Esther Maki, RN, MS, PHN, CHES May 15, 2008 Minnesota Department of Health Alcohol Exposed Pregnancy Prevention Project Funded by the Centers for Disease Control Reducing Harm to Minnesota Women Who Drink Too Much : The Smart Women Smart Choices Program University of Minnesota Powell Center for Women’s Health 3 rd Annual Women's Health Nursing Conference

Presentation Objectives Describe trends in Minnesota women’s drinking and preventable conditions associated with problem drinking which may be influenced by early intervention. Describe Minnesota women’s risk perceptions regarding risky drinking and their use of birth control and alcohol. Discuss effective science based treatment for risky/problem drinking. Describe components of a promising behavior change intervention for women at risk for alcohol exposed pregnancy and other alcohol-related problems.

Describe trends in Minnesota women’s drinking and preventable conditions associated with problem drinking which may be influenced by early intervention.

Describe Minnesota women’s risk perceptions regarding risky drinking and their use of birth control and alcohol.

Discuss effective science based treatment for risky/problem drinking.

Describe components of a promising behavior change intervention for women at risk for alcohol exposed pregnancy and other alcohol-related problems.

“ The impact of two drinks on a man is roughly equivalent to one drink on a woman.” Center on Addiction and Substance Abuse, 2006 Women and Problem Drinking

Minnesota Women’s Drinking Since the mid 1990s, national and state surveys confirm that Minnesota women are: Drinking at an earlier age Drinking more heavily and more often Continue to drink during pregnancy Binge drink, consuming 3 or more drinks in one sitting. Minnesota Survey on Adult Substance Abuse, 1997 Minnesota Department of Health,2006. PRAMS Summary Book, 2002-2003. Alcohol Consumption Among Women Who are Pregnant or Who Might Become Pregnant---U.S. 2002. Vol. 53, No. 50: 1178. 2004

Since the mid 1990s, national and state surveys confirm that Minnesota women are:

Drinking at an earlier age

Drinking more heavily and more often

Continue to drink during pregnancy

Binge drink, consuming 3 or more drinks in one sitting.

Minnesota Survey on Adult Substance Abuse, 1997

Minnesota Department of Health,2006. PRAMS Summary Book, 2002-2003.

Alcohol Consumption Among Women Who are Pregnant or Who Might Become Pregnant---U.S. 2002. Vol. 53, No. 50: 1178. 2004

Rise in College Women’s Binge Drinking Minnesota In a 2006 survey of 7,638 undergraduate students on 12 campuses state wide Nearly 33% of women said they binge drank in the past 2 weeks. Core Survey Report for University of Minnesota, 2006 Nationally The Harvard School of Public Health National College Alcohol Study reports A sharp increase (124 %) in frequent binge drinkers at the five all-women’s colleges in the 2001 College Alcohol Survey. Harvard School of Public Health, 2005

Minnesota

In a 2006 survey of 7,638 undergraduate students on 12 campuses state wide

Nearly 33% of women said they binge drank in the past 2 weeks.

Core Survey Report for University of Minnesota, 2006

Nationally

The Harvard School of Public Health National College Alcohol Study reports

A sharp increase (124 %) in frequent binge drinkers at the five all-women’s colleges in the 2001 College Alcohol Survey. Harvard School of Public Health, 2005

Women’s Alcohol Related Preventable Risks Unprotected sex Sexual assault and violence Death or injury Depression/anxiety Unplanned and alcohol exposed pregnancy (AEP)

Unprotected sex

Sexual assault and violence

Death or injury

Depression/anxiety

Unplanned and alcohol exposed pregnancy (AEP)

Preventable Health Risks Unintended Pregnancy and FASD Women’s behaviors associated with AEP risk: Binge or heavy drinking Inconsistent or ineffective birth control use Unintended Pregnancy Nationally, nearly 50% of all pregnancies are mistimed or unwanted. Many women continue their drinking habits before realizing they may be pregnant. Hatcher, R.A. et al., 2004 and Guttmacher Institute, 2003 Alcohol Related Birth Defects Fetal Alcohol Spectrum Disorders (FASD) Fetal Alcohol Syndrome (FAS)

Women’s behaviors associated with AEP risk:

Binge or heavy drinking

Inconsistent or ineffective birth control use

Unintended Pregnancy

Nationally, nearly 50% of all pregnancies are mistimed or unwanted.

Many women continue their drinking habits before realizing they may be pregnant.

Hatcher, R.A. et al., 2004 and Guttmacher Institute, 2003

Alcohol Related Birth Defects

Fetal Alcohol Spectrum Disorders (FASD)

Fetal Alcohol Syndrome (FAS)

The Need for Effective Interventions for Risk/Problem Drinking Problem Drinking Research Sobell, LC and Sobell, MB. Problem Drinkers: Guided Self-Change Treatment, 1996. New York, NY: Guilford Press .

Defining Risk/Problem Drinking Drinking at levels that places individuals at risk for health, safety, and social problems. U.S. Preventive Services Task Force USPSTF, 2004 In Women – More than 7 drinks per week (heavy drinking) or more than 3 drinks in a 2-hour period (binge drinking). In Men – More than 14 drinks per week or more than 5 drinks in a 2-hour period. D HHS and Department of Agriculture, 2005

Drinking at levels that places individuals at risk for health, safety, and social problems.

U.S. Preventive Services Task Force USPSTF, 2004

In Women – More than 7 drinks per week (heavy drinking) or more than 3 drinks in a 2-hour period (binge drinking).

In Men – More than 14 drinks per week or more than 5 drinks in a 2-hour period.

D HHS and Department of Agriculture, 2005

Binge Drinking is “Dangerous” Drinking College Students Definition of Binge and Heavy Drinking Rutgers University study found college students preferred the term “dangerous drinking” as less judgmental and salient to their experiences of drinking that resulted in impaired judgment and negative consequences. Lederman, et al., 2003 The facts are that however excessive drinking is defined: Binge drinking, (even occasionally) is especially risky for women. When a woman drinks too much, her judgment, memory, and balance are impaired. Thus, she may be more vulnerable to a wide range of dangers . NIAAA, 2005

College Students Definition of Binge and Heavy Drinking

Rutgers University study found college students preferred the term “dangerous drinking” as less judgmental and salient to their experiences of drinking that resulted in impaired judgment and negative consequences.

