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The transtheoretical model of change for mutli-level interventions for alcohol abuse on campus.



Abstract

This paper brings together the pressing problem of alcohol abuse on college campuses on one of the most promising solution--stage-based interventions applied at multiple levels. The interventions fit the Transtheoretical Model The transtheoretical model of change in health psychology explains or predicts a person's success or failure in achieving a proposed behavior change, such as developing different habits. It attempts to answer why the change "stuck" or alternatively why the change was not made. , which construes behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness.  as a process that unfolds over time and involves progress through a series of stages. Unique to the paper is how the stage paradigm can be applied at four levels of the university (leadership, facility, and staff, students, and alumni) and into the community. This approach to change can produce impressive impacts on alcohol abuse and its serious consequences.

Index Terms: alcohol abuse on campus, Transtheoretical Model, multilevel mul·ti·lev·el  
adj.
Having several levels: a multilevel parking garage.

Adj. 1. multilevel - of a building having more than one level
 interventions

**********

Alcohol abuse is considered by college presidents and administrators to be the number one health problem on campuses (Presidents Leadership Group, 1997). One of the most promising approaches to this problem on a population basis is to apply the Transtheoretical Model of Change (TTM TTM

Trailing 12 months. Often used with Earnings Per Share.
) at multiple levels of a campus. TTM construes behavior change as a process that unfolds over time and involves progress through a series of changes: Precontemplation, Contemplation Contemplation
Compleat Angler, The

Izaak Walton’s classic treatise on the Contemplative Man’s Recreation. [Br. Lit.: The Compleat Angler]

Thinker, The

sculpture by Rodin, depicting contemplative man.
, Preparation, Action and Maintenance (Prochaska, Diclemente, & Norcross, 1992). The TTM is a comprehensive model that integrates ideas from several different theories and approaches to change to explain and predict how and when individuals end high-risk behaviors high-risk behavior Public health A lifestyle activity that places a person at ↑ risk of suffering a particular condition. See Safe sex practices.  or adopt health ones. This paper will describe TTM and how it can be applied at four levels (leadership, faculty and staff, students, and alumni). Practical examples will be presented, drawing primarily from experiences at a state university in the northwest that has been part of Weschsler and colleagues' (2002) studies since 1993. Finally, results will demonstrate how an organization and population approach to change can produce impressive impacts on alcohol abuse and its serious consequences.

Alcohol abuse is a major contributing factor to individual and social problems on campuses throughout the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  (Carnegie Foundation
This article is about the Dutch Carnegie Foundation, owner and manager of the Peace Palace. For other uses, see The Carnegie Foundation.


The Carnegie Foundation ("Carnegie Stichting" in Dutch) is an organization based in The Hague, The Netherlands.
 for the Advancement of Teaching, 1990; Presley, Meilman, & Lyerla, 1995; U.S. Department of Education Safe and Drug-Free Schools Program, 2000). The first two years of college is a time of transition to independent adulthood for many students, and offers new opportunities to experiment with lifestyles and behaviors that place students at high risk for alcohol abuse. While most traditional college age students cannot drink legally, Wechsler's 2002 Harvard School of Public Health The Harvard School of Public Health is (colloquially, HSPH) is one of the professional graduate schools of Harvard University. Located in Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill, next to Harvard Medical School and Cambridge, Massachusetts,  study at 119 nationally representative colleges reported that 44.4 percent of college students admitted binge drinking binge drinking An early phase of chronic alcoholism, characterized by episodic 'flirtation' with the bottle by binges of drinking to the point of stupor, followed by periods of abstinence; BD is accompanied by alcoholic ketoacidosis–accelerated lipolysis and  (five or more drinks in one sitting for males, four for females) in the previous two weeks. Moreover, this percentage remained relatively unchanged from similar Harvard studies by Wechsler and colleagues (Wechsler, Davenport Davenport, city (1990 pop. 95,333), seat of Scott co., E central Iowa, on the Mississippi River; inc. 1836. Bridges connect it with the Illinois cities of Rock Island and Moline; the three communities and neighboring Bettendorf, Iowa, are known as the Quad Cities. , Dowdall, Moeykens, & Castillo, 1994; Weshsler, Dowdall, Maenner, Gledhill-Hoyt, & Lee, 1998; Wechsler, Lee, Kuo, & Lee, 2000).

Heavy drinking
  • Heavy drinking may mean drinking large amounts of water or alcohol.
  • Heavy drinking may also mean drinking alcohol to the point of Drunkenness.
 by college students has been consistently associated with higher rates of property damage, driving under influence, injury, behaviors that are regretted, missed classes, interpersonal relationship This article or section may contain original research or unverified claims.

