Reducing alcohol-related harm in disadvantaged men: development and feasibility assessment of a brief intervention delivered by mobile telephone

Automated, tailored adaptive mobile messaging to reduce alcohol consumption in help-seeking adults: A randomized controlled trial

AIMS

To test differential outcomes between three 6-month text-messaging interventions to reduce at-risk drinking in help-seeking adults.

DESIGN

A three-arm single-blind randomized controlled trial with 1-, 3-, 6- and 12-month follow-ups.

SETTING

United States. A fully remote trial without human contact, with participants recruited primarily via social media outlets.

PARTICIPANTS

Seven hundred and twenty-three adults (mean = 39.9 years, standard deviation = 10.0; 62.5% female) seeking to reduce their drinking were allocated to 6 months of baseline 'tailored statically' messaging (TS; n = 240), 'tailored adaptive' messaging (TA; n = 239) or 'drink tracking' messaging (DT; n = 244).

INTERVENTIONS

TS consisted of daily text messages to reduce harmful drinking that were tailored to demographics and alcohol use. TA consisted of daily, tailored text messages that were also adapted based on goal achievement and proactive prompts. DT consisted of a weekly assessment for self-reported drinking over the past 7 days.

MEASUREMENTS

The primary outcome measure was weekly sum of standard drinks (SSD) at 6-month follow-up. Secondary outcome measures included drinks per drinking day (DDD), number of drinking days (NDD) per week and heavy drinking days (HDD) at 1-, 3-, 6- and 12-month follow-ups.

FINDINGS

At 6 months, compared with DT, TA resulted in significant SSD reductions of 16.2 (from 28.7 to 12.5) drinks [adjusted risk ratio (aRR) = 0.80, 95% confidence interval (CI) = 0.71, 0.91] using intent-to-treat analysis. TA also resulted in significant improvements in DDD (aRR = 0.84; 95% CI = 0.77-0.92) and drinking days per week (b = -0.39; 95% CI = -0.67, -0.10), but not HDD compared with DT at 6 months. TA was not significantly different from TS at any time-point, except DDD at 6 months. All groups made improvements in SSD at 12-month follow-up compared with baseline with an average reduction of 12.9 drinks per week across groups.

CONCLUSIONS

Automated tailored mobile messaging interventions are scalable solutions that can reduce weekly alcohol consumption in remote help-seeking drinkers over time.

Text messaging interventions for reducing alcohol consumption among risky drinkers: systematic review and meta-analysis

BACKGROUND AND AIMS

The global growth of mobile phone use has led to new opportunities for health interventions, including through text messaging. We aimed to estimate the effects of text messaging interventions on alcohol consumption among risky drinkers.

METHODS

Systematic review and meta-analysis of reports on randomized controlled trials (RCTs) published in English. Searches were conducted on 23 May 2019 in PubMed; PubMed Central; CENTRAL; CDSR; DARE; NHS-EED; Scopus; PsycINFO; PsycARTICLES; CINAHL; and Web of Science. Measurements included number of episodes of heavy drinking (HED) per month and weekly alcohol consumption (WAC) in grams. Trials among risky drinkers who were not receiving co-interventions were included in the review (n = 3481, mean age 29 years, 41% female). Data were extracted from reports and authors were contacted for additional data.

RESULTS

Ten trials were included and all analyses were based on random-effects models. Primary analyses, including seven trials (n = 2528) for HED and five trials (n = 2236) for WAC, found that the interventions may reduce self-reported HED [-0.33 episodes per month; 95% confidence interval (CI) = -0.79, 0.12] and WAC (-18.62 g per week; 95% CI = -39.61, 2.38), although both estimates included the null. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality of evidence was judged to be low for both HED and WAC, primarily due to risk of attrition and performance bias, heterogeneity and influence of pilot trials on estimates.

CONCLUSIONS

Text messaging alcohol interventions may reduce alcohol consumption compared with no or basic health information; however, there are doubts about the overall quality of the evidence.

Assessment of Health Information Technology Interventions in Evidence-Based Medicine: A Systematic Review by Adopting a Methodological Evaluation Framework

BACKGROUND

The application of Health Information Technologies (HITs) can be an effective way to advance medical research and health services provision. The two-fold objective of this work is to: (i) identify and review state-of-the-art HITs that facilitate the aims of evidence-based medicine and (ii) propose a methodology for HIT assessment.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Furthermore, we consolidated existing knowledge in the field and proposed a Synthesis Framework for the Assessment of Health Information Technology (SF/HIT) in order to evaluate the joint use of Randomized Controlled Trials (RCTs) along with HITs in the field of evidence-based medicine.