Lederman, et al., 2003

The facts are that however excessive drinking is defined:

Binge drinking, (even occasionally) is especially risky for women.

When a woman drinks too much, her judgment, memory, and balance are impaired. Thus, she may be more vulnerable to a wide range of dangers .

NIAAA, 2005

Distribution of Alcohol Use in Adults Sobell, LC and Sobell, MB. Problem Drinkers: Guided Self-Change Treatment, Guilford Press, New York, NY 1996.

Drinking and Young Adults Ages of 18 and 29 years. A time of transition and of increased risk for problems with alcohol. The youngest segment—young adults ages 18–24 are: Most at risk for alcohol problems, compared with other age-groups. Most likely to drink heavily, regardless of gender, ethnicity, and school or work status—whether they attend college or are employed. The problem continues to escalate: alcohol-related deaths rose 5 percent for 18- to 24-year-olds between 1998 and 2001. NIAAA , January 2008

A time of transition and of increased risk for problems with alcohol.

The youngest segment—young adults ages 18–24 are:

Most at risk for alcohol problems, compared with other age-groups.

Most likely to drink heavily, regardless of gender, ethnicity, and school or work status—whether they attend college or are employed.

The problem continues to escalate: alcohol-related deaths rose 5 percent for 18- to 24-year-olds between 1998 and 2001.

Problem Drinkers Are Not Alcoholics No history of severe alcohol withdrawal. Have shorter drinking history, 5-10 years. Will not necessarily progress to more severe drinking. Sobell, LC and Sobell, MB, 1996 Risk/problem drinkers do not fit criteria For chemical dependency treatment

No history of severe alcohol withdrawal.

Have shorter drinking history, 5-10 years.

Will not necessarily progress to more severe drinking.

Sobell, LC and Sobell, MB, 1996

Problem Drinkers May be open to Self-Change Tend to have greater economic and social resources to call upon to help themselves change their drinking. Tend to have higher self-esteem (confidence in the ability to change). Need information and support to resolve their conflict about their drinking. Problem drinkers do not self-identify as alcoholic and are likely to resist suggestions for addiction treatment services. S obell, LC and Sobell, MB, 1996

Tend to have greater economic and social resources to call upon to help themselves change their drinking.

Tend to have higher self-esteem (confidence in the ability to change).

Need information and support to resolve their conflict about their drinking.

The Need for New Approaches The Centers for Disease Control and Prevention recommends: “ Preventing FAS requires intervening not only with pregnant women but also with childbearing-aged women before conception .” FAS is 100% preventable if women avoid drinking during the conception and prenatal periods.

The Centers for Disease Control and Prevention recommends:

“ Preventing FAS requires intervening not only with pregnant women but also with childbearing-aged women before conception .”

FAS is 100% preventable if women

avoid drinking during the conception

and prenatal periods.

Reasons Women Are Not Screened or Counseled for Alcohol Use Despite the availability of national guidelines* to routinely screen adults, a CASA 2000 study of primary care providers found that less than one-third do. Lack of time and reimbursement for counseling. Lack of awareness or confidence in: Screening tools and interventions Their own screening or counseling skills. Uncertainty about: How to assist problem drinkers. Safe drinking guidelines The difference between problem drinking and dependence. Fear of alienating clients. ACOG, NIAAA, CDC/NCBDDD, USPSTF

Despite the availability of national guidelines* to routinely screen adults, a CASA 2000 study of primary care providers found that less than one-third do.

Lack of time and reimbursement for counseling.

Lack of awareness or confidence in:

Screening tools and interventions

Their own screening or counseling skills.

Uncertainty about:

How to assist problem drinkers.

Safe drinking guidelines

The difference between problem drinking and dependence.

Fear of alienating clients. ACOG, NIAAA, CDC/NCBDDD, USPSTF

Finding Effective Approaches For College Students A need for prevention programs that “do not assume that every choice college students make has been carefully considered before they act on it.” Effective Programs: Combine cognitive-behavioral skills with Norms clarification and Motivational enhancement . NIAAA, College Drinking, Changing the Culture, 2007

Finding Effective Approaches For College Students

A need for prevention programs that “do not assume that every choice college students make has been carefully considered before they act on it.”

Effective Programs:

Combine cognitive-behavioral skills with

Norms clarification and

Motivational enhancement .

NIAAA, College Drinking, Changing the Culture, 2007

Alcohol Exposed Pregnancy Prevention Project Minnesota Department of Health Funded 2003-2008 through a Cooperative Agreement with the Centers for Disease Control and Prevention National Center on Birth Defects and Developmental Disabilities

Alcohol Exposed Pregnancy Prevention Project Goals Minnesota Department of Health funded to a dapt and implement: A CDC designed and tested behavior change intervention for Minnesota women to prevent alcohol exposed pregnancy (AEP). A CDC designed Fetal Alcohol Syndrome surveillance system.

Minnesota Department of Health funded to a dapt and implement:

A CDC designed and tested behavior change intervention for Minnesota women to prevent alcohol exposed pregnancy (AEP).

A CDC designed Fetal Alcohol Syndrome surveillance system.

CDC Behavior Change Intervention to Prevent Alcohol Exposed Pregnancy The CDC designed and tested intervention goal: Reduce women's risk for unintended and alcohol exposed pregnancy by giving women the choice and tools to: Increase effective birth control use And/OR Decrease drinking to below risky levels

The CDC designed and tested intervention goal:

Reduce women's risk for unintended and alcohol exposed pregnancy by giving women the choice and tools to:

Increase effective birth control use

And/OR

Decrease drinking to below risky levels

CDC Intervention Based on Alcohol Treatment Research Motivational Interviewing for Behavioral Change Miller & Rollnick, 1995 “ Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” Guided Self Change For Problem Drinking Linda & Mark Sobell, 1993 Self-guided change materials are print and media tools which integrate: MI change strategies, and A client centered approach, “the spirit and style of motivational interviewing”.

Motivational Interviewing for Behavioral Change

Miller & Rollnick, 1995

“ Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”

Guided Self Change For Problem Drinking

Linda & Mark Sobell, 1993

Self-guided change materials are print and media tools which integrate:

MI change strategies, and

A client centered approach, “the spirit and style of motivational interviewing”.

CDC AEP Intervention Based on Alcohol Treatment Research The problem drinking intervention studies integrate the principles, practices and tools developed in the alcohol research and treatment field. Stages of Change Theory Prochaska and DiClemente, 1992 Motivational Interviewing for Behavioral Change Miller & Rollnick, 1991 Guided Self Change Treatment Linda and Mark Sobell, 1993

The problem drinking intervention studies integrate the principles, practices and tools developed in the alcohol research and treatment field.

