Adolescent Satisfaction with Brief Motivational Enhancement for Alcohol Abuse

Brief Report

Adolescent Satisfaction with Brief MotivationalEnhancement for Alcohol Abuse

Maryam Kia-Keating, PhDSandra A. Brown, PhDMarya T. Schulte, MSTeresa K. Monreal, MA

Abstract

Although many investigations point to the importance of treatment satisfaction and workingalliance as predictors of treatment engagement and outcome, few studies have closely examinedthese issues among adolescents. This study investigates satisfaction among a nonclinicaladolescent sample participating in a school-based alcohol-prevention program. Adolescents self-selected to one of three formats: individual, group, and website. Three hundred nineteensatisfaction measures completed at the time of each participant’s final session were used foranalyses. Hierarchical regression analyses examined predictors of consumer satisfaction. Ingeneral, greater participation in the program was significantly related to satisfaction. Studentswho participated in the group and individual formats reported greater satisfaction than studentswho participated in the website format. Current alcohol users were less satisfied with the sessionfocusing on how experimental use can lead to problem use; lifetime abstainers were more satisfiedwith the session focusing on stress and coping. These analyses have implications for informingfuture adolescent school-based interventions for alcohol problems.

Alcohol involvement among adolescents remains prevalent regardless of the obvious legalbarriers and the well-publicized negative consequences of use. By the time teens reach high schoolgraduation, approximately one third will report episodes of current heavy drinking (i.e., five ormore drinks in a row during the prior 2 weeks1) and consequently be at risk for myriad of bothphysical and psychological problems.2–5

Address correspondence to Maryam Kia-Keating, PhD, Department of Counseling, Clinical, and School Psychology,University of California, Santa Barbara, Gevirtz Graduate School of Education, Santa Barbara, CA 93106-9490, USA.Email: [email protected].

Sandra A. Brown, PhD, University of California, San Diego, San Diego, CA, USA.Marya T. Schulte, MS, University of California, San Diego, San Diego, CA, USA.Teresa K. Monreal, MA, University of California, San Diego, San Diego, CA, USA.

Journal of Behavioral Health Services & Research, 2008. c) 2008 National Council for Community BehavioralHealthcare.

Adolescent Satisfaction with Motivational Enhancement KIA-KEATING et al.

Despite the risks and negative sequelae associated with alcohol use among adolescents, alcoholremains the most commonly used drug of America’s youth, and traditional alcohol and substanceabuse treatment approaches have had limited success in enlisting and engaging adolescents.6–8

Alcohol-abusing youth often express less motivation than adults to change their alcohol-usebehaviors and may be more invested in the perception of drinking as normative among their peers.9

Much of the literature to date illustrates a dearth of efficacious substance-use treatment programsdesigned for an adolescent population.10,11 Traditional programs may fail to acknowledge thenatural developmental changes occurring as youth progress into young adulthood and thereforeappear inapplicable to teen drinkers.6,12 Thus, the creation of developmentally sensitive and easilyaccessible interventions is important in better assisting adolescents who wish to reduce or ceaseuse.

In addition to the challenges of this developmental context, treatment engagement is particularlya concern among adolescents with high levels of alcohol and substance use and among minoritypopulations. In one study of Hispanic substance-abusing youth, adolescents with greater levels ofexternalizing disorders and parents who used less effective parenting strategies were less likely toutilize standard mental health services.13,14 In general, as alcohol problems increase, youth are lesslikely to be willing to participate in help-seeking activities, with the exception of seeking friend-only support.14

Although research has historically given much attention to the more definable predictors such asfamily history and treatment modality, the more “nonspecific” factor of consumer satisfaction hasnot been a focus within child and adolescent mental-health or substance-abuse services.15,16

Among the literature that does exist on satisfaction among youth, there is some evidence to suggestthat treatment satisfaction may be related to client engagement factors such as treatmentacceptability, compliance, and retention.17

While a few studies have investigated treatment satisfaction within the adolescent population,prevention and early intervention satisfaction within nonclinical samples of adolescents have notbeen adequately represented. By focusing on adolescents who have limited drinking experience,prevention efforts can impact those who might go on to experience clinical levels of alcohol useprior to the emergence of problematic drinking and negative consequences. Due to the emotionaland cognitive changes which are core to adolescent development, an understanding of satisfaction-related intervention characteristics can provide insight into features of the intervention thatcontribute to adolescent engagement across time.6 These features then become considerations whendesigning developmentally appropriate interventions for youth. Given the voluntary nature of thepresent school-based prevention program, understanding treatment satisfaction is critical topromoting and maintaining attendance levels. By addressing these fundamental components oftreatment engagement, our model of adolescent drinking and cessation is better specified. Thus,interventions targeting teens can be more effective and efficient at reducing alcohol involvement.

