy persons are susceptible to these problems; and that many alternatives are available to reduce the severity or susceptibility of students to these problems. Both the individually focused and the environmental interventions are more effective when appropriate models (e.g., peers) deliver the message. The ITMADP provides a message, a process, and levels of intervention for structuring preventive campus alcohol and other drug education programs. According to the ITMADP, a consistent message regarding problem severity, personal susceptibility, and viability of options should be provided. The message delivered should be consistent with the principles described earlier. The ITMADP suggests that information alone is not sufficient to achieve behavioral change. Instead, a process by which the skills necessary to resist environmental pressures are developed is also suggested. This means that effective prevention programs are likely to require extensive skills-building activities that provide opportunities for practice and reinforcement in social environments.
The ITMADP suggests that informational campaigns and skills-building activities will require a focus on both the individual and the environment. The dynamic interaction between the person and the environment is seen as crucial to the development and maintenance of behaviors that enhance health and reduce drug use. Although an ideal application of the ITMADP requires a comprehensive, campuswide approach, subcomponents of such a program can be designed in accordance with the model.
For example, an academic drug education course can be designed to include information on the severity of drug abuse problems, the susceptibility of students to these problems, and the viability of alternative behaviors to drug abuse (Gonzalez 1990). The course can include practice in assertiveness, interpersonal skills and out-of-class assignments so that students can practice the skills to become aware of and resist pressures to use drugs. Likewise, a media campaign might be designed to call attention to the susceptibility of college students to alcohol-and drug-related problems. Ideally, all efforts should be coordinated as part of a comprehensive, communitywide campus program (Benard 1990; Perry 1986).
The ITMADP can be used to evaluate the effectiveness of both the immediate and the long-range goals of prevention programs. Environmental changes can be assessed, to determine the programs' effects on the availability of educational messages and opportunities for alternatives to alcohol and other drugs. Increases in the perception of risk can be assessed to determine the immediate impact of the program. Students' acquisition of resistance skills and self-efficacy expectations can be measured to assess the effects of training activities. Ultimately, attitudes and drug use behavior must be measured to determine the long-range outcome of the prevention program.
The interactions among the various predictors of the ITMADP and its long-range outcomes are crucial factors in assessing program effectiveness. For example, if an increase in the perception of risk associated with the use of drugs is achieved, the extent to which peers and institutional policies reinforce these perceptions must be measured. Such a model requires considerable resources and cooperation between researchers and practitioners (Cowen 1978; Gottfredson 1988). Some models have been proposed for creating such a relationship among researchers, program practitioners, and community members (Kelly & Hess 1987; Rappaport 1981). These models have not yet been applied to evaluations of alcohol and other drug abuse prevention programs.
Although some anecdotal evidence suggests that educational programs that impact the individual and the environment can help reduce alcohol and other drug-related problems (Gonzalez 1988b), the cost and complexity of such large-scale efforts make them very difficult to validate empirically. It is not yet known how the environmental and personal variables proposed in the ITMADP interact to motivate people to change their behaviors. The most appropriate mix of emphases for a college population is also unknown. An important research question might be how motivation for change is related to efficacy expectations of students practicing the skills necessary to resist environmental pressures to use alcohol and other drugs. A large-scale, longitudinal, collaborative study of college prevention programs is needed to address these issues.
Summary
Alcohol and other drug abuse prevention programs on the college campus, have generally developed in an atheoretical manner. Most college prevention programs have been based on the assumption that increasing students' knowledge about alcohol and other drugs would lead to an attitude change, resulting in a behavioral change precluding the use of these substances. The assumptions made under this knowledge-attitude-behavior model have been examined empirically and have been found to be seriously flawed (Goodstadt 1978; Miller & Nirenberg 1984; Moskowitz 1986). Nevertheless, college prevention programs and research efforts have continued to develop on the basis of this idea.
A major reason programs continue to develop on the basis of judgments not supported in the research literature is the lack of viable theoretical models regarding campus-based prevention efforts (Gonzalez 1988b; Saltz & Elandt 1986). Several theoretical models emerging in the prevention literature may be useful for college prevention programs and research (Amatetti 1987; Ray, Faegre & Lowery 1990). Although most of these models focus on school-based approaches and on younger populations, expansion of these models to college-age populations is possible. One growing realization in the prevention field, especially on the college campus, is that comprehensive, communitywide approaches are needed (Benard 1990; Gonzalez 1988a; Holder 1984; Kumpfer, Moskowitz, Whiteside & Klitzner 1986; Wallack 1984). It appears that a long-term, systems approach that addresses the relationships among individual and social factors is necessary for effective prevention.
Appropriate theoretical and research models are needed to ascertain the most effective combinations of interventions and the most productive mix of emphases for specific populations. It cannot be assumed that generic program models will be equally effective with different populations. Most prevention efforts today are being geared to preventing the initial use of alcohol and other drugs among young people (DuPont 1990). The prevention of initial use of cocaine may be an appropriate goal for college students, but it would not be an appropriate goal regarding alcohol or marijuana use. The risk of initiation into alcohol and marijuana use is highest for young people before they reach college age, but the levels of consumption of all these substances is highest for students between the ages of 17 and 22 (Kandel & Logan 1984). Thus, prevention goals that may be appropriate for a school-age population may not be appropriate for a college-age population.
Theory-driven, targeted research can help answer a variety of questions. Comprehensive efforts must be defined as more than a conglomerate of different activities. Program activities in a comprehensive effort must be carefully planned to complement each other and to provide the appropriate level of emphasis to specific populations. Empirically tested theory provides a framework for cost-effective program design and evaluation. Such theory-based efforts would not only enhance program outcomes but also advance the knowledge base for further program development.
The ITMADP framework proposed by the author (Gonzalez 1989a) provides an integrated model for program planning and research to prevent alcohol and other drug-related problems on the college campus. The practical aspects of the ITMADP are evidenced by its applicability to planning and evaluation of preventive educational efforts at various levels of intervention (Gonzalez 1990; Gonzalez & Haney 1990); but the model still needs to be applied and evaluated in a comprehensive, campuswide approach.
Models in addition to the ITMADP are needed. Application of theoretical models being developed for younger populations and communities-at-large must be tested on the college campus. Although several promising approaches to alcohol and other drug abuse prevention are emerging in the research literature (Ray et al. 1990), it cannot be assumed that these models will apply to the college campus. As Kuh and Whitt (1988) point out, American college campuses are characterized by a unique culture that significantly affects the lives of individual students. An understanding of this culture is essential to preventing alcohol and other drug-related problems on campus. Until appropriate models are developed and tested empirically, programs will continue to be developed in a trial-and-error manner. Such an approach can be very costly and ineffectual.
Checklist on Theories, Dominant Models, and the Need for Applied Research
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Introduction
Current Knowledge in Prevention of Alcohol and Other Drug Abuse
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