RESULTS

55 articles met the inclusion criteria and refer to 51 (RCTs) published between 2008 and 2016. Significant improvements in healthcare through the use of HITs were observed in the findings of 31 out of 51 trials-60.8%. We also confirmed that RCTs are valuable tools for assessing the effectiveness, acceptability, safety, privacy, appropriateness, satisfaction, performance, usefulness and adherence.

CONCLUSIONS

To improve health service delivery, RCTs apply and exhibit formalization by providing measurable outputs. Towards this direction, we propose the SF/HIT as a framework which may help researchers to carry out appropriate evaluations and extend their studies.

Design and development of a complex narrative intervention delivered by text messages to reduce binge drinking among socially disadvantaged men

Background

Socially disadvantaged men are at high risk of suffering from alcohol-related harm. Disadvantaged groups are less likely to engage with health promotion. There is a need for interventions that reach large numbers at low cost and which promote high levels of engagement with the behaviour change process. The aim of this study was to design a theoretically and empirically based text message intervention to reduce binge drinking by socially disadvantaged men.

Results

Following MRC guidance, the intervention was developed in four stages. Stage 1 developed a detailed behaviour change strategy based on existing literature and theory from several areas. These included the psychological theory that would underpin the intervention, alcohol brief interventions, text message interventions, effective behaviour change techniques, narratives in behaviour change interventions and communication theory. In addition, formative research was carried out. A logic model was developed to depict the pathways between intervention inputs, processes and outcomes for behaviour change. Stage 2 created a narrative which illustrated and modelled key steps in the strategy. Stage 3 rendered the intervention into a series of text messages and ensured that appropriate behavioural change techniques were incorporated. Stage 4 revised the messages to ensure comprehensive coverage of the behaviour change strategy and coherence of the narrative. It also piloted the intervention and made final revisions to it.

Conclusions

The structured, systematic approach to design created a narrative intervention which had a strong theoretical and empirical basis. The use of a narrative helped make the intervention realistic and allowed key behaviour change techniques to be modelled by characters. The narrative was intended to promote engagement with the intervention. The intervention was rendered into a series of short text messages, and subsequent piloting showed they were acceptable in the target group. Delivery of an intervention by text message offers a low-cost, low-demand method that can reach large numbers of people. This approach provides a framework for the design of behaviour change interventions which could be used for interventions to tackle other health behaviours.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0298-0) contains supplementary material, which is available to authorized users.

Text message intervention to reduce frequency of binge drinking among disadvantaged men: the TRAM RCT

Background

Socially disadvantaged men are more likely to binge drink frequently and to experience high levels of alcohol-related harm.

Objectives

To test the effectiveness and cost-effectiveness of a text message intervention in reducing the frequency of binge drinking among disadvantaged men.

Study design

A four-centre, parallel-group, pragmatic, individually randomised controlled trial was conducted. Randomisation was carried out using a secure remote web-based system. It was stratified by participating centre and recruitment method and restricted using block sizes of randomly varying lengths.

Setting

The study was conducted in the community. Members of the public helped to develop the study methods.

Participants

Participants were men aged 25–44 years who had ≥ 2 episodes of binge drinking (> 8 units of alcohol in a single session) in the preceding 28 days. Men were recruited from areas of high deprivation.

Interventions

An empirically and theoretically based text message intervention was delivered by 112 interactive text messages over a 12-week period. The control group received an attentional control comprising 89 text messages on general health.

Primary outcome measure

The primary outcome measure was the proportion of men consuming > 8 units of alcohol on ≥ 3 occasions (in the previous 28 days) at 12 months post intervention.

