Applying behavioral theory to an innovative school-based program for preventing underage drinking and impaired driving.
Abstract: Objective: This paper describes the development and proposed behavioral theory underlying Shattered Dreams, a school-based intervention aimed at reducing underage drinking and alcohol-related crashes. The program has been widely disseminated; however, few published studies have conceptualized the underlying behavioral change mechanisms.

Methods: We applied constructs from the transtheoretical model and social cognitive theory in order to operationalize change among program participants.

Results: Program components align well with constructs of the trans-theoretical model and social cognitive theory.

Conclusions: Mapping program components on to well-established theories may prove useful in quantifying the program's impact on underage drinking and driving outcomes.
Subject: Public health (Health aspects)
Drinking of alcoholic beverages (Health aspects)
Drunk driving (Health aspects)
Traffic accidents (Health aspects)
Alcohol and youth (Health aspects)
Drinking and traffic accidents (Health aspects)
Authors: Price, Michelle A.
Salazar, Camerino I.
Villarreal, Cynthia L.
Guerra, Christina M.
Villarreal, Roberto
Stewart, Ronald M.
Pub Date: 01/01/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2009 Source Volume: 24 Source Issue: 1
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Organization: Government Agency: United States. Centers for Disease Control and Prevention
Geographic: Geographic Scope: Texas Geographic Code: 1U7TX Texas
Accession Number: 308743750
Full Text: INTRODUCTION

The physical, cognitive, and psychological changes that are the hallmark of adolescence have various positive and negative behavioral manifestations. Behaviors that test social and legal limits and involve risk taking are public health concerns because they contribute to morbidity and mortality. The combination of alcohol use and driving is one conspicuous example of such behaviors. The personal and social risks of drinking and driving are addressed in Focus Area 15 of Healthy People 2010 --Injury and Violence Prevention: Reduce deaths and nonfatal injuries caused by motor vehicle crashes (United States Department of Health and Human Services [USDHHS], 2000). Reaching this focus area's target of 9.2 deaths or 933 nonfatal injuries per 100,000, a substantial reduction from the 1998 baseline rates of 15.6 deaths or 1,181 fatal injuries, will require a variety of strategies and intervention programs. Here we review school-based programs for preventing alcohol-impaired driving and summarize a program widely implemented by schools and communities throughout Texas and other states, Shattered Dreams. We propose the application of behavioral theory to describe the change mechanisms behind its components.

COSTS AND CONSEQUENCES OF UNDERAGE DRINKING AND IMPAIRED DRIVING

Alcohol is the drug of choice for adolescents, with an average age at first use of 13.2 years (Green-blatt, 2000; Harris et al, 2000; Maney et al., 2002; Stewart, 1999). Alcohol use progressively increases with age; between 80% and 90% of high school seniors report having experimented with alcohol (Centers for Disease Control and Prevention [CDC], 2004; Ellickson et al., 1996; Maney et al., 2002;). Almost half of teens report drinking within the past thirty days, and nearly a third admit binge drinking (5 or more drinks on one occasion) (Centers for Disease Control and Prevention (CDC), 2001). Underage drinking costs an estimated $53 billion annually in losses stemming from traffic fatalities, violent crime, and other behaviors that threaten the well-being of America's youth (National Research Council, 2003).

Motor vehicle-related crashes are the leading cause of death for persons 15 to 20 years of age (Web-based Injury Statistics Query and Reporting System [WISQRS], 2005). The National Highway Traffic and Safety Administration (2001) reported that in 2001, 3,608 drivers between the ages of 15 and 20 were killed and an additional 337,000 were injured in motor vehicle crashes. Approximately 25% of drivers between the ages of 16 and 19 who are killed in crashes are legally intoxicated (Insurance Institute for Highway Safety, 2002). Driving after drinking or riding with a drinking driver is common among high school students, however participation in these risky behaviors has decreased by less than 10% since 1991 (CDC, 2002; O'Malley & Johnston, 1999). In 2001, 13% percent of high school students reported driving a vehicle one or more times while drinking alcohol, and 31% reported riding with someone who had been drinking (CDC, 2002). Although adults are more likely than teens to drive after drinking, teens are much more likely to be involved in a crash when combining drinking and driving (Insurance Institute for Highway Safety, 2002). The increased risk for teens begins with even low levels of alcohol consumption and may result from the combination of alcohol-impaired judgment and driver inexperience. Female teen drivers with blood alcohol levels between 0.05% and 0.08% are 7 times more likely to be involved in a crash than sober teen drivers; male teen drivers are 17 times more likely to be involved (Insurance Institute for Highway Safety, 2002).

