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Due to limited reporting of intervention rationale, little is known about what distinguishes a good intervention from a poor one. To support improved design, there is a need for comprehensive reports on novel and complex theory-based interventions. Specifically, the emerging trend of just-in-time tailoring of content in response to change in target behavior or emotional state is promising.
The objective of this study was to give a systematic and comprehensive description of the treatment rationale of an online alcohol intervention called Balance.
We used the intervention mapping protocol to describe the treatment rationale of Balance. The intervention targets at-risk drinking, and it is delivered by email, mobile phone text messaging, and tailored interactive webpages combining text, pictures, and prerecorded audio.
The rationale of the current treatment was derived from a self-regulation perspective, and the overarching idea was to support continued self-regulation throughout the behavior change process. Maintaining the change efforts over time and coping adaptively during critical moments (eg, immediately before and after a lapse) are key factors to successful behavior change. Important elements of the treatment rationale to achieving these elements were: (1) emotion regulation as an inoculation strategy against self-regulation failure, (2) avoiding lapses by adaptive coping, and (3) avoiding relapse by resuming the change efforts after a lapse. Two distinct and complementary delivery strategies were used, including a day-to-day tunnel approach in combination with just-in-time therapy. The tunnel strategy was in accordance with the need for continuous self-regulation and it functions as a platform from which just-in-time therapy was launched. Just-in-time therapy was used to support coping during critical moments, and started when the client reports either low self-efficacy or that they were drinking above target levels.
The descriptions of the treatment rationale for Balance, the alcohol intervention reported herein, provides an intervention blueprint that will aid in interpreting the results from future program evaluations. It will ease comparisons of program rationales across interventions, and may assist intervention development. By putting just-in-time therapy within a complete theoretical and practical context, including the tunnel delivery strategy and the self-regulation perspective, we have contributed to an understanding of how multiple delivery strategies in eHealth interventions can be combined. Additionally, this is a call for action to improve the reporting practices within eHealth research. Possible ways to achieve such improvement include using a systematic and structured approach, and for intervention reports to be published after peer-review and separately from evaluation reports.
Improved reporting of intervention rationales within eHealth will extend the evidence base and may improve the design of future intervention programs [
Generally, we can say that eHealth interventions [
This paper uses intervention mapping (IM) to give a systematic and comprehensive description of the treatment rationale. The IM protocol [
The objective of the paper is to describe treatment rationale, hence, we focused on the 4 applicable steps of IM: (1) a brief needs assessment, (2) defining the goal and the objectives of the intervention, (3) identification of intervention methods and applications, and (4) developing the actual program materials. Step 2 is further broken down into 3 levels of detail, which are the overall program goal, the performance objectives, and the change objectives. The program goal is the result you want to achieve with the intervention (eg, to make at-risk drinkers drink less), the performance objectives describe the actual behaviors that each client must perform to reach the program goal, and the change objectives outlines what needs to change with regard to specific behavior determinants for the program participants to do each of the performance objectives. In this way, the performance objective is a specification of the program goal, and the change objective is a specification of the performance objectives. The end result of step 2 is a matrix in which the performance objectives are crossed with the behavior determinants to form a set of change objectives. This matrix constitutes the core of the treatment rationale of which the subsequent steps of the development process is based upon.
Alcohol use is the third leading contributor to the global burden of disease [
While face-to-face alcohol screening and brief interventions are effective in reducing alcohol consumption [
With regard to the intended aims of an intervention, the first level is the program goal, and the result one wants to achieve with the program. The goal of the current program is to diminish health risk and mitigate negative consequences of alcohol by encouraging lowered alcohol consumption among at-risk drinkers (ie, hazardous and harmful drinkers). Stated differently, the intervention is intended to make at-risk drinkers drink less. The performance objectives, change objectives, and sub-aims of the intervention will specify how this goal can be achieved.
