Personalized feedback as a universal prevention approach for college drinking: a randomized trial of an e-mail linked universal web-based alcohol intervention

A systematic review on eHealth technology personalization approaches

Despite the widespread use of personalization of eHealth technologies, there is a lack of comprehensive understanding regarding its application. This systematic review aims to bridge this gap by identifying and clustering different personalization approaches based on the type of variables used for user segmentation and the adaptations to the eHealth technology and examining the role of computational methods in the literature. From the 412 included reports, we identified 13 clusters of personalization approaches, such as behavior + channeling and environment + recommendations. Within these clusters, 10 computational methods were utilized to match segments with technology adaptations, such as classification-based methods and reinforcement learning. Several gaps were identified in the literature, such as the limited exploration of technology-related variables, the limited focus on user interaction reminders, and a frequent reliance on a single type of variable for personalization. Future research should explore leveraging technology-specific features to attain individualistic segmentation approaches.

Effectiveness of web-based personalised feedback interventions for reducing alcohol consumption among university students: A systematic review and meta-analysis

ISSUES

Meta-analysis was conducted to examine standalone web-based personalised feedback interventions (PFI) delivered in non-structured settings for reducing university students' alcohol consumption. Subgroup analyses by gender-focus, type-of-content and accessibility were conducted. Characteristics of the sample, the intervention and study quality were examined as moderators.

APPROACH

Ten databases were searched from 2000 to 2023. Eligible articles involved only randomised controlled trials. Random-effects meta-analysis was conducted to calculate the effect size on weekly alcohol consumption comparing web-PFIs and non-active controls. Meta-regressions were applied to explore effect moderators.

KEY FINDINGS

Thirty-one studies were included in the narrative synthesis, 25 of which were meta-analysed. Results found significant effect size differences on weekly alcohol consumption in favour of the intervention group in the short- (SMD = 0.11, 95% confidence interval [CI] 0.06, 0.15) and long-term period (SMD = 0.09, 95% CI 0.02, 0.15). Subgroup analyses identified that interventions which were gender-specific, multicomponent and had unlimited access had higher and significant effect sizes, although they were very similar with respect to comparative groups. Moderator analyses showed that times feedback was accessed significantly contributed to the effectiveness of the intervention. Effects diminished over time, although they remained significant.

IMPLICATIONS

The meta-analysis evidences the effectiveness of web-PFI for addressing university students' alcohol use, decreasing by 1.65 and 1.54 drinks consumed per week in the short- and long-term, respectively.

CONCLUSIONS

The results offer empirical evidence that supports the significant, although small, effect of web-PFI delivered remotely in universities. Future research should focus on increasing their impact by introducing booster sessions and content components based on students' preferences.

Negative Consequences Related to Nonmedical Prescription Stimulant Use: Development and Psychometric Validation of the Prescription Stimulant Consequences Questionnaire

Nonmedical prescription stimulant use (NPS) is prevalent among undergraduates and associated with several negative consequences. However, no validated measures exist assessing NPS-related consequences. The present study aimed to develop and psychometrically validate a Prescription Stimulant Consequences Questionnaire (PSCQ) for use among college students. A multisite sample of college students endorsing NPS ( N = 715, 68.4% female) completed the PSCQ and measures of NPS frequency and correlates of NPS via an online survey. Exploratory factor analysis supported a 27-item measure, with three factors (i.e., Compulsive Behavior, Risky Behaviors, and Physical and Mental Health) and a total score. Each PSCQ factor and total score demonstrated good internal consistency, and were significantly positively associated with all NPS frequency indicators, route of administration, alcohol-related problems, sleep problems, and depressive/anxiety symptoms. Findings demonstrate support for the psychometric validity and reliability of the newly developed PSCQ, which may demonstrate potential as a screening and outcome measure for intervention.

A Gamified Personalized Normative Feedback App to Reduce Drinking Among Sexual Minority Women: Randomized Controlled Trial and Feasibility Study

BACKGROUND

Sexual minority women disproportionately engage in heavy drinking and shoulder the burden of alcohol dependence. Although several intensive interventions are being developed to meet the needs of treatment-seeking sexual minority women, there remains a lack of preventive interventions to reduce drinking and its consequences among women not yet motivated to reduce their alcohol consumption.

OBJECTIVE

We aimed to examine the feasibility and efficacy of reducing alcohol-related risks via personalized normative feedback (PNF) on alcohol use and coping delivered within LezParlay, a social media-inspired digital competition designed to challenge negative stereotypes about lesbian, bisexual, and queer (LBQ)-identified sexual minority women.

METHODS

Feasibility was assessed by examining engagement with LezParlay outside the context of an incentivized research study, assessing the characteristics of the LBQ women taking part, and examining the competition's ability to derive risk-reducing actual norms as well as levels of acceptability and perceived benefits reported by participants. Intervention efficacy was examined by randomizing a subsample of 499 LBQ alcohol consumers (ie, drinkers) already taking part in the competition to receive sexual identity-specific PNF on alcohol use and coping, alcohol use only, or control topics over only 2 rounds of play. Changes in alcohol use and negative consequences were examined 2 and 4 months after the delivery of treatment PNF.

RESULTS

A total of 2667 diverse LBQ women played ≥1 round of LezParlay. The competition attracted large numbers of moderate and heavy drinkers; however, risk-reducing actual norms could still be derived from competition rounds and featured in PNF. Efficacy results revealed that drinkers who received PNF on alcohol use and both alcohol use and coping had similar reductions in their weekly drinks (P=.003; P<.001), peak drinks (P<.001; P<.001), and negative consequences (P<.001; P<.001) relative to those who received PNF on control topics at the 2-month follow-up. However, at the 4-month follow-up, reductions in alcohol consumption outcomes faded among those who received alcohol PNF only (weekly: P=.06; peak: P=.11), whereas they remained relatively robust among those who received PNF on both alcohol use and coping (weekly: P=.02; peak: P=.03). Finally, participants found the competition highly acceptable and psychologically beneficial as a whole.

