Anderson

Babor

Cabana

Fleming

Funk

Hart

Heather

Higgins-Biddle

McAvoy

Roche

Saunders

Thom

Whitlock

WHO Brief Intervention Study Group.

English

Heather, Nick

Northumbria University Research Portal

07-0065A LONG-STANDING WHO COLLABORATIVE PROJECT ONEARLY IDENTIFICATION AND BRIEF ALCOHOLINTERVENTION IN PRIMARY HEALTH CARE COMES TO ANENDNICK HEATHER,Technical Focal Point, WHO Phase IV Study,Emeritus Professor of Alcohol & Other Drug Studies,Division of Psychology, Northumbria University,Newcastle upon Tyne, NE1 8ST, UKnick.heather@unn.ac.ukEditorial for Addiction2After 25 years, the WHO Collaborative Project on Detection and Management ofAlcohol-related Problems in Primary Health Care has finally come to an end. Areport on the fourth and final phase of the project, entitled Development ofCountrywide Strategies for Implementing Early Identification and Brief Interventionin Primary Health Care, was recently posted on the WHO web site [1]. Researchcentres from Australia and 11 European countries (Belgium [Flanders], Bulgaria,Denmark, Finland, France, Italy, Russian Federation (North-west Russia], Slovenia,Spain [Catalonia], Switzerland and United Kingdom [England]) took part in the PhaseIV study and each contributed a chapter to the report. The study was coordinated bythe Centre for Alcohol and Drug Studies, Newcastle upon Tyne, UK and aninternational website http://www.who-alcohol-phaseiv.net was managed by the HealthDepartment of the Government of Catalonia in Barcelona.Previous phases of the Collaborative Project were:Phase I (1982-87): a reliable and valid screening instrument for detecting hazardousand harmful drinkers in primary health care (PHC) settings was developed (theAUDIT questionnaire) [2];Phase II (1987-92): a cross-national clinical trial of screening and brief intervention inPHC was carried out [3];Phase III (1993-99): the practices and perceptions of general medical practitioners(GPs) regarding alcohol screening and brief intervention were assessed (Strand 1) [4],in-depth telephone interviews with GPs and personal interviews with key informantswere conducted (Strand 2) [5] and methods for encouraging the uptake and utilisation3of a screening and brief intervention package by GPs were evaluated in a controlledtrial (Strand 3) [6].ORIGINS AND BROAD FEATURES OF THE PHASE IV STUDYFollowing on from previous phases in the Collaborative Project, Phase IVinvestigators agreed to develop and evaluate country-wide strategies for thewidespread, routine and enduring implementation of early identification and briefintervention (EIBI) in the PHC systems of participating countries. Whereas earlierphases had applied a single study design adapted to the situation of each participatingcountry, Phase IV represented a collection of studies that shared the same overallobjective but with the design and procedures adapted to take account of the verydifferent contexts of PHC in the participating countries. However, this flexibility wascontained within clearly defined parameters with all studies sharing four commoncomponents [7]:a) create customized materials and services;b) reframe understandings of alcohol issues;c) establish lead organizations and build strategic alliances;d) establish and evaluate demonstrations.Phase IV was thus a much more practical and policy-oriented group of studies thanseen in previous phases of the WHO Collaborative Project. It was in many ways anexample of action research [8] in which the central aim was to make a significantdifference to the “real world” conditions under which brief interventions aredisseminated in a particular country and to establish a programme of action leading tothe widespread, country-wide implementation of EIBI in PHC. Action research is4especially suited to the goal of filling the gap between research evidence and practice,as in the field of EIBI where impressive research evidence of effectiveness in PHC[e.g., 9] is accompanied by equally firm evidence of a failure to implement EIBI inpractice [e.g., 10]. A further difference from previous phases was that, in terms ofresearch methods, qualitative approaches often assumed equal or greater importancethan quantitative methods in Phase IV.LIMITATIONS AND ACHIEVEMENTS OF PHASE IVDespite its flexible nature across participating countries, a few broad generalisationsregarding the collective experience of the Phase IV study can be made. First, the well-known description in 1987 of the attempt to involve PHC staff in the detection andmanagement of alcohol problems [11] as “a difficult business” was amply confirmed20 years later. This occurred despite the fact that in many cases the principalinvestigators were themselves GPs. This increased the credibility and practicalrelevance of the study but was clearly insufficient to engender the full co-operation ofthose it sought to enlist in action research. Possible reasons for this relativelydisappointing response and possible solutions are discussed in the WHO Report [1].A related problem was lack of support from governmental authorities. With somenotable exceptions among participating countries, this was found at all levels ofgovernment – local, regional and national. A specific facet of this lack of support wasthe difficulty found in persuading authorities to include alcohol EIBI in healthpromotion campaigns and strategies and in plans for the regulation andreimbursement of PHC activity. This probably reflects the long-standing failure bygovernments to recognise the full extent of alcohol-related harm.5An important argument in attempting to persuade governments to support EIBI is thatit leads to tangible economic benefits for society – the claim that the costs ofdelivering EIBI in PHC are more than offset by reductions in costs of the future use ofhealth services. While there is evidence that such cost-offsets do occur, this comesmostly from the USA [e.g., 14] and there is a need for similar demonstrations in otherhealth care systems. While it was recognised that a full and rigorous economicevaluation would be beyond the resources of most participating countries in Phase IV,it was hoped that a start could be made by at least calculating the costs of deliveringEIBI. Unfortunately, these intentions were not fulfilled; with a few exceptions,participating countries were not able to mount an economic study of the kindenvisaged. This should be included in countries’ further plans to gather governmentsupport for EIBI in PHC after the end of the Phase IV study.It was in the customisation component of the study that most progress was made.Using focus groups and Delphi surveys, all participating countries succeeded inmaking adaptations to materials or procedures involved in EIBI implementation –screening instruments and methods of delivery, the intervention package and itsdelivery, the EIBI training programme – to suit the requirements of the local healthsystem and socio-cultural setting.With regard to the reframing component of the study, the concept of hazardousdrinking and its relevance to public health was introduced without much difficulty toa range of PHC professionals and other stakeholders in formal training programmesand in other ways. But while the attempt to reframe understandings of alcohol issues6among health professionals met with much success, this did not extend to the generalpublic. To shift the general public towards a broadened understanding of alcoholproblems, and away from an exclusive focus on “alcoholism”, would presumablyrequire the support and financial backing of central governments.One palpable achievement of the Phase IV study was the establishment in eachparticipating country of a lead organisation for the country-wide implementation ofEIBI that could serve as a base for future developments in this field of work. At thesame time, all these lead organisations