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Attitudes towards brief interventions to reduce smoking and problem drinking behaviour in gynaecological practice
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
available at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Attitudes towards brief interventions to reduce smoking and problem drinking behaviour in gynaecological practice A. Demmert*, J.M. Grothues, H.-J. Rumpf Department of Psychiatry and Psychotherapy, University of Lubeck, Ratzeburger Alle 160, 23538 Lu¨beck, Germany
article info
abstract
Article history:
Objective: To assess attitudes towards brief interventions, obstacles and assessment rates
Received 19 April 2010
for smoking and problem drinking in gynaecological practice, and to evaluate the differ-
Received in revised form
ences between smoking and problem drinking.
9 November 2010
Study design: Cross-sectional survey.
Accepted 14 December 2010
Method: An anonymous mail survey was conducted with all 358 primary care gynaecolo-
Available online 24 March 2011
gists in the state of Schleswig-Holstein, Germany. Results: Most gynaecologists considered brief interventions for problem drinking to be less
Keywords:
important in gynaecological practice than in general (74% vs 64%). Brief interventions were
Brief intervention
believed to be ineffective, particularly for problem drinking (64% vs 53% for smoking).
Gynaecologists
Gynaecologists felt better prepared to counsel their patients than to assess substance use.
Problem drinking
Only 35% stated that they assess the smoking status of every patient, and less than 12%
Smoking
stated that they assess the alcohol consumption of every patient. The counselling rate for smoking was high (79%), but problem drinkers were often referred to specialists (counselling rate 36%). The most important obstacles for the implementation of brief interventions were lack of time and poor patient compliance. In addition, for problem drinking, insufficient specialization was a further obstacle. Conclusion: Although a link was found between primary gynaecological care and tobacco and alcohol use, brief interventions are not yet integrated into gynaecological practice. There are, however, some promising starting points for patients who smoke, as motivation among gynaecologists to conduct brief interventions and counselling is high. The findings underscore the need for increased medical education and information about brief interventions, as well as assessment programmes for gynaecologists. ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction In general, 8% of women in developing countries and approximately 15% of women in developed countries currently smoke cigarettes. By 2025, it is predicted that the current 187 million female smokers in the world will have increased to 532 million.1
In several industrialized countries, including Denmark, Germany and the USA, more young women (aged 14e19 years) smoke compared with young men.2 This is especially alarming in the light of evidence for the susceptibility of women to health disorders related to these substances.3 Furthermore, women progress faster towards alcohol dependence and related physical
* Corresponding author. Tel.: þ49 451 500 2871; fax: þ49 451 500 3480. E-mail address: [email protected] (A. Demmert). 0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2010.12.003
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
and mental disorders than men.4,5 Many of the disorders associated with tobacco and alcohol use in women are usually diagnosed and treated by gynaecologists.6,7 For example, women who smoke are at greater risk of infertility than non-smokers,8 and exhibit poorer results in assisted reproductive treatment.9 Smokers who use oral contraceptives have a highly increased risk of coronary disease and stroke,10 and there is sufficient evidence to establish a causal association of cervical cancer with smoking.11 Alcohol consumption, on the other hand, promotes the development of breast cancer, the leading cancer among women.12 Although most women are aware of the risks of alcohol consumption and smoking during pregnancy, they still represent the main preventable causes of fetal and infant illness and mortality.13,14 These implications offer a good starting point for preventive methods and interventions, and emphasize that gynaecologists are not only highly specialized surgeons and endocrinologists, but also important primary care physicians for women.15 To tackle the problem of tobacco and alcohol consumption in primary care, a number of brief intervention methods and manuals have been created.16e19 Most have a limited duration of approximately 3e5 min, and application in primary care practice is common. The main goal is to motivate the patient to attempt reduction or cessation of substance use. Results from the Cochrane Library20 confirm the efficacy of brief interventions for smoking cessation and reduction of problem drinking.21,22 However, to date, their efficacy in gynaecological practice has not been the focus of research. In order to implement brief interventions in gynaecological practice on a regular basis, it is important to understand gynaecologists’ attitudes towards prevention, as well as the obstacles with which they are confronted. This study focuses on the differences in attitudes of gynaecological practitioners towards brief interventions, and tobacco and alcohol problems. Gynaecologists were chosen for this study because they are in a unique position as an important primary care physician for women from adolescence to menopause. They often attend to young healthy women for the prescription of oral contraceptives or preventive medical check-ups.15
183
5 min. Items were scored on a five-point Likert scale ranging from 1 (no accordance) to 5 (full accordance). The study sought to prevent social desirability bias by ensuring anonymity and by keeping the items as neutral as possible. To promote participation, the study was introduced to gynaecologists at the annual meeting of the Association of Gynaecologists in Schleswig-Holstein. In addition to a first wave of data collection at this meeting, three further waves of mailings and one telephone contact were undertaken for non-responders.