CONCLUSIONS

The LezParlay competition was found to be a feasible and efficacious means of reducing alcohol-related risks in this population. Our findings demonstrate the utility of correcting sexual identity-specific drinking and coping norms to reduce alcohol-related risks among LBQ women and suggest that this approach may also prove fruitful in other stigmatized health disparity populations. To engage these populations in the real world and expand the psychological benefits associated with PNF, our findings also point to packaging PNF within a broader, culturally tailored competition designed to challenge negative group stereotypes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24647.

Prevention of Alcohol-related Incidents in the U.S. Air Force: Results From a Cluster Randomized Trial

BACKGROUND

Alcohol misuse poses significant public health concerns in the U.S. Military. An Alcohol Misconduct Prevention Program (AMPP), which includes a brief alcohol intervention (BAI) session, plus random breathalyzer program, has been shown to reduce alcohol-related incidents (ARIs) among Airmen undergoing training.

PURPOSE

The current study sought to examine whether a booster BAI administered at the end of Airmen's training reduced ARIs out to a 1-year follow-up.

METHODS

Participants were 26,231 U.S. Air Force Technical Trainees recruited between March 2016 and July 2018. Participants were cluster randomized by cohort to two conditions: AMPP + BAI Booster or AMPP + Bystander Intervention. The primary analysis was a comparison of the interventions' efficacies in preventing Article 15 ARIs at a 1-year follow-up, conducted using a generalized estimating equations logistic regression model controlling for covariates.

RESULTS

There was no significant difference by condition in Article 15 ARIs at the 1-year follow-up (P = .912).

CONCLUSIONS

Findings suggest that a booster may not be necessary to produce maximum effects beyond the initial AMPP intervention. It is also possible that alcohol behaviors changed as a result of the intervention but were not captured by our outcome measures. Future research should consider alternative outcomes or participant-tracking measures to determine whether a different or more intensive BAI booster is effective. The majority of Article 15 ARIs were for underage drinking; therefore, developing an intervention focused on this problem behavior could lead to large reductions in training costs in the military.

A Gamified, Social Media-Inspired, Web-Based Personalized Normative Feedback Alcohol Intervention for Lesbian, Bisexual, and Queer-Identified Women: Protocol for a Hybrid Trial

BACKGROUND

Sexual minority women are more likely to drink alcohol, engage in heavy drinking, and experience alcohol-related problems than heterosexual women. However, culturally tailored interventions for this population have been slow to emerge.

OBJECTIVE

This type 1 effectiveness-implementation trial examines the feasibility and efficacy of a gamified, culturally tailored, personalized normative feedback (PNF) alcohol intervention for sexual minority women who psychologically identify as lesbian, bisexual, or queer (LBQ).

METHODS

The core components of a PNF intervention were delivered within LezParlay, a fun, social media-inspired, digital competition designed to challenge negative stereotypes about LBQ women and increase visibility. The competition was advertised on the web through social media platforms and collaboration with LBQ community organizations. After 2 rounds of play by a large cohort of LBQ women, a subsample of 500 drinkers already taking part in the competition were invited to participate in the evaluation study. Study participants were randomized to receive 1 of 3 unique sequences of PNF (ie, alcohol and stigma coping, alcohol and control, or control topics only) over 2 intervention rounds. Randomization was fully automated by the web app, and both researchers and participants were blinded.

RESULTS

Analyses will evaluate whether PNF on alcohol use reduces participants' drinking and negative consequences at 2 and 4 months postintervention; examine whether providing PNF on stigma-coping behaviors, in addition to alcohol use, further reduces alcohol use and consequences beyond PNF on alcohol alone; identify mediators and moderators of intervention efficacy; and examine broader LezParlay app engagement, acceptability, and perceived benefits.

CONCLUSIONS

This incognito intervention approach is uniquely oriented toward engaging and preventing alcohol-related risks among community populations of LBQ women who may view their heavy drinking as normative and not in need of change because of the visibility of alcohol use in sexual minority community spaces. Thus, this intervention strategy diverges from, and is intended to complement, more intensive programs being developed to meet the needs of LBQ women already motivated to reduce their consumption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24647.

A systematic review of alcohol education programs for young people: do these programs change behavior?

Numerous education programs have addressed young peoples' alcohol use. To date, no peer-reviewed publication has evaluated the effectiveness of such programs delivered across a range of contexts to change alcohol-related behaviors, attitudes and/or knowledge. This systematic review aimed to identify alcohol education programs addressing young people, and determine whether they changed alcohol-related behavior, knowledge and attitudes; and, ascertain components of successful programs. Studies were identified, guided by the PRISMA review process, from the earliest records until June 2020. Included studies (N = 70) comprised an alcohol education program which focused on young people (15-24 years). Forty programs reported behavior changes, and these programs were the highest quality. Others impacted attitudes and/or knowledge only (n = 12); or reported no impacts (n = 17). Recent programs were more likely than older programs to feature online delivery and report behavior changes. To enhance alcohol education, future programs should include the identified quality criteria, alongside process and long-term outcome evaluations, to better monitor effectiveness. Findings indicated some education programs have capacity to positively change alcohol-related behavior; however, outcome consistency varied even in high-quality programs. Alcohol education programs should be designed alongside health education/promotion models and best-practice recommendations, to improve the likelihood of desirable behavior-related outcomes.

Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review

BACKGROUND

Web-based interventions are thought to overcome barriers to treatment, such as accessibility and geographical location, which can undermine the effectiveness of traditional face-to-face interventions. Owing to these features, researchers are increasingly testing the efficacy of web-based interventions as ways to reduce alcohol misuse, binge eating, and gambling. However, many web-based interventions have poorly defined mechanisms of action; therefore, it is often uncertain how they propose to bring about behavior change.

OBJECTIVE

This systematic review aims to identify effective behavior change techniques (BCTs) present in web-based interventions aimed at reducing alcohol consumption, binge eating, or gambling.

METHODS

This systematic review covered research conducted in the last 20 years. Inclusion criteria for interventions were web-based administration; targeting alcohol use, binge eating, and/or gambling; and reporting on baseline and postintervention measures of behavior. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. We coded intervention effectiveness, study quality, and BCTs present in the interventions.

