Challenging Dogma - Fall 2011

Wednesday, December 28, 2011

Why We Are Not Getting Through to Teens: A Critique of the ‘Every 15 Minutes’ Program — Sarah Baird

Whether it is realistic to expect teens to wait until they turn 21 to drink alcohol is debatable, but one thing is certain—some teens do drink. Teenage drinking is a risky behavior that 71% of high school seniors have participated in at least once and 41.2% report drinking within the last month (1). The prevalence of underage drinking combined with the fact that motor vehicle fatality is the leading cause of death amongst teens, has spurred many anti-drunk driving programs, some more successful than others (2). When I was in high school, my school chose the ‘Every 15 Minutes’ program to sell the “don’t drink and drive” message. ‘Every 15 Minutes’ is a worldwide, school based, anti-drunk driving intervention. The origins of the program date back to 1995 when the Chico Police Department developed this two-day intervention (3). The program’s name was coined from an early 1990’s statistic that someone in the United States dies every 15 minutes from an alcohol-related collision (3).

When a high school chooses to host this program, it involves the participation of community members such as law enforcement, paramedics, hospital staff, coroners, and funeral homes, in addition to actual high school students and staff members (4). Several students are chosen to participate in the intervention and on day one a “grim reaper” pulls one of the selected students out of class every fifteen minutes, their obituary is read, and they return to class as the “living dead” unable to communicate with their fellow classmates (4). A drunk driving collision is then simulated on school grounds with students watching. The simulation is intended to be as realistic as possible. Emergency response teams attempt to rescue injured students, some students are pronounced dead on scene and others are rushed away by ambulance, police officers administer sobriety tests to the drivers and they are booked on drunk driving charges (4). In order to simulate the separation from friends and family that occurs with death or jail time, the students who participate in the collision retreat to a hotel for the night (4). Day two involves an assembly with a video presentation of the previous day’s events and reflections from participants. The students who played a part in day one read letters addressed to their parents as if they actually died and parents read similar letters addressed to their children (4). A parent who actually lost a child in an alcohol-related collision will speak to the student body along with hospital staff and police officers (4). The program is intended to be dramatic and evoke strong emotions, provoking students to think about the consequences of their actions. A video showing this intervention in further detail can be seen on the ABC news program Good Morning America: Every 15 Minutes (5). Despite the widespread use of this intervention at high schools across the country, ‘Every 15 Minutes’ is flawed and unsuccessful in effecting change in teens’ behavior.

The Danger of Expectations
The expectation established by this intervention is one of the major downfalls of this program. The entire program is represented under the idea that a tragic death occurs every 15 minutes as a result of an alcohol-related crash. In reality, 10,839 deaths occurred in 2009 as a result of alcohol-impaired driving collisions, which translates to one death every 48 minutes (6). Alcohol-related driving fatalities have declined in recent years, but even when this program first began in 1995 there was one alcohol-related crash on average of every 30 minutes (7). From the start, the foundation of this intervention was based upon an incorrect statistic. While the ‘Every 15 Minutes’ website does acknowledge the number of individuals killed in alcohol-related crashes has decreased, an updated statistic is not referenced (4).

The inflated statistic is of concern for multiple reasons—one being that the ‘Every 15 Minutes’ message is increasing the perception of the prevalence of the problem. The message causes students to overestimate the norm of drinking and alcohol-related fatalities. Researches have linked the failure of the anti-drug campaign DARE to this same flaw, criticizing the program for making drugs seem too “normal” and misrepresenting the prevalence of drug use (8). Social norms are often a strong predictor of behavior and this correlation is explored by social norms theory, which is based on the principle that people incorrectly perceive the behaviors and attitudes of others to differ from their own (9). Perkins and Berkowitz first suggested what is now social norms theory in 1986 and have done extensive research of social norms relating to student alcohol use (9). Studies of this theory have shown individuals often overestimate the prevalence of risk behaviors and change their own behavior to conform to the perceived norm (10). Additionally, those who partake in risky behaviors use the misperceived norm to rationalize or justify their unhealthy behavior (10).

