USEFULNESS, LENGTH AND CONTENT OF ALCOHOL-RELATED DISCUSSIONS IN PRIMARY HEALTH CARE: THE EXIT POLL SURVEY

MAURI AALTO1,* and KAIJA SEPPÄ2,3

1 Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, 2 Department of Psychiatry, Tampere University Hospital and 3 Medical School, University of Tampere, Tampere, Finland

* Author to whom correspondence should be addressed at: National Public Health Institute, PO Box 33, FIN-00251 Helsinki, Finland. Tel.: +358 9 4744 8139; Fax: +358 9 4744 8133; E-mail: mauri.aalto{at}ktl.fi

(Received 23 April 2004; first review notified 2 May 2004; in revised form 21 July 2004; accepted 24 July 2004)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To evaluate patients' opinions of the usefulness of alcohol-related discussions with general practitioners (GPs), the time used for the discussion and its main content. Methods: Exit poll survey to 2000 consecutive patients right after GP consultations. Results: The response rate was 60.2% (1203/2000). Of the patients 11.6% (139/1203) reported that they were asked and/or advised about alcohol during the consultation. The time used for discussion about alcohol was mostly <4 min; longer for heavy than for non-heavy drinkers. Main topics of the discussion dealt with quantities consumed and harm caused by alcohol. The majority of the patients (81%) reported that discussions concerning alcohol were useful. In that respect heavy drinkers did not differ from non-heavy drinkers. Conclusions: Discussions about alcohol in primary health care were rare and short, but patients' opinions about their usefulness were mainly positive.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
There is an increasing interest in implementation research concerning early identification and brief intervention of hazardous and harmful drinking. Widespread implementation of brief intervention seems to be time-consuming and challenging (Beich et al., 2002Go; Aalto et al., 2003aGo; Roche and Freeman, 2004Go). At present in Finland, primary health care has up-to-date information on patients' alcohol consumption in ~20% of cases (Aalto et al., 2003aGo). Among other factors, lack of time and training of general practitioners (GPs) has been found to constitute barriers to implementation (Adams et al., 1997Go; Deehan et al., 1998Go; Bendtsen et al., 1999Go; Kaner et al., 1999Go). Probably one of the important things in promoting brief intervention is ongoing feedback to primary health care professionals (Huntley et al., 2001Go).

Even if the attitudes towards alcohol-related discussions are positive, GPs and also primary health care nurses are cautious about discussing alcohol with the patients (Aalto et al., 2003bGo). They are worried that the patients may not see the benefit of bringing alcohol into the discussion and may be offended. One way to look at the challenge of widespread implementation of brief intervention has been if the patients approve of talking about alcohol during health care consultations. The evidence is strong that in general, patients report that it is good if alcohol issues are discussed during the consultation (Wallace and Haine, 1984Go; Wallace et al., 1987; Richmond, 1996Go; Aalto et al., 2002Go). However, there is no information about their reactions in real-life situations. The aim of the present study was to ascertain the patients' (heavy and non-heavy drinkers) immediate opinion of the usefulness of alcohol-related discussions with GPs. Other aims were to find out how much time is used for discussing alcohol and what the main content of the discussion is.


    SUBJECTS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The Finnish city of Tampere has a population of ~200 000. Out of the seven health centres, two were chosen for the study for pragmatic reasons, such as acceptance by management. They provide services for ~30 000 inhabitants. The 14 GPs who were employed in the two centres during the study represent average practitioners without any special interest in brief intervention. The Ethics Committee of Tampere City Hospital approved the study protocol.

This study continues the earlier regional efforts to increase brief intervention for alcohol problems in health care settings in Finland (Kääriäinen et al., 2001Go). It was part of Phase IV of the World Health Organization Collaborative Project on Identification and Management of Alcohol-Related Problems in Primary Health Care (Aalto et al., 2003aGo; www.who-alcohol-phaseiv.net/). The Phase IV project aims were to develop the application of strategies for the widespread, routine and enduring implementation of brief intervention in the primary health care of the participating countries.

Data were collected among 2000 patients during daytime from Monday to Friday in two 4-week periods. During these study periods, receptionists gave a closed envelope containing a self-administered questionnaire to consecutive 16–65-year-old patients visiting a GP for any reason. The envelope was given with spoken and written information about not opening it until after the consultation. Patients were asked to return the completed questionnaire to a box in the health centre. The survey was anonymous regarding both the patients and GPs. The GPs knew that there was a survey among patients about alcohol-related issues, but they were not told the exact content of the questionnaire.

