Keywords

1 Introduction and Background

1.1 The Issue

According to the 2008 Department of Defense (DoD) Survey of Health Related Behaviors Among Active Duty Personnel, “binge drinking” in the Navy increased from 42 % in 2005 to 48 % in 2008 [1]. Eighteen percent of Navy respondents reported heavy drinking (more than five drinks on the same occasion at least once a week), and one in five heavy drinkers indicated that they had experienced serious consequences as a result of drinking in the past year. There are a number of serious issues and consequences associated with binge drinking, including failure to fulfill major responsibilities at work, school, or home; legal and financial problems; sexual assault and/or domestic violence; alcohol-related illness and death; and depression and suicide.

The Department of Navy Alcohol and Drug Abuse Prevention (NADAP) office launched the “Right Spirit” Campaign in 1995 to deglamorize the use of alcohol; however, NADAP recognized a need to reinvigorate the campaign after many years of stagnation. An assessment of the Right Spirit Campaign was conducted in 2004 and the following observations were documented regarding alcohol abuse prevention strategies:

  • Avoid moralistic and prohibitionist tones. The Right Spirit was perceived by many as having those tones.

  • Target specific and definable problems, such as drinking and driving and underage drinking, for which it is possible to build a consensus.

  • Target specific populations. The Right Spirit targeted the entire Navy when alcohol abuse was simply not an issue with the majority of Sailors. Identify and target those populations and situations that are really problems.

  • Create an effective education and training system that is rational, has identifiable standards, is measurable and remains current. The Right Spirit only partially addressed these issues.

  • Ensure that there is a data reporting system that is current, accurate, and easy to use so that trends can be identified and program and policies guided by data, not ideology [2].

These observations were used by NADAP as evidence to support the need for a revamped approach to alcohol abuse prevention efforts. NADAP contracted with Booz Allen Hamilton (hereinafter referred to as Booz Allen), a strategy and technology consulting firm (disclosure: the authors of this paper are employed by Booz Allen), for help in designing developing, and implementing its new campaign, as described in subsequent sections of this paper.

1.2 Review of Related Literature and Work

Prior to developing the campaign concept in 2012, the team conducted a landscape and literature review to better understand the challenge (alcohol misuse/abuse) and nature, extent, and efficacy of existing interventions. Key observations included:

  • A number of studies reviewed documented the rise in alcohol abuse and alcohol-related incidents among young adults, especially college students. One study found that “Driving Under the Influence” infractions have increased since 1998 from 2.3 million students to 2.8 million [3]. Reported incidents of sexual assault, rape, and death involving alcohol had also increased among college students. Social norms were cited as a reason for drinking [3].

  • Like the aforementioned studies, DoD and service-specific studies found evidence of binge drinking and alcohol misuse among young adult service members ages 18−24. Specifically, the Navy conducted a study on alcohol and tobacco use to identify trends [5]. More than 50 % of binge drinking was reported by service members aged 21−25 followed by 42 % aged 26−34. In another study, conducted by the Journal of Studies on Alcohol and Drugs, service members age 21−25 were more likely to be frequent heavy drinkers than all other age groups [6].

  • Many factors contribute to the probability of one’s drinking habits, including demographic information such as where one grew up, the kind of family they have, experiences in childhood, etc. This study specifically concentrated on college drinking behaviors and trends [4]. They found that there are many factors on college campuses that affect drinking, such as the local community and availability of alcohol. Other factors included biological and genetic predisposition to use, belief system and personality, and expectations about the effects of alcohol [4].

  • While there are treatment programs and resources for alcohol addiction, only a small portion of programs or interventions focused specifically on alcohol abuse prevention. Even fewer such program targeted young adult service members or Sailors. Many of the existing prevention programs put the pressure on the “drinker” [7]. For example, the Department of Defense’s “That Guy” campaign uses humor to show audiences that drinking affects behavior in a negative way, making the drinker look like a fool. Also, the “rethinking drinking” campaign, developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is a personal plan to reduce alcohol use. It begins clearly with an “are you ready” question, putting the pressure of committing to a plan on the participant [7].

