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A systematic review of the effectiveness of alcohol
brief interventions for the UK military personnel
moving back to civilian life
Sarah Wigham,
1
A Bauer,
1
S Robalino,
2
J Ferguson,
3
A Burke,
4
D Newbury-Birch
3
▸Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
jramc-2016-000712).
1
Institute of Neuroscience,
Newcastle University,
Newcastle upon Tyne, UK
2
Institute of Health and
Society, Newcastle University,
Newcastle upon Tyne, UK
3
Health and Social Care
Institute, Teesside University,
Teesside, UK
4
Northumberland Tyne and
Wear NHS Foundation Trust,
Newcastle upon Tyne, UK
Correspondence to
Dr Sarah Wigham, Faculty of
Medical Sciences, Newcastle
University, Henry Wellcome
Building, Framlington Place,
Newcastle upon Tyne NE2
4HH, UK;
sarah.wigham@ncl.ac.uk
Received 5 September 2016
Revised 12 December 2016
Accepted 19 December 2016
To cite: Wigham S,
Bauer A, Robalino S, et al.J
R Army Med Corps
Published Online First:
[please include Day Month
Year] doi:10.1136/jramc-
2016-000712
ABSTRACT
Background Higher levels of alcohol consumption
have been observed in the UK armed forces compared
with the general population. For some, this may increase
the risk of using alcohol as a coping strategy when
adjusting to multiple life events occurring when moving
back into civilian life.
Method Asystematicreviewwasconductedtodetermine
the effectiveness of alcohol brief interventions for military
personnel during transition. Electronic databases including
Medline, Central, Healthcare Management Information
Consortium (HMIC) and Embase, and grey literature, were
searched. Two reviewers independently assessed potential
studies for inclusion, extracted data and assessed quality of
selected articles using an established instrument.
Results Ten studies met criteria for inclusion. Studies
were synthesised narratively. Interventions were hetero-
geneous, and bias within studies may have acted to
increase or decrease their reported effectiveness. The
findings suggest some evidence for effectiveness of
self-administered web-based interventions, involving
personalised feedback over a number of sessions, and
system-level electronic clinical reminders. All studies were
from the USA. Delivery of interventions by a clinician
during motivational interviews was most effective for
those with post-traumatic stress disorder symptoms.
Conclusions A UK trial of web-based interventions
with personalised feedback is recommended.
INTRODUCTION
Clusters of life events have been found cumula-
tively stressful in the general population and
moving back into civilian life from the military may
require simultaneous adjustment to changes in
employment, accommodation, geographical loca-
tion, finances, relationships and family life.
12
Most
service personnel make the move back to civilian
life successfully, however, for some this particular
time may increase susceptibility to stress because
adjustments to several life changes are required.
134
Coupled with this, events experienced while
serving may be alienating when among civilian
peers, and it may be a challenge to adjust to a more
individualistic civilian culture.
5–7
Higher levels of
alcohol consumption have been observed in the UK
armed forces, with 67% of men defined as drinking
harmful amounts compared with 38% in the
general population.
8
If alcohol is used to cope, this
may complicate the process of moving back to civil-
ian life, for example, by exacerbating any subclin-
ical mental health symptoms or by causing further
adverse life events.
9–11
Alcohol screening and brief interventions
Screening the adult population for harmful levels of
drinking and providing feedback and brief advice has
been shown to result in a reduction in the amount
consumed in a proportion of people.
12 13
The 10
question Alcohol Use Disorders Identification Test
(AUDIT) is seen as the gold standard for alcohol
screening.
14
The AUDIT can be scored between 0
and 40. A score of 8+ is referred to as a ‘positive
screen’and indicates an alcohol use disorder; hazard-
ous drinking (score of 8–15), harmful drinking (16–
19) or probable dependent drinking (20+). A score
of 8 or more out of a possible 40 on the AUDIT is
able to detect genuine excessive drinkers (92% sensi-
tivity) and to exclude false cases (94% specificity).
14
Brief interventions are typically applied to
opportunistic, non-treatment seeking populations,
and delivered by practitioners other than addiction
specialists in a variety of settings.
12 15 16
Alcohol
brief interventions largely consist of two different
approaches. Simple structured advice which, fol-
lowing screening, seeks to raise awareness through
the provision of personalised feedback and advice
on practical steps to reduce drinking behaviour and
adverse consequences; and extended brief interven-
tion which generally involves behaviour change
counselling.
