Designing NUDGE-based interventions for people with excess alcohol drinking: a proof of concept study

Mohsan Subhani; Usman Talat; Saval Khanal; Joanne R Morling; Katy A Jones; Stefan Rennick-Egglestone; Indra Neil Guha; Justin Greenwood; Stephen D Ryder; Ivo Vlaev

doi:10.3310/nihropenres.13802.1

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Method Article

Designing NUDGE-based interventions for people with excess alcohol drinking: a proof of concept study

[version 1; peer review: 1 not approved]

Mohsan Subhani ^1,2, Usman Talat³, Saval Khanal⁴, [...] Joanne R Morling^1,2,5, Katy A Jones⁶, Stefan Rennick-Egglestone^2,7, Indra Neil Guha^1,2, Justin Greenwood², Stephen D Ryder^1,2, Ivo Vlaev⁸

Mohsan Subhani ^1,2, Usman Talat³, [...] Saval Khanal⁴, Joanne R Morling^1,2,5, Katy A Jones⁶, Stefan Rennick-Egglestone^2,7, Indra Neil Guha^1,2, Justin Greenwood², Stephen D Ryder^1,2, Ivo Vlaev⁸

PUBLISHED 28 Apr 2025

Author details Author details

¹ Nottingham Digestive Diseases Centre (NDDC), School of Medicine, University of Nottingham Digestive Diseases Centre, Nottingham, England, NG7 2RD, UK
² 2NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
³ Dyson School of Design Engineering, Imperial College, London, SW72BX, UK
⁴ Health Economics for Life Sciences and Medicine, King's College London, London, England, WC2R2LS, UK
⁵ Lifespan and Population Health, University of Nottingham, Nottingham, Nottinghamshire, NG5 1PB, UK
⁶ Academic Unit of Mental Health and Clinical Neurosciences, School of Medicine, Institute of Mental Health, University of Nottingham, Nottingham, NG72TU, UK
⁷ School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, NG7 2TU, UK
⁸ Warwick Business School, University of Warwick, Warwick, CV47AL, UK

Mohsan Subhani
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Usman Talat
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Saval Khanal
Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing

Joanne R Morling
Roles: Conceptualization, Funding Acquisition, Writing – Original Draft Preparation, Writing – Review & Editing

Katy A Jones
Roles: Conceptualization, Funding Acquisition, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Stefan Rennick-Egglestone
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Indra Neil Guha
Roles: Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Justin Greenwood
Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing

Stephen D Ryder
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Ivo Vlaev
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Alcohol Use Disorder (AUD) is a major public health issue linked to over 200 medical conditions and driven by complex cognitive, affective, behavioral, and socioeconomic factors. We used a novel “Nudgeathon” approach, based on MINDSPACE behavioral theory, to design targeted interventions for AUD by utilising liver stiffness results to promote change in high-risk drinking behaviours.

Methods

This study reports on "Nudgeathon," a one-day, collaborative multidisciplinary workshop designed to identify behaviour-change strategies with the potential to enhance AUD management using the MINDSPACE framework. With the intention of combining liver stiffness test results with subtle behavioural nudges, the event brought together stakeholders—healthcare professionals, behavioural scientists, and patients—to co-design prototypes aimed at reducing harmful alcohol consumption without restricting choice. The APPEASE criteria were used to evaluate intervention feasibility based on affordability, practicability, effectiveness, acceptability, safety, and equity.

Results

In the Nudgeathon, an experienced behavioural scientist introduced participants to behavioural change theories such as the MINDSPACE framework as a guide to design interventions for AUD. Diverse stakeholder groups collaborated to design digital “nudges,” including a liver icon that changes colour based on liver stiffness data to highlight alcohol’s impact. Facilitated by behavioural scientists, these groups developed descriptions of prototype interventions to encourage recovery behaviours. The APPEASE criteria were applied to evaluate the feasibility, resource needs, and potential population impact. Challenges identified through the Nudgeathon included technical requirements for data processing and effective patient communication, especially given the digital format of our planned interventions.

Conclusions

The Nudgeathon approach leverages behavioural science and digital tools to encourage healthier alcohol-related behaviours, focusing on environmental and psychological cues rather than individual willpower. This method may enhance traditional AUD treatments and engage patients non-responsive to standard recovery. Further research is needed to implement and confirm the effectiveness of the prototype interventions that were identified.

