Brief Alcohol Interventions are Effective through 6 Months: Findings from Marginalized Zero-inflated Poisson and Negative Binomial Models in a Two-step IPD Meta-analysis

Exploratory analysis of blood alcohol concentration-related technology use and drinking outcomes among young adults

BACKGROUND

Mobile health (mHealth) technology use may reduce alcohol use and related negative consequences; however, little is known about its efficacy without prompting from researchers or pay-per-use. This exploratory analysis assessed relationships between mHealth technology use frequency and alcohol-use outcomes.

METHODS

Young adults who drink heavily (N = 97, Mage = 23, 51% male, 64% non-Hispanic White, Mdrinks/week = 21) had the option to use three mHealth technologies (breathalyzer device/app, blood alcohol content estimator app, drink counting via text message) while drinking for 2 weeks. Relationships between alcohol-related outcomes and any, multiple, and specific mHealth technology use across study days and drinking days were evaluated via bivariate correlations and multiple regressions.

RESULTS

Participants used one or more mHealth technologies on approximately 68% of drinking days (33% of field days), with multiple technologies used on 34% of drinking days. Bivariate correlations revealed that a higher percentage of study days with any mHealth technology use was related to higher mean weekly drinks. However, a higher percentage of drinking days with any mHealth technology use was related to lower mean weekly drinks, percent of heavy and high-intensity drinking days, and negative consequences. There were several significant, inverse correlations between alcohol variables and using the mHealth technologies that provided personalized feedback. Multiple regression analyses (holding sex and baseline alcohol variables constant) indicated that a higher percentage of drinking days with any mHealth technology use was related to lower mean weekly drinks and lower percentage of heavy drinking days.

CONCLUSIONS

Using mHealth technologies to moderate drinking without direct prompting from the research team or per-use incentives was related to less overall alcohol use and heavy drinking. This indicates potential real-world engagement with mHealth apps to assist with in-the-moment drinking. Normalizing mHealth technology use during drinking could help curb the public health crisis around harmful alcohol use in young adult populations.

A simulation study of the performance of statistical models for count outcomes with excessive zeros

BACKGROUND

Outcome measures that are count variables with excessive zeros are common in health behaviors research. Examples include the number of standard drinks consumed or alcohol-related problems experienced over time. There is a lack of empirical data about the relative performance of prevailing statistical models for assessing the efficacy of interventions when outcomes are zero-inflated, particularly compared with recently developed marginalized count regression approaches for such data.

METHODS

The current simulation study examined five commonly used approaches for analyzing count outcomes, including two linear models (with outcomes on raw and log-transformed scales, respectively) and three prevailing count distribution-based models (ie, Poisson, negative binomial, and zero-inflated Poisson (ZIP) models). We also considered the marginalized zero-inflated Poisson (MZIP) model, a novel alternative that estimates the overall effects on the population mean while adjusting for zero-inflation. Motivated by alcohol misuse prevention trials, extensive simulations were conducted to evaluate and compare the statistical power and Type I error rate of the statistical models and approaches across data conditions that varied in sample size (N = 100 $$ N=100 $$ to 500), zero rate (0.2 to 0.8), and intervention effect sizes.

RESULTS

Under zero-inflation, the Poisson model failed to control the Type I error rate, resulting in higher than expected false positive results. When the intervention effects on the zero (vs. non-zero) and count parts were in the same direction, the MZIP model had the highest statistical power, followed by the linear model with outcomes on the raw scale, negative binomial model, and ZIP model. The performance of the linear model with a log-transformed outcome variable was unsatisfactory.

CONCLUSIONS

The MZIP model demonstrated better statistical properties in detecting true intervention effects and controlling false positive results for zero-inflated count outcomes. This MZIP model may serve as an appealing analytical approach to evaluating overall intervention effects in studies with count outcomes marked by excessive zeros.

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.

Is the 21st birthday a turning point for alcohol and cannabis use? A monthly study of young adults

BACKGROUND

An important life-course event with respect to alcohol and cannabis use is turning 21 years of age, which may be associated with increases in use of these substances due to celebrations during the month and easier access to them on and following this birthday. We examined the trajectories of alcohol and cannabis use behaviors in the months leading up to, during, and following the 21st birthday month. We also examined whether the use trajectories vary by college status and baseline levels of use.

METHODS

We used data from 203 young adults recruited from the Greater Seattle region who turned 21 during the course of the study. Surveys were administered each month for 24 consecutive months. Measures included the typical number of drinks per week for the past month, the frequency of heavy episodic drinking, the number of cannabis use days, and any simultaneous alcohol and cannabis use. Multilevel spline models were run that estimated linear slopes over time at four intervals: (1) up to 1 month before the 21st birthday month; (2) from 1 month before to the month of the 21st birthday; (3) from the 21st birthday month to 1 month following; and (4) from 1 month following the 21st birthday month through all following months.

