tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a...

Tobacco and alcohol-related interventions for peoplewith mild/moderate intellectual disabilities: a systematicreview of the literaturejir_1543 1..16

S. Kerr,1 M. Lawrence,1 C. Darbyshire,2 A. R. Middleton2 & L. Fitzsimmons3

1 Institute for Applied Health Research/School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK2 School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK3 Learning Disability Service (Child and Adolescent Mental Health), NHS Greater Glasgow & Clyde, Glasgow, UK

Abstract

Background The behavioural determinants ofhealth among people with mild/moderate intellec-tual disabilities (ID) are of increasing concern. Withthe closure of long-stay institutions, more peoplewith ID are living in the community. As they leadmore ordinary and less restricted lives, people withID may be exposed to social and environmentalpressures that encourage them to adopt behavioursthat impact negatively on their health. Levels ofsmoking and alcohol consumption in this clientgroup are of particular concern.Methods We undertook a mixed method review ofthe literature, aiming to assess the Feasibility, Appro-priateness, Meaningfulness and Effectiveness(FAME) of interventions designed to address theuse of tobacco and/or alcohol in people with mild/moderate ID. Key electronic databases weresearched (e.g. Medline, Cochrane Register of Con-trolled Trials, PsycINFO) from 1996 to 2011.Thesearch was developed using appropriate subject

headings and key words (e.g. intellectual disability,tobacco use, alcohol drinking, health promotion).On completion of the database searches, inclusion/exclusion criteria, based on an adaptation of thePICO framework (Population, Intervention, Com-parison, Outcomes), were applied. Methodologicalquality was assessed using a seven-point rating scale.Results Database searches identified 501 uniquerecords, of which nine satisfied the inclusion crite-ria. Four focused on tobacco, three on alcohol andtwo on both tobacco and alcohol. Located in theUK, the USA and Australia, the studies aimed toincrease knowledge levels and/or change behaviour(e.g. to encourage smoking cessation). One was arandomised controlled trial, one a quasi-experimentand the others were before and after studies and/orcase studies. Methodological quality was poor ormoderate. The combined studies had a sample sizeof 341, with ages ranging from 14 to 54 years. Theinterventions were delivered by professionals (e.g. inhealth, social care, education) during sessions thatspanned a period of three weeks to one academicyear. The studies highlighted a number of importantissues linked to the appropriateness of interventionsfor this client group (e.g. use of pictures, quizzes,role play, incentives); however, in the majority of

Correspondence: Dr Susan Kerr, Institute for Applied HealthResearch/School of Health & Life Sciences, Glasgow CaledonianUniversity, Cowcaddens Road, Glasgow G4 0BA, UK (e-mail:[email protected]).

Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2012.01543.x1

© 2012 The Authors. Journal of Intellectual Disability Research © 2012 Blackwell Publishing Ltd

cases the interventions appeared to lack a theoreti-cal framework (e.g. behaviour change theory). Theappropriateness of the outcome measures for usewith this client group was not tested. One studydiscussed feasibility (teachers delivering lessons onalcohol and tobacco) and only one was informativein terms of effectiveness i.e. increasing knowledge ofthe health and social dangers of smoking and exces-sive alcohol consumption.Conclusions This review is the first to systemati-cally collate evidence on tobacco and alcohol-related interventions for people with ID. While thereis currently little evidence to guide practice, thereview delivers clear insights for the development ofinterventions and presents a strong case for morerobust research methods. In particular there is aneed to test the effectiveness of interventions inlarge-scale, well-designed trials and to ensure thatoutcome measures are developed/tailored appropri-ately for this client group.

Keywords alcohol, health promotion, intellectualdisability, mixed methods review, smoking

Introduction

Epidemiological studies demonstrate that intellec-tual disability (ID) is a common condition world-wide (World Health Organisation 2007a). Reportedprevalence in the developed world ranges from 3 to30 per 1000 members of the population. Variationsin prevalence across countries are linked to differentmethods of case ascertainment, inclusion/exclusioncriteria and classification (Fujiura & Taylor 2003;Leonard et al. 2003; NHS Health Scotland 2004;Emerson & Hatton 2008; Søndenaa et al. 2010). InScotland, estimates suggest that 3–4 people in every1000 have a severe/profound ID and that 20 peoplein every 1000 have a mild/moderate ID (NHSHealth Scotland 2004).

While people with ID have an increased risk ofearly death, life expectancy is rising over time, andfor people with a mild ID, it is approaching thatof the general population (Patja et al. 2000; NHSHealth Scotland 2004; Emer Lavin et al. 2006;Emerson & Hatton 2008). Improvements in thehealth of people with ID are linked to advances inmedical science and an increase in proactive treat-ment; however, health problems in this client group,

as a whole, continue to be more common andcomplex than in the general population and somuch still needs to be accomplished to improvehealth and reduce inequalities (NHS Health Scot-land 2004; Robertson et al. 2010).

In recent years there has been increasing concernregarding behavioural determinants of healthamong people with ID (Emerson & Hatton 2008).With the closure of long-stay institutions, morepeople with ID are living in the community withsupport from their family and/or health and socialcare professionals (Department of Health 2001). Asthey lead more ordinary and less restricted lives,people with ID may be exposed to social and envi-ronmental pressures that encourage them to adoptbehaviours that impact negatively on their health(Emerson & Turnbull 2005; Taggart et al. 2008).

Smoking and excessive alcohol consumption havebeen identified as two of the most significant behav-ioural risks to health in the developed world (WorldHealth Organisation 2002). In England and Walesthe prevalence of smoking is currently 21% (Officefor National Statistics 2011); in Scotland it is 24.2%(Scottish Government 2011). Rates of smokingamong people with mild/moderate ID appear tobe similar to the general population (Emerson &Turnbull 2005).

The health-related consequences of smoking arewell established. Similar to the general population,people with ID who smoke have an increased risk ofdeveloping a range of health problems includingcancer, heart disease, chronic obstructive pulmonarydisease, circulatory problems, stroke and cognitivedecline (Royal College of Physicians 2000). Smokingalso exacerbates a number of conditions prevalentamong people with ID, such as diabetes (Meyer et al.2000; Royal College of Physicians 2000).

In terms of alcohol consumption, approximately26% of men and 18% of women in the generalpopulation in the UK regularly exceed the recom-mended weekly limits of 21 units for men and 14

units for women (Office for National Statistics2011). Binge drinking is common, particularly inyoung men (Office for National Statistics 2011).Alcohol consumption/excessive consumption inpeople with ID, is, in the main, lower than in thegeneral population (e.g. Emerson & Turnbull 2005;Taggart et al. 2006). However, levels of alcoholconsumption in people with mild ID appear to be

2Journal of Intellectual Disability Research

S. Kerr et al. • Tobacco and alcohol-related interventions


similar to those in the general population (McGilli-cuddy 2006).

Excessive alcohol consumption in people withmild/moderate ID presents a number of concerns,including risks to personal safety, interpersonal rela-tionships and physical and mental health (Taggartet al. 2008). More specifically, alcohol intoxicationleads to impaired judgement and risk taking, conse-quences of which may include accidental injury,unintended unprotected sex, offending behaviourand acts of violence (e.g. McGillivray & Moore2001; George et al. 2009; Taylor et al. 2010). Long-term health problems associated with persistentheavy drinking include skin and hair damage, circu-latory disorders, anaemia, cancer, gastric irritation,cardiac and cerebrovascular disease, neurologicaldisorders and liver disease (World Health Organisa-tion 2007b). Excessive alcohol consumption is alsoassociated with mental health problems, includingstress, anxiety and depression (World HealthOrganisation 2007b).

With the recent introduction in the UK of primarycare-based annual health checks for people with ID,greater efforts are now being made to identify andaddress the physical and mental health needs of thispopulation (Robertson et al. 2010; Royal College ofGeneral Practitioners 2010).While general practitio-ners and practice nurses are encouraged to ask aboutsmoking and alcohol consumption (Royal College ofGeneral Practitioners 2010), there is little evidenceregarding the accuracy of the information gathered.For example, issues relating to quantity, the strengthof alcoholic beverages and units of alcohol are par-ticularly difficult for people with ID to understand(Lawrence et al. 2009). Another important issue isthat while health checks have been shown to detectunmet needs and to prompt delivery of targetedinterventions, a recent systematic review of the effec-tiveness of health checks for people with ID high-lighted that few studies have explored the short,medium and long-term impact of interventions onhealth status and/or health-related behaviour (Rob-ertson et al. 2010).

