In pursuit of a self-sustaining college alcohol intervention: Deploying gamified PNF in the real world

Examining the viewing pattern of Web-delivered personalized feedback interventions aimed at reducing alcohol-related risky sexual behavior among young adults

OBJECTIVE

The present study examined young adults' completion of the Web-based intervention content in a randomized trial that tested two Personalized Feedback Interventions (PFIs) for alcohol use and risky sex behavior (RSB).

METHOD

Data are from a study that evaluated efficacy of two Web-delivered PFIs (combined PFI and integrated PFI) among 269 sexually active young adults between the ages of 18 and 25. We described the view patterns of the Web-based intervention and examined if baseline sociodemographic and alcohol- and sex-related behavioral factors were associated with the completion of PFI.

RESULTS

Many participants viewed the intervention more than one time, and the majority finished all intervention pages in at least one session. Older participants and participants who drink more frequently prior to or during sex were more likely to complete.

CONCLUSIONS

Most participants, especially the young adults who were at higher risk, utilized the intervention contents as intended.

Therapeutic Content of Mobile Phone Applications for Substance Use Disorders: An Umbrella Review

Mobile phone applications (MPAs) for substance use disorder (SUD) treatment are increasingly used by patients. Although pilot studies have shown promising results, multiple previous systematic reviews noted insufficient evidence for MPA use in SUD treatment-many of the previously published reviews evaluated different trials. Subsequently, we aimed to conduct an umbrella review of previously published reviews investigating the efficacy of MPAs for SUD treatment, excluding nicotine/tobacco because umbrella reviews have been done in this population and the nicotine/tobacco MPA approach often differs from SUD-focused MPAs. No previous reviews have included a statistical meta-analysis of clinical trials to quantify an estimated overall effect. Seven reviews met inclusion criteria, and 17 unique studies with available data were taken from those reviews for the meta-analysis. Overall, reviews reported a lack of evidence for recommending MPAs for SUD treatment. However, MPA-delivered recovery support services, cognitive behavioral therapy, and contingency management were identified across multiple reviews as having promising evidence for SUD treatment. Hedges g effect size for an MPA reduction in substance use-related outcomes relative to the control arm was insignificant (0.137; 95% CI, -0.056 to 0.330; P=.16). In subgroup analysis, contingency management (1.29; 95% CI, 1.088-1.482; τ 2=0; k=2) and cognitive behavioral therapy (0.02; 95% CI, 0.001-0.030; τ 2=0; k=2) were significant. Although contingency management's effect was large, both trials were small (samples of 40 and 30). This review includes an adapted framework for the American Psychiatric Association's MPA guidelines that clinicians can implement to review MPAs critically with patients.

Mobile apps to reduce depressive symptoms and alcohol use in youth: A systematic review and meta-analysis: A systematic review

Background

Among youth, symptoms of depression, anxiety, and alcohol use are associated with considerable illness and disability. Youth face many personal and health system barriers in accessing mental health care. Mobile applications (apps) offer youth potentially accessible, scalable, and anonymous therapy and other support. Recent systematic reviews on apps to reduce mental health symptoms among youth have reported uncertain effectiveness, but analyses based on the type of app-delivered therapy are limited.

Objectives

We conducted this systematic review with youth co-researchers to ensure that this review addressed the questions that were most important to them. The objective of this review is to synthesize the best available evidence on the effectiveness of mobile apps for the reduction of depressive symptoms (depression, generalized anxiety, psychological distress) and alcohol use among youth.

Search Methods

We conducted electronic searches of the following bibliographic databases for studies published between January 1, 2008, and July 1, 2022: MEDLINE (via Ovid), Embase (via Ovid), PsycINFO (via Ovid), CINAHL (via EBSCOHost), and CENTRAL (via the Cochrane Library). The search used a combination of indexed terms, free text words, and MeSH headings. We manually screened the references of relevant systematic reviews and included randomized controlled trials (RCTs) for additional eligible studies, and contacted authors for full reports of identified trial registries or protocols.

Selection Criteria

We included RCTs conducted among youth aged 15-24 years from any setting. We did not exclude populations on the basis of gender, socioeconomic status, geographic location or other personal characteristics. We included studies which assessed the effectiveness of app-delivered mental health support or therapy interventions that targeted the management of depressive disorders and/or alcohol use disorders. We excluded apps that targeted general wellness, apps which focused on prevention of psychological disorders and apps that targeted bipolar disorder, psychosis, post-traumatic stress disorder, attention-deficit hyperactivity disorder, substance use disorders (aside from alcohol), and sleep disorders. Eligible comparisons included usual care, no intervention, wait-list control, alternative or controlled mobile applications. We included studies which reported outcomes on depressive symptoms, anxiety symptoms, alcohol use and psychological distress over any follow-up period.