Results

The recruitment target of 798 was exceeded and 825 men were randomised. Retention was high and similar in the intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged enthusiastically with the text messages: almost all (92%) replied to text messages and over two-thirds (67%) replied more than 10 times. The intervention was estimated to have had a modest, statistically non-significant effect on the primary outcome at the 12-month follow-up [odds ratio 0.79, 95% confidence interval (CI) 0.57 to 1.08]. This corresponds to a net reduction of 5.7% in regular binge drinking. Five secondary outcomes showed small non-significant and inconsistent effects on alcohol consumption, with one suggesting a positive effect and four suggesting an adverse effect. Both the short- and the long-term cost per quality-adjusted life-year (QALY) analysis suggested that the brief intervention was dominated by a ‘do-nothing’ option. The intervention’s impacts on patterns of alcohol consumption, QALYs and downstream costs were inconsistent and uncertain.

Limitations

The study used an active control that, combined with the recruitment procedures and baseline assessments, could have biased the treatment effect towards the null. The measurement of alcohol consumption relied on self-reported drinking.

Conclusions

The trial has demonstrated that it is possible to recruit and retain large numbers of socially disadvantaged men in a research study. The text messages delivered a complex theoretically and empirically based intervention that fostered enthusiastic engagement with the key components of the behaviour change sequence. The intervention produced a modest, statistically non-significant effect on the primary outcome, with wide CIs. Further research is needed to reduce uncertainty about the treatment effect. The methods developed for this study provide a platform for the design and testing of interventions to reduce inequalities in health.

Future work

A future trial could reduce the uncertainty around the treatment effect of the intervention.

Trial registration

Current Controlled Trials ISRCTN07695192.

Funding

This study was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 6. See NIHR Journals Library website for further information.

Real Time Monitoring of Engagement with a Text Message Intervention to Reduce Binge Drinking Among Men Living in Socially Disadvantaged Areas of Scotland

Purpose

This study identified the extent and nature of engagement with a theoretically based behaviour change text message intervention intended to reduce binge drinking. The data were from a randomised controlled trial tackling binge drinking among socially disadvantaged men.

Method

An intervention, comprising 112 text messages, and based on the principles of the Health Action Process Approach, was delivered to 411 socially disadvantaged men. Participants sent almost 7500 responses to the text messages. Engagement was assessed by whether text message replies showed the intended response to key components of the behaviour change strategy.

Results

The median number of responses to the text messages was 17 per man (range 0–81). Men often gave detailed sensitive personal information about their drinking and the harms it caused them. They also described their attempts at drinking less, the setbacks encountered and the benefits they enjoy when they are successful at cutting down. Specific examples of engagement with the targeted messages include the following: of the 248 men who responded to the prompt on outcome expectancies, most (230) identified potential benefits of cutting down; for intention to reduce drinking, 260 men responded of whom 44% said they had thought about changing; of the 172 men who responded to the question on goal setting, 158 reported personal goals.

Conclusions

The responses showed that most men engaged as intended with the key components of the intervention. Text message interventions should include questions addressing key components of the behaviour change strategy to determine whether there is effective engagement with intervention components.

The NIHR public health research programme: intervention approaches to tackle health inequalities

Background

The National Institute for Health Research (NIHR) Public Health Research (PHR) Programme evaluates interventions intended to improve the health of the public and reduce inequalities in health in the UK. The aim of the research was to establish how projects funded by the PHR Programme between 2009 and 2014 addressed health inequalities.

Methods

A health inequalities intervention framework developed by Bambra et al. was used to map PHR funded studies to a typology. The framework is based on interventions that are characterized by their level of action and their approach to tackling inequalities.

Results

A total of 57 primary research projects funded by the PHR Programme were categorized using the framework; 16 PHR research projects were classified as strengthening individuals, 24 strengthening communities, 15 improving living and school/work conditions and 2 promoting healthy macro policies. Eighteen were classified as targeted interventions whereas 39 were universal.

Conclusions

Mapping the interventions being evaluated by the PHR Programme to a typology differentiated health inequality interventions and illustrates how they are expected to have an impact. Emerging findings will contribute to the evidence base for addressing health inequalities to inform research and future commissioning of public health services.

Modifying Alcohol Consumption to Reduce Obesity (MACRO): development and feasibility trial of a complex community-based intervention for men

BACKGROUND

Obese men who consume alcohol are at a greatly increased risk of liver disease; those who drink > 14 units of alcohol per week have a 19-fold increased risk of dying from liver disease.

OBJECTIVES

To develop an intervention to reduce alcohol consumption in obese men and to assess the feasibility of a randomised controlled trial (RCT) to investigate its effectiveness.