Analysis The Wilcoxon rank sum test was conducted to compare differences in attitudes towards tobacco and alcohol use. Overall, gynaecologists’ attitudes towards smoking and problem drinking were compared in 21 items. In order to correct for multiple testing, significance was set at 0.002.
Results Sample In total, 375 gynaecologists (89%) met the selection criteria. However, over the course of data collection, 17 (5%) had to be excluded as they had given up their practice for various reasons, leaving 358 gynaecologists eligible for participation. Of the 358 physicians contacted, 229 (64%) returned a completed questionnaire. Of the non-responders (36%), only 7% explicitly refused to participate; the rest could not be persuaded by mail or telephone to either complete the questionnaire or indicate their reason for refusal. The population in Schleswig-Holstein comprises 61.5% male and 38.5% female gynaecologists, but men were less likely to participate than women. This led to a gender ratio of 43% women and 57% men, with a mean age of 52 years and a mean practice period of 14 years. Eighty percent of gynaecologists worked in urban areas and 62% worked at a single practice.
Attitudes towards brief interventions
Methods Procedure Gynaecologists in the state of Schleswig-Holstein, Germany who offered general gynaecological and obstetric consultation (n ¼ 419) were surveyed. Gynaecologists who were working in hospitals or laboratories were excluded (11%). The population was identified using the handbook of the healthcare system in Schleswig-Holstein.23 The questionnaire was based on the World Health Organization’s collaborative study questionnaire for general practitioners,24,25 and mailed to gynaecologists with a covering letter and an agreement form. Questions covered personal and demographic data of the physician, as well as attitudes towards, obstacles to and implementation of brief interventions for smoking and problem drinking in gynaecological and obstetric patients. The questionnaire was designed to be as short and concise as possible in order to increase participation. The approximate completion time was
To evaluate the importance of brief interventions, gynaecologists were asked to differentiate between the importance of brief interventions in general and the importance for their patients (Table 1). The importance of brief interventions was rated lower for their own patients. Agreement with several aspects of brief interventions, such as necessity, efficacy, accountability and quantity (Table 2), was assessed in order to determine attitudes towards brief interventions. Significant differences between tobacco and alcohol use were found for most of these aspects. The majority of gynaecologists felt responsible for brief interventions for both problem drinking and smoking. Although gynaecologists felt less responsible for brief interventions for problem drinking and considered them to be even less effective than brief interventions for smoking, a clear majority stated that substance use should generally be assessed at every visit. Conversely to smoking, the majority of gynaecologists were opposed to giving out information about problem drinking.
184
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
Table 1 e Importance of brief interventions. Importance of brief interventions Smoking Drinking
In general With own patients In general With own patients
Mean
Standard deviation
Positive rank (n)
Negative rank (n)
Z; P
4.49 4.42 4.69 4.47
0.751 0.751 0.637 0.847
26
17
1.970; 0.05
40
12
4.261; <0.001
Bold figures indicate significance according to the Bonferroni corrected significance level.
The competence of gynaecologists in diagnostics and counselling about substance use was self-assessed. This showed a considerable amount of uncertainty, especially in diagnostics. Whereas 67% of gynaecologists rated themselves capable of counselling smokers, only 34% felt capable to assess nicotine dependence. For alcohol use, 49% of the gynaecologists did not consider themselves to be trained for diagnostics, and 35% indicated a lack of competence in alcohol counselling.
Obstacles The most important obstacles for implementing brief interventions were lack of time, poor patient compliance and insufficient specialization (Table 3). Twice as many gynaecologists feared losing patients when assessing alcohol use compared with tobacco use, but this was still the least important obstacle.
Assessment rates and counselling To compare their attitudes about assessment and counselling rates, gynaecologists were questioned about assessment rates, counselling and referring patients to specialists. Overall, gynaecologists were more hesitant to assess alcohol consumption than smoking (Table 4). Only 12% stated that they assessed every patient, while two-thirds indicated that they assessed alcohol consumption in less than half of patients. Although the great majority of gynaecologists stated that they offered counselling to smokers, only about one-third stated that they assessed the smoking status of every patient. The vast majority (79%) of gynaecologists stated that they counselled smokers, but 98% never or seldom referred
smokers to a specialist. Conversely, 35% of gynaecologists offered counselling to problem drinkers, and 36% often or always referred their patients to a specialist.
