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 trial to test the concept and the materials, changes were introduced to emphasize practical aspects related to the typical routine of a Family Health Team, and more emphasis was placed on the confrontation of stigma and negative attitudes about alcohol use and alcoholics. This article presents the results of quantitative and qualitative assessments of the implementation process and trainings conducted by PAI-PAD for the dissemination of alcohol screening and brief intervention activities in the region of Ribeirão Preto. Methods � Training Program The current 16-hour course format of the PAI-PAD Training Program is divided into four modules. The first module is a general introduction focusing on epidemiological evidence about the impact of risky drinking on public health as well as basic information about the AUDIT screening test. The second module is dedicated to the identification of risk zones, as proposed in the WHO Manuals (Babor et al. 2003a; 2003b), and the discussion of safe drinking limits. The third module presents practical aspects of the “Stages of Change: theory”. The fourth module deals with how to use brief interventions in the context of referring severe cases. Each module is divided into two parts with the first section devoted to theory and the second section to a workshop with exercises and group interaction. The underlying theoretical framework has been published in Brazil in 2004 (Marques & Furtado 2004). The number of participants is generally 20 to 25, and includes all health professions to facilitate discussion of practical aspects of the local SBIRT implementation at the Family Health Unit 542 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 level. For the workshop section, participants are asked to organize themselves in small groups. After the small group activities, participants return to the original group and discuss their questions and conclusions. The participants receive a kit of educational materials consisting of WHO manuals, AUDIT forms, booklets with information for patients and general information about the PAI-PAD activities. � Study Design Implementation of the PAI-PAD SBIRT program was evaluated using both quantitative and qualitative methods. Comparisons of attitudes, knowledge and behavioral intentions (Training Outcome Measures) were conducted before and after a series of 35 training workshops for health professionals by means of individual selfreport questionnaires. Further analyses were conducted to describe differences between municipalities using secondary data from official statistics on demographic characteristics, health personal and services distribution. In addition, focus group meetings (Qualitative Assessment) were conducted following implementation of the program to identify themes that would explain the kinds of changes identified after the training. � Participants These training workshops took place over a five year period between May, 2003 and March, 2008, and were conducted in 14 municipalities. The total sample included 772 health professionals (92.5% female, mean age 35.6, range: 18–62) who agreed to participate in the evaluation study, completed the training and signed the Informed Consent. There were no refusals.

About 30% of the initial sample did not participate in the post-training research waves, mostly due to job leaves, job terminations or changing employment. For some pre- and post-training comparisons the sample size changed as a function of the completeness of the research data. Concerning educational level, 23% of the training participants had achieved the basic primary school level, 45.8% had obtained at least a high school education and 31.2% had a college or university graduate degree. The distribution of the sample according to major professional categories was 59.2% community health agents, 9.7% nurse assistants, 9.6% graduate nurses, 5.6% psychologists, 4.7% physicians, 2.6% health managers (mostly physicians and nurses), 2.1% social workers and 2.8% professionals without direct involvement with the PHC system, including administrative staff and other professionals (dentists, pharmacists, nutritionists, physiotherapists, juvenile counselors, etc.). PHC professionals composed the majority of the sample (91.4%). The study protocol was reviewed and approved by the Human Research Ethics Committee of the Health Center of the School of Medicine of Ribeirão Preto. � Research Instruments The following instruments were used to collect data from the training workshop participants: Inventory of Alcohol Positive Beliefs and Expectancies (IECPA – Inventário de Expectativas e Crenças Positivas Sobre o Álcool). This is a self-report questionnaire with 61 items rated on a 5-point Likerttype scale (completely disagree to completely agree). The statements describe 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 positive aspects of alcohol use with higher scores generally reflecting greater alcohol involvement and positive expectations for its effects. The instrument was developed by Pinto Golveia et al. (1996) in Coimbra, Portugal. The Brazilian version showed good psychometric properties comparable to the original Portuguese version. SBIRT Knowledge Test (SBIRT-KT): This test has three sections and nine items. The first section contains four multiple choice questions dealing mostly with the definition of a standard drink and related risky drinking behaviors. The second section has three “true-false” questions concerning optimal patient interviewing styles, use of screening instruments and whether nurses can be effective when doing brief interventions. The last two questions ask about moderate drinking limits for men and women. This questionnaire is based on factual information communicated in the training program. Health Professions Study Questionnaire (HPSQ). This structured self-report questionnaire with 50 items was developed by Babor et al. (2005) to measure performance indicators and mediating factors associated with the implementation of SBIRT programs. The first section (14 items) asks about frequency of doing screening for alcohol problems as well as for other health risk factors such as exercise and diet. It also includes questions about whether the respondent “feels prepared” to perform alcohol counseling. The additional 36 items, rated on a five-point Likert scale (agree – disagree), make statements about professional attitudes and institutional climate regarding SBIRT implementation. Autonomy Level Assessment of the PHC Clinic Team (ALS-CT). A group of 21 PHC NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 543

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