Participants
Thirty-eight patients were approached in the waiting room of the DHC, and 36 (95%) agreed to participate. Of the 36, 17 (47%) were eligible OEF/OIF veterans who reported consuming alcohol on three or more days in the previous week. Eight of 17 (47%) eligible patients either did not have time to participate following their appointment or did not return from the clinic, which was on a different floor than the waiting room. One female and eight male OEF/OIF veterans representing multiple military service branches (Table ) and a broad age range (23–55
years; mean, 33
years) completed the study. During the interview, each participant volunteered that their drinking was categorized as risky, high-risk, or very high-risk by the e-SBI feedback and that they had also received feedback on heavy episodic drinking. To avoid identification of the one female participant, participants are hereafter referred to as male.
| Table 2Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veteran participant characteristics |
A priori domains
Participants provided useful feedback on six a priori domains regarding features of DrinkCheck (Table ). Overall, they were pleased with its length, standard drinks image, and feedback on alcohol calories and money spent on alcohol. They were not surprised by the feedback on blood alcohol concentration and legal driving limits. They also reported the anonymity of DrinkCheck was important for obtaining truthful responses.
| Table 3A PrioriDomains and Selected Quotes from Interviews with Nine Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans |
Emergent domains
Seven emergent domains were identified from participant interviews and are described below.
Questions about alcohol consumption “in the past year” were difficult to answer for recently returned veterans
Veterans reported alcohol was scarce and was generally prohibited during deployment. As a result, most participants said they did not drink alcohol while serving overseas. However, the AUDIT-C questions assessed typical and heavy-episodic drinking in the past year and were therefore challenging for participants who had recently returned:
"[Veteran C]: I guess the timing on it… it plays a major factor, because at some points in the year, you actually don’t even drink."
Participants were aware that their drinking when not deployed was probably most pertinent to the assessment, yet many averaged their consumption over the entire year:
"[Veteran E]: But over the past year people’s situations will be different.... I was just on deployment, so for six months I didn’t have anything… and then this past six months, it’s like, “Well, OK, now I’m getting back into the swing of things.” And so, they average it out over that, that entire time."
Questions about health and relationship concerns were confusing to veterans
DrinkCheck included questions about the frequency of health and relationship concerns in the past four weeks. Despite an introductory statement, “These questions ask about symptoms and concerns veterans may have that can be influenced by drinking,” veterans did not understand why they were being asked about such concerns:
"[Veteran H]: So, the question is, okay, “How often are you bothered by the following?” Well, why do you care?… What is it you’re trying to get at when you ask me these questions?"
Additionally, participants wondered how and in which causal direction the concerns were associated with alcohol:
"[Veteran B]: Some of these I also look as being effect, not so much a cause.... “Managing pain”—don’t really see it so much as an effect as a cause. “Trouble falling asleep, staying asleep or nightmares” can actually go both sides."
"[Veteran F]: Those were all pretty good questions that apply to drinking. I answered them honestly, but… some of those you can have whether you’re drinking or not."
Veterans wanted transparent nonjudgmental feedback and practical advice
The alcohol-risk feedback posed several problems for participants. First, they did not understand how or why they were assigned to their particular risk category:
"[Veteran B]: It doesn’t show me what it is that I do that put me in that risk category versus the next one down or the one below that.... What makes me very high risk? You know, outline it [referring to risk categories]. What about me makes me so much higher risk than the person in this one?"
"[Veteran D]: We didn’t go into depth about the category you’re putting me in….what do I do? Why does it matter?… You know, am I going to die that week because I had 15 drinks?"
Overall, participants wanted an explanation of what specifically about their drinking was risky as well as risk-reduction strategies tailored to their alcohol consumption and problems. Veteran D suggested adding more detail to the risk categories (e.g., “probably needs no assistance,” “should seek assistance”), as he wanted to know what he could do to reduce his risk:
"Okay, so, yeah, I drink too much. I’ve thrown up. I’ve had a hangover. That’s risky.... And, I’m aware of that. [It] doesn’t tell me maybe I should do something different. Doesn’t motivate me to."
Veteran F explained how greater personalization could encourage a decrease in drinking:
"[Referring to risk assignment]: If you saw that and were thinking about what could make my relationship better, and it says ‘less drinking,’ you’d be like, “Oh, well, there’s an eye-opener.” …[I]f it said something personal that could really only apply to you, by taking this, then I think people would think twice about going and drinking a lot."
Further, for some veterans, the risk feedback implied a judgment about them and their drinking:
"[Veteran B]: [People] use this and it just turns back and says, “Yeah, you’re drinking too much.” And, all of a sudden, what has that done? Just one more person accusing them."
Although the risk categories were intended to highlight the continuum of alcohol-related risk, some veterans viewed alcohol risk as “all or nothing”:
"[Veteran I]: If society says that you drink too much, then you’re deemed an alcoholic or a drunk. And, you know, it’s like there’s no real safe gray area in there that you could play with all that much."
Veterans felt the context for their drinking should be considered when assessing risk
Participants did not typically consider their alcohol consumption as risky or inappropriate for the occasion and thought the context for drinking and whether problems were present, not just the level of consumption, were relevant to the assessment of risk:
"[Veteran A]: Maybe it‘s just me, but maybe the wording ‘risky drinking.’ You know, you’re doing risky drinking. Well, it doesn’t seem risky when I’m doing it. (Laughter) I’m not going to hurt anybody. I’m not going to do anything wrong."
