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6
METHODOLOGICAL ISSUES IN ALCOHOL PREVENTION RESEARCH:
CONCLUSIONS AND RECOMMENDATIONS
No single set of research designs or analytical strategies has characterized research on the
prevention of alcohol problems. A variety of approaches can be used depending on the
goals of the research, the setting or opportunity afforded, the amount and type of variation
one wishes to control or explain, and the generalizability of the findings. One of the
difficulties in prevention research--particularly the kind of research that is most relevant
to public policy deliberations--is the need to conduct such research outside the laboratory
setting. ~Real-world" research, however, is difficult to undertake, often expensive to
conduct, and difficult to analyze. It is less precise than laboratory work because researchers
do not have the opportunity to manipulate variables as they would in laboratory
experimentation. It also raises questions of ascertainment and of the validity of self-reports
and other measures that are commonly used to assess the efficacy of a preventive
intervention. On the other hand, because of the controlled or "hothouse" conditions used
in laboratory settings, the extent to which prevention research undertaken in the laboratory
can be generalized to the real world is not known.
In recent years, alcohol prevention research has made use of a variety of qualitative and
quantitative methods. For example, ethnographic methods and the observation of behavior
in natural settings have been employed. Ethnographers gather data through semistructured
interviews and through traditional participant-observer techniques. Examples of
ethnographic/observational studies in prevention include studies of blue-collar workers and
family drinking (Ames and Janes, 1987), of public drinking and drinking contexts
(Rosenbluth, Nathan, and Lawson, 1978; Storm and Cutler, 1981; Harford et al., 1983;
Single and Storm, 1985; Geller, Russ, and Altomari, 1986), and of the work site (Ames,
1987~.
In many respects, the social and health problems that are associated with alcohol need to
be viewed in a historical context. Historical analysis, by using both U.S. and international
data sources, offers promising opportunities for prevention research. For example, it has
been reported that between 1830 and 1850 there was a dramatic decline in per capita
consumption in the United States (Rorabaugh, 1976) and that the temperance movement
and government policies contributed to this decline and to a concomitant decrease in
alcohol problems (Popham, 1978; Moore and Gerstein, 1981; Pendergast, 1987~. Historical
analysis could provide a method to discover potential "lessons" that might be useful in the
modern alcohol problem prevention arena.
Community, school, and work site prevention trials have begun to reflect the use of
combinations of several relevant theories (learning, organization, communication, behavior
change, health education, and social marketing) in their design. Interest in such designs
has been stimulated by the success in health promotion programs to reduce heart disease
that are discussed in Chapter 5 (Farquhar et al., 1984; Puska et al., 1985~. These
approaches have been used in studies of community interventions for alcohol problems at
schools (see the review by Moskowitz, 1989), local availability of alcohol (Wittman and
Hilton, 1987), and the influence of the mass media (Hewitt and Blane, 1984~. Because of
the difficulty of random assignment in field studies, quasi-experimental designs have been
used (Cook and Campbell, 1979~. These designs are often employed in the policy analysis
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of Naturals experiments, such as changes in alcohol availability. One useful statistical tool
Is the interrupted time-series analysis (Box and Tiao, 1975; Box and Jenkins, 1976), which
has more power than conventional least-squares regression to deal with problems of
autoregression, seasonali~, and trending (Skim lo Wanennar 19~ Rln.ce ~nr1 Mn1~1f~.r
1987; Holder and Those, 1987a).
O ~=, , ~-, _ _, ~^ ~,,
Quasi~xperimental designs are also used to address problems related to nonequivalent
control conditions or groups (Cook and Campbell, 1979~. These designs frequently employ
multivariate analysis techniques to increase statistical power. Examples include evaluations
of server intervention (Saltz, 1987), happy-hour bans (Smart and Adlaf, 1986), college
prevention programs (Mills et al., 1983), cross-cultural drinking behavior (Moskowitz, 1989),
alcohol taxes (Cook and Tauchen, 1982), and changes in driving-under-the-influence
sanctions and enforcement in Maine (Hingson et al., 1987~.
The multifaceted and dynamic nature of the social, cultural, and economic systems in which
prevention occurs requires techniques that can deal with such complexity. One approach
that has been used is computer modeling. This tool is used in astronomy, physics, and
business and economic research and has particular utility for prevention research because
it provides the ability to predict potential outcomes prior to expensive field implementation
(Katzper, Ryback, and Hertzman, 1976; Holder and Those, 1987b). For example, complex
statistical modeling has been used to examine the sensitivity of drinking and alcohol
problems to changes in price levels. Examples include studies by Grossman, Coate, and
Arluck (1987) and by Levy and Sheflin (1983~.
