Despite research linking substance use/abuse to pejorative academic outcomes, the underlying behavior and cognitive mechanisms responsible for this association are largely unknown. This study addresses a specific call for understanding learning strategies and skills associated with substance alcohol use/abuse. Four hundred fifty undergraduates  completed measures of hazardous drinking behavior and student learning strategies. Approximately 35.3% of the sample reported hazardous drinking scores in the clinical range. Bivariate correlations and a regression framework were utilized to understand the associations among hazardous drinking behavior, academic skills/strategies, and student liabilities. In the present study, hazardous drinking behavior was associated with 4 learning strategies: note-taking/listening skills, test-taking strategies, organizational techniques, and time management. Moreover, hazardous drinking behavior was associated with 2 student liabilities: low academic motivation and concentration/attention difficulties. Results from follow-up analyses suggest that only organizational techniques and concentration/attention difficulties predicted hazardous drinking behavior. Promising areas for future research and potential intervention targets are discussed. Extant research links alcohol consumption to numerous negative outcomes including both health-related and legal concerns. Approximately 10% of all emergency room visits at a large university medical center are alcohol related.3 Moreover, approximately 500 000 college students in the United States report alcohol-related injuries and alcohol is linked to more than 1700 deaths.4 Similarly, alcohol-related problems are associated with lower levels of general life satisfaction.5 Binge drinking is related to legal problems  and alcohol use is linked to both social difficulties  and health impairments .6Alcohol is the most commonly used drug on college campuses, with over 60% of undergraduates consuming alcohol in the past month7 documented an association between hazardous drinking behavior and four academic-related problems: completing assignments in a timely fashion, concentrating in class, missing class, and being late for class. Similarly, Presley and colleagues8 documented consistent near-term academic correlates of hazardous drinking behavior. They noted associations among alcohol consumption, performing poorly on a test/project, and missing a class during the academic year.8 In a report to college presidents, Presley and Meilman noted that long-term academic consequences of alcohol use/abuse include college retention problems, lower overall grade point averages (GPA), and academic probation.9 Moreover, a relationship between alcohol consumption and GPA is documented even after controlling for Scholastic Aptitude Test (SAT) scores and high school class rank.10While extant research links problematic drinking behavior to health, legal, and social problems, it is important to understand the associations between alcohol use/abuse and academic-related concerns. McGee and Kypri11 Moreover, alcohol-related disorders are associated with visual spatial problems13 and concerns with psychomotor speed and coordination.13 Researchers posit that substance use/abuse is associated with impaired study habits or skills which may, in turn, lead to long-term academic consequences.11 While hazardous drinking behavior is associated with impairments in executive functions, no study, to date, has examined the associations between hazardous drinking behavior and specific study strategies.Although research links hazardous drinking behavior to near-  and long-term academic consequences , the underlying behavioral and cognitive mechanisms responsible for this association are largely unknown. Researchers posit that substance use impairs both learning and memory, particularly the development of higher-order cognitive processes  that are critical to learning and navigating the transition to adulthood. These higher-order processes include inhibition and planning/organization and are essential for problem-solving and guiding everyday behavior.14 Learning strategies, however, are related to specific cognitive tactic for storing/encoding and processing stored information.15 Specific learning strategies include study strategies, note-taking/listening strategies, and reading comprehension strategies. Referred to as the “third pillar supporting collegiate academic performance,”16 study skills/learning strategies are informed by both indirect/distal determinants  and direct/proximal determinants .17 Among adolescents, substance use/abuse is associated with attention problems and problems retrieving both verbal and visual material.18 While research documents positive outcomes for interventions aimed at improving learning strategies, most research on learning strategies has been conducted with adolescent students with identified learning disabilities.14 Despite concerns regarding the documented relation between hazardous drinking behavior and learning, the extent to which hazardous drinking behavior is related to specific study skills and learning strategies in a college student sample is unknown.It is important to note that while study strategies and study skills are often used interchangeably, study skills are global in scope and refer to a task-specific subset of behaviors that facilitate the learning  of presented material.14 Academic-related student liabilities include test anxiety, attention problems, and poor student motivation. The present study addresses a specific call for understanding learning strategies and skills associated with hazardous drinking behavior11 and is the first study, to date, to examine the association between specific study skills/learning strategies and hazardous drinking behavior. The study aims to identify potential treatment targets and inform the development of impairment-specific academic interventions for college students at risk of engaging in hazardous drinking behavior. First, bivariate correlations were conducted to understand the associations among hazardous drinking behavior, school motivation, and learning strategies. A multiple regression framework was then utilized to understand the direct effects of school motivation and learning strategies on hazardous drinking behavior. Based on the work of Zeigler and colleagues11 examining underage drinking and study skills, it is hypothesized that hazardous drinking will be associated with greater study skill deficits and problematic learning strategies. The present study examines the following seven factors known to affect academic performance: study strategies, note-taking/listening skills, reading/comprehension strategies, writing/research skills, test-taking strategies, organization techniques, and time management. Based on extant research,11 we expect to document negative associations between hazardous drinking behavior and employing learning and study strategies effectively. In addition, relationships between hazardous drinking behavior and the following three student liabilities were explored: academic motivation, test anxiety, and concentration/attention. We expect to document positive associations between hazardous drinking behavior and the 3 student liabilities. The aim of this work is to identify potential treatment targets for individuals who report problematic hazardous drinking profiles.To expand existing knowledge, the present study attempts to understand the associations among hazardous drinking behavior, learning strategies, and student liabilities in a college student sample. Student liabilities are modifiable behaviors that affect the acquisition, processing, and retrieval of information.The sample consisted of 450 students (at least 18 years of age) enrolled in a psychology department research pool at a public, southeastern university. Participants were recruited by a clinical research laboratory through the SONA Research Participant Recruitment System, a cloud-based research participant pool. Students recruited through the SONA system received research participation credits for their course grade.Participants completed a demographic questionnaire to assess basic demographic information including age, handedness, gender, sex, race, educational history, health  history, family history, and social history.14 The SMALSI utilizes a 4-point Likert-type scale that ranges from 1 (“never”) to 4  and assesses seven student strengths: study strategies (15 items), note-taking/listening skills (17 items), reading/comprehension strategies (12 items), writing/research skills (9 items), test-taking strategies (13 items), organizational techniques (13 items), and time management (14 items). In addition, the measure assesses 3 student liabilities: low academic motivation (26 items), test anxiety (25 items), and concentration/attention difficulties (20 items). The SMALSI has adequate internal consistency. The following Cronbach alphas are associated with SMALSI subscales: study strategies (α = .81), note-taking/listening skills (α = .81), reading/comprehension strategies (α = .79), writing/research skills (α = .73), test-taking strategies (α = .78), organizational techniques (α = .77), time management (α = .80), and time management (α = .80), low academic motivation (α = .91), test anxiety (α = .92), and concentration/attention difficulties (α = .84). Lower Student Strength scores indicate greater impairment. Lower Student Liabilities scores denote less difficulty.The SMALSI is a comprehensive self-report measure of learning skills and strategies.19 Participants were asked to provide information regarding alcohol-related consequences , the frequency of alcohol consumption , and the quality of alcohol consumption . The AUDIT has adequate internal consistency reliability (α = .76-.83)21 and good 1-week test–retest reliability (r = .84).21 In the present study, hazardous drinking behavior was defined as having an AUDIT score of 7 for men and 6 for women. Higher scores on the AUDIT denote greater hazardous drinking behavior.The AUDIT is a 10-item assessment of hazardous drinking behavior.IRB approval was obtained prior to data collection. On the university’s SONA Research Participant Recruitment website, participants were asked to view the study intent, general procedures, time involvement, potential benefits of participation, potential risks of participating, limits of confidentiality, and the right to cease participating in the study at any time without penalty or consequence. Students were invited to complete online questionnaires after consenting to study participation. Participants were invited to complete a lab-based research appoint after completing the online measures.SD = 0.81). With respect to gender, 268 participants (59.6%) identified as female, 179 participants (39.8%) identified as male, 2 participants (0.4%) self-identified as inter-gender, and 1 participant (0.2%) chose not to provide information regarding gender. Approximately 82.4% (n = 371) identified as white/Caucasian, 8.9% (n = 40) identified as black/African American, 5.6% (n = 25) identified as Asian, 1.1% (n = 5) identified as Native Hawaiian or Pacific Islander, and 2% (n = 9) of the sample chose not to provide information regarding