Effect of electronic screening and brief intervention on hazardous or harmful drinking among adults in the hospital outpatient setting: A randomized, double-blind, controlled trial

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.

Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial

We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16-21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates-individual, interpersonal, community, study, and product-related factors-quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%-10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.

Baseline preferences for oral pre-exposure prophylaxis (PrEP) or dapivirine intravaginal ring for HIV prevention among adolescent girls and young women in South Africa, Uganda and Zimbabwe (MTN-034/IPM-045 study)

INTRODUCTION

Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by the HIV epidemic and face an array of challenges using proven behavioral and biomedical prevention methods. To address the urgent need for expanding prevention options, we evaluated the baseline preferences of HIV prevention methods among participants enrolled in the MTN-034/REACH crossover trial along with their stated product preference prior to product initiation.

METHODS

AGYW aged 16-21 years were enrolled at 4 study sites: Cape Town and Johannesburg, South Africa; Kampala, Uganda; and Harare, Zimbabwe and randomly assigned to the sequence of using oral PrEP and the dapivirine ring for 6 months each, followed by a choice period in which they could choose either product (or neither) for an additional six months. Eligible AGYW were HIV-negative, not pregnant and using effective contraception for at least two months prior to enrollment. Descriptive statistics were used to summarize demographic and behavioral data while multinomial analysis was used to determine predictors of stated product preference (ring or oral PrEP).

RESULTS

Of the 247 AGYW enrolled in REACH, 34% were aged 16-17 and 89% had a primary partner.The median age of sexual debut was 16 years and 40% had ever been pregnant. At screening, 35% of participants were diagnosed with a sexually transmitted infection (STI), 39% had an AUDIT-C score associated with harmful drinking and 11% reported intimate partner violence in the past 6 months. Overall, 28% of participants, had CESD-10 scores suggestive of depressive symptoms (≥12) in the past week. At baseline, similar proportions stated a preference for the ring and oral PrEP (38.1% and 40.5% respectively), with 19% of participants stating they preferred both products equally. Only study site was significantly associated with product preference (P<0.05) with AGYW from Johannesburg having higher odds of preferring the ring and those from Kampala having higher odds of preferring both options equally.

CONCLUSIONS

We successfully enrolled African AGYW with a clear unmet need for HIV prevention. The balanced preference between the two products suggests that multiple biomedical prevention options may be appealing to this age group and could address their prevention needs.

Findings From the Step Up, Test Up Study of an Electronic Screening and Brief Intervention for Alcohol Misuse in Adolescents and Young Adults Presenting for HIV Testing: Randomized Controlled Efficacy Trial

BACKGROUND

Substance use, particularly binge drinking of alcohol and noninjection substance use, is associated with increased risk for HIV infection among youth, but structured substance use screening and brief intervention are not often provided as part of HIV risk reduction.

OBJECTIVE

The purpose of the study was to test the efficacy of a fully automated electronic screening and brief intervention, called Step Up, Test Up, to reduce alcohol misuse among adolescents and young adults presenting for HIV testing. Secondary objectives were reduction in sexual risk and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention.

METHODS

Youth aged 16 years to 25 years who presented for HIV testing at community-based locations were recruited for study participation. Those who screened at moderate to high risk on the Alcohol Use Disorders Identification Test were randomized (1:1) to either an electronic brief intervention or a time-attention control. The primary outcome was change in alcohol use at 1, 3, 6, and 12-month follow-ups. Negative binomial and log binomial regression analyses with generalized estimating equations were conducted to evaluate the intervention efficacy.

RESULTS

Among a sample of 329 youth, there were no significant differences in alcohol use outcomes between conditions over time or at the 1, 3, 6, or 12-month time points. In terms of secondary outcomes, there was evidence of reduction in condomless insertive anal sex under the influence of alcohol and drugs at 12 months compared with 3 months in the intervention versus the attention control condition (incidence rate ratio=0.15, 95% CI 0.05-0.44); however, there were no other significant differences in sexual risk and no difference in PrEP engagement.

CONCLUSIONS

We found no effect of electronic brief intervention to reduce alcohol use and some effect on sexual risk among youth aged 16 years to 25 years who present for HIV testing.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT02703116; https://clinicaltrials.gov/ct2/show/NCT02703116.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-020-8154-6.

Seeking care where they can: A systematic review of global trends in online alcohol treatment utilization among non-veteran and veteran women

Background

Findings from a person-level meta-analysis of online alcohol intervention trials suggest that women disproportionately seek out such interventions (Riper et al., 2018). Although women may be a "hidden population" that is particularly drawn to online alcohol interventions, trial design features may explain women's apparent over-representation in these trials.

Methods

This systematic review examined associations between gender-tailored recruitment/inclusion criteria and proportions of women enrolled in online alcohol intervention trials, evaluated whether community samples have greater proportions of women than clinical samples, and compared country-specific average proportions of women in trials to country-specific proportions of women with Alcohol Use Disorder (AUD).

Results

Forty-four trials met inclusion/exclusion criteria, 34 community samples and 10 drawn from clinical settings; 4 studies included U.S. veterans and were examined separately. The average proportion of community-recruited women across the studies was 51.20% and the average proportion of clinically-recruited women was 35.81%, a difference that was statistically significant. Across the countries with relevant trials, the expected proportion of those with AUD who are women is 27.1% (World Population Review, 2022). Only 2 studies used targeted recruitment for women so no between-group tests were conducted. There was not a statistically significant difference in the proportion of women across trials that did and did not use gender-tailored alcohol inclusion criteria.

Conclusions

Results from this systematic review suggest that study design factors do not account for the marked over-representation of women in online alcohol interventions, indicating that women are indeed a "hidden population" whose needs should be understood and accommodated.

Digital Health Screening in People With HIV in Uganda to Increase Alcohol Use Reporting: Qualitative Study on the Development and Testing of the Self-administered Digital Screener for Health

Background

Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting.

Objective

This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy.

Methods

We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy.

Results

A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener.

Conclusions

We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.

An integrative review of personalized feedback interventions for pain and alcohol

Interrelations between pain and alcohol consumption are considered to be bidirectional in nature, leading to greater pain and increased drinking over time. Personalized feedback interventions (PFIs), which typically aim to motivate behavior change via presentation of personalized and normative feedback, hold great promise for integrated treatment. There has been no previous review of PFIs for pain, and limited work has focused on examining the utility of PFIs for more established, adult drinkers. Our review of the literature revealed that brief, computer-based PFIs can improve pain outcomes and decrease problematic alcohol consumption. Future research would likely benefit from developing integrated, computer-based PFIs for pain and alcohol misuse. Such approaches offer potential for broad impact, while simultaneously reducing patient and healthcare provider burden.