Engagement, Screening and Assessment

There can be sensitivities around discussing alcohol use, especially if the client perceives or fears discrimination or is ashamed of harms from their drinking. It is important for the clinician to take time to build rapport with the client. Ideally, screening will be preceded by informal conversation to build a relationship between clinician and client. Asking the client “Who’s your people?” and “Where’s your country?” may help to show respect and interest, as well as help the clinician place the healthcare needs of the client in a cultural context of their relationships to family and country. Wherever possible, a consultation should be long enough to allow an unrushed approach. 

If the client seems uncomfortable in a face-to-face interview, sitting alongside the person rather than in front of them, and having a less clinical environment (e.g. with art on the wall, or being outdoors) may help. Some Aboriginal or Torres Strait Islander individuals from (or in) more traditional communities may find a series of direct questions intrusive. An unrushed, conversional style may be more comfortable. In more traditional Aboriginal or Torres Strait Islander communities it can be respectful (for patients  and clinicians) to avoid eye contact. This should not be misinterpreted as evasiveness. The clinician should also be alert to other cultural protocols, including around interactions with the other gender, or respect for older people, and seek guidance as needed.  

Converting drinking into ‘standard drinks’ can be challenging for the patient (or the clinician), especially when drinking is from non-standard containers. The challenge is increased if the person is from a remote area where English is a second (or third, or fourth) language and where numbering systems may differ. Asking the type, size and fullness of containers that clients drink from is likely to improve the accuracy of screening. Visuals aids can be used to help identify containers. It is also important to ask about sharing of alcohol, as some clients may report on how much the group drank rather than their own drinking.  

In terms of screening tools, the 3-item AUDIT-C (a shortened version of the Alcohol Use Disorders Identification Test, that only includes its three consumption questions) has been successfully used with Aboriginal or Torres Strait Islander patients in a primary care setting. It has been found to be less time-consuming and is potentially less ‘invasive’ than the full 10-question AUDIT, but provides comparable results.  

The WHO-ASSIST (and ASSIST-Lite) which screen for alcohol and other drugs risk jointly have also been used, but not validated, in Aboriginal or Torres Strait Islander settings. The Indigenous Risk Impact Screen (IRIS) was developed and validated specifically for Aboriginal or Torres Strait Islander settings, and screens jointly for alcohol and other drug disorders and mental health issues.  

In some communities, intermittent or episodic drinking may be common. Clients may have long “dry patches”, where they may go months without drinking until there is a specific event (e.g. sorry business [grieving after death], football grand final). Accordingly, the quantity-frequency method of asking about alcohol consumption, or asking about a “usual” drinking pattern may sometimes pose challenges. As an alternative screen for unhealthy drinking, the clinician can ask about the quantity of alcohol consumed on the last drinking occasion, and the timing (i.e. date) of the last 2-4 occasions.  If a person says they do not usually drink, this may reflect their usual drinking status. Ask about high risk drinking on special occasions, such as football grand final or New Year.