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

1. 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

2. National Prevention Research Initiative

3. The Down Your Drink Team Paul Wallace Stuart Linke Jim McCambridge Elizabeth Murray Zarnie Khadjesari Charles Elstone Toni Brisbee Don Shenker Ria Kalaitzaki Andrew Brown Ceri Butler Orla O’Donnell Robert Harrison Elisa Harwood Harvey Linke Richard McGregor Simon Thompson Ian White Christine Godfrey

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

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

11. Age Mean = 37.5yrs White British 82% Men 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% First 10,000 users (registrants)

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

13. 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 Number of users completing each week of the program

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

15. User Feedback At the end of the 6 week programme users were invited to send in (anonymous) emails responding to probe questions

16. “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)

18. “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)

19. “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)

20. 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 (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

21. 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

22. 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?

23. 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

25. 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)

27. 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.

28. 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, 3Impact and Costs of Incentives to Reduce Attrition in Online Trials: Two Randomized Controlled TrialsKHADJESARI, 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 trialMcCambridge, J., Kalaitzaki, E., White, I. R., Khadjesari, Z., Murray, E., Linke, S., . . . Wallace, P. (2011).. J Med Internet Res, 13 (4),

29. DYD is very popular! • Pilot Study - 1300 • Naturalistic Cohort Study - 10000 • Trial - 7935

30. DYD use since finishing the trial

31. 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

32. 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

33. 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

34. 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

35. ODHIN Optimizing delivery of health care interventions

37. 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.

38. 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

39. 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

40. 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

44. Thank You