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Alcohol brief interventions: how can content, provider and setting reduce alcohol consumption?

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Alcohol brief interventions (ABIs) provide structured advice on alcohol use. They involve an assessment of individual risk with feedback and advice, brief motivational interviewing, or a combination of these techniques.

While the Government’s Alcohol Strategy (HM Government, 2012) recommends that ABIs be implemented increasingly inprimary care settings and accident and emergency (A&E) departments, the National Institute for Health and Care Excellence (NICE) calls for alcohol brief interventions to be offered by a range of practitioners and in a range of different settings.

Given national-level support for increasing and wider use of ABIs, this systematic review and multi-level meta-regression by Platt and colleagues assessed the effectiveness of ABIs on alcohol consumption and how effectiveness of ABIs differs by:

  1. Content of intervention,
  2. Provider group and
  3. Setting.
Alcohol brief interventions usually involve a combination of risk assessment, feedback, advice and brief motivational interviewing.

Alcohol brief interventions usually involve a combination of risk assessment, feedback, advice and brief motivational interviewing.

Methods

Studies were peer-reviewed randomised controlled trials (RCTs) where participants were randomly allocated to a control group (such as treatment as usual) or a group which received an alcohol brief intervention.

Brief interventions were defined as person-to-person discussions on alcohol, with between 1 and 4 sessions and a total of 2 hours intervention time. ABIs which were delivered in groups or via a computer were excluded as were those which included participants with complex health problems where it is difficult to generalise findings to the general population.

The primary outcome measure was a quantitative continuous measure of total alcohol consumption, reported as the standardised mean difference between ABI group and control group measured at follow-up. The authors also examined how ABIs influenced the frequency of alcohol consumption.

Different types of setting, provider and content were examined and these are shown (along with the number of studies in each category) in the Results section below.

A multi-level meta-analysis method was used, which allowed the authors to include a number of different effect sizes from individual studies (i.e. amount of alcohol consumed per unit of time and/or amount of alcohol consumed per drinking occasion) rather than just trying to selecting one comparable effect size for each study).

Results

Study characteristics

50 studies were included in the analyses, with 29,891 individuals contributing data. 45% of studies were conducted in the USA and 22% in the UK.

The percentage of studies which examined alcohol brief interventions with different types of content, providers and settings are shown below:

Intervention content:

  1. Motivational interviewing (MI) (48%)
  2. Enhanced motivational interviewing (MI+) (40%)
  3. Brief advice approaches (24%)

Intervention providers:

  1. Counselors (44%)
  2. General practitioners (22%)
  3. Nurses (18%)
  4. Different providers (12%)
  5. Peer-delivered (4%)

Setting of intervention delivery:

  1. Primary or ambulatory care in clinical settings such as outpatient services (38%)
  2. A&E services (20%)
  3. University (20%)
  4. Community-based delivery (12%)
  5. Hospital inpatient services (10%)

Quality of the evidence

71% of studies were classified as having a low risk of bias regarding randomisation and allocation concealment strategies. However, the method of allocation concealment was unclear in most of the studies. An intention-to-treat analysis was conducted in 47% of the studies and loss to follow-up was assessed in 80% of studies.

The overall impact of ABIs as compared with control conditions

ABIs reduced alcohol consumption by -0.15 SDs (95% confidence interval (CI) = -0.20 to -0.10) a result the authors describe as a ‘small but statistically significant effect’. However, the extent to which this is clinically meaningful is less clear.

Note: The authors present the effect sizes as SDs because they have summarised their data as standardised mean differences. This method is used when included studies all assess the same outcome, but measure it in a variety of ways. Although this makes sense statistically, it does make understanding how important these effects are clinically a little more difficult.

The authors found that this effect persisted after controlling for covariates and when conducting sensitivity analyses. The studies included in this analysis were found to have a small to medium level of heterogeneity (I2 = 37%; this figure is the percentage of variation between trials which is due to actual variation between studies as opposed to variation due to chance. A small I2 value means that the majority of the differences observed between studies was due to chance).

ABIs reduced frequency of alcohol consumed by a similar amount (-0.15 SDs, 95% CI = -0.20 to -0.11).

Content

Splitting studies by ABI content didn’t reduce the heterogeneity between studies (I2 = 39%: no, or little change in this I2 value from when all studies are considered together (I2 = 37%) indicates that this categorisation by content does not adequately explain the heterogeneity between studies).

However, it did appear that all content types were effective at reducing amount of alcohol consumed, and there was some evidence that while brief advice is more effective than MI or MI+ for amount of alcohol consumed, brief advice did not appear to reduce the frequency of consumption while MI and MI+ did.

Providers

Splitting studies by ABI provider was not found to reduce the heterogeneity between studies (I2 = 34%).

ABIs delivered by a range of different providers or by peers were not found to be effective at reducing amount consumed or frequency of consumption (although it’s important to note that very few studies were included in these categories).

