A systematic review of event-level measures of risk-taking behaviors and harms during alcohol intoxication

Addictive Behaviors 99 (2019) 106101

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A systematic review of event-level measures of risk-taking behaviors and harms during alcohol intoxication Michael Brooksa,b, Rebecca Nguyena,b, Raimondo Brunob,c, Amy Peacockb,c,

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a

School of Medicine, University of New South Wales, UNSW Sydney, NSW 2052, Australia National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street, Randwick, NSW 2031, Australia c School of Psychology, University of Tasmania, Private Bag 30, Hobart, Tasmania 7004, Australia b

HIGHLIGHTS

review of scales measuring behaviors and consequences while intoxicated. • Systematic scales were identified with at least one relevant item. • Nineteen one scale met criteria; three measures with relevant subscales were identified. • No • Opportunity to develop measures for ecological momentary assessment whilst intoxicated. ARTICLE INFO

ABSTRACT

Keywords: Alcohol Risk-taking Behavior Harm Measure Psychometrics Ecological momentary assessment

Alcohol intoxication is associated with transient increases in risk-taking behaviors which can lead to harm. Certain assessment and intervention evaluation approaches require measurement of risk behaviors and associated harms at the event-level (i.e., within a single drinking session). This systematic review aimed to identify measures solely assessing risk-taking behaviors and harms while intoxicated and identify evidence of their reliability and validity. EMBASE, Medline, PsycINFO, and PsycTESTs were searched for articles published between 1997 and 2019. Articles were selected based on use of a scale with one or more items measuring risk-taking behaviors and harms (to the individual or others around them) occurring while intoxicated. Additional searches were run to identify studies reporting estimates of reliability and validity for identified measures. Nineteen measures were identified containing at least one relevant item. Most measures indexed both acute and chronic risk behaviors and consequences, mainly with the intent of screening for established patterns of problematic use. No individual measure was identified exclusively quantifying risk-taking behavior and harms which had occurred within a drinking session (with the exception of one scale measuring tendency to engage in risk behaviors), yet three measures had a subscale meeting this criterion. These measures demonstrated good validity and reliability. This gap represents an opportunity for scale development, designed for use in ecological momentary assessment and evaluation of structural interventions targeting risk behaviors and harms whilst intoxicated.

1. Introduction Alcohol is one of the most widely used psychoactive substances worldwide. Reports of any alcohol use in the past year varies significantly by geographical region, yet data from the World Health Organization suggests 39.3% of the population aged over 15 years consumed alcohol within the past year (World Health Organization, 2014). The harms associated with this use contribute substantially to the global burden of disease (Lim et al., 2012), and this is partly attributable to the acute consequences of consumption (e.g.,

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unintentional injuries, violence and suicide; Rehm et al., 2017). With acute administration, alcohol is known to have a significant effect on the pre-frontal cortex of the brain: the area in which executive functions are carried out (Yuan & Raz, 2014). Specifically, alcohol inhibits GABAA receptors in the brain (Kumar et al., 2009), overriding the normal processing of the neocortex (Oscar-Berman & Marinković, 2007), leading to greater disinhibitory effects. This disinhibition in turn leads to increased propensity for risk-taking behaviors and, in turn, experience of harm. A risk-taking behavior is defined as any behavior that puts an

Corresponding author at: National Drug and Alcohol Research Centre, University of New South Wales, Randwick, Sydney 2052, NSW, Australia. E-mail address: [email protected] (A. Peacock).

https://doi.org/10.1016/j.addbeh.2019.106101 Received 1 April 2019; Received in revised form 17 July 2019; Accepted 13 August 2019 Available online 14 August 2019 0306-4603/ © 2019 Published by Elsevier Ltd.

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Fig. 1. PRISMA flowchart.

individual or others around them at an increased chance of harm, where the individual weighs up the possible outcomes of their actions (Sitkin & Pablo, 1992). Risk-taking can be divided into various domains, including: physical; financial; emotional; sexual; and anti-social behavior (de Haan et al., 2011). These behaviors, such as driving while under the influence of alcohol or getting into a fight, will have either positive or negative outcomes which can vary in severity and time to onset (Devos-Comby & Lange, 2008). Indeed, these behaviors can lead to experience of physical or psychological injury as a consequence of behaviors while intoxicated. A strong body of epidemiological literature shows associations between alcohol consumption and increased engagement in risk-taking behaviors which may cause harm to the individual or others, such as sexual assault (Ullman, 2003), and laboratory evidence points to elevated risk-taking behavior on objective measures (e.g. the Balloon Analogue Risk Task; Lejuez et al., 2002) following acute alcohol administration (Fernie, Cole, Goudie, & Field, 2010). Key to the study of risk behaviors and harm is the distinction between measuring acute (i.e., behaviors occurring whilst intoxicated, such as driving while intoxicated) and chronic (i.e., long-term effects of alcohol use, such as addiction and dependence) outcomes. Measurement of the former indexes risk behaviors and harms at the event-level (i.e., related to a single period of intoxication). Indeed, certain methodologies, such as patron interviews in the night-time economy (Lubman, Droste, Pennay, Hyder, & Miller, 2014) and behavioral ecological momentary assessment (EMA; Neal et al., 2006), aim to assess risk behaviors and harms in real time at the event-level; in this

