Social Equity in the Efficacy of Computer-Based and In-Person Brief Alcohol Interventions Among General Hospital Patients With At-Risk Alcohol Use: A Randomized Controlled Trial

Effectiveness of proactive video therapy for problematic alcohol use on treatment initiation, compliance, and alcohol intake: a randomised controlled trial in Denmark

BACKGROUND

Few people with problematic alcohol use reach treatment and dropout is frequent. Therapy for problematic alcohol use delivered via video conference (e-alcohol therapy) might overcome treatment barriers. In this randomised study, we tested whether proactive e-alcohol therapy outperformed face-to-face alcohol therapy (standard care) regarding treatment initiation, compliance, and weekly alcohol intake at 3-month and 12-month follow-up.

METHODS

In this two-arm randomised controlled trial, we recruited individuals who had problematic alcohol use, defined as a score of 8 or more on the Alcohol Use Disorders Identification Test; were 18 years or older; and had access to a personal computer, smartphone, or tablet with internet access in Denmark through online advertisements. Participants were assigned to receive alcohol therapy delivered either face-to-face or via video conference. The number, frequency, and duration of therapy sessions were individualised in both groups. Data analysis was conducted using masked data. Primary analyses were based on an intention-to-treat sample. The study is registered with ClinicalTrials.gov (NCT03116282).

FINDINGS

Between Jan 22, 2018, and June 29, 2020, 816 individuals signed up for the trial and 502 (63%) were assessed for eligibility. We randomly assigned 379 to proactive e-alcohol therapy (n=187) or standard care (n=192), of which, 170 (48%) participants were female and 186 (52%) were male. In the intervention group, more participants initiated treatment (155 [88%] of 177 vs 96 [54%] of 179; odds ratio [OR] 6·3; 95% CI 2·8 to 13·8; p<0·0001 at 3 months; 151 [85%] of 177 vs 115 [64%] of 179; OR 3·2; 95% CI 1·6 to 6·2; p=0·0007 at 12 months) and complied with treatment (130 [73%] of 177 vs 74 [41%] of 179; OR 4·0; 95% CI 2·2 to 7·2; p<0·0001 at 3 months; 140 [79%] of 177 vs 95 [53%] of 179; OR 3·4; 95% CI 1·8 to 6·3; p=0·0002 at 12 months). Weekly alcohol intake was significantly lower in the intervention group only after 3 months (13·0 standard drinks per week vs 21·3 standard drinks per week; adjusted difference -6·7; 95% CI -12·3 to -1·0; p=0·019).

INTERPRETATION

Proactive e-alcohol therapy was associated with increased treatment initiation and compliance and is promising as an easily accessible and effective alcohol treatment for individuals with problematic alcohol use.

FUNDING

TrygFonden.

Content Validity and Cognitive Testing in the Development of a Motivational Interviewing Self-Assessment Questionnaire

Aim

To develop and content validate a self-assessment questionnaire on motivational interviewing (MI) practice as the first stages in forming the questionnaire to be used in cross-sectional studies involving practitioners conducting the MI-based alcohol screening and brief intervention (ASBI).

Methods

A comprehensive mixed methods approach included a literature review, 3 rounds of expert panel (EP) opinions (n=10), cognitive testing (CT) with 10 MI-based ASBI practitioners, and questionnaire piloting with 31 MI-based ASBI practitioners. Based on the EP opinions in the second round, content validity indices (CVIs) and the modified kappa coefficient (k*) were calculated, focusing on the relevance and understandability of questions and comprehensiveness and meaningfulness of the response options. This analysis was performed in 2020, at the conclusion of the national "Together for a Responsible Attitude Towards Alcohol Consumption" ("Skupaj za odgovoren odnos do pitja alkohola", SOPA) project's pilot implementation.

Results

On a scale level, CVI values based on universal agreement for the entire questionnaire were high for 3/4 categories (S-CVI-UA>0.80), and CVI values based on average agreement were high across all categories (S-CVI-Ave>0.90). At the item level, CVI values (I-CVI) were never <0.50 (automatic item rejection), and the modified kappa value (k*) indicated poor validity for two items in the understandability category (k*=0.33). All problematic parts of the questionnaire were further tested and successfully modified based on the results of CT, and accepted in the third round of testing.

Conclusions

The final version of the questionnaire demonstrated appropriate content validity for use in studies among Slovenian MI-based ASBI practitioners and is now ready for further psychometric testing.

E-Health intervention for subthreshold depression: Reach and two-year effects of a randomized controlled trial

BACKGROUND

There is evidence for e-Health interventions for full-blown depression. Little is known regarding commonly untreated subthreshold depression in primary care. This randomized controlled multi-centre trial assessed reach and two-year-effects of a proactive e-Health intervention (ActiLife) for patients with subthreshold depression.

METHODS

Primary care and hospital patients were screened for subthreshold depression. Over 6 months, ActiLife participants received three individualized feedback letters and weekly messages promoting self-help strategies against depression, e.g., dealing with unhelpful thoughts or behavioural activation. The primary outcome depressive symptom severity (Patient Health Questionnaire;PHQ-8) and secondary outcomes were assessed 6, 12 and 24 months.

RESULTS

Of those invited, n = 618(49.2 %) agreed to participate. Of them, 456 completed the baseline interview and were randomized to ActiLife (n = 227) or assessment only (n = 226). Generalised estimation equation analyses adjusting for site, setting and baseline depression revealed that depressive symptom severity declined over time, with no significant group differences at 6 (mean difference = 0.47 points; d = 0.12) and 24 months (mean difference = -0.05 points; d = -0.01). Potential adverse effects were observed at 12 months, with higher depressive symptom severity for ActiLife than control participants (mean difference = 1.33 points; d = 0.35). No significant differences in rates of reliable deterioration or reliable improvement of depressive symptoms were observed. ActiLife increased applied self-help strategies at 6 (mean difference = 0.32; d = 0.27) and 24 months (mean difference = 0.22; d = 0.19), but not at 12 months (mean difference = 0.18; d = 0.15).

LIMITATIONS

Self-report measures and lack of information on patients' mental health treatment.

DISCUSSION

ActiLife yielded satisfactory reach and increased the use of self-help strategies. Data were inconclusive in terms of depressive symptom changes.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.