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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 Clinics received monthly supervision vis- its after completing the training program between 2006 and 2008. At the end of the supervision period each clinic was evaluated by two raters independently using a 4-item rating scale (very low, low, medium and high) to assess the autonomy level of the clinic team regarding local SBIRT implementation. The following topics were rated: presence of educational material for patients; number of AUDIT screenings; number of engaged health professionals; leadership, formal or informal, for implementation; SBIRT utilization in group activities for patients; local projects; numer of interventions; solicitation of advice; and specific case discussions. In order to assess the effectiveness of SBIRT training in changing PHC professionals’ attitudes, motivation and level of knowledge, a post-training assessment was performed within an average time interval of 7.1 months for the first phase (N = 167; min. 1.84 – max. 21.45; SD = 2.99) and 6.2 months for the second phase (N = 179; min. 3.42 – max. 17.91; SD = 2.52). Outcome measures for IECPA, RTC and SBIRT-KT are provided only for the first phase participants. The ALS-CT was performed only in the second phase, as well the estimates of screening frequency using AUDIT, frequency of counseling and number of families and patients who were reached. � Qualitative Assessments Focus group meetings were conducted with four independent groups of health professionals in the post-training period. Each group originated from the same health unit team. The health teams trained in the first phase provided the groups. These meetings 544 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 occurred four to six months after the training. The focus groups were conducted to provide additional qualitative information that expanded upon the quantitative data collected in questionnaires. There were no selection criteria, so these were samples of convenience. Each group was composed of seven to eight health professionals, with a total of 30 professionals recruited into the qualitative study sample. All participants had attended the screening and brief intervention training workshops. Each group of health professionals belonged to a different Family Health PHC out-patient community clinic. The School of Medicine of Ribeirão Preto of the University of São Paulo is the owner and manager of these clinics, which are devoted to PHC services as well as education and practical training for medical students, residents, nurses and students of other health professions. Following recommended focus group techniques (Krueger 1988), two central questions were formulated and presented for open discussion to all groups. The questions covered the benefits of training and the perceived barriers to implementing brief interventions at the PHC site level (Rush et al. 1996; Aalto et al. 2003). Each group was moderated by a member of the evaluation research team. All discussions were tape recorded and transcribed for these analyses. Three independent judges read the transcripts to establish meaningful categories representing the central ideas expressed by the focus group participants. Further qualitative data were derived from administrative documents, reports, statistics and communications. Other in-

formation was obtained from direct obser- vations of several hours of meetings and personal interviews and appointments with health managers at all levels. Results � Training Outcome Measures Figure 1 shows the cumulative number of professionals trained during the two phases of the project. The figure documents the general implementation of the program over the three year training period, with a higher rate of implementation during the second phase. At the pre-training assessment the SBIRT knowledge test (SBIRT-KT) mean score was 3.94 (SD = 1.45; 95% CI 3.72-4.16). At the post-training assessment this score showed an improvement of approximately two points (μ = 5.47; SD = 1.65; 95% CI 5.22-5.72). This increment was statistically significant (N = 172; ∆ = 1.53; SE = 0.17; t = 9.13; p < 0.0001). Better educational level was positively correlated with higher scores on the SBIRT-KT at the post-training Cumulative Frequency (N) 800 700 600 500 400 300 200 100 0 May -03 PHASE 1 - N = 301 (04 Cities) Jan. -04 July -04 Jan. -05 July -05 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 Time Line assessment (r = 0.20; p < 0.01; N = 184), as well with duration of job experience (r = 0.16; p < 0.05; N = 150). No significant difference was found across different job categories in the knowledge scores between pre- and post-training phases. The measure of positive expectancies for alcohol (IECPA) showed a mean score of 91.2 (SD = 39.85; 95% CI 85.23-97.23) at the pre-training assessment. After the training the mean decreased to 82.5 (SD = 31.04; 95% CI 77.86-87.20). This difference was statistically significant (N = 172; ∆ = - 8.70; SE = 3.85; t = -2.26; p < 0.05). Higher scores in the SBIRT knowledge test correlated positively with larger rates of reduction of alcohol positive expectancies as measured by IECPA at the post-training assessment (r = 0.215; p < 0.005; N = 185). These changes are illustrated in Figure 2. When using the HPSQ to evaluate the proportion of PHC professionals who declared themselves as “prepared” to perform counseling before and after training, a significant difference was found. At the PHASE 2 - N = 473 (14 Cities) Figure 1. Cumulative number of primary health care professionals trained by PAI-PAD. Jan. -06 Sept. -06 Jan. -07 July -07 Jan. -08 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 March -08 545

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