Development of community strategies supporting brief alcohol advice in three Latin American countries: a protocol

Brief alcohol advice offered to patients was shown to be a clinically- and cost-effective intervention to prevent and manage alcohol-related health harm. However, this intervention is not yet optimally implemented in practice. A suggested strategy to improve the implementation of brief alcohol advice is through community actions which would enhance the environment in which primary healthcare providers must deliver the intervention. However, there has been scarce research conducted to date regarding which community actions have most influence on the adoption and implementation of brief alcohol advice. The current protocol presents the development of a package of community actions to be implemented in three Latin American municipalities, in Colombia, Mexico and Peru. The community actions were based on the Institute for Health Care Improvement's framework for going to full scale, and include: (i) involvement of a Community Advisory Board, (ii) involvement of a project champion, (iii) adoption mechanisms, (iv) support systems and (v) a communication campaign. By presenting a protocol for developing community actions with input from local stakeholders, this article contributes to advancing the public health field of alcohol prevention by potentially stimulating the sustainable adoption and implementation of brief alcohol advice in routine practice.

Shared medical appointments in English primary care for long-term conditions: a qualitative study of the views and experiences of patients, primary care staff and other stakeholders

Background

Shared medical appointments (SMAs) or group consultations have been promoted in primary care to improve workload pressures, resource-use efficiency and patient self-management of long-term conditions (LTCs). However, few studies have explored stakeholders’ perspectives of this novel care delivery model in the English NHS context, particularly patients’ views and experiences of SMAs.

Method

Semi-structured interviews were used to explore the perspectives of stakeholders (21 patients, 17 primary care staff, 2 commissioners and 2 SMA training providers) with and without SMA experience from a range of geographical and socio-economic backgrounds in the North East and North Cumbrian region of England. Thematic analysis was conducted to examine perceptions around impact on patient care and outcomes and barriers and facilitators to implementation.

Results

Three main themes were identified: ‘Value of sharing’, ‘Appropriateness of group setting’, ‘Implementation processes’. Patients experiences and perceptions of SMAs were largely positive yet several reported reservations about sharing personal information, particularly in close-knit communities where the risk of breaching confidentiality was perceived to be greater. SMAs were considered by patients and staff to be inappropriate for certain personal conditions or for some patient groups. Staff reported difficulties engaging sufficient numbers of patients to make them viable and having the resources to plan and set them up in practice. Whilst patients and staff anticipated that SMAs could deliver high quality care more efficiently than 1:1 appointments, none of the practices had evaluated the impact SMAs had on patient health outcomes or staff time.

Conclusion

Stakeholder experiences of SMA use in English primary care are largely similar to those reported in other countries. However, several important cultural barriers were identified in this setting. Further work is needed to better understand how patient and staff perceptions, experiences and engagement with SMAs change with regular use over time. Concerns regarding staff capacity, additional resource requirements and numbers of eligible patients per practice suggest SMAs may only be feasible in some smaller practices if facilitated by primary care networks. Further mixed-method evaluations of SMAs are needed to inform the evidence base regarding the effectiveness, efficiency and feasibility of SMAs long-term and subsequently their wider roll-out in English primary care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01790-z.

OS07.2.A Evaluation of Intraoperative Surgical Adjuncts and Resection of Glioblastoma (ELISAR GB): A UK and Ireland multicentre, prospective observational cohort study

Background

Despite operative and adjuvant therapies, glioblastoma remains incurable, with the extent of resection being one of few treatments that can improve survival. To improve resection, operative adjuncts are used, with neuronavigation and 5-aminolevulinic acid (5-ALA) recommended as a standard of care in those aimed for maximal safe resection. Despite the standards, meta-analysis concluded that the impact of 5-ALA on the extent of surgical resection is of low quality due to bias in reporting tumour location and additional image guidance used, factors impacting on extent of resection as well as short-term neurological outcomes being uncertain. Therefore we aimed to evaluate the availability and use of 5-ALA and other adjuncts and compare surgical outcomes of 5-ALA-guided versus non-5-ALA-guided resections.

