A Web-Based Toolkit to Provide Evidence-Based Resources About Crystal Methamphetamine for the Australian Community: Collaborative Development of Cracks in the Ice

Background The use of crystal methamphetamine (ice) and the associated harms for individuals, families, and communities across Australia has been the subject of growing concern in recent years. The provision of easily accessible, evidence-based, and up-to-date information and resources about crystal methamphetamine for the community is a critical component of an effective public health response. Objective This paper aims to describe the codevelopment process of the Web-based Cracks in the Ice Community Toolkit, which was developed to improve access to evidence-based information and resources about crystal methamphetamine for the Australian community. Methods Development of the Cracks in the Ice Community Toolkit was conducted in collaboration with community members across Australia and with experts working in the addiction field. The iterative process involved the following: (1) consultation with end users, including community members, crystal methamphetamine users, families and friends of someone using crystal methamphetamine, health professionals, and teachers (n=451) via a cross-sectional Web-based survey to understand information needs; (2) content and Web development; and (3) user testing of a beta version of the Web-based toolkit among end users (n=41) and experts (n=10) to evaluate the toolkit’s acceptability, relevance, and appeal. Results Initial end user consultation indicated that the most commonly endorsed reasons for visiting a website about crystal methamphetamine were “to get information for myself” (185/451, 41.0%) and “to find out how to help a friend or a family member” (136/451, 30.2%). Community consultation also revealed the need for simple information about crystal methamphetamine, including what it is, its effects, and when and where to seek help or support. Feedback on a beta version of the toolkit was positive in terms of content, readability, layout, look, and feel. Commonly identified areas for improvement related to increasing the level of engagement and personal connection, improving the ease of navigation, and balancing a “low prevalence of use, yet high impact” message. A total of 9138 users visited the website in the 3 months immediately post launch, and over 25,000 hard-copy Cracks in the Ice booklets and flyers were distributed across Australia. Of these resources, 60.93% (15,525/25,480) were distributed to relevant organizations and mailing list subscribers, and 39.07% (9955/25,480) were ordered directly by individuals, services, and community groups via the Cracks in the Ice website. Conclusions The codevelopment process resulted in an engaging Web-based resource for the Australian community to access up-to-date and evidence-based resources about crystal methamphetamine. The Cracks in the Ice Community Toolkit provides much-needed information and support for individuals, families, and communities.


Background
The use of methamphetamine and related harms has been the subject of growing concern among the Australian community and media in recent years.Although methamphetamine is not a new drug in the Australian market [1,2], growth in the availability and consumption associated with the high-purity, crystalline form of methamphetamine (crystal methamphetamine or ice) has caused considerable concern among the community.Recent data suggest that there has been a shift toward using crystal (ice) rather than powder (speed) forms of methamphetamine among regular methamphetamine users [3,4] as well as an increase in methamphetamine-related harms [2] and deaths [5].Indeed the physical, psychological, and social harms associated with methamphetamine use are significant.Major harms include increased risk of stroke and other cardiovascular problems, dependence, psychosis and other mental health problems, violence, and overdose [5][6][7][8][9].
In April 2015, the Australian Government established a National Ice Taskforce to provide advice to the government on the impacts of crystal methamphetamine in Australia and the actions needed to address this growing problem.Findings from the taskforce indicated that there was a clear need to support families, workers, and communities to better respond to drug and alcohol issues, including crystal methamphetamine use [10].One critical aspect of responding to this issue is the provision of easily accessible, evidence-based, and up-to-date information and resources about crystal methamphetamine for the general population.Over the past 10 to 15 years, there has been a rapid growth in the number of individuals with access to the internet, with almost 40% of the world's population now having access to online information [11].In 2017, 86% of Australia's population were internet users [12] and an estimated 80% of Australians use the internet to search for health information [13].The potential of the internet to improve accessibility and to overcome geographic and physical constraints makes it a medium of growing importance for the dissemination of health information, support, and treatment [14], including in relation to substance use and mental health problems [15].With similar rates of internet access reported among active users of illicit drugs [16], the potential for technology to reach marginalized groups in the community is large.