The social environment plays an important role in shaping underage drinking. Teens' drinking behaviors are influenced by friends who drink, liberal attitudes of parents toward drinking, and alcohol advertising (Grube & Wallack, 1994). Most high school students (71%) report that alcohol is easy to obtain, primarily from friends and at parties, and that drinking is common among their peers (Liu, 2002). Compounding the risk of the social ease and acceptability of alcohol use among teens is their perception that events such as car crashes will not happen to them; this perception is fueled by their inflated confidence in their ability to drive skillfully (Nygaard, Waiters, Grube, & Keefe, 2003). This same study indicates that adolescents were well informed about zero tolerance and blood alcohol concentration laws but at the same time doubted that they would be stopped or ticketed by police. Adolescents also reported strong reluctance to confront a peer about alcohol-impaired driving (Nygaard et al., 2003). Interventions designed to reduce underage drinking and alcohol-impaired driving must effectively address such interpersonal, intrapersonal, and environmental influences.

INTERVENTIONS AIMEDATREDUCINGUNDERAGE DRINKING AND ALCOHOL-IMPAIRED DRIVING

Underage drinking and alcohol-impaired driving can be reduced in much the same way in which other health-related behaviors are modified: with a focus on behavior change at the individual, interpersonal, or community level. Programs targeting individual change directly affect personal attitudes, knowledge, and behavior. Programs that strive to produce interpersonal change focus on peer influence or pressure, role modeling, and social norms. Programs that influence change on the community level focus on systemic changes to the environment that will support healthy behaviors and discourage unhealthy behaviors. Complex problems such as underage drinking and alcohol-impaired driving demand a comprehensive program with interventions at each level if the program is to be effective.

The field of injury prevention has often favored passive strategies that do not require the individual to take action (such as airbags or policy enforcement) over active strategies that rely on behavior change (Gielen & Girasek, 2000). Educational interventions are often perceived as frustrating "because they lack power to create a significant difference in outcomes when judging their ability to 'move a person from non-action to action'" (p. 284) (Kidd, Reed, Weaver, Westneat, & Rayens, 2003). Nevertheless, several studies over the past 15 years (see Table I) have shown some impact and have suggested future directions for reducing underage drinking and alcohol-impaired driving.

The length of student exposure in the five interventions summarized in Table I varied from approximately three to 15 hours. Three of the 5 interventions used constructs from behavior change theories (Theory of Planned Behavior, Social Cognitive Theory, the Stages of Change component of the Transtheoretical Model, or the Stages of Acquisition Model). The intervention Stop the Drinking Driver reported limited evaluation of outcomes (Yates & Dowrick, 1991). Alcohol, Drugs, Driving and You reported a decrease in aggressive driving and an increase in knowledge about the consequences of drinking and driving, but it provided little information about the evaluation instrument (Young, 1991). Plan a Safe Strategy showed a self-reported reduction in drinking and riding with a drinking driver; the greatest response was reported by students already engaging in the targeted behavior (Sheehan et al., 1996). Exposure to the Alcohol Misuse Prevention program did not change driving and drinking scores, whereas Start Taking Alcohol Risks Seriously claimed an improvement in alcohol use and driving behaviors among adolescents who had experienced negative consequences of the targeted behaviors (Shope et al., 1996; Werch et al., 2001). Two programs (Alcohol Misuse Prevention and Start Taking Alcohol Risks Seriously) demonstrated a positive impact on behavior one year after the intervention. The evaluation of these programs, especially Alcohol Misuse Prevention and Start Taking Alcohol Risks Seriously, demonstrates the potential impact of school-based interventions in reducing underage drinking and impaired driving but also supports the need for further innovations that can produce sustained reductions in these risky behaviors.

