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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.

INEBRIA 2012 presentations

2 Nov

A selection of presentations and posters from the INEBRIA 2012 Barcelona conference are now available. The conference covered the theme of ‘Research into practice’ as explored in this recent post.

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

INEBRIA 2012: research into practice?

8 Oct

INEBRIA is the International Network for Brief Interventions for Alcohol and Other Drugs. The 2012 conference was held in Barcelona on 27th and 28th September 2012.

This year I attended my first INEBRIA conference which was an overwhelmingly positive experience. The breadth of presentations, posters, and leading international experts available to talk to was inspiring. Of course much of it was focused on the latest research – to a non-academic this often leaves one constantly asking the question “How does this influence what happens in real world?”. Continue reading

SIPS: largest ever UK study into alcohol brief interventions

15 May

Orginally posted on Alcohol Policy UK:

SipsFindings from the SIPS trial, the largest UK alcohol screening and brief intervention study, have been released.

The study took place across key settings of Primary Care, Emergency Departments and Probation and tested the effectiveness of a range of brief intervention approaches and screening tools. A conference event took place on the 5th of March 2012 to launch the findings, with presentations available to download.

SIPS covered 9 Emergency Departments, 29 GP surgeries and 20 Probation Offices across London, the South East and the North East of England. During the 13-month data collection period 10,530 patients were screened with 2,481 recruited into the study. The trial tested three key ‘brief intervention’ approaches of:

  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

For Emergency Departments, the Modified Single Alcohol Screening Question (M-SASQ) was found to be the most efficient and effective screening tool. However successful implementation in EDs required champions and dedicated staff. In terms of results, all three approaches showed positive outcomes on drinking behaviours, with greater effects at 12 than 6 months. However when compared to simple feedback and leaflet, brief structured advice or longer 20 minute lifestyle counselling did not offer any significant advantage in terms of drinking behaviour or alcohol use disorder outcomes. However lifestyle counselling was considered to have a greater cost impact due to greater QALY gains and a greater reduction in societal costs.

In Primary Care settings, the FAST alcohol screening tool was the most efficient and effective screening tool. Successful implementation though required financial incentives, training and ongoing specialist support, though longer lifestyle/extended interventions were harder to implement. All brief intervention approaches resulted in reductions in alcohol use, but when compared to simple feedback and leaflet, brief structured advice or longer 20 minute lifestyle counselling did not offer any significant advantage in terms of drinking behaviour or alcohol use disorder outcomes. Feedback and leaflet was found to be the most cost-effective approach.

In Probation (Criminal Justice) settings, the FAST was also found to be the most effective screening tool. Successful implementation was challenging, requiring managerial support and ongoing specialist input to maintain activity. For ‘increasing risk’ [hazardous drinkers] who scored between 8-15 on the AUDIT, simple feedback and leaflet was as effective as longer interventions or lifestyle counselling. However for ‘higher risk’ [harmful] drinkers scoring 16 or more on the AUDIT, more intensive interventions were beneficial.

See the SIPS website for forthcoming further analysis and details of the SIPS ‘junior’ trial which will explore the impact of brief intervention approaches on young people.

IBA in Wider Settings: Conference Report

9 May

Social work, criminal justice, pharmacy, housing, homelessness, police: all these settings are becoming increasingly the focus of research and implementation initiatives relating to IBA.  A recent conference (27th March 2012) organised by Edinburgh Cyrenians, in association with Comic Relief, Create Consultancy, Alcohol Research UK and INEBRIA was attended by professionals and researchers from all these fields.  With a key note address on the state of the evidence base for IBA by Dr. Richard Saitz, and a following presentation ‘How to decide what to do, whatever the evidence‘ from Dr. Andrew Tannahill, the day got off to an intriguing start.

Further presentations focused on how to implement IBA into routine practice, an example of how Edinburgh Cyrenians rolled out alcohol interventions across their frontline homelessness services, and a discussion of the place of alcohol in the lives of hard to reach groups.  Workshops discussed selection of screening tools, training, gender issues and web technology relating to IBA.

The full list of speakers and presentations from the conference are available.

Last year the Alcohol Academy held an event and published a briefing paper exploring ways to achieve widespread IBA delivery.