Within-person associations between daily motivation and self-efficacy and drinking among problem drinkers in treatment

Applying models of self-regulated learning to understand engagement with digital health interventions: a narrative review

Digital health interventions (DHIs) are often burdened by poor user engagement and high drop-out rates, diminishing their potential public health impact. Identifying user-related factors predictive of engagement has therefore drawn significant research attention in recent years. Absent from this literature-yet implied by DHI design-is the notion that individuals who use DHIs have well-regulated learning capabilities that facilitate engagement with unguided intervention content. In this narrative review, we make the case that learning capacity can differ markedly across individuals, and that the requirements of self-guided learning for many DHIs do not guarantee that those who sign up for these interventions have good learning capabilities at the time of uptake. Drawing upon a rich body of theoretical work on self-regulated learning (SRL) in education research, we propose a user-as-learner perspective to delineate parameters and drivers of variable engagement with DHIs. Five prominent theoretical models of SRL were wholistically evaluated according to their relevance for digital health. Three key themes were drawn and applied to extend our current understanding of engagement with DHIs: (a) common drivers of engagement in SRL, (b) the temporal nature of engagement and its drivers, and (c) individuals may differ in learning capability. Integrating new perspectives from SRL models offered useful theoretical insights that could be leveraged to enhance engagement with intervention content throughout the DHI user journey. In an attempt to consolidate these differing-albeit complementary-perspectives, we develop an integrated model of engagement and provide an outline of future directions for research to extend the current understanding of engagement issues in self-guided DHIs.

Using causal mediation to examine self-efficacy as a mechanism through which continuing care interventions reduce alcohol use

OBJECTIVE

Understanding the causal mechanisms through which telephone and mobile health continuing care approaches reduce alcohol use can help develop more efficient interventions that effectively target these mechanisms. Self-efficacy for successfully coping with high-risk alcohol relapse situations is a theoretically and empirically supported mediator of alcohol treatment. This secondary analysis aims to examine self-efficacy as a mechanism through which remote-delivered continuing care interventions reduce alcohol use.

METHOD

The study included 262 adults (Mage = 46.9, SD = 7.4) who had completed 3 weeks of an intensive outpatient alcohol treatment program. The sample was predominantly male (71%), African American (82%), and completed a high school education (71%). The four-arm randomized clinical trial compared three active continuing care interventions (telephone monitoring and counseling [TMC], addiction comprehensive health enhancement support system [ACHESS], and combined delivery of TMC and ACHESS) to usual care and assessed longitudinal measures of alcohol use and self-efficacy. Analyses employed the potential outcomes framework and sensitivity analyses to address threats to causal inference resulting from an observed mediator variable.

RESULTS

Relative to usual care, the two intervention conditions that included TMC reduced alcohol use through improvements to self-efficacy. There was no evidence that self-efficacy mediated the effect of ACHESS on alcohol use.

CONCLUSIONS

Based on our findings, self-efficacy is an important mechanism through which telephone continuing care interventions affect alcohol use. Future research to identify which components of TMC influence self-efficacy and factors that mediate ACHESS effects could enhance the effectiveness of remote delivery of continuing care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examining the daily reciprocal relations between alcohol abstinence self-efficacy and drinking among non-treatment seeking individuals with alcohol use disorder (AUD)

Theoretical and empirical models of alcohol use and misuse indicate that abstinence self-efficacy (ASE) predicts improvements in treatment outcomes among individuals with alcohol use disorder (AUD). More recently, studies have begun examining daily fluctuations in ASE to better understand in-the-moment determinants of drinking behaviors. With the goal of assessing how ASE is implicated in maintenance (rather than changing) of hazardous drinking patterns, the current study examined daily reciprocal relations between ASE and drinking among individuals with AUD. Non-treatment seeking adults (n = 63) with AUD were recruited and completed daily surveys assessing ASE and drinking behaviors for 14 days. Data were analyzed using time-lagged multilevel modeling. Results indicated that both within- and between-person elevations in ASE predicted decreased likelihood of drinking, but only within-person ASE predicted fewer drinks consumed on drinking days. Previous-day drinking behavior was unrelated to next-day ASE; however, higher percentage of drinking days during the monitoring period (between-person) was associated with lower daily ASE. These results demonstrate that confidence in one's ability to abstain from drinking varies considerably across days, and that fluctuations may be implicated in daily drinking decisions. The lack of effect of previous-day drinking on ASE (combined with the significant effect of average drinking frequency) may suggest that sustained periods of reduced drinking or abstinence are necessary to impact ASE. This study points to ASE's role in the maintenance of daily drinking behavior among non-treatment-seeking individuals with AUD and reiterates the importance of self-efficacy in behavioral control and decision-making at the daily level.

FRAMES Elements Associated With Alcohol Treatment Research Assessments and Related Behavior Change

OBJECTIVE

Assessment reactivity research has contributed substantially to our understanding of alcohol treatment research protocols influencing clinical outcomes. The state of the science is such that relatively little is known about how alcohol treatment research participation influences behavior. The purpose of this study was twofold: (a) to determine the distribution of FRAMES elements (i.e., Feedback, personal Responsibility, Advice, a Menu of options, Empathic style of interaction, and support for Self-efficacy) contained in alcohol treatment research assessment interviews; and (b) to examine their association with subsequent alcohol use among a sample of clients presenting for alcohol use disorder treatment.

METHOD

Audiotaped recordings of participant (n = 189) research assessment interviews were converted to digital recordings and reviewed for FRAMES elements using the FRAMES Checklist Instrument.

RESULTS

Feedback, personal responsibility, empathic style of interaction, and support for self-efficacy were the more frequently occurring elements across follow-up periods. Alternatively, menu of options and advice occurred infrequently. Feedback and support for self-efficacy predicted subsequent alcohol use, although the association between feedback and alcohol use was unexpectedly positive.

CONCLUSIONS

As part of the assessment interview process, alcohol treatment research participants receive multiple instances of feedback and support for self-efficacy specific to their alcohol use that are predictive of changes in alcohol use.

Mechanisms of behavior change during alcohol treatment among negative affect drinkers: A time-varying effect model analysis using 84 consecutive days of ecological momentary assessment

OBJECTIVE

To better understand the timing and unique contribution of four potential mechanisms of behavior change (MOBC) during alcohol use disorder (AUD) treatment (negative affect, positive affect, alcohol craving, and adaptive alcohol coping), we used a time-varying effect modeling analytic approach to examine the change trajectories of alcohol abstinence, heavy drinking, the hypothesized MOBCs, and the time-varying associations between the MOBCs and alcohol outcomes.

