BookPDF Available

Brief Interventions for Risky Drinkers

July 2016

July 2016

DOI:10.3389/978-2-88919-887-0

Authors:

Hugo Lopez

Hospital Clínic de Barcelona

Antoni Gual

Hospital Clínic de Barcelona

| Evidence of effectiveness of ASBI, implementation barriers for ASBI, and future research needs for ASBI in workplace settings.

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| Search strategy utilized in the review.

…

| Frequency histogram of p-values (%) for 1,500 simulated experiments (see text). Adapted from Cumming ((11), p. 139).

…

| Health system key characteristics.

…

| Continued

…

Figures - uploaded by Hugo Lopez

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Content uploaded by Hugo Lopez

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BRIEF INTERVENTIONS

FOR RISKY DRINKERS

EDITED BY : Antoni Gual, Peter Anderson, Hugo López-Pelayo,

and Jillian Reynolds

PUBLISHED IN : Frontiers in Psychiatry

1Frontiers in Psychiatry June 2016 | Brief Interventions for Risky Drinkers

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ISSN 1664-8714

ISBN 978-2-88919-887-0

DOI 10.3389/978-2-88919-887-0

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BRIEF INTERVENTIONS

FOR RISKY DRINKERS

Topic Editors:

Antoni Gual, Hospital Clinic, Spain

Peter Anderson, Newcastle University, UK

Hugo López-Pelayo, Fundació Clínic per la Recerca Biomèdica, Spain

Jillian Reynolds, Fundació Clínic Recerca Biomèdica, Spain

Alcohol is the sixth leading risk factor for

disability and premature death all over the

world, and one of the leading causes of

premature mortality in western societies; it is

a leading risk factor for death in young and

middle-age males. Heavy drinking accounts

for about two thirds of the burden of disease

attributable to alcohol.

In the early 1980s, screening and brief

interventions (SBI) in primary health care

settings were proposed as effective strategies to

identify risky drinkers and to help them reduce

their drinking. Since then, a growing body of

evidence, including several meta-analysis and

Cochrane reviews, has shown the efﬁcacy and

effectiveness of SBI in primary health settings.

However, demonstrating the effectiveness of

SBI has not been insufﬁcient to facilitate its

general implementation in the routines of

primary health care physicians, and in fact the

dissemination of SBI has proven to be a difﬁcult

business. Qualitative and quantitative research

has identiﬁed most of the facilitators and

barriers for its implementation, and publicly funded research has been earmarked to address

the dissemination problems worldwide. Some examples are the World Health Organization

Phase III and Phase IV studies on the identiﬁcation and management of alcohol-related

problems in primary care, EU funded projects (PHEPA, AMPHORA, ODHIN, BISTAIRS),

the UK SIPS trials and the SBIRT developments sponsored by the Substance Abuse & Mental

Health Services Administration (SAMHSA) in the USA.

2Frontiers in Psychiatry June 2016 | Brief Interventions for Risky Drinkers

lanceb_info> | Dreamstime Stock Photos

<http://www.dreamstime.com/>

The efﬁcacy and effectiveness of SBI in primary health is now well established, but there are still some

questions that remain unsolved: which practitioners should deliver them; what length should they be;

is there a need for booster sessions; is there added value of a motivational approach? These questions,

together with other relevant aspects of SBI, need ongoing research.

In recent years, SBIs have been tested in settings other than primary health care, including hospitals,

accident and emergency rooms, criminal justice, colleges and universities, social services and

pharmacies. In some of those areas, the evidence is scarce (for example, pharmacies) while in others

it is very promising (for example, students and hospitals). New technologies have also offered the

possibility of online tools, and, in the last few years, different digital-based applications have been

tested successfully as new ways to deliver effective SBIs to larger amounts of people. Brief interventions

have also spread to drugs other than alcohol.

This book aims to be an update of the state-of-the art of brief advice. It is a compilation of articles

published by some of the most relevant researchers in the ﬁeld in Frontiers in Psychiatry between 2014

and 2016.

Citation: Gual, A., Anderson, P., López-Pelayo, H., Reynolds, J., eds. (2016). Brief Interventions for Risky Drinkers.

Lausanne: Frontiers Media. doi: 10.3389/978-2-88919-887-0

3Frontiers in Psychiatry June 2016 | Brief Interventions for Risky Drinkers

Chapter 1: Efﬁcacy, Effectiveness and mechanisms of action of

Brief Interventions

05 Editorial: Brief Interventions for Risky Drinkers

Antoni Gual, Hugo López-Pelayo, Jillian Reynolds and Peter Anderson

08 From efﬁcacy to effectiveness and beyond: what next for brief interventions in

primary care?

Amy O’Donnell, Paul Wallace and Eileen Kaner

16 Interpreting null ﬁndings from trials of alcohol brief interventions

Nick Heather

27 Mechanisms of action of brief alcohol interventions remain largely

unknown – a narrative review

Jacques Gaume, Jim McCambridge, Nicolas Bertholet and Jean-Bernard Daeppen

Chapter 2: SBI beyond primary health care

36 Brief interventions for hazardous and harmful alcohol consumption in

accident and emergency departments

Marcin Wojnar and Andrzej Jakubczyk

41 Alcohol screening and brief intervention in workplace settings and social

services: a comparison of literature

Bernd Schulte, Amy Jane O’Donnell, Sinja Kastner, Christiane Sybille Schmidt,

Ingo Schäfer and Jens Reimer

50 Screening and brief intervention for unhealthy drug use: little or no efﬁcacy

Richard Saitz

Chapter 3: Cost-effectiveness and Implementation

55 What are the implications for policy makers? A systematic review of the

cost-effectiveness of screening and brief interventions for alcohol misuse in

primary care

Colin Angus, Nicholas Latimer, Louise Preston, Jessica Li and Robin Purshouse

65 Brief interventions implementation on alcohol from the European health

systems perspective

Joan Colom, Emanuele Scafato, Lidia Segura, Claudia Gandin and Pierluigi Struzzo

77 Internet applications for screening and brief interventions for alcohol in

primary care settings – implementation and sustainability

Paul Wallace and Preben Bendtsen

Table of Contents

4Frontiers in Psychiatry June 2016 | Brief Interventions for Risky Drinkers

EDITORIAL

published: 17 March 2016

doi: 10.3389/fpsyt.2016.00042

Frontiers in Psychiatry | www.frontiersin.org 5 March 2016 | Volume 7 | Article 42

Edited and Reviewed by:

Giovanni Addolorato,

Catholic University of Rome, Italy

*Correspondence:

Antoni Gual

tgual@clinic.cat

Specialty section:

This article was submitted to

Addictive Disorders,

a section of the journal

Frontiers in Psychiatry

Received: 02March2016

Accepted: 04March2016

Published: 17March2016

Citation:

GualA, López-PelayoH, ReynoldsJ

and AndersonP (2016) Editorial: Brief

Interventions for Risky Drinkers.

Front. Psychiatry 7:42.

doi: 10.3389/fpsyt.2016.00042

Editorial: Brief Interventions

forRiskyDrinkers

Antoni Gual1* , Hugo López-Pelayo2 , Jillian Reynolds2 and Peter Anderson3,4,5

1 Grup de Recerca en Addiccions Clínic (GRAC-GRE), Hospital Clínic de Barcelona, IDIBAPS, Red de Trastornos adictivos

(RETICS), Barcelona, Spain, 2 Grup de Recerca en Addiccions Clínic (GRAC-GRE), Hospital Clínic de Barcelona, Fundació

Clínic per la Recerca Biomèdica, Red de Trastornos adictivos (RETICS), Barcelona, Spain, 3 Institute of Health and Society,

Newcastle University, Newcastle, UK, 4 Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht,

Netherlands, 5 Centre for Addiction and Mental Health, Toronto, ON, Canada

Keywords: alcohol drinking, hazardous drinking, at-risk drinking, brief intervention, brief advice

e Editorial on the Research Topic

Brief Interventions for Risky Drinkers

Alcohol consumption is a wholly or contributory cause for more than 200 diseases, injuries, and other

health conditions with three-digit ICD-10 codes (1). Globally, alcohol is the h most important risk

factor for ill-health and premature death (2). Risky alcohol use can be dened as a quantity or pattern

of alcohol use that places individuals at risk for adverse health and social outcomes (3). Harmful use,

in turn, can be dened as alcohol use that results in physical, psychological, or social harm (3). Using

a threshold of an average of 60g of alcohol/day for a man and 40g/day for a woman (4), about one

in four Europeans aged 15–64years use alcohol in a risky fashion (5). And, using a threshold of an

average of 100g of alcohol/day for a man and 60g/day for a woman, about one in eight of Europeans

aged 15–64years use alcohol in a harmful fashion (5). Harmful use causes comorbid illnesses such

as liver disease, depression, and raised blood pressure (6). Risky and harmful alcohol use and their

comorbid illnesses are frequently detected in primary health care, emergency departments, and other

non-specialized clinical settings. Brief advice emerged in the 1980s (7–9) and progressed during the

three following decades as a strategy to reduce risky and harmful alcohol use in non-specialized

clinical settings (10). is article provides an update of the state-of-the art of brief advice.

EFFICACY AND EFFECTIVENESS OF BRIEF ADVICE

Twenty-four systematic reviews have demonstrated the ecacy and eectiveness of brief advice

delivered in primary health care settings to reduce risky and harmful alcohol use [O’Donnell etal.;

(11, 12)]. e negative results found in some studies can be explained by several misconceptions

about null ndings and should not diminish the strength of the evidence base for the ecacy and

eectiveness of brief advice (Heather). Examples of misconceptions include diculties in distin-

guishing between “evidence of absence and absence of evidence” and the interference of reduction

in consumption in control groups from baseline to follow-up mediated by regression to the mean, a

research participation eect, or assessment reactivity.

WHY DOES BRIEF ADVICE WORK?

e underlying mechanisms of the eectiveness of brief advice are only partially known (Gaume

etal.). Personalized feedback seems an eective ingredient. Other components (including advice

to reduce/stop drinking, presenting alternative change options, moderation strategies, changes

in norms perception, discrepancy between current behavior and goals/values, and change plan

Gual et al.

Brief Interventions for Risky Drinkers

Frontiers in Psychiatry | www.frontiersin.org March 2016 | Volume 7 | Article 42

exercises) appear to be promising. Change talk seems to acts as a

mediator of brief advice, whereas readiness to change seems an

inconsistent mediator of the eectiveness of brief advice. More

research on other potential active ingredients is needed, such as

the perceived risk/benet of alcohol intake, alcohol treatment

seeking, self-ecacy, or enhanced awareness.

FOR WHOM CAN BRIEF ADVICE HELP?

Brief advice seems to work in primary health care and, in emer-

gency departments, for men without other drug use (Wojnar and

Jakubczyk). Brief advice does not seem to work for men seen in

emergency departments as a consequence of violence-related

events, or for women as a whole seen in emergency departments.

In general, the eectiveness of brief advice in primary health care

for women remains limited (11). Research on the eectiveness

of brief advice in social service settings and at the workplace

is understudied, and no conclusions of its impact can be made

(Schulte etal.). Data on the ecacy of brief advice for illegal drug

users are lacking for a number of reasons: concomitant unhealthy

alcohol use, comorbid mental health conditions, variety of drugs

used, and a wide range in severity (Saitz). In conclusion, there

is insucient evidence to support the implementation of brief

advice in settings other than primary health care or for drugs.

Further research is needed in these areas.

IMPLEMENTATION BARRIERS

Although the cost-eectiveness of brief advice is well-established

(Angus etal.), it has not proved a sucient trigger for the wide-

spread implementation of brief advice in clinical practice, even

though key stakeholders in several European health systems

(for example, Catalonia, England, Finland, Italy, Scotland, and

Sweden) have pushed for it (Colom etal.). Several barriers for

implementing brief advice have been identied, including a risk

of upsetting patients and a lack of time, training, and incentives

(13). is is why a fair share of the current research on brief

advice focusses on implementation science, seeking strategies to

overcome these barriers.

FUTURE LINES FOR BRIEF ADVICE

Facilitated access to e-health and m-health modules could

potentially boost the implementation and coverage of brief

advice, and a number of clinical trials are underway [Wallace

and Bendtsen; (14, 15)]. Ambitious projects have already been

carried out, such as the FP7 EU funded project ODHIN (www.

odhinproject.eu), which compared three strategies for promoting

screening and brief advice activity in primary care (training and

support, nancial reimbursement, and referral to internet-based

brief interventions), delivered separately or in combination. e

ODHIN project showed the relevance of training and support

and of nancial incentives to increase the delivery rates of screen-

ing and brief advice but failed to nd a signicant impact of the

option of referral to internet-based brief interventions1.

Despite the evidence of the eectiveness of brief advice, its

uptake in Europe is very low (16). Several authors have recently

proposed a new approach to improve dissemination of brief

advice for heavy drinking in primary health care (17, 18). Rehm

etal. propose a shi from the “prevention approach” to a more

medical “treatment approach,” where alcohol problems should be

managed with the same strategies and up to the same standards

applied for other chronic conditions, such as high blood pressure

and diabetes (19). According to this model, special attention

should be paid to comorbid conditions such as hypertension,

insomnia, liver problems, depression, and anxiety disorders, all

of them very prevalent in primary health care.

In conclusion, despite strong evidence on the ecacy, eec-

tiveness, and cost-eectiveness of brief advice in primary health

care, its implementation in Europe is still very low. erefore, new

approaches making the best use of new technologies and aiming

for a medical management of risky and harmful and alcohol use

in primary health care, with the same standards used for common

chronic medical conditions, should be tested.

AUTHOR CONTRIBUTIONS

All authors have contributed in the writing and intellectual

content of the article. All authors have read and approved the

manuscript for submission to the journal.

ACKNOWLEDGMENTS

Research leading to this paper has received funding from the

European Union’s Seventh Framework Programme for research,

technological development and demonstration under grant

agreement no 259268–Optimizing delivery of health care inter-

vention (ODHIN). Participant organizations in ODHIN can be

seen at www.odhinproject.eu. e views expressed here reect

those of the authors only and the European Union is not liable for

any use that may be made of the information contained therein.

1Anderson P, Bendtsen P, Spak F, Reynolds J, Drummod C, Segura L, et al.

Improving the delivery of brief interventions for heavy drinking in primary health

care: outcome results of the ODHIN ve country cluster randomized factorial trial.

(under review in Addiction ).

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men. Br J Addict (1992) 87:891–900. doi:10.1111/j.1360-0443.1992.tb01984.x

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et al. e impact of brief alcohol interventions in primary healthcare: a

systematic review of reviews. Alcohol Alcohol (2014) 49:66–78. doi:10.1093/

alcalc/agt170

12. Kaner EF, Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N,

etal. Eectiveness of brief alcohol interventions in primary care populations.

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Report on the Mapping of European Need and Service Provision for Early

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Alcohol Alcohol (2015). doi:10.1093/alcalc/agv127

Conflict of Interest Statement: AG has received grants from Lundbeck, DyA

Pharma y TEVA and honoraria from Lundbeck, DyA Pharma and Abbivie that

have no relation with the study. HL-P has received honoraria from Lundbeck

and Janssen and travel grants from Lundbeck, Lilly, Pfizer, Rovi, and Esteve

that has no relation with this work. JR and PA have no conflict of interest to

declare.

access article distributed under the terms of the Creative Commons Attribution

License (CC BY). e use, distribution or reproduction in other forums is permit-

ted, provided the original author(s) or licensor are credited and that the original

publication in this journal is cited, in accordance with accepted academic practice.

No use, distribution or reproduction is permitted which does not comply with these

terms.

PSYCHIATRY

REVIEW ARTICLE

published: 28 August 2014

doi: 10.3389/fpsyt.2014.00113

From efﬁcacy to effectiveness and beyond: what next for

brief interventions in primary care?

Amy O’Donnell1*, Paul Wallace2and Eileen Kaner 1

1Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK

2Department of Primary Care and Population Health, University College London, London, UK

Edited by:

Hugo López-Pelayo, Fundació Clínic

per la Recerca Biomèdica, Spain

Reviewed by:

Roberta Agabio, University of Cagliari,

Italy

Marcin Wojnar, Medical University of

Warsaw, Poland

*Correspondence:

Amy O’Donnell, Institute of Health

and Society, Newcastle University,

Baddiley-Clark Building, Richardson

Road, Newcastle uponTyne NE2 4AX,

e-mail: amy.odonnell@

newcastle.ac.uk

Background: Robust evidence supports the effectiveness of screening and brief alcohol

interventions in primary healthcare. However, lack of understanding about their “active

ingredients” and concerns over the extent to which current approaches remain faithful to

their original theoretical roots has led some to demand a cautious approach to future roll-out

pending further research. Against this background, this paper provides a timely overview

of the development of the brief alcohol intervention evidence base to assess the extent to

which it has achieved the four key levels of intervention research: efﬁcacy, effectiveness,

implementation, and demonstration.

Methods: Narrative overview based on (1) the results of a review of systematic reviews

and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare

and (2) synthesis of the ﬁndings of key additional primary studies on the improvement and

evaluation of brief alcohol intervention implementation in routine primary healthcare.

Results: The brief intervention ﬁeld seems to constitute an almost perfect example of the

evaluation of a complex intervention. Early evaluations of screening and brief intervention

approaches included more tightly controlled efﬁcacy trials and have been followed by more

pragmatic trials of effectiveness in routine clinical practice. Most recently, attention has

shifted to dissemination, implementation, and wider-scale roll-out. However, delivery in

routine primary health remains inconsistent, with an identiﬁed knowledge gap around how

to successfully embed brief alcohol intervention approaches in mainstream care, and as

yet unanswered questions concerning what speciﬁc intervention component prompt the

positive changes in alcohol consumption.

Conclusion: Both the efﬁcacy and effectiveness of brief alcohol interventions have been

comprehensively demonstrated, and intervention effects seem replicable and stable over

time, and across different study contexts. Thus, while unanswered questions remain,

given the positive evidence amassed to date, research efforts should maintain a continued

focus on promoting sustained implementation of screening and brief alcohol intervention

approaches in primary care to ensure that those who might beneﬁt from screening and

brief alcohol interventions actually receive such support.

Keywords: brief alcohol intervention, efﬁcacy, effectiveness, implementation, research needs, secondary preven-

tion, primary care

INTRODUCTION

Brief interventions for alcohol provide a clinically effective and

cost-effective means of identifying and addressing alcohol-related

problems when delivered in primary healthcare settings (1–4).

Originating in the ﬁeld of smoking cessation (5), and grounded in

social cognitive theory (6), brief alcohol interventions aim to detect

problems at an early stage, when they are most amenable to adjust-

ment, to promote positive behavior change (7), and thus avoid the

development of more serious future problems in an individual (8).

WHAT IS THE BASIS FOR BRIEF INTERVENTIONS FOR ALCOHOL?

Brief intervention comprises two broad modalities. First, simple

structured advice in the form of personalized feedback on how

to address problematic drinking behavior as well as information

and/or advice on how to avoid its adverse consequences. This form

of intervention is typically delivered in one to ﬁve sessions, which

are short in duration [a review by Kaner et al. who found a mean

of 25 min per intervention (9)]. Second, extended or more inten-

sive intervention, using counselling and other psycho-therapeutic

techniques such as motivational interviewing or cognitive behav-

ioural therapy (CBT), which may extend up to 50minutes per

session (9,10). These more intensive interventions may be deliv-

ered either in a single appointment, or via a series of related

sessions and the overall treatment exposure has been reported

to be 60–175 minutes overall (9). Nevertheless, while the con-

tent and delivery style of brief interventions may vary, all are

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O’Donnell et al. From efﬁcacy to effectiveness and beyond

designed to promote awareness of the negative effects of drinking

and to motivate positive behavior change (11). The core elements

of brief alcohol intervention are based on “FRAMES” (Feedback,

Responsibility, Advice, Menu, Empathy, and Self-efﬁcacy) princi-

ples (12), and important components include drawing out indi-

viduals’ beliefs and attitudes about drinking, their self-efﬁcacy or

sense of personal conﬁdence about changing their drinking, and

a view about how their drinking sits in relation to other people’s

drinking behavior (normative comparison) (13).

WHAT ARE THE OVERALL FINDINGS FROM THE EVIDENCE?

From the ﬁrst study of the effects of opportunistic brief interven-

tion carried out in Malmo, Sweden in the early 1980s (14) over

three decades of research has been undertaken both locally and

internationally to develop these simple technologies to assist with

the identiﬁcation of individuals at risk from their alcohol con-

sumption, and the delivery of short, cost-effective interventions in

community and health-care settings. A recent review of systematic

reviews, covering a total of 56 unique primary healthcare-based

randomized controlled trials, found consistent evidence for the

effectiveness of brief alcohol interventions in reducing hazardous

and harmful drinking when delivered in primary care settings (15).

However, some of the more recent individual large scale pragmatic

trials have failed to demonstrate signiﬁcant differences between

the effect sizes in the control and intervention groups (16,17). In

addition, as Heather has emphasized, while the evidence base for

the implementation of brief structured advice as a form of oppor-

tunistic ASBI appears reasonably sound, this is not the case for

extended, intensive interventions based more explicitly on moti-

vational interviewing principles (18), despite the sound theory

informing such approaches (19).

WHY MIGHT SOME STUDIES FAIL TO FIND SIGNIFICANT TREATMENT

EFFECTS?

A consistent trend in trials of brief intervention is that of reduction

of alcohol consumption in both the control and active interven-

tion conditions (20–22). It is not yet clear if this is due to an

artifact of participating in the research process itself (see below)

or a response to active ingredients of behavior change, which

may be provided to participants allocated to the control condition

(23). These include feedback, provision of bibliometric informa-

tion, and cursory advice about alcohol, which may be embedded

with other lifestyle behaviors such as smoking or physical activity.

Despite awareness of these issues, there has been little progress to

address concerns about assessment reactivity, for example,through

the use of Solomon 4-group designs (24–26).

WHAT DO WE KNOW ABOUT THE KEY ELEMENTS OF INTERVENTION

AND HOW WELL THEY ARE DELIVERED?

Whilst there is undoubtedly a considerable and largely convinc-

ing body of literature supporting the overall effectiveness of brief

interventions for alcohol, as the recent McCambridge review con-

ﬁrmed, our understanding of their “active ingredients” remains

limited (27). Evidence suggests that for interventions to achieve

statistically signiﬁcant improvements in alcohol outcomes, they

should include at least two of the following three elements – feed-

back, advice, and goal-setting (28). However, the results of a study

by Bertholet and colleagues were far less clear-cut, ﬁnding that

across different populations and settings, intervention character-

istics viewed as central to efﬁcacious brief motivational interviews

were inconsistent predictors of drinking outcome (29). Further,

as both Whitlock and Beich have emphasized (28,30), given

the inevitable “helping relationship” that exists between patient

and practitioner, it remains challenging to isolate the impact that

the additional support general practitioners might have on inter-

vention effectiveness, particularly when such interventions may

be delivered on multiple occasions, and via multiple modali-

ties. There has been some recent work that focused on speciﬁc

behavior change techniques embedded in advice or counseling

(31) but we are not closer to understanding potential therapist

effects (either skill, rapport-building, or trust) or the interac-

tion between intervention per se and other aspects of recipients’

lives (policy, corporate behavior, and family or personal context).

There are also concerns as to whether current brief interven-

tion approaches remain faithful to their theoretical roots. It has

therefore been suggested that poor delivery of brief interventions

coupled with potential content drift, should result in a cautious

approach to future roll-out, whilst additional research is carried

out to establish the efﬁcacy of individual intervention components

more conclusively (29).

Taking all the above considerations into account,it seems timely

to review the current state of the screening and brief alcohol

intervention evidence base to determine the extent to which fur-

ther research is actually required, and to consider which research

questions such studies might most usefully examine. After all,

any additional research must build upon previous work to save

public time and money. For “while replication is an important

part of the scientiﬁc method, a ﬁeld needs to progress rather

than merely generate volume” (32). Importantly, the develop-

ment, evaluation, initial adoption, and wider roll-out of a new

health intervention or treatment should ideally be supported by a

sequence of research studies, ranging from basic“proof of concept”

research to demonstration studies. Flay identiﬁes four key levels of

experimental research: efﬁcacy (or explanatory) trials; treatment

effectiveness (or pragmatic) studies; implementation studies; and

ﬁnally, program evaluation (or demonstration) research to mea-

sure the actual impact of an intervention at wider population level

once an intervention becomes part of large scale, mainstream care

(33,34). These levels are both interlinked and interdependent,thus

most research is best conceptualized as existing on a continuum,

from optimized to naturalistic conditions, as opposed to being

easily positioned within one distinct study category (35). Cru-

cially,however,efﬁcacy must be demonstrated before effectiveness

is assessed, and the latter is a necessary pre-condition for wider

dissemination and subsequent adoption (36).

Against this background, this paper aims to provide an

overview of the development of the screening and brief alco-

hol intervention research ﬁeld in primary health care drawing

primarily on published systematic reviews in the ﬁeld, supple-

mented with key recent literature to ensure the evidence pre-

sented reﬂects the cutting edge of this ﬁeld. In doing so, it

will assess the extent to which the existing ASBI evidence base

has achieved Flay’s four key levels of intervention research (efﬁ-

cacy →effectiveness →implementation →demonstration) (33,

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O’Donnell et al. From efﬁcacy to effectiveness and beyond

34), which in turn, will help highlight any outstanding questions

for future research.

METHODS

First, the paper draws on the results of a recent overview of system-

atic reviews and meta-analyses of the effectiveness of brief alcohol

intervention in this setting (15). This overview searched key elec-

tronic databases (MEDLINE, EMBASE, PsycInfo, The Cochrane

Database, The Database of Abstracts of Reviews of Reviews, and

the Alcohol and Alcohol Problems Science Database) for system-

atic reviews and meta-analyses of studies examining the effec-

tiveness of brief alcohol intervention in comparison to control

conditions in primary healthcare settings, which were published

between 2002 and 2012. Second, the paper synthesizes the ﬁnd-

ings of more recently published primary studies focused on the

improvement and evaluation of the implementation of brief inter-

ventions for alcohol in routine primary healthcare to ensure the

presented evidence reﬂects the state-of-the-art in this ﬁeld.

For the purposes of this paper, primary healthcare has been

operationalized to include all immediately accessible general

healthcare facilities but not emergency settings. Brief intervention

comprises a single session and/or up to a maximum of ﬁve sessions

of engagement with a patient, and the provision of information

and advice designed to achieve a reduction in risky alcohol con-

sumption or alcohol-related problems. Heavy drinking is deﬁned

as drinking in excess of 60 g of alcohol per day for men and 40 g

for women (37). Hazardous drinking is consumption at a level,

or in such a pattern, that increases an individual’s risk of phys-

ical or psychological consequences (38), while harmful drinking

is deﬁned by the presence of these consequences (39). Alcohol

consumption, at a dependent level, results in repetitive problems,

affecting three or more areas of life, including a strong desire or

compulsion to use alcohol, inability to control use, and withdrawal

from and tolerance to alcohol (40).

RESULTS

EFFICACY, EFFECTIVENESS, IMPLEMENTATION, AND PROGRAME

EVALUATION: THE FOUR PHASES OF BRIEF ALCOHOL INTERVENTION

RESEARCH

Level 1: Do brief interventions work? Efﬁcacy studies on brief

alcohol interventions

An efﬁcacy trial is designed to evaluate what an intervention

achieves under optimum conditions (33). It provides a test of

(a) a well-speciﬁed and standardized treatment or therapy that

(b) is made available in a uniform fashion, within standard-

ized contexts or settings, to a speciﬁc target audience, which (c)

completely accepts, participates in, complies with, or adheres to

the treatment/programe as delivered (33). According to the US

Society for Prevention Research (36,41), efﬁcacy testing necessi-

tates the conduct of a minimum of two robust trials [deﬁned as

those which include tightly deﬁned populations; psychometrically

reliable measures and data collection procedures; rigorous statisti-

cal analysis; consistent positive effects (without adverse impacts);

and one or more long-term follow-ups]. The randomized con-

trolled trial is generally considered to be the “gold-standard” for

intervention evaluation in medical research and the most rigor-

ous way of determining whether a cause–effect relation exists

between treatment and outcome (42). This is because this method-

ological approach is speciﬁcally designed to minimize bias and

potentially confounding variables through randomization of study

participants to prevent systematic differences between interven-

tion groups in any factors (both known and unknown); and

double blinding to ensure that the preconceived views of sub-

jects and/or clinicians cannot systematically bias the assessment of

outcomes (43).

Clinical drug trials, where a discrete dose of a pharmacolog-

ical agent is delivered to patients, face fewer challenges in meet-

ing the required standards of treatment efﬁcacy. For behavioral

interventions, which generally involve signiﬁcant inter-personal

interaction in the delivery and receipt of advice or counseling,

the conditions are more challenging. There is inherent complex-

ity where human actors are required to be a substantial part of

“the therapy” (44). Although it can be argued that practitioners

often deliver and/or explain the pharmaco-therapy in drug trials,

the tablet or pill is generally regarded as the key active ingredi-

ent not the explanation or advice per se. Despite this challenge,

an attempt has been made to disaggregate the component parts

of brief alcohol intervention in trial-based evaluations (by char-

acteristics of practitioners, patients, delivery settings, intervention

content, scope for ﬂexibility, skill-based training, implementation

support, and ﬁdelity monitoring) to assess the extent to which

trial-based evaluations show features of uniformity and standard-

ization (efﬁcacy) or not (9). The conclusion of this work was that

evaluations in this ﬁeld sit on a continuum from efﬁcacy to effec-

tiveness trials, because a perfect model of either extreme is hard to

achieve. In general, the older trials, which tended to include more

tightly controlled evaluations with high levels of internal validity,

demonstrated consistently positive outcome effects. Moreover, a

series of sensitivity analyses excluding trials with less than adequate

features of methodology found persistently positive outcomes.

Thus, proof of concept via efﬁcacy trials seems to have been com-

prehensively demonstrated (45) and more recently re-conﬁrmed

by a further systematic review by Jonas et al. (46).

Level 2: Do brief interventions work in the real world of primary

care? Effectiveness trials

Efﬁcacy trials can establish whether an intervention works (or does

more good than harm) when delivered in optimum conditions;

effectiveness trials determine whether those beneﬁts continue to

be realized in more real-world settings. Sufﬁcient replicability and

stability of effects are important aspects of this work especially

in “typical” conditions of delivery where availability, compliance

or acceptance, and measurement factor may vary (33). As Flay

writes “an intervention will be effective only if an efﬁcacious

treatment/program is delivered/implemented in such a way as to

be made available to an appropriate target audients in a manner

acceptable to them (i.e. that they will be receptive to, participate

in, comply with, or adhere to)” (33).

A recent review of reviews identiﬁed at least 56 separate ran-

domized controlled trials of screening and brief alcohol interven-

tions in primary health care, which consistently reported that

brief alcohol interventions are effective at reducing hazardous

and harmful drinking in primary healthcare, with weekly alco-

hol consumption the most commonly reported outcome (15). A

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O’Donnell et al. From efﬁcacy to effectiveness and beyond

key issue here, is the size of the outcome effect and the extent to

which it is diminished (or not) in more variable pragmatic eval-

uations. In 2007, meta-analysis of the results from 25 RCTs of

screening and brief intervention by Kaner et al. (9) reported an

average reduction in the quantity of alcohol drunk of 38 g/week

for brief intervention compared with control conditions [95%

CI (conﬁdence interval): 23–54 g]. More recently, analysis of the

pooled results from 23 RCTs and 6 systematic reviews by Jonas

et al. (46) found a slightly increased reduction of 49 g/week

for adults aged 18–64 (95% CI: 33–66 g). Thus outcome effects

appear to have been generally stable over time as trials have

become increasingly pragmatic in nature (9). Finally, in addition

to reduced alcohol consumption, this ﬁeld of work has regularly

reported reductions in other outcomes such as alcohol-related

problems (9) and reduced health-care utilization (47) and mor-

tality (48). Importantly, delivery by a range of practitioners in

primary healthcare settings has beneﬁcial effects (49), although

ﬁndings of one review suggest that the effect sizes are greater if

delivered by doctors (50). In summary, there appears to be ample

evidence of replicability and consistency of effects on a number of

parameters.

This said, while the overall evidence base seems to show that

brief alcohol interventions are both efﬁcacious and effective when

delivered in primary care settings, some individual large scale prag-

matic trials have reported null ﬁndings. For example, a recent large

UK trial (SIPS) reported no signiﬁcant differences in hazardous

and harmful drinking status in patients receiving simple feed-

back after screening plus a patient information leaﬂet (the control

condition), those receiving 5min of structured advice, and those

receiving a further 20 min brief lifestyle counseling (16). This ﬁnd-

ing accords with three systematic reviews that focused on control

conditions only and found consistently reduced drinking in these

groups over time (20–22). It may be that the mere fact of partici-

pation in a brief intervention trial may be associated with positive

behavior change. This may be due to a general “Hawthorn effect,”

whereby increased attention or scrutiny might inﬂuence drink-

ing (51). It may be that most individuals who agree to participate

in a trial have already started a change process. Moreover, given

the fact that extreme measures of behavior tend to shift to less

extreme positions over time (known as regression to the mean),

such reductions in control groups may also be explained by natural

reductions in heavy drinking over time (52). Finally, there is grow-

ing evidence to suggest that patients’ reactions to the screening or

measurement activity itself could inﬂuence their decision to cut

down their alcohol consumption (known as assessment reactiv-

ity) (53,54). Conversely, while it is possible that individuals with

lower reported levels of consumption might increase their drink-

ing over time, this is rarely captured in alcohol trials where only

risky drinkers are included at enrolment. Nevertheless, an inter-

esting trend in this ﬁeld is that the deﬁnition of heavier or risky

drinkers seems to have been falling over time (9). For example in

a 2007 review, average weekly consumption at enrollment (base-

line) was 55 standard drink units in the earliest trial (55) but was

only 25 standard drink units in the most recent trial (16). Hence,

it is possible that the scope for regression to the mean might be

reducing in this ﬁeld. Furthermore, the cumulative (pooled) meta-

analyses reported in successive systematic reviews reveal positive

outcome effects“over and above” those seen or expected in control

conditions (15).

Level 3: What factors promote widespread adoption of brief

interventions into routine practice? Implementation trials

Whilst there have been successive attempts to encourage the rou-

tine delivery of brief alcohol interventions in day-to-day prac-

tice, most efforts have demonstrated limited success (56–60), and

implementation of this form of preventive care remains inconsis-

tent. In the UK, for example, although survey data suggest that

GPs see both preventative medicine and alcohol intervention as

increasingly high priority public health areas, and they generally

view primary health care as an appropriate setting to raise and

discuss alcohol issues (61), most do not routinely ask patients

about their drinking (62). In recognition of this mismatch, there

has been an increased focus on implementation research to test

potential approaches to improve their delivery (63).

Implementation studies may take a number of forms, explor-

ing the many inﬂuences on patient, healthcare professional, and

organizational behavior in either healthcare or population settings

(63). In the alcohol intervention ﬁeld, therehas arguably been most

progress in identifying the various obstacles experienced by practi-

tioners seeking to deliver screening and brief alcohol interventions

in routine primary health care. Some of the barriers to the provi-

sion of brief alcohol interventions identiﬁed to date concern the

socio-cultural, interactional and attitudinal factors that inﬂuence

their delivery by individual primary healthcare practitioners (64,

65). For example, there is an evidence to suggest that many GPs

remain unconvinced that patients will heed advice to change their

drinking behavior, particularly those patients drinking at heavier

or dependent levels (66–68). Practitioners are also concerned that

they might offend patients by discussing alcohol, or at least view

alcohol as a “delicate” subject to raise in the standard consulta-

tion situation (65,68), which potentially risks jeopardizing the

patient–doctor relationship (69,70). This “role insecurity” (71)

may also relate to the potential impact that practitioners’ own

drinking practices may have on intervention delivery, alongside

confusion about what advice they should actually be delivering on

lower risk drinking (61).

In addition, previous research also points toward a series of

structural and organizational factors that inﬂuence alcohol inter-

vention delivery. Lack of training or suitable intervention materials

(68,72), inadequate ﬁnancial incentives (73,74), unsupportive

specialist alcohol service provision (3,67), and everyday time pres-

sures (67,75) has all been identiﬁed by GPs and other health practi-

tioners as barriers to their successful engagement in and delivery of

brief interventions for alcohol (32,59,62,64,73,76–79). Moreover,

these barriers are often interrelated. Thus GPs’ discussions around

alcohol are shaped by both the practical challenge of incorporat-

ing discussions about alcohol within the pressured, time-limited

consultation process and their own (and the patient’s) complex

social, cultural, and moral beliefs about what constitutes“normal”

versus “problematic”drinking (64,80,81).

Alongside research to identify notable barriers to the routine

delivery of screening and brief alcohol intervention in primary

care, there have also been studies exploring facilitating factors. For

example, Screening, Brief Intervention, and Referral to Treatment

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O’Donnell et al. From efﬁcacy to effectiveness and beyond

(SBIRT) is US-based program to promote the use of evidence-

based practice to identify, reduce, and prevent problematic use,

abuse, and dependence on alcohol and illicit drugs (82–86). One

key message arising from this program of activities has been that

effective training strategies for health professionals are an essential

ﬁrst step in the successful implementation of SBIRT, with team-

based learning a potentially promising strategy to help maintain

newly learned clinical skills (87). In addition, Ronzani et al. have

shown the importance of involving managers in the dissemina-

tion of screening strategies and brief interventions to increase their

implementation rates (88). Results from comparative work carried

out in New Zealand, England, and Catalonia demonstrated the

need to tailor procedures to ﬁt with local circumstances, to break

the process down into clinically acceptable steps, and to negotiate

implementation strategies and timing taking into account local

needs and competing demands to successfully embed interven-

tion activity (89). The recent developments in the use of digitally

mediated brief interventions (eBI) delivered via the internet and

mobile phones represent another way of dealing with these issues

(90). These offer practitioners a way to avoid the need to engage

their patients directly in a discussion about alcohol, while at the

same time providing an opportunity to reﬂect on their drinking

behavior in a secure and conﬁdential setting (see Internet appli-

cations for screening and brief interventions for alcohol in primary

care settings – implementation and sustainability by Wallace and

Bendtsen in this issue for more on this subject).

