Confirming the Prevalence, Characteristics, and Utility of Ecological Theory in Explaining Prescription Stimulant Misuse

• Author: Niloofar Bavarian,Jocelyne Mendez,Summer Takeda,Sheena Cruz,Cassandra Schroeder,Stephanie Sumstine
• DOI: 10.1177/0022042617740910
• Date: 01 January 2018
• Published date: 01 January 2018
• Subject Matter: Articles

https://doi.org/10.1177/0022042617740910

Journal of Drug Issues

2018, Vol. 48(1) 118 –133

© The Author(s) 2017

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DOI: 10.1177/0022042617740910

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Article

Confirming the Prevalence,

Characteristics, and Utility of

Ecological Theory in Explaining

Prescription Stimulant Misuse

Niloofar Bavarian1, Stephanie Sumstine1,

Sheena Cruz1, Jocelyne Mendez1, Cassandra Schroeder1,

and Summer Takeda1

Abstract

To examine the prevalence, characteristics, and utility of ecological theory in explaining

prescription stimulant misuse, a probability sample of 499 students from one southern

California university (response rate = 94.71%) completed a 100-item paper-based survey. The

illicit use of prescription stimulants (IUPS) during college was reported by approximately 21%

of students, with approximately 13% of users reporting 10 or more occurrences per academic

term. Characteristics of use that were examined suggest a growing trend toward recreational

use. We used structural equation modeling to replicate a previously tested ecological model.

The number of significant paths in this replication study (i.e., 22) was similar to the number of

significant paths in the original study (i.e., 25), and 21 of the significant paths from the original

study retained their significance in the replication. Results confirm prescription stimulant misuse

remains prevalent, characteristics of the behavior are cause for concern, and ecological theories

are a useful tool for explaining the multifaceted nature of IUPS.

Keywords

prescription stimulant misuse, health behavior theory, ecological frameworks

Background

Health behavior theory is often used to understand drug-performing behaviors (Glanz, Rimer, &

Viswanath, 2008). Initial studies on emerging drug-performing behaviors provide preliminary

insight on the prevalence and characteristics of these behaviors, and can employ theory to examine

behavioral etiology. Replication studies are needed, therefore, to determine new trends in preva-

lence and characteristics of use, as well as to assess the accuracy of previous behavioral etiology

work by demonstrating its reproducibility and generalizability (Park, 2004). Discovering differ-

ences in prevalence, emerging higher risk characteristics of use, and establishing a consistent set of

behavioral correlates can each serve as a call to action. The current study, therefore, is a replication

of an initial study that used health behavior theory to examine a drug-performing behavior that is

negatively affecting the public’s health: the illicit use of prescription stimulants (IUPS).

1California State University, Long Beach, USA

Corresponding Author:

Niloofar Bavarian, Assistant Professor, Health Science Department, California State University, Long Beach,

CA 90840, USA.

Email: Niloofar.Bavarian@csulb.edu

740910JODXXX10.1177/0022042617740910Journal of Drug IssuesBavarian et al.

research-article2017

Bavarian et al. 119

IUPS, which we classify as use of any class of prescription stimulants without a prescription

from a health care provider, use for nonmedical purposes (e.g., to stay awake, to enhance the

effects of alcohol, etc.), and/or use in excess of what is prescribed, is particularly prevalent in the

college population. For example, in a single-campus study conducted in 2012, the prevalence of

having engaged in IUPS during college was 25.6% (Bavarian, Flay, Ketcham & Smit, 2013b).

Moreover, a separate longitudinal cohort study following students throughout their collegiate

careers revealed that 31.0% of the sample had engaged in IUPS by their fourth academic year

(Garnier-Dykstra, Caldeira, Vincent, O’Grady, & Arria, 2012). Given that prescription stimulants

are associated with morbidity (e.g., cardiomyopathy, hypertension, myocardial infarction, psy-

chosis, seizures), mortality, and addiction (e.g., Holloway, Bennett, Parry, & Gorden, 2014;

Lakhan & Kirchgessner, 2012; McCarthy, Cranswick, Potts, Taylor, & Wong, 2009; Substance

Abuse and Mental Health Services Administration [SAMHSA], 2013), understanding the etiol-

ogy of IUPS in the college population, and thus replicating existing studies, is warranted.

The original study (Bavarian et al., 2014; Bavarian et al., 2017) was the first, to our knowl-

edge, to employ structural equation modeling to test the ability of the Theory of Triadic Influence

(TTI; Flay & Petraitis, 1994; Flay, Snyder, & Petraitis, 2009) to explain frequency of IUPS. The

TTI is an ecological meta-theory that unifies existing theories such as Social Cognitive Theory

(Bandura, 1986) and the Theory of Planned Behavior (Ajzen, 1988, 2012) into one framework.

According to the theory, behavior is the product of interactions within and between three streams

of influence (i.e., intrapersonal, social situation/context, and sociocultural environment) and

four levels of causation (i.e., ultimate, distal, proximal, and immediate precursor). Of the 44

paths specified in the structural equation model (SEM), we found 25 paths to be significant at

the p < .05 or p < .01 levels. Moreover, the final model provided a comprehensive understanding

of the multifaceted nature of IUPS.

The original study served as a key starting point to understanding prevalence, characteristics,

and the multifaceted etiology of IUPS; the original study, however, was conducted at a single

university. Thus, it is possible that patterns have changed and that associations observed within

the original study may not generalize to a different population. Thus, the novelty of our current

study is that its purpose was to determine any emerging changes in prevalence and characteris-

tics of IUPS, as well as assess the veracity of existing etiologic findings and the reproducibility

and generalizability of the original model, by conducting a replication study at a different col-

lege campus. We feel this replication is important for several reasons. First, it is possible that

prevalence differences exist, which would suggest the need to understand environmental con-

text prior to initiating prevention and intervention activities on campus. Second, it is possible

that characteristics of IUPS reported in the original study (conducted in 2013) may have

changed. For example, 23.8% of misusers in the original study reported ingesting the drug by

smoking (Bavarian et al., 2017); should this behavioral pattern remain consistent, it would be

important for health care providers who treat students to screen for this behavior and provide

immediate, brief intervention. Finally, if findings from the replication study related to behav-

ioral correlates parallel the original study, it lends support that the findings did not occur by

chance, and thus can be targets of intervention. Specifically, findings may better suggest rela-

tionships that can serve as intervention targets (e.g., patient–provider and/or peer–peer dyads).

To date, intervention research focused on IUPS has been limited and narrow in scope (e.g.,

expectancy intervention lead by Looby, De Young and Earleywine, 2013). Because the corre-

lates we are examining encompass all three streams of influence and all four levels of causation,

confirmed correlates across studies can be targeted, and multifaceted interventions (e.g., inter-

ventions that address both ultimate-level and proximal-level correlates) can be implemented,

whereby increasing the likelihood of sustained impact (Glanz et al., 2008). In addition, the find-

ings from the replication study that refute results from the original study may inspire new

hypotheses and research questions.