Opinions on alcohol-related issues among professionals in primary, occupational, and specialized health care

Janne Kääriäinen1,2, Pekka Sillanaukee1,3, Pauli Poutanen4 and Kaija Seppä1,4,*

1 University of Tampere, Medical School, Tampere,
2 Department of Otorhinolaryngology, Head and Neck Surgery, Tampere,
3 University of Tampere, Institute of Medical Technology, Tampere and
4 Tampere University Hospital, Department of Psychiatry, Tampere, Finland

Received 15 May 2000; accepted 23 October 2000


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
— The objective of this study was to analyse differences in health care personnel's knowledge, skills, and attitudes in relation to alcohol-related matters by a postal questionnaire between primary, occupational, and specialized health care. Heavy drinking was considered to be common among patients at all health care levels, and particularly in specialized health care. However, early recognition and treatment of heavy drinkers was considered more appropriate in primary and occupational health care, than in specialized health care. Alcohol consumption was found to be an easy subject to discuss at all health care levels. In addition, 90% (165/183) of the respondents thought that patients had a positive or neutral attitude towards questions on their alcohol consumption. Of the respondents, 32% (58/182) considered discussing alcohol-related matters unacceptable and 81% (121/149) believed that they could not influence patients' drinking using brief intervention; there was no significant difference between different settings. Additionally, motivational skills of doctors and nurses were found to be poor at all health care levels. Our study shows that, although discussing alcohol consumption is easy, better motivational skills and more positive attitudes are needed in primary, occupational, and specialized health care. Professionals need further education at all health care levels, but particularly in specialized health care.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Heavy alcohol consumption is a significant factor, which increases both morbidity and mortality (Shaper, 1990Go; Poikolainen, 1995Go; Thun et al., 1997Go; Tenth Special Report to the US Congress on Alcohol and Health, 2000aGo). It has a detrimental effect both on physical and mental health (Eckardt et al., 1981Go). Problem drinkers make more use of health care services than the general population and generally cause high costs for society (Royal College of Physicians, 1987Go; Rush and Brennan, 1990Go; Tenth Special Report to the US Congress on Alcohol and Health, 2000bGo). Therefore, early identification and treatment of alcohol problems in health care can be considered essential to prevent the harm caused by heavy drinking.

Brief intervention provides a suitable method of treatment for the health service to intervene in early-phase heavy alcohol consumption. Brief intervention includes: (a) identification of excessive alcohol consumption; (b) informing patients of disadvantages of alcohol use; (c) motivation to change consumption habits; (d) setting personal aims; (e) giving instructions to achieve these aims; (f) follow-up. A number of studies have shown brief intervention to be an effective and a cost-effective method of treatment (Holder et al., 1991Go; Bien et al., 1993Go; Wilk et al., 1997Go). Despite the good results, brief intervention is still rarely used (Andersson and Scott, 1992Go). This is explained by the conservative attitudes and haste of the health service, lack of knowledge and skills, negative attitudes, and relatively limited experience of secondary prevention (Clement, 1986Go; Weller et al., 1992Go; Roche et al., 1995Go; Bendtsen and Åkerlind, 1999Go; Kaner et al., 1999Go).

Hitherto, as far as we know, there is no research information on the differences of knowledge, skills, and attitudes in relation to alcohol-related matters between different health care settings. In order to be able to better target education, we have studied in the present work these differences between primary, occupational, and specialized hospital health care settings.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The study was carried out in Pirkanmaa Health Care District in southern Finland, with a population of 440 000, which is about 8.6% of the total population of Finland. One university hospital, three regional hospitals, and 22 primary health care centres are situated in this area.

In Finland, patients have equal access to the municipal communal public primary health care services. Private doctors also provide services. Thus, patients can choose between these two alternatives. Additionally, there are also many private and public occupational health care providers. The occupational health care system provides services to employed persons. Employers can make contracts either with public or private sector doctors. The differences between primary and occupational health care patients are that the former are not necessarily employed but the latter are, and that the former are always living in the geographical public health care area but the latter may live elsewhere. An employed person can choose freely to attend either occupational or public primary health care. Specialized health care hospitals treat patients referred by primary health care or private doctors, and, additionally, serious emergency cases are treated without referral.

At the beginning of 1996, 473 questionnaires were mailed to 139 units in the region, including all primary and occupational health care units and each department in specialized health care in hospitals. The distribution was via head physician and nurse, and the covering letter enclosed with each questionnaire stressed that the survey was anonymous. The covering letter was signed by the principal researcher (J.K.) and the chief physician of the University Hospital Department of Psychiatry (P.P.). Responses were requested from one doctor and one nurse per unit and ward. Each unit or ward was allowed to select the respondents themselves. Return of completed questionnaires was via reply-paid envelopes. One follow-up reminder letter with a questionnaire was mailed to maximize the response rate.

The questionnaire was piloted among 10 physicians not included in the study group. The questionnaire (available from the corresponding author K.S.) included 40 structured questions with two to six different alternatives. Characteristics of the respondents were first asked. The following questions enquired how often the respondents met heavy drinkers in their work and how often they thought that alcohol was the reason for seeking medical care. In addition, attitudes and skills in discussing alcohol consumption were asked. Subjects were also asked how well they knew brief intervention, and also if their skills and knowledge related to brief intervention were sufficient. The alcohol consumption of the respondents was also ascertained. Further different methods of recognizing heavy drinkers were asked. The last question enquired as to how important the subjects thought that their employers and the whole working group found treating heavy drinkers.

Questionnaires were analysed statistically using BMDP statistical software (BMDP, Cork, Ireland). The {chi}2-test was performed to measure the differences between different settings (specialized health care, primary health care, and occupational health care were compared). A P-value <0.05 was considered significant.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Of the questionnaires 39% (186/473), covering 51% (71/139) of the units, were returned. Some of the questions were inadequately filled in, which made the total number of answers 149–186 depending on the question. Of the respondents, 46/186 (25%) were men and 140/186 (75%) were women; 98/186 (53%) were physicians, and 88/186 (47%) nurses. The mean age of the respondents was 43 years (range 26–61 years) and the average time in the profession was 17 years (range 0.3–35 years).

Of the responses (n = 186), 60 (32%) came from specialized, 69 (37%) from primary, and 57 (31%) from occupational health care. Thirty-nine per cent (60/152) of the questionnaires sent to the specialized health care units were returned. Corresponding numbers for primary and occupational health care units were 44% (69/157) and 35% (57/164) respectively. There was no significant difference between the response rates of these three types of units. Questionnaires were unreturned equally from different specialties within specialized health care. The ratio of returned and unreturned questionnaires was similar in small (2–6 professionals; single-handed practices do not exist in Finland), and bigger, primary health care units. In occupational health care, the number of returned questionnaires was slightly higher in big, compared to small, occupational health care units.

Estimates of the prevalence of heavy drinkers in health care
Of the respondents, 79/186 (42%) thought that alcohol was very or quite often the reason for patients seeking medical care; 55% in specialized, 45% in primary, and 26% in occupational health care respectively, were of this opinion (d.f. = 8, {chi}2 = 29.7, P < 0.001) (Fig. 1Go). Drunken patients were met very or quite often by 88/186 (47%) of the respondents. There was no significant difference between specialized or primary or occupational health care. Heavy drinkers were considered to use health care services more often than other patients by 152/178 (85%) of all respondents; 93% in specialized, 86% in primary, and 76% in occupational health care (d.f. = 2, {chi}2 = 6.3, P < 0.05).



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Fig. 1. Alcohol as a reason for seeking medical care. Respondents' estimates of how often alcohol is the reason for patients to seek medical care in specialized, primary, and occupational health care.

 
Attitudes of the health care professionals to heavy drinkers
Asking the patients about alcohol consumption was found meaningful very or quite often by 110/185 (59%) of the respondents. There was no significant difference between the primary, occupational or specialized health care units.

Discussing alcohol consumption was considered as interfering in patients' private affairs and thus not acceptable by 58/182 (32%) of the respondents. However, 69/182 (38%) of the respondents found it fully acceptable to discuss alcohol consumption with the patients. There was no significant difference between the respondents in primary, occupational, and specialized health care.

Early recognition as well as the treatment of heavy drinkers was considered quite appropriate, very or extremely appropriate for their work, by 131/185 (71%) of the respondents; 26/60 (43%) in specialized, 51/68 (75%) in primary, and 54/57 (95%) in occupational health care (d.f. = 10, {chi}2 = 50.1, P < 0.001) (Fig. 2Go).



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Fig. 2. Appropriateness of early recognition and treatment of heavy drinkers for one's work. Respondents' estimates of how appropriate early recognition and treatment of heavy drinkers is for their work in specialized, primary, and occupational health care.

 
Knowledge and skills
Of the respondents, 125/185 (68%) thought that they could bring up alcohol problems for discussion very or quite well. However, only 32/182 (18%) of the respondents found their skills to motivate the patients to change their drinking habits were very or quite good (Fig. 3Go). Only 28/149 (19%) of the respondents believed that they could influence patient's drinking very or quite well using brief intervention (Fig. 3Go). There was no significant difference concerning the sex, age, occupation or length of the career of the respondents.



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Fig. 3. Ability to bring up alcohol for discussion, motivational skills, and possibilities of influencing alcohol consumption. Respondents' estimates on how well they can bring up the alcohol problem for discussion, how good they believe that their motivational skills are and how good the chances they believe they have of influencing patients' alcohol consumption.

 
Of the respondents, 88/184 (48%) thought that heavy drinking could be recognized simply by asking about a patient's alcohol consumption. There were 140/186 (75%) respondents who did not know of any structured questionnaires developed for recognizing heavy drinkers. The AUDIT questionnaire (Saunders and Aasland, 1987Go) was known by 19/186 (10%), the CAGE questionnaire (Ewing, 1984Go) by 35/186 (19%) and the Mm-MAST questionnaire (Kristenson and Trell, 1982Go) by 28/186 (15%) of the respondents. More than one questionnaire was known by 24/186 (13%) of the respondents.

The content of brief intervention treatment was known very or quite well by 51/184 (28%) of the subjects, whereas 38/60 (63%) in specialized, 22/67 (33%) in primary, and 18/57 (32%) in occupational health care knew it slightly or not at all (d.f. = 8, {chi}2 = 20.2, P < 0.01).

Alcohol consumption of the respondents
Of the respondents, 10/183 (5%) had been abstainers during the last year. There was no significant difference concerning sex, age, occupation, length of career or working unit. Forty-three per cent (79/185) of the subjects reported binge drinking (>6 doses) at least once a year and 5/185 (3%) of the respondents did this weekly; with male respondents doing so more often than female respondents (d.f. = 3, {chi}2 24.7, P < 0.001) and younger (<35 years) more often than older ones (d.f. = 6, {chi}2 18.6, P < 0.001). The mean number of drinks (e.g. 12 g of absolute alcohol)/week for male subjects was 5.2 drinks, whereas the corresponding number for females was 2.5 drinks (P < 0.0001). Alcohol consumption did not correlate with attitudes, knowledge or skills.

Opportunities to perform brief intervention in practice
Of the respondents, 94/183 (51%) thought that patients had very or quite positive attitudes towards asking about alcohol-related matters, whereas 9% of the respondents thought that patients had negative attitudes. There was no significant difference on this opinion concerning sex, age, occupation, length of career or working unit.

Working unit of the respondent was considered to find it important or very important to treat heavy drinkers by 30/68 (44%), 38/57 (67%), and 26/60 (43%) of the respondents in primary, occupational, and specialized health care, respectively. Of the respondents, 34/65 (52%) in primary, 31/55 (56%) in occupational, and 21/59 (36%) in specialized health care considered that their employers find it important or very important to treat heavy drinkers.

Of the respondents, 150/177 (85%) also thought that additional skills were needed to master brief intervention in practice; 60/67 (90%) in primary, 49/55 (89%) in occupational, and 41/55 (75%) in specialized health care, respectively, had this opinion. Further education to identify heavy drinking was considered necessary by 150/185 (81%) of the respondents. In primary, occupational, and specialized health care, 58/60 (85%), 51/57 (89%), and 41/60 (68%) of the respondents, respectively, had this opinion.


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The participation rate in our study was rather low. Dropping response rates have been shown to be an increasing problem in postal questionnaire studies in health care (McAvoy and Kaner, 1996Go; Kaner et al., 1998Go). Reminder letters and a new copy of the questionnaire were used to boost response rates. It has been shown that telephoning could be a more effective booster (McAvoy and Kaner, 1996Go; Kaner et al., 1998Go). In our study, questionnaires were answered anonymously. Some of the centres had only one to two physicians and nurses and thus, to maintain anonymity, the telephone was not used.

Lack of time and encumbering health care professionals with several studies may have lowered the response rate. The fact that heavy drinkers are often considered to be difficult and hopeless patients to treat may have lowered willingness to answer the questionnaire. Work units which did not respond to the questionnaire at all may have the most negative attitudes and poor knowledge of alcohol consumption. General willingness to answer questionnaires seemed to be similar in different health care settings, as the response rates in primary, occupational, and specialized health care did not differ. In addition, there were no major differences between the characteristics of the responded and non-responded units in different health care settings. These facts may lower the possibility of bias and thus make the comparison between different health care settings more reliable. However, there was a trend of small occupational health care units returning the questionnaires more seldom than the bigger units. This might indicate that motivation and activity in alcohol-related matters could be more prevalent if the numbers of staff were higher. Every centre was allowed to choose who should answer, which might have biased results. Most of the respondents may have been those who were interested in problem drinking and thus our results may be more optimistic than the real situation in the health care field with regard to brief intervention. Thus, the intention-to-treat analysis would only highlight the need to motivate and educate health care professionals in alcohol-related matters. The possibility that some of the respondents may have been forced to answer by a head physician or nurse is unlikely in Finnish culture. If no one expressed a wish to answer, the questionnaire would usually remain unreturned. The same would also be true with solo practices.

