Doctoral Thesis
Refine
Document Type
- Doctoral Thesis (5) (remove)
Has Fulltext
- yes (5)
Is part of the Bibliography
- no (5)
Keywords
- alcohol (5) (remove)
Background: Common to most theory-based intervention approaches is the idea of supporting intentions to increase the probability of behavior change. This principle works only if (a) intentions can be explained by the hypothesized socio-cognitive constructs, and (b) people actually do what they intend to do. The overall aim of this thesis was to test these premises using two health behavior theories applied to reducing at-risk alcohol use. Method: The three papers underlying this thesis were based on data of the randomized controlled “Trial Of Proactive Alcohol interventions among job-Seekers” (TOPAS). A total of 1243 job-seekers with at-risk alcohol use were randomized to stage tailored intervention (ST), non-stage tailored intervention (NST), or control group. The ST participants (n = 426) were analyzed in paper 1. Paper 2 was based on the baseline and 3-month data provided by the NST participants (n = 433). Paper 3 was based on baseline, 3-, 6-, and 15-month data provided by the control and ST group not intending to change alcohol use (n = 629). Latent variable modeling was used to investigate the associations of social-cognitive constructs and intentional stages (paper 1), the extent to which intentions were translated into alcohol use (paper 2), and the different trajectories of alcohol use among people not intending to change as well as the ST effect on the trajectories (paper 3). Results: Persons in different intentional stages differed in the processes of change in which they engaged, in the importance placed by them on the pros and cons of alcohol use, and in the perceived ability to quit (ps < 0.01). The association between intentions and alcohol use was weak. The magnitude of this intention-behavior gap depended on the extent to which normative expectations have changed over time (p < 0.01) and was reduced when controlling for the mediating effect of temporal stability of intentions. The gap was also present among people not intending to change: Even without intervention, 35% of the persons reduced the amount of alcohol use after 15 months (p < 0.05) and 2% achieved abstinence. Persons with heavier drinking (33%) and persons with low but frequent use (30%) did not change. Persons with frequent alcohol use seem to benefit less from ST than those with occasional use, although differences were not statistically significant. Conclusions: Intentions can be quite well explained by the hypothesized socio-cognitive constructs. In a sample of persons who were, as a whole, little motivated to change, the precision of how well intentions predict subsequent alcohol use was modest though. Time and socio-contextual influences should be considered.
Alcohol-related somatic disorders are highly prevalent among general hospital inpatients. Alcohol problem drinking can be differentiated into alcohol use disorders (alcohol dependence and alcohol abuse) and three subtypes of drinking above recommended levels (at-risk drinking only [AR], heavy episodic drinking only [HE], at-risk and heavy episodic drinking [ARHE]). The aims of this study were threefold. First, proportions of alcohol problem drinking among general hospital inpatients in a region of north-eastern Germany were estimated (study 1). Second, among individuals with alcohol problem drinking the association between beverage preference and alcohol-related diseases was tested (study 2). Third, subtype differences regarding demographics, alcohol-related variables, motivation to change drinking behaviors, and the risk to develop short-term alcohol dependence among the three subtypes of drinking above recommended levels were analyzed (study 3). The data presented in this dissertation are based on the randomized controlled trial “Early Intervention at General Hospitals”, which is part of the Research Collaboration Early Substance Use Intervention (EARLINT). Study 1 includes a sample of consecutively admitted general hospital inpatients between 18 and 64 years old (n = 14,332). The study adopted a two-stage-sampling approach: (a) screening and (b) ascertainment of alcohol problem drinking. Those who were identified with alcohol problem drinking were asked for written consent for further study participation. This included further baseline assessment, the consent to use routine treatment diagnoses and participation in a follow-up interview 12 months after hospitalization. For study 2, routine treatment diagnoses were provided by hospital physicians for a total of 1,011 men with problem drinking. These diagnoses were classified into three categories according to their alcohol-attributable fractions (AAF): diseases totally attributable to alcohol by definition (AAF=1), diseases