Applying social norms theory to ‘Every 15 Minutes’ suggests students will drink and drive and possibly justify their behavior because they misperceive their peers to be tolerant of and partaking in the behavior themselves. Social norms theory also implies students could feel uncomfortable speaking out against drinking and driving because they misperceive their peers to be drinking and driving at a greater rate than reality would dictate. Research has consistently found that students considerably overestimate the prevalence of heavy drinking and drunk driving (11). Perkins suggests interventions aimed at dispelling misperceptions can reduce problem drinking through empowering responsible students and restraining those who partake in the risk behavior (11). The ‘Every 15 Minutes’ program does the exact opposite, creating a negative cycle where risk behaviors are perpetuated and healthy behaviors are suppressed (10). Thus, the expectation of this intervention perpetuates an existing misperception, making the misperception reality.

Provoking Reactance
The overarching message of ‘Every 15 Minutes’ could be summarized as “don’t drink and drive or else.” Ideally teens would never choose to drink and drive, but the choice exists. This intervention removes that choice without offering much of an alternative. The program’s message is not only simplistic, but the domineering tone also threatens teens’ freedom.

The fear appeal structure of ‘Every 15 Minutes’ poses a threat to teens’ freedom. The standard fear appeal structure involves threat-to-health and threat-to-freedom components (12). The threat-to-health component is substantiated through the physical and emotional consequences, fake injuries and death, and statistics on alcohol-related fatalities. The threat-to-freedom component is validated through the staged prosecution and punishment, and idea that the only option is to abstain from drinking and driving. Health promotion messages that utilize strong threats to health and freedom have been associated with increased reactance (12). Under Brehm’s theory of psychological reactance, when free behaviors are threatened or eliminated, people experience a motivational state to reestablish those freedoms (12). Specifically, Brehm defines reestablishing freedoms as participating in the behavior that one has been told they cannot or should not participate in (13). Individuals will act to restore freedoms through any available means and their level of reactance is proportional to their value of the lost freedom (12). It is also of note that individuals may or may not be aware they are experiencing reactance (12).

Under the principles of the psychological reactance theory, telling teens ‘no’ could motivate them to say ‘yes’ and ‘Every 15 Minutes’ does just that. The program uses scare tactics to emphasize drinking and driving is a big problem with drastic consequences, which teens are at risk of, and in the face of this immense threat the underwhelming answer is—just do not drink and drive. Students walk away from this intervention knowing what they are not supposed to do, but not much else. The only solution offered up by the intervention is to act responsibly—a paternalistic message often hammered into teens. Looking back on our teen years we all know this is easier said than done. The “Just Say No” approach did not work for DARE and the equivalent message does not work here (8). Reactance is minimized when someone familiar and relatable delivers the message, which this intervention partly does, but the message is just too simple here to be effective (14). This theory also explains that those most likely to engage in the free behavior that is being threatened exhibit the highest degree of reactance (13). Thus, students that are most likely to drink and drive are also most likely to feel this intervention is trying to tell them what to do, motivating them to reestablish their control of the situation. By using threats, fear, and a paternalistic tone to persuade teens to adopt a responsible behavior this intervention just positions itself to provoke rebellion in those that are most at risk.
Failure to Overcome Teens’ Invincibility

‘Every 15 Minutes’ acknowledges that teens understand the dangers of drinking and driving, yet most believe it will never happen to them (3). In light of this knowledge, the program was designed to show teens they are not invincible (3). In terms of social science theories, teens believing they are invincible would be called optimistic bias, illusion of control, or restraint bias. Combating teens’ optimistic bias and illusion of control seems like an effective approach to address this public health problem; however, ‘Every 15 Minutes’ fails to do so.

