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. Author manuscript; available in PMC: 2025 Aug 27.
Published in final edited form as: Psychol Health. 2024 Apr 22;40(9):1551–1568. doi: 10.1080/08870446.2024.2342464

Bystander intervention for problematic alcohol use among graduate and international students: opportunities and challenges

Annelise Mennicke a, Sasha Zabelski b, Bridget N Jules c, Gabrielle Haley d, Keshawn Mathews e, Jessamyn Bowling b, Ava Peters b, Erika Montanaro c, Robert J Cramer b
PMCID: PMC11493846  NIHMSID: NIHMS2016876  PMID: 38650452

Abstract

Objectives:

Bystander intervention (BI) is a prevention approach commonly used for interpersonal violence, but is less studied for problematic alcohol use (PAU). Domestic graduate and international students’ life experiences bring a unique context for the potential application of BI to PAU.

Methods and Measures:

We conducted a mixed methods study that consisted of a needs assessment and focus groups at a southeastern university in the U.S. The aims of this study were to understand (1) differences in PAU BI opportunities for domestic graduate versus international students, (2) reasons for differences in PAU BI use, and (3) barriers/facilitators in use of PAU BI.

Results:

Overall, participants had few opportunities to use BI. Domestic graduate students had slightly more opportunities compared to international students. Most prominent reasons for lack of opportunities included not wanting to drive, the cost of drinking, and holding a graduate student identity (e.g. not interested in heavy drinking). Trusting others to be responsible for themselves was a common barrier noted for not using BI for PAU.

Conclusion:

PAU BI programs should contextualize experiences of domestic graduate and international students to provide appropriate skill development that considers unique barriers and facilitators to intervention use.

Keywords: Bystander intervention, graduate students, international students, alcohol use

Problematic alcohol use (PAU), including binge drinking and drinking too frequently, can lead to several negative consequences, ranging from failing grades to death (White & Hingson, 2013). PAU is a common concern among college students in the United States (U.S.) (National Institute on Alcohol Abuse & Alcoholism, 2022). Among full-time undergraduate college students in the U.S., 53% consumed alcohol in the past month, which is higher than non-college students in their age group. Rates of PAU among graduate students tend to be studies less frequently than undergraduate students, however, estimates put the rate of graduate student binge drinking at 26.2% within a two-week period (Rutledge et al., 2016). Other estimates of problematic drinking among graduate students report that 1.9% of students have alcohol use negatively impact their academics (compared to 3.1% of undergraduates), with 12.9% reporting moderate alcohol risk behavior across 21,047 respondents (American College Health Association, 2023). Furthermore, emerging research seems to suggest that, while not a monolith, international students studying in the U.S. appear to have similar (Koyama & Belli, 2011; Sa et al., 2015) or lower rates of drinking than domestic students from the U.S. (Guo et al., 2022; Misra et al., 2003; Misra & Castillo, 2004). Thus, graduate student status and international student status should be considered when designing, planning, and implementing alcohol reduction programs on college campuses.

Problematic alcohol use among graduate and international students often occurs in social settings (e.g. parties, bars; Allen et al., 2022). Additionally, those who are socially motivated to drink are more likely to have heavy binge-drinking sessions (Cooper et al., 2016; White et al., 2016). Taken together, this evidence suggests that social norms play a role in this groups drinking behavior; thus, underscoring the potential for prevention via bystander intervention. Bystander intervention (BI), has the potential to reduce PAU among college students. However, its application has mostly been applied to undergraduate students within the domain of interpersonal violence (Banyard, 2008; Salazar et al., 2023; Zinzow et al., 2018) with some focus on the intersection of sexual violence and problematic drinking (Leone et al., 2018; Morean et al., 2021). The purpose of this investigation is to examine elements that should be considered when designing a BI program for PAU among graduate and international students.

Bystander intervention

Decades of intervention work trying to reduce college students’ problematic alcohol use has almost exclusively focused on the person drinking (Scott-Sheldon et al., 2014). While norms are frequently cited as important predictors of binge drinking behavior (Merrill et al., 2016), they are only addressed in interventions via feedback on normative comparisons (Carey et al., 2009). Rarely do interventions focused on the reduction of binge drinking capitalize on the social setting in which this behavior typically occurs. We argue that normative-beliefs interventions should both incorporate mechanisms that focus on individual change (i.e. what prior work has done) and leverage the powerful role of others to reduce PAU via bystander intervention.

