Developing, evaluating and implementing alcohol brief interventions in Europe

ISSUES

This article traces the history of research on the development, evaluation and implementation of alcohol brief intervention (BI) in Europe.

APPROACH

Narrative and historical review.

KEY FINDINGS

BI originated in Europe and, following a definition of opportunistic BI, early pioneering studies are summarised. The role of European scientists in the series of studies making up the WHO Collaborative Project on Detection and Management of Alcohol-related Problems in Primary Health Care (1982-2006) is then described, followed by a short account of a current EU-funded project (Primary Health European Project on Alcohol) with the aim of achieving a widespread, routine and enduring implementation of BI in EU member states. In addition to involvement in these two major projects, a great deal of research on BI has been carried out in a range of European countries and some of this research is noted.

IMPLICATIONS

Several European governments are now taking the rolling out of BI in routine services very seriously as a policy measure. There is no necessary conflict between widely available BI and alcohol control measures.

CONCLUSION

While much remains to be done regarding practical implementation, the mood of those interested in the promotion of BI as a means of reducing alcohol-related harm, in Europe as elsewhere, is cautiously optimistic.

New developments in brief interventions to treat problem drinking in nonspecialty health care settings

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.

Intervention against excessive alcohol consumption in primary health care: a survey of GPs' attitudes and practices in England 10 years on

AIMS

To ascertain the views of general practitioners (GPs) regarding the prevention and management of alcohol-related problems in practice, together with perceived barriers and incentives for this work; to compare our findings with a comparable survey conducted 10 years earlier.

METHODS

In total, 282 (73%) of 419 GPs surveyed in East Midlands, UK, completed a postal questionnaire, measuring practices and attitudes, including the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ).

RESULTS

GPs reported lower levels of post-graduate education or training on alcohol-related issues (<4 h for the majority) than in 1999 but not significantly so (P = 0.031). In the last year, GPs had most commonly requested more than 12 blood tests and managed 1-6 patients for alcohol. Reports of these preventive practices were significantly increased from 1999 (P < 0.001). Most felt that problem or dependent drinkers' alcohol issues could be legitimately (88%, 87%) and adequately (78%, 69%) addressed by GPs. However, they had low levels of motivation (42%, 35%), task-related self-esteem (53%, 49%) and job satisfaction (15%, 12%) for this. Busyness (63%) and lack of training (57%) or contractual incentives (48%) were key barriers. Endorsement for government policies on alcohol was very low.

CONCLUSION

Among GPs, there still appears to be a gap between actual practice and potential for preventive work relating to alcohol problems; they report little specific training and a lack of support. Translational work on understanding the evidence-base supporting screening and brief intervention could incentivize intervention against excessive drinking and embedding it into everyday primary care practice.

Implementing brief interventions in health care: lessons learned from the Swedish Risk Drinking Project

The Risk Drinking Project was a national implementation endeavour in Sweden, carried out from 2004 to 2010, based on a government initiative to give alcohol issues a more prominent place in routine primary, child, maternity and occupational health care. The article describes and analyses the project. Critical factors that were important for the results are identified. The magnitude of the project contributed to its reach and impact in terms of providers' awareness of the project goals and key messages. The timing of the project was appropriate. The increase in alcohol consumption in Sweden and diminished opportunities for primary prevention strategies since entry to the European Union in 1995 have led to increased expectations for health care providers to become more actively involved in alcohol prevention. This awareness provided favourable conditions for this project. A multifaceted approach was used in the project. Most educational courses were held in workshops and seminars to encourage learning-by-doing. Motivational interviewing was an integral aspect. The concept of risk drinking was promoted in all the activities. Subprojects were tailored to the specific conditions of each respective setting, building on the skills the providers already had to modify existing work practices. Nurses were afforded a key role in the project.

Exploring treatment attendance and its relationship to outcome in a randomized controlled trial of treatment for alcohol problems: secondary analysis of the UK Alcohol Treatment Trial (UKATT)

AIMS

To identify client characteristics that predict attendance at treatment sessions and to investigate the effect of attendance on outcomes using data from the UK Alcohol Treatment Trial.

