Development and piloting of a fully automated, push based, extended session alcohol intervention on university students a feasibility study

Transcription

1 Department of Computer and Information Science Informationsteknologi LIU-IDA/LITH-EX-A--13/001--SE Development and piloting of a fully automated, push based, extended session alcohol intervention on university students a feasibility study Marcus Bendtsen Tutor Johan Åberg

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3 Abstract Introduction Single session interventions Multi session interventions Advantage of e- health interventions Challenges for alcohol e- health interventions Aims Research aims Development aims Theoretical considerations Definition of push based Intervention design Message content Food for thought Reflective Tasks Challenge Existing studies Technical considerations Service Oriented Architecture (SOA) Multi tier architecture Data layer Logic layer Exposure Short Message Service (SMS) Mobile applications Content Deliverer Identification Methods Study design Technical platform Services Data preparation Dataset General data Risky drinkers Estimation compared to peers and thoughts of change Enrolment data Follow- up data Correlations Results Aim Enrolment Delivery method Activation Ordinal logistic regression Aim

4 6.2.1 Choice of length and frequency Satisfaction of length and frequency Aim Responses Content in general Motivational, fact and challenges Recommend to a friend Discussion Technical outcomes Research outcomes Is it worth further development and studies Same length and frequency for all future participants Human- computer interaction Conclusions Tables References Enclosures Enclosure Enclosure Enclosure Enclosure Approved by ethics committee: Dnr 2012/

5 Abstract Alcohol consumption amongst university students in Sweden has repeatedly been measured to be at risky levels for more than 50% of students. Internet based brief interventions aimed to intervene and prevent risky drinking have been developed with some success during recent years. Single session interventions have been implemented into routine practice in Sweden and other countries, however not all risky drinkers benefit from these single session brief interventions. This feasibility study attempted to develop and pilot an extended session intervention, where participants received messages with motivating content several times a week for a few weeks. All students on semester 1, 3 and 5 at Linköpings Universisty were invited to join a brief single session intervention as part of routine practice, and those who completed the single session intervention were invited to join the new extended intervention. Out of a total of 11,284 students that were invited to complete the single session intervention 4916 (%=43.6) responded. Out of these 1216 (%=24.7) decided to enrol to the extended intervention and 898 (%=77.9) completed the follow up questionnaire after the extended intervention. Participants that enrolled to the extended intervention were automatically placed in a draw for one of two ipads. Issues were found with participants that wanted to receive messages via SMS, as 28.3% didn t activate their SMS intervention and hence didn t enrol to the extended intervention. Furthermore there was some indication that participants exposed to more messages were more positive towards the content, as were participants receiving SMS messages over message. This might be an indication that may not be up to par with SMS for delivering this type of intervention. The study showed that this kind of extended intervention is worthwhile pursuing. Risky drinkers were more likely to find the intervention useful, and a majority of all participants would possibly or definitely recommend the intervention to a friend that needed help with their alcohol consumption. Future studies should focus on decreasing the number of participants not activating their SMS intervention, experimenting with enrolment without any prize and possibly detached from single session intervention, measuring the effect on alcohol consumption of the intervention as well as identifying any differences between receiving the intervention via or SMS. The responsibility of expanding and enhancing the research of fully automated brief interventions lay upon researches from several fields. There is a need of refining the human- computer interaction as well as the content and design of the intervention. This cannot occur effectively from a single department but should be a joint venture in order to be cost effective and to utilize expertise. 5

6 1 Introduction Alcohol continues to be a widely spread reason for a number of health problems. An estimated 3.8% of all global deaths and 4.6% global disability- adjusted life- years are attributed to alcohol. This makes alcohol one of the largest avoidable risk factors for health problems, and the extent to which this is a burden is even greater within younger groups [1]. A worldwide study of heavy drinking, including over 17,000 students in 21 countries, showed that alcohol consumption is common in many countries, but also varies with social and economic factors [2]. A survey of Swedish undergraduate university students (n = 4575) concluded that 96% of students had consumed alcohol in the preceding 12 months, and that 33% had consumed enough to classify as binge drinking twice a month or more often (55% had consumed this quantity at least once a month) [3]. A more recent study of university undergraduate students (n = 2858) showed that more than 50% of all students consumed enough alcohol to be considered binge drinking once a month or more often [4,5]. Although face- to- face interventions (i.e. motivating conversation with a health care provider in various settings) have shown to have a reasonable effect, the implementation of such interventions in routine health care has been hampered by a number of barriers such as time, money, professional skills and not least uninterest from staff to engage in life style interventions [7,8]. The expansion of access to electronic devices with network communication capabilities has prompted a new approach for reaching individuals, including those not offered life style interventions within the health care system. This has led to a rapid growth of Internet based lifestyle interventions during the past decades. In order to make a clear distinction between the various new, so- called e- health interventions, the CONSORT- EHEALTH statement seeks to clarify the difference between all computerized interventions. The CONSORT- EHEALTH statement defines Fully automated interventions as: e- health interventions delivered without any human interaction in the intervention method. This makes a clear distinction between interventions that are fully automated and those who might use the Internet for recruitment to more hands on interventions, such as counselling over the phone. Research in the area of fully automated interventions has evolved around two main strains: single- and multi- session interventions [9]. 1.1 Single session interventions Fully automated single session interventions are usually web- based self- assessment forms with personal feedback, sometimes including normative and safe drinking limits. Participants are lead to the website (either via , advertisement etc.) and fills out the questionnaire. Once complete the participant is showed his or her personal feedback based on the responses. The effect of the method has been documented to be fairly on par with brief face- to- face interventions [10,11,12]. 6