race/ethnicity status. Of the enrolled participants, 75.3% (n = 339) identified as freshmen, 17.1% (n = 77) identified as sophomores, 5.1% (n = 23) identified as juniors, and 2.4% (n = 11) identified as seniors.The mean age of participants was 18.59 years  nor gender (P = .10) correlated with hazardous drinking behavior. Hazardous drinking behavior was not related to class standing (P = .11). Hazardous drinking behavior correlated with the following 4 learning strategies: Note-taking/Listening Skills , Test-taking Strategies , Organization  and Time management , suggesting that as hazardous drinking behavior increases, note-taking/listening, test-taking, organization, and time management abilities decrease. Hazardous drinking behavior was not related significantly to Study Strategies (P = .06), Reading/Comprehension Strategies (P = .07), or Writing/Research Skills (P = .48). Regarding student liabilities, hazardous drinking behavior correlated with both low academic motivation  and concentration/attention difficulties , suggesting that as hazardous drinking behavior increases, academic motivation and concentration/attention problems increase. Hazardous drinking behavior was not associated with test anxiety (P = .162) in the present study.Means, standard deviations, possible ranges of scores, and inter-correlations among study variables are presented in 2 = 0.024) and student liabilities (adjusted R2 = 0.045) on hazardous drinking behavior. Regarding student strengths, organizational techniques  was the only significant predictor of hazardous drinking behavior after controlling for both gender and age, b = –.163, t(448) = 12.23, P = .001. Study strategies, note-taking/listening skills, reading/comprehension strategies, writing/research skills, test-taking strategies, and time management were not significant predictors of hazardous drinking behavior. Regarding student liabilities, only concentration/attention difficulties  predicted AUDIT scores significantly after controlling for both gender and age, b = .112, t(448) = 22.36, P < .001  will inform the identification for potential treatment targets for populations at risk of engaging in hazardous drinking behavior. To our knowledge, this is the first examination, to date, to examine the associations among hazardous drinking behavior, academic skills/strategies, and student liabilities.The present investigation aims to understand the associations among hazardous drinking behavior, academic skills/strategies, and student liabilities. The SMALSI was utilized to assess 7 learning skills/strategies: study strategies, note-taking listening skills, reading/comprehension strategies, writing/research skills, test-taking strategies, organizational techniques, and time management.22 more than a third of participants in our sample exhibited AUDIT scores in the clinical range (35.3%). It is important to note that most of the study participants were freshmen. Targeted recruitment efforts were not adopted by the research team  in this pilot investigation. Traditionally, freshmen fall between 17 and 20 years of age.23 This group is below the legal drinking age and rates/frequency of hazardous drinking behavior may change as this population transitions to upperclassmen status. Hansson and colleagues24 found that approximately 54% of college students (average age 25 years) have scores above the AUDIT cutoff. These participants reported having at least 1 parent with self-reported alcohol problems.24 In a sample of 401 current drinkers, DeMartini and Carey22 found that 52% of the sample met criteria for the at-risk status. Our findings suggest that it is important for campus-based interventions to be mindful of this high-risk/vulnerable population, as treatment gains obtained during the freshmen year may inform future academic success and improve the academic outlook. Research suggests that alcohol consumption during the freshman year is predictive of academic problems throughout the college years.2527 Future research should examine the extent to which Greek membership and/or common concerns experienced by college students  may impact college drinking behavior.Based on the adopted AUDIT criteria,11 our findings suggest that hazardous drinking behavior is associated with 4 of 7 learning strategies. Our findings are consistent with research suggesting a link between hazardous drinking behavior and both learning and memory.11 It is important for future research to examine whether higher-order cognitive processes  moderate the relation between learning strategies and hazardous drinking behavior. Note-taking is a “developmental process” that encompasses encoding/storing information and monitoring comprehension with self-questioning.28 Evidence-based methods used to improve note-taking skills include using shorthand writing methods to train individuals to write faster, reviewing subject material before class, writing questions about the study material, and using guided lecture notes provided by the professor.29 Test-taking strategies, however, aim to improve performance by familiarizing students with the testing situation and reviewing test formats.30 At least 6 evidence-based test-taking strategies have been identified: using retrieval cues, adopting time strategies, avoiding common errors, appropriate guessing techniques, deductive reasoning skills, and considering the intent of the question.31 Time management, however, involves effectively managing time to complete tasks/assignments and estimating the time needed to complete goals and related subtasks. Researchers posit that time management is the “self-management of behavior” and individuals must be mindful of schedules, goals, and required tasks for goal completion at all times. Time management should also include dividing complex tasks into management subtasks and designated incentives/rewards for task completion.32 The significant association between hazardous drinking behavior and time management in the present study is consistent with research on hazardous drinking behavior and completing assignments in a timely fashion, missing class, and being late for class.7 In the present study, only organization techniques predicted hazardous drinking behavior after controlling for both gender and age. Organization/planning is a higher-order cognitive process that is linked to both attention problems and hazardous drinking behavior. Researchers posit that organization involves 3 components: time, object, and idea.33 Adequate time should be devoted to identify the required materials and brainstorm. Organization includes the following behaviors: (a) managing tasks within a specified time context, (b) arranging supplies for assignments within space for easy access and deployment, and (c) configuring a systematic approach to a task.33Moreover, consistent with research linking substance use/abuse to impaired learning,18 we did not document an association between hazardous drinking behavior and reading/comprehension strategies. It is important to note that Brown and Tapert18 examined the attention skills and the retrieval of both verbal and nonverbal material in a sample of adolescents with alcohol use disorders. We did not document an association in our older, nonclinical sample.In the present study, hazardous drinking behavior was not related to study strategies, reading/comprehension strategies, or writing/research skills. While research links substance use to retrieval problems for both verbal and visual material,34 academic motivation requires skill, self-regulation, willpower , and investment in the process of learning. Motivated students are “empowered learners”35 who expect to complete tasks/goals and esteem the learning experience. Self-efficacy36 and student attributions38 are central to evidence-based strategies to improve academic motivation. Moreover, attention/concentration abilities are central to learning, as attention is a precursor to encoding, processing, and retrieving information.39 Attention is a multifaceted construct that includes divided attention, sustained attention, and focused attention.40 Evidence-based strategies aimed at improving attention/concentration abilities target identifying important/relevant information, ignoring irrelevant information, allocating attention, and monitoring understanding/comprehension.41 The unique association between attention/concentration abilities and hazardous drinking behavior is consistent with research on substance use and concentration in the classroom environment.7 Individuals with chronic and debilitating attention problems  are more likely to use substances,42 with both attention problems and impulsivity being related to alcohol use/abuse.43 Campus-based intervention for individuals diagnosed with ADHD should consider comorbid mental health concerns  and underlying learning challenges unique to this population. In the present study, concentration/attention difficulties were related to hazardous drinking behavior and 7 learning strategies: study strategies, note-taking/listening skills, reading/comprehension strategies, test-taking strategies, organizational techniques, and time management. Similarly, concentration/attention difficulties were related to both low academic motivation and text anxiety. It is important for future research to assess and treat (if necessary) comorbid hazardous drinking behavior in college students with chronic attention problems that impair functioning.Regarding student liabilities, hazardous drinking behavior was associated with both low academic motivation and concentration/attention difficulties in the present study. An association between hazardous drinking behavior and test anxiety was not documented in the present study. According to researchers,While our findings suggest that note-taking/listening skills, test-taking strategies, organizational techniques, time management, academic motivation, and concentration/attention abilities are potential treatment/interventions for individuals at risk of engaging in hazardous drinking behavior, several methodological concerns should be considered. First, this cross-sectional design relied exclusively on self-report data. It is important for future research to examine longitudinally the development of learning strategies and student liabilities across the college experience, with special consideration of higher-order cognitive processes  that underlie/support learning strategies and student liabilities. In addition, most of the participants in the present study identified as freshmen (75.3%), as participants were largely recruited from lower-level classes that require research participation. Finally, it is important for future work to consider student academic records and objective measures both hazardous drinking behavior and learning strategies in a more diverse sample. Students at risk of engaging in hazardous drinking behavior should be evaluated in a lab and/or applied setting  to understand the associations among attention problems, learning strategies, and hazardous drinking behavior. In addition, the utilization of external collateral information from multiple informants  and controlling for positive impression management would lend support to our finding that attention problems predict hazardous drinking behavior.


