Journal of Software Engineering and Applications, 2013, 6, 14-26
http://dx.doi.org/10.4236/jsea.2013.610A003 Published Online October 2013 (http://www.scirp.org/journal/jsea)
Feasibility of a Fully Automated Multiple Session Alcohol
Intervention to University Students, Using Different Modes
of Electronic Delivery—The TOPHAT 1 Study
Bendtsen Marcus1,2, Bendtsen Preben1
1Department of Medicine and Health, Linköping University, Linköping, Sweden; 2Department of Computer and Information Science,
Linköping University, Linköping, Sweden.
Received August 14th, 2013; revised September 5th, 2013; accepted September 12th, 2013
Copyright © 2013 Bendtsen Marcus, Bendtsen Preben. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
Background: In recent years more and more electronic health behaviour interventions have been developed in order to
reach individuals with an unhealthy behaviour such as risky drinking. This is especially relevant in university students
who are among those who most frequently are risky drinkers. This study explored the acceptability and feasibility, in an
unselected group of university students, of a fully automated multiple session alcohol intervention offering different
modes of delivery such as email, SMS and Android. Material and Methods: A total of 11,283 students at Linköping
University in Sweden were invited to perform a single session alcohol intervention and among those accepting this
(4916 students) a total of 24.7% accepted to further participate in the extended multiple intervention lasting 3 - 6 weeks.
The students could choose mode of delivery, total length of the intervention (between 3 - 6 weeks) and number of mes-
sages per week (3, 5, or 7 per week). A follow-up questionn aire was applied after the intervention to which 82.7% re-
sponded. Results: most students wanted to receive the messages by email with the shortest intervention length (3 weeks)
and as few messages as possible per week (3 messages). However, no major difference was seen regarding satisfaction
with the length and frequency of the intervention despite chosen length and frequency. Most students also expressed
satisfaction with the content of the messages and would recommend the intervention to a fellow student in need of re-
ducing drinking. Discussion and Conclusion: Based upon feedback from the students, a multiple push-based interven-
tion appears to be feasible to offer additional help for those who have interest after a single session alcoho l interv en tion.
In a forthcoming study we will further explore the optimal mode of delivery and length of intervention and number of
messages p e r week.
Keywords: Excessive Alcohol Drinking; University Students; Fully Automated Intervention; Health Behavior Change
1. Introduction
Alcohol continues to be a widely spread reason for a num-
ber of health problems, predominantly among young
people [1]. Time and again more than 50% of students in
Sweden are measured to have drinking habits that clas-
sify them as risky drinkers [2-5]. Although brief face-to-
face interventions delivered in various health care set-
tings have been shown to effective, the implementation
has been po or [6,7].
The expansion of access to electronic devices with net-
work communication capabilities has prompted a new
approach for reaching individuals with behaviour change
interventions. In a review (based upon 85 studies of In-
ternet based health behaviour change interventions) the
effects on health behaviour varied across behaviours and
studies, and were on average small. Additional effects
were enhanced by adding short message service (SMS)
to other kinds of Internet based interventions [8].
Web-based interventions, i.e. where a person is guided
to a web page with reflective information, exercises and
home work to be done before logging in at a later stage,
has shown to be difficult to implement. Not least in the
area of alcohol interventions [9].
As part of their routine practice 90% of student health-
care centres in Sweden are using a proactive Internet-
based screening system with brief and normative feed-
back [2,3,5]. The student healthcare centres use a web-

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
15
based portal to send an inv itation via email to all students
enrolled at the university. In the email there is a link that
takes the willing participant to a short questionnaire and
once all questions have been answered and processed a
personalized and normative feedback is given. This kind
of brief intervention (often referred to as fully automated
single session intervention) has been shown to have a
positive outcome on risky drinkers [10-15]. The method
has been compared to other forms of interventions (indi-
vidual and group face-to-face, pen-and-paper screening)
and shown to be as effective and cost less to implement
[16].
However, the effect size of alcohol interventions, bo th
delivered face-to-face or via the Internet is small and the
numbers needed to treat in order to get one risky drinker
to reduce drinking below safe limits is 10. Consequently
a large group of individuals that receives a brief Internet
based intervention continue to drink at levels that are
considered risky. Therefore more development and re-
search is needed in order to optimize existing interven-
tions and develop new means of communicating health
behaviour change in order to accomplish an effect on a
population level.
Using simple proactive messages, delivered via SMS
or email, has been used successfully in trials where con-
sideration has been taken to smoking habits [17], physi-
cal activity [18] and weight loss [19]. Although slightly
different in their nature, the main component of the in-
terventions has been messages delivered continuously
during a set time period. The method of using mobile
phone messaging for changing health behaviour has
shown great promise, e.g. one of the more recent trials,
txt2stop [17], was found to significantly improve smok-
ing cessation rates at 6 months. A number of reviews
have also highlighted the advantage of using text mes-
saging as a tool for behaviour change support [20-23]. So
far, only a few inconclusive attempts have been made in
order to evaluate the feasibility an d effectiveness of SMS
interventions in comparison to other means of communi-
cating such as email and apps [23].