Linked to the above, while generic evidence-based approaches exist to encourage and supportsmoking cessation attempts and the consumption ofalcohol at non-hazardous/harmful levels, studiesincluded in the systematic reviews that inform con-temporary Guidelines for practice have generally

excluded people with cognitive and/or communica-tion impairments (e.g. National Institute for Healthand Clinical Excellence 2006). Therefore, it cannotbe assumed that these generic approaches areappropriate for people with ID. Indeed, key policydocuments highlight the need to tailor interventionsfor this client group, taking into account specificcommunication and learning needs that may impacton health literacy (e.g. Disability Rights Commis-sion 2004; NHS Health Scotland 2004; Robertsonet al. 2010).

Our preliminary searches of the published litera-ture highlighted that evidence-based tobacco and/oralcohol-related health promotion interventions forpeople with ID are rare (Lawrence et al. 2009). Inresponse to this identified gap in the evidence-base,and guided by the Medical Research Council(MRC) framework for the development and evalua-tion of complex healthcare interventions (MRC2008), we are undertaking a programme of researchwhich aims to develop, implement and evaluatetobacco and alcohol-related health promotion inter-ventions for people with mild/moderate ID. In thedevelopmental phase (MRC 2008), we sought toexplore the current evidence base and to undertakeprimary research with key stakeholders, includingpeople with ID (Lawrence et al. 2009). This paperreports the results of our review of the evidencebase.

Aim

We undertook a mixed methods review of the litera-ture. Our aim was to assess the Feasibility, Appro-priateness, Meaningfulness and Effectiveness(FAME) of interventions designed to address theuse of tobacco and/or alcohol by people with mild/moderate ID. The FAME Model was developed bythe Joanna Briggs Institute (JBI) for Evidence-Based Healthcare to complement their inclusiveapproach to the categorisation, synthesis and imple-mentation of evidence (Pearson 2004; Pearson et al.2005). In this context, the term feasibility refers toevidence that demonstrates whether it is possible toimplement an activity or intervention within a givencontext (e.g. practice nurses delivering alcoholinterventions to people with ID). Appropriatenessrefers to evidence that demonstrates whether anactivity or intervention is ethically or culturally




appropriate. In this instance we assessed whetherthe interventions identified had been designed spe-cifically for people with ID. Meaningfulness refersto evidence that takes the form of participants’/professionals’ views and experiences of interven-tions, including their content and mode of delivery.Effectiveness is concerned with evaluating the effectsof interventions on specified outcomes, e.g. alcoholconsumption.

Methods

Search strategy

In August–September 2011, key electronic biblio-graphic databases were searched, includingMedline, the Cochrane Register of ControlledTrials, DARE, PsycINFO, CINAHL, ERIC andAMED. To identify any additional papers, we alsoscanned the reference lists of papers included in thereview.

The search was developed using subject headings(e.g. MeSH) and keywords, e.g. ‘intellectual dis-abilities’, ‘developmental disabilities’ ‘health promo-tion’, ‘behaviour change’, ‘tobacco use’, ‘smoking’,and ‘alcohol drinking’. Subject headings wereexploded, where appropriate, and standard symbolsused as wildcards, to truncate keywords and/or indi-cate proximity (e.g. intellectual disabilit*, behavio#rchange, smoking N3 cessation). The Medline searchis presented in Appendix 1. Other searches werebroadly similar; however, some revisions wererequired linked to minor differences in subjectheadings across databases and differences in thestandard search symbols across platforms (e.g.Ebsco and Ovid). The dates searched were 1996–2011, with the search being restricted to ‘Englishlanguage’. Each database was searched individually.RefWorks was used to manage the bibliographicrecords.

Inclusion/exclusion criteria

Following completion of the database searches,the titles and abstracts of identified papers werescreened for inclusion. At this stage, broad inclusion/exclusion criteria were applied, and papers wereincluded if they had a focus on tobacco and/oralcohol use in people with ID. In the next stage, we

applied narrow inclusion/exclusion criteria, whichwere produced using an adaptation of the PICO(Population, Interventions, Comparison, Outcomes)framework i.e. SPIO (Study design, Population,Interventions, Outcomes) (Table 1) ( Joanna BriggsInstitute 2008).Where insufficient detail was pro-vided in the abstract, the full text was retrieved toenable an informed judgement regarding inclusion/exclusion.Two members of the review team (CDand SK) applied the SPIO inclusion/exclusion crite-ria independently.The researchers then met todiscuss any discrepancies and reach consensus. Athird reviewer (ML) was asked to provide an addi-tional opinion, as required.

Methodological appraisal

To assess the quality of the studies, we used arevised version of a seven-point rating scaledesigned to enable synthesis of diverse sources ofevidence (Popay 2006). Studies were assessed inrelation to (1) design; (2) clarity of aims and objec-tives; (3) sampling; (4) description of the interven-tion (including theoretical underpinnings) and anycomparator/control interventions; (5) data collectionand analysis; (6) reliability/validity/rigour; (7)presentation/interpretation of the results/findings.Details of the ‘study design’ and ‘the descriptionof the intervention’, as discussed above, replacedPopay’s assessment of the ‘supporting literature’and the ‘context in which the studies were set’. Onepoint was awarded for each of the seven areas if theissues had been addressed in a manner that wasjudged as satisfactory, no points were awarded if theprocedures used were unclear, poorly addressedand/or open to bias (e.g. the sampling strategy).The possible range of scores was, therefore, 0–7.Studies scoring six or more were rated as good,scores of 4–5 were considered to be of moderatequality and studies scoring three or less were ratedas poor. As is common in mixed method reviews,no papers were excluded on the grounds of quality(Garcia et al. 2002; Harden 2006).

Data extraction and synthesis

Following application of the narrow inclusion/exclusion criteria, data were extracted from thepapers remaining in the review. A review-specific




data extraction tool was developed. Two reviewers(CD, SK) undertook data extraction for each paperindependently. Initially there were a small numberof discrepancies regarding extracted data; however,these were easily resolved following discussion. Thedata extracted are compiled in an evidence table(Table 2) and are synthesised and summarisedbelow. Meta-analysis was not possible because ofdesign issues (most were before and after studieswith no control group), heterogeneity and limita-tions associated with reporting of the results. Alack of qualitative papers/findings also precludedmeta-synthesis.

Results

Searches and inclusion/exclusion of papers

Database searches identified 501 unique papers(once 149 duplicates had been removed) (Fig. 1).Following application of the broad inclusion/

exclusion criteria, 421 papers were excluded. Com-monly, papers were excluded because they focusedon foetal alcohol syndrome. SPIO inclusion/exclusion criteria were then applied to the remain-ing 80 papers, with 72 being excluded. The mainreason for exclusion at this stage was because thepapers did not report on interventions (e.g. theydiscussed prevalence of smoking or alcohol con-sumption in people with ID). A scan of the refer-ence lists of the papers at this point identified oneadditional paper, resulting in a total of nine papersthat met the SPIO inclusion criteria. These paperswere subject to quality appraisal and data extractionprocesses.

