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A pragmatic randomised trial of two counselling models at the Swedish national alcohol helpline


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Background: Alcohol telephone helplines targeting alcohol consumers in the general population can extend thereach of brief interventions while preserving in-person counselling. So far, studies of client outcomes in the settingof alcohol helplines are scarce. This study aims to compare the 6-months alcohol-related outcomes of twocounselling models delivered at the Swedish National Alcohol Helpline. Methods: A pragmatic randomised trial was set up at the Swedish National Alcohol Helpline. First-time callers withcurrent hazardous or harmful alcohol use who contacted the helpline, from May 2015 to December 2017, were invitedto participate. Clients were allocated with 1:1 ratio to two groups: (1) brief, structured intervention (n= 128), includingself-help material and one counsellor-initiated call, and (2) usual care (n= 133), i.e. multiple-session counselling usingMotivational Interviewing (MI). The primary outcome was a downward change in AUDIT risk-zone between baselineand 6-months follow-up. The analysis followed an intention-to-treat approach. Results: Recruitment ended in December 2017. At 6-months follow-up, 70% of the enrolled participants had data onthe outcome. In the brief, structured intervention (n= 107) 68% changed to a lower risk-level, compared to 61% in theusual care group (n= 117), yielding a risk ratio (RR) of 1.12 (95% CI 0.93 to 1.37) and risk difference of 0.08 (95% CI -0.05to 0.20). The total AUDIT score and the scores from the AUDIT consumption questions (AUDIT-C) did not reveal anybetween-group differences in the mean change at follow-up. Conclusions: The counselling at the Swedish National Alcohol Helpline was followed by a significant decrease inalcohol use among clients, without clear superiority for either counselling model.
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R E S E A R C H A R T I C L E Open Access
A pragmatic randomised trial of two
counselling models at the Swedish national
alcohol helpline
Eleonor Säfsten
, Yvonne Forsell
, Mats Ramstedt
, Kerstin Damström Thakker
and Maria Rosaria Galanti
Background: Alcohol telephone helplines targeting alcohol consumers in the general population can extend the
reach of brief interventions while preserving in-person counselling. So far, studies of client outcomes in the setting
of alcohol helplines are scarce. This study aims to compare the 6-months alcohol-related outcomes of two
counselling models delivered at the Swedish National Alcohol Helpline.
Methods: A pragmatic randomised trial was set up at the Swedish National Alcohol Helpline. First-time callers with
current hazardous or harmful alcohol use who contacted the helpline, from May 2015 to December 2017, were invited
to participate. Clients were allocated with 1:1 ratio to two groups: (1) brief, structured intervention (n= 128), including
self-help material and one counsellor-initiated call, and (2) usual care (n= 133), i.e. multiple-session counselling using
Motivational Interviewing (MI). The primary outcome was a downward change in AUDIT risk-zone between baseline
and 6-months follow-up. The analysis followed an intention-to-treat approach.
Results: Recruitment ended in December 2017. At 6-months follow-up, 70% of the enrolled participants had data on
the outcome. In the brief, structured intervention (n= 107) 68% changed to a lower risk-level, compared to 61% in the
usual care group (n=117), yielding a risk ratio (RR) of 1.12 (95% CI 0.93 to 1.37) and risk difference of 0.08 (95% CI -0.05
to 0.20). The total AUDIT score and the scores from the AUDIT consumption questions (AUDIT-C) did not reveal any
between-group differences in the mean change at follow-up.
Conclusions: The counselling at the Swedish National Alcohol Helpline was followed by a significant decrease in
alcohol use among clients, without clear superiority for either counselling model.
Trial registration: This trial was retrospectively registered with (ID: ISRCTN13160878) 18/01/2016.
Keywords: Hazardous alcohol use, Harmful alcohol use, Drinking, Telephone helpline, Brief intervention, Counselling,
Randomised controlled trial
The high prevalence of hazardous and harmful alcohol
use and the substantial harm attributable to alcohol con-
sumption [1,2] highlights the need for easily applicable
intervention and prevention efforts directed towards at-
risk consumers.
In part, the harm caused by alcohol could be prevented
by increasing help -seeking in the population with hazard-
ous or harmful alcohol consumption [3]. Only a minority
seek formal treatment and help-seeking usually occurs at
arelativelylatestage[4,5], partially due to stigma, scepti-
sism toward treatment alternatives and ignorance of the
problemsseverity [6,7]. Brief interventions (BI) are recog-
nised as effective and cost-effective in primary care popu-
lations [8,9]. However, the extent to which these
interventions reach the target population is limited by op-
portunistic identification [10]; the failure to identify at-risk
drinkers [11]; health professionals attitudes and insuffi-
cient implementation strategies [12,13]. Strategies to
reach individuals that would not seek regular treatment
includes personalised digital interventions. Recently, a
Cochrane review found personalised digital behavioural
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International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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( applies to the data made available in this article, unless otherwise stated.
* Correspondence:
Department of Public Health Sciences, Karolinska Institutet, 171 77
Stockholm, Sweden
Full list of author information is available at the end of the article
Säfsten et al. BMC Psychiatry (2019) 19:213
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interventions effective for reducing hazardous or harmful
alcohol consumption compared to no or minimal inter-
ventions [14]. However, extended counselling does not
seem to be more effective for modifying hazardous alcohol
use than brief interventions [15]. In the context of tele-
phone helplines the effectiveness of different interventions
are unknown.
While telephone-based alcohol counselling via help-
lines is gaining momentum, its effectiveness has not
been evaluated with experimental studies [16,17]. The
existing studies on brief intervention using telephone
counselling typically consist of clinical populations, i.e.
not seeking help for alcohol problems per se. These
studies suggest that the telephone may be an effective
mode for alcohol counselling [18][19][20][21], a sug-
gestion supported by previous reviews on telephone
counselling in mental health and addiction [22,23]. Fur-
ther, the scant evaluation of alcohol helplines limits the
knowledge about effective models of delivery.
Population-based telephone counselling, combines
ease of access and anonymity with the advantages of in-
person individual counselling, thus reducing potential
barriers to treatment seeking. Last but not least, tele-
phone helplines may be cost-effective for the delivery of
in-person counselling.
The Swedish National Alcohol Helpline (SAH), operat-
ing since 2007, offers a unique possibility to study tele-
phone counselling aimed at the general population.
From the very start, a strong emphasis was put on devel-
oping and providing the most cost-effective counselling
setting. Previous observational studies at SAH offered a
suitable proof of conceptof the usefulness of the ser-
vice [24,25]. This study seeks to move the agenda fur-
ther, comparing the effects of two counselling models on
hazardous and harmful alcohol use within the SAH. 1) A
brief structured intervention consisting of self-help ma-
terial combined with one counsellor-initiated call, and 2)
usual care, i.e. multiple-sessions of Motivational Inter-
viewing (MI) with components of cognitive behavioral
therapy (CBT). The alternative hypothesis was that the
brief structured intervention would be more effective
than usual care in promoting change in a clients alcohol
drinking habits.
