Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review

A Comprehensive Literature Review of Digital Health Interventions in the Treatment of Substance Use Disorder With Special Focus on Mobile Applications

COVID-19 quarantine showed an increase in opioid-related deaths partially due to the limited capacity of clinics and treatment centers. Digital health interventions (DHIs) such as telehealth have improved access to treatment, reduced psychosocial barriers, and helped patients with substance use disorder (SUD). An in-depth literature review was conducted to gauge the efficacy and usefulness of DHIs on substance use disorder. PubMed was used with string search terms to identify studies analyzing telehealth for substance use disorders. Studies were eligible and selected if they used health interventions (HIs) and reported outcomes on the efficacy of DHIs, benefits of DHIs, and limitations of DHIs. The Agency of Healthcare Research and Quality (AHRQ) was used to analyze the impact of DHIs on SUD. Lastly, Apple's App Store was used to identify the current DHI available. The analysis indicated that mobile phone apps were the most appropriate sources to use for patients with substance use disorders. The search also found 36 mobile applications available on the market for patients, containing mainly pain medication diaries and trackers. The study did not find any apps for clinical usage that met the standards necessary for adequate healthcare in the opioid crisis, largely due to a lack of clinician involvement in using applications. Developing adequate DHIs has the potential to improve outcomes in patients with SUD and aid in recovery time. The research concluded that physicians looking to develop DHIs should take into consideration the mode of delivery of DHI, the aim to produce specific health outcomes as opposed to multiple outcomes, and clinician involvement in DHI development. DHIs can become a vital tool for medical professionals, especially during the COVID-19 crisis, as the use of healthcare technology has limited in-person contact, maintained current doctor-patient relationships, and allowed for contact tracing of the disease.

Digital interventions for reducing alcohol use in general populations: An updated systematic review and meta-analysis

This article updates a 2017 review on the effectiveness of digital interventions for reducing alcohol use in the general population. An updated systematic search of the MEDLINE database was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to identify randomized controlled trials (RCTs) published from January 2017 to June 2022 that evaluated the effectiveness of digital interventions compared with no interventions, minimal interventions, and face-to-face interventions aimed at reducing alcohol use in the general population and, that also reported changes in alcohol use (quantity, frequency, quantity per drinking day, heavy episodic drinking (HED), or alcohol use disorders identification test (AUDIT) scores). A secondary analysis was performed that analyzed data from RCTs conducted in students. The review was not preregistered. The search produced 2224 articles. A total of 80 studies were included in the review, 35 of which were published after the last systematic review. A total of 66, 20, 18, 26, and 9 studies assessed the impact of digital interventions on alcohol quantity, frequency, quantity per drinking day, HED, and AUDIT scores, respectively. Individuals randomized to the digital interventions drank 4.12 (95% confidence interval (CI): 2.88, 5.36) fewer grams of alcohol per day, had 0.17 (95% CI 0.06, 0.29) fewer drinking days per week, drank approximately 3.89 (95% CI: 0.40, 7.38) fewer grams of alcohol per drinking day, had 1.11 (95% CI: 0.32, 1.91) fewer HED occasions per month, and had an AUDIT score 3.04 points lower (95% CI: 2.23, 3.85) than individuals randomized to the control condition. Significant reductions in alcohol quantity, frequency, and HED, but not quantity per drinking day, were observed among students. Digital interventions show potential for reducing alcohol use in general populations and could be used widely at the population level to reduce alcohol-attributable harms.

Equity and behavioral digital health interventions: Strategies to improve benefit and reach

BACKGROUND

Behavioral digital health interventions (e.g., mobile apps, websites, wearables) have been applied widely to improve health outcomes. However, many groups (e.g., people with low income levels, people who are geographically isolated, older adults) may face obstacles to technology access and use. In addition, research has found that biases and stereotypes can be embedded within digital health interventions. As such, behavioral digital health interventions that intend to improve overall population health may unintentionally widen health-related inequities.

PURPOSE

This commentary offers guidance and strategies to mitigate these risks when using technology as a means for delivering a behavioral health intervention.

METHODS

A collaborative working group from Society of Behavioral Medicine's Health Equity Special Interest Group developed a framework to center equity in the development, testing and dissemination of behavioral digital health interventions.

RESULTS

We introduce Partner, Identify, Demonstrate, Access, Report (PIDAR), a 5-point framework to avoid the creation, perpetuation, and/or widening of health inequities in behavioral digital health work.

CONCLUSIONS

It is critically important to prioritize equity when conducting digital health research. The PIDAR framework can serve as a guide for behavioral scientists, clinicians and developers.

Digital interventions to moderate alcohol consumption in young people: a Cancer Prevention Europe overview of systematic reviews

Background

Strategies to reduce alcohol consumption would contribute to substantial health benefits in the population, including reducing cancer risk. The increasing accessibility and applicability of digital technologies make these powerful tools suitable to facilitate changes in behaviour in young people which could then translate into both immediate and long-term improvements to public health.

Objective

We conducted a review of systematic reviews to assess the available evidence on digital interventions aimed at reducing alcohol consumption in sub-populations of young people [school-aged children, college/university students, young adults only (over 18 years) and both adolescent and young adults (<25 years)].

Methods

Searches were conducted across relevant databases including KSR Evidence, Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE). Records were independently screened by title and abstract and those that met inclusion criteria were obtained for full text screening by two reviewers. Risk of bias (RoB) was assessed with the ROBIS checklist. We employed a narrative analysis.

Results

Twenty-seven systematic reviews were included that addressed relevant interventions in one or more of the sub-populations, but those reviews were mostly assessed as low quality. Definitions of "digital intervention" greatly varied across systematic reviews. Available evidence was limited both by sub-population and type of intervention. No reviews reported cancer incidence or influence on cancer related outcomes. In school-aged children eHealth multiple health behaviour change interventions delivered through a variety of digital methods were not effective in preventing or reducing alcohol consumption with no effect on the prevalence of alcohol use [Odds Ratio (OR) = 1.13, 95% CI: 0.95-1.36, review rated low RoB, minimal heterogeneity]. While in adolescents and/or young adults who were identified as risky drinkers, the use of computer or mobile device-based interventions resulted in reduced alcohol consumption when comparing the digital intervention with no/minimal intervention (-13.4 g/week, 95% CI: -19.3 to -7.6, review rated low RoB, moderate to substantial heterogeneity).In University/College students, a range of E-interventions reduced the number of drinks consumed per week compared to assessment only controls although the overall effect was small [standardised mean difference (SMD): -0.15, 95% CI: -0.21 to -0.09]. Web-based personalised feedback interventions demonstrated a small to medium effect on alcohol consumption (SMD: -0.19, 95% CI: -0.27 to -0.11) (review rated high RoB, minimal heterogeneity). In risky drinkers, stand-alone Computerized interventions reduced short (SMD: -0.17, 95% CI: -0.27 to -0.08) and long term (SMD: -0.17, 95% CI: -0.30 to -0.04) alcohol consumption compared to no intervention, while a small effect (SMD: -0.15, 95% CI: -0.25 to -0.06) in favour of computerised assessment and feedback vs. assessment only was observed. No short-term (SMD: -0.10, 95% CI: -0.30 to 0.11) or long-term effect (SMD: -0.11, 95% CI: -0.53 to 0.32) was demonstrated for computerised brief interventions when compared to counsellor based interventions (review rated low RoB, minimal to considerable heterogeneity). In young adults and adolescents, SMS-based interventions did not significantly reduce the quantity of drinks per occasion from baseline (SMD: 0.28, 95% CI: -0.02 to 0.58) or the average number of standard glasses per week (SMD: -0.05, 95% CI: -0.15 to 0.05) but increased the risk of binge drinking episodes (OR = 2.45, 95% CI: 1.32-4.53, review rated high RoB; minimal to substantial heterogeneity). For all results, interpretation has limitations in terms of risk of bias and heterogeneity.

Conclusions

Limited evidence suggests some potential for digital interventions, particularly those with feedback, in reducing alcohol consumption in certain sub-populations of younger people. However, this effect is often small, inconsistent or diminishes when only methodologically robust evidence is considered. There is no systematic review evidence that digital interventions reduce cancer incidence through alcohol moderation in young people. To reduce alcohol consumption, a major cancer risk factor, further methodologically robust research is warranted to explore the full potential of digital interventions and to form the basis of evidence based public health initiatives.

Compliance challenges in a longitudinal COVID-19 cohort using wearables for continuous monitoring

BACKGROUND

Wearables to Investigate the Long Term Cardiovascular and Behavioral Impacts of COVID-19 (WEAICOR) study is a prospective observational study using continuous monitoring to detect and analyze biometrics. Compliance to wearables was a major challenge when conducting the study and was crucial for the results.

OBJECTIVE

The aim of this study is to evaluate patients' compliance to wearable wristbands and determinants of compliance in a prospective COVID-19 cohort.

METHODS

Biostrap wearable device was used to monitor participants' biometric data. Compliance was calculated by dividing the total number of days in which transmissions were sent by the total number of days in the study. Univariate correlation was performed between compliance, days in the study and age, BMI, sex, symptom severity, and number of complications/comorbidites as independent variables. Also, multivariate linear regression was then performed with days in the study as a dependent variable to assess the power of different parameters in determining days in the study.

RESULTS

On hundred twenty-two patients were included in the study. Patients were on average 43 years old and 32% were female. Age was found to be correlated with compliance (r=0.23, P=0.01). In addition, age (r=0.30, P=0.001), BMI (r=0.19, P=0.03) and severity of symptoms (r=0.19, P=0.03) were found to be correlated with days spent in the study. On multivariate analysis with days spent in the study as a dependent variable, only increased age was a significant determinant of compliance with wearables (adjusted R2 = 0.1, β = 1.6, P= 0.01).

CONCLUSIONS

Compliance is a major obstacle in remote monitoring studies and the reasons for a lack thereof are multifactorial. Patient factors such as age, in addition to environmental factors can affect compliance to wearables.

Evaluation of OPTIMISE (Online Programme to Tackle Individual's Meat Intake Through Self-regulation): Cohort Study

BACKGROUND

There is an urgent need to reduce society's meat consumption to help mitigate climate change and reduce noncommunicable diseases.

OBJECTIVE

This study aimed to investigate changes in meat intake after participation in an online, multicomponent, self-regulation intervention.

