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Who and where for IBA – are nurses and universities best?

11 Oct

A recent systematic review of alcohol brief interventions looked specifically at whether the ‘setting, practitioner group and content matter?’. Based on data from 52 research trials, the results conclude that alcohol brief interventions ‘play a small but significant role in reducing alcohol consumption’ – but also identifies some differences based on where and by whom.nurse

Perhaps the most significant finding is that IBA delivered by nurses were found to be most effective. This may be seen as promising given the reach of nurses and recognition of the role of IBA in healthcare settings. However the study cannot tell us how much this finding may be as a result of the way in which nurses deliver the intervention versus other factors such as nurses being seen as a credible person to offer alcohol advice.

As such it suggests nurses should be seen as a priority for the delivery of IBA, with efforts needed to address key barriers of time, worry about losing trust of the patient and inadequate training. It also emphasises previous research suggesting ‘a good relationship between the practitioner and the client’ as an important factor.

The findings also suggest the less intensive approach of ‘brief advice’ was found more effective than longer motivational interviewing interventions. However concerns over ‘brief advice’ being interpreted as simply feedback and a leaflet -rather than say 5-10 minutes structured advice – should be noted.

Another key finding was that when comparing settings, universities were found to have the greatest effect size alongside primary care – surprising given the limited level of attention to IBA in universities. Perhaps another unexpected findings was a lack of evidence for IBA in A&E settings. Whilst previous studies have found small effects, the review suggests that the specific time pressures within A&Es, lack of privacy and seriousness of injuries may be significant in hampering its value as a setting.

The authors rightly highlight limitations to the research and caution over drawing firm conclusions about role and settings. However it may be fair to summarise that it strengthens the case for shorter ‘brief advice’ to be delivered by nurses in particular. In addition, further focus on the potential of universities as a setting for delivery may also be an important area for development. Meanwhile the possibly limited benefits of IBA delivery in busy A&E settings may need to be weighed up against the level of effort required.

See here for an analysis of the research on the Mental Elf blog.

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Substance use and sight loss guide

4 Dec

A new practice guide has been produced to help practitioners support people with overlapping sight loss and drug and alcohol issues.

Download Substance Use and Sight Loss: A guide for substance use and sight loss professionals [pdf]

The guide follows research identifying that neither sight loss or substance abuse services feel adequately equipped to deal with these overlapping issues, and as such aims to help support better identification and responses in this area.

The issue highlights how many professionals with the chance to offer alcohol brief interventions will be working with a range of different issues that may be closely interlinked. As such ensuring practitioners feel able to respond appropriately is essential, and often why often IBA itself is overlooked as an important early intervention.

Sight loss is of course one of a large number of issues that may be contributing or linked to drug and alcohol problems. Professor Sarah Galvani, one of the authors of the guide said: “Substance abuse can sometimes be used as a coping mechanism for sight loss but the combination of both issues can create a complex challenge for support professionals.”

IBA is about offering a person an opportunity to make an informed decision about their alcohol use. Sometimes it will be straightforward, and discussions around motivations and strategies for change will be along more common lines. At other times, discussion may need to reflect and support other issues – for some people sight loss will be one of them.

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.

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.

#UKalcohol – Twitter discussion on IBA/brief interventions

30 Jul

A planned Twitter discussion on addressing alcohol harms will take place on Wednesday the 13th August at 8pm (= 20.00 BST = 19.00 GMT = 3pm/15.00 EDT) on the theme of alcohol brief advice and brief interventions.  This follows on from an initial discussion on alcohol-related hospital admissions which you can read here.

Who can take part?

The aim of the #UKalcohol discussions is to identify and discuss key issues facing those working in the alcohol field – either as commissioners, researchers, service providers or policy roles. It is hoped a different ‘theme’ will be addressed each month, reflecting key areas of interest.

#UKalcohol discussion 13th August: alcohol brief advice, brief interventions

The 2nd planned discussion is intended to cover the broad theme of design, delivery, support and monitoring of alcohol brief advice in addressing alcohol-related risks and harm.

The following issues may be used as needed as prompts/themes for discussion:

  1. What is brief advice, what is a brief intervention, does it matter?
  2. How widely should we implement brief advice/interventions on the basis of current evidence?
  3. What is needed to support brief advice/interventions in practice? How do the needs of different settings differ?
  4. How should brief advice/interventions on alcohol fit with attempts to address other lifestyle issues?
  5. What monitoring and evaluation of these interventions is needed and is it feasible?

