Date Published: March 29, 2018
Publisher: BioMed Central
Author(s): M. Mofizul Islam, Helen T. Oni, K. S. Kylie Lee, Noel Hayman, Scott Wilson, Kristie Harrison, Beth Hummerston, Rowena Ivers, Katherine M. Conigrave.
Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHSs) around Australia have been asked to standardise screening for unhealthy drinking. Accordingly, screening with the 3-item AUDIT-C (Alcohol Use Disorders Identification Test—Consumption) tool has become a national key performance indicator. Here we provide an overview of suitability of AUDIT-C and other brief alcohol screening tools for use in ACCHSs.
All peer-reviewed literature providing original data on validity, acceptability or feasibility of alcohol screening tools among Indigenous Australians was reviewed. Narrative synthesis was used to identify themes and integrate results.
Three screening tools—full AUDIT, AUDIT-3 (third question of AUDIT) and CAGE (Cut-down, Annoyed, Guilty and Eye-opener) have been validated against other consumption measures, and found to correspond well. Short forms of AUDIT have also been found to compare well with full AUDIT, and were preferred by primary care staff. Help was often required with converting consumption into standard drinks. Researchers commented that AUDIT and its short forms prompted reflection on drinking. Another tool, the Indigenous Risk Impact Screen (IRIS), jointly screens for alcohol, drug and mental health risk, but is relatively long (13 items). IRIS has been validated against dependence scales. AUDIT, IRIS and CAGE have a greater focus on dependence than on hazardous or harmful consumption.
Detection of unhealthy drinking before harms occur is a goal of screening, so AUDIT-C offers advantages over tools like IRIS or CAGE which focus on dependence. AUDIT-C’s brevity suits integration with general health screening. Further research is needed on facilitating implementation of systematic alcohol screening into Indigenous primary healthcare.
Although Aboriginal and Torres Strait Islander (Indigenous) Australians are more likely to abstain from drinking alcohol than other Australians, a greater proportion of those who do consume alcohol engage in risky drinking . These patterns of drinking have historical roots and often reflect ongoing experience of dispossession, marginalisation, disadvantage, racism, grief, trauma and loss. As a result, Indigenous Australians are up to eight times more likely to be hospitalised and five times more likely to die from an alcohol-related condition than their non-Indigenous counterparts .
A review was conducted of all original data on validity, acceptability or feasibility of alcohol screening among Indigenous Australians published up to April 2017. A range of search terms were used in Web of Science, PubMed and MEDLINE to identify potential peer-reviewed articles (Fig. 1). Grey literature was also searched (e.g., reports, monographs and clinical guidelines) for original data on alcohol screening among Indigenous Australians using the Australian Indigenous HealthInfoNet, the Indigenous Australian Alcohol and Other Drugs Bibliographic Database and the Google Scholar search engine. Finally, hand searching of reference lists was undertaken. The literature search was conducted by the first and second author (MMI, HO), and the search approach and retrieved articles were checked by an expert librarian.Fig. 1Diagram summarising procedure for selecting eligible articles for systematic review of alcohol screening among Indigenous Australians. Search terms used: Alcohol (MeSH), Aboriginal (MeSH), Australia (MeSH), Aboriginal OR Indigenous, screening, alcohol AND screening, Alcohol Use Disorders Identification Test. AUDIT-C, valid*, (((((Alcohol) AND screening) OR valid*) AND Aboriginal) AND Australia), (((((Alcohol) AND screening) OR Alcohol Use Disorders Identification Test) AND Aboriginal) AND Australia), TOPIC: (Alcohol) AND TOPIC: (Alcohol Use Disorders Identification Test) AND TOPIC: (Aboriginal) AND TOPIC: (Australia)
A total of 170 articles were found from searches of mainstream academic databases and an additional 10 references from other sources (Fig. 1). After applying the inclusion/exclusion criteria, 15 articles were considered and 13 were finally selected for data extraction and analysis.
Screening and early discussion of drinking is important in improving health, given the role of alcohol as a risk factor for a wide range of common conditions, such as diabetes, hypertension, cardiac arrhythmias and cancers [39, 40]. However, only a small number of screening tools have been validated for use with Indigenous Australian peoples. AUDIT and its short forms, IRIS and CAGE were all found to have validity compared to other screening tools or questions on alcohol consumption. Responses to the 12-item KAT correlated with those of AUDIT, but KAT was found less easy to use in Indigenous settings. AUDIT and its short forms were the only instruments for which data was available on feasibility of routine implementation in ACCHS primary care. Services found the full 10-item AUDIT too lengthy for busy primary care settings, and strongly preferred only 2–3 of AUDIT’s consumption questions.
Research on appropriate alcohol screening tools for Indigenous Australians is sparse. However the short forms of AUDIT, including AUDIT-C appear to be suitable and valid for ACCHS primary care settings when delivered in locally appropriate language. Training may be needed to facilitate implementation, including accurate screening of consumption level, responses to a positive screening result. Embedding the screening questions into practice software will also support implementation of screening. Clients (and clinicians) should be supported to quantify drinking by an interpreter, and/or by use of visual aids and/or computer technology. Positive screening should be followed either by clinical assessment or a second stage screen (e.g. IRIS or the remaining AUDIT questions). IRIS may be valuable as an additional tool in drug and alcohol, or social and emotional wellbeing sections of ACCHSs where there may be less time pressure, and to put alcohol use in its broader context of other substance use and mental health. Given the high prevalence of alcohol-related harms, routine and regular screening in ACCHSs needs to proceed, even while consultation, research and evaluation continues to optimise screening approaches.