Stuart Linke Clinical Psychologist Camden and Islington NHS Foundation Trust

1. Using the internet to provide interventions for hazardous and harmful drinkers in the general population, primary care and work place settings Stuart Linke Clinical Psychologist Camden and Islington NHS Foundation Trust Honorary Research Fellow University College London

2. National Prevention Research Initiative

3. The Down Your Drink Team Charles Elstone Toni Brisbee Ria Kalaitzaki Andrew Brown Ceri Butler Orla O’Donnell Robert Harrison Harvey Linke Richard McGregor

4. The size of the problem • estimated that 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

5. Half of us may be secret binge-drinkers who lie about the amount of booze we knock back. • We own up to drinking at least 3billion litres of alcohol less than is being bought every year. • It means about eight in ten people may be exceeding the daily recommended levels for safe drinking – and half of us would be classified as binge-drinkers. • The problem is most prevalent among well-off women who live in the south.

6. 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

7. develop integrated local treatment ‘systems’, through the tiered framework of provision improving the effectiveness of screening and assessment developing integrated care pathways (‘alcohol treatment pathways’) Tier 2 open access facilities and outreach targeting alcohol misusers, which provide: • alcohol-specific information, advice and support • extended brief interventions and brief treatment • Tier 1 • • alcohol advice and information • • targeted screening and assessment • brief interventions for hazardous and harmful drinkers

8. 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

9. The Development of Down Your Drink • DYDv0 - paper manual sent by post • DYDv1 - 6 week automated on line brief treatment • DYDv2 - extended on line brief intervention • DYDv3 - bespoke & customised for different populations and settings • DYDv4 - multi media, multi platform, (planned) optimised brief treatment

10. Down Your Drink Home Page (v.1)

11. 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

12. 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

13. Who Uses Down Your Drink? • Pilot Study (DYD v1) - 1300 • Naturalistic Cohort Study (DYD v1) - 10,000 • Trial (DYD v2) - 7935

14. Weekly DYD use since finishing the trial

15. Age Mean = 37.5yrs White British 82% Men 49% White Other 9% Single 37.5% White Irish 5% Living with Children 42% Asian 1% Managerial 25.8% UK resident 84% Self-employed 9% US resident 5.5% Admin/secretarial 8% Ireland resident 2% IT 8% Australia resident 1% Academic 5% Canada resident 1% Homemaker 4% Unemployed 3.5% First 10,000 users (registrants)

16. All Users Male Users Female Users No. % No. % No. % Registered 10000 100.0 4891 100 5109 100 Completed week 1 8933 89.3 4302 88.0 4631 90.6 Completed week 2 4020 40.2 1916 39.2 2104 41.2 Completed week 3 3006 30.1 1403 28.7 1603 31.4 Completed week 4 2411 24.1 1128 23.1 1283 25.1 Completed week 5 1928 19.3 887 18.1 1041 20.4 Completed week 6 1654 16.5 770 15.7 884 17.3 Number of users completing each week of the program

17. User Feedback At the end of the 6 week programme users were invited to send in (anonymous) emails responding to probe questions Thematic Analysis Increased Motivation For Change Increased Self-Efficacy Support For Change

18. “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)

20. The Drinking Diary “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) “I have particularly valued the opportunity for writing a daily record of how it is going….my thoughts, fears hopes and plans to sort this issue out all went in! I often revisit this for motivation and to renew my confidence.” (participant 36) I have particularly valued the opportunity for writing a daily record of how it is going….my thoughts, fears hopes and plans to sort this issue out all went in! I often revisit this for motivation and to renew my confidence.” (participant 36)

21. “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)

23. Content Self Assessment and Automated Feedback 3 Phases: • It’s Up To You (Motivational Interviewing) • Making the Change (Behavioural Self Control & Cognitive Behaviour Therapy) • Keeping on Track (Relapse Prevention)

26. 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

27. On-line Randomized Controlled Trial of an Internet Based Psychologically Enhanced Intervention for People with Hazardous Alcohol ConsumptionWALLACE, P and MURRAY, E and MCCAMBRIDGE, J and KHADJESARI, Z and WHITE, I and THOMPSON, S and KALAITZAKI, E and GODFREY, C and LINKE, S (2011) On-line Randomized Controlled Trial of an Internet Based Psychologically Enhanced Intervention for People with Hazardous Alcohol Consumption. PLOS ONE , 6 (3) , Article e14740. • Mean age was 37yrs • 57% were women • 52% educated to at least degree level. • The majority identified themselves as white British (84%), but some were from ethnic minorities with 73 countries represented. • All the participants were drinking hazardously at the beginning of the study (mean of 46 units per week) • This reduced substantially at 3 and 12 months (to 26 units) • The same changes happened in both groups.

28. 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 don’t just use DYD

29. Where is the evidence so far? • Meta analyses show benefits in student populations • There are a number of studies showing benefits in selected treatment populations, but not all studies show the same thing • DYD is the only pragmatic trial in the general population • Major challenge is retention and engagement (which DYD v4 will attempt to address)

32. Health on the web: randomised trial of work-based online screening and brief intervention for hazardous and harmful drinkingBMC Public Health 2013, 13:505 doi:10.1186/1471-2458-13-505Elizabeth Murray, Zarnie KhadjesariStuart LinkeRachael HunterNick Freemantle

33. Health on the Web Workplace study • large UK-based organisation with an international workforce of around 100,000 • AUDIT C part of a confidential online health check • tailored feedback which either 1) reinforced healthy behaviour and reminded people of recommended guidelines, or 2) encouraged a change in behaviour by highlighting the risk • employees scoring 5 or more on the AUDIT-C were automatically entered into the trial and randomised to the intervention or the control group • The intervention group received feedback on all health behaviours and alcohol feedback. Control group did not get alcohol feedback

34. ODHIN Optimizing delivery of health care interventions (Paul Wallace)

35. 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

38. What is the role of digital interventions? • There are now many alcohol interventions on a range of different platforms – vary hugely in quality of information and adherence to behaviour change principles • Evidence base is inconsistent and at an early stage • 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

39. Thank You