Stigmatism among physicians and nurses towards patients with alcohol use disorder: a systematic review

Abstract

Background and aims

Alcohol use disorder (AUD) is a common and debilitating condition in Western countries. AUD is often stigmatized, which can worsen the condition and be a barrier for treatment seeking. This is a systematic review that aimed to identify and analyze stigmatizing attitudes and behaviors of physicians and nurses towards patients with AUD in Western hospital and primary care settings, 2014–2024. The study also examines potential differences between physicians and nurses, settings, and changes over time.

Methods

A systematic review was conducted in accordance with the PRISMA reporting guideline. Pubmed, PsycINFO and Embase were searched using MeSH terms and free-text keywords covering alcohol use disorders, healthcare professionals and stigma-related concepts (e.g. “Stereotyping,” “Attitude,” “Prejudice”). Two reviewers independently completed the full screening of articles, data extraction, and quality assessment. The included studies were assessed for quality using the Critical Appraisal Skills Programme (CASP).

Results

Of the 2835 articles screened, 11 studies were included. Stigmatizing behaviors and attitudes towards patients with AUD were common and often characterized by stereotyping, prejudice, and negative feelings. Recurring themes and patterns included avoidance of patients, moral judgment, and perceptions of patients as resistant to treatment, all contributing to the perception that treatment is futile. No differences were observed between physicians and nurses, across healthcare settings, or over time. The qualitative studies were generally of higher quality, while the quantitative studies showed methodological weaknesses.

Conclusion

Stigmatizing attitudes and behaviors towards patients with AUD persist among physicians and nurses, hindering effective care. Further research, including patient perspectives and ethnographic approaches, is needed to understand these behaviors and their impact on patient care and treatment-seeking. Addressing stigma is crucial for improving care outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14882-8.

Introduction

Alcohol use disorder (AUD) is a common and debilitating condition in Western countries, with prevalence rates varying across regions. In the United States about 10.9% of adults over 18 years are affected by AUD [1], and in 2019 one in twelve consumed alcohol on a daily basis in the EU [2]. These statistics show the widespread nature of AUD and highlight its substantial impact and presence in these societies. AUD is characterized by a persistent inability to control alcohol consumption despite its negative consequences, which include significant physical, psychological and social problems [3]. While AUD is widely recognized as a public health issue, it is often accompanied by widespread stigmatization of the individuals, manifesting as discriminatory attitudes and behaviors. This stigmatization not only hinders access to care but also acts as a barrier to treatment seeking, reinforcing feelings of isolation and shame, which can worsen the condition. Furthermore, the reduced willingness to seek or remain in treatment can lead to delayed diagnosis and poorer health outcomes. Healthcare professionals, including physicians and nurses, may unintentionally contribute to this stigma through negative perceptions and attitudes. For instance, they may use stigmatizing language, engage in stereotyping, or view AUD as a moral failing rather than a medical condition in their interaction with patients living with AUD [4]. This is evident when hospitals try to implement strategies to identify and address symptoms of AUD among patients, for example Screening, Brief Intervention, and Referral to Treatment (SBIRT) [5].

Previous systematics reviews of SBIRT have primarily focused on the effectiveness of the interventions [6]. Some have also highlighted the stigma, avoidance, avoidance bias, and alcohol health literacy as particular challenges in implementing screening and interventions for harmful alcohol use (HAU) [7]. While these studies offer valuable insights into intervention outcomes and barriers to implementation of interventions, they lack an in-depth description of the explicit stigmatizing attitudes and behaviors of healthcare providers. So far, only a few systematic reviews, have explored in more detail the stigma surrounding substance use disorders (SUD), including AUD. The studies performed are either broad, addressing public stigma [8] or healthcare professionals as a collective group [9], or highly specific, focusing solely on patients from minoritized populations, such as ethnic or migrant groups [10]. This leaves a gap in the literature regarding studies that exclusively examine nurses’ and physicians’ stigmatizing attitudes and behaviors in their interactions with the full spectrum of patients with AUD. Addressing this gap is essential for greater understanding of how explicit stigma manifests in clinical settings and its impact on patient care. It is important to distinguish between alcohol consumption and alcohol use disorder (AUD), which is a clinical diagnosis. While some studies refer specifically to AUD, others describe harmful or hazardous alcohol use. In this review, these groups are considered collectively as representing problematic alcohol use.

The aim of the present systematic review was to determine the explicit stigmatizing attitudes or behaviors held by physicians and nurses towards patients with AUD in Western hospital and primary care settings during 2014–2024. Specifically, we wanted to identify and analyze the explicit stigmatism and look at potential differences between i) physicians and nurses, ii) the setting, and iii) potential changes over the 10-year time frame.

Methods

A systematic review that was conducted and reported in accordance with ‘Preferred Reporting Items for Systematic Reviews and Meta-Analysis’ (PRISMA) [11] and registered to ‘International prospective register of systematic reviews’ (PROSPERO) prior to data extraction [12].