A specific intervention may target one or several performance objectives. Performance objectives make up the actual behaviors that each client must perform for the program goal to be reached and their behavior to be changed. A performance objective is a specification of the program goal, and it defines more precisely what it is to drink less, in terms of behavior. The goal of the program was to make at-risk drinkers drink less. Self-regulatory processes appear to play key roles in both the causes and effects of alcohol consumption [
In a broad sense, self-regulation refers to any effort to alter personal responses, including thoughts, actions, feelings, and desires. Without regulation effort a person would respond to a situation according to habit, previous learning history, innate tendencies, or biological needs. Self-regulation is comprised of 3 sub-processes: (1) self-observation, (2) self-evaluation, and (3) self-reaction. These processes are interdependent and take place in an ongoing circular process [
Self-observation, or self-monitoring, refers to conscious efforts to explicitly identify one’s own impulses. It is important to observe the thoughts, feelings, or environmental factors that precede craving or deciding to have a drink (eg, “the argument with my spouse made me feel poorly, and I had a drink to cheer me up” or “meeting my friend at the pub made me feel like drinking”). Self-evaluation involves using criteria or standards to assess situations, problems, or behaviors according to personal goals (eg, “my goal today was maximum 2 beers, but now I’ve emptied the fourth bottle - this was not what I planned for”). Self-reaction refers to any active effort to alter an unwanted impulse and comes as a response to self-observation and self-evaluation. Self-reaction includes self-stopping, rewarding or punishing oneself, making implementation intentions, coping, and action plans [
The decisions and processes involved when initiating a behavior change attempt may be different from those involved in maintaining a new behavior [
Self-regulatory processes place demands on people’s mental capabilities and when these mental resources are depleted, people are vulnerable to self-regulatory failure. Such failures, like a lapse or a relapse, are more likely to occur when people are tired or experience negative emotions [
To develop the change objectives of the program, 2 considerations were made. First, what the clients needed to do to successfully change their behavior was defined (ie, the performance objectives above). Second, what makes people carry out these actions was identified (ie, the behavior determinants). For this purpose, the change objectives related to knowledge, attitudes, norms, planning, self-efficacy, skills, and behavior were included [
The matrix of change objectives.
Performance objectives for at-risk drinkers | Determinants | ||
Knowledge and outcome expectancies | Attitudes and self-efficacy | Planning, skills, and actions | |
1. Continued self-observation and self-evaluation | Express that sustained effort in self-observation/ evaluation is necessary | Active involvement in own change attempt |
Keep a record of drinks and compare with personal standard |
2. Implementation of the behavior change attempt | Know how own drinking relates to official guidelines | Express positive feelings for receiving help to drink less |
Set exact maximum limits for the number of drinks to be consumed |
3. Maintenance of the behavior change attempt over time | Recognize relapse vulnerability and need for long-term efforts | Express that intervention provides help that are personally relevant and according to own goals |
Plan how and when to reward oneself for achievements |
3a. Avoid lapse by coping adaptively with the antecedents of drinking | List the most personally relevant antecedents of drinking | Express confidence in ability to cope with urges and temptations etc | Make implementation intentions about activating tools and strategies to handle craving or temptation, including techniques to improve mood |
3b. Avoid relapse by resuming the change effort after a lapse | Know the psychological consequences of having a lapse and the distinction between lapse and relapse | Attribute failures to transient situational factors and achievements to self |
Make implementation intention, after a lapse, about sticking to original plan (drink less) |
3c. Constructive regulation of emotions | List a set of techniques to improve mood | Express confidence in ability to regulate mood | Apply the learned mood regulation techniques |
The previous step of the mapping process is largely concerned with what needs to change (ie, conceptual theories), while the current step is concerned with how change is brought about (ie, action theories). As demonstrated in the previous step, self-regulation theory [
Making heavy drinkers track their own alcohol consumption on a daily basis using automated technology may help to reduce drinking [
In translating methods into practical strategies, one needs to consider the feasibility and the practical context. Thus, this task has to be done in iterative steps with the next task, developing the actual materials, to fit the strategies with this context. For example, the combination of goal setting and behavioral monitoring to serve as a trigger system for launching the just-in-time therapy would not be feasible in the practical context of group therapy with biweekly meetings.
Theoretical methods, practical strategies, and considerations for use.
