IBA in non-health settings: Middlesex research programme findings

17 Jul

A series of reports are available following the conclusion of a Middlesex University project exploring the delivery of alcohol brief interventions outside of health settings.

A growing effort to deliver alcohol ‘Identification & Brief Advice’ (IBA) in a range of different settings has emerged over the last decade, but the actual level of delivery by front line practitioners remains questionable. The reports appear to confirm many of the suspected reasons why IBA delivery has proven difficult, ranging from individual level perceived barriers to failures to adopt ‘system wide’ approaches.

To those in the field, it may be no surprise that simply ‘parachuting’ in training without recognising and addressing many of the contextual issues at play is insufficient. Despite this, training is likely to be an important component of any efforts to secure delivery, and participants generally value the knowledge and skills gained. Different roles in different settings though report varied barriers and opportunities and so training and all important organisational strategies may need to reflect these nuances.

The main report looks at these through work on influences on behaviour change undertaken by Susan Michie and colleagues at UCL. Whilst the more traditional ‘cycle of change’ is often used to consider a drinker’s motivation to change, Michie’s work demonstrates the importance of considering the wide range of factors that influence practitioner’s behaviour as potential IBA agents. For example training may address a practitioner’s ‘capability’, but may not address key issues of ‘opportunity’ (e.g when is ‘identification’ actually going to be feasible) or ‘motivation’ (perhaps recognition of doing IBA or personal satisfaction).behaviour change wheel

Other questions addressed in the research include important questions such as whether in fact IBA should be pursued in various non-health settings. A ‘health in all polices’ approach may be sound, and other added benefits such as possible impact on important indicators like re-offending rates or housing status could also be seen. Yet the evidence base proving the effectiveness of IBA in non-health settings is rather sparse.

Wider brief intervention questions are also relevant. Research efforts are being focused on questions of ‘how’ and ‘who’ does IBA work for. As cited in one of the papers Professor Nick Heather, who has been instrumental in the emergence and development of IBA over 3 decades, summarises this as:

“What kind of brief intervention, delivered in what form, by what kind of professional, is most effective in reducing alcohol consumption and/or problems in what kind of excessive drinker, in what kind of setting and circumstances?”

Given that seeking to secure routine IBA delivery even in health settings includes a range of distinct challenges, any help knowing where else and how IBA will be most effective will be particularly welcome.

See here to access the full suite of publicaitons.

PHE updated ‘IBA tool’ following new guidelines

6 May

The two sided ‘IBA tool’ appears to have been a popular resource amongst roles delivering IBA, so PHE have released an updated version following the recent change to the recommended guidelines.

Indeed it is easy to see why the tool may have been popular as it neatly includes key ‘components’ of FRAMES based brief advice. Having these prompts and visual aids may take pressure off the practitioner to remember the various things that may be useful to discuss, or perhaps better still, use them as prompts for a drinker to identify things relevant to them. For example:population drinkers England

  • ‘Feedback’ – the tool has several sections that may help the drinker understand what their level of risk is and what that means. The ‘risk category’ table gives an indication of what that may look like in terms of units, whilst the population graph (right)is thought helpful to highlight most people actually drink at ‘lower risk’ amounts.
  • ‘Advice’ – practitioners should of course be careful here. Rather than giving direct ‘advice’, generally better to ask “could you think of any benefits if you did decide to cut down?”. The tool suggests some ‘common benefits of cutting down’ which can be useful prompts.
  • ‘Menu’ of options (goals or strategies) – as above, best to ask “would any these strategies listed here be useful if you did decide to cut down?”. Easy to assume what works for you will work for them, but important they ‘own’ their responses as much as possible (Responsibility).

Not forgetting of course ’empathy’ and ‘self-efficacy’ as the final FRAMES elements – not on the tool because these are skills we try and embed throughout brief intervention – and probably at other times we are in contact with people.

What about the tool itself?

It is of course impossible to build the ‘perfect’ one size fits all tool when people and drinking motivations are so varied and complex. This is why the tool should just be an aid to facilitating person-centred IBA, rather than the focus.