Data Collection and Analysis

We standardized the PICO definitions (population, intervention, comparison, and outcome) of each included study and grouped studies by the type of therapy or support offered by the app. Whenever app design and clinical homogeneity allowed, we meta-analyzed outcomes using a random-effects model. Outcome data measured using categorical scales were synthesized using odds ratios. Outcome data measured using continuous scales were synthesized as the standardized mean difference. We assessed the methodological quality of each included study using the Cochrane Risk of Bias 2.0 tool and we assessed certainty of the evidence using the GRADE approach.

Main Results

From 5280 unique citations, we included 36 RCTs published in 37 reports and conducted in 15 different countries (7984 participants). Among the 36 included trials, we assessed two with an overall low risk of bias, 8 trials with some concern regarding risk of bias, and 26 trials with a high risk of bias. Interventions varied in the type of therapy or supports offered. The most common intervention designs employed mindfulness training, cognitive behavioral therapy (CBT), or a combination of the two (mindfulness + CBT). However, other interventions also included self-monitoring, medication reminders, cognitive bias modification or positive stimulation, dialectical behavioral therapy, gamified health promotion, or social skill building. Mindfulness apps led to short term improvements in depressive symptoms when compared to a withheld control (SMD = -0.36; 95% CI [-0.63, -0.10]; p = 0.007, n = 3 RCTs, GRADE: very low certainty) and when compared to an active control (SMD = -0.27; 95% CI [-0.53, -0.01]; p = 0.04, n = 2 RCTs, GRADE: very low). Apps delivering this type of support also significantly improved symptoms of anxiety when compared to a withheld control (SMD = -0.35; 95% CI [-0.60, -0.09]; p = 0.008, n = 3 RCTs, GRADE: very low) but not when compared to an active control (SMD = -0.24; 95% CI [-0.50, 0.02]; p = 0.07, n = 2 RCTs, GRADE: very low). Mindfulness apps showed improvements in psychological stress that approached statistical significance among participants receiving the mindfulness mobile apps compared to those in the withheld control (SMD = -0.27; 95% CI [-0.56, 0.03]; p = .07, n = 4 RCTs, GRADE: very low). CBT apps also led to short-term improvements in depressive symptoms when compared to a withheld control (SMD = -0.40; 95% CI [-0.80, 0.01]; p = 0.05, n = 2 RCTs, GRADE: very low) and when compared to an active control (SMD = -0.59; 95% CI [-0.98, -0.19]; p = 0.003, n = 2 RCTs, GRADE: very low). CBT-based apps also improved symptoms of anxiety compared to a withheld control (SMD = -0.51; 95% CI [-0.94, -0.09]; p = 0.02, n = 3 RCTs, GRADE: very low) but not when compared to an active control (SMD = -0.26; 95% CI [-1.11, 0.59]; p = 0.55, n = 3 RCTs, GRADE: very low). Apps which combined mindfulness and CBT did not significantly improve symptoms of depression (SMD = -0.20; 95% CI [-0.42, 0.02]; p = 0.07, n = 2 RCTs, GRADE: very low) or anxiety (SMD = -0.21; 95% CI [-0.49, 0.07]; p = 0.14, n = 2 RCTs, GRADE: very low). However, these apps did improve psychological distress (SMD = -0.43; 95% CI [-0.74, -0.12]; p = 0.006, n = 2 RCTs, GRADE: very low). The results of trials on apps to reduce alcohol use were inconsistent. We did not identify any harms associated with the use of apps to manage mental health concerns. All effectiveness results had a very low certainty of evidence rating using the GRADE approach, meaning that apps which deliver therapy or other mental health support may reduce symptoms of depression, anxiety and psychological distress but the evidence is very uncertain.

Authors' Conclusions

We reviewed evidence from 36 trials conducted among youth. According to our meta-analyses, the evidence is very uncertain about the effect of apps on depression, anxiety, psychological distress, and alcohol use. Very few effects were interpreted to be of clinical importance. Most of the RCTs were small studies focusing on efficacy for youth at risk for depressive symptoms. Larger trials are needed to evaluate effectiveness and allow for further analysis of subgroup differences. Longer trials are also needed to better estimate the clinical importance of these apps over the long term.

Digital interventions for substance use disorders in young people: rapid review

BACKGROUND

Young people are disproportionately more likely than other age groups to use substances. The rise in substance use and related harms, including overdose, during the Covid-19 pandemic has created a critical need for more innovative and accessible substance use interventions. Digital interventions have shown effectiveness and can provide more engaging, less stigmatizing, and accessible interventions that meet the needs of young people. This review provides an overview of recent literature on the nature of recently published digital interventions for young people in terms of technologies used, substances targeted, intended outcomes and theoretical or therapeutic models employed.

METHODS

Rapid review methodology was used to identify and assess the literature on digital interventions for young people. An initial keyword search was conducted using MEDLINE the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA) and PROSPERO for the years 2015-2020, and later updated to December 2021. Following a title/abstract and full-text screening of articles, and consensus decision on study inclusion, the data extraction process proceeded using an extraction grid developed for the study. Data synthesis relied on an adapted conceptual framework by Stockings, et al. that involved a three-level treatment spectrum for youth substance use (prevention, early intervention, and treatment) for any type of substance.

