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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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Can ‘nudge’ help IBA delivery?

17 Dec

IBA works to reduce risky drinking, but despite significant efforts, regular good quality IBA delivery seems some way off. However there may be some simple ‘nudges’ for supporting IBA delivery that are being overlooked. nudge

‘Nudge theory’ became popular following the Coalition Government’s favour for policy approaches that did not restrict choice or require legislation. It set up a ‘nudge unit’ and its controversial public health responsibility deal. However reports have warned that nudge alone is not enough to change behaviour at population level, though it may have a useful role to play.

IBA itself is not really a ‘nudge’, it is a more conscious and collaborative form of intervention. ‘Nudges’ are more about changing the environment to affect non-conscious decision making. Popular ‘nudge’ examples include placing healthier food choices in more visible places or designing buildings with stairs more accessible than the lifts. In an Amsterdam airport, an image that looked like a fly embossed in the men’s urinals apparently resulted in an 80% reduction in ‘spills’ by focusing the men’s aim! Use of incentives may also be considered ‘nudging’, but there has been lots of debate over what may be ‘nudge’, ‘shove’ or ‘push’.

However, policy and actions to encourage IBA delivery by front-line roles is often in line with ‘nudge’ theory. For instance, incentives and recording systems may mean that screening (identification) tools,  like the AUDIT, may pop up on a nurse’s computer screen. Or GP practices collect a payment when offering IBA to new patients when they register.

Incentives may have gone some way to initiating IBA delivery, but have not proved enough in isolation. We need to make front line role’s work environments as conducive to doing IBA as possible. For example, having resources as easily accessible as possible. Having to print off screening tools or leaflets each time is off-putting and time consuming.

Some areas have produced ‘IBA packs’ for front line roles. Packs typically include all the tools and materials needed for IBA and posters or local referral options. Having resources already printed out makes it more likely for roles to initiate IBA and offer appropriate information. Ordering free alcohol materials from the DH orderline is not the easiest of processes.

There could be other ‘nudges’ we are missing out on. In some hospitals all staff have been given a credit card sized lanyard with the three AUDIT-C questions to wear alongside their staff badge. Roles often cite concern over asking patients about their alcohol use. Perhaps wearing a badge stating “I try to ask all patients about their alcohol use” could ease this pressure and remind them about IBA.

Just as reports have found for nudge in general, it’s not the solution, but it may be a part of it.

IBA for alcohol… and diet…and physical activity…and smoking….and…

19 Jun

I have just had the pleasure of writing and delivering a one-day training course entitled ‘Brief Advice for Health Behaviour Change’ that aimed to enable practitioners to deliver brief interventions using a motivational approach on the four issues of alcohol, smoking, diet and physical activity. The target audience was frontline staff, not just in healthcare (hospital staff and those delivering NHS Health Checks) but also prisons and workplaces. It is not the first time we have written training on IBA for topics other than alcohol (try IBA for alcohol and drugs for youth workers, or for alcohol and sexual risk-taking) but combining four topics into one process for IBA is not easy.

Firstly, there are basic practical difficulties of how you build the knowledge and understanding of practitioners and address any prejudices or myths that may exist about not one but four issues, in a single day. This is by no means easy, but pre-course work helps.

Even more tricky is how to describe and teach the process of ‘IBA’ for such a broad range of ‘lifestyle’ issues.  Finally, the challenge is to design a process that can realistically be implemented in a 10 minute (max) conversation.

While the basic IBA skills remain the same, we designed a completely new framework or IBA process in which to present and teach them. The course included discussion not only of how and when to raise the issue of ‘lifestyle’ generally, but also how to narrow the conversation down to one or two topics which the individual is ready to discuss. We discussed stages of change in terms of just three stages to simplify thinking and decision-making. And the ‘Identification’ or ‘Screening’ process inherent in IBA was simplified to exploring the individual’s current behaviour and comparing it to national guidelines rather than using a formal screening tool.

The pilot went well, and I am confident that the challenges described can be met – but perhaps not for all of the people all of the time!  And one key question remains – are some issues harder to raise than others?  If you try to cover them all together, will practitioners avoid the issue they find most sensitive? And if so, which issue will be left out? In Scotland, I know that when Keep Well practitioners offering cardiovascular check ups (similar to NHS Health Checks in England) were trained on generic health behaviour change approaches, it was found that they avoided alcohol as an issue and separate training specifically on alcohol was provided. Was this a one-off? Or could we expect that diet and weight issues would be just as sensitive?

We will soon be training 18 people to roll out the Brief Advice for Health Behaviour Change course to others via a two-day training for trainers course… watch this space!

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.