METHOD

Participants (N = 181; Mage = 50.8 years, SD = 10.6; 51% women; 93.5% Caucasian) were enrolled in a 12-week randomized clinical trial of cognitive behavioral outpatient treatment program for AUD. For 84 consecutive days, participants provided self-reports of positive and negative affect, craving, alcohol use, and adaptive alcohol coping strategies employed.

RESULTS

Throughout the 84-day treatment window, higher daily average craving levels were associated with both decreased likelihood of alcohol abstinence and increased odds of heavy drinking, whereas higher adaptive alcohol coping was associated with increased odds of abstinence and decreased odds of heavy drinking. Higher negative affect was associated with decreased odds of abstinence in the first 10 days of treatment and increased odds of heavy drinking before Day 4 or Day 5. Higher positive affect was associated with decreased odds of heavy drinking during the first 4 or 5 days.

CONCLUSIONS

The differential time-varying associations between negative affect, positive affect, alcohol craving, adaptive alcohol coping, and alcohol use provide insights into how and when each of the MOBCs is active during AUD treatment. These findings can help optimize the efficacy of future AUD treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Fully Understanding Eating and Lifestyle Behaviors (FUEL) trial: Protocol for a cohort study harnessing digital health tools to phenotype dietary non-adherence behaviors during lifestyle intervention

Objective

Lifestyle intervention can produce clinically significant weight loss and reduced disease risk/severity for many individuals with overweight/obesity. Dietary lapses, instances of non-adherence to the recommended dietary goal(s) in lifestyle intervention, are associated with less weight loss and higher energy intake. There are distinct "types" of dietary lapse (e.g., eating an off-plan food, eating a larger portion), and behavioral, psychosocial, and contextual mechanisms may differ across dietary lapse types. Some lapse types also appear to impact weight more than others. Elucidating clear lapse types thus has potential for understanding and improving adherence to lifestyle intervention.

Methods

This 18-month observational cohort study will use real-time digital assessment tools within a multi-level factor analysis framework to uncover "lapse phenotypes" and understand their impact on clinical outcomes. Adults with overweight/obesity (n = 150) will participate in a 12-month online lifestyle intervention and 6-month weight loss maintenance period. Participants will complete 14-day lapse phenotyping assessment periods at baseline, 3, 6, 12, and 18 months in which smartphone surveys, wearable devices, and geolocation will assess dietary lapses and relevant phenotyping characteristics. Energy intake (via 24-h dietary recall) and weight will be collected at each assessment period.

Results

This trial is ongoing; data collection began on 31 October 2022 and is scheduled to complete by February 2027.

Conclusion

Results will inform novel precision tools to improve dietary adherence in lifestyle intervention, and support updated theoretical models of adherence behavior. Additionally, these phenotyping methods can likely be leveraged to better understand non-adherence to other health behavior interventions.

Trial Registration

This study was prospectively registered https://clinicaltrials.gov/study/NCT05562427.

Data driven mixed effects modeling of the dual process framework of addiction among individuals with alcohol use disorder

Alcohol use disorder (AUD) comprises a continuum of symptoms and associated problems that has led AUD to be a leading cause of morbidity and mortality across the globe. Given the heterogeneity of AUD from mild to severe, consideration is being given to providing a spectrum of interventions that offer goal choice to match this heterogeneity, including helping individuals with AUD to moderate or control their drinking at low-risk levels. Because so much remains unknown about the factors that contribute to successful moderated drinking, we use dynamical systems modeling to identify mechanisms of behavior change. Daily alcohol consumption and daily desire (i.e., craving) are modeled using a system of delayed difference equations. Employing a mixed effects implementation of this system allows us to garner information about these mechanisms at both the population and individual levels. Use of this mixed effects framework first requires a parameter set reduction via identifiability analysis. The model calibration is then performed using Bayesian parameter estimation techniques. Finally, we demonstrate how conducting a parameter sensitivity analysis can assist in identifying optimal targets of intervention at the patient-specific level. This proof-of-concept analysis provides a foundation for future modeling to describe mechanisms of behavior change and determine potential treatment strategies in patients with AUD.

A Comparison of Mathematical and Statistical Modeling with Longitudinal Data: An Application to Ecological Momentary Assessment of Behavior Change in Individuals with Alcohol Use Disorder

Ecological momentary assessment (EMA) has been broadly used to collect real-time longitudinal data in behavioral research. Several analytic methods have been applied to EMA data to understand the changes of motivation, behavior, and emotions on a daily or within-day basis. One challenge when utilizing those methods on intensive datasets in the behavioral field is to understand when and why the methods are appropriate to investigate particular research questions. In this manuscript, we compared two widely used methods (generalized estimating equations and generalized linear mixed models) in behavioral research with three other less frequently used methods (Markov models, generalized linear mixed-effects Markov models, and differential equations) in behavioral research but widely used in other fields. The purpose of this manuscript is to illustrate the application of five distinct analytic methods to one dataset of intensive longitudinal data on drinking behavior, highlighting the utility of each method.

A new statistical model for longitudinal ecological momentary assessment data on dual use of electronic and combustible cigarettes

Background: Existing studies of dual use of electronic and combustible cigarettes either collected longitudinal data with long gaps in between waves or conducted ecological momentary assessment (EMA) over a short period of time. In recent years, the measurement burst design that embeds an EMA protocol in each wave assessment of a traditional longitudinal study has become more popular and yet conventional generalized linear mixed models (GLMM) have important limitations for handling data from this design.Objectives: This study proposed a new statistical method to analyze data from the measurement burst design.Methods: This new statistical method was designed to model the short-term (within-wave) as well as long-term (between-wave) changes and was validated by a simulation study. Secondary analysis was conducted to analyze data from 205 dual users (52% male) and 146 exclusive smokers (50% male) who participated in a recent study using the measurement burst design.Results: The simulation study shows that the proposed method can handle the gap between waves well and is also robust to nonlinear changes across waves. Although no short-term change in smoking was found, dual users reported a long-term reduction in cigarette use that was more rapid compared to exclusive smokers (β ˆ = - 0.0127 , p = .0167 ). Vaping more was associated with smoking less (β ˆ = - 0.0058 , p = .0054 ).Conclusion: The proposed method is highly applicable as it can be easily implemented by substance use researchers and the results can be straightforwardly interpreted. The results suggest that e-cigarette use may play a role in promoting a long-term reduction in smoking among dual users.

