Project objectives

The original objectives of the project were to compile evidence on the potential effectiveness of the DrinkThink intervention, both at (a) reducing the quantity and frequency of alcohol consumption among young people; and (b) at training health care and non-health care workers engaged with young people to undertake alcohol screening and brief intervention. The key objectives were to determine: (i) the impact of DrinkThink on excessive drinking, (ii) the acceptability, facilitators, and barriers of ASBI to young people (with young people referring to those aged 15-17 years, hereafter), (iii) the acceptability, facilitators, and barriers of professionals in delivering ASBI to young people in social service, youth service, and healthcare settings.

It was a mixed methods study that sought to address the following research questions: 'is the DrinkThink training acceptable by professionals across healthcare, education, social care, and criminal justice settings', and 'is the subsequent delivery of the intervention acceptable to professionals from healthcare, social care, and youth service settings', 'is DrinkThink acceptable to young people who receive the intervention', and 'is there evidence to suggest that DrinkThink is effective in reducing alcohol consumption among young people'.

The evaluation components included:-

1. focus groups with professionals from organisations in social service, youth service, and healthcare settings who have received DrinkThink training;
2. focus groups with young people who received the DrinkThink intervention;
3. an online questionnaire to measure alcohol outcomes among young people;
4. micro-costing and resource use questionnaires to estimate the cost of the intervention and the broader economic impact of excessive drinking.

Changes to project objectives

A revised protocol was developed in December 2015, based in interim findings showing that staff trained to deliver DrinkThink were not implementing the intervention as planned and consequently, young people were not receiving the intervention. Following consultation with collaborators and local public health colleagues at BANES, a new set of objectives were agreed:-

1. To identify the facilitators and barriers to implementation of DrinkThink among staff working in health and youth social care settings;
2. To conduct a follow-up focus group with staff who received a training update, to ascertain any changes in implementation;
3. To conduct follow-up interviews with trained staff and team leaders to support the interim findings.

In the analysis, data were used from the initial phase of the study on which the interim findings were based, and from newer data obtained from the follow-up focus group and individual interviews.

There were three researchers who undertook the study (Dr Judi Kidger until December 2015, Dr Angela Beattie) and finally Dr Jane Derges from April 2016).

The protocol was revised and ethics approval was obtained on 17th June 2016, (Social Care NRES Research Ethics Committee REC reference: 15/IEC08/0018. IRAS project ID: 165553).

Brief Summary

Methods

Two inter-related questions were explored: ‘is the DrinkThink training acceptable to professionals across health, youth, and social care service settings?’, and ‘is DrinkThink being delivered by professionals from health, youth, and social care service settings as intended?’

There were 4 participating agencies in the study: a sexual health clinic, school nursing, a youth service and a social care service. These were selected to ensure a range of settings were represented and participating staff were selected according to whether they had received the DrinkThink training. Those staff who had received the training from 2013 onwards, were eligible for inclusion. Excluded were those agencies who had not received the DrinkThink training, or professionals working in adult services.

Focus groups were conducted with each of the 4 participating agencies and arranged no less than two months after training had been delivered, with a total of 33 participants. Each group was organised and run by 2 researchers using a topic guide. Participants were asked open-ended questions about what they thought of the training; the content of the DrinkThink materials; whether they were implementing the DrinkThink intervention; and any views they had concerning the value of the intervention for their work. Opportunities were given to elaborate further on any related themes. The groups were audio recorded and transcribed before being coded.

A focus group was held to find out if refresher training had impacted the delivery of DrinkThink. In addition, 8 interviews were conducted to provide supporting evidence about why implementation was low; participants included 6 team leaders from the 4 participating agencies and 2 recently trained school nurses. These interviews were conducted over telephone or by email and additional notes from correspondence, where relevant, and training observations were also included.

Observations of the training course were also conducted by 2 of the researchers (JK and JD).

Results (including findings in relation to the objectives)

Most participants trained in the DrinkThink intervention appreciated the knowledge they had gained, and they used parts of the intervention to conduct informal conversations, but few were delivering DrinkThink in its entirety. Use of the M-SASQ screening tool was sporadic and most staff relied on their own judgement as to whether a young person required the intervention. Failure to implement the intervention in its entirety was due to several factors that can be categorised according to three core themes:

1. the training staff received;
2. the working ‘culture’ into which DrinkThink was introduced;
3. the participants’ attitudes towards alcohol use.

