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IBA and the wider ‘workforce’ – will it happen?

2 Oct

Wider workforce RSPHEarlier this year the Royal Society for Public Health (RSPH) generated headlines following a report saying  ‘15 million workers including firemen, hairdressers and postal workers could form part of “wider public health workforce”.’

With the ‘core’ public health workforce totalling only 40,000 people, they are unlikely to be able to deliver widespread health behaviour interventions to much of the population. As such, the report calls for anyone who has “the opportunity or ability to positively impact health and wellbeing through their work” to join the wider public health workforce.

Whilst the media focused on the idea of bar maids and hairdressers giving out health ‘tips’, it’s certainly true that many areas have sought to extend well beyond healthcare for IBA delivery. A recent review into IBA in non-health settings found settings like schools, criminal justice, pharmacies and universities have shown promise in terms of the feasibility of IBA delivery, although most of these wider settings including the workplace still lacked evidence.

Healthy conversations

“Healthy conversations”

Another report from the RSPH, ‘Healthy Conversations and the Allied Health Professionals’, highlights Allied Health Professionals (AHPs) as an auxiliary Public Health workforce of around 170,000, made up of 12 professions including Physiotherapists, Occupational Therapists, paramedics and dietitians.

The AHP workforce certainly seem a realistic workforce for delivering brief interventions than perhaps hairdressers or posties, and indeed some areas have already been seeking to engage AHP roles in IBA. The report itself specifically gives some examples of AHPs delivering alcohol IBA or other support, and also some insights into AHP’s attitudes and experiences.

Of particular note may be the findings on AHP’s confidence to discuss different ‘health conversations’ by topic. This may be of relevance given that barriers to delivering alcohol IBA are often related to patient or practitioner beliefs about alcohol. In some areas ‘Making Every Contact Count’ (MECC) approaches have been adopted to try to facilitate widespread health conversations, but the level of alcohol IBA activity specifically is unclear.

Indeed it seems that when compared to smoking, diet, exercise and weight, AHP’s felt more confident to discuss these than alcohol. However AHPs did feel more confident to discuss alcohol than areas such as dementia, domestic violence or sexual health, though perhaps unsurprising.

Wider workforce RSPH

What does this mean for IBA? We know alcohol brief intervention is effective, and possibly more so than for other health topics. But it may also be that quality alcohol brief interventions may be at risk of getting lost or diluted within the wider ‘healthy conversations’ agenda.


Setting achievable goals & the ‘dose effect’

19 Feb

Paracelsus 2Mentioning either ‘units’ or the ‘guidelines’ alone can trigger a sceptical response from a drinker. I’m sure you’ve heard someone protest that “units are confusing” or that they “don’t believe the guidelines”. How should we respond to such statements or beliefs?

Firstly we should accept that people may have ambivalent attitudes about their drinking and may appear dubious or dismissive of health advice we may offer. They may also be right; units can be confusing and hard to keep track of, and we can’t take a ‘one size fits all’ health guideline too literally.

However the principle behind understanding units and applying these to the guideline is important. Consuming any drug – including alcohol – can be considered in terms of the ‘dose effect’ (or the dose-response relationship). Essentially, the greater the dose consumed, the greater the chance of unwanted (as well as perhaps wanted) effects. The recommended guidelines therefore set out the approximate ‘dose’ (in units) which alcohol can be consumed with a low risk of negative effects.

how muchA crucial consideration here is that there is no clear ‘threshold effect’, or no point at which the dose the longer matters. Put simply, the more you drink, the greater the risks . This is important because even if someone says ‘forget the guidelines, I’m never going to stick to them’, they still may be open to considering the fact that 5 pints is still less risky than 6.

There is evidence that some people who drink to get drunk only consider their ‘limits’ in terms of behaviour and whether they are ‘in control’. As such, health guidelines may not feel relevant for them. But emphasising that reducing health or behavioural risks still applies in terms of how much they drink. One message that has been found to be possibly more appealing is to try and ‘drink 2 less’, rather than perhaps ‘only drink 2’! And perhaps more importantly, it may feel much more achievable.

Can we quit “binge drinking”?

19 Nov

pg-08-alcohol-Rex_235373s ‘Binge drinking’ is probably the defining alcohol term of the last few decades. Hype over alcopops, dramatic media headlines and the variety of ‘binge Britain’ based low budget TV shows are testament to its enduring popularity. As such, people often frame their ideas of problem drinking around ‘binge drinking’ (and of course ‘alcoholics’). Both potentially problematic terms.

In terms of where  people ‘fit’ with regard to their alcohol use then, it’s important to recognise the alcohol use/misuse spectrum. That is that drinking ‘categories’ are fluid, and so individuals don’t fit or stick neatly into boxes. People, their circumstances and their consumption are often in various states of change, and labelling or subjective terms carry many risks.

Most adults are ‘low risk’ drinkers, but at certain times of the year their drinking might go up. Generally though they will re-set their consumption of their own accord, or when an occasion (such as Christmas) has passed. The same can even be said for dependency in some ways – most people who do experience some level of dependency recover on their own, usually without any formal support or treatment.alcohol & language

So where do ‘binge drinkers’ fit in all this? And can it ever be a useful term?