Regarding work that actively promotes uptake and adoption of

brief interventions in practice, the largest study conducted to date

was part of a World Health Organisation Collaborative project.

This study found that active dissemination strategies were needed

to ensure that practitioners were aware of the evidence on brief

interventions, whilet both training and support were needed to

convert this knowledge into action (60). Moreover, a systematic

review and meta-analysis of strategies to engage practitioners in

brief intervention activity found that a speciﬁc focus on alco-

hol per se and multi-component support programes were more

effective (79) than focusing on several behavior and just a single

education or support strategy. Bringing this ﬁeld right up to date

is the optimizing delivery of health care interventions (ODHIN)

study, an ongoing Europe wide project involving research insti-

tutions from nine European countries. This trial has a factorial

design and it aims to assess the impact on practitioner behavior

of out-reach training, ﬁnancial incentives, and the opportunity to

refer patients to an electronic brief intervention programe, both

individually and in differing combinations of approaches. This

study is due to report in 2015.

Level 4: Wider roll-out work: Demonstration studies

A key limitation of earlier implementation research, however, is

that changes in practitioner behavior tend to be limited to the

time-frame of each individual study that attempts to promote

screening and brief alcohol intervention. When the research work

ends, the focus on screening and brief alcohol intervention also

tends to stop. A signiﬁcant challenge is to ﬁnd ways of embed-

ding this activity in mainstream clinical work to achieve sustained

delivery (70), and also to be able to measure when and how often

it occurs, and to whom it is delivered.

The development of national alcohol strategies, speciﬁc guid-

ance for practitioners on when and how to deliver screening and

brief interventions, and national payment programs for ASBI has

recently been introduced in the UK to promotetheir w ider roll-out

(91,92). Khadjesari et al. drew on routine UK general practice data

(covering 382,609 patients, drawn from over 500 general practices)

to examine the impact of ﬁnancial incentives on the rates of screen-

ing for alcohol-use disorders (93). It found that following the

introduction of screening incentives, relatively high rates of newly

registered adult patients (76% nationally) were being screened for

an alcohol-use disorder in English general practice settings. In

addition, research conducted in the North East of England, which

used routine data to compare recorded rates of delivery between

general practices that were incentivized or non-incentivized for

ASBI activity, determined that overall, practices associated with

higher recorded rates of key ASBI service indicators were signed

up to pay-for-performance schemes (94). Finally, and moving the

ﬁeld beyond the UK, the ongoing EU co-funded research brief

interventions in the treatment of alcohol-use disorders in relevant

settings (BISTAIRS) project seeks to intensify the implementation

of brief alcohol intervention across Europe, including through the

identiﬁcation and dissemination of existing pockets of evidence-

based good practice in established national primary health-care

programs, with results from this work expected in 2015 (95).

CONCLUSION

This paper demonstrates that overall, there is a plentiful outcome

evaluation literature, which consistently reports positive effects of

screening and brief alcohol intervention when delivered in pri-

mary care. Much of this literature is of a moderate to high quality,

and the outcome effects persist even when the less well designed

studies are discounted from the assessment. As such, we have surely

long passed the point of needing to ask the question “do these inter-

ventions work?,” or even “do the y work in the real world of primary

care?.” Both efﬁcacy and effectiveness have been comprehensively

demonstrated through this substantial body of evidence, and inter-

vention effects seem replicable and indeed stable over time, and

across different study contexts. Indeed, with the beneﬁt of hind-

sight, the brief intervention ﬁeld seems to constitute an almost

perfect example of the evaluation of a complex intervention (96).

Early evaluations of screening and brief intervention approaches

included more tightly controlled efﬁcacy trials and were followed

by more pragmatic trials of effectiveness in routine clinical prac-

tice. Attention then shiftedto dissemination, implementation (60),

and wider-scale roll-out (97). Nevertheless, we still seem to be a

long way from consistent delivery of brief interventions to the

majority of heavy drinking patients in routine primary care, and

day-to-day implementation of this approach seems to be at best

very modest (94). Moreover, while new studies appear at regu-

lar intervals in the published literature, these are still primarily

focused on the assessment of intervention effects rather than on

how to embed brief intervention approaches in mainstream care.

No ﬁeld of research work is perfect however, and especially one

that has been evolving over a 30 year period. Consequently, it is

not surprising that a considerable degree of heterogeneity exists

within the screening and brief intervention literature or that there

can often seem to be a re-treading over previously covered ground.

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O’Donnell et al. From efﬁcacy to effectiveness and beyond

There is also a genuinely interesting and as yet unanswered ques-

tion concerning what speciﬁc factors prompt the positive changes

in alcohol consumption that occur after brief alcohol interven-

tion that undoubtedly needs further examination. However, the

search for these “active ingredients” should not delay progress

in rolling out these interventions into health systems for patient

beneﬁt. Many people do not fully understand how their car actu-

ally works, yet most still successfully drive them each day. Given

the positive evidence amassed to date, research efforts should

maintain a continued focus on promoting sustained implemen-

tation of screening and brief alcohol intervention approaches in

primary care.

Moreover, frontline practitioners responsible for the imple-

mentation of any policy or health program may make adapta-

tions based on the availability of resources, compatibility with

organizational or professional values, expertise, and knowledge

(98), resulting in their “reinvention” of the intervention (99).

The research community needs to accept this reality which might

result in some loss of scientiﬁc purity (98). For the credibility

of research in practice is judged less by its rigor than how it ﬁts

with professional wisdom and experience, and understanding of

what “best evidence” actually means in day-to-day health care

(100). Looking further forward, therefore, the key challenge for

the brief intervention ﬁeld in the future is to embrace translational

research (101), in which academics, practitioners, and policy-

makers work in closer partnership, potentially also with patients,

in order to understand their world-view more clearly, and iden-

tify mutually acceptable ways of embedding brief interventions in

practice (102).

ACKNOWLEDGMENTS

This work was in part supported by the health program of the

European Union as part of the BISTAIRS research project (agree-

ment number 2011_1204). The sole responsibility lies with the

author and the ExecutiveAgency is not responsible for any use that

may be made of the information contained therein. For further

information, visit the project website at www.bistairs.eu.

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Conﬂict of Interest Statement: The authors declare that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 18 May 2014; accepted: 12 August 2014; published online: 28 August 2014.

Citation: O’Donnell A, Wallace P and Kaner E (2014) From efﬁcacy to effectiveness

and beyond: what next for brief intervent ions in primary care? Front. Psychiatry 5:113.

doi: 10.3389/fpsyt.2014.00113

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

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Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol August 2014 | Volume 5 | Article 113 | 15

PSYCHIATRY

REVIEW ARTICLE

published: 16 July 2014

doi: 10.3389/fpsyt.2014.00085

Interpreting null ﬁndings from trials of alcohol brief

interventions

Nick Heather*

Department of Psychology, Faculty of Health and Life Sciences, Northumbria University, Newcastle uponTyne, UK

Edited by:

Peter Anderson, Newcastle

University, UK

Reviewed by:

Carla Cannizzaro, University of

Palermo, Italy

Kesong Hu, Cornell University, USA

Paul George Wallace, National

Institute of Health Research Clinical

Research Networks, UK

*Correspondence:

Nick Heather, Department of

Psychology, Faculty of Health and Life

Sciences, Northumbria University,

Northumberland Building, Newcastle

upon Tyne NE1 8ST, UK

e-mail: nick.heather@

northumbria.ac.uk

The effectiveness of alcohol brief intervention (ABI) has been established by a succession

of meta-analyses but, because the effects of ABI are small, null ﬁndings from randomized

controlled trials are often reported and can sometimes lead to skepticism regarding the

beneﬁts of ABI in routine practice. This article ﬁrst explains why null ﬁndings are likely to

occur under null hypothesis signiﬁcance testing (NHST) due to the phenomenon known

as “the dance of the p-values.” A number of misconceptions about null ﬁndings are then

described, using as an example the way in which the results of the primary care arm of

a recent cluster-randomized trial of ABI in England (the SIPS project) have been misunder-

stood. These misinterpretations include the fallacy of “proving the null hypothesis” that

lack of a signiﬁcant difference between the means of sample groups can be taken as evi-

dence of no difference between their population means, and the possible effects of this

and related misunderstandings of the SIPS ﬁndings are examined. The mistaken inference

that reductions in alcohol consumption seen in control groups from baseline to follow-up

are evidence of real effects of control group procedures is then discussed and other pos-

sible reasons for such reductions, including regression to the mean, research participation

effects, historical trends, and assessment reactivity, are described. From the standpoint

of scientiﬁc progress, the chief problem about null ﬁndings under the conventional NHST

approach is that it is not possible to distinguish “evidence of absence” from “absence of

evidence.” By contrast, under a Bayesian approach, such a distinction is possible and it is

explained how this approach could classify ABIs in particular settings or among particular

populations as either truly ineffective or as of unknown effectiveness, thus accelerating

progress in the ﬁeld of ABI research.

Keywords: alcohol-related problems, brief interventions, randomized controlled trials, null ﬁndings, null hypothesis

signiﬁcance testing, Bayesian statistics

The effectiveness of alcohol brief intervention (ABI) in reduc-

ing alcohol consumption among hazardous and harmful drinkers

is generally considered to have been demonstrated by a succes-

sion of systematic reviews with meta-analysis (1). The focus of

these reviews in terms of types of ABI and settings for imple-

mentation has varied, together with the precise form in which

effectiveness has been demonstrated (e.g., with regard to the inten-

sity of effective intervention) (2,3). The conclusions of secondary

analyses concerning, for example, gender differences in response

to ABI (2,4) have also differed. There is little good evidence as

yet for the effects of ABI on outcomes beyond consumption, e.g.,

morbidity or mortality (5). While apparently strong in the pri-

mary health care (PHC) setting, the evidence to support ABI in

emergency (6) and general hospital (7) settings is more equiv-

ocal. But despite these reservations, all meta-analytic reviews of

ABI in general and ABI in PHC in particular have found, with-

out exception, that participants who receive ABI show greater

reductions in alcohol consumption at follow-up than those who

do not.

This positive verdict on the effectiveness of ABI notwithstand-

ing, null ﬁndings from randomized or otherwise controlled trials,

in which the statistical superiority of ABI over control conditions

has not been demonstrated, frequently occur; they are often

encountered in the literature and routinely reported at scientiﬁc

conferences. Given the overall beneﬁts of ABI shown in meta-

analyses, reasons for these frequentfailures to conﬁrm effectiveness

are not obvious but it may be that the effects of ABI are sufﬁciently

small that they are difﬁcult to detect (see below), in addition to

other possible reasons. Whatever the reasons, they can have a

dispiriting effect on researchers, health care administrators, and

policy-makers. Researchers may be discouraged from pursuing

research in the ﬁeld of ABI and may not bother to submit their null

ﬁndings for publication (8). Even if papers reporting null ﬁndings

are submitted, and despite frequent admonitions that null ﬁnd-

ings based on competently designed research should be published

(9), they may be rejected by journal editors, thus possibly biasing

the results of meta-analyses. Health administrators may be per-

suaded to devote more resources to other areas of health care and

policy-makers may listen more sympathetically to the arguments

of those who are opposed to the widespread implementation of

ABI as a means of reducing alcohol-related harm in the popula-

tion (10). The damaging effects of null ﬁndings may be especially

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Heather Interpreting null ﬁndings

pronounced when they originate from large, expensively funded,

and well-publicized trials.

Another kind of problem associated with null ﬁndings is that

they may be misinterpreted, leading sometimes to inappropriate

calls for the implementation of interventions that lack support-

ing evidence. A prominent source of such misinterpretation arises

because of the classic error of “proving the null hypothesis.”Con-

fusion is also likely to arise because of the frequent ﬁnding in trials

of ABI of reductions in drinking, sometime quite large, in control

conditions. Lastly, a limitation of the interpretation of null ﬁnd-

ings under the conventional null hypothesis signiﬁcance testing

(NHST) approach to ABI research is that it is unable to distin-

guish between two potentially different conclusions: that there is

no evidence that the intervention under study is effective and that

there is evidence that it is ineffective. As we shall see,this limitation

has a retarding effect on scientiﬁc progress in this area of research.

Against this background, the issue of null ﬁndings from trials

of ABI will be discussed with the following aims:

i. To show that, even though effects of ABI in the population may

be real, it is not surprising that these effects often fail to be

detected in research trials.

ii. To describe ways in which null ﬁndings are often misunder-

stood, with potentially damaging consequences for practice and

policy on ABI.

iii. To explore one of the key characteristics of null ﬁndings in the

ﬁeld of ABI research – the tendency for control groups to show

relatively large reductions in alcohol consumption.

iv. To suggest a way in which one of main drawbacks arising from

null ﬁndings – the inability to distinguish between “absence of

evidence” and“evidence of absence” – can be overcome.

THE DANCE OF THE p-VALUES

Over the past few years a YouTube video presentation by Emeri-

tus Professor Geoff Cumming of La Trobe University, Melbourne,

VIC, Australia, entitled “The dance of the p-values,”1has been

circulating universities around the world [see also Ref. (11), p.

135–42]. Cumming amusingly and persuasively illustrates the

enormous variability in the p-value simply due to sampling vari-

ability. He claims that most researchers fail to appreciate how

unreliable the p-value is as a measure of the strength of evidence

to support a ﬁnding.

In his demonstration, Cumming considers an experiment con-

sisting of two independent groups, Experimental (E) and Control

(C), designed to investigate the effect of an intervention on a vari-

able measuring some relevant participant behavior. He assumes a

population effect of the intervention, unknown of course to the

experimenter, equivalent to an effect size of half a standard devi-

ation or Cohen’s δ=0.5, conventionally regarded as a medium

effect (12). This results in two normally distributed populations

with standard deviations of the same size. In the experiment, both

E and C groups have size N=32, giving a power to detect a

medium-sized effect of 0.52 for a two-tailed test with α=0.05.

1http://www.youtube.com/watch?v=ez4DgdurRPg&feature=youtu.be

Using his Explanatory Software for Conﬁdence Intervals (ESCI)2,

Cumming runs a simulation of 1,500 experiments by sampling

from the assumed populations and observes the resulting distri-

bution of p-values for the obtained differences between E and C

group means. These range from p=0.8 to p<0.001, even though

there has been no change in the population effect. When grouped

in a frequency histogram (Figure 1), the most frequent category

of p-values at 36.1% is those exceeding p=0.10 and clearly non-

signiﬁcant. A further 12.3% are in the questionable,“approaching

signiﬁcance” range of between p<0.10 and >0.05. Altogether,

48.4% of p-values are >0.05, meaning that by orthodox statisti-

cal practice on nearly half the occasions this experiment might be

conducted a null ﬁnding would eventuate,even though there is an

effect of intervention in the population. The other 51.6% of results

would be taken as statistically signiﬁcant but these are distributed

over the conventional labels of “signiﬁcant”(p<0.05), “highly sig-

niﬁcant”(p<0.01), and “very highly signiﬁcant” (p<0.001), even

though, again, nothing has changed in the size of the effect in the

population. Cumming likens running a single experiment under

these circumstances to visiting “the p-value casino” because the

obtained p-value will be randomly chosen from the inﬁnite series

of possible values; obtaining a statistically signiﬁcant p-value is like

winning at roulette. The calculation of effect sizes with conﬁdence

intervals gives much more reliable information on what is likely

to happen on replication (13).

It might be objected here that randomized controlled trials of

ABI are usually more powerful than the experiment in the pre-

ceding paragraph. This may be true, although sample sizes not

much different from N=32 per group are not unknown in the

scientiﬁc literature on ABI. Against that, the effect size for ABI is

likely to be smaller than δ=0.5 and is better estimated as small to

medium (14), say δ=0.35. The distribution of possible p-values

2http://www.latrobe.edu.au/psy/research/cognitive-and- developmental-psychology/

esci

p >.10 p < .10 >

.05

p < .05 p < .01 p < .001

36.1

12.3

23.4

18.4

9.8

FIGURE 1 | Frequency histogram of p-values (%) for 1,500 simulated

experiments (see text). Adapted from Cumming ((11), p. 139).

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Heather Interpreting null ﬁndings

from any given experiment depends solely on statistical power.

If the conventional recommendation for adequate power of 80%

is accepted, in a two-group comparison similar to that described

above, the sample size necessary to detect a small to medium effect

by a two-tailed t-test at the 5% signiﬁcance level and assuming

equally sized groups is 130 per group [G*Power 3.0.10, (15)]. A

minority of trials of ABI are this big and the remainder will be sub-

ject to varying degrees to the casino scenario described above. Even

with a power of 80% to detect a real but small to medium effect,

one-ﬁfth of possible p-values will fail to reach the 0.05 signiﬁcance

level and will be erroneously regarded as null ﬁndings, i.e., they

will be Type II errors. If the assumption of the effect of ABI is made

more conservatively at δ=0.2, conventionally regarded as a small

effect and arguably a minimally interesting effect of ABI, a sample

size of 394 per group is needed to give a 80% chance of detecting

an effect and very few trials of ABI are this large.

The solution to this problem of widely varying p-values carry-

ing little information is, according to Cumming (11) and to many

others, to abandon NHST in favor of estimating effect sizes with

conﬁdence intervals. He points out that this estimation approach

to research ﬁndings is standard in the “hard” sciences like physics

and chemistry, is commonly employed in most areas of medical

research, and has been recommended in the Publications Man-

ual of the American Psychological Association (16). At the same

time, NHST has been severely criticized now for over 50 years

(17) but still continues to be popular and standard practice in

many disciplines within the human sciences. Without attempting

to resolve this issue here,what can be said is that the abandonment

of NHST – and particularly the abandonment of the dichotomy

between observed differences that are“real” and those that are“just

due to chance”(18) – would be a radical solution to the problem we

are concerned with here – the difﬁculties inherent in interpreting

null ﬁndings from trials of ABI.

COMMON MISUNDERSTANDINGS OF NULL FINDINGS: THE

SIPS PROJECT

As we have seen, despite its apparent shortcomings, NHST con-

tinues to be the preferred framework for investigation in much of

psychology,psychiatry, and other branches of human science, and

is certainly still prevalent in research evaluations of the effective-

ness of ABI. (NHST as taught in textbooks today is a hybrid of the

Fisher and the Neyman–Pearson approaches and no distinctions

between these two approaches will be discussed here.) Opponents

of NHST would no doubt attribute the misunderstandings of null

ﬁndings that we will shortly consider to basic ﬂaws in the logic of

NHST (17,18).

To illustrate these misunderstandings, we will focus on the so-

called Screening and Intervention Program for Sensible drinking

(SIPS) project in England. Other research on ABI could have been

chosen for this purpose but SIPS is a recent and prominent eval-

uation, with potentially important implications for policy and

practice and from which all the necessary points may be made. The

project was funded by the UK Department of Health in 2006 fol-

lowing the publication of the Government’sAlcohol Harm Reduc-

tion Strategy for England (AHRSE) (19).In a section on Screening

and Brief Interventions, the strategy said: “. . . the research evi-

dence on brief interventions draws heavily on small-scale studies

carried out outside the UK. More information is needed on the

most effective methods of targeted screening and brief interven-

tions, and whether the successes shown in research studies can be

replicated within the health system in England. . .. The Depart-

ment of Health will set up a number of pilot schemes by Q1/2005

to test how best to use a variety of models of targeted screening and

brief intervention in primary and secondary healthcare settings,

focusing particularly on value for money and mainstreaming”

[(19), p. 43]. This led eventually to the funding of SIPS which

consisted of a pragmatic, cluster-randomized controlled trial in

each of three settings: PHC, accident and emergency services, and

the criminal justice system. At the time of writing, only the results

for the PHC trial have been published (20) and the other two trials

will not be covered here. As was clear in the Government’s remit

for this research stated above,the trials looked at issues to do with

optimal forms of screening as well as effects of different modes of

ABI but only the latter is of interest here.

The trial had a “step-up” design involving three groups in which

components were successively added: (i) a control group consist-

ing of the provision of a Patient Information Leaﬂet (PIL) together

with the brief feedback of assessment results (i.e., whether or not

the patient was drinking at a hazardous/harmful level); (ii) a brief

advice (BA) group consisting of 5 min of structured advice about

drinking plus the PIL; (iii) a brief counseling group (BLC) con-

sisting of 20 min of counseling preceded by BA and followed by

the PIL, and given to those patients who returned for a subsequent

consultation. Across three areas of England, GPs and nurses from

24 practices that had not already implemented ABI were recruited

and general practices were randomly allocated to one of the three

conditions described above. Practices were incentivized to partic-

ipate by payments amounting to £3,000 on successful completion

of stages in the project. All primary care staff taking part in the trial

were trained to deliver alcohol screening and brief intervention

according to the trial protocol. Patients aged 18 or over routinely

presenting in primary care and who screened positive on one of

the screening instruments used in the trial were eligible for entry

and a total of 756 were included. Analysis of outcomes at 6 and

12 months following intervention was by intention to treat which

included all patients randomized to study groups whether or not

they had been successfully followed up. Follow-up rates were 83%

at 6 months and 79% at 12 months. Further details of the trial

will be found in the protocol paper (21) and the main outcome

paper (20).

With respect to interventions, the main hypothesis was that

more intensive intervention would result in greater reduction in

hazardous or harmful drinking, thus BLC >BA >PIL. In this con-

text, and recalling the step-up design, the BA condition served as

a control for the speciﬁc effects of BLC, the PIL condition served

as a control for the speciﬁc effects of BA, and the PIL condition

served as a control for the combined effects of BA and BLC). In

the event, there were no signiﬁcant differences between groups on

the main outcome measure of the proportion of patients in each

group who obtained a negative score on the Alcohol Use Disorders

Identiﬁcation Test [AUDIT, Ref. (22)]. This is shown by Figure 2,

which gives these proportions at baseline, 6- and 12-month follow-

up. Neither were there signiﬁcant differences between groups on

any other alcohol outcome measure [i.e., mean AUDIT score or

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Heather Interpreting null ﬁndings

FIGURE 2 | Proportion of patients scoring <8 (negative status) on the

alcohol use disorders identiﬁcation test, representing non-hazardous

or non-harmful drinking. Reproduced from Kaner et al. [(19), p. 14].

extent of alcohol problems (23)]. A per-protocol analysis, which

included only those patients who received a complete interven-

tion and were successfully followed up, also failed to show any

signiﬁcant differences between groups.

The SIPS PHC trial was thus a well-designed and efﬁciently

conducted investigation of the effects of two forms of brief inter-

vention in real-world settings with adequate statistical power to

detect an effect of brief intervention if one existed. The null ﬁnd-

ings were no doubt disappointing to the SIPS investigators and

to many in the ABI ﬁeld. But how should these null ﬁndings be

interpreted or,of equal or possibly greater importance, how should

they not be interpreted? We will now consider a number of ways in

which the ﬁndings of the SIPS PHC trial have been misunderstood.

(i) The ﬁndings show that the three “interventions” under study

are of equal effectiveness in reducing hazardous or harmful

drinking.

This interpretation makes the classic error of “proving the null

hypothesis” (24). The logic of NHST is based on the assumption

that the null hypothesis is true. (The null hypothesis can be any

speciﬁed difference between population parameters against which

the research hypothesis is tested but in practice is almost always

taken to be the “nil hypothesis” that the samples come from pop-

ulations with identical parameters, e.g., that there is no difference

between their means.) In a comparison of an experimental ver-

sus a control procedure, the NHST method gives the conditional

probability of the occurrence of an experimental effect equal to

or greater than that observed given that the null hypothesis is true.

If that probability is sufﬁciently small at a preselected level, con-

ventionally 0.05 or smaller, the null hypothesis is rejected and

the alternative hypothesis that the samples come from different

populations is accepted. However, NHST gives us no information

whatever about the conditional probability of the null hypothesis

being true given the observed data and to imagine that it does is one

of the most common errors in the interpretation of the results of

statistical tests [(17), Chapter 3]. If the probability of the observed

difference is greater than the pre-set level for signiﬁcance, all one

can conclude is that one has failed to reject the null hypothesis, not

that the null hypothesis has been proved or in any way supported.

Put simply, it is not possible to prove something that has already

been assumed. Note, however, that it is also fallacious to believe

that the null hypothesis can eventually be “proved” by increasing

the sample size and statistical power (25). Thus, with regard to the

SIPS null ﬁndings, all that they should be interpreted as showing

is that there is no evidence from this trial that the brief interven-

tions under study are superior in effectiveness to their respective

controls – “absence of evidence,”not “evidence of absence.”

In more practical terms, in addition to sampling variability and

lack of statistical power, there may be many reasons for the failure

to observe a statistically signiﬁcant difference between experimen-

tal and control group means. It could be, for example, that the

interventions, although shown to be efﬁcacious in randomized

controlled trials conducted in ideal research conditions, are not

effective in more real-world conditions of routine practice (26)

because they have not been faithfully implemented by the prac-

titioners taking part in the trial (27) or because of some other

difference between real-world conditions and the ideal research

conditions in which efﬁcacy was demonstrated.

One particular version of the “proving the null hypothesis”

error focuses on the control condition in the SIPS trial and con-

cludes that, since the PIL and assessment feedback making up that

condition has been shown to be no less effective that the two suc-

cessively more intensive brief interventions, this shows that the

provision of an information leaﬂet combined with feedback of

assessment results can substitute in practice for ABI. Indeed, this

approach has been called “BI lite” (28). This issue will be returned

to below.

Given that the fallacy of “proving the null hypothesis” is taught

at an elementary level in courses on research methodology and

statistics all over the world, it may be found surprising that such

an error is frequently made in relation to the SIPS PHC ﬁndings.

However, the present author can attest that this error is commonly

encountered in commentaries on the SIPS ﬁndings in publications

of various kinds, in papers given and conversations overheard at

scientiﬁc conferences and other meetings, and in grant propos-

als seeking funding to pursue in some way the implications of

the misinterpreted SIPS ﬁndings. Just one example comes from

Pulse, a magazine for health professionals and which claims to

be “at the heart of general practice since 1960” (29). This arti-

cle is headed, “Patient leaﬂet enough to tackle problem drinking,

researchers suggest” and begins “GPs should give patients with

problem drinking a leaﬂet rather than advise them to reduce their

alcohol intake.” This is because: “the SIPS study found informing

patients of their drinking levels and offering a leaﬂet – handed to

patients by a practice nurse – was just as effective as giving patient

5- or 10-min of lifestyle counseling.”

A possible contribution to this level of misunderstanding may

be the fact that in some publications, the SIPS investigators

described the trials as a comparison of the effects of “three inter-

vention conditions” [e.g., Ref. (21)]. This may have led readers to

view the before–after changes in consumption shown by control

group patients as of interest in their own right and as a ﬁnding

forming part of the evidence base relevant to the effects of ABI.

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What these changes mean will be discussed in the next section of

this article but what can be said now is that the changes in the

control group cannot be considered to be a “ﬁnding” about the

effects of what was included in the control condition. At the risk

of stating the obvious, any conclusion about these effects would

have to be based on a comparison with a further non-intervention,

assessment-only control group that did not include the PIL and/or

assessment feedback, whichever of the two ingredients or their

combination was thought to be of more interest. This was clearly

recognized in the SIPS PHC outcome paper [(20), p. 5]. In view

of the extensive evidence supporting ABI in general, the control

condition used in the SIPS trials was the only kind likely to be

found ethically acceptable. However, although the composition of

the control group was perfectly defensible, to call it an interven-

tion may have misled some consumers of the trial results and it

would have been better to describe the trial in conventional terms

as having two interventions that were evaluated in comparison to

a control condition.

(ii) The PIL plus assessment feedback has been shown to be

more cost–effective than BA and brief counseling and should

therefore be implemented in practice.

This common misinterpretation is clearly related to the previ-

ous one but has more direct and very misleading implications for

practice. It is certainly true that the provision of a leaﬂet together

with information about assessment results would be cheaper to

implement than either of the two forms of ABI because it would

take less time and would require much less training to deliver.

However, the conclusion that it would be less costly, even statisti-

cally signiﬁcantly so, is all that can be claimed and, indeed,all that

was claimed by the SIPS investigators (20). The underlying mis-

take is to infer that, because the three“interventions” were equally

effective, then the less costly one must be more cost–effective but,

as we have seen, it cannot be concluded that the ABI and control

conditions were equally effective. And something cannot be called

cost–effective if there is no evidence that it is effective in the ﬁrst

place.

(iii) The reductions in consumption shown in all three groups

were caused by the“interventions” participants had received.

Again, this misunderstanding is closely related to the two pre-

viously described. The phenomenon in question will be explored

in detail in the following section. Here though it can be noted

that, by the logic of experimental research, in order to make a

causal inference of this kind it is necessary to show that reductions

in drinking shown in the ABI groups were statistically signiﬁcant

larger than those shown in their appropriate controls and this was

obviously not the case. With regard to the control group reduc-

tions, as noted above, there was no appropriate further control

for the effects of the ingredients of the SIPS control group, so no

causal inferences of any kind may be made. Thus, there was no

evidence from the SIPS PHC trial that any of the conditions under

study led to changes in participants’ drinking.

It should be stressed that the importance of these misunder-

standings is not limited to academic debates between scientists in

learned journals; they could well affect the future provision of ABI

in England and perhaps in other countries. It is well known that

there have been considerable difﬁculties in persuading GPs, nurses,

and other healthcare professionals to implement ABI routinely in

their practices; there is a copious literature on this problem (30)

and how it may be redressed (31). In surveys of health profession-

als’ attitudes to this work, one of the most commonly encountered

obstacles is “lack of time” or “too busy” (32,33). There has also

been resistance in England to the inclusion of ABI in the NHS

Quality and Outcomes Framework, under which general practices

are reimbursed for preventive activity. This has created consid-

erable pressure on the relevant sections of the Department of

Health in London (and now its replacement body for this area

of work, Public Health England) to make the interventions that

health professionals are being encouraged to implement as short

and easy to deliver as possible. So too, given the multitude of

demands on their time from a large number of health bodies,

it would be expected that many GPs would call for ABI to be

whittled down to more manageable forms. In times of austerity,

the appeal of shorter, simpler, and less expensive interventions

for widespread implementation in practice must be seductive to

policy-makers.

It is little wonder then that the misunderstandings of the SIPS

ﬁndings listed above have been used to recommend the provision

in practice of a PIL as a substitute for ABI, as in the Pulse article

mentioned above. At the risk of repetition, it is not being argued

here that this minimal kind of intervention would necessarily be

ineffective, merely that there is no good evidence at present that

it would be effective. If it is ineffective, or substantially less effec-

tive than ABI proper, and even if GPs and practice nurses deﬁnitely

prefer it, its roll-out would represent a waste of precious resources.

And before its ineffectiveness is clearly demonstrated,it might also

derail the effort to achieve the full implementation of ABI proper

that is necessary for widespread clinical beneﬁt and put back the

prospect for achieving this implementation by many years.

It might be conceded that the offer of a PIL following an assess-

ment of alcohol-related risk and harm and the feedback of the

results of that assessment could be defended on purely pragmatic

a priori grounds. Given that resources to implement ABI proper

are scarce and that most GPs and nurses are unwilling to imple-

ment anything more intensive, given too the principle that it is

unlikely to do harm and may even do some good – perhaps start-

ing a process of contemplating the need for change that might

eventually lead to action to cut down drinking (34) – this could

amount to a justiﬁcation for implementing this minimal inter-

vention (28). The claim would be that it must surely be better

than nothing. But however it is justiﬁed, it should not be by a

fallacious inference from the ﬁndings of the PHC arm of the SIPS

trial.

WHY DO CONTROL GROUPS IN TRIALS OF ALCOHOL BRIEF

INTERVENTION SHOW REDUCTIONS IN MEAN

CONSUMPTION?

Control groups in trials of ABI frequently show reductions in mean

alcohol consumption from baseline to follow-up and this was cer-

tainly the case in the SIPS PHC trial (see Figure 2). In a review

of such trials, it was calculated that control group participants

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Heather Interpreting null ﬁndings

reduce their drinking by approximately 20% (35,36). A reduction

in drinking of this size is larger than overall differences between

experimental and control groups at follow-up (2) and it is a rea-

sonable assumption that reductions in control groups of this order

may prevent the true effects of ABI from being observed (37). We

also saw that the reductions in consumption shown by control

group participants in the SIPS trial (or, rather, the increase in the

proportion of participants not showing hazardous/harmful drink-

ing – see Figure 2) has been wrongly assumed to have been caused

by the control group procedures,i.e., the provision of a PIL and/or

the feedback of assessment results. To clarify further why it is a

mistake to make this inference, we will now consider other possi-

ble reasons for reductions in control group consumption. In recent

times, our understanding of these reasons had been greatly assisted

by the work of Dr. Jim McCambridge of the London School of

Hygiene and Tropical Medicine and his various colleagues.

REGRESSION TO THE MEAN

This must be one of the most misunderstood concepts in health

care science (38). It is often thought that because, for example,

participants in a trial of an alcohol intervention are recruited at a

particularly high point in their alcohol consumption, they make

a decision to try to cut down drinking, which is reﬂected in their

lower consumption at follow-up. This is incorrect; regression to

the mean is a purely statistical phenomenon with no reference

whatever to decisions by trial participants or any other causal

factor impinging on the outcome variable of interest.

Regression to the mean can be thought of as the obverse of

correlation (39). If any two randomly distributed properties of

individuals are less than perfectly correlated in a population, then

it must be the case that extreme scorers on one of the variables will

tend to show less extreme scores on the other. This applies in both

directions; high scorers on the ﬁrst variable will tend to show lower

scores on the second and low scorers on the ﬁrst will tend to show

higher scores on the second. The smaller the correlation between

the two variables, the greater will be the tendency for those with

more extreme scores on one variable to approach the mean in their

scores on the other. In the example in which we are interested,the

two variables in question are the same participants’ scores on the

AUDIT questionnaire (22) at entry to the trial and at follow-up.

In this case, however, participants will have been selected for entry

to the trial on the basis of their relatively high scores (i.e., above

the recognized cut-point for hazardous/harmful drinking) on the

AUDIT. As a consequence, it is inevitably true that participants’

scores at follow-up will tend to be lower than at intake due only to

the nature of random ﬂuctuation and statistical correlation. The

same applies to any variable used for trial selection that is corre-

lated, but less than perfectly so, with a variable used to evaluate

outcome at follow-up.

The possible effects of regression to the mean on control group

participants in brief intervention trials were studied empirically

by McCambridge and colleagues (40). These authors gave the

AUDIT to a large cohort of university students in New Zealand

at baseline and 6 months later, without any attempt to intervene

in their drinking. Selecting from this cohort for analysis those

individuals with a baseline AUDIT score of 8+, the usual cut-

point for entry to trials of ABI, the observed mean reduction over

time was approximately half that obtained in the full sample with-

out selection. When selection was made using a series of higher

AUDIT thresholds, the observed reductions in mean alcohol con-

sumption were successively larger. This evidence suggests that a

substantial part of the reduction in consumption shown by con-

trol groups can be explained by the statistical artifact of regression

to the mean.

RESEARCH PARTICIPATION EFFECTS

This is an umbrella term referring to a range of ways in which

merely taking part in a research study can inﬂuence participants’

behavior, quite apart from any effects on behavior the researchers

may intend (41). An older term for these inﬂuences is “Hawthorne

effects,” referring to a famous series of studies from 1924 to 1933

at the Hawthorne Works of Western Electric outside Chicago. The

results of these studies were interpreted as showing that the pro-

ductivity of workers increased just through their awareness of

having their behavior monitored as part of a research project,

although other explanations are possible (42). In a systematic

review of the literature relevant to the Hawthorne effect (43), it

was concluded that the effect certainly existed but that little could

be conﬁdently known about it, including how large it was, without

more research.

The wider term “research participation effects” refers to a range

of phenomena that might introduce bias in estimates of behavior

change in randomized controlled trials. These include the effects

of signing an informed consent form and of reactions to ran-

domization – for example, disappointment or resentment at being

allocated to the control rather than the intervention condition. The

possible effects on behavior of being screened or assessed prior

to randomization will be considered below. Another important

class of research participation effects is known by psychologists as

“demand characteristics” (44). This refers to expectations partici-

pants may have about what the researcher is interested in studying

and possible attempts by them to conform, or not, to what they

think the researcher is trying to demonstrate. This source of bias

is mainly relevant to laboratory research but McCambridge and

colleagues have reviewed evidence of its possible inﬂuence on

participant behavior in non-laboratory settings (45). An obvious

example here is a tendency by a participant at research follow-up

to underestimate their alcohol consumption because they surmise

that the project is trying to reduce this outcome and they wish to

please the follow-up interviewer; alternatively, they might exagger-

ate their consumption in a deliberate attempt to undermine what

they guess is the purpose of the project. Inﬂuences of this sort

could apply both to control and intervention group participants

and represent one kind of problem with the validity of self-reports

of behavior in research trials.

HISTORICAL TRENDS

An obvious way in which the alcohol-related behavior of control

group participants might be inﬂuenced is by changes over time in

the per capita consumption of alcohol in the geographical area in

which the research is taking place. Average consumption at follow-

up compared with trial entry could be reduced due to the increased

price of alcoholic beverages, through higher taxation or in other

ways, which is known to be strongly related to consumption levels

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Heather Interpreting null ﬁndings

(46). Changes in the density of alcohol retail outlets, community

attitudes to drunkenness, stricter enforcement of drink-driving

legislation and a large number of other variables that can affect

the level of alcohol consumption in a population (47) could also

contribute to these reductions.

