A multisite randomized trial of normative feedback for heavy drinking: Social comparison versus social comparison plus correction of normative misperceptions

A systematic review on eHealth technology personalization approaches

Despite the widespread use of personalization of eHealth technologies, there is a lack of comprehensive understanding regarding its application. This systematic review aims to bridge this gap by identifying and clustering different personalization approaches based on the type of variables used for user segmentation and the adaptations to the eHealth technology and examining the role of computational methods in the literature. From the 412 included reports, we identified 13 clusters of personalization approaches, such as behavior + channeling and environment + recommendations. Within these clusters, 10 computational methods were utilized to match segments with technology adaptations, such as classification-based methods and reinforcement learning. Several gaps were identified in the literature, such as the limited exploration of technology-related variables, the limited focus on user interaction reminders, and a frequent reliance on a single type of variable for personalization. Future research should explore leveraging technology-specific features to attain individualistic segmentation approaches.

Efficacy of Social Norm Interventions on Addictive Behaviours-A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Mental health-related behaviours including addictive behaviours contribute significantly to the global burden of disease. Social norm interventions appear to be a cost-effective means of reducing addictive behaviour. We conducted a systematic review and meta-analysis of the efficacy of social norm interventions for addictive behaviours. We searched the databases Medline and PsycInfo from inception to April 2024 as well as reference lists of eligible studies and related systematic reviews for randomised controlled trials (RCTs) comparing the efficacy of social norm interventions for addictive behaviours to control conditions. Out of the 11,515 potentially eligible RCTs, 52 trials with a total of 31,764 adult participants met inclusion criteria, with 45 trials targeting alcohol consumption, three trials targeting Marijuana use, two trials targeting other substance abuse and two trials targeting gambling. Overall, 37 trials were included in the random-effects meta-analysis. The comparison of social norm interventions to control conditions at posttreatment showed a small but statistically significant effect (g = -0.12; 95% CI = -0.22 to -0.02; p < 0.01). Risk of bias was rated low in 37 RCTs, 14 RCTs were rated as having some risk of bias concerns and one RCT was rated as having high risk of bias. Social norm interventions can be an effective intervention method for reducing substance abuse and gambling. Yet, data is largely derived from studies targeting alcohol consumption and current trials suffer from methodological and practical limitations. The small effect sizes need to be appraised in the context of cost-effectiveness of these interventions.

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

Examining engagement effects in an adaptive preventive intervention for college student drinking

OBJECTIVE

This study determined the characteristics of engagement and whether engagement in an adaptive preventive intervention (API) was associated with reduced binge drinking and alcohol-related consequences.

METHOD

Incoming students were recruited for a sequential multiple assignment randomized trial (SMART; N = 891, 62.4% female, 76.8% non-Hispanic White) with an assessment-only control group. The API occurred during the first semester of college, with outcomes assessed at the end of the semester. The API involved two stages. Stage 1 included universal intervention components (personalized normative feedback [PNF] and self-monitoring). Stage 2 bridged heavy drinkers to access additional resources. We estimated the effect of engagement in Stage 1 only and in the whole API (Stages 1 and 2) among the intervention group, and the effect of the API versus control had all students assigned an API engaged, on alcohol-related outcomes.

RESULTS

Precollege binge drinking, intention to pledge a fraternity/sorority, and higher conformity motives were most associated with lower odds of Stage 1 engagement. Action (readiness to change) and PNF engagement were associated with Stage 2 engagement. API engagement was associated with significant reductions in alcohol-related consequences among heavy drinkers. Compared to the control, we estimated the API would reduce the relative increase in alcohol-related consequences from baseline to follow-up by 25%, had all API students engaged.

CONCLUSIONS

Even partial engagement in each component of the "light-touch" API rendered benefits. Analyses suggested that had all students in the intervention group engaged, the API would significantly reduce the change in alcohol-related consequences over the first semester in college. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Personalized normative feedback for hazardous drinking among college women: Differential outcomes by history of incapacitated rape

OBJECTIVE

Personalized normative feedback (PNF) interventions are effective at reducing hazardous drinking in college. However, little is known about who is most receptive to PNF. College women with a history of alcohol-related incapacitated rape (IR) are at elevated risk for hazardous drinking, but it is unclear what impact intervention messaging may have on this group and how their outcomes compare to those without past IR. To address this gap, this study involved secondary data analysis of a large web-based clinical trial.

METHOD

Heavy drinking college women (N = 1,188) were randomized into PNF (n = 895) or control conditions (n = 293). Postintervention, women reported their reactions to intervention messaging. Hazardous drinking outcomes (typical drinking, heavy episodic drinking [HED], peak estimated blood alcohol content [eBAC], blackout frequency) were assessed at baseline and 12 months.

RESULTS

Past IR was reported by 16.3% (n = 194) of women. Women with a history of IR reported more baseline hazardous drinking and greater readiness to change than women without IR. For those who received PNF, history of IR related to greater perceived impact of the intervention, but no difference in satisfaction with the message. After controlling for baseline drinking, regressions revealed the effect of PNF was moderated by IR for frequency of HED at 12 months. Simple main effects revealed PNF was associated with lower levels of hazardous drinking at follow-up among women with past IR.

CONCLUSIONS

This initial investigation suggests PNF is a low resource and easily disseminated intervention that can have a positive impact on college women with past IR. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Strengthening personalized norm feedback interventions: The ambivalent-attitude effect

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Personalized norm feedback effectively reduces heavy drinking in college students.

