A Comparison of Changes in Knowledge and Attitude Between Problem Drinkers and Non-Problem Drinkers Following a Reeducation Program

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1 A Comparison of Changes in Knowledge and Attitude Between Problem Drinkers and Non-Problem Drinkers Following a Reeducation Program James L. Malfetti and Kenneth J. Simon1 For some time it has been recognized that drunken driving is a disproportionately large contributor to highway accidents and fatalities ( 8, 13). The question now is what can be done to reduce the distressful problem of Driving While Intoxicated (DWI). New York State DWI Counterattack is one attempt. This experimental program is a joint effort of the New York State Automobile Association and the Department of Motor Vehicles, made possible by Article 21 of the Vehicle and Traffic Law. Versions of the program are operative in three counties: Erie, Onondaga and Westchester. It is intended to reduce the approximately 3,000 traffic fatalities in New York State each year, about half of which are related to alcohol ( 1 2). THE PROGRAM DWI Counterattack substitutes reeducation and rehabilitation for traditional punitive measures since punishment alone does not seem to work. The program involves only those motorists who have been convicted in Erie, Onondaga and Westchester Counties for alcohol-related violations under Section 1192 of the Vehicle and Traffic Law, or those who have refused the chemical test for alcohol blood level. Participation is voluntary. Those who elect to take part retain their driving privileges if they attend all sessions of the course held once each week for 5 consecutive weekday evenings in classrooms of the State University College at Buffalo, Onondaga Community College at Syracuse, and Westchester Community College at Valhalla. Each session lasts 2 Vi hours and is conducted by professional personnel from the affiliated educational institutions. The aims of the course are to provide information on the consequences of drinking and driving and to consider why people drink and drive, and what countermeasures they can take. The sessions are conducted in a way which encourages a participant to analyze his own drinking habits against the opinions of his peers and his instructors, and to examine ways in which he might modify his behavior. Counselors with special training in alcoholism are present for referrals to community agencies as appropriate. Attendees pay a 30 dollar registration fee, and the course is self-support - ing. Tests and inventories are administered at the first and last sessions of the course. The results are used to assist in an evaluation of the course, as well as for program and 1Box 114, Teachers College, Columbia University, New York, New York. 737

2 738 J. L. Malfetti and K. J. Simon referral counseling purposes. Full details of course organization and content are contained in an Instructor s Manual (2). The New York State DWI Counterattack program was initiated with class one on November 15, It was modeled after a similar program in Phoenix (5, 11), and incorporated procedures, teaching aids, and evaluation techniques tested in that program. While DWI Counterattack began simultaneously in three counties, this report relates only to the Westchester County Program, which the authors have been monitoring directly, and to classes and the 566 graduates of those classes. Westchester County Program The ultimate objective of the Westchester course is behavioral modification, specifically reduction or elimination of DWI habits. Although the most generally acceptable way to measure such change is through driving records, such results will not be forthcoming in New York State for some time, and, when they are, will be subject to all the built-in difficulties of such a criterion (4, 14, 15). Meanwhile, the authors have selected knowledge and attitude toward alcohol and driving as measures of change produced by this course. The curriculum is based on three assumptions: (a) drinking is a significant force in traffic accidents; (b) alcohol reduces the skills needed in driving vision, perception, judgment, motor response; and (c) in a friendly, nonjudicial class setting led by competent educators, violators can be helped to understand the foregoing assumptions and to find ways to improve their own DWI behavior. It was judged reasonable, therefore, to investigate the extent to which the course was successful in increasing relevant information and improving attitudes, and to assume that persons educated to possess accurate information about the effects of alcohol and the implications of their own drinking and driving behavior would be in a better position to take appropriate countermeasures. The authors then administered a DWI knowledge inventory and an attitude test in a simple pretest-posttest design to the 360 graduates of the first 9 classes of the Westchester program. Scores on both instruments were significantly (p <.001) improved ( 6 ). THE PROBLEM Meanwhile, numerous studies suggested that of the convicted DWIs sent to rehabilitation such as Westchester DWI Counterattack, at least a third and perhaps a half were problem drinkers (1, 7). Since alcohol was a pervasive problem for them the question of whether they would profit from a DWI course was raised. The course dealt with only one symptom of their overall problem and therefore efforts relating to DWI knowledge and attitude change might be entirely lost upon them. The investigators were unable to find any studies which have looked into the differential impact of a drunken driver rehabilitative effort on persons with various degrees of drinking problems on the criterion measures of DWI knowledge and attitude change. Specifically, then, the question became: How do problem drinkers and those not so classified compare on DWI knowledge and attitude change after a DWI course? Definitions K n ow ledge is intended to mean possession of factual information relevant to drinking