Plain Language Summary

Alcohol Use Disorder (AUD) affects many individuals and is linked to over 200 health conditions, highlighting a need for new approaches beyond standard treatment methods. This study used a collaborative "Nudgeathon" event to co-design interventions that subtly influence alcohol-related behaviour. Using the MINDSPACE framework, a behavioural change model, the Nudgeathon brought together healthcare professionals, behavioural scientists, and patients in a one-day workshop to design prototypes aimed at reducing harmful alcohol consumption. In this event, participants used liver stiffness test results to design visual nudges, like a digital liver icon that changes colour based on liver health data, to communicate alcohol’s impact to people experiencing harm due to alcohol misuse. Guided by behavioural scientists, teams developed strategies to encourage recovery without restricting patient choice. They assessed each prototype using the APPEASE (affordability, practicability, effectiveness, acceptability, safety, and equity) criteria, evaluating feasibility, cost-effectiveness, and potential social impact. This collaborative process revealed challenges, particularly in creating an effective digital infrastructure for personalized patient communication.

The Nudgeathon represents an innovative approach that combines digital tools and behavioural science, focusing on environmental cues rather than just willpower to influence alcohol consumption. This method may complement traditional AUD treatments by engaging individuals who are less responsive to conventional recovery programs. Future research will be necessary to further validate these findings and explore the broader potential of digital nudges in supporting AUD recovery.

Keywords

NUDGE. Alcohol. Alcohol use disorder. MINDSPACE. Intervention.

Corresponding author: Mohsan Subhani

Competing interests: No competing interests were disclosed.

Grant information: This project is funded by the National Institute for Health and Care Research (NIHR) under its (Grant Reference Number NIHR-155469). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. 
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © Crown copyright, 2025 Subhani M et al.. This open access work is licensed under the Open Government Licence v3.0

How to cite: Subhani M, Talat U, Khanal S et al. Designing NUDGE-based interventions for people with excess alcohol drinking: a proof of concept study [version 1; peer review: 1 not approved]. NIHR Open Res 2025, 5:38 (https://doi.org/10.3310/nihropenres.13802.1) First published: 28 Apr 2025, 5:38 (https://doi.org/10.3310/nihropenres.13802.1) Latest published: 28 Apr 2025, 5:38 (https://doi.org/10.3310/nihropenres.13802.1)

Introduction

Alcohol use disorder (AUD) is a growing problem in the United Kingdom (UK)¹. The Department for Health Improvement and Disparities estimates 14 adult persons per every 1000 identified as alcohol dependent for 2019–20 recorded at 1.4%. Socioeconomic and demographic factors that influence alcohol use include income, location, gender, and employment status². A UK government report on alcohol dependence in England emphasises the link between higher household incomes and increased alcohol consumption³. Among high-income groups, 35% of men and 24% of women reported drinking above the recommended limits, compared to 22% of men and 9% of women in lower-income households. This 13% difference in men and 15% in women suggests that higher income groups are more likely to consume alcohol at levels deemed risky by public health standards. These income-based differences in drinking habits may be influenced by lifestyle, social factors, and accessibility to alcohol, reflecting trends seen in national health statistics regarding alcohol use and income³. In the UK the geographical distribution of addictive behaviours, their concentration and clustering at a country-wide scale indicates a gradual rise in alcohol dependence from 11.6/1000 in the South to 17.47/1000 in the Northern regions. The report by the Department for Health Improvement and Disparities acknowledges a greater risk of alcohol dependence for younger men³.

Determinants of alcohol addiction are complex and can include the intersection of a variety of social, psychological, and demographic factors⁴. Social pressures, such as occupational stress and peer influence, can contribute to harmful drinking patterns, while psychological factors like depression, anxiety, and trauma, exacerbate the problem⁵. These determinants make it difficult for individuals to engage in recovery behaviours and overcome addiction⁶. Cognitive and emotional dysfunctions associated with AUD often lead to a cycle of harmful alcohol consumption. These cycles are reinforced by emotional triggers and negative life experiences, making recovery a daunting process for many⁷.