A protocol of the trial, including full information of the
design and methods, has been published and is sum-
marised here [26].
Study design
A pragmatic randomised controlled trial was initiated in
2015 at the SAH. The Ethical Review Board of Stockholm,
Sweden approved the study (DNR 2014/173231/5), and
the corresponding protocol was registered in the ISRCTN
registry (ID: ISRCTN13160878). The analytical approach
to hypothesis testing has been changed [26]fromthatre-
ported in the trial register from non-inferiority to super-
iority due to a lower recruitment rate then what was
expected at inception.
Recruitment of participants and random allocation
Participants were clients from the general population
seeking help at the SAH for at least hazardous alcohol
use. Counsellors assessed the eligibility of clients at their
first contact, before informing about the study. Eligible
clients who expressed interest in participating were con-
tacted by telephone within a week by trained inter-
viewers not involved in the counselling at the helpline.
The interviewers performed the following sequence of
tasks: 1) obtained formal consent, 2) conducted the
baseline interview, and 3) opened a sequentially num-
bered, sealed envelope containing the results of the
randomization algorithm and communicated the group
allocation to the participant. Clients were allocated with
1:1 ratio to the two groups. The research coordinator
prepared the envelopes containing the computer-
generated allocation sequence. Detailed information on
the randomisation and recruitment process can be found
in the study protocol [26]. The enrolment period was
from May 27, 2015, to December 15, 2017, while the 6
months follow-up was completed between December 5,
2015 and June 20, 2018.
First-time callers or callers with a washout period of at
least 1 year since last SAH contact, that were adults
(18 years) who spoke Swedish and sought help for at
least hazardous alcohol use were eligible to participate
in the trial. Hazardous alcohol use was identified by the
Alcohol Use Disorders Identification Test (AUDIT),
using a cut-off of 6 and 8 points or more for women and
men respectively [27]. Clients were excluded if the
counsellor made the assessment that a caller required
referral to treatment for severe alcohol problems or if
the client reported the concurrent use of illicit drugs, or
the suffering from severe psychiatric conditions or other
acute health problems that required medical attention.
Further, counsellors refrained from informing clients
about the study if the overall assessment at the first call
indicated that clients were not able at that time to
understand the conditions for participation in the study.
Trial groups
Brief structured intervention
The brief structured intervention includes a self-help
booklet and one counsellor-initiated call (i.e. proactive).
The self-help booklet is based on CBT and provides a
step-by-step guide to change alcohol use. In brief, it aims
to increase motivation to change, initiate reflection, fa-
cilitate goal-setting and self-monitoring, and provide
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suggestions on how to build resistance skills. The self-
help booklet was delivered by e-mail or ordinary mail or
could be downloaded from a password-protected web-
site. Two weeks after dispatching the self-help booklet a
counsellor contacted the participant. The counselling in
the proactive call was based on a brief manual with the
focus of facilitating the use of the material. Counsellors
were asked to document the delivery of the proactive
call as 1) completed according to the manual, 2) com-
pleted with other content, i.e. usual MI counselling with
other focus than the material, or 3) not completed, i.e.
not rescheduled within 2 weeks from the first contact or
could not be reached after five attempts.
After the proactive call, no further contacts were initi-
ated by the counsellor. However, clients were not pro-
hibited from calling the SAH again if they felt the need
to do so. If additional contacts were initiated by the cli-
ent, usual counselling was provided.
Usual care
The usual care at the SAH builds on MI with compo-
nents of CBT. The purpose is to promote clients motiv-
ation to change, develop resistance skills and prevent
relapses. The sessions vary in number, duration and
mode, (i.e. reactive or proactive), and is determined by
the counselling need of each client. The counselling is
tailored according to the stage of change of the client
(contemplation, preparation, action and maintenance).
In case of a fifth session the counsellor and the client
make a joint evaluation of whether the client has
reached his or her alcohol-related goals or if there is a
need for further support. When necessary either a max-
imum of two additional reactive calls may be offered or
the client is referred to a specialised treatment provider.
After each session the core content and the clients
alcohol-related goals are registered in an electronic rec-
ord, to enable consistent counselling between sessions.
Data collection
Data was collected by structured interviews at baseline
and at 6 months follow-up. At baseline, the interview
covered questions of demographics (sex, age, education,
employment, and living arrangements), and social sup-
port. Additional information included co-morbidity, in-
dicators of general health, and help-seeking for alcohol-
related problems (past 6 months). To screen for major
depressive episodes (MDE, past 2 weeks) and generalized
anxiety disorder (GAD, past 6 months), the measured
mental-health problems, two sections of the M.I.N.I.
(Mini-International Neuropsychiatric Interview M.I.N.I.)
were used [28,29]. Indicators of general health status
were: sick-leave during the past 6 months, and self-
assessed health, the latter measured by How would you
rate your overall health status?in which responses were
collapsed into three alternatives: Very good to Good,
Fair,Bad to Very bad)[30]. Motivation to change was
measured at baseline as it could be a predictor of the
outcome [31,32]. This was measured by the Readiness
to change ruler ranging from 0 to 10, where 10 defines
very high degree of readiness [31]. At baseline, AUDIT
was primarily completed at the first call, since this scale
is usually administered at the SAH as an essential tool
for the diagnosis of the severity of alcohol problems. In
some cases when AUDIT was not completed at the first
call, it was administered in the subsequent baseline
interview. Data retrieved from the client record at the
helpline included AUDIT score at baseline and number
and length of calls. A call was considered a counselling
session if it lasted at least 5 min. AUDIT was re-
administrated at the 6-month follow-up interview. Inter-
viewers who performed the follow-up interviews were
blinded as to the participants experimental group.
Outcome definition and measures
Problematic alcohol use was measured by the Alcohol
Use Disorders Identification Test (AUDIT) [27]. AUDIT
is a validated instrument, sensitive to problematic alco-
hol use in the lower end of the spectrum [33,34]. Risk
levels were based on cut-offs described in the Swedish
AUDIT manual: low-risk use(score 05 women; 07
men), hazardous use(score 613 women; 815 men),
harmful use(score 1417 women; 1619 men), and
probable dependence(score 18 women; 20 men)
[27]. Further, the AUDIT-C was used to assess frequency
and quantity of drinking. This measure includes the first
three questions of the AUDIT instrument and has a
maximum score of 12.
The primary outcome was defined as any downward
shift in AUDIT risk level at 6 month follow-up, i.e. a
downward change in risk level compared to baseline.
An upward shift or no change in risk level was defined
as no downward change in risk level. Secondary out-
come measures were: 1) change to low risk level accord-
ing to the AUDIT cut-offs, 2) mean change in the total
AUDIT score, and 3) mean change in AUDIT-C at 6-
month follow-up, this latter representing a measure of
current alcohol use.
