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Towards a new strategy for systematic screening for hazardous and harmful alcohol consumption in primary health care
Linköping University, Department of Department of Health and Society, Division of Preventive and Social Medicine and Public Health Science. Linköping University, Faculty of Health Sciences.
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Alcohol consumption is the third largest risk factor for morbidity and mortality in developed countries. In order to counteract the negative effects of the increasing alcohol consumption in Sweden, there is an urgent need to disseminate and integrate screening for hazardous and harmful alcohol use into the existing routines of primary health care. Although the primary health care system is considered well placed to implement prevention of alcohol-related harm, this is still seldom done. This should be seen in the light of good evidence with regard to the efficacy of screening and intervention methods, which take little time to deliver.

The primary aim of this thesis was to explore the prevailing status of alcohol preventive measures in a primary health care setting. The focus was upon the staff's knowledge, skills and attitudes concerning routine screening of patients for hazardous and harmful alcohol consumption. The secondary aim was to formulate a renewed screening strategy for primary health care.

The thesis includes five studies performed in the county of Östergötland, Sweden. Alcohol is by far disseminated into the existing routines in primary health care. Alcohol is the lifestyle factor that is most seldom raised by the health care staff. The groups of patients who receive some advice about their alcohol consumption are mainly those in least need of screening and advice such as older men with advanced illness on recurring scheduled visits, in contrast to younger persons with hazardous drinking.

The health care staff are mainly screening patients in whom they expect to find excessive alcohol consumption, in one sense making screening unnecessary. Both primary health care nurses and physicians are uncertain and reluctant to screen for hazardous alcohol consumption when there are no established medical symptoms. The staff mainly fmd alcohol screening to be practical and justified when a patients' complaint is perceived to be related to alcohol consumption, i.e. when the patient is thought to have harmful consumption. The great proportion of patients with hazardous drinking, i.e. above recommended limits but with no developed harm, are thus mostly not screened and therefore not identified. However, this group of individuals has the best potential to respond positively to brief alcohol intervention when delivered by a nurse or physician.

A truly preventive measure would be to screen all patients for excessive alcohol consumption including both hazardous and harmful drinkers, but the current organisation of the primary health care does not allow this approach. Instead, both nurses and physicians in the studies suggest a more selective strategy to mainly not include hazardous drinkers without symptoms. In order to establish which patient groups are the most appropriate to select for screening, taking into account the demands from the health care staff, as well as ensuring that even hazardous drinkers are included, a model was developed and empirically tested in order to identify such groups of patients. The model appears to be a reasonable means to identify groups of patients who should be included in a selective screening strategy by their presenting complaint. However, the hazardous drinkers were distributed within the various complaints fairly evenly and thus there was not enough strength in the study to identify specific patient groups despite the inclusion of all consecutive patients during a 2-week period.

The criteria for a selective screening strategy suggested in this thesis take into consideration the demands from primary health care staff as well as the need for a truly preventive approach that includes hazardous drinkers with no established alcohol-related harm. The suggested model for identifying groups of patients fulfilling these preconditions can be used in future research in order to identify relevant groups of patients to be included in a selective screening strategy that has the potential to be integrated into the existing routines of primary health care.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2005. , 82 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 886
Keyword [en]
alcohol consumtion, screening
National Category
Social Sciences
Identifiers
URN: urn:nbn:se:liu:diva-29402Local ID: 14741ISBN: 91-7373-866-2 (print)OAI: oai:DiVA.org:liu-29402DiVA: diva2:250216
Public defence
2005-04-01, Aulan, Hälsans hus, Universitetssjukhuset (ingång 16), Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-09-28Bibliographically approved
List of papers
1. Advice to patients in Swedish primary care regarding alcohol and other lifestyle habits: how patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation
Open this publication in new window or tab >>Advice to patients in Swedish primary care regarding alcohol and other lifestyle habits: how patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation
2005 (English)In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 15, no 6, 615-620 p.Article in journal (Refereed) Published
Abstract [en]

Background: Lifestyle advice given by general practitioners (GPs) may be a cost-effective means of health promotion; however, it is not fully put into routine practice. The aim of this study was to explore to what extent GPs' patients expect and receive advice concerning alcohol, tobacco, exercise and diet in relation to sociodemographic characteristics, type of visit and patient satisfaction.

Methods: A postal questionnaire was sent to a representative sample (n = 9750) of patients who had consulted GPs in a county in Sweden. The response rate was 69% (n = 6734).

