With a much greater number of men than women consenting to participate in both the feasibility study and the pilot RCT, participants were asked if they could provide any insight into gender differences that might influence participation. Participants raised the issue of potential gender differences in orthopaedic surgery and in alcohol consumption that would make women less likely to meet the inclusion criteria. However, these opinions were not consistent across interviewees, with some explaining that women drank as much as or as often as men and that from their experience a greater number of women than men were undergoing surgery:
Oh God, this day and age, I don’t know. I go out and just see more women out than bloody men.
Male, knee, 64 years
Two participants also explained that women were generally less likely to want to share information about their personal lives. These views suggest that women may decline screening, refuse participation or under-report their alcohol consumption when screened:
I don’t think women like being asked invasive questions about themselves. I’m trying to picture my
wife being asked the questions and I think you’d be getting a lot of. ‘Erm, but, erm’. Maybe she
wouldn’t quite give you the exact amount.
Male, knee, 70 years
Other participants felt that men would be more open about their alcohol consumption than women, with one suggesting that this might be motivated by seeing friends and family members going through health scares and treatment:
Maybe they’ve come to their senses and think too much drink is doing too much damage. There are a
lot of people, like I’ve got a couple of friends who are having problems and going through tests on
their liver and stuff like that. Maybe it’s something to do with that, too much drink, and they realised.
Female, hip, 67 years
One participant also felt that male participants may have been motivated to take part by their female partners:
I don’t know. Probably their wives have told them to do it.
Male, knee, 70 years Health-care professional interview results
Eleven HCPs were recruited during the pilot RCT: four each from sites 1 and 2 and three from site 3. Of these, eight went on to deliver at least one intervention session, one conducted screening only and two had no further involvement. Five HCPs (two from site 1, one from site 2 and two from site 3) consented to and participated in interviews about their experience of being involved in the trial. All five
were female: three conducted both screening and intervention, one conducted the screening only and one conducted the intervention only. Owing to the small number of HCPs involved in the trial and the visibility of their involvement, quotations are identified by site only.
Coherence
Differentiation and individual specification
The HCPs interviewed were asked about both their day-to-day roles and their study-specific roles. The descriptions provided clearly demonstrated that participants had an understanding of their own tasks and responsibilities within the pilot RCT as well as how these differed from their usual preassessment role:
We do the AUDIT, the alcohol questions and then we go through the materials so reasons to cut
down, why it’s important for surgery and then looking at ways to cut it down . . .
Site 3
I was doing pre-assessments for patients that were going through surgery, minor surgery. Taking heights, weights, blood pressure, bloods, stuff like that.
Site 1
Similarly, when asked how appointments differed for patients involved in the study, HCPs were able to identify key differences between the trial intervention and standard PA processes. They highlighted a focus on taking additional time to complete the AUDIT questionnaire and discuss alcohol consumption as the key aspect of the trial for those involved specifically in intervention delivery. They also mentioned that completion of screening and co-ordination were trial tasks for others:
So it’s about we take some extra time to go through the questionnaire and to talk more about
alcohol. Sometimes I am doing the pre-assessment as well so I will mention it at the beginning of the assessment and say we will come back to that at the end and I think they have some more questionnaires and forms to fill out for the study . . .
Site 3
There was also some recognition that as the trial participants were taking part in something additional on a voluntary basis it was important to ensure that the experience was as positive as possible for them:
. . . people that are coming in for a booked BIRDS appointment, I never let them wait. So, if their
appointment time is 2 o’clock, they won’t be in this room any later than 2 o’clock, even if the research
team are not here, just give them a cuppa, ask them if they want a cuppa, and let them feel relaxed really. Whereas the other appointments, some people are waiting there a very long time . . .
Site 3 Communal specification
Interview transcripts revealed that the study processes, and specifically screening and intervention, were considered to fit well with existing PA specifically because questions about alcohol use and other health behaviours are already a standard part of PA. Trial processes could be seen to build and expand on these aspects of TAU:
. . . we do already ask about alcohol but we don’t really do much with that information. Other than
maybe refer the notes to anaesthetist review if they are drinking a lot or maybe do like liver function tests and see how that comes out. So it does fit and it gives a bit something extra that we can do . . .
From the patient perspective, the delivery of screening and intervention was also considered to fit well because it was scheduled around times when patients were already attending the hospital for appointments:
So I think it is quite good, the fact of having it in pre-assessment when they come, because they’ve
got to come for their appointment anyway.
Site 3
Because the pilot RCT tasks were additional to TAU, it was considered necessary to have additional time allocated for these sessions in order to allow for implementation:
Although it fitted in well, time is a big thing in this clinic. I think they found it was a bit more time-consuming for them and they were getting held back a little bit. It went OK, just time wise. Some patients like to talk more than others.
Site 1
Further to this, even when adequate time was available to deliver the intervention, there were instances when issues emerged that had to be prioritised over intervention delivery to ensure patient safety:
I think one patient wanted to talk more about something else like they were using some other drugs as well so that was what we talked about that a lot more really but otherwise it was fine with all the others it really was fine.
Site 3 Internalisation
Interviewees identified a number of potential benefits of the trial and intervention at personal, system and societal level. Personal benefits included positive outcomes for professional development, with potential cost-saving benefits for the NHS and wider benefits of addressing alcohol consumption:
I think it will have a positive impact on the NHS. People are taking it in and cutting down on their drinking, it’s going to benefit them and us . . .
Site 1
Well, it was to move myself up and get more experience within the NHS. I know the research is a good thing to have on a CV [curriculum vitae].
Site 3
There was a clear indication that many of the potential benefits of screening and intervention were communicated during the trial training suggesting limited understanding of the association between alcohol and surgery:
. . . in the training it said about alcohol making it more likely for the patients to have complications and possibly get infections and things like that and taking longer to recover so if they can cut down then obviously that would help.
Site 3