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The feasibility of assessing alcohol use among college students using wireless mobile devices: Implications for health education and behavioural research Darren Mays, Jennifer Cremeens, Stuart Usdan, Ryan J Martin, Kimberly J Arriola and Jay M Bernhardt Health Education Journal 2010 69: 311 originally published online 4 May 2010 DOI: 10.1177/0017896910364831 The online version of this article can be found at: http://hej.sagepub.com/content/69/3/311

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Article

The feasibility of assessing alcohol use among college students using wireless mobile devices: Implications for health education and behavioural research

Health Education Journal 69(3) 311–320 © The Author(s) 2010 Reprints and permission: sagepub. co.uk/journalsPermissions.nav DOI: 10.1177/0017896910364831 http://hej.sagepub.com

Darren Maysa, b, Jennifer Cremeensc, Stuart Usdand, Ryan J Martine, Kimberly J Arriolaa and Jay M Bernhardtb a

Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, USA National Center for Health Marketing, Centers for Disease Control and Prevention Public Health, USA c Department of Health Education and Promotion, East Carolina University, USA d Department of Health Science, University of Alabama, USA e Thomas Cummings Fellow, Division on Addictions, Medford, MA, USA b

Abstract Objective:  This study examined the feasibility of using wireless mobile devices (MDs) to collect daily alcohol information among college students, in particular examining feasibility in the context of costs associated with the use of wireless MDs.This study reports on practical aspects of using MDs to collect alcohol data, including compliance, technical success, user preferences for completing MD-based assessments, and cost. Setting:  The study took place at a large, public university in the south-eastern United States. Design:  A two-group, randomized design was used. A daily assessment of alcohol use administered using wireless MDs was completed by a group of college students (n=86) for 30 days and compared to a paperbased (PB) daily assessment of alcohol use completed by a second group of college students (n=83) over the same time period. Results:  Completion rates for the MD assessment (85.8 per cent) were comparable to the PB assessment (97.6 per cent) given the differences in mode of administration. Participants found the MDs easy to use (83.7 per cent), easy to read (94.2 per cent), and on average liked completing the daily MD assessment (M 4.47, SD 1.16) significantly more than respondents liked completing the PB assessment (M 3.88, SD 1.08; t [164] 3.84, p < 0.001). Few participants in the MD group reported that they were uncomfortable (9.3 per cent) or nervous (2.3 per cent) completing daily assessments using the MDs. Conclusion:  Results indicate that the feasibility of using MDs for data collection may be influenced by user preferences and should be tested on different health behaviours in more diverse populations.

Keywords alcohol use, data collection, mobile devices, wireless Corresponding author: Darren Mays, PhD, MPH, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 557, Atlanta, GA 30322, USA Email: [email protected]

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Introduction Mobile technologies such as hand-held computers and smart phones are utilized for many purposes in medicine and public health, ranging from administrative tasks and clinical decision support to medical education and data collection1–4. From a research perspective, data collection with such technology has numerous advantages over traditional methods, including the elimination of data entry and the ability to elicit more accurate data for sensitive behaviours5–7. Compared to paper and pencil assessments, computing technology may reduce time needed for data entry, decrease missing data, more easily accommodate skip patterns, and provide better estimates of compliance by constraining research participants to complete assessments according to instructions8–10. Wireless mobile devices (MD) with the capability to transmit data, such as mobile phones, smart phones, and hand-held computers allow for data collection in the field and in real time using methods such as ecological momentary assessment (EMA) or daily monitoring11–14. The ability of MDs to collect real-time data also allow for the delivery of ‘just in time’ interventions15,16. There is accumulating evidence for the use of wireless MDs for interventions seeking to impact behaviours such as alcohol use17, physical activity18–20, diet16, smoking21,22, and sexual health23. The constantly improving technology of recent MDs also provides health educators with the means to deliver more diverse intervention messages, beyond the relatively simple text messages such as those used in previous intervention studies17,18,21. Yet, MDs come with a cost, ranging from approximately US$100 to US$500 or more per unit depending on the capabilities and features of the device, plus additional charges for programming and wireless data services, which may limit some health educators from considering their application. With more people utilizing wireless MDs in their daily lives (e.g. smart phones, portable digital assistants, and mobile phones), MDs are becoming an increasingly important tool for research and intervention. The wireless capabilities of MDs, however, have been underutilized in health education research and in particular in research related to alcohol use. While a number of studies have used MDs to collect data on alcohol use24–28, these studies have not utilized the wireless capabilities of MDs, and the feasibility of using wireless MDs to collect daily data on alcohol use has not been previously reported. The objective of this study was to examine the feasibility of the use of MDs to collect alcohol data among college students and to consider these results in the context of the costs associated with the use of MDs. In order to do so, the Handheld Assisted Network Diary (HAND)17, 25 , a daily alcohol assessment administered using MDs, was compared to a daily paper-based (PB) form of the daily social monitoring log (DSML)29, comprised of the same questions as the HAND.

