1 Centre for Quality of Care Research, University Medical Centre Nijmegen, Nijmegen, The Netherlands, 2 Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, 4 Centre for Alcohol and Drug Studies, University of Northumbria, Newcastle upon Tyne, UK, 3 Department of Public Health and Community Medicine, University of Sydney, Sydney and 5 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
(Received 12 June 2003; first review notified 5 July 2003; in revised form 21 July 2003; accepted 28 July 2003)
* Author to whom correspondence should be addressed at: Centre for Quality of Care Research, University Medical Centre Nijmegen, 229 WOK, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Fax: +31 24 344 3137; E-mail: PDAnderson{at}compuserve.com
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ABSTRACT |
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INTRODUCTION |
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There has been an increasing emphasis on the role of primary health care in the prevention and management of alcohol-related harm (Babor et al., 1986; Anderson, 1996
; Babor and Higgins-Biddle, 2000
). However, despite the evidence for the effectiveness and cost-effectiveness of brief interventions in primary health care (Anderson, 1993
; Effective Health Care Team, 1993
; Moyer et al., 2002
), such interventions have yet to be integrated into routine clinical practice (Brotons et al., 1996
; Heather, 1996
; Gomel et al., 1998
; Spandorfer et al., 1999
; Aalto et al., 2001
; Rumpf et al., 2001
). General Practitioners (GPs) find alcohol a difficult issue, and they frequently lack the skills and the confidence necessary to provide preventive advice or even to screen effectively (Anderson, 1985
; Clement, 1986
; Thom and Tellez, 1986
; Dickinson et al., 1989
; Ockene et al., 1990
; Sallis et al., 1990
; Roche and Richard, 1991
; Roche et al., 1991
; Rabin, 1993
; Schofield et al., 1994
; Roche et al., 1996
; Deehan et al., 1998
). In the 1970s, the Maudsley Alcohol Pilot Project proposed that the key to increasing experience and effectiveness was to provide both education and training to primary health care providers, along with a supportive working environment, to improve their role security and their therapeutic commitment (Shaw et al., 1978
). The present study aimed to test this proposition using data from a survey carried out as part of a World Health Organization (WHO) Collaborative Study on Brief Interventions for Hazardous and Harmful Alcohol Use (Anderson, 1996
; Monteiro and Gomel, 1998
; McAvoy et al., 2001
). The hypotheses to be tested were that high scores on GPs' education on alcohol, on their perceptions of a working environment supportive of intervening with alcohol problems and on their role security and therapeutic commitment are associated with a greater number of patients managed for alcohol problems; and that high scores on GPs' education on alcohol, and on their perceptions of a supportive working environment, are associated with high scores on their role security and therapeutic commitment.
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SUBJECTS AND METHODS |
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Participants
The GPs were representative random samples selected from databases of practitioners maintained by national or regional health authorities or by academies and associations of GPs in each of the countries (Saunders and Wutzke, 1998). Self-completion questionnaires were posted to GPs together with instructions for completion of the questionnaire and a reply-paid envelope. In seven countries (Australia, Belgium, Canada, England, France, Italy, and New Zealand) non-responding GPs were telephoned 2 weeks after questionnaires were posted to encourage them to respond. In three countries (Belgium, England and Norway) up to two further questionnaires were posted to non-responding GPs to encourage them to participate in the study. Attempts were made to obtain a final sample of at least 200 GPs per country, randomly selected after stratification for age, sex, activity level of the general practitioner and socio-economic status of the practice area, where possible. Only one general practitioner per practice was selected for participation in the study.
Questionnaire and preparing variables for analysis
The questionnaire was developed by the Co-ordinating Centre of the Phase III WHO study in Sydney, Australia (Saunders and Wutzke, 1998). (A copy of this questionnaire is available from the first author on request.) The core version was translated into the national language of each participating country and independently back-translated into English to check accuracy of the initial translation, both literally and idiomatically.
Number of patients managed
The number of patients managed specifically for their hazardous drinking or alcohol-related problems in the previous year was classified on a self-reported ordinal scale; none, 16, 712, 1324, 2549 and 50 or more. Following the method adopted by Anderson (1985), GPs were grouped into those who managed seven or more patients in the previous year and those who managed fewer than seven patients in the previous year, including non-respondents.
Education and training
Education and training received on alcohol, including post-graduate training, continuing medical education or clinical supervision on alcohol and alcohol-related problems was classified on a self-reported ordinal scale; none, less than 4 h, 410 h, 1140 h and more than 40 h. Following the method adopted by Anderson (1985), GPs were grouped into those with >4 h of education on alcohol and those with <4 h, including non-respondents and those who indicated don't know.
Supportive working environment
A working environment supportive of intervening for alcohol problems was measured by four items that resulted from a factor analysis of 18 statements that indicated the extent to which the respondents thought that each one of a number of reasons explained why doctors in general practice spend very little or no time at all on early interventions for hazardous alcohol consumption. The factor analysis was undertaken with SPSS version 10, varimax rotation, and eigenvalue of <1.0. The four items measured the availability of suitable screening materials; the availability of suitable counselling materials; availability of training in counselling; and the availability of help with handling difficult family and social problems (Cronbach's standardized item alpha = 0.76). Individual missing values for any of the items of the factor were assigned the mean value of the remaining items before being summed. Responses to the four statements comprising the factor were summed. GPs were grouped as those with a supportive working environment (the top half of the total possible score) and those with a non-supportive working environment (the bottom half of the total possible score).
