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 searchers and research grants to influence delivery of alcohol SBI services in areas served by government health systems. The directors of these projects were leaders in the effort to increase prevention and treatment services in the oft-neglected area of alcohol misuse, and their accomplishments in some cases were significant. The importance of champions of the cause can not be underestimated, especially those who are willing to involve themselves in the arenas of government healthcare administration and health policy, which must be influenced for broad-based change to occur. These investigators wisely linked their interventions to important medical consequences in their areas (liver disease in Brazil and fetal alcohol syndrome in South Africa), utilized team approaches to implementation and benefitted from the policy changes happening at the federal level (in Brazil). The heavy reliance on non-physicians in these projects, without the exclusion of physicians, is important to future planning in SBI for large population groups, given the current reality that large segments of the medically underserved in both industrialized and developing nations receive healthcare provided by non-physicians. These projects confirm findings of previous research that SBI services are more readily and more economically offered by non-physicians than physicians, and they point toward the need for more focused development of training materials for such workers. The one- and two-day workshops utilized in these projects produced modest increases in confidence in providing SBI services by non-physicians, but these gains were not as great as those among physicians and nurses. Future re- 572 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 search should evaluate trainings of different durations using different methods in an effort to maximize benefit for workers who may not have previously addressed alcohol or who may be unaccustomed to providing “treatment services.” These projects suggest that the attitudinal barriers faced in many areas of Africa and Latin America may indeed be greater than those faced in some industrialized countries. The disease concept of alcoholism has been widely publicized in more industrialized countries, with varying degrees of success. Whether such concepts are as commonly disseminated and endorsed in the developing world is unclear, as participants frequently mentioned the stigma associated with alcoholism in their areas. In addition to that, the social acceptance of alcohol intoxication as part of leisure activities and the culture in these countries make it difficult to change attitudes of health professionals, who may not view such patterns of consumption as problematic, preventable or related in any way to alcohol dependence. In addition, it is likely that in countries with higher levels of binge drinking, alcohol misuse is relatively common among healthcare workers as well. Though the best way to change such attitudes is unknown, more time may be needed in training programs to address this issue in both education and discussion formats. The question of how to train and motivate healthcare professionals who themselves misuse alcohol is greatly in need of study and represents an important area for future research. The twin issues of philosophy and health policy surfaced in most of these studies: Is alcohol SBI an issue for primary care or for psychiatry, and are SBI preventive

services—interventions which primarily benefit at-risk drinkers with few or limited alcohol-related consequences—appropriate for primary care, where curative services are often prioritized? The findings of these studies would seem to provide partial answers in both these areas. The PAI-PAD program in Brazil, similar to the “Beveu Menys” regional SBI program in Spain (Gual 2008), demonstrated minimal evidence of increased screening and brief intervention in primary care, but significantly increased referrals of alcoholic patients to specialty services. Where specialty services are in place, SBI programs appear to increase referrals for treatment of patients with alcohol dependence, a positive outcome whose impact needs to be celebrated and utilized to greater advantage. US data have long demonstrated that most referrals to specialty treatment come from friends, families or the legal system, with physician referrals accounting for only 2–10% (Atkinson et al. 2003; National Treatment Center Study 2004a; 2004b). It is refreshing to see some change in this pattern. Contrariwise, SBI programs cause great frustration for clinicians who learn how to diagnose alcohol dependence without anywhere to refer patients who are beyond their expertise. These patients are often the first to be identified following SBI trainings. This finding points to the need for SBI programs to identify and link with existing formal and informal treatment resources, thereby strengthening the natural referral relationship between psychiatry and primary care. For some developing countries, this may also require efforts at creating a treatment infrastructure, which could involve lobbying with government The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa health programs, the private sector, selfhelp or mutual help programs such as Alcoholics Anonymous, or faith-based programs (Marques & Furtado 2004). At the same time, these SBI demonstration projects show that mid-level health providers who provide preventive services are more likely to actually perform SBI after training. SBI implementation efforts should seek to identify those personnel and those sectors of government healthcare systems where preventive and public health services are routinely provided and lobby for integration of SBI services in these arenas. Virtually all of these studies indicate the difficulty and complexity of implementing routine SBI at the clinic level. For the most part, efforts fell short of achieving the goal of routine screening and intervention of most primary care patients, and actual numbers of patients screened were small. In South Africa, “successful implementers” were clinics which screened 20 or more patients per month. Clinics in Juiz de Fora, Brazil screened only an average of 24 patients per clinic per month, and Diadema health administrators who embraced SBI asked patients to screen only two patients per week. The barriers to routine implementation described by participants are core issues in healthcare delivery in developing countries: competing demands, especially in facilities with high patient volumes; competition with other health system priorities and official programs for treatment of diseases such as HIV, tuberculosis, hypertension, and diabetes; high staff turnover in underserved areas; and challenges of bureaucracy (one proposed implementation site in Brazil never received promised funding because NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 573

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