The Promise of Systems Science in Health Behavior Research: The Example of Studying Drinking Events

This paper is based on my Research Laureate Address to the American Academy of Health Behavior, Portland Oregon, March 4th, 2018. The paper follows the basic content and structure of my address but has been written in a style more consistent with a scientific essay rather than a transcript of a verbatim speech

Contextual characteristics of adults’ drinking occasions and their association with levels of alcohol consumption and acute alcohol‐related harm : a mapping review

Background and Aims There is a growing literature using event‐level methods to estimate associations between contextual characteristics of drinking occasions, consumption levels, and acute harms. This literature spans many research traditions and has not been brought together as a whole. This mapping review aimed to identify and describe the theoretical approaches to conceptualising drinking occasions, study designs, predictors, and outcome measures used in existing research with a view to identifying dominant approaches, research gaps and areas for further synthesis. Methods Eligible papers studied adults’ drinking occasions using quantitative event‐level methods and considered one or more contextual characteristics (e.g. venue, timing, or company) and at least one event‐level consumption or acute alcohol‐related harm outcome. We systematically searched Ovid MEDLINE, PsycInfo, and the Web of Science Social Sciences Citation Index, extracting data on studies’ theoretical approach, data collection methods, settings, populations, drinking occasion characteristics, and outcome measures. Results Searches identified 278 eligible papers (from 1975 to 2019), predominantly published after 2010 (n=181; 65.1%). Most papers reported research conducted in the United States (n=170; 61.2%) and half used student participants (n=133; 47.8%). Papers typically lacked a stated theoretical approach (n=203; 73.0%). Consistent with this, only 53 (19.1%) papers studied three or more occasion characteristics and most used methods that assume occasion characteristics do not change during an occasion (n=189; 68.0%). The most common outcome type considered was consumption (n=224; 80.6%) and only a few papers studied specific acute harm outcomes such as unprotected sex (n=24; 8.6%), drink driving (n=14; 5.0%) or sexual violence (n=9; 3.2%). Conclusions Studies from 1975 to 2019 using event‐level methods to estimate associations between contextual characteristics of drinking occasions, consumption levels, and acute harms were largely focused on students and consumption outcomes and most have considered a limited range of contextual characteristics

Evaluating local-level interventions to address alcohol-related harms in England: the development and application of a complex systems perspective to process evaluations

Background: Alcohol misuse is a wicked problem that may be best addressed by applying a complex systems perspective to the development and evaluation of alcohol interventions. Public health researchers have increasingly advocated this perspective, but the methods for complex systems process evaluations are under-developed. This thesis aims to develop and apply a framework for the application of a complex systems perspective to process evaluations of interventions to reduce alcohol-associated harms. Methods: The research involved 4 elements: i) a qualitative study involving interviews (n=30) and a focus group to evaluate the mechanisms by which the intervention ‘Reducing the Strength’ (RtS) may generate multi-level changes; ii) a scoping review of 87 primary studies and 3 systematic reviews to describe the scope of complex systems alcohol research; iii) a systematic review of 21 complex systems process evaluations and the development of a framework for qualitative process evaluation from a complex systems perspective; and iv) the application of this framework to evaluate the ‘Late Night Levy’ (LNL) using documentary analysis, interviews (n=21) and observations (35.5 hours). Findings: Alcohol interventions may generate multiple changes within and beyond the systems into which they are implemented. Alcohol research taking a complex systems perspective focuses on individual and local systems, with far less analysis of regional, national and international systems. Process evaluations from a complex systems perspective describe systems at a single timepoint, but utilise few complexity concepts to analyse system change. A two-phase process evaluation framework illustrates how to assess mechanisms of system change following intervention implementation. Applying the framework to evaluate the LNL demonstrated how the levy generated system changes which were both anticipated and unanticipated by system actors. Conclusion: The process evaluation framework can produce holistic appraisals of how interventions generate system changes across system levels; evaluators should further apply and refine the framework

The development of a context specific survey to measure drinking occasions

Background Extensive research has examined how contextual characteristics of drinking occasions, such as why and where an individual drinks, independently influence alcohol-related outcomes. Limited research has considered which characteristics should be measured and how they should be measured. This thesis aimed to undertake literature-based and primary research to develop and test a context-specific survey to measure the characteristics of drinking occasions. Methods Firstly, a systematic review identified and assessed the data collection techniques used within the event-level literature to measure occasion characteristics. Secondly, a content analysis of discussion forums identified the most mentioned characteristics of heavy drinking occasions within posts to online alcohol support discussion forums. Thirdly, drawing on the findings from the first two studies, the process of developing and testing a context-specific drinking occasion survey, using expert and public input and cognitive testing is described. Finally, the survey is used to collect and analyse cross-sectional data to identify which occasion characteristics are associated with consumption amongst heavy drinkers and their heavy drinking occasions. Results Whilst no gold-standard data collection approach was found, retrospective drinking diaries were identified as most appropriate for the current research due to good compliance rates and low participant burden. In identifying which characteristics should be measured, why, where, who, when, and what individuals drank were salient within discussions of their heavy drinking occasions. Through expert and public input, several changes to survey design led to the creation of a context-specific survey. In using the survey, contextual characteristics accounted for significantly more variance in consumption than individual characteristics within heavy drinkers’ occasions and their heavy drinking occasions. Conclusions and recommendations Through an iterative development and testing process this thesis produced a novel context-specific drinking occasion survey which contains key characteristics relevant to heavy drinking. Future research should use this survey to provide a comprehensive analysis of the drinking occasion characteristics that account for variation in consumption