RESULTS

In total, the review identified 43 articles describing 39 different digital interventions. Most were early interventions (n = 28), followed by prevention interventions (n = 6) and treatment interventions (n = 5). The identified digital technologies included web-based (n = 14), game-based (n = 10), mobile-based (n = 7), and computer-based (n = 5) technologies, and virtual reality (n = 3). Most interventions targeted alcohol use (n = 20) followed by tobacco/nicotine (n = 5), cannabis (n = 2), opioids (n = 2), ketamine (1) and multiple, or any substances (n = 9). Most interventions used a personalized or normative feedback approach and aimed to effect behaviour change as the intended outcome. Interestingly, a harm reduction approach guided only one of the 39 interventions.

CONCLUSIONS

While web-based interventions represented the most common type of technology, more recently developed immersive and interactive technologies such as virtual reality and game-based interventions call for further exploration. Digital interventions focused mainly on alcohol use, reflecting less concern for tobacco, cannabis, co-occurring substance use, and illicit drug use. Specifically, the recent exacerbation in the opioid crisis throughout North American underlines the urgent need for more prevention-oriented digital interventions for opioid use. The uptake of digital interventions among youth also depends on the incorporation of harm reduction approaches.

The Impact of Mobile Technology-Delivered Interventions on Youth Well-being: Systematic Review and 3-Level Meta-analysis

BACKGROUND

Rates of mental health problems among youth are high and rising, whereas treatment seeking in this population remains low. Technology-delivered interventions (TDIs) appear to be promising avenues for broadening the reach of evidence-based interventions for youth well-being. However, to date, meta-analytic reviews on youth samples have primarily been limited to computer and internet interventions, whereas meta-analytic evidence on mobile TDIs (mTDIs), largely comprising mobile apps for smartphones and tablets, have primarily focused on adult samples.

OBJECTIVE

This study aimed to evaluate the effectiveness of mTDIs for a broad range of well-being outcomes in unselected, at-risk, and clinical samples of youth.

METHODS

The systematic review used 5 major search strategies to identify 80 studies evaluating 83 wellness- and mental health-focused mTDIs for 19,748 youth (mean age 2.93-26.25 years). We conducted a 3-level meta-analysis on the full sample and a subsample of the 38 highest-quality studies.

RESULTS

Analyses demonstrated significant benefits of mTDIs for youth both at posttest (g=0.27) and follow-up (range 1.21-43.14 weeks; g=0.26) for a variety of psychosocial outcomes, including general well-being and distress, symptoms of diverse psychological disorders, psychosocial strategies and skills, and health-related symptoms and behaviors. Effects were significantly moderated by the type of comparison group (strongest for no intervention, followed by inert placebo or information-only, and only marginal for clinical comparison) but only among the higher-quality studies. With respect to youth characteristics, neither gender nor pre-existing mental health risk level (not selected for risk, at-risk, or clinical) moderated effect sizes; however, effects increased with the age of youth in the higher-quality studies. In terms of intervention features, mTDIs in these research studies were effective regardless of whether they included various technological features (eg, tailoring, social elements, or gamification) or support features (eg, orientation, reminders, or coaching), although the use of mTDIs in a research context likely differs in important ways from their use when taken up through self-motivation, parent direction, peer suggestion, or clinician referral. Only mTDIs with a clear prescription for frequent use (ie, at least once per week) showed significant effects, although this effect was evident only in the higher-quality subsample. Moderation analyses did not detect statistically significant differences in effect sizes based on the prescribed duration of mTDI use (weeks or sessions), and reporting issues in primary studies limited the analysis of completed duration, thereby calling for improved methodology, assessment, and reporting to clarify true effects.

CONCLUSIONS

Overall, this study's findings demonstrate that youth can experience broad and durable benefits of mTDIs, delivered in a variety of ways, and suggest directions for future research and development of mTDIs for youth, particularly in more naturalistic and ecologically valid settings.

Serious games supporting the prevention and treatment of alcohol and drugs consumption in youth: a scoping review (Preprint)

Background

The consumption of alcohol and drugs, particularly in adolescents and young adults, has increased worldwide in the last several years, representing a significant public health challenge. Serious games have the potential to support preventive and treatment interventions for substance use, facilitating the acquisition of relevant knowledge and the motivation for changes in attitudes and behaviors regarding substance consumption.

Objective

This scoping review aims to analyze a set of 7 relevant characteristics of current serious games designed to support the prevention and treatment of alcohol and drug consumption in adolescents and young adults—the substance addressed, the type of intervention, the theoretical basis, the computational techniques used, the mechanism for data security and privacy, the evaluation procedure followed, and the main results obtained.

Methods

The review was performed by following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Data were retrieved from January 2010 to May 2022, using PubMed, Scopus (Elsevier), IEEE Xplore, and ACM Digital as data sources. The eligibility criteria included studies that described serious games designed to support the prevention or treatment of alcohol and drug consumption, targeted a population aged between 12 and 30 years, and included an evaluation procedure. Authors (JMM and IEEC) individually screened the titles and abstracts, and then full articles were reviewed for a final inclusion decision.