Stages of Change Theory

Prochaska and DiClemente, 1992

Motivational Interviewing for Behavioral Change

Miller & Rollnick, 1991

Guided Self Change Treatment

Linda and Mark Sobell, 1993

Alcohol Treatment Research Guided Self-Change Treatment Guided self-change integrates the strategies, tools, and “spirit of motivational interviewing”, into print and media formats. Helps individuals recognize and use their strengths to resolve their drinking problem. Sobell LC and Sobell MB, 1996 “ Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be.” Miller, Zweben, DiClemente, & Rychtarik, 1992

Guided self-change integrates the strategies, tools, and “spirit of motivational interviewing”, into print and media formats.

Helps individuals recognize and use their strengths to resolve their drinking problem.

Miller, Zweben, DiClemente, & Rychtarik, 1992

Assessment and Feedback —gathers data about person’s drinking and provides feedback to increase understanding of the problem Self-Study Materials —reading materials and homework assignments provided Follow up Sessions —to monitor progress and identify additional support Additional treatment available upon request. Components of Guided Self-Change Sobell LC and Sobell MB, 1996

Assessment and Feedback —gathers data about person’s drinking and provides feedback to increase understanding of the problem

Self-Study Materials —reading materials and homework assignments provided

Follow up Sessions —to monitor progress and identify additional support

Additional treatment available upon request.

Adapting the Intervention for Minnesota Women Minnesota Department of Health Research Findings

Minnesota Women Formative Research Focus Groups, Fall 2005 Women’s knowledge, attitudes, behaviors Phase 1: Women Statewide 18-44 years of age (N=38) Phase 2: College Women 18-25 years of age (N=18) Based on findings, a community advisory group recommended a self-guided change program designed for college women 18-25 years of age. Media Promotion Campaign, Spring 2006 Focus groups pretesting with college women Website Usability Pretesting, Fall 2006 1-to-1 sessions with college women Self-guided Change Workbooks, Fall 2006

Focus Groups, Fall 2005

Women’s knowledge, attitudes, behaviors

Phase 1: Women Statewide 18-44 years of age (N=38)

Phase 2: College Women 18-25 years of age (N=18)

Based on findings, a community advisory group recommended a self-guided change program designed for college women 18-25 years of age.

Media Promotion Campaign, Spring 2006

Focus groups pretesting with college women

Website Usability Pretesting, Fall 2006

1-to-1 sessions with college women

Self-guided Change Workbooks, Fall 2006

Key Findings and Challenges Sexual Activity and Birth Control Use Nearly all the women (88%) reported being sexually active, and nearly half used contraception ineffectively. More than half of college women did not seem worried about unintended pregnancy. Birth Control Use : Statewide women reported a little higher use (55%) than college women (50%). Unintended Pregnancy : Nearly four times as many college students (45%) than statewide women (12%) said they worried “a great deal” or “some” about unintended pregnancy .

Nearly all the women (88%) reported being sexually active, and nearly half used contraception ineffectively.

More than half of college women did not seem worried about unintended pregnancy.

Birth Control Use : Statewide women reported a little higher use (55%) than college women (50%).

Unintended Pregnancy : Nearly four times as many college students (45%) than statewide women (12%) said they worried “a great deal” or “some” about unintended pregnancy .

Three quarters of the women said they did not worry about their drinking. Binge and Heavy Drinking: Half of the college women (50%) and over a third (34%) of the statewide women admitted to binge drinking five or more times in the last 30 days. Key Findings and Challenges Alcohol Use

Three quarters of the women said they did not worry about their drinking.

Binge and Heavy Drinking:

Half of the college women (50%) and over a third (34%) of the statewide women admitted to binge drinking five or more times in the last 30 days.

Key Findings and Challenges Linked Drinking and Sex “ I think the sex kind of goes along with drinking because like when your friends go out, you always ask did you go home alone ?” Minnesota Statewide Woman MN Department of Health Focus Group, 2005

“ I think the sex kind of goes along with drinking because like when

your friends go out, you always ask

did you go home alone ?”

Key Findings and Challenges Campus Drinking Norms “ Most students who binge drink probably would be considered to have a problem, but in this context, you just shrug it off and say it is just part of college life.” Minnesota College Women MN Department of Health Focus Group, 2005

“ Most students who binge drink

probably would be considered to

have a problem, but in this context,

you just shrug it off and say

it is just part of college life.”

Minnesota College Women

MN Department of Health Focus Group, 2005

Key Findings and Challenges Women’s Perception of Risks Source: Women’s personal surveys completed at focus group sessions. 37% 23% — 34% 38% 12% 16% NA 29% 72% 61% 61% 61% 45% 45% 45% 39% NA The dollar costs of my drinking Weight gain and drinking STIs Legal consequences of drinking Sexual assault & safety when drinking Unintended pregnancy and drinking Disease or other health risks Poor academic performance Social/Relationship consequences of drinking Statewide (N= 38) College (N= 18) I worry some or a great deal about:

The dollar costs of my drinking

Weight gain and drinking

STIs

Legal consequences of drinking

Sexual assault & safety when drinking

Unintended pregnancy and drinking

Disease or other health risks

Poor academic performance

Social/Relationship consequences of drinking

Key Findings and Challenges Perceived No Risk or Need for Change Few women seemed concerned about their contraception use. May believe they are safe from unintended pregnancy; they believe they are effectively using contraception. Far fewer expressed concern about their drinking. May see college drinking as “normal” and a temporary condition that will end once they have completed school.

Few women seemed concerned about their contraception use.

May believe they are safe from unintended pregnancy; they believe they are effectively using contraception.

Far fewer expressed concern about their drinking.

May see college drinking as “normal” and a temporary condition that will end once they have completed school.

Key Findings and Challenges Knowledge and Risk Perception Had difficulty distinguishing risky drinking from dependence. Expressed greater concern about the dollar costs and weight gain than the more serious potential alcohol related health risks. Not concerned about FAS. Agreed the fear of unintended pregnancy may be the critical issue to draw women to the program.

Had difficulty distinguishing risky drinking from dependence.

Expressed greater concern about the dollar costs and weight gain than the more serious potential alcohol related health risks.