Statistical analysis
The analysis was carried on as a modified intention-to-
treat analyses (ITT), i.e. participants with outcome infor-
mation at 6-month follow-up were analysed according
to their randomly allocated counselling model, irrespect-
ive of the counselling received. To assess the impact of
attrition a sensitivity analysis was performed assuming
that AUDIT risk level among those lost to follow-up did
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not change or was worsened as compared to their base-
line score; and by the last observation carried forward
(LOCF) scenario, i.e. assuming that participants lost to
follow-up did not change their baseline AUDIT score.
A descriptive analysis of the implementation of the two
counselling models was also conducted. Baseline charac-
teristics of participants in the two trial groups are pre-
sented as percentages for categorical variables and as
means and standard deviations (SD) for continuous vari-
ables. The distribution of selected characteristics at base-
line in the two trial groups was reviewed in order to assess
the success of the random assignment. We used general
linear models (GLM) as we did not adjust for any covari-
ates, assuming differences in baseline characteristics to
arise by chance. The treatment effect was estimated as risk
ratio (RR) using the probability of downward change in
AUDIT risk level as the outcome (pre-specified); as well
as risk difference (RD) and 95% confidence interval (CI).
Additionally, we estimated the risk ratio (RR) and 95%
confidence interval (CI) using the probability of change to
low risk level at follow-up as the outcome. Further, we
analysed the between-groups difference in the mean
change in AUDIT and AUDIT-C score from baseline to
follow-up using a t-test. The level of conventional
statistical significance was set to p= 0.05. All analyses
were performed using Stata 14.1.
In total 1796 first time callers were screened for eligibility
during the recruitment period (see Fig. 1). Of these, 816
met the eligibility criteria and were informed about the
study, and 320 (39% of the eligible) agreed to participate
and were randomised. Out of the randomised participants,
224 participants could be followed-up for outcome infor-
mation at 6-month. In the brief structured intervention
68% were retained while 72% were retained in usual care.
Participants with missing AUDIT score (n=2) or low-risk
use (n= 2) at baseline were excluded from further analysis.
Tabl e 1shows the baseline characteristics of retained
participants by trial group, as compared to those not
followed. The not followed participants tended to be
younger and employed. Additionally, the proportion
defined as probably dependentwas higher among par-
ticipants lost to follow-up (66%) than among those who
completed the 6-month follow-up (49%), Table 2.
Tabl e 2shows that the trial groups were balanced at
baseline based on demographic characteristics with the
only exception being self-assessed general health, i.e.
Fig. 1 Flowchart over the recruitment, randomisation and follow-up
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good to excellent health was more frequently reported
in the brief structured intervention (71% vs 59%). The
readiness to change ruler (range 110), similarly indi-
cated high motivation in the two groups mean (sd);
brief structured intervention 9.3 (1.6) vs usual care 9.3
(1.2). About one-third of the sample displayed MDE or
GAD at baseline (brief structured intervention 27% vs
usual care 33%). AUDIT risk levels at baseline were
similar between the two groups. In the analytical sam-
ple it was defined as hazardous for 18% vs 21%, as
harmful for 33% vs 31% and as probable dependence
for 50% vs 48% of the participants in the brief struc-
tured intervention and usual care respectively. Add-
itional file 1display sociodemographic and health
related characteristics by trial group for the complete
In the brief structured intervention, 73% of the partici-
pants in the analytical sample received the proactive call ac-
cording to the protocol and 5% received a modified
proactive call. Among the retained participants, the mean
number (sd) of contacts recorded at the SAH was 1.8 (0.8)
in the brief structured intervention, and 3.4 (2.4) in usual
care. The time spent in counselling was on average 43 (26)
minutes in the brief structured intervention and 89 (76) mi-
nutes in the usual care.
In the group receiving the brief structured interven-
tion 68% displayed a downward shift in AUDIT risk level
at follow-up compared to 61% in the group receiving the
usual care, (Table 3). Consequently, the probability of
downward change was 12% higher in the brief structured
group than in the usual care group but the confidence
intervals included the null (RR 1.12, 95% CI 0.93 to
1.37). The mean decrease in AUDIT score was 7.9 in the
brief structured intervention and 7.1 in the usual care
group, with a between-group difference of 0.8 points
(95% CI 1.0 to 2.8) (Table 3). Regarding alcohol con-
sumption, the mean change in AUDIT C displayed no
between-group differences 0.2 (0.5 to 0.9) (AUDIT C),
(Table 3). The proportion who changed to low-risk was
30% in the brief structured intervention and 26% in the
usual care (RR 1.17, 95% CI 0.76 to 1.78), (data not
shown in the table). In the total sample 8% (n= 19) were
abstainers at follow-up, and 6% (n= 13) had changed to
a higher risk level, with no difference between the
Since the attrition was similar in the two counselling
groups the risk ratio in the alternative scenario (i.e. lost
to follow-up did not change or was worsened as com-
pared to their baseline score) was close to that obtained
in the available case ITT analysis (RR 1.08; 95% CI 0.85
to 1.38). In the LOCF scenario, the mean difference be-
tween groups remained in the same direction as in the
ITT analysis in-between group difference 0.4 points (
1.14 to 1.95).
Table 1 Sociodemographic characteristics at baseline of the followed participants by trial group, and the not followed participants
Brief structured intervention
n= 107
Usual care n= 117 Total sample n= 224 Not followed
Age (mean, sd)
48.5 ± 13.9 49.7 ± 13.8 49.1 ± 13.8 45.6 ± 13.0
Sex, n (%)
Women 31 (29.0) 29 (24.8) 60 (26.8) 36 (37.5)
Men 76 (71.0) 88 (75.2) 164 (73.2) 60 (62.5)
Employment status, n (%)
Unemployed 26 (24.5) 37 (32.2) 63 (28.5) 13 (13.7)
Employed 80 (75.5) 78 (67.8) 158 (71.5) 82 (86.3)
Education, n (%)
Primary 12 (11.4) 9 (7.8) 21 (9.6) 9 (9.4)
Secondary 33 (31.4) 50 (43.5) 83 (37.7) 45 (46.9)
Post-secondary 60 (57.1) 56 (48.7) 116 (52.7) 42 (43.8)
Living arrangement, n (%)
Living alone (yes) 26 (24.3) 27 (23.1) 53 (23.7) 18 (18.8)
Cohabiting with partner (yes) 70 (65.4) 76 (65.0) 146 (65.2) 70 (72.9)
Living with children (yes) 42 (39.3) 33 (28.2) 75 (33.5) 39 (40.6)
Social support during crisis, n (%)
Always 3 (2.8) 7 (6.0) 10 (4.5) 9 (9.4)
Occasionally 23 (21.7) 33 (28.4) 56 (25.2) 23 (24.0)
Never 80 (75.5) 76 (65.5) 156 (70.3) 64 (66.7)
Numbers may not sum up to the total because of a few missing values
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Figure 2shows the proportion of downward, up-
ward and no change in AUDIT risk zones by baseline
risk level and intervention group. Hazardous users
were more likely to shift to low-risk use in the brief
structured intervention than in the usual care group,
while the proportion downward shift in harmful and
probable dependent risk levels was similar between
treatment groups.
