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Watson J.M., Fairhurst C., Jinshuo L. et al.
Drug and Alcohol Dependence: 2015, 154, 117–124.
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This UK study tested the idea that a multi-behaviour healthy living intervention would be more acceptable and more effective among problem drinking patients identified by a screening test than a specific alcohol intervention, but in both options found recruitment and retention challenging.
Summary This English study aimed to compare a healthy living intervention against an alcohol-focused intervention for 86 patients admitted to three general hospitals with conditions which were or might be related to heavy drinking such as pancreatitis or high blood pressure, and whose answers to the 10 questions of the Alcohol Use Disorders Identification Test (AUDIT) screening test indicated problem drinking.
A healthy living intervention was compared with an alcohol-specific intervention for problem drinkers identified while attending three UK hospitals with alcohol-related conditions.
Six and 12 month later there were no significant differences in alcohol risk scores between patients randomly allocated to the two interventions.
A key limitation was the unexpectedly low number of participants recruited and retained in the study, highlighting the challenges of engaging problem drinkers (who typically do not seek treatment) in research and interventions.
Effectiveness was measured by comparing the change in participants’ AUDIT scores six and 12 months after they had been randomly allocated to the interventions, and participant engagement with the interventions by looking at recruitment, drop-out, follow-up rates and number of treatment sessions attended.
The alcohol-specific intervention focused on building a network of people who actively support positive changes in drinking. The healthy living intervention supported participants to change in up to three health-behaviour domains from a choice of seven (drinking, drug use, diet, smoking, exercise, personal care and medication compliance). Each intervention consisted of four 30–45 minute sessions, intended to be delivered one to two weeks apart and completed over up to eight weeks. Sessions could be delivered at the specialist clinic, participants’ homes or at a mutually agreed alternative location.
There was no evidence of a difference in the change in AUDIT scores between the healthy living and alcohol-focused intervention at either the six- or 12-month follow-ups, but this conclusion was based on just the 16 and 11 patients respectively who completed these assessments.
The average cost of the alcohol-focused treatment was almost half that of the healthy living treatment (£32 per participant versus £60). On average, use of health and social services decreased in both treatment groups at follow-up, as did the average cost of contact with policing and the criminal justice system.
Recruitment proved challenging and follow-up rates were poor. Of the 518 patients screened for eligibility, 86 were recruited and randomised into one of the two treatment groups, and only 41 attended at least one treatment session. A greater proportion of the healthy living group attended all four treatment sessions (33% versus 19%) – a notable difference, but not statistically significant. Follow-up rates across both were 29% at six months and 22% at 12 months.
Despite high levels of drinking and drinking-related harm, this study underscores the difficulty of engaging non-treatment seeking populations in both traditional and non-traditional alcohol interventions. The researchers experienced a higher rate of refusal to participate than anticipated, and similarly had to exclude a higher number than anticipated due to them already being involved in treatment. The authors concluded that we need to find better ways of helping patients recognise the harms associated with their drinking and overcome barriers to engaging with treatment.
commentary This study sought to investigate whether a healthy lifestyle approach may be more acceptable to non-treatment seeking populations of problem drinkers than an intervention focused on alcohol, but was ultimately hampered by low rates of engagement, treatment uptake and follow-up. The authors concluded that a healthy living intervention may be at least as acceptable as an alcohol-focused intervention, but it’s unclear whether the results support this. Feasibility and acceptability were measured by recruitment, number of treatment sessions attended, follow-up rates and drop-out. Both treatment arms did poorly on these fronts, leaving too few participants to establish whatever differences there may have been between the effectiveness of the interventions.
It was not anticipated that such a large number would need to be excluded from the study due to already being involved in treatment – 168 out of 518. However, the researchers did cast their recruitment net towards the upper range of AUDIT scores, seeking problem drinkers with a score of 16 or higher. This not only included people with unhealthy alcohol use that was causing damage to physical or mental health, but also people psychologically and/or physically dependent on alcohol. Scores clustering around an average of over 31 are well into the range considered indicative of the need for specialist treatment. The number already engaged with treatment probably reflected the severity of drinking in this population.
The researchers had set out to test whether a “a healthy living intervention would have greater acceptability and patient adherence, and thereby better outcomes, than a specific alcohol intervention in terms of drinking behaviour change in this population”. This was based on the premise that people may be more likely to talk about drinking in the context of a conversation about everyday health, rather than as a medical or psychological issue in need of intervention. Though this makes logical sense, it could be argued that a downside of the healthy living intervention is that instead of merging drinking into a generic lifestyle discussion, drinking remained a distinct issue, one among a list of other stigmatised practices (drug use, diet, smoking, exercise, personal care and medication compliance) which people may be reluctant to talk about. In fact, in advance fewer patients (18% versus 26%) said they would prefer the healthy lifestyle intervention than preferred that focused on alcohol. Among these highly problematic drinkers, admitted to hospital for reasons their doctors may have told them were related to drinking, drinking was the most commonly chosen of the seven health behaviours offered healthy lifestyle patients, yet still 44% did not choose it.
One possibility is that the alcohol-specific treatment was unsuited to patients not seeking treatment. It was based on the social behaviour and network therapy programme developed for and tested on dependent drinkers already in treatment in the UKATT (UK Alcohol Treatment Trial) trial in England and Wales. The aim was to assertively engage the drinker’s social network such as family and friends to support them in moderating their drinking. The featured study included elements intended to encourage patients to set a drinking goal, but perhaps the intervention started too far down a road of intention to drink less which the patients had yet to reach. In particular, engaging their social circle – and therefore alerting them to the patient’s drinking problem – could well have seemed threatening. The healthy living intervention similarly aimed to recruit a supportive ‘buddy’ to support the patient’s attempts to improve their health.
Last revised 18 February 2015. First uploaded 14 December 2015
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