  • Social norm campaigns were tested on college campuses, however, it is hard to measure the effectiveness of these campaigns. Most studies reported that social norm campaigns work best when combined with other interventions [8].

  • NIAAA launched a College Drinking – Changing the Culture campaign that uses a 3−1 approach. The campaign targets three different audiences (Individuals, Including At-Risk or Alcohol-Dependent Drinkers, the Student Body as a whole, and the College and the Surrounding Community) through the same campaign [4]. Research strongly supported this comprehensive approach of addressing multiple audiences with complementary campaign components [4].

  • Research indicated that “anti-drinking” campaigns can often be seen as prohibitionist with moralistic tones. These types of campaigns were found to cause the very things they are trying to prevent, alcohol abuse. Some perceived these campaigns to frame all alcohol use in a negative way and those who drink it to be wrong [9].

  • Smartphones were found to be underutilized as modes of alcohol abuse prevention efforts, but have shown promise in other types of health behavioral interventions, especially when best practices in designing for behavior change are adopted. Studies suggest that a number of inherent features implicit in smartphones make them good candidates for the delivery of behavioral interventions. For example, as portable devices that are highly valued by individuals, they tend to be switched on and remain with the owner throughout the day [22–24]. Therefore, they offer the opportunity to bring behavioral interventions into important real life contexts where people make decisions about their health and encounter challenges to change [23, 25, 26].

In reviewing relevant work and literature, the campaign team found that there were programs in place to treat alcohol abuse and alcoholism for Navy service members, but there had been less concentration on preventing abuse (though there are efforts underway to tackle the issue). Thus, there was a need to create a culture of responsible drinking behaviors in the Navy to curb misuse before it became a bigger problem. Furthermore, the team determined that the design of the campaign would be most effective using a socio-ecological approach, addressing the multitude of factors that influence alcohol-related beliefs and behaviors. In addition, the design needed to cater to the needs, preferences, and interests of young adult Sailors, many of whom prefer visual messages delivered through online vs. offline mediums. As such, the campaign should make use of the inherent opportunities implicit in social media, multimedia, and mobile channels. Furthermore, it should avoid messages that could be seen as prohibitionist or moralistic in tone, as well as messages that center too much on long-term health consequences (vs. more immediate job performance and career consequences).

2 Methods

In September 2011, NADAP contracted Booz Allen, to evaluate Sailors’ attitudes and behaviors regarding alcohol use and to develop a health communications campaign to help decrease the number of alcohol-related incidents. The Booz Allen team was made up of health communication and digital innovation subject matter experts, who worked closely with NADAP leadership and alcohol abuse prevention personnel in the development and execution of the campaign.

Seeking to deter alcohol abuse among young, enlisted Sailors within U.S. Navy populations, the authors identified three target audiences, including Sailors (ages 18−24), leaders, and community groups, to address both the campaign’s individualistic (behavioral) and collectivist (cultural) goals, modeled similarly after the 3−1 approach found in the NIAAA campaign [4].

The primary target audience for the campaign is U.S. Navy Sailors aged 18−24 years, because formative research indicated that this population has a greater prevalence of alcohol incidents and is thus at significant risk of abusing alcohol and engaging in binge-drinking behavior [1]. A second audience for the campaign is Navy leadership, because they can have a positive influence on setting the cultural tone (norms) of responsible drinking behavior at both base and Navy-wide levels due to the hierarchical nature of the military. The third target market is community partners – including both private and public sector partners – because they (like leadership) can support the notion of responsible drinking behavior within the Navy organization culture, including disseminating messages through local bars and establishments.

This three-pronged target audience approach is based on the socio-ecological framework, which suggests that health behaviors are affected by multiple levels of influence, including the individual (e.g., Sailor), interpersonal/group (e.g., shipmates, Command), institutional (e.g., U.S. Navy), and community (e.g., fleet-concentrated regions) factors and public policy (e.g., Uniform Code of Military Justice) [10]. Research showed that community-based alcohol abuse prevention and intervention programs can have a positive impact on drinking habits [11]. Research also supported the implementation of a community partnership to reduce drinking and driving and underage drinking, given that working with the local community might encourage the Navy personnel to gain an emotional connection to their community making them feel responsible for their actions [4]. Family and friends outside of the Navy were not considered a primary audience for this campaign given that most young, enlisted service members must leave home as a function of joining the Navy and live in the barracks (military housing).