17
Extended alcohol brief interventions
introduce and evoke change by giving individuals
the opportunity to explore their alcohol use as well
as their motivations and strategies for change. Both
types share the common aim of helping people to
change drinking behaviour to promote health, but
they vary in the precise means by which this is
achieved. Typically, brief interventions aim to
reduce alcohol consumption rather than achieve
abstinence. There is a wide variation in the dur-
ation and frequency of alcohol brief interventions,
however, they are typically delivered in a single
session or a series of related sessions (not exceeding
five sessions), lasting between 5 and 60 min.
13
Evidence to date on the effectiveness of alcohol
brief interventions comes from general population
Key messages
▸The evidence of effectiveness of alcohol brief
interventions for the UK military personnel
moving back to civilian life was reviewed.
▸All studies were from the USA.
▸The findings suggest web-based interventions
may have some utility in the UK context.
Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712 1
Review
studies primarily in primary healthcare settings.
18 19
However,
results may be different for military personnel who have differ-
ent pressures and demands. Therefore, it is important to
examine the effectiveness of alcohol brief interventions in this
setting. This review includes serving personnel and veterans so
the findings are of relevance to both groups.
This study therefore considers the evidence of the effective-
ness of alcohol brief interventions in reducing harmful levels of
drinking for armed forces personnel transitioning back to civil-
ian life. The authors are not aware of any previous published
systematic reviews of the effectiveness of alcohol brief interven-
tions relevant to the UK military personnel moving back to civil-
ian life. A previous systematic review has evaluated alcohol brief
interventions for the US active-duty soldiers.
20
The current
review also includes veterans, considers the UK context and
interventions for individuals rather than making changes to the
environment (eg, availability of alcohol). The findings of the
review will be of benefit in public health settings, military and
veteran medical primary care, community mental health and
third sector organisations.
METHODS
The review is presented in accordance with Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines.
21
Searches were undertaken in the following databases in
November 2015: Medline; PubMed; Cumulative Index to
Nursing and Allied Health Literature (CINAHL); EBM
Reviews: Cochrane Central Register of Controlled Trials
(CENTRAL); Web of Science; Embase; PILOTS: Published
International Literature On Traumatic Stress; PsycINFO; PAIS
International; Healthcare Management Information Consortium
(HMIC); Project Cork. The results from the search were down-
loaded into Endnote X7.
The search strategy comprised three facets: (1) military person-
nel (both active and those in transition), (2) alcohol-related disor-
ders and (3) interventions. Online supplementary appendix 1
shows the Medline search. The search strategy was translated
(eg, thesaurus terms, syntax) for use in different databases.
In some instances, a search string was used to exclude records
with PubMed IDs or using the ‘Exclude Medline journals’
limiter to reduce duplication of results given limited resources.
No further limits were used. The Ministry of Defence (via gov.
uk), the US Defence Technical Information Centre (dtic.mil)
and a general internet search were conducted to identify grey
literature. A further search in March 2016 was conducted to
locate papers related to acceptability of interventions. This
included a fourth facet of acceptability terms, with the search
conducted using the following structure: Alcohol-related disor-
ders AND Military personnel AND Acceptability, leaving out
the interventions facet used in the original searches (see online
supplementary appendix 2). This informed the facilitators and
barriers section in the discussion. The reference lists of included
articles were searched and forward citation searches were
carried out in Web of Science, as were hand searches of Military
Medicine and Journal of Studies on Alcohol and Drugs.
Inclusion criteria
The inclusion criteria were articles in English with the following
characteristics: population: serving or former armed forces per-
sonnel; intervention: screening and brief intervention; compara-
tor: usual care, other intervention or none; outcome: measure
of alcohol consumption; study design: observational or inter-
ventional. Evaluations of effectiveness of interventions in
purposively selected clinical groups, for example, traumatic
brain injuries, post-traumatic stress disorder (PTSD) were
excluded. Studies were included if participants were current or
former military personnel; interventions for military spouses or
children were excluded.
Study selection
Screening of titles and abstracts was carried out by one
researcher (SW). Potential full texts were then screened inde-
pendently against the inclusion criteria by two researchers (SW,
DN-B), and consensus reached on all by discussion. Two
authors were contacted to request further details not reported
in the publication that were required to make a decision.
