Key Points
• Getting the Measure training and resources have been effective in encouraging frontline workers to discuss alcohol with service users, and has been particularly useful for staff who work to the Key Worker Practice Model.
• The AI training was successful in improving staff confidence and knowledge levels and to a lesser extent on staff attitudes.
• While most staff felt it was appropriate for them to discuss alcohol with their clients, some groups of staff have been less able to implement alcohol interventions than others. This is partly due to a difficulty within some services in raising the issue of alcohol in a way that feels relevant and appropriate. A key challenge for Cyrenians is finding solutions to the identified barriers to implementing AI in these settings.
• There is a need for further research into the potential use of a validated screening tool to assist staff in accurately capturing the drinking patterns and related risk of the clients they work with and assessing their suitability for the Cyrenians alcohol intervention.
• The training had a positive impact on staff knowledge about Motivational Interviewing (MI) approaches and confidence in implementing these and wider behaviour change approaches, through case file analysis it was difficult to assess whether these techniques were being applied in practice.
• Staff identified a number of ongoing support materials and training that would help them to more fully implement AI in practice including refresher courses on MI, clearer visual prompts, accessible written information for clients, and guidance relating to units and limits for under 18 year olds.

About the Evaluation
The evaluation used a mixed method approach. Pre and post course questionnaires, with follow up questionnaires at 3 and 6 month intervals were completed by staff (n=39) who had attended the AI training, combined with 13 qualitative interviews, the analysis of 22 case files and two validation groups with 12 members of staff.

The research was carried out and report written by Julie Dowds and Steven McCluskey of Create Consultancy Ltd. The training and evaluation was commissioned by Cyrenians Scotland and was funded by the Comic Relief UK grants programme.

Background
Edinburgh Cyrenians is a charity that aims to make a difference in the lives of people who are at risk from poverty and homelessness, many of whom struggle to recognise the direct impact of alcohol use on their health and everyday lives. Cyrenians recognised this, and their experience of specialist alcohol services being over-subscribed or not aimed at working with vulnerable people, as a challenge for staff in being able to effectively support individuals with their alcohol use and related problems. The Comic Relief UK funded Getting the Measure: alcohol intervention project has been in operation since October 2008 and was a response to these identified challenges. The project aimed to build internal capacity to enable staff to more effectively address problematic alcohol use among its service users.

The one day training course, jointly developed and delivered by STRADA, aimed to develop awareness and knowledge of alcohol use, equip staff with tools, including motivational interviewing, to be able to talk about alcohol with service users, and develop an understanding of units, drinking limits and harm reduction strategies. Alongside the training a number of resources were developed to aid staff. This included the “Getting the Measure” website with downloadable resources and support materials.

Training was delivered to 52 staff members in 2010. The design of the training was informed by the available evidence in relation to alcohol early interventions and good practice within the homelessness field. In addition, it was based upon many of the underlying principles and elements which are common to an alcohol brief intervention approach while being mindful of the complex circumstances and needs of Cyrenians service users. It aimed to address barriers and promote the implementation of AI in practice.

This research used engagement with staff to assess the effectiveness of the training and resources in supporting them to discuss alcohol with their clients and to explore the effectiveness of the model for wider use.

“I found the course very informative and [it] has given me confidence in approaching people’s drinking.”

An Adapted Model
“Knowing all about it [alcohol] is the biggest thing so that if it arises I have that knowledge and background.”

The Cyrenians alcohol intervention model draws upon and incorporates some of the key principles and elements of a brief intervention on alcohol approach including a focus on non-threatening ways of raising the issue of alcohol, exploring alcohol consumption, assessing risk, and providing information and feedback. It uses Motivational Interviewing techniques, provides harm reduction advice and assesses and supports an individual’s readiness to change. Adaptations were made to the widely practiced brief intervention approach to reflect the complex needs of the client group and include:
• The incorporation of the intervention into key-work as part of ongoing case management support rather than a one off intervention
• A focus on building clients motivation, knowledge and skills to change and supporting them through the change process with less of an emphasis on self help
• No formal or validated screening tool, in response to concerns about appropriateness, and the negative impact this might have on the client and key worker relationship
• The introduction of assessment, monitoring and planning tools to plan and monitor changes in alcohol use and related problems on an ongoing case management basis.