7 Some single session interventions are designed to be proactive [5,10,13,14], where participants are recruited to the intervention through [10,14]. This allows healthcare professionals to take an active role in large- scale prevention work. This type of system is in use today at 90% of student healthcare services across Sweden. Here a single staff member at the student healthcare centre can, within minutes, send several thousands of s paired with an invitation to students, thus exposing them to an intervention they didn t actively seek with a comparable effect to brief face- to- face conversations [15]. Other single session interventions take a more passive approach [16,17], creating an open website which participants can stumble upon, either through search engines, advertisements or referral from other websites. This passive approach broadens the target group, as there is no single healthcare professional that offers the intervention to his or her clients. However there is some indication that it s harder to entice participants to start the intervention once they ve found the website [18]. Whichever method is used, active or passive, fully automated single session interventions show a lot of promise, and has matured to a level where systems can be implemented into routine practice of healthcare professionals [14]. Furthermore, recent research has opened up for the possibility that self- assessment alone, or with minimal feedback, could give a positive effect on participant s consumption [12,19]. This could lead to the effect of single session interventions being underestimated, and actually surpassing those of brief face- to- face interventions. 1.2 Multi session interventions Fully automated multi session interventions are designed in a manner where participants are asked to complete several steps on different occasions. This could be a website where participants are asked to login each week to answer questions or fill in a diary. Studies of multi session interventions aren t as easily generalized as single session interventions. These type of interventions can include several methods of delivery, ranging from TV, , SMS, web etc. [20,21]. Studies conducted using multi session websites have shown varying effect [19,22]. A review of both single and multi session interventions show that methods with an extended nature might outperform single sessions [12], however the number of studies are still too few to make any definitive conclusions and also the enclosed studies (n = 9) where very different in their nature and execution. One issue that multi session interventions suffer from is high attrition rates. Trials where participants are aware of the trial settings, give consent and self- report that they are motivated to change still have low adherence. One study showed that only 45% of participants ever accessed the website [17]. The same system was translated to the real world [18], and very few (5%) returned to complete more steps in the program other than the first self- assessment. 7

8 Using a more active approach could possibly increase adherence, as participants are reminded to complete their intervention or take part in necessary steps [23]. Greater adherence has been observed using SMS technology [20]. Here a motivational and diary keeping SMS service succeeded in keeping nearly 75% of participants throughout the trial, however it should be noted that the adherence rate probably was boosted by the fact that participants knew they were being observed, were given incentives and a limited sampling size. However the study takes steps towards a more proactive type of multi session interventions. Participants were recruited via and face- to- face. An interesting observation was that both groups showed similar levels of adherence, making the step of actually talking to participants before the intervention redundant concerning attrition levels. 1.3 Advantage of e- health interventions Individual face- to- face and group alcohol interventions suffer from similar issues such as participants not adhering to the program as well as high- risk groups not being reached [24]. These two issues might be related to phenomenon such as anonymity, geographical, religious or cultural differences. Furthermore face- to- face and group interventions are more time consuming and therefore naturally more expensive per individual reached. Fully automated interventions have the potential of reaching more people, without the aforementioned phenomenon becoming an obstacle. Data collected during fully automated interventions show that a great number of risky- drinkers are reached using these methods; giving them access to an intervention they didn t actively seek. Although there are costs involved in developing and maintaining fully automated systems, these are often justified in the light of the reach and effect the intervention might have. Even passive interventions, where one could argue that the approach might reach less people due to advertisement costs or other recruitment fees, show economic viability even with a modest number of participants [22]. 1.4 Challenges for alcohol e- health interventions Thus reaching larger proportions of individuals with a fully automated intervention has been proven effective with both single and multi session interventions. When using an active approach, for instance by ing a link to the intervention group, one can target specific individuals. On the other hand using a more passive approach, for instance a public website, broadens the intervention group. Naturally not all individuals (e.g. students) change their behaviour when completing an alcohol intervention. There is a lack of research exploring how fully automated interventions can be improved or extended to increase their effectiveness. 1.5 Extending the session Rather than placing the burden of action upon the recipient of the intervention, as is common in multi session interventions e.g. asking somebody to come back to a website to complete more steps at a later time, this study proposes the term extended session. Here the participant is kept in session without any (or minimal) need for action, removing the need for the user to remember any kind of password or other method to complete more tasks. There is a fine line between the concepts of multi session and the 8

9 proposed extended session, however the difference should be found in the delivery and burden of the intervention. In extended intervention the session is never broken, the participant is constantly in session over a given time period. The intervention content is delivered to the participant, rather than the participant fetching the content at will. 9

10 2 Aims This study takes the first steps in creating a pairing of a single session intervention with an extended intervention. The extended session intervention will be offered as part of the individual feedback from a single session intervention, giving those who decide they want more help the opportunity of extending their intervention for a specified time period (e.g. a few weeks), furthermore the extended session intervention will be using push technologies to help participants stick to the program rather than simply asking them to return at a later date. In short, the extended session intervention will consist of a number of messages delivered to participants several times a week during a specified time period. The messages are intended to increase motivation for change as well as prompting actual change. By doing this participants are encouraged to stay in session for an extended time period, and also bring the intervention with them into their daily routine. 2.1 Research aims The research aims of this study is to identify participant s ability and attitude in relation to joining and completing a push based extended session intervention after completing a single session intervention. Aim 1: Signing up for the extended intervention requires several steps. First the baseline questionnaire needs to be completed and the signup form, as part of the individual feedback, needs to be filled out. Getting started with SMS and Android requires activating phone numbers or downloading apps. The first aim of the study attempts to identify any issues signing up for the extended intervention. o Who enrols to the extended intervention? o What predicts choice of delivery method? o How many activate their SMS intervention? o How many download and activate the Android app? Aim 2: Participants are free to choose extended intervention length (3,4,5 or 6 weeks), frequency of messages (3, 5 or 7 messages per week). The second aim is to identify satisfaction of these choices. o What predicts choice of length and frequency? o What predicts satisfaction of the intervention length and frequency? Aim 3: The third aim of the study is to analyse how students responded to the content, and if they thought that the messages might be useful for a student that needs to decrease their consumption. o What is the satisfaction of the message content? What predicts satisfaction? o Would the participant recommend the intervention to a friend, and what predicts this willingness? 10

