Behaviour change: individual approaches

Assessing the evidence

The purpose of this exceptional review was to examine any impact on NICE's guideline on behaviour change following the publication of a Cochrane review on the Effectiveness of brief alcohol interventions in primary care populations (Kaner et al. 2018). This is an update of a 2007 Cochrane review (Kaner et al. 2007). Apart from considering the findings of the previous surveillance review, no additional evidence published since the launch of the NICE guideline in January 2014 was considered by the exceptional review.

Cochrane review summary

Guideline development

The effectiveness review for the NICE guideline involved a systematic search for RCTs with a sample size greater than 100 which assessed the effectiveness of individual-level behaviour change interventions compared to a control condition in changing either alcohol use, diet, physical activity, sexual behaviour and/or smoking, published from 2003 up to September 2012. It included 26 RCTs assessing the effectiveness of individual-level behaviour change interventions compared to a control condition in changing alcohol use in people who consume a hazardous or harmful amount of alcohol. A meta-analysis indicated that individual-level behaviour change interventions had a very small but significant overall effect on alcohol consumption (and there was low heterogeneity between studies). However when results were assessed according to sub-groups, it was found that compared with usual care, interventions were only effective at changing the alcohol consumption behaviour of pregnant and postpartum women. There was no significant effect on the alcohol consumption behaviours of:

Overall, studies found that brief alcohol interventions (single sessions lasting less than 30 minutes) were no more effective than usual care at altering behaviour (usual care varied from minimal intervention to fairly robust alcohol interventions). Few studies assessed extended alcohol interventions. These were mainly provided to heavy/risky drinking university students with the aim of reducing alcohol consumption. However, across the 5 behaviours of interest, multi-session interventions were more likely to be used and more likely to be effective than the other types of intervention.

Previous surveillance

A surveillance review of the NICE guideline was undertaken in November 2017. Sixty new studies, 2 reports and 10 pieces of ongoing research were identified. While none of the new evidence was assessed as having a substantial effect on the guideline recommendations, it did indicate that there was evidence that addressed a recommendation for research on remotely delivered behaviour change interventions. This led to the commissioning of the in-development NICE guideline on behaviour change: digital and mobile health interventions. No evidence directly relevant to the Cochrane review findings concerning brief and extended behaviour change interventions for people who are hazardous or harmful drinkers was identified in the surveillance review.

Views of topic experts

In this exceptional review we engaged with topic experts who were members of the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty. We received feedback from 3 topic experts, all of whom felt the guideline should not be updated.

The responses from the topic experts suggested that the recommendation on delivering very brief, brief, extended brief and high intensity behaviour change interventions and programmes in the NICE guideline did not need to be updated. Topic experts noted that the findings of the Cochrane review reinforce the existing recommendation concerning delivering brief behaviour change interventions for people who engage in risky behaviours including hazardous or harmful drinking. They did not think that the evidence questioning the effectiveness of extended interventions had an impact on existing recommendations in the NICE guideline due to the very small sample size of studies measuring brief against extended interventions and the low quality of those studies. Topic experts also noted that while dose-response is an important area of research, other issues also impact on effectiveness such as the content of the intervention (behaviour change techniques, psychological constructs addressed) context, person characteristics and characteristics of the intervention provider (skills, attitude, empathic approach, and so on), fidelity of intervention and how effectiveness is evaluated. These issues are addressed within recommendations in the NICE guideline.

Impact

The Cochrane review findings are directly relevant to recommendation 9 in the NICE guideline on delivering very brief, brief, extended brief and high intensity behaviour change interventions and programmes. This states that adults involved in risky behaviours, including alcohol misuse, should be offered interventions to support them in reducing their alcohol intake. Depending on the health and social care staff's background, staff's level of contact with people, and an individual's needs, a very brief intervention, brief intervention, extended brief intervention or a high intensity intervention should be offered.

The new evidence identified showed that when compared with no or minimal intervention, brief alcohol interventions result in a small but significant reduction in alcohol consumption per week, number of days of drinking and binge days per week at 12 months follow-up in people who consume a hazardous and harmful amount of alcohol. The evidence indicates that more intensive interventions may not provide any additional benefit over and above that which is achieved following a brief alcohol intervention (as defined within the Cochrane review). These findings appear to support the recommendation to provide brief interventions, but question whether extended interventions are appropriate given that they appear to be no more effective than lower intensity interventions at changing alcohol consumption.

It should be noted that the definition of a brief alcohol intervention within the Cochrane review would encompass a very brief intervention, brief intervention or extended brief intervention as defined within the NICE guideline; and that an extended alcohol intervention as defined within the Cochrane review would most closely represent a high intensity intervention within the NICE guideline: typically these last more than 30 minutes and are delivered over a number of sessions. The current recommendation in the NICE guideline states that behaviour change service providers and practitioners should be encouraged to provide high intensity interventions for people they regularly work with under specific circumstance: for those who have been assessed as being at high risk of causing harm to their health and wellbeing and/or have a serious medical condition that needs specialist advice and monitoring and/or have not benefited from lower intensity interventions.

The conclusions in the Cochrane review concerning the (lack of) impact of extended (high intensity) versus brief alcohol interventions was made on low-quality evidence from a small number of studies that assessed extended interventions. In addition, the remit of the NICE guideline was to provide recommendations for a range of behaviours, not just alcohol use, and to consider more broadly what the common components are of effective behaviour change interventions to ensure that interventions are appropriately developed and delivered.

After taking into account the new evidence and views of topic experts, we have concluded that the new evidence does not have an impact on the recommendations within the NICE guideline. For this reason, we will not update the guideline at this time.

Equalities

No equalities issues were identified during the surveillance process.