Partnership

This 2nd discussion is being brought to you by the UK Centre for Tobacco and Alcohol Studies with the support from a range of partners and stakeholders who will be jointly supporting the alcohol Twitter discussion, and may initiate further themed discussions in future.

Next steps

If you are interested in participating in the proposed Twitter discussion either as an individual or on behalf of your organisation simply sign in via Twitter on Wednesday the 13th August at 8pm and use the #UKalcohol. Discussion may be subsequently captured and shared via Storify.  You can also follow @ukctas to see tweets about this in advance.

If you’d like to ask any questions or help with Twitter please do get in touch via niamh.fitzgerald@stir.ac.uk or james@alcoholacademy.net.

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.

SIPS Primary Care research: not just a leaflet

28 Jan

SIPS: largest ever UK study into alcohol brief interventionsThe SIPS trial, a £4 million study applying brief intervention approaches in key settings, has published the Primary Care results in the BMJ. The A&E and Probation results will follow shortly.

I’m not going to try and summarise the results here – the BMJ article is easy enough to garner and a Findings bulletin also interprets them in a simplified form. Instead I wish to consider some implications for those interested in delivering IBA.

However I should point out that I will be writing on the assumption that SIPS findings did show that brief intervention is effective. But I certainly expect to return to the discussion that this may not be the case. These charges are not so much based on a question of brief intervention efficacy, but whether SIPS can be seen to validate effectiveness in real world settings.

So assuming we accept the SIPS findings as evidence that brief interventions can be effective in practice, I will explore some key implications. Not surprisingly, of headline interest is the finding of no significant difference in outcome between the 3 intervention approaches tested (all 3 showed a reduction at 6 at 12 months). The three main intervention approaches were:

  1. Feedback [of screening result] + Patient Information Leaflet (PIL)
  2. Feedback + five minutes of structured advice using the SIPS brief advice tool + PIL
  3. Feedback + 20 minutes of ‘Brief Lifestyle Counselling’ (BLC) + PIL

Level 2 might be considered standard IBA, with 1 being the most minimal intervention, and 3 being more ‘extended’ brief intervention. So do SIPS findings suggest that “less is more”?

To some degree it would seem so, but they DO NOT suggest that giving out a leaflet is all that’s needed. Crucially, the simplest intervention included ‘feedback’ in addition to the leaflet. Feedback generally means informing a person that their answers to the screening question suggests their drinking places them at risk. Often we teach people to follow this with “How do you feel about that?”, encouraging contemplation and often leading nicely into ‘brief advice’. So is ‘advice’ beyond feedback unnecessary?

In many cases, simple screening + feedback and leaflet could well be enough as the trial suggests. However, although we have a lot of evidence that IBA works in Primary Care, there is still relatively little known about how. It it is probable though that IBA works largely by triggering at-risk drinkers to start to think about their drinking, rather than the element of helping them to cut down (e.g. brief advice or leaflet).

To me this makes sense; we know well that IBA is based on the ‘stages of change’ behaviour change theory where ‘contemplation’ about whether a behaviour (smoking/diet/exercise/drinking) is crucial as the start of the process. So can we really forget about offering brief advice or extended brief motivational approaches?

With all these things, there is a risk of a reductionist ‘one size fits all’ approach. Many risky drinkers will not be wanting ‘advice’ straight after being told something that could have come as a bit of a shock. Their ‘contemplation’ phase may well need some time to process.

Sometimes though, a person may move quickly into ‘preparation’ (i.e. deciding to cut down), or already be thinking about it and welcome some help. Perhaps because these people are smaller in number, the benefit of brief advice in SIPS did not come out as statistically significant. We must also note previous studies have shown the benefit of advice or ‘brief counselling’ over no intervention.

So common sense should apply to IBA delivery in many ways – make sure proper screening is followed with ‘feedback’ (not just a leaflet), and if someone seems to want some help, there’s a good chance they’ll appreciate it. One further finding that was statistically significant in SIPS was that patients receiving the longest intervention were most positive about their experience with the practitioner.

I think the results can be seen as good news if we accept them at face value. In many cases, IBA may commonly only require the shortest and easiest forms of “advice”- feedback and a leaflet. Sometimes a bit more may be helpful, but it is nothing new to suggest asking the questions in the first place is what really counts. The debate about how we interpret the SIPS findings is probably just beginning.