The research project focuses on different questions concerning the entering behaviour of the non-anonymous treatment option available. To give answers to the research questions there was an anonymous online questionnaire constructed with mainly quantitative and some qualitative questions. As very different aspects are involved it was decided to use a questionnaire to detect the various underlying reasons why people behave as they do. The construction, distribution and analytical methods are described in this chapter, beginning with the sample build-up, continuing with the instrument and the procedure of the research and ending with the analytical methods.
The sample needed to be chosen in a way that allowed generalization about the actual target group. To recruit the respondents an email was sent to approximately 250 participants. This email contained an introduction to the research project and also explained the procedure. Two groups of individuals exhibiting alcohol-related problems were enrolled into the study: persons who were already receiving the treatment (Treatment receivers) and people waiting for treatment (Treatment waiters). To maintain their anonymity both groups were recruited via email. There were approximately 140 persons from the waiting list for the anonymous treatment and 110 persons already receiving the treatment were recruited via email. The email contained a text introducing the research project and assuring the anonymity of the participants. A link to the questionnaire was contained in the email through which the participants were able to directly access the questionnaire. The survey was completed by N=62 patients in total, N=31 in each group. Participants who didn’t fill in the whole survey where automatically excluded from the programme.
Using Ajzen en Fishbein’s (1980) theory, there was an instrument constructed (based on detailed literature research) that assessed the ten variables theorized to influence help-seeking behaviour for alcohol abuse: (1) Subjective Norm, (2) Outcome Beliefs, (3) Perceived Severity, (4) Motivation to change, (5) Barriers, (6) Information Status, (7) Intention, (8) Solution Suggestions and (9) Demographics measured the primary determinants of the decision process to choose against the non-anonymous variant.
People were informed that participation was voluntary and anonymous. They were told that the procedure would involve answering questions regarding their thoughts about the online-treatment Alcoholdebaas.nl. Research participants completed the revised questionnaire for the anonymous participation of the online treatment for alcohol problems.
The questionnaire consists of 51 items, most of them with five point Likert-rating scales or check boxes, including one open-ended question asking the participants about solution suggestions aiming to stimulate more people to sign up for the non-anonymous treatment.
In order to investigate the questions concerning the two different groups, two versions of the questionnaire were developed. The versions were almost the same except for specific wording adjustments of the questions.
How the questionnaire was constructed can be found in table 3.1. The two versions of the questionnaire can be found in appendix A and B.
Table 3.1 Constructs and variables in the questionnaire
Status of treatment (started or waiting)
1 question (checking box)
The perceived severity of own alcohol misuse
2 questions on a five point Likert scale (1=strongly agree to 5= strongly disagree)
It was important to investigate the treatment status of the participants to know whether they were still waiting for treatment, had already started or had finished the treatment. This was measured by a simple check box question.
Perceived severity towards abuse
The most common reasons given by people for delaying help-seeking was the belief that their drinking was not serious enough (Jordan & Oei, 1989).
Many individuals are aware that they have a drinking problem, but they do not decide that change is needed. They may engage in minimization of the negative impact that drinking has on their lives.
Perceived Severity towards abuse was measured by asking participants to rate how they perceive their alcohol consumption in comparison to “most people” and how long they have thought about changing this problem. One item is: “Ik denk dat ik meer drink dan de meeste mensen”. This was measured by two items on a five point Likert-scale ranging from “strongly agree” to “strongly disagree”.
Perceived Self-efficacy reflects people’s beliefs about whether they think they can perform a given activity which, in this study, would be “changing drinking behaviour.” Perceived Self-efficacy portrays individuals’ beliefs in their capability to exercise control over challenging demands and over their own functioning (Bandura, 2000). According to Bandura (2000) Perceived Self-efficacy involves the regulation of thought processes, affective states, motivation, behaviour, or changing environmental conditions. Self-efficacy relates to the estimation of one’s ability to perform the necessary actions to change the relevant (i.e., consuming alcohol) behaviour. It is not about real skills but about one’s own estimation of one’s ability and whether you can rely on your abilities regardless of skills. Self-efficacy beliefs determine how people feel, think, motivate themselves and behave. This variable is measured by one item ”Ik denk dat ik goed in staat ben mijzelf ertoe te zetten mijn huidige alcoholgebruik te veranderen,” and is based on the scale developed by Schwarzer and Jerusalem (1995).