Interestingly, PHE have done away with the old ‘large white wine’ with 3 units on the side. This is  a good move as people frequently commented on the drink’s visual appeal. Indeed a ‘priming’ effect has been found in studies and is one of the reason why ‘responsible drinking messages’ with pictures of alcohol are controversial. Weren’t thinking about wanting a drink? Perhaps you are now you’ve seen one!

It’s replacement though is the new ‘One You’ campaign promoting healthier living in general. I’m not quite sure on how I feel about this yet, although I do agree alcohol brief interventions need to be considered as part of wider health behaviour initiatives.

One thing that could still probably do with updating is the unit examples. ‘This is one unit’ contains some rather dubious examples – when was the last time anyone was served a 125 ml glass of wine at only 9% ABV? Certainly far less often than a 250 ml 14% one, registering at a considerable 3.5 units.

However these finer points may not be that important when considering the likely impact. We know ‘identification’ and ‘feedback’ are most likely to be the critical ‘active’ elements of IBA, complimented by conversations that feel helpful and supportive to the drinker. Such resources are probably more important for nudging and helping practitioners to start these valuable conversations.

Should we be training everyone everywhere in IBA?

29 Apr

DARCThere are a few places left for an upcoming event exploring whether IBA training should offered en masse, which poses some interesting questions. Flyer here [pdf].

The event, hosted by Middlesex University’s Drug and Alcohol Research Centre (DARC), follows several projects exploring the role of IBA in non-health settings.

The research has found many of same challenges focussed around beliefs and attitudes of non-health staff having alcohol conversations, and of course that training alone doesn’t neccessarily result in routine delivery. Crucially, organisations need to buy in to it so that practitioners are supported and recognised for helping people look at their alcohol use, even if its not in their job description.

There are also many other aspects to consider, not least that people who attend IBA training are given a chance to contemplate their own drinking, or develop skills that may be beneficial in other ways – for example to talk about other health behaviours or things that may need an empathetic approach.

I’ll be on the panel to discuss some of these points and while I won’t be pretending that training is all we need, I will most likely highlight that without it, good quality IBA is unlikely to happen anywhere. And whilst wider alcohol policy is arguably rather weak, IBA is something we shouldn’t give up on.

New drinking guidelines – IBA implications?

7 Mar

0005623507Y-1440x1920Earlier this year the new adult weekly recommended drinking guidelines sparked a bit of a media frenzy. On the plus side, this raised awareness (in the short term at least), and perhaps got some people talking about them. On the other hand, awareness of the guidelines alone doesn’t tend to lead to behaviour change. Much of the media also pandered to the distraction of the ‘nanny state’, arguably failing to recognise the basic principle of a ‘guideline’ to support informed decision making – one of the reasons why it should not be described as a ‘limit’.

Yet to be answered though is what the implications are for alcohol interventions and other policy areas. Obviously most recent alcohol literature (and alcoholic drinks packaging) will now be ‘outdated’ if displaying the old daily guidelines – although you can find an updated tool here [ppt]. Certainly there will be further work underway about how we calculate and define ‘at risk’ drinkers, but overall we must not get too caught up in trying to pin point exact ‘cut-offs’.

As such the important point is that alcohol misuse is a spectrum, and people are often unknowingly changing their consumption and the actual or potential effects on their health and wellbeing. IBA is about helping people understand where they sit and helping facilitate change where relevant.

So whether we use the alcohol guidelines as a general indicator of our risk level, or something more sophistaced like the AUDIT, it is important not to get too literal about things. A person drinking near 14 units a week (or say a person scoring AUDIT 7 or less) should not consider themselves to be risk free, just as a person drinking 15 units (or scoring AUDIT 8+) should not assume they will certainly suffer alcohol problems. The basic principle of the dose effect applies – the more of a drug one consumes, or the more frequently, the greater the risks – generally speaking.