Eligibility criteria

The eligibility criteria were made using the PICo (Population, Phenomenon of Interest, Context) framework for qualitative studies [13]. The population included physicians and nurses, while studies focusing on other healthcare professionals were excluded. The phenomenon of interest was studies examining explicit stigmatizing attitudes or behaviors among healthcare professionals towards patients with alcohol use disorder; studies with a different focus were excluded. The context was defined as hospital or primary care settings in Western countries.

Information sources and search strategy

A systematic literature search was conducted in the following databases: Pubmed, PsycInfo and Embase. The search strategy was developed in collaboration with a research librarian and adapted for each database. The search strategy was piloted and adjusted through repeated testing prior to final implementation. The three different search strings combined MeSH terms and free-text words across three domains: alcohol use disorders (e.g., “Alcohol-Related Disorders,” “alcohol use disorder,” “alcohol abuse”), healthcare professionals (e.g., “Health Personnel,” “Physicians,” “Nurses”), and stigma-related concepts (e.g., “Stereotyping,” “Attitude,” “Prejudice,” “Discrimination,” “Bias”). The complete search strategy can be found in Supplementary Table 1, 2, 3. The search was limited to articles written in English, Danish, Swedish, and Norwegian and published from 2014 to 2024. The last search was conducted on September 18, 2024.

Relevant reviews, as well as excluded conference abstracts and poster presentations, were manually searched to identify additional studies for potential inclusion.

Study selection

Study selection was carried out using Covidence, a web-based collaborative software platform designed to streamline the systematic review process [14]. The three different searches from the databases were imported into Covidence. Duplicates were found and removed by an automated tool in Covidence [15] or by EK and CO. All articles were screened independently by EK and CO blinded for each other. First, titles and abstracts were screened based on the inclusion and exclusion criteria. Subsequently, the studies proceeded to full-text screening, where they were thoroughly reviewed by each of the two screeners (EK and CO). Cases of disagreement were discussed and resolved with the rest of the team (KA and AN).

Data collection

In Covidence a customized data extraction template was created collaboratively by EK and CO to obtain relevant information. EK and CO completed it independently and extracted the following: first author, published year, country, design, relevant method items, setting (hospital or primary care), study period (during which the study was conducted), population with the number of participants including the proportion of physicians, nurses and other (other types of health care professionals), and finally relevant results for the study’s research objectives. Relevant results included explicit stigmatizing attitudes and behaviors, perception on patients with AUD, challenges in caring for patients with AUD, and reported differences between physicians and nurses. The extracted data was reviewed by EK and CO to reach consensus. Disagreements were resolved through discussion with the rest of the team (KA and AN)

Quality assessment

The quality assessment was done using the Critical Appraisal Skills Programme (CASP). CASP is designed to systematically evaluate the reliability, relevance, and results of published studies [16]. Two different checklists were applied to the studies. The CASP checklist for qualitative studies was used for the six qualitative studies, while the CASP checklist for cross-sectional studies was applied to the five quantitative studies and the mixed-method study (comprising both qualitative and quantitative components) [17]. An overview of the elements from the two checklists can be found in Supplementary Tables 4 and 5. The completion of the checklists was carried out by two individuals (EK and CO) and subsequently reviewed and discussed thoroughly until consensus was reached. The compilation of the checklists into concise and organized tables was performed by EK. Studies with higher methodological quality and validity were given greater weight during the synthesis of findings. Studies with poorer methodological quality and lower validity were interpreted with caution. Additionally, the quality assessment informed the discussion of overall study limitations and ensured transparency of the methodological weaknesses.

Analysis and synthesis of results

A descriptive and thematic analysis was conducted to categorize the complex findings and provide an overall summarization of the findings, given the diversity in study designs and approaches. Figure 2 was made to provide a quick overview. Additionally, a narrative synthesis was performed to describe the findings in relation to possible differences between physicians and nurses, settings, and potential changes over time.

Fig. 2.

Venn diagram visualization of themes and patterns across the 11 included studies. A venn diagram that visualizes the themes and patterns identified in the 11 included studies for the systematic review of stigmatizing attitudes and behaviors among physicians and nurses towards patients with alcohol use disorder. The diagram categorizes these into three main areas: stigmatizing behaviors, stigmatizing attitudes, and stereotypes of patients with alcohol use disorder (AUD), each with distinct elements and overlaps

Results

Study selection and characteristics

The search strategy provided 2835 hits (Fig. 1). Of these, 499 duplicates were removed. Following the screening of titles and abstracts, 175 articles were identified as relevant to the research question and proceeded to full-text screening. Among these, 11 fulfilled the inclusion criteria and were deemed eligible for data extraction and quality assessment. Of the included studies, six were qualitative research studies, four were quantitative studies, and one was a combined cross-sectional study with qualitative and quantitative components (Table 1). The quantitative studies were primarily cross-sectional, except for Molin-Mula et al. [18], which was a multicenter prospective descriptive and cross-observational study. The studies were evenly distributed over the time-period with five studies conducted before 2019, four after 2019, and one spanning from 2018 to 2020 (Table 1). One of the studies did not report its study period [19].