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Inducing ambivalence makes norms a stronger predictor of behavior.

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We predicted that ambivalence before the PNF would lower alcohol intentions.

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Ambivalent Ps intended to drink less re compared to those low in ambivalence.

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Ambivalence should be included in personalized norm feedback interventions.

This study investigated the effect of induced attitude ambivalence on the relationship between the personalized norm feedback (PNF) intervention and heavy drinking by college students. College students consume more alcohol and engage in binge drinking at greater rates than most segments of the population. Given the harmful effects of binge drinking and other risky drinking behaviors, it is important to implement effective interventions to reduce alcohol consumption. PNF is an effective intervention for reducing heavy drinking where students compare their drinking and perceptions of normative drinking with actual drinking norms. Past research suggests that inducing ambivalence makes norms a stronger predictor of behavior. We hypothesized that induced attitudinal ambivalence before the PNF intervention would lower intentions to consume alcohol. This study was a one-way design with ambivalence about drinking (high vs low) as the independent variable and intentions to drink alcohol in the future as the dependent variable (N = 338, 76 % female, M_age = 19.76, SD = 2.61). All participants received the PNF intervention after the ambivalence manipulation and before the intentions to drink alcohol measure. Results from the generalized linear model revealed a significant effect for ambivalence, p =.028. As predicted, participants in the high ambivalence condition intended to drink fewer drinks in one sitting in the future compared to those in the low ambivalence condition. These results suggest that ambivalence may play an important role in make PNF interventions more effective, though more research is necessary to untangle the relationship between ambivalence and norms.

Feigning Symptoms to Obtain Prescription Stimulants: A Vignette-Based Study on Its Conditions

This vignette-based study examined the willingness to feign symptoms to obtain a prescription following an analysis on who might use prescription stimulants to enhance performance ( N = 3,468). It experimentally manipulated three factors: the social disapproval of prescription stimulant use for enhancement purposes, the physicians’ diagnostic efforts, and the medical condition (attention-deficit/hyperactivity disorder and narcolepsy); respondent characteristics of self-control, personal morality, and self-efficacy were also measured. Our results showed that social disapproval of prescription drug use, a personal morality that disapproves of drug use, high self-control, and high self-efficacy were negatively associated with the willingness to use. Willingness increased especially in situations of social approval when there was a stronger personal approval of drug use, or surprisingly when physicians’ diagnostic efforts were higher. The feigning willingness was lower in situations of social disapproval and when personal morality disapproved of feigning. Thus, personal and situational characteristics are relevant to understand both behaviors.

Integrating social media inspired features into a personalized normative feedback intervention combats social media-based alcohol influence

BACKROUND

Research suggests that the social media platforms popular on college campuses may reflect, reinforce, and even exacerbate heavy drinking practices among students. The present study was designed to directly examine: (1) whether exposure to alcohol-related content on social media diminishes the efficacy of a traditional web-based personalized normative feedback (PNF) alcohol intervention among first-year drinkers; and (2) if social media inspired features and digital game mechanics can be integrated into a PNF intervention to combat social media-based alcohol influence and increase efficacy.

METHOD

Alcohol experienced first-year college students (N = 223) completed a pre-survey that assessed exposure to alcohol-related content and social media and were randomized to 1 of 3 web-based alcohol PNF conditions (traditional, gamified only, or social media inspired gamified). One month later, participants' alcohol consumption was reassessed.

RESULTS

Among participants who received traditional PNF, social media-based alcohol exposure interacted with pre-intervention drinking such that traditional PNF was less effective in reducing drinking among heavier drinkers reporting greater exposure to alcohol-related social media content. Further, when regression models compared the efficacy of all three conditions, the social media inspired gamified PNF condition was significantly more effective in reducing drinking than was traditional PNF among moderate and heavy drinkers reporting greater exposure to alcohol on social media.

CONCLUSION

Although additional research is needed, these findings suggest that representing the population of students on whom normative statistics are based with social media-like user avatars and profiles may enhance the degree to which alcohol PNF is relatable and believable among high-risk students.

Leveraging dynamic norms to reduce alcohol use among college students: A proof-of-concept experimental study

BACKGROUND

Norm-correcting interventions are an effective alcohol harm-reduction approach, but innovation is needed to increase modest effect sizes. Recent social psychology research shows that individuals may be influenced by social norms that are increasing in prevalence. Contrary to static norms that reflect the current state of normative behavior, dynamic norms reflect behavioral norms that are shifting over time. This proof-of-concept study tested the utility of dynamic norms messages within norm-correcting interventions.

METHOD

Undergraduate student drinkers (N = 461; Mage  = 19.97; 64.43% female) were randomly assigned to receive (a) dynamic norms messages highlighting a steady decrease over the past six years in heavy drinking among college students; (b) static norms messaging stating only the current norms; or (c) a control condition without normative information. Proximal outcomes assessed immediately following the experimental paradigm included intentions for total weekly drinks and heavy episodic drinking. Self-reported information on alcohol use behavior was collected at 1-month follow-up.