Results

A total of 629 records were obtained, and 29 (4.6%) fulfilled the inclusion criteria. Most of the serious games (14/29, 48%) were focused on the prevention or treatment of alcohol use. The type of intervention that was the most supported was prevention (18/29, 62%), and most studies mentioned the theory, theoretical construct, or therapeutic technique used as a foundation (22/29, 76%). Most of the studies only provided information about the platform for execution (23/29, 79%), and few described the use of computational techniques, such as virtual reality or motion-based interaction (5/29, 17%). A small set of studies (10/29, 34%) explicitly mentioned how data security and privacy were addressed. Most of the reported evaluation protocols were pilot studies (11/29, 38%), followed by randomized controlled trials (10/29, 34%), and the reported results were positive in terms of acceptability, usability, and efficacy. However, more research is needed to assess long-term effects.

Conclusions

Given the increasing interest in the use of serious games as digital interventions to support the prevention or treatment of substance use, knowing their main features is highly important. This review highlights whether and how current serious games incorporate 7 key features that are useful to consider for the further development of the area.

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

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

Integrating social media inspired features into a personalized normative feedback intervention combats social media-based alcohol influence

BACKROUND

Research suggests that the social media platforms popular on college campuses may reflect, reinforce, and even exacerbate heavy drinking practices among students. The present study was designed to directly examine: (1) whether exposure to alcohol-related content on social media diminishes the efficacy of a traditional web-based personalized normative feedback (PNF) alcohol intervention among first-year drinkers; and (2) if social media inspired features and digital game mechanics can be integrated into a PNF intervention to combat social media-based alcohol influence and increase efficacy.

METHOD

Alcohol experienced first-year college students (N = 223) completed a pre-survey that assessed exposure to alcohol-related content and social media and were randomized to 1 of 3 web-based alcohol PNF conditions (traditional, gamified only, or social media inspired gamified). One month later, participants' alcohol consumption was reassessed.

RESULTS

Among participants who received traditional PNF, social media-based alcohol exposure interacted with pre-intervention drinking such that traditional PNF was less effective in reducing drinking among heavier drinkers reporting greater exposure to alcohol-related social media content. Further, when regression models compared the efficacy of all three conditions, the social media inspired gamified PNF condition was significantly more effective in reducing drinking than was traditional PNF among moderate and heavy drinkers reporting greater exposure to alcohol on social media.

CONCLUSION

Although additional research is needed, these findings suggest that representing the population of students on whom normative statistics are based with social media-like user avatars and profiles may enhance the degree to which alcohol PNF is relatable and believable among high-risk students.

Systematic Review of Smartphone Apps as a mHealth Intervention to Address Substance Abuse in Adolescents and Adults

BACKGROUND

Substance abuse represents a foremost national concern for adolescents and adults; investigators have implemented a variety of interventions, delivered with both in-person and mobile-based apps' modalities. The electronic techniques could be more effective because they avoid the cost, privacy, and accessibility issues associated with in-person intervention. To address this issue, a systematic review of the scientific evidence relative to the efficacy of app-based interventions delivered by mobile devices (smartphones) to reduce substance abuse in adolescents and adults was carried out.

METHODS

To identify relevant studies published from 2005 to 2019, a comprehensive search was conducted. Databases that were searched include CINAHL, Cochrane CENTRAL, Embase, PsycINFO, PubMed, and Web of Science. Keywords and relevant controlled vocabulary terms related to substance abuse and technology were included. Studies were included if they had examined reductions in substance abuse and problem behaviors as a primary outcome with app-based interventions delivered to adolescents and adults.

RESULTS

The initial search yielded 21,641 articles, duplicates were removed, and 14,797 citations remained; title/abstract screening yielded 190 full-text articles. One hundred seventy-three were excluded because they did not meet the inclusion criteria, leaving 17 final articles to be analyzed in this review. Use of app-based interventions showed some evidence of effectiveness in reducing substance abuse in the adolescent adult population.

CONCLUSION

Most intervention studies analyzed focused on alcohol reduction. Further research is needed on diverse substance abuse utilizing larger sample sizes, longitudinal studies, and theoretical foundations on the practice of delivering interventions using mobile-based apps.

Prospective Relationships Between Objectively Assessed Social Media Use, Drinking Norms, and Alcohol Consumption Among First-Year Students

OBJECTIVE

Previous research has linked social media involvement and alcohol use among college students. However, this literature has been limited by self-report measures of social media use, cross-sectional data, inadequate attention to potential moderators and mediators, and unclear implications for interventions. To improve and extend this work, students' (N = 297) daily time on Facebook, Twitter, Instagram, and Snapchat during the transition into college were assessed objectively and examined as predictors of later drinking.

METHOD

Time spent on social media overall and on each individual platform between August and September were examined as predictors of alcohol consumption in March. Perceptions of peer drinking norms in October were examined as a potential mediator of these relationships, and sex as a potential moderator.

