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RRP 11-436 – HSR&D Study

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RRP 11-436
Factor Impacting the Screening and Management of Alcohol Misuse in Women
Eleanor Theodora Lewis PhD MS BA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: November 2012 - February 2014

BACKGROUND/RATIONALE:
As many as 10-22% of Veterans presenting to primary care screen positive for alcohol misuse, with research showing that alcohol misuse is increasing among women Veterans. Unfortunately, significant challenges exist in identifying alcohol misuse among women resulting in their being less likely to receive effective interventions when compared to men. Improving the detection and management of alcohol misuse in primary care is a major objective of the Substance Use Disorder (SUD) QUERI 2010 Strategic Plan. The aims of the present study are to support this objective by identifying patient, provider, and system factors that serve as facilitators and barriers to women drinkers' openly discussing alcohol use with their providers and considering treatment when appropriate.

OBJECTIVE(S):
This project had two primary aims: Among women engaging in alcohol misuse, (Aim 1) identify patient, provider, and system factors that serve as facilitators or barriers to women openly discussing alcohol use with their providers and, (Aim 2) identify patient, provider, and system factors that may impact women's receptivity to receiving treatment (including Brief Alcohol Interventions and referral to SUD specialty care) for alcohol misuse, when appropriate. Findings from this study will provide a foundation for future research aimed at implementing and potentially re designing existing screening and intervention options for improving the management of alcohol misuse in this population.

METHODS:
We conducted semi-structured interviews with 30 women Veterans screening positive for alcohol misuse (AUDIT-C score > 3) and 14 primary care providers (including physicians, nurses, and co-located mental health staff) recruited from the VA Palo Alto Health Care System (VAPAHCS) and VA Greater Los Angeles Health Care System (VA GLA). Consistent with the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009), participants were asked open-ended questions relevant to factors that impact the effectiveness of alcohol screening and treatment related to (a) the outer and inner care setting, (b) the characteristics of individuals involved in the care process, and (c) the characteristics of interventions included in VA primary care for alcohol misuse.

All interviews were audio recorded and transcribed. Template analysis (also known as thematic coding) was used to identify themes in the textual data. Interviews were coded using Atlas.ti 7.0.Two separate codebooks for patients and providers were developed through an iterative process. The final set of themes consisted of both themes defined a priori and new themes that emerged from each set of interviews. After data coding was complete, data analysis focused on the frequency of code occurrence (by participant and code) and patterns of code co-occurrence for each set of interviews.

FINDINGS/RESULTS:
The majority of our sample was over the age of 40 (60%), single (76.7%), and unemployed (63.3%). Half of our sample identified as African-American/Black, 26.7% as White, 13.3% as Other/Multi-Racial, and 10% as Hispanic/Latino. Seventeen percent had a documented alcohol use disorder (AUD) and 23.3% had a documented AUD and drug use disorder.

We have completed analysis of interview data for Aim 1 and Aim 2. Our analysis of data for Aim 1 confirmed six a priori themes and identified three emergent themes that women reported as most often having an impact on their decision to disclose their alcohol use to a primary care provider (PCP); see Table 1 below. The most common factors that had a negative impact on women Veterans' disclosure of alcohol use include negative emotions such as concerns about being judged or labeled an "alcoholic" by their provider, self-appraisal of her drinking behavior such as whether she defined her level of drinking as "problematic", and clinic factors including the presence of trainees in the exam room while screening was occurring. Factors that had a positive impact on disclosure of alcohol use included support and/or encouragement by family, friends, and significant others and having concerns about the potential impact of alcohol use on overall well-being. Women reporting a positive patient-provider relationship, and specifically a PCP who was compassionate, listened intently, and was not judgmental about their level of drinking tended to report feeling more comfortable discussing their alcohol use with their provider.

CFIR Domain and corresponding themes n (%)
A. Outer setting
1. Social support encourages disclosure 13 (43)
B. Inner setting
2. PCP behaviors encourage disclosure 23 (77)
3. PCP behaviors discourage disclosure 13 (43)
4. Clinic factors influence disclosure 24 (80)
C. Characteristics of individuals that influence disclosure
5. Negative emotions 20 (67)
6. Positive relationship with PCP 17 (57)
7. Self-appraisal of drinking behavior 17 (57)
8. Health concerns 14 (47)
9. Concern about consequences of drinking 10 (33)

Our analysis of data for Aim 2 confirmed 4 a priori themes and identified 2 emergent themes reported most often by women as having an impact on their receptivity to receiving alcohol-related treatment, including brief counseling or referral to SUD specialty care; see Table 2. The most common themes that impacted receptivity to treatment included self-appraisal of drinking behavior, having access to gender-specific services, and being able to receive services in a preferred care setting (e.g., VHA) or specific format (e.g., 12-step or individual therapy). Women Veterans receptivity to SUD treatment was also influenced by concerns about the physical health and life consequences of their drinking. Primary care providers were an important influence on womens' receptivity to treatment through specific actions including presenting treatment options in a patient-centered way, or educating the patient on the important health consequences of their alcohol consumption and the role that treatment could play in helping them decrease their drinking.

Table 2. CFIR Domain and corresponding themes n (%)
A. Outer setting
1. *Access to preferred care setting/format14 (47)
B. Inner setting
2. Access to gender-specific services14 (47)
3. Patient-centered presentation of treatment options11 (37)
4. Presentation of health consequences of alcohol 9 (30)
C. Characteristics of individuals that influence disclosure
5. *Self-appraisal of drinking behavior19 (63)
6. Mental health or physical health factors13 (43)
* Emergent themes

IMPACT:
The knowledge gathered from these interviews may help us better understand factors that impact women Veterans' willingness to disclose their alcohol use to a primary care provider and consider alcohol-related care when deemed appropriate. Better understanding of these aims may inform the development of more acceptable and accurate strategies for screening women Veterans for alcohol misuse within the context of primary care. Our findings may also help us modify existing care strategies for treating alcohol misuse among women Veterans and enhancing treatment engagement in this population.

PUBLICATIONS:

Journal Articles

  1. Cucciare MA, Lewis ET, Hoggatt KJ, Bean-Mayberry B, Timko C, Durazo EM, Jamison AL, Frayne SM. Factors Affecting Women's Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2016 Mar 1; 26(2):232-9.
  2. Cucciare MA, Weingardt KR, Ghaus S, Boden MT, Frayne SM. A randomized controlled trial of a web-delivered brief alcohol intervention in Veterans Affairs primary care. Journal of studies on alcohol and drugs. 2013 May 1; 74(3):428-36.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: Prognosis
Keywords: QUERI Implementation
MeSH Terms: none