Knowledge and practices of doctors at the National Hospital of Sri Lanka on screening and management of alcohol misuse among patients

Introduction Problems related to alcohol misuse in Sri Lanka are on the rise. Early screening and structured interventions by doctors have been shown to make a significant diminution in alcohol misuse among patients. Objectives This study aimed to assess the knowledge and practices of doctors at the National Hospital of Sri Lanka on screening and management of alcohol misuse among patients. Methods This was a hospital based descriptive cross-sectional study. Doctors (n=385) of all designations attached to wards where patients with alcohol related problems are admitted, were assessed using a self-administered questionnaire. Factors associated with practices were assessed using cross tabulations and χ 2 statistic. Results Response rate was high (91.4%). Respondents were mainly males (63.6%; n=224) in the age group of 25-34 years (48.0%; n=169). A majority were in the category of „medical officers‟ (39.4%; n=139) attached to general medicine or surgery units (49.7%; n=175) with work experience of <10 years (68.2%; n=240). A weighted score was developed for overall knowledge on screening and management. The proportion of doctors with „Good‟ overall knowledge was high (75.9%; n=267). However, only 53.4% (n=188) were aware of available standard screening tools. The majority (93.5%; n=329) of doctors were inquiring into alcohol habits of male patients during their routine practice. However, those utilizing standard screening tools to determine alcohol misuse was low (22.8%; n=75). Though the proportion of doctors who took steps to reduce misuse was high (80.3%; n=283), the steps that would achieve sustainable reduction were taken by only 45.9 %( n=130). „Good‟ overall knowledge (p<0.001), working in a medical unit (p<0.001), work experience <10 years (p<0.001), were associated with „always inquiring‟ into alcohol habits in routine practice while „Good‟ overall knowledge (p<0.001), being a house officer (p<0.001) and work experience <10 years (p<0.001) were associated with taking steps to reduce misuse. Conclusion and Recommendations Overall knowledge was found to be „Good‟. Gaps in practice of screening and management were evident, which need to be corrected.


Introduction
Alcohol misuse can cause physical and psychological problems to the individuals (1).The problems related to alcohol misuse can have an impact on the individual who consumes alcohol, on family members (especially the spouse and the children), and there can be consequences to the society as a whole (2).A large number of people who misuse alcohol are admitted to hospitals with either a considerable number of doctors of various specialities of medicine including general medicine, general surgery, accident service, orthopaedic, cardiology, cardiothoracic surgery, neurology, psychology, neurosurgery and gastroenterology attend to their presenting problem and provide treatment as needed.There is reasonable doubt whether the doctors who treat them, inquire into the alcohol consumption patterns of these patients and identify alcohol misuse.In most instances, patients with alcohol dependence are identified and managed only when they present with related medical problems.Then the patients are referred to a psychiatry unit for further management (4).It has been found that early screening of alcohol misuse among patients and adoption of evidence based management steps will lead to sustainable reduction in alcohol misuse among the patients (5).Information regarding the practices of the doctors in the ward setup on screening and managing patients with alcohol misuse is very scarce in Sri Lanka.This study aimed at finding out the extent to which the doctors in the hospital setup are involved in screening and management of alcohol misuse of patients, their knowledge, attitude and practices for doing so.Association between selected factors and practices of screening and management was also assessed.

Methodology
This descriptive cross sectional study was conducted at the National Hospital of Sri Lanka (NHSL).The NHSL was selected as the study setting for the present study, because a considerable number of patients with various problems due to misuse of physical, psychological problems or accidental and non-accidental injuries (3) alcohol are admitted (6).Being a teaching hospital, all categories of doctors including post graduate trainee doctors were available to be included in the study.The study population was considered as all the doctors (Consultants, senior registrars, registrars, medical officers, and house officers) who are directly involved in the management of patients and have the opportunity to communicate with patients who are admitted to wards with problems related to alcohol misuse.All the doctors attached to the wards of general medicine, general surgery, accident service, orthopaedic, cardiology, cardiothoracic surgery, psychiatry, neurology, gastroenterology and burns unit were considered as eligible to be included in the study.It was decided to include all the doctors (n=385) who were attached to those relevant unit of NHSL.Data collection was done during the study period extending from August to November of 2008.The numbers of eligible doctors and the ward/unit to which they are attached to and their designation was obtained from the updated data base of administration unit of NHSL.Each of these wards/units was visited and a brief introduction of the study along with an information sheet was provided to each of the selected study participant personally by the principal investigator and they were invited to participate in the study.

