Community support intervention (s) for alcohol abuse in adults living in Glasgow, UK; A Proposal
International perspective on alcohol abuse
Alcoholism is a collective term for alcohol related disorders including, but not limited to, alcohol abuse, binge drinking and alcohol dependence (World Health Organisation [WHO], 2016). Global alcohol consumption levels in 2010 were estimated to be 6.2 litres of pure alcohol in persons aged 15 years and above (WHO, 2017). In the United Kingdom, the Health and Social Care Information Centre (2014) recommended that among the adult population group, women and men should not consume more than 3 and 4 units of alcohol a day, respectively. Furthermore, existing evidence trends on alcohol consumption levels indicate that the greater the economic prosperity/wealth of the country, the higher the alcohol consumption levels and thus the lower the number of abstainers among the populations (WHO, 2017).
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Additionally, statistics from the WHO (2017) indicate that in 2012, approximately 3.3 million recorded deaths globally were due to alcohol abuse, and at least 15.3 million people are thought to have a drug and/or alcohol disorder. Furthermore, 7.6% and 4% of the 3.3 million deaths globally were observed in males and females, respectively (WHO, 2017). Similarly, 139 million disability-adjusted life years (DALYs) recorded in 2012 were associated with alcohol consumption globally (WHO, 2017). Therefore, harmful alcohol consumption is associated with negative health consequences which impact on the quality of life of individuals and their families, as well as society as a whole due to reduced productivity levels and financial costs associated with treating and managing alcohol misuse related conditions (National Institute for Health and Care Excellence [NICE], 2011).
Alcohol abuse relative to Scotland
In 2007, a joint research undertaken by the Glasgow City Council, Strathclyde Police and NHS Greater Glasgow and Clyde indicated that increased rates of harmful alcohol consumption have been observed across Scotland, with an estimated increase expected in the next decade (Glasgow City Council, Strathclyde Police and NHS Greater Glasgow and Clyde, 2007). The report indicated that at least 20.7% of all hospital admissions in the Glasgow area were associated with harmful alcohol consumption, which was associated with a cost of £207 million to manage appropriately. In 2015, a survey by NHS Health Scotland, indicated that 1 in 4 Scottish people drink at hazardous levels and about 36% and 17% of men and women, respectively, consume more than 14 units of alcohol each week (NHS Health Scotland, 2015). Furthermore, at least 1,150 alcohol related deaths were recorded in Scotland and 386 of these were women while 764 were males, a figure expected to increase if alcohol misuse is not tackled in Scotland (National Records of Scotland, 2015). Additionally, in those aged between 45 and 59 years, largest proportion of alcohol related deaths are observed each year in Scotland (National Records of Scotland, 2015). Nevertheless, although the statistics indicate that the rates of harmful alcohol consumption have declined over the last few years in Scotland, the rates are on average still relatively higher than those recorded in Wales and England, and therefore more investment in managing alcohol misuse is still a public health priority (Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) work programme, 2014).
Research undertaken by the Information Service Division, NHS Health Scotland (2015/2016) indicated that about 90% and 10% of alcohol related hospital admissions were to either to general acute hospitals or psychiatric hospitals, respectively. Similarly, 48,420 patients are thought to have accessed primary care equating to 94,630 alcohol related consultations in 2012/2013; higher rates observed in those aged 65 years and above (Scottish Public Health Observatory [ScotPHO], 2017). Furthermore, 25% of all trauma patients and 33% of all major traumas in 2015 were associated with alcohol misuse (The Scottish Trauma Audit Group, 2016). In terms of societal costs of alcohol misuse, a report by the Scottish Government (2010) indicated that alcohol related harms cost about £3.6 million annually in social care, crime, productivity, health as well as wider/indirect costs in Scotland. In addition, at least £267 million each year is spent by the NHS Health Scotland on alcohol related care, and £727 million a year on managing alcohol related crimes across Scotland (Scottish Government, 2010).
Alcohol policies and interventions are often developed with the main aim of reducing alcohol misuse as well as alcohol related social and health burden (NHS Health Scotland, 2015). Additionally, these policies or interventions may be formulated and implemented at a local, regional, national, sub-national and global level to ensure alignment and consistency of combating alcohol misuse across care settings (WHO, 2017). Nevertheless, the NHS Scotland in joint collaboration with other government bodies such as the Police have expressed a commitment to monitoring and evaluating alcohol misuse in Scotland with the aim of reducing the alcohol related health and social burden (Glasgow City Council, Strathclyde Police and NHS Greater Glasgow and Clyde, 2007).
