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Brief interventions can reduce alcohol consumption in young people through screening and delivery of personally relevant feedback. Recently, Web and mobile platforms have been harnessed to increase the reach of brief interventions. Existing literature on mobile-based alcohol brief interventions indicates mixed use of theory in developing interventions. There is no research available to guide the development of SMS text messaging (short message service, SMS) interventions delivered during risky drinking events.
The aim of this study was to develop and pilot an alcohol-related risk-reduction brief intervention delivered by SMS to Australian young adults during drinking events. This paper describes the development of intervention message content, with specific focus on the context of delivery during drinking events.
A sample of 42 young adults attended 4 workshops; these comprised focus-group style discussion on drinking habits and motivations, discussion of intervention design, analysis of existing alcohol media campaigns, and participant development of message content. Data were analyzed thematically.
Participants described a focus on having fun and blocking out any incongruent negative influences during drinking episodes. For content to be acceptable, nonjudgmental and non-authoritative language was deemed essential. A preference for short, actionable messages was observed, including suggestions for reminders around drinking water, organizing transport home, checking on friends, and plans the next day. Participants were excited about the potential for messages to be tailored to individuals, as previous alcohol-related campaigns were deemed too generic and often irrelevant. Normative-based messages were also perceived as largely irrelevant as participants felt that they understood the drinking-related norms of their immediate peers already.
Findings from this study offer insights into young adults’ drinking events and practical advice for designing alcohol-related brief interventions. During our formative development process, we demonstrated a neat correspondence between young people’s preferences for alcohol harm reduction interventions and the theoretical principles of brief interventions, including acceptable topics and message style.
Alcohol consumption is a significant public health concern in Australia, particularly in relation to risky single-occasion drinking in young people [
One of the few individual-level prevention strategies known to effectively reduce alcohol consumption in young people is called brief intervention. Well-designed brief interventions are a low-cost strategy to reduce alcohol consumption and harm [
Motivational interviewing is a key component of brief interventions [
Recently, Web and mobile phone platforms have been harnessed to increase the reach of interventions intended to change behaviors in the realms of sexual health, physical activity, chronic disease management, and alcohol consumption [
The feedback provided within mobile brief interventions has also varied considerably in terms of both content and tone. Many publications describe content developed solely by researchers or clinicians [
Although other studies have examined young people’s opinions of alcohol interventions [
We developed and piloted an alcohol-related risk-reduction intervention delivered by SMS to Australian young adults during drinking events [
We recruited young adults to participate in the development, testing, and evaluation of the intervention [
Four development workshops were held in June 2014, with 8-12 participants in each group; each workshop lasted for 3 h. Participants were given an Aus $40 gift card and offered light refreshments. Two groups were mixed gender, one was female only, and one was male only. Participants were allocated to groups depending on preference and availability.
At the beginning of each session, we told participants that we wanted to create a mobile phone–based intervention to be delivered during nights on which they were planning to drink alcohol. We indicated that our plan included repeated reporting of alcohol consumption throughout the night and the provision of tailored messages which could correspond to surveys they filled in during the night. Participants were then engaged in a facilitated discussion relating to intervention design.
The workshops had four stages: (1) a focus-group style discussion on drinking habits and motivations, (2) discussion of the design features of the intervention, (3) analysis of existing media campaigns related to alcohol, and (4) a development component in which participants generated their own message content and gave further design feedback.
First, participants were asked to describe a “typical” night out, including usual drinking patterns and their as well as their peers’ event-level behavior. They also discussed their own motivations, if any, for reducing alcohol consumption within drinking events as well as more broadly, including what intervention features they felt would motivate them, and separately, what they felt would motivate their peers and young people in general. The groups also identified the types of health promotion content they found acceptable and relevant. Message style, language, framing, and topics were discussed. Participants reflected on tailoring required for different genders and ages, as well as event-specific contexts (eg, messages which might apply when drinking at a bar but not at private venues and messages relevant to stages of the night).
Second, participants were asked questions relating to the design of the intervention including ideal platforms, frequency of data collection and message delivery, questionnaire items, and feasibility. The results of this specific component of the study are reported elsewhere [
Third, participants were engaged in a media content analysis of over 20 diverse alcohol-related campaigns from Australia and elsewhere. These examples were taken from previous studies and public campaigns that included short alcohol messages. We selected examples which represented different message communication approaches, with a combination of text and image-based formats. Participants were shown examples one-by-one on a projector and asked to discuss reactions, comprehension, relevance, persuasion, and attractiveness. We asked which, if any, examples would be useful and appropriate and how to modify those that they thought were potentially useful. Participants discussed how best to translate messages for mobile phone and in-moment delivery, including format, length, topic appropriateness, and language.
Finally, participants were divided into groups of 2 to 4 people and asked to develop their own content for messages to be sent at different stages of their typical night out, based on topics that they felt would be relevant to them. Participants were given activity sheets developed by the researchers on which to list content and ideas.
