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5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

Large scale

Large scale implementation of early identification and brief intervention in Swedish primary health care – will it be successful? the coming years. It is also likely that the screening for alcohol issues will become a part of general health (or lifestyle-related) screening. A key issue will be to focus on the sustainability of EIBI methods, possibly through continuous support, e.g. by coaching or pay-perperformance economic reimbursement. KEywORDS Alcohol, secondary prevention, early identification, implementation, primary health care, Sweden 478 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 25. 2008 . 6 to the early identification of and brief intervention (EIBI) for alcohol problems and risk drinking. A report from the Swedish Council on Technology Assessment in Health Care (Statens beredning för medicinsk utvärdering, SBU) 2001 presented a critical review of 27 randomized controlled international trials on the effects of screening and brief interventions (SBI) (Salaspuro 2001). The conclusion was that SBI, based on identifying harmful consumption/risk drinking and providing information, motivation, and support – leads to a reduction in alcohol consumption. Despite the fact that there are today several simple and effective methods available to prevent the physical and psychological damage caused by alcohol, it has been difficult to routinely implement these methods in the health care system (Aalto et al. 2003). There are several terms for the activity of early identification. When SBI is used, this signifies that screening is employed, but as several authors and doctors do not consider screening to be an activity that naturally complies with the physician’s ordinary patient communication style, the term EIBI is used. Sweden is in the context of EIBI an interesting country, as the “Risk Drinking Project”, as far as we know, is the broadest national effort to implement EIBI. As Sweden has a well developed health care sector throughout the country, a failure of this implementation would probably indicate that it would also be difficult in other countries. The aim of this article is to present and discuss possibilities and problems with EIBI based on the Swedish experiences. Primary and secondary alcohol prevention Sweden has a long tradition of working with prevention of alcohol problems, mainly as primary prevention with the responsibility shared between the national and the local levels. Since the eighties there has been an increased activity concerning secondary prevention, primarily in PHC, although the activities in the beginning were sporadic and locally limited. This activity has increased tremendously over the last few years, and there is now (2008) a high activity level all over the country, especially regarding the dissemination of knowledge and education about the harmful use of alcohol and SBI/EIBI.

Since 1982 the Health and Medical serv- ice Act equalizes prevention with evaluation and treatment (SOSFS 1982:763), and this intention is also supported by two (out of eleven) national public health objectives; promoting a health-oriented health service and stimulate prevention of alcohol-related harm (RP 2007/08:110). A national action plan to prevent alcoholand drug problems was adopted by the Swedish Parliament in 2001 with the aim of reducing the harmful effects of alcohol from both the medical and the social perspectives (RP 2000/01:20). This plan has since been followed by a second plan (Prop 2005/06:30) that covers the period 2006–2010 and stresses the need for continuity, improved co-operation between different local, responsible authorities, as well as an increase in local preventive activities in both the social and health care sectors (RP 2005/06:30). Sweden’s EU membership in 1995 was followed by a large increase in consumption. The traditional Swedish restrictive alcohol policy has been continued (Norström 2002), but due to adjustments to the EU alcohol policy the possibilities of restricting availability has been reduced. Activities to reduce demand have instead become more emphasized. From 2001 the government increased the funding for enforcing a restrictive alcohol policy, and since 2004 one of the main goals has been to enhance EIBI. As a consequence, the “Risk Drinking Project” was started in 2004. In 2007 the National Board of Health and Welfare (Socialstyrelsen) presented guidelines for medical and social measures provided by the municipal social services, as well as by the county council operated dependency units for treating persons Large scale implementation of early identification and brief intervention in Swedish primary health care – will it be successful? with misuse and dependency problems (Socialstyrelsen 2007). These guidelines are based on reviews and meta-analyses of methods and techniques. The conclusions were that secondary prevention—enacted with clear strategies and the use of brief interventions—supports many people in reducing their alcohol consumption and that the methods are cost-effective. However, the evidence varies for different health care sectors, and is so far strongest for PHC and Emergency Departments (ED). The recommendations discuss EIBI and its implementation. Evidence concerning implementation in this field, and knowledge about organisational influence on treatment, are insufficient. Yet the authors conclude that co-ordination of resources (professionals, equipment, premises etc.) is a basic condition for spreading knowledge and to implement methods (Socialstyrelsen 2007). Secondary prevention studies and projects in Sweden � Scientific studies For the last three decades, we have identified three Swedish randomized controlled trials within the field of secondary prevention in PHC (Kristenson et al. 1983; Romelsjö et al. 1989; Tomson et al. 1998) and one from an ED (Forsberg et al. 2003). In one trial from a PHC setting, Kristenson et al. tested screening using a Brief Intervention with biofeedback from test results and demonstrated that a reduction in harmful alcohol consumption resulted in a significantly lower morbidity and less health care utilization and mortality (Kristenson et al. 1983). However, unlike many other trials, this procedure often entailed repeated visits to the treatment center. Some NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 479