ASSESSMENT REACTIVITY

This last category of possible explanations for control group reduc-

tions in consumption has been the one to which most attention

has been devoted in the literature on ABI. The idea here is that

simply requiring a research participant formally to answer ques-

tions about their drinking can affect the drinking itself (48). This

might be by directing participants’ attention to their drinking and

raising the possibility in their minds that it might be hazardous or

harmful, thus leading to attempts to cut down, or in some other

unknown way. The literature has focused on the effects of research

assessment conducted after informed consent has been obtained,

which can sometime take longer to complete than the ABI itself

(49), but the effects of screening carried out prior to informed

consent and entry to the trial have also been examined (50). Possi-

ble screening effects will be included under “assessment reactivity”

in the remainder of this discussion.

McCambridge and Kypri (51) conducted a systematic review

and meta-analysis of studies in the ﬁeld of ABI that had attempted

to answer the question of whether and by how much research

assessments inﬂuence behavior by using randomized experimen-

tal methods. Ten studies were identiﬁed, of which eight provided

ﬁndings for quantitative analysis. The general conclusion of this

review was that research assessment did alter subsequent self-

reported behavior in relation to alcohol consumption but that

the effect was small, equivalent to 13.7g of ethanol per week (one

US standard drink or 11/2 UK units). On the other hand, as the

authors point out, although small, this effect amounted to about

35% of the most recent and reliable estimate of the effect of ABI

itself (2).

Of the eight studies included in the meta-analysis (51), ﬁve took

place in university student populations and might be considered

less than fully relevant to the matter at hand here. The three studies

that took place in health care settings included two in emergency

departments (52,53) and one in PHC (54). None of these studies

reported signiﬁcant effects of assessment (or, indeed, of ABI). It is

obvious that we need more studies of this kind to arrive at reliable

estimates of the effects of assessment on subsequent drinking but

at present it appears that such effects are smaller in health care

than in university student settings.

McCambridge and colleagues subsequently conducted a study

in Sweden (the AMADEUS Project) (55) to evaluate the effects of

online assessment and feedback of results from the AUDIT-C (56).

University students were randomized to groups consisting of (i)

assessment and feedback; (ii) assessment-only without feedback;

and (iii) neither assessment nor feedback. Findings were that stu-

dents in group (i) had signiﬁcantly fewer risky drinkers at 3-month

follow-up than those in group (iii), while students in group (ii)

scored lower on the AUDIT-C at follow-up that those in group

(iii). This study thus provided some evidence for the effects of

assessment and feedback on drinking behavior but ﬁndings were

short-term and inconsistent, and the effects themselves small.

To return to a consideration of the SIPS primary care ﬁndings,

it is sometimes suggested that a mere assessment of someone’s

drinking can serve as well as an ABI or, at least, will result in

a reduction in alcohol consumption that would be valuable in

busy health care settings with little time to do much else. The

notion that research assessments could be the ABIs of the future

has received serious attention (57). There are several points to

make here. First, we have just seen that the evidence to support

this suggestion is very thin; more research may reveal a different

picture but, at present, there is insufﬁcient evidence to conclude

that assessments, at least of the kind normally used in research,

can substitute for ABI as it has traditionally been conceived in

health care settings. Secondly, although they may have the effect

of inducing behavioral change by drawing attention to drinking,

questions making up conventional research assessment are not

designed explicitly to promote such change, e.g., by deliberately

seeking to foster a discrepancy between the person’s actual self-

concept in relation to drinking behavior and the drinking of their

ideal self, by asking explicitly about intentions to cut down or quit,

or by enquiring about the perceived beneﬁts of more moderate

drinking (51,58). Thus, future research might evaluate the effects

of assessments of alcohol-related behavior deliberately designed to

encourage changes in drinking. Thirdly, an appropriate research

design for the investigation of the effects of assessment reactivity

would be a non-inferiority trial (59) in which an assessment-only

condition is compared to an ABI with the hypothesis that it is not

inferior in its effects on drinking at follow-up. Using the methodol-

ogy and recommended analysis for a non-inferiority trial, it would

be possible to show that two types of intervention do not differ in

effectiveness.

Lastly, the suggestion that assessments might serve to reduce

drinking says nothing about the possible effects of feeding back

assessment results or of providing a PIL. If it is true that assess-

ments are effective in themselves, the contents of the control

condition in the SIPS trial might be entirely redundant and need

not be part of an effective intervention. On the other hand, it

is reasonable to think that assessment feedback would make an

additional contribution to change and that giving the patient infor-

mation to take away that could be consulted if the motivation to

change increases might also be an effective ingredient of inter-

vention. In the ﬁrst case, assessment feedback forms an essential

part of a type of intervention known in different circumstances to

be effective (60), albeit over two sessions, and is also integral to

Motivational Enhancement Therapy (61), albeit over three or four

sessions. In relation to the provision of a PIL, and depending on

how much information of what kind it contained, bibliotherapy

in general has been shown to be an effective means of decreasing

alcohol problems (62). The truth, however,is that we do not know

if assessments, assessment feedback or PILs are effective in them-

selves or in combination, and it is to these questions that research

should be directed.

It will not have escaped the reader’s attention that all four pos-

sible explanations above for reductions in alcohol consumption in

control groups in trials of ABI apply equally well to reductions in

intervention groups in those trials. It is precisely for that reason

that, if we wish to make real progress in implementing effective

ABIs in routine practice, we cannot avoid relying on randomized

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Heather Interpreting null ﬁndings

trials in which these factors are controlled across intervention and

control groups, leaving the only difference between groups the

intervention component under test. However, plausible current

inferences from the literature may seem in which a case is made

for the widespread introduction of assessment feedback and PIL

as a substitute for ABI proper, there is no way such a policy can

pretend to be evidence-based. If they believe at all in evidence-

based practice, those who favor the implementation of screening

followed by simple feedback and written information must be

able to show that such a procedure is superior in effectiveness to

appropriate control conditions in well-designed and sufﬁciently

powered pragmatic randomized controlled trials. To implement

this procedure without such evidence risks wasting hard-fought

gains of 30 years research on ABI.

DISTINGUISHING BETWEEN ABSENCE OF EVIDENCE AND

EVIDENCE OF ABSENCE

We saw above that, under the conventional NHST approach to

statistical inference from RCTs, when no signiﬁcant differences on

outcome measures between intervention and control groups have

been found, we are unable to distinguish between two conceivable

interpretations of these null ﬁndings: (i) there is no evidence that

the means of the two groups differ and nothing can be said about

the effectiveness of intervention one way or the other, and (ii) there

is evidence that the means do not differ, that the null hypothesis

is true and that the intervention is therefore ineffective. These two

interpretations have been shortened here to (i) absence of evi-

dence and (ii) evidence of absence. This dilemma can be applied,

of course, to more than one experimental group in comparison to

a control group, as in the SIPS PHC ﬁndings discussed above. It

is this dilemma, so this article has argued, that has held back, and

continues to hold back, progress in a scientiﬁc understanding and

beneﬁcial application of ABI.

There are two sets of unfortunate possible consequences of

this lack of information. First, in the situation where absence of

evidence is properly concluded from non-signiﬁcant ﬁndings but

there is actually no difference between means in the population,

time and resources may be wasted on continuing to search for

an effect of intervention when none in fact exists. On the other

hand, if it is improperly concluded under the NHST approach

that there is evidence of an absence of difference between means

when there is in fact a real potential effect of intervention in the

population, then an opportunity to implement, or at least to sup-

port the implementation of, an effective intervention will have

been missed. Both these kinds of negative consequence may have

interfered with progress on particular forms of ABI in the past.

More important from the present perspective, they are likely to

retard research on the effects of ABI in the many novel popula-

tions of hazardous and harmful drinkers in which it is desired to

implement ABI and the novel settings in which these drinkers may

be found.

There is, however, a solution to this problem but it means aban-

doning the NHST handling of null ﬁndings in favor of an approach

from Bayesian statistics. The Bayesian approach to the problem

of interpreting null ﬁndings has been developed recently by Dr.

Zoltán Dienes of the University of Susses (63) and this section

will rely heavily on his work. This is not the place to attempt a

complete description of Bayesian statistics but good introductions

are available (64,65), including one by Dienes (66) comparing

the Bayesian approach to statistical inference by the orthodox

approach.

Sufﬁce it to say here that Bayesian statistics is founded on a com-

pletely different philosophical understanding of probability from

conventional NHST statistics. Bayesian statistics deﬁnes proba-

bility subjectively, as a measure of the degree of conﬁdence one

has that some event will occur or that some particular hypoth-

esis is true. The conventional, Neyman–Pearson approach on

which NHST is based deﬁnes probability objectively, in terms of

long-run relative frequencies of the occurrence of events. From

this fundamental difference in the understanding of probability

all other differences ﬂow. The mantra of Bayesian statistics is:

“the posterior is proportional to the likelihood times the prior.”

Working backwards, the “prior” is the subjective probability that

a hypothesis is true before collecting data; the “likelihood” is

the probability of obtaining the observed data given that the

prior hypothesis is true; the “posterior” is the probability of the

hypothesis being true given the observed data and is calculated

by multiplying the likelihood by the prior. From the Bayesian

perspective, scientiﬁc progress consists of updating the proba-

bility of hypotheses being true in the light of observed data

(66).

While under NHST only two conclusions are possible from the

results of an experiment, either the null hypothesis is rejected or

it is not, from a Bayesian perspective there are three: (i) there is

strong evidence for the alternative hypothesis; (ii) there is strong

evidence for the null hypothesis; (iii) the data are insensitive with

respect to the alternative and null hypotheses. To determine which

of these conclusions applies to any given sets of results, it is neces-

sary to calculate something called the Bayes Factor (B). This is the

ratio of the likelihood of the observed data given the alternative

hypothesis over the likelihood of the data given the null hypoth-

esis. If this ratio is >1, the alternative hypothesis is supported;

if it is <1, the null hypothesis is supported; and if it is about 1

the experiment is insensitive and neither hypothesis is supported.

To arrive a ﬁrm decision in practice, recommended cut-offs (67)

are that B >3 represents substantial evidence for the alternative

hypothesis and B less that 1/3 represents substantial evidence for

the null hypothesis, with values in between representing a range

of weak evidence for either hypothesis depending on whether B is

greater or less than 1.

One immediate advantage of the Bayesian method is that the

researcher is forced to stipulate an alternative hypothesis in terms

of the size of the effect that, say,an intervention is expected to show

relative to a control condition and its minimum and maximum

values. While the stipulation of the alternative hypothesis is often

said to be desirable under NHST, it is rarely done. In practice, the

Bayesian researcher speciﬁes a range of population values for the

parameter of interest, say the difference between intervention and

control group means, with prior probabilities for each population

value and the way in which these probabilities are distributed over

the range of population values [(66), Chapter 4]. This procedure

facilitates good science.

It will have been noted that, although the Bayesian approach

allows the null hypothesis to be accepted, there is still an

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol July 2014 | Volume 5 | Article 85 | 23

Heather Interpreting null ﬁndings

intermediate range of values of B, conventionally between 1/3

and 3, where the evidence is weak and which can therefore be

considered a reappearance of the absence of evidence conclusion.

However, the striking difference between Bayes and NHST in this

situation is that, in the former, the researcher can quite legitimately

continue to collect data until one of the two boundary conditions,

either 3 or 1/3, is reached; this is the only “stopping rule” that

applies to data collection under Bayes. By contrast, under NHST

the collection of further data beyond the sample size given by the

power calculation and stipulated before the experiment began is

methodologically spurious and, if not openly declared, unethical.

Of course, owing to the ﬁnite nature of research funding, ﬁxed

research plans and other practical matters, it will often be impos-

sible to collect more data but the opportunity remains available in

principle under the Bayesian method. And it is important to repeat

that, even if further data collection is not possible, the information

deriving from the Bayesian approach is still superior to that from

NHST in allowing the distinction to be made between evidence of

absence and absence of evidence.

In more general terms, the battle for dominance between

Bayesian and Fisher/Neyman–Pearson statistical inference has

been waged for many years between camps of statisticians, philoso-

phers, and those researchers who take an interest in the funda-

mentals of their scientiﬁc disciplines (68). Those who favor Bayes,

and have described its varied advantages over conventional sta-

tistics, have found that change in scientiﬁc practice, especially in

the human sciences, is slow to occur. Journal editors, for example,

may be loath to accept papers based on Bayesian statistics and,

in any event, Bayesian and conventional analyses will often agree

in their conclusions. As Dienes (63) points out, however, one way

in which they do clearly disagree is in the interpretation of non-

signiﬁcant results. The solution here is to use mainly orthodox

statistics but, whenever a non-signiﬁcant result is found, to calcu-

late a Bayes factor in the interest of disambiguation. This seems an

eminently sensible solution to the problem of null ﬁndings which,

as has been argued in the article, holds back progress in the ﬁeld

of ABI research. A program for calculating Bayes Factors can be

accessed at http://www.lifesci.sussex.ac.uk/home/Zoltan_Dienes/

inference/Bayes.htm.

If this solution were adopted, when we observed a non-

signiﬁcant result from an RCT, it would be possible to conclude

that the speciﬁc form of ABI being evaluated was ineffective and

not worth pursuing further, so that precious resources would not

be wasted. On the other hand, we could conclude that it was

unclear whether the ABI in question was effective or not and that

further research was needed. The difference from the conclusion

based on the conventional perspective, however, is that we would

already have ruled out the possibility that the intervention was

ineffective. [It is also possible that the Bayes Factor could provide

evidence for the alternative hypothesis and allow the conclusion

that the intervention was effective when the conventional NHST

approach had not been able to reject the null hypothesis (63).]

This method could be applied to the non-signiﬁcant results of

trials such as SIPS to reduce uncertainly about and possible mis-

understanding of their results. The results of an analysis of SIPS

data using the Bayesian approach to null ﬁndings will form the

basis of a further communication.

ACKNOWLEDGMENTS

The author is grateful to Geoff Cumming, James Morris, and

Zoltán Dienes for useful advice on various points in this article.

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Conﬂict of Interest Statement: The present author was a Principal Investigator on

the SIPS trial that is discussed in this article and an author on papers arising from

it. He has no other possible conﬂicts of interest to declare.

Received: 15 May 2014; paper pending published: 17 June 2014; accepted: 03 July 2014;

published online: 16 July 2014.

Citation: Heather N (2014) Interpreting null ﬁndings from trials of alcohol brief

interventions. Front. Psychiatry 5:85. doi: 10.3389/fpsyt.2014.00085

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

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www.frontiersin.org July 2014 | Volume 5 | Article 85 | 26

PSYCHIATRY

REVIEW ARTICLE

published: 26 August 2014

doi: 10.3389/fpsyt.2014.00108

Mechanisms of action of brief alcohol interventions remain

largely unknown – a narrative review

Jacques Gaume1*, Jim McCambridge2, Nicolas Bertholet 1and Jean-Bernard Daeppen1

1Alcohol Treatment Center, Department of Community Health and Medicine, Lausanne University Hospital, Lausanne, Switzerland

2Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene &Tropical Medicine, London, UK

Edited by:

Antoni Gual, Hospital Clínic de

Barcelona, Spain

Reviewed by:

Henri-Jean Aubin, Hôpital Paul

Brousse, France

Nick Heather, Northumbria University,

*Correspondence:

Jacques Gaume , Alcohol Treatment

Center, Department of Community

Health and Medicine, Lausanne

University Hospital, Avenue de

Beaumont 21 bis – P2, Lausanne

1011, Switzerland

e-mail: jacques.gaume@chuv.ch

A growing body of evidence has shown the efﬁcacy of brief intervention (BI) for hazardous

and harmful alcohol use in primary health care settings. Evidence for efﬁcacy in other

settings and effectiveness when implemented at larger scale are disappointing. Indeed,

BI comprises varying content; exploring BI content and mechanisms of action may be a

promising way to enhance efﬁcacy and effectiveness. Medline and PsychInfo, as well as

references of retrieved publications were searched for original research or review on active

ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including

brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredi-

ents have been scarcely investigated, almost only within BMI, and mostly among patients

in the emergency room, young adults, and US college students. This body of research

has shown that personalized feedback may be an effective component; speciﬁc MI tech-

niques showed mixed ﬁndings; decisional balance ﬁndings tended to suggest a potential

detrimental effect; while change plan exercises, advice to reduce or stop drinking, present-

ing alternative change options, and moderation strategies are promising but need further

study. Client change talk is a potential mediator of BMI effects; change in norm percep-

tions and enhanced discrepancy between current behavior and broader life goals and values

have received preliminary support; readiness to change was only partially supported as a

mediator; while enhanced awareness of drinking, perceived risks/beneﬁts of alcohol use,

alcohol treatment seeking, and self-efﬁcacy were seldom studied and have as yet found

no signiﬁcant support as such. Research is obviously limited and has provided no clear and

consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen

in randomized trials remains mostly unknown and should be investigated to inform the

development of more effective interventions.

Keywords: brief intervention, alcohol, mechanisms, active ingredients, components, mediators, motivational

interviewing

INTRODUCTION

A growing body of evidence has shown the efﬁcacy of brief inter-

vention (BI) for hazardous alcohol use in primary health care

settings (1). In a review of systematic reviews and meta-analyses

of the effects of alcohol BI in primary health care, O’Donnell and

colleagues (1) found 34 systematic reviews covering a total of 56

randomized controlled trials reporting about 80 papers, among

which it was consistently reported that BI was efﬁcacious for

addressing hazardous and harmful drinking in primary health

care, particularly in middle-aged, male drinkers. However, even

within this important body of research, it was limited on the effects

of BI among certain groups such as women, older and younger

drinkers, minority ethnic groups, dependent and other co-morbid

drinkers, and those living in transitional and developing countries

(1). They also concluded that evidence was lacking as regards to

the optimum length and frequency of BI, as well as the optimum

content of BI. Furthermore, recent null ﬁndings from large prag-

matic trials (2,3) have called into question the extent to which

the systematic review evidence on BI efﬁcacy can be generalized to

effectiveness in routine primary care, and further pointed to the

lack of knowledge on intervention content and active ingredients.

As primary health care providers have the ability to reach a

broad population, primary health care was identiﬁed as the most

desirable setting within the health care system to screen, identify,

and deliver BI to people with hazardous or harmful drinking. As

such, most of the BI research from 1980s onward was designed

and conducted in primary health care [even though seminal stud-

ies of BI were originally conducted in the emergency department,

see Ref. (4)]. This may explain why primary health care is the set-

ting in which evidence of BI efﬁcacy has been most established.

However, BI has been implemented and tested in several other

settings such as general hospitals (5), emergency departments (6),

and colleges and universities (7,8). While BI has been shown to

produce small effects within US college settings (7,8), evidence

has been surprisingly slow to accumulate in other settings (9),

and additional research is required to investigate mixed ﬁndings,

reﬁne current practice guidelines, and continue to bridge the gap

between science and practice (10).

www.frontiersin.org August 2014 | Volume 5 | Article 108 | 27

Gaume et al. Mechanisms of brief alcohol interventions

Brief intervention is an umbrella term that is used to describe a

quite heterogeneous group of interventions, from advice to more

personalized forms of intervention based on motivational inter-

viewing (MI). This heterogeneity in intervention content may

well explain some of the inconsistencies observed in intervention

effects across studies. Differences in setting characteristics (e.g.,

ongoing vs. single contacts with health care provider, professional

training, and context of delivery) may also explain differences in

efﬁcacy.

In many ways, BI research has been conducted as if the inter-

vention could be treated as a black box,without regard for detailed

content, as has been the case for most behavioral treatments (11).

The problem is that, over the years and across studies, the black box

content has been drastically modiﬁed (12), with little, if any, care-

ful study of the implications. Researchers have not deployed the

same diligence in efforts to study BI content as has been done for

the study of the efﬁcacy of the different versions of the black box.

Conﬂicting evidence between efﬁcacy studies and pragmatic

trials, as well as between studies conducted in different contexts

and settings might be explained by the wide range of interven-

tions, and the effects of setting characteristics, on the various

hypothesized active ingredients of efﬁcacy. For these reasons, it

has been suggested that “BI content matters” in research (13) is of

great importance to identify which element of intervention may

be related to efﬁcacy, in order to develop more effective interven-

tions. It is also crucial for implementation since training clinicians

to deliver BIs is challenging, particularly so when key skills needed

for the accomplishment of key tasks remain to be clariﬁed. There-

fore, in order to establish the state of current knowledge about

which elements of content matter,we conducted a review of stud-

ies that reported on mechanisms of action of BI for hazardous or

harmful alcohol use. This is fundamentally a hypothesis generation

study, seeking to identify important targets for further study.

MATERIALS AND METHODS

INCLUSION CRITERIA

We included publications meeting the following criteria: (1) the

intervention was described as “BI,” “brief advice,” “brief moti-

vational intervention,” or “BMI”; (2) the intervention targeted

alcohol; (3) the intervention was delivered face-to-face (i.e., group

interventions and computer interventions were excluded); (4)

some mechanism of intervention effect was investigated; and (5)

the publication was either an original research article or a literature

review, published in a peer-reviewed journal. Literature reviews

were included if at least part of the content met the above crite-

ria (i.e., reviews comparing different type of interventions were

included if some but not all studied interventions met inclusion

criteria).

DATA COLLECTION

The electronic databases PubMed and PsychInfo were ﬁrst

searched for studies meeting the aforementioned inclusion cri-

teria. We had three key constructs, which were operationalized

for keywords searches as follows: active ingredient (component,

mechanism, or process); BI (brief advice, brief motivational

intervention, or BMI); and alcohol (drinking). Then, we reviewed

references of retrieved publications.

DATA ANALYSIS

Retrieved articles that met inclusion criteria were very hetero-

geneous with respect to their type, methods, and focus. It was

apparent that meta-analysis would not be appropriate or feasible.

We thus chose to analyze the retrieved articles in topics and types

of mechanisms, and to present them in a narrative review for-

mat. The key distinction in the included evidence-base pertains

to two different types of mechanisms: BI components (i.e., inter-

vention strategies, or components,that were isolated and analyzed

as possible predictors of enhanced effects), and BI effect media-

tors (i.e., psychological dimensions, psycholinguistic behaviors, or

cognitive states affected by the intervention and associated with

targeted behavior change). A short introduction and discussion of

evidence for each mechanism is presented below. The discussion at

the end of the paper offers a more general synthesis and overview

of possible implications for further developments in BI research.

RESULTS

COMPONENTS

In their early review of BI for alcohol problems (which included

both opportunistic BI for non-treatment seekers, where the

research comparison is with no or more minimal intervention,

and BI for treatment seekers, where the comparison is with longer

forms of regular treatment), Bien and colleagues (14) showed that

BI (a) were usually signiﬁcantly more effective than no inter-

vention, (b) commonly showed similar impact to that of more

extensive interventions, and (c) could enhance the effectiveness

of subsequent treatment. In the second part of this article, they

reviewed common elements of effective BIs, and six elements

summarized by the acronym FRAMES (feedback, responsibil-

ity, advice, menu, empathy, and self-efﬁcacy) were identiﬁed for

further study.

In the review of systematic reviews of alcohol BI studies in

primary health care (1), the authors found few reviews consid-

ering the impact of the actual content of interventions on their

effectiveness (15–18). In general, these reviews highlighted the

lack of available evidence on this issue, mainly due to the het-

erogeneity of the included studies (1). Whitlock and colleagues

(17) reported that all interventions demonstrating statistically sig-

niﬁcant improvements in alcohol outcomes included at least two

of the three key elements: feedback, advice, and goal setting. Dif-

ferent BI components highlighted in the empirical studies of BI

mechanisms or derived from meta-analyses are presented below.

Feedback

Early BI models have focused explicitly on feedback of risk or harm

as a tool for instigating change (14). In the review on alcohol BI in

primary health care by Bertholet and colleagues (19), all BI mod-

els but one included feedback. The role of feedback within BI has

more recently been empirically questioned in the studies reported

below.

Murphy and colleagues (20) evaluated the relative efﬁcacy of

personalized drinking feedback delivered with and without BMI

among 54 drinking college students. At 6-month follow-up, par-

ticipants in both groups showed signiﬁcant, small to moderate

reductions in alcohol consumption, but the groups did not dif-

fer. The hypothesis that a BMI would enhance the efﬁcacy of

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Gaume et al. Mechanisms of brief alcohol interventions

feedback was thus not supported. Another study (21) evaluated

the relative efﬁcacy of BMI and feedback among 122 hazardous

drinking college students. Participants were randomized to (a)

BMI with feedback, (b) BMI without feedback, (c) mailed feed-

back only, (d) BMI with mailed feedback, or (e) assessment-only

control. At 2-month follow-up, all groups reduced their consump-

tion, peak BAC, consequences, and dependence symptoms, with

no signiﬁcant difference between groups. Walters and colleagues

(22) used a similar design among 279 heavy-drinking students,

which were randomized to (a) web feedback only, (b) a single BMI

session without feedback, (c) a single BMI session with feedback,

or (d) assessment only. At 6-month follow-up, BMI with feed-

back signiﬁcantly reduced drinking, as compared with assessment

only (effect size =0.54), BMI without feedback (effect size =0.63),

and feedback alone (effect size =0.48). Neither BMI alone nor

feedback alone differed from assessment only.

One study (23) evaluated the costs and cost-effectiveness of

combining BMI with feedback to address heavy drinking among

university freshmen (i.e., ﬁrst year), with a total of 727 students

randomized to four conditions: (a) assessment only, (b) BMI

only, (c) feedback only, and (d) BMI with feedback, followed-

up 3 months later. Cost–effectiveness analyses showed that despite

being the most expensive intervention, BMI with feedback was

the most effective intervention and might be a cost–effective

intervention.

In their meta-analysis of prevention interventions for drinking

college students, Carey and colleagues (8) suggested that individ-

ual, face-to-face interventions using MI and personalized norma-

tive feedback predicted greater reductions in alcohol-related prob-

lems than other interventions. In their subsequent meta-analysis

(7), face-to-face interventions including feedback were signiﬁ-

cantly more effective on alcohol outcomes than interventions not

including it.

Brought together,the studies presented above suggest that feed-

back might be an important component of BMI, but some caveats

should be noted. Meta-analytic ﬁndings were supportive of the use

of feedback (7,8,14). These are, however, observational data, and

other study characteristics may be relevant. Studies that exper-

imentally investigated this question via dismantling the relative

efﬁcacy of feedback and BMI produced more mixed ﬁndings. Two

studies showed signiﬁcantly enhanced effects when BMI included

feedback (22,23), while two other found equivalent effects (20,21),

thus showing no impact of feedback. It must, however, be noted

that the latter two studies had smaller sample sizes. An important

limitation to these ﬁndings is that, with the exception of the meta-

analysis by Bien and colleagues (14), all studies reported above

included only US college students.

Decisional balance

The decisional balance is a brief detailing of the advantages (the

“pros”) and disadvantages (the“cons”) of behavior change, origi-

nally conceptualized by Janis and Mann (24),which has become a

critical construct in the transtheoretical model of behavior change

(25) and a common component of BI (or at least BMI).

Three studies empirically evaluated the effects of decisional bal-

ance as a stand-alone BI, or as a component of alcohol BI (26–28),

all within the US college setting. Collins and Carey (26) examined

the effects of decisional balance exercises on measures of risky

drinking among college students with alcohol-related problems

(N=131). Students were randomized to (a) an in-person 30-min

decisional balance discussion, (b) a written decisional balance, or

among the groups were found at 2-week and 6-month follow-up

on alcohol consumption, heavy-drinking episodes, alcohol con-

sumption during peak drinking occasions, and alcohol-related

problems. In another randomized controlled trial (27), the authors

compared (a) a basic BMI, (b) BMI enhanced with a decisional

balance module, and (c) an assessment-only control group. Assess-

ments at 1, 6, and 12months showed that the basic BMI improved

all drinking outcomes beyond the effects of the assessment-only

control group at 1 month, whereas the enhanced BMI did not. Risk

reduction achieved by both BMI models maintained throughout

the follow-up year. Thus, both studies did not provide support for

decisional balance as an effective component of BI or stand-alone

BI for at-risk drinking college students.

LaBrie and colleagues (28) examined the impact of decisional

balance among 47 men in the college setting. The students com-

pleted questionnaires on alcohol use and unsafe sexual practices

and were engaged in a discussion of pros and cons of decreas-

ing their drinking, but not of safer sex. One-month follow-up

data showed statistically signiﬁcant decreases in drinking, but no

change in sexual behaviors. This study thus suggests a potential

impact of decisional balance, but the small size and design of the

study limits conﬁdence in its conclusions.

Two meta-analyses also tested whether interventions includ-

ing decisional balance were more effective than interventions not

including it. In a meta-analysis of 62 controlled studies evaluating

prevention interventions for drinking college students (8), it was

suggested that the interventions were somewhat more successful

at reducing alcohol-related problems at short-term follow-up if

the intervention content contained a decisional balance exercise

(B=0.17, p=0.05). However, in their more recent meta-analytic

review of BI for college students, Carey and colleagues (7) found

that the reductions in quantity of alcohol consumption (per

week/month) were smaller when face-to-face BIs included a deci-

sional balance exercise (B=-0.60, p=0.04, 7 studies including

decisional balance compared to 26).

The abovementioned analyses showed mixed ﬁndings,and tend

to suggest a potential detrimental effect of the decisional balance

exercise. Miller and Rose (29) have suggested that decisional bal-

ance may be both theoretically and empirically contraindicated

with ambivalent people when the goal of treatment is to foster

change. They recommended that clinicians using MI to help clients

resolve ambivalence and to promote behavior change should not

include decisional balance as a part of the intervention. For these

authors, evocation of change talk (i.e., only one part of the deci-

sional balance) is more appropriate when the clinician intends to

help clients resolve ambivalence in the direction of change.

MI skills

Among the essential effective BI components summarized by

the FRAMES acronym (14), several are directly shared with MI

(30). This is the case for the emphasis on personal responsibility

for change (i.e., patients are advised that change in drinking

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Gaume et al. Mechanisms of brief alcohol interventions

is their own responsibility and choice), therapeutic empathy

as a counseling style (i.e., warm, reﬂective, and understanding

approach in opposition to directive, aggressive, authoritarian, or

coercive elements), and enhancement of client’s self-efﬁcacy for

change (i.e., optimism regarding the possibility of change rather

than emphasizing helplessness or powerlessness). In the meta-

analysis on prevention interventions for drinking college students,

Carey and colleagues (8) showed that interventions using MI

predicted greater reductions in alcohol-related problems.

Several studies did directly and empirically addressed MI skills

as active ingredients of alcohol BI and are presented below.

McNally and colleagues (31) examined the role of ﬁve MI com-

ponents in a BMI for heavy episodic alcohol use among college

students (Nnot speciﬁed, random half of 73 participants included

in the study). These components were evaluated by the students at

post-intervention. Two of these were MI skills (perceived empathy

and relative focus on personal responsibility for change). Partial

correlations were conducted between the individual component

and a composite alcohol involvement score measured at 6-week

follow-up (controlling for baseline drinking). Participants’ sub-

jective experience of the relative focus on personal responsibility

for change was not signiﬁcantly associated with outcome in these

analyses. However, ﬁndings suggested that BMI participants who

reported a greater sense of perceived empathy from the counselor

were more likely to show lower levels of alcohol involvement at

follow-up.

Feldstein and Forcehimes (32) examined the speciﬁc role of

empathy in a BMI for alcohol use among underage heavy-drinking

college students. Contrary to predictions, empathy was not corre-

lated with 2-month outcomes (binge drinking and alcohol-related

problems). Authors noted, however, that limited variability existed

for empathy, due to therapists’consistent high performance on the

empathy variable (mean of 6.92, SD =0.27 on a scale of 1–7) and

that the sample was small (N=35).

Gaume and colleagues (33) tested several counselors’ behav-

iors as predictors of change in alcohol use among patients in the

emergency department receiving BMI. Counselor’s empathy was

correlated with decreases in alcohol use (baseline to 12-month

follow-up difference) but this association was no longer signiﬁcant

when a signiﬁcant patient predictor (patient ability to change, see

below) was covaried. Using the same data, however, these authors

used multilevel models to test MI skills taking clustering within

counselors into account (34). Findings showed that counselors

with better MI skills achieved better outcomes overall and main-

tained efﬁcacy across all levels of the signiﬁcant patient predictor

mentioned above (i.e., patient ability to change). On the other

hand, counselors with poorer MI skills were effective mostly at

high levels of ability to change. Findings indicated that avoid-

ance of MI-inconsistent skills was more important than frequency

of using MI-consistent skills and that training and selection of

counselors should be based more on an overall MI-consistent atti-

tude (combining acceptance,MI spir it,confrontation and warning

avoidance, use of complex reﬂective listening, and more reﬂecting

than asking) than on particular MI techniques.

Bertholet and colleagues (35) found that MI skills measured

within three BMI studies were neither robust nor consistent

predictors of drinking outcomes. These authors coded audio

recordings of 314 BMIs across one US BMI study among

middle-aged medical inpatients with unhealthy alcohol use

(N=124) and two Swiss BMI studies among young men with

binge drinking in a non-clinical setting (N=62 and 128). In all

three studies, mean MI counselor’s rating scores were consistent

with MI proﬁciency but most MI skills were not signiﬁcantly asso-

ciated with alcohol outcomes at 3/6-month follow-up. In the US

study,confrontation (an MI-inconsistent behavior) was associated

with more drinking. Limited variability in scores was proposed by

the authors to explain this lack of effect.

The limited variability in scores points to methodological limi-

tations of the abovementioned studies. All of these were secondary

analyses of the BMI condition of randomized controlled trial,

where counselors were trained to perform high-quality BMI. On

the other hand, results from meta-analyses cited above [e.g., Ref.

(8,14)] compared BI including MI skills to BI not including

this approach. A recent study tried to address these limitations

by designing a study including heterogeneous counselors (18

counselors ranging from beginners to MI experts) and compar-

ing participants receiving a BMI with high level of MI skills to

those receiving a BMI with low MI skill level and to a control

group receiving no BMI (36). This study included non-treatment

seeking young men (age 20) screened as hazardous drinkers and

found that BMI where MI global ratings (acceptance, empathy,

and MI spirit) were high, with no MI-inconsistent behaviors,

and with a higher percentage of complex reﬂections, had bet-

ter outcomes than those having had no intervention, whereas

those with lower scores on these dimensions did not signiﬁcantly

differ from those in the non-intervention control group. Surpris-

ingly, young men receiving BMI with counselors exhibiting a high

number of MI-consistent behaviors did not signiﬁcantly differ

in outcome from those in the control group, while those hav-

ing a lower number of MI-consistent behaviors had signiﬁcantly

better outcomes. The authors proposed that the quality and the

exact combination of skills might have mattered more than the

quantity.

Two studies by Tollison and colleagues (37,38) also suggested

potential iatrogenic effects of some MI skills. Speciﬁcally, these

authors examined the association between change in the drinking

behavior of the college student and peer facilitator adherence to

MI microskills within a BMI. In the ﬁrst publication (37), results

indicated that a higher number of simple reﬂections were associ-

ated with increased rather than decreased drinking at the 3-month

assessment among the 67 participants; however, complex reﬂec-

tions were found to attenuate the effects of simple reﬂections on

changes in drinking. In a replication of this study with 327 students

(38), higher frequency of both open questions and simple reﬂec-

tions were associated with increases in drinking quantity over 5-

and 10-month follow-up. These data are not necessarily in conﬂict

with the view that MI skillfulness is an important component of

BI, as greater use of these speciﬁc microskills may be indicative of

lower overall skill. Together with results from the study by Gaume

and colleagues (36), these ﬁndings highlight the key importance of

competent reﬂective listening skills (i.e., the use of more complex

reﬂections).

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Gaume et al. Mechanisms of brief alcohol interventions

Direct advice to reduce or stop drinking, alternative change options,

and drinking moderation strategies

In their early review of BI for alcohol problems, Bien and col-

leagues (14) identiﬁed advice as the essence of BI. They further

observed that all of the interventions described in their review

contained explicit verbal or written advice to reduce or stop drink-

ing. The studies described in their review seldom prescribed a

single approach, but advised either a general goal or a range of

options. Bien and colleagues (14) consequently posited that this

“menu” of alternative change options may increase the likelihood

that an individual will ﬁnd an approach appropriate and acceptable

to his or her own situation.

In their meta-analysis of BI for college students, Carey and

colleagues (7) showed that face-to-face interventions including

moderation strategies were signiﬁcantly more effective than those

not including moderation strategies, in reducing quantity of alco-

hol consumed, frequency of heavy drinking, and alcohol-related

problems. Interventions including alcohol/BAC education also

reduced quantity of alcohol consumed signiﬁcantly more.

On the other hand, in their examination of the components

of a BMI for heavy episodic alcohol use among college students,

McNally and colleagues (31) showed that students’ (Nnot speci-

ﬁed, random half of 73 participants included in the study) subjec-

tive report of whether change options had been proposed was not

signiﬁcantly associated with 6-week alcohol outcomes.

In the study by Bertholet and colleagues (35), MI skills mea-

sured within three BMI studies were assessed, as previously

described, and giving advice was signiﬁcantly associated with

less drinking in one of the studies (BMI with 62 Swiss non-

treatment seeking young men with binge drinking in a non-clinical

setting).

Meta-analytic ﬁndings showed that BI models including advice

giving as a strategy had enhanced alcohol outcomes. However,

studies that empirically assessed advice giving gave more contrast-

ing results. It should also be noted that this kind of studies was

rare (only two studies), and the lack of study of the effects of direct

advice is striking.

Change plan

Completion of a plan to change alcohol use is an MI compo-

nent that may represent a culmination of the motivational dialog

resulting in verbal statements of intention and a written contract

for behavior change (39). Change plans are supposed to be con-

ducted only when the patient is engaged in change, when the client

and clinician are working on strengthening commitment to change

(“Phase 2” in MI), and if the patient agrees to complete one (40).