RESEARCH DESIGN FOR FUTURE ALCOHOL PREVENTION RESEARCH PROGRAMS
There are several primary issues relevant to the design of prevention research in the alcohol
field. Three of these issues are discussed below: (1) the importance of using theory as a
basis for design, (2) the need for both laboratory and field research, and (3) the practical
as well as the statistical significance of research findings.
The Importance of Theory
A truly comprehensive theory for prevention research must encompass complex and
dynamically changing biobehavioral mechanisms, individual and group behaviors,
organizational influences, and cultural patterns. It is particularly important to incorporate
the dimension of time into theoretical models in order to take account of life-span or
developmental milestones. Theory is required to establish priorities, to develop and test
hypotheses about mediating mechanisms, and to develop or select appropriate interventions,
program evaluation, and intermediate and longer term outcome measures. When used for
these purposes, theory can help prevention researchers identify the active ingredients in
prevention programs and anticipate and account for intervention effects. Theory-driven
programmatic research could then be undertaken by using combinations of methodologies
including laboratory-based randomized trials, analogue studies, ethnographic and other
naturalistic data collection methods, and complex model building. Such research can be
undertaken within and between different levels of the social structure ranging from the
individual to the community.
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In other public health efforts that have utilized community, school, or work site as the base
in prevention trials, combinations of several relevant theories (learning, organizational,
communication, behavior change, health education, media, social marketing) have been used
to guide intervention and evaluation (Flay, 1984; Farquhar et al., 1985; Abrams et al.,
1986~. This diversity in approach is illustrated by the Stanford, Minnesota, and Pawtucket
heart disease prevention trials discussed in the preceding chapter (Maccoby et al., 1977;
Blackburn et al., 1984; Lasater et al., 1984; Farquhar et al., 1985~. Crucial to developing
effective and adequate strategies of prevention intervention is the use of formative research,
program evaluation, process tracking, and assessment of program impact and potential
problems.
A varietr of research approaches can be used in which the design of programs results from
an interactive process, combining theoretical and scientific input with practical input from
the community and individual consumers. These approaches include ethnographic methods
derived from anthropology, unobtrusive or naturalistic observation, the use of focus groups,
random-digit rapid telephone surveys, and the use of small-scale randomized designs in the
field or laboratory. ~ -' - -'
O
ouch eva~uauon methods are crucial for developing effective
interventions, for making early or midcourse corrections in a program, and for evaluating
whether, in fact, the manipulation of independent variables did occur at a sufficiently strong
level (dosage) and with the intended impact on the target variables, mediating mechanisms,
or processes.
In community prevention programs, interactive and synergistic effects sometimes occur or
are intentionally encouraged, making it necessary to consider the question of contamination
and to measure impact in areas other than the direct intervention targets. For example,
do single-focus, school-based smoking prevention programs actually reduce (or increase)
alcohol and other drug use? Are multifocus programs more or less effective? Unlike
traditional research in which one variable is manipulated whereas all other factors are
controlled, the use of multiple criteria (including factors such as cost-effectiveness) may be
more appropriate in program evaluation or prevention research (e.g., Warner and Luce,
1982; Altman et al., 1987~. In some cases, the spillover effects that result from such
multifocused, synergistic processes as changing social norms and social network interactions
in a school, work site, or other system are regarded as beneficial. They are viewed as an
intentional part of the intervention and evaluation process rather than ~contamination."
However, it is crucial to decide what is acceptable synergism and what is contamination,
especially with respect to the unit of analysis, the questions being asked, and the
comparison groups and settings being used.
Need for Both Laboratory and Field Prevention Research
The term laboratory research is used here to mean research conducted under conditions
that permit the direct manipulation of the variables under investigation. Studies conducted
within a controlled environment to allow the manipulation of variables have the advantage
of providing better opportunities to assign subjects randomly to treatment and no-treatment
conditions. Laboratory studies permit the examination of particular variables and the
determination of whether specific experimental factors may play a role in a prevention
program or policy. For example, the potential role of retail price in alcohol use can be
demonstrated in a laboratory experiment that simulates an actual retail drinking situation
in which the subjects' drinking is measured as the price of alcohol is manipulated. Such
analogue studies can demonstrate (or fail to demonstrate) that retail price (or the economic
accessibility of alcohol) affects drinking behavior. Such studies cannot tell, however,
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whether price is actually a significant variable in the natural setting, given the number of
other factors at work.