Video game technology is changing from 2D to 3D and virtual reality (VR) graphics. In this research, we analyze how an identical video game that is either played in a 2D, stereoscopic 3D or Head-Mounted-Display (HMD) VR version is experienced by the players, and how brands that are placed in the video game are affected. The game related variables, which are analyzed, are presence, attitude towards the video game and arousal while playing the video game. Brand placement related variables are attitude towards the placed brands and memory  for the placed brands. 237 players took part in the main study and played a jump’n’run game consisting of three levels. Results indicate that presence was higher in the HMD VR than in the stereoscopic 3D than in the 2D video game, but neither arousal nor attitude towards the video game differed. Memory for the placed brands was lower in the HMD VR than in the stereoscopic 3D than in the 2D video game, whereas attitudes towards the brands were not affected. A post hoc study (n = 53) shows that cognitive load was highest in the VR game, and lowest in the 3D game. Subjects reported higher levels of dizziness and motion-sickness in the VR game than in the 3D and in the 2D game. Limitations are addressed and implications for researchers, marketers and video game developers are outlined. The video game industry is one of the fastest-growing industries. The global value for the video games market is expected to grow from almost USD 71 billion in 2015 to about USD 90 billion in 2020 . At leasVideo games create a virtual reality in which the individual plays the game. Virtual reality is understood as an environment that is created by a computer or other media and in which the user has a feeling of being present in the environment . Over thOne phenomenon that exists in many video games are brand placements and they are also addressed in the current research. Brand placements in video games are a form of advertising in which branded goods or services are featured in the video game e.g. –23). The. The23])The present study investigates how the game play experience is affected, depending on whether players play an identical video game in 2D, stereoscopic 3D (in the following just “3D”) or Head-Mounted-Display VR (“VR”). In addition, the study analyzes how brand placements in the video games are affected and whether they gain or suffer from advanced technology. By shedding light on the evaluation of 2D, 3D and VR video games and the brands placed therein, the study yields important insights for researchers, video game producers as well as marketers who want to promote their brands via placements in video games.In comparison to the conventional 2D technology, which does not give depth to the objects, 3D and VR technology offer additional experiences for the user. The technologies allow for the perception of spatial depth on the screen. In the 3D technology, this is realized by using stereoscopic displays, which creates spatial depth off the screen with 3D pop-up visualizations, so that some objects within the game appear closer to the player and seem touchable, the usage of 3D-capable screens or the usage of dedicated 3D-capable glasses. 3D technology can be more realistic, immersive and allows e.g. improved eye-hand coordination, as compared to the 2D technology experience that lacks depth perception. One of the first 3D home video game devices was Tomytronic 3D in which 3D was simulated using two LCD panels, developed by a Japanese toy maker in 1982. Other early home devices were developed by e.g. Nintendo in 1995 ,29.In comparison to the 3D technology, HMD VR tries to deliver an even stronger feeling of being in the world or in the moment . VR is aHowever, the quality of 3D technologies ,41,42 asThe concept of presence in virtual environments has received a lot of attention during the last decades, especially with the rise of interactive technologies in the 90s, and has been debated from different perspectives e.g. ,45,46). ,46. 45,4The level of presence seems to be of special interest for the comparison of different technological environments and in the game context. The question is how deeply participants are immersed or “inside” the game ,54. Kim We therefore expect that presence should be higher in the VR than in the 3D than in the 2D video game.“H1: Presence will be highest in the VR video game, lower in 3D and lowest in the 2D video game.”Arousal can be defined as stimulation, alertness or activation and is a process, which initiates behavior . Accordi“H2: Arousal will be highest in the VR video game, lower in the 3D and lowest in the 2D video game.”Attitude towards the game in this research is defined as the overall evaluation of the game played. Attitudes are a composite of feelings and beliefs as well as behavioral intentions toward an object . The comAs outlined above, 3D and VR offer additional technological features (e.g. higher immersion) that may allow for a better attitude towards the game. On the other hand, negative aspects are also related to the technological enhancements , which are likely to impair attitudes towards the game. Since the literature is contradictory with regard to whether the positive or negative aspects related to the technology enhancement dominate, and since no research has examined the attitude towards the game when playing the game either in a 2D or in a 3D or in a VR condition, hence no empirical evidence is available so far, we investigate the impact of the technology on attitude towards the game and formulate the following research question:“RQ1: Do attitudes toward the game differ in the 2D, stereoscopic 3D and HMD VR condition?”As outlined above, brand placements play an important role in video games. Though previous research has analyzed several factors that influence the recipients’ attitude towards brands placed in computer games, such as game involvement , enjoymeTo the best of the authors’ knowledge, no study has addressed this question in the context of 2D, stereoscopic 3D and HMD VR video games. Hence, several studies have shown that an enhanced technology might influence the attitude towards the brand positively. We therefore derive the following hypothesis:“H3: Attitude toward the placed brands will be more positive in the VR video game compared to the 3D, and it will be least positive in the 2D video game.”Recall and recognition are the most common measures to examine the memory of brand placements , leaving less cognitive resources for secondary tasks, such as memorizing the brand placements in the video game. This leads us to the following hypothesis:“H4: Recall and recognition of the brands included in the video game will be lowest in the VR condition, higher in the 3D condition and highest in the 2D condition.”Skepticism towards advertising, general attitude towards video games, prior video game playing experience and video game literacy serve as control variables.In Austria, it is not necessary to go through an Institutional Review Board or an Ethical Committee when performing a study with human participants who are of legal age. The research design and the questionnaire are in line with the Austrian and the EU privacy regulations. The research as well as the questionnaire have been approved by several professors and employees of the University. Subjects have been notified and have been properly instructed about their voluntary participation in an experiment and that their data will be handled strictly confidential by using appropriate tools, instruments, and protocols to secure their privacy. Consenting participants have been informed about the survey verbally and in written form in advance and after filling out the questionnaire. The data was handled in a strictly confidential fashion and anonymously.In order to address the above proposed hypotheses and research question, a “jump’n’run” video game was designed and developed in a 2D, 3D and VR condition by a professional game designer. The 2D condition was developed with traditional pictures and without depth of the objects. The 3D condition refers to stereoscopic three-dimensional technology, where the objects pop-up with true depth and float off the screen . The VR In total eight different brands were integrated in the game, each brand appeared in each level (hence each brand appeared three times during game play). The brands belonged to the following product categories: airline, chocolate, bank, energy drink, coffee, fitness club, nachos, and smartphone. All brands were fictitious to avoid confounding effects of previous brand knowledge. The size and presentation type of all brands were kept constant across all three different levels and across all three game conditions. The brands remained on screen until they were collected by the player. One goal that players pursued was to collect as many brands as possible in order to get to the next level. All participants reached the last level. At the end of the game, participants could record their name in a high score list. After playing the game, each participant filled out an electronic questionnaire see .2p) was used for the effect size measurement for the analysis of variance (ANOVA). It measures the strength of the effect on a continuous field, where η2p = 0.01 indicates a small effect, η2p = 0.06 indicates a medium effect and η2p = 0.14 indicates a strong effect )S1 Appendix(PDF)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.S3 Appendix(PDF)Click here for additional data file.S1 Data(SAV)Click here for additional data file.S2 Data(SAV)Click here for additional data file.


