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The Evidence of Effectiveness & Minimum Standards for IBA in Community Health Settings

31 Mar

A new document outlining the evidence for IBA and standards for delivery in a range of settings has been released. Commissioned by the Safe Sociable London Partnership, the document provides an overview of the evidence base for IBA as a short ‘brief intervention’, and suggests how it should be delivered in key community health settings.IBA evidence and standards_community health

The Evidence of Effectiveness & Minimum Standards for the Provision of Alcohol Identification and Brief Advice in Community Health Settings [pdf]

‘Identification and Brief Advice’ has been central to England’s alcohol policy, particularly given its effectiveness in comparison to other individual level interventions. Brief intervention is most likely to ‘work’ because a combination of ‘identifying’ a level of risk – and ‘feedback’ to the drinker to inform them of this – may trigger a process of change.

In contrast, just handing someone a booklet means even if it is read, a risky drinker may not realise the information is relevant to them and assume they are fine. Brief advice may also give added benefits, such as helping build a person’s motivation or belief in their ability to change.

As such, the guides summarises the evidence base behind IBA, for example it states:

“On average, following intervention, individuals reduced their drinking by 15%. While this may not be enough to bring the individual’s drinking down to lower risk levels, it will reduce their alcohol-related hospital admissions by 20% and “absolute risk of lifetime alcohol-related death by some 20%” as well as have a significant impact on alcohol–related morbidity.”

As well as setting out an interpretation of how IBA should be delivered, it provides specific suggestions and statements for key community health roles including:nurse IBA

  • Primary Care Staff
  • Community Pharmacists
  • Midwives and Health Visitors
  • Mental Health Service Staff
  • Drug Service Staff
  • Delivery by Sexual Health Workers

The report also addresses the crucial issue of ‘making it happen’ through what it describes as ensuring ‘organisational ownership’, as well as the need for training, materials and inter-linking IBA with related issues and policy.

Some of the statements within the report will still be subject to debate. In particular, exactly what ‘brief advice’ consists of, and whether IBA should be implemented in all community health settings without more setting specific evidence.

Exactly what ‘IBA’ is as a form of brief intervention has been explored in the ‘Clarifying brief interventions’ briefing [pdf], and IBA in non-health settings has been explored in recent research report.

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Clarifying Brief Interventions: 2013 update – beware ‘IBA lite’?

16 Jan

goodIn 2010 the first Clarifying brief interventions briefing mainly aimed to shed light on the differences between ‘IBA’ as simple brief intervention and EBI as Extended Brief intervention. This was in response to an apparent lack of clarity between the two approaches, and perhaps a false assumption that EBI was ‘better’ then IBA as a general approach.

For the 2013 Clarifying Brief Interventions update the focus appeared quite different. Although the IBA agenda has clearly moved on, the focus appears to have shifted to  simpler approaches, or ‘IBA lite’ as posed in the new briefing. These minimal or ‘lite’ approaches appear to reflect the challenges of implementing IBA across front line settings. Using shorter screening tools and providing just a feedback statement + leaflet takes very little time. ‘IBA lite’ also relieves practitioners of the need to offer ‘brief advice’ which may often be perceived as lengthy or difficult. The appeal of IBA lite is therefore obvious.

The briefing however highlights the limited evidence to support ‘lite’ approaches, but accepts that it may be a good starting point. If people are being ‘identified’ and informed of their risk level they are more likely to consider their drinking. But considering one’s drinking and making a change to it are not the same. Behaviour change is often much more complex, and the opportunity to further affect the drinker’s motivation to change is lost with ‘IBA lite’.

Take for instance a drinker who after ‘IBA lite’ decides they would like to reduce their risk, but feels it will be too difficult to cut down. They are not aware of some very simple strategies that could help them, or that they can change via ‘small steps’ rather than needing to take one giant leap. Helping identify simple strategies or manage expectations are some of the obvious benefits of offering ‘brief advice’.

However, it cannot be said that IBA, as in including the offer of verbal brief advice, is the most ‘superior’ form of brief intervention. Nor can the same be said for EBI including more motivational techniques. The truth is there is still much more to be learned about the effective elements of brief intervention, and it what circumstances they might apply. In Scotland, more emphasis on empathy and motivational enhancement was placed in their national brief intervention programme, although in England ‘IBA training’ has been provided widely and to no common framework.

