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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 pap smears correlated negatively with SBI success. Reasons cited by nurses not attending the training included feeling that they were not good examples because they were alcohol drinkers themselves, feeling the training was irrelevant because they did not advise patients but only took vital signs, or because they were nearing retirement age. Overall, the relatively low number of patients screened (averaging one patient per clinic per day) seems to indicate that alcohol screening had not yet become routine, even in “successful” clinics. As in previous studies, nurses were exercising some level of selection in which patients were screened. Findings affirm a number of barriers cited in previous studies, including the negative impact of heavy clinical workloads, competing demands, and personal alcohol use patterns. In this government-sponsored health system, no financial incentives were offered for performing SBI (trainees received a certificate of attendance), and endorsement was obtained from district, province and national health officials. Factors that appeared to facilitate SBI implementation included a higher percentage of clinic staff trained and ability of staff to work together as a team. One interesting new finding was the association between implementation success and early adoption, suggesting that early onsite support that enables early adoption, especially for clinic staff who view SBI implementation as “complex”, may increase the chance of successful implementation. Another important finding of this study was that high levels of perceived benefit of SBI did not correlate with implementation success, affirming the need to assess actual SBI performance measures rather 568 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 than limiting assessment to the knowledge and attitudes of trainees. � Minas Gerais, Brazil The presentation and paper by Ronzani et al. (2005; 2008) in the Brazilian state of Minas Gerais described a regional project carried out in 42 health care facilities (mostly primary healthcare centers) in five cities. Data were collected from 195 (58%) of 334 healthcare workers who received eight hours of training in SBI, including 99 auxiliary nurses and community health workers (AN/CHW), 36 psychologists and social workers (PSY/SW), 35 nurses, and 25 general practitioners. While all trainees demonstrated significant increases in SBI knowledge, the greatest gains from training occurred in the AN/CHW group, who reported significant increases in every positive domain measured (confidence in SBI, self-efficacy to do SBI, and high expectations of SBI) and significant decreases in both negative domains measured (perceived obstacles to screening and brief intervention). After three months, 3,061 AUDITs had been administered (average: 24 patients per clinic per month). CHWs and psychologists administered the majority (72%) of the AUDITs and performed the highest percentage of BIs (72% and 59%, respectively) among AUDIT-positive patients. Of interest, 5% of patients selfadministered the AUDIT. Ronzani noted apparent changes in the attitudes of health professionals, who began to see alcohol misuse as a general health problem and to embrace the possibility of preventive actions in primary care. However, he also noted that “no systematic implementation was observed in the health centers.” In key informant interviews, trainees,

clinic administrators and service coordinators described a familiar set of barriers: lack of time, excess work duties, lack of motivation, resistance to working with alcohol issues, inadequate system infrastructure, and inadequate referral resources. One potentially important new concern was the lack of official support by the government. Attitudinal issues such as pessimism regarding treatment efficacy and a view of problem drinking as a moral issue were noted, and the curative paradigm in primary care training also appeared to be a significant barrier. The positive exception was the CHWs, who appeared to embrace SBI as consistent with their mission and perform it at a significantly higher level than other trainees. This study, like the Cutting Back study in the USA (Babor et al. 2005), seems to point us toward focusing training and implementation on midto lower-level healthcare personnel, who seem to face fewer barriers in embracing preventive management of alcohol misuse as part of their healthcare mission and perform it on a more consistent basis. � Ribeirão Preto, Brazil Furtado and colleagues (2008a; 2008b) described Brazil’s PAI-PAD Project, a regional effort in the Ribeirão Preto region which eventually expanded beyond its borders. The area targeted has a high social tolerance for alcohol consumption and an elevated incidence of liver disease. From 2003–2008, 774 health professionals recruited from 104 Family Health Program facilities in 14 (56%) of 25 different municipalities across the region, participated in a 16-hour SBI training workshop (average 7 health professionals per facility). The range of medical professionals trained in- The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa cluded 59% CHWs, 10% graduate nurses, 10% nursing assistants, 6% psychologists, 4% physicians, 3% health managers, and 2% social workers (92.5% female). Administrative organizing included creation of a network of representatives from each of the municipalities, monthly meetings for planning and information exchange, monthly supervision visits distributed among 21 of the PHC clinics, and periodic public events such as “alert campaigns.” Four focus groups were conducted with independent groups of health professionals from four different clinics four to six months after training. The study found an inverse relationship between trainees’ alcohol expectancies and their readiness to support SBIRT. The authors also found that alcohol expectancies decreased after training as SBIRT knowledge increased. While all professional groups felt more prepared to counsel individuals with alcohol misuse after counseling, increases in confidence were significantly greater among nurses and physicians. Focus group participants noted that training changed their stereotyped views of alcoholics to embrace a broader spectrum of alcohol use patterns (“risk zones”) and to adopt a disease model rather than a moralistic view toward alcohol misuse. While no data are available on numbers of patients screened (the National Mental Health Coordination reports major barriers to collecting reliable data on services provided in their outpatient clinics), SBIRT procedures were noted to have become part of the routine in some clinics, even some without supervision visits, and related SBI projects were started in five remote sites in four different states. High turnover of trained personnel and clinic managers was identified as a significant NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 569

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