Not concerned about FAS.

Agreed the fear of unintended pregnancy may be the critical issue to draw women to the program.

What College Women Said Would Work There are places that deal with drinking. There are places you go for birth control. There are plenty of both... So the combining of the two is the only thing that really makes the program .“ Minnesota College Woman MN Department of Health Focus Group, 2005

Who Needs Information About Drinking and Contraception on Campus Younger college women are the most unprepared to handle campus drinking and partying. Design the delivery, messages and content to attract women in transition between high school and college. A program addressing both contraception and alcohol use is unique, and beneficial.

Younger college women are the most unprepared to handle campus drinking and partying.

Design the delivery, messages and content to attract women in transition between high school and college.

A program addressing both contraception and alcohol use is unique, and beneficial.

Focus Group Findings Liked Media vs. Face-to-Face Delivery Web-delivered: “ It is just another method of communication at the University. It is just what people turn to right away.” Self-paced and flexible: “ I think that it is a good idea that it’s self-paced so you don’t have someone pushing them.” Provide program access options: “ And different points of entry like you can choose to call …” Minnesota College Women MN Department of Health Focus Group, 2005

Web-delivered:

“ It is just another method of communication at the University. It is just what people turn to right away.”

Self-paced and flexible:

“ I think that it is a good idea that it’s self-paced so you don’t have someone pushing them.”

Provide program access options:

“ And different points of entry like you can choose to call …”

Focus Group Findings Mad About Self Rated Quizzes “ We are suckers for quizzes. Come on, who doesn’t like to take quizzes. We all do. Women do.” Use Quizzes to: Challenge women’s perceptions and knowledge about alcohol related risks. Promote the program to women. Engage women in the program content. Minnesota College Woman MN Department of Health Focus Group, 2005

“ We are suckers for quizzes.

Come on, who doesn’t like to take quizzes.

We all do. Women do.”

Use Quizzes to:

Challenge women’s perceptions and knowledge about alcohol related risks.

Promote the program to women.

Engage women in the program content.

Application of Focus Group Findings Designing and Delivering a Self-Change Program for College Women

Smart Women Smart Choices Program iPartySmarter Website

Smart Women Smart Choices Program

iPartySmarter

Website

What is the Program Smart Women Smart Choices? A self-study education program designed to reduce unintended pregnancy, risk drinking, and alcohol exposed pregnancy.

A self-study education program designed to reduce unintended pregnancy, risk drinking, and alcohol exposed pregnancy.

What is the Program Smart Women Smart Choices? Website and pilot intervention launched by the Minnesota Department of Health March 19, 2007 through May 1, 2008. Targets college students, 18-24 , but women 18-44 may participate. Participants complete self-guided change materials over 4 months. The program is delivered in multi-media formats : • Website • Mailed self-guided change workbooks • • Toll Free Phone • E-mail • • Internet and Campus Media Promotion Campaign •

Website and pilot intervention launched by the Minnesota Department of Health March 19, 2007 through May 1, 2008.

Targets college students, 18-24 , but women 18-44 may participate.

Participants complete self-guided change materials over 4 months.

The program is delivered in multi-media formats :

• Website • Mailed self-guided change workbooks •

• Toll Free Phone • E-mail •

• Internet and Campus Media Promotion Campaign •

What is the Program Smart Women Smart Choices? A primary prevention behavior change intervention designed to reduce risks for alcohol exposed pregnancy (AEP). A harm reduction program designed to decrease women’s risk drinking and improve birth control use. A self-change intervention for pre and interconceptional women. Integrates best practices from alcohol and behavior change research.

A primary prevention behavior change intervention designed to reduce risks for alcohol exposed pregnancy (AEP).

A harm reduction program designed to decrease women’s risk drinking and improve birth control use.

A self-change intervention for pre and interconceptional women.

Integrates best practices from alcohol and behavior change research.

Program Development Decisions Program Content Includes information content about college women's perceived risks: Unintended Pregnancy Sexual exploitation Sexually Transmitted infections Poor decision-making and consequences Academic achievement Relationship issues with partners and friends “ If you get a hangover it goes away. If you get an STD or get pregnant, that is a much bigger deal.” Minnesota College Woman MN Department of Health Focus Group, 2005

Includes information content about college women's perceived risks:

Unintended Pregnancy

Sexual exploitation

Sexually Transmitted infections

Poor decision-making and consequences

Academic achievement

Relationship issues with partners and friends

“ If you get a hangover it goes away.

If you get an STD or get pregnant,

that is a much bigger deal.”

Program Development Decisions Program Marketing Website is the primary program entry point. Online link to program e-mail Toll-free phone line College campus promotion: Online social networking sites Online and print newspapers Student health, housing and counseling settings Promotion and education messages address women’s perceived risks related to drinking.

Website is the primary program entry point.

Online link to program e-mail

Toll-free phone line

College campus promotion:

Online social networking sites

Online and print newspapers

Student health, housing and counseling settings

Promotion and education messages address women’s perceived risks related to drinking.

Smart Women Smart Choices Benefits to Women Offers a more accessible and attractive opportunity than costly CD treatment. Offers greater convenience, anonymity and privacy. Allows statewide access via distance learning methods. May reach women before more serious alcohol related problems occur.

Offers a more accessible and attractive opportunity than costly CD treatment.

Offers greater convenience, anonymity and privacy.

Allows statewide access via distance learning methods.

May reach women before more serious alcohol related problems occur.

Smart Women Smart Choices Women Eligible Women 18-44 years of age who are problem drinkers, not alcohol dependent : Binge drink: 3 or more drinks in a sitting Heavy drinking: 7 or more drinks/week At risk for an unintended pregnancy: Fertile Sexually active with male partner Ineffective or no contraceptive use

Women 18-44 years of age who are problem drinkers, not alcohol dependent :

Binge drink: 3 or more drinks in a sitting

Heavy drinking: 7 or more drinks/week

At risk for an unintended pregnancy:

Fertile

Sexually active with male partner

Ineffective or no contraceptive use

Smart Women Smart Choices Women Ineligible Pregnant or attempting to become pregnant Medical conditions that contradict any alcohol use (liver disease, diabetes) Use of medications with alcohol History of alcohol dependence treatment

Pregnant or attempting to become pregnant

Medical conditions that contradict any alcohol use (liver disease, diabetes)

Use of medications with alcohol

History of alcohol dependence treatment

Smart Women Smart Choices Program Steps Personal Risk Survey and Feedback: Complete a baseline survey to determine drinking and unintended pregnancy risks. Personalized feedback helps women understand their situation and problem. Workbook: Complete a self-study workbook: MI decision-making and self-reflection exercises Develop change plan to reduce drinking and/or improve birth control and condom use. Community and internet resource directory.