Prevention research also requires studies that are conducted in the field or in naturalistic
environments in which physical manipulation of the situation may be difficult or impossible.
Such studies can be more generalizable, but they lack the convenience or appropriateness
of random assignment for controlling variance in extraneous factors; however, multivariate
statistical tools are available as the means for control. Both laboratory and field studies
are needed in prevention research because they have complementary strengths. In
particular, the validity of conclusions is strengthened when consistency is demonstrated
between the two approaches.
In recent years, empirically minded social scientists have become increasingly concerned
with the problem of inferring individual-level behavior from aggregate data (Lanbein and
Lichtman, 1978~. (The term ecological fallacy has been used to describe an incorrect
inference about individual behavior based on proud data.)
By far the most obvious
intervening variable in need of disaggregation is the consumption history of the drinker.
Many authors who have written about the policy implications of economic variables have
lamented the fact that current models have been unable to differentiate among
alcohol-dependent persons, heavy drinkers, and moderate consumers.
Although there has never been a systematic program of experimental research designed
to investigate the interaction between environmental variables and alcohol consumption, a
number of studies have been conducted to investigate the important policy questions raised
by economic and epidemiological studies. For example, several studies have investigated
the relative impact of economic variables on the behavior of alcohol abusers (Mello, 1968;
Cohen et al., 1971; Bigelow and Liebson, 1972; Engle and Williams, 1972; Marlatt,
Demming, and Reid, 1973~. The findings in these studies suggest that the strengths of both
experimental and quasi-experimental research designs can be combined in complementary
studies that move from laboratory analogues to more complicated natural settings.
One question of interest in prevention research concerns whether persons with alcohol
problems differ from persons without alcohol problems in their responsiveness to economic
incentives for drinking or abstinence. Babor and colleagues (1978) demonstrated that heavy
drinkers were as responsive as casual drinkers to the afternoon price manipulation known
as the happy hour. Indeed, one of the most encouraging findings of the happy-hour studies
was the extent to which the discount drink policy was associated with similar alterations in
drinking behavior in both laboratory and natural settings (Babor et al., 1980~.
Laboratory analogue research was also combined with naturalistic observation in the studies
of Langenbucher and Nathan (1983~. Three experiments were used to test the ability of
social dnnkers, bartenders, and police officers to estimate sobriety. This study has
important implications for public policy regarding alcohol sale or use and the legal
penalties for purveyors who knowingly or unknowingly serve alcohol to intoxicated persons.
Naturalistic studies have the advantage of being heuristic, realistic, and relevant to
important social problems when they include three important dimensions: natural behavior
(e.g., drinking), natural settings (e.g., a tavern or bar), and natural treatment (e.g., price
variations).
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The Practical Significance of Prevention Research
In addition to the concern that no false conclusions be drawn from data, the prevention
researcher must also consider the practical significance of any finding. A statistical change
may be too small to justifier the operational costs of a prevention strategy. Alternatively,
the level of statistical significance may be set so high by the researcher, or the variable
selected for measurement may occur so infrequently, that a finding of practical significance
is overlooked. In selecting a research design, the variables to be studied, and the statistical
approach, researchers should be aware that prevention research must accommodate both
substantive and statistical significance.
DIRECTION AND DESIGN OF FUTURE ALCOHOL PREVENTION
RESEARCH PROGRAMS: CONCLUSIONS AND RECOMMENDATIONS
The conclusions discussed below constitute the committee's recommendations for future
directions in research designed to reduce alcohol-related problems.
· Attempts should be made to integrate findings from biomedical research (e.g.,
biobehavioral vulnerability) with theories on individual, social, educational, and economic
variables that influence alcohol use and abuse. Integrated models can then be used to
guide the development of prevention interventions and the matching of at-risk subgroups
with appropriate intervention strategies.
· It is important to ensure that theory drives the research, which can be achieved
by borrowing theory-based analogues from studies in other health fields. Although such
theories as social learning approaches have helped in understanding behavior change in
individuals, there is little assurance that an adequate theoretical framework is available
for the fields of community organization, regulatory and polipy-based interventions,
environmental change strategies, and interventions that depend on changing the
organizations themselves.