Please help Wikipedia by adding references. See the for details.
This article has been tagged since September 2007.
 difficulties, and unprotected or unplanned sex (Johnson, O'Malley, & Bachman, 1996). Wechsler and colleague's (1994) national college study reported that students who binged were at higher risk for experiencing a variety of alcohol related problems than those who drank but did not binge. In that study heavy drinkers were five times more likely than non-binge drinkers to report that they had experienced five or more of twelve alcohol-related problems. A dose response relationship has also been observed, with more frequent bingers experiencing substantially higher risks than less frequent bingers (Johnston et al., 1996). In the 1996, the northeastern university Northeastern University, at Boston, Mass.; coeducational; founded 1898 as a program within the Boston YMCA, inc. 1916, university status 1922, fully independent of the YMCA 1948.  reported that approximately 80% of violations of community standards Community standards are local norms bounding acceptable conduct. Sometimes these standards can itemized in a list that states the community's values and sets guidelines for participation in the community.  involved substance use, primarily alcohol abuse (Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
 & Rogers, 1997).

Alcohol abuse is an issue that has concerned the northeast university for many years. For three years during the 90's the Princeton Review college guide listed the university as the nation's top party school. Sixty-seven percent of the students reported that they were binge drinkers, compared to 44% nationally (Wechsler et al., 1994). Healthy people 2010 reports a 1998 baseline rate of 39% for binge drinking among college students with a 2010 target of 20% (U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
 (USDHHS USDHHS,
n.pr See United States Department of Health and Human Services.
), 2000). Given the problem on this campus, the President recognized that he needed an intervention strategy that could be applied on a population basis and at multiple levels. As (Wechsler, Nelson, & Weitzman, 2000) encourage, colleges need to move beyond a simple didactic di·dac·tic
adj.
Of or relating to medical teaching by lectures or textbooks as distinguished from clinical demonstration with patients.
 model of education interventions. Some of the strategies that developed over time were based a priori a priori

In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience.
 on the Transtheoretical Model, while others will be analyzed post hoe hoe, usually a flat blade, variously shaped, set in a long wooden handle and used primarily for weeding and for loosening the soil. It was the first distinctly agricultural implement. The earliest hoes were forked sticks.  from a Transtheoretical perspective.

The Transtheoretical Model (TTM) is one of the leading intervention models for behavior change (O'Donnell, 1997). It offers a promising approach to behavior change on college campuses. The model systematically integrates four theoretical concepts central to change: (1) Stages of Change (readiness to act); (2) Processes of Change (10 cognitive, affective affective /af·fec·tive/ (ah-fek´tiv) pertaining to affect.

af·fec·tive
adj.
1. Concerned with or arousing feelings or emotions; emotional.

2.
, behavioral activities that facilitate change); (3) Self-Efficacy (confidence to make and sustain changes in difficult situations); (4) Decisional Balance (pros and cons pros and cons
Noun, pl

the advantages and disadvantages of a situation [Latin pro for + con(tra) against]
 of changing).

The TTM has been shown to be robust in explaining and facilitating change across a broad range of health behaviors, including smoking cessation smoking cessation Public health Temporary or permanent halting of habitual cigarette smoking; withdrawal therapies–eg, hypnosis, psychotherapy, group counseling, exposing smokers to Pts with terminal lung CA and nicotine chewing gum are often ineffective. , and dietary change (Prochaska, Diclemente, Velicer, & Rossi, 1993; Greene, Rossi, Rossi, Velicer, Fava, & Prochaska, 1999). The model has been applied to organizational change efforts including collaborative service delivery, time-limited therapy, and continuous quality improvement in healthcare (Levesque, Prochaska, & Prochaska, 1999; Prochaska, 2000; Levesque, Prochaska, Dewart, Hornby, & Weeks, 2001).

Stage of Change represents the temporal and motivational dimensions of the change process. Longitudinal studies longitudinal studies,
n.pl the epidemiologic studies that record data from a respresentative sample at repeated intervals over an extended span of time rather than at a single or limited number over a short period.
 found that people move through a series of five stages (Prochaska & Diclemente, 1983). In the Precontemplation Stage, individuals deny the problem, are unaware of the negative consequences of their behavior, believe the consequences are insignificant, or have given up on changing because they are demoralized de·mor·al·ize  
tr.v. de·mor·al·ized, de·mor·al·iz·ing, de·mor·al·iz·es
1. To undermine the confidence or morale of; dishearten: an inconsistent policy that demoralized the staff.
. They are not intending to take action in the next months. Individuals in the Contemplation Stage are likely to recognize more of the pros of changing. However, they overestimate o·ver·es·ti·mate  
tr.v. o·ver·es·ti·mat·ed, o·ver·es·ti·mat·ing, o·ver·es·ti·mates
1. To estimate too highly.