As a Subjective Norm, the decision-maker has subjective assumptions about other’s expectations. These may be organizational, professional, local or otherwise shared norms regarding accepted and expected behaviour. In case of the decision-making about participating in an alcohol treatment program, it is about social influence in terms of social barriers which are reported as a greater reason for not seeking treatment for an alcohol problem than for an emotional problem (Codd & Cohen, 2003). With respect to the present matter in question it is about social influences of family, friends and colleagues at work. Also the insurance and family doctor seem to play a role when it comes to choosing the treatment variant for receiving help. Therefore it is important to ask the patient about his perceived reactions and attitudes toward the treatment to find out the real impact of the direct environment. Subjective Norms can be inhibitive or facilitative and it is important to examine the relationship between perceived social norms and the outcome behaviour.
The Subjective Norms of those close to us for seeking help was measured with the question derived from an item by Bayer and Pay (1997). It asks participants to rate on a 5 point Likert-type scale ranging from “strongly agree” to “strongly disagree” the item “De meeste mensen die belangrijk voor mij zijn zouden graag willen dat ik de behandeling ga volgen.” Bayer and Pay found that this Subjective Norm uniquely predicted help-seeking intent such that those who were likely to seek help responded to this item more favorably. This item was used as a single observed indicator of the Subjective Norm latent variable.
In this research, the Subjective Norm refers to the influence of the direct environment of the patient with an alcohol abuse problem to undergo the online treatment. In the TRA, the Subjective Norm is being determined through environmental influences of the client. In this research, the Subjective Norm refers to the expectancies of clients about the judgments of people about being treated for an alcohol abuse problem.
Motivation to change
Motivation is a set of reasons that determines one to engage in a particular behavior (Fishbein & Aijzen, 1986). The motivation to change the problematic drinking behavior was measured with one item: “Ik ben heel gemotiveerd om mijn drinkgedrag te veranderen”, on a five point Likert-scale ranging from strongly agree to strongly disagree. Regarding the item, general Motivation to change the drinking behavior is measured. It has to be taken into account that when filling-in the questionnaire, the participants already signed up for the anonymous variant. This shows that the “general motivation” has to be linked to the fact that the participants are more or less motivated to change their drinking behavior under the condition that they are treated through the anonymous variant because that is what they signed up for in the first place.
Attitudes are predicted by a person’s outcome expectations (Ajzen & Fishbein, 1980). For example, if a person anticipates a positive outcome for a certain behaviour (e.g. choosing the non-anonymous variant will enable them to start the treatment right away which will lead to more control over their drinking behaviour), then they will have a positive attitude (e.g. choosing for the non-anonymous training is a good thing). Conversely, if a person anticipates harmful outcome for a certain behaviour (“If I seek help, others will think I am crazy”), then they will have a more negative attitude (e.g., seeking help is a bad thing). These outcome expectancies can be the most influential beliefs in the motivation to change (Suls & Wallston, 2003).
This construct consists of 10 items with possible outcomes of the online treatment as “alcohol consumptie reduceren” or “relatie met vrienden en familie verbeteren“. As orientation for these construct, we used the modal set of salient beliefs identified in Study 1 of Codd and Cohen (2003).