METHODS

We conducted a pre-post observational study among adult meat eaters in the United Kingdom who signed up to a website offering support based on self-regulation theory to reduce meat consumption. The program lasted 9 weeks (including a 1-week baseline phase, a 4-week active intervention phase, and a 4-week maintenance phase), comprising self-monitoring, goal setting, action planning, and health and environmental feedback. Meat intake was estimated during weeks 1, 5, and 9 using a 7-day meat frequency questionnaire. We analyzed the change in mean daily meat intake from baseline to week 5 and week 9 among those reporting data using a hierarchical linear mixed model. We assessed changes in attitudes toward meat consumption by questionnaire and considered the acceptability and feasibility of the intervention.

RESULTS

The baseline cohort consisted of 289 participants, of whom 77 were analyzed at week 5 (26.6% of the baseline sample) and 55 at week 9 (71.4% of the week 5 sample). We observed large reductions in meat intake at 5 and 9 weeks: -57 (95% CI -70 to -43) g/day (P<.001) and -49 (95% CI -64 to -34) g/day (P<.001), respectively. Participants' meat-free self-efficacy increased, meat-eating identities moved toward reduced-meat and non-meat-eating identities, and perceptions of meat consumption as the social norm reduced. Participants who completed the study reported high engagement and satisfaction with the intervention.

CONCLUSIONS

Among people motivated to engage, this online self-regulation program may lead to large reductions in meat intake for more than 2 months, with promising signs of a change in meat-eating identity toward more plant-based diets. This digital behavior change intervention could be offered to complement population-level interventions to support reduction of meat consumption.

Technology-based and digital interventions for intimate partner violence: A systematic review and meta-analysis

BACKGROUND

A growing body of research shows the promise and efficacy of technology-based or digital interventions in improving the health and well-being of survivors of intimate partner violence (IPV). In addition, mental health comorbidities such as anxiety, post-traumatic stress disorder (PTSD), and depression occur three to five times more frequently in survivors of IPV than non-survivors, making these comorbidities prominent targets of technology-based interventions. Still, research on the long-term effectiveness of these interventions in reducing IPV victimization and adverse mental health effects is emergent. The significant increase in the number of trials studying technology-based therapies on IPV-related outcomes has allowed us to quantify the effectiveness of such interventions for mental health and victimization outcomes in survivors. This meta-analysis and systematic review provide critical insight from several randomized controlled trials (RCTs) on the overall short and long-term impact of technology-based interventions on the health and well-being of female IPV survivors.

OBJECTIVES

To synthesize current evidence on the effects of technology-based or digital interventions on mental health outcomes (depression, anxiety, and PTSD) and victimization outcomes (physical, psychological, and sexual abuse) among IPV survivors.

SEARCH METHODS

We examined multiple traditional and grey databases for studies published from 2007 to 2021. Traditional databases (such as PubMed Central, Web of Science, CINAHL Plus, and PsychINFO) and grey databases were searched between April 2019 and February 2021. In addition, we searched clinical trial registries, government repositories, and reference lists. Authors were contacted where additional data was needed. We identified 3210 studies in traditional databases and 1257 from grey literature. Over 2198 studies were determined to be duplicates and eliminated, leaving 64 studies after screening titles and abstracts. Finally, 17 RCTs were retained for meta-analysis. A pre-registered protocol was developed and published before conducting this meta-analysis.

SELECTION CRITERIA

We included RCTs targeting depression, anxiety, PTSD outcomes, and victimization outcomes (physical, sexual, and psychological violence) among IPV survivors using a technology-based intervention. Eligible RCTs featured a well-defined control group. There were no study restrictions based on participant gender, study setting, or follow-up duration. Included studies additionally supplied outcome data for calculating effect sizes for our desired outcome. Studies were available in full text and published between 2007 and 2021 in English.

DATA COLLECTION AND ANALYSIS

We extracted relevant data and coded eligible studies. Using Cochrane's RevMan software, summary effect sizes (Outcome by Time) were assessed using an independent fixed-effects model. Standardized mean difference (SMD) effect sizes (or Cohen's d) were evaluated using a Type I error rate and an alpha of 0.05. The overall intervention effects were analyzed using the Z-statistic with a p-value of 0.05. Cochran's Q test and Higgins' I ² statistics were utilized to evaluate and confirm the heterogeneity of each cumulative effect size. The Cochrane risk of bias assessment for randomized trials (RoB 2) was used to assess the quality of the studies. Campbell Systematic Reviews registered and published this study's protocol in January 2021. No exploratory moderator analysis was conducted; however, we report our findings with and without outlier studies in each meta-analysis.

MAIN RESULTS

Pooled results from 17 RCTs yielded 18 individual effect size comparisons among 4590 survivors (all females). Survivors included college students, married couples, substance-using women in community prisons, pregnant women, and non-English speakers, and sample sizes ranged from 15 to 672. Survivors' ages ranged from 19 to 41.5 years. Twelve RCTs were conducted in the United States and one in Canada, New Zealand, China (People's Republic of), Kenya, and Australia. The results of this meta-analysis found that technology-based interventions significantly reduced depression among female IPV survivors at 0-3 months only (SMD = -0.08, 95% confidence interval [CI] = -0.17 to -0.00), anxiety among IPV survivors at 0-3 months (SMD = -0.27, 95% CI = -0.42 to -0.13, p = 0.00, I ² = 25%), and physical violence victimization among IPV survivors at 0-6 months (SMD = -0.22, 95% CI = -0.38 to -0.05). We found significant reductions in psychological violence victimization at 0-6 months (SMD = -0.34, 95% CI = -0.47 to -0.20) and at >6 months (SMD = -0.29, 95% CI = -0.39 to -0.18); however, at both time points, there were outlier studies. At no time point did digital interventions significantly reduce PTSD (SMD = -0.04, 95% CI = -0.14 to 0.06, p = .46, I ² = 0%), or sexual violence victimization (SMD = -0.02, 95% CI = -0.14 to 0.11, I ² = 21%) among female IPV survivors for all. With outlier studies removed from our analysis, all summary effect sizes were small, and this small number of comparisons prevented moderator analyses.

AUTHORS' CONCLUSIONS

The results of this meta-analysis are promising. Our findings highlight the effectiveness of IPV-mitigating digital intervention as an add-on (not a replacement) to traditional modalities using a coordinated response strategy. Our findings contribute to the current understanding of "what works" to promote survivors' mental health, safety, and well-being. Future research could advance the science by identifying active intervention ingredients, mapping out intervention principles/mechanisms of action, best modes of delivery, adequate dosage levels using the treatment intensity matching process, and guidelines to increase feasibility and acceptability.

Time-restricted eating to improve cardiometabolic health: The New York Time-Restricted EATing randomized clinical trial - Protocol overview

Re-aligning eating patterns with biological rhythm can reduce the burden of metabolic syndrome in older adults with overweight or obesity. Time-restricted eating (TRE) has been shown to result in weight loss and improved cardiometabolic health while being less challenging than counting calories. The New York Time-Restricted EATing study (NY-TREAT) is a two-arm, randomized clinical trial (RCT) that aims to examine the efficacy and sustainability of TRE (eating window ≤10 h/day) vs. a habitual prolonged eating window (HABIT, ≥14 h/day) in metabolically unhealthy midlife adults (50-75 years) with overweight or obesity and prediabetes or type 2 diabetes (T2D). Our primary hypothesis is that the TRE will result in greater weight loss compared to HABIT at 3 months. The efficacy of the TRE intervention on body weight, fat mass, energy expenditure, and glucose is tested at 3 months, and the sustainability of its effect is measured at 12 months, with ambulatory assessments of sleep and physical activity (ActiGraph), eating pattern (smartphone application), and interstitial glucose (continuous glucose monitoring). The RCT also includes state-of-the-art measurements of body fat (quantitative magnetic resonance), total energy expenditure (doubly-labelled water), insulin secretion, insulin resistance, and glucose tolerance. Adherence to self-monitoring and reduced eating window are monitored remotely in real-time. This RCT will provide further insight into the effects of TRE on cardiometabolic health in individuals with high metabolic risk. Sixty-two participants will be enrolled, and with estimated 30% attrition, 42 participants will return at 12 months. This protocol describes the design, interventions, methods, and expected outcomes. Clinical trial registration:NCT04465721 IRB: AAAS7791.

Rethink My Drink: study protocol for a 12-month randomised controlled trial comparing a brief internet-delivered intervention to an online patient information booklet in reducing risky alcohol consumption among older adults in Australia

BACKGROUND AND AIMS

Alcohol consumption is increasing among older adults. Rethink My Drink is a brief internet-delivered intervention to reduce alcohol consumption and related harms, adapted specifically for older adults. This protocol for a large-scale randomised controlled trial will evaluate whether Rethink My Drink is effective in reducing alcohol consumption and cognitive decline in a sample of older risky drinkers, compared with an active control.

DESIGN

1:1 parallel group, randomised controlled trial.

SETTING

Online trial in Australia.

PARTICIPANTS

Hazardous or harmful drinkers (defined as those scoring ≥5 on the Alcohol Use Disorders Identification Test [AUDIT]) age 60 to 75 years old (n = 842). Participants will be recruited from August 2021 to August 2022 through online social media advertisements and community networks.

INTERVENTION AND COMPARATOR

Participants will be randomly allocated to receive access to Rethink My Drink (intervention) or Alcohol: The Facts (comparator), an online patient information booklet provided by New South Wales (NSW) Health.

MEASUREMENTS

Primary outcomes include (i) average weekly standard drinks and (ii) rate of cognitive decline. Secondary outcomes include (i) typical quantity of drinks per drinking day; (ii) heavy episodic drinking; (iii) age-specific risky drinking; (iv) alcohol-related harms; (v) subjective cognitive complaints; and (vi) quality of life. All primary and secondary outcomes will be assessed at baseline, post-intervention (4 weeks) and 12 months. Effectiveness will be evaluated using multilevel linear regression, adjusting for baseline demographic differences. Bonferroni adjustments will be used to control for multiple comparisons. Multiple imputation, regression weighting and sensitivity analyses will assess the effect of attrition.

COMMENTS

This will be the first large-scale trial, internationally, to examine whether a brief internet-delivered intervention is effective in reducing alcohol consumption and cognitive decline among older adults. If successful, the intervention will provide an accessible and highly scalable treatment to reduce risky alcohol consumption in older adulthood.

