"Information about Drinking for Ex-serving personnel (InDEx)" - Development of a personalised alcohol app

Lead Research Organisation: King's College London
Department Name: Psychological Medicine

Abstract

It is well known that alcohol problems are more common in the military than in the rest of the population. Levels of alcohol consumption and binge drinking (drinking lots of alcohol in a short space of time) are almost twice as high. Whilst this difference could be explained by the peer pressure of being in a military unit, with others who are drinking heavily, it is surprising that levels of drinking do not seem to decrease when someone leaves the Armed Forces. Previous research has shown that people who drink heavily (both in the military and the general population) do not seem to recognise that they have a problem, so they are unlikely to change their drinking without any prompts. There may be a benefit in providing a treatment (also known as an intervention) to people when they are leaving the military, to help them to reduce their drinking, at a time when the peer pressure of military life may lessen. There is limited evidence on what interventions or treatments might be suitable for ex-serving personnel who need to lower their drinking, but who are not dependent on alcohol. Existing research has shown that electronic interventions (such as computer or mobile phone applications), which aim to help someone lower the amount they drink, can be helpful. These treatments, which have been developed for the general population, may also be suitable for people from the military. But it is likely that some changes will need to be made.
The aim of this research is to develop an electronic intervention, which can be delivered through a mobile phone, to help people leaving the Armed Forces to lower their alcohol consumption and to drink less in a single session. There isn't a lot of research in this area so an early study would be helpful before testing the intervention on a larger scale. There are a number of questions we want to answer in this early study; these are: 1) to look at the reasons why people who are currently in, or leaving, the Armed Forces drink heavily; 2) to use this information to design a mobile phone application that is relevant and meaningful to the ex-serving military population, and so should help them to reduce their drinking, and 3) to test if this intervention is acceptable to a small number of ex-serving personnel and to find out how they think that it could be improved. Once these questions have been answered then it should be possible to test the intervention with a larger number of people.
The benefits of this research are that it can help us understand why people in the Armed Forces drink heavily and why they don't lower their drinking when they leave. This information will be relevant to a number of organisations, such as health services and veterans' charities. It will also help us to develop a treatment that is more likely to be successful, because it will be more relevant to these individuals. There are lots of possible benefits to reducing the amount ex-service people drink; it can help to lower the risk of many conditions such as liver disease and cancer, it can improve how productive people are in their daily lives and can lower the number of times people visit their doctor with alcohol related injuries and illness. As well as benefitting the individuals, these changes could also save money for employers and public services.

Technical Summary

Hazardous alcohol use remains high among Service personnel even after they have left service, more than twice as high as in the general population. Binge drinking is also very common, with established negative health consequences. Yet there is poor recognition of this misuse within personnel, little understanding of the motivations and beliefs leading to heavy alcohol use and a lack of tailored alcohol interventions, with none tested in the UK. The effectiveness of electronic brief alcohol interventions has been evidenced in the general population, with effects maintained up to 12 months. The aims for this research are to study the effectiveness of a tailored electronic alcohol app 'Information about Drinking for Ex-serving personnel' (InDEx) to reduce the frequency of binge drinking in ex-serving personnel who meet criteria for hazardous use. The aims for the early phase study are to 1) to identify what are the motivations for drinking in a military population, how they may differ in ex-serving personnel, and associations with drinking patterns; 2) develop a tailored brief alcohol mobile phone app for ex-serving personnel and 3) to examine the acceptability and usability of this alcohol app in a small number of ex-serving personnel. This research is novel because there is no UK data on motivations for drinking in ex-serving personnel, which is required to develop relevant health messages. The InDEx app also focuses on patterns of alcohol use and the social context of drinking, which differs to existing apps that focus on consumption. InDEx will be a tailored intervention that uses personalised information to target the motivational drivers of binge drinking and hazardous use. This early phase work will lead into a larger randomised trial through the platform for the InDEx app, quantitative data on adherence and usage, qualitative data on acceptability and usability, and information on the feasibility of recruitment in Defence Dental Services.
 
