Reaching out : Internet-based self-assessment of problematic substance use with personalized feedback

Background: Effective treatment methods for reducing problematic substance use exist for delivery by professional treatment providers. However, they are highly underutilized since the vast majority of the substance users never seek professional help for their problematic use. In recent years, Internet-based interventions have been recognized as potentially effective tools for reaching individuals with problematic substance use and reducing such use. The aim of this thesis is to describe the development of eScreen.se, a Swedish Internet-based screening and brief intervention service for problematic alcohol and drug use, and to explore whether eScreen.se is an effective way of reaching problematic alcohol and drug users as well as an effective service for reducing their problematic substance use. Method: In a naturalistic study, eScreen.se users were studied with regard to their individual characteristics and utilization patterns during the first 20 months of public availability for eScreen.se (Study I). Using the same electronic screening instruments that are part of eScreen.se, the prevalence of problematic alcohol and illicit drug use was explored among 1861 individuals in a random sample from the Swedish general population (Study II). The effects of eScreen.se on reducing problematic substance use were explored in two randomized controlled trials, one with 634 problematic alcohol users (Study III) and the second with 202 illicit drug users (Study IV). In both trials, the interventions were compared to Internet-based assessment only. In the alcohol trial, eScreen.se was also compared to an online self-help intervention based on the principles of Cognitive-Behavioral Therapy (CBT) and Motivational Interviewing (MI), Alkoholhjalpen.se. Participants in both trials were followed up for 6 months (drugs) and 12 months (alcohol) after recruitment to the study. Results: Of the 2361 individuals that created an account at eScreen.se during the first 20 months of public availability, 51 percent were women, with a mean age of 23 years (SD=10) in the total sample. In total, 67 percent reported problematic alcohol use while 46 percent reported problematic use of illicit drugs. The highest prevalence of problematic use was found among 18- 24 year olds (76 percent for problematic alcohol use and 64 percent for illicit drug use), with small gender differences. Corresponding prevalence figures for the sample from the Swedish general population were 21 percent for problematic alcohol use and 3 percent for illicit drug use. The psychometric properties of the electronic tests used in eScreen.se were very good, with Cronbach's α values well above 0.80. The two randomized controlled trials showed that eScreen.se was associated with a decrease in substance use occurring in the first three months and maintained for up to 12 months. However, among individuals with problematic alcohol use, eScreen.se was equally effective to Internet-based assessment only and partial indications were found showing that the use of the more intensive service Alkoholhjalpen.se was more effective in reducing problematic alcohol use than the use of eScreen.se or assessment only. Partial indications also showed that the use of eScreen.se among illicit drug users was more effective in reducing drug-related problems than Internet-based assessment only, up to three months after recruitment to the study, with effects maintained up to six months. Use of eScreen.se was also associated with decreasing alcohol consumption and alcohol-related problems among drug users, up to six months after recruitment to the study. Conclusions: Through eScreen.se, an Internet-based screening and brief intervention service, professional instruments for identifying individuals with problematic substance use have been made available on a broad population basis. eScreen.se has been shown to be an important platform for reaching groups that are underrepresented in traditional treatment settings and the use of the service is associated with decreases in substance use including alcohol and illicit drugs

Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care

Background: Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention. Methods: Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving na\uefve understanding, structural analysis and comprehensive understanding. Results: Two major themes captured clinicians\u27 perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one\u27s perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines. Conclusions: In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors

Key Intervention Characteristics in e-Health: Steps Towards Standardized Communication

PURPOSE: This paper reports expert opinion on e-health intervention characteristics that enable effective communication of characteristics across the diverse field of e-health interventions. The paper presents a visualization tool to support communication of the defining characteristics. METHODS: An initial list of e-health intervention characteristics was developed through an iterative process of item generation and discussion among the 12 authors. The list was distributed to 123 experts in the field, who were emailed an invitation to assess and rank the items. Participants were asked to evaluate these characteristics in three separate ways. RESULTS: A total of 50 responses were received for a response rate of 40.7%. Six respondents who reported having little or no expertise in e-health research were removed from the dataset. Our results suggest that 10 specific intervention characteristics were consistently supported as of central importance by the panel of 44 e-intervention experts. The weight and perceived relevance of individual items differed between experts; oftentimes, this difference is a result of the individual theoretical perspective and/or behavioral target of interest. CONCLUSIONS: The first iteration of the visualization of salient characteristics represents an ambitious effort to develop a tool that will support communication of the defining characteristics for e-health interventions aimed to assist e-health developers and researchers to communicate the key characteristics of their interventions in a standardized manner that facilitates dialog