METHODS

Logistic regression was used to determine whether there were characteristics that could predict attendance and then continuation in treatment. Linear regression was used to explore the effects of treatment attendance on outcomes.

RESULTS

There were significant positive relationships between treatment attendance and outcomes at Month 3. At Month 12, these relationships were only significant for dependence and alcohol problems for those randomized to motivational enhancement therapy (MET). There were significant differences between groups in attendance, with MET clients more likely to attend than clients allocated to social behaviour and network therapy (SBNT). MET clients were also more likely to attend all sessions (three sessions) compared with SBNT (eight sessions). MET clients with larger social networks and those with confidence in their ability not to drink excessively were more likely to attend. SBNT clients with greater motivation to change and those with more negative short-term alcohol outcome expectancies were more likely to attend. No significant predictors were found for retention in treatment for MET. For those receiving SBNT, fewer alcohol problems were associated with continuation in treatment.

CONCLUSION

Attending more sessions was associated with better outcomes. An interpretation of these findings is that, to improve outcomes, methods should be developed and used to increase attendance rates. Different characteristics were identified that predicted attendance and continuation in treatment for MET and SBNT.

The effectiveness of brief alcohol interventions in primary care settings: a systematic review

ISSUES

Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials.

APPROACH

A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted.

KEY FINDINGS

The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials.

CONCLUSIONS

Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.

Screening and brief interventions for hazardous and harmful alcohol use in probation services: a cluster randomised controlled trial protocol

BACKGROUND

A large number of randomised controlled trials in health settings have consistently reported positive effects of brief intervention in terms of reductions in alcohol use. However, although alcohol misuse is common amongst offenders, there is limited evidence of alcohol brief interventions in the criminal justice field. This factorial pragmatic cluster randomised controlled trial with Offender Managers (OMs) as the unit of randomisation will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in probation and different intensities of brief intervention to reduce excessive drinking in probation clients.

METHODS AND DESIGN

Ninety-six OMs from 9 probation areas across 3 English regions (the North East Region (n = 4) and London and the South East Regions (n = 5)) will be recruited. OMs will be randomly allocated to one of three intervention conditions: a client information leaflet control condition (n = 32 OMs); 5-minute simple structured advice (n = 32 OMs) and 20-minute brief lifestyle counselling delivered by an Alcohol Health Worker (n = 32 OMs). Randomisation will be stratified by probation area. To test the relative effectiveness of different screening methods all OMs will be randomised to either the Modified Single Item Screening Questionnaire (M-SASQ) or the Fast Alcohol Screening Test (FAST). There will be a minimum of 480 clients recruited into the trial. There will be an intention to treat analysis of study outcomes at 6 and 12 months post intervention. Analysis will include client measures (screening result, weekly alcohol consumption, alcohol-related problems, re-offending, public service use and quality of life) and implementation measures from OMs (the extent of screening and brief intervention beyond the minimum recruitment threshold will provide data on acceptability and feasibility of different models of brief intervention). We will also examine the practitioner and organisational factors associated with successful implementation.

DISCUSSION

The trial will evaluate the impact of screening and brief alcohol intervention in routine probation work and therefore its findings will be highly relevant to probation teams and thus the criminal justice system in the UK.Ethical approval was given by Northern & Yorkshire REC.

TRIAL REGISTRATION NUMBER

ISRCTN 19160244.

Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol

BACKGROUND

There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients.

METHODS AND DESIGN

GPs and nurses from 24 practices across the North East (n=12), London and South East (n=12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n=8); brief structured advice (n=8); and brief lifestyle counselling (n=8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial.

DISCUSSION

The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN06145674.

Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol

BACKGROUND

There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments.

METHODS/DESIGN

The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation.

DISCUSSION

This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.

TRIAL REGISTRATION

ISRCTN 93681536.