Developing a brief motivational intervention for young adults admitted with alcohol intoxication in the emergency department - Results from an iterative qualitative design

Consolidated guidance for behavioral intervention pilot and feasibility studies

BACKGROUND

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

METHODS

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

RESULTS

A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

CONCLUSION

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions

Background

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

Methods

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

Results

A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

Conclusion

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review

Introduction

Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU.

Methods

A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized.

Results

One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems.

Discussion

Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility.

Systematic Review Registration

Open Science Framework doi: 10.17605/OSF.IO/S849R.

Who benefits from brief motivational intervention among young adults presenting to the emergency department with alcohol intoxication: A latent-class moderation analysis

BACKGROUND

Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED).

METHODS

We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes.

RESULTS

Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance).

CONCLUSIONS

This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.

Adolescent: provider connectedness and STI risk reduction following a brief alcohol intervention: findings from a randomized controlled trial

Objective

Given the frequent co-occurrence between alcohol use and sexual behavior among adolescents, alcohol interventions may play a role in helping prevent sexually transmitted infections (STIs) in this age group. Psychotherapy "common factors" are one potential active ingredient in intervention efficacy. Thus, the purpose of this study was to evaluate the influence of a critical common factor, adolescent: provider connectedness, on STI risk reduction at 3 months post-intervention.

Methods

Community-based youth (N = 168) were randomized to two 60-min individual sessions of either motivational interviewing (MI) or brief adolescent mindfulness (BAM). Logistic regressions predicted post-intervention positive STI from adolescent: provider connectedness, intervention condition, and their interaction. Path analytic models tested post-intervention hazardous drinking as a mediator of the association between adolescent: provider connectedness and reduction in STI risk at 3-month follow-up.

Results

Stronger adolescent: provider connectedness reduced risk of STI at 3 months post-intervention, with no differences by treatment condition. A mediational relationship between adolescent: provider connectedness and STI risk via hazardous drinking was not observed.

Conclusion

Psychotherapeutic common factors, including adolescent: provider connectedness, may be important in mitigating adolescent health risk in behavioral interventions, above and beyond intervention condition and beyond the target behavior of the intervention.

Alcohol, the overlooked drug: clinical pharmacist perspectives on addressing alcohol in primary care

BACKGROUND

Attempts to routinely embed brief interventions in health systems have long been challenging, with healthcare professionals concerned about role adequacy, legitimacy, and support. This is the first study to explore clinical pharmacists' experiences of discussing alcohol with patients in their new role in UK primary care, in developing a novel approach to brief intervention. It investigates their confidence with the subject of alcohol in routine practice and explores views on a new approach, integrating alcohol into the medication review as another drug directly linked to the patient's health conditions and medicines, rather than a separated 'healthy living' issue. The study forms part of wider efforts to repurpose and reimagine the potential application of brief interventions and to rework their contents.

METHODS

Longitudinal qualitative study of 10 recruits to the new clinical pharmacist role in English primary care, involving three semi-structured interviews over approximately 16 months, supplemented by 10 one-off interviews with pharmacists already established in general practice.

RESULTS

When raised at all, enquiring about alcohol in medication reviews was described in terms of calculating dose and level of consumption, leading to crude advice to reduce drinking. The idea was that those who appeared dependent should be referred to specialist services, though few such referrals were recalled. Pharmacists acknowledged that they were not currently considering alcohol as a drug in their practice and were interested in learning more about this concept and the approach it entailed, particularly in relation to polypharmacy. Some recognised a linked need to enhance consultation skills.

CONCLUSIONS

Alcohol complicates routine clinical care and adversely impacts patient outcomes, even for those drinking at seemingly unremarkable levels. Changing clinical practice on alcohol requires engaging with, and supportively challenging, routine practices and entrenched ideas of different kinds. Framing alcohol as a drug may help shift the focus from patients with alcohol problems to problems caused for patients by alcohol. This is less stigmatising and provides role legitimacy for pharmacists to address alcohol clinically in medication reviews, thus providing one element in the formation of a new prevention paradigm. This approach invites further innovations tailored to other healthcare professional roles.

The effectiveness of a mobile intervention to reduce young adults' alcohol consumption to not exceed low-risk drinking guidelines

Background

Young adults' drinking habits often exceed low-risk drinking guidelines. As young adults show increased access, use, and interest in personalized content related to physical and mental well-being, mobile applications might be a suitable tool to reach this target group. This study investigates the effectiveness of "Boozebuster", a self-guided mobile application incorporating various therapeutic principles to reduce young adults' alcohol consumption to not exceeding low-risk drinking guideline levels, compared to an educational website condition.

Method

Young adults aged 18-30 wanting to reduce their alcohol consumption entered a two-arm, parallel-group RCT. There were no minimum drinking severity inclusion criteria. Primary outcomes included alcohol consumption quantity and frequency. Secondary outcomes included binge drinking frequency and alcohol-related problem severity. Baseline, 6-week postbaseline, and 3-month post-baseline assessments were analyzed using linear mixed model analyses. Sex, treatment adherence, experienced engagement and motivation to change alcohol use behavior were investigated as moderators. Sub-group analyses contained problem drinkers and binge drinkers.

Results

503 participants were randomized to the intervention or control condition. Results showed no intervention effects on primary or secondary outcomes compared to the control group. Both groups showed within-group reductions on all outcomes. Sub-group analyses in problem drinkers or binge drinkers showed similar results. Motivation to change drinking behavior and experienced engagement with the application significantly moderated the intervention effect regarding the quantity or frequency of alcohol consumption, respectively. Exploratory analyses showed that participants who indicated they wanted to change their drinking patterns during the initial PNF/MI module showed a significantly greater reduction in drinking quantity compared to those who indicated not wanting to change their drinking patterns.

Conclusion

The intervention group did not show a greater reduction in alcohol-related outcomes compared to the control group, but both groups showed a similar decrease. Potential explanations include similar effectiveness of both condition due to using a minimal active control in participants predominantly in the action stage of motivation to change. Future research should further explore the effectiveness of using mobile application to reduce young adults' drinking behavior to not exceed low-risk drinking guideline levels and identify factors that motivate participants to engage with such an intervention.

Assessment of substance use among injured persons seeking emergency care in Nairobi, Kenya

Introduction

Trauma is a leading cause of morbidity and mortality in Kenya. In many countries, substance use is common among patients presenting with injuries to an emergency center (EC).

Objective

To describe the epidemiology of self-reported substance use among adult injured patients seeking ED care in Nairobi, Kenya.

Methods

This prospective cross-sectional study, assessed patients presenting with injuries to the Kenyatta National Hospital ED in Nairobi, Kenya from March through June of 2021. Data on substance use, injury characteristics and ED disposition were collected. Substances of interest were alcohol, stimulants, marijuana, and opiates. The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) tool was used to characterize hazardous alcohol use.

Results

A total of 1,282 patients were screened for participation, of which 646 were enrolled. Among participants, 322 (49.8%) reported substance use in the past month (AUDIT-C positive, stimulants, opiates, and/or marijuana). Hazardous alcohol use was reported by 271 (42.0%) patients who screened positive with AUDIT-C. Polysubstance use, (≥2 substances) was reported by 87 participants in the past month. Median time from injury to ED arrival was 13.1 h for all enrolees, and this number was significantly higher among substance users (median 15.4 h, IQR 5.5 - 25.5; p = 0.029).

Conclusions

In the population studied, reported substance use was common with a substantial proportion of injured persons screening positive for hazardous alcohol use. Those with substance use had later presentations for injury care. These data suggest that ED programming for substance use disorder screening and care linkage could be impactful in the study setting.

Effect of a Novel Brief Motivational Intervention for Alcohol-Intoxicated Young Adults in the Emergency Department: A Randomized Clinical Trial

IMPORTANCE

Heavy drinking among young adults is a major public health concern. Brief motivational interventions in the emergency department have shown promising but inconsistent results.

OBJECTIVE

To test whether young adults receiving a newly developed brief motivational intervention reduce their number of heavy drinking days and alcohol-related problems over 1 year compared with participants receiving brief advice.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at an emergency department of a tertiary care university hospital in Lausanne, Switzerland. Recruitment ran from December 2016 to August 2019. Follow-up was conducted after 1, 3, 6, and 12 months. All adults aged 18 to 35 years presenting for any cause and presenting with alcohol intoxication were eligible (N = 2108); 1764 were excluded or refused participation. Follow-up rate was 79% at 12 months and 89% of participants provided follow-up data at least once and were included in the primary analyses. Statistical analysis was performed from September 2020 to January 2021.

INTERVENTIONS

The novel intervention was based on motivational interviewing and comprised in-person discussion in the emergency department and up to 3 booster telephone calls. The control group received brief advice.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the number of heavy drinking days (at least 60 g of ethanol) over the previous month and the total score on the Short Inventory of Problems (0-45, higher scores indicating more problems) over the previous 3 months. Hypotheses tested were formulated before data collection.

RESULTS

There were 344 young adults included (median [IQR] age: 23 [20-28] years; 84 women [24.4%]). Among the 306 participants providing at least 1 follow-up point, a statistically significant time × group interaction was observed (β = -0.03; 95% CI, -0.05 to 0.00; P = .02), and simple slopes indicated an increase of heavy drinking days over time in the control (β = 0.04; 95% CI, 0.02 to 0.05; P < .001) but not in the intervention group (β = 0.01; 95% CI, -0.01 to 0.03; P = .24). There was no effect on the Short Inventory of Problems score (β = -0.01; 95% CI, -0.03 to 0.02; P = .71).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a brief motivational intervention implemented in the emergency department provided beneficial effects on heavy drinking, which accounts for a substantial portion of mortality and disease burden among young adults.

TRIAL REGISTRATION

ISRCTN registry: 13832949.

Addressing complex pharmacy consultations: methods used to develop a person-centred intervention to highlight alcohol within pharmacist reviews of medications

BACKGROUND

Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations.

METHODS

This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations.

RESULTS

Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan.

CONCLUSIONS

Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.