Transcript Paul Wallace and Stuart Linke Presentation >>

Digital Approaches to Alcohol Problems: Ten
Years Experience with Down Your Drink
(DYD)
Professor Paul Wallace
National Institute of Health Research and University College London
Stuart Linke
Consultant Clinical Psychologist
Camden and Islington NHS Foundation Trust and University College
London
National
Prevention
Research Initiative
The Down Your Drink Team
Paul Wallace
Stuart Linke
Jim McCambridge
Elizabeth Murray
Zarnie Khadjesari
Charles Elstone
Toni Brisbee
Don Shenker
Simon Thompson
Ian White
Ria Kalaitzaki
Andrew Brown
Ceri Butler
Orla O’Donnell
Robert Harrison
Elisa Harwood
Harvey Linke
Richard McGregor
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
1986
Evaluation of a self-help manual for media-recruited
problem drinkers: Six-month follow-up results
Nick 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)
First 10,000 users (registrants)
Age
Mean = 37.5yrs
White British
82%
49%
White Other
9%
Single
37.5%
White Irish
5%
Living with
Children
42%
Asian
1%
Managerial
25.8%
UK resident
84%
Self-employed
9%
US resident
5.5%
Admin/secretarial
8%
Ireland resident
2%
IT
8%
Australia resident
1%
Academic
5%
Canada resident
1%
Homemaker
4%
Unemployed
3.5%
Men
Mean hourly usage of Down Your Drink
(Jan to Dec 2004)
Number of users completing each week of the program
All Users
Male Users
Female Users
No.
%
No.
%
No.
%
Registered
10000
100.0
4891
100
5109
100
Completed
week 1
8933
89.3
4302
88.0
4631
90.6
Completed
week 2
4020
40.2
1916
39.2
2104
41.2
Completed
week 3
3006
30.1
1403
28.7
1603
31.4
Completed
week 4
2411
24.1
1128
23.1
1283
25.1
Completed
week 5
1928
19.3
887
18.1
1041
20.4
Completed
week 6
1654
16.5
770
15.7
884
17.3
Change in clinical outcomes between week 1 and
week 6 in users who completed the 6-week program
12
10
8
6
Baseline
Final
4
2
0
SADD SADD
Men Women
APQ
Men
APQ
Women
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 to
reduce alcohol consumption among hazardous drinkers
BMC Public Health 2007, 7:306 doi:10.1186/1471-2458-7-306
Elizabeth Murray ([email protected])
Jim McCambridge ([email protected])
Zarnie Khadjesari ([email protected])
Ian R White ([email protected])
Simon G Thompson ([email protected])
Christine Godfrey ([email protected])
Stuart Linke ([email protected])
Paul Wallace ([email protected])
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
ODHIN
Optimizing delivery
of health care interventions
Patient leaflet
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.uk
Once you have found the website, please log on using the personalized
username and password below:
Your username: 01003
Your password: XXXXX
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