You are on page 1of 25

TABLE OF CONTENTS

Abstract Introduction

ABSTRACT
Introduction
21st birthday celebrations are often linked with high-risk alcohol consumption, which can lead to a host of negative health and safety consequences including alcohol poisoning, motor vehicle accidents and assault. To address this behavior among University of Arizona (UA) students who are celebrating their 21st birthday, the Health Promotion and Preventive Services (HPPS) office within the UA Campus Health Service (CHS) is developing Project 21: an event-specific, web-based intervention that provides 1) individualized feedback on planned blood alcohol content (BAC) levels, 2) alternative activities to alcohol consumption, and 3) additional health resources related to alcohol consumption. This will be CHS' first program designed to address high-risk alcohol consumption specifically among 21-year -olds at the University.

Goals
1) To design a responsive website (responsive meaning adaptable to a variety of devices including smartphones and tablets) based on the content and site map devised by the Project 21 team prior to the start of the internship; and 2) 2) To prepare a survey that will be used to evaluate the website's appeal and effectiveness within the target population.

Methods
Utilized the software Adobe Illustrator to create initial mockups for each page of the website, including the interactive features "Plan Your Night" and "BAC Calculator". Several design ideas were evaluated and modified to achieve a minimalist aesthetic and optimal responsive design. Electronic evaluation forms were created using Google Forms.

Output
The final designs were shared with the Student Affairs Systems Group (SASG) so that they could use these designs to build the website. The evaluation forms were created, as well as the email invitations that will be sent to students.

INTRODUCTION
HERE ARE MANY COLLEGE EXPERIENCES that are associated with highrisk, heavy episodic drinking (also known as binge drinking) typically defined as five or more drinks in a row for men and four or more drinks in a row for women 1 from tailgating at football games to holidays and special events like New Year's Day, Spring Break, and Graduation. On a more regular basis are the parties and casual drinking events (e.g., "Thirsty Thursday") that may also encourage students to binge drink 2. A student's 21st birthday is a particularly noteworthy opportunity for high-risk drinking since drinking on this particular occasion is considered by many to be a rite of passage carried out in celebration of reaching legal drinking age. Many of the traditions associated with 21st birthdays involve binge drinking: drinking 21 shots of alcohol in one sitting; drinking at several bars in one location (known as a bar crawl or pub crawl); and drinking during the "Power Hour" (the objective here is to drink a shot of beer every sixty seconds for one hour, or to drink as much as possible in the hour after midnight) 3. Studies have found that, on their 21st birthdays, students are more likely to consume alcohol than to abstain from it, and tend to drink more on their 21st birthday compared to any other previous occasion 4,5. Students who binge drink on their 21st birthday face a greater risk for alcohol poisoning, unintentional injuries (e.g., car crashes, falls, drowning), intentional injuries (e.g., physical assault, sexual assault), and other health consequences6.

The University of Arizona (UA) Campus Health Service (CHS), whose mission is to promote the health and wellbeing of students at the UA through its services and programs, is developing a Web-based intervention titled Project 21 in an effort to address high-risk 21st birthday drinking among students at the university. Project 21, which is being developed by the Health Promotions and Preventive Services Office (HPPS) in CHS, is a website that will encourage students to plan the amount of drinks they will have on their birthday (if they do intend to drink); take precautions during their celebrations; and incorporate alternative activities to drinking into their birthday celebrations. On their 21st birthday, UA students will receive an email invitation encouraging them to visit the Project 21 website and plan their birthday celebrations. Students will also be encouraged to provide feedback, through an online survey, on the website's appeal and usefulness. This feedback will be used by CHS to improve upon the website and, eventually, perform case-control studies to evaluate how effective Project 21 is at reducing student intentions to binge drink on their 21st birthday as well as actual birthday drinking behaviors.

I worked on the design elements of Project 21 as a volunteer in the Fall semester of 2011, and as an intern in the Summer of 2012 while completing my Bachelor of Science degree in Public Health. Much of this time was spent familiarizing myself with the software I would use to design the website (Adobe Photoshop and Illustrator). I continued my work during a second internship this time while completing my Master of Public Health degree. My goals for this internship were to: 1. Finalize the designs for the website, email invitations, and evaluation surveys using content and research findings provided by the Project 21 team (HPPS Outreach Specialist, Melanie Fleck, and HPPS Director David Salafsky) 2. Collaborate with the University of Arizona Student

Affairs Systems Group (SASG) on the development of the website; and 3. Facilitate the live release of the website (including the collection and analysis of the student surveys). I was very eager to work on this project as it granted me the opportunity to contribute to the development of a public health intervention and apply myself towards addressing the public health core competencies and essential services in a practical setting.