Objectives of This Study
Although there has been a proliferation of information about crystal methamphetamine in Australia, both in the media and on the Web, the credibility of such information is not always apparent, and it is likely difficult for members of the community to evaluate what is evidence-based and what is not.Thus, as part of a coordinated response to the National Ice Taskforce recommendation, the Cracks in the Ice Community Toolkit [17] was developed.The Web-based toolkit was designed to improve access to evidence-based and up-to-date information and resources about crystal methamphetamine for Australians, including concerned community members, users, their friends and family members, health professionals and emergency service workers, and schools.This paper summarizes the comprehensive codevelopment and beta-testing process of the Cracks in the Ice Community Toolkit.

Overview of the Codevelopment Process
Development of the Cracks in the Ice Community Toolkit was a broad-reaching and iterative process, involving multiple phases over an 18-month period.As an initial step, an Expert Advisory Group (EAG), consisting of researchers with expertise in drug and alcohol prevention and treatment, internet interventions, and intervention development, was established to provide guidance and advice throughout the development process.Collaborations with consumer experts (ie, individuals with a lived experience of addiction, especially related to ice use, or mental health issues) were also established to provide advice throughout the development process.For example, consumer experts contributed to initial brainstorming, provided feedback on preliminary designs and different iterations of the Web-based toolkit, reviewed the beta website, and provided ideas for future development.Consumer participation is important to ensure that consumer needs, concerns, and values are not overlooked [18,19].Engaging and linking with consumers was a critical component of the codevelopment process and ensured a strong end user voice in the final Cracks in the Ice toolkit.
The development process was informed by the latest available literature and data on crystal methamphetamine use [2,4,7,8,[20][21][22] and drug education [23] and was developed in collaboration with community members across Australia and expert collaborators.Development occurred across 3 specific phases, which are outlined below: The codevelopment process is outlined in Figure 1, and key phases are summarized in further detail below.

Measures
Demographic data collected included gender, age, place of residence, occupation, and country of birth.Lifetime use of methamphetamine was assessed using 2 items: " Have you ever used methamphetamine (also known as ice, speed, base, crystal meth, meth, shabu, Tiny, goey or glass)?" (Yes or No) and " What type of methamphetamine have you used ?"(Ice [crystal], speed or base).Respondents who reported crystal methamphetamine use were asked a further set of items to assess route of administration (smoking, injecting, other), history and frequency of use, reasons for using, and intentions to use in the future.Harms associated with crystal methamphetamine use were assessed among the whole sample using an adapted version of the Social Harm from Others Scale [24].These items were assessed to inform development of content for the Web-based toolkit, particularly for family and friends of people who use crystal methamphetamine.Participants were also asked to indicate reasons for visiting an information website about crystal methamphetamine, information areas of most interest, and preferences for how and where to seek help related to ice use.Finally, all respondents were asked to provide feedback on preliminary design concepts (eg, logos, webpage layout, and designs) to be included in the Web-based toolkit.

Data Analysis
Data were collated and analyzed in IBM SPSS Statistics 22 (IBM Corp, Armonk, NY, USA).Descriptive analyses were conducted to illustrate the sample characteristics and summarize interest in components of the proposed toolkit.

Phase 2: Content and Web Development
Content development occurred at multiple stages throughout the development process.First, a preliminary site structure was developed in consultation with the EAG to identify key content areas and target audiences for the Web-based toolkit.Feedback on the structure was collected during Phase 1, with results from end users confirming the key areas and target groups proposed by the EAG.A key aim of this project was to bring together the best available evidence and resources about crystal methamphetamine rather than creating entirely new material.
As such, the next step in the content development process was to review existing resources developed by members of the project team for the Positive Choices portal [23,25].This portal houses evidence-based drug education resources and factsheets for school students, parents, and teachers, including those related to methamphetamine, which were developed in relation to the latest available literature.These factsheets were used as the basis for the development of the Cracks in the Ice key webpages, with adaptations made as necessary (eg, adapting content to reflect a general population rather than a school-based audience).
Scholarly databases and relevant websites were also searched using keywords related to methamphetamine (eg, "crystal methamphetamine," "ice," "ice information") to identify other relevant resources to inform development of webpage content.
All new content was developed by a member of the project team with reference to existing evidence-based resources and the relevant research literature and were subject to expert review by at least two members of the EAG.