RESULTS

Students spent the most daily time on Snapchat, followed by Instagram. The results indicated that among men, but not women, daily social media time during the transition into college predicted second semester drinking. This relationship was mediated by perceptions of same-sex student drinking norms. Analysis of individual platforms revealed that daily time on Snapchat drove the relationships among men.

CONCLUSIONS

Greater time on social media during the transition to college, and on Snapchat in particular, predicted increases in perceptions of peer drinking norms and, in turn, greater alcohol consumption among men only. These findings carry precise implications for interventions seeking to reduce alcohol-related risks among first-year men and underscore the need for additional research examining developmental factors and social media user experiences that may explain the sex-specific patterns of relationships observed.

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.

Temporal, Sex-Specific, Social Media-Based Alcohol Influences during the Transition to College

The transition to college is an important developmental phase, usually met with increased social desirability, access to alcohol, and new peer groups. Recently, research has utilized social media as a predictor of events during college, but few have assessed how social media can influence alcohol use during the transition to college. Methods: Participants (N = 320) were recruited prior to entering their first year of college. Participants were 18 years old, 60.7% were women, with 46.3% identifying as White, 16.5% Hispanic, 14.9% Asian, 9.5% Black, and 7.6% other. Each participant was assessed three times: prior to matriculation, first semester, and second semester of their freshman year. We assessed the effect of exposure to alcohol content via social media on long-term trajectories of alcohol use. We also assessed self-reported sex as a moderator. Results: Exposure to alcohol content (over and above one's own posting of alcohol content) was associated with greater frequency of drinking during the transition to college. In the multi-group model, exposure to alcohol content was associated with greater drinking prior to matriculation for men. However, for women, exposure to alcohol content was associated with greater alcohol use in the first semester of college. Conclusion: Our results indicate exposure to alcohol-related media content is a strong predictor, over and above one's own positing, of increased drinking, and this effect varies by sex and point in time. Our results lend support for more tailored and time-specific prevention programming for incoming freshmen that should integrate social media normative feedback.

Recommendations for Implementing Gamification for Mental Health and Wellbeing

Gamification is increasingly being proposed as a strategy to increase engagement for mental health and wellbeing technologies. However, its implementation has been criticized as atheoretical, particularly in relation to behavior change theory and game studies theories. Definitions of the term “gamification” vary, sometimes widely, between and within academic fields and the effectiveness of gamification is yet to be empirically established. Despite this, enthusiasm for developing gamified mental health technologies, such as interventions, continues to grow. There is a need to examine how best to implement gamification in mental health and wellbeing technologies in a way that takes quick production cycles into account while still emphasizing empirical investigation and building a rigorous evidence base. With reference to game studies and the medical (eHealth/mHealth) literature, this article interrogates gamification for mental health and wellbeing by examining core properties of the game form. It then explores how gamification can best be conceptualized and implemented for mental health and wellbeing goals from conceptualization through to iterative co-development and evaluation that accommodates software development schedules. Finally, it summarizes its conceptual analysis into recommendations for researchers and designers looking to do so. These recommendations are: (1) assess suitability, (2) implement to support, (3) assess acceptability, (4) evaluate impact, and (5) document comprehensively. These recommendations aim to encourage clear language, unified terminology, the application and evaluation of theory, comprehensive and constant documentation, and transparent evaluation of outcomes.

Mobile Apps to Reduce Tobacco, Alcohol, and Illicit Drug Use: Systematic Review of the First Decade

Background

Mobile apps for problematic substance use have the potential to bypass common barriers to treatment seeking. Ten years following the release of the first app targeting problematic tobacco, alcohol, and illicit drug use, their effectiveness, use, and acceptability remains unclear.

Objective

This study aims to conduct a systematic literature review of trials evaluating mobile app interventions for problematic tobacco, alcohol, and illicit drug use.

Methods

The review was conducted according to recommended guidelines. Relevant databases were searched, and articles were included if the mobile app study was a controlled intervention trial and reported alcohol, tobacco, or illicit drug consumption as outcomes.

Results

A total of 20 studies met eligibility criteria across a range of substances: alcohol (n=11), tobacco (n=6), alcohol and tobacco (n=1), illicit drugs (n=1), and illicit drugs and alcohol (n=1). Samples included the general community, university students, and clinical patients. The analyzed intervention sample sizes ranged from 22 to 14,228, and content was considerably diverse, from simple stand-alone apps delivering self-monitoring or psychoeducation to multicomponent apps with interactive features and audio content, or used as adjuncts alongside face-to-face treatment. Intervention duration ranged from 1 to 35 weeks, with notifications ranging from none to multiple times per day. A total of 6 of the 20 app interventions reported significant reductions in substance use at post or follow-up compared with a comparison condition, with small to moderate effect sizes. Furthermore, two other app interventions reported significant reductions during the intervention but not at post treatment, and a third reported a significant interaction of two app intervention components.

