Does socio-economic status influence the acceptability of, attendance for, and outcome of, screening and brief interventions for alcohol misuse: a review

Relationship Between Educational Level and Attitudes Towards Alcohol Conversations in Healthcare: A Cross-Sectional Survey Conducted in Four European Countries

Objectives: To examine the association between educational level and attitudes towards alcohol conversations in healthcare using population-based surveys of adults in England, the Netherlands, Norway, and Sweden; and to compare attitudes towards alcohol conversations in healthcare between these four countries. Methods: Cross-sectional surveys were conducted amongst adults in the general population in England (n = 3,499), the Netherlands (n = 2,173), Norway (n = 1,208), and Sweden (n = 3,000). Logistic regression analysis was used to examine associations between attitudes towards alcohol conversations in healthcare and educational level, key demographic variables, alcohol consumption, and country of residence. Results: In all four countries, low educational level (p < 0.001) and male gender (p < 0.001) were associated with holding negative attitudes towards discussing alcohol in healthcare. Risky drinkers had more negative attitudes than low risky drinkers towards discussing alcohol in healthcare (p < 0.001) in all countries except England (p = 0.48), and also reported low levels of perceived honesty and confidence in healthcare (p < 0.001). Conclusion: These findings highlight the importance of considering patients' socio-economic status when developing and implementing alcohol prevention interventions in healthcare.

Social Equity in the Efficacy of Computer-Based and In-Person Brief Alcohol Interventions Among General Hospital Patients With At-Risk Alcohol Use: A Randomized Controlled Trial

BACKGROUND

Social equity in the efficacy of behavior change intervention is much needed. While the efficacy of brief alcohol interventions (BAIs), including digital interventions, is well established, particularly in health care, the social equity of interventions has been sparsely investigated.

OBJECTIVE

We aim to investigate whether the efficacy of computer-based versus in-person delivered BAIs is moderated by the participants' socioeconomic status (ie, to identify whether general hospital patients with low-level education and unemployed patients may benefit more or less from one or the other way of delivery compared to patients with higher levels of education and those that are employed).

METHODS

Patients with nondependent at-risk alcohol use were identified through systematic offline screening conducted on 13 general hospital wards. Patients were approached face-to-face and asked to respond to an app for self-assessment provided by a mobile device. In total, 961 (81% of eligible participants) were randomized and received their allocated intervention: computer-generated and individually tailored feedback letters (CO), in-person counseling by research staff trained in motivational interviewing (PE), or assessment only (AO). CO and PE were delivered on the ward and 1 and 3 months later, were based on the transtheoretical model of intentional behavior change and required the assessment of intervention data prior to each intervention. In CO, the generation of computer-based feedback was created automatically. The assessment of data and sending out feedback letters were assisted by the research staff. Of the CO and PE participants, 89% (345/387) and 83% (292/354) received at least two doses of intervention, and 72% (280/387) and 54% (191/354) received all three doses of intervention, respectively. The outcome was change in grams of pure alcohol per day after 6, 12, 18, and 24 months, with the latter being the primary time-point of interest. Follow-up interviewers were blinded. Study group interactions with education and employment status were tested as predictors of change in alcohol use using latent growth modeling.

RESULTS

The efficacy of CO and PE did not differ by level of education (P=.98). Employment status did not moderate CO efficacy (Ps≥.66). Up to month 12 and compared to employed participants, unemployed participants reported significantly greater drinking reductions following PE versus AO (incidence rate ratio 0.44, 95% CI 0.21-0.94; P=.03) and following PE versus CO (incidence rate ratio 0.48, 95% CI 0.24-0.96; P=.04). After 24 months, these differences were statistically nonsignificant (Ps≥.31).

CONCLUSIONS

Computer-based and in-person BAI worked equally well independent of the patient's level of education. Although findings indicate that in the short-term, unemployed persons may benefit more from BAI when delivered in-person rather than computer-based, the findings suggest that both BAIs have the potential to work well among participants with low socioeconomic status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01291693; https://clinicaltrials.gov/ct2/show/NCT01291693.