Personal Risk Survey and Feedback:

Complete a baseline survey to determine drinking and unintended pregnancy risks.

Personalized feedback helps women understand their situation and problem.

Workbook:

Complete a self-study workbook:

MI decision-making and self-reflection exercises

Develop change plan to reduce drinking and/or improve birth control and condom use.

Community and internet resource directory.

Smart Women Smart Choices Program Steps Scheduled Follow-up: A program educator monitors progress and offers support and resources for change. 1 and 4 month follow up surveys 2 and 3 month “booster” messages Personal Support: May request educator support at any time via a toll free phone line or by email.

Scheduled Follow-up:

A program educator monitors progress and offers support and resources for change.

1 and 4 month follow up surveys

2 and 3 month “booster” messages

Personal Support:

May request educator support at any time via a toll free phone line or by email.

Smart Women Smart Choices Incentive Gift Cards Participants receive Target gift cards after returning surveys: First card : $10.00, baseline Second card : $15.00, first follow-up Third card : $25.00, final follow-up

Participants receive Target

gift cards after returning surveys:

First card : $10.00, baseline

Second card : $15.00, first follow-up

Third card : $25.00, final follow-up

Smart Women Smart Choices Measuring Success Risk Reduction: Change either drinking or contraceptive use or both, thereby reducing risks for alcohol exposed pregnancy and other health, safety, and social problems. If successful: Send a completion certificate and final gift card Offer additional self-help support resources to maintain behavior change. If not successful at 4 months: Refer to substance abuse assessment and treatment services.

Risk Reduction:

Change either drinking or contraceptive use or both,

thereby reducing risks for alcohol exposed pregnancy and other health, safety, and social problems.

If successful:

Send a completion certificate and final gift card

Offer additional self-help support resources to maintain behavior change.

If not successful at 4 months:

Refer to substance abuse assessment and treatment services.

Smart Women Smart Choices Outcomes: Women Followed-up Inquired: 142 women Screened: 112 (79 % of inquiries) Eligible: 47 (42 % of screened) Total participation rate: 45 (96 % of eligible) Completed Program: 19 (40 % of eligible) Currently Enrolled: 26 (55 % of eligible) March 2007 to April 15, 2008

Inquired: 142 women

Screened: 112 (79 % of inquiries)

Eligible: 47 (42 % of screened)

Total participation rate: 45 (96 % of eligible)

Completed Program: 19 (40 % of eligible)

Currently Enrolled: 26 (55 % of eligible)

Smart Women Smart Choices Behavior Change Improved BC use: 58% Decreased drinking to below risky levels: 10.5% Changed both behaviors: 16% Decreased risk for AEP: 84% 16 out of 19 completes

Improved BC use: 58%

Decreased drinking to below

risky levels: 10.5%

Changed both behaviors: 16%

Decreased risk for AEP: 84%

Smart Women Smart Choices Change in Frequency of Risk Drinking Self-reported decrease in frequency of binge and weekly heavy drinking in the last 3 months: March 2007 to April 21, 2008 64.82% overall decrease in frequency of binge drinking 71.43% overall decrease in frequency of heavy weekly drinking

Self-reported decrease in frequency of binge and weekly heavy drinking in the last 3 months:

64.82% overall decrease in frequency of binge drinking

71.43% overall decrease in frequency of heavy weekly drinking

Shifts in Knowledge & Readiness to Change Drinking Self-reported increase in drinking knowledge and readiness to change drinking: March 2007 to April 21, 2008 28% overall increase in readiness to change drinking 19.86% overall increase in drinking knowledge

Self-reported increase in drinking knowledge and readiness to change drinking:

28% overall increase in readiness to change drinking

19.86% overall increase in drinking knowledge

Smart Women Smart Choices Participant Comments “ The program is great–easy to do yet very eye opening and influential on my habits.” “ This has been very easy to participate in and very influential in my decisions – good as is.” Program Participants March to December, 2007

“ The program is great–easy to do yet very eye opening and influential on my habits.”

“ This has been very easy to participate

in and very influential in my decisions –

good as is.”

Program Participants March to December, 2007

Smart Women Smart Choices Participant Comments I really like the self-study booklet. It's kind of like a diary.” “ The topics are relevant to my life and hopefully the results will benefit women in the future.” “ I have realized that I need to make some changes and this program looked interesting and easy to help me do that.” Program Participants March to December, 2007

I really like the self-study booklet.

It's kind of like a diary.”

“ The topics are relevant to my life and hopefully the results will benefit women in the future.”

“ I have realized that I need to make some changes and this program looked interesting and easy to help me do that.”

Program Participants March to December, 2007

Smart Women Smart Choices Participant Comments “ I feel that this program has been VERY beneficial for me. Even though…I do know most if not all of the info, I had never really taken the time to consider my own actions regarding BC methods and alcohol use.” Program Participant, August 2007

“ I feel that this program has been VERY beneficial for me.

Even though…I do know most if not all of the info, I had never really taken the time to consider my own actions regarding BC methods and alcohol use.”

Program Promotion and Marketing

Challenges College Women See No Need for Change How to increase risk perception, without offending them? How to motivate to participate in a 4-month long program they don’t think they need? Gift Card Incentives Website Campus Media Campaign

How to increase risk perception, without offending them?

How to motivate to participate in a 4-month long program they don’t think they need?

Gift Card Incentives

Website

Campus Media Campaign

Motivate Women to and Enroll Answering “What’s in it for me?” Gift card incentives Stay safe and in control when partying Avoid alcohol-related risks and regrets Help other women by testing pilot program It’s free, easy, private, no classes!

Answering “What’s in it for me?”

Gift card incentives

Stay safe and in control when partying

Avoid alcohol-related risks and regrets

Help other women by testing pilot program

It’s free, easy, private, no classes!

Naming the Program & Website iPartysmarter.com Links drinking with sexual behaviors in the context of women’s college social experience . Smart Women Smart Choices Appeals to the desire to maintain her self-respect and to stay in control of herself and her choices when drinking.

iPartysmarter.com

Links drinking with sexual behaviors in the context of women’s college social experience .