The context for risky drinking was perceived as particularly relevant if drinking was associated with a festive occasion:
"[Veteran E]: [It’s been] my birthday, then Christmas, then New Year’s, all in two weeks. And, I’m always responsible with my drinking. I always make sure that if I, I’ve had more than three drinks total in the night, I always take it easy at least an hour before I drive. Make sure I’m calmed down."
Context was also considered particularly relevant for a difficult occasion:
"[Veteran G]: For me, once a month going out and doing 13 drinks over 9 hours. Like, that’s not much compared to the two or three drinks I’ll have once or twice a week… Usually when I do have those binge nights, there’s a very specific reason I go out and drink like that, whether I’m celebrating… but this last time it was—I didn’t get a job, and I was very upset, and I thought I was gonna get it and it’s been two months, and I’m just like, uh. So, there was a reason; it was, “I’m just gonna go out and do this, and get all my frustrations out.”"
Individual differences were also important for explaining heavy episodic drinking:
"[Veteran F, referring to risk feedback]: That didn’t scare me into drinking any less ‘cause, honestly, I think people’s recommended limits aren’t everybody’s. ‘Cause people are, like, “Oh, don’t drink any more than a six pack.” And, that’s pretty much what I like. And, I don’t really seem to be having a problem with it."
Veterans dismissed the normative feedback because it lacked credibility
All participants voluntarily reported receiving normative feedback for heavy episodic drinking, which attempted to highlight the incongruence between participants’ perception of “normal” drinking and actual norms. However, they had difficulty accepting veteran outpatients as an appropriate comparison group given differences in experiences among veterans:
"[Veteran E]: If you’re just taking into account all VA patients 30 to 39 over the entire country, doesn’t necessarily mean that they spent as much time on deployment, doesn’t mean that they went to the same places that we did, or that I have."
Moreover, a few were skeptical of the comparison group data, believing it underrepresented OEF/OIF veterans’ drinking, and that other OEF/OIF veterans would think so as well. Participants felt they knew what their peers were consuming, and it was as much or more than their own consumption:
"[Veteran H]: This one here is one of the ones that I thought, “Oh, bull.” “I drink more drinks in a single day than 99 percent of male VA patients my age.” I don’t believe that for a second, okay?… I mean, I know a lot of guys, a lot of Vets… you know, and, they drink just as much as I do, if not more."
Veterans spontaneously offered unsolicited stories/anecdotes about drinking
Although the interview was designed to elicit participant opinions about DrinkCheck and not private information about themselves, every participant volunteered personal details about their experience with alcohol. Personal stories were interwoven throughout the interviews and were often the byproduct of a participant’s review of a specific e-SBI feature. In reference to “managing pain” listed among the health concerns, Veteran F shared this:
"I’ll have to say, I do drink sometimes cause of that. Like, I separated my shoulder last week, and I can’t just go to the doctors anytime and pick up medication. And, so, a six pack helps. And, a six pack and a hot tub does a pretty good job on that one. So, I have to say I do drink for that sometimes."
Veterans also spoke openly about their experience with alcohol without responding to a specific e-SBI feature. In explaining his tolerance for alcohol, Veteran E offered:
"My family has a history of alcoholism, and I remember being seven years old and having to drive my dad home drunk from the bar. At seven. It’s kind of screwy. Since then, my father has severely cut back on his drinking. He’s 74 now. He’ll go out, you know, maybe once, twice, a week.... He’ll go out with his buddy, and they’ll have six, seven beers… another night during the week, they’ll do the same thing."
Veterans reported benefits of completing DrinkCheck
Despite elicited criticism regarding specific e-SBI features, all nine OEF/OIF veterans found the program somewhat helpful in encouraging consideration of their drinking. Specifically, some veterans appreciated being provided the recommended drinking limits [
42] and felt the information succinctly summed up what they needed to know to avoid unsafe consumption:
"[Veteran C]: I’ve seen a whole bunch of, like, drinking videos and stuff like that, and they really don’t say, you know, what the actual limit is for, you know, not really harming yourself."
Further, despite some doubts and dissatisfaction with the feedback, a few OEF/OIF veterans expressed interest in changing their drinking:
"[Veteran A]: You know, it definitely makes me reflect. I think, “Well, hold on a second, you know, it would be better not to drink quite so much at those times.”"
Some were surprised by their consumption and suggested other veterans using the program might be as well:
"[Veteran G referring to normative feedback]: I liked this page, because I was like “Oh my god” (laughs). Cause I just didn’t realize… putting it on the most that you drank in one night, I was like, “Wow, remind me not to do that very often.” I’ll think about that a lot more."
Lastly, several participants indicated interest in assistance with their drinking beyond what DrinkCheck had to offer:
"[Veteran D]: I don’t want to stop drinking alcohol. And I think I can safely have a drink or two, but maybe I should look at some strategies. Not for quitting, ‘cause I saw [the “Strategies for Cutting Down” link on the Resource page] and I thought, “That’s it.”"
In particular, Veteran B, who described a family history of problem drinking and experience with Alcoholics Anonymous, suggested offering additional resources:
"[Veteran B]: Maybe resource links if the VA has resources… “These are healthy drinking habits. These are resources that are available to you to help you get there.”…[I]f it takes more of a, a corrective approach, giving them steps, giving them resources, giving them options… those types of things are going to cause people to want to come back, to want to re-evaluate themselves, to continue to use the system."
1,5 Eric J Hawkins,1,2 Laura J Chavez,1,5 Carol E Achtmeyer,1,2,3 Emily C Williams,1,5 Rachel M Thomas,1 Evette J Ludman,6 Kypros Kypri,7 Stephen C Hunt,4 and Katharine A Bradley1,2,6