RESULTS

Following removal of 4152 ineligible articles, 45 were included in the review: 32 (71%) targeted alcohol misuse, 6 (13%) targeted binge eating, and 7 (16%) targeted gambling. In total, 5 frequency counts were performed to identify the most commonly used BCTs: all studies, effective interventions, high-quality studies at 2 thresholds, and both high quality and effective studies. The results obtained from this were integrated to identify 7 BCTs. These 7 BCTs were problem solving, feedback on behavior, self-monitoring of behavior, self-monitoring of outcomes, instruction on how to perform a behavior, information about social and health consequences, and social comparison. A total of 4 BCTs were found in all frequency counts: feedback on behavior, self-monitoring of behavior, instruction on how to perform a behavior, and social comparison. Self-monitoring of outcomes of behavior was found in 3 of the 5 frequency counts, problem solving was found in 2 frequency counts, and information about social and health consequences was found in 1 frequency count.

CONCLUSIONS

This systematic review identified 7 of the most frequently used BCTs used in web-based interventions focused on alcohol misuse, binge eating, and gambling. These results can inform the development of evidence-based eHealth interventions that have the potential to lead to effective, positive behavior changes in all 3 areas.

[Internet-based alcohol interventions for college students: systematic reviewIntervenciones por Internet para reducir el consumo de alcohol de los estudiantes universitarios: revisión sistemática]

Objective

To identify the main modalities of Internet-based interventions to limit alcohol use among university students, and to describe the effects of these interventions on alcohol use and related consequences.

Methods

A systematic review of PubMed, PsycINFO, and SciELO was performed using as search terms "alcohol drinking AND Internet," without date or language restrictions. Inclusion criteria were randomized controlled trial design, focus on college students and on Internet-based interventions, and evaluating the effects of the intervention on alcohol use or alcohol-related consequences.

Results

Thirty-six articles were analyzed. Two main intervention modalities were identified: personalized normative feedback (PNF, n=28) and multicomponent interventions (n=8). Twelve studies with PNF reported reductions in alcohol use 3 months after the intervention. Multicomponent interventions reduced alcohol use and related consequences; most studies focused on the website AlcoholEdu, which reduced alcohol consumption and the consequences of alcohol use 6 months after the intervention.

Conclusions

FNP and the AlcoholEdu website, the most frequently evaluated interventions among the selected studies, were effective in reducing alcohol use in university students. These strategies are an alternative to increase the access of university students to interventions aimed at limiting alcohol use.

Online Intervention as Strategy to Reach Men Who Have Sex With Other Men and Who Use Substances in a Sexual Context. Development of the MONBUZZ.ca Project

Men who have sex with men (MSM) use more psychoactive substances and a greater variety of them compared to their heterosexual peers. In this population, substance use is particularly characterized by polydrug use, binge, and sexualized substance use. MSM who use substances do not recognize themselves in public health messages targeting substance users. In addition, they recognize their problematic substance use later than heterosexuals and, as a result, they use addiction services later in their addiction trajectories. When accessing addiction services, the links between drug use and sexual life are rarely considered. Because of this profile, online interventions are a promising way to reach this hard-to-reach population. Currently available online interventions targeting MSM address the topics of substance use and sexual life separately. To deal with this situation, our team wanted to develop an online intervention platform for MSM who use substances in a sexual context. Given that online addiction interventions do not address sex and that MSM drug use is highly related to sexual activity, we first explored the literature related to online interventions targeting MSM and HIV risk behaviors, as well as online interventions targeting general population in order to: (1) identify relevant (or personalized) intervention methods; (2) describe the approaches used; and (3) describe their effects. Second, we turned to the literature to develop the MONBUZZ.ca project in collaboration with community organizations. The results of the narrative review provided a critical portrait of online interventions for MSM and guided the development process of MONBUZZ.ca. We discuss issues of co-development of a research and brief intervention tool based on promising practices as well as challenges of its implementation and evaluation.

Efficacy of interventions targeting alcohol, drug and smoking behaviors in university and college students: A review of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of interventions targeting alcohol consumption, drug use and smoking for college/university students.

PARTICIPANTS

College/University students.

METHODS

Studies were eligible if: (1)included students attending universities/colleges; (2)implemented in a university/college setting; (3)aimed to improve at least one of the following behaviors: alcohol and/or drug use and/or smoking; (4)were RCTs. The effect of the interventions on behaviors was determined by the percentage of studies that reported an effect. Due to the heterogeneity of outcomes meta-analysis was not conducted.

RESULTS

88 studies met criteria. University-based interventions were effective for reducing alcohol-related outcomes (drinking patterns, BAC, consequences, problem drinking). Inconsistent findings for drug and smoking were observed.

CONCLUSIONS

University-based interventions have the potential to improve health for students. While there is a breadth of research examining the efficacy of interventions to reduce alcohol consumption, further research is needed to determine the best approach for addressing smoking and drug use among students.

A Critical Appraisal of the Social Norms Approach as an Interventional Strategy for Health-Related Behavior and Attitude Change

The Social Norms Approach is a widely used intervention strategy for promoting positive health-related behaviors. The Approach operates on the premise that individuals misperceive their peers' behaviors and attitudes, with evidence of under- and over-estimations of behaviors and peer approval for a range of positive and negative behaviors respectively. The greater these misperceptions, the more likely an individual is to engage in negative behaviors such as consuming heavier amounts of alcohol and other substances and reduce positive behaviors such as eating healthily and using sun protection. However, there are many complexities associated with the use of social norms feedback in interventions and empirical studies. Many social norms interventions do not attempt to change misperceptions of social norms or measure changes in normative perceptions pre- and post-intervention. This has led to a conflation of generic social norms interventions with those that are explicitly testing the Approach's assumptions that it is misperceptions of peer norms which drive behavior. The aim of the present review was to provide a critical appraisal of the use of the Social Norms Approach as an intervention strategy for health-related behaviors, identify the current issues with its evidence base, highlight key opportunities and challenges facing the approach, and make recommendations for good practice when using the approach. There are three core challenges and areas for improved practice when using the Social Norms Approach. Firstly, improvements in the methodological rigor and clarity of reporting of 'social norms' research, ensuring that studies are testing the approach's assumption of the role of misperceptions on behaviors are differentiated from studies investigating other forms of 'social norms.' Secondly, the need for a more explicit, unified and testable theoretical model outlining the development of normative misperceptions which can be translated into interventional studies. Finally, a need for a more robust evaluation of social norms interventions in addition to randomized controlled trials, such as the inclusion of process evaluations, qualitative studies of participant experiences of social norms feedback, and alternative study designs better suited for real-world public health settings. Such improvements are required to ensure that the Social Norms Approach is adequately tested and evaluated.

