RAND Review News for Fall 2003

Project ALERT Helps Even High-Risk Teens

Critics have argued that schoolbased drug prevention efforts have failed to help high-risk adolescents. But a new study has shown that the RAND-developed Project ALERT program successfully curbs the use of alcohol, cigarettes, and marijuana among middle-school students—even high-risk youth who have already started smoking and drinking by the seventh grade.

The results are based on a randomized, controlled study of the effectiveness of Project ALERT in 55 middle schools in South Dakota from 1997 to 1999. Nationwide, the program reaches more than 1 million adolescents in all 50 states.

Compared with control students, Project ALERT students reduced their use of cigarettes, marijuana, and alcohol. The program was especially successful with the highest-risk early drinkers, substantially reducing their likelihood of engaging in risky forms of alcohol use (such as binge drinking) or of experiencing other problems from drinking. The program also helped keep those who had experimented with cigarettes from making the transition to regular smoking.

"These early smokers and drinkers have substantially elevated risks for increased drug use and a variety of other high-risk behaviors such as violence, unsafe sex, and dropping out of school," said lead author Phyllis Ellickson.

"These are precisely the youth who need help the most. Curbing alcohol and cigarette use among these high-risk youth when they are in middle school may help prevent the emergence of more serious problems later on."

Can TV Help Teach Teens About Sex?

Television has come under fire for its negative influence on teens, but new study—part of a national effort examining the role television plays in teen sexual attitudes and behavior—shows that television programs can be responsible sex educators for teens.

The study surveyed a group of teens who watched an episode of "Friends" in which a condom failure caused a pregnancy. Most teen viewers remembered that the pregnancy involved a condom failure. But teen viewers who watched with an adult or discussed the episode with an adult were twice as likely as others to remember this—and also to remember the statistic presented in the episode about condoms being more than 95 percent effective.

"Our study suggests that if more shows included a message about responsible sexual behavior and what the risks are in having sex, we might have fewer problems with teen pregnancy and sexually transmitted diseases," noted Rebecca Collins, a RAND psychologist.

"But parents are also really important. The message in the "Friends" episode was accurate but a bit ambiguous. Although it’s important to know that condoms can fail when making a decision to have sex, teens might have come away thinking condoms aren’t worth using. The kids who watched the show with their parents or discussed it with an adult got the message that condoms are mostly effective. So it was the parents who determined what was learned, after ‘Friends’ broached the topic."

Fifty Years of Homework

Do students have too much homework? Do they have too little? Public opinion about homework has been contentious throughout the 20th century. However, the figure below, created by examining major national surveys over the past 50 years, shows there was no "golden age" when American students did massive amounts of homework. Except for a temporary spike in the amount of homework done during the post-Sputnik years, the trend has remained essentially flat. Today, only about one high school student in eight spends more than two hours per day on homework; that share was no higher in 1948 than it is today.

Figure: Fifty Years of Homework

Shortfalls Found in Quality of Health Care for Vulnerable Seniors

About one-third of senior citizens in the United States have health problems that make them vulnerable to losing their independence and their ability to carry out daily activities. When this vulnerable elderly population receives health care, only 31 percent receive the care recommended for age-related conditions, according to a new RAND-UCLA study of treatments given for 22 of the conditions.

Vulnerable older patients received about the same quality of health care as other U.S. adults for various general medical conditions, including diabetes, stroke, and heart disease. But the quality of care dropped off sharply for such age-related illnesses as pressure ulcers, dementia, urinary incontinence, and end-of-life care.

"With the number of Americans over 65 nearing 15 percent of our population, this study should be a sentinel call for improving medical care given to older people," noted lead author Neil Wenger, a RAND researcher and professor of medicine at UCLA.

The study shows that the health care system must make a major effort to improve the ability of primary care physicians to identify and to treat the diseases of aging. Equally important, older patients and their families need to become better informed about geriatric health care to ensure that these patients receive proper care.

"Family members and patients need to make sure that everything is being done for age-related ailments, just as they would speak up if their chest pain wasn’t being attended to," said Paul Shekelle, another study author.

RAND-Qatar Institute Brings Analytic Capabilities to Middle East

The RAND-Qatar Policy Institute formally opened in Doha, the capital of the Persian Gulf nation of Qatar, on Oct. 13. The new institute is part of Education City, which is being created in Doha as a regional center of excellence in learning, research, medicine, science, engineering, and technology development.

The institute’s primary mission is to become a source of highquality, nonpartisan, and rigorously objective analysis of the most important and difficult issues facing public and private decisionmakers in the Middle East, North Africa, and South Asia. Other missions include building a base of expertise in policy analysis in the region, enhancing the value of various university branches located in Education City by drawing their faculty and students into analyses of important practical problems, and assisting in strategic and operational planning for Education City itself.

To fulfill all these missions, the institute will use its base in Doha as a gateway through which clients can gain access to all of RAND’s capabilities. On behalf of regional clients, the small local staff will "reach back" to RAND offices in the United States and Europe for the right talent to deal with each particular question.

