Abstract
Context:
Binge drinking is a salient problem on college campuses, with estimates as high as 40% of students engaging in it. Binge drinking is associated with numerous negative consequences among college students, such as suicide attempts, unsafe sex practices, property damage, and driving under the influence. Several behavioral approaches in this regard have had modest impact and only short-term effects, however.
Objective:
To use the multitheory model (MTM) of health behavior change to predict initiation and sustenance of responsible drinking or abstinence among binge-drinking college students in a sample drawn from a large southern public university.
Methods:
This cross-sectional survey study included a sample of college students who binge drank in the past 30 days. A 39-item face- and content-valid instrument was used. In addition, construct validity using confirmatory factor analysis and internal consistency reliability using the Cronbach α were established. Hierarchical regression modeling was used to build models.
Results:
A total of 289 students participated. The Cronbach α for the scale and all subscales ranged from 0.81 to 0.94 and demonstrated acceptable internal consistency reliability. Construct validity using confirmatory factor analysis yielded 1-factor solutions for each of the subscales. On hierarchical regression modeling, gender (P=.05), race/ethnicity (P=.004), behavioral confidence (P=.029), and changes in physical environment (P=.001) were associated with intended initiation for drinking responsibly/abstinence behavior change. The addition of MTM constructs led to a significant increase in R2 of 0.20 (F3,194=18.1; P<.001). The sustenance constructs yielded a significant increase in R2 of 0.20 (F3,193=19.4; P<.001).
Conclusion:
This study provides empirical justification for MTM constructs that can be used to inculcate the intention to drink responsibly or abstain among college students who binge drink. This predictive model may prove valuable in the design of interventions aiming to improve responsible drinking behavior in this population.
Binge drinking is defined as a pattern of drinking that raises a person's blood alcohol level to 0.08% or above per 100 g of blood.
1,2 Binge drinking occurs when within a 2-hour time frame, women consume at least 4 drinks and men consume at least 5 drinks.
3 The Substance Abuse and Mental Health Services Administration, responsible for conducting the annual National Survey on Drug Use and Health, classifies binge drinking as “5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (ie, at the same time or within a couple of hours of each other) on at least 1 day in the past month.”
4
According to a national survey by the National Institute of Alcohol Abuse and Alcoholism, the prevalence of binge drinking among college students aged 18 to 24 years is about 40%, or 2 of every 5 students.
5 About 60% of college students in this age bracket reported drinking alcohol within the past month. Binge drinking in college students is associated with adverse repercussions that may cause a strain on their intellectual, family, and social lives. Missed lectures, poor academic consequences, suicide attempts, unsafe sex practices, property damage, altercation with law enforcement, and driving under the influence of alcohol are potential consequences of binge drinking among college students.
5-7
According to the US
Dietary Guidelines for Americans 2015-2020,
8 responsible drinking entails no more than 2 drinks per day for men and 1 drink per day for women. A typical standard drink in the United States is about 14 g of alcohol. This quantity can be found in 5 ounces of wine (12% alcohol), 12 ounces of beer (5% alcohol), and 1.5 ounces of distilled spirits (40% alcohol).
3 However, variations occur when a standard drink has been mixed with other types of alcohol, which leads to inaccurate alcohol percentage interpretations.
5 By law, abstinence is mandatory for persons younger than 21 years.
Various brief motivational intervention studies conducted during the past 10 years have addressed the individual and environmental causative factors of persistent binge drinking among college students in an effort to promote responsible drinking or abstinence.
9-11 However, the effects of these interventions are short lived.
12-14 Research into individual-level interventions targeting college students to create awareness of binge drinking and alter students’ knowledge, attitudes, and behaviors related to alcohol abuse aim to reduce the negative consequences of binge drinking. Individual-level interventions use 1 or a combination of multiple behavioral interventions, such as face-to-face and web-based health education and awareness programs and cognitive-behavioral skill-based approaches.
5,15-18 Ecological-level strategies include changing the environmental conditions that lead to binge drinking.
5,19-22
To alter binge drinking behavior in college students, several behavioral theories have been identified in the literature, including the health belief model,
23,24 Bandura's social cognitive theory,
25 transtheoretical model,
10,23 theory of planned behavior,
23 precaution adoption process model,
23 and social ecological model.
