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Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences How do Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences How do individuals process the information we provide? Using verbal protocols to explore the user experience of brief personalised e-intervention for alcohol use Dr Bridgette M Bewick Associate Professor Society for Study of Addiction Travelling Scholar Recipient of the SSA 2012 Fred Yates Prize SSA Annual Symposium York, 2014

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Acknowledgements Unitcheck: Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Acknowledgements Unitcheck: Michael Barkham; Andrew J Hill; Brendan Mulhern; Karen Trusler; Robert West Change. Drinking: Duncan Raistrick; Gillian Tober; Kat Rumball; Jakki Birtwistle, Alina Serafin, Owen Johnson, Joe Shaw Doctorate of Clinical Psychology student: Sarah Marley (co-supervisor: Hilary Bekker) The above is a list of key individuals who contributed to material subsequently included in this presentation. Acknowledgement is given that unfortunately it is not possible to list everyone who has had any input in to the projects – therefore thanks to all that contributed in some shape or form. Thanks to participants, student union executive members, university staff; Leeds Addiction Unit staff, and National Health Service (NHS) staff who gave their time to be involved in the projects. Conflicts of interest: In the past Bewick has received funding from the European Research Advisory Board, and has received reimbursement from Anheuser-Busch and the International Centre for Alcohol Policies.

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thanks to Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thanks to support from. . . Change. Drinking was independent research funded by the National Institute of Health Research (NIHR) through the NIHR Collaboration for Leadership in Applied Health Research and Care for Leeds, York and Bradford. The views expressed throughout this presentation are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health. The NIHR had no role in the study design, collection, analysis or interpretation of the data, writing the presentation, or the decision to submit the article for dissemination. The views and opinions expressed in this presentation are those of the authors and not necessarily those of the NHS, the Department of Health, or the NIHR.

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Intervening via Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Intervening via the web: Personalised feedback Very brief Single session (but can revisit) Automated (no therapeutic input) Instant Ethos: Social Norms Approach

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Intervening via Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Intervening via the web: Personalised feedback Very brief Single session (but can revisit) Automated (no therapeutic input) Signposting to specialist face-to-face services Instant Ethos: Motivational Interviewing

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Ethos: Motivational Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Ethos: Motivational Interviewing “website and structure modelled on motivational dialogue … personalised pre-determined dialogue with strong theory-practice links … applying principles of conveying empathy and reflection was challenging within the confines of a predetermined dialogue. Reflective listening in Change. Drinking does not extend to inviting statements of resistance to be entered” (Bewick et al. , 2014)

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thinking my Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thinking my thoughts aloud, thinking my thoughts aloud …

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences [Sarah Marley, Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences [Sarah Marley, Doctoral Student (Dclin)] • Verbal protocols • First year students • Service users from specialist addiction treatment service • Drinking over recommended weekly limits • Over 16 years of age, fluent in English, alcohol as • n=21 (n=14 ♀; n= 7 ♂) • Age range 18 -21 years • Highly computer literate substance of concern • n=10 (n=4 ♀; n= 6 ♂) • Age range 31 -58 years • Computer literacy varied across sample

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Interaction with Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Interaction with the website

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Successful interaction Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Successful interaction • All n=10 had some successful navigation of the website • All participants had some level of basic interaction with the website “and I’m now submitting that so that should take me to page seven. Yep, page seven” Technical barriers • n=5 had persistent difficulty as they completed the website • All n=5 had limited computer skills and infrequently accessed the internet

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Interaction with Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Interaction with the programme “I think that, I suppose as stupid as it sounds, because the website looks professionally designed, it makes you. . Much more, much more willing to believe it is accurate. The fact that it wasn’t covered in all sorts of annoying pop up adverts. . Makes it more believable” [P 12, MA]

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Active thinking Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Active thinking

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change drinking Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change drinking encourages thought relating to drinking behaviour • All considered and reflected on past experiences with alcohol • Active consideration of questions and responses How Change. Drinking was received • Personal relevance, quantity of information, credibility, trustworthiness Active thinking • Engaging with the data and relating them to their own experience • Often this resulted in evaluation of own drinking • Actively reasoning where they stand in relation to information given

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences . . Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences . . . that's your life that's like life recommendations to you and it's saying that I'm it's putting it that I weekly, yeh have arguments with my girlfriend, I break the law, but you know that's and they are because of drinking yeh, arguments with the Mrs are definitely because of drinking she said on our one year anniversary she said that I had a drinking problem, I was like well and I think that's literally that's just hit me now. . which is s***, yeh, its literally just hit me. [P 7, MA] (Marley, 2012)

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences This evaluative Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences This evaluative process started early on in the Unitcheck programme. 17 out of 21 participants negatively evaluated some aspect of their drinking behaviour before receiving any feedback. Um, so that would be 100 ml um, 200 ml er, lets call it. . . 15 – actually and then I had a couple of shots when I got to the club as well. God that's really bad! (P 16, MB) (Marley, 2012)

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences . . Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences . . . It nearly put me in tears because you don’t realise, you know what I mean, what damage you’re doing until you see it you know like that [P 8]

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Response to Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Response to feedback

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking elicits a response • Actively engaged and did not agree In a total of last week you drank eighty four units, well to be frank that is a stupid answer because it would depend on the volume of alcohol and the type of wine I was drinking and I tend to go for quite strong wine [P 6]