Mobile phone brief intervention applications for risky alcohol use among university students : a randomized controlled study

BACKGROUND: Brief interventions via the internet have been shown to reduce university students' alcohol intake. This study tested two smartphone applications (apps) targeting drinking choices on party occasions, with the goal of reducing problematic alcohol intake among Swedish university students.METHODS: Students were recruited via e-mails sent to student union members at two universities. Those who gave informed consent, had a smartphone, and showed risky alcohol consumption according to the Alcohol Use Disorders Identification Test (AUDIT) were randomized into three groups. Group 1 had access to the Swedish government alcohol monopoly's app, Promillekoll, offering real-time estimated blood alcohol concentration (eBAC) calculation; Group 2 had access to a web-based app, PartyPlanner, developed by the research group, offering real-time eBAC calculation with planning and follow-up functions; and Group 3 participants were controls. Follow-up was conducted at 7 weeks.RESULTS: Among 28574 students offered participation, 4823 agreed to join; 415 were excluded due to incomplete data, and 1932 fulfilled eligibility criteria for randomization. Attrition was 22.7-39.3 percent, higher among heavier drinkers and highest in Group 2. Self-reported app use was higher in Group 1 (74%) compared to Group 2 (41%). Per-protocol analyses revealed only one significant time-by-group interaction, where Group 1 participants increased the frequency of their drinking occasions compared to controls (p = 0.001). Secondary analyses by gender showed a significant difference among men in Group 1 for frequency of drinking occasions per week (p = 0.001), but not among women. Among all participants, 29 percent showed high-risk drinking, over the recommended weekly drinking levels of 9 (women) and 14 (men) standard glasses.CONCLUSIONS: Smartphone apps can make brief interventions available to large numbers of university students. The apps studied using eBAC calculation did not, however, seem to affect alcohol consumption among university students and one app may have led to a negative effect among men. Future research should: 1) explore ways to increase user retention, 2) include apps facilitating technical manipulation for evaluation of added components, 3) explore the effects of adapting app content to possible gender differences, and 4) offer additional interventions to high-risk users.TRIAL REGISTRATION: clinicaltrials.gov: NCT01958398

Mobile phone apps for university students with hazardous alcohol use : study protocol for two consecutive randomized controlled trials

Background: About 50% of university students overconsume alcohol, and drinking habits in later adulthood are to some extent established during higher educational studies. Several studies have demonstrated that Internet-based interventions have positive effects on drinking habits among university students. Our recent study evaluated two mobile phone apps targeting drinking choices at party occasions via personalized feedback on estimated blood alcohol concentration (eBAC) for students with hazardous drinking. No changes in drinking parameters were found over a seven-week period apart from an increase in number of drinking occasions among men for one of the apps tested. Up to 30% of the study participants drank at potentially harmful levels: higher than the national recommended number of standard drinks per week (a maximum of 9 for women and 14 for men) in Sweden. Objective: (1) To evaluate improved versions of the two mobile phone apps tested in our prior trial, in a new, 3-armed randomized controlled trial among university students with at least hazardous drinking habits according to the Alcohol Use Disorders Identifications Test (AUDIT; Study 1). (2) After 6 weeks, to target study participants showing alcohol consumption higher than the national recommended levels for standard drinks per week by offering them participation in a second, 2-armed randomized trial evaluating an additional mobile phone app with skill enhancement tasks (Study 2). (3) To follow participants at 6, 12 and 18 weeks after recruitment to Study 1 and at 6 and 12 weeks after recruitment to Study 2. Methods: Two randomized controlled trials are conducted. Study 1: Students are recruited at four Swedish universities, via direct e-mail and advertisements on Facebook and student union web sites. Those who provide informed consent, have a mobile phone, and show at least hazardous alcohol consumption according to the AUDIT (≥6 for women; ≥8 points for men) are randomized into three groups. Group 1 has access to the Swedish government alcohol monopoly’s app, Promillekoll, offering real-time estimated eBAC calculation; Group 2 has access to a Web-based app, PartyPlanner, developed by the research group, offering real-time eBAC calculation with planning and follow-up functions; and Group 3 participants are controls. Follow-up is conducted at 6, 12 and 18 weeks. Study 2. Participants who at the first 6-week follow-up show drinking levels higher than 9 (W) or 14 (M) standard drinks (12 g alcohol) per week, are offered participation in Study 2. Those who consent are randomized to either access to a skills training app, TeleCoach or to a wait-list control group. Results: Latent Markov models for Study 1 and mixed models analyses for Study 2 will be performed. Study 2 data will be analyzed for publication during the spring of 2016; Study 1 data will be analyzed for publication during the fall of 2016. Conclusions: If mobile phone interventions for reducing hazardous alcohol use are found to be effective, the prospects for positively influencing substance use-related health among university students can considerably improve