3 Reeducation and Attitude Change 739 and driving. It is operationally defined as the numerical score on the Drinking and Driving Knowledge Inventory (KI). A ttitu d e refers specifically to one s feeling about driving after drinking. It is operationally defined as the numerical score on the Drinking and Driving Opinion Survey (OS). P roblem D rinker is the designation given to a person whose consumption of alcoholic beverages exerts a chronic and detrimental influence on his social and/or economic functioning. Operationally, persons with scores on the Alcoholism Indicator (Al) of 5 or more are classified as problem drinkers. METHODOLOGY Population The 637 DWIs assigned to classes of the Westchester DWI course which ran from October 2, 1972 to November 5, Sample The 566 DWIs from that population who attended both data collection sessions and thus had prebaseline and postbaseline data available. No data are available on dropouts and no shows. Also, it is possible that some persons included attended both data collection sessions, but missed some intervening class sessions. Instruments Drinking and D riving K now ledge In ven tory (KI). This is an objective test comprising 2 0 multiple-choice items, to measure knowledge of relationships between alcohol and driving. It requires about 10 minutes to administer. The inventory represents a refinement of the original 40 item Drinking and Driving Knowledge Inventory developed by Simon (10) using internal consistency item-analysis techniques on a pool of 152 items. The original inventory had a corrected difficulty level of.54, a mean item discrimination of.56, Kuder-Richardson Formula 20 reliability coefficients of.80,.84, and.85, and apparent content validity. Using further collected item analysis data from 781 persons, the 40 item inventory was reduced to 2 0 on the basis of item-test correlation while preserving the content distribution of the test as originally conceived. Thus, the best items from the standpoint of statistical functioning were assembled for the 20 item inventory. Scores on the instrument may range from 0 to 20. Estimates of reliability ranging from.70 to.79 have been made using Kuder-Richardson Formula 20. Content validity is judged to be high. A detailed description of the development of this instrument appears elsewhere (9). D rinking and D riving Opinion Survey (OS). This is an attitude scale comprising 20 true-false items, designed to measure opinions toward driving after drinking. It requires about 5 minutes to administer. The scale represents a refinement of the original 38 item Drinking and Driving Opinion Survey developed by Simon (10) using equalappearing interval scaling techniques from a pool of 70 items. The original scale had a mean s value of 5.0, ranging from 1.8 to 8.9, and a mean Q value of 1.5, ranging from