RESULTS

Following the experimental paradigm, participants in the dynamic norms condition estimated that future drinking norms would decrease, while those in the static norms and control groups estimated that future drinking norms would increase. Participants in the dynamic norms condition reported lower intentions for weekly drinks and heavy episodic drinking than those in the static norms and control conditions. No significant differences between conditions were found on alcohol use indices reported at the 1-month follow-up. However, dynamic norms messaging had a favorable indirect effect on heavy episodic drinking intentions mediated through lower perceived future drinking norms.

CONCLUSIONS

These findings provide proof-of-concept that dynamic norms messaging may be a prudent strategy for reducing alcohol use intentions, which can be integrated into or used alongside existing norm-correcting strategies.

Finding the Right Balance: A Social Norms Intervention to Reduce Heavy Drinking in University Students

Introduction: Heavy alcohol consumption constitutes a major health risk among University students. Social relationships with peers strongly affect University students' perception of the drinking behavior of others, which in turn plays a crucial role in determining their own alcohol intake. University students tend to overestimate their peers' alcohol consumption – a belief that is associated with an increase in an individual's own consumption. Therefore, we implemented a social norms intervention with personalized normative feedback at a major University in Germany to reduce and prevent excessive drinking among University students.

Methods: Our intervention was part of a regular health monitoring survey. We invited all enrolled University students to take part in this survey on two occasions. A total of 862 University students completed the questionnaire, 563 (65.3%) of which received e-mail-based feedback upon request concerning their peers' and their own alcohol consumption. For the intervention group (n = 190) as well as the control group (no feedback requested; n = 101), we included only University students in the evaluation who overestimated their peers' alcohol use and indicated above average consumption of the peers. We applied analyses of variance to assess intervention effects with regard to the correction of overestimated group norms as well as University students' drinking behavior.

Results: Within the intervention group, we observed a significantly larger reduction of the previously overestimated behavioral norms compared to the control group (p < 0.001; ηp2 = 0.06). With regard to behavioral outcomes the intervention group showed a significantly larger reduction in the AUDIT-C score (p = 0.020; ηp2 = 0.03).

Discussion: Our study confirms previous research whereupon personalized, gender-specific and selective normative feedback is effective for alcohol prevention among University students. However, University students still overestimated their peers' alcohol intake after the intervention. Furthermore, we did not reach high-risk groups (University students with the highest alcohol intake) since no feedback was requested. Future studies should address factors influencing the impact of the intervention and reachability of selective groups.

Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

Testing the Effect of Social Norms Theory-based Interventions: Are they Harmful for University Students who Drink Less than the Peer Norm?

Background. Social norms theory-based interventions have been widely used to reduce alcohol consumption among college and university students. Lately, it has been argued that such interventions may actually increase alcohol use among light drinkers. However, little studies have been focused on testing this possible negative effect. Objectives. The aim of this study was to examine possible negative impact of descriptive normative feedback (DNF) on drinking intentions among students whose baseline drinking scores were below the average of a reference group. We also studied the preventive effect of injunctive normative feedback (INF). Methods. Actual descriptive and injunctive norms were collected from 234 university students. From those who reported drinking below the norm, 26 were randomly assigned to a control or intervention condition that received normative feedback via PowerPoint presentations over two meetings. Results. DNF increased students’ intentions of spirits drinking frequency and quantity. Meanwhile intentions to drink beer, cider, wine and cocktails remained the same. Increased intentions to drink spirits were not reduced by INF. Conclusions. Findings suggest that DNF-based interventions might negatively affect the use of spirits among those students who consume less than their peer norm by increasing their intentions to drink spirits more often and in larger quantities. Ways other than the INF to prevent this negative effect need to be further explored.

Computer-delivered brief alcohol intervention for patients with liver disease: a randomized controlled trial

BACKGROUND AND AIMS

Reducing alcohol consumption by liver disease patients can reduce morbidity and mortality. This study compared a computer-delivered brief alcohol intervention (cBAI) with standard care in a sample of US military veterans with liver disease.

DESIGN

Multi-site, randomized controlled trial of a cBAI plus standard care (n = 67) versus standard care only (n = 71). Participants were assessed at baseline and 3- and 6-month follow-up.

SETTING

US Veterans Health Administration liver clinics.

PARTICIPANTS

Participants were mostly male and diagnosed with hepatitis C.

INTERVENTIONS AND COMPARATORS

A cBAI tailored to veterans with liver disease and consisting of assessment and personalized feedback. Standard care was brief education and advice about alcohol and liver disease.

MEASUREMENT

Primary outcomes were self-reported number of drinking days and unhealthy drinking days (defined as more than two drinks for men and more than one for women) in the past 30 days at 6-month follow-up. Secondary outcomes were these two variables at 3-month follow-up, and drinks consumed per drinking day, depression and overall health at 3- and 6-month follow-ups. Missing data were imputed using multiple imputation.

FINDINGS

Compared with standard care, cBAI participants reported significantly fewer drinking days at 6-month follow-up and fewer unhealthy drinking days at both 3- and 6-month follow-ups. Least square means (LS-means) for number of drinking days were 3.78 for the cBAI condition and 6.89 for the standard care condition at 6 months [LS-mean ratio = 3.78/6.89 = 0.55, 95% confidence interval (CI) = 0.34, 0.89]. LS-means for number of unhealthy drinking days were 1.04 for the cBAI condition and 2.57 for the standard care condition at 3-month follow-up (LS-mean ratio = 1.04/2.57 = 0.41, 95% CI = 0.19, 0.85). At 6-months follow-up, LS-means were 1.18 for the cBAI condition and 2.75 for the standard care condition (LS-mean ratio = 1.18/2.75 = 0.43, 95% CI = 0.20, 0.91).