partially attributable to alcohol (AAF<1) and diseases with no empirical relationship to alcohol or with a possibly protective effect associated with alcohol (AAF=0). Study 3 was restricted to study participants with drinking above recommended levels (n=425). Study 1: Among all general hospital inpatients, 8.9% were identified with current problem drinking in the following descending order: 5.3% exhibited alcohol use disorders and 3.6% drinking above recommended levels. Higher proportions of problem drinking were found at rural sites compared to urban sites (13.7 vs. 7.5%, p<.001). Study 2: Because of the low proportion of women with alcohol problem drinking the following analyses were restricted to males. Multinomial regression analyses revealed different risks for alcohol-related diseases in relation to beverage preference while controlling for alcohol-associated and demographic confounders. Compared to all other groups, spirits only drinkers had the highest risk for having a disease with AAF>0; e.g., beer only drinkers had lower odds of having a disease with AAF<1 (odds ratio, OR=0.50, 95% confidence interval, CI: 0.27-0.92). Study 3: Men with alcohol use disorder were excluded from the following analysis. At baseline, multinomial logistic regression revealed differences between individuals with AR, HE and ARHE while controlling for age. ARHE was associated with higher odds of having a more severe alcohol problem (OR=2.06, CI: 1.23-3.45), using formal help (OR=2.21, CI: 1.02-4.79), and having a disease with AAF=1 (OR=3.43, CI: 1.58-7.43), compared with AR. In addition, individuals with ARHE had higher odds of taking action to change drinking behaviors (i.e., beginning to implement change) than individuals with HE (OR=2.29, CI: 1.21-4.34) or AR (OR=2.11, CI: 1.15-3.86). At follow-up, individuals with ARHE had higher odds of having alcohol dependence according to the DSM-IV (OR=4.73, CI: 1.01–22.20) compared to individuals with AR. In addition to alcohol use disorders, drinking above recommended levels is a common problem among general hospital inpatients. Thus, the implementation of systematic alcohol screening and brief interventions should be considered. These data suggest an association between beverage preference and alcohol-related diseases. Among hospitalized problem drinkers, spirits only drinkers had the greatest risk of having diseases with AAF>0. Of the three subtypes of drinking above recommended levels, ARHE seems to be particularly problematic because there appears to be an indication of a subclinical diagnosis. To provide adequate intervention, clinical practice should distinguish between the three groups of drinking above recommended levels. Brief alcohol intervention should be tailored to the individual’s motivation to change and to the type of alcohol problem drinking. The effectiveness of such a procedure remains to be evaluated in further studies.
Background: Depressive disorders are highly prevalent and disabling diseases. Epidemiological studies have shown that they often co-occur with addictive behaviors, which in part might be explained by common risk factors. Rumination might be such a risk factor. Comorbidity can have substantial adverse effects for those affected. Thus, combined treatment approaches are needed. These should not be restricted to individuals with clinical disorders. In light of an apparent treatment gap, new treatment approaches that provide widespread access to evidence-based treatments need to be explored. In recent years, e-health interventions received a lot of attention. With their potential to be widely disseminated, they might be suitable to provide population-based intervention approaches. Developing population-based interventions might present special challenges to intervention developers, for example, in terms of intervention design or the selection of samples to preliminary test interventions. This thesis explored the application of e-health interventions in the treatment and prevention of depressive symptoms and addictive behaviors. Its first aim was to provide an overview on publicly accessible evidence-based e-health interventions for the treatment and prevention of depressive symptoms (study 1). The second aim was to test the feasibility, acceptability and potential effectiveness of a newly developed computer-based expert system intervention simultaneously targeting hazardous alcohol consumption and depressive symptoms and to investigate the importance of the sample selection when preliminary testing interventions (study 2). The third aim was to further investigate rumination with its subfactors brooding and reflection as a common cause of depression and addictive behaviors and thus as a potential target for combined interventions by analyzing its associations with symptoms of pathological gambling (SPGs; study 3).