4 740 J. L. M alfetti and K. J. Simon 0.6 to 2.4. Reliability estimates of.79 and.84 were obtained using a split-half technique after rank-ordering the items according to item weight, corrected for shortened test length with the Spearman-Brown prophecy formula. Evidence of scale validity was presented using criterion groups. The 38 item scale was reduced to 20 items using item response pattern data of 792 subjects and maintaining a balance of the scale continuum. Scores on the instrument may range from 2.1 to 8.9. Estimates of scale reliability range from.70 to.90 using the same procedures described above. A detailed description of this instrument appears elsewhere (9). Behavioral D escription Scales (BDS). These scales are composed of 5 items of the multiple-choice type, in which the options represent increasingly positive points along a continuum. The items relate to the individual s 1) willingness to accept responsibility for his DWI arrest; 2) his impression of the fairness of the arrest; 3) feelings about his chances for future arrest; 4) feelings about his chances for changing DWI behavior; and 5) sense of the value of the course in altering his DWI behavior. Only scales 1, 2, and 5 are considered in this report. They provide measures of attitude supplementary to the OS. The other scales were designed to assist in counseling and referral and not as attitude measures. The BDS requires about one minute for administration. The scales were derived informally from the literature on the personality characteristics of alcoholics, and on the objectives of alcoholism therapy programs. A lcoholism In dicator (A l). This is the instrument used to assign the sample to drinking problem classifications. It is a composite of 9 factors, each contributing a weighted score. From various data collection forms administered to DWIs, the following items and scoring comprise the Al: Have you ever been arrested for other driving offenses involving alcohol? (yes=4 points); Do you think you might have a drinking problem? (yes=2 points); Have you ever sought help? (yes=3 points); Do other members of your family object to your drinking? (yes=2 points); Have you ever lost a job because of drinking? (yes=4 points); 2 points for drinking before noon; 1 point for drinking alone; 1 point for drinking when there is no occasion; 1 point for drinking when there is no reason. The possible range of scores is The items were developed by counselors with training and experience in working therapeutically with alcoholics, from approximately 1500 case histories of DWIs, including behavioral records and the results of personal interviews. Items were developed, assembled and weighted by the counselors to reflect the same criteria they use to categorize DWIs by degree of drinking problem: no problem, potential or emerging problem, definite problem. The development procedure has built-in content validity. Data Collection Procedure All data in this study were gathered at the data collection sessions which precede and follow each course. Data collection procedures are standardized: printed test batteries are distributed, a brief introduction to the task is made, and persons are directed to complete all forms following the written instructions accompanying the instruments. The test package includes several instruments in addition to those analyzed here. All instruments are scored by a course assistant; BDS, KI, OS, and Al scores are then entered on a coding sheet and keypunched.

5 Reeducation and A ttitude Change 741 Research Paradigm A three group before-and-after design was created. The sample was divided into three groups as follows: no drinking problem (AI=0-1), potential drinking problem (AI=2-4), definite drinking problem (AI=5+). The three groups were compared for knowledge and attitude change by analyzing postcourse scores while adjusting for precourse dissimilarities. Analysis o f Data The data were first analyzed descriptively: distribution of Al scores in the sample; mean pre-and-post course scores for each of the three groups computed for BDS, KI, and OS; mean improvement for each Al score computed for BDS, KI, and OS. The data were then treated inferentially: an analysis of covariance on posttest scores treating the pretest scores as covariates; correlations of difference scores (post minus pre scores, yielding an improvement score) of BDS, KI, OS with Al scores. RESULTS Of the total sample (N=566), Al scores range from 0 to 16. There are 251 subjects (44.3%) without Al scores.2 For the 315 subjects with scores, the mean Al is 4.10, with a standard deviation of 3.51 and a standard error of The distribution of Al scores is presented in Table I. TABLE I Distribution of Scores on the Alcoholism Indicator (Al), N = 566 Al f % adj. % cum. adj. % missing The percentage of missing scores is so high because data were accepted only when answers appeared for all nine Al determinants.

6 742 /. L. Malfetti and K. J. Simon TABLE II Measure KI OS BDS 1 BDS 2 BDS 5 Mean Pretest, test, and Difference Scores, and t Values for Knowledge Inventory (KI), A ttitude Scale (OS), and Behavioral Description Scale (BDS) 1, 2, and 5 for Persons without a Drinking Problem (AI=0-\ ), Potential Drinking Problem (AI=2-4), and Problem Drinkers (AI=5+), N=566 Drinking Problem None 65 Pre Potential 127 Pre Definite 101 Pre Unclassified3 233 Pre None 56 Pre Potential 121 Pre Definite 95 Pre Unclassified3 222 Pre None 69 Pre Potential 131 Pre Definite 101 Pre Unclassified3 238 Pre None 70 Pre Potential 132 Pre Definite 103 Pre Unclassified3 236 Pre None 68 Pre Potential 130 Pre Definite 100 Pre Unclassified3 233 Pre N Administration Mean SD XDiff. SD t *** *** *** *** *** ** *** j *** ** gj*** ** i9*** * *** i*** *** ** ** g 92*** * p <05 ** p< 0 1 *** p< amissing Al data

