Acceptability and Feasibility of a Mobile Health Intervention Grounded in Behavioral Economics to Reduce Alcohol Use and Improve Health in Rural-Dwelling Adults with At-Risk Alcohol Use

Abstract

At-risk alcohol use is associated with increased likelihood of adverse health consequences, yet it is undertreated in healthcare settings. Rural populations need improved access to early intervention services for at-risk use; however, very few interventions are tailored to meet the needs of rural individuals. Mobile interventions can provide feasible, low-cost, and scalable means for reaching rural adults. This pilot randomized factorial trial evaluated acceptability and feasibility of a mobile behavioral economic intervention for rural-residing adults with at-risk alcohol use. Rural-dwelling participants (i.e. RUCA Category E rural designation and/or residing in a CMS Rural Health Clinic Program) with at-risk alcohol use (i.e. AUDIT-C of >=3/>=4 females/males) were recruited from a large healthcare system and randomized into one of three active conditions: episodic future thinking (EFT; envisioning future events), volitional choice (VC; alternative behaviors), both EFT and VC, or enhanced usual care (EUC). All active conditions included a phone-based induction session to collaboratively develop personalized cues followed by two weeks of twice-daily ecological momentary interventions (EMIs) of cues and a daily ecological momentary assessment (EMA) that included prior day alcohol use. Participants completed measures of alcohol consumption at baseline, post-intervention, and 2-month post-baseline follow-up, in addition to focus testing. Of the 340 potential participants screened, 135 (39.7%) were eligible for the trial, and 75 randomized participants (N=75; 62.7% female, mean age=55.2 years, SD=15.9) completed the induction session. Average EMA completion rates across conditions was 93.0%. Retention was high: 97.3% completed post-intervention, and 93.3% completed follow-up. At focus testing, most participants (86.3%) said they recommend this study, and 69.9% reported the study influenced their future drinking behaviors. Of the participants in active conditions, 89.3% (EFT=88.2%, VC=89.5%, EFT/VC=89.5%) reported finding the induction session to be at least 'a little helpful', and 89.1% found the EMIs at least 'a little helpful'. Participants' qualitative feedback noted intervention strengths such as high accessibility and person-centeredness and areas for improvement such as increasing flexibility of EMI development and delivery windows. The behavioral economic intervention components evaluated here appear to be feasible and acceptable. Preliminary findings suggest the potential of these mobile-delivered strategies to reduce the progression of risky alcohol use. Next steps include evaluation of the efficacy to reduce alcohol use and public health harms.