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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

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IBA for young people: a promising picture?

12 Aug

A common question about IBA is ‘does it work for young people?’ – and a straightforward answer isn’t easy, though we are getting closer. Recently two new publications have reviewed the evidence for IBA in children and adolescents:

The good news is the reviews are broadly in agreement and make some useful points, notably that AUDIT and CRAFT screening tools are considered the most effective and should be be used with adolescents for IBA. The bad news is, as you might expect, more research is needed as many issues remain largely unanswered. Fortunately SIPS Junior is under-way and will shed some further light, especially given the absence of UK based evidence for young people’s IBA.

One of the key issues is the significant differences between young children and older adolescents. In particular, any alcohol use may be considered problematic in younger children (especially under 15), whereas ‘lower risk’ drinking in older adolescents may not be of such concern. However what is considered ‘low risk’ for adults is not considered ‘low risk’ for adolescents based on the CMO guidance, so lower scoring cut-offs on screening tools are deemed necessary – but not yet researched. And given the broad but important age range covering children and young people, it won’t be straight-forward.

The reviews do however identify a number of research trials that identified positive effects of brief interventions (as well as some null-findings, which another paper recently suggested should not be interpreted as showing IBA not to be effective). Some evidence was also found of indications that electronic forms of brief intervention (or e-BI, or e-BA if ‘IBA-ing’ it) were effective, but also one meta-analysis found traditional face-to-face approaches superior.

All in all, IBA for young people seems an important opportunity where we can make it happen effectively, even if the research, tools and guidance aren’t up to speed with that for adults. As listed in this blog’s 2012 post on this subject, here are some IBA and young people centred resources:

The alcohol calorie catastrophe

19 Jun

A single drinking occasion can lead to a multiple calorie catastrophe that can really undermine attempts at weight loss or healthy lifestyles. So even if health or other risks aren’t a concern for someone, its hard not respect the extra calorie count that alcohol can ramp up. But its not simply the calories in drinks themselves to be aware of…calories

First off, the calories in alcohol itself – an average UK drinker may consume 10% of their total calorie intake through alcohol alone. Per gram, alcohol has nearly the same calorie content as fat (7 calories per gram for alcohol and 9 per gram for fat).

And its not just beer that’s calorie loaded – a large glass of wine can have as many calories as a pint of lager. That’s around 180 calories, significantly more than a  packet of crisps (130 kcal in a 28g bag). So whilst someone on a diet would presumably never consider three bags of crisps in one go, three glasses of wine on a weekend occasion might not get a second thought.

There’s then there’s the possibility of a drink induced food binge. Alcohol is thought to interfere with the brain in way that can lead to hunger cravings, despite the body not needing more food. It is also thought that alcohol reduces the amount of fat the body burns for energy.

The final nail in the great calorie catastrophe is what might follow the next day – a recent study said drinking more than three large glasses of wine can push people to consume up to 6,300 extra calories in the following 24 hours. The survey found that around half of people consuming over 9 units consumed an extra 2,051 calories the next day on top of their usual diet. In addition, many stayed in bed, watching TV and using social media while hungover – instead of doing anything active.

Of course the additional downside is that alcohol calories are empty calories – there is not real nutritional value. So no, cider does not count towards your five a day!

Adding it all up…

So the alcohol calorie catastrophe can be a quadruple whammy of:

  • The calories in the drink itself
  • The extra calories consumed due to alcohol induced hunger (or perhaps loss of self-control!)
  • Alcohol reducing the amount of fat the body burns for energy
  • The extra calories consumed or not burned the following day

So it’s not surprising that many people might be more motivated to cut back on the drinks for reducing calories above reducing longer term health risks. This might be especially true for younger people, where more immediate issues like appearance or saving money might have stronger appeal.

One concern sometimes raised is young people aware of alcohol’s high calorie content opting to skip meals to compensate. Certainly a worrying issue and unfortunately sometimes there is little parents or professionals can do to prevent young people taking such risks. But adopting motivational brief intervention approaches, supporting and encouraging a person to reflect on the pros and cons of any risky behaviour can help.

But generally, cutting back on alcohol consumption for reducing calories can still bring many other benefits. When it comes to changes in drinking, it’s often a world of vicious -or virtuous – cycles.

IBA for children and young people: evidence, guidance and resources?

11 Jun

Although NICE advises that IBA be offered to those aged 16 and over, there is limited evidence as to the effectiveness and best delivery approaches for children and young people. However a new SIPS junior trial is getting underway focussing on younger adolescents presenting to A&E departments (but don’t expect the results anytime too soon – it’s a 5 year project!). The SIPS junior website has a good summary of the issue though, highlighting:

“advice to children under 15 years (2009) is to abstain from alcohol due to risks of harm, and 15-17 year olds are advised not to drink, but if they do drink it should be no more than 3-4 units and 2-3 units per week in males and females, respectively. In contrast, alcohol use is increasing in adolescents in the UK: the average amount consumed by 11-15 year olds doubled in the last 13 years to 2007. Adolescents in the UK are now amongst the heaviest drinkers in Europe.

Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self harm, unprotected and regretted sex, violence and disorder, poisoning and accidental death. Early drinking in adolescence is associated with intellectual impairment and an increased risk of more serious alcohol problems in later life. Methods of alcohol screening and early intervention have been developed for adolescents in the USA, and show evidence of benefit, but have not been studied in the UK. Further these methods have several shortcomings including not providing screening and intervention methods appropriate to the age and developmental stage of the younger adolescent.”

In the meantime, I believe there is still a good case for IBA with younger adolescents as long as safeguarding and other risks are covered (see NICE PH24 recommendation 6). If IBA opportunities present, practitioners should be able to use a combination of common sense and good IBA skills. For instance it’s broadly accepted that children and young people are more likely to be motivated around risks to their personal safety, injuries, appearance or other more immediate harms. So highlighting things like risks to high blood pressure probably aren’t going to be the most effective approaches for framing IBA for younger groups. Nonetheless, we shouldn’t overlook that we have been seeing a trend in younger and younger adults presenting with liver disease.

Here are a few useful IBA resources aimed at practitioners working with children and young people:

One of the key things SIPS Junior will reveal will be which screening (identification) tools may be best suited for younger adolescents. For children aged 10-15 in contact with professionals, NICE suggests consent and use of the Common Assessment Framework (CAF) to obtain a detailed history of their alcohol use, including background factors such as family problems or other issues.

A comprehensive list of further guidance, resources and reports relating to children and young people is available here from the Alcohol Learning Centre.