HIFA Discussion: Alcohol Use Disorders - Drink Aware and Change

Dear HIFA colleagues,

I would like to invite you to retweet the following that I have just sent on our X/Twitter account:

"Pls RT: I just took the DrinkAware test as if I drank 3 pints a day (well over the recommended limit). The result was "Great news! You are at lower risk of alcohol-related problems". We invite others to check. Thx NPW https://www.drinkaware.co.uk/tools/drinking-check#/ "

You can see the tweet and retweet here: https://twitter.com/hifa_org/status/1762399130154885617

We are unsure why the test - which is taken by 900 people every day - is providing such misinformation.

DrinkAware is funded by the alcohol industry.

Thank you for your help to publicise this issue.

Best wishes, Neil

HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil AT hifa.org

To which I replied:

RT'd as requested.. 

Reply from twitter ... 

This evergreen article was written 10 years ago
"Be aware of @Drinkaware "https://t.co/UGcVFb5gFB via @peter_g_miller et al

— Ash Paul (@pash22) February 27, 2024

McCambridge J, Kypri K, Miller P, Hawkins B, Hastings G. Be aware of Drinkaware. Addiction. 2014 Apr;109(4):519-24. doi: 10.1111/add.12356. Epub 2013 Oct 28. PMID: 24164565; PMCID: PMC3992896.

UPDATE 10th March

Dear HIFA colleagues,

Further to our discussions on HIFA, in the past week DrinkAware HAS CHANGED THEIR ADVICE to people who drink 42 units per week (3X the recommended maximum). Questions remain about how many people were misled by previous advice, whether that advice was deliberate, and whether WHO's AUDIT test (currently used as the basis for the DrinkAware test) should continue to be used by anyone as an unsupervised self-evaluation tool.

BACKGROUND On 22 February 2024 I reported on HIFA an apparent problem with DrinkAware, the UK's largest alcohol charity, funded by the alcohol industry. https://www.hifa.org/dgroups-rss/alcohol-use-disorders-79-role-alcohol-industry-10-alcohol-industry-and-misinformation

I took their Drinking Check. I posed as a man who drinks 42 units per week (3X the recommended maximum) and DrinkAware told me: "Great news! You are at lower risk of alcohol-related problems. This means you are at lower risk of serious diseases such as stroke, heart and liver disease, and seven types of cancer and may already be noticing the benefits of lower risk drinking such as deeper sleep, more energy and brighter moods."

There was no advice to reduce my consumption.

This test was repeated by other HIFA members in subsequent days, with the same results.

On 4 March 2024 we reported our findings to the World Health Organization.

CHANGE IN ADVICE Today, 10 March 2024, I took the test again. As before I posed as a man who drinks 42 units per week. This time I got a different result:

"You are on the right track. You are at lower risk of alcohol-related problems... To keep your health risks low, the UK Chief Medical Officers advice is to drink no more than 14 units a week. If you are regularly drinking above 14 units per week there are tips and advice below about how to cut down."

INTERPRETATION Prior to 4 March 2024, DrinkAware was encouraging many heavy drinkers (up to 42 units per week) to continue drinking as they are.

DrinkAware claims that its Drinking Check tool was used by 250,991 people in 2021, so it appears that potentially tens or even hundreds of thousands of people drinking 14-42 units per week may have been misinformed.

At some point between 4 March and 9 March, Drinkaware changed their Drinking Check tool so that heavy drinkers (up to 42 units per week) are now advised to cut down.

SHOULD WHO's AUDIT TEST BE USED AS AN UNSUPERVISED SELF-EVALUATION TOOL?

Previous messages on HIFA have suggested that AUDIT should only be used as a clinical tool by health professionals, and not as an unsupervised self-evaluation tool. WHO's AUDIT manual notes: 'Care must be taken to tell patients why questions about alcohol use are being asked and to provide information they need to make appropriate responses. A decision must be made whether to administer the AUDIT orally or as a written, self-report questionnaire.' https://iris.who.int/bitstream/handle/10665/67205/WHO_MSD_MSB_01.6a-eng.pdf

NEXT STEPS

How many people were misled by previous advice, was that advice deliberate, and should WHO's AUDIT test (currently used as the basis for the DrinkAware test) continue to be made available as an unsupervised self-evaluation tool?