2.1 Health Communications Model

Upon establishing the target audiences, the team, using the National Cancer Institute’s (NCI) Health Communications Model, conducted quantitative and qualitative research to use as the foundation for developing the “Keep What You’ve Earned” campaign [13]. Methods included focus groups, intercept interviews, one-on-one interviews, campaign concept testing, and a survey.

The NCI model is a science-based framework for health communications and social marketing, which is based on formative research, continuous evaluation and improvement. The stages of the communications process include:

  • Stage 1: Planning and Strategy Development (e.g., communications product audit, baseline media report, literature review, intercept interviews)

  • Stage 2: Developing and Pretesting Concepts, Messages, and Materials (e.g., concept/message development, focus groups)

  • Stage 3: Implementing the Program

  • Stage 4: Assessing Effectiveness and Making Refinements [13]

The formative research included a literature review (including works cited in Introduction and Background), materials audit, baseline media report, 396 Sailor intercept interviews, and 17 interviews with alcohol and drug abuse prevention personnel. This was followed by concept development and testing with 16 focus groups, leading to a final campaign concept, “Keep What You’ve Earned.”

Key findings that emerged from these stages and informed the development of this campaign plan include:

  • Sailors primarily drink because of stress related to the workplace, their families, and life changes (moving locations, new surroundings, new peers).

  • Sailors indicated that the most significant consequence of alcohol abuse to them is Navy discipline (alcohol related incident, separation, loss of pay/rank).

  • Affirmative messages/images combined with a reminder of what they could lose as a result of alcohol abuse resonated with Sailors of all ages and ranks.

  • Sailors identified videos and mobile as the preferred methods of communication.

  • The Navy’s alcohol abuse prevention efforts need to be locally driven.

  • The campaign should use the desire to avoid negative, immediate job-related consequences (vs. delayed, long-term health consequences) as the prime motivating factor to encourage to people to take positive health actions.

  • Although the desired outcome (drinking responsibly) has health benefits, the connection to their job, not health, is effective in the message.

Based on the aforementioned research findings, NADAP implemented the Navy’s flagship responsible drinking campaign, “Keep What You’ve Earned,” in April 2013. The campaign uses value-affirmative messaging to remind Sailors of how hard they have worked and how much they have to lose [14]. The campaign follows a social marketing approach—a behavior change theory involving the use of commercial marketing techniques grounded by behavioral science to promote the adoption of attitudes or behaviors that will improve the health or well-being of a stakeholder group or of society as a whole [15]. Furthermore, the campaign uses the tactic of motivating people to take positive health actions using the desire to avoid a negative, near-term career consequences as the prime motivation based on the high value Sailors place on their careers in the Navy, as indicated during formative research methods [14].

A combination of traditional and non-traditional campaign elements enabled NADAP to reach key stakeholders in their communities. Through the development of 40 + tailored and targeted materials, which worked together in unison, the team increased awareness of the campaign and educated primary and secondary audiences on responsible drinking. These products provided clear and direct information to encourage Sailors to drink responsibly and were accessible across multiple platforms (online, mobile, print). Some of the most popular products of the campaign are its testimonial videos, which support research that testimonials are more effective compared to simple informational health messages [16].

2.2 Online Interventions

As indicated in the above findings, traditional print products had become a barrier to reaching younger Sailors. Instead, interviews and focus groups with Sailors revealed that they wanted to be reached on the platforms they were most engaged with—video sites, social media, and mobile applications. This is consistent with research findings observed in the initial literature review, which revealed the efficacy of online interventions on health behaviors and documented promising, albeit preliminary, results in the area of serious games for advancing health. While the average public health campaign, done well, can impact roughly 5 % of the target population’s behavior, online behavior change interventions can expect to impact twice that amount based on preliminary studies [17, 18]. The results are small but statistically significant, while also offering an advantage of lower costs and larger reach [18]. However, these online interventions are most effective when they employ behavior change strategies in combination with persuasive design strategies [17].

