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Journal of American College Health

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Brief Screening and Intervention for Alcohol and Drug Use in a College Student Health Clinic: Feasibility, Implementation, and Outcomes

Hortensia Amaro PhD , Elizabeth Reed ScD, MPH , Erin Rowe BA , Jennifer Picci RN, MPH , Philomena Mantella PhD & Guillermo Prado MS, PhD

To cite this article: Hortensia Amaro PhD , Elizabeth Reed ScD, MPH , Erin Rowe BA , Jennifer Picci RN, MPH , Philomena Mantella PhD & Guillermo Prado MS, PhD (2010) Brief Screening and Intervention for Alcohol and Drug Use in a College Student Health Clinic: Feasibility, Implementation, and Outcomes, Journal of American College Health, 58:4, 357-364, DOI: 10.1080/07448480903501764

To link to this article: http://dx.doi.org/10.1080/07448480903501764

Published online: 08 Jul 2010.

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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 58, NO. 4

Brief Screening and Intervention for Alcohol and Drug Use in a College Student Health Clinic: Feasibility, Implementation, and Outcomes

Hortensia Amaro, PhD; Elizabeth Reed, ScD, MPH; Erin Rowe, BA; Jennifer Picci, RN, MPH; Philomena Mantella, PhD; Guillermo Prado, MS, PhD

Abstract. Objective: Evaluation of the Brief Alcohol Screen and Intervention in College Students (BASICS) in a university pri- mary care setting. Participants/Methods: Undergraduates (N = 449) participated in BASICS and electronic surveys assessing fre- quency/quantity of alcohol and drug use, psychosocial and mental health outcomes, and demographic information. Data were collected at baseline and 6-month follow-up between August 2006 and August 2008. Results: Drinking and drug use decreased between baseline and 6 months. Participants reported an increase in protective factors and in readiness to change alcohol-related behaviors, and a decrease in alcohol-related consequences and in distress symptoms. Heavy episodic drinking at baseline significantly moderated the changes in number of drinks in a typical week and in a typical weekend, and number of drinks on the occasion drank most on a weekend. Conclusions: BASICS can be implemented in a primary health care setting and university students may reduce their alcohol and/or drug use.

Keywords: alcohol and drug use, college students, brief screening and intervention, prevention, primary care

A lcohol and drug misuse among college students isan important public health problem in the UnitedStates.1,2 A national study indicated that in 2007, 36% of female and 49% of male college students reported

Dr Amaro is with the Institute on Urban Health Research at Northeastern University in Boston, Massachusetts. Dr Reed is with the Department of Prevention & Community Health, George Wash- ington University School of Public Health, Washington, DC. Ms Rowe is with the Institute on Urban Health Research at Northeast- ern University. Ms Picci is with the University Health and Counsel- ing Services of Northeastern University, Boston, Massachusetts. Dr Mantella is with the Office of the Vice President of Student Affairs of Northeastern University, Boston, Massachusetts. Dr Prado is with the Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Miami, Florida.

Copyright © 2010 Taylor & Francis Group, LLC

drinking 5 or more drinks in one sitting during the prior 2 weeks.3 Furthermore, 35% of college students reported use of an illicit drug and 17% reported use of an illicit drug other than marijuana in the past year.3 Studies have documented the negative health and safety consequences of alcohol and drug misuse among this population,4 including increased risk of alcohol abuse and dependence,1 academic impairment,5

campus security problems and police involvement,6 suicide attempts,5 unprotected sex,6 and assault and injuries.7 Given the high proportion of students affected and the numerous adverse consequences, there is a need for the development of effective interventions to address this health topic among college students.3

One promising intervention is the Brief Alcohol Screen- ing and Intervention for College Students (BASICS). Studies have demonstrated that BASICS can help reduce quantity8–12 and frequency9,13 of alcohol use, as well as neg- ative consequences8,10,13 among college populations. These studies have largely documented the effectiveness of BA- SICS in mental health and nonclinical settings and among specific subgroups of university populations such as man- dated undergraduates,10 fraternity or sorority members,11 and incoming freshmen.13 However, fewer studies have focused on the effectiveness of BASICS conducted more generally within a university primary care health center context.14–16

Given the extent of illegal drug use among college students, the effectiveness of BASICS on reducing drug use also de- serves further investigation.