PROGRAM BACKGROUND AND DESCRIPTION

Shattered Dreams is a school-based prevention program aimed at reducing underage drinking and alcohol-impaired driving among high school students. The program was developed in 1998 by the multidisciplinary Bexar County (Texas) DWI Task Force Advisory Board on Underage Drinking. Based on the Every 15 Minutes program developed in Chico, California, Shattered Dreams is now used in over 75 high schools each year. In Bexar County, program development was community-driven; researchers and community members conducted focus groups with high school students to identify key issues related to underage drinking and alcohol-impaired driving. Identified issues were incorporated to the curriculum, along with research-based content on developing student leadership across social groups with the goal of promoting alcohol abstinence and avoiding drinking and driving. Additional focus groups were held with teens to test the program's name, logo, and collateral materials. Researchers provided infrastructure support for the program by producing the program planning guide, a program evaluation manual, program videos, and collateral materials. These activities were supported by funding from the local hospital district and the Texas Alcoholic Beverage Commission. The program was disseminated primarily through field agents of the state alcoholic beverage commission.

After the program had been extensively implemented throughout the state, additional focus groups were conducted with coalition members to identify program deficits. In response subsequent program modifications focused on improving parental involvement and incorporating refusal skills training. The program's goals are to reduce underage drinking and impaired driving through increased awareness of the potential negative consequences of underage drinking and impaired driving, peer-to-peer and teen-to-parent communication about alcohol risks, and skills training. School administrators and faculty members, students, parents, community organizations, law enforcement, emergency medical services, and hospitals are involved in the planning and implementation of the program's components. Partnerships between the schools and various agencies develop during the planning and implementation of the program and serve as a foundation for ongoing reinforcement and environmental measures aimed at preventing underage drinking in the community. The program's components are as follows:

* Parent-student workshop

* The Living Dead

* Mock alcohol-related motor vehicle crash on campus

* Mock death notifications to the parents of participating students

* Student retreat

* Parent retreat

* Mock memorial service

These interactive components are complemented by student-parent counseling and optional follow-up activities, including a mock sentencing trial. The components are described in Table II. A complete description is provided in Shattered Dreams: A Guide for Program Planners (2nd ed.) (Price, Guerra, Munoz, & Salazar, 2004).

METHODS

APPLYING BEHAVIORAL THEORY

The importance of behavioral theory and models for effective injury prevention programming is evidenced by the fact that a substantial proportion of injury is attributed to behavior choices such as failing to use safety belts, speeding, and impaired driving. Behavioral theories and models provide a "platform" for understanding why people elect to engage in activities that enhance or diminish their health (DiClemente et al., 2002). Behavioral theories also help researchers move beyond stable risk factors to focus on how and why people can change their behavior (Trifiletti et al., 2005). Several researchers have called for the application of behavioral theories and models to the entire field of injury prevention (Gielen & Sleet, 2003). Despite the potential for improving program development, evaluation, and effectiveness, Trifiletti et al. (2005) noted that there continue to be "enormous gaps in the research on behavioral and social sciences theories and models applied to unintentional injury prevention" (p. 7). In collaboration with the original developers of Shattered Dreams, we used the Transtheoretical Model (TTM) (Prochaska & DiClemente, 1984) and Bandura's (1986) Social Cognitive Theory (SCT) to characterize the intervention and formulate evaluation criteria. The constructs of these theories are consistent with the program's foci of changing individual (TTM) and interpersonal behavior (SCT). The program's components and corresponding theoretical constructs are presented in Table II.

RESULTS

TRANSTHEORETICAL MODEL (STAGES OF CHANGE)

The TTM theorizes that persons move through stages as they change their behavior, with different mechanisms facilitating progress through the stages (Prochaska & DiClemente, 1986). The five stages of behavior change proposed by the model are precontemplation, contemplation, preparation, action, and maintenance. In the precontemplation stage, the person has not considered that a particular behavior may be problematic. In the contemplation stage, the person begins to recognize possible problems but has not committed to changing the behavior. The preparation stage is marked by a personal decision to change and preparation to do so by learning new skills or gaining new knowledge. In the action stage, the person begins making the behavior change. The final stage, maintenance, is the stage in which the person persists in the behavior change. These stages are not necessarily linear in nature in that a person may spiral up or down through the stages at different points in behavior change.

