Department of Primary Health Care, School of Health Sciences, The Medical School, Framlington Place, University of Newcastle upon Tyne NE2 4HH and
1 Centre for Alcohol and Drug Studies, Northern Regional Alcohol & Drug Service, Newcastle City Health NHS Trust, Plummer Court, Carliol Place, Newcastle upon Tyne NE1 6UR, UK
Received 6 July 1998; in revised form 27 October 1998; accepted 11 November 1998
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ABSTRACT |
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INTRODUCTION |
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Beginning with the first development of the community response to alcohol problems during the 1970s (Shaw et al., 1978), there has been a concerted attempt in Britain to persuade GPs, among other frontline professionals, to become involved in identifying and intervening briefly with excessive drinkers. Research during the 1980s suggested that this effort had been largely unsuccessful at that time; studies by Anderson (1985) and by Clement (1986) reported low levels of activity among GPs in screening and intervention with heavy drinkers encountered in their practices. More recently, a household survey in England by the Office of Population Censuses and Surveys (Malbon et al., 1996
) found that, of current and former drinkers who had spoken to a medical practitioner or other health professional in the last year, only 12% of men and 5% of women reported having discussed alcohol consumption with their GP at the surgery.
The study reported here was a survey of GPs in the English midlands which aimed to investigate their recognition of and intervention for excessive drinking and alcohol problems among their patients. It also aimed to assess GPs' attitudes to this work and to determine whether any changes in these attitudes had occurred in the last decade. Factors related to screening and intervention and to attitudes to working with excessive drinkers, such as GPs' levels of training and perceived levels of support for this work, were also studied. Finally, GPs' views were obtained on barriers and incentives relating to brief alcohol intervention in primary health care settings. The study represented the British arm of Phase III (Strand 1) of the WHO Collaborative Project on Implementing and Supporting Early Alcohol Intervention Strategies in Primary Health Care.
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METHOD |
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Questionnaire
The 132-item questionnaire was developed as part of the WHO Collaborative Project and was pre-tested and piloted on 160 GPs from 11 countries. A copy of the study questionnaire is available from the first author (E.K.) on request. GPs' attitudes to alcohol issues were assessed via responses to a number of scales:
Statistics
All data were analysed using the SPSS for Windows computing program.
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RESULTS |
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Sample characteristics
Average age of GPs was 43.7 (SD = 8.5) years and 76% were male. Respondents had been in general practice for an average of 13 years (SD = 8.3) and spent an average of 5.4 (SD = 1.0) days per week in practice. The largest proportion (48%) said they saw more than 150 patients per week and 39% saw between 101 and 150 per week. Half (50%) worked in urban practices, 16% in rural practices and 34% described theirs as a mix between urban and rural practices. The majority of GPs (77%) worked in group practices, with an average of 3 (SD = 1.9) partners per practice.
Extent of medical education and training on alcohol
The largest proportion of respondents (34%) indicated that they had received between 4 and 10 h of post-graduate training, continuing medical education or clinical supervision on alcohol and alcohol-related problems, whereas 31% indicated less than 4 h. A further 10% said they had received no post-graduate training on alcohol at all. Amount of training did not differ significantly by gender, age, solo versus group status of GPs or practice rurality.
Current management of excessive drinkers
Two-thirds of GPs (65%) reported that they had managed between one and six patients specifically for hazardous drinking or alcohol-related problems in the previous year and 4% indicated that they managed none. Male GPs reported having managed significantly more patients for alcohol problems than female GPs (2 = 5.3, df = 1, P < 0.05). The largest proportion of GPs (34%) indicated that they had taken or requested a blood test because of a concern about alcohol consumption 35 times in the previous year, with 23% having taken or requested a blood test 612 times. There were no significant differences by gender, age, solo versus group status of GPs or practice rurality in requests for blood tests.
