Assessing the feasibility, acceptability, and initial efficacy of a multiple behavior change intervention addressing alcohol use, sexual risk taking, and bystander intervention.

OBJECTIVE: Prevention programs that address the intersecting health problems of risky alcohol use, unsafe sexual behaviors, and sexual violence are needed. This pilot project assessed the feasibility, acceptability, and preliminary efficacy of a two-session group-based intervention, Sex Positive Lifestyles: Addressing Alcohol & Sexual Health (SPLASH), targeting these highly interconnected risks for college students across genders. METHOD: A total of 217 participants (51.6% male, ages 18-24) took part in the SPLASH intervention or a nutrition/exercise control condition. SPLASH included three approaches aimed at reducing the incidence of alcohol problems, unsafe sex, and sexual victimization: normative feedback to modify misperceptions around peers' drinking, sexual behaviors, and support of bystander intervention; drinking and sexual-related protective behavioral strategy training to enhance safer drinking and sex-risk behaviors; and bystander intervention skills training to promote bystander efficacy and engagement. Participants completed baseline and follow-up (1-month and 6-month) online assessments. RESULTS: SPLASH demonstrated high acceptability and feasibility, as well as preliminary efficacy. SPLASH participants reported strong acceptability of the intervention, particularly its integrated content and interactive, in-person group format. Successful enrollment (70% randomized) and retainment point to the feasibility of recruiting students to this two-session in-person intervention. Results showed sustained trends toward more accurate perceived sex-related norms and indications of increasing bystander norms among intervention but not control participants. CONCLUSIONS: Results demonstrate the potential for SPLASH to effectively address the interrelated health risks of risky alcohol use, unsafe sex, and sexual violence on college campuses and point to the need for larger-scale studies.

Using the Pan American Health Organization Digital Conversational Agent to Educate the Public on Alcohol Use and Health: Preliminary Analysis.

BACKGROUND: There is widespread misinformation about the effects of alcohol consumption on health, which was amplified during the COVID-19 pandemic through social media and internet channels. Chatbots and conversational agents became an important piece of the World Health Organization (WHO) response during the COVID-19 pandemic to quickly disseminate evidence-based information related to COVID-19 and tobacco to the public. The Pan American Health Organization (PAHO) seized the opportunity to develop a conversational agent to talk about alcohol-related topics and therefore complement traditional forms of health education that have been promoted in the past. OBJECTIVE: This study aimed to develop and deploy a digital conversational agent to interact with an unlimited number of users anonymously, 24 hours a day, about alcohol topics, including ways to reduce risks from drinking, that is accessible in several languages, at no cost, and through various devices. METHODS: The content development was based on the latest scientific evidence on the impacts of alcohol on health, social norms about drinking, and data from the WHO and PAHO. The agent itself was developed through a nonexclusive license agreement with a private company (Soul Machines) and included Google Digital Flow ES as the natural language processing software and Amazon Web Services for cloud services. Another company was contracted to program all the conversations, following the technical advice of PAHO staff. RESULTS: The conversational agent was named Pahola, and it was deployed on November 19, 2021, through the PAHO website after a launch event with high publicity. No identifiable data were used and all interactions were anonymous, and therefore, this was not considered research with human subjects. Pahola speaks in English, Spanish, and Portuguese and interacts anonymously with a potentially infinite number of users through various digital devices. Users were required to accept the terms and conditions to enable access to their camera and microphone to interact with Pahola. Pahola attracted good attention from the media and reached 1.6 million people, leading to 236,000 clicks on its landing page, mostly through mobile devices. Only 1532 users had a conversation after clicking to talk to Pahola. The average time users spent talking to Pahola was 5 minutes. Major dropouts were observed in different steps of the conversation flow. Some questions asked by users were not anticipated during programming and could not be answered. CONCLUSIONS: Our findings showed several limitations to using a conversational agent for alcohol education to the general public. Improvements are needed to expand the content to make it more meaningful and engaging to the public. The potential of chatbots to educate the public on alcohol-related topics seems enormous but requires a long-term investment of resources and research to be useful and reach many more people.

The development of the Pan American Health Organization digital health specialist on alcohol use.

