Family Practice Vol. 20, No. 3, 270-275
© Oxford University Press 2003
Communication |
Factors influencing inquiry about patients’ alcohol consumption by primary health care physicians: qualitative semi-structured interview study
Health Centre of Inner-Savo,
a Department of Public Health and General Practice and
c Department of Sociology, University of Kuopio and
b Department of Public Health and General Practice, University of Oulu, Finland.
Correspondence to Marja Aira, Health Centre of Inner-Savo, Hoitotie 20, 72100 Karttula, Finland; E-mail: marja.aira{at}fimnet.fi
Aira M, Kauhanen J, Larivaara P and Rautio P. Factors influencing inquiry about patients’ alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Family Practice 2003; 20: 270–275.
Received 28 May 2002; Revised 26 November 2002; Accepted 13 January 2003.
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Abstract |
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Background. Early recognition of and intervention in risky alcohol consumption has been shown to be an effective way to reduce the harm. However, primary care physicians are still not screening for and intervening sufficiently in their patients’ alcohol misuse.
Objective. The purpose of this study was to explore factors having an effect on primary health care physicians inquiring about patients’ alcohol consumption.
Method. A qualitative study of primary care physicians’ experiences and views based on tape recorded semi-structured interviews was carried out on all physicians (n = 35) working at four health centres in Eastern Finland.
Results. Seven main categories were identified that either prevent or promote discussion about alcohol consumption: the sensitive nature of alcohol drinking; the reason for consultation; awareness of a patient’s alcohol problem; patient factors; availability of intervention tools; expectations of effectiveness of interventions; and lack of time.
Conclusions. There still exist many barriers to initiating discussions about alcohol in the consultation room. Changing the frame of reference of the concept of alcohol drinking from an addictive disease to a general lifestyle risk factor could overcome many of these barriers.
Keywords. Alcohol consumption, interviews, prevention and control, primary health care, qualitative research.
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Introduction |
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Alcohol misuse has been shown to be a considerable cause of premature death.1 In addition, excessive alcohol consumption affects physical, mental and social health in multiple ways.2,3 Research has shown that early detection of, and counselling in alcohol misuse by primary care physicians, known as a brief alcohol intervention, is an effective way to reduce harm.4–6 Therefore, the World Health Organization and other health authorities recommend asking all patients about their alcohol consumption pattern, and intervention when necessary by primary health care workers.7
In general, patients do not seek help for their alcohol problems directly, but present many other complaints, which can be alcohol related, such as dyspepsia, sleeplessness, heart arrhythmias or psychosocial problems. In these circumstances, inquiring about alcohol consumption is called opportunistic screening. None of the single biomarkers or laboratory tests is 100% sensitive by itself in detecting harmful alcohol consumption in all cases.8 Evaluation of lifestyle health risks should always also include an evaluation of alcohol consumption pattern. This is one reason why it is important to raise the alcohol issue in discussions with the patient during the consultation. Inquiring about alcohol consumption is also the first step of a brief intervention.
However, many studies have shown that GPs find it difficult and are still reluctant to raise questions regarding alcohol consumption.9,10 Obstacles and difficulties that affect preventive work regarding alcohol use have been studied in quantitative surveys,9,11,12 and earlier also by qualitative methods in a few studies.13–15 Some factors that may hinder discussing alcohol-related matters in a primary care setting, such as lack of time, inadequate training and pessimism about the effectiveness of interventions, have been revealed in these studies, but there are still many questions remaining.
The aim of this study was to determine factors that influence inquiring about patients’ alcohol consumption. We used qualitative methods to gain a better understanding of the process from the physicians’ point of view.
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Method |
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Setting
The study was performed in four primary health care centres in Eastern Finland. Two of them were in rural communities with
4000 inhabitants, and two were in towns with 25 000 inhabitants. These health centres were chosen to form pairs for comparison in a future intervention study. The research ethics committee of Kuopio University approved the study.
Participants
There were 36 practising physicians in these health centres, and they all agreed to participate. One interview was cancelled for logistical reasons. Of the physicians, 18 were female and 17 male. Their mean age was 42 years (29–55 years). They had practised medicine on average for 16 years (1–25 years).