instance, within a drinking session. Measurement tools tapping into long-term consequences are not applicable in these contexts. The same argument applies when evaluating the impact of interventions targeted at reducing risk on a given night, such as targeted text-messaging to reduce alcohol consumption during university orientation (Riordan, Conner, Flett, & Scarf, 2015). EMA comprises real-time, repeated assessment of people's behaviors and the consequences of these behaviors (Shiffman, Stone, & Hufford, 2008). This is becoming a particular focus in alcohol research as it allows for in situ assessment of dynamic behaviors while intoxicated, and reduces the risk of bias in retrospective assessment of behaviors (Wray, Merrill, & Monti, 2014). As such, it is pertinent to identify the most appropriate measures of alcohol-related risk-taking behaviors and associated harms which are able to be adopted for EMA to assess experiences at the event-level (i.e., within the drinking session). Currently, no gold-standard measure has been identified for measuring alcohol-related risk-taking behaviors and consequences at the eventlevel, with most studies relying on ad-hoc compilations of items (e.g. Simons, Gaher, Oliver, Bush, & Palmer, 2005). A previous systematic review by Devos-Comby and Lange (2008) summarized nine measures of alcohol-related problems that had been used among college students. There is a need to: 1) update this review to include more recently published scales, 2) explore scales applicable to the general population rather than just college students, and 3) concentrate specifically on scales which examined alcohol-related risk behaviors and consequences occurring within a drinking session. Thus, the aims of the present systematic review were to: 1) identify measures 2

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assessing behaviors and harms at the event-level (within a single drinking session) which might be appropriate for use in EMA or other methodologies focused on these outcomes, and 2) identify the reliability and validity of these measures.

2.3. Psychometric properties of scales extracted The three constructs considered for the current study comprised: construct validity, internal consistency, and test-retest reliability (Bland & Altman, 2002). After the list of included measures was finalized, M.B. conducted further searches using the aforementioned databases to identify any validation and reliability studies for each scale where not identified in the original paper detailing the scale. Relevant articles were identified, and data extracted into Microsoft Excel 2016 by M.B.; article selection and extraction were checked by A.P. Internal consistency indicates the degree to which the items on the scale relate to one another, suggestive that they most likely measure the same construct (Bland & Altman, 1997). The widely-accepted measure of internal consistency is Cronbach's alpha, with values of 0.70 or greater considered indicative of good internal consistency between items (Cronbach, 1951). Owing to the nature of internal consistency, it is not suitable to use as a stand-alone measure of psychometric validity (Dunn, Baguley, & Brunsden, 2014), and thus scales with information available only for internal consistency were excluded. Construct validity refers to the degree to which the measure taps into the specific construct of interest. One aspect of construct validity is convergent validity, defined as the relationship between the measure and a validated ‘gold standard’ measure of the domain being assessed (Clark & Watson, 1995). This relationship can be determined by computing a correlation coefficient between the two scale scores (Husted, Cook, Farewell, & Gladman, 2000), with values ≥0.50 considered indicative of strong convergent validity (DeVon et al., 2007). Test-retest reliability is a measure of consistency in measurement of the construct over time when assessed for the same group of individuals (i.e., the repeatability of the measure). Test-retest reliability is measured using a correlation statistic, with a coefficient ≥ 0.60 considered statistically acceptable (Weir, 2005). The interpretation of test-retest for measures assessing time-dependent variables, particularly those that may vary at the event-level (e.g., from one drinking session to the next), need to be treated with caution as endorsement may change with time. This is particularly pertinent in the context of behavioral measures designed for EMA, as behaviors may not remain consistent over different events.

2. Method 2.1. Search strategy This systematic review was undertaken following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist (Appendix A; Moher, Liberati, Tetzlaff, & Altman, 2009). Medline, EMBASE, PsycTESTS and PsycINFO databases were searched in March 2017 for English-language articles published since January 1997; this search was subsequently updated in May 2019. The search strategy involved using subject terms and keywords (developed in consultation with a librarian) related to ‘alcohol use’, ‘risk-taking/ consequences’, and ‘measurement tools’, conjoined using the ‘AND’ function (see Appendix B for complete search strategy). The protocol for the systematic review was registered on PROSPERO (Brooks, Nguyen, Peacock, & Bruno, 2017). 2.2. Screening process Search results were stored in an Endnote (Version X8) library and screened using the Covidence platform (Leven et al., 2015). Titles and abstracts were screened by author M.B. (Fig. 1). Articles were included for full-text screening if the study reported on use of any measurement tool or self-designed questionnaire of alcohol-related risk-taking behaviors or harms (‘any action which directly stems from alcohol consumption which increases risk of – or pertains to physical or psychological harm to self or others’). Full text screening was undertaken by author M.B.; the aim of this stage was to compile a list of the individual tools and self-designed questionnaires used in measurement of alcoholrelated risk-taking behaviors and harms occurring to the individual while intoxicated. Following this, authors A.P. and R.B. independently reviewed the index article in which the scale was first used, and excluded those which:

3. Results One hundred and two scales were identified; of these, nineteen were included in this study (see Table 1 for list of scales). Of the nineteen scales analyzed, none solely contained items quantifying risk-taking behaviors and/or harms that had occurred while intoxicated for all age ranges (e.g., also contained items assessing risk behaviors/harms experienced after the drinking session), nor were any concentrated on assessment of risk behaviors and associated harms at the event-level (i.e., all assessed outcomes in drinking sessions occurring in the past 3 months or over a longer period). Three measures were identified which had a total of four subscales where the majority of items pertained to risk-taking behaviors and harms occurring during the drinking session. These three measures have been considered in depth below. The remaining scales comprised a mixture of items assessing acute (e.g., drink-driving), and immediately subsequent (e.g., missed work/school due to hangover) risk-taking behaviors, as well as long-term/chronic consequences of intoxication (e.g., long-term physical health harm due to drinking). One scale, the Dysregulated Alcohol-Related Behaviors Index (DARBI; Isaak, Perkins, & Labatut, 2011), consisted entirely of acute risk behaviors (i.e., those occurring within a drinking session), but did not assess endorsement in these activities. Rather, responders were asked to indicate if alcohol intoxication would make them more or less likely to engage in each behavior, scored on a 5-point Likert scale (1 ‘much more likely’ to 5 ‘much less likely’). As the DARBI did not quantify the acute behaviors or harms, it was not included for further discussion (see Table 1 for further details).

1. Measured anticipated behaviors or consequences (as opposed to enacted behaviors/outcomes) or personality traits (e.g., likelihood of acting in a certain way); 2. Did not measure behaviors or harms that were directly linked to alcohol intoxication (e.g., any physical aggression regardless of alcohol use); 3. Had no evidence of psychometric validation in the index article (or only evidence of internal consistency), and for which no further validation studies were able to be identified by the authors; 4. Did not measure risk-taking behavior or harms in real-world contexts (e.g. measured risk-taking in the laboratory through a computerised task); 5. Measured only risk behaviors or consequences of alcohol use occurring after the conclusion of the drinking session (e.g. frequency of missing school/work due to a hangover); 6. The scale was an abridged version of a scale which had already been analyzed; 7. Measured alcohol-related behaviors not pertaining to risk-taking or harms; or 8. Measured psychological or physiological effects of alcohol, not behavioral effects (e.g. lack of energy as a result of drinking); All conflicts were resolved by A.P. and R.B. in consultation with M.B and R.N. 3

Description

Number of items

4

A screening measure designed to measure hazardous and harmful patterns of alcohol use to inform intervention

Subscale measuring social/interpersonal consequences of excess consumption

YAACQ: Risk Behaviors subscale

Other scales included Alcohol Use Disorder Identification Test (AUDIT) (Saunders, Aasland, Babor, De La Fuente, & Grant, 1993)

A measure containing eight subscales, designed to focus on different areas of alcohol problems Subscale measuring social/interpersonal consequences of excess consumption

Subscale measuring consequences of excess consumption

DrInC: Impulse Control Consequences subscale

Young Adult Alcohol Consequences Questionnaire (YAACQ) (Read et al., 2006)a YAACQ: Social Consequences subscale

A measure containing five subscales each relating to adverse acute consequences of drinking

Drinker Inventory of Consequences (DrInC) (Miller et al., 1995)a

10

8 (8 items relevant)

General population

As above

As above

6 (5 items relevant)

Past year (two items lifetime)

As above

As above

Past year

As above

As above

Young adults

Lifetime, past three months

As above

As above

General population

Lifetime, past year

Timeframe assessed

University students

Target population

48

12 (12 items relevant)

45

Scales included for in-depth review (subscales of interest in italics) College Alcohol A measure containing 10 (8 revised Problems Scale two subscales focusing version) (CAPS) on social and personal (O'Hare, 1997) problems of acute and Note revised version long-term alcohol use byMaddock et al. (2001)commonly used CAPS-r: Social Problems A subscale measuring risk 4 (4 items relevant) subscale behaviors while intoxicated

Measure

Table 1 Measures of risk-taking behaviors and consequences during alcohol intoxication.

