This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.
Alcohol screening and brief intervention is recommended for widespread implementation in health care systems, but it is not used routinely in most countries for a variety of reasons. Electronic screening and brief intervention (e-SBI), in which patients complete a Web-based questionnaire and are provided with personalized feedback on their drinking, is a promising alternative to practitioner delivered intervention, but its efficacy in the hospital outpatient setting has not been established.
The objective of our study was to establish the feasibility of conducting a full-scale randomized controlled trial to determine whether e-SBI reduces alcohol consumption in hospital outpatients with hazardous or harmful drinking.
The study was conducted in the outpatient department of a large public hospital in Newcastle (population 540,000), Australia. Adults with appointments at a broad range of medical and surgical outpatient clinics were invited to complete an e-SBI program on a laptop, and to report their impressions via a short questionnaire. Follow-up assessments were conducted 2-8 weeks later by email and post.
We approached 172 outpatients and 108/172 (62.8%) agreed to participate. Of the 106 patients capable of self-administering the e-SBI, 7/106 (6.6%) did not complete it (3 due to technical problems and 4 because they were called for their appointment), 15/106 (14.2%) indicated that they had not consumed any alcohol in the past 12 months, 43/106 (40.6%) screened negative for unhealthy alcohol use (scored less than 5 on the Alcohol Use Disorders Identification Test Consumption [AUDIT-C] questions), 33/106 (31.1%) screened positive for hazardous or harmful drinking (AUDIT-C score 5-9), and 8/106 (7.5%) screened positive for possible alcohol dependence (AUDIT-C score 10-12). Among the subgroup with hazardous or harmful drinking, 27/33 (82%) found the feedback on their drinking very, quite, or somewhat useful, 33/33 (100%) thought the intervention would appeal to most or some of the people who attend the service, and 22/30 (73%) completed the follow-up. We also found that some well established procedures used in trials of e-SBI in the primary care setting did not translate to the hospital outpatient setting (1) we experienced delays because the e-SBI program had to be developed and maintained by the health service’s information technology staff for security reasons, (2) recruiting patients as they left the reception desk was impractical because patients tended to arrive at the beginning of the clinics with few arrivals thereafter, and (3) use of a laptop in a fixed location resulted in some patients rushing through the e-SBI so they could return to their seat in the area they had been advised to wait in.
e-SBI is acceptable to outpatients and with some adaptation to organizational and physical conditions, it is feasible to recruit and screen patients and to deliver the intervention without disrupting normal service provision. This suggests that e-SBI could be provided routinely in this important setting if shown to be efficacious.
Unhealthy alcohol use is a leading risk factor for premature death and disability globally [
Electronic alcohol screening and brief intervention (e-SBI) is a promising alternative because it circumvents many provider-level barriers. Systematic reviews and meta-analyses of computer-delivered interventions have generally been positive [
The hospital outpatient setting serves a large proportion of the population. In Australia, a country of 23 million people [
Ethical approval for this study was obtained from the Hunter New England Human Research Ethics Committee (08/12/17/5.16) and the University of Newcastle Human Research Ethics Committee (H-2009-0332).
This single-arm feasibility study was conducted in the Ambulatory Care Center (outpatient department) at the John Hunter Hospital, a large public hospital located in Newcastle (population 540,000) [
Adult (18 years of age or older) outpatients capable of self-administering the e-SBI instrument were eligible to participate. The recruitment process was modelled on research conducted by Kypri and colleagues in a New Zealand university student primary care service [
Eligible outpatients who gave written informed consent were invited to complete the e-SBI instrument and to provide feedback on their impressions of it via a short pen-and-paper questionnaire while waiting for their appointment. Participants were advised to stop the e-SBI if they were called for their appointment, so as not to interfere with normal service provision, but were asked to return to the waiting area to complete it before leaving the hospital.
