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Digital Approaches to Alcohol Problems: Ten Years Experience
with Down Your Drink (DYD)
Professor Paul WallaceNational Institute of Health Research and
University College London Stuart LinkeConsultant Clinical
PsychologistCamden 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 TeamCharles ElstoneToni Brisbee
Don Shenker
Ria Kalaitzaki Andrew BrownCeri ButlerOrla ODonnellRobert
HarrisonElisa Harwood
Harvey LinkeRichard McGregorPaul WallaceStuart LinkeJim
McCambridgeElizabeth MurrayZarnie KhadjesariSimon ThompsonIan
WhiteChristine Godfrey
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The size of the problemestimated 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 Background1986Evaluation of a self-help manual for
media-recruited problem drinkers: Six-month follow-up resultsNick
Heather*, Barbara Whitton1, Ian Robertson1987 (or
thereabouts)Alcohol Services Pontefract & Wakefield
1988 The DYD 6 week postal programme
2001
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Key FeaturesHome Page Screening Questionnaire (FAST) (on screen
feedback)
6 sequential weekly modulesOnline Drinking DiaryAlcohol
Consumption CalculatorBAC calculatorPersonal thinking drinking
logIntelligent 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-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.
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(J Med Internet Res 2007;9(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 toreduce 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
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2-arm trial - comparison with information only website
Primary Outcome - total past week alcohol consumption at 3
months
Secondary outcomes questionnaireshazardous or harmful drinking
dependence harm caused by alcoholmental healthhealth 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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ContentSelf 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 37yrs57% were women52% 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 monthsThe 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-1300Naturalistic 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 changeThe continuing
digital divideThe level of noise in the IT/Communications age
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Current and Future Projects
Occupational settingsWe 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 URLReferral by GPDedicated 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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ODHINOptimizing delivery of health care interventions
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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
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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.org.ukOnce you
have found the website, please log on using the personalized
username and password below:
Your username: 01003Your password: XXXXX
Patient leaflet
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Effectiveness of primary care based facilitated access to
alcohol reduction website EFARNon-inferiority randomised controlled
trialComparison of online intervention with face to face for
hazardous drinkersRecruitment in general practiceOn-line consent,
assessment, randomisation and follow-upEffect 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
reviewOption to share the data which patient enters on the website
with referring GP
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