Enhancing the effectiveness of alcohol and drug education programs through social cognitive theory.

Use of theory in designing, implementing, and evaluating health education programs is becoming more and more important. Application of theory serves several significant functions: specifies methods for behavior change, helps in discerning measurable program outcomes, identifies timing for interventions, helps in choosing right mix of strategies, improves replication, and enhances program efficiency and effectiveness. One such theory that has been popular in health education for close to three decades is Social Cognitive Theory given by Albert Bandura. Despite its popularity in academic settings and hundreds of publications in professional journals, the theory needs to be applied more in practice settings.

Social Cognitive Theory was earlier called Social Learning Theory. The theory essentially purports triadic reciprocity between behavior, personal factors and environment. The theory has evolved over the years. In a recent article, Bandura (2004) has identified the primary constructs or determinants of this theory. These are knowledge of health risks and benefits of healthy practices, self-efficacy or behavior specific confidence in one's ability to influence one's habits, outcome expectations about expected costs and benefits for different health habits, goals that a person sets for himself or herself, perceived facilitators and impediments or obstacles.

Knowledge is the prerequisite for any behavior change and self-efficacy is a fundamental requirement for behavior change. Outcome expectations are of three kinds that pertain to physical outcomes, social outcomes of approval and disapproval, and positive and negative self-evaluative reactions. Goals are proximal and distal that set the course for change. Perceived facilitators and impediments pertain to personal/situational factors and to those of the health system.

Social Cognitive Theory has been applied in alcohol and drug education literature. There are three kinds of publications: review articles, descriptive studies, and intervention studies. Several review articles in alcohol and drug education literature have talked about Social Cognitive Theory. For example, Johnson and colleagues (1988) summarized the theories and models for alcohol prevention among youth for the Alcohol, Drug Abuse, and Mental Health Administration's Office for Substance Abuse Prevention (OSAP). Likewise, Vakalahi (2001) has discussed Social Cognitive Theory while discussing adolescent substance use and family-based risk and protective factors. Similarly, Botvin (1983) has discussed Social Cognitive Theory while reviewing prevention approaches for adolescent substance abuse.

In alcohol and drug education, descriptive studies have been done that have utilized Social Cognitive Theory as a framework. For example, a study by Burke and Stephens (1999) examined the relationship between social anxiety and heavy drinking in college students using Social Cognitive Theory model. In another study, Williams and Kleinfelter (1989) examined the relationship between social learning theory, postulated problem solving skills and drinking among college students. The study found lower self-efficacy in problem solving skills resulted in higher consumption of alcohol.

In alcohol and drug education, intervention studies have been done that have been based on Social Cognitive Theory. For example, Wilhelmsen and colleagues (1994) implemented and tested school-based alcohol prevention programs for 7th grade students that were based on Social Cognitive Theory. Twelve schools were recruited and four were assigned to a highly role-specified version of the intervention, another four to a less role-specified version of the intervention and the remaining four served as no treatment comparison groups. Pre test and post test measurements were taken on alcohol use, self-efficacy, expectations, intentions, norms, and attitudes. The results indicated that a highly role-specified version had a higher degree of student involvement and was more successful in engaging students in alcohol prevention activities. In another study, Newman and colleagues (1992) developed and evaluated a ninth grade alcohol education program that was based on problem behavior theory, social cognitive theory and role theory. Students' knowledge, skills and practices were measured before the program, six weeks after the program, and one year after the program. Significant increases in knowledge and perceived ability to resist pressures to drink were found among experimental students but no significant differences were found for drinking or drinking and driving practices. However, at one year after the program, it was found that significantly fewer experimental students reported riding with a driver who had been drinking. In another work, Ramirez and colleagues (1999) developed substance abuse prevention intervention for low-income Mexican American youth aged 9-13 years. The intervention was distributed via a satellite television network and featured social models with cognitive behavioral skills and conservative norms regarding substance abuse.

Most useful among the types of studies represented in the application of Social Cognitive Theory for alcohol and drug education are the intervention studies. Bandura (2004) suggests a three level stepwise implementation model to enhance the effectiveness of interventions. In the first level the target audience includes people with knowledge, high outcome expectations, and high self-efficacy for whom minimal guidance interventions that remove impediments are helpful. In the second level the target audience includes people with knowledge but low self-efficacy and low outcome expectations for whom tailored print or telephone counseling that enhances self-efficacy, increases outcome expectations, sets goals and removes impediments are helpful. In the third level the target audience includes people who do not believe that health behaviors are in their control and for whom personal guidance and mastery programs involving all constructs are helpful. Regarding channels for delivery of effective interventions, Bandura (2004) advocates for use of interactive computer technologies, Internet delivered guidance sessions, and serial dramas. Utilizing some of this guidance, the practitioners and researchers in alcohol and drug education can benefit, and need to apply Social Cognitive Theory more in their work.

References

Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143-164.

Botwin, G. J. (1983). Prevention of adolescent substance abuse through the development of personal and social competence. NIDA Research Monograph, 47, 115-140.

Burke, R. S., & Stephens, R. S. (1999). Social anxiety and drinking in college students: A social cognitive theory analysis. Clinical Psychology Review, 19, 513-530.

Johnson, E. M., Amatetti, S., Funkhouser, J. E., & Johnson, S. (1988). Theories and models supporting prevention approaches to alcohol problems among youth. Public Health Reports, 103, 578-586.

Newman, I. M., Anderson, C. S., & Farrell, K. A. (1992). Role rehearsal and efficacy: Two 15-month evaluations of a ninth-grade alcohol education program. Journal of Drug Education, 22, 55-67.

Ramirez, A. G., Gallion, K. J., Espinoza, R., & Chalela, P. (1999). Developing a media- and school-based program for substance abuse prevention among Hispanic youth: A case study of Mirame!/Look at Me! Nicotine & Tobacco Research, 1 (Suppl 1), S99-104.

Vakalahi, H. F. (2001). Adolescent substance use and family-based risk and protective factors: A literature review. Journal of Drug Education, 31, 29-46.

Wilhelmsen, B. U., Laberg, J. C., & Klepp, K. I. (1994). Evaluation of two student and teacher involved alcohol prevention programmes. Addiction, 89, 1157-1165.

Williams, J. G., & Kleinfelter, K.J. (1989). Perceived problem-solving skills and drinking patterns among college students. Psychology Reports, 65, 1235-1244.

Manoj Sharma, MBBS, CHES, Ph.D.

Editor, Journal of Alcohol & Drug Education

University of Cincinnati 

526 Teachers College

PO Box 210002

Cincinnati, OH 45221-0002