Simple messages have been used in some settings
within the field of brief alcohol interventions. In on e set-
ting SMS messages were used to improve alcohol diary
keeping as part of a self-assessment of consumption [24].
Similarly SMS messages have been used to assess and
give feedback to participan ts in an attempt to red uce hea-
vy drinking among young people seeking care at an emer-
gency department [25]. Besides these two studies, there
is a lack of research using simple messages or emails as
the main component of an intervention aimed at reducing
alcohol consumption to non-risk levels. One limitation of
the two existing studies has been sample size and re-
cruitment methods. The intervention design in this study
uses a more proactive appro ach, inviting everybody from
a student population, not only treatment seekers.
The present study evaluates the feasibility of an inno-
vative proactive approach of extending an initial single
session Internet based alcohol intervention with a new
extended multiple session intervention (delivered by
SMS, email or an Android app) to those participants that
are curious or motivated for more help to decrease their
alcohol consumption.
The objective of the stud y is to evaluate the feasibility
and user satisfaction of this new extended intervention
when applied to university students. Furthermore the
study is a pilot of the developed software prior to a
planned larger scale RCT.
2. Methods
2.1. Population and Recruitment
All students starting their 1st, 2nd or 3rd year at the
Linköping University (a total of 11,283 students) were,
in mid-October 2012, invited via their official university
email address to complete a fully automated Internet
based alcohol single session intervention by clicking on
an embedded link in the email. The cont ents of the email
and single session intervention was the same as is used
during routine practice at Universities around Sweden as
reported previously [26], with additional information re-
garding the option of being able to join a research pro-
ject after having received the usual 3-pages of feedback
from the single session intervention. After 1 and 2
weeks, a reminder was sent to those who had not com-
pleted the single session intervention, and after 3 weeks
the questionnaire was closed and no more responses
were accepted. The students completed the single ses-
sion on a computer/smartphone/tablet at their own con-
venience.
Students having completed the single session interven-
tion were offered to be included in a draw of an iPad if
they were willing to participate in an extended interven-
tion as part of a research project. This also included an-
swering a follow-up questionnaire after having com-
pleted the extended intervention. All students, regardless
of alcohol consumption, were offered to join the research
project and participate in the extended intervention. No
other means of registering to the study or the extended
intervention was made available. An overview of the
recruitment process and study design is shown in Figure
1.
2.2. Signing up and Completion of the Extended
Intervention
Participants that were willing to join the study after the
single session intervention were given three options. First
they choose their preferred delivery method, the choices

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
16
Figure 1. Flowchart of recruitment process of participants and design of the study.
were email, SMS or Android. Secondly they choose the
number of weeks they would like to receive messages (3,
4, 5 or 6 weeks). Lastly they selected the number of
messages they wanted to receive per week (3, 5 or 7
messages p e r week).
Since the participants were invited via email to com-
plete the single session interven tion no further steps were
necessary for those who choose email, as we already had
their email address from the initial invitation. For those
who choose SMS, a code was presented on the screen as
well as a phone number. Participants had to send an SMS
to the phone number containing the code. This allowed
us to verify the participants phone number as well as
keeping track of their answers during the single session.
Participants who choose to use an Android app were in-
structed how to download the application, and once
downloaded and installed they had to activate the appli-
cation with a code shown on screen.
Once these steps were complete the intervention ran
for the selected number of weeks. When the last message
was sent to a particular participant the system sent an
email to them. The email contained a link to a question-
naire with follow-up questions.
2.3. Content of the Extended Intervention
The new extended intervention consists of text messages
delivered to participants at a specific time during the

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
17
week. The method of delivery varies depending of per-
sonal choice, including email, SMS (Short Text Messag-
ing) and delivery to custom-made smartphone applica-
tions. The delivery of messages goes on for a specified
number of weeks as decided beforehand by the individ-
ual participants.
Based upon prevailing theories within the field of be-
haviour change, including: Self-Determination Theory,
Social Cognition Models, Social Cognitive Theory, The-
ory of Planned Behaviour and Model of Action Phases,
textual content for the messages was created. The content
of the messages were labelled as “food for thought”,
“task”, “facts”, “reflective” or “challenges”. A schedule
was created for when to send what type of message dur-
ing the week. An example of a “food for though” mes-
sages is: “What are the most important things in your life?
