ReviewThe effectiveness of web-based interventions designed to decrease alcohol consumption — A systematic review
Introduction
Brief interventions for health problems such as alcohol use disorders have been of growing interest over the last few decades (Moyer et al., 2002). Several reviews have been conducted on the effectiveness of face-to-face brief interventions in health care and treatment settings (Moyer et al., 2002, Bien et al., 1993). Results are consistent, showing that brief interventions are more effective than no counseling (Bien et al., 1993).
Personalized feedback is often incorporated into brief interventions and aims to encourage behavior and/or attitude change. Studies suggest that incorporating social norms information into feedback interventions can help decrease alcohol consumption, encouraging participants to become more aware of the level and consequences of their drinking and how their drinking behaviors compare to others of a similar social or demographic group (White, 2006, Walters and Neighbors, 2005, Neighbors et al., 2004, Collins et al., 2002).
Although brief feedback interventions for alcohol use have traditionally been delivered by more conventional face-to-face (e.g., Humphreys and Klaw, 2001, Borsari and Carey, 2000) and postal mail methods (e.g., Collins et al., 2002, Walters et al., 2000, Agostinelli et al., 1995), they have more recently been delivered electronically via computer programs (e.g. Neighbors et al., 2004, Matano et al., 2000) and the internet (e.g., Davies Kirsch and Lewis, 2004, Saitz et al., 2004, Kypri et al., 2003, Cunningham et al., 2000). Both experimental and review studies comparing a combination of such methods have found that providing feedback as an intervention for alcohol use can be effective regardless of the delivery mode (e.g. White et al., 2006, Kypri et al., 2005, Walters and Neighbors, 2005).
Although delivery mode does not impact on the effectiveness of feedback interventions, the widespread and growing availability of the internet does present an opportunity for broad dissemination and improved access to interventions (Cunningham et al., 2005, Copeland and Martin, 2004). Nielsen//NetRatings global trends data from 2002 show that as many as 79% of Americans, 72% of Australians and 68% of the UK population have access to the internet with access figures continuing to rise (Steyn and Chan, 2003). Furthermore research shows that there is potentially a sizable demand for internet-based interventions for substance use (Saitz et al., 2004, Cloud and Peacock, 2001, Cunningham et al., 2000). It is also suggested that internet-based interventions may have a number of advantages over the more traditional modes of delivery. Specifically, they are able to reach a large audience in a cost effective manner (White, 2006, Walters et al., 2005), can offer participants privacy and anonymity through the ability of users to access the intervention at times and in locations that suit their needs, and are flexible in their ability to provide automated and tailored information (Moyer and Finney, 2004/2005, Fotheringham et al., 2000).
Currently information on the feasibility, utility and effectiveness of web-based interventions is limited (Evers et al., 2005, Ritterband et al., 2003). The majority of studies to date have focused their work on the feasibility of various interventions for substance use and alcohol problems in particular (e.g. Moyer and Finney, 2004/2005, Collins et al., 2002, Bien et al., 1993). Previously published reviews which have included information on web-based interventions for alcohol use have either provided only narrative accounts of the results, descriptions of the interventions with limited details on outcome results, and/or have not designated web-based interventions as their primary focus (e.g. Walters et al., 2005, Copeland and Martin, 2004). Non-systematic reviews have concluded that computer generated personalized feedback can be effective in reducing alcohol consumption (e.g. White, 2006, Kypri et al., 2005), although these reviews have not included systematic appraisal of the effectiveness of web-based interventions.
Furthermore, it should be recognized that the few research studies that have concentrated on the quality of web-based interventions have found that many interventions lack the basic elements needed for health behavior change (Evers et al., 2005). Many e-health websites require improvements to ensure that issues of quality, accuracy of information and efficacy are more adequately addressed (Evers et al., 2005, Kunst et al., 2002). Research also highlights the on-going problem of access to the internet, particularly for those in socially or linguistically disadvantaged cultures who do not have the resources or ability to access the interventions, Neuhauser and Kreps (2003) refer to these issues as the ‘broadband divide’ which may restrict many people from accessing features of e-health communication.
Given that health behavior change using the internet is still in the early stages of development (Evers et al., 2005) and that there is current interest in using this technology for alcohol use interventions, it is timely that a systematic review focusing on the effectiveness of web-based alcohol interventions should be carried out.
To summarize, this paper provides a systematic appraisal of the best available evidence on: 1) the effectiveness of web-based interventions aimed at decreasing alcohol consumption; and 2) participants' perceptions of the usefulness and potential benefits of the intervention. Additionally this paper aims to systematically assemble and evaluate the quality of the evidence available using established systematic review techniques. Systematic reviews are defined by key methodologies, including: (a) highly comprehensive searches in order to identify relevant studies; (b) explicit inclusion criteria and transparency concerning study eligibility and (c) rigorous quality appraisal. The use of a standardized quality rating tool (i.e., Downs and Black, 1998) was employed as part of this process.
Section snippets
Literature search and selection of studies
Relevant articles published up to, and including, May 2006 were identified through electronic searches of Medline, PsycInfo, Embase, Cochrane Library, ASSIA, Web of Science and Science Direct. The following terms were used in the search: (a) intervention and web and alcohol; (b) intervention and electronic and alcohol; (c) internet and alcohol consumption; (d) internet and drinking behavior; (e) internet and drinking behavior. Searches were not limited by language. The titles and abstracts of
Results
From the initial search 191 articles were identified and 27 of these were found to be eligible for inclusion (20 primary studies and seven review studies). The kappa statistic for inter-rater agreement on the inclusion or exclusion of studies was 0.83 — indicating substantial agreement (Viera and Garrett, 2005). Of these, 10 primary studies and 7 review studies were excluded upon closer reading due to the content of the articles not meeting the inclusion criteria (κ = 1.0). One dissertation was
Discussion
The Downs and Black (1998) ratings suggest that the strength of the evidence provided within the current review is weak with only one of the 10 included studies (Kypri and McAnally, 2005) meeting more than 75% of the criteria and only a further three (Chiauzzi et al., 2005, Moore et al., 2005, Kypri et al., 2004) meeting more than 50%. These relatively low scores reflect the lack of rigor within the research designs employed.
The one randomized control trial included in the review (i.e. Kypri
Limitations
The current review has a number of limitations, namely that outcome data were not available for all of the ten studies identified for inclusion. Furthermore the heterogeneous nature of the studies, in terms of the interventions evaluated and the study objectives, prohibited any meta-analysis to be carried out. It is therefore not possible or advisable to draw any firm inferences from these results.
Conclusions
Earlier published non-systematic reviews have investigated the potential feasibility and content of web-based interventions designed to moderate alcohol use. The current review is the first to systematically evaluate the effectiveness of such interventions and has found inconsistent results across studies. Process research suggests that web-based interventions are generally well received. However further randomized control trials are needed to investigate their effectiveness. All of the
Acknowledgments
We would like to thank Dr Judith Slaa for her contribution to the rating process. Authors affiliated to PTRC and LIHS were also partially funded by the European Research Advisory Board, R&D Levy from Leeds Community and Mental Health Teaching Trust and the Artemis Trust. The investigation was initiated and analyzed by the project team.
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