Method Procedures A pre-test, post-test, randomized controlled design was used to examine the use of the MD-based HAND to assess alcohol use among college students at a large, public, university in the southeastern United States. The study procedures are described in detail elsewhere30. Briefly, a convenience sample of college students was recruited and students were randomly assigned to complete a daily assessment of their drinking using either the MD-based HAND17,25 or the daily PB assessment of alcohol use, a form of the DSML29. Participants completed baseline measures and were given an MD or PB assessment with instructions. Participants were asked to complete the daily MD or PB assessment for 30 days and to return the assessment and complete follow-up measures at a meeting on campus. At follow-up, participants were provided with up to US$100 compensation for their time. The characteristics of the sample are displayed in Table 1.

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Mays et al. Table 1.  Sample characteristics Demographics

Gender    Female    Male    Other/missing Race   White    Black/African American    Other/Missing Housing    Residence Hall    House/Apartment    Fraternity/Sorority    Other/Missing Live With    Alone    Room-mates    Other/Missing Alcohol Use Baseline TLFB    Drinking days    Drinks/Drinking Day PB assessment    Drinking days    Drinks/Drinking Day MD assessment    Drinking days    Drinks/Drinking Day Follow-up TLFB    Drinking days    Drinks/Drinking Day

MD Group

PB Group

n

%

n

%

43 42  1

50% 48% 1.2%

40 41  2

48% 49%   2%

66  7 13

77%   8% 15%

64  8 11

77% 10% 13%

55 28  2  1

64% 32%   2%   1%

60 17  4  2

73% 21%   5%   1%

 7 70  9

  8% 81% 10%

 9 66  8

11% 80%   9%

n

Mean (SD)

n

Mean (SD)

86 86

5.93 (3.22) 5.77 (2.87)

83 83

5.89 (3.29) 4.87 (3.02)

– –

– –

83 83

8.31 (4.59) 5.24 (3.09)

86 86

8.84 (4.80) 5.87 (2.91)

– –

– –

86 86

8.65 (4.80) 5.74 (2.88)

83 83

7.71 (4.77) 5.13 (3.42)

MD: mobile device (assessment) (n = 86), PB: paper-based (assessment) (n = 83),TLFB: timeline follow back (assessment).

The HAND assessment was designed using Entryware™ Designer software developed by Techneos Systems, Inc. (Vancouver, British Columbia, Canada). The MDs, Palm™ Tungsten W smart phones, were enabled to wirelessly transmit data to a secure, web-based data server after each assessment was completed, which could then be accessed by study personnel. If the MD was unable to connect to the server, the data were saved in the MD until a successful synchronization occurred. A series of reminders were also built into the MD assessments. Participants set daily alarm times for weekdays and weekends and were given the option to change the reminder times each time they completed the assessment. Participants who did not complete the daily MD assessment by 12:00 p.m. each day were sent an automated, pre-written email reminding them to complete the assessment. Participants who still had not completed the MD assessment by 17:00 p.m. each day received an automated, pre-recorded phone call reminder.

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Measures Baseline measures included the Timeline Follow Back (TLFB), a valid retrospective assessment of alcohol use31, and other assessments of alcohol use. To complete the TLFB, respondents were provided with a calendar spanning the previous 30 days and were asked to report how many standard drinks they consumed on each day. The daily MD and PB assessments assessed whether participants consumed alcohol during the previous day, between when they woke up and when they went to sleep, and if so how many standard drinks were consumed. Standard drinks were defined on all assessments as 12 oz of beer, 5 oz of wine or champagne, 3 oz of fortified wine, or 1.5 oz of hard liquor. All participants completed paper and pencil follow-up assessments after 30 days, which included the same assessments administered at baseline. In addition, follow-up questions assessed participants’ compliance in completing the daily assessment, preferences about using the MD and PB assessment (five questions), the reminders they received over the course of the study, and the technical support received over the course of the study (for participants in the MD group only). Responses were based on five-point, Likert-type scales. A technical support log was also kept by study staff to track support contacts with MD group participants.

