Archive by Author

What’s our strategy for IBA?

8 Feb

dr-matt-andrewsIn this guest post, Dr Matthew Andrews from the Safe Sociable London Partnership calls for further strategic attention to IBA implementation, inviting any interested stakeholders to get in touch.

Identification and Brief Advice (IBA) has incredible potential to prevent and reduce alcohol related harm.  The figure of a 15% decrease in alcohol consumption on average for those who receive an IBA is a compelling and significant impact.  For the individual this can mean reducing alcohol related hospital admissions and risk of alcohol related mortality by a fifth.  For England this could lead to reductions in a wide range of health and social harms.

Despite this, our strategic approach to rolling out IBA in the English population has been lacking.  In the last two national strategies IBA has been noted, but with little strategy for implementation.  The Safe. Sensible. Social alcohol strategy did highlight a research approach, and the development of web-based commissioning tools.  In the 2012 strategy, IBA isn’t raised until after social marketing, the sobriety pilot and licensing amongst others – and all it does, is say is that IBA will be part of the NHS health checks and that Local Authorities should consider it for commissioning in primary care settings. We’re yet to have another national alcohol strategy. Local Alcohol strategies tend to be better, but still, there is very little strategic coherence to IBA implementation.

For years IBA has been highlighted as something to be rolled out, the evidence has been clear and further research has been commissioned; examples of good practice have been collected and shared.  However, no real strategic approach to the implementation of IBA has been set out.

Without a clear strategic direction:

  •  The roll out of IBA in primary care – through both Direct and Local Enhanced Services – did not live up to expectation.
  • Other settings, such as pharmacy, have been the site of IBA initiatives and some research and evaluation work, but we are still unclear of the evidence, practice and approaches that might best work for wider implementation.
  • Since the move of Public Health to Local Authorities, NHS buy-in at commissioning level has initially been limited. The joint commissioning between Public Health and CCGs that we optimistically hoped for a few years ago is still developing.
  • Digital IBA has become increasingly popular.  Although there is definite development and innovation in this space, there is still a fragmented approach across local commissioners – there is little clear guidance and little sharing of good practice despite the evidence base being solid and growing.

If we are to realise the potential of IBA and make best use of the learnings of the past few years, we need a strategic approach to IBA implementation.  This would need to:

  • Make the case: clinically, socially and economically (each being as important for the case as the other).  We need to better make the case for IBA implementation.  Currently we have failed to win over decision makers, commissioners and clinicians sufficiently for the wide-scale, effective delivery of IBA to take place that would show significant impact.
  • Commissioning: we need to be clear that when commissioning IBA it shouldn’t be service by service or project by project, it should be a comprehensive IBA approach – the HIN IBA Commissioning toolkit (Watson, Knight, Hecht and Currie) provides a detailed and effective guide for commissioning IBA strategically and effectively.
  • Training and workforce development: We need to learn from our smoking cessation partners and develop a minimum standard of training, possibly with accreditation, and a professionalised training and skills acquisition pathway around IBA for more junior staff’s professional development and career progression.
  • Digital integration: We need to work with the existing digital field, in practice, research and innovation; and examine and experiment with how digital and traditional IBA can align, complement and enhance each other for the best ‘merged’ IBA pathways to be available to practitioners and the population.
  • Expanding the knowledge and scope: redeveloping a research and evaluation strategy to genuinely enhance and build our knowledge of what works.  A collaborative strategy that sees our researchers and evaluators work with commissioners and practitioners to fill in the gaps and expand the boundaries of our knowledge rather than reinventing the wheel.

We think that now is the right time to build an alliance of interested parties to start scoping out and developing what an IBA Strategy would look like and what it could achieve.

We would be keen to hear from anyone who is interested in supporting or being involved in this. Get in touch here.

This post orginally appeared on the Safe Sociable London website.

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Mind the credibility gap: 5 insights to give ‘binge drinking’ public health interventions more punch

1 Oct

In this guest post, John Isitt, Director of Insight of Resonant Media, reports on some of the key lessons learned from local work to reach at-risk drinkers beyond IBA. Many similarities were evident with recent Drinkaware research on ‘Drunken Nights Out’ – but what are the implications for local level action?

binge drinkingYoung people don’t find the public health messages on alcohol credible. Their disbelief means that 18 to 30 year old ‘binge drinkers’ dismiss messages to moderate the amount they drink, according to research we carried out for Lambeth and Southwark Councils.

Working with people who drink at increasing or higher risk levels, it’s clear that they don’t have any inherent desire to moderate their drinking. Younger drinkers believe they “know their own limit” and are secure with this knowledge, having earned it through years of drinking experience.

