Collaborative Centres:

Wetenschappelijke Vereniging voor Vlaamse Huisartsen (WVVH) Dept Research and Flemish For Alcohol and other Drugs Problems (VAD)
HOUVOL , Huisartsen Overijsse Vilvoorde en omliggende streken

Chief Investigators:

Overall co-ordination and evaluation:
Dr. Pas Leo Co-ordinator project WVVH , coordinator of Health Services Research WVVH
Medical Co-ordinator CENTRUMLOGO
Research co-ordinator Free University Brussels Academic Centre General Practice
Mrs M Geirnaert Director, VAD (Flemish Association Alcohol and Drug problems)

Collaborating centres under consideration

Goedele Slots - Prevention Worker Primavera, Centre Mental Health co-ordinating municipality workers on substance abuse
Dr I Bertels - Chairman of HOUVOL, federation of GP groups in the area of CENTRUMLOGO
Dr B Aertgeerts - Interuniversity Centre for General Practice teaching
Dr Van Casteren - Sentinel Network of GP Institute Public Health

Customising materials and strategy:

R Caris - Customisation Focus groups primary health care and specialised care
Delphi study and Customisation Focus groups primary health care and specialised care
Regional Quality circles
E Aertsen - Focus groups community workers
Primary care intervention and evaluation :
Dr I Bertels Houvol - Quality assurance strategy
Dr. B Garmyn - WVVH Overal evaluation strategy
Dr. Hoeree - WVVH Evaluation of quality assurance packages
Cost offset studies

Community support strategy:

VAD - regular support to communities and companies
Development of local community actions :
LOGO teams in area’s selected and municipality prevention collaborators
Primavera co-ordination of municipality workers substance abuse
CENTRUMLOGO co-ordination and action in collaboration with municipalities

Geographical Area in which Implementation Strategy will be applied:

Flemish Region (Vlaams Gewest).
Note1 : smaller regions (250-300.000) to which the demonstration community intervention will be applied are negotiated with LOGO’s. Involving LOGO’s may be dependent on the new regulations to be agreed upon by the Ministry of the Flemish Community responsible for health for 2002-2005. As GP groups within HOUVOL are organised municipality wise sub-units for intervention may be defined in those municipalities where community workers have been installed for substance abuse (Asse,Overijsse,Vilvoorde).
Note 2: if results of cost offset studies are positive the health Insurance may decide nationwide application of its reimbursement principles in federal state of Belgium.

Starting Date

Strand I 1/9/98.

The study started during phase III strand III in autumn 1998 with focus group research on strategies for shared care and focus groups research on the adaptations needed for the Drink-less package and early detection and brief intervention strategy.
During the months April till June 1999 a Delphi study runs as a pilot to the European Ecatod project till May 99 were run in potential regions for action. They will be repeated in the specific intervention are as soon this has been clearly determined.
Based on these results a package for quality assurance and CME has been developed and will be tested in some local groups of GP. In autumn 2001 evaluation of the adapted package will lead to harmonisation with other modules for QA of WVVH and VAD.
Furthermore a Flemish recommendation is developed according to the habitual strategy of the Flemish college of GP.
An adapted Audit questionnaire is validated in Ecatod study using CIDI as golden standard.

Further strands

Further timing will depend on financial support and interest of local regions to agree with a local action philosophy as outlined here.
A preparatory phase will be planned just before or at the start of