26 However, among the aforementioned studies, there is a deficiency of robust theoretical models directly applicable to altering binge-drinking behavior in college students for the long term. This gap in intervention research highlights the need for newer theories that tackle multilevel behavioral factors related to binge drinking, especially those theories that effect long-term behavioral changes. The purpose of the current study was to apply the multitheory model (MTM)
27 of health behavior change to predict intention to change from binge drinking to responsible drinking/abstinence among a sample of college students drawn from a university in the southern United States.
Methods
After institutional review board approval, students were recruited via email and directed to a link to an MTM-based online questionnaire upon agreement to participate in the study. Responses were collected during a 3-week period, with reminder emails sent at the start of September 2017 and again at the second and third weeks. Undergraduate and graduate students who reported binge drinking (per National Institute of Alcohol Abuse and Alcoholism guidelines) within the past 30 days and were aged 18 years or older were included in the study.
MTM of Health Behavior Change
The MTM health behavior theory uses a combination of evidence-based proven constructs from previous theories to address behavioral change at multifaceted levels of change settings.
27 Attempting to be parsimonious, the MTM avoids overlap among constructs, addresses both immediate and long-term behavior change, attempts to be culturally feasible, and is appropriate for intervention settings with limited resources.
27 The model represents a 2-component health behavior change pattern: initiation of behavior change and sustenance of behavior change. To address binge drinking among college students, initiation of behavior change begins with the decision to abstain from drinking, quit binge drinking, or start drinking responsibly. Sustenance of behavior change would involve the ability to completely abstain or continue efforts to practice responsible drinking.
27
For initiation of responsible drinking from binge drinking according to the MTM, the following constructs are important: (1) participatory dialogue in which advantages supersede disadvantages; (2) behavioral confidence that can be internal or external and aim to affect future behavior; and (3) changes in the physical environment that entail removing or reducing exposure to alcohol in the immediate environment. For sustaining or maintaining the behavior change of responsible drinking from binge drinking according to the MTM, the following constructs are necessary: (1) emotional transformation in which the person is able to use his or her emotions in setting goals toward responsible drinking; (2) practice for change that entails constant reflection on the need for responsible drinking, and (3) changes in the social environment that necessitate help from family and friends to continue with responsible drinking. The utility of the MTM has been shown to be effective in previous studies with other health behaviors, such as physical activity,
28 adequate sleep,
29 portion size consumption,
30 water consumption instead of sugar-sweetened beverages,
31 and fruit and vegetable consumption.
32 However, to our knowledge, this is the first study to test the predictive ability of the MTM in explaining behavior change from binge drinking to responsible drinking.
Design
To assess the utility of the MTM in predicting initiation and sustenance of responsible drinking/abstinence behaviors, a cross-sectional design was used. Sample size for hierarchical regression modeling for
R2 increase was calculated using G*Power (Heinrich-Heine-Universität Düsseldorf). An α of .05, a power of .80, 3 demographic predictors (gender, race, and work status), 3 predictors in each of the initiation and sustenance model, and an estimated effect size of 0.05 (small to medium) yielded a sample size of 223 participants. Therefore, we determined that a sample size in the vicinity of 200 participants would suffice for this study even if the effect sizes were small. This sample size was also adequate for confirmatory factor analysis.
33,34
Instrumentation
The 39-item MTM-based survey was used to predict intention to change from binge drinking to responsible drinking/abstinence. Responsible drinking was defined as drinking 1 or 2 alcoholic beverages on a single occasion or drinking at most 1 alcoholic beverage per day for women and 2 per day for men. Abstinence was defined as not drinking alcoholic beverages at all.
The first 2 items assessed study eligibility, and the subsequent 8 items assessed sociodemographic characteristics: age, gender, race, class level, work status, age at first alcohol consumption, alcoholic drinks consumed in the past 30 days, and living arrangements (on or off campus). The remaining 29 items measured the MTM constructs for initiation and sustenance. Answers used 5-point Likert scales from 0 to 4, defined according to section.
