Are Brief Alcohol Interventions Adequately Embedded in UK Primary Care? A Qualitative Study Utilising Normalisation Process Theory
Abstract
:1. Introduction
2. Materials and Methods
2.1. Setting and Participants
2.2. Data Collection
2.3. Data Management and Analyses
3. Results
3.1. Coherence—Making Sense of Screening and Brief Interventions for Alcohol
“By and large yes they are, they’re helpful… they certainly remind you of which questions to ask and perhaps fill in some of the details that you sometimes don’t ask.”GP2, male, directed enhanced service
“… where there are issues that alcohol comes up, then you would possibly use the brief intervention screening. Probably not as often as we should I would imagine. We probably ask more about alcohol and do our own sort of version of brief interventions rather than use the formal screening tool.”GP2, male, directed enhanced service
3.2. Cognitive Participation—Investing in Preventative Care for Risky Drinking
“… tying someone down to the number of units per week can take quite a long time and can disrupt the flow of the consultation…for my purposes, if the patient will or won’t acknowledge that it’s a problem is more important to me than specific numbers…”GP11, male, local and directed enhanced service
“…if somebody says it was insomnia and it transpired they were sleeping badly because they were drinking 70 or 80 units of alcohol a week then you would discuss it…If someone comes in with gout or something that would be a wonderful opener…but…we don’t proactively ask alcohol. We don’t go out to seek alcohol on its own.”GP12, female, local and directed enhanced service
“…the practice nurses probably have a much more structured approach…most of their work is chronic disease management and they tend to be filling in screening tools. So that’s what they do all the time, so they’re much better at it.”GP2, male, directed enhanced service
“…the biggest challenge is time. Because almost entirely that’s not what the patient has come about you know, erm, if they come asking to speak about their alcohol I don’t think it’s, well it may happen a once a year… but the rest of the time they’ve come about something else and, and so to give that something else its full appointment’s worth and then also fit in a little bit of our own agenda that’s the most challenging thing.”GP14, male, directed enhanced service
3.3. Collective Action—Implementing Brief Alcohol Interventions
“You know, are they in a place where they’re actually thinking about it, or is it not even on their radar, or is it just, you know that’s what they’ve come to talk about? So that’s what I would do next”.GP6, male, no enhanced service
“I suppose one of the key things I feel with alcohol to some extent is, I suppose people have to be wanting to change before you can take them too far down the road of an intervention. And so sometimes yes, they know they’re drinking too much but they’re not that ready to change, so going through a whole pathway doesn’t always help.”GP2, male, directed enhanced service
“…obviously there is evidence of brief interventions…but there is a perception that when it comes to lifestyle and things like that, people will just do what they want to do.”GP8, male, local and directed enhanced service
“...we tackle the DES through our new patient questionnaire that we post out to patients and they send it back and that fulfils the DES, you know I think it’s just a paper exercise…”GP14, male, directed enhanced service
“…that tends not to be done by the doctors, the AUDIT-C, that tends to be done by our healthcare assistants and nurses who are delivering the health promotion stuff, so everybody who comes through the hypertension clinic, the diabetic clinic, COPD, the asthma, the just the standard man off the street just wanting his cholesterol done, they all get fed through that template.”GP12, female, local and directed enhanced service
“We are encouraged to do opportunistic but I don’t think that happens, the way it tends to be done is as part of health checks so it’s more in people who have chronic diseases, so if they are seen about asthma, chronic heart disease any of those things.”GP13, female, local and directed enhanced service
3.4. Reflexive Monitoring—Evaluating and Modifying Brief Alcohol Interventions, and Embedding Change
“So while we’re signed up to it, and I think we are probably certainly asking people questions about their alcohol consumption at the relevant opportunities, such as new patient medicals and that sort of thing, we’re probably not doing anything too different from what we’d be doing anyway, which is just kind of dealing with stuff as it happens.”GP8, male, local and directed enhanced service
“I have been on the brief interventions training course although that now seems quite a long time ago. But we have, I suppose we tend to, I would admit that we probably don’t, we certainly don’t routinely screen every consultation or anything. So where there are issues that alcohol comes up, then you possibly use the brief intervention screening. Probably not as often as we should I would imagine. We probably ask more about alcohol and do our own sort of version of brief interventions rather than use the formal screening tool. Or I probably do but that’s because I’m not good at using screening tools.”GP2, male, directed enhanced service
“I think it’s partly just because that’s the way we’ve always done things. That it’s just to do things from experience rather than reverting to tools. And I think partly because people usually consult with other problems and alcohol is a bi-product of the consultation. So often the screening is quite an add-on at the end and the screening tools are a bit more formal.”GP2, male, directed enhanced service
4. Discussion
- First, as GPs often prioritise treating the main presenting condition in their patients, one strategy would be to ensure that when there is a recognised link between problem drinking and particular health conditions, then screening and brief alcohol intervention is delivered. For example, there is good evidence for the impact of alcohol consumption, and especially heavy drinking, on raised blood pressure [70].
