Stepwise, Tailored Implementation of Brief Alcohol Intervention for Risky Drinkers in Health Care

Abstract

Suomen liityttyä jäseneksi Euroopan Unioniin alkoholin verohelpotukset loivat uhkakuvan terveydenhuoltoon alkoholin lisääntyvästä käytöstä ja sen mukanaan tuomista haitoista. Haittoja ehkäisemään on kehitetty varhaisen puuttumisen hoitomuoto, mini-interventio, joka on todettu vaikutuksiltaan tehokkaaksi ja kustannustehokkaaksi. Mini-intervention tarkoituksena on tunnistaa alkoholin suurkulutus, antaa tietoa liiallisen alkoholin käytön terveyshaitoista ja ohjata alkoholin käyttöä maltillisempaan suuntaan, alle riskirajojen. Mini-intervention on todettu olevan terveydenhuollon rutiinikäyttöön sopiva hoitomuoto, se on helppo omaksua eikä vaadi paljon aikaa.

Lupaavista tutkimustuloksista huolimatta mini-intervention käyttö on ollut vähäistä. Tämän tutkimuksen tarkoitus oli selvittää mini-intervention jalkauttamista osaksi terveydenhuollon tavanomaista toimintaa.

Tutkimukseen liittyvä pohjakartoitus, jossa selvitettiin päihdeongelmien laajuutta terveydenhuollossa, tehtiin Tampereen yliopistollisessa sairaalassa. Terveydenhuollon henkilökunnan koulutuksen ja mini-interventiotoiminnan mahdollisimman hyvän käyttöönoton optimoimiseksi tehtiin Pirkanmaan sairaanhoitopiirissä kartoituskysely henkilökunnalle. Saadun tiedon perusteella organisointiin sairaanhoitopiirin alueelle toimintatutkimus mini-interventiotoiminnan saattamiseksi käytännön työvälineeksi. Tästä saadun palautteen, kahden myöhemmin järjestetyn kyselytutkimuksen ja videoitujen fokusryhmähaastatteluiden perusteella tehtiin mahdollisimman yksinkertainen ohje mini-interventioaktiivisuuden lisäämiseksi.

Uusien toimintojen käyttöönotto terveydenhuollossa on hidasta ja vastaan tulee erilaisia esteitä. Terveydenhuoltohenkilöstön tarpeet ja heidän ymmärryksensä uusien asioiden tärkeydestä ovat ensiarvoisen tärkeitä otettaessa uusia toimintamalleja käyttöön. Kyseinen tutkimus osoitti alkoholin ongelmakäyttäjien suuren määrän terveydenhuollossa.

Tutkimuksen suurin hyöty oli luoda pohja mini-intervention käytön laajentumiselle ja kehittämiselle Suomessa. Pirkanmaan sairaanhoitopiirissä alkanut projekti on levinnyt nyt koko maahan.

Vaikka alkoholin käytön seulonta ja varhainen puuttuminen hoitomuotona ovat juurtuneet odotettua hitaammin jokapäiväisiksi toiminnoiksi terveydenhuoltoon, ovat henkilöstön asenteet muuttuneet edellä mainittuja toimintoja kohtaan positiivisemmiksi. Toisaalta kansalaisten suhtautuminen vallitsevaan alkoholipolitiikkaan on muuttunut tiukemmaksi. Kaikki edellä mainittu suosii mini-interventiotoiminnan laajentamista ja tämän kustannustehokkaan hoitomuodon käytön lisäämistä, kohteena alkoholin varhaisen vaiheen riskikäyttäjät.

This study was initiated after Finland had joined the EU and the intended alcohol tax reductions caused concern both generally and willing health care. Several studies had shown that brief alcohol interventions are useful and cost-effective, and be considered feasible as part of health care professionals´ daily work as, as little time is required and the skills needed, and can be easily learned. In spite of the scientific evidence, however implementation of brief intervention activity has been slow. The objective here was to assess means of implementing this new activity, alcohol screening and brief intervention for early-phase heavy drinkers, in different health care settings in a wide geographic area in Finland.