Description Working with Defence Dental Services to develop a protocol for delivery of the InDEx intervention through the dental appointments in which alcohol screening is already conducted. We are working with them to develop the protocol for a RCT
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description An RCT to assess the efficacy of InDEx to reduce alcohol consumption in veterans at Combat Stress
Amount £310,144 (GBP)
Organisation Forces in Mind Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2019 
End 06/2022
 
Description Mental Health Research Programme
Amount £154,000 (GBP)
Organisation Forces in Mind Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 06/2018 
End 09/2019
 
Description Collaboration with King's College London 
Organisation King's College London
Country United Kingdom 
Sector Academic/University 
PI Contribution This project was conducted as a collaboration between the University of Liverpool and King's College London. At the University of Liverpool we have taken a lead role in the development of the content of the InDEx intervention, we have conducted recruitment to the qualitative aspects of the data collection and we have conducted and are writing up the qualitative analyses. I have also supervised the statistical analyses from the feasibility study and contributed to the development of the source code for the intervention.
Collaborator Contribution King's College London have led the development of the source code for the InDEx intervention and they have led the recruitment to the quantitative feasiblity study and the write up of the usability aspect of this feasibility study.
Impact All papers from this project have been collaborative.
Start Year 2016
 
Description Collaboration with the Royal British Legion to facilitate recruitment of participants to the study 
Organisation The Royal British Legion
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We have worked with the Royal British Legion to deliver the findings of our study and discuss them in context with the services and provisions they are currently providing in the North West region. We are planning to still meet regularly after the project has finished.
Collaborator Contribution The Royal British Legion supported us with participant recruitment to focus groups by sending emails out to their clients providing them with details of our study and our contact details. RBL also attended for our steering group meetings and at the public engagement event.
Impact This collaboration facilitated recruitment to the focus groups for our study and we have developed a collaborative working relationship which can support future studies.
Start Year 2016
 
Title Development on an alcohol intervention for ex-serving personnel 
Description This alcohol intervention app is currently in development and involves a novel component of tailored SMS messages which will be assigned to an individual based upon machine learning. The tailored messages have been written to reflect the different behaviour change techniques relevant to targeting binge drinking and the data collected through the app in initial screening questionnaires and through completion of a drinks diary and action planning will determine which messages are administered. The content of the tailored messages have been assessed in focus groups with ex-serving personnel and the app will be tested in a small number of ex-serving personnel in a usability and acceptability study. 
Type Therapeutic Intervention - Psychological/Behavioural
Current Stage Of Development Initial development
Year Development Stage Completed 2017
Development Status Under active development/distribution
Impact Presentation on the app development has resulted in wide interest through the Army and Defence Medical Services and they are supporting this early trial in ex-serving personnel and want to support future work to scale this intervention out to serving personnel in all three services. 
URL https://index-app.org/
 
Title Development of an alcohol app for ex-serving personnel 
Description A hybrid app has been developed for both Android and IOS which is an alcohol intervention for ex-serving personnel in the UK who drink hazardously. This app will be open sourced and all code will be made publicly available for other researchers to use. The app involves a drinking diary, provision of normative feedback, action planning using implementation intentions and tailored SMS messaging. 
Type Of Technology Webtool/Application 
Year Produced 2017 
Impact There has been interest in the app from other alcohol researchers, particularly in the tailored SMS messaging. This messaging is being developed to use machine learning to select appropriate messages for an individual and we will be collaborating with other researchers, such as at UCL and KCL who would like to use this approach. 
 
Title Public release of the software for the InDEx app 
Description InDEx is a software package for reporting and monitoring alcohol consumption via a smartphone application. Consumption of alcohol is self-reported by the user, and the app provides a visual representation of drinking behaviour and offers feedback on consumption levels compared to the general population. InDEx is intended as an exemplar app, operating as a standalone smartphone application and is highly customisable for a variety of research domains. InDEx is written in JavaScript, using IONIC framework which is cross-platform and is available under the liberal GNU General Public License (v3) 
Type Of Technology Software 
Year Produced 2018 
Open Source License? Yes  
Impact This software can be used by other academics and practitioners to support them to develop an alcohol app. The open source release of this software was complemented at the UCL Digital Behaviour Change conference as this sets a precedent for future similar academic projects. 
 
Description Article for the Conversation on 'Heavy Drinking in the UK military - how our alcohol app could help' - to be published March 19 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We have written an article about the InDEx alcohol app to be published by the Conversation in March 2019 to coincide with the Veterans' Mental Health Conference at KCL to be attended by both Prince Harry and Tobias Elwood (MP). The article will be publicised at the event to encourage a broad range of readers and it may be picked up by press who will be attending the event.
Although there is no impact yet it is expected to attract media and public interest.
Year(s) Of Engagement Activity 2019
 
Description Article in the Independent online newspaper about the digital alcohol intervention and suitability for a military population 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Article in the Independent newspaper which was informed by the article in the Conversation and reported on the suitability of digital apps as an intervention to reduce alcohol use in a military context. This article provided national coverage of this project and of the intervention.
Year(s) Of Engagement Activity 2019
URL https://www.independent.co.uk/news/health/alcohol-abuse-british-army-ptsd-post-traumatic-stress-diso...
 
Description Blog post in The Conversation around the problem of heavy alcohol use in the UK military and how a digital alcohol app may help 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Blog post in the Conversation around the digital alcohol app, increased publicity of the intervention and resulted in media coverage and broader enquiries about the intervention.
Year(s) Of Engagement Activity 2019
URL http://theconversation.com/alcohol-misuse-is-more-common-in-the-armed-forces-than-post-traumatic-str...
 
Description Conference presentation at the European Psychiatric Association Section of Epidemiology and Social Psychiatry conference April 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Oral conference presentation "The acceptability of Information for Drinking in Ex-serving personnel application (InDEx app): A qualitative evaluation" at the European Psychiatric Association Section of Epidemiology and Social Psychiatry conference on 6th April 2018.

The audience were particularly interested in how text messages had been used to tailor the alcohol intervention.
Year(s) Of Engagement Activity 2018
 
Description Departmental talk in the Addictions group at the University of Liverpool 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact JP presented on the InDEx study to the department and the format of the talks allows for extensive group discussion. There was interest in the intervention and this resulted in the development of specific collaborations for JP and for the study more generally.
Year(s) Of Engagement Activity 2017
 
Description Development of a study website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact The InDEx app website was developed to disseminate information about the study and the intervention and so that participants in our feasibility study could have access to additional information before they made a decision about whether to participate. The website address is included in all dissemination materials and presentation slides and views of the site increase after any public events.
Year(s) Of Engagement Activity 2017
URL https://index-app.org/
 
Description Interview with BBC Defence correspondent 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Media (as a channel to the public)
Results and Impact Informal interview with BBC Defence correspondence in relation to the blog and publication around drinking motivations in military personnel. The interview was conducted to gain more general research on the area, with plans for a future article and networks were made with direct links to the journalist who requested that we notify them personally when future papers are released.
Year(s) Of Engagement Activity 2020
 
Description Invited blog article after publication of article in Occupational Medicine on motivations for drinking in UK military personnel 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Article was requested by the authors of a national blog providing support for military personnel and veterans with alcohol problems. Publication of the blog resulted in further enquiries, including from a BBC Defence correspondent who was interested in the findings.
Year(s) Of Engagement Activity 2020
URL https://www.4-alpha.co.uk/blog/new-research-irizar?fbclid=IwAR1_zlcetJovUrQb9BTkdcBa1UjHg-rk3zdu_JZp...
 