7 Reeducation and A ttitude Change 743 Mean pre, post and difference scores are presented for all instruments (KI, OS, and BDS 1, 2, and 5) for the three groups classified by relative drinking problem in Table II. For the no problem, potential problem, and definite problem drinkers, respectively, mean improvement in KI scores is 4.29, 4.41, and 3.84; and 0.95, 0.35, and 0.51 in OS scores. Improvement in these 6 cases is significant at.001 except OS for the p o ten tia l problem group (p<.01). Also, improvement on BDS scores is significant at.001 in all cases except BDS 1 for no problem and defin ite problem groups (p<.01 for each), BDS 2 for no problem group (p< 05), and BDS 5 for no problem and definite problem groups (p<.0 1 for each). Improvement in KI and OS scores is presented by Al score in Table III. KI improvement ranges from 3.28 (AI=7) to 5.00 (AI=9). All improvement scores are significant at the.0 1 level or higher, and there does not appear to be a connection between KI improvement and Al score. OS improvement ranges from 0.12 (AI=9) to 1.17 (AI=0). There is no clear connection between OS improvement and Al score. TABLE III M ean Im provem en t in K n ow ledge Score (K I) and A ttitu d e Score (O S) by Score on Alcoholism Indicator (A l), N =566 Score Alcoholism Index N X Diff. SD t KI *** *** *** *** n 2 2 *** *** ** ** ** *** *** missing *** OS *** *** * * *** * missing a n j *** * p ^.o s ** p C.O l *** p<.001

8 744 J. L. Malfetti and K. J. Simon Improvement scores when Al is 4, 5, 6, 8, and 9 are not significant. For remaining scores, they are significant at the.05 level or higher. TABLE IV Mean Im provem en t in Behavioral D escription Scale (B D S) 1, 2, and 5 Scores b y Score on A lcoh olism Indicator (A l), N = 566 Score Alcoholism Index N X Diff. SD t BDS * ** ** *** * missing *** BDS * * ** * * missing *** BDS ** * *** * ** missing *** * p <.0 5 ** p<.01 *** p <.0 0 1

9 Reeducation and A ttitude Change 745 Similar data presentation appears for BDS 1,2, and 5, in Table IV. Improvement scores for BDS 1 range from (AI=6) to 1.22 (AI=8), for BDS 2 from 0.30 (AI=5) to 1.40 (AI=6), and for BDS 5 from 0.00 (AI=9) to 0.67 (AI=4). No trend is apparent from improvement in either BDS 1, 2, or 5 score by the Al score. Most improvement scores are not statistically significant. Covariance analysis was applied to the three groups to compare their posttest scores while adjusting for pretest dissimilarities. The posttest scores, adjusted posttest scores, as well as the pretest scores, are presented for the three groups for all measures in Table V. Inspecting the adjusted posttest scores, possible trends are noted: for the no problem, p o ten tia l problem, and problem drinker groups, respectively, KI scores are 14.48, 14.20, 14.00; BDS 2 scores are 3.67, 3.90, 4.14; BDS 5 scores are 4.36, 4.48, That none of these trends is statistically significant can be seen from the results of the covariance analysis summarized in Table VI. The F statistic for the BDS 2 analysis is, however, almost significant (.05<p<.10). There is one significant difference found through the analysis, however, and this relates to OS scores. Here are found adjusted posttest scores of 6.58 for the no problem group, 6.04 for the p o ten tia l problem group, and 6.21 for the p roblem group. The analysis yields an F of 7.08, significant at.01. The highest scores are found for the no problem group, followed by the definite problem group and then the potential problem group. TABLE V Measure Mean Scores on Five Measures (KI, OS, B D S 1, B D S 2, and BD S 5 ) fo r N o Problem, P oten tial Problem, and D efinite Problem D rinker Groups: Pretest, Unadjusted test, and P osttest A djusted fo r E ffect o f Pretest. Drinking Problem Group N Pretest X Unadjusted test X Adjusted test X KI None Potential Definite OS None Potential Definite BDS 1 None Potential Definite BDS 2 None Potential Definite BDS 5 None Potential Definite Scatter plots were created to look at the nature of the relationship between Al and the 5 measures (KI, OS, BDS 1,2, and 5). Inspection of the scatter plots revealed no systematic relationship of Al with any score.