How does drinking affect them?” An example of a “task
messages” is: “List three good things and three not so
good things about your drinking”. An example of a “fact
messages” is: “Alcohol influences your sleeping nega-
tively. You might fall asleep quickly after drinking but
wake up earlier than usual not being able to fall asleep
again. This could lead to more chronic sleeping distur-
bance if you often drink excessive”. An ex ample o f a “r e-
flective messages” is: “Is the way that you drink fully in
accordance with your own values?” An example of a
“challenge messages” is: “Tonight or next time you are
going out for a drink—decide to take a glass a water
between every drink”. This will make you feel better the
next day—and you will probably save some money.
2.4. Extended Intervention Messages Schedule
Based upon the chosen number of messages per week at
signup a delivery schedule was created for each partici-
pant. There were three possible schedules depending on
the choice of 3, 5 or 7 messages per week. These possi-
bilities are presented in Figure 2. If a student choose 3
messages per week they would receive a message with
“food for thought” content on Wednesdays a message
with a “challenge” of Fridays and a message with “reflec-
tive” content on Sundays.
2.5. Measurements
2.5.1. Risky D r i nking at Baseline
Risky drinking was defined according to the official
definition used in Sweden that includes two criteria: the
total weekly consumption and frequency of heavy epi-
sodic drinking (HED).
Risky total weekly consumption of alcohol was de-
fined as drinking more 9 (females) or 14 (males) standard
units per week (1 standard unit = 12 g of alcohol, e.g. a
small glass of wine). Heavy episodic drinking was de-
fined as drinking more than 4 (females) or 5 (males)
standard units on a single occasion, e.g. during an eve-
ning. Having one or more episodes of heavy drinking
per month was considered risky drinking. Participants
were considered risky drinkers if they fulfilled either
or both of the above definitions. These drinking limits for
safe dri nking are the official lim its as used in Sweden .
2.5.2. Perceived Drinking Compared to Peers at
Baseline
Student were asked if they think they drank more, less or
the same as their peers as part of the assessment in the
single session intervention. This was used in the analysis
of the feasibility evaluation of the extended intervention.
In the single session feedback the students were graphi-
cally shown a comparison between their actual consump-
tion compared with peers in the same age group and sex.
The comparison was based on a reference database held
by the authors from the previous 5 years of surveys com-
pleted throughout Sweden, consisting of more than
150.000 measurements on students.
2.5.3. Fo l low-Up Questionna i r e
The follow-up questionnaire contained 10 questions ex-
ploring the feasibility and usefulness of the extended
intervention as perceived by the students. Two questions
explored whether the student had changed their alcohol
consumption and reasons for a reduction of the consump-
tion. (Analysis not included in his study since it was only
a feasibility study). One question explored whether the
student had any problems signing of for the SMS or
email delivery method or downloading the Android ap-
plication. Two questions explored satisfaction with the
chosen length of the intervention period with the fol-
lowing response options: too long/just right/too short/
don’t know and numbers of messages with the following
response options: too many/just right/too few/ don’t know.
One question explored the students overall perception
of the content of the messages with the following re-
Messages per week Mon Tue Wed Thu Fri Sat Sun
7 FFT Task FFT Task Challenge Challenge Reflection
5 FFT FFT Challenge Challenge Reflection
3 FFT Challenge Reflection
Figure 2. Delivery schedule for messages.

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
18
Sponse options: very good/good/poor/very poor. Three
questions explored the students’ perception of the use-
fulness of three different themes or categories of mes-
sages (motivating, facts and challenges) with the follow-
ing response options: great use/some use/almost no use/
don’t know. The last questions asked whether the student
would recommend the intervention to a friend that
drinks too much with the following response options:
yes definitely/possibly/doubtful/don’t know. The par-
ticipants could also comment their responses to each
question.
The study was approved by the Regional Ethical Com-
mittee in Linköping, Sweden, No. 2012/255-31.
2.6. Statistical Analysis
Differences between students within different response
options to the questions in the follow-up questionnaire
were examined using chi-square tests. All data from the
single session and from the sign up were used to charac-
terize students. In some cases cell values were too small
for reliable chi-square output. Pooling was done for these
variables, as well as an attempt at using Fisher’s exact
test. Only tests were p < 0.05 were considered. All statis-
tics were performed using R version 2.15.1.
3. Results
3.1. Response Rate and Characteristics of
Participants
Among the 11,284 students who were invited to partici-
pate in the first step of the study 43.6% completed the
single session intervention and received feedback. The
initial single session intervention was sent to all students
starting their 1st, 2nd and 3rd years at the University of
Linköping, using the official university mailing list, and
therefore we did not know the age, sex and social status
of the total population of the 11,284 students invited to
participate. However the proportion of students partici-
pating in the single session interven tion were fairly simi-
lar comparing the different years with a slightly lower
response rate for first-year students on 41% compared
with 45% for students in years 2 and 3. The characteris-
tics of the responders to the single session intervention
providing baseline data are shown in Table 1.