11 It s important to note that this study will invite all participants regardless of alcohol consumption, and there will be a prize draw between those participating to boost participation rates. Thus the aim is not to assess if there is enough curiosity or motivation after a single session intervention, but rather to assess the attitudes in regards to the intervention and the completion of it. 2.2 Development aims Besides the research aims the study also attempts to develop and pilot the necessary software components. These components are to be used during this study but also for future studies. Furthermore there is an interest in implementing the extended intervention into routine practice and thus these software components need to be developed, modified and tested before they can be used live. 11

12 3 Theoretical considerations 3.1 Definition of push based As previously discussed multi session interventions have issues with adherence, and as such needs to become more engaging in their approach. One way of doing this is to continually activate the participants by prompting them to do something, such as an reminder or an SMS. This approach will be referred to as push based interventions. In this setting participants don t actively need to seek or remember to complete some task, but rather are prompted when a task or step needs completing. To further the terminology, electronic means of communicating with individuals such as , SMS, automated phone, Android app, iphone app, etc. are referred to as push based delivery methods if they don t require the user to remember to interact with them. This definition needs to be interpreted from every individuals point of view, for instance some people might not read their s every day or even every week and some wont read them unless they know they have one waiting for them. For these individuals isn t a push based delivery method. Therefore it is important to find a balance between what method delivers the intervention in an optimal way with what method can be considered push based for participants. Different types of delivery methods all carry with them their own unique set of limitations and possibilities. s have the capability of carrying longer body text and can optionally include images or links to questionnaires and websites allowing for two- way communication. However s are often overlooked or forgotten in the inbox, as individuals might receive a great number of s every day and prioritizes what s to deal with first. Also requires the participant to have Internet access. How individuals check s can range from some checking them every five minutes to others who actually plan ahead when to check them. SMS messages are not delivered via the Internet but rather mobile networks that have a greater worldwide reach. This allows individuals to receive messages to their phone even when there is no Internet access. Messages are limited in size, but most modern phones concatenate multiple messages from the same sender so that it looks like one message. Two- way communication is done by allowing participants to respond with their own SMS back to the system using a predefined syntax. This quickly gets very complex and participants need to be thought what syntax is correct and what options are available. There is also a cost involved in sending and sometimes receiving SMS messages. Mobile applications (Android or iphone) are very free in their construction. It s possible to send messages, prompt the user for answers to questions, visualize with graphs etc. Applications can also be designed to not constantly be in need of Internet connection. One of the main limitations is the fact that applications are distributed through either Play (Android) or App Store (iphone), this means that participants need to be prompted to open up these applications first, then download and install the intended application. 12

13 Not everybody owns an Android device or an iphone, which limits the reach of this method. 3.2 Intervention design The main idea behind the intervention is to allow participants to sign up for a push based intervention that delivers a predefined number of messages during a predefined number of weeks. The intervention will not allow for any two- way communication. The idea is to keep participants in session during their normal day activities, hence creating an extended session from a single session intervention. 3.3 Message content Numerous theories have arisen from years of research in the field of behaviour change. These theories have a common approach to change, allowing the subject to go through three distinctive phases: becoming motivated, translating motivation to change and maintain the new behaviour [25]. Messages are divided into four categories: Food for Thought, Task, Challenge and Reflective Food for thought Food for thought messages are thought to increase intrinsic motivation to reduce drinking and self- efficacy, lending its theoretical base from Social Cognition Models such as Theory of Planned Behaviour and Health Belief Models that emphasize the importance of attitudes, subjective social norms, perceived risk and personal control or effectiveness. The messages will also be created with inspiration from Self- determination theory that emphasizes the need for finding an intrinsic motivation to change and maintain a changed behaviour as opposed to external motivation, such as being told to do something. The Food for thought messages contained fact like content as well as questions that respondents were meant to think about during the week Examples Consuming alcohol increases the risk for negative consequences, such as falling over and hurting yourself. Have you ever had to skip something that you enjoy due to being hung- over, such as a soccer game or similar? Reflective Reflective messages are more or less the same as Food for thought, however the wordings were a bit different as they were sent on Sundays and were targeted towards reflecting over the past couple of days. 13

14 Examples Hope you had a nice evening. When you have time now or maybe later take a few minutes to reflect over how you normally feel the day after you ve drunken a fair amount of alcohol? Are you dissatisfied with any of your emotions? Tasks Tasks are inspired by Social Cognitive Theory that focuses on behaviour change intention as an important factor for future change. Also, a great emphasize is placed on self- efficacy as a learning process in which people select, react and learn from experiences. Having good examples in ones surrounding that have succeeded with similar change is also valuable, as is appraisal and support from others Examples Write down 3 good things about your alcohol consumption and 3 not so good. Does the positive outweigh the negatives? Amongst the negatives, what is most important? Think about why that is. If you want to decrease your consumption then tell the people in your surroundings that you are doing so. You will surely feel an unexpected amount of respect for your decision Challenge Challenge will rely on the Model of Action Phases that emphasizes the need to formulate specific goals i.e. when, where and how to act by thinking ahead and formulating if- then plans for various situations Examples Tonight, or the next time you will consume alcohol, try not drinking any alcohol until you get to the party and meet your friends. Notice how the first positive effect of alcohol is noticeable whilst among friends rather than at home getting ready. Good evening. Tonight, or the next time you will consume alcohol, decide to drink a glass of water between each alcoholic beverage. You will feel a lot better the following day, guaranteed. You will save a fair amount of money as well. Good evening. 3.4 Existing studies Using simple push messages delivered via SMS or has been used successfully several times in trials where consideration has been taken to smoking habits, physical activity and weight loss [38,39,40]. Although slightly different in their nature the main component of the interventions have been messages delivered continuously during a set time period. This method has show promise, e.g. one of the more recent ones, txt2stop [38], was found to significantly improve smoking cessation rates at 6 months. Using simple push messages as part of alcohol intervention trials has been used to try and improve upon diary keeping methods, where SMS was used to try and improve self- assessment [20]. Similarly SMS messages have been used to assess and give feedback to 14