The indirect effect of negative emotionality via alcohol craving on abstinence self-efficacy among women in alcohol treatment

Women with alcohol use disorder (AUD) often present to treatment with heightened negative emotionality, including negative affect, anxiety, stress, and depression. Negative emotionality might impact women's alcohol abstinence self-efficacy (AASE), or confidence in their ability to remain sober, which is an important predictor of treatment outcomes. It is also plausible that other variables, such as alcohol craving, influence AASE. The present work examined the indirect effect of negative emotionality on AASE via alcohol craving as a mediator cross-sectionally among a sample of women enrolled in AUD treatment reporting co-occurring depressive symptoms (N = 73). Participants completed baseline measures of negative emotionality (e.g. anxiety and depression symptoms, stress, negative affect), alcohol craving, and AASE. All indices of negative emotionality were positively correlated with each other and alcohol craving (r's ranging from 0.244 to 0.671) and all but depression were inversely associated with AASE (r's ranging from -0.341 to -0.234; p <.05). In separate simple mediation models, we found that alcohol craving mediated the association of each of the four measures of negative emotionality with AASE. Further longitudinal and experimental work is necessary to determine if teaching skills to cope with alcohol craving in the context of co-occurring negative emotionality might lead to better therapeutic outcomes.

Daily diary study of loneliness, alcohol, and drug use during the COVID-19 Pandemic

BACKGROUND

Research conducted during the COVID-19 Pandemic has identified two co-occurring public health concerns: loneliness and substance use. Findings from research conducted prior to the pandemic are inconclusive as to the links between loneliness and substance use. This study aimed to measure associations of loneliness with three different types of substance use during COVID-19: daily number of alcoholic drinks, cannabis use, and non-cannabis drug use.

METHOD

Data were obtained between October 2020 and May 2021 from 2,648 US adults (Mage  = 38.76, 65.4% women) diverse with respect to race and ethnicity using online recruitment. Participants completed baseline surveys and daily assessments for 30 days. A daily loneliness measure was recoded into separate within- and between-person predictor variables. Daily outcome measures included the number of alcoholic drinks consumed and dichotomous cannabis and non-cannabis drug use variables. Generalized linear multilevel models (GLMLM) were used to examine within- and between-person associations between loneliness and substance use.

RESULTS

The unconditional means model indicated that 59.0% of the variance in the daily number of alcoholic drinks was due to within-person variability. GLMLM analyses revealed that, overall, people drank more on days when they felt a particularly high or particularly low degree of loneliness (positive quadratic effect). There was a negative and significant within-person association between daily loneliness and the likelihood of cannabis use. There was also a positive and significant within-person association between daily loneliness and the likelihood of non-cannabis drug use.

CONCLUSIONS

Associations between loneliness and substance use vary with substance type and whether within- or between-person differences are assessed. These findings are relevant to the persistence of substance use disorders and thus of potential clinical importance. Individuals who do not experience severe loneliness at intake but who show daily increases in loneliness above baseline levels are at heightened risk of alcohol and non-cannabis drug use. Future research could profitably examine just-in-time adaptive interventions that assess fluctuations in loneliness to prevent the development or exacerbation of substance use disorders.

Processing incomplete questionnaire data into continuous digital biomarkers for addiction monitoring

Purpose

eHealth systems allow efficient daily smartphone-based collection of self-reported data on mood, wellbeing, routines, and motivation; however, missing data is frequent. Within addictive disorders, missing data may reflect lack of motivation to stay sober. We hypothesize that qualitative questionnaire data contains valuable information, which after proper handling of missing data becomes more useful for practitioners.

Methods

Anonymized data from daily questionnaires containing 11 questions was collected with an eHealth system for 751 patients with alcohol use disorder (AUD). Two digital continuous biomarkers were composed from 9 wellbeing questions (WeBe-i) and from two questions representing motivation/self-confidence to remain sober (MotSC-i). To investigate possible loss of information in the process of composing the digital biomarkers, performance of neural networks to predict exacerbation events (relapse) in alcohol use disorder was compared.

Results

Long short-term memory (LSTM) neural networks predicted a coming exacerbation event 1–3 days (AUC 0.68–0.70) and 5–7 days (AUC 0.65–0.68) in advance on unseen patients. The predictive capability of digital biomarkers and raw questionnaire data was equal, indicating no loss of information. The transformation into digital biomarkers enable a continuous graphical display of each patient’s clinical course and a combined interpretation of qualitative and quantitative aspects of recovery on a time scale.

Conclusion

By transforming questionnaire data with large proportion of missing data into continuous digital biomarkers, the information captured by questionnaires can be more easily used in clinical practice. Information, assessed by the capability to predict exacerbation events of AUD, is preserved when processing raw questionnaire data into digital biomarkers.

GAMBLINGLESS IN-THE-MOMENT: Protocol for a micro-randomised trial of a gambling Just-In-Time Adaptive Intervention (Preprint)

Background

The presence of discrete but fluctuating precipitants, in combination with the dynamic nature of gambling episodes, calls for the development of tailored interventions delivered in real time, such as just-in-time adaptive interventions (JITAIs). JITAIs leverage mobile and wireless technologies to address dynamically changing individual needs by providing the type and amount of support required at the right time and only when needed. They have the added benefit of reaching underserved populations by providing accessible, convenient, and low-burden support. Despite these benefits, few JITAIs targeting gambling behavior are available.

Objective

This study aims to redress this gap in service provision by developing and evaluating a theoretically informed and evidence-based JITAI for people who want to reduce their gambling. Delivered via a smartphone app, GamblingLess: In-The-Moment provides tailored cognitive-behavioral and third-wave interventions targeting cognitive processes explicated by the relapse prevention model (cravings, self-efficacy, and positive outcome expectancies). It aims to reduce gambling symptom severity (distal outcome) through short-term reductions in the likelihood of gambling episodes (primary proximal outcome) by improving craving intensity, self-efficacy, or expectancies (secondary proximal outcomes). The primary aim is to explore the degree to which the delivery of a tailored intervention at a time of cognitive vulnerability reduces the probability of a subsequent gambling episode.