Armed with feedback on Sailor communication preferences and literature review findings from the planning stage, the campaign utilized a combination of web 2.0 tools and tactics, “gamification” (the use of game design elements in non-game contexts, such as for responsible drinking interventions and learning), and social and traditional media outreach to engage Sailors.

The Keep What You’ve Earned webpage is seen as the centralized information hub on the campaign with access to all campaign materials, which results in hundreds of downloads of campaign materials each month (see full list of metrics below).

2.3 Pier Pressure Mobile Application

One of the campaign’s primary platforms is “Pier Pressure,” a mobile game grounded in multi-disciplinary research from the behavioral psychology, persuasive technology, mHealth, and serious game domains. Pier Pressure integrates best practices in software design and game mechanics with public health theories and cognitive behavioral research insights. It takes a “show, don’t tell” approach, enabling Sailors to explore the consequences of alcohol-related decisions and behaviors on their job performance and career attainment (two factors Sailors indicated as extremely important and motivating to them) through a novel, entertaining, and safe medium.

As observed during the team’s initial literature review, games have shown initial promise as a method for motivating audiences to engage in healthy behaviors [17, 18]. Although the field of serious games is still in its infancy, promising pilots have emerged in the area of games for self-care, exercise, autism, sexual and reproductive health, diabetes, asthma, confronting death, and more [20]. An empirical review conducted by Cugelman (2013) found seven common ingredients of successful gamification systems grounded in behavioral theories, including providing feedback on performance (receiving constant feedback throughout the experience), reinforcement (gaining rewards, avoiding punishments), comparing progress (monitoring progress with self and others), and fun and playfulness (playing out an alternative reality) [17]. These core persuasive ingredients of gamification were incorporated into the app through dialogue with non-player characters, leaderboards, and the alternate reality of mini-games representing the work-life and the play-life of a Sailor avatar.

This body of knowledge was called upon throughout the planning and design of Pier Pressure, a multi-part app featuring a role-playing game true to the “Navy experience.” In keeping with the “fun + function” mantra, the mobile app engages Sailors in gameplay while indirectly sharing messages about responsible drinking. The game is coupled with practical resources to help Sailors practice responsible drinking behaviors in real life, including a blood alcohol content (BAC) calculator and local taxi cab search.

Through gameplay, Sailors are encouraged to think about the repercussions of alcohol abuse, and are reminded of positive steps they could take to avoid incidents, such as taking a cab and not drinking on an empty stomach. To accomplish this, the game presented a virtual environment that allowed players to explore the effects of alcohol abuse through a role-playing game and presented them with frequent, game-embedded messaging to reinforce desired concepts. Though not intended for training, the app could be accurately described as a “serious game” (i.e., a game designed for a primary purpose other than pure entertainment). While engaging and entertaining, this product’s primary aim was to affect beliefs and behaviors through messaging and immersive gameplay. As a function of being a serious game, the game must be appealing and enticing enough to overcome the barriers of educational messages about responsible drinking behavior throughout gameplay [19]. In his book chapter on game-based learning, Prensky (2001) explains that the role of “fun” in the learning process in that it aids in relaxation and motivation: relaxation enables the learner to take things in easier, while motivation inspires them to put forth effort without resentment [19].

Players begin the game by selecting and customizing a Sailor avatar. The overall gameplay follows the pattern of a natural “day” where players’ characters go to work and then go out to a bar with friends, making choices along the way. While “at work” players will engage in a mini-game based on the “tower defense” game genre, in which you must load crates onto Navy ships and carriers at the pier.