The sessions were recorded digitally and the recordings transcribed verbatim. Four digital recorders were used in each session, so that any conversations which occurred during small group work could be captured. All transcripts from workshops, as well as notes written by participants, were analyzed thematically using NVivo 10 Software (QSR International Pty Ltd.) [
In total, 42 people attended the development workshops—21 women and 21 men aged 18-25 years. Findings were divided into two categories: (1) the style of messages preferred for delivery during a drinking event, and (2) the topics that participants considered were appropriate for this type of intervention.
Participants were asked about the preferred style and tone of the intervention. Without prompting or leading, almost all agreed that in order for content to be acceptable, nonjudgmental and non-authoritative language was essential. Participants described getting into a different state of mind when they commenced a drinking episode. This seemed to involve a concentrated focus on having fun and blocking out any incongruent negative influences on their night. This is an important idea with respect to any intervention occurring during a social event. Participants also advocated for some messages to be framed as questions, so as to allow them to reflect on their own behavior without being told by someone else why they should change. One participant felt that this would be more effective if applied to a message sent the day following the event:
At the time, if you are drinking, if you are doing things, you are going to be like, “I’m so awesome, I’m doing this thing,” and then the next day you go, “that was not good. Everyone is going to be remembering that. I’m going to remember that. That was awful.” I think it would be more the next day because if you were regretting it at the time, you probably wouldn’t maybe do it.
Participants requested that some positive reinforcement be provided during the intervention to create a more positive interaction. One participant communicated the desire for an intervention to “tell me what I’m doing right.” This sentiment was echoed across the workshops, with participants frequently mentioning the need for more encouraging messaging.
Fear-based campaigns or messages were described as likely to be ineffective as participants of both genders felt easily able to dismiss the seriousness or relevance of harms while in a social context. The following statements exemplify a common attitude among the participants:
I don’t know anyone who got drinking-related cancer...
...people pass out all the time...
If you get alcohol poisoning then they just pump your stomach and you’re fine the next day.
A clear preference for short, actionable harm-reduction focused messages was observed, including suggestions for reminders around drinking water, organizing a ride home, checking on friends, eating enough, and reminders of plans the next day. One participant articulated these points as follows:
If you tell me I’ll get sick when I’m old...What do I care? I can’t change that anyway. It’s the short-term stuff I can do something about.
Both male and female participants were excited about the potential for topics to be tailored to individual preference, as they felt many of the recent public alcohol-related campaigns were too generic and often irrelevant to them and their peers. Participants were keen for the messages to provide genuinely tailored feedback based on their reported preferences and behaviors, such as reminders based on their reported plans, tracking of cumulative drinking and spending, and the reflection of their own personally reported motivations.
Our participants reported that messages based on drinking norms messages were largely irrelevant to them; they felt they had a strong grasp on the norms of their social circles and were not concerned about what was normal to other young people. In each group, regardless of gender, the messages provided to participants from the norms-based example campaign were contested by at least one participant who did not believe the statistics presented were accurate. This was seen to compound the preexisting idea held by many participants that researchers and practitioners were “out of touch” with young people’s needs. A number of male participants touched on the idea that norms-based campaigns could have an effect opposite to that intended because of the “proud” culture around excessive drinking in Australian males:
Nah, and on the contrary, I reckon you would be like, “YOLO! (You Only Live Once). We do this.” I reckon...Yeah, that doesn’t resonate with me at all.
Indeed, most participants from our workshops claimed that they already knew about the harms related to alcohol consumption, but they did not seem serious or relevant in a social context. This did not seem to differ by gender. Unsurprisingly, long-term harms were described as especially unmotivating, despite many of the participants not knowing about, for example, the cancer-related harms of drinking. “Wouldn’t even read that—buzz killer, etc.”; “I’d just ignore it. Everything gives you cancer, may as well just have fun.” Instead, participants felt they would be most motivated by avoiding the consequences that they themselves had previously experienced—such as hangovers, losing possessions, vomiting, and memory loss—and therefore messages to aid the avoidance of these proximal harms were seen as useful.
Social burden was also seen as relevant: young people didn’t want to let down their peers or “ruin the night.” This sentiment was the same across genders, although described in a slightly different language. Participants in the male-only focus group discussed extensively the stereotype of the “shit mate,” or “maggot” who would “cut loose” at the expense of others. They recounted regretful episodes where they or their friends had drunkenly started fights, passed out and been too heavy to move, had been ejected from nightclubs, or had vomited in cars. Females across both the single-gender group and mixed groups more commonly described wanting to avoid being “that messy girl” who cried, whose makeup was smudged, and who needed greater protection and supervision. Safety and protection from others was a key concern for females and for female friends, whereas protection of males was more likely to relate to stopping them from hurting themselves by engaging in a risky behavior or violence.
