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.

3 Responses to “SIPS Primary Care research: not just a leaflet”

  1. Iain Armstrong January 29, 2013 at 9:10 pm #

    Thanks James for the most intelligent public comment that I’ve heard since the publication of this snippet from SIPS.

    Clearly AUDIT, simply followed by the exchange of a leaflet isn’t enough, nor is it clinically appropriate to identify a health risk without explaining the implications and I don’t think this is what SIPS found.

    However I think the findings reinforce what we’ve always said… It’s not rocket science, it’s not onerous and when the biggest single health impact from drinking above lower risk levels is hypertension, one would think that a couple of minutes advising pateints of such a risk, when it’s demonstrated by this and 56 other RCTs that it will have an effect, should be a matter of course for any professional with the health of their patient in mind.

    Sorry, that’s a very long sentence.

    • Niamh Fitzgerald January 30, 2013 at 10:33 am #

      I also have a theory on what may be happening with these results. I think that at the moment there is still a large majority of the (UK and others) population who have little or no idea that their current levels of drinking, which are culturally very normal, may be risky for their health. So when we start to do anything, we are sort of picking off the low-lying fruit – the people who had no idea, then get a bit of feedback, and are therefore relatively easy to affect. If there is a large group of these people, then they will perhaps make up most of the effect size. Some of them might be willing to attend for further discussion, but that might not make much difference as they kind of instantly become open to changing once they realise that they are drinking more than might be healthy.

      As awareness grows about the harms of alcohol (and that will take a long time), then we may start to find that it requires more intensive/complex interventions to help the remaining people to change. I think we might already be there with smoking – smoking is virtually dying out in less deprived communities in the UK – due in part to support to individuals and large part to population-level efforts. Everyone knows smoking is not good for them, but those who continue to smoke tend to be more deprived and face multiple health inequalities. It is logical to think that they would therefore need more support. See also my main blog on SBI and inequalities…(just coming!)


      • deryn January 30, 2013 at 5:27 pm #

        I agree that it is not enough to screen, offer feedback and give a leaflet, however informative that leaflet might be. The feedback element of IBA is about helping the recipient to understand the possible risk level that their current drinking pattern puts them in; the advice should be pertinent to whyever you are seeing the person in the first place. So for example advice in a primary care surgery where the person is having BP measured might just be about awareness of the links of consumption and hypertension; in a gynae oputpatients it might be about reducing alcohol consumption to increase fertility status; in podiatry it may be about making the person aware of alcohol and nerve pathway damage etc. To me the crucial thing about the advice giving is that it links the alcohol with the person’s own issues (be they health, relationship, money or whatever) rather than enters into advice on how to change behaviour at that point. all of which takes a minute or two!

        I think it’s important to emphasise that IBA is short, sweet and still needs to be delivered effectively…Im anxious that alcohol doesnt get lost in the making every contact count agenda as an also ran or just too complicated to deliver effectively

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