Magill and colleagues (39) examined the change plan com-

ponent within an alcohol-focused BMI among patients included

in a hospital-based clinical trial (N=291). This study examined

within-session therapist and client language predictors of a client’s

decision to complete a written change plan. Logistic regression

analyses found that therapist MI-consistent behaviors and client

change talk were signiﬁcant positive predictors, and client sustain

talk was a signiﬁcant negative predictor of the decision to complete

a change plan regarding alcohol use. This study provides ﬁrst ele-

ments to link the completion of a change plan with MI-consistent

behaviors during a BMI. However, the study did not investigate

if the completion of a change plan was associated with follow-up

alcohol outcomes.

Lee and colleagues (41) examined the potential predictive role

of the quality of an alcohol-related change plan on BMI outcomes

within an emergency department sample of injured hazardous

drinkers. A mediational analysis framework tested directional

hypotheses between pre-treatment readiness, quality of change

plan (interventionists completed the change plans with their

patients by hand and the quality of the resulting written change

plans were coded on 0–3 scale), and treatment outcomes. Partic-

ipants who completed a BMI and a change plan were included

(N=333). Pre-treatment readiness to change was signiﬁcantly

negatively associated with alcohol consequences at 12 months and

good-quality change plans. While controlling for pre-treatment

readiness to change, good-quality change plan remained a signif-

icant predictor of treatment outcomes in the expected direction.

Follow-up generalized linear modeling including an interaction

term (change plan and pre-treatment readiness) revealed that

those with high readiness and a good-quality change plan vs.

those with low readiness and a poor-quality change plan had better

than predicted outcomes for either readiness or change plan alone.

The authors concluded that their ﬁndings suggest that the change

plan may be an active ingredient of BMI associated with better

outcomes over and above the inﬂuence of pre-treatment readiness.

If further research and study replication obviously seem nec-

essary, these preliminary elements showed that the completion of

a change plan and the quality of this plan might be important

components of BMI efﬁcacy. It should be cautioned,however,that

change plans will only be completed when sessions have gone well

and change has been decided upon, so this evidence may consti-

tute a marker of successful implementation of MI skills resulting

in a change plan, rather than suggesting that a change plan may be

effective in isolation from other components.

MEDIATORS

Mediators of treatment effects might be deﬁned as psychologi-

cal dimensions, psycholinguistic behaviors, or cognitive state that

are affected by the intervention and transmitted its effects on tar-

geted behavior change. Effects may be partially or fully mediated

in this way. Full-mediation analyses (42) posit how, or by what

means, an independent variable (X) affects a dependent variable

(Y) through one or more potential intervening variables,or medi-

ators (M). Several paths are tested: path arepresents the effect of

Xon the proposed mediator(s), path bis the effect of Mon Y, and

the ab path is the indirect effect of Xon Ythrough M. A few BMI

studies empirically evaluated full-mediation models (see below).

Several studies only investigated either the aor bpaths and are

also presented below.

Readiness to change

Despite its emphasis on motivation, surprisingly little is known

about the role of motivation within BI (and particularly BMI). If

motivation or readiness is only thought about and measured pre-

intervention, this makes it a moderator rather than only a mediator

and such data were not considered here. Motivation, or readiness

to change, has been tested as a mediator of BMI’s effects in three

studies.

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Gaume et al. Mechanisms of brief alcohol interventions

Using data from three published randomized trials implement-

ing BMIs among drinking college students, Borsari and colleagues

(43) examined readiness to change as a potential mediator of inter-

vention effects. Two of the three studies indicated that BMI was

associated with increases in motivation to change alcohol use that

are apparent immediately after BMI sessions and persist up to

6-month post-intervention. However, readiness to change did not

appear to be a mechanism of behavior change, as it did not mediate

reductions in alcohol use or problems in any of the studies.

Barnett and colleagues (44) evaluated several moderators and

mediators of alcohol BMI for young adults (18–24 years; N=172)

conducted in an emergency department. Readiness to change was

evaluated as a mediator of the intervention’s efﬁcacy but no signiﬁ-

cant mediation was found. BMI was associated at the trend level to

higher readiness to change post-intervention (p<0.1), but higher

readiness to change did not predict better alcohol outcome.

Stein and colleagues (45) examined readiness to change drink-

ing as a mediator of the effects of BMI on alcohol-related conse-

quences also within an emergency department setting. Participants

were randomized into three conditions: (a) standard care plus

assessment, (b) standard care plus BMI, and (c) standard care

plus BMI plus a booster session. Patients receiving any BMI main-

tained higher readiness scores 3 months after treatment than did

patients receiving standard care. At 12-month follow-up, BMI

plus a booster session patients had signiﬁcantly reduced alcohol

consequences more than standard-care patients. However, readi-

ness mediated treatment effects only for those highly motivated to

change prior to the intervention but not for those with low pre-

intervention motivation. Authors speculated that two sessions of

BMI will be sufﬁcient to sustain the motivation to change for those

more highly motivated to change prior to the intervention,but for

those less ready to change prior to the intervention, two sessions

of BMI are insufﬁcient to motivate the patient to mobilize his or

her resources to initiate or sustain the targeted behavioral change.

Even if motivation and readiness to change are theoretically

central constructs of all BIs (and not just BMI), there are sparse

and unsupportive data as mediators of BMI effects. There are

also few investigations of motivation within the alcohol treat-

ment literature [see Ref. (46)]. Difﬁculties in measurement may

explain these ﬁndings of lack of effect. Interestingly, more detailed

analyses, such as those proposed by Stein and colleagues (45)

might help understand how interventions work. Using a mod-

erated mediation framework, these authors showed that readi-

ness to change did mediate BMI effects only under speciﬁc

circumstances. Such conditional effects might help understand

inconsistent ﬁndings.

Change talk

Motivational interviewing has been described as a collaborative

conversation style for strengthening a person’s own motivation

and commitment to change (30) and central to it is the hypoth-

esis that people are more likely to be persuaded by what they

hear themselves say (30,47). Client statements toward and against

change (or change talk and sustain talk) are thus hypothesized to

mediate MI intervention efﬁcacy (48).

Baer and colleagues (49) analyzed 54 recordings of BMI with

homeless adolescents, who used alcohol or illicit substances but

were not seeking treatment. Results indicated that statements

about desire not to change or inability to change, although infre-

quent (mean =0.61/5 min), were strongly predictive of less absti-

nence of alcohol and substance use at both 1- and 3-month follow-

up. Statements about reasons for change were associated with

greater reductions in days of substance use at 1-month assessment.

Commitment language was not associated with outcomes.

Gaume and colleagues (33,50) and Bertholet and colleagues

(51) assessed change talk during 97 BMIs in an emergency depart-

ment. They showed that MI-consistent behaviors were the only

counselor behaviors that were signiﬁcantly more likely to be fol-

lowed by patient change talk overall (i.e., aggregating the different

sub-dimensions such as ability, desire, commitment to change,

etc.) (50). Using the same data, these authors showed that patient

ability to change expressed during BMI was a signiﬁcant predic-

tor of alcohol use at 12-month follow-up (33). Patient change

talk overall was not tested as a predictor of alcohol outcomes

so that a complete chain from counselor’s behaviors to patient

change talk to outcome cannot be derived from these two stud-

ies. Nevertheless, another analysis using these data (51) suggested

that change talk might have been a mechanism of change within

this intervention. Using a hidden Markov model, analyses showed

that a patient’s attitude “toward change” at the end of the inter-

vention was associated with improved outcomes at follow-up,

independent of the type of change talk at the beginning of the

intervention.

Similar analyses were carried by the same group using data on

BMI among young men from the general population (52,53).

Again, MI-consistent behaviors were the only counselor behav-

iors that were signiﬁcantly more likely to be followed by patient

change talk overall (53) and alcohol use at 6-month follow-up was

signiﬁcantly predicted by a change talk variable combining ability,

desire, and need to change or not to change (52). Patient change

talk overall was not a signiﬁcant predictor of alcohol outcomes but

change talk averaged strength (i.e., a composite variable combin-

ing statements expressed toward change and away from change)

trended toward prediction of alcohol outcome (p=0.08). Again,

the complete chain from counselor’s behaviors to patient change

talk to outcome was not observed in these two studies, leaving the

mediation hypothesis needing to be further tested.

A full-mediation analysis was addressed in the paper by Vader

and colleagues (54). In this study, the authors examined the rela-

tionship between counselor behaviors and client change talk, per-

sonalized feedback and change talk, and client change talk and

client drinking outcome (composite score consisting of drinks per

week, peak blood alcohol concentration, and protective drinking

strategies), in a sample of heavy-drinking college students. MI

was delivered in a single session with or without a personalized

feedback report. A. In the MI with feedback group, MI-consistent

counselor’s behaviors were positively associated with client change

talk. After receiving feedback, MI with feedback clients showed

lower levels of sustain talk, relative to MI only clients. Finally,

in the MI with feedback group, clients with greater change talk

showed improved drinking outcomes at 3months, while clients

with greater sustain talk showed poorer drinking outcomes. Build-

ing on these positive ﬁndings within the MI with feedback group,

the authors tested change talk as a mediator between MI-consistent

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Gaume et al. Mechanisms of brief alcohol interventions

behaviors and drinking outcomes but observed a non-signiﬁcant

indirect effect (i.e., no evidence of mediation).

Self-efﬁcacy

Enhancing client self-efﬁcacy was previously a central compo-

nent of MI (40), which has more recently been referred to as

strengthening conﬁdence to change (30). Research on self-efﬁcacy

as a mediator has shown mixed ﬁndings, but self-efﬁcacy has not

been well evaluated in studies of BMI for alcohol use (44).

Among the heavy-drinking college students who were ran-

domly assigned to a BMI (Nnot speciﬁed, random half of 73

participants included in the study) in the study by McNally and

colleagues (31), the participants’ subjective experience of how

much the counselor encouraged self-efﬁcacy was not signiﬁcantly

associated with 6-week alcohol outcomes.

Barnett and colleagues (44) evaluated moderators and medi-

ators of brief alcohol interventions conducted in an emergency

department. Patients (18–24 years; N=172) received a BMI with

personalized feedback or feedback only, with 1- and 3-month

booster sessions and 6- and 12-month follow-up.Among the tested

mediators, self-efﬁcacy was not signiﬁcant. Individual path analy-

sis showed that higher self-efﬁcacy was signiﬁcantly associated

with lower levels of alcohol use, but randomization status (BMI

vs. feedback only) was not related to a shift in self-efﬁcacy.

Enhancement of discrepancy

Motivational interviewing seeks to develop and resolve discrep-

ancy between the individual’s current behavior and broader life

goals and values (30). McNally and colleagues (31) examined the

effects of a BMI for heavy, episodic alcohol use on discrepancy-

related psychological processes. Heavy-drinking college students

(N=73) were randomly assigned to a BMI or an assessment-only

control condition. Cognitive (actual–ideal discrepancy) and affec-

tive (cognitive dissonance) discrepancy processes were assessed at

baseline and immediately following the experimental manipula-

tion. At 6-week follow-up, BMI participants demonstrated signif-

icantly greater reductions in problematic drinking than controls.

Moreover, actual–ideal discrepancy and negative, self-focused dis-

sonance were signiﬁcantly increased following the intervention

(discomfort-related dissonance was not) and were correlated with

the outcome alcohol involvement. These discrepancy processes

did not, however, signiﬁcantly mediate the relationship between

condition and outcome.

Within the same study (31), the authors also tested whether MI

components assessed after the BMI (Nnot speciﬁed, random half

of the 73 participants) were related with alcohol outcome at 6-

week follow-up (controlling for baseline drinking). The ﬁndings

suggested that BMI participants who reported enhanced aware-

ness of their drinking were more likely to show better outcomes.

In their discussion, these authors suggested that this raised aware-

ness might be conceptualized as having a direct relationship to

discrepancy-related psychological processes as students’ conscious

awareness of their actual drinking patterns (enhanced through

personalized feedback and/or through the MI format discussion)

might raise their cognitive or affective discrepancy.

In their study evaluating moderators and mediators of emer-

gency department based BMI for young adults (18–24 years;

n=172), Barnett and colleagues (44) tested a risk-beneﬁt differ-

ence score as a potential mediator of the effect of BMI. Analysis

of individual paths showed that as compared to feedback only, the

BMI with personalized feedback group did not show the expected

shift in perceived risks/beneﬁts of drinking at 6-month follow-up.

On the other hand, a shift in perceived risks/beneﬁts at 6-month

follow-up showed a trend toward lower alcohol use (p<0.1) at

12-month follow-up. No signiﬁcant mediation was observed.

Norm perceptions

In their trial on BMI with or without feedback to reduce heavy

drinking among college students, Walters and colleagues (22) also

tested if norm perceptions did mediate the effect of the interven-

tion. They found that (a) BMI with feedback (N=73) signiﬁcantly

affected the alcohol outcomes as compared to the assessment-

only control condition (N=69); (b) the intervention reduced

norm discrepancies at 6 months, becoming more accurate in their

norm estimates (i.e., smaller discrepancies); (c) smaller norm dis-

crepancies were associated with better alcohol outcomes; and (d)

adjusting for norm discrepancies reduced the magnitude of the

intervention effect on alcohol outcomes.

Use of protective behavior and alcohol treatment seeking

Two other mediators were tested in two papers already presented

above, but were not signiﬁcant.

In their trial of BMI with or without feedback to reduce heavy

drinking among college students, Walters and colleagues (22) also

tested if the use of protective behaviors when drinking alcohol

[e.g., set a target for number of drinks, alternate alcoholic and

non-alcoholic drinks, and use a designated driver; (55)] mediated

the effect of the BMI with feedback (N=73) as compared to the

assessment-only control condition (N=69). They indicated that

protective behaviors were only weakly related to the intervention

and to the 6-month outcomes (no statistics reported) and did not

mediate the intervention effect.

Alcohol treatment seeking was tested by Barnett and colleagues

(44) within a BMI with personalized feedback for young adults

(18–24 years; n=172). Analysis of individual paths showed that

as compared to feedback only, the BMI group showed a trend

toward greater treatment seeking at 6-month follow-up (p<0.1),

but treatment seeking at 6 months was not signiﬁcantly related

with lower alcohol use at 12-month follow-up.

DISCUSSION

We conducted a review of studies reporting mechanisms of action

of BI for hazardous or harmful alcohol use. Overall, BI active

ingredients have been scarcely investigated, almost only within

BMI studies, and mostly among patients in the emergency room,

non-treatment seeking young adults, and US college student pop-

ulations. This is surprising considering that BI evidence of efﬁcacy

comes mostly and primarily from studies conducted in primary

health care settings. It may indicate that null trials have led

researchers to investigate the BI black box in search for clues as to

which elements of BI may carry efﬁcacy, a task they somewhat did

not carry in the context of efﬁcacious studies. As such, it should be

noted that some of the evidence summarized herein comes from

null trials and that almost all of it comes from research conducted

www.frontiersin.org August 2014 | Volume 5 | Article 108 | 33

Gaume et al. Mechanisms of brief alcohol interventions

in settings in which evidence of BI efﬁcacy should be considered

inconclusive [with the exception of the US colleges, see Ref. (7,8)].

On the basis of the evidence reviewed herein, we summarize

that:

(1) personalized feedback may be an effective component;

(2) decisional balance showed mixed ﬁndings, which tend to

suggest a potential detrimental effect;

(3) some MI skills and techniques showed mixed ﬁndings;

(4) direct advice to reduce or stop drinking has not been empiri-

cally studied; presenting alternative change options,and relat-

edly using a range of moderation strategies are promising but

need further study;

(5) change plan exercises are promising and need to be further

studied as discrete components and also in relation to MI

skills;

(6) client change talk is a potential mediator of BMI effects;

(7) change in norm perceptions and enhanced discrepancy have

received preliminary support, but from only one study each;

(8) enhanced awareness of drinking, perceived risks/beneﬁts of

alcohol use, alcohol treatment seeking, and self-efﬁcacy have

as yet found no signiﬁcant support as mediators, but were

seldom studied; and

(9) readiness to change was only partially supported as a mediator

of BI effect.

Readers familiar with the BI literature will notice that the

conclusions summarized here include active ingredients from

different models of BI (e.g., normative feedback, MI, and psycho-

education). The paucity of studies, especially of studies designed

speciﬁcally to investigate active ingredients of BI shows that more

research is needed. In addition, most of the evidence on active

ingredients comes from studies conducted on one particular sub-

type of BIs, i.e., those derived or adapted from MI, and is limited

to particular settings and populations (college students and young

adults, emergency department). It is important that active ingre-

dients can be identiﬁed in settings in which BI has been shown

efﬁcacious, like primary health care (1). For now, it is still unknown

how BI achieves the effects observed in these randomized trials.

Another important area for future research is BI effects on the

moderators, i.e., for whom or under which conditions BI is effec-

tive (or not). These were not the focus of our study (here we have

investigated how BI works rather than for whom), and we sug-

gest a contribution to be made on studying moderators effects,

but also on investigating moderators of mediators effects. Deter-

mining what are the active ingredients of BI, and whether these

ingredients are robust across settings and populations, is crucial to

further develop effective interventions and will aid understanding

of observed discrepancies between studies on both mediators and

effects. Which combination (if any) of active ingredients (possi-

bly across the different theoretical models of BI) is most effective

deserves to be investigated but must await progress in the areas

identiﬁed for further study.

ACKNOWLEDGMENTS

Work on this paper was supported by a Wellcome Trust Research

Career Development fellowship in Basic Biomedical Science

(WT086516MA) to Jim McCambridge.

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Conﬂict of Interest Statement: No conﬂicts of interest are to be reported. The

authors disclose that part of the studies reviewed in the present article were their

own work. They tried to consider those as objectively as possible, but some partiality

might have remained.

Received: 26 June 2014; accepted: 06 August 2014; published online: 26 August 2014.

Citation: Gaume J, McCambridge J, Bertholet N and Daeppen J-B (2014) Mechanisms

of action of brief alcohol interventions remain largely unknown – a narrative review.

Front. Psychiatry 5:108. doi: 10.3389/fpsyt.2014.00108

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

access article distributed under the terms of the Creative Commons Attribution License

(CC BY). The use, distribution or reproduction in other forums is permitted, provided

the original author(s) or licensor are credited and that the original publication in this

journal is cited, in accordance with accepted academic practice. No use, distribution or

reproduction is permitted which does not comply with these terms.

www.frontiersin.org August 2014 | Volume 5 | Article 108 | 35

PSYCHIATRY

MINI REVIEW ARTICLE

published: 03 November 2014

doi: 10.3389/fpsyt.2014.00152

Brief interventions for hazardous and harmful alcohol

consumption in accident and emergency departments

Marcin Wojnar 1,2* and Andrzej Jakubczyk1

1Department of Psychiatry, Medical University of Warsaw,Warsaw, Poland

2Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA

Edited by:

Hugo López-Pelayo, Fundació Clínic

per la Recerca Biomèdica, Spain

Reviewed by:

Luigi Janiri, Università Cattolica del

Sacro Cuore, Italy

Nicolas Bertholet, Lausanne

University Hospital, Switzerland

*Correspondence:

Marcin Wojnar, Department of

Psychiatry, Medical University of

Warsaw, Nowowiejska 27, Warsaw

00-665, Poland

e-mail: marcin.wojnar@wum.edu.pl

The prevalence of alcohol abuse among patients treated in accident and emergency depart-

ments (A&E) is considered as substantial. This paper is a narrative review of studies

investigating the effectiveness of brief interventions (BI) for hazardous and harmful alcohol

consumption in A&E. A&E departments in hospitals (and other health care infrastructures)

are commonly the place where serious consequences of alcohol drinking are seen and

need to be tackled, supporting the suggested theoretical usefulness of delivering BI in this

environment. Available research shows that BI may be considered a valuable technique

for dealing with alcohol-related problems. However, it is suggested that the usefulness of

BI may depend signiﬁcantly on the target population to be dealt with. BI have proved to

be beneﬁcial for male individuals and those patients who do not abuse other psychoac-

tive substances. In contrast, evidence indicates that BI in A&E settings are not effective

at all when dealing with men admitted as a consequence of a violence-related event. In

addition, some studies were unable to conﬁrm the effectiveness of BI in female popula-

tion, in emergency setting. Studies investigating the association between drinking patterns

and the effectiveness of BI also present inconsistent results. Most studies assessing the

effectiveness of BI in A&E settings only adopted a short perspective (looking at the impact

up to a maximum of 12months after the BI was delivered). When assessing the effects

of BI, both the amount of alcohol consumed and expected reductions in alcohol conse-

quences, such as injuries, can be taken into account. Evidence on the implementation of

brief intervention in emergency departments remains inconclusive as to whether there are

clear beneﬁts. A variety of outcome measures and assessing procedures were used in the

different studies, which have investigated this topic.

Keywords: emergency department, brief intervention, alcohol, implementation, effectiveness

INTRODUCTION

Accident and emergency departments (A&E) can be deﬁned as

a medical treatment setting specialized in acute care of patients

who are admitted presenting rapid symptoms and without prior

appointment. The prevalence of alcohol abuse among patients

treated (or least diagnosed) in this setting is considered to be

substantial. Not surprisingly, alcohol is regarded as one of the

leading causes of car accidents (1) as well as injuries in general

(2). According to different studies, up to 77% (2,3) of subjects

admitted in A&E presented an alcohol-related injury, with about

30% of patients drinking alcohol above recommended levels (4),

and between 6 and 22% (2,3) meeting the criteria of alcohol

dependence according to DSM-IV (5). It has been shown that

injuries (which are responsible for about 40% of visits to A&E)

are especially associated with alcohol drinking. A recent system-

atic review by Zerhouni et al. (6) has shown that, compared to

uninjured patients, individuals with injuries admitted into A&E

have a signiﬁcantly higher probability of presenting elevated blood

alcohol levels. Furthermore, in comparison to non-injured indi-

viduals entering A&E, injured individuals more frequently report

having drunk alcohol during the 6-h preceding the fatal event and

suffer from drinking-related consequences that adversely affect

their social life. Notably, a recent meta-analysis (7) has shown that

compared with general population, male subjects with alcohol-

use disorders had more than 6.5-fold higher risk for mortality by

injury in 10 years follow-up.

The above mentioned numbers regarding prevalence of

alcohol-related problems in A&E exceed the general frequency of

dealing with patients with problem drinking that occurs in other

medical settings (8). However, they also show that most of the vic-

tims of alcohol-related health problems admitted to A&E are not

alcohol-dependent individuals according to DSM-IV, but rather

subjects drinking alcohol in a risky or harmful way. Therefore,

actions aimed at reducing the amount of alcohol consumed but not

requiring absolute abstinence such as SBIRT (screening, brief inter-

vention, and referral to treatment ) programs may be considered

particularly useful.

The drinking pattern of special concern in A&E departments

would probably be binge drinking (deﬁned as consuming four or

more standard drinks for females and ﬁve or more standard drinks

for males on one occasion; with one standard drink containing 10 g

of pure ethanol), which has been identiﬁed as particularly risky,

www.frontiersin.org November 2014 | Volume 5 | Article 152 | 36

Wojnar and Jakubczyk Brief interventions in A&E

leading to injuries and general health consequences (9,10). More-

over, A&E is usually the place where individuals are confronted for

the ﬁrst time with serious consequences of their own or others’

alcohol drinking. Therefore, the usefulness of brief interventions

(BI) in this setting is strongly supported.

The aim of this paper was to summarize the available evi-

dence on the effectiveness of BI in A&E departments, as well as

the effectiveness of speciﬁc BI implementation strategies that have

been used in this setting. In order to do so, the Medline database

has been searched using the following terms: “brief intervention,”

“alcohol,” “emergency department,” “emergency room,” “accident

and emergency room,” “alcohol drinking,”“harmful drinking,”and

“screening.” All papers included in this review were published

during the last decade, as to provide a summary of the most

recent research results. References listed in all selected articles were

additionally searched.

EFFICACY OF BI IN ACCIDENT AND EMERGENCY

DEPARTMENTS

A systematic review performed by Nilsen et al. (11) showed that

a positive effect of BI delivered in A&E on the level of alcohol

drinking or the frequency of injuries was observed in 11 out of 12

studies. In addition, more intensive interventions were shown to

yield more positive effects. The positive effects were observed in

alcohol intake, risky drinking practices, alcohol-related negative

consequences, and injury frequency, although in different studies

different outcomes were measured and not in all of these outcome

measures a positive effect was observed. In more recent random-

ized controlled trials, the positive effect of BI has been shown to

reduce all outcomes: number of drinking days, amount of alcohol

drunk on a single occasion, as well as the negative consequences

of drinking (12). Notably, the study by Cherpitel et al. provides

evidence for effectiveness of BI itself not just as an assessment reac-

tivity (reactivity to the results of questionnaires evaluating amount

of alcohol drunk and consequences of drinking), which has been

raised as a potential mechanism of BI efﬁcacy (12). In addition,

Drummond et al. (13) showed that, contrary to the conclusions

of the review by Nilsen et al., more intensive clinical interventions

do not add signiﬁcant beneﬁts to very simple and short interven-

tions. Importantly,BI directed toward subjects in the mild range of

drinking severity have been shown to be signiﬁcantly less effective

compared to BI used in individuals within the moderate to heavy

range of drinking (12).

In available research studies on BI inA&E departments, BI were

shown to be effective in the short-term (with a follow-up measure

up to 12 months after the BI took place). Most of these studies

have assessed effectiveness in 12months of observation only (14–

17), whereas the few projects, which followed subjects for a longer

period of time, did not conﬁrm long-term effectiveness. On the

other hand, in a study by Gwaltney et al. (18) the effects of BI did

not emerge immediately after an initial session (evaluation after

1 month), but became visible later – at 3- and 6-months follow-

up visits. In a study by Woolard et al. (19), a reduction of binge

drinking days occurred and persisted also during 12 months of

observation after delivering BI; however, a signiﬁcant decrease in

the consequences of drinking (such as injuries) was not observed

when the BI group was compared to controls. However, results of

many studies, also conﬁrmed by meta-analyses (11,20), suggest

the opposite association – that BI reduces negative consequences

of alcohol rather than the amount of alcohol consumed.

The analysis of the literature shows that the results of the

studies on the effectiveness of BI in accident and emergency

departments, although in most cases encouraging, remain incon-

sistent. D’Onofrio et al. (21) described no differences in effec-

tiveness between emergency practitioner-performed Brief Nego-

tiation Interview and usual discharge instructions in terms of

either alcohol-use or alcohol-related negative consequences. As

previously described, numerous studies showed that the experi-

ence of being injured and having to be attended in an emergency

department by itself may provide enough motivation for reducing

drinking, without any alcohol-related intervention taking place

(11). Also, it has been suggested that the environment of A&E

with its chaos, hurry, and quick decisions is not a context offering

a desirable atmosphere enabling reﬂection for change (11). Finally,

in the randomized controlled clinical trial performed by Daeppen

et al. (22), no effect of BI delivered in A&E on alcohol drinking

outcomes during the follow-up was observed.

Interestingly, the use of SBIRT techniques and questionnaires

in a group of non-risky drinkers from emergency settings has

been shown to lead to increases in the amount of alcohol drunk

(23). The authors suggested as an explanation that these non-risky

drinking subjects might have felt to be low consumers and at“safe

levels” according to the presented thresholds, which emphasizes

the signiﬁcance of screening in this procedure.

GENDER PERSPECTIVE

Like in other settings (24,25), results of the studies considering

gender differences in the efﬁcacy of BI in accident and emer-

gency departments are inconsistent and conﬂicting. In a study

by Choo et al. (26) BI turned out not to be effective at all in female

participants and successful in men, but only for those without a

history of involvement in violence. Also in a study by Woodruff

et al. (27), men were more likely than women to beneﬁt from BI,

However, in another study, no differences between genders were

reported (28), whereas, in a study by Blow et al. (16), younger adult

women (ages 19–22 years) were most likely to decrease their heavy

episodic drinking after receiving brief advice. Despite these con-

tradicting ﬁndings, the general trend is for men to be more prone

to beneﬁt from BI in A&E settings. This observation is consistent

with research ﬁndings showing that alcohol misuse is commonly

a primary problem in male individuals, while in women alcohol

drinking is often associated with other psychiatric conditions (per-

sonality,depressive, or anxiety disorders) (29). Therefore,from this

perspective, interventions in women may be more effective when

aimed at psychiatric symptoms rather than drinking itself. On the

other hand, in male individuals interventions directed on drinking

itself may appear to be the most appropriate, reasonable strategy.

BRIEF INTERVENTIONS IN YOUNG INDIVIDUALS

It has been suggested that emergency departments are especially

suitable for interventions of a preventive kind as the age of patients

treated in A&E is lower than in any other medical setting, thus

allowing identiﬁcation of harmful and risky behaviors at early

stages. The results of studies conducted in young individuals are

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol November 2014 |Volume 5 | Article 152 | 37

Wojnar and Jakubczyk Brief interventions in A&E

in accordance with data concerning older patients. Two system-

atic reviews of literature concerning the effectiveness of BI in A&E

in youngsters and college drinkers show that most of the stud-

ies conﬁrm a positive effect of BI in alcohol drinking (30,31).

BI turned out to be effective in reducing alcohol intake and risky

behaviors associated with drinking [including aggression (32)],

although these effects were measured in just a short-term (up to

1 year) perspective (30,31,33). Also, similarly to adult individuals,

the female gender was shown to be associated with signiﬁcantly

weaker effects of BI in adolescents (34), and computer-assisted

SBIRT procedures were shown to be as effective as those conducted

face-to-face (33). However, due to numerous inconsistencies in the

results of previous research studies (33,35), clear conclusions con-

cerning the usefulness of delivering BI to the young population in

emergency settings cannot be drawn.

PATIENTS’ CHARACTERISTICS

Few studies have investigated the psychological factors contribut-

ing to the success (or lack of success) of BI in emergency depart-

ments. The small number of studies aimed at more sophisticated

elaboration of the procedure is, however, consistent with the core

idea of brief intervention, which is that it has to be brief, easy to

implement, and not time-consuming. Designing a study assess-

ing psychological factors and investigating detailed mechanisms

of BI effectiveness would probably mean that the whole procedure

would no longer be brief.

Brief interventions have been shown to be particularly effec-

tive in individuals who attribute their injury to alcohol (36,37),

suggesting that one of the major aims of BI in accident and emer-

gency departments may be to identify the link between alcohol and

injury. As previously mentioned (see Gender Perspective), BI were

reported to be ineffective in individuals involved in violent actions

(26). The largest reduction in drinking following discharge from

A&E without receiving a BI was observed in subjects characterized

by a history of alcohol-related accidents and injuries, and more

severe consequences of drinking in general (37). Most likely, this

was the group with highest motivation and readiness for change,

which has been identiﬁed as one of the main factors diminishing

the effectiveness of brief intervention (38).

As mentioned previously, a history of involvement in violence

(26) and comorbid misuse of other substances (than alcohol) (27)

have been shown to decrease the effectiveness of BI in A&E depart-

ments. These observations emphasize the plausible association

between the level of psychopathology (e.g., personality disorders)

and efﬁcacy of BI in accident and emergency departments. This

issue remains a possible objective for further research, although

this idea may be challenged by the concept of BI as a short, not

complicated, and easy to administer intervention.

IMPLEMENTATION OF BRIEF INTERVENTIONS IN THE

EMERGENCY SETTING

As shown above, the emergency setting seems to be an appro-

priate place to introduce BI for alcohol drinking, both from a

theoretical and a clinical perspective, whereas the efﬁcacy of BI

in A&E has been shown by the results of most of the studies. It

has been emphasized that the moment directly after an accident

or admission to A&E may be considered the most “teachable” one.

Moreover, in most of the studies reduction of drinking was even

observed in control groups not receiving BI (11), making it rea-

sonable to assume that the injury and admission to A&E by itself

constitute a motivation for change in drinking habits, and thus

a favorable moment to take advantage for delivering BI. Notably,

the implementation of BI in accident and emergency department

has also been recommended in ofﬁcial guidelines for alcohol pre-

vention (39–41). However, the speciﬁcity of A&E departments

includes brevity of contact with patients, overloading of the

staff, and engaging in numerous activities that may be consid-

ered more important and more directly associated with life-saving

approaches that remain the core of A&E functioning. In addition, a

lack of adequate training has been suggested as a signiﬁcant barrier

in implementing BI in the emergency setting (42,43).

This clear discrepancy between the needs and capabilities has

been conﬁrmed in numerous studies showing that less than one-

third of accident and emergency departments offers BI for alcohol

drinking by trained personnel (42). Such surprisingly low preva-

lence of BI implementation stimulated studies aimed at identifying

barriers and facilitators of SBIRT use in the emergency setting.

Among possible facilitators, presence of ofﬁcial guidelines and

health policy (44), as well as use of computer-assisted screen-

ing and brief intervention procedures (45,46) were emphasized.

In addition, during the introduction of a screening procedure

into everyday routine practice (47), a positive change in atti-

tudes toward screening and BI of A&E staff was observed, as they

reported to experience that the procedure worked well and that

patients were willing to cooperate.

DIFFERENT WAYS OF IMPLEMENTING BRIEF INTERVENTION

Taking into account the barriers and facilitators identiﬁed in

previous research for implementing BI in emergency settings, a

few recent research studies focused on the possibility of using a

computer-assisted SBIRT procedure in A&E. The results of these

studies show that the use of such technological supports substan-

tially increases screening rates (even up to 89–97%) (45,46), but

the outcomes in terms of effectiveness remain inconsistent (11).

Therefore, more research is needed to establish knowledge about

possible beneﬁts of technologically modiﬁed SBIRT procedures.

Other research analyzing the kinds of intervention performed,

showed that individuals for whom alcohol was not a factor

involved in the injury or cause of admission, although they pre-

sented symptoms of risky or harmful alcohol use justifying the

delivery of BI beneﬁted from a counselor-guided intervention

(consideration of the risks related to their alcohol use), whereas

subjects already experiencing previous consequences of alcohol

use did not show added beneﬁt from the counselor intervention

compared to receiving the feedback report only (28).

Telephone-applied BI delivered orally decreased impaired dri-

ving and alcohol-related injuries in patients discharged from A&E

with greatest effects for those with more severe alcohol drink-

ing (48,49). However, this type of intervention was not shown

to be effective in terms of change in alcohol consumption and

other alcohol-related consequences (49). In a recent multisite

randomized clinical trial, brief intervention using personalized

feedback delivered before the subject was discharged from A&E

and followed by a telephone booster once discharged, was shown

www.frontiersin.org November 2014 | Volume 5 | Article 152 | 38

Wojnar and Jakubczyk Brief interventions in A&E

to be the most effective way of reducing alcohol drinking in A&E

patients (50).

CONCLUSION

Available research studies show that BI may be considered a useful

technique for dealing with alcohol problems in A&E departments.

However, it is suggested that the usefulness of BI may depend sig-

niﬁcantly on the population that it is offered to. The effects of BI

can be measured both in terms of the amount of alcohol consumed

and in terms of expected reductions in alcohol consequences, such

as injuries, and therefore, different outcome measures were taken

into consideration and a variety of assessing procedures were used

in the studies addressing this topic. In addition, different methods

of BI implementation were assessed, hampering the comparison

between results. It is also important to consider that the number

of research studies on the effectiveness of BI in A&E settings is still

relatively small, while the most important methodological limita-

tion of such studies consists in the fact that in most of them BI

effectiveness was assessed in a short (up to 12 months) perspective.

Although, it may seem challenging for a brief intervention to result

in signiﬁcant long-term effects, it would be useful to examine their

effectiveness in longitudinal research studies designed for long-

term observation, also providing more insight as to whether BI

delivered in A&E departments have a signiﬁcantly greater impact

in reducing drinking and alcohol-related harm than the effect of

being admitted into A&E after an alcohol-related event in itself.

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Conﬂict of Interest Statement: The authors declare that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 01 August 2014; accepted: 17 October 2014; published online: 03 November

2014.

Citation: Wojnar M and Jakubczyk A (2014) Brief interventions for hazardous

and harmful alcohol consumption in accident and emergency departments. Front.

Psychiatry 5:152. doi: 10.3389/fpsyt.2014.00152

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

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www.frontiersin.org November 2014 | Volume 5 | Article 152 | 40

PSYCHIATRY

REVIEW ARTICLE

published: 06 October 2014

doi: 10.3389/fpsyt.2014.00131

Alcohol screening and brief intervention in workplace

settings and social services: a comparison of literature

Bernd Schulte1*, Amy Jane O’Donnell2, Sinja Kastner 1, Christiane Sybille Schmidt 1, Ingo Schäfer1and

Jens Reimer1

1Centre for Interdisciplinary Addiction Research, University Medical Centre Hamburg-Eppendorf, Hamburg University, Hamburg, Germany

2Institute of Health and Society, Newcastle University, Newcastle, UK

Edited by:

Hugo López-Pelayo, Fundació Clínic

per a la Recerca Biomédica, Spain

Reviewed by:

Roberta Agabio, University of Cagliari,

Italy

Lidia Segura, Generalitat de

Catalunya, Spain

*Correspondence:

Bernd Schulte, University Medical

Center Hamburg-Eppendorf,

Martinistraße 52 D – 20246,

Hamburg, Germany

e-mail: b.schulte@uke.de

Background:The robust evidence base for the effectiveness of alcohol screening and brief

interventions (ASBIs) in primary health care (PHC) suggests that a widespread expansion

of ASBI in non-medical settings could be beneﬁcial. Social service and criminal justice

settings work frequently with persons with alcohol use disorders, and workplace settings

can be an appropriate setting for the implementation of alcohol prevention programs, as a

considerable part of their social interactions takes place in this context.

Methods: Update of two systematic reviews on ASBI effectiveness in workplaces, social

service, and criminal justice settings. Review to identify implementation barriers and

facilitators and future research needs of ASBI in non-medical settings.

