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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? non-randomized controlled trial intervention studies have focused on the alcohol issue in PHC-settings with the intention of decreasing the harmful use of alcohol (Montin & Viklund 1987; Persson & Magnusson 1989; Persson et al. 1997; Bendtsen & Åkerlind 1999; Eriksson et al. 2000; Andréasson et al. 2000; Winberg & Nordström 2002). But more often the Swedish studies have focused on screening methods, on factors that affect the intention of asking questions about alcohol, and on attitudes towards working with secondary prevention (Arborelius & Damström Thakker 1995; Nordström et al. 1998; Bendtsen & Timpka 1999; Rosenqvist 2001; Johansson et al. 2002; Andréasson & Graffman 2002; Geirsson et al. 2005; Johansson et al. 2005; Göransson et al. 2006; Holmqvist et al. 2008). Lately implementation studies on reducing excessive alcohol consumption and web-based screening in ED have been carried out (Karlsson & Bendtsen 2005; Karlsson et al. 2005; Nordqvist et al. 2005; Bendtsen et al. 2007). Further, since 1994, several projects aiming at increasing alcohol knowledge and implementing EIBI have been carried out. These activities have generally been initiated by local interests. � Projects Among the more extensive projects in the 1980s and 1990s was the ALP-project (Alkohol, länssjukvård och primärvård) in Western Sweden 1985–1986, which had the aim of developing methods for working with alcohol prevention in health care (Montin & Viklund 1987). From 1992 to 1997 the “Ersboda project” was carried out in Northern Sweden (Persson et al. 1997). This was a collaboration project 480 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 between a PHC centre, social services and the addiction unit, with the purpose of developing methods for EIBI of harmful alcohol use and creating conditions for co-operation between the responsible authorities. The STAD-project in Stockholm started in 1995 and was financed by the county and city councils of Stockholm for ten years. The aim was to identify promising approaches to alcohol prevention and implement these in realistic settings to decrease alcohol- and drug-related problems and binge drinking. The project was built on both the principles of community action and policy initiatives, and consisted of secondary prevention in health care, youth programmes and a responsible beverage service (Andréasson et al. 2000). In 2005 the project was given a specific section at the Addiction centre (Beroendecentrum) in Stockholm. The Swedish Association of General Practice (Svensk förening för allmänmedicin, SFAM) initiated the project “Risk use of alcohol” 1996–2000. Within the SFAM project the General Practitioners (GPs) developed a method for training physicians in handling early alcohol problems– called “The risk drinking workshop” (Hedberg et al. 2000). The method is based on intercollegial discussions and training in asking patients about alcohol and when it is considered appropriate. The method did not use screening, which was regarded as “inconsistent” with GPs working tradition. � “The Risk Drinking Project” The national Swedish Risk Drinking Project was established in 2004. It was initiated by the Familjemedicinska institutet – Institute of Family Medicine (FAMMI), but the unit was wound up and since 2006 the Swedish

National Institute of Public Health (Statens Folkhälsoinstitut, FHI) has been responsible for the activity. The objective is to establish the issues about alcohol consumption as a natural part of daily health care work and to stimulate the development of effective measures to decrease the harmful use of alcohol, mainly through in-service training in PHC (including maternity and child health care) and occupational health care. From 2007 hospitals were also included in the project, and this has been run by the WHO network for health promoting hospitals. On the national level, the Risk Drinking Project promotes the dissemination of knowledge about risk drinking and knowledge exchange between the county councils. Within the project there are eight sub-projects: occupational health care, maternity health care, GPs, internist training, district nurses at PHC, nurses in child health care, motivational interviewing and hospital activity. The main strategies for developing and implementing the methods are co-operation with the professional organisations within the health care sector and focusing education and networking so as to increase knowledge and to change attitudes. In the project it is proposed that the effectiveness in alcohol prevention is enhanced by using motivational interviewing techniques and finding methods to work with the alcohol issue suited to daily practice. An evaluation, done by the National Board of Health and Welfare, showed that half of the PHC´s in Sweden had trained their employees in dealing with risk drinking over the past few years (Hedberg et al. 2000). However, the proportion of trained PHC´s differed between the county councils – from 94 per cent to 30 per cent. Large scale implementation of early identification and brief intervention in Swedish primary health care – will it be successful? The assignment for the Risk Drinking Project was stated by the Swedish government in proposition 2005/06:30. The county councils can apply for funding for working with secondary prevention on a local basis with national support. 20 of the 21 Swedish county councils have applied for and received this support. In 2007 the governmental part of the project funding was EUR 4.3 million. Each county council decides independently how to use the money and which models they want to work with: for example, three county councils applied for pay-for-performance incentives connected to goals concerning how often to ask questions about alcohol when patients/clients visited the PHC or hospitals (Spak & Andersson 2008). Further, a few county councils have employed specific coaches to support the employees in working with alcohol prevention to try to implement the methods. Two studies have been initiated to follow up the processes and results within the Risk Drinking Project. The first was a survey done in 2005–2006 addressing GPs’ and nurses’ knowledge about and attitudes towards working with alcohol prevention. The results showed that the professionals in the PHC and occupational health care regarded alcohol as equally important to ask about as any other lifestyle habit (Holmqvist et al. 2008). Yet, as found in another Swedish study (Geirsson et al. 2005) the professionals regarded themselves as much less effective and capable of helping patients/clients concerning alcohol issues, compared to other lifestyle behaviours. The GPs requested wider possibilities for referral to specialists, while the nurses requested more time devoted to health-oriented work and knowledge NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 481