Often applied in undergraduate university contexts, BI is a prevention method that focuses on empowering community members to notice potential harm and take action to stop or prevent harm from occurring (McMahon & Banyard, 2012). BI is a strategy that has largely been applied to domains of interpersonal violence (e.g. sexual assault, dating violence, bullying; Banyard, 2008; Casey et al., 2017). Evaluations of BI programs indicate effectiveness at increasing precursors to bystander behaviors (e.g. likelihood to intervene; Powers & Leili, 2018), as well as increasing use of actual bystander behaviors (Coker et al., 2011).

Within the domain of interpersonal violence, several prominent theories inform the field of BI, including the situational model and Action Coils Model. The situational model (Burn, 2009; Latane and Darley & Latané, 1968) asserts that there are five linear steps that a bystander goes through. First, they must notice a situation. Second, they must interpret that situation as problematic. Third, they must assume responsibility to act. Fourth, they must identify an intervention strategy; and fifth, they must act. The Action Coils Model (Banyard, 2015) expands the previous model to consider the unique circumstances and outcomes that influence individuals’ decisions to intervene. Inherent within both of these models, and important to understanding BI, is that a bystander must have the opportunity to intervene. That is, they must be exposed to problematic or concerning situations.

Drinking may increase opportunities for BI, such that PAU has been demonstrated to be connected to various potentials for harm (i.e. sexual assault, physical effects of intoxication including poisoning and overdose, drunk driving, etc.; e.g. Beck et al., 2013; Tuliao & McChargue, 2014). Additionally, these harms have been shown to occur in the context of bystanders (Haikalis et al., 2018). For example, Haikalis et al. (2018) reported that bystanders had the opportunity to intervene in 23% of the sexual assaults that occurred, and in those situations, alcohol was used widely by bystanders, victims, and perpetrators. Opportunities for bystander behavior in situations of sexual violence often overlap with opportunities in situations of PAU (Waterman et al., 2022). In a daily diary study among college students, participants were significantly more likely to report an alcohol risk bystander opportunity on days in which they had at least one alcoholic drink, compared to days when they did not drink (Waterman et al., 2022). These results suggest that one’s alcohol use increases their opportunities for intervening upon others’ risky situations, both in situations of sexual and dating violence and PAU. Researchers have begun to explore the potential of applying BI techniques to prevent PAU among college students. One such program is being pilot-tested (Barnett, 2019), and others have identified a model of BI for PAU among college students (Mennicke et al., 2023). Within this model, an important barrier/facilitator to using BI for PAU that was identified was personal/social identities, which may apply to graduate/international student status.

Social identities are an important consideration for BI in interpersonal violence. For example, research indicates that personal demographics such as gender and race are associated with the frequency of using bystander intervention behaviors (Banyard, 2008; Brown et al., 2014; Hoxmeier et al., 2022). Furthermore, the effectiveness of BI programs appears to be moderated by personal identities and life experiences. For example, an evaluation of BI program Green Dot identified that the program was less effective for sexual minority high school youth (Coker et al., 2020), but more effective for youth who had previously been exposed to family violence (Mennicke et al., 2022). A recent study found that graduate students reported fewer opportunities to intervene in instances of interpersonal violence compared to undergraduate students (16.2 versus 35.5%), however when given the opportunity, both groups had similar rates of intervention (Palmer & Hoxmeier, 2022). Altogether, these findings suggest that personal identities and life experiences are important to consider for understanding BI, underscoring the importance of examining the potential for BI for PAU among domestic graduate and international students.

Purpose

Because the application of BI to PAU is new, and there are unique drinking behaviors observed within international and graduate students (Guo et al., 2022; Rutledge et al., 2016), there is a need to examine the utility of applying the BI approach within these populations. As such, the purposes of this paper are to

  • 1.

    Quantitatively identify opportunities for BI for PAU among domestic graduate and international students;

  1. Identify whether opportunities are different between domestic graduate students and international students

  2. Assess the association between bystander opportunity and alcohol use

  • 3.

    Qualitatively identify reasons that opportunities for BI for PAU for domestic graduate and international students are different from opportunities for undergraduate/domestic students

  • 4.

    Qualitatively identify unique barriers and facilitators to BI for PAU among domestic graduate and international students.

Methods

The current study utilized an explanatory mixed methods design to understand BI for PAU in domestic graduate and international student groups. Part I utilized a quantitative approach through administration of a survey, which informed Part II in which we utilized a qualitative approach via focus group discussions. The qualitative portion of this study was developed to provide further context to the identified opportunities (or not) for bystander intervention that were identified in the survey. Our postpositivist stance (Panhwar et al., 2017) is reflected in the idea that context is important for BI for PAU.