Methods

GamblingLess: In-The-Moment interventions are delivered to gamblers who are in a state of receptivity (available for treatment) and report a state of cognitive vulnerability via ecological momentary assessments 3 times a day. The JITAI will tailor the type, timing, and amount of support for individual needs. Using a microrandomized trial, a form of sequential factorial design, each eligible participant will be randomized to a tailored intervention condition or no intervention control condition at each ecological momentary assessment across a 28-day period. The microrandomized trial will be supplemented by a 6-month within-group follow-up evaluation to explore long-term effects on primary (gambling symptom severity) and secondary (gambling behavior, craving severity, self-efficacy, and expectancies) outcomes and an acceptability evaluation via postintervention surveys, app use and engagement indices, and semistructured interviews. In all, 200 participants will be recruited from Australia and New Zealand.

Results

The project was funded in June 2019, with approval from the Deakin University Human Research Ethics Committee (2020-304). Stakeholder user testing revealed high acceptability scores. The trial began on March 29, 2022, and 84 participants have been recruited (as of June 24, 2022). Results are expected to be published mid-2024.

Conclusions

GamblingLess: In-The-Moment forms part of a suite of theoretically informed and evidence-based web-based and mobile gambling interventions. This trial will provide important empirical data that can be used to facilitate the JITAI’s optimization to make it a more effective, efficient, and scalable tailored intervention.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000490774; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380757&isClinicalTrial=False

International Registered Report Identifier (IRRID)

PRR1-10.2196/38958

Alcohol use, behavioral and mental health help-seeking, and treatment satisfaction among sexual minority women

BACKGROUND

Sexual minority women (SMW) report higher rates of heavy episodic drinking (HED) and adverse alcohol-related outcomes, including poor mental health, than heterosexual women. These disparities indicate a greater need for behavioral and mental health treatment for SMW. This study examined associations among alcohol outcomes, behavioral and mental health help-seeking, and treatment satisfaction among SMW by age, sexual identity, race/ethnicity, and income.

METHODS

Participants included a community sample of 695 SMW (Mage  = 40.0, SD = 14.1; 74.1% lesbian, 25.9% bisexual; 37.6% White, 35.8% Black, 23.2% Latinx; 26.3% annual income $14,999 or less). We used bivariate analyses to characterize the sample's demographic characteristics and multivariable logistic regression analyses to examine associations among variables.

RESULTS

SMW subgroups based on age, race/ethnicity, and annual income differed in alcohol outcomes (i.e., HED, DSM-IV alcohol dependence, alcohol-related problem consequences, alcohol problem recognition, and motivation to reduce drinking); help-seeking; and treatment satisfaction. SMW who engaged in help-seeking for alcohol-related concerns were more likely than those who did not to meet criteria for DSM-IV alcohol dependence (adjusted odds ratio [aOR] = 7.13; 95% CI = 2.77; 18.36), endorse alcohol-related problem consequences (aOR = 11.44; 95% CI = 3.88; 33.71), recognize problematic drinking (aOR = 14.56; 95% CI = 3.37; 62.97), and report motivation to reduce drinking (aOR = 5.26; 95% CI = 1.74; 15.88). SMW's alcohol outcomes did not differ based on their satisfaction with treatment or with providers.

CONCLUSIONS

This study's findings confirm SMW's elevated risk for HED and other alcohol-related outcomes and underscore the importance of identity-affirmative and accessible behavioral and mental health treatment for young, Black, and low-income SMW. Clinicians and intervention scientists should develop or enhance existing brief behavioral and mental health treatments for SMW engaging in HED who may not recognize that their drinking is problematic or who are not motivated to reduce drinking.

Adaptive Text Messaging for Postpartum Risky Drinking: Conceptual Model and Protocol for an Ecological Momentary Assessment Study (Preprint)

Background

Risky drinking is prevalent among women of childbearing age. Although many women reduce their drinking during pregnancy, more than half return to prepregnancy levels during the early postpartum period. Risky drinking in new mothers may be associated with negative child and maternal health outcomes; however, new mothers are unlikely to seek treatment for risky drinking because of stigma and fear of child protective service involvement. SMS text messaging is a promising approach for reaching non–treatment-seeking new mothers at risk because of risky drinking. SMS text messaging interventions (TMIs) are empirically supported for alcohol use, but a tailored intervention for new mothers does not exist. This study aims to fill this gap by developing a just-in-time adaptive TMI for postpartum risky drinking.

Objective

The objectives of this paper are to present a preliminary conceptual model of postpartum risky drinking and describe the protocol for conducting an ecological momentary assessment (EMA) study with new mothers to inform the refinement of the conceptual model and development of the TMI.

Methods

This paper presents a preliminary conceptual model of postpartum risky drinking based on the motivational model of alcohol use, social cognitive theory, and temporal self-regulation theory. The model proposes three primary intervention targets: motivation, self-efficacy, and self-regulation. Theoretical and empirical literature in support of the conceptual model is described. The paper also describes procedures for a study that will collect EMA data from 30 participants recruited via social media and the perinatal Central Intake system of New Jersey. Following the baseline assessment, EMA surveys will be sent 5 times per day for 14 days. The assessment instruments and data analysis procedures are described.

Results

Recruitment is scheduled to begin in January 2022 and is anticipated to conclude in March 2022. Study results are estimated to be published in July 2022.

Conclusions

The study findings will enhance our understanding of daily and momentary fluctuations in risk and protective factors for risky drinking during the early postpartum period. The findings will be used to refine the conceptual model and inform the development of the TMI. The next steps for this work include the development of intervention components via an iterative participatory design process and testing of the resulting intervention in a pilot microrandomized trial.