If we really mean to change people’s drinking behaviours, taking an insight led approach is crucial; understanding their current behaviours, their motivations for change, the environment that they live, and their capability for change. (Behaviour Change Wheel by Mitchie et al.)

Here are five insights drawn from our research that help to highlight the barriers to change, understand people’s motivations and, importantly, retain credibility of future alcohol interventions.

1. Alcohol is good – Drinking alcohol is seen to offer a number of positive benefits that are not easily available elsewhere. These include generating a general “feel good feeling”, building confidence, relieving stress and offering an escape from boredom as an ability to cope with difficult situations.

Without understanding this simple perceived truth amongst 18 to 30 year olds, interventions will fail. Simplistic messages that try to cast alcohol as the profane are dismissed, as the target audience have already tried it and realise that alcohol gives them great pleasure at little cost.

By re-labelling ‘binge drinking’ as ‘calculated hedonism’ (Szmigin et al) it’s easier to understand people’s motivations and recognise that people generally drink for a good reason. Understanding this, rather than demonising drink, means we can start working constructively ‘with the grain’ of people’s behaviour to change the way they behave towards alcohol.

2. Drinking to fit into the social norm – failure to adhere to this norm can restrict an individual’s ability to be part of a social group, whether this group comprises of work colleagues or friends.

Social and workplace cultures are key drivers for consumption. Without tackling the underlying cultures it will be very difficult for an individual to change their behaviour, even in the face of rational educational or informational messages. (For example, one young man told us about the “beer trolley” at his workplace. Starting at 4pm every Thursday and Friday the expectation was that everyone would start drinking and then move onto the pub at the end of the day.)

These bonds are incredibly powerful. Light touch health promotion – a leaflet here, or a poster there – is going to have little or no impact on these social attachments and cultural pressures.

3. Few alcohol downsides – knowledge is patchy about the impact that alcohol can have on health and wellbeing. What awareness there is, is generally limited to liver and kidney damage.

For 18 to 30 year olds, this is a sticking point as both liver and kidney issues are seen to be so far removed into the future they are not valid risk (a form of temporal discounting). In addition, they’ve heard it all before – so the risks have little impact.

Our insight showed that risks of cancer or blood clots in the brain had shock value to get their attention. But after the initial surprise, 18 to 30 year olds also want to understand the impact and short-term downsides of alcohol. And not just the serious health related issues. This group generally feels immortal – health risks that may emerge years in the future have limited sway on behaviour. Whereas more immediate, but perhaps less ‘serious’ effects may have more influence.

4. Relate it to ‘me’ and make it immediate – whatever the intervention it needs to make people stop and think with credible information that relates to them in the now. Hackneyed or vague messages will be dismissed: as participants pointed out, when everything in life seems to increase our risk of “heart disease by 10%”, an alcohol public health message saying the same thing is generally dismissed.

To have impact, any messaging (health or otherwise) needs to be tailored and specific to a particular segment of the population. A 22 year old is going to respond to different ‘risks’ or ‘benefits’ than a 52 year old. The typical young binge drinker responds better to short-term benefits and risks, and side effects that impact on their self-image.

5. Attitude – individuals believe they can “self-manage” their alcohol consumption and therefore don’t believe they require interventions, treatment or specific support. Any interventions need to “go alongside” these attitudes and not come from a position of authority, but one of personal support – working with people, not telling them what to do. More ‘why’ and ‘how’, less of ‘what’.

These insights may also give us a good indication as to why ‘IBA’ is considered much more effective than generic alcohol messages. IBA highlights an individual’s personal risk based on their own answers, and encourages a person to identify their individual reasons for change. This is why we are exploring ways to take these crucial ‘behaviour change’ elements and see if we can reach out to groups who might be unlikely to receive IBA via normal routes.

Amongst at-risk groups, it’s still going to be difficult to enact large-scale behaviour change without changing the social norms. Multiple approaches are needed to shift overall attitudes, and of course price, availability and product marketing are huge influences. However, increasingly popular ‘Dry January’ type approaches are interesting. Without demonising alcohol, they are getting larger numbers of people to try out different behaviours. The more we move away from relying on simplistic health messages, the more chance we have of seeing behaviour change amongst at-risk drinkers

John Isitt is the director of insight at Resonant Media, an independent agency specialising in achieving health and wellbeing behaviour change and efficiencies in service use. Contact him on Twitter @resonantjohn or email john@resonantmedia.co.uk

Delivering alcohol IBA in non-health settings?