Although this work has been impressive, I argue that it might miss important ways in which symbolic boundaries become effective in everyday social life. I therefore develop an understanding of how symbolic boundaries affect people’s ideas and decisions about themselves and their own behavior. Based on this, I argue that focusing on boundary violations—that is, what happens if people express opinions or enact behavior that contravenes what is considered (in)appropriate for people like them—might offer an important way to understand how symbolic boundaries initiate and shape cultural and social change. Using data from Add Health, I demonstrate the utility of this line of argument and show that boundary violations play an important role in channeling social influence. Conservative/Evangelical Protestants and to a lesser degree Catholics, but not Mainline Protestants are highly influenced by the drinking of co-religionists. I consider the implications for cultural sociology.Scholars of social influence can benefit from attending to symbolic boundaries. A common and influential way to understand symbolic boundaries is as widely shared understandings of what types of behaviors, tastes, and opinions are appropriate for different kinds of people. Scholars following this understanding have mostly focused on how people judge  Social influence is widespread. People adopt behavior and change opinions as a result of interacting with others e.g. –3). Stud. Stud3])To gain leverage over these questions, I turn towards a concept from cultural sociology: symbolic boundaries. Sociologists have long argued that culture might moderate social influence ,11; alsoOne common and influential way to understand symbolic boundaries is as widely shared conceptual distinctions between kinds of people, practices and things (see ). These This understanding of symbolic boundaries has proven useful to gain insights into a range of important issues. It has helped advance an understanding of how people create, maintain, and contest institutionalized social differences. To do so, scholars have focused on how people do “boundary work,” that is, how they produce, rationalize, and contest similarities and differences between social groups based on class, race, religion or gender e.g., –24). For. For24])others. What has rarely been asked is whether and how symbolic boundaries might affect individuals’ ideas about themselves. An answer to this question might help to understand more fully how symbolic boundaries become effective in everyday life. A second limitation of existing work is that scholars have focused almost exclusively on how symbolic boundaries align with and thus reproduce social differences. Less studied has been the question of what happens when symbolic boundaries are violated. Yet attending more closely to such violations could help to understand the role of symbolic boundaries for social influence and thus social change.Although this (and related) work has been impressive, most scholars (explicitly or implicitly) have followed two understandings in using symbolic boundaries: First, scholars have mainly used the concept to analyze how people judge own self-classifications and behavior. If people selectively attend to others who are on the same side of a salient symbolic boundary to evaluate their own behavior, symbolic boundaries might turn out to be important moderators of social influence.In this paper, I develop a conceptual and empirical approach to symbolic boundaries that complements existing work by directly addressing these two limitations in order to advance an understanding of how symbolic boundaries might moderate social influence. First, I develop an understanding of how symbolic boundaries shape individuals’ decisions about themselves. Most behavior (or tastes or opinions) are not simply classified as “good” or “bad” in general; they are classified as good or bad for a certain type of person. Symbolic boundaries capture such cultural classifications. While these cultural classifications are essentially ascriptive, I argue that they also affect how people (selectively) attend to and take into account the behavior/opinions of others as people determine their Second, I focus on processes of boundary violation; that is, what happens if people express opinions or enact behavior that contravenes what is considered (in)appropriate for people like them. Specifically, I argue that observing such boundary violations might motivate (or at least authorize) people to change their own classifications and behavior. Boundary violations could thus lead to changes in what behavior, opinions and tastes are considered (in)appropriate for what kinds of people. If people selectively adjust their behavior based on violations made by others in their own symbolic groups, such a phenomenon might be key to understanding how symbolic boundaries stimulate and channel the direction of social change more generally.Building on this, I then derive a model of social influence that takes the potential role of boundary violation into account. I test this model empirically using the case of drinking behavior among adolescents from different religious traditions. If the argument above is correct, an adolescent’s own drinking should be more influenced by the drinking of members of their own religious tradition. To investigate this possibility, I draw on data from Add Health, a nationally representative survey  and levethese kinds of people do these kinds of things and those kinds of people do those kinds of things . If . If 29])his, see ).how (and only if) these group classifications are associated with expectations about behavior, opinions, and tastes considered appropriate or inappropriate for their members—in short, symbolic boundaries are the differential associations between group identifications and such expectations. Of course, to the extent that group identifications rest on ascribed rather than achieved characteristics and self-identifications, people may, in turn, also use knowledge about the behavior and opinions of others to aid classifying them into groups . Nevertheless, keeping group identifications and expectations about the behavior, opinions and tastes appropriate for members of these groups conceptually separate is necessary for theorizing mechanisms that build on the interplay between the two.Symbolic boundaries are not synonymous with social identifications. While social identifications are important for how people classify others into groups, symbolic boundaries consist in From an individual’s perspective then, the dual classifications marked by symbolic boundaries define primarily one’s own group in relation to other groups . They caothers (either of their own group or of other groups). Examples include studies of how individuals create, mobilize and negotiate “typical” differences among professionals and managers )Religion provides a strong basis for self-identification in the US  that drink may not be influenced by that fact because she does not see that behavior as relevant for her own decisions about drinking. She may infer that drinking is acceptable “for people like them” but not “for people like me.”Based on this reasoning, I hypothesize that having at least one same-religion drinking friend will predict drinking frequency above and beyond the amount expected given the simple number of drinking friends (and the simple number of same-religion friends). Focusing on differences across religious traditions offers additional theoretical leverage: On the one hand, it allows me to explore whether the effect of boundary violation varies with the salience of the symbolic boundaries. Accordingly, I expect the effect to be stronger for religious traditions that uphold stricter norms against drinking such as Conservative/Evangelical Protestantism than those with more lenient prescriptions such as Mainline Protestantism  is ideal to test these predictions ,76). ThiI focus on AH’s wave I and II in-home interview data. In the 1994 to 1995 school year, 20,745 adolescents in grades 7 to 12 were interviewed at home. 7,106 adolescents in saturated schools were asked to list up to 5 of their closest male and female friends respectively. In 1996, 5,264 of these adolescents were re-interviewed and the same network information collected. The data allows matching respondents on friend nominations and thus to describe friends in terms of their own self-reports. The Institutional Review Board at Duke University approved this study.I construct the following measures  someone who drinks alcohol, (2) someone who shares the respondent’s own religious tradition, and (3) someone who drinks alcohol and shares the respondent’s own religious tradition.gender, age, frequency of attending religious services during the past year  and a dummy for the interview wave.This includes participants’ N = 4,510 adolescents .Because of the nature of my hypothesis, I limit the sample as follows. I only analyze youth who identify with one of the three major religious traditions: Conservative/Evangelical Protestants, Mainline Protestants, and Catholics (80.7%). That is, I exclude non-religious adolescents since we have no way of knowing whether they belong to a group marked by a salient religious symbolic boundary  and relIdeally I would make use of the panel structure of the data to gain leverage over the question of causality by means of cross-lagged panel models or even fixed effects panel models to eliminate time constant unobserved heterogeneity at the individual level. However, I lack individuals who participated in both waves, switched drinking status in-between, and for whom I have sufficient network information. This is partly the case because participants’ network characteristics depend on answers from their friends. Given this, I chose to pool data from both waves and use dual equation models to get closer to an estimate of the effect of boundary violation on drinking.My analytical strategy is as follows: Although the main dependent variable is dichotomous, I follow best practice in econometrics and use ordinary least squares (OLS) regression to establish the main effect (see ). This cI begin by fitting a series of 6 regressions predicting drinking status. The key predictor is the boundary violation indicator—whether the respondent has at least one same-religion friend who drinks alcohol. I use robust standard errors, clustered within schools, to account for downward biases of estimated standard errors due to the “grouped” nature of the data (see ).Models 1 to 4 take a standard full-sample regression approach and add increasing controls to isolate the effect of boundary violation. Model 1 is the standard model, with drinking status as a function of the number of same-religion and drinking friends alone. Model 2 includes only a dummy variable for boundary violation. Model 3 combines the two previous models. Model 4 adds controls, including an interaction term between the number of same-religion friends and the number of drinking friends. I include this interaction to rule out the possibility that it is the distribution of both sets of ties that is driving the effect rather than boundary violation per se. Moreover, Model 4 includes dummies for religious traditions.Model 5 adds interaction terms between boundary violation and religious traditions to account for the possibly varying salience of religious denominations for drinking. Model 6 replaces the linear terms for the number of friends with indicators for each possible combination of same-religion and drinking friends in order to rule out that the effects of any combination of