International Registered Report Identifier (IRRID)

PRR1-10.2196/36849

The Condom Use Self-Efficacy Scale in Substance Use Disorder Treatment-Seeking American Indian Adults

American Indians (AIs) experience substance use disorder and sexual risk related inequities with elevated rates of sexually transmitted infections, unintended pregnancy, and fetal alcohol spectrum disorders. Substance misuse is associated with risky sexual behaviors including condomless sex. Objectives: The current study aimed to test the validity of the Condom Use Self-Efficacy Scale (CUSES) and the relationship between self-efficacy and condom use behaviors in AI individuals with substance use disorders (SUDs). Exploratory analyses also examined changes in condom use self-efficacy across SUD treatment. Methods: As part of a larger randomized controlled trial, AI individuals (N = 79) seeking SUD treatment completed baseline measures of condom use self-efficacy and sexual risk behaviors. Results: Confirmatory factor analysis (CFA) indicated that a 3-factor, 10-item version of the CUSES was a reliable and valid measure in this population. Condom use self-efficacy was associated with condom use behavior and increased during SUD treatment. Conclusions: Overall, it appears that the CUSES is a valid measure in AI individuals, is related to condom use behavior, and increases with SUD treatment. There is a need for future research to integrate these findings into AI cultural values. Addressing sexual risk behaviors in SUD treatment may be an important target and future research is needed to understand predictors of condom use self-efficacy and determine potential intervention targets to reduce sexual risk behaviors and related health inequities.

Exploratory and confirmatory factor analyses and invariance assessment of the perceived powerlessness scale among youth in Baltimore

Generalized perceived powerlessness is an important psychosocial construct that determines a wide range of health behaviors and outcomes. This study has two aims: (1) examine the structure of the newly developed perceived powerlessness scale using exploratory and confirmatory factor analyses and (2) assess the scale's invariance across key demographic variables using multi-group confirmatory factor analysis among a random household sample of African American and White youth (aged 15-24 years) residing in Baltimore, MD. Our study results demonstrated that the powerlessness scale is valid among a demographically diverse sample of urban youth, showing promise for use in future health behavior and outcome studies.

Notifications to Improve Engagement With an Alcohol Reduction App: Protocol for a Micro-Randomized Trial

BACKGROUND

Drink Less is a behavior change app that aims to help users in the general adult population reduce hazardous and harmful alcohol consumption. The app includes a daily push notification, delivered at 11 am, asking users to "Please complete your mood and drinking diaries." Previous analysis of Drink Less engagement data suggests the current notification strongly influences how users engage with the app in the subsequent hour. To exploit a potential increase of vulnerability of excess drinking and opportunity to engage with the app in the evenings, we changed the delivery time from 11 am to 8 pm. We now aim to further optimise the content and sequence of notifications, testing 30 new evidence-informed notifications targeting the user's perceived usefulness of the app.

OBJECTIVE

The primary objective is to assess whether sending a notification at 8 pm increases behavioral engagement (opening the app) in the subsequent hour. Secondary objectives include comparing the effect of the new bank of messages with the standard message and effect moderation over time. We also aim to more generally understand the role notifications have on the overall duration, depth, and frequency of engagement with Drink Less over the first 30 days after download.

METHODS

This is a protocol for a micro-randomized trial with two additional parallel arms. Inclusion criteria are Drink Less users who (1) consent to participate in the trial; (2) self-report a baseline Alcohol Use Disorders Identification Test score of 8 or above; (3) reside in the United Kingdom; (4) age ≥18 years and; (5) report interest in drinking less alcohol. In the micro-randomized trial, participants will be randomized daily at 8 pm to receive no notification, a notification with text from the new message bank, or the standard message. The primary outcome is the time-varying, binary outcome of "Did the user open the app in the hour from 8 pm to 9 pm?". The primary analysis will estimate the marginal relative risk for the notifications using an estimator developed for micro-randomized trials with binary outcomes. Participants randomized to the parallel arms will receive no notifications (Secondary Arm A), or the standard notification delivered daily at 11 am (Secondary Arm B) over 30 days, allowing the comparison of overall engagement between different notification delivery strategies.

RESULTS

Approval was granted by the University College of London's Departmental Research Ethics Committee (CEHP/2016/556) on October 11, 2019, and The London School of Hygiene and Tropical Medicine Interventions Research Ethics Committee (17929) on November 27, 2019. Recruitment began on January 2, 2020, and is ongoing.

CONCLUSIONS

Understanding how push notifications may impact engagement with a behavior change app can lead to further improvements in engagement, and ultimately help users reduce their alcohol consumption. This understanding may also be generalizable to other apps that target a variety of behavior changes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18690.

The Motivational Thought Frequency Scales for increased physical activity and reduced high-energy snacking

OBJECTIVES

The Motivational Thought Frequency (MTF) Scale has previously demonstrated a coherent four-factor internal structure (Intensity, Incentives Imagery, Self-Efficacy Imagery, Availability) in control of alcohol and effective self-management of diabetes. The current research tested the factorial structure and concurrent associations of versions of the MTF for increasing physical activity (MTF-PA) and reducing high-energy snacks (MTF-S).

DESIGN

Study 1 examined the internal structure of the MTF-PA and its concurrent relationship with retrospective reports of vigorous physical activity. Study 2 attempted to replicate these results, also testing the internal structure of the MTF-S and examining whether higher MTF-S scores were found in participants scoring more highly on a screening test for eating disorder.

METHODS

In Study 1, 626 participants completed the MTF-PA online and reported minutes of activity in the previous week. In Study 2, 313 participants undertook an online survey that also included the MTF-S and the Eating Attitudes Test (EAT-26).

RESULTS

The studies replicated acceptable fit for the four-factor structure on the MTF-PA and MTF-S. Significant associations of the MTF-PA with recent vigorous activity and of the MTF-S with EAT-26 scores were seen, although associations were stronger in Study 1.

CONCLUSIONS

Strong preliminary support for both the MTF-PA and MTF-S was obtained, although more data on their predictive validity are needed. Associations of the MTF-S with potential eating disorder illustrate that high scores may not always be beneficial to health maintenance.

