Innovations in Behavioral Health Care

Maximizing the Effectiveness of Virtual Brief Alcohol Screening and Intervention for College Students (BASICS)

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA

The negative consequences associated with high-risk drinking, including academic impairment, social harms, injury, and death (White & Hingson, 2013) are perennial concerns. Nearly one-third (33%) of college students (compared with 22% of same-age non-college peers) have consumed five or more drinks on one occasion during the past two weeks (Schulenberg et al., 2020). As campuses resume in-person instruction and programming in Fall 2021, there are many questions about what to expect with two “incoming” classes of first-year students (i.e., the actual first-year students of the incoming 2021 class, and second-year students who spent their first year of college away from classmates). Ongoing access to evidence-based approaches to reduce alcohol misuse remains a priority. In this commentary, we provide a brief background on BASICS, the most widely-accepted, individual-level intervention to reduce high-risk drinking and offer our perspectives on how to maximize its effectiveness in the post-pandemic era. Many campuses quickly adapted and implemented their substance use programming using virtual formats during the COVID-19 pandemic, including delivery of BASICS. With in-person instruction, events, and programming set to resume in the upcoming months as we are emerging from the pandemic, campuses that have become fluent in using virtual programming are considering keeping telehealth (e.g., videoconferencing and virtual services) as an option within their range of services provided. As virtual options become more mainstream, including in general healthcare, we discuss implementation considerations for an evidence-based virtual BASICS program, offer recommendations for student affairs professionals as they deliver BASICS in this virtual setting, and provide additional considerations for the use of other telehealth services.

BASICS

The Brief Alcohol Screening and Intervention for College Students [BASICS; (Dimeff, Baer, Kivlahan, & Marlatt, 1999)] program is a widely-used, evidence-based approach to reduce high-risk drinking and associated negative consequences (National Institute on Alcohol Abuse and Alcoholism, 2019). BASICS is a brief motivational intervention that includes a baseline alcohol screening used to generate personalized feedback, followed by an in-person session led by a trained facilitator with the goal of reviewing the feedback and increasing the student’s motivation and commitment to change high-risk alcohol use. The facilitator conducts the session using motivational interviewing (Miller & Rollnick, 2012), a non-judgmental, non-confrontational approach where the student’s motivations for change and goals are explored. Personalized feedback on the student’s alcohol use (e.g., typical and peak alcohol consumption; estimated blood alcohol concentration), negative consequences, and other alcohol-related outcomes are discussed, in addition to the student’s perception of drinking norms for a reference group (e.g., “typical college student”) as well as the accurate norms for that reference group.

Evidence for the Effectiveness of Virtual BASICS

Evidence-based treatments for mental health and substance use have been shown to be just as effective when delivered using telehealth as when delivered in person (Substance Abuse and Mental Health Services Administration, 2021). Previously, our team (Lee et al., 2021) evaluated a web-conferencing (i.e., virtual) BASICS for community college students and found the intervention was effective at reducing alcohol use and consequences. VSee was used, a HIPAA compliant web-conferencing and screen-sharing software package for the sessions, similar to many of the other platforms used during the pandemic. At a three-month follow up, students who completed the web-conferencing BASICS had 29% fewer drinks per week and 24% fewer consequences than those who did not receive the intervention. We also found the use of web-conferencing was appreciated by students, as nearly all students rated their web-conferencing experience between good to excellent (97%), found the web-conferencing program useful (95%), and reported they were attentive during the session [95%; (Lee et al., 2021)]. This suggests the use of a virtual platform to deliver BASICS is an acceptable and effective strategy to reduce alcohol misuse for college students.

Implementation Considerations for Virtual BASICS

There is every hope that Fall 2021 will be approximately “normal,” with the assumption that more in-person instruction and activities will resume. However, beyond the COVID-19 pandemic, there is value in offering virtual services within a campus’s range of services. For institutions of higher education considering implementation of BASICS in a virtual setting, we offer the following implementation considerations.

Why offer virtual sessions?

As more students assume multiple roles, including parenting, going to school while working, being a student-athlete, and others, a virtual session eliminates commute time and could be seen as respectful to a very full schedule. When campuses deal with inclement weather but remain open, services can still be provided. Virtual sessions allow for flexibility and could even be provided to students not taking classes locally (e.g., studying abroad, online classes) who report struggling with substance use (assuming any logistics related to time zones and restrictions in scope of services related to professional licensure can be resolved).