Because studies suggest that the effectiveness of alcohol or drug (AOD) interventions may vary as a function of dif- ferent mechanisms, including demographic factors such as age or gender3,17 as well as initial levels of drinking and/or drug use,18,19 further investigation of these mechanisms is warranted. Additionally, trauma or abuse is more commonly reported among those who use substances,20,21 and yet little

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is known about whether BASICS will work well among stu- dents with such histories. Substance use treatment programs often include participants who are mandated to attend and those who are self-referred; evidence suggests that no differ- ences in treatment success exist by these referral types.22,23

However, studies have not examined whether effectiveness varies by recruitment process (self referral or provider refer- ral) within a university setting treatment program. Finally, BASICS operates on the premise that individuals’ readiness to change their AOD use behavior is important in influencing reduction of AOD use24; however, this aspect has not been well examined among college populations.

The current study therefore aimed to (1) test the feasibility of implementing a brief screen and BASICS intervention at a large urban university health center’s primary care service; (2) assess changes over time in alcohol and drug use and related factors; and (3) examine potential mechanisms for significant reductions in AOD use. The following variables were included: age, sex, self-referral or referred through the health center, history of abuse, AOD use–related variables (eg, initial levels of drinking and drug use), and psychosocial variables (eg, readiness to change, protective strategies).

METHODS

Recruitment Procedure Participants were recruited from among students who

sought medical or mental health care through the Univer- sity Health and Counseling Services (UHCS) via UHCS providers or through self-referral within an urban university in Boston, Massachusetts. Self-referral was made possible via on-campus flyers, activity fairs, campus mailings, and word of mouth.

Referred students were contacted by a research assistant who gave them information regarding the study and protocol. Students were eligible if they satisfied criteria for problem- atic substance use, were at least 18 years of age, and were available on campus for sufficient time to complete the inter- vention. In order to assess problematic substance use, UHCS referrals completed a health center questionnaire during the visit with their provider that included the CRAFFT screen,25

a 6-item alcohol and drug screening test developed for use by clinicians with young or adolescent patients. Clinicians referred students who responded positively to 2/6 items. Be- cause the CRAFFT is a clinical assessment and it was in- appropriate for nonclinical research staff to administer the instrument to self referrals, self referrals were screened for eligibility via telephone by research staff to determine if they had at least one occasion in the last month where they re- ported drinking 4 or more drinks or had used an illegal drug.

Data Collection and Study Procedure Once eligibility was confirmed, research staff obtained in-

formed consent for all referrals. Measurements were at base- line, post intervention, and 6 months follow-up. Participants completed the initial survey online at the research site. After receiving the BASICS intervention, students were e-mailed

a link to complete the postintervention survey and 6-month follow-up. Participants received a $20 gift card to a bookstore for each survey completed. The postintervention survey did not include information on behavioral outcomes and is there- fore not used in the analyses reported here. The study was approved by the university institutional review board.

Participants Of the students referred to the intervention via UHCS and

self-referral between August 2006 and June 2008, 31% and 69% participated, respectively. Analyses are limited to those who had complete information for baseline and follow-up (n = 449) during this period. The majority of participants were female (62%), White (83%), and born in the United States (90%). The sample was evenly distributed across years of study at the university. About half (54%) lived on campus. Most were self-referred (67%). No significant differences were found across demographics related to referral type. The majority (98%) reported current alcohol use, with 67% re- porting heavy episodic drinking as part of their weekly drink- ing behaviors over a typical past month. Illicit drug use was reported by 56% of participants (mostly marijuana). Almost 20% reported illegal use of prescription drugs in the past 6 months and 17% reported having a prior alcohol or drug violation from the University (Table 1).

BASICS Intervention The BASICS intervention consisted of 2 sessions (45 to

60 minutes in length each),4 and was modified to include drug use, if applicable, using the same format and style as for alcohol. During the first session, information about the student’s AOD use was gathered. The student was given alcohol self-monitoring cards to complete with the study nurse between the first and second sessions. At the second session, the student and nurse reviewed the self-monitoring cards and the personalized feedback packet together. The personalized feedback packet includes data on the student’s alcohol consumption, perceptions of other students’ drinking compared to actual usage data, blood alcohol content, beliefs about alcohol, consequences, risk factors, and the readiness ruler.26 The readiness ruler, implemented at both sessions, asks students to rate their readiness or motivation to change any aspect of their drinking behavior on a scale of 1 to 10 and to describe their reasons for change. At the end of the sessions, students are given their feedback packet, which includes all the information reviewed in both sessions and goals they have set for reducing their drinking and drug use, strategies they have chosen to achieve these goals, and local service resources should they choose to use these in future.

