More Than Activity: The Effect of Sustained Engagement in Digital Alcohol Support Interventions for Regional and Remote Communities.

PURPOSE: This study examines differences between major city and regional and remote participants in engagement in a digital alcohol support intervention (Daybreak), risky drinking, and psychological distress and tests the mediating role of psychological distress. METHODS: This was a longitudinal, observational cohort study of Daybreak participants between January 2019 and December 2024 (N = 12,824). Outcomes were risky drinking and psychological distress. Ordered logistic regression examined associations between the outcomes and program engagement, and multilevel generalized structural equation modeling tested mediation by psychological distress. FINDINGS: At 6 months, risky drinking scores declined by 42% in major city participants and 57% in regional and remote participants. High engagement in reacting to posts reduced risky drinking in both metro (OR = 0.47, 95% CI 0.27-0.80) and regional and remote areas (OR = 0.42, 95% CI 0.18-0.99). High engagement in post sharing was associated with lower odds of high risky drinking only in major city participants (OR = 0.56, 95% CI 0.33-0.98). In regional areas, participants who aimed to quit drinking at registration had lower risky drinking (OR = 0.72, 95% CI 0.53-0.99), while longer program inactivity increased odds of psychological distress (OR = 1.95, 95% CI 1.13-3.38). Psychological distress mediated 56% of the association between post reactions and risky drinking in major city participants and 33% in regional and remote participants. CONCLUSIONS: Distinct engagement pathways across regional and remote and major city settings suggest the need for more flexible digital program designs. Psychological distress, as a partial mediator, should be both a treatment target and a mechanism of change.