I invite HIFA members to suggest next steps. Are you a health journalist (or do you know a health journalist) who might be interested to look into this in more depth? Please pass this on and/or contact me: neil@hifa.org

Meanwhile I shall report this new finding to WHO.

I look forward to your comments and suggestions: hifa AT hifaforums.org

Best wishes, Neil

Finally ...

Dear HIFA colleagues,

We now enter our 6th and final week of the deep-dive into Alcohol Use Disorders, where I invite you to reflect on what has been discussed so far (and what has not been discussed). In your view, what is the key learning in relation to the 5 questions we have explored:

1. Do people understand the health, socio-economic and environmental harms of alcohol? What matters to them? How can they be better informed? How to reduce stigma? 2. Do health workers have adequate knowledge to prevent and manage alcohol use disorders among their patients? What matters to them? How can they be better informed? 3. What is the role of the alcohol industry? What can be done to address misinformation from the alcohol industry? 4. Do public health professionals and policymakers have adequate knowledge to prevent and treat alcohol use disorders in their country? What are current national policies and what more can be done to fully implement those policies? 5. How can we define and measure alcohol use disorders?

To help with this, I have prepared a full compilation of our discussion so far (205 pages):

https://www.hifa.org/sites/default/files/publications_pdf/Alcohol_Use_Disorders_Compilation2.pdf

I shall now work on an edited version (selected text organised under subheadings for each of the 5 questions and for other topics) and will get this to you asap.

Many thanks, Neil

Theory on Demand #29 Good Data

GOOD DATA

"Data can have power in numbers. Not only in the literal sense, rather, just as repeat - ability is important, so aggregation and meta-analysis of repeated and comparable studies acts to reduce the uncertainty of individual studies. Cochrane reviews in medical research carry a good deal of weight for this reason and are considered 'gold standard'.33 These reviews reduce the influence of individual companies or vested interests, and lead to more informed health policy." (p.48).

"Those questions underpin a consideration of contemporary genomic initiatives, particularly those that are marketed as 'recreational genomics', and gene patents such as those held by Myriad Inc. More broadly they underpin thought about population-scale health data initiatives such as the UK care.data program that, as discussed below, encountered fundamental difficulties because bureaucratic indifference to consent eroded its perceived legitimacy."54 (p.144).

See other TOD titles c/o The Institute of Network Cultures (INC)

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Something you know values value personal ethics ('good' data = 'here'?)	biometrics: Something you are Something you have  (proximity = 'are' + 'have')? 'open data index'
social activism social assets social capital social data social ends social (collective) ethics social good social justice social media(?) social science	data: "power in numbers" values value bureaucratic ethics audit records security corruption

My source: https://twitter.com/ArnaldoPellini/status/1089196464310501377

Antipsychotics & Dementia: Managing medications (across Hodges' model)

individual
INTERPERSONAL : SCIENCES

humanistic ------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

group

person-centered care, communication	diagnosis medication management assessment - review premature deaths, stroke side-effects observation Anti-psychotics: Traditional - 1st generation Atypical - 2nd generation de-prescribing pain, analgesia,  research anti-depressant cholinesterase inhibitors titration trial reduction avoid benzodiazepines if possible
Team working, collaborative care, family nursing homes challenging behaviours - shouting, aggression, psychosis, agitation Behavioural and psychological symptoms of dementia (BPSD) psychosocial interventions, reassuring staff, knowledge and skills	Policy, Reports, Governance, Audit, Consent, Capacity, Consultation, Multi-disciplinary approach, institutions, choice

My source: AlzheimersAustralia via twitter
https://www.dementia.org.au/

Compare and contrast potential - Energy for Change Index and Hodges' model

The biopsychosocial model is quite all encompassing used as it is to help explain and represent pain, explain human development and balance the physical excesses of psychiatry.

For all its scope the biopsychosocial model is two domains short of Hodges' model.

