Digital Approaches to Alcohol Problems: Ten Years Experience with Down Your Drink

(DYD)

Professor Paul WallaceNational Institute of Health Research and University College London

Stuart LinkeConsultant Clinical Psychologist

Camden and Islington NHS Foundation Trust and University College London

National Prevention

Research Initiative

The Down Your Drink Team

Charles ElstoneToni Brisbee

Don Shenker

Ria Kalaitzaki Andrew BrownCeri ButlerOrla O’DonnellRobert HarrisonElisa Harwood

Harvey LinkeRichard McGregor

Paul Wallace

Stuart Linke

Jim McCambridgeElizabeth MurrayZarnie Khadjesari

Simon Thompson Ian White Christine Godfrey

The size of the problem

• estimated 26% of the population of England (38% of men and 16% of women aged 16 – 64) drink hazardously or harmfully, equating to approximately 7.1 million people in England alone

• associated with physical problems, mental health problems, antisocial behaviour, violence, accidents, suicides, injuries, road traffic accidents, unsafe sexual behaviour, underperformance at work or school, and crime

• cost to the NHS alone calculated as £1 billion – £2 billion

Alcohol Needs Assessment Research Project (ANARP)

fewer than 1 in 18 people with an alcohol misuse disorder in the UK have access to appropriate treatment

Digital interventions may assist in reducing this discrepancy

The Background

1986Evaluation of a self-help manual for media-recruited problem drinkers: Six-month follow-up resultsNick Heather*, Barbara Whitton1, Ian Robertson

1987 (or thereabouts)Alcohol Services Pontefract & Wakefield

1988 The DYD 6 week postal programme

2001

Key Features

Home Page Screening Questionnaire (FAST) (on screen feedback)

6 sequential weekly modules

Online Drinking Diary

Alcohol Consumption Calculator BAC calculator

Personal “thinking drinking” log

Intelligent email

50,000 leaflets outlining the main features of DYD were distributed as inserts in GP magazines

Launched at the AERC annual conference in Edinburgh with associated press releases

Listings in Health Publications & BBC website

Registration with Yahoo Search Engine

Down your drink: a web-based intervention for people with excessive alcohol consumption.

Linke S, Brown A, and Wallace P

Alcohol and Alcoholism 2004 Jan-Feb;39(1):29-32.

RESULTS: During the 6-month study there were 7581 visits to the site and 1319 registrations. Of the registrants, 61.8% completed week 1, and 6.0% stayed with the programme until the end. The 6% who stayed for 6 weeks provided encouraging feedback about the value of the site.

(J Med Internet Res 2007;9(2):e10)

4%Homemaker

3.5%Unemployed

1%Canada resident5%Academic

1%Australia resident8%IT

2%Ireland resident8%Admin/secretarial

5.5%US resident9%Self-employed

84%UK resident25.8%Managerial

1%Asian42%Living with Children

5%White Irish37.5%Single

9%White Other49%Men

82%White BritishMean = 37.5yrsAge

First 10,000 users (registrants)

Mean hourly usage of Down Your Drink (Jan to Dec 2004)

17.388415.777016.51654Completed week 6

20.4104118.188719.31928Completed week 5

25.1128323.1112824.12411Completed week 4

31.4160328.7140330.13006Completed week 3

41.2210439.2191640.24020Completed week 2

90.6463188.0430289.38933Completed week 1

10051091004891100.010000Registered

% No. % No. % No.

Female Users Male Users All Users

Number of users completing each week of the program

0

2

4

6

8

10

12

SADDMen

SADDWomen

APQMen

APQWomen

BaselineFinal

Change in clinical outcomes between week 1 and week 6 in users who completed the 6-week program

User Feedback

At the end of the 6 week programme users were invited to send in (anonymous) emails

responding to probe questions

“Signing on everyday to complete the drinking diary meant i had to take ownership of my drinking- it was staring me in the face- if I had lied I would have been

lying to myself” (participant 56)

“you don’t tell people off or come up with scare tactics” (participant 6)

“I particularly appreciated the non-judgmental attitude of the course – it is helpful to know that the aim is not to cut alcohol out of one’s life completely.” (participant 8)

“I am learning from my mistakes. I think a lot about how I drink alcohol, what triggers are involved and have started to try and avoid drinking, when I do drink I go to a good wine and sip slowly”. (participant 47)

The DYD-RCT protocol: an on-line randomised controlled trial of an interactive computer-based intervention compared with a standard information website toreduce alcohol consumption among hazardous drinkers

BMC Public Health 2007, 7:306 doi:10.1186/1471-2458-7-306

Elizabeth Murray (elizabeth.murray@pcps.ucl.ac.uk)Jim McCambridge (Jim.McCambridge@lshtm.ac.uk)Zarnie Khadjesari (z.khadjesari@pcps.ucl.ac.uk)Ian R White (ian.white@mrc-bsu.cam.ac.uk)Simon G Thompson (simon.thompson@mrc-bsu.cam.ac.uk)Christine Godfrey (cg2@york.ac.uk)Stuart Linke (stuart.linke@candi.nhs.uk)Paul Wallace (p.wallace@pcps.ucl.ac.uk)

MRC Complex Interventions Framework Phase 2/3 trial

2-arm trial - comparison with information only website

Primary Outcome - total past week alcohol consumption at 3 months

Secondary outcomes questionnaires hazardous or harmful drinking dependence harm caused by alcohol mental health health economic analysis

Randomisation to secondary outcome measures to minimise assessment burden

Online Trial – but offline details requested for follow up

Primary analysis based on completers, not ITT

Methodological Challenges • Recruitment to ensure sufficient statistical power

•What constitutes an adequate comparison and what are we controlling for?

