Attitudes and Learning through Practice Are Key to Delivering Brief Interventions for Heavy Drinking in Primary Health Care: Analyses from the ODHIN Five Country Cluster Randomized Factorial Trial

Can the presence of specialized addiction staff in primary health care increase the number of alcohol-related medical consultations - A controlled intervention study

Background

Few individuals with alcohol use disorders receive treatment. Primary care has been suggested as an arena for early treatment for these disorders.

Aim

To evaluate whether the presence of a specialized addiction nurse can increase alcohol-related physician consultations in a primary care setting.

Method

This controlled intervention study included one intervention and one control primary care unit in Malmö, Sweden. At the intervention unit, an addiction nurse experienced in alcohol use disorder treatment was present 20 h weekly for 12 months. At both units, an educational lecture on alcohol use disorders was given at study start. The outcome was physicians' monthly number of alcohol-related diagnostic codes. Data were compared between intervention and control units using Poisson Regression. Eight statistical models were analyzed and Akaike information criterion was used to select the final model.

Results

The intervention was significantly associated with an increased number of registered alcohol-related diagnostic codes (risk ratio 1.33, 95 confidence interval 1.08-1.62). However, in sensitivity analyses, such a slope effect was more uncertain and no step effect was seen. A significant association was seen between the educational lecture and an increase in the number of registered alcohol-related codes at the sites (risk ratio 2.47, 1.37-4.46).

Conclusion

The presence of specialized addiction staff in a primary healthcare setting might increase the number of alcohol-related physician consultations in primary care, although more research is needed. An educational lecture about alcohol use disorders could be a simple but effective intervention to increase alcohol-related physician consultations in primary care.

Exploring Lithuanian social workers' attitudes towards individuals with alcohol usage problems

Aim: Social workers are at the front line of helping individuals experiencing alcohol usage, due to their professional duties, ideology and values that underpin it. In Lithuania, where social work still continues to develop in both practice and education, it is crucial to supplement with relevant information to strengthen social work's response to issues with alcohol usage. Therefore, the aim of this study was to explore social workers' attitudes towards individuals with alcohol usage problems. Methods: In total, 149 Lithuanian social workers completed a web survey that gathered information about education, work experience and workplace, and filled in the Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ) to measure their attitude towards individuals with alcohol usage problems. Results: The social workers showed a positive attitude towards individuals with alcohol usage problems (mean 35.81 [SD 4.8]). Attitude domain analysis revealed Role Legitimacy (91.3% above the midpoint) to reflect the most positive attitudes and Work Satisfaction (24.2% above the midpoint) to reflect the least positive attitudes. Those with master's degrees scored higher on the total SAAPPQ (t = -2.44, p = 0.016) and its subscales Work Satisfaction (t = -2.52, p = 0.013) and Therapeutic Commitment (t = -2.21, p = 0.029). Having 6-13 years of work experience (mean SAAPPQ = 37.02 [SD 5.11]) was associated with a more positive attitude compared to those with less than 5 years of experience (mean SAAPPQ = 34.08 [SD 3.87]). Conclusion: Although social workers understand their professional responsibility to work with individuals with alcohol usage problems, their dedication to work, motivation and task-specific self-esteem are low. The results also support education, as those with master's degrees showed more positive attitudes. This study further encourages support for social workers just beginning their career, who might report lower attitudes towards individuals with alcohol usage problems.

Development of community strategies supporting brief alcohol advice in three Latin American countries: a protocol

Brief alcohol advice offered to patients was shown to be a clinically- and cost-effective intervention to prevent and manage alcohol-related health harm. However, this intervention is not yet optimally implemented in practice. A suggested strategy to improve the implementation of brief alcohol advice is through community actions which would enhance the environment in which primary healthcare providers must deliver the intervention. However, there has been scarce research conducted to date regarding which community actions have most influence on the adoption and implementation of brief alcohol advice. The current protocol presents the development of a package of community actions to be implemented in three Latin American municipalities, in Colombia, Mexico and Peru. The community actions were based on the Institute for Health Care Improvement's framework for going to full scale, and include: (i) involvement of a Community Advisory Board, (ii) involvement of a project champion, (iii) adoption mechanisms, (iv) support systems and (v) a communication campaign. By presenting a protocol for developing community actions with input from local stakeholders, this article contributes to advancing the public health field of alcohol prevention by potentially stimulating the sustainable adoption and implementation of brief alcohol advice in routine practice.

Is clinicians' alcohol consumption associated with their preventive practices to reduce unhealthy alcohol use? A systematic review of current evidence

Clinicians' risk behaviors, including their personal alcohol use, may influence patients' attitudes and motivation to make changes in their lifestyle, as well as the provision of clinical preventive services to reduce unhealthy behaviors. The aim of the systematic review was to summarize the existing evidence on the association between clinicians' alcohol consumption and their preventive practices to reduce unhealthy alcohol use. The review was conducted following Cochrane guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidance. Three databases (Cochrane, MEDLINE, Web of Science) were queried from July 1, 2021, through November 30, 2021. We included quantitative observational studies reporting clinicians' alcohol use associations with relevant preventive practices. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of selected studies. Ten studies, published from 1986 to 2018, were included. We found a statistically significant association between clinicians' alcohol consumption and their preventive practices to reduce unhealthy alcohol use in eight of the 10 studies. Clinicians who drank larger quantities of alcohol offered less screening and counseling to their patients about alcohol use. Clinicians who drank regularly (3 days a week or more) were less likely to screen for alcohol use, and the frequency of alcohol use by those professionals was inversely related to recommending quitting. Clinicians' alcohol use appears to be associated with their screening for unhealthy alcohol use and counseling to reduce it. The frequency and quantity of clinicians' alcohol consumption were also associated with their practices to address unhealthy alcohol use.

Danish feasibility study of a new innovation for treating alcohol disorders in primary care: the 15-method

BACKGROUND

The 15-method: a new brief intervention tool for alcohol problems in primary care has shown promising results in Sweden for mild to moderate alcohol use disorders. The present study evaluated the 15-method's usability, organizational integration, and overall implementation feasibility in Danish general practice in preparation for a large-scale evaluation of the method's effectiveness in identifying and treating alcohol problems in general practice.

METHODS

Five general practices in the Central and Southern Region of Denmark participated: seven general practitioners (GPs), eight nurses. Participants received a half day of training in the 15-method. Testing of implementation strategies and overall applicability ran for 2 months. A focus group interview and two individual interviews with participating GPs along with five individual patient interviews concluded the study period.

RESULTS

Results indicate that implementation of the 15-method is feasible in Danish general practice. The healthcare professionals and patients were positive about the method and its possibilities. The method was considered a new patient centered treatment offer and provided structure to a challenging topic. An interdisciplinary approach was much welcomed. Results indicate that the method is ready for large scale evaluation.

CONCLUSIONS

Implementation of the 15-method is considered feasible in Danish general practice and large-scale evaluation is currently being planned.

Effect of Community Support on the Implementation of Primary Health Care-Based Measurement of Alcohol Consumption

Alcohol measurement delivered by health care providers in primary health care settings is an efficacious and cost-effective intervention to reduce alcohol consumption among patients. However, this intervention is not yet routinely implemented in practice. Community support has been recommended as a strategy to stimulate the delivery of alcohol measurement by health care providers, yet evidence on the effectiveness of community support in this regard is scarce. The current study used a pre-post quasi-experimental design in order to investigate the effect of community support in three Latin American municipalities in Colombia, Mexico, and Peru on health care providers' rates of measuring alcohol consumption in their patients. The analysis is based on the first 5 months of implementation. Moreover, the study explored possible mechanisms underlying the effects of community support, through health care providers' awareness of support, as well as their attitudes, subjective norms, self-efficacy, and subsequent intention toward delivering the intervention. An ANOVA test indicated that community support had a significant effect on health care providers' rates of measuring alcohol consumption in their patients (F (1, 259) = 4.56, p = 0.034, ηp2 = 0.018). Moreover, a path analysis showed that community support had a significant indirect positive effect on providers' self-efficacy to deliver the intervention (b = 0.07, p = 0.008), which was mediated through awareness of support. Specifically, provision of community support resulted in a higher awareness of support among health care providers (b = 0.31, p < 0.001), which then led to higher self-efficacy to deliver brief alcohol advice (b = 0.23, p = 0.010). Results indicate that adoption of an alcohol measurement intervention by health care providers may be aided by community support, by directly impacting the rates of alcohol measurement sessions, and by increasing providers' self-efficacy to deliver this intervention, through increased awareness of support. Trial Registration ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599.

Factors affecting primary care practitioners' alcohol-related discussions with older adults: a qualitative study

BACKGROUND

Risk of harm from drinking is heightened in later life, owing to age-related sensitivities to alcohol. Primary care services have a key role in supporting older people (aged ≥50 years) to make healthier decisions about alcohol.

AIM

To examine primary care practitioners' perceptions of factors that promote and challenge their work to support older people in alcohol risk-reduction.

DESIGN AND SETTING

Qualitative study consisting of semi-structured interviews and focus groups with primary care practitioners in Northern England.

METHOD

Thirty-five practitioners (GPs, practice/district nurses, pharmacists, dentists, social care practitioners, and domiciliary carers) participated in eight interviews and five focus groups. Data were analysed thematically, applying principles of constant comparison.

RESULTS

Practitioners highlighted particular sensitivities to discussing alcohol among older people, and reservations about older people's resistance to making changes in old age; given that drinking practices could be established, and promote socialisation and emotional wellbeing in later life. Age-related health issues increased older people's contact with practitioners, but management of older people's long-term conditions was prioritised over discussion of alcohol. Dedicated time to address alcohol in routine consultations with older people and training in alcohol intervention facilitated practitioners, particularly pharmacists and practice nurses.

CONCLUSION

There are clear opportunities to support older people in primary care to make healthier decisions about alcohol. Dedicated time to address alcohol, training in identification of alcohol-related risks (particularly those associated with old age), and tailored interventions for older people, feasible to implement in practice settings, would help primary care practitioners to address older people's alcohol use.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America

INTRODUCTION

Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare.

MATERIALS AND METHODS

Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status.

RESULTS

550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained.

CONCLUSIONS

Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Factors associated with primary health care providers' alcohol screening behavior in Colombia, Mexico and Peru

Background: Screening for unhealthy alcohol use in routine consultations can aid primary health care (PHC) providers in detecting patients with hazardous or harmful consumption and providing them with appropriate care. As part of larger trial testing strategies to improve implementation of alcohol screening in PHC, this study investigated the motivational (role security, therapeutic commitment, self-efficacy) and organizational context (leadership, work culture, resources, monitoring, community engagement) factors that were associated with the proportion of adult patients screened with AUDIT-C by PHC providers in Colombia, Mexico and Peru. Additionally, the study investigated whether the effect of the factors interacted with implementation strategies and the country. Methods: Pen-and-paper questionnaires were completed by 386 providers at the start of their study participation (79% female, M_age = 39.5, 37.6% doctors, 15.0% nurses, 9.6% psychologists, 37.8% other professional roles). They were allocated to one of four intervention arms: control group; short training only; short training in presence of municipal support; and standard (long) training in presence of municipal support. Providers documented their screening practice during the five-month implementation period. Data were collected between April 2019 and March 2020. Results: Negative binomial regression analysis found an inverse relationship of role security with the proportion of screened patients. Self-efficacy was associated with an increase in the proportion of screened patients only amongst Mexican providers. Support from leadership (formal leader in organization) was the only significant organizational context factor, but only in non-control arms. Conclusion: Higher self-efficacy is a relevant factor in settings where screening practice is already ongoing. Leadership support can enhance effects of implementation strategies.

Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation: the 15-method

OBJECTIVE

This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.

METHODS/DESIGN/SETTING/SUBJECT

General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory.

RESULTS

The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects.

CONCLUSIONS

The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.KEY POINTSLittle attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings.This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach.Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.

Training health providers to address unhealthy alcohol use in primary care: a cross-sectional, multicenter study

BACKGROUND

Health professionals' training is a key element to address unhealthy alcohol use in Primary Care (PC). Education about alcohol use can be effective in improving PC provider's knowledge and skills addressing alcohol-related problems. The aim of the study was to evaluate the training of health professionals to address unhealthy alcohol use in PC.

METHODS

An observational, descriptive, cross-sectional, multicenter study was performed.

LOCATION

PC centres of the Spanish National Health System (SNHS).

PARTICIPANTS

Family physicians, residents and nurses completed an online questionnaire that inquired about their training (none, basic, medium or advanced), knowledge and preventive practices aimed at reducing unhealthy alcohol use. The study population was recruited via random sampling, stratified by the regions of the SNHS's PC centre, and by email invitation to members of two Spanish scientific societies of Family Medicine.