You all have that one mate that just gets agro and you’re like oh god, where’s he gone, what’s he doing now—have to pull him away non-stop.
One female participant described that sending messages relating to checking on friends could serve the dual purpose of encouraging them to sober up in order to be able to protect their friends, while simultaneously reminding them not to be that drunk person themselves:
When you drink, or when I do, and your friend is—[pause]. You all of a sudden become like this protective person that wants to help. I think a lot of people do, if you love your friends or whatever [laughter]. The protecting your friends part is important. Even, “Check on your friends, how are they going?” because it could make you look at them and be like, wait, okay, this person is acting weird. Maybe I should tone down so I can help. But also you don’t want to be that weird friend either.
Spending was seen as a key motivator, as young people reported that they often experienced financial hardship and felt inexperienced at sticking to a budget. Some participants suggested the use of diet and exercise-based messages; across all focus groups, there was a clear gender difference with females more supportive of diet-based messages and males more supportive of sporting-related messages. A suggested form of feedback was comparing calories consumed as alcohol with those as junk food: “How many cheeseburgers am I drinking?” A male participant advocating for an exercise message reported: “I have footy (football) every Saturday, so if you reminded me about that...“However not all participants were interested in diet and exercise messages, and a few females expressed concern for the unintended consequences of this message type. “If you sent me that then I probably would just skip dinner instead.” Another female participant worried that it may even encourage existing disordered behavior:
The only thing with that is can it make people who are really insecure, anxious. It makes you not want to eat...You could get that random one person that gets it and she is like, "Oh no, I’m going to go and throw up."
Without any prompting, young people advocated for a style very similar to motivational interviewing in approach involving four basic strategies: open-ended questions, affirmations, reflective statements and summary statements [
Our participants dismissed some previous alcohol intervention strategies and campaigns as unappealing due to their focus on health. This finding is aligned with previous studies such as that of de Visser et al who found that their young participants were generally unconcerned by health consequences and more motivated by social factors [
Findings relating to motivations for drinking less, such as burdening friends, have also been discussed in previous studies [
Diet and exercise-based messages have been used in some recent public alcohol-related campaigns, but in light of this study and other relevant findings, there is a need for caution to ensure that unintended harm is not caused. Knight [
Reactions to normative-based messages were surprising, considering that these are an increasingly common feature of alcohol brief interventions [
Preference for short and actionable messages is well suited to the mobile platform and the in-moment delivery of messages. However, the style and tone of these short messages is important for acceptability [
This study used a small, nonprobability sample, but generalizability is not a focus of this qualitative research. Deep and rich insights are more important in this context, given how little is known about how to intervene during risky drinking events. Considering how new and emerging this area is, we could have chosen to employ in-depth interview methods instead, to allow deeper probing with each participant. We chose to use focus groups not only because of resource constraints but also due to the benefit of idea generation and examination of consensus which can occur in groups. At the completion of data collection, some new ideas were still emerging and some researchers may have chosen to continue collecting data. Our team decided that our main research questions had been answered with enough consistency across the four groups that we could be confident in our decision to close data collection. Acceptability might not equal behavior change. The efficacy of our intervention and the message content developed in these workshops in reducing alcohol consumption has not yet been tested; this will be the subject of future research.
Recent research has attempted to harness technology to deliver brief interventions via mobile phone platforms, including for alcohol harm reduction. Although this innovation offers new opportunities, there is a need for improved content development processes (such as use of theory and participatory research), as well as transparency in reporting these processes.
Findings from this study offer insights into young adults’ drinking events, as well as practical advice for designing alcohol-related brief interventions. During our formative development process, we demonstrated a neat correspondence between young people’s preferences for alcohol-reduction interventions and the theoretical principles of both brief interventions and motivational interviewing, including acceptable topics and message style. It is recommended that creators of future mobile brief interventions look beyond the basic “feedback” component of brief interventions and consider integrating more of the FRAMES model components in order to maximize both the acceptability and theory-base of their interventions. Delivery of interventions during risky events such as drinking alcohol also offers new opportunities, but careful consideration of the context is required when designing message content to maximize its effectiveness. In order to advance the evidence base for alcohol brief interventions delivered by SMS, further work is needed to test differences in brief intervention types, including varying approaches to messaging within interventions.
Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-efficacy
The project was funded by an Australian Government Department of Health Preventive Health Research Fellowship. Cassandra Wright is supported by an Australian Government Research Training Program Scholarship. Paul Dietze is supported by a National Health and Medical Research Council (NHMRC) senior research fellowship. Megan Lim is supported by the Jim and Margaret Beever Fellowship from the Burnet Institute. This manuscript was proof read by Dr Campbell Aitken of the Burnet Institute. The authors gratefully acknowledge the Victorian Operational Infrastructure Support Program received by the Burnet Institute.
Professor Dietze has received funding from Gilead Sciences Inc. and Reckitt Benckiser for work unrelated to this study. The authors declare that they have no other competing interests.