Among the 4916 students that answered the baseline
survey and thus were invited to sign up for the extended
intervention 1216 (24.7%) choose to sign up. The char-
acteristics of those who signed up are seen in Table 2.
Male participants were significantly more likely to sign
up for the extended intervention than females (28% ver-
sus 22%). Those reporting that they had a partner were
also more likely to join the extended intervention (26%
versus 24%). Participants that reported that they were
Table 1. Characteristics of participants that participated in
the single session baseline intervention (n = 4.916).
University year n (%)
1 1957 (39.8)
2 1665 (33.9)
3 1294 (26.3)
Sex
Female 2630 (53.5)
Male 2286 (46.5)
Age
18 - 20 1454 (29.6)
21 - 25 2735 (55.6)
26 - 30 427 (8.7)
31+ 300 (6.1)
Motivation to change
I have tried to decrease my
consumption, but failed 35 (0.8)
I am thinking about how to
change my habits 203 (4.6)
I have thought about changing,
but I’m not thinking about it right now. 549 (12.3)
I have started decreasing my consumption 989 (22.2)
I have not had any thoughts
regarding chang e 2683 (60.2)
Risky drinking
No risk 1803 (36.7)
Risky drinking 3113 (63.3)
thinking about changing their alcohol consumption or
that they had taken action towards changing their con-
sumption were also more likely to join the intervention
(28% versus 24%). However, there were no difference in
the proportion of risky drinkers and non-risky drinkers
that signed up for the extended intervention.
Although the numbers of students that initially decid ed
that they wanted to join the extended intervention were
1216, a number of students choosing SMS or Android
did not manage to activate the method of delivery. In
total, 62 (28.3%) of participants th at choose SMS did not
activate the intervention or choose another delivery
method. The point of failure activating the SMS inter-
vention was the step that required participants to send an
SMS with a specified code to a specified phone number.
Thus the number of participants that managed to acti-
vate their choice of delivery method was 1138, with 952
students (83.1%) choosing email, 160 (14%) choosing
SMS and 33 (2.9%) choosing the Android application.

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
19
Table 2. Characteristics of students enrolled in the extended intervention (n = 1.216).
Enrolled n (%) Not enrolled n (%) χ2 (df) p-value
Sex
Female 576 (21.9) 2054 (78.1)
Male 640 (28.0) 1646 (72.0) 24.08 (1) <0.0005
Age
18 - 20 350 (24.1) 1104 (75.9)
21 - 25 67 (24.7) 2059 (75.3)
26 - 30 121 (28.3) 306 (71.7)
31+ 69 (23.0) 231 (77.0) 3.81 (3) 0.2832
Social status
(pooled data)
No partner 684 (23.7) 2207 (76.3)
Have a partner 532 (26.3) 1493 (73.7) 4.22 (1) 0.0398
Perceived drinking compared
to peers (pooled data)
More 138 (24.0) 437 (76.0)
Same 337 (23.8) 1082 (76.2)
Less 728 (25.6) 2114 (74.4) 2.03 (2) 0.3619
Motivating to change
(pooled data)
No thoughts of change 642 (24.0) 2041 (76.0)
Thought of change 212 (28.2) 540 (71.8)
Taken action 264 (25.8) 760 (74.2) 6.04 (2) 0.0489
Risk drinking
No risk 455 (25.2) 1348 (74.8)
Yes risk 761 (24.5) 2352 (75.5) 0.34 (1) 0.5591
A total of 941 follow-up questionnaires were returned
giving a total response rate of 82.7%. The response rate
was 81.9% for the email group, 82.5% for the SMS
group and 87.9% for the Android group (Figure 1). All
questions had to be completed so there were no internal
missing data on any qu estions.
3.2. Choice of Delivery Methods
The choice of delivery method did not differ between the
different semesters, sex, age or social statuses, but those
students that thought they drank somewhat more than
their peers (n = 128) choose significantly more often
SMS as the mode of delivery (28% versus 20%, χ2 =
15.62 (df 4), p = 0.0036). Students who were thinking
about changing their consumption significantly more
often choose the SMS mode of delivery (26% versus
15%, χ2 = 15.34 (df 4), p = 0.004) compared with stu-
dents not considering changing their consumption. Risk
drinkers were not more likely to initially sign up for a
specific d e livery method.