Analyses Data were analysed using SAS 9.2 (SAS Institute, Inc., Cary, North Carolina, USA). The primary analyses were tests for differences in means between the MD and PB groups regarding preferences for the study assessments. To reduce the probability of a type I error, an adjusted alpha level of 0.01 was used for statistical significance based on a standard Bonferroni correction.

Results Compliance The mean number of completed MD assessments was 25.8 (SD 5.9), with an average completion rate of 85.8 per cent (SD 19.6). A small portion of MD participants indicated that they accidentally entered incorrect information (13.8 per cent) or accidentally skipped a question (14.9 per cent). Only one participant (1.2 per cent) reported at follow-up intentionally entering incorrect information on the MD assessment that could not be corrected (the design of the MD-based HAND prevented participants from changing the assessments after they were submitted). The mean number of completed PB assessments was 29.3 (SD 0.91), with an average completion rate of 97.6 per cent (SD 3.0). Nearly half (48.2 per cent) of PB participants indicated that they accidentally entered incorrect information, and approximately one in every four participants (25.3 per cent) reported intentionally skipping a question on the PB assessment. One participant (1.2 per cent) reported at follow-up that he or she intentionally entered incorrect information on the PB assessment that he or she did not correct. The majority of PB participants (63.8 per cent) indicated they skipped an assessment and filled it out later.

Technical success The majority of MD participants (85.0 per cent) indicated that they encountered challenges completing the daily assessment. MD participants reported that they contacted staff an average of 3.61 (SD 1.99) times for technical support. Study staff technical support records show that MD received

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on average 0.61 (SD 0.79) contacts via email and 1.86 (SD 1.33) contacts by phone. Of those who contacted study staff for technical support (n = 73), 95.9 per cent (n = 70) indicated that the technical support they received was somewhat helpful or very helpful. Nearly all MD participants (94.2 per cent) indicated receiving some type of reminder to complete their daily assessments. The majority of MD participants (83.9 per cent) reported receiving both email and phone reminders during the study, while few reported receiving only phone (6.9 per cent) or only email (4.6 per cent) reminders. Many MD participants reported that phone reminders were most helpful in prompting them to complete the assessment that day (44.8 per cent), while a third of participants (33.3 per cent) indicated that email reminders were most helpful, and 6.9 per cent indicated both reminder types were helpful.

Usability preferences The usability preferences reported by respondents in the MD and PB groups are displayed in Table 2. Most MD participants agreed or strongly agreed that the MD assessment was easy to complete (83.7 per cent; M 4.28 [SD 1.06]), easy to read (94.2 per cent; M 4.79 [SD 0.60]), and liked using the MD to complete daily alcohol assessments (88.3 per cent; M 4.47 [SD 0.98]). The majority of participants were comfortable using the MDs (84.9 per cent; M 4.42 [SD 1.16]) and were not nervous completing the MD-based assessment (93.0 per cent; M 4.79 [SD 0.60]). Similar patterns were also observed among the PB participants (Table 2). The only mean that differed significantly between the two groups was on the item assessing whether participants liked using the MD and PB assessments. The mean among MD participants was significantly greater than PB participants (t [164] = 3.84, p < 0.001), indicating that on average, participants liked completing the MD assessment more than the PB assessment.

Cost The cost to administer daily assessments on alcohol use among college students for 30 days was approximated based on the cost to implement the present study. Approximate costs for each MD included an average device cost of US$250 and US$70 per MD for wireless data service. Study staff included two graduate assistants who worked on average 20 h per week during the 1 month data collection period at US$12/h, which amounts to approximately US$22 per device (US$1920 total for 86 devices). The total cost incurred per MD participant was approximately US$344. The total cost per MD assessment was approximately US$11.47 ([US$344 x 86 participants]/2580 possible assessments). The approximate cost to implement the PB assessment includes US$3 per packet of assessments (approximately 30 pages at US$0.10 per page) and US$46 per PB assessment for data entry and cleaning, accounting for two graduate assistants working 20 h a week for 2 months at a rate of US$12/h (US$3840 in total for 83 participants). The total cost per PB assessment was US$1.63 ([US$49 x 83 participants]/2490 possible assessments).