Interviews
We used qualitative semi-structured interviews with the intention to allow new viewpoints to emerge freely. A loose interview schedule was designed on the basis of key themes identified from issues prevalent in the research literature and from the analysis of three pilot interviews of physicians at another health centre. The purpose of the study was described to all practising physicians in a meeting. The interviews were carried out in the physicians’ workplace by one researcher (MA). As she was not known to interviewees, she introduced herself as a colleague doing research on the issue that was called to her attention in her own practice. All the interviews were initiated with the same question: what is the first thing that comes into your mind when you think about the alcohol consumption of your patients? The interviews resembled a general conversation between two professionals. However, the interviewer attempted not to take any leading position, but was a listener who gently directed the conversation to cover the main themes if necessary. She also used probing questions to verify her interpretations of answers.16,17 Emerging new ideas that were not anticipated with the initial schedule were followed in subsequent interviews. We had decided beforehand to interview all the physicians with the assumption that not all of them would participate. Towards the end of the study, no new themes emerged, indicating the saturation of the data. Consent for participation and tape recording was obtained before each interview. The duration of the interviews varied between 45 and 70 min, and they were tape recorded and transcribed verbatim.
Analysis
The interviewer listened to all the audio recordings and verified the precision of transcription. The physicians were coded using numbers. The transcripts were entered into QSR NVIVO 1.0, a computer software package. All data were examined line-by-line, and the main categories and themes were identified and coded using thematic analysis and constant comparison of the data. We searched thoroughly for all divergent views to form a rich description of different factors.
The main researcher (MA) coded all data. Another researcher (PR) also coded the pilot interviews and checked and discussed the analysis of the study data.
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Results |
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We found seven main categories or factors that influence the initiation of the subject of alcohol in a discussion during the medical consultation. Some quotes are chosen to illustrate the data.
Sensitive nature of alcohol drinking
The physicians stated that it was easy to continue if patients were seeking help for their alcohol problem or raised the issue themselves; but this seldom happened. Therefore, doctors had to take the initiative. The doctors are members of the community, and they have the same attitudes towards alcohol drinking as their patients. Drinking alcohol was seen as a more sensitive issue than smoking, overeating or lack of exercise. The harm done by alcohol could also be seen as self-inflicted.
"You can guess it from the background. The patient does not bring it up and obviously is hiding it. Then it makes you think how you should approach it. It is a more awkward issue; which of course must be brought up. It is such a difficult matter as for instance some psychiatric issue, which the patient does not reveal himself." Doctor 24
"It is somehow a more prohibited matter, this alcohol. Smoking has been more accepted and you can smoke openly, but alcohol has always been taken out of sight and you cannot confess your drinking." Doctor 11
"It is somehow more self-inflicted. The cholesterol and so on increases partly because of your genetic constitution." Doctor 17
"When I think of my own patients, like those regularly visiting for heart disease and high blood pressure, I always ask about their exercise, eating and smoking. Then after that I often might forget the alcohol. It is still a somehow sensible question, however." Doctor 28
Some doctors’ opinion was that it is not appropriate to ask questions about issues related to patients’ private lives. In some cases, they were reluctant to write down alcohol data on patients’ health records, because there might be a chance of stigmatizing the patient. Doctors also thought that patients, who have fairly easy access to their records in Finland, perhaps would not like such intimate issues to be recorded. However, none of the doctors stated that fear of harming the doctor–patient relationship was an obstacle to asking about alcohol consumption, when we asked about this specifically.
"Somehow there is a gap between one’s privacy and health. It is so much a private matter how much one drinks, and then it is a health concern. It is difficult to find the limit, is this really my business how much he drinks, or should I intervene more strictly." Doctor 27
"You must be careful in some cases what you put down in that text. I think I am not the only one." Doctor 5
Reason for consultation
None of the physicians was ready to ask about alcohol consumption routinely in every consultation, but only when the reason is connected to alcohol. In many conditions, such as high blood pressure, diabetes or dyspepsia, physicians had routines for history taking. However, alcohol often was not included in those lists of lifestyle risk factors. If there was an abnormal laboratory finding, it formed a useful basis for inquiring about a patient’s level of alcohol consumption. However, laboratory tests, such as 
-glutamyl transferase (GGT), were not routinely controlled. Physicians asked for them only when there was strong clinical evidence of alcoholism.
"I don’t ask always as a rule. If there is a symptom where it could be a contributing factor, then it is plausible. Some sleeplessness, dyspepsia or high blood pressure, or such like. But, if the condition has nothing to do with it I don’t know if it is natural." Doctor 23
"When I dictate the list there, it does not belong to it automatically. I think, it is only a matter of habit; you are not used to putting it in that list." Doctor 21
"And then, if there is a laboratory—a blood sample taken and there is high MCV value, then I am used to say that there are three common causes, and so on. How is your alcohol consumption? I think it is a good and clear opportunity to bring the matter up. You cannot ask flu patients if they happen to drink." Doctor 33
Awareness of patient’s alcohol problem
Sometimes physicians were aware of patients’ alcohol problem in advance of the visit. They could recognize the alcohol problem on health records of previous visits for frequent accidents or sick leave. Sometimes family members, health nurses or employers asked for help. Then doctors had to wait for an opportunity of raising the issue in a subsequent consultation.