Discussion This survey investigated the attitudes of gynaecologists towards brief interventions for smoking and problem drinking. To the authors’ knowledge, this is the first investigation to focus on the differences between tobacco and alcohol consumption in a gynaecological setting. The high response rate in this study gives rise to hope that gynaecologists are generally interested in brief interventions, and want to conduct them although they may have some doubts about how and how well they work. Furthermore, they seem to be a homogenous group regarding brief interventions, which facilitates the development of future programmes. This study found that the vast majority of gynaecologists attributed high importance to brief interventions. When comparing the importance of brief interventions for smoking and problem drinking, interventions were considered to be more important for smoking than for problem drinking in gynaecological practice. A reason for this discrepancy may be that gynaecologists are very aware of the risks of smoking during pregnancy or in combination with oral contraceptives.6,26 Conversely, the higher importance that was given to brief interventions for problem drinking in general may reflect the recognition of alcohol misuse and consequential disease in society. In contrast to tobacco use, problem drinking was considered to be significantly less important in gynaecological practice than in the general population, and gynaecologists
Table 2 e Attitudes towards brief interventions. Attitudes towards brief interventions: items Patients do not need help Brief interventions are not effective Brief interventions are not my responsibility Information should be given Substance use should be assessed at every visit
Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking
Mean
Standard deviation
Negative rank (n)
2.98 1.58 3.44 3.60 1.92 2.45 3.93 2.56 2.94 3.78
1.076 0.830 0.999 1.149 1.063 1.127 1.148 1.309 1.349 1.319
174
6
57
82
26
102
6.439; <0.001
147
22
9.777; <0.001
33
126
6.858 <0.001
Bold figures indicate significance according to the Bonferroni corrected significance level.
Positive rank (n)
Z; P 1.035; <0.001 2.236; 0.025
185
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
Table 3 e Obstacles to brief interventions. Obstacles to brief intervention Lack of time Poor compliance Insufficient specialization Fear of scaring patients off Insufficient remuneration
Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking
Mean
Standard deviation
Negative rank (n)
Positive rank (n)
Z; P
3.64 3.73 3.71 4.05 3.07 3.90 1.89 2.42 3.11 3.28
1.240 1.295 0.984 0.900 1.192 1.111 1.143 1.346 1.365 1.331
34
47
1.260; 0.2
36
75
4.022; <0.001
14
121
8.615; <0.001
19
87
6.084; <0.001
29
54
3.116; 0.002
Bold figures indicate significance according to the Bonferroni corrected significance level.
felt less responsible to address the issue. One probable explanation may be that problem drinking is still considered to be a man’s problem, and is not yet linked to gynaecological disorders. Furthermore, there is still a stigma attached to problem drinking, which could make it easier for gynaecologists to suppress the issue. The majority of gynaecologists did not believe brief interventions to be effective, although efficacy for both smoking and problem drinking has been proven in several studies.18,20,27 Fleming et al.28 showed that physicians had superior results for the efficacy of brief interventions in women who had a drinking problem compared with men in primary care practice. Gynaecologists feel responsible for conducting brief interventions, especially with smokers. This responsibility may be a good starting point when motivating gynaecologists to conduct brief interventions. When assessing the obstacles that prevent gynaecologists from implementing brief interventions, it became clear that most arise from an incomplete image of the method. One of the main obstacles was lack of time for both smoking and problem drinking. Brief interventions, however, are not supposed to be time consuming; on the contrary, they have been established to meet the needs of physicians who only have limited time per patient. Even an intervention that takes 3e5 min has been proven to be effective.20 Another important obstacle was poor
Table 4 e Assessment of substance use. Patients assessed
None 25% 50% 75% 100% Mean Standard deviation Negative rank (n) Negative rank (n)
Percentage of obstetriciangynaecologists who regularly assess patients’ substance use (Z: 10.091; P < 0.001) Smoking
Alcohol consumption
1.3 24.7 18.8 20.2 35.0 2.9 1.35 139.0 6.0
17.0 49.3 12.1 9.4 12.1 2.5 1.13
Bold figures indicate significance according to the Bonferroni corrected significance level.
