Mobile Phone Text Message Intervention for People with Hazardous Alcohol Use: Development of Intervention and Evaluation of Effect

Abstract

Alcohol use is a leading risk factor for injuries, diseases, disabilities, and premature death and contributes to large and inequitably-distributed health, social, and economic burdens in societies. Alcohol Screening and Brief Intervention (SBI) is an important evidence-based component of a comprehensive public health strategy to reduce hazardous alcohol use and prevent alcohol-related harm but is often not implemented in the healthcare system due to a range of barriers, including resource constraints. Mobile health (mHealth) approaches show promise as an innovative, low-cost, and scalable way of delivering alcohol SBIs, however the evidence of effectiveness is limited, and more research attention is needed. The aim of this thesis is to develop and evaluate a mobile phone text message intervention for people with hazardous alcohol use. Methods: This thesis is comprised of four parts: 1) a systematic literature review examining the effectiveness of mobile phone text message interventions in reducing hazardous or harmful alcohol use; 2) the development of a mobile phone text message intervention for people with hazardous alcohol use, in the inpatient trauma ward setting, involving conceptualisation and creation of content based on Brief Intervention (BI) evidence and behaviour change theory, followed by formative qualitative research with patients and key stakeholders to pre-test and refine the content; 3) the evaluation of the effect of the mobile phone text message intervention, compared with usual care, on hazardous alcohol use and alcohol-related harms in a parallel, two-group, single-blind, randomised controlled trial (RCT) in 598 injured patients aged 16-69 years identified as medium-risk drinkers at recruitment, with follow-up at three, six, and 12 months; and 4) exploration of the participants' perspectives of the positive and negative aspects of being involved in the study through qualitative analysis of free-text responses to two questions included in the trial's 12-month online survey. Results: The systematic literature review identified six RCTs, five of which were small feasibility trials with inadequate power to detect statistically significant effects, but which suggested mobile phone text message alcohol interventions may have the potential to reduce alcohol consumption and harms. One large trial in the Emergency Department setting found that an intervention involving text message assessments and tailored feedback was more effective than no text messages in reducing alcohol consumption and alcohol-related injury at six months follow-up. All trials were conducted in the USA and five of six trials were in young adult participants. The findings of the review suggest that more research in this area is indicated, particularly large studies in different countries and settings, and considering a wider range of ethnicity and age groups. The mobile phone text message intervention development research identified four key themes that were important to ensuring the intervention text messages were engaging, relevant, and useful for participants: 1) reducing the complexity of message content and structure, 2) increasing the interactive functionality of the text message programme, 3) ensuring an empowering tone to text messages, and 4) optimising the appropriateness and relevance of text messages for Māori and Pacific people. The fourth theme was an important focus of the refinement process and a key strength of this research. The output of this part of the thesis was the content for the 'YourCall' text message intervention, a low intensity, automated, unidirectional intervention designed to reduce alcohol consumption and alcohol-related harms in patients admitted to hospital due to an injury. The RCT evaluating the effect of the 'YourCall' mobile phone text message intervention revealed that hazardous drinking was significantly lower in the intervention group, compared to controls, at three months and a modest effect was maintained over the 12-month follow-up period (least squares mean difference in Alcohol Use Disorder Identification Test - Consumption [AUDIT-C] scores: -0.322; 95% Confidence Interval: -0.636, -0.008; p = 0.04). The intervention effect was similar among Māori and non-Māori, and among younger and older participants. However, the secondary outcomes analysis did not detect any differences between intervention and control groups at 12-months in the measures of alcohol-related harms and troubles, readiness to change drinking patterns, and help-seeking behaviours. Exploration of participants' perspectives showed mainly positive perceptions of being involved in the study, from both intervention and control group respondents. The most dominant theme that emerged was 'contemplation about alcohol use' suggesting that respondents were prompted to become more aware of, and think about, their alcohol use. The findings suggest there may be research participation effects among participants. It is also possible there has been a treatment effect (i.e. assessment reactivity) for the control group, which may have decreased the differences in outcome measures between the intervention and control groups and underestimated the effect of the intervention. Conclusion: This thesis provides evidence of the effectiveness of a mobile phone text message alcohol intervention in reducing hazardous alcohol consumption. MHealth alcohol interventions such as this have potential as an alternative delivery mode for face-to-face BI and could help to address current barriers preventing access to alcohol interventions as part of routine trauma care. Further research is required into the preventive potential of mHealth alcohol interventions. This thesis suggests that, whilst mHealth alcohol interventions are an important healthcare system response, they are just one component of a multi-pronged strategy for reducing alcohol-related harms and should be considered alongside the 'best-buy' strategies that address alcohol availability, price, and advertising, marketing, and sponsorship.