Results:We found a limited number of randomized controlled trials in non-medical settings

with an equivocal evidence of effectiveness of ASBI. In terms of barriers and facilitators to

implementation, the heterogeneity of non-medical settings makes it challenging to draw

overarching conclusions. In the workplace, employee concerns with regard to the conse-

quences of self-disclosure appear to be key. For social services, the complexity of certain

client needs suggest that a stepped and carefully tailored approach is likely to be required.

Discussion: Compared to PHC, the reviewed settings are far more heterogeneous in terms

of client groups, external conditions, and the focus on substance use disorders.Thus, future

research should try to systematize these differences, and consider their implications for the

deliverability, acceptance, and potential effectiveness of ASBI for different target groups,

organizational frameworks, and professionals.

Keywords: brief alcohol intervention, workplace health, social services, criminal justice setting

BACKGROUND

Alcohol is a signiﬁcant risk to public health (1) and globally,

heavy drinking represents the ﬁfth leading cause of morbidity

and premature death after high-blood pressure, tobacco smok-

ing, household air pollution from solid fuels, and a diet low in

fruits (2). A variety of interventions exist for the prevention and

treatment of alcohol-related risk and harm, ranging from health

promoting interventions aimed at tackling hazardous and harmful

drinking, to more intensive and specialist treatment for severely

dependent drinking (3). Alcohol screening and brief intervention

(ASBI) has emerged as an effective, and cost-effective, preven-

tative approach to reduce hazardous, and harmful drinking in

non-treatment seeking individuals, and has been shown consis-

tently to reduce the quantity, frequency, and intensity of drinking

when delivered in primary health care (PHC) settings (4).

The robust evidence for ASBI effectiveness in PHC suggests that

an extension of ASBI implementation into further settings with

groups that may be at an increased risk of alcohol-related harm

may be beneﬁcial (5). For example, while the evidence remains

equivocal, individual studies have demonstrated positive effects

of ASBI in emergency departments and general hospital wards (6,

7). Also, non-medical settings may also provide a valuable point of

contact to risky drinkers (5), and to target groups who are not rou-

tinely accessed via PHC settings. Not least, as in addition to the well

documented health harms (2), alcohol also impacts signiﬁcantly

upon individuals, families, and communities, with heavy drinkers

potentially experiencing social harms such as family disruption,

interpersonal violence (8–10), involvement in crime, problems

within the workplace, and ﬁnancial difﬁculties (11).

First, social work has a long history of working with persons

with alcohol or substance use disorders (12,13), and therefore,

social services in their various forms potentially represent an

important ﬁeld for brief intervention delivery. In an US survey

on a large and representative sample of social workers, 71% of

respondents reported having taken some action related to sub-

stance abuse diagnosis and treatment in the preceding 12 months

with clients, whereas only 2% stated substance use disorders being

their primary practice area (14). Indeed, further studies con-

ﬁrm the substantial contribution of substance misuse to a social

worker’s caseload in children’s services (8), mental health services

(15), adult’s services (16), as well as those employed within spe-

cialist drug and alcohol teams (17). Importantly, delivering ASBI

www.frontiersin.org October 2014 | Volume 5 | Article 131 | 41

Schulte et al. ASBI beyond medical settings

within a social service setting may take advantage of the teach-

able moment wherein individuals can consider their alcohol use

behavior within the context of the contact with a social worker:

an approach, which has been shown to be beneﬁcial within PHC

(18). Thus, social service and criminal justice system settings may

be another valuable point to contact further populations of risky

and hazardous drinkers who are not necessarily reached within

healthcare settings.

Second, given that alcohol is the most widely used substance

among working adults, and the fact that almost 80% of risky

drinkers are employed,workplace health services may also present

a valuable opportunity for the delivery of preventative alcohol

work. Alcohol abuse is associated with multiple negative work-

place outcomes, including absenteeism, accidents, turnover, and

other sources of productivity losses (19–23). Speciﬁc job-related

inﬂuences associated with problem drinking, including job stres-

sors and participation in work-based drinking networks, may

pose a particular problem for young adults as they try to ﬁt

in their workplace (24). Using the workplace for the provision

of alcohol prevention is important because the workplace is an

identiﬁable setting where a prevention program can be dissem-

inated (25). Further, the workplace is a traditional setting for

providing prevention messages to individuals with drinking prob-

lems (26), and therefore, a useful existing network in which

health psychologists, behavioral medics, public health profession-

als, and employers can deliver health-related messages and inter-

ventions regarding alcohol consumption that reach the majority

of employees (27). Workplaces also appear to be appropriate sites

for conducting early interventions as most people spend sub-

stantial periods of time at work (26,28). For example, 28% of

the 18 million salaried French people who are looked after by

their occupational health doctor see no other doctor during the

year (29).

Against this background, this paper examines the existing evi-

dence for the delivery of ASBI in social service and workplace

settings, and considers the challenges that providers and recip-

ients alike might experience in achieving their routine imple-

mentation. In doing so, we report on the ﬁndings of two

recent setting-speciﬁc (social services and workplace) systematic

literature reviews focused around three key questions:

1. First, what evidence is there for the effectiveness of ASBI in

social service and workplace settings?

2. Second, what barriers and facilitators exist to ASBI implemen-

tation in social service and workplace settings?

3. Third, and ﬁnally, what are the key evidence gaps and future

research needs in this area of ASBI research?

The present study aimed to update the results obtained in a pre-

vious search1conducted as part of the European Union ﬁnanced

BISTAIRS research project. Additionally, we expanded the origi-

nal research question by adding the analysis of barriers/facilitators

to ASBI implementation and by reviewing the need for future

research in these settings.

1http://bistairs.eu/material/BISTAIRS_WP4_evidence_report.pdf

METHODS

The following electronic databases were searched: Medline

(OVID); EMBASE (OVID); PsycInfo (OVID); The Cochrane

Library (Wiley); CINAHL (EBSCO); and Web of Science (Data-

bases: SCI-EXPANDED, SSCI, A&HCI) using appropriate MeSH

terms. The search was divided into three core concepts:

A. Setting: workplace, worksite, occupational, employee, or labor;

social service, social work, services for homeless people,

employment agencies, non-scholar youth work, criminal jus-

tice, and probation/rehabilitation services (including interven-

tions for trafﬁc offenders under the inﬂuence of alcohol),

and community-based institutions, e.g., (drug) counseling

centers;

B. Intervention: alcohol, brief intervention, alcohol therapy,

counseling, and early intervention; and

C. Study design: primarily randomized controlled trials (RCTs).

Additional information and further sources obtained from

experts in the ﬁeld and websites of relevant organiza-

tions/networks and reference lists of included articles were consid-

ered. The selection of studies comprised, in a ﬁrst step, screening

of title and abstract, which was also achieved by identifying key-

words for exclusion. Second, for potentially relevant articles, the

full text was retrieved and examined in-depth against a detailed

set of inclusion criteria.

Studies on the effectiveness of brief alcohol intervention in

comparison to control conditions, which were delivered in either

workplace or social service settings, and published between Jan-

uary 2002 and June 2013 in English, were eligible for inclusion.

Primarily,we aimed to include RCTs and also searched for prospec-

tive observational studies to consider them subordinately, as an

initial scoping search suggested that only a small number of RCTs

in social service and workplace settings would be identiﬁed. ASBI

was deﬁned as a single session or up to a maximum of four ses-

sions of engagement with a client or employee and the provision

of information and advice that is designed to achieve a reduction

in risky alcohol consumption or alcohol-related problems. Stud-

ies with single sessions longer than 40 min were excluded. Brief

interventions were typically compared to control conditions of

assessment only or treatment as usual.

Primary outcomes of interest included changes in self- or other-

reports of drinking quantity and/or frequency, drinking intensity

(e.g., number of drinks per drinking day), and drinking within

recommended limits. Risky drinking was deﬁned as drinking in

excess of 60 g of alcohol per day for men and 40g for women

(30). Hazardous drinking is consumption at a level, or in such

a pattern, that increases an individual’s risk of physical or psy-

chological consequences (31), while harmful drinking is deﬁned

by the presence of these consequences (32). While the concept of

workplace setting is relatively well deﬁned, the deﬁnition of the

setting “social services” is more ambiguous. We included studies

based in the following settings or populations: homeless people,

offenders under the inﬂuence of alcohol, youth work/youth wel-

fare services, employment agencies, and (drug) counseling centers.

The methodological quality of included studies was assessed using

the Cochrane risk-of-bias tool (33,34).

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol October 2014 | Volume 5 | Article 131 | 42

Schulte et al. ASBI beyond medical settings

Data were extracted from each eligible paper against a compre-

hensive data abstraction template with reference to the full article

text. For the ﬁrst review question (1), data were extracted on the

delivery context, participant characteristics, study design, inter-

vention details, outcome measures, and outcomes. The systematic

review on the effectiveness of ASBI was part of the European

Project BISTAIRS and can be read in detail elsewhere1(35).

For the second and third review questions (2 and 3), data

were extracted on any barriers to ASBI implementation identiﬁed

in each effectiveness study. Further, in order to supplement the

results for questions (2) and (3), additional guided searches were

carried out focused around the additional questions of setting-

speciﬁc implementation barriers and needs for further research.

Compared to the report published in 2012, the present study (a)

updated the search strategy; (b) used the Cochrane risk-of-bias

tool for quality assessment; (c) expanded the research question by

the analysis of barriers/facilitators; and (d) reviewed the need for

future research in these settings. No statistical analyses or meta-

analyses were conducted. Instead,the existing analyses reported in

the articles reviewed were extracted systematically, with the ﬁnd-

ings reported in a structured narrative synthesis in response to the

three overarching review questions.

RESULTS

EVIDENCE OF EFFECTIVENESS OF ASBI IN WORKPLACE SETTINGS

In this section, we provide an update of the results of our sys-

tematic review conducted in the framework for the EU project

BISTAIRS2. Compared to the report published in 2012, the present

study retrieved one additional article (36) in the workplace setting,

resulting in 9 out of 3037 studies meeting our inclusion criteria (see

Table 1). Key reasons for exclusion concerned, e.g., intervention

characteristics (too long duration or general prevention), lack of

effectiveness analyses, or inappropriate setting. The methodolog-

ical quality varied due to study design, measurements, inclusion

criteria, and analysis. Quality appraisal based on the Cochrane

collaboration’s risk-of-bias tool revealed that most studies failed

to describe in detail the approach to selection [random sequence

generation (24,36–40); allocation concealment (24,37–42)] and

performance biases [blinding of participants and personnel (24,

36–39,41,42)], resulting in the assessment of “unclear” in those

areas. The random sequence generation of the study of Osilla

et al. (41) was rated to have a “high risk-of-bias,” the reporting

of Michaud et al. (36) was regarded as incomplete.

The majority of included studies were conducted in the USA

(24,37,38,40,41), with a further three in Europe (27,36,42), with

one in Japan (39). The company employment sector varied signif-

icantly, including organizations based in the transportation, food,

and retail or manufacturing sectors. Some authors did not reveal

speciﬁc company information due to privacy agreements with the

companies. All companies were either large employers (about 1000

employees or more) or the participants were draw from several

companies. The companies’ ﬁelds of activity and general descrip-

tion of the participants’ work (blue collar or white collar) varied

2www.bistairs.eu

between studies. Araki et al. (39) surveyed factory workers and

some of the remaining studies were conducted in the service sec-

tor (24,37,42). However, the rest of the studies did not describe

the workplace characteristics of their participants.

Recruitment of participants was either via management referral

or company occupational health services. Methods for the identiﬁ-

cation of potentially harmful drinkers included adapted screening

tools (e.g., AUDIT-C) or blood tests with unspeciﬁc or speciﬁc

markers like carbohydrate-deﬁcient-transferrin (CDT).All stud-

ies excluded participants with more intensive treatment needs due

potential alcohol dependence (e.g., AUDIT score >19) or with

severe health problems. The included studies tested face-to-face

ASBI delivered by a trained counselor (27,37,41,42),or web-based

interventions, either alone (38,40) or combined with a face-to-face

approach (24,39).

All except one study (42) showed signiﬁcant reductions on

alcohol consumption for brief interventions at least in some of

their primary outcomes such as alcohol intake or numbers of

drinking days. Araki et al. (39) observed a reduction of alcohol

intake from 24.8 to 12.1 g ethanol/day. Anderson et al. (37) found

a reduction of drinking days per week (from 2.39 to 1.95), and

Osilla et al. (41) reported a signiﬁcant reduction of peak drinks

per occasion from 7.56 to 4.78 in the intervention group that

received ASBI within an employee assistance program (EAP). Sig-

niﬁcant reduction in the AUDIT score after 12 months (6.59 vs.

7.55; p=0.01) were found by Michaud et al. (36), but without

showing signiﬁcant effects in reducing hazardous drinking. The

face-to-face plus website intervention of Doumas and Hannah

(24) reduced the number of drinks per weekend from 2.42 to 1.87.

Face-to-face ASBI was as effective as the stand-alone web-based

intervention.

Three out of four studies, which used web-based interventions

reported some positive effects (24,38,40). The participants in the

intervention group of Walters and Woodall (38) decreased their

alcohol consumption by 0.87 drinks per week (DPW), whereas

those in the control group increased their consumption by 1.75

DPW. The website intervention scrutinized by Matano et al. (40)

reduced binge drinking in participants with a moderate risk for

alcohol problems by 48%,but due the inadequate sample size a fur-

ther evaluation of treatment effects is not possible. The web-based

interventions (web-based feedback and web-based feedback plus

15 min motivational interviewing) by Doumas and Hannah (24)

show signiﬁcant reductions of alcohol drinking within 30 days in

young “high-risk” binge drinkers (deﬁned by binge drinking at

least once in the past 2 weeks). In contrast to these studies, Araki

et al. (39) indicated that face-to-face educational interventions

are more effective to increase the knowledge about and attitude

toward drinking than a comparable email intervention. Notewor-

thy are the small response rates to web-based services, for instance,

the website of Matano et al. (43) was visited by only 2.7% of all

employees.

Finally, only the study by Hermansson et al. (42) found no

superiority effects of ASBI compared to controls, but showed sig-

niﬁcant reductions in both groups. Most studies used short dura-

tions for follow-up of up to 6 months, only two choose follow-up

assessment after 12 month (36,42).

www.frontiersin.org October 2014 | Volume 5 | Article 131 | 43

Schulte et al. ASBI beyond medical settings

Table 1 | Evidence of effectiveness of ASBI, implementation barriers for ASBI, and future research needs for ASBI in workplace settings.

Reference Evidence of effectiveness ofASBI Implementation barriers for ASBI Future research needs for ASBI

Hermansson

et al. (42)

Comparable reductions in all groups

over time

Long-term effectiveness of alcohol

interventions

Araki et al. (39) Reductions in alcohol intake (g/day)

for face-to face intervention

Low participation rates and group imbalances

between control- and test group

Anderson et al.

(37)

Effect for number of drinking days,

not for (peak) BAC

Low participation rates of hazardous and

harmful drinkers

Filling the knowledge gap in relation to the

cost-related outcomes of workplace ASBI

Osilla et al.

(41)

Improvements for peak drinks/day

and peak BAC; work performance

improved in both groups

Lack of therapeutic work Understand gender differences for

implementing ASBIs in EAPs

Michaud et al.

(36)

ASBI superiority for alcohol intake

(g/week) and AUDIT mean score;

reduction in AUDIT category in both

groups

High rates of “lost” patients in follow-up Evaluate important worksite cost-related

outcomes, such as health care utilization,

absenteeism rates, job performance ratings,

turnover, and reported accidents

Doumas and

Hannah (24)

Web-based and face-to face

interventions both reduced peak

consumption and weekend drinking

Tailoring an established model to young

adults in the workplace

Walters and

Woodall (38)

(Partly) signiﬁcant reductions in

drinking levels

Low participation rates of hazardous and

harmful drinkers

Matano et al.

(40)

ASBI superiority in binge-drinking

only for moderate drinkers

Potentially negative consequences of

self-disclosure

Hagger et al.

(27)

ASBI superiority in units per week,

both groups reduced binge drinking

Low participation rates of hazardous and

harmful drinkers

Does present mental simulation intervention

would have greater efﬁcacy in a sample with

hazardous levels of alcohol consumption and

higher rates of binge-drinking occasions?

AUDIT, alcohol use disorder identiﬁcation test; BAC, blood alcohol concentration; EAP, employee assistance program.

IMPLEMENTATION BARRIERS FOR ASBI IN WORKPLACE SETTINGS

Effectiveness studies of ASBI in the workplace have mostly focused

on the individual level obstacles experienced by both employers

seeking to deliver alcohol prevention activities, and those employ-

ees who might beneﬁt from such interventions. In contrast, there

was no identiﬁed data illustrating organizational obstacles to rou-

tine ASBI delivery. In particular, as in other delivery settings,

including PHC (44–46), the stigma associated with receiving an

alcohol-related intervention impacts signiﬁcantly on the imple-

mentation of ASBI in the workplace. Indeed, the reviewed studies

suggest that this may be a reason for the low-participation rates of

hazardous and harmful drinkers in this particular setting (37,38).

Employees may be anxious about participating in ASBI delivered at

their workplace because of the potentially negative consequences

of self-disclosure (43). Further, hazardous drinking is more preva-

lent in males, who are generally more inclined to reject therapeutic

interventions for mental health conditions (47). In contrast to this,

persons with a need of mental health service might more readily

accept ASBI than those without (48,49), which again might affect

ASBI completion rates and outcome measures, and limit the gen-

eralizability of the results. Finally, the evidence also suggested that

a lack of therapeutic work might be another reason for higher

drop-out rates in ASBI groups (41).

FUTURE RESEARCH NEEDS FOR ASBI IN WORKPLACE SETTINGS

The low participation and high-drop-out rates suggest that a clear

need for further research both to explore the acceptability and

feasibility of ASBI in workplace settings; and to address ques-

tions around the effective implementation of alcohol prevention

strategies in different working environments. Further, there is an

identiﬁed knowledge gap in relation to the cost-related outcomes

of workplace ASBI [such as health care utilization, absenteeism

rates, job performance ratings, turnover rates, and rate of work-

related accidents (37)]; alongside the long-term effectiveness of

alcohol interventions delivered in this setting (42).

In terms of the actual effectiveness of ASBI in the work-

place, due to the limited number of RCTs in this ﬁeld, it is not

possible to identify under which circumstances ASBI is likely

to effective, and or whether employees who work in a certain

ﬁeld would be more likely to beneﬁt from speciﬁc ASBIs. We

found no studies with workers from smaller companies and

respective ASBI approaches for those employees are missing.

In addition, most of our reviewed studies in workplace set-

tings (ﬁve out of nine) were carried out in the United States,

and thus, their outcomes cannot easily be transferred to the

different and highly variable European health care and occupa-

tional health systems. There was also an absence of studies of

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Schulte et al. ASBI beyond medical settings

workplace ASBI conducted in countries with a lower economic

status.

EVIDENCE OF EFFECTIVENESS OF ASBI IN SOCIAL SERVICES

In this section, we refer to the results of our systematic review

conducted in the framework for the EU project BISTAIRS2, which

can also be read in a critical commentary published in the BJSW

(35). Six out of 1856 studies (seven publications) met our inclu-

sion criteria (see Table 2). Reasons for exclusion included too

long duration of intervention, lack of effectiveness analyses, or

inappropriate setting. Two studies examine ASBI within homeless

populations; two of which include homeless adolescents (50) and

one study with homeless veterans (51). Another study has been

conducted in a community-based drug and alcohol counseling

center (52). In the criminal justice setting, we found three studies

for inclusion, two of them conducted with participants arrested

for driving while intoxicated (DWI) offenses (53,54), and another

among violent, alcohol-intoxicated offenders (55). These six stud-

ies show mixed results for the effectiveness of ASBI, and the

heterogeneity of settings make it challenging to compare results.

Compared to the report published in 2012, the updated search

retrieved no additional studies to be included.

Peterson et al. (50) worked with homeless substance-using ado-

lescents aged 14–19 years. Comparing brief motivational enhance-

ment to one of two control groups (assessment only or assessment

at follow-up), this study did not ﬁnd any changes in alcohol mea-

sures (days of alcohol use, standard drink units, binge drinking),

but demonstrated reductions in drug use (other than marijuana)

at 1 month follow-up. In comparison, a study by Wain et al. (51)

with alcohol-dependent homeless veterans measured the effec-

tiveness of a single session of brief motivational interviewing upon

treatment entry and completion. Treatment entry was signiﬁcantly

higher in the brief intervention group (95 vs. 71%; p=0.017);

and also length of stay, treatment completion, and graduation

was higher, although these ﬁndings failed to reach signiﬁcance

(51). The study in a community-based drug and alcohol counsel-

ing center compared BI with the more intensive CBT. Here, the

equal improvement of both BI and CBT participants in all drink-

ing outcomes (weekly units, heavy drinking days, AUDIT scores)

demonstrates a non-inferiority of ASBI, and the cost-effectiveness

score was signiﬁcantly better in the ASBI condition (52).

Among studies conducted in criminal justice settings, Watt

et al. (51) conducted a study examining intervention with violent

offenders comparing brief intervention against assessment only

and found comparable reductions in both conditions for weekly

units, number of drinking days, AUDIT scores, and heavy episodic

drinking. Furthermore, no difference in recidivism rates could be

determined during the 12-month follow-up period. However, sig-

niﬁcantly lower rates of injury (unintentional and self-harm) were

reported in the brief intervention group (27.4 vs. 39.6%) (55).

The two studies among DWI recidivists showed positive between-

group ﬁndings on drinking levels favoring brief interventions,

which approached signiﬁcance (53,54). Further, Wells-Parker

and Williams (54) investigated differential effects on individuals

with high- vs. low-depression scores (as measured by the sad-

ness/depression subscale of the Mortimer-Filkins questionnaire).

Although they failed to determine an overall superiority of adding

two brief intervention sessions and a follow-up to standard treat-

ment, rates of DWI recidivism were signiﬁcantly lower among

highly depressed participants receiving the extended brief inter-

vention (16.7% extended brief intervention vs. 25.6% standard

treatment) (54).

IMPLEMENTATION BARRIERS FOR ASBI IN SOCIAL SERVICES

As with alcohol prevention work delivered in workplace settings,

research conﬁrms that the participation rate in ASBI in social

Table 2 | Evidence of effectiveness of ASBI, implementation barriers for ASBI, and future research needs for ASBI in social services.

Reference Evidence of effectiveness ofASBI Implementation barriers forASBI Future research needs for ASBI

Peterson et al. (50) No intervention effect on alcohol measures, but

small effect on drug use

Low participation rates To link ASBIs to others homeless

services

Wain et al. (51) Higher rates of treatment entry and completion

Shakeshaft et al. (52) Non-inferiority in drinking outcomes compared

to CBT, better cost-effectiveness

Recruitment problems, as the

majority did not know how to use a

computer

Assessments of treatment

outcome should measure actual

behavior change, rather than

perceptions of counseling alone

Wells-Parker and

Williams (54)

Effect on DUI recidivism (60months) for

depressed subgroup

Social service providers might not

feel responsible for alcohol-related

interventions

Brown et al. (53) Reduction of risky drinking days in both groups Low female participation rates

Watt et al. (55) Both groups improved in weekly units, no. of

drinking days, and AUDIT score

Rather specialist referral, diagnostic

assessments, and treatment than

ASBI for high-bonded groups

AUDIT, alcohol use disorder identiﬁcation test; CBT, cognitive behavioral therapy; DUI, driving under the inﬂuence of alcohol.

www.frontiersin.org October 2014 | Volume 5 | Article 131 | 45

Schulte et al. ASBI beyond medical settings

service and criminal justice settings is low, and the drop-out rate

for follow-up is high. Further,compared to medical settings, which

focus speciﬁcally on alcohol-related problems, the implementa-

tion of ASBI in these settings might result in additional personal

challenges for social service providers, as they might not feel

responsible for alcohol-related interventions (54). However, the

lack of available evidence of ASBI in social services makes it chal-

lenging to draw ﬁrm conclusions in relation to the speciﬁc barriers

and facilitators to their successful implementation in such settings.

Moreover, the already identiﬁed heterogeneous nature of this set-

ting, potentially suggests that approaches will need to be carefully

tailored to the speciﬁc needs of different delivery contexts.

For example, looking at Peterson’s study with homeless ado-

lescents (42), given the multiple social, psychological, and health

problems often experienced by homeless adolescents, one may

conclude that a brief intervention of around 30 min is simply

not sufﬁcient to intervene with such needs. Moreover, instability

and transience characterize the lives of homeless youth, resulting

in intensive and sustained intervention being hard to achieve. In

addition, the study by Watt et al. showed that alcohol-dependent

clients are highly prevalent in services of criminal justice sys-

tems (55). More than one-third of the sample scored >20 in

AUDIT, thus, exceeding the indicative cut-off points for alcohol

dependence. As such, those clients need specialist referral, diag-

nostic assessments, and treatment, rather than ASBI. Both these

examples, suggest that a stepped-care approach of the type dis-

cussed in relation to the Wells-Parker and Williams (54) study

above, is likely to be an important consideration in designing ASBI

implementation strategies within social service settings.

FUTURE RESEARCH NEEDS FOR ASBI IN SOCIAL SERVICES

Of all the potential delivery contexts for ASBI, the evidence base

around social service settings remains arguably in its infancy.

While it may well be possible to capitalize on the substantial

progress made in this research ﬁeld in other settings (and in par-

ticular in ASBI), the low-participation/high-drop-out rates and

complex client needs suggest that a strong need for further work

to explore the feasibility and acceptability of ASBI work in this

varied and challenging delivery context.

DISCUSSION

In stark contrast to the robust and comprehensive literature sup-

porting their effectiveness in PHC, the ASBI research ﬁeld in

non-medical settings paints a far more complex, patchy, and var-

ied picture of what works best, in which contexts, and with whom.

Since our previously published BISTAIRS project report (REF),

this picture has changed little, with only one additional study

retrieved in the search update. As such,the evidence base for ASBI

in non-medical settings remains sparse.

While the results of this review provide some encouraging sup-

port for ASBI delivery in workplace settings, it also highlights the

fact that there has been little attention paid to research based in

this context to date, despite this being where millions of working-

age adults spend most of their day. Currently, the development of

ASBI workplace approaches has been restricted to occupational

health services in large factories, and therefore, little is known

about whether such strategies would be transferable to smaller

organizations, or to businesses outside the manufacturing or con-

struction sectors. Nevertheless, although the evidence does not

yet suggest any clear recommendation for a widespread imple-

mentation of workplace ASBI, occupational health services could

consider offering brief advice to employees who are considered

as drinking in a risky or potentially harmful way. A useful toolkit

and manual has been issued by the European workplace and alco-

hol (EWA) project (56). Further, the evidence does emphasize the

importance of the existence of comprehensive alcohol at work pol-

icy, embedded within overall healthy living policies and actions at

the workplace, that take into account the structural and working

environments that increase risky drinking in the ﬁrst place (57).

Results of the Swedish Risk Drinking Project, which implemented

tailored training courses around ASBI in a large number of pri-

mary, maternal, and occupational health services, demonstrated

improvements in knowledge, self-efﬁcacy, and alcohol-preventive

activity in occupational health services, especially in nurses, who

were afforded a key role in the project (58).

The evidence base for ASBI in social services is essentially non-

existent, and although some reviews (59) and some trials (60)

have included social service settings, it is difﬁcult to identify a

clear positive impact of brief advice programs. The UK criminal

justice system – screening and intervention program for sensible

drinking (SIPS) trial found evidence for an impact of receipt of a

patient information leaﬂet, brief advice, and brief lifestyle coun-

seling, with no differences between the three interventions (61).

Thus, because of the paucity of evidence, rather than suggesting

comprehensive delivery of roll-out of brief advice programs in

social service settings, it might be more beneﬁcial at this stage to

gather further evidence as to the acceptability and feasibility of

ASBI in social service settings, generating useful system readiness

data, until more evidence for effectiveness is gathered.

In particular, for example, future studies need to consider what

setting-speciﬁc differences exist (in terms of client–patient target

groups, institutional characteristics, or acceptance among pro-

fessionals), and to assess how these differences might inﬂuence

the deliverability, acceptance, and potential effectiveness of ASBI.

Receiving and delivering alcohol interventions in the types of

non-medical settings described in this paper entails a range of

client–provider relationships and expectations that are arguably

not easily comparable to those evident in generalist medical set-

tings. In PHC, for example, individual patients often build up

long-term, positive relationships with their GP and practice nurse

(62), and (crucially) are generally motivated to enter into such

relationships for primarily health-related reasons. ASBI strategies

that prove successful in PHC,therefore, may not be appropriate for

implementation in the workplace, where employer and employee

are necessarily ﬁnancially committed to each other. However, in

the framework of occupational health services, a setting, which is

more comparable to PHC, this barrier might be reduced, as occu-

pational health staff is supposed to keep conﬁdentiality. Another

difﬁculty to the acceptance of ASBI may arise in criminal justice

systems, where offenders are engaged in an involuntary, legally

binding relationship with their probation workers as a result of

“deviant” behavior.

Further, and in particular, in respect of ASBI in social service

settings, one might also question whether a focus on drinking

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol October 2014 | Volume 5 | Article 131 | 46

Schulte et al. ASBI beyond medical settings

reductions is a realistic and achievable ﬁrst-line goal for all target

groups that social service professionals might come into contact

with. The studies with homeless people (who generally have more

needs and numerous impairments other than alcohol abuse), sug-

gest that brief approaches may be unlikely to reduce drinking levels

in certain patient populations (50,51,63), but that other factors

might be successfully addressed, such as rates of entry in addiction

treatment (51) and service utilization (63). Further, the results of

Wells-Parker and Williams (54) in DWI offenders with high rates

of depression and low self-efﬁcacy, but high willingness to reduce

consumption suggest that additional motivational components

might not be necessary for all risky drinkers to achieve drinking

reductions, but they may be of relevance for particular subgroups.

Providing extended interventions only to those in need, is in line

with stepped-care approaches (64). For certain client groups, BI

approaches might thus more serve as a“door-opener,” in the sense

of enabling referral to other services, and should not be seen as a

tool, which directly inﬂuences the amount of drinking.

At the same time, and while recognizing the heterogeneous

nature of the social services evidence base, it was notable that in

all except one study in these settings (homeless youth), control

groups achieved comparable reductions in their drinking levels

over time. This is in line with previous ﬁndings from ASBI stud-

ies in the medical ﬁeld. For example, drinking reductions ranging

between 10 and 40% among participants in control groups were

shown in reviews by Jenkins et al. (65) and Bernstein et al. (66). A

further review by McCambridge and Kypri (67) comparing longer

vs. shorter (or no) assessment found reductions in weekly con-

sumption levels attributable to interview procedures. In addition,

the recent SIPS trials, conducted in primary care practices, could

not determine a signiﬁcant additional beneﬁt of brief advice or

lifestyle counseling over and above the provision of short person-

alized feedback and provision of a leaﬂet (68). This non-inferiority

of “control” conditions might suggest that the implementation of

any kind of very brief alcohol interventions may be of value, even

in these challenging settings.

In conclusion, therefore, the overriding message is that “more

research is needed,” and in particular, that there is a strong need

for more robust ASBI trials in non-medical settings in order to

address the identiﬁed knowledge gaps on obstacles and difﬁcul-

ties in ASBI implementation in these settings. In tandem with

outcome assessments, information on the acceptability and feasi-

bility of ASBI in their various forms are needed to provide data

on the system readiness for workplace and social care settings,

rather than focusing solely on demonstrating ASBI effectiveness.

However, given the large existing evidence base for ASBI in PHC

and other health settings, which has taken decades to accrue, it is

nevertheless to be hoped that alcohol prevention work in occupa-

tional and social service settings might gain from this substantial

body of knowledge in order accelerate the evaluative process and

achieve the potential beneﬁts for clients and employees in a far

shorter time-frame.

ACKNOWLEDGMENTS

This work was in part supported by the health program of the

European Union as part of the BISTAIRS research project (Agree-

ment number 2011_1204). The sole responsibility lies with the

author and the ExecutiveAgency is not responsible for any use that

may be made of the information contained therein. For further

information, visit the project website at www.bistairs.eu.

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Conﬂict of Interest Statement: The authors declare that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 16 June 2014; accepted: 05 September 2014; published online: 06 October

2014.

Citation: Schulte B, O’Donnell AJ, Kastner S, Schmidt CS, Schäfer I and Reimer J

(2014) Alcohol screening and brief intervention in workplace settings and s ocial services:

a comparison of literature. Front. Psychiatry 5:131. doi: 10.3389/fpsyt.2014.00131

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

an open-access article distributed under the terms of the Creative Commons Attribution

License (CC BY). The use, distribution or reproduction in other forums is permitted,

provided the original author(s) or licensor are credited and that the original publica-

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distribution or reproduction is permitted which does not comply with these terms.

www.frontiersin.org October 2014 | Volume 5 | Article 131 | 49

PSYCHIATRY

MINI REVIEW ARTICLE

published: 02 September 2014

doi: 10.3389/fpsyt.2014.00121

Screening and brief intervention for unhealthy drug use:

little or no efﬁcacy

Richard Saitz1,2*

1Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA

2Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University

School of Medicine, Boston, MA, USA

Edited by:

Hugo López-Pelayo, Fundació Clínic

per la Recerca Biomèdica, Spain

Reviewed by:

Pablo Barrio, Clinic Hospital

Barcelona, Spain

Laia Miquel, University Hospital Clínic

de Barcelona, Spain

*Correspondence:

Richard Saitz, Department of

Community Health Sciences, Boston

University School of Public Health,

801 Massachusetts Avenue 4th ﬂoor,

Boston, MA 02118, USA

e-mail: rsaitz@bu.edu

Unhealthy drug use ranges from use that risks health harms through severe drug use dis-

orders. This narrative review addresses whether screening and brief intervention (SBI),

efﬁcacious for risky alcohol use, has efﬁcacy for reducing other drug use and conse-

quences. Brief intervention among those seeking help shows some promise. Screening

tools have been validated though most are neither brief nor simple enough for use in gen-

eral health settings. Several randomized trials have tested the efﬁcacy of brief intervention

for unhealthy drug use identiﬁed by screening in general health settings (i.e., in people not

seeking help for their drug use). Substantial evidence now suggests that efﬁcacy is limited

or non-existent. Reasons likely include a range of actual and perceived severity (or lack of

severity), concomitant unhealthy alcohol use and comorbid mental health conditions, and

the wide range of types of unhealthy drug use (e.g., from marijuana, to prescription drugs,

to heroin). Although brief intervention may have some efﬁcacy for unhealthy drug users

seeking help, the model of SBI that has effects in primary care settings on risky alcohol

use may not be efﬁcacious for other drug use.

Keywords: screening and brief intervention, unhealthy drug use, illicit drug, efﬁcacy, randomized trials,counseling,

identiﬁcation, primary care

INTRODUCTION

Screening and brief intervention (SBI) for unhealthy alcohol use

in primary care is among the most effective and cost-effective of

preventive services (1). Unhealthy alcohol use is the target and

is deﬁned as the spectrum from use that increases the risk for

health consequences through a diagnosable alcohol use disorder

(2). No randomized trials have compared SBI to no SBI for alco-

hol. Numerous studies in primary care ﬁnd efﬁcacy for BI vs. no

BI among patients identiﬁed by screening for modest reductions

in self-reported alcohol consumption (3). Although efﬁcacy has

yet to be demonstrated for moderate to severe alcohol use dis-

orders (also known as dependence) (4–6), the conceptual model

includes referral to specialty treatment as one of the goals of brief

intervention for those with more severe conditions.

Brief counseling has also been applied to other health behav-

iors, such as medication adherence, nutrition, tobacco use, and

physical activity with some success (7). Since the principles may

be the same regardless of the health behavior there has been

optimism that SBI will have efﬁcacy for other drugs. Unhealthy

drug use is deﬁned as use of illicit drugs or potentially addic-

tive medications more than prescribed or without a prescription.

The US government has spent approximately half a billion dollars

in the past decade on clinical programs to screen and provide

brief intervention for alcohol and other drugs (8). Given the

impact of drug use on health and the need to address drug use

in general health settings, knowing whether SBI has efﬁcacy for

preventing or reducing drug use and consequences takes on great

importance.

Observational studies have suggested possible effectiveness of

drug SBI. For example, Madras et al. (9) conducted a before/after

study and 6 months after screening found a 68% decrease in self-

reported drug use and improvements in overall health, employ-

ment, criminal justice involvement, and housing status. The effect

size is much larger than any ever seen in a randomized trial of

a similar intervention and is not plausibly attributable to SBI. A

well-done observational study with matched controls found that

exposure to SBI in the emergency department was associated with

subsequent linkage to specialty addiction treatment (10). How-

ever, one must interpret these studies with great caution and not

take them as evidence for efﬁcacy because there are many expla-

nations for decreased use besides SBI, such as regression to the

mean, assessment reactivity, secular trends and natural history,

self-change, and others.

EFFICACY OF BRIEF INTERVENTION FOR DRUG USE

Randomized trials of brief intervention in people seeking help

can suggest possible efﬁcacy, but they should not be taken as evi-

dence for SBI in unselected patients identiﬁed by screening. In a

meta-analysis that included interventions some consider longer

than brief (e.g., 1–2 h, often multi-session), drug BI had an effect

size of 0.29 in studies of motivational interviewing (11). In stud-

ies of treatment-seeking people, motivational interventions have

often had efﬁcacy (12–19), though at least one high-quality study

found no efﬁcacy (20). Several studies have found beneﬁt in a

focused area – reducing prescriptions for benzodiazepines (21–

23). BI studies in special populations have had mixed results (24).

www.frontiersin.org September 2014 | Volume 5 | Article 121 | 50

Saitz Screening and intervention for drugs

A computerized intervention and voucher decreased use of drugs,

except marijuana, in postpartum women (25). A single feedback

session decreased drug (though not alcohol or marijuana) use

in homeless adolescents (26). Another study at youth agencies

found no effect on ecstasy or cocaine use (27). But other studies

have found some effects in youth in mandated treatment and high

schools (28–30).

