Challenging Dogma - Spring 2011

Sunday, May 8, 2011

Birth Control and Alcohol Awareness: Negotiating Choices Effectively Stabilizing the BALANCE Intervention – Lindsay Kirsch

Alcohol-Exposed Pregnancies: Who is at Risk and Why?

Within the past decade, there has been an increase in the number of interventions targeted towards women in colleges and universities with the goal of reducing the inconsistent use of contraception while intoxicated. The Harvard School of Public Health conducted a study focused on alcohol use, involving over 10,000 college students. The findings were concerning: 40 percent of the female students reported having four or more drinks in a row within the past two weeks, which constitutes acts of binge drinking (1). Drinking in the college setting increases students’ participation in other unhealthy and risky behaviors such as smoking cigarettes, drug use, driving under the influence, and unprotected sex. Although all of these behaviors may lead to long-term consequences, the frequency of unprotected sexual intercourse between college students during a time of intoxication has lead to an increase in the number of alcohol-exposed pregnancies (AEP) among females (1).

A national survey on alcohol and related conditions found that 74 percent of college women who were sexually active were also “risk drinkers,” or in other words, binge drinkers. In addition, 21 percent of these women did not use contraception regularly (2). Evidently, the misuse of alcohol and inconsistent use of contraception by college students has become a significant problem. Prenatal exposure to alcohol can lead to a number of developmental issues for infants and children, including Fetal Alcohol Syndrome (2).

The BALANCE intervention (Birth Control and Alcohol Awareness: Negotiating Choices Effectively) was first conducted at a university in Atlanta, GA. Women in this intervention considered at risk for an AEP were between the ages of 18 and 24, had unprotected sex or used contraceptives ineffectively, and had an episode of binge drinking within the past three months (1). For this intervention, researchers defined binge drinking as having five or more drinks on one occasion or consuming eight or more drinks per week (1).

BALANCE is a 60-75 minute session in which facilitators use information gained from the recruitment assessment about each woman’s experience with alcohol and drug use, sexual history, and health beliefs, behaviors and knowledge. Counselors then engage participants in a motivational interview (MI) session, including counseling and activities (1). MI is “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (3). Although there are evidence-based studies showing MI to be a successful method of counseling (3), aspects of MI contradict natural human behavior. Although much of this behavior is quite irrational, its importance cannot be overlooked.

BALANCE Does Not Properly Account for Unplanned and Spontaneous Behavior:

During the BALANCE intervention, each woman sat down with a counselor who guided her in coming up with “importance, confidence and readiness rulers for changing drinking and contraception behaviors” (1). This part of the program is based on the MI counseling method, and it is an unrealistic way to change an individual’s behavior. Participants will not be able to create realistic rules for changing behavioral decisions they will encounter under very different circumstances in the future.

George Loewenstein discusses this point in his explanation of behavior and human decision processes. He attributes the difficulties of changing future behaviors in the present to what is called the “visceral factor” (4). The visceral factor is a drive state, such as hunger, sexual desire, physical pain, or craving for alcohol or another drug. Loewenstein posits that when planning for behavioral changes in future scenarios, people ignore visceral factors they are bound to experience (4). An AEP occurs when the craving for alcohol, coupled with sexual desire, overpowers the decision to use contraception. Extensive research about STD’s has found that unprotected sex occurs in “the heat of the moment but people cannot remember or predict what the heat felt like and so are unprepared to deal with it” (4).

As the counselors helped the women plan for how they would decrease their risky behaviors, the women were in what can be termed a “cold state” (5). Presumably, they were not drunk, and they were not about to make a decision about whether to use a form of contraception during sexual intercourse or not. The women may have felt ready to change their future behavior, and understood the potential consequences of their actions if they continued their recklessness. However, by attempting to decide how to make these changes while not driven by specific visceral factors, participants did not have a realistic or rational idea of how difficult the changes would be when intoxicated and posed to have unplanned sex. As counselors guided the women through how they would balance their temptations with their personalized risk, they did not factor in future, unavoidable emotions the college women would experience.

Research by Loewenstein and Ariely shows that when sexually aroused, adherence to behaviors that one considers ethical, such as unprotected sex, become less important (5). In a study done on UC Berkeley’s campus, Ariely found that when college students were aroused, “they were 25 percent more likely…to predict that they would forego condoms” and “they failed to predict the influence of arousal on their sexual preferences, morality, and approach to safe sex” (6). It is important to note that Ariely’s study did not include the effect that alcohol would have on the aroused state, which will additionally impair one’s choices.