Effectiveness of digital interventions for people with comorbid heavy drinking and depression: A systematic review and narrative synthesis

INTRODUCTION

Heavy drinking and depression frequently co-occur and make a substantial contribution to the global non-communicable disease burden. Positive evidence exists for the use of digital interventions with these conditions alone, but there has been limited assessment of combined approaches.

OBJECTIVE

A systematic review of the effectiveness of combined digital interventions for comorbid heavy drinking and major depression in community-dwelling populations.

METHODS AND ANALYSIS

Electronic databases were searched to October 2021 for randomised controlled trials that evaluated any personalised digital intervention for comorbid heavy drinking and depression. Primary outcomes were changes in quantity of alcohol consumed and depressive symptoms. Two reviewers independently assessed study eligibility, extracted data, and undertook risk of bias assessment. Due to the limited number and heterogeneity of studies identified, meta-analysis was not possible, therefore data were synthesised narratively.

RESULTS

Of 898 articles identified, 24 papers were reviewed in full, five of which met the inclusion criteria (N = 1503 participants). Three utilised web-based intervention delivery; two computer programmes delivered in a clinic setting. All involved multi-component interventions; treatment length varied from one to ten sessions. Four studies found no evidence for the superiority of combined digital interventions for comorbid heavy drinking and depression over therapist-delivered approaches, single condition interventions (including online), or assessment-only controls. Positive impacts of integrated online therapy compared to generalist online health advice were reported in a fifth study, but not maintained beyond the 1-month follow-up.

LIMITATIONS

Few eligible, heterogeneous studies prevented meta-analysis.

CONCLUSION

Limited evidence exists of the effectiveness of combined digital interventions for comorbid heavy drinking and depression in community dwelling populations.

The effectiveness of a web-based intervention for Japanese adults with problem drinking: An online randomized controlled trial

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We conducted an online randomized controlled trial for a web-based intervention.

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The intervention comprised normative comparison, psychoeducation, and a short quiz.

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Participants were Japanese adults aged 20 years or older and scored AUDIT ≥ 8.

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The weekly drinking quantity at the two- and six-month follow-ups decreased.

Aims

This study aimed (1) to delineate how a web-based intervention affects the problem drinking behaviors of Japanese adults and (2) to examine the moderating effects of disorder levels and alcohol outcome expectancies on intervention outcomes.

Methods

We implemented an online two-armed parallel-group randomized controlled trial with 546 Japanese adults. Adults aged 20 years or older and who scored eight or higher on the Alcohol Use Disorder Identification Test were included in this study. Participants were randomly allocated to the intervention group or the waitlist/control group. The intervention comprised assessment of drinking behavior, personalized normative feedback, psychoeducation about the consequences of problem drinking, and a short quiz. The outcomes were weekly drinking quantity and abstinent days, largest drinking quantity in one day, and alcohol-related consequences reported at baseline and at one-, two-, and six-month follow-ups. A mixed-effects model regression was conducted to compare the intervention and control groups.

Results

The attrition rates at each follow-up were 52.93%, 49.45%, and 32.60%, respectively. The time × condition interaction effect on weekly drinking quantity was significant at the two- and six-month follow-ups, d = 0.28, 95% CI [0.04, 0.51], d = 0.34, 95% CI [0.05, 0.63], respectively. Moderations related to the intervention effect were not statistically significant.

Conclusion

A web-based intervention was found to be effective for two and six months only on drinking quantity measures of Japanese adults with problem drinking. Limitations including high drop-out rates in are discussed.

Adolescents’ opinions on the use of a smartphone application as an oral health education tool: A qualitative study

Developing health-related smartphone applications for oral health education should consider the end-user's perspectives to ensure they will be usable. This study aimed to explore the opinions of secondary school students in Selangor, Malaysia regarding the use of a smartphone application for oral health education and to identify the features for an oral health education smartphone application from the perspectives of adolescents. Focus group discussions were conducted among Form Two (14-year-old) and Form Four (16-year-old) students from selected government secondary schools in Selangor utilising a semi-structured topic guide until data saturation was achieved. Data were analysed using framework analysis. Ten focus group discussions were conducted involving 77 participants. Mixed opinions were recorded on the use of health-related smartphone applications for oral health education. The preferred features in a health-related smartphone application are disease detection, have games and rewards, educational and fun, access to a dentist, reminders, and user-friendliness. Adolescents are aware of the positive aspect of using health-related smartphone applications for oral health education; however, they are wary of the need to install one. Nevertheless, identifying adolescents’ preferred features of an oral health education app is the first step in developing an application tailored to their needs. Smartphone application could be a timely strategy to improve oral health education delivery and behaviour improvement for this age group.

Conversational Agent for Healthy Lifestyle Behavior Change: Web-Based Feasibility Study

BACKGROUND

The rising incidence of chronic diseases is a growing concern, especially in Singapore, which is one of the high-income countries with the highest prevalence of diabetes. Interventions that promote healthy lifestyle behavior changes have been proven to be effective in reducing the progression of prediabetes to diabetes, but their in-person delivery may not be feasible on a large scale. Novel technologies such as conversational agents are a potential alternative for delivering behavioral interventions that promote healthy lifestyle behavior changes to the public.

OBJECTIVE

The aim of this study is to assess the feasibility and acceptability of using a conversational agent promoting healthy lifestyle behavior changes in the general population in Singapore.

METHODS

We performed a web-based, single-arm feasibility study. The participants were recruited through Facebook over 4 weeks. The Facebook Messenger conversational agent was used to deliver the intervention. The conversations focused on diet, exercise, sleep, and stress and aimed to promote healthy lifestyle behavior changes and improve the participants' knowledge of diabetes. Messages were sent to the participants four times a week (once for each of the 4 topics of focus) for 4 weeks. We assessed the feasibility of recruitment, defined as at least 75% (150/200) of our target sample of 200 participants in 4 weeks, as well as retention, defined as 33% (66/200) of the recruited sample completing the study. We also assessed the participants' satisfaction with, and usability of, the conversational agent. In addition, we performed baseline and follow-up assessments of quality of life, diabetes knowledge and risk perception, diet, exercise, sleep, and stress.

RESULTS

We recruited 37.5% (75/200) of the target sample size in 1 month. Of the 75 eligible participants, 60 (80%) provided digital informed consent and completed baseline assessments. Of these 60 participants, 56 (93%) followed the study through till completion. Retention was high at 93% (56/60), along with engagement, denoted by 50% (30/60) of the participants communicating with the conversational agent at each interaction. Acceptability, usability, and satisfaction were generally high. Preliminary efficacy of the intervention showed no definitive improvements in health-related behavior.

CONCLUSIONS

The delivery of a conversational agent for healthy lifestyle behavior change through Facebook Messenger was feasible and acceptable. We were unable to recruit our planned sample solely using the free options in Facebook. However, participant retention and conversational agent engagement rates were high. Our findings provide important insights to inform the design of a future randomized controlled trial.

Public Perceptions of Diabetes, Healthy Living, and Conversational Agents in Singapore: Needs Assessment

Background

The incidence of chronic diseases such as type 2 diabetes is increasing in countries worldwide, including Singapore. Health professional–delivered healthy lifestyle interventions have been shown to prevent type 2 diabetes. However, ongoing personalized guidance from health professionals is not feasible or affordable at the population level. Novel digital interventions delivered using mobile technology, such as conversational agents, are a potential alternative for the delivery of healthy lifestyle change behavioral interventions to the public.

Objective

We explored perceptions and experiences of Singaporeans on healthy living, diabetes, and mobile health (mHealth) interventions (apps and conversational agents). This study was conducted to help inform the design and development of a conversational agent focusing on healthy lifestyle changes.

Methods

This qualitative study was conducted in August and September 2019. A total of 20 participants were recruited from relevant healthy living Facebook pages and groups. Semistructured interviews were conducted in person or over the telephone using an interview guide. Interviews were transcribed and analyzed in parallel by 2 researchers using Burnard’s method, a structured approach for thematic content analysis.

Results

The collected data were organized into 4 main themes: use of conversational agents, ubiquity of smartphone apps, understanding of diabetes, and barriers and facilitators to a healthy living in Singapore. Most participants used health-related mobile apps as well as conversational agents unrelated to health care. They provided diverse suggestions for future conversational agent-delivered interventions. Participants also highlighted several knowledge gaps in relation to diabetes and healthy living. Regarding barriers to healthy living, participants mentioned frequent dining out, high stress levels, lack of work-life balance, and lack of free time to engage in physical activity. In contrast, discipline, preplanning, and sticking to a routine were important for enabling a healthy lifestyle.

Conclusions

Participants in this study commonly used mHealth interventions and provided important insights into their knowledge gaps and needs in relation to changes in healthy lifestyle behaviors. Future digital interventions such as conversational agents focusing on healthy lifestyle and diabetes prevention should aim to address the barriers highlighted in our study and motivate individuals to adopt healthy lifestyle behavior.

Opportunities to Integrate Mobile App-Based Interventions Into Mental Health and Substance Use Disorder Treatment Services in the Wake of COVID-19

The COVID-19 pandemic has heightened concerns about the impact of depression, anxiety, alcohol, and drug use on public health. Mobile apps to address these problems were increasingly popular even before the pandemic, and may help reach people who otherwise have limited treatment access. In this review, we describe pandemic-related substance use and mental health problems, the growing evidence for mobile app efficacy, how health systems can integrate apps into patient care, and future research directions. If equity in access and effective implementation can be addressed, mobile apps are likely to play an important role in mental health and substance use disorder treatment.

A clinical trial on a brief motivational intervention in reducing alcohol consumption under a telehealth supportive counseling

It is known that among those seeking to cease consumption of alcohol, there can be as high as a 50% relapse rate in the first 12 months. Different tools for treatments have been developed, such as telehealth, with the aim of helping this population. As a result of this demand, technology has gained strength in recent years. A new point of view about the treatment will broaden our knowledge far beyond just efficacy. It seems that understanding the mechanisms that lead to treatment success is as important as knowing its effectiveness. Therefore, the present study examined the relationships between Brief Motivational Intervention by telephone (BMI), motivational stage, outcome, and coping strategies using path analysis. In the post-evaluation, variables such as BMI (randomized individuals), motivational stage and decreased consumption of alcohol reached statistical significance (p<.001), suggesting that BMI might improve motivational stage and reduced consumption of alcohol. In terms of coping, the results also indicate that positive thinking might be a variable of interest when planning to decrease alcohol consumption. More research is needed to recognize the potential of new technology in the health area and to uncover the innumerable possibilities of using these tools as a strategy to help alcohol users.