5-point Likert scale of frequency (mostly 0 ‘never’ to 4 ‘daily or almost daily’) with two items 3-point scale (no, yes in last year, yes but not in last year)

As above

As above

Dichotomous (yes/no)

As above

Dichotomous (yes/no)

As above

6-point Likert scale (0 ‘No problem’ to 5 ‘Severe’)

Scoring system

Cronbach's alpha of 0.94 (Meneses-Gaya et al., 2010)

Cronbach's alpha of 0.82 (Read et al., 2006)

Cronbach's alpha of 0.79 (Read et al., 2006)

Cronbach's alpha of 0.96 (Read et al., 2007)

Cronbach's alpha of 0.70 (past 3 months) and 0.74 (lifetime score) (Miller et al., 1995)

Cronbach's alpha of 0.94 (past 3 months) and 0.91 (lifetime) (Miller et al., 1995)

Cronbach's alpha of 0.75 (Maddock et al., 2001)

Cronbach's alpha of 0.79 for personal subscale, and 0.75 for social subscale (Maddock et al., 2001)

Internal consistency

Pearson correlation coefficient of 0.88 with the Michigan Alcoholism Screening Test (Bohn, Babor, & Kranzler, 1995)

Pearson correlation coefficient of 0.79 with the Rutgers Alcohol Problem Index (Read et al., 2006) Significant positive correlation with the Rutgers Alcohol Problem Index (Read et al., 2006) Significant positive correlation with the Rutgers Alcohol Problem Index (Read et al., 2006)

Pearson correlation coefficient of 0.76 with the Young Adult Alcohol Problem Screening Test (Maddock et al., 2001) Pearson correlation coefficient of 0.57 with the Alcohol Use Disorders Identification Test (Donovan et al., 2006) None identified

Pearson correlation coefficient of 0.78 with the Young Adult Alcohol Problem Screening Test (Maddock et al., 2001)

Convergent validity

Intra-class correlation coefficient of 0.84 when reassessed one month later (Selin, 2003)

Pearson correlation coefficient of 0.86 when reassessed one week later (Read et al., 2007) Pearson correlation coefficient of 0.74 reassessed one week later (Read et al., 2007) Pearson correlation coefficient of 0.77 when reassessed one week later (Read et al., 2007)

Pearson correlation coefficient of 0.79 when re-assessed two days later (Miller et al., 1995)

Pearson correlation coefficient of 0.93 when re-assessed two days later (Miller et al., 1995)

None identified

None identified

Test-retest reliability

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Injure self or other

Drink driving, foolish risks, physical fights, property damage, unprotected sex, impulsive things, regretted sexual situations, injured someone else

Embarrassing things, rude, said harsh/cruel things to others, said things regretted, interpersonal harms

Drink driving, drug use, foolish things, regretted behaviors, physical fight, smoking, arrested for drink driving, other trouble with the law, had an accident, injured someone, property damage Passed out, vomited, difficult to limit consumption (see other items below)

Vomited, physically hurt, not eaten, spent too much, embarrassed self, cruel things to others (see other items below)

See above

Unplanned sexual activity, unprotected sexual activity, drink driving, drug use

Example items

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A measure of the nature, scope, and consequences of the use of alcohol and other drugs among university students

A screening test designed to screen adolescents for alcohol and drug related problems and disorders A measure designed to assess the positive and negative consequences of drinking episodes

Core Drug and Alcohol Survey (CDAS) (Presley, Meilman, & Lyerla, 1994)

CRAFFT (Knight, Sherritt, Shrier, Harris, & Chang, 2002)

5

A measure of typical drinking frequency, quantity of alcohol consumption, degree of “drunkenness”, and the problems encountered while drinking

A measure designed to assess the tendency of an individual to engage in ill-advised behaviors

A measure assessing heavy drinking, consequences, and symptoms of alcohol dependence A measure containing five subscales, focusing on characteristics expressed when intoxicated A measure focusing on the legal consequences of acute alcohol

Drinking Styles Questionnaire (DSQ) (Smith, McCarthy, & Goldman, 1995)a

Dysregulated AlcoholRelated Behaviors Index (DARBI) (Isaak et al., 2011)b

Hazardous Drinking Index (HDI) (Riley et al., 2017)

Legal Risk Behaviors while using Alcohol

Intoxicated Personality Scale (IPS) (Ward, Brinkman, Miller, & Doolittle, 2015)

A measure of excessive alcohol consumption, adverse consequences of drinking, and dependence symptoms

Drinking Problem Index (DPI) (Finney, Moos, & Brennan, 1991)

Daily Alcohol-Related Consequences and Evaluations (DACE) (Lee et al., 2017)

Description

Measure

Table 1 (continued)

19

23

13

8

13

17

13

6

22 (one item, with multiple sub questions, regarding alcohol and drug consequences)

Number of items

University students

University students

Sexual minority women

General population

Adolescents

Older adults

Young adults

Adolescents

University students

Target population

Past month

Lifetime

Current tendency to engage in behaviors while intoxicated compared to while sober Lifetime, past 12 months

Past 2 years

Past year

Previous drinking episode

Lifetime

Past year

Timeframe assessed

4-point Likert scale of frequency (0 ‘Never’ to 3 ‘Always)

6-point Likert scale of frequency (‘Never’ to ‘Always’)

Dichotomous (yes/no)

5-point Likert scale (1 ‘Much more likely’ to 5 ‘Much less likely’)

Dichotomous (Yes/No) for assessing the problems encountered

5-point Likert scale of frequency (‘Never’ to ‘Often’)

Dichotomous (yes/no)

Dichotomous (yes/no)