In this pragmatic trial of counselling at the SAH, there
was no evidence of superiority of either intervention
Table 3 Risk ratio and risk difference of transition to lower AUDIT category and change in AUDIT mean scores from baseline to 6
month follow-up, Intention to treat analysis (ITT)
AUDIT risk level at follow-up % Change in AUDIT risk level
n l II III IV % Risk ratio (95% CI) Risk difference (95% CI)
Brief structured intervention 107 29.9 40.2 13.1 16.8 68.2 1.12 (0.93 to 1.37) 0.08 (0.05 to 0.20)
Usual care 117 25.6 40.2 14.5 19.7 60.7 Reference
n Baseline mean
Follow-up mean
Mean difference (95%CI) Mean difference between groups (95% CI)
AUDIT score
Brief, structured intervention 107 19.7 (5.8) 11.7 (6.9) 7.9 (9.3 to 6.4) 0.87 (1.0 to 2.8)
Usual care 117 19.1 (5.7) 12.1 (7.3) 7.1 (8.4 to 5.7)
AUDIT C score
Brief, structured intervention 107 7.8 (2.2) 5.0 (2.8) 2.8 (3.3 to 2.3) 0.20 (0.53 to 0.92)
Usual care 117 7.6 (2.0) 5.0 (2.8) 2.6 (3.1 to 2.1)
AUDIT risk levels: I low riskII hazardous III harmful IV probable dependence
Table 2 Baseline AUDIT score and health-related characteristics of the followed (analytical sample) participants by trial group and
not followed participants
Brief structured intervention n= 107 Usual care n= 117 Total sample n= 224 Not followed n=96
AUDIT score
mean (sd) 19.6 ± 5.2 19.1 ± 5.8 19.4 ± 5.5 20.9 ± 6.0
AUDIT risk level, n (%)
a, b, d
Low risk 0 0 0 2 (2.1)
Hazardous 19 (17.8) 25 (21.4) 44 (19.6) 13 (13.8)
Harmful 35 (32.7) 36 (30.8) 71 (31.7) 17 (18.1)
Probable dependence 53 (49.5) 56 (47.9) 109 (48.7) 62 (66.0)
Readiness ruler (110) mean (sd) 9.3 ± 1.6 9.3 ± 1.2 9.3 ± 1.4 9.6 ± 1.1
MDE & GAD, n (%)
28 (26.7) 38 (33.0) 66 (30.0) 35 (37.6)
Self-assessed health, n (%)
Very poor to poor 3 (2.8) 4 (3.4) 7 (3.1) 7 (7.3)
Fair 28 (26.2) 44 (37.6) 72 (32.1) 25 (26.0)
Good to excellent 76 (71.0) 69 (59.0) 145 (64.7) 64 (66.7)
Past 6-month sick-leave, n (%)
07 days 68 (80.0) 77 (88.5) 145 (84.3) 67 (78.8)
8 days 17 (20.0) 10 (11.5) 27 (15.7) 18 (21.2)
Past 6-month help-seeking for alcohol problems, n (%)
Health care
(yes) 12 (11.3) 17 (14.5) 29 (13.0) 19 (19.8)
Other care (yes) 7 (6.5) 10 (8.5) 17 (7.6) 14 (14.6)
Medication for alcohol dependence (yes) 5 (4.7) 9 (7.7) 14 (6.3) 9 (9.4)
Number may not sum up to the total because of a few missing values
AUDIT score (women; men) 1 (05; 07), 2 (613; 815) 3 (1417; 1619) 4 (1840;2040)
Major depressive episode and generalized anxiety disorder
n= 94, including baseline AUDIT scores below the threshold for hazardous use (n=2)
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(brief structured intervention or usual care) towards the
other. However, the results of the downward shift in
AUDIT risk level indicated a trend in favour of the
less labour intensive structured intervention. Both
groups in this trial reduced their AUDIT risk levels
indicating reductions in hazardous and harmful alco-
hol use over time. Overall, about 2/3 of the partici-
pants changed to a lower AUDIT risk level, and
about 1/3 changed to low-risk in the two counselling
groups at 6 months follow-up.
Population-based telephone helplines are nowadays
widely implemented for the counselling of problematic al-
cohol use. However, scientific evaluations of their potential
to change alcohol consumption are rare [23], and have
mainly described the services [35], or been observational
[24,35]. While the effectiveness of telephone counselling in
smoking cessation is well-documented [36], we found only
one comparable trial aiming to evaluate a population-based
telephone counselling for problematic alcohol use [16]. In
contrast to our findings, Signor et al. found that brief MI
counselling was more effective than the control condition
(self-help booklet combined with brief advice) for abstin-
ence at 6 months follow-up (70% vs 41%). However, this
study suffered from high attrition (77%); also, the partici-
pants had severe alcohol problems at inception and often
reported the concurrent use of illicit drugs [16].
Our study indicated that a brief structured intervention
including a self-help material and one proactive call might
be as beneficial as the more counselling intensive counter-
part. Bibliotherapy is a recognised method to reduce alco-
hol consumption [37,38], especially when coupled with
feedback sessions [39,40]. However, a recent study found
no additional effects by adding MI telephone sessions to
bibliotherapy alone among self-referred problematic alco-
hol users, without severe dependence [41]. In this study,
interventions led to similar reductions in alcohol use, with
constant improvements seen between post-treatment and
12 months. However, the sample size was small (n=111),
thus differences between groups may have not been de-
tected [41]. With the exception of these studies, telephone
counselling for problematic alcohol use has primarily been
studied in RCTs of clinical populations identified by
screening interventions in healthcare settings including
participants with lower problem severity than among cli-
ents contacting the SAH [18,19].
There are several potential explanations of the null find-
ing in this study. First, the effect of the two counselling
models might truly be comparable. In fact, many clients
calling the SAH are likely to be highly motivated to change
their behaviour, and probably already started the process of
change before the first contact. Highly motivated individ-
uals may benefit from a structured intervention that offers
planning and support to implement personal strategies to
reach their goals. Second, at the initial contact, many partic-
ipants were screened for alcohol use and received assess-
ment feedback from a counsellor, which might have
enhanced motivation and thus constitute an active inter-
vention component per se. Thus, the effect might be due to
assessment reactivity rather than the added intervention
components [42,43]. Third, the low sample size may have
entailed low power to detect small differences between
groups as statistically significant.