Traditional interventions for alcohol-related harm have focused on structured treatment programs, including medication, counselling, and peer support⁸. Hospital-based treatments can assume that individuals with AUD are motivated to change and ready to engage in recovery processes⁹. Other interventions, such as incentive-based programs and educational campaigns, rely on individuals actively participating in their recovery journey¹⁰. While such programs can be effective for some, they often fail to address the underlying psychological and environmental factors that drive addiction. As a result, there is a need for more innovative approaches that go beyond individual motivation and actively influence behaviour change in subtle, strategic ways.

The Nudgeathon offers a novel solution by drawing on behavioural science principles to co-design interventions for reducing alcohol-related harm¹¹. Grounded in the concept of "nudging"—the use of subtle influences to guide decision-making without limiting personal freedom—the Nudgeathon approach is built on the MINDSPACE framework¹². MINDSPACE outlines nine key factors that shape behaviour: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego¹². These factors help explain how people make decisions and they can be leveraged to design and implement interventions to encourage healthier drinking habits. Central to the Nudgeathon approach is co-design, which involves collaboration between diverse stakeholders, including health professionals, policymakers, and behavioural scientists¹³. The goal is to create intervention prototypes that integrate behavioural insights and real-world data, such as liver stiffness test results. Liver stiffness refers to the scarring of liver tissue, commonly known as fibrosis, which results from chronic liver injury. Its is measured by Fibroscan, which is an ultrasound-based technology¹⁴.

Liver stiffness is a powerful diagnostic tool that provides tangible evidence of alcohol-related harm. By using this data in combination with the MINDSPACE framework, the Nudgeathon aims to design interventions that not only resonate with individuals but also have a meaningful impact on their drinking behaviour.

While nudging techniques have been successfully applied in other areas of public health, such as smoking cessation and obesity prevention¹⁵, their use in addressing alcohol-related harm remains underexplored. The Nudgeathon seeks to fill this gap by developing and testing interventions specifically aimed at reducing harmful drinking. We present a case study using "the Nudgeathon," an innovative tool grounded in MINDSPACE behaviour change theory, to design interventions for alcohol use disorder (AUD) by utilising liver stiffness results to promote change in high-risk drinking behaviours.

Methods

Patient and Public Involvement

Although there were no patients or public involved in the current study, a PPI representative (JG) participated in the multidisciplinary group during the Nudgeothon workshop, alongside the PPI coordinator from Nottingham University Hospitals. The agreed plan is to seek full patient and public input on the draft feedback as part of a potential NIHR-funded research project.

Intervention evaluation

Guidance on health and social interventions by the UK Medical Research Council (MRC) and the National Institute for Healthcare Research (NIHR) emphasises the crucial task of intervention evaluation prior to implementation¹⁶. The rationale is that evaluation tools improve the quality of interventions, tilt chances of success favourably and provide the opportunity to compare stakeholder perspectives in relation to significant issues.

The intervention evaluation tool reported in the current section is the Nudgeathon and the intervention in question applies to choices made by patients in recovery from alcohol use disorder, under active treatment in hospital settings or community alcohol services in England. The concept of the Nudgeathon is a hybrid of ‘nudging’ and ‘hackathons where events are typically conducted over 1--2 days, bringing together a diverse range of stakeholders to create a nudge solution to a specific problem within a time-pressured environment.”¹⁷.

Prospect for nudging addiction

Behavioural scientists use the term "nudging" for the strategic application of subtle influences to encourage decision-making behaviour without constraining individual choices¹⁸. In Public Health and Policy, numerous initiatives similar to the Nudgeathon have demonstrated the efficacy of co-designing interventions that use nudge principles.

The "Smarter Lunchrooms Movement" demonstrated nudging strategies to influence food choices in school cafeterias, promoting healthier eating habits among students¹⁹. In the UK civil service, the Behavioural Insights Team has pioneered the application of rigorous behavioural science to public policy challenges, delivering projects targeting tax compliance and organ donation, nudging to achieve positive societal outcomes²⁰. Similarly, the "Nudge for Good" challenge, organised by behavioural science organisations, spurred the development of interventions for health-related issues. The nudge approach improves intervention design and offers application across diverse societal terrain.