Motives for drinking alcohol and eating palatable foods: An evaluation of shared mechanisms and associations with drinking and binge eating

BACKGROUND

Young adulthood is a high-risk period for heavy drinking and binge eating, both of which can impact weight and lead to obesity. Examining motives for drinking alcohol and eating palatable foods may facilitate a more integrated understanding of these behaviors during the college years. The current study tested whether shared or distinct (i.e., behavior-specific) motivational mechanisms may explain the occurrence of reward-driven drinking and eating in young adults.

METHODS

A sample of college freshmen (N = 103) stratified by sex, race/ethnicity, and heavy drinking status were selected to participate. Participants completed questionnaires measuring alcohol use, eating behavior, and motives assessed by the Drinking Motives Questionnaire-Revised and Palatable Eating Motives Scale. Confirmatory factor analysis (CFA) tested whether drinking and eating motives were better represented as single latent motives, or two behavior-specific motives. Structural equation modeling (SEM) was used to test the association between motivational factors and behaviors.

RESULTS

Behavior-specific CFA models demonstrated stronger model fit and higher factor loadings than single motive models. SEM models indicated that eating to cope with negative emotions, to enhance positive experiences, to obtain social reinforcement, and to conform with peers were significantly associated with binge eating (p values < .001). Enhancement and social drinking motives were significantly associated with number of weekly drinks (p values < .001).

CONCLUSIONS

While motives for drinking alcohol and eating palatable foods may satisfy common goals, findings suggest motivational mechanisms may be behavior-specific. Enhancement and social motives may be important factors to target in prevention programs for both drinking and binge eating.

The Utility of a Brief Web-Based Prevention Intervention as a Universal Approach for Risky Alcohol Use in College Students: Evidence of Moderation by Family History

Background: Alcohol use on college campuses is prevalent and contributes to problems that affect the health, emotional wellbeing, and academic success of college students. Risk factors, such as family history of alcohol problems, predict future alcohol problems, but less is known about their potential impact on intervention effectiveness. The purpose of this study was to examine the effect of an intervention implemented in a non-randomized sample of drinking and non-drinking college freshmen.

Methods: Freshmen college students recruited for the intervention study (n = 153) completed a web-adaptation of the Brief Alcohol Screening and Intervention for College Students (BASICS) at the start of spring semester. We compared their 30-days post-intervention alcohol initiation, number of drinking days (DAYS), drinks per occasion (DRINKS), maximum drinks in 24 h (MAX24) and alcohol use disorder symptoms (AUDsx) to 151 comparison participants retrospectively matched on demographics and baseline alcohol use behaviors. We also tested baseline DRINKS, DAYS, AUDsx, MAX24, and parental family history (PFH) of alcohol problems as moderators of the effect of the intervention.

Results: At follow-up, intervention participants had lower rates of AUDsx than comparison participants, especially among baseline drinkers. Among participants drinking 3+ days/month at baseline, intervention participants showed fewer DAYS at follow-up than the comparison group participants. BASICS was also associated with a decreased likelihood of initiation among baseline non-drinkers. PFH significantly interacted with treatment group, with positive PFH intervention participants reporting significantly fewer AUDsx at follow-up compared to positive PFH comparison participants. We found no evidence for an effect of the intervention on DRINKS or MAX24 in our analyses.

Conclusions: Results suggest some indication that novel groups, such as non-drinkers, regular drinkers, and PFH positive students may experience benefits from BASICS. Although conclusions were limited by lack of randomization and short follow-up period, PFH positive and low to moderate drinking groups represent viable targets for future randomized studies.

Effectiveness of a Combined Web-Based and Ecological Momentary Intervention for Incoming First-Year University Students: Protocol for a 3-Arm Randomized Controlled Trial

BACKGROUND

Alcohol use among university students is common, and those who drink often choose to drink heavily (ie, 4 or more drinks per session for women or 5 or more for men). Web-based interventions (WBIs), in which students complete assessments and receive personalized feedback about their alcohol use, and ecological momentary interventions (EMIs), which use mobile devices as a method of delivering intervention information, are 2 methods that have had some success in reducing alcohol use among university students.

OBJECTIVE

The aim of this study was to investigate the effectiveness of a combined WBI and EMI intervention to reduce alcohol use among university students.

METHODS

The study is a 3-arm randomized controlled trial. Participants will be randomized into either a WBI+EMI condition, a WBI-only condition, or an assessment-only control. Our sample will consist of first-year university students, recruited through 5 residential colleges at the University of Otago, New Zealand. All participants will complete an online survey at baseline (ie, before Orientation Week); those in the WBI-only and WBI+EMI conditions will immediately receive personalized feedback (ie, the WBI), whereas participants in the assessment-only condition will receive no feedback. In addition, participants randomized into the WBI+EMI, but not those in the WBI-only or assessment-only groups, will receive 8 Orientation Week (2 per day on nights with large social events) and 6 academic year EMIs (delivered fortnightly). Participants in all conditions will complete brief surveys at the end of the first and second semester and report their weekend alcohol use fortnightly throughout each semester via ecological momentary assessments.

RESULTS

The primary hypothesis is that participants in the WBI+EMI group will consume significantly fewer drinks during weekends in their first semester at university compared with WBI-only and assessment-only groups. Secondary hypotheses are that, when compared with the WBI-only and assessment-only groups, the WBI+EMI group will report consuming fewer drinks during Orientation Week, report experiencing fewer negative alcohol-related consequences after first semester, and report lower Alcohol Use Disorder Identification Test-Consumption scores following their first semester.

CONCLUSIONS

This study adds to a growing body of work investigating the utility of WBIs and EMIs in curbing alcohol consumption. In addition, the study will help to inform policy approaches aimed at curbing alcohol consumption and alcohol-related harm in university students.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000015246; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374104&isReview=true (Archived by WebCite at http://www.webcitation.org/6z9jRLTz6).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/10164.