Material and Methods

A multicenter prospective observational cohort study was conducted across 27 out of 31 available centres in the UK and Ireland from 6 January until 19 March 2020. Inclusion criteria included adults with first diagnosis, supratentorial glioblastoma undergoing resection. Primary outcomes included: i) the availability and use of surgical adjuncts and ii) complete resection of enhancing tissue (CRET). Secondary outcomes included adverse events, new onset of postoperative neurological deficit and post-operative neurological function. Descriptive and inferential statistics were used for analysis with a p-value <0.05 deemed significant.

Results

232 consecutive cases were identified. 142/232 cases were aimed for maximal safe resection subsequently divided into 5-ALA-guided (n=92) versus non-5-ALA-guided (n=50) resections. 5-ALA and neuronavigation were available across all centres. Neuronavigation and 5-ALA were used in 91% (n=129/142) and 65% (n=92/142) of cases aimed for maximal safe resection whereas 83% (n=75/90) and 49% (n=44/90) for debulk surgery. 35 unique combinations of surgical adjuncts were used in 232 operations. 5-ALA-guided resection yielded a higher percentage of CRET than without (55% versus 28%, p < 0.01). The two groups showed no difference in adverse events (p=0.98), new onset of neurological deficit (p=0.88) nor neurological function (p=0.7). A logistic regression analysis showed that 5-ALA was an important predictor of CRET regardless of additional adjuncts used (OR 2.4, CI 0.96-5.97, P = 0.05), tumour location and molecular characterisation (OR 3.48, CI 1.61-7.51, P <0.01).

Conclusion

Firstly, we showed that 5-ALA is not always used for glioblastoma aimed for CRET. Secondly, we report a great heterogeneity of adjuncts used for resection, possibly explained by a lack of high-quality evidence and surgeon training. Thirdly we demonstrate that 5-ALA-guided resection leads to higher percentage of CRET regardless of other adjuncts used, tumour location and molecular characterisation.

Substance Use, Health, and Adverse Life Events amongst Amphetamine-Type Stimulant Users in North East England: A Cross-Sectional Study

Amphetamine-type stimulants (ATS) are the second most commonly used class of illicit drugs globally, yet there is limited understanding of which factors contribute to different pathways of ATS use. We sought to compare current, former, and exposed non-ATS users’ substance use, mental/physical health, and adverse life experiences. A cross-sectional survey, using computer-assisted personal interview software, was conducted between June 2018 and March 2019 in North East England. Quota-based sampling was used to recruit 389 individuals (aged 18 to 68; 52.6% male): 137 current ATS users; 174 former users; and 78 exposed non-users. Standardized screening questionnaires captured current/prior substance use. Participants self-reported diagnoses of selected physical and mental health disorders and specific adverse life experiences. Analysis used descriptive statistics and comparative tests (including chi-square, Kruskal–Wallis and Mann–Whitney U). Early exposure to illicit substances, challenging mental health, and certain adverse life experiences (such as growing up in statutory care) were more common in individuals currently using ATS compared to those who had never used or stopped using stimulants. Multi-level interventions are needed that address the mental health, social, and economic needs of people with dependent drug use. These could include targeted efforts to support children growing up under care, integrated mental health and substance use support, and joined-up substance use interventions reflective of wider structural factors.

The impact of lower strength alcohol products on alcohol purchases: ARIMA analyses based on 4 million purchases by 69 803 households, 2015-2019

BACKGROUND

Lowering the strength of alcohol products could lead to less alcohol being bought and drunk. In its prevention White Paper, the UK Government aims to promote a significant increase in the availability of alcohol-free and low-alcohol products by 2025.

METHODS

Through descriptive analysis and ARIMA modelling of >4 million alcohol purchases from 69 803 British households, we study the potential impact of lower strength alcohol products in reducing household purchases of grams of alcohol over 2015-2019. Households are divided into predominantly beer, wine or spirits purchasers.