Introduction: On 19 November 2021 the Pan American Health Organization (PAHO) developed and deployed the first-ever digital health worker dedicated to alcohol-related topics, named Pahola. This paper describes this developmental process and the first results of its uptake and interactions with the public. Methods: PAHO secured a non-exclusive worldwide license with a technology company to use their Human OS ecosystem, which enables human-like interactions between digital people and users via an application. Google Digital flow ES was used to develop the conversations of Pahola on topics related to alcohol and health, screening of alcohol risk using the AUDIT and providing a quit/cut back plan to users, along with additional treatment services and resources in each country of the Americas. A communication campaign was also implemented from launching date until 31 December 2021. Results: Pahola attracted good attention from the media, and potentially reached 1.6 million people, leading to 236,000 sessions on its landing page, mostly through mobile devices. The average time people effectively spent talking to Pahola was five minutes. Major dropouts were observed in different steps of the conversation flow. Discussion: Pahola was quickly able to connect to a large worldwide population with reliable alcohol information. It could potentially increase the delivery of SBI and improve alcohol health literacy. However, its preliminary results pointed to much needed changes to its corpus and on its accessibility, which are being currently implemented.

The moderating effects of alcohol use with and without parent permission on alcohol risk communication in early adolescence.

The frequency of parental alcohol risk communication (ARC) is considered an integral component of socializing youth about alcohol, but the literature offers mixed findings on whether such communication is protective. Early adolescents' prior drinking experiences may moderate the effectiveness of ARC, but evidence for such an interaction is inconsistent. One limitation of this work considering prior drinking experience is that it has not distinguished drinking with versus without parental permission. Parents are one of the earliest sources of information about alcohol use and many parents view allowing adolescents to drink alcohol with permission as a harm reduction strategy, despite some work suggesting the opposite effect. Using a random effects multilevel regression, we tested the unique moderating effects of drinking with and without parental permission on the prospective association between alcohol risk communication and later drinking without parental permission. Adolescent and parent dyads completed 3 annual assessments (first assessment mean age = 12.6, 52% girls, 76% White/non-Hispanic). Results supported a three-way interaction. There was a modest protective effect of parental ARC on later adolescent drinking, but only for adolescents who had prior experience drinking both with and without parental permission. For all other combinations of prior drinking experience, parental communication was not prospectively related to later drinking. These results help clarify the mixed literature on alcohol communication and suggests that ARC may help reduce some of the risk associated with allowing youth to drink alcohol but only for youth who also have experience with alcohol outside of parental supervision.

Exploring the characteristics of newly defined at-risk drinkers following the change to the UK low risk drinking guidelines: a retrospective analysis using Health Survey for England data.

BACKGROUND: Alcohol guidelines enable individuals to make informed choices about drinking and assist healthcare practitioners to identify and treat at-risk drinkers. The UK Low Risk Drinking Guidelines were revised in 2016 and the weekly guideline for men was reduced from 21 to 14 units per week. This study sought to retrospectively establish 1) the number of additional at-risk male drinkers in England, 2) which demographic characteristics were associated with being an at-risk drinker under the previous versus new guidelines. METHODS: Average weekly alcohol consumption for men aged 16+ from the cross-sectional nationally representative Health Survey for England were used to 1) calculate annual population prevalence estimates for newly defined at-risk (> 14 to ≤21 units/week) male drinkers from 2011 to 2015 (N = 3487-3790), and 2) conduct logistic regression analyses for at-risk vs low risk male drinkers under the previous (> 21 vs ≤21 units/week) and new (> 14 vs ≤14 units/week) guidelines to assess characteristics associated with being at-risk drinkers under each guideline using 2015 data (N = 2982). RESULTS: Population prevalence estimates of newly defined at-risk drinkers ranged from 10.2% (2014 = 2,182,401 men)-11.2% (2011 = 2,322,896 men). Under the new guidelines, men aged 55-74 (OR = 1.63,95% CI = 1.25-2.12); men in managerial/professional occupations (OR = 1.64,95% CI = 1.34-2.00); current smokers (OR = 2.26,95% CI = 1.73-2.94), ex-regular smokers (OR = 2.01,95% CI = 1.63-2.47) and ex-occasional smokers (OR = 1.85,95% CI = 1.25-2.74); men from the North East (OR = 2.08,95% CI = 1.38-3.13) and North West (OR = 1.91,95% CI = 1.41-2.60) of England all had greater odds, and non-white men had reduced odds (OR = 0.53,95% CI = 0.34-0.80) of being at-risk drinkers, as they had under the previous guidelines. Under the new guidelines only: a higher percentage of at-risk drinkers aged 16-34 (32% vs 19%) attenuated the odds of men aged 35-54 being at-risk (OR = 1.18,95% CI = 0.92-1.51); a higher percentage of married at-risk drinkers (37% vs 24%) attenuated the odds of single men being at-risk (OR = 1.28,95% CI = 0.99-1.67); men from the West Midlands (OR = 1.68,95% CI = 1.17-2.42) and London (OR = 1.53,95% CI = 1.03-2.28) had greater odds of being at-risk drinkers. CONCLUSIONS: The change to the Low Risk Drinking Guidelines would have resulted in more than 2 million additional male at-risk drinkers in England. Most groups with greater odds of being at-risk drinkers under the new guidelines were those already known to be drinking the most, strengthening the case for targeted screening and education. Additionally, under the new guidelines, a marked proportion of 16-35 year olds and married men were at-risk and men in the West Midlands and London had greater odds of being at-risk drinkers. These groups may benefit from specific education around the new Low Risk Drinking Guidelines.