15 participants in an attempt to reduce heavy drinking [41]. In preparation there is a study trying to improve adherence to pharmacotherapy [42]. The method of having simple push messages central to the intervention has been trialled to some extent [43] where messages were used to improve outcome for patients with depression and co- morbid Alcohol Use Disorder. There is however still a lack of research in the area of using push based interventions within high- risk alcohol treatment. One limitation of existing studies has been sample size and recruitment methods. An interesting approach is to increase sample size and use a more proactive approach that reaches not only those already curious or motivated to change. 15

16 4 Technical considerations 4.1 Service Oriented Architecture (SOA) Service oriented architecture can be described as a set of services communicating to create a larger system. These services can be within the same enterprise or communications can also be done to external services. A common example is the use of pre existing services to handle credit card payments on an e- commerce website. However SOA shouldn t only be viewed as a means of abstracting services externally, but as a set of guidelines and principles for building entire systems and by doing so abstracting complexity, knowledge, workload, stability etc. SOA is a set of guidelines and principles, although software companies might have an interest in developing and marketing frameworks for creating SOA services enabling standardizations for development and deployment. This set of guidelines and principles are agnostic and do not force upon the architect any kind of framework or programming environment. The guidelines and principles themselves also differ somewhat between architects and companies, however the basic idea of splitting a big system into several independent services is always at the core of SOA. SOA has been used for a long time within enterprise application development. Over time drastic changes have been made to the technologies used to implement SOA, especially the method of exposing the services going from complex binary- based communication such as CORBA or DCOM to more lightweight methods such as REST. Four commonly used SOA principles are: Contract There should be some kind of written documentation that helps others to understand the externalized functions of the service. At least there should be information regarding endpoint, expected parameters as well as return values and possible errors. Abstraction The service developer should keep all parts of the implementation hidden from the client. The client shouldn t have to understand the implementation to be able to use the service. Autonomy The service developer shouldn t be governed by external forces as to how the service is developed. The implementation is completely done by the service developer and as such the correctness and dependability of the service is the developer s responsibility. Stateless The service itself shouldn t remember state using local memory. Agnostic scalability requires that the service sees every request as completely new and has no local history as to what this particular client has requested before. This is not so say that history can t exist in a distributed memory fashion, such as a database etc. 16

17 4.2 Multi tier architecture Once in discussion around SOA the topic usually pivots into discussion around implementation and fine- grained architecture. A common place to start is with the multi tier architecture. Design patterns such as Smalltalk s MVC are usually confused with multi tier architecture, and rightfully so as they look very common, however multi tier architecture is not a full blown design pattern with rigorous implementation, but instead a principle of viewing a service as a stack, where each layer of the stack has a very clear and distinct principle. These layers that make up the multi tier architecture can be referred to as: data, logic and exposure. These layers are written in the service- preferred language, such as Java, Python, JavaScript etc. Staying true to SOA principles the preferred language should be the developer s choice. However as multi tier architecture isn t a rigorous design pattern, some implementations use more layers to get finer control of certain parts of the architecture Data layer Consisting of routines to communicate with some kind of persistent storage (SQL, LDAP, tape etc). The key to successfully creating a data layer is to ensure that all communication to the persistent storage is done via it alone, no other parts of the multi tier architecture should be allowed to created connections to storage. The data layer exposes routines that allow for retrieval and modification of data in storage Logic layer The only layer that is allowed to communicate with the data layer, hence creating a stack. The name logic comes from the longer business logic, and refers to the use of the layer. This is the layer that should implement routines that allow success for the service (and in length the enterprise). Typical routines combine calls to other services (external and internal) with the data layer. An example would be a routine that first uses an external service to debit a credit card then uses another routine to send a written notification via mail and finally uses the data layer to write this information to storage Exposure A lot has happened to this layer through time, since moving from complex exposure such as CORBA and DCOM to lighter REST based exposure. The layer s only responsibility is to accept incoming request, routing them to the correct routines in the logic layer and returning correct responses to requests. Today it s very popular to do this using the JSON format and large systems (Facebook, Twitter, etc) are heavily reliant of this today. 4.3 Short Message Service (SMS) Short Message Service gives users of GSM based mobile phones the ability to send and receive short text messages over the GSM network. SMS messages have a limit of 140 characters, however modern mobile phones often simulate the possibility of sending and receiving longer SMS messages by concatenating them. The SMS specification is maintained by 3GPP [26]. If the recipient is not available (mobile phone turned off or out of network range) messages are saved at the service carrier and retried later. When using SMS as part of software there are two viable options. There are online services that allow easy access to their REST API s, giving programmers access to 17

