Socioeconomic inequalities of adolescent alcohol use are not as consistent as for other health risk behaviours. Thesis hypotheses were that a) alternative familial early socioeconomic position indicators of both immaterial and material resources presented specific associations with several modalities of alcohol consumption; b) associations of immaterial capital typically diluted from early to middle adolescence and material/immaterial influences varied between genders; and c) the socioeconomic context of schools exerted influence on middle adolescent alcohol misuse. Outcome data were collected at age 12, 13 and 15 from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth-cohort. Self-reported early alcohol onset, ever/past use, misuse and problem use were investigated in early and mid-adolescence. Socioeconomic position included mother's reported questionnaire-based measures of maternal education, parental social class and disposable household income. School level indicators were retrieved from Annual School Census data linked to ALSPAC. Multiple logistic regressions assessed associations between variables. Sensitivity analyses used multiple imputations. Multilevel models accounted for ALSPAC participants nested within schools. Maternal education was negatively associated with most measures of alcohol investigated, including early onset and use/misuse at both age 13 and 15. Conversely, household income had positive associations with measures of early alcohol use and later measures of alcohol misuse. Girls in more disadavantaged families were at lower risk of alcohol related problems than boys. However, for increasing levels of income and maternal education their risks overtook and matched that of boys, respectively. Non negligible residual variance of alcohol misuse among schools (~ to 3%) was not explained by the school socioeconomic context. Socioeconomic gradients on underage drinking manifest since early alcohol exposure and differ by construct through mid-adolescence. Policies on youth drinking should reflect that material advantage across the socioeconomic spectrum may increase risk of alcohol misuse and problem use, particularly in girls.

Introduction. Early psychological and environmental factors appear to play an important role in the development of alcohol abuse and alcohol dependence and increasing self-esteem and problem-solving abilities is often the aim of psychological interventions for these problems. The purpose of this study was to examine parental bonding, self-esteem and problem solving in alcohol-dependent individuals, using multi-dimensional measures. Method. An inpatient sample from a specialist treatment facility consisting of 90 volunteers who completed questionnaires focusing on alcohol consumption (Timeline Followback), alcohol-related problems (Alcohol Problems Questionnaire), self-esteem (The Self- Liking/Competence Scale [Revised]), social problem solving (Social Problem Solving Inventory [Revised]) and perceived parenting (Parental Bonding Instrument). Inclusion/exclusion criteria were applied. The data were analysed using Pearson Correlations and Stepwise Regression. Results. Alcohol problems were related to maternal parenting patterns but not paternal parenting patterns. A significant negative relationship was found between social problem solving and alcohol problems; a positive significant relationship was found between alcohol problems and the dysfunctional styles of social problem solving (Negative Problem Orientation, Impulsivity/Carelessness Style, Avoidance Style). Both aspects of self-esteem were significantly related to parental care, social problem solving and alcohol-related problems. The hypothesised role of self-esteem as a mediator between Maternal Care and alcohol problems, and between social problem solving and alcohol problems, was not supported. Conclusions. In problem drinkers, dysfunctional aspects of problem solving and low maternal bonding during childhood and adolescence appear to be related to their alcohol problems. Although a role for self-esteem in the development and maintenance of alcohol problems has been identified, the precise mechanisms through which self-esteem, problem solving and parental bonding are connected with alcohol problems have yet to be established. However, self-esteem and social problem solving need to be considered as important factors when planning treatment options. In addition, the negative effects of drinking alcohol at an early age on problems later in life were discussed.

