World Health Organization Collaborative Project on Identification and Management of Alcohol-related Problems

 in Primary Health Care: Phase IV

[Customisation] [Communications] [Strategic Alliance] [Demonstration Project]

Final Country Chapter, January 2006

Collaborative Centre:

Tampere University Hospital, Department of Psychiatry and Tampere University, Department of General Practice.

Chief investigators:

Kaija Seppä MD, PhD, Mauri Aalto MD, Petteri Pekuri Project Nurse, Martti Kuokkanen, MD, PhD, Janne Kääriäinen, MD.

Geographical Area in which Implementation Strategy will be Applied:

FINLAND

Starting Date:

1.1.1996

Completion Date:

31.12.2003

Project Strands and Milestones:

• During spring 1996 development of material (AUDIT, information for patients, hand-outs, posters for patients) for a wide health-care region (Pirkanmaa, where city of Tampere is situated).
• During year 1996 basic training for health care staff in the region (reframing understanding).
• During years 1996-1998 development of local and national strategic alliances.
• During year 1997 continuing education based on needs from the region.
• During year 1998 development of close contacts to Tampere city health care staff; training for the staff, structured questionnaire to measure. knowledge, skills and attitudes. Similar questionnaire in the City of Turku's primary health care. Also, questionnaire to patients.
• Beginning in the end of 1998 and continuing during winter 1999 focus groups in Tampere City Health Centre to create a model on how to do BI.
• Beginning 1.4.99 demonstration project in Tampere City primary health care including active participation of one project worker.
• 31.12.2001 demonstration project ends.
• During the years 2000-2001 new measurements on how early identification and brief intervention (EIBI) is adapted; questionnaire to patients in Tampere and to staff in Tampere and Turku. Also, videotaped consultations in primary health care in Tampere.
• During the years 2002 – 2004 economic evaluation and final reports of the project.

Proposed Funding Sources:

Ministry of Social Affairs and Health, City of Tampere, Tampere University Hospital

Local Support:

• City of Tampere
• Tampere University
• Tampere University Hospital

CUSTOMIZING MATERIALS AND SERVICES

Brief Intervention Package, including delivery systems:

• AUDIT-questionnaire (is translated into Finnish for Pirkanmaa-project)
• Early identification and brief intervention (EIBI) instructions for staff (ready material prepared for Lahti-project)
• Hand-out for patients (including risky limits - prepared for Lahti-project)
• Safe-drinking leaflet for patients (prepared for Lahti-project)
• Posters for waiting-rooms (including 'what is a drink' and risk limits - prepared for Pirkanmaa-project)
• All material has been customised during the training included in Pirkanmaa-project 1996-1997.

Early Identification (Screening):

AUDIT is the best known questionnaire in Finland also launched as part of 'Drinking and Driving' project and it was chosen by the focus groups.

Brief Intervention Process:

FRAMES is the basis for intervention content. The decision to do opportunistic, not systematic screening was decided in focus groups. Also, the number of contacts during BI was allowed to vary based on individual needs of the patient.

Training of Primary Health Care Staff:

Basic and continuing training have already been given; some lectures but mainly group work and sociodrama. Training in future will be part of demonstration project and consists of active support by project workers.

Data Analysis:

Questionnaire results will be compared between project (Tampere) and control (Turku) cities in the beginning and in the end of the demonstration project using cross tabulations and khii2 test.

REFRAMING UNDERSTANDING OF ALCOHOL ISSUES

General Public:

Hitherto, AUDIT has been delivered to every household in the city of Tampere twice. Local newspapers and other media have been contacted and information of risky drinking has been widely given to general public. Posters have been hung to all waiting rooms in primary health care. AUDIT-questionnaires can be found in physicians' waiting rooms - information of the impact of different scores are included to these patient-directed AUDIT's.

Health Professionals:

See education above.
Several articles have been written in Finnish medical journals to reframe understanding of alcohol matters.

Other Stakeholders:

• Collaboration with the local Temperance Movement.
• Collaboration with the local Educational Institute for Nurses
• Collaboration with several Work places in Tampere
• Collaboration with local Police (Drinking and Driving project)

Media Advocacy:

Close contacts to local radio and television broadcasting companies and local newspapers.

Control of Communications Strategy:

Control of the communication strategy is a specific responsibility of the project steering group: Pirkanmaa Region's Working Group for Drug and Alcohol Treatment. This will include individuals with relevant expertise from different sorces.