Barriers towards signing up for the non-anonymous variant
Attitudes and social stereotypes about people and alcohol use can create barriers to the detection and treatment of alcohol abusers. Barriers against treatment seeking might be congruent with barriers against signing up for the non-anonymous variant. These are reasons people have against utilizing specialized addiction treatment services or modifying the target problem behaviours (Bandura, 1986). Barriers inhibit an individual’s motivation to modify the addictive behaviour (Schober & Annis, 1996.). Research has found several barriers that prevent help-seeking behaviours for alcohol abuse among the general population. Stigma yields two kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities (Corrigan et al., 2005). Social barriers (social stigma) were reported as a greater reason for not seeking treatment for an alcohol problem than it was for an emotional problem (Vogel & Wester, 2003).
Participants’ experience of Barriers to the non-anonymous treatment was evaluated via a questionnaire created for this study. 12 items listing possible Barriers to treatment, based on literature research were sent to them. Our conceptualization of the treatment barriers include two components: Instrumentall barriers and psychological barriers (stigma).
Instrumental barriers are operationalized in this study by using well thought-out items chosen on basis of the literature read about this subject. Respondents were asked to indicate the extent to which they agreed with statements like “Ik ben geen Nederlander en anders wordt de behandeling niet vergoed” and “Ik ben niet bereid om de eigen bijdrage te betalen.” Response categories uses were “strongly agree,” “agree,” “do not agree/do not disagree,” “disagree,” and “strongly disagree.”
We operationalized stigma using a four item scale (alpha = 0,705). Item content focuses on being avoided, feeling guilty of their alcohol problem or being judged negatively by people because of having a problem with alcohol. The items of the stigma were obtained by using the two strongest items of the 5-item Stigma Scale for Receiving Psychological Help (Komiya, Good, & Sherrod, 2000). The version used is a shortened 5-item revision of the original 12 item measure. Items are rated on a 5-pont Likert-type scale ranging from strongly agree to strongly disagree.By asking the respondent to report on the perspective of “most people,” the scale enables stigmatizing beliefs that are not socially acceptable to be endorsed.
Each item was answered with a 5-point Likert scale anchored at “strongly agree,” “agree,” “do not agree/do not disagree,” “disagree,” “strongly disagree” (see Appendix for item wording).
The separate constructs of instrumental and psychological barriers were combined to one construct because of the large overlap of items.
Information Status is one of the psychological variables which can be seen as an important determinant of behavior. According to Brug and colleges (2003) insight and knowledge only lead to behavior change in people who are willing to do something but don’t really know how they can reach the goal or what the behavior would be. In our case the supposed knowledge gaps include the possibility of being able to start immediately with the program when choosing the non-anonymous variant, knowledge about who will be involved in treatment process, and who has insight in the personal data and reports.
Intention to sign up for the non-anonymous variant afterwards
Ajzen and Fishbein (1980) operationally defined intention as the person’s subjective probability judgment of how he or she intends to behave. Items assessing behavioral intention thus need to assess the strength of the person’s intention on an appropriate probability dimension. Intention to sign up for the non-anonymous variant was measured with an item asking the respondent to rate how likely, ranging from “very likely” to ”very unlikely,” they would be to sign up for the non-anonymous variant after getting some information about the payment through the insurance. This item is based on a recommendation of Aijzen and Fishbein (1980) who say that an Intention statement should be rated as “unlikely” or “likely.” (Terry, Gallois, & McCamish, 1993).
Based on the observed (literature) reasons for participants to make the decision to not sign up for the insurance-paid option, there were some relevant Solution Suggestions devised to find out how these propositions are accepted by the participants. Thereby it was aimed to explore the effectiveness in practice of the different options.
In addition to the quantitative rated items, an open question was also added to this construct to extend the answer possibilities and to gain some important insights into the ideas of participants. The qualitative answers to these questions are analysed via content analysis.
In Demographics respondents had to check their gender and indicate their age (Van Hooft et al., 2005), education level, occupation and country of birth in check box questions.
Most demographic questions were written for the survey, and several include response options suggested during the expert review. Some questions for these items were taken from existing demographic measuring scales used by Tactus for the intake questionnaire.