Confidentiality and logistical issues

Issues of confidentiality are especially important during virtual sessions, as many students are participating in sessions from their family home or shared living environment with peers or partners and could be in close proximity to others. In our virtual BASICS study (Lee et al., 2021), most students were alone during BASICS (82.5%), however it is somewhat concerning that 17.5% reported another person was with them or in the same room [e.g., 2.5% family; 12.5% partner (boyfriend/girlfriend) was there]. Facilitators should ask students if they feel comfortable discussing sensitive topics (like alcohol use) in their current location and if anyone is in the room with them. Another option is to simply suggest relocating to a private location and if that is not possible, reschedule the session. If students are not comfortable, facilitators could encourage the student to move to a private location for the session, such as a car, another area of the house, or even outside in a quiet spot. We also encourage that both facilitator and student use headphones and a microphone to maintain confidentiality, to prevent someone else from overhearing the session, and to improve audio quality.

Correction of inaccurate drinking norms

Students often overestimate peer alcohol use and assume their peers are drinking more than they actually are. Providing accurate drinking norms to correct this misperception is one of the primary mechanisms of change in a BASICS session (Larimer & Cronce, 2007) and is associated with a reduction in one’s alcohol use (Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011). Correcting the misperception is achieved by showing the student a graphical representation of their alcohol use (e.g., typical number of drinks consumed during a drinking occasion), their perception of others’ alcohol use, and the accurate norm.

As students resume in-person activities both on and off campus, the correction of inaccurate drinking norms remains an important intervention target. One study during the early stages of the pandemic found even though young adults increased how often they drank but decreased the number of drinks consumed per drinking occasion, they continued to overestimate how much alcohol their peers were drinking (Graupensperger et al., 2021). Student affairs professionals will want to exercise caution in how they talk about their own impressions of what “most” students are going to do, because statements like “we know drinking increased during the pandemic” is simply not the case for most students. Inquiring about their specific experiences during the pandemic related to changes in their drinking pattern might be appropriate. As Fall 2021 approaches and more in-person events resume, young adults might continue to overestimate peer alcohol use, suggesting norms-based approaches (i.e., BASICS) are both relevant and needed.

Screen share functionality to display feedback

In a virtual BASICS session, showing graphical feedback of normative comparisons and correcting misperceptions are important elements of the intervention. The use of a screen share function enables the facilitator to display this graphical feedback with a student, while still having the video screen to see the student. In our virtual BASICS study (Lee et al., 2021), facilitators alternated between the screen share function (where the personalized feedback was displayed) and unsharing function (where the personalized feedback was hidden). For the VSee platform, there were differences between devices and the view of the screen. For example, those with a mobile phone could see only the facilitator or only the feedback, not both. Those using a laptop or tablet could view both facilitator and feedback simultaneously. We found this approach of alternating back and forth between sharing and unsharing the feedback was important for both participants to maintain a personal connection while also viewing the feedback, especially as 35% of students used mobile phones which only had the capability to see one display at a time (Lee et al., 2021). Student affairs professionals could ask students what type of device they are using and be mindful of alternating between viewing the feedback and the facilitator. After the session, the personalized feedback was emailed to the student so they had a copy and could continue to view it.

Recommendations Moving Forward

As higher education institutions prepare to welcome students back on campus in Fall 2021, we encourage the use of virtual platforms to expand access to care, increase capacity to serve students, and address co-occurring mental health and substance use problems. We offer the following recommendations:

1. Increase access to evidence-based interventions

Telehealth could reduce traditional barriers to treatment engagement and increase access to evidence-based interventions. For example, offering virtual sessions might especially benefit non-traditional students (e.g., full-time employment, parents) who are engaged in many social roles that could limit their ability to attend in-person sessions on campus. Offering virtual sessions can also be attractive to those who commute to campus and might spend more time away from campus when not attending class. Providing telehealth also makes hybrid work for health professionals a meaningful option given the ever-increasing demand for mental health and substance use intervention services.

