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Evan Gray

Wake Forest University School of Medicine
The Division of Public Health Sciences
Winston-Salem, NC
Preceptor: Kate Egan

Part I Problem Definition

Underage alcohol use is a major cause of morbidity and mortality locally, and
in the United States. Alcohol use has a multitude of short and long-term effects,
especially on developing adolescent brains. The Centers for Disease Control (CDC)
(CDC, 2014) lists unintentional injuries (including motor vehicle crashes), risky
sexual behaviors, and violence as short-term outcomes that heavy or binge drinking
of alcohol makes one more likely to experience. The 2007 Surgeon Generals Call to
Action to Prevent and Reduce Underage Drinking states underage drinking
contributes to the annual death of close to 5,000 people under 21 from motor
vehicle crashes, homicides, and suicides (U.S. DHHS, 2007). Drinking early in life,
including during teenage and early adult ages, can lead to increased risk of alcohol
dependence and severe alcohol related outcomes later in life (NIH, 2006). Long-
term adverse health outcomes associated with drinking include: cancers, heart
disease, liver disease, mental health disorders, and learning and memory conditions
(CDC, 2014). An increase in alcohol dependency on a large scale would make
frequent alcohol use more probable and increase the prevalence of such physical
and mental health conditions. Underage alcohol use also has significant economic
costs. Miller, Levy, Spicer and Taylor (2006) estimated an annual 61.9 billion dollar
economic cost was attributable to alcohol use by underage persons.
Despite established laws that have created minimum drinking ages across
the United States, minors continue to use alcohol at alarming rates. The Johns
Hopkins Center on Alcohol Marketing and Youth states alcohol is the most used drug

by American youth, and close to 5000 children under age 16 try alcohol for the first
time every day (Center on Alcohol Marketing and Youth, 2011). The 2010 National
Survey on Drug Use and Health shows that over a quarter of persons aged 12-20
reported alcohol use in the last month. Of that, 17% were binge drinkers and 5.1%
were heavy drinkers. The authors state that binge drinking can be defined as
having five or more drinks on one occasion in the past thirty days; heavy drinking is
defined as five or more drinks on the same occasion five or more days in the past
thirty days (SAMHSA, 2011).
Alcohol use is not only relatively common nationally, but also in North
Carolina. A 2013 report to Congress by the United States Department of Health and
Human Services (U.S. DHHS) states that one fifth of surveyed North Carolina 15-17
year olds, and over 40% of surveyed North Carolina 18-20 year olds reported
alcohol use in the past month. Over one quarter of the 18-20 year old age group
reported binge drinking in the past month. That year, among North Carolina traffic
fatalities with drivers between 15 to 20 years old, 23% had a blood alcohol level
greater than .01.
A non-health problem contributing to underage alcohol use includes legal
and social environments that enable, or encourage, use. A common way underage
youth obtain and consume alcohol is at gatherings hosted by those of legal drinking
age, who then supply the alcohol for the minors. These parties are considered high
risk as teens tend to drink more heavily when with peers and in large groups
(Mayer, Forster, Murray, & Wagenaar, 1998). Social host ordinances are laws which
impose criminal or civil penalties on adults who provide alcohol for minors on

property which they control (Friese & Grube, 2014). Not all states or cities have
social ordinance laws, and among areas that do have them, their enforcement can
vary (NIAAA, 2014; Paschall et al., 2012). Past research shows that enforcement of
these laws, community and adult drinking norms, and alcohol outlet density impact
underage drinking behavior (Paschall et al., 2012).
The Department of Social Sciences and Health Policy at the Wake Forest
School of Medicine has a mission to improve the human condition through the
application of social sciences and policy research to health and healthcare. The
Department of Social Sciences and Health Policy is engaged in a NIH grant funded
study, Evaluating Community Driven Strategies to Prevent Underage Drinking
Parties. This study will utilize a community-based participatory research (CPBR)
approach to study the effect social host ordinances and their development, passage,
and enforcement have on underage drinking behavior, as well as peripheral
behavioral and community outcomes. Better understanding how social host
ordinances impact underage drinking will lead to more effective implementation of
similar laws, or interventions, which will decrease underage drinking and related
health issues.
SWOT analysis is used to identify the strengths, weaknesses, opportunities,
and threats that a program or organization may have. Figure 1. Includes a SWOT
diagram. An organizational strength of the Wake Forest School of Medicines
Department of Social Sciences and Health Policy is that the study pertains to an area
of expertise of my preceptor, and the studys principle investigator. Another positive
is that the NIH has funded the study this is both a strength and an opportunity as it