The aim of this essay is to explore the extent of alcohol misuse in Scotland and provide community support to the affected populations through the implementation of a relevant strategy/intervention to reduce harmful alcohol consumption. The epidemiological consideration of alcohol misuse/abuse will be discussed first and thereafter followed with the identification of the relevant strategy or intervention in combi nation with the implementation procedures, monitoring and evaluating its progress, based on a pre-specified assessment criteria/framework, to ensure that it continues to meet the needs of the population affected by alcohol misuse.
Epidemiological consideration to exploring the level of alcohol abuse among adults in Scotland.
Research suggests that the most effective alcohol interventions and policies are those that have combined measures that address the issue at a population level (WHO, 2007). Nevertheless, national levels should be aligned to local strategies to ensure consistency in the delivery of care/support for alcohol misuse (Faculty of Public Health UK, 2016).
Therefore, to initiate a strategy or intervention to combat alcohol misuse in Scotland it is fundamental that the epidemiology of alcohol misuse (such as risk factors, aetiology, incidence, prevalence, prognosis, current service evaluation and the unmet need) is established based on evidence based medical literature which can take the form of systematic reviews or population longitudinal studies or clinical trials (National Institute for Health and Care Excellence, 2011). Furthermore, having a thorough understanding of the needs and priorities of those affected as well as the payors and clinicians need to be put in to consideration prior to initiating an intervention to combat alcohol misuse (Griffin and Botvin, 2011). This can be undertaken by conducting a needs assessment which aims to identify health issues of the patients as well as establishing resource allocation to help plan, and implement a strategy or intervention that meets the unmet need of alcohol abusers (Care Information Scotland, 2015). The health needs assessment should primarily be undertaken by a team of stakeholders representing various relevant perspectives including, but not limited to, healthcare professionals, patients or patient groups and payors with the aim of ensuring that all perspectives to reduce health inequalities have been explored, thus providing confidence that the proposed intervention to combat alcohol misuse will be accessible to relevant persons across care settings (NICE, 2005).
Both quantitative and qualitative data are fundamental in identifying and establishing the community profiles of those affected by alcohol misuse in Scotland (NICE, 2014). A qualitative framework enables the researchers to obtain an in-depth understanding of the views and perception of those consuming alcohol at harmful levels and therefore the themed information can be used to shape the focus and implementation of the proposed intervention (Brownson et al. 2009). Additionally, qualitative framework can be utilised in terms of focus groups, audio recordings and one to one interviews across different sample sizes and sample types to ensure generalisability of study findings across adults in Scotland who misuse alcohol (Wilson et al. 2013). On the other hand, quantitative framework helps researchers to decide on what to focus on within the research based on data collected from participants, and thus quantify the data by analysing it in an unbiased and objective manner (Cairns et al. 2011). Therefore, this will help researchers profile the trends of alcohol misuse in Scotland and provide potential explanations of the observed relationships between analysed variables (Jones and Sumnall, 2016). Therefore, both quantitative and qualitative data should be put in to consideration by the various stakeholders to help make informed decisions on the most appropriate intervention to tackle alcohol misuse in Scotland (Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) work programme, 2014).
The nature of the data to be collected (i.e. primary and/or secondary) is often determined by the research question at hand (NICE CG21, 2010). For example, with regards to alcohol misuse, both primary and secondary data are critical because in combination, the data provide a comprehensive representation of the extent of the alcohol misuse among adults in Scotland, which could be limited if one or the other were to be used to inform policy making (Centre for Reviews and Dissemination, 2008).
Furthermore, the hierarchy of evidence is dictated by the nature of the study design informing the evidence, and thus various stakeholders will put different weight to the study evidence obtained from various study designs (Scottish Intercollegiate Guidelines Network, 2015). For example, research recommendations consider randomised controlled trials (RCTS) as the superior study design due to the limited bias associated with the design and exploration of evidence, and therefore evidence from RCTs is considered to be of robust and of high quality (NICE, 2006; Higgins and Green, 2011). Subsequent from the RCTS, the other study designs of interest include cohort studies, case-control, case series and expert, in that order, are considered to be useful in answering certain types of research questions (Centre for Reviews and Dissemination, 2008). Nevertheless, meta-analyses and systematic reviews of RCTs are given more weight in the hierarchy to be able to provide robust data to inform decision making. However, it should be noted that conducting a RCT to establish alcohol misuse would be considered unethical by various stakeholders and therefore, qualitative studies or real world evidence studies would be more plausible to explore the concept in detail (National Institute on Alcohol Abuse and Alcoholism, 2017).