ESTABLISHING LEAD ORGANIZATION(S) AND BUILDING STRATEGIC ALLIANCES

Lead organizations:

Pirkanmaa Region's Working Group for Drug and Alcohol Treatment

Building strategic alliances:

• Ministry of Social Affairs and Health
• National Research and Development Centre for Welfare and Health (STAKES)
• Finnish A-Clinic Foundation
• Some Pharmaceutical Industries
• Finnish Society for Addiction Medicine
• Finnish Society for Alcohol Researchers
• Tampere City Primary Health Care
• Tampere City Temperance Movement
• Finnish Society for General Practice

DEMONSTRATION PROJECT(S)

Location(s):

City of Tampere

Projected Start Date:

1.4.1999

Projected Completion Day:

31.12.2001

Design of Project:

Two basically similar cities are compared - one with an active project (Tampere) and the other with natural development (Turku). Part of the measures only measure the changes in the project city (see below - outcome measures)

Outcome measures:

Core Measures:

1. Number of early identification and brief interventions (EIBI's) given (based on patient questionnaire at the beginning and end in Tampere)
2. Changes in activity (based on questionnaires to staff in the beginning and end of the study in Tampere and Turku)
3. Separately, change in the number of primary health care occupational units in early identification and brief intervention (EIBI) activity in Tampere
4. Cost of one EIBI

Optional Measures:

1. Quality of the intervention (based on videos and questionnaires to the patients)
2. Changes in knowledge, attitude and skills of the staff (based on questionnaires to the staff and on videos)

Process measures:

Project worker supports the units based on their demands. During every contact information is written down in project diary with special emphasis on:

a) activity of early identification and brief intervention (EIBI) in the unit
b) barriers

Economic Analysis

The cost of one early identification and brief intervention (EIBI) session has been counted based on the workload and time put on EIBI, and on the present salaries of staff.

Results

MEASUREMENTS IN THE BEGINNING

Aalto M, Pekuri P, Seppä K. Primary health care nurses’ and physicians’ attitudes, knowledge and beliefs regarding brief intervention for heavy drinkers. Addiction 2001;96:305-311.

Aalto M, Pekuri P, Seppä K. Primary health care personnels’ activity in intervening in patients’ alcohol drinking: a patient perspective. Drug Alcohol Depend 2002;66:39-43

Aalto M, Seppä K. Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug and Alcohol Review 2003;22:169-173

DESCRIPTION OF THE IMPLEMENTATION – ACTION DURING THE PROJECT

Aalto M, Seppä K. At which drinking level to advice a patient? – general practitioners’ views. Alcohol Alcoholism 2001;36:431-433.

Aalto M, Värre T, Pekuri P, Seppä K. The role of general practitioners’ working style on brief alcohol intervention activity. Addiction 2003;98:1447-1451.

Seppä K, Pekuri P, Kääriäinen J, Aalto M. Widespread implementation of brief alcohol intervention in primary health care – description of an action research project. Submitted for publication.

Seppä K, Aalto M. Alkoholisairauksien sekundaaripreventio perusterveydenhuollossa. (Secondary prevention of alcohol-related diseases in primary health care). Kunnallislääkäri 2001;16(3):15-17.

Seppä K, Aalto M, Kuokkanen M. Tietoa alkoholin suurkuluttajien mini-interventiosta WHO:n projektin uudelta kotisivulta (Information of brief alcohol intervention from WHO project’s new web page). Suom Lääkäril. (Finnish Medical Journal) 2001;56:4909-4911.

MEASUREMENTS IN THE END

Aalto M, Pekuri P, Seppä K. Primary health care professionals’ activity in intervening in patients’ alcohol drinking during a three-year year intervention implementation project. Drug Alcohol Depend 2003; 69:9-14.

Seppä K, Aalto M, Raevaara L, Peräkylä A. Activity to do brief intervention for risky drinking –analysis of videotaped consultations in primary health care. In press.

Aalto M, Pekuri P, Seppä K. Change of primary health care nurses’ and general practitioners’ attitudes and knowledge regarding brief intervention during implementation project. Submitted for publication.

ECONOMIC EVALUATION

Seppä K, Lappeteläinen V, Aalto M. Mitä maksaa? Alkoholin suurkuluttajan lyhytneuvonnan kustannus perusterveydenhuollossa. Screening and brief alcohol intervention – costs in primary care. Sosiaalilääketieteellinen Aikakauslehti. Journal of Social Medicine 2004;41:3-9 (with English Abstract).

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