Social cognitions and smoking behaviour: Temporal resolution matters

Objectives Health behaviour theories outline how cognitions predict behaviours, but rarely specify the temporal relation between cognitions and behaviours. It is not known whether these predictive relationships vary depending on temporal resolution or whether the relative influence of cognitions varies with measurement schedules. The current exploratory study therefore investigates whether the associations between behavioural cognitions (self-efficacy, intention, and risk perception) and smoking vary when measured momentarily, at day level, or using the more common baseline-follow-up design. Design EMA study involving 36 continuing smokers over 17 days. Participants logged cigarettes and reported their cognitions at baseline, daily (evening), and in response to momentary surveys. Methods Random-effects models were used to compare the effects of cognitions measured at different time points on (1) the number of cigarettes smoked daily and (2) the time interval until the next cigarette smoked. Results Self-efficacy and risk perception measured at baseline significantly predicted cigarettes smoked each day, but this effect became non-significant when daily measurements of cognitions were included in the model. Momentary smoking behaviour was predicted by momentary measurements of risk perception, with no significant effects of social cognitions at baseline. Conclusions Relationships between cognitions and behaviours vary according to the temporal resolution of the measurement schedule. Ensuring that the temporal resolution of assessment is appropriate for the temporal dynamics of the behaviour being assessed is important. Future research is needed to investigate the potential for leveraging specific cognitive processes depending on temporal importance in order to increase health-promoting behaviours. Statement of contribution What is already known on this subject? Social cognitions including intentions, risk perception, and self-efficacy have been observed to predict smoking. Little is known about the role of time in the cognition-behaviour relationship. Cognitions have been observed to fluctuate, but instability is typically not considered in research design. What does this study add? Daily measurement of social cognitions predicts behaviour better than measurements taken at baseline. Momentary smoking behaviour is predicted by momentary cognitions at the intra-individual level. Temporal resolution of measurement should be considered when investigating cognition-behaviour relationships.

Examining motivational interviewing's effect on confidence and commitment using daily data

Mechanisms of behavior change (MOBC) within Motivational Interviewing (MI) are thought to operate via both relational and technical elements. These elements are hypothesized to increase client motivation and self-efficacy for change and subsequently decrease drinking. Only partial support for this causal chain exists, particularly when using within-session change talk as the primary intervening variable. This study explored whether commitment to moderate or abstain from drinking and confidence to moderate drinking in the next day measured via ecological momentary assessment (EMA) provided alternative support for the theory. Data were from a pilot randomized controlled trial testing active ingredients of MI. Problem drinkers (N = 89) seeking to moderate their drinking were randomly assigned to one of the three conditions: 1) MI; 2) Spirit only MI (SOMI), consisting of non-directive elements of MI, e.g., reflective listening; and 3) a non-therapy control. Participants completed daily EMA that measured confidence, both types of commitment, and drinks per day for a week prior to and during seven weeks of treatment. Hypotheses were not supported, and results were unexpected. Participants in SOMI were more likely to have higher daily confidence than those in MI; there were no condition differences for either type of commitment. All daily measures significantly predicted drinking; however, the MI group did not demonstrate a stronger relationship between the intervening variables and drinking, as hypothesized. Instead, participants in SOMI yielded the strongest relationship between daily commitment to abstain and drinking compared to the other two conditions. Multiple possible explanations for the unexpected findings are discussed.

Daily factors driving daily substance use and chronic pain among older adults with HIV: An exploratory study using ecological momentary assessment

BACKGROUND

Adults 50 and older make up approximately 50% of persons living with HIV. Multiple co-morbidities are common among this group, including chronic pain and substance abuse, yet little is known about the daily factors that either enhance or inhibit these experiences or behaviors. This study explored daily drivers of substance use, pain, and relief from pain among older adults living with HIV utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 55), ages 49-71, completed seven consecutive days of daily EMA online surveys prior to treatment initiation within a randomized controlled trial. Multilevel modeling tested predictors of pain, substance use, and relief from pain by examining within- and between-person relationships.

RESULTS

Results revealed an associational, reciprocal relationship between daily worst pain and daily drinking, where greater worst pain ratings predicted heavier drinking and heavier drinking predicted greater daily and overall pain. Greater happiness and poorer quality of sleep predicted greater daily worst pain. Exercising and overall confidence to cope with pain without medication were associated with lower levels of daily worst pain. Finally, spending less time with a loved one over time and reporting any coping behavior were associated with relief from pain.

CONCLUSION

Investigation of daily factors that drive pain and substance use behaviors among this unique population help inform which daily factors are most risky to their health and well-being. Alcohol use emerged as the only substance associated with both driving pain and responding to pain. Findings suggest key points for prevention and intervention.

Assessment of Alcohol Use in the Natural Environment

The current article critically reviews 3 methodological options for assessing drinking episodes in the natural environment. Ecological momentary assessment (EMA) typically involves using mobile devices to collect self-report data from participants in daily life. This technique is now widely used in alcohol research, but investigators have implemented diverse assessment strategies. This article focuses on "high-resolution" EMA protocols that oversample experiences and behaviors within individual drinking episodes. A number of approaches have been used to accomplish this, including using signaled follow-ups tied to drinking initiation, asking participants to log entries before and after individual drinks or drinking episodes, and delivering frequent signaled assessments during periods of the day when alcohol use is most common. Transdermal alcohol sensors (TAS) are devices that are worn continuously and are capable of detecting alcohol eliminated through the skin. These methods are appealing because they do not rely upon drinkers' self-report. Studies using TAS have been appearing with greater frequency over the past several years. New methods are making the use of TAS more tractable by permitting back-translation of transdermal alcohol concentration data to more familiar estimates of blood alcohol concentration or breath alcohol concentration. However, the current generation of devices can have problems with missing data and tend to be relatively insensitive to low-level drinking. An emerging area of research investigates the possibility of using mobile device data and machine learning to passively detect the user's drinking, with promising early findings. EMA, TAS, and sensor-based approaches are all valid, and tend to produce convergent information when used in conjunction with one another. Each has a unique profile of advantages, disadvantages, and threats to validity. Therefore, the nature of the underlying research question must dictate the method(s) investigators select.

Self-Efficacy to Limit Drinking Mediates the Association between Attitudes and Alcohol-Related Outcomes

Personal attitudes toward alcohol consumption are reliable predictors of alcohol use and related problems, with emerging work suggesting that one's favorable attitude toward limited drinking (i.e., at levels below the threshold for heavy episodic drinking) is a buffer against alcohol use and binge drinking. However, little work has examined the specific mechanism(s) through which one's personal attitude toward limited drinking is associated with alcohol use and related problems. One such mechanism may be an individual's self-efficacy to limit their alcohol use. The current study aimed to evaluate whether self-efficacy to limit one's alcohol use mediates the association between one's personal attitude toward limited drinking and actual alcohol use and related problems over time. Participants were mandated students (n = 568; 28% female) who violated campus alcohol policy and received a brief motivational intervention. Mediation models were used to test (a) self-efficacy to limit one's alcohol use as a traditional mediator of the attitudes-drinking quantity association and (b) self-efficacy and drinking quantity as serial mediators of the attitudes-alcohol-problems link. Favorable attitudes toward limiting drinking at baseline were positively associated with self-efficacy to limit drinking at 1 month, which was associated with a reduction in drinking quantity at 3 months; this, in turn, was associated with a reduction in alcohol-related problems at 5 months. These findings provide a rationale for incorporating attitudes and self-efficacy in the development and refinement of intervention strategies.