Sensible drinking limits
GPs reported the upper limit for alcohol consumption for healthy adult males and non-pregnant females before they would give advice to cut down. Most (94%) answered this question in terms of units (standard drinks) per week rather than grammes of alcohol (one unit was described as ~10 g of alcohol). For men, the mean upper limit was 23 units per week (SD = 5.8); both median and modal values were 21, with 41% of GPs recording this value. For non-pregnant women, the mean upper limit was 16 units per week (SD = 4.5); median and modal values were 14, with 50% of GPs recording this limit. These data are reported in more detail elsewhere (Kaner et al., 1997).
Recognition of alcohol-related problems
The majority of GPs (67%) indicated that they asked their patients about alcohol consumption some of the time. A further 23% asked most of the time and only 4% asked all the time. These responses did not differ by age, gender or practice rurality. GPs from solo practices reported asking patients about alcohol consumption more often than GPs from group practices (2 = 10.4, df = 1, P < 0.01). In an open-ended question, GPs were asked about typical conditions that would elicit an enquiry about alcohol consumption, and the categorized responses to this question are shown in Table 1
. Thirty-one per cent of GPs listed both physical and psychological symptoms and 36% listed a combination of physical, psychological, social and other conditions. Other conditions' referred mostly to new patient registrations. Only 1% of GPs listed psychological symptoms alone and none listed social problems alone. Responses did not differ significantly by either gender, age, solo versus group status of GPs, or practice rurality.
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Diagnostic and management skills
GPs indicated that the drinking problem was significantly more severe (z = 12.4, P < 0.001) in Case B (the dependent drinker) than in Case A (the excessive drinker) and they were more concerned that Case B should stop drinking alcohol altogether (z = 11.9, P < 0.001). However, GPs were significantly less confident (z = 4.10, P < 0.001) about being able to help Case B alleviate his drinking problem compared to Case A. Ratings were not significantly related to gender, age, solo versus group status of GPs, or practice rurality. The most frequent action recorded for Case A was to advise the patient to cut back on drinking (89% of respondents), whereas for Case B it was to advise abstinence (74% of respondents). A similar proportion of GPs (96% and 95%) indicated that they would ask some further questions about drinking for Case A and Case B, and 99% indicated that alcohol was probably related to some of the associated problems for both cases. Significantly more GPs (99%) indicated that they would order a complete blood count for Case B compared to Case A (85%) (2 = 27.3, df = 1, P < 0.001). Significantly fewer GPs (
2 = 113, df = 1, P < 0.001) said they would refer Case A to a specialist agency (15%) compared to case B (71%). These responses did not differ by gender, age, solo versus group status of GPs, or practice rurality.
Attitudes to working with excessive drinkers
Most respondents (88%) felt that GPs should be: involved (40%) or definitely involved (48%) in promoting non-hazardous alcohol consumption, and a similar number (86%) felt that GPs should be: involved (36%) or definitely involved (50%) in providing alcohol information. GPs were less accepting of a role in treating alcohol-dependent patients, with 60% endorsing the responses: involved (41%) or definitely involved (19%).
Table 2 shows the proportions of GPs agreeing with statements relating to the five variables of the SAAPPQ when working either with excessive drinkers or dependent drinkers. Mean role adequacy and work satisfaction scores were significantly higher for working with excessive drinkers than for working with dependent patients (z = 6.00, P < 0.001 and z = 4.89, P < 0.001 respectively). Role motivation and role legitimacy scores did not differ significantly between excessive drinkers and dependent patients. In contrast, mean self-esteem scores were significantly higher for working with dependent patients than for working with excessive drinkers (z = 5.22, P < 0.001).
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DISCUSSION |
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There was little effect of age, gender, solo versus group status of GPs, or practice rurality on experience of alcohol education and training or attitudes and practices relating to alcohol. The only differences were that male GPs reported managing more patients for alcohol problems during the last year than female GPs and solo GPs reported asking about alcohol consumption more often than GPs from group practices.