 1) Training

Factual knowledge gained through the DrinkThink training was appreciated by some participants; primarily those who were already addressing health problems through their existing assessment procedures. For example, school nurses said it fit easily with health-related questions they were already asking young people. However, they rarely identified young people with alcohol problems in schools. Participants in other settings such as youth social care services, described feeling ill-equipped to deliver the toolkit after training, particularly if they were not using the materials on a regular basis. It was noted that during observations of the training, participants often asked if they could adapt the materials to fit their particular client group, suggesting the materials were not applicable in all service settings.

2) Working ‘cultures’

Sexual health staff, who deliver a ‘walk-in’ service for young people, found the intervention had to compete with other pressing health needs and interventions, so that finding time to implement the intervention was difficult. Youth and social care staff described their work culture as ill-suited to ASBIs in general. Youth services use an informal, non-directive approach and engage young people according to their individual needs. DrinkThink was perceived as a more ‘formal’ approach. Youth and social care staff also noted practical barriers to the delivery of DrinkThink; for example, working in mobile settings or other informal venues meant they did not always have the DrinkThink materials with them, or the venue was unsuitable for private one to one conversations.

2) Attitudes

Alcohol was not always perceived to be a significant problem among the young people seen by staff participants, nor was it identified in referrals to youth services; other drug use, especially marijuana, was considered more of a problem. There was also a lack of clarity among staff about what constituted ‘normal’ and ‘problem’ alcohol use among young people, and drinking was often perceived as a ‘social norm’.

Alcohol was often evaluated according to what other problems young people presented with. For example, a youth team leader ranked mental health problems, domestic violence, and drug use over and above alcohol problems. Similarly, sexual health nurses identified their role as primarily to address the sexual health needs of young people and therefore they made this their priority, although there was some acknowledgement that alcohol often played a role in sexual encounters. In contrast, youth and social care teams reported that they routinely discussed alcohol use with the young people they saw, but according to their own therapeutic aims and approach, which reflected comments made about the unsuitability of DrinkThink for youth and social care services. 

Conclusions

DrinkThink was not delivered as planned by health, youth, or social care staff. Whilst there was positive acknowledgement of the DrinkThink materials, this did not translate into practice. Reasons for this included a lack of confidence in applying the materials; a general perception that alcohol was not a big problem among young people; competition with other work priorities; and the perceived unsuitability of ASBIs to the working culture of, in particular, youth and social care services. Linked with this, some staff reported they already routinely addressed alcohol use but through their own informal approaches.

Most of these issues can be attributed to a failure to implement fully the co-production approach; although young people were involved in the design of the materials, the professionals intended to deliver the intervention were not consulted about the content or the ASBI approach. If they had been,contextual factors related to work culture, the ‘fit’ between DrinkThink and therapeutic approaches already being used with young people, and staffs’ attitudes to alcohol and ASBIsmay have been picked up and addressed both in the design of DrinkThink, and in the training that professionals receive before its delivery.

Plain English summary

Alcohol use among young people is an important public health concern in the UK. Several approaches have been found to be effective in addressing alcohol use among the adult population, but less is known about effective interventions for younger age-groups. This study aimed to investigate how DrinkThink, a specially designed alcohol screening and brief intervention (ASBI) for young people, was being used by staff who regularly work with young people in youth, social care and health services. Young people were involved in the design of the DrinkThink materials, in order to ensure that the intervention was age-appropriate.

In order to evaluate DrinkThink, a qualitative study was conducted by researchers at the University of Bristol alongside partners at a local youth drug and alcohol service located in Bath and North East Somerset (BANES). A total of 5 focus groups and 8 individual interviews were held with staff from health, youth and social care services who had been trained to deliver the intervention. The training included consideration of the risks to health from alcohol use, information regarding units of alcohol and current Department of Health guidelines, and practice in using the DrinkThink materials.