18 resources for sending and receiving SMS messages [27,28,29]. The entire feature set for these services are not yet available in Sweden, and an example price is approx. $0.036 per SMS [27]. Assuming that we had 1000 participants for 3 weeks receiving 1 message per day, that gives us 1000 * 3 * 7 = messages, priced at $0.036 gives us a cost of $756 (approx SEK, USD/SEK rate at October 2012). For this study we might send more or less messages than this, however even at this modest estimation the cost is high. Considering external validity of the intervention this price wouldn t make the intervention useable in a real world setting. The second option is to invest in a GSM modem (approx SEK) and a SIM card from a carrier. Currently there are SIM cards available in Sweden at 699 SEK per month that will allow unlimited SMS messages to be sent. Although obvious upside in cost one has to be aware that the GSM modem needs to be integrated into the software by writing code and maintained by being connected to a server at all times. The cost of development and maintenance could exceed the gateway option, especially if the software is only used once. 4.4 Mobile applications Mobile applications are written in different programming languages and different work environments depending on what operative systems are to be targeted, these could include ios (iphone/ipad), Android, Windows Mobile, Windows 8, etc. There are also considerations to be made regarding what versions of these operative systems should be supported. Newer versions of the operative systems will allow for a more advanced feature set available for programmers whilst at the same time limiting the market, as users with older devices won t be able to use the application. Applications written in the preferred language of the operative system are usually (when written well) more advanced and responsive. This includes advanced 3D graphics as well as use of cameras etc. However if several operative systems are to be supported costs of developing using these native language approach could be costly and difficult to maintain. To avoid this cost the option of writing HTML5 applications that can be deployed to all operative systems is sometimes used. A small program still needs to be written for each operative system that includes this HTML5 application, however it s usually a very straightforward matter that doesn t take a significant amount of time and shouldn t incur great cost. This type of hybrid application however is usually not as responsive and should only be used if there are simple interactions with the application. To be able to communicate with the user of an application mobile operative systems have developed the ability to push messages. This requires additional setup depending on operative system. For Android, the mobile application needs to be modified to send a notice of registration when the application is started for the first time. Furthermore there is need of a server that can receive device registrations and send messages [30]. These features may or may not be available depending of operative system versions, and the use of them might exclude potential users that don t have an updated phone. 18

19 Once a push system has been setup the application developer can at any time send a message (via Internet not GSM) to all devices registered. This could be used to inform users of new content that is available, or remind them to complete some task. As there are no costs involved in the actual sending of messages (there might be cost involved in setting it up and maintaining it), this is an interesting possibility to replace SMS costs is cheap but suffers from deliverability issues. Legitimate messages are often not received as they are filtered into SPAM folders or even stopped by the mail server. Although a common problem, there are steps that can be taken to ensure increased deliverability of s Content s can contain HTML elements so that content is formatted prettier than just plain text. This also opens up for images to be included in the content. However if sending HTML s one should always append a plain text version for those who are not able to read HTML in their clients, this can be done using multipart s. Clients able to read HTML s will not see the plain text . s containing only HTML and no plain text will have a higher SPAM score. If images are used it s important to have a good ratio between images and text. If there is to many images compared to text characters then SPAM scores will rise. Furthermore it s important to avoid certain sentences, such as free drugs, viagra, etc. servers recognize these key words and SPAM scores are increased [31] Deliverer Simply installing server software on a computer and sending s from a static or dynamic IP is going to be perceived as SPAM. When sending s from a mail server one should make sure that the mail server is listed in so called whitelists. A common whitelist [32] classifies senders in trust categories (high, mid, low, none), being listed as a trusted sender helps s avoiding SPAM classification at receiving mail servers Identification It s possible for any mail server to send from any sender, e.g. a server could send an from name@example.com without having any kind of ownership of this domain name. This kind of spoofing infers great risk, as it s easy for someone to impersonate somebody else. By introducing SPF records [33] domain owners are able to list authorized senders in their DNS configuration. SPAM filters are then able to verify that an comes from an authorized sender. Although SPF ensures that the SMTP header MAIL FROM is authorized it does not consider the actual content of the . By using DKIM [34] the integrity of the headers in the (From, To, etc) and the body can be checked. DKIM uses a set of keys (public and private) to create a signature of these fields. The DNS contains a field with the public key, and as such any receiver can use the public key and the signature in the to ensure that the sender actually had access to the private key [35]. To further minimizing spoofing attempts Message- ID was introduced as a way of creating a unique id for every [36]. This means that two s should never have the same Message- ID. This is an attempt to avoid replay attacks where a malicious user 19

20 could re- use DKIM signatures or resend the exact same . Exactly how these Message- IDs are created slightly differ depending on the senders client, however there are recommendations [37]. 20

21 5 Methods 5.1 Study design The study is a pilot and feasibility study. All students on semester 1,3 and 5 (n = 11283) at Linköping s University were, in mid October 2012, invited via to complete an alcohol single session intervention. This is part of the student healthcare centre s routine practice. The contents of the sent to students was the same used as during routine practice with the addition of information about the possibility to participate in a research project at the end of the questionnaire. See enclosure 1 for the contents. After answering the questionnaire each student was presented with his or her personal and normative feedback, this is part of the routine practice. However for the sake of this study, information about the research project was prepended to the feedback. All students, regardless of alcohol consumption, were offered to join the extended intervention. No other means of registering for the intervention was offered to the students. During registration students were made aware that they are giving informed consent to participate. Participants were also made aware that they entered a draw for one of two ipad s when signing up for the extended intervention. For the prepended information please see enclosure 2. Participants that were willing to join the extended intervention were given the option of selecting delivery method ( , SMS or Android), how many weeks they would like to get messages delivered (3,4,5 or 6) and how often they would like messages (once a day, five a week or three a week). If selecting as delivery method they would have completed the signup (as we already had validated their address from the initial invitation to the single session intervention), if selecting SMS they would have to send an SMS with an activation code to a displayed phone number and if selecting Android they were given instructions on how to download the app and activate it. Those who selected Android but weren t able to find the app on Google Play were allowed to go back and choose another delivery method. This courtesy was not given to the other delivery methods. Once signup was complete messages were delivered at the length and frequency requested. See figure 1 for a schematic overview of message delivery. Figure 1 Schematic overview of message delivery Messages per week Mon Tue Wed Thu Fri Sat Sun 7 FFT Task FFT Task Challenge Challenge Reflection 5 FFT FFT Challenge Challenge Reflection 3 FFT Challenge Reflection 21