Summary of the papers reviewed

Four papers focused on tobacco-related interven-tions (Kelman et al. 1997; Tracy & Hosken 1997;Chester et al. 2011; Singh et al. 2011), three onalcohol-related interventions (Forbat 1999; Mendel

Table 1 SPIO (Study design, Population,Interventions, Outcomes) frameworkInclude Exclude

Study design Randomised controlled trials,quasi-experiments, before andafter studies, cohort studies,feasibility studies, exploratorytrials, qualitative studies

Discussion papers, surveys

Population People with a mild/moderatelearning disability

People with a severe orprofound learning disability

Intervention Information/advice, education,brief interventions, intensiveinterventions, group support,other psychologicalinterventions, pharmacologicalinterventions (e.g. nicotinereplacement therapy) relatingto tobacco and/or alcohol

Interventions that did notinclude at least one lifestylecomponent (i.e. alcohol ortobacco)

Outcomes Tobacco: carbon monoxidelevels, cotinine levels,self-reported consumption,health-related quality of life,knowledge, attitudes

Alcohol: biological markers(e.g. gamma-glutamyltransferase), self-reportedconsumption, health-relatedquality of life, knowledge,attitudes

Outcomes relating to otherlifestyle behaviours includingweight management, diet andphysical activity




Tabl

e2

Stu

dies

incl

uded

inth

ere

view

(n=

9)

Aut

hors

,aim

,Qua

lity

Rat

ing

(QR

)D

esig

n+

sam

ple

Inte

rven

tio

nM

etho

dsR

esul

ts/fi

ndin

gs

Sm

oki

ngpr

even

tio

n/ce

ssat

ion

inte

rven

tio

nsS

ingh

etal

.(20

11)

US

AA

imto

asse

ssth

eef

fect

iven

ess

ofa

min

dful

ness

-bas

edsm

okin

gce

ssat

ion

prog

ram

me

for

peop

lew

ith

IDQ

R:

3

Cas

est

udy

Com

mun

ity-b

ased

grou

pho

me

n=

1N

oco

ntro

lgro

upSm

oker

Age

:31

year

sM

ale

Trai

ning

invo

lved

(1)

inte

ntio

n;(2

)m

indf

ulob

serv

atio

nof

thou

ghts

;(3)

med

itatio

non

the

sole

sof

the

feet

.Tau

ght

tech

niqu

es3

mon

ths

ahea

dof

quit

atte

mpt

,‘top

-up’

sess

ions

infir

st12

mon

ths

afte

rqu

ittin

gA

imto

redu

ceci

gare

ttes

by1

ever

ytim

eab

leto

mai

ntai

npr

evio

usnu

mbe

rfo

r3

days

Inte

rven

tion

last

ed82

days

(12-

0ci

gare

ttes

)

Logg

ednu

mbe

rof

ciga

rett

essm

oked

Part

icip

ant

kept

log,

staf

fal

som

onito

red

ciga

rett

eco

nsum

ptio

nD

ata

colle

cted

:dai

lydu

ring

inte

rven

tion

peri

od;f

ollo

w-u

pat

12m

onth

san

d3

year

sA

naly

sis:

Basi

cde

scri

ptiv

est

atis

tics

(freq

uenc

ies)

12ci

gare

ttes

/day

atba

selin

eR

educ

edin

ast

epw

ise

man

ner

until

0/da

y.D

urat

ion

82da

ysD

idno

tsm

oke

duri

ngth

e12

-mon

thm

aint

enan

cepe

riod

orin

3-ye

arfo

llow

-up

peri

od

Che

ster

etal

.(20

11)

Eng

land

,U

KA

imto

esta

blis

hth

epr

eval

ence

ofsm

okin

gan

dde

scri

beth

eef

fect

ofa

smok

ing

cess

atio

npr

ogra

mm

efo

rpe

ople

wit

hID

QR

:3

Aud

itFo

rens

icin

patie

ntun

it(lo

wse

cure

,med

ium

secu

rean

dre

habi

litat

ion)

n=

79N

oco

ntro

lgro

up48

/79

smok

ers

onad

mis

sion

Age

:Not

repo

rted

53m

en,2

6w

omen

1-to

-1he

alth

info

rmat

ion

from

nam

ednu

rse

Gro

upse

ssio

nsdi

dno

tre

lyhe

avily

onlit

erac

yor

abst

ract

thin

king

incl

uded

disc

ussi

ons,

quiz

zes,

vide

os,p

ictu

res.

7w

eekl

yse

ssio

nsPa

tient

sal

soen

cour

aged

toob

tain

rele

vant

leafl

ets

from

aG

Pan

dco

uld

mak

eap

poin

tmen

tsw

itha

cess

atio

nnu

rse;

nico

tine

repl

acem

ent

ther

apy

(NRT

)pr

ovid

edif

suita

ble

Smok

ing

timet

able

:num

ber

ofci

gare

ttes

smok

edre

stri

cted

to1

per

hour

duri

ngw

akin

gho

urs

Dat

aga

ther

edby

4nu

rses

from

case

note

s,pa

tient

san

dch

arge

nurs

esov

era

1-w

eek

peri

odD

ata

colle

cted

:ret

rosp

ectiv

ely,

peri

odbe

twee

nad

mis

sion

and

the

poin

tof

data

colle

ctio

nas

sess

edA

naly

sis:

Basi

cde

scri

ptiv

est

atis

tics

+ch

i-squ

ared

anal

ysis

for

cate

gori

calv

aria

bles

and

t-te

sts

for

cont

inuo

usva

riab

les

29/4

8ba

selin

esm

oker

sat

tem

pted

tost

op;

15w

ere

succ

essf

ulPr

opor

tion

ofpa

tient

ssm

okin

gfo

llow

ing

expo

sure

toth

ece

ssat

ion

prog

ram

me

drop

ped

sign

ifica

ntly

Mal

esm

oker

sm

ore

likel

yto

have

quit

(P<

0.05

)Pa

tient

sin

low

secu

rew

ards

mor

elik

ely

toha

vequ

itth

anpa

tient

sin

med

ium

secu

rew

ards

(P<

0.05

)

Kel

man

etal

.(19

97)

Scot

land

,UK

Aim

toas

sess

the

effe

ctiv

enes

sof

ahe

alth

educ

atio

npr

ogra

mm

efo

rpe

ople

with

IDQ

R:

2

Befo

rean

daf

ter

stud

yR

ecru

ited

from

adul

ttr

aini

ngce

ntre

n=

5N

oco

ntro

lgro

up2

smok

ers

+3

non-

smok

ers

Age

:26–

40ye

ars

2m

en,3

wom

en

Focu

son

harm

fulp

hysi

cal,

soci

alan

dfin

anci

alco

nseq

uenc

esof

smok

ing

and

bene

fits

ofbe

ing

ano

n-sm

oker

Rol

epl

ay,v

ideo

s,qu

izze

s7

wee

kly

grou

pse

ssio

nsD

eliv

ered

bytr

aini

ngce

ntre

staf

f

Que

stio

nnai

re:t

oas

sess

know

ledg

eof

smok

ing

Dat

aco

llect

ed:b

asel

ine,

1w

eek

(Tim

e2)

and

3m

onth

s(T

ime

3)af

ter

the

heal

thed

ucat

ion

prog

ram

me

Pote

ntia

lsco

ring

rang

e0–

40A

naly

sis:

Basi

cde

scri

ptiv

est

atis

tics

Base

line

scor

es:r

ange

dfr

om15

to33

Tim

e3

scor

es:r

ange

dfr

om28

to37

Base

line

toT

ime

2:K

now

ledg

ele

vels

inal

l5

part

icip

ants

incr

ease

dT

ime

2–T

ime

3:Sc

ores

dipp

edbu

tkn

owle

dge

incr

ease

was

mai

ntai

ned

com

pare

dw

ithBa

selin

e

Tra

cy&

Ho

sken

(199

7)A

ustr

alia

Aim

tode

sign

and

test

asm

okin

ged

ucat

iona

lcou

rse

for

peop

lew

ithID

QR

:2

Befo

rean

daf

ter

stud

yR

ecru

ited

from

tert

iary

educ

atio

nfa

cilit

yn

=11

No

cont

rolg

roup

All

wer

esm

oker

sA

ge:<

25ye

ars

8m

en,3

wom

en

Mod

ified

vers

ion

ofan

esta

blis

hed

gene

ric

smok

ing

cess

atio

npr

ogra

mm

eG

roup

disc

ussi

ons,

vide

os,r

ole

play

,boa

rdga

mes

,inc

entiv

es(p

ens,

badg

es,

cert

ifica

tes)

7w

eekl

ygr

oup

sess

ions

Unc

lear

who

deliv

ered

the

inte

rven

tion

Que

stio

nnai

re:t

oas

sess

smok

ing

habi

ts,

know

ledg

ean

din

tere

stin

stop

ping

Dat

aco

llect

ed:b

asel

ine

and

end

ofco

urse

Pote

ntia

lran

geof

scor

esno

tre

port

edA

naly

sis:

Basi

cde

scri

ptiv

est

atis

tics

n=

3st

oppe

d,3

cut

dow

n5

peop

leex

pres

sed

ade

sire

toqu

itat

the

star

tof

the

cour

se,9

expr

esse

da

desi

reto

quit

atth

een

d(in

clud

ing

thos

ew

hoha

dqu

it)K

now

ledg

ele

vels

:inc

reas

ed(n

osc

ores

prov

ided

)