This will enable the institute to undertake analyses across the full range of RAND’s analytical expertise: education, health, science and technology, environmental protection, effective governance, demographics, labor markets, organizational effectiveness, managing social change, and enhancing domestic and international security, for example.

"The integration of RANDQatar into Education City is an exciting step in a joint effort in initiating research and analysis and transforming these studies into practical action plans," said Sheikha Mozah Bint Nasser Al-Missned, chairperson of the Qatar Foundation and consort of the Emir of Qatar, His Highness Sheikh Hamad bin Khalifa Al-Thani.

"The dynamic relationship between research and policymaking will assist Qatar and the region in constructing our own course toward development that utilizes the full capacity of our citizens and preserves our cultural identity."

How Can Individuals Protect Themselves in a Terrorist Attack?

One of the lasting impressions of the 9/11 terrorist attacks is that Americans are vulnerable to such attacks on their own soil and must prepare for them, just as they prepare for natural disasters like hurricanes or earthquakes.

But unlike the effects of natural disasters, the effects of terrorist attacks"especially those involving chemical, radiological, nuclear, and biological weapons"are unfamiliar to most people, and the instinctive responses of many people during such events could actually lead them into greater danger. Thus, individuals need simple, concrete guidance, tailored to different types of terrorist attacks, to help them survive. A new RAND report seeks to provide that guidance.

Starting with scenarios for chemical, radiological, nuclear, and biological attacks, a RAND research team—consisting of experts with technical, health, and policy backgrounds—developed a strategy for individuals to follow. Critical to any response is rapidly assessing the type of attack that has occurred. The strategy provides guidance about how to make that determination quickly. The strategy explains the characteristics of different types of attacks and then defines an overarching goal and describes specific actions for individuals to take in each type of attack. Finally, the strategy sets forth essential preparatory actions needed to be able to respond to the different types of terrorist attacks.

"In seeking to understand the effects of an attack from an individual’s perspective, we put ourselves in situations to see what needs we would have and then what could be done," said lead author Lynn Davis. "Even in the most dangerous of attacks, our needs were relatively few and could be met by keeping in mind a set of overarching goals and following some simple rules."

Individuals are likely to have to act on their own very quickly. "In most cases, the few minutes immediately following an attack, before professional emergency responders are likely to arrive, are critical to survival," said coauthor Tom LaTourrette. "Our recommendations are intended to help people act rationally to protect themselves while waiting to learn more and for authorities to arrive."


For more information:

Individual Preparedness and Response to Chemical, Radiological, Nuclear, and Biological Terrorist Attacks, RAND/MR-1731-SF.

Individual Preparedness and Response to Chemical, Radiological, Nuclear, and Biological Terrorist Attacks: A Quick Guide, RAND/MR-1731/1-SF.

Emergency Responders Believe They Have Inadequate Protection

According to a groundbreaking RAND study, emergency responders in America believe they are inadequately protected against some of the dangers they face, particularly terrorist attacks, and want better protective clothing and equipment, more compatible communications systems, and expanded training and information on safety practices and equipment.

Emergency responders are this country’s first line of defense against fires, vehicle collisions, medical emergencies, crimes, natural disasters, terrorist attacks, and every other conceivable emergency. RAND researchers conducted indepth discussions with 190 representatives from 83 emergency responder, technology supplier, and research and professional organizations across the nation.

"The majority of emergency responders feel vastly underprepared and underprotected for the consequences of chemical, biological, or radiological terrorist attacks," the study notes.

The level of protection varies tremendously from service to service and from hazard to hazard. For example, while firefighters are generally pleased with the fire protection their clothing and equipment afford, they are concerned that using the clothing and equipment can cause severe physical stress and overexertion and decrease their perception of imminent dangers.

Emergency medical responders feel inadequately protected against assaults and hazards associated with terrorism.

Police officers feel especially exposed to assaults and automobile injuries during their everyday duties. Police are also concerned that much of the protective equipment needed for terrorism incidents is not designed with the law enforcement mission in mind, such as the needs for running, using weapons, and apprehending suspects.

For more information:

Protecting Emergency Responders, Volume 2, RAND/MR-1646-NIOSH.

Shipping Containers Seen as Global Terrorist Targets

Terrorists could use containers on ships to transport weapons and dangerous materials, or terrorists could use the containers themselves as weapons of mass destruction, according to a new RAND Europe report that looks at the global scale of the problem.

Over the course of a year, 15 million sea containers circulate globally, amounting to over 250 million moves annually. Of these 250 million moves, only about 2 percent are physically checked to verify what is inside the containers.

The global sea-container problem is particularly difficult to resolve because it cuts across the public and private sectors. As a result, there is confusion about ownership of, and responsibility for, the problem, with no single stakeholder who can clearly be identified as responsible for implementing countermeasures.