Conclusions

Although most app interventions were associated with reductions in problematic substance use, less than one-third were significantly better than the comparison conditions at post treatment. A total of 5 out of the 6 apps that reported intervention effects targeted alcohol (of those, one targeted alcohol and illicit drugs and another alcohol and tobacco) and 1 targeted tobacco. Moreover, 3 out of 6 apps included feedback (eg, personalized) and 2 had high risk of bias, 1 some risk, and 3 low risk. All 6 apps included interventions of 6 weeks or longer. Common study limitations were small sample sizes; risk of bias; lack of relevant details; and, in some cases, poorly balanced comparison conditions. Appropriately powered trials are required to understand which app interventions are most effective, length of engagement required, and subgroups most likely to benefit. In sum, evidence to date for the effectiveness of apps targeting problematic substance use is not compelling, although the heterogeneous comparison conditions and trial designs across studies limit the ability to compare efficacy between apps. We discuss potential approaches that can help ascertain whether the promise of mobile app interventions for problematic substance use can be fulfilled.

Components evaluation of a web-based personalized normative feedback intervention for alcohol use among college students: a pragmatic randomized controlled trial with a dismantling design

AIMS

To evaluate the effects of the two main components of a personalized normative feedback (PNF) [normative feedback only (NFO); and consequences feedback only (CFO)] compared with the full intervention (PNF) in reducing alcohol use and consequences.

DESIGN

Three-arm pragmatic randomized controlled trial with dismantling design and 1-, 3- and 6-month follow-ups.

SETTING

Web-based among Brazilian college students.

PARTICIPANTS

College students (aged 18-30 years) who reported alcohol use in the last 3 months (n = 5476).

INTERVENTIONS

(1) Full PNF (a) drinking profile; (b) normative comparisons; (c) practical costs; (d) alcohol consequences; (e) strategies to decrease risks; (2) NFO components (a), (b) and (e); or (3) CFO components (c), (d) and (e).

MEASUREMENTS

The primary outcome was change in Alcohol Use Disorders Identification Test (AUDIT) score; secondary outcomes were the number of alcohol consequences, drinking frequency and typical/maximum number of drinks. We used mixed models with multiple imputation and a pattern-mixture model to account for attrition. Subgroup analyses considered participant motivation to know more about their drinking (less motivated versus motivated).

FINDINGS

Dismantled components reduced rather than increased AUDIT score compared to full PNF, with significant effects for NFO at 1 month [b = -0.23, 95% confidence interval (CI) = -0.46; -0.002] and for CFO at 3 months (b = -0.33, 95% CI = -0.62; -0.03). Compared with PNF, NFO reduced the number of alcohol consequences at 1 month (b = -0.16, 95% CI = -0.25; -0.06) and drinking frequency at 3 months (b = -0.42, 95% CI = -0.79; -0.05), but increased the number of typical drinks at 6 months (b = 0.38, 95% CI = 0.04; 0.72). CFO reduced drinking frequency at 3 months (b = -0.37, 95% CI = -0.73; -0.01). Attrition models confirmed all results, except for the NFO effect on typical drinks and drinking frequency. Subgroup analyses indicated superiority of dismantled components among the students less motivated in knowing more about their drinking.

CONCLUSIONS

There was no evidence that either the normative or the consequences components of a web-based personalized normative feedback intervention to reduce alcohol use and its consequences contributed to intervention effects. There was some evidence of adverse effects of personalized normative feedback, and these results were driven by 20% of participants who were less motivated in knowing more about their drinking.

Effectiveness of a Theory-Based mHealth Intervention for High-Risk Drinking in College Students

Background: College students are among the most vulnerable groups to problems associated with high-risk drinking consequences such as illness, injury, sexual abuse, and death. Promising mobile health (mHealth) approaches, such as smartphone (SP) apps, can be used in interventions to address or prevent excessive drinking. Method: The aim of the investigation was to examine the efficacy of a theoretically based mHealth SP app for alcohol intervention in two independent samples (N = 379): Mandated participants (Study 1) and voluntary participants (Study 2). Study 1 included a controlled trial with Mandated participants randomized into either an in-person Brief Motivational Interviewing BMI (n = 70) or BMI + SP app intervention (n = 71). Study 2 included Voluntary participants who participated in either a Control group (n = 157) or the BMI + SP app intervention (n = 81). Participants in both studies completed baseline and 6-week assessments. Results: In Study 1, peak Blood Alcohol Concentration (BAC) of participants in the in-person BMI group had increased slightly at six weeks, while it had decreased for the app-based BMI + SP group. Study 2 participants using the BMI + SP app reported significant reductions in drinking and consequences; there were no changes in the (AO) Control group. Conclusions: The BMI + SP app was effective with both Mandated and Voluntary participants. Future testing with the BMI + SP app is needed to assess whether reach, adoptability, portability, and sustainability are greater with the mHealth smartphone app for alcohol intervention than in-person approaches.