Theoretical method | Practical strategy: |
Considerations for use: |
Active learning | Give information in texts (a psychoeducational approach). |
Should be relevant, plain, rewarding to follow, and vary in format and media. Learning moments should be short and many, rather than few and lengthy. |
Consciousness raising | Provide information, guidelines, assignments, examples and tips to increase self-awareness. | Feedback and confrontation should be followed by increase in problem solving ability and self-efficacy. |
Self-reward | Encourage self-reward. | Should be a clear criterion for acquiring a pre specified reward. |
Reattribution | Teach to explain setbacks and successes in terms of adaptive attributions (ie, transient and external attributions for failure, and stable and internal attributions for mastery). | Optimistic attribution pattern should be primed early, and reinforced after lapse (just-in-time). |
Provide social cues | Provide social cues (physical, psychological, language, social dynamics, and social roles) that elicit instinctive social responses. | Excessive use of these techniques may backfire into annoyance. |
Visible expectations | Stimulate thinking about expectations from significant others. | Timing: prior to drinking situations, weekends. |
Self-reevaluation | Further cognitive and affective assessments of one’s self-image with and without at-risk drinking (eg, comparing self-image of being at-risk versus no-risk). | Raising awareness must be quickly followed by increase in problem solving ability and self-efficacy. |
Environmental reevaluation | Further affective and cognitive assessments of how the presence or absence of risky drinking affects one’s social environment (eg, describes how drinking affects family and reflect on self as role model). | Raising awareness must be quickly followed by increase in problem solving ability and self-efficacy. |
Anticipated regret | Stimulate anticipation the negative affective consequences of continued at-risk drinking. | Must stimulate imagination. |
Modeling | Show potential role models and how they coped with difficulties etc. | Model should be reinforced. |
Resistance to pressure | Promote making of counter arguments. | Requires building of refusal skills. |
Positive self-talk | Encourage making positive statements to inner ear about self, own abilities etc. | Not applicable. |
Reframing | Teach how to put negative facts into another frame of reference that makes the fact positive or neutral. | Not applicable. |
Support | Stimulate mapping the environment for potential supporters. Encourage contact, and provide suggestion for contact email. | Not applicable. |
Implementation intentions | Stimulate formation of implementation intentions, by texts, prompts and assignments. | Must include specification of when, where and how to act. |
Planning coping responses | Promote identification of potential barriers and ways to overcome these. | Not applicable. |
Mastery experiences | Teach to imagine and write down previous mastery experiences, and encourage a focus on what is mastered until now (eg, you have kept your targets for many days). | Beneficial with domain similarity. Can be used for just-in-time therapy in critical situations. |
Vicarious experience | Provide stories of mastery/success from others, and encourage identification of such stories in own environment. | Requires identification with model. |
Persuasion | Communicate optimism about the outcomes, and point out that change is not an instantaneous venture. | Enhanced by the prior development of confidence in treatment provider. |
Behavioral monitoring | Prompt to perform daily logging of target behavior. | Not applicable. |
Goal setting | Encourage setting specific and time-targeted goals with regard to drinking. | Not applicable. |
Count the good things in life | Promote noticing and appreciating the positive aspects of life—anticipate future pleasures, mindful of present pleasures, and reminisce about past pleasures. | Not applicable. |
Socializing | Encourage mapping social network for doing pleasant activities. Encourage contact, and provide suggestion for contact text messages or phone calls. Tips to make or improve social bonds. | Persons should decide in advance not to drink, go to places without alcohol, or with persons that do not drink. |
Cognitive defusion | Encourage combating the tendency to reify thoughts, emotions, and memories. | Acceptance and defusion is not an end in itself, but a mean to increase psychological flexibility and value based action. |
Mindfulness | Provide exercises that fosters contact with the present moment and self as a context, not self as the content of thoughts. | Not applicable. |
Identify value-based goals | Promote defining core values, deciding specific value based goals, and acting on the goals. | Goals should be specific, measurable, achievable, realistic and time-targeted. |
Nonviolent communication | Teach to distinguish an action from the assessment of or the feelings evoked by the action, identifying and expressing the feeling, the need and what one want in a non-demanding way. | Client should practice the distinctions and the concept and be given feedback. |