DESIGN OF THE INTERVENTION

The intervention was developed using formative research, public involvement and behaviour change theory. It was organised in two phases, comprising a face-to-face session with trained laypeople (study co-ordinators) followed by a series of text messages. Participants explored how alcohol consumption contributed to weight gain, both through direct calorie consumption and through its effect on increasing food consumption, particularly of high-calorie foodstuffs. Men were encouraged to set goals to reduce their alcohol consumption and to make specific plans to do so. The comparator group received an active control in the form of a conventional alcohol brief intervention. Randomisation was carried out using the secure remote web-based system provided by the Tayside Clinical Trials Unit. Randomisation was stratified by the recruitment method and restricted using block sizes of randomly varying lengths. Members of the public were involved in the development of all study methods.

SETTING

Men were recruited from the community, from primary care registers and by time-space sampling (TSS). The intervention was delivered in community settings such as the participant's home, community centres and libraries.

PARTICIPANTS

Men aged 35-64 years who had a body mass index (BMI) of > 30 kg/m² and who drank > 21 units of alcohol per week.

RESULTS

The screening methods successfully identified participants meeting the entry criteria. Trial recruitment was successful, with 69 men (36 from 419 approached in primary care, and 33 from 470 approached via TSS) recruited and randomised in 3 months. Of the 69 men randomised, 35 were allocated to the intervention group and 34 to the control group. The analysis was conducted on 31 participants from the intervention group and 30 from the control group. The participants covered a wide range of ages and socioeconomic statuses. The average alcohol consumption of the men recruited was 47.2 units per week, more than twice that of the entry criterion (> 21 units per week). Most (78%) engaged in binge drinking (> 8 units in a session) at least weekly. Almost all (95%) exceeded the threshold for a 19-fold increase in the risk of dying from liver disease (BMI of > 30 kg/m² and > 14 units of alcohol per week). Despite this, they believed that they were at low risk of harm from alcohol, possibly because they seldom suffered acute harms (e.g. hangovers) and made few visits to a general practitioner or hospital.

INTERVENTION

The intervention was delivered with high fidelity. A high follow-up rate was achieved (98%) and the outcomes for the full RCT were measured. A process evaluation showed that participants engaged with the main components of the intervention. The acceptability of the study methods was high.

CONCLUSIONS

This feasibility study developed a novel intervention and evaluated all of the stages of a RCT that would test the effectiveness of the intervention. The main stages of a trial were completed successfully: recruitment, randomisation, intervention delivery, follow-up and measurement of study outcomes. Most of the men recruited drank very heavily and were also obese. This places them at a very high risk of liver disease, making them a priority for intervention.

FUTURE WORK

A RCT to test the effectiveness and cost-effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55309164.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 19. See the NIHR Journals Library website for further project information.

Development of a text message intervention aimed at reducing alcohol-related harm in patients admitted to hospital as a result of injury

BACKGROUND

Screening for alcohol misuse and brief interventions (BIs) for harm in trauma care settings are known to reduce alcohol intake and injury recidivism, but are rarely implemented. We created the content for a mobile phone text message BI service to reduce harmful drinking among patients admitted to hospital following an injury who screen positive for hazardous alcohol use. The aim of this study was to pre-test and refine the text message content using a robust contextualisation process ahead of its formal evaluation in a randomised controlled trial.

METHODS

Pre-testing was conducted in two phases. First, in-depth interviews were conducted with 14 trauma inpatients (16-60 years) at Auckland City Hospital and five key informants. Participants were interviewed face-to-face using a semi-structured interview guide. Topics explored included: opinions on text message ideas and wording, which messages did or did not work well and why, interactivity of the intervention, cultural relevance of messages, and tone of the content. In a second phase, consultation was undertaken with Māori (New Zealand's indigenous population) and Pacific groups to explore the relevance and appropriateness of the text message content for Māori and Pacific audiences.

RESULTS

Factors identified as important for ensuring the text message content was engaging, relevant, and useful for recipients were: reducing the complexity of message content and structure; increasing the interactive functionality of the text message programme; ensuring an empowering tone to text messages; and optimising the appropriateness and relevance of text messages for Māori and Pacific people. The final version of the intervention (named 'YourCall(™)') had three pathways for people to choose between: 1) text messages in English with Te Reo (Māori language) words of welcome and encouragement, 2) text messages in Te Reo Māori, and 3) text messages in English (with an option to receive a greeting in Samoan, Tongan, Cook Island Māori, Niuean, Tokelauan, Tuvaluan, or Fijian).