Assessment of Eligibility of External Resources
Existing resources developed by individuals or groups external to the research team, such as guidelines and Web-based programs, were independently reviewed by the Cracks in the Ice project team.Resources were assessed for eligibility for inclusion using an adapted version of the National Health and Medical Research Centre Body of Evidence Matrix [26] against 4 specific criteria: (1) evidence base, (2) impact and utility, (3) generalizability, and ( 4) applicability (see Multimedia Appendix 1 for additional information).In addition, resources were only eligible for inclusion if they were less than 10 years old at the time of development (ie, developed during 2006-2016), unless a justification could be made as to why the resource should be included (eg, no other existing resources were available or the resource addresses an important area of need).To avoid duplication of content, resources were ineligible if their content substantially overlapped with other resources already included on the Cracks in the Ice website.

Readability Testing
To assess whether the vocabulary to be used in the developed content was appropriate, potentially problematic words, identified by 2 members of the research team, were checked for their frequency of use in the English language, as an indication of how well known and understood they would be by a general population audience.This was conducted using the Oxford English Dictionary Key to Frequency tool, where word frequency is ranked between Band 1 (extremely rare) and Band 8 (very common).All words within Bands 5 and 8 were permitted for inclusion on the website.Words in Bands 1 to 3 were excluded or replaced.Band 4 words, described by the Oxford English Dictionary as "recognisable to English speakers," were assessed on a case-by-case basis and included if they were deemed to be the most appropriate term to use.Terms that described specific mental health or physical health conditions, for example, were included and a glossary hover function was used to provide a definition for users.

Expert Review of Information for Aboriginal and Torres Strait Islander People
The preliminary site structure for the Cracks in the Ice toolkit included a webpage containing a directory of key support services (by state and territory) specific to Aboriginal and Torres Strait Islanders.Key support services and their relevant contact information (eg, phone number, website, email, and postal address) were collated during the scoping exercise described previously.To ensure the information was presented in a culturally appropriate manner, an Indigenous creative agency was engaged to review the content and language and to create the design elements used on the page.Recommendations made included simplifying the language used throughout the webpage, including more personal language (eg, "you" and "your"), reordering of content to reflect that much of the key toolkit information (eg, what is ice, its effects, and how to stay safe) was also relevant to Indigenous communities, and use of landscape imagery (eg, desert or beach) to represent the different states and territories across Australia.

Design and Procedure
Following Phases 1 and 2, a beta version of the Cracks in the Ice Community Toolkit website was developed.Beta testing was conducted among community members and the EAG to ensure the Web-based toolkit was appealing, easy to understand, and engaging, before being launched to the general public.Individuals who participated in the initial end user consultation survey, and who agreed to being contacted in the future, were sent an email invitation to participate in the second phase of consultation.Participants were also recruited via social media channels (Facebook and Twitter) and the research team's personal and professional networks.Recruitment and beta testing took place over a 5-week period during August and September 2016.Respondents were required to be over the age of 16 years and to be living in Australia to be eligible to take part, and all participants were required to provide informed consent.All participants were asked to view a beta version of the Cracks in the Ice toolkit via a preview site and to complete a Web-based survey (of approximately 60 min) to provide in-depth feedback about the website.Members of the EAG (n=10) were also invited to participate in in-house beta testing via the Web-based survey.Approval was obtained from the UNSW HREC (HC15732).A full copy of the questionnaire is available on request.

Measures
Respondents were asked to provide closed and open-ended feedback about the ease of navigation, whether the content was easy to understand and informative, how much they liked or disliked the images and infographics used on the website, their likelihood of engaging with specific toolkit features (eg, a quiz or bookmarking functionality to save resources), and overall impressions.

Patterns of Methamphetamine Use
Of the 451 survey participants, 37.8% (155/451) had used some form of methamphetamine in their lifetime and 30.4% (137/451)

Help-Seeking Preferences
When asked where they would be comfortable seeking help if they needed help for their ice use, the most common responses were a "friend or family member" (52/137, 38.0%), counselor or psychologist (42/137, 30.7%), and general practitioner (39/137, 28.5%).Moreover, 21.9% (30/137) of crystal methamphetamine users indicated that they would be comfortable seeking help online; however, one-quarter (34/137, 24.8%) said that they would not feel comfortable asking for help at all.Additionally, 51.2% (197/385) of all participants indicated that they did not feel that effective treatments were available for people seeking help related to the use of ice.