Despite that the intended target population of the
SAH consists of problematic alcohol users at the lower
Fig. 2 Change in AUDIT risk level (%) between baseline and 6 month follow-up, by intervention group
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
end of the spectrum [26], a high proportion of partici-
pants was classified as probably dependent at baseline,
reflecting the average level of problematic alcohol con-
sumption in SAH clients overall. Similar to previous
studies, the attrition was related to the severity of prob-
lematic drinking [44]. This suggests that clients with
probable dependencewould benefit from other support
strategies than those offered at the helpline.
Strengths and limitations
The retention in this study was reasonably high com-
pared to previous studies in the field [16,45], with no
differential loss to follow-up between the two counsel-
ling groups. The similar retention between experimental
groups, besides reassuring about selection bias also sug-
gests that both counselling models were acceptable to
many of the SAH clients. The study protocol was imple-
mented as planned, and the delivery of the brief, struc-
tured intervention was ascertained by regular meetings
between the employees at SAH and the study team. Fur-
ther, the personnel conducting the interviews were not
part of the SAH and blinded to the clients group assign-
ment. The random allocation was concealed.
Limitations of this study include the low recruitment
rate, as only 46% of first-time callers were assessed as
eligible. This was due to a service-basedscreening,
which left great freedom of decision to each counsellor
at the SAH. In fact, counsellors assessed the eligibility of
each caller not only based on the pre-defined criteria,
but also taking into account the complexity of the prob-
lem presented by the individual at the moment of the
call. For instance, clients who were too emotionally dis-
turbed at the time of the call, or who reported serious
social consequences of their drinking calling for immedi-
ate actions, such as involvement of minors were judged
unreceptive to questions about the study, therefore dis-
carded as not eligible. Of the eligible and only 39% par-
ticipated. Besides resulting in a small sample size, this
selection certainly limits the generalizability of the re-
sults. However, age and alcohol use profile of the partici-
pants in this study were comparable to those of the
overall SAH clients [26].
Some contamination of the experimental groups may
have occurred since the counsellors interacting with the
clients were the same in both groups. However, the aver-
age number and length of the sessions were substantially
higher in the usual care group, confirming that the brief,
structured intervention was less labour intensive, as ex-
pected. Additionally, the documentation of the content
in the proactive call did not indicate major deviations
from the study protocol. As in most trials of behavioural
modification the endpoints in this study rely on self-
reported data, thus are potentially prone to information
bias. However, the follow-up assessment was conducted
by interviewers not involved in the counselling, which
should at least limit the risk of socially desirable reports.
The main outcome measure AUDIT has traditionally
been scored as a three-factor screening instrument, how-
ever a review of studies support a two factor model; pat-
terns of intake/consumption (item 13) and alcohol
problems (item 49) [46]. Therefore a change in the
AUDIT score may not necessarily depend on changes in
alcohol consumption, which is instead captured by the
AUDIT-C subscale. This was included as an additional
sensitivity analysis, yielding results in line with those ob-
tained from the complete AUDIT.
As this was a trial enrolling callers who sought help for
alcohol use at a well-established service, a no-treatment
control condition was considered unethical. Therefore,
the conclusions of this study apply to the model of the
counselling, and not to the effectiveness of the helpline in
comparison with other counselling settings or a no-
treatment control group.
A brief structured intervention did achieve favourable
changes in problematic alcohol use among clients of the
Swedish National Alcohol Helpline that were similar to
those of a more labour intensive MI-based telephone
counselling. Both approaches were followed by significant
changes in clientsAUDIT risk levels, comparable to the
effect of other interventions. The results suggest that both
approaches are feasible and acceptable for clients seeking
help at the helpline.
Additional file
Additional file 1: Table S1. Baseline characteristics by trial group.
Table S2. Baseline AUDIT score and health-related characteristics by trial
group. Sociodemographic characteristics Baseline AUDIT score and
health-related characteristics of the participants at baseline by trial group,
total sample. (DOCX 17 kb)
AUDIT: Alcohol Use Disorders Identification Test; CBT: Cognitive behavioral
therapy; CI: Confidence interval; GAD: Generalized anxiety disorder;
M.I.N.I.: Mini-international neuropsychiatric interview; MDE: Major depressive
episodes; MI: Motivational Interviewing; RD: Risk difference; RR: Risk ratio;
SAH: Swedish National Alcohol Helpline; Sd: Standard deviation
We want to thank the counsellors at the Swedish National Alcohol helpline
for their effort in recruiting clients, as well as all the SAH clients who
participated in the study. Further, we would like to thank the former project
coordinator Suvi Virtanen for her great efforts at the study start-up.
MRG conceived and designed the study and critically revised the manuscript.
ES performed the statistical analyses, interpreted the data and drafted the
manuscript. YF, MR and KDT provided technical advice and participated in
the interpretation and the discussion of the results. All authors read and
approved the final version of the manuscript.
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
The study was supported by the Public Health Agency of Sweden (grant No.
055762014-6.2), and SRA Systembolagets råd för alkoholforskning (grant No.
45/2018). The funders had no role in study design, data collection and
analysis, interpretation of data, writing of the manuscript or decision to
Availability of data and materials
The datasets generated and/or analysed during the current study are not
publicly available due to ethical reasons but are available from the
corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approval was permitted by the Ethical Review Board of the
Stockholm region (DNR 2014/173231/5). Consent to participate was
obtained verbally by interviewers. In order to respect the participants wish
to not disclose their contact with the helpline in their social environment,
and also in order to minimize non-response. The consent procedure was ap-
proved by the Ethical Review Board. All participants gave their consent to
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
Department of Public Health Sciences, Karolinska Institutet, 171 77
Stockholm, Sweden.
Centre for Epidemiology and Community Medicine,
Stockholm Health Care District, Stockholm County Council, 104 31
Stockholm, Sweden.
Department of Clinical Neuroscience, Karolinska
Institutet, 171 77 Stockholm, Sweden.
The Swedish Council for Information
on Alcohol and Other Drugs (CAN), 107 25 Stockholm, Sweden.
Received: 2 December 2018 Accepted: 25 June 2019
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... A total of 7149 participants, among 19 RCTs, were included in the systematic review [37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55]. The average age of participants was showed that 65% (n = 85) and 25% (n = 69) of participants had a family history, respectively [38,47]. ...
... A summary of the risk of bias assessment is provided in Supporting information, Appendix S12. Of the 19 studies included in the systematic review, 11 were found to be low risk [40-44, 46, 47, 49, 50, 52, 53], four high risk [37,39,45,51] and four wunclear risk of bias [38,48,54,55]. Of the four overall high-risk studies, two had incomplete data [39,51] and two did not adequately protect against contamination [37,45]. ...
... Of the four overall high-risk studies, two had incomplete data [39,51] and two did not adequately protect against contamination [37,45]. The four studies with overall unclear risk were due to incomplete outcome data [38] and inadequately protecting against contamination [55]. Barticevic (2021) [40] Baseline AUDIT scores and risk status of participants were reviewed with normative feedback which aligned with content in an alcohol leaflet. ...