Part I: survey

Procedure

We partnered with campus agencies, including the international student organization and graduate education office, to identify international and domestic graduate students at a southeastern university to complete a survey. These campus partners then distributed an online Qualtrics survey link to their email listservs to advertise the survey. Participants provided electronic consent for participation and answered survey questions, which took around 20 min to complete. Participants were provided resources for campus and national mental health services upon completion. Procedures were reviewed and approved by the IRB at the University of North Carolina Charlotte. Data were collected anonymously, and participants were provided a $5 Amazon e-gift card as incentive for participation.

Participants

A total of 186 students completed the online survey. Inclusion criteria were that participants were (1) an international or graduate student enrolled at the university; (2) 18 years old or older; and (3) able to read English at an approximate 10th grade level. Complete demographic information for the sample is provided in Table 1. About half of students (49.5%) from the survey identified as a domestic graduate student, and 50.5% identified as an international student (inclusive of graduate students and undergraduate students). The mean age of the total sample was 26.2 (SD = 6.01). Most individuals identified their race as Asian (42.5%), followed by white (37.6%). Only a small percentage of the sample identified as Hispanic or Latinx, (7.5%). The majority (61.3%) of participants identified as women. Finally, the majority (79.6%) of participants identified as heterosexual.

Table 1.

Participant demographics.

Quantitative
 Qualitative
Sample characteristics N % N %
Student status
 International graduate 83 44.6% 9 27.3
 International undergraduate 11 5.9% 6 18.2
 Domestic graduate 92 49.5 18 54.5
Gender
 Woman 65 70.7 17 51.5
 Man 20 21.7 11 33.3
 Other 6 6.5 5 15.2
Race
 Black 18 9.7 3 9.1
 White 70 37.6 12 36.4
 Asian 79 42.5 13 39.3
 Multi racial 8 4.3 -- --
 Other 8 4.3 2 6.1
Ethnicity
 Not Hispanic/Latinx 172 92.5 30 90.9
 Hispanic/Latinx 12 6.5 3 9.1
Sexual identity
 Heterosexual 148 79.6 22 66.7
 Lesbian 2 1.1 2 6.1
 Gay 4 2.2 -- --
 Bisexual 16 8.6 4 12.1
 Other 13 7.1 5 15.2
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Measures

Demographics.

Participants completed an online questionnaire that assessed demographic characteristics, including age, gender identity, student status, race, ethnicity, and sexual orientation.

Bystander opportunities.

Participants responded to the Bystander Opportunity Scale (Waterman et al., 2022). The Bystander Opportunity Scale is an 11-item scale which asks participants to identify the number of times they were in a particular situation in the last six months. This scale was utilized to identify the number of opportunities students had to use bystander behaviors. Response options include ‘yes’, ‘no’, and ‘I don’t know’. A total score was created to identify the number of opportunities that were present in the past 6 months. Sample items include ‘suspected someone had been drugged’, ‘saw someone alone at a party who looked really drunk’, and ‘saw someone who was pouring too much alcohol in a drink’.

Alcohol use.

Alcohol use was measured by the Alcohol Use Disorder Identification Test-C (AUDIT-C; Bush et al., 1998). This three-item measure examines alcohol use over the last year. Follow-up items were skipped if the participant answered ‘Never (0)’ for the first question (‘How often did you have a drink containing alcohol in the past year?’). The total score was summed up with a clinical cut-off score of 5 for females and 7 for males (Rumpf et al., 2013). The AUDIT-C has good internal consistency (α = 0.80; Rumpf et al., 2013).

Part II: focus groups

Procedure

Participants were recruited to complete an hour and a half online focus group. Recruitment happened via email solicitation, campus flyers, and social media posts. Once recruited, participants were directed to an online screener survey, and if eligible, an intake survey. Participants were offered a $20 e-gift card for their participation. Once informed consent was completed and the intake form was submitted, students were invited to attend a virtual focus group for either international students or domestic graduate students.

Focus groups were conducted electronically via HIPAA-compliant Zoom and facilitated by two research assistants (from a team of three: second, third, and fifth coauthor). Although facilitators held a common student identity with participants, they were not international students. Participants were encouraged to keep their cameras on for the discussion, and measures were taken to protect participant confidentiality. All participants were able to choose their own pseudonyms as a measure of confidentiality. Focus group discussions were audio recorded and sent to an online transcription service. Transcripts were manually reviewed and revised to improve accuracy by study personnel. At the end of the focus group discussion, participants were provided a resource guide with links to local and national mental health and substance use resources.