Most GPs did not routinely enquire about alcohol and relatively few blood tests were requested in the last year because of concerns about alcohol. The fact that 65% of GPs had managed one to six patients in the last year for excessive alcohol consumption was striking in view of evidence suggesting that ~20% of patients presenting to primary health care are likely to be excessive drinkers (Anderson, 1993). Given that the average list size per GP is 1820 patients (Royal College of General Practitioners, 1996b
), it is likely that the mean number of excessive drinkers seen by GPs each year is ~364. Thus the majority of GPs may be missing as many as 98% of the excessive drinkers presenting in primary health care. GPs' failure in identifying excessive drinkers may be due to a reliance on physical symptoms to elicit enquiry about alcohol which suggests that they are focusing on a medical model of alcohol problems.
Most GPs felt that moderate alcohol consumption was important for health promotion. However, only a third of GPs always enquired about patients' alcohol consumption and a further 58% enquired only if symptoms indicated that this was necessary. These figures may be over-estimates, given the data reported for actual practice during the last year. Most GPs felt prepared to counsel patients about alcohol consumption, although only a fifth of the sample felt effective in helping patients reduce consumption.
Whilst it is difficult to draw firm conclusions from comparisons with previous GP surveys, due to differences in context and methodology, such comparison is useful in highlighting trends over recent years. The scale of perceived ineffectiveness in helping to reduce alcohol consumption is disappointing since a study more than 10 years ago reported that, although only 29% of GPs regularly gave advice to patients to reduce alcohol consumption, 56% believed their advice was effective (Anderson, 1985). Experience of training and education about alcohol issues may have improved in recent years, since 42% of GPs in this study reported receiving <4 h post-graduate training on alcohol-related issues compared to 66% reported in the Anderson (1985) study. GPs' estimates of how much they would benefit from more training and support suggest that efforts to increase training in this area would on the whole be welcome by GPs.
In comparison with earlier work (Anderson, 1985; Clement, 1986
) more GPs felt that they should work with problem drinkers (role legitimacy) and that they possessed adequate knowledge and skills to do so (role adequacy). However, there appears to have been a deterioration in GPs' motivation to work with problem drinkers and in the satisfaction they expect to gain from doing so. Our findings fit with those reported in a recent national GP survey (Deehan et al., 1995
). This apparent increase in GPs' role legitimacy in recent years may be due to the increased emphasis on preventive medicine and health promotion in medical training and practice.
However, despite increased role legitimacy, many GPs do not feel confident about their abilities to intervene with alcohol problems. Accepting that it may be difficult to generalize from responses to case vignettes to actual practice, GPs in this survey were able to discriminate between cases of excessive drinking and alcohol dependence and indicate appropriate action in each case. Nevertheless, GPs lacked confidence in their ability to help alleviate drinking problems, particularly in the case of alcohol dependence. On the other hand, 60% of the GP respondents reported that they should be involved in treating alcohol dependent drinkers if appropriate support was provided.
The main disincentives for brief intervention for excessive alcohol consumption were insufficient time and training and lack of help from government policy. Lack of time may relate to the high workloads reported by GPs in this survey and more generally in the UK (Royal College of General Practitioners, 1996c). Among the 14 countries involved in the WHO International Collaborative Project, UK GPs were second only to those in Hungary in numbers of patients seen each week. It is interesting that patient resentment and GP awkwardness were not considered important barriers to brief intervention work. This might be seen as an improvement, given the earlier literature on the role of these interpersonal factors in discouraging enquiries about alcohol consumption (Cartwright, 1980
; Thom and Tellez, 1986
) and also suggests that interpersonal factors are now less important than the obvious structural and professional factors of workload and training. GPs regarded support services as essential if they were to become involved in brief alcohol intervention work. It may be that GPs are reluctant to screen for alcohol problems because they suspect that this will reveal too many serious problems for which they feel unskilled and unsupported in responding to (Durand, 1994
). Finally, GPs reported that evidence of the effectiveness of brief intervention was an important incentive for being more active in the alcohol area. This finding suggests a need for more proficiency in disseminating the strong evidence for the effectiveness of brief alcohol intervention that already exists (Bien et al., 1993
; Freemantle et al., 1993
; Heather, 1995
; Kahan et al., 1995
).
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APPENDIX 1. CASE HISTORY A: THE EXCESSIVE DRINKER |
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APPENDIX 2. CASE HISTORY B: THE DEPENDENT DRINKER |
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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