Build it so they will come? Feasibility and efficacy of a gamified personalized normative feedback alcohol intervention for sexual minority women

Sexual minority women (SMW) disproportionately engage in heavy drinking and shoulder the burden of alcohol dependence. Much research has emphasized the need for culturally tailored alcohol interventions for this population, highlighting sexual minority stigma-related experiences, maladaptive coping, and misperceived peer drinking and coping norms as potential intervention targets. Focusing on the latter, this research examines the potential utility of personalized normative feedback (PNF) in reducing consumption among moderate and heavy drinking SMW. PNF is a popular, evidence-based intervention strategy associated with reliable (albeit modest) reductions in alcohol use in other heavy drinking populations. To remedy limitations associated with traditional PNF intervention formats and tailor this strategy to reflect the interests, social identities, and stigma experiences of SMW, a novel gamified intervention format was developed wherein PNF on drinking and coping behaviors was organically delivered to SMW within LezParlay, a larger competition designed to challenge negative stereotypes about lesbian, bisexual, queer (LBQ) women and increase the visibility of community members. The current study evaluates the efficacy and feasibility of this approach. In total, 2,677 LBQ women between the ages of 21 and 65 years signed up to take part in the LezParlay competition, with players logging over 44,0000 web app page views. Following several rounds of play, a sub-sample of 499 moderate-to-heavy drinking SMW were randomized to receive 1 of 3 sequences of PNF (i.e., alcohol+coping, alcohol+control, or control topics only) over two subsequent rounds. Alcohol use was assessed prior to randomization and two months post-intervention, along with potential demographic and sexual minority stigma-related moderators. Following the competition, these participants completed feedback surveys assessing acceptability, perceived benefits, and ideas for future versions of LezParlay. At follow-up, participants who received alcohol+coping and alcohol+control PNF significantly reduced their alcohol consumption relative to those who received control PNF only (d =.49 -.50). No differences were observed between treatment conditions overall; however, moderator analyses revealed alcohol+coping PNF to be more effective than alcohol only PNF among SMW who entered the study as heavier drinkers. Interpersonal stigma exposure also moderated intervention efficacy with enhanced effects observed among SMW in both treatment conditions reporting greater (relative to lesser) violence and harassment due to sexual minority status. Study participants found the competition to be highly acceptable and 93% reported psychological benefits, which most frequently included stigma reduction, social comparison, community connection, entertainment, self-confrontation, and mood enhancement. Findings support the feasibility and efficacy of this palatable approach to alcohol intervention for SMW, suggest that culturally tailored game mechanics may bolster PNF intervention engagement and potentially carry psychological benefits beyond core intervention content, and illuminate several priority directions for future research. Foremost, as findings suggest that PNF may particularly risk-reducing in the context of severe interpersonal stigma experiences like violence and harassment due to sexual minority status, additional research with SMW and members of other stigmatized groups is needed to more extensively examine potential interactions between norm correcting PNF and sexual minority stigma experiences in the context of heavy drinking and other health-risk behaviors. More broadly, this research advances several new directions for PNF intervention research, demonstrates the efficiency of hybrid feasibility/efficacy trial designs for evaluating digital health interventions, and illuminates the potential utility of incognito digital health intervention formats for nonclinical populations.