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Armed forces deploy brief interventions: will it work?

25 Aug

This post originally appeared on Alcohol Policy UK.

https://alcoholibablog.files.wordpress.com/2017/08/8e9df-6a00d8341c070353ef01bb09b8f2ea970d-pi.png?w=181&h=213The Ministry of Defence (MoD) have released figures on an initiative to deliver alcohol brief interventions across the armed forces via dental check ups, identifying 61% of military personnel drinking at a risky or harmful levels.

The MoD has previously come under fire over a lack of action to address high levels of alcohol misuse amongst the armed forces. In 2015 Professor Neil Greenberg, lead on military health at the Royal College of Psychiatrists and a former Navy Commander, said an approach based education alone was not effective. Subsequently an MoD alcohol working group was instigated to “review policy and data to identify what more we can do to tackle alcohol misuse in the armed forces”.

Alcohol brief interventions (ABI), often referred to as Identification and Brief Advice (IBA) in England, have been increasingly sought as a strategy to promote behaviour change amongst at-risk drinkers, as advised by NICE and national health bodies. Much debate has been had though over how and where they should be delivered, with question marks over to what extent various national and local efforts may have been successful.

The MoD report highlights Armed Forces personnel are expected to attend a dental inspection between every 6 to 24 months, therefore presenting an opportunity to deliver ABI to the whole workforce. The initiative used AUDIT-C, a 3 item assessment tool utilising the first three questions of the full AUDIT. Scores of 5 or above on the AUDIT-C indicate a level of risk and/or harm, though it is considered less effective at distinguishing different levels of risk or probable dependence in comparison with the full AUDIT.

The MoD sought to offer all personnel with a score of 1+ (any level of drinking) an alcohol advice leaflet, reporting 80% (n = 80,662) as receiving one. Of the 61% personnel who scored 5-12 on the AUDIT-C, 63% (n = 42,074) were given an ‘Alcohol Brief Intervention’ (ABI), though the report states it is ‘not currently possible to measure how many of these ABIs have been delivered’. Indeed a key question for all ABI initiatives has been to what extent the reported interventions have been delivered, particularly in view of time time limitations and other issues such as a lack of training.

For those scoring 10-12 on the AUDIT-C, a total of 2% (n = 2,502), the MOD states personnel should have also been ‘advised on the importance of seeking further advice from their GP or a local alcohol support service’ in addition to the ABI. Overall, higher alcohol risk levels were associated with being young and single, being of more junior rank and being of white ethnicity, with navy personnel indicating the highest AUDIT-C scores. MoD ABI fig

Will dental ABIs reduce alcohol misuse in the military?

The report states the MoD is undertaking other initiatives to reduce alcohol misuse, including ABI beyond its dental settings. Measuring the specific impacts of such schemes is notably difficult, though having such data on the levels of alcohol misuse may prove useful data for any future evaluation. However as with wider debates over approaches to reduce alcohol misuse, researchers tend to highlight the need for ‘multi-component’ programmes and supply side controls rather than relying on single initiatives to have a sustained impact.

The MoD’s alcohol working group is likely to face many specific challenges in shifting what MPs have described as a heavy drinking culture within the armed forces. The availability of subsidised alcohol, attitudes and expectations of personnel towards alcohol and the many other complex factors influencing health and wellbeing are all likely to play important roles in seeking such changes. Observers may see a committent to ABIs as welcome, but will hope that they are not relied upon as the sole strategy for addressing alcohol misuse in the military services.

See the MoD report here, or a 2013 letter in The BMJ’s Journal of the Royal Army Medical Corps and a 2011 report on ‘Alcohol use and misuse within the military: A review’ [pdf].

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95% people are ‘comfortable’ talking to GPs about alcohol

30 Sep

iba-gpResults from the 2015 British Social Attitudes (BSA) were recently released, revealing the vast majority of patients felt either fairly (20%) or very comfortable (75%) talking to their doctor about their alcohol consumption.