Social Harms Resulting From Someone Else's Use of Crystal Methamphetamine
Harms

Information Needs About Crystal Methamphetamine
The mostly commonly endorsed reasons for visiting a website about crystal methamphetamine were to "seek information for myself" (185/451, 41.0%) and "to find out how to get help for a friend or a family member" (136/451, 30.2%; see Table 3).In terms of preferences for topic areas, respondents were most interested in obtaining information about the "effects of ice" (199/451, 44.1%), "why do people use ice?" (134/451, 29.7%), and "how many people use ice?" (125/451, 27.7%).When asked to provide open-ended feedback, participants indicated they wanted additional information about a range of topics, including how to help a family member using ice, how to protect yourself from aggressive behavior, the long-term effects of ice use, ice and the law, and warning signs of dependence.

Phase 2: Content and Web Development
Content development was informed by the Web-based survey with end users and the EAG, literature searching and scoping of evidence, and consultation with external collaborators.The beta version of the toolkit was structured to provide information for the general Australian community across 3 key areas: ice itself ("What is ice?"), its physical and mental health effects ("What are the effects of ice?"), and where and how to access support or treatment for issues related to ice ("Staying Safe").The toolkit also included user-specific information and resources for community groups and organizations, families and friends of someone using crystal methamphetamine, health professionals and emergency services workers, and schools (parents, teachers, and students).In addition to desktop computers, the toolkit was also optimized for mobile phones, laptops, and tablet devices.A hard-copy booklet was also developed as a companion resource to promote the Web-based toolkit and to provide community groups (eg, support groups, local drug action teams), health professionals, and individuals with tangible Cracks in the Ice resources and information about crystal methamphetamine.The decision to develop and distribute hard-copy booklets was made in consultation with the EAG and is consistent with previous dissemination activities conducted by the research team.

Participants
A total of 41 participants completed the Web-based survey.The mean age of participants was 34.4 years (SD 15.0) and 49% (20/41) of the sample were female.Nearly half of the sample (19/41, 46%) resided in NSW and almost one-quarter in Victoria (9/41, 22%), with 61% (25/41) of all participants living in metropolitan areas at the time of the survey and 39% (16/41) in regional or rural areas.Over two-thirds of the sample (28/41, 68%) indicated that they knew someone who uses ice, with 39% (16/41) identifying themselves as a friend of an ice user and 20% (8/41) as a family member of someone who uses ice.The sample consisted of individuals representing a variety of different groups, including parents (16/

Feedback
Overall, feedback on the beta version of the Cracks in the Ice Community Toolkit was positive in terms of content, readability, layout, and aesthetic quality of the site.All community participants (41/41, 100%) rated the content as easy to understand and informative, and the vast majority (38/41, 93%) rated the site's navigation as "good" or "very good."Example qualitative feedback is provided in Multimedia Appendix 2. The EAG was also positive in its feedback about the Web-based toolkit, with the main areas for improvement relating to the need to improve the ease of navigation and layout of information on some content pages (see Multimedia Appendix 2 for example feedback).Three quarters of participants (28/37, 75%) indicated that they liked the toolkit's mission statement "Trusted, evidence-based information about crystal methamphetamine," and more than half (20/37, 54%) indicated that an evidence base was most important when looking for information about crystal methamphetamine.
Table 5. Overview of user-specific content on the Cracks in the Ice website.

Description User group
The community toolkit provides local councils, parents and citizen groups, community organizations, or concerned community members with the appropriate tools (including factsheets, brochures, booklets, and PowerPoint presentation and talking notes) for use at community forums and events

Community toolkit
This section provides information about helping a loved one who may be using ice, including tips for starting a conversation, how to protect yourself, and where to get additional support Families and friends Factsheets, guidelines, and Web-based resources for professionals working across a range of sectors, including general practitioners, frontline workers in hospital settings and emergency departments, frontline workers in alcohol and other drug settings, mental health practitioners (eg, psychologists, social workers, and counselors), paramedics, and police services Health professionals Access to information and resources for parents, teachers, and students, including webinars, factsheets, and interactive games Schools

