Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil: evaluation of the PAI-PAD training model ages? I do. How much? I drink a beer on the weekend’. This was what we started to hear in a different way. Because ‘to drink a beer on the weekend’ I drink also, but we started to learn to ask how many drinks, why do you drink, how often in the week… Because the people, for example, they thought that to drink socially was to drink two beers per day and we see that now, now we have learned to ask more and to ask what it is to drink socially ‘ah, I drink socially’. ‘But, how much is that? How many do you drink? Which kinds of beverage do you drink? How many drinks do you have?’ So, we learned to look, to listen to that in a different way because this thing of ‘sometimes I drink’, ok, you make a note (in their medical files) about that ‘drinks socially’ and with AUDIT, with the training, we learned to do that in a different way.” In the same way they felt more competent in approaching patients as well as in giving advice and counseling regarding general education about the limits of low risk drinking. “To talk about that, I didn’t have courage…, how to approach it. I didn’t know how to approach it, when I saw the man of the ‘cachaça’ (a typical Brazilian distilled beverage), I spoke with him. I don’t even know how to tell you how it was (the speech), it was in my way. I think it made it easier for us to approach.” Discussion It is important to note that this was an open-field study, in some aspects very exploratory. Generalization of the findings may be limited to the socio-cultural context in which the research was carried out, including the administrative culture 548 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 in the public health sector present in the northwest region of the State of São Paulo, Brazil. Nevertheless, the methods and the findings may be useful in planning SBIRT training and implementation programs in countries with PHC systems like Brazil, especially in Latin America. There was an increase in the level of health professionals’ knowledge concerning alcohol screening and brief intervention following the PAI-PAD training program. This change was observed in both the quantitative and qualitative data. Professionals with higher levels of education seemed to benefit more from the training concerning the limits of low risk use and how to conduct screening. They felt more prepared to conduct interventions after the training than the health workers with lower levels of education. According to the instruments used, the community health agents had the least accurate information about the contents of the training (such as drink limits, risk zones). Nevertheless, in the qualitative study they reported improvement on the knowledge scale and feeling more confident to carry on interventions after having acquired this new knowledge. The graduate professionals, having had more contact with the formal education system, were perhaps more familiar with the need to memorize information and answer test questions, and that could have influenced their higher scores on the knowledge test. The community health agents, even though they had difficulties remembering the contents of the training course, nevertheless admitted to being more open to talk about the issue (problematic alcohol use), including the way they ask questions about that subject.
The training course also helped the pro- fessionals to reflect on their own personal expectations concerning alcohol consumption. Positive expectation scores declined after the training. This may have been due to the information that even occasional atrisk alcohol use can lead to social, emotional and physical harms. Before the training many professionals, as showed by the qualitative study, thought only about alcohol leading to dependence. Increasing their knowledge about the risks of excessive drinking seems to have decreased their positive expectations about alcohol consumption. Talking about problematic alcohol use as a health problem rather than a moral problem brought the alcohol issue into their field of action, increasing their sense of responsibility and removing the fear of asking screening questions and talking about this issue with the patient. They reported that before the training, they did not know how to approach this issue, but after the training they had new skills and more courage to talk about alcohol. This courage seems to come from the information received and the feeling that when asking about alcohol, they were not invading their patient’s privacy, but were rather playing an appropriate role as health professionals. Alternatively, the reason for the lower alcohol expectancy score could have been due to the changes in the trainees’ perceptions of the most socially desirable responses at the six month follow-up. Other evidence supports the first hypothesis, such as the increase in knowledge, which was inversely correlated with their attitudes toward alcohol. Perhaps the most important aspect of Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil: evaluation of the PAI-PAD training model this descriptive study is the extent to which the SBIRT process and training was established within the health care system of a large population area of Brazil. Although training does not necessarily guarantee that screening and brief intervention will be performed regularly and systematically, the results suggest that most health professionals change their attitudes and knowledge in a direction that should be conducive to the use of evidence-based alcohol screening and brief intervention techniques. In addition, the program was disseminated to a large enough proportion of the health professionals in small cities to have a significant reach into the general population of heavy drinkers. Beginning in 2006 the São Paulo State Health Department became the major sponsor of the program, with an annual budget of about 300,000 Brazilian Reais (ca. 94,000 €) for the total costs of the program, including general maintenance costs and salaries of supervisors and trainers (two psychiatrists, two psychologists, two nurses, one social worker) and three administrative staff. The resulting annual individual cost for each trained health professional is estimated at 1,000 Brazilian Reais (ca. 310 €), or 0.35 Brazilian Real (0.01 €) for each inhabitant of the municipalities reached by the program. More research will be necessary to evaluate the cost-effectiveness of the program. However, even if the program succeeds in changing 1% of the population affected by risky drinking, this could translate into a reduction in the number of deaths due to hepatic alcoholic disease (75 cases / 100,000 inhabitants), and contribute to a reduction in the need for liver transplants (one liver transplant costs about 60,000 Brazilian Reais – the NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 549