3.3. Choice of Length of the Intervention and
Frequency of Messages
The choice of the length of the intervention (possible
options were 3, 4, 5 or 6 weeks) is seen in Table 3. In
total 51% of the participants choose a 3 week interven-
tion, 16% choose 4 weeks, 5% choose 5 weeks and 28 %
choose a 6 week intervention. Students on their first year
at the University and age group 26 - 30 more often
choose a 6 week intervention. Those who choose SMS or
Android as the mode of delivery more often signed up
for a 6 week intervention. There were no significant dif-
ference concerning choice of delivery methods between
male and female students, social status (living with or

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
20
Table 3. Choice of length of the intervention in relation to semester, age and delivery method and frequency of messages.
Choice of length of intervention period
University year 3 weeks 4 weeks 5 week s 6 week s χ2 (df) p value
1 246 (48.4%) 82 (16.1%) 24 (4.7%) 156 (30.7%)
2 226 (56.9%) 59 (14.9%) 13 (3.3%) 99 (24.9%)
3 150 (48.2%) 57 (18.3%) 22 (7.1%) 82 (26.4%)
13.31 (6) 0.0383
Age, n (%)
18 - 20 195 (55.7%) 56 (16%) 15 (4.3%) 84 (24%)
21 - 25 347 (51.3%) 108 (16%) 38 (5.6%) 183 (27.1%)
26 - 30 47 (38.8%) 25 (20. 7 %) 3 (2.5%) 46 (38%)
31+ 3 3 (47.8%) 9 (13%) 3 (4.3%) 24 (34.8%)
17.30 (9)
0.0442
Delivery method
chosen, n (%)
ANDROID 17 (34%) 9 (18%) 5 (10%) 19 (38%)
EMAIL 506 (53.4%) 150 (15.8%) 43 (4.5%) 248 (26.2%)
SMS 99 (45.2%) 39 (17.8%) 11 (5%) 70 (32%)
12.93 (6) 0.0441
Frequency, n (%)
3-a-week 593 (56.1%) 170 (16.1%) 51 (4.8%) 243 (23%)
5-a-week 13 (19.4%) 21 (31.3%) 7 (10.4%) 26 (38.8%)
7-a-week 16 (17.4%) 7 (7.6%) 1 (1.1%) 68 (73.9%)
141.73 (6) <0.0005
without a partner and having children), perceived drink-
ing compared to other students, motivating to change
consumption and risk drinking status.
Concerning the choice of frequency of messages [the
options were 3, 5 or 7 a week] the majority, 87% choose
to receive 3 messages per week and 6% choose 5 per
week and 7% choose 7 messages per week. Students on
their first year, males, and students perceiving that they
drank more than their peers also more frequently choose
7 messages per week. It is seen in Table 4 that those par-
ticipants who signed up for SMS and Android more fre-
quently wanted 7 messages per week than those who
choose email as the mode of delivery.
3.4. Satisfaction with the Chosen Length of the
Interventions Period
Around 3% of the participants thought that the interven-
tion chosen was too long independently of the chosen
length of the intervention period. The majority, 77%,
found the length “just right” whereas 14% found the in-
tervention length too short and 6% could not decide.
Risky drinkers significantly more often found the inter-
vention to be too short than non-risk drinkers (17% ver-
sus 9%, χ2 = 22.16 (df 3), p = 0.0001) as well as those
who choose SMS compared with email (18% versus 13%,
p = 0.0066, Fischer’s exact test). A few, 3.6% of those
who choose email perceived the intervention too long
compared to none in both the SMS and Android group.
No difference was seen in satisfaction with chosen length
of the intervention period and year, sex, age, social status
(living with or with a partner and having children) or
chosen frequency of messages per week.
3.5. Satisfaction with the Chosen Number of
Messages per Week
Most participants, around 70% - 80%, were satisfied with
the chosen numbers of messages per week. However,
significantly more students among those who had chosen
7 messages a week perceived the messages to be too fre-
quent (26%) compared to those who had chosen 3.
a) Fishers exact test (13%) or 5 (21%) per week. There
were no differences in satisfaction with the frequency of
messages concerning sex, age, social status (living with
or without a partner and having children) or motivation
to change at baseline. Students on their third year, risky
drinkers and those that perceived they drank more than
their peers were more prone to think that the numbers of
messages were too few (Table 5). Participants who
choose email and Android as the mode of delivery more
often thought that the frequency of messages was too

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
21
Table 4. Choice of frequency of messages in relation to other parameters.