The report identifies a number of ways to improve sea-container security. For example, a new "risk analysis" software tool developed by the European Commission could help to detect suspicious cargo and thus enable it to be intercepted for inspection. Container integrity could be improved by using "active" seals, which have the capability of giving a notification on status change, rather than "passive" seals, which merely indicate whether a container has been opened. The majority of containers currently use only passive seals.

There could be better systems to track and trace containers and better approaches to verify container loads. The report even envisions an "intelligent container" that could scan its own contents, detect illicit and dangerous cargo, and then contact and warn authorities.

But since the private sector dominates the cargo business, implementing any solution will require the private sector to own the problem. This, in turns, means focusing on theft prevention, for which private companies would see some benefit for investment.

Introducing a security tax, such as what is already in place in airports, could also be used to encourage companies with a vested interest in container security to invest in more sophisticated measures, such as active seals.

For more information:

"Seacurity": Improving the Security of the Global Sea-Container Shipping System, RAND/MR-1695-JRC.

Is the Military Aircraft Industry Serving U.S. Needs?

When the Joint Strike Fighter—the F-35—is deployed in the future, it will be one of the mainstays of national security. But in another sense, it could represent a threat to national security.

The F-35, to be built by a team led by Lockheed Martin, is the only new fighter aircraft program the U.S. military has planned for the next 30 years. As a result, in the absence of a new major combat aircraft program, the military aircraft industrial base is likely to shrink (see figure), as military aircraft designers with unique skills leave the industry. Such shrinkage could degrade national security by diminishing the industry’s competition and innovation, according to a new RAND report.

"When some manufacturers look to the future, they just don't see enough business on the horizon to keep their design teams in place," said John Birkler, a senior analyst at RAND and lead author of the report. "Unless something is done, business practices will dictate that [manufacturers] reassign their talent to other areas. Indeed, this is already beginning to happen."

While several smaller projects will likely provide work for military aircraft designers, such work will sustain design teams only through the end of the decade. Spreading production of the F-35 among manufacturers has been suggested as a way to support industry competition, but an earlier RAND report found that this option would be very expensive and would do little to preserve unique design and development capabilities.

A better and less-expensive option, according to the report, would be to fund both a continuing series of advanced design studies and the development of experimental concept demonstrators. This approach would yield a range of new technologies and system concepts to support future military capabilities, while sustaining a vigorous and competitive design and development capability in the industry.

But an even more fundamental issue is whether it is in the country’s best interest to preserve the current industrial structure and capabilities. New developments—such as the growing role for unmanned combat aircraft—are likely to alter the military’s requirements in the future.

Instead of preserving the current industrial model, policymakers may want to consider new types of aircraft research and development programs—and new models of the industrial base—that could do a better job of meeting the U.S. military’s future needs.

For more information:

Competition and Innovation in the U.S. Fixed-Wing Military Aircraft Industry, RAND/MR-1656-OSD.

Fastest Increasing Group of Obese Americans Are "Severely Obese"

Reports that most Americans are either overweight or obese have raised the level of public discussion about obesity. The focus generally has been on typical obesity, or on those roughly 30 or more pounds overweight. Little is known about severely obese individuals, or those roughly 100 pounds or more overweight. Severely obese individuals have much higher rates of chronic health problems and encounter very different challenges in the health care system than do the majority of obese individuals.

A recent RAND report provides empirical evidence to address this issue. According to the study, based on about 1.5 million respondents to the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey, the proportion of Americans with clinically severe obesity quadrupled from 1 in 200 adults in 1986 to 1 in 50 adults in 2000.

This means that the severely obese population is growing twice as fast as the population of Americans who are simply obese and who have been the focus of an "obesity epidemic" that has been widely discussed in health care circles. (For a discussion of the health care costs of obesity, see "Obesity Costs More Than Smoking, Drinking" in the Spring 2002 RAND Review.)

To be classified as severely obese, an individual must have a body mass index (weight in kilograms divided by the square of height in meters) of 40 or more, which corresponds to about 100 pounds or more overweight for an average adult man. Typically, a severely obese man weighs 300 pounds at a height of 5 feet 10 inches, while a severely obese woman weighs 250 pounds at a height of 5 feet 4 inches.

The findings challenge the common belief that severe obesity is a rare pathological condition among genetically vulnerable individuals, affecting a relatively fixed proportion of the population—as if this proportion is not affected by changes in eating and physical activity patterns in the rest of the population. Instead, the data demonstrate that even clinically severe obesity is a part of the population’s weight distribution and reflects all trends. As the whole population becomes heavier, the weight distribution shifts toward the heaviest, which results in the extreme category—the severely obese—growing the fastest (as shown in the figure).

As a consequence, the widely published data on obesity in the United States underestimate the long-term social and cost consequences of obesity, because morbidity and service use are much higher among severely obese individuals than among other obese individuals.

"With these growth rates, accommodating severely obese patients in clinical practice will no longer be an unusual occurrence in the near future," says the author, RAND economist Roland Sturm. "Doctors, hospitals, and other health providers must be prepared to treat these people on a regular basis."