Participants

Eligibility criteria included (1) being enrolled full-time at the university; (2) being 18 years old or older; (3) having friends who drink alcohol; and (4) being a graduate student or international student. A total of 11 focus groups were conducted, consisting of 33 people total (range 2–6). Participants were recruited from the broader international and graduate student communities on campus by partnering with the same campus partners that distributed the survey link. Focus groups were held separately for international students and domestic graduate students, with a nearly even split between these subgroupings. See Table 1 for further demographic information.

Interview guide

A semi-structured interview guide was developed to facilitate the discussion (Appendix A). The guide was based on existing literature (e.g. Banyard, 2008), theoretical frameworks (e.g. situational model, Action Coils Model), findings from preliminary quantitative results, and input from student and expert advisors. The finalized guide covered six topics: defining concerning alcohol use, noticing a concerning situation, taking action, barriers and facilitators, knowing what to do, and identity-specific questions. In line with postpositivism (Panhwar et al., 2017), we included probes to examine salient identities and contexts for decision-making.

Data analysis

Quantitative data were analyzed to answer the first research question utilizing IBM SPSS statistics v. 28. Descriptive statistics are reported for the Bystander Opportunity Scale and AUDIT for all who participated in the survey. Subgroup analyses were conducted for international and domestic graduate students separately. Independent sample t-tests were used to compare international student scores to domestic graduate student scores. Graduate student scores were not compared to undergraduate students because of the small number of undergraduate students who completed the survey (n = 10). Correlations were computed between AUDIT scores and Bystander Opportunities Scale scores.

Qualitative data was used to answer the second and third research questions. Transcripts were analyzed using deductive and inductive thematic analysis (Boyatzis, 1998). A codebook was developed based on the situational model of bystander intervention (Darley & Latané, 1968), and the Action Coils Model (Banyard et al., 2015). Dedoose online qualitative software was utilized for coding processes; study personnel used the “memo” function in Dedoose to document their biases or assumptions while coding. The coding team first analyzed two transcripts, and reliability of coding was examined using the “test” function in Dedoose, and Kappas less than 0.6 were discussed (less than “substantial” agreement; McHugh, 2012). After discussion, the codebook was refined and re-testing was conducted, ensuring Kappas were above 0.6. Utilizing the finalized codebook, each transcript was coded by two study personnel in which meaningful chunks of text were coded into categories (Saldaña, 2016). Then, secondary coding occurred to identify significant themes and subthemes (Saldaña, 2016) with a focus on how both identity and situational factors affected decision-making.

Results

Part I: opportunities for BI

Frequencies for bystander opportunities are highlighted in Table 2. Among the survey respondents, few BI opportunities were reported (M = 1.39, SD = 1.97, range = 0–8). The most frequently reported experiences for students included hearing a friend talking about getting really wasted/drunk/”shit faced” (30.6%), seeing someone playing drinking games when they are getting really drunk (22.0%), seeing someone pouring too much alcohol in a drink (19.4%), and seeing someone who was drinking and talking about driving (18.8%).

Table 2.

Bystander opportunity frequencies by student status.

International student
 Graduate student
Bystander opportunity Yes No Yes No χ 2
I suspected someone had been drugged. 1 (1.1%) 93 (98.9%) 3 (3.3%) 89 (96.7%) 1.07
I saw someone spiking or drugging someone’s drink without the drinker’s knowledge. 1 (1.1%) 93 (98.9%) 0 (0.0%) 92 (100.0%) 0.98
I saw someone taking a very intoxicated or unconscious person to a private location. 0 (0.0%) 94 (100.0%) 0 (0.0%) 92 (100.0%)
I saw someone alone at a party who looked really drunk. 9 (9.6%) 85 (90.4%) 6 (6.5%) 86 (93.5%) 0.58
I saw someone showing signs of alcohol poisoning. 11 (11.7%) 83 (42.5%) 13 (14.1%) 79 (85.9%) 0.24
I saw someone who was drinking and talking about driving. 9 (9.6%) 85 (90.4%) 26 (28.3%) 66 (71.7%) 10.63***
I saw a friend who was physically hurt while drinking. 6 (6.4%) 88 (93.6%) 10 (10.9%) 82 (89.1%) 1.19
I heard a friend talking about getting really wasted/drunk/ ‘shit faced’. 22 (23.4%) 72 (76.6%) 35 (38.0%) 57 (62.0%) 4.69*
I saw someone who was pressuring other people to drink. 12 (12.8%) 82 (87.2%) 17 (18.5%) 75 (81.5%) 1.15
I saw someone who was pouring too much alcohol in a drink. 17 (18.1%) 77 (81.9%) 19 (20.7%) 73 (79.3%) 0.20
I saw someone playing drinking games when they are getting really drunk. 16 (17.0%) 78 (83.0%) 25 (27.2%) 67 (72.8%) 2.79
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*

p<.05

***

p<.001.