A recent review identified models of hospital-based addiction treatment for opioids, alcohol and psychiatric disorders⁹. The Hospital-Based Alcohol Treatment (HBAT) involved a hepatology physician offering, for example, pharmacological agents alongside other recommended support services such as Alcohol Anonymous (AA). HBAT assumes that patients with AUD are interested in treatment⁹. Matching this approach, interventions to prevent and bring down addiction to alcohol have focused on practices including incentive-based programs of rehabilitation that involve rewarding compliance. Digital interventions, for example those conceptualised within the framework of mHealth, involve text messaging on mobile devices, reminding individuals with underlying AUDs to reduce alcohol consumption²¹. Other interventions use storied dramatization to convey valuable learning and messages as well as the use of digital apps²².

These interventions engage the person’s deliberations, often highly affective memories, and assume a degree of intrinsic motivation and rational ability to participate in recovery. This is in contradiction to the condition in populations²³. Specifically, this is a ‘design error’ to be avoided where intervention design implicitly asserts the willingness and mental capability of participants to engage with programs and discern the impact of consumption choices for self and others. Thereby, supporting the proposed notion that a person experiencing AUD may exhibit some boundaries to their ability to make rational choices, along with a disruptive level of emotional dysregulation concerning the place of self in relation to broader society^5,24,25. The person nonetheless is not completely irrational, rather as noted “But the truth is that even people with severe AUD respond to their environment, for example, the availability of alcohol, the cues to use them (e.g. advertising), what they cost, how approving or disapproving friends and family are, and the like”²³. All this points to a choice architecture that may be influenced by stakeholders involved in the treatment and well-being of patients. Building on this idea of person-environment interaction, the Nudgeathon tool and approach reported in the current study is designed using principles of Behavioural Science and postulates a relatively encompassing, holistic and effective strategy.

A key assumption when designing interventions is that choices to consume are largely automatic and operate in conjunction with conscious deliberations and environmental stimuli²⁶. This provides the opportunity to non-coercively influence and nudge individuals towards favourable choices. Whilst the susceptibility of AUD populations to Nudges is uncertain, this serves to emphasize the lack of research in this area. The impact of nudges and measurability of how susceptible populations might turn out to be remains unknown for promoting health behaviour²⁷. Recent emphasis has been placed on the potential for MINDSPACE-based nudges to address problem alcohol use, reported in the following sections.

The Nudgeathon

The current study reports a Nudgeathon which was conducted with the aim of designing interventions to promote recovery from alcohol addiction. The core team hosted the one-day event that has been applied to a host of health-related behaviours^13,17,28.

Krishane Patel et al. (2022)¹³ described Nudgeathons “as competitive, two-stage workshops wherein teams use insights from the behavioural sciences (so-called ‘nudge theory’), augmented by design thinking and drama theory, to generate potential solutions for problems related to human behaviour. The first stage captures the ‘empathy’ and ‘define’ stages of the Stanford d. School’s (2017) model²⁹. The second stage captures the ‘ideate’ stage with emergent conceptual ‘prototypes’ evaluated by an expert panel.”¹³. Prior to the event, preliminary meetings and discussions were held by the core team - three Behavioural Scientists (n=3), Hepatology specialists (n=4) working in Nottingham University Hospital, a lived experience expert (n=1), an academic psychologist (n=1), members of the public and an individual with lived experience (n=3), staff from community alcohol services (n=2), a research fellow and assistant (n=2), a research methodologist (n=1), and a public health expert (n=1).

Discussion involved determining the need for a Nudgeathon and its value in developing improved treatment designs, intended to facilitate patient recovery rates. Post-event the core team reconvened to assess the designs (prototypes) that were generated at the Nudgeathons by participants. Using insights from Nudge theory and application through the MINSPACE framework, a two-stage workshop is core to the design of Nudgeathons. The Nudgeathon day was organised and conducted using a three-step design consisting of delivery of theory, exercises in groups and collective evaluation. Followed by post-event evaluation. This has been illustrated in Figure 1.

Figure 1. Design of the Nudgeathon event.