Alc

oho

l-re

late

din

terv

enti

ons

Ste

el&

Rit

chie

(200

4)Sc

otla

nd,U

KA

imto

expl

ore

pote

ntia

lof

aps

ycho

-edu

catio

nala

ppro

ach

toin

crea

sekn

owle

dge

and

mot

ivat

ion

toch

ange

beha

viou

rQ

R:

3

Cas

est

udy

Rec

ruite

dfr

omse

cure

acco

mm

odat

ion

n=

1N

oco

ntro

lgro

upH

arm

fuld

rink

erA

ge:2

3ye

ars

Mal

e,no

rmal

lyliv

esat

hom

ew

ithpa

rent

s

Info

rmat

ion

on:t

heef

fect

sof

alco

hol;

alco

hola

ndth

ela

w;s

ensi

ble

drin

king

;w

hat

influ

ence

sal

coho

luse

;ph

ysic

al+

psyc

holo

gica

ldep

ende

nce;

subs

tanc

eus

ean

dm

enta

lhea

lth;h

ealth

issu

esM

otiv

atio

nali

nter

view

ing

tech

niqu

es,

hom

ewor

k,m

odifi

edha

ndou

ts12

wee

kly

sess

ions

of40

min

(thi

sin

clud

edse

ssio

nson

drug

use)

;unc

lear

who

deliv

ered

Kno

wle

dge

ques

tionn

aire

,20

alco

hol-

rela

ted

ques

tions

,with

true

/fals

ere

spon

ses

Dat

aco

llect

ed:b

asel

ine

and

post

-in

terv

entio

n;po

tent

ialr

ange

ofsc

ores

0–20

Ana

lysi

s:Ba

sic

desc

ript

ive

stat

istic

s

Alc

ohol

-rel

ated

know

ledg

ele

velr

ose

from

8at

base

line

to14

atth

een

dof

the

12-w

eek

cour

sePa

rtic

ipan

tw

illin

gto

enga

gebu

tea

sily

dist

ract

ed,u

nder

took

hom

ewor

k

Men

del

&H

ipki

ns(2

002)

Engl

and,

UK

Aim

tous

em

otiv

atio

nali

nter

view

ing

toas

sist

clie

nts

inm

ovin

gth

roug

hth

eSt

ages

ofC

hang

epr

oces

sQ

R:

4

Befo

rean

daf

ter

stud

yR

ecru

ited

from

med

ium

secu

reac

com

mod

atio

nn

=7

No

cont

rolg

roup

All

had

alco

holp

robl

ems

Age

:18–

54ye

ars

All

men

Alc

ohol

Aw

aren

ess

Cou

rse

aim

edto

:pr

ovid

ein

form

atio

non

alco

hol;

enco

urag

eth

ede

velo

pmen

tof

lear

ning

skill

s;he

lpth

epa

rtic

ipan

tsm

ake

info

rmed

choi

ces

rega

rdin

gal

coho

lco

nsum

ptio

nM

otiv

atio

nali

nter

view

ing,

inte

ract

ive

sess

ions

,gro

upex

erci

ses,

visu

alai

ds,

case

vign

ette

s,re

fere

nces

toce

lebr

ities

3¥

1h

sess

ions

over

a2-

wee

kpe

riod

;de

liver

edby

2tr

aine

ecl

inic

alps

ycho

logi

sts

+2

supp

ort

wor

kers

CA

GE:

4-ite

mm

easu

re,a

sses

ses

quan

tity

+fr

eque

ncy

ofal

coho

lco

nsum

ptio

n;no

deta

ilsof

scor

ing

Alc

ohol

Rel

ated

Prob

lem

sQ

uest

ionn

aire

:ch

eckl

ist

toas

sess

rela

tions

hip

betw

een

drin

king

+pr

oble

ms

caus

ed,n

ode

tails

ofsc

orin

gR

eadi

ness

toC

hang

eQ

uest

ionn

aire

:12

-item

mea

sure

;no

deta

ilsof

scor

ing

Ana

lysi

s:Ba

sic

desc

ript

ive

stat

istic

s

CA

GE

(use

dat

base

line

only

):ra

nge

12–2

88un

its/w

eek;

mea

n=

101

(pri

orto

adm

issi

onto

secu

reun

it–

relie

don

retr

ospe

ctiv

em

emor

y)A

lcoh

olR

elat

edPr

oble

ms

(use

dat

base

line

only

):6

ofth

e7

part

icip

ants

iden

tified

prob

lem

sw

ithth

eir

drin

king

prio

rto

adm

issi

one.

g.ag

gres

sion

,tro

uble

with

polic

eR

eadi

ness

toC

hang

e:T

1(b

asel

ine)

:pr

e-co

ntem

plat

ors

n=

2;co

ntem

plat

ors

n=

5;ac

tion

n=

0;T

2(e

ndof

cour

se):

pre-

cont

empl

ator

sn

=1;

cont

empl

ator

sn

=1;

actio

nn

=5

Forb

at(1

999)

Eng

land

,U

KA

imto

pilo

tan

alco

hol

awar

enes

sco

urse

for

peop

lew

ith

IDQ

R:

1

Befo

rean

daf

ter

stud

yR

ecru

ited

from

am

ediu

mse

cure

unit

n=

5N

oco

ntro

lgro

upN

ode

mog

raph

icin

form

atio

npr

ovid

ed.

Part

icip

ants

appe

ared

toha

velim

ited

expe

rien

ceof

alco

hol

Con

tent

focu

sed

on:w

here

/why

/wha

tpe

ople

drin

k;th

ela

wan

dal

coho

l;st

reng

thof

diffe

rent

drin

ks/u

nits

;ph

ysic

al,e

mot

iona

land

beha

viou

ral

effe

cts;

attit

udes

;pro

blem

drin

king

;in

divi

dual

drin

king

plan

sQ

uizz

es,g

roup

disc

ussi

on,d

iagr

ams,

vide

os,

vign

ette

s;3

faci

litat

ors

8w

eekl

ygr

oup

sess

ions

(2h)

,inc

ludi

nga

trip

toth

epu

b

Kno

wle

dge

alon

eas

sess

ed.N

otcl

ear

how

info

rmat

ion

was

gath

ered

.Pos

sibl

era

nge

ofsc

ores

0–30

Dat

aco

llect

ed:b

asel

ine,

atth

een

dof

the

inte

rven

tion

and

6m

onth

spo

st-in

terv

entio

nA

naly

sis:

Basi

cde

scri

ptiv

est

atis

tics

Kno

wle

dge

ofal

l5pa

rtic

ipan

tsro

seat

the

end

ofth

ein

terv

entio

n,it

cont

inue

dto

rise

in2

ofth

epa

rtic

ipan

ts6

mon

ths

post

-inte

rven

tion

and

fell

in3

ofth

epa

rtic

ipan

tsM

ean

scor

eat

base

line

21.5

(ran

ge16

–24)

Mea

nsc

ore

post

-inte

rven

tion

25.3

(ran

ge22

.5–2

7.5)

Mea

nsc

ore

at6

mon

ths

25.4

(ran

ge23

–27.

5)




Tabl

e2

Con

tinue

d

Aut

hors

,aim

,Qua

lity

Rat

ing

(QR

)D

esig

n+

sam

ple

Inte

rven

tio

nM

etho

dsR

esul

ts/fi

ndin

gs

Toba

cco

and

alco

hol

inte

rven

tio

nsL

inds

ayet

al.(

1998

)S

cotl

and,

UK

Aim

tode

velo

pan

dev

alua

tem

ater

ials

tom

ake

peop

lew

ith

IDaw

are

ofhe

alth

and

soci

alda

nger

sof

smok

ing

and

the

abus

eof

alco

hol

QR

:5

RC

TR

ecru

ited

from

are

sour

cece

ntre

and

aho

spita

lfor

peop

lew

ithID

Smok

ing:

n=

48,3

grou

psof

16;

inte

rven

tion

grou

p,no

trea

tmen

tco

ntro

l,co

ntro

lgro

upth

atre

ceiv

eda

leafl

etA

lcoh

ol:n

=46

,2gr

oups

of23

;int

erve

ntio

ngr

oup,

notr

eatm

ent

cont

rol

Ran

dom

allo

catio

nto

grou

psIn

terv

entio

nan

dco

ntro

lgro

ups

sim

ilar

inag

ean

dse

xan

dnu

mbe

rsw

hosm

oked

and

drun

kal

coho

lN

oot

her

deta

ilspr

ovid

ed

Smok

ing:

wha

tis

smok

ing;

why

peop

lesm

oke;

shor

tan

dlo

ng-t

erm

effe

cts;

pass

ive

smok

ing;

cost

;way

sof

refu

sing

Alc

ohol

:why

peop

ledr

ink;

whe

nis

drin

king

appr

opri

ate;

drun

kenn

ess;

effe

cts

ofal

coho

l,de

sign

erri

nks,

stre

ngth

ofal

coho

l,se

nsib

ledr

inki

ng,e

ffect

son

heal

th,s

ocia

lhaz

ards

ofdr

inki

ngFa

ctsh

eets

,illu

stra

tions

/car

toon

s,te

amga

mes

,rol

epl

ay,q

uizz

es,d

iscu

ssio

n,de

mon

stra

tions

Part

icip

ants

taug

htin

grou

psof

5–6

by1

trai

ner;