will improve the thoroughness of the study and funds staff activities. Another
opportunity that enhances the study is that the public is concerned about, and has
an interest in curbing underage drinking.
The principle weaknesses of the study and opportunity are that, inevitably,
there will be limits to what research staff can accomplish and study. A threat to the
study includes practical threats to any study such as: difficulty recruiting
participants, attrition, poor inter-rater reliability, and other events that can threaten





a studys validity.

Researchers area of specialty

Funding and Resources




Funding and Resources

Publics interest in problem

Limited time resources of

Limits to study opportunities


Threats to successful study

(recruitment, attrition, etc.)

Figure 1. SWOT analysis.

Ethical considerations must be made to ensure that study participants are

protected from harm and/or exploitation. Study data must be protected or specially
coded such that those outside the study team are not able to identify participants
based on data. To this end, the research team must stay in compliance with
institutional review board (IRB) recommendations.

Part II Problem Analysis

Much research has been done that has studied the effects, as well as causes,
of underage drinking. To better understand the health problem of underage
drinking, a review of the literature as it relates to that topic is needed. When
analyzing a health problem such as underage drinking, it is helpful to use a model to
conceptualize the problems multiple causes and how they relate to one another. A
conceptual map is shown in Figure 2. In this model, three factors that directly
contribute to underage drinking are attitudes, subjective norms, and behavioral
control. Past research shows that these variables impact underage drinking, as
suggested by the Theory of Planned Behavior (TPB) (Lac et al. 2013). According to
TPB, attitudes can be defined as how positively one views an object or behavior,
subjective norms are how common and acceptable one deems an object or behavior
to be, and behavioral control is the extent to which one feels they control if they
engage an object or behavior (Simons-Morton, McLeroy, & Wendel, 2012).
Demographic factors can also contribute to ones likelihood to engage in
underage drinking. Utilizing data from a 2010 national survey, Mason et al. (2014)
found gender and racial differences in substance abuse related attitudes. Windle
(2003) also found that high school aged males were more likely than females of the
same age to have used alcohol heavily in the last two weeks. There were also racial
differences discovered in that study, with those identifying as White having higher
30-day prevalence of alcohol use than their Hispanic or African American

Advertising is a major expenditure for United States alcohol suppliers, and it

is helpful for them in bringing in new customers and keeping existing customers. A
2014 report by the United States Federal Trade Commission (FTC) states at least
3.45 billion dollars were spent on alcohol advertising in 2011. Research by Ellickson
et al. (2005) shows that alcohol advertising consumption can predict underage
alcohol use, and that relationships between different mediums of advertisement
(television, magazine, store signs) are mediated by demographic factors.
Part I noted that the non-health problem consisted of environments that
enabled youth to drink alcohol that had been supplied by adults of drinking age
likely at parties. Frise and Grube (2014) state that 70% of youth who hosted a party
with alcohol said their parents definitely knew there was alcohol at the party. At
the top of Figure 2 are three factors: local policies, enforcement, and availability.
These three factors are hypothesized to directly impact that non-health problem,
and they will be the focus of the internships research activities. The primary local
policies that will be the focus of the internship activities are social host ordinances.
Social host ordinances are meant to prevent adults from hosting events where youth
drink by imposing sanctions on the adult who controls the partys premises,
regardless of who provided the alcohol (Frise & Grube, 2014). The presence of social
host ordinances is not enough, however, for these policies to be effective they must
be enforced by police. This police enforcement is not seen consistently according to
Thomas et al. (2015). The perceived enforcement of alcohol policies has been shown
to impact drinking behavior, this perceived enforcement influences ones perceived
behavioral control (Pascall et al., 2012). The goal of the study described in Part I is

to examine the effects social host ordinances, their different levels of enforcement,
and how that impacts alcohol availability, which leads to underage drinking.