· Life-span considerations and developmental factors over time should be
incorporated into comprehensive theories. If it can be anticipated that a specific interaction
between individual characteristics (e.g., social skills deficits) and environmental/cultural
demands (e.g., peer pressure to conform during early puberty) is likely to produce a large
at-risk group, then such predictions can be used to plan both individual and community
prevention programs. In this manner, findings from biological, psychological, and cultural
areas can be used to plan prevention strategies for use during an earlier developmental
phase so as to ~inoculate" a vulnerable population prior to exposure. Research should
also be undertaken to shed light on the determinants of social norms regarding alcohol use.
Such research should include creative methods to determine the effects of corporate
policies, advertising, and the popular mass media on the nation's attitudes regarding the use
of alcohol.
· Multidisciplinary collaboration in theory development should be encouraged from
such diverse fields as the biomedical sciences, econometrics, education, psychology,
sociology, clinical epidemiology, anthropology, and other relevant disciplines. The
development of theories that examine the interaction.s amen ~ varinhles rl~.riv~1 from
adherent levels or analysis or olllerent olsclpllnes should be particularly encouraged,
especially if the theories can be used to guide the selection of intervention components and
evaluation approaches. The use of new methodologies for formal theory development and
model building should also be encouraged. Such methods as structural modeling and
path-analytic procedures, computer simulation, and other multivariate approaches to causal
. .
ana yses appear promising.
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· Program planning and implementation should be integrated with evaluation. The
use of formative research, one of the main components of social marketing, should be
increased to ensure success in pilot studies of untested components of programs.
Researchers are often unable to obtain sufficient funding to implement programs they may
want to evaluate, and program personnel often do not have the funds to support a full
evaluation of their programs. The result is that major prevention programs are ~evaluated"
after the fact and only in a descriptive or cursory manner. A mechanism needs to be found
to facilitate a coherent demonstration evaluation plan whereby program and research
designs are fully integrated. Until then, program evaluations, particularly at the community
level, will remain piecemeal, inconsistent, and generally inadequate. (One of the great
barriers to community prevention research is the enormous cost of collecting the data
necessary for measuring whether an intervention has had an effect. NIAAA may want to
consider ways to encourage local and county agencies to develop information management
systems that can sense as existing data bases for measuring changes within the community.
As local agencies begin to see the value of such data bases, they would undoubtedly expand
their range to incorporate community and environmental variables that at first may seem
remote to their needs. Ideally, such a system might include regular spot surveys of the
alcohol-related concerns, knowledge, consumption, and problems of the community.)
· Community trials of prevention strategies should be instituted. One essential
prevention research finding derived from heart disease and cancer prevention studies is the
value of long-term community trials, such as those reported in Chapter 5. Such approaches
have rarely been undertaken in efforts to prevent or reduce alcohol problems or to conduct
alcohol problem prevention research. Tested research components should be combined into
comprehensive, integrated, and reasonably long-term community-based projects to test the
hypothesis that synergistic effects occur and that significant reductions in alcohol-related
problems may be demonstrated. Effective community trials are long-term investments in
the health and well-being of community members. They represent an opportunity to
carefully monitor changes or the absence of change in targeted behaviors and situations.
Prevention efforts to reduce alcohol problems have matured to a stage at which
cost-effective longitudinal research projects could be undertaken. Such community
prevention research trials will require (a) a long-term funding commitment for project
development, implementation, and evaluation; (b) an effective partnership between
prevention program specialists and prevention researchers; and (c) application of the latest
research findings to identify behaviors and situations that can be effectively targeted for
change.
· Prevention research should be used in policy development. The interests of
researchers, prevention policymakers, and program planners are similar but not identical.
Polipymakers and planners are interested not merely in understanding the general effects
of a particular strategy or documenting its past impact but also in anticipating its future
impact in a specific situation. Conventional research and evaluation studies do not by
themselves Drovide the tvDes of "Drosnective" information that nolicvmakers require.