So in practice, a little common sense applies. When we offer ‘brief advice’ to people, we automatically take into account a wide range of factors – what the person is there for, how motivated they are, how much time we have etc. etc. A change in the guidelines may be just another ‘common sense’ consideration to take into account. For instance we might inform or ask people if they knew that the guidelines have recently reduced a bit, and although any level of drinking carries some risk, sticking to them means a person is unlikely to develop serious negative effects in the long run. running

Drinking is of course just one of many ‘health behaviours’. If someone is getting overly focused on debating specific cut-offs, it could be worth pointing out the many other factors that will influence their likely health outcomes; especially those that they may be able to change.

‘IBA direct’ evaluation shows people welcome IBA in public

21 Dec

An evaluation has shown that taking ‘IBA direct’ to people on the streets of South London was found to be highly effective in engaging people and delivering brief intervention.

The project, branded ‘The London Challenge: are you healthier than your mates?’, took place over three days in August and tested a number of methods to engage passersby and deliver IBA.

Resonant, a specialist behaviour change agency, had been commissioned by NHS Lambeth to deliver the activity in a way which would engage at-risk drinkers in their 20’s as an identified target group. Within the borough, this age range were found to be less likely to access services where they might receive IBA, but many were found to be drinking at risky levels.

As part of the ‘The London Challenge’, four ‘brand ambassadors’ were trained to engage passersby and offer IBA. Free ‘mocktails’ were offered as an incentive to ‘hook’ the public into completing the AUDIT.

Resonant developed the approach based on research and ‘co-creation’ with the target group who identified that answering alcohol questions and receiving ‘brief advice’ was acceptable as long as it was engaging and non-judgemental.

The evaluation was independently conducted by the South London Health Innovation Network (HIN) Alcohol team.

Rod Watson, Senior Project Manager (Alcohol) for the Health Innovation Network highlights some key observations on the evaluation findings:

  • The service evaluation found IBA Direct is feasible and acceptable at being delivered in a public setting by non-health professionals.
  • Over the course of the three days of the project, 402 people received IBA.
  • The brand ambassadors engaged people with professionalism and their approach was central to the large number of people taking part.
  • A small follow up sample of the 402 people who received IBA direct showed a reduction in AUDIT scores six weeks following the intervention. (Note: caution should be exercised here as no control group was used).
  • A participant feedback form was completed by 61 people. Participants rated both the ‘London Challenge’ and the service they received from a brand ambassador highly.
  • All respondents found the setting to be suitable and 90% stated they would take part in this service in a public setting again. There was nothing reported back that indicated any concerns from people about the public setting of the project.

As such the project shows significant potential for delivering IBA ‘direct’ to people in public spaces. Given the challenges facing IBA in other settings, this approach could offer a promising channel to reach new groups of at-risk drinkers.

The full report can be downloaded here:

‘The London Challenge: are you healthier than your mates?’ Service Evaluation of Alcohol Identification and Brief Advice Direct to the Public [pdf]

To find out more about IBA direct please get in touch.

Substance use and sight loss guide

4 Dec

A new practice guide has been produced to help practitioners support people with overlapping sight loss and drug and alcohol issues.

Download Substance Use and Sight Loss: A guide for substance use and sight loss professionals [pdf]

The guide follows research identifying that neither sight loss or substance abuse services feel adequately equipped to deal with these overlapping issues, and as such aims to help support better identification and responses in this area.

The issue highlights how many professionals with the chance to offer alcohol brief interventions will be working with a range of different issues that may be closely interlinked. As such ensuring practitioners feel able to respond appropriately is essential, and often why often IBA itself is overlooked as an important early intervention.

Sight loss is of course one of a large number of issues that may be contributing or linked to drug and alcohol problems. Professor Sarah Galvani, one of the authors of the guide said: “Substance abuse can sometimes be used as a coping mechanism for sight loss but the combination of both issues can create a complex challenge for support professionals.”

IBA is about offering a person an opportunity to make an informed decision about their alcohol use. Sometimes it will be straightforward, and discussions around motivations and strategies for change will be along more common lines. At other times, discussion may need to reflect and support other issues – for some people sight loss will be one of them.