10 746 J. L. Malfetti and K. J. Simon TABLE VI A nalysis o f Covariance B etw een Three G roups (N o Problem, P oten tial Problem, and D efin ite P roblem D rinker ) on Five Measures: P o sttest Scores on K I, OS, B D S 1, B D S 2, and B D S 5, using P retest Scores as Covariates, N =566 Measure Source df SS MS F KI Between * Error Total OS Between ** Error Total BDS 1 Between * Error Total BDS 2 Between * Error Total BDS 5 Between * Error Total * not significant ** p <.0 1 Product moment correlations computed for improvement in each of the 5 measures (KI, OS, BDS 1, 2, and 5) and Al, range in magnitude from.00 to.11, showing a negligible relationship. Thus improvement in any measure is not related to Al score. These findings appear in Table VII. TABLE VII Correlation o f Im provem ent Scores (Difference Scores on BDS 1, 2, 5, KI, and OS) with A lcoholism Indicator DISCUSSION Measure BDS 1.00 BDS 2.04 BDS KI OS -.11 In the present sample, defin ite problem drinkers account for approximately 34.3 per cent, potential problem drinkers 43.5 per cent and those without a drinking problem Al

11 Reeducation and A ttitude Change per cent. These findings are approximately consistent with earlier cited findings of the problem drinking classifications of DWIs. The statistical test comparing the three classified drinker groups on improvement on knowledge and attitude measures used analysis of covariance. In the analysis, posttest scores were compared after being adjusted for pretest influence. This powerful technique (3) is appropriate even in instances where statistical adjustment for pretest differences is minimal, such as with the OS, although in such cases its function approaches the analysis of variance. The descriptive findings are inconclusive. The groups appear to be fairly similar and improvement on KI, OS, and BDS 1, 2, and 5 by Al score seems to be irregular. The inferential test findings revealed that with covariance analysis, the three groups could not be differentiated on knowledge improvement (F=0.56) but could be on attitude improvement (F=7.08). The major difference here seems to be that the no problem group showed significantly more improvement than the p oten tial problem group, with adjusted posttest scores of 6.58 and 6.04, respectively. The definite problem group came in at 6.21; it seems reasonable to conclude from this that the no problem group improves more than the others. A possible explanation for this finding is the fact that for the defin ite problem group (and even the poten tia l problem group) to make the type of attitude change sought here would necessitate greater conflict and incompatibility with existing value structure and lifestyle than would be the case for those with no drinking problem. As a result, it may be posited that definite and potential problem drinkers are more resistant to attitude change than non-problem drinkers. If such a speculation is valid, it would seem appropriate to avail these groups of additional and more intensive efforts to deal with the sources of conflicts. However, it should be made clear that the poten tia l problem and definite problem groups do show significant improvement in attitude, but not to the same extent as the nonproblem drinkers. This suggests that while the former groups profited from the DWI course, further affective experiences would be desirable to bring them up to the level of change of the latter group. Data were checked for linearity and no curvilinear relationship was found between Al and any of the 5 variables of this study. Thus, it seems that the arbitrary grouping into the three drinking classifications by Al has resulted in nonequivalent groups in terms of attitude improvement despite the fact that there is no relationship between Al and OS improvement. However, the fact that there is no systematic relationship between Al and OS improvement suggests that the group differences by OS improvement might not be a stable characteristic of such samples. However, further study would be necessary to support such a speculation. Another finding of interest relates to BDS 2. Here some tendency, although not significant, was found for defin ite problem drinkers to show greater change in the direction of stating that their DWI arrest was fair. Adjusted posttest scores for no problem, p o ten tia l problem, and defin ite problem groups were 3.67, 3.90, and 4.14, respectively. Here too, however, the finding of no relationship between the variables using a product moment correlation may suggest that any observed difference in BDS 2 improvement by drinker group might be an artifact of arbitrary classification. Further investigation into this area would be desirable because of some of the important implications for rehabilitation of having problem drinkers face the fact that their arrest was fair.