The delivery of the event focuses on expert knowledge and adapts exercises designed to engage constructive discussion by attendees from a diverse range of specialisms. Subject-level expertise (such as Behavioural Science, Hepatology, Gastroenterology, and senior Consultants running treatment groups, participated in the current Nudgeathon). The inclusion of diverse participants constitutes a significant factor in Nudgeathons success, as well as in similar events such as Hackathon or Designation type events^17,30,31.

Results

Delivering theory selectively

On the day of the Nudgeathon a senior and experienced Behavioural Economist (IV) with experience facilitating Nudgeathon workshops - first introduced participants to the theory of Behaviour change (e.g. MINDSPACE framework and Design thinking). At the outset, theory is essential for interventionist thinking and enables the evaluation of different, potentially insightful perspectives^32,33. This educational component laid the foundation for the subsequent co-designing phase where two groups consisting of a diverse set of practitioners played with ideas about designing potential interventions to facilitate behaviour change during addiction (Figure 2).

Figure 2. Physical layout of Nudgeathon event.

For Nudgeathon participants drawing on developed Behaviour Sciences theory in this way provides an opportunity to gain perspectives from past studies. To connect theory with their practice, discussions, and insights gained in treating patients with addiction. The theory component delivered prior to group activity also provides context to guide interpretation by participants in determining important factors, particularly applicable across situations encountered during addiction recovery.

Two groups of stakeholders worked on prototypes (Conceptual development and application in group discussions). Two mid-level Behaviour Scientists facilitated and moderated the interactions. Guidance involves the interpretation of theory (Figure 3). In the two teams, the seven stages of the Nudgeathon were implemented with the aid of a template. Reflection on intervention design through such phases that are retrospective can enable broader consensus and critical treatment of ideas in the Nudgeathon process^28,33.

Figure 3. The key components of the MINDSPACE framework.

To contextualise and facilitate brainstorming and discussion within the groups, the moderation involved the provision of templates that tabulated – PRINCIPLE, EFFECTS, APPLICATION and INTERVENTIONS proposed by the participants (Table 1 Underlying data).

Prototype: Digital nudging for improved addiction recovery

Nudges can be timed, and their salience could be moderated using artificial intelligence (AI), such as through implementation of neural networks. For example, with current patients, treatment involves the use of imagery to explain Fibroscan results. This involves face-to-face interaction. The purpose is to indicate the severity and harms of liver sclerosis and prevent the individual from relapsing (Figure 4).

Figure 4. Prototype: Digital Nudging for Improved Addiction Recovery.

The figure shows the digitalization of paper-based communication between patient-physician.

Challenges of implementation

The complexity of the proposed Nudge emerges from the communication infrastructure, data analysis using Neural network processing and human skills required for interpretation on the part of the treatment physicians’ team, as well as the ability of the addicted patient to interpret and be nudged by the shape and colour change in the Icon.

The MINDSPACE framework offers a range of nudges, whilst the team at the Nudgeathon explored the features of salience (the colour and shape of the liver icon positioned on the App) and messenger (the idea that this message relies on the authority of attending healthcare professionals) in the mind of the patient.

Technological challenges and computational requirements

Mobilising the nudge system involves a specific set of technical skills, experience and labour. Namely, the software requirements discussed include the use of a programming language (e.g. Python), the use of standard machine learning frameworks (e.g. Keras), data processing library (e.g. Pandas), Socket programming for network communication of data, and the handheld device (e .g application of JavaScript to code for the Nudge Logo in the shape of the liver that changes colour) – presented on the user interface.

APPEASE

The Nudgeathon involved evaluation of the proposed ideas, this was facilitated by the Behaviour Scientists and with the use of APPEASE Criteria (Table 2). The application of the APEASE criteria enables a balanced understanding of the complications involved in the implementation of interventions.

Table 2. The APPEASE FRAMEWORK EVALUATION.

