Collegiate Drinking: The Prevention Paradox
Another
academic year is upon us and with it its challenges, many continued from the previous spring…if not time immemorial. Among those challenges is the perennial
Previous
essays have chronicled the advances made in addressing AOD issues in higher ed.
Interestingly, and I suspect inadvertently, these advances fall into two large
groups…those that target the individual student and those that target college
students in general or sub-populations of college students. Without intending
to, higher ed has followed the lead of epidemiologists who long ago realized that issues regarding health need to be
addressed at both the “micro” level, that is, “treat the individual with the
disease,” while at the same time attempting to prevent others in the general
population from contracting the disease, that is, addressing disease on a “macro
level.” Not only has this understanding been around for 30+ years, influencing
the work of public health professional and epidemiologists alike, but Geoffrey
Rose (see the original Rose article - [Department
of Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street,
London WC1E7HT, UK]. “Sick individuals and sick populations.” International Journal of Epidemiology
1985, 14: 32-38 – an online copy is available at http://ije.oxfordjournals.org/content/14/1/32.full.pdf+html),
an epidemiologist, identified what he called the “prevention
paradox.” Only now has this become an issue of interest to social scientists
and student affairs professionals regarding higher education’s “collegiate
drinking” dilemma.
The
Prevention Paradox essentially suggests that although the likelihood of “getting
a disease” is much greater for members of a high-risk sub-population, the total
number of those “with the disease” will be greater in the general population. A
simple example will illustrate this point: if 33% of a sub-population contract the
disease because of their high-risk behavior when only 5% of the general
population do, if there are 1 million individuals in the high-risk
sub-population this will result in 330,000 individuals with the disease yet 5%
of the 10 million in the general population equals 500,000 individuals with the disease.
If prevention efforts are focused on the high-risk population alone, there is
likely little change in the total number of cases of reported disease and in
all likelihood, that number will grow. If, however, “individual treatment” is
developed for those with the disease while designing effective prevention strategies
that target the general population, it is reasonable to believe that eventually
the disease will be controlled if not one day eliminated…HIV being a current example of
addressing a disease on both the “micro” and “macro” levels.
Higher
education has “sort of” been doing this for the last 20 years. It has developed
environmental management strategies that have affected general student drinking
behaviors and augmented this with social norms campaigns designed to address misperceptions of the general population regarding the normative behavior
of one’s peers—both being “macro approaches.” Likewise, brief individual student interventions
using motivational counseling technique, e.g., BASICS (Brief Alcohol Screening
and Intervention for College Students), have proven effective in intervening with high-risk collegiate drinkers—a “micro approach.” Yet in spite of this, higher ed seems to reach a plateau with intractable 80+% of all students reporting that they drink, at
least occasionally, and 20+% reporting
that they frequently “binge.”
To
return to the original Rose article, he posits that a dilemma exists regarding
how best to address this paradox. To
concentrate on the macro of general population alone, which higher ed has
tended to do historically:
...offers only
a small benefit to each individual, since most of them were going to be all
right anyway, at least for many years. This leads to the prevention paradox: “A
preventive measure which brings much benefit to the population [however] offers
little to each participating individual” … and thus there is poor motivation
for the subject. … In mass prevention each individual has usually only a small
expectation of benefit, and this small benefit can easily be outweighed by a
small risk’.(p.38)
Consequently,
our traditional approach to preventing high-risk and dangerous behavior falls on
proverbial “deaf ears” because students see neither the opportunity for
personal benefit nor likelihood of needing to avoid what is perceived as
unlikely personal risk. Add to this that we adults deliver health care messages
to students suggesting things like 4+ drinks for a woman or 5+ drinks for a man
is a “binge,” and our credibility as professionals becomes suspect.
Consequently, the result of these apparently disparate but nonetheless
connected facts may explain the apparent student intransigence regarding collegiate
drinking.
Higher
ed adopted a course correction in the early 2000s and moved from viewing
prevention as “primary, secondary, or tertiary” with its focus on the
individual user, to a more realistic current consideration where “universal,
selective, and indicated” strategies focus on target populations; this has helped.
Further, the development of the NIAAA Tier System for rating prevention strategy
effectiveness has likewise moved prevention areas in a more orderly,
intentional direction. The point remains, however, that although we continue to
pursue new prevention strategies, we tend to evaluate their effectiveness using
dated criteria. Consequently, I would like to pose a new way of thinking about
our efforts to address high-risk collegiate drinking..
Instead
of attempting to “prevent what we fear,” what about promoting what we know? Efforts
with college students are less about preventing, to use Rose’s word, “disease”—and
in the case of drinking, addition—and more about promoting wellness…or at the
least promoting harm reduction. The majority of high-risk collegiate drinkers
will likely NOT progress to alcohol dependence…although they will likely experience
a disproportionally greater percentage of untoward consequences associated with
their drinking. Having said this I suggest several steps:
- · Continue the employ environmental management strategies, social norms campaigns, BASICS, and like “macro” and “micro” prevention strategies. We do not need to put new wheels on the bus, just acknowledge that it has need for more than 3.
- · Concentrate on making health promotion messages that target universal populations more attractive and easier to consume by the individual members of that population. Such messages need to stress the likely personal, social, and academic benefits of abstinence and moderate use rather than the possible consequences of use
- · Explore the symbolic meaning of “alcohol” as a substance and “drinking” as a behavior for college student in order to understand the role such play in personal choice. In particular, explore the process by which most student “mature out” of their high-risk adolescent perspectives in order to facilitate a quicker, more proactive behavioral transition via this natural phenomenon
Remember
that no one, especially college students, will change a behavior until reaching
a point where the change represents less hassle and greater potential reward
than a continuation of current attitudes, values, and beliefs. It is our role
as student development and student affairs professionals to motivate this
change by facilitating contemporary students to engage in what economists refer
to as a “cost benefit analysis” of their current behavior and its consequences.
What do you think?
Dr. Robert
To
read more regarding Rose’ Prevention
Paradox, consider:
