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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: Psychol Addict Behav. 2023 Sep 28;38(3):269–276. doi: 10.1037/adb0000963

A Randomized Controlled Trial of a Brief Motivational Interviewing-Based Group Intervention for Emerging Adults Experiencing Homelessness: 24-Month Effects on Alcohol Use

Joan S Tucker 1, Anthony Rodriguez 2, Elizabeth J D’Amico 1, Eric R Pedersen 3, Rick Garvey 1, David J Klein 1
PMCID: PMC10972771  NIHMSID: NIHMS1927838  PMID: 37768593

Abstract

Objective:

Despite rates of alcohol misuse being higher among emerging adults experiencing homelessness compared to those who are stably housed, there are few brief evidence-based risk reduction programs for this population that focus on alcohol use and assess outcomes for more than one year. This study examines alcohol outcomes from a 24-month evaluation of AWARE, a brief Motivational Interviewing (MI)-based group risk reduction intervention for emerging adults experiencing homelessness.

Method:

In a cluster randomized crossover trial, 18–25 year olds received AWARE (n = 132) or standard care (n = 144) at one of three drop-in centers serving young people experiencing homelessness in Los Angeles County. We evaluated intervention effects on past month alcohol use, consequences, and related cognitions such as motivation to change behavior.

Results:

AWARE participants showed significant reductions over 24 months in alcohol use and negative consequences from drinking, and reported significant increases in their use of drinking protective strategies. Except for drinking frequency, control group participants did not show significant change in these outcomes.

Conclusions:

Findings build on earlier work by demonstrating that AWARE is effective in reducing alcohol use and related problems among emerging adults experiencing homelessness over a two-year period.

Keywords: homelessness, emerging adults, alcohol use, brief intervention, longitudinal

1. Introduction

Young people experiencing homelessness (YEH) report higher rates of alcohol misuse and related problems compared to those who are stably housed (Burke et al., 2022). For example, Youth Risk Behavior Survey data indicate that YEH are 196% more likely than non-homeless young people to report problematic alcohol use in the past month, such as heavy drinking or driving under the influence (Cutuli et al., 2020). Among other factors, the harsh living conditions of YEH such as increased risk of physical or sexual assault (Bender et al., 2015) may contribute to alcohol use. For example, research using ecological momentary assessment found that when YEH experienced physical or sexual victimization on a specific day, they were more likely to report drinking alcohol later that day (Tyler et al., 2018), suggesting that alcohol may be used to cope with stressors that are often associated with homelessness (Motta-Ochoa et al., 2023). Alcohol use is particularly concerning in this population as YEH are more susceptible to a range of health problems (Kulik et al., 2011), some of which can be exacerbated by heavy alcohol use (Rehm, 2011). Further, an event-based study of sexual risk behavior found that 30% of YEH’s most recent sexual event involved alcohol use before or during sex, which was marginally associated with a lower likelihood of using a condom after controlling for drug use and a range of other factors (Tucker et al., 2012). Effective alcohol use interventions for YEH are needed; yet, providing services can be challenging due to many factors, including mobility of YEH, resistance to using certain homeless services, and limited capacity of the often resource-constrained programs serving YEH (Pedersen et al., 2016). Thus, programs are needed that that are easily accessible to young people, as well as feasible to deliver in the settings where YEH tend to seek services, such as drop-in centers.

One promising substance use program is AWARE, a four-session Motivational Interviewing (MI)-based group intervention for emerging adults (18–25 year olds) experiencing homelessness that focuses on both substance use and sexual risk behavior (Tucker et al., 2017). We developed AWARE to address important gaps in prevention services for emerging adults experiencing homelessness noted above, with content informed by well-established theories of health behavior change (e.g., Bandura, 1986; DeVellis & DeVillis, 2001; Kahneman & Tversky, 2000). AWARE is delivered in a small group format, which enhances delivery feasibility and allows the facilitator to capitalize on prosocial processes (e.g., reinforcement for behavior change, norm change, vicarious learning experiences; D’Amico et al., 2010). AWARE includes components utilized in other effective programs for YEH (Rotheram-Borus et al., 1991, 2003) and other at-risk adolescent and emerging adult populations (e.g., D’Amico et al., 2018, 2020) such as enhancing protective factors and reducing risk factors, targeting multiple interrelated behaviors, encouraging active involvement, and reinforcing skills. Finally, AWARE is delivered using MI, an evidence-based non-judgmental and non-confrontational approach (Miller & Rollnick, 2012), which is important as many YEH avoid using available services when they perceive staff to be judgmental (Pedersen et al., 2016). During development of AWARE, focus group feedback indicated that emerging adults experiencing homelessness did not want to attend a program that addressed marijuana use (Tucker et al., 2017). Thus, alcohol is the substance of primary focus for AWARE, although there is reference to drug use throughout the curriculum, and the use of marijuana or other specific drugs is discussed if brought up during the group discussion.

A pilot evaluation of AWARE showed self-reported positive change in AWARE participants’ past 3 month and past 30 day alcohol use (Tucker et al., 2017). In addition, sequential analysis from the groups indicated that facilitator open-ended questions and reflections of change talk were associated with increased group change talk during AWARE groups, which was then associated with a lower likelihood of heavy drinking 3 months later (D’Amico et al., 2017). In a larger evaluation of AWARE delivered in three drop-in centers in Los Angeles County (Tucker et al., 2023), participants who received AWARE significantly reduced their past month frequency of drinking, frequency of heavy drinking, and number of drinks on drinking days, as well as significantly increased their use of drinking protective strategies over a 12-month period. In addition, AWARE participants showed a marginally significant increase in their perceived importance of cutting down or quitting drinking. For drinking consequences, assessed with 14 items from the Brief Young Adult Alcohol Consequences Questionnaire (B-YAACQ; Kahler et al., 2005), AWARE participants showed a non-significant linear change over a 12-month period; however, there was a significant quadratic downturn indicating that although initially there was no change, there was a sudden drop in reported consequences by the 12-month assessment. Although there were initial intervention effects on drug use other than marijuana and increases in the importance of cutting back or quitting drugs other than marijuana, these were partially or fully attenuated by the 12-month follow-up. Intervention effects were not found for marijuana use, importance of cutting back or quitting marijuana, or drug resistance self-efficacy. Thus, this paper focuses exclusively on the alcohol-related outcomes when evaluating 24-month intervention effects for AWARE.

The current study extends prior work evaluating effects of AWARE on alcohol use by examining whether initial program effects for alcohol-related outcomes remain at the 24-month follow-up of the cohort. To date, few studies evaluate long-term effects of programs for YEH, and this study adds to the nascent literature by evaluating this brief MI-based group intervention over two years at multiple drop-in centers which serve a diverse YEH community in the Los Angeles area, and examining a range of alcohol-related outcomes that encompass behaviors (quantity and frequency of drinking, use of protective strategies), consequences from use, and cognitions (importance of reducing drinking, drinking resistance self-efficacy).

2. Methods

Participants and setting

The study was conducted at three drop-in centers serving YEH in Los Angeles County. Eligibility criteria included: being between the ages of 18 to 25; seeking services (e.g., food, clothing) at one of the drop-in centers; planning to be in the study area for the next month; willing to provide name and contact information; could be reached by e-mail or phone for follow-up; no evidence of cognitive impairment during screening and consent process (as judged by the survey staff); and English speaking. We planned to enroll 400 participants in the trial, but enrollment and program delivery ended early due to the COVID-19 pandemic. As shown in Figure 1, 276 of the 371 individuals approached for screening were eligible and participated (n=132 AWARE, n=144 control). The sample was 72% male, 57% heterosexual, and 84% non-White. Mean age is 22 years. The only difference between AWARE and control groups on demographics involved sexual orientation, with the AWARE group more likely to identify as heterosexual (63.64% vs. 51.43%, p = .0498). The study was approved by RAND’s Human Subjects Protection Committee and performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Figure 1.

Figure 1.

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CONSORT diagram

Study design

As described in detail elsewhere (Tucker et al., 2020), we used a form of group-randomized design (Bauer et al., 2008; Murray, 1998) for this evaluation, with crossover of conditions and groups to avoid problems of power reduction associated with conventional group randomization (Keogh-Brown et al., 2007). The unit of analysis is the individual, but individuals were assigned to groups based on the drop-in center where they were seeking services at the time of recruitment. Participants in the intervention condition received the AWARE program, whereas participants in the usual care control condition had access to the full range of programs and services already available at the drop-in centers (these were available to intervention participants as well). In addition, all participants received an HIV informational brochure and a Community Resource Guide that listed free or low-cost substance use and HIV-related services in the study area.