Each session was facilitated by a study nurse at the UHCS. There was 1 full-time nurse throughout the study and 2 part-time nurses at busier times of the year. The nurses at- tended a 2-day BASICS Practitioner training and received weekly supervision by a clinical psychologist expert on BA- SICS. To assess and maintain fidelity to the BASICS model across interventions, the trained nurses sat in on each others’ session(s) to provide critique and assessment of the nurse

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TABLE 1. Baseline Profile of Participants Who Completed 6-Month Follow-Up (n = 449)

Total sample Total sample Demographics % (n) History of trauma % (n)

Gender History of physical or emotional neglect Male 37.8 (168) Yes 13.6 (61) Female 62.3 (277) No 86.4 (388)

Race/Ethnicity History of physical abuse Black 4.5 (20) Yes 6.5 (29) Hispanic 2.5 (11) No 93.5 (419) Asian 8.4 (37) History of sexual abuse White 83.1 (368) Yes 6.5 (29) Other 1.6 (7) No 93.5 (420)

Age History of sexual harassment <21 48.6 (218) Yes 22.8 (102) ≥21 51.4 (231) No 77.2 (346)

Hometown Participants’ alcohol and drug use Rural 19.6 (88) Alcohol use, past 6 months Urban 19.4 (87) Yes 98.4 (442) Suburban 60.9 (273) No 1.6 (7)

Born in US Weekly heavy episodic drinking, past month Yes 89.5 (402) Yes 67.2 (299) No 10.5 (47) No 32.8 (146)

Participate in campus athletic activities or teams Illicit drug use, past 6 months Yes 43.8 (193) Yes 56.1 (252) No 56.2 (248) No 43.9 (197)

Student year of study Prescription drug use, past 6 months Middlera or more junior 52.1 (234) Yes 19.6 (88) Junior/senior/advanced 47.9 (215) No 80.4 (361)

Sexual orientation Previous drug violation from University Heterosexual 94.4 (423) Yes 16.8 (75) Bisexual 2.9 (13) No 83.2 (372) Lesbian, homosexual, gay 1.3 (6) CRAFFT score Mean (standard deviation) Questioning 1.1 (5) 2.8 (1.5) Other 0.2 (1)

Residence On campus 53.6 (240) Off Campus 46.4 (208)

Participation in fraternity Yes 5.1 (23) No 94.9 (426)

Participation in other campus organization Yes 27.6 (124) No 72.4 (325)

Referral type Self-referred 67.0 (301) Health Center referred 33.0 (148)

aMiddler refers to students’ third year of study; students at this university engage in 5 years of study.

delivering BASICS using Motivational Interviewing with College Student Checklist.27 These checks demonstrated consistent application of the BASICS components across the sessions with high fidelity.

Measures Student characteristics. Information was collected on age,

race/ethnicity, class year, affiliations with campus organiza- tions, hometown type, place of birth, type of residence, and previous alcohol or drug violation from the University.

History of physical or emotional neglect, physical abuse, sexual abuse, and sexual harassment was assessed using the Life Stressor Checklist.28 Emotional neglect was measured using 1 item: “Have you ever been emotionally abused or neglected (for example, being frequently shamed, embar- rassed, ignored, or repeatedly told that you were no good)?” Physical neglect was measured using 1 item: “Have you ever been physically neglected (for example, not fed, not properly clothed, or left to care for yourself when you felt you were too young or ill)?” Emotional and physical neglect were combined into one item representing neglect (yes/no).

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Physical abuse was measured dichotomously (yes/no) by ask- ing participants, “Have you ever been physically abused—for example, hit, choked, burned, or beaten, by someone you knew well such as a parent, sibling, boyfriend, or girlfriend?” Sexual abuse was measured dichotomously (yes/no) and re- flected positive responses to either of the following 2 items: “Have you ever been touched or made to touch someone else in a sexual way, because you felt forced in some way, or threatened by harm to yourself or someone else?” and “Did you ever have sex because you felt forced in some way or threatened by harm to yourself or someone else? (sex mean- ing oral, anal, or genital).” Sexual harassment was also mea- sured dichotomously by asking participants, “Have you ever been bothered or harassed by sexual remarks, jokes, inap- propriate touching or demands for sexual favors by someone at work or school? (for example, a boss, teacher, or another student).”