Internship Site: The University of Arizona Campus Health Service


The University of Arizona Campus Health Service promotes health, wellness and safety at the University of Arizona and in the surrounding community through its health care services, health education, and contributions toward health-related policy development at the University16. CHS is the first fully accredited college health service in the country, and was accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1978 as well as the Accreditation Association for Ambulatory Health Care (AAAHC) in 1981 17. Students enrolled at the UA have a number of options for accessing health care at CHS: fee-for-service, CampusCare Supplement, Student Health Insurance, and Commercial Insurance. Costs to the student vary for each system. Students are not required to have health insurance in order to access health care at CHS, though CHS recommends that students "maintain adequate health insurance to cover unexpected medical expenses". The fee-for-service option is automatically available to all currently enrolled UA students. CHS fees are generally less expensive than those charged by other providers in the community, and CHS accepts a number of payments, including cash, check credit card (only for faculty and staff) or Bursar billing (only for registered students). CHS also offers after-hours telephone medical assistance by means of an on-call physician or nurse practitioner18.

The Health Promotion and Preventive Services (HPPS) office within CHS offers a number of programs and services to promote the health and wellbeing of the university's student population. These include health education materials; presentations; individual and group instruction; counseling; and referrals. HPPS covers an array of heath topics, including those related to mental health, sexual health, nutrition, sleep health, violence prevention and substance use including alcohol use. Project 21 will be HPPS' first program designed to address high-risk alcohol consumption specifically among 21-year-olds at the UA.

LITERATURE REVIEW
College students tend to drink more alcohol, in general, compared to their non-college peers, and several factors have been found to contribute to highrisk drinking among college students, including peer and media influences 7. The following literature review examines the prevalence of high-risk 21st birthday drinking among students, potential risk factors for this behavior, and the research-supported benefits (as well as disadvantages) of Web-based interventions that have been used to address it.

Prevalence of binge drinking during 21st birthday Factors associated with celebrations binge drinking during 21st Study findings suggest that students are more likely birthday celebrations to drink alcohol on their 21 birthday than to abstain
st

from it. One study involving over 3,000 undergraduate students found that over 80% drank on their 21st birthday. Nearly half of the participants reported drinking more on their 21st birthday compared to any other previous occasion5. Another study, involving over 1,000 undergraduate students who were turning 21 between January and August 2008, observed that over 90% of participants drank on their 21st birthday, and that participants' BAC levels due to 21st birthday drinking was 50% higher than their BAC levels during normal drinking (0.186 vs. 0.08) 8. Finally, a third study involving over 2,000 students found that 83% drank on their 21st birthday, compared to 79% of their non-college peers 5.

Factors that are associated with heavier 21st birthday drinking include the following:

This study also observed the prevalence of binge drinking associated with 21st birthdays: 79% of men and 68% of women engaged in binge drinking on their 21st birthday 5. In this study, women were more likely to drink than men, but male students who drank consumed more drinks than women (14.6 vs 11.4 drinks). 12% of both male and female students who drank on their birthday reported that they consumed exactly 21 drinks (which may be attributed to the tradition of having 21 drinks on ones 21st birthday), while an additional 22% of male birthday drinkers and 12% of female birthday drinkers reported having more than 21 drinks 5.

Male gender Fraternity/ sorority membership Younger drinking initiation Normative misperceptions (e.g., overestimating the number of drinks consumed by peers on their 21st birthdays) Heavier precelebration intentions

"..situational/ contextual factors such as patronizing bars, larger celebration groups, engaging in drinking traditions, and peer encouragement for drinking" 9.

Brister, Sher and Fromme suggest that heavy eventrelated drinking, such as drinking on ones 21st birthdays, may be more strongly influenced by peer motivation and environmental factors than individual attitudes and social norms 9. Another factor that may influence the risk of experiencing negative outcomes during 21st birthday celebrations is the individual's level of drinking experience; some studies have observed that inexperience with drinking is associated with a higher risk for negative outcomes, though the 2011 Brister, Sher and Fromme study observed that greater drinking experience was associated with a much higher likelihood for negative

Negative Outcomes for high-risk 21st birthday


Some of the negative physical and behavioral outcomes reported by students in the 2011 Brister, Sher and Fromme study are illustrated in Figure 1. 35% of students reported vomiting after drinking; 41% blacked out; and 45% experienced a hangover the day after their 21st birthday.

Figure 1. Negative Outcomes Associated with 21st Birthday Drinking. Data from "21st birthday drinking and associated physical consequences and behavioral risks", by Brister, Sher and Fromme (2011). n = 150

In addition to the physical consequences of heavy 21st birthday drinking, students may face a number of behavioral risks and other negative consequences as well, which are also presented in Figure 1, and include flirting with others (23% of students); making out with one or more people (29%); and drunk dialing or posting on Myspace/Facebook. In another study, involving 244 students who drank on their 21st birthday, 27.8% reported missing school or work the day after their birthday; 27.2% neglected responsibilities; and 17.4% found themselves in a place they could not remember arriving at10. These studies strongly suggest that students, by engaging in heavy drinking on their 21st birthday, may place themselves at a greater risk for injury, unsafe behaviors (including unsafe sexual activities), and consequences

related to regular responsibilities such as school and work. These consequences may range from minor to severe, and have the potential to have long-term implications (e.g., pregnancy, long-term physical damage from injuries) as well as place the individual at a greater risk of death (e.g., from alcohol poisoning, accidents, physical assault).