Data collection and data items
A data extraction form was developed in Excel to record data
on: country, participant characteristics, study eligibility, interven-
tion and comparator information, study design, outcome mea-
sures and findings. Data were extracted independently by three
reviewers (SW, AB, JF).
Risk of bias
All studies meeting the inclusion criteria were assessed inde-
pendently (SW, AB) using the Quality Assessment Tool for
Quantitative Studies, which has demonstrated validity and reli-
ability.
22 23
Where global ratings fell in between the bias cat-
egories of low, moderate or high risk, the lower rating was
given.
Synthesis of results
Heterogeneity of study design and shared recruitment
sources
24 25
meant meta-analysis was inappropriate and results
were synthesised narratively.
RESULTS
Following de-duplication, 3415 studies were assessed for the
study. Ten studies met inclusion criteria and were included in
the review (Figure 1).
Study characteristics
All included studies were from the USA. Study designs included
randomised controlled trials (RCTs),
26 27
controlled clinical
trials (CCTs)
28–31
and retrospective secondary data ana-
lyses.
24 25 32
Eligibility for all studies was screening positive for
unhealthy alcohol use or drinking above recommended guide-
lines apart from two studies. For these two studies, eligibility
was active-duty personnel, or those attending a veterans transi-
tion clinic.
29 31
All studies had >80% and in six studies >90%
male participants.
Data used in the studies were collected from individuals
attending Veterans Affairs primary care clinics
24 27 32
including
two studies which recruited across ≥30 clinics.
25 28
In two
papers using the same data set participants were recruited via
Facebook.
26 33
Participants were also recruited from across eight
military installations
31
or were attending transition clinics for
veterans of operations in Afghanistan and Iraq.
29 30
In five
studies, mean age of participants was over 50 years.
24 25 27 28 32
The other five studies recruited a younger demographic with a
mean age of 32 years
26 29 30 33
and 69% being between 21 and
34 years.
31
Study characteristics are shown in Table 1.
Risk of bias within studies
Good inter-rater reliability for the risk of bias assessments was
demonstrated by a κvalue of 0.76 for 20% of included
2 Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712
Review
studies.
34
The characteristics of studies that may have caused an
increase or decrease in reported effectiveness of interventions
are discussed in this review and are shown in Table 2. Five
studies had a high risk of selection bias because <60% of
invited individuals agreed to participate, participants were self-
selecting or were recruited from a clinic.
26 27 30 31 33
Study
designs were moderate to good with four being retrospective
cohort or secondary analysis of an RCT
24 25 32 33
and the rest
being RCTs
26 27
and CCTs.
28–31
There was moderate risk of
bias across all studies as blinding was not or only partially
addressed. Two studies had an overall strong risk of bias because
participants self-selected into the study, there was high attri-
tion
26 31
plus randomisation could not be carried out across all
participants.
31
These same studies were otherwise moderate to
strong on design and factored attrition into their analysis. A
variety of different tools were used to measure alcohol con-
sumption/risk. These included measures of alcohol consumed
(Timeline Follow Back, Quick Drink Screen, Daily Drinking
Questionnaire); measures of alcohol use disorders (AUDIT,
AUDIT-C); estimates of blood alcohol content and measures of
consequences of drinking (Short Inventory of Problems, Drinker
Inventory of Consequences). One study had a moderate risk of
bias rating for data collection
31
and the rest of the studies lower
risk of bias as there was some psychometric evidence for the
outcome measures they used. However, the variety of different
tools used and their different purposes in studies compromised
cross study comparisons of results.
Outcome measures used in the studies reviewed
The outcome measures used in the studies to demonstrate a
reduction in harmful levels of alcohol consumption and so a
successful outcome are shown in Table 3.
STUDY FINDINGS
The findings from the studies in the review are presented in
Table 4.
Systems-level electronic clinical reminders prompting
clinicians to give advice
Three studies evaluated systems-level electronic clinical remin-
ders.
24 25 32
These were triggered in the clinical notes by a posi-
tive alcohol screen and prompted clinicians to give advice to
reduce drinking. Data from veterans primary care settings was
retrospectively analysed with the AUDIT-C used as a screening
and outcome measure. Two studies found that electronic clinical
reminders and documented advice did not improve resolution of
harmful alcohol consumption compared with controls.
25 32
One
study did find evidence of effectiveness of electronic clinical
reminders with resolution of harmful levels of alcohol consump-
tion significantly better (31%) than controls (28%) (p=0.03).