Discussion This study examined the feasibility of using wireless MDs to assess alcohol use among college students for 30 days. The results suggest that participants found the MDs easy to use and easy to read, and liked completing the daily MD assessments. Completion rates for the MD assessments were comparable to those of the PB group, considering the follow-up compliance data. The

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0% – 0% –

7.0% (n = 6) 4.8% (n = 4)

67.4% (n = 58) 31.3% (n = 26)

84.9% (n = 73) 74.7% (n = 62)

57.0% (n = 49) 68.7% (n = 57)

2.3% (n = 2) 1.2% (n = 1)

2.3% (n = 2) 2.4% (n = 2)

20.9% (n = 18) 31.3% (n = 26)

9.3% (n = 8) 19.3% (n = 16)

26.7% (n = 23) 21.6% (n = 18)

2.3% (n = 2) 7.2% (n = 6)

4.7% (n = 4) 9.6% (n = 8)

3.5% (n = 3) 26.5% (n = 22)

2.3% (n = 2) 3.6% (n = 3)

3.5% (n = 3) 7.2% (n = 6)

b

Row percentages do not add to 100% because some participants were missing data. Satterthwaite’s t-test was used because equality of variances assumption was not met. c Bonferroni correction was applied and p values < 0.01 were considered statistically significant. MD: mobile device (assessment) (n = 86), PB: paper-based (assessment) (n = 83).

a

   MD Group    PB Group

Assessment made me nervous

   MD Group    PB Group

Uncomfortable using the assessment

   MD Group    PB Group

Liked using the assessment

   MD Group    PB Group

Easy to read the assessment

   MD Group    PB Group

Easy to complete the assessmentb

Strongly Agree Slightly Agree Neutral

Table 2.  Preferences for completing daily assessmentsa

9.3% (n = 8) 20.5% (n = 21)

12.8% (n = 11) 25.3% (n = 21)

3.5% (n = 3) 4.8% (n = 4)

2.3% (n = 2) 0% –

9.3% (n = 8) 0% –

Slightly Disagree

83.7% (n = 72) 67.5% (n = 56)

72.1% (n = 62) 54.2% (n = 45)

3.5% (n = 3) 2.4% (n = 2)

0% – 0% –

2.3% (n = 2) 0% –

4.79 (0.60) 4.60 (0.69)

4.42 (1.16) 4.26 (1.08)

4.47 (0.98) 3.88 (1.01)

4.79 (0.60) 4.69 (0.66)

4.28 (1.06) 4.63 (0.62)

