School of Social Science, Middlesex University, Queensway, Enfield, Middlesex EN3 4SF and
1 Centre for Research on Drugs and Health Behaviour, Imperial College School of Medicine, 200 Seagrave Road, London SW6 1RQ, UK
Received 3 February 1999; in revised form 22 April 1999; accepted 24 May 1999
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ABSTRACT |
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INTRODUCTION |
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To date, A&E departments which have become involved in responding to alcohol-related attendances have concentrated on intervening in heavy or dependent drinking (Green et al., 1993; Smith et al., 1996
; Peters et al., 1998
; Wright et al., 1998
); opportunistic intervention in attendances associated with intoxication or heavy drinking has received much less attention. This means that young people are unlikely to be questioned about their alcohol consumption or offered advice, although studies of younger age groups (under 25 years old) indicate that they are likely to be involved in drinking contests and practices which incur a risk of accidental injury leading to hospital attendance (Royal College of Physicians and British Paediatric Association, 1995
; Murgraff et al., 1999
). Research on alcohol-related attendances at A&E departments has not examined young people as a distinct group, and the extent to which A&E attendance might afford an opportunity to identify problematic drinking or alcohol-related risk in young people has not been addressed in the literature (Hayden, 1995
).
This paper describes the extent to which ambulant attendances by young people at two London hospitals were alcohol related, and considers the potential for screening and intervention with non-dependent young drinkers.
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METHODS |
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At each site, the sample comprised all ambulant patients attending over the course of one sample week, between the hours of 08:00 and 24:00 (midnight) from Sunday to Thursday and between 08:00 and 03:00 on Friday and Saturday respectively. The field work took place in March 1996 at Central, where the week comprised 7 days spread throughout 1 month and in May 1996 at Suburban where data were collected on 7 consecutive days. The difference in procedure occurred at the request of A&E staff, who had been consulted on ways to minimize disruption in the departments.
Researchers, working in shifts of two in the A&E waiting room, handed patients a written explanation about the study, provided further verbal explanation if necessary, and asked all patients aged 16 years or over to complete a short, anonymous, self-completion questionnaire. On completion, the questionnaire was put in an envelope and the respondent posted it in a box in the waiting room.
The questions covered socio-demographic details, the reason for attendance, the location of the accident, injury or illness, whether alcohol had been consumed in the 6 h prior to attendance, and perceptions of the extent to which alcohol had contributed to hospital attendance. The questionnaire included the Alcohol-Use Disorders Identification Test (AUDIT), which explores levels of alcohol intake, degrees of dependence, adverse reactions, and alcohol-related problems. It has been suggested that the AUDIT is a more sensitive screening instrument than other questionnaires (Bohn et al., 1995), and Conigrave et al. (1995) concluded that a cut-off point of 8 or above was able to detect those experiencing current alcohol problems as well as those at risk of future harm. This ability to detect risky drinking made the questionnaire a particularly suitable choice for screening younger people who are less likely to manifest symptoms of dependent drinking.
Initially univariate frequency tables were generated, to describe the data by respondent characteristics. Multiple logistic regression analysis was performed in a hierarchical manner to determine the independent contribution of each factor to the overall odds of the outcome of interest. All independent factors were subsequently controlled for when any factor of interest was considered. Statistical significance was assessed using the likelihood ratio statistic (Clayton and Hills, 1996). The statistical software package Stata 5.0 (Stata Corp, College Station, TX, USA) was used for all analyses.
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RESULTS |
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Sample characteristics are given in Table 1. There were no differences between the two hospital samples in terms of age, sex, employment, marital status, and trauma. A higher proportion of Suburban respondents were Asian, compared to the Central sample. Within each age group, there was no statistical evidence of differences between hospital attended and sex, employment, marital status, or trauma (all P-values > 0.07). Subsequent analyses grouped departments of both together.
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Strong evidence of interaction was detected between age and sex (P = 0.007). Among 16- to 24-year-olds, there was no difference in the odds of males and females scoring 8 or more on the AUDIT (P = 0.792 after adjustment), although among older respondents, males were nearly three times more likely to score 8 or above, compared to females (OR = 2.845, P < 0.001 after adjustment).
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DISCUSSION |
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Even among those reporting that they had not consumed alcohol in the 6 h prior to attendance, almost 30% of young people scored 8 or more on the AUDIT. Whether or not drinking prior to attendance was accurately reported by this group, the figure emphasizes the usefulness of using a screening instrument sensitive enough to detect hazardous drinking in young people, rather than relying entirely on self-report or on detection methods, such as alcohol on the breath. It also indicates the need to acknowledge the heterogeneity of drinking patterns and attitudes to drinking among young people when developing future preventive and intervention approaches in A&E departments.
Earlier studies (Green et al., 1993; Smith et al., 1996
; Wright et al., 1998
) have already demonstrated that it is possible to screen and respond positively within A&E settings to problem (hazardous and dependent) drinking. Currently, there is interest in developing the role of A&E departments to screen and intervene in a broader range of alcohol-related attendances, including attendances related to intoxication, binge drinking, and hazardous, but non-dependent, drinking patterns. At the same time, other data from this study (Herring and Thom, 1999
) and from elsewhere (Peters et al., 1998
; Waller et al., 1998
) reveal considerable barriers to developing such a role.