29 Sep

IBA questionsIn this guest post Dr Fizz Annand takes a quick look at recent research she was involved in exploring alcohol brief intervention as ‘IBA’ in non-health settings.

A team of researchers from the Drug and Alcohol Research Centre based at Middlesex University have completed a literature review as part of a larger research project funded by an Alcohol Research UK grant. A short ‘insight report’ of the research can be found here.

The evidence base for the effectiveness of IBA in health settings particularly primary care and to a smaller extent A&E, is well documented and because of the proven effectiveness in these settings there is a push to extend the delivery of alcohol IBA into other, non-health settings. This is despite there not being anywhere near the same weight of evidence to do so.

Some studies in schools, criminal justice, pharmacies and universities have shown promise in terms of the feasibility of IBA delivery, however in order to deliver, staff in these settings have needed extra support in order to be able to embed it into their everyday practice. Some studies on computerised or web-based versions if IBA show potential with students or people not in touch with services but more evidence is needed.

In most other settings evidence is weak or non-existent. The workplace has been proposed as an obvious context where benefits could be felt by both workers and employers given the impact of alcohol on productivity. Occupational Health teams could provide a structure in which IBA could be delivered as part of wider health screening and support. In order to convince employers of the benefit a business case would have to be demonstrated.

The researchers highlight the potential for financial rewards to operate as incentives to implementation however it is unclear how much the incentives should be.

A number of barriers to implementation were documented in the studies which included:

  • Lack of buy-in from organisations
  • Staff not feeling it’s their job, or that they have sufficient skills
  • Workload pressure
  • Reluctance to engage on part of staff and/or clients and concerns about confidentiality

Whilst IBA training was rolled out in many organisations, this alone did not necessarily result in widespread implementation of IBA. Very little monitoring or evaluation of the implementation was undertaken.

The researchers concluded that there’s good reason to feel optimistic that IBA in non-health settings can be delivered. Thought does however need to be given to how to adapt the implementation to take account of organisational, professional and context- specific issues that hamper implementation and, in particular, the sustainability of initiatives in the long term. Financial incentives may generate interest in delivery, and monitoring/evaluation will allow measurement of implementation, activity and ultimately help to justify the use of resources.

A full version of the report ‘Delivering Alcohol IBA Broadening the base from health to non-health contexts: Review of the literature and scoping’ can be found here.

Follow Fizz on Twitter @FizzAnnand or see here for contacts.

Making Every Contact Count for alcohol… not always IBA

17 Mar

MECCIn this guest post, Deryn Bishop, Health Behaviour Specialist, explores why the Making Every Contact Count is important, and doesn’t always mean doing IBA.

Much has been written regarding the effectiveness of alcohol interventions, brief or otherwise. Recently some of the concerns about the delivery of what has come to be known as “IBA-Lite” have been highlighted, particularly following the publication of PH49 Behaviour Change: Individual Approaches, which states:

Recommendation 9:  Encourage health, wellbeing and social care staff in direct contact with the general public to use a very brief intervention to motivate people to change behaviours that may damage their health. The interventions should also be used to inform people about services or interventions that can help them improve their general health and wellbeing. Encourage staff who regularly come into contact with people whose health and wellbeing could be at risk to provide them with a brief intervention. (The risk could be due to current behaviours, sociodemographic characteristics or family history.)

The use of the term “very brief intervention” may at first glance seem to be a deviation away from the recommendation of “Clarifying alcohol brief interventions 2013 update” which discussed concerns about diluting alcohol brief advice (IBA).

As a member of the Development Group for the  above NICE Guidance, I can assure readers that much discussion was had regarding the evidence supporting behaviour change techniques, and we upheld the view that workforce staff should be properly trained and supported to deliver interventions appropriate to their role or to the environment within which they work. The existence of very brief interventions in no way assumes that it is only the minimal intervention that should be offered, where there is the opportunity to offer a more in-depth intervention.

One concern I have about the Clarifying Brief Interventions briefing is it’s continuance to use the word “patient”, even within the case study chart at the end of the document. My viewpoint would be that in any situation where staff are having a conversation with a “patient”, there surely must be the opportunity to deliver IBA as the minimum.

Making Every Contact Count (MECC) is about developing the larger public health workforce to look for opportunities to empower the people whom they meet, whatever health behaviour it is concerning.

MECC brief advice describes a short intervention, which may last from one to 3 minutes, delivered opportunistically.

It may differ from “IBA Lite” however. “IBA lite” is comprised of a screening process but is “lite” because of the absence of Brief Advice or a full AUDIT.