6-point Likert scale of frequency (‘Never’ to ‘10 or more times’)

Scoring system

Cronbach's alpha of between 0.65 and 0.83 for each subscale

Cronbach's alpha of 0.87 to 0.95 for each item (Ward et al., 2015)

Kuder-Richardson 20 coefficient of 0.80 (Riley et al., 2017)

Cronbach's alpha of 0.85 (Isaak et al., 2011)

Cronbach's alpha of 0.92–0.94 for Drink/ Drunkenness subscale, and 0.66–0.80 for Alcohol-Related Problems subscale (Smith et al., 1995)

Cronbach's alpha of 0.94 (Finney et al., 1991)

A generalizability coefficient of 0.89 for the negative consequences (Lee et al., 2017)

Cronbach's alpha of 0.81 on individual items (Cummins et al., 2003)

Cronbach's alpha of 0.79 for personal consequences (Martens, Brown, Donovan, & Dude, 2005)

Internal consistency

The Risky Behaviors subscale has a 0.48 Pearson's correlation

Intraclass correlation co-efficient ranging from 0.20 to 0.56 to CAGE scores (Riley et al., 2017) Weak correlation of between subscales and the RAPI (0.07–0.31) (Ward et al., 2015)

Pearson correlation coefficient of 0.41 with the RAPI and 0.40 with the MAST (Isaak et al., 2011)

None identified

Baseline predictor of latent variable construct demonstrated significant correlation between RAPI and negative consequences B̂ 0.04 (Lee et al., 2017) None identified

Spearman correlation coefficient of 0.79 with the RAPI (Cummins et al., 2003)

None identified

Convergent validity

Test-retest correlation coefficient of 0.75 to

None identified

None identified

Pearson correlation coefficient of 0.66 correlation reassessed 1 year later (Finney et al., 1991) Correlation coefficient of 0.89 for Drink/ Drunkenness subscale, and 0.81 for Alcohol-Related Problems subscale after 4 weeks (Smith et al., 1995) Correlation coefficient of 0.71 although retest interval was not provided (Isaak et al., 2011)

None identified

Pearson correlation coefficient of between 0.61 and 1.0 at a two and four year interval (Lanier, Nicholson, & Duncan, 2001) A 0.93 ICC when reassessed one week later (Levy et al., 2004)

Test-retest reliability

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Physical violence, illegal drugs, verbal fights,

Verbal fights, physical violence, pass out, sexual risk

Drunk driving, physical fights, verbal fights

Behaviors regret, physical violence, unprotected sex, illegal drugs, foolish risks, financial risks, property damage

Physical fights, drunk driving, legal

Spent too much, physical injury

Embarrassing behaviors, injured self, vomited

Passenger of someone drink driving, gotten in trouble

Trouble with authority, property damage, physical violence, vomited, drink driving, sexual risk, physical injury

Example items

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A measure of both positive and negative consequences of five health risk behaviors, including alcohol use

A measure designed to assess the context of alcohol drinking events, including negative consequences

A scale measuring the consequences and riskybehaviors associated with both alcohol intoxication and cannabis use

A measure focusing on problems of drinking in acute; mid-term; and long-term environments A measure of common alcohol-related negative consequences

Positive and Negative Consequences Experienced (PNCE) (D'amico & Fromme, 1997)

Retrospective Alcohol Context Scale (RACS) (Mays et al., 2009)

Risks and Consequences Questionnaire (RCQ) (Stein et al., 2010)

Rutgers Alcohol Problem Index (RAPI) (White & Labouvie, 1989)a

6 27

23

26 (15 for alcohol)

14 items (negative consequences)

53

25

Number of items

University students

Adolescents

Adolescents

University students

Young adults

General population

Target population

Past year, lifetime

Past year

Past year

Past month

Past three months

Lifetime

Timeframe assessed

5-point Likert scale scored according to endorsement in lifetime, past year, and frequency of occurrence in past year

4-point Likert scale of frequency (0 ‘Never’ to 4 ‘ > 10 times’)

Dichotomous (yes/no)

30-day calendar, with events filled out retrospectively with dichotomous yes/no options

7-point Likert scale of frequency

Dichotomous (yes/no)

Scoring system

Cronbach's alpha of 0.92 initially and 0.93 3 years later (White & Labouvie, 1989) Cronbach alpha of 0.87 (lifetime) and 0.83 (past year) (Hurlbut & Sher, 1992)

Cronbach's alpha of 0.79 for the alcohol subscale (Stein et al., 2010)

None identified

Cronbach's alpha of 0.54–0.93 for all subscales (D'amico & Fromme, 1997)

Cronbach's alpha of 0.90 (Gibbs, 1983)

(Leedy & Leffingwell, 2006)

Internal consistency

Pearson correlation coefficient of 0.76 with the AUDIT (Thomas & McCambridge, 2008) Pearson correlation coefficient of 0.61 (lifetime) and 0.43 (past year) with the sMAST (Hurlbut & Sher, 1992)

Weak item correlation, ranging from −0.1 to 0.53 with Alcohol Consequence Expectancy Scale (Mays et al., 2009) None identified