Results: Exercise was the most (16%) and alcohol the least (5%) common type of advice. The patients received advice more often than they expected in all areas except alcohol. The patients reported the highest rate of unfulfilled advice expectation and the lowest rate of unexpected advice in the case of alcohol. Male gender, poorer self-rated health and scheduled appointment were independent predictors of all types of advice. Continuity of GP contact was only favourable for exercise and diet advice. The patients who received advice were more satisfied with their visit to the doctor.

Conclusions: A tertiary preventive perspective guides GPs' practice of giving advice. Male patients with advanced illnesses are given priority. Women and patients with long-term risk habits are more neglected. The GPs tend to misjudge the expectations and needs of their patients and are too restrained in their counselling practice. Alcohol is the most disregarded area of advice in proportion to the patients' expectations and needs.

Keyword
alcohol drinking, counselling, health behaviour, patient satisfaction, primary health care
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-29717 (URN)10.1093/eurpub/cki046 (DOI)15111 (Local ID)15111 (Archive number)15111 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
2. Early intervention for problem drinkers: readiness to participate among general practitioners and nurses in Swedish primary health care
Open this publication in new window or tab >>Early intervention for problem drinkers: readiness to participate among general practitioners and nurses in Swedish primary health care
2002 (English)In: Alcohol and Alcoholism, ISSN 0735-0414, E-ISSN 1464-3502, Vol. 37, no 1, 38-42 p.Article in journal (Refereed) Published
Abstract [en]

An exploration was made of attitudes and practices of general practitioners (GPs) and nurses concerning early identification of, and intervention for, alcohol-related problems. Sixty-five GPs and 141 nurses in 19 primary health centres in a county in southern Sweden answered a 28-item questionnaire before implementation of an intervention programme. The questionnaire covered experiences with patients with alcohol-related health problems, knowledge and perceived capacity concerning early identification and intervention, attitudes towards the role of primary care staff in early identification and intervention and current intervention methods in use at the health centre. Self-reported frequency of asking about alcohol use was higher among GPs than nurses. Both groups reported more frequently asking about alcohol consumption in cases where they believed that the health status was influenced by alcohol. For both professions, knowledge and skills concerning identification were rated as better understood than that concerning intervention methods. Nurses rated their knowledge and skills less confidently than GPs. The overall attitude was fairly positive towards early identification and intervention, but nurses were more worried than GPs that patients would react negatively to questions about alcohol. Attitudes, self-rated capacity, and practice were related. The low level of early identification and intervention in primary care appears to be related more to insufficient practical skills than to attitudes. Nurses appear to be an unexploited resource, in need of training and support. Nurses may need to be convinced that an active role does not interfere with the nurse-patient relationship. Building teams of GPs and nurses in primary care might enhance the dissemination of alcohol prevention into regular practice.

National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-26254 (URN)10.1093/alcalc/37.1.38 (DOI)10760 (Local ID)10760 (Archive number)10760 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
3. Under what circumstances are nurses willing to engage in brief alcohol interventions?: a qualitative study from primary care in Swedena
Open this publication in new window or tab >>Under what circumstances are nurses willing to engage in brief alcohol interventions?: a qualitative study from primary care in Swedena
2005 (English)In: Addictive Behaviours, ISSN 0306-4603, E-ISSN 1873-6327, Vol. 30, no 5, 1049-1053 p.Article in journal (Refereed) Published
Abstract [en]

To improve alcohol prevention in primary health care, it has been suggested that primary care nurses are an under-utilised resource. The aim of this study was to identify under what circumstances primary care nurses in Sweden are willing to engage in alcohol prevention. All nurses at three primary health care centres in Östergötland, Sweden were invited to participate in focus group interviews; 26 nurses participated. The nurses considered primary health care to be just one among other sectors within the community with responsibility for alcohol prevention. The role of health care in alcohol prevention was perceived to be important but mainly secondary preventive. The nurses felt justified screening all patients' alcohol habits only when they could refer to an obligation or a time-limited project. Otherwise, they mainly wanted to engage in screening patients with alcohol-related symptoms or diagnoses and other risk groups. Reasons for refraining from alcohol screening and intervention included lack of self-efficacy, time consumption and fear of harming their relationship with the patient. New strategies for alcohol prevention in primary care are discussed.