Choice of frequency of messages
University year 3-a-week 5-a-week 7-a-week χ2 (df) p value
1 421 (82.9%) 37 (7.3%) 50 (9.8%)
2 357 (89.9%) 19 (4.8%) 21 (5.3%)
3 279 (89.7%) 11 (3.5%) 21 (6.8%)
13.59 (4) 0.0087
Sex, n (%)
Female 517 (89.8%) 28 (4.9%) 31 (5.4%)
Male 540 (84.4%) 39 (6.1%) 61 (9.5%) 8.74 (2) 0.0126
Perceived consumption
compared to peers (Pooled), n (%)
More 105 (76.1%) 11 (8%) 22 (15.9%)
Same 298 (88.4%) 17 ( 5%) 22 (6.5%)
Less 644 (88.5%) 37 (5.1%) 47 (6.5%)
18.51 (10) 0.0010
Delivery method
chosen, n (%)
ANDROID 35 (70%) 8 (16%) 7 (14%)
EMAIL 850 (89.8%) 40 (4.2%) 57 (6%)
SMS 172 (78.5%) 19 (8.7%) 28 (12.8%)
< 0.0005a)
Intervention length
chosen weeks, n (%)
3 weeks 593 (95.3%) 13 (2. 1%) 16 (2.6%)
4 weeks 170 (85.9%) 21 (10.6%) 7 (3.5%)
5 weeks 51 (86.4%) 7 (11.9%) 1 (1.7%)
6 weeks 243 (72.1%) 26 (7. 7%) 68 (20.2%)
141.73 (6) NA
Fishers exact test.
high (Table 5).
3.6. Perceived Satisfaction with the Content of
the Messages
Most participants (92.2%) found the overall content of
the intervention to be “good” or “very good”. The per-
ceived satisfaction did not differ between participants
from the three different years, nor between age groups,
motivation to change, risky drinking status, mode of de-
livery, length of chosen intervention or frequency of
messages. But females (96% versus 90% for men) and
those living with a partner (4% versus 91% without a
partner) was in general more positive concerning the con-
tent.
In the follow-up questionnaire we asked the partici-
pants to consider the usefulness of three different groups
of messages that we thought the students would be able
to distinguish; “motivating”, “facts” and “challenges”.
We asked the students to think of a student that needs to
reduce his/hers drinking. The results are displayed in
Figure 3 and few significantly differences were seen
between the groups of students. However, the partici-
pants that choose SMS were significantly more satisfied
with the motivating messages compared with the two
other means of delivery (30% satisfied compared to
around 20% for email and Android, χ2 = 13.6 (df 6), p =
0.043). Also, participants choosing a 6 week interv ention
was significant more satisfied (“great use”) with the fact
messages compared to participants choosing a shorter
duration of the intervention (40% compared with 26% -
34%, χ2 = 26.79 (df 9), p = 0.0015 ). Risky drinkers were
less prone to agree that the challenge messages were of
“great use” than non-risky drinkers (23% versus 30%, χ2 =
12.24 (df = 3), p = 0.0066).
Lastly, we asked the students whether the participants
would recommend the intervention to a friend that was in

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
22
Table 5. Satisfaction with chosen frequency of messages.
Satisfacti on with the frequency of messages n (%)
Too many Just right Too few Don’t know χ2 (df) p value
University year 57 (15.0) 312 (81.9) 6 (1.6) 6 (1.5)
1 46 (14.6) 240 (76.2) 14 (4.4) 15 (4.8)
2 33 (13.5) 194 (79.2) 13 (5.3) 5 (2.0)
3
15.01 (6) 0.0201
Perceived consumption compared to
peers (Pooled data)
More 9 (9.1) 81 (81.8) 6 (6.0) 3 (3.0)
Same 26 (9.5) 228 (83.5) 13 (4.8) 6 (2.2)
Less 99 (17.7) 431 (77.0) 14 (2.5) 16 (2.9)
0.0007a)
Risk drinking
No risk 72 (20.3) 264 (74.4) 5 (1.4) 14 (3.9)
Risk 64 (10.9) 482 (82.3) 28 (4.8) 12 (2.0) 25.17 (3) <0.0005
Activated delivery method
Android 7 (24.1) 19 (65.5) 2 (6.9) 1 (3.5)
EMAIL 119 (15.3) 615 (78.8) 24 (3.1) 22 (2.8)
SMS 10 (7.6) 112 (84.8) 7 (5.3) 3 (2.3)
0.0448a)
Frequency of messages
3 per week 107 (13.0) 663 (80.8) 28 (3.4) 23 (2.8)
5 per week 11 (21.2) 35 (67.3) 74 (7.7) 2 (3.9)
7 per week 18 (26.4) 48 (70.6) 1 (1.5) 1 (1.5)
0.0167a)
a)Fishers exact test.
Figure 3. The participants’ perception of the usefulness of
the different messages, thinking on a student that needs to
reduce drinking (n = 941). Response to the question: “How
useful do you think the different categories of messages
would be for a student that drinks too muc h?”
need of cutting back on the alcohol consumption and
around 33.4% would definitely recommend the interven-
tion, and 46.4% would possibly recommend it whereas
18.6% was doubtful and 1.6% d id not know. Female par-
ticipants, non-risky drinkers, those who choose a 6 week
intervention or SMS were more likely to recommend the
intervention to a friend. The greatest difference was seen
with regards to the chosen length of the intervention;
where 27% of those who had chosen a 3 week interven-
tion indicated that they definitely would recommend a
friend to use the intervention compared with 42% among
those who had chosen a 6 week intervention (χ2 = 25.3
(df 9), p = 0.0027). No difference was seen between the
participants choosing different frequency of messages a
week.
