These interviews have identified considerable enthusiasm among stakeholders for the study. Some of the stakeholders saw it as their role to provide access to health promotion for their members/customers/employees. Others did not see it as their role but still thought that weight and alcohol consumption were problems that needed to be addressed. Not only were they willing to provide access to potential participants, many could provide rooms for delivery of the face-to-face component of the intervention. This augurs well for recruitment. The enthusiasm for the research is more than just altruism and a general willingness to help. It derives from a shared assessment of the scale of the public health problems posed by alcohol and by obesity. Furthermore, many of the organisations that were approached identified improving the health and well-being of their staff or their client group as a core value of their institution. This raises the possibility that, if the intervention proved effective, there could be opportunities for national roll-out through organisations that have similar
THE STAKEHOLDER INTERVIEWS
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core values. Naturally, there may be organisational obstacles that impede the progress of roll-out; however, the findings suggest that a possible approach could begin with discussions with senior staff in order to review shared values and the potential benefits arising from the intervention. This could lead to an evaluation of how the intervention could be implemented and an assessment of obstacles that would need to be overcome. A possible attraction for senior staff could be the low cost and time commitment of the intervention.
For the present study, the interviews have identified that although there may be many potential participants at some venues, accessing them may be difficult. Perceived lack of time may be the main issue. The
stakeholders thought that the men would not be annoyed by being approached, although this falls some way short of being receptive to the invitation to participate in a research study. Another potential
impediment is the preference of stakeholders to act as intermediaries in recruiting their staff. This could cause reluctance among staff to volunteer, as it could imply that they are overweight and drink too much. In summary, these interviews have identified an unexpected enthusiasm for the research. This may extend to the provision of support for recruitment and of rooms for conducting face-to-face sessions. In addition, if managed sensitively, there may be opportunities for national roll-out of an effective intervention.
Chapter 4 Designing the intervention
Background
The remit for this study included the design of an intervention that used the motivation of weight loss to promote reduced drinking. The study focused on men who were obese (BMI of> 30 kg/m2) and who drank> 21 units of alcohol per week. These men are at a 19-fold increased risk of mortality from liver disease because alcohol and obesity have a supra-additive effect on risk.1The rationale for the intervention is that alcohol is high in calories, and therefore reducing alcohol consumption could have a similar effect to eating less, thus reducing both risk factors at once. However, the logic of the health promotion message is complex. It takes the form of: if you take this action (drink less) then, because of this fact (alcohol is high in calories), you will get this benefit (consume fewer calories) and achieve that outcome (lose weight). The challenge is to deliver this logic in a form that is understood and that engages middle-aged men. This may be difficult, as the target group comprises men who are not seeking help, who do not think they have a drinking problem and who may well believe that they drink moderately.
The intervention was planned to involve a face-to-face session at which BMI (height and weight) would be measured and alcohol consumption would be assessed. This session would be delivered by trained laypeople (study co-ordinators). It was to be followed by a series of text messages developed using the techniques established in our previous NIHR funded studies (NIHR PHR 09/3001/09,39NIHR PHR 11/3050/3041).
Together, these components would deliver a complete strategy for behaviour change. Both components of the intervention drew heavily on the elements of effective brief alcohol interventions described in systematic reviews34,68and a review of reviews.35
The intervention was to be based on the causal model for behaviour change specified in the protocol, with modifications made in light of the findings from the focus groups. The initial causal model for behaviour change was (1) generate interest in the study, (2) increase awareness of consumption levels that are defined as harmful, (3) identify motivational beliefs, (4) increase awareness of susceptibility to alcohol-related harm for men who are already obese, (5) increase motivation to lose weight by reducing alcohol consumption, (6) alter alcohol expectancies, (7) gain commitment to change, (8) develop goals, action plans and coping plans, (9) increase refusal skills, (10) implement strategies to prevent relapse and (11) reduce total alcohol consumption, which would in turn lead to weight loss.
This chapter describes the rationale for the activities, discussions and behaviour change techniques that were incorporated into the face-to-face session and the subsequent series of text messages. Initially, several questions were identified:
l How should the causal model be modified by the focus group findings?
l How should the intervention be divided between the face-to-face session and the text messages?
l To what extent should the content of the text messages reinforce the face-to-face session?
Separate issues for the face-to-face session were how best to use the measurements of BMI and alcohol consumption in the intervention and what constraints would be imposed by the use of laypeople (study co-ordinators) to deliver the intervention. A further concern was how to design the intervention to overcome potential barriers to engagement and behaviour change.