Methods: This thesis provides a summary of different working steps in the process of developing and testing a computer-based intervention for health care patients (HCPs) with comorbid hazardous alcohol consumption patterns and depressive symptoms. In study 1, a systematic literature search was conducted to identify evidence-based e-health interventions for depressive symptoms. Interventions were considered for further inspection if studies provided evidence for at least small intervention effects and if the interventions were accessible to at least selected groups of individuals. For study 2, 2773 consecutive HCPs were screened for hazardous drinking and depressive symptoms. Of the 41 HCPs who were offered to participate in the study, 27 (65.9%) consented. To investigate the importance of the sample selection when preliminary testing interventions, HCPs were compared to media recruited volunteers (MVs). Over a period of 6 months, study participants received 6 individualized counselling letters and weekly short messages. Pre-post data were analyzed for 30 participants (15 HCPs, 15 MVs). Intervention acceptability was assessed in post-intervention interviews conducted with 32 study participants. In study 3, cross-sectional data of 506 (80.4% male) individuals aged 14 to 64 years with a history of gambling problems were analyzed. Associations between the rumination subfactors and SPGs across different levels of problem gambling severity were investigated by means of sequential quantile regression.
Results: In study 1, 37 publicly accessible evidence-based e-health interventions for depressive symptoms were identified. Most interventions (81.1%) were available in English. For the German language area, only 3 interventions were identified. In study 2, HCPs and MVs reduced regular binge drinking (HCPs: p = 0.016; MVs: p = 0.031) and depressiveness (HCPs: p = 0.020; MVs: p < 0.001). MVs further reduced average daily consumption (p = 0.034). Both subsamples rated the intervention positive. Compared to HCPs, MVs rated the alcohol module more favorably (p = 0.012). Intervention usage was higher in MVs than in HCPs (p = 0.013). Study 3 showed that at the median, ruminative brooding was positively associated with the severity of problem gambling after controlling for covariates (p = 0.005). Along the distribution of problem gambling severity, findings did hold for all but the lowest severity level. Ruminative reflection was not associated with problem gambling severity at the median (p = 0.347).
Conclusions: E-health interventions show great potential in the treatment and prevention of depressive symptoms and addictive behaviors. However, more research is needed to clarify how to make the most of this potential. Important questions that remain to be answered include, for example, how to best provide e-health interventions to those in need or how to design interventions in order to maximize their reach and thus their public health impact. This thesis showed that 1) publicly accessible evidence-based e-health interventions for depressive symptoms were available. However, the supply in the German language area was low. 2) The computer-based expert system intervention targeting hazardous alcohol consumption and depressive symptoms was technically and logistically feasible, acceptable, and may have the potential to reduce hazardous drinking and depressive symptoms in different populations, including populations unselected in terms of their motivation to change. To avoid biased conclusions about the potential of interventions, intervention developers should preliminary test interventions on intended target populations. 3) Rumination might be important in the development and maintenance of addictive behaviors. With its relations to depression and addictive behaviors, it should be considered as a target for future combined interventions.
Suchtprävention in der Grundschule - Effekte der Programme Eigenständig werden und Klasse2000
(2011)