Web-Based Alcohol Intervention in First-Year College Students: Efficacy of Full-Program Administration Prior to Second Semester

BACKGROUND

Commercially available, web-based interventions for the prevention of alcohol use are being adopted for universal use with first-year college students, yet few have received empirical evaluation.

OBJECTIVES

This randomized controlled trial investigated the effectiveness of a novel, commercially available, personalized web-based alcohol intervention, Alcohol-Wise (version 4.0, 3^rd Millennium Classrooms), on multiple measures of alcohol consumption, alcohol consequences, alcohol expectancies, academic achievement, and adaptation to college in first-year students.

METHOD

Participants received Alcohol-Wise either prior to first semester or were waitlisted and received the intervention second semester. As longitudinal effectiveness was of interest, follow-up surveys were conducted 10 weeks (n = 76) and 24 weeks (n = 64) following the web-based alcohol intervention.

RESULTS

Completion of Alcohol-Wise had effects on academic achievement. Specifically, at the 24 week follow-up, academic achievement was higher in participants who received the intervention first semester of their freshman year as compared to the waitlist control. The incremental rise in heavy episodic drinking during the first semester of college was also reduced in waitlisted participants by Alcohol-Wise administration prior to second semester. Conclusion/Importance: Implications for the timing of web-based alcohol interventions to include administration prior to both first and second semesters of the freshman year are discussed.

Web-based alcohol intervention for nightclub patrons: Opposite effects according to baseline alcohol use disorder classification

BACKGROUND

This study aimed to test the effectiveness of a Web-based intervention in preventing alcohol abuse among nightclub patrons.

METHODS

A probabilistic sample of the patrons of 31 nightclubs in São Paulo, Brazil, was invited to participate in an online screening using the Alcohol Use Disorders Identification Test (AUDIT). A total of 1057 patrons met the inclusion criteria to participate in the randomized controlled trial, with data collection at 0, 3, 6, and 12 months. At baseline, participants were classified into 2 AUDIT score groups: a "high-risk" group (AUDIT ≥8; 44%) and a "low-risk" group (AUDIT <8; 56%). In both groups, the intervention subgroup was exposed once to a personalized normative feedback screen with information on the participant's alcohol consumption and its potential consequences.

RESULTS

After 12 months, no differences were found between the intervention and the control conditions in either risk group. In the "high-risk" group, there were significant reductions of both the AUDIT score and the prevalence of binge drinking (BD) over time in both the control and the intervention subgroups. In addition, an effect of the intervention was observed at 6 months, i.e., there was an estimated 13% reduction in the AUDIT score in favor of the intervention subgroup (odds ratio [OR] = 0.87; 95% confidence interval [CI]: 0.76, 1.00). In the "low-risk" group, both the control patrons and those receiving the intervention had increased AUDIT scores.

CONCLUSION

The results suggest that the time effect of participating in the study may have had a beneficial outcome in reducing harmful drinking among patrons in the "high-risk" group. The intervention is not recommended to the "low-risk" group.

Effectiveness of a web-based intervention in reducing binge drinking among nightclub patrons

OBJECTIVE

To evaluate the effectiveness of a web-based intervention in reducing binge drinking among nightclub patrons after six months.

METHODS

We carried out a website survey with probabilistic sample in 31 nightclubs in the city of São Paulo, Brazil, which originated a randomized controlled trial with 1,057 participants. Those classified as problem drinkers (n = 465) using the Alcohol Use Disorders Identification Test were randomized into two study groups – intervention and control. The web-based intervention consisted of exposing the participants to a normative feedback screen about their alcohol consumption, characterizing the risks associated with amount consumed, money spent on drinks, drinking and driving, risk classification of Alcohol Use Disorders Identification Test, and tips to reduce damage.

RESULTS

There was a significant reduction in the practice of binge drinking in the week estimated at 38% among participants in the intervention group after six months (p < 0.05). However, there was no significant reduction in the outcomes when we analyzed the intervention and control groups and at baseline and after sixth months, simultaneously.

CONCLUSIONS

We cannot conclude that digital tools reduce the pattern of binge drinking among party goers in São Paulo. More studies are needed with this methodology because of its attractiveness to this type of group, given the privacy and speed that personalized information is transmitted.

Text messaging as an adjunct to a web-based intervention for college student alcohol use: A preliminary study

Brief, web-based motivational interventions have shown promising results for reducing alcohol use and associated harm among college students. However, findings regarding which alcohol use outcomes are impacted are mixed and effects tend to be small to moderate, with effect sizes decreasing over longer-term follow-up periods. As a result, these interventions may benefit from adjunctive strategies to bolster students' engagement with intervention material and to extend interventions beyond initial contacts into student's daily lives. This study tested the efficacy of text messaging as an adjunct to a web-based intervention for heavy episodic drinking college students.

METHODS

One-hundred and thirteen undergraduate student risky drinkers recruited from an introductory psychology class were randomly assigned to one of three conditions-assessment only (AO), web intervention (WI), and web intervention plus text messaging (WI+TXT). Heavy drinking episodes (HDEs), weekend quantity per occasion, and alcohol-related consequences were assessed at baseline and one month follow-up. Univariate analysis of covariance (ANCOVA) was used to assess the influence of condition assignment on 1-month outcomes, controlling for baseline variables.

RESULTS

Planned contrasts showed that those in the WI+TXT condition showed significantly less weekend drinking than those in the AO and WI conditions. Although those in the WI+TXT condition showed significantly fewer HDEs compared to AO, it was not significantly different than the WI only condition. No differences were observed on alcohol-related problems.

DISCUSSION

These findings provide partial support for the view that text messaging may be a useful adjunct to web-based interventions for reducing alcohol consumption among student drinkers.