Alcohol use was measured using 4 items: any alco- hol use, heavy episodic drinking, number of drinks per week/weekend, and number of drinks on occasions drank most. Any alcohol use was measured by asking participants how often they drank in the past 6 months, with responses ranging from “did not drink at all” to “all days.” Heavy episodic drinking was defined as having 5 or more drinks in one sitting for males and 4 or more drinks in one sitting for females, given biological differences in toleration and metabolism of alcohol.29 An item from the Daily Drinking Questionnaire30 asked participants the number of drinks they consumed per day over a typical week during the past month. Number of alcoholic drinks in a typical week and on a typi- cal weekend (past month) was measured using 2 continuous measures from the Daily Drinking Questionnaire. Number of drinks during occasion drank most in the past month during the week and on the weekend was measured using 2 contin- uous variables taken from the Quantity and Frequency Index Scale.31

Illicit drug use and prescription drug use (nonprescriptive purposes) were measured using dichotomous and continuous variables. Items were from the Monitoring the Future study.3

Participants were asked about their use of a range of illicit drugs and asked to estimate the frequency of drug use in the past 6 months. Similar questions were used to assess prescription drugs. Two dichotomous variables were created, reflecting any illicit drug use or any illicit prescriptive drug use in the past 6 months. Two continuous variables were used reflecting the frequency of use in the past 6 months for the most common illegal drugs: marijuana and cocaine. High frequency of drug use was defined as reporting at least 1 type of drug use 10 or more times in the past 6 months.

Protective drinking strategies were measured using 10 items that asked students the frequency with which they en- gaged in protective drinking strategies in the past 6 months. Responses were based on a 6-point Likert scale, ranging from “never” to “always,” and including “didn’t drink” as the most protective strategy. A higher score indicated using more protective drinking strategies; a continuous variable reflecting the sum of all items was used for analyses. Exam-

ples of strategies included switching between alcoholic and nonalcoholic beverages, setting drink limits, choosing not to drink, using a designated driver, eating before and/or during drinking.

Alcohol-related consequences (past 6 months) were as- sessed using a continuous variable derived from the Rutgers Alcohol Problem Index,32 consisting of 23 items asking par- ticipants how often various events occurred while they were drinking or as a result of their drinking. Items were scored on a 5-point ordinal scale ranging from “never” to “more than 10 times”; a summation score of all items was used for analyses. Examples of items include “neglected your responsibilities,” “noticed a change in your personality,” and “kept drinking when you promised yourself not to.”

Consequences to drug use (past 6 months) were mea- sured using the 16-item Customary Drinking and Drug Use Record (CDDR),33 which asked about 4 drug-related do- mains: level of involvement, withdrawal characteristics, psy- chological/behavioral dependence symptoms, and negative consequences. The CDDR has been shown to have good in- ternal consistency, with alpha coefficients ranging from .60 to .94. A summation score of all items was created for con- sequences to drug use and analyzed continuously.

Distress symptoms (past month) were analyzed using a continuous variable reflecting the sum of the 10-item Per- ceived Stress Scale,34 which asked how often participants were nervous, upset, angered, or feeling loss of control in their lives and in their ability to cope. Responses were based on a 5-point Likert scale and ranged between “never” and “fairly often.”

Readiness to change alcohol use was measured with the Readiness to Change Scale.26 Using a 10-point Likert scale, participants were asked how ready they were to change rang- ing from “not ready” to “trying to change.” Responses to all items were summed for a total alcohol readiness score and analyzed using a continuous measure.