EFFICACY OF SBI FOR DRUG USE IN GENERAL HEALTH

SETTINGS

Most people who use drugs and/or have drug use disorders neither

seek nor receive treatment (31). As a result, interventions with the

greatest potential to affect health in this area must have efﬁcacy in

general health settings, especially in primary and preventive care

settings. Patients who receive these interventions should include

those identiﬁed by screening, not only those who seek help for

these conditions speciﬁcally. The US Preventive Services Task

Force, a leading agency that rates and recommends preventive

services based on the best evidence in the literature, reﬂects this

view (32).

Few studies have tested the efﬁcacy of SBI in general health set-

tings compared with no-intervention control groups, and results

are largely disappointing (see Table 1). Key issues are that to draw

valid conclusions, adequate follow-up rates are needed, biological

testing should conﬁrm self-reports, and outcomes beyond use are

of importance. These issues are also relevant to alcohol SBI and

although numerous studies with self-report outcome in primary

care for unhealthy alcohol use have conﬁrmed efﬁcacy, few have

found effects on biological or clinical outcomes, raising questions

about whether the evidence base for alcohol SBI is sufﬁcient to

suggest that efﬁcacy for alcohol or other substances. One study

of drug SBI compared computer to live human brief interven-

tion for drugs in primary care and included biological outcomes.

Results were similar in both groups, with some outcomes favoring

the computer group, but drug use did not change much in either

group [three points decrease in global alcohol, smoking, and sub-

stance involvement screening test (ASSIST) score], and with no

control group, efﬁcacy could not be determined (33).

Bernstein et al. (39) reported results of a randomized trial

among adults with cocaine or heroin use identiﬁed by screening, in

women’s health, homeless, and urgent care clinics. Most (82%) had

follow-up though one in ﬁve were excluded because they had no

evidence of drug use by hair testing at study entry. Opioid absti-

nence was 9% greater and cocaine abstinence 5% greater in the

brief intervention groups though there was no increase in receipt

of addiction treatment.

In a small randomized trial (n=59) among adolescents in pri-

mary care in Brazil, BI reduced marijuana and ecstasy related

problems (42). In project CHAT (n=42), teenagers with drug

use consequences who had brief intervention reported less mari-

juana use than controls (43). In three randomized controlled trials

among adolescents in the emergency department, BI decreased

recidivism related to drug consequences, increased abstinence, or

increased entry into treatment (44–46). One randomized trial in

adults using psychoactive prescription drugs in a general hospi-

tal found two counseling sessions were associated with decreased

Table 1 | Randomized trial evidence regarding drug screening and brief intervention in adult general health settingsathat include at least some

primary care patients.

Citation Intervention Result (between group

differences at follow-up)

Comment

Gelberg et al. (34) Very brief advice, video doctor,

and two booster sessions

Less frequent (4 days) drug use at 3 months;

effect larger among more severe

78% Follow-up; attention control; no

biological testing; excluded those with

likely moderate to severe disorder

Roy-Byrne et al. (35,48) Single BI with 1 week phone

booster done by social workers

3, 6, 9, and 12months outcomes. No signiﬁcant

differences in days drug use or drug use severity

Biological testing; 87% follow-up

Saitz et al. (36,37) Single 10–15min health

promotion advocate/health

educator BI

45-min psychologist BI with

one booster

6-month outcomes. No differences in days drug

use or drug use severity, health-related quality of

life, emergency department or hospital utilization

or HIV risk behaviors

Biological testing; 98% follow-up

Humeniuk et al. (38) Single BI largely done by clinic

staff (some by researchers in

Brazil)

Seven points or smaller difference in drug use risk

scale with 338 points theoretical maximum at

most sites except US where control group had

greater decrease in the score

86% Follow-up; no biological testing;

excluded those likely to have moderate

to severe disorderb

Bernstein et al. (39) Single BI done by health

promotion advocate

5% Absolute risk increase in cocaine abstinence;

9% risk increase in opioid abstinence

Biological testing; 82% follow-upb

aTwo additional studies have been done exclusively in emergency department settings. One had 58% loss to follow-up and found no beneﬁt of SBI (40).The other, a

multi-site trial, has not yet had results published (41).

bSome participants in primary care (see text for details).

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Saitz Screening and intervention for drugs

drug use though whether the use was misuse or appropriate use

for pain was not clear (47).

Perhaps the most relevant study to the question at hand is the

World Health Organization randomized trial in ﬁve countries in

731 adults reporting risky drug use (excluding those with more

severe use). Patients were recruited from sexually transmitted dis-

ease clinics, dental and walk-in clinics, and community medical

care sites. Very small differences were found favoring the BI group

on a global scale of drug use risk of uncertain clinical importance

and results at the US site were negative (point estimates favored

the control group) (38). More speciﬁcally, both groups began at a

global ASSIST score of 36; the BI group reduced to 30 while the

control group reduced to 32, a 2-point difference in a scale with a

maximum score of 338. In the US, the global score decreased by

nine points in the control group and ﬁve points in the BI group

(p=0.11, n=218). In India, decreases were 4 vs. 8 points, respec-

tively (p=<0.005, n=177); Brazil 2 vs. 7 (p<0.005, n=165);

and in Australia 0 vs. 8 (p<0.001, n=170).

Several recent studies provide information on the efﬁcacy of

SBI for drugs. Saitz et al. tested the efﬁcacy of SBI for drugs ran-

domizing 528 primary care patients identiﬁed by screening to one

of two brief motivational interventions delivered by trained health

educators or psychologists, the latter of which included a booster

session (36,37). At 6 months with 98% follow-up, there were no

signiﬁcant differences in drug use outcomes overall or in analyses

stratiﬁed by drug type or drug use severity. This study used hair

testing to corroborate self-report. Gelberg et al. have preliminar-

ily reported a randomized trial of drug SBI in primary care, with

78% 3-month follow-up (34) (registered at www.clinicaltrials.gov

NCT01942876). Patients with more severe risky use were excluded.

The intervention was <5 min of brief advice, then a video doc-

tor, and two follow-up counseling sessions. Results were a greater

reduction in drug use days (by four) in the intervention vs. the

control group,particularly among those who used drugs more fre-

quently.Validity concerns include the absence of laboratory testing

to corroborate outcomes, which leaves social desirability bias as a

likely explanation for the results (given the largely negative ﬁnd-

ings in trials with biological outcomes and large changes in drug

use in observational studies). In addition, the intervention was not

particularly brief as it included several repeat contacts (and those

with two or more such contacts had better outcomes).

Another large study in primary care also in the US has been

published (35,48), and outcomes were veriﬁed by laboratory test-

ing. Roy-Byrne et al. (48) randomized 868 adults identiﬁed by

screening to a single brief motivational intervention and a 10-min

booster at 2 weeks by phone. At follow-up (≥87% at 3, 6, and

12 months), there were no signiﬁcant differences in frequency of

use or in drug use severity.

Although not in primary care, a large randomized trial of SBI

in emergency department patients found no differences in drug

use outcomes, though 58% of participants were lost to follow-up,

substantially limiting the ability to draw ﬁrm conclusions from

the results (40). A large multi-site study of SBI in emergency

departments in the US with a minimal screening control group

and a no-intervention control group is also underway (41). Both

of these emergency department studies used biological testing to

corroborate self-report outcomes.

CONCLUSION AND IMPLICATIONS

There is little evidence that SBI for drugs other than alcohol and

tobacco will have efﬁcacy in adult primary care settings. Three

trials have been done exclusively in primary care. One with 98%

follow-up of a large sample and biologically corroborated out-

comes is entirely negative. Another with 87% follow-up and bio-

logically corroborated outcomes also found no effects. Another

trial, smaller and with short-term and substantially lower follow-

up, has positive ﬁndings but no biological outcome conﬁrmation.

A large multi-site emergency department study is as yet unpub-

lished. A single site study was negative and substantially limited

methodologically. A study in mixed settings including urgent care

did ﬁnd small reductions in heroin and cocaine use corroborated

by biological outcomes. A hospital study of prescription drug use

was difﬁcult to interpret. The WHO multi-site study found results

of questionable clinical importance that were inconsistent across

country (and negative in the US). In general, these results do not

support the hypothesis that SBI has efﬁcacy for drug use.

This narrative review may have some limitations. It is a nar-

rative review based on searching Google scholar for randomized

trials of drug SBI, attendance at national and international meet-

ings where such research is likely to be presented, review of studies

funded by the National Institute on DrugAbuse (nihreporter.gov)

and search of the clinical trials.gov registry, and by review of a cur-

rent systematic review that has full methodology published (49).

While not a full systematic review,it is very unlikely that an impor-

tant clinical trial of drug use SBI has been missed though that is a

possibility.

If health behaviors are similar, why might SBI not have efﬁcacy

for drug use? Drug use may well be different from other health

behaviors and from risky alcohol use speciﬁcally. First of all, drug

use is often illegal and socially proscribed. As a result, when it is

addressed in a health setting, the patient is using drugs despite

this social sanction, whereas for a number of other health behav-

iors that respond to brief interventions, the patient’s behavior may

be normative; when they realize their personal risks they decide to

make changes. Most people who use drugs are aware of some risks.

Drug use may be more severe than some other health behaviors.

Drug use could range from occasional marijuana use (perceived

by patients as safe) to prescription opioid misuse (a very com-

plex problem that often involves chronic difﬁcult to treat pain),to

injection heroin or cocaine use. It seems unlikely that single brief

counseling sessions could adequately address this range, even if the

goal is to link patients to further and more specialized treatment.

Future research should always include biological outcomes.

New approaches might address multiple risk behaviors and involve

prioritizing them for intervention. Such approaches might then

focus on subgroups of patients, such as those with prescription

drug misuse or marijuana use. New approaches will also very likely

need to test multi-contact longitudinal interventions of the type

known to be more efﬁcacious for alcohol.

For clinicians, the absence of efﬁcacy of drug SBI does not mean

that identifying and addressing drug use in patients is not impor-

tant. It simply means that doing so by screening using validated

tools to detect unhealthy use may not immediately lead to reduced

drug use and problems after a brief intervention. Patients with

symptoms need to be asked about drug use just as they would

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Saitz Screening and intervention for drugs

be asked about medication use, use of complementary therapies

(e.g., herbal treatments), and dietary habits. Such information is

critical both to appropriate diagnosis of medical and psychiatric

conditions and to safe prescribing, particularly of psychoactive

and addictive medications.

The evidence for efﬁcacy of drug SBI is lacking. Editorial-

ists, leaders at the US National Institute on Drug Abuse and the

National Institute on Alcohol Abuse and Alcoholism, the largest

supporters of substance use research in the world, say it is time

to “go back to the drawing board” regarding screening and BI for

drugs in primary care (50). Clinicians need to address drug use

but cannot rely on SBI, a seemingly simple solution, to solve what

is, in fact, a complex problem. Researchers need to ﬁnd more effec-

tive means in general health settings to address what is a common

preventable cause of death in the world.

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Conﬂict of Interest Statement: The author declares that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 08 July 2014; accepted: 18 August 2014; publishedonline: 02 Se ptember 2014.

Citation: Saitz R (2014) Screening and brief intervention for unhealthy drug use: little

or no efﬁcacy. Front. Psychiatry 5:121. doi: 10.3389/fpsyt.2014.00121

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

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www.frontiersin.org September 2014 | Volume 5 | Article 121 | 54

PSYCHIATRY

REVIEW ARTICLE

published: 01 September 2014

doi: 10.3389/fpsyt.2014.00114

What are the implications for policy makers? A systematic

review of the cost-effectiveness of screening and brief

interventions for alcohol misuse in primary care

Colin Angus1*, Nicholas Latimer 1, Louise Preston1, Jessica Li 1and Robin Purshouse2

1School of Health and Related Research (ScHARR), University of Shefﬁeld, Shefﬁeld, UK

2Department of Automatic Control and Systems Engineering, University of Shefﬁeld, Shefﬁeld, UK

Edited by:

Antoni Gual, Hospital Clínic de

Barcelona, Spain

Reviewed by:

Antoni Gual, Hospital Clínic de

Barcelona, Spain

Robert F. Leeman, Yale School of

Medicine, USA

*Correspondence:

Colin Angus, School of Health and

Related Research (ScHARR),

University of Shefﬁeld, Regents

Court, 30 Regent Street, Shefﬁeld S1

4DA, UK

e-mail: c.r.angus@shefﬁeld.ac.uk

Introduction:The efﬁcacy of screening and brief interventions (SBIs) for excessive alcohol

use in primary care is well established; however, evidence on their cost-effectiveness is

limited. A small number of previous reviews have concluded that SBI programs are likely

to be cost-effective but these results are equivocal and important questions around the

cost-effectiveness implications of key policy decisions such as stafﬁng choices for delivery

of SBIs and the intervention duration remain unanswered.

Methods: Studies reporting both the costs and a measure of health outcomes of programs

combining SBIs in primary care were identiﬁed by searching MEDLINE, EMBASE, Econlit,

the Cochrane Library Database (including NHS EED), CINAHL, PsycINFO, Assia and the

Social Science Citation Index, and Science Citation Index via Web of Knowledge. Included

studies have been stratiﬁed both by delivery staff and intervention duration and assessed

for quality using the Drummond checklist for economic evaluations.

Results:The search yielded a total of 23 papers reporting the results of 22 distinct studies.

There was signiﬁcant heterogeneity in methods and outcome measures between stud-

ies; however, almost all studies reported SBI programs to be cost-effective. There was no

clear evidence that either the duration of the intervention or the delivery staff used had a

substantial impact on this result.

Conclusion:This review provides strong evidence that SBI programs in primary care are a

cost-effective option for tackling alcohol misuse.

Keywords: alcohol drinking, screening and brief intervention, primary care, systematic review, policy making,

resource allocation, brief alcohol intervention, brief intervention

INTRODUCTION

The misuse of alcohol is a substantial concern for public health

policy makers across the world, with over 5% of the global burden

of disease and injury estimated as being alcohol-attributable (1).

In addition to these deleterious effects on health and the associated

economic costs, excessive consumption of alcohol is also associ-

ated with a range of social harms such as increased crime, public

nuisance, and reduced workplace productivity, which impact not

just on the drinker, but on society as a whole (2).

Primary care provides an avenue through which a large propor-

tion of the population can be reached by interventions aimed at

reducing alcohol misuse and the related consequences. In particu-

lar, excessive drinkers attend primary care with greater frequency

than moderate drinkers (3) and may therefore be more easily

targeted through this channel. Programs of Screening and Brief

Interventions (SBIs), in which patients are screened opportunisti-

cally for alcohol misuse and those screening positively are offered

a brief session of advice can harness these properties to achieve

broad coverage of the population at risk (4).

There is a substantial body of existing research into the effec-

tiveness of SBI programs in primary care, with a recent review of

reviews identifying 24 previous systematic reviews (5). The con-

sistent ﬁnding of these studies is that SBIs are effective at reducing

excessive alcohol consumption and this weight of evidence has

led to the inclusion of SBIs in a range of international policy rec-

ommendations including the World Health Organisation’s global

strategy for tackling harmful alcohol use (6). However, in spite of

these calls for the implementation of such policies, evidence on

the cost-effectiveness of SBI programs is less equivocal. This is a

key question for the policy makers and healthcare budget planners

being urged to instigate or fund these programs and there have

been few attempts to draw together the existing literature in order

to inform their decisions.

There have been three major previous reviews of the cost-

effectiveness evidence on SBIs in primary care (7–9). While all

three conclude that they are cost-effective, none examine the

impact that implementation decisions such as the staff used to

deliver the SBI, or the duration of the intervention itself, have

on overall program cost-effectiveness. These issues are critical

as the use of general practitioners (GPs) to deliver SBIs is usu-

ally a substantially more expensive option than nursing staff and

a lack of available time is the single greatest perceived barrier

www.frontiersin.org September 2014 | Volume 5 | Article 114 | 55

Angus et al. Cost-effectiveness of SBIs

to early intervention in alcohol problems in primary care (10).

In addition, these existing reviews either predate several impor-

tant studies or have a narrow scope which misses a number of

key papers. This study updates and expands the 2008 review

by Latimer et al. (8) in order to provide a systematic overview

of the existing cost-effectiveness evidence for SBIs in primary

care, together with an examination of the differential impact of

alternative implementation options.

METHODS

The original search was undertaken in May 2008 (8) and refreshed

on four subsequent occasions, with the latest update undertaken

in April 2014. Searches were conducted on the following electronic

databases:

Medline in Process and Other Non-Indexed Citations and

Medline 1950-present via OVID SP

EMBASE via OVID SP

Science Citation Index via Web of Knowledge

Social Science Citation Index via Web of Knowledge

Cochrane Library Databases via Wiley

Assia via CSA

PsycINFO via OVID SP

Econlit via OVID SP

The original search undertaken in 2008 adopted an iterative

emergent approach. Rather than developing an a priori search

strategy, smaller individual searches were undertaken in order

to develop understanding of the research area. The information

specialist (Louise Preston) and lead reviewer (Nicholas Latimer)

worked together to develop further iterations of the search strat-

egy based on the ﬁndings of earlier searches. As a result, for this

update, the use of a predetermined search strategy was possible as

search terms had been tested and validated as part of the original

searches. The search strategy is presented in Figure 1.

The title and abstracts of all retrieved studies were screened

by one reviewer (Colin Angus) against a set of pre-deﬁned inclu-

sion and exclusion criteria. These criteria, listed in Supplementary

Material, were piloted with a second reviewer (Jessica Li) on an

initial subsample of 10 studies and subsequently reﬁned, follow-

ing discussions between both reviewers, to ensure clarity in their

interpretation. Any study reporting the costs and health or other

economic beneﬁts of SBI programs in primary care were consid-

ered for inclusion. Studies were excluded which were not published

in English, which examined multi-behavior interventions (e.g.,

combined drink and drugs education programs), which included

components occurring outside of primary care, or which evalu-

ated interventions comprising more than four patient contacts (on

the grounds that these no longer constitute“brief ”interventions).

Studies examining SBI implementation strategies only (e.g., GP

education programs to increase delivery rates of SBIs to patients)

were excluded unless they presented a separate economic evalua-

tion of the SBI delivery itself. Similarly, studies that examined only

screening tools (e.g., AUDIT or CAGE) were excluded unless they

also included a BI component.

Data from all included studies were extracted by one reviewer

(Colin Angus) using a standard template (see Supplementary

INTERVENTION And PROBLEM

Interven*

(Early or Minimal or Brief)

adj5 intervention*

Counsel?ing

Motivation* interview*

Brief Advice

Alcohol

(Hazard* or harmful or

excess* or problem*) drink*

FIGURE 1 | Search strategy utilized in the review.

Material) adapted from that used by Latimer et al. (8). Studies

were assessed for methodological quality using the Drummond

checklist for economic evaluations (11) as recommended for use

in Cochrane reviews (12). Five of the included studies were ran-

domly selected and additionally assessed for quality by a second

reviewer (Jessica Li) to ensure consistency (agreement was 100%

between both reviewers).

RESULTS

Twenty-three papers reporting the results of 22 distinct studies

that met the criteria for inclusion in the review were identi-

ﬁed. These fall into two major categories: economic evaluations

alongside clinical trials (EEACTs) (13–21) and stand-alone mod-

eling evaluations (4,7,22–33). Table 1 summarizes these studies,

while excluded studies are reported in Supplementary Mater-

ial. A glossary of relevant health economic terms is included in

Supplementary Material.

These 23 studies examine the cost-effectiveness of SBIs in

almost exclusively high-income countries (Chisholm et al. being

the only exception (30)), with the majority of studies covering the

USA (8 studies), UK (5 studies), or Australia (3 studies). There

was considerable variation in the quality of the studies, with 7

rated as being of low quality, 10 of moderate quality, and 5 of high

quality, although there are signs of an improving trend over time

with more recent papers scoring more highly. The main issues

encountered were an inadequate description of the intervention

itself, poor reporting of the sources of cost data used in the studies,

and insufﬁcient sensitivity analysis.

Of the nine studies reporting evaluations alongside clinical tri-

als, two compared different levels of brief intervention (13,14),

both concluding that a longer “stepped care” intervention was the

most cost-effective option. Another six studies compared brief

interventions with usual care (15,17–21). The trials that these

studies are associated with ran for between 6 and 48 months, while

the full effect of changes in drinking behavior on health outcomes

can take many years to develop (34). It is therefore perhaps unsur-

prising that these studies found few statistically signiﬁcant results

and do not allow any ﬁrm conclusions to be drawn around the

cost-effectiveness of SBI programs.

All except one of the 14 modeling studies compared SBI pro-

vision to an alternative do-nothing scenario in which no SBIs are

delivered. The other study (24) examined the cost-effectiveness

of increasing the current uptake rate. Among these studies, the

most common health outcome measures were QALYs (4,23,25,

26,28,31,33), with two studies using DALYs (22,30) and two

using life years gained (7,32). Almost all these studies found SBIs

to be either cost-saving and health improving (i.e., they dominate

a do-nothing scenario) or to have very low costs relative to health

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol September 2014 | Volume 5 | Article 114 | 56

Angus et al. Cost-effectiveness of SBIs

Table 1 | Characteristics of included studies.

Study Country Study

type

Comparators Costs included Health

outcomes

included

Results Quality Duration of

intervention

BI delivery

staff

Angus

et al. (28)

Italy CUA (1) Do-nothing scenario (2)

Screening with AUDIT-C followed

by 10min brief intervention

Intervention costs and

health and social care

resource use over

30 years following start

of program

QALYs gained

over 30 years

follow-up

SBI delivered at next GP

registration has an ICER of C550

per QALY vs. do-nothing. SBI at

next GP consultation has an ICER

of C590 per QALY vs. do-nothing.

++ 10min GP

Angus

et al. (33)

Netherlands

and Poland

CUA (1) Do-nothing scenario

(2) Screening with AUDIT-C

followed by 10 min brief

intervention

Intervention costs and

health and social care

resource use over

30 years following start

of program

QALYs gained

over 30 years

follow-up

Netherlands: SBI delivered at next

GP registration has an ICER of

C6340 per QALY vs. do-nothing.

SBI at next GP consultation has an

ICER of C5748 per QALY vs.

do-nothing. Poland: SBI delivered

at next GP registration has an

ICER of zł3696 per QALY vs.

do-nothing. SBI at next GP

consultation has an ICER of zł3269

per QALY vs. do-nothing.

++ 10min GP

Babor

et al. (15)

USA EEACT/

CEA

Screening with AUDIT followed by

either: (1) Treatment as usual

(2) 3–5 min brief intervention

Intervention costs SF-12 score and

mean alcohol

consumption at

12 months

follow-up

Small but signiﬁcant reduction in

consumption for BI group vs.

treatment as usual. No signiﬁcant

difference in SF-12 scores. No

signiﬁcant differences in either

outcome between GP- and

nurse-delivered intervention

groups

−3–5 min GP or nurse

Chisholm

et al. (30)

International CUA (1) Do-nothing scenario

(2) Screening followed by brief

intervention involving four primary

care visits inside a year

Intervention costs DALYs averted

over a lifetime

horizon

SBI varies from dominated by to

dominating a do-nothing scenario

depending on WHO region with

9/12 regions having an ICER of

≤5000I$ per QALY

+Not stated GP

Cobiac

et al. (22)

Australia CUA (1) Do-nothing scenario

(2) Screening followed by

counseling, supportive written

materials and follow-up

consultations with further advice

“if necessary”

Intervention costs,

patient time/travel and

health and social care

resource use over

lifetime horizon

DALYs averted

over a lifetime

horizon

ICER of $6800 per DALY averted

vs. do-nothing

−Not stated GP

(Continued)

www.frontiersin.org September 2014 | Volume 5 | Article 114 | 57

Angus et al. Cost-effectiveness of SBIs

Table 1 | Continued

Study Country Study

type

Comparators Costs included Health

outcomes

included

Results Quality Duration of

intervention

BI delivery

staff

Dillie et al.

(16)

USA EEACT/

Cost

mini-

mization

analysis

Screening with self-reported

alcohol consumption followed by

either:

(1) 2 ×15 min brief interventions

each followed up with a 5 min

telephone call

(2) Additional screened with %

CDT followed by 2×15 min brief

interventions each followed up

with a 5 min telephone call

Intervention costs,

patient time/travel,

health and social care

resource use, motor

vehicle crashes and

legal/criminal costs over

4 years follow-up

N/A Addition of % CDT screening

saves $212 per patient screened

+40 min GP (nurse

delivers

follow-up

phone calls)

Drummond

et al. (14)

UK (Wales) EEACT/

CUA

Screening with AUDIT followed by

either:

(1) 5-min nurse-led “minimal

intervention”

(2) ”Stepped care” – 20 min

behavioral change counseling

session followed up with referral

to motivational enhancement

therapy and/or specialist alcohol

services if indicated

Intervention costs,

health and social care

resource use costs and

costs of crime at

6 months follow-up

QALYs gained at

6 months follow

Stepped care 98% likely to be

most cost-effective option at a

threshold of £20,000–30,000 per

QALY. No ICER presented

−5 min

(minimal

intervention)

or 20+min

(stepped

care)

Practice

nurse

Fleming

et al. (17,

18)

USA EEACT/

CBA

Screening with 7-day timeline

follow back followed by either:

(1) Patient information leaﬂet

(2) 2 ×15 min brief interventions

each followed up with a 5 min

telephone call

Intervention costs,

patient time/travel,

health and social care

resource use, motor

vehicle crashes and

legal/criminal costs over

lifetime horizon

Mean alcohol

consumption at

various points up

to 4 years

follow-up

Signiﬁcant reduction in

consumption observed in SBI

group (32% in men, 43% in

women). SBI estimated to save

$546 per patient from healthcare

perspective and $7780 from a

societal perspective vs. patient

information leaﬂet

+40 min GP (nurse

delivers

follow-up

phone calls)

Freeborn

et al. (19)

USA EEACT/

Resource

utiliza-

tion

analysis

Screening with AUDIT followed by

either:

(1) Treatment as usual

(2) Brief advice from GP then

15min motivational session with

trained counselor

Health and social care

resource use over

2 years follow-up

N/A No signiﬁcant difference in health

and social care resource use

between BI and care as usual

groups

−15+min GP and

trained

counselor

(Continued)

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol September 2014 | Volume 5 | Article 114 | 58

Angus et al. Cost-effectiveness of SBIs

Table 1 | Continued

Study Country Study

type

Comparators Costs included Health

outcomes

included

Results Quality Duration of

intervention

BI delivery

staff

Freemantle

et al. (29)

International CEA (1) Do-nothing scenario

(2) Screening with AUDIT followed

by 15min brief inter vention

Intervention costs Mean alcohol

consumption at

24 months

follow-up

SBI costs £8–20 per patient,

which equates to £18–47 per

patient who reduces their

drinking, with a mean reduction of

24% among those who cut down

−15 min GP

Kapoor

et al. (23)

USA CUA (1) Do-nothing scenario

(2) Screening with AUDIT followed

by full clinical assessment of

unhealthy alcohol use and

5–10min brief inter vention

(3) Screening with AUDIT and %

CDT followed by full clinical

assessment of unhealthy alcohol

use and 5–10min brief

intervention

Intervention costs,

health and social care

resource use over

lifetime horizon

QALYs gained

over lifetime

horizon

Both screening strategies

dominate vs. do-nothing.

Incremental cost of adding % CDT

to screening is $15,500 per QALY

+5–10min Not stated

Lock et al.

(20)

(England)

EEACT/

Cost

mini-

mization

analysis

Screening with AUDIT followed by

either:

(1) Treatment as usual

(2) 5–10min nurse-led brief

intervention

Intervention costs,

health and social care

resource use and

personal costs at

12 months follow-up

SF-12 score at

12 months

follow-up

No statistically signiﬁcant

difference in costs or health

outcomes between arms

+5–10min Nurse

Ludbrook

et al. (7)

(Scotland)

CEA (1) Do-nothing scenario

(2) Screening using 7-day timeline

follow back followed by 2×15 min

brief interventions each followed

up with a 5 min telephone call

Intervention costs,

patient time/travel,

health and social care

resource use, motor

vehicle crashes and

legal/criminal costs over

lifetime horizon

Life years gained

over lifetime

horizon

SBI dominates vs. do-nothing −40 min GP (nurse

delivers

follow-up

phone calls)

Mundt

et al. (21)

USA EEACT/

CBA

Screening with health screening

survey and assessment interview

followed by either:

(1) Treatment as usual

(2) 2 ×15 min bried interventions

each followed up with a 5 min

telephone call

Intervention costs,

patient time/travel and

health and social care

resource use over

2 years follow-up

Life years lost

(valued at

$50,000 each)

over 2 years

follow-up

Non-signiﬁcant cost savings of

$467 from healthcare perspective

and $812 from societal

perspective for BI vs. treatment as

usual

+40 min GP (nurse

delivers

follow-up

phone calls)

(Continued)

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Angus et al. Cost-effectiveness of SBIs

Table 1 | Continued

Study Country Study

type

Comparators Costs included Health

outcomes

included

Results Quality Duration of

intervention

BI delivery

staff

Navarro

et al. (24)

Australia CEA (1) Current level of SBI provision

(2) Increased levels of screening

and brief intervention or combined

SBI provision

Intervention costs

(including training)

Number of risky

drinkers who

reduce their

alcohol

consumption

Additional cost of between

$174–1041 per risky drinker who

reduces their drinking, depending

on the scenario

+Not stated GP

Purshouse

et al. (4)

(England)

CUA (1) Do-nothing scenario

(2) Screening with AUDIT followed

by 5 min brief intervention

Intervention costs and

health and social care

resource use over

30 years following start

of program

QALYs gained

over 30 years

follow-up

SBI delivered at next GP

registration dominates do-nothing

scenario. SBI at next GP

consultation has an ICER of £1175

per QALY vs. do-nothing

++ 5 min Practice

nurse/GP

(both

modeled)

Rehm

et al. (27)

Canada CBA (1) Do-nothing scenario

(2) Screening followed by brief

intervention

Health and social care

resource use costs,

costs of crime and

productivity losses due

to death and disability

per annum. Unclear if

intervention costs are

included

Deaths, years of

life lost and

acute hospital

days averted per

annum

Introduction of BI would avoid 360

deaths, 9000 years of life lost,

56,000 acute care hospital days

and would reduce

alcohol-attributable costs by

$602m per annum vs. do-nothing

+Not stated Not stated

Saitz et al.

(31)

USA CUA (1) Do-nothing scenario

(2) Screening followed by brief

intervention

Intervention costs and

health and social care

resource use over

lifetime horizon

QALYs gained

over a lifetime

horizon

SBI dominates vs. do-nothing −Not stated Not stated

Solberg

et al. (25)

USA CUA (1) Do-nothing scenario

(2) Annual screening followed by

5 min BI

Intervention costs,

patient time/travel and

health and social care

resource use over

lifetime horizon

QALYs gained

over lifetime

horizon

ICER of $1750 per QALY vs.

do-nothing with healthcare

perspective. SBI dominates with

societal perspective

+5 min GP

Tariq et al.

(26)

Netherlands CUA (1) Do-nothing scenario

(2) Screening with AUDIT followed

by 10–15 min brief intervention

Intervention costs and

health and social care

resource use costs over

a lifetime horizon

QALYs gained

over lifetime

horizon

ICER of C5400 per QALY gained

for brief interventions vs.

do-nothing

++ 30–45 min GP

(Continued)

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Angus et al. Cost-effectiveness of SBIs

Table 1 | Continued

Study Country Study

type

Comparators Costs included Health

outcomes

included

Results Quality Duration of

intervention

BI delivery

staff

Watson

et al. (13)

(England

and

Scotland)

EEACT/

CUA

Screening with AUDIT followed by

either: (1) 5-min nurse-led

“minimal intervention”

(2) “Stepped care” – 20 min

behavioral change counseling

session followed up with referral

to motivational enhancement

therapy and/or specialist alcohol

services if indicated

Intervention costs and

health and social care

resource use at 6 and

12 months follow-up

QALYs gained at

6 and 12 months

follow-up

ICER of £1100 per QALY for

stepped gain over minimal

intervention at 6 months, stepped

care dominates at 12months

++ 5 min

(minimal

intervention)

or 20+min

(stepped

care)

Practice

nurse

Wutzke

et al. (32)

Australia CEA (1) Do-nothing scenario

(2) Screening with AUDIT followed

by 5 min brief intervention

Intervention costs

(including training and

support for GPs)

Life years gained

(time horizon not

stated)

ICER of between $586–650 per

life year gained for SBI vs.

do-nothing

+5 min GP

CBA, cost–beneﬁt analysis; CDT, carbohydrate deﬁcient transferrin; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; DALY, disability-adjusted life year; EEACT, economic evaluation alongside a controlled

trial; GP, general practitioner; ICER, incremental cost–effectiveness ratio; N/A, not applicable; QALY, quality-adjusted life year; SBI, screening and brief interventions. For detailed deﬁnitions of terms see Supplementary

Material.

gains, making SBI programs highly likely to be considered cost-

effective under the relevant national guidelines. The sole exception

was Chisholm et al. (30), who presented separate costs and bene-

ﬁts for each of 12 World Health Organization (WHO) sub-regions

and found that SBI programs are dominated by current taxation

in parts of Africa (region AfrE), although they estimated that they

are either cost-effective or cost-saving in the remaining 11 sub-

regions using the WHO’s estimated cost-effectiveness thresholds

(35). Of the remaining modeling studies, one (27) uses a burden

of disease approach to estimate SBIs would be substantially cost-

saving (Canadian $602m per annum). The remaining studies (24,

29) use intermediate end points (number of risky drinkers averted

and change in mean alcohol consumption), which make the results

unhelpful for the purpose of informing resource allocation deci-

sions without additional modeling to estimate the impact of these

end points on health outcomes. The majority of these modeling

studies consider outcomes over a 30 year (4,28,33) or lifetime (7,

22,23,25,26,30,31) time horizon, ensuring that the long-term

impacts are reﬂected in the results.

Fifteen studies examine the cost-effectiveness of GP-delivered

interventions (4,7,15,16,18,21,22,24–26,28–30,32,33), while

only ﬁve examine nurse-delivered interventions (4,13–15,20).

Owing to the substantial heterogeneity between studies both in

terms of methods and outcomes it is difﬁcult to draw any clear

conclusions about the relative cost-effectiveness of using different

staff to deliver SBI programs, although the lack of a clear differ-

ence between the two options may be of interest to policy makers.

Only two studies directly compare both options: Purshouse et al.

(4) assume a priori that delivery staff do not impact on the effec-

tiveness of the BI but ﬁnd that even the use of the more expensive

GP-delivered BI option is unlikely to prevent the program from

being cost-effective. Meanwhile, Babor et al. (15) conducted a

trial with separate nurse-delivered and GP-delivered SBI arms.

The authors found no signiﬁcant difference in effectiveness of the

intervention between these arms, while the nurse-delivered option

was around 1/3 cheaper, indicating it to be a more cost-effective

option.

With regards to the total duration of the intervention (i.e., the

total contact time between patient and delivery staff, either face-

to-face or over the telephone, aggregated over multiple contacts

where appropriate), 12 studies evaluate interventions of 10 min or

less (4,13–15,20,23,25,28,32,33) and 11 consider interventions

of over 10 min (with a maximum duration of 45 min) (4,7,13,

14,16,18,21,26,28,29). Again the heterogeneity of methods and

outcomes makes direct comparison difﬁcult, although there is no

clear difference in terms of cost-effectiveness between shorter and

longer interventions. Only ﬁve studies consider both longer and

shorter interventions. Two of these (13,14) report that the longer

intervention is cost-effective relative to the shorter one, although

this conclusion is difﬁcult to make on the basis of the analysis

presented in the studies, particularly given the short follow-up of

the trials. The other three studies (4,28,33) assume no difference

in effectiveness but ﬁnd that longer, more expensive interventions

are still highly likely to be considered cost-effective compared to

no intervention.

In order to further explore the relationship between delivery

staff, BI duration, and cost-effectiveness, Figure 2 presents a direct

www.frontiersin.org September 2014 | Volume 5 | Article 114 | 61

Angus et al. Cost-effectiveness of SBIs

£2,000

£4,000

£6,000

£8,000

£10,000

£12,000

0 5 10 15 20 25 30 35 40 45

ICER - Cost per QALY/DALY/Life Year Saved

(2013 £)

Total duraon of Intervenon (minutes)

Nurse

Dominates

FIGURE 2 | Cost-effectiveness of SBI programs by SBI duration and

delivery staff.

comparison of the cost-effectiveness results converted to 2013 UK

£, for those studies which report delivery staff, intervention dura-

tion, and an Incremental Cost–Effectiveness Ratio (ICER) (4,13,

25,26,28,33,36).

DISCUSSION

This systematic review provides strong evidence that SBIs in a pri-

mary care setting are a cost-effective policy option for tackling

alcohol-related harms, at least in high-income countries. There is

a paucity of evidence for lower- or middle-income countries and

that does exist indicates that there may be substantial heterogene-

ity in both the expected costs and effectiveness of SBI programs

depending on the local context in these areas (30).

There is also substantial heterogeneity in study methods,

included costs, and reported health outcomes between the

included studies, which makes it difﬁcult to determine the impli-

cations of this diverse body of evidence for those making resource

allocation decisions, although there is an apparent trend for more

recent studies to use standardized measures such as QALYs or

DALYs, which makes between-study comparison more meaning-

ful. There are also signiﬁcant differences in the national contexts

between studies (for example the existing level of drinking or the

current suite of alcohol policies in the country), which must be

considered when making international comparisons.

Considering these differences, there is no clear evidence that

the choice of delivery staff for SBI programs has a substantial

impact on the program’s cost-effectiveness. This may be because

GP-delivered interventions are more effective but more costly than

those delivered by nurses, although this would be at odds with

existing literature, which suggests that the use of less costly nursing

staff to conduct tasks that would otherwise be the responsibility of

GPs is unlikely to impact negatively on the quality of care received

by patients (37,38). Figure 2 also suggests that nurses may be a

more cost-effective option, although heterogeneity in settings and

methods between the included studies mean that the graph should

be interpreted with caution.