Description Podcast about the alcohol app for the MoD JHub 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Podcast recorded for the Ministry of Defence JHub on "InDEx: Using technology to automate alcohol management in veterans" in December about the alcohol app and the potential utility of our app for veterans and the UK Armed Forces more broadly. Whilst the podcast has not yet been released it has already attracted interest from the JHub and the MoD on how these techniques could be used for other applications and they discussed potential for funding. Once the podcast is broadcast then additional interest is expected.
Year(s) Of Engagement Activity 2018
URL https://www.gov.uk/government/organisations/jhub-defence-innovation
 
Description Poster presentation at the BPS DHP Conference, 6th September 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Talk titled "Information about Drinking in Ex-serving Personnel (InDEx): Development of a mobile based alcohol intervention.". JP presented a poster on the InDEx intervention and there was much interest from academics in the study and she was awarded the poster prize for this work.
Year(s) Of Engagement Activity 2017
 
Description Poster presentation at the UKSBM Conference, 13th December 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Talk titled "Development of a bank of personalised and tailored text messages to provide Information about Drinking for Ex-serving personnel (InDEx)." JP presented on the development of the bank of text messages and this facilitated discussion and potential collaborations with other academics interested in using text messaging in interventions.
Year(s) Of Engagement Activity 2017
 
Description Poster presentation at the University of Liverpool PGR Conference 2019 on the Drinking motivations in UK serving and ex-serving military personnel. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact Poster presentation on the research investigating drinking motivations in UK military personnel, resulted in enquiries from other postgraduate students and academics working at University of Liverpool and the development of new networks of academics working in related areas.
Year(s) Of Engagement Activity 2019
 
Description Poster presentations at the Division of Health Psychology conference in 2019 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Poster presentations on the acceptability of the InDEx intervention and on the linked work in understanding drinking motivations in military personnel and how we should best intervene gained a lot of interest from the conference attendees. This dissemination resulted in the development of networks with Health Psychologists working within the British Army and with the Royal Air Force in planning for future studies in testing the alcohol intervention.
Year(s) Of Engagement Activity 2019
URL https://www.bps.org.uk/events/division-health-psychology-annual-conference-2019
 
Description Presentation at Defence and Security Equipment International (DSEI) 2019 conference on Medical Innovation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presentation at national Defence conference which resulted in enquiries about the alcohol intervention and the technology behind the digital intervention. Links and networks were developed in developing digital technologies for veterans.
Year(s) Of Engagement Activity 2019
URL https://www.dsei.co.uk/speakers?&azletter=L&searchgroup=00000001-speakers
 
Description Presentation at Forces in Mind Trust conference in October 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Presentation at the Forces in Mind trust charities research conference, titled "InDEx: Managing alcohol misuse by automation" on the 11/10/2018". This has led to discussion with FiMT about possible funding for a study delivering the app to veterans seeking treatment for their mental health through Combat Stress.
Year(s) Of Engagement Activity 2018
URL https://www.fim-trust.org/
 
Description Presentation at Institute of Psychiatry, Psychology and Neuroscience (London). 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The lead researcher on this study presented on the development of the intervention, both on the psychological and technical side of the app development. Following the presentation there have been a number of enquiries regarding the technical side of the intervention.
Year(s) Of Engagement Activity 2017
 
Description Presentation at KCL eHealth Working Group - March 19 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Presentation at the KCL eHealth Working Group on "The use of digital technology in the Armed Forces Community" - 13/03/2019.
Attendees evidenced an interest in the approach used to personalisation and the examples of how techniques such as machine learning can be used to improve the acceptability of e health interventions.
Year(s) Of Engagement Activity 2019
 
Description Presentation at King's College London as part of the King's Centre for Military Health Research and University of Southern California collaborative symposium 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Symposium organised between researchers and PhD students at King's College London and the University of Southern California to facilitate future collaborative projects. Discussions at the event have resulted in the development of ideas for other digital health projects in the area of veterans health.
Year(s) Of Engagement Activity 2019
 
Description Presentation at a computer science conference about using machine learning 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Industry/Business
Results and Impact Presentation at RE:Work Deep Learning conference on "InDEx: Managing alcohol misuse by automation" - 20/09/2018".
Invited presentation to discuss the app development and the technical approaches that have been used. There was interest from the audience, including industry and academics on the unique aspects of how we have used technology in a health intervention.
Year(s) Of Engagement Activity 2018
URL https://www.re-work.co/events/deep-learning-in-healthcare-summit-london-2018/speakers/daniel-leightl...
 