RESULTS

Over 5 years, there were decreases in purchases of grams of alcohol within beer amongst beer-purchasing households and increases in purchases of grams of alcohol within wine and spirits amongst, respectively, wine- and spirits-purchasing households. Almost all the changes were due to beer-purchasing households buying less regular strength beer, and wine and spirits-purchasing households buying, respectively, more regular strength wine and spirits, rather than increases in purchases of no- and low-alcohol products.

CONCLUSIONS

In general, lower strength alcohol products have not contributed to British households buying fewer grams of alcohol over the 5-year follow-up period during 2015-2019.

Reduced alcohol consumption during the COVID-19 pandemic: Analyses of 17 000 patients seeking primary health care in Colombia and Mexico

Background

During the COVID-19 pandemic, an increase of heavy alcohol use has been reported in several high-income countries. We examined changes in alcohol use during the pandemic among primary health care (PHC) patients in two middle income countries, Colombia and Mexico.

Methods

Data were collected during routine consultations in 34 PHC centres as part of a large-scale implementation study. Providers measured patients’ alcohol consumption with the three item ‘Alcohol Use Disorders Identification Test’ (AUDIT-C). Generalized linear mixed models were performed to examine changes in two dependent variables over time (pre-pandemic and during pandemic): 1) the AUDIT-C score and 2) the proportion of heavy drinking patients (8+ on AUDIT-C).

Results

Over a period of more than 600 days, data from N = 17 273 patients were collected. During the pandemic, the number of patients with their alcohol consumption measured decreased in Colombia and Mexico. Each month into the pandemic was associated with a 1.5% and 1.9% reduction in the mean AUDIT-C score in Colombia and Mexico, respectively. The proportion of heavy drinking patients declined during the pandemic in Colombia (pre-pandemic: 5.4%, 95% confidence interval (CI) = 4.8% to 6.0%; during the pandemic: 0.8%, 95% CI = 0.6% to 1.1%) but did not change in Mexico.

Conclusions

Average consumption levels declined and the prevalence of heavy drinking patterns did not increase. In addition to reduced opportunities for social drinking during the pandemic, changes in the population seeking PHC and restrictions in alcohol availability and affordability are likely drivers for lower levels of alcohol use by patients in this study.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

A Qualitative Exploration of Stakeholder Involvement in Decision-Making for Alcohol Treatment and Prevention Services

The concept of providing individuals with a ‘voice’ via stakeholder involvement has been advocated within English health care policy for several decades. Stakeholder involvement encourages people affected by an issue to contribute to planning and decision making regarding treatment and care, inclusive of providers and recipients of care. This paper explores stakeholder involvement in the design and delivery of public health alcohol services. A qualitative case study approach was adopted, including in-depth interviews with 11 alcohol commissioners, 10 alcohol service providers and 6 general practitioners plus three facilitated focus groups with 31 alcohol service users. Findings show that most participants were aware of, and could name, various methods of stakeholder involvement that they had engaged with; however, the extent and impact of stakeholder involvement in decision making are not transparent. It is essential that a deeper understanding is generated of the different roles that stakeholders can play within the entire decision-making process to maximise its utility.

The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019

British supermarket-panel data suggest no increases in overall sales and purchases of alcohol following COVID-19 lockdowns, yet survey and mortality data suggest otherwise. This paper attempts to unravel the paradox. Based on purchase data of 79,417 British households from Kantar Worldpanel, we undertake controlled interrupted time series analysis of the impact of COVID-19 confinement introduced on 23rd March 2020, and variably applied during 2020, compared to purchases during 2015 to 2019 as controls. We also undertook Poisson regression analyses to estimate if changes in purchases differed by household socio-demographic and economic factors. Excess off-trade household alcohol purchases (expressed as grams of ethanol) following the introduction of confinement, were 29.2% higher (95% CI = 25.8% to 32.5%) for the post-confinement months of 2020, being larger until mid-July 2020 (37.5%, 95%CI = 33.9 to 41.26%) when pubs re-opened with restrictions, and smaller (24.6%, 95%CI = 21.6 to 27.7) thereafter. During the time of complete pub closures, and fully adjusting for no on-trade purchases, household purchases of alcohol did not change when compared with the same time period during 2015-2019 (coefficient = -0.9%, 95%CI = -5.6 to 3.8). Excess purchases from 23rd March to 31st December 2020 varied by region of Great Britain, being higher in the north of England, and lower in Scotland and Wales. Excess purchases were greater in the most deprived households, compared with the least deprived households. Excess purchases increased substantially as the amount of alcohol normally purchased by a household increased, with the top one fifth of households that normally bought the most alcohol increasing their purchases more than 17 times than the bottom one fifth of households that bought the least alcohol. That the heaviest buyers of alcohol increased their purchases the most, with some independent impact of socio-economic disadvantage, might explain why reported alcohol problems and recent alcohol-related death rates might have increased. A conclusion of this is that alcohol policy to reduce high consumption of alcohol, and the availability of help and treatment to reduce alcohol consumption become more important during extraordinary times, such as COVID lockdowns.