Personalised digital interventions for reducing hazardous and harmful alcohol consumption in community-dwelling populations

BACKGROUND

Excessive alcohol use contributes significantly to physical and psychological illness, injury and death, and a wide array of social harm in all age groups. A proven strategy for reducing excessive alcohol consumption levels is to offer a brief conversation-based intervention in primary care settings, but more recent technological innovations have enabled people to interact directly via computer, mobile device or smartphone with digital interventions designed to address problem alcohol consumption.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of digital interventions for reducing hazardous and harmful alcohol consumption, alcohol-related problems, or both, in people living in the community, specifically: (i) Are digital interventions more effective and cost-effective than no intervention (or minimal input) controls? (ii) Are digital interventions at least equally effective as face-to-face brief alcohol interventions? (iii) What are the effective component behaviour change techniques (BCTs) of such interventions and their mechanisms of action? (iv) What theories or models have been used in the development and/or evaluation of the intervention? Secondary objectives were (i) to assess whether outcomes differ between trials where the digital intervention targets participants attending health, social care, education or other community-based settings and those where it is offered remotely via the internet or mobile phone platforms; (ii) to specify interventions according to their mode of delivery (e.g. functionality features) and assess the impact of mode of delivery on outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, ERIC, HTA and Web of Knowledge databases; ClinicalTrials.com and WHO ICTRP trials registers and relevant websites to April 2017. We also checked the reference lists of included trials and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effectiveness of digital interventions compared with no intervention or with face-to-face interventions for reducing hazardous or harmful alcohol consumption in people living in the community and reported a measure of alcohol consumption.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 57 studies which randomised a total of 34,390 participants. The main sources of bias were from attrition and participant blinding (36% and 21% of studies respectively, high risk of bias). Forty one studies (42 comparisons, 19,241 participants) provided data for the primary meta-analysis, which demonstrated that participants using a digital intervention drank approximately 23 g alcohol weekly (95% CI 15 to 30) (about 3 UK units) less than participants who received no or minimal interventions at end of follow up (moderate-quality evidence).Fifteen studies (16 comparisons, 10,862 participants) demonstrated that participants who engaged with digital interventions had less than one drinking day per month fewer than no intervention controls (moderate-quality evidence), 15 studies (3587 participants) showed about one binge drinking session less per month in the intervention group compared to no intervention controls (moderate-quality evidence), and in 15 studies (9791 participants) intervention participants drank one unit per occasion less than no intervention control participants (moderate-quality evidence).Only five small studies (390 participants) compared digital and face-to-face interventions. There was no difference in alcohol consumption at end of follow up (MD 0.52 g/week, 95% CI -24.59 to 25.63; low-quality evidence). Thus, digital alcohol interventions produced broadly similar outcomes in these studies. No studies reported whether any adverse effects resulted from the interventions.A median of nine BCTs were used in experimental arms (range = 1 to 22). 'B' is an estimate of effect (MD in quantity of drinking, expressed in g/week) per unit increase in the BCT, and is a way to report whether individual BCTs are linked to the effect of the intervention. The BCTs of goal setting (B -43.94, 95% CI -78.59 to -9.30), problem solving (B -48.03, 95% CI -77.79 to -18.27), information about antecedents (B -74.20, 95% CI -117.72 to -30.68), behaviour substitution (B -123.71, 95% CI -184.63 to -62.80) and credible source (B -39.89, 95% CI -72.66 to -7.11) were significantly associated with reduced alcohol consumption in unadjusted models. In a multivariable model that included BCTs with B > 23 in the unadjusted model, the BCTs of behaviour substitution (B -95.12, 95% CI -162.90 to -27.34), problem solving (B -45.92, 95% CI -90.97 to -0.87), and credible source (B -32.09, 95% CI -60.64 to -3.55) were associated with reduced alcohol consumption.The most frequently mentioned theories or models in the included studies were Motivational Interviewing Theory (7/20), Transtheoretical Model (6/20) and Social Norms Theory (6/20). Over half of the interventions (n = 21, 51%) made no mention of theory. Only two studies used theory to select participants or tailor the intervention. There was no evidence of an association between reporting theory use and intervention effectiveness.

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that digital interventions may lower alcohol consumption, with an average reduction of up to three (UK) standard drinks per week compared to control participants. Substantial heterogeneity and risk of performance and publication bias may mean the reduction was lower. Low-quality evidence from fewer studies suggested there may be little or no difference in impact on alcohol consumption between digital and face-to-face interventions.The BCTs of behaviour substitution, problem solving and credible source were associated with the effectiveness of digital interventions to reduce alcohol consumption and warrant further investigation in an experimental context.Reporting of theory use was very limited and often unclear when present. Over half of the interventions made no reference to any theories. Limited reporting of theory use was unrelated to heterogeneity in intervention effectiveness.

Online and Mobile Interventions for Problem Gambling, Alcohol, and Drugs: A Systematic Review

Online interventions for gambling, alcohol, and illegal drug related problems have been developing at a fast pace over the past decade. Yet, little is known about the content and efficacy of interventions provided entirely online for reducing drug/alcohol use and gambling, or about the characteristics of those who use these interventions. This systematic review aims to describe the characteristics of online interventions, their efficacy, and the profile of their clientele. Documentation was mainly obtained through four scientific databases in psychology, technology, and medical research (PsychINFO, MedLine, Francis, and INSPEC) using three keywords (substances or gambling, intervention, Internet). Of the 4,708 documents initially identified, 18 studies meeting admissibility criteria were retained and analyzed after exclusion of duplicates and non-relevant documents. No study in the review related to problem gambling. The majority of interventions were based upon motivational or cognitive-behavioral theoretical approaches and called upon well-established therapeutic components in the field of addictions. The participants in these studies were generally adults between 30 and 46 years old with a high school education and presenting a high risk or problematic use. More than three quarters of the studies showed a short-term decrease in use that was maintained 6 months later, but only two studies included a 12 months follow-up. Online interventions seem promising and appear to meet the needs of participants who are in the workforce and seeking help for the first time. Long-term efficacy studies should nonetheless be conducted.