Project 21 as a Public Health Intervention


Public health interventions may be classified as upstream, mid-stream or down-stream interventions depending on their method of addressing the health issue in question and the scope of their influence (see Table 1). Interventions that use policy approaches to change the circumstances that contribute to adverse health behaviors for example, establishing a nation-wide legal drinking age are considered up-stream interventions. Downstream interventions focus on changing adverse health behaviors at the individual level through services such as individual counseling. Mid-stream interventions focus on individuals within a particular setting or organization, such as a university, and utilize organizational channels to prevent adverse health behaviors 11. Project 21 incorporates elements of both mid-stream and down-stream interventions in that it targets a specific group of people (students at the UA) through an organizational channel (the University of Arizona Campus Health Service), and provides individual-level self-help/educational resources that students can use when planning their 21st birthday celebrations. The Project 21 team wanted to address this issue with a Web-based intervention since there are many advantages to its use (e.g., easy access for students via computers and mobile devices) and since Web-based interventions, along with other electronic health interventions, have demonstrated effectiveness at reducing the quantity and frequency of alcohol consumption among college students 12.

Type of intervention Upstream

This intervention affects Large populations

This intervention involves.

Example

Macro-level policy approaches (e.g., governLaws that prohibit alcohol ment regulation, economic incentives) that pro- vendors from selling alcomote healthy behaviors while redirecting hol to minors. "unhealthy societal and industry counterforces"11. Population-level interventions that seek to change and/or prevent adverse health behaviors through important organizational channels or natural environments (e.g., worksite, schools, communities). Individual-level interventions "with an emphasis on changing rather than preventing healthdamaging behaviors"11 (e.g., group/individual counseling, self-help programs, patient health education, pharmacologic treatments). Alcohol-related health resources (such as Project 21) that are provided by CHS specifically for students at the UA Project 21, as a form of patient health education/ cognitive-behavioral intervention

Midstream

Everyone within a defined population or setting (e.g., within a university or worksite)

Downstream Individuals (particularly targeted higher-risk individuals)

Pros and Cons of Web-Based Interventions for 21st Birthday Drinking


A meta-analysis of 35 manuscripts with 43 separate computer-delivered interventions (CDIs) to reduce alcohol use among college students found that CDIs "[reduced] the quantity and frequency of drinking among college students", producing small to moderate within-group effect sizes at short-term and longer-term follow-ups. The authors concluded that "CDIs are generally equivalent to alternative alcohol-related comparison interventions14. A Web-based randomized controlled trial involving 295 college students all of whom reported that they planned to have 2 or more drinks on their 21st birthday observed that the Web-based personalized intervention was effective at reducing estimated BAC levels reached by the students on their birthday. This was especially noticeable among students who reported intentions to reach higher BAC levels10. experiencing in-person interventions, compared to Webbased interventions, students may be more likely to go over each feedback component, ask questions about the feedback, and change their behaviors in response to the feedback. Other benefits to using an in-person intervention include being able to monitor the students' level of attention when they receive the feedback (these observations can be applied towards making the intervention more engaging), and being able to recruit students' friends to administer or support the intervention efforts (this incorporates the beneficial influence friends can have on drinking behaviors). Despite the advantages to in -person interventions, the Web-based delivery of Project 21 is arguably more feasible for CHS due to its cost efficiency and easy access for the target population. Students at the UA may be more inclined to visit an alcohol education website than to attend a similarly-themed in-person While this study successfully demonstrated the efficacy of activity. Web-based personalized feedback, Neighbors et al. note that "the effects were relatively small but comparable in magnitude to those of more general individual approaches to alcohol prevention among college students" and that interventions involving personalized feedback might have a larger effect size when delivered in person. When

Figure 2. Benefits to Using a Web-Based Intervention for Project 21 17,19

Project 21 Needs Assessment


The content for Project 21 was developed by Melanie Fleck who previously spearheaded the project during her own Master of Public Health internship and David Salafsky, Director of Campus Health Promotions and Preventive Services. In assessing the needs of the target population and relevant stakeholders, Ms. Fleck performed three main investigations:

1. An evaluation of data from the 2011 CHS annual Health and Wellness Survey 2. An online survey involving varied University and community stakeholders from the UA Alcohol Coalition, and 3. Student intercept surveys on Project 21 and perceptions regarding 21st birthday-related alcohol consumption.