2. Implement virtual screening in primary care/student health center and counseling center

The model of screening, brief intervention, and referral to treatment (SBIRT) is an effective way to identify those at-risk for alcohol misuse and then facilitate a connection with evidence-based services, such as BASICS. Still, issues related to the implementation of screening in remote, virtual settings remain. Prior to the COVID-19 pandemic, screening could be conducted in a student health or counseling center by having students complete a self-report instrument [typically the Alcohol Use Disorders Identification Test; AUDIT (Babor, Higgins-Biddle, Suanders, & Monteiro, 2001)], followed by subsequent referral to a brief alcohol intervention. However, approximately one quarter (26%) of young adults delayed accessing medical care because of the pandemic (Centers for Disease Control and Prevention, 2021a). This suggests that the opportunity for young adults to be screened for alcohol misuse in a primary care, student health, or counseling setting has also been delayed, as students are delaying their appointments. Unfortunately, some college health centers might have cut back on screening due to staff shortages during the pandemic, compounding the problem. Improving both engagement in medical care and methods of virtual screening for substance use (if the appointment is telehealth) could be important for identifying those at risk for alcohol misuse. For telehealth primary care appointments, the implementation of virtual screening for alcohol misuse, followed by referral to BASICS as the “BI” in SBIRT, could be an effective method of increasing the dissemination of evidence-based interventions. This could be achieved by having the student complete an online version of the AUDIT before their telehealth appointment or completing it with the student during the appointment by reading the items out loud for the student to answer or using the screen share function.

3. Integrate substance use and mental health screening and referral

Young adults with mental health problems are at risk for co-occurring alcohol misuse. National data from SAMHSA (2020) show that young adults with mental health impairment are more likely than those without impairment to binge drink alcohol (31% versus 25%, respectively). During the COVID-19 pandemic, anxiety, depression, and loneliness have been highest among young adults compared with other age groups (Luchetti et al., 2020; McGinty, Presskreischer, Han, & Barry, 2020), with increases in loneliness largely accounting for increases in depressive symptoms (Lee, Cadigan, & Rhew, 2020). CDC data as of May 2021 indicate 34% of young adults aged 18 to 29 years old reported depressive symptoms during the past week and 39% reported anxiety symptoms, significantly higher than the national averages of 22% and 25%, respectively (Centers for Disease Control and Prevention, 2021b). Taken together, these findings suggest that nearly one-third of all students presenting at a BASICS session might be struggling with symptoms of depression or anxiety.

Addressing barriers to improve access to mental health and substance use services remains a crucial task.  The proportion of young adults who need mental health services but did not access them increased from 15% to 21% between August 2020 and May 2021 (Centers for Disease Control and Prevention, 2021c). Widespread screening for both mental health and substance use can identify students at risk for either or both problems. Easy-to-use depression and anxiety screening instruments are available (e.g., Patient Health Questionnaire (PHQ), Generalized Anxiety Disorder Assessment (GAD), which can be followed by as-needed referrals to on-campus mental health resources. Our work has shown that heavy drinking college students with acute mental health symptoms experience more barriers to accessing services than those without symptoms (Cadigan & Lee, 2019), and many young adults do not access services because they could not afford it or did not know where to go (Cadigan, Lee, & Larimer, 2019). Student affairs professionals and BASICS facilitators could provide information to students to address logistical barriers (e.g., a handout with contact information of free/low-cost/sliding scale mental health services on campus and in the surrounding community) or help them directly with making the appointment.

4. Make changes sustainable

If virtual BASICS, in addition to other telehealth services, will continue to be offered, what systemic efforts and structure are in place to maintain telehealth services? For example, sustainability could include the ongoing use of HIPPA-compliant video services, programming efforts that advertise virtual services, and access to private rooms equipped with webcams and headphones for facilitators to lead the virtual sessions as well as maintaining space for in-person sessions. We also encourage the ongoing training of facilitators in best practices for substance use prevention and intervention, including continuing training and consultation for BASICS and motivational interviewing to maintain intervention fidelity.

NIAAA’s College Alcohol Intervention Matrix (CollegeAIM) encourages a mix of individual-level and environmental-level strategies to address high-risk drinking (National Institute on Alcohol Abuse and Alcoholism, 2019). Certainly, BASICS has proven to be an important part of that mix. It is always important to consider how changes to evidence-based strategies affect the actual impact on outcomes; fortunately, virtual delivery of BASICS still results in reductions in drinking and related consequences. Thus, efforts to reduce barriers on access to this evidence-based approach, including providing virtual options, will ultimately broaden the reach of this approach.

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