Fragestellung: Anhand des Lebenskompetenzprogramms Eigenständig werden sowie des Suchtpräventions- und Gesundheitsförderungsprogramms Klasse2000 sollen die Effekte von Grundschulprogrammen sowohl auf Vorläufer des Einstiegs in den (problematischen) Substanzkonsum als auch auf das erste Experimentieren mit psychotropen Substanzen wie Zigaretten und Alkohol untersucht werden. Zusätzlich soll überprüft werden, inwieweit Klasse2000 aufgrund der angestrebten Korrektur rauchbezogener Normen zu iatrogenen Effekten in Form von Bullying sowie zu erwünschten Effekten in Form der Erhöhung der Resistenz gegenüber sozialen Einflüssen führt. Methodik: Eigenständig werden sowie Klasse2000 begleiten die Kinder über die gesamte Grundschulzeit. Eigenständig werden umfasst 42 45- bis 90-minütige Einheiten (10 pro Schuljahr), die durch trainierte Lehrkräfte im Unterricht umgesetzt werden. Für Klasse2000 existieren Ausarbeitungen für 48 45- bis 90-minütige Einheiten (14 bis 15 pro Schuljahr), deren Durchführung sowohl durch Lehrkräfte als auch durch Klasse2000-Gesundheitsförderer im schulischen Alltag erfolgt. Zu Eigenständig werden wurde eine vierjährige quasiexperimentelle Kontrollgruppenstudie mit Messwiederholung in Sachsen durchgeführt. Daten zur Baseline und zu mindestens einem weiteren Befragungszeitpunkt lagen für 919 Schüler aus 50 Grundschulen vor. Aufgeteilt auf die Bedingungen „Teilnahme an Eigenständig werden“ und „Keine Teilnahme an Eigenständig werden“ wurden die Schüler anhand von Lehrkrafturteilen zu der Ausprägung ihrer Lebenskompetenzen sowie ihrer externalisierenden und internalisierenden Verhaltensauffälligkeiten, die als Vorläufer des späteren Substanzkonsums identifiziert werden konnten, mittels Mehr-Ebenen-Wachstumskurvenmodellen verglichen. Zur Überprüfung der Programmeffekte von Klasse2000 wurde eine vierjährige Kontrollgruppenstudie mit Messwiederholung in Hessen realisiert. Während in Klassen der Interventionsgruppe das Präventionsprogramm Klasse2000 kontinuierlich über den Verlauf der Grundschulzeit umgesetzt wurde, nahmen Klassen der Kontrollgruppe „lediglich“ am normalen Unterricht teil. Zur Beantwortung der Fragestellung, inwieweit sich Klasse2000 auf den Einstieg in den Substanzkonsum auswirkt, wurden die Ende der dritten Klasse als Nie-Raucher (N=1.027), Nie-Trinker (N=1.072) und gleichzeitig als Nie-Raucher und Nie-Trinker (N=979) identifizierten Schüler am Ende der vierten Klasse hinsichtlich der Inzidenz des Substanzkonsums verglichen. Hierzu wurden multiple hierarchische Poisson-Regressionen unter Kontrolle soziodemographischer Charakteristika sowie sozialer Einflussfaktoren berechnet. In die Analysen der Programmeffekte auf Bullying sowie die Resistenz gegenüber sozialen Einflüssen gingen alle 1.096 Schüler, von denen Ende der dritten und vierten Klasse Daten vorlagen, mit ein. Die Auswertung erfolgte mittels deskriptiver Methoden und Regressionsverfahren. Ergebnisse: Die Teilnahme an Eigenständig werden führte im Vergleich zur Kontrollgruppe zu einer stärkeren Abnahme sowohl externalisierender als auch internalisierender Verhaltensauffälligkeiten (p<0,01). Eine besonders starke Abnahme konnte unter Schülern mit höheren Ausgangswerten hinsichtlich externalisierender Verhaltensauffälligkeiten beobachtet werden (p<0,01). Keine Programmeffekte ergaben sich hinsichtlich der Entwicklung von Lebenskompetenzen (p=0,22). Die Untersuchungen zu Klasse2000 ergaben signifikante Effekte auf den Einstieg in den Zigaretten- als auch den generellen Substanzkonsum, d. h. den Konsum von Zigaretten, Alkohol oder beidem (p=0,031 bzw. p=0,010). Die Number needed to treat wies einen Wert von 28 für den Zigaretten-, und einen Wert von 19 für den generellen Substanzkonsum auf. Hinsichtlich der Rate des Einstiegs in den heimlichen Alkoholkonsum unterschieden sich die Interventions- und die Kontrollgruppe nicht (p=0,092). In den weiterführenden Analysen bezüglich der möglichen Auswirkungen der angestrebten Korrektur rauchbezogener Normen konnte kein Unterschied zwischen der Interventions- und Kontrollgruppe hinsichtlich der Auftretenshäufigkeit von Bullying gegenüber rauchenden Mitschülern (p>=0,118), jedoch hinsichtlich der Stärke des Einflusses rauchender Freunde gefunden werden, d. h. in der Interventionsgruppe fiel der Einfluss rauchender Freunde auf den Rauchbeginn der Schüler bedeutsam geringer aus (p<=0,001). Schlussfolgerungen: Die Ergebnisse der Studien deuten auf die Effektivität der untersuchten Grundschulprogramme Eigenständig werden und Klasse2000 hin, Vorläufer des späteren (problematischen) Substanzkonsums bedeutsam reduzieren bzw. den Einstieg in den Substanzkonsum zumindest zeitlich verzögern zu können. Zumindest für Klasse2000 bestehen zudem Hinweise, dass das Programm trotz der angestrebten Normenkorrektur hinsichtlich des Rauchens nicht zu einer Zunahme an Bullying führt, jedoch zu einer Erhöhung der Resistenz gegenüber sozialen Einflüssen beitragen kann.