None identified

A correlation of 0.88 with the AUDIT (Bohn et al., 1995)

coefficient with the CAPS-r (Leedy & Leffingwell, 2006)

Convergent validity

Correlation of 0.63 when reassessed after a median of 255 days, in a group of incarcerated adolescents (Stein et al., 2010) Correlation of 0.92 when reassessed 1 year later (E. Miller et al., 2002) Intraclass correlation coefficient of 0.85 (lifetime) and 0.73 (past year) when reassessed one year later (Hurlbut & Sher, 1992)

0.88 for each subscale when reassessed one week later (Leedy & Leffingwell, 2006) Reliability coefficient of 0.94 when reassessed 3 days later (Storgaard, Nielsen, & Gluud, 1994) Test-retest correlation of 0.59–0.89 when reassessed 1 week later (D'amico & Fromme, 1997) None identified

Test-retest reliability

Note: AUD is defined as Alcohol Use Disorder; DSM-IV is the Diagnostic and Statistical Manual of Mental Disorders 4th Edition. a Denotes an abridged version of the scale has been developed. b Not included for further analysis as it measured tendencies to engage in behaviors rather than quantification of behaviors engaged in or harms resulting from these behaviors.

Young Adult Alcohol Problem Screening Test (YAAPST) (Hurlbut & Sher, 1992)

Michigan Alcoholism Screening Test (MAST) (Selzer, Vanosdall, & Chapman, 1971)a

intoxication, split into three subscales (‘Risky Behaviors’ subscale relevant to current study) A screening test to identify problem drinking and alcohol dependence

Description

(LRBA) (Leedy & Leffingwell, 2006)

Measure

Table 1 (continued)

Drunk driving, vomited, physical fights, damaged property, interpersonal problems, sexual risk, trouble with authority

Physical violence, passed out, verbal fight

Drunk driving, physical injury, property damage, trouble with authority, vomited, passed out, physical violence, embarrassment Physical injury, sexual risk, driving risk, verbal fight

Drunk driving, drug use, sexual risk

Physical violence, hospitalization, drunk driving, arrested

drunk driving, passenger with person drunk diving

Example items

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Of the total nineteen measures, the authors identified that five had no available data on convergent validity; one had no available data on internal consistency; and five had no available data on test-retest reliability. In one instance, a scale had multiple missing indicators of reliability and validity. Most (n = 10) of the scales with data on convergent validity showed strong concordance with validated scales measuring the same or similar construct (r > 0.50). Similarly, all scales with data showed good internal consistency (α ≥ 0.70 in at least one subscale; n = 18), and all fourteen scales with data showed evidence of good test-retest reliability (r > 0.60) in at least one measurement. The following describes the psychometric properties of the three aforementioned measures, with a specific focus on the subscales relevant to the primary objective of the study.

3.3. Young Adult Alcohol Consequences Questionnaire (YAACQ; Read, Kahler, Strong, & Colder, 2006) The YAACQ is a screening measure for alcohol-related problems, with a strong focus on acute and chronic consequences of intoxication. YAACQ contains eight subscales, most of which have items relevant to risk behavior and harm while intoxicated, and two which predominantly measure these outcomes: Social Consequences subscale and Risk Behaviors subscale. Items from these subscales cover behaviors including inappropriate social actions (including physical and verbal conflicts), drink driving, and risky sexual encounters; items from other subscales cover physical harms to self (e.g., passing out, vomiting, psychological distress). The YAACQ has been abridged into a brief version: the brief-YAACQ (Kahler, Strong, & Read, 2005). YAACQ has been psychometrically analyzed for overall reliability and validity (Table 1), recording a Cronbach's alpha of 0.79 for the Social Consequences subscale, and 0.82 for the Risk Behaviors subscale (Read et al., 2006). Further to this, both the total score and subscale scores show a significant positive correlation with the Rutgers Alcohol Problem Index (Read et al., 2006). The test-retest reliability of these subscales were 0.74 and 0.77, respectively (Read, Merrill, Kahler, & Strong, 2007).

3.1. College Alcohol Problems Scale (CAPS; O'Hare, 1997) The CAPS is a measure designed to focus on social and personal problems commonly experienced by college students due to alcohol use. A revised version comprising 8 items is more commonly employed than the original scale (Maddock, Laforge, Rossi, & O'Hare, 2001). The revised scale comprises two subscales: Personal Problems subscale and Social Problems (formerly Community Problems) subscale. All four items for the latter scale relate to behaviors and harms during intoxication, specifically: engaging in unplanned sexual activity, not using protection when engaging in sexual activity, illegal drug use, and driving under the influence of alcohol. Cronbach's alpha for the Social Problems subscale was reported as 0.75 (Maddock et al., 2001; O'Hare, 1997) and a strong correlation coefficient of 0.76 was demonstrated with the YAAPST (0.78 for the revised (8-item) total CAPS scale; Maddock et al., 2001). Despite this, no studies examining the test-retest reliability of the Social Problems subscale were identified.

