JANNE KÄÄRIÄINEN Stepwise, Tailored Implementation of Brief Alcohol Intervention for Risky Drinkers in Health Care ACADEMIC DISSERTATION To be presented, with the permission of the Faculty of Medicine of the University of Tampere, for public discussion in the Main Auditorium of Building M, Pirkanmaa Hospital District, Teiskontie 35, Tampere, on December 3rd, 2010, at 12 o’clock. UNIVERSITY OF TAMPERE ACADEMIC DISSERTATION University of Tampere, Medical School Finland Supervised by Reviewed by Professor Kaija Seppä Professor John Cunningham University of Tampere University of Toronto Finland Canada Docent Pekka Sillanaukee Docent Arto Vehviläinen University of Tampere University of Eastern Finland Finland Finland Distribution Tel. +358 40 190 9800 Bookshop TAJU Fax +358 3 3551 7685 P.O. Box 617 [email protected] 33014 University of Tampere www.uta.fi/taju Finland http://granum.uta.fi Cover design by Mikko Reinikka Acta Universitatis Tamperensis 1569 Acta Electronica Universitatis Tamperensis 1018 ISBN 978-951-44-8282-3 (print) ISBN 978-951-44-8283-0 (pdf) ISSN-L 1455-1616 ISSN 1456-954X ISSN 1455-1616 http://acta.uta.fi Tampereen Yliopistopaino Oy – Juvenes Print Tampere 2010 Contents Abstract................................................................................................................................................ 5 Yhteenveto........................................................................................................................................... 8 Abbreviations .................................................................................................................................... 11 List of original publications............................................................................................................... 12 Introduction ....................................................................................................................................... 13 Review of the literature ..................................................................................................................... 15 1. Definitions of alcohol consumption .......................................................................................... 15 1.1 Drinks and drinking............................................................................................................ 15 1.2 Lexicon of alcohol consumption ........................................................................................ 16 2. Prevalence of risky drinking..................................................................................................... 17 2.1 General population ............................................................................................................. 17 2.2 Health care.......................................................................................................................... 18 3. Risky drinking and health care ................................................................................................. 19 3.1 Symptoms and signs ........................................................................................................... 19 3.2 Deterioration of disease...................................................................................................... 20 3.3 Abnormal blood tests.......................................................................................................... 20 3.4 Traumas, injuries and indirect consequences of drinking .................................................. 20 3.5 Alcohol-related diagnoses .................................................................................................. 21 4. Detection of risky drinking....................................................................................................... 21 4.1 Interview............................................................................................................................. 21 4.2 Structured questionnaires ................................................................................................... 22 4.3 Clinical examination........................................................................................................... 23 4.4 Laboratory markers ............................................................................................................ 23 5. Brief intervention...................................................................................................................... 25 5.1 Content ............................................................................................................................... 25 5.1.1 Identification................................................................................................................ 26 5.1.2 Advice.......................................................................................................................... 26 5.1.3 Follow-up and documentation..................................................................................... 27 5.2 Effectiveness....................................................................................................................... 27 5.3 Cost-effectiveness............................................................................................................... 29 6. Obstacles to brief intervention.................................................................................................. 29 6.1 Patients’ attitudes................................................................................................................ 30 6.2 Professionals’ knowledge, skills and attitudes ................................................................... 30 6.3 Other obstacles ................................................................................................................... 31 7. Implementation of brief intervention........................................................................................ 32 7.1 Implementation theories ..................................................................................................... 32 7.2 Implementation in health care ............................................................................................ 33 7.3 Effectiveness of implementation of brief intervention....................................................... 34 7.4 Cost of implementation ...................................................................................................... 36 Aims of the study............................................................................................................................... 38 Subjects and Methods........................................................................................................................ 39 Results ............................................................................................................................................... 43 3 Discussion.......................................................................................................................................... 46 1. Weaknesses and strengths of the study .................................................................................... 46 2. Risky drinking is more prevalent in health care than documented............................................ 47 3. Obstacles and facilitating factors in brief alcohol intervention are manifold .......................... 49 3.1 Attitudes among health care professionals vary................................................................. 49 3.2 Professionals need more knowledge and skills .................................................................. 49 3.3 People and patients are willing to consider their own drinking ......................................... 50 4. Implementation can be promoted ............................................................................................. 50 4.1 Tools for practical work are essential................................................................................. 50 4.2 Clear instructions are needed.............................................................................................. 51 Summary and conclusions................................................................................................................. 53 Acknowledgements ........................................................................................................................... 55 References ......................................................................................................................................... 56 Appendix I Appendix II Original publications 4 Abstract This study was initiated after Finland had joined the EU and the intended alcohol tax reductions caused concern both generally and willing health care. Several studies had shown that brief alcohol interventions are useful and cost-effective, and be considered feasible as part of health care professionals’ daily work as, as little time is required and the skills needed, and can be easily learned. In spite of the scientific evidence, however implementation of brief intervention activity has been slow. The objective here was to assess means of implementing this new activity, alcohol screening and brief intervention for early-phase heavy drinkers, in different health care settings in a wide geographic area in Finland. In order to motivate health care professionals to acknowledge the importance of this patient group, prevalence data were first collected (I). Six-year diagnoses in retrospective discharge