"Sometimes wives ask if you could talk about this matter when their husband comes next time." Doctor 31
"From time to time they inform you from the workplace that you should intervene in this matter." Doctor 10
"If a health nurse tells you the day before that you will have that kind of patient who has a lot of (alcohol) problems in the workplace and the patient has some other reason for the consultation, then it is not simple to turn the conversation round to it, because it is not nice that you are going to ask on the grounds of a rumour." Doctor 30
Patient factor
Before openly asking about alcohol consumption, physicians often made an attempt to evaluate if a patient could be an excessive drinker. If they were not sure, they did not raise the issue. Physicians made this assessment by patients’ appearance, age, sex or profession.
"In my own work I have noticed at least one fault. When it is clearly visible that this person could be a user, then I always ask about alcohol consumption, but I certainly ask the others too seldom." Doctor 13
"Then there are those elderly women, you don’t think . . . You almost feel ashamed to ask if they drink alcohol." Doctor 2
"With people who seem very controlled and clever and so on, it is very difficult to get down to asking about their alcohol consumption. But for a person who already is a little shabby, it is easy to ask how their drinking actually is, when it is already visible by their appearance." Doctor 27
Availability of intervention tools
Physicians do not have many tools for handling alcohol problems. All the doctors stated that they were not trained to manage early alcohol problems during their graduate training, and they had not attended any postgraduate training. They knew how to handle late alcohol problems, such as liver cirrhoses or delirium tremens, but they could not define risky limits of alcohol consumption, and they did not feel able to motivate their patients to cut down. Though 20 physicians stated that they knew something about brief interventions, none of them had self-help booklets for patients or other counselling materials available. In the case of high blood cholesterol level, a pharmacological treatment always exists, if changing eating habits fails, but in excessive drinking there are very few drugs available. The doctors noted that their patients often are reluctant to go to specialist clinics for alcohol problems, even when they are given a referral. In excessive alcohol drinking, health nurses were not used as aids in counselling a healthy lifestyle in the way that they were used in diabetes or hypertension.
"In graduate training, alcohol was presented through these conditions: liver cirrhosis, cardiomyopathy, and in the public health course through social problems, but I don’t remember that in those days there were discussions of these mini-interventions or other matters. They were those fatty liver, cirrhosis and oesophagus varix kind of things." Doctor 23
"How can I measure it? When a pateint is overweight, it is easy to say and measure, and all these blood pressure, and others. Such gradually step-by-step beginning and hidden use of alcohol. At which stage it changes to a disease and a problem, and at which stage should I intervene, and at which stage can it be identified? I still don’t know." Doctor 4
"There I have a tottering feeling like being on thin ice, that now I know but so what." Doctor 21
"Of course, if there were medications and such you could use, it could also motivate doctors in a whole different way. Then the doctor would check out these and other things." Doctor 5
Expectations of effectiveness of interventions
Expectations of effectiveness in counselling were very low. The effectiveness of a treatment is judged by the feedback we have. The immediate feedback comes from patients’ reaction to alcohol questioning and counselling. These reactions were more positive than doctors had expected. However, they mentioned patients’ denial of alcohol problems as an obstacle for further processing. None of the interviewed doctors asked their patients for follow-up visits only to check how the alcohol problem was being managed. Thus they could not observe whether the counselling had been successful. Instead, they had a flow of feedback in the form of relapses of alcoholics and heavy drinkers in acute emergency situations.
"And, sure we tell, we do a brief intervention. We say, ‘you must not use alcohol’, but it does not necessarily lead to anything." Doctor 10
"When I have seen them for years and years, whether it changes anything, so there is really some kind of hopelessness at hand." Doctor 28
"It is important particularly in this work that you do not unnecessarily bang your head against the wall and waste energy on it. To know on the one hand what you can do and on the other what is realistic, and how much therapies help." Doctor 20
Lack of time
Most doctors considered lack of time to be an important obstacle. There were so many other tasks to perform during a consultation that doctors felt unable to take on any extra workload. They had to keep to their timetable.