Assessing the quality of RNA isolated from human breast tissue after ambient room temperature exposure

High quality human tissue is essential for molecular research, but pre-analytical conditions encountered during tissue collection could degrade tissue RNA. We evaluated how prolonged exposure of non-diseased breast tissue to ambient room temperature (22±1°C) impacted RNA quality. Breast tissue received between 70 to 190 minutes after excision was immediately flash frozen (FF) or embedded in Optimal Cutting Temperature (OCT) compound upon receipt (T0). Additional breast tissue pieces were further exposed to increments of 60 (T1 = T0+60 mins), 120 (T2 = T0+120 mins) and 180 (T3 = T0+180 mins) minutes of ambient room temperature before processing into FF and OCT. Total exposure, T3 (T0+180 mins) ranged from 250 minutes to 370 minutes. All samples (FF and OCT) were stored at -80°C before RNA isolation. The RNA quality assessment based on RNA Integrity Number (RIN) showed RINs for both FF and OCT samples were within the generally acceptable range (mean 7.88±0.90 to 8.52±0.66). No significant difference was observed when RIN at T0 was compared to RIN at T1, T2 and T3 (FF samples, p = 0.43, 0.56, 0.44; OCT samples, p = 0.25, 0.82, 1.0), or when RIN was compared between T1, T2 and T3. RNA quality assessed by quantitative real-time PCR (qRT-PCR) analysis of beta-actin (ACTB), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), cyclophilin A (CYPA), and porphobilinogen deaminase (PBGD) transcripts showed threshold values (Ct) that indicate abundant and intact target nucleic acid in all samples (mean ranging from 14.1 to 25.3). The study shows that higher RIN values were obtained for non-diseased breast tissue up to 190 minutes after resection and prior to stabilization. Further experimental exposure up to 180 minutes had no significant effect on RIN values. This study strengthens the rationale for assessing RIN and specific gene transcript levels as an objective method for determining how suitable RNA will be for a specific research purpose (“fit-for purpose”).

Training primary health care providers in Colombia, Mexico and Peru to increase alcohol screening: Mixed-methods process evaluation of implementation strategy

Background

Initial results from the SCALA study demonstrated that training primary health care providers is an effective implementation strategy to increase alcohol screening in Colombia, Mexico and Peru, but did not show evidence of superior performance for the standard compared to the shorter training arm. This paper elaborates on those outcomes by examining the relationship of training-related process evaluation indicators with the alcohol screening practice.

Methods

A mix of convergent and exploratory mixed-methods design was employed. Data sources included training documentation, post-training questionnaires, observation forms, self-report forms and interviews. Available quantitative data were compared on outcome measure - providers' alcohol screening.

Results

Training reach was high: three hundred fifty-two providers (72.3% of all eligible) participated in one or more training or booster sessions. Country differences in session length reflected adaptation to previous topic knowledge and experience of the providers. Overall, 49% of attendees conducted alcohol screening in practice. A higher dose received was positively associated with screening, but there was no difference between standard and short training arms. Although the training sessions were well received by participants, satisfaction with training and perceived utility for practice were not associated with screening. Profession, but not age or gender, was associated with screening: in Colombia and Mexico, doctors and psychologists were more likely to screen (although the latter represented only a small proportion of the sample) and in Peru, only psychologists.