8se

ssio

ns(e

ach

topi

c)

Que

stio

nnai

re:4

2ite

mad

min

iste

red

byR

esea

rch

Ass

ista

nt.R

ange

ofsc

ores

0–42

Dat

aco

llect

ed:b

asel

ine,

onco

mpl

etio

nof

the

8-w

eek

inte

rven

tion

+3-

mon

thpo

st-in

terv

entio

nA

naly

sis:

desc

ript

ive

stat

istic

s+

two

way

anal

ysis

ofva

rian

ce( A

NO

VA).

Whe

nap

prop

riat

e,se

lect

edpa

irs

com

pare

dus

ing

Tuke

y’s

pair

wis

eco

mpa

riso

n

Gro

ups

sim

ilar

atba

selin

eSm

okin

g:di

ffere

nces

post

-inte

rven

tion,

trea

tmen

tgr

oup

diffe

red

sign

ifica

ntly

from

cont

rolg

roup

s(P

<0.

01).

Mea

nsc

ore

inth

etr

eatm

ent

grou

p30

.9at

3m

onth

s,19

.9in

no-t

reat

men

tco

ntro

l,19

.6in

leafl

etco

ntro

lA

lcoh

ol:S

igni

fican

tdi

ffere

nces

inth

e2

grou

pspo

st-in

terv

entio

n(P

<0.

00).

At

3m

onth

sm

ean

scor

ein

the

trea

tmen

tgr

oup

22.7

,10.

3in

the

notr

eatm

ent

cont

rol

Dem

ers

etal

.(20

00)

USA

Aim

toev

alua

tea

prog

ram

me

(PA

LS)

toad

dres

sth

esu

bsta

nce

use/

prev

entio

nne

eds

ofsc

hool

-age

dst

uden

tsw

ithsp

ecia

ledu

catio

naln

eeds

QR

:3

Qua

si-e

xper

imen

t(p

relim

inar

yev

alua

tion)

Rec

ruite

dfr

om6

scho

ols

n=

13te

ache

rs;n

=13

8st

uden

tsIn

terv

entio

ngr

oup:

3sc

hool

s,6

teac

hers

,65

stud

ents

Con

trol

grou

p:3

scho

ols;

7te

ache

rs;7

3ch

ildre

nA

ge:1

4–17

year

sM

enan

dw

omen

(num

bers

not

prov

ided

)D

emog

raph

ics

ofst

uden

tsin

inte

rven

tion

and

cont

rolg

roup

ssa

idto

besi

mila

r

Teac

hers

taug

htto

adap

tex

istin

ghe

alth

prom

otio

nm

essa

ges

for

child

ren

with

spec

iale

duca

tiona

lnee

ds.1

-day

trai

ning

+bo

oste

rse

ssio

nsov

er1

year

Prog

ram

me

focu

sed

onda

nger

sof

alco

hol

and

toba

cco,

resi

stin

gpe

erpr

essu

re;

avoi

ding

part

icul

ar‘r

isky

’situ

atio

ns,

deal

ing

with

stre

ss5

less

ons

deliv

ered

duri

ngcl

ass

time;

teac

hers

also

enco

urag

edto

take

adva

ntag

eof

‘teac

habl

e’m

omen

ts’;

noot

her

deta

ilspr

ovid

ed

Teac

hers

com

plet

edqu

estio

nnai

reon

usef

ulne

ssof

trai

ning

+ho

wof

ten

prov

ided

prev

entio

nm

essa

ges.

Dat

aco

llect

edat

base

line,

post

-tra

inin

gan

den

dof

acad

emic

year

Que

stio

nnai

reus

edto

dete

rmin

e:if

stud

ents

ever

used

alco

hola

ndto

bacc

o(A

&T

);us

eof

A&

Tin

last

30da

ys;i

nten

tto

use

A&

Tin

futu

re;p

erce

ptio

nof

harm

from

A&

T;pe

erpr

essu

rere

latin

gto

A&

T;se

lf-im

age;

port

raya

lof

best

frie

nds’

use

ofA

&T

(7cr

iteri

a).P

oten

tialr

ange

ofsc

ores

not

prov

ided

Dat

aco

llect

ed:b

asel

ine

(T1)

,win

ter

brea

k(T

2),e

ndof

scho

olye

ar(T

3)D

escr

iptiv

ean

din

fere

ntia

lsta

tistic

s:ch

i-squ

are

+M

ann–

Whi

tney

U-t

est

Teac

hers

unan

imou

sly

expr

esse

dsu

ppor

tfo

rth

epr

ogra

mm

e,st

atin

gth

atth

eyw

ere

disc

ussi

ngA

&T

ona

regu

lar

basi

s(w

eekl

y)fo

llow

ing

trai

ning

and

thro

ugho

utth

eac

adem

icye

arN

oin

form

atio

npr

ovid

edon

teac

hers

from

the

‘con

trol

’sch

ools

Res

ults

dem

onst

rate

leve

lsof

smok

ing

and

alco

holc

onsu

mpt

ion

inth

ePA

LSsc

hool

sw

ere

sim

ilar

toco

ntro

lsch

ools

atba

selin

eO

nal

l7cr

iteri

ath

epe

rfor

man

ceof

the

stud

ents

inth

ein

terv

entio

nsc

hool

s,at

the

end

ofth

esc

hool

year

,was

high

eror

mor

epo

sitiv

eth

anst

uden

tsin

the

cont

rols

choo

ls.R

esul

tsw

ere

not

stat

istic

ally

sign

ifica

nt

GP,

gene

ral

prac

titi

oner

;ID

,in

telle

ctua

ldi

sabi

lity;

RC

T,

rand

omis

edco

ntro

lled

tria

l.




& Hipkins 2002; Steel & Ritchie 2004), and two oninterventions designed to address both tobacco andalcohol (Lindsay et al. 1998; Demers et al. 2000).

Methodological quality

The methodological quality of the studies wasassessed using the adaptation of Popay’s (2006)rating scale; all papers were judged as being of pooror moderate quality (Table 2). The quality of thefour tobacco-related papers was poor (Kelman et al.1997; Tracy & Hosken 1997; Chester et al. 2011;Singh et al. 2011). Lindsay et al.’s (1998) tobaccoand alcohol-related study scored highest (i.e. 5/7).

Geographical spread

Two of the tobacco-related studies were undertakenin the UK (Kelman et al. 1997; Chester et al. 2011),one in the USA (Singh et al. 2011) and one in Aus-tralia (Tracy & Hosken 1997). The three alcohol-related studies were undertaken in the UK (Forbat1999; Mendel & Hipkins 2002; Steel & Ritchie

2004). One of the studies that focused on bothtobacco and alcohol was conducted in the USA(Demers et al. 2000), the other in Scotland(Lindsay et al. 1998).

Aims

One of the tobacco-related studies aimed toincrease knowledge levels linked to physical, socialand financial consequences of smoking (Kelmanet al. 1997). The others sought to encourage cessa-tion attempts (Tracy & Hosken 1997; Chester et al.2011; Singh et al. 2011). The alcohol-related studiesaimed to increase knowledge and motivation tochange behaviour (Forbat 1999; Steel & Ritchie2004) and to increase clients’ readiness to change(Mendel & Hipkins 2002). Demers et al. (2000)aimed to evaluate a school-based health educationprogramme designed to address/prevent the use oftobacco and alcohol in 14–17-year-olds. Lindsayet al.’s (1998) study sought to increase knowledgelevels linked to the health and social dangers ofsmoking and excessive alcohol consumption.