Initiation Measures
The advantages of participatory dialogue were assessed with 5 survey items (10-14) representing the possible effects of drinking responsibly or abstaining from alcohol (ie, “be healthy,” “save money,” “not get into trouble,” “have better relationships,” and “do well academically”). Each item was scored on a scale of 0 (never) to 4 (always), and responses to all items in the section were summed for a maximum possible score of 20.
Five items (15-19) measured perceived disadvantages of participatory dialogue. For example, “If you abstain from alcohol or drink responsibly you will … ‘not be able to socialize well.’” These items were scored from 0 (never) to 4 (always), with a maximum possible score of 20. The total score for disadvantages was subtracted from the total score for advantages to give an overall score for the participatory dialogue construct.
The next 5 items (20-24) assessed the construct of behavioral confidence, with participants being asked about certainty regarding their ability to drink responsibly or abstain from alcohol. For example, “How sure are you that you will be able to abstain from alcohol or drink responsibly…‘this week without getting anxious?’” Each item was scored on a scale from 0 (not at all sure) to 4 (completely sure), with a maximum possible score of 20.
Three items (25-27) gauged changes in physical environment, which asked about participants’ confidence in their ability to create an alcohol-free physical environment (ie, “how sure are you that you will… ‘be able to get rid of alcohol from your home environment this week,’ ‘not buy any alcohol this week,’ and ‘be able to replace drinking with something else this week’”). Each item was scored on a scale from 0 (not at all sure) to 4 (completely sure), with a maximum possible score of 12.
Initiation of behavior change was assessed with a single question (37) asking, “How likely is it that you will abstain from alcohol or drink responsibly in the upcoming week?” Possible scores ranged from 0 (not at all sure) to 4 (completely sure) units.
Sustenance Measures
Three items (28-30) assessed the first component of the sustenance model, emotional transformation. For example, “How sure are you that you can…‘motivate yourself to be alcohol free or drink responsibly every week?’” Response options were scored from 0 (not at all sure) to 4 (completely sure), with a maximum possible score of 12.
Items 31 to 33 measured practice for change. For example, “How sure are you that you can…‘keep a self-diary to monitor your alcohol drinking desire every week?’” Responses for each item were scored from 0 (not at all sure) to 4 (completely sure), with a maximum possible score of 12.
Changes in social environment were measured in items 34 to 36, which assessed participants’ certainty in their ability to get the help of someone to support their responsible drinking/abstinence. For example, “How sure are you that you can get the help of a…’family member to support you in being alcohol free or drinking responsibly every week?’” Possible responses ranged from 0 (not at all sure) to 4 (completely sure), with a maximum possible score of 12.
Sustenance was assessed with 1 item (38) asking: “How likely is it that you will abstain from alcohol or drink responsibly every week from now on?” The possible item score ranged from 0 (not at all sure) to 4 (completely sure) units.
Validity and Reliability
Six experts were invited to establish face and content validity of the survey instrument. Confirmatory factor analysis using the maximum likelihood method was performed to establish construct validity. The survey instrument's internal consistency reliability was calculated with the Cronbach α.
Statistical Analyses
Data were analyzed using IBM SPSS statistical software version 22.0. Descriptive statistics were calculated for all measured variables. Pearson product-moment correlation was used for continuous demographic variables, and analysis of variance was used for categorical demographic variables. Both dependent variables (intention to initiate and sustain responsible drinking/abstinence behaviors) were measured on a continuous scale. Statistical significance level of .05 was set a priori for all analyses. The following analyses were carried out to determine the utility of MTM in predicting intention to initiate and sustain responsible drinking/abstinence behaviors.
1. After assessing statistically significant demographic covariates (gender, race/ethnicity, and work) for the initiation model (model 1), we conducted hierarchical multiple regression to determine the relationship between independent variables (participatory dialogue, behavioral confidence, changes in physical environment) and intention to initiate responsible drinking/abstinence behaviors after adjusting for demographic covariates. In block 1, significant demographic covariates were entered, and in block 2, MTM constructs were entered.
2. After determining statistically significant demographic covariates (gender, race/ethnicity, and work) for the sustenance model (model 2), we performed hierarchical multiple regression to assess the relationship between independent variables (MTM constructs) and intention to sustain responsible drinking/abstinence behaviors after adjusting for demographic covariates. In block 1, significant demographic covariates were entered, and in block 2, MTM constructs were entered.
