It is important to understand that IMAGE was developed after examining the theory and research in the prevention and behavior field relevant to the development of an effective program. Thus, IMAGE is unique in that it links best practices and theories of prevention programming with theories of behavior change including: Stages of Change Theory (meeting students “where they are” in terms of readiness to change); Motivational Interviewing (non-threatening personalized feedback to motivate change); Social Norms Theory (to correct normative misperceptions); and Theory of Reasoned Action/Planned Behavior (statements of intent to strengthen the likelihood that students will follow-through with the specified change behavior).
Social Norms Theory
One of the most influential prevention theories developed in the past twenty years is without a doubt Social Norms Theory. 8 The theory posits that college students tend to overestimate the amount that their peers are drinking, and in doing so they are given implied permission to drink larger amounts of alcohol themselves. 9 It also states that if that misperception is corrected, college students’ drinking will be subsequently reduced. 8, 10 - 11 As a result, many colleges and universities across the country implemented campus-wide social norming campaigns to distribute the message that most students are making healthy choices about their drinking. As of late, the efficacy of these marketing campaigns in impacting drinking rates has been debated. 12-14 One component of the debate involves the observation that corrected misperceptions have not uniformly led to reductions in drinking. What has been observed, however, is that campuses have had success with social norming when conducted in small groups, as opposed to campus-wide efforts. University of Arizona has seen consistent decreases in drinking among sorority women 15-16, while University of North Carolina Chapel Hill and University of Virginia have seen reductions in drinking among first year students who were targeted with norming messages. 17-18
Washington State University developed a unique approach to social norming, the Small Groups Norms Challenging Model 19 (SGNM). Rather than provide students with normative feedback based on campus-wide data, Far and Miller 19 provided group-specific normative data to targeted groups. The results included reductions in both small group drinking (in fraternities, sororities, and first-year students) and campus-wide reductions. 20 This same model was applied on other campuses with similar results: University of Virginia saw decreased negative consequences among fraternity men 21-22 ; University of Rhode Island witnessed reduced drinking and negative consequences 23; and University of Washington reported reduced drinking rates, lowered peak BAC, and reduced negative consequences among fraternity men. 24 Such success using SGNM piqued interest at UH Wellness and helped guide the formulation of the intervention.
Stages of Change
The Transtheoretical Model (or Stages of Change theory) examines the process of purposive behavior change, and states there are a series of stages through which people pass when making changes. 25-26 The first, Precontemplation, involves a lack of awareness of the need or an unwillingness to change. Next, in Contemplation, the person begins to think about making behavior changes. Then, the person moves through Preparation in order to get ready to make the change and into Action (during which behavior change occurs). The final stage is Maintenance, when the change is incorporated into the person’s self-image and is maintained. 25
Although Stages of Change originated in the addictions field, the importance of this theory cuts across many aspects of wellness, including alcohol prevention. Rather than treating all clients with a “cookie-cutter” approach, the Stages of Change encourages professionals to meet students where they are in their readiness to make changes in their behavior. In terms of prevention, it has been found that students are impacted by normative information differently depending on their readiness to change their drinking behavior. Specifically, students in Precontemplation (not currently willing to make changes in their drinking) are impacted by both campus-wide normative data and cohort normative data. Students in Contemplation are only impacted by cohort normative data, while students in Action are not impacted by normative data at all. 27 This strengthened UH Wellness’ interest in creating an intervention using cohort-based norms as opposed to focusing exclusively on the campus at large.