The use of motivational enhancement principles has had some preliminary success in effectingchanges in addictive behaviors of youth.18–21 The client-oriented perspective of motivationalenhancement works in concert with the processes of self-change, supporting personal endeavors torecover from alcohol problems among youth.18,22–24

The present school-based secondary prevention program is an ongoing study utilizing acombined motivational enhancement and cognitive behavioral approach to reducing alcoholinvolvement and related problems in youth.6,18,25 To accommodate variation in service preferences,three types of formats were simultaneously offered to adolescents in the school context: meeting onan individual basis with an interventionist, attending a group meeting with peers, or workingindependently on a self-paced intervention website. Although many investigations point to theimportance of consumer satisfaction and working alliance as predictors of treatment engagement andoutcome, few studies have closely examined these issues among adolescent samples using differentservice formats which are simultaneously available. This study is the first known to these authors to

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investigate consumer satisfaction among a nonclinical adolescent sample participating in a school-based alcohol secondary prevention program. Gaining a better understanding of adolescentpreferences among a sample with early alcohol exposure and related problems is important forestablishing prevention programs that can effectively intervene with teenagers before their alcoholuse escalates and requires more traditional, long-term treatments.6

Methods

Participants

Four hundred twenty-three high school students from six public high schools completedconsumer-satisfaction questionnaires after voluntary participation in prevention sessions. Thesample included 195 girls (46%) and 228 boys (54%), with 38% in 9th grade, 36% in 10th grade,20% in 11th grade, and 6% in 12th grade. The sample reflected a diverse ethnic/racial groupincluding 51% Caucasian, 15% African-American or black, 15% Latino/a, 9% Asian, and 9% other/mixed ethnic backgrounds (1% of participants did not specify their ethnic/racial background). Giventhe voluntary and fluid nature of the program, participants were allowed to self-select into theprogram and attend sessions at any time throughout the school year. Each student participated in anaverage of 2.5 sessions (SD=1.8; mode=1; range, 1–7). Although students were remindedthroughout their participation that there was a maximum limit of six sessions, a small group ofstudents (2%) returned after their sixth session and were allowed to participate in one extra sessionfor a total of seven. In contrast, 45% of participants chose only to attend one session. Of the 55% ofparticipants who attended more than one session, the average attendance was 3.7 sessions (SD=1.6).

Procedure

Data for the current study were collected using procedures approved by the University ofCalifornia, San Diego Committee for the Protection of Human Subjects, the school district, and theindividual high schools. Parental permission was obtained using a passive consent procedure.26

Students from six public high schools were invited to voluntarily participate in a brief school-basedsecondary prevention program,6,18 Project Options. Self-selection into the program and voluntaryongoing participation at any time during the school year were important components to allowadolescents maximal control over their interactions with the program.6 Services took place over thelunch period in on-campus classrooms, and a meal was provided. Three simultaneously availableformats (group, individual, and website) were offered to address diverse adolescent preferences forintervention delivery.6,7 Group sessions were facilitated by one or two leaders, while a singlefacilitator met with one student (and a friend, if requested) in the individual format. In the websiteformat, students examined the Project Options website independently and at their own pace.Groups were made up of an average of 10.4 students (SD=3.7) for each session. The websiteformat was continuously available, 24 h/day, on any on- or off-campus computer with onlineaccess. However, over the school lunch period, at the time other intervention formats wereavailable, the format was limited to up to three students who could use the three laptop computersprovided by Project Options staff.

