ReviewAre brief alcohol interventions targeting alcohol use efficacious in military and veteran populations? A meta-analysis
Introduction
A high prevalence of hazardous and harmful alcohol use has repeatedly been reported in the US and the UK forces (Bray et al., 2009, Fear et al., 2007). In the US Army, the prevalence of binge drinking (i.e., ≥4 or ≥5 drinks on one occasion, for women and men respectively) is 43% (Stahre et al., 2009), compared to 23% in the general population (Substance Abuse and Mental Health Services Administration, 2011). Even when controlling for age and gender, U.S. military personnel drink more than the general population (Bray et al., 2009). Similarly, both hazardous drinking (drinking which increases the risk of mental or physical harm) and harmful drinking (which results in consequences to mental or physical health) (Babor and Higgins-Biddle, 2001), are higher in the UK military compared to the general population. 67% of men and 49% of women in the UK Armed Forces drink at least at a hazardous level (Fear et al., 2007), compared to 38% of men and 15% of women in the general population (Coulthard et al., 2002).
It is worth noting, however, that data from other countries do not seem to reflect the same situation. While rates of hazardous and harmful drinking are not reported, there seems to be lower levels of ‘risky drinking’ (i.e., >2 drinks per day) among Australian serving and former Defence Force members (Waller et al., 2015) and a lower prevalence of alcohol use disorders in the German military (Trautmann et al., 2016), compared to the general population.
The literature on alcohol interventions in the general population shows promising results in tackling hazardous and harmful drinking, in particular in relation to brief alcohol interventions (BAIs). A systematic review of systematic reviews suggested that face-to-face BAIs are effective in reducing hazardous drinking in primary healthcare settings (O’Donnell et al., 2014). Computer-delivered alcohol interventions are also promising, with a meta-analysis of randomised controlled trials (RCTs) showing an overall significant reduction of alcohol use in the general population (effect size (d) 0.20, p < 0.001) and which did not show heterogeneity between studies of diverse characteristics (Rooke et al., 2010).
According to WHO/AUDIT guidelines, BAIs are of short duration (less than ten minutes) (Babor and Higgins-Biddle, 2001) and can be delivered face-to-face (Bertholet et al., 2005) or online (Kypri et al., 2004). The content is variable but should include brief advice, skills training and practical advice to reduce drinking, and follow-up (Babor and Higgins-Biddle, 2001). These interventions are not designed for use in those with alcohol dependence/alcohol use disorder, who generally require more intensive management (Babor and Higgins-Biddle, 2001).
Many BAIs focus on providing personalised normative feedback (PNF), which compares the subject’s drinking to the general population norm (i.e., a social norms comparison). This approach aims to challenge misconceptions of peer behaviour by contrasting what one perceives to be the drinking norm with the actual norm. For example, in the general population, young people tend to overestimate the drinking behaviour of their peers, and these perceived norms strongly predict their alcohol consumption (Borsari and Carey, 2003). Correcting overestimations of peer drinking norms using PNF results in a reduction in drinking in college students (Miller et al., 2013).
While BAIs have been used in the military to tackle alcohol use, a meta-analysis looking at overall effects of these has yet to be carried out in this population. Military and veteran populations are unique and differ from the general population, not least in their exposure to an entrenched drinking culture (Jones and Fear, 2011). However, like in the general population, misperceptions of peer drinking exist in military and veteran populations. Both veterans and active duty service members tend to overestimate their peers’ drinking, and these misperceptions predict greater personal drinking (Neighbors et al., 2014, Pedersen et al., 2016). As a result, though only in its infancy, research is now looking at the most effective ways of employing PNF interventions to reduce drinking in military and veteran populations (e.g., Pedersen et al., 2016).
This systematic review aimed to explore which BAIs have been used in the military and to conduct a meta-analysis to determine whether these interventions are efficacious in reducing alcohol use in military and veteran populations.
Section snippets
Search strategy
The literature search was conducted in March 2017 using Medline, EMBASE and PsycINFO electronic databases to identify relevant studies published since January 2000. The search terms used were: alcohol AND (army OR armed forces OR armed services OR veterans OR soldiers OR raf OR royal air force* OR military OR navy) AND (intervention OR prevention). The search was applied to include articles where search terms appeared in the title, abstract or keywords. The de-duplicate function was applied.
Inclusion criteria
- 1.
The
Study selection
The search identified 1487 abstracts. Screening of these resulted in the exclusion of 1389 abstracts which were not relevant, or which were literature reviews, with 98 abstracts remaining. The full texts were screened, resulting in the exclusion of a further 88 articles which did not meet the inclusion criteria. This resulted in a total number of 10 papers reporting data on 11 interventions that were included for systematic review (1 paper (Pemberton et al., 2011) reported data on 2 separate
Discussion
This systematic review identified a small number of studies (n = 10) that have investigated the efficacy of interventions (n = 11) targeted to alcohol consumption at a hazardous level in the military. A meta-analysis (of n = 8 studies, n = 9 interventions) showed no efficacy of brief alcohol interventions in terms of AWD. Only one of 11 interventions showed a significant effect, which was an intensive rather than brief alcohol intervention (Brief et al., 2013). The lack of efficacy persisted regardless
Conclusion
This review revealed a dearth of studies published in this area, particularly in serving military populations. Studies included in this review and meta-analysis used various alcohol measures, but using the comparable measure of AWDs, brief alcohol interventions in military and veteran populations were not efficacious. This study finds limited evidence that longer, more intensive interventions may be more helpful. Future research investigating the most suitable normative feedback for delivery of
Source role of funding
Nothing declared.
Contributors
LG and AD contributed to the conception and design of this study, AD, CM and LG conducted the data extraction, LG conducted the statistical analysis, AD and LG revised and drafted the article and all authors contributed to and approved the final draft.
Conflict of interest
None.
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