Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study

AIMS

To determine if GPs' attitudes towards working with drinkers moderated the impact that training and support had on screening and brief intervention activity in routine practice.

METHODS

Subjects were 340 GPs from four countries who were part of a World Health Organization randomized controlled trial to evaluate the effectiveness of training and support in increasing screening and brief alcohol intervention. GPs' self-reported attitudes towards working with drinkers were measured with the Shortened Alcohol and Alcohol Problems Perception Questionnaire.

RESULTS

Whereas training and support increased GPs' screening and brief intervention rates, it did so only for practitioners who already felt secure and committed in working with drinkers. Training and support did not improve attitudes towards working with drinkers and, moreover, worsened the attitudes of those who were already insecure and uncommitted.

CONCLUSIONS

To enhance the involvement of GPs in the management of alcohol problems, interventions that increase both actual experience and address practitioners' attitudes is required. Such support could take the form of on-site support agents and facilitators.

ATTITUDES AND MANAGEMENT OF ALCOHOL PROBLEMS IN GENERAL PRACTICE: DESCRIPTIVE ANALYSIS BASED ON FINDINGS OF A WORLD HEALTH ORGANIZATION INTERNATIONAL COLLABORATIVE SURVEY

AIMS

To determine if general practitioners' (GPs) experience of education on alcohol, support in their working environment for intervening with alcohol problems, and their attitudes have an impact on the number of patients they manage with alcohol problems.

METHODS

1300 GPs from nine countries were surveyed with a postal questionnaire as part of a World Health Organization (WHO) collaborative study.

RESULTS

GPs who received more education on alcohol (OR = 1.5; 95% CI, 1.3-1.7), who perceived that they were working in a supportive environment (OR = 1.6; 95% CI, 1.4-1.9), who expressed higher role security in working with alcohol problems (OR = 2.0; 95% CI, 1.5-2.5) and who reported greater therapeutic commitment to working with alcohol problems (OR = 1.4; 95% CI, 1.1-1.7) were more likely to manage patients with alcohol-related harm.

CONCLUSION

Both education and support in the working environment need to be provided to enhance the involvement of GPs in the management of alcohol problems.

Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial

This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention (SBI) by nurses in primary care. Randomisation was at the level of the practice and the interventions were: written guidelines (controls, n=76); outreach training (n=68); and training plus telephone-based support (n=68). After 3 months, just 39% of controls implemented the SBI programme compared to 74% of nurses in trained practices and 71% in trained and supported practices. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues. However, there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management. Thus cost-effectiveness ratios (cost per patient appropriately treated) were similar between the three strategies. Given the potential for anxiety due to misdirected advice about alcohol-related risk, the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care.

Audit-3 and audit-4: effectiveness of two short forms of the alcohol use disorders identification test

AIMS

To identify suitable short versions of the Alcohol Use Disorders Identification Test (AUDIT) and to evaluate their effectiveness as screening tests for 'risky drinking' among men and women in primary health care (PHC) settings.

METHODS

A total of 255 patients attending five PHC centres in Catalonia (Spain) were interviewed by clinicians regarding health status and drinking pattern. Patients also completed the AUDIT. Clinicians' diagnosis of risky drinking was used as a gold standard to evaluate the effectiveness of three forms of AUDIT.

RESULTS

AUDIT-3 and AUDIT-4 performed similarly to AUDIT-10 in detecting risky drinking and had equivalent receiver operating characteristics curves and their areas under the curve.

CONCLUSIONS

Both short forms of AUDIT seem to be as effective as the full AUDIT for detecting risky drinking among men and women in PHC settings.