There was evidence that interventions delivered by counselors, physicians and nurses were effective, with those delivered by nurses the most effective (-0.23 SDs amount consumed, 95% CI = -0.33 to -0.13).

Setting

Splitting studies by ABI setting didn’t reduce the heterogeneity between studies (I2 = 34%).

There was no evidence that ABIs delivered in hospital inpatient services and in community settings were effective in reducing either amount or frequency of alcohol consumed.

Interventions delivered in A&E, ambulatory care settings and in universities were found to reduce alcohol both amount and frequency of alcohol consumed.

This review suggests that alcohol brief interventions have a ‘small but statistically significant effect’, but it's unclear whether or not this is clinically meaningful.

This review suggests that alcohol brief interventions have a ‘small but statistically significant effect’, but it’s unclear whether or not this is clinically meaningful.

Conclusions

The authors conclude that their study provides:

important new evidence on how the effectiveness of brief alcohol interventions differs by setting, provider and content.

While this analysis does show that ABIs reduce amount of alcohol consumed and frequency of consumption, the size of this effect is small. It will be important to determine to what extent this is a clinically meaningful effect.

Although the authors claim that their findings suggest that the “provider of interventions may matter” (with nurses providing the best results) there is only weak evidence for this. As the categorisation of studies by provider (and setting and content for that matter) didn’t really have any impact on the heterogeneity (as measured by I2) between studies, there is little evidence that the effectiveness of ABIs differed meaningfully across providers.

Interventions delivered by nurses appeared the most effective, although further work is needed to confirm this finding.

Interventions delivered by nurses appeared the most effective, although further work is needed to confirm this finding.

Strengths and limitations

Strengths

As the authors used a multi-level meta-analysis, they were able to include all relevant outcomes into their analysis, rather than just picking one outcome (and consequently having to exclude studies which did not assess this outcome). This is also likely to have reduced study level heterogeneity.

Limitations

As the authors were interested in the difference in effectiveness of a range of different ABI settings, providers and contents, the number of studies included within each of these categories was small. This makes drawing firm conclusions regarding the effectiveness of particular forms of ABIs difficult.

Implications

Given that there is little evidence to suggest that the effectiveness of alcohol brief interventions differs meaningfully according to setting, provider or content, the authors do note that this indicates that resources should be allocated to those settings, providers and contents where ABIs are likely to be most cost-effective and feasible.

For example, A&E may not be the best setting for ABIs given the lack of privacy, the brevity of the visit and the fact that the patient is likely to be suffering from a severe injury at the time.

Nurses are likely to be well placed to provide ABIs given their repeated contact with patients, although appropriate training should be provided to nurses so that they can embed these practices into their care.

Focusing on interventions that are feasible and cost-effective seems like the biggest practical advice from this evidence.

Focusing on interventions that are feasible and cost-effective seems like the biggest practical advice from this evidence.

Links

Primary paper

Platt L, Melendez-Torres GJ, O’Donnell A, Bradley J, Newbury-Birch D, Kaner E, et al. (2016) How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis. BMJ Open. 2016;6(8).

Other references

HM Government (2012) The Government’s Alcohol Strategy PDF. CM 8336, March 2012.

Photo credits

Teaming up to improve the Psychology PhD

by David Troy @DavidTroy79 and Jim Lumsden @jl9937

Human beings are social creatures; we evolved to work together. Our education system is built around this fact; and throughout school and university we encourage students to team up to solve problems, discuss concepts and answer questions. At the same time, as science advances into the 21st century, we find ourselves trying to answer increasingly difficult questions. These new problems cannot be effectively addressed by one person working alone, and academia and industry are increasingly embracing ‘Team Science’, with many articles ssbeing authored by large groups of individuals with a range of specialisms. As experts in disparate fields, these scientists combine their strengths to triangulate evidence and build robust theories. However, in our experience, the field of experimental psychology has yet to adapt to this model of working, and we suspect this has its root at the very beginning of a psychologist’s career: the solo nature of the psychology PhD. This final stage of training to be a scientist consists of a 3-4 year long solo project which, by its very nature, does not foster close collaboration between researchers. A PhD is a course in independent working – it might teach determination, motivation and self-confidence, but it does not teach teamwork. We believe this needs to change.

A new model:

We would like to see a new model of PhD, based on the kind of team environment found in the software development world. Under this model, a research group would be subdivided into several small teams of scientists, with perhaps 3 or 4 PhD students and a postdoc working very closely together. The group would be located in the same office and tackle research questions collaboratively. Overall supervision would come from multiple senior academics, but the post-doc would act as team-leader on a day-to-day basis. Other stakeholders such as clinicians, policy makers and industry-partners may be invited to work within the group to improve the translatability and relevance of the research.