Data Analysis The data analysis plan consisted of 3 steps. First, to assess

changes in alcohol and drug use as well as AOD-related psy- chosocial factors and related consequences between baseline and 6-month follow-up, we used chi-square tests for cate- gorical variables and t tests for continuous variables. Sec- ond, we conducted moderation analyses to examine whether the effects of the intervention varied as a function of the following factors: age, sex, referral type, history of sex- ual or physical abuse, heavy episodic drinking at baseline, and baseline heavy drug use (reporting at least 1 type of drug use 10 or more times in past 6 months, and using a cutoff slightly greater than an average once a month). For these moderation analyses, logistic regression was used for dichotomous outcomes and linear regression for continuous measures; relevant interaction terms were included in each model to assess significant moderation (defined as p < .05). For variables found to be significant moderators, separate stratified analyses were conducted to report the differences

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TABLE 2. Changes in Alcohol and Drug Use, Reported Protective Factors, Consequences of AOD Use, and Perceived Distress (n = 449)a

Baseline 6-Month follow-up Chi-

Drug and alcohol use % yes (n) % yes (n) square (p value)

Alcohol use, past 6 months 98.4 (442) 93.1 (418) 14.3 (.0002 ) Weekly heavy episodic drinking, past month 67.2 (299) 50.3 (224) 77.1 (<.0001 ) Illicit drug use, past 6 months 56.1 (252) 51.0 (229) 190.1 (<.0001 ) Illegal use of prescription drugs (any), past 6 months 19.6 (88) 16.9 (76) 116.9 (<.0001 )

Baseline 6-Month follow-up t test

Frequency of drug use and alcohol use quantity M (SD) M (SD) statistics (p value)

Frequency of marijuana use, past 6 months 2.5 (2.1) 2.3 (2.2) 2.7 (.007 ) Frequency of cocaine use, past 6 months 1.6 (1.7) 1.2 (1.4) 2.0 (.049 ) Number of drinks in a typical week, past month 12.2 (10.0) 9.6 (9.6) 6.8 (<.0001 ) Number of drinks in a typical weekend, past month 10.6 (8.1) 8.2 (7.7) 8.2 (<.0001 ) Number of drinks during occasion drank most, past month 7.8 (4.4) 6.6 (4.4) 6.0 (<.0001 ) Number of drinks during occasion drank most on a given

weekend, past month 8.0 (5.7) 6.7 (5.2) 5.3 (<.0001 )

Baseline 6-Month follow-up t test

AOD-related psychosocial factors and consequences M (SD) M (SD) statistics (p value)

Protective factors, past month 19.0 (7.7) 22.1 (9.9) −7.4 (<.0001 ) Consequences of alcohol use, past 6 months 9.1 (7.9) 7.7 (9.4) 2.2 (.03 ) Top tertile 0.8 (0.3) 0.5 (0.3) 7.0 (<.0001 ) Consequences of drug use, past 6 months 2.1 (2.2) 1.9 (2.8) 1.3 (.20) Top tertile 3.8 (1.9) 3.1 (3.3) 2.3 (.03 ) Distress symptoms, past month 14.4 (6.3) 13.5 (6.6) 2.6 (.01 ) Readiness to change alcohol 2.9 (2.4) 3.2 (2.8) −2.1 (.03 ) aItalicized figures represent those significant at p < .05.

in outcomes by groups in order to provide clarity in inter- pretation. Third, analyses to examine mediation were con- ducted to explore whether changes in protective factors or in readiness to change alcohol use scores between baseline and 6-month follow-up were associated with any of the sig- nificantly changed AOD-use outcomes between baseline and 6-month follow-up. For these analyses, regular linear regres- sion models were used for continuous variables and analysis of variance (ANOVA) for all categorical variables.

RESULTS

Changes in Alcohol and Drug Use and Related Psychosocial Factors and Consequences

Participants’ drinking and drug use decreased between baseline and 6 months. Specifically, there was a significant decrease in participants’ reports of past 6-month alcohol use, past-month weekly heavy episodic drinking, past 6-month illicit drug use, and past 6-month illicit prescription drug use (see Table 2 for test statistics and p values). Participants also reported a lower frequency and quantity of drinking and/or drug use at follow-up compared to baseline. The follow- ing variables decreased significantly between time points: past 6-month frequency of marijuana and cocaine use, past-

month number of drinks in a typical week and in a typi- cal weekend, and past-month number of drinks on occasion drank most, and number of drinks drank most on a weekend (Table 2).

Participants also reported an increase in protective factors, a decrease in alcohol-related consequences, a decrease in distress symptoms (eg, unable to control important things in life, felt nervous and stressed), and an increase in readiness to change alcohol-related behaviors. Although, overall, par- ticipants did not report significant reductions in drug-related consequences (eg, driven a car while high, arrested because of drugs, used drugs at school or work), those who reported scores within the top tertile on drug-related consequences at baseline reported decreased drug consequences at follow-up (Table 2).

