The objectives of this thesis are to: (1) highlight the impact of alcohol on patients’ health; (2) describe alcohol-related attitudes among general practitioners and district nurses who work with patients whose alcohol consumption is too high or risky; and (3) focus on the achievements of the Swedish Risk Drinking Project (RDP). Special attention has been devoted totwo themes: the gender perspective and general practitioners (GPs) perceptions on the limits of sensible/safe drinking.
Two main data sources constitute the basis for this thesis. For studies I and II, the material is based on a postal survey that was carried out
from December 2001 to February 2002 of all GPs and nurses working in primary health care (PHC) in the County of Skaraborg. For studies III and
IV, the material is based on two national postal surveys that were carried out to evaluate the effect of the RDP.
One of the surveys was conducted between November 2005 and February 2006 and the other between November 2008 and April 2009. They targeted all GPs, districts nurses (DNs) and registrars working in Sweden.
To evaluate if a change in clinical practice that could be related to RDP activities had occurred, we triangulated the results with two population surveys (Vårdbarometern and Monitor surveys) in which the participants reported whether they had been asked about alcohol when visiting PHC in the last year. We also studied changes in the number of alcohol-related diagnoses in PHC in western Sweden between 2005 and 2009.
The importance of drinking alcohol moderately, using counselling skills to reduce alcohol consumption and perceived current effectiveness in helping patients to reduce their alcohol consumption ranked lower than working with other lifestyle behaviours such as smoking, overweight, exercise and stress for both GPs and nurses.
For alcohol, the GPs assessed their role adequacy, role legitimacy and motivation higher than the nurses did. The main obstacles for the GPs to carry out alcohol intervention were
lack of training in counselling on reducing alcohol consumption, time constraints, and the fact that the doctors did not know how to identify
problem drinkers who had no obvious symptoms of excess consumption.
Both the gender of the patients and of the GPs influenced the advice and the referrals that the patients received. Men were more often recommended to reduce drinking (83%) than women (47%) as they were more often advised to stop drinking. Men were less often referred to any treatment, odds ratio 0.33. Male GPs referred excessive drinkers less often to any treatment than female GPs (odds ratio 0.26).
The upper limit of alcohol consumption before GPs advised the patient to cut down was significantly higher for GPs with an AUDIT-C score ≥3. The limit was 146 g/week for male patients and 103 g/week for female patients.
Corresponding figures for GPs with an AUDIT-C score ≤2 were 89 and 68 g/week. The mean recommended upper limit for safe drinking was
7.8 standard drinks/week for male patients and 5.3 drinks for female patients.
Respondents lacking postgraduate education on handling risk drinking stated significantly lower limits (6.9 drinks for males and 4.7 for females) thanthose with half a day or shorter education (8.0 drinks for males and 5.5 for females). GPs with higher self-perceived alcohol-related competence
suggested significantly higher limits than those who stated lower competence. Fifty-five percent of the participants in the 2009 survey had participated in alcohol-related education in the past 3 years.
For all three competence-related parameters analysed, discussion, knowledge and effectiveness of perceived competence in handling risk drinking, the increase was significant during these 3 years, particularly among DNs.
However, the population surveys showed no changes in the patients being asked about their alcohol consumption. There was only a small increase in alcohol-related diagnoses in
this time period; 9% in western Sweden from a very low number (in 2006, 1,443 patients had an alcohol-related diagnosis compared with 1,723 patients in 2008).
GPs and DNs estimated their alcohol-related competence as lower compared with many other health-related lifestyles issues. These results can possibly be explained by lack of practical skills and lack of training in suitable intervention techniques; thus unsupportive working
environments and negative attitudes may also have an influence. All these elements must be considered when planning secondary alcohol prevention programs in PHC. Male patients were less likely to be advised to stop drinking altogether than female patients and were also less likely to be referred to other treatments. Taking into account that male patients have a higher prevalence of alcohol problems, this may be of considerable importance for men’s health outcomes.
These findings show that there is a need for increased awareness of excessive drinking in men and that gendered perceptions might bias alcohol management recommendations. We found that 9 out of 10 GPs stated limits that were lower than the widely applied recommended levels in Sweden of 14 standard drinks per week for men and 9 for women.
Assuming that the GPs would take action at the limits they proposed in this study, it would mean that they would intervene with a very large proportion of their patients, many of whom consume rather modest amounts of alcohol and who do not feel that they have any problems with their alcohol intake. It can be questioned as to whether this is the best approach for screening and brief intervention.
The national RDP is a likely cause of enhanced self-perceived competence in the alcohol field among nurses and GPs. Using a combination of data sources to evaluate the impact of the RDP, it is uncertain whether this mainly educational effort has been sufficient to increase screening and brief intervention in PHC in Sweden.
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