Loewenstein and Ariely also found that the ability to predict how to change future behavior in the “hot” state would be understated while in the “cold” state. In turn, the women participating in BALANCE would not be able to fully capture the effect of the future visceral factors they will encounter when craving alcohol or driven by sexual desire. Furthermore, if future behavior is projected incorrectly in the present, individuals are less likely to take precaution to avoid dangerous situations (4). While the women in the BALANCE intervention attempted to change their behavior by creating rules for future situations, they were unable to correctly predict how difficult it may be to decline sex or ensure use of contraception when intoxicated and aroused. Consequently, BALANCE does not account for impending visceral factors in what Loewenstein and Ariely term “hot-cold empathy gaps” (4,5).

Knowledge Does Not Effectively Change Behavior

Part of the BALANCE intervention devotes time for counselors and participants to have a one-on-one conversation using a method referred to as elicit-provide-elicit (EPE) (1). This method instructs the counselor to elicit information from the participant to determine how much knowledge she has about specific health behaviors. Following this, the counselor provides information to the woman to fill in knowledge gaps. Specific to the BALANCE intervention would be information about alcohol abuse and the importance of using contraception. Next, the counselor will elicit information again to determine how much the women understood and took in from the information given (7). Ideally, EPE facilitates future behavioral changes by providing knowledge, data, and statistics about the risky behaviors the women in BALANCE partake in. However, this counseling method assumes people participate in risky behaviors because they do not have the knowledge of and are not informed about the dangers of their actions.

The use EPE has similar intentions as the Health Belief Model (HBM). The HBM posits that people make behavioral decisions based on balancing several factors including perceived susceptibility and severity of an outcome, barriers that will discourage completion of the health behavior, and one’s self-efficacy (8). Using the HBM to design an intervention, the format tends to be more informational. Although an “informational intervention” may appear to be less controversial than a skill based intervention (i.e. one that demonstrates and allows the practice for how to use contraception), they generally do not prove to be effective in changing very risky behaviors—such as the inconsistent and incorrect use of contraception (9).

In the BALANCE program, counselors and facilitators give each woman a feedback form based on her answers to questions about drinking and use of contraception. The feedback form states personalized statistics for each woman. Some examples are, “You are currently drinking more than 80% of women your age” and “You are at risk for pregnancy because you missed four pills in a row and had sex without a backup method such as condoms” (2). The goal of this step is that by providing this information, the women will finally end their behavior when they see statistics and facts about its obvious dangers. By using EPE and a feedback form, counselors hope to give participants the appropriate information to convince them that they are at risk for contracting an AEP when they abuse alcohol and have unprotected sex.

Unfortunately, the BALANCE intervention does not accommodate the growing premise that knowledge is not enough to change a behavior. The counselors could provide endless amounts of information to the participants in BALANCE, but it does not guarantee a change in their actions (9). In fact, studies over the past several decades, particularly those focused on avoiding STDS and unplanned pregnancies, have disproved the effectiveness of the Health Belief Model in transforming young people’s behaviors through showing evidence of the threats in the risks they take (9).

In a study of adolescents to determine AIDS epidemiology and prevention knowledge, Allyson Imperato found that the level of knowledge about safe sex was high within the sample of participants. Imperato also found that 57 percent of the 142 young adults about to enter college had been intoxicated before, and 15 percent had been sexually active while inebriated (10). However, although the “vast majority” knew about the importance of condom use, only half of the sexually active sample used contraception. Additionally, over 60 percent of the entire sample found it difficult or embarrassing to even purchase condoms (10). As this group demonstrates, knowledge about condom use does not ensure the use of protection during intercourse.

BALANCE Does Not Acknowledge the Hierarchy of Needs

The design of the BALANCE intervention assumes that when women make plans to change future behavior related to alcohol use and unprotected sex, and have the appropriate knowledge about the dangers of these actions, they will be able to decrease their risk of an AEP. According to Abraham Maslow’s Hierarchy of Needs, the women are not lacking information or an action plan. The Hierarchy of Needs theorizes that people ultimately crave the need for self-actualization, but before that is possible other needs must be met. The first of five levels of needs on Maslow’s hierarchy is physiological (food, water, sleep, air), followed by safety and security needs, the need for love and belonging, the need for self-esteem, and finally, the need for self-actualization (11).