Results
A total of 5000 students received the survey. Of the 735 students who completed the survey, 289 met the inclusion criteria (age >18 years and binge drank in the past 30 days). The majority of participants were white (247 [87.6%]), and gender distribution was nearly even between men (136 [48.1%]) and women (147 [51.9%]). Study participants had a mean (SD) age of 21.4 (5.3) years, and the majority were undergraduates (239 [85.7%]). A total of 176 (63%) worked, and 101 (36.5%) did not work (
Table 1). Participants estimated that on average they consumed a mean (SD) of 34.3 (31.5) (range, 2-150) drinks in the past 30 days. The mean (SD) age of participants when they had first consumed alcohol was 15.6 (2.7) years.
Table 1.
Predictors of Responsible Drinking Among College Students Using a Multitheory Model Approach: Sociodemographic Characteristics (N=289)a
| Characteristic | No. (%) |
| Age, mean (SD), y | 21.4 (5.4) |
| Gender | |
| Male | 136 (48.1) |
| Female | 147 (51.9) |
| Race/Ethnicity | |
| White | 247 (87.6) |
| Black | 12 (4.3) |
| Hispanic | 6 (2.1) |
| Asian American | 5 (1.8) |
| American Indian | 1 (0.4) |
| Other | 11 (3.9) |
| Class Level | |
| First-year undergraduate | 56 (20.1) |
| Second-year undergraduate | 56 (20.1) |
| Third-year undergraduate | 62 (22.2) |
| ≥Fourth-year undergraduate | 65 (23.3) |
| Graduate/professional degree | 40 (14.3) |
| Living Arrangements | |
| On campus | 84 (31.3) |
| Off campus | 184 (68.7) |
| Work Status | |
| Yes | 101 (36.5) |
| No | 176 (63.5) |
Table 1.
Predictors of Responsible Drinking Among College Students Using a Multitheory Model Approach: Sociodemographic Characteristics (N=289)a
| Characteristic | No. (%) |
| Age, mean (SD), y | 21.4 (5.4) |
| Gender | |
| Male | 136 (48.1) |
| Female | 147 (51.9) |
| Race/Ethnicity | |
| White | 247 (87.6) |
| Black | 12 (4.3) |
| Hispanic | 6 (2.1) |
| Asian American | 5 (1.8) |
| American Indian | 1 (0.4) |
| Other | 11 (3.9) |
| Class Level | |
| First-year undergraduate | 56 (20.1) |
| Second-year undergraduate | 56 (20.1) |
| Third-year undergraduate | 62 (22.2) |
| ≥Fourth-year undergraduate | 65 (23.3) |
| Graduate/professional degree | 40 (14.3) |
| Living Arrangements | |
| On campus | 84 (31.3) |
| Off campus | 184 (68.7) |
| Work Status | |
| Yes | 101 (36.5) |
| No | 176 (63.5) |
×
Descriptive Statistics of Variables
As presented in
Table 2, the mean (SD) score of advantages on the participatory dialogue construct was 13.4 (4.6) on a scale of 0 to 20. The mean (SD) score of participatory dialogue disadvantages was 6.5 (4.4). The mean (SD) total score on participatory dialogue was 6.9 (6.8). The mean (SD) score of behavioral confidence was 13.3 (5.8) and changes in physical environment was 6.8 (4.1). The mean scores of the sustenance model constructs were also in the middle of the range. The Cronbach α of the scale and the subscales ranged from 0.8 to 0.9 and demonstrated acceptable internal consistency reliability (ie, ≥0.7). Construct validity using confirmatory factor analysis yielded 1-factor solutions for each of the subscales. The criteria of factor loadings over 0.3 (all factor loadings >0.5) and eigen values over 1.0 yielding 1-factor solution were met for all subscales.
Table 2.