It is also important to note that policy makers will need to con-

sider the total budget impact of any policy options in addition to

the potential cost-effectiveness, an issue highlighted in several of

the included studies (28,33,39). This may suggest that nurse-led

SBI programs, which are likely to be less costly overall, may be

more appealing option, although consideration must be given to

the existing primary care systems in each country. For example,

in countries such as the UK or the Netherlands where practice

nurses already undertake many primary care services such as vac-

cinations or health checks, nurse-led SBIs may be a more practical

option than in other countries where care is currently delivered

exclusively by the GP.

There is also no clear evidence that the duration of intervention

delivered has a substantial impact on cost-effectiveness.Again this

may indicate that longer interventions are more effective but more

expensive, although studies on the effectiveness evidence have not

found a consistent relationship between amount of patient con-

tact and effectiveness (5,40). While the studies by Watson and

Drummond provide limited evidence that longer interventions

may be more cost-effective in the short-term in the UK context,

it is not clear that this translates to the longer term, or to other

countries (13,14).

In addition to the substantial heterogeneity between studies

already mentioned, there are a number of limitations to this sys-

tematic review. Only studies published in the English language

were included, something which may be at least partly responsible

for the lack of included studies from the developing world. Some of

the included studies are also of low methodological quality which

makes it difﬁcult to evaluate the robustness of their conclusions.

Finally,there are two key issues, which no study of SBI effectiveness

can escape. The ﬁrst is that the estimates of effectiveness, which

underpin the cost-effectiveness estimates examined here may be

exaggerated by the impact of regression to the mean, caused by

drinkers changing their consumption over time for reasons unre-

lated to the receipt of a brief intervention (e.g., public holidays

or seasonal variation) (41). The second, countervailing issue is

that of an intervention or Hawthorne effect, whereby the act of

being enrolled into a trial acts as an intervention in itself, some-

thing which may at least partly explain why many SBI effectiveness

studies observe a reduction in alcohol consumption over time in

the control groups (42).

Limitations in the evidence base mean that this review is unable

to address a number of other issues that may be of interest to pol-

icy makers such as the cost-effectiveness of SBI programs targeting

speciﬁc groups within the general population. Further research to

examine the differential effectiveness of, and the likely coverage

by, SBI programs in these subgroups is important to allow this

area to be explored further. The other key priority for further

research to inform decision makers concerns the uptake among

primary care providers of SBI programs. Difﬁculties in persuad-

ing GPs and nurses to fully deliver SBI programs could have a

substantial impact on the effectiveness and cost-effectiveness of

these programs. A recent international trial conducted as part

of the optimizing delivery of healthcare interventions (ODHIN)

project will go some way to addressing this challenge by examin-

ing the effectiveness and cost-effectiveness of different strategies

at increasing SBI delivery rates in primary care (43).

In conclusion, while there are signiﬁcant differences between

the studies included in this review, the overwhelming conclusion is

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol September 2014 | Volume 5 | Article 114 | 62

Angus et al. Cost-effectiveness of SBIs

that SBIs in primary care are a cost-effective option,at least in hig h-

income countries. There is no clear evidence that the duration of

the intervention, or the type of staff used to deliver it, changes

this conclusion. Policy makers should, however, be mindful of

the differing budget implications that alternative implementation

options may present.

AUTHOR CONTRIBUTIONS

Louise Preston undertook the literature searches.Colin Angus con-

ducted the review, with assistance from Jessica Li, and drafted the

article. Robin Purshouse and Nicholas Latimer provided guidance

and expertise. All authors read and approved the ﬁnal manuscript.

ACKNOWLEDGMENTS

The research leading to these results or outcomes has received

funding from the European Union’s Seventh Framework Pro-

gram for research, technological development and demonstration

under grant agreement no. 259268 – optimizing delivery of health

care intervention (ODHIN). Participant organizations in ODHIN

can be seen at www.odhinproject.eu/partners.html. The views

expressed here reﬂect only the authors’ and the European Union

is not liable for any use that may be made of the information

contained therein.

SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found online

at http://www.frontiersin.org/Journal/10.3389/fpsyt.2014.00114/

abstract

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Conﬂict of Interest Statement: The authors declare that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 30 June 2014; accepted: 12 August2014; published online: 01 Septembe r 2014.

Citation: Angus C, Latimer N, Preston L, Li J and Purshouse R (2014) What are the

implications for policy makers? A systematic review of the cost-effectiveness of s creening

and brief interventions for alcohol misuse in primar y care. Front. Psychiatry 5:114. doi:

10.3389/fpsyt.2014.00114

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

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PSYCHIATRY

REVIEW ARTICLE

published: 11 November 2014

doi: 10.3389/fpsyt.2014.00161

Brief interventions implementation on alcohol from the

European health systems perspective

Joan Colom1, Emanuele Scafato2, Lidia Segura1, Claudia Gandin2and Pierluigi Struzzo3,4*

1Program on Substance Abuse, Public Health Agency of Catalonia, Barcelona, Spain

2Istituto Superiore di Sanità, Rome, Italy

3Regional Centre for the training in Primary Care (Ceformed), Monfalcone, Italy

4Department of Life Sciences, University ofTrieste, Trieste, Italy

Edited by:

Hugo López-Pelayo, Fundació Clínic

per la Recerca Biomèdica, Spain

Reviewed by:

Giovanni Martinotti, Università degli

Studi Gabriele D’Annunzio, Italy

Luigi Janiri, Università Cattolica del

Sacro Cuore, Italy

*Correspondence:

Pierluigi Struzzo, Department of Life

Sciences, University of Trieste,Via

Weiss 2,Trieste 34128, Italy

e-mail: pstruzzo@gmail.com

Alcohol-related health problems are important public health issues and alcohol remains

one of the leading risk factors of chronic health conditions. In addition, only a small pro-

portion of those who need treatment access it, with ﬁgures ranging from 1 in 25 to 1 in

7. In this context, screening and brief interventions (SBI) have proven to be effective in

reducing alcohol consumption and alcohol-related problems in primary health care (PHC)

and are very cost effective, or even cost-saving, in PHC. Even if the widespread imple-

mentation of SBI has been prioritized and encouraged by the World Health Organization,

in the global alcohol strategy, the evidence on long term and population-level effects is still

weak. This review study will summarize the SBI programs implemented by six European

countries with different socio-economic contexts. Similar components at health profes-

sional level but differences at organizational level, especially on the measures to support

clinical practice, incentives, and monitoring systems developed were adopted. In Italy,

cost-effectiveness analyses and Internet trials shed new light on limits and facilitators of

renewed, evidence-based approaches to better deal with brief intervention in PHC. The

majority of the efforts were aimed at overcoming individual barriers and promoting health

professionals’ involvement. The population screened has been in general too low to be

able to detect any population-level effect, with a negative impact on the acceptability of

the program to all stakeholders.This paper will present a different point of view based on a

strategic broadening of the implemented actions to real inter-sectoriality and a wider holis-

tic approach. Effective alcohol policies should strive for quality provision of health services

and the empowerment of the individuals in a health system approach.

Keywords: alcohol, brief interventions, health system, empowerment, resilience

INTRODUCTION AND METHODS

This is a review study to discuss how screening and brief interven-

tions (SBI) for harmful alcohol use and alcohol dependence can

be better embedded in health system (HSys) and implemented

effectively. To do so, ﬁrst the challenges for AUD treatment and

the HS responses, as recommended by World Health Organiza-

tion (WHO), are presented, followed by a review of the existing

SBI evidence and the cases of SBI wide implementation and ﬁnally

some future directions toward the achievement of this objective

are proposed. Even if there is still considerable confusion in the

literature regarding the SBI evidence, SBI programs have been

implemented nation-wide in some countries with some positive

results and could be seen as important cornerstones to implement

more broaden national policies on alcohol risk reduction. There

is, however, a long road ahead. The situation regarding alcohol

use is changing dramatically, with the frequent presence of binge

drinking in youths, the constant of poly abuse, typically of novel

psychoactive substances (1), and the regular report of co-morbid

psychiatric disorders (2). The results of the existing experiences

urge HSys to move beyond a focus on individual (professional’s

and patient’s) behavior toward implementing policies having into

account a wide range of social and environmental interventions,

the so-called health promotion, as deﬁned by the WHO1.

The novelty that this review will bring to the reader mainly

refers to a point of view that focuses on “what works” and also

on broadening future actions with real inter-sectorial strategies

encompassing health services (HS) with other sectors of the society

and addressing the individual alcohol user with SBI included into a

broader,holistic, risk-reduction approach. As alcohol is a complex

issue, the general idea is to move from a health service-centered to

a broader HSys intervention.

HEALTH SERVICES IN RESPECT TO BRIEF INTERVENTIONS

FOR ALCOHOL USE DISORDERS IN EUROPE: THE CHALLENGE

OF THE TREATMENT GAP

According to theWHO, HS, the most visible functions of any HSys,

include all services dealing with the diagnosis and treatment of dis-

ease or the promotion, maintenance,and restoration of health. In

1Health promotion is the process of enabling people to increase control over, and

to improve, their health. It moves beyond a focus on individual behavior toward a

wide range of social and environmental interventions (WHO deﬁnition).

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Colom et al. Brief interventions and health systems

this sense, WHO have stressed that HS for AUD have the following

objectives:

•provide prevention and treatment interventions to individu-

als and families at risk of, or affected by, AUDs and associated

conditions;

•inform societies about the public health and social consequences

of hazardous and harmful alcohol consumption (HHAC);

•support communities in their efforts to reduce HHAC;

•advocate effective societal responses.

Despite the efforts made by WHO and all the countries to

improve AUD treatment, evidence still shows that the so-called

treatment gap is huge. From one side harmful alcohol users are still

socially stigmatized and do not seek treatment and from another

access to effective alcohol treatment services is limited in many

European countries. It has been estimated that only 1 in 20 of

those with HHAC are actually identiﬁed and offered brief advice

by a primary care service provider. Similarly, <1 in 20 with a

diagnosis of alcohol dependence has actually seen a specialist for

treatment (3).

Taking into account this reality and the ambitious AUD treat-

ment objectives, it is clear that a cultural change in the way alcohol

problems are seen is needed. As a consequence of that we need

to mobilize and involve of a broad range of players inside and

outside the health sector, sufﬁciently strengthened and properly

funded in a way that is commensurate with the magnitude of the

public health problems caused by HHAC. This means broadening

the horizon to a much wider HSys approach2(3).

The provision of early intervention and treatment services is a

key part of any comprehensive policy framework to reduce alcohol

harm (4). The WHO “Global Strategy to Reduce the Harmful Use

of Alcohol,” 2010, lists National HSys’ response as one of its key

priority policy areas (5): (1) leadership, awareness, and commit-

ment; (2) HS’s response; (3) community action; (4) drink–driving

policies and countermeasures; (5) availability of alcohol; (6) mar-

keting of alcoholic beverages; (7) pricing policies; (8) reducing the

negative consequences of drinking and alcohol intoxication; (9)

reducing the public health impact of illicit alcohol and informally

produced alcohol; and (10) monitoring and surveillance.

The portfolio of policy options and interventions recom-

mended by the WHO for HSys’s response area include

(a) increasing capacity of health and social welfare systems to

deliver prevention, treatment and care for AUDs, including

support and treatment for affected families, and support for

mutual help or self-help activities and programs;

(b) supporting initiatives for SBI for HHAC at primary health

care (PHC) and other settings including initiatives among

pregnant women and women of child-bearing age;

interventions for individuals and families living with fetal

alcohol syndrome and a spectrum of associated disorders;

2A health system is the sum total of all the organizations, institutions, and resources

whose primary purpose is to improve health.

(d) development and effective coordination of integrated and/or

linked prevention, treatment, and care strategies and services

for AUDs, including drug-use disorders, depression, suicides,

HIV/AIDS, and tuberculosis;

(e) securing universal access to health, enhancing availability,

accessibility,and affordability of treatment services for groups

of low socio-economic status;

(f) establishing and maintaining a system of registration and

monitoring of alcohol-attributable morbidity and mortality,

reported on a regular basis;

(g) provision of culturally sensitive health and social services as

appropriate (5).

In respect to SBI for alcohol-related problems, HS are central

to tackling harm at individual level among those with AUDs and

other conditions caused by HHAC. The outcome expected by the

WHO action plan to reduce HHAC 2012–2020 is a progressive

reduction in the gap between the number of people who would

beneﬁt from alcohol consumption advice to reduce or prevent

harm, engagement in social rehabilitation programs or treatment

for AUDs and the number who actually receive such advice or

treatment to be monitored (using as indicators the proportion

of the adult population with HHAC, and of the population with

HHAC who have received therapy and advice from a primary care

provider to reduce their alcohol consumption) (3).

The health sector and the social welfare, education, and work-

place sectors have real opportunities to reap both health gain and

ﬁnancial savings through the widespread implementation of SBI

programs that have been shown to reduce ill health and pre-

mature death subsequent to HHAC and the implementation of

evidence-based treatment programs for AUDs (3).

It is estimated that of the total cost to the NHS from alcohol

harm each year, only around 2% is spent on identifying and treat-

ing AUDs. Implementing SBI does not require extensive training

and can be delivered in a variety of settings: emergency and hospi-

tal care, PHC, schools, job centers and pharmacies, social services,

accident, workplace settings, and prisons (6).

There is a strong evidence to support the beneﬁts of widespread

implementation of SBI provided by Primary Care and other health

or social care professionals while, for alcohol dependent subjects,

access to effective treatment services can play a vital role in both

recovery from and management of AUDs (6).

According to the WHO, Governments should support SBI

programs and referral to specialist services by ensuring that

•clinical guidelines for such interventions are widely available;

•primary care providers receive the training, clinical materi-

als/tools, and advice they need to set up such programs;

•primary care providers are adequately reimbursed for the

interventions.

Furthermore, primary care providers should be encouraged to

undertake this intervention when they are supported by specialist

services to which they can refer problem drinkers. Thus, specialist

services for AUDs should be available and evidence-based non-

pharmacological and pharmacological treatments should also be

offered to those who have been assessed as likely to beneﬁt.

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Colom et al. Brief interventions and health systems

Data from a number of recent European projects show that PHC

providers considered resources currently allocated for training and

delivery of early intervention and treatment not sufﬁcient. The

trend has been to move away from lengthy inpatient treatment

toward outpatient and community-based one (3).

The current challenge for HS in Europe is how to stick to

the values of universality, access to good quality care, equity, and

solidarity taking into account the growing challenges (increased

costs, population aging, rise of chronic diseases, and multi-

morbidity leading to growing demand for healthcare, shortages,

and uneven distribution of health professionals, health inequali-

ties and inequities in access to healthcare) and bearing in mind

the economic crises that are putting endanger the HS’s sustain-

ability. EC stresses that HS reforms should focus on (1) strengthen

their effectiveness, (2) increase their accessibility, and (3) improve

their resilience meaning capable to adapt effectively to chang-

ing environments, tackling signiﬁcant challenges with limited

resources.

WIDESPREAD IMPLEMENTATION OF SBI PROGRAMS: WHAT

THE EVIDENCE SAYS

Screening and brief intervention is an effective and cost-effective

method for treating subjects with HHAC in PHC. Evidence on the

reduction of alcohol consumption is consistent, but its impact on

alcohol problems is less clear (7). There are,however, a lot of issues

on SBI that need further research: identifying the effective compo-

nents, their utility among dependent drinkers, assessing ﬁdelity to

contents, skills needed to implement SBI, and how professionals

may best acquire them. SBI effectiveness in the context of chronic

diseases should be tested and demand for alcohol SBI may also be

potentiated (8).

Despite its effectiveness and strong research evidence to sup-

port its implementation in real-world clinical settings, widespread

implementation of SBI has occurred in very few places and it is

still unclear if the programs will be sustained. In addition, little

is known about the most successful strategies for widespread SBI

implementation. Babor et al. (9) found that the effectiveness of dif-

ferent implementation models depends on complex provider and

organizational characteristics. Thus, the ability of PHC centers to

implement SBI was correlated with prior SBI expertise, centers sta-

bility, and number of clinicians trained and negatively correlated

with lack of provider time, staff turnover, and competing priori-

ties. Authors suggest that the best option is to combine different

methods or multi-faceted strategies (10). In his revision, Williams

et al. (11) analyzed under the consolidated framework for imple-

mentation research (CFIR) (12) eight implementation programs

in nine different countries. He found SBI rates varied a lot and were

non-comparable because of the use of different measures, scopes,

and durations. He concluded that the use of strategies related to

inner setting (“features of the structural, political, and cultural

context through which the implementation process proceeds”),

outer setting (“economic, political, and social context in which

an organization resides”), and process implementation domains

could be positively associated with higher screening rates and thus

to successful implementation.

So far, institutionalization of SBI, which is sustained and

nation-wide extensive SBI activity, has only been reported by

programs in Finland, Sweden, and Scotland. Seppänen et al. (13)

found an increase over the years and a high percentage of physi-

cians (78.5%) offering BI at least occasionally. Among the factors

associated with high BI was long experience in PHC and being a

PHC specialist.

Studies in Sweden and Finland have shown that only a minor-

ity of the population has been asked about their drinking by PHC

professionals and a minority of risky drinkers has been advised

to cut down. Nilsen et al. (14,15) found that only 14–20% of the

overall sample who had visited a physician in the last year recalled

having received an alcohol enquiry. Reduced alcohol consump-

tion was reported by 12% and especially among those who were

exposed to a 1–10 min (versus 1 min) conversation on alcohol. In

the case of Finland, only one-third recalled being asked, and 37%

had been given advice (16).

In England, Kaner (17) claims that national alcohol strategies

alone do not result in a wide-scale SBI activity and for that to

happen it is needed to create necessary conditions (shaping the

policy and commissioning) in which brief interventions become

meaningful for those working in clinical practice. Authors also

suggest considering system-level factors that inﬂuence drinking

behavior and policy-level interventions (minimum price per unit

for the alcohol sales, restrictions on the density of outlets, etc.)

that can reinforce or complement practitioner-level interventions.

It was recognized that SBI activity could not occur in public HSys

without the prioritization, the support of senior management, or

without appropriate resources,including tr aining and support and

the deﬁnition of integrated care pathways for alcohol prevention

and treatment.

Heather (18) also advised that SBI alone, especially with such

low levels of people screened and of risky drinkers advice, would

be unlikely to result in public health beneﬁts and recommends

proposing opportunistic screening to ensure acceptability of SBI

programs and to research population-level effects of SBI, especially

in combination with other alcohol control measures.

In Scotland (19), where a speciﬁc 3-year target (HEAT H4)

on brief intervention (149,449 from April 2008 to March 2011

and 61,081 from April 2011 to March 2012) was established to

support population-wide implementation, it was proven to be

possible to reach it nationally in all priority settings and health-

care staff saw SBI as a worthwhile activity. The reach and impact

of the initiative was mixed across Scotland and gaps in cover-

age were noted, especially in rural and remote areas in relation

to age/gender groups who less frequently attended mainstream

services.

According to Angus et al. (20), SBI is highly cost-effective for

brief intervention at next registration as well as at next general

practitioner consultation. Thus, investments in SBI programs not

only improve health and save lives but also save HSys money by

two levels of action:

•Offering brief interventions to 60% of the population at risk.

This ambitious target would require that every patient who

receives primary care services would be offered these inter-

ventions, irrespective of the reason for the consultation, and

a greater investment in training and supporting primary care

providers.

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Colom et al. Brief interventions and health systems

•Offering early brief interventions to 30% of the population at

risk of HHAC. It can be achieved by putting into place appro-

priate systems, including provider training, so that every patient

who registers with a new primary care provider, receives a health

check, consults a provider about particular disease categories

(such as hypertension or tuberculosis) or goes to particular

types of clinics is offered these interventions. At this level of

action, as alternative to standard face-to-face interventions,

web-based approaches and self-help guidance could be con-

sidered. In this regard, a number of studies are underway to

test the effectiveness and the acceptability of this new approach

to know if the provision of facilitated access by primary care

providers to an alcohol reduction website could signiﬁcantly

increase brief intervention rates by offering a time-saving alter-

native to face-to-face intervention. These studies include the

randomized controlled trial carried out in the Friuli Venezia

Giulia Region, Italy (21).

CASE STUDIES PRESENTATION: HSys FOR BI IN SIX

EUROPEAN COUNTRIES

A literature search showed that only six countries/regions in

Europe have been working on the wide implementation of SBI

on alcohol, i.e., they have invested intensive and continuous efforts

aimed at institutionalizing that programs and their initiatives have

been endorsed by national laws, policies, or guidelines. In other

countries, such as Slovenia, Czech Republic information is miss-

ing. These countries are Finland, Sweden, Scotland, England, Italy,

and Catalonia and in Table 1 below, a summary of some health

resources indicators is given. Sweden is the country that invests

more in health and has the highest ratio in nurses and physi-

cians. Finland is the one with the highest ratio in terms of hospital

beds. The majority has a shared implementation model, but in

Italy and Catalonia regions are fully responsible. Sweden, Fin-

land, and Catalonia have a similar PHC organizational model,

whereas in Italy, Scotland, and England PHC is organized as inde-

pendent contractors. According to the ODHIN assessment report

(22), the integration of the management of HHAC in the PHC sys-

tem (scale 0–10) is best in Sweden, followed by Catalonia/Spain,

and in secondary health care it is best in Catalonia/Spain, followed

by England/UK.

During the last decade all of these countries undertook

major reforms of their healthcare systems in the ﬁve key iden-

tiﬁed areas: strengthening health care ﬁnancing, continuum of

care, quality of HSs, linkage with community, and advances in

public health. This process has slowed down or even stopped

in Catalonia and Italy due to the recession and the cuts in

the HSys.

CASE STUDIES ANALYSIS: WHAT HAS BEEN DONE

Interest in the SBI in the six countries started early, especially in

Sweden and Scotland, where the ﬁrst studies began in the early

80s. All the countries, except Sweden and Scotland, took part

in the WHO Collaborative Study (Table 2). Countries joined

in different phases, England in Phase II (SBI trial), Italy and

Catalonia in Phase III (best ways to achieve wide implementa-

tion), and Finland in Phase IV (country-wide SBI implementation

strategies).

Phase IV began in 1999 and ended in 2006. While partic-

ipating countries shared the same objective the speciﬁc design

and procedures varied among participating countries in order to

take account of different country speciﬁc needs, factors, and poli-

cies and PHC organizational models (23). In Table 2 below, you

can ﬁnd the main characteristics of the implementation that has

taken place.

The so-called treatment gap, the proportion of people who

actually access treatment out of those who need it, has been

reported in the majority of the countries as one of the main

motivations to implement SBI. In the study from Wolstenholme

et al. (24) across six European countries studied, there was a great

variation in the HSys and treatment provision for alcohol use dis-

orders, with the proportion of people in need of treatment who

actually access it ranging from 1 in 25 to 1 in 7. Italy was the

country with highest access to treatment (23.3%) and England

(7.1%) had one of the lowest. Interestingly, in Sweden the SBI

project was launched against a backdrop of increasing alcohol

consumption since the country’s entry in the EU in 1995 (15).

In Scotland, a substantial rise in alcohol-related harm is reported

too (25).

As detailed in Table 2, SBI programs share some communalities

(AUDIT as screening tool and FRAMES adapted brief interven-

tion), especially among those that participated in the WHO Col-

laborative project, but its implementation has been adapted to the

country HSys organization (PHC settings structure, professionals

involved, referral pathways). An important issue is that regardless

of the origins, governments have been involved in the SBI pro-

gram implementation mainly by endorsing national guidelines or

policies and providing speciﬁc funding for HHAC. As far as we

know,only Scotland established a national target and incentivized

accordingly. It is not clear, however, if sustainability actions are

undertaken in order to maintain results obtained in the different

countries.

Italy and Catalonia have based their evaluation more on con-

tinuous monitoring strategies than on speciﬁc research trials or

studies; UK and other countries have followed a much more for-

mal monitoring including a national Audit. Studies on ﬁdelity to

national guidelines in such countries do not exist.

Taking into consideration the main conclusions of the Odhin

assessment exercise (22), success in the wide implementation of

SBI depends on a number of factors: the presence of a formal

partnership or coalition to support the process, the integration of

the management of the SBI in the health care system, the pro-

vision of a formal, mandatory on-going training and medical

education on SBI, the existence of written alcohol policies funded

SBI research projects (cost-effectiveness,ﬁdelity, quality of advice,

evaluation surveys, performance records, etc.), available guidelines

and protocols provision of materials and incentive measures,sup-

port by specialists services, etc. Furthermore, it is essential that

speciﬁc activities should be devoted to the dissemination of avail-

able sources of knowledge, research results, and information to

health care providers together with the provision of materials and

tools as well as incentive measures aimed at ensuring that preven-

tion, particularly SBI, is implemented in PHC and supported by

specialist services according to a real networking of the available

servicers and competencies.

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Colom et al. Brief interventions and health systems

Table 1 | Health system key characteristics.

Finland Sweden UK Italy Spain

Populationa5,413,971 9,519,374 63,705,000 59,539,720 46,146,580

Total expenditure on

health/capita, US$

purchasing power parity,

2011a

2,544.7 3,203.6 2,821.1 2,344.5 2,244.2

Health resources density

per 1000 population

(head counts)a

10.45 (Nurses) 11.09 (Nurses) 8.21 (Nurses) (Nurses) 5.24 (Nurses)

2.72 (Physicians) – 2008 3.92 (Physicians) 2.75 (Physicians) 3.85 (Physicians) 3.82 (Physicians)

5.3 (Hospital beds) 2.62 (Hospital beds) 2.81 (Hospital beds) 3.4 (Hospital beds) 2.97 (Hospital beds)

Type Compulsory tax-based Compulsory tax-based National taxation General taxation Tax-based

Planning/implementation National planning, local

(municipalities)

implementation

Central state, regions

and local health

authorities (shared

responsibility)

Country (England, NI,

Scotland, and Wales)

deliver services

through public

providers

Central state, regions,

and local health

authorities (shared

responsibility)

Central state deﬁnes

minimum

requirements and

coordinates,

autonomous

communities are fully

responsible

Health care provision PHC centers are

multidisciplinary and

public owned and provide

(primary care, preventive

care and public health

services)

PHC services deliver

both basic curative

care and preventive

services through local

health centers

PHC is provided by

GPs in group practices

(three per practice)

GPs and pediatricians

working as

independent

contractors provide

primary health care

PHC centers are

multidisciplinary and

public owned and

provide primary and

preventive care

Self-declared unmet

needs for medical

examination (EU

rate =3.4%)b

Above Below Below Above Below

Integration of the

management of

hazardous and harmful

alcohol consumption in

the primary and

secondary health care

system (scale 0–10)c

5/5 10/4 5/6 (England only) 5/4 8/8

aOECD Health Statistics, 2013 – http://stats.oecd.org/index.aspx?DataSetCode=SHA

bEurostat statistics on income and living conditions, 2012.

cODHIN assessment tool – report, 2013 – http:// www.odhinproject.eu/ project-structure/ wp6.html

PROPOSAL FOR THE FUTURE: THE WHO-EURO STRATEGY ON

HSys FOR BI

Alcohol, in contrast to other behaviors and lifestyles poses impor-

tant challenges to the HSys, mainly because of moral prejudices

existing in our society, to the fact that alcohol consumption is cul-

turally and socially determined and to the fact that there in some

cases it is associated to brain malfunctioning or a brain disease.

This together with the barriers in every day practice to sustaining

commitment such of lack of time, lack of training and resources, a

belief that patients will not take advice to change drinking behavior

and a fear of offending patients by discussing alcohol (26,27) has

resulted in HSys oriented toward an individualized, passive, and an

illness-centered model of health care in which SBI implementation

is utopic.

Coming to this point, it is clear that unless the HSys adopts

more holistic and patient-centered implementation models, the

SBI implementation on HHAC will not be achieved and sustained

despite all the research and efforts done. In this direction,we would

like to emphasize the relevance of the contributions made by:

TBLISI RESOLUTION

Behavior Change strategies and health: the role of HSys (6)

that acknowledges the fact that behavior-related risk factors have

become the leading causes of morbidity and mortality and that

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Colom et al. Brief interventions and health systems

Table 2 | SBI programs characteristics.

FinlandaSweden ScotlandbEngland Italy Catalonia/Spain

Origin Late 90s. Phase IV of the

WHO Collaborative

Projectc. PHC and

occupational health

Early 80s Malmö study.

Risky drinking Project

(2004–2010) in PHC,

maternity and occupational

health care

Early 80s DRAM Study.

Scotland performance

management target

(H4:Heat target)d

Late 80s. Phase II of the

WHO collaborative project.

SIPS trials (PHC,

emergency departments

and criminal justice

settings

Early 90s. Phase III strand I

of the WHO Collaborative

Project

Mid 90s. Phase III-strand

III of the WHO

Collaborative Project.

Phase IV on

implementation started in

2002

National

guidelines

Yes. Part of other clinical

care guidelines

Yes. Stand alone guidelines

(GP)

Yes. Stand alone guidelines

(GP and nurses). The

management of harmful

drinking and alcohol

dependence in primary

caref

Yes. Stand alone guidelines

(GP and nurses) NICE

guidance on the prevention

of hazardous and harmful

drinking plus a Nationally

Directed Enhanced service

Yes. Stand alone guidelines

(GP). PHEPAeadapted at

national level

Yes. Stand alone guidelines

(GP and nurses). PHEPAe

adapted at national level

and PAPPSf

Professionals Both GP (1,000) and

nurses (2,000)

Both GP, residents in

family medicine and

district nurses

GP and other PHC

professionals (practice and

community nurses and

health visitors)

Both GP and nurses GPs, psychiatrists, family

advice bureau from PHC;

psychologists, professional

from the Ser.T.S. and

workplace

Both GP and nurses

Screening Opportunistic screening

with AUDIT

AUDIT Clinical presentations and

new registrations.

Abbreviated forms of

AUDIT (e.g., FAST), or

CAGE plus two

consumption questions,

should be used in primary

care when alcohol is a

possible contributory

factor

Targeted screening with

AUDIT and AUDIT-C

Targeted screening with

AUDIT and AUDIT-C on a

voluntary basis

Universal with existing

tools (quantity and

frequency) in medical

records and AUDIT

(voluntary)

Brief intervention FRAMES adapted BI Feedback and BI.

MI-principles

FRAMES adapted BI

(10min)

Simple structured advice

and brief behavioral

counseling

Based on PHEPA

guidelines (FRAMES

adapted BI)

FRAMES adapted BI

TraininggBoth vocational and

continuing medical

education (GP and nurses)

Only vocational training

(GP). During the project:

half and whole day

information seminars and

network meetings

Training of trainers (100).

NHS health Scotland

trained over 3200

practitioners (Training

manual, DVD and a

national competency

Partially available

vocational training and

continuing medical

education (GP and nurses).

During the project: training

of trainers (How much is

too much package)

Only vocational training

(GP). During the project:

training of trainers (PHEPA

training manual) and

continuing medical

education (ECM)

Both vocational and

continuing medical

education (GP and nurses)

Training by peers in the

PHC (Beveu Menys

package)

(Continued)

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Colom et al. Brief interventions and health systems

Table 2 | Continued

FinlandaSweden ScotlandbEngland Italy Catalonia/Spain

Incentives or part

of normal salaryg

Part of normal salary Incentives Incentives Part of normal salary Part of normal salary Small incentives

Support for

managing SDA in

specialized

treatment

facilities

Yes Yes Yes. Access to relapse

prevention treatments

Yes. Evidence-based care

pathway for different levels

of alcohol-related risk harm

and dependence

Yes Yes. Strategy on

coordination between PHC

and specialist services for

alcohol dependence

Monitoring and

evaluation

Pre-post. Mailed

questionnaire to all PHC

physicians (2002–2007).

Face-to-face interviews

(2008) (self-report

measures). 25% of Finnish

population but concerted

attempt to cover the whole

country

Pre-post.

Telephone-administered

questionnaire to general

population (2006–2009)

(self-report measures)

Trials, case studies to

assess extend of adoption

and reach

National audit ofﬁce report.

annual care quality

commission report

Not on SBI

implementation but on

alcohol consumption,

mortality, attributable

hospital discharges and on

public specialist alcohol

service activities (125/2001

law on alcohol)

Annual screening rates

(contract with PHC

providers)

Governmental

funding for

services for

HHAC

Yes Yes Yes No Yes Yes

Speciﬁc national

policy

Yes. Finnish alcohol

program (2004–2007)

Government initiative Health service target of

delivering 149,449 BI

2008/2009–2010/2011

National alcohol strategies

(2 since 2004)

Frame law on alcohol

125/2001

National alcohol and health

plan (PNAS)

National prevention plan

(PNP)

National health plan (PSN)

No but included in the

health Plan (2012–2016)

and in the drug prevention

plan

Presence of

country coalition

for the

management of

HHAC

Yes Yes. Cooperation with 21

county councils.

Supervision by the

professional organizations,

local authorities, Hospitals,

etc

– Yes Yes. National Observatory

on Alcohol – CNESPS,

Istituto Superiore di Sanità

(with funding from the

MoH and the Presidency

of the Council of the

Ministries, Dept of

antidrugs policies)

Yes. Program on

Substance Abuse of the

Department of Health (full

time nurse and half time

administration staff) in

collaboration with PHC

providers and Catalan

Society of Family and

Community Physicians and

Nurses

(Continued)

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Colom et al. Brief interventions and health systems

Table 2 | Continued

FinlandaSweden ScotlandbEngland Italy Catalonia/Spain

General and

family practice

availability and

accessibility

Mean =6g

Mean Mean – Below Below Above

Professionals

accountability GP

Mean =5.4

Nurses

Mean =4.5g

Above/above Below/below – Below/above Below/below Above/above

aWHO-Phase IV, Finland report – http://www.gencat.cat/salut/phaseiv/ﬁnland.htm

bAlcohol Brief Interventions: communication and Guidance – http://www.healthscotland.com/topics/health/alcohol/alcohol-brief-interventions-communications-and-guidance.aspx

cWHO-Phase IV website: http://www.gencat.cat/salut/phaseiv/index.htm

dSIGN no. 74 (2003) – http://www.sign.ac.uk/guidelines/fulltext/74/index.html

ePHEPA guidelines: http://www.phepa.net/units/phepa/html/en/dir361/doc13210.html

fPrograma de actividades preventivas y de promoción de la salud (PAPPS) – http://www.papps.org/upload/ﬁle/Grupo_Expertos_PAPPS_2_2.pdf

gODHIN assessment tool – report – A description of the available services for the management of hazardous and harmful alcohol consumption (2013) – http://www.odhinproject.eu/project-structure/wp6.html

they cannot be seen in isolation, as they mostly are inextricably

connected with the social determinants of health.

TALLINN CHARTER

Health system for health and wealth (6) that stresses that effective

primary care is essential to provide a platform for the interface of

HSs with communities and families and for intersectoral cooper-

ation and health promotion that HSys should integrate targeted

disease-speciﬁc programs into existing structures and services and

that HSys need to ensure a holistic approach to services, involv-

ing health promotion, disease prevention, and integrated disease

management programs, as well as coordination among a vari-

ety of providers, institutions, and settings, irrespective of whether

these are in the private or public sector and including primary

care, acute,and extended care facilities and people’s homes, among

others.

Thus, talking speciﬁcally about the management of HHAC, the

Tblisi resolution tells us that complex factors inﬂuencing alcohol

behavior change should be taken into account in order to design

proper interventions (see Table 3).

All the factors listed above are applicable to alcohol behavior

change and to the design of alcohol interventions. The behavioral

change model acknowledges the important role that, for example,

the physical and social environments, the social relationships, and

the social norms play on the alcohol consumption and as a result of

this, alerts on the limit to a person’s capacity to change, if the envi-

ronment militates against the desired change; and the importance

to create conditions and incentives for change, in addition to giv-

ing messages and advice and building personal skills. This model

also stresses that some people are just physiologically incapable of

drinking moderately and that in such cases actions to empower

(29), to increase self-esteem (30) and resilience (31) of the harm-

ful drinkers should also be implemented to increase effectiveness.

Thus, behavior change could beneﬁt frominformation, education,

and capacity building interventions, at community and, especially,

at individual level.

In addition to that, according to the Tallinn charter, it is clear

that the implementation of SBI in PHC alone would not produce

the effect we are aiming for.

From the model proposed (see Table 4), it is clear that in order

to introduce such individually oriented strategies by PHC it is

essential to embed them into settings and systems oriented strate-

gies such as health promotion approaches and community and

population strategies such as mass media campaigns regulation

and legislation and capacity building.

Taking all this into account, the following considerations could

be made.

•From a Public Health point of view,to increase the effectiveness

of any alcohol risk reduction all these aspects need to be taken

into consideration and the respective stakeholders need to be

involved in a wide, holistic, intersectoral approach. Social and

HSs, culture and education, pharma industry, local authorities,

private sector, general population representatives, and the eco-

nomic sector are only some of the participants that need to be

involved.

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol November 2014 |Volume 5 | Article 161 | 72

Colom et al. Brief interventions and health systems

Table 3 | Common factors inﬂuencing behavior change and their implications for intervention design [adapted from WHO European Ministerial

Conference on Health Systems (28)].