Ms. Flecks findings were used to develop the content of the Project 21 website. For example, the website's BAC calculator was influenced by the UA Alcohol Coalition's interest in a BAC calculator smartphone application, while the What Other Students Say section of the Plan Your Night Results page was influenced by studentreported interest in tips for students who are planning to celebrate their 21st birthday15. An analysis of alcohol-related behaviors among UA students (based on annual CHS Health and Wellness surveys from 2002 to 2011) found that students who are over 21 years old tend to drink more frequently than their younger peers, though students under 21 tend to reach significantly higher BAC levels despite having a lower average of drinks consumed per week (3.7 versus 4.9). These findings suggest that interventions for UA

students who are under 21 should emphasize high-risk episodic drinking, while interventions for UA students over 21 should emphasize sustained typical drinking behaviors15. While these findings do not specifically address 21st birthday drinking among UA students, they arguably support the use of an event-based intervention, such as Project 21, to address the high-levels of alcohol consumption that occurs uniquely during 21st birthday celebrations, rather than an intervention that focuses more on typical drinking. drinking among UA students, they arguably support the use of an event-based intervention, such as Project 21, to address the high-levels of alcohol consumption that occurs uniquely during 21st birthday celebrations, rather than an intervention that focuses more on typical drinking.

Goals, Objectives and Activities


The overarching goal of this internship was to collaborate with HPPS and SASG to develop the Web-based intervention Project 21, which is intended to provide interactive and personalized feedback to UA students who are turning 21 years old so that they can better plan their birthday celebrations, especially if they plan to drink alcohol. Internship goals, learning objectives and activities are summarized in Table 2, while public health core functions and essential services to be addressed by the internship are summarized in Table 3.

Table 2 Internship Goals, Learning Objectives, and Actions

Learning Objectives
Goal 1: Design, Develop and Promote Project 21

Internship Activities

Collaborate with SASG in developing the website. 1. Develop necessary skills for creating a Web-based Develop skills in relevant software (namely Adobe Illusintervention. trator). Evaluate the visual presentation of the website to determine if it is age-appropriate, accessible, easy to under2. Tailor a Web-based intervention to a specific tar- stand, and neutral in regards to gender, sexuality, etc. get audience. Obtain the input of the target audience regarding the appeal and usefulness of the websites design and content (to be conducted after live release of website).
3. Develop skills in the accurate visual presentation of health information on alcohol-related topics.

Collaborate with the Project 21 team to ensure that the material is accurate and appropriately presented. Maintain regular correspondence via email with the SASG team and with the rest of the Project 21 team.

4. Improve upon written communication skills in order to engage effectively with collaborators on a virtual/remote project.

Goal 2: Develop and Disseminate Evaluation Surveys


Utilize online databases such as PubMed to find studies, meta-analyses, and literature reviews that have been conducted for Web-based interventions similar to Project 21 to determine how best to evaluate the effectiveness of the website. Evaluate the data obtained in the literature review (e.g., 6. Evaluate the integrity and comparability of data. look for gaps in data, study limitations) Work with preceptor to generate survey questions, com7. Develop necessary skills for conducting a study to plete the human subjects approval process, prepare the evaluate the effectiveness of an intervention. electronic means of delivery, and arrange for compensation of study participants (if possible). Review evaluation questions for accuracy and clarity; solicit feedback from rest of Project 21 team and other 8. Improve upon written communication skills in collaborators. order to convey evaluation questions accurately and Solicit feedback from target audience by including quesclearly. tions in the survey regarding the wording and presentation of the survey questions. 5. Develop necessary skills for conducting a literature review on evaluations of Web-based interventions similar to Project 21.

Goal 3: Analyze and Apply Survey Findings


9. Gain experience analyzing data; apply necessary Compile data from surveys and perform statistical analstatistical methods to make relevant inferences from yses to determine if the intervention was associated with data. a decrease in student intent to engage in high-risk birthday drinking. 10. Apply study findings towards improving an inter- Work with HPPS and SASG to make relevant changes to vention. the website based on the feedback of the target audience.

PROJECT 21 Timeline
2009

2010 2011

2012

2013

DESIGNING PROJECT 21
There are six features in the Project 21 website: BAC Calculator, Plan Your Night, Alcohol IQ, Mocktail Recipes, Birthday Ideas, and Resources & FAQ (Frequently Asked Questions). A summary of the content for each feature is presented in Table 4, with the complete written content available in Appendix . My role during my undergraduate and graduate internships at HPPS was to design the website around this content.

Project 21 Feature
BAC Calculator

Content
Provides users BAC level based on: 1) weight and sex, 2) number of standard drinks consumed, and 3) number of hours spent drinking. The BAC calculator also features a chart illustrating the users change in BAC level over time, and also a description of what the users overall BAC level means (i.e., how the alcohol they have consumed may affect them). Provides personalized feedback and ideas for the users 21st birthday celebration, including predicted BAC level, birthday horoscope, signature mocktail recipe (based on the students birthdate), and ideas from fellow students. Debunks various myths about alcohol consumption on 21st birthdays. Presents a list of alcohol-free mocktail recipes as an alternative to alcoholic beverages. Offers non-alcohol-related activities that students can add to their birthday celebrations. Provides additional resources on alcohol (such as Campus Healths RedCup newsletter) as well as details regarding the Project 21 website.