22 Once the intervention period was past each participant received a new paired with a link to a follow- up questionnaire, allowing him or her to evaluate various aspects of the intervention. This questionnaire is presented in enclosure 3. A decision was made during the design of the follow- up questionnaire that it would be of interest to ask students about the different type of content. Since the participants are not aware of the labelling of messages that was done during the design of the intervention it was found easiest to ask participants what they thought about the motivating, factual and challenge content. Although some participants might consider Task to be challenge content as well, this was found to be acceptable as the aim was to evaluate the nature of the content rather than the labelling. Similarly motivating could fall under FFT, Task and Reflection however factual content was only sent as part of FFT. The study design is presented in figure 2 as a flowchart. Figure 2 - Study design flowchart All#students#(semester#1,#3#and#5)#at#Linköpings#University# received#an#invita=on#by# #to#complete#an#alcohol# ques=onnaire#(n#=#11284)# # Students#comple=ng#the#interven=on## Students#not#comple=ng#the#interven=on# Students#that#ini=ally#decided#that#they#want#to# join#the#extended#interven=on# Students#that#decide#not#to#join#the# extended#interven=on# Students#that#were#able#to#ac=vate#their# interven=on# Students#unable#to#ac=vate#their# interven=on## # SMS# ANDROID# Once#the#extended#interven=on#has#ended#par=cipants# will#be#sent#a#new# #with#a#followrup#ques=onnaire.# Some#par=cipants#might#decide#to# drop#out#of#the#study.# Par=cipants#that#complete#the#followRup# ques=onnaire.# ## Par=cipants#that#don t#complete#the# followrup#ques=onnaire.# ## 5.2 Technical platform In order to facilitate the study three separate SOA services were developed, herein called Goalkeeper, Bank and Telegraph. Furthermore, an existing system called 22

23 Livsstilsportal ( was used to sending out baseline and follow- up questionnaires. In developing Goalkeeper, Bank and Telegraph Java Enterprise Edition 6.0 was used, including libraries such as JAX- RS (Java EE library for creating REST services) and JPA (Java EE library for ORM). The service used Googles GSON library for JSON parsing. In Telegraph it was necessary to communicate with a GSM modem, and this was done using a Java library called SMSlib. Goalkeeper and Bank were deployed to Amazon EC2 and static web content was deployed to Amazon S3. Telegraph was deployed to a local computer since connection to GSM modem was necessary it couldn t be placed on a virtual computer. The app was developed using jquery UI to facilitate easy deployment on both Android and ios. However the ios application was refused at Apple App Store review for requiring activation and being too simple. The study required activation of apps and for basic messaging communication and as such the ios version was dropped. All time- based events were scheduled and maintained using Jenkins Continuous Integration server. A schematic is available in schema 1. Schema 1 Flow between SOA services Web$form$for$signup$to$ interven1on$ 1.$Par1cpants$choice$of$ delivery$method,$length$ and$frequency$are$sent$ to$goalkeeper.$ 2.$Returns$ac1va1on$code$for$ use$when$ac1va1ng$sms$and$ Android$interven1ons.$ 3.$If$par1cipant$chose$SMS$then$a$SMS$ message$is$sent$to$telegraph.$ 4.$If$par1cipant$chose$Android$then$ ac1va1on$is$done$straight$to$ Goalkeeper$from$the$App.$ 5.$On$receiving$a$code$via$SMS$ it s$sent$to$goalkeeper$for$ ac1va1on.$ GSM$ Telegraph$ SMTP$ GCM$ 7.$When$crea1ng$the$ schedule$unique$message$ ID s$are$requested.$$ Goalkeeper$ 6.$When$the$interven1on$is$ac1vated$a$schedule$is$ set$up$in$the$database.$this$contains$informa1on$ about$what$message$id$to$send$and$when.$ 10.$Messages$that$should$be$ delivered$are$sent$to$telegraph$ with$the$message$content,$the$ delivery$method$and$as$needed$ the$ $address,$phonenumber$ or$device$id.$ Bank$ 9.$Before$a$message$is$sent$the$ contents$are$fetched$from$bank$ via$the$message$id.$ Jenkins$ 8.$Every$5$minutes$a$small$job$is$run$to$check$if$there$ are$any$entries$in$the$schedule$database$where$the$ delivery$1me$has$expired,$and$as$such$should$be$ delivered.$ 23

24 5.2.1 Services Bank was developed to be a simple service that clients could request messages from. Messages are stored in a MySQL database separated within topics (in this case the only available topic was alcohol). Messages were also tagged with FFT, Challenge, Task and Reflective. Messages could have multiple tags, however this was never used in this study. Clients were then able to ask for a random message within a topic and given a specific tag. In the call for messages a list of excluding messages could be sent, allowing clients to ask for a random message without receiving duplicates. Goalkeeper was developed to facilitate registration of participants, keep track of participant s choices (delivery method, weeks and frequency) and scheduling deliveries of messages. The service was built to only allow one registration per address per topic (so that in theory a person could be signed up for two different interventions e.g. tobacco and alcohol). Each participant had it s own delivery schedule created at activation. Telegraph was developed to be a simple queue for the GSM modem. The only exposed routine was simply to send a message to a specified number. All messages were written to a database (used as a queue) and tagged with ready to be delivered. If delivery later was successful the tagged was changed, so it wasn t sent again. If delivery failed for some reason the tag was not changed, allowing for another attempt at a later time. A stand- alone application was written to read messages from the GSM modem and make SOA calls to e.g Goalkeeper to activate a specific participant depending on SMS content. 5.3 Data preparation Dataset The data used in the analyses were gathered during three stages of the study. At baseline participants general information was collected, as well as their drinking habits and related questions to alcohol consumption. After baseline, at the same time as their summary was presented, students were able to enrol in an extended intervention and the options they chose during the enrolment is also used in the analyses. Finally those who completed the extended intervention were asked to complete a follow- up questionnaire regarding their experience during the extended intervention General data Semester, gender, age and status were all general information collected at baseline. Some answers to status generally have a low count, a pooled variable was introduced to handle this (see enclosure 5) Risky drinkers Drinking habits were collected and calculated into a variable indicating if the respondent had a consumption that classifies them as risky or non- risky drinking. This classification was done using two models, one that follows the general guidelines given by the Swedish National Institute of Health and another that allows a slightly higher consumption. This alternative model is sometimes used on students (as the general calculation usually classifies more than 60% of students as risky drinkers). 24