Description Presentation at the KCL Veterans' conference in London 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Presentation on the alcohol intervention resulted in the development of new networks and organisations interested in getting access to the intervention for their clients when it is on general release.
Year(s) Of Engagement Activity 2019
URL https://www.kcmhr.org/vmhc2019/index.html
 
Description Presentation at the University of Liverpool 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The Principal Investigator for this study presented on the development of this intervention to academics at the Institute of Psychology, Health and Society at the University of Liverpool. The presentation resulted in discussion regarding both the content and development of the intervention and the audience commented that the intervention seemed to be strongly driven by theory and research by the study team. Researchers from Liverpool have requested further information on the content of the intervention.
Year(s) Of Engagement Activity 2016
 
Description Presentation on InDEx at European Health Psychology conference in Galway 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation at the European Health Psychology Society conference in August 2018 in Galway, at an interesting symposium around mobile health and electronic interventions. There was a lot of interest and high attendance at the symposium with many questions regarding the personalisation aspects of the application.
Year(s) Of Engagement Activity 2018
URL http://2018.ehps.net/
 
Description Public engagement event held in London 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact A public engagement event was held with representatives invited from the Ministry of Defence, NHS England, third sector organisations (Forces in Mind Trust, Centre for Mental Health, Walking with the Wounded, Combat Stress) to disseminate the findings of the study and further information about the InDEx intervention. There was interest from many of the organisations about how they may be able to use the intervention with their clients.
Year(s) Of Engagement Activity 2018
URL https://index-app.org/
 
Description Public lay summary booklet produced and disseminated 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact A lay summary booklet was produced describing the findings of the study and the content of the InDEx intervention and this was disseminated at our public engagement event in January. The booklet has also been included on our study website so it can be downloaded by the general public.
Year(s) Of Engagement Activity 2018
URL https://index-app.org/
 
Description Research seminar open to the public at KCL 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Presentation in the department of Psychological Medicine at KCL which is open to the public on "InDEx: Using technology to automate alcohol management in veterans" - 11/02/2019;
There are queries from the audience around the value of using techniques such as machine learning for personalisation and about how we had used a rule based approach in the current study.
Year(s) Of Engagement Activity 2019
 
Description Steering group meetings with representation from third sector organisations 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Steering group meetings were held every 3 months as part of this project to get input from the project partners who were the Royal British Legion and Alcohol Research UK. These organisations provided input on the development of the intervention and provided advice and guidance to support participant recruitment.
Year(s) Of Engagement Activity 2016,2017
 
Description Talk - presentation at the 13th UKSBM Annual Scientific Meeting, Liverpool, December 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact LG presented on the findings of the feasiblity study of InDEx and there was interest in both the content and development of the study and the finding that adherence to the study was high.
Year(s) Of Engagement Activity 2017
URL http://www.uksbm.org.uk/liverpool-2017-annual-scientific-meeting/
 
Description Talk - presentation at the 4th Annual Conference - Behaviour Change for Health: Digital & Beyond, London, 2018. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact There was real interest from the audience in the intervention, how we had used text messaging to personalise the intervention and how we had considered mental health as important to alcohol as an outcome. There was also interest and compliments from the audience on the fact that we have made the source code open access and there was active discussion of this on twitter and that this evidences exemplary practice to be followed by future intervention studies.
Year(s) Of Engagement Activity 2018
URL http://www.ucl.ac.uk/behaviour-change/cbc-events/conf-2018
 
Description Talk at Defence Mental Health Services conference (England). 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact There was interest at the conference in the intervention we are developing from the Defence Medical Services, which covers all three services in Great Britain. The intervention is currently being administered to ex-serving personnel but the Surgeon General for Defence Medical Services has asked for further information on this study in order to consider plans to roll this out for serving personnel, which would mean that the intervention would reach a large population.
Year(s) Of Engagement Activity 2016
 
Description Talk at University of Liverpool open day about the project 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Schools
Results and Impact LG presented on the InDEx intervention at the University of Liverpool open day, which was attended by college students and their families. There was interest in the work and many of the audience members came to discuss the project further after the presentation.
Year(s) Of Engagement Activity 2018