Self-Persuasion on Facebook Increases Alcohol Risk Perception.

In this experiment, we examined if participating in a Facebook group by generating antialcohol arguments (self-persuasion) is more effective than reading antialcohol posts of others (direct persuasion) in changing alcohol consumption, risk perception, and attitudes. In addition, it was examined if submitting posts moderated these effects. Participants logged into their Facebook account and joined a group that contained posts with antialcohol arguments. They either generated their own arguments with or without posting them, or read those present in the group with or without posting that they had read them. Next, participants rated movie clips in a 30-minute ad libitum drinking session in dyads, and their alcohol consumption was measured. Finally, measures of alcohol risk perception and attitudes were completed. Results show that generating antialcohol arguments-regardless of whether they are posted online-is effective in increasing alcohol risk perception but does not affect immediate alcohol consumption.

National Cancer Societies and their public statements on alcohol consumption and cancer risk.

BACKGROUND AND AIMS: Studies have shown that alcohol consumption is a risk factor for oral, pharyngeal, laryngeal, esophageal, liver, colon, rectal and breast cancer. It would therefore be expected that cancer prevention organizations would incorporate these facts into their public stance on the consumption of alcohol. The aims of this study were to: (1) assess how national cancer societies in developed English-speaking countries [i.e. English-speaking countries belonging to the Organization for Economic Co-operation and Development (OECD)] communicate alcohol-related cancer risk to the public and (2) compare whether these organization's advocacy of increased alcohol taxes is in line with their advocacy of tobacco tax increases to reduce cancer risk. METHODS: We searched the websites of the following national cancer organizations for all statements related to the relationship between alcohol consumption and cancer risk: Cancer Council Australia, Canadian Cancer Society, Irish Cancer Society, Cancer Society New Zealand, Cancer Research UK and the American Cancer Society. A categorical system was developed to code the qualitative data for health statements, alcohol consumption recommendations, and tax policy recommendations. Websites were analyzed in March of 2017. RESULTS: All organizations, with the exception of the American Cancer Society and Canadian Cancer Society, state that alcohol is a group 1 carcinogen and that even low-level alcohol consumption increases risk for some cancers. Additionally, while the American Cancer Society supports increasing tobacco taxes through its cancer action network, it has not advocated for increased alcohol taxes in relation to support for tobacco tax increases. CONCLUSION: Analysis in 2017 of the websites for national cancer societies in Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States-including Cancer Council Australia, the Canadian Cancer Society, the Irish Cancer Society, Cancer Society New Zealand, Cancer Research UK and the American Cancer Society-shows that only the American Cancer Society and Canadian Cancer Society websites fail to state that alcohol is a group 1 carcinogen and can cause cancer at low doses, and that there is no safe threshold for cancer risk.

Health Risk Behavior Patterns in a National Adult Population Survey.

Background: The aim of this paper is to analyze the co-occurrence of health risk behaviors (HRBs), namely, tobacco smoking, alcohol risk drinking, overeating, and physical inactivity, as well as their 16 combinations (patterns), which are stratified by age and gender. Methods: The data of 19,294 study participants, from a telephone survey among the adult general population of Germany that was conducted in 2012, were analyzed. Results: In adults, two or more of the four HBRs were found among 51.5% of females and 61.9% of males. The single most prevalent HRB pattern among all of the female (20.7, 19.6⁻21.8%) and male participants (18.2, 17.1⁻19.3%) was being overweight combined with a lack of physical activity, and its prevalence increased by 4% with each year of life. A multinomial regression analysis revealed that education was inversely associated with 11 of the 15 HRB patterns. The risk of having four, compared to zero, HRBs was 3.3 (2.5⁻4.4) for males relative to females. Conclusion: Similar to the findings from other western countries, the majority of the participants in this adult national sample from Germany had two or more HRBs. The most common of all possible HRB patterns was overweight and inactivity. The data confirm inverse relations between education and most HRB patterns.

