World
Health Organization Collaborative Project on Identification and Management of
Alcohol-related Problems
in
Primary Health Care: Phase IV
Development
of Country-wide Strategies for Implementing Early Identification and Brief Alcohol Intervention in
Primary Health Care.
France
[Customisation]
[Communications] [Strategic Alliance]
[Demonstration Project]
Final Country Chapter, January 2006
Collaborative Centre:
Paris. Centre Magellan, 10 rue de la
Paix, F-92230 Gennevilliers
Tel: + 33 1 41 21 05
63 Fax: + 33 1 47 94 84 39 Email: centre.medical.magellan@wanadoo.fr
Chief Investigators:
Dr Philippe Michaud (Email: philippe.michaud@wanadoo.fr),
Pr Francois Paille (Nancy), Dr Elisabeth Kind (Paris), Dr Anne-Violaine Dewost
(Paris), Dr Sabrina Levy (Paris) Mme Veronique Dorner (Paris)
Geographical Area in which
Implementation Strategy will be Applied:
Île-de-France (Parisian administrative
area: 10 million inhabitants)
Starting Date:
16/03/99
Completion Date:
End 2005
Project Strands and Milestones:
1999:
-
(Strand 1a) French validation of
AUDIT
-
(Strand 1b) Material
customisation (focus group: (i) alcohol issues general understanding (ii)
adapting screening process and intervention package: GPs, primary health
care staff,
patients)
-
Baseline measures (pool)
2000-2
-
(Strand 2a) Training of three
groups of general practitioners out of three separate but similar
communities ('villes nouvelles' i.e. recently built suburban communities):
Saint-Quentin-en-Yvelines, Evry, Orly, for screening and brief intervention.
-
(b) RCT (CO): Comparison of two
methods of screening AUDIT vs AUDIT in health questionnaire
-
(c) Final version of the
screening and brief intervention material
2003-4
-
Implementation regional
programme
-
(Strand 3a) Focus groups of
general practitioners about the best way for adapting the marketing
strategies: group training, tutorial support, mail plus telephone.....
-
(b) Study: Is money a good way
of convincing GPs to intervene in a liberal system?
-
Comparison of two communities,
the first one with economic incentive (by social insurance system), the
second one only with motivational information.
-
(c) Outcome measures at the
community level (pool, alcohol-related incidents, emergency consultations,
consumption, etc...)
-
(d) Communication strategies
about the results
-
(e) Final choice for marketing
strategies
-
(f) Training the trainers for
implementation
2003-4
-
Implementation in acts: (Strand
4-a) Screening and brief intervention (SBI) in medical post graduate training
-
(b) SBI in medical schools
-
(c) Mass media communication
2004-6
-
(d) Final outcome measures at
region level and economic analysis
-
(e) Consensus meeting
-
(f) Mass media communication
-
(g) Legal action: nation-wide
implementation
Proposed funding Sources:
-
Social security prevention funds
-
Regional council
-
'Départements' councils
-
'Fondation de France'
-
Ministry of public health and
social affairs
-
Private sponsoring (insurance,
pharmaceutics, soft drinks)
Local Support:
-
Observatoire régional de santé
(ORS)
-
Caisse régionale d'assurance
maladie (CRAMIF)
-
Groupement régional
d'alcoologie (GFA)
-
Direction régionale des
affaires sanitaires et sociales (DRASSIF)
-
Comité régionale d'éducation
pour la santé (CRESIF)
-
Délégation régionale de
l'assocation nationale de prévention de l'acoolisme (DRPA/ANPA)
-
Public health specialists from
the following cities: Evry, Orly and from the départment des Yvelines
Support at national level:
-
Société Française de
médecine générale (SFMG)
-
Société Française
d'alcoologie (SFA)
-
Comité Française
d'éducation pour la santé (CFES)
-
Collége national des
généralistes enseignants (CNGE)
-
Ecole nationale de la santé
publique (ENSP)
-
Ecole de santé publique de la
Faculté de médecine de Nancy
CUSTOMIZING MATERIALS AND SERVICES
Focus groups with GPs, receptionists
(in Public Health Centres with a primary care section), patients, occupational
doctors and nurses on the following themes:
-
Goals of an intervention for
risky drinking
-
Screening proposition
-
Screening material (AUDIT
included in a health questionnaire)
-
Intervention package
-
Financial incentives and
others
-
Barriers to a systematic
approach of early detection
-
What could be a useful
pre-screening
-
Better follow up procedures
-
The best way of training the
doctors about alcohol issues
-
Quality assurance
Structured questionnaires (postal
study, enhanced by telephone., or face-to-face)
Early Identification
(Screening):
French (validated) translation of
AUDIT questionnaire and AUDIT questions inside a wider health questionnaire.
Pre-screening will be discussed (antecedents of accidents, shorter
questionnaire, list of opportunities for proposing screening....)
Brief Intervention Package:
The Drink-less programme will be
adapted by the focus groups. Mail and/or group training plus phone will be used
for dissemination, after adaptation by the focus groups.
Brief Intervention process:
Two (or three) interventions in the
course of medical interviews
Training of Primary Health
Care Staff:
Basis and continuing training are
both necessary. The training of public primary health care centre receptionists will be
integrated into public staff continuing education (delivered by a state agency).
The contents of the training will be discussed, after customisation, between the
medical associations and the Steering Group, with possible relations with other
themes (e.g. tobacco, or preventive action against withdrawal syndrome for
physically dependent patients) and with other institutions (e.g. medical
schools). It must be kept in mind that the programme should be finally
integrated into initial medical training.