24
Figure 1 Summary of the search
selection process.
Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712 3
Review
Table 1 Study characteristics
Study (country) Population Eligibility Intervention Design
Systems-level electronic reminders prompting clinicians to give advice
Williams et al (2010)
24
(USA)
VA primary care (8 clinics) (N=4198).
94% male; 83% ≥50 years; 72%
white; 49% married
Positive screen for unhealthy alcohol
use, and FU screen at 14.5 months
(mean)
Reminder in electronic clinical records triggered by positive alcohol screen for clinician to
give and document advice to reduce or abstain from alcohol consumption (n=2975).
Comparator: no documented advice
Retrospective cohort via
secondary data
Williams et al (2010)
32
(USA)
VA primary care (N=1358).
94% male; mean age 59 years;
64% white; 54% unmarried
Positive screen for unhealthy alcohol
use, and FU screen (≥18 months)
As above (n=692).
Comparator: no documented advice
As above
Williams et al (2014)
25
(USA)
VA primary care (30 clinics) (N=6210).
97% male; 89% ≥50 years; 49%
married
Positive screen for unhealthy alcohol
use, and FU screen (mean 350 days)
Clinical reminder triggered by positive alcohol screen for clinician
to give and document alcohol-related advice (n=1751).
Comparator: no documented advice
As above
Clinician-administered face-to-face interventions
McDevitt-Murphy
et al (2014)
30
(USA)
Primary care for veterans of
Afghanistan and Iraq (N=68).
91% male; mean age 32 years; 65%
white; 41% married; 57% PTSD
Positive screen on AUDIT or AUDIT-C Personalised drinking feedback (PDF: information on alcohol,
norms, mental health and coping) discussed during 1 hour motivational interview (MI)
(n=35).
Comparator: written PDF with no MI (n=33)
CCT
6-week and 6-month FU
Clinician-administered telephone interventions
Helstrom et al (2014)
28
(USA)
42 VA providers (N=139).
98% male; mean age 57 years, 55%
white, 30% married
Positive screen on AUDIT-C Telephone care management: sessions at 3, 6 and 9 months postscreen with a clinician: on
motivation, decisions, education, risk, comorbidity, behaviour change plan and goals
(n=68).
Comparator: usual care (advice to reduce, risks, recommended drinking limits) (n=71)
CCT
4-month, 8-month and
12-month FU
Self-administered web-based interventions
Pemberton
et al (2011)
31
(USA)
Active-duty (8 installations) (N=3070).
83% male; 69% 21–34 years; 65%
white; 59% married
Active-duty personnel ‘Drinker’s Check-Up’(modified for military): ‘high’and ‘low risk’versions (AUDIT>/<8) pros/
cons of drinking, family history, consequences, personalised feedback, norms, BAC,
tolerance, goals, risk factors, helping others (n=1470; 6-month FU n=256).
‘Alcohol Savvy’: 3 multimedia modules on drinking levels, consequences, skills to change
and decision-making (n=686; 6-month FU n=175). Control: delayed intervention (n=914)
CCT
1-month and 6-month FU
Brief et al (2013)
26
(USA)
Afghanistan and Iraq veterans recruited
via Facebook (N=600). 86% male;
mean age 32 years;
79% white
Drinking above guidelines; AUDIT
score between 8 and 25 (men) and 5
and 25 (women)
‘VetChange’: 8 weeks; CBT-based, motivational and self-control strategies; 8 modules:
personalised feedback, readiness to change, goals, risk situations, support system (n=404;
FU n=183).
Comparator: 8 weeks delayed intervention (n=196; FU n=78)
RCT
8 weeks and
3-month FU
Cucciare et al (2013)
27
(USA)
Veterans Affairs general medical clinics
(N=167).
88% male; mean age 59 years; 69%
white; 43% married; 35% positive
PTSD screen
Positive screen on AUDIT-C Web-delivered (10–15 min) involving assessment of and personalised feedback on: alcohol
consumption, substance use, negative consequences of drinking, for example, financial cost,
potential effects of combat and PTSD on drinking, motivation to change, norms for age and
gender and tolerance (n=89; 6-month FU n=75).
Comparator: treatment as usual (n=78; 6-month FU n=67).
RCT
3 and 6 month FU
Enggasser et al (2015)
33
(USA)
Veterans of Afghanistan and Iraq
recruited via Facebook (N=305).