Identification and management of alcohol use and illicit substance use in outpatient psychiatric clinics in Sweden : a national survey of clinic directors and staff

Background:  Swedish national guidelines recommend that all health care settings systematically screen patients for alcohol use and illicit substance use. When hazardous use is identified, it should immediately be addressed, preferably through brief interventions (BI). It is well known that the prevalence of alcohol use and illicit substance use among  psychiatric patients is high, but it is not known to what extent screening and BI are routinely carried out in such  clinics.Methods:  Two online surveys investigating the use of screening and BI for alcohol and illicit substances were constructed; one for psychiatric outpatient clinic directors and one for staff at these clinics. The main analyses were calculated as simple frequencies. In secondary analyses, we investigated the associations between substance abuse  training, type of clinic and screening/BI delivery. For these analyses, the Chi square test was used.Results:  Most clinic directors reported that they have guidelines to screen for alcohol (93.1%) and illicit substance use (78.9%) at initial assessment. Fifty percent reported having guidelines for delivering BI when identifying hazard-ous alcohol use (35.9% for hazardous illicit substance use). Among staff, 66.6% reported always screening for alcohol  use and 57.8% reported always screening for illicit substance use at initial assessment. Further, 36.7% reported that  they usually deliver BI when identifying hazardous alcohol use (35.7% for hazardous illicit substance use). Secondary  analyses indicated that staff with substance abuse training were significantly more likely to screen for alcohol use than  staff without such training. Further, staff at psychosis clinics were significantly less likely to screen for both alcohol and  substance use than staff at both general and specialist psychiatric clinics.Conclusions:  Most clinic directors reported having clear guidelines for staff to screen for alcohol use and illicit substance use, but fewer staff members than expected indicated that these guidelines were adhered to. Providing training about substance use disorders for staff may increase use of screening for alcohol use, and psychosis clinics  may need to improve their screening routines.Keywords:  Substance use, Alcohol use, Psychiatry, Guideline adherence, Screening, Brief interventio

Smartphone apps targeting risky and excessive drinking patterns among university students show differing subgroup effects over 20 weeks

Background and Aims: University students with risky drinking are a clear target group for intervention via smartphone apps. This study compared three different apps over a 20-week period, for university students with hazardous and excessive drinking patterns. Materials and Methods: Students from six campuses were invited to a three-armed trial (A). Those with hazardous alcohol use (n = 2166) were randomly assigned to one of two smartphone apps offer- ing feedback on real-time estimated blood alcohol concentration (eBAC) levels, or to a control group, with three follow-ups at 6, 12 and 20  weeks. At 6  weeks, participants in the app groups with excessive weekly alcohol consumption of >9 (women) or >14 (men) drinks per week (n  =  257), were offered participation in a second trial (B); con-senters (n  =  186) were randomly assigned to a skills-based app or a waitlist group, and compared with an assessment-only control group. Results: Six-week analyses (n = 2166) replicated our earlier trial from 2014, re-confirming earlier results: the Promillekoll app was associated with higher quantity and frequency of drinking compared to controls, and a higher risk for excessive drinking; the PartyPlanner group did not differ from controls. Lower-risk drinkers from trial A (n = 1177) up to 20 weeks did not differ from controls on main outcomes. However, sub-analyses showed that individuals with higher consumption had higher motivation to reduce intake. In both intervention groups, con-sumption was lower for more highly motivated participants compared to controls at 6- and 20-week follow-ups. Latent class analysis of par- ticipants in both trials (n = 2166) revealed a class (n = 146) that drank several days a week and that differed significantly from the remain- ing cohort in gender, age, and alcohol consumption. For this class, access to the Promillekoll app appeared marginally associated with lower quantity over time; access to the skills-based TeleCoach app was clearly associated with fewer drinking days up to 20 weeks. Conclusions: Smartphone apps targeting eBAC can influence drink-ing levels up to 20 weeks for university students with hazardous use and higher motivation to reduce their drinking. A skills-based app that reduces intake among students with excessive weekly consumption can be particularly effective for students with daily drinking habits