Participants were followed-up using an adapted tailored design method [
Participants who reported consuming alcohol in the past 4 weeks (ie, those who might be eligible for inclusion in a trial) were followed-up in December 2010 (ie, 2-8 weeks after recruitment) regardless of the actual date of recruitment. This procedure was adopted in preference to rolling follow-up due to resource constraints. Participants who provided an email address received an email message with a link to the brief Web-based follow-up questionnaire, while those who did not provide an email address received a paper questionnaire by post. Up to three email/postal reminders were sent following the initial invitation to complete the follow-up surveys. Participants who did not respond to the initial and reminder emails/postal surveys were followed-up by telephone.
The e-SBI program for hospital outpatients was based upon the Tertiary Health Research Intervention Via Email (THRIVE) program, which has been shown to reduce alcohol consumption among university students with hazardous or harmful drinking [
Page 1 provided a brief description of the Hospital Outpatient Alcohol Project (HOAP). Page 2 collected demographic data (gender, age, and postcode). Page 3 asked respondents if they had consumed alcohol in the last 12 months. Those who had not were sent to a “Thanks” page at this point, while those who had consumed alcohol proceeded to page 4. The Alcohol Use Disorders Identification Test (AUDIT) [
All participants (ie, including those who screened negative for unhealthy alcohol use and those who screened positive for possible alcohol dependence) received (1) feedback on their AUDIT score and guidance on its meaning [
Screenshot from the pilot HOAP e-SBI program showing the AUDIT.
Screenshot from the pilot HOAP e-SBI program showing feedback regarding a hypothetical participant’s score on the AUDIT.
Screenshot from the pilot HOAP e-SBI program comparing a hypothetical participant’s (1) typical episodic consumption and (2) weekly consumption with (3) medical recommendations and (4) adults of the same age and gender.
Participants in the proposed full-scale RCT will be screened for hazardous and harmful drinking using the AUDIT-Consumption (AUDIT-C) subscale [
The feasibility of delivering e-SBI in the waiting area of the outpatient department of a large, public hospital was measured as the proportion of participants who completed the e-SBI.
The acceptability of the e-SBI (eg, ease of completion, clarity of questions, privacy) was assessed using self-administered survey questions (1) immediately on completion of the e-SBI using a procedure described by Hallet et al [
The feasibility of contacting participants to complete assessments of their drinking was measured as the proportion who returned the follow-up questionnaire comprising nine questions: three seeking information on alcohol consumption (“On how many days in the last 4 weeks did you drink alcohol?”, “On average, how many standard drinks did you have per drinking day?”, and “On how many days in the last 4 weeks did you have 6 or more standard drinks on one occasion?”), and six questions seeking feedback regarding the e-SBI program.
Data were analyzed using STATA 11.1 (STATA Corporation, College Station, TX, USA). Descriptive statistics (frequencies and percentages for discrete variables and medians with interquartile ranges for continuous variables) were used to summarize the characteristics of study participants (gender, age group, and alcohol consumption) and outcomes related to recruitment, intervention completion, acceptability of e-SBI, and retention.
The e-SBI program for hospital outpatients was essentially the same as the THRIVE program except for the addition of (1) the revised Australian drinking guidelines [
Although research assistants were trained in the application of a study protocol stipulating they should invite the next patient leaving the reception desk to participate in the study, it quickly became apparent that this recruitment procedure was inefficient because patients arrived in large groups around the time that specific clinics opened, followed by long periods of time with very few arrivals. Our solution was to approach patients who occupied designated seats in rotation around the waiting area and it was often possible to approach all outpatients because of the long waiting times. Of the 172 outpatients we approached, 108/172 (62.8%) consented, 62/172 (36.0%) refused, and 2/172 (1.2%) were not eligible. Among those who consented, 2/108 (1.9%) were found to be ineligible and excluded (1 patient was unable to self-administer the e-SBI due to arthritis and the other person was not an outpatient). Among the 106 eligible consenting patients, 7/106 (6.6%) did not complete the e-SBI, 15/106 (14.2%) had not consumed any alcohol in the past 12 months, 43/106 (40.6%) screened negative for unhealthy alcohol use (scored less than 5 on the AUDIT-C), 33/106 (31.1%) screened positive for hazardous or harmful drinking (scored 5-9 on the AUDIT-C), and 8/106 (7.5%) screened positive for possible alcohol dependence (scored 10-12 on the AUDIT-C).