Smart Women Smart Choices

Appeals to the desire to maintain her self-respect and to stay in control of herself and her choices when drinking.

Website iPartySmarter.com http://www.ipartysmarter.com /

Smart Women Smart Choices Program Promotion Website is the primary program entry point. Online link to program e-mail Toll-free phone line College campus promotion: Online social networking sites Online and print newspapers Student health, housing and counseling settings

Website is the primary program entry point.

Online link to program e-mail

Toll-free phone line

College campus promotion:

Online social networking sites

Online and print newspapers

Student health, housing and counseling settings

Increase readiness to consider trying the program. Present facts that challenge perceptions about risk drinking: It’s harmless and fun. It’s the “norm” on college campuses. Discuss drinking as a woman’s choice to avoid behaviors and decisions they would not have made when sober and may later regret. The SWSC program empowers women to learn how to stay in control when drinking . Website Designed to Increase Risk Perception

Increase readiness to consider trying the program.

Present facts that challenge perceptions about risk drinking:

It’s harmless and fun.

It’s the “norm” on college campuses.

Discuss drinking as a woman’s choice to avoid behaviors and decisions they would not have made when sober and may later regret.

The SWSC program empowers women to learn how to stay

in control when drinking .

Redefine Binge/Risk Drinking Define “risk drinking” as drinking to the level that impairs a woman’s judgment and can result in poor decisions, dangerous situations, and post-party regrets. Website content broadened to include: Immediate risks : unintended pregnancy, STIs, injury, assault, blackouts, academic failure, DWIs, embarrassing behaviors. Long term risks : physical and mental health risks.

Define “risk drinking” as drinking to the level that impairs a woman’s judgment and can result in poor decisions, dangerous situations, and post-party regrets.

Website content broadened to include:

Immediate risks : unintended pregnancy, STIs,

injury, assault, blackouts, academic failure, DWIs, embarrassing behaviors.

Long term risks : physical and mental health risks.

Focus Group Recommendations Use a Thought Provoking Risk Message Use humor to catch attention and lighten a heavy topic. Get women to stop and think about their own experiences when they drank too much.

Use humor to catch attention and lighten a heavy topic.

Get women to stop and think about their own experiences when they drank too much.

Deliver Message with Humor When I drink too much, I might say yes. Oh No !

When I drink

too much,

I might say yes.

Oh No !

Posters & Facebook Ads

Smart Women Smart Choices Campus Media Ads Fall 2007 to May 1, 2008 Online Flyers: www.Facebook.com Campus posters Campus newspaper print and online ads Minnesota Daily, U of M Mankato State Reporter, MSU Campus recruitment screening Website

Fall 2007 to May 1, 2008

Online Flyers: www.Facebook.com

Campus posters

Campus newspaper print and online ads

Minnesota Daily, U of M

Mankato State Reporter, MSU

Campus recruitment screening

Website

Integrating Self-Guided Change (SGC) into Primary Care Practice Smart Women Smart Choices

The Promise of Integrating SGC Interventions into Primary Care Settings Research-based self-guided change interventions for problem drinking can overcome common barriers to providing effective patient-centered care for problem drinking: Offers problem drinkers an option to initially address their drinking without attending classes or referral to costly treatment . Offers providers an opportunity to support client self-change and diminish the risk of alienating problem drinkers who may be resistant to chemical dependency assessment. Requires providers to screen and recommend SGC but can reduce clinic based counseling and education time .

Research-based self-guided change interventions for problem drinking can overcome common barriers to providing effective patient-centered care for problem drinking:

Offers problem drinkers an option to initially address their drinking without attending classes or referral to costly treatment .

Offers providers an opportunity to support client self-change and diminish the risk of alienating problem drinkers who may be resistant to chemical dependency assessment.

Requires providers to screen and recommend SGC but can reduce clinic based counseling and education time .

Integrating SGC for Problem Drinking into Practice Setting Imbed SGC program information into existing consumer education delivery models: Provide “just in time” client access to SGC website program materials, and program educators via clinic phones and computers. Promote the program via consumer/patient websites, newsletters, clinic poster and brochure distribution. Support providers to encourage problem drinkers to check out the program, especially when they present a “ready to change” moment or incident.

Imbed SGC program information into existing consumer education delivery models:

Provide “just in time” client access to SGC website program materials, and program educators via clinic phones and computers.

Promote the program via consumer/patient websites, newsletters, clinic poster and brochure distribution.

Support providers to encourage problem drinkers to check out the program, especially when they present a “ready to change” moment or incident.

Supporting Providers to Integrate SGC for Problem Drinking Educate and equip providers: The difference between addiction and problem/risk drinking. The use of screening and brief motivational counseling skills and tools. Motivational interviewing and self-guided change for problem drinking. Gender and culturally appropriate guidelines of care and referral resources for the continuum of drinking problems.

Educate and equip providers:

The difference between addiction and problem/risk drinking.

The use of screening and brief motivational counseling skills and tools.

Motivational interviewing and self-guided change for problem drinking.

Gender and culturally appropriate guidelines of care and referral resources for the continuum of drinking problems.

Free Provider Education Drinking and Reproductive Health: Fetal Alcohol Spectrum Disorders Prevention Tool Kit CD-ROM guide, screening tool, and patient handouts. CEUs available. American College of Obstetricians and Gynecologists and the Centers for Disease Control http://www.cdc.gov/ncbddd/fas/acog_toolkit.htm Clinical Tools, Inc. Supported by the American Society of Addiction Medicine (ASAM) www2.tobaccocme.com/TopicReq?id=749 Introduction to Alcohol Use Problems: Prevalence, Detection, and Diagnosis in Primary Care Online course reviews the continuum of alcohol use problems, best practice guidelines for screening and screening instruments. CEUs available.

Drinking and Reproductive Health: Fetal Alcohol Spectrum Disorders Prevention Tool Kit

CD-ROM guide, screening tool, and patient handouts. CEUs available.

Introduction to Alcohol Use Problems: Prevalence, Detection, and Diagnosis in Primary Care

Online course reviews the continuum of alcohol use problems, best practice guidelines for screening and screening instruments. CEUs available.

Helen Hayes “ Childhood is a short season. The hardest years in life are those between ten and seventy!”

Questions? Comments? Ideas? Thoughts? Interested in obtaining intervention materials: Contact: Esther Maki, Project Coordinator [email_address] OR [email_address]

Questions?