RESULTS

Alcohol use, generally, and simultaneous alcohol and cannabis use showed sharp increases from the month before the 21st birthday month to the 21st birthday month and decreases following the 21st birthday month. For cannabis use, there were significant increases in the months leading up to the 21st birthday and no other significant changes during other time intervals. Patterns differed by baseline substance use and college status.

CONCLUSIONS

Findings from the current study have implications for the timing and personalization of prevention and intervention efforts. Event-specific 21st birthday interventions may benefit from incorporating content targeting specific hazardous drinking behaviors in the month prior to the 21st birthday.

Behavioral economic and wellness-based approaches for reducing alcohol use and consequences among diverse non-student emerging adults: study protocol for Project BLUE, a randomized controlled trial

BACKGROUND

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The substance-free activity session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the relaxation training (RT) session teaches relaxation and stress reduction skills.

METHODS

The present study is a randomized 3-group (BAI + SFAS vs. RT + SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women and 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12 months post-intervention. The primary hypothesis is that both BAI + SFAS and RT + SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

DISCUSSION

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04776278.

Behavioral Economic and Wellness-based Approaches for Reducing Alcohol Use and Consequences Among Diverse Non-Student Emerging Adults: Study Protocol for Project BLUE, a Randomized Controlled Trial

Background

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The Substance-Free Activity Session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the Relaxation Training (RT) session teaches relaxation and stress reduction skills.

Methods

The present study is a randomized 3-group (BAI+SFAS vs. RT+SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women & 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12-months post-intervention. The primary hypothesis is that both BAI+SFAS and RT+SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

Discussion

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

ClinicalTrialsgov Identifier

NCT04776278.

Dynamic social network analysis of a brief alcohol intervention trial in heavy-drinking college students shows spillover effects

BACKGROUND

Heavy-drinking college students tend to have close social networks, and there is theoretical and empirical support for the idea that behavior change can spread through those networks via close ties. The objective of this research was to determine whether intervention-induced behavior change in a subset of heavy drinkers in a sociometric (whole) college class-year social network is transmitted to other heavy drinkers in the network, resulting in reduced behavioral risk and change in network ties.

METHODS

We conducted a controlled trial in which most of a first-year college class (N = 1236; 56.9% female) was enrolled, with alcohol use and social network ties measured early in each of three semesters. Following a baseline assessment, the network was divided into two groups, brief motivational intervention (BMI) and natural history control (NHC) according to dormitory residence location. A subset of heavy drinkers in each group was selected, and those in the BMI group received an in-person intervention.

RESULTS

Using stochastic actor-oriented modeling, we found a significant tendency for participants in the BMI group to shed ties with individuals with similar drinking behaviors between the first and second semesters, relative to the NHC group. Furthermore, heavy drinkers with reciprocal ties to intervention recipients in the BMI group showed a significant reduction in drinks per week.

CONCLUSIONS

Individual alcohol interventions appear to have effects both on behavior and network connections among individuals who did not receive the intervention. Continued research is needed to identify the optimal conditions for the diffusion of behavior change.

The selection of statistical models for reporting count outcomes and intervention effects in brief alcohol intervention trials: A review and recommendations

Understanding the efficacy and relative effectiveness of a brief alcohol intervention (BAI) relies on obtaining a credible intervention effect estimate. Outcomes in BAI trials are often count variables, such as the number of drinks consumed, which may be overdispersed (i.e., greater variability than expected based on a given model) and zero-inflated (i.e., greater probability of zeros than expected based on a given model). Ignoring such distribution characteristics can lead to biased estimates and invalid statistical conclusions. In this critical review, we identified and reviewed 64 articles that reported count outcomes from a systematic review of BAI trials for adolescents and young adults from 2013 to 2018. Given many statistical models to choose from when analyzing count outcomes, we reviewed the models used and reporting practices in the BAI trial literature. A majority (61.3%) of analyses with count outcomes used linear models despite violations of normality assumptions; 75.6% of outcome variables demonstrated clear overdispersion. We provide an overview of available count models (Poisson, negative binomial, zero-inflated or hurdle, and marginalized zero-inflated Poisson regression) and formulate practical guidelines for reporting outcomes of BAIs. We provide a visual step-by-step decision guide for selecting appropriate statistical models and reporting results for count outcomes. We list accessible resources to help researchers select an appropriate model with which to analyze their data. Recent advances in count distribution-based models hold promise for evaluating count outcomes to gauge the efficacy and effectiveness of BAIs and identify critical covariates in alcohol epidemiologic research. We recommend that researchers report the distributional properties of count outcomes, such as the proportion of zero counts, and select an appropriate statistical analysis for count outcomes using the provided decision tree. By following these recommendations, future research may yield more accurate, transparent, and reproducible results.