A “MECC” conversation, as delivered by a Community Police Officer, or a Trading Standards Officer, or as part of a conversation from one colleague to another, where an opportunity to raise awareness about alcohol has proffered itself, may not include a screen, even one as short as SASQ. One can easily see that in these circumstances it is inappropriate to whip out a screening tool. That is not to say, however, that the understanding of how to assess risk has not been part of the MECC training, and that an assessment of risk is not implicit.

In MECC training, frontline staff gain the capability and confidence to assess risk, to deliver feedback that it pertinent and salient to the person with whom they are conversing, and to encourage the person to consider the benefits of making a change. Staff working in situations where a conversation may open a door to a more in-depth intervention, should also feel confident and capable to move into a brief intervention (as say a worker engaged in a home assessment, for fire risk, for health and safety concerns or whatever, who has the time and skills to go a little further with the conversation).

There is an excellent MECC Competency Framework that sets out in detail the knowledge and skills base required to deliver MECC effectively (Y and H MECC competency framework), whatever the level of intervention.

As a MECC trainer I strongly believe that the quality of the intervention is paramount, whatever the length.

MECC is one way in which we can  “shape the way citizens are involved in their own health and well-being” (What Local Authorities Need to Know about Public Health: South et al Feb 2014);  we should encourage all staff to consider how and when they can best be advocates of healthier lifestyles.

Deryn Bishop is a trainer for The Training Tree, specialising in health behaviour change. You can contact Deryn at deryn.bishop@live.co.uk.

Are we using social media enough to enhance alcohol working?

7 Nov

In this guest post Richard Gratton, a specialist substance misuse nurse for Chesterfield Royal Hospital NHS Foundation Trust (Derbyshire, UK) writes about the missed social media opportunities for the field. Richard also writes his own blog positivebehaviourchange.blogspot.co.uk

In recent years, the use of social media by professionals has increased exponentially, and health organisations are no exception. Whilst there should be some caution in terms of the type of information and comment that is broadcast, on the whole it has had a positive impact on the way we provide healthcare.Twitter

Social media has for instance led to improvements in communication between staff and patients, and enhanced the dissemination of information, learning or messages. In addition it has greatly helped networking between staff in ways that were previously not possible.

I currently work as service lead for the Hospital Alcohol and Drug Liaison Team at Chesterfield Royal Hospital NHS Foundation Trust (Derbyshire, UK). The team consists of 2 nurses providing a range of specialist interventions where substance misuse is a feature of patient’s lifestyle. It also plays a vital role in improving the knowledge and skills of the hospital workforce (such as in IBA) and enhancing the effectiveness of the local treatment system.

Around 5 years ago, the majority of hospitals in the UK did not employ substance misuse workers; only a handful of services existed, which to some extent caused isolated working and pockets of good practice. It is now thought that more than 65% of hospitals employ at least one worker, with growing evidence of the impact of these roles.  Further benefits to patient care and increased opportunities to engage with people on substance misuse issues are also apparent.

For hospital-based substance misuse services sharing of good practice includes a forum on the Alcohol Learning Centre and a Liaison Network, but missed opportunities for more through social media. The same can probably be said for the IBA agenda.

In my experience social media should be considered by all those working in the substance misuse field or delivering health interventions like IBA for the following reasons:

Twitter:

  • ’Tweeting’ can be an excellent way of commenting on good practice, sharing innovations in your area of work, and providing links to useful articles and comment.
  • Using hashtags to bookmark discussions allows for debate amongst like-minded people in regard to contemporary issues: #wenurses is an excellent example of this, providing a weekly platform to debate contemporary issues. An #alcoholiba tag is sometimes used too.

Blogs:

  • Writing a regular blog on a variety of issues can be a great method of sharing good practice and encouraging others to improve their knowledge and skills in a particular area.
  • Many blogs will welcome ‘guest posts’ such as the one you are reading now!

Facebook:

  • What was traditionally a truly ‘social’ media has increasingly become a platform for all kinds of professional information, events and information sharing

Whilst social media does not provide a single answer, it can be a crucial tool to enhance our practice and foster healthy debate about substance misuse work. So whether it’s exploring specialists’ role in the provision of IBA, or issues such as the treatment of alcohol withdrawal syndrome, social media is an opportunity to highlight the good work that we do, enhance knowledge, improve the consistency of approaches and share learning and innovative practice.

Greater use of social media has the potential to bring with it significant benefits to our practice and the care that we provide to patients.

See here for a recent Guardian piece on Five powerful ways to increase your social impact with social media.