Usage Statistics
The Cracks in the Ice Community Toolkit was officially launched on April 3, 2017.In the 3 months immediately post launch, the toolkit received a total of 9138 visitors.Excluding the homepage, the most frequently visited toolkit pages were the following: How many people use ice?, the Community Toolkit, and What is ice?.Since launch, a total of 25,480 hard-copy Cracks in the Ice resources (14,040 booklets and 11,440 flyers) have been distributed to individuals, organizations, and communities across Australia.Of these resources, 60.93% (15,525/25,480) were distributed to relevant organizations and subscribers on the Cracks in the Ice mailing list, and 39.07%(9955/25,480) were ordered directly by individuals and organizations via the Cracks in the Ice website.
A full evaluation of engagement with the website is planned to determine who is visiting the website, the usefulness of the Web-based toolkit among visitors, and to better understand how people respond to the information provided in the toolkit.These data will be used to better tailor and target the information and resources on the Cracks in the Ice Community Toolkit.

Summary of Findings
This paper described the codevelopment process of Cracks in the Ice, a Web-based toolkit designed to provide evidence-based information and resources about crystal methamphetamine for the Australian community.The codevelopment process was broad-reaching and iterative, involving more than 450 community members across the country and expert collaborators and researchers over an 18-month period.The initial Web-based survey conducted with end users provided important insights into the information needs of the Australian community in relation to crystal methamphetamine and validated the preliminary site structure.Results indicated that community members were seeking information about crystal methamphetamine, particularly in relation to its effects and reasons for use, and were likely to visit a Web-based toolkit to search for information for themselves and to help a friend or family member.Social harms related to the use of crystal methamphetamine were considerable in our sample, with nearly one-third of the respondents reporting 1 or more harm related to someone's use of the drug.Overall, 63.6% (287/451) of the Web-based survey sample reported either having ever used crystal methamphetamine or experiencing at least one social harm from someone else's use of ice Thus, the majority of the sample had lived experience of the impacts of crystal methamphetamine use, either through their own use or that of someone else.
Consistent with previous research [27,28], participants in this study indicated that their preferred source of help would be from friends and family members.One in 4 ice users from our Web-based scoping survey said that they would not feel comfortable seeking any help for their ice use and only 21.9% (30/137) said they would be comfortable seeking help online.Additionally, just over half of the whole sample (197/385, 51.2%) said they did not feel effective treatments were available for methamphetamine use.Stigma and the belief that no effective help is available are 2 of the most commonly stated barriers to help-seeking for substance use and mental health problems [29][30][31].Internet-based interventions do hold promise to overcome these barriers to care [32,33], particularly if information can be presented in a nonjudgmental and stigmatizing manner [34].Further research is needed to clarify the reasons why some individuals do not feel comfortable seeking help online for their methamphetamine use (eg, privacy or stigma) and to understand how these concerns can be addressed in online treatment delivery.Importantly, the Cracks in the Ice Community Toolkit was developed to provide evidence-based information about ice, including information about when and where to get help, and what types of treatment are available, but not as a treatment intervention.Results from the beta testing survey indicated that the Web-based toolkit was well received by end users as a source of information about ice.
Overall, the beta-testing results were overwhelmingly positive and served to both reinforce the development work conducted thus far and further refine the toolkit to ensure it was as relevant, acceptable, and appealing as possible for the target audience.
Three key areas for improvement emerged from the beta-testing process.First, end users indicated that they wanted an increased level of engagement and personal connection with the site.In response to this, additional images and infographics were included across the website.Specifically, photos were paired with real quotes from individuals about their experiences related to methamphetamine and prominently displayed on all key pages across the Cracks in the Ice site.For example, the homepage was modified to include a rotating banner of different pairs of images and quotes, for example, "If we can provide support to people form a young age we can help."Second, beta-testing data indicated that there was a clear need to improve the ease of navigation on the website to ensure that site users could easily locate the information they were seeking.To improve navigation, the project team worked in consultation with the Web developers to modify the layout across several webpages, for example, including drop-down menus on the homepage, adding "Related Content" links on each page to allow users to easily navigate to similar content, and using the Show and Hide functionality to collapse large amounts of text into smaller sections.Third, beta testing revealed that there was a need to better covey a "low prevalence of use, yet high impact" message.To address this feedback, text was modified on the How many people use ice?webpage to reflect the difficulties in measuring methamphetamine use in the general population, and additional sources of data on harms were included.In addition, an infographic was developed to convey the message that although rates of use might be low, the impact of crystal methamphetamine use on individuals, families, and communities is substantial.