Briefing on IBA & LGBT people – a key group to ‘target’?

9 Oct

LGBT IBAA short briefing highlights the potential for IBA to reduce alcohol related harm amongst lesbian, gay, bisexual and transgender (LGB&T) people. It describes LGBT groups as a ‘high-risk group’ for alcohol misuse given research that shows higher prevalence.

The briefing provides a short background of IBA as a short alcohol intervention, and considerations for ensuring IBA can reach LGBT people. For those already seeking IBA implementation, it may highlight another setting or area to consider engaging front line roles with training and support, or opportunity to build IBA into service commissioning.

Of course the debate about which wider settings should IBA be sought in goes on, and the challenges may not be wholly different from many other settings where IBA is sought. At the same time, it urges all staff delivering IBA to ‘ensure their approach is culturally sensitive and LGB & T-inclusive’, given discrimination that LGB&T service users often report when using mainstream services.

The briefing though may be of most use in encouraging LGBT specific services to incorporate IBA as something to potentially benefit their service users. As the briefing advises, ‘IBAs can readily be incorporated into initial screening and triage for new service users; into case or care plan reviews with existing service users; or into outreach interventions in LGBT social settings.’

Of course any practitioner delivering IBA should show key skills that both underpin brief intervention and non-judgmental person-centred approaches relevant for ensuring people of any sexual orientation feel well treated . The reality though is that more training, support and resources are needed for quality IBA to be adopted more widely. And with LGBT people likely to make up between 1.5 – 7% of the adult population, as a ‘high risk’ group for alohol misuse it makes sense to support LGBT services specifically in IBA delivery.

 

IBA and the wider ‘workforce’ – will it happen?

2 Oct

Wider workforce RSPHEarlier this year the Royal Society for Public Health (RSPH) generated headlines following a report saying  ‘15 million workers including firemen, hairdressers and postal workers could form part of “wider public health workforce”.’

With the ‘core’ public health workforce totalling only 40,000 people, they are unlikely to be able to deliver widespread health behaviour interventions to much of the population. As such, the report calls for anyone who has “the opportunity or ability to positively impact health and wellbeing through their work” to join the wider public health workforce.

Whilst the media focused on the idea of bar maids and hairdressers giving out health ‘tips’, it’s certainly true that many areas have sought to extend well beyond healthcare for IBA delivery. A recent review into IBA in non-health settings found settings like schools, criminal justice, pharmacies and universities have shown promise in terms of the feasibility of IBA delivery, although most of these wider settings including the workplace still lacked evidence.

Healthy conversations

“Healthy conversations”

Another report from the RSPH, ‘Healthy Conversations and the Allied Health Professionals’, highlights Allied Health Professionals (AHPs) as an auxiliary Public Health workforce of around 170,000, made up of 12 professions including Physiotherapists, Occupational Therapists, paramedics and dietitians.

The AHP workforce certainly seem a realistic workforce for delivering brief interventions than perhaps hairdressers or posties, and indeed some areas have already been seeking to engage AHP roles in IBA. The report itself specifically gives some examples of AHPs delivering alcohol IBA or other support, and also some insights into AHP’s attitudes and experiences.

Of particular note may be the findings on AHP’s confidence to discuss different ‘health conversations’ by topic. This may be of relevance given that barriers to delivering alcohol IBA are often related to patient or practitioner beliefs about alcohol. In some areas ‘Making Every Contact Count’ (MECC) approaches have been adopted to try to facilitate widespread health conversations, but the level of alcohol IBA activity specifically is unclear.

Indeed it seems that when compared to smoking, diet, exercise and weight, AHP’s felt more confident to discuss these than alcohol. However AHPs did feel more confident to discuss alcohol than areas such as dementia, domestic violence or sexual health, though perhaps unsurprising.

Wider workforce RSPH

What does this mean for IBA? We know alcohol brief intervention is effective, and possibly more so than for other health topics. But it may also be that quality alcohol brief interventions may be at risk of getting lost or diluted within the wider ‘healthy conversations’ agenda.

 

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