Recruitment occurred between November 2018 and March 2020 in a series of 16-week cycles, with three drop-in centers alternating across cycles in serving as the intervention site or control site. Recruitment was done by advertising the study at the sites, and through soliciting volunteers during recruitment visits. Individuals signed up on a sign-in sheet to participate in the study. On recruitment visits when more individuals signed up than could be accommodated, we randomly selected individuals from the pool of interested individuals to screen for eligibility. Eligible participants provided written consent and completed a baseline scannable self-report survey in the presence of a staff member who could provide assistance if needed. To minimize the possibility of “contamination” across conditions (e.g., participants in the control condition being exposed to AWARE content through their interactions with peers at the drop-in center who attended AWARE during the previous cycle), participants were recruited during the first eight weeks of each cycle and the remainder of the cycle served as a “wash out” period as it allowed for significant client turnover at the drop-in centers. The four-session AWARE program was delivered four times during each 16-week cycle, allowing intervention participants multiple opportunities to complete all sessions. Follow-up surveys at 3-, 6-, 12- and 24-months post-baseline could be administered using a scannable paper-pencil survey, using a web-based version of the survey, or by phone; most follow-ups were completed using the web-based version of the survey.

Intervention content

Each of the four AWARE sessions is designed to be free standing and thus can be completed in any order. Sessions 1 and 2 primarily focus on HIV/STD risk, and Sessions 3 and 4 primarily focus on substance use, but each session emphasizes the connection between substance use and risky sexual behavior. Briefly, Session 1 covers basic information on HIV/STDs (including the role of substance use), how to evaluate partner risk, normative feedback about HIV-related behaviors, and how to use a condom. Session 2 includes content to help participants identify potential causes for sexual risk behavior (including substance use), strategize on how to deal with those situations and plan ahead, develop skills to better deal with risky situations through a role-playing exercise, and evaluate their willingness and confident to change their behavior. Session 3 provides normative feedback about alcohol use, as well as helps participants weigh the pros and cons of substance use (including its connection with sexual risk behavior) so they can make thoughtful choices about their use, develop strategies for decreasing negative consequences of use and reap positive benefits without use, and evaluate their willingness and confidence to change their behavior. Session 4 provides information on the brain and how substance use can affect brain functioning, how substance use can affect behavior (providing personalized feedback on negative alcohol consequences as concrete examples), and strategies for protecting themselves while drinking in order to avoid negative consequences from use. Each session includes a handout, tailored to the topics of the session, with general information on substance use and sexual risk behavior (e.g., links to relevant websites), as well as fill-in information (e.g., checklist of alcohol consequences they have experienced, triggers for condomless sex) that are incorporated into the group discussion to help participants better assess their current situation and identify whether they are ready to make changes to help them be safer in the future. The AWARE curriculum is grounded in MI delivery and facilitators focus on eliciting change talk throughout each group session by using open ended questions, reflections, affirmations and summaries (OARS), in addition to Focusing and Evoking and Planning (D’Amico et al., 2017). More detail on the AWARE curriculum and materials can be found elsewhere (Tucker et al., 2020). Participants received $5 for each session attended, and free snacks and condoms were available at each session. Two trained project staff, not affiliated with the drop-in center, attended each AWARE session: one was a facilitator who delivered the curriculum and the other was an individual who provided any needed assistance (e.g., distributing materials, maintaining sign-in sheets).

Fidelity and quality of the AWARE sessions

As reported in detail elsewhere (Tucker et al., 2023), facilitators received training on MI and the AWARE protocol, and were required to complete a role play of each session that had to be approved by the first and second authors before they could deliver AWARE in the field. Fidelity to MI delivery (using the Motivational Interviewing Treatment Integrity (MITI) scale 3.1.1 (Moyers et al., 2010) and protocol adherence were assessed for 20% of the sessions and found to be acceptable.

Measures

Drinking behavior.

