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? about interview techniques (Holmqvist et al. 2008). The other survey investigated patients’ experience of questions asked about their alcohol habits during a visit in health care (Socialstyrelsen 2007). Nearly 50 per cent of the GPs stated that they always or often asked questions about alcohol habits, whereas only 25 per cent of the district nurses did so. According to this patient-survey, only 13 per cent of those who visited a GP in the last year reported that they were asked about alcohol. Implementation of EIBI – problems and solutions � Research Most of the Swedish research has so far been directed towards attitudes and general issues concerning EIBI rather than treatment efficacy. Sweden has mainly relied on research from other countries as the evidence basis for the huge efforts recently to increase EIBI. Evaluation research is evolving though it remains in its infancy. As more people lately have been engaged in EIBI research, both in connection with implementation and research, our prediction is that this research field will be boosted in the coming years. This will perhaps be done as a joint venture with secondary prevention for other lifestyle issues, rather than as research on alcohol issues alone. � Problems in the national implementation policy of EIBI Compared to the implementation of the EIBI in most other countries, these activities appear to have been promoted at a high level in Sweden. As far as we know this activity level has been achieved similarly high only in Catalonia, Finland, parts of Great Britain and perhaps Flandern. 482 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 Why is the level so high in Sweden? As far as we know this has not been scientifically investigated, so the following reflections are our own. This development is probably the result of several activities in this field, both national and international, rather than the result of any single measure. The diffusion researcher Everett Rogers has stated that diffusion of a new practice (or innovation) requires a long period of implementation before institutionalisation is realized (Rogers 2003). He also believed that motivational interviewing had recently achieved that level (Everett 2003). In Sweden EIBI in the alcohol field has been promoted for more than 25 years. The same applies to motivational interviewing, with the start in Sweden dating back to the mid-1980s. There has been a very strong focus on motivational interviewing in all health organisations, and also in other human supportive and caring work. The increased implementation has also been boosted by a Swedish and WHO driven move towards a more health oriented treatment sector. As described above, Sweden has had and still has a very high level of alcohol prevention activities. The direction of this preventive work has changed this century, with for example school activities becoming even more focused from 2001 when funding increased for alcohol prevention. However, this type of primary prevention has been debated in recent years due to insufficient scientific evidence of its effectiveness. This change in views regarding primary prevention may have opened up the field to the present widespread use of EIBI, partially because this activity is carried out in a health care setting that previously was underutilized

for preventive purposes (Socialstyrelsen 2005). This means that there is, at present, a great opportunity to disseminate EIBI, but this window of opportunity will be open only for a limited time. If EIBI does not produce sufficiently rapid and, from a political point of view, acceptable results, it is likely that the next problem with EIBI will be loss of sustainability due to withdrawal of governmental funding before the local activities are sufficiently rooted in everyday care. An even more challenging problem is that although there is solid evidence that more education is not a sufficient solution alone to implement a new method, the main focus in Sweden is put on competence enhancement (Socialstyrelsen 2008; Spak & Andersson 2008). And although there is solid scientific evidence that telephone coaching or similar methods support more efficient implementation (Funk et al. 2005; Kaner et al. 1999), few attempts have been made to support the sustainability of SBI/EIBI by coaching or supporting the activities. We consider such methods a possible future key to increase the durability of activities. This would also mean that some of the implementation activities should be diverted from competence enhancement to competence maintenance. � To screen or not to screen? Concerning the Swedish Risk Drinking Project, it appears today as if one of the obstacles that hinders the spread of SBI is built into the very project. Although a considerable amount of evidence supports SBI as being an evidence-based practice, there now appears to be a move away from SBI towards EIBI; in other words away from systematic screening. We believe that the Large scale implementation of early identification and brief intervention in Swedish primary health care – will it be successful? main driving force in this process has been, and still is, some of the GPs, while nurses may be less reluctant to avoid screening. E.g., presently the question of alcohol is brought up by midwives with all pregnant mothers (Göransson et al. 2003). This shift towards EIBI means that the Risk Drinking Project now simultaneously advocates screening and non-screening – and in our thinking rather than being a broad strategy, this development reflects ambivalence towards goals. Several GPs argue that systematic screening does not suit the health care sector, and in particular that it does not suit the physician’s consultation style. Instead, the advocates of a non-screening strategy wish to promote asking questions about alcohol when it’s considered “natural” and “appropriate”. Such a strategy is supposed to better adhere to stimulating the confidence of the patient when the alcohol issue is brought up, or that the patient would react negatively when this is done (Arborelius & Damström Thakker 1995; Johansson et al. 2005; Göransson et al. 2006; Nordqvist et al. 2005). However well such a strategy would comply with the current move towards paying more respect to patient autonomy, it may actually miss the task of the PHC to work with prevention, or to be health promoting (WHO 1986). Our reason for believing this is that acting only when specific symptoms or conditions are present can preserve the present ailment of failing to detect problems at an early stage of problem development. This also has to do with the observation that medical sequelae come at rather advanced at-risk drinking, and later than early social problems (Dawson 2008). This means that if this non-screening strategy actually NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 483

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