Comments?

Ideas?

Thoughts?

Interested in obtaining intervention materials:

Contact:

Esther Maki, Project Coordinator

[email_address] OR

[email_address]

Minnesota Department of Health AEP Prevention Project Staff Esther Maki, Project Coordinator [email_address] MaryJo Chippendale, Grant Director maryjochippendale @health.state.mn.us Minnesota Department of Health Community and Family Health- Maternal Child Health 85 E. 7th Place, Suite 220 St. Paul, MN 55164-0882

Esther Maki, Project Coordinator

[email_address]

MaryJo Chippendale, Grant Director

maryjochippendale @health.state.mn.us

Minnesota Department of Health

Community and Family Health-

Maternal Child Health

85 E. 7th Place, Suite 220

St. Paul, MN 55164-0882

Smart Women Smart Choices Adaptation/Development Team Formative Research Dianne Morehouse, QED Consulting Russell Herder Advertising University of MN Boynton Health Service educators Caroline Dunn, Epidemiologist, MN Dept. of Health Media Campaign Materials Design Russell Herder Advertising Web Development and Design Chad Kielas, Web Designer, MN Department of Health Russell Herder Advertising

Formative Research

Dianne Morehouse, QED Consulting

Russell Herder Advertising

University of MN Boynton Health Service educators

Caroline Dunn, Epidemiologist, MN Dept. of Health

Media Campaign Materials Design

Russell Herder Advertising

Web Development and Design

Chad Kielas, Web Designer, MN Department of Health

Russell Herder Advertising

Smart Women Smart Choices Adaptation/Development Team Curriculum Design Esther Maki, Public Health Nurse Educator, MN Dept. of Health Sheran McNiff, Health Educator, MN Dept. of Health Heidi Kammer, Women’s CD Counselor Karen DeYoung, Curriculum Designer MaryKate Weber, CDC/ NCBDDD Patricia Green, CDC/ NCBDDD Sherry Ceperich, CDC/ NCBDDD Research Consultant Jennifer O’Brien, Teen Health, MN Dept. of Health

Curriculum Design

Esther Maki, Public Health Nurse Educator, MN Dept. of Health

Sheran McNiff, Health Educator, MN Dept. of Health

Heidi Kammer, Women’s CD Counselor

Karen DeYoung, Curriculum Designer

MaryKate Weber, CDC/ NCBDDD

Patricia Green, CDC/ NCBDDD

Sherry Ceperich, CDC/ NCBDDD Research Consultant

Jennifer O’Brien, Teen Health, MN Dept. of Health

References Alcohol Consumption Among Women Who are Pregnant or Who Might Become Pregnant---U.S. 2002. Vol. 53, No. 50: 1178. 2004. American College of Obstetrics and Gynecology, Primary Prevention Care Practice Guidelines, 1993 Center on Addiction and Substance Abuse. 2006. Women under the influence. Baltimore: John Hopkins University Press. Centers for Disease Control and Prevention. Motivational intervention to reduce alcohol-exposed pregnancies - Florida, Texas, and Virginia, 1997-2001. Morbidity and Mortality Weekly Report 2003 52(19):441-444. Centers for Disease Control and Prevention, 2006. Project Choices. www.cdc.gov/ncbddd/fas/ choices.htm Cunradi, S. C., Caetano, R., and Schafer, J. 2002. Alcohol-related problems, drug-use, and male intimate partner violence severity among U.S. couples. Alcoholism: Clinical and Experimental Research, 26: 493. Department of Health and Human Services and the Department of Agriculture. Dietary Guidelines for Americans, 2005. Department of Society, Human Development and Health, Harvard School of Public Health, “College Binge Drinking Rate 44 Percent Remains the Same Eight Years Running: Positive Trends Fail to Bring Down Binge Drinking Rate, According to Harvard College Alcohol Study” (online). Boston, MA: Harvard School of Public Health, 2005. Guttmacher Institute. 2006. Contraception counts: Minnesota.www.guttmacher.org/pubs/state_data/ states/minnesota.html Hamajima, N., et al. 2002. Alcohol, tobacco and breast cancer—collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer 87: 1234-1245. Harvard School of Public Health. Ongoing. College Alcohol Study. www.hsph.harvard.edu/cas/About/index.html Hatcher, R.A. et al. Contraceptive technology. New York: Ardent Media. 2004. Institute of Medicine. 1990. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press. Ingersoll KS, Ceperich SD, et.al. Reducing alcohol-exposed pregnancy risk in college women: Initial outcomes of a clinical trial of a motivational intervention. Journal of Substance Abuse Treatment 2005;29:173-180.

Alcohol Consumption Among Women Who are Pregnant or Who Might Become Pregnant---U.S. 2002. Vol. 53, No. 50: 1178. 2004.

American College of Obstetrics and Gynecology, Primary Prevention Care Practice Guidelines, 1993

Center on Addiction and Substance Abuse. 2006. Women under the influence. Baltimore: John Hopkins University Press.

Centers for Disease Control and Prevention. Motivational intervention to reduce alcohol-exposed pregnancies - Florida, Texas, and Virginia, 1997-2001. Morbidity and Mortality Weekly Report 2003 52(19):441-444.

Centers for Disease Control and Prevention, 2006. Project Choices. www.cdc.gov/ncbddd/fas/

choices.htm

Cunradi, S. C., Caetano, R., and Schafer, J. 2002. Alcohol-related problems, drug-use, and male intimate partner violence severity among U.S. couples. Alcoholism: Clinical and Experimental Research, 26: 493.

Department of Health and Human Services and the Department of Agriculture. Dietary Guidelines for Americans, 2005.

Department of Society, Human Development and Health, Harvard School of Public Health, “College Binge Drinking Rate 44 Percent Remains the Same Eight Years Running: Positive Trends Fail to Bring Down Binge Drinking Rate, According to Harvard College Alcohol Study” (online). Boston, MA: Harvard School of Public Health, 2005.

Guttmacher Institute. 2006. Contraception counts: Minnesota.www.guttmacher.org/pubs/state_data/

states/minnesota.html

Hamajima, N., et al. 2002. Alcohol, tobacco and breast cancer—collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. British Journal of Cancer 87: 1234-1245.

Harvard School of Public Health. Ongoing. College Alcohol Study. www.hsph.harvard.edu/cas/About/index.html

Hatcher, R.A. et al. Contraceptive technology. New York: Ardent Media. 2004. Institute of Medicine. 1990. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press.

