5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

Alcohol prevention

Alcohol prevention activity in Swedish primary health care and occupational health services drinking, with almost one-third of the two categories having participated in at least one day of training. In contrast, nearly two-thirds of PHC nurses had received no training whatsoever of this type. Education was positively associated with activity in addressing alcohol issues for all categories except OHS nurses, which could be due to their already high activity. The strongest association between activity and education was seen with OHS physicians. There are several mechanisms by which education may affect preventive activity, including raised awareness of the importance of addressing risky alcohol consumption, improved knowledge of appropriate risk levels, more positive attitudes to intervening with risky drinkers, and an increased self-confidence in raising and handling the issue. Although previous research has emphasized the importance of education and training for alcohol preventive activity (Aalto et al. 2001; Anderson et al. 2003; Funk et al. 2005), the results are somewhat inconsistent. For example, a study conducted in Finland reported that brief intervention activity did not change following a 3-year project that involved training as an important component (Aalto et al. 2003b). Furthermore, a randomized controlled study as part of a WHO project demonstrated that intervention activity following training increased only for those physicians who were already committed to working with alcohol issues (Anderson et al. 2004). Physicians often choose not to stray outside of their “comfort zone” when given the freedom to select which educational events to attend, which means that those most in need of education may not be reached (Sibley et al. 1982). 500 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 Clearly, education in and of itself is not sufficient to yield increased alcohol preventive activity. Research in the continuing medical education field has shown that approaches that involve multiple educational interventions, outreach events (also known as academic detailing, i.e. office-based approaches where healthcare providers are visited by an expert), and peer review and group-learning models are among the most effective, whereas lecture format teaching and unsolicited printed materials are the least effective methods (Cantillon & Jones 1999). It is also important to view education as part of a wider context since motivation to change an established way of working is influenced not only by individual factors but also by such aspects as organisational commitment, perceived support from management and colleagues, and contact with other health care professionals (Allery et al. 1997; Angelöw 1991; Wensing et al. 1998). While education and training in handling risky alcohol consumption can be expected to improve skills and knowledge, there is likely a two-way causality between activity and skills/knowledge due to the practice-based learning that occurs when practitioners reflect on work experience to facilitate improved practice (Nikkarinen, 2002). Educational efforts that link learning to clinical practice, by combining acquisition learning (accumulation of experience) and formalised learning (a more decontextualised learning consisting of guided episodes of learning), are most effective (Davis et al. 1995; Oxman et al. 1995). Inconsistent associations were noted in the present study between activity and two variables directly related to practice experience, i.e. number of patients per

week and years in practice. This finding underscores that learning through practice experience alone may not be sufficient for increased activity in addressing alcohol issues. Education specifically targeting risky alcohol consumption, using effective educational approaches, is needed to achieve increased alcohol preventive activity. The generalisability of some of our findings is restricted due to the lack of possibility to analyze those who did not reply. It is well known that more motivated and opinionated people are more likely to respond to surveys (Brodie et al. 1997). Hence, it is likely that those who did respond to the survey have more favourable attitudes towards discussing alcohol and providing advice to patients with risk consumption. Consequently, the results pertaining to the frequency of discussing alcohol could be overestimated. A considerable strength of the study is that it is a national survey where all currently active OHS and PHC professionals in Sweden had the possibility to answer the questionnaire. While the response rates might be considered fairly low, ranging from 47% (PHC physicians) to 69% (OHS nurses), they are, in fact, quite typical for mail surveys (Frankfort-Nachmias & Nachmias 1996). The study findings are based on responses from as many as 1000 OHS and 5000 PHC professionals, which is important when discussing and preparing strategies to facilitate increased secondary alcohol prevention in Sweden. Ultimately, comparing PHC and OHS may be considered a case of “apples and oranges”. It can be argued that the aim of OHS is more overtly preventive than that of PHC, where treatment of acute illness and chronic health conditions often needs to be prioritized (Johanson et al. 1995; Stan- Alcohol prevention activity in Swedish primary health care and occupational health services ge et al. 2002). However, OHS’ preventive services are frequently underutilized and the focus tends to be more on treatment than would be recommended by published guidelines (Statskontoret 2001). Although PHC reaches a wider population than OHS, a large share of the PHC’s resources are consumed by older patients who drink considerably less than the occupationally active part of the population reached by OHS (Leifman & Gustafsson 2003). The number of PHC visits increases with age and the average age of PHC patients is increasing over time with the aging Swedish population (Yearbook of Health and Medical Care 2002). On the other hand, the present study shows that OHS physicians are substantially older than all other professional categories, pointing to a pressing need for many OHS units to find replacements in the forthcoming years in order to maintain or increase alcohol prevention efforts. While there are many differences between OHS and PHC, and between the professional categories working in the two arenas, both arenas and all four professional categories have important roles to play in achieving increased secondary alcohol prevention in Sweden. In conclusion, the present study found that OHS professionals were more active than their colleagues in PHC in addressing alcohol issues with their patients. OHS professionals considered themselves more skilful in achieving a change in patients’ alcohol habits and more knowledgeable concerning providing advice to patients with risky alcohol consumption. Education, knowledge, and skills were positively associated with activity for most professional categories in the two settings. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 501

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