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NAT 6/08 - THL

NAT 6/08 - THL

The dissemination of

The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa alcohol misuse, social acceptance of recreational intoxication, competing demands of other priority government health services, lack of emphasis on prevention and reluctance to provide SBI to patients without major alcoholrelated consequences. DISCUSSION Future efforts may benefit from focusing efforts on increasing intervention as well as screening levels, addressing specific training needs of nonphysicians, linking to formal and informal treatment services, utilizing quality improvement approaches, and including SBI projects in broader efforts at alcohol policy change. Project leaders should seek avenues for promoting health policies which emphasize alcohol SBI as a top priority in primary care. KEywORDS Screening, brief intervention, alcohol, implemantation, Brazil, South Africa. 566 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 25. 2008 . 6 forts are timely, given the high burden of alcohol-related disease in many developing countries. While alcohol is a major worldwide health issue, accounting for 3.2% of the global deaths and 4.0% of the global estimate of Disability-adjusted Life Years (DALYs) in the year 2000 (Rehm et al. 2003), this burden is not evenly distributed. Alcohol consumption in the Americas averages more than 50% higher than worldwide consumption, accounting for 4.8% of all the deaths and 9.7% of all DALYs lost in the year 2000 (Rehm & Monteiro 2005). In South Africa, alcohol was estimated to account for 7.1% of all deaths and 7.0% of total DALYs in 2000 (Schneider et al. 2007). The articles in this special thematic issue provide insights into the unique challenges of SBI implementation in developing countries. Efforts at SBI implementation in the European Union, Australia and the USA have identified a number of common barriers that must be overcome in order to mount successful programs. Practical logistical issues include determining who does the screening, when, where, and how often, as well as who pays for it (Babor et al. 2007). Efforts to involve physicians in routine SBI efforts have consistently met with major resistance, with some authors concluding that efforts at implementing physician-based brief interventions have failed (Roche & Freeman 2004). In Denmark and Sweden, general practitioners did not think that all patients should be screened, with Danish physicians citing as barriers their lack of time, lack of financial incentives, and skepticism that patients wanted to be screened (Hansen et al. 2001; Johansson et al. 2005b ). A review of early SBI meta-analyses by Modesto-Lowe and Boornazaian (2000) cited additional physician barriers of physicians’ lack of diagnostic skills regarding alcohol misuse, negative attitudes and the perception that diagnosing problem drinkers was not part of the physician’s role. US physicians who provide emergency care have expressed concern over cost, confidentiality, and threats to insurance coverage if alcohol misuse is discovered and documented (Schermer et al 2003). Swedish generalist physicians and nurses trained to perform SBI preferred to limit screening to patients with alcohol-related symptoms or diagnoses, and nurses often refrained from SBI activities due to lack of self-efficacy, time

constraints, and fear of harming their relationship with the patient (Johansson et al. 2005a; Johansson et al. 2005b). Researchers who implemented SBI in a US managed care network (Babor et al. 2004; 2005) found that ability to conduct SBI was significantly correlated with prior experience, organizational stability, number of clinicians trained, and quality of the coordinator’s work. Lack of time, staff turnover and competing priorities correlated negatively with SBI implementation, and success appeared to be related to adequate clinician training and reimbursement and the presence of a stable, well-functioning clinical setting. In addition, trained midlevel providers demonstrated significantly higher rates of both screening and intervention than physicians in similar clinical sites. The implementation efforts described in this special thematic issue offer the opportunity to compare and contrast these findings with the results of SBI implementation efforts in South Africa and Brazil. Methods The authors reviewed the following materials related to SBI implementation in three sites in Brazil and one site in South Africa: a PowerPoint presentation on each project from a 2008 International Society for Biomedical Research on Alcoholism symposium, the three articles submitted to this special thematic issue, and three previously-published journal articles related to SBI implementation in these projects. Findings were compared with similar reports from industrialized countries. The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa Results � South Africa In South Africa, Peltzer et al. (2005; 2008) implemented SBI by providing two days of training to 196 (81%) of 243 nurses from 18 primary healthcare centers which had agreed to implement an SBI program. The program was endorsed by officials at the national department of health, the province and the district health office. Each clinic was allowed to choose between two different SBI implementation models and received at least two support visits by a trainer during the first three months of implementation. Implementation was assessed by collecting completed questionnaires after six months and by interviewing clinic managers. After six months, 2,670 patients had been screened, or an average of 25 patients per clinic per month, with nine clinics identified as successful implementers (120 or more patients screened, or at least 20 patients per month). Among clinic managers, 16 of 18 reported that they believed in the benefits of SBI, while two felt SBI went against their beliefs and values because alcohol was used for traditional purposes, because it gave people power, and because it was a habit that went back to their grandmothers, and also because of concerns that asking elderly people about their alcohol use might be considered a sign of disrespect. Factors most strongly correlated with SBI implementation success included having all nurses trained, early adoption of SBI (within two months after training), teamwork, and lower nurse clinical workload (

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