Online interventions for people hospitalized for deliberate self-harm and problematic alcohol use: Lessons learned from the iiAIM trial

Deliberate self-harm and suicide affect all age groups, sexes, and regions, and their prevention is a global health priority. Acute alcohol misuse and chronic alcohol misuse are strong, modifiable risk factors, and Internet interventions aiming to reduce alcohol misuse and comorbid mental health problems (e.g., depression) are a promising and effective treatment modality. The research team aimed to evaluate the feasibility and effectiveness of an Internet-based comorbidity intervention primarily aiming to reduce alcohol consumption, and secondarily to reduce readmission for deliberate self-harm and improve psychological outcomes among people hospitalized for deliberate self-harm who also engage in problematic alcohol use. However, due to several barriers to recruitment, the trial could not be completed and was discontinued. The authors present a "Lessons Learned" discussion and describe the Internet Intervention for Alcohol Improvement (iiAIM) trial, discuss the key barriers experienced by the research team, and recommend potential solutions that may help future trials in this area.

Vaccine indicator and reminder band to improve demand for vaccination in Northern Nigeria: A qualitative evaluation of implementation outcomes

INTRODUCTION

Vaccination coverage is low in Nigeria, partly due to poor demand for the vaccines. Till date, there is limited understanding of what works to improve demand for vaccination. A Vaccine Indicator and Reminder (VIR) band was designed to be worn on a child's ankle to serve as a constant reminder to parents/caregivers on when to bring their children for vaccinations. This study assessed the acceptability of the band as a wearable reminder for infant vaccination in Kebbi State, Nigeria.

METHODS

A total of 503 infants who met the eligibility criteria were enrolled between August 2017 and February 2018. The intervention involved 1) sensitisation and mobilisation of community gatekeepers to advocate for immunisation; 2) engaging traditional birth attendants (TBAs) to refer mothers for vaccination and VIR bands; and 3) training facility-based health workers to secure the band on an eligible child. Focus group discussions and in-depth interviews were conducted at baseline (May 2016) and end-line (July 2018) with purposively selected participants. These interviews were analysed thematically.

RESULTS

There was general acceptability of the band at all levels, especially among community members who likened it to a "wristwatch" that constantly reminds mothers when next to vaccinate their children. The strong support from community leaders, TBAs and participating health workers increased acceptability of the band. Similarly, the VIR band's aesthetics, ease of use and perceived benefits contributed to its acceptability. Wearing the VIR band was not perceived as an impediment because similar accessories are worn on new-borns. However, there were concerns about wearing accessories on the ankle, the red indicator colour, and the malfunctioning of some bands.

CONCLUSIONS

This study demonstrates that cultural adaptability of interventions and engagement with community structures are important in facilitating acceptability of new innovations. Further studies will evaluate the effectiveness of VIR band in improving vaccination coverage.

Effectiveness of an Integrated Intervention Program for Alcoholism (IIPA) for enhancing self-regulation: Preliminary evidence

OBJECTIVE

Alcoholism could be a core problem of self-regulatory failure. Several neurocognitive theories have hypothesized hypo-functioning or dysfunction of reflective (executive) system and heightened functioning of reactive (impulsive) system in self-regulatory failure implicated in drug addiction. Similarly, stress and affect dysregulation may breakdown self-regulation. The present study aimed to develop an Integrated Intervention Program for Alcoholism (IIPA) to enhance self-regulation and to test its effectiveness in the treatment of alcoholism.

METHOD

Individuals with early onset alcoholism (n = 50) were recruited after getting written informed consent. The study used randomized case control design. The participants were matched on age (+/-1 year) and education (+/-1 year). The TAU group received usual treatment for alcoholism which included pharmacotherapy, 6 sessions/week yoga and 3 sessions/week group therapy on relapse prevention. The intervention group received IIPA for 18 days along with usual treatment (except yoga sessions). The IIPA included several cognitive remediation tasks and mind-body exercise (Qigong and Tai Chi Chuan). Both groups were assessed on executive function tests and affect regulation scale at pre and post-intervention. The subjects were also followed up for 6 months to compare the abstinence between groups.

RESULTS

Both groups were comparable at baseline. At post-intervention, the IIPA group showed a significant improvement compared to the TAU group on executive functioning and affect regulation. Follow-up results showed lower relapses in six months in the IIPA group.

CONCLUSION

Preliminary evidence showed that IIPA is effective in facilitating self-regulation. Further study may examine its utility and feasibility in other clinical conditions.

Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England

OBJECTIVES

Brief interventions (BI) for smoking and risky drinking are effective and cost-effective policy approaches to reducing alcohol harm currently used in primary care in England; however, little is known about their contribution to health inequalities. This paper aims to investigate whether self-reported receipt of BI is associated with socioeconomic position (SEP) and whether this differs for smoking or alcohol.

DESIGN

Population survey of 8978 smokers or risky drinkers in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies.