Efficacy of moderation-oriented cue exposure for problem drinkers: a randomized controlled trial

The effectiveness of cue exposure following a priming dose was compared with cognitive-behavioral intervention in a community sample of problem drinkers. Participants were randomly allocated to 1 of the 2 conditions and received a mean of 5.84 (SD = 2.69) sessions. A psychologist blind to treatment condition conducted an 8-month follow-up. Compared with pretreatment levels, significant decreases in alcohol consumption were evident posttreatment and maintained at follow-up for both groups. Reductions in severity of dependence, impaired control, and alcohol-related problems were also evident for both groups at follow-up. No differences in outcome associated with initial severity of alcohol dependence were apparent. The results raise the issue of the appropriateness of reserving a goal of controlled drinking for those with relatively mild alcohol problems and low alcohol dependence.

Efficacy of moderation-oriented cue exposure for problem drinkers: a randomized controlled trial

The effectiveness of cue exposure following a priming dose was compared with cognitive-behavioral intervention in a community sample of problem drinkers. Participants were randomly allocated to 1 of the 2 conditions and received a mean of 5.84 (SD = 2.69) sessions. A psychologist blind to treatment condition conducted an 8-month follow-up. Compared with pretreatment levels, significant decreases in alcohol consumption were evident posttreatment and maintained at follow-up for both groups. Reductions in severity of dependence, impaired control, and alcohol-related problems were also evident for both groups at follow-up. No differences in outcome associated with initial severity of alcohol dependence were apparent. The results raise the issue of the appropriateness of reserving a goal of controlled drinking for those with relatively mild alcohol problems and low alcohol dependence.

Patient and practitioner characteristics predict brief alcohol intervention in primary care

BACKGROUND

The effectiveness of an evidence-based health care intervention depends on it being delivered consistently to appropriate patients. Brief alcohol intervention is known to be effective at reducing excessive drinking and its concomitant health and social problems. However, a recent implementation trial reported partial delivery of brief alcohol intervention by general practitioners (GPs) which is likely to have reduced its impact.

AIM

To investigate patient-practitioner characteristics influencing brief alcohol intervention in primary care.

DESIGN OF STUDY

Cross-sectional analysis of 12,814 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires.

SETTING

Eighty-four GPs who had implemented a brief alcohol intervention programme in a previous trial based in the Northeast of England.

METHOD

GPs were requested to screen all adults (aged over 16 years) presenting to their surgery and follow a structured protocol to give a brief intervention (five minutes of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of the screening questionnaire were collected from all practices after a three-month implementation period.

RESULTS

Although AUDIT identified 4080 'risk' drinkers, only 2043 (50%) received brief intervention. Risk drinkers that were most likely to receive brief intervention were males (58%), unemployed (61%), and technically-trained patients (55%). Risk drinkers that were least likely to receive brief intervention were females (44%), students (38%), and university educated patients (46%). Logistic regression modelling showed that patients' risk status was the most influential predictor of brief intervention. Also, GPs' experience of relevant training and longer average practice consultations predicted brief intervention. However, personal characteristics relating to patients and GPs also predicted brief intervention in routine practice.

CONCLUSION

Interpersonal factors relating to patients and practitioners contributed to the selective provision of brief alcohol intervention in primary care. Ways should be found to remedy this situation or the impact of this evidence-based intervention may be reduced when implemented in routine practice.

Levels of aggression among a group of anabolic-androgenic steroid users

There have been numerous case studies and press reports of individuals committing acts of extreme violence while taking large doses of Anabolic-Androgenic Steroids (AAS). However, research using psychometric measures of aggression has tended to use small numbers of subjects which makes generalizing results difficult. In the current study the State Trait Anger Expression Inventory (STAXI) was administered to 50 AAS users and 40 non AAS-using control subjects. Subjects also underwent a semistructured interview focusing on AAS's effects on levels of aggression. Results showed that AAS users reported being significantly less in control of their aggression than controls. The semi-structured interview findings showed that elevations in aggression due to AAS use were reported by 60 per cent of AAS users. However, these elevations appeared more related to irritability and bad temper than acts of physical violence. The study also found that more AAS users than controls had worked as doormen/bouncers. This highlights the issue of whether AAS use causes aggression or whether aggressive individuals are attracted to AAS use. Future research should investigate this question.