This thesis examined self-regulation and motivational structure as two important psychological constructs related to alcohol consumption. Three studies were conducted for this thesis. Study One was designed to assess relationships among self-regulation, motivational structure, and alcohol use. Participants were student drinkers (N = 105, females = 77.7%, mean age = 19.82 years). They were asked to complete four questionnaires, including a brief demographic characteristics questionnaire, the Personal Concern Inventory, Alcohol Use Questionnaire, and Short Self-Regulation Questionnaire. The results partially supported one of the hypotheses of the study. Total SSRQ scores were negatively correlated with the amount of alcohol that students drank on atypical occasions, as was predicted. That is, as participants’ degree of self-regulation increased, the amount of alcohol that they consumed decreased. In Study Two, a manipulation technique was used to examine individuals’ self-regulation and to clarify whether a manipulation for changing their self-regulation caused their motivational structure to become more adaptive and thereby reduce their alcohol consumption. Participants were 80 students (males = 26.6 %, males, mean age = 21.19 years). The main purpose of Study Two was to examine the effects of a task that used Concept Identification Cards on participants’ self-regulation. The task aimed to enhance individuals’ self-regulation and clarify whether manipulations aimed at triggering changes in their motivational structure to become more adaptive would reduce their alcohol drinking. Two types of instruments were employed. The first type included those that were administered to identify changes in participants’ self-regulation, motivational structure, self-efficacy, procrastination and urges to drink. The second type included those that the experimenter used to manipulate self-regulation in the experimental group. The results partially supported one of the hypotheses of the study. Total SSRQ scores were negatively correlated with students ‘atypical drinking, as was predicted. That is, as participants’ degree of self-regulation increased, the amount of alcohol that they consumed decreased. However, the results only partially supported the fourth hypothesis of the study, viz. that motivational structure would partly mediate the relationship between self-regulation and amount of alcohol consumed. This outcome was not consistent with the results of previous studies. Study Three was designed to explore whether relationships among a withholding response, impulsivity, self-regulation, and memory capacity were related to one another and to drinking behaviour. The hypotheses tested in Study Three were as follows: (a) Participants who were heavy drinkers and low in self-regulation, high in impulsivity, and low in working memory capacity would perform more poorly than others on a Go/No Go task. (b) More errors would be made when the stimuli on Go/No Go trials were alcohol-related than when they were alcohol-unrelated. Participants were students (N = 108, male = 41.8%, males’ mean age = 19.86 years). Measures used in the study were a measure of (a) alcohol consumption, (b) impulsivity, and (c) self-regulation. In addition, two computerised tasks were used to measure participants’ behavioural impulsivity and memory capacity. The results of Study Three supported both of the hypotheses. In conclusion, this thesis demonstrates that self-regulation and related psychological constructs play an important role in university students’ alcohol consumption.

Purpose: To develop a user interface with embedded clinical decision support software for detecting self or proxy reports of lifetime exposure to TBI with patients receiving community drug and alcohol treatment. Method: Human centred design standard was adopted in the adaptation of the Ohio State University Traumatic Brain Injury Identification Method. A prototype head injury survey user interface was developed following usability design guidelines with stakeholder involvement. The initial instrument design underwent formative usability evaluation using cognitive walkthrough with a concurrent embedded mixed methods design. Four patients and four staff from a community drug and alcohol treatment service were purposively recruited for usability testing. Results: A thematic analysis was conducted and three themes were identified; user interface problems and improvements, living with TBI, and high tech or low tech healthcare. The theme user interface problems and improvements was quantified using problem discovery analysis to prioritise the five pre-defined user interface categories; navigation, content, page layout, terminology, data entry and technology for redesign (Rubin, 1996). Patients’ highest redesign priority was navigation and for staff it was data entry and technology. Design recommendations: The prototype head injury survey application had ten user interface design recommendations. The next design iteration will be sensitive to neurological deficits, limited IT skills and low reading ability. Several implications for practice in conducting TBI screening were identified. Staff should retain control over the administration of the head injury survey application as the recollection of past traumatic events was distressing for patients. Family and friends should be involved in TBI screening to help differentiate any changes in neurological functioning post head injury. Administration of the instrument should be restricted. Preferred delivery method was clinical interview using mobile computer technology. Electronic healthcare records could provide prompts to conduct TBI screening if associated clinical markers for head trauma have been detected.

Introduction Alcohol brief interventions (ABI) are an area of focus for policymakers and clinicians alike. ABI's role and effectiveness in primary care has been well documented and researched, whereas its place within general hospital is less established. In addition to the lack of definitive evidence of effectiveness within general hospital, little research has focused on the participants' views on alcohol, ABI and the barriers and enablers to change. Methods This thesis begins with a systematic review featuring a meta-analysis of ABI in general hospital. It then describes a mixed methods study combining a randomised controlled trial with qualitative research. This captures quantitative data, assessing changes in alcohol consumption following ABI, together with semi-structured interviews exploring participants' views on alcohol, ABI and the barriers and enablers to change. A total of 124 participants identified from a screening test as hazardous/harmful drinkers were randomly allocated to receive an ABI or usual hospital care. Of these, 87 (70%) completed the follow up assessment approximately six months after enrolment, and a sub-group of ten participants from the intervention group took part in individual semi-structured telephone interviews.