Figure 2. Conceptual Model of Underage Drinking

Alcohol policies already exist in multiple states and municipalities
throughout the United States. Saltz et al. (2010) studied the effect that
environmental interventions, or policies, had on drinking behavior in communities
around eight college campuses in California. The environmental interventions
included nuisance party enforcement, social host ordinances, driving checkpoints,
and other strategies. The authors found that the policies, and their enforcement, did
lead to significantly less incidence of alcohol use at parties. The highest levels of
implementation (adaption of policies or enforcement) lead to the greatest reduction
in alcohol use.

A changeability matrix is helpful for those planning an intervention or study

to view the factors within the context of how important they are to the health
outcome, and how changeable they are. Though all factors are important, it is often
wise to focus on those that are the most important, and the most changeable. An
example of a changeability matrix is shown in Figure 3. In the case of the study and
its internship activities, policies, enforcement, availability will be explicitly
measured. Attitudes, norms, and behavioral controls relationship to those factors
will be implied, and not directly measured.

High Importance

High Changeability

Local Policies



Attitudes, Norms,

Low Changeability

Demographic Factors

Low Importance

Behavioral Control


Figure 3. Changeability Matrix

Studying the effect that alcohol policy, enforcement, and availability have on

underage drinking behavior will lead to more effective interventions in the future.
Researchers and public health professionals will be able to look to the current study
and draw from what was shown to work and what had not worked. The community
involvement mentioned in Part I, will empower the communities involved to make
necessary legal and environmental changes to reduce underage drinking in their
own communities. The current study, and my internship activities which will
support it, will add to the body of knowledge that directs the future of substance
abuse prevention.


Part III Internship Activities

Logic models are helpful tools for intervention and project planning. Logic

models, read left to right, explain what resources are needed to engage in
intervention activities, and what immediate, short, and long term outcomes can be
expected as a result of the activities. Figure 4 shows a logic model explaining how
internship activities will relate to the success of the study, and to underage drinking.

There are four inputs that are necessary for the completion of all internship

activities. These inputs are funding, workspace, equipment (including computers),

and software. The study has obtained funding through a National Institutes of
Health grant. This funding will be used to cover any expenses involved in carrying
out the study. The Wake Forest School of Medicine will provide the workspace,
computer and other equipment, and the necessary software.

The top activity in the logic model is data collection, coding, and entry. These

tasks will consist of obtaining data from study personnel and community members
and entering it into one location where it is easily accessible. Study personnel who
have already collected data will have that data in a medium that is likely not within a
dataset that can be analyzed, such as a workbook, notes, or survey sheets. This will
require entry of the data collected while in the field into another dataset or
database. Interpretation of this data before it is entered may be needed as well, and
coding, as directed by the preceptor will be necessary. A direct output of these tasks
will be the presence of an accurate, clean, and complete data set that is ready to be


Once the raw data has been collected, coded, and entered and a complete and

reliable dataset exists, the data will be ready to be analyzed. The data analysis
activity will include assisting the preceptor and other data analysts or statisticians
with choosing an appropriate analysis and writing software code to execute the test.
The statistical findings will then need to be interpreted by study staff to determine if
the research questions had been answered, and if a revision to the analysis plan
needs to be made. An output from this activity will be a correct assumption
regarding the nature of the studys target factors, as explained in Part II (local
policies, enforcement, availability, and underage drinking).

Reviewing literature relevant to the studys area of focus will be helpful in

the studys development. A literature review will also be an asset as the research
time begins work on a manuscript once the study has been completed. An output
related to literature review is that study personnel will have information from past
findings of similar research and they will be able to apply that to current study
efforts. The last activity in the logic model is presenting to groups inside and outside
of the Wake Forest School of Medicine regarding the studys efforts, progress, and
findings after completion.

The activities and outputs of the study and internship activities will

contribute to the body of substance abuse prevention literature, which will inform
future interventionists regarding what has been shown to work, and what has not.
The activities will also help researchers better understand how communities can
mobilize existing resources to address underage drinking. Ultimately, the study
activities will lead to a decrease in underage alcohol use. Communities will be able


to utilize the study findings to better address underage drinking on their own as

Figure 4. Internship Logic Model

Below, Figure 5 shows a Gantt chart explaining the internship activities and

the order in which they will take place. The first activities that will be needed are
data collection, coding, entry, and literature review. These activities will take place
beginning in February and go until March or April. Beginning in April and ending in
May are data analysis and presentation. The order and/or duration of these
activities are subject to change at the request of the internship preceptor.


Figure 5. Internship Gantt Chart


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