Background and aims: Psychosocial approaches are the hallmark of treatment for harmful alcohol use. However, the most effective psychosocial intervention has not been identified. We aimed to compare the effectiveness of psychosocial therapy for harmful alcohol use using a network meta-analysis approach. Methods: We searched PubMed, Embase, CENTRAL, CINAHL and ProQuest Dissertations & Theses from inception to January 2022. Randomized controlled trials in adults age >18 years with harmful alcohol use were included. Psychosocial interventions were classified using the Theme, Intensity, and Provider/Platform (TIP) framework. The mean differences (MD) of the Alcohol Use Disorder Identification Test (AUDIT) score were estimated in the primary analysis using a random-effects model. Surface under the cumulative ranking curve (SUCRA) methods were used to rank different interventions. The certainty of evidence was evaluated using the Confidence in Network Meta-Analysis (CINeMA) approach. This review was registered with PROSPERO (CRD42022328972). Results: 4,225 records were retrieved from searching; 19 trials (n=7,149) met the inclusion criteria. The most common TIP combination was brief interventions delivered once via face-to-face sessions (6 studies) and 11 TIP features were included in the network meta-analysis. A significant difference in AUDIT score was evident among 16 out of 55 treatment comparisons, with the highest effect size observed when motivational interviewing plus cognitive behavioral therapy in multiple sessions via face-to-face (MI-CBT/Mult/F2F) was compared with usual care (MD: -4.98; 95% confidence interval [CI]: -7.04, -2.91). This finding was consistent with SUCRA, which suggested that MI-CBT/Mult/F2F is most likely to be better than other interventions (SUCRA=91.3). MI-CBT/Mult/F2F remained the highest-ranking intervention in our sensitivity analyses (SUCRA=64.9, 80.8). However, the certainty of evidence for most treatment comparisons was low. Conclusions: Combined psychosocial intervention with more intensive approach may provide greater effect in reducing harmful alcohol consumption behavior.
... The main hypothesis was that the effectiveness of the two counselling modes would not differ, thus making the brief intervention potentially more cost-effective compared with the multi-session intervention. The results at six-month follow-up have been reported (Safsten et al., 2019). This article presents results after 12 months of follow-up, focusing on both concurrent and sustained behavioural changes. ...
... Likewise, outcome assessment at follow-up was conducted by interviewers blinded to the participants' group allocation. Further details on methods of data collection can be found in previous publications (Safsten et al., 2019;Säfsten et al., 2017). ...
... The selected sample of participants in this study imposes caution about the generalisability of the results. While participants in this study were largely representative of the clients calling the SAH (Safsten et al., 2019) they presented a more problematic alcohol use than could be expected from the general population prevalence. Motivation to change was probably higher in this sample than in a general population of problematic drinkers. ...
Full-text available
Aim This two-arm parallel randomised controlled trial explored the effectiveness of a brief counselling model compared with the usual multi-session counselling at an alcohol telephone helpline. Methods A total of 320 callers who contacted the Swedish Alcohol Helpline (SAH) because of hazardous or harmful alcohol use were randomised to either brief structured intervention (self-help booklet plus one proactive call) or usual care (multi-session telephone counselling). The primary outcome was a downward shift in risk level at 12-month follow-up compared with baseline, based on self-reports. Sustained risk level reduction throughout the whole follow-up was also assessed as secondary outcome. Results Both interventions were significantly associated with a shift to a lower level of risky alcohol use (75% among participants in the brief structured intervention, and 70% in the usual care group) after 12 months. There was no difference between the two interventions in the proportions changing alcohol use or sustaining risk level reduction. Conclusion In the context of telephone helplines, minimal and extended interventions appear to be equally effective in promoting long-term change in alcohol use.
... Säfsten and colleagues report a superiority trial comparing two counselling models delivered via a national alcohol helpline [1]. Their efforts are laudable given the need for effective countermeasures to the heavy burden of alcohol in Sweden and globally [2]. ...
... Their finding was that among participants who provided follow-up data six months after randomisation, 61% of those allocated to receive usual care (reactive telephone counselling) versus 68% of those allocated to receive a novel intervention (less labour intensive telephone counselling with proactive elements), had AUDIT scores that placed them in the 'low-risk drinking' category [1]. Effect estimates expressed as a risk ratio (RR = 1.12; 95% CI: 0.93, 1.37), and a risk difference (RD = 0.08, 95%CI: − 0.05, 0.20), were judged as "[not showing] clear superiority for either counselling model". ...
... "A brief structured intervention did achieve favourable changes in problematic alcohol use … similar to those of a more labour intensive MIbased telephone counselling" [1] (p. 8) In addition to drawing an inference that extends beyond what a superiority trial can support, Säfsten and colleagues appear to have overlooked the simplest explanation for the "significant changes in clients' AUDIT risk levels" [1] (p.8) they observed, namely, regression to the mean [4]. ...
Full-text available
Abstract In medicine, it is common to observe improvement after intervention, at least partly because patients present for care in extremis and would have improved without intervention. Controlling for this counterfactual explanation for improvement is the principle reason to conduct a trial in which patients are randomised to treatment or a control group. Accordingly, it is not reasonable to infer that both interventions are effective when the groups show similar improvements in outcome.
... With regard to other online interventions studies Smoktunowicz et al., 2019), we expected a high dropout rate, therefore we decided to qualify a sample of 141 participants, according to baseline conditions. Because of expected high dropout rate as well as approach of prototyping the blended intervention, willingness of participants, and testing in real-life, we decided to use pragmatic trial (Patsopoulos, 2011;Ford and Norrie, 2016;Säfsten et al., 2019;Zvonareva, 2021). ...
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Generally, the solutions based on information and communication technologies (ICT) provide positive outcomes for both companies and employees. However, the process of digital transformation (DT) can be the cause of digital transformation stress (DTS), when the work demands caused by fast implementation of ICT are elevated and employees’ resources are limited. Based on the Job Demand-Resources (JD-R) Model we claim that DT, rapidly accelerating in the COVID-19 pandemic, can increase the level of DTS and general stress at work. To reduce these negative effects of DTS, we propose the online intervention aimed to strengthen employees’ resources, such as self-efficacy. In this article we evaluate the effectiveness of the blended intervention, based on cognitive behavioral therapy (CBT) and social cognitive therapy, composed of a prototyped online training (e-stressless) and series of interactive online workshops. In a longitudinal study, we examined the change in DTS, perceived stress at work, attitudes toward DT, self-efficacy and burnout in two time points, before and after the intervention. We compared five groups of participants (558 in total), three groups not qualified (n = 417), and two groups qualified to intervention (n = 141). Our results revealed that the designed blended intervention decreased DTS and one of the dimensions of burnout, namely disengagement. More specifically, the results showed that in the group of active participants of the blended intervention DTS significantly decreased [MT1 = 3.23, MT2 = 3.00, t(432) = 1.96, p = 0.051], and in the group of ineligible participants DTS significantly increased [MT1 = 1.76, MT2 = 2.02, t(432) = 4.17, p < 0.001]. This research paves way for the creation of blended online intervention which could help in addressing employee digital transformation stress before it starts having adverse effects on employee performance and well-being.