CONCLUSIONS

A computer-delivered brief alcohol intervention reduced drinking days and unhealthy drinking days at 6-month follow up in military veterans with liver disease compared with brief education and advice to reduce consumption.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

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.

College Students' Perceptions of Peer Alcohol Use: A Social Network Analytic Approach

Traditional measures attempting to capture students' perceptions of peer drinking fail to capture the unique social influence of their most proximal peers. Purpose: This study presents egocentric social network data assessing the relationship between students' personal drinking behaviors and those of their closest social ties. Methods: 697 college students participated in the study by reporting on demographic information, alcohol use (AUDIT scores), and egocentric networks. Hierarchical linear regression assessed whether egocentric network variables uniquely predicted personal alcohol use, controlling for age, gender, race/ethnicity, and Greek-life affiliation. Results: Students with higher AUDIT scores were more likely to nominate persons close to them that engaged in more frequent, higher quantity drinking, and were also likely to mirror drinking behaviors to that of their close ties. Conclusion: Future studies should utilize SNA to capture the nuance associated with individuals' perceptions of close others' alcohol use and their own drinking behaviors. Interventions aimed at reducing collegiate drinking should consider the interpersonal nature of drinking behaviors among college student networks.

Adolescent Tobacco Use and Misperceptions of Social Norms Across Schools in the United States

OBJECTIVE

This study assesses tobacco use norm misperceptions by distinguishing between perceived and actual peer norms for both tobacco use attitudes and behavior, and examines the association between perceived norms and personal use among U.S. students in Grades 6-12.

METHOD

Anonymous self-report surveys were conducted with 28,070 students across 64 schools in 11 U.S. states between 1999 and 2017.

RESULTS

Although 77% of students said tobacco use is never good, 64% of students thought that most students in their grade believed that use is acceptable. Similarly, although 79% of students reported never using tobacco, 85% of students perceived that most students in their grade typically use tobacco, with 66% thinking that peers use monthly or more often. Substantial norm misperception existed regardless of student and school factors, increasing by grade. Perceiving that most peers thought tobacco use is acceptable was highly predictive of personal attitude, and perceiving tobacco use as the norm among same-grade peers strongly predicted personal tobacco use, even after we adjusted for actual peer use prevalence and other factors. Males' perception of the male peer norm was a stronger predictor of personal use than was their perception of the female peer norm. Females' perceptions of sex-specific norms were associated with personal use, each at about the same magnitude.

CONCLUSIONS

Norm misperceptions are pervasive across a diversity of students and schools, whereas perceptions of peer norms about tobacco use are highly associated with personal attitude and use. Results suggest that population-wide interventions correcting these misperceptions may help reduce tobacco use broadly among youth.

Lessons learned from a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda

Evidence suggests that simple text messaging interventions may not suffice to improve ART adherence among youth in low-resource settings. To address this shortcoming, we developed an intervention that shared weekly real-time adherence feedback to youth in Uganda using short message services (SMS), based on information tracked by an electronic device (Wisepill). We present results from 7 formative and 6 exit focus groups (FGs) in Mulago and Entebbe, Uganda with youth ages 15-24, providers, and Community Advisory Board members. Participants consistently conveyed positive impressions of Wisepill, noting that it helped store their medications, facilitated travel, served as a reminder, and motivated adherence. Participants raised phone-related issues before the study; most were addressed but some remained (e.g., limited network access, electricity for powering phones). Further, they highlighted the importance of carefully crafting text messages (e.g., use slang rather than potentially stigmatizing words) and viewed personalizing messages favorably but were divided on the desirability of including their name in study-related texts. Exit FGs confirmed that sharing group adherence levels with participants tapped into the competitive spirit common among youth. Our results suggest future mobile technology-based interventions can be improved by providing messages that go beyond simple reminders to provide individual and group-level adherence feedback.

A randomized controlled trial study of the acceptability, feasibility, and preliminary impact of SITA (SMS as an Incentive To Adhere): a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda

BACKGROUND

Studies report serious adherence problems among youth (individuals age 15-24 years of age) in Uganda. Recent growth in mobile phone ownership has highlighted the potential of using text-based interventions to improve antiretroviral treatment (ART) adherence among Ugandan youth. We piloted a randomized controlled trial of a text-based intervention providing weekly real-time antiretroviral adherence feedback, based on information from a smart pill box, to HIV-positive Ugandan youth. In this paper, we report the acceptability, feasibility, and preliminary impact of the intervention.

METHODS

We randomized participants to a control group, or to receive messages with information on either their own adherence levels (Treatment 1 - T1), or their own adherence and peer adherence levels (Treatment 2 - T2). We conducted six focus groups from December 2016 to March 2017 with providers and youth ages 15-24, double coded 130 excerpts, and achieved a pooled Cohen's Kappa of 0.79 and 0.80 based on 34 randomly selected excerpts.

