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Internetbased secondary prevention of alcohol problems

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Title: Internetbased secondary prevention of alcohol problems


1
Internet-based secondary prevention of alcohol
problems
  • Anja Koski-Jännes

2
Interest in different forms of self-help in a
general population sample of drinkers(Koski-Jänne
s, A. Cunningham, J. 2001)
3
Use of Internet
  • Fast expansion all over the world ever since the
    middle of the nineties.
  • Wide general interest in health topics
  • 80 of US Internet users have searched online
    information about health topics of those 8 have
    searched for information about problems with
    alcohol and drugs.
  • In 2006 four out of five Finns between 15 and 79
    have used Internet 85 of them use it weekly.
  • 92-99 of people under the age of 35 are current
    users.
  • ?
  • Internet has turned to a viable channel for
    secondary prevention of heavy drinking.

4
Merits of Internet-based services
  • Highly accessible in time and space
  • Affordable
  • Discreet
  • Appealing to people who want to avoid being
    labeled as problem drinkers or alcoholics
  • Could be used either on ones own or as an
    adjunct to other services
  • Easily modifiable can be kept up-to-date

5
Previous research
  • A number of pilot studies and feasibility trials
    have reported on participants' initial
    evaluations of Internet sites providing self-help
    materials for problem drinkers
  • Cunningham, Humphries Koski-Jännes (2000a)
  • Cloud and Peacock (2001)
  • Lieberman (2003)
  • Westrup et al. (2003)
  • Linke, Brown and Wallace (2004)
  • Saitz et al. (2004)
  • Squires and Hester (2002 2004)
  • RCTs
  • Hester Delaney (1997) Kypri et al. (2004)
  • participants used the Internet in the
    researchers office or a health-care centre.
  • ? Comparability to the use of Internet at home?

6
Finnish pilot
  • An Internet site where people could receive
    normative feedback on their drinking was launched
    in the web pages of the Addiction link in June
    2003.
  • Juomatapatesti Drinking Habit Test
  • http//www.paihdelinkki.fi/testaa/juomatapatesti
  • - Comprises of a brief assessment and produces
    a personalized feedback summary designed to
    motivate change in drinkers.
  • Modeled after the one created in Toronto (see
    Cunningham, Humphreys, Koski-Jännes 2000) with
    minor changes in its set-up.

7
Drinking habit test
  • 10 AUDIT questions
  • 6 psychosocial consequence questions
  • of drinks consumed on each day of a typical
    week, or if irregular drinking pattern drinking
    diary over the past month
  • of drinks in the last drinking occasion
  • Demographic data (age, sex, weight)
  • Anonymous responses were saved with an ID number
    in a safe dataset by the A Clinic Foundation
  • Time needed for responding 5 minutes.

8
Personalized normative feedback
  • Comparison of the participants drinking with
    other Finns (males and females)
  • Total of drinking days in a year
  • T of drinks in a year
  • Money spent on alcohol in a year
  • Caloric intake in a typical drinking day
  • Drinks consumed and BAC
  • Probability of accidents at different levels of
    BAC
  • A link for estimating hours to eliminate daily
    intake
  • of hours under the influence in a year
  • Personal AUDIT score and level of risk
  • Upper limits of sensible drinking

9
(No Transcript)
10
Goals of the study
  • Comparison of the volunteer study participants
    with the anonymous users of this Internet service
  • Survey on participant reactions to the
    personalized feedback.
  • Comparison of alcohol consumption and problems at
    the time of screening and three months later
    among the volunteer study participants.

11
Subjects
  • During the recruitment period (March October,
    2004)
  • 22 536 self-assessments were completed,
  • 7 of whom responded to the survey.
  • The survey respondents (n1598) were asked if
    they wanted to participate in the follow-up
    study.
  • 22 (n351) agreed by providing their e-mail
    address
  • 3 persons who responded for somebody else and 5
    persons with incomplete data were excluded.
  • Study sample (n 343)
  • Comparison sample A random sample (n 581) of
    the service users

12
Table 1. Background data on the study subjects
compared to a random sample of service users
during the same period __________________________
____________________________________________ S
tudy sample Service usersVariable (n
343) (n 581) p____________________________
__________________________________ women
60.6 49.2 .001 Mean (SD) age 32.6
(11.9) 30.4 (12.5) .007 Mean (SD) AUDIT 17.0
(8.7) 14.1 (8.1) .000
Mean (SD SqrtMean)
drinks in the last occasion 8.5 (6.2
2.6) 7.8 (5.7 2.7) ns.


