Improving existing E-health programs: the results of Drinktest.nl

1. Improving existing E-health programs: the results of Drinktest.nl Britt van Lettow¹ MSc., MPH. Hein de Vries² PhD. Alex Burdorf¹ PhD. Pepijn van Empelen¹,³ PhD. ¹Erasmus MC, dep. of Public Health, ²Maastricht University, dep. of Health Promotion, ³TNO, Research Group Lifestyle The Netherlands

2. Presenters disclosure • This research and my visit to the E-Health conference was supported by a grant of project no. 121020020 from ZonMW, Organization for Health Research and Development, the Netherlands. • No conflicts of interest • No commercial support

3. Drinking behavior • All ages: 9.4% (16% among men) • Males (34.1%) > females (9.4%) • Young adults aged 18−25 drink the most: 20% drinks excessively • 1 glass = 10 grams alcohol • Excessive drinking norms in NL: • Males: Females • max. 6 glasses p/d max. 4 glass p/d • max. 5 days p/w max. 5 days p/w • max. 21 glasses p/w max. 14 glasses p/w • Short and long term health and other consequences • Diseases: cancer, cardiovascular diseases • Traffic accidents, injuries • Etc.

4. What is Drinktest.nl? • Meant as online “screening” instrument for people at home • Self-report of own behavior, awareness, etc. • Design: • One moment: questions  feedback  questions  feedback • Tailored feedback regarding their drinking behavior in relation to • Attitude – information on e.g. health to increase awareness • E.g., questions regarding their thoughts on the effect of their drinking behavior on their brains, liver, etc. • Socialnorms – own behavior compared to others, drinking norms • Perceived behavioral control – tips and advice on how to overcome difficulties/barriers

5. Improving E-health program Drinktest.nl • Addition of • Prototypes • Cue reminders  2 studies first, as basis for the development of modules added to original drinktest (not discussed today)

6. Prototypes definition Prototypes – “Perceptions or cognitions of images of a typical person engaging in certain risk or health behavior”  personal characteristics Typical drinker Typical exerciser Typical smoker ……

7. Why prototypes? Prototypes have been related to many (un)healthy behaviors Impact on intention, willingness, and behavior Changing perception is promising for health interventions Based on changing desirability and importance of characteristics The e-health program will provide feedback on which characteristics are attributed to heavy and moderate drinker prototypes.

8. Why cue reminders? Cue reminders help people remember goals, advice, and interventions Cue unrelated to behavior itself E.g. power button – recall info on alcohol use E.g. bracelet – Moroccan women – less sugary meals and snacks E.g. bracelet – condom use among young adults E.g. smiley fridge magnet – healthy diet, less snacking

9. Developing modules added to Drinktest.nl • Aim: reduce alcohol consumption among excessive drinking people • How to best improve drinktest.nl with extra modules? • Inclusion of feedback with prototypes characteristics? • Inclusion of a cue reminder? • Combination of both? • Or nothing?

10. Design • Online • Baseline (T0): 4 study groups (next slide) • Randomisation by computer • Follow-up & evaluation after 1 month (T1) • Only excessive drinkers • Excessive drinking = exceeding: drinking on a max. of 5 days per week, a max. of 4 glasses per day and 14 per week for women, and 6 glasses per day and 21 per week for men • Non-excessive drinkers only receive “original” drinktest.nl and are excluded from further analyses • Incentive: €50, €100 or €250 (raffle) after completion of 3 measurements

11. Overview e-health program: 4 study groups

12. E-health program – Control group • Control group = Original drinktest.nl modules: • Tailored feedback regarding their drinking behavior in relation to • Attitude – information on e.g. health to increase awareness • Social norms – own behavior compared to others, drinking norms • Perceived behavioral control – advice on how to overcome difficulties • Provides info on how much is “responsible” to drink, tailored to gender and own drinking behavior

14. E-health program – Prototype group • Original drinktest.nl modules (tailored feedback on attitude, social norms, pbc) • Tailored feedback based on prototype characteristics: • Which characteristics do you desire for yourself?  feedback which characteristics are related to moderate and heavy drinking • what would happen if you change your drinking behavior: If you decrease your consumption, you will more likely acquire your desired characteristics • Formulate action plans

16. E-health program – Cue reminder group • Original drinktest.nl modules (tailored feedback on attitude, social norms, pbc) • Formulate action plans • Receive a silicon bracelet to remind themselves of their plans and/or information of drinktest.nl  If bracelet is refused, choice of no cue, own jewelry, or other object

18. E-health program – Combi of prototype + cue group Respondent gets all modules Cue reminder to remind of both plans and (un)desired characteristics (thus not only of plans as in cue condition)

19. Overview e-health program: 4 study arms – follow-up after 1 month

20. Results – sample • Online only • Total sample: start with 4827 cases • Only excessive drinkers included • Duplicates and outliers excluded • N = 2924 at T0 (drinktest.nl) • N = 784 (26.8% response) who completed drinktest.nl and follow-up of one month (T1). • 48.1% males • M age = 39.7 (SD = 15.4, range 18-77) • 75.6% high education • 96.2% Western ethnicity

21. Results – Drinking behavior at follow-up • All regression analyses corrected for their baseline outcomes • Differences between groups were tested • Group  Drinking behavior (T1): • Week total – ns • Average nr. of glasses per week day – ns • Average nr. of glasses per weekend day – model: F (3, 783) = 117.6, p = .00, group variable: t = -1.81, p < .007 • combi group < control group (p = .054) • Excessive drinking (i.e., type of drinker) – • combi group < cue group: OR = .65, p < .05 • Tried to decrease consumption (T1): F(3, 780) = 2.91, p < .05 • control < all other groups (p’s < .05)

22. Results continued • All regression analyses corrected for their baseline outcomes • Differences between groups were tested (LSD) • Group intention to reduce drinking (T1): Model: F(2, 782) = 190.5, p < .001, group variable: t(784) = 1.84, p =.07: • combi group > control group (p = .07) • Group  willingness to drink (T1): Model: F(2, 782) = 217.6, p < .001, group variable t(784) = -1.77, p = .08 • combi group < control group (p = .08) • Group  thought of drinktest (T1): F(3, 780) = 6.1, p < .001 • control < all other groups (p’s < .05) • No difference in evaluation of intervention between groups

23. Conclusion and discussion intervention • Combination of feedback on prototypical characteristics and use of a cue reminder most effective compared to control group (i.e., original drinktest) • Temptations, intentions, willingness, drinking in weekends • Trying to decrease consumption, thinking of intervention • Thus, drinktest.nl could be enhanced by the additional modules of a cue reminder and feedback on prototypical characteristics • Preliminary data – still collecting

24. Conclusion and discussion intervention • The results may help in tailoring and targeting interventions (e-health programs) aimed at reducing alcohol consumption via prototypes and cue reminders • Both prototypes and cue reminders can be helpful tools in other interventions to improve lifestyles • Cues do not need to be related to the behavior • Results may be applicable for other behaviors

25. CHEERS!

26. Results – Descriptives Table 13. Descriptives per study group No significant differences between conditions

27. Baseline (T0) differences between groups • Intention – ns • Willingness – ns • Drinking behavior • Weektotal – p < .10 (M = 27.1, SD = 17.3) • Average nr. of glasses per weekday (M = 4.2, SD = 3.6) – ns • Average nr. of glasses per weekendday (M = 6.0, SD = 3.7) – ns