Fig. 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart of study inclusions and exclusions. Flowchart showing the identification, screening, and inclusion of articles in the systematic review of stigmatizing attitudes and behaviors among physicians and nurses towards patients with alcohol use disorder (AUD)

Table 1.

Overview of the study characteristics and results of the 11 included studies. Overview of the study characteristics and results for the 11 studies included in the systematic review of stigmatizing attitudes and behaviors among physicians and nurses toward patients with AUD

Author Country	Design Relevant method items	Setting Study period	Population (N)	Results
Qualitative studies
Hakala et al., 2021 Finland	Data is derived from the nurse’s essays and analyzed with inductive content analysis.	Emergency Department (ED) 2018	N = 17 Nurses N = 17 (100%)	Negative perceptions and attitude towards patients with AUD: - Frustration: with repeated visits in ED, the intoxicated patients, futility of care, and the feeling that intervention makes no difference. - Lack of faith: in the patient’s lifestyle change and ability to accept help or to become sober. - Negative feelings: such as anger and irritation, which prevent the nurse’s commitment to the patient. - Shame: cannot understand why the patients do not feel ashamed.
Hakala et al., 2020 Finland	Theme interviews analyzed with inductive content analysis.	ED with a sobering unit. 2016	N = 6 Nurses N = 6 (100%)	Negative perceptions and attitude towards patients with AUD: - Frustration: Taking care of patients under the influence is difficult. - Self-inflicted: The patients cause their own problem, so the nurses sympathize with the other patients. - Negative feelings towards the patients. Perceptions on Challenges in Providing Care: - Disruptive behavior: The patients cause disturbances, noise, conflicts, and can be restless. - Untruthful: What the patient tell do not align with the breathalyzer test (alcohol test).
Johnson et al., 2022 Canada	Semi-structured interviews via Zoom. Analyzed with a theoretical thematic analysis approach.	Alberta Health Services care delivery zones: Primary care and hospital care 2021	N = 16 Physicians N = 11 (57,9%) Nurses N = 5 (26.3%)	Negative perceptions and attitude towards patients with AUD: - Acknowledgement of stigmatization: lot of prejudice among physicians. - Unworthy: Patients is believed to be unworthy of treatment. Perceptions on Challenges in Providing Care: - More challenging: Than the other patients without AUD because of their behavior, chaotic lives, and unreliability.
Ketterer et al., 2014 Belgium	Semi-structured interviews analyzed with the constant comparison technique.	Primary care (General practitioners) 2012	N = 20 Physicians N = 20 (100%)	Negative perceptions and attitude towards patients with AUD: - Underprivileged: Alcohol abuse is seen as more common among patients with low socioeconomic level, young age, and social problems. - Refusal to treat: Some of the GP’s refuse to treat patients with alcohol abuse. - Moral judgment: The alcohol problem is seen as the patient’s own fault, and they are seen as untrustworthy (liars).
Kools et al., 2024 The Netherlands	Semi-structured interviews analyzed with inductive thematic analysis	Mental health service organizations (primary care) 2021	N = 18 Physician N = 3 (16.7%) Nurse N = 5 (27.8%) Other N = 10 (55.6%)	Negative perceptions and attitude towards patients with AUD: - More responsible: Patients with AUD often viewed as more responsible for their problems compared to other psychiatric disorders. - Less empathy and sympathy: For patients with AUD compared to other psychiatric disorders.
Sivertsen et al., 2021 Denmark	Qualitative exploratory ethnographic field study Semi-structured interviews and observations analyzed with a cultural analysis.	ED 2018–2020	N = 11 Nurses N = 11 (100%)	Negative perceptions and attitude towards patients with AUD: - Explicit stigma through labeling: Observation room for AUD patients called ‘slyngelstuen’ meaning room for villains or rogues. Furthermore, the patients are referred to as ‘the alcoholics’ and the patients with AUD admitted as ‘the poorest of the poor’. - Prejudice based on appearance: Patients appearing unkempt with unclear home situation rises suspicion of AUD among the nurses, whereas they may not notice it, if it is not obvious. - Indifferent: One strategy among the nurses is to become indifferent or even cynical. - Untruthful: Patients are seen as denying, refusing or lying about their intake. - Self-inflicted: The nurses’ questions whether AUD is a legitimate disease and/or self-inflicted. Perceptions on Challenges in Providing Care: - Risky environment: nurse’s covers their name stickers. - Isolation of patients with AUD: The nurse’s justify stigmatizing actions by grouping patients with AUD together to protect other patient groups. - Avoidance: Patients with AUD are often passed on to the junior doctors by the senior doctors. - Requires a disproportionate amount of resources. - No progress: causes loss of interest among the nurses.