t [164] = -1.84, p = 0.07

t [164] = -0.92, p = 0.35

t [164] = -3.84, p < 0.001

t [164] = -0.99, p = 0.32

t [164] = 2.58, p = 0.02

Strongly Disagree Mean (SD) t-statisticc

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findings are consistent with those reported by Bernhardt and others11 using MDs to assess alcohol use among a similar sample of college students. While participants using MDs reported encountering some technical difficulties, the findings indicate that technical problems did not have a major influence on completion rates of the MD assessments. The MD had a comparable completion rate to the PB, particularly given that the majority of PB group participants indicated they completed at least one assessment after that day had passed. The design of the MD prevented participants from completing the daily assessments retrospectively. These results are consistent with previous research suggesting that for clinical data collection, paper-based assessments generally have higher completion rates than MDs9. This study also used first-generation wireless MDs; newer devices have improved wireless capabilities and mobile networks are also regularly improving. If similar studies use more recent technology, these improvements may help reduce technical difficulties experienced by participants. The findings also suggest that the use of MDs for behavioural assessment may have two advantages in particular over traditional paper and pencil methods: participants liked using the MDs and were very comfortable using the technology. On average, MD group participants liked using the MDs more than PB group participants, and the majority of participants also reported that the MDs were easy to use, easy to read, and they were comfortable using the devices. These findings indicate that the feasibility of using wireless MDs to administer daily assessments of health behaviours may be influenced by the preferences of the target population towards the technology. Further research is needed to fully examine the assessment and intervention capabilities of MDs, especially to investigate differences in efficacy for assessment and intervention based on users’ preferences and attitudes towards such technology (i.e. preferences and attitudes as moderating variables). Overall, the total cost per participant and per assessment administered using the MD was substantially higher than the PB group. After taking into account the initial cost to purchase the MDs, however, the cost per MD participant and per MD assessment administered was only approximately twice that of the cost per PB participant and per PB assessment. Furthermore, the costs from this study also imply that if MDs are applied over a longer time period the costs may be more comparable to the PB assessments. The major cost for the PB data was for data entry and cleaning, and this cost would increase if more PB data were collected. In contrast, the cost for MDs would remain relatively stable with the exception of potential changes in rates for mobile services and replacement or repair of devices. Future studies are needed to compare the costs to implement assessments using MD technology over longer study periods to confirm this finding. More precise data regarding costs including the elements not included in the present analysis would also be informative (e.g. costs for utilities to charge devices and other overhead costs). MDs have been applied in research related to numerous different health behaviours17,25,32,33; however, few studies have utilized the wireless capabilities of MDs to deliver health education interventions17,18,21,34. Limited evidence suggests that the use of MDs to deliver theory-based, individually tailored, intervention messages is effective in reducing drinking and related negative consequences among college students17, and this may be a useful approach to improving other health behaviours such as physical activity18 and smoking21. The studies examining the efficacy of MD-based interventions, however, have been primarily limited to small, convenience samples17,18,21 and have consisted of a single intervention component (e.g. text messaging). While this body of evidence suggests that it may be feasible to use wireless mobile technology for health behaviour assessment and health education interventions, effectiveness studies are needed to demonstrate the assessment and intervention capabilities of wireless technology in larger, more diverse populations. Future studies should also include more detailed cost–benefit analyses of the application of such technology for health education interventions. If the use of mobile technology for behavioural assessment and intervention can have a greater effect on targeted health behaviours

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compared to more traditional methods, it may be worth the additional cost to apply methods that are driven by MDs. As a health education tool, wireless MDs offer advantages that may be useful for more timesensitive assessment and interventions and the potential to deliver timely interventions seeking to address health behaviours. Furthermore, the constantly improving technology of MDs can also provide a means to deliver more diverse intervention messages beyond the relatively simple text messages used in previous intervention studies17,18,21. Newer MDs (e.g. iPhone™, BlackBerry™) have enhanced media capabilities that may allow for the delivery of intervention messages that are interactive and incorporate multiple media including text, audio, and video, and web-based content. As the capabilities of MDs are enhanced, the utility of these devices for delivering health education interventions also appears to be increasing. Health educators should carefully consider the security of MDs as well. MDs are capable of securely transmitting data; however, security features are not necessarily standard in these devices and it is the responsibility of the health educator to ensure that information security standards are met35. Security measures available for most hand-held devices include password protection, encryption of data, data removal, authentication, and virus protection35. Despite such measures, hand-held devices are vulnerable to assaults in ways similar to desktop and laptop computers, such as virus attacks36. The results from this study should be considered in light of several limitations. This study was conducted with a moderately sized convenience sample of college students who reported drinking on at least two occasions per week. As a result, the findings may have limited generalizability. All behaviours assessed were based on self-report, and the results are susceptible to bias. While research suggests that self-reported alcohol use behaviours are reliable37, the results presented should be interpreted with this limitation in mind. Finally, while the findings suggest that technical difficulties did not affect the completion rates of the MDs, the results should be interpreted in light of technical problems that occurred during the study and the possible impact of technical problems on completion rates.

Conclusions MDs have been used to assess numerous health behaviours, and have proven to be a valid method of behavioural assessment in a number of health behaviour areas compared to traditional methods. However, few studies have utilized the wireless capabilities of MDs for behavioural assessment. The findings suggest that wireless MDs represent a promising tool for behavioural assessment and health education intervention. Future research should examine the use of wireless MD technology among diverse study populations and health behaviours. The MDs used in this study were well received and found to be usable by participants, perhaps further enhancing the feasibility of using the MDs for alcohol assessment. The improving data and media capabilities of newer MDs may provide researchers with a means to provide portable, multimedia health education interventions. However, these capabilities remain largely untested. Acknowledgments The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention (CDC). This research was supported by grant number 5R21AA013969-03 from the National Institute on Alcohol Abuse and Alcoholism. The preparation of this manuscript was supported in part by an appointment to the Research Participation Program for the CDC administered by the Oak Ridge Institute for Science and Education through an agreement between the Department of Energy and the CDC (author DM).

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