Category: Substance misuse
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NF - Naimh Fitzgerald
The Evidence Exchange programme, an Alliance for Useful Evidence initiative, seeks to encourage the sharing and use of social policy evidence across the UK. One of the programme’s themes is the role of evidence in developing policy and interventions that reduce people’s risk of alcohol related harm, such as ABIs - Alcohol Brief Interventions. In this episode, Dr Naimh Fitzgerald discusses what is known about ABIs, how and where they work; her recent research on delivery of ABIs outside of primary healthcare, and pointers for practitioners.
NF: My name is Naimh Fitzgerald and I am a Lecturer in Alcohol Studies at the School of Health Sciences, and that is at the University of Stirling in Scotland.
Stirling University is part of the UK Centre for Tobacco and Alcohol Studies, and that’s a partnership of 13 universities working on alcohol and tobacco research in teaching. My role at Stirling is to support teaching and public engagement on alcohol for the UK partnership, and if people are interested there are a number of ways they can access our teaching or get involved. If they have a look at our website which is www.ukctas.net. So I am going to talk today about Alcohol Brief Interventions. Alcohol Brief Interventions are also known as Identification & Brief Advice, or IBA, and that term might be better known to some people. So I’m going to talk about what is an Alcohol Brief Intervention, who is it for, does it work, how can services deliver Alcohol Brief Interventions and I’ll finish up with some key messages and key questions for the future.
So firstly, what is an Alcohol Brief Intervention? Well Alcohol Brief Intervention is quite a long term that we use to describe a variety of kinds of activity - and those activities try to identify people who might benefit from cutting down on their drinking, and they also try to motivate them to do something about it. So Alcohol Brief Interventions include interventions that can be delivered by the internet, through mobile phone applications, by text messages or in person. I am going to talk mostly today about traditional, face-to-face Alcohol Brief Interventions, and those are the most common - and particularly the ones that there is the most history of research in relation to.
So a face-to-face Alcohol Brief Interventions would normally be a fairly short conversation between a doctor or a nurse and their patient. And even in these face-to-face conversations, the length and the content of the conversation can vary quite widely, and I’ll come back to that later.
So who are these conversations for? Who would the doctors and nurses be talking to? Historically Alcohol Brief Interventions have been used with people drinking alcohol at lots of different levels. Some of the really early trials back in the 1960’s were successful in reducing drinking with very heavy drinkers - so people who might be stereotypically dependent drinkers. But in the last few decades, Alcohol Brief Interventions have mostly been used as a tool for helping people who are drinking at much lower levels than that.
So what kind of levels of drinking would be suitable for somebody to receive an Alcohol Brief Intervention? Well really anyone drinking above the recommended guidance. In the UK, for men, the recommended guidance is that men shouldn’t drink more than 21 units of alcohol a week, and they shouldn’t regularly drink more than 3 or 4 units in a day. Just to give an idea of what that means, 21 units of alcohol a week, 21 units is maybe 7-10 pints of beer or a couple of bottles of wine, and that would of course depend on the strength. For women, the recommended limit is no more than 14 units of alcohol a week, and not regularly drinking more than 2-3 units in a day. 2-3 units might be what you would pour if you were pouring a home measure of spirits, or about 1 glass of wine - obviously again that depends on the size.
So it might surprise people to realise that drinking above these levels puts people at greater risk of various health problems in the future. So the kind of health problems that we know are associated with alcohol are liver problems, mild depression, other health problems, other mental health problems - but also it might surprise people to know that we have more and more information that shows that alcohol is related to cancer - so alcohol is implicated in causing 7 types of cancer, and in particular it’s associated with breast and bowel cancer.
At what levels do you have to drink to increase your risk of these diseases? Well really the more you drink, the greater the risk. So once we get above the recommended limits, every increase in alcohol consumption will increase people’s risk of these health problems over the longer term, and conversely, even small reductions in alcohol can reduce people’s risk of these health problems in the future. And the point of Alcohol Brief Interventions is to try to reduce people’s drinking in order to lower their risk of those problems.
So is there any evidence that these conversations, that these Alcohol Brief Interventions actually work? Well we have very good evidence form a large number of randomised controlled trials that Brief Interventions can reduce alcohol consumption, when they are delivered by doctors or nurses in primary care settings. So primary care settings in the UK - that means GP practices. One systematic review suggested that ABI’s in primary care could reduce total alcohol consumption and episodes of binge drinking in people who are at increasing risk for periods of time up to a year. And just how much do people reduce by? Well it’s important to recognise that because Alcohol Brief Interventions are not for people who necessarily need to give up drinking altogether, the reduction in alcohol consumption is in the order of 15-35%, and there is no suggestion that Alcohol Brief Interventions are intended to get people to become abstinent from alcohol - it really is to help them to but down.
So how do you deliver an Alcohol Brief Intervention? Some Alcohol Brief Interventions, known as Brief Advice, involve the use of a screening questionnaire - so a quiz or a set of questions that ask people about their alcohol consumption. Those questions tell the health professional about what the person is drinking so that they can give feedback to the person about how their drinking compares to others, and so that they can also judge if their drinking is putting them at risk of health problems. If it is at a level that is putting them at risk of health problems, then the health professional might just give them some advice on ways that they might cut down. So that is kind of a simple form of Alcohol Brief Intervention known as ‘Brief Advice’.