2. To esteem too greatly.
 the cons of changing and, therefore, experience ambivalence ambivalence (ămbĭv`ələns), coexistence of two opposing drives, desires, feelings, or emotions toward the same person, object, or goal. The ambivalent person may be unaware of either of the opposing wishes. . They are intending to act within the next six months. Individuals in the Preparation Stage have decided to take action in the next 30 days, and have begun to take small steps toward that goal. Individuals in the Action Stage are overtly engaged in modifying their problems behaviors. Individuals in the Maintenance Stage have been able to sustain action for at least six months, and are striving to prevent relapse. For most people, the change process is not linear, but spiral, with several relapses to earlier stages before they attain permanent behavior change (Prochaska & Diclemente, 1986). The importance of a stage approach can be illustrated by data from the northeast university. A survey that included TTM assessment of stage of change for alcohol abuse was given to approximately 1500 freshman and sophomores and found that about 70% are in the Precontemplation stage and less than 10% were in the Preparation stage for stopping abusing alcohol (Laforge, 2001). If only 10% of students are prepared to take action, it should come as no surprise that many organizational change initiatives fail. Individuals in Precontemplation and Contemplation are likely to see change as imposed, and can become resistant and defensive if forced to take action before they are ready.

Processes of Change. In comparison of 24 systems of therapy, 10 change processes were identified (Prochaska, 1984). Table 1 illustrates how the processes could be applied in interventions for an alcohol free campus.

Research on a variety of health behaviors has identified strategies or processes of change that are employed in each stage to facilitate change. Individuals in the early stages rely more on cognitive, affective and evaluative strategies to change. Individuals in the later stages rely more on behavioral strategies including social support, reinforcement, commitments, and environmental management techniques. For example, the data show that individuals in the Precontemplation stage emphasize Consciousness Raising Consciousness raising (often abbreviated c.r.) is a form of political activism, pioneered by United States radical feminists in the late 1960s. It often takes the form of a group of people attempting to focus the attention of a wider group of people on some cause or , Dramatic Relief, and Environmental Reevaluation; individuals in Contemplation emphasize Self-Reevaluation; individuals in Preparation emphasize Self-Liberation; and individuals in Action emphasize Reinforcement Management, Helping Relationships, Counter Conditioning Noun 1. counter conditioning - conditioning in which a second incompatible response is conditioned to an already conditioned stimulus; "counter conditioning lies behind many of the procedures used in behavior therapy" , and Stimulus Control Stimulus control
We refer to stimulus control when a discriminative stimulus changes the probability of a behavior (operant response). The discriminative stimulus comes to control behavior when it predicts something about the consequences of that behavior.
 to sustain changes (Prochaska et al., 1992).

Self-efficacy is the confidence to change in challenging situations, such as resistance from students, faculty or alumni. Self-efficacy has been found to increase as people process through the stages of change, with the greatest increases occurring in Action and Maintenance. One way to increase self-efficacy is to apply a stage-based approach that increases confidence as populations progress from one stage to the next.

Decisional Balance. The decision to move towards action is based on the relative weight given to the pros and cons of changing. Across 12 problem behaviors consistent patterns emerged that generate principles for producing progress (Prochaska et al., 1994). In Precontemplation, the cons always outweigh the pros. From Precontemplation to Contemation the pros always increase and the cons consistently decrease from Contemplation to Action. The pros begin to outweigh the cons of changing prior to action being taken. From Precontemplation to Action the pros increase about one standard deviation In statistics, the average amount a number varies from the average number in a series of numbers.

(statistics) standard deviation - (SD) A measure of the range of values in a set of numbers.
 while the cons decrease one-half standard deviation from Contemplation to Action (Prochaska et al., 1994). Therefore, twice as much emphasis should be placed on increasing appreciation on campus of the pros of changing to an alcohol free campus. The functional relationships of pros and cons across the stages of change have been replicated in separate studies of alcohol abuse among college students, high school students and adults in an HMO HMO health maintenance organization.

HMO
n.
A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial,
 population (Prochaska, 2002). Table 2 lists some of the pros and cons that could occur as a result of intervening on alcohol abuse on campus. Cons like a decline in admissions are less likely to occur if the leadership takes care to communicate the way the pros are outweighing the cons.