Doing kind acts | Encourage ideas for kind acts, keep track of them, and plan them ahead of time. | Not applicable. |
Visualizing best possible life | Encourage envisioning scenarios of a future life in which many goals and dreams are actualized and personal potential had been met. | Recognize what is already achieved, challenge barrier thoughts, and break major goals down into achievable sub-goals and milestones. |
Screening may support an informed choice about whether to change drinking habits or not, and starting alcohol interventions with screening is standard practice [
The program relies on 2 distinct and complementary strategies for delivering intervention content—tunnel information architecture and just-in-time therapy. The tunnel information architecture is a core organizing feature of the program. Tunnel designs use a screen-by-screen and a session-by-session approach in which the user follows a predetermined sequence of units of content. As opposed to in a hierarchical design, where the user must navigate menus to find the desired content, the user is guided through the various program materials in a fixed sequence in a tunnel design. To avoid distraction, a tunnel program restricts access to any ancillary or related content, and oftentimes it limits user navigation to the “next” and “prior” buttons, thus offering low user workload [
A tunnel design is double-edged sword. Upon entering a tunnel the user accepts a lowered degree of autonomy, and there is a danger that reduced autonomy may lead to frustration and dropout. On the other hand, a tunnel design may also increase the chances that the user will engage in activities and see content that would otherwise not be encountered [
In the current program, the tunnel design was applied both at micro and macro levels. On a micro level, it dictated that each session was broken into smaller portions or pages; the user can flip between pages but not sessions (
Including proactive elements and supplementary modes of communication can improve adherence to Web-based interventions [
Although a tunnel design restricts user self-determination, such a design does not dictate passive users, as the tunnel design is well suited to foster interactive dialogues with the user [
In the current intervention, goal setting, behavior logging, and the just-in-time therapy are practically and theoretically intertwined. Each session the client is asked to log the number of drinks had on the previous day. Such behavior logging is important because it stimulates self-awareness. During each Monday session, the client determines their drinking targets for the coming week. To support this goal setting, a graph presenting the targets set and the logged consumption (week totals from all previous weeks in the program), and a detailed comparison of target and result for each day from the last week, is displayed. Then the client is asked whether the goals from previous week should be kept or adjusted. If they choose to adjust the targets, they are provided with a form where they fill in the maximum number of drinks to be consumed for each day of the week. The client is encouraged to cut down slowly at first, and then gradually cut further down as the initial targets are met. The client is told to set targets that he/she perceives to be achievable. By making the clients set their own targets, client autonomy is maintained. However, if the week goal is higher than baseline, this is pointed out to the client and the client is asked whether he/she is sure about the targets. The client may either respond “Yes, this week is special and I want to allow myself such goals”, or “No, I want to set myself lower goals.” As such, behavior logging and goal setting may contribute to successful behavior change [
After logging of the drinks consumed on the previous day, the datum is compared with the target that was previously set by the client for that day (
The therapy consists of a prerecorded dialogue between a client and a counselor (a 5 minute audio recording,
During each session, the lapse prevention system follows the relapse prevention described above. Here, the client is reminded of that day’s target and asked how confident he/she feels about reaching it. The lapse prevention therapy is activated if the client replies, “I'm not sure” (as opposed to, “I'm fairly certain I’ll manage”). Before the therapy starts, the client is asked to elaborate, by selecting 1 of 3 options: (1) “I feel worn out and down”, (2) “I don’t feel so sure of myself today,” and (3) “I seem to have lost some motivation.” The options are intended to cover depletion of resources, self-efficacy, and motivation, respectively (
At the final screen of the lapse prevention therapy, the client is asked to provide a time point for that day or evening for the program to send an encouraging mobile phone message via short message service (SMS). The client is encouraged to provide a time point when they would need it the most. The content of the SMS is related to the topic of the lapse prevention therapy. For example, if the therapy included planning how to cope with a challenging situation, the SMS would be a reminder about the coping plan; if the topic is previous mastery experiences, the SMS would be a reminder of those previous experiences.