Stage 1650 potentially relevant papers

identified

421 papers excluded after review of the abstracts

Stage 2501 abstracts reviewed, with broad

inclusion/exclusion criteria being applied

Stage 380 abstracts/papers reviewed with narrow (SPIO) inclusion/exclusion

criteria being applied72 papers excluded after review of the

abstracts/papers

Stage 48 papers included in the review.

Reference lists scanned for additional appropriate papers.

1 paper added

Stage 59 papers included in the review

4 tobacco-related interventions

3 alcohol-related interventions

2 tobacco & alcohol-related interventions

149 duplicates removed

Figure 1 Search results and selectionof papers.




Design of the studies

The studies that focused on both tobacco andalcohol were strongest in terms of research designi.e. Lindsay et al. (1998) conducted a randomisedcontrolled trial and Demers et al. (2000) a quasi-experiment. Otherwise, three of the studies used acase-study approach [Singh et al. 2011 (tobacco);Kelman et al. 1997 (tobacco); Steel & Ritchie 2004

(alcohol)], three were before and after studies[Mendel & Hipkins 2002 (alcohol); Forbat 1999

(tobacco); Tracy & Hosken 1997 (tobacco)] andone was an audit [Chester et al. 2011 (tobacco)].Four studies were also described as pilot studies/preliminary evaluations (Tracy & Hosken 1997;Forbat 1999; Demers et al. 2000; Mendel & Hipkins2002). No qualitative studies were identified.

Recruitment/sampling

The total number of participants with mild/moderate ID across the nine studies was 341. Littledetail was provided regarding recruitment/sampling.Only two of the nine studies reported control/comparator groups (Lindsay et al. 1998; Demerset al. 2000) and only Lindsay et al. (1998) randomlyallocated participants to groups. The ages of theparticipants ranged from 14 to 54 years (Table 2).

The interventions

Three of the four tobacco-related interventionssought to increase knowledge levels. They deliveredthe interventions in a group format over 7 weeks(Kelman et al. 1997; Tracy & Hosken 1997; Chesteret al. 2011). A number of standard educationalapproaches were adopted in the three studies,including group discussions, quizzes, videos, boardgames, and visual prompts. Participants wereencouraged to be actively involved, and role playwas used to reinforce new ideas and to workthrough problem-solving scenarios. Positive rein-forcement was used (e.g. badges) following particu-lar tasks. No educational or behaviour changetheories were discussed. The tobacco-related inter-vention discussed in Singh et al. (2011) aimed tosupport a cessation attempt. It was delivered on aone-to-one basis over a period of 82 days and useda ‘mindfulness’ approach (described as a form ofmeditation).

Two of the alcohol-related interventions aimed toincrease levels of motivation to change behaviour(Mendel & Hipkins 2002; Steel & Ritchie 2004),with Steel & Ritchie (2004) also seeking to increaseknowledge levels. The one-to-one interventiondeveloped by Steel & Ritchie (2004) was deliveredweekly for 12 weeks. Six sessions focused on alcoholconsumption; the remainder focused on illicitdrugs. Motivational interviewing techniques, asdescribed by Miller & Rollnick (1991), were used inthis study. Mendel & Hipkins (2002) ran group ses-sions over a period of 2 weeks (three sessions), withmotivational interviewing also being used, in addi-tion to visual aids and vignettes. Forbat (1999)aimed to increase knowledge levels. Group sessionsran over a period of 8 weeks, with quizzes, groupdiscussions, videos and vignettes being used.

Lindsay et al.’s (1998) intervention sought toincrease tobacco and alcohol-related knowledge.Small group sessions ran over a period of 8 weeksthat incorporated discussions, fact sheets, cartoons,team games and quizzes. The school-based pro-gramme developed by Demers et al. (2000) aimedto equip the children with attitudes/skills that wouldhelp them resist peer pressure. It ran throughoutone academic year and was delivered by teachers.The programme included five planned lessons; inaddition, teachers were encouraged to take advan-tage of ‘teachable’ moments if a child raised anissue about smoking and/or alcohol during anotherlesson.

Data collection and analysis

Two of the tobacco-related studies used question-naires to collect data (Kelman et al. 1997; Tracy &Hosken 1997). Singh et al. (2011) used a log bookand Chester et al. (2011) used an audit tool. Thereliability and validity of the data collection toolswere not discussed and there was no attempt todetermine smoking status objectively (e.g. by mea-suring levels of expired carbon monoxide or salivarycotinine). Singh et al. (2011) followed their one par-ticipant up for a period of 3 years. All four studiesused descriptive statistics to report results, Chesteret al. (2011) using chi-squared analysis and t-tests tomake comparisons across groups.

The three alcohol-related studies used question-naires to collect data. Steel & Ritchie (2004) and




Forbat (1999) developed a questionnaire, based onthe content of their educational programmes.Mendel & Hipkins (2002) used instruments whichhad not been validated for use with people with IDi.e. CAGE (Mayfield & McLeod 1974) and theReadiness to Change Questionnaire (Rollnick et al.1992). Basic descriptive statistics appear to havebeen undertaken; however, little detail is provided.

The two studies that focused on tobacco andalcohol (Lindsay et al. 1998; Demers et al. 2000)developed their own data collection instruments(questionnaires) which were not assessed for reli-ability and/or validity. Lindsay et al. (1998) high-lighted that data collection was not always ‘blind’ asparticipants sometimes inadvertently disclosed theirgroup allocation. Descriptive and inferential statis-tics were used to analyse the data. Further details,including the data collection time points for allstudies are presented in Table 2.

Effectiveness of the interventions

While the four tobacco-related studies provideinteresting information on knowledge levels andquit rates (Table 2), the study designs are weak (nocontrol groups, data collection instruments usedwith no demonstrable reliability and validity, nobiochemical verification of smoking status); there-fore, little can be deduced regarding the effective-ness of the interventions.

Again, when considering the alcohol-related inter-ventions, methodological issues, e.g. small numbers,lack of control groups and use of data collectioninstruments not tested for reliability and validitywith people who have ID, indicate that the resultsshould be treated with caution. Steel & Ritchie(2004) and Forbat (1999) reported that partici-pants’ knowledge levels rose (a combined total ofsix participants). Mendel & Hipkins (2002)reported an increase in readiness to change alcohol-related behaviour following delivery of their inter-vention. However, as the participants (n = 7) had noaccess to alcohol (they were currently in secureaccommodation and no details of their release dateswere provided), the relevance of moving partici-pants into the ‘action’ phase is difficult to judge.

The studies that focused on both tobacco andalcohol were of higher quality therefore more maybe deduced from the results. The study undertaken

by Lindsay et al. (1998) reported a significantincrease in knowledge levels (compared with thecontrol group) that was maintained over time (3months). Demers et al. (2000) found that, measuredagainst all seven criteria (Table 2), students in theintervention group achieved higher/more positiveresults than students in the control group; however,differences between the groups were not statisticallysignificant.

Feasibility, appropriateness and meaningfulness ofthe interventions

No qualitative papers/papers with a substantialqualitative element were identified and we weretherefore able to extract little information on themeaningfulness of the interventions (i.e. partici-pants’ views on/experience of the interventions).Chester et al. (2011) summarised comments madeby the participants exposed to their tobacco-relatedintervention. Participants who did not try to stopsmoking reported that they enjoyed smoking and didnot want to give up.Those who had stoppedsmoking or cut down reported that, following theintervention, they understood more about the effectsof smoking on their health, and that of others, andthis had encouraged them to try to stop smoking.Nicotine replacement therapy and the smoking time-table were also thought to have been useful.

When considering feasibility, Demers et al. (2000)found that teachers who had received training couldeasily incorporate tobacco and alcohol-related mes-sages into their lessons. No other findings relatingto feasibility were identified.

All studies addressed the issue of appropriateness,with efforts being made to tailor the interventionsin a manner suitable for people with ID. Kelmanet al. (1997) and Tracy & Hosken (1997) in theirtobacco-related interventions reported that the par-ticipants readily engaged with group work, whichincluded role play, quizzes and board games.However, Mendel & Hipkins (2002) (alcohol-related intervention) felt that some people withmild ID do not have sufficient verbal and interper-sonal skills to enable them to interact effectively ina group situation. Steel & Ritchie (2004), whoreported on a one-to-one intervention relating toalcohol use, found that holding the participant’sattention was problematic.