A brief summary of the Motivational Interviewing (MI) approach is that clients can be motivated to make changes in their lives using a non-threatening approach which incorporates personalized feedback. 28 Motivational Interviewing incorporates the Stages of Change theory in that professionals employing this model use varying techniques depending upon their client’s readiness to change. The non-threatening approach is important when working with the college-aged population as it breaks down the defensiveness and frustration often exhibited when conversations about alcohol are initiated within this group. The Project Investigator has extensive training and experience using MI, and has published a book which integrates the Stages of Change approach and MI techniques. 29
One of the most significant contributions of MI to the prevention field, however, is the use of personalized feedback. This is simply providing students with information about their own drinking behavior as compared to other students whom they view as being similar to themselves. Not only has MI demonstrated positive results with personalized feedback in college student alcohol treatment 30, it has also been shown to be effective repeatedly in terms of alcohol prevention among college students. 11, 31-33 In addition, Lewis and Neighbors 32 indicated that interventions which personalize normative information are more likely to be effective. In fact, the stronger the referent (meaning that the student sees himself or herself as very similar to the comparison student), the stronger the impact of the personalized normative feedback. 27, 32, 34-36 As such, UH Wellness noted the importance of working among cohorts of students who see themselves as part of a reference group (such as a fraternity, sorority, sports team, or residence hall floor). Interestingly, research supports providing group-specific feedback to these very groups of students, who are often defined as being “high-risk”; specifically, Greek Life students 24, 30, 37, student athletes 38, and first-year students. 32, 39
Theory of Reasoned Action/Planned Behavior
In designing the approach, UH Wellness identified a set of behavior theories which documented the link between cognition and behavior change, thus facilitating a mechanism by which staff could collect reliable outcome data immediately following the completion of the program. Ajzen and Fishbein 40found that engaging in a behavior is predicted by the intention to do so; from this finding, they developed the Theory of Reasoned Action. Specifically, they stated that the likelihood of engaging in any given behavior is strengthened by making a “statement of intent,” or a commitment to follow through with the behavior. Such intention is impacted by the person’s: 1) attitude towards the behavior, 2) normative beliefs about the behavior, and 3) self-efficacy with regards to the behavior. 41 Note: With the addition of the self-efficacy construct, the theory was expanded to the Theory of Planned Behavior. 42 The authors indicated that attitude is a combination of the person’s belief in whether or not the behavior is effective and his/her outcome expectancies about that behavior. Self-efficacy was defined as having the skills needed to perform the behavior as well as perceiving a lack of obstacles or environmental constraints. 41-42 The strength of this model was summarized by Sayeed and colleagues 43 when they indicated, “By including measures of behavioral intention…we may capture future behavior, even if we cannot detect change in current behavior (p.21)”.
Statements of intent have been linked with subsequent behavior change across a range of behaviors including marijuana use 43-44, HIV prevention 45, nursing practice adaptation 46, nutrition 47-54, mammography 48, violence prevention 49, exercise acquisition 52, and smoking 53 to name a few.
Construction of the Model: Putting it All Together
In designing a comprehensive theoretical model, UH Wellness sought to construct an intervention that increased motivation to change while providing the tools and ability to do so. Walters 50 indicated that personalized feedback produces just such motivation among college students, while Martens and colleagues 51 suggested incorporating a discussion of self-protective behaviors into personalized feedback sessions. After reviewing literature which documents that less frequent use of self-protective behaviors is related to increased negative alcohol-related consequences 51, UH Wellness decided to focus on self-protective behaviors as the mechanisms of change.
To synthesize the relevant theory and research outlined above, it was determined that an effective intervention should: 1) Take into account students’ readiness to change; 2) Increase confidence in making changes; 3) Provide behavior-specific skills-building; 4) Examine outcome expectancies; 5) Reduce environmental constraints; 6) Provide personalized feedback (as compared to both cohort and campus); 7) Correct normative perceptions of the reference group; and 8) Solicit statements of intent to change. Each component of the IMAGE intervention has been specifically designed to target these key elements of effective prevention programs as described in the theory and research.
The IMAGE model, then, suggests that students can be motivated by normative, cohort-based feedback to overtly state an intention to implement an alcohol-related self-protective behavior. Further, those that do so are more likely to follow-through with that intention, resulting in subsequent changes to their alcohol use behavior.