Results
A total of 67 health professionals met with a Public Health Nurse or Health Promoter for an academic detailing. All of them agreed to participate in this study and completed the initial interview. Six months later, 38 of the 67 health professionals completed the follow-up interview, giving a response rate of 56.7%.
To assess for a potential non-response bias in the study, those who completed both the initial and follow-up interviews (respondents) were compared to those who completed the initial interview only (non-respondents) with respect to sex, profession, attitudes and practices towards screening for alcohol, tobacco and abuse. Non-respondents were more comfortable than respondents asking female patients about abuse. No other significant differences between the groups were found.
Table 1.1: Characteristics of responding and non-responding health professionals (n)
|
Characteristic |
Group Respondents (n) |
Group Non-Respondents (n) |
Significance (p-value) (n) |
|---|---|---|---|
|
Sex - Male |
12 |
15 |
.08 |
|
Sex - Female |
26 |
13 |
.08 |
|
Health professional group - Family Physician |
32 |
24 |
1.00 |
|
Health professional group - Midwife or Nurse Practitioner |
6 |
5 |
1.00 |
|
Comfortable asking about tobacco - Yes |
38 |
29 |
1.00 |
|
Comfortable asking about tobacco - Neutral/No |
-- |
-- |
-- |
|
Currently discuss tobacco use with all of my patients |
31 |
21 |
.56 |
|
Currently discuss tobacco use with some of my patients |
7 |
7 |
.56 |
|
Comfortable asking about alcohol - Yes |
36 |
27 |
1.00 |
|
Comfortable asking about alcohol - Neutral/No |
2 |
2 |
1.00 |
|
Currently ask about alcohol use with all of my patients.... |
25 |
18 |
.80 |
|
Currently ask about alcohol use with some of my patients |
13 |
11 |
.80 |
|
Comfortable asking about abuse - Yes |
23 |
25 |
.03 |
|
Comfortable asking about abuse - Neutral/No |
15 |
4 |
.03 |
|
Currently ask about abuse with all of my patients |
10 |
3 |
.12 |
|
Currently ask about abuse with some of my patients |
27 |
26 |
.12 |
|
Characteristic |
Group Respondents (%) |
Group Non-Respondents (%) |
|---|---|---|
|
Sex - Male |
31.6% |
53.6% |
|
Sex - Female |
68.4% |
46.4% |
|
Health professional group - Family Physician |
84.2% |
82.8% |
|
Health professional group - Midwife or Nurse Practitioner |
15.8% |
17.2% |
|
Comfortable asking about tobacco - Yes |
100.0% |
100.0% |
|
Comfortable asking about tobacco - Neutral/No |
-- |
-- |
|
Currently discuss tobacco use with all of my patients |
81.6% |
75.0% |
|
Currently discuss tobacco use with some of my patients |
18.4% |
25.0% |
|
Comfortable asking about alcohol - Yes |
94.7% |
93.1% |
|
Comfortable asking about alcohol - Neutral/No |
5.3% |
6.9% |
|
Currently ask about alcohol use with all of my patients.... |
65.8% |
62.1% |
|
Currently ask about alcohol use with some of my patients |
34.2% |
37.9% |
|
Comfortable asking about abuse - Yes |
60.5% |
86.2% |
|
Comfortable asking about abuse - Neutral/No |
39.5% |
13.8% |
|
Currently ask about abuse with all of my patients |
27.0% |
10.3% |
|
Currently ask about abuse with some of my patients |
73.0% |
89.7% |
| Pre intervention attitudes and practices towards screening | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Attitudes and practices towards screening for tobacco useTable 2 shows that almost all health professionals agreed that it is appropriate to screen all of their female patients for tobacco use (98.6%) and they are comfortable asking their patients about their tobacco use (100%). Fifty (74.8%) health professionals reported that they know how to intervene effectively with female patients who smoke. Few reported that they do not have enough time with their patients to discuss tobacco use (18.1%).Two-thirds of health professionals agreed that telling their patients they should quit smoking is an effective cessation intervention and that they know what local programs and services are available to help their patients quit smoking (66.7% and 64.2% respectively).