25 Risky drinking when considering total weekly consumption of alcohol is defined as drinking more than 9/14 (female/male) standard units per week (1 standard unit = 12g of alcohol, e.g. a glass of wine). Heavy episodic drinking (HED) is defined as drinking more than 4/5 (female/male) standard units on a single occasion, e.g. during an evening. Having one or more episodes of heavy drinking per month is considered risky drinking in the general population. For students however it is sometimes considered non- risky to have one heavy episode of drinking per month. This gives us two definitions of risky drinkers, normal and alternative. This study considers participants normal risky drinkers if they exceed either total weekly consumption or normal heavy episode drinking limits. Similarly participants are considered alternatively risky drinker if they exceed either total weekly consumption or alternative heavy episode drinking limits Estimation compared to peers and thoughts of change Two more questions that are used in the analysis are participants own estimation of their consumption compared with their peers and if they ve had any thoughts of changing their habits. Some of the available options to these two questions have a very low response rate and for some analysis cell values will become small, therefore additional pooled variables were created to allow analysis to complete. See enclosure 4 for details of this pooling Enrolment data Participants that enrolled in the extended intervention had to choose the number of weeks they wanted to receive messages (weeks = 3, 4, 5 or 6) and how often per week they wanted to receive messages (frequency = 3, 5 or 7). They also had to make a choice of delivery method ( , SMS or Android App). These choices are used in the analyses Follow- up data Several questions were asked in relation to participant s satisfaction with the extended intervention. These are the questions found in enclosure Correlations Only pooled variables were used during regression models, so only these were used during correlation testing. Other than the obvious correlation between the two risk calculations, the only significant and strong correlation was found between risk and pooled estimation compared to peers (Spearman s Rho = 0.552, p < ) as well as alternative risk and estimation compared to peers (Spearman s Rho = 0.627, p < ). These combinations were also chi- squared tested and strong significance was found (p < ). As a result these combinations should be avoided during multivariate regression analysis. 25

26 6 Results Completion rate of baseline intervention was 43.6%, a normal response rate during routine practice at Linköpings University, out of these 24.7% enrolled to the extended intervention. Out of those who signed up for the extended intervention 77.9% completed the follow- up questionnaire. See figure 3 for overview of numbers and figure 5 for full attrition flowchart. Table 1 shows baseline responders characteristics. Figure 3 - Attrition throughout study Attrition throughout study Invited Completed baseline Enrolled to intervention Activated intervention Completed follow- up questionnaire 6.1 Aim 1 Signing up for the extended intervention requires several steps. First the baseline questionnaire needs to be completed and the signup form, as part of the individual feedback, needs to be filled. Getting started with SMS and Android requires activating phone numbers or downloading apps. The first aim of the study attempts to identify any issues signing up for the extended intervention. Who enrols to the extended intervention? What predicts choice of delivery method? How many activate their SMS intervention? How many download and activate the Android app? Enrolment Male participants were significantly more likely to sign up for the extended intervention than females. Those reporting that they had a partner were also more likely to join the extended intervention. Participants that reported that they were thinking about changing their alcohol consumption or that they had taken action towards changing their consumption were also more likely to join the intervention. See table 2 for details and independence tests. 26

27 6.1.2 Delivery method Those who thought that they drank more or the same as their peers were significantly more likely to choose SMS over (compared to those who thought they drank less than their peers). Risky drinkers (both calculations) also tended towards choosing SMS over . Participants who had thoughts about changing their alcohol consumption or had taken action were both more likely to choose SMS over compared to those who didn t have any thoughts of change. Participants signing up for longer interventions tended towards choosing SMS as was the case for those selecting a more frequent intervention. At the same time those choosing 3- weeks and 3- a- week tended toward . See table 3 for details and independence tests Activation The majority of participants decided to go with as their delivery method (83.1%), followed by SMS (14.0%) and Android (2.9%). See figure 4. A large amount of those initially choosing SMS didn t activate their intervention, this could be due to participant not understanding how to or decided against it. 28.3% (table 4) didn t activate their intervention, even after filling out the forms necessary. The point of failure was the step that required participants to send an SMS with a specified code to a specified phone number. Figure 4 - Chosen delivery method Chosen delivery method 3% 14% SMS Android 83% There were very few that decided to chose Android, in total there were 50, of these 5 doubled back and activated (might be because they thought the download was cumbersome or that they didn t find the app on Google Play), 3 did the same thing and activated SMS. Nine of the original 50 didn t activate any intervention. This is a total of 34% of those initially choosing Android that weren t able to activate their Android intervention. Although low count, the percentage is quite high giving some indication that there are issues to be resolved when asking participants to download an activate an app Ordinal logistic regression An attempt was made to create multivariate ordinal logistic regression models with enrolment, activation and completion of follow- up as dependent variables in order to find predictors to these outcomes, however no strong models were found and left out of the analysis. 27