87% male; mean age 32 years;
79% white
Drinking above guidelines; AUDIT
score: 8-25 (men);
5-25 (women)
‘VetChange’(see Brief et al
26
): Participants selected own drinking goals at intervention start
and end: abstinence only, abstinence to moderation, moderation to abstinence, moderation
only (selected by majority).
Comparator: before, after and between goal group
Retrospective analysis of RCT.
Postintervention and 3-month
FU
Educational information
Martens et al (2015)
29
(USA)
Afghanistan and Iraq Veterans
transition clinic (N=325).
93% male; mean age 32 years; 82%
white
All veterans attending clinic Information to read for 10 min in clinic. Personalised feedback: educational information on
norms, BAC, risk, health and social problems, protective strategies, calories, financial costs.
Comparator: educational information on physical effects of alcohol
CCT
1-month and 6-month FU
AUDIT, Alcohol Use Disorders Identification Test; AUDIT-C, Alcohol Use Disorders Identification Test—Consumption; BAC, blood alcohol content; CBT, cognitive behavioural therapy; FU, follow-up; PTSD, post-traumatic stress disorder; RCT, randomised
controlled trial; CCT, controlled clinical trial; VA, Veterans Affairs.
4 Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712
Review
Clinician-administered interventions
Two studies evaluated clinician-administered interventions face
to face, and by telephone.
28 30
Individually adapted information
delivered by a clinician over the telephone, on drinking motiva-
tions and decisions, risk, education, co-occurring disorders,
goals and plans for changing behaviour was evaluated.
28
Although significantly reduced alcohol outcomes continued to
12 months follow-up, effectiveness was not significantly higher
than when brief advice was given in combination with informa-
tion on drinking guidelines in written form.
28
Personalised
drinking feedback delivered during a 1 hour motivational inter-
view by a clinician was evaluated with veterans of Afghanistan
and Iraq.
30
Again although alcohol outcomes significantly
reduced and were sustained 6 months later, effectiveness was
not significantly higher than when personalised information was
delivered in written form. However, for those with PTSD symp-
toms, there were significantly greater reductions in drinking
6 weeks after a brief intervention delivered during a motiv-
ational interview with a clinician (compared with written infor-
mation only).
30
Self-administered web-based interventions
Four studies evaluated self-administered web-based interventions
and yielded mixed results.
26 27 31 33
‘Drinkers Check-Up’is a
web-based intervention comprising several components, for
example, personalised feedback, motivation and goals, plus
information on tolerance. Two formats of ‘Drinkers Check-Up’
were evaluated with over 3000 active-duty personnel across
eight bases.
31
The formats modified for a military population
were ‘high’and ‘low risk’versions based on AUDIT thresholds,
and these effected significant reductions on a number of alcohol
outcomes compared with a delayed control group. Effects were
maintained 6 months after the intervention (n=702). ‘Alcohol
Savvy’, a multimedia web-based intervention, was not found
effective.
31
‘VetChange’is an eight-module cognitive behavioural therapy-
based web intervention comprising several components, for
example, personalised feedback, information on mental health
and coping and setting personal goals. ‘VetChange’was evalu-
ated in 600 military personnel reporting an average of two
tours and 20 months total deployment. Compared with delayed
controls, those receiving the intervention demonstrated signifi-
cantly more reductions in alcohol outcomes, which were main-
tained at 3 months follow-up.
26
The improvements were found
independent of which personal drinking goal was chosen, for
example, abstinence or moderation.
33
A 15-min web-delivered assessment followed by personalised
feedback was found no more effective than receiving informa-
tion on recommended drinking limits and the effects of alcohol
on health.
27
The web-based interventions included a variety of different
components, although common across all was personalised
feedback.
Educational information and personalised feedback
One study evaluated the effectiveness of educational information
and personalised feedback.
29
Veterans attending a transition
clinic were given either personalised feedback about their drink-
ing, for example, alcohol-related financial costs and calories, or
general educational information on the physical effects of
alcohol. Drinking outcomes improved over time for those receiv-
ing personalised feedback. Those receiving only educational
information demonstrated an initial improvement then a slight
Table 2 Assessment of bias
Williams et al
(2014)
25
Williams et al
(2010)
24
Williams et al
(2010)
32
Pemberton et al
(2011)
31
Martens et al
(2015)
29
Helstrom et al
(2014)
28
Enggasser et al
(2015)
33
*
Cucciare et al
(2013)
27
Brief et al
(2013)
26
*
McDevitt-Murphy et al
(2014)
30
Selection bias
Study design
Confounders
Blinding
Data collection
Withdrawals/
dropouts
Overall
*Same data set.
