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 |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
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., 2003b). 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, 1984
; Wallace et al., 1987; Richmond, 1996
; Aalto et al., 2002
). 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 |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
This study continues the earlier regional efforts to increase brief intervention for alcohol problems in health care settings in Finland (Kääriäinen et al., 2001). 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., 2003a
; 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 1665-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., 1993) were used as a quantityfrequency 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 (79 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 quantityfrequency method underestimates the real consumption in Finnish populations (Poikolainen, 1985
; Poikolainen et al., 2002
). 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?
Which of the following matters were addressed during the consultation? (Please circle all relevant choices)
Did you find the discussion concerning alcohol drinking useful?
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 |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
|
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 |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
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, 2004). 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, 1984
; Wallace et al., 1987; Richmond, 1996
; Aalto et al., 2002
). 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 1520% 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., 2003
). 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, 2001
). 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., 2001
).
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., 2003b).
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) 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 |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
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, 13711379.[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, 3943.[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, 914.[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, 169173.[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, 291294.[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.
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, 536542.
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, 795800.
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, 249258.[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, 99104.
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, 559566.
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, 822827.[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, 6773.
Poikolainen, K. (1985) Underestimation of recalled alcohol intake in relation to actual consumption. British Journal of Addiction 80, 215216.[ISI][Medline]
Poikolainen, K., Podkletnova, I. and Alho, H. (2002) Accuracy of quantityfrequency and graduated frequency questionnaires in measuring alcohol intake: comparison with daily diary and commonly used laboratory markers. Alcohol and Alcoholism 37, 573576.
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, 195200.[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, 10531061.[CrossRef][ISI][Medline]
Roche, A. and Freeman, T. (2004) Brief interventions: good in theory but weak in practice. Drug and Alcohol Review 23, 1118.[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 ConsumptionII. Addiction 88, 791804.[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, 203209.[ISI][Medline]
Wallace, P. G. and Haines, A. P. (1984) General practitioner and health promotion: what patients think. British Medical Journal 289, 534536.[ISI][Medline]
|