28 Figure 5 - Attrition flowchart All#students#on#semester#1,#3#and#5#at# Linköpings#University#received#an#invita<on#by# #to#complete#an#alcohol#ques<onnaire## (n#=#11284)# # Students#not#comple<ng#the#interven<on# (n#=#6368,#%#=#56.4)# Students#comple<ng#the#interven<on## (n#=#4916,#%#=#43.6)# Students#that#ini<ally#decided#that#they#wanted# to#join#the#extended#interven<on# (n#=#1216,#%#=#24.7)# Students#that#decided#not#to#join#the# extended#interven<on# (n#=#3700,#%#=#75.3)# Students#that#were#able#to#ac<vate#their# interven<on# (n#=#1145#,#%#=#94.2#)# Students#unable#to#ac<vate#their# interven<on## (n#=#71,#%#=#5.8)# # (n#=#952,#%#=#83.1)# SMS# (n#=#160,#%#=#14.0)# ANDROID# (n#=#33#,#%#=#2.9)# Once#the#extended#interven<on#was#finished# par<cipants#were#sent#a#new# #with#a# followyup#ques<onnaire.# (n#=#1138,#%#=#99.4)# Some#par<cipants#decided#to#drop#out#of# the#study.# (n#=#7,#%#=#0.6)# Par<cipants#that#completed#the#followYup# ques<onnaire.# (n#=#898,#%#=#77.9)# ## #(n#=#742,#%#of# ##=#78.1)# Par<cipants#that#didn t#complete#the# followyup#ques<onnaire.# (n#=#295,#%#=#22.1)# ## #(n#=#208,#%#of# #=#21.9)# SMS#(n#=#128,#%#of#SMS#=#82.6)# SMS#(n#=#27,#%#of#SMS#=#17.4)# ANDROID#(n#=#28,#%#of#ANDROID#=#84.8)# ANDROID#(n#=#5,#%#of#ANDROID#=#15.2)# 28

29 6.2 Aim 2 Participants are free to choose extended intervention length (3,4,5 or 6 weeks), frequency of messages (3, 5 or 7 messages per week). The second aim is to identify satisfaction of these choices. What predicts choice of length and frequency? What predicts satisfaction of the intervention length and frequency? Choice of length and frequency Figure 6 summarizes the choices made at enrolment. As is evident the most popular length was 3- weeks followed by 6- weeks. The most popular frequency was 3- a- week followed by 7- a- week. Students on their first semester seemed to be more likely to choose a 6- week intervention compared to students on their third and fifth semester. This was also the case for older students aged compared to younger Those choosing Android or SMS were more likely to choose a 6- week intervention compared to those choosing . See table 5 for details and independence tests. As with length there were similar patterns with choice of frequency. First semester students were more likely to chose a higher frequency compared to third and fifth, as were Android and SMS over . Students that reported that they thought they drank more than their peers were more likely to choose a 7- a- week intervention compared to the students that thought they drank the same or less. Males seemed to be more likely to choose a longer intervention compared to females. See table 6 for details and independence tests. Both table 5 and 6 show the relationship between length and frequency. A pattern of participants selecting either short interventions with low frequency or a long intervention with high frequency emerges from the tables. Figure 6 - Descriptive statistics over choices made at enrolment Number of weeks chosen at enrolment. Number of messages per week chosen at enrolment. 5% 28% 16% 51% 3 weeks 4 weeks 5 weeks 6 weeks 5% 8% 87% 3- a- week 5- a- week 7- a- week 29

30 6.2.2 Satisfaction of length and frequency Figure 7 summarizes the responses to the follow- up questions regarding satisfaction of length and frequency. It s quite obvious that in general participants were satisfied with their choices. Figure 7 Descriptive statistics over satisfaction of choices made at enrolment The number of messages per week I chose was: 3% The number of weeks I chose to participate was: 3% 6% 4% 14% Don't know Just right 14% Don't know Just right 79% Too few Too many 77% Too short Too long Satisfaction of intervention length Students that reported that they thought they drank the same amount of alcohol as their peers were more likely to report that they thought the intervention was too short rather then just right, compared to those who thought they drank less. This was also the case for students that were classified as risky drinkers, compared to non- risky drinkers (both calculations). Furthermore there was data suggesting that risky drinkers were less likely to find the intervention too long rather than just right compared to non- risky drinkers. Students aged were more likely to find the intervention too short rather than just right compared to students aged 18-30, as were students on semester 3 compared to semester 1. There were data showing that students that choose a 6- week intervention were less likely to find the intervention too short rather than just right compared to those who chose 3 weeks, however there was no data indicating that the 6- week group was more likely to think the intervention was too long. None of both the Android and SMS group thought the intervention was too long compared to where 3.8% thought the intervention was too long. The Android and SMS groups were also more likely to think that the intervention was too short compared to the group. Chi- square and Fisher exact tests p- values as well as odd ratios from multivariate multinomial regression models are available in table 7, 9 and Satisfaction of intervention frequency Students that reported that they thought they drank less than their peers at baseline were more likely to find the intervention too frequency compared to those who thought 30

31 they drank the same or less. Similarly risky drinkers were more likely to find the intervention too infrequent rather than just right compared to non- risky drinkers. The risky drinkers were also less likely to respond that they thought the intervention was too frequent rather than just right. The group that selected 7 messages per week were more likely to find the intervention too frequent rather than just right (compared to the 3- a- week group). Participants that chose SMS were more likely to find the intervention infrequent compared to those who chose . Chi- square and Fisher exact tests p- values as well as odd ratios from multivariate multinomial regression models are available in table 8 and Aim 3 The third aim of the study is to assess how students responded to the content, and if they thought that the messages might be useful for a student that needs to decrease their consumption. What is the satisfaction of the message content? What predicts satisfaction? Would the participant recommend the intervention to a friend, and what predicts this willingness? Responses The response to the question regarding content in general was mostly positive (figure 7), as was the response to the individual types (figure 8). A large majority would possibly or definitely recommend the intervention to a friend (figure 9). Figure 7 Satisfaction of content in general In total the content of the messages was (%) Very bad Bad Good Very good 31

32 Figure 8 - Satisfaction of content For a student that drinks to much the messages with content would probably be of (%) Don't know Almost no use Some use Great use Motivating content Fact content Challange content Figure 9 - Recommend to a friend Would you recommend a friend that needs to cut back on their alcohol consumption to use this service (%) Don't know Doubtful Possibly Yes, deyinitely Content in general For the content in general females were more likely to find the content positive, as were respondents that had partners. Furthermore participants choosing a 6- week intervention were more likely to be more positive to the content than participants in a 3- week intervention. Table 12 and 13 include independence tests and regression models Motivational, fact and challenges For the messages with motivational content the same pattern for females and respondents with partners emerged. However here SMS participants were also more 32