In the initial Interview, 52 (77.6%) of health professionals indicated that they screened all female patients for tobacco use. The remaining 14 indicated that they screened only some of their patients. They reported discussing tobacco use most frequently with patients who reported smoking, patients interested in quitting smoking and pregnant patients. Attitudes and practices towards screening for alcohol useMost health professionals agreed that it is appropriate to screen all of their female patients for alcohol use (95.5%), that they are comfortable asking their patients about their alcohol use (94%) and that problem drinking is common enough to warrant universal screening (86.6%) (Table 3). However, fewer health professionals agreed that they know what local programs and services are available to help their patients deal with problem drinking (67.1%), that they know how to intervene effectively with female patients who are problem drinkers (58.2%) and that telling their patients they should cut down on their drinking is an effective intervention to reduce alcohol consumption ( 57.6%). Only one in four (25.7%) felt that they do not have sufficient time with their patients to discuss alcohol use. Table 3.1: Attitudes of health professionals towards screening for alcohol use (n), level of agreement
Forty-three (64.2%) health professionals indicated that they discussed alcohol use with all of their female patients. Those who discussed alcohol use with some of their patients did so with almost all patients who reported alcohol use, pregnant women, and patients known to abuse alcohol or on medications that interact with alcohol. They also discussed alcohol use with more than half of new patients and those perceived to be at risk for alcohol abuse. Attitudes and practices towards screening for abuseMost health professionals agreed that it is appropriate to screen all of their female patients for abuse ( 83.5%), that they are comfortable asking their patients about abuse (71.6%) and that they think abuse is common enough to warrant universal screening (76.1%) (Table 4). However, only about half of the health professionals reported knowing what local programs and services are available to help their female patients who are being abused by a male partner (55.2%). Approximately a third of the health professionals reported knowing how to intervene effectively with female patients who are abused (40.3%). One in four health professionals (22.7%) agreed that they do not have sufficient time with their patients to discuss abuse.
Only 13 health professionals (19.4%) indicated that they currently discussed abuse with all of their female patients. Those who discussed abuse with some patients indicated that they were most likely to discuss abuse if the patient disclosed being abused or presented with suspicious injury or bruising. These professionals discussed abuse with about half of their pregnant patients. |
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| Screening practices prior to academic detailing | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Table 5 presents the level of routine screening during periodic health examinations. Fifty-four (86.6%), 44 (65.7%) and 9 (13.6%) of all the health professionals routinely screened more than 90% of their female patients for tobacco use, alcohol use and abuse respectively prior to academic detailing.
Table 5.1: Level of routine screening for tobacco use, alcohol use and abuse reported by all health professionals, pre-intervention (n)
Table 5.2: Level of routine screening for tobacco use, alcohol use and abuse reported by all health professionals, pre-intervention (row%)
Almost all of the 11 midwives and nurse practitioners screened over 90% of their female patients for tobacco and alcohol use, and over 50% for abuse. For family physicians only (n=56), 47 (83.9%), 34 (60.7%) and 3 (5.4%) routinely screened more than 90% of their female patients for tobacco use, alcohol use and abuse respectively during a periodic health examination in the previous 12 months (Table 6). Table 6.1: Level of routine screening for tobacco use, alcohol use and abuse reported by family physicians, pre-intervention (n)
Table 6.2: Level of routine screening for tobacco use, alcohol use and abuse reported by family physicians, pre-intervention (row%)
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| Change in practice between initial and follow-up interviews | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tobacco useBecause all respondents reported screening for tobacco use prior to academic detailing, questions on screening for tobacco use were not included in the follow-up interview. Alcohol useTable 7 presents the proportion of female patients with whom health professionals reported discussing alcohol before and after academic detailing. McNemar's test revealed no change in practice. Table 7.1: Proportion of female patients with whom health professionals discussed alcohol use before and after academic detailing (n)
p = .06 by McNemar's test Table 7.2: Proportion of female patients with whom health professionals discussed alcohol use before and after academic detailing (% of total)
p = .06 by McNemar's test Table 8 presents the priority groups selected for a discussion about alcohol use before and after academic detailing. Among health professionals who reported during the initial interview that they did not discuss alcohol use with all patients, the priority groups selected for this discussion were similar before and after academic detailing. The rankings of priority groups did not change between the initial and follow-up interviews. Table 8.1: Proportion of health professionals* who discussed alcohol use with selected groups of patients (n(% of sample))
* excludes professionals who discussed alcohol use with all of their female patients Table 8.2: Proportion of health professionals* who discussed alcohol use with selected groups of patients (% of sample)
* excludes professionals who discussed alcohol use with all of their female patients Table 9 presents the proportion of female patients screened for alcohol use during a periodic health examination, before and after academic detailing. Again, using McNemar's test for significance, there was no change in practice.
Table 9.1: Proportion of female patients screened for alcohol use by health professionals before and after academic detailing (n)
p = .68 by McNemar's test
Table 9.2: Proportion of female patients screened for alcohol use by health professionals before and after academic detailing ( % of total)
p = .68 by McNemar's test AbuseTable 10 presents the proportion of female patients with whom health professionals reported a discussion of abuse, before and after academic detailing. Again, there was no change in practice, using McNemar's test. Table 10.1: Proportion of female patients with whom health professionals discussed abuse before and after academic detailing (n)
p = 1.00 by McNemar's test
Table 10.2: Proportion of female patients with whom health professionals discussed abuse before and after academic detailing (% of total)
p = 1.00 by McNemar's test
Table 11 presents the groups with whom health professions most frequently discussed abuse before and after academic detailing. Patients who disclosed abuse, patients with suspicious bruising and pregnant patients were most often selected for discussion at both time periods. Table 11.1: Proportion of health professionals* who discussed abuse with selected groups of patients (n)
* excludes professionals who discussed alcohol use with all of their female patients Table 11.2: Proportion of health professionals* who discussed abuse with selected groups of patients (% of sample)
* excludes professionals who discussed alcohol use with all of their female patients Table 12 presents the proportion of female patients screened for abuse during a periodic health examination, before and after academic detailing. Again, McNemar's test showed no change. Table 12.1: Proportion of female patients screened for abuse by health professionals before and after academic detailing (n)
p = .34 by McNemar's test
Table 12.2: Proportion of female patients screened for abuse by health professionals before and after academic detailing (% of total)
p = .34 by McNemar's test
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| Use of the tobacco, alcohol and abuse screening tool | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Of 35 respondents at follow-up, 23 (65.7%) had read the resource package provided by KFL&A staff at the initial interview, and 32 of 34 (94.1%) found academic detailing "very" or "somewhat useful". Of 33 respondents at follow-up, 14 (42.4%) had used the tobacco, alcohol and abuse screening tool. Few patients completed the tool themselves; in most cases the professional asked the questions directly. Fourteen respondents found having all three tools (tobacco screening, T-ACE and RUC) combined into one tool either "useful", or "very useful". Table 13 presents the extent to which health professionals used the tobacco, alcohol and abuse sections of the screening tool. Although only about 10% used the tool itself, about 50% of respondents used the same questions. Few professionals provided reasons for not using the tool. When given, the reasons were either that the tool was too time-consuming, or that they had a better tool.
Table 13: Use of the tobacco, alcohol and abuse screening tool by health professionals (n(row%))
Use of the tobacco, alcohol and abuse screening tool and change in practiceNine of 32 health professionals (28.1%) reported an increase in the referral of women for smoking cessation, 7 of 33 professionals (21.2%) reported an increase in alcohol-related referrals and 4 of 35 professionals (11.2%) reported an increase in referrals for abuse. No physicians reported a decrease in their rate of referral. These changes in referrals were not associated with use of the corresponding portion of the tobacco, alcohol and abuse screening tool (p=.68 for tobacco, p=.36 for T-ACE and p=.23 for RUCS, by Fisher's Exact Test). In addition, use of the T-ACE component of the screening tool was unrelated to the level of screening for alcohol use at follow-up (p=.14) or to a change in level of screening for alcohol use (p=.57). Likewise, use of the RUCS component of the screening tool was unrelated to the level of screening for abuse at follow-up (p=.31) or a change in screening practice with respect to abuse (p=.46).
Intention to use the tobacco, alcohol and abuse screening toolIntention to use the tobacco, alcohol and abuse screening tool was highly correlated with whether or not the health professional had used it during the study period (Table 13). Of 19 professionals who had used T-ACE or questions from T-ACE, 14 (73.6%) felt that they would it in future, compared to 4 of 13 health professional (30.8%) who did not use the screening tool (p=.03). Results for RUCS were similar. Fifteen of 19 professionals who used the RUCS (78.9%) intended to use it in future, whereas only 4 of 16 professionals (25.0%) who did not use the tool intended to do so in the future (p=.002).
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