5 years ago

NAT 6/08 - THL

NAT 6/08 - THL

Implementing brief

Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil: evaluation of the PAI-PAD training model their perceived feeling of being “prepared to counsel” patients about risky alcohol use. Qualitative analysis showed an improvement in the level of awareness of alcohol problems, adoption of a disease model, and an increase in referrals for alcohol treatment. The program was disseminated to a large enough proportion of the health professionals in small cities to have a significant reach into the general population of heavy drinkers. CONCLUSION The training model combined with concurrent supervision and support seem to be effective in the implementation of SBIRT in the routine of health professionals in primary health care. This model shows promise as a way to implement alcohol screening and brief intervention as a standard practice in primary health care in large population areas of Brazil. It has been extended to other parts of Brazil and could serve as a model for other Latin-American countries. KEYWORDS alcohol screening, brief intervention, SBIRT, implementation, early intervention tions and health education. 540 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 25. 2008 . 6 It is generally believed that in Brazil, as in other countries, most patients with alcohol-related problems are not detected in primary health care settings, despite their obvious medical and psychiatric complications. Rosa et al. (1998) investigated the ability of Brazilian medical doctors and nurses to detect alcohol misuse among patients in a general hospital. The physicians considered only half of the patients that were assessed as having an alcohol problem with the CAGE assessment instrument as alcohol abusers, while the nurses identified only a third of them. Even medical residents in psychiatry fail to detect alcohol misuse in their patients. Macedo et al. (2002) reported that less than 25% of CAGEpositive psychiatric outpatients had been recognized by psychiatrists in residency training. In Brazil the prevalence rates of risky drinking by some high risk groups could exceed that of developed countries. Fabbri et al. (2007) reported that 22% of 450 pregnant women in the city of Ribeirão Preto were positive cases in a screening study of risky drinking, using the Brazilian version of the T-ACE (a short questionnaire developed by Sokol et al. 1989, the T-ACE acronym refers to Tolerance, Annoyance, Cut-down and Eye-opener). Ribeirão Preto is probably the most important center of the alcohol industry in Brazil, being the largest producer of sugarcane, sugar, and industrial alcohol in the country. Alcohol in the region is chiefly produced for chemical or energy purposes, not primarily for beverages. However, the region is also known as “the capital of draft beer” because of the high per capita consumption rate and its very popular breweries. This region has a high social tolerance for alcohol consumption. Despite restrictive laws, alcoholic beverages are universally accessible for teenagers. This may account for the observed increase in emergency room admissions of young people diagnosed with alcohol-related problems (Furtado 1998). Brazil as a whole is known as one of the most affected countries in the world because of its share of the burden of disease attributable to alcohol consumption (Rehm & Monteiro 2005). The region of Ribeirão Preto has the highest rate of liver disease among males in the State of São Paulo, reaching about 75.5 deaths/100,000 inhabitants, with 44.5 attrib

utable to alcohol abuse (SEADE 2004). Re- cent findings corroborate these data. About 50% of fatal victims of auto accidents had BAC levels above the Brazilian legal limit (Martinis 2006). In a study of health conditions among truck drivers, 51% were identified as alcohol abusers according to the AUDIT screening test, which was administered to drivers on the highway routes in the region of Ribeirão Preto (Domingos & Pillon 2007). According to a recent population based study in urban regions (Laranjeira et al. 2007), 52% of adult Brazilians are current drinkers (65% male, 41% female). Among them 60% of men and 33% of women drank five or more standard drinks if they had a heavy drinking episode. Considering the whole sample of men, 11% drink daily while another 28% drink 1–4 times weekly. Information about the drinking of rural populations in Brazil is scarce. According to the 2000 National Census, 81.2% of Brazilians live in urban areas. In a case-control study (Santos et al. 2003) about risk factors for paracoccidioidomycosis in rural workers, it was found that 68.3% answered positively to the question about current drinking. Since 1999 the University of São Paulo at Ribeirão Preto has been the home of PAI-PAD (Program of Integrated Action for Prevention of Alcohol and Drug Problems in the Community), which is based at the School of Medicine’s teaching hospital. This program was established in 1999 with the purpose of disseminating early identification and intervention procedures to health professionals working at the primary health care level. In 2002, after a meeting in Alicante, Spain, convened by the World Health Organization, PAI- Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil: evaluation of the PAI-PAD training model PAD was invited to join a cross-national initiative to adapt and disseminate brief interventions for alcohol problems. Following this meeting, PAI-PAD organized a symposium in 2003 with the participation of representatives of the Federal Ministry of Health, State Health Department and health managers from the public health system at the regional, city and local levels. In the same year the Ministry of Health published a policy document where, for the first time, a recommendation was made for the inclusion of brief interventions as part of the officially prescribed health strategies for alcohol and drug users. In 2004, the Ministry of Health published a federal rule establishing that brief counseling and brief interventions are components of the basic services to be provided at general outpatient clinics, the family health program and the program of community health agents (Ministério da Saúde 2004). Brazil’s Family Health Program is the most important government attempt to improve primary health care by providing a comprehensive range of preventive and curative health care services delivered by a team composed of one physician, one nurse, a nurse assistant, and five or more community health workers. The latter group tends to have a low educational level, and no formal education in health sciences. They live in the target community, perform home visits, conduct screening and monitor the most prevalent health problems, including alcoholism. The team is responsible for the care of all families in a specific geographic area, usually consisting of about 3,500 people per team. The PAI-PAD Training Program for Family Health Professionals was developed in 2003 (Furtado 2003). Following a pilot NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 541

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