COMPLIANCE RATE AND ASSOCIATED FACTORS FOR ENTERING AN ALCOHOL BRIEF INTERVENTION TREATMENT PROGRAMME

Mauri Aalto1 and Pekka Sillanaukee1,2,3,4,*

1 Alcohol Research Centre, National Public Health Institute, Helsinki,
2 Medical School, University of Tampere,
3 Tampere University Hospital, Finland and
4 Medical School, Karolinska Institute, Stockholm, Sweden

Received 15 October 1999; in revised form 28 February 2000; accepted 27 March 2000


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The study aim was to ascertain the compliance rate and to compare associated factors among heavy drinkers willing and unwilling to enter an alcohol brief intervention treatment programme. Patients aged 20–60 years visiting five primary healthcare clinics for any reason were both asked to complete a health questionnaire and interviewed to identify early phase heavy drinkers and to collect sociodemographic and health data. About half of the heavy drinkers (487/1011) complied with a recommendation for brief intervention. Gender, age, drinking variables, smoking, and exercise were associated with compliance. Women and young adults are subgroups of heavy drinkers whose compliance was lower than others and special attention should be given to them when planning brief intervention strategies.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Heavy drinking of alcohol is a common health risk, which frequently leads to alcohol dependency and to a multitude of other medical, psychological, and social problems. Studies published during the last decade have shown alcohol brief intervention treatment to be effective in reducing alcohol drinking and associated problems. Brief intervention can be described as any therapeutic or preventive activity of short duration undertaken by a healthcare professional. In contrast to conventional alcoholism treatment, brief intervention is commonly performed by a healthcare provider who is not a specialist in addiction treatment, usually takes place elsewhere than in an addiction treatment setting, and generally has as its treatment goal moderate drinking, not total abstinence. In brief intervention, 20–48% of the heavy drinkers reduce their drinking (Kristenson et al., 1983Go; Chick et al., 1985Go; Wallace et al., 1988Go; Babor and Grant, 1992Go; Bien et al., 1993Go).

Many people who consume alcohol at the risk level do not seek treatment or do not want to change their drinking behaviour. Such patients have to be motivated to change. For many patients, the decision to change a behaviour such as heavy drinking is not easy to make. When attempting to motivate heavy drinkers to change their drinking habits, it is important to understand factors affecting that motivation. Promising techniques to help patients to work through ambivalence about drinking behaviour change have been developed (Rollnick et al., 1992Go). However, it is not fully known which factors related to a patient have an effect on readiness to undergo treatment. For enhanced understanding of a successful brief intervention, it is important to identify groups of less compliant heavy drinkers. The present study was conducted with a non-alcohol treatment-seeking population of primary healthcare out-patients to ascertain their rate of compliance to recommendations to enter brief intervention and to define factors associated with such compliance.


    PATIENTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The study was a part of the multi-component collaboration community action project of the World Health Organization Regional Office for Europe, called the Lahti Project (Sillanaukee, 1997Go). The study protocol was approved by the Ethical Committee of Lahti Primary Health Care Clinics, and was conducted according to the Helsinki Declaration on Human Experimentation.

The study was carried out in five primary health care clinics of the Finnish town of Lahti (95 000 inhabitants). All the practices and general practitioners (GPs) participated and no selection was involved. A total of 41 GPs participated and were given two half-day training sessions in identifying heavy drinkers, motivating heavy drinkers to participate in brief intervention, and carrying out brief intervention. All patients aged 20–60 years visiting the primary healthcare clinics between February 1993 and May 1994 were screened in order to define the prevalence of heavy drinkers and gain experience in carrying out long-lasting brief intervention (3 years) as a part of routine clinical work (Sillanaukee, 1997Go). Patients were offered a health survey and given a health questionnaire to be completed before the normal GP's consultation time. The response rate was 81.1% (11 797/14 548).

The questionnaire contained the four-question CAGE (Mayfield et al., 1974Go) and a structured quantity–frequency alcohol consumption scale from the last 2 months to screen heavy drinkers. The structured quantity–frequency scale included nine different fixed quantities (one portion to 30 or more portions), six different fixed frequencies (less than once a week to daily), and four different beverages (beer, long drinks, wine, and spirits). The weekly consumption (g of absolute ethanol/week) was calculated from these quantity and frequency numbers. A male patient was suspected of being a heavy drinker if his self-reported alcohol consumption was at least 280 g of absolute ethanol/week and/or his CAGE had at least three affirmative answers (Seppä et al., 1990Go). For women the limits were 190 g/week and two affirmative answers (Seppä et al., 1992Go). The health behaviour questionnaire also contained questions related to the following sociodemographic and health factors: gender, age, education (comprehensive school to university), employment, marital status, smoking (5 fixed quantities, not at all to more than 20 cigarettes per day), coffee drinking (4 fixed quantities, not at all to more than 8 cups per day), exercise (5 fixed quantities, not at all to more than 3 times per week), weight, height, type of fat used on bread, sleeping time/night, and self-assessment of physical and mental health (5 descriptions, poor to excellent).

After screening, based on the information received from medical records and a face-to-face interview, GPs excluded patients, who: (1) had severe somatic or psychiatric disease; (2) had had detoxification treatment; (3) were known to be alcohol-dependent or who had other alcohol-related disease; (4) were social drinkers and had a CAGE score above screening limits because of earlier heavy drinking, but had now stopped or reduced their drinking. At the same time, GPs recorded the use of anxiolytics or sleeping pills. Altogether, 1011 (658 men and 353 women) early phase heavy drinkers were identified. After detection, GPs offered the patients participation in a brief intervention treatment programme (Sillanaukee, 1997Go).

SPSS statistical software was employed. For the analysis, heavy drinkers were divided into two groups: (1) compliant heavy drinkers and (2) non-compliant heavy drinkers. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated to contrast the groups. The ORs were considered to be significant if the CIs did not include the value 1.0. Adjustments for gender and age were made based on a logistic regression model.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
In all, 487 out of 1011 (48.2%) heavy drinkers agreed to enter brief intervention treatment. The effects of demographic factors on compliance are shown in Table 1Go. Men complied 1.8 times more with treatment than women. Patients aged 40–60 years agreed to treatment 1.8–1.9 times more than younger ones. Patients aged 30–39 years did not differ from those aged 20–29 years. Adjustment lowered the ratios only a little. Education, employment, or having a partner did not affect compliance.


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Table 1. Odds ratios (OR) and 95% confidence intervals (95% CI) for willingness to enter brief intervention treatment according to sociodemographic characteristics
 
All drinking factors had a marked effect on compliance to start the treatment (Table 2Go). The higher the weekly self-reported consumption, drinking frequency, and usual drinking amount were, the larger the proportions of compliant patients. No CAGE score predicted higher entry into brief intervention.


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Table 2. Odds ratios (OR) and 95% confidence intervals (95% CI) for willingness to enter brief intervention treatment according to alcohol drinking characteristics
 
Table 3Go shows ORs for agreement to start brief intervention according to other health factors studied. Patients who smoked more than 20 cigarettes/day were 1.6 times more willing to begin treatment than non-smokers. Those who exercised only occasionally were 1.8 times more willing than those who exercised more than three times/week. Coffee drinking, body mass index, type of fat used on bread, and use of anxiolytics or sleeping pills did not affect the desire for brief intervention.


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Table 3. Odds ratios (OR) and 95% confidence intervals (95% CI) for willingness to enter brief intervention treatment according to several health characteristics
 
Self-assessment of physical or mental health did not affect willingness, even if the poorer the patient felt his/her health to be, the more willing he or she was to begin the treatment (Table 4Go). However, the difference was not statistically significant.


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Table 4. Odds ratios (OR) and 95% confidence intervals (95% CI) for willingness to enter brief intervention treatment according to self-assessment of health
 

    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The heavy drinking subjects in the present study were consecutive patients attending a primary healthcare out-patient clinic for any reason. This type of non-alcohol treatment-seeking population is a natural target for brief intervention in routine primary healthcare work. Subjects represent early phase alcohol misusers, since alcohol-dependent or patients having some other alcohol-related disease were not included. Because binge drinking is the most common type of alcohol misuse in Finland, the chosen criteria of heavy drinking are valid (Seppä et al., 1990Go, 1992Go) and the subjects are really in early phase even if CAGE scores are high. As far as we know, the present study is the first that attempts to find factors associated with early phase heavy drinkers' willingness to enter brief intervention (Edwards and Rollnick, 1997Go). The factors found here are associated with willingness to enter the treatment and they may differ from those associated with completing the treatment according to a plan or those factors associated with a good outcome.

A patient's motivation for treatment is not only intrinsic, it depends also on the interaction with the person trying to get them into treatment. However, in the present study, GPs' characteristics were not collected. GPs were not selected and they used mainly skills that they had adapted before, through practical work and professional training. They were given only two half-day training sessions in identifying heavy drinkers, motivating heavy drinkers to participate in brief intervention, and carrying out brief intervention.

In the present study, approximately half of all the early phase heavy drinkers were willing to start a brief intervention programme when the GP was offering it. Men complied with the treatment almost twice as frequently as women. This may indicate higher social thresholds for women than men to overcome, if they are to enter treatment for their alcohol problems (Duckert, 1987Go). In the study by Wallace et al. (1988), 60% of men and 64% of women screened as heavy drinkers, including alcoholics, attended initial interview. In the present study, the proportions were lower (54% for men and 39% for women) and men demonstrated higher compliance than women. The reason for the difference is probably due to the exclusion of alcoholics from the present study. In one study, attendance rate has been as low as 29% (Heather et al., 1990Go). In many brief intervention studies, no compliance rate for entering treatment comparable to the present study has been reported. Variation in study designs and in populations also makes comparison of compliance rates difficult.

Wallace et al. (1988) noted that compliance was greater among older patients with lower levels of alcohol consumption, than in younger and heavier drinkers. We found the same phenomenon concerning age, but those who reported drinking more had higher compliance. Other self-reported drinking variables were also strongly associated with willingness to enter brief intervention in the present study. A higher refusal rate among young patients has also been found in earlier studies concerning the treatment of alcoholism (Rees et al., 1984Go; Noel et al., 1987Go).

In treating addiction, the most important factors associated with lack of treatment compliance have been found to be low socio-economic status, lack of family support, and co-morbid psychiatric conditions (McLellan et al., 1980Go; Alterman and Cacciola, 1991Go; Havassy et al., 1995Go). According to the present data, non-addicted heavy drinkers' education, employment or partner status did not affect willingness to enter the treatment. Neither did the use of anxiolytics, which refers to psychiatric disorder. Additionally, even if there was a trend suggesting that unhealthy lifestyle is slightly associated with greater compliance, only in the groups smoking more than a pack a day or exercising only occasionally was the ratio significant.

It is somewhat surprising that factors such as CAGE score, hours of sleep, or self-assessment of health indicating consequences of drinking were not sufficiently associated with compliance to reach significance. However, there was a trend in self-assessment suggesting poorer health being associated with higher compliance. CAGE score indicating mainly the social consequences of drinking did not show any association with compliance. This can probably be explained by the fact that high CAGE score was the most common inclusion criterion in the present study.

In conclusion, it may be stated that for many heavy drinking patients, it is not easy to make the decision to participate in a brief intervention treatment programme or that they are not sufficiently aware of their drinking problem. However, as many as about half of the heavy drinkers will agree to enter brief intervention. Gender, age, drinking variables, smoking, and exercise are associated with willingness to enter brief intervention and should be taken into account when trying to motivate heavy drinkers to moderate their drinking habits. Sociodemographic status, CAGE score and self-assessment of health do not seem to affect compliance. Among patients having risk behaviours, such as heavy drinking, there are subgroups whose willingness to enter brief intervention is lower than others. According to the present study, these subgroups of heavy drinkers are women and young adults, and they especially should be taken into consideration when planning brief intervention strategies. The study also raises the question of how better to motivate women and young adult heavy drinkers to reduce their drinking.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The authors thank the Lahti Primary Health Care Brief Intervention Study Group, the Lahti Project Group, especially Marja Holmila and Kari Haavisto, and Hannu Koponen for helping in statistical analyses.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed at: FIT, Lenkkeilijänkatu 8, FIN-33520 Tampere, Finland. Back


    REFERENCES
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 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
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