Factors Design implication

A desire for change must be present in the audience There is a need both to create a demand for positive change and to create

the conditions to enable people to make positive choices

Participatory involvement leads to greater behavioral change effects Interactive engagement strategies and the development of coalition

approaches to change should be part of all behavior change interventions

People are often motivated to do the “right thing” for the community as

well as for themselves and their families

Programs should encourage and incentivize socially responsible behavior

and penalize behaviors that are not socially responsible

Social relationships, social support, and social norms have a strong and

persistent inﬂuence on behavior

Incorporating peer and family support strategies into individual risk change

programs increases likely success

Change is usually a process not an event Programs should be sustained over time and tailored to the needs of

different groups

Psychological factors, beliefs, and values inﬂuence how people behave Programs need to address values and beliefs, as well as information and

knowledge acquisition

People can be “locked into” patterns of behavior and need practical help to

break them

Policy and services need to be designed to meet the speciﬁc needs of

different communities, in order to help them change engrained habits

Change is more likely if an undesired behavior is not part of an individual’s

life situation coping strategy

Create incentives, offer practical support for change, and give positive

reinforcement. Provide alternative forms of support and reinforcement to

aid behavior change

People’s behavior is inﬂuenced by their physical and social environments There is a limit to a person’s capacity to change, if the environment

militates against the desired change; conditions and incentives for change

must therefore be created, in addition to giving messages and advice and

building personal skills

People’s perception of their vulnerability to a risk and of its severity is key

to understanding behavior

There is a need to develop individual and community understanding of risk

and vulnerability in relation to major threats

Perceptions of the effectiveness of the recommended behavior change are

key factors affecting decisions to act

Programs should seek to ensure that people understand the scale of the

rewards associated with positive behavior change

The more beneﬁcial or rewarding an experience, the more likely it is to be

repeated

Reinforcing and incentivizing positive behavior in the short term should be

part of any change program

People are loss-averse: they will put more effort into retaining what they

have than into acquiring new assets

Programs should emphasize the advantages of positive behaviors that

enable a continuation of immediate beneﬁts, rather than long-term gains

People often rely on mental short cuts and trial-and-error to make

decisions, rather than on rational computation

Programs should develop a deep understanding about what will motivate

people to change and how they perceive speciﬁc issues

•From an individual point of view, primary healthcare and

general practitioners (GPs), in particular, need to participate

because they can take care of all those issues and work for

behavioral change in an effective way (32,33). They provide life-

long, continuing, co-ordinated, and community oriented care to

their patients and are widely seen by them as their most trusted

health providers. They are also recognized as being the gate-

keepers in many European HSys and they are the only health

professionals that have the formal role and possibility to recover

information on every health determinant, educate, and pro-

vide support to their patients. Genetics, mental health, family

situation, culture, religious beliefs, and socio-economic posi-

tions can be easily accessed by these experts assuring thus a

holistic approach. In their everyday work, GPs should know that

increasing awareness and knowledge is essential for behavioral

change but they are seldom sufﬁcient to promote a sustain-

able modiﬁcation in health behaviors. The ability to change is

also inﬂuenced by each citizen’s values, attitudes and norms,

self-perception and capacity for sustaining the change, expec-

tations of success and failure before embarking on a change

program.

•Apart from increasing health literacy and managing health

issues, we need to inﬂuence individual attitudes and the level

of conﬁdence, which are more bound to health determi-

nants such as culture, social models, economic, and working

conditions. Individual health needs should be addressed and

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Colom et al. Brief interventions and health systems

Table 4 | Components of a comprehensive approach to health behavior change [adapted from WHO European Ministerial Conference on Health

Systems (28)].

Community and whole of population strategies

Legislation and regulation Environmental Change (footpaths, cycleways, lighting) Mass media campaigns

Community partnerships Community capacity building Existing community structures

and leadership

Culturally and behaviorally tailored

programs

Settings and systems oriented strategies

Setting intervention:

workplaces

Setting intervention:

educational institutions

Setting intervention:

primary health care

Setting intervention:

home and family

Social support, e.g., walking group Telephone counseling Signs/cues at points of

decision-making

Internet

Individually oriented strategies

Personal goal-setting Self-monitoring, e.g., daily–diary 1:1 or group counseling Brief advice from GP or health

professional

also individual resources, in a non-medical, positive, health

promotion approach.

CONCLUSION

This review contextualizes the importance of the implementation

of SBI in the context of effective alcohol policies, summarizes the

main effectiveness and cost-effectiveness evidence, and describes

the major accomplishments achieved with nation-wide SBI imple-

mentation programs in Europe. This review also provides the

means to think of different approaches if more effective AUDs

strategies are to be proposed at European level. Social, economic,

and health promotion points of view are also presented as impor-

tant aspects to be explored for the good outcome of any AUDs

strategy.

Major and diverse issues were identiﬁed in this review:

•Implementation is still not Country- and Europe-wide. Pilot

experiences should be generalized. The recent trial results

strongly reinforce the already expressed suspicion that it is

extremely difﬁcult to get health professionals to deliver SBI; The

ODHIN assessment tool shows that, in 2012, EIBI was still not

the norm in daily consultation in PHC and that more resources

are needed to overcome the main obstacles.

•Enduring behavior change and improvements on biochemical

and biometric measures are unlikely after a single routine con-

sultation with a clinician trained in behavior change counseling,

without additional intervention.

•A tailored, implementation multi-faceted program aimed at

improving general practitioner management of alcohol con-

sumption showed little evidence to support the use of such an

intensive implementation program to improve the management

of harmful and hazardous alcohol consumption in primary care.

•Despite the efforts made toward the country-wide implemen-

tation of SBI programs, comparisons are difﬁcult, not only due

to the different context and implementation strategies used but

also by the diversity of the outcome and output indicators used.

Little can be said about what works, what does not and in what

contexts.

•As stated by many authors (11,34), further evaluation of all the

programs under a common evaluation framework like the reach,

effectiveness, adoption, implementation, and maintenance (RE-

AIM) or the CFIR that go beyond the standard models of

technology diffusion would be essential in order to extract more

structured ideas on the implementation needs. Authors (8,35)

suggest that new modes of delivery such as via internet may

help to surmount some of the challenges of wide dissemina-

tion, such as strains on expertise, time, and resources but still

more research has to be done on its efﬁcacy and effectiveness. In

addition to that, in order to achieve a population-wide dissem-

ination it is essential to involve other health and social settings

and actors, thus, expanding SBI evidence is essential. In this

sense, initiatives such as the “BISTAIRS project” – will provide

useful information on how to foster the implementation of SBI

for AUDs in a variety of settings (PHC, workplace HSs, emer-

gency care, and social services) and extending best practices in

Europe (36,37).

•Implementing SBI through a PHC system approach is impor-

tant because addressing risky drinking is a complex issue, involv-

ing different actors from different parts of the society. Families,

local communities, and work environments are the usual set-

tings where those risks are generated and PHC is the right

place to understand the conditions that bring people to adopt

unhealthy lifestyles.

Taking into account all these elements listed above, leads

inevitable to the need to reframe SBI. The challenge is how to

do it without impacting on its cost-effectiveness and practicability

in PHC to reduce alcohol health risks (20,38). Some suggestions

will be:

•To broaden it to a brief motivational intervention, which could

allow professionals to understand and evaluate individual health

determinants and self-esteem and to determine people’s moti-

vations to change by addressing patient’s importance and con-

ﬁdence to change and help them to understand the individual

conditions underlying their risky drinking.

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol November 2014 |Volume 5 | Article 161 | 74

Colom et al. Brief interventions and health systems

•To strengthen the links with territorial services as an essential

way to provide structural support, when needed.

•To broaden brief interventions to allow a more traditional,

pharmacological treatment, more in line with professional’s

(especially GPs) attitudes and views.

•To abandon simplistic and potentially unhelpful positions of

putting on each individual patient the sole responsibility and

decision to adopt healthier behaviors to avoid ill health.

•To integrate peer and family support strategies into individual

risk modiﬁcation in order to increase the SBI success (39).

•To propose alcohol SBI within the broader issues of all lifestyles

and within the context of a global cardiovascular and cancer

risk reduction. Asking about alcohol drinking, food intake or

tobacco smoking, just like asking about blood pressure, can be

an easy step forward to increase effectiveness.

•To integrate brief interventions with on-going practical support

for structural changes performed by other actors (social ser-

vices, community networks, psychologists, psychiatrists, etc.)

could ease the work of primary healthcare and allow a better

management of AUDs.

•To take advantage of new information and communications

technologies (ICT) to help addressing the problem and enabling

patients and health care providers to work as co-producers of

health. Without abandoning completely the traditional face-to-

face engagement, there is mounting evidence of the effectiveness

of delivering aspects of healthcare using the Internet and mobile

phone applications for the promotion of healthier lifestyles

(smoking cessation, healthier drinking choices,and weight loss)

(40,41). Work is also underway on the development of digi-

tal technologies to enable patients with long-term conditions

such as AUDs, obesity, and chronic obstructive airways disease

to engage more actively in the management of their own health

and trials are being undertaken to evaluate the potential of these

applications to deliver beneﬁts in relation to patient satisfaction

and wellbeing as well as clinical outcomes (21).

•To work closely in connection with patients and the public as

well as different stakeholders (medical and social, the pharma-

ceutical industry, public health authorities, ICT and m-health

actors, health economists, health insurers) to understand peo-

ple’s attitudes and motivations, as well as barriers to change,

perceived or real, in a real community holistic approach, to

address health determinants and explore new, co-produced

health models. Be involved in alcohol risk management con-

sidering the need to reduce stigma by including alcohol in usual

care, with other lifestyle related risks and in the broader question

of cardiovascular risk management.

•To create more appealing specialist services to help reducing

stigma associated to AUD.

•The fact that it is difﬁcult to effectively implement and maintain

SBI strategies should bring policy makers to explore new possi-

bilities, linking different stakeholders with different approaches,

and trying new methodologies, including the provision of

appropriate training, incentives,and implementation strategies.

In summary, alcohol use is a complex issue, at least as much so

as hypertension or diabetes. Thus, thinking that a single interven-

tion, even if effective, such as SBI, could solve the problem is, to

our point of view, naïve, and restrictive. Future strategies should

aim at broadening the perspective from an individual and a HSys

point of view. HSs are important in addressing AUDs but only if

individual tailored strategies are proposed, taking into considera-

tion all the complexity of human being and his environment in a

Health System approach (42).

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Conﬂict of Interest Statement: The authors declare that the researchwas conducted

in the absence of any commercial or ﬁnancial relationships that could be construed

as a potential conﬂict of interest.

Received: 30 June 2014; accepted: 28 October 2014; published online: 11 November

2014.

Citation: Colom J, Scafato E, Segura L, Gandin C and Str uzzo P (2014) Brief interven-

tions implementation on alcohol from the European health systems perspective. Front.

Psychiatry 5:161. doi: 10.3389/fpsyt.2014.00161

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

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Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol November 2014 |Volume 5 | Article 161 | 76

PSYCHIATRY

REVIEW ARTICLE

published: 30 October 2014

doi: 10.3389/fpsyt.2014.00151

Internet applications for screening and brief interventions

for alcohol in primary care settings – implementation and

sustainability

Paul Wallace1* and Preben Bendtsen2

1University College London, London, UK

2Department of Medical Specialist and Department of Medicine and Health Sciences, Linköping University, Motala, Sweden

Edited by:

Hugo López-Pelayo, Fundació Clínic

per la Recerca Biomèdica, Spain

Reviewed by:

Carlos Soler-González, Hospital Clínic i

Universitari de Barcelona, Spain

Robert Patton, King’s College London,

*Correspondence:

Paul Wallace, Department of Primary

Care and Population Health, Royal

Free Campus, Pond St, London NW3

2PF, UK

e-mail: p.wallace@ucl.ac.uk

Screening and brief interventions head the list of effective evidence-based interventions

for the prevention and treatment of alcohol use disorders in healthcare settings. How-

ever, healthcare professionals have been reluctant to engage with this kind of activity

both because of the sensitive nature of the subject and because delivery is potentially

time-consuming. Digital technologies for behavioral change are becoming increasingly

widespread and their low delivery costs make them highly attractive. Internet and mobile

technologies have been shown to be effective for the treatment of depression, anxiety,

and smoking cessation in healthcare settings, and have the potential to add substantial

value to the delivery of brief intervention for alcohol. Online alcohol questionnaires have

been shown to elicit reliable responses on alcohol consumption and compared with con-

ventional prevention techniques, digital alcohol interventions delivered in various settings

have been found to be as effective in preventing alcohol-related harms.The last decade has

seen the emergence of a range of approaches to the implementation in health care set-

tings of referral to Internet-based applications for screening and brief interventions (eSBI)

for alcohol. Research in this area is in its infancy, but there is a small body of evidence pro-

viding early indications about implementation and sustainability, and a number of studies

are currently underway.This paper examines some of the evidence emerging from these

and other studies and assesses the implications for the future of eSBI delivery in primary

care settings.

Keywords: eSBI, online interventions, alcohol, health care setting, Internet, digital

BACKGROUND

Screening and brief interventions have been demonstrated to be

highly cost-effective but despite the strength of the evidence,

implementation by healthcare professionals has been disappoint-

ingly low (1,2). The delivery of a standard brief intervention can

add up to 15 min to the primary consultation and thus constitutes

a signiﬁcant barrier to implementation. In primary health care

settings, commonly <10% of hazardous and harmful drinkers are

identiﬁed, and <5% of those who could beneﬁt are offered brief

interventions (3). Primary health care based interventions for haz-

ardous and harmful alcohol consumption are among the most

infrequently delivered interventions when compared with other

cost-effective clinical preventive services (4).

Digital technologies for behavioral change are becoming

increasingly widespread and their low delivery costs make them

highly attractive. Internet and mobile technologies have been

shown to be effective for the treatment of depression and anx-

iety (5–7). Similarly, digital smoking cessation intervention has

shown promising results (8–10). Concerning risky alcohol use,

there is also a growing evidence base on the effectiveness of

electronic screening and brief interventions (eSBI), both in

the general population and in university student populations

where there is the largest body of evidence (11–16). A review

of computer-based interventions (on- and ofﬂine) for college

drinkers and a meta-analysis of trials on the same subject con-

cluded that computer-delivered interventions reduce the quantity

and frequency of drinking in student populations when com-

pared with assessment-only controls, and that computer-based

interventions are as effective as other alcohol-related interventions

(16,17).

Several systematic reviews have been undertaken to assess the

effectiveness of digital interventions across a wider range of set-

tings (18–20). All concluded that the weight of evidence suggests

that users can beneﬁt from online alcohol interventions and that

this approach could be particularly useful for groups less likely to

access traditional alcohol-related services. However, all also sug-

gested that caution should be exercised in drawing conclusions

given the limited number of studies allowing extraction of effect

sizes and the heterogeneity of outcome measures and follow-up

periods. A recent review by Donoghue et al. identiﬁed such a high

level of diversity of interventions with regards to length, content,

and theoretical basis that it was not practical to perform a meta-

analysis of the effectiveness of eSBI (21). Although there is growing

evidence for modest effectiveness of a broad range of internet-

delivered interventions, a number of issues remain to be resolved

(18,19) with more research still needed into the nature of the active

www.frontiersin.org October 2014 | Volume 5 | Article 151 | 77

Wallace and Bendtsen Internet alcohol interventions in primary care

elements of an Internet intervention and the support required to

ensure effective use is made of the intervention (19,20,22).

So, what can health care staff do in order to facilitate patient

referral and uptake of eSBI and to promote the intended use of

the intervention? Research on referral of patients by health care

professionals to Internet applications for screening and brief inter-

ventions for alcohol (eSBI) is still in its infancy, with early studies

having been undertaken in Sweden and the UK, and a number of

further studies currently underway.These include the ODHIN tr ial

taking place in general practice settings in ﬁve European countries,

and the EFAR trials, currently in progress in northern Italy and in

the planning stages in Spain, Australia, and the UK (23,24). This

paper considers the development of eSBI for delivery in health

care settings and the evidence emerging from studies on imple-

mentation and uptake, and assesses the implications for the role

of eSBI in the future delivery of screening and brief interventions

in primary care.

eSBI DELIVERED IN PRIMARY CARE SETTINGS: CASE

STUDIES FROM SWEDEN AND THE UK

The majority of studies on eSBI have concentrated on popula-

tion studies where individuals access these online facilities largely

unprompted and of their own volition. These inevitably tend to

recruit participants who are self-selected and motivated to engage,

presumably because they are actively concerned about their drink-

ing and keen to take action to reduce. There is substantial potential

to increase the reach of eSBI beyond these populations by promot-

ing their use in health care settings, particularly primary care where

the great majority of health encounters take place. There is already

an extensive literature on the effectiveness of face-to-face lifestyle

interventions delivered by primary care professionals, which sug-

gests that the interaction between the clinician and patient can be

highly effective in bringing about lifestyle change in patients who

may not necessarily have made any prior decision to change. There

is also a growing literature on guided interventions and facilitated

access by health care professionals to online resources for anxiety

and depression and risky drinking (5,25). In a recent meta-review,

Riper et al. pointed out that most studies on alcohol eSBI are deliv-

ered as stand-alone interventions accessible to the community at

large and to a far lesser extent are guided interventions initiated

via primary care (25). In the review, no differences in effectiveness

were seen between guided and unguided low-intensity eSBI. As

has been pointed out by Kohl et al., “one of the most substantial

problems in online prevention is the low use of the interven-

tions” (19), and although Brouwer et al. found indications that

counselor support may facilitate the uptake of referral to an eSBI

(20), more studies are needed on how best to combine face-to-

face support with eSBI. We describe below two early initiatives

in Sweden and the UK, which were designed to test the feasibil-

ity and acceptability of referral to eSBI in primary care settings

as an alternative to traditional face-to-face screening and brief

interventions.

EXPERIENCES FROM SWEDEN

In a series of implementation projects undertaken in Sweden

during 2007–2010, the use of stand-alone computers to facilitate

automated alcohol screening and personalized feedback topatients

was tested in a total of 28 primary care centers (PHCs). For the pur-

poses of the study, a computer-based alcohol screening and brief

intervention (eSBI) module was developed. In short, the single-

session intervention offered a two pages simple text and graphical

based feedback on the persons drinking pattern comparing this

with the recommend ofﬁcial sensible drinking limits in Sweden.

Suggestions on how to cut down were given based on the per-

son’s motivation to change. A drinking diary for self-monitoring

of drinking level was also included in the feedback. While the pri-

mary aim of the study was to evaluate the uptake and usefulness

of the Internet-based intervention (eBI) module for alcohol, an

additional module on physical activity was developed in order to

limit stigmatizing patients using the computer (26).

PILOTING THE INTERVENTION AND IMPLEMENTATION

In the initial pilot phase, the managers and health coordinators at

9 PHC units were informed in a meeting about the computerized

system. Staff in each PHC center was encouraged to decide for

themselves, which patients to refer to the computerized test. The

9 PHC units were provided with a stand-alone computer in an

integrated IT-kiosk with a touch screen and a printer. The kiosks

were placed in the waiting rooms, suitable corridors, or more pri-

vate rooms at the PHC unit. The staff was given weekly statistics

about the number of tests performed and the risk proﬁles of their

patients. All tests were anonymous,but the patients were given two

copies of the two pages written feedback in case they wanted to

share a copy with the caregiver.

Although the prime objective of the implementation project

was for staff members to actively refer patients to the comput-

erized intervention, patients were also free to perform the test

without referral. One question in the program asked whether the

patients had been referred by a staff member to the computer or

had done the test by themselves, and this information was used in

the feedback to the staff.

After the ﬁrst year, a total of 3027 patients had completed the

computerized screening module, comprising on average 5.7% of

all visitors to the PHC during the period (range 3.6–11.1%). The

proportion of patients referred to the intervention by the staff in

relation to the total number of tests varied by PHC unit from 11

to 87% of all interventions. A total of 28% of the men and 14% of

the women who completed the computer-based screening mod-

ule had a risky drinking proﬁle. No differences were seen in the

proportions of patients with risky drinking between those who

had been referred and those who undertook the computer-based

screening on their own initiative (26).

FURTHER IMPLEMENTATION AND EVALUATIONS

A number of evaluations and reports have been published on the

pilot study,a subsequent experimental implementation study on 6

PHC units and lastly a larger scale implementation study involving

28 PHC units in the region (26–29). These showed that the patients

found the computer-based eSBI module easy to use,irrespective of

gender and age, and only 3% of the referred patients expressed neg-

ative views about having been referred to the intervention (27). In

a follow-up study, 3,169 risky drinkers were invited to participate

in a 3 months follow-up after having performed the intervention.

Of the 587 patients who agreed to be contacted after 3 months, 347

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol October 2014 | Volume 5 | Article 151 | 78

Wallace and Bendtsen Internet alcohol interventions in primary care

patients were eventually contacted for follow-up. Of the respon-

ders, 84% conﬁrmed that they had read the written feedback that

they received on completion of the eSBI module, and 77% stated

that they remembered the content. Eighty-two percent agreed that

the feedback was relevant, 45% had discussed the feedback with

a friend or relative, and 26% had talked about it with someone

at the PHC unit. Nearly all (92%) found the information easy to

understand (27).

In a sub study on six PHC units, interviews were performed

with managers and health care professionals. The managers were

unanimously positive about the computerized intervention and

saw openness among their staff for this innovation. However, they

also indicated more negative attitudes among certain groups of

staff, especially the GPs. Interviews with GPs conﬁrmed that there

was less enthusiasm in this group, and some pointed out that they

had enough to do without the tool. Commonly,the GPs stated that

they did not need a new tool as they integrated lifestyle advice into

their consultations. This stood in contrast to much more positive

attitudes from nurses to the computerized intervention (28).

A follow-up study undertaken 2 years subsequent to the intro-

duction of the computerized intervention into the six PHC units

showed that levels of maintenance/sustainability were low. How-

ever, most staff agreed that computerized or Internet-based inter-

ventions could facilitate healthy lifestyle promotion and that using

computers is an important tool for increasing healthy lifestyle

promotion (29).

In summary

The Swedish experience tells us that the stand-alone computerized

intervention may be implemented within the PHC settings in the

short term, and succeeded in reaching large numbers of patients.

Many patients and some staff expressed generally positive attitudes

about the eSBI module. However, there was less enthusiasmamong

the GPs and importantly usage decreased over time even though

many of the staff considered the computerized tool as an impor-

tant part of the healthy life style promotion. It therefore seems

unlikely that this model could be sustainable in routine practice

not least due to the low levels of interest among staff in promoting

a healthy life style among patient with no obvious risk factors.

EXPERIENCES FROM THE UK

An implementation study was designed to test the feasibility of

offering an online self-help alcohol reduction program [Down

Your Drink (DYD)] and support from a trained alcohol worker

to general practice patients found to have hazardous or harmful

drinking (30). The project was carried out in Kingston Primary

Care Trust, which is situated on the outskirts of London, UK. For

the duration of the study, an alcohol project co-ordinator (APC)

was employed to work with the risky drinkers identiﬁed by GPsand

nurses in the participating practices, and to help them use DYD in

order to reduce their drinking. Once the GPs and practice nurses

identiﬁed a patient with hazardous or harmful consumption, they

referred the patient to the APC,who then contacted the patient and

arranged an appointment. The APC explained the nature of DYD

to the patient, provided an introduction to the various sections of

the intervention, and gave the patient personalized login details.

The patient was then invited to log in to the intervention from

their own computer. On average, this appointment lasted just over

40 min. Patients were able to call the APC if they experienced

any difﬁculties using the web site, and the APC arranged three

follow-up phone calls at fortnightly intervals in order to ensure

that patients were succeeding in using the website. They did not

engage in counseling.

A total of 18 of 28 practices expressed an interest in referring

patients to the web-based intervention, but after 12months, only

31 patients had been referred to the service of whom 19 attended

the appointment with the APC. Only 6 of these 19 patients seen

by the APC subsequently logged on to the web-based interven-

tion. However, those who chose to use the web site did this to a

high degree, with a mean of eight log-ins per patient and a mean

of 13 pages visited per session. Interviews were subsequently per-

formed with patients and the health care staff in the participating

practices, and these suggested that both staff and patients found

the service highly acceptable. They also reported that the service

worked smoothly and that it was convenient being able to access

the intervention in their own time.

In summary

The English experience of referring patients to a web-based self-

help alcohol intervention suggested that where practices are willing

to innovate, implementation is feasible and it is generally accept-

able to both staff and patients. There were, however, few referrals,

probably in part as a consequence of low levels of screening for

hazardous and harmful drinking, which is typical of primary care.

The cost of running the service was high due to the amount of

time that the APC spent with each patient, and it seems unlikely

that this model could be sustainable in routine practice.

FACILITATED ACCESS TO eSBI IN PRIMARY CARE SETTINGS:

THE ODHIN STUDY AND EFAR STUDIES

These early studies in Sweden and the UK suggested that while

eSBI might have potential to supplement conventional face-to-

face approaches to SBI in primary care settings, more attention

clearly needed to be given to make the technology sustainable.

Research was also required to determine whether eBI was as effec-

tive as face-to-face intervention in these settings. The following

section examines two sets of studies designed to determine how

simple referral of patients by GPs and nurses to an eSBI website

(“facilitated access”) might affect screening and brief intervention

activity in primary care settings (the ODHIN study), and whether

this approach could be as effective as face-to-face intervention (the

EFAR studies).

THE ODHIN STUDY

The ODHIN Study (Optimizing Delivery of Health Care Inter-

ventions) is a Europe wide project designed to help to optimize

the delivery of health care interventions by understanding how

better to translate the results of clinical research into every day

practice (23). ODHIN uses hazardous and harmful alcohol con-

sumption in primary health care as a case study to investigate the

implementation of identiﬁcation and brief intervention program.

The ODHIN study is being undertaken in Spain, England,

the Netherlands, Poland, and Sweden. In each country, 24 PHCs

are participating in a cluster randomized study with eight arms.

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Wallace and Bendtsen Internet alcohol interventions in primary care

The aim is to study the effectiveness of training and support,

ﬁnancial reimbursement, and referral to an eBI targeted singly or

in combination. Each country referred to existing Internet-based

interventions already in use in the particular country. This meant

that in Sweden, the patients were referred to a single-session inter-

vention similar to the one described previously in this paper. In

the UK, the patients were referred to a modiﬁed version of “DYD.”

In the Netherlands, the “Minderdrinken.nl” web site was used. In

Spain, the patients were referred to an existing web site run by the

Ministry of Health. In Poland, a new web site developed by the

WHO was used.

For all arms of the trial, staff in participating practices are

encouraged to use a short screening questionnaire administered

face-to-face to screen their patients for hazardous and harmful

drinking and to subsequently deliver brief interventions to those

who screen positive. In the eBI condition, the health care profes-

sionals have the option to activelyrefer patients who screen positive

to the online resource as an alternative to offering a face-to-face

intervention. In this case, the health care professional is asked to

spend 2–3 min providing the patient with facilitated access to the

alcohol reduction website, including a short conversation and the

offer of a leaﬂet offering information about the website, encour-

agement to log-on, and a personalized login code. The doctors

and nurses participating in the study participating in the study

are instructed to follow a script when offering facilitated access,

including a negotiation on when the patient thinks that he/she

would have time to log-on. The patients are handed a short leaﬂet

informing them why they have been referred, and on this leaﬂet

there are also given a personal login code, which can subsequently

be used to track log in activity.

The study is still in progress and the deﬁnitive results are

expected to be available in 2015. However, the preliminary data

indicate that facilitated access activity was highly variable across

the participating practices randomized to this arm of the trial. Fur-

thermore, it appears that while for some staff a high proportion

of the patients they refer to eBI complete the log-in process, for

others only a few do so. Such variability is almost certainly due at

least in part to the nature of the facilitated access provided by each

individual health care professional to their patients.

In summary

This model appears to hold signiﬁcant promise as it has the advan-

tage that it does not require any additional staff. However,effective

implementation will probably depend critically on ensuring con-

sistency among staff in the delivery of facilitated access to the

web-based intervention. Furthermore, studies need to be per-

formed in order to explore whether facilitated access at the index

consultation is sufﬁcient to ensure that patients to make adequate

use of the service, or whether active follow-up is needed. Also, it is

unclear to what extent staff want or need a feedback on the effects

of the web-based intervention in order to sustain motivated to the

use of the referral system.

THE EFAR STUDIES

The EFAR studies form part of a multi-country initiative involving

a series of randomized controlled non-inferiority trials of primary

care based facilitated access to an alcohol reduction website,which

are at various stages of development in Italy, Spain, Australia, and

the UK. The EFAR-FVG trial is being undertaken in general prac-

tices in the Friuli Venezia Giulia Region of Italy and is the ﬁrst

in the series (24). EFAR-FVG compares delivery by GPs of facili-

tated access to a dedicated website for risky drinkers with standard

face-to-face brief intervention. The trial website is an Italian lan-

guage online facility, which includes modules for all the key trial

components including screening, consent, assessment, random-

ization, and follow-up. It also incorporates the alcohol reduction

website for the patients in the experimental group. The site has

been adapted from the website developed for the DYD-RCT trial.

Details of the DYD website and the psychological theory,which has

underpinned its development, have been reported elsewhere (31).

The EFAR-FVG trial website additionally incorporates a menu-

driven facility to enable the GPs to personalize the automated

patient messages by adding a photograph of themselves and/or an

audio/video recorded message.

All patients aged 18 years or over who attend the participat-

ing practices are offered facilitated access to the eSBI facility by

their GP or another staff member. This consists of a 2–3 min

discussion followed by the offer of a trial brochure providing

a unique access number enabling the patient to log on to the

trial website from their own computer. Once online, patients are

asked to complete the three-question short Alcohol Use Disor-

ders Identiﬁcation Test (AUDIT-C) and to provide agreement for

the results of the test to be sent to their practice. For the pur-

poses of the trial, cut points of four for women and ﬁve for men

have been used. Those scoring at or above the cut points receive

personalized feedback advising that their stated drinking patterns

indicate that they are at risk from their drinking and inviting

them to take part in the study. They are then invited to complete

the online EFAR-FVG trial consent module before being invited

to complete the online baseline assessment, which includes the

full AUDIT, and two brief questionnaires on demographics and

quality of life. Completion of the questionnaires leads to auto-

mated online randomization to either online (experimental) or

face-to-face (reference) intervention.

Those in the experimental group are greeted by a personal-

ized online message from their GP with tailored feedback about

their responses to the questionnaires and encouragement to spend

some time online to consider their alcohol consumption and ways

to reduce. Patients receive an email 1 week laterencouraging them

to log on again. They are also asked online to review their alcohol

consumption and are invited to discuss their website experience

when they next see their GP. Patients allocated to the standard

intervention group are invited to check a box online, which auto-

matically generates an email to their practice requesting a GP

appointment for a face-to-face brief intervention within the next

7–10 days.

The ﬁndings of the pilot study indicated that this approach was

acceptable both to the participating GPs and the patients receiving

facilitated access (unpublished data). The numbers of brochures

distributed by each GP ranged between 22 and 280, and on aver-

age 42% of the patients receiving a brochure subsequently logged

on to the website. Of these, 93% completed the screening ques-

tionnaire, and of the 20% who screened positive, 84% went on

to randomization. The main trial, which commenced in January

Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol October 2014 | Volume 5 | Article 151 | 80

Wallace and Bendtsen Internet alcohol interventions in primary care

2014, has recruited in excess of 500 patients and is due to report

in 2015.

In summary

The facilitated access approach adopted in the EFAR-FVG study

appears to have been generally effective in achieving relatively high

rates of online screening in the participating practices, though the

rates varied considerably between GPs. The results of the relative

effectiveness of facilitated access to eSBI compared with face-to-

face intervention are yet to be published. The other EFAR trials

will examine additional approaches to practice based eSBI, such

as the use of a digital tablet in the practice and whether the GP

personalization facility in the alcohol reduction website adds to

the effectiveness of the online intervention. The results of these

trials will give an indication about whether GP facilitated access

to an alcohol reduction website is as effective as face-to-face, and

while the issue of sustainability will not be directly addressed, use-

ful indications about this might well emerge from add-on studies

conducted after the conclusion of the trials.

DISCUSSION

The last decade has seen the emergence of a range of approaches

to the delivery of eSBI as an integrated part of primary health care

settings as outlined in this paper, most of which have been under-

taken in European settings. Experimentation of this approach is

also being undertaken in other settings (32,33) and we are aware

of at least one study of electronic screening currently taking place

in accident and emergency departments in the UK as part of the

SIPS Junior study (http://www.sipsjunior.net/).

To date, the literature on evaluation of implementation of

referral to eSBI is limited, but in our view there are grounds for

cautious optimism about the potential for implementation and

sustainability in primary health care settings. For example, there

is reasonable evidence about the potential for internet applica-

tions to increase alcohol screening rates. This includes the ﬁndings

from the Swedish study where more than 3000 primary health care

patients (5.7% of all visitors to the PHC) used the computerized

screening facility in the space of year (26), and from the DYD

trial in the general population where high screening rates were

achieved with more than 10,000 screen positive subjects identiﬁed

over the course of the trial. (31) Additionally, in the EFAR trial

more than 40% of all the patients who received facilitated access

from their GP went on to complete the online alcohol screen-

ing module (unpublished data). There thus appears to be real

potential for internet applications substantially to increase alco-

hol screening rates. Given the consistently low screening rates,

which have been achieved by conventional approaches, it would

appear to be reasonable to advocate the more widespread imple-

mentation of online screening in primary health care settings.

This might be achieved either through the direct provision in

the clinic of access to a screening module using a computer or

a tablet, or by the GP or other health professional facilitating

their patients’ access to a suitable internet application through

provision of website details and/or log-on codes. There are as yet

unanswered questions about how the results of each patient’s alco-

hol screening test should best be fed back to the relevant health

care professional, though in any case, patients will need to be

reassured that their data will be treated in strict conﬁdence and

notiﬁcation should be conditional on provision of consent. Ide-

ally automated electronic transmission should be used to transfer

the screening results direct to the patient’s care record, but the

wide variety of primary health care systems providers operating

in most countries poses signiﬁcant technical challenges to this

approach, and thus more simple procedures using printout maybe

more practical.

While we believe that the evidence on internet applications for

screening in primary healthcare settings is encouraging, we feel

that the case for using these applications for brief intervention

(eBI) is currently less clear cut. Overall, there appears to be evi-

dence that internet applications may be as effective as face-to-face

intervention for risky drinkers, especially for student populations.

(16,17) However, a number of authors of systematic reviews

have cautioned over-interpretation of the ﬁndings from the lit-

erature, given the predominance of small-scale studies of variable

quality. The evidence for the use of eBI in health care settings

is certainly not yet convincing, but as highlighted in this paper,

there are some indications of promise for this approach, and a

number of important studies are now underway, which should

provide better evidence. The UK study of referral to eBI following

face-to-face screening was too small to enable ﬁrm conclusions

to be drawn (30). The results from the ODHIN study, which are

still to be published, should provide more robust evidence on the

impact of providing health care professionals with the option to

use facilitated access to an internet application for patients who

have screened positive on direct testing with the AUDIT-C. How-

ever,the study will not provide any evidence of effectiveness of eBI

relative to face-to-face intervention, and in the absence of other

studies in this area, we will need to await the results of the EFAR

trials before this question can be answered.

Taking all of these factors into account, we believe that there is

a good case for advocating the more widespread use of or referral

to internet applications for alcohol screening in primary health-

care settings. We think that the same is likely to be true for internet

applications for brief intervention, though robust evidence on this

is still awaited. Whatever the case, it is clear that sustainability will

depend on appropriate conﬁguration to meet the needs and wishes

of both patients and healthcare professionals, and the degree to

which these interventions become embedded in everyday practice

will depend critically on the way in which their implementation

is conﬁgured. Although many patients appear to respond posi-

tively to advice from their health care professional to undertake

eSBI, the professionals themselves demonstrate much more vari-

able levels of engagement. Effective mechanisms will therefore be

needed to enable referral to internet applications for screening and

brief intervention to become embedded in professional practice.

The challenges involved are complex and relate not only to con-

siderations of whether patients and healthcare professionals are

prepared to place their trust in internet applications but also to

the general attitude of healthcare professionals toward working

with alcohol and other life style areas.

CONCLUSION

If an appropriate balance can be identiﬁed between the use of refer-

ral to the internet and the personal engagement of the healthcare

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Wallace and Bendtsen Internet alcohol interventions in primary care

professional, it is likely that the use of internet applications for

alcohol screening and brief advice will prove increasingly suc-

cessful. Indeed, this approach may well ﬁnd a growing range of

applications beyond alcohol not only for other lifestyle behaviors

but also for the management of long term conditions such as

asthma, diabetes, and arthritis. There is thus real potential to

develop integrated virtual healthcare environments designed to

complement face-to-face delivery of health care and capable of

providing patients with access to internet applications for a grow-

ing range of their health care needs. As with eSBI, their success

will depend critically on our ability to identify the key ele-

ments, which contribute not only to effectiveness but also to

sustainability.

AUTHOR CONTRIBUTIONS

Both authors contributed to the design and content of the manu-

script as well as the ﬁrst draft of the manuscript and all subsequent

revisions. Both authors have approved the ﬁnal version of the

manuscript.

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Frontiers in Psychiatry | Addictive Disorders and Behavioral Dyscontrol October 2014 | Volume 5 | Article 151 | 82

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Conﬂict of Interest Statement: Preben Bendtsen partly owns a private company

that distributes alcohol and other life style online interventions. Paul Wallace has

intellectual property rights for www.downyourdrink.org.uk, is PI in the EFAR and

ODHIN studies and provides private consultancy on the topic of screening and brief

interventions.

Received: 15 June 2014; accepted: 15 October 2014; published online: 30 October 2014.

Citation: Wallace P and Be ndtsen P (2014) Internet applications for screening and brief

interventions for alcohol in primary care settings – implementation and sustainability.

Front. Psychiatry 5:151. doi: 10.3389/fpsyt.2014.00151

This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section

of the journal Frontiers in Psychiatry.

under the terms of the Creative Commons Attribution License (CC BY). The use, dis-

tribution or reproduction in other forums is permitted, provided the original author(s)

or licensor are credited and that the original publication in this journal is cited, in

accordance with accepted academic practice. No use, distribution or reproduction is

permitted which does not comply with these terms.

www.frontiersin.org October 2014 | Volume 5 | Article 151 | 83

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