those distributions might drive the effect of boundary violation.For each of the three different religious traditions, I then conduct a counterfactual analysis  to estimWe need to exercise caution about interpreting estimates of these single equation models. The difficulty of inferring peer effects from observational data is well-known –91. At lInstrumental variable (IV) methods are dual equation approaches that allow identifying the causal effect of an endogenous variable on the outcome in question. A valid instrument is a variable that meets two criteria: It needs to have a substantial direct impact on the outcome, and, net of controls, it needs to affect the outcome solely through its effect on the endogenous variable while being uncorrelated with unobserved covariates of the outcome. Whereas the first assumption can be tested, the second assumption can be supported but never fully validated by empirical results .Accordingly, I conceptualize adolescents’ sorting into boundary violating networks as a matter of choice at the school level and use the chance to meet a boundary violating other at school as an instrument . Everytbeyond possible sorting based on the prevalence of drinking or same-religion others at school.)This choice of instrument rests on two assumptions. First, consistent with my argument, I assume that boundary violating others influence one’s own drinking solely if they breach into one’s friendship network. Results support this assumption; i.e. net of controls including the prevalence of drinking others and of same-religion others at school, the prevalence of same-religion drinking others at school shows no significant effect on drinking. Second, although this modelling strategy explicitly models peer selection, it implicitly assumes that school composition is exogenous to adolescents’ friendship choices. . Finally, Model IV (FE) adds fixed effects for schools, limiting the estimation to within-school variance and thus eliminating sources of bias that are constant at the school level.not decisive proof; however, it helps provide additional plausibility for a possible causal interpretation.The IV approach is particularly well-suited to estimate effects like these. This is because the IV approach yields an estimate for the average effect of boundary violation on drinking behavior for all those who “chose” to have boundary violating friends because of the availability of such friends at their school, regardless of the effects for those who would have self-selected into friendships with boundary violating others for reasons unrelated to the availability of boundary violating others and that might also be related to their drinking behavior , followed by Catholics (11 percentage points) and barely existing among Mainline Protestants (1 percentage point). This corresponds to known variations in the salience of corresponding religious beliefs with regard to drinking ,74,96 anModel 6 includes dummies for each of the observed combinations between number of same-religion friends and number of drinking-religious friends. Results remain nearly unchanged, except that the interaction between boundary violation and being a Mainline Protestant drops below significance, which is likely due to this group being the smallest  to estimate the effect of experiencing a boundary violating tie. For each of the three religious traditions, I model drinking experience among all adolescents who did not experience boundary violation, including dummies for the number of same-religion and drinking friends, gender, age, religious tradition and attendance. Based on the model estimates, I then predict the expected drinking probability for cases outside of the area of common support. Difference in probabilities tests show that, for Conservative/Evangelical Protestants, the proportion of adolescents who drank among those who experienced boundary violation is 24 percentage points higher than we would have expected if they had not, and for Mainline Protestants 12 percentage points and for Catholics 10 percentage points see .and share their own religious tradition beyond their preferences for drinking friends and/or same-religion friends per se.To this point, the results are strongly consistent with the hypothesis that symbolic boundary violation has a qualitative effect on drinking among adolescents. Moreover, the best controlled results (Models 5 and 6) are consistent with a theoretical model of social influence that argues that drinking friends matter mainly when they are members of one’s own religious group. However, we should be cautious of premature interpretations. These estimates might be biased to the extent that having boundary violating friendships itself is a matter of choice or determined by unobserved variables. In the extreme, one might argue that the estimated effect of boundary violation on drinking merely reflects the tendency of drinking adolescents to prefer friends who drink I tackle this issue by using an IV approach (described above) and instrument boundary violation by the chance to meet a potential boundary violating friend at school. In a first equation, I regress boundary violation on the prevalence of drinking others, same-religion others and boundary violating others at school as well as all previous controls  attend to and evaluate the behavior/opinions of others as they determine their own symbolic group commit such violations might motivate (or at least authorize) people to adjust their own classifications and behavior.Second, beyond their role in social reproduction, I have argued that symbolic boundaries might also shape cultural and social change and that we can understand this more fully by focusing on boundary violations—that is, what happens if people enact behavior that contravenes what is considered (in)appropriate for people like them. In particular, observing members of one’s To demonstrate the utility of this line of argument, I tested this mechanism with regard to the case of religion and adolescents’ drinking behavior. Results yielded strong support for the hypothesis that models that take boundary violations into account are a better fit to the data than the standard model of social influence. In all models, respondents who have at least one same-religion drinking friend  are predicted to drink more than would be expected by the number of same-religion and drinking friends alone (or their linear interaction). The strict test of only comparing respondents with exactly the same numbers of co-religious and drinking friends shows an even stronger effect.Furthermore, results from an instrumental variable approach are at least consistent with the assertion that this peer effect is not an artifact of sorting into boundary violating networks. In this regard, my findings are similar to that of others who find that peer effects persist even after accounting for social selection ,48,77 anbeyond the prevalence of drinking or same-religion others at school as exogenous. This means that my approach might over- or underestimate the effect of boundary violation on drinking in so far as factors exist that influence (i) drinking behavior and (ii) the prevalence of boundary violating others at school beyond the prevalence of drinkers at school or the religious makeup of the school population.This study is of course limited in specific ways. First, I control for the effect of drinking friends and/or same-religious friends as well as account for the possibility that respondents select into boundary violating friendships themselves. Nevertheless, my modelling strategy implicitly treats the prevalence of boundary violating others at school Second, it rests on the assumption that at least some religious traditions form symbolic groups that are salient with regard to drinking in the US. This is likely the case  that agents are indifferent about which peers enact a behavior or hold an opinion (see ). The reFor cultural sociology , my findings offer both methodological and theoretical implications. Methodologically, they show that to unravel the working of culture in everyday life, approaches attuned to its classificatory and thus often qualitative logic can be extremely helpful. Accounting for the joint distribution between people and behavior in a classificatory fashion was essential to successfully detect the crucial role that symbolic boundaries play in this particular case. While others have studied heterogeneous peer effects in the past by means of linear interaction effects  or subgTheoretically, my findings imply that, beyond their role in social reproduction, symbolic boundaries also need to be understood as potential catalysts for socio-cultural change. As sources of selective attention to others and differential evaluation of their behavior, opinions, and tastes, symbolic boundaries function as moderators of social influence. Especially through their violation, symbolic boundaries might thus initiate and channel cultural and social change.S1 Notes(PDF)Click here for additional data file.S1 Tables(PDF)Click here for additional data file.S1 Appendices(PDF)Click here for additional data file.


The objective of this study was to identify behaviors and culture of drinking alcohol in Korean people.Among a panel of subjected enrolled in existing domestic survey companies, adults aged 19 to 59 yr old who replied that their drinking frequency was more than once a month for the past one year were selected in 2017. Sample size and methods used for analysis were determined by considering demographically proportioned stratified sampling and monthly alcohol drinking rate. A total of 1,185 subjects  responded to questionnaires.P< 0.001).Most drinking behaviors were in the domain of leisure time. Drinking for two or more times a month and binge drinking were mainly concentrated in five occasions types: going out with friends (44.2%), going out with colleague (34.2%), drinking at home or friend’s home with friends (32.9%), drinking at home alone (29.3%), and drinking with meals at home (27.5%). Regarding the ratio of experiences in drinking for subjects according to occupations, ‘Directors/Managers’ who participated in receptions of guests, either hosted by or invited thereto, had the highest percentage (64.2%), followed by ‘Individual Proprietors’ (56.4%). Differences between each type of occupation were found to be statistically significant (The drinking culture in Korea was characterized by more social drinking than by drinking alone at home. The drinking behavior was often one-shot at a time rather than drinking a little sip. The practices of collective drinking should be improved to avoid secondary harmful effects. Alcoholic drinks, together with tobacco, have been regarded as choices of one’s preference. Thus, drinking alcoholic beverage or selecting preferred drinks depends on one’s taste and one’s individual life style. However, in terms of behaviors involving drinking such as when, how, and what kinds of spirits do people drink, drinking is a social behavior determined by the society that people live in . The notMotives behind drinking of alcohol in different countries may be similar. However, attitudes toward drinking or behavioral styles (manners) of drinking alcohol are significantly different depending on religions and cultures of each country . The wayA number of studies have been carried out to identify factors of alcoholism and/or identification/prevention of problems due to heavy drinking –11. HoweThus, the objective of this study was to identify substantive realities of drinking alcohol in aspects of ‘the significance of alcoholic drinks’ perceived by domestic