Quantitative studies
Coloma-Carmona et al., 2017 Spain	Cross sectional study Ad hoc 9-item (barriers) questionnaire. Level of agreement on a scale of 1 to 5 (strongly disagree to strongly agree)	Primary care centers NR	N = 107 Medical team N = 67 (62.7%) Nursing team N = 40 (32.4%)	Participants mean scores in the perceived barriers* (mean/max agreement): - The patient will lie about his/her consumption: 3.3/5 - The patient will not identify the negative consequences of consumption: 3.2/5 - The patient will refuse treatment: 3.1/5 Differences between medical team and the nursing team on all 9 items (perceived barriers): - No significant differences (p > 0.05).
Miller et al., 2016 Australia	Cross sectional study Questionnaire in paper-based and online format analyzed with descriptive analysis	General practitioners who attended a national series of seminars 2014	N = 894 Physicians N = 894 (100%)	- Not always honest about alcohol intake: 84% agreement. - Do not want to hear about health risks associated with drinking: 33% agreement. - Approx. 30% of participants agrees that they raise alcohol issues with patients depending on the patient’s age, sex, ethnicity, occupation and socioeconomics.
Molina-Mula et al., 2018 Spain	Multicenter prospective descriptive and cross observational study Questionnaire using the Seaman-Mannello scale with 1–5 level of agreement	Emergency and mental health services in hospitals 2015	N = 167 Nurses N = 167 (100%)	Tendency towards the patient (mean/max agreement): - The lives of alcoholics are not pleasant: 4.2/5 - In general, alcoholics have poor physical health: 3.7/5 Perceptions towards alcoholics’ personal characteristics (mean/max agreement): - Alcoholics are loners: 3.1/5 - Alcoholics usually exhibit serious emotional difficulties: 3.6/5 − 61.9% considered that alcoholics had very poor health. − 80.1% of the nurses agreed or totally agreed that the lives of alcoholics were not pleasant. − 76% of the nurses considered alcoholics to be ill individuals − 42.7% and 30.4% did not feel better nor comfortable working with alcoholics, respectively. - Tendency to disagree that alcoholics wanted to quit drinking or that they respect their families.
Russolillo et al., 2023 Canada	Cross sectional study Variables/statements from the Brief Substance Abuse Attitudes Survey with 25-items. Five predefined attitude subgroups were evaluated. Respondents’ attitudes towards substance use were associated with level of education on questions from two subscales.	Tertiary care hospital 2022	N = 71 Nurses N = 35 (49.3%) Physicians N = 2 (2.8%) Other N = 34 (47.9%)	Alcoholism is associated with a weak will (p-value 0.625) - Somewhat agree: 5.6% - Somewhat disagree: 18.3% - Strongly disagree: 76.1% Alcoholism is a treatable illness (p-value 0.493) - Strongly agree: 66.2% - Somewhat agree: 29.6% - Undecided: 1.4% - Somewhat disagree: 1.4% - Strongly disagree: 1.4% 10.0% of participants somewhat agree with the statement that most individuals who use alcohol or drugs are unpleasant to work with as patients.
Qualitative and quantitative study
Blake et al., 2023 Europe (91.1%) America (3.0%) Africa (2.2%) Asia (1.6%) Australia/ New Zealand (2.0%)	Cross sectional study Open international survey with closed and open-ended responses. Analyzed quantitative data and qualitative data. Main themes established on their codes and groupings.	ED 2022	N = 362 Physician N = 176 (48.6%) Nurse N = 81 (22.4%) Other N = 91 (25.1%)	Quantitative findings: Expected patient denial of alcohol issue: 48.3% Expected patient resistance to advice: 61.9% Qualitative findings: - Embarrassment: patients don’t want to discuss their alcohol problem due to embarrassment. - Untruthful: Physicians don’t think the patients can have an honest conversation. - Waste of time: Other patients need their time more. Difference between the health personnel: - Paramedics find that the negative attitudes are primarily held by physicians.