Participants reported the number of days (0–30) they drank at least one full drink of alcohol and drank 5 or more drinks of alcohol in a row (i.e., within a couple of hours) in the past 30 days. Among participants who reported at least one full drink of alcohol in the past 30 days, quantity of alcohol use was assessed with items asking about average number of drinks consumed on drinking days and maximum number of drinks consumed on any day in the past 30 days. Engagement in drinking protective strategies was assessed with nine items from the Drinking Protective Strategies Scale (Martens et al., 2007), which asked participants to rate how often they engaged in certain behaviors when they were drinking alcohol or “partying” (e.g., alternating alcoholic and non-alcohol drinks; deciding not to exceed a set number of drinks). Items were rated on a scale from 1 = never to 5 = always and averaged (baseline α = .87).

Drinking consequences.

Negative consequences were assessed with 14 items from the Brief Young Adult Alcohol Consequences Questionnaire (B-YAACQ; Kahler et al., 2005), in which the number of different types of consequences experienced in the past 30 days were summed.

Drinking cognitions.

Alcohol resistance self-efficacy was assessed with four items asking: “Suppose someone you know offered you a drink of alcohol and you did not want it. How easy or hard would it be for you to do the following: refuse it; explain why you didn’t want it; avoid the situation in the first place; just leave the situation” (Choi et al., 2013). Items were rated on a 4-point scale (1 = very easy to 4 = very hard), reverse scored, and averaged such that higher scores indicated greater resistance self-efficacy (α = .85-.93). Motivation to change alcohol use was assessed with a ruler modified from prior work (Boudreaux et al., 2012), asking how important it was to participants to cut down or stop their use of alcohol (0 = not at all to 10 = extremely). Those who did not drink reported on motivation to remain abstinent.

Covariates.

We controlled for standard demographic characteristics that are often associated with substance use outcomes: age, sex assigned at birth (female vs. not), race/ethnicity (Hispanic, Black, White, Multiracial/other), and sexual orientation (straight/heterosexual vs. not). We also controlled for treatment site.

Statistical analysis

We investigated effectiveness of randomization in producing equivalent groups by using two-sample t tests for continuous characteristics, Fisher’s exact tests for binary characteristics, and chi-squared tests for categorical characteristics. For measures examined longitudinally across all 5 timepoints, we estimated a multiple-group latent growth model (LGM) with Mplus v8.1 (Muthén & Muthén 2012–2018). We used robust maximum likelihood estimation which can provide unbiased and consistent estimates that are robust to the presence of missing data or non-normality. In LGM, the intercept reflects the predicted value of the outcome when the predictor is equal to zero and thus represents a baseline or initial level. The slope reflects rate of change over time. Models were evaluated using conventional model fit criteria: χ2, Root Mean Square Error of Approximation (RMSEA: ≤ .08), and Comparative Fit Index (CFI: ≤ .95). The multiple-group LGM framework estimates LGMs in each group (AWARE and control) simultaneously but separately in order to examine differences in growth parameters. Further, this method permits statistical testing of observed differences in growth parameters by imposing and testing parameter equality constraints (e.g., alcohol use frequency slope to be equal between AWARE and control conditions) using the Wald test. For all models, we estimated linear and non-linear functions and report on models which best characterize the functional form. All models included covariates described previously. Deidentified data from this study will be available from the corresponding author on reasonable request one year after all aims of the project are completed.

3. Results

Table 1 shows descriptive statistics for alcohol-related outcome variables at each wave. At baseline, there were three statistically significant differences by intervention condition: compared to those in the control group, AWARE participants initially reported more drinks per day, a higher maximum number of drinks, and lower importance of cutting back or quitting drinking. Intercepts from the LGMs capture baseline differences in each group. Across all models and between groups, the linear model best characterized the functional form; that is, non-linear functions did not improve models or better characterize longitudinal trajectories. Wald tests were conducted comparing slope parameters between AWARE and control groups on all outcomes (Supplemental Table S1).

Table 1.

Descriptive Statistics for Alcohol Related Outcomes by Wave and Condition

Outcome Baseline 3 month 6 month 12 month 24 month
Days of alcohol use Usual Care 4.58 4.35 4.58 4.23 2.86
AWARE 5.87 4.71 4.59 4.14 3.64
Days of heavy use Usual Care 2.32 1.96 1.77 2.21 1.66
AWARE 3.14 2.39 2.43 1.54 1.91
Number of drinks on drinking days Usual Care 3.66 3.85 3.80 4.13 4.23
AWARE 5.09 3.78 3.60 3.17 3.06
Maximum number of drinks Usual Care 6.60 5.44 6.09 6.28 5.95
AWARE 8.42 6.88 6.64 5.52 5.49
Drinking protective strategies   Usual Care 2.31 2.50 2.53 2.56 2.56
AWAE 2.38 2.68 2.88 2.68 3.01
Alcohol consequences Usual Care 3.33 3.00 3.13 3.20 2.54
AWARE 3.75 4.05 3.76 2.48 3.41
Importance of reducing drinking Usual Care 5.52 5.28 5.71 5.31 4.82
AWARE 4.51 5.28 5.50 5.38 5.25
Alcohol resistance self-efficacy Usual Care 3.55 3.56 3.50 3.59 3.62
AWARE 3.64 3.53 3.59 3.62 3.48
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Note. Possible ranges: drinking protective strategies (1–5), alcohol consequences (0–14), importance ruler (0–10), and alcohol resistance self-efficacy (1–4). Number of drinks on drinking days and maximum number of drinks are modeled among individuals who reported past month alcohol consumption at each wave.

LGM parameters for all longitudinal measures by condition are presented in Table 2. AWARE participants showed significant declines over the 24 month period in past month frequency of drinking (b = −0.476, p = 0.003), frequency of heavy drinking (b = −0.362, p = 0.001), number of drinks on drinking days (b = −0.317, p < 0.001), maximum number of drinks (b=−0.587, p = 0.003), and alcohol consequences (b −0.231, p = 0.030), as well as significant increases in their use of drinking protective strategies (b = 0.117, p < 0.001). With the exception of past month drinking frequency (b = −0.439, p = 0.005), control group participants did not show significant change in any of these alcohol-related outcomes (all ps > .05), and neither group showed a significant change in their alcohol resistance self-efficacy or perceived importance of cutting down or quitting drinking.

Table 2.

Growth Parameters and Standard Errors for Longitudinal Outcomes by Condition

Intercept Slope
Outcome Usual Care AWARE Usual Care AWARE
Days of alcohol use 4.85 (.54)‡ 5.50 (.58)‡ −0.44 (.16)† −0.48 (.16)†
Days of heavy alcohol use 2.19 (.40)‡ 2.97 (.40) ‡ −0.14 (.12) −0.36 (.11)†
Number of drinks on drinking days 3.60 (.33)‡ 4.22 (.33)‡ 0.11 (.13) −0.32 (.10)‡
Maximum number of drinks 5.61 (.46)‡ 7.78 (.60)‡ −0.02 (.19) −0.59 (.20)‡
Drinking protective strategies   2.40 (.08)‡ 2.49 (.08)‡ 0.05 (.03) 0.12 (.03)‡
Alcohol consequences 3.30 (.33)‡ 3.87 (.34)‡ −0.17 (.10) −0.23 (.11)*
Importance of reducing drinking 5.64 (.31)‡ 4.87 (.29)‡ −0.12 (.10) 0.14 (.11)
Alcohol resistance self-efficacy 3.53 (.05)‡ 3.62 (.27)‡ 0.02 (.02) −0.02 (.02)
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Note.

*

p < .05.

†

p < .01.

‡

p < .001.

4. Discussion

The current study answers an important question about whether a brief motivational interviewing-based group intervention can have long-term effects on alcohol use and related outcomes among emerging adults experiencing homelessness. Overall, 18–25 year olds experiencing homelessness who attended the AWARE program reported significant declines over a 24-month period in their past month frequency of drinking, frequency of heavy drinking, number of drinks on drinking days, and maximum number of drinks consumed on any day in the past month. AWARE participants also showed a significant increase in drinking protective strategies, which can limit the amount of alcohol consumed and reduce alcohol-related harms, and a significant decrease in the negative consequences they experienced from drinking. In contrast, those in the usual care control condition did not report significant changes on these alcohol-related outcomes, with the exception of past month drinking frequency (which also significantly declined).

