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
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ABSTRACT |
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INTRODUCTION |
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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., 1992). 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.
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PATIENTS AND METHODS |
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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 2060 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, 1997). 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., 1974) and a structured quantityfrequency alcohol consumption scale from the last 2 months to screen heavy drinkers. The structured quantityfrequency 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., 1990
). For women the limits were 190 g/week and two affirmative answers (Seppä et al., 1992
). 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, 1997).
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.
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RESULTS |
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DISCUSSION |
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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, 1987). 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., 1990
). 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., 1984; Noel et al., 1987
).
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., 1980; Alterman and Cacciola, 1991
; Havassy et al., 1995
). 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.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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Babor, T. F. and Grant, M. (1992) Program on Substance Abuse: Project on Identification and Management of Alcohol-related Problems. Report on Phase II: A Randomized Clinical Trial of Brief Interventions in Primary Health Care. WHO/PSA/91.5: World Health Organization, Geneva.
Bien, T. H., Miller, W. R. and Tonican, S. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315336.[ISI][Medline]
Chick, J., Lloyd, G. and Crombie, E. (1985) Counselling problem drinkers in medical wards: A controlled study. British Medical Journal 290, 965967.[ISI][Medline]
Duckert, F. (1987) Recruitment into treatment and effects of treatment for female problem drinkers. Addictive Behaviors 12, 137150.[ISI][Medline]
Edwards, G. and Rollnick S. (1997) Outcome studies of brief intervention in general practice: The problem of lost subjects. Addiction 92, 16991704.[ISI][Medline]
Havassy, B. E., Wasserman, D. and Hall, S. M. (1995) Social relationships and cocaine use in an American treatment sample. Addiction 90, 699710.[ISI][Medline]
Heather, N., Kissoon-Singh, J. and Fenton, G. W. (1990) Assisted natural recovery from alcohol problems: Effects of a self-help manual with and without supplementary telephone contact. British Journal of Addiction 85, 11771185.[ISI][Medline]
Kristenson, H., Öhlin, H., Hulten-Nosslin, M. B., Trell, E. and Hood, B. (1983) Identification and intervention of heavy drinking in middle-aged men: Results and follow-up of 2460 months of long term study with randomized controls. Alcoholism: Clinical and Experimental Research 7, 203209.[ISI][Medline]
Mayfield, D., McLeod, G. and Hall, P. (1974) The CAGE questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry 131, 11211123.[ISI][Medline]
McLellan, A. T., Druley, K. A., O'Brien, C. P. and Kron, R. (1980) Matching substance abuse patients to appropriate treatments. A conceptual and methodological approach. Drug and Alcohol Dependence 5, 189193.[ISI][Medline]
Noel, N. E., McCrady, B. S., Stout, R. L. and Fisher-Nelson, H. (1987) Predictors of attrition from an outpatient alcoholism treatment program for couples. Journal of Studies on Alcohol 48, 229235.[ISI][Medline]
Rees, D. W., Beech, H. R. and Hore, B. D. (1984) Some factors associated with compliance in the treatment of alcoholism. Alcohol and Alcoholism 19, 303307.[ISI][Medline]
Rollnick, S., Heather, N. and Bell, A. (1992) Negotiating behavior change in medical settings: The development of brief motivational interviewing. Journal of Mental Health 1, 2537.
Seppä, K., Sillanaukee, P. and Koivula, T. (1990) The efficiency of a questionnaire in detecting heavy drinkers. British Journal of Addiction 85, 16391645.[ISI][Medline]
Seppä, K., Koivula, T. and Sillanaukee, P. (1992) Drinking habits and detection of heavy drinking among middle aged women. British Journal of Addiction 87, 17031709.[ISI][Medline]
Sillanaukee, P. (1997) Brief intervention in primary health care. In Community Prevention of Alcohol Problems, Holmila, M. ed, pp. 108122. Macmillan, Basingstoke.
Wallace, P., Cutler, S. and Haines, A. (1988) Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal 297, 663668.[ISI][Medline]