In a previous study, high school students identified confidentiality as a primary barrier totreatment engagement.6 Confidentiality, within the limitations of the laws of the state of California,was emphasized at the beginning of every session. Participants were encouraged to participatewithout having to divulge personal information (i.e., by posing nonconfrontational discussionsabout common challenges that adolescents in general face and referring to ‘someone I know’ ratherthan having to admit their own use patterns), and the motto “what’s said in here, stays in here” wasutilized as an encouragement to participants to protect group confidentiality.6 The program was

Adolescent Satisfaction with Motivational Enhancement KIA-KEATING et al.

advertised towards talking about issues important to teenagers rather than only focusing on alcoholor substance use, and both nonusers and users were recruited to reduce stigma associated withprogram participation.

The program included up to six sessions utilizing motivational enhancement, normativefeedback, and skills training. Session topics (described in Table 1) were advertised at each schooland rotated in an ongoing manner, thus allowing students to enter into the program at any time. Thetheoretical basis for the program, the developmental social information processing model,6,27

suggests that cognitive and emotional states within a social context influence adolescent drinkingbehaviors. Therefore, adolescents were provided with expanded resources for alternate behaviors,behavioral skills to supplement personal change efforts, and effective communication strategies inaddition to ongoing motivational enhancement for drinking reduction or cessation. Themotivational enhancement approach emphasized a directive, adolescent-centered, and nonconfron-tational method on the part of the interventionists, highlighting and respecting adolescents’knowledge and capacity to change.25

Satisfaction measures were completed at the end of each session to assess consumer satisfactionwith specific session topics as well as overall satisfaction with the treatment style andinterventionist. Although satisfaction was assessed at the end of each session, consumersatisfaction at the time of each participant’s final session was used for analyses. Thus, althoughparticipants might be exposed to different program formats (group, individual, or website)throughout their participation in the program, only the format of their final visit was utilized in thecurrent analysis. At the time of their final sessions, 319 participants were attending group sessions,50 participants were attending individual sessions, and 54 participants were attending websitesessions. Specific to those attending the group format only (website provided all topics for thebrowser’s choice, and the sample of students attending individual sessions was not large enough toanalyze by topic), 71 students were attending session 1, 47 in session 2, 41 in session 3, 31 insession 4, 61 in session 5, and 68 in session 6 (refer to Table 1 for topic descriptions). Given therotating nature of the session topics, variations in level of attendance for different topics atstudents’ final sessions were most likely a result of the times when the topic happened to fallthroughout the school year (e.g., during large school-wide events, such as lunchtime pep rallies,attendance tended to decrease).

Measures

Background characteristics Participants provided demographic information including gender,grade in school (9th–12th grade), age, and ethnicity. To account for a disproportionately lownumber of 12th graders self-selecting into the prevention program, participants were combined by

Table 1Project options session topics

Session Topic Brief description

1 Normative feedback Perceived versus actual peer alcohol use2 Outcome expectancies Expected versus actual effects of alcohol use3 Coping with stress Coping skills4 Progression of problematic use How experimental use can lead to problem use

Advantages of change efforts5 Behavioral management Resistance/Refusal and problem-solving skills6 Communication skills Communication skills

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grade into lower grades (9th and 10th grades) and upper grades (11th and 12th grades). Dummyvariables were created for sex (female, male), grade (lower, upper), and ethnicity (non-Hispanicwhite, non-white).

Alcohol use Alcohol use prior to participation in the prevention program was assessed usingparticipant self-reports about number of alcohol drinks in their lifetime and in the past 30 days.These self-reports were collected upon intake to the prevention program. Dummy variables werecreated to indicate lifetime alcohol use (no/yes) and current (past 30 days) alcohol use (no/yes).

Consumer satisfaction Consumer satisfaction was assessed with four items asking participants toevaluate the helpfulness of the discussion, usefulness of the information, style of the meeting, andinterventionist using a visually adapted five-point Likert-type scale (depicting a range of sad,neutral, and happy faces) for a maximum of 20 points.

Statistical procedures

Statistical analyses were performed using SPSS 15.0. Prior to analysis, all data were examinedfor accuracy of data entry, missing values, and fit between their distributions and the assumptionsof multivariate parametric analysis. Individual variables were screened for normality throughsignificance tests of skewness and kurtosis.