Hodges' model is dated though, a child of the mid-1980s. The biopsychosocial model predates Hodges' and as models of nursing have fallen out of favour in terms of the attention they receive the biopsychosocial is subjected to critique as per:

Ghaemi, S.N. (2009). The rise and fall of the biopsychosocial model. Br J Psychiatry.195(1):3–4.

Hatala, A.R. (2012). The status of the “biopsychosocial” model in health psychology: Towards an integrated approach and a critique of cultural conceptions. Open Journal of Medical Psychology, 1, 51-62. doi: 10.4236/ojmp.2021.14009

A cursory check reveals a diverse and current literature on the biopsychosocial model. If this is positive for the general role of 'models' in health and social care education and learning then there is another encouraging source in the five energies for change with its five domains:

• Spiritual
• Social
• Physical
• Psychological
• Intellectual

There is great similarity with Hodges' model although in h2cm the spiritual combines all the four domains of which the political also replaces the intellectual. I would equate the intellectual with the psychological, accepting of course the existence of individual and group psychologies. Being intellectual and becoming intellectual to the extent of an individual realising their potential has long been recognised as a political matter and consequence (Freire). As such the Political domain within Hodges' model is central to its relevance within the field of engagement and innovation and beyond.

Whilst the energy for change domains have a specific derivation and (instrumental) purpose I would suggest that a possible strength for Hodges' might lie in the notion (which it is) that there is an underlying conceptual structure from which the domains arise. This structure might support the model's application in time, as well as assuring its longevity and the stamina of its champion.


My prompt: Land, M., et al. (2014) Pedal to the metal to improve the NHS. HSJ, 124, 6389, 26-27.

Evidence Hodges' model #1: Research in Nursing

When as a nurse (OT, physio, medic....) you are on a course, especially one about research you may be required to complete a study or more significant piece of research. Courses at graduate and post graduate level invariably include such demands and stress the hope that this course will spur you to continue the research effort in the work place. The ideal is of course to routinise research in clinical settings. Whatever the debate regarding the merits of evidence-based nursing, medicine and so on, this still needs to happen in part to help bridge the theory - practice gap.


In the same way all nurses have a professional responsibility to educate their student peers, (patients and carers...) there is an expectation that nurses are like embedded media commentators in a war zone. Part of your time in practice will be devoted to research, audit and governance.

While there are audit and governance teams there willing to help, many people multi-task in their work and nurses are seasoned practitioners. Many just want to do what they were trained for and nurse. They recognize this as they hear the expectations of the course leaders, lecturers and yet they are aware of the constraints. The scope for research is weighed against other commitments, notably:

• direct(ing) patient care and safety
• management and supervision
• audit duties for management information

There are of course a host of psychosocial influences that come into play. What is my personal interest in research? Where do I prefer to be at work: office, ward, or home or retired? Cynical? No! Just being realistic. The information systems frequently in place can assist as a research tool, but their chief role is to provide management information through the collation of aggregated data. This is done by-and-large transparently in the background ('back-end'), and that is the problem. Nurses need to get their feet wet. The option must be there, and not just when on courses. Nurses need to immerse themselves in the data and information streams they help to create and source.

As the list above suggests nurses and not just senior nurses need direct access to the icon labelled 'reports'. There should be ways for nursing work to be captured in-situ, but how? Many clinical information system vendors have their solutions to this, but as regular readers know for a long time I've been wondering about -

1. How can the balance between management data and intelligence needs and clinical needs be supported and bridged?*
2. What is the evidence base to support Hodges' model in theory, practice, management and policy?
3. What is the state, characteristics, access and usability of nursing terminology, taxonomy, classification systems in informatics - information and communication systems?
4. If I am individually compelled (nuts!) to create a new website could I ally this aim with a course?

More to follow - including some of the sessions at Drupalcon Paris.....

*To this list we also need to add other stakeholders - members of the public.

Additional link:
https://www.icn.ch/what-we-do/projects/ehealth-icnp

Image sources:
Mind the gap: http://ci.coe.uni.edu/facstaff/zeitz/web/itag/mindthegap/
Report icon: http://artistsvalley.deviantart.com/art/Free-Task-Icons-Reports-Icons-89509953