patient compliance. A more profound knowledge of the stages of behaviour change29 might help physicians to better adapt their advice to the individual patient and her readiness to quit, and thus increase the success of brief interventions. Gynaecologists felt better trained to counsel smokers than to assess them. It is encouraging that more than two-thirds of gynaecologists felt sufficiently trained for counselling, but smoking assessment is the first step to effective brief interventions.19 If gynaecologists only assess the smoking status of a minority of patients, an even smaller number will receive advice or counselling. Gynaecologists seem to have doubts about what comprises the assessment of smoking, and therefore consider it to be more extensive and difficult than counselling. Similar to tobacco use, they felt better prepared to counsel problem drinkers than to assess their alcohol consumption. There was, however, a considerable discrepancy between general attitudes towards assessment and the assessment rates for problem drinking. These figures (attitudes towards assessment in general and assessment rates) agreed well for smoking, but differed for problem drinking. Gynaecologists apparently have greater difficulties conducting brief interventions with problem drinkers than smokers, even if they acknowledge that there is a need to do so. It appears that gynaecologists deal with this problem by referring their patients to specialists. The findings indicate that gynaecologists are more willing and better prepared to conduct brief interventions for smoking compared with problem drinking, and that it might be easier and more successful to implement area-wide brief interventions for smokers in gynaecological practice. One reason for the persistent differences in the attitudes of gynaecologists towards alcohol and tobacco interventions might be that smoking seems to be more easily detectable to gynaecologists. Furthermore, gynaecologists might address smoking rather than drinking because they are more familiar with interventions in this field. Further efforts seem to be indicated to strengthen education in medical schools and professional training, especially in the field of assessment of substance use as well as the methods of brief interventions on offer. This could be helpful for gynaecologists to better understand behaviour change models and the efficacy of brief interventions. Kaner et al.24,30 showed a positive relationship between the level of education on brief interventions and the management of problem drinking in gynaecological practice. Assessment programmes that are especially created for gynaecological practice might
186
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be an important step to implement brief interventions. Additionally, to convince gynaecologists to implement brief interventions in their practice, it is important to highlight their efficacy, to raise awareness of the impact of problem drinking in gynaecological practice, and to address the obstacles that make it difficult to implement brief interventions.
Conclusion Although there is a link between primary gynaecological care and tobacco and alcohol use, brief interventions are not yet integrated into gynaecological practice. There are, however, some promising starting points for patients who smoke, as motivation and counselling rates among gynaecologists are high. The study findings underscore the need for increased medical education and information about brief interventions, as well as assessment programmes for gynaecologists.
Ethical approval Ethics Committee of the University of Lu¨beck.
Funding None declared.
Competing interests None declared.
references
1. Samet JM, Yoon S-Y. Women and the tobacco epidemic e challenges for the 21st century; 2001. 2. Women and tobacco. Geneva: World Health Organization; 1992. 3. John U, Hanke M. Tobacco smoking and alcohol drinking attributable cancer mortality in Germany. Eur J Cancer Prev 2002;11:11e7. 4. Brady KT, Randall CL. Gender differences in substance use disorders. Psychiatr Clin North Am 1999;22:241e52. 5. Randall CL, Roberts JS, Del Boca FK, Carroll KM, Connors GJ, Mattson ME. Telescoping of landmark events associated with drinking: a gender comparison. J Stud Alcohol 1999;60:252e60. 6. British Medical Association. Smoking and reproductive life: the impact of smoking on sexual, reproductive and child health. London: British Medical Association; 2004. 7. Cyr MG, McGarry KA. Alcohol use disorders in women. Screening methods and approaches to treatment. Postgrad Med 2002;112. p. 31e32, 9e40, 3e7. 8. Phipps WR, Cramer DW, Schiff I, et al. The association between smoking and female infertility as influenced by cause of the infertility. Fertil Steril 1987;48:377e82. 9. Van Voorhis BJ, Syrop CH, Hammitt DG, Dunn MS, Snyder GD. Effects of smoking on ovulation induction for assisted reproductive techniques. Fertil Steril 1992;58:981e5. 10. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, caseecontrol study. Lancet 1996;348:498e505. 11. Tobacco smoke and involuntary smoking. IARC Monogr Eval Carcinog Risks Hum 2004;83:1e1438.