Optimistic bias is the phenomenon that people tend to underestimate the risk of something bad happening to them and overestimate the risk of something good happening to them (15). People tend to underestimate the probability that bad things will happen to them even when they understand or overestimate the risk that bad things will happen to other people (15). For instance, 72% of drivers do not believe it is very likely that they will get caught drinking and driving and students have been shown to think their risk of developing a drinking problem is much lower than that of other students (15-16). Under the principles of optimistic bias, even if teens fully understood or overestimated the risks associated with drinking and driving, they would underestimate their own personal risk. According to Professor Siegel, optimistic bias tends to be highest in teenagers and when trying to overcome optimistic bias, telling stories about individuals is much more impactful than delivering public health messages via statistics. ‘Every 15 Minutes’ attempts to deliver the anti-drunk driving message through a story involving peers; however, this story is only a dramatization. The intervention takes the theatrics too far with fake blood, a grim reaper, and students playing dead, so it seems like a cheesy television show rather than a realistic situation. The fact that the events of the intervention are staged limits the believability and detracts from the effectiveness in overcoming the optimistic bias of the teen audience.

Illusion of control is the idea that people have an unrealistic sense of the extent to which they can control an event or the events that happen to them (17). Illusion of control and restraint bias are essentially one in the same, with restraint bias being the idea that people overestimate their ability to control their behavior, particularly as it relates to temptation (18). Applying these principles to the problem of teenage drinking and driving would imply teens overestimate their ability to control whether or not they would drink and drive in general or be involved in a drunk driving accident. In simple terms, these overestimations account for a sense of invincibility. In studies exploring temptation control under a hot versus cold state, individuals tend to overestimate their impulse control when in a cold state and be more realistic of their abilities when in a hot state (18). Since ‘Every 15 Minutes’ is delivered in the cold state (i.e. teens are sober), teenagers will tend to overestimate their ability to say no to driving after drinking or getting in a car with someone who has been drinking. Interventions delivered in the cold state are less effective and without effectively addressing how to handle the hot state, the impact of the program is limited by its delivery.

Conclusion
‘Every 15 Minutes’ is potentially an effective intervention for anti-drunk driving. The message is delivered in a story format, largely by peers, and relies more on appealing to emotions than persuasion via statistics and facts. The intervention’s website claims participants are satisfied with the program, but does this satisfaction translate into behavior changes? Unfortunately it does not. Research has shown this intervention changes teens’ attitudes for the short term, but not their behavior (19).
The failure of this program can be partially attributed to the aggressive dramatization of the intervention. The reality is the program aims at creating a sense of hysteria in order to scare teens into changing their behavior. Teens are often hormonal and emotional, so throwing some fake blood on their friends and rushing them away in ambulance will provoke a strong emotional reaction in some teens. However, at the end of the day, teens know this two-day intervention was staged and their friends and family are safe and sound. Students can rationalize the events of the intervention are just a tall tale and go back to relying on their optimistic bias and illusion of control. Without empowering students or giving them any sense of control ‘Every 15 Minutes’ is unsuccessful in effecting behavior change amongst teens. Once the shock of experiencing the intervention wears off, it seems as though the message does as well.

Proposed Intervention
In order to reach teens, we must understand them. Through comprehending where ‘Every 15 Minutes’ fails and the application of social science theories, a more effective school-based anti-drunk driving intervention can be developed. Based on the pitfalls of ‘Every 15 Minutes,’ a more successful intervention would dispel misperceptions, minimize reactance, and combat optimistic bias and illusion of control shared by teens.

Instead of focusing on a staged, dramatization of a drunk-driving collision, the new and improved intervention could focus on sharing a true story. An individual who has lived through an alcohol-related driving experience, preferably a recent alumnus of the target high school or a neighboring school, would share their story with the high school students. The individual could be someone who was charged with a DUI or in an alcohol-related collision. They would speak to the student body about the reality of being charged with a DUI and the effect it had on their life and their friends and family. Rather than telling students what not to do, the emphasis would be on what they learned from the experience, what they lost, and how it has changed them as a person. The speech would highlight the gravity of the situation with intent to inform rather than to scare the students. The tone would be serious, but not accusatory.

