Archive | September, 2013

An EBI case study: where are the rest?

18 Sep

‘It’s Your Choice’ Evaluation – Making the case for EBI

Last year, I delivered an Extended Brief Alcohol Intervention (EBI) program called It’s Your Choice. I hope that sharing the results and learning from the program will be helpful for other people who are looking to develop alcohol EBI’s. The aim was to reduce alcohol related harm in Sefton by providing EBI in the form of a one to one coaching service. The program was promoted as a “coaching” service rather than an “alcohol intervention”, in order to test how effective this approach would be in engaging patients.IYC

NHS Sefton Public Health identified a cohort of drinkers, who whilst not requiring or consenting to a referral to specialist treatment support, do require more than IBA (Identification and Brief Advice). NHS Sefton worked in partnership with Sefton Council for Voluntary Service to develop a program to meet the needs of these drinkers. I was the coach that delivered the program.

It’s Your Choice is based on the principles of Motivational Interviewing that have been in proven effective in previous programs such as Project Match in the USA and the United Kingdom Alcohol Treatment Trial.

It’s Your Choice was available to increasing and higher risk drinkers (those who scored between 8 and 19 on the AUDIT – Alcohol Use Disorders Identification Test). Drinkers were referred by Primary care staff and coaching sessions took place in GP surgeries and a community healthy living centre. Drinkers were able to have up to 6 x 1 hour one to one sessions (with an optional further 2 follow up sessions if required). However the program highlighted that more sessions do not necessarily mean better outcomes.

42 patients were referred onto It’s Your Choice of which 76% of those patients engaged fully in the programme. 80% of all sessions were attended. 72% of patients reported a post intervention reduction in their drinking and 65% of patients reported a reduction in their drinking 12 weeks post intervention. On average patients reported a 30% reduction in their drinking, equating to an average AUDIT reduction of 6 points.

The full report is available here, including quotes, key learning and recommendations for future work.

At present there is very little EBI in comparison with IBA, as highlighted in a recent blog EBI: lost in the shadow of IBA?.

NICE guidance recognises that access to EBI’s such as It’s Your Choice is currently limited.  This gap in EBI type approaches is noted in NICE costing report CG115: Alcohol dependence and harmful alcohol use which highlights that the national proportion of people with mild alcohol dependence who are provided with evidence-based specialist treatment is estimated at 1.13%.

NICE also acknowledge that “some people drink alcohol as a result of underlying problems. Clearly these need to be addressed along with any alcohol related issues”. (NICE PH24 Preventing Harmful Drinking). Whilst only a small scale pilot, the results and feedback from the drinkers who took part in It’s Your Choice show that this way of working provides a means of addressing both the alcohol use and the underlying problems.

As the coach, the most powerful learning for me was understanding how coaching can help people develop an awareness of how their problems and their drinking are connected. Once the patients make this connection, then making a change to their drinking becomes possible and in many cases, it happens.

Matt Ball

Talking or Testing? Which is easier?

4 Sep

I recently read a brilliant insight from Dr. Richard Saitz on the INEBRIA Google Group – he was commenting on a discussion about doctors objecting to IBA delivery on the grounds that it is ‘additional work’.  His insight was:

“BUT I have never heard a physician object to doing an electrocardiogram or checking a blood pressure or listening to a heart or ordering a mammogram…So…”additional work” must be code for “additional work for a stigmatized problem” or for something about which people have attitudes about….”

As Richard is a doctor himself, this got me thinking about how we need to get into the psyche of doctors if we want them to implement IBA.  That psyche is undoubtedly formed and normed throughout their lives and especially in education and early years of post-graduate training.

It reflects a wider problem I think which is a reluctance to accept a social model of health where a genuine curiosity about someone’s life and health is helpful in diagnosis and treatment (in the broadest sense).  Why the emphasis on the physical?  My experience is that doctors would love to have a (better) biomedical test for over-consumption of alcohol, even though screening tools are very good, non-invasive etc., because they really don’t want to have to talk to people about it…what does that say?

This reluctance, fear, distaste for actually communicating effectively with patients is very pervasive, and GPs who are very caring, lovely and wise still do not seek out people’s own story, their perspective, their ICE (ideas, concerns and expectations) in consultations as well as they could.  Why?  Well there are many reasons.  But our research in the NHS found that they were not taught it, and even if they were, it was not modelled by others so it wasn’t valued/encouraged.  Our system simply does not prioritise it.  My guess is that the reason underpinning that is probably that we don’t have deep enough pockets to prove it helps, or failing that ‘market it’ anyway (as Pharma do).

So a reluctance to communicate effectively in general makes it hard to feel comfortable with an open conversation about alcohol that IBA really entails.

Your thoughts?

Brief Advice bullets: reducing hangovers?

4 Sep

Not everyone gets hangovers – a study from Boston University found that  as many as 30% of people may be immune to them. But for those of us that are susceptible, one must assume they act as a powerful preventative agent.

ow my headSo the appeal of reducing those painful after effects could be a useful ‘brief advice’ bullet for a risky drinker to contemplate. This may be especially powerful considering that there appears to be no evidence that hangover cures actually work.

So asides from the more serious risks of heavy drinking, like over 60 medical conditions and diseases, feeling fresher the next day may be a good reason for some to think about change. In fact a popular moderation movement originating in Australia called Hello Sunday Morning has based itself on this idea.

Of course many drinkers are still likely to experience those uncomfortable after effects of excessive alcohol from time to time. In which case, advising to drink water or soft drinks during and after is still the most sound advice to avoid the dehydrating effects. It has also been touted that soft drinks before and during drinking sessions may slow down drinking by quenching thirst or leaving less room for booze.

But remember, each to their own. Ask a drinker what their reasons for change might be, and perhaps offer suggestions rather than ‘advice’ per se.

See here for a Guardian article busting the myth of hangover cures, or a Drinkaware page on dealing with hangovers.

See here for previous ‘brief advice bullets’.