Messenger	People are influenced by who communicates the information. The authority or trustworthiness of the source is key.	The prototype involves healthcare professionals (doctors) as “the messengers”. This is a strong choice since patients are likely to trust their doctors and follow their guidance. The messenger enhances the impact of the nudges with their authority as a trusted figure, this influences the likelihood of patients taking the intervention seriously.
Incentives	People’s behaviour is influenced by rewards and punishments, but their responses are shaped by factors such as timing and perception of gains vs. losses.	The prototype provides indirect incentives through the colour-coded liver icon (green for good health, yellow for warning, red for poor health). This creates a psychological reward when patients experience health improvements (green icon). There are no tangible or financial incentives offered, which could enhance engagement. Implementing small rewards or recognitions for milestones (e.g., consistent improvement) could further boost motivation.
Norms	Social norms influence people’s behaviour. We are more likely to follow behaviours we believe are commonly adopted by others.	The current prototype does not include social norms. However, adding a feature that shows how similar patients are progressing (anonymised) could encourage individuals to stay on track by creating a sense of collective responsibility or healthy competition. The suggestion being that “peer comparisons” and “group norms” could be powerful motivators in addiction recovery.
Defaults	Pre-set options (defaults) tend to stick, as people often follow the path of least resistance.	The prototype design does not include “defaults” (a type of nudge). However, automatic features could be added, such as setting the app to send regular, timely reminders to check progress of the user. Default settings could also include “pre-scheduled consultations” or “check-ins” that minimise patient effort in maintaining engagement with the intervention.
Salience	People’s attention is drawn to things that are novel, simple, and relevant to them. Visual cues are powerful.	The colour-coded liver icon (green, yellow, red) adapts the use of “salience”. This offers a simple visual representation of health status that immediately grabs attention and is easy to understand. The icon’s changes are designed to make the patient’s health status both visible and meaningful, increasing the likelihood that they will act on the information. However, over time, the novelty of the icon may fade, so periodic changes in the app interface or notifications could help maintain user engagement.
Priming	Behaviour can be influenced by subtle, subconscious cues that prime people to act in certain ways.	The prototype does not explicitly use priming, however, this could be introduced by embedding subtle cues in the app interface. As an example consider showing motivational images (associated with affect, healthy individuals or families) or positive messages when the patient logs into the app. These could unconsciously steer patients toward healthier behaviour. Priming could also be incorporated by sending uplifting or goal-oriented messages before a patient interacts with the app. That offers a psychological reward and feeling of improvement.
Affect	Emotions play a significant role in decision-making and behaviour. Positive or negative emotional associations can drive behaviour change.	The liver icon triggers an emotional response based on the colour: green provides a sense of achievement and progress, while red signals danger and can evoke fear or concern. Whilst emotional engagement is crucial for behaviour change, there is a risk that consistently negative feedback (e.g., repeated red icons) could demotivate or discourage patients. It’s important that the app balances these emotional triggers with frequency and intensity of positive reinforcement. And encouragement when progress is made.
Commitments	People tend to stick to publicly made commitments or pledges. This helps increase accountability and motivation.	The prototype could enhance its use of “commitment” by allowing patients to set personal health goals and publicly commit to them within the app (for example, in a virtual support group, a social commitment to act induces a sense of obligation and regard for others). These commitments could be reinforced by regular reminders and progress updates, helping patients stay accountable. Integrating a feature that allows patients to track their adherence to goals (e.g., staying sober for X days) could increase motivation and accountability.
Ego	People act in ways that make them feel good about themselves or protect their self-image. Positive feedback and reinforcement can support this.	The app could strengthen awareness in relation to the user's “Ego”, a principle activated by incorporating more features that highlight the patient’s progress and achievements over time. For instance, displaying a visual chart of health improvements, or issuance of badges and rewards for reaching milestones. This may influence patients to feel positive about their efforts. The idea is that celebrating small victories reinforces positive behaviour and supports the patient’s self-esteem, making them more likely to stick with the recovery process.

The APPEASE criteria were developed to evaluate and understand the feasibility of interventions in public health. To provide a system for comprehending the potential impact on a population^34–38. The aspects under the criteria assume the desirability of cost-effective interventions, applied in context, checked for unintended consequences and resource availability; that includes acceptance by stakeholders responsible for its implementation and sustained effects. We applied the criteria to our proposed prototype. To our knowledge, the criteria have not been applied to alcohol addiction treatment interventions in the United Kingdom. The table provides a detailed evaluation (Table 2).

