5 years ago

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 barrier. The authors suggest that an ongoing process of quality improvement might be effective in mobilizing the large numbers of trained professionals to significantly increase primary care screening rates. This project highlights the potential advantages of tying SBI implementation efforts to alcohol-related health indicators such as liver disease. The training strategy was similar to that employed by Ronzani and colleagues: training of health professionals at all levels, training multiple individuals from each clinic, and concentrating training among mid- and lowerlevel providers. The important finding of an inverse relationship between alcohol expectancies and readiness to support SBIRT, followed by a decrease in such expectancies as SBIRT knowledge increased, indicates that SBI training may in fact be reversing some of the negative attitudes that impede alcohol intervention efforts. This was confirmed by statements from focus group participants, who noted changes in their stereotyped, moralistic views of alcoholics. Notably absent from this report was any mention of problems due to a lack of treatment infrastructure, perhaps due to the existence of the program’s specialty treatment services in the center of the region. The ongoing growth of this project highlights the positive impact of program champions who demonstrate clinical, administrative and political leadership over an extended period of time. As part of this project’s startup, PAI-PAD organized a symposium in 2003 which included participation of representatives of the Federal Ministry of Health, State Health Department, and health managers from regional, city and local levels, thereby including stakeholders from all three levels of health- 570 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 care funding in Brazil. Challenges from this project that await solutions include dealing with high personnel turnover and instituting monitoring systems that can document and track services provided. � São Paulo and Curitiba, Brazil Souza-Formigoni and colleagues (2008) describe an intensive attempt to implement SBI by training 174 health professionals (physicians, nurses, orderlies, or CHWs) from 30 PHC clinics in the Brazilian cities of Diadema, São Paulo and Curitiba and to study its impact on patient alcohol use and adoption of SBI. Using the WHO’s Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), 2,665 patients were screened by either researchers (in Curitiba; median of 14 screens per health professional over 12 months) or primary health care professionals (São Paulo). Half of the at-risk patients received brief intervention immediately and the other half (control group) received a delayed brief intervention three months after the initial screening. After three months, those receiving immediate brief intervention had significantly lower ASSIST scores (72.6% scored at the low risk range at follow-up), when compared with controls (33.8% low risk). Surprisingly, after training most health professionals (65.5%) did not want to participate in SBI implementation, and there was great variability in the number of screens done by professionals who participated. Reported difficulties included the professionals’ negative attitudes toward alcohol and drugs abusers, lack of a network for referring dependent patients, difficulties in working as a united team and the lack of time to include SBI in the clini-

cal routine. Importantly, SBI was viewed as an “unofficial research proposal” which was given lower priority than official government programs for treatment of diabetes, hypertension, etc., and the program received little support from clinic managers. But after sharing with health system managers in Diadema the positive results found with the use of SBI in the early phases of implementation, some managers and health professionals became more motivated, and significant “natural dissemination” occurred. SBI was adopted as an official health policy at the municipal level and two new rounds of training were provided. One committed manager trained 45 additional CHWs in SBI. Each CHW was asked to screen at least two patients per week, and plans were developed to extend training to the rest of Diadema’s PHC clinics in 2009. A group of Paraná researchers trained 120 health professionals from Cajuru, Lapa and São Jose dos Pinhais, with plans to meet with local officials and health professionals to provide feedback on the results obtained. On the other hand, during the development of the project, the high turnover in the team of managers in São Paulo and Curitiba hindered the establishment of a permanent commission that could assume responsibility for the integration, planning, implementation and frequent mobilization of all the sectors involved in the project. In conclusion, the study demonstrates the fact that opportunities for SBI research may serve as a motivator for performing SBI, especially in academic centers, and that patient outcome data from clinics which are targeted for SBI implementation may be used to increase motivation for implementation and support from The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa policy makers. Administrative leadership and policy changes which institutionalize SBI appear to be key ingredients to the widespread dissemination of SBI in Brazil. Nationwide training efforts are underway in Brazil which will equip large numbers of professionals to use SBI in their daily practice, and these should occur in parallel to policy changes at local and national health system levels. All three Brazilian projects occurred in the context of important health policy changes related to alcohol misuse. Brazilian researchers were active in presenting SBI data at both scientific and political meetings. In the Ribeirão Preto region, PAI- PAD was established in 1999 as a program of the Medical School of Ribeirão Preto – University of São Paulo dedicated to the improvement of the public health system, with a priority to integrate interventions for alcohol misuse into the primary health care system. From 2002–2007, a national policy was developed, the Ministry of Health defined principles for integrated care for alcohol and other drug problems in primary health care and other services. Demonstration projects were funded for implementing SBI in three states (São Paulo, Paraná & Minas Gerais). In addition, funding was allocated by the State of São Paulo for the implementation and dissemination of SBI, and the National Secretary on Drugs developed a distance learning course and trained 4,000 health professionals in alcohol and drug SBIRT. Discussion The projects described in this review provide an opportunity to evaluate a novel approach to SBI implementation in developing countries: the use of academic re- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 571

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