An evaluation of the “Daybreak” program: A digital intervention addressing alcohol use problems
Why did we undertake this research?
The role of alcohol as a risk factor for a wide range of health conditions is well documented, such that the most recent Global Burden of Disease study listed alcohol use as the seventh leading risk factor for disease burden and deaths (1). Importantly, in addition to the consumer, the harms that arise from alcohol use also impact on other people. In Australia, alcohol consumption including harms to others is estimated to cost society about AUD 30 billion per year (2).
Only about one-fifth of those with an alcohol use disorder report using a treatment service for any mental health problem in the previous year (3). To overcome this reticence, and to identify people with less severe alcohol problems, there has been increasing emphasis on finding those with risky patterns of alcohol use through opportunistic screening in settings where people are not seeking treatment for alcohol-related problems (4, 5). Those with less severe problems receive brief or less intensive interventions, while those who appear to have more entrenched problems can still be referred for more traditional treatment methods. The importance of this approach has resulted in screening, brief intervention, and referral to treatment (SBIRT) being mandated in the USA for level 1 and 2 trauma centres (6).
Nevertheless, SBIRT has not been widely adopted in either hospitals or primary care in Australia. Alternative models for reaching people with risky patterns of alcohol use via the internet have been tested in both university student and general population samples and found to be effective in reducing alcohol consumption and harms (7-9). In the general population (e.g. excluding studies based on university students) significant reductions in problem drinking were found at 6 and 9 months, with more intensive interventions having greater effects than single session interventions (8). Compared with control participants, those in the Intervention group were drinking about two standard drinks per week fewer and were more likely to be drinking within low-risk guidelines, but the inclusion of professional guidance did not increase the effect of interventions compared with unguided trials (7). However, again the reach of these programs has generally been limited.
Hello Sunday Morning
Hello Sunday Morning is an Australian non-profit that builds technology to support people to change their relationship with alcohol. In 2010, Hello Sunday Morning released an online blogging platform that supported people to reduce their alcohol consumption or abstain from alcohol for a period of three to twelve months. Within this platform, participants relate their experiences with alcohol and their changing relationship with alcohol. This involves both a public commitment, for example, a period of abstinence or reduced alcohol use, and a supportive environment where others have encountered similar challenges in changing their use of alcohol. In addition to potential benefits of peer-to-peer support (10), Hello Sunday Morning also provides an evidence-based set of resources in the background. These resources encourage and support participants in learning and implementing new skills, for example in developing resilience to setbacks.
A recent evaluation of the original Hello Sunday Morning’s combined blog platform, supportive online community and learning resources reported on the three-month outcomes for nearly 2000 participants (11). Notably, there were significant reductions in alcohol risk scores (Alcohol Use Disorders Identification Test (12)), including for those in the highest risk category. In August 2018 the ‘legacy’ version of the Hello Sunday Morning web program was closed, having registered over 100,000 members since 2010. New participants join the Daybreak program, which is accessible via mobile app and desktop.
What was the objective of the research?
The objective of the research was to evaluate the new Daybreak program, which was developed by Hello Sunday Morning to support high-risk drinking individuals looking to change their relationship with alcohol. In particular, we compared the effect of adding ‘online coaching’ via real-time ‘chat’ messages (Intervention group) to an otherwise self-guided program (Control group).
What did we do?
We designed the intervention as a randomized control trial, but as some (48, 11.9%) people in the Control group were able to use the online coaching, the main analysis comprised all participants. We collected on-line surveys at one and three months. The primary outcome was change in alcohol risk (measured with alcohol use disorders identification test – consumption (AUDIT-C) score). Other outcomes included the number of standard drinks per week, alcohol-related days out-of-role, psychological distress (Kessler-10), and quality of life (EUROHIS-QoL). Markers of ‘engagement’ with the program included posts to the site and comments to others’ posts. The primary analysis used Weighted Generalized Estimating Equations.
What did we find?
We recruited 398 (50.2%) people to the Intervention group and 395 (49.8%) to the Control group. Most (71%) were female and the mean age was 40.1 years. Most (550, 69%) participants were classified as ‘probably dependent’ on the AUDIT-10 with 243 (31%) classified with ‘hazardous/harmful’ consumption. We followed-up 334 (42.1%) participants at one and 293 (36.9%) at three months. By three months there were significant improvements in AUDIT-C scores (down from mean 9.1 (SD 1.9) to 5.8 (SD 3.1)), alcohol consumed per week (down from 37.1 (SD 28.3) to mean 17.5 (SD 18.9)), days out-of-role (down from mean 1.6 (SD 3.6) to 0.5 (SD 1.6)), quality of life (up from 3.2 (SD 0.7) to 3.6 (SD 0.7)) and reduced distress (down from 24.8 (SD 7.0) to 19.0 (SD 6.6)). Figure 1 shows the change in alcohol consumption and AUDIT scores by study group.
Accessing online coaching was not associated with improved outcomes, but engagement with the program (eg posts and comments to the posts of others) was significantly associated with improvements (eg in AUDIT-C, alcohol use and EUROHIS-QoL). Reduced alcohol use was found for both ‘probably dependent’ and ‘hazardous/harmful’ alcohol users (respective estimated marginal means 40.8 to 20.1 drinks: 22.9 to 11.9 standard drinks). For full details, please see the open access paper (13).
Figure 1: Change in alcohol measure by study group
What does it mean?
Use of the Daybreak program resulted in significantly improved outcomes in terms of alcohol measures, mental health and quality of life. An important finding was that the program was effective in those who were classified as ‘probably dependent’ at baseline. Face-to-face brief interventions are recommended for those with ‘at-risk’ alcohol use but are regarded as ineffective for those with alcohol use disorders (14, 15). It is therefore important to determine the range of alcohol use for which ehealth interventions are effective. Overall, these findings need to be tempered with the fact that the trial was not implemented as designed and the longest period of follow-up was only three months.
Where to next
The Daybreak’ program contains many ‘active’ components including peer-support, online coaching and access to evidence based training modules. However, we currently do not know which elements or combination of elements assist which people in changing their behavior and how to successfully engage those who at the moment drop out of the program. A greater understanding of the drivers of behavioural change would enable further improvements in the program.
Since October 2016, Daybreak has reached more than 50,000 participants. Therefore, there is potential to impact on alcohol-related problems at a population health level, importantly including ‘probably dependent’ drinkers.
Robert Tait 1; Raquel Paz Castro 2; Jessica Kirkman 3; Jamie Moore 3; Michael P Schaub 2.
- National Drug Research Institute, Curtin University
- Swiss Research Institute for Public Health and Addiction, associated to the University of Zurich, Switzerland
- Hello Sunday Morning
The trial was funded by Hello Sunday Morning under support from the nib foundation and Ian Potter Foundation.
- Griswold MG, Fullman N, Hawley C, Arian N, Zimsen SRM, Tymeson HD, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2018;392(10152):1015-35.
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- American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, Il: American College of Surgeons; 2014.
- Riper H, Blankers M, Hadiwijaya H, Cunningham J, Clarke S, Wiers R, et al. Effectiveness of guided and unguided low-intensity internet interventions for adult alcohol misuse: A meta-analysis. PLoS ONE. 2014;9(6):e99912.
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