3.4. Additional scales of note In our search, one scale was identified which was specifically developed for an EMA event-level study, assessing alcohol-related behaviors/expectations on a daily basis. The Daily Alcohol-related Consequences and Evaluations (DACE; Lee et al., 2017) is a psychometrically validated scale which is intended for use the day after the drinking session. While it assesses a range of alcohol-related behaviors, it did not fulfil the original aim of this review in identifying a scale which quantifies risk-taking behaviors and associated harms in a single drinking session, as the DACE also includes positive consequences, such as “I was in a better mood”, and “I got a buzz”. It also can only be administered at the conclusion of a drinking session (specifically, the following day) because of asking about experience of hangover. Thus, this measure cannot be used in studies undertaking repeated assessment of risk-taking within a single drinking session to understand temporality of consumption and engagement in risk behaviors and/or experience of harm. It was validated using repeated assessments the day after the drinking session, over fourteen days, and can therefore be used as an accurate assessment of concurrent validity.

3.2. Drinker Inventory of Consequences (DrInC; Miller, Tonigan, & Longabaugh, 1995) The DrInC comprises five subscales which measure acute and longterm behaviors and consequences of alcohol use (Kline, 2013). One subscale (‘Impulse Control Consequences’) could be used for the purpose of measuring risk-taking behavior and harms while intoxicated, comprising twelve items assessing impulsive actions and risk-taking behaviors, including drink driving, drug use and social interactions while consuming alcohol (noting that one item ‘I have been overweight because of my drinking’ refers to longer-term outcomes of consumption). Select items from other subscales (e.g., ‘Physical Consequences’ and ‘Interpersonal Consequences’) are also pertinent to risk behaviors/ harms while intoxicated, although these subscales contain consequences both in the short- and long-term following a drinking session. DrInC has also been abridged to create the Short Inventory of Problems (Miller et al., 1995). The psychometric properties of the overall DrInC scale have been assessed, showing high levels of reliability and validity. Overall, DrInC had a Cronbach's alpha of 0.91 (lifetime score), a test-retest correlation of 0.93 (Miller et al., 1995), and a Pearson's correlation coefficient of 0.57 with the Alcohol Use Disorder Identification Test (Donovan, Kivlahan, Doyle, Longabaugh, & Greenfield, 2006). Examining the psychometric properties of the Impulse Control Consequences subscale shows evidence of validity and reliability. Specifically, a Cronbach's alpha of 0.74 (lifetime score) for internal consistency of items was reported, and a strong test-retest correlation (0.79) was noted following assessment of people two days apart (Miller et al., 1995). Despite this, no studies examining the convergent validity of the Impulse Control Consequences subscale were identified.

4. Discussion This systematic review set out to identify all current measures assessing alcohol-related risk-taking and harms at the event-level (i.e., for a single drinking session) to identify those appropriate for use in EMA (or other scenarios where assessment is concentrated on experiences during the drinking session). A secondary aim was to subsequently seek out any available psychometric validation studies of the identified scales. This review identified nineteen such measures meeting our initial inclusion criteria by containing items which assessed participants' engagement in risk-taking behaviors and experience of harm while intoxicated. These scales were generally psychometrically sound, despite some lacking appropriate psychometric evaluation. Apart from the Retrospective Alcohol Context Scale (Mays, Usdan, Arriola, Weitzel, & Bernhardt, 2009), which has yet to be tested for internal consistency to the current authors' knowledge, the remaining scales demonstrated adequate internal consistency for at least one subscale, if not the complete scale. Similarly, while around a quarter of the scales analyzed had no data for test-retest reliability, all the remaining scales demonstrated adequate reliability. While the majority of identified scales showed strong construct validity, they were predominantly tested for convergence with other 7

