‘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.

Setting achievable goals & the ‘dose effect’

19 Feb

Paracelsus 2Mentioning either ‘units’ or the ‘guidelines’ alone can trigger a sceptical response from a drinker. I’m sure you’ve heard someone protest that “units are confusing” or that they “don’t believe the guidelines”. How should we respond to such statements or beliefs?

Firstly we should accept that people may have ambivalent attitudes about their drinking and may appear dubious or dismissive of health advice we may offer. They may also be right; units can be confusing and hard to keep track of, and we can’t take a ‘one size fits all’ health guideline too literally.

However the principle behind understanding units and applying these to the guideline is important. Consuming any drug – including alcohol – can be considered in terms of the ‘dose effect’ (or the dose-response relationship). Essentially, the greater the dose consumed, the greater the chance of unwanted (as well as perhaps wanted) effects. The recommended guidelines therefore set out the approximate ‘dose’ (in units) which alcohol can be consumed with a low risk of negative effects.

how muchA crucial consideration here is that there is no clear ‘threshold effect’, or no point at which the dose the longer matters. Put simply, the more you drink, the greater the risks . This is important because even if someone says ‘forget the guidelines, I’m never going to stick to them’, they still may be open to considering the fact that 5 pints is still less risky than 6.

There is evidence that some people who drink to get drunk only consider their ‘limits’ in terms of behaviour and whether they are ‘in control’. As such, health guidelines may not feel relevant for them. But emphasising that reducing health or behavioural risks still applies in terms of how much they drink. One message that has been found to be possibly more appealing is to try and ‘drink 2 less’, rather than perhaps ‘only drink 2’! And perhaps more importantly, it may feel much more achievable.

Can we quit “binge drinking”?

19 Nov

pg-08-alcohol-Rex_235373s ‘Binge drinking’ is probably the defining alcohol term of the last few decades. Hype over alcopops, dramatic media headlines and the variety of ‘binge Britain’ based low budget TV shows are testament to its enduring popularity. As such, people often frame their ideas of problem drinking around ‘binge drinking’ (and of course ‘alcoholics’). Both potentially problematic terms.

In terms of where  people ‘fit’ with regard to their alcohol use then, it’s important to recognise the alcohol use/misuse spectrum. That is that drinking ‘categories’ are fluid, and so individuals don’t fit or stick neatly into boxes. People, their circumstances and their consumption are often in various states of change, and labelling or subjective terms carry many risks.

Most adults are ‘low risk’ drinkers, but at certain times of the year their drinking might go up. Generally though they will re-set their consumption of their own accord, or when an occasion (such as Christmas) has passed. The same can even be said for dependency in some ways – most people who do experience some level of dependency recover on their own, usually without any formal support or treatment.alcohol & language

So where do ‘binge drinkers’ fit in all this? And can it ever be a useful term?

Taking the technical definition of drinking twice the daily guideline or more in one go, ‘binge drinkers’ can actually ‘fit’ into any of the main drinking ‘risk’ groups – depending on frequency. Someone who ‘binge drinks’ once a year on their birthday but generally keeps within the guidelines will be a ‘low risk’ drinker overall. But someone who ‘binges’ regularly, most days of the week, will probably be showing at least some signs of dependency.

‘Binge drinking’ overlooks one crucial risk factor: frequency

Of course the media obsession with ‘binge drinking’ means that it’s so commonly used to describe drinking patterns, but as highlighted, frequency of drinking can be just as relevant as the amount consumed on a given occasion. People tend to recognise the role of alcohol free days for ‘giving the body a break’, but for many people it may be reducing the risk of dependency that is more relevant. In fact my own experience of increasingly frequent ‘binge drinking’ resulted in increasing tolerance and other symptoms of dependency.

At the time though I was actually quite proud to be a ‘binge drinker’ in some ways – drinking was part of my identify. I saw alcohol largely as positive, and I gave little consideration to the damage it might have been doing – until I actually did develop related health problems. These problems actually triggered contemplation, and eventually I went a long period without drinking at all. The main benefit of IBA though may be to trigger contemplation before problems or dependency develop.

Binge drinking will continue to be used, and perhaps more accurately to describe ‘drinking to get drunk’, rather than a fixed amount. But like with the term ‘alcoholic’, we should seek to avoid describing individuals as such, unless they choose that term themselves. Using a validated assessment tool like the AUDIT gives us a more useful way to identify what risk someone’s drinking they may pose, so may help us quit “binge drinking”.

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

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.

Should we ease off GPs not doing alcohol IBA (properly)?

27 Aug

IBAPrimary Care is the key setting for alcohol brief intervention or ‘IBA’. Most the evidence base revolves around delivery in Primary Care settings and in England ‘DES’ payments are made for new registrations screened (and then in theory offered brief intervention when appropriate). IBA is also is part of the NHS health checks being offered to all 40-74 year olds. But..

“Alcohol, OK, so you drink 20 drinks per week on average?” “Yes”. “Right, OK that’s around 20 units per week, which is within the government guidelines of 21 for men”

Whoops. That was from a Practice Nurse when I joined a new surgery not that long ago. Sadly, anecdotal reports of poor or simply incorrect IBA practices are not unusual from those who know what it should look like. But we have nothing else to go on other than ‘activity’ data to get a picture of what’s really going on.

