[Show abstract][Hide abstract] ABSTRACT: Aims: To document the attitudes of general practitioners (GPs) from eight European countries to alcohol and alcohol problems and how these attitudes are associated with self-reported activity in managing patients with alcohol and alcohol problems.
Methods: A total of 2345 GPs were surveyed. The questionnaire included questions on the GP's demographics, reported education and training on alcohol, attitudes towards managing alcohol problems and self-reported estimates of numbers of patients managed for alcohol and alcohol problems during the previous year.
Results: The estimated mean number of patients managed for alcohol and alcohol problems during the previous year ranged from 5 to 21 across the eight countries. GPs who reported higher levels of education for alcohol problems and GPs who felt more secure in managing patients with such problems reported managing a higher number of patients. GPs who reported that doctors tended to have a disease model of alcohol problems and those who felt that drinking was a personal rather than a medical responsibility reported managing a lower number of patients.
Conclusion: The extent of alcohol education and GPs' attitudes towards alcohol were associated with the reported number of patients managed. Thus, it is worth exploring the extent to which improved education, using pharmacotherapy in primary health care and a shift to personalized health care in which individual patients are facilitated to undertake their own assessment and management (individual responsibility) might increase the number of heavy drinkers who receive feedback on their drinking and support to reduce their drinking.
Alcohol and Alcoholism 09/2014; 49(5):531-9. · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Robust evidence supports the effectiveness of screening and brief alcohol interventions in primary healthcare. However, lack of understanding about their “active ingredients” and concerns over the extent to which current approaches remain faithful to their original theoretical roots has led some to demand a cautious approach to future roll-out pending further research. Against this background, this paper provides a timely overview of the development of the brief alcohol intervention evidence base to assess the extent to which it has achieved the four key levels of intervention research: efficacy, effectiveness, implementation, and demonstration.
Methods: Narrative overview based on (1) the results of a review of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare and (2) synthesis of the findings of key additional primary studies on the improvement and evaluation of brief alcohol intervention implementation in routine primary healthcare.
Results: The brief intervention field seems to constitute an almost perfect example of the evaluation of a complex intervention. Early evaluations of screening and brief intervention approaches included more tightly controlled efficacy trials and have been followed by more pragmatic trials of effectiveness in routine clinical practice. Most recently, attention has shifted to dissemination, implementation, and wider-scale roll-out. However, delivery in routine primary health remains inconsistent, with an identified knowledge gap around how to successfully embed brief alcohol intervention approaches in mainstream care, and as yet unanswered questions concerning what specific intervention component prompt the positive changes in alcohol consumption.
Conclusion: Both the efficacy and effectiveness of brief alcohol interventions have been comprehensively demonstrated, and intervention effects seem replicable and stable over time, and across different study contexts. Thus, while unanswered questions remain, given the positive evidence amassed to date, research efforts should maintain a continued focus on promoting sustained implementation of screening and brief alcohol intervention approaches in primary care to ensure that those who might benefit from screening and brief alcohol interventions actually receive such support.
[Show abstract][Hide abstract] ABSTRACT: Aim: To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling. Methods: A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of <8). Secondary outcomes were AUDIT status at 12 months, experience of alcohol-related problems, health utility, service util-ization, readiness to change and reduction in conviction rates. Results: Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention. Conclusion: Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.
Alcohol and Alcoholism 07/2014; · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.
PLoS ONE 06/2014; 9(6):e99463. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: New clinical research findings may require clinicians to change their behaviour to provide high-quality care to people with type 2 diabetes, likely requiring them to change multiple different clinical behaviours. The present study builds on findings from a UK-wide study of theory-based behavioural and organisational factors associated with prescribing, advising, and examining consistent with high-quality diabetes care.Aim: To develop and evaluate the effectiveness and cost of an intervention to improve multiple behaviours in clinicians involved in delivering high-quality care for type 2 diabetes.Design/methods: We will conduct a two-armed cluster randomised controlled trial in 44 general practices in the North East of England to evaluate a theory-based behaviour change intervention. We will target improvement in six underperformed clinical behaviours highlighted in quality standards for type 2 diabetes: prescribing for hypertension; prescribing for glycaemic control; providing physical activity advice; providing nutrition advice; providing on-going education; and ensuring that feet have been examined. The primary outcome will be the proportion of patients appropriately prescribed (using anonymised computer records), advised, and examined (using anonymous patient surveys) at 12 months. We will use behaviour change techniques targeting motivational, volitional, and impulsive factors that we have previously demonstrated to be predictive of multiple health professional behaviours involved in high-quality type 2 diabetes care. We will also investigate whether the intervention was delivered as designed (fidelity) by coding audiotaped workshops and interventionist delivery reports, and operated as hypothesised (process evaluation) by analysing responses to theory-based postal questionnaires. In addition, we will conduct post-trial qualitative interviews with practice teams to further inform the process evaluation, and a post-trial economic analysis to estimate the costs of the intervention and cost of service use.