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screening scales for a potential alcohol use disorder. None of the identified scales solely assessed risk taking behaviors or harms occurring while intoxicated, and only three contained subscales which mostly assessed these outcomes. Predominantly, most identified scales contained minimal (one to five) items assessing acute behaviors or harms. These individual subscales often lacked adequate psychometric analysis, rendering them inappropriate to quantify acute, alcohol-related risk-taking behaviors. With the current trend towards using EMA to accurately research consumption patterns and the effects of alcohol and other drugs, as well as novel interventions similarly aimed at minimizing risk during a single drinking session, it is imperative that alcohol-related risk-taking behaviors and harms within a drinking session can also be quantified in this timeframe. Our review identified only three scales which contained at least one subscale designed for the specific purpose of assessing risk-taking behaviors while acutely intoxicated or associated harms arising during the drinking session. All three of the complete scales met benchmarks for internal consistency and test-retest reliability (with the exception of the CAPS where test-retest reliability could not be identified). However, these benchmarks were only met for the complete scales, and psychometrics of the individual subscales were often not reported. Indeed, only the Impulse Control Consequences subscale of the DrInC had evidence of test-retest reliability and internal and convergent validity. None of these scales were validated for assessment at the event level; one additional scale (DACE) was validated for use at this level, but assessed positive and negative consequences of consumption, and could only be administered the day following a drinking session. Further to this, the relevant subscales of all three measures lack breadth in the risk-taking behaviors assessed; none comprehensively measure all domains of risk-taking behaviors and harms experienced while acutely intoxicated, particularly in relation to financial outcomes. It is important to look at the complete array of behavior domains to gain a holistic picture of the risk-taking profile of the individual as this information can be used in planning future targeted interventions aimed at reducing the number of high-risk behaviors in which individuals engage. Further, it is vital to glean engagement in a variety of different behaviors in each domain, with varying degrees of severity in potential harm, to fully comprehend the full extent of the impact of alcohol-induced behaviors on the individuals' life. This includes considering behaviors which are engaged in by all alcohol consumers, and not just those which apply to young adults, with many existing scales targeted purely at this demographic. This review highlights the need for a new measure assessing acute, intoxicated behaviors and associated harms which is designed and psychometrically validated for use in EMA. Current attempts to measure alcohol-related risk behaviors and consequences in EMA contexts mostly rely on a brief ad-hoc compilation of items (e.g., Labhart, Livingston, Engels, & Kuntsche, 2018) with little-to-no psychometric analysis of the measure. There are significant anticipated challenges in the development of such a scale. Scale design will need to be considered in light of participant burden with repeated real-world assessment, impacting capacity for in-depth assessment across all domains of risktaking behavior (e.g., driving, sexual, financial, other substance risk behaviors) and their potential acute consequences (e.g., various types of psychological and physical injury to self or others). There are two primary options here: 1) development of a scale assessing key behaviors and outcomes across the various domains or 2) development of scale(s) targeted at in-depth evaluation of a specific domain (e.g., sexual risktaking). Given that most scales included in this review attempted to cover multiple domains, we would suggest that the former is the priority, and could be informed by this review in terms of ensuring coverage of the most common acute risk behaviors and consequences assessed across the scales included here (e.g., vomiting, passing out, other physical injury, drunk driving, sex without contraception, physical or verbal aggression or violence, property damage, other interpersonal problems, financial risks; see Table 1). Scale development may

need to consider timing of assessment (e.g., within versus post-session), with the latter (e.g., assessments completed the morning after a drinking session) more commonly employed in EMA work published in this area to date (Labhart et al., 2018; Lee et al., 2017; Simons, Dvorak, Batien, & Wray, 2010; Simons, Wills, & Neal, 2014). Psychometric validation will be critical but may need to be concentrated predominantly on testing validity, with time-dependent behaviors assessed at the event-level likely to cause issues for assessment of test-retest reliability. Such a measure could provide important information at the eventand individual-level. Specifically, data collected could 1) inform understanding of antecedents to risk behaviors and experience of harm at the event-level that could be targeted in intervention efforts, 2) identify those individuals at risk of repeated harm, and 3) measure impact of interventions targeted at this population. In all instances, EMA assessment could be evaluated against standard retrospective recall assessment (e.g., behaviors in the past month) to determine concordance and additional value offered by event-level, repeated assessment. 4.1. Limitations of the current review The search and screening processes were systematic and comprehensive, minimizing the risk that scales might be missed. However, there is still a chance that scales meeting our criteria might have been omitted; for example, a scale being used in clinical practice but not identified in peer-reviewed literature or published in a language other than English or prior to 1997. The authors consider this risk to be low, as scales commonly used in clinical practice are psychometrically analyzed before becoming integrated into assessment; scales are often translated for use in multiple languages; and finally, because we noted any measure of alcohol-related risk-taking referred to in articles included in full-text screening, even if the measurement tool was originally published outside of the original reference range. The authors may not have identified all published studies detailing psychometric validation of scales, yet our search processes (including searching for papers which cited the index article for a scale) should have minimized any such oversight with respect to identifying the absence of efforts to assess validity/reliability. We do acknowledge that we have not summarized all studies of psychometric validation for each scale, instead focusing on presence of evidence to support reliability/validity. We also acknowledge that those items considered as occurring ‘within the drinking session’ may be subject to debate; much of this arises from vagueness in scale instructions and/or item wording as to when the behavior or consequences are experienced (during the drinking session or in the immediate or long-term subsequent). 5. Conclusion A multitude of alcohol-related measurement tools exists however, the primary focus is often directed at assessing longer-term consequences of use. A total of three scales, containing four relevant subscales, have been identified that can be used to assess risk behavior and harms at an event-level during a drinking session. Yet, these four subscales all lack sufficient coverage of all domains of risk-taking, highlighting the necessity of a new measurement tool. This is particularly pertinent given the current increasing trend to use EMA in studying alcohol and drug consumption and related problems, and to evaluate interventions to minimize risk behavior while acutely intoxicated (e.g., drink-driving). Role of funding source The researchers received no funding for this study. AP is funded by a National Health and Medical Research Council Early Career Fellowship (#1109366). The National Drug and Alcohol Research Centre is funded by the Australian Government Department of Health under the Drug and Alcohol Program. 8

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Contributors

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