The exit questionnaire comprised questions on gender, age, alcohol consumption and whether the patient had been asked and/or advised about alcohol drinking during the consultation or previously. Questions 1 and 2 of the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al., 1993Go) were used as a quantity–frequency measure and a cut-off of 5 points was chosen to indicate heavy drinking. This cut-off point indicates either continual very heavy episodic drinking (≥10 at drinking occasion), frequent episodic heavy drinking (7–9 drinks at least twice a month), regularly drinking at least 12 drinks in a week or some combination of these three. Relatively low limits were chosen due to evidence that the quantity–frequency method underestimates the real consumption in Finnish populations (Poikolainen, 1985Go; Poikolainen et al., 2002Go). Patients reporting being asked and/or advised about alcohol drinking during the consultation were asked to answer the three following questions:

How long did the discussion about alcohol last?

  1. Less than 1 minute
  2. 1–4 minutes
  3. 5–10 minutes
  4. More than 10 minutes

Which of the following matters were addressed during the consultation? (Please circle all relevant choices)

  1. I was informed about the harm caused by alcohol.
  2. I was told what amount of alcohol is hazardous.
  3. I was asked how much I drink.
  4. I was given written material about alcohol drinking.
  5. I was asked if I was willing to reduce my drinking.
  6. I was given practical advice on how to reduce my drinking.

Did you find the discussion concerning alcohol drinking useful?

  1. Yes
  2. No

Statistical analyses were carried out with the Statistical Package for Social Sciences 10.1. In frequency comparisons Pearson chi-square test or Fisher's exact test, and in mean comparisons, independent-samples t-test were used. Differences were considered statistically significant at P < 0.05.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Of the sample of 2000 patients, 1203 (60.2%) reported in the questionnaire whether they were asked and/or advised about alcohol drinking during the consultation and were subjects for further analyses. Of these respondents, 37.3% (428/1148) were males and 62.7% (720/1148) females (for 55 gender unknown). Mean age (SD) was 44.2 (14.9) years. Prevalence of heavy drinking was 11.4% (135/1184, for 19 drinking status unknown). Of all 1203 respondents 139 (11.6%), including 84 males (21 heavy drinkers) and 51 females (nine heavy drinkers) (for four gender unknown) reported that they were asked and/or advised about alcohol during the consultation. Mean age did not differ between those with whom GPs had discussed or had not discussed about alcohol [mean years (SD): 46.5 (14.1) vs 43.9 (15.0), P = 0.061]. Of 139 who reporting discussions about alcohol, 91 (65.5%), including 16 male and six female heavy drinkers, completed at least partly the following three questions relating to the content of asking and advising (Tables 1Go3).


View this table:
[in this window]
[in a new window]
 
Table 1. Distribution of time used for discussing alcohol during the consultation

 

View this table:
[in this window]
[in a new window]
 
Table 2. Comparison of different topics discussed during consultations between heavy drinkers and non-heavy drinkersa

 

View this table:
[in this window]
[in a new window]
 
Table 3. Usefulness of discussions on alcohola

 
The proportion of those who were asked but not advised was 5.5% (66/1203), the proportion of those only advised but not asked was 3.8% (46/1203), and the proportion of those both asked and advised was 2.2% (27/1203). In each of these groups there were heavy drinkers: 7.6% (5/66), 26.1% (12/46) and 48.1% (13/27), respectively. Of those 46 only advised during the present consultation, 40 had been asked about alcohol drinking in previous consultations.

Time used for discussions about alcohol was mostly <4 min (Table 1). As expected, the time was longer more frequently in heavy drinkers than in non-heavy drinkers. The main topics of the discussions were amount consumed and harm caused by alcohol (Table 2). More than one topic was discussed with 35.2% (25/71) of the patients. Heavy drinkers, as compared to non-heavy drinkers, were asked more frequently if they were willing to reduce drinking. In other topics statistical differences were not reached. The majority of the patients reported that the discussions about alcohol were useful. In this respect heavy drinkers did not differ from non-heavy drinkers (Table 3).


