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

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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

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National Prevention Research Initiative
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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
ODonnell Robert Harrison Elisa Harwood Harvey
Linke Richard McGregor
Simon Thompson
Ian White
Christine Godfrey
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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

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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

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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
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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

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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
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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-Feb39(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.
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(J Med Internet Res 20079(2)e10)
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First 10,000 users (registrants)
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Mean hourly usage of Down Your Drink (Jan to Dec
2004)
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Number of users completing each week of the
program
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Change in clinical outcomes between week 1 and
week 6 in users who completed the 6-week program
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User Feedback At the end of the 6 week
programme users were invited to send in
(anonymous) emails responding to probe
questions
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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)
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you dont 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 ones life completely.
(participant 8)
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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)
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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, 7306
doi10.1186/1471-2458-7-306 Elizabeth Murray
(elizabeth.murray_at_pcps.ucl.ac.uk) Jim McCambridge
(Jim.McCambridge_at_lshtm.ac.uk) Zarnie Khadjesari
(z.khadjesari_at_pcps.ucl.ac.uk) Ian R White
(ian.white_at_mrc-bsu.cam.ac.uk) Simon G Thompson
(simon.thompson_at_mrc-bsu.cam.ac.uk) Christine
Godfrey (cg2_at_york.ac.uk) Stuart Linke
(stuart.linke_at_candi.nhs.uk) Paul Wallace
(p.wallace_at_pcps.ucl.ac.uk)
MRC Complex Interventions Framework Phase 2/3
trial
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• 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

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• 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?

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• 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

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Content

• Self Assessment and Automated Feedback
• 3 Phases
• Its Up To You (Motivational Interviewing)
• Making the Change (Behavioural Self Control
  Cognitive Behaviour Therapy)
• Keeping on Track (Relapse Prevention)

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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.

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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 trialMcCambridge, J.,
Kalaitzaki, E., White, I. R., Khadjesari, Z.,
Murray, E., Linke, S., . . . Wallace, P. (2011)..
J Med Internet Res, 13 (4),
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DYD is very popular!

• Pilot Study - 1300
• Naturalistic Cohort Study - 10000
• Trial - 7935

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DYD use since finishing the trial
78.04 New Visitor 21.96 Returning Visitors
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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
  dont just use DYD

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• 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

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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

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• 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

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• ODHIN
• Optimizing delivery
• of health care interventions

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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.
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Patient leaflet
This leaflet gives you details of how to log on
using the personalized GP referral username and
password which youll 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.or
g.uk Once you have found the website, please log
on using the personalized username and password
below
Your username 01003 Your password XXXXX
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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

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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

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Thank You