A significant proportion of patients seen by family physicians drink alcoholic beverages above recommended limits [
Several studies dwelled on the reasons why such contradiction exists [
Physicians’ attitudes towards excessive drinkers are a key aspect to have into consideration when designing alcohol screening and brief interventions implementation programs. A previous study showed that training and support increased physicians’ intervention rates but only of those who already felt secured and committed in working with risky drinkers; those feeling insecure and uncommitted in the first place worsened their attitudes [
This paper aims to characterize the above-mentioned groups by comparing their characteristics and views on barriers and facilitators for alcohol screening and brief advice. We hypothesize that family physicians with better attitudes towards at-risk drinkers report fewer constraints in working with them.
A proportional random sampling strategy was conducted from April to June 2012. The Portuguese family physician national database, from which the sample was extracted, was stratified by age, sex, and health region. Selected family physicians were invited by e-mail to fill in the online questionnaire, available at a specifically designed and secured website. The survey was part of the Optimizing Delivery of Health Care Interventions (ODHIN) project. This was a four-year research project (2011–2014), cofinanced by the European Union, which included nine European countries. The project focused on the implementation of screening and brief intervention programs for hazardous and harmful drinking in primary health care. The survey instrument is available at the ODHIN project webpage [
A response rate of 30% was assumed based on previous studies showing that e-mailed surveys’ response rates are usually low [
The questionnaire was adapted from questionnaires applied in the World Health Organization Phase III strand I study [
Participants answered the survey through a secured website. They received an e-mail invitation explaining the study’s objectives, survey filling details, and a direct website link. The data collection method was completely anonymous and did not retain any information that could be used to differentiate respondents from nonrespondents.
Previous education and training on alcohol was dichotomized from a self-reported ordinal scale into “less than four hours” or “four or more hours” of alcohol specific education and training. Beliefs about family physicians’ effectiveness after being adequately trained in reducing patients’ alcohol consumption were dichotomized into “effective” or “ineffective.”
According to the Portuguese guidelines [
Alcohol-related clinical practice questions were recoded from a self-reported ordinal scale as follows: asking patients about alcohol even if they do not was dichotomized into “All the time/Most of the time” or “Some of the time/Rarely or never”; obtaining information on patients drinking alcohol moderately was dichotomized into “Always/As indicated” or “Occasionally/Rarely or Never”; preparedness to counsel patients reducing alcohol consumption was dichotomized into “Very prepared/Prepared” or “Unprepared/Very unprepared”; effectiveness in reducing patients’ alcohol consumption was dichotomized into “Very effective/effective” or “Ineffective/Very ineffective”; number of times a blood test was requested in the last year because of concern about alcohol consumption was dichotomized into “More than twelve times” or “Twelve times or less”; number of self-reported patients managed specifically for their hazardous drinking or alcohol-related problems in the last year was dichotomized into “Less than seven” or “Seven or more.”
Finally, barriers and facilitators were recoded as “Don’t know/Not at all” or “Little/Quite a bit/Very much” to differentiate between physicians who expressed agreement with the statement and those in disagreement or who had no opinion.
Data are shown as mean ± standard deviation or frequency distribution as appropriate. Family physicians groups were compared with independent samples
Sampled family physicians were on average
Family physicians with better attitudes towards at-risk drinkers were younger and less experienced and with higher proportion of male doctors than the group with worse attitudes (Table
Demographic characteristics of the sample of Portuguese family physicians participating in the survey.
Demographics | Group with worse attitudes | Group with better attitudes |
|
---|---|---|---|
Age | 53.7 ± 7.7 | 50.3 ± 9.8 | 0.005 |
Years practicing as a family physician | 24.0 ± 8.6 | 21.4 ± 10.3 | 0.04 |
Sex |
|||
Male | 41 (29.3) | 43 (45.7) | 0.01 |
Female | 99 (70.7) | 51 (54.3) | |
Practice characteristic |
|||
Urban | 62 (44.3) | 42 (44.7) | 0.57 |
Rural | 23 (16.4) | 11 (11.7) | |
Mixed urban/rural | 55 (39.3) | 41 (42.7) |
A majority of physicians (
Number of hours of training on alcohol received and views on effectiveness in reducing patients’ alcohol consumption if properly trained.