A systematic review of eHealth behavioral interventions targeting smoking, nutrition, alcohol, physical activity and/or obesity for young adults

A systematic review of randomized control trials (RCT) was undertaken to evaluate the effectiveness of eHealth behavioral interventions aiming to improve smoking rates, nutrition behaviors, alcohol intake, physical activity levels and/or obesity (SNAPO) in young adults. Seven electronic databases were searched for RCTs published in English from 2000 to April 2015 and evaluating eHealth interventions aiming to change one or multiple SNAPO outcomes, and including young adult (18-35years) participants. Of 2,159 articles identified, 45 studies met the inclusion criteria. Most interventions targeted alcohol (n=26), followed by smoking (n=7), physical activity (n=4), obesity (n=4) and nutrition (n=1). Three interventions targeted multiple behaviors. The eHealth interventions were most often delivered via websites (79.5%). Most studies (n=32) compared eHealth interventions to a control group (e.g. waiting list control, minimal intervention), with the majority (n=23) showing a positive effect on a SNAPO outcome at follow-up. Meta-analysis demonstrated a significantly lower mean number of drinks consumed/week in brief web or computer-based interventions compared to controls (Mean Difference -2.43 [-3.54, -1.32], P<0.0001, n=10). Sixteen studies compared eHealth delivery modes, with inconsistent results across target behaviors and technology types. Nine studies compared eHealth to other modes of delivery (e.g. in person) with all finding no difference in SNAPO outcomes between groups at follow-up. This review provides some evidence for the efficacy of eHealth SNAPO interventions for young adults, particularly in the short-term and for alcohol interventions. But there is insufficient evidence for their efficacy in the longer-term, as well as which mode of delivery is most effective.

Short message service (SMS)-based intervention targeting alcohol consumption among university students: study protocol of a randomized controlled trial

BACKGROUND

Despite significant health risks, heavy drinking of alcohol among university students is a widespread problem; excessive drinking is part of the social norm. A growing number of studies indicate that short message service (SMS)-based interventions are cost-effective, accessible, require limited effort by users, and can enable continuous, real-time, brief support in real-world settings. Although there is emerging evidence for the effect of SMS-based interventions in reducing alcohol consumption, more research is needed. This study aims to test the effectiveness of a newly developed SMS-based intervention targeting excessive alcohol consumption among university and college students in Sweden.

METHODS

The study is a two-arm randomized controlled trial with an intervention (SMS programme) and a control (treatment as usual) group. Outcome measures will be investigated at baseline and at 3-month follow up. The primary outcome is total weekly alcohol consumption. Secondary outcomes are frequency of heavy episodic drinking, highest estimated blood alcohol concentration and number of negative consequences due to excessive drinking.

DISCUSSION

This study contributes knowledge on the effect of automatized SMS support to reduce excessive drinking among students compared with existing support such as Student Health Centres.

TRIAL REGISTRATION

ISRCTN.com, ISRCTN95054707 . Registered on 31 August 2016.

Web-based self-help intervention reduces alcohol consumption in both heavy-drinking and dependent alcohol users: A pilot study

As part of a multicenter project supported by the World Health Organization, we developed a web-based intervention to reduce alcohol use and related problems. We evaluated the predictors of adherence to, and the outcomes of the intervention. Success was defined as a reduction in consumption to low risk levels or to <50% of the baseline levels of number of drinks. From the 32,401 people who accessed the site, 3389 registered and 929 completed the full Alcohol Use Disorders Identification Test (AUDIT), a necessary condition to be considered eligible to take part in the intervention. Based on their AUDIT scores, these participants were classified into: low risk users (LRU; n=319) harmful/hazardous users (HHU; n=298) or suggestive of dependence users (SDU; n=312). 29.1% of the registered users (LRU=42; HHU=90; SDU=82) completed the evaluation form at the end of the six-week period, and 63.5% reported low-risk drinking levels. We observed a significant reduction in alcohol consumption in the HHU (62.5%) and SDU (64.5%) groups in relation to baseline. One month after the intervention, in the follow-up, 94 users filled out the evaluation form, and their rate of success was similar to the one observed in the previous evaluation. Logistic regression analyses indicated that HHU participants presented higher adherence than LRU. Despite a relatively low adherence to the program, its good outcomes and low cost, as well as the high number of people that can be reached by a web-based intervention, suggest it has good cost-effectiveness.

Internet-Based Brief Intervention to Prevent Unhealthy Alcohol Use among Young Men: A Randomized Controlled Trial

Introduction

Alcohol use is one of the leading modifiable morbidity and mortality risk factors among young adults.

Study Design

2 parallel-group randomized controlled trial with follow-up at 1 and 6 months.

Setting/Participants

Internet based study in a general population sample of young men with low-risk drinking, recruited between June 2012 and February 2013.

Intervention: Internet-based brief alcohol primary prevention intervention (IBI). The IBI aims at preventing an increase in alcohol use: it consists of normative feedback, feedback on consequences, calorific value alcohol, computed blood alcohol concentration, indication that the reported alcohol use is associated with no or limited risks for health. Intervention group participants received the IBI. Control group (CG) participants completed only an assessment.

Main Outcome Measures

Alcohol use (number of drinks per week), binge drinking prevalence. Analyses were conducted in 2014–2015.

Results

Of 4365 men invited to participate, 1633 did so; 896 reported low-risk drinking and were randomized (IBI: n = 451; CG: n = 445). At baseline, 1 and 6 months, the mean (SD) number of drinks/week was 2.4(2.2), 2.3(2.6), 2.5(3.0) for IBI, and 2.4(2.3), 2.8(3.7), 2.7(3.9) for CG. Binge drinking, absent at baseline, was reported by 14.4% (IBI) and 19.0% (CG) at 1 month and by 13.3% (IBI) and 13.0% (CG) at 6 months. At 1 month, beneficial intervention effects were observed on the number of drinks/week (p = 0.05). No significant differences were observed at 6 months.

Conclusion

We found protective short term effects of a primary prevention IBI.

Trial Registration

Controlled-Trials.com ISRCTN55991918

Internet-based brief intervention for young men with unhealthy alcohol use: a randomized controlled trial in a general population sample

AIM

To test the efficacy of an internet-based brief intervention (IBI) in decreasing alcohol use among young Swiss men aged 21 years on average.

DESIGN

Two parallel-group randomized controlled trial with a 1 : 1 allocation ratio containing follow-up assessments at 1 and 6 months post-randomization

SETTING

Internet-based study in a general population sample.

PARTICIPANTS

Twenty-one-year-old men from Switzerland with unhealthy alcohol use (> 14 drinks/week or ≥ 6 drinks/occasion at least monthly or Alcohol Use Disorders Identification Test (AUDIT) scores ≥ 8) INTERVENTION: IBI consisting of (1) normative feedback, (2) feedback on consequences of alcohol use, (3) calorific value of reported consumption, (4) computed blood alcohol concentration for reported consumption, (5) indication of risk, (6) information on alcohol and health and (7) recommendations indicating low-risk drinking limits. Control condition: no intervention (assessment only).