MEASURES

Survey participants answered questions regarding whether they had received advice and support to cut down their drinking or smoking from a primary healthcare professional in the past 12 months as well as their SEP, demographic details, whether they smoke and their motivation to cut down their smoking and/or drinking. Respondents also completed the Alcohol Use Disorders Identification Test (AUDIT). Smokers were defined as those reporting any smoking in the past year. Risky drinkers were defined as those scoring eight or more on the AUDIT.

RESULTS

After adjusting for demographic factors and patterns in smoking and drinking, BI delivery was highest in lower socioeconomic groups. Smokers in the lowest social grade had 30% (95% CI 5% to 61%) greater odds of reporting receipt of a BI than those in the highest grade. The relationship for risky drinking appeared stronger, with those in the lowest social grade having 111% (95% CI 27% to 252%) greater odds of reporting BI receipt than the highest grade. Rates of BI delivery were eight times greater among smokers than risky drinkers (48.3% vs 6.1%).

CONCLUSIONS

Current delivery of BI for smoking and drinking in primary care in England may be contributing to a reduction in socioeconomic inequalities in health. This effect could be increased if intervention rates, particularly for drinking, were raised.

Engagement in Behavioral Parent Training: Review of the Literature and Implications for Practice

Engagement in behavioral parent training (BPT), including enrollment, attrition, attendance, within-session engagement, and homework completion, has long been a critical issue in the literature. Several estimates of various aspects of engagement have been suggested in the literature, but a systematic review of the available literature has never been accomplished. This review examines engagement data across 262 studies of BPT. Recruitment attrition, program attrition, attendance, and within-session engagement are examined across studies, with particular emphasis on the impact that SES, study purpose (efficacy vs. effectiveness), treatment format (individual vs. group), and age of child may have on those rates. Results of this review suggest that the significant amount of attrition occurs prior to enrollment in BPT, with at least 25 % of those identified as appropriate for BPT not enrolling in such programs. An additional 26 % begin, but drop out before completing treatment. Still the combined dropout rate of at least 51 % leaves at best half of identified parents completing treatment. While SES status had a small effect on attrition, other variables were not found to meaningfully impact engagement. Information on within-session engagement (homework and ratings of participation) was not often reported in studies. Key issues in this literature (e.g., varying definitions of engagement, limited attention to reporting key aspects of engagement) are discussed, and recommendations are made to further improve this important area of research and clinical practice.

Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework

BACKGROUND

It is increasingly acknowledged that 'acceptability' should be considered when designing, evaluating and implementing healthcare interventions. However, the published literature offers little guidance on how to define or assess acceptability. The purpose of this study was to develop a multi-construct theoretical framework of acceptability of healthcare interventions that can be applied to assess prospective (i.e. anticipated) and retrospective (i.e. experienced) acceptability from the perspective of intervention delivers and recipients.

METHODS

Two methods were used to select the component constructs of acceptability. 1) An overview of reviews was conducted to identify systematic reviews that claim to define, theorise or measure acceptability of healthcare interventions. 2) Principles of inductive and deductive reasoning were applied to theorise the concept of acceptability and develop a theoretical framework. Steps included (1) defining acceptability; (2) describing its properties and scope and (3) identifying component constructs and empirical indicators.

RESULTS

From the 43 reviews included in the overview, none explicitly theorised or defined acceptability. Measures used to assess acceptability focused on behaviour (e.g. dropout rates) (23 reviews), affect (i.e. feelings) (5 reviews), cognition (i.e. perceptions) (7 reviews) or a combination of these (8 reviews). From the methods described above we propose a definition: Acceptability is a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention. The theoretical framework of acceptability (TFA) consists of seven component constructs: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy.

CONCLUSION

Despite frequent claims that healthcare interventions have assessed acceptability, it is evident that acceptability research could be more robust. The proposed definition of acceptability and the TFA can inform assessment tools and evaluations of the acceptability of new or existing interventions.

Alcohol risk drinking, quality of life and health state among patients treated at the Sobering Unit in the emergency department - One year follow-up study

OBJECTIVES

To evaluate impacts of brief intervention on patients' alcohol risk drinking, quality of life and health state after treatment at the Sobering Unit in the emergency department at three months, six months, and one year follow-up.

METHODS

This was a quasi-experimental study without control group (one-year follow-up). Alcohol use of patients in emergency department (Sobering Unit) in specialized care in Finland (AUDIT-test), quality of life (EQ-5D-3L) and health state (EQ VAS) at baseline, three months, six months and one year following the brief intervention were analyzed with Wilcoxon Signed-Rank test.