In terms of the magnitude of change among AWARE participants over the 24 month period, on average they reported about 2 fewer heavy drinking days and 3 fewer maximum drinks in the past 30 days. This translates, for example, into a reduction of more than 20 heavy drinking days over the course of a year. Overall, participants’ reductions in drinking and consequences experienced have practical importance given associations of alcohol use with health threats facing young people experiencing homelessness such as physical and sexual victimization (Tyler et al., 2018) and STI-related sexual risk behavior (Tucker et al., 2012).

We did not find significant intervention effects on drinking-related cognitions; namely, alcohol resistance self-efficacy and the perceived importance of cutting down or quitting drinking. While the lack of effect on resistance self-efficacy is consistent with results at the 12-month follow-up, we did find a marginally significant (p = .08) increase among AWARE participants in their perceived importance of cutting down or quitting drinking at 12-months (Tucker et al., 2022). It may be the case that changing these cognitions becomes less important as AWARE participants become more disciplined about their drinking. That is, cognitions may change earlier on, as shown in other longitudinal intervention work, followed by behavior change (D’Amico et al., 2018). We saw a marginally significant change in AWARE participants’ perceived importance of cutting down on their drinking at the 12 month follow up (Tucker et al., 2023). However, once emerging adults have already significantly reduced their quantity and frequency of drinking they may no longer see the critical importance of resisting drinking or cutting down on their drinking.

Results should be interpreted in light of limitations. First, results are based solely on self-reported alcohol use as it was not feasible to conduct biochemical verification of alcohol use. However, the potential for bias may have been minimized by the brief (past 30 day) recall period, and lack of any obvious incentive for participants to mischaracterize their alcohol use. In addition, results are based on YEH recruited from drop-in centers in the Los Angeles area. As such, it is possible that results may not generalize to other age groups, those not already seeking services at a drop-in center, or individuals residing in other geographic regions.

In conclusion, the ongoing evaluation of this brief MI-based group intervention for YEH indicates that AWARE not only has short-term beneficial effects on alcohol use and related negative consequences, but that benefits of program participation remain two years later. This raises the possibility that by reducing alcohol use in the long-term, AWARE may have positive effects on secondary outcomes often correlated with greater alcohol use. For example, prior work suggests that there are small beneficial effects of AWARE attendance on depression, physical health, social functioning, and housing stability at 12 month follow-up (Pedersen et al., 2023). Further research is needed on how AWARE, and other brief risk reduction interventions for YEH designed for delivery in drop-in center settings, might be enhanced to have an even greater impact on important health and housing stability outcomes. Finally, prior work has demonstrated the acceptability and feasibility of AWARE in drop-in center settings (Tucker et al., 2017; 2023), indicating its potential for dissemination. However, AWARE has only been delivered by facilitators hired and trained by the research team. Additional work is needed to evaluate the acceptability and feasibility of AWARE when delivered by case managers or other drop-in center staff.

Supplementary Material

Supplemental table

Public health significance:

This study indicates that a brief Motivational Interviewing-based group risk reduction intervention is effective in reducing alcohol use and negative consequences from drinking, and increasing use of drinking protective strategies, over a 24-month period among emerging adults experiencing homelessness.

Funding:

This work was supported by grant R01AA025641 from the National Institute on Alcohol Abuse and Alcoholism (PI: Tucker)

Footnotes

Conflicts of interest/Competing interests: The authors have no competing interests to declare that are relevant to the content of this article.

Trial registration: ClinicalTrials.gov Identifier: NCT03735784. Registered November 18, 2018, https://clinicaltrials.gov/ct2/show/record/NCT03735784.

Availability of data and material:

Deidentified data from this study will be available from the corresponding author on reasonable request one year after all aims of the project are completed. Requestors of data will be asked to complete a data-sharing agreement that provides for (1) a commitment to using the data only for research purposes and not to identify any individual participant; (2) a commitment to securing the data using appropriate computer technology; and (3) a commitment to destroying or returning the data after analyses are completed.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental table
NIHMS1927838-supplement-Supplemental_table.docx (13.5KB, docx)

Data Availability Statement

Deidentified data from this study will be available from the corresponding author on reasonable request one year after all aims of the project are completed. Requestors of data will be asked to complete a data-sharing agreement that provides for (1) a commitment to using the data only for research purposes and not to identify any individual participant; (2) a commitment to securing the data using appropriate computer technology; and (3) a commitment to destroying or returning the data after analyses are completed.

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