Of the 106 eligible consenting outpatients, 99/106 (93.4%) completed the e-SBI program. Among the 7 noncompleters, 3/7 (43%) could not complete it due to technical problems, and 4/7 (57%) were called for their appointment before completing the program and did not return. In addition, because the laptop used to deliver the e-SBI was located 10-15 meters from some sections of the waiting area where outpatients had been advised to wait and from where they would be called for their appointment, we noticed that some participants were rushing through the program so they could return to the area they had been advised to wait in. This was a concern because it would reduce the efficacy of the intervention if participants did not read and absorb the feedback.
Feedback regarding the usability and acceptability of the program for all drinkers and the subgroup who screened positive for hazardous or harmful drinking is shown in
Of the 69 participants who were invited to complete the follow-up assessment, 52/69 (75%) completed it. The follow-up rate among the subgroup with hazardous or harmful drinking was slightly lower, (22/30, 73%). Information obtained at follow-up is shown in
Due to concerns that arose during the pilot study regarding the usability of laptop computers, we returned to the outpatient waiting area six months later (June 2012) to assess the feasibility of using iPads. There were 9 patients (4/9, 44% male; 2/9, 22% aged 18-34 years; 4/9, 44% with an AUDIT-C score of 5-9) that agreed to participate. Although all were able to self-administer the e-SBI using the iPad, patients with larger fingers (mainly older men) would have found it easier if a stylus were available.
Demographic characteristics and alcohol use of participants.
|
|
Total | All drinkers | AUDIT-C Score | ||
|
(n=99) | (n=84) | <5 |
5 - 9 |
>9 |
|
Male, n (%) |
|
53 (54) | 49 (58) | 16 (37) | 26 (79) | 7 (88) |
Age group, n (%) |
|
|||||
|
18-34 years | 33 (33) | 29 (35) | 11 (26) | 14 (42) | 4 (50) |
|
35-54 years | 32 (32) | 26 (31) | 11 (26) | 13 (39) | 2 (25) |
|
55+ years | 34 (34) | 29 (35) | 21 (49) | 6 (18) | 2 (25) |
Access to email, n (%) |
|
72 (73) | 63 (75) | 33 (77) | 24 (73) | 6 (75) |
AUDIT score, median (25th and 75th percentiles) |
|
- | 5 (3, 12) | 3 (1,4) | 11 (7, 16) | 19 (14.5, 27) |
LDQ score, median (25th and 75th percentiles) |
|
- | 0 (0, 3) | 0 (0, 0) | 3 (0, 6) | 5.5 (2, 11) |
Consumed alcohol in the past 4 weeks, n (%) |
|
- | 69 (82) | 32 (74) | 30 (91) | 7 (88) |
Consumed more than 4 drinks on a single occasion at least once in the last 4 weeks, n (%) |
|
- | 41 (49) | 5 (12) | 29 (88) | 7 (88) |
Largest number of standard drinks consumed on a single occasion in the past 4 weeks, median (25th and 75th percentiles) |
|
- | 6 (3, 12) | 2 (2, 4) | 9 (7, 15) | 20 (7, 24) |
Flow of participants through pilot study.
Acceptability of e-SBI.