4. Discussion
The study aimed to explore the feasibility of offering an
extended alcohol intervention to students having per-
formed an Internet based single session alcohol interven-
tion. This is the first explorative study in a series of
planned studies, the TOPHAT studies (Trial and Optimi-
sation of Push based High Alcohol Treatment) that has
been proposed in order to find an optimal length and
content of proactive extended alcohol intervention to
university students. Others and we have previously re-
ported a modest effect of a single session alcohol inter-
vention delivered by mail and although this effect is in
parity with a short person-to-person intervention there is
a need for more effective interventions [11,16,26].
We therefore hypothesized that a certain proportion of
students with risky drinking identified by a single session

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
23
intervention are willing to sign up for a proactive ex-
tended intervention for a number of weeks in contrast to
just offering access to a web site. However we do not
know the feasibility of such an offer with regards to how
long time this extended interven tion preferable should be
and how many messages per week is perceived to be
optimal by the target group. Our approach is a fully au-
tomated intervention based upon push techniques, which
means that the participants do not have to log-on to a
website but receives the messages/intervention at certain
predefined times. This stands in contrast to most previous
Internet based alcohol interventions where the partici-
pants had to remember to log-on to a web site, which has
shown to have very low compliance [9].
The response rate to the initial sin gle session interven-
tion was 43.6%, which is somewhat higher than in our
previous studies [3,5,10]. One possible reason for this
could be that we were offering all participants to be in-
cluded in a draw of an iPad. We decided to include such
an incitement in order to get as many participants in this
explorative study as possible. We had expected the sign
up rate for the extended intervention to be somewhat
higher, having in mind the possibility to win an iPad, but
we still managed to include nearly 25% of those who
hade performed the single session intervention. We stress-
ed that both risky and non risky drinkers could sign up
for the extended intervention since we wanted as many
views as possible on the structure and content of the ex-
tended intervention. Therefore somewhat less than one
third of the participan ts in the evaluation of the extend ed
intervention were non-risky drinkers (Table 2). However
the proportion of participants signing up for the extended
intervention was surprisingly equally distributed with
regards to all baseline characteristics (Table 2). In a na-
turalistic or routine administration of the extended inter-
vention we would expect less students to sign up for
more help although this might vary between groups of
students and universities and still has to be tested in
forthcoming TOPHAT studies.
The follow-up rate was as high as 82.7 and somewhat
better than expected from previous studies. Whether this
reflects the possibility to win an iPad or a genuine inter-
est in furthering the development of an extended inter-
vention is difficult to know, but we believe that many
students are concerned about the alcohol culture at the
universities and therefore probably have an interest in
participating.
4.1. Choice of Delivery
The choice of delivery of the extended intervention was
somewhat surprising since most students (83.1%) choose
email. One reason for this could be that the single session
was delivered by an email and the students thought it was
convenient to continue getting emails. Whether email is
an optimal means of delivering an extended push based
intervention will be explored in coming TOPHAT studies,
exploring when a message are read and if it is read. We
can plan a SMS for example on a Friday evening and if
the message is delivered by SMS this might be read im-
mediately, but if it is an email this might not be read as
intended before going out on a pub. Although smart-
phones have narrowed the difference between SMS and
email, most individuals might still be more prone to read
a SMS when it arrives, rather than a new email. However,
we got some indication that SMS was more often chosen
by students who perceived their consumption to be more
than peers and by students who were thinking about re-
ducing their consumption. Whether this is an indication
that SMS would be the best choice for individuals in an
action phase of changing consumption is difficult to con-
clude from the feasibility study.