At the leadership level, considerable time is usually taken debating the pros and cons of adopting a program for reducing alcohol abuse. When the leaders become convinced that the pros clearly outweigh the cons, they are ready to take action. The problem is that other levels of the organization have not gone through this process and are not likely to be prepared to take action. If the leaders launch an action intervention when staff, faculty and students are in Precontemplation, they are highly likely to encounter resistance in their program is likely to fail.

Stage-Matched Versus Action-Oriented Interventions

Research has shown that stage-matched interventions can have greater impacts than action-oriented programs. First, stage-matched interventions cal allow all individuals to participate in the change process, even if they are not prepared to take action. The impact of a program equals participation rate times the efficacy rate (percent of students who take action). Therefore, the more at risk students who are at risk for alcohol who participate the greater the impact the program can be. Second, stage-matched interventions can increase the likelihood that individuals will take action. Stage-matched interventions for smokers more than doubled the efficacy on cessation rates of one of the best action oriented o·ri·ent  
n.
1. Orient The countries of Asia, especially of eastern Asia.

2.
a. The luster characteristic of a pearl of high quality.

b. A pearl having exceptional luster.

3.
 interventions available (Prochaska et al., 1993). Stage-matched interventions have been out-performed one-size-fits-all interventions for exercise acquisition, dietary behavior, and other health behaviors in population-based studies (Diclemente & Hughes, 1990); (Campbell et al., 1994). These findings have important implications for alcohol elimination on campuses. Interventions should be individualized in·di·vid·u·al·ize  
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.

2. To consider or treat individually; particularize.

3.
 and matched to students' readiness to change to reduce resistance, reduce stress, and reduce the time needed to implement the change by accelerating movement toward the Action stage.

In most TTM research, stage-matched interventions are delivered directly to individuals via counselors, computor-based expert systems, and/or manuals or other tailored communications (Velicer, Prochaska, Fava, Laforge, & Rossi, 1999). However, organizations also can become powerful change agents by creating more optimal conditions for change. If a majority of students are in the Precontemplation stage, universities can facilitate early-stage processes like Consciousness Raising (e.g., by communicating about the change at orientation, convocation CONVOCATION, eccles. law. This word literally signifies called together. The assembly of the representatives of the clergy. As to the powers of convocations, see Shelf. on M. & D. 23., See Court of Convocation. , and in the student newspaper) and Dramatic Relief(e.g., by giving examples about the consequences of not changing) to help students progress to the Contemplation stage. If a majority of students are already in Action, universities can facilitate behavioral processes like Counter Conditioning and Stimulus Control (e.g., providing resources like alcohol free events to support the change) and Helping Relationships (e.g., by providing R.A.'s and counselors) to help students make and sustain the changes. Students who are asked to change without adequate information, inspiration, resources, or assistance are more likely to become apathetic ap·a·thet·ic
adj.
Lacking interest or concern; indifferent.



apa·thet
, resistant, or resentful re·sent·ful  
adj.
Full of, characterized by, or inclined to feel indignant ill will.



re·sentful·ly adv.
.

Leadership Level

The TTM can be applied to better understand interventions that were applied at each level of the northeast university--leadership, faculty and staff, and alumni. The change initiative began at the leadership level with the President. The President was leading a campus that received national recognition for being the number one party school in the country. Alcohol abuse was deeply embedded Inserted into. See embedded system.  in its history and identity, but this cultural context did not keep this President from declaring at the 1995 convocation ceremonies that "it was time to take a stand" and henceforth From this time forward.

The term henceforth, when used in a legal document, statute, or other legal instrument, indicates that something will commence from the present time to the future, to the exclusion of the past.
 "the university would be a university in recovery" (Carothers, 1995). One of the first challenges at the leadership level is to decide on the action criteria for the campus. Unfortunately, there is no consensus about what represents optimum action for a campus. This is not like changing smoking behavior on an individual level, where there is a scientific consensus that abstinence abstinence: see fasting; temperance movements.  is the appropriate goal. Leaders must debate the pros and cons of alternative goals for their campus. Leadership at the northwest university Northwest University may refer to:
  • Northwest University, China a university founded 1902 in China
  • Northwest University, United States a university founded 1934 in the United States
 set an action criteria by adopting a policy of an alcohol free campus. For those who might see an alcohol free campus as regressive re·gres·sive
adj.
1. Having a tendency to return or to revert.