Community Response and Future Directions
Importantly, beta-testing data confirmed that end users valued the toolkit's emphasis on providing evidence-based information, with more than half of participants indicating that an evidence base was the most important aspect when looking for information about crystal methamphetamine.Given the considerable focus on ice use in Australia in recent times and the potential for misinformation about crystal methamphetamine to be disseminated via the media and the internet, a key strength of the Cracks in the Ice Community Toolkit is the ease of access to evidence-based information and resources.To ensure that the information and resources remain evidence-based and up-to-date, important next steps for the maintenance of the website will be to review the academic literature and other relevant sources at regular intervals in the future and to update the website accordingly.Since its launch, community response has been positive, with steady increases in visitors to the Cracks in the Ice website and regular requests to receive hard-copy booklets and flyers.The dissemination and early demand for hard-copy resources is another strength of Cracks in the Ice, with booklets ordered by, and distributed to, a range of groups across the country, including drug and alcohol services, community centers, and support groups.Although developed as a companion resource to the Web-based toolkit, dissemination of hard-copy resources may be important for providing support to people who are less familiar with Web-based resources, or those without easy access to computers or the internet.Ultimately, the final Cracks in the Ice Community Toolkit XSL • FO RenderX provides Australians, including community groups, families and friends of someone using ice, health professionals and emergency service workers, and individuals affected by crystal methamphetamine, with the much-needed evidence-based and up-to-date information and support, in one easily accessible Web-based toolkit.

Limitations
The findings presented in this paper should be considered in light of some limitations.First, the sample recruited for the initial end user consultation was not representative of the general Australian population, and prevalence of methamphetamine use (155/451, 37.8%), including ice, was significantly higher than the population rates [3].Although we did not primarily target methamphetamine users in our recruitment advertisements, it is likely that our strategy attracted individuals with a particular concern about methamphetamine use, that is, individuals who use ice and their friends or family members.The Web-based consultation survey was also restricted to individuals who use the internet, and in particular, Facebook.Nonetheless, the survey methodology was successful in identifying key knowledge gaps and information needs in the community, as well as design and aesthetic preferences for the website, thereby directly informing the development of the Web-based toolkit.It should also be noted that the consultation survey was completed by only a small number of teachers and health professionals, 2 target audiences of the toolkit.Importantly, the content housed on Cracks in the Ice for these 2 groups primarily draws on existing resources that were previously developed in consultation with end users (eg, the Positive Choices website, which was developed with input from teachers, and guidelines developed by expert health professionals).Nonetheless, there is opportunity for future development work for the toolkit to involve further consultation with teachers and health professionals.Similarly, beta testing was conducted among a relatively small sample, via convenience sampling, and may not be representative of the general population.Fortunately, the Cracks in the Ice Community Toolkit contains feedback loops and opportunities for website users to submit questions and provide feedback, ensuring the continuing involvement of additional community members as the site is maintained into the future.

Conclusions
This recently developed Cracks in the Ice Community Toolkit involved in-depth community consultation and brings together the latest evidence and resources pertaining to crystal methamphetamine in Australia.Ultimately, the toolkit provides the Australian community with a central access point for trusted, evidence-based, and up-to-date information about crystal methamphetamine.Important next steps are to monitor engagement and use of the website, to embed the most recent evidence into the Web-based toolkit to ensure the currency of information, and to remain responsive to emerging information needs about crystal methamphetamine among the community.

Figure 1 .
Figure 1.The codevelopment process of the Cracks in the Ice Community Toolkit.

Figure 2 .
Figure 2. The Cracks in the Ice Community Toolkit home page (at time of launch).

Figure 3 .
Figure 3. Screenshot of the Community Toolkit page (at time of launch).

Figure 4 .
Figure 4. Screenshot of the Families & Friends page (at time of launch).
Beta testing among end users and the EAG to ascertain feedback about the acceptability and relevance of the Cracks in the Ice Community Toolkit.
a Participants could endorse multiple reasons.

Table 2 .
Social harms associated with someone else's use of crystal methamphetamine (N=451).

Table 3 .
Reasons for visiting a website about crystal methamphetamine (N=451).
a Participants could endorse multiple reasons.