succeeded in gathering endorsements from arange of organisations and individuals highly relevant to the aims of the study. Thus,the foundations of a broad movement of support for the widespread, routine andenduring implementation of EIBI in PHC were laid down, as was the originalintention of the study protocol.All Phase IV demonstration projects made some contribution to showing howwidespread implementation could be achieved in the circumstances of the country inquestion but the majority were simple before-after designs. There remains a need forthe more ambitious kind of study originally envisaged by Phase IV investigators butrejected as too expensive for most participating countries. First, we need firmevidence that particular methods of achieving routine implementation are moreeffective than others since this cannot be taken for granted. For instance, there is goodevidence that clinical guidelines alone are insufficient for this purpose [13]. Althoughthey are complex in design and expensive to run, the firm evidence required can onlycome from adequately controlled quasi-experimental studies or cluster RCTs [14].Moreover, we do not have evidence yet that the beneficial public health effects of7routine and widespread implementation of EIBI in PHC can be detected at acommunity level in reduced levels of hazardous alcohol consumption and indices ofalcohol-related harm in the population at large (e.g., morbidity and mortality statistics,drunkenness arrests, drink-driving offences, etc.). Again, such evidence could only beobtained from adequately controlled community-based studies.FUTURE DEVELOPMENTSWithout exception, the work initiated in the Phase IV study will continue in all thecountries taking part and there are encouraging signs that governments around theworld are beginning to realise the potential benefits of widespread EIBI in PHC asone effective means of responding to a rising tide of alcohol problems in theirsocieties. This was partly seen in the Phase IV study in which, towards the end of theresearch, some governments of participating countries began to include alcohol EIBIin national strategies to combat alcohol-related problems.At the same time, the aims of Phase IV have been taken up on a wider internationalstage. As well as the majority of countries taking part in Phase IV, the EU-fundedPrimary Health Care European Project on Alcohol (PHEPA) (15) included 12additional European countries in its first stage (2002-05) and a total of 24 countries inits second stage (2006-08). While sharing the goal of achieving routineimplementation of EIBI in PHC, PHEPA entails the development and roll-out of fourrelated products: (i) clinical guidelines for delivering EIBI in PHC that can serve as abasis for guidelines to be used in participating countries; (ii) a training manual linkedto the clinical guidelines that can also be adapted for use in participating countries;(iii) a website containing an Alcohol Management Database for use by PHC8professionals and others interested in the promotion of EIBI in primary care; and (iv)a country-based strategy aimed at integrating EIBI for hazardous and harmful drinkersin the PHC systems of participating countries. Another WHO Collaborative Project isseeking to disseminate brief interventions in the PHC systems of developing countriesand a start has been made in South Africa and Brazil (16). Finally, following on fromPhase IV an international network was formed (International Network on BriefInterventions for Alcohol Problems: INEBRIA) to share ideas and increasecommunication among researchers and practitioners interested in alcohol EIBI [17].Thus, in addition to its achievements in the participating countries, Phase IV hascontributed to an international movement dedicated to reducing alcohol-related harmby achieving the widespread, routine and enduring implementation of EIBI forhazardous and harmful alcohol consumption, a movement that is steadily gatheringmomentum.9References1. Heather N. editor. WHO Collaborative Project on Identification and Managementof Alcohol-related Problems in Primary Health Care – Report to the WorldHealth Organisation on Phase IV: Development of Country-wide Strategies forImplementing Early Identification and Brief Intervention in Primary Health Care.Geneva: World Health Organisation, Department of Mental Health and SubstanceAbuse: 2006.http://www.who.int/substance_abuse/publications/identification_management_alcoholproblems_phaseiv.pdf2. Saunders J.B., Aasland O.G., Babor T.F., de la Fuente J.R., Grant M.Development of the Alcohol Use Disorders Identification Test (AUDIT): WHOCollaborative Project on Early Detection of Persons with Harmful AlcoholConsumption--II. Addiction 1993; 88: 791-804.3. WHO Brief Intervention Study Group. A cross-national trial of brief interventionswith heavy drinkers. American Journal of Public Health 1996; 86: 948-955.4. Anderson P, Kaner EFS, Wutzke S, Wensing M, Grol R, Heather N, et al.Attitudes and management of alcohol problems in general practice: descriptiveanalysis based on findings of a World Health Organization internationalcollaborative survey. Alcohol & Alcoholism 2003; 38: 597-601.5. McAvoy B., Donovan R., Jalleh G., Saunders J., Wutzke S., Lee N. et al. Generalpractitioners, prevention and alcohol: a powerful cocktail? Facilitators andinhibitors of practising preventive medicine in general and early intervention foralcohol in particular - a twelve nation key informant and general practitionerstudy. Drugs: Education, Prevention &Policy 2001; 8: 103-7.6. Funk M, Wutzke S, Kaner E, Anderson P, Pas L, McCormick R, et al. Amulticountry controlled trial of strategies to promote dissemination andimplementation of brief alcohol intervention in primary health care: findings of aWorld Health Organisation collaborative study. Journal of Studies on Alcohol2005; 66: 379-388.7. Higgins-Biddle J.C., Babor T.F. Reducing Risky Drinking: A Report on EarlyIdentification and Management of Alcohol Problems Through Screening and BriefIntervention. (Report to Robert Wood Johnson Foundation). Farmington CT:Alcohol Research Center, University of Connecticut Health Center; 1996.8. Hart E., Bond M. Action Research for Health and Social Care. Buckingham, UK:Open University Press; 1995.9. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counselinginterventions in primary care to reduce risky/harmful alcohol use by adults: asummary of the evidence for the US Preventive Services Task Force. Annals ofInternal Medicine 2004; 140: 557-68.10. Roche AM, Freeman T. Brief interventions: good in theory but weak in practice.Drug & Alcohol Review 2004; 23: 11-8.11. Thom B, Tellez C. A difficult business: detecting and managing alcohol problemsin general practice. British Journal of Addiction 1986; 81: 405-18.12. Fleming M.F, Mundt MO, French MT, Manwell LB, Stauffacher EA, Barry KL.Brief physician advice for problem drinkers: long-term efficacy and benefit-costanalysis. Alcoholism: Clinical & Experimental Research 2002; 26: 36-43.13. Cabana M, Rand C, Powe N, Wu A, Wilson M, Abboud P. et al. Why don'tphysicians follow clinical practice guidelines? A framework for improvement.Journal of the American Medical Association 1999; 282: 1458-1465.1014. Babor T, Higgins-Biddle J, Dauser D, Burleson J, Zarkin G, Bray J. Briefinterventions for at-risk drinking: patient outcomes and cost-effectiveness inmanaged care organizations. Alcohol & Alcoholism 2006; 41: 624-31.15. Primary Health Care European Project on Alcohol www.phepa.net16. World Health Organisation, Management of Substance Abuse. Dissemination ofBrief Interventions for Alcohol Problems in Primary Health Care: A Strategy forDeveloping Countries.www.who.int/substance_abuse/activities/en/alicante_meeting_report.pdf17. International Network on Brief Interventions for Alcohol Problemswww.inebria.net

A difficult business: detecting and managing alcohol problems in general practice.

A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organisationcollaborative study.

Action Research for Health and Social Care.

Attitudes and management of alcohol problems in general practice: descriptive analysis based on findings of a World Health Organization international collaborative survey. Alcohol & Alcoholism

Babor T.F.Reducing Risky Drinking: A Report on Early Identification and Management of Alcohol Problems Through Screening and Brief Intervention. (Report to Robert Wood Johnson Foundation). Farmington CT: Alcohol Research

Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine

Brief interventions for at-risk drinking: patient outcomes and cost-effectiveness in managed care organizations.Alcohol & Alcoholism

Brief interventions: good in theory but weak in practice. Drug & Alcohol Review

Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.

Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II. Addiction

Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers.

Organisation, Management of Substance Abuse. Dissemination of Brief Interventions for Alcohol Problems in Primary Health Care: A Strategy for Developing Countries. www.who.int/substance_abuse/activities/en/alicante_meeting_report.pdf

Primary Health Care European Project on Alcoholwww.phepa.net

Why don't physicians follow clinical practice guidelines? A framework for improvement.

A long standing World Health Organization collaborative project on early identification and brief alcohol intervention in primary health care comes to an end

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A long-standing World Health Organization collaborative project on early identification and brief alcohol intervention in primary health care comes to an end

A long standing World Health Organization collaborative project on early identification and brief alcohol intervention in primary health care comes to an end

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