RESULTS

The quantitative and qualitative data show that the intervention was deemed acceptable and feasible. After controlling for baseline adherence, the T1 group had 3.8 percentage point lower adherence than the control group (95% CI -9.9, 2.3) and the T2 group had 2.4 percentage points higher adherence than the control group (95% CI -3.0, 7.9). However, there was an increasing treatment effect over time for the T2 group with the largest effect towards the end of the study; a 2.5 percentage point increase in the initial 9-weeks that grows steadily to 9.0 percentage points by the last 9-weeks of the study. We find negative treatment effects for T1 in 3 of the 4 9-week intervals. This pilot study was not designed to detect statistically significant differences.

CONCLUSIONS

Improving youth's adherence by supplementing information about their adherence with information about the adherence of peers is a promising new strategy that should be further evaluated in a fully-powered study. Providing one's own adherence information alone appears to have less potential.

TRIAL REGISTRATION

NCT02514356 07/30/2015.

Longitudinal Associations Between Perceptions of Peer Group Drinking Norms and Students' Alcohol Use Frequency Within College Sport Teams

BACKGROUND

Students' alcohol use behaviors are shaped by the attitudes and behaviors of others, especially the peers within students' proximal social groups. Explaining the association between perceived drinking norms and alcohol use, researchers propose contradicting pathways that focus on conformity (i.e., social norms predict alcohol use) and projection (i.e., alcohol use predicts perceived norms). The current study examined the extent to which conformity and projection processes were evident in the association between college student alcohol use and the perceived alcohol use norms for students' club sport teams.

METHODS

The sample comprised 1,054 college students (61% female) nested in 35 intact same-sex club sport teams. On 3 separate occasions during a single school year (3-month lag), participants reported drinking frequency and perceptions of descriptive and injunctive group drinking norms. We employed random intercepts cross-lagged panel modeling to estimate prospective within-person associations separately from stable trait-like between-person associations.

RESULTS

Descriptive and injunctive group drinking norms were both positively related to students' alcohol use frequency at the between-person level. Individuals nevertheless demonstrated variability at the within-person level. Results revealed a strong contemporaneous association between descriptive norms and alcohol use frequency within each timepoint, but no prospective associations. Models including perceptions of injunctive drinking norms demonstrated similar contemporaneous associations with alcohol use frequency, but also identified significant prospective associations signifying conformity.

CONCLUSIONS

Findings align with previous research reporting a strong and positive association between student's self-reported alcohol use and subjective peer alcohol use norms. After disentangling within- and between-person effects to probe for conformity and projection processes, the current findings are somewhat contrary to previous research that has reported reciprocal relationships between social norms and alcohol use behavior. Further investigation of the potential conformity and projection mechanisms of social norms is critical to advance norm-based strategies to reduce harm.

Demographic differences in perceived social norms of drug and alcohol use among Hispanic/Latinx and non-Hispanic White college students

Social norms are a modifiable treatment target that can decrease problematic alcohol use among college students. However, little is known about how social norms may be related to cannabis, opioid, and stimulant use. Further, it is not known how these relations might differ by gender and race/ethnicity. This study sought to examine the role of descriptive social norms of two peer reference groups (close friend and acquaintance) in relation to personal substance use among four substances (opioids, alcohol, cannabis, and stimulants), and if these relations may be moderated by gender or race/ethnicity in a sample of Hispanic/Latinx (H/L) and Non-Hispanic White (NHW) students. Participants were primarily H/L (58%), women (70%), and freshman (47%). Findings indicated that higher perceived peer substance use was associated with higher personal use for alcohol and cannabis. Higher perceived close friend stimulant use was associated with higher personal stimulant use, although perceived acquaintance stimulant use was not associated with personal stimulant use. There was no association between perceived peer opioid use and personal opioid use. Men had a stronger positive association between perceived peer cannabis use and personal use. Women had a stronger positive association between perceived acquaintance stimulant use and personal use. H/L students had a stronger positive association between perceived peer cannabis use and personal use. NHW had no significant association between perceived peer opioid use and personal use. Findings suggest that men and H/L students may be more susceptible to peer influences on cannabis and opioid use.

Online personalized normative feedback intervention to reduce event-specific drinking during Mardi Gras

High-risk drinking events (e.g., Mardi Gras) are associated with heavy and problematic drinking behaviors in college students. Online personalized normative feedback (PNF) interventions have been found to reduce college drinking, yet few studies have investigated the effect of event-specific PNF on drinking. The present study investigated the impact of a Mardi Gras-specific PNF intervention on Mardi Gras drinking and normative beliefs. Undergraduate students who reported intending to drink during Mardi Gras were randomly assigned to receive PNF (n = 74) or nondrinking control feedback (n = 73), both delivered online. Compared to those in the control condition, those in the PNF condition reported lower normative beliefs at follow-up. Follow-up beliefs mediated the relation between condition and peak estimated blood alcohol content (eBAC) during Mardi Gras such that the PNF condition was related to lower follow-up maximum estimated eBAC via lower follow-up normative beliefs. Baseline drinking moderated treatment effects such that the PNF was related to lower follow-up eBAC among heavier but not lighter baseline drinkers. This is the first known study to find that an event-specific stand-alone PNF intervention administered online in anticipation of a university-wide holiday associated with drinking can result in decreased event-specific drinking via changes in event-specific normative beliefs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cognitive factors and addiction

The present paper provides a brief review of cognitive factors related to addiction. Five representative cognitive constructs were selected from the current literature. These include the distinction between implicit and explicit cognitions; metacognitions; expectancies; motives; and social norms. For each of these a general overview is provided along with specific findings from selected recent studies. The intention is to provide the reader with a succinct but reasonable view of how each construct is currently studied in relation to the use of alcohol and other substances and to become aware of some of the strengths and limitations corresponding to the study of these constructs.

