Alcohol prevention in Swedish primary health care

Abstract Aims: The objectives of this thesis are to describe attitudes among general practitioners (GPs) and district nurses (DN) towards working with risk alcohol drinking and focus on the achievements of the Swedish Risk drinking project (RDP). Special attention has been devoted to the gender perspective and to the limits of sensible/safe drinking. Methods: The data sources used are a postal survey to GPs and nurses in the primary health care (PHC) in the County of Skaraborg, Sweden, 2002 and two national postal surveys (2006 and 2009) which had the aim to evaluate the effect of the Risk Drinking Project (RDP). To evaluate a change in clinical practice following RDP, we triangulated the results with two population surveys in which the participants reported whether they had been asked about alcohol when visiting the PHC and if the number of alcohol-related diagnoses increased in PHC. Results: Counseling skills to reducing alcohol consumption and effectiveness in helping patients reducing alcohol consumption ranked lower than working with other lifestyle behaviours for both GPs and DNs. The main obstacles for the GPs to carry out alcohol intervention were lack of training in counselling for reducing alcohol consumption, time constraints, and that the doctors did not know how to identify problem drinkers. Both the gender of the patients and of the GPs influenced the advice given and the referrals the patients received. Women were more often recommended to stop drinking while men were recommended to reduce drinking. Men were less often referred to any treatment, odds ratio 0.33. The upper limit of alcohol consumption before the GPs would advise the patient to cut down was significantly higher for GPs having an AUDIT-C score ≥ 3, 146 g/week for men and 103 g/week for women, than for GPs with an AUDIT-C score ≤ 2, 89 and 68 g/week, respectively. GPs lacking post-graduate education stated lower limits for safe drinking than GPs with some education. We found a significant increase for all three competence-related parameters analyzed (discussion, knowledge and effectiveness) between 2006 and 2009, with a higher increase for DNs than GPs. The population surveys showed no changes concerning how often the inhabitants were asked about alcohol. There was only a small increase of alcohol-related diagnoses over this time period. Conclusion: Some of the implications of these findings are that there is a need to increase the awareness of male excessive drinking and that gendered perceptions might bias alcohol management recommendations. If the GPs would take action on the limits they proposed, it would mean that they would intervene with a very large proportion of their patients that are drinking moderately and that will be both unmanageable and unnecessary. Finally there is conflicting evidence to whether RDP, which mainly was an educational enterprise, has been a sufficient means of increasing screening and brief intervention in PH