Question |
|
All drinkers | AUDIT-C Score |
|
||||
(n=84) |
<5 (n=43) |
5-9 (n=33) |
>9 (n=8) |
|
||||
|
||||||||
|
Very low | 19 (23) | 9 (21) | 8 (24) | 2 (25) | |||
|
Low | 29 (35) | 15 (35) | 13 (39) | 1 (13) | |||
Moderate | 15 (18) | 7 (16) | 5 (15) | 3 (38) | ||||
High | 9 (11) | 4 (9) | 3 (9) | 2 (25) | ||||
Very high | 12 (14) | 8 (19) | 4 (12) | 0 (0) | ||||
|
||||||||
Very hard | 1 (1.2) | 0 (0) | 0 (0) | 1 (13) | ||||
Hard | 5 (6) | 1 (2) | 2 (6) | 2 (25) | ||||
Somewhat hard | 16 (19) | 2 (5) | 12 (36) | 2 (25) | ||||
Not hard at all | 62 (74) | 40 (93) | 19 (58) | 3 (38) | ||||
|
||||||||
All of the time | 79 (95) | 42 (98) | 31 (94) | 6 (75) | ||||
Most of the time | 4 (5) | 1 (2) | 1 (3) | 2 (25) | ||||
Some of the time | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||||
|
None of the time | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |||
|
||||||||
Very surprising | 5 (6) | 3 (7) | 1 (3) | 1 (13) | ||||
Quite surprising | 14 (17) | 3 (7) | 9 (27) | 2 (25) | ||||
Somewhat surprising | 16 (19) | 4 (9) | 9 (27) | 3 (38) | ||||
Not surprising at all | 48 (57) | 33 (77) | 13 (39) | 2 (25) | ||||
|
||||||||
Very useful | 21 (25) | 11 (26) | 6 (18) | 4 (50) | ||||
Quite useful | 20 (24) | 7 (16) | 11 (33) | 2 (25) | ||||
Somewhat useful | 25 (30) | 13 (30) | 10 (30) | 2 (25) | ||||
Not useful at all | 17 (20) | 12 (28) | 5 (15) | 0 (0) | ||||
|
||||||||
Yes | 11 (13) | 5 (12) | 6 (18) | 0 (0) | ||||
No | 51 (61) | 32 (74) | 16 (48) | 3 (38) | ||||
Possibly | 21 (25) | 6 (14) | 10 (30) | 5 (63) | ||||
|
||||||||
|
Yes, all of the time | 1 (1) | 1 (2) | 0 (0) | 0 (0) | |||
Yes, most of the time | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||||
Yes, some of the time | 1(1) | 1 (2) | 0 (0) | 0 (0) | ||||
No, none of the time | 81 (96) | 41 (95) | 32 (97) | 8 (100) | ||||
|
||||||||
Yes, all of the time | 71 (85) | 37 (86) | 26 (79) | 8 (100) | ||||
Yes, most of the time | 11 (13) | 6 (14) | 5 (15) | 0 (0) | ||||
|
Yes, some of the time | 1 (1) | 0 (0) | 1 (3) | 0 (0) | |||
No, none of the time | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||||
|
||||||||
Yes | 79 (94) | 41 (95) | 30 (91) | 8 (100) | ||||
No | 4 (5) | 2 (5) | 2 (6) | 0 (0) | ||||
|
||||||||
Yes, all of them | 12 (14) | 11 (26) | 0 (0) | 1 (13) | ||||
Yes, most of them | 41 (49) | 22 (51) | 15 (45) | 4 (50) | ||||
Only some of them | 30 (36) | 10 (23) | 17 (52) | 3 (38) | ||||
None of them | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
Alcohol consumption and acceptability of e-SBI at follow-up.