The nature of A&E care and the structure and organization of A&E departments present difficulties for staff expected to respond to an increasing range of preventive activities (Herring and Thom, 1999). One major factor is the time required to screen. The AUDIT takes approximately 2 min to complete and score (Conigrave et al., 1995
). Other instruments, such as the Paddington Alcohol Test take only 1 min (Smith et al., 1996
). Identification of an effective screening instrument which can be applied speedily within A&E procedures, which will identify non-dependent (hazardous) as well as dependent drinkers and be effective in screening younger patients, and which is acceptable to staff, is a prerequisite for encouraging routine screening beyond a few committed A&E departments.
Barriers also arise from attitudes towards alcohol use, perceptions of the role of A&E departments in responding to alcohol-related attendances and the limited training of staff in alcohol issues. As Peters et al. (1998) commented, the attitudes of nursing staff are crucial. In their study, the majority of the nursing staff interviewed claimed a holistic approach to health care, but did not equate this with the incorporation of screening and health promotion activity into the routine triage examination. Interviews with nurses conducted in the course of the current study found that attendances related to intoxication tended to be accepted as normal, and intervention was seen as inappropriate in the case of injured patients who had been drinking (Herring and Thom, 1999).
Such barriers are particularly pertinent in considering responses to young people. It is easier to argue for screening for dependent drinking where referral to specialist services or (in rare circumstances) to a specialist A&E nurse is a possibility. But it is more difficult to encourage screening for harmful, non-dependent drinking among young people if there are insufficient support services either within the hospital or the community. Clearly, A&E departments have a role to play in responding to harms related to youthful drinking. Such a role is unlikely to flourish, unless it is part of an integrated programme of activities involving partnership between local schools and colleges, the youth service, criminal justice workers, and health promotion specialists.
Questions remain, therefore, as to how best to encourage A&E departments to extend their role in screening for alcohol-related attendances, especially those of a non-dependent nature; which screening procedures and screening instruments are best suited for routine application in A&E departments; and whether intervention with young people possibly in the form of brief interventions' is a viable option in this setting. There is no doubt that A&E departments could play an important community role in monitoring and responding to alcohol-related harm. But if policy is to drive A&E departments in that direction, the above issues and questions must be addressed and the cost effectiveness of routine screening and intervention in A&E departments demonstrated. Equally, however, the need for appropriate resources and support in A&E departments must be acknowledged and steps taken to put supportive structures in place before negative attitudes and organizational difficulties hinder the implementation of screening and intervention initiatives and reinforce current reluctance to engage in alcohol work. Existing models of good practice merit extension and trial in a wider range of A&E settings and alternative forms of response, including brief interventions, require pilot studies to determine an appropriate range of effective interventions suitable for targeting different patient groups and different types of alcohol-related A&E attendances.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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Bohn, M. J., Babor, T. F. and Kranzler, H. R. (1995) The Alcohol-Use Disorders Identification Test (AUDIT): validation of a screening instrument for use in medical settings. Journal of Studies on Alcohol 56, 423432.[ISI][Medline]
Clayton, D. and Hills, M. (1996) Statistical Models in Epidemiology. Oxford University Press, Oxford.
Conigrave, K. M., Saunders, J. B. and Reznik, R. (1995) Predictive capacity of the AUDIT questionnaire for alcohol-related harm. Addiction 90, 14791485.[ISI][Medline]
Department of Health (1993) Health of the Nation Key Area Handbook on Accidents. HMSO, London.
Green, M., Setchell, J., Hames, P., Stiff, G., Touquet, R. and Priest, R. (1993) Management of alcohol-abusing patients in accident and emergency departments. Journal of the Royal Society of Medicine 86, 393395.[Abstract]
Hayden, D. (1995) Young people and alcohol-related accidents. Executive Summary No. 45. Centre for Research on Drugs and Health Behaviour, London.
Herring, R. and Thom, B. (1999) Alcohol-related attendances in the A&E department: could nurses have a preventative role? Nursing Times 95, 5962.
Murgraff, V., Parrott, A. and Bennett, P. (1999) Risky single-occasion drinking amongst young people, definition, correlates, policy, and intervention: a broad overview of research findings. Alcohol and Alcoholism 34, 314.[Abstract]
Peters, J., Brooker, C., McCabe, C. and Short, N. (1998) Problems encountered with opportunistic screening for alcohol-related problems in patients attending an Accident and Emergency department. Addiction 93, 589594.[ISI][Medline]
Rowland, N. and Maynard, A. K. (1987) Doctors have no time for alcohol screening. British Medical Journal 295, 9596.
Royal College of Physicians and British Paediatric Association (1995) Alcohol and the Young. The Royal College of Physicians, London.
Smith, S. G. T., Touquet, R., Wright, S. and Das Gupta, N. (1996) Detection of alcohol misusing patients in accident and emergency departments: The Paddington Alcohol Test (PAT). Journal of Accident and Emergency Medicine 86, 393395.
Waller, S., Thom, B., Harris, S. and Kelly, M. (1998) Perceptions of alcohol-related attendances in accident and emergency departments in England: a national survey. Alcohol and Alcoholism 33, 354361.[Abstract]
Wright, S., Moran, L., Meyrick, M., O'Connor, R. and Touquet, R. (1998) Intervention by an alcohol health worker in an accident and emergency department. Alcohol and Alcoholism 33, 651656.[Abstract]