Brief alcohol intervention as pragmatic intervention: Who is voluntarily taking an offered intervention?

Abstract

Brief alcohol interventions (BAI) have shown the potential to decrease problematic alcohol use among adolescents and young adults. Most of the BAI studies have been efficacy trials designed to achieve high internal validity but have raised questions regarding the feasibility of large-scale implementation. Providing interventions for those voluntarily wanting them might offer an alternative, and studies using this design would be more similar to effectiveness studies. The present research compares randomly selected 20-year-old men who took part in a scientific trial (efficacy) with those who voluntarily sought an intervention (effectiveness). Sampling took place during army recruitment procedures that are mandatory for all males in Switzerland. At-risk drinking (20+ drinks per week, or more than one risky drinking occasion of 6+ drinks per month) was determined a posteriori; there was no screening. There were a higher percentage of at-risk drinkers in the volunteer arm at baseline, but at-risk drinkers did not differ from those in the trial arm on any of the assessed alcohol measures. This suggests that offering BAI on a large-scale, voluntary basis may reach at-risk drinkers as effectively as do more scientifically oriented trials, without needing to adhere to screening and stringent research procedures. Nevertheless, BAI was more effective for at-risk drinkers who were invited for trial participation versus those who volunteered. This could be due to behavior that is already consolidated and is difficult to change. Lacking further modifications, real-world implementations of BAI for young men may be less effective than randomized controlled trials designed to test the efficacy of BAI.

Introduction

The detrimental effects of alcohol, particularly from risky single occasion drinking (RSOD), defined as the consumption of a large amount of alcohol on one occasion likely to lead to intoxication, are well documented (Hingson et al., 2005, Perkins, 2002, Windle, 2003). Alcohol use constitutes the greatest risk factor for mortality and morbidity among adolescents and young adults in established market economies (Rehm, Taylor, & Room, 2006). There are fairly many meta-analyses showing that brief interventions may have beneficial effects on reducing alcohol use (e.g. Bertholet et al., 2005, Kaner et al., 2007, Moyer et al., 2002), and there have been promising findings for brief alcohol interventions (BAI) using motivational interviewing (MI) elements among adolescents and young adults (Grenard et al., 2006, Larimer et al., 2004, Toumbourou et al., 2007). The potential is seen because of the concentration on avoiding argumentation and hostile confrontation, the acceptance of individuals without giving lectures or ultimatums, and by fostering an atmosphere of self-directed change that teachers, parents or other authority figures have trouble developing easily (Tevyaw & Monti, 2004).

The Public Health impact of interventions largely depends on how many of those who need an intervention actually receive it. Some implementation trials (Anderson et al., 2004, Nilsen et al., 2006) have shown that there are barriers to systematically screening and providing BAI. As argued by Beich, Thorsen, and Rollnick (2003), systematic screening, assessment and intervention is time-consuming and laborious and other ways to provide BAI should be looked for. In many settings systematic screening may not be feasible, but the setting may create an opportunity to use BAI as a possible intervention provided by independent and confidential counselors, e.g. in places where many young people meet. BAI may also be provided by specialized helpdesks, where individuals can get assistance without being screened by teachers, family doctors or other authorities. In the present study, the opportunity for BAI was provided to those young adults who volunteered for it, without systematic selection based on mass screening. One aim of this research was to investigate whether individuals to whom a possibility for getting a BAI was offered would actually need and use it, absent any laborious or unwanted systematic screening.

There is not much research on differences between pre-selected participants and volunteers in BAI trials. Moyer et al. (2002) showed that within some non-seeker populations almost 80% of the research designs did not include the heaviest or problem drinkers, or those with dependence. Treatment seekers (who are not directly comparable with BAI volunteers, as herein) may have heavier alcohol use patterns; outcomes in studies excluding heavier drinkers were more efficacious than those including them. A second aim of the study was to test whether volunteers for BAI, who may be heavier users, received the same benefits from BAI as suggested in scientific trials using screening.

There are currently only a few studies of interventions among young people who are voluntary. Brown, Anderson, Schulte, Sintov, and Frissell (2005) studied high school students at about age 16, and reported significant effects only for the heaviest users, defined as having 50 or more lifetime drinking episodes. The authors did not report on potential changes in alcohol use (although consumption was measured in the study), but focused mostly on attempts to cut down. In addition, there was no control group; this was the case in another study of voluntary participation (Berghuis, Swift, Roffman, Stephens, & Copeland, 2006). Prior research using volunteers has usually consisted of interventions that are more intensive. D’Amico and Edelen (2007), matching an intervention and control middle school, used five group sessions and found that increases in alcohol and marihuana use were significantly slowed down in the intervention group. Bailey, Baker, Webster, and Lewin (2004), with a treatment group of seventeen participants aged 12–17, used four sessions; neither of these studies were comparable to our single 20-min session design. Overall, not much is known regarding the effectiveness of single short BAI sessions offered to young volunteers.

Most of the BAI studies have been randomized controlled trials designed to achieve high internal validity, and have focused on efficacy not effectiveness. Efficacy trials are often constrained by the demand characteristics in the design (Babor et al., 2006), such as the exclusion of certain segments of the population (e.g. heavy or dependent drinkers, for which BAI has been shown to be less efficacious), funding for staff and client participation, selection of specially trained staff, restrictions on therapeutic flexibility, or financial support for intervention and monitoring (Kaner et al., 2007, Saitz et al., 2006). These elements may not be available in “real-world” settings. Kaner et al. (2007) compared efficacy oriented brief intervention studies with those of effectiveness oriented studies, and found no significant differences, despite a mean reduction of 28.5 g per week in effectiveness trials versus 48.5 g per week in efficacy trials (Table 1.4). In sum, the present study investigates the feasibility of a more general offer of BAI. It compares individuals randomly selected to participate in a randomized controlled trial with those who actively volunteered to receive an intervention. This approach may be more akin to “real-world” conditions than are research-driven situations with random selection under controlled trial conditions. We believe that providing BAI without systematic screening raises fewer barriers to participation and could increase the availability of these interventions in many settings. We hypothesize that voluntary offers will reach individuals at risk; however, the effectiveness will be less than in meticulously planned scientific trials.