Can alcohol screening and brief intervention work in a young people’s sexual health service?

Note: This report was funded and/or written by our predecessor organisation, the Alcohol Education Research Council (AERC).

The use of alcohol by young people, and its links to antisocial and risk-taking behaviour, has been the subject of much government and media attention. Links to sexual risk-taking have been shown in some studies and not in others. Sandyford offers an integrated sexual, reproductive and emotional health service across Greater Glasgow and Clyde. Within that service, The Place is a “one stop shop” for young people up to the age of 17 giving them the information to make informed choices about their own health and well being. Alcohol use and its consequences is a major concern for this sexual health service.

In 2003 three hundred young people attending sexual health clinical services across Greater Glasgow were asked about their alcohol intake, and the relationship to various health and social behaviours. This revealed that a large proportion of young people in this group were drinking alcohol regularly and that regretted, unprotected sex was only one of the adverse unintended consequences of this. The results had several implications for the education of young people, provision of services for them and the training of staff. They identified a need and provided an opportunity for the clinic to improve young people’s knowledge of the effects of alcohol and provide early intervention support at the clinic.

This pilot examined the practical and service implications involved in implementing a routine screening and brief intervention model alongside the day-to-day running of a young persons’ sexual health clinic. The brief intervention model was designed to be responsive to young people attending the Place clinic who binge drink and whose alcohol consumption borders on the early stages of problem drinking behaviour, to offer and deliver important health education and support.

Before implementing the pilot

• A validated alcohol screening tool appropriate to the client group was selected.
• Ethical approval from the local ethics and research and development departmentwas obtained.
• The training needs of staff were identified using a questionnaire.
• Information posters were designed, printed and displayed in Place waiting areas.
• A short alcohol questionnaire was distributed to young people in the clinic waiting area.

Screening and brief intervention pilot model

Questionnaire

The alcohol questionnaire contained eight basic questions about alcohol and was distributed to young people in the clinic waiting area. Completing the questionnaire was voluntary and anonymous. Two hundred were handed out to young people by youth workers and 190 were completed and returned.

Screening

Throughout the three months of the pilot 472 young people attended the clinic, and 104 completed TWEAK screening (7 males, 7%). Scores ranged from 0 to a high of 6, with a median of 3. Seventy-seven young people (74% of all respondents) scored 3 or more which suggested they were at risk of problem drinking and eligible for brief intervention.

Brief Interventions

Forty seven young people accepted the offer of a brief intervention, the model for the brief intervention consisted of six elements Feedback, Responsibility, Advice, Menu, Empathy and Self efficacy. The intervention was found to be useful by more than 95% who completed it.

Pre-brief intervention questionnaire

Before the brief intervention each young person was asked six questions by the alcohol and drugs worker. Several participants were unaware that alcohol was a drug. Several described accidents related to alcohol use. A particular theme emerged of concerns about alcohol use in the young people’s families.

Post Intervention questionnaire

A further eight questions were asked after the brief intervention was delivered. Most (94%) now knew the recommended safe alcohol units for their gender (compared to only 17%) before the brief intervention. Similar proportions found the information provided in the brief intervention had been helpful, felt more aware of the risks of binge drinking, and where to get help.

Discussion

This pilot was a large undertaking, with several components that needed to be incorporated to make it work.

There were some unexpected benefits, which were difficult to formally measure, including the awareness of how open and receptive young people were to receiving alcohol information.

The pre-pilot staff questionnaire made it clear that although all staff had some awareness they lacked knowledge & confidence in dealing with alcohol issues.

The training aimed to address that and increase knowledge and confidence. Evaluation of the effectiveness of this training was not formally done and this is a potential limitation of the study. If the screening tool is to be used more widely training of all staff including proper evaluation would need to be undertaken.

The pre-pilot young people’s questionnaire showed a very low level of baseline knowledge about safe units for alcohol consumption in adults (there are no guidance on ‘safe limits’ in people as young as our study respondents). It confirmed that young people in our client group regularly drink large amounts and that they do not know where to go for information about alcohol. This supported the idea that alcohol screening and brief intervention is appropriate in the sexual health setting.

The alcohol screening tool that was used (TWEAK) had been selected because it was validated in young people, although in a different setting. In practice, however, some questions seemed to be of limited value in our setting; for example very few young people said they drank alcohol on first waking (‘eye-opener’). The same number of young people would have been eligible for brief intervention if this question had been omitted. Evaluation of different screening tools by the young people in our setting may be a useful study for the future.

Clinical staff were concerned that as young people locally often drink direct from bottles or with ‘home’ measures rather than standard measures, it would difficult to be certain what constituted ‘three drinks or more’ as meant by the screening tool. This was addressed in the clinic by making available a list of commonly used drinks and the alcohol content in commonly sold amounts. Although this screening tool is easy and quick to administer, clinic nurses found it difficult to incorporate into routine practice during the pilot, so the alcohol worker administered the screening tool herself. This has training and resource implications for a roll out into routine practice.

The brief intervention was found to be useful by almost all who completed it. A limitation is that evaluation was done immediately after the intervention; it would be useful in any future work to be able to test recall of information and perceived benefit some weeks or months after the intervention.

While acknowledging some difficulties with the pilot and challenges in implementing alcohol screening to all young people attending our sexual health services,

• The pilot supports the idea that alcohol screening in this setting is feasible and would be acceptable and useful to young people, although the most appropriate screening tool to use is uncertain.
• Future training will be arranged for all Sandyford staff to improve awareness of alcohol issues and train them in the use of appropriate screening tools.
• Sandyford will examine how to make this a routine part of clinical practice for young people accessing our services and potentially to other youth health services.
• How to roll out alcohol screening to all young people in our setting and offer brief intervention to all who are eligible needs to be considered in the light of training and other resource implications. This might include training some of the specialist sexual health nurses in brief intervention techniques.
• This model could easily be adapted for other settings, with consideration given to the practical aspects outlined above.

Chan AWK; Pristach; EA; Welte JW; Russell M. Use of the TWEAK test in screening for Alcoholism/heavy drinking in three populations. Alcoholism: Clinical and Experimental Research 17(6): 1188-1192, 1993 (30refs).

FRAMES Brief intervention model: Miller and Sanchez 1993.