[Show abstract][Hide abstract] ABSTRACT: Objective: This article reviewed the literature and critically analysed the concept of preparation for parenthood. The analysis is mainly of a discursive nature with some theoretical underpinnings. Background: Preparation for parenthood is a concept that is generally used within psychology, sociology and health professional practice especially midwifery, in terms of preparation for birth and parenthood sessions. However, parents often report feeling unprepared during this period. In order to ensure appropriate delivery of support and education during this time it is important to fully understand what preparation for parenthood really means by unravelling its component elements and understanding its contemporary relevance. Methods: A number of sources were searched using the keywords ‘preparation’ and ‘parenthood’. The concept analysis framework put forward by Walker and Avant was used to develop appropriate cases to further illustrate and explore meaning. Results: The literature search confirmed limited evidence with regards to an in-depth exploration of the concept and the separate elements that are related to each other. This investigation is the first of its kind considering the full range of meanings with regards to the concept and the contemporary evidence available. Law, gender, culture and spirituality all influence the concept and thus antecedents and consequences cannot always be applied to contexts which are fundamentally different. Conclusion: Preparation for parenthood is multi-faceted and changing, thus further research with regards to this concept is warranted. This analysis provides the groundwork for the development of measures that may be used within clinical practice.
Journal of Reproductive and Infant Psychology 01/2014; 32(2). · 0.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities.
A review of existing reviews (2003-2013) and a systematic review of recent research not included in earlier reviews.
The CRAFFT and AUDIT tools are recommended for identification of 'at risk' adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm.
Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.
Alcohol and Alcoholism 11/2013; · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Alcohol and Alcoholism 11/2013; · 1.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: From International Network on Brief Interventions for Alcohol and Other Drugs (INEBRIA) Meeting 2013 Rome, Italy. 18-20 September 2013 Optimizing Delivery of Health care Interventions (ODHIN) is an ongoing European project (EC, FP7) invol-ving research institutions from 9 European countries using the implementation of Early Identification and Brief Inter-vention (EIBI) programmes for Hazardous and Harmful Alcohol Consumption (HHAC) in Primary Health Care (PHC) as a case study to better understand how to trans-late the results of clinical research into everyday practice. The Italian National Health Service (ISS) is the project leader of the Work Package 6 assessment tool. The aim of the ODHIN assessment tool is to formalise, operationalise and test the questionnaire developed under the PHEPA project in order to produce an update instrument to assess the extent of implementation of EIBIs for HHAC through-out PHC settings. The ODHIN assessment tool has been conceived as a semi-structured questionnaire for the iden-tification of the state of the art, gaps and areas in the country that need further work and strengthening; to monitor the adequacy of brief intervention programmes for HHAC in order to provide recommendations to improve and optimize delivery of health care interventions. It analyses 24 questions distributed across 7 key sections. Data have been collected from 9 ODHIN collaborating countries (
[Show abstract][Hide abstract] ABSTRACT: Background: There is clear evidence of the detrimental impact of hazardous alcohol consumption on the
physical and mental health of the population. Estimates suggest that hazardous alcohol consumption
annually accounts for 150,000 hospital admissions and between 15,000 and 22,000 deaths in the UK. In
the older population, hazardous alcohol consumption is associated with a wide range of physical,
psychological and social problems. There is evidence of an association between increased alcohol
consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic
stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is
identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can
also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in onethird
of all suicides in the older population.
Objective: To compare the clinical effectiveness and cost-effectiveness of a stepped care intervention
against a minimal intervention in the treatment of older hazardous alcohol users in primary care.
Design: A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation.
Setting: General practices in primary care in England and Scotland between April 2008 and
Participants: Adults aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test (10-item)
(AUDIT) were eligible. In total, 529 patients were randomised in the study.
Interventions: The minimal intervention group received a 5-minute brief advice intervention with the
practice or research nurse involving feedback of the screening results and discussion regarding the health
consequences of continued hazardous alcohol consumption. Those in the stepped care arm initially
received a 20-minute session of behavioural change counselling, with referral to step 2 (motivational enhancement therapy) and step 3 (local specialist alcohol services) if indicated. Sessions were recorded and
rated to ensure treatment fidelity.
Main outcome measures: The primary outcome was average drinks per day (ADD) derived from
extended AUDIT – Consumption (3-item) (AUDIT-C) at 12 months. Secondary outcomes were AUDIT-C
score at 6 and 12 months; alcohol-related problems assessed using the Drinking Problems Index (DPI) at 6
and 12 months; health-related quality of life assessed using the Short Form Questionnaire-12 items (SF-12)
at 6 and 12 months; ADD at 6 months; quality-adjusted life-years (QALYs) (for cost–utility analysis derived
from European Quality of Life-5 Dimensions); and health and social care resource use associated with the
Results: Both groups reduced alcohol consumption between baseline and 12 months. The difference
between groups in log-transformed ADD at 12 months was very small, at 0.025 [95% confidence interval
(CI) –0.060 to 0.119], and not statistically significant. At month 6 the stepped care group had a lower
ADD, but again the difference was not statistically significant. At months 6 and 12, the stepped care group
had a lower DPI score, but this difference was not statistically significant at the 5% level. The stepped care
group had a lower SF-12 mental component score and lower physical component score at month 6 and
month 12, but these differences were not statistically significant at the 5% level.
