The word "motive" originates from "movere," a Latin word referring to "move." In a psychological context, motive means the fundamental power that leads a person to move and refers to a tendency or attitude determining the direction of a subject's behavior.¹⁾ Motive is the driving force that leads to changes in behavior. Motivation is the process by which a subject moves toward a goal. Motivation plays an important role in inducing patients with alcohol-related problems to change their behavior and maintain the change. According to De Leon et al.,²⁾ enhancing motivation is an important element in caring for patients with problems related to alcohol, as well as abuse of other substances. Cox and Klinger³⁾ also perceived the patients' level of motivation as a fundamental component in caring for patients with such problems.

Brief intervention has been used to motivate at-risk drinkers and enforce their willingness to undergo treatment. Fleming⁴⁾ explained that there are three forms of brief interventions that can be applied according to the patient's drinking level: simple advice, regular counseling, and intensive intervention requiring 15 to 20 minutes. In terms of effectiveness, he also mentioned that the effect of brief outpatient counseling is not inferior to that of an intensive alcohol treatment program.

It has been indicated that a brief educational program on drinking can improve an at-risk drinker's readiness to change.⁵⁾ Brief intervention is also an effective tool in improving problems related to drinking.^6,7) However, the medical circumstances of Korea may limit the ability of physicians to perform such time-consuming interventions in their office. Another possible problem is that primary care physicians may lack the confidence and training to deal with drinking-related problems. Hence, if shorter, simpler advice was offered by a majority of physicians, the motivational state of a patient to change their drinking behavior could be improved. Such methods would be valuable in primary care practice.

Brown et al.⁸⁾ suggested brief interventions by telephone as a method of treating patients. Counseling by telephone is an intervention method used to induce changes in a patient's behavior and is utilized to correct problematic habits, including smoking, improper meals, and deficient exercise. Various studies^9,10) have reported the excellent effect of telephone intervention, which is not inferior to that of personal counseling. However, no studies have reported the effect of telephone counseling on improving problems related to drinking in Korea.

Problem drinking includes at-risk drinking, alcohol abuse, and alcohol dependence. The present study was conducted on patients identified as at-risk drinkers to investigate whether simple advice from family physicians could improve a patient's readiness to change their drinking behavior. Furthermore, this study investigated the effect of telephone advice on a patient's readiness to change in comparison with that of in-person advice.

The purpose of this study was to investigate the effect of brief advice on the readiness to change of at-risk drinkers, who are commonly encountered in primary care. Our study showed an improvement in the readiness to change of a patient after receiving brief advice. A previous study by Pal et al.²¹⁾ also investigated the effect of five minutes of advice on the readiness to change of patients with alcohol use disorders, and reported that the patient distribution pattern of 6 (13.3%) in the precontemplation stage, 32 (71.1%) in the contemplation stage, and 7 (15.6%) in the action stage before the brief advice was changed into 2 (4.5%), 23 (52.3%), and 19 (43.2%), respectively, 1 month after the brief advice. The results of our study, that two minutes of brief advice led to a significant change in the readiness to change one month after the advice was given, is in agreement with the previous study.

Various difficulties in managing drinking problems have been reported. An accurate diagnosis may be difficult, and treatment may take longer than that for general physical problems. Alcohol abuse may be perceived as a lack of morality rather than a medical condition. In addition, the treatment outcome of patients with drinking problems may be viewed negatively.²²⁾ However, the results of our study encourage clinicians not to give up on patients with drinking problems. In addition, our study suggests the need for changes in clinicians' negative perception that it is difficult to treat patients with drinking problems.

Pal et al.²¹⁾ reported that the effect of brief advice on the improvement in readiness to change of a patient did not last three months. The distributions of patients changed to 13 (29.5%) in the precontemplation stage, 26 (59.1%) in the contemplation stage, and 5 (11.4%) in the action stage three months after the advice. In contrast, another study²³⁾ reported that the effect of group education on readiness to change of at-risk drinkers lasted for > 1 year. Before participating in the group education, there were 11 (32.4%) patients in the precontemplation stage, 23 (67.6%) in the contemplation stage, and 0 (0.0%) in the action stage, these changed to 2 (5.9%), 16 (47.1%), and 16 (47.1%), respectively, one year after the education. However, our research is limited in its scope because it does not examine whether the effect on the readiness to change of a patient lasts for > 3 months.

The majority of previous studies on telephone intervention dealt only with the effect on the change in a patient's drinking behavior, not with their motivation, which is an important component for improving drinking behavior. In the present study, short and simple advice appeared to be effective in improving the motivational state of a patient. Furthermore, the effect of telephone advice appeared to be the same as in-person advice, even after adjustment for the severity of drinking behavior, family function, stress level, and the demographic characteristics of a patient, including age, whether living with a spouse, monthly income, occupation, religion, and residency. In other words, the effect on the improvement of the motivational state of a patient is not affected by the method used to deliver the brief advice. However, it is difficult to conclude from our results that brief advice is effective in improving the motivation of patients, because our study was performed without a control group that did not receive the simple advice. This would be difficult from a methodological perspective because for medical ethical reasons, a doctor must recommend that any at-risk drinkers moderate their drinking when visiting the office.

Bischof et al.²⁴⁾ compared the effect of a brief telephone intervention on at-risk drinkers with that based on outpatient treatment. The results showed a decrease in daily alcohol intake by 12.2 ± 38.3 g in the telephone intervention group and 13.0 ± 37.2 g in the outpatient intervention group, however, these differences were not significant. Research by Oslin et al.²⁵⁾ also showed that the weekly drinking level of at-risk drinkers in old age decreased significantly from 26.1 ± 20.1 to 17.4 ± 12.3 drinks four months after the telephone intervention. These results suggest that brief intervention by telephone leads to time- and cost-saving results when managing at-risk drinkers compared with interventions focused on hospital treatment. Our study showed no significant difference between the two groups in terms of the improvements in both weekly drinking level and the maximum number of drinks in one day, which is in agreement with previous studies. Accordingly, it seems that telephone advice is a useful method of intervention in patients with drinking-related behavior. The strength of telephone intervention is that it is easier to focus on the problem at a low cost in both money and time. This method may also ensure inclusion of patients with treatment limitations due to personal circumstances.

Regarding the demographic characteristics of the subjects, the mean age of the patients in the in-person advice group was 50.1 years, which was significantly higher than the 44.9 years in the telephone advice group. It seems that younger patients are more likely to have jobs, which makes them less likely to have spare time. There were also more patients not living with a spouse in the telephone advice group compared with those in the in-person advice group. This may be because the patients in the telephone advice group were younger and thus less likely to be married.

There were many dropouts during the follow-up telephone interview because respondents' level of focus decreased as they were asked to answer increasing numbers of questions on drinking behavior during the last month and on their readiness to change. For convenience, the Short Form Stages of Change questionnaire developed by Rollnick et al.¹⁴⁾ was considered as a more appropriate tool. However, the reliability and validity of the questionnaire has not yet been proven in Korea.

Some limitations of this study in terms of generalizing the results should be addressed. The subjects were all male. Therefore, the results may not apply to females. In addition, the patients were not classified randomly into in-person or telephone advice groups because of methodological difficulties. Moreover, the results of self-reports were used as observational variables without tracking the biological markers related to drinking. This study used a filling-up questionnaire before and telephone questioning after the brief advice. The differences in the method of questioning should be taken into consideration when interpreting the results. Finally, this study investigated the effect of simple advice on a patient's readiness to change only one month after the advice. Therefore, further long-term studies are needed to investigate the effect of simple advice on an at-risk drinker's readiness to change.