The relationship between in-session commitment language and daily self-reported commitment to reduce or abstain from drinking

BACKGROUND

Motivational interviewing is hypothesized to operate by enhancing a client's internal motivation to change. Past research operationalizes this process by measuring in-session statements for change (i.e., change talk), yet relationships between change talk and other measures of motivation have yet to be substantiated. This study tested whether in-session change talk predicted subsequent reports of commitment to abstain or moderate drinking assessed via ecological momentary assessment (EMA), and explored each of their contributions to drinking outcomes.

METHOD

Secondary data analysis was performed on data from 48 study participants who received therapy within a randomized controlled trial testing mechanisms of actions of MI. Multilevel models were used to test whether in-session commitment statements (strength, frequency, and slope of strength) made in two therapy sessions predicted subsequent daily reports of commitment to abstain or not drink heavily and drinking (21 days of data) in the weeks following each respective session.

RESULTS

A weak, negative relationship between in-session commitment and average daily commitment to abstain emerged. No relationship between in-session statements and average daily commitment to not drink heavily emerged. Only EMA commitment predicted drinking outcome. Post hoc analyses demonstrate a moderating impact of EMA commitment to abstain on in-session commitment strength: low pre-treatment commitment to abstain and increasing commitment strength across a session yielded the greatest drink reduction.

CONCLUSION

In-session change talk and EMA commitment may represent distinct aspects of motivation, yet their interaction appears important to treatment prognoses. Commitment to abstain may be important for treatment selection and successful drink reduction.

Alcohol-induced blackouts, subjective intoxication, and motivation to decrease drinking: Prospective examination of the transition out of college

OBJECTIVE

We prospectively examined whether subjective intoxication serves as a risk factor for experiencing alcohol-induced blackouts. We then examined whether subjective intoxication and/or blackouts predicted motivation to decrease their drinking, and whether this motivation to change would promote future changes in drinking behavior.

METHOD

Participants (N=1854, 62.1% female, 53.2% Caucasian, M_age=21.8) were recruited the summer prior to matriculating into a large, public university to complete a 6-year longitudinal study. Self-reported motivation to decrease their drinking behavior, their frequency of blackouts, quantity of alcohol consumption, and subjective intoxication (i.e., feeling drunk) were assessed annually during the transition out of college (Years 4-6).

RESULTS

In a cross-lagged model, subjective intoxication (i.e., feeling drunk) prospectively predicted experiencing blackouts (p<0.001). Controlling for both objective (e.g., quantity) and subjective intoxication, blackouts at Year 4 predicted greater motivation to decrease drinking behavior at Year 5 (p<0.01), but this motivation did not predict less quantity of alcohol use by Year 6 (p=0.076).

CONCLUSIONS

Subjective intoxication is a robust predictor of blackouts across time. Additionally, blackouts are modest, developmentally-limited predictors of motivation to change drinking behavior, but blackouts do not predict future behavior change.

A Text Message Intervention with Adaptive Goal Support to Reduce Alcohol Consumption Among Non-Treatment-Seeking Young Adults: Non-Randomized Clinical Trial with Voluntary Length of Enrollment

Background

Stand-alone text message–based interventions can reduce binge drinking episodes (≥4 drinks for women and ≥5 drinks for men) among nontreatment-seeking young adults, but may not be optimized. Adaptive text message support could enhance effectiveness by assisting context-specific goal setting and striving, but it remains unknown how to best integrate it into text message interventions.

Objective

The objective of this study was to evaluate young adults’ engagement with a text message intervention, Texting to Reduce Alcohol Consumption 2 (TRAC2), which focuses on reducing weekend alcohol consumption. TRAC2 incorporated preweekend drinking-limit goal-commitment ecological momentary assessments (EMA) tailored to past 2-week alcohol consumption, intraweekend goal reminders, self-efficacy EMA with support tailored to goal confidence, and maximum weekend alcohol consumption EMA with drinking limit goal feedback.

Methods

We enrolled 38 nontreatment-seeking young adults (aged 18 to 25 years) who screened positive for hazardous drinking in an urban emergency department. Following a 2-week text message assessment-only run-in, subjects were given the opportunity to enroll in 4-week intervention blocks. We examined patterns of EMA responses and voluntary re-enrollment. We then examined how goal commitment and goal self-efficacy related to event-level alcohol consumption. Finally, we examined the association of length of TRAC2 exposure with alcohol-related outcomes from baseline to 3-month follow-up.

Results

Among a diverse sample of young adults (56% [28/50] female, 54% [27/50] black, 32% [12/50] college enrolled), response rates to EMA queries were, on average, 82% for the first 4-week intervention block, 75% for the second 4-week block, and 73% for the third 4-week block. In the first 4 weeks of the intervention, drinking limit goal commitment was made 68/71 times it was prompted (96%). The percentage of subjects being prompted to commit to a drinking limit goal above the binge threshold was 52% (15/29) in week 1 and decreased to 0% (0/15) by week 4. Subjects met their goal 130/146 of the times a goal was committed to (89.0%). There were lower rates of goal success when subjects reported lower confidence (score <4) in meeting the goal (76% [32/42 weekends]) compared with that when subjects reported high confidence (98% [56/57 weekends]; P=.001). There were reductions in alcohol consumption from baseline to 3 months, but reductions were not different by length of intervention exposure.

Conclusions

Preliminary evidence suggests that nontreatment-seeking young adults will engage with a text message intervention incorporating self-regulation support features, resulting in high rates of weekend drinking limit goal commitment and goal success.