Just 2% of respondents were either fairly or very uncomfortable doing so, suggesting there is little justification for the commonly perceived barrier that patients may be defensive when offered brief intervention. A further 3% said they did not feel either comfortable or not.

Furthermore over four-fifths (85%) of people say that they “would answer completely honestly”, while 14% say that they would “bend the truth a little”. Whilst the study found people were more likely so say they would answer honestly if they didn’t drink or were lower risk drinkers, 62% of risky drinkers still said they would be truthfull.

This may in part be because many at-risk drinkers are not aware of their drinking as such, but still the results suggest a widespread public acceptance of the role of IBA in health care settings. Unfortunately, despite ongoing efforts to incentivise and support Primary Care roles to deliver IBA, less than 10% of at-risk drinkers report recieving alcohol advice, compared to over 50% of smokers.

‘How’ you ask is important too

Despite such a high percentage of patients being comfortable to discuss their alcohol use, it is important to note that how such questions – and any subsequent ‘advice’ – is carried out is crucial to the effectiveness of brief intervention.

One of the most important things is to ensure patients do not feel they are being judged or picked out individually for alcohol questions. Whilst many practices screen patients at certain points, initiating IBA can be done whenever a spare moment arises.

raising-the-subject

Patients of course do have the right to decline, and any following conversation should not be pushy or lecturing. Delivering a validated alcohol assessment such as the AUDIT and offering brief feedback on the person’s score appear to be the most important elements – Primary Care roles musn’t think that patients are against this.

Briefing on IBA & LGBT people – a key group to ‘target’?

9 Oct

LGBT IBAA short briefing highlights the potential for IBA to reduce alcohol related harm amongst lesbian, gay, bisexual and transgender (LGB&T) people. It describes LGBT groups as a ‘high-risk group’ for alcohol misuse given research that shows higher prevalence.

The briefing provides a short background of IBA as a short alcohol intervention, and considerations for ensuring IBA can reach LGBT people. For those already seeking IBA implementation, it may highlight another setting or area to consider engaging front line roles with training and support, or opportunity to build IBA into service commissioning.

Of course the debate about which wider settings should IBA be sought in goes on, and the challenges may not be wholly different from many other settings where IBA is sought. At the same time, it urges all staff delivering IBA to ‘ensure their approach is culturally sensitive and LGB & T-inclusive’, given discrimination that LGB&T service users often report when using mainstream services.

The briefing though may be of most use in encouraging LGBT specific services to incorporate IBA as something to potentially benefit their service users. As the briefing advises, ‘IBAs can readily be incorporated into initial screening and triage for new service users; into case or care plan reviews with existing service users; or into outreach interventions in LGBT social settings.’

Of course any practitioner delivering IBA should show key skills that both underpin brief intervention and non-judgmental person-centred approaches relevant for ensuring people of any sexual orientation feel well treated . The reality though is that more training, support and resources are needed for quality IBA to be adopted more widely. And with LGBT people likely to make up between 1.5 – 7% of the adult population, as a ‘high risk’ group for alohol misuse it makes sense to support LGBT services specifically in IBA delivery.

 

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.

 

The Evidence of Effectiveness & Standards for IBA: Hospital & Criminal Justice settings

16 Jul

Further guidance for IBA delivery has been released, outlining the evidence for IBA and minimum standards for delivery in Hospital and Criminal Justice settings.

Download: IBA hospital settings

Guidance for community health settings was also released earlier this year – full report here [pdf].

Although the documents share many of the same sections in terms of explaining IBA and the evidence base, setting specific implications and invest to save rationale are included.