Early application of the TTM focused on the treatment of current substance abusers or on early interventions for problem drinkers. These programs involve tertiary prevention because their goal is to prevent further harm or deterioration by helping the subject stop using drugs or alcohol (DiClemente, 1999). More recently, the constructs of the TTM have been applied to the stages of change that occur during the acquisition or initiation of a behavior (Werch, et al., 2001, 2003). During the stages of behavior acquisition, a person progresses through the same five stages, but each stage characterizes the development rather than the cessation of a behavior. This expansion of the model allows for its application to primary prevention programs, whose goal is to prevent the emergence of problem behavior, and to secondary prevention programs, one of whose goals is to prevent full-blown substance abuse or dependence in at-risk populations (DiClemente, 1999).

The components of Shattered Dreams may appeal to students who are in the various stages of change with the goal of facilitating progress toward the next stage and, ultimately, behavior change (see Table II). All program components support the processes of change from one stage to the next. Some components raise awareness among those who have not considered the risks of underage drinking or impaired driving (precontemplation). Other activities provide opportunities to learn new skills that help make change possible (preparation), and still others support teens who are initiating or maintaining alcohol-free behavior (action and maintenance). Overall, each component motivates students to become or remain alcohol-free and to avoid impaired driving behaviors by:

1) increasing perceived advantages (such as avoiding risk) while decreasing perceived disadvantages (such as peer pressure), and

2) increasing students' confidence that they can avoid the targeted behaviors (self-efficacy).

As a person adopts a new behavior or ceases to behave in a particular way, experiential and behavioral processes facilitate change (Glanz et al., 2002). Shattered Dreams facilitates change by using the TTM processes of consciousness raising, dramatic relief, environmental and self re-evaluation, self-liberation, helping relationships, and reinforcement management. Consciousness-raising activities increase information about self and the problem behavioral through observations, confrontations, and education. Dramatic relief is accomplished through experiencing and expressing feelings about one's problems and solutions such as psychodrama, grieving losses, and role playing. Environmental re-evaluation activities consist of assessing how the problem behavior affects the physical environment, whereas self re-evaluation involves assessing how one feels and thinks about oneself with respect to the problem behavior. Self-liberation is the process of committing to change or belief in the ability to change; it is accomplished through training in decision-making skills, developing resolutions, and behavioral contracting. Helping relationships are those that facilitate being open and trusting about problem behaviors with someone who cares, such as supportive peer groups. Reinforcement management consists of rewarding oneself or being rewarded by others for making changes (Prochaska et al., 2002).

SOCIAL COGNITIVE THEORY

Social cognitive theory (SCT) assumes that people, their behavior, and their environments interact continuously and that specific mediators facilitate behavioral change (Bandura, 1986). Self-efficacy, originally formulated by Bandura as a primary construct of SCT, is a critical determinant of change. Perhaps more important, Bandura (1997) offers compelling evidence that efficacy beliefs have a causal influence on behavior; thus, strong perceptions of self-efficacy about avoiding drinking and impaired driving should lead teens to persist in the face of incentives and pressures to behave irresponsibly. Although Bandura originally conceived SCT to account for individual change, he later broadened the theory to take into account environmental factors, including social transactions among persons in small or large groups. Attitudes and self-efficacy are intertwined concepts in the SCT view of behavior. Self-efficacy about handling high-risk situations is crucial for acquisition of knowledge and skills because behaviors are affected more by what people believe than by objective truth (Bandura, 1986). Moreover, perceived self-efficacy affects every phase of substance use and abuse (Bandura, 1997).

The SCT constructs integrated into the Shattered Dreams program are self-efficacy, behavioral capability, expectations, and observational learning. Self-efficacy is confidence in one's ability to perform a behavior or to change a behavior. Behavioral capability consists of the knowledge or skills needed to perform the behavior. Expectations are the anticipated outcomes of a behavior, whereas expectancies are the value that one places on the outcome. Observational learning is the process of acquiring a behavior by watching others' actions and seeing the outcome of their behavior.