People tend to react to and interact with objects in their environment, including media applications, as if it were real people [
Emotion regulation makes up a significant proportion of the intervention content, and consists of 7 distinct tracks, each covering a unique topic including gratitude, socializing, turning negative thoughts, nonviolent communication, doing acts of kindness, optimism, and pleasant activities. The contents and assignments from these tracks are taken from the positive psychology tradition and from cognitive behavioral therapy [
Two of the tracks are provided to all users, the gratitude track and the socializing track. The gratitude track involves assignments like counting ones blessings, writing down 3 good things that happened during the day, writing a letter of gratitude, and saying “thank you” more often than usual. The socializing track is about encouraging social interaction with friends and relatives (without alcohol). Assignments in this track includes calling a friend and inviting him/her out, mapping one’s social network, advice on how to get new friends, and strengthening existing relationships (eg, find out about a friend’s plan and follow up the next week by asking how it went, or give compliments to a partner or friend).
Then, based on a cue-reactivity test [
The turning negative thoughts track is based on the acceptance and commitment therapy [
Then based on a person-activity fit diagnostic [
We have used IM to give a systematic and comprehensive description of the treatment rationale of an alcohol intervention, named Balance. Its treatment rationale is essentially based on a self-regulation perspective [
Tailoring of intervention content in response to dynamic processes in target behavior or emotional states, as described above, is an emerging trend to eHealth design [
There are several limitations to the current research. The target group of the program is very broad. On one side of the spectrum, the target group includes persons with a long history of harmful drinking that might be very conscious about the negative impact from alcohol on their life, that are already motivated to change. On the other side of spectrum, the target group also includes persons that drink only marginally above the limits for sensible drinking. They have probably never experienced any serious negative consequences of alcohol, their drinking pattern is largely within the borders of what is culturally acceptable, and many of them probably do not think that they need to change at all. Targeting such a diverse population, with regard to motivation for change, drinking pattern, and alcohol history, with one single intervention may turn out to be overly optimistic. That is, the intervention will be more or less acceptable to use for certain sub-groups within the broader target population. Exactly what outcomes to expect in the various sub-groups, however, is an empirical question, which we will try to shed light on in later evaluation reports.
The dropout rates from eHealth interventions, including alcohol interventions, tend to be high [
EHealth is an applied science in which interventions are designed to solve specific health problems, meaning that the design process ought to be problem driven [
The step-by-step manualized approach of IM prescribes a process to designing an intervention that functions as a useful planning tool. The manualized approach is also advantageous in that it provides a clear structure to the reporting that may aid in writing it, reading it, and in comparing the rationale across interventions. In completing the IM steps, theory and evidence is systematically linked to eHealth practice through a logical chain of decisions. Each step and decision shapes how an intervention influences its users, and by making the choices explicit, they are subjected to the test of evidence [
Scientists, reviewers, and editors alike are inevitably influenced by the trial report conventions [
Several solutions to this issue have been suggested, including digital preservation of intervention content in a Web archive [
The descriptions of the treatment rationale for the alcohol intervention Balance, provides an intervention blueprint that will aid in interpreting the results from future program evaluation, it will ease comparisons of intervention rationale across interventions, and it may assist intervention development. By putting the just-in-time therapy within a complete theoretical and practical context, including the tunnel delivery strategy and the self-regulation perspective, we have contributed to an understanding of how multiple delivery strategies in eHealth interventions can be combined. Additionally, this is a call for action to improve the reporting practices within eHealth research. As one way to achieve such improvement, we advocate for using a systematic and structured approach, and for intervention reports to be published peer-reviewed and separately from evaluation reports.
A compilation of screenshots from the Balance program.
Sample items from the weekly quizzes.
A transcription of one of the audio therapies for managing a recent lapse (relapse prevention).
intervention mapping
short message service
This study was funded by the Norwegian Research Council and the Norwegian Centre for Addiction Research. The intervention was funded by the Workplace Advisory Center for Issues Relating to Alcohol, Drugs and Addictive Gambling. Thanks are extended to Elin Olsen Kallevik, Filip Drozd, Harald Schjelderup-Lund, and Pål Kraft at Changetech, who all played key roles in the development of Balance. We would also like to thank the Workplace Advisory Center for Issues Relating to Alcohol, Drugs and Addictive Gambling, especially its director at the time Kjetil Frøyland, who also contributed in planning.
None declared.