Other forms of Alcohol Brief Intervention known as ‘Brief Motivational Interventions’, tend to focus more on identifying how the person feels about their drinking, whether they want to change or not, and they also tend to use more skilled listening techniques to help the patient or the person make plans to change their drinking in line with their values, in line with what is important to them. So because there is this variety in Alcohol Brief Interventions, you know, in terms of their length and their content and their design, it makes it difficult to recommend any one model of Brief Intervention.
There are a number of research projects that are underway that are starting to unpick what are the most important elements of a Brief Intervention - what is core? What is really essential for Alcohol Brief Interventions to really work, to change someone’s drinking? That research is at a really early stage, so our conclusions in terms of what might be useful have to be treated with caution. But it does seem that personalised feedback about the risks of drinking may be important in terms of being effective in changing their drinking.
So who is delivering these Alcohol Brief Interventions at the moment? I guess because we have such good evidence in primary care, there have been a wide range of efforts to get Alcohol Brief Interventions delivered in GP practices - not just in the UK but in other countries in the world. But as we have found with lots of other innovations, like trying to get people to wash their hands or to stop the overuse of antibiotics - just because we know that something is important and it works, isn’t necessarily enough to get busy practitioners, or even practitioners who are a bit sceptical, to actually deliver it on a routine basis. If you look at the level of the individual GP or Nurse, it is simply quite hard to change their practice, and the topic of alcohol added to that, makes it perhaps more tricky for a number of reasons. What we found is that sometimes when health professionals know about the drinking limits, to the 21 units for men a week, the 14 units for women and the daily limits - what happens is that they realise that they themselves might be drinking more than is recommended, and that they might benefit from cutting down. And sometimes that makes them feel uncomfortable, or a bit hypocritical about raising the issue with patients. This is of course less of a problem if the practitioner recognises that their role is help the patient make the choice for themselves, regardless of the practitioner’s own behaviour.
There are other things practitioners worry about - quite often they tell us that they are worried about how people will react if they ask them about alcohol, especially if the person has come into that practitioner, or come into their GP practice to talk about something else. So they have come in with their own problem, and maybe they will think that the practitioner is sort of jumping to conclusions or judging them, or not really listening if they start to introduce alcohol into the conversation. So the trick here really for the practitioner is to think about why they are asking the patient and to share that thinking with the patient.
Why do they need to know about alcohol and how does that relate to the problem that that patient, or that service user, has come in with? Because there are so many health and social problems that can be caused or worsened when people drink more than is recommended - that is not difficult to do. So if we think of an example where a patient comes in saying they have been feeling down, they are not sleeping very well - the practitioner can explain that sometimes people don’t realise that alcohol, along with other things, can contribute to feeling down or can disturb sleep. And so they can just ask, you know, “what do you think? Could that be a factor in your case?” We also know that when we ask patients whether they mind their doctors or nurses asking them about their alcohol consumption, they are generally not that bothered, and in fact lots of them say that they expect to be asked.
So perhaps because health professionals have some of these concerns, and also I am sure due to the fact that there is so much pressure on time for practitioners, particularly in short appointment times, it has been pretty difficult to make alcohol brief interventions part of routine GP practice - and even routine practice of other professionals within the primary care setting.
So as a result, government’s both in Scotland and in England have sought to incentivise delivery and they do that by paying GP’s for both asking and/or advising people about alcohol.
What about outside of health settings? Outside GP practices, can Alcohol Brief Interventions work in other places? In settings outside of primary care, apart from probably in university students and some evidence in A&E departments, there isn’t very much evidence at all to show that Alcohol Brief Interventions work. In most cases, we just don’t have the evidence of effectiveness, but there have been very few trials - so there isn’t evidence that they are not effective, but there isn’t evidence either that they are effective. But there has been a huge amount of interest in delivering Alcohol Brief Interventions in a huge range of health services. So for example pharmacies, dentists, hospital wards, sexual health clinics - but also in lots of non-health settings - and examples include probation, prison services, youth work, social work, workplaces, housing services, employment services like Job Centres and so on and so on.
In both Scotland and England there is some support for that implementation - the Scottish government has included wider settings in the Alcohol Brief Intervention targets that they set for local areas to meet. And the National Institute for Health & Care Excellence has recommended widespread delivery of Brief Advice. In Wales the ‘Have a Word’ campaign has trained practitioners in a wide range of settings. But this wider setting delivery is a little bit contentious, because we don’t know whether or not it will make a difference to people’s behaviour. We are also not sure how appropriate or acceptable it is for such services to deliver Alcohol Brief Interventions, or how exactly we should design Alcohol Brief Interventions to fit with their needs.
One issue is that Alcohol Brief Interventions, because they have historically been used in health settings, the screening quizzes or the screening questionnaires that we have might not make that much sense in non-health settings. So if a housing officer or a social worker wants to identify alcohol related risk, they may need a screening tool that tells them more about housing or parenting risks than about health risks. Getting the design right is important to ensure that what the staff are being asked to deliver fits with the goals of their service. And it’s more likely to be welcomed by staff and service users if it does fit with the goals of the service.