CONCLUSIONS

We have developed a text message intervention underpinned by established BI evidence and behaviour change theory and refined based on feedback and consultation. The next step is evaluation of the intervention in a randomised-controlled trial.

A mobile phone intervention to reduce binge drinking among disadvantaged men: study protocol for a randomised controlled cost-effectiveness trial

BACKGROUND

Socially disadvantaged men are at a substantially higher risk of developing alcohol-related problems. The frequency of heavy drinking in a single session is high among disadvantaged men. Brief alcohol interventions were developed for, and are usually delivered in, healthcare settings. The group who binge drink most frequently, young to middle-aged disadvantaged men, have less contact with health services and there is a need for an alternative method of intervention delivery. Text messaging has been used successfully to modify other adverse health behaviours. This study will test whether text messages can reduce the frequency of binge drinking by disadvantaged men.

METHODS/DESIGN

Disadvantaged men aged 25 to 44 years who drank >8 units of alcohol at least twice in the preceding month will be recruited from the community. Two recruitment strategies will be used: contacting men listed in primary care registers, and a community outreach method (time-space sampling). The intended sample of 798 men will be randomised to intervention or control, stratifying by recruitment method. The intervention group will receive a series of text messages designed to reduce the frequency of binge drinking through the formation of specific action plans. The control group will receive behaviourally neutral text messages intended to promote retention in the study. The primary outcome measure is the proportion of men consuming >8 units on at least three occasions in the previous 30 days. Secondary outcomes include total alcohol consumption and the frequency of consuming more than 16 units of alcohol in one session in the previous month. Process measures, developed during a previous feasibility study, will monitor engagement with the key behaviour change components of the intervention. The study will incorporate an economic evaluation comparing the costs of recruitment and intervention delivery with the benefits of reduced alcohol-related harm.

DISCUSSION

This study will assess the effectiveness of a brief intervention, delivered by text messages, aimed at reducing the frequency of binge drinking in disadvantaged men. The process measures will identify components of the intervention which contribute to effectiveness. The study will also determine whether any benefit of the intervention is justified by the costs of intervening.

TRIAL REGISTRATION

ISRCTN07695192. Date assigned: 14 August 2013.

Perceptions of adult trauma patients on the acceptability of text messaging as an aid to reduce harmful drinking behaviours

Background

Brief interventions (BIs) have been shown to be effective in modifying hazardous drinking behaviours in a range of settings. However, they are underutilised in hospitals due to resource constraints. We explored the perspectives of admitted trauma patients about the appeal, acceptability and content of a Brief Intervention (BI) delivered via text messages.

Methods

Thirty mobile phone users (≥16 years old) admitted to Auckland City Hospital as a result of injury were recruited (December 2010 – January 2011). Participants were interviewed face-to-face during their hospital stay using a semi-structured interview guide that explored topics including perceptions of the proposed intervention to reduce hazardous drinking and related harm, and perceived acceptability of an m-health program. Where issues relating to content of messages were raised by participants these were also captured. In addition, a brief survey captured information on demographic information, mobile phone usage and type of phone, along with the frequency of alcohol use.

Results

22 of the 30 participants were male, and almost half were aged 20 to 39 years. The majority of participants identified as New Zealand Europeans, six as Māori (New Zealand's indigenous population) and of the remainder two each identified as Pacific and of Asian ethnicity. Most (28/30) participants used a mobile phone daily. 18 participants were deemed to be drinking in a non-hazardous manner, seven were hazardous drinkers, and three were non-drinkers. Most participants (21/30) indicated that text messages could be effective in reducing hazardous drinking and related harms, with more than half (17/30) signalling they would sign-up. Factors identified that would increase receptiveness included: awareness that the intervention was evidence-based; participants readiness-to-change; informative messages that include the consequences of drinking and practical advice; non-judgemental messages; and ease-of-use. Areas of potential concern included: confidentiality and frequency of messages. The cultural relevance of the messages for Māori was highlighted as important.

Conclusions

This study indicates that trauma patients recognize potential benefits of mobile-health interventions designed to reduce hazardous drinking. The feedback provided will inform the development of an intervention to be evaluated in a randomised controlled trial.