A strong positive correlation (r=0.91; pG0.001) between consumer satisfaction at the end of one’slast session and each individual’s mean satisfaction score (using all satisfaction scores collected at theend of each session) indicated convergent validity. In order to avoid over-representing participantswho attended more sessions, each individual’s last session satisfaction score (hereafter, simplyreferred to as satisfaction) was utilized as the criterion variable in the analyses. The averagesatisfaction rating out of 20 was 17.43 (SD=2.61), with a median of 18 and a modal score of 20.Satisfaction ratings ranged from scores of 5 to 20. In order to correct for negative skew, satisfactionwas first reflected and then a square root transformation was applied.28

Independent sample t tests were used to compare satisfaction by background characteristics.One-way analysis of variance was conducted to determine differences in mean satisfaction byschool and by intervention format. Hierarchical regression analyses were utilized to test the sizeand significance of incremental contributions to satisfaction by entering variables in a theoreticallydetermined sequence of static variables followed by dynamic variables, after controlling for thepossible effect of variables entered in earlier steps.29 For the website format, demographic variables(sex, grade, and ethnicity) variables were entered in the first step, followed by alcohol use; sessiontopics were not examined because information for all program topics are available simultaneouslyon the website, and participants peruse this information at their own pace. For individual andgroup-format participants, separate regressions were run for current/lifetime alcohol users versusnonusers, entering demographic variables in the first step and session topics in the second step.Thus, the changes in predictability associated with session topics, over and above the contributionof demographic variables, were determined.

Results

Lifetime alcohol-use experience was reported by 53% of the participants, while 41% had nolifetime alcohol use, and 6% left this item blank. Twenty percent of the sample reported havingexperienced over ten lifetime episodes of alcohol use. Current alcohol-use experience was reportedby 23% of the participants, while a majority (73%) reported that they had not engaged in alcoholuse over the past 30 days, and 4% did not respond to this item.

Adolescent Satisfaction with Motivational Enhancement KIA-KEATING et al.

Satisfaction was significantly positively related to total number of visits to the program (r=0.20,pG0.001). Independent-samples t tests comparing the mean satisfaction scores on backgroundcharacteristics found no significant differences between boys and girls [t(421)=0.68, p90.05],between students in lower versus upper grade levels [t(419)=1.19, p90.05], or between non-Hispanic white versus non-white students [t(421)=−1.87, p90.05]. In addition, when examiningstudents’ self-reported drinking behaviors at the time of intake to the program, there were nodifferences in mean satisfaction found between students who self-reported as current versus non-current drinkers [t(404)=1.35, p90.05] or students who self-reported lifetime alcohol use versus noprevious alcohol-use experience [t(394)=1.24, p90.05].

Figure 1 depicts graphically the pattern of mean satisfaction by treatment dosage group acrosseach successive session attended. Participants were offered a maximum of six sessions and couldchoose to attend as many of those sessions as they wanted. A few students (n=7) were able toattend an extra, seventh session when they returned even after multiple reminders that they hadalready attended their final session; these students were allowed an extra session in order to assessand address their potential needs. Although this sample was small, we chose to depict themgraphically as their own dosage group in order to highlight the differences in dosage andsatisfaction patterns.

Figure 2 depicts mean satisfaction by alcohol-use categories across each program topic. Bothcurrent alcohol and lifetime alcohol-use categories were included in the figure to highlight students

Figure 1Mean satisfaction by treatment dosage across each successive session attended (n=423)

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in the two most discrepant groups: non-lifetime users (a population that can be targeted for primaryprevention, since these students have no alcohol-use experience) and current users (the populationof interest for a secondary prevention program such as the one described here).

A significant difference was found for program formats [F(2,420)=4.41, p=0.01]. Tukey’s posthoc analysis revealed that students reported greater satisfaction in the group (M=17.51; SD=2.57)and individual (M=18.00; SD=1.81) formats than they did in the website (M=16.40; SD=3.16)format. Mean satisfaction did not differ between schools [F(5,410)=1.21, p90.05].