DISCUSSION

Although Shattered Dreams and similar programs have been widely disseminated and enjoy strong community support, few studies have assessed their effectiveness or proposed mapping the constructs to behavioral theory (Beer, Price, Villarreal, & Salazar, 2002; Bordin, Bumpus, & Hunt, 2003; Dougherty, 2004; Fiscus, 2003; Hollis, 2002; Hover, Hover, & Young, 2000; Price, Salazar, Bayles, & Villarreal, 2003; Salazar et al., 2006). Preliminary findings on Shattered Dreams indicated improved student awareness of the risks and consequences of underage drinking and driving and suggested that students' expectations about alcohol use were less positive after participation in the program (Price et al., 2003; Salazar et al., 2006).

A recent study used SCT constructs to measure behavioral expectancies related to drinking alcohol, self-efficacy and self-reported drinking and drinking behaviors among program participants (Salazar & Villarreal, 2007; Salazar, Sunil, Villarreal, & Guerra, 2009). In this study, Salazar et al. measured students' expectancies regarding alcohol (positive and negative consequences), self-efficacy, knowledge and self-reported underage drinking and impaired driving among student participants at seven Texas high schools (in a single-group, pre- and post-test design; n = 139). On the 30 day post-test, program participants reported significant decreases in the number of drinking days in the past 30 days (pre-test mean = 1.81; post-test mean = 0.91, p = 0.001), number of days having 5 or more drinks (binge drinking) (pretest mean = 1.09; post-test mean = 0.56, p =0.001), and number of times driving/riding after drinking. The majority of participants also reported that they would be more likely to discuss the risks of underage drinking (76%) and of drinking and driving (86%) with their peers suggesting an improvement in self-efficacy. The study did not find evidence of significant change in alcohol expectancies, however.

These findings are hampered by design challenges that are inherent in many community-driven, school-based interventions, such as the lack of a control group, the absence of random selection, and the reliance on self-report as a proxy for measuring actual behavior change. Clearly, additional research is needed if we are to better understand the program's impact on underage drinking and impaired driving among teens. Subsequent studies might include an evaluation of movement through the TTM's stages of change for underage drinking and alcohol-impaired driving; an assessment of changes in self-efficacy, capability, and expectancies; and long-term monitoring of drinking and driving related outcomes (alcohol-related offenses or injuries).

Limitations: There are limitations in the practical application of theoretical constructs to evaluate school-based interventions such as Shattered Dreams. First, the research required to thoroughly validate the use of the constructs to measure change related to this type of program is considerable and there may be significant barriers to conducting this research (logistically, financially and otherwise). The number of survey items required to adequately measure all of the constructs would add to the burden of administering the instrument during instructional classroom time. Also, considerable resources would be required to measure student attitudes and behaviors at several time points after the intervention (to allow sufficient time for change to occur and evaluate whether change is maintained). Finally, our evaluation team has found that some school systems are cautious regarding the administration of survey instruments that ask students sensitive questions regarding illegal activity (i.e., alcohol availability to minors, underage drinking and impaired driving). These considerations must be balanced with the pursuit of empirically evaluating the program's effectiveness.

In conclusion, more research is needed to further evaluate school-based interventions such as Shattered Dreams. Contemporary behavioral theory provides a useful framework for evaluating the mechanisms involved in changing behavior toward a desired outcome. Using the Transtheoretical Model (TTM) to measure and understand movement toward change rather than using an "all or nothing" approach can be very useful in injury prevention research (Kidd et al., 2003). The combination of using the Transtheoretical Model to assess progress toward change and constructs of Social Cognitive Theory (behavior, personal factors, and environmental influences), can advance the field of injury prevention, particularly in the areas of underage drinking and impaired driving.

ACKNOWLEDGEMENTS

The Shattered Dreams program was made possible by school personnel, students, parents, and the San Antonio Shattered Dreams Coalition members, who are dedicated to reducing underage drinking and alcohol-related injury, particularly Lt. Christina Guerra of the Texas Alcoholic Beverage Commission.

This manuscript was produced under the US Office of Juvenile Justice and Delinquency Prevention Contract--Texas Alcoholic Beverage Commission contract # 2001-AH-FX-4048. Program funding was also provided by University Health System of Bexar County under contracts # 2201063-LS, 2301075-LS, and 2402130-LS.