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In primary health care, discussing alcohol is not a frequent practice (Volk et al., 1996Go; Aalto et al., 2002Go) and thus collecting data as in the present study is challenging. Here we were able to evaluate 91 primary, secondary or tertiary prevention sessions during primary health care consultations. As far as we know, these are the first data revealing information on duration, content and patients' opinions of alcohol discussions during primary health care consultations. The fact that the data were collected right after the consultations probably increases its validity. The difficulty with the data is that we are not able to identify who initiated the discussion, the patient or the GP. Also, the low prevalence, particularly of male heavy drinkers, as compared to earlier results in Finnish primary health care (Aalto et al., 1999Go) suggests that heavy drinkers especially failed to answer the questionnaire. If, therefore, heavy drinkers were more prevalent among non-respondents and GPs seem to be more active in asking and advising them than non-heavy drinkers, it is possible that discussions about alcohol would be more frequent among non-respondents. It is also possible that the non-respondents, especially the heavy drinkers, were not as positive about discussing alcohol with the GPs as the respondents. Thus, the results regarding the usefulness of discussion may be less than presented here.

Our main justification for the present study was that primary health care is reluctant to adopt early identification and brief intervention for alcohol problems (Roche and Freeman, 2004Go). This is the case in spite of strong evidence that patients do not mind if alcohol issues are raised during the consultation. In the previous literature, patients' approval of discussing alcohol is well documented (Wallace and Haine, 1984Go; Wallace et al., 1987; Richmond, 1996Go; Aalto et al., 2002Go). In our study, 81% of patients consider discussions to be useful as well as acceptable (Table 3). This was the case even if the time used for the discussion was short, mostly lasting only <4 min (Table 1). This should be encouraging for GPs who are considering making brief intervention part of their daily practice. However, one should be cautious about concluding that almost all patients consider discussing alcohol to be useful. The GPs discussed alcohol with 30 of the 135 heavy drinkers. We estimate that this proportion was lower among the non-respondent heavy drinkers, and only 15–20% of all heavy drinkers seen at the practice were asked and/or advised about alcohol and most probably they were not randomly selected by GPs. Rather, the GPs most likely talked about alcohol more frequently with those who were receptive. This group has the highest likelihood of benefiting from brief intervention (Beich et al., 2003Go). The GPs used quite a lot of time to talk about alcohol with non-heavy drinkers. This concurs with our previous results that Finnish GPs are willing to advise patients whose alcohol consumption does not reach risky levels (Aalto and Seppä, 2001Go). This target group for primary prevention also reported the discussions to be useful. GPs seem to be adept either at selecting those patients who are receptive to alcohol discussions or at discussing in a way which respects the patient. Probably both are partly true. In accordance with previous findings males were asked and/or advised more often than females (Kaner et al., 2001Go).

The main topics of the discussions were amounts consumed and harm caused by alcohol. This was expected, because in our previous qualitative study, GPs and nurses felt more comfortable talking about alcohol when there was some symptom or finding that could be related to alcohol drinking (Aalto et al., 2003bGo).

Written material was given to patients very rarely as part of counselling. In the primary health care centres where the present data were collected there were leaflets available on heavy drinking. No feasibility studies on educative alcohol-related written materials are available and thus the reasons for the present finding are only speculative. A simple explanation could be that written materials were not easily at hand inside the offices. Another possibility is that GPs could offer the same information verbally and did not consider it necessary to provide additional written material. This is likely, because GPs discussing alcohol with their patients were probably what Roche et al. (1991)Go called problem-solvers, who communicate very actively with patients and are thus probably also in the frontline in adopting the habit of counselling on alcohol. An additional possibility is that GPs do not consider it beneficial to provide written materials.

As a conclusion, discussions about alcohol in primary health care were rare and short, but patients' opinions about their usefulness were mainly positive. The main topics of the discussion dealt with quantities consumed and harm caused by alcohol. Cultural issues in general and especially related to a health care system may modify the results of a study such as the present one. However, mostly the findings related to the implementation of brief alcohol intervention have been surprisingly parallel in different countries. We therefore suppose that the present results can be generalized certainly to other parts of Finland and most probably also to many other countries.


    ACKNOWLEDGEMENTS
 
The Ministry of Social Affairs and Health of Finland supported this study. It was done as part of the Phase IV study of the World Health Organization Collaborative Project on Identification and Management of Alcohol-related Problems in Primary Health Care. We thank all the members of the Phase IV study group for their support during the study.


