Alcohol IBA blog

The two sided ‘IBA tool’ appears to have been a popular resource amongst roles delivering IBA, so PHE have released an updated version following the recent change to the recommended guidelines.

Indeed it is easy to see why the tool may have been popular as it neatly includes key ‘components’ of FRAMES based brief advice. Having these prompts and visual aids may take pressure off the practitioner to remember the various things that may be useful to discuss, or perhaps better still, use them as prompts for a drinker to identify things relevant to them. For example:

• ‘Feedback’ – the tool has several sections that may help the drinker understand what their level of risk is and what that means. The ‘risk category’ table gives an indication of what that may look like in terms of units, whilst the population graph (right)is thought helpful to highlight most people actually drink at ‘lower risk’ amounts.

• ‘Advice’ – practitioners should of course be careful here. Rather than giving direct ‘advice’, generally better to ask “could you think of any benefits if you did decide to cut down?”. The tool suggests some ‘common benefits of cutting down’ which can be useful prompts.

• ‘Menu’ of options (goals or strategies) – as above, best to ask “would any these strategies listed here be useful if you did decide to cut down?”. Easy to assume what works for you will work for them, but important they ‘own’ their responses as much as possible (Responsibility).

Not forgetting of course ’empathy’ and ‘self-efficacy’ as the final FRAMES elements – not on the tool because these are skills we try and embed throughout brief intervention – and probably at other times we are in contact with people. As such the evidence behind FRAMES as central to IBA is often questioned, but in a general sense it may be considered useful as a guiding framework.

What about the tool itself?

It is of course impossible to build the ‘perfect’ one size fits all tool when people and drinking motivations are so varied and complex. This is why the tool should just be an aid to facilitating person-centred IBA, rather than the focus.

Interestingly, PHE have done away with the old ‘large white wine’ with 3 units on the side. This is  a good move as people frequently commented on the drink’s visual appeal. Indeed a ‘priming’ effect has been found in studies and is one of the reason why ‘responsible drinking messages’ with pictures of alcohol are controversial. Weren’t thinking about wanting a drink? Perhaps you are now you’ve seen one!

It’s replacement though is the new ‘One You’ campaign promoting healthier living in general. I’m not quite sure on how I feel about this yet, although I do agree alcohol brief interventions need to be considered as part of wider health behaviour initiatives.

One thing that could still probably do with updating is the unit examples. ‘This is one unit’ contains some rather dubious examples – when was the last time anyone was served a 125 ml glass of wine at only 9% ABV? Certainly far less often than a 250 ml 14% one, registering at a considerable 3.5 units.

However these finer points may not be that important when considering the likely impact. We know ‘identification’ and ‘feedback’ are most likely to be the critical ‘active’ elements of IBA, complimented by conversations that feel helpful and supportive to the drinker. Such resources are probably more important for nudging and helping practitioners to start these valuable conversations.

There are a few places left for an upcoming event exploring whether IBA training should offered en masse, which poses some interesting questions. Flyer here [pdf].

The event, hosted by Middlesex University’s Drug and Alcohol Research Centre (DARC), follows several projects exploring the role of IBA in non-health settings.

The research has found many of same challenges focussed around beliefs and attitudes of non-health staff having alcohol conversations, and of course that training alone doesn’t neccessarily result in routine delivery. Crucially, organisations need to buy in to it so that practitioners are supported and recognised for helping people look at their alcohol use, even if its not in their job description.

There are also many other aspects to consider, not least that people who attend IBA training are given a chance to contemplate their own drinking, or develop skills that may be beneficial in other ways – for example to talk about other health behaviours or things that may need an empathetic approach.

I’ll be on the panel to discuss some of these points and while I won’t be pretending that training is all we need, I will most likely highlight that without it, good quality IBA is unlikely to happen anywhere. And whilst wider alcohol policy is arguably rather weak, IBA is something we shouldn’t give up on.

Earlier this year the new adult weekly recommended drinking guidelines sparked a bit of a media frenzy. On the plus side, this raised awareness (in the short term at least), and perhaps got some people talking about them. On the other hand, awareness of the guidelines alone doesn’t tend to lead to behaviour change. Much of the media also pandered to the distraction of the ‘nanny state’, arguably failing to recognise the basic principle of a ‘guideline’ to support informed decision making – one of the reasons why it should not be described as a ‘limit’.

Yet to be answered though is what the implications are for alcohol interventions and other policy areas. Obviously most recent alcohol literature (and alcoholic drinks packaging) will now be ‘outdated’ if displaying the old daily guidelines – although you can find an updated tool here [ppt]. Certainly there will be further work underway about how we calculate and define ‘at risk’ drinkers, but overall we must not get too caught up in trying to pin point exact ‘cut-offs’.

As such the important point is that alcohol misuse is a spectrum, and people are often unknowingly changing their consumption and the actual or potential effects on their health and wellbeing. IBA is about helping people understand where they sit and helping facilitate change where relevant.

So whether we use the alcohol guidelines as a general indicator of our risk level, or something more sophistaced like the AUDIT, it is important not to get too literal about things. A person drinking near 14 units a week (or say a person scoring AUDIT 7 or less) should not consider themselves to be risk free, just as a person drinking 15 units (or scoring AUDIT 8+) should not assume they will certainly suffer alcohol problems. The basic principle of the dose effect applies – the more of a drug one consumes, or the more frequently, the greater the risks – generally speaking.

So in practice, a little common sense applies. When we offer ‘brief advice’ to people, we automatically take into account a wide range of factors – what the person is there for, how motivated they are, how much time we have etc. etc. A change in the guidelines may be just another ‘common sense’ consideration to take into account. For instance we might inform or ask people if they knew that the guidelines have recently reduced a bit, and although any level of drinking carries some risk, sticking to them means a person is unlikely to develop serious negative effects in the long run.

Drinking is of course just one of many ‘health behaviours’. If someone is getting overly focused on debating specific cut-offs, it could be worth pointing out the many other factors that will influence their likely health outcomes; especially those that they may be able to change.