Therefore, after consideration of the nature/type of evidence in combination with the epidemiology of alcohol misuse among adults in Scotland, a brief intervention that would be considered both clinically and cost effective would be a plausible approach (WHO, 2014). The brief intervention incorporates policy guidelines, training, as well as education on alcohol misuse to help patients and healthcare providers make informed decision on its applicability (Anderson et al. 2009). Brief interventions are preferred over other types, such as alcohol taxation because they aim to provide health and social support to alcohol abusers and thus they are more likely to be motivated to help change attitudes towards harmful drinking (Institute for Alcohol Studies, 2013). Therefore, a plausible intervention should include various phases such as planning, preparing other stakeholders for the intervention, establishing an intervention team, identifying consequences/benefits and harms as well as sharing information on the intervention with the relevant stakeholders and ensure that informed consent from users of the intervention is put in to consideration prior to implementation (Holland, 2016).
Monitoring and evaluation of the intervention
Monitoring and evaluation of an ABI is fundamental in ensuring that the intervention is fit for purpose and delivers expected outcomes to those in need of care (National Collaborating Centre for Methods and Tools, 2010). Monitoring and evaluation of an intervention follows a set of criteria which measures the effectiveness of the intervention such as the RE-AIM model which aims to evaluate the Reach, Efficacy, Adoption, Implementation and Maintenance (Glasgow et al. 1999). For example, the Reach category puts in to consideration the proportion and characteristics of alcohol abusers that access the intervention and can be assessed on an individual level which aims to provide first-hand information on what patients’ thoughts are (NICE, 2014). However, given the difficulty in accessing information on the non-respondents it is challenging to establish why the intervention was not deemed essential to suit their needs and therefore, this creates challenges quantifying the cost effectiveness of an intervention that was designed to reach a large proportion of patients (Vogt et al. 1998). Efficacy of the ABI considers the measuring of both positive and negative outcomes to ensure that a balanced evaluation of evidence is assessed on the value of the intervention to individuals who want to reduce alcohol misuse (National Collaborating Centre for Methods and Tools, 2010). Additionally, the ABI should aim to collect behavioural, biologic, and quality of life outcomes which are fundamental in assessing whether patients are benefiting from the program or otherwise (NHS Scotland, 2017). Additionally, it is essential to establish if payors are investing in a valuable intervention, and if healthcare professionals are delivering the strategy correctly or it needs to be adapted for each individual to optimize outcomes (Kaplan et al. 1993).
The adoption of the ABI takes in to perspective the proportion of care settings utilising the intervention across Scotland (NHS Scotland, 2017). This could be within the community, hospitals, and work and leisure settings to ensure that the hard to reach populations are given the opportunity to access the intervention without incurring significant costs (Alcohol Focus Scotland, 2017). Although direct observation may provide measurable outcomes, audits, surveys and interviews may provide further evidence to support the monitoring and evaluation of the ABI (Scottish Government, 2017). Similarly, the implementation and maintenance of the ABI is fundamental in assessing the extent to which the intervention has been executed in the real world setting as intended, as well as the extent to which the intervention is sustained over a pre-specified period of time (WHO, 2014). Implementation can be assessed at an individual level, and maintenance may be accessed both at an individual and organisation level to ensure alignment and consistency in the delivery of the ABI. Nevertheless, the RE-AIM framework across the five categories is not often put in to consideration across settings to evaluate alcohol interventions, and therefore the time points for evaluation of optimal effectiveness of the ABI in Scotland are often dependent on amount of available resource within the care settings which make generalisability of findings across settings challenging to ascertain (Institute for Alcohol Studies, 2013; Scottish Government, 2017).
Alcohol misuse presents a significant burden on the health and social aspects of adults in Scotland both in the short and long term. Given the quantifiable burden in the alcohol misuse related illness, crime and costs of management, this has necessitated a change in the harmful consumption levels of alcohol in Scotland through the implementation of ABIs in conjunction with national and local policies. The epidemiology of alcohol abuse in Scotland through existing literature from both primary and secondary data sources is key in providing a comprehensive insight in to the alcohol misuse circumstances over time, and how the issue can be addressed.Â Likewise, the implementation of ABI across care settings in Scotland ensures that the population at need is given access to care through education and training on the harms of excessive alcohol consumption in the short and long term.
Additionally, this ensures that the patients are given the option to receive care, after informed consent, and are able to take control of their care. Therefore, healthcare providers have the duty of care to promoting confidence among alcohol abusers to help them come up with various coping strategies to change their attitudes and behaviours. For those that decline care, the opportunity to access care in the future should be provided, but most importantly their decisions should be respected. The monitoring and evaluation of the intervention should also encompass a set of pre-specified criteria such as the RE-AIM framework to establish effectiveness of the intervention as well as the cost effectiveness of the ABI over time.
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