Conclusions

The SCALA training programme was well received by the participants and led to half of the participating providers conducting alcohol screening in their primary health care practice. The dose received and the professional role were the key factors associated with conducting the alcohol screening in practice.Plain Language Summary: Primary health care providers can play an important role in detecting heavy drinkers among their consulting patients, and training can be an effective implementation strategy to increase alcohol screening and detection. Existing training literature predominantly focuses on evaluating trainings in high-income countries, or evaluating their effectiveness rather than implementation. As part of SCALA (Scale-up of Prevention and Management of Alcohol Use Disorders in Latin America) study, we evaluated training as implementation strategy to increase alcohol screening in primary health care in a middle-income context. Overall, 72.3% of eligible providers attended the training and 49% of training attendees conducted alcohol screening in practice after attending the training. Our process evaluation suggests that simple intervention with sufficient time to practice, adapted to limited provider availability, is optimal to balance training feasibility and effectiveness; that booster sessions are especially important in context with lower organizational or structural support; and that ongoing training refinement during the implementation period is necessary.

Impact of Training and Municipal Support on Primary Health Care-Based Measurement of Alcohol Consumption in Three Latin American Countries: 5-Month Outcome Results of the Quasi-experimental Randomized SCALA Trial

PURPOSE

We aimed to test the effects of providing municipal support and training to primary health care providers compared to both training alone and to care as usual on the proportion of adult patients having their alcohol consumption measured.

METHODS

We undertook a quasi-experimental study reporting on a 5-month implementation period in 58 primary health care centres from municipal areas within Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru). Within the municipal areas, units were randomized to four arms: (1) care as usual (control); (2) training alone; (3) training and municipal support, designed specifically for the study, using a less intensive clinical and training package; and (4) training and municipal support, designed specifically for the study, using a more intense clinical and training package. The primary outcome was the cumulative proportion of consulting adult patients out of the population registered within the centre whose alcohol consumption was measured (coverage).

RESULTS

The combination of municipal support and training did not result in higher coverage than training alone (incidence rate ratio (IRR) = 1.0, 95% CI = 0.6 to 0.8). Training alone resulted in higher coverage than no training (IRR = 9.8, 95% CI = 4.1 to 24.7). Coverage did not differ by intensity of the clinical and training package (coefficient = 0.8, 95% CI 0.4 to 1.5).

CONCLUSIONS

Training of providers is key to increasing coverage of alcohol measurement amongst primary health care patients. Although municipal support provided no added value, it is too early to conclude this finding, since full implementation was shortened due to COVID-19 restrictions.

TRIAL REGISTRATION

Clinical Trials.gov ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America

INTRODUCTION

Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare.

MATERIALS AND METHODS

Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status.

RESULTS

550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained.

CONCLUSIONS

Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Feasibility of alcohol screening and brief intervention in primary health care in Kazakhstan: study protocol of a pilot cluster randomised trial

BACKGROUND

Identifying and addressing heavy drinking represents a major public health priority worldwide. Whilst the majority of alcohol screening and brief intervention (ASBI) research has been conducted in western, high-income countries, evidence is growing that ASBI can also impact positively on heavy drinkers in low- and middle-income country populations. This mixed methods study aims to assess the feasibility of conducting a fully randomised controlled trial of the effectiveness of ASBI in primary care in Kazakhstan and explore the feasibility and acceptability of implementing ASBI in this setting from patients' and physicians' perspectives.

METHODS

Six primary health care units in the region of Pavlodar will be cluster randomised to either an intervention (WHO manualised 5 min alcohol brief intervention plus alcohol leaflet) or control group (simple feedback plus alcohol leaflet). Primary feasibility measures will be rates of participation at baseline and retention of eligible patients at the 3-month follow-up point. Patient/physician questionnaires and physician focus groups will assess additional dimensions of feasibility, as well as acceptability, according to the RE-AIM framework: Reach (rates of eligible patients screened/received advice); Effectiveness (change in AUDIT-C score); Adoption (rate/representativeness of participating physicians); Implementation (quality of ASBI/barriers and facilitators to delivery); and Maintenance (potential sustainability of intervention).