Regression analyses

Program format Each format was examined separately. For website participants, neitherdemographic variables alone [F(3,46)=1.03, p90.05] nor demographics and current alcohol usewere significant predictors of satisfaction [F(4,45)=1.03, p90.05]. Similarly, when adding lifetimealcohol use as the predictor in the second step, the results were nonsignificant [F(4,45)=0.93, p90.05]. Thus, satisfaction levels with the website format did not vary based on sex, grade, race/ethnicity, or either current or lifetime alcohol use.

Demographic variables did not significantly account for the variance in satisfaction levels forcurrent alcohol users participating in the group and individual formats [F(3,77)=1.36, p90.05].Session topics, added in the second step of the model, was also a nonsignificant contribution to

Figure 2Mean satisfaction by alcohol-use categories across each program topic (n=423)

Adolescent Satisfaction with Motivational Enhancement KIA-KEATING et al.

predicting satisfaction [F(3,77)=1.36, p90.05]. However, notably, among current alcohol users,attendance in session 4, a session focused on identifying the progression of problematic alcoholuse, was significantly related to lower satisfaction (see Table 2). Among students who reported nocurrent alcohol use, similarly neither demographic variables [F(3,269)=1.19, p90.05] nor sessiontopics [F(8,426)=0.96, p90.05] predicted satisfaction.

Satisfaction for lifetime alcohol users participating in group and individual formats was neitherpredicted by demographic variables [F(3,190)=1.16, p90.05] nor session topics [F(8,185)=0.79,p90.05]. Likewise, for those students who had no lifetime alcohol use, neither demographicvariables [F(3,146)=1.09, p90.05] nor session topics [F(8,141)=1.54, p90.05] predicted asignificant amount of variance in reported satisfaction with the group and individual. Notably,among lifetime abstainers, attendance in session 3, a session focused on developing coping skills,was significantly related to higher levels of satisfaction (see Table 2).

Discussion

This study examined youth satisfaction ratings of a brief school-based motivational enhancementalcohol-prevention program. The sample provides data on a nonclinical population of adolescentsin a typical high school setting, and the results are therefore particularly useful for prevention-focused efforts. Moreover, given the multi-format approach of the intervention, the results help todelineate student preferences. In this study, students who participated in the group and individualformats reported greater satisfaction than students who participated in the website format. Thisdifference may be due to the importance, in adolescence, of belonging to a peer world andengaging in significant relationships with adults,30 facets particular to the group and individualformats. Nonetheless, when each format was examined separately, students experienced similarlevels of satisfaction with the program regardless of sex, grade, or race/ethnicity, suggesting that a

Table 2Summary of hierarchical regression analyses examining predictors of satisfaction for current

alcohol users and lifetime abstainers after participation in group and individual formats

Current alcohol users (n=175) Lifetime abstainers (n=97)

R2 ΔR2 B SE β R2 ΔR2 B SE β

Step 1: Demographics 0.05 0.05 0.02 0.02Constant 3.19 0.13 3.36 0.11Sex −0.08 0.15 −0.06 −0.13 0.11 −0.10Grade 0.15 −0.09 −0.06 0.12 −0.04Race 0.15 0.20 0.11 0.10 0.09Step 2: Topics 0.14 0.09 0.08 0.06Constant 3.27 0.23 3.16 0.14Sex −0.12 0.15 −0.09 −0.08 0.11 −0.06Grade −0.23 0.16 −0.17 −0.05 0.12 −0.03Race 0.28 0.15 0.21 0.10 0.10 0.08Expectancies 0.13 0.27 0.07 0.19 0.18 0.10Coping skills −0.01 0.29 −0.01 0.43 0.18 0.23*Problem use −0.62 0.30 −0.29* −0.06 0.20 −0.03Refusal skills 0.04 0.24 0.02 0.27 0.15 0.07Communication 0.04 0.25 0.02 0.23 0.14 0.16

*pG0.05

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school-wide prevention program such as Project Options can be appealing to students from diversedemographic backgrounds.

Two satisfaction findings were related to alcohol-use characteristics. First, the session focused onhow experimental use can lead to problem use, and alcohol-related consequences were related tolower satisfaction among current alcohol users. Second, for students who had never used any alcohol,the preference for a session focused more generally on stress and positive ways of coping wasapparent. Presumably, students currently engaging in alcohol use might experience uncomfortablelevels of cognitive dissonance when faced with a topic that reminds them of the risks and possiblenegative long-term consequences of their behaviors.31 On the other hand, life-long abstainers, forwhom the program is a primary prevention, may experience topics that have a greater alcohol usefocus as less personally relevant than a session emphasizing more general coping skills. In thisongoing study, these relationships will be investigated further to gain a better understanding onboth satisfaction and the relative impact of these session topics on mediators and outcomes.