12 748 /. L. M a lfetti and K. J. Sim on CONCLUSION Although no problem drinkers seemed to show greater OS improvement than poten tia l problem and d efin ite problem drinkers combined, no relation was found between drinking problem classification (defined by Al) and knowledge and attitude change. The findings clearly suggest that those DWIs suffering more serious and pervasive problems with alcohol gain significantly in knowledge about DWI and to the same extent as other DWIs. In so far as such change is deemed important, the Westchester County reeduction program is not lost upon them. In addition, the findings suggest that while DWIs with a potential or definite drinking problem improve significantly in attitude, the change is less than that shown for non-problem drinkers. Perhaps the former group should be encouraged to become involved in follow-up experiences planned to produce additional attitudinal and behavioral change. REFERENCES 1. U.S. Department of Transportation, Alcohol Safety Action Project, Evaluation o f Operations, Washington, D.C., Vol. 1, Summary, Page American Automobile Association, AAA Instructor s Manual for DWI Counterattack. The Association, Washington, D.C., Atiquallah, M., The Robustness of the Covariance Analysis of a One-Way Classification, Biometrika 51, 365 (1964). 4. Barmack, Joseph E., Methodological Problems in the Design of Motor Vehicle Accident Research, American Journal o f Public Health 52, 1866 (1962). 5. Developm ent and Preliminary Tryout o f Evaluation Measures for the Phoenix Driving-While- Intoxicated Reeducation Program. A report to PPG Industries Foundation. Arizona State University, Tempe, Arizona, Malfetti, James L. and Simon, Kenneth J. Evaluation o f a Program to Rehabilitate Drunken Drivers, Traffic Quarterly 28, 49 (1974). 7. Malfetti, James L. and Stewart Ernest I. Drunken Driving: The Twelve Hours Before Arrest, A nd What To Do A b o u t Them. A report to PPG Industries Foundation. Teachers College, Columbia University, New York, New York, National Safety Council. Accident Facts, 1973 Edition, pages 40 and Simon, Kenneth J., The Development of Evaluative Instruments for Rehabilitative Programs for Drunken Drivers, Proceedings o f the 18th Annual Conference o f the American Association for Autom otive Medicine, In press. 10. Simon, Kenneth J., The Effectiveness o f the Phoenix DWI (Driving While Intoxicated) Course in Changing Knowledge and A ttitude Concerning Driving After Drinking. Unpublished Doctoral Dissertation. Columbia University, New York, New York, pp Stewart, Ernest I. and Malfetti, James L. Rehabilitation o f the Drunken Driver: A Corrective Course in Phoenix, Arizona, for Persons Convicted o f Driving Under the Influence o f Alcohol. Second Printing. Teachers College Press, New York, New York, Tofany, Vincent L., New York State s Concern. In R eport on the Governor s Conference on Alcohol Problems, New York State Department of Mental Hygiene, Albany, New York, pp Waller, Julian A., Alcohol and Injury, Safety, 28 (May-June 1969). 14. Zylman, Richard, Evaluating Driver and Traffic Safety Education Programs: It May Be Tougher Than You Think, Journal o f Traffic Safety Education 21, 7 (October 1973). 15. Zylman, Richard and Bacon, Seldon D. Police Records and Accidents Involving Alcohol, Quarterly Journal o f Studies on Alcohol, Suppl. 4, 178 (1968).