# Presentation: 376161

## In Pursuit of Worldwide Community Impact:

*The Importance of Reach and the Need for Authorable Intervention Software*
*Steven J. Ondersma, PhD*
*Psychiatry and Behavioral Neurosciences*
*Obstetrics and Gynecology*

## Disclosure

- The speaker is the primary inventor of software designed to facilitate development of computer-based interventions
- Although no marketing is currently taking place, this software may in the future be made commercially available, to the financial benefit of the speaker and Wayne State University

## Overview

- The case for brief, opportunistic, solely computer-based interventions
- Efficacy of brief computer-based interventions
- Describe a new system for flexible authoring of computer-based interventions

## The Case For Computer-Only Brief Interventions

**Notes:**
(1)  Challenges to traditional; (2) advantages

## Challenge 1:  Worldwide Access to Addiction Treatment is Inadequate 

- Worldwide:
- 				_Use of_	     _Disorder_
- Alcohol		2 billion	     76.3 million
- Drugs		185 million	     15.3 million
- Tobacco	1.3 billion
- Treatment capacity is not nearly adequate to meet this need

## Challenge 2:  Most Don’t Want Treatment

**Challenge 2:**  Most Don’t Want Treatment

**Treated**
**(2.3 million)**

**Not Treated and Did Not Feel They Needed Treatment**
**(19.7 million)**

**Not Treated and**
**Did Feel They **
**Needed Treatment**
**(1.2 million)**
**(26% Made Effort**
**to Get Treatment)**

**Of 23.2 Million With a Drug or Alcohol Use Disorder In USA:**

**85%**

**5%**

**10%**

*NSDUH, 2005*

**Notes:**
SPECIALTY TX—NOT 12-step, doc, etc.; 3.9 million, or 17%, got SOME form of Tx; NESARC says 6.1 and 30.7 for abuse and dependence, respectively (Compton et al., AGP, 2007)
When we do find them, half drop out
15.6% of those with lifetime DUD received any help in lifetime

## Challenge 3:  The Research-Practice Gap

- Training is expensive and moderately effective at best
- Many trainees don’t meet criteria for adequate motivational interviewing (Baer et al., 2004)
- Training-related changes fade with time (Miller & Mount, 2001), and are of small magnitude (Schoener, Madeja, Henderson, Ondersma, & Janisse, 2005)
- Interest in and time for new approaches is limited (Beich et al., 2002; Yarnall et al., 2003)
- Effect sizes can drop substantially from efficacy to effectiveness studies (for example, .81 to .26; Curtis et al., 2004)

## Challenge 4:  The Effect Size Glass Ceiling

- Meta-analyses suggest that substance use disorder interventions have, at best, a moderate positive effect
- Prendergast et al., 2002:  Mean effect size for drug use interventions = .30 (95% CI = .25 - .35)
- Berglund, 2005:  Mean effect size for alcohol use interventions = .37
- These effects are often independent of service intensity, hover in a fairly tight range, and rarely exceed *d* = .5

## Consequences of These Challenges

## Advantages of Computer-OnlyBrief Interventions

**Replicability:** no issues related to fidelity to treatment manual
**Cost:** very low cost per session, once developed
**Accessibility:** easily implemented in range of settings, in many languages
**Acceptability:** Can be presented and used with non-treatment seekers
**Tailoring:** nearly infinite targets, approaches, and formats to suit individual users

_***REACH***_

**Notes:**
-NO DOUBT computers can’t do much of what a person can. BUT...
-Regarding traditional approaches: problems with dissemination (cost, willingness, time), training, engagement and retention, effect size
85%, 37%

## The Importance of Reach

***Population Impact*** is the product of efficacy and reach (defined roughly as the proportion of persons with a given risk/condition who can be accessed)
- In practice, efficacy seems to vary within a relatively small window
- In contrast, reach may vary widely...

## The Importance of Reach (Cont.)

**Population Impact = effect size * proportion reached**
- Intensive treatment:  	.40 * 6.5% = **.03**
- Brief intervention:  		.30 * 20% =  **.06**
- Very high reach*:		.20 * 60% =  **.12**

- *Computer-based, tailored messaging, public health education, sin taxes, etc.

**Notes:**
-What might happen if we thought first about reach, and second about effect size? REACH varies tremendously!!! Why pour money into effect size, only to get another .05?
-What proportion of resources and attention go to each type? What proportion should go to each type?

## Efficacy of Computer-Only Interventions

## Encouraging Evidence So Far...

- For alcohol, *d* = .36 - .40 (Kypri et al., 2004; Neighbors et al., 2004; Hester et al., 2005; Hester, Chiauzzi et al., 2005)
- HIV risk behaviors, *d* = .31 on condom use among sexually active college students (Kiene & Barta, 2006)
- Diet and exercise, *d* = .48 on weight loss (Tate, 2003)
- Drug use, *d* = .46 on drug use frequency (Ondersma et al., 2007)

**Notes:**
Focusing on trials looking at behavioral outcomes; more studies report on changes in attitude, knowledge, etc.
Di Noia et al., 2004, with adolescents: knowledge and self-efficacy, but not attitudes changes relative to control

## Interactive Multimedia for Perinatal Drug Use (NIDA R21)

- Goal:  To develop interactive software capable of maximally replicating the components of a brief intervention for post-partum women
- Screening
- Assessment
- Intervention (single-session, brief, MI-based: pros and cons, feedback, and optional goal-setting)
- Intervention conducted in private hospital rooms, and presented via Tablet PC’s with touch-screen and aural presentation of all content

## Development Phase ResultsOndersma, Chase, Svikis, & Schuster, 2005, JSAT

- Likert ratings, 1 (not at all) to 5 (very much),  *N* = 47:
- Like working with computer?  	4.7
- Was it easy to use?			5.0
- Was it interesting?			4.1
- Qualitative responses were strong overall, with most being very interested in using the computer and pleased with the content

## Clinical Trial ResultsOndersma et al., 2007, American Journal of Preventive Medicine

- Four month follow-up assessment of 107 urban, post-partum women
- Follow-up *N* is 76 (follow-up rate = 71%)
- No baseline differences, control vs. intervention
- Primary outcomes:
- Changes in self-reported frequency of drug use
- Proportion using drugs at follow-up, as defined  by self-report or a positive urinalysis

**Notes:**
Mention verification of self-report

## Frequency of Self-Reported Drug Use from Baseline to 4-Month Follow-Up

*(Drug use frequency converted to Z scores; *
*N = 107; d = .46, p < .05, Mann-Whitney U)*

**Baseline****	**** Follow-Up**

## Proportion Positive for Drug Use at 4-Month Follow-Up

- OR’s = 2.4 - 2.6 Logit *d* = .47
- No dichotomous outcomes were statistically significant
- Sensitivity analysis suggests results are stable across outcome definitions

## Computerized Intervention Authoring Software (CIAS)

## Two Factors Limiting Development of Computer-Based Interventions

**Expense**.  Developing sophisticated, tailored, and interactive intervention software requires tremendous up-front costs
**Inflexibility**.  Software is usually hard-coded and developed for a particular setting, population, and target behavior

**Notes:**
But the marketability is not established enough to foster industry commitment to development, as with pharma development.

## Computerized Intervention Authoring Software (CIAS)

- Designed to allow easy development and modification of screening, assessment, **and** intervention components without new programming
- Flexible options include:
- Colors, narrator, voice, and language
- Single-choice, multiple choice, VAS, or text input
- Skip-outs and subgroup formation
- Eligibility criteria
- Intervention components:  recap of past responses in natural language, video insertion, image with pointing/explanation, web surfing, normed feedback, and conversation
- Randomization and counterbalancing
- Tailored messaging and/or session summary

**Notes:**
Emphasize how tests and packages can be copied and pasted, etc.

## Language Capability Using Synthetic Text-To-Speech (TTS) Engines

- Arabic
- Basque
- Chinese
- Croatian
- Czech
- Dutch
- Finnish
- French
- German
- Greek
- Hebrew
- Hungarian
- Italian

- Japanese
- Korean
- Norwegian
- Polish
- Portugese
- Romanian
- Russian
- Slovakian
- Slovenian
- Swedish
- Thai
- Turkish

- English & Spanish currently; easily added languages:

**Notes:**
Swahili—maybe. Kiswahili, Hausa, Yoruba, or any of 2,000 other African languages not listed here:  None known.

## Narrator Text and Direction

## Adding a New Intervention Slide

## Subgroup Management

## Branching Intervention Components

## Tailored Branching for MES-III (Post-Partum Women With Histories of Drug, Alcohol, or Tobacco Abuse/Dependence)

## Randomization

## Image Intervention “Slide”

## Decisional Balance:  Pros

## Feedback Intervention “Slide”

## Live Demonstration

## Conclusions	

- There are many theoretical advantages of computer-based interventions for the prevention and treatment of substance use disorders
- Early evidence suggests that such interventions are both highly acceptable and surprisingly efficacious
- Such interventions may be especially applicable in international settings

## Acknowledgements

- NIDA
- K23 DA00516 to Dr. Ondersma (mentor:  Charles R. Schuster, PhD; Program Officer:  Dorynne Czechowicz, MD)
- DA00516 and DA021329 to Dr. Ondersma (Program Officer:  Cecelia Spitznas, PhD)
- Collaborators
- Dr. Dace Svikis, Virginia Commonwealth University
- Dr. Farshad Fotouhi and Sonali Karandikar, Wayne State University, Department of Computer Science
- Sara Chase, Aulesha Harris, Jessica Beatty, Laura Strathdee, & Nancy Lockhart

## Slide 36