After work, players will make decisions about “going out” for the evening. These choices include whether and/or how much to drink and if to eat a meal before going out. The “going out” portion of the game is set in a bar scene where one plays a variation of shuffleboard (a.k.a., shufflepuck). While playing, the user is presented with “power-up” opportunities, either by choosing to drink more than previously intended or by alternating alcoholic drinks with water. But players are forewarned: choices made at the bar will affect players’ level at work the next day, which in turn affects their character’s evaluations. Smart drinking choices will result in achieving the next pay grade, while poor choices and performance at work result in separation from the Navy (game over).

The game also includes two of Paredes et al.’s conceptualization of games for health behavior change. There are also forced pauses after the “work game” and the “evening game” involving fictional text message conversations with the non-player characters in the game. These forced pauses and prompts allow for introspection and have been show to assist in players’ reflection and increase people’s awareness of their own problems [21]. The game also involves progress as a proxy for self-efficacy; the progress players see their character making as they make responsible choices and move up the ranks allows players to realize that change is possible [21].

The app features leaderboards enabling Sailors to compete with their friends and shipmates. By making responsible drinking choices, players will advance through the game and raise their score on the leaderboard, while irresponsible choices will interfere with their ability to progress through the game and advance their careers.

The mobile application game was developed using Unity3D, a third-party game development engine. Gameplay mechanics were developed by collaboratively iterating on prototypes, with the two primary mini-games being inspired by the popular mobile game “Plants vs. Zombies” and the offline game of shuffleboard, respectively. For instance, the shuffleboard game is based on a “casual game” model present in many of the most popular and addictive games. This model dictates the use of a single verb (in this case, a puck throw) and a rapid, simple feedback loop in which the player takes an action, gets immediate feedback, and adjusts his/her mental model for the next action. Similarly, the other minigame was based on design conventions for audiences seeking a more intricate experience. This design started from a proven mechanic (“tower defense”), and was iterated upon as much as possible, resulting in a game which was relatable to Navy Sailors.

2.4 Secondary Audience Outreach Activities

To engage Navy leadership, a set of leadership messaging was developed to provide key messaging and talking points to ensure that campaign messages remained new and fresh each month. Presentation briefings were also developed that provided an overview of the campaign that ADCOs, DAPAs, Navy public affairs personnel, and other military leaders can present to Sailors and their local communities to promote responsible drinking at the environmental level and enact behavior change.

In reaching the secondary audience of community partners, formal and informal partnerships were developed throughout the launch and implementation of the campaign with organizations including, but not limited to: the U.S. Navy Office of Information (CHINFO) and public affairs community, Navy and Marine Corps Public Health Center (NMCPHC), Navy Exchange (NEX), Navy Morale, Welfare and Recreation Program (MWR), Coalition of Sailors Against Destructive Decisions (CSADD), and the Partnership at DrugFree.org. NADAP worked with official partners on promoting the website, tools and resources via their social media channels.

For example, NADAP engaged CHINFO and the Navy public affairs community to promote Keep What You’ve Earned messages and materials on the official U.S. Navy social media sites, including Twitter, Flickr, YouTube and Pinterest. Sample social media messages were provided to partners as an easy starting point to promote the campaign using consistent messaging, and were encouraged to tailor the posts as they saw fit. Lastly, a Virtual Partner Summit was held in early 2014 near the campaign’s one-year anniversary to further collect feedback from these secondary audiences and incorporate those findings into the future development of the campaign.

3 Results

In September 2013, the U.S. Navy’s 21st Century Sailor Office, which oversees NADAP, announced a 51 % decrease in alcohol incidents during the summer months (Memorial Day through Labor Day 2013) compared to the same period the previous year (2012). These figures were calculated based on the U.S. Navy’s Alcohol and Drug Management Information Tracking System (ADMITS) alcohol incident numbers pulled in September 2013.

The Navy credits the Keep What You’ve Earned campaign, in combination with a variety of other supporting cultural and policy-related measures and changes (e.g., random breathalyzers and restricted alcohol sale hours on base), with contributing to the 51 % decline. While system limitations make it impossible to meaningfully attribute a certain percentage of the change to the campaign vs. other anti-abuse measures, leadership has cited the Keep What You’ve Earned campaign as playing a significant role. This impact is attributed to its social ecological framework and its deliberate use of applied social marketing and persuasive technology principles that targeted the individual and contextual factors associated with alcohol use.