Predictors of Responsible Drinking Among College Students Using A Multitheory Model Approach: Descriptive Statistics of Study Variables (N=289)
| Constructs | Rangea | Mean (SD) | Cronbach α |
| Initiation | 0 to 4 | 1.6 (1.4) | … |
| Participatory dialogue | | | |
| Advantages | 0 to 20 | 13.4 (4.6) | 0.85 |
| Disadvantages | 0 to 20 | 6.5 (4.4) | 0.79 |
| Advantages-disadvantages | −20 to 20 | 6.9 (6.8) | … |
| Behavioral confidence | 0 to 20 | 13.3 (5.8) | 0.90 |
| Changes in physical environment | 0 to 12 | 6.8 (4.1) | 0.83 |
| Sustenance | 0 to 4 | 1.1 (1.4) | … |
| Emotional transformation | 0 to 12 | 7.1 (4.1) | 0.94 |
| Practice for change | 0 to 12 | 5.3 (3.7) | 0.81 |
| Changes in social environment | 0 to 12 | 8.1 (3.8) | 0.87 |
| Entire Scale | … | … | 0.88 |
Table 2.
Predictors of Responsible Drinking Among College Students Using A Multitheory Model Approach: Descriptive Statistics of Study Variables (N=289)
| Constructs | Rangea | Mean (SD) | Cronbach α |
| Initiation | 0 to 4 | 1.6 (1.4) | … |
| Participatory dialogue | | | |
| Advantages | 0 to 20 | 13.4 (4.6) | 0.85 |
| Disadvantages | 0 to 20 | 6.5 (4.4) | 0.79 |
| Advantages-disadvantages | −20 to 20 | 6.9 (6.8) | … |
| Behavioral confidence | 0 to 20 | 13.3 (5.8) | 0.90 |
| Changes in physical environment | 0 to 12 | 6.8 (4.1) | 0.83 |
| Sustenance | 0 to 4 | 1.1 (1.4) | … |
| Emotional transformation | 0 to 12 | 7.1 (4.1) | 0.94 |
| Practice for change | 0 to 12 | 5.3 (3.7) | 0.81 |
| Changes in social environment | 0 to 12 | 8.1 (3.8) | 0.87 |
| Entire Scale | … | … | 0.88 |
×
Hierarchical Multiple Regression Predicting Intention to Initiate Responsible Drinking/Abstinence
In the multivariable analyses for model 1, gender (
P=.017) and race/ethnicity (
P=.003) were associated with intention to initiate responsible drinking/abstinence behavior change. In model 2, gender (
P=.05), race/ethnicity (
P=.004), behavioral confidence (
P=.029), and changes in physical environment (
P=.001) were associated with intention to initiate responsible drinking/abstinence behavior change. The addition of participatory dialogue, behavioral confidence, and changes in physical environment to the prediction of intention to initiate responsible drinking/abstinence led to a significant increase in
R2 of 0.20 (
F3,194=18.1;
P<.001;
Table 3).
Table 3.
Hierarchical Multiple Regression Predicting Initiation for Drinking Responsibly/Abstinence Among College Students Who Binge Drank in the Past 30 Days (N=289)a
| Variables | B | SEB | β | P Value | 95% CI |
| Model 1b | | | | | |
| Gender | −0.478 | 0.199 | −0.165 | .017 | −0.87 to 0.09 |
| Race/ethnicity | −0.946 | 0.318 | −0.205 | .003 | −1.57 to 0.32 |
| Work | 0.254 | 0.204 | 0.086 | .215 | −0.15 to 0.66 |
| Model 2c | | | | | |
| Gender | −0.351 | 0.179 | −0.121 | .051 | −0.70 to 0.001 |
| Race/ethnicity | −0.822 | 0.285 | −0.178 | .004 | −1.38 to 0.26 |
| Work | 0.116 | 0.185 | 0.039 | .530 | −0.25 to 0.48 |
| Participatory dialogue | 0.016 | 0.016 | 0.069 | .322 | −0.02 to 0.05 |
| Behavioral confidence | 0.048 | 0.022 | 0.183 | .029 | 0.01 to 0.09 |
| Changes in physical environment | 0.098 | 0.029 | 0.274 | .001 | 0.04 to 0.15 |
Table 3.