• How do we detect multiple registrations and how do we deal with them?

• How do we minimise attrition from:• the intervention (stickiness)• the trial (problem of missing data)

• What constitutes an adequate intervention “dose” or “exposure” and how can this be measured?

• Does online assessment behave in the same way as conventional assessment?

Changes to the Intervention

•Removed the lock out and 6 week structure

• Explicit Psychological Treatment Model

•Updated the “look and feel” and images

The new site was “runner up” for the NHS London Innovations Award

Content

Self Assessment and Automated Feedback

3 Phases:• It’s Up To You (Motivational Interviewing)

• Making the Change (Behavioural Self Control & Cognitive Behaviour Therapy)

• Keeping on Track (Relapse Prevention)

MAIN RESULTS.

• Mean age was 37yrs• 57% were women• 52% educated to at least degree level.• The majority identified themselves as white British (84%)

• All the participants were drinking hazardously at the beginning of the study (geometric mean of 46 units per week)

• This reduced to 26 units at 3 months and maintained at 12 months

• The same changes happened in both groups.

How big is the elephant in the room? Estimated and actual IT costs in an online behaviour change trial.McCambridge, J., O'Donnell, O., Godfrey, C., Khadjesari, Z., Linke, S., Murray, E., & Wallace, P. (2010). BMC Research Notes, 3

Impact and Costs of Incentives to Reduce Attrition in Online Trials: Two Randomized Controlled Trials KHADJESARI, Z., Murray, E., Kalaitzaki, E., White, I. R., McCambridge, J., Thompson, S. G., . . . Godfrey, C. (2011). Journal of Medical Internet Research, 13 (1)

Impact of length or relevance of questionnaires on attrition in online trials: randomized controlled trial

McCambridge, J., Kalaitzaki, E., White, I. R., Khadjesari, Z., Murray, E., Linke, S., . . . Wallace, P. (2011).. J Med Internet Res, 13 (4),

DYD is very popular!

• Pilot Study - 1300

• Naturalistic Cohort Study - 10000

• Trial - 7935

DYD use since finishing the trial

78.04% New Visitor 21.96% Returning Visitors

What do the results mean?

• Lots of people register - only a few make full use of the intervention (dose) – but many dramatically reduce their drinking

• Users do not distinguish between the intervention assessments and being in the trial (reactivity)

• Users are probably look for help and are highly motivated to change (regression to the mean) and don’t just use DYD

What is the role of digital interventions

• There are now many alcohol interventions on a range of different platforms

• Apps and websites can be embedded within social networks, medical information systems and public educational material.

• We need a strategic approach to the application of this technology recognising:

– The rapid speed of change

– The continuing “digital divide”

– The level of “noise” in the IT/Communications age

Current and Future Projects

• Occupational settings– We are currently analysing the data from a trial with a

large multinational company.– Alcohol Health Network – Don Shenker

• EFAR and ODHIN

• Increasing Access through Primary Care

– Pilot implementation study in Kingston (Murray et al 2012)

• Dedicated URL• Referral by GP• Dedicated worker providing facilitated access

– Islington IAPT (Improving Access to Psychological Therapies)

• Primary Care Mental Health Workers offering routine Screening and Brief Interventions and signposting to DYD

ODHINOptimizing delivery

of health care interventions

Why am I giving you this personalized referral leaflet?I am giving you this personalized referral leaflet with your own Internet login number because I would like you to make use of the Internet based advice resources at www.healthierdrinkingchoices.org.uk. This specially designed website which can only be used following a GP referral will help you reflect on your drinking and the possible impact it might be having on your health and wellbeing. It will also give you the chance to make some positive choices about how you are going to drink in the future.

Patient leaflet

This leaflet gives you details of how to log on using the personalized GP referral username and password which you’ll find in the box below. Either of these can be changed once you have logged on to create your own personal profile if you wish. Either way, your data is completely confidential and no-one else will be able to see which information you enter on the website. What to do now?Please find a time over the next 2-3 days when you are able to use an appropriate way to access the Internet at home or elsewhere. Once you are online, please access the HealthierDrinkingChoices website either by typing “healthydrinking choices” into your browser by going directly to www.healthierdrinkingchoices.org.ukOnce you have found the website, please log on using the personalized username and password below:

Your username: 01003Your password: XXXXX

Patient leaflet

Effectiveness of primary care based facilitated access to alcohol reduction website – EFAR

• Non-inferiority randomised controlled trial• Comparison of online intervention with face to face for

hazardous drinkers• Recruitment in general practice• On-line consent, assessment, randomisation and

follow-up• Effect size to be excluded: 5% difference between two

arms

The intervention 

• High quality alcohol reduction website • Introductory patient information pack, including a leaflet

and a (scratch) card with the patient's unique log-on user number and the website URL.

• Explanation of the nature and purpose of the site • Offer of follow up and review• Option to share the data which patient enters on the

website with referring GP