people and ‘how alcoholic drinks are taken’ by domestic people selected through probability sampling.th Korea National Health and Nutrition Examination Survey . The survey was carried out from Nov 1st, 2017 to Nov 8th, 2017 through on-line communication. A total of 1843 individuals were contacted with the questionnaire through on-line communication and 1222 subjects retuned responses to the questionnaire . After excluding 37 subjects with incomplete responses, the remaining 1185 subjects with complete responses were then selected as participants in this study.Occupations of subjects had the following: ‘Professionals/Sedentary Workers’, ‘Directors/Managers’, ‘Sales (Service) Persons/Daily Laborers’, ‘Employees of Production/Transportation’, ‘Individual Proprietors’, and ‘Students/Unemployed/Retirees’. Occupations of these subjects were then classified into the following categories: ‘Professionals/Sedentary Workers’, ‘Directors/Managers’, ‘Salesperson/Daily Laborers’, ‘Workers in Production/Transportation Industries’, ‘Individual Proprietors’, and ‘Students/Unemployed/Others (Retirees)’.Instead of meeting up in one place and staying there the entire night, groups of Korean friends will jump around from place to place in what is called “rounds” (cha in Korean). Sometimes it’s to change up the activity (i.e. restaurant for eating -> cafe for coffee) or simply just a change of venue (i.e. drinking at a bar -> drinking at a chicken joint). Whatever the case, be ready to move around. Thus, drinking rounds were distinguished into three cases of venues: drinking with meals, post-meal drinking, and drinking late at night or continued until dawn.Drinking at receptions of guests signified that subjects were either invited to the reception or they hosted the reception.To identify drinking behaviors of subjects, types of alcoholic drinks ) taken by each subject during the past one year were examined. Since types and amounts of alcoholic drinks are dependent on when and who participated in drinking occasions, the frequency of drinking and the amount of alcoholic drinks were examined at different situations: 1) Drinking at Ceremonial Occasions , 2) Drinking with Family Meals, 3) Drinking at Home or at Friends’ Home, 4) Drinking when Dining with Friends or Acquaintances, etc., 5) Drinking when Dining with Colleagues, 6) Drinking in Groggeries/Pubs or Bars, and 7) Drinking Alone.Regarding the definition of binge drinking (crapulence), subjects corresponded to the following conditions: drinking frequency of more than once a month and more than 7 standard drinks  or 5 standard drinks  at each drinking, irrespective of types of alcoholic drinks.From the inquiry delved into time of drinking, the time starting from 6 o’clock in the evening after completion of daily work of subjects was found to be the most frequent time employed for drinking. Regarding the frequency of time used for drinking after 6 o’clock according to weekdays and weekends, results were as follows: Friday evening, 74.6%; Saturday evening, 71.8%; Wednesday evening, 31.4%; Thursday evening, 31.1%; Sunday evening, 31.1%; Tuesday evening, 24.0%; and Monday evening, 20.4%. Daytime drinking was mostly found on Saturday (13.5% among entire subjects) and Sunday (9.9% among entire subjects). It occurred less on weekdays (1% ∼ 5% among entire subjects). Subjects in their 20s were found to mostly participate in the drinking after 6 o’clock on Saturday evenings whereas subjects belonging to other age groups mostly participated in the drinking on Friday afternoons .From subjects who replied to the inquiry on the number of drinking rounds they usually took, results for frequencies of drinking rounds were as follows: taking sole dinking session (30%), taking two drinking rounds (55.5%), and taking more than two drinking rounds (14.5%). Subjects in their 20s were dominant in the three rounds of drinking. Differences in numbers of drinking rounds between each age group were found to be statistically significant .P<.001). For subjects in the age group of the 20s, 54.6% of them showed ‘Drinking while Dining with Friends or Acquaintances etc.’ and 28.6% of them showed ‘Drinking in Groggeries/Pubs or Bars’. These portions were significantly higher than those in other age groups (P<.001). For subjects in the age group of the 30s, 35.2% had ‘Drinking while Dining with Colleagues’ and 30.4% of them showed ‘Drinking Alone’. These proportions were higher than those in other age groups. However, such differences between age groups were not statistically significant.The subjects in the age group of 50s showed significantly higher portion of the situation of ‘Drinking with Family Meals’ compared to those in other age groups . Besides, subjects in their 50s had a mean of 2.6 standard drinks for situation of ‘Drinking at Ceremonial Occasions ’. This number for such situation was also significantly higher than subjects in other age groups (P<.001).Subjects in the age group of the 50s were found to have a frequency of 33.1% for ‘Drinking with Family Meals’. This was significantly higher than the frequency of subjects in other age groups (P<.05) for ‘Drinking when Dining with Friends or Acquaintances etc.’ and 52.4% (P<.01) for ‘Drinking in Groggeries/Pubs or Bars’. These frequencies were significantly higher than those of subjects in other age groups.Subjects in the age group of the 20s had binge drinking frequencies of 79.9% (P<0.001).One-third of subjects provided responses about their experience related to ‘Passive and Reluctant Participation in Collective Drinking’ and the ‘Experience of One-Shot of Glassful Drinks’. For the experience related to drinking of ‘Bomb Cocktails ’, the frequency was 22%. For the experience involving ‘Coercive or Involuntary Sharing, Exchanging, or Cascading Glassful Drinks’, the frequency was 15.0% among replies from subjects.Subjects who replied their occupations as workers in ‘Production or Transportation’ industry had the highest portions of the following experiences: 61.3% for ‘Passive and Reluctant Participation in Collective Drinking’ and 38.7% for ‘Experience of One-Shot of Glassful Drinks’. Subjects with occupations of ‘Professionals/Sedentary Workers’ had the following results: 26.9% for drinking of ‘Bomb Cocktails’ and 18.8% for ‘Coercive or Involuntary Sharing, Exchanging, or Cascading Glassful Drinks’. These frequencies were relatively higher than those of subjects with other occupations.The inquiry delved into the most frequent time of drinking. Based on replies from subjects, the time after 6 o’clock in the evening after completion of daily work was found to be the most frequent time used for drinking. This implies that most drinking behaviors can be counted as one’s leisure activities. One’s daily life is comprised of working and leisure time. The culture of giving reception to one’s guests (with drinking) can also be counted as a bridge that connects both working and leisure in one’s daily life. Subjects with occupations of ‘Directors/Managers’ appeared to have more frequent experiences of ‘Drinking at Receptions’ than subjects in other categories of occupations. This implies another aspect of drinking as one is transformed into different labor beyond its typically recognized conception as one’s behavior to relieve fatigue accumulated by respective labors ; Thus, tThe culture of drinking in our domestic society shows the dominance of types of drinking with purposes of promoting relationships or developing acquaintance with other participants. These were also identified in this study. Frequent occasions of drinking with purposes of developing relationships with others were thus identified, with occasions of ‘Drinking when Dining with Friends or Acquaintances etc.’ and ‘Drinking when Dining with Colleagues’ being the most frequent. In such occasions of drinking, ‘exchanging glassful drinks”, “the ritual of drinking alcoholic drinks in a bowl”, “drinking of bomb cocktails”, or “the practice of one-shot drinking” would be counted as a means of “the culture of collective drinking”.One-third of subjects were found to have respective experiences of one-shot drinking (complete drinking of glassful drinks at once), with experiences of drinking of bomb cocktail (22.0%) and (coercive or involuntary) sharing, exchanging, or cascading of glassful drinks (15.0%). Coercive or involuntary sharing, exchanging, or cascading of glassful drinks has been pointed out as evil practice of long standing. It requires participants in drinking occasions to drink alcohol with one-shot rather than to drink them sip after sip. Following the one-shot drink, next participants are offered to take subsequent one-shot drink with the empty glass handed over to them. This is a scene frequently found in occasions of drinking held in Korea. According to results obtained from one previous survey, the dominant reason behind the taking or offering of the one-shot drink was the ‘intention of participants to get intoxicated as soon as possible’ . In the Recently, the case of drinking alone has been increasing due to the desire of people to take preferred drinks. This trend was also identified in this study . The porAccording to results obtained from the ‘Survey of the Hours of Living’ conducted by National Statistical Office in 2014, domestic adults aged over 20 yr enjoyed approximately 4 h and 52 min of daily leisure time , with watching TVs or being with media occupied approximately 2 h and 28 min, followed by 42 min  of the time spend for social occasions with friends, colleagues, and so on. The composition of leisure time of domestic people shows no particularity of hobbies or preferences. Except for the time consumed for the use of mass media, the time allocated to social occasions with friends or others had the highest portion. Besides, most subjects participated in this survey replied that they would usually “participate in occasions of drinking”. This corresponded to the result obtained from this study showing that subjects would participate in occasions of drinking, including drinking at receptions of respective important guests after completing daily work.The culture of drinking in our society can be considered as one of collective cultures wherein every participant would drink alcoholic drinks together in perfect order. Representative means employed for cultural practices thereof include ‘exchanging of drinks”, “the ritual of drinking alcoholic drinks in a bowl”, “drinking of bomb cocktails”, and “the practice of one-shot drink” requiring every participant to avoid drinking of glassful drinks sip after sip. Coercive offers of one-shot drink to other participants sharing the occasion of drinking would lead participants to have consequential binge drinking .The culture of drinking could lead them directly to the state of intoxication. One-shot drink of alcohol typically increases blood alcohol concentration rapidly. This frequently leads people to have various harmful consequences. It may cause suffocation due to vomiting or acute alcoholism typically accompanying comatose state or lethality, with highly probable experience of black-out. The black-out may lead patients to physical damages, including reduced capabilities of judgment, impaired impulse control, reduced retentive memory, and secondary ill effects involving violence or robberies; Thus, drinking behavior involving the offering of one-shot drinking needs to be changed. Participants in drinking occasions should be encouraged to be moderate in respective drinking of alcoholic drinks without coercive offers for one-shot drink.Ethical issues  have been completely observed by the authors.