Parent SMART (Substance Misuse in Adolescents in Residential Treatment): Pilot randomized trial of a technology-assisted parenting intervention

Adolescents in residential level of care for substance-related problems have high risk of relapse following discharge. Parent engagement lowers relapse risk, but there are myriad barriers to engaging parents in residential treatment and continuing care. Parent SMART (Substance Misuse in Adolescents in Residential Treatment) is a technology-assisted parenting intervention that was designed to circumvent barriers associated with traditional, office-based continuing care interventions to better engage parents. This pilot randomized trial assessed the acceptability, feasibility, and preliminary effectiveness of Parent SMART as an adjunctive intervention to adolescent residential treatment-as-usual (TAU). Sixty-one parent-adolescent dyads were randomized to Parent SMART+TAU or TAU-only. Thirty-seven dyads were recruited from a short-term facility and 24 dyads were recruited from a long-term facility. Those randomized to Parent SMART received a multi-component technology-assisted intervention combining an off-the-shelf online parenting program, coaching sessions, and a parent networking forum. Parent and adolescent assessments were conducted at baseline, 6, 12, and 24-weeks post-discharge. Feasibility (e.g., parental effectiveness) and acceptability (e.g., parental satisfaction, willingness to recommend the intervention) benchmarks were specified a priori as the primary hypotheses. Secondary effectiveness indicators were the proportion of days adolescent used alcohol, cannabis, and any substance. All acceptability and feasibility benchmarks were met or exceeded among dyads in both short- and long-term residential. Generalized linear mixed models showed no significant effects pooled across sites. Analyses by facility revealed two significant time by condition interactions. Adolescents in short-term residential whose parents received Parent SMART showed fewer drinking days and fewer school problems over time, relative to adolescents whose parents received TAU. Results indicate that Parent SMART was both acceptable and feasible, with preliminary indication of effectiveness among those in short-term residential. A fully-powered trial is warranted to reliably test the effectiveness of Parent SMART and understand possible mechanisms of improvement.

PROTOCOL: Technology-based and digital interventions for intimate partner violence: A meta-analysis and systematic review

INTRODUCTION

Studies show digital interventions such as mobile and wireless platforms (e.g., smartphone apps, text messaging) and web-based platforms (online support groups and telehealth services) can improve the mental health outcomes for victims/survivors of partner abuse. Depression, posttraumatic stress disorder (PTSD), and anxiety are three to five times higher among victims than nonvictims and are thus popular targets of digital interventions. Even then, the evidence is scant. The current review uses both narrative and quantitative (meta-analysis) techniques to present extensive evidence on the effects of intimate partner violence (IPV) digital interventions on the mental health outcomes among survivors of partner violence across all genders and ages, specifically, depression, anxiety, and PTSD. This is the first meta-analysis on IPV-related mental health outcomes targeted by digital interventions.

OBJECTIVES

To synthesize current evidence on the intervention and treatment effects of digital and technology-based interventions (mHealth and eHealth) addressing IPV mental health outcomes (depression, anxiety, and PTSD) among survivors of IPV. This study's research questions are as follows: (a) What are the overall average treatment effects of IPV digital interventions on IPV survivors' mental health outcomes? (b) Do these mental health outcomes vary based on methodological study designs, sample characteristics, and intervention characteristics?

METHODS

An extensive search strategy will be utilized to find qualifying studies. Various electronic bibliographic databases will be searched for studies since 2009 (coinciding with the onset of mobile health interventions). Other databases, such as government databases, grey literature databases, trial registers, specialty journals, and citations in other studies will be searched. Also, we will search "grey databases," such as Google Scholar. Ethical and safety concerns preclude the randomization of IPV survivors to specific intervention conditions. Therefore, we will not exclude studies based on a lack of random assignment. Studies will be full-text accessible, published in any language (translatable into English). We will also contact researchers where needed data is missing in their report. Neither language, study location, nor study settings will be a limiter for searches. Keyword and MeSH headings will be used. Effect sizes (Hedges' g) will be estimated with a Type I error rate set at an alpha of .05.

RESULTS

All studies will measure IPV-related mental health as an outcome and provide outcome data to calculate effect sizes for PTSD, anxiety, depression, and victimization (physical, psychological, and sexual violence).

CONCLUSION

Digital interventions may clinically reduce depression, anxiety, PTSD, and IPV victimization. Summary effect sizes ranging from small to large will signal the usefulness of digital interventions to IPV survivors contending with common mental health issues. Future studies beyond this one may identify other active intervention ingredients of digital interventions, best modes of delivery, and guidelines to increase their feasibility and acceptability.

Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study

BACKGROUND

Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment.

OBJECTIVE

This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR.

METHODS

This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps.

RESULTS

At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019.

CONCLUSIONS

Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23669.

Efficacy of a complex smartphone application for reducing hazardous alcohol consumption: Study protocol for a randomized controlled trial with analysis of in-app user behavior in relation to outcome

OBJECTIVE

The efficacy of alcohol reduction applications is variable, and the underlying factors are largely unknown. The aim of this study is threefold: evaluate the relationship between user engagement and intervention efficacy, investigate the efficacy of the different functions applied, and investigate the efficacy of the intervention application compared to control groups.

METHODS

A randomized controlled trial will be conducted to determine the efficacy of a newly developed smartphone application compared to the controls in reducing alcohol consumption at a 30, 60, 90, 120, 150, and 180 days follow-up. Hazardous drinkers, aged 18 years or older, will be recruited through web articles and will be randomized (blinded to their allocation), to receive one of the two versions of the application (educational or control application) for 30 days, or will be allocated to a wait-list control group. Function usage times will be recorded on a single-user level to determine the association between application usage and efficacy.

RESULTS

Data collection will be completed by July 2020, and follow-up will be completed by January 2021.

CONCLUSIONS

The evaluation of intervention efficacy as a function of user behavior will hopefully contribute to the science of developing more efficient alcohol intervention applications in the future.

Engagement With Motivational Interviewing and Cognitive Behavioral Therapy Components of a Web-Based Alcohol Intervention, Elicitation of Change Talk and Sustain Talk, and Impact on Drinking Outcomes: Secondary Data Analysis

Background

Down Your Drink (DYD) is a widely used unguided web-based alcohol moderation program for the general public based on cognitive behavioral therapy (CBT) and motivational interviewing (MI); it provides users with many opportunities to enter free-text responses.

Objective

The aim of this study was to assess participants’ use of key CBT and MI components, the presence of change talk and sustain talk within their responses, and whether these data are associated with drinking outcomes after 3 months.

Methods

An exploratory secondary data analysis was conducted on data collected in 2008 from the definitive randomized trial of DYD (N=503). Past week alcohol use at baseline and 3-month follow-up were measured with the TOT-AL. Covariates included baseline alcohol use, age, gender, education level, and word count of the responses. Use of MI and CBT components and presence of change talk and sustain talk were coded by two independent coders (Cohen κ range 0.91-1). Linear model regressions on the subsample of active users (n=410) are presented along with a negative binomial regression.

Results

The most commonly used component was the listing of pros and cons of drinking. The number of listed high-risk situations was associated with lower alcohol use at 3-month follow-up (B_adj −2.15, 95% CI −3.92 to −0.38, P=.02). Findings on the effects of the percentage of change talk and the number of listed strategies to deal with high-risk situations were inconsistent.

Conclusions

An unguided web-based alcohol moderation program can elicit change talk and sustain talk. This secondary analysis suggests that the number of listed high-risk situations can predict alcohol use at 3-month follow-up. Other components show inconsistent findings and should be studied further.

Fostering Engagement in Health Behavior Change: Iterative Development of an Interactive Narrative Environment to Enhance Adolescent Preventive Health Services

PURPOSE

Accidents and unintentional injuries account for the greatest number of adolescent deaths, often involving use of alcohol and other substances. This article describes the iterative design and development of Interactive Narrative System for Patient-Individualized Reflective Exploration (INSPIRE), a narrative-centered behavior change environment for adolescents focused on reducing alcohol use. INSPIRE is designed to serve as an extension to clinical preventive care, engaging adolescents in a theoretically grounded intervention for health behavior change by leveraging 3D game engine and interactive narrative technologies.

METHODS

Adolescents were engaged in all aspects of the iterative, multiyear development process of INSPIRE through over 20 focus groups and iterative pilot testing involving more than 145 adolescents. Qualitative findings from focus groups are reported, as well as quantitative findings from small-scale pilot sessions investigating adolescent engagement with a prototype version of INSPIRE using a combination of questionnaire and interaction trace log data.

RESULTS

Adolescents reported that they found INSPIRE to be engaging, believable, and relevant to their lives. The majority of participants indicated that the narrative's protagonist character was like them (84%) and that the narrative featured virtual characters that they could relate to (79%). In the interactive narrative, the goals most frequently chosen by adolescents were "stay in control" (60%) and "do not get in trouble" (55%).

CONCLUSIONS

With a strong theoretical framework (social-cognitive behavior change theory) and technology advances (narrative-centered learning environments), the field is well positioned to design health behavior change systems that can realize significant impacts on behavior change for adolescent preventive health.

Social Media Interventions for Risky Drinking Among Adolescents and Emerging Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite intervention efforts to date, the prevalence of risky drinking among adolescents and emerging adults remains high, increasing the risk for health consequences and the development of alcohol use disorders. Peer influences are particularly salient among this age group, including via social media. Thus, the development of efficacious early interventions for youth, delivered with a broad reach via trained peers on social media, could have an important role in addressing risky drinking and concomitant drug use.

OBJECTIVE

This paper describes the protocol of a randomized controlled trial (RCT) testing the efficacy of a social media intervention among adolescents and emerging adults who meet the criteria for risky drinking (using the Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]), delivered with and without financial incentives for participation, compared with an attention placebo control condition (ie, entertaining social media content), on alcohol consumption and consequences.