~ ~ or-- -- r---r~ ~~ ~~~~~ a---- ~~-~- ~~~-
Although traditional research methods are often the most effective approach for examining
a small number of variables in isolation from other factors, the policymaker must deal with
the considerable Messiness" of detail contained in the real world. Tools are needed to
assist policymakers and planners in making the best use of available resources, which would
enable them to bring empirical and theoretical knowledge to bear on (a) understanding the
complex network of factors that surround a set of alcohol problems and (b) estimating the
likely impact of interventions in specific situations. Prevention research must develop the
methods and techniques needed to assist prevention planners in estimating potential effects
based on the best available research. One potentially valuable area of research is computer
simulation, which permits perturbation (nwhat ifs) experiments to be undertaken to examine
changes in a complex system. In such research, the computer is programmed to act like
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the system under study and changes are made to represent the analogous changes expected
with a planned prevention policy or program. This type of computer-based experiment is
intended to provide policymakers and researchers with data about likely or possible
long-term results or outcomes of a set of potential prevention actions.
· Cost factors must be considered in prevention research. Much of prevention
research is still in a formative stage and thus basic in nature. However, some areas of
prevention research have developed beyond this stage to a point at which public policy and
programs to prevent or reduce alcohol problems have already been based on such research.
In these cases, both program costs and effects should be part of the evaluation; that is,
what does it cost to undertake this program or policy given its effect in comparison with
other strategies? As has been learned in other public health prevention efforts, cost/effect
considerations aid in the selection of the best mix of programs and policies for reducing
problems. All prevention approaches do not have similar costs or similar effects. To
date, most prevention research has addressed contributory and risk factors and the potential
effects of specific prevention strategies. Such research has not addressed the cost to
implement or create programs based on research findings. Prevention research should
include cost as a part of the outcome measures when such research has moved beyond the
formative and developmental stages to a point at which programs can be based on this
research.
Together, these recommendations present an ambitious program for the coming years.
Considerable financial resources and a commitment from researchers in the field will be
required to realize the progress called for in this report. Yet the benefits to be gained
from reductions in the human and economic tolls of alcohol-related problems will most
certainly justify the needed investments of money and intellectual energy.
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II
RESEARCH OPPORTUNITIES IN THE TREATMENT OF ALCOHOL-RELATED PROBLEMS
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INTRODUCTION
Within the framework of universal, selected, and indicated interventions noted in
Chapter 1 of this report, treatment can be said to be an indicated intervention; its focus
is on persons with already evident problems rather than on the preventions of problems
in unaffected individuals. Given the heterogeneity of persons with alcohol problems--
and the wide range of such problems--reflected in the concept espoused by the
committee of a continuum of severity, it should be no surprise to find that a variety of
treatment methods and modalities have arisen in response. These numerous approaches
testify to the vigorous interest of treatment providers and researchers and offer
numerous opportunities for continued development and research on treatment efficacy
and effectiveness.
In response to its charge, the committee conducted an extensive review of recent
treatment research with a view toward identifying promising avenues of inquiry for
future studies. Chapters 7 though 14 summarize its findings, necessarily presenting
illustrative as opposed to comprehensive considerations of the various topics. Chapter 7
describes the social and historical context of alcohol treatment research, noting the past
extent of federal support as well as emerging trends in service delivery and
demographics that may affect future funding and research interests. Chapter 8 deals
with issues of assessment, methodology, and research design. It describes some of the
notable achievements in treatment evaluation in recent years (e.g., conceptual advances,
new measurement techniques) and discusses a number of the major unresolved research
issues. Many of the available treatment approaches have not been systematically or
rigorously evaluated. Nevertheless, Chapter 9 surveys outcome evaluation research since
1980 on several treatment modalities (e.g., pharmacotherapies, psychotherapy and
counseling, mutual help groups) and also considers recent process evaluation research.
Chapters 10 and 11 discuss research on two recent trends that appear to offer promise
for impairing treatment outcome--namely, early identification of persons with alcohol
problems and patient-treatment matching. Both of these areas hold promise for
improving treatment outcome. Chapter 12 highlights selected findings from treatment
studies of other psychoactive substance-use disorders that may be applicable to research
on the treatment of alcohol problems; Chapter 13 discusses treatment of health
consequences of heavy alcohol use or dependence; and Chapter 14 considers recent
research on some of the public policy implications of alcohol treatment, particularly
those related to costs and efficiency. In all of these chapters, the committee reviews
research directions that have already been pursued and highlights potentially fruitful
opportunities for further progress in identifying effective treatment approaches for
alcohol problems.
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Representative terms from entire chapter:
prevention programs