Hierarchical Multiple Regression Predicting Initiation for Drinking Responsibly/Abstinence Among College Students Who Binge Drank in the Past 30 Days (N=289)a
| Variables | B | SEB | β | P Value | 95% CI |
| Model 1b | | | | | |
| Gender | −0.478 | 0.199 | −0.165 | .017 | −0.87 to 0.09 |
| Race/ethnicity | −0.946 | 0.318 | −0.205 | .003 | −1.57 to 0.32 |
| Work | 0.254 | 0.204 | 0.086 | .215 | −0.15 to 0.66 |
| Model 2c | | | | | |
| Gender | −0.351 | 0.179 | −0.121 | .051 | −0.70 to 0.001 |
| Race/ethnicity | −0.822 | 0.285 | −0.178 | .004 | −1.38 to 0.26 |
| Work | 0.116 | 0.185 | 0.039 | .530 | −0.25 to 0.48 |
| Participatory dialogue | 0.016 | 0.016 | 0.069 | .322 | −0.02 to 0.05 |
| Behavioral confidence | 0.048 | 0.022 | 0.183 | .029 | 0.01 to 0.09 |
| Changes in physical environment | 0.098 | 0.029 | 0.274 | .001 | 0.04 to 0.15 |
×
Hierarchical Multiple Regression Predicting Intention to Sustain Responsible Drinking/Abstinence
In the multivariable analyses for model 1, gender (
P=.035) and race/ethnicity (
P<.001) were associated with intention to sustain responsible drinking/abstinence behavior. In model 2, race/ethnicity (
P<.001) and practice for change (
P<.001) were associated with intention to sustain responsible drinking/abstinence behavior. The addition of changes in social environment, practice for change, and emotional transformation to the prediction of intention to sustain responsible drinking/abstinence led to a significant increase in
R2 of 0.20 (
F3,193=19.4;
P<.001;
Table 4).
Table 4.
Hierarchical Multiple Regression Predicting Sustenance for Drinking Responsibly/Abstinence Among College Students Who Binge Drank in the Past 30 Days (N=289)a
| Variables | B | SEB | β | P Value | 95% CI |
| Model 1b | | | | | |
| Gender | −0.410 | 0.194 | −0.143 | .035 | −0.79 to 0.03 |
| Race/ethnicity | −1.228 | 0.316 | −0.265 | <.001 | −1.85 to 0.60 |
| Work | 0.303 | 0.199 | 0.104 | .130 | −0.09 to 0.70 |
| Model 2c | | | | | |
| Gender | −0.302 | 0.172 | −0.105 | .081 | −0.64 to 0.04 |
| Race/ethnicity | −1.042 | 0.282 | −0.224 | <.001 | −1.60 to −0.49 |
| Work | 0.052 | 0.180 | 0.018 | .772 | −0.30 to 0.41 |
| Emotional transformation | 0.033 | 0.031 | 0.093 | .280 | −0.03 to 0.10 |
| Practice for change | 0.150 | 0.034 | 0.382 | <.001 | 0.08 to 0.22 |
| Changes in social environment | 0.011 | 0.027 | 0.028 | .677 | −0.04 to 0.06 |
Table 4.
Hierarchical Multiple Regression Predicting Sustenance for Drinking Responsibly/Abstinence Among College Students Who Binge Drank in the Past 30 Days (N=289)a
| Variables | B | SEB | β | P Value | 95% CI |
| Model 1b | | | | | |
| Gender | −0.410 | 0.194 | −0.143 | .035 | −0.79 to 0.03 |
| Race/ethnicity | −1.228 | 0.316 | −0.265 | <.001 | −1.85 to 0.60 |
| Work | 0.303 | 0.199 | 0.104 | .130 | −0.09 to 0.70 |
| Model 2c | | | | | |
| Gender | −0.302 | 0.172 | −0.105 | .081 | −0.64 to 0.04 |
| Race/ethnicity | −1.042 | 0.282 | −0.224 | <.001 | −1.60 to −0.49 |
| Work | 0.052 | 0.180 | 0.018 | .772 | −0.30 to 0.41 |
| Emotional transformation | 0.033 | 0.031 | 0.093 | .280 | −0.03 to 0.10 |
| Practice for change | 0.150 | 0.034 | 0.382 | <.001 | 0.08 to 0.22 |
| Changes in social environment | 0.011 | 0.027 | 0.028 | .677 | −0.04 to 0.06 |
×
Discussion
The purpose of this study was to provide a robust theoretical model that could be used to predict intention to change from binge drinking to responsible drinking/abstinence in the college student population. An evidence-based and effective predictive model may prove valuable in the design of interventions aiming to improve responsible drinking behavior in this population. The MTM is a novel and well-supported theory that incorporates tenets of other commonly used models in public health to address 2 primary constructs: initiation of health behavior change and sustenance of health behavior change.