*Only the three barriers deemed relevant are included

The included studies were conducted in different healthcare settings: six in hospitals, four in primary care, and one covered both. In terms of the population, four studies focused on nurses, two studies on physicians, and five studies included both groups, with three of these additionally including other types of healthcare professionals, data on the latter not included in this study (Table 1). Furthermore, the included studies used a range of terms to refer to patients with AUD, including alcohol consumption [20], alcohol issue [21], problem drinkers [19], alcohol-intoxicated patients [22, 23], alcohol abuse [24], unhealthy alcohol use [25], and AUD [26].

Quality of studies

Quality assessment with Critical Appraisal Skills Programme (CASP)

The qualitative studies were generally rated to be of higher quality compared to the quantitative studies. All the qualitative studies had a clear aim, appropriate methodology, and research design, whereas some of the quantitative studies were weaker in these areas. Additionally, several of the quantitative studies had small sample sizes and lacked sufficient information on aspects such as data collection, power calculations, and non-participants. One study even lacked reporting of the study period [19]. Overall, there was considerable variation among the quantitative studies in the extent to which individual elements of the study were adequately reported (Table 2, 3, 4).

Table 2.

Critical appraisal summary from qualitative- and cross-sectional studies checklists and validity of the 11 studies. Critical Appraisal Skills Programme (CASP) critical appraisal summary from the checklists for qualitative and cross-sectional studies on the 11 included studies, along with a validity assessment ranked from low to high

Author	Positive/Methodologically sound	Negative/Relatively poor methodology	Unknowns	Validity
Qualitative studies
Hakala et al., 2021	- Clear aim - Appropriate method and recruitment - In-depth data collection and thematic analysis - Authors are explicit on possible selection bias and provide a detailed discussion on the issue. - Clear statement of findings including contradicting results.	- Interviews conducted during working hours raising concerns on response bias.	- No information on relationship between researcher and participants leads to possible interviewer bias.	Internal validity: Medium External validity: High
Hakala et al., 2020	- Clear aim - Appropriate method and data collection. - The researchers were outsiders in relation to the department. - Rigorous thematic data analysis with triangulation for confirmation of the results. - Clear statement of findings and discussion on credibility.	- Low generalizability and transferability due to selection bias (nurses from a sobering unit).	- No discussion around recruitment	Internal validity: High External validity: Low
Johnson et al., 2022	- Clear aim. - Appropriate method. - Appropriate recruitment with acknowledgement of possible selection bias, addressed through detailed participant demographic. - Detailed theoretical thematic analysis. - Clear statement of findings.	- Refinement of interview guide during the interview progress raising concerns on sampling bias. - Potential selection bias.	- No information on relationship between researcher and participants leads to possible interviewer bias. - No discussion on transferability of findings.	Internal validity: High External validity: Medium
Ketterer et al., 2014	- Clear aim. - Appropriate method - Comprehensive data collection and rigorous thematic data analysis using I-Change model. - Clear statement of findings with discussion on contradicting findings from existing literature. - Discuss generalizability to similar cultural setting (western nations).	- Potential selection bias by excluding specific group of GPs without explanation.	- No information on relationship between researcher and participants leads to possible interviewer bias. - No discussion on the study’s contribution to existing literature or new areas for research.	Internal validity: Medium External validity: Medium
Kools et al., 2024	- Clear aim - Appropriate method. - Comprehensive data collection with data saturation. - Rigorous inductive thematic data analysis. - Clear statement of findings and address that some of the aims remains unclear.	- Purposive sampling causing selection bias.	- No information on relationship between researcher and participants leads to possible interviewer bias.	Internal validity: High External validity: Low
Sivertsen et al., 2021	- Clear aim - Appropriate method. - Comprehensive data collection and rigorous data analysis with validity considerations. - Clear statement of findings.	- Limited discussion on the study’s value.	- Limited information on recruitment strategy. - No information on relationship between researcher and participants leads to possible interviewer bias. - No information on consent from participants.	Internal validity: Medium External validity: Medium
Quantitative studies
Blake et al., 2023*	- Clearly focused issue. - Appropriate method and recruitment. - Full completion rate enhances reliability. - Rigorous data analysis with qualitative analysis of comments in free text questions as an “add-on” to the quantitative findings. - Clear statement of findings.	- Low participation rate with lack of non-responder data raise concerns on generalizability and selection bias.	- Unclear data collection - No information on power calculation - Validation of questionnaires	Internal validity: Medium External validity: Low
Coloma-Carmona et al., 2017	- Clearly focused issue. - Evaluation of perceived barriers. - Objective measurements and a detailed evaluation of reliability in the data analysis. - Comprehensive data collection and rigorous data analysis. - Clear statement of findings with comparison between medical and nursing teams. - Thorough discussion on limitations	- Questionnaire lacks qualitative component. Participants constrained by the specified barriers. - Small sample limited to one province in Spain raise concerns on generalizability. - No specification on the term “problem drinkers”.	- No information on participation rates, completion rates or data on non-responders introduces possible selection bias. - No information on power calculation. - No information on recruitment or when data collection took place.	Internal validity: Medium External validity: Low
Miller et al., 2016	- Clearly focused issue. - Comprehensive data collection. - Large sample size. - Results are mainly significant and the non-significant are clearly stated. - Rigorous data analysis including considerations on potential bias and confounding. - Clear statement of findings with contradicting findings and ideas for future research.	- Inappropriate method due to limitations to the responses and variables. Lacks details and nuances in perceptions. - GP’s from a seminar leading to possible selection bias. - Measurements have not been validated. - Administrative delay in data analysis resulting in two approaches.	- No information on power calculation. - Value of research are unclear.	Internal validity: Low External validity: Medium
Molina-Mula et al., 2018	- Clearly focused issue. - Questionnaire with validated scale. - Acceptable recruitment. - Validated measurements and method of data collection. - Power calculation to assess internal reliability with an acceptable result. - Rigorous data analysis and significant.	- Small sample size. - Does not contribute new knowledge. - The study emphasizes the need for qualitative studies instead.		Internal validity: Medium External validity: Medium
Russolillo et al., 2023	- Appropriate method. - Rigorous data analysis and - Clear statement of findings and discussion. - Openly address limitations and concludes that the study is a minor addition to existing literature.	- Unclear the need for this research. - Convenience sample with non-nursing providers lowers the representativeness and introduces selection bias.	- No information on validation of BSAAS. - No consideration given to the fact that 85% of participants were women. - Unclear data collection. - No information on power calculation.	Internal validity: Low External validity: Medium

*Blake et al., is quality assessed with the cross-sectional checklist and is therefore referred to as a quantitative study

Table 3.