Introduction: To help reduce relapse rates following alcohol and other drug (AOD) treatment, continuing care interventions have been recommended. Previous continuing care interventions have incorporated telephone and face-to-face sessions to help promote participant engagement. The study was conducted as a randomised controlled feasibility study and examined a call centre delivered continuing care intervention for people leaving residential rehabilitation services. Methods: Participants were attending AOD residential treatment services in NSW, Australia (N = 154). Participants were randomised to either 12- or 4-sessions of continuing care. Follow up assessments were completed at 6-months. The primary outcomes were demand and implementation. Secondary outcomes were AOD use, mental health and physical health at 6-months. Results: Interest in continuing care was high, with 93% of participants approached reporting an interest in being involved. Of the participants who completed the consent and baseline procedures, 29% of people were contacted post residential treatment and randomised. For those people randomised, the average number of sessions completed was 2.78 (SD = 1.65) for the 4-session arm and 4.81 (SD = 4.46) for the 12-session arm. Fidelity to the treatment manual was high. Both treatment arms showed higher complete abstinence at 6-months compared to baseline (12-session OR 28.57 [2.3, 353.8]; 4-session OR 28.11 [3.6, 221.2]). Discussion and conclusions: A major challenge associated with the call centre approach was re-engaging participants once they left the residential facility and delivering the planned dose of treatment. Further work is required to promote greater uptake of these protocols once people leave residential treatment.
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Background: Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007. Objectives: To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews. Selection criteria: We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review. Data collection and analysis: We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption. Main results: We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment. Authors' conclusions: We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.
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Objective The primary objective was to evaluate 6-month outcomes for brief and extensive automated telephony interventions targeting problematic alcohol use, in comparison to an assessment-only control group. The secondary objective was to compare levels of problematic alcohol use (hazardous, harmful or probable dependence), gender and age among study participants from clinical psychiatric and addiction outpatient settings and from population-based telephone helpline users and Internet help-seeker samples. ResultsThe Alcohol Use Disorders Identification Test (AUDIT) was used for screening of problematic alcohol use and 6-month follow-up assessment. A total of 248 of help-seekers with at least hazardous use (AUDIT scores of ≥ 6/≥ 8 for women/men) were recruited from clinical and general population settings. Minor recruitment group differences were identified with respect to AUDIT scores and age at baseline. One hundred and sixty persons (64.5%) did not complete the follow-up assessment. The attrition group had a higher proportion of probable dependence (71% vs. 56%; p = 0.025), and higher scores on the total AUDIT, and its subscales for alcohol consumption and alcohol problems. At follow up, within-group problem levels had declined across all three groups, but there were no significant between-group differences.Trial registration NCT01958359, Registered October 9, 2013. Retrospectively registered
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Background: Excessive alcohol use contributes significantly to physical and psychological illness, injury and death, and a wide array of social harm in all age groups. A proven strategy for reducing excessive alcohol consumption levels is to offer a brief conversation-based intervention in primary care settings, but more recent technological innovations have enabled people to interact directly via computer, mobile device or smartphone with digital interventions designed to address problem alcohol consumption. Objectives: To assess the effectiveness and cost-effectiveness of digital interventions for reducing hazardous and harmful alcohol consumption, alcohol-related problems, or both, in people living in the community, specifically: (i) Are digital interventions more effective and cost-effective than no intervention (or minimal input) controls? (ii) Are digital interventions at least equally effective as face-to-face brief alcohol interventions? (iii) What are the effective component behaviour change techniques (BCTs) of such interventions and their mechanisms of action? (iv) What theories or models have been used in the development and/or evaluation of the intervention? Secondary objectives were (i) to assess whether outcomes differ between trials where the digital intervention targets participants attending health, social care, education or other community-based settings and those where it is offered remotely via the internet or mobile phone platforms; (ii) to specify interventions according to their mode of delivery (e.g. functionality features) and assess the impact of mode of delivery on outcomes. Search methods: We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, ERIC, HTA and Web of Knowledge databases; and WHO ICTRP trials registers and relevant websites to April 2017. We also checked the reference lists of included trials and relevant systematic reviews. Selection criteria: We included randomised controlled trials (RCTs) that evaluated the effectiveness of digital interventions compared with no intervention or with face-to-face interventions for reducing hazardous or harmful alcohol consumption in people living in the community and reported a measure of alcohol consumption. Data collection and analysis: We used standard methodological procedures expected by The Cochrane Collaboration. Main results: We included 57 studies which randomised a total of 34,390 participants. The main sources of bias were from attrition and participant blinding (36% and 21% of studies respectively, high risk of bias). Forty one studies (42 comparisons, 19,241 participants) provided data for the primary meta-analysis, which demonstrated that participants using a digital intervention drank approximately 23 g alcohol weekly (95% CI 15 to 30) (about 3 UK units) less than participants who received no or minimal interventions at end of follow up (moderate-quality evidence).Fifteen studies (16 comparisons, 10,862 participants) demonstrated that participants who engaged with digital interventions had less than one drinking day per month fewer than no intervention controls (moderate-quality evidence), 15 studies (3587 participants) showed about one binge drinking session less per month in the intervention group compared to no intervention controls (moderate-quality evidence), and in 15 studies (9791 participants) intervention participants drank one unit per occasion less than no intervention control participants (moderate-quality evidence).Only five small studies (390 participants) compared digital and face-to-face interventions. There was no difference in alcohol consumption at end of follow up (MD 0.52 g/week, 95% CI -24.59 to 25.63; low-quality evidence). Thus, digital alcohol interventions produced broadly similar outcomes in these studies. No studies reported whether any adverse effects resulted from the interventions.A median of nine BCTs were used in experimental arms (range = 1 to 22). 'B' is an estimate of effect (MD in quantity of drinking, expressed in g/week) per unit increase in the BCT, and is a way to report whether individual BCTs are linked to the effect of the intervention. The BCTs of goal setting (B -43.94, 95% CI -78.59 to -9.30), problem solving (B -48.03, 95% CI -77.79 to -18.27), information about antecedents (B -74.20, 95% CI -117.72 to -30.68), behaviour substitution (B -123.71, 95% CI -184.63 to -62.80) and credible source (B -39.89, 95% CI -72.66 to -7.11) were significantly associated with reduced alcohol consumption in unadjusted models. In a multivariable model that included BCTs with B > 23 in the unadjusted model, the BCTs of behaviour substitution (B -95.12, 95% CI -162.90 to -27.34), problem solving (B -45.92, 95% CI -90.97 to -0.87), and credible source (B -32.09, 95% CI -60.64 to -3.55) were associated with reduced alcohol consumption.The most frequently mentioned theories or models in the included studies were Motivational Interviewing Theory (7/20), Transtheoretical Model (6/20) and Social Norms Theory (6/20). Over half of the interventions (n = 21, 51%) made no mention of theory. Only two studies used theory to select participants or tailor the intervention. There was no evidence of an association between reporting theory use and intervention effectiveness. Authors' conclusions: There is moderate-quality evidence that digital interventions may lower alcohol consumption, with an average reduction of up to three (UK) standard drinks per week compared to control participants. Substantial heterogeneity and risk of performance and publication bias may mean the reduction was lower. Low-quality evidence from fewer studies suggested there may be little or no difference in impact on alcohol consumption between digital and face-to-face interventions.The BCTs of behaviour substitution, problem solving and credible source were associated with the effectiveness of digital interventions to reduce alcohol consumption and warrant further investigation in an experimental context.Reporting of theory use was very limited and often unclear when present. Over half of the interventions made no reference to any theories. Limited reporting of theory use was unrelated to heterogeneity in intervention effectiveness.