Pertinent conclusions of data analyses showed that of the constructs proposed for initiation of responsible drinking/abstinence—behavioral confidence and changes in physical environment—were significant and that the full model predicted 26.4% of the variance in the intention to initiate responsible drinking/abstinence, a substantial value for a behavioral study. The construct of behavioral confidence in the MTM is based on well-established principles in the field of public health: Bandura's self-efficacy construct
35 and Ajzen's perceived behavioral control.
36 Similar to the study by Wrye and Pruitt,
25 behavioral confidence is well-supported in this study as a significant predictor of responsible drinking behavior and a potential point of focus in interventions.
36 Another potential point of focus to most effectively influence responsible drinking behavior in this population, based on the results of this study, is changes in physical environment. Derived from Bandura's environmental construct
35 and several other well-established theoretical models in public health,
37,38 this construct involves altering the convenience, availability, and readiness of resources.
39 The role of physical environment is also supported by the work of McBride et al,
40 who studied the role of fraternities and sororities in the initiation of binge drinking.
Among sustenance model constructs, practice for change was found to be a significant predictor for intention to sustain responsible drinking/abstinence. Derived from Freire's adult education model praxis, practice for change entails active reflection and reflective action.
41 Embodiment of this construct involves consistent thought about one's behavior change, actively correcting one's strategy, overcoming barriers, and remaining focused on the behavior change goal. Application of this construct in the design of health behavior interventions and clinical practice may prove effective in sustaining responsible drinking behavior in the college student population.
The results of the current study also show that gender and race are significant predictors of both initiation and sustenance of responsible drinking/abstinence. Women were found to be significantly more likely to initiate and sustain responsible drinking behavior than men. A large-scale survey study by Wilsnack et al
42 found that long-term abstention from alcohol was definitively more prevalent among women. That study also found that of former drinkers, women were more likely to have stopped drinking and practiced abstinence than men. Male drinkers also have been shown to be at greater risk than female drinkers for developing alcohol use disorders.
43 In the design of interventions, group or individualized, it is recommended to allocate more time and understand the greater effort required to initiate and sustain responsible drinking behavior in college-aged men who binge drink. Nonwhite race/ethnicity was also found to significantly predict likelihood of initiation and sustenance of responsible drinking behavior among binge drinkers. This finding is supported by previous studies that showed greater alcohol consumption rates among whites.
44,45 The generalizability of this result is limited, however, as the majority of respondents in the current study were white, with just 35 of 283 participants reporting nonwhite race/ethnicity.
The descriptive data on study variables generally showed the mean scores on the constructs to be either on the lower side of the range or in the middle of the range. This factor signifies that there is scope for further improvement of the construct scores through interventions designed to modify these constructs.
Implications for Practice
With the high prevalence of binge drinking—2 of every 5 students
2 among the college-aged demographic binge drink—and the harmful effects associated with binge drinking in this population, interventions are clearly necessary. In the field of public health, such interventions are often designed and planned with evidence-based, behavioral models at their foundation. Such interventions can be implemented by primary care physicians, college wellness programs, and other health care professionals.
The MTM offers the advantage of brief and precise interventions by way of leveraging the significant constructs of the model after empirical testing. These targeted constructs are nonoverlapping and free of moderating variables, which allow for relatively straightforward application in interventions across health behaviors. With the incorporation of constructs devoted to understanding the drivers for sustenance, the MTM also has the potential to effect long-term changes in behavior. Although longitudinal studies have not been performed, the results of MTM studies across multiple health behaviors are promising for their utility in maintenance of behavior change.