Moderating Effects of Weekly Heavy Episodic Drinking and High Frequency of Drug Use at Baseline

Heavy episodic drinking at baseline significantly moder- ated the changes in number of drinks in a typical week, num- ber of drinks on a typical weekend, and number of drinks on the occasion drank most on a weekend (Figure 1). For those not reporting heavy episodic drinking at baseline, the change in number of drinks during a typical week was not

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Baseline Follow-up

Drinks during typical week

Baseline Follow-up

Drinks during typical weekend

Baseline Follow-up

Occasion drank most

Baseline Follow-up

Occasion drank most on weekend

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Baseline Binge Drinking No baseline Binge drinking

t=-0.47 (p=0.64)

t=7.6 (p<0.0001)

t=9.4 (p<0.0001)

t=-0.63 (p=0.53)

t=1.6 (p=0.12)

t=5.6 (p<0.0001)

t=-0.17 (p=0.86)

t=6.0 (p<0.0001)

FIGURE 1. Modification by heavy episodic drinking at baseline. Variables shown in the figure were significant (p < .05) in regression models testing for interaction.

significant; among those reporting baseline heavy episodic drinking, there was a significant decrease in number of drinks during a typical week. Reduced alcohol use and illicit drug and prescription drug use between baseline and follow-up did not differ by whether or not participants reported typical weekly heavy episodic drinking in the past month at baseline.

High frequency of drug use, defined as reporting at least 1 type of drug use 10 or more times in the past 6 months, was also a significant moderator for select AOD outcomes. Weekly heavy episodic drinking between base- line and follow-up differed by whether or not participants reported a high frequency of drug use at baseline (Figure 2). Among those who initially reported high frequency of drug use, those who reported heavy episodic drinking at baseline compared to those who did not were about 7 times more likely to report heavy episodic drinking at follow-up. Among those not reporting high frequency of drug use at baseline, those who reported heavy episodic drinking at baseline compared to those who did not were about 6 times more likely to report heavy episodic drinking at follow-up.

Changes in frequency of marijuana use and cocaine use between baseline and follow-up also differed by whether or not participants reported a high frequency of drug use at baseline (Figure 2). Among those not reporting high drug use at baseline, there was no significant change in marijuana use between baseline and follow-up, whereas among those with high frequency of drug use at baseline, there was a significant reduction in marijuana use. No moderation was found by age, gender, referral type, or history of sexual or physical abuse.

Mediating Effects of Protective Factors and Readiness to Change

Changes in protective factors between baseline and 6- month follow-up were associated with changes during the same time period for the following variables: number of

drinks on occasion drank most (β = −1.2, p < .0001), num- ber of drinks on occasion drank most on the weekend (β = −1.0, p < .0001), number of drinks during typical week over the past month (β = −1.6, p < .0001), number of drinks during typical weekend over the past month (β = −1.4, p < .0001), weekly heavy episodic drinking over the past month (F = 11.54, p < .0001), and drinking any alcohol over the past 6 months (F = 14.5, p < .0001). Therefore, change in protective factors between baseline and follow-up appears to be significant in determining reduced alcohol intake between these time points. Upon further controlling for baseline pro- tective factor score, only slight changes were found in main effects, suggesting that the change in protective factor score may be more important than participants’ baseline score in determining these findings.

Readiness to change alcohol use was associated with changes between baseline and 6-month follow-up for any alcohol use (F = 3.7, 0.02), frequency of cocaine use (β = 0.2, p = .006), and number of drinks during typical week- end (past month) (β = −0.22, p = .04). Upon controlling for baseline readiness to change, the effects for any alcohol use, cocaine use, and for number of drinks during a typical weekend (past month) remained significant; however, all ef- fect estimates changed by greater than 10%, suggesting the importance of participants’ readiness to change score both at baseline and between baseline and follow-up. In summary, findings indicate that increase in readiness between baseline and follow-up is important in influencing change in these key variables; however, this also suggests that baseline readiness potentially contributes to this change over time. Exploratory analyses showed that change in protective factors was signif- icantly associated with change in alcohol readiness between baseline and follow-up, both in crude models (β = 0.29, p = .045) and in models adjusted for baseline protective fac- tor score and readiness to change alcohol scores (β = 0.39, p = .01).

