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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 a mechanism for appropriate transfer of funds from the US granting agency could not be found). None of these problems are easily solved, and the next phase of SBI implementation research should seek to explore different mechanisms for overcoming them. Future projects might test the impact of utilizing quality improvement efforts in SBI projects, including regional or national health authorities on implementation teams, focusing implementation in preventive health service delivery systems rather than primary care, or combining SBI implementation efforts with other changes in health policy or laws related to alcohol use. Linking SBI training with the adoption of policies which mandate addressing alcohol at various levels of the healthcare system, as has occurred recently in Brazil, appears to be an effective mechanism for increasing alcohol prevention and treatment activities. Alcohol has now been designated one of the top ten priorities in Brazil’s National Family Health Program (Marques & Furtado 2004), and SBI projects are now expanding throughout the country. In other developing nations, the need for policy support within government healthcare systems and at the legislative level can not be underestimated. High levels of alcohol-related morbidity and mortality in many developing countries provide a clear mandate for action. Based on the prevalence of alcohol-related illness worldwide, the World Health Organization (WHO) recently approved a resolution calling for the development of a worldwide alcohol strategy (Grimm 2008). SBI training efforts should be combined 574 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 with efforts to convince ministries of health and legislative bodies to establish alcohol SBI “programs” at a level of importance equal to other disease-focused government programs such as HIV or hypertension, and SBIRT activities should be emphasized as priority health issues at the national level. As WHO’s global strategy on alcohol is developed and implemented and WHO regional offices step up their work on alcohol related topics, programs should be developed which include SBI as one component in a broader, more comprehensive alcohol policy approach aimed at reducing the harmful effects of alcohol. Existing comprehensive tobacco control efforts provide an example of such programs, as governments introduce curricula on tobacco control in the training of health professionals and step up actions to provide counseling and pharmacological treatments for smoking cessation, while also supporting measures to increase taxes on tobacco products and implement controls on advertising. In relation to alcohol, attempts to disseminate SBI in primary health care, supported by proper allocation of funds, increased capacity building, and changes in the roles of primary care workers, may be more effective when combined with other policy changes such as increasing alcohol taxes, restricting hours of alcohol sales, enforcement of laws restricting alcohol use by minors, and limiting alcohol advertising. SBI training may in fact prove to be more effective in changing clinician behavior when undertaken as other policy changes are occurring and the debate around the harmful effects of alcohol is lively and well-publicized. Despite some limitations, the accomplishments of the programs described in

this issue are significant. Thousands of healthcare professionals have been trained in SBI, and in areas where they have demonstrated effectiveness, programs are being disseminated. The evidence presented from these pilot projects indicates that screening services, referred to by Babor et al. (2007) as the “linchpin of SBIRT,” are increasing as a result. These studies provide a foundation which can help move SBI to the next level. A major focus of future efforts should be increasing and documenting interventions and referrals, as well as screenings. Many developing countries have demonstrated their ability to increase critical preventive services such as immunizations by formally designating the service as a priority, allocating funds, providing needed training, requiring employees to provide such services, documenting that they were provided, and rewarding those who meet expectations. Similar approaches, when applied to alcohol SBI, should bear fruit as well. The process of change is slow and at times painstaking, but this is not unique to the alcohol field. According to the US Centers for Disease Control, the effective- REFERENCES Atkinson, R.M. & Misra, S. & Ryan, S.C. & Turner, J.A. (2003): Referral paths, patient profiles and treatment adherence of older alcoholic men. Journal of Substance Abuse Treatment 25 (1): 29–35 Babor, T.F. & McRee, B.G. & Kassebaum, P.A. & Grimaldi, P.L. & Ahmed, K. & Bray, J. (2007): Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management The dissemination of screening and brief intervention for alcohol problems in developing countries: lessons from Brazil and South Africa ness of handwashing, now considered to be medical science’s most important infection control technique, was scientifically demonstrated by Semmelweiss in 1847. It took another 50 years for handwashing to be widely accepted by the medical profession (CDC 2000), and the battle to continue performing this simple measure goes on daily in hospitals and clinics around the world. Effecting change in attitudes and behaviors related to alcohol screening, intervention and referral in large healthcare systems may also require more than a generation of education, training, and effort. Nonetheless, the studies in this issue document that changes in attitudes and behaviors have indeed begun. J. Paul Seale, Prof., dir. of research department of Family Medicine Medical center of central Georgia and Mercer university school of Medicine, Macon, Ga 31201, usa e-mail: seale.paul@mccg.org Maristela G. Monteiro, senior advisor on tobacco control, alcohol and substance abuse Pan american health organization Washington, dc, usa e-mail: monterim@pana.org of substance abuse. Substance Abuse 28 (3): 7–30 Babor, T.F. & Higgins-Biddle, J. & Dauser, D. & Higgins, P. & Burleson, J.A. (2005): Alcohol screening and brief intervention in primary care settings: implementation models and predictors. Journal of Studies on Alcohol 66 (3): 361–368 Babor, T.F. & Higgins-Biddle, J. & Higgins, P. & Gassman, R.A. & Gould, B.E. (2004): NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 575

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