RESULTS

A total of 1760 professionals participated in the study. Sixty-seven percent (95% CI: 67.5-71.8) reported not having received specific training to address unhealthy alcohol use, 30% (95% CI: 27.4-31.7) reported having received basic training, and 3% (95% CI: 2.3-4.0) medium/advanced training. The training received was greater in younger providers (p < 0.001) who participated in the PAPPS (Preventive Activities and Health Promotion Programme) (p < 0.001). Higher percentages of providers with intermediate or advanced training reported performing screening for unhealthy alcohol use (p < 0.001), clinical assessment of alcohol consumption (p < 0.001), counselling of patients to reduce their alcohol intake (p < 0.001) or to abstain, in the cases of pregnant women and drivers (p < 0.001).

CONCLUSION

Our study reveals a low level of training among Spanish PC providers to address unhealthy alcohol use. A higher percentage of screening, clinical assessment and counselling interventions aimed at reducing unhealthy alcohol use was reported by health professionals with an intermediate or advanced level of training.

Structure and longitudinal invariance of the Short Alcohol and Alcohol Problems Perception Questionnaire

Many studies have employed the Short Alcohol Attitudes Problem Perception Questionnaire (SAAPPQ) to measure professionals' attitudes toward working with people experiencing alcohol problems. However, research has not confirmed the internal structure of the SAAPPQ, leaving open the possibility that scale scores are not valid empirical proxies for underlying attitudes. It is also unclear if measurement invariance holds over time or across groups. This is an important gap in light of evidence that (a) experiences can change the structure of scales and (b) structures of some popular scales differ dramatically between groups. Thus, measurement bias may confound comparisons of composite SAAPPQ scores between measurement occasions or groups. To address these gaps in the literature, we conducted a longitudinal examination of the psychometrics of the SAAPPQ using data from 241 human services professionals-in-training. We found a four-factor structure, rather than the previously reported five factors. Configural, metric, and a strong degree of scalar invariance held longitudinally. Few factor intercorrelations were significant at time one and they strengthened over time, suggesting that the SAAPPQ should not be aggregated at higher-order levels (i.e., global scores should not be used). Findings suggest four SAAPPQ subscale scores may be used as valid proxies for attitudes toward alcohol users; however, additional confirmatory studies are needed to ensure that measurement bias does not compromise inferences based on SAAPPQ scores.

[Effectiveness of training programs on alcohol consumption in the Primary Care setting: Systematic review]

OBJECTIVE

To evaluate the effectiveness of training activities directed at Primary Health Care personnel on the management of patients with alcohol consumption problems.

DESIGN

A systematic review of randomised controlled trials.

DATA SOURCES

Trip Database, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, EMBASE, CINAHL, Web of Science, Scopus, Alcohol and Alcohol Problems Science Database - ETOH and FAMILY RESOURCES DATABASE. The search was performed in June 2017.

STUDY SELECTION

The final sample was n=3 studies. Randomised controlled trials, indexed until 30 May 2017, with the objective of assessing the effectiveness of training programs directed at Primary Care providers in the management of patients with alcohol abuse disorder were included.

DATA EXTRACTION

The main variables were expressed in terms of effectiveness of the training program: level of global implementation, screening of alcohol consumption, intervention in patients with a consumption risk, and level of support required.

RESULTS

Three Randomised controlled trials, published from 1999 to 2004, were included. Both screening and short intervention techniques showed an increase of its application in the three studies after the development of the three training programs. Statistical significance in terms of effectiveness was achieved in 2 of the 3 selected trials: both in detection of risk consumers, and in short intervention.

CONCLUSION

The development of training programs in the management of patients with alcohol abuse disorder is an effective strategy for Primary Care providers, allowing the implementation of population screening, as well as the application of intervention techniques.

Impact of a primary care training program on the prevention and management of unhealthy alcohol use: A quasi-experimental study

OBJECTIVE

To assess the impact of a training program targeted to Primary Care (PC) professionalson the acquisition of communication skills, attitudes, and knowledge about the prevention and management of unhealthy alcohol use.

METHODS

A quasi-experimental, pre- and post-intervention study was performed in PC centers of Cordoba (Spain). Family doctors, residents and nurses participated in the study. The intervention was based on a motivational interviewing training program, which consisted in a workshop on learning skills, attitudes and knowledge about the alcohol management. PC providers were videotaped with a standardized patient in order to check the clinical and communication competencies acquired. A descriptive, bivariate and multivariate analysis was carried out (p < 0.05).

RESULTS

PC providers' communication skills and attitudes showed significant improvements in the variables studied (p < 0.001), as well as in the clinical interview evaluation parameters.