The speech would be coupled with educational and interactive components. The educational component would focus on dispelling myths about teen drinking habits, empowering teens with skills on how to deal with their decisions regarding alcohol use, and providing information on local designated driver services or who to call if they ever need a ride. There would be an anonymous question and answer session where students could safely voice any questions or concerns. The intervention would get parents and the community involved much like ‘Every 15 Minutes’ does, providing an opportunity to open up dialogue with parents about drinking. The success of the anti-drunk driving campaign would be maximized through community efforts to enforce laws and a no tolerance policy on selling alcohol to minors.
Using Expectations in Another Way

The new intervention would use expectations in another way than they are used in the ‘Every 15 Minutes’ program. Rather than representing the program under a negative, exaggerated statistic, the program would flip the statistics around. Focus would be placed on dispelling misperceptions related to teen alcohol use and drinking and driving, using social norms theory to impact teen behavior. The speaker would emphasize that they are the exception not the norm and encourage students not to share in their mistake. The program would highlight the positive side of teen trends, such as the fact that the majority of teens do not drink—a recent study found that almost 60% of teens surveyed did not have a drink within the last month (1). An even greater majority, almost 83%, of people age 12-20 are not binge drinkers (20). In 2009, 90% of teens had never driven a car or vehicle after they had been drinking and 72% of teens had never ridden in a car with a driver that had been drinking (21). Drawing attention to the good decisions teens make establishes positive rather than negative expectations.

As discussed early, expectations and perceived social norms are a powerful indicator of behavior. In particular, there have been many studies on how norms influence drinking amongst adolescents and how norms can be used to reduce alcohol consumption (9-11). Correcting misperceptions has been shown to reduce problematic behavior and encourage healthy behavior (10). Most students already believe their peers drink more than they actually do and perceive their peers to be more permissive in their drinking attitudes than they actually are (11). The expectations delivered by ‘Every 15 Minutes’ only add to the misperceptions already held by students. Setting the story straight on teens’ actual attitudes and behaviors as they relate to drinking and driving will help to correct these misperceptions. Empowered with the facts, teens can feel more comfortable abstaining from drinking, reducing their drinking, or voicing their opinion against drinking and driving.
Changing Words to Minimize Reactance

The new intervention will employ the principles of psychological reactance to increase acceptance of the message and effect change in teen behavior. ‘Every 15 Minutes’ focuses on pointing out teens’ bad decisions and telling them what not to do, the new intervention will remove the accusatory tone and focus on alternative options. Instead of a ‘just abstain from the behavior’ message, the new program will have a ‘be in control message’—reminding teens they are the one’s with the power. The speaker will incorporate messages such as “We know some of you will choose to drink. If you are going to drink, arrange a safe ride home. Figure your ride out before you start drinking. Have a cab’s number in your cell phone.” These messages are more neutral in tone and leave the option up to the student, making them feel in control and thus minimizing reactance. In preparation of the intervention, the school can send home flyers to parents encouraging parents to let their children know they can always call them for a ride, no questions asked. Of course not all parents will feel comfortable with this, but for those that are, it is important their teens know they have this option.

Research has shown the persuasiveness of anti-drinking campaigns is largely dependent on the level of reactance they create (22). Reactance is minimized when more gentle, subtle language is used and when someone familiar delivers a message (12,14). ‘Every 15 Minutes’ attempts to reduce psychological reactance by involving students in the intervention program. The new intervention will go a step further, using someone familiar and toning down the paternalistic message. Students will be able to relate to the speaker because they are close in age and from the same area, creating a sense of familiarity. Removing the graphic visualizations from the intervention and using positive statistics helps to reduce the threat-to-health aspect seen in ‘Every 15 Minutes.’ By giving teens freedom to choose from options, making them feel in control, and minimizing the perceived threats, the message is more likely to be accepted by a broader audience (12-14).