Findings showed that, although staff appreciated new knowledge gained through training, few of them were delivering the intervention as planned. There were three core reasons for this: 

1. Staff felt unsure how to deliver the materials, despite the training they had received;
2. Staff did not consider alcohol to be a key health problem among young people they saw, and were more concerned about their drug use and sexual health;
3. Youth and social care staff found the DrinkThink approach to be too formal for their services, compared to the informal conversations that they typically used to engage with young people.

These issues therefore acted as a barrier to DrinkThink being implemented. Staff from youth, health and social care services were not involved in developing the DrinkThink intervention. If they been been, some of the problems highlighted in this evaluation study could have been addressed at an earlier stage.

Dissemination

Academic dissemination

Derges, J., Kidger, J., Fox, F., Campbell, R., Kaner, E., Taylor, G., McMahon, C., Reeves, L., Hickman, M. “DrinkThink” Alcohol Screening and Brief Intervention for Young People: a qualitative evaluation of training and implementation. Journal of Public Health (accepted for publication).

Derges J, Kidger J, Fox F, Campbell R, Kaner E, Hickman M. Alcohol screening and brief interventions for adults and young people in health and community-based settings: a qualitative systematic literature review. BMC Public Health 2017 17:562. DOI: 10.1186/s12889-017-4476-4

Hickman M, Kidger J, Beattie A, Fox F, Campbell R, Hollingworth W, Taylor G, Kaner EFS. DrinkThink: Alcohol Screening and Brief Intervention for young people – an evaluation and intervention development study. South West Public Health Scientific Conference, Bristol, 16 Mar 2016

Kidger, J. (2016) DrinkThink: alcohol screening and brief intervention for young people- an evaluation and intervention study. SPHR Conference, March 2016.

Practitioner dissemination

A workshop was held to disseminate findings from the study to participants in health and youth services as well as other professionals and project partners involved in DrinkThink, organised by Bath and North East Somerset Public Health department. The workshop also provided the opportunity to raise awareness of the problem of alcohol use among young people, and to discuss as to how young people’s services might best address alcohol use in the future.

Poster presentation ‘Drink Think: experiences and views of professionals trained to deliver an Alcohol Screening and Brief Intervention (ASBI) tool for young people.’ NIHR SPHR PHPES event, University of Sheffield, 25 January, 2017 and NIHR SPHR Annual Scientific Meeting, London, 23 March 2017. 

Public involvement

Young people were successfully involved in the design and evaluation of the DrinkThink materials, and gave feedback that was then used to adapt the materials and also to provide ways to encourage participation.

Staff who were involved in delivery of the DrinkThink intervention were included only at the training stage, which was too late. This had a direct impact on implementation (see above). Despite re-focusing the training to provide more information on how to deliver the materials, this did not have an impact on the implementation of DrinkThink. It is possible this was too late to address the issues that were preventing delivery of DrinkThink; such as staffs’ attitudes towards alcohol use, and the working culture of youth services which was not compatible with ASBI approaches (see above). In future, inclusion of both young people and the staff who will be delivering an intervention should take place at the earliest development and design stages.

Project 28 partners assisted with recruitment by providing access to health and social care teams. They enabled observation of the training and were involved in discussions about how to implement changes in the training, following interim findings.

The BANES public health collaborator also helped with access and was involved in discussions resulting from the interim findings about the future direction of the DrinkThink intervention.

A workshop organised by BANES public health team, attended by education, youth, social care and health services and the DrinkThink study team, provided the opportunity to discuss the implications of the DrinkThink findings, and consider how to address young people’s alcohol use in the future in the light of those findings.

Impact

This study has provided important information on the necessity of using co-production in public health intervention practices. It highlights the importance of including all participants involved in an intervention at all stages of development and design. Linked to this, we have shown the importance of understanding context; in this instance, the participant’s working ‘culture’ which can assist in identifying both facilitators and barriers to an intervention. This is also applicable to wider public health interventions. Although the study findings were disappointing in the sense that they showed the DrinkThink intervention was not being used, this was valuable information for the BANES public health team and Project 28, and it has led to a re-evaluation of the best way to involve young people’s services in addressing alcohol use.

This project was funded by the National Institute for Health Research School for Public Health Research (SPHR-BRI-PES-DTK)

 Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.