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This study investigated the relative effects of 3 12-week secondary prevention interventions for problem drinking men and women in rural counties in New York State. The participants were 111 self-referred men and women without severe dependence on alcohol who nevertheless reported heavy drinking and a desire to reduce their alcohol consumption. They were assigned randomly to 1 of 3 12-week interventions focused on reducing alcohol intake: bibliotherapy (a self-directed manual) alone, bibliotherapy with 1 telephone-administered motivational interview, or bibliotherapy with 1 telephone-administered motivational interview and 6 biweekly telephone therapy sessions. Results showed that, across conditions, participants significantly increased their abstinent and light drinking days and significantly decreased their heavy drinking days over the course of treatment and a 12-month follow-up period. In addition, participants reported moderate reductions in alcohol consequences and increases in confidence not to drink heavily across a variety of situations from pre- to posttreatment, with these changes remaining stable across the course of the follow-up. Use of the drinking reduction strategies presented in the self-directed manual also remained stable from posttreatment to the 12-month follow-up. These results provide support for consideration of bibliotherapy for rural problem drinkers who are not severely dependent on alcohol, with or without the addition of telephone contacts.
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Background Systematic reviews of alcohol screening and brief interventions (ASBI) highlight the challenges of implementation in healthcare and community-based settings. Fewer reviews have explored this through examination of qualitative literature and fewer still focus on interventions with younger people. Methods This review aims to examine qualitative literature on the facilitators and barriers to implementation of ASBI both for adults and young people in healthcare and community-based settings. Searches using electronic data bases (Medline on Ovid SP, PsychInfo, CINAHL, Web of Science, and EMBASE), Google Scholar and citation searching were conducted, before analysis. Results From a total of 239 papers searched and screened, 15 were included in the final review; these were selected based on richness of content and relevance to the review question. Implementation of ASBI is facilitated by increasing knowledge and skills with ongoing follow-up support, and clarity of the intervention. Barriers to implementation include attitudes towards alcohol use, lack of structural and organisational support, unclear role definition as to responsibility in addressing alcohol use, fears of damaging professional/ patient relationships, and competition with other pressing healthcare needs. Conclusions There remain significant barriers to implementation of ASBI among health and community-based professionals. Improving the way health service institutions respond to and co-ordinate alcohol services, including who is most appropriate to address alcohol use, would assist in better implementation of ASBI. Finally, a dearth of qualitative studies looking at alcohol intervention and implementation among young people was noted and suggests a need for further qualitative research.
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Background Hazardous and harmful consumption of alcohol is a leading cause of preventable disease and premature deaths. Modifying the amount and pattern of risky alcohol consumption conveys substantial benefits to individuals and to society at large. Telephone helplines provide a feasible alternative to face-to-face counselling in order to increase the reach of brief interventions aiming at modifying the hazardous and harmful use of alcohol. However, there is a lack of studies on the implementation and evaluation of population-based telephone services for the prevention and treatment of alcohol misuse. Methods/design A randomised controlled trial was designed to compare a brief, structured intervention to usual care within the Swedish National Alcohol Helpline (SAH), concerning their effectiveness on decreasing the hazardous use of alcohol. Between May 2015 and December 2017, about 300 callers are to be individually randomised with a 1:1 ratio to a brief, structured intervention (n = 150) or to usual care (n = 150). The brief, structured intervention consists of the delivery of a self-help booklet followed by one proactive call from SAH counsellors to monitor and give feedback about the client’s progression. Callers assigned to usual care receive telephone counselling according to existing practice, i.e., motivational interviewing in a tailored and client-driven combination of proactive and reactive calls. The primary outcome is defined as a change from a higher to a lower AUDIT risk-level category between baseline and follow-up. General linear modeling will be used to calculate risk ratios of the outcome events. The primary analysis will follow an intention-to-treat (ITT) approach. Discussion The trial is designed to evaluate the effectiveness in decreasing the hazardous and harmful consumption of alcohol of a brief, structured intervention compared to usual care when delivered at the SAH. The results of the study will be used locally to improve the effectiveness of the service provided at the SAH. Additionally, they will expand the evidence base about optimal counselling models in population-based telephone services for alcohol misuse prevention and treatment. Trial registration, ID: ISRCTN13160878. Retrospectively registered on 18 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2005-5) contains supplementary material, which is available to authorized users.
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Background While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention. Methods We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check. Results 52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=−0.23, 95% CI (−0.33 to −0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=−0.20, 95% CI (−0.30 to −0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time. Conclusions ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.
Babor, T., & Robaina, K. (2016). The Alcohol Use Disorders Identification Test (AUDIT): A review of graded severity algorithms and national adaptations. The International Journal Of Alcohol And Drug Research, 5 (2), 17-24. doi: Aims: Since it was first released in 1989, the Alcohol Use Disorders Identification Test (AUDIT) has generated a large amount of research to evaluate its psychometric properties. The purpose of this review is to critically evaluate the literature relevant to applications of the AUDIT in screening, brief intervention, and treatment referral programs, and identify national adaptations of the AUDIT to country-specific health, education, and reimbursement needs. Methods: Methods comprised a search of the world literature published since 2004, combined with review articles published since 1997. Findings: We identified 431 studies of the AUDIT, including 386 articles, 26 review papers, and 11 book chapters since 2004, with a six-fold increase in the last decade. The factor structure of the AUDIT items remains unclear, but the weight of evidence supports a two-factor model. Despite the translation of the AUDIT into numerous languages, the alcohol consumption questions were rarely adapted to suit cultural or national conditions. Although numerous studies have supported the recommended cutoff thresholds for a possible alcohol use disorder, only three studies evaluated the classification accuracy of the AUDIT’s graded severity system. Conclusions: Further development of the AUDIT score’s severity zones is needed to guide intervention selection in clinical settings.