Taking the technical definition of drinking twice the daily guideline or more in one go, ‘binge drinkers’ can actually ‘fit’ into any of the main drinking ‘risk’ groups – depending on frequency. Someone who ‘binge drinks’ once a year on their birthday but generally keeps within the guidelines will be a ‘low risk’ drinker overall. But someone who ‘binges’ regularly, most days of the week, will probably be showing at least some signs of dependency.

‘Binge drinking’ overlooks one crucial risk factor: frequency

Of course the media obsession with ‘binge drinking’ means that it’s so commonly used to describe drinking patterns, but as highlighted, frequency of drinking can be just as relevant as the amount consumed on a given occasion. People tend to recognise the role of alcohol free days for ‘giving the body a break’, but for many people it may be reducing the risk of dependency that is more relevant. In fact my own experience of increasingly frequent ‘binge drinking’ resulted in increasing tolerance and other symptoms of dependency.

At the time though I was actually quite proud to be a ‘binge drinker’ in some ways – drinking was part of my identify. I saw alcohol largely as positive, and I gave little consideration to the damage it might have been doing – until I actually did develop related health problems. These problems actually triggered contemplation, and eventually I went a long period without drinking at all. The main benefit of IBA though may be to trigger contemplation before problems or dependency develop.

Binge drinking will continue to be used, and perhaps more accurately to describe ‘drinking to get drunk’, rather than a fixed amount. But like with the term ‘alcoholic’, we should seek to avoid describing individuals as such, unless they choose that term themselves. Using a validated assessment tool like the AUDIT gives us a more useful way to identify what risk someone’s drinking they may pose, so may help us quit “binge drinking”.

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

Aim for an extra ‘alcohol free day’?

5 May
Mocktail anyone?

Mocktail anyone?

‘Brief advice bullets’ are motivators or tips to offer to people contemplating cutting down their drinking, like improved sleep, switching to lower strength drinks or reduced hangovers. However one of the most achievable goals for many drinkers seems to be to aim for an extra alcohol free day or two within the week.

Adding an extra alcohol free day often works best for those who have got into a ‘regular’ drinking pattern, perhaps without realising it.  The biggest trend in alcohol consumption has been the rise in home drinking, often synonymous with ‘a glass of wine to relax at the end of the day’.

Many such drinkers may have assumed that because they are not ‘binge drinking’, there are not significant health risks. Yet someone drinking an average of 2 medium glasses of 13% wine each night is clocking up around 32 units a week. Adding just two alcohol free nights will bring that down to around 23 units, much closer to the weekly guideline of 21 for men.

However since the recommended guidelines were changed from a weekly to a daily guideline, one of the concerns is that the message of at least two alcohol free days has been lost. Do most people realise that ‘not regularly exceeding 2 to 3 units (women) or 3 to 4 units (men)’ means having at least two nights of a week off the sauce? Even drinking five nights of the week within the daily guidelines seems a little too close to a ‘habit’ for my comfort. Perhaps the forthcoming change to the alcohol consumption guideline will better account for alcohol free days.

Of course like all ‘ brief advice bullets’, aiming to add an extra alcohol free night or two won’t appeal to everyone. But over the course of a week, a month, a year.. those health, financial or functioning improvements could really add up.

IBA – before addiction sets in…

30 Oct

One of the fundamental points about IBA is that it is an early intervention – a chance for a drinker to change their alcohol use before it becomes a problem. By problem in this sense I mean a dependency or addiction issue. Of course many non-dependent drinkers experience serious alcohol problems, even death, as a result of their drinking (think accidents and injuries as well as liver disease etc.)

A big challenge though is that many people tend to perceive dependency only in its extreme or physical form. Yet the majority of drinkers with some level of alcohol dependence will not have a physical reliance on alcohol, but a psychological one. Broadly, this means they experience a strong psychological desire to drink and difficulty controlling their alcohol use. For most dependent drinkers, that is not because their body needs it (yet), but perhaps because their brains have become overly used to drinking, often to deal with other problems or as a coping mechanism.

Perhaps the easiest way to think about the importance of the psychological aspect of dependence is the high re-lapse rate amongst severely dependent drinkers having undergone detox. Their body has dealt with the physical need to drink, but it is the ‘addicted mind’ that compels them back to drink. Whilst there is great debate over what works for ‘recovery’, one thing can be agreed for sure – achieving it is not easy.

But most alcohol misuse is amongst non-dependent drinkers so their drinking is still well within their control. They can therefore very often change their drinking without great difficulty should they choose to. They may be confronted with peer pressure, or need to find some other ways of enjoyment, but these challenges are small compared to overcoming dependency. IBA empowers risky drinkers to recognise the value of cutting down their drinking – while it still well within their control.

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!

IBA – are all settings equal? Presentations and experiences

27 Oct

Two recent events explored evidence, experience and views on delivering IBA across different settings. The first – ‘IBA: are all settings equal?’ – was held in partnership between the Alcohol Academy and DrinkWise NorthWest in July. More recently the Academy teamed up with the Nottingham Recovery Partnership to deliver ‘IBA: Making Every Contact Count?’.

Both events aimed to bring together alcohol leads and practitioners to assess how IBA implementation is going – and how and whether it should be extended across further settings. Of course, ‘all settings are not equal’ because the evidence base and policy focus is on IBA in Primary Care. Yet there is clearly both an enthusiasm and investment in delivering IBA across a wide range of settings.

A few of the key presentations and discussion points are outlined below, but all presentations can be accessed here and here. Continue reading