Social norms, misperceptions, and mosquito net use: a population-based, cross-sectional study in rural Uganda

BACKGROUND

Mosquito net use is an essential part of malaria prevention. Although previous research has shown that many people sleep under a mosquito net in endemic areas, it is unknown whether people underestimate how common it is to sleep under a net every night. Furthermore, perceived social norms about whether most others sleep under a mosquito net every night may contribute to personally sleeping under a net, given decades of research showing that people often mimic others' behaviours.

METHODS

Population-based data were collected from 1669 adults across eight villages in one rural parish in southwestern Uganda. Individuals' perception about whether most adults in their community sleep under a mosquito net every night was compared with whether daily mosquito net use was the actual norm in their community to identify the extent of norm misperception. The association between whether an individual perceived daily mosquito net use to be the norm and personal mosquito net use was assessed while adjusting for the ratio of nets:people in the household and other factors.

RESULTS

Although the majority (65%) of participants reported sleeping under a mosquito net every night (and 75% did so among the 86% of people with at least one net), one-quarter of participants thought that most adults in their community did not sleep under a mosquito net every night. Another 8% were unsure how many nights per week most adults in their community sleep under a mosquito net. Participants who perceived that daily mosquito net use was the norm were 2.94 times more likely to report personally sleeping under a mosquito net every night (95% CI 2.09-4.14, p < 0.001) compared to participants who thought doing so was not normative, adjusting for other factors.

CONCLUSIONS

Results suggest an opportunity for anti-malarial interventions to reduce misperceptions about mosquito net use norms and emphasize the commonness of daily mosquito net use in malaria-endemic regions. If people correctly perceive most others to sleep under a net every night, then they may personally do so when possible and support others to do so too.

Incorporating Writing into a Personalized Normative Feedback Intervention to Reduce Problem Drinking Among College Students

BACKGROUND

Personalized normative feedback (PNF) interventions have repeatedly been found to reduce drinking among undergraduates. However, effects tend to be small, potentially due to inattention to and inadequate processing of the information. Adding a writing component to PNF interventions may allow for greater cognitive processing of the feedback, thereby boosting intervention efficacy. Additionally, expressive writing (EW) has been shown to reduce drinking intentions; however, studies have not examined whether it can reduce drinking behavior. The present experiment evaluated whether including a writing task would improve the efficacy of PNF and whether EW alone can be used to reduce drinking and alcohol-related problems.

METHODS

Heavy drinking undergraduates (N = 250) were randomized to receive either: (i) PNF about their alcohol use; (ii) EW about a negative, heavy drinking occasion; (iii) PNFplus writing about the norms feedback; or (iv) attention control feedback about their technology use in an online brief intervention. Participants (N = 169) then completed a 1-month follow-up survey about their past month alcohol use and alcohol-related problems online.

RESULTS

PNFplus writing reduced alcohol-related problems compared to all other conditions. No significant reductions were found for EW. Both PNF and PNFplus writing reduced perceived norms and perceived norms mediated intervention effects for both feedback conditions.

CONCLUSIONS

The current findings suggest that adding a writing component to traditional norms-based feedback approaches might be an efficacious strategy, particularly for reducing alcohol-related consequences.

Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Unhealthy alcohol use is common, increasing, and a leading cause of premature mortality.

OBJECTIVE

To review literature on the effectiveness and harms of screening and counseling for unhealthy alcohol use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through October 12, 2017; literature surveillance through August 1, 2018.

STUDY SELECTION

Test accuracy studies and randomized clinical trials of screening and counseling to reduce unhealthy alcohol use.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction by 2 reviewers. Counseling trials were pooled using random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drinks per week, exceeding recommended limits, heavy use episodes, abstinence (for pregnant women), and other health, family, social, and legal outcomes.

RESULTS

One hundred thirteen studies (N = 314 466) were included. No studies examined benefits or harms of screening programs to reduce unhealthy alcohol use. For adolescents (10 studies [n = 171 363]), 1 study (n = 225) reported a sensitivity of 0.73 (95% CI, 0.60 to 0.83) and specificity of 0.81 (95% CI, 0.74 to 0.86) using the AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) to detect the full spectrum of unhealthy alcohol use. For adults (35 studies [n = 114 182]), brief screening instruments commonly reported sensitivity and specificity between 0.70 and 0.85. Two trials of the effects of interventions to reduce unhealthy alcohol use in adolescents (n = 588) found mixed results: one reported a benefit in high-risk but not moderate-risk drinkers, and the other reported a statistically significant reduction in drinking frequency for boys but not girls; neither reported health or related outcomes. Across all populations (68 studies [n = 36 528]), counseling interventions were associated with a decrease in drinks per week (weighted mean difference, -1.6 [95% CI, -2.2 to -1.0]; 32 studies [37 effects; n = 15 974]), the proportion exceeding recommended drinking limits (odds ratio [OR], 0.60 [95% CI, 0.53 to 0.67]; 15 studies [16 effects; n = 9760]), and the proportion reporting a heavy use episode (OR, 0.67 [95% CI, 0.58 to 0.77]; 12 studies [14 effects; n = 8108]), and an increase in the proportion of pregnant women reporting abstinence (OR, 2.26 [95% CI, 1.43 to 3.56]; 5 studies [n = 796]) after 6 to 12 months. Health outcomes were sparsely reported and generally did not demonstrate group differences in effect. There was no evidence that these interventions could be harmful.