Even if we do have Alcohol Brief Interventions that are acceptable to services, many people have argued that we should be cautious about widespread implementation in settings where we don’t have that robust evidence that they work, that they actually make a difference to people’s drinking.
Some people argue that it’s a good thing to do anyway, because there is very low risk that they will cause any harm - but there is always an opportunity cost - so that staff time that is spent learning about and delivering Alcohol Brief Intervention could be used for something else, and we can’t always be sure that there won’t be unintended consequences in other settings outside of primary care in terms of how people will react and what impact that will have on the services and how people approach the services and use the services.
It seems really important to get the balance right between implementation and further research. It’s clear that the desire to implement Alcohol Brief Interventions in wider settings comes from a recognition that alcohol is a problem for many of those service users in those wider settings, and that it’s impacting on their lives in important ways that practitioners want to address.
So it’s not that we shouldn’t have any implementation in these new settings until we have robust research studies, but maybe a sensible approach is to try to build that robust research into any implementation initiatives that are happening in those newer settings. If that is done well, then what that would mean is that at the end of an implementation initiative, we would have a better idea than we do now about whether interventions in that setting actually reduce people’s drinking or have any other effects.
So we are coming near to the end of the podcast and I just want to talk a little bit about how we can get services and practitioners to deliver Alcohol Brief Interventions. We need to be able to get services and practitioners to deliver Alcohol Brief Intervention, to research them or to implement them widely - so it’s a key question, regardless of where people stand, on whether they should be implemented widely anyway or whether we need more research to begin with.
I have done a study in 2013 where I interviewed 14 senior professionals who were responsible for leading the implementation of Alcohol Brief Interventions and they were responsible for doing that in 3 settings - in Accident & Emergency, in Antenatal and in some wider settings. And they did that under the national programme that was initiated by the Scottish government. I asked them what lessons they would share with others who were trying to implement Alcohol Brief Interventions in new settings. They told me that achieving this kind of large scale, routine implementation of Alcohol Brief Interventions was challenging in all of the setting. And they identified 5 main strategies that, in their experience, they felt would be useful for other areas to take note of.
The first was having a high profile target for the number of Alcohol Brief Interventions delivered in a specific time period, and crucially, having that with clarity about whose responsibility it was to implement the target. That target didn’t necessarily need to be a national target - it could also be a local or a service level target.
The second thing they said was important was gaining the support of senior staff from the start. One of the things that they felt was important in gaining that support though was having evidence of effectiveness in that setting.
The third thing that they described as being really important was being flexible about the interventions - using a kind of pragmatic, collaborative approach with frontline staff and with mangers and senior practitioners, to design an Alcohol Brief Intervention model that would fit with current practice in that setting.
The fourth thing that they said was important was to establish robust and practical recording systems - so that they could monitor and report on how many Alcohol Brief Interventions were being delivered before it was expected that you would have to deliver them widely. So it was really important to have these recording systems in place first and then to expect the implementation after that.
And the final thing that they said was really important was having really close working relationships with frontline staff - so that they were very flexible about how the staff could access training and other support. And they felt that the importance of having support on the ground where staff were working, that was readily available, was really key.
So the five things that they said were particularly useful strategies for implementing in new settings weren’t always easy to achieve. And what we concluded was that even though this was a national programme in Scotland that had quite a lot of funding and a very specific and high profile delivery target, the implementation of Alcohol Brief Interventions in new settings wasn’t straightforward.
We also felt that much could be learned from experiences in other areas and with other interventions - so there is a whole body of research that looks at how innovations can be implemented into normal practice, and that’s called Implementation Science - and we felt that some of the learning that our interviewees gained could have been pre-empted had they had training in Implementation Science before they started.
So drawing all of this together then - what are the key messages about Alcohol Brief Interventions?
Well Alcohol Brief Interventions are structured conversations about alcohol that have been shown to reduce people’s drinking, particularly when they are delivered in primary care. Although the evidence for their effectiveness is very good in that setting, it can be difficult to get health professionals to deliver Alcohol Brief Interventions for a variety of reasons.
What I would advise health professionals and other practitioners who are interested in Alcohol Brief Interventions to do, is to look out for skills training - but there are also some excellent resources both online and in hard copies that can provide them with background theoretical information.
But at the most basic level, all an Alcohol Brief Intervention involves is asking someone about alcohol consumption in a non-judgemental way, helping them to be able to measure how much they are drinking and how they feel about their drinking, and giving them personalised feedback about the risks of their drinking.
And lastly there are some unanswered questions about Alcohol Brief Interventions - can they work when they are delivered outside of primary care? What are the core components or best types of Alcohol Brief Interventions for effectiveness? What training do practitioners need to be able to deliver Alcohol Brief Interventions effectively? And what are the best ways to implement Alcohol Brief Interventions in routine care? It’s important that any implementation initiatives include a research component to contribute where they can to answering these questions, so that we know more in the future.
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