Excessive consumption of alcohol is associated with a range of behavioural and health problems. In particular, alcohol is an important risk factor for unsafe sexual practices and is implicated in the spread of sexually transmitted infections (STIs).1 2 Several studies have been published about alcohol screening in sexual health clinics. The tools most often used are questionnaires—for example, AUDIT,1 3 CAGE and its variants,1 4 5 CRAFFT1 and FAST6—while others have used frequency and quantity questions,7 laboratory tests8 and blood alcohol reading.9 Brief advice has been shown to be effective in a variety of settings.10 Two studies reported attempts to give advice in a sexual health service. In one, 90% of the participants were willing to accept written material; however, less than a third agreed to accept an appointment with an alcohol health worker and only one person attended the appointment, leading to a disappointing result.11 This experience suggests that timely on-the-spot intervention is more likely to be deliverable. A pilot study reported a trial of the feasibility of screening and brief intervention for substance abuse in one clinic; however, the effect of the intervention was not measured and it was not the focus of the study.5

Our project tested the feasibility, acceptability and effectiveness of screening and brief intervention for risky alcohol consumption by sexual health clinic patients using a trained registered nurse. Effectiveness of the intervention was assessed by measuring recall of the intervention and any reported changes in drinking behaviour or reduction in levels of drinking by patients at 3 months after the index visit. Other aims were to assess the acceptability and efficiency of the screening and intervention process to practice staff.

METHOD

Sydney South West Area Health Service provides public sexual health clinics in two locations in central Sydney, Australia. Subjects were recruited at four to five clinic sessions per week, including one male-only clinic. Over a 6-month period, patients older than 16 years were asked by a research nurse to participate in a survey about alcohol while waiting to be seen by clinic staff (described as the index visit). Patients ineligible for screening were those with a language or literacy problem, mental health problem or who were too sick to participate.

The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was programmed into a handheld computer with Pendragon Software 5.1 (Pendragon Software Corporation, Illinois, USA, 2005). Basic demographical information (age, gender) was also included. AUDIT is a validated 10-item instrument to detect hazardous and harmful drinking in ambulatory care settings.12 Three questions ask about quantity and frequency, three relate to possible symptoms of dependence and four ask about social and health problems—with a maximum possible score of 40. A cut-off score of 8 on AUDIT is recommended, so that those who score between 8 and 15 are classed as risky drinkers, scores between 16 and 19 suggest hazardous use and scores of 20 and above clearly indicate further assessment for dependence.13 Question 3 is often used on its own (as AUDIT-3) to assess the frequency of drinking above recommended limits (that is, binge drinking).

All screening and intervention was conducted in privacy away from the waiting room. After completing the questions, the handheld computer was returned to the research nurse to check the score. Those scoring <8 were given feedback about their score and nationally recommended safe levels of drinking were reinforced. If the total score was ⩾8, or if the score for question 3 (AUDIT-3) was either 3 or 4 (that is, drinking more than six drinks on one occasion either daily or weekly), patients were asked to participate further and asked if they would be available for a follow-up telephone interview in 3 months’ time. Those who provided written consent were assigned randomly to either the intervention or control group by pre-coded consent forms in sealed envelopes. This took about 5–10 minutes. The brief intervention (also 5–10 minutes), guided by the Drink-less handy card,14 was given to participants assigned to the intervention group. Two nurses had been previously separately trained in brief intervention for alcohol using the Drink-less package by one of the principal researchers and staff specialists in a one-on-one session lasting 1.5 hours.15

Follow-up

A structured telephone interview was developed for the 3 month follow-up, consisting of the AUDIT questionnaire (modified to reflect the shorter interval—3 months’ timeframe as opposed to the original 12 months) and questions relating to any changes in alcohol consumption, having any recent treatment for alcohol problems, and recall and acceptability of being asked about alcohol and getting advice from a research nurse at their (index) visit to the clinic. At the end of the interview, all patients were offered feedback about the meaning of their AUDIT scores and were offered self-help materials (a Drink-less pocket guide); thus, ensuring that the control group patients were included. Follow-up data were directly entered into SPSS V.15 by the telephone interviewer who was blind to group status.

To assess the acceptability of the screening and intervention process to clinic staff, a seven-item self-administered survey was developed. Copies were mailed to the manager of the clinic after the final day of screening with cover letters and reply paid envelopes for return.

Statistical analysis

Frequencies were calculated for all variables. χ² analyses were also carried out to compare risky and high-risk drinkers, defined by their AUDIT scores (8–12 for risky, >13 for high-risk) from baseline to follow-up, for both groups. These cut-off scores were chosen because they follow those given in the Drink-less intervention package.15 Paired samples t tests were also performed to test for levels of significance in the differences in mean AUDIT scores, question 3 for episodic heavy drinking (AUDIT-3) and for AUDIT-C (the first 3 questions of AUDIT), from baseline to follow-up for both groups.

RESULTS

Altogether, 599 patients were approached to participate in the study and 519 (87%) agreed to initial screening. Of the 511 patients who provided demographical data, 377 (74%) were male and 134 (26%) were female. The mean age was 34 years (range 16–81; SD 10.7). Of the 80 people who declined or were ineligible, 54 (66%) were male and 26 (34%) female.

Altogether, 40% of patients had a total AUDIT score ⩾8: 22% of all patients screened scored between 8 and 12 suggesting hazardous drinking, 12% had scores between 13 and 19, and 6% scored ⩾20. Therefore, 18% were drinking at levels likely to be harmful or dependent.14 The AUDIT-C was significantly correlated with the total AUDIT score (p<0.01, r = 0.814).