The ward round is a key element in everyday hospital inpatient care irrespective of the medical speciality. The underperformance in conducting ward rounds of junior clinicians has already been described. Therefore, necessary skills and competences of clinicians need to be defined, taught and delivered for curricular instruction. In addition to published data on ward round competences in internal medicine this study aims to determine the common competences for surgical and psychiatric ward rounds in order to find differences depending on the speciality.N = 30) and psychiatric ward staff (N = 30) of a university hospital and five community hospitals were conducted. Competences necessary for performing ward rounds as well as structural aspects were identified by systematic content analysis and frequency analysis, supported by adequate statistics.Semi-structured interviews with surgical  contains supplementary material, which is available to authorized users. Ward rounds are important in every medical field in in-patient care. By definition, hospitalized patients need multidisciplinary care from medical doctors, nurses, therapists, social workers and others - otherwise outpatient care would be appropriate . The traCurriculum development for the teaching of ward rounds requires knowledge about the learning objectives, e.g., regarding ward round competency. Being able to conduct a ward round can hardly be trained as a single skill. It requires different competencies as well as the ability to fulfil several tasks at the same time. One educational method which is suitable for addressing the challenge of teaching and assessing a ward round is the entrustable professional activity (EPA), a concept devised by Ten Cate in 2005 . EPAs reAs a lot of prior research about ward round skills has focused on internal medicine, the aim of this study was to identify the competences needed for conducting a surgical and psychiatric ward round. We assumed that these specialities represent quite opposite fields of activity in medical care and therefore exhibit a broad range of medical competences. Our objective was to identify competences relevant in both specialities for conducting a ward round as well as competences more important in one of the two specialities.We chose a qualitative procedure, supplemented with quantitative elements. Interviews about conducting a ward round were performed, evaluated by content analysis and frequency analysis.The sample contains 30 interviewees for each speciality, surgery and psychiatry, while also including participants working on psychotherapeutic and psychosomatic wards. The interviewees represent experts: clinicians, nursing staff and - for psychiatric and psychosomatic wards - psychologists, all selected for a satisfactory amount of work experience Table . Cliniciprocedural part). Further open-ended questions focused on the tasks of and relevant skills required by a resident and, as interviews hinted at a strong participation of a senior doctor, questions about the tasks and skills of a senior doctor (tasks-and-skills part). Direct questions were based on a perusal in internal medicine and were complemented with questions regarding particular topics from the specialities psychiatry and surgery like documentation, empathy and decision making (literature-based part) [We used an adapted version of the semi-structured interview guide from a previous study  –8, 18.The feasibility of the interview guideline was assessed in a series of pilot interviews with participants representing the target group. Once practicability of the guideline was reached, one researcher (EV) conducted all interviews. The guideline consisted of both closed and open-ended questions relating to the ward round process and relevant ward round competences and corresponding activities. The interviews were audiotaped and subsequently transcribed with the audio software f4transkript (edu) 2012/ 2013. The transcripts were evaluated by qualitative content analysis using MAXQDA 10 . The codThe analysis focused on the occurrence of competences described by the interviewees in different parts of the interviews.tasks-and-skills part. In summary, the frequencies of the competences described in % were compared applying the following differentiations:surgery versus psychiatryentire interview versus answers in the procedural partanswers in the resident versus senior doctorFirstly, to find common and differing competences between the two specialities we evaluated the frequencies of the competences in the entire interview. Secondly, to find out which competences would be described by the interviewees themselves in the context of the work routine. we evaluated the frequencies of the competences in the procedural part. Finally, to contrast the competences of a senior doctor and a resident we analysed the For describing the structural aspects, additional noncompetence based codes were taken into account.p < .05) and, if required, a Fisher exact test were conducted using Excel 12/ SPSS 22.0. To test an association between the specialities and the competences, the phi coefficient (ɸ) was calculated. To reduce a dependence on the marginal distribution, a corresponding maximum value of phi was computed and phinorm (ɸnorm) was calculated. To determine the significance of different obtained frequencies of the competences for a senior doctor and resident, we used the McNemar test, defined p < .05.To analyse the significance of the relationship between the frequencies of the competences and the medical speciality a chi-squared test with Yates correction  minutes in surgery and 43 (SD =13) minutes in psychiatry on average.Structural aspects of the ward round described by the interviewees of both specialties are shown in Table collaborative clinical reasoning, (2) clinician - patient communication, (3) clinician - team communication, (4) organization, (5) teamwork, (6) management of difficult situations and error-management, (7) self-management, (8) teaching, (9) empathy and (10) nonverbal communication  ication,  organizaprofessionalism, (12) patient-management and, for surgery, (13) clinical skills.Additionally, qualitative analysis revealed six further competences, which were not included in the interviews by a direct question, but were mentioned by the experts in the interviews Table . Among tcollaborative clinical reasoning, (2) clinician - patient communication, (3) clinician - team communication, (4) organization, and (5) teamwork were reported with a frequency of over 30%  ication,  organizanonverbal communication between clinician and patient was more often commented by psychiatric interviewees (S: 70%/ PP: 93%), ɸ = .302, ɸnorm = .636, χ2  = 4.00, p = .045 whereas the competence clinical skills was described more frequently by surgical participants (S: 97%/ PP: 30%), ɸ = .692, ɸnorm = .909, χ2  = 25.91, p < .001.Statistically significant differences between surgery and psychiatry were found regarding two competences in the entire interview Table : nonverbempathy  = 6.60, p = .01. A trend could also be identified for senior doctors (S: 13%/ PP: 44%), ɸ = .330, ɸnorm = .616, χ2  = 3.33, p = .07.When contrasting the roles in the ward round of a senior doctor to a resident, significant differences between the specialities surgery and psychiatry appear. In the answers to the questions about the tasks and skills of a resident, codes regarding the competence Reynolds ) were mocommunication clinician - team was more frequently described as a competence of a resident in psychiatric than in surgical interviews (S: 50%/ PP: 79%) ɸ = .306, ɸnorm = .419, χ2  = 4.32, p = .04.The competence teaching was much more frequently described as a competence of a senior doctor with statistically significant differences in surgery, p = .031, and psychiatry, p = .002. In surgery organizational competence was more often assigned to a resident, p = .008. A similar trend was identified in psychiatry, this difference did not turn out to be significant, p = .065. The competence communication clinician - team was, in psychiatry, more often attributed to a resident than to a senior doctor, p < .001.When contrasting the tasks and skills of a resident with a senior doctor in the ward round, a distribution of competences became apparent Fig. . In bothThis study shows a comprehensive compilation of ward round competences which cover ward round practice of two rather different disciplines, surgery and psychiatry.collaborative clinical reasoning , (2) communication clinician - patient, (3) communication clinician - team, (4) organization, (5) teamwork (including leadership skills), (6) management of difficult situations and error-management, (7) self-management, (8) teaching, (9) empathy and (10) nonverbal communication (frequency > 70%). These competences were also asked about directly in the interview guide and correspond to findings in the literature concerning ward rounds in internal medicine [professionalism, (12) patient-management and (13) clinical skills in surgery were identified to be important (frequency > 67%).Interviewees of both specialities described the following competences in the entire interview: (1) medicine . The resIn the open-ended questions about the ward round work process at the beginning of the interview, the experts focus on the competences (1)–(5) among the literature-based competences (1)–(10). This stresses their importance for ward round procedure and they also correspond to skills found in the surgical literature , 22. HowWe analysed the differences between the specialities surgery and psychiatry regarding the ward round. Structural aspects like duration and frequency of the ward rounds differ strongly. This is a reflection of the differences between the daily routines in both specialities. Nevertheless, the relevance of the ward round was rated to be high by most interviewees in both specialities. Additionally, as described above, many competences required for the ward round are the same in both medical fields.nonverbal communication was significantly less often described in surgery than in psychiatry, even though the interviews included a direct question about it. Nonverbal behaviour and nonverbal communication play an important role in psychiatry considering the clinician patient relationship and therapeutic aspects [However, differences in the description of competences were also manifest. The competence  aspects –25. Howe aspects , 27. Theclinical skills is correlated to the surgical speciality. Practical procedures and physical examinations are an important clinical instrument in technical specialities. Patient consultation, for example by checking wounds and drains, is a relevant part in ward round practice and has also been integrated in a ward round safety checklist and in an assessment tool in surgery [The competence  surgery , 28.empathy to psychiatry was also identified, whereas surgical experts described it with low frequency. This is consistent with the fact that psychiatrists have a higher rating scale in empathy scores than surgeons [empathy in the open-ended questions in surgery is most likely an indication of poor awareness of it. Therefore self-reflection by using a checklist of ward round competences may help clinicians to increase awareness regarding empathy in ward rounds.For residents a significant correlation of the competence surgeons , 30. Morsurgeons , 7. Stilsurgeons , 32. Theorganization in both specialities, whereas the senior doctor needs to have teaching competence. This reveals a role distribution that can ensure patient service as well as educational aspects, particularly when not only the student but also the resident takes the part as a learner. The competence communication with the team is significantly correlated to psychiatric residents. It is attributed especially to the resident and not to the senior doctor, as, for example, the resident presents the status of the patient to the senior.Comparing residents to senior doctors with respect to the necessary ward round competences, some differences could be revealed. In contrast to a senior doctor, a resident is expected to focus on the competence teaching is more likely to be assigned to a senior doctor. It is also noteworthy that the competence teaching was only coded once when asking the experts about the general ward round process. This points to the putative opinion that educational aspects play a minor role in the ward round process. Similar effects were identified in studies of Claridge and of Laskaratos et al., in which first year doctors and trainees described the ward