Plan Your Night Alcohol IQ Mocktail Recipes Birthday Ideas Resources & FAQ

Project 21 Homepage
Several designs were considered for the Project 21 homepage. Figure 2 presents an early concept design I made for Project 21 during my undergraduate internship with HPPS: the everyday objects in the des ign (e.g., s mar tphone, calculator) serve as links to the features of the website (e.g., the smartphone links to the Plan Your Night feature while the cocktail umbrellas link to the recipes page).

Figure 3. Project 21 Homepage Concept Art from Undergraduate Internship

I used a hand-drawn style and "ink wash" background to convey a relaxed atmosphere, and an unconventional layout to pique the users interest and encourage them to explore the site. This design ultimately proved unfeasible due to the difficulties it posed in adapting the website to tablet and mobile devices. My subsequent designs took into greater consideration the responsiveness of the website design so that this could be more readily achieved. The Project 21 team and SASG wanted to achieve a design that could be compatible with a variety of devices from computers to tablets to smartphones so that a mobile version of the site would not be needed. An example of a website with a mobile version is presented in Figure 3, with the mobile site (http:// en.m.wikipedia.org/wiki/University_of_Arizona) on the left and the regular site (http://en.wikipedia.org/ wiki/University_of_Arizona) on the right. Figure 4 presents an example of a website with a responsive design; users visit the same address (http://www.arizona.edu/apply) regardless of the device they use.

Figure 4. Example of a Mobile Version of a Website

Figure 5. Example of Responsive Website Design

One of my later designs which was presented to the Project 21 team two months prior to the start of my internship used a "chalkboard lettering" style that was inspired by sidewalk sandwich-board menus used by restaurants, bars and cafes (Figure 5). This design took into consideration the responsiveness of the website: as shown in Figure 3, the links are arranged in a grid, which could be rearranged depending on the width of the browser. While the Project 21 team liked the aesthetic of this design, we quickly realized with feedback from SASG that the image-heavy design could lengthen browser loading times, which would be burdensome to users.

At SASG's suggestion of simplifying the design, I replaced the link-illustrations with plain text (e.g., Plan Your Night) and minimalist icons (e.g., a cake slice). Three different designs were considered using this new style (Figure 4). Ms. Fleck conducted an informal survey among the HPPS staff to obtain feedback on the most appealing design. The design with the light grey background and dark grey icons received the most votes, and was used as the basis for the design of the other pages. I worked on these designs throughout the Fall 2013 semester, and Appendices A through C chart the progression of my work. The finalized designs, which were shared with SASG in February 2014, are presented in Appendix D.

Figure 6. Project 21 Homepage Concept Art, Chalkboard Style (June 2013)

Figure 7 Project 21 Homepage Concept Art, Minimalist Style (August 2013)

Plan Your Night & BAC Calculator


Plan Your Night is the main feature of the website, and provides personalized feedback that students can use to plan their 21st birthday celebrations regardless of whether they plan to drink or not. Upon arriving the Plan Your Night page the link in the email invitation will take the users to this page first rather than the homepage users will see only the first two questions shown in Figure 8: 1) Do you plan on drinking alcohol on your birthday?, and 2) When is your birthday? If the user selects Yes for question1, question 3 will appear, prompting the user to enter details about the number of drinks they plan to have, as well as other relevant information needed to calculate their BAC. As the user enters this information, the red box at the bottom of question 3 will update their BAC output with both the BAC level and a brief description of what it means. Earlier drafts of Plan Your Night included an additional question, which prompted students to select a number of activities they planned to do on their birthday, including ways they planned to enjoy alcohol safely (if they intended to drink) (Figure 9). This section was ultimately excluded from the Plan Your Night questionnaire since it did not have a corresponding response in the Results section. In place of this is the What Other Students Say section in the Plan Your Night Results page, which offersstudents suggestions on how to have a safe and enjoyable 21st birthday (Figure 10).

Figure 8. Plan Your Night Final Design (Without Background)

Figure 9. Plan Your Night Deleted Section, How Will You Enjoy Your 21st Birthday?