2. Characterized by regression.



re·gres
 like prohibition, there are other action criteria that could be applied. Policies that are being instituted at other campuses include no illegal drinking and no drinking of three or more drinks on any occasion. Further research will need to determine which of the criteria help produce better outcomes. As will be shown, several policies flowed from this first policy of no alcohol on campus. They include such areas as an increase in alcohol free alternative activities, Friday classes, longer library and recreation hours, and the prohibition of alcohol “Prohibition” redirects here. For other uses, see Prohibition (disambiguation).
Prohibition of alcohol, often shortened to the term prohibition, also known as Dry Law, refers to a sumptuary law in a given jurisdiction which prohibits alcohol.
 product ads.

To begin to move the faculty staff and students from the Precontemplation stage to Contemplation, the President, who knows TTM well, raised awareness (Consciousness Raising) of the pros of change at all parent/student orientation sessions. This was measured in part by the percent of students aware of alcohol policies (97%). The President also provided inspiration for the change and raised anxiety about the status quo [Latin, The existing state of things at any given date.] Status quo ante bellum means the state of things before the war. The status quo to be preserved by a preliminary injunction is the last actual, peaceable, uncontested status which preceded the pending controversy.  (Dramatic Relief). Then leadership encouraged the faculty, staff and students to imagine how they might think and feel about themselves as part of an alcohol free campus that could become a leader in the field of substance abuse prevention. It was described how an alcohol free campus would produce a healthier environment for the entire campus community. Being a party school and abusing alcohol was shown as inconsistent with having a positive learning setting (Self and Environmental Reevaluation). To demonstrate his commitment the President accepted an appointment to the Higher Education higher education

Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art.
 Center for Alcohol Prevention Leadership Group that compiled a report, Be Vocal, Be Visible, Be Visionary. He also joined the NIAAA NIAAA National Institute on Alcohol Abuse and Alcoholism (National Institutes of Health)
NIAAA National Interscholastic Athletic Administrators Association
NIAAA Northwestern Illinois Area Agency on Aging
 Advisory Committee on College Drinking where he assumed a leadership role in bringing together leading researchers and university Presidents to evaluate the quality of research on college drinking and to establish the agenda for future research. He helped others realize that social norms were changing in ways to support alcohol risk reduction (Self-Liberation and Social Liberation).

For those students in Preparation, the behavioral processes were used to help them progress to Action. Stimulus Control was applied through the prohibition of alcohol product ads in University publications; the non-availability of alcohol at any campus function; date of birth was placed on student ID cards; and substance free wellness residence halls were created. Contingency Management
For use in management theory, see Contingency theory.


Contingency Management is a type of treatment used in the mental health or substance abuse fields.
 strategies included reinforcing those who supported an alcohol free campus, discipline and fines for minor infractions with a "three strikes you're out" policy, a judicial system to hear problem cases, and letters sent to students and parents if arrested. A hotline was established to report problems and a Substance Abuse Prevention Director was hired (Helping Relationship). Counter Conditioning was supported through increased non-alcohol entertainment options for students.

Faculty and Staff

While the President provided the leadership, faculty and staff became involved in delivering Consciousness Raising by providing substance abuse educators as guest speakers in academic courses, offering a three credit course to train peer educators, and giving an interactive social norms correction class for freshmen funded by the U. S. Department of Education. In this intervention based on social norms theory, data are collected during a class presentation and correct norm information is fed back to the students in the same period. The class intervention encourages Consciousness Raising, Dramatic Relief and Self-Reevaluation to new students on campus who primarily are in Precontemplation or Contemplation for reducing high risk drinking. Faculty also schedule classes on Fridays to emphasize the importance of academics and discourage the alcohol fueled partying that may occur on Thursday nights if students do not need to attend class on Fridays (Counter Conditioning). Staff keeps the library and recreation facilities open longer (Stimulus Control).

In an effort to provide Helping Relationships to at risk students more ready to take action, the Counseling Center and Substance Abuse Services offer short-term treatment for alcohol abuse and referrals for long-term treatment. Individuals in violation of the alcohol policy are required after two violations to attend an educational meeting to examine their current patterns of alcohol use and to work on strategies for risk reduction. Motivational interviewing Motivational interviewing refers to a counseling approach initially developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D.  based on the TTM is used in the session. Motivational interviewing is a directive, client-centered counseling style of eliciting behavior change by helping clients to explore and resolve ambivalence (Rollnick & Miller, 1995).

An Alcohol Team was formed to apply a range of change strategies and processes. The alcohol Team's goals are to build a unified campus-wide collaborative approach to alcohol abuse prevention and research, reduce harm from abusive use of alcohol, and apply research in its interventions. Team meetings serve as a mechanism for: communication and collaboration between researchers and practitioners, a sounding board for policy revision and implementation, an exchange of information about research and resources, an avoidance of duplication, and pooling budget and space for team efforts. Members are from the Psychology Department, the Cancer Prevention Research Center, marketing, communications, the Counseling Center, Research & Grants, Health Services health services Managed care The benefits covered under a health contract , Housing and Residential Life, and Student Life.