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aalto, M. and Seppä, K. (2001) At which drinking level to advise a patient? General practitioners' views. Alcohol and Alcoholism 36, 431–433.[Abstract/Free Full Text]

Aalto, M., Seppä, K., Kiianmaa, K. and Sillanaukee, P. (1999) Drinking habits and prevalence of heavy drinking among primary health care outpatients and general population. Addiction 94, 1371–1379.[CrossRef][ISI][Medline]

Aalto, M., Pekuri, P. and Seppä, K. (2002) Primary health care professionals' activity in intervening in patients' alcohol drinking: a patient perspective. Drug and Alcohol Dependence 66, 39–43.[CrossRef][ISI][Medline]

Aalto, M., Pekuri, P. and Seppä, K. (2003a) Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project. Drug and Alcohol Dependence 69, 9–14.[CrossRef][ISI][Medline]

Aalto, M., Pekuri, P. and Seppä, K. (2003b) Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug and Alcohol Review 22, 169–173.[CrossRef][ISI][Medline]

Adams, P. J., Powell, A., McCormick, R. and Paton-Simpson, G. (1997) Incentives for general practitioners to provide brief interventions for alcohol problems. New Zealand Medical Journal 110, 291–294.[ISI][Medline]

Beich, A., Gannik, D. and Malterud, K. (2002) Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ 325, 870.[Abstract/Free Full Text]

Beich, A., Thorsen, T. and Rollnick, S. (2003) Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ 327, 536–542.[Abstract/Free Full Text]

Bendtsen, P. and Åkerlind, I. (1999) Changes in attitudes and practices in primary health care with regard to early intervention for problem drinkers. Alcohol and Alcoholism 34, 795–800.[Abstract/Free Full Text]

Deehan, A., Templeton, L., Taylor, C., Drummond, D. C. and Strang, J. (1998) Low detection rates, negative attitudes and the failure to meet "Health of the Nation" targets: findings from a national survey of GPs in England and Wales. Drug and Alcohol Review 17, 249–258.[ISI]

Huntley, J. S., Blain, C., Hood, S. and Touquet, R. (2001) Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emergency Medicine Journal 18, 99–104.[Abstract/Free Full Text]

Kaner, E. F., Heather, N., Mcavoy, B. R., Lock, C. A. and Gilvarry, E. (1999) Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners. Alcohol and Alcoholism 34, 559–566.[Abstract/Free Full Text]

Kaner, E. F., Heather, N., Brodie, J., Lock, C. A. and McAvoy, B. R. (2001) Patient and practitioner characteristics predict brief alcohol intervention in primary care. British Journal of General Practice 51, 822–827.[ISI][Medline]

Kääriäinen, J., Sillanaukee, P., Poutanen, P. and Seppä, K. (2001) Brief intervention for heavy drinkers: an action project for health care implementation. Alcologia 13, 67–73.

Poikolainen, K. (1985) Underestimation of recalled alcohol intake in relation to actual consumption. British Journal of Addiction 80, 215–216.[ISI][Medline]

Poikolainen, K., Podkletnova, I. and Alho, H. (2002) Accuracy of quantity–frequency and graduated frequency questionnaires in measuring alcohol intake: comparison with daily diary and commonly used laboratory markers. Alcohol and Alcoholism 37, 573–576.[Abstract/Free Full Text]

Richmond, R., Kehoe, L., Heather, N., Wodak, A. and Webster, I. (1996) General practitioners' promotion of healthy life styles: what patients think. Australian and New Zealand Journal of Public Health 20, 195–200.[ISI][Medline]

Roche, A. M. and Richard, G. P. (1991) Doctors' willingness to intervene in patients' drug and alcohol problems. Social Science and Medicine 33, 1053–1061.[CrossRef][ISI][Medline]

Roche, A. and Freeman, T. (2004) Brief interventions: good in theory but weak in practice. Drug and Alcohol Review 23, 11–18.[CrossRef][ISI][Medline]

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R. and Grant, M. (1993) Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction 88, 791–804.[ISI][Medline]

Volk, R. J., Steinbauer, J. R. and Cantor, S. B. (1996) Patient factors influencing variation in the use of preventive interventions for alcohol abuse by primary care physicians. Journal of Studies on Alcohol 57, 203–209.[ISI][Medline]

Wallace, P. G. and Haines, A. P. (1984) General practitioner and health promotion: what patients think. British Medical Journal 289, 534–536.[ISI][Medline]





This Article
Abstract
Full Text (PDF)
All Versions of this Article:
39/6/532    most recent
agh090v1
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Search for citing articles in:
ISI Web of Science (3)
Request Permissions
Google Scholar
Articles by AALTO, M.
Articles by SEPPÄ, K.
PubMed
PubMed Citation
Articles by AALTO, M.
Articles by SEPPÄ, K.