A Web-Based Intervention for Alcohol Misuse in VA Primary Care
Web-based brief alcohol interventions are effective in reducing alcohol consumption among adults and college students who misuse alcohol. These interventions have also been used effectively in ambulatory care clinics, including primary care, hepatitis C clinics, and emergency departments. Users typically complete the intervention, which consists of an initial assessment of alcohol use and related problems, in five to ten minutes. These data are then used to generate personalized feedback comparing a person's reported alcohol use with that of age- and gender-matched peers and provide information about alcohol-related consequences and risk factors. Despite growing evidence of their effectiveness, brief alcohol interventions have yet to be used to address alcohol misuse by U.S. veterans seeking primary care, where rates of alcohol misuse are estimated to range from 20% to 25%. Therefore, we conducted a pilot study to examine the feasibility of implementing a Web-based brief alcohol intervention in a large Veterans Affairs (VA) primary care clinic.
We conducted two focus groups with primary care administrators and clinic staff to determine their interest in and need for this intervention in their clinic. Both groups expressed a desire to implement the protocol but emphasized the need for effective intervention tools that minimally affect clinic operations. On receiving approval from clinic administrators, a single computer and printer were set up within the primary care clinic to be used by eligible patients. Twenty veterans who screened positive (men, ≥4; women, ≥3) on the three-item Alcohol Use Disorders Identification Test-Consumption Items (AUDIT-C) were invited to participate. Screening was conducted by a clinic nurse at intake. Nurses gave veterans who screened positive a flyer describing the study and obtained informed consent. After completing their primary care visit, veterans were handed off to study staff also at the clinic. Participants were asked to complete the intervention, print out and review their personalized feedback report, and complete a brief set of questionnaires assessing their experience of the study protocol.
About half of our sample was Caucasian and reported an annual income of ≤$30,000. More than half of participants (60%) reported a history of receiving treatment for a substance use disorder and AUDIT-C scores in a range indicating alcohol misuse (mean±SD=6.2±2.69 out of 12 points). These results suggest that clinic nurses were referring appropriate patients to the brief alcohol intervention.
On completion of the intervention, most participants reported being willing to discuss their alcohol use with a primary care provider or nurse (90%) and to attend a first appointment with an alcohol counselor if recommended by their provider (73%). However, most veterans also reported that they could reduce (83%) or abstain (76%) from using alcohol on their own, which suggests that veterans who screened positive for alcohol misuse were open to discussing their alcohol use with a provider and considering treatment if recommended but also felt able to reduce their alcohol consumption without (or with minimal) assistance.
All participants completed a brief questionnaire assessing usability of the brief intervention. A majority of participants (95%) indicated that the program was easy to use and that personalized feedback was easy to understand, and they found the graphics helpful and easy to interpret. Most participants (90%) also felt comfortable disclosing information about their alcohol use via computer, with 90% feeling that their information would be secure and confidential. This is an especially important finding given some initial concern that veterans might feel uncomfortable disclosing private behavior via computer.
In terms of perceived effectiveness, almost all participants reported that the brief intervention helped them more clearly understand how their alcohol use may affect their overall health and would recommend it to a friend. Most participants also felt that they would be more likely to reduce their alcohol use (and possibly seek treatment) in the future as a result of the intervention.
This pilot study was a first step in establishing the feasibility of a Web-based brief alcohol intervention in VA primary care. Larger studies are needed to determine whether reductions in alcohol use observed in prior studies (with nonveteran populations) generalize to U.S. military personnel who misuse alcohol. This is particularly important in light of findings indicating that veterans may use alcohol excessively to cope with complex negative emotions associated with highly prevalent mental health problems (such as posttraumatic stress disorder).