Figure 10. Plan Your Night Results, What Other Students Say

Figure 11. Plan Your Night Results: BAC, Birthday Horoscope, Signature Recipe

In the final version of the Results page, the BAC section will be displayed at the top of the page (see Appendix D), so that the user sees their BAC results first (since this is the most important aspect of the Plan Your Night feature). The rest of the Results page is comprised of the users BAC feedback, Birthday Horoscope, and Signature Recipe (selections shown in Figure 11). The BAC feedback in the Results section provides further detail about the effects of the users BAC level, and encourages the user to visit Project 21s BAC calculator page to further plan their birthday drinking. Users who select No for question 1, indicating that they do not plan to drink on their 21st birthday, will still see the BAC feedback section, though the BAC level reported will be .00, with the accompanying description congratulating the user on choosing not to drink. The concept design presented in Figure 12 illustrates the responsiveness of the Plan Your Night Results page: the images, which serve as anchors to the various sections of page (e.g., clicking on the cake illustration will take the user further down the page to the horoscope section) , adapt to changes in browser size, thus allowing users to easily access the feature on a variety of devices. This ease of access encourages students to use the website on the go, whether at home, on campus, or around town. If a student decides to visit a bar on their birthday, they can easily access the BAC calculator to calculate their estimated BAC levels depending on the number of drinks they plan on having.

Figure 12. Plan Your Night Results, Responsive Design

In the final version of the Results page, the BAC section will be displayed at the top of the page (see Appendix D), so that the user sees their BAC results first (since this is the most important aspect of the Plan Your

Alcohol IQ and Mocktail Recipes


The Alcohol IQ page presents a few myths and facts about alcohol consumption related to 21st birthday celebrations, citing research findings. When users visit this page, only the red text boxes, each presenting a potential myth or fact, will be visible (see Figure 13 for a cropped version of the page, and Appendix D for the full version). Clicking on a text box will reveal its corresponding answer. These collapsible accordion-style content panels encourage the user to first think about whether the statement is true or not before they see the answer. It also infuses some interactivity into the page while being very touch-screen-friendly, allowing for easy use on smartphones and tablets. The pages relatively limited content and interactivity could be improved upon in future modifications to the site with more myths/facts and other interactive elements to promote user interaction with the page and retention of the information presented. The Mocktail Recipes page (also cropped in Figure 13) is presented in the same format as the Alcohol IQ page: users click on the white text box containing the title of the mocktail to reveal the recipe, and the close button at the bottom of the panel to make it collapse again. There are 12 mocktail recipes in this page, which are also used in the Plan Your Night feature (each recipe is matched with horoscope dates). Earlier concept designs for this feature included cocktail recipes as well, but this was ultimately excluded since the inclusion of alcoholic recipes might encourage users to try them over the non-alcoholic ones.

Figure 13. Alcohol IQ (Cropped Version)

Figure 14. Mocktail Recipes (Cropped Version)

Birthday Ideas and Resources &FAQ


The Birthday Ideas page presents a handful of ideas that students might add to their celebration plans. The purpose of this page is to encourage students to celebrate their birthdays in unique, memorable ways that do not necessarily involve alcohol. Some of the birthday ideas, as shown in Figure 14, provide links to external sites where users can get more information about these activiites. There are currently six birthday ideas listed on the page, and the Project 21 team may add more in the future. The page could also be improved upon with more interactive features (e.g., embedded videos, interactive content panels) to further engage the users interest.

Figure 15. Resources & FAQ

Figure 14. Birthday Ideas

Project 21 Email Invitations and Surveys


Upon the live release of the Project 21 website, UA students who are turning 21 will receive the Project 21 email invitation (Figure 17), wishing them a happy birthday and encouraging them to visit the Project 21 website to plan their birthday celebrations. The Project 21 team is currently working with SASG to plan the logistics of this process, from identifying students in the university records who are turning 21 to disseminating the email invitations. Student feedback on Project 21 will allow HPPS to evaluate the websites effectiveness at reducing student intent to engage in high-risk drinking on their 21st birthdays. Students receiving the Project 21 email invitations will be encouraged to provide feedback on the website's appeal and usefulness through an online survey, which will be sent to them shortly after the initial email invitations. The survey is Figure 17. Project 21 Email Invitation currently intended to be delivered via Google Forms. Initial drafts of the survey included a number of multiple choice and short answer questions regarding each feature of the website, as well as the visitors overall perceptions of the website. However, the survey was condensed to 5 multiple choice questions that the Project 21 team deemed most critical (Table 5). The team felt that a longer questionnaire might discourage students from taking the time to complete it. Formal focus group studies may be conducted on Project 21 at a later date to obtain more input on the effectiveness of each feature of the website. Case-control studies may also be conducted to evaluate the impact of the website on students 21st birthday drinking behaviors when compared to controlgroup interventions (e.g., pamphlets). The Project 21 team and I had hoped to begin student evaluations of the website during my internship; however, the design and development stage took a longer time than expected, and so we modified our project plan and moved the evaluation stage to a later date. As of March 2014, the website is currently being developed by SASG, while the materials for the evaluation stage including the email invitations and surveys are being developed by the Project 21 team. The team hopes to be able to disseminate the invites and surveys to students soon after the website is completed.