To create conditions to counter alcohol abuse and substitute healthier alternatives, the faculty has several grants in progress. A five-year project based on social cognitive theory Social Cognitive Theory utilized both in Psychology and Communications posits that portions of an individual's knowledge acquisition can be directly related to observing others within the context of social interactions, experiences, and outside media influences.  works with approximately 400 students to examine the effects of individualized normative nor·ma·tive  
adj.
Of, relating to, or prescribing a norm or standard: normative grammar.



nor
 feedback and alcohol expectancy challenges in reducing alcohol abuse. The program is designed to correct first-year students' misperceptions of high risk drinking. The intervention group receives statistics about alcohol intake, thereby debunking de·bunk  
tr.v. de·bunked, de·bunk·ing, de·bunks
To expose or ridicule the falseness, sham, or exaggerated claims of: debunk a supposed miracle drug.
 the myth that everyone drinks. Among students who learn about their misperceptions, drinking levels decreased about half a drink per week (Caliri, 2001). Those who did not receive the normative correction substantially increased their weekly drinking over the course of the first semester se·mes·ter  
n.
One of two divisions of 15 to 18 weeks each of an academic year.



[German, from Latin (cursus) s
.

A three year program to create peer athlete mentors for athletic teams is underway as well as a three year project on the applicability of TTM tailored communications to college student alcohol abuse. The TTM study is designed to test the efficacy of a low cost and readily disseminable computerized expert system intervention program for college students to reduce high-risk alcohol behaviors and minimize alcohol related problems. The proactive harm reduction intervention consists of three telephone survey assessments at three-month intervals, each followed by mail delivery of an individualized intervention feedback report. Over sixteen hundred students are participating--78% of all eligible freshmen and sophomores. The participation rates are particularly encouraging given that population surveys have indicated that about 70% of at risk students are in the Precontemplation stage and less than 10% are in Preparation (Laforge, 2001).

Students

Students serve as peer educators and provide Consciousness Raising and other processes through workshops on risk reduction to their peers. A Student Against Drunk Driving chapter was formed and helps provide change processes like Dramatic Relief by emphasizing some of the terrible tragedies that could be prevented by zero tolerance The policy of applying laws or penalties to even minor infringements of a code in order to reinforce its overall importance and enhance deterrence.

Since the 1980s the phrase zero tolerance has signified a philosophy toward illegal conduct that favors strict imposition of
 for drink driving. To express a firm commitment to act and to encourage other to do so (Self-Liberation) and to help students realize that social norms are changing in ways that help students be free from alcohol on campus (Social Liberation), undergraduate and graduate student interns This article or section is written like an .
Please help [ rewrite this article] from a neutral point of view.
Mark blatant advertising for , using .
 have initiated and advance abuse prevention and research activities throughout the campus. Counseling, pharmacy, public relations public relations, activities and policies used to create public interest in a person, idea, product, institution, or business establishment. By its nature, public relations is devoted to serving particular interests by presenting them to the public in the most , and public speaking students are all involved in developing prevention programs, creating alternative approaches, and working in the above-mentioned research grants.

For those more ready to change to an alcohol free campus, students are available to provide Helping Relationships and other processes through AA meetings on campus. To substitute healthier alternatives (Counter Conditioning) at the beginning of every academic year, student teams offer "Same Planet, Different World" programs designed to get new students off to a safe start with a variety of non-alcohol entertainment and social options. A month-long series of events aimed at providing "fun without the buzz" include scavenger hunts scavenger hunt
n.
A game in which individuals or teams try to locate and bring back miscellaneous items on a list.
 and Hawaiian luaus on the quad.

Alumni

In comparison to the leadership, faculty, staff, and students, the alumni appear to be primarily in Precontermplation for being alcohol free on any of the University's campuses. For the first time in the summer of 2001, the alumni magazine included an article on reducing alcohol abuse on the campus. While the intention was to raise the consciousness level of the alumni this was not assessed. Soon after an action plan was mandated. Until 2001, alcohol was tolerated on campus at tailgating Tailgating

The action of a broker or advisor purchasing or selling a security for his or her client(s) and then immediately making the same transaction in his or her own account.
 activities at Homecoming Homecoming
Odyssey

concerning Odysseus’s difficulties in getting home after war. [Gk. Myth.: Odyssey]

You Can’t Go Home Again

revisiting his home town, a writer is disillusioned by what he sees. [Am. Lit.
. When alcohol tailgating was banned in 2001 there was an angry alumni reaction. Being primarily in Precontemplation, the alumni saw the change as imposed and became resistant and defensive. They were not ready to take action to have an alcohol free campus.