Future brief intervention research is increasingly focussing on not if, but how it works. This needs particular attention to the challenges faced on the ground. In the meantime, we still need to be aiming for something more than the easiest minimal approaches. ‘IBA lite’ may be a start, but my sense it is probably not close enough to what really helps most drinkers to enact a change in their drinking.

EBI: lost in the shadow of IBA?

9 Aug

Over recent years there has been a strong policy focus on IBA as a simple brief intervention: front-line roles giving simple feedback or ‘brief advice’ to risky drinkers. Big questions remain though over whether IBA is happening on the ground, or when it does, is it being done so effectively.

Another big issue though is whether Extended Brief Interventions (EBI) have been left in the shadow of simple IBA? However, since it seems most at risk drinkers will respond as well to IBA as EBI, why bother? A question perhaps strengthened by the SIPS trial which appeared to suggest even 5 minutes of brief advice is no superior to feedback and a leaflet.

v2However not everyone is content to take SIPS findings as word. Practically speaking , there are drinkers who need more than brief advice, but less than full ‘treatment’ offered by specialist services (which they are also less likely to engage with). Where someone either does not change following IBA, wants more help, is still unsure but does not need full structured treatment, EBI fills this potentially rather large gap of often ‘higher risk’ drinkers.

Another debate is of course whether EBI is actually a form of brief treatment rather than brief intervention. Semantics though are less important than identifying gaps in what’s currently being offered to all types of alcohol misusers. There are lots drinkers out there, maybe millions, who could arguably benefit from EBI or ‘brief treatment’ approaches, but very few will be offered or seek it.

How to increase access to EBI?

Of course EBI comes at a greater cost than IBA. It is part of the simple appeal of IBA that practically any front line role can do it with a quick bit of training or even e-learning. EBI however is an advanced skill based on Motivational Interviewing (MI) techniques, which are trickier than they sound. Most existing EBI services are therefore offered by alcohol roles working in community settings. However there are not many of these commissioned, although the case is there in the NICE alcohol guidance. (see 3.1 of the costing report in particular).

In some cases though other roles are stepping in, such as health trainers, ‘coaches’ or other independent practitioners working through GP practices. Certainly Primary Care settings seem the most logical arena for taking EBI to those that might benefit from it.

Avoiding ALCOHOL in the service name?

One further key consideration about EBI or ‘brief treatment’ approaches is that drinkers may often be wary of engaging in any form of ‘treatment’ or intervention. Many people view alcohol misuse as only applying to dependency, often at the more severe end, and so are unfamiliar with the concept of ‘risky’ or harmful use.

As a result, many EBI or other alcohol services have been wise to market themselves as services that are about helping people make healthier choices. This clearly fits well with the psychosocial nature of addressing alcohol misuse, but at the same time people need to understand what the service is really about.

One final plus

One further benefit of having EBI roles available is the impact on IBA delivery. EBI roles can play a crucial leadership role in ensuring routine identification is taking place by primary care roles, as well as being there as a referral resource for those otherwise left with not more than a leaflet to help them cut down.

In conclusion, the case and method for improving EBI acces is less straightforward than for IBA. Yet there is still a clear need and cost benefit to increasing access to interventions offering more than brief advice and less than structured treatment. More real world learning is needed on the best ways to achieve this.

Further reading

If you have any EBI evaluations or local case studies please let us know!

Extended Brief Interventions: who, when, where, and other questions?

29 May

Last year, I did a study Evaluating EBI in alcohol settings – May 2011 as part of a Certificate in Drug and Alcohol Studies at University of Stirling which I thought might be useful for other people looking to offer EBI/Brief Treatment in alcohol settings delivered by alcohol specialists.  It is very small scale and, of course, biased by my position in relation to the research participants, and was my first foray into the Social Sciences but hoping it will be of some use.

Abstract

While Increasing Risk drinkers can access Brief Advice (short, structured advice) through generalists, and High Risk/dependent drinkers can access specialist alcohol treatment, the needs of those drinkers who fall between these two groups—known as Higher Risk drinkers—are often overlooked by both generalist services and specialist alcohol settings.  Extended Brief Interventions (EBI)—short motivational sessions with follow-ups—have been recommended in national guidance as a means of filling this gap in provision.  The present study sought to explore and evaluate the effectiveness of alcohol specialists delivering EBI as a form of Brief Treatment (BT).