- Second, given the time pressured context of primary care, we may need to rethink screening approaches. Successfully identifying the one in four primary care patients likely to be drinking above recommended levels [18] could result in an untenable burden on health systems. The introduction of higher AUDIT cut-off levels could both ensure the most problematic drinkers are prioritised for support [4], at the same time as tackling resistance amongst busy practitioners who are concerned about the impact of false positives both on workload and their rapport with patients [12].
- Third, and finally, there is a need to ensure that the translation of screening and brief alcohol interventions into real world practice does not stray too far from the evidence-base [67]. There remains ongoing debate as to what exactly constitutes the “active ingredients” of brief alcohol interventions [71], and around the most cost- and clinically-effective screening strategy [67,72]. However, on the basis of the available evidence, clinicians should be reminded that validated screening questionnaires, even in their shortest forms, remain the most efficient tools to reliably identify problem drinkers, and that prompting self-recording of alcohol intake is associated with greater intervention effect sizes [73]. Training and support can help build GPs’ knowledge and skills in this area, and is associated with higher rates of intervention activity, which in turn boosts role security and GPs’ therapeutic commitment over time [69].
5. Conclusions
Acknowledgments
Author Contributions
Conflicts of Interest
Abbreviations
AUDIT | Alcohol Use Disorders Identification Test |
AUDIT C | Alcohol Use Disorders Identification Test Consumption |
DES | Directed Enhanced Service |
FAST | Fast Alcohol Screening Test |
LES | Local Enhanced Service |
NHS | National Health Service |
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|
Sampling Criteria | Sub-Criteria | N (14) |
---|---|---|
Gender | Male | 7 |
Female | 7 | |
Experience in practice | >5 years | 4 |
5–15 years | 3 | |
>15 years | 7 | |
Employment status | Partner | 7 |
Salaried GP | 6 | |
Registrar | 1 | |
Location | Area A | 7 |
Area B | 7 | |
Enhanced service status | No Enhanced Service | 3 |
Directed Enhanced Service | 4 | |
Directed Enhanced Service & Local Enhanced Service | 7 |
NPT Construct | Theme | Sub-Themes |
---|---|---|
Coherence | Making sense of screening and brief alcohol interventions |
|
Cognitive Participation | Investing in preventative interventions for alcohol |
|
Collective Action | Implementing or day-to-day delivery of brief alcohol interventions |
|
Reflexive Monitoring | Evaluating and modifying brief alcohol interventions, and embedding change |
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O’Donnell, A.; Kaner, E. Are Brief Alcohol Interventions Adequately Embedded in UK Primary Care? A Qualitative Study Utilising Normalisation Process Theory. Int. J. Environ. Res. Public Health 2017, 14, 350. https://doi.org/10.3390/ijerph14040350
O’Donnell A, Kaner E. Are Brief Alcohol Interventions Adequately Embedded in UK Primary Care? A Qualitative Study Utilising Normalisation Process Theory. International Journal of Environmental Research and Public Health. 2017; 14(4):350. https://doi.org/10.3390/ijerph14040350
Chicago/Turabian StyleO’Donnell, Amy, and Eileen Kaner. 2017. "Are Brief Alcohol Interventions Adequately Embedded in UK Primary Care? A Qualitative Study Utilising Normalisation Process Theory" International Journal of Environmental Research and Public Health 14, no. 4: 350. https://doi.org/10.3390/ijerph14040350