Family and carer-involved interventions are increasing as a result of changes in policy and guidance as to 'what works' in drug and alcohol treatment. This change of focus from individualistic treatment of alcohol-dependent people (ADPs), to involving their significant others, is a sign of the strong research evidence into the benefits of more socially inclusive options. These advantages are not only for the ADPs' recoveries, which in turn are important for commissioners and service providers, but they help family members and carers. Those connected with an ADP, such as partners, are a disadvantaged and neglected group who can gain from being involved in their ADP's treatment through learning about alcohol dependency and coping strategies. They can also gain support and advice in their own right. The literature review examines partner-based interventions so far: what they involve, whether they are effective, and the challenges and issues of working and researching in this way. The main conclusion was that working in this way can be effective if the treatment goal, intervention, and outcome measures are congruous (the triad of congruence). The research paper describes the study undertaken: a quantitative study into predictors of enabling behaviour in partners of ADPs. Enabling was defined as inadvertent reinforcement of the ADP drinking by partners, and represents one coping strategy employed by partners in their management of a highly stressful and personally challenging situation. Enabling is considered a particularly costly strategy to partners and ADPs, so an examination into predictors

The current thesis aimed to explore the associations between hazardous drinking, automatic processing of alcohol-related cues and behavioural impulsivity. In addition to assessing the impact of these processes on hazardous drinking in isolation, the specific prediction of dual process models of addiction, that the association between automatic cognitive processes and hazardous drinking would be moderated by behavioural impulsivity, was also tested. These general research questions were investigated cross sectionally in young adult student populations (chapter 3), / adolescents (chapter 4), and older adults (chapter 5). The aim of the study described in chapter 6 was to investigate the effect of a priming dose of alcohol on these processes and their association with alcohol-seeking behaviour. Finally, chapter 7 was an investigation into the mediators and moderators of the effects of ego depletion on drinking behaviour from the perspective of dual process models of addiction. Automatic processing of alcohol-related cues predicted drinking behaviour in all cross sectional studies, although the specific aspects of automatic processes that predicted drinking behaviour differed. The effects of the alcohol prime and anticipated effects of alcohol on different measures of cognitive bias were inconsistent, and automatic cognitive processes only predicted ad-lib drinking in non-intoxicated individuals. Impulsivity only had a direct association with drinking within the sample of older adults, and neither the alcohol prime or ego depletion manipulation increased either measure of behavioural impulsivity. There was evidence that the alcohol priming effect was the result of general impairments in executive cognitive functioning. In the cross sectional studies support for dual process models of addiction was only found in the adolescent sample, in which impulsive decision making moderated the association between attentional bias and problem drinking in adolescents. There was evidence that increases in automatic approach responses towards alcohol-related cues following an alcohol prime were the result of impairments in executive cognitive function. Although ego depletion resulted in increased alcohol consumption this was not due to increased behavioural control by automatic cognitive processes. The results from the current thesis offer considerable support for incentive- motivational models of addiction, arid-highlight the importance of the roles of specific aspects of automatic cognitive processing in different samples. As behavioural impulsivity was only associated with hazardous drinking in older adults this suggests that cumulative experience with alcohol is necessary before these processes impact behaviour. Although support for dual process models of addiction was only found in adolescents, previous research would suggest that the predictions of these models are most likely to be found in such samples.

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Alcohol is a major cause of social, health and economic problems in the United Kingdom. Thus reduction in excessive drinking was one of the targets included in the White Paper, "Saving Lives: Our Healthier Nation" and is the subject of a National Harm Reduction Strategy. However alcohol problems are responsive to brief intervention (5-10 minutes of structured advice accompanied by written material). A number of randomised controlled trials have shown that, in comparison with controls, excessive drinkers receiving brief advice will reduce their alcohol consumption by around 25%. General practice is a particularly valuable point of contact for the delivery of brief intervention for excessive alcohol use because of the large proportion (70%) of the population who access their general practice each year. Excessive drinkers present twice as often as other patients and may constitute 20% of patients on a practice list. However, the potential of both General Practitioners and primary health care nurses to reduce the prevalence of alcohol related problems contrasts sharply with current practice. This Doctorate of Philosophy by published work is based on a programme of research, using the principles of social marketing, to disseminate and implement screening and brief alcohol intervention in primary health care. The submission includes a series of papers, published in a variety of peer-reviewed journals. Although the papers included in this thesis address different research questions and report a range of research techniques each makes a contribution to the field of screening and brief alcohol intervention. Publications reveal that General Practitioners remain unaware of the evidence for screening and brief alcohol intervention. While effective dissemination and implementation strategies are available, General Practitioners exhibit selective provision of screening and brief alcohol intervention. This is also the case for primary health care nurses. Although health professionals often cite negative patient reactions, patients consider screening and brief alcohol intervention appropriate when carried out under suitable conditions.