Overview of the CASP checklist for qualitative studies on six qualitative studies. Summary of the CASP checklist for qualitative studies applied to the six included qualitative studies. The answers (“yes,” “no,” and “can’t tell”) are marked with symbols as shown in the footnote

Table 4.

Overview of the CASP cross-sectional study checklist on one mixed-method study and five quantitative studies. Summary of the CASP cross-sectional study checklist applied to one mixed-method study and five quantitative studies. The answers (“yes,” “no,” and “can’t tell”) are marked with symbols as shown in the footnote

A recurring issue across studies, regardless of design, was potential selection bias, which may affect the generalizability of the findings (Table 2). Furthermore, only one of the qualitative studies addressed the relationship between the interviewer and the participant [22], whereas the remaining five qualitative studies did not mention this aspect. Consequently, it remains unclear whether the interviewer knew the participants, raising the possibility of response bias. There was considerable variation across all studies in whether they contextualized their findings, discussed their applicability, and addressed their transferability. This raises concerns about the overall value of the studies. Only four were considered valuable, indicating that the remaining results should be interpreted cautiously.

Validity

Overall, the studies showed a higher internal validity compared to external validity, with qualitative studies generally performing better than quantitative ones. In the qualitative studies, internal validity was predominantly higher than external validity, except for Hakala et al., 2021 [23]. The quantitative studies, on the other hand, all fell within the low-to-medium range for both internal and external validity. (Table 2).

Description and thematic analysis of stigmatizing behaviors and attitudes

Two main themes emerged from the qualitative findings: negative perceptions and attitudes towards patients living with AUD, and perceptions of challenges in providing care, each with various subthemes across the different articles (Table 1). Regarding the first theme, subthemes such as negative feelings (e.g., frustration, shame, and anger [22, 23]) and moral judgment (e.g., self-inflicted, unworthy of treatment, and more responsible compared to other kinds of mental health issues [22, 24–27]) were identified in all the qualitative studies. The second theme was identified in only three out of six qualitative studies and highlighted how the physicians and nurses found the patients with AUD to be disruptive, untruthful, challenging, and requiring a disproportionate amount of resources [21, 22, 25, 27]. Furthermore, physicians and nurses found interaction with these patients to be risky, with some even avoiding patients with AUD [25]. The findings indicated great tendency to stigmatize and stereotype patients with AUD. One example on stereotyping behavior was shown by labeling them as ‘alcoholics’ [25] or judging them based on appearance and background [24, 25]. The studies showed staff avoiding these patients [24, 25], displaying negative emotions towards them [22, 23, 25–27], and approaching them with the attitude that treatment is futile and a waste of time [21, 25].

The quantitative findings appeared to show similar patterns. Here, once again, stereotyping of patients with AUD was observed. There was a tendency to view patients as dishonest, vulnerable both physically, psychologically, and socially, and negative towards seeking treatment and unreceptive to advice on their drinking behavior [18–21]. However, many of the results were only slightly tilted towards agreeing with these statements and remain close to a neutral position, making it a less convincing trend [19–21]. Furthermore, three studies stood out, with only a small proportion of respondents agreeing that these patients have weak will [28], less than half agreeing that they are unpleasant to work with [18, 28], and only one-third agreeing that the patients do not want to hear about health risks [20].

The findings from both the qualitative and quantitative analyses, as seen in Fig. 2, indicated recurring themes and patterns. The main findings suggested patterns of stigmatizing behavior, including avoidance of patients with AUD due to unwillingness to work with them and labeling them with negative terms. Stigmatizing attitudes were often characterized by a lack of empathy and negativity. Across both types of findings, frustration emerged as a common element, evident in both attitudes and actions towards patients. Additionally, frequently recurring patterns were related to the stereotypical perception of patients with AUD. As illustrated in Fig. 2, resistance, both from healthcare personnel and the belief that patients with AUD would resist treatment, was evident in both the stereotypical perceptions of AUD and stigmatizing behavior. Similarly, prejudice was observed across stereotypical perceptions of AUD and stigmatizing attitudes. Overall, this appears to result in the physicians and nurses feeling that treating these patients is a waste of time, and that they cannot improve.