N/A: not applicable; low risk of bias; moderate risk of bias; strong risk of bias.
Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712 5
Review
decrease, although between-group differences were not signifi-
cant. Abstainers receiving personalised information however
were significantly more likely to still be abstaining 6 months later
compared with those receiving general/non-personalised
information.
29
DISCUSSION
Study findings
The findings from this review indicate mixed evidence regarding
the effectiveness of using electronic clinical reminders to
prompt brief interventions. One study did find evidence of
effectiveness,
24
but two studies did not measure any significant
effects.
25 32
Delivering information in written format was as
effective as when delivered by a clinician face to face
30
or over
the telephone.
28
Although written personalised feedback
(including information on hazardous drinking, PTSD symptoms,
depression and coping) delivered by a motivational interviewing
counselling session was more effective for those with PTSD
symptoms than when provided without.
30
‘VetChange’and
‘Drinkers Check-Up’web-based interventions demonstrated
effectiveness in resolving unhealthy levels of alcohol consump-
tion.
26 31
However, ‘Alcohol Savvy’and a 15-min web-based
intervention were not found to show significant effects.
27 31
No
significantly greater effect on resolution of unhealthy drinking
was found when information about alcohol was personalised as
opposed to general educational information in the context of a
10-min intervention.
29
However, personalised information was
effective for encouraging abstainers to maintain abstinence.
29
Previous research on facilitators and barriers to the effective-
ness of brief interventions can highlight reasons why some inter-
ventions in the review appeared to work better than others.
Facilitators and barriers may need to be considered when imple-
menting brief interventions in order to create circumstances that
maximise their effectiveness. For example, a lack of understand-
ing by individuals and organisations of the goals of brief inter-
ventions has been described as a barrier to their successful
implementation,
25 47
so that for maximum effectiveness of brief
interventions training may be important.
Where interventions are made up of a number of compo-
nents, it may not be clear which ones are having the most
effect.
29 31
For example, linking financial cost and calories to
drinking has been reported a useful motivator.
48
In the review,
‘Drinkers Check-Up’worked better than ‘Alcohol Savvy’,
although both are self-administered web-based interventions.
This is aligned with previous findings, where ‘Drinkers
Check-Up’but not ‘Alcohol Savvy’facilitated changing perceived
drinking norms, which affected alcohol outcomes 6 months
later.
49
The findings in the review which supported effectiveness
of web-based interventions accord with previous reports on the
acceptability of web-based brief interventions to military person-
nel
48 50
and the use of smartphone applications in the general
population.
51
Strengths and limitations
All included studies in this review were from the USA. Given
different military organisational, social and drinking cultures
between the US and the UK, generalisability of the findings
cannot be assumed. There are different age restrictions on
alcohol in the USA, and alcohol consumption is suggested to be
lower in the US armed forces compared with the UK.
52
In add-
ition, research suggests that alcohol is used to promote unit
cohesion in the UK.
53 54
Furthermore, the range of different
Table 3 Outcome measures used to show resolution of harmful alcohol use
Study
Outcome
measure Characteristics
Measures of alcohol use disorders
McDevitt-Murphy et al (2014)
30
Brief et al (2013)
26
AUDIT Alcohol Use Disorders Identification Test: the AUDIT is a standardised 10-item self-report screening measure of alcohol
use. It is widely used and was developed by WHO.
35
Individual items are scored 0–4; a score of 8+ indicates harmful
levels of drinking.
14
Psychometric properties have been demonstrated in veterans
36
Williams et al (2010; 2010;
2014)
24 25 32
McDevitt-Murphy et al (2014)
30
AUDIT-C Alcohol Use Disorders Identification Test—Consumption: the AUDIT-C is a short form of the AUDIT comprising the
first three items.
36
A score of 3+ for women and 4+ for men indicates harmful levels of drinking.
37
Psychometric
properties have been demonstrated in veterans
36 38
Measures of alcohol consumed
Mc-Devitt-Murphy et al (2014)
30
Helstrom et al (2014)
28
Cucciare et al (2013)
27
TLFB Timeline follow back
39
a calendar style self-report measure of drinks (frequency and quantity) over the past 28 or
30 days. Psychometric properties have been demonstrated.