28-32
After identification of a negative health behavior and recognition of the harmful ramifications of such behaviors, the next step for public health professionals—particularly behavioral and social scientists involved in public health intervention design—and health care professionals should be to better understand the afflicted population with regard to the positive health behavior change; understanding the negative impact of a health behavior is not sufficient—the specific individual or population in question must also be investigated to gauge their potential responsiveness to behavioral interventions. However, in the primary care setting, time with the patient is limited, and time to motivate patients regarding health behavior change is even more so.
With the majority of osteopathic physicians practicing in primary care,
46 it is worthwhile to research the most efficient and effective constructs for osteopathic physicians to use to improve health behavior in their patients. An evidence base to guide clinical practice should be applied to health behavior change as it is to drug dosing schedules. This study proposes the value of the MTM as an evidence-based model to provide the predictive empirical framework for the design of large-scale interventions, as well as guidance for individual-scale interventions in clinical practice. Multiple constructs were identified in the current study as significantly predictive and therefore suitable for the planning and execution of interventions for this population.
To initiate responsible drinking/abstinence, the current study found that the constructs of behavioral confidence and changes in physical environment were significant. Teaching responsible drinking in manageable small steps and aiding students to develop behavioral confidence in their ability to drink responsibility should be one area of emphasis. This aspect could entail educating patients on the responsible number of drinks to consume per hour and empowering them with strategies to maintain that responsibility. A core principle of the behavioral confidence construct is that the source of confidence is not restricted to self but is also external. Physicians could advise at-risk patients to educate an influential individual close to them to foster shared accountability. Patients could be given an infographic or refrigerator magnet that clearly outlines the responsible rate of alcohol consumption, serving as an external motivating reminder. Physicians could also advise patients to keep an alarm on their phone to maintain appropriate intervals between drinks and make an active effort to keep track of the number of drinks consumed. Another point of emphasis should be changes in physical environment. The current study found that college students have low certainty in their ability to remove alcohol from their home environment, not buy alcohol throughout the week, or to replace drinking with something else. Physicians could advise their patients to abstain from “stocking up” on alcohol and purchase small amounts as needed. Patients could be advised to seek housing options that are not proximal to liquor stores and to remove alcohol from their homes during the week. Emphasizing the importance of seeking activities that do not involve drinking could also prove fruitful. Educating at-risk patients about the significant impact that changing their physical environment has on their ability to drink responsibly/abstain should be a point of emphasis.
To sustain responsible drinking/abstinence behavior using the MTM, practice for change was the key construct found to be statistically significant. Patients could be advised to keep a journal that records their drinking behavior, engage in introspection of their behaviors, and identify barriers and ways to overcome them to sustain responsible drinking. The core of this construct is active reflection, and health care professionals and college wellness programs should focus efforts on improving patients’ macroscopic self-awareness of drinking behaviors. Survey scoring on this particular construct was lower than all other measured constructs, indicating room for improvement through focused intervention or counseling.
Limitations
The cross-sectional design of this study limits the temporal conclusions that can be drawn from the results. Therefore, it cannot be explicitly said that the MTM constructs precede responsible drinking behavior. However, the theories and models that the MTM is derived from indicate that environmental and attitudinal constructs come before health behavior change.
34 More robust longitudinal and experimental study designs could be executed in future studies. Other possible limitations were that the majority of the participants were white, and data were collected at 1 southern US university. Thus, caution must be exercised when generalizing these findings to all college students. Furthermore, for the sake of feasibility, proxies for intention and sustenance behavior were measured rather than actual behavior. Future studies could look into finding more objective measures of behavior. Additionally, although choices were limited for attitudinal assessments, this was a self-reported survey study, and, therefore, measurement bias and false reporting are potential confounders. Stability testing (test-retest) reliability of the survey instrument was not performed—future studies replicating this work should include reliability assessments.
Conclusion
Associated with a 6-fold poorer performance in academic examinations, unsafe sex practices, property damage, and driving under the influence of alcohol, binge drinking in college students is a widely prevalent concern.
5 Physicians, especially primary care physicians, are best equipped to guide intervention design and clinical practice with the college student population regarding change from binge drinking to responsible drinking/abstinence. This study provides empirical justification for MTM constructs that may lead to targeted interventions. Behavioral confidence and changes in physical environment should be the point of focus to initiate responsible drinking/abstinence and practice for change to sustain the behavior.
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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