The Keep What You’ve Earned campaign’s impact has been further substantiated through a variety of other mechanisms, including feedback collected through a Navy-wide survey. The survey, conducted by NADAP and disseminated to Sailors through the Navy Personnel Research, Studies and Technology (NPRST) in April 2014, was open for six weeks and closed in May 2014. Over 1,400 Navy stakeholders participated in the survey, which was promoted through social media channels and a Navy Newsstand article. Survey participants shared information about their alcohol-related beliefs and behaviors as well as the Keep What You’ve Earned campaign. Findings included:

  • About 1 in 3 respondents reported noticing a positive change in behavior towards drinking over the past year.

  • Encouraging responsible drinking is now seen as the focus of leadership messaging (54 %) as opposed to discouraging drinking in general (16 %).

  • Sailors specifically mentioned an increase in awareness of safe ride programs (45 %), which were also viewed by Sailors as the most effective measure.

  • 95 % of respondents had seen or heard alcohol abuse prevention messaging in the Navy, and 76 % had heard of the Keep What You’ve Earned campaign.

  • 31 % of respondents were motivated by the Keep What You’ve Earned campaign to perform a desired action (e.g., decrease consumption, talk to a Sailor).

  • 80 % of respondents said the campaign is very effective or effective.

In addition to these qualitative findings, communication outcome metrics indicate that the campaign was very well received by Sailors, Navy leadership, alcohol abuse prevention personnel, partner organizations, and media from coast to coast. Communication outcomes/results from April 2013−August 2014 include:

  • 47,101 + website page views and 43,212 + website unique visitors

  • 9,708 + downloads of campaign materials

  • 29,552 + social media interactions (likes, retweets, comments, etc.)

  • 13,200 + views of campaign PSA videos on YouTube and Vimeo

  • 33,790 + Flickr account views (associated with the social media posts)

  • 1,450 + online pledges and 22 grassroot events

  • 159 + news articles with an estimated 1 billion + impressions

  • 5,000 + mobile app users/downloads and more than 25,000 + gameplay sessions

  • 473,000 + estimated impressions from Navy Times mobile web ads for mobile app

These figures are better contextualized in the context of the campaign’s intended primary audience of young, enlisted Sailors, which comprise about 72,000 of the estimated 266,778 enlisted Sailors in the Navy (data as of February 2015) [12]. Beyond target audience validation and behavioral change observations, the Keep What You’ve Earned campaign has been recognized for excellence in communication through eight industry awards, allowing the campaign to gain third-party validation, credibility, and trust.

4 Discussion

Taken together, these results (i.e., the reduction in the number of alcohol-related incidents, the positive feedback yielded through survey and focus group methods, and the campaign reach and engagement outcome measures) suggest that the Keep What You’ve Earned campaign has demonstrated initial success in helping to encourage responsible drinking among Sailors. Its three-pronged approach, coupled with its use of novel persuasive technology and applied social marketing techniques, is at the root of its success. Although these findings are preliminary, practitioners can consider these approaches as logical and theoretically promising, and use these methods as a basis for further experimentation and testing.

The Navy plans to build on these strengths and continue to refine and expand in the areas of socio-ecological digital-based interventions, as well as in the areas of research to further validate claims of the campaign’s impact on Sailors behavior. Specifically, the team plans to continue to evolve its Pier Pressure app to include additional practical tools to support Sailors in goal setting and self-monitoring, and to refine its gameplay to increase engagement and ease of use and to promote sustained us through greater integration of social sharing and community features.

Additional evaluation methods are planned to take place over the course of the campaign to determine changes in Sailors’ knowledge, attitudes, and behaviors regarding alcohol use within the Navy. These methods include follow-up focus groups and annual surveys on Sailors’ knowledge, attitudes and behaviors regarding alcohol use, and further objective analysis of alcohol incidents before and after the campaign launch.