Discussion

The Nudgeathon represents an innovative approach that combines digital tools and behavioural science, focusing on environmental cues which could influence addictive behaviours^11,28. However, their application in alcohol services is limited. This study used a collaborative "Nudgeathon" approach to co-design interventions that subtly influence alcohol-related behaviour. The Nudgeathon assembled an interdisciplinary team of healthcare professionals, behavioural scientists, and patients to co-design interventions that target alcohol use disorder (AUD). The strategies that were developed in guidance with the MINDSPACE framework, leveraged liver stiffness data in the form of biofeedback to mitigate high-risk drinking behaviours¹².

The proposed nudge draws on MINDSPACE and Design Thinking, to present an innovative design that is personalised to each patient’s behaviour and needs essential for successful recovery. The use of salient messages by an authority messenger (prescribing healthcare professional) as part of digital infrastructure that provides real-time monitoring for patients and attending physicians, can improve outcomes. As Perianez et al. (2017), note “AI-enhanced adaptive interventions are not only tailored but also continuously evolve, adapting in real-time to each user’s unique choices and circumstances, thereby determining the content and timing of interventions, and identifying who may need additional support”³⁹.

The prospect of recovery from alcohol use disorder presents challenges for patients and healthcare providers in the UK. Additionally, the National Health Service (NHS) in its aim to provide sustainable, cost-effective and clinically enhanced treatment for patients in the UK has much to gain. The results of the activities conducted at the Nudgeathon event manifested in the notion of “digitalized Nudging in real-time”. The prototype offers benefits in the form of working with past data, to predict future tendencies and risks posed for patient recovery. A recent study applied within the context of Chronic Obstructive Pulmonary Disease (COPD) used time series patient data to manage patient health and cost-effective measures⁴⁰.

With AUD cases recovery the patient may be motivated by real-time messages that reinforce a sense of self-improvement and goal achievement by making beneficial choices. Models based on machine learning can track health data; and enhance visibility over clusters of the population. This may also enable better investment and allocation of healthcare resources. Studies additionally emphasize the importance of themes associated with technology acceptance and use by physicians⁴¹. This includes potential issues with resistance to change and trust as well as the perils of siloed systems that are not integrated within the broader encompassing healthcare system of Information communication technology.

Although the proposed prototype offers a promising model there remain several limitations to consider. The evidence on the effectiveness of nudging in alcohol use contexts is still limited¹¹, particularly regarding sustained long-term behaviour change among AUD populations. Alcohol use disorder can be associated with a cognitive impairment which may impact decision making hence the efficacy of nudging may vary significantly across individuals⁴². More work is needed to tailor support to those with more complex needs. While MINDSPACE has shown efficacy in other areas, such as promoting healthier eating habits or tax compliance, its specific application to AUD warrants further empirical validation. This is especially true given the unique psychological and social complexities associated with AUD^43,44.

Future research may explore the longevity of nudge-based interventions in AUD management and explore how such interventions interact with conventional treatments both in primary and secondary care. Additionally, exploring tailored nudges that take individual differences into account (such as motivational levels or cognitive capacity) may enhance the precision and impact of these interventions⁴⁵. Lastly, evaluating the ethical implications of nudging in health interventions is crucial⁴⁶. While nudges are non-coercive by design, the potential for misuse or manipulation highlights the value of transparent frameworks applied to healthcare settings⁴⁶.

Conclusion

The proposed intervention aims to reduce inequalities and the increase of alcohol use disorder and alcohol-related harm in the context of the UK and the growing cost to the public health sector. A reduction in alcohol intake and the development and escalation of AUD benefits the sustainable operations of the NHS.

We propose that due to the limited ability of addicted patients to engage with traditional education programs and interventions that distribute helpful information; MINDSPACE and nudges in concert with digital technology and machine learning, provide opportunity.

Ethics and consent

Ethics approval is not required because primary data is not collected. Written informed consent was obtained from all the participants.

Data availability

OSF (OpenScienceFramework): Nudgeathon NIHR - paper, https://doi.org/10.17605/OSF.IO/3ZAUF⁴⁷.

The project contains the following underlying data:

Table 1 - An example of the template provided to participants to guide creating a Nudge for alcohol use disorder.

Data is available under CC0 1.0 Universal license.

Faculty Opinions recommended

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