The female college students participating in the BALANCE intervention presumably have their physiological and safety needs met—they should not be in states of starvation, or homelessness. However, by binge drinking and having unprotected sex, these women are nowhere near reaching the level of self-actualization. Women at risk for an AEP need more than statistics and information about the dangers of their behavior, or to have a plan for how to make changes. If their needs for love, belonging, and self-esteem were met, these women may be less likely to feel the desire to binge drink and have unprotected intercourse.

In looking to deliver services specifically for women who abuse alcohol, Ann Abbot theorizes that women’s reasons for substance abuse differs from those of most men (12). For example, women place higher value on love and relationships than material objects, where the reverse is true for men. Furthermore, when women feel that they do not have control over love and relationships in their lives, many turn to a substance to self medicate—something that they can control (12).

Continuing the theme behind Abbot’s theory, an investigation into why college students have sex showed differences between reasons given by males and females. Men in college felt it was easier to have sex without an emotional connection, while women reported having sex mostly in hopes of finding love, commitment or to fill an emotional gap (13). There are no parts of the BALANCE intervention that address these emotional reasons for the participants’ behavior.

Various studies have shown that college females with low self-esteem drink more alcohol than their colleagues with high self-esteem (14,15). In addition, those with low self-esteem who abuse alcohol tend to have sex more often and use condoms less frequently (14, 16). Women who are abusing alcohol may be trying to mask the pain they feel in a search for love, to escape social isolation, or to feel better about themselves. BALANCE does not focus on addressing the emotions and needs that drive the self-destructive behaviors college women are feeling when they put themselves at risk for an AEP. For an intervention protecting women against an AEP, the BALANCE intervention will need vast improvements.

The “New BALANCE” Intervention

To successfully move college women out of high risk for an Alcohol Exposed Pregnancy (AEP) an intervention must focus on the emotional needs of the target audience. An intervention such as BALANCE is designed with the purpose of curbing excessive binge drinking and having unprotected sex. In order to ensure college women do not become pregnant while intoxicated, New BALANCE must progress beyond “safe” activities of making change plans for future events, and providing participants with fear inducing information and statistics.

What College Women Need

Female college students that are taking part in risky behaviors such as binge drinking and ineffective contraception use do not have enough of their emotional and psychological needs met. As the discussion of Maslow’s Hierarchy of Needs portrays, New BALANCE participants may have their physiological needs met (food, water, air), as well as their needs for safety (security of body, employment, health, property, resources), but they do not have enough of their needs met for love, belonging and self-esteem (11). The current BALANCE intervention is only 60-75 minutes long, and within this time, it is not feasible to instill women with enough love and self-esteem to end their risky behaviors. The intervention must be extended to include more sessions, and should begin by addressing the emotions and difficult issues young women are attempting to ignore by excessive drinking and dangerous sexual behavior.

The New BALANCE intervention will begin as one group, or smaller groups of seven to ten people, depending on the number of participants. The program will not begin with individualized questionnaires about their behaviors; instead, the women will take part in a focus group. All of the counselors in the BALANCE intervention have a master’s degree in social work or psychology (2), and are plenty capable of understanding the underlying reasons for participants’ reckless behavior. Introducing the participants to the intervention will be done through a focus group about the emotional difficulties of being a young woman in college, and the feelings and urges that arise when making decisions in potentially dangerous situations.

Research has shown that when addressing health related behaviors, qualitative methods, such as a focus group, can be highly successful (17). Although the New BALANCE focus group would be discussing the health related behaviors of drinking and contraception, the qualitative information gained would be about the women’s emotional challenges and the ways in which they view themselves as individuals. Subsequently, the counselors could understand the gaps in the participants’ needs for love and self-esteem. This information will allow the counselors to adjust individual and group session topics accordingly, along with using their experience and expertise.

Throughout the focus groups, the counselors will have gathered information about the women’s feelings and personal circumstances that may contribute to their risky behaviors. They will be then able to use the individual time previously spent on elicit-provide-elicit to promote ways to increase self-esteem in the participants. It will be important in the one-on-one counseling to identify and focus on each woman’s positive qualities, and discuss proactive ways for women to express their difficult emotions in a non-destructive manner (i.e. sports, art, writing, etc.) (18).