Training | Group with worse attitudes |
Group with better attitudes |
|
---|---|---|---|
Hours of any form of postgraduate training on alcohol ever received | |||
<4 hours | 98 (70.0) | 43 (45.7) | <0.001 |
≥4 hours | 42 (30.0) | 51 (54.3) | |
Would family physicians be effective with adequate information and training? | |||
Effective | 128 (91.4) | 92 (97.9) | 0.04 |
Ineffective | 12 (8.6) | 2 (2.1) |
Ninety-eight participants (41.9%) reported they would consider two standard drinks as the upper limit for alcohol consumption before they would advise a healthy adult man to cut down. A similar proportion (
We found no differences between the groups in respect to sensible drinking limits (Table
Family physicians’ knowledge about sensible drinking limits.
Sensible drinking limits | Group with worse attitudes |
Group with better attitudes |
|
---|---|---|---|
Upper daily limit for a healthy man | |||
=2 standard drinks/units per day | 57 (40.7) | 41 (43.6) | 0.66 |
≠2 standard drinks/units per day | 83 (59.3) | 53 (56.4) | |
Upper daily limit for a nonpregnant healthy woman | |||
=1 standard drink/unit per day | 62 (44.3) | 40 (42.6) | 0.79 |
≠1 standard drink/unit per day | 78 (55.7) | 54 (57.4) |
Most family physicians (
Both groups gave similar answers concerning alcohol-related clinical practice except when it comes to feeling prepared to counsel, and effective in helping, patients to cut down on their drinking: more family physicians with better attitudes felt prepared and effective in doing so (Table
Alcohol-related clinical practice behaviours.
Group with worse attitudes |
Group with better attitudes |
| |
---|---|---|---|
Ask about alcohol even if patients do not | |||
All the time/Most of the time | 102 (72.9) | 76 (80.9) | 0.16 |
Some of the time/Rarely or never | 38 (27.1) | 18 (18.9) | |
Extent to which information was obtained on patients’ drinking alcohol moderately | |||
Always/As indicated | 124 (88.6) | 86 (91.5) | 0.47 |
Occasionally/Rarely or Never | 16 (11.4) | 8 (8.5) | |
Feel prepared to counsel patients reducing alcohol consumption | |||
Very prepared/Prepared | 104 (74.3) | 86 (91.5) | <0.001 |
Unprepared/Very unprepared | 36 (25.7) | 8 (8.5) | |
Feel effective in helping patients reducing alcohol consumption | |||
Very effective/effective | 68 (48.6) | 73 (77.7) | <0.001 |
Ineffective/Very ineffective | 72 (51.4) | 21 (22.3) | |
Number of times a blood test was requested in the last year because of alcohol concern | |||
>12 times | 77 (55.0) | 61 (64.9) | 0.13 |
≤12 times | 63 (45.0) | 33 (35.1) | |
Number of patients managed for alcohol in the last year | |||
≥7 patients | 92 (65.7) | 71 (75.5) | 0.11 |
<7 patients | 48 (34.3) | 23 (24.5) |
In general, nearly half or more participants agreed with all suggested barriers.
In respect to health provider-related barriers, family physicians agreed doctors believe counselling is too difficult (
Regarding patient-related barriers, family physicians agreed doctors believe patients would disregard their advice (
Concerning organizational barriers, family physicians agreed doctors lack suitable counselling materials available (
Family physicians from both groups overlapped their views on most suggested barriers (Table
Agreement with selected barriers for the implementation of alcohol screening and brief interventions.