Data Analysis:
The baseline data will be of three
different sorts:
-
Qualitative information about
alcohol consumption in the demonstration project areas, and its effects on
figures like DWI sentences, emergency room consultations.. (official
statistics)
-
Qualitative information about
the importance of risky/hazardous drinking and alcohol dependence among
primary health care staff
-
Semi-quantitative and
qualitative information about how GPs deal with 'excessive drinking'
(questionnaires).
This information could be gathered
and analysed by the ORS, with the help of Social Security Bureau of Statistics.
A pool among a sample of adults living in the areas could be necessary.
For the Demonstration project, the
economic analysis is of prominent importance, and will be held by or with the
social security and a public health school (Ecole nationale de santé publique
and/or école de santé publique de la faculté de médecine). The other
outcome data will be analysed like the baseline data.
REFRAMING UNDERSTANDING OF ALCOHOL
ISSUES
General Public:
-
Focus groups with patients
-
New communications target, e.g.
'Your physician should ask you about your drinking'
-
Newspapers could be involved
with a journalist as counsellor in the Steering Group
-
The regional TV network can be
very useful in the communications strategy, but using an event to wake the
journalists' interest (for instance a WHO meeting.....)
-
The CFES has communications
specialists, and it participation in mass media campaigns, or better,
campaigns held in common must be included in the plan.
-
The doctors responsible for
public health at the local (community) level can enhance efficiency of a
national campaign with local actions (posters, letters to the citizens,
local radio)
-
Trade unions, occupational
doctors, ex-drinkers associations can endorse the aims of a campaign
explaining that risky drinking is a good thing to detect.
-
Internet sites with alcohol
implications could be used as vectors of information about the programme,
whether they include the complete programme description and explanation or
only hyper -text links.
Health Professionals:
-
Medical press system: articles
in daily medical newspapers or illustration file in weekly journals
-
The communication strategies of
the pharmaceutical industry could be useful and carefully used
-
See section on training above
-
A consensus meeting about early
identification and brief intervention (EIBI)
could also be held at the end of the whole process
Other Stakeholders:
-
Occupational doctors, trade unions, AA and other ex-drinkers
associations
-
The 'Association nationale de prévention de l'alcoolisme'
and ' Fédération française de l'alcoologie
ambulatoire' both usually lobby for new means to reduce about alcohol
consumption and/ or harm (specially towards Ministry of Health and Social
Security). Both can also help by naming professionals able to 'train
the trainers'
-
The 'conférences régionales de
santé and the 'conférence nationale de
santé', held every year, are an efficient way of making an action well
known. This is because they address politicians and administrative
authorities as much as the press and the general public. The 'programme
régional alcool' as a place in these 'conférences'. The public
health doctor belonging to both steering group and 'programme régional
alcool' will make the link.
Media Advocacy and control of
Communications Strategy:
Close contact with the press, the
radio and the TV will be one of the constant preoccupation of the Steering
Group
ESTABLISHING LEAD
ORGANIZATION(S)
AND BUILDING STRATEGIC ALLIANCES
Lead Organisation(s):
If possible: Groupement francilien
d'acoologie. If not, Délégation
régionale de l'Assocation nationale de prévention de l'acoolisme (DRPA)
Fédération française de
l'alcoologie ambulatoire & Société Française de médecine générale (SFMG)
Building Strategic Alliances:
The Steering Group is one of the
main ways of building alliances. It has been composed to give a wide
representation of GPs, but there is also key -persons to install and
maintain the project under a positive atmosphere: 'representatives' of the
Ministry of Health, regional health authorities.
Many contacts must be continued. the
difficulty will be to get funds for co-operation, with maybe a necessity to
shift aspects of the programme to allow an effective collaboration (e.g. CFES,
which has already developed its own instrument for intervention).
The main allies could be:
-
Social security regional
organisation - Caisse régionale d'assurance maladie
-
Regional council
-
Ministry of public health and
social affairs
-
Observatoire régional de santé
(ORS)
-
Direction régionale des
affaires sanitaires et sociales (DRASSIF)
-
Comité régionale d'éducation
pour la santé (CRESIF)
-
Public health specialists of the
following cities: Evry, Orly, and of the départment
des Yvelines
-
Société Française
d'alcoologie (SFA)
DEMONSTRATION
PROJECT(S)
Locations:
Ville nouvelle d'Evry (département
de l'Essonne, 50 000 inhabitants) Ville nouvelle de Saint-Quentin-en-Yveline (50
000 inhabitants) Agglomération d'Orly/Choisy-le-Roi (40 000 inhabitants)
Projected Start date:
September 2000
Projected Completion Date:
December
2002
Design of Projects:
a) Randomized control study with
crossing-over: Use of AUDIT alone versus AUDIT included in a wider health
questionnaire (AUDIT-HQ) in GP practices and in public PHC facilities.
b) Community-based study, comparing
two (or four) 'similar' communities where early identification and brief
intervention (EIBI) is promoted either (i) with a
(low) economic incentive, e.g. 10 FF (1.52 €) per filled AUDIT and 20 FF (3.04
€) per preformed brief intervention; or (ii) without any economic incentive.
Outcome Measure:
a) Number of patients filling AUDIT
or
AUDIT-HQ/Number of patients screened 'positive' (relevant for BI) and 'dependent' Pool in
a sample of GPs and patients about acceptability (analogic scales and/or
structured interviews)
b) Number of patients
screened/Number of patients screened 'positive' (relevant for BI) and 'dependent'
Number of interventions preformed
Process Measures:
The process will be observed during
the whole time of the study by a specialist of human and sciences (sociologist,
ethnologist and anthropologist), and the description will be submitted regularly
to the Steering Group.
Economic Analysis:
The Ecole nationale de santé
publique and/or a Ph D student of the Ecole de santé Publique, faculté de
médecine de nancy, will do the economic survey with an economist specialised in
health issues.
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