METHODS

This RCT involved recruiting 955 youths (aged 16-24 years) via advertisements on Facebook and Instagram to self-administer a brief web-based screening survey. Those screening positive for past 3-month risky drinking (AUDIT-C positive: ages 16-17 years: ≥3 females and ≥4 males; and ages 18-24 years: ≥4 females and ≥5 males) were eligible for the RCT. After providing consent (a waiver of parental consent was obtained for minors), participants completed a web-based baseline survey and several verification procedures, including a selfie photo matched to Facebook profile photos. Participants were then randomized to join invitation-only secret Facebook groups, which were not searchable or viewable by parents, friends, or anyone not recruited by the study. The 3 conditions were social media intervention with incentives, social media intervention without incentives (SMI), and attention placebo control. Each condition lasted 8 weeks and consisted of bachelor's-level and master's-level therapist electronic coaches posting relevant content and responding to participants' posts in a manner consistent with Motivational Interviewing. Participants in the control condition and SMI condition did not receive payments but were blind to condition assignment between these 2 conditions. Follow-ups are ongoing and occur at 3, 6, and 12 months poststart of the groups.

RESULTS

We enrolled 955 participants over 10 waves of recruitment who screened positive for risky drinking into the RCT.

CONCLUSIONS

The findings of this study will provide the critical next step in delivering early alcohol interventions to the youth, capitalizing on social media platforms, which could have significant public health impact by altering alcohol use trajectories of adolescents and emerging adults engaged in risky drinking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02809586; https://clinicaltrials.gov/ct2/show/NCT02809586.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16688.

Smartphone apps for managing alcohol consumption: a literature review

Background

Smartphone applications (apps) designed to assist users to reduce hazardous and harmful alcohol consumption show potential as an inexpensive alternative to traditional brief intervention in primary care. The aim of this paper is to provide an overview of the literature on alcohol reduction apps and the availability of evidenced-based apps on top commercial app stores.

Methods

We reviewed literature through to December 2019 using the databases PubMed, MEDLINE, PsycINFO and Google Scholar and keyword search terms smartphone/mobile/phone AND application/app AND alcohol. Articles were included if the primary intervention was a smartphone app and the study measured participant changes in frequency or volume of alcohol consumption.

Results

21 relevant articles were identified that evaluated 19 unique smartphone apps. Of the 19 unique apps, seven were designed for use among youth and 12 in adult populations. The available evidence for the efficacy of alcohol reduction apps among youth is inconclusive, with results from these evaluations not showing a clear benefit in reducing alcohol consumption compared to control groups. The results of apps designed for adult populations appears more promising, but results are still mixed. Of the 19 alcohol reduction apps that have been evaluated only eight of these are currently publicly available in commercial app stores. Of these eight apps, only four were demonstrated in the literature to assist with reducing alcohol consumption.

Conclusion

The evidence for alcohol reduction apps is promising but inconclusive. Few apps that have been evaluated in the scientific literature are currently available for download in commercial app stores.

Smartphone-based secondary prevention intervention for university students with unhealthy alcohol use identified by screening: study protocol of a parallel group randomized controlled trial

BACKGROUND

Unhealthy alcohol use is a leading cause of morbidity and mortality among young people, including university students. Delivering secondary prevention interventions against unhealthy alcohol use is challenging. Information technology has the potential to reach large parts of the general population. The present study is proposed to test a proactive secondary prevention smartphone-based intervention against unhealthy alcohol use.

METHODS

This is a parallel-group, randomized controlled trial (1:1 allocation ratio) among 1696 university students with unhealthy alcohol use, identified by screening and followed up at 3, 6, and 12 months. Participants will be randomized to receive access to a smartphone-based intervention or to a no intervention control condition. The primary outcome will be self-reported volume of alcohol drunk over the past 30 days, reported as the mean number of standard drinks per week over the past 30 days, measured at 6 months. Secondary outcomes will be number of heavy drinking days over the past 30 days, at 6 months. Additional outcomes will be maximum number of drinks on any day over the past 30 days, alcohol-related consequences (measured using the Short Inventory of Problems (SIP-2R), and academic performance.

DISCUSSION

The aim of this trial is to close the evidence gap on the efficacy of smartphone-based secondary prevention interventions. If proven effective, smartphone-based interventions have the potential to reach a large portion of the population, completing what is available on the Internet.

TRIAL REGISTRATION

ISRCTN, 10007691. Registered on 2 December 2019. Recruitment will start in April 2020.

A randomized trial of brief web-based prevention of unhealthy alcohol use: Participant self-selection compared to a male young adult source population

BACKGROUND

How much a randomized controlled trial (RCT) sample is representative of or differs from its source population is a challenging question, with major implications for generalizability of results. It is particularly crucial for freely-available web-based interventions tested in RCTs since they are designed to reach broad populations and could increase health disparities if they fail to reach the more vulnerable individuals. We assessed the representativeness of a sample of participants in a primary/secondary prevention web-based brief intervention RCT in relation to its source population. Then we compared those recruited to those not recruited in the RCT.

METHODS

There is a mandatory army recruitment process in Switzerland at age 19 for men. Between August 2010 and July 2011, 12,564 men (source population) attended two recruitment centers and were asked to answer a screening questionnaire on alcohol use. Among 11,819 (94.1%) who completed it, 7027 (59.5%) agreed to participate in a longitudinal cohort study with regular assessments. In 2012, these participants were invited to a web-based brief intervention RCT. Participation was not dependent on the presence or quantity of alcohol use. We assessed the representativeness of the RCT sample in relation to the source population and compared participants recruited/not recruited in the RCT with respect to education level and alcohol use.

RESULTS

The RCT sample differed from the source population: individuals 20 and over were significantly less represented (34.3% vs 37.9%, p = 0.006), as were those with lower education level (58.6% vs 63.0%, p = 0.0009). The prevalence of any alcohol use was higher in the RCT population (92.3% vs 90.6%, p = 0.03) but unhealthy alcohol use was less represented (37.1% vs 43.2%, p < 0.0001). Differences on alcohol use measures and education were similarly found when those recruited in the RCT were compared to those who were not, including in a multivariable model, showing independent associations between less unhealthy alcohol use and higher education and recruitment in the RCT.

CONCLUSIONS

RCT participants differed from other members of the source population, with those participating in the RCT having higher prevalence of any alcohol use but lower levels of consumption and lower prevalence of indicators of unhealthy alcohol use. Individuals with higher education were overrepresented in the RCT sample. Selection bias may exist at both ends of the drinking spectrum and individuals with some indicators of greater vulnerability were less likely to participate. Results of web-based studies may not adequately generalize to the general population.Trial registration: The trial was registered at current controlled trials: ISRCTN55991918.

Study protocol for a systematic review of evidence for digital interventions for comorbid excessive drinking and depression in community-dwelling populations

INTRODUCTION

Excessive drinking and depression are frequently comorbid and make a substantial contribution to the global non-communicable disease burden. A range of effective interventions and treatments exist for either excessive drinking or depression alone, including a positive emerging evidence base for the use of digital interventions. Computerised and/or smartphone delivered advice could provide flexible, coordinated support for patients with comorbid excessive drinking and depression. However, to date, no systematic review of the evidence has been conducted focused on the effectiveness of digital interventions for this specific comorbid population. This systematic review will identify and evaluate the effectiveness of digital interventions for reducing comorbid excessive drinking and depression in community-dwelling populations.

METHODS AND ANALYSIS

We will search MEDLINE, The Cochrane Library, CENTRAL, CINAHL, PsycINFO, ERIC and SCI from inception to end of July 2019 for randomised controlled trials that evaluate any personalised digital intervention for comorbid excessive drinking and depression and published in any language. Primary outcomes will be changes in quantity of alcohol consumed and depressive symptoms. Screening, data extraction and risk of bias assessment will be undertaken independently by two reviewers, with disagreements resolved through discussion. Meta-analytic methods will be used to synthesise the data collected relating to the primary outcomes of interest.

ETHICS AND DISSEMINATION

As a systematic review, ethical approval is not needed. Findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

CRD42019130134.

Meta-analysis of the difference of medians

We consider the problem of meta-analyzing two-group studies that report the median of the outcome. Often, these studies are excluded from meta-analysis because there are no well-established statistical methods to pool the difference of medians. To include these studies in meta-analysis, several authors have recently proposed methods to estimate the sample mean and standard deviation from the median, sample size, and several commonly reported measures of spread. Researchers frequently apply these methods to estimate the difference of means and its variance for each primary study and pool the difference of means using inverse variance weighting. In this work, we develop several methods to directly meta-analyze the difference of medians. We conduct a simulation study evaluating the performance of the proposed median-based methods and the competing transformation-based methods. The simulation results show that the median-based methods outperform the transformation-based methods when meta-analyzing studies that report the median of the outcome, especially when the outcome is skewed. Moreover, we illustrate the various methods on a real-life data set.

Help-Seeking for Sexual Difficulties and the Potential Role of Interactive Digital Interventions: Findings From the Third British National Survey of Sexual Attitudes and Lifestyles

Sexual difficulties are common and can negatively impact health and well-being. A wide range of support is available, but there are multiple barriers to accessing help. Interactive digital interventions (IDIs) for sexual difficulties have the potential to provide a convenient, wide-reaching, and cost-effective source of support, but little is known about who might use them. We explored the potential reach of IDIs by assessing the prevalence of help-seeking among people with distressing sexual difficulties, including who seeks which sources of help. Data came from sexually active men and women, ages 16 to 74, participating in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) (N = 11,637). Help/advice was sought by less than half of those with distressing sexual difficulties, and help-seeking was associated with younger age in women but not men. The most popular sources of support were family doctor (47.5% to 54.8%), Internet (22.0% to 25.6%), and family/friend (20.7% to 41.8%), with older participants (≥ 35), particularly men, preferring to seek help from a family doctor, and younger participants (<35) preferring to seek help from the Internet or family/friend. Despite a paucity of good digital support sites for sexual function, the Internet is a common source of help. As Internet access continues to increase, so too does the potential for well-designed IDIs to support those with sexual difficulties.

Acceptability and feasibility of a computer-based application to help Aboriginal and Torres Strait Islander Australians describe their alcohol consumption

We examined acceptability and feasibility of a tablet application ("App") to record self-reported alcohol consumption among Aboriginal and Torres Strait Islander Australians. Four communities (1 urban; 3 regional/remote) tested the App, with 246 adult participants (132 males, 114 females). The App collected (a) completion time; (b) participant feedback; (c) staff observations. Three research assistants were interviewed. Only six (1.4%) participants reported that the App was "hard" to use. Participants appeared to be engaged and to require minimal assistance; nearly half verbally reflected on their drinking or drinking of others. The App has potential for surveys, screening, or health promotion.