DISCUSSION

This is the first trial of the feasibility and acceptability of ASBI in Kazakhstan. As the planning and assessment of implementation determinants is based on the RE-AIM framework, the project outcomes will be relevant for the future development, tailoring and implementation of ASBI in Kazakhstan.

TRIAL REGISTRATION

DRKS, DRKS00015882, Registered 17 December 2018.

Primary care physicians' attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework

BACKGROUND

Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework.

METHODS

MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools.

RESULTS

Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs' attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs' views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use.

CONCLUSIONS

By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice.

TRIAL REGISTRATION

PROSPERO CRD42016038790 .

'I take my tablets with the whiskey': A qualitative study of alcohol and medication use in mid to later life

Background

Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.

Methods

Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England.

Results

Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication.

Conclusions

As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use.

Beliefs and attitudes about addressing alcohol consumption in health care: a population survey in England

BACKGROUND

Despite robust evidence for their effectiveness, it has proven difficult to translate alcohol prevention activities into routine health care practice. Previous research has identified numerous provider-level barriers affecting implementation, but these have been less extensively investigated in the wider population. We sought to: (1) investigate patients' beliefs and attitudes to being asked about alcohol consumption in health care; and (2) identify the characteristics of those who are supportive of addressing alcohol consumption in health care.

METHODS

Cross-sectional household interviews conducted as part of the national Alcohol Toolkit Study in England between March and April 2017. Data were collected on age, gender, social grade, drinking category, and beliefs and attitudes to being asked about alcohol in routine health care. Unadjusted and multivariate-adjusted logistic regression models were performed to investigate associations between socio-demographic characteristics and drinking category with being "pro-routine" (i.e. 'agree completely' that alcohol consumption should be routinely addressed in health care) or "pro-personal" (i.e. 'agree completely' that alcohol is a personal matter and not something health care providers should ask about).

RESULTS

Data were collected on 3499 participants, of whom 50% were "pro-routine" and 10% were "pro-personal". Those in social grade C1, C2, D and E were significantly less likely than those in AB of being "pro-routine". Women were less likely than men to be "pro-personal", and those aged 35-44 or 65 years plus more likely to be "pro-personal" compared with participants aged 16-24. Respondents aged 65 plus were twice as likely as those aged 16-24 to agree completely that alcohol consumption is a personal matter and not something health care providers should ask about (OR 2.00, 95% CI 1.34-2.99).

CONCLUSIONS

Most adults in England agree that health care providers should routinely ask about patients' alcohol consumption. However, older adults and those in lower socio-economic groups are less supportive. Drinking status appears to have limited impact on whether people believe that alcohol is a personal matter and not something health care providers should ask about.

REGISTRATION

Open Science Framework ( https://osf.io/xn2st/ ).

Managing Alcohol Use Disorder in Primary Health Care

PURPOSE OF REVIEW

The aim of this study is to summarise the current literature on both the impact and the implementation of primary health care-based screening and advice programmes to reduce heavy drinking, as an evidence-based component of managing alcohol use disorder in primary health care.

RECENT FINDINGS

Systematic reviews of reviews find conclusive evidence for the impact of primary health care delivered screening and brief advice programmes in reducing heavy drinking. The content, length of advice and which profession delivers the advice seems less important than the actual encounter between provider and patient. Despite the global burden of disease due to heavy drinking and the evidence that this can be reduced by screening and brief advice programmes delivered in primary health care, such programmes remain poorly implemented. Were such programmes widely implemented, there would be substantial health and productivity gains. Systematic reviews and international studies indicate that improved implementation requires tailoring of training and programme content to match the needs of providers, training and ongoing support and embedding of programmes within local community support, championed by local leaders. The next stage of implementation and scale-up of evidence-based screening and brief advice programmes should take place embedded within supportive local community action, with appropriate research to demonstrate impact.