The provision of concrete examples of the effectsof smoking was found to be an appropriate educa-tional tool (Kelman et al. 1997). However, abstractconcepts, such as long-term health effects, were dif-ficult for people with ID to grasp (Kelman et al.1997). In particular the concept of units of alcoholwas raised as something that was difficult for peoplewith ID to understand (Mendel & Hipkins 2002).As discussed, in order to address cognitive and lit-eracy needs of people with ID, information wasprovided in a variety of formats including pictures/cartoons, videos and team games (Table 2). Inter-estingly, Steel & Ritchie (2004) found thathomework, which required reference to informationmaterials provided during the course, was an appro-priate learning aid.

When reflecting upon the appropriateness of thedata collection instruments, Mendel & Hipkins(2002) stated that while the instruments used (i.e.CAGE, Stages of Change Questionnaire) had beenvalidated with the general population, they believedthey were too complex for use with people whohave ID. Little comment was made by otherauthors about the appropriateness of their data col-lection instruments; none appeared to have beenassessed for reliability and validity with people whohave ID.

Discussion

In recent years there has been increasing concernregarding the mortality, morbidity and behaviouraldeterminants of health in people with ID (Emerson& Hatton 2008). When considering health-relatedbehaviours, levels of smoking and alcohol consump-tion in people with mild/moderate ID present acause for concern (Emerson & Turnbull 2005;McGillicuddy 2006; Taggart et al. 2006, 2008).

This review has demonstrated that worldwide thebody of evidence on the feasibility, appropriateness,meaningfulness and effectiveness of tobacco andalcohol-related interventions for people with ID issmall. The evidence that does exist is of poor/moderate methodological quality, drawn fromstudies which often used small conveniencesamples, and with two exceptions, did not use acontrol/comparator group. None of the studiesincluded in the review was hypothesis-driven, which

would be expected in quantitative studies purport-ing to assess effectiveness. In many of the papers,reporting of data collection and analysis processeslacked detail.

Although the studies included in the review havesignificant methodological limitations, and thereforemake a limited contribution to our understandingof the impact of the tobacco and alcohol-relatedinterventions they described, they did highlightsome important issues linked to the appropriatenessof health promotion interventions for this clientgroup. The papers tended to focus on the contentof the interventions and their mode of delivery, thusdemonstrating an awareness of the need to tailorinterventions to meet the specific needs of peoplewith ID. One of the studies sought to help partici-pants develop skills that would assist them in resist-ing the urge to smoke or consume alcohol in anattempt to conform or ‘fit in’ (Demers et al. 2000).This is an important issue, as research suggests thatpeople with ID may be encouraged to smoke and/ordrink alcohol in order to be, in their view, more liketheir peers who do not have ID (Lawrence et al.2009). While some authors commented on the par-ticipants’ high level of engagement with the inter-vention(s), little qualitative data were collected.Consequently, little is known about the participants’views of the interventions (meaningfulness).

Another important issue is that only two of thenine studies appeared to have appropriate theoreti-cal underpinnings i.e. the two alcohol-relatedstudies used motivational enhancement techniques(Miller & Rollnick 1991), with one also incorporat-ing the concept of Readiness to Change, whichlinks to the Transtheoretical Model of BehaviourChange (Prochaska & DiClemente 1992). This issurprising, as there is strong evidence that healthpromotion interventions designed to alter behaviourshould be based on a solid understanding of thepersonal and environmental factors that can influ-ence both behaviour and behaviour change(National Institutes of Health 2005). Issues such asempowerment, health literacy and the ability tomake informed decisions are particularly importantin this client group (NHS Health Scotland 2004;Lawrence et al. 2009; Robinson et al. 2010). Theapparent tendency to develop and deliver healthpromotion interventions without identifying anappropriate theoretical approach with which to




inform these processes has been noted in other spe-cialties, such as stroke (Lawrence et al. 2011).

When considering feasibility, only one study com-mented on this (Demers et al. 2000). As discussedpreviously, the issue raised related to the teachers’ability to incorporate the health education pro-gramme into their regular work.

The only study that is informative in terms ofeffectiveness is the study undertaken by Lindsayet al. (1998). This randomised controlled trialappeared to be effective in terms of raising theknowledge levels of people with ID in relation totobacco and alcohol. However, there were method-ological limitations that may impact on the validityof the results.

Conclusions

This review is the first to systematically collate evi-dence on tobacco and alcohol-related interventionsfor people with ID. The dearth of evidence in thisarea has important implications for practice, asthere is little to guide the approaches that healthand social care professionals should take whenworking with this client group. There is, therefore,an urgent need to develop theoretically driventobacco and alcohol-related health promotion inter-ventions and to ensure that the effectiveness ofthese interventions is tested in large-scale well-designed trials. In addition to addressing issuesrelating to the research design, there is a need toensure that interventions and outcome measures aredeveloped/tailored appropriately for this clientgroup.

Informed by the systematic review and qualitativeinterviews with people with ID and professionalswho have regular contact with this client group(Lawrence et al. 2009; Fitzsimmons 2011), wenow plan to develop and test a series of tobaccoand alcohol-related interventions for people withmild/moderate ID. Our aim is to improve thehealth of this population and to help reducehealth inequalities.

References

Chester V., Green F. N. & Alexander R. (2011) An auditof a smoking cessation programme for people with an

intellectual disability resident in a forensic unit.Advances in Mental Health and Intellectual Disabilities 5,33–41.

Demers J., French D. & Moore D. (2000) The prelimi-nary evaluation of a programme to help educatorsaddress the substance use/prevention needs of specialstudents. Journal of Alcohol and Drug Education 46,14–26.

Department of Health (2001) Valuing People: A New Strat-egy for Learning Disability for the 21st Century. DoH,London.

Disability Rights Commission (2004) Equal Treatment:Closing the Gap. Disability Rights Commission, Stratfordupon Avon.

Emer Lavin K., McGuire B. & Hogan M. J. (2006) Age atdeath of people with an intellectual disability in Ireland.Journal of Intellectual Disabilities 10, 155–64.

Emerson E. & Hatton C. (2008) People with Learning Dis-abilities in England. Centre for Disability Research, Uni-versity of Lancaster, Lancaster.

Emerson E. & Turnbull L. (2005) Self-reported smokingand alcohol use amongst adolescents with intellectualdisabilities. Journal of Intellectual Disabilities 9, 58–69.

Fitzsimmons L. (2011) SupportWorkers’ Perceptions of theHealth Promotion Needs of People with Learning DisabilitiesRelating to Tobacco and Alcohol. Glasgow CaledonianUniversity, Glasgow.

Forbat L. (1999) Developing an alcohol awareness coursefor clients with a learning disability. British Journal ofLearning Disabilities 27, 16–19.

Fujiura G. & Taylor S. (2003) Continuum of IntellectualDisability: demographic evidence for the ‘ForgottenGeneration’. Mental Retardation 41, 420–9.

Garcia J., Bricker L., Henderson J., Martin M. A.,Mugford M., Nielson J. et al. (2002) Women’s views ofpregnancy ultrasound: a systematic review. Birth 29,225–50.

George W. H., Davis K. C., Norris J., Heiman J. R.,Stoner S. A. & Schacht R. L. et al. (2009) Indirecteffects of acute alcohol intoxication on sexual risk-taking: the roles of subjective and physiological sexualarousal. Archives of Sexual Behavior 38, 498–513.

Harden A. (2006) Extending the boundaries of systematicreviews to integrate different types of study: examples ofmethods developed within reviews on young people’shealth. In: Moving beyond Effectiveness in Evidence Syn-thesis (ed. J. Popay), pp. 31–40. National Institute forHealth and Clinical Excellence, London.

Joanna Briggs Institute ( JBI) (2008) Joanna Briggs InstituteReviewers’ Manual 2008 Edition. Joanna Briggs Institute,Adelaide, SA.

Kelman L., Lindsay W., McPherson F. & Mathewson Z.(1997) Smoking education for people with learning dis-abilities. British Journal of Learning Disabilities 25, 95–9.




Lawrence M., Kerr S., Darbyshire C., Middleton A. &Fitzsimmons L. (2009) Tobacco and Alcohol Use in PeopleWho Have A Learning Disability: GivingVoice to TheirHealth Promotion Needs. Glasgow Caledonian University,Glasgow.