Do As I Say: Using Communication Role-Plays to Assess Sexual Assertiveness Following an Intervention.

Sexual risk reduction interventions are often ineffective for women who drink alcohol. The present study examines whether an alcohol-related sexual risk reduction intervention successfully trains women to increase assertive communication behaviors and decrease aggressive communication behaviors. Women demonstrated their communication skills during interactive role-plays with male role-play partners. Young, unmarried, and nonpregnant African American women (N = 228, ages 18-24) reporting unprotected vaginal or anal sex and greater than three alcoholic drinks in the past 90 days were randomly assigned to a control, a sexual risk reduction, or a sexual and alcohol risk reduction (NLITEN) condition. Women in the NLITEN condition significantly increased assertive communication behavior compared to women in the control condition, yet use of aggressive communicative behaviors was unchanged. These data suggest assertive communication training is an efficacious component of a sexual and alcohol risk reduction intervention. Public health practitioners and health educators may benefit from group motivational enhancement therapy (GMET) training and adding a GMET module to existing sexual health risk reduction interventions. Future research should examine GMET's efficacy in combination with other evidence-based interventions within other populations and examine talking over and interrupting one's sexual partner as an assertive communication behavior within sexual health contexts.

Risk of alcohol abuse in urban versus rural DUI offenders.

BACKGROUND: Research concerning driving under the influence (DUI) offenses in rural populations is scarce and has often been carried out in the context of substance abuse and illicit drug use. Although previous studies have suggested that rural individuals are more likely to abstain from alcohol use, recent trends suggest that alcohol and substance abuse problems in rural areas are occurring at rates similar to urban areas. It is possible that urban and rural DUI offenders may differ on psychological and behavioral characteristics associated with heavy alcohol consumption. OBJECTIVE: The aim of this study was to examine alcohol use differences between urban and rural DUI offenders. METHODS: Data from 11 066 DUI offenders in a Midwestern state were used for this study. The Alcohol subscale of the Driver Risk Inventory II was used to assess the risk of problem alcohol use. RESULTS: Higher levels of alcohol risk were associated with rural DUI offenders after adjusting for several demographic variables and blood-alcohol content level at time of arrest [Medium Risk OR = 1.43, 95% CI: (1.20, 1.71); Problem Risk OR = 1.43, 95% CI: (1.19, 1.72); Severe Risk OR = 1.38, 95% CI: (1.14, 1.67)]. CONCLUSIONS: The results of this study indicate that rural DUI offenders have a significantly greater risk of heavy alcohol use when compared to urban DUI offenders. Practical implications of these results suggest that evaluators and assessors should be aware of an increased likelihood of alcohol problems in rural DUI individuals relative to those in urban areas.

Parents' and students' perceptions of college alcohol risk: the role of parental risk perception in intentions to communicate about alcohol.

INTRODUCTION: The current study aims to examine discrepancies in parents' and college students' perceptions of alcohol risk and the role of perceived risk in predicting parents' intentions to discuss alcohol with their child. METHODS: In total, 246 college student-parent dyads (56.1% female students, 77.2% mothers) were recruited from a mid-size university. Participants completed measures of absolute likelihood, comparative likelihood, and severity of alcohol consequences. RESULTS: In comparison to students, parents perceived the risks of alcohol poisoning (p<.001), academic impairment (p<.05), and problems with others (p<.05) to be more likely. In addition, parents rated the majority of alcohol consequences (e.g., passing out, regrettable sexual situation, throwing up) as more severe than students (all ps<.001). However, parents tended to be more optimistic than their child about the comparative likelihood of alcohol consequences. After controlling for demographics and past alcohol communication, greater absolute likelihood (ß=.20, p=.016) and less confidence in knowledge of student behavior (ß=.20, p=.013) predicted greater intentions to discuss alcohol. CONCLUSIONS: Providing parents of college students with information about college drinking norms and the likelihood of alcohol consequences may help prompt alcohol-related communication.