In one local area, working with commissioners we attempted to get local practices to complete a short survey on their IBA delivery – about 8% responded. A subsequent proposal for a collaborative ‘mystery shopping’ approach, based on a successful pilot in sexual health settings, was rejected by the local medical committee – most members (yes some were GPs) didn’t support it. No alternative suggestions were offered though.

Not surprisingly, there can be a sense of despondency amongst those trying to raise the standard of Primary Care IBA. Is there any point in organising good IBA training, resources and pathways if there’s no interest in taking them up? If we can’t get it right in Primary Care, is there hope for any other settings?

Or perhaps there is more chance for IBA in other settings? The news is full of stories about General Practice in crisis. More doctors needed, less being spent, more demand and an ageing population – I’m not going to argue Primary Care isn’t under a lot of pressure. But we can and must expect more in terms of understanding and improving IBA delivery if we are paying for it.

It’s not just my own anecdotal experiences that suggest real world ‘IBA’ isn’t true to nature. Key researchers have called for more work here, and a recent Primary Care review stated: “On videotaped or observed interviews, alcohol-related discussions were often superficial and yielded little information regarding patients’ drinking practices.”

“Well, I don’t know what these [AUDIT] scores mean”  – just another of the comments I’ve heard first hand from a GP! Of course some are doing it well, but I’ve little doubt these are a minority.

One crucial point though, its not really GPs we are talking about here as the key Primary Care IBA role, rather than Practice Nurses or Health Care Assistants. These are the people doing most new registrations and health checks. So when we talk about the issue of IBA in Primary Care, it isn’t really about GPs finding an extra 5 minutes in an already tight window, its about something that is supposed to be planned into other contacts.

Of course if someone is talking to their GP about a commonly alcohol linked issue – high blood pressure, depression, tiredness to name but a few – then IBA should be certainly be offered by the GP. But the real issue is the thousands of Practice Nurse or HCA contacts every day where the IBA box might be ticked on the system, but the actual intervention could be anything – and we’ve no way to tell. Or do we?

Holding practices to account?Primary Care IBA - good enough?

The DES (Direct Enhance Service) alcohol contract has been criticised for not being robust enough by offering payment for screening only, following which brief advice ‘should’ be offered to at-risk drinkers. Perhaps saying ‘at-risk’ drinkers ‘should’ be offered brief intervention isn’t legally binding, but what about a basic duty of care? Furthermore, the current DES contract is clear that local ‘area team’ commissioners can and should hold practices to account:

Area teams are responsible for post payment verification. This may include auditing claims of practices to ensure that not only the initial screening was conducted but that the full protocol described in the enhanced service was followed i.e. that those individuals who screened positive on the initial screening tool were then administered the remaining questions of AUDIT and that a full AUDIT score was determined and that appropriate action followed, such as the delivery of brief advice, lifestyle counselling or where needed, referral to specialist services or assessment/screening for anxiety and/or depression

Where required, practices must make available to area teams any information they require and that the practice can reasonably be expected to obtain, in order to establish whether or not the practice has fulfilled its obligation under the ES arrangements.

So the current DES is clear. Doing AUDIT-C only and giving a leaflet to all risky drinkers isn’t in line with the contract. And commissioners have the right to ask practices to prove they are doing it properly. I’m well aware that good care and interventions mean less form filling and more time with the patient. But until the picture coming through is one of a better overall standard for IBA, practices should be required to demonstrate IBA is a person-centred intervention, not an opportunity to trigger a quick payment.

IBA for young people: a promising picture?

12 Aug

A common question about IBA is ‘does it work for young people?’ – and a straightforward answer isn’t easy, though we are getting closer. Recently two new publications have reviewed the evidence for IBA in children and adolescents:

The good news is the reviews are broadly in agreement and make some useful points, notably that AUDIT and CRAFT screening tools are considered the most effective and should be be used with adolescents for IBA. The bad news is, as you might expect, more research is needed as many issues remain largely unanswered. Fortunately SIPS Junior is under-way and will shed some further light, especially given the absence of UK based evidence for young people’s IBA.

One of the key issues is the significant differences between young children and older adolescents. In particular, any alcohol use may be considered problematic in younger children (especially under 15), whereas ‘lower risk’ drinking in older adolescents may not be of such concern. However what is considered ‘low risk’ for adults is not considered ‘low risk’ for adolescents based on the CMO guidance, so lower scoring cut-offs on screening tools are deemed necessary – but not yet researched. And given the broad but important age range covering children and young people, it won’t be straight-forward.

The reviews do however identify a number of research trials that identified positive effects of brief interventions (as well as some null-findings, which another paper recently suggested should not be interpreted as showing IBA not to be effective). Some evidence was also found of indications that electronic forms of brief intervention (or e-BI, or e-BA if ‘IBA-ing’ it) were effective, but also one meta-analysis found traditional face-to-face approaches superior.

All in all, IBA for young people seems an important opportunity where we can make it happen effectively, even if the research, tools and guidance aren’t up to speed with that for adults. As listed in this blog’s 2012 post on this subject, here are some IBA and young people centred resources: