Gender differences in the efficacy of brief interventions with a stepped care approach in general practice patients with alcohol-related disorders.
ABSTRACT To analyse gender differences in the efficacy of stepped care brief interventions for general practice patients with alcohol problems.
Data are part of "Stepped Interventions for Problem Drinkers," in which 10,803 patients from 85 general practitioners were screened using alcohol related questionnaires; 408 patients were randomized (32% were female) to a control (booklet only) or two different intervention groups: stepped care (feedback, manual, and up to three counselling sessions depending on the success of the previous intervention) and fixed care (four sessions). Response rate for the 12 months follow-up was 91.7%.
Regression analysis revealed a significant effect size only in women (P = 0.039). After excluding alcohol dependents and binge drinkers, an effect size (R(2)) of 0.031 (P = 0.050) in women and an effect size (R(2)) of 0.069 (P = 0.057) in men was obtained. Among the patients in stepped care who, by the first assessment point, had reduced drinking to within safe-drinking limits, there was a tendency for females to have achieved this more often than males (40% vs. 24%; P = 0.089).
In a heterogeneous sample, the intervention was only effective for women. Women tended to profit more from the first, less intensive intervention than men. When analysis was limited to those reporting "at risk" average daily consumption and "alcohol abuse," the gender differences in efficacy appeared to be less, but the study was not sufficiently powered to affirm that.
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ABSTRACT: ABSTRACT\BACKGROUND:Mood and anxiety disorders are highly prevalent and have a large impact on the lives of the affected individuals. Therefore, optimal treatment of these disorders is highly important. In this study we will examine the effectiveness of a stepped care program for primary care patients with mood and anxiety disorders. A stepped care program is characterized by different treatment steps that are arranged in order of increasing intensity. METHODS: This study is a randomised controlled trial with two conditions: stepped care and care as usual, whereby the latter forms the control group. The stepped care program consists of four evidence based interventions: (1) Watchful waiting, (2) Guided self-help, (3) Problem Solving Treatment and (4) Medication and/or specialized mental health care. The study population consists of primary care attendees aged 18-65 years. Screeners are sent to all patients of the participating general practitioners. Individuals with a Diagnostic and Statistical Manual of mental disorders (DSM) diagnosis of major depression, dysthymia, panic disorder (with or without agoraphobia), generalized anxiety disorder, or social phobia are included as well as individuals with minor depression and anxiety disorders. Primary focus is the reduction of depressive and anxiety symptoms. Both conditions are monitored at 8, 16 and 24 weeks. DISCUSSION: This study evaluates the effectiveness of a stepped care program for patients with depressive and anxiety disorder. If effective, a stepped care program can form a worthwhile alternative for care as usual. Strengths and limitations of this study are discussed. Trial registration: Current Controlled Trails: ISRCTN17831610
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ABSTRACT: The prevalence of alcohol abuse among patients treated in accident and emergency departments (A&E) is considered as substantial. This paper is a narrative review of studies investigating the effectiveness of brief interventions (BI) for hazardous and harmful alcohol consumption in A&E. A&E departments in hospitals (and other health care infrastructures) are commonly the place where serious consequences of alcohol drinking are seen and need to be tackled, supporting the suggested theoretical usefulness of delivering BI in this environment. Available research shows that BI may be considered a valuable technique for dealing with alcohol-related problems. However, it is suggested that the usefulness of BI may depend significantly on the target population to be dealt with. BI have proved to be beneficial for male individuals and those patients who do not abuse other psychoactive substances. In contrast, evidence indicates that BI in A&E settings are not effective at all when dealing with men admitted as a consequence of a violence-related event. In addition, some studies were unable to confirm the effectiveness of BI in female population, in emergency setting. Studies investigating the association between drinking patterns and the effectiveness of BI also present inconsistent results. Most studies assessing the effectiveness of BI in A&E settings only adopted a short perspective (looking at the impact up to a maximum of 12 months after the BI was delivered). When assessing the effects of BI, both the amount of alcohol consumed and expected reductions in alcohol consequences, such as injuries, can be taken into account. Evidence on the implementation of brief intervention in emergency departments remains inconclusive as to whether there are clear benefits. A variety of outcome measures and assessing procedures were used in the different studies, which have investigated this topic.Frontiers in Psychiatry 11/2014; 5:152.
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ABSTRACT: There has been growing evidence in recent years of the importance of gender specific issues in the addiction field. This paper explores specific problems and including specific health consequences faced by women who drink or use drugs. We describe helpful screening tools that can be used in the primary care setting and offer an understanding of some of the barriers preventing women from seeking help. This article also provides guidance on the best pharmacotherapy and psychological interventions that can be used to help women recover from their addiction.CNS spectrums 02/2011; 16(2):37-47. · 1.30 Impact Factor
Alcohol & Alcoholism Vol. 0, No. 0, pp. 1–7, 2008doi: 10.1093/alcalc/agn004
GENDER DIFFERENCES IN THE EFFICACY OF BRIEF INTERVENTIONS WITH A STEPPED
CARE APPROACH IN GENERAL PRACTICE PATIENTS WITH ALCOHOL-RELATED DISORDERS
SUSA REINHARDT1,∗, GALLUS BISCHOF1, JANINA GROTHUES1, ULRICH JOHN2, CHRISTIAN MEYER2
and HANS-J¨URGEN RUMPF1
1Psychiatry and Psychotherapy, University of Luebeck, L¨ ubeck, Germany and2Institute of Epidemiology and Social Medicine,
Greifswald University, Greifswald, Germany
(Received 31 August 2007; first review notified 00 2007; in revised form 19 December 2007; accepted 3 January 2008)
Abstract — Aim: To analyse gender differences in the efficacy of stepped care brief interventions for general practice patients with
alcohol problems. Methods: Data are part of “Stepped Interventions for Problem Drinkers,” in which 10,803 patients from 85 general
practitioners were screened using alcohol related questionnaires; 408 patients were randomized (32% were female) to a control (booklet
of the previous intervention) and fixed care (four sessions). Response rate for the 12 months follow-up was 91.7%. Results: Regression
analysis revealed a significant effect size only in women (P = 0.039). After excluding alcohol dependents and binge drinkers, an effect
size (R2) of 0.031 (P = 0.050) in women and an effect size (R2) of 0.069 (P = 0.057) in men was obtained. Among the patients in
stepped care who, by the first assessment point, had reduced drinking to within safe-drinking limits, there was a tendency for females
to have achieved this more often than males (40% vs. 24%; P = 0.089). Conclusions: In a heterogeneous sample, the intervention was
only effective for women. Women tended to profit more from the first, less intensive intervention than men. When analysis was limited
to those reporting “at risk” average daily consumption and “alcohol abuse,” the gender differences in efficacy appeared to be less, but
the study was not sufficiently powered to affirm that.
Providing brief interventions in medical settings is a promis-
ing approach in secondary prevention of problematic drinking
behaviour (Babor and Higgins-Biddle, 2000; Bertholet et al.,
2005). General practices have been shown to be an ideal set-
ting for brief interventions due to high prevalence rates of al-
cohol use disorders (Hill et al., 1998). Furthermore, a study in
Germany found at least one contact per year to a general prac-
titioner (GP) for 80% of alcohol dependent and 67.4% for
alcohol abusing individuals (Rumpf et al., 2000). Randomized
controlled trials have shown a significant reduction in patient’s
(Wallace et al., 1988; WHO Brief Intervention Study Group,
1996; Fleming et al., 1997; Poikolainen, 1999).
There is no consistent conclusion to draw on the topic of
gender differences and meta-analyses of brief interventions:
Earlier meta-analyses emphasized gender differences (Bien
et al., 1993; Kahan et al., 1995; Wilk et al., 1997), whereas
the more recent ones showed the equality of outcomes among
Bertholet et al., 2005). Earlier meta-analyses sometimes found
a trend for a better efficacy of brief interventions in women
(Wilk et al., 1997), others revealed no consistent results in
women at all (Chang, 2002), and even others showed a bet-
ter and stronger efficacy of brief interventions in men (Kahan
et al., 1995). The meta-analysis by Poikolainen (1999) found
efficacy of brief interventions only in women attributed to a
lack of homogeneity in men and in both genders combined.
Dept. of Psychiatry and Psychotherapy, University of Luebeck, Ratzeburger
Allee 160, 23538 Luebeck, Germany. Tel.: +49 (0)451-500-2871; Fax: +49
(0)451-500-3480; E-mail: Hans-Juergen.Rumpf@psychiatrie.uk-sh.de
This stands in contrast to an important meta-analysis on the
topic of gender differences which found no difference between
genders (Ballesteros et al., 2004). The authors included seven
studies and used as outcome measures the quantity of weekly
consumption and the frequency of drinkers who reported con-
sumption below hazardous levels. Ballesteros et al. (2004)
found similar standard effect sizes in men (d = −0.25) and
women (d = −0.26) for the reduction of alcohol consumption
and similar odds ratios in men (2.32) and women (2.31) for
the frequency of individuals drinking below the harmful level.
The meta-analysis by Bertholet and colleagues also showed an
effectiveness of brief interventions for both men and women in
reducing alcohol consumption at 6 and 12 months (Bertholet et
al., 2005). More recent is the review by Kaner and colleagues
intervention in men, but not in women. Often a null finding
in women was described-–that both control and intervention
groups tend to reduce alcohol consumption in trials of brief
interventions (Chang, 2002).
As an important new development in order to effectively
treat patients with alcohol-related disorders, stepped care ap-
proaches are applied. Following Borsari et al. (2007, p. 131)
stepped care is a “dynamic, performance-based procedure in
which individuals not responding to an initial level of treat-
ment that is the least intensive are then provided a more inten-
sive treatment” and “within this framework, different levels of
interventions are linked together.” Especially in times of lim-
and individual attention a patient needs, but not more” (Haaga,
2000, p. 547).
When this study was planned, only one study examined
a stepped care approach for reducing alcohol consumption
(Breslin et al., 1998). The authors evaluated a standard alcohol
treatment for heavy drinking adults and provided a supplemen-
tal treatment for non-responders, who continued to drink above
C ?The Author 2008. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
Alcohol and Alcoholism Advance Access published February 9, 2008
by guest on June 1, 2013
2 R. SUSA et al.
the recommended levels. But they did not find group differ-
ences between the non-responders with additional treatment
and the ones without, arguing that the additional treatment was
not intensive enough.
The main question of the following study of counselling
for patients with problem drinking in general practice was to
examine whether time can be saved using stepped care for
conventional brief interventions, and to compare the outcome
after these interventions to the outcome of a control group. Our
results, which reveal that stepped care for individuals with at-
risk drinking and/or alcohol use disorders is time saving and
can have a similar effect to traditional “brief interventions” are
published elsewhere (Bischof et al., in press-a).
The aim of this paper is to examine whether the patient’s
gender affects the efficacy of brief interventions in patients of
general practitioners with problematic alcohol consumption.
Recruitment of general practices and procedure
In our study “Stepped Interventions for Problem drinkers
(SIP),” 81 general practices in the northern German city of
Luebeck and its surrounding areas as well as four practices in
the city of Kiel took part. Of the 241 practices in Luebeck, 82
had to be excluded because of various reasons and 78 were
not willing to participate, resulting in a response rate of 50.9%
among the physicians (in the city of Kiel the response rate
was 31.8%). Data gathering ranged between 2 and 4 weeks per
practice and was conducted by study nurses, medical students
and research staff between January 2002 and March 2003.
Within the waiting rooms, patients were asked to fill out a
screening questionnaire on alcohol consumption embedded in
items on smoking, mental health and socio-demography. Par-
ticipants were deemed positive when they scored five points or
more in the Alcohol Use Disorder Identification Test (AUDIT,
Allen et al., 1997) and/or two or more points in the Luebeck Al-
cohol dependence and abuse Screening Test (LAST, Rumpf
et al., 1997). Patients fulfilling the inclusion criteria were
asked to further participate and sign informed consent. Then,
a questionnaire was sent via mail and after a few days a pre-
intervention assessment to diagnose alcohol dependence and
abuse according to the Diagnostic and Statistical Manual of
1995) was administered by phone.
dependence symptoms, and alcohol-related problems. Recent
studies report a Cronbach’s alpha ranging between 0.75 and
0.97 (Reinert and Allen, 2007). Validity was tested against di-
agnoses of harmful use, dependence as well as at-risk drinking
and was found to be generally good (Babor et al., 2001; Rein-
ert and Allen, 2007). The recommended cut-off point is eight
(Babor et al., 2001). However, in two German samples, five
points turned out to be the best cut-off point to maximize sen-
sitivity (Rumpf et al., 2002; Dybek et al., 2006). The screening
tool LAST consists of seven items for detecting alcohol abuse
and dependence. Two positive responses are the cut-off; in-
ternal consistency ranges between 0.69 and 0.81 (Cronbach’s
alpha); validity data show sensitivity ranging between 0.63 and
0.87 and a specificity of 0.88 to 0.93 (Rumpf et al., 1997).
For diagnosis according to DSM IV, the alcohol section
of the Munich Composite International Diagnostic Interview
(M-CIDI) (Wittchen et al., 1995) was used, which is the Ger-
man version of the Composite International Diagnostic In-
terview (CIDI) (Robins et al., 1988). The M-CIDI is a fully
structured and computerized interview and reports whether the
diagnostic criteria are fulfilled. The inter-rater reliability, test-
(Lachner et al., 1988; Andrews and Peters, 1998).
In addition to the M-CIDI, other questions concerning alco-
hol consumption and the core constructs of the transtheoretical
assessed, partly via telephone and partly by post.
The questionnaire MHI-5 (Berwick et al., 1991) consists of
Health Inventory (Veith and Ware, 1983; Davies-Avery et al.,
1988). MHI-5 is appropriate to detect anxious and depressive
disturbances within the last month (German translation Rumpf
et al., 2001b) with a higher sum of the Likert-scaled and trans-
formed items indicating a higher psychological pressure. The
internal consistency showed a good performance with a Cron-
bach’s alpha of 0.74, a sensitivity of 0.83 and a specificity of
0.78 (Rumpf et al., 2001b).
The stages of change were assessed using a German
translation of the Readiness to Change Questionnaire—RCQ
(Rollnick et al., 1992; Heather et al., 1993; Hann¨ over et al.,
2002, 2003). Stages of change were allocated using the quick
method (Heather et al., 1993). Here the Cronbach’s alpha is
reported for three subscales: precontemplation (0.67), contem-
plation (0.80), and action (0.83). Data suggest good predictive
validity for the instrument (Hann¨ over et al., 2003).
Inclusion and exclusion criteria
Patients were eligible if they sent back the questionnaire and
were either diagnosed with alcohol dependence or alcohol
abuse according to the DSM-IV criteria or fulfilled criteria
of at-risk or binge drinking only, descending in a hierarchi-
cal order, choosing always the most severe diagnosis. At-risk
drinking was defined as an average alcohol consumption of
more than 20 g alcohol per day for women and more than 30 g
per day for men according to the common criteria of the British
Medical Association (1995); binge-drinking was specified as
more than 60 g alcohol for women and more than 80 g for men
two or more times a month (adapted from a WHO study, Babor
and Grant, 1992). At the time of planning this study, no general
criteria were available. Some studies had used lower criteria,
but BMA criteria are quite common.
Exclusion criteria were no alcohol consumption within the
last 4 weeks, already in treatment for alcohol problems within
the last year, severe or terminal illness, severe drug depen-
The recruitment procedure is depicted in Fig. 1.
In total, 13,033 consecutive patients aged 18 to 64 years
were contacted during the practices and 10,803 patients were
screened. Of these patients, 2,239 (20.7%) screened positive
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GENDER DIFFERENCES IN BRIEF INTERVENTIONS3
Figure 1. Recruitment of study participants.
and 1,410 of those agreed to further participate (response rate
63%). In 79.2% (n = 1,119) of the cases, interviews could be
59.3% (n = 664) were not eligible (not fulfilling criteria of
alcohol dependence, alcohol abuse, at-risk or binge-drinking).
Of 408 final study participants, 124 were diagnosed as alcohol
dependants and 59 as alcohol abusers. The inclusion criteria of
at-risk drinking fulfilled 112, for binge-drinking 113 patients.
Of the study participants, 32% were female. In order to include
one female patient in the study, 47 of the women willing to
take part had to be screened. For one male study participant, 17
screenings of willing men were necessary.
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4R. SUSA et al.
Table 1. Prediction of alcohol consumption at follow-up; intervention status (0 = CG; 1 = IG) entered at step 2
Overall baseline consumption
CG = Control group. IG = Intervention groups
Randomization and intervention
After the diagnostic procedure, participants were randomly al-
located to a control group or to one of the two intervention
groups. The unit of randomization was the individual patient.
Randomization was carried out prior tothetelephone interview
using sealed cards drawn by study staff from one container.
This anomaly was necessary for organisational reasons—it did
not lead to unbalanced groups, because envelopes with cards
of ineligible patients were sealed again and put back in the
the diagnostic procedure. The feedback consisted of individu-
alized information tailored to the client’s motivation to change
and included normative feedback on drinking and drinking-
related risks as well as core constructs of the TTM (Prochaska
and self-efficacy. The computerized feedback alone was asso-
ciated with outcomes no different from those of a traditional
manual. Counselling sessions for patients in the intervention
groups were conducted via phone and based on Motivational
Interviewing (MI, Miller and Rollnick, 2002) and Behaviour
Change Counselling (BCC, Rollnick et al., 1999). The main
content of each intervention was the enhancement of motiva-
tion to reduce the alcohol consumption or become abstinent,
according to the individual’s stage of change. Participants in
fixed care (n = 131), received four counselling sessions up to
30 minutes each, directly after the diagnostic procedure and
1, 3, and 6 months later. Patients in stepped care (n = 138)
received the same feedback and the manual as the first, less
intensive, intervention. At the second contact after one month,
the success of the first intervention was checked. If the patients
reached safe drinking limits and were confident to maintain
the reduction (at least six points on a 10-point Likert scale),
they received no further intervention. If the first intervention
was not successful, patients were offered acounselling session.
The same procedure was conducted at the third contact after
3 months and the fourth contact after six months. The coun-
selling sessions for the stepped care group lasted up to 40 min-
Training of counsellors and supervisor
All interventions were conducted by three psychologists with
expertise in clinical treatment and research. They completed a
4-week training in MI (principles, basic techniques and prac-
tical exercises). This workshop and later supervisions were
conducted by the project manager and member of the MI com-
munity (HJR). All counselling sessions were audio taped and
a random sample was coded for MI consistency by the other
researchers. For supervision all four collaborators met on a
weekly basis. The use of the manual was checked and possi-
ble discrepancies were corrected. Quality control included the
rating of MI consistency and advanced training over the whole
Follow-up was scheduled after 12 months. A blinded personal
interview was conducted by research staff who had no con-
tact with the patient prior to the outcome assessment. There
was a mean interval between baseline assessment and follow-
up interview of 401 days (SD = 56.7). In the case of non-
accessibility via telephone, participants were personally con-
tacted at their homes. Of the baseline sample described above
27 (6.6%) were not attainable, 4 individuals (1%) withdrew
their further participation, and 374 individuals (91.7%) were
Data were analysed using SPSS for Windows, version 14.0.
ing that the patient who could not be reached for the follow-up
assessment did not change in outcome variables. The primary
of pure alcohol). In order to test time-saving of the stepped
care approach, the total amount of counselling in minutes
was used. Groups were compared using t-test, Mann–Whitney
U-test (used for comparing expended time for counselling be-
tween the intervention groups) and Kruskal–Wallis H-test. In
to compare the intervention groups concerning drinking out-
comes, and group differences for expended time when efficacy
of the intervention was held constant. Finally, we conducted
an OLS regression to compare intervention and control group
concerning drinking outcome. Because the distribution of our
outcome variables were highly skewed, we conducted these
analyses after transforming time expended for counselling and
alcohol consumption using the logarithmic scale, which made
the variables nearly normally distributed. After examining the
residuals of these regressions for normality and checking for
for the categorical variables using the formula (eb− 1) × 100.
This transformation is appropriate when the errors are normal
and homoscedastic and should be interpreted as the percentage
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GENDER DIFFERENCES IN BRIEF INTERVENTIONS5
Table 2. Prediction of alcohol consumption at follow-up, intervention status (0 = CG; 1 = IG) entered at step 2 of the regression analysis; at risk drinkers and
patients with alcohol abuse only
Overall baseline consumption
CG = Control group. IG = Intervention groups.
Table 3. Stepped care patients who reached safe drinking levels: Comparison
T2 n (%) T3 n (%)T4 n (%)
P = 0.089
P = 0.934
P = 0.898
T2 = contact one month after intake. T3 = contact three months after intake.
T4 = contact six months after intake.
difference in drinking outcome between that variable and the
comparison group (Manning, 1998). In addition, for analysing
a gender specific intervention effect an interaction term of
gender and intervention was calculated for the regression
The first analysis was to compare male and female study par-
ticipants. There was a significant difference in age, showing
a younger age for female patients (t = 2.48, df = 402, P =
(U = 15398,50; P = 0.016) and showed less negative mental
health and therefore lower points in MHI-5 (U = 14113,50;
P = 0.007). Education showed a slightly higher education
for women (U = 9274,00; P = 0.061). Regarding group ran-
domization, distribution of diagnoses and distribution of TTM
stages analyses showed no gender differences. Participants in
stepped care and fixed care did not differ significantly in any
demographic variables and alcohol risk terms; more details are
described elsewhere (Bischof et al., in press-a).
For the purpose of examining the efficacy of the intervention
in relation to gender, the intervention groups (stepped care
and fixed care) were collapsed yielding a higher statistical
Regression analysis for reduction of the drinking amount
revealed no intervention effect comparing control and inter-
vention groups with an effect size of R2= 0.006 (P = 0.124,
see Table 1). Splitting the sample by gender, analyses showed a
men showed an effect size of R2= 0.001 (P = 0.564). Based
on this analysis, the intervention effect for women was 35.5%
with a small to medium effect size and for men a reduction of
9.6% with no relevant effect size.
but showed no significant result.
A calculation of number needed to treat (NNT)—using
drinking reduction as an outcome—revealed that 10 women
had to be treated to get an improvement in one female patient,
which would not have occurred with the booklet only. The
corresponding number for men was 17.
For the next analysis, patients with a diagnosis of alcohol
were excluded. In this analysis men showed an R2-change of
0.031 with a tendency of P = 0.057 and women showed a
change of R2= 0.069 with a tendency of P = 0.050. Male at-
39.3% and female 36.1%, indicating again small to medium
effect sizes (see Table 2). Within this subsample the gender–
intervention interaction term was also included in the analysis,
but again showed no significant contribution to the regression
Response to step 1 of the stepped care intervention occurred
more often in females than males. At the second contact, con-
stituting the first efficacy check, 40% of the female study par-
ticipants in stepped care had responded to the first intervention
(i.e. reached safe-drinking limits) in comparison to 24.4% of
the male participants (P = 0.089). There was no difference at
any other point in time (see Table 3).
In order to check whether differences in drinking behaviour
help explain responses tostep1 (reduction consumption tosafe
drinking was calculated with no significant difference (U =
1151,00; P = 0.118). Mean ranks showed a lower chance of
dropping out for patients with a more severe risk status.
(M = 40.01; SD = 41.24) of intervention in minutes compared
to fixed care participants (M = 80.31; SD = 40.30), showing
a significant difference (P < 0.001). Less counselling time
was consumed by women in stepped care than by men (P =
0.026). Also, the percentage reduction of drinking in women
of the stepped care group was greater than in men (P = 0.050).
In control and fixed care group, men and women showed no
differences in the amount of drinking reduction.
Whether the patient’s gender affects the efficacy of brief in-
terventions for alcohol problems is unclear in the literature
This study provides new data on this point. In addition, this
is the first study to analyse gender differences in a stepped
care approach of brief interventions in problem drinking GP
patients. In the heterogeneous sample, consisting of alcohol
by guest on June 1, 2013
6R. SUSA et al.
dependents, alcohol abusers, at-risk drinkers and binge
drinkers, the efficacy of the intervention showed significant re-
sults and a small to medium effect size only for women. Since
recent meta-analyses show that brief interventions are not ef-
fective in alcohol dependent individuals, we excluded these
patients as well as binge drinkers from our sample in the next
step of data analysis. An analysis of this sub-sample (at-risk
studies, with brief intervention associated with tendencies and
small to medium effect sizes in men and women.
contribution to the regression model, for the whole group and
within the subsample. This is a major problem with the inter-
pretation of the results and suggests that other variables are
more important for efficacy than gender. The usual explanation
for findings that men do better with brief intervention (Kaner
et al., 2007) is that women show more assessment reactivity
mask the effects of intervention (Fleming et al., 1997). In the
presented study gender does not seem to be the most important
factor. Efficacy in brief intervention might be a question of
severity in alcohol-related problems or influenced by other, yet
to explore, variables.
Analysing the responses to the stepped care procedure
showed that women tended to profit more than men from the
first step, which in our study was the computerized feedback
and the stage-tailored manual. In comparison to 40% of the fe-
male study participants, only 24% of the male participants left
drinking below recommended limits and revealed sufficient
self-efficacy to maintain this reduction. This non-significant
tendency for more women than men to benefit from the first
step should be explored in further research. (Perhaps the small
sample size of this sub-group contributed to the failure to show
significance in that analysis.) Responders to the first stage did
not differ from non-responders in risk status at baseline. Those
closer to a cut-off point for at-risk drinking might be more
likely to reach this point after the first intervention, since less
behaviour change is required, than those with heavier drink-
ing, where much more behaviour change is required. Again
the small sample size might be a barrier in showing evidence
for this consideration. Mean ranks in the analysis showed the
amount of intervention in stepped care condition. Following
the higher rate of leaving the programme for women due to
intervention success after the first step, the difference in time
expended for counselling is explainable.
There are some limitations to this study. In particular, the
original trial was not powered sufficiently for this subgroup
analysis. Thus the lack of significant differences between con-
trol and intervention groups may be due to type II errors.
In addition, a low cut-off in AUDIT for positive screening
(5 points) produced an extraordinary high rate of patients
screening positive, but not fulfilling the inclusion criteria of the
on the other hand strengthens the sensitivity of the screening
instrument and therefore satisfies a high reachability.
ing the heterogeneous results concerning gender differences in
earlier studies and meta-analyses. Describing and explaining
the content of brief interventions in detail is necessary to anal-
yse gender specific responses.
Because treatment resources are limited, research needs to
look for the most appropriate but cost effective way for provid-
drinkers. Future studies should focus on efficacies of brief in-
terventions in different risk statuses (efficacy as a function of
severity) and the processes within the intervention that leads to
change and to what extent and in which ways men and women
differ in these processes.
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