Believing Is Seeing: A Proof-of-Concept Semiexperimental Study on Using Mobile Virtual Reality to Boost the Effects of Interpretation Bias Modification for Anxiety

BACKGROUND

Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and reinforce anxiety. The repetitive and monotonous features of CBM-I can negatively impact training adherence and learning processes.

OBJECTIVE

This proof-of-concept study aimed to examine whether performing a CBM-I training using mobile virtual reality technology (virtual reality Cognitive Bias Modification of Interpretations [VR-CBM-I]) improves training experience and effectiveness.

METHODS

A total of 42 students high in trait anxiety completed 1 session of either VR-CBM-I or standard CBM-I training for performance anxiety. Participants' feelings of immersion and presence, emotional reactivity to a stressor, and changes in interpretation bias and state anxiety, were assessed.

RESULTS

The VR-CBM-I resulted in greater feelings of presence (P<.001, d=1.47) and immersion (P<.001, η_p²=0.74) in the training scenarios and outperformed the standard training in effects on state anxiety (P<.001, η_p²=0.3) and emotional reactivity to a stressor (P=.03, η_p²=0.12). Both training varieties successfully increased the endorsement of positive interpretations (P<.001, d_{repeated measures} [d_rm]=0.79) and decreased negative ones. (P<.001, d_rm=0.72). In addition, changes in the emotional outcomes were correlated with greater feelings of immersion and presence.

CONCLUSIONS

This study provided first evidence that (1) the putative working principles underlying CBM-I trainings can be translated into a virtual environment and (2) virtual reality holds promise as a tool to boost the effects of CMB-I training for highly anxious individuals while increasing users' experience with the training application.

Smartphone application for unhealthy alcohol use: Pilot randomized controlled trial in the general population

BACKGROUND

There is limited evidence of the efficacy of smartphone applications to reduce unhealthy alcohol use. We tested the efficacy of providing access to a smartphone-based brief intervention for unhealthy alcohol use.

METHODS

We conducted a two parallel-group randomized controlled trial with follow-up at 6 months, among 977 individuals with an Alcohol Use Disorder Identification Test ≥8 and drinking 15 or more drinks/week. Participants were randomized to receive (or not) access to a smartphone application consisting of personalized feedback, risk assessment and self-monitoring. The primary outcome was the mean number of drinks/week. An intention to treat analysis (ITT) and a per protocol analysis (PP) were conducted.

RESULTS

Mean age of participants was 34.2(9.8), 46% were female. The baseline mean number of drinks per week was 28.9(16.7). Results differed by type of analysis: ITT: all 977 participants were included in the analysis. Follow-up rate was 70.7% (n = 691). There was no significant intervention effect: the Incidence Rate Ratio (IRR) (95%CI) for number of drinks per week was 0.93(0.84; 1.03). PP: 702 participants were included in the analysis. Follow-up rate was 78.1% (n = 548). There was a significant intervention effect: the IRR for number of drinks per week was 0.88(0.78; 0.99).

CONCLUSIONS

Providing access to a smartphone-based brief intervention had no impact on drinking at 6 months and does not appear to be an effective intervention in reducing drinking. Those who downloaded the app appear to benefit from it, nevertheless downloads were limited and further development of similar apps should focus on increasing use.

Effectiveness and treatment moderators of internet interventions for adult problem drinking: An individual patient data meta-analysis of 19 randomised controlled trials

BACKGROUND

Face-to-face brief interventions for problem drinking are effective, but they have found limited implementation in routine care and the community. Internet-based interventions could overcome this treatment gap. We investigated effectiveness and moderators of treatment outcomes in internet-based interventions for adult problem drinking (iAIs).

METHODS AND FINDINGS

Systematic searches were performed in medical and psychological databases to 31 December 2016. A one-stage individual patient data meta-analysis (IPDMA) was conducted with a linear mixed model complete-case approach, using baseline and first follow-up data. The primary outcome measure was mean weekly alcohol consumption in standard units (SUs, 10 grams of ethanol). Secondary outcome was treatment response (TR), defined as less than 14/21 SUs for women/men weekly. Putative participant, intervention, and study moderators were included. Robustness was verified in three sensitivity analyses: a two-stage IPDMA, a one-stage IPDMA using multiple imputation, and a missing-not-at-random (MNAR) analysis. We obtained baseline data for 14,198 adult participants (19 randomised controlled trials [RCTs], mean age 40.7 [SD = 13.2], 47.6% women). Their baseline mean weekly alcohol consumption was 38.1 SUs (SD = 26.9). Most were regular problem drinkers (80.1%, SUs 44.7, SD = 26.4) and 19.9% (SUs 11.9, SD = 4.1) were binge-only drinkers. About one third were heavy drinkers, meaning that women/men consumed, respectively, more than 35/50 SUs of alcohol at baseline (34.2%, SUs 65.9, SD = 27.1). Post-intervention data were available for 8,095 participants. Compared with controls, iAI participants showed a greater mean weekly decrease at follow-up of 5.02 SUs (95% CI -7.57 to -2.48, p < 0.001) and a higher rate of TR (odds ratio [OR] 2.20, 95% CI 1.63-2.95, p < 0.001, number needed to treat [NNT] = 4.15, 95% CI 3.06-6.62). Persons above age 55 showed higher TR than their younger counterparts (OR = 1.66, 95% CI 1.21-2.27, p = 0.002). Drinking profiles were not significantly associated with treatment outcomes. Human-supported interventions were superior to fully automated ones on both outcome measures (comparative reduction: -6.78 SUs, 95% CI -12.11 to -1.45, p = 0.013; TR: OR = 2.23, 95% CI 1.22-4.08, p = 0.009). Participants treated in iAIs based on personalised normative feedback (PNF) alone were significantly less likely to sustain low-risk drinking at follow-up than those in iAIs based on integrated therapeutic principles (OR = 0.52, 95% CI 0.29-0.93, p = 0.029). The use of waitlist control in RCTs was associated with significantly better treatment outcomes than the use of other types of control (comparative reduction: -9.27 SUs, 95% CI -13.97 to -4.57, p < 0.001; TR: OR = 3.74, 95% CI 2.13-6.53, p < 0.001). The overall quality of the RCTs was high; a major limitation included high study dropout (43%). Sensitivity analyses confirmed the robustness of our primary analyses.

CONCLUSION

To our knowledge, this is the first IPDMA on internet-based interventions that has shown them to be effective in curbing various patterns of adult problem drinking in both community and healthcare settings. Waitlist control may be conducive to inflation of treatment outcomes.

Promoting Youth Mental Health via Text-Messages: A New Zealand Feasibility Study

BACKGROUND

A growing body of research has documented the positive effects of gratitude programs on participants' mental health and well-being. For children and adolescents, these programs typically rely on school-based group designs tied with a health curriculum, whereas innovative technology-based programs are relatively understudied.

METHODS

This experiment investigated the feasibility and efficacy of a gratitude text-messaging program for promoting adolescent mental health relative to a positive reflective control condition.

RESULTS

Young people showed positive changes over the course of the program in their general sense of gratitude, subjective well-being, and reduced depressive symptoms, with some evidence that those with higher levels of depressive symptoms benefited more from the gratitude program. However, there were no significant differences across the two groups in the magnitude of these mental health changes. Participants in both conditions valued and were highly engaged with the interactive text-messaging approach.

CONCLUSION

This interactive e-health promotion strategy seemed to promote strong engagement and showed promising effectiveness with young people, with some challenges to feasibility due to the labor intensive nature of sending and responding to a large number of text-messages. The importance of carefully considering risk management strategies when developing such programs was also highlighted.

A web-based self-management programme for people with type 2 diabetes: the HeLP-Diabetes research programme including RCT

Background

In the UK, 6% of the UK population have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Diabetes mellitus accounts for 10% of NHS expenditure (£14B annually). Good self-management may improve health outcomes. NHS policy is to refer all people with T2DM to structured education, on diagnosis, to improve their self-management skills, with annual reinforcement thereafter. However, uptake remains low (5.6% in 2014–15). Almost all structured education is group based, which may not suit people who work, who have family or other caring commitments or who simply do not like group-based formats. Moreover, patient needs vary with time and a single education session at diagnosis is unlikely to meet these evolving needs. A web-based programme may increase uptake.

Objectives

Our aim was to develop, evaluate and implement a web-based self-management programme for people with T2DM at any stage of their illness journey, with the goal of improving access to, and uptake of, self-management support, thereby improving health outcomes in a cost-effective manner. Specific objectives were to (1) develop an evidence-based theoretically informed programme that was acceptable to patients and health-care professionals (HCPs) and that could be readily implemented within routine NHS care, (2) determine the clinical effectiveness and cost-effectiveness of the programme compared with usual care and (3) determine how best to integrate the programme into routine care.

Design

There were five linked work packages (WPs). WP A determined patient requirements and WP B determined HCP requirements for the self-management programme. WP C developed and user-tested the Healthy Living for People with type 2 Diabetes (HeLP-Diabetes) programme. WP D was an individually randomised controlled trial in primary care with a health economic analysis. WP E used a mixed-methods and case-study design to study the potential for implementing the HeLP-Diabetes programme within routine NHS practice.

Setting

English primary care.

Participants

People with T2DM (WPs A, D and E) or HCPs caring for people with T2DM (WPs B, C and E).

Intervention

The HeLP-Diabetes programme; an evidence-based theoretically informed web-based self-management programme for people with T2DM at all stages of their illness journey, developed using participatory design principles.

Main outcome measures

WPs A and B provided data on user ‘wants and needs’, including factors that would improve the uptake and accessibility of the HeLP-Diabetes programme. The outcome for WP C was the HeLP-Diabetes programme itself. The trial (WP D) had two outcomes measures: glycated haemoglobin (HbA1c) level and diabetes mellitus-related distress, as measured with the Problem Areas in Diabetes (PAID) scale. The implementation outcomes (WP E) were the adoption and uptake at clinical commissioning group, general practice and patient levels and the identification of key barriers and facilitators.