A literature review was conducted, focusing first on the evidence regarding the comparative efficacy of Brief Advice (BA) and EBI, and then on comparative studies of EBI with more intensive treatment.  In reviewing the literature, it was concluded that, whilst there is a broad consensus that BA is as effective as EBI and that BT can be as effective as intensive treatment, it does not follow that either EBI or more intensive treatment is ineffective or unnecessary.  In spite of some patent flaws in the evidence base, EBI and BT are legitimate modalities for Higher or High Risk individuals who require more than BA and less than treatment proper.

In January 2011, a local alcohol service in North London, HAGA—the author’s employer—introduced EBI as a new treatment option.  Under this new treatment pathway, all clients were to be screened at entry and exit using the Alcohol Use Disorders Identification Test (AUDIT) in addition to the Treatment Outcomes Profile (TOPS).   All appropriate Higher Risk drinkers (AUDIT score 16-19) were to be offered one to four EBI sessions instead of longer-term treatment.

The researcher undertook analysis of data relating to HAGA’s EBI client cohort (January-March 2011), conducted semi-structured interviews with members of this cohort, and sought commissioner perspectives on EBI through an online questionnaire

During the period under analysis, twelve individuals were allocated as EBI clients; of which 75% (n=9) received EBI.  All twelve clients were approached to take part in semi-structured interviews and 41.67% (n=5) took part; of which 80% had received EBI.  The interviews explored client’s experiences of EBI, and the advantages and disadvantages of alcohol services providing EBI.

At follow-up, all EBI clients had improved AUDIT and TOPS scores, which while subject to biasing effects, were not negligible.  There was a 53.6% reduction in the mean TOPS drinking days over the last month from entry to follow-up.  This is a substantial short-term change in cohort drinking levels. 100% of EBI clients reported either sustained abstinence or controlled drinking.

Commissioning leads were not so much interested in debates around terminology but rather driven by a perceived need to fill an identified gap in provision for Higher Risk and motivated High Risk drinkers with EBI (or other BT modalities).

The provision of EBI as a form of BT in a specialist service appears to have met the needs of the majority (80% n=4)) of the follow-up cohort assessed here.  The findings of this study further support the idea that local alcohol services should integrate EBI (and/or other BT modalities) into their service provision.  In order to reach those individuals put off by the stigma of attending an alcohol service and less motivated to seek treatment, commissioners should seriously consider specialist-led EBI satellites in primary care and other settings.

A large-scale longitudinal study of the short- and long-term outcomes for treatment-seeking Higher Risk and suitable High Risk drinkers allocated to three different study groups who would either receive EBI as BT in an alcohol setting, receive EBI from a specialist in a primary care setting, or remain in primary care and receive no support (or only BA) would test these recommendations.

Why an IBA blog?

9 Apr

I have thought long and hard about whether to do this blog. My main reservation was that it may be duplicating existing web resources, but overall I think there is room for a blog that highlights new ideas and relevant updates. I hope this blog will attract a range of contributions and prove of value as a simple space largely aimed to support those delivering IBA.

Another decision I wrestled with was whether to use ‘Identification and Brief Advice’ (IBA) or Screening and Brief Interventions (SBI) terminology. Actually, I lean towards SBI for a number of reasons, namely its used by NICE and has a longer history. However in my experience, it seems IBA now has a wider recognition outside the research field. The Department of Health coined IBA, along with the ‘risk’ terminology and so I wanted to keep the language as consistent as possible for the target audience of this blog.

In defence of IBA, I would also back this as applying to the simpler form or simple ‘brief advice’, not lasting much more than 5 minutes at the most. ‘Brief intervention’ however covers a wider range of approaches including longer lifestyle counselling or ‘brief motivational interviewing’ approaches. Following the release of the recent SIPS trial findings, we know that overall shorter approaches are in most cases as effective as longer interventions. For this reason, emphasising IBA as a short but effective brief intervention approach seems pragmatic to me.

See here for a paper on ‘Clarifying brief interventions’ or here for further links.