CONCLUSIONS AND RELEVANCE

Among adults, screening instruments feasible for use in primary care are available that can effectively identify people with unhealthy alcohol use, and counseling interventions in those who screen positive are associated with reductions in unhealthy alcohol use. There was no evidence that these interventions have unintended harmful effects.

Prototype Willingness Model Drinking Cognitions Mediate Personalized Normative Feedback Efficacy

Personalized normative feedback (PNF) interventions have been shown to be efficacious at reducing college student drinking. Because descriptive norms have been shown to mediate PNF efficacy, the current study focused on examining additional prototype willingness model social reaction cognitions, namely, prototypes and willingness, as mediators of intervention efficacy. We expected the PNF interventions to be associated with increased prototype favorability of students who do not drink, which would in turn be associated with decreased willingness to drink and subsequently, less drinking. The current study included 622 college students (53.2% women; 62% Caucasian) who reported one or more heavy drinking episodes in the past month and completed baseline and three-month follow-up assessments. As posited by the framework of the prototype willingness model, sequential mediation analyses were conducted to evaluate increases in abstainer prototype favorability on willingness on drinking, and subsequently willingness to drink on drinking behavior. Mediation results revealed significant indirect effects of PNF on three-month drinking through three-month prototypes and willingness, indicating that the social reaction pathway of the prototype willingness model was supported. Findings have important implications for PNF interventions aiming to reduce high-risk drinking among college students. Study findings suggest that we should consider looking at additional socially-based mediators of PNF efficacy in addition to perceived descriptive norms.

A quantification of the alcohol use-consequences association in college student and clinical populations: A large, multi-sample study

BACKGROUND

The present study sought to quantify the relationship between alcohol use and alcohol-related consequences in both college student and clinical samples.

METHODS

We gathered 33 college student datasets comprising of 15,618 participants and nine clinical sample datasets comprising of 4,527 participants to determine the effect size of the relationship between alcohol use and alcohol-related consequences. We used random-effects meta-analytic techniques, separately in college and clinical samples, to account for a distribution of true effects and to assess for heterogeneity in effect sizes.

RESULTS

Results demonstrated that the clear majority of the variability in alcohol-related consequences is not explained by alcohol use (ie, >77% in college samples; >86% in clinical samples), and that there was significant heterogeneity in all effect sizes.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Experiencing alcohol-related consequences results from factors that extend beyond frequency and quantity of alcohol consumed suggesting a need to examine other predictors of alcohol-related consequences beyond alcohol use. (Am J Addict 2018;27:116-123).

Actual Versus Perceived HIV Testing Norms, and Personal HIV Testing Uptake: A Cross-Sectional, Population-Based Study in Rural Uganda

HIV testing is an essential part of treatment and prevention. Using population-based data from 1664 adults across eight villages in rural Uganda, we assessed individuals' perception of the norm for HIV testing uptake in their village and compared it to the actual uptake norm. In addition, we examined how perception of the norm was associated with personal testing while adjusting for other factors. Although the majority of people had been tested for HIV across all villages, slightly more than half of men and women erroneously thought that the majority in their village had never been tested. They underestimated the prevalence of HIV testing uptake by 42 percentage points (s.d. = 17 percentage points), on average. Among men, perceiving that HIV testing was not normative was associated with never testing for HIV (AOR = 2.6; 95% CI 1.7-4.0, p < 0.001). Results suggest an opportunity for interventions to emphasize the commonness of HIV testing uptake.

Drinking to cope moderates the efficacy of changing veteran drinking norms as a strategy for reducing drinking and alcohol-related problems among U.S. veterans

Heavy and problematic drinking is a concern among young adult military veterans. Personalized normative feedback (PNF) interventions that target normative misperceptions regarding drinking have been efficacious among young adults and have recently begun to be implemented among veteran populations in an effort to reduce heavy drinking. However, moderators of PNF intervention efficacy among veterans are largely unexplored. This study is a secondary data analysis that evaluated whether a PNF intervention would work better at reducing perceived norms, drinking, and alcohol-related problems specifically for young adult veterans who drink to cope with negative affect. Veterans of the United States (U.S.) military (86% male; Mean age = 28.9 years, SD = 3.4) were randomly assigned to receive either: 1) PNF comparing their drinking and perceived norms to actual drinking rates for same sex veterans; or 2) feedback about same sex veteran video game play (control condition). Seven hundred eighty-four individuals completed baseline and 622 completed 1-month follow-up assessments (79% follow-up), including measures of alcohol use, alcohol-related problems, and drinking motives. Moderated mediation analyses indicated that changes in normative misperceptions as a result of the intervention were more strongly associated with reductions in drinking and problems among veterans scoring higher on drinking to cope. These findings suggest that PNF may be an especially efficacious brief intervention for veterans who drink for coping reasons. (PsycINFO Database Record

Cross-cultural examination of college drinking culture in Spain, Argentina, and USA: Measurement invariance testing of the College Life Alcohol Salience Scale

OBJECTIVE

Perceptions about what is "normal" drinking in college, measured by the College Life Alcohol Salience Scale (CLASS; 15 items), have been robustly associated with elevated levels of problematic alcohol use, yet the role of these beliefs has not been studied outside the U.S. The present work examined measurement invariance of the CLASS across sex, drinker status, and in individuals from three different countries (i.e., U.S., Argentina, Spain). Additional goals were to evaluate differences on the CLASS (i.e., latent mean differences) as a function of sex, drinker status and country and to compare construct validity (i.e., correlations with alcohol variables) across sex and different countries.