New BALANCE Warms Up

Reformatting BALANCE to an intervention that accounts for exact future visceral factors would be very difficult. Nonetheless, it is necessary for participants to do more than create change plans by discussing and balancing future temptations. New BALANCE cannot be successful by ignoring the fact that women are currently in the “cold state” (sober and not posed to have unprotected sex). New BALANCE will acknowledge that humans can be irrational and underpredict their future behaviors while aroused (6).

To address this important issue, the New BALANCE intervention must be creative. One part of the New BALANCE program will incorporate the use of fatal vision goggles–sometimes known by their slang term “beer goggles.” Fatal vision goggles simulate the experience of being intoxicated. Thy have begun to be used in experimental studies aimed at reducing drunk driving and other risky behaviors young adults encounter when intoxicated (19).

Studies in which participants watch a person wearing fatal vision goggles have shown moderate improvements in reducing risky behaviors of the participants. However, it is significantly more effective in changing behavior when participants wear the goggles themselves. One study found that while wearing the goggles, “the individual may begin to form a belief that drinking does impair their judgment and visual perception, while they are not under the influence of alcohol, which tends to distort a person's thinking and allow them to overestimate their abilities” (20). It is important to note that this particular study was conducted with all college students, and the majority of the participants were females (20).

In small groups, each participant of New BALANCE will wear the fatal visions goggles for a period of time. With the help of their peers, the women will attempt to recreate and practice cutting one’s self off from drinking, and ensuring protection is used when tempted to be sexually active. Acknowledging these decisions are made while impaired will assist the women in addressing realistic difficulties of these future scenarios. By experiencing a more similar feeling to a previous or future hot state, discussions about how to change one’s behavior with counselors and peers will be more realistic and honest.

New BALANCE and the Real World

The BALANCE intervention provides individualized data and statistics for participants about the specific dangers of their drinking and irregular use of contraception. Presenting data and statistics is not enough to change behavior. Various studies have shown that people can be very informed about the likelihood of negative events happening based on absolute facts and statistics, and still believe their risk is not as high as the numbers show. Neil Weinstein refers to this “error in judgment” as unrealistic optimism (21). In his study, Weinstein interviewed college students about possible future life events, such as owning a home (positive) or having a drinking problem (negative). The study showed that students believe they are more likely to experience positive events and less likely to experience negative events than their peers will (21).

Apparently, college students’ opinions about the likelihood of future experiences are not based on solid statistics, or factual odds of developing a disease. In studies testing similar theories, in spite of statistics smokers in the US repeatedly underestimate their risk for developing heart disease or cancer (22). As opposed to presenting statistics, the New BALANCE intervention must introduce their participants to one person’s life story. For the women to understand the potential severity of their actions, they will connect more with someone they can relate with or even talk to. Facilitators of New BALANCE will find young women who contracted AEPs in college, and incorporate them into the intervention to speak to the participants.

The Massachusetts Tobacco Control Program used the real life story approach in their campaign to encourage people to quit smoking cigarettes by telling the story of a woman named Pam Laffin, a mother who died of emphysema at age 31. One study of focus groups among young adults concluded that the “Pam campaign” was effective because of the “real world story” (23). In another study, of all the anti-tobacco advertisements that had been televised in MA within the prior year (some examples were the “Think, don’t smoke” and “Where’s the outrage?” campaigns), the majority of students participating in the study remembered the one that entailed a real person telling her story (i.e. Pam) (23).

Advertisements that mainly depict the consequences of one’s action through a personal story have been shown to have a stronger impact on adolescents and young adults than those that give informational health facts, such as the message that smoking cigarettes creates a tar build up in one’s lungs (24). The New BALANCE intervention can become an incredibly impactful program by portraying the consequences of a woman’s actions that lead to an AEP, and how the experience changed her life, presumably for the worse.

New BALANCE will reduce the risk of an Alcohol Exposed Pregnancy for women in college through focus groups that target the emotions and insecurities that influence the harmful behaviors of combining binge drinking and unprotected sex. Additionally, the intervention will allow women to experience the feelings of intoxication through a simulation using fatal vision goggles, and realistically decide ways in which to avoid becoming pregnant while drunk, or even drinking in excess altogether. Finally, the women will listen to the stories of women who have experienced an AEP, and be able to discuss with them the effect their behavior had on the rest of their lives. These evidence-based methods accurately account for irrational human behavior while lessening the odds of incurring detrimental health outcomes.


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