RESULTS

The patients' alcohol risk use decreased statistically significantly after the treatment period at the Sobering Unit. The patients' health-related quality of life did not change statistically significantly during three months following the treatment period, whereas a statistically significant increase took place after six months. Self-perceived health status improved statistically significantly between the treatment period and three- and six-month follow up time points.

CONCLUSIONS

The study gave some suggestive evidence that a brief intervention could be effective for harmful drinkers or alcohol-dependent patients when used in an emergency department. The Sobering Unit in the emergency department is one solution to encourage patients to pay attention to their alcohol risk drinking.

A laboratory-based evaluation of exercise plus contingency management for reducing cigarette smoking

BACKGROUND

Both contingency management (CM) and exercise have shown promise as smoking cessation treatments, but their combined effects have not been evaluated. The present study evaluated whether CM (in which motivational incentives are provided for abstinence) plus exercise reduced smoking more than either component alone.

METHOD

In a within-subjects design, 20 smokers were exposed to exercise plus CM, exercise plus CM-control (non-contingent incentives), inactivity plus CM, and inactivity plus CM-control.

RESULTS

CM increased latencies to smoke and decreased total puffs (Mdns = 39.6 min and .8 puffs, respectively) relative to CM-control (Mdns = 2.5 min and 12.8 puffs). Exercise decreased craving relative to baseline for craving based on both the pleasurable consequences of smoking (D=-10.7 on a 100-point visual analog scale) and anticipated relief from withdrawal (D=-5.9), whereas inactivity increased both components of craving (Ds=7.6 and 3.5). Exercise had no effect on smoking or a measure of temporal discounting.

CONCLUSIONS

Although exercise decreased craving, it did not affect smoking behavior. Exercise plus CM was not more effective than CM alone.

A pilot feasibility cluster randomised controlled trial of screening and brief alcohol intervention to prevent hazardous drinking in young people aged 14–15 years in a high school setting (SIPS JR-HIGH)

Background

Approximately 33% of 15- to 16-year-olds in England report alcohol intoxication in the past month. This present work builds on the evidence base by focusing on Alcohol Screening and Brief Intervention (ASBI) to reduce hazardous drinking in younger adolescents.

Objectives

To explore the feasibility and acceptability of a future definitive cluster randomised controlled trial (cRCT) of ASBI in a school setting to staff, young people and parents; to explore the fidelity of the interventions as delivered by school learning mentors; to estimate the parameters for the design of a definitive cRCT of brief alcohol intervention, including rates of eligibility, consent, participation and retention at 12 months; and to pilot the collection of cost and resource-use data to inform the cost-effectiveness/utility analysis in a definitive trial.

Setting

Seven schools across one geographical area in North East England.

Methods

Feasibility of trial processes, recruitment and retention and a qualitative evaluation examined facilitators and barriers to the use of ASBI approaches in the school setting in this age group. A three-arm pilot cRCT (with randomisation at the school level) with qualitative evaluation to assess the feasibility of a future definitive cRCT of the effectiveness and cost-effectiveness of ASBI in a school setting, with an integrated qualitative component. The trial ran in parallel with a repeated cross-sectional survey, which facilitated screening for the trial.

Participants

Year 10 school pupils (aged 14–15 years).

Interventions

Young people who screened positive on a single alcohol screening question, and consented to take part, were randomised to one of three groups: (1) feedback that their drinking habits may be risky and provision of an advice leaflet (control condition,n = two schools); (2) feedback as for the control condition plus a 30-minute brief interactive session, which combined structured advice and motivational interviewing techniques, delivered by the school learning mentor (intervention 1,n = two schools); or (3) feedback as for the control condition plus a 30-minute brief interactive session as for intervention 1 plus a 60-minute session involving family members delivered by the school learning mentor (intervention 2,n = three schools). Young people were followed up at 12 months.

Main outcome measures

Feasibility and acceptability.

Randomisation

Randomisation was carried out at the school level. Randomisation achieved balance on two school-level variables (numbers of pupils in school year and proportion receiving free school meals).

Blinding

School staff, young people and researchers were not blind to the intervention allocated.

Results

A total of 229 young people were eligible for the trial; 182 (79.5%) were randomised (control,n = 53; intervention 1,n = 54; intervention 2,n = 75). Of the 75 randomised to intervention 2, 67 received intervention 1 (89%). Eight received both intervention 1 and intervention 2 (11%). In total, 160 out of 182 were successfully followed up at 12 months (88%). Interviews were carried out with six school lead liaisons, 13 learning mentors, 27 young people and seven parents (n = 53). Analysis shows that the school setting is a feasible and acceptable place to carry out ASBI, with learning mentors seen as suitable people to do this. Intervention 2 was not seen as feasible or acceptable by school staff, parents or young people.

Outcomes/conclusions

It is feasible and acceptable to carry out a trial of the effectiveness and cost-effectiveness of single-session ASBI with young people in the school setting, with learning mentors delivering the intervention. Future work should include a definitive study that does not include a parental arm.

Trial registration

Current Controlled Trials ISRCTN07073105.

Funding

The National Institute for Health Research Public Health Research programme.

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial

IMPORTANCE

Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

OBJECTIVE

To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

INTERVENTIONS

Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

RESULTS

Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

CONCLUSIONS AND RELEVANCE

A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.

The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews

Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research. Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012. Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effectiveness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in transitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness. Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.

Income received during treatment does not affect response to contingency management treatments in cocaine-dependent outpatients

BACKGROUND

Prior studies find no effect of baseline income on response to contingency management (CM) interventions. However, income among substance disordered patients is variable, particularly at treatment entry. This study investigated the impact of during-treatment income, a more proximal estimate of economic resources at the time that CM is in effect, on response to standard treatment or the standard treatment plus CM.

METHOD

These secondary analyses included 418 cocaine dependent participants initiating community intensive outpatient treatment. We examined whether differences were present in pretreatment and during-treatment overall income, as well as specific income sources. We then conducted a series of regression models to investigate the impact of during-treatment income on treatment outcome.

RESULTS

Participants' during-treatment income was significantly lower compared to pretreatment income, and this difference was largely attributable to decreases in earned income, illegal income, and support from friends and family. Neither the main effect of income, nor the interaction of income and treatment condition, was significantly associated with treatment outcome. CM, however, was a significant predictor of improved treatment outcome relative to standard treatment. Income sources and some demographic characteristics were also significant predictors of outcomes; public assistance income was associated with improved outcomes and illegal income was associated with poorer outcomes.

CONCLUSIONS

These results suggest that substance abusers benefit from CM regardless of their income level, and these data add to the growing literature supporting the generalizability of CM across a variety of patient characteristics.

What makes emergency department patients reduce their alcohol consumption?--a computer-based intervention study in Sweden

OBJECTIVES

This study investigates the effectiveness of a computerized emergency department intervention for alcohol consumption and identifies explanation factors associated with reduced alcohol consumption from risk to non-risk drinking.

METHODS

Patients aged 18-69 years registered at the ED triage answered alcohol-related questions on a touch-screen computer. Follow-up data were collected by means of a postal questionnaire that was mailed to the patients 6 months after their ED visit.

RESULTS

There were four independent explanations for reduced alcohol consumption: being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider. 339 patients could be followed up and of these were 97 categorized as risk drinkers at baseline and 45 became non-risk drinker 6 month later.

CONCLUSIONS

Being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider were predictors for change from risk to non-risk drinking 6 months later.

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

BACKGROUND

This review aimed to synthesize qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years.

METHODS

A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesized thematically.

RESULTS

A total of 47 papers varying in design and quality were included in the review. Most evaluated implementation in primary care settings. Implementation was reported to be limited by lack of resources, training and support from management, as well as workload. The appropriateness of context in which discussions take place was reported as an acceptability factor for patients and practitioners. Health professionals require sufficient knowledge about alcohol guidelines and risk in order to implement screening and intervention to those most in need.

CONCLUSIONS

Whilst brief screening and brief intervention have been shown to be effective in some settings, this review has identified a number of barriers and facilitators to implementation. Adequate resources, training and the identification of those at risk without stereotyping are the main facilitators in primary care. More research is needed to assess implementation in other settings.

Income does not affect response to contingency management treatments among community substance abuse treatment-seekers

The present study examined a commonly held belief that contingency management (CM) may be less effective for substance abusers with relatively more economic resources compared to those with relatively few resources. Using a combined sample of 393 treatment-seeking cocaine abusers from three clinical trials involving randomization to standard care or standard care plus CM conditions, we assessed the impact of past year income, alone and in combination with treatment condition, as well as income type (i.e., earned, illegal, unstable) on the longest duration of continuous verified abstinence (LDA) achieved during treatment. Results suggested that income had no effect on LDA in either condition, and that CM's effectiveness did not deteriorate among those with better economic resources in the present sample. This finding may be of value to clinicians and administrators who are considering the addition of CM to standard care treatments in community outpatient substance abuse clinics and have concerns about the generalizability of CM across clients with various economic resources.