MEASUREMENTS

At 1 and 6 months: quantity/frequency questions on alcohol use (primary outcome: number of drinks/week) and binge drinking prevalence; at 6 months: AUDIT score, consequences of drinking (range = 0-12).

FINDINGS

Follow-up rates were 92% at 1 month and 91% at 6 months. At 6 months, participants in the intervention group (n = 367) reported greater reductions in the number of drinks/week than participants in the control group (n = 370) [treatment × time interaction, incidence rate ratio (RR) = 0.86, 95% confidence interval (CI) = 0.78; 0.96], but no significant differences were observed on binge drinking prevalence. There was a favourable intervention effect on AUDIT scores (IRR = 0.93, 95% CI = 0.88; 0.98), but not on the number of consequences (IRR = 0.93, 95% CI = 0.84; 1.03).

CONCLUSIONS

An internet-based brief intervention directed at harmful alcohol use among young men led to a reduction in self-reported alcohol consumption and AUDIT scores compared with a no-intervention control condition (assessment only).

Drinking Patterns and HIV Risk Behaviors Among Black and Latino Men Who Have Sex Within Los Angeles County

Alcohol, the most widely used substance among men who have sex with men (85%), remains an important factor in HIV research among this high-risk population. However, research on alcohol use among Black and Latino men who have sex with men (BLMSM), a population disproportionately affected by HIV in the United States, is limited and inconclusive. This study explored sociodemographic and HIV risk with daily heavy and low-risk drinking patterns among BLMSM. BLMSM (N = 188) aged 18 to 40 years were recruited through social media, local colleges, heteronormative clubs, private men’s groups, gay establishments, and organized events in Los Angeles County. Participants completed self-administered questionnaires. Fisher’s exact tests revealed significant relationships between drinking patterns and condomless insertive anal intercourse (p = .001), race (p < .001), age (p = .02), and perception of alcohol-related HIV risk (p = .007). The Fisher’s exact tests findings for age held true in the multiple regression model (p = .014). Findings suggest that BLMSM who engage in higher risk drinking also engage in alcohol-related HIV risk. Culturally competent interventions should consider including a combined focus to explore the synergy between risky drinking patterns and HIV risk among BLMSM.

Reflections on How a University Binge Drinking Prevention Initiative Supports Alcohol Screening, Brief Intervention, and Referral for Student Alcohol Use

What's Your Cap: Know When to Put a Lid on Drinking (WYC) is a student-led and research-based binge-drinking prevention campaign at the University of Saskatchewan, Canada. It was formed to encourage a culture of alcohol moderation on the university campus through peer-to-peer engagement that emphasizes promotional items and activities of interest to students. Since its development in 2011, WYC has been guided by a logic model that promotes: 1) perceived and actual student drinking norms on campus; 2) benefits of a student-led initiative; and 3) merits of working with community partners. With the release of a clinical guide in Canada for alcohol screening, brief intervention, and referral (SBIR) in 2013, WYC was prompted to consider whether it is a form of population-based SBIR. SBIR is commonly undertaken in the substance use field by health care practitioners, and this paper shares the potential for a student-based SBIR modification on a university campus.

Very-Brief, Web-Based Interventions for Reducing Alcohol Use and Related Problems among College Students: A Review

Very-brief, web-based alcohol interventions have great potential due to their convenience, ease of dissemination, and college students' stated preference for this intervention modality. To address the efficacy of these interventions, we conducted a review of the literature to identify randomized controlled trials (RCTs). Fifteen published reports were included. All RCTs meeting criteria for inclusion tested an intervention that featured personalized feedback on students' patterns of alcohol consumption. This review found some evidence to support the efficacy of very-brief, web-based interventions among college students for alcohol use reduction. Several trials, however, reported no evidence of efficacy and the methods of multiple trials raised concerns about potential bias that may have influenced study results. By contrast, this review did not yield evidence to support the efficacy of very-brief, web-based interventions for reduction of alcohol--related problems among college students. We found evidence to support the efficacy of two main types of intervention content: (a) focused solely on personalized normative feedback designed to correct misconceptions about peer alcohol consumption and (b) multi-component interventions. Future research is needed to test enhancements to very-brief, web-based interventions that feature personalized feedback on patterns of alcohol use and to determine for which types of college drinkers (e.g., heavier or lighter drinkers) these interventions are most efficacious. In addition, future studies are needed to test novel, very-brief, web-based interventions featuring approaches other than personalized feedback. In summary, this review yielded some evidence supporting very-brief, web-based interventions in reducing alcohol use but not related problems in college students. Very-brief, web-based interventions are worth pursuing given their convenience, privacy, and potential public health benefit.

Recruiting U.S. and Canadian college students via social media for participation in a web-based brief intervention study

OBJECTIVE

Recruiting young adults for health research is challenging. Social media provides wide access to potential research participants. We evaluated the feasibility of recruiting students via free message postings on Facebook and Twitter to participate in a web-based brief intervention study. The sample comprised students attending U.S. and Canadian universities.

METHOD

During three semesters, institutional review board-approved recruitment messages were posted in 281 Facebook groups, 7 Facebook pages, and 27 message "tweets" on Twitter.

RESULTS

A total of 708 eligible participants were recruited from Facebook. The mean enrollment rate per Facebook group was 0.21%; the rate was higher for host university groups (1.56%) compared with groups at other universities (0.10%). We recruited seven participants from Twitter. The sample was predominantly female (70%) with a mean age of 20.0 years. There were no significant differences between host university participants recruited through social media and traditional methods. The web-based intervention completion rate was 65%, and participants from the host university were more likely to complete the intervention than were groups at other universities (p = .01).

CONCLUSIONS

Social media provides access to a large number of potential participants, and social media recruitment may be useful to researchers who can harness this broad reach. Facebook recruitment was feasible and free and resulted in a large number of enrolled participants. Social media recruitment for researchers at their own universities may be particularly fruitful. Despite wide access to students with Twitter, recruitment was slow. Social media recruitment allowed us to extend web-based intervention access to students in the United States and Canada.