12. Smith-Warner SA, Spiegelman D, Yaun SS, et al. Alcohol and breast cancer in women: a pooled analysis of cohort studies. J Am Med Assoc 1998;279:535e40. 13. Kleinman JC, Pierre Jr MB, Madans JH, Land GH, Schramm WF. The effects of maternal smoking on fetal and infant mortality. Am J Epidemiol 1988;127:274e82. 14. Florey CD. EUROMAC. A European concerted action: maternal alcohol consumption and its relation to the outcome of pregnancy and child development at 18 months: methods. Int J Epidemiol 1992;21(Suppl. 1):S38e9. 15. Kreienberg R. The gynecologist as family doctor for women e a model of the future? Gynakol Geburtshilfliche Rundsch 2004; 44:154e61. 16. Simpson D. Doctors and tobacco: medicine’s big challenge. Tobacco Control Resource Centre at the British Medical Association; 2000. 17. Fiore B, Bailey WC, Cohen SJ, Dorfmann SF, Goldstein MG, Gritz ER, et al. Treating tobacco use and dependence. A clinical practice guideline; 2000. 18. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002;97: 279e92. 19. Fiore MC. Treating tobacco use and dependence: an introduction to the US Public Health Service clinical practice guideline. Respir Care 2000;45:1196e9. 20. Silagy C. Physician advice for smoking cessation. Cochrane Database Syst Rev; 2000. CD000165. 21. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and metaanalysis. Arch Intern Med 2005;165:986e95. 22. Kaner EF, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev; 2007. CD004148. 23. Handbuch fu¨r das Gesundheitswesen Schleswig-Holstein. Neumu¨nster: Verlag; 2002. 24. Kaner EF, Wutzke S, Saunders JB, Powell A, Morawski J, Bouix JC. Impact of alcohol education and training on general practitioners’ diagnostic and management skills: findings from a World Health Organization collaborative study. J Stud Alcohol 2001;62:621e7. 25. Anderson P, Kaner E, Wutzke S, Wensing M, Grol R, Heather N, et al. Attitudes and management of alcohol problems in general practice: descriptive analysis based on findings of a World Health Organization international collaborative survey. Alcohol Alcohol 2003;38:597e601. 26. Schiff I, Bell WR, Davis V, Kessler CM, Meyers C, Nakajima S, et al. Oral contraceptives and smoking, current considerations: recommendations of a consensus panel. Am J Obstet Gynecol 1999;180:S383e4. 27. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26:36e43. 28. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. J Am Med Assoc 1997;277:1039e45. 29. DiClemente CC, Prochaska JO, Fairhust SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation and preparation stages of change. J Consult Clin Psychol 1991;59:295e304. 30. Kaner EF, Heather N, Brodie J, Lock CA, McAvoy BR. Patient and practitioner characteristics predict brief alcohol intervention in primary care. Br J Gen Pract 2001;51:822e7.
available at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Attitudes towards brief interventions to reduce smoking and problem drinking behaviour in gynaecological practice A. Demmert*, J.M. Grothues, H.-J. Rumpf Department of Psychiatry and Psychotherapy, University of Lubeck, Ratzeburger Alle 160, 23538 Lu¨beck, Germany
article info
abstract
Article history:
Objective: To assess attitudes towards brief interventions, obstacles and assessment rates
Received 19 April 2010
for smoking and problem drinking in gynaecological practice, and to evaluate the differ-
Received in revised form
ences between smoking and problem drinking.
9 November 2010
Study design: Cross-sectional survey.
Accepted 14 December 2010
Method: An anonymous mail survey was conducted with all 358 primary care gynaecolo-
Available online 24 March 2011
gists in the state of Schleswig-Holstein, Germany. Results: Most gynaecologists considered brief interventions for problem drinking to be less
Keywords:
important in gynaecological practice than in general (74% vs 64%). Brief interventions were
Brief intervention
believed to be ineffective, particularly for problem drinking (64% vs 53% for smoking).
Gynaecologists
Gynaecologists felt better prepared to counsel their patients than to assess substance use.
Problem drinking
Only 35% stated that they assess the smoking status of every patient, and less than 12%
Smoking
stated that they assess the alcohol consumption of every patient. The counselling rate for smoking was high (79%), but problem drinkers were often referred to specialists (counselling rate 36%). The most important obstacles for the implementation of brief interventions were lack of time and poor patient compliance. In addition, for problem drinking, insufficient specialization was a further obstacle. Conclusion: Although a link was found between primary gynaecological care and tobacco and alcohol use, brief interventions are not yet integrated into gynaecological practice. There are, however, some promising starting points for patients who smoke, as motivation among gynaecologists to conduct brief interventions and counselling is high. The findings underscore the need for increased medical education and information about brief interventions, as well as assessment programmes for gynaecologists. ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction In general, 8% of women in developing countries and approximately 15% of women in developed countries currently smoke cigarettes. By 2025, it is predicted that the current 187 million female smokers in the world will have increased to 532 million.1
In several industrialized countries, including Denmark, Germany and the USA, more young women (aged 14e19 years) smoke compared with young men.2 This is especially alarming in the light of evidence for the susceptibility of women to health disorders related to these substances.3 Furthermore, women progress faster towards alcohol dependence and related physical
* Corresponding author. Tel.: þ49 451 500 2871; fax: þ49 451 500 3480. E-mail address: [email protected] (A. Demmert). 0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2010.12.003
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
and mental disorders than men.4,5 Many of the disorders associated with tobacco and alcohol use in women are usually diagnosed and treated by gynaecologists.6,7 For example, women who smoke are at greater risk of infertility than non-smokers,8 and exhibit poorer results in assisted reproductive treatment.9 Smokers who use oral contraceptives have a highly increased risk of coronary disease and stroke,10 and there is sufficient evidence to establish a causal association of cervical cancer with smoking.11 Alcohol consumption, on the other hand, promotes the development of breast cancer, the leading cancer among women.12 Although most women are aware of the risks of alcohol consumption and smoking during pregnancy, they still represent the main preventable causes of fetal and infant illness and mortality.13,14 These implications offer a good starting point for preventive methods and interventions, and emphasize that gynaecologists are not only highly specialized surgeons and endocrinologists, but also important primary care physicians for women.15 To tackle the problem of tobacco and alcohol consumption in primary care, a number of brief intervention methods and manuals have been created.16e19 Most have a limited duration of approximately 3e5 min, and application in primary care practice is common. The main goal is to motivate the patient to attempt reduction or cessation of substance use. Results from the Cochrane Library20 confirm the efficacy of brief interventions for smoking cessation and reduction of problem drinking.21,22 However, to date, their efficacy in gynaecological practice has not been the focus of research. In order to implement brief interventions in gynaecological practice on a regular basis, it is important to understand gynaecologists’ attitudes towards prevention, as well as the obstacles with which they are confronted. This study focuses on the differences in attitudes of gynaecological practitioners towards brief interventions, and tobacco and alcohol problems. Gynaecologists were chosen for this study because they are in a unique position as an important primary care physician for women from adolescence to menopause. They often attend to young healthy women for the prescription of oral contraceptives or preventive medical check-ups.15
183
5 min. Items were scored on a five-point Likert scale ranging from 1 (no accordance) to 5 (full accordance). The study sought to prevent social desirability bias by ensuring anonymity and by keeping the items as neutral as possible. To promote participation, the study was introduced to gynaecologists at the annual meeting of the Association of Gynaecologists in Schleswig-Holstein. In addition to a first wave of data collection at this meeting, three further waves of mailings and one telephone contact were undertaken for non-responders.
Analysis The Wilcoxon rank sum test was conducted to compare differences in attitudes towards tobacco and alcohol use. Overall, gynaecologists’ attitudes towards smoking and problem drinking were compared in 21 items. In order to correct for multiple testing, significance was set at 0.002.
Results Sample In total, 375 gynaecologists (89%) met the selection criteria. However, over the course of data collection, 17 (5%) had to be excluded as they had given up their practice for various reasons, leaving 358 gynaecologists eligible for participation. Of the 358 physicians contacted, 229 (64%) returned a completed questionnaire. Of the non-responders (36%), only 7% explicitly refused to participate; the rest could not be persuaded by mail or telephone to either complete the questionnaire or indicate their reason for refusal. The population in Schleswig-Holstein comprises 61.5% male and 38.5% female gynaecologists, but men were less likely to participate than women. This led to a gender ratio of 43% women and 57% men, with a mean age of 52 years and a mean practice period of 14 years. Eighty percent of gynaecologists worked in urban areas and 62% worked at a single practice.
Attitudes towards brief interventions
Methods Procedure Gynaecologists in the state of Schleswig-Holstein, Germany who offered general gynaecological and obstetric consultation (n ¼ 419) were surveyed. Gynaecologists who were working in hospitals or laboratories were excluded (11%). The population was identified using the handbook of the healthcare system in Schleswig-Holstein.23 The questionnaire was based on the World Health Organization’s collaborative study questionnaire for general practitioners,24,25 and mailed to gynaecologists with a covering letter and an agreement form. Questions covered personal and demographic data of the physician, as well as attitudes towards, obstacles to and implementation of brief interventions for smoking and problem drinking in gynaecological and obstetric patients. The questionnaire was designed to be as short and concise as possible in order to increase participation. The approximate completion time was
To evaluate the importance of brief interventions, gynaecologists were asked to differentiate between the importance of brief interventions in general and the importance for their patients (Table 1). The importance of brief interventions was rated lower for their own patients. Agreement with several aspects of brief interventions, such as necessity, efficacy, accountability and quantity (Table 2), was assessed in order to determine attitudes towards brief interventions. Significant differences between tobacco and alcohol use were found for most of these aspects. The majority of gynaecologists felt responsible for brief interventions for both problem drinking and smoking. Although gynaecologists felt less responsible for brief interventions for problem drinking and considered them to be even less effective than brief interventions for smoking, a clear majority stated that substance use should generally be assessed at every visit. Conversely to smoking, the majority of gynaecologists were opposed to giving out information about problem drinking.