The overall average cost per patient, taking into account health and social care resource use, was £488
[standard deviation (SD) £826] in the stepped care group and £482 (SD £826) in the minimal intervention
group at month 6. The mean QALY gains were slightly greater in the stepped care group than in the
minimal intervention group, with a mean difference of 0.0058 (95% CI –0.0018 to 0.0133), generating an
incremental cost-effectiveness ratio (ICER) of £1100 per QALY gained. At month 12, participants in the
stepped care group incurred fewer costs, with a mean difference of –£194 (95% CI –£585 to £198), and
had gained 0.0117 more QALYs (95% CI –0.0084 to 0.0318) than the control group. Therefore, from an
economic perspective the minimal intervention was dominated by stepped care but, as would be expected
given the effectiveness results, the difference was small and not statistically significant.
Conclusions: Stepped care does not confer an advantage over minimal intervention in terms of reduction
in alcohol consumption at 12 months post intervention when compared with a 5-minute brief (minimal)
Trial registration: This trial is registered as ISRCTN52557360.
Funding: This project was funded by the NIHR Health Technology Assessment programme and will be
published in full in Health Technology Assessment; Vol. 17, No. 25. See the HTA programme website for
further project information.
[Show abstract][Hide abstract] ABSTRACT: Background: UK health policy has sought to encourage alcohol screening and brief intervention (SBI) delivery in primary care, including via the introduction of pay-for-performance (P4P) schemes in 2008. In order to measure the impact of such policies, a range of data exist, including General Practitioner (GP) Read codes which record all clinical activity.
Research question: Can routinely recorded Read code data help evaluate the implementation of alcohol SBI in primary healthcare?
Method: Sequential mixed methods design: descriptive statistical analysis of alcohol Read code data by systematically interrogating 16 GP practice IT systems in North East England; followed by 10 in-depth GP interviews to explore factors influencing recording behaviour
Results: 287 alcohol-related Read codes existed, however only 40 (13.9%) were used between 2007-11, generally relating to the recording of a patient’s alcohol consumption status, BI delivery and screening tool administration (57.6%, 34.9% and 7.2% respectively of all codes used 2007-11). Further, many of the 287 available Read codes related to relatively rare alcohol conditions (52.2%) or duplicate/outmoded terminology (31%). Use of formal screening tools was rare pre-2008, but rates increased steadily after this point. In 2010-11 practices with higher SBI recording rates were typically signed up to P4P schemes (e.g. screening rates ranged from 3.73% (CI: 3.65-3.89) in P4P practices to 0.05% (CI: 0.03-0.08) in non-P4P practices (p <0.00)). However, GP interviews suggested that nurse-led SBI was most likely to be coded and delivered consistently, whilst GP delivery of SBI was more ad hoc, with a strong reliance on weekly alcohol consumption measures rather than validated screening tools to assess risk.
Conclusions: Whilst routine data may detect more successfully embedded screening activity in primary care post-2008, measuring SBI delivery remains challenging, particularly for GPs.
European General Practice Research Network; 05/2013
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/design: In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals' role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling. DISCUSSION: Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registration: ClinicalTrials.gov. Trial identifier: NCT01501552.
[Show abstract][Hide abstract] ABSTRACT: Alcohol use is an important issue among problem drug users. Although screening and brief intervention (SBI) are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users.
The objective of this study is to determine if a complex intervention including SBI for problem alcohol use among problem drug users is feasible and acceptable in practice. This study also aims to evaluate the effectiveness of the intervention in reducing the proportion of patients with problem alcohol use.
Psychosocial intervention for alcohol use among problem drug users (PINTA) is a pilot feasibility study of a complex intervention comprising SBI for problem alcohol use among problem drug users with cluster randomization at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction treatment. Patient must meet the following inclusion criteria to participate in this study: 18 years of age or older, receiving addiction treatment/care (eg, methadone), or known to be a problem drug user. This study is based on a complex intervention supporting SBI for problem alcohol use among problem drug users (experimental group) compared to an "assessment-only" control group. Control practices will be provided with a delayed intervention after follow-up. Primary outcomes of the study are feasibility and acceptability of the intervention to patients and practitioners. Secondary outcome includes the effectiveness of the intervention on care process (documented rates of SBI) and outcome (proportion of patients with problem alcohol use at the follow-up). A stratified random sampling method will be used to select general practices based on the level of training for providing addiction-related care and geographical area. In this study, general practitioners and practice staff, researchers, and trainers will not be blinded to treatment, but patients and remote randomizers will be unaware of the treatment.
This study is ongoing and a protocol system is being developed for the study. This study may inform future research among the high-risk population of problem drug users by providing initial indications as to whether psychosocial interventions for problem alcohol use are feasible, acceptable, and also effective among problem drug users attending primary care.
This is the first study to examine the feasibility and acceptability of complex intervention in primary care to enhance alcohol SBI among problem drug users. Results of this study will inform future research among this high-risk population and guide policy and service development locally and internationally.