Does the ICD 10 classification accurately describe subtypes of borderline personality disorder?

The aim of the paper is to explore whether the division of borderline personality disorder, as described in the DSM classification, into impulsive and borderline subtypes of emotionally unstable personality disorder in the ICD classification of personality disorder, is a valid division. The self-report questionnaire responses of 288 referrals to a personality disorder service were rated on each of the eight criteria for DSM-III-R diagnosis of borderline personality disorder. Factor analysis identified two factors; factor one closely corresponds with the borderline subtype of ICD10, whilst factor two closely corresponds with the impulsive subtype of ICD10. Criteria common to both factors unstable relationships and identity confusion - were considered core features of borderline personality disorder. The pattern of occurrence of the two factors was similar to the complex binary picture described by ICD10. However there were also differences. Firstly, identity confusion is found to be a core feature of both our factors, and this does not conform to the restriction of identity confusion to the borderline subtypes in ICD10. Secondly, we found a residual pool of undifferentiated borderline patients and a small group of pure non-impulsive borderline patients who are not currently accommodated within the ICD10 emotionally unstable personality disorder. We conclude that future classifications of this disorder should accommodate four subtypes, and suggest these subtypes have implications for treatment and further research.

A randomized controlled trial of Moderation-Oriented Cue Exposure

OBJECTIVE

A randomized controlled trial was conducted to examine the effectiveness of Moderation-Oriented Cue Exposure (MOCE) in comparison to Behavioral Self-Control Training (BSCT). The main hypothesis was that MOCE would be more effective than BSCT among a sample of problem drinkers aiming at moderate drinking. A subsidiary hypothesis was that MOCE would be relatively more effective than BSCT among problem drinkers with higher levels of alcohol dependence.

METHOD

Clients (N = 91; 75% men) were randomly allocated to either MOCE or BSCT. Treatment was delivered in weekly sessions by two trained therapists, in a nested design in which therapists switched to the alternative treatment modality approximately halfway through the trial. Follow-up was carried out 6 months following posttreatment assessment, with 85% successful contact.

RESULTS

There was no evidence for the general superiority of MOCE over BSCT. The subsidiary hypothesis was not confirmed. A subsample of clients (n = 14) showing levels of dependence at baseline above the commonly accepted cut-point for a moderation goal (Severity of Alcohol Dependence Questionnaire [SADQ] > 29) showed outcomes at least as favorable as those below the cut-point. The validity of self-reports of alcohol consumption and problems was supported by significant relationships with liver function tests (gamma-glutamyl transferase and alanine transferase).

CONCLUSIONS

These results provide no grounds for the replacement of BSCT by MOCE in routine, moderation-oriented treatment practice. Assuming they prefer it to abstinence and that it is not contra-indicated on other grounds, there seems no reason why clients showing a higher level of dependence (SADQ = 30-45) should not be offered a moderation goal.

Risk behaviours for HIV and hepatitis infection among anabolic-androgenic steroid users

This study examined HIV and hepatitis risk behaviours among anabolic-androgenic steroid (AAS) users and controls, providing a detailed assessment of both injection and sexual practices. Fifty AAS-using and 40 non-AAS-using weight trainers completed a semi-structured interview followed by a detailed questionnaire. The 'high risk' behaviour of sharing needles and syringes was not current practice among the AAS-using sample, with only one user reporting sharing injecting equipment in the past. However, for some users it was common practice to share multi-dose vials (19%) and to divide drugs using syringes (17%). Both these practices are potential routes for HIV and hepatitis infection. Significantly more AAS users (36%) reported increases in sex drive over the last three months than did the control subjects (5%). More AAS users than controls were engaging in sex with more than one partner while infrequently using condoms. These findings support the maintenance of needle exchange schemes which are essential to continued safe injecting practices among AAS users. The elevated sexual risk behaviour of AAS users could be due to AAS's effect of increasing sex drive or to a 'risk taking' personality trait among AAS users.