184
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 1 8 2 e1 8 6
Table 1 e Importance of brief interventions. Importance of brief interventions Smoking Drinking
In general With own patients In general With own patients
Mean
Standard deviation
Positive rank (n)
Negative rank (n)
Z; P
4.49 4.42 4.69 4.47
0.751 0.751 0.637 0.847
26
17
1.970; 0.05
40
12
4.261; <0.001
Bold figures indicate significance according to the Bonferroni corrected significance level.
The competence of gynaecologists in diagnostics and counselling about substance use was self-assessed. This showed a considerable amount of uncertainty, especially in diagnostics. Whereas 67% of gynaecologists rated themselves capable of counselling smokers, only 34% felt capable to assess nicotine dependence. For alcohol use, 49% of the gynaecologists did not consider themselves to be trained for diagnostics, and 35% indicated a lack of competence in alcohol counselling.
Obstacles The most important obstacles for implementing brief interventions were lack of time, poor patient compliance and insufficient specialization (Table 3). Twice as many gynaecologists feared losing patients when assessing alcohol use compared with tobacco use, but this was still the least important obstacle.
Assessment rates and counselling To compare their attitudes about assessment and counselling rates, gynaecologists were questioned about assessment rates, counselling and referring patients to specialists. Overall, gynaecologists were more hesitant to assess alcohol consumption than smoking (Table 4). Only 12% stated that they assessed every patient, while two-thirds indicated that they assessed alcohol consumption in less than half of patients. Although the great majority of gynaecologists stated that they offered counselling to smokers, only about one-third stated that they assessed the smoking status of every patient. The vast majority (79%) of gynaecologists stated that they counselled smokers, but 98% never or seldom referred
smokers to a specialist. Conversely, 35% of gynaecologists offered counselling to problem drinkers, and 36% often or always referred their patients to a specialist.
Discussion This survey investigated the attitudes of gynaecologists towards brief interventions for smoking and problem drinking. To the authors’ knowledge, this is the first investigation to focus on the differences between tobacco and alcohol consumption in a gynaecological setting. The high response rate in this study gives rise to hope that gynaecologists are generally interested in brief interventions, and want to conduct them although they may have some doubts about how and how well they work. Furthermore, they seem to be a homogenous group regarding brief interventions, which facilitates the development of future programmes. This study found that the vast majority of gynaecologists attributed high importance to brief interventions. When comparing the importance of brief interventions for smoking and problem drinking, interventions were considered to be more important for smoking than for problem drinking in gynaecological practice. A reason for this discrepancy may be that gynaecologists are very aware of the risks of smoking during pregnancy or in combination with oral contraceptives.6,26 Conversely, the higher importance that was given to brief interventions for problem drinking in general may reflect the recognition of alcohol misuse and consequential disease in society. In contrast to tobacco use, problem drinking was considered to be significantly less important in gynaecological practice than in the general population, and gynaecologists
Table 2 e Attitudes towards brief interventions. Attitudes towards brief interventions: items Patients do not need help Brief interventions are not effective Brief interventions are not my responsibility Information should be given Substance use should be assessed at every visit
Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking
Mean
Standard deviation
Negative rank (n)
2.98 1.58 3.44 3.60 1.92 2.45 3.93 2.56 2.94 3.78
1.076 0.830 0.999 1.149 1.063 1.127 1.148 1.309 1.349 1.319
174
6
57
82
26
102
6.439; <0.001
147
22
9.777; <0.001
33
126
6.858 <0.001
Bold figures indicate significance according to the Bonferroni corrected significance level.
Positive rank (n)
Z; P 1.035; <0.001 2.236; 0.025
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Table 3 e Obstacles to brief interventions. Obstacles to brief intervention Lack of time Poor compliance Insufficient specialization Fear of scaring patients off Insufficient remuneration
Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking Smoking Drinking
Mean
Standard deviation
Negative rank (n)
Positive rank (n)
Z; P
3.64 3.73 3.71 4.05 3.07 3.90 1.89 2.42 3.11 3.28
1.240 1.295 0.984 0.900 1.192 1.111 1.143 1.346 1.365 1.331
34
47
1.260; 0.2
36
75
4.022; <0.001
14
121
8.615; <0.001
19
87
6.084; <0.001
29
54
3.116; 0.002
Bold figures indicate significance according to the Bonferroni corrected significance level.
felt less responsible to address the issue. One probable explanation may be that problem drinking is still considered to be a man’s problem, and is not yet linked to gynaecological disorders. Furthermore, there is still a stigma attached to problem drinking, which could make it easier for gynaecologists to suppress the issue. The majority of gynaecologists did not believe brief interventions to be effective, although efficacy for both smoking and problem drinking has been proven in several studies.18,20,27 Fleming et al.28 showed that physicians had superior results for the efficacy of brief interventions in women who had a drinking problem compared with men in primary care practice. Gynaecologists feel responsible for conducting brief interventions, especially with smokers. This responsibility may be a good starting point when motivating gynaecologists to conduct brief interventions. When assessing the obstacles that prevent gynaecologists from implementing brief interventions, it became clear that most arise from an incomplete image of the method. One of the main obstacles was lack of time for both smoking and problem drinking. Brief interventions, however, are not supposed to be time consuming; on the contrary, they have been established to meet the needs of physicians who only have limited time per patient. Even an intervention that takes 3e5 min has been proven to be effective.20 Another important obstacle was poor
Table 4 e Assessment of substance use. Patients assessed
None 25% 50% 75% 100% Mean Standard deviation Negative rank (n) Negative rank (n)
Percentage of obstetriciangynaecologists who regularly assess patients’ substance use (Z: 10.091; P < 0.001) Smoking
Alcohol consumption
1.3 24.7 18.8 20.2 35.0 2.9 1.35 139.0 6.0
17.0 49.3 12.1 9.4 12.1 2.5 1.13
Bold figures indicate significance according to the Bonferroni corrected significance level.
patient compliance. A more profound knowledge of the stages of behaviour change29 might help physicians to better adapt their advice to the individual patient and her readiness to quit, and thus increase the success of brief interventions. Gynaecologists felt better trained to counsel smokers than to assess them. It is encouraging that more than two-thirds of gynaecologists felt sufficiently trained for counselling, but smoking assessment is the first step to effective brief interventions.19 If gynaecologists only assess the smoking status of a minority of patients, an even smaller number will receive advice or counselling. Gynaecologists seem to have doubts about what comprises the assessment of smoking, and therefore consider it to be more extensive and difficult than counselling. Similar to tobacco use, they felt better prepared to counsel problem drinkers than to assess their alcohol consumption. There was, however, a considerable discrepancy between general attitudes towards assessment and the assessment rates for problem drinking. These figures (attitudes towards assessment in general and assessment rates) agreed well for smoking, but differed for problem drinking. Gynaecologists apparently have greater difficulties conducting brief interventions with problem drinkers than smokers, even if they acknowledge that there is a need to do so. It appears that gynaecologists deal with this problem by referring their patients to specialists. The findings indicate that gynaecologists are more willing and better prepared to conduct brief interventions for smoking compared with problem drinking, and that it might be easier and more successful to implement area-wide brief interventions for smokers in gynaecological practice. One reason for the persistent differences in the attitudes of gynaecologists towards alcohol and tobacco interventions might be that smoking seems to be more easily detectable to gynaecologists. Furthermore, gynaecologists might address smoking rather than drinking because they are more familiar with interventions in this field. Further efforts seem to be indicated to strengthen education in medical schools and professional training, especially in the field of assessment of substance use as well as the methods of brief interventions on offer. This could be helpful for gynaecologists to better understand behaviour change models and the efficacy of brief interventions. Kaner et al.24,30 showed a positive relationship between the level of education on brief interventions and the management of problem drinking in gynaecological practice. Assessment programmes that are especially created for gynaecological practice might
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be an important step to implement brief interventions. Additionally, to convince gynaecologists to implement brief interventions in their practice, it is important to highlight their efficacy, to raise awareness of the impact of problem drinking in gynaecological practice, and to address the obstacles that make it difficult to implement brief interventions.
Conclusion Although there is a link between primary gynaecological care and tobacco and alcohol use, brief interventions are not yet integrated into gynaecological practice. There are, however, some promising starting points for patients who smoke, as motivation and counselling rates among gynaecologists are high. The study findings underscore the need for increased medical education and information about brief interventions, as well as assessment programmes for gynaecologists.
Ethical approval Ethics Committee of the University of Lu¨beck.
Funding None declared.
Competing interests None declared.
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