Improving existing E-health programs: the results of Drinktest.nl

Britt van Lettow¹ MSc., MPH.

Hein de Vries² PhD.

Alex Burdorf¹ PhD.

Pepijn van Empelen¹,³ PhD.

¹Erasmus MC, dep. of Public Health, ²Maastricht University, dep. of Health Promotion, ³TNO, Research Group Lifestyle The Netherlands

Presenters disclosure

This research and my visit to the E-Health conference was supported

by a grant of project no. 121020020 from ZonMW, Organization for

Health Research and Development, the Netherlands.

No conflicts of interest

No commercial support

Drinking behavior

All ages: 9.4% (16% among men)

Males (34.1%) > females (9.4%)

Young adults aged 18−25 drink the most: 20% drinks excessively

1 glass = 10 grams alcohol

Excessive drinking norms in NL:

Males: Females

max. 6 glasses p/d max. 4 glass p/d

max. 5 days p/w max. 5 days p/w

max. 21 glasses p/w max. 14 glasses p/w

Short and long term health and other consequences

Diseases: cancer, cardiovascular diseases

Traffic accidents, injuries

Etc.

What is Drinktest.nl?

Meant as online “screening” instrument for people at home

Self-report of own behavior, awareness, etc.

Design:

One moment: questions feedback questions feedback

Tailored feedback regarding their drinking behavior in relation to

Attitude – information on e.g. health to increase awareness

E.g., questions regarding their thoughts on the effect of their

drinking behavior on their brains, liver, etc.

Social norms – own behavior compared to others, drinking norms

Perceived behavioral control – tips and advice on how to

overcome difficulties/barriers

Improving E-health program Drinktest.nl

Addition of

Prototypes

Cue reminders

2 studies first, as basis for the development of modules added

to original drinktest (not discussed today)

Prototypes definition

Prototypes – “Perceptions or cognitions of images of a typical person engaging

in certain risk or health behavior” personal characteristics

Typical drinker

Typical exerciser

Typical smoker

……

Typical person Characteristic Characteristic Characteristic

A scientist is... Smart Boring Nerd

A granny is... Slow Fragile Talkative

A movie star is.… Self-confident Conscientious Social

Why prototypes?

Prototypes have been related to many (un)healthy behaviors

Impact on intention, willingness, and behavior

Changing perception is promising for health interventions

Based on changing desirability and importance of characteristics

The e-health program will provide feedback on which characteristics

are attributed to heavy and moderate drinker prototypes.

Why cue reminders?

Cue reminders help people remember goals, advice, and interventions

Cue unrelated to behavior itself

E.g. power button – recall info on alcohol use

E.g. bracelet – Moroccan women – less sugary meals and snacks

E.g. bracelet – condom use among young adults

E.g. smiley fridge magnet – healthy diet, less snacking

Developing modules added to Drinktest.nl

Aim: reduce alcohol consumption among excessive drinking people

How to best improve drinktest.nl with extra modules?

Inclusion of feedback with prototypes characteristics?

Inclusion of a cue reminder?

Combination of both?

Or nothing?

Design

Online

Baseline (T0): 4 study groups (next slide)

Randomisation by computer

Follow-up & evaluation after 1 month (T1)

Only excessive drinkers

Excessive drinking = exceeding: drinking on a max. of 5 days per

week, a max. of 4 glasses per day and 14 per week for women,

and 6 glasses per day and 21 per week for men

Non-excessive drinkers only receive “original” drinktest.nl and are

excluded from further analyses

Incentive: €50, €100 or €250 (raffle) after completion of 3

measurements

Overview e-health program: 4 study groups

Control group Prototype group Cue reminder group

Combi: Prototype + Cue group

Demography, behavior, intentions, willingness

Demography, behavior, intentions, willingness

Demography, behavior, intentions, willingness

Demography, behavior, intentions, willingness

Drinktest.nl modules (attitude, control, social norms)

Drinktest.nl modules (attitude, control, social norms)

Drinktest.nl modules (attitude, control, social norms)

Drinktest.nl modules (attitude, control, social norms)

- Feedback based on prototype characteristics

- Feedback based on prototype characteristics

- Formulate action plans

Formulate action plans

Formulate action plans

- - Receive bracelet to remind of plans and Drinktest

Receive bracelet to remind of plans and characteristics

E-health program – Control group

Control group = Original drinktest.nl modules:

Tailored feedback regarding their drinking behavior in relation to

Attitude – information on e.g. health to increase awareness

Social norms – own behavior compared to others, drinking norms

Perceived behavioral control – advice on how to overcome

difficulties

Provides info on how much is “responsible” to drink, tailored to gender

and own drinking behavior

E-health program – Prototype group

Original drinktest.nl modules (tailored feedback on attitude, social

norms, pbc)

Tailored feedback based on prototype characteristics:

Which characteristics do you desire for yourself?

feedback which characteristics are related to moderate and heavy

drinking

what would happen if you change your drinking behavior: If you

decrease your consumption, you will more likely acquire your desired

characteristics

Formulate action plans

E-health program – Cue reminder group

Original drinktest.nl modules (tailored feedback on attitude, social

norms, pbc)

Formulate action plans

Receive a silicon bracelet to remind themselves of their plans and/or

information of drinktest.nl

If bracelet is refused, choice of no cue, own jewelry, or other

object

E-health program – Combi of prototype + cue group

Respondent gets all modules

Cue reminder to remind of both plans and (un)desired characteristics

(thus not only of plans as in cue condition)

Overview e-health program: 4 study arms – follow-up after 1 month

Control + Prototype groups

Combi + cue only groups

Drinking behavior, Intentions, Willingness √ √

Awareness of alcohol use and of info from drinktest.nl

√ √

Attempted to reduce alcohol consumption? √ √

Choice of cue reminder, awareness of cure reminder, use of reminder

√ X

Evaluation of intervention √ √

Results – sample

Online only

Total sample: start with 4827 cases

Only excessive drinkers included

Duplicates and outliers excluded

N = 2924 at T0 (drinktest.nl)

N = 784 (26.8% response) who completed drinktest.nl and follow-up of

one month (T1).

48.1% males

M age = 39.7 (SD = 15.4, range 18-77)

75.6% high education

96.2% Western ethnicity

Results – Drinking behavior at follow-up

All regression analyses corrected for their baseline outcomes

Differences between groups were tested

Group Drinking behavior (T1):

Week total – ns

Average nr. of glasses per week day – ns

Average nr. of glasses per weekend day – model: F (3, 783) = 117.6, p = .00, group variable: t = -1.81, p < .007

combi group < control group (p = .054)

Excessive drinking (i.e., type of drinker) –

combi group < cue group: OR = .65, p < .05

Tried to decrease consumption (T1): F(3, 780) = 2.91, p < .05

control < all other groups (p’s < .05)

Results continued

All regression analyses corrected for their baseline outcomes

Differences between groups were tested (LSD)

Group intention to reduce drinking (T1): Model: F(2, 782) = 190.5, p

< .001, group variable: t(784) = 1.84, p =.07:

combi group > control group (p = .07)

Group willingness to drink (T1): Model: F(2, 782) = 217.6, p < .001,

group variable t(784) = -1.77, p = .08

combi group < control group (p = .08)

Group thought of drinktest (T1): F(3, 780) = 6.1, p < .001

control < all other groups (p’s < .05)

No difference in evaluation of intervention between groups

Conclusion and discussion intervention

Combination of feedback on prototypical characteristics and use of a

cue reminder most effective compared to control group (i.e., original

drinktest)

Temptations, intentions, willingness, drinking in weekends

Trying to decrease consumption, thinking of intervention

Thus, drinktest.nl could be enhanced by the additional modules of a

cue reminder and feedback on prototypical characteristics

Preliminary data – still collecting

Conclusion and discussion intervention

The results may help in tailoring and targeting interventions (e-health

programs) aimed at reducing alcohol consumption via prototypes and

cue reminders

Both prototypes and cue reminders can be helpful tools in other

interventions to improve lifestyles

Cues do not need to be related to the behavior

Results may be applicable for other behaviors

CHEERS!

Results – Descriptives

No significant differences between conditions

Control group

Prototype group

Cuegroup

Combi group

Statistics

N 207 233 177 167

M age (SD) 39.8 (15.6) 39.8 (14.5) 39.7 (15.4) 41.1 (16.3) F(3, 780) = .85

% males 46.9 45.5 50.8 50.3 X2 (3) = 1.62

% high education

75.2 77.6 74.6 74.3 X2 (3) = 0.78

% Western 85.7 97 94.9 97 X2 (3) = 1.66

Table 13. Descriptives per study group

Baseline (T0) differences between groups

Intention – ns

Willingness – ns

Drinking behavior

Weektotal – p < .10 (M = 27.1, SD = 17.3)

Average nr. of glasses per weekday (M = 4.2, SD = 3.6) – ns

Average nr. of glasses per weekendday (M = 6.0, SD = 3.7) – ns