The main purpose of a team-PhD would be to work towards publishable projects much like a conventional company works towards product release deassssdlines or software updates. However, this increased emphasis on publications should not come at the cost of rigour and integrity with the primary focus remaining the adequate training of the candidate in scientific best practice during their PhD. By pooling resources and effort, such a team would be able to tackle the questions addressed by a traditional PhD thesis in less time. Joint 1st authorships would be common, with each team member’s contribution made explicit, rather than recognised implicitly via authorship order. A common theme of research chosen by team members (with direction from the post-doc team leader and supervisors) would be apparent from the team’s output over several years, but the studies and directions chosen should not need to be as cohesive as a traditional PhD. Given that a PhD is supposed to be training there is currently far too much focus on producing a coherent output (the “narrative arc”), rather than developing essential skills (not intending to diminish the important skill of clear, concise scientific writing). We are scientists, not novelists, and should be free to move around various fields to where our skills are needed most.

Let’s imagine a typical working day: You’re busy handling the response letter to the reviewers of your team’s latest paper. Every now and again you turn around to ask your teammates “How should we handle this question? Should we run some extra analysis?”. Your colleague beside you is writing the protocol for your group’s next project. She’s writing in Google Docs, so any member of the team can chip in whenever they want to. The experiment is designed collaboratively, and you will collect the data together. When the data are in, two team members handle the analysis, while the others write the introduction and methods. The team leader allocates different roles on each project, so you’re always learning new skills, but never far from help. Each day starts with a 10-minute meeting, discussing the plan for the day and flagging up any new papers that people have read and any good ideas that have arisen in the last 24 hours.

We believe that working together in a small group would bring many benefits: individuals can read papers and report back summarised findings, they can discuss theories, bounce ideas off each other, cross-check analysis and spot mistakes. Together they can run larger samples, read more widely, attempt more complex analyses, discuss more deeply, and so on. This sort of introspection and group effort leads to rigour, improved quality control, and ultimately higher throughput. Working in a team in this way would be motivating, with more camaraderie and positive peer-pressure, compared to the current PhD experience. Expertise would be shared between team members with the end result being a team of researchers competent in essential scientific skills (e.g., programming, statistics, study design, etc.). A team-PhD would also help to combat the isolation so many postgraduate students feel.

In order to accommodate this change to the nature of the PhD, the existing application process, whereby the candidate prepares a research proposal describing their own project, would need to be replaced with a more general application in which the applicant describes their research skills, areas of interest and motivations for long-term study. Successful applicants would be added to the research team most in need of their skillset: if a team is already strong in statistical methods then perhaps a psychologist could add a new perspective, for example.

A change in the PhD structure would also require a change to the assessment process. It is often said that PhD theses ends up in university libraries, never to be read again. Given that PhDs are often publically funded, the time spent altering a publication to fit the narrative arc of a thesis would be better spent dedicated to science that can have tangible impact. University of Bristol, alongside other universities, offers an alternative, if rarely used, PhD by published work. In this format candidates do not submit a thesis, but rather must publish a series of “coherent” works, alongside a commentary on the general direction of their research, its scope and aims. Currently, it takes ~10 years to amass enough publications to qualify for this route; however, it is plausible to alter this to the timeframe of a normal PhD. This format of PhD is more likely to produce high quality scientific output, published in academic journals, rather than rotting on a library shelf. Additionally, a PhD-by-publication still requires an oral examination. This exam would be used to ensure that team-PhD candidates are still capable, independent scientists with a sound understanding of their field, even though the bulk of their research was conducted as part of a team.

The teaming up of researchers with different competencies working on publications may have unintended consequences. It may be difficult to find one person to adequately review such work as is currently the case in neurogenetics for example. A possible remedy would be to restructure the review process to include teams of reviewers, where each member of the team specialises in addressing one of the specialisms described in the paper.ssssssssss

So, how can we move from solo training to team-based training? We suggest it is possible to trial the addition of team science to the PhD process by mandating that new PhD candidates work in a team, as part of their 1st year of study. In recent years, the 1+3 year PhD has become more common, whereby candidates carry out solo mini-projects in their 1st year to acquire experience and training in disparate fields. This could be altered to incorporate close teamwork in the execution of these mini-projects. This would provide an opportunity to examine the everyday benefits and challenges of this new mode of working. This way, students would not be overly disadvantaged when emerging from their PhD into a world of academia still concentrated around the principal investigator model, as the majority of their training would still be focused on generating and implementing their own ideas and developing their own “brand” or intellectual identity as a scientist.

Conclusion

The current model of attaining a PhD in psychology is too focused on solo work. We argue that introducing a more collaborative and cohesive framework to the PhD would aid in the development of research skills and produce more well-rounded PhD graduates equipped to tackle complex research questions. We hope this blog post will spark debate about the suitability of current training for psychological research and generate further ideas on how it can be improved to produce researchers with the skillset necessary for science in the 21st century.

 

Photo credits:

  1. http://dk.hjernekraft.org/turnering/279/lillestrom/lag.aspx?id=5602
  2. https://fbs.admin.utah.edu/research-corner/2015/07/28/enhancing-the-effectiveness-of-team-science/
  3. http://deevybee.blogspot.co.uk/2016/10/on-incomprehensibility-of-much.html