Results

Data from WPs A and B supported our holistic approach and addressed all areas of self-management (medical, emotional and role management). HCPs voiced concerns about linkage with the electronic medical records (EMRs) and supporting patients to use the programme. The HeLP-Diabetes programme was developed and user-tested in WP C. The trial (WP D) recruited to target (n = 374), achieved follow-up rates of over 80% and the intention-to-treat analysis showed that there was an additional improvement in HbA1c levels at 12 months in the intervention group [mean difference –0.24%, 95% confidence interval (CI) –0.44% to –0.049%]. There was no difference in overall PAID score levels (mean difference –1.5 points, 95% CI –3.9 to 0.9 points). The within-trial health economic analysis found that incremental costs were lower in the intervention group than in the control group (mean difference –£111, 95% CI –£384 to £136) and the quality-adjusted life-years (QALYs) were higher (mean difference 0.02 QALYs, 95% CI 0.000 to 0.044 QALYs), meaning that the HeLP-Diabetes programme group dominated the control group. In WP E, we found that the HeLP-Diabetes programme could be successfully implemented in primary care. General practices that supported people in registering for the HeLP-Diabetes programme had better uptake and registered patients from a wider demographic than those relying on patient self-registration. Some HCPs were reluctant to do this, as they did not see it as part of their professional role.

Limitations

We were unable to link the HeLP-Diabetes programme with the EMRs or to determine the effects of the HeLP-Diabetes programme on users in the implementation study.

Conclusions

The HeLP-Diabetes programme is an effective self-management support programme that is implementable in primary care.

Future work

The HeLP-Diabetes research team will explore the following in future work: research to determine how to improve patient uptake of self-management support; develop and evaluate a structured digital educational pathway for newly diagnosed people; develop and evaluate a digital T2DM prevention programme; and the national implementation of the HeLP-Diabetes programme.

Trial registration

Research Ethics Committee reference number 10/H0722/86 for WPs A–C; Research Ethics Committee reference number 12/LO/1571 and UK Clinical Research Network/National Institute for Health Research (NIHR) Portfolio 13563 for WP D; and Research Ethics Committee 13/EM/0033 for WP E. In addition, for WP D, the study was registered with the International Standard Randomised Controlled Trial Register as reference number ISRCTN02123133.

Funding details

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 5. See the NIHR Journals Library website for further project information.

Four-year follow-up of an internet-based brief intervention for unhealthy alcohol use in young men

AIM

To estimate the long-term efficacy of an internet-based brief intervention (IBI) in decreasing alcohol use among men on (1) number of drinks/week and (2) monthly or more binge drinking prevalence. In addition, overall changes in alcohol use were assessed.

DESIGN

Participants in a cohort study were recruited in a two parallel-group randomized controlled trial of an IBI versus no-intervention control condition, showing a positive intervention effect at 6 months. As part of the regular cohort assessments, participants were re-assessed 47 months after the initial trial, offering an opportunity to determine long-term efficacy.

SETTING

Young Swiss men from the general population.

PARTICIPANTS

Of 737 randomized trial participants with unhealthy alcohol use (> 14 drinks/week or ≥ 6 drinks/occasion at least monthly, or Alcohol Use Disorders Identification Test (AUDIT) ≥ 8), 626 completed a cohort assessment at mean ± standard deviation (SD) = 47.4 ± 2.6) months after their randomized trial baseline assessment.

INTERVENTION

IBI included normative and personalized feedback on alcohol use, risk indicators, information about alcohol and health and recommendations; controls: assessment only.

MEASUREMENTS

Self-reported number of drinks/week and monthly or more binge drinking prevalence.

FINDINGS

Comparisons at follow-up were adjusted for baseline drinking. Missing values were replaced with the last observation carried forward. There was no evidence of differences between the IBI and control group on either the number of drinks/week [IBI: 10.8 (14.2); control: 10.7 (14.1), P = 0.8] or monthly or more binge drinking prevalence (IBI: 65.1%; control: 63.5%, P = 0.5). Although there was no evidence of overall change from baseline in number of drinks/week [9.8 (7.9) at baseline, 10.8 (14.1) at 47 months, P = 0.051], there was evidence that monthly or more binge drinking prevalence had decreased during the follow-up time (84.9% at baseline, 64.3% at 47 months, P < 0.001).

CONCLUSIONS

An internet-based brief intervention directed at unhealthy alcohol use among young men does not appear to reduce drinking over the long-term.

DIAMOND (DIgital Alcohol Management ON Demand): a feasibility RCT and embedded process evaluation of a digital health intervention to reduce hazardous and harmful alcohol use recruiting in hospital emergency departments and online

BACKGROUND

The harmful use of alcohol is a causal factor in more than 200 disease and injury conditions and leads to over 3 million deaths every year worldwide. Relatively few problem alcohol users access treatment due to stigma and lack of services. Alcohol-specific digital health interventions (DHI) may help them, but trial data comparing DHI with face-to-face treatment are lacking.

METHODS

We conducted a feasibility RCT of an alcohol DHI, testing recruitment, online data-collection and randomisation processes, with an embedded process evaluation. Recruitment ran from October 2015 for 12 months. Participants were adults, drinking at hazardous and harmful levels, recruited from hospital emergency departments (ED) in London or recruited online. Participants were randomised to HeLP-Alcohol, a six module DHI with weekly reminder prompts (phone, email or text message), or to face-to-face treatment as usual (TAU). Participants were invited to take part in qualitative interviews after the trial.

RESULTS

The trial website was accessed 1074 times: 420 people completed online eligibility questionnaires; 350 did not meet eligibility criteria, 51 declined to participate, and 19 were recruited and randomised. Follow-up data were collected from three participants (retention 3/19), and four agreed to be interviewed for the process evaluation. The main themes of the interviews were:Participants were not at equipoise. They wanted to try the website and were disappointed to be randomised to face-to-face, so they were less engaged and dropped out.Other reasons for drop out included not accepting that they had a drink problem; problem drinking interfering with their ability to take part in a trial or forgetting appointments; having a busy life and being randomised to TAU made it difficult to attend appointments.

CONCLUSIONS

This feasibility RCT aimed to test recruitment, randomisation, retention, and data collection methods, but recruited only 19 participants. This illustrates the importance of undertaking feasibility studies prior to fully powered RCTs. From the qualitative interviews we found that potential recruits were not at equipoise for recruitment. An alternative methodology, for example a preference RCT recruiting from multiple locations, needs to be explored in future trials.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN31789096.

New steps for treating alcohol use disorder

Alcohol use disorder is a complex syndrome with multiple treatment points including drug-induced pathology, withdrawal management, behavioral/cognitive strategies, and relapse prevention. These different components may be complicated by genotype and phenotype. A huge milestone for the treatment of alcohol use disorder across several countries in the last 10 years was the introduction of practice guidelines integrating clinical expertise and research evidence. These provide a summary of interventions that have been shown to be effective following rigorous and replicated clinical trials. Inspection of these guidelines reveals good consistency, but little evidence of progress in treatment approaches for alcohol use disorder over the past decade. In this mini-review, we discuss emerging treatments for alcohol use disorder that may supplement or improve the evidence-based treatments that are currently recommended. New medications, the emergence of digital technology, and other novel approaches such as transcranial magnetic stimulation are all discussed with reference to treatments already in practice. We also consider how individual differences in genotype and phenotype may affect outcomes. Together with improvements in technology, this knowledge offers a powerful tool for designing personalized approaches to treatment, and hence improving prognosis for rehabilitation programs.

Behavior Change Techniques Used in Digital Behavior Change Interventions to Reduce Excessive Alcohol Consumption: A Meta-regression

Background

Digital behavior change interventions (DBCIs) appear to reduce alcohol consumption, but greater understanding is needed of their mechanisms of action.

Purpose

To describe the behavior change techniques (BCTs) used in DBCIs and examine whether individual BCTs, the inclusion of more BCTs or more Control Theory congruent BCTs is associated with increased effectiveness.

Methods

Forty-one randomized control trials were extracted from a Cochrane review of alcohol reduction DBCIs and coded for up to 93 BCTs using an established and reliable method. Random effects unadjusted and adjusted meta-regression models were performed to assess associations between BCTs and intervention effectiveness.

Results

Interventions used a mean of 9.1 BCTs (range 1-22), 23 different BCTs were used in four or more trials. Trials that used "Behavior substitution" (-95.112 grams per week [gpw], 95% CI: -162.90, -27.34), "Problem solving" (-45.92 gpw, 95% CI: -90.97, -0.87) and "Credible source" (-32.09 gpw, 95% CI: -60.64, -3.55) were significantly associated with greater alcohol reduction than trials without these BCTs. The "Behavior substitution" result should be treated as preliminary because it was reported in only four trials, three of which were conducted by the same research group. "Feedback" was used in 98% of trials (n = 41); other Control Theory congruent BCTs were used less frequently: for example, "Goal setting" 43% (n = 18) and "Self-monitoring" 29%, (n = 12).

Conclusions

"Behavior substitution," "Problem solving," and "Credible source" were associated with greater alcohol reduction. Many BCTs were used infrequently in DBCIs, including BCTs with evidence of effectiveness in other domains, such as "Self-monitoring" and "Goal setting."

Alcohol Consumption Reduction Among a Web-Based Supportive Community Using the Hello Sunday Morning Blog Platform: Observational Study

BACKGROUND

Alcohol misuse is a major social and public health issue in Australia, with an estimated cost to the community of Aus $30 billion per annum. Until recently, a major barrier in addressing this significant public health issue is the fact that the majority of individuals with alcohol use disorders and alcohol misuse are not receiving treatment.

OBJECTIVE

This study aimed to assess whether alcohol consumption changes are associated with participation in Hello Sunday Morning's blog platform, an online forum discussing experiences in abstaining from alcohol.

METHODS

The study reports on Hello Sunday Morning participants who signed up for a 3-month period of abstinence from November 2009 to November 2016. The sample comprised 1917 participants (female: 1227/1917, 64.01%; male: 690/1917, 35.99%). Main outcome measures were Alcohol Use Disorders Identification Test (AUDIT) scores, mood, program engagement metrics, and slip-ups.

RESULTS

Individuals who reported hazardous (preprogram AUDIT mean 11.92, SD 2.25) and harmful consumption levels (preprogram AUDIT mean 17.52, SD 1.08) and who engaged in the Hello Sunday Morning program reported a significant decrease in alcohol consumption, moving to lower risk consumption levels (hazardous, mean 7.59, SD 5.70 and harmful, mean 10.38, SD 7.43), 4 months following program commencement (P<.001). Those who reported high-risk or dependent consumption levels experienced the biggest reduction (preprogram mean 25.38, SD 4.20), moving to risky consumption (mean 15.83, SD 11.11), 4 months following program commencement (P<.001). These reductions in risk were maintained by participants in each group, 7 months following program commencement. Furthermore, those who engaged in the program more (as defined by more sign-ins, blogs posted, check-ins completed, and engagement with the community through likes and following) had lower alcohol consumption. Finally, those who experienced more slip-ups had lower alcohol consumption.