Ingersoll KS, Ceperich SD, et.al. Reducing alcohol-exposed pregnancy risk in college women: Initial outcomes of a clinical trial of a motivational intervention. Journal of Substance Abuse Treatment 2005;29:173-180.

References Institute of Medicine. 1990. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press. Johnson, K. et.al. Recommendations to Improve Preconception Health and HealthCare --- United States A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care, MMWR, 55(RR06), April 2006 Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Malik, S., Sorenson, S. B., and Anesthesia, C. S. 1997. Community and dating violence among adolescents: Perpetration and victimizations. American Journal of Drug and Alcohol Abuse 15(2), 173-189. Mohler-Kuo M. Dowdall G.W. Koss M. Wechsler H. 2004. Correlates of rape while intoxicated in a national sample of college women. Journal of Studies on Alcohol. 2004; 65(1): 37-45. Minnesota Department of Health, 2006. PRAMS Summary Book, 2002-2003. http://www.health.state.mn.us/divs/chs/ prams/mnprams2002_2003sb.pdf Naimi, T.S. Lipscomb, L.E. Brewer R.D. et al. 2003. Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children. Pediatrics Vol. 111 No. 5, pp. 1136-1141 National Institute of Alcohol Abuse and Alcoholism. 2005. Alcoholic liver disease. Alcohol Alert No. 64. (online) National Institute of Alcohol Abuse and Alcoholism. 2004. Alcohol- An important women’s health issue. Alcohol Alert No. 62. National Institute on Alcohol Abuse and Alcoholism. College drinking, changing the culture. 2007. Online http://www.collegedrinkingprevention.gov/StatsSummaries/4tier.aspx National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. 2003. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

Institute of Medicine. 1990. Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press.

Johnson, K. et.al. Recommendations to Improve Preconception Health and HealthCare --- United States A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care, MMWR, 55(RR06), April 2006

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Malik, S., Sorenson, S. B., and Anesthesia, C. S. 1997. Community and dating violence among adolescents: Perpetration and victimizations. American Journal of Drug and Alcohol Abuse 15(2), 173-189.

Mohler-Kuo M. Dowdall G.W. Koss M. Wechsler H. 2004. Correlates of rape while intoxicated in a national sample of college women. Journal of Studies on Alcohol. 2004; 65(1): 37-45.

Minnesota Department of Health, 2006. PRAMS Summary Book, 2002-2003. http://www.health.state.mn.us/divs/chs/

prams/mnprams2002_2003sb.pdf

Naimi, T.S. Lipscomb, L.E. Brewer R.D. et al. 2003. Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children. Pediatrics Vol. 111 No. 5, pp. 1136-1141

National Institute of Alcohol Abuse and Alcoholism. 2005. Alcoholic liver disease. Alcohol Alert No. 64. (online)

National Institute of Alcohol Abuse and Alcoholism. 2004. Alcohol- An important women’s health issue. Alcohol Alert No. 62.

National Institute on Alcohol Abuse and Alcoholism. College drinking, changing the culture. 2007. Online

http://www.collegedrinkingprevention.gov/StatsSummaries/4tier.aspx

National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. 2003. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

References National Institute on Alcohol Abuse and Alcoholism. 2002. A Snapshot of Annual High- Risk College Drinking Consequences. Alcoholism. College Drinking: What is alcoholism? 9/23/2005. Online at: www.collegedrinkingprevention.gov/ National Institute on Alcohol Abuse and Alcoholism. January 2008 . Alcohol Research: A Lifespan Perspective. Alcohol Alert, No. 74. http://pubs.niaaa.nih.gov/publications/ AA74/AA74.htm National Institute on Alcohol Abuse and Alcoholism. July 2005. Brief interventions. pubs.niaaa.nih.gov/publications/AA66/AA66.htm National Institute on Alcohol Abuse and Alcoholism. April 5, 2005. Make Your Own Luck on 7th National Alcohol Screening Day: April 7th Marks 7th Annual Event. Online news release www.niaaa.nih.gov/NewsEvents/NewsReleases/NatlScreenDay-05.htm Rollnick S., & Miller, W.R. 1995. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334. Sobell, L. C. Sobell MB, et al. 2002. Alcoholism: Clinical & Experimental Research. 26(6):936-948, June 2002. Sobell, L. C., and Sobell, M. B. 1996. Problem drinkers: Guided self-change treatment. New York: Guilford Publishing. University of Minnesota, 2006 Core Survey Report for University of Minnesota , 2006.http://www.bhs.umn.edu/healthdata/results/core/2006_Core_UofM.pdf U.S. Preventive Services Task Force USPSTF. 2004. Behavioral counseling in primary care to reduce alcohol misuse. Annals of Internal Medicine.

National Institute on Alcohol Abuse and Alcoholism. 2002. A Snapshot of Annual High- Risk College Drinking Consequences.

Alcoholism. College Drinking: What is alcoholism? 9/23/2005. Online at: www.collegedrinkingprevention.gov/

National Institute on Alcohol Abuse and Alcoholism. January 2008 . Alcohol Research: A Lifespan Perspective. Alcohol Alert, No. 74. http://pubs.niaaa.nih.gov/publications/ AA74/AA74.htm

National Institute on Alcohol Abuse and Alcoholism. July 2005. Brief interventions. pubs.niaaa.nih.gov/publications/AA66/AA66.htm

National Institute on Alcohol Abuse and Alcoholism. April 5, 2005. Make Your Own Luck on 7th National Alcohol Screening Day: April 7th Marks 7th Annual Event. Online news release

www.niaaa.nih.gov/NewsEvents/NewsReleases/NatlScreenDay-05.htm

Rollnick S., & Miller, W.R. 1995. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.

Sobell, L. C. Sobell MB, et al. 2002. Alcoholism: Clinical & Experimental Research. 26(6):936-948, June 2002.

Sobell, L. C., and Sobell, M. B. 1996. Problem drinkers: Guided self-change treatment. New York: Guilford Publishing.

University of Minnesota, 2006 Core Survey Report for University of Minnesota , 2006.http://www.bhs.umn.edu/healthdata/results/core/2006_Core_UofM.pdf

U.S. Preventive Services Task Force USPSTF. 2004. Behavioral counseling in primary care to reduce alcohol misuse. Annals of Internal Medicine.