Barriers | Group with worse attitudes |
Group with better attitudes |
|
---|---|---|---|
Doctors are too busy dealing with other problems | 120 (85.7) | 74 (78.7) | 0.16 |
Doctors have a disease model training and do not think about prevention | 99 (70.7) | 57 (60.6) | 0.11 |
Doctors think preventive health should be patients’ responsibility not theirs | 71 (50.7) | 41 (43.6) | 0.29 |
Doctors are not sufficiently encouraged to work with alcohol problems | 111 (79.3) | 82 (87.2) | 0.12 |
Doctors feel awkward about asking questions about alcohol consumption | 109 (77.9) | 63 (67.0) | 0.07 |
Doctors do not know how to identify problem drinkers who have no obvious symptoms | 112 (80.0) | 61 (64.9) | 0.01 |
Doctors do not have a suitable screening device to identify problem drinkers | 115 (82.1) | 69 (73.4) | 0.11 |
Doctors do not have suitable counselling materials available | 117 (83.6) | 79 (84.0) | 0.92 |
Doctors are not trained in counselling for reducing alcohol consumption | 124 (88.6) | 78 (83.0) | 0.22 |
Doctors believe that alcohol counselling is too difficult | 133 (95.0) | 79 (84.0) | 0.005 |
Doctors do not believe that patients would take their advice | 117 (83.6) | 73 (77.7) | 0.26 |
Doctors themselves have a liberal attitude towards alcohol | 91 (65.0) | 58 (61.7) | 0.61 |
Doctors themselves may have alcohol problems | 96 (68.6) | 65 (69.1) | 0.93 |
Doctors believe that patients would resent being asked about their alcohol consumption | 82 (58.6) | 52 (55.3) | 0.62 |
The vast majority agreed with all suggested incentives to implement alcohol screening and brief intervention.
In respect to health provider-related facilitators, family physicians agreed they would be encouraged to do more early intervention for hazardous alcohol consumption if early intervention for alcohol was proven to be successful (
Concerning patient-related facilitators, family physicians agreed they would be encouraged to do more early interventions if patients requested health advice about alcohol consumption (
As to organizational facilitators, participants agreed they would be encouraged to do more early interventions if general support services (self-help/counselling) were readily available to refer patients to (
Family physicians from both groups showed similar views on all suggested barriers (Table
Agreement with selected facilitators for the implementation of alcohol screening and brief interventions.
Facilitators | Group with worse attitudes |
Group with better attitudes |
|
---|---|---|---|
Public health education campaigns | 136 (97.1) | 92 (97.9) | 1.0 |
Patients requesting advice about alcohol | 139 (99.3) | 90 (95.7) | 0.16 |
Having quick and easy screening questionnaires | 134 (95.7) | 88 (93.6) | 0.55 |
Having quick and easy counselling materials | 136 (97.1) | 92 (97.9) | 1.0 |
Proof of alcohol’s early intervention effectiveness | 136 (97.1) | 90 (95.7) | 0.72 |
Training programs for early intervention for alcohol | 136 (97.1) | 90 (95.7) | 0.72 |
General support services (self-help/counselling) | 137 (97.9) | 92 (97.9) | 1.0 |
Better salary and working conditions | 115 (82.1) | 77 (81.9) | 0.96 |
This study shows that family physicians with better attitudes towards risky drinkers report fewer constraints to implement alcohol screening and brief advice, specifically when it comes to physician-related barriers. Both groups reported similar views on organizational and patient-related barriers and differed only in two physician-related barriers concerning beliefs about knowledge and skills fundamental to approach patients’ alcohol-drinking habits. We also found a trend towards more doctors in the worse attitudes group feeling uncomfortable asking patients about alcohol. Taken together, these findings suggest that doctors with worse attitudes have higher knowledge and skills-training needs and also lower confidence levels in their abilities to implement alcohol screening and brief advice. This claim finds support in the differences found in education and training on alcohol: the group with better attitudes had more hours of postgraduate training, which may imply that previous training may have boosted physicians’ knowledge, skills, and confidence; they also believed that family physicians can increase their counselling effectiveness if they receive proper training. However, this was a cross-sectional study, which means that causality cannot be inferred. It is possible that physicians already with better attitudes prior to training sought to obtain education on alcohol simply because they had interest in alcohol issues. On the other hand, having more education and training on alcohol does not seem to improve knowledge of daily drinking limits, which points to the need of improving the way information is delivered during training.