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Michelle A. Price, PhD, is affiliated with Department of Surgery, The University of Texas Health Science Center at San Antonio. Camerino I. Salazar, MS, is affiliated with Texas Diabetes Institute, University Center for Community Health. Cynthia L. Villarreal, MA, is affiliated with South Texas Poison Center, The University of Texas Health Science Center at San Antonio. Christina M. Guerra, is a Founder/CEO, CMG and Associates. Roberto Villarreal, MD, MPH, is Vice President of Community Initiatives and Translational Research, University Health System. Ronald M. Stewart, MD, is affiliated with Department of Surgery, The University of Texas Health Science Center at San Antonio. Please address all correspondence to Michelle A. Price, PhD, 7701 Floyd Curl Drive--MS 7840 San Antonio, TX 78229-3900, USA. PHONE: 210-5675704, FAX: 210-567-3447, E-mail: pricema@uthscsa.edu.
Table 1. School-Based Interventions for Preventing Underage
Drinking and Impaired Driving

Program                      Program              Supporting
                              Length                Theory

Stop the Drinking            1 week               None
  Driver(1)
Alcohol, Drugs,              5-15 days            None
  Driving and You(2)
Plan a Safe Strategy(5)      12 sessions          Theory of Planned
  Strategy(5)                                     Behavior
Alcohol Misuse               1 week               Social Cognitive
  Prevention(4)                                   Theory
Alcohol Misuse               Follow-up            Social norms,
  Prevention(5)              study 7 years        skills training
                             after intervention
Start Taking Alcohol         2 years              Stages of
  Risks Seriously                                 Acquisition
  (STARS)for Families(6)                          Model-McMos8
Start Taking Alcohol Risks   Follow-up            Stages of
  Seriously (STARS)for       study 1 year         Acquisition
  Families(7)                after intervention   Model-McMos 8

Program                             Intervention
                                     Strategies

Stop the Drinking            School-based peer modeling,
  Driver (1)                 peer pressure, and refusal
Alcohol, Drugs,              School-based with community
  Driving and You (2)        and parent components
Plan a Safe Strategy (5)     School-based intervention for
  Strategy (5)               reducing drinking and driving
                             and increasing intention to the
                             use of alternative strategies
Alcohol Misuse               School-based teaching of refusal
  Prevention (4)             skills, alcohol knowledge, and
                             risks of impaired driving
Alcohol Misuse               Evaluated driving records and
  Prevention (5)             self-reported drinking 7 years
                             after 10th-grade intervention
Start Taking Alcohol         School-based multi-modal
  Risks Seriously            intervention based on Stages of
  (STARS)for Families (6)    Acquisition
                             with materials for child-parent
                             discussions
Start Taking Alcohol Risks   School-based multi-modal
  Seriously (STARS) for      intervention based on Stages of
  Families (7)               Acquisition with
                             materials for child-parent
                             discussions

Program                            Primary
                                   Outcomes

Stop the Drinking            67% of students reported
  Driver (1)                 impaired driving or riding
                             with impaired driver
Alcohol, Drugs,              Reduction in self-reported
  Driving and You (2)        aggressive driving, increased
                             knowledge of drug and alcohol
                             effects and legal consequences
Plan a Safe Strategy (5)     Reduction in driving after
  Strategy (5)               drinking and riding with a
                             drinking driver
Alcohol Misuse               Improved refusal skills, increase
  Prevention (4)             in knowledge and decrease in
                             reported alcohol misuse
Alcohol Misuse               Positive effect in decreasing
  Prevention (5)             first-year driving offenses for
                             students drinking less than 1
                             drink per week at baseline
Start Taking Alcohol         Interaction between prior alcohol
  Risks Seriously            consequences and intervention
  (STARS) for Families (6)   yielded less intent and less
                             frequent use of alcohol at
                             one year
Start Taking Alcohol Risks   Intervention groups showed
  Seriously (STARS) for      less alcohol risk and less
  Families (7)               intention to drink than
                             control groups 1 year after
                             the intervention

Program                            Implications/
                                    Limitations