A pilot feasibility cluster randomised controlled trial of screening and brief alcohol intervention to prevent hazardous drinking in young people aged 14–15 years in a high school setting (SIPS JR-HIGH)

Background

Approximately 33% of 15- to 16-year-olds in England report alcohol intoxication in the past month. This present work builds on the evidence base by focusing on Alcohol Screening and Brief Intervention (ASBI) to reduce hazardous drinking in younger adolescents.

Objectives

To explore the feasibility and acceptability of a future definitive cluster randomised controlled trial (cRCT) of ASBI in a school setting to staff, young people and parents; to explore the fidelity of the interventions as delivered by school learning mentors; to estimate the parameters for the design of a definitive cRCT of brief alcohol intervention, including rates of eligibility, consent, participation and retention at 12 months; and to pilot the collection of cost and resource-use data to inform the cost-effectiveness/utility analysis in a definitive trial.

Setting

Seven schools across one geographical area in North East England.

Methods

Feasibility of trial processes, recruitment and retention and a qualitative evaluation examined facilitators and barriers to the use of ASBI approaches in the school setting in this age group. A three-arm pilot cRCT (with randomisation at the school level) with qualitative evaluation to assess the feasibility of a future definitive cRCT of the effectiveness and cost-effectiveness of ASBI in a school setting, with an integrated qualitative component. The trial ran in parallel with a repeated cross-sectional survey, which facilitated screening for the trial.

Participants

Year 10 school pupils (aged 14–15 years).

Interventions

Young people who screened positive on a single alcohol screening question, and consented to take part, were randomised to one of three groups: (1) feedback that their drinking habits may be risky and provision of an advice leaflet (control condition,n = two schools); (2) feedback as for the control condition plus a 30-minute brief interactive session, which combined structured advice and motivational interviewing techniques, delivered by the school learning mentor (intervention 1,n = two schools); or (3) feedback as for the control condition plus a 30-minute brief interactive session as for intervention 1 plus a 60-minute session involving family members delivered by the school learning mentor (intervention 2,n = three schools). Young people were followed up at 12 months.

Main outcome measures

Feasibility and acceptability.

Randomisation

Randomisation was carried out at the school level. Randomisation achieved balance on two school-level variables (numbers of pupils in school year and proportion receiving free school meals).

Blinding

School staff, young people and researchers were not blind to the intervention allocated.

Results

A total of 229 young people were eligible for the trial; 182 (79.5%) were randomised (control,n = 53; intervention 1,n = 54; intervention 2,n = 75). Of the 75 randomised to intervention 2, 67 received intervention 1 (89%). Eight received both intervention 1 and intervention 2 (11%). In total, 160 out of 182 were successfully followed up at 12 months (88%). Interviews were carried out with six school lead liaisons, 13 learning mentors, 27 young people and seven parents (n = 53). Analysis shows that the school setting is a feasible and acceptable place to carry out ASBI, with learning mentors seen as suitable people to do this. Intervention 2 was not seen as feasible or acceptable by school staff, parents or young people.

Outcomes/conclusions

It is feasible and acceptable to carry out a trial of the effectiveness and cost-effectiveness of single-session ASBI with young people in the school setting, with learning mentors delivering the intervention. Future work should include a definitive study that does not include a parental arm.

Trial registration

Current Controlled Trials ISRCTN07073105.

Funding

The National Institute for Health Research Public Health Research programme.

Does an allergy to fish pre-empt an adverse protamine reaction? A case report and a literature review

The operating theatre exposes patients to myriad potential agents which could result in a life-threatening anaphylactic reaction. Anaesthetic drugs, blood products, and latex are only some of the possible allergens. Reactions are deemed to be anaphylactic when immediate sensitivity is combined with cardiovascular collapse. A patient who had a known allergy to shellfish presented for first time cardiopulmonary bypass. The perfusion team were concerned that there was a realistic possibility that an adverse reaction to protamine could occur. Anaphylactic reactions to protamine in patients allergic to fish have been reported. The anaesthetic team were informed and the necessary precautions taken. We report on the outcome for our patient and also discuss other risk factors and the types of reactions that can result when an adverse reaction to protamine occurs.