It was found that professionals consider excessive consumption of alcohol as a significant problem in health care. Almost half of the respondents considered alcohol as a common reason for patients to seek medical help; more often in specialized than in primary or occupational health care. The frequent use of the health service among heavy drinkers compared to other patients was found least common in occupational health care and most common in specialized health care. These results agree well with the fact that prevalence of patients with alcohol-related health problems in specialized health care is the same or even higher than in primary health care (Persson and Magnusson, 1987Go; Nielsen et al., 1994Go; Gentilello et al., 1995Go; Rambaldi et al., 1995Go; Wallerstedt et al., 1995Go).

Although almost one-half of the respondents found discussing alcohol consumption with the patients acceptable and over two-thirds found early identification of heavy drinking as well as treatment of heavy drinkers very appropriate for their work, one-third of the respondents thought that discussing alcohol problems was interfering in patients' private affairs and thus not acceptable. Family physicians have also, in earlier studies, found appropriateness of discussing alcohol consumption a problem (Rush et al., 1995Go). It was interesting to note that, in spite of the fact that alcohol problems are seen most often in specialized health care and least often in occupational health care, the figures concerning appropriateness of treatment of heavy drinkers in these settings were the opposite of this.

It was shown in the study by Wallace and Haines (1984) that patients expect doctors to ask about their alcohol consumption and other health risk factors. This has also been demonstrated in Canada in the study by Herbert and Bass (1997), where 85% of the patients expected doctors to ask about their alcohol habits. These studies are in agreement with our study, in which only 9% of the health care staff thought that patients have a negative attitude towards discussing their alcohol consumption. Positive attitude of the patients may therefore be an important matter to be emphasized in the education to increase the health care staff's acceptance of discussing alcohol-related problems. However, one must remember that patients accept advice, but not dictation of their lifestyles (Stott and Pill, 1990Go).

Over two-thirds of the respondents reported that they could bring up possible alcohol problems for discussion, but only one-fifth of the respondents believed that they could influence patient's alcohol behaviour or that they had a good command of motivational skills. Our findings are consistent with earlier reports, which have also shown that attitude towards intervening in excessive alcohol consumption is positive, although the intervention itself is not believed to be successful (Roche et al., 1995Go, 1996Go; Adams et al., 1997Go; Bendtsen and Åkerlind, 1999Go; Kaner et al., 1999Go). These pessimistic views on the success of brief intervention are reflected in actual clinical performance i.e. intervention is rarely used in practice. Now, health professionals are willing and able to recognize heavy drinkers. The future aim is thus to assist health care professionals to acquire better command of motivational skills and to gain more self-confidence from successful treatment. There is evidence that improvements in levels of self efficacy can increase intervention rates (Gottlieb et al., 1987Go). Giving more information regarding the scientific evidence demonstrating the significant success of brief intervention may also motivate health care staff to use brief intervention more often.

In our study very little was known of the content of brief intervention. Structured questionnaires developed for recognizing heavy drinkers were also poorly known. There was a great difference between levels in the health care system, as the knowledge of the content of brief intervention was significantly poorer in specialized health care, compared to occupational and primary health care. In addition, the respondents working in specialized health care did not find early recognition and treatment of alcohol consumption to be very appropriate to their work, compared to respondents working in primary and occupational health care. This seems logical; when brief intervention is not considered appropriate for one's work, it is not necessary to know the content. However, recognition and guidance of alcohol consumption included in brief intervention has been shown to be effective at every level in the health care system (Drummond et al., 1990Go). In addition, the number of heavy drinkers is even higher in specialized health care (see above), compared to primary and occupational health care. Thus, it is important to start brief intervention in specialized health care and to ensure the continuity of treatment by taking appropriate documentation.

Based on our results, the amount of alcohol consumption by the health care professionals did not correlate with their knowledge, skills or attitudes. However, the number of abstainers or heavy drinkers among the respondents was smaller than generally in the Finnish population. Based on these small numbers, no further conclusions on these relationships can be drawn from this study.

In summary, our study has shown that patients' attitudes do not prevent wide use of brief intervention, because the attitude of patients towards bringing alcohol consumption into discussion was found to be very positive in all the health care settings studied. In addition, employers were found to have a positive attitude towards treating heavy drinkers. Therefore, the better knowledge and skills of the health care professionals regarding brief intervention and more positive attitudes towards it are prerequisites for the wider recognition and treatment of heavy drinkers. These aspects should be emphasized in every health care sector. In particular, specialized health care professionals should be motivated and educated in performing brief intervention among the many heavy drinkers they meet every day in their work.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
This study was supported by a grant from The Medical Research (EVO) Fund of Tampere University Hospital.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed at: Medical School, University of Tampere, FIN-33014 Tampere, Finland. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
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