International students (M = 1.10, SD = 1.76) reported a lower mean number of bystander opportunities compared to domestic graduate (M = 1.67, SD = 2.14) students (t(194) = −1.98, p = .049, d = 1.95). When breaking these differences down further by the types of bystander opportunities between domestic graduate students and international students, significant differences emerged in two opportunities. Domestic graduate students (N = 26, 28.30%) reported significantly more opportunities than international students (N = 9, 9.60%) to intervene when they saw someone who was drinking and talking about driving (x2(1)=10.63, p<.001, Cramer’s V = 0.24). Domestic graduate students (N = 35, 38.0%) also had more experiences of hearing a friend talk about getting really wasted/drunk/”shit faced” compared to international students (N = 22, 23.4%) (x2(1)=4.69 p = 0.04, Cramer’s V = 0.16).

Finally, we found that problematic drinking was associated with more opportunities for BI. The average AUDIT score for the whole survey sample was 2.75 (SD = 2.45), well below the clinical cut-off scores for both males and females. The association between AUDIT scores and bystander opportunities was moderately positively correlated (r(186)=0.39, p<.001, [0.26, 0.50]). When comparing differences in PAU between student groups, domestic graduate students reported significantly higher AUDIT scores (M = 3.75, SD = 2.29) as compared to international students (M = 1.76, SD = 2.20) (t(184)=6.05, p<.001, [1.34, 2.64], d = 2.25). For international students, higher alcohol use was moderately correlated to more opportunities for BI (r(94)=0.31, p = 0.002, [0.12, 0.46]). However, domestic graduate students had a stronger positively correlated relationship between alcohol use and opportunities for BI (r(92)=0.41, p<.001, [0.23, 0.57]).

Part II: reasons for differences in opportunities

On average, the number of opportunities for BI for PAU was relatively low. Thus, we utilized focus groups to better understand why domestic graduate and international students endorsed fewer instances and types of BI. International and domestic graduate focus group participants identified numerous reasons their opportunities for BI for PAU were different from domestic or undergraduate students (respectively) and how these reasons led to fewer overall opportunities suggested by survey results. Reasons included issues related to oneself (internal), and issues related to the context (external). Subthemes were identified within each of these categories. Figure 1 depicts how these opportunities and barriers relate to oneself or the context. In general, these issues led to less PAU among participants in the sample and their friend groups, thereby decreasing their opportunities for BI for PAU.

Figure 1.

Figure 1.

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Conceptual map of reasons for differences in opportunities in bystander intervention for problematic alcohol use.

Self

Aspects that related to participants themselves included professionalism norms, life experience with alcohol, condemnation of drinking and driving, and medications’ interactions with alcohol.

Professionalism norms.

In focus groups, participants revealed feeling the need to be more responsible in all aspects of their lives. This can include academics and jobs taking a higher priority. This sense of self-responsibility decreased the likelihood of participants engaging in PAU with their friends, thus reducing their opportunity to use BI. For example, one participant stated,

There’s way higher standards for graduate students because we’re seen as, like, we got into grad school, so it’s clearly harder. …And so, I can’t be a lush, and most of us can’t be drinking all the time at least to stay at the top of our program. (Emma B., Domestic Graduate Student, White, Cisgender woman).

Participants also discussed how their role as a graduate student means that there is a time and place for engaging in drinking activities, which may not happen often, resulting in limited opportunities participants have for BI for PAU. The public-facing nature of many graduate students’ jobs also limited their abilities to drink publicly. Notably, this may relate to southern professional norms in which being inebriated in public can be seen as a poor reflection of character. For example, one participant stated, We’re talking about the students that do more public work in the sense of like they’re getting out there showing their research at conferences, things like that. Or they’re working as employees for the school, like they’re teaching assistants or they got graduate assistantships or research assistantships. (Mad Max, Domestic Graduate Student, White, Cisgender man).

Life experience.

Participants reported having experiences in the past that influence their current decisions on what they drink and the social context surrounding drinking opportunities. Past experiences can potentially cause a reduction in situations of PAU for graduate students, diminishing opportunities for BI. Participants spoke about previous experiences during their undergraduate years and their current drinking norms. Some of these experiences revolved around not participating in events like undergraduate fraternity parties, or going through “a phase”.

Just having all the consequences of drinking and saw the way they acted, or we did that ourselves and then we kind of got it out of our system and grad school came around and you’re like, “that”s a lot more work and a lot more stuff that you have to do that you can’t really slack off on”, and being drunk is not going to help you do that. (Stephanie B., Domestic Graduate Student, Asian, Nonbinary, Genderqueer).

Previous experiences with drinking as an undergraduate have led graduate students to have new standards and expectations when it comes to drinking. Binge drinking is no longer a goal, and alcohol consumption is not a new experience. This new mindset changes graduate students’ overall drinking behavior, which lessens the chance of them engaging in PAU with their friends, therefore, limiting opportunities for BI. For example, one participant stated,

It’s a changing of the perspective on what’s problematic behavior itself…In college people would definitely drink very heavily, myself included, especially in comparison to now. And I think that growing up pretty much in the last couple of years, seeing that, “Hey, that’s not normal behavior. People do not need to black out or get that drunk this often that’s so bad for you”. (WB, Domestic Graduate Student, White, Cisgender man).

Several participants noted how their taste in alcohol has changed with age and transitioning to graduate school. Explaining a newfound appreciation for alcohol was tied to the expense of alcohol and reduction in PAU. This refinement in taste led to fewer opportunities for BI with friends. For example, one participant stated,

I feel like as my friends and I are older, your taste becomes a little more refined, so then what you wanna drink, like, if you’re only gonna have a couple of drinks, you want them to like taste good, which only means they’re even more expensive (Jethro Q., Domestic Graduate Student, White, Non-binary).

International participants noted how their alcohol preferences were heavily influenced by their home country. Many international student participants discussed the cultural differences in their drinking norms compared to standard American drinking norms.

Back in El Salvador, obviously the drinking age is 18 years old, like most countries around the world. But the culture, and also the fact that it is a very Catholic country… when they get to a certain age, they start drinking more like vodka or other stuff like that…And then when they are 21…They drink more like wine and more, formal things and they don’t get drunk as much. It’s more about how, how it tastes and enjoying this reunion and not just getting drunk without any sense. (Pam, International Student, Latinx/Hispanic, Cisgender woman).

Condemnation of drinking and driving.

Condemning drinking and driving led to fewer PAU behaviors among participants, and consequently fewer opportunities for BI. Notably, the campus is not within easily walkable distance to student-frequented bars or clubs. Many participants spoke about drinking at home rather than going out to bars or others’ houses as a means of avoiding drinking and driving.

For me, most of the times my friends are drinking at home in one person’s apartment or the others’. So yeah, we are not driving immediately after drinking most of the time. (Shiv, International Student, Asian, Cisgender woman).

Overall, there was a general disapproval of drinking and driving, especially with the easy access to rideshare (e.g. Uber, Lyft) and public transportation. For example, one participant stated,

Drinking and driving is not normal around my group of friends…I’ve had Uber and Lyft since early high school or early college, or late high school or early college. So, we’re just used to it and seeing people that do drink and drive, we have a general rule that if you’re gonna have more than two beers, then just take an Uber, get on the light rail, or something like that. (WB, Domestic Graduate Student, White, Cisgender man).

Medications.

One unique reason for a decrease in PAU among participants, in turn reducing opportunities for BI, was the concern of mixing medications with alcohol. For example, one participant stated,

My third concern would be someone who is on medication and them drinking because I have known one case where my friend who was on medication went to the bar and drank and yeah, the reaction. So that’s something I’m kind of concerned about. People should know if they’re on medication, they should drink or not (Cicada, International Student, Asian, Cisgender man).

This was also noted as a concern that could affect their own drinking.

I know one time I was on a medication that told me I can’t drink. And I remember I was considering doing it and I talked to a friend and she happened to be a pharm tech. And she was like, “yeah…no, you’re gonna start throwing up right away” (Jane D., Domestic Graduate Student, Latinx/Hispanic, Cisgender woman).

This attunement to the possible dangers of mixing medication and alcohol was the underlying explanation for drinking less and being proactive in encouraging others to think about the way medication affects their alcohol consumption. Preventative measures allow participants to stop problematic drinking behavior before needing to use BI with friends.

Context

Contextual components of barriers included trust in others, place of drinking, and home country norms related to drinking and emergency services.

Trust.

Participants’ different levels of trust within the groups they drink with creates a barrier of knowing the appropriateness of one’s intervention. Among the participants who viewed trust as a barrier, having high levels of trust in people they are drinking with can create a barrier, such that intervention could have occurred earlier. For example, one participant stated,

The point is for the most part hoping people look after themselves. And one of the scenarios that prevents me from acting as a barrier is the fact that I think I probably trust them. Maybe it’s some notion of projection in the sense that…I feel like I can control myself while under the influence…I’m hoping someone else does the same. (Darth V., Domestic Graduate Student, Asian, Cisgender man).

Another trust related barrier was believing that people know their own body’s limit and can watch over oneself since they are adults. For example, one participant stated,

Wanting to trust someone too because we’re all adults. Kind of wanting to trust that somebody knows their body and somebody knows how they’re doing and that you have the relationship with ‘em that they’re gonna be able to tell you. (Jethro Q., Domestic Graduate Student, White, Nonbinary)

Jethro highlights not only trusting one’s self-awareness but also communication norms of others being able to voice their needs.

Place of drinking.

Both social and financial components of drinking influenced BI for PAU. Participants brought up the variety of new environments in which they drink, and how that impacts their alcohol consumption. As an example, one participant stated,

Because of my grad school experience, it has been harder to make friends and be in these social situations specifically. So for me, a lot of the time is at my apartment, or at a local bar or restaurant where I might be eating out. (Jane D., Domestic Graduate Student, Latinx/Hispanic, Cisgender woman).

Opportunities for participants to engage in PAU were described as limited due to the cost of alcohol; therefore, limiting the number of occasions that participants can use BI among friends. Participants spoke about the budget restrictions they experience with limited income. One participant spoke about saving money by drinking at home.

“I don’t wanna go out, I wanna stay at my apartment and I wanna get my money’s worth. Rent is expensive. My undergrad experience is very different. I went to a different university and rent was less expensive” (Jane D., Domestic Graduate Student, Latinx/Hispanic, Cisgender woman).

Participants also spoke to the connection between being grounded in professionalism as a graduate student and not wanting to go out and spend money on alcohol.

I think that a lot of people going into undergrad, it’s their first taste of freedom of being an adult, of being on their own. So they wanna experience things… But then when you’re in grad school, it’s just like, “Alcohol’s expensive and I need to do these five essays so I’m just gonna stay in my room”. (Anni N., Domestic Graduate Student, White, Cisgender woman).

Home country norms.

Domestic graduate and international students also described how elements of their identity acted as barriers to using BI for PAU among their friends. Other country norms of responsible alcohol use left some students unprepared to intervene in PAU. Some international participants expressed the negative impact that calling 911 can have on international participants. For example, one participant stated,

“Yeah, for them calling police, calling 911 – they’re Indian, it will be a problem for them because they know what could be the consequence they know they can handle that” (Riya Taneja, International Student, Asian, Cisgender woman).

Others expressed how there is not a huge concern about contacting emergency services, indicating that their international identity is a facilitator to BI for PAU. For example,

In Austria, I’ve had to call the ambulance two or three times because one time it was alcohol poisoning. Two times it was just injuries because they were too drunk. And even at those parties, there’s usually an EMT tent set up. So me and my friends would actually pick up strangers, girls, that we did not know and helped them to the EMT tent. I think where I’m from it’s a pretty small state. So, even though you might not know each other, you would still help each other out. (Emma Z, International Student, White, Cisgender woman).

Discussion

The results of this mixed methods study highlight some challenges that may arise when attempting to apply BI to PAU among domestic graduate or international students. Due to infrequent drinking reported by these groups, BI interventions targeted for these populations may be less successful than simply ensuring generalized BI for PAU is inclusive of graduate and international student experiences. Through the quantitative data, we learned that domestic graduate and international students are less likely to drink than undergraduates, ultimately leading to fewer opportunities for BI for PAU. Qualitative data further extrapolated on this finding by indicating that internal issues related to self and external issues related to context created different cultures and norms among domestic graduate and international students, which led to fewer opportunities for BI for PAU. Specific reasons related to self included professionalism norms, life experiences with alcohol, condemnation of drinking and driving, and medication interactions with alcohol. Specific contextual reasons included trust of others, place of drinking, and home country drinking norms.