|
All drinkers | AUDIT-C Score | |||
(n=52) | <5 (n=26) | 5-9 (n=22) | >9 (n=4) | ||
Number of days consumed alcohol in the past 4 weeks, median (25thand 75thpercentile) | 9.5 (3, 20) | 4 (2, 10) | 11.5 (5, 20) | 23 (13.5, 28) | |
Number of standard drinks per typical drinking occasion in the past 4 weeks, median (25thand 75thpercentile) | 2 (1, 4) | 2 (1, 2) | 3 (2, 6) | 9 (7, 10) | |
Number of times more than 6 standard drinks were consumed in past 4 weeks, median (25thand 75thpercentile) | 0 (0, 3) | 0 (0, 0) | 2 (0, 4) | 10.5 (5, 15) | |
|
|||||
No | 3 (6) | 2 (8) | 0 (0) | 1 (25) | |
Yes | 48 (94) | 24 (92) | 21 (100) | 3 (75) | |
|
|||||
No | 7 (14) | 4 (15) | 3 (14) | 0 (0) | |
Yes | 33 (65) | 17 (65) | 13 (62) | 3 (75) | |
I did not receive this feedback but would like to receive it | 6 (12) | 4 (15) | 2 (10) | 0 (0) | |
I did not receive this feedback and am not interested in receiving it | 5 (10) | 1 (4) | 3 (14) | 1 (25) | |
|
|||||
About what I expected | 23 (46) | 11 (42) | 9 (45) | 3 (75) | |
Higher than I expected | 5 (10) | 3 (12) | 1 (5) | 1 (25) | |
Lower than I expected | 3 (6) | 1 (4) | 2 (10) | 0 (0) | |
|
I had no idea what the average was | 10 (20) | 7 (27) | 3 (15) | 0 (0) |
|
I did not receive this feedback but would like to receive it | 5 (10) | 3 (12) | 2 (10) | 0 (0) |
I did not receive this feedback and am not interested in receiving it | 4 (8) | 1 (4) | 3 (15) | 0 (0) | |
|
|||||
Not changed | 39 (81) | 23 (92) | 13 (68) | 3 (75) | |
Decreased | 9 (19) | 2 (8) | 6 (32) | 1 (25) | |
Increased | 0 (0) | 0 (0) | 0 (0) | 0 (0) | |
|
|||||
No | 37 (77) | 19 (76) | 15 (79) | 3 (75) | |
Yes | 11 (23) | 6 (24) | 4 (21) | 1 (25) | |
|
|||||
No | 77 (34) | 8 (31) | 6 (30) | 3 (75) | |
Yes | 23 (66) | 18 (69) | 14 (70) | 1 (25) |
Our results show that e-SBI is acceptable to hospital outpatients and that it is possible to recruit, screen, and deliver e-SBI in the hospital outpatient setting without disrupting normal service provision. Almost two-thirds (108/172, 62.8%) of the patients we approached consented, almost two in five adults (41/106, 38.7%) reported unhealthy alcohol use (compared with one in five adults aged 18 years and over in the general Australian population) [
In addition to obtaining estimates of the consent rate, the proportion that would be eligible for inclusion in a full-scale RCT, and the likely response at follow-up, we discovered that some well established procedures used in trials of e-SBI in the primary care setting did not translate to the hospital outpatient setting. First, we could not utilize the services of IT staff who had been involved in the development of the THRIVE program because of the health service’s requirement that the program use a particular programming language. This reliance on personnel employed by another organization who had other priorities delayed the project considerably. Second, the health service did not allow the inclusion of links to external websites for security reasons. While suboptimal, this is not a major concern because previous analyses of the Web pages accessed by more than 1000 users of the THRIVE instrument showed the e-SBI was efficacious [
Limitations of the study include the short follow-up, attrition, and the small number of participants who completed the e-SBI using an iPad. The loss-to-follow-up is a concern because attrition reduces the effective sample size and can bias effect estimates [
Strengths of the study include the use of an intervention informed by more than a decade of research on the development and evaluation of e-SBI in university students [
We obtained estimates of the consent rate, proportion with hazardous or harmful drinking, and response at follow-up, which are essential to the design of a full-scale RCT to determine whether e-SBI reduces hazardous or harmful drinking in hospital outpatients. In addition, our study demonstrated that e-SBI is acceptable to hospital outpatients with hazardous or harmful drinking and, given the feasibility of recruiting and screening patients, and of delivering the intervention without disrupting normal service provision, that it could be provided routinely in this important setting.
Alcohol Use Disorders Identification Test
Alcohol Use Disorders Identification Test Consumption subscale
blood alcohol concentration
electronic alcohol screening and brief intervention
information technology
Leeds Dependence Questionnaire
The study was funded by a grant from the Foundation for Alcohol Research and Education. A National Health and Medical Research Council Senior Research Fellowship (APP1041867) supported KK. We thank the Hunter New England Local Health District, the manager of the Ambulatory Care Center in particular, for facilitating the research; Stephanie Love, who collected the data; and Joanna Latter, who assisted with the preparation of this manuscript.
None declared.