The Power of a True Story
‘Every 15 Minutes’ acknowledges that there is a sense of optimistic bias and illusion of control in teens, but solely relies on theatrics and fear to overcome these obstacles. In the proposed intervention, the speaker will share their story without any of the hysterics of ‘Every 15 Minutes,’ making the message more genuine and believable. Students can dismiss ‘Every 15 Minutes’ because it is fake, the raw honesty of an individual who has actually lived through a DUI arrest or alcohol-related collision is something students cannot deny. Students will walk away feeling moved by the personal story, but not scared by fake blood and mangled cars. People can understand probabilities and even overestimate them but still not grasp their own risk—telling stories about individuals will be a lot more impactful than probabilities (15).

The most realistic approach to combating illusion of control and restraint bias is empowering teens so the illusion is removed and they are in fact in control. Interventions delivered during the hot state tend to be more impactful because people are more realistic about the level of control they have over a given situation (18). This could be difficult to accomplish because this public health issue involves underage drinking and it would obviously be inappropriate to have teens drink before the intervention. However, the goggles that simulate vision when intoxicated could be used to illustrate to teens what their coordination and perception is like when they have been drinking. By empowering teens with information, whether it is the reality on teen drinking trends or what their options are when they find themselves in a situation involving alcohol, knowledge is power. The new intervention would remove the theatrics of ‘Every 15 Minutes’ and inform teens about the less dire consequences of a DUI such as the embarrassment of telling friends you do not have a drivers license, the nuisance of not being able to drive yourself anywhere, and the negative impact it has on your ability to get a job. These consequences that affect one’s independence and social life are more relatable and relevant to teens than killing a friend or going to jail, which just seem too farfetched for most teens to fully comprehend. Illusion of control and optimistic bias are difficult to overcome, but the new intervention aims to combat these tendencies by leaving teens with a more realistic grasp on the situation.

Conclusion
Whether a life is lost every 15 minutes or every 48 minutes, the point is a life is lost. The tragedy is a death from an alcohol-related collision is completely avoidable. As public health practitioners we are responsible for intervening and educating the public on this risky behavior. However, designing and implementing an effective public health intervention is no small feat. People are complex and irrational, but social science theories can help demystify the motivations, attitudes, and behaviors of individuals. Hopefully by using these theories to design and implement an anti-drunk driving intervention teens will be persuaded to maintain healthy behaviors and change unhealthy behaviors.

































REFERENCES

1. National Institute on Drug Abuse InfoFacts. High School and Youth Trends. Bethesda, MD: National Institute on Drug Abuse National Institutes of Health, 2011.
2. Miniño AM. Mortality Among Teenagers Aged 12–19 Years: United States, 1999–2006. NCHS Data Brief, no 37. Hyattsville, MD: National Center for Health Statistics, 2010.
3. Farrow JA. Every 15 Minutes Procedural Manual: A “How-To” Guide for Communities Dedicated to Reducing Teen Drinking and Driving. CA: State of California—California Highway Patrol, 2011.
4. The Every 15 Minutes Program. About Us. Lehigh Valley, PA: Every 15 Minutes Organization. http://www.every15minutes.com/aboutus/
5. Every 15 Minutes Channel. Good Morning America: Every 15 Minutes. San Bruno, CA: YouTube. http://www.youtube.com/user/Every15Min#p/a/u/2/nyBFkvW5D10
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11. Perkins HW. Social Norms and the Prevention of Alcohol Misuse in Collegiate Context. Journal of Studies on Alcohol and Drugs 2002; 14: 164-172.
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14. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
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1 Comments:

  • At May 22, 2014 at 6:34 PM , Blogger Drew Rinella said...

    This program must end. Your article inspired me to write my own at the link below:

    http://stupidheartrhythms.blogspot.com/2014/05/reefer-madness.html

    I also wrote a brief commentary about the fake Dan Rather DUI video that schools are passing off as real:

    http://stupidheartrhythms.blogspot.com/2014/05/sniff-test.html

     

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