CONCLUSIONS

Participation in an online forum can support long-term behavior change in individuals wishing to change their drinking behavior. Importantly, reductions in AUDIT scores appeared larger for those drinking at high-risk and hazardous levels before program commencement. This has promising implications for future models of alcohol reduction treatment, as online forums are an anonymous, accessible, and cost-effective alternative or adjunct to treatment-as-usual. Further research is needed into the specific mechanisms of change within a Web-based supportive community, as well as the role of specific mood states in predicting risky drinking behavior.

Computer-Based Interventions for Problematic Alcohol Use: a Review of Systematic Reviews

Purpose

The aim of this review is to provide an overview of knowledge and knowledge gaps in the field of computer-based alcohol interventions by (1) collating evidence on the effectiveness of computer-based alcohol interventions in different populations and (2) exploring the impact of four specified moderators of effectiveness: therapeutic orientation, length of intervention, guidance and trial engagement.

Methods

A review of systematic reviews of randomized trials reporting on effectiveness of computer-based alcohol interventions published between 2005 and 2015.

Results

Fourteen reviews met the inclusion criteria. Across the included reviews, it was generally reported that computer-based alcohol interventions were effective in reducing alcohol consumption, with mostly small effect sizes. There were indications that longer, multisession interventions are more effective than shorter or single session interventions. Evidence on the association between therapeutic orientation of an intervention, guidance or trial engagement and reductions in alcohol consumption is limited, as the number of reviews addressing these themes is low. None of the included reviews addressed the association between therapeutic orientation, length of intervention or guidance and trial engagement.

Conclusions

This review of systematic reviews highlights the mostly positive evidence supporting computer-based alcohol interventions as well as reveals a number of knowledge gaps that could guide future research in this field.

Steering Clear of Driving After Drinking: a Tailored e-Health Intervention for Reducing Repeat Offending and Modifying Alcohol Use in a High-Risk Cohort

PURPOSE

Digital interventions to reduce risk behaviours are emerging as effective public health measures; however, few have been applied to drink driving and associated alcohol use based on a harm reduction perspective. This paper reports on the design, development, and pilot of a novel intervention which aims to reduce repeat offending by first-time convicted drink driving offenders. It explores whether an online program is acceptable and user friendly and contains useful and relevant content, with a sample of first-time drink driving offenders recruited at the time of conviction.

METHOD

Building upon existing research into interventions to reduce drink driving recidivism and problem alcohol use, a tailored program was designed to provide content specifically concerned with drink driving and with an additional component related to alcohol use. Following stakeholder and internal review, the 'Steering Clear First Offender Drink Driving Program' was subsequently piloted with 15 first-time drink driving offenders. Evaluative data was analysed both quantitatively and qualitatively.

RESULTS

The pilot results indicate that the participants found the program to be user friendly, as demonstrated by high scores in relation to navigation, online delivery, engagement, avatar usage and straightforwardness. They reported that they found the content to be useful and relevant and that the key learning area was in relation to the consequences of drink driving.

CONCLUSION

Online interventions for reducing risky behaviour such as drink driving may be useful and cost effective from a public health perspective. Potentially, they can directly address risky behaviours associated with alcohol use in high-risk cohorts that may not ordinarily receive intervention.

Understanding Mechanisms of Change for Brief Alcohol Interventions Among Youth: Examination of Within-Session Interactions

OBJECTIVE

Alcohol brief interventions (BIs) for youth are efficacious, but effect sizes found have been modest. This article presents secondary data analyses from a randomized controlled trial of motivational interviewing-based (MI) alcohol BIs among youth in an emergency department, examining within-session predictors of alcohol outcomes at 3 months among those receiving BIs.

METHOD

Risky drinkers (ages 14-20) received either a computer BI (n = 277) or therapist BI (n = 278). Within-session measures were obtained via computer metrics (therapist and computer BIs) and coding of audiotapes (therapist BI only). Parallel structural equation models examined direct and indirect effects of BI components on 3-month alcohol consumption and consequences, with posttest precursors of behavior change (e.g., importance, readiness, and intentions) as potential mediators. Components examined included reasons to avoid or reduce drinking, strengths, strategies for change, benefits of change, and leisure activities (computer BI only), and MI global ratings and MI-adherent behaviors (therapist BI only).

RESULTS

For both BIs, greater number of strategies directly predicted greater posttest scores, with posttest scores mediating the relationship between strategies and alcohol consumption at 3 months. Greater number of strengths directly predicted fewer alcohol-related consequences at 3 months for both BIs; however, strengths also indirectly predicted greater consumption, mediated by posttest scores. Greater number of reasons to avoid or reduce drinking directly predicted greater alcohol consumption for the therapist BI only.

CONCLUSIONS

These findings suggest ways to optimize the content and efficacy of alcohol BIs. Reviews of strategies such as refusal skills, protective behavioral strategies, and coping with negative affect may be particularly salient for reducing alcohol misuse.

A smartphone app to reduce excessive alcohol consumption: Identifying the effectiveness of intervention components in a factorial randomised control trial

Our aim was to evaluate intervention components of an alcohol reduction app: Drink Less. Excessive drinkers (AUDIT>=8) were recruited to test enhanced versus minimal (reduced functionality) versions of five app modules in a 25 factorial trial. Modules were: Self-monitoring and Feedback, Action Planning, Identity Change, Normative Feedback, and Cognitive Bias Re-training. Outcome measures were: change in weekly alcohol consumption (primary); full AUDIT score, app usage, app usability (secondary). Main effects and two-way interactions were assessed by ANOVA using intention-to-treat. A total of 672 study participants were included. There were no significant main effects of the intervention modules on change in weekly alcohol consumption or AUDIT score. There were two-way interactions between enhanced Normative Feedback and Cognitive Bias Re-training on weekly alcohol consumption (F = 4.68, p = 0.03) and between enhanced Self-monitoring and Feedback and Action Planning on AUDIT score (F = 5.82, p = 0.02). Enhanced Self-monitoring and Feedback was used significantly more often and rated significantly more positively for helpfulness, satisfaction and recommendation to others than the minimal version. To conclude, in an evaluation of the Drink Less smartphone application, the combination of enhanced Normative Feedback and Cognitive Bias Re-training and enhanced Self-monitoring and Feedback and Action Planning yielded improvements in alcohol-related outcomes after 4-weeks.

Reported Theory Use by Digital Interventions for Hazardous and Harmful Alcohol Consumption, and Association With Effectiveness: Meta-Regression

BACKGROUND

Applying theory to the design and evaluation of interventions is likely to increase effectiveness and improve the evidence base from which future interventions are developed, though few interventions report this.

OBJECTIVE

The aim of this paper was to assess how digital interventions to reduce hazardous and harmful alcohol consumption report the use of theory in their development and evaluation, and whether reporting of theory use is associated with intervention effectiveness.

METHODS

Randomized controlled trials were extracted from a Cochrane review on digital interventions for reducing hazardous and harmful alcohol consumption. Reporting of theory use within these digital interventions was investigated using the theory coding scheme (TCS). Reported theory use was analyzed by frequency counts and descriptive statistics. Associations were analyzed with meta-regression models.

RESULTS

Of 41 trials involving 42 comparisons, half did not mention theory (50% [21/42]), and only 38% (16/42) used theory to select or develop the intervention techniques. Significant heterogeneity existed between studies in the effect of interventions on alcohol reduction (I2=77.6%, P<.001). No significant associations were detected between reporting of theory use and intervention effectiveness in unadjusted models, though the meta-regression was underpowered to detect modest associations.

CONCLUSIONS

Digital interventions offer a unique opportunity to refine and develop new dynamic, temporally sensitive theories, yet none of the studies reported refining or developing theory. Clearer selection, application, and reporting of theory use is needed to accurately assess how useful theory is in this field and to advance the field of behavior change theories.

Technology-Based Interventions for Substance Use and Comorbid Disorders: An Examination of the Emerging Literature

Among individuals with substance use disorders (SUDs), comorbidity with other psychiatric disorders is common and often noted as the rule rather than the exception. Standard care that provides integrated treatment for comorbid diagnoses simultaneously has been shown to be effective. Technology-based interventions (TBIs) have the potential to provide a cost-effective platform for, and greater accessibility to, integrated treatments. For the purposes of this review, we defined TBIs as interventions in which the primary targeted aim was delivered by automated computer, Internet, or mobile system with minimal to no live therapist involvement. A search of the literature identified nine distinct TBIs for SUDs and comorbid disorders. An examination of this limited research showed promise, particularly for TBIs that address problematic alcohol use, depression, or anxiety. Additional randomized, controlled trials of TBIs for comorbid SUDs and for anxiety and depression are needed, as is future research developing TBIs that address SUDs and comorbid eating disorders and psychotic disorders. Ways of leveraging the full capabilities of what technology can offer should also be further explored.

Moving alcohol prevention research forward-Part I: introducing a complex systems paradigm

BACKGROUND AND AIMS

The drinking environment is a complex system consisting of a number of heterogeneous, evolving and interacting components, which exhibit circular causality and emergent properties. These characteristics reduce the efficacy of commonly used research approaches, which typically do not account for the underlying dynamic complexity of alcohol consumption and the interdependent nature of diverse factors influencing misuse over time. We use alcohol misuse among college students in the United States as an example for framing our argument for a complex systems paradigm.

METHODS

A complex systems paradigm, grounded in socio-ecological and complex systems theories and computational modeling and simulation, is introduced. Theoretical, conceptual, methodological and analytical underpinnings of this paradigm are described in the context of college drinking prevention research.

RESULTS

The proposed complex systems paradigm can transcend limitations of traditional approaches, thereby fostering new directions in alcohol prevention research. By conceptualizing student alcohol misuse as a complex adaptive system, computational modeling and simulation methodologies and analytical techniques can be used. Moreover, use of participatory model-building approaches to generate simulation models can further increase stakeholder buy-in, understanding and policymaking.

CONCLUSIONS

A complex systems paradigm for research into alcohol misuse can provide a holistic understanding of the underlying drinking environment and its long-term trajectory, which can elucidate high-leverage preventive interventions.