Stop the Drinking            Limited evaluation (post-test
  Driver (1)                 only); self-reporting supports
                             the need for effective interventions
Alcohol, Drugs,              Limited information about the
  Driving and You (2)        evaluation instrument; may have
                             positively affected students'
                             driving style
Plan a Safe Strategy (5)     Students who were already
  Strategy (5)               experimenting with the target
                             behaviors were the most
                             responsive to the intervention
Alcohol Misuse               Driving after drinking scores
  Prevention (4)             did not change.
Alcohol Misuse               Results support the effectiveness
  Prevention (5)             of early intervention on long-term
                             behavioral outcomes with a reduction
                             in serious driving offenses
Start Taking Alcohol         Results support application
  Risks Seriously            of stage-based intervention to
  (STARS) for Families (6)   reduce alcohol use (this program
                             did not address impaired driving)
Start Taking Alcohol Risks   Results show that intervention
  Seriously (STARS) for      effects were maintained
  Families (7)               one year after intervention;
                             this finding supported the
                             effectiveness of stage-matched
                             prevention

1. (Yates & Dowrick, 1991)

2. (Young, 1991)

3. (Sheehan et al., 1996)

4. (Shope, Copeland, Maharg, & Dielman, 1996)

5. (Shope, Elliott, Raghunathan, & Waller, 2001)

6. (Werch, Carlson, Owen, DiClemente, & Carbonari, 2001)

7. (Werch et al., 2003)

8. Multi-component Motivational Stages (Werch and DiClemente, 1994)

Table 2. Program Components Linked to Constructs of the
Transtheoretical Model and Social Cognitive Theory

Program Components               Theoretical Constructs

Parent-student                  Consciousness Raising (TTM)
workshop--Parents
in an alcohol-related crash.
participate in                  Expectancies (SCT)
program introduction,
complete consent forms,
and prepare a mock
obituary as if the
student had been killed
in an alcohol-related crash.

Living Dead--Participants       Consciousness Raising (TTM)
are removed from the            Dramatic Relief (TTM)
classroom at regular
intervals; removal
symbolizes the frequency
of crash deaths due to
impaired driving. Students'
obituaries are read aloud
to classmates.                  Expectancies (SCT)
Although participants
return to class, they
do not  interact with their
classmates for the
remainder of the day.

Mock crash-- With the           Consciousness Raising (TTM)
cooperation of local            Environmental Reevaluation (TTM)
law enforcement and
Emergency Medical               Expectancies (SCT)
Services, the immediate
aftermath of an alcohol-
related crash is simulated
on campus. Student
participants play the
roles of victims and
the impaired driver.

Mock death notification--Law    Dramatic Relief (TTM)
enforcement officers deliver
mock notifications to
participants' parents.

Student retreat--On the         Environmental Reevaluation (TTM)
evening of the mock             Self-Reevaluation (TTM)
crash, students                 Self-Liberation (TTM)
participate                     Helping Relationships (TTM)
in an overnight                 Reinforcement Management (TTM)
skills-building
retreat. Students               Behavioral Capability (SCT)
receive letters                 Expectations/Expectancies (SCT)
from their parents              Observational Modeling (SCT)
stressing how they              Self-efficacy Development (SCT)
would be affected if their
son or daughter were
killed in an
alcohol-related
crash. Students
write a letter to
their parents.

Parent retreat--On the          Environmental Reevaluation (TTM)
evening of the mock             Self-Reevaluation (TTM)
crash, parents take part        Self-Liberation (TTM)
in a 2-hour program             Helping Relationships (TTM)
discussing environmental        Reinforcement Management (TTM)
strategies for reducing
underage drinking and           Behavioral Capability (SCT)
impaired driving.               Expectations/Expectancies (SCT)
They learn about                Observational Modeling (SCT)
the legal consequences          Self-efficacy Development (SCT)
of providing alcohol
to minors.

Mock memorial--On               Dramatic Relief (TTM)
the day after the               Environmental Reevaluation (TTM)
mock crash, a student           Reinforcement Management (TTM)
assembly includes
presentations by                Observational Modeling (SCT)
participants and                Expectancies (SCT)
speakers from
the community who
either work with
some aspect of
underage drinking
or impaired driving
or have lost a family
member to an
alcohol-related crash.
Alcohol-free pledge
cards and information
on zero tolerance
laws are also
distributed to
attendees.

TTM: Transtheoretical Model; SCT: Social Cognitive Theory.
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