Changes in receptionists' attitudes towards involvement in a general practice-based trial of screening and brief alcohol intervention

BACKGROUND

Primary health care receptionists are increasingly expected to be involved in research. However, little is known about receptionists' attitudes to research or health programmes.

AIM

To examine changes in receptionists' attitudes, with different levels of training and support, towards involvement in a general practice-based trial of screening and brief alcohol intervention.

METHOD

Subjects were 84 receptionists, one per practice, who assisted in the implementation of a screening and brief alcohol intervention programme. Receptionists were randomly assigned to one of three conditions: control (no training or support), training alone, and training plus ongoing telephone support. Baseline and follow-up questionnaires were used to assess changes in receptionists' attitudes.

RESULTS

Of 40 items that measured receptionists' attitudes to involvement in the programme, 70% had deteriorated after three months, 20% significantly so. There was no effect of training and support condition. Receptionists' and GPs' attitudes to research and health programmes conflicted.

CONCLUSION

Receptionists developed more negative views about involvement in research and health programmes over the three-month study period, regardless of level of training and support.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners

BACKGROUND

Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice. An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines.

AIM

To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention (SBI) by general practitioners (GPs).

METHOD

Subjects were 128 GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority, who agreed to use the 'Drink-Less' SBI programme in an earlier dissemination trial. GPs were stratified by previous marketing conditions and randomly allocated to three intensities of training and support: controls (n = 43) received the programme with written guidelines only, trained GPs (n = 43) received the programme plus practice-based training in programme usage, trained and supported GPs (n = 42) received the programme plus practice-based training and a support telephone call every two weeks. GPs were requested to use the programme for three months. Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with.

RESULTS

Seventy-three (57%) GPs implemented the programme and screened 11,007 patients for risk drinking. Trained and supported GPs were significantly more likely to implement the programme (71%) than controls (44%) or trained GPs (56%); they also screened, and intervened with, significantly more patients. Costs per patient screened were: trained and supported GPs, 1.05 Pounds; trained GPs, 1.08 Pounds; and controls, 1.47 Pounds. Costs per patient intervened with were: trained and supported GPs, 5.43 Pounds; trained GPs, 6.02 Pounds; and controls, 8.19 Pounds.

CONCLUSION

Practice-based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs.

A randomized trial of three marketing strategies to disseminate a screening and brief alcohol intervention programme to general practitioners

BACKGROUND

Research findings are of little benefit to patients or society if they do not reach the audience they are intended to influence. A dissemination strategy is needed to target new findings at its user group and encourage a process of consideration and adoption or rejection.

AIM

To evaluate the effectiveness and cost-effectiveness of different marketing strategies for the dissemination of a screening and brief alcohol intervention (SBI) programme to general practitioners (GPs).

METHOD

Seven hundred and twenty-nine GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority were randomly assigned to one of three marketing strategies: postal marketing (mailing a promotional brochure to GPs), telemarketing (following a script to market the programme over the telephone), and personal marketing (following the same script during face-to-face marketing at GPs' practices). GPs who took up the programme were asked if they would agree to use it. Outcome measures included the proportions of GPs who took up the programme and agreement to use it.

RESULTS

Of the 614 GPs eligible for the study, 321 (52%) took the programme. There was a significant difference in the proportions of GPs from the three marketing strategies who took the programme (82% telemarketing, 68% personal marketing, and 22% postal marketing). Of the 315 GPs who took the programme and were eligible to use it, 128 (41%) agreed to use the programme for three months. GPs in the postal marketing group were more likely to agree to use the programme (55% postal marketing, 44% personal marketing, and 34% telemarketing). Personal marketing was the most effective overall dissemination strategy; however, economic analysis revealed that telemarketing was the most cost-effective strategy. Costs for dissemination per GP were: 13 Pounds telemarketing, 15 Pounds postal marketing, and 88 Pounds personal marketing.

CONCLUSION

Telemarketing appeared to be the most cost-effective strategy for dissemination of SBI to GPs.