Lawrence M., Kerr S., McVey C. & Godwin J. (2011) Asystematic review of the effectiveness of secondary pre-vention lifestyle interventions designed to change lif-estyle behaviour following stroke. JBI Library ofSystematic Reviews 9, 1782–827.

Leonard M., Petterson B., Bower C. & Sanders R. (2003)Prevalence of intellectual disability in Western Australia.Paediatric and Perinatal Epidemiology 17, 58–67.

Lindsay W. R., McPherson F. M., Kelman L. V. &Mathewson (1998) Health promotion and people withlearning disabilities: the design and evaluation of threeprogrammes. Health Bulletin 56, 694–8.

Mayfield D. & Mcleod G. (1974) The CAGE question-naire: validation of a new alcoholism screening instru-ment. American Journal of Psychiatry 131, 1121–3.

McGillicuddy N. B. (2006) A review of substance useresearch among those with mental retardation. MentalRetardation and Developmental Disabilities ResearchReview 12, 41–7.

McGillivray J. A. & Moore M. R. (2001) Substance use byoffenders with mild intellectual disability. Journal ofIntellectual and Developmental Disability 26, 297–310.

Medical Research Council (2008) Developing and evaluat-ing complex interventions: new guidance. Available at:http://www.mrc.ac.uk/complexinterventionsguidance(retrieved 10 January 2011).

Mendel E. & Hipkins J. (2002) Motivating learning dis-abled offenders with alcohol-related problems: a pilotstudy. British Journal of Learning Disabilities 30, 53–158.

Meyer J. S., Rauch G. M., Rauch R. A., Haque A. &Crawford K. (2000) Cardiovascular and other riskfactors for Alzheimer’s Disease and vascular dementia.Annals of the NewYork Academy of Sciences 903, 411–23.

Miller W. R. & Rollnick S. (1991) Motivational Interview-ing: Preparing People to Change Addictive Behaviour.Guilford Press, London.

National Institute for Health and Clinical Excellence(2006) Brief interventions and referral for smoking cessationin primary care and other settings. Available at: http://www.nice.org.uk/nicemedia/live/11375/31864/31864.pdf(retrieved 10 January 2011).

National Institutes of Health (2005) Theory at A Glance:A Guide for Health Promotion Practice, 2nd edn. USDepartment of Health and Human Services, NationalInstitutes of Health, Washington, DC.

NHS Health Scotland (2004) Health Needs AssessmentReport. People with Learning Disabilities in Scotland. NHSScotland, Glasgow.

Office for National Statistics (2011) General LifestyleSurvey 2009 – Smoking and Drinking among Adults 2009.

Office for National Statistics, London. Available at:http://www.ons.gov.uk (retrieved 18 November 2011).

Patja K., Iivanainen M., Vesala H., Oksanen H. & Ruop-pila I. (2000) Life expectancy of people with intellectualdisability: a 35-year follow-up study. Journal of Intellec-tual Disability Research 44, 591–9.

Pearson A. (2004) Balancing the evidence: incorporatingthe synthesis of qualitative data into systematic reviews.JBI Reports 2, 45–64.

Pearson A., Wiechula R., Court A. & Lockwood C.(2005) The JBI model of evidence-based healthcare.International Journal of Evidence-based Healthcare 3, 207–16.

Popay J. (2006) Moving beyond Effectiveness in EvidenceSynthesis: Methodological Issues in the Synthesis of DiverseSources of Evidence. National Institute for Health andClinical Excellence, London. Available at: http://www.publichealth.nice.org.uk (retrieved 10 October2009).

Prochaska J. O. & DiClemente C. C. (1992) Stages ofchange in the modification of problem behaviours.Progress in Behaviour Modification 28, 184–218.

Robertson J., Roberts H. & Emerson E. (2010) HealthChecks for People with Learning Disabilities: A SystematicReview of Evidence. Improving Health and Lives: Learn-ing Disabilities Observatory, London. Available at:http://www.improvinghealthandlives.org.uk/uploads/doc/vid_7646_IHAL2010-04HealthChecksSystemticReview.pdf (retrieved January 2011).

Rollnick S., Heather N., Gold R. & Hall W. (1992) Devel-opment of a short ‘readiness to change’ questionnairefor use in brief, opportunistic interventions amongexcessive drinkers. British Journal of Addiction 87, 743–54.

Royal College of General Practitioners (2010) AnnualHealth Checks for People with A Learning Disability: AStep by Step Guide for GP Practices. Royal College ofGeneral Practitioners, London.

Royal College of Physicians (2000) Nicotine Addiction inBritain. Royal College of Physicians, London.

Scottish Government (2011) Scotland’s People. AnnualReport: Results from 2009/2010 Scottish Household Survey.Scottish Government, Edinburgh. Available from: http://www.scotland.gov.uk/Publications/2011/08/17093111/11

(retrieved 18 November 2011).

Singh N. N., Lancioni G. E., Winton A. S. W., SinghA. N. A., Singh J. & Singh A. D. A. (2011) Effects of amindfulness-based smoking cessation program for anadult with mild intellectual disability. Research in Devel-opmental Disabilities 32, 1180–5.

Søndenaa E., Rasmussen K., Nøttestad J. & Lauvrud C.(2010) Prevalence of intellectual disabilities in Norway:domestic variance. Journal of Intellectual DisabilityResearch 54, 161–7.




Steel A. & Ritchie G. (2004) Psycho-educationalapproach to addiction: a case study. Drugs and Alcohol4, 30–3.

Taggart L., McLaughlin D. & Quinn B. (2006) An explo-ration of substance misuse in people with intellectualdisabilities. Journal of Intellectual Disability Research 59,588–97.

Taggart L., Huxley A. & Baker G. (2008) Alcohol andillicit drug misuse in people with learning disabilities.Advances in Mental Health and Learning Disabilities 2,11–21.

Taylor B., Irving H. M., Kanteres F., Room R., Borges G.,Cheripitel C. et al. (2010) The more you drink, theharder you fall: a systematic review and meta-analysis.Drug and Alcohol Dependence 110, 108–16.

Tracy J. & Hosken R. (1997) The importance of smokingeducation and preventative health strategies for people

with intellectual disability. Journal of Intellectual Disabil-ity Research 41, 416–21.

World Health Organisation (2002) World Health Report2002: Reducing Risks, Promoting Healthy Life. WorldHealth Organisation, Geneva.

World Health Organisation (2007a) TheWorld HealthReport 2001 – Mental Health: New Understanding, NewHope. World Health Organisation, Geneva. Available at:http://www.who.int/whr/2001/en/whr01_en.pdf (retrieved26 August 2010).

World Health Organisation (2007b) WHO Expert Commit-tee on Problems Related to Alcohol Consumption. WorldHealth Organisation, Geneva. Available at: http://www.who.int/substance_abuse/expert_committee_alcohol_trs944.pdf (retrieved 10 January 2011).

Accepted 5 February 2012




Appendix 1 Search (Medline)

Topic MeSH headings and keywords

Intellectual disability 1. learning disorders/ OR developmental disabilities/ OR mental retardation/ OR mentallydisabled persons/

2. intellectual disabilit*3. intellectual N3 disabilit*4. developmental disabilit*5. developmental N3 disabilit*6. learning disabilit*7. learning N3 disabilit*8. learning disabled9. mental retardation

10. mental N3 retardation11. mental handicap12. mental N3 handicap13. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12

Tobacco and alcohol 14. ethanol/ OR drinking behavior/ OR alcoholism/ OR alcohol intoxication/ OR alcohol drinking/15. alcohol16. problem N3 drink*17. hazardous N3 drink*18. harmful N3 drink*19. dependent N3 drink*20. binge N3 drink*21. alcohol N3 use22. alcohol N3 misuse23. smoking/ OR tobacco use24. tobacco N3 smoking25. smoking26. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25

Interventions 27. health promotion/ OR health education/ OR preventive medicine/ OR primary prevention/OR secondary prevention/ OR smoking cessation/ OR tobacco use cessation/

28. health N3 promotion29. health N3 education30. prevention31. relapse N3 prevention32. smoking N3 cessation33. behavio#r N3 change34. behavio#r35. psycho N3 education36. psychosocial N3 intervention37. counsel#ing38. nicotine replacement therapy39. 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 3840. 13 and 26 and 3941. limit to 1996–2011, English language, humans




tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a...

Documents