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking elicits a response • Actively engaged and agreed Guilt and remorse is common, yes, because you’ve done and said things, well I have that I’d really rather I hadn’t. Unable – unable to, yep definitely happen to me because people have told me. I’ve harmed someone, I’ve fell over, I’ve got marks actually and scars on me face from me falling over. I’ve caused harm to other people, not physical but I’ve upset them. Someone’s suggested you cut down, yeah I use to be defensive but no I know, I’ve accepted I’ve got a problem [P 3]

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Beliefs and Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Beliefs and knowledge about alcohol consumption • What participants believe to be true, what they question, what they do not know Um, I dunno, I think I always considered binge drinkers as like people who don’t know how to control themselves and like out of control, and their behaviours awful. And so being told I’m a binge drinker, I think its quite insulting actually [P 9, FA] • Inter-relationship of personal codes and context …there’s a lot of factors in my life … if they weren’t there and I was drinking the same … there would be more … reason to be worried … my awareness is a lot higher than a lot of people … don’t’ mean to sound like I know more than other people … from experience I feel … more in control … I don’t ever crave a drink … I. . enjoy them. I don’t need them … I think I’m all right personally [P 17, FA]

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences What did Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences What did use of verbal protocols add?

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Relatively Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Relatively minor changes to the website could increase accessibility for those with limited experience of using the internet • Individuals with relatively low levels of computer literacy could complete the assessments online and actively engage with feedback • Possible to transfer aspects of the MI ethos into pre-determined dialogue • Designs endorsed by service users ‘on paper’ may not transfer well to an e-format • It is possible to engage those with relatively low literacy and/or some cognitive impairment with the verbal protocol task

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Good Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Good design resulted in design aspects not being attended to • Individuals actively engage with the assessment and this engagement provides insight into the monitoring effect observed in our trials • The structure of the e-intervention facilitates self-reflection and engagement prior to receipt of feedback • Active comparison begins early in the process and deeper comparative reflection is supported by the delivery of social norms feedback • Personalisation is integral in participants engagement and assessment of personal relevance

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Active Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences • Active engagement with assessment • Feedback elicits a response • Consideration of personal relevance • Reflection on opportunity (or not) to change Thinking my thoughts aloud, thinking my thoughts aloud …

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thanks for Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Thanks for listening Faculty of Medicine and Health, School of Medicine, Charles Thackrah Building 101 Clarendon Road, Leeds, United Kingdom. LS 2 9 LJ b. m. [email protected] ac. uk www. leeds. ac. uk/lihs +44 (0) 113 343 0809

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Unitcheck Bewick, Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Unitcheck Bewick, B. M. , Trusler, K. , Barkham, M. , Hill, A. J. , Cahill, J. and Mulhern, B. (2008). The effectiveness of web-based interventions designed to decrease alcohol consumption – a systematic review. Preventive Medicine, Doi: 10. 1016/j. ypmed. 2008. 01. 005. Bewick, B. M. Trusler, K. , Mulhern, B. , Barkham, M. and Hill, A. J. (2008). Feasibility and effectiveness of a web-based personalized feedback and social norms alcohol intervention in UK university students: a randomized control trial. Addictive Behaviors, Doi: 10. 1016/j. addbeh. 2008. 05. 002. Bewick, B. M. , West, R. M. , Gill, J. , O’May, F. , Mulhern, B. , Barkham, M. and Hill, A. J. (2010). Providing web-based feedback and social norms information to reduce student alcohol intake: a multi-site investigation. Journal of Medical Internet Research, 15(7), e 137. Bewick, B. M. , West, R. M. , Barkham, M. , Mulhern, B. , Marlow, R. , Traviss, G. and Hill, A. J. (2013). The effectiveness of a web -based personalized feedback and social norms alcohol intervention on United Kingdom university students: Randomised Controlled Trial. Journal of Medical Internet Research, Marley, S. L. (2012). Understanding the role of social norms in a web-based personalised, feedback intervention for alcohol use. Doctoral of Clinical Psychology, University of Leeds.

Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking Leeds Institute of Health Sciences Academic Unit of Psychiatry and Behavioural Sciences Change. Drinking Bewick, B. M. , Rumball, K. , Birtwistle, J. C. , Shaw, J. R. , Johnson, O. , Raistrick, D. and Tober, G. (2014). Developing a webbased intervention to increase motivation to change and encourage uptake of specialist face-to-face treatment by hospital inpatients: Change. Drinking. Drug and Alcohol Review. Student alcohol consumption Barrass, C. J. (2012). Drinking experiences of first year female students: Using narratives to explore the transition to university life. Doctoral of Clinical Psychology, University of Leeds. Bewick, B. M, Mulhern, B. , Barkham, M. , Trusler, K. , Hill, A. J. and Stiles, W. B. (2008). Changes in undergraduate student alcohol consumption as they progress through university. BMC Public Health, 8, 163, Doi: 10. 1186/1471 -2458 -8 -163. Craigs, C. L. , Bewick, B. M. , Gill, J. , O’May, F. and Radley, D. (2011). UK student alcohol consumption: A cluster analysis of drinking behaviour typologies. Health Education Journal, Doi: 10. 1177/00 i 7896911406967.