"How do you find time for everything, as there are those other things to see in many other conditions, too?" Doctor 32
"One feels very busy and takes on only what one is obliged to treat." Doctor 33
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Our study identified many factors that either prevent or promote physicians’ inquiring about alcohol consumption in primary health care. The credibility of a qualitative study is judged by its comprehensibility and coherence with what is already known.18
A highly important factor was that alcohol drinking is a sensitive issue. Thus, physicians considered it as part of a patient’s private life which should not be invaded. Thom and Téllez have shown the same results in their interview study.13 The sensitiveness of the alcohol issue may reflect the moral aspect of the concept of alcoholism. Alcohol problems used to be handled mostly by social welfare authorities and the police in Finland, and the disease model was adopted only later with the arrival of the Alcoholics Anonymous movement. Doctors and patients do not see the difference between addictive disease—alcoholism—and lifestyle risk—excessive drinking.19 Changing the frame of reference when discussing alcohol drinking in medical training and in health education could reduce some of this stigmatizing effect of alcohol use—although the label also depends on the social and cultural environment. Alcoholism and its early prevention are taught in many countries by psychiatrists in the context of other substance misuse and addictive diseases. The whole scale of alcohol consumption, of which early alcohol misuse is a part, therefore takes on a shameful and hopeless aspect. Prevention of risky or harmful alcohol consumption, on the contrary, should be taught together with other lifestyle risk factors in general medicine. In that way, routine inquiries about alcohol consumption could be included in any medical history taking, and for all patients.
There are recommendations that doctors should ask all patients about their alcohol consumption. However, patients’ sex, age, appearance and profession did influence inquiries about alcohol. The existence of this patient factor has also been described by Volk in a patient survey20 and by Kaner in a recent implementation study of brief interventions.21 These quantitative studies confirmed that men and patients of lower social class are asked more often about and advised on alcohol consumption. Do physicians suspect more frequent alcohol consumption among these patients or, as we suppose, is it a question of doctor–patient communication, which is experienced differently with these patients? Giving advice may be easier from the top down.
The doctors felt that they did not really have enough tools in their practice to manage excessive drinking. Physicians feeling a lack of adequate training is a common finding in almost all studies.19,22 Physicians are used to screen risk factors using laboratory tests and to place reliance on medicaments if simple counselling is not successful. Examining laboratory findings is a traditional and well-accepted part of a doctor’s work. Although there is no sufficiently reliable laboratory marker for high alcohol consumption, some laboratory measurements, such as mean corpuscular volume (MCV), GGT and carbohydrate-deficient transferrin (CDT), could be useful in health checking.8 In addition to identifying excessive drinkers, they facilitate initiation of the discussion of alcohol and promote the organization of follow-up visits. Structured written questionnaires also help doctors in identification of alcohol risks.
Our study confirmed the negative expectations of the results of brief interventions reported in other studies.22 Some positive outcomes might occur if physicians were to ask their patients to come to follow-up visits to check the results of alcohol counselling. Using motivational intervention described by Prochaska et al. could overcome a patient’s denial as a barrier to further processes.23
Most implementation studies have suggested that time restrictions are very considerable barriers.19,22 In our study the physicians also cited lack of time to be an obstacle. The issue is whether we can take this at face value. Why do we not have any barriers to examining diabetic patients or to follow-up of high blood pressure, even if it takes a lot of time? Another interpretation could be that we set priorities for screening conditions for which we have tools and knowledge, or based on our patients’ requests.
The profession of the researcher has been shown to influence results in qualitative interview research.24 Some researchers have stated that interviewees give more restricted answers if they think that the interviewer does not understand the issue sufficiently.25 In this research, all the interviews were performed by a GP. She has practised medicine for many years and thus knows the field well. Therefore, it was possible to use professional language in these interviews, and being a colleague also helped in gaining the interviewees’ confidence. On the other hand, being part of the profession may cause some blind spots. This possible bias was reduced by performing the qualitative research in the Department of Social Psychology and by an attempt to take an external view. The resources did not allow use of two separate analysers. On the other hand, only the interviewer has the opportunity to use non-verbal information not present in tape records or transcripts.26
As a conclusion, our study suggests that there still exist many obstacles in doctors’ attitudes, knowledge and skills for recognizing and reducing risky alcohol consumption in their patients. To overcome the sensitive nature of excessive alcohol drinking, which is one of the most important barriers, we propose changing the frame of reference of the concept of alcohol drinking from an addictive disease to a risky lifestyle habit in doctors’ training, patient information and media campaigns.
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