Keyword
Primary care, nurses, alcohol prevention, dissemination strategies, focus groups
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-29733 (URN)10.1016/j.addbeh.2004.09.008 (DOI)15132 (Local ID)15132 (Archive number)15132 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
4. Factors influencing GPs' decisions regarding screening for high alcohol consumption: a focus group study in Swedish primary care
Open this publication in new window or tab >>Factors influencing GPs' decisions regarding screening for high alcohol consumption: a focus group study in Swedish primary care
2005 (English)In: Public Health, ISSN 0033-3506, E-ISSN 1476-5616, Vol. 119, no 9, 781-788 p.Article in journal (Refereed) Published
Abstract [en]

Objective The aim of this study was to explore factors that influence general practitioners' (GPs') decisions regarding screening for high alcohol consumption.

Methods GPs working at three primary healthcare centres in Sweden participated in focus group interviews. The interviews were recorded and transcribed verbatim, and a deductive framework approach was used for the analysis.

Results The majority of the participating GPs did not believe in asking all patients about their alcohol consumption. Reported factors that influenced how many and which patients were questioned about alcohol consumption were time, age of the patient, consultation setting, patient–physician relationship, what symptoms the patient presented with, and knowledge of measures if patients appear to have a high alcohol consumption. Thus, alcohol screening and intervention were not performed in all patient groups as was originally intended, but were performed in limited groups of patients such as those with alcohol-related symptoms.

Conclusions Although the number of participants in this study was small and the conclusions cannot be generalized, the results provide some valuable insights into why GPs are hesitant to engage in screening for high alcohol consumption. Since prevention of alcohol-related health problems is an important public health issue, many different screening and intervention strategies have to be formulated and evaluated in order to reach patients with both hazardous and harmful alcohol consumption within the healthcare system. Screening all consecutive patients for a limited period or screening patient groups known to include a fairly high frequency of high alcohol consumers are two ways of limiting the time requirements and increasing role legitimacy. Still, there is a need for a broader public health strategy involving many players in the community in alcohol preventive measures, especially in more primary preventive approaches.

Keyword
Alcohol, screening, primary health care, dissemtion, GPs attitudes
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-29718 (URN)10.1016/j.puhe.2004.12.006 (DOI)15112 (Local ID)15112 (Archive number)15112 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
5. Towards implementation of alcohol preventive interventions into primary health care: testing a new model for selection of clinically meaningful patient groups for alcohol screening
Open this publication in new window or tab >>Towards implementation of alcohol preventive interventions into primary health care: testing a new model for selection of clinically meaningful patient groups for alcohol screening
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The aim of the study was to explore alcohol consumption and drinking patterns among primary health care patients in relation to their complaints as presented to the nurse in the reception at the health care centre. A model for identifying clinically meaningful groups of patients to be included in systematic screening for hazardous alcohol consumption was empirically tested.

Methods : The study was conducted at two primary health care centres in a large city in the county of Ostergiitland in southern Sweden. All patients 16 years or older visiting the health care centres during a 2-week period, received a questionnaire concerning their complaints and alcohol habits when registering at the reception. The patients returned the completed questionnaires in sealed boxes before leaving the health care centre. A model for identifying clinically meaningful patient groups to be included in systematic alcohol screening was developed and applied on the results from the questionmrire.

Results: Among 358 female respondents 10.6% (38 patients) were hazardous drinkers and among the 203 male respondents 20.2% (41 patients). When applying the model on the questionnaire results, it was possible to identify the most optimal patient groups for systematic alcohol screening on basis of the patient's complaints. Among the female respondents the most optimal patient groups to screen were those presenting skin, stomach/bowel, psychological, lung, or urinary tract complaints. Among the males were the patient groups presenting complaints concerning lungs, psychological problems, back, neck or shoulder problems, hypertension or injuries found to be the most optimal. There were, however, no significant differences in the proportion of hazardous drinkers for the different complaints, with the exception of male respondents with lung complaints, where 100% were hazardous drinkers.

Conclusions: As the proportion of hazardous drinkers among primary health care patients within each presented complaint was found to be rather low during the two week study period, it was not possible to make any definite conclusion about an optimal screening strategy. However the model presented may be useful in future research to identify clinically meaningful patient groups to be included in selective screening, although this requires a much larger data collection

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82032 (URN)
Available from: 2012-09-28 Created: 2012-09-28 Last updated: 2012-09-28Bibliographically approved

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