Mean
(SD SqrtMean) drinks in a typical week
19.0 (18.5 2.7) 12.2 (14.4 3.8) .000
Mean (SD)
consequences of drinking 2.7(2.1)
1.9 (1.9) .000





































_________________________________________________
_____________ SqrtMean is the mean square root
transformed value employed in the comparison for
this variable because of positive skew .
Mann-Whitney U-test.
13
Table 2. Responses to the survey (n343)
  • __________________________________________________
    _______________
  • Questions
  • __________________________________________________
    _______________
  • How useful did you Very useful 41
  • find the feedback? Somewhat 52
  • Not at all 7
  • Was there something Yes 40
  • surprising in it? No 60
  • Has your drinking been Unproblematic 38
  • problematic in your Partly problematic 40
  • own opinion? Clearly problematic 22
  • Audit scores no problem (lt 8) 16
  • at risk drinking (8-13) 20
  • high risk drinking (gt13) 64
  • Did the recommended Too tight 34

14
Typical causes of surprise
  • That I drink so much more than people on
    average.
  • How slowly alcohol disappears from ones body.
  • The number of days spent under the influence of
    alcohol.
  • That my drinking was clearly harmful.
  • The calories.

15
3-month follow-up
  • The subjects received an e-mail asking them to
    click a link to the follow-up questions.
  • Their ID number was attached to this link and it
    was automatically saved with their responses in a
    separate data set.
  • Questions similar to the baseline questions
    (concerned the last 3 months)
  • Additional questions (on past 3 months)
  • Have you received any treatment or participated
    in self help groups?
  • Have you changed your drinking in any way?
  • Have you recommended this site to anybody else?
  • Has the reduction of prices on alcohol had any
    effect on your drinking?
  • 78 response rate.
  • No significant differences between the responders
    and non-responders.

16
Table 3. Data on drinking by those who responded
to the baseline and 3-month follow-up (n
269) _____________________________________________
____________________ Variable Baseline 3-month
follow-up p _____________________________________
____________________________ Mean (SD) AUDIT
score 16.6 (8.6) 13.8 (8.0) .000 Mean (SD)
AUDIT-C score 7.4 (2.5) 6.8 (2.6) .000 Mean
(SD, sqrtMean) drinks in a typical
week 19.1 (18.5, 3.8) 13.8 (14.5,
3.1) .000 Mean (SD, sqrtMean) drinks
in the in the last occasion 8.4 (6.0, 2.7)
7.1 (6.4, 2.4) .000 Mean (SD) of drinking
consequences 2.7 (2.1) 2.1
(2.0) .000 ____________________________________
_____________________________ SqrtMean is the
mean square root transformed value employed in
the comparison for this variable because of
positive skew. Wilcoxon Signed Ranks test.
17
Additional findings at 3 months
  • Only 4 participated in treatment/self-help
    groups during past 3 months
  • 27 had recommended the test to others
  • 34 of women and 18 of men (p .006)
  • 41 had done the test again on their own.
  • Perceived effects of price reductions 13
    increased, 70 no change, 18 decreased.
  • The largest drop in AUDIT-C scores occurred in
    subjects who regarded their drinking as at least
    somewhat problematic in the beginning (p lt
    .05).

18
Summary of main results
  • 93 found the feedback useful.
  • Highly significant reductions in all the outcome
    variables.
  • Women were
  • more eager to participate than men (61 vs. 40 )
  • more surprised by the feedback (47 vs. 30)
  • recommended the test more often to others (34
    vs. 18).
  • No sex differences in the main outcome variables.
  • People who regarded their drinking as problematic
    at the baseline were more successful reducers
    (plt.05) than those who did not.

19
Discussion
  • Were the reductions caused by the personalized
    feedback?
  • AUDIT scores ? in the study sample, while they ?
    among the service users in general from the first
    to the last quarter of the study period (13.8
    ?14.2) reflecting the general increase of
    drinking in Finland after the price reductions of
    April 2004.
  • The changes in drinking were similar to those in
    Cunningham et al. (2005) with a smaller sample
    (ns.)

20
Other possible explanations
  • Attempts to please the researchers?
  • not probable due to subject anonymity ( nothing
    to gain by lying)
  • Seasonal variation?
  • not probable because the follow-up data were
    gathered over the heavier drinking summer and
    fall months.
  • Regression to the mean?
  • Possible in populations where heavier users
    self-select themselves to the study.
  • Controlling for this possibility requires a
    randomized study.

21
Research continues...
  • Cunningham, Humphries, Koski-Jännes Cordingley
    (2005)
  • After receiving web-based normative feedback the
    subjects could click a link to the consent form
    and sign up for the study.
  • Random assignment to
  • web-based self-assessment or web-based
    self-assessment a mailed self-help book
  • Combined approach gt the self-assessment alone.
  • Drinking was reduced also in the self-assessment
    alone about the same amount as in Finland, but
    due to small sample size the effect was ns.
  • ?Limitation Lack of no treatment control group

22
Conclusion
  • Internet-based self-assessment services provide a
    highly promising avenue for primary and secondary
    prevention of excessive drinking.
  • Huge public health potential for various
    underserved populations young people, those
    living in rural areas, people with limitations in
    transportation, etc.
  • Heavy drinkers seem to profit more than lighter
    drinkers
  • Especially appealing for women.
  • Some initial research has also been made with
    other drug use
  • Internet services for substance abusers should be
    further developed and studied.
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