Table 5. Project 21 Evaluation Survey Survey Question


What device did you use to access the Project 21 website when you first visited it?

Answer Options
a.Mobile device (e.g., smart phone) b.Tablet device (e.g., iPad, Kindle, Galaxy) c.Computer (e.g., laptop, desktop) The text is difficult to read (due to the font or size) The pages take too long to load The links don't work I did not have any problems using the website Other (text box provided for user to type in description)

Did you have any problems using the website on your device? Select all that apply.

Once you completed the questionnaire on the None of the feedback was useful BAC feedback Plan Your Night page, you were directed to a Re- Birthday Horoscope Signature Recipe What sults page with feedback such as your Birthday Other Students Say Horoscope and estimated BAC level. What feedback did you find useful*? Select all that apply. "Useful" feedback means feedback you could imagine yourself acting on (e.g., trying out a mocktail recipe; using your BAC results to plan the number of drinks will have on your birthday) How would you rate the BAC calculator in terms a.1 Very difficult to use b.2 c.3 d.4 Very easy to of "ease of use"? use How likely are you to recommend our website to other people? a.1 Very unlikely b.2 c.3 Neutral d.4 e.5 Very likely

DISCUSSION
My internship at HPPS has been a fulfilling experience in contributing to the development of a public health intervention, and has allowed me the opportunity to employ the core competencies I learned throughout my MPH program in a practical setting. Two out of three core functions of public health were addressed in this project: Assurance and Policy Development. The Policy Development component involved the creation of the website, which is intended to educate and empower students about high-risk drinking while providing them with ideas on celebrating their 21st birthday safely. The second core function, Assurance, involves connecting students to this resource, which my internship began to address by developing the Project 21 email invitations. While there are many Universityrelated and publicly-available resources on alcohol that are available to students at the UA from smartphone BAC applications to CHS' Red Cup Newsletter (published weekly in the University newspaper) CHS wished to provide a service that was specifically tailored to 21-year-old students at the UA to reduce the prevalence of 21st birthday-related binge drinking. My contributions in this internship have helped to fill this gap in their alcohol programs.

Challenges
This internship presented a number of challenges for me and the Project 21 team. The first was geographic: SASG and the Project 21 team were based at the main UA campus in Tucson, while I was based in the Phoenix Biomedical campus. However, we were able to overcome this with relative ease by scheduling regular teleconference meetings to conduct updates. I typically shared my work via PowerPoint presentations, and on occasion, when the allotted meeting duration allowed for it, was able to implement changes to the designs and share them immediately via email. design and build the website. I had hoped to begin evaluations sometime in September or October 2013, but as of March 2014, the website is still in development. As such, the third core function of public health that I had hoped to address, Assessment, was not achieved during this internship; however, I was able to address it in part by designing the survey that students will take once they visit the website. Once HPPS begins to collect this information, they can assess the strengths and weaknesses of the website in terms of its effectiveness at reducing student intent to engage in high-risk drinking, and make changes to the website Another challenge lay in my lack of experience with accordingly. Web design: greater experience in this area would have not only helped me to avoid some of the impracticalities in my designs, but would have also helped me to better gauge the time it would take to

Contributions to the Existing Field of Knowledge


The data that will be collected during the upcoming midstream interventions like Project 21 if circumstances survey stage will contribute to the existing knowledge call for it. base of alcohol-related Web interventions and their effectiveness. While these interventions may be less effective than upstream policy interventions, I feel that it is important to have health promotion resources such as Project 21 in conjunction with environmental management strategies to create a greater combined effect. However, as with all public health interventions, limited resources and funds must be allocated appropriately for maximal effect, and I feel that CHS and the University should prioritize policy changes over downstream/

CONCLUSION
Project 21 is an endeavor 5 years in the making, and it may take several more years for it to be further developed and refined to achieve its full potential as an alcohol resource for students at the University of Arizona. It may even become a resource for students at other universities, as HPPS has expressed interest in sharing this resource. My internship tack- Figure 18. Early Concept Art for Project 21, Featuring Couled the development stage of Project pons and Taxi Resources 21, with much of my internship dedicated towards designing the features of the website based on the content created by the Project 21 team. I had hoped to begin work on the evaluation stage as well but the long development stage compelled us to modify our project plan so that we could accomplish the higher-priority goal of finalizing the website designs by the end of my internship. We were able to achieve this goal, and once SASG has completed development on Project 21, HPPS will be able to begin disseminating my email invitations and website evaluations surveys to students so that we can begin to collect student feedback on the usefulness and appeal of the website. Future opportunities for Project 21 include further refinement of the websites features for example, adding more interactivity and content to the Alcohol IQ and Birthday Ideas pages as well as the addition of more features, depending on student feedback. Features that the Project 21 team may consider adding to the website include coupons (Figure 18) for local restaurants, movie theaters, attractions (e.g., museums, parks, historical sites), entertainment events and other non-alcoholrelated venues that offer students more ways to celebrate their birthday. This internship has built my confidence in working on public health interventions, and I am eager to apply my newfound knowledge and skills towards other Web-based interventions in my public health career. I had a tremendously rewarding experience collaborating with the Project 21 team and SASG, and I look forward to the evolution and improvement of Project 21.