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A pre tested, self administered questionnaire was used to obtain data related to socio demographic and work related information, Knowledge on detection and management of alcohol misuse, attitudes and self reported information pertaining to practices on screening and management.
The data were analysed using Statistical Package for Social Sciences version 16.Ethical clearance was obtained from the Ethical Review Committee of the Faculty of Medicine, University of Colombo and administrative approval was obtained from the Director of NHSL.Informed verbal consent was obtained from each participant.Ensuring anonymity, the confidentiality of the information that was supplied was stressed.

Results
Study included 352 doctors with a response rate of 91.4% (352/385).No significant differences were seen between the respondents and the non respondents after analysing preliminary data.Table 1 describes the socio demographic characteristics of the study participants.The study population were asked whether in their routine practice they take any steps to reduce the misuse among patients with alcohol misuse, a total of 283 (80.3%) responded positively.Among the respondents a majority (93.6%) educated the patients on the ill effects on health.Counselling to change behaviour and referrals to specialized care was carried out by 45.8% and 42.8% respectively as reported by the respondents.Table 3 describes the barriers identified by the study population to carrying out screening and management to reduce alcohol misuse in the ward setup.

Identified barriers Frequency (n=280) Percent
Lack More than one response was allowed Association between making inquiries into alcohol habits in routine practice when encountered with a male patient and selected factors as well as the association between taking steps to reduce alcohol misuse and selected factors were assessed by cross tabulation and by applying chi-squared test.
The findings are summarized in Tables 4  and 5 respectively.

Discussion
The number of wards of general medicine and general surgery is higher than the other specialities in the study setting, so is the number of doctors attached to those units, which justifies the representation of approximately half (49.7%) The study population from those two specialities combined.These are the units to which most of the patients with direct or indirect effects of misuse of alcohol get admitted for care.
The fact that more than half (57.7%) of the study population who were attached to general medicine, general surgery and accident service come across a total of 31 or more new patients per week, reflects the increased opportunity presented for a majority of doctors attached to those units to screen for alcohol misuse.On the other hand, one can also argue that when the average number of patients increases the average time that can be devoted for each patient may be reduced which may affect the practice of screening and management related to alcohol misuse, which is evident by the fact that nearly half (46.8%) of the study participants who made inquiries into alcohol habits utilized 3-5 minutes to screen patients while only 1.8% used more than 10 minutes to do so.
In the present study, 53.4% of the population were aware of a standard screening questionnaire for detecting alcohol misuse among patients which is better compared to the study conducted among GPs" in 2 districts in Sri Lanka revealed that the awareness on screening tools were low (25.7%)(7).Even though study groups are not directly comparable, this may be due to the increased opportunities of learning available in a teaching hospital in the present study.Among the respondents in the present study who knew of a standard screening tool, the majority (72.3%) were aware of the CAGE questionnaire which is a reliable and valid screening tool (8) that can be applied quickly and easily in a ward setup (9).However, awareness on the evidence of the effectiveness of this tool among them was low (51.1%).The most (84%) cited source of information on the screening methods was undergraduate training even though approximately one third of the doctors had practiced for more than 10 years after their undergraduate training.
The proportion of the study population with "Good" overall knowledge on screening and management of alcohol misuse was high (75.9%).This indicates that majority have the correct knowledge regarding the conditions which should trigger a doctor to inquire into alcohol use in a patient and to take steps to reduce.It was encouraging to observe that a majority (93.5%) of the study population was making inquiries in to alcohol habits of male patients during their routine practice.However, only half (49.1%) practice that "Always", highlighting the potential for improvement of the current practices in order to encourage doctors to always inquire into alcohol habits as recommended by the National Institute of Alcohol Abuse and Alcoholism (10).The cross sectional study conducted among GPs" in Colombo and Gampaha districts revealed that only 15% of the respondents had routinely inquired about alcohol use (7) while in another study among a random sample of surgeons in the United States, routine screening was found to be low (11).These are in contrast to the present study.Among those who inquired into alcohol habits, the proportion of the study participants utilizing standard screening questionnaires to determine alcohol misuse was low (22.8%)despite the fact that more than half the respondents were reported as being aware of the screening tools.
Regarding the steps that doctors take to reduce alcohol misuse, a majority (93.6%) of the study population educated the patients on the ill effects of alcohol on health.
Simple education as such has been proven to reduce the alcohol consumption among patients (12)  The proportion of doctors who always inquired into alcohol misuse when encountered with a patient and the use of screening tools for this purpose was low.The recommendation of the National Institute of Alcohol and Alcoholism on always inquire into alcohol habits should be conveyed to the doctors.The proportion of doctors who adopt management methods that are proved to have long term effects to reduce consumption was low.Doctors should be offered more opportunities of developing their counselling skills to improve long term reduction of alcohol misuse among patients.

Table 5 -Association between taking steps to reduce alcohol misuse and selected factors
but this has not shown long term sustainability of reduction of misuse.