Findings from the Questionnaires
• Prior to the training few respondents discussed any aspect of alcohol on a weekly basis. Few respondents indicated that they had used the key components of brief interventions on alcohol on a regular basis, and over half had never or only a few times in their career provided written information related to sensible drinking.
• At all stages of the evaluation the majority of respondents felt that it was very important for Cyrenians staff to be able to address clients’ drinking behaviour.
• Respondent perceptions of how knowledgeable they felt on alcohol related statements increased after training. This increase was statistically significant.
• There was some positive improvement post training on the average ratings given by respondents on how much they agreed with attitude statements relating to how alcohol issues can be addressed, however only three of these increases were statistically significant. This may reflect the already favourable attitudes held by participants prior to training and/or ongoing concerns by some participants about the legitimacy of them raising the issue of alcohol in some situations.
• Respondent confidence levels in managing a series of alcohol related statements increased after training and were largely maintained at 3 and 6 months. This increase was statistically significant.
• The largest increases in knowledge and confidence related to statements specific to the use of MI and wider behaviour change approaches, though at each stage of the evaluation some of these statements were given the lowest knowledge and confidence scores.
• The majority of respondents indicated that they had found the training very useful or useful. Feedback included perceived improvement in knowledge and skills, increased confidence, a consolidation of previous learning and an opportunity to reflect on practice.

“It’s given me more confidence to discuss this quite openly with people and people have been very responsive to it.”

Following training all respondents indicated that they would integrate AI into practice.

Findings from Qualitative Approaches
• The majority of interviewees indicated that the training had positively impacted on their practice.
• Key facilitators for implementation included units information and the unit calculators, increased knowledge and confidence from training, opportunities to put learning into practice particularly through alcohol questions being part of the personal plan, and having an awareness of MI.
• Questions were raised about the appropriateness of the AI approach with some client groups e.g. younger clients, clients with learning disabilities, clients that indicate that they don’t have alcohol issues or are unable or unwilling to admit to alcohol use.
• Other barriers to implementation included lack of opportunity for certain staffing groups to raise the issue of alcohol, feeling that certain services did not lend themselves to discussing alcohol use, loss of knowledge and confidence if AI is not used regularly, and feelings amongst some staff that alcohol is a taboo subject.
• While overall interviewees were positive about AI as an approach, notes of caution included the recognition of multiple client support needs and competing priorities, the need to raise alcohol at an appropriate time and place, and an awareness of literacy issues among some clients which impact on their ability to engage with the materials.
• Interviewees identified a number of ongoing support needs with suggestions of revision courses, advanced training, peer support and specialist agency input into team meetings.
• Case file analysis indicated greater and improved focus on alcohol with staff more likely to raise the issue of alcohol with clients. In addition that client alcohol consumption and related problems are being more effectively monitored and that some staff are exploring alcohol consumption more effectively at initial contact.

“I think it has a lot to do with the person you are working with and where they are in terms of admitting that their drinking has become problematic.”

A number of issues were identified in the case file analysis including inconsistencies in how staff are assessing risk in levels and patterns of consumption, the quality of discussion on alcohol and information recorded. Actions were often described in vague and general terms, and it was difficult to identify from the case notes whether certain stages of the AI were being applied in practice.

Key Conclusions
• In general the “Getting the Measure” training has had a significant impact on staff ability to raise the issue of alcohol. Where there has been less impact is among the services and staffing groups that follow the Key Worker Light approach and where there was no built relationship between practitioner and client. This was confirmed in the validation groups.
• Analysis indicates that while for many staff the training had a positive and sustained impact on their knowledge and skills relating to the assessment of risk, for others some inconsistencies were apparent. The validation process confirmed that the alcohol consumption questions used do not always accurately capture the drinking patterns and related risk of some clients. Some staff may benefit from further information and guidance in relation to units of alcohol and recommended limits, and assessing a client’s suitability for AI.
• There is some indication that the training has had a positive impact on staff knowledge and use of motivational interviewing and wider behaviour change approaches though it was difficult to assess from the case files whether MI approaches techniques and tools were being used in practice. Further training and tools which support the use of these techniques were identified as being useful.
• Specific factors which were identified as supporting the process of raising the issue and carrying out alcohol interventions were the development of staff confidence and recognition that clients won’t generally be offended when alcohol is discussed, the changes in paperwork which provide prompts and support raising the issue, and the provision of materials such as unit wheels and cups. Suggestions for additional support include refresher courses, opportunities for peer support and clear visual prompts and materials for use with clients.

Recommendations for Action
• The development of tailored training for differing staffing groups to address specific concerns.
• The development of refresher sessions incorporating opportunities for staff to practice their skills and receive feedback, share good practice and specific example from practice, and opportunities for reflective practice supported by a practice reflection sheet that outlines the core components of the AI approach.
• The ongoing development of visual and tactile resources to help assess risk and carry out specific behaviour change techniques. Suggestions include the continuum of risk arrow and visual prompts for MI and behaviour change techniques. These would be in addition to the resources currently available on the Getting the Measure website.
• Further exploration into the potential use of a validated screening tool, which includes consideration of issues such as whether service users would perceive the use of such tools to be a legitimate part of the role of Cyrenians staff, and takes into account the differences in worker/client relationships across the range of Cyrenians services.
• Development of 2nd stage research with a focus on the engagement of clients to explore issues around role legitimacy and impact of the intervention.