Differences between physicians and nurses

No pattern of differences between physicians and nurses in stigmatizing behavior or attitudes towards patients with AUD could be observed. In general, the same themes and patterns emerged in articles focusing solely on physicians and those focusing solely on nurses: negative feelings towards the patients, the perception of patients as being untruthful and the belief that it is the patient’s own fault [19–26, 28]. This is supported by Coloma-Carmona et al., 2017 [19], which did not find any significant differences between the medical team and the nursing team on any of the nine items in their questionnaire.

Differences across healthcare settings

The studies included various healthcare settings, spanning from primary care to different hospital departments, and were relatively evenly distributed across different settings with a little overrepresentation of emergency departments (Table 1). Although one of the studies included healthcare professionals from both hospital and primary care it did not examine possible differences in stigmatizing behavior or attitude across settings [27]. Based on the overall findings, there was no observable difference across healthcare settings (Table 1).

Progression over time

Despite the studies being evenly distributed over the past 10 years, with data collection spanning from 2012 to 2022, no observable changes in stigmatizing behaviors or attitude over time were identified (Table 1). However, one of the more recent studies from 2023 reported lower agreement with stigmatizing statements compared to the other included studies. Specifically, 5.6% agreed that alcohol use disorder is associated with weak will, and 10% agreed that these patients are unpleasant to work with [28].

Discussion

Main findings

In this systematic review, 11 articles were identified, providing insight into the prevalence and varied manifestations of stigmatizing behaviors and attitudes towards patients with AUD among physicians and nurses. Qualitative studies were of medium to high quality, while quantitative studies showed methodological weaknesses, such as small sample sizes and inadequate reporting, leading to their findings being interpreted with caution and given less weight. The qualitative findings revealed recurring themes of stigmatizing behaviors and attitudes, including avoidance of patients with AUD, negative labeling, and moral judgment. These studies highlighted a tendency to stereotype patients as untruthful, self-inflicted, and challenging to treat. The quantitative findings echoed some of these patterns, such as negative perceptions of patients as untruthful, vulnerable, and resistant to treatment, though these trends were less pronounced, with some results leaning towards neutral positions. Studies reporting lower levels of stigmatization did not differ systematically from those reporting higher levels. No clear patterns were observed by publication year, professional group, or study context, and no obvious explanatory factors were identified. At the same time, limited reporting of sociodemographic characteristics precluded further exploration. Collectively, the findings highlight the enduring presence of stigmatizing attitudes and behaviors among physicians and nurses, characterized by frustration, resistance, prejudice, and perceptions of care as a waste of time (Fig. 2). Interestingly, no patterns of difference in stigmatizing behaviors or attitudes towards patients with AUD were observed between physicians and nurses. Additionally, no notable differences were found across healthcare settings, nor were any changes in stigmatizing behaviors or attitudes identified over time. Although one of the more recent studies from 2023 [28] stood out by reporting more positive attitudes, this finding alone does not allow for a general conclusion. This consistency across professions, settings, and time suggests that stigmatizing behaviors and attitudes toward patients with AUD may be a more systemic issue within healthcare, rather than one confined to specific professional groups or contexts.

To our knowledge, no systematic review with the same perspective as the present has previously been published, and only a few systematic reviews examining similar topics were identified. One study examined public stigma and its impact on individuals with AUD. It concluded that persons with AUD were generally less likely to be considered mentally ill, while being perceived as more dangerous and responsible for their condition, which aligns with our findings [8]. Another study examined healthcare professionals and individuals with substance use disorders in Western countries. It found that healthcare professionals generally held negative attitudes towards patients with substance use disorders, which is likewise consistent with our findings [9]. The lack of similar studies indicates that our systematic review addresses a unique perspective, but also that additional support for the review’s findings is so far lacking.

Methodological quality of included studies

CASP was chosen for its broad applicability, allowing it to be used for both qualitative and quantitative studies. While more specialized tools such as STROBE could have offered a more detailed evaluation of the quantitative studies, CASP was deemed appropriate for maintaining methodological comparability within this mixed review. This methodological choice is important given the several limitations noted in the included studies. One of the recurring issues with the studies was selection bias and missing information on non-participants, which may affect their external validity. This raises the question of whether the populations included are representative of the general attitude. One needs to consider if there is a pattern in who chooses to participate and who does not. Since the research focuses on people’s perceptions and views through interviews and questionnaires, it can be assumed that those who might be indifferent to the topic are less likely to participate. Furthermore, many of the studies - especially the quantitative ones - demonstrated inadequate handling of missing data. Some of the missing data significantly impacts the value of the study. This is particularly true for the lack of reporting on the study period in one of the studies, as it leaves uncertainty about when the data was collected and whether the study is outdated [19]. Another notable issue is the variation in terminology used to describe patients with AUD across the studies. Terms such as “problem drinkers,” “alcohol abuse,” and “unhealthy alcohol use” carry different connotations, which may reflect or reinforce stigmatizing attitudes. By contrast, the term “AUD” aligns with a clinical and neutral understanding of the condition. These variations may introduce bias or limit the comparability of results across studies, thus affecting the overall methodological quality and coherence of the included studies. The strength of the included studies primarily lies in the qualitative studies, which were of medium to high quality and well-suited for investigating the topic. They provide many nuances without restrictions of predefined outcomes.