Community

Student alcohol use and abuse is a problem of the campus and the entire surrounding community. What is required is community-level action, including the local government, law enforcement, community prevention advocates, owners of local bars and restaurants, realtors, and high schools (Gebhardt, Kaphingst, & DeJong, 2000). In this case study the local town council came to the university President and demanded action. The President quickly responded. Regular town/gown meetings have resulted in enhanced and publicized pub·li·cize  
tr.v. pub·li·cized, pub·li·ciz·ing, pub·li·ciz·es
To give publicity to.

Adj. 1. publicized - made known; especially made widely known
publicised
 police enforcement of the age 21 drinking and drunk driving laws, the local police stepping up bar checks, the Realtors Association creating model leases that the university distributes, landlords now being responsible for tenants disturbing the peace, the university listing where students can volunteer in the community, the Neighborhood Associations A neighborhood association is a group of residents, sometimes organized as 501(c)(3) nonprofit organization, who take on problems or organize activities within a neighborhood. An association may have elected leaders and voluntary or mandatory dues.  hosting brunches in September to welcome students who live in their communities. In addition, at college fairs at high schools, university representatives emphasize the university's alcohol policy of no alcohol use on campus.

The university also has three federally funded population based research trails that reach out to all ninth graders in 14 Rhode Island schools Rhode Island schools

Note: The schools of Providence County, Rhode Island, USA are in a separate table: Providence County, Rhode Island schools High schools
See also
School Name District County City Students*
, their parents at home, and members of a New England New England, name applied to the region comprising six states of the NE United States—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The region is thought to have been so named by Capt.  HMO. The adolescent and parents project will intervene on six major behavioral risk factors including alcohol abuse. The HMO project intervenes only on alcohol abuse. Besides reaching the community, these projects have the potential to help the university reduce alcohol abuse by having more high school students, their parents and community members participating in alcohol abuse programs. These populations should provide increasing support for campus-based programs designed to combat alcohol abuse.

Outcomes or Impacts

Leaders at the northeast university knew it was not enough to distribute its alcohol policy printed in the back of a handbook, host a one session alcohol awareness program, offer counseling programs for those who sought them, and expect the alcohol abuse problem to go away. Instead, the university President brought together administrators, faculty and staff, students, parents, alumni and local community members to develop and implement effective policies and programs. The university deceased the availability of alcohol, increased the number and variety of alcohol-free activities, and created a climate that discourages high-risk drinking and reinforces students to abstain or drink legally and moderately. To facilitate change, TTM and other models of behavior change were used at multiple levels. To evaluate how the interventions were working the university leaders needed to look at outcomes from multi levels and multi perspectives. For example, did the decline in binge drinking on campus at the same time increase problem drinking in nearby towns? Among the findings, the following demonstrate that was not the case:

* a 13% decline in binge-drinking (Wechsler, 2002)

* a 39% decline in town police complaints from 1999 to 2000 (Narragansett, 2001)

* fewer alcohol poisonings at Health Services and a local hospital (except Homecoming Day prior to 2001) (Cohen, 1999)

* a rise in simple violations (underage possession or consumption) from 70 to 267 (Cohen, 1999)

* a decline in complex violations (vandalism or endangerment) from 155 to 63 (Cohen, 1999)

* an increased voluntary attendance at drug awareness workshops form 25% to 50% (University of Rhode Island History
The University was first chartered as the state's agricultural school in 1888. The site of the school was originally the Oliver Watson Farm, and the original farmhouse still lies on the campus today.
, 1999)

* only 10% of students cited a second time for violations (University of Rhode Island, 1999)

* 97% of students aware of alcohol policies (73% nationwide) (University of Rhode Island, 1999)

* an increase in SAT scores by 140 points (University of Rhode Island, 1999)

* an increase number of faculty and staff committed to alcohol abuse reduction (University of Rhode Island, 1999)

* an increase in research grants and monies (Cohen, 1999).

Conclusion

Current theory is consistent with the lessons that can be learned from this case study. Maximum impacts of major problems like alcohol abuse on campuses can best be accomplished when intervention strategies apply principles and processes that can produce change at each stage of change. An eclectic approach that drives interventions from across a variety of theories is one way of applying multiple principles and processes. In many ways, the case study was more eclectic than systematic. A more systematic and intergrataive approach would be to consistently use a model, like TTM, that is designed to tailor change principles and processes to individuals at each stage of change.