REFERENCES
1. Wechsler H, Davenport A, Dowdall G, Moeykens B,Castillo S,. Health and behavioral consequences of binge drinking in college. A national survey of students at 140 campuses. JAMA : the journal of the American Medical Association. 1994;272(21):1672-7. Accessed 4/17/2014 1:00:18 PM. 2. Mallett KA, Varvil-Weld L, Borsari B, Read JP, Neighbors C,White HR,. An update of research examining college student alcohol-related consequences: New perspectives and implications for interventions. Alcohol Clin Exp Res. 2013;37(5):709-16. Accessed 3/25/2014 9:54:08 PM. 3. The University of Kansas. Risky birthday traditions. https://alcohol.ku.edu/risky-birthday-traditions. Updated n.d. Accessed March 15, 2014. 4. Neighbors C, Walters ST, Lee CM, et al. Event-specific prevention: Addressing college student drinking during known windows of risk. Addictive behaviors. 2007;32 (11):2667-2680. 5. Rutledge PC, Park A, Sher KJ. 21st birthday drinking: Extremely extreme. J Consult Clin Psychol. 2008;76(3):511516. D, Mittmann A, Fossos N,Rodriguez LM,. Event-specific drinking among college students. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2011;25(4):702-7. Accessed 3/18/2014 11:58:59 AM. 12. Brister HA, Sher KJ,Fromme K,. 21st birthday drinking and associated physical consequences and behavioral risks. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2011;25(4):573-82. Accessed 3/25/2014 10:01:27 PM. 13. Lewis MA, Neighbors C, Lee CM,Oster-Aaland L,. 21st birthday celebratory drinking: Evaluation of a personalized normative feedback card intervention. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2008;22(2):176-85. Accessed 3/26/2014 3:25:27 PM. 14. Orleans CT, Gruman J, Ulmer C, Emont SL,Hollendonner JK,. Rating our progress in population health promotion: Report card on six behaviors. Am J Health Promot. 1999;14(2). Accessed 4/21/2014 10:32:26 AM.

15. Carey KB, Scott-Sheldon LAJ, Elliott JC, Bolles JR, Carey MP. Computer-delivered interventions to reduce 6. Centers for Disease Control and Prevention. Binge college student drinking: A meta-analysis. Addiction. drinking. Centers for Disease Control and Prevention Web 2009;104(11):1807-1819. Accessed 4/15/2013 2:03:02 PM. site. http://www.cdc.gov/alcohol/fact-sheets/bingedrinking.htm. Updated 2010. Accessed March 1, 2014. 16. Brownson RC, Seiler R,Eyler AA,. Measuring the impact of public health policy. Preventing chronic disease. 2010;7 7. The University of Arizona Campus Health Service. Wel- (4). Accessed 4/20/2014 10:04:39 PM. come to the campus health service: About us. http:// 17. Carey KB, Scott-Sheldon LAJ, Elliott JC, Bolles JR, www.health.arizona.edu/about_us.htm. Updated n.d. Ac- Carey MP. Computer-delivered interventions to reduce cessed March 10, 2014. college student drinking: A meta-analysis.(report). Addiction. 2009;104(11). Accessed 4/12/2013 1:06:34 AM. 8. The University of Arizona Campus Health Service. Ac18. Neighbors C, Lee CM, Lewis MA, Fossos N, Walter T. creditation. http://www.health.arizona.edu/ Internet-based personalized feedback to reduce 21stabout_us_accreditation.htm. Updated n.d. Accessed birthday drinking: A randomized controlled trial of an March 10, 2014. event-specific prevention intervention. J Consult Clin Psychol. 2009;77(1):51-63. Accessed 4/15/2013 3:23:54 PM; 9. The University of Arizona Campus Health Service. 4/15/2013 3:23:54 PM. Health care options. http://www.health.arizona.edu/ 19. Fleck M. Project 21: A website to provide individualinsurance.htm. Updated n.d. Accessed March 10, 2014. ized feedback to reduce high-risk alcohol use of university 10. Hingson R WA. New research findings since the 2007 of arizona students on 21st birthdays. . 2011. surgeon general's call to action to prevent and reduce underage drinking: A review. Journal of studies on alcohol and drugs. 2014;75(1):158-69. Accessed 4/18/2014 11:31:52 AM. 11. Neighbors C, Atkins DC, Lewis MA, Lee CM, Kaysen 20. TRAIN National. Core competencies for public health professionals: Introduction. https://www.train.org/ DesktopShell.aspx?tabId=94. Updated n.d. Accessed April 25, 2014.