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 Knowledge Test Scores 6 5 4 3 2 1 0 PRE PO ST Alcohol Positive Expectancies – IECPA Knowledge Test Score IECPA Scores Figure 2. SBIRT knowledge scores and alcohol expectancies before and after SBIRT training. pre-training assessment 60.1% felt pre- pared to perform counseling while at the post-training assessment this proportion increased to 89.1% (N pre = 286; N post = 64; ∆ = 29.00%; χ² = 18.18; p < 0.0001). Physicians showed the highest increment in positive scores for the question about “feel prepared to counsel”. Comparing physicians and nurses with community health agents and nurse helpers, we found a statistically significant difference in the ratings of being prepared to counsel patients (U = 1791; P < 0,05). Regarding the post-training assessment of the 4-level ALS-CT autonomy measure of the trained PHC teams, the mean score was 2.52 (N = 21 clinics; SD = 0.87; 95% CI 2.13-2.92). Three PHC teams comprising 14.3% of the group (3/21) scored at the highest autonomy level, another 33.3% (7/21) at the high level, 42.9% (9/21) scored at the low level and other 9.5% (2/21) at the lowest autonomy level. The PHC teams classified as high or low autonomy level were found to be distinctively different regarding the average scores on the agreement scale for the question “no 546 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6 92 90 88 86 84 82 80 78 information is provided for the referral of individuals identified as alcohol abusers”. The high autonomy group showed the lowest scores (N = 10; μ = 1.88; N low low high = 8; μ = 1.40; ∆ = - 0.48; SE = 0.15; t = high -3.19; p = 0.006). � Differences between Municipalities As noted above, 14 different municipalities were represented in this sample. The administrative region of Ribeirão Preto comprises 25 municipalities (1,162,794 inhabitants). Thus, the SBIRT training reached 56% (14/25) of the municipalities of the region, which represents 74.5% (866,001 inhabitants) of the region’s entire population. The majority of the health professionals (50.9%; 393/772) came from Ribeirão Preto, which is the largest city of the region and its capital with approximately 560,000 inhabitants. Despite the large amount of trained health professionals in this sample, the training in Ribeirão Preto reached only 10.2% of the PHC professionals. A small town like Sta. Cruz da Esperança contributed only 1.7% (13/772) to the training sample, but this small group of PHC professionals represents 40% of the total working in the public health system of that town. In order to examine the influence of the city population size on the implementation of training among PHC professionals, the average population size was compared between the cities with up to 15% of trained PHC professionals and the cities with a larger proportion. In this analysis the city of Ribeirão Preto was excluded from the list because it was too large and thus was considered an outlier. The difference was found to be statistically sig-

nificant (t = 10.04; p < 0.001; ∆ = 0.20; SE = 0.02; CI 95%: 0.16-0.25). It was easier to reach a larger proportion of the population in the smaller than the larger cities. In small cities the ability to reach stakeholders and form an alliance is easier than in larger cities, making it easier to sustain the program. With respect to the number of clinics enrolled in the implementation program, this sample represents a total of 104 PHC clinics (Basic Care units, Family Health teams, Community Health programs), with seven to eight PHC professionals per clinic on average. � Qualitative Assessment Regarding the qualitative assessments obtained by means of the focus groups, the major findings were related to perceived changes in the conceptualization of problematic alcohol use. PHC professionals provided statements suggesting they had moved beyond a stereotyped view of the alcoholic patient and had gained a more nuanced perception of their patients because of the “risk zones” provided by the AUDIT score. They also gave evidence of changing their somewhat moralistic view about the etiology of alcohol problems, adopting more of a disease model. Focus group participants reported that before the training they would not have thought that a person with a job and a family could have any problems related to drinking. After the training, having learnt that there are risks other than dependence, they emphasized the importance of asking about alcohol consumption. “Before this training we thought that an alcoholic person was the kind of person that is on the floor. You know, we didn’t 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 imagine that the person that drinks one or two cans (of beer) in a day or every day, during the week, we didn’t know that… (we thought) this person is not an alcoholic, he just drinks a can of beer today, tomorrow another one, understand? So, it is interesting because you can look at it differently, you can separate better, “this one is at risk”. So, we had the idea that the alcoholic was the one that had fallen on the floor. Now the look is very different. We manage to look at the people more carefully and see what risk they are carrying.” They also admitted changing their somewhat moralistic views about alcohol etiology and adopted a disease model. Before the training they reported having an idea that the person with alcohol dependence did not have good moral values, but after the training they started to see them as people with a disorder. “I never thought that a person who drinks, that is an alcoholic, for example, that he was sick, (I thought) he was an immoral person who liked to drink. But then I started to realize that it is not like that.” Concerning their perceptions of competence in performing SBIRT, they felt more confident as well as competent in conducting screening and brief interventions. They reported that before the training they did not know how to advise patients about risky alcohol consumption. The training provided them with information about low risk drinking, the consequences of problematic alcohol use, how to screen for alcohol problems, the different risk zones, and the importance of establishing a goal and doing a follow up. “I think we changed a bit our way of listening? ‘Do you use alcoholic bever- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 547

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