CONCLUSION

The present study reveals the impact of a training program targeted to PC professionals on communication skills, attitudes, and knowledge about the prevention and management of patients with unhealthy alcohol use.

PRACTICE IMPLICATIONS

Training activities targeted to PC providers represent a valuable strategy to improve communication skills, attitudes and knowledge of these professionals in their clinical practice.

Are German family practitioners and psychiatrists sufficiently trained to diagnose and treat patients with alcohol problems?

Background

Harmful alcohol consumption in Germany is a serious public health problem: About 7.7 million adults in Germany can be classified as risky alcohol consumers, about 74,000 deaths per year are related to alcohol consumption, and about 1.8 million adults in Germany (18–64 years) are classified as alcohol dependent. A treatment rate of 9% of all alcohol dependent patients in Germany implies a lack of supply and misuse of medical care. The aim of the study was to examine whether family practitioners (FPs) and psychiatrists have sufficient skills to diagnose and treat patients with alcohol problems.

Methods

A total of 6324 FPs and psychiatrists in the states of Saxony and Rhineland-Palatinate in Germany were invited to participate in this survey. Nine hundred seventy-four participants (90.3%/FPs) could be included in the statistical analysis (response rate: 14.3%/FPs, 21.6%/psychiatrists). Data was analysed descriptively and logistical regressions were used to identify predictors for physicians’ ability to feel adequately trained to diagnose and treat patients with alcohol problems.

Results

In comparison to psychiatrists, less FPs reported feeling sufficiently trained to counsel patients with alcohol problems (81.5% vs. 44.8%). Regression analysis revealed that FPs who felt not adequately trained had less experience with patients with alcohol dependence (OR 7.4), had attended fewer hours on alcohol addiction in continuing medical education (OR 4.8), and were more likely to be female (OR 1.9). A minimum of 10 h of training was associated with improved self-assessed competence.

Conclusion

Harmful drinking is a serious public health problem, and patients with alcohol dependence represent a large and demanding patient group in primary health care setting. Our study shows that the lack of training is a severe barrier in the work with this patient group in the primary care setting.

Knowledge, attitudes and preventive practices of primary health care professionals towards alcohol use: A national, cross-sectional study

INTRODUCTION

Primary care (PC) professionals' knowledge about alcohol use has been identified as one of the barriers PC providers face in their clinic. Both PC professionals' level of training and attitude are crucial in the clinical practice regarding alcohol use.

OBJECTIVE

To evaluate the knowledge, attitude, and preventive practices of Spanish PC physicians and nurses towards alcohol use.

DESIGN

An observational, descriptive, cross-sectional, multi-center study.

METHODOLOGY

Location: PC centers of the Spanish National Health System (NHS). Participants: PC physicians and nurses selected randomly from health care centers, and by sending an e-mail to semFYC and SEMERGEN members. Healthcare providers completed an online survey on knowledge, attitude, and follow-up recommendations for reducing alcohol intake. A descriptive, bivariate, and multivariate statistical analysis was conducted (p<0.05).

RESULTS

Participants: 1,760 healthcare providers completed the survey (75.6% [95% CI 73.5-77.6] family physicians; 11.4% [95% CI 9.9-12.9] medical residents; and 12.5% [95% CI 10.9-14.1] nurses), with a mean age of 44.7 (SD 11.24, range: 26-64, 95% CI: 47.2-48.2). Knowledge was higher in family physicians (p<0.001), older professionals (Spearman's r = 0.11, p<0.001), and resident trainers (p<0.001). The PC professional most likely to provide advice for reducing alcohol use was: a nurse (p <0.001), female (p = 0.010), between 46 and 55 years old (p <0.001).

CONCLUSIONS

PC providers' knowledge and preventive practices regarding alcohol use are scarce, hence specific training strategies to increase their knowledge and improve their attitude and skills with regard to this health problem should be considered a healthcare policy priority.

Moderation of alcohol consumption as a recommendation in European hypertension management guidelines: a survey on awareness, screening and implementation among European physicians

OBJECTIVES

Moderation of alcohol consumption is included as a class I, level of evidence A recommendation in the current European guidelines for the management of hypertension. We investigated its awareness and self-reported implementation among European physicians across different specialties and workplaces.

DESIGN AND SETTING

A cross-sectional survey study conducted in two annual German meetings (German Society of Cardiology and the German Society of Internal Medicine) and two annual European meetings (European Society of Hypertension and European Society Cardiology) in 2015.