Retrospective Psychometrics and Effect Heterogeneity in Integrated Data Analysis: Commentary on the Special Issue

The current special issue of Prevention Science indicates that momentum in using individual participant data (IPD) and integrative data analysis (IDA) to combine and synthesize findings in prevention science has accelerated over the past decade. In this commentary, we focus on two general themes involving methods for harmonizing measures and findings of effect heterogeneity. We describe methods for harmonization as retrospective psychometrics, requiring that we attend to the assumptions necessary for accurate measurement, but adjust our methods given the constraints of working with existing datasets that often involve different measures in different studies. We point to novel approaches for increasing confidence that semantic matching and empirical modeling used in these studies will yield accurate and valid measurements that can be combined in IDA. We also review findings about effect heterogeneity, emphasizing the importance of using etiologic and action theories to identify and evaluate sources of such effects. We note that all of the papers in this issue deserve careful attention, as they illustrate how prevention scientists are approaching the complexities of IDA and exploring novel methods for overcoming its challenges.

Advancing Intervention and Prevention Research for Behavioral Health Problems Through Data Synthesis

This commentary on the special issue, "Innovations and Applications of Integrative Data Analysis (IDA) and Related Data Harmonization Procedures in Prevention Science" summarizes the utility of data synthesis techniques to elucidate prevention effects in important ways, including effects on low base-rate conditions and effects across multiple small-scale studies of preventive interventions, long-term and crossover effects of preventive interventions, and addressing for whom preventive interventions work, and for how long. In addition, articles tackle methodological challenges by integrating and harmonizing data. Much progress has occurred in the past 5 years. We consider in this commentary the full collection of papers in the special issue, and their ongoing contributions of data synthesis methods for advancing research on the prevention of mental, emotional, and behavioral health problems. We organize our observations by several themes noted across the papers. We also highlight the National Institute of Mental Health's investments that align with many of the efforts summarized here to advance our understanding of prevention research.

Cross-Tailoring Integrative Alcohol and Risky Sexual Behavior Feedback for College Students: Protocol for a Hybrid Type 1 Effectiveness-Implementation Trial

BACKGROUND

Underage drinking and related risky sexual behavior (RSB) are major public health concerns on United States college campuses. Although technology-delivered personalized feedback interventions (PFIs) are considered a best practice for individual-level campus alcohol prevention, there is room for improving the effectiveness of this approach with regard to alcohol-related RSB.

OBJECTIVE

The aims of this study are to (1) evaluate the impact of a brief PFI that integrates content on alcohol use and RSB and is adapted to include a novel cross-tailored dynamic feedback (CDF) component for at-risk first-year college students and (2) identify implementation factors critical to the CDF's success to facilitate future scale-up in campus settings.

METHODS

This study uses a hybrid type 1 effectiveness-implementation design and will be conducted in 3 phases. Phase 1 is a stakeholder-engaged PFI+CDF adaptation guided by focus groups and usability testing. In phase 2, 600 first-year college students who drink and are sexually active will be recruited from 2 sites (n=300 per site) to participate in a 4-group randomized controlled trial to examine the effectiveness of PFI+CDF in reducing alcohol-related RSB. Eligible participants will complete a baseline survey during the first week of the semester and follow-up surveys at 1, 2, 3, 6, and 13 months post baseline. Phase 3 is a qualitative evaluation with stakeholders to better understand relevant implementation factors.

RESULTS

Recruitment and enrollment for phase 1 began in January 2022. Recruitment for phases 2 and 3 is planned for the summer of 2023 and 2024, respectively. Upon collection of data, the effectiveness of PFI+CDF will be examined, and factors critical to implementation will be evaluated.

CONCLUSIONS

This hybrid type 1 trial is designed to impact the field by testing an innovative adaptation that extends evidence-based alcohol programs to reduce alcohol-related RSB and provides insights related to implementation to bridge the gap between research and practice at the university level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05011903; https://clinicaltrials.gov/ct2/show/NCT05011903.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43986.

Does abstaining from alcohol in high school moderate intervention effects for college students? Implications for tiered intervention strategies

Brief motivational intervention (BMI) and personalized feedback intervention (PFI) are individual-focused brief alcohol intervention approaches that have been proven efficacious for reducing alcohol use among college students and young adults. Although the efficacy of these two intervention approaches has been well established, little is known about the factors that may modify their effects on alcohol outcomes. In particular, high school drinking may be a risk factor for continued and heightened use of alcohol in college, and thus may influence the outcomes of BMI and PFI. The purpose of this study was to investigate whether high school drinking was associated with different intervention outcomes among students who received PFI compared to those who received BMI. We conducted moderation analyses examining 348 mandated students (60.1% male; 73.3% White; and 61.5% first-year student) who were randomly assigned to either a BMI or a PFI and whose alcohol consumption was assessed at 4-month and 15-month follow-ups. Results from marginalized zero-inflated Poisson models showed that high school drinking moderated the effects of PFI and BMI at the 4-month follow-up but not at the 15-month follow-up. Specifically, students who reported no drinking in their senior year of high school consumed a 49% higher mean number of drinks after receiving BMI than PFI at the 4-month follow-up. The results suggest that alcohol consumption in high school may be informative when screening and allocating students to appropriate alcohol interventions to meet their different needs.