Exploration of treatment matching of problem drinker characteristics to motivational interviewing and non-directive client-centered psychotherapy

Motivational Interviewing (MI) is a known effective intervention for alcohol use disorder (AUD). MI's mechanisms of action remain inconsistently substantiated, and research in this area has been reliant on identifying relationships through strength of association rather than experimental manipulation of active ingredients. In two previous studies, a pilot and a larger replication study, we disaggregated MI into its hypothesized active ingredients by creating three conditions: MI, Spirit Only MI (SOMI, in which evocation of change talk was proscribed), and a non-therapy condition (NTC). Results from both studies yielded equivalent findings across all three conditions. In the current analyses, data from both studies were combined to test five participant characteristics as moderators of MI's component parts: 1) severity of baseline drinking, 2) severe AUD (met 6 or more criteria), 3) baseline self-efficacy to moderate drinking, 4) mean daily confidence to resist heavy drinking in the week prior to treatment initiation, and 5) depression. There were no significant findings related to baseline drinking, severe AUD, or baseline self-efficacy. Confidence yielded a significant interaction effect. When participants had high baseline confidence, drinking for those in MI increased compared to those in SOMI. Depression also yielded a significant moderating effect such that in the context of higher depressive symptoms, receipt of either therapy reduced drinking relative to NTC. Results are discussed in light of existing literature on MOBC with MI and the potential role exploring ambivalence may play for participants with particular characteristics.

Comparing daily drivers of problem drinking among older and younger adults: An electronic daily diary study using smartphones

BACKGROUND

By 2030, numbers and proportions of older adults with substance-use problems are expected to increase. While risk factors for problem drinking in late life have been identified, it remains unknown whether these factors drive daily drinking among older problem drinkers. This study examined the daily drivers of drinking among problem drinkers, moderated by age, utilizing ecological momentary assessment (EMA).

METHOD

Participants (N = 139), ages 20-73, received daily EMA online surveys completed via a smartphone prior to initiation of treatment. Multilevel modeling tested the moderating impact of age on within- and between-person relationships between drinking and focal predictors (mood, loneliness, boredom, stress, poor sleep, social factors, alcohol salience, commitment and confidence not to drink heavily).

RESULTS

Older adults reported greater alcohol consumption when daily boredom levels were higher. Heavier drinking among younger adults was associated with poorer sleep quality. Greater daily confidence, daily commitment and daily alcohol salience did not impact drinking to the same extent for older adults as for younger adults. Greater person-level commitment predicted reduced drinking equivalently across age, but low person-level commitment predicted greater drinking among older adults compared to their younger counterparts.

CONCLUSION

Older adults may have unique daily drivers of drinking that are not fully realized in current research and intervention efforts. Addressing the growing substance-use treatment needs among this population will require identifying the unique drivers of drinking among older adults, such as boredom, when compared to younger adults.

Ecological momentary assessment of daily discrimination experiences and nicotine, alcohol, and drug use among sexual and gender minority individuals

OBJECTIVE

Sexual and gender minority (SGM) individuals experience elevated rates of minority stress, which has been linked to higher rates of nicotine and substance use. Research on this disparity to date is largely predicated on methodology that is insensitive to within day SGM-based discrimination experiences, or their relation to momentary nicotine and substance use risk. We address this knowledge gap in the current study using ecological momentary assessment (EMA).

METHOD

Fifty SGM individuals, between 18 and 45 years of age, were recruited from an inland northwestern university, regardless of their nicotine or substance use history, and invited to participate in an EMA study. Each were prompted to provide data, six times daily (between 10:00 a.m. and 10:00 p.m.) for 14 days, regarding SGM-based discrimination, other forms of mistreatment, and nicotine, drug, and alcohol use since their last prompt.

RESULTS

Discrimination experiences that occurred since individuals' last measurement prompt were associated with greater odds of nicotine and substance use during the same measurement window. Substance use was also more likely to occur in relation to discrimination reported two measurements prior in lagged models. Relative to other forms of mistreatment, discrimination effects were consistently larger in magnitude and became stronger throughout the day/evening.

CONCLUSION

This study adds to existing minority stress research by highlighting the both immediate and delayed correlates of daily SGM-based discrimination experiences. These results also contribute to our understanding of daily stress processes and provide insight into ways we might mitigate these effects using real-time monitoring and intervention technology. (PsycINFO Database Record

Dynamical Systems Modeling to Identify a Cohort of Problem Drinkers with Similar Mechanisms of Behavior Change

One challenge to understanding mechanisms of behavior change (MOBC) completely among individuals with alcohol use disorder is that processes of change are theorized to be complex, dynamic (time varying), and at times non-linear, and they interact with each other to influence alcohol consumption. We used dynamical systems modeling to better understand MOBC within a cohort of problem drinkers undergoing treatment. We fit a mathematical model to ecological momentary assessment data from individual patients who successfully reduced their drinking by the end of the treatment. The model solutions agreed with the trend of the data reasonably well, suggesting the cohort patients have similar MOBC. This work demonstrates using a personalized approach to psychological research, which complements standard statistical approaches that are often applied at the population level.

Dismantling motivational interviewing: Effects on initiation of behavior change among problem drinkers seeking treatment

Motivational interviewing (MI) is an efficacious treatment for alcohol use disorders. MI is thought to enhance motivation via a combination of 2 therapeutic strategies or active ingredients: 1 relational and 1 directional. The primary aim of this study was to examine MI's hypothesized active ingredients using a dismantling design. Problem drinkers (N = 139) seeking treatment were randomized to 1 of 3 conditions: MI, relational MI without the directional elements labeled spirit-only MI (SOMI), or a nontherapy control condition and followed for 8 weeks. Those assigned to MI or SOMI received 4 sessions of treatment over 8 weeks. All participants significantly reduced their drinking by Week 8, but reductions were equivalent across conditions. The hypothesis that baseline motivation would significantly moderate condition effects on outcome was generally not supported. Failure to find support for MI's hypothesized active ingredients is discussed in the context of the strengths and limitations of the study design. (PsycINFO Database Record

Dynamic Modeling of Problem Drinkers Undergoing Behavioral Treatment

We use dynamical systems modeling to help understand how selected intra-personal factors interact to form mechanisms of behavior change in problem drinkers. Our modeling effort illustrates the iterative process of modeling using an individual's clinical data. Due to the lack of previous work in modeling behavior change in individual patients, we build our preliminary model relying on our understandings of the psychological relationships among the variables. This model is refined and the psychological understanding is then enhanced through the iterative modeling process. Our results suggest that this is a promising direction in research in alcohol use disorders as well as other behavioral sciences.