Role security and therapeutic commitment
Role security and therapeutic commitment were measured by responses to the short form of the Alcohol and Alcohol Problems Perception Questionnaire (Anderson and Clement, 1987). Role security measures role adequacy (for example, I feel I can appropriately advise my patients about drinking and its effects) and role legitimacy (for example, I feel I have the right to ask patients questions about their drinking when necessary). The Maudsley Alcohol Pilot Project found that role insecurity was expressed at the emotional level as a separate construct, which was termed therapeutic commitment (Shaw et al., 1978
). Therapeutic commitment measures motivation (for example, pessimism is the most realistic attitude to take toward drinkers), task specific self-esteem (for example, all in all I am inclined to feel I am a failure with drinkers) and work satisfaction (for example, in general, it is rewarding to work with drinkers). Individual missing values for any of the items of the domains were assigned the mean value of the remaining items of the domains before being summed. GPs were grouped into those with higher role security and therapeutic commitment (a score higher than the median value for each scale) and those with lower role security and therapeutic commitment (a score including and lower than the median value for each scale).
Statistical analyses
The whole dataset was combined and analysed at the level of the individual GP. Multilevel logistic regression analyses were used to test for interactions and to calculate odds ratios (OR) with 95% confidence intervals (CI), with country as a nesting random factor, using SASv6.12, macro:glimmix. The regression analyses were controlled for the sex and age of the GP and the total number of general practice patients the GPs reported they saw in an average week. Multilevel analysis was used because the GPs came from different countries and GPs within one country are expected to be more alike than GPs from different countries. Data that are structured in this way are said to be multilevel or hierarchical. In this instance, the hierarchy has two levels: level one consists of the individual GPs and level two consists of the countries in which the general practitioners are nested. Ignoring the grouping of the GPs within countries in the analysis is likely to result in effects being reported as significant when they are not (Healy, 2001). The odds ratio is the odds of an event in an intervention group divided by the odds of an event in the non-intervention group (Deeks and Altman, 2001
). An example in this study would be the odds of having high role security/therapeutic commitment in the presence of high education divided by the odds of having high role security/therapeutic commitment in the presence of low education.
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RESULTS |
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DISCUSSION |
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As a whole, GPs had limited experience in training in the management of alcohol problems. Only two-fifths stated that they had received >4 h of postgraduate training or continuing medical education on alcohol in the past. Whilst four-fifths of GPs felt secure in their role, only just over one-quarter felt therapeutically committed or that they were working in a supportive environment.
Strand 1 of the third phase of the WHO Collaborative Study on Brief Interventions for Hazardous and Harmful Alcohol Use provided a sample of 1300 GPs across nine high-income countries. The use of representative sample pools and the random sampling of subjects into the survey attempted to ensure that the GPs would be typical of practitioners within each country. However, despite attempts to maximize the number of responding GPs in each country, there was a variable response rate across countries, with an overall level of 56%. Although the non-responders may have differed in characteristics to those who responded (McAvoy and Kaner, 1996), in terms of interest and experience in the management of alcohol problems, the respondents and non-respondents were similar in age, gender, and activity level.
The measures were self-reported, which may have made them prone to socially desirable responding, for example, by reporting more positive attitudes towards working with drinkers or stating a higher number of patients managed for alcohol-related problems. An attempt was made to minimize this type of bias by ensuring anonymity and confidentiality to GP respondents, and by providing them with don't know/can't remember options in a number of the responses. Recall bias was also possible, with GPs who were more active in the number of patients that they managed being more likely to recall having received education and training on alcohol. The survey was cross-sectional in nature, allowing for no inferences of paths of causality. It could be, for example, that, whereas more positive attitudes predicted a larger number of patients managed, a larger number of patients managed could have led to more positive attitudes.
Despite the methodological reservations, and therefore the need for caution in interpreting the results, the perceptions of GPs themselves would suggest that, in order for primary health care to fulfil its potential, both education and training and the creation of a supportive work environment to ensure role security and therapeutic commitment need to be provided (Deehan et al., 1998), a finding consistent with the conclusions of the Maudsley Alcohol Pilot Project (Shaw et al., 1978
) some 25 years ago. This study did not address the elements of effective education, although analyses reported elsewhere indicated that education was not only related to the number of patients managed, but also to the practitioners' diagnostic and clinical management skills as assessed by responses to standardized case vignettes (Kaner et al., 2003
). A supportive work environment was defined in this study as one in which GPs regarded screening and counselling materials, availability of training in counselling and help in dealing with difficult situations as being available. This is consistent with the evidence that supports the value of on-site support agents, for example facilitators (Fullard et al., 1987
), to act as role models, coaches and colleagues in shared care arrangements for dealing with more difficult areas of care such as the management of alcohol problems (Richmond and Anderson, 1994
; Rush et al., 1995
; Roche, 1996
).
In conclusion, although caution should be exercised in interpreting the results, which were derived from a cross-sectional self-report survey, GPs who reported managing a higher number of patients with alcohol problems stated that they had received more education on alcohol, expressed increased security and therapeutic commitment in their role and perceived that they were working in a more supportive environment. To enhance the involvement of GPs in the management of alcohol problems it is likely that a combination of both education and support in the working environment needs to be provided. Continuing research should examine the effectiveness of different strategies to engage GPs in the management of alcohol problems, and the extent to which such support can increase GPs' role security and therapeutic commitment.
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