The total eligible for inclusion in the study was 204 patients; 28 patients refused to participate further and 4 patients were inadvertently not included, leaving 184 in the study population (87 patients in the intervention group and 97 patients in the control group) (fig 1). There were no differences in baseline scores between the control and intervention groups or between males and females.

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Figure 1 Flowchart of patients participating.

Follow-up

Patients scoring ⩾20 or more on AUDIT, and therefore at a high risk of dependence, were less likely to agree to participate in follow-up (p = 0.093, data not shown). Altogether, 133 patients (67 (69%) of controls and 66 (76%) of the intervention group) were followed up at a 3-month interval. Those lost to follow-up did not differ in age or gender from those re-interviewed. Again, however, patients in the highest risk category were significantly more likely to be uncontactable (table 1).

Of all those followed, 41 (31%) of patients reduced their AUDIT scores to a level where they were no longer categorised as drinking at either hazardous or harmful levels. The proportions of patients drinking at any risk level were correspondingly reduced for both the control and intervention groups (table 2). The proportion of people drinking more than six drinks daily, almost daily or weekly, as measured by AUDIT-3, was reduced by 12% in the intervention group (from 51% to 39%). The control group remained stable at 46%. AUDIT scores and AUDIT-C scores (questions 1–3) were all normally distributed for both groups at baseline. Mean AUDIT scores decreased from 13.7 to 11.5 (difference of 2.2) for the control group and from 14.0 to 10.7 (difference of 3.3) for the intervention group. Both groups showed significant changes in 10-item AUDIT scores from baseline to follow-up, but the amount of change did not differ significantly between the groups. The intervention group showed a significant reduction in their AUDIT-C score and a slight lowering of their AUDIT-3 score (table 3).

All patients were asked whether their general practitioner had ever asked them about alcohol, whether they had seen any other health professional about their drinking or had any treatment for alcohol problems in the past 3 months. When asked if they remembered any advice about alcohol at the index visit, 94% of the intervention group recalled the advice, 80% thought the advice had been acceptable and 75% of all patients thought it would be acceptable from a nurse (table 4). More of the intervention group found it acceptable to receive advice about alcohol on a routine visit compared with control group.

Patients were also asked about any change in drinking habits in the past 3 months. Altogether, 62% of the intervention group reported that they had reduced their drinking, whereas only 47% of controls had done so, showing a tendency towards significance (p = 0.09).

Acceptability and efficiency of the process to clinic staff

All clinic staff completed the brief survey. Five out of seven found that the presence of the nurse made little impact on the routine of the clinic; two found it inconvenient because of shortage of space. The concern about space was considered valid as we had to restrict screening to the sessions when a room was free. Staff felt it useful to have a nurse screen patients for excessive alcohol consumption; all clinicians thought it was important to know about a patient’s alcohol use and that it could be incorporated into their role to screen and give advice if time allowed. They nominated doctors, nurses and counsellors all as appropriate people to provide the service.

DISCUSSION

Our study reinforces previous findings that patients of sexual health clinics have higher levels of risky alcohol consumption than those in the general population or patients in other healthcare settings. Over 40% of patients we screened were drinking at hazardous or harmful levels compared with an average of 30% in the general population—with more than 20% of patients drinking more than six standard drinks at least once a week. This is consistent with other studies conducted in sexual health clinics where the prevalence of heavy drinking ranged from approximately 30%4 11 to 65%.6

The screening and advice session was innovative in using handheld computers and patients were extremely interested in their results. Both intervention and control patients significantly decreased their AUDIT score after 3 months and the intervention group also significantly reduced their AUDIT-C score. Comments from respondents included “this was a wake-up call for me”. Both groups reduced their drinking, suggesting that screening alone is sufficient to produce an effect on alcohol consumption.

The extreme mobility of the patient population presented a challenge to successful follow-up; however, this was partly overcome by the use of follow-up phone calls to mobile telephones made out of business hours. Constraints on space within the clinics were a problem and we were only able to screen patients on selected days when room was available. This caused the screening and intervention process to lengthen in order to recruit sufficient patients to provide sufficient power for the study.

Limitations of the study included the reluctance of those with higher baseline AUDIT scores to participate. This meant that a group with the potential for larger changes in alcohol consumption did not participate. This reflects a characteristic of alcohol use disorders—that is, a greater dependence on alcohol as the disorder progresses. The use of AUDIT as a tool to examine changes in drinking over 3 months presented both advantages and disadvantages for this study. A more detailed measure of quantity and frequency may have revealed significant differences in alcohol consumption at follow-up. However, AUDIT was selected as a simple and validated measure that could easily be done at both baseline and follow-up in a client group attending a busy clinic with limited time to participate in a study of this type.

Excessive alcohol consumption is associated with myriad adverse effects and accounts for approximately 4% of total morbidity in Australia.16 Early intervention is one of the most promising approaches to address alcohol problems, yet it is not implemented in many settings where it might be particularly effective. Incorporating a brief screening instrument (for example, AUDIT-C) would add no more than 1 minute to a consultation; a brief intervention could be given in 5 minutes. Economic costs would be more than offset by the benefit accruing from reduced future demand on clinical services for alcohol-related conditions.17 This study has shown that a nurse with a modest level of training in this intervention can be successfully introduced into a clinic with a relatively high proportion of patients who experience alcohol problems. Space and time pressures may have limited our implementation. It is also recognised that in order to produce an intervention effect that persists beyond a 3 month interval, reinforcement of advice at subsequent visits may be necessary. Nevertheless, integration of alcohol screening into the core role of the sexual health clinic nursing staff would appear to be an appropriate strategy to explore for the further implementation of brief intervention for alcohol use disorders in this setting.