round as a suboptimal opportunity for teaching [teaching ought to be included in the EPA “ward round practice”.Above, it was shown that the competence teaching , 34. In teaching . EPAs mateaching . TherefoConcerning the teaching of ward round practice itself, it can be noticed that ward round skills and teaching receive more and more attention in surgical literature, as a checklist, an assessment tool and a learning environment for teaching ward rounds have been developed , 28, 37.While the use of checklists can help graduated clinicians, structured instructions of conducting ward rounds in undergraduate education may give medical students the chance to get ready for the clinical daily routine and may improve ward round practice in general. Nikendei et al. showed that ward round simulation with standardised patients can serve as a valuable learning environment for students . It provAn EPA “Conducting a ward round” can provide both, the theoretical background and practical approach for teaching ward rounds in clinical practice or simulation courses . The EPAWith our study, we extend prior knowledge on ward rounds in psychiatry and surgery. It provides a sound basis for deriving learning goals as well as for structuring the teaching and learning of ward round practice.By using a qualitative method supplemented with quantitative elements, this study gives a general overview of the ward round competences in both specialities. For developing an EPA, the general competences discussed in this study would have to be further divided into more specific subcompetences and linked to their observable tasks. While comparing the frequency of the descriptions of the competences, the results have to be interpreted in their context of the respective interview passages (direct question/ open-ended questions) and of the existing literature. Also, statistical analyses have to be seen as supporting the decision which divergent frequencies show a relevant effect. The wards, especially in psychiatry and psychosomatics, also show a marked heterogeneity as the patient groups and therapy concepts can differ. Additionally, the ward rounds depicted in the interviews represent only the status quo of actual ward round practice in Germany, and have to be proven for general validity.collaborative clinical reasoning, communication with the patient and the team, organization, teamwork, management of difficult situations and error-management, self-management, teaching, empathy, professionalism and patient-management. Additionally, clinical skills were mentioned very frequently in surgery. Nonverbal communication is more often described in psychiatry and the competence empathy is more frequently depicted as a characteristic of a psychiatric resident than of a surgical one. Experts focus on few competences in the low-structured parts of the interview: collaborative clinical reasoning, communication clinician - patient, communication clinician - team, teamwork and organization. This stresses the importance of these competences. However, it may also show a lack of awareness regarding other competences.In summary, the identified competences for conducting a ward round in surgery and psychiatry are similar and correspond to competences in internal medicine, which were found in literature. Relevant competences are: With this work we have contributed a foundation of competences that can be used to assess and teach ward round practice in both specialities, in surgery as well as psychiatry. A related study, which this work was based on, has proposed an EPA “Conducting an internal medicine ward round” with overlapping competences. This offers the possibility to transfer it to other specialities - bearing in mind the differences.Additional file 1:Interview schedule. (DOC 84 kb)


Reactive case detection (RCD) is an integral part of many malaria control and elimination programmes and can be conceived of as a way of gradually decreasing transmission. However, it is unclear under what circumstances RCD may have a substantial impact on prevalence, how likely it is to lead to local elimination, or how effective it needs to be to prevent reintroduction after transmission has been interrupted.Analyses and simulations of a discrete time compartmental susceptible-infectious-susceptible (SIS) model were used to understand the mechanisms of how RCD changes transmission dynamics and estimate the impact of RCD programmes in a range of settings with varying patterns of transmission potential and programme characteristics. Prevalence survey data from recent studies in Zambia were used to capture the effects of spatial clustering of patent infections.RCD proved most effective at low prevalence. Increasing the number of index cases followed was more important than increasing the number of neighbours tested per index case. Elimination was achieved only in simulations of situations with very low transmission intensity and following many index cases. However, RCD appears to be helpful in maintaining the disease-free state after achieving malaria elimination (through other interventions).RCD alone can eliminate malaria in only a very limited range of settings, where transmission potential is very low, and improving the coverage of RCD has little effect on this range. In other settings, it is likely to reduce disease burden. RCD may also help maintain the disease-free state in the face of imported infections. Prevalence survey data can be used to estimate a targeting ratio  which is an important determinant of the effect of RCD.The online version of this article (10.1186/s12936-019-2882-z) contains supplementary material, which is available to authorized users. The effects of different interventions against malaria have different temporal dynamics. Spectacular short-term effects do not necessarily result in elimination or in long-term transmission reduction, but both preventive  and curative (mass treatment) interventions deployed at fixed coverage generally have their maximal impact on the reproduction number at the start of the programme. This applies even when deployment is recurrent , unless In contrast to this, the recent history of malaria programmes seems to indicate that elimination requires sustained intervention over long periods . In someAn alternative or complementary explanation for long timelines is that intervention programmes have had impacts on the reproduction number that increased over time. One way in which this may have occurred is that impacts may cumulate with interventions with long durations. For instance, distribution of long-lasting insecticidal nets (LLINs) at a rate greater than their attrition rate, or larval source reduction by incrementally removing breeding sites may lead to gradual increases in impact, eventually leading to environments that cannot sustain transmission.Another way of gradually decreasing transmission, leading to a steady advance towards elimination may be reactive intervention deployment. Approaches are reactive if there is targeting in space or time in response to information gained in the course of the programme. Targeting and containment of local epidemics was the main approach of the only successful eradication programme for a human infection to date, that of smallpox , and it Effective surveillance-response (i.e. reactive) strategies are essential in final stages of an elimination programme, since persistence of the disease-free-state depends both on detecting imported infections and preventing their spread . If elimThis paper considers the theory of reactive intervention strategies applied in malaria intervention programmes with the analysis of a simple discrete-time susceptible-infectious-susceptible (SIS) model  of infecThe distinguishing characteristic of reactive interventions is that they are deployed selectively in time and space, in response to surveillance data. This selectivity means that the number of infections that are addressed at any one time-point is inflated above the number that would be addressed if the intervention was applied indiscriminately. In the models proposed here for RCD, this effect is captured by inflating the number of infections treated with a quantity termed the targeting ratio, defined as the ratio between the number of infected individuals treated by the reactive component, to the number that would have been treated had the selection been a simple random sample rather than neighbours of the index cases. The targeting ratio is thus approximately equivalent to the ratio of the prevalence of infection in the neighbourhood of an index case to the prevalence in the general population. The targeting ratio is a single parameter that quantifies the clustering of malaria infections due to spatial heterogeneity. Using the Zambian data, it is shown how this quantity can be estimated from survey data obtainable before the RCD is initiated, making it feasible to predict the dynamic effect of an RCD programme from cross-sectional data obtainable in advance without the need for detailed spatial analysis techniques (which are often difficult for programmes to conduct).The state variable, parameters and notation of the SIS model are given in Table The equation for the number of infectious individuals, IS model  in the aThis quadratic equation has two solutions, the disease-free  equilibrium, mentclass2pt{minimThe value of the basic reproduction number isRc, is then determined by The RCD programme is assumed to be added to a routine case management system, which serves as a passive surveillance component of a surveillance-response system. The RCD functions by investigating a constant number of passively detected index cases per unit time , is reduced by The model for RCD with the simplest dynamics assumes a constant value for Equation entclass1pt{minimaAn alternative to assuming fore Eq.  remains It follows that, if It follows that the escape probability increases with The fixed points of this system are the solutions ofentclass1pt{minimaThe stability of the fixed points is not analytically derived here, but explored through numerical simulations and bifurcation analysis.p and of ν satisfying the constraints More generally, both mentclass2pt{minimThe escape probability again varies over time and isAnalytical determination of the fixed points of this model is not feasible, so the fixed points and their stability was explored numerically.To parameterize model (c), the function , Zambia  were usePlasmodium falciparum and treating all members of households in which any individuals had positive tests, and achieved 62.5% and 54.0% coverage in the two distinct rounds  may speed up interruption of transmission but will be successful in fewer settings than the strategy of model (c) with constant search intensity, corresponding most closely to existing practice. Front-loading will make little difference to the total number of treatments required where transmission is interrupted, which is mainly a function of Where RCD is effective, its effects depend largely on the targeting ratio. This is a measurable quantity, and can be determined from basic parasitological survey data even in the absence of a programme, so this could be part of a feasibility study before any commitment is made to implementing RCD. Alternatively (and better) data to parameterize the model could be obtained directly from programmes already implementing targeted case searches, providing there is some way of estimating the overall prevalence in the community. A meta-analysis four studies of RCD gave an average estimate of the case . This isThe analyses here suggest that elimination of malaria can be achieved via RCD alone in only a very limited range of settings where transmission potential is very low, and improving the coverage of RCD has little effect on this range. RCD may also help maintain the disease-free state in the face of imported infections. In a rather wider range of settings it is likely to reduce disease burden and achieve new steady state endemicities. The reduction depends strongly on the targeting ratio, which can be estimated from prevalence survey data. Where the endemicity is reduced this may make it more feasible to achieve elimination by adding in further interventions. Conversely scaling up of other interventions such as LLINs might reduce transmission to levels where RCD could achieve elimination. Further analyses of these models can be used to examine the synergies of non-targeted interventions with RCD, indicating the most efficient ways to complement it.Additional file 1.  Parameterisation of the models using Zambian field data.