Lesbians' use of popular social media sites is associated with perceived drinking norms & interest in receiving personalized normative feedback on alcohol use

Alcohol-related problems disproportionately impact sexual minority women. Recent research suggests that lesbian-identified women overestimate peer drinking norms and therefore, personalized normative feedback (PNF) may be an appropriate and efficacious intervention strategy for reducing alcohol-related risks in this population. To inform the development and packaging of such interventions, this study examines lesbians' use of the popular social media sites Facebook, Instagram, Snapchat, and Twitter in relation to alcohol consumption, perceptions of peer drinking norms, confidence in normative perceptions, and interest in receiving alcohol PNF. Findings suggest that the lesbians who are most likely to benefit from a PNF alcohol intervention may also be the most readily reached via social media sites. Alcohol interventions that both recruit and deliver PNF via widely used social media platforms such as Facebook and Instagram represent a promising and cost-effective strategy to reduce heavy drinking among lesbians.

Leveraging copresence to increase the effectiveness of gamified personalized normative feedback

Virtual copresence, or the sense of being with others in an online space, is a feeling induced on many apps and websites through user avatars and browsable profile pages. Despite the small/modest effect sizes observed in popular web-based personalized normative feedback (PNF) alcohol interventions for college students, previous research has yet to consider how copresence might boost efficacy. This study builds on previous PNF gamification work to investigate whether specific copresence features (visual and text-based information about peers) increase PNF's ability to reduce alcohol use relative to a standard PNF condition and a gamified PNF condition. Copresence and perceptions of drinking norms (average drinks, peak drinks, and binge episodes) were assessed during a 3-week period following random assignment of college students (N = 235) to 1 of the 4 web-based PNF conditions (Standard PNF, Gamified PNF Only, Gamified PNF + Visual Copresence, and Gamified PNF + Maximum Copresence). These conditions asked the same questions about drinking and delivered identical PNF on alcohol use, but differed in the level of visual and text-based information about peers. Overall, only the gamified condition that featured maximum copresence significantly reduced drinking outcomes relative to standard PNF. However, conditional effects were moderated by pre-intervention drinking. Among heavier pre-intervention drinkers, both gamified conditions that featured copresence significantly improved upon Standard PNF in reducing alcohol use at follow-up. Findings suggest that including social media-like copresence features to visually represent and provide basic information about the peers contributing to the norms can enhance the efficacy of gamified PNF interventions, especially among high-risk heavy drinkers.

Increasing Chance-Based Uncertainty Reduces Heavy Drinkers' Cognitive Reactance to Web-Based Personalized Normative Feedback

OBJECTIVE

Despite its prominence in the health communication literature, psychological reactance has rarely been considered as a factor that may undermine web-based Personalized Normative Feedback (PNF) alcohol interventions for college students. This study built on recent gamification work to examine how chance-based uncertainty, a popular game mechanic associated with motivation and attention in digital games for learning, might be leveraged to reduce the psychological reactance experienced by heavy drinking students receiving alcohol PNF, thereby leading to larger reductions in their alcohol consumption.

METHOD

Psychological reactance, perceptions of norms, and drinking behaviors were assessed during a 3-week period following random assignment of binge drinking students (N = 141, 51% female) into one of four web-based PNF conditions. These conditions asked the same questions about drinking and delivered identical PNF on alcohol use but differed in whether animated slot-machine spinners appeared to select participants' question and feedback topics as well as the number of additional topics (beyond alcohol) on which questions were asked and PNF was delivered.

RESULTS

All conditions similarly reduced drinking norms but differed in the degree to which they aroused cognitive reactance and reduced drinking. Relative to a no-spinner alcohol-only condition, increasing chance-based uncertainty by giving question and feedback topics the appearance of being selected by gamelike spinners substantially reduced cognitive reactance, which, in turn, reduced drinking 20 days later. Overall, participants experienced the least cognitive reactance when spinners first selected three question topics and later selected two of these topics to deliver feedback on.

CONCLUSIONS

Findings suggest that introducing chance-based uncertainty through gamelike spinners, asking questions about multiple topics, and delivering feedback on additional topics unrelated to alcohol together work to reduce the degree to which the task feels like an alcohol intervention overtly aimed at reducing consumption, thereby making the alcohol PNF more effective among heavy drinking students.

Efficacy of a Web-Based Screening and Brief Intervention to Prevent Problematic Alcohol Use in Korea: Results of a Randomized Controlled Trial

BACKGROUND

Web-based alcohol screenings and brief interventions have been shown to be effective methods for changing drinking behavior. This study evaluated the efficacy of the online-based Brief Empowerment Program for Alcohol-Use Monitor (on-BEAM), a brief intervention applying personalized normative feedback (PNF) and components of motivational interviewing (MI) techniques.