  • Alcohol misuse costs the NHS £3.5 billion per annum; much of this burden is from hospital care.
  • In 2010/2011 there were 1.2 million alcohol-related hospital admissions. This equated to 7% of all hospital admissions and offers a substantial opportunity to intervene.
  • Over 14 million people are treated in ED in England each year. The Department of Health estimates that 35% of ED attendances in the UK are attributable to alcohol, increasing to 70% between midnight and 5am.
  • Almost one third of London fire deaths are alcohol related.
  • 11% of male high blood pressure is alcohol related.
  • Over 4,000 people die each year as a result of alcoholic liver disease.51
  • A National Statistics study found that 27% of people with severe and enduring mental health problems had an AUDIT score of 8 or more in the year before interview, including 14% who were classified as alcohol dependent.IBA Criminal Justice

For Criminal Justice Settings, the rationale for IBA is also convincing:

  • The prevalence of individuals with an alcohol use disorder in the criminal justice setting
    is three times greater than in the general population.
  • As many as 75% of arrestees may be risky drinkers and therefore appropriate for brief advice.
  • In 2010/2011 1.4 million people were arrested in England and Wales highlighting police custody as an effective setting to reach around 3% of the adult population annually.
  • Self-reported associations between drinking alcohol and the offence were identified in two fifths of respondents and for 50% of violent crimes.
  • 47 % of violent crime is believed to be alcohol related.
  • 45% of victims of domestic violence say their attacker had been drinking.
  • The national cost of domestic violence to criminal justice, health, social, housing and legal services as well as the economy amounts to more than £5.7 billion a year.
  • A study of arrestees and offenders who had been given brief advice and treatment in police custody or referred elsewhere identified that 40% of respondents found the advice useful.
  • 74% of probation clients in a study in South London were AUDIT-C positive

The guidance was commissioned by the Safe Sociable London Partnership, a regional body aiming to supports alcohol improvement work in London.

‘IBA Direct’ – new opportunities for brief intervention?

20 May

IBA directIn London a piece of work has been underway seeking to design and deliver interventions to ‘at-risk’ drinkers who are unlikely to come into contact with a health care professional. Young ‘twenty-somethings’ are less likely to visit their GP, but more likely to drink heavily when they do drink. So how else can these drinkers be reached?

We know ‘responsible drinking’ messages alone are unlikely to be effective, particularly when we consider the environment and all those alcohol cues. We also know IBA is effective, particularly in Primary Care, but serious questions remain over actual delivery, even for the minority that do receive it. But what about cutting out the middle man and taking IBA straight to the target group?

This was the idea behind ‘IBA direct’. Resonant, an agency who specialise in behaviour change, went out and found local twenty-somethings drinking at risky levels and worked with them to co-create how they could be reached in an effective way. Young risky drinkers said they were more than happy, in fact actually liked doing the ‘alcohol quiz’ – i.e the AUDIT. They found it interesting and it made them think, especially when they knew it was credible rather than just a magazine style quiz.  Perhaps surprisingly they actually liked a person offering them ‘feedback’ and ‘advice’, rather than a less personalised web approach.

The real challenge is how to reach significant numbers of these drinkers with ‘IBA direct’, and whether it can be done cost-effectively. The drinkers themselves identified that it needed to be engaging, part of something that would grab their attention and hook them in. As you would also expect, it also need to avoid being presented as something that would make them feel judged or lectured.

chuggerPerhaps one way of delivering ‘IBA direct’ can akin to ‘chugging’ – aka those ‘charity muggers’, except not going after anyone’s money. In fact they are offering a person something that might them make a healthier, informed choice about something they didn’t realise carried so many risks (or benefits from cutting down). Perhaps there are many opportunities where we can engage the public directly through IBA, rather than relying on busy practitioners.

In some ways ‘IBA direct’ is also not entirely new. If you’ve invited someone to do IBA at a community event, for instance during Alcohol Awareness Week, that’s IBA direct. Apps or web-based approaches could also be argued to be, but IBA in its true form is delivered by a person. The question is, how cost-effective is it going to be, and what’s the best way to really hook people in? Work is under-way to test this out, so watch this space!

IBA direct summary

You can read more about Resonant’s work with Lambeth 20-somethings via IBA direct (pdf) or get in touch here.

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.

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.