PARTICIPANTS

1064 physicians attending the European meetings were interviewed including 52.1% cardiologists, 29.2% internists and 8.8% general practitioners.

MAIN OUTCOME MEASURES

Physician screening of alcohol consumption, awareness and self-implementation of the recommendation of the current European guidelines about moderation of alcohol consumption for the management of hypertension.

RESULTS

Overall, 81.9% of physicians reported to generally quantify alcohol consumption in patients with hypertension. However, only 28.6% and 14.5% of participants reported screening alcohol consumption in their patients with newly detected or treatment-resistant hypertension. Physicians recommended a maximum alcohol intake of 13.1±11.7 g/day for women (95% CI 12.3 to 13.8) and 19.9±15.6 g/day for men (95% CI 18.8 to 20.9). In case of moderate to high alcohol consumption, 10.3% would manage only hypertension without addressing alcohol consumption, while 3.7% of the physicians would do so in case of alcohol dependence (p<0.001).

CONCLUSIONS

The average amount of alcohol intake per day recommended by European physicians in this survey was in agreement with the guidelines. The low number of physicians that screen for alcohol consumption in patients with newly detected and with treatment-resistant hypertension indicates an important deficit in the management of hypertension.

Barriers to implement screening for alcohol consumption in Spanish hypertensive patients

BACKGROUND

Alcohol intake and hypertension (HT) are interrelated public health problems with cost-effective interventions at the primary care level that, to date, are poorly implemented.

OBJECTIVE

This study aims to explore the barriers to implementing alcohol interventions for people with HT in primary care.

METHODS

As part of the project BASIS (Baseline Alcohol Screening and Intervention Survey), an internet survey from five European countries was developed to determine the role of alcohol in the management of HT in primary care practice. The survey contained 28 core items and 7 country-specific items. We present answers from Spanish general practitioners (GPs), who were reached through the main professional and scientific societies via e-mail and asked to take the online survey.

RESULTS

In total, 867 GPs answered the survey (65.1% women, 70.4% > 30 years old). As indicated by the Alcohol Use Disorders Identification Test-C scores, 12.4% of GPs who responded were risky drinkers (21.3% of men versus 7.1% of women). GPs reported considering alcohol relatively unimportant in HT treatment, as well as a difficult condition to deal with. The three main barriers to implement screening for alcohol consumption in HT patients were the lack of time (50.0%), considering alcohol unimportant for HT (28.4%) and stigma (16.5%).

CONCLUSIONS

GPs did not consider alcohol consumption a relevant factor for HT and, additionally, found it difficult to deal with alcohol problems. Some of the barriers for alcohol screening could be overcome through structural changes in the health system, such as empowering GPs to treat alcohol use disorders (rather than a single focus on implementing preventive strategies) by enhancing training in alcohol diagnosis and treatment.

Are Brief Alcohol Interventions Adequately Embedded in UK Primary Care? A Qualitative Study Utilising Normalisation Process Theory

Despite substantial evidence for their effectiveness, the adoption of alcohol screening and brief interventions (ASBI) in routine primary care remains inconsistent. Financial incentive schemes were introduced in England between 2008 and 2015 to encourage their delivery. We used Normalisation Process Theory-informed interviews to understand the barriers and facilitators experienced by 14 general practitioners (GPs) as they implemented ASBI during this period. We found multiple factors shaped provision. GPs were broadly cognisant and supportive of preventative alcohol interventions (coherence) but this did not necessarily translate into personal investment in their delivery (cognitive participation). This lack of investment shaped how GPs operationalised such “work” in day-to-day practice (collective action), with ASBI mostly delegated to nurses, and GPs reverting to “business as usual” in their management and treatment of problem drinking (reflexive monitoring). We conclude there has been limited progress towards the goal of an effectively embedded preventative alcohol care pathway in English primary care. Future policy should consider screening strategies that prioritise patients with conditions with a recognised link with excessive alcohol consumption, and which promote more efficient identification of the most problematic drinkers. Improved GP training to build skills and awareness of evidence-based ASBI tools could also help embed best practice over time.

Scaling-up primary health care-based prevention and management of heavy drinking at the municipal level in middle-income countries in Latin America: Background and protocol for a three-country quasi-experimental study

Background: While primary health care (PHC)-based prevention and management of heavy drinking is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support.

Protocol: A quasi-experimental study will compare PHC-based prevention and management of heavy drinking in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors.

Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment.

Study status: The four-year study will start on 1 ^st December 2017.