METHODS

A community-based, double-blind, parallel-group randomized controlled trial with individual randomization was conducted in Korea (registered at Clinical Research Information Service-KCT0003050). An e-mail about participating in a survey on drinking behavior was sent to 5,684 individuals, aged 20 to 40, that were registered as part of a research panel. Male and female participants with AUDIT-C scores of ≥4 and ≥3, respectively, were randomly assigned to either an intervention (received a drinking behavior assessment and the results with normative feedback) or control group (assessment and results without normative feedback). To evaluate the effects of the intervention with 2 sessions over the course of a month, a follow-up assessment was performed online 4 weeks after completion of the intervention. The main outcome was the number of standard drinks consumed during the past week measured using the timeline followback method. The rate ratios (RRs) were calculated to test the effects of the intervention.

RESULTS

In total, 1,496 participants were randomized and 93% of them followed up. The intervention group reported consuming less alcohol during the past week (RR = 0.13; p = 0.012) than the control group. Additionally, the intervention group had fewer binge drinkers (RR = 0.69; p < 0.001) and a lower AUDIT-C score (RR = 0.59; p = 0.009) than the control group.

CONCLUSIONS

The web-based intervention, on-BEAM, which applies PNF and MI components related to high-risk drinking reduced the amount of alcohol consumption in our study population. Further research is needed to determine the duration of on-BEAM's effects and evaluate its effectiveness in the real world.

Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

BACKGROUND

There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators.

OBJECTIVE

This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions.

METHODS

We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3.

RESULTS

The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers' justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention's intended effects.

CONCLUSIONS

Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

An App That Incorporates Gamification, Mini-Games, and Social Connection to Improve Men's Mental Health and Well-Being (MindMax): Participatory Design Process

BACKGROUND

Men have different mental health needs as compared with women, and women make up the primary audience of most digital mental health interventions. An Australian football-themed (specifically Australian Football League, AFL) app named MindMax incorporating psychoeducation, gamification, mini-games, and social connection was developed in an effort to address this issue.

OBJECTIVE

The aim of this study was to identify the best way to structure and present MindMax, an app that aims to deliver psychoeducational modules, and create a Web-based community centering on well-being, AFL, and video games for men aged 16 to 35 years who are interested in AFL or video games.

METHODS

We conducted 6 participatory design (PD) workshops with people aged 16 to 35 years in 3 cities in Australia, to identify the best way to present MindMax, and contracted a digital development agency to develop MindMax. We then iteratively tested MindMax prototypes with 15 user experience testing interviews across 3 separate time points: 2 before app launch and 1 after app launch.

RESULTS

A total of 40 individuals (25 male and 15 female) participated in the PD workshops, and a total of 15 individuals (10 male and 5 female) participated in user experience interviews. Broadly, participants expressed a preference for activities requiring active engagement that practiced useful skills. They were also sensitive to how content was presented and wanted the ability to customize their own app experience. Although participants agreed that social motivations were important for engagement with an app, they recommended not to mimic existing social networks.

CONCLUSIONS

In basing itself strongly within the AFL subculture and by incorporating gamification as well as mini-games, MindMax aimed to tackle mental health help-seeking barriers for people who enjoy AFL or video games, with a particular emphasis on men, and to provide psychoeducation on strategies to increase mental health and well-being. If MindMax is successful, this would indicate that generalizing this approach to other traditional sporting codes and even competitive video gaming leagues (esports) would be fruitful.

Increasing Chance-Based Uncertainty Reduces Heavy Drinkers' Cognitive Reactance to Web-Based Personalized Normative Feedback

OBJECTIVE

Despite its prominence in the health communication literature, psychological reactance has rarely been considered as a factor that may undermine web-based Personalized Normative Feedback (PNF) alcohol interventions for college students. This study built on recent gamification work to examine how chance-based uncertainty, a popular game mechanic associated with motivation and attention in digital games for learning, might be leveraged to reduce the psychological reactance experienced by heavy drinking students receiving alcohol PNF, thereby leading to larger reductions in their alcohol consumption.

METHOD

Psychological reactance, perceptions of norms, and drinking behaviors were assessed during a 3-week period following random assignment of binge drinking students (N = 141, 51% female) into one of four web-based PNF conditions. These conditions asked the same questions about drinking and delivered identical PNF on alcohol use but differed in whether animated slot-machine spinners appeared to select participants' question and feedback topics as well as the number of additional topics (beyond alcohol) on which questions were asked and PNF was delivered.

RESULTS

All conditions similarly reduced drinking norms but differed in the degree to which they aroused cognitive reactance and reduced drinking. Relative to a no-spinner alcohol-only condition, increasing chance-based uncertainty by giving question and feedback topics the appearance of being selected by gamelike spinners substantially reduced cognitive reactance, which, in turn, reduced drinking 20 days later. Overall, participants experienced the least cognitive reactance when spinners first selected three question topics and later selected two of these topics to deliver feedback on.

CONCLUSIONS

Findings suggest that introducing chance-based uncertainty through gamelike spinners, asking questions about multiple topics, and delivering feedback on additional topics unrelated to alcohol together work to reduce the degree to which the task feels like an alcohol intervention overtly aimed at reducing consumption, thereby making the alcohol PNF more effective among heavy drinking students.