In order to motivate health care professionals to acknowledge the importance of this patient group, prevalence data were first collected (I). Six-year diagnoses in retrospective discharge data in Tampere University Hospital were compared with prospective data gathered from separately completed forms added to every outpatient´s discharge papers during an 8-week period. In the retrospective study (1988?1993) the prevalence of substance use-related diagnoses was 0.4% of all recorded diagnoses. In the prospective study (eight weeks in 1994) the corresponding figure was 1.1%. The percentage of substance use-related visits, not necessarily producing a diagnosis was even higher, 5.6%, being highest in the emergency setting (12.5%) and in psychiatry (6%).

To optimize training and implementation strategies health care professionals were interviewed (II). Altogether 473 questionnaires, comprising 40 questions, each with two to six alternatives, were mailed to 139 units in the Pirkanmaa Health Care District, i.e. all primary and occupational health care units and each department in specialized health care in hospitals. Health care professionals´ attitudes, knowledge and skills were asked and analysed in relation to alcohol-related matters. Altogether 59% of health care professionals in primary, occupational and specialized health care were positive in the matter of asking patients´ alcohol consumption and 68% could bring up alcohol problems for discussion. Nonetheless only 18% of respondents found it fully acceptable to discuss patients´ alcohol consumption, and only 19% believed that they could influence patients´ drinking very or quite well. Respondents´ own alcohol consumption did not correlate with attitudes, knowledge or skills. They also thought that patients´ attitudes towards inquiry into alcohol consumption were positive (II).

Based on observed needs (II), information from the field (I, II), and earlier scientific evidence on implementation, practical education and implementation were organized (III). The key issues in this action research project were engaging leaders, keeping training short, affecting attitudes and acting on feedback. Leaders had separate half-day sessions and other professionals had five half-day seminars with the same content in different parts of the region. The aim was to reach at least one nurse and one physician from every municipality. Participants came from 26/34 municipalities, altogether 50 physicians and 117 nurses. It was hoped that this key group would deliver information in their own centers. They were also provided with all the material used in session. To respond to the need from the field a practical video, two posters and an AUDIT (Alcohol Use Disorders Identification Test) booze quiz leaflet were produced.

To activate the public to assess about their alcohol consumption and ask for help, if needed the AUDIT pamphlet was delivered to every household (90 000) in Tampere as part of the Booze Weeks action project (IV). Using the Telephone Interview system questionnaire data from 500 randomly selected inhabitants were collected. This material included twenty-two questions covering respondents´ own alcohol consumption and questions on their awareness of the AUDIT pamphlet and the Booze Weeks and whether this had any effect on their alcohol use. Those who drank most frequently were also most likely to have noticed the Booze Weeks campaign and felt most concern about their drinking.

To facilitate activity in the field the final brief intervention instructions were drawn up(V). These were based on feedback from the whole action research project (III), on two questionnaires, one for health care professionals and one for patients, and on six video-taped focus groups including primary health care professionals. Qualitative analysis of this information led to a "mini-model" formulating the least that should be done for early-phase heavy drinkers in health care.

Implementation of a new activity in health care is slow and fraught with obstacles. Awareness of the needs of professionals and their perception of the importance of the activity are crucial for implementation. The present study brought on the high prevalence of cases of heavy drinking in health care. It evaluated the views of professionals and public with an eye to implementing brief interventions and used feedback to create the final instructions for action. The main contribution of the present study was in laying a basis for future development in Finland and worldwide. It activated a new study which became part of and gave content to the WHO Phase IV project, "WHO Collaborative Project on Detection and Management of Alcohol-related Problems in Primary Health Care". This was subsequently followed by a nationwide Finnish project supported by the Government. Since the present project work to prevent alcohol-related harm in health care has expanded from the Pirkanmaa hospital region to national level. Even if alcohol screening and brief intervention have been slower than hoped in becoming part of health care professionals´ daily work, their attitudes have gradually become more favourable. Also public opinions on alcohol policy have become stricter. These developments have served to facilitate the continuation and expansion this cost-effective activity to manage the growing patient group of hazardous drinkers.