Limitations and strengths of this study

The present systematic review has limitations that warrant consideration. Several conference abstracts were identified and excluded (Fig. 1), many of which were never published as full-text articles, indicating a considerable amount of grey literature. Furthermore, limiting our search to studies published between 2014 and 2024 may have excluded potentially relevant studies. However, we argue that more recent literature is most relevant for investigating people’s attitudes and behaviors. In addition, the restriction to English and Scandinavian languages may have resulted in the exclusion of relevant studies, introducing a potential language bias. This restriction could have influenced the results by narrowing the cultural and contextual diversity, thereby affecting the generalizability of the findings. However, this systematic review intentionally focused on studies conducted in Western countries to reduce cultural and religious heterogeneity, as these factors were assumed to influence how alcohol use disorder is perceived and stigmatized. Moreover, two articles by the same author were included in this systematic review, which introduces potential bias, as similar methodologies and perspectives may dominate the findings [22, 23]. Some of the included studies also involved other types of healthcare professionals beyond nurses and physicians [21, 26, 28]. This could impact the findings on stigmatizing attitudes and behaviors towards people with AUD, as different healthcare professionals bring unique experiences and educational backgrounds to their interactions with these patients. This should be considered alongside the fact that sociodemographic characteristics of study populations were not examined. Although such factors (e.g., age, gender, and clinical experience) may influence healthcare professionals’ attitudes towards patients with AUD, inconsistent and limited reporting across studies prevented further analysis. Another limitation is the exclusion of studies examining stigma toward substance use disorders (SUD) in general. While such studies may have included individuals with AUD, they were not considered because the findings were not substance specific. This choice aimed to maintain a clear focus, as attitudes toward drug use and alcohol use may differ. Regarding the narrative and thematic analysis, potential bias in the form of subjectivity may have arisen, as it was conducted by a single author despite efforts to standardize the process. Additionally, this systematic review did not provide an inter-rater reliability score, meaning the level of agreement between the two reviewers was not measured or reported, which could affect the reliability of the study selection process. The strength, on the other hand, of this systematic review includes the use of the standardized tool CASP for critical appraisal, and combination of qualitative and quantitative studies for broader views on stigmatizing attitude and behavior. In addition, all conflicts were discussed by the entire research team until consensus was reached, ensuring reliability and consistency in the decision-making process, and enhances this study’s validity.

Implication for future research and clinical practice

Further studies are needed to gain a complete understanding of physicians’ and nurses’ stigmatizing attitudes and behaviors towards patients with AUD. Future studies would benefit from more standardized reporting of participant characteristics and sociodemographic variables, as well as studies that explore the patients’ point of view or include more ethnographic approaches, including observing physicians and nurses from an external perspective. Collectively, these efforts could provide a broader and more comprehensive understanding of this subject. Moreover, the impact of stigma on patients with AUD warrants deeper exploration, as it not only exacerbates their condition but also discourages individuals from seeking treatment. This underscores the importance of addressing stigma in both clinical and research settings. Reducing stigma can involve using non-stigmatizing and supportive language, prioritizing education, and fostering genuine curiosity about the patient’s experiences [4]. These strategies are not only essential for improving the quality of care but also for creating an environment where patients feel safe and valued. Such efforts should form part of a broader commitment to integrating stigma reduction into future clinical practice and research initiatives.

Conclusion

This systematic review consolidates the latest research on stigmatizing behaviors and attitudes towards patients with AUD, highlighting it as a persistent issue among physicians and nurses, often characterized by stereotyping, prejudice, and negative feelings. Potentially leading to the perception of treatment as futile. Notably, no differences were observed between physician and nurses, across healthcare settings, or over time. While some limitations were noted in the included studies, particularly in the quantitative research, the findings underscore the need to address stigma as a barrier to provide equitable and effective care for this patient group. This may be achieved through targeted education and training of healthcare professionals, promoting the use of non-stigmatizing language, and fostering openness and reflection in patient encounters.

Electronic supplementary material

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Abbreviations

AUD

Alcohol Use Disorder

CASP

Critical Appraisal Skills Programme

SBIRT

Screening, Brief Intervention and Referral to Treatment

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

PROSPERO

International prospective register of systematic reviews

PICo

Population, Phenomenon of Interest, Context

Author contributions

The article screening was conducted by EK and CO, who also performed data extraction and quality assessment. EK carried out the data analysis and interpretation. The manuscript, along with the tables and figures, was created by EK. All aspects of the article’s preparation were supervised and guided by KA and AN. All authors read and approved the final manuscript.

Funding

Open access funding provided by University of Southern Denmark

Data availability

All data generated or analyzed during this study are included in this article (and its supplementary information files).

Declarations

Ethical approval and consent to participate

Ethical approval and consent to participate were not required as no primary data was collected.

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.