METHOD

A large sample of 1841 college students enrolled in universities from the U.S., Spain and Argentina completed, via an online survey, a battery of instruments that assess college alcohol beliefs, drinking motives, alcohol consumption and alcohol-related negative consequences.

RESULTS

We found that a shortened 12-item version of the CLASS to be invariant across sex and drinker status, but only metric invariance was found across countries. As expected, men and drinkers showed significantly higher scores on the CLASS than women and non-drinkers, respectively. Bivariate correlations between CLASS scores and drinking outcomes strongly supported criterion-related validity of this measure across multiple countries and sex with differing strengths in relationships with alcohol-related constructs.

CONCLUSIONS

Taken together, perceptions of the centrality of alcohol to the college experience appear to be an important target for college student alcohol interventions across various cultures and countries, especially for male college student drinkers.

Addictive Behavior Interventions Among College Students

PURPOSE OF REVIEW

Addictive behaviors among college students are a significant public health concern. This manuscript reviews the past two years of literature on prevention and treatment approaches for college students who engage in addictive behaviors.

RECENT FINDINGS

In-person skills-based interventions and motivational interventions that incorporate personalized feedback are effective in the short-term but little support was found for long-term effects. Although web-based interventions reduced certain addictive behaviors (e.g., alcohol, problematic gambling), in-person interventions that include motivational interviewing components and personalized feedback appear to be more efficacious.

SUMMARY

Research has largely focused on alcohol and little is known about the utility of interventions for students who use tobacco or illicit substances or who engage in problematic gambling. Research on interventions for these high-risk behaviors is recommended.

An exploratory pilot study of mechanisms of action within normative feedback for adult drinkers

Background. Normative feedback (NF), or receiving information about one’s drinking compared to peer drinking norms, is one of the most widely used brief interventions for prevention and intervention for hazardous alcohol use. NF has demonstrated predominantly small but significant effect sizes for intention to change and other drinking related outcomes. Identifying mechanisms of action may improve the effectiveness of NF; however, few studies have examined NF’s mechanisms of action, particularly among adults.

Objective. This study is an exploratory analysis of two theorized mechanisms of NF: discrepancy (specifically personal dissonance—the affective response to feedback) and belief in the accuracy of feedback.

Method. Using Amazon’s Mechanical Turk, 87 men (n = 56) and women (n = 31) completed an online survey during which they were asked about their perceptions about their drinking and actual drinking behaviors. Then participants were provided tailored NF and evaluated for their reactions. Severity of discrepancy was measured by the difference between one’s estimated percentile ranking of drinking compared to peers and actual percentile ranking. Surprise and worry reported due to the discrepancy were proxies for personal dissonance. Participants were also asked if they believed the feedback and if they had any plans to change their drinking. Mediation analyses were implemented, exploring whether surprise, worry, or belief in the accuracy of feedback mediated severity of discrepancy’s impact on plan for change.

Results. Among this sample of adult drinkers, severity of discrepancy did not predict plan for change, and personal dissonance did not mediate severity of discrepancy. Severity of discrepancy was mediated by belief in the accuracy of feedback. In addition, viewing one’s drinking as a problem prior to feedback and post-NF worry both predicted plan for change independently.

Conclusions. Results revealed that NF may not work to create personal dissonance through discrepancy, but belief in the accuracy of feedback may be important. It appears the more one believes the feedback, the more one makes a plan for change, suggesting practitioners should be mindful of how information within feedback is presented. Findings also indicate NF may work by validating a preexisting perception that drinking is a problem instead of creating concern related to discrepancy where none existed. Limitations regarding generalizability are discussed.

Reciprocal relationships over time between descriptive norms and alcohol use in young adult sexual minority women

Young adulthood, roughly ages 18-25, is a period of great risk for excessive consumption of alcohol, especially among sexual minority women (SMW). Despite the substantial literature examining the relationships between social norms and behavior in general, little attention has been given to the role of descriptive norms on the drinking behaviors of sexual minorities. The present study had 3 aims: to compare both typical woman descriptive norms and sexual minority-specific descriptive normative perceptions among a sample of SMW, to examine reciprocal associations between sexual minority-specific descriptive norms and alcohol consumption over time, and to examine whether these reciprocal associations were moderated by sexual orientation (i.e., whether 1 identifies as lesbian or bisexual). A national sample of 1,057 lesbian and bisexual women between the ages of 18 and 25 was enrolled in this study. Participants completed an online survey at 4 time points that assessed the constructs of interest. Results indicated that SMW consistently perceived that SMW drank more than their nonsexual minority peers; that SMW-specific descriptive drinking norms and alcohol consumption influenced 1 another over time in a reciprocal, feed-forward fashion; and that these associations were not moderated by sexual orientation. These findings highlight the importance of considering SMW-specific norms as an important factor in predicting alcohol consumption in SMW. Results further support the development and testing of normative interventions for high-risk drinking among SMW.