4.2. Choice of Length and Frequency of
Messages
We wanted to explore what choices students would make
if given a choice concerning the length of the interven-
tion and frequency of messages. Although the majority of
the students choose the shortest duration of the interven-
tion with the least number of messages per week, we still
saw that 27% wanted a 6 week intervention. These stu-
dents more often choose SMS as the mode of delivery
indicating the feasibility of offering a longer in tervention
by this mode of delivery. Concerning the frequency of
messages 87% choose 3 per week, but those who wanted
more frequent messages were characterized as students
that perceived to drink more than their peers and choos-
ing SMS as the mode of delivery. This indicates that a
subgroup of students might want and perhaps benefit
from more frequent messages. Still, it is impossible to
conclude what would be the optimal length of an ex-
tended intervention and optimal number of messages per
week from the choices made by the students. But, when
looking at satisfaction with the choices the students made
we had assumed that we would be able to see a clarifying
pattern in order to decide the length of the intervention
and frequency of the messages in a forthcoming TO-
PHAT 2 study. However, despite the chosen length of the
intervention (3, 4, 5 or 6 weeks), less than 5% thought
that the intervention was too long. Also, the majority
though that the frequency of messages were “just right”
independent of choice. Still, students having asked for 5
or 7 messages per week were more prone to think that it
was too many. Thus, it appears that most students were
able to make a choice that fitted with their perceived
needs and interest but a forthcoming TOPHAT 2 study
will clarify satisfaction with an extended intervention

Feasibility of a Fully Automated Multiple Session Alcohol Intervention to University Students,
Using Different Modes of Electronic Delivery—The TOPHAT 1 Study
24
were all students gets the same length of an extended
intervention and the same number of messages per week.
4.3. Perceived Perception of the Messages
Overall the messages were perceived as good or very
good by the participants (Figure 2). In an attempt to ex-
plore whether there were any different opinions about the
usefulness of the motivating, facts or challenge messages
we found a fairly similar satisfaction with all three
groups of messages. Somewhat surprising, risky drinkers
were less satisfied with the challenges indicating either a
lack of motivation or poor ly formulated challenges. Only
a few students we re doubtful to recommend the extended
intervention to a friend but surprisingly more students
having chosen a longer intervention expressed an interest
in recommending the intervention. This indicates a some-
what more perceived usefulness having participated in a
longer intervention.
4.4. Study Limitations
The study was performed in an unselected group of stu-
dents primarily not seeking help for their alcohol con-
sumption including both risky and non-risky drinkers.
We also introduced a bias when offering the participants
to be included in a draw of an iPad. However, from pre-
vious studies we know that this helps us getting a suffi-
cient number of participants, wh ich we decided would be
acceptable in this first explorative study. This means that
the results should be taken with some reservations. In a
non-treatment seeking population it is natural to select as
few messages per week and as short intervention as pos-
sible whereas in a treatment seeking population we
would have found a somewhat different picture. Still, the
purpose of this first study was to get an idea wh at is fea-
sible to expose students to in order to get a good compli-
ance since we assume that both single session and ex-
tended interventions always will meet individuals with a
strong motivation as well as less strong motivation and
preferable should satisfy both groups. In a forthcoming
TOPHAT 2 study we will change the study design and
randomize students to either SMS or email excluding the
choice of an Android app since this was chosen by so
very few. In this forthcoming study all students will re-
ceive a 4-week intervention with 4 messages per week.
Using the same follow-up questionnaire we will explore
differences in answers when not having the options to
choose mode of delivery. W e will also explicitly explor e
if and when a message was read in order to be able to
insure correct timing of challenges i.e. before going to
the pub on a Friday evening.
5. Conclusions
This study aimed at exploring the interest in signing up
for an extended alcohol intervention in an unselected
student population that had participated in a single ses-
sion alcohol intervention. About 25% of the students
signed up and gave information about what would con-
stitute an optimal extended intervention in their opinion,
keeping in mind that both risky and non-risky drinkers
were included. Thus in the present research context in-
cluding both risky and non risky drinkers most partici-
pants preferred email, but students who perceived they
drank more than their peers more often preferred SMS.
Most stud ents wanted a fair ly short, 3-week, intervention,
with as few messages (three) as possible per week. These
findings might be due to selection bias since the partici-
pants were participating in a draw of an iPad if they join-
ed the study. Still, stud ents choo sing a lengthier interven-
tion were just as satisfied with the length than those who
had chosen a shorter intervention time. However, stu-
dents who received 7 messages per week were more
prone to perceive the messages to be too many. Overall
the students found the content of the various messages to
be good, or very good. Overall the results from the pre-
sent study will be valuable in further development of the
software to be tested in upcoming studies with fewer
choices, but based upon the same content. The sign-up
problems with the SMS will also have to be sorted out in
the new version of the software with a different sign-on
procedure to be implemented.
Based upon the feedback from the students, an ex-
tended push based intervention appears to be feasible to
offer those interested in additional help after a single
session intervention, which is also underlined by the
large proportion of the students that would recommend
the intervention to a friend who was in need of cutting
down on drin king.
In a forthcoming TOPHAT 2 study we will further ex-
plore the optimal mode of delivery and length of inter-
vention and number of messages per week before per-
forming a larger effectiveness
6. Acknowledgements
Statistician Nadine Karlsson is thanked for her valuable
help with the statistics
7. Conflict of Interest
Both authors own shares in and work in a private com-
pany that develops and distribute mobile health inter-
ventions.
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