Despite the differences found on the above-mentioned barriers, the groups shared similar views on all suggested facilitators. It seems that family physicians in both groups can equally benefit from changes in the primary care infrastructure. Possible changes are the availability of screening and counselling materials (e.g., having a screening tool installed on the electronic health record software, leaflets to hand over to patients), easy access to support services (e.g., specialist advice on difficult cases, a working referral network), and better payment and working conditions overall. Social pressure may also play an important part in increasing alcohol consumption discussions as most physicians would like to see patients asking for advice on this specific issue, pointing public health education campaigns as a possible way to achieve this.
Other interesting results relate to clinical practice issues. When advising patients to cut down, more family physicians with better attitudes reported feeling prepared and effective in reducing alcohol consumption. Despite this, we found similar self-reported practice behaviours on the number of patients advised, blood tests required, and information obtained on alcohol from patients. It seems that having more positive feelings towards at-risk drinkers does not necessarily translate into more self-reported screening and advice. This suggests that, despite its importance, addressing only physicians’ emotional aspects may fail to significantly increase screening and advice rates.
Groups differed also in demographic variables. Younger, less experienced family physicians reported better attitudes towards patients with excessive alcohol consumption. When it comes to gender, male physicians reported feeling more role-secured and therapeutically committed towards working with at-risk drinkers than female doctors. How to interpret these results remains elusive.
Physicians’ agreement with barriers and facilitators found in this study mirrors that reported in the literature. Many studies point to organizational factors as a major impediment to implement screening and brief interventions. The most common organizational barriers cited in these studies are lack of time [
Based on the findings of this study it seems reasonable to postulate that differences between groups relate essentially to their views on alcohol issues and to the way they feel about addressing those issues with patients. As such, we hypothesize that fine-tuning implementation programs only to the differences found may set the ground to an improvement in the way physicians think and feel about alcohol-related problems but will probably fail to achieve higher screening and advice rates. We believe we need a more comprehensive strategy to address the way family physicians deal with these issues in their daily practice. For example, we must carefully consider the role of other primary health care professionals. Nurses doing screening and even delivering brief advice might have a positive impact on family physicians own screening and advice rates. Receptionists handing self-administered screening tools to patients might boost screening rates. Including residents in the program may also be a positive influence. Implementation programs must be carefully planned if one wants to change deeply rooted routine clinical practice, which usually obliviates alcohol screening and brief advice.
The results of this study must be interpreted having its limitations in mind. The first is the low response rate achieved. Electronic surveys usually result in low response rates, but they seem to allow for generalization when the sampling method is conducted using probability samples of full populations [
As mentioned earlier, this was a cross-sectional study, which does not allow establishing causality paths. The example given earlier is illustrative: we cannot ascertain the direction of the association between training and physicians’ attitudes. It is possible that training may have improved physicians’ attitudes but is also conceivable that physicians with better attitudes to begin with sought to get training on alcohol-related problems. Nevertheless, results are consistent with similar studies previously reported, which gives support to the conclusions drawn.
Finally, data are self-reported and no external data validation was conducted. Some variables such as number of patients advised on alcohol, number of blood tests required, or frequency of asking about alcohol consumption are personal estimations and possibly subjected to bias.
Family physicians with better attitudes towards problem drinkers report fewer physician-related barriers to implement alcohol screening and brief interventions. They face similar difficulties concerning organizational and patient-related barriers and also enablers of these practices. We plan to integrate these results in the design of a new implementation program for alcohol problems in Portugal, seeking to increase family physicians’ screening and brief advice.
The study protocol was approved by the Ethics Committee of the Faculty of Medicine of Lisbon.
The authors report no conflict of interests.
The ODHIN project received funding from the European Union’s Seventh Framework Programme for Research, Technological Development and Demonstration under Grant Agreement no. 259268.