Archive | January, 2013

SBI & Health Inequalities

30 Jan

What do we know about how SBI (aka IBA) may impact on health inequalities?  The evidence we have so far is fairly limited on this.  There has been a suggestion that effectiveness may be less well-proven for women for example, but little conclusive in relation to SBI for those from lower socio-economic groups.

As those interested in SBI/IBA, we need to be aware of to whom the SBIs are being delivered.  I would love to see an analysis of the socio-economic characteristics of those for whom it has proven effective and comparing that to different lengths of intervention.  Until we have that, I think we need to be taking a careful look at how mass delivery of SBI might impact on health inequalities.  If those who are most likely to engage with it, are those who are least in need in general, then it is possible that SBI will increase health inequalities.

The Cochrane systematic review of SBI in primary care concluded that:

“There is a clear need for more evaluative research on brief interventions with women, younger people and those from cultural minority groups. In addition there is a need for more research in transitional and developing countries.”

No mention of socioeconomic deprivation or health inequalities though – this would seem a clear gap in what we know and something we should be mindful of.

For more info on health inequalities – check out the Glasgow Centre for Population Health’s Framework described in their:

Briefing Paper 23: The development of a framework for monitoring and reviewing health and social inequalities.

Briefing Paper 30: Focus on Inequalities: A Framework for Action

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SIPS Primary Care research: not just a leaflet

28 Jan

SIPS: largest ever UK study into alcohol brief interventionsThe SIPS trial, a £4 million study applying brief intervention approaches in key settings, has published the Primary Care results in the BMJ. The A&E and Probation results will follow shortly.

I’m not going to try and summarise the results here – the BMJ article is easy enough to garner and a Findings bulletin also interprets them in a simplified form. Instead I wish to consider some implications for those interested in delivering IBA.

However I should point out that I will be writing on the assumption that SIPS findings did show that brief intervention is effective. But I certainly expect to return to the discussion that this may not be the case. These charges are not so much based on a question of brief intervention efficacy, but whether SIPS can be seen to validate effectiveness in real world settings.

So assuming we accept the SIPS findings as evidence that brief interventions can be effective in practice, I will explore some key implications. Not surprisingly, of headline interest is the finding of no significant difference in outcome between the 3 intervention approaches tested (all 3 showed a reduction at 6 at 12 months). The three main intervention approaches were:

  1. Feedback [of screening result] + Patient Information Leaflet (PIL)
  2. Feedback + five minutes of structured advice using the SIPS brief advice tool + PIL
  3. Feedback + 20 minutes of ‘Brief Lifestyle Counselling’ (BLC) + PIL

Level 2 might be considered standard IBA, with 1 being the most minimal intervention, and 3 being more ‘extended’ brief intervention. So do SIPS findings suggest that “less is more”?

To some degree it would seem so, but they DO NOT suggest that giving out a leaflet is all that’s needed. Crucially, the simplest intervention included ‘feedback’ in addition to the leaflet. Feedback generally means informing a person that their answers to the screening question suggests their drinking places them at risk. Often we teach people to follow this with “How do you feel about that?”, encouraging contemplation and often leading nicely into ‘brief advice’. So is ‘advice’ beyond feedback unnecessary?

In many cases, simple screening + feedback and leaflet could well be enough as the trial suggests. However, although we have a lot of evidence that IBA works in Primary Care, there is still relatively little known about how. It it is probable though that IBA works largely by triggering at-risk drinkers to start to think about their drinking, rather than the element of helping them to cut down (e.g. brief advice or leaflet).

To me this makes sense; we know well that IBA is based on the ‘stages of change’ behaviour change theory where ‘contemplation’ about whether a behaviour (smoking/diet/exercise/drinking) is crucial as the start of the process. So can we really forget about offering brief advice or extended brief motivational approaches?

With all these things, there is a risk of a reductionist ‘one size fits all’ approach. Many risky drinkers will not be wanting ‘advice’ straight after being told something that could have come as a bit of a shock. Their ‘contemplation’ phase may well need some time to process.

Sometimes though, a person may move quickly into ‘preparation’ (i.e. deciding to cut down), or already be thinking about it and welcome some help. Perhaps because these people are smaller in number, the benefit of brief advice in SIPS did not come out as statistically significant. We must also note previous studies have shown the benefit of advice or ‘brief counselling’ over no intervention.

So common sense should apply to IBA delivery in many ways – make sure proper screening is followed with ‘feedback’ (not just a leaflet), and if someone seems to want some help, there’s a good chance they’ll appreciate it. One further finding that was statistically significant in SIPS was that patients receiving the longest intervention were most positive about their experience with the practitioner.

I think the results can be seen as good news if we accept them at face value. In many cases, IBA may commonly only require the shortest and easiest forms of “advice”- feedback and a leaflet. Sometimes a bit more may be helpful, but it is nothing new to suggest asking the questions in the first place is what really counts. The debate about how we interpret the SIPS findings is probably just beginning.

Step-by-step IBA (in a nutshell)

10 Jan

Sometimes IBA is seen as something complicated. But it’s not – the beauty of it is that its short, simple and effective. To the trained practitioner, brief advice is a simple conversation framed around some key parameters; don’t push someone, ask open questions, listen etc. To the unfamiliar, discussions around IBA often seem to over-complicate things. Below is something I’ve come up with to emphasise how simple IBA really is…

Nutshell

See here for a PDF version of IBA in a Nutshell. For a more detailed look at IBA see our About IBA or IBA skills pages.

New look to the blog…

10 Jan

As our readership grows we want to keep improving the blog. We’ve had some feedback the old look was maybe a bit ‘crowded’. What do you think, is this an improvement? We’re going to give it some further tweaks, but hopefully you’ll like the new look. But please leave a comment below if you have a preference!