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Follow-upBaseline

Binge Drinking (%)

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t=3.4 (p=0.002) t=-0.94

(p=0.35)

Baseline heavy drug use No Baseline heavy drug use

t=-0.09 (p=0.92)

t=5.2 (p<0.0001)

OR=5.7 95% CI:(1.3-25.1)

OR=6.7 95% CI:(4.1-11.0)

FIGURE 2. Modification by heavy drug use at baseline. High frequency of drug use = reporting at least 1 type of drug use 10 or more times in past 6 months. Variables shown in the graphs were significant in tests for interaction.

COMMENT The current study is among the first to document the fea-

sibility of implementing BASICS in a primary care setting within a university health care center. Findings suggest that BASICS delivered in this setting appears to be effective in reducing both quantity and frequency of AOD use among participants between baseline and 6-month follow-up. The intervention appears most effective among those reporting past-month heavy episodic drinking and past 6-month heavy drug use during the baseline interview. However, the effec- tiveness of the intervention did not appear to be influenced by other factors, such as demographics or history of abuse. Finally, findings confirm that increasing individuals’ readi- ness to change is an important aspect of BASICS and suggest that increasing protective factors related to AOD use appears to be an effective strategy for reducing AOD use and related consequences among university students.

The current study has expanded previous similar research findings evaluating BASICS in this setting14–16 by also doc- umenting the effectiveness of BASICS on reducing drug use. Further, our study showcased the effect of BASICS on reducing quantity and frequency of alcohol and drug use, re- lated consequences, and AOD-related distress levels, while increasing engagement in protective strategies to reduce AOD consequences and in readiness to change. The current study is the first evaluation of BASICS in a university setting suggesting that increasing individuals’ readiness to change and protective strategies appears to be effective in reducing AOD use and related consequences among university stu- dents. Further, our study showed that both baseline readiness and change in readiness were important in reducing alcohol and cocaine use. These findings confirm the importance of the BASICS framework, which posits that reduction in AOD use requires effecting readiness to change and highlights the necessity of BASICS components that focus on the promo- tion of protective strategies in order to effectively reduce AOD use and related consequences.

Given the documented reduction across a wide range of AOD variables, the current study adds to the literature sup-

portive of delivering BASICS within a primary care uni- versity setting. Our findings also extend previous work by determining that the BASICS intervention did not vary in effectiveness based on student demographic variables nor on experiences of past traumatic events, thus highlighting the implications for wide use of this intervention in university settings and populations. Further, this is the first study to show that referral type did not influence intervention effec- tiveness in a university health setting.

The finding that BASICS is most effective among cer- tain higher-use groups also has implications for developing future efforts within university contexts; for example, fu- ture efforts may focus the intervention on those reporting heavy episodic drinking or heavy drug use (rather than using CRAFFT). However, although students who did not report heavy episodic drinking or heavy drug use did not have sta- tistically significant reductions in AOD use, the BASICS intervention may be preventing these students from increas- ing AOD use or AOD-related consequences. More research is needed to evaluate the longer-term impact of this interven- tion.

Results should be considered with the following limita- tions. Because the current study did not include a control group, we were not able to conclude that the reductions in AOD use and other outcomes were a specific result of the in- tervention. Other environmental factors at the time of study assessment could have influenced students’ AOD use; how- ever, no such occurrences were observed during this time. Further, our outcome data were solely based on students’ self- reported responses; given the stigma and fear often attached to reporting behaviors such as illicit drug use, students may have underreported their AOD use. Also, given that the inter- vention was focused on decreasing AOD use, involvement in the intervention may have resulted in students reporting more favorable or underreported responses for their AOD use at follow-up. Although a limitation, computer-based surveys, such as those employed in the current study, have been found to reduce reporting biases of stigmatized behaviors such as illicit drug use.34 Finally, generalizability of the study may

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Amaro et al

be limited to college populations with similar demographic profiles.

These limitations notwithstanding, study findings show- case the feasibility of implementing the BASICS interven- tion within a primary care university health center setting and highlight the potential effectiveness of the intervention on reducing AOD use as well as related consequences.

ACKNOWLEDGMENT This study was funded by the Substance Abuse and Mental

Health Services Administration grant TI 17311.

NOTE For comments and further information, address corre-

spondence to Dr Hortensia Amaro, Institute on Urban Health Research, Northeastern University, 360 Hunting- ton Avenue, 503 ST, Boston, MA 02115, USA (e-mail: [email protected]).

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