Within the domain of interpersonal violence, Banyard’s (2015) Action Coils Model has highlighted that unique circumstances influence a person’s decision to intervene. This assertion appears true for the possibility of applying BI for PAU among domestic graduate and international students. Participants described how the few opportunities for BI for PAU were heavily influenced by their own drinking cultures and norms, ultimately leading to unique barriers to BI for PAU. Similar to prior research (Haikalis et al., 2018), personal alcohol use was significantly correlated with opportunities for BI. Therefore, unsurprisingly, lower rates of PAU within this sample were correlated with fewer opportunities for BI.

While BI is a technique that is used across ages (ranging from middle school to college), research has not examined the utility of this approach to combat PAU among domestic graduate and international students. Findings from this research suggest that the BI approach to reduce PAU and related consequences among domestic graduate and international students may not be useful, due to drinking norms that lead to fewer opportunities for BI for PAU. However, several recommendations can be offered to ensure general BI programs are representative of the domestic graduate and international student experience. Many of the “typical” drinking scenarios presented in PAU interventions may not be typical for domestic graduate and international students (e.g. drinking at large parties, binge drinking via drinking games, etc.). Instead, graduate and international students described a more mature, methodical, and planned approach to drinking, ultimately reporting fewer instances of PAU. This included drinking in smaller, more intimate settings, choosing drinking venues that reduced the opportunity for drunk driving, and being mindful of personal responsibilities when drinking. Thus, content in existing BI programs can be updated to reflect these realities using case scenarios.

Several unique barriers to BI for PAU emerged for domestic graduate and international students, including placing a high amount of trust in others, and the role of personal identities. Existing programming could be tailored to attempt to counteract these barriers by increasing feelings of collective responsibility and presenting BI options that work within a person’s identities. Tailoring programs may be especially salient for international students who endorsed fewer opportunities for BI and had specific barriers to BI (e.g. cost of ambulance). Students should be well educated on drug and alcohol amnesty programs available at the university, and these programs should be inclusive and broad enough to consider the challenges of both the bystander and the person who needs help. Of course, our results may also suggest that BI for PAU is not an appropriate prevention strategy for this population. However, so little research on graduate and international students’ alcohol use has been done, this research question should be explored in other populations.

Limitations

Limitations must be noted. For both the needs assessment and the focus groups, the majority of international students also identified as graduate students. Therefore, generalizing results to undergraduate international students is limited due to unique opportunities, barriers and facilitators that undergraduate international students may face. For example, several international undergraduate students noted their country’s drinking age to be 18, leading to maturity around alcohol at a younger age and less need to drink excessively. Additionally, the rates of drinking were relatively low among this sample. While this seems to be consistent with the scant literature on drinking patterns among graduate and international students, it is possible that high risk drinkers, who may benefit from the BI approach, did not participate in this study.

Additionally, the overall sample size for both the needs assessment and focus groups was small, limiting the ability to extrapolate findings to all domestic graduate and international students. Our smallest focus group discussion included only two participants, which is smaller than the recommended minimum of four participants (Kitzinger, 1995). However, we sought somewhat homogenous groups (i.e. an international student group) and smaller groups may have the benefit of producing more information as opposed to larger groups (Fern, 1982).

Finally, this study took place at a southeastern university in the U.S. where the population of international students may differ from other universities. For example, a large percentage of the international students who completed the survey and focus groups identified as Asian, which may not reflect the predominant international student population at other universities. Future studies could examine universities that have international students from more varied backgrounds to understand whether lower BI opportunities are consistent for individuals from countries where drinking culture may be more similar/different to the U.S. Additionally, though results indicated that BI programming for these student populations may not seem as necessary, understanding how to tailor BI programming for this population is still important as these populations are more likely to come across PAU in more public spaces (e.g. bars or breweries) compared to undergraduates (e.g. house parties) where intervening may seem more high risk.

Conclusions

The current study draws attention to the BI opportunities and barriers that both domestic graduate and international students face in situations involving PAU. Having a different set of social norms in the domestic graduate and international student communities when compared to undergraduate students can affect the norms around PAU, which in turn affect how an individual may intervene as a bystander. The results indicated that while there were limited opportunities for BI for graduate and international students, these opportunities were unique. The same was true in the barriers faced by both groups. An emphasis on BI for PAU for domestic graduate and international students in college settings can help to tailor future programming towards these populations, and better equip them with intervention skills appropriate for situations of PAU.

Supplementary Material

Appendix A

Funding

Funding for this project was provided by a grant from the Substance Abuse and Mental Health Services Administration (1H79SM083941–01) and National Institute of Alcoholism and Alcohol Abuse (1R15AA028910–01).

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental data for this article can be accessed online at https://doi.org/10.1080/08870446.2024.2342464.

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Supplementary Materials

Appendix A
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