In general, greater participation in the program was significantly related to satisfaction, andalthough the present finding provides no directionality, speculating based on the broader researchliterature on this topic,17 it is possible that satisfaction is a component of continuation in treatmentand should be considered in school-based efforts to increase adolescent retention in earlyinterventions for alcohol. Future research on the present secondary prevention program willexamine the impact of treatment dosage, satisfaction, and longitudinal alcohol outcomes.

Selection bias is a potential threat to the generalizability of these findings. For example, studentswho self-select to participate in alcohol-related services may have a higher level of interest ormotivation than students who choose not to participate in such services. Attempts to preserveexternal validity, such as school-wide recruitment using diverse advertising strategies, may havehelped to minimize the differences between participants and nonparticipants by having a broadarray of students self-select into the program; in fact, prior work has demonstrated that studentswho participate in Project Options have comparable lifetime drinking experience to the studentbody at each of the schools at which the prevention is provided.18 Nonetheless, self-selection doeslimit the interpretation of findings about satisfaction of a program, since students who chose toparticipate already may have a strong bias towards finding the idea of the program appealing.

While student satisfaction rates may be affected by pretreatment factors, it is important that thebrief intervention, which has been associated with elevated quit attempts, is appealing to the youthwho choose to participate. Students who self-selected into Project Options only attended anaverage of 2.5 sessions out of their possible maximum of 6 sessions, resulting in a smaller samplewho experienced higher treatment dosage. Despite this limitation, the prevention program wasdesigned as a brief intervention in line with other effective programs targeting substance-usebehaviors.32 Future analyses of program outcome will be critical to examining whether there is acritical point for dosage and effectiveness. In addition, it is important for future research to analyzewhether there are individual characteristics which relate to the level of intervention associated withpositive outcome. In other words, given the self-selection design for adolescents, perhaps studentswere choosing the best dosage that met their individual needs, and only a small percentage ofparticipants needed more than a few sessions to impact their behaviors.

Future studies should examine adolescent reasons for initial participation, ongoing participation,as well as discontinuation of involvement in the program. In addition, consumer satisfaction andprogram outcomes such as alcohol quit attempts and reductions in alcohol use and related problemsare a critical area for future research.

Implications for Behavioral Health

These results have important implications for informing future school-based preventionprograms, in general, and alcohol and drug problem prevention for adolescents in particular. It is

Adolescent Satisfaction with Motivational Enhancement KIA-KEATING et al.

important to include adolescents with a variety of past alcohol-use histories, including no previoususe, in secondary prevention programs in order to reduce stigma of participation to support the datapresented during the normative feedback sessions and to impact adolescents at both primary andsecondary prevention levels. In the present study, differences in satisfaction occurred with regard toparticular session topics that adolescents preferred based on their alcohol-use histories. Thepreferences of abstinent adolescents provides a window into topics that might best engageteenagers at a primary prevention level; focusing on stress and coping may increase adolescentinterest and satisfaction and can easily address multiple problem behaviors such as alcohol anddrug use. At a secondary prevention level, adolescent alcohol users experienced lower satisfactionwhen the session focused on alcohol trajectories and alcohol-related negative consequences. Animportant consideration for alcohol-prevention services is to find innovative ways to address theseissues with adolescents who have already started experimenting with alcohol, while maintainingtreatment engagement and retention and ultimately while most effectively impacting adolescentchoices and risk behaviors.

Voluntary motivational enhancement, school-based brief intervention appears to be acceptable toyouth. Providing a nonconfrontational, respectful, honest approach and emphasizing adolescentpreferences and confidentiality contrasts with traditional alcohol services and may better meetadolescent developmental needs.6,7,33 Notably, satisfaction is related to participation and, thus, is alaunching point to gain a better understanding of adolescent engagement, compliance, andretention in school-based alcohol-prevention programs.

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