Other universities and colleges will need to experiment with applying TTM more systematically versus eclectically. They will need to experiment with what action criteria fit their campus, e.g., alcohol free versus responsible drinking. They will also need to assess their campus for students' readiness to adopt action criteria for drinking. The more their students are in Precontemplation the more resources they will need to dedicate ded·i·cate  
tr.v. ded·i·cat·ed, ded·i·cat·ing, ded·i·cates
1. To set apart for a deity or for religious purposes; consecrate.

2.
. With such replication across different campuses we can better learn which approaches to population-based interventions work best for universities and colleges.

Maximum impacts on major problems like alcohol abuse can best be accomplished when principles and processes are applied at multiple levels of change (Institute of Medicine, 2001). While more controlled research to support this conclusion is needed, there is a consensus amongst leaders in behavior change that a multiple level approach is most promising. In the case of the northeast university, the President knew what all Presidents learn: they do not have enough power or influence to transform an organization without bringing on board as many faculty, staff, students and alumni as possible. Some levels of the university will be further along in the stages of change, such at the leaders and the Alcohol Team at this university, while some will be much more in Precontemplation stage, such as the students and the alumni. By applying TTM principles and resources that can be inclusive for people at each stage and each level, interventions of alcohol abuse can maximize participation at each level which can maximize impacts across the organization. This is not to say that the northeast university has recovered. As the President diagnosed it, it is a university in recovery. But it is also a case where many more people at each level of change are participating in the change process and are pulling together to help the university progress toward its goal of being an alcohol free campus.
Table 1. Processes of Change for Becoming an Alcohol Free Campus

Processes                        Illustrations

1. Consciousness Raising         Communicating information about the
                                 goals and benefits of making a campus
                                 alcohol free.
2. Dramatic Relief               Generating inspiration for the change
                                 and anxiety about the status quo.
3. Self-Reevaluation             Encouraging students to imagine how
                                 they will think and feel about them-
                                 selves as members of a campus that
                                 treats alcohol seriously.
4. Environmental Reevaluation    Encouraging students to imagine how an
                                 alcohol free campus will produce a
                                 healthier environment for the entire
                                 campus community.
5. Self- Liberation              Expressing a firm commitment to act
                                 and encouraging others to do so.
6. Helping Relationships         Offering social support for the
                                 healthy behavioral change and
                                 encouraging students to seek support.
7. Counter Conditioning          Creating conditions that will counter
                                 alcohol use on campus and will
                                 substitute healthier alternatives
                                 (e.g., wellness dorms).
8. Stimulus Control              Removing cues that encourage drinking
                                 (e.g., alcohol ads and alcohol in
                                 dorms) and providing cues that
                                 encourage a healthy alternative (e.g.,
                                 ads about alcohol free events).
9. Social Liberation             Helping students realize that the
                                 social norms are changing in ways that
                                 will help students be free from
                                 alcohol on campus.
10. Contingency Management       Reinforcing students and staff for
                                 supporting the alcohol free campus
                                 (articles about improvement) and
                                 punishing students for violating the
                                 policies (expulsion after three
                                 violations).

Table 2. Pros and Cons for Intervening on Alcohol Abuse on Campus

* Pros

Reduce hangovers, nausea, blackouts
Reduce injuries and alcohol poisonings
Reduce legal suits
Reduce unplanned sex
Reduce unwanted pregnancies
Reduce drop-outs
Reduce crime and violence
Increase academic performance
Improve community image
Bring in resources through grants
Become a national leader
Bring SAT scores up
Reduce property damage
Improve town/gown relations
Reduce negative publicity

* Cons

Decline in applications for admission
Can lose students at orientation
Risk alienating alumni
Risk conflict with parents
Takes more effort and time
Can hurt athletic teams
Can have lawsuits


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standardized mortality rate
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JANICE M. PROCHASKA, MSW (MicroSoft Word) See Microsoft Word. , Ph.D *

Pro-Change Behavior Systems, Inc. President & CEO (1) (Chief Executive Officer) The highest individual in command of an organization. Typically the president of the company, the CEO reports to the Chairman of the Board.  

JAMES O. PROCHASKA, Ph.D

FRANCES C. COHEN, MA

SUSAN O. GOMES, MA

ROBERT G. LAFORGE, ScD

ANDREA L. EASTWOOD, BS

University of Rhode Island

* Contact author: Janice M. Prochaska, MSW, PhD, President & CEO, Pro Change Behavior Systems, Inc. P.O. Box 755, West Kingston, ILI 02892

410-874-4109 (phone) fax 401- 874-4103

jmprochaska@prochange.com
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