Exploring the Teachable Moment for Alcohol Reduction in Breast Clinics: Formative Work to Inform Intervention Design, Development, Process Evaluation

The Chief Medical Officers have recently announced updates to the national alcohol guidelines reflecting new scientific evidence that risks of alcohol on health are dose-dependent, and there is no 'safe' level of alcohol consumption. There is now a need to increase public awareness of this recent evidence to all types of alcohol consumers, whether light or heavy drinkers, in order to reduce alcohol intake across the whole population. There is relatively little research as to whether providing alcohol brief interventions for moderate drinkers (who are still at increased risk of cancer including breast cancer) is either acceptable or feasible.
Evidence tends to show that patients and the wider public are both more receptive to health improvement advice and more open to make positive changes in their lifestyle when facing significant health events, for instance pregnancy or a visit to an Emergency Department, this has been described as 'readiness to change'. Many opportunistic brief interventions use these health service encounters to increase the effectiveness of public health advice.
We propose an early phase study to determine the information about alcohol needed by women attending these clinics, how tailored and supportive feedback can be provided, and what tools may help develop this into a long-term intrinsic motivation to reduce alcohol consumption. We propose to explore the acceptability and feasibility of an opportunistic alcohol brief intervention (ABI) delivered electronically to women during health care attendances related to breast cancer, when women maybe particularly alert to breast health initiatives. Every year, approximately 275,000 women in England are referred urgently to clinics for suspected breast cancer, and a further 4.4 million women take up a mammography as part of the NHS Breast Screening Programme. Our recent Cancer Research UK-funded pilot study found that less than 20% of women attending these appointments identified alcohol as a risk factor for breast cancer, despite now well-established evidence that this is the case.
The proposed formative work is driven by what women in clinics would find most useful and acceptable. It aims to identify the most appropriate means to empower women to better understand their own alcohol consumption, and the benefits of reduction, capitalising on the heightened receptivity provided by the context of breast clinic waiting areas. We will do this using a range of research methods (survey, semi structured interviews, and focus groups), the results of which will feed into each other to give us the most appropriate format to share alcohol risk information and health improvement advice that addresses women referred to these clinics information needs in a positive and empowering way. We will also explore the acceptability of spreading the ABI to the family and friends of participants, where appropriate.
Finally, we will test the prototype intervention with clinic attendees. Results will show whether enough patients engage with the intervention, accept and understand the advice, and ultimately feel a determination to act upon it. All these would confirm sufficient potential to justify a future main study assessing the efficacy of the intervention on alcohol reduction.

Existing research on alcohol brief interventions (ABI) has yet to examine the potential for suspected breast cancer clinics and breast screening mammography as a 'teachable moment'. We propose an early phase study to assess:
(i) women's information needs regarding effects of alcohol on cancer risk,
(ii) the nature of tailored feedback required, and
(iii) the potential of a digital ABI to develop alcohol awareness into a long-term intrinsic motivation to reduce alcohol consumption.
We will also investigate the potential to involve their social network, with the hypothesis that friends and family may also experience a 'teachable moment' due to the anxiety surrounding a suspected breast cancer referral or screening appointment.
Early phase work will finalise a comprehensive review of the literature on alcohol intervention and behaviour change techniques in health care settings and efficacy of digital lifestyle interventions, and complete our draft logic model, started in preparation for this application.
This knowledge will feed into a person-based approach to intervention development to involve patients in the design of an ABI. A continuous electronic clinic survey will measure determinants of readiness to change, intrinsic motivation, participants' demographic and clinical characteristics and level of alcohol consumption. Semi-structured interviews and focus groups will comment on currently available applications, and help design personalised feedback and optional web-based modules helping participants maintain awareness and motivation over time. Acceptability and feasibility will finally be measured in real-world conditions by testing the intervention prototype in clinics (using the LifeGuide digital behaviour change design software platform).
Patients, clinicians, public health specialists, and commissioners, will be involved throughout to co-create the planned intervention.