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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? would be adopted, it should rather focus on psychological ailments and “minor” social problems, such as inter-marital problems than on medical sequelae. Rogers (2003) wrote that it is easier to succeed with implementation if you do stay close to the old practices. Albeit this seems natural we must not let “staying close” with the familiar practice mean that we miss truly early identification, which can be achieved more effectively by screening. � What is at-risk drinking? Another vital issue that should be resolved is the question of what risk use is. Geirsson has recently found that education in SBI/ EIBI has raised the levels of alcohol consumption that the GPs regard as risky (Personal communication 2008). This indicates that the GPs concepts of risk consumption were rather restrictive to begin with. On the other hand many physicians advocate alcohol as a health promotive substance, in particular concerning vascular diseases. A clinical impression is that often the recommended limits stated by physicians advocating alcohol for health beneficiary reasons, has been at least 2 standard units per day, although this recommendation does not comply with a more official Swedish viewpoint on this matter (Andréasson & Allebeck 2005), which states that this effect can also be obtained with a lower drinking level. Two standard units per day coincide with the Swedish recommended limit for males, but is higher than that for women (140 and 90 grams respectively) (Andreásson & Allebeck 2005). Probably this seaming contradiction concerning the global effect alcohol has on health must be resolved before there will be a clear message on the health hazards of alcohol from 484 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 physicians. One possibility to resolve this problem is, as stated above, to primarily focus on the social consequences of alcohol. This would also put in focus the effect of at-risk drinking on other people and on social networks, perhaps in a similar way as with passive smoking. � Other current issues A key issue currently being discussed in Sweden is whether the alcohol issue should be incorporated in general lifestyle promotion, rather than being promoted as a separate issue. The present government policy to increase health promotion and lifestyle factors in general (RP 2007/08:110), may be beneficial for expanding the focus also to alcohol. But as the staff insecurity in dealing with alcohol issues repeatedly has been found to be greater compared to the self-efficacy concerning dealing with other lifestyle issues (Geirsson et al. 2005; Holmqvist et al. 2008), special stimulating efforts will probably be needed for a long time to come, in order to keep the activity as high on alcohol issues as for other health hazards. Swedish health care is presently undergoing a financial and organizational transition, with free choice of treatment provider and privatization as the outstanding new features, though the main bulk of the health care sector remains publicly produced. Will this development stimulate or hinder the health care sector in developing into a more health oriented organisation? This is not clear, but if the demand for even shorter visits in primary health care is carried through, methods like Motivational Interviewing would come under threat. This may, in general, apply to all measures undertaken from the provider, as

they are not primarily requested by the patient/client. An example of the latter may be asking questions on alcohol consumption. But it is too early to make a prediction on the outcome of this issue, as there also are several studies showing that the patients/clients actually consider alcohol to be an important issue for GPs and nurses to discuss with patients (Andréasson & Graffman 2002; Johansson et al. 2005; Miller et al. 2006). This brings us to our final reflection. Evaluation of other alcohol preventive projects in Sweden (Spak & Blanck 2006), show that many activities will stop when state funding is withdrawn. Although the intention on the part of the state is to “localize” as much of the funding responsibility as possible, this is a policy that REFERENCES Aalto, M. & Pekuri, P. & Seppä, K. (2003): Primary health care professionals’ activity in intervening in patients’ alcohol drinking during a 3-year brief intervention implementation project. Drug and alcohol dependence 24: 555–8 Andréasson, S. & Allebeck, P. (ed.)(2005): Alkohol och hälsa. En kunskapsöversikt om alkoholens positiva och negativa effekter på vår hälsa. (Alcohol and health. A survey on positive and negative effects of alcohol on our health). Rapport 2005:11. Statens folkhälsoinstitut Andréasson, S. & Graffman, K. (2002): Alkoholprevention i primärvården. Patienterna positiva till att frågor om alkohol och livsstil tas upp. (Prevention of alcohol problems in primary health care. Patients receptive to questions concerning alcohol and life style). Läkartidningen 43: 4252– 4255 Large scale implementation of early identification and brief intervention in Swedish primary health care – will it be successful? may not lead to the desired sustainability. One reason is that the activities may have not settled enough before state funding is withdrawn, while another reason is ethical in nature; there will always arise other competing well-intentioned and justified goals, and these will tend to favour dealing with severe cases rather than preventive measures. Fredrik Spak, Md, Phd department of social Medicine Gothenburg university sweden e-mail: fredrik.spak@socmed.gu.se Annika Andersson, Ba department of social Medicine Gothenburg university sweden e-mail: annika.m.andersson@socmed.gu.se Andréasson, S. & Hjalmarsson, K. & Rehnman, C. (2000): Implementation and dissemination of methods for alcohol problems in primary health care: a feasibility study. Alcohol and Alcoholism 35 (5): 525–530 Arborelius, E. & Damström Thakker, K. (1995): Why is it so difficult for general practitioners to discuss alcohol with patients? Family Practice 12 (4): 419–22 Bendtsen, P. & Åkerlind, I. (1999): Changes in attitudes and practices in primary health care with regard to early intervention for problem drinkers. Alcohol and Alcoholism 34 (5): 795–800 Bendtsen, P. & Holmqvist, M. & Johansson, K. (2007): Implementation of computerized alcohol screening and advice in an emergency department – a nursing staff perspective. Accedent & Emergence Nursing 15 (1): 3–9. Epub 2006 Nov 20 Bendtsen, P. & Timpka, T. (1999): Acceptabi- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 485

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