40
Enggasser et al (2015)
33
Brief et al (2013)
26
QDS Quick Drink Screen:
41
a self-report measure with 4 items focussing on quantity and frequency of drinking in the last
month. Some evidence of reliability has been demonstrated.
41 42
Martens et al (2015)
29
DDQ Daily Drinking Questionnaire:
43
a method of calculating self-reported average weekly drinks over the past month
Measures of consequences of drinking
Helstrom et al (2014)
28
Brief et al (2013)
26
Enggasser et al (2015)
33
Cucciare et al (2013)
27
Martens et al (2015)
29
SIP Short Inventory of Problems:
44 45
a self-report measure with 15 items (scored 0–3), it is a shortened version of the
Drinkers Inventory of Consequences measuring any problems resulting from drinking over the past 3 months.
Psychometric properties have been demonstrated
45 46
McDevitt-Murphy et al (2014)
30
DrInC Drinkers Inventory of Consequences:
44 46
a 50-item self-report measure of any recent (past 3 months) adverse
consequences of drinking across five areas relating to self, social and relationships, physical consequences and
impulsivity). A 4-point scale allows rating presence and frequency, and current and lifetime scores can be calculated.
Acceptable internal consistency was demonstrated in the study
Estimates of BAC
Pemberton et al (2011)
31
Martens et al (2015)
29
BAC Peak blood alcohol content: calculated from an individual’s weight, plus self-reported number of drinks consumed and
time spent drinking on the heaviest drinking occasion during the past month
6 Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712
Review
screening tools, and interventions used in the studies reviewed
means that it is impossible to ascertain efficacy or effectiveness
across trials. Given this, the need for a trial of alcohol brief
interventions in the UK in this setting is imperative to the field.
This review looks at interventions appropriate for transition
between military and civilian life. The review therefore includes
serving personnel and veterans so the findings are of relevance
to both groups. Some veterans may experience adjustment diffi-
culties a number of years after moving back into civilian life,
and serving personnel will move between deployment and non-
deployment and more so if they are reservists.
55
Directions for future research
Although there are some modest positive findings, certain study
characteristics may have acted to increase or decrease reported
effectiveness, for example, large numbers lost to attrition result-
ing in underpowered analyses. A UK trial of alcohol screening
and brief interventions using the results of this study is
imperative. Further examination of the most effective parts of
composite programmes would facilitate streamlining interven-
tions for best use of resources.
29
Conclusions and policy implications
There was substantial heterogeneity across studies in interven-
tion and design. Brief interventions are quick, preventative and
can be implemented upstream of acute clinical services to
reduce the risk of developing long-term alcohol-related health
and social difficulties requiring clinical treatment but require
more investigation in the UK setting. The findings also suggest
web-based interventions may have some utility. Resources for
technology development, set up and maintenance are required
for web-based interventions, although being online and self-
administered costs and overheads could be minimised.
Web-based interventions also allow flexibility with regard to
time and geographic coverage.
56
Table 4 Study findings
Study Findings
Systems-level electronic reminders prompting clinicians to give advice
Williams et al (2010)
24
Resolution of unhealthy alcohol use: significantly higher with reminder in electronic clinical records (31%) than control (28%), p=0.03
Williams et al (2010)
32
No significant association between resolution of unhealthy alcohol use and intervention (40%) vs control (43%), p=0.25
No significant increase in resolution of unhealthy alcohol use with documented electronic clinical reminder or brief intervention
Williams et al (2014)
25
No significant difference between intervention 48% and control 47% for resolution of unhealthy alcohol consumption, p=0.5; or when
stratified by drinking severity, or presence/absence of alcohol disorder
Clinician-administered face-to-face interventions
McDevitt-Murphy et al
(2014)
30
Significant reduction at 6 weeks sustained at 6 months in drinking quantity, frequency, binge drinking days, drinks per drinking occasion
across all participants. Significant reduction across time in adverse consequences of drinking (physical, interpersonal, social responsibility,
impulse control) for all participants. No significant difference in effect with or without motivational interviewing. At 6 weeks those with PTSD
symptoms significantly reduced drinks per week when receiving feedback with motivational interviewing vs feedback only
Clinician-administered telephone interventions
Helstrom et al (2014)
28
Both groups reduced number of drinks, drinking days and heavy drinking days (by average 4 days/month); <60% met criteria for at-risk
drinking by end of intervention. Significant pre-post differences in number of drinks and days drinking in past month. No between-group
differences (telephone intervention vs information on drinking guidelines only)
Self-administered web-based interventions
Pemberton et al (2011)
31
‘Drinkers Check-Up’: 1 month after baseline, participants significantly reduced average number of drinks per drinking occasion, frequent heavy
episodic drinking and peak BAC compared with a waiting control group. Reductions in heavy episodic drinking relative to controls approached
significance at 1-month follow-up. Reductions maintained at 6 months, although no significant further change. ‘Alcohol Savvy’: no significant
effects baseline to 1-month and 6-month follow-up, although frequent heavy episodic drinking reductions approached significance compared
with controls
Brief et al (2013)
26
Baseline: 59%–62% screened PTSD positive. Significantly greater reductions for ‘VetChange’group across all measures of drinking and PTSD
compared with waiting control at baseline to time 1, and time 1 to 3-month follow-up (all p<0.01)
Cucciare et al (2013)
27
Both groups showed statistically significant reductions on all outcomes from baseline to 3-month and 6-month follow-up (apart from
treatment as usual+brief intervention), which only approached significance on drinks per drinking day baseline to 3 months. No significant
change in outcomes from 3 to 6 months.
No significant difference in alcohol outcomes between the groups (treatment as usual or treatment as usual+brief intervention) at any time.
Allocation to the treatment as usual+brief intervention group was not associated with better alcohol outcomes over time. Small effect size for
baseline to 6-month follow-up on all outcomes (all ≤0.18; p<0.01) apart from number of drinking days (moderate: 0.24)
Treatment as usual: information on the US government recommended drinking limits and health effects of alcohol
Enggasser et al (2015)
33
Significant reductions from baseline to postintervention and 3-month follow-up on all alcohol outcomes (drinks per drinking day; average
drinks per week; per cent heavy drinking days; drinking-related problems) for all drinking goals apart from abstinence to moderation, which
took until 3 months to show significant change). Those with more severe baseline drinking showed significantly less improvements on all
alcohol outcomes at follow-up. At 3-months follow-up:
>56% with initial and final drinking goals of moderation met personal goals for drinks per drinking day and average drinks per week
>66% with goals of abstinence to moderation met personal goals for drinks per drinking day and average drinks per week
>84% of abstainers still abstaining/drinking within guidelines. Those changing goals reported similar rates of drinking within guidelines
3-months later
Educational information
Martens et al (2015)
29
Personalised drinking feedback group: significant decreases in BAC and drinks per week from baseline to 6-month follow-up; only significant
effect at 1-month follow-up on drinks per week for ‘drinkers’and BAC for ‘heavy drinkers’. Education-only group: significant decreases in BAC
from baseline to 1-month follow-up, then increases 1-month to 6-month follow-up. No significant between-group differences (p>0.05).
Personalised drinking feedback group significantly more likely to continue abstaining 6-months later than education-only group (96% vs 79%;
p<0.05)
BAC, blood alcohol content; PTSD, post-traumatic stress disorder.
Wigham S, et al.J R Army Med Corps 2017;0:1–9. doi:10.1136/jramc-2016-000712 7
Review
The findings of this review will benefit the UK armed forces
personnel by summarising the evidence base for the effective-
ness of alcohol brief interventions relevant to transitioning to
civilian life. Alcohol brief interventions can signpost healthier
coping strategies. Furthermore, findings will also benefit service
providers by informing decisions on which interventions to
fund and develop, and researchers by highlighting future
research priorities.
Acknowledgements We would like to thank Forces in Mind Trust for funding the
study, and for consultation Helen Neal and Tanya Scott of Thirteen Care and
Support, Robin Brims, Stephen Rice, Andrea Docherty and Domhnall Jennings.
Contributors SW, DN-B and SR contributed to the conceptualisation, data
collection, analysis and write up of the study and approval of the final manuscript.
AB contributed to the conceptualisation and write up of the study and approval of
the final manuscript. AB and JF contributed to analysis and write up of the study
and approval of the final manuscript.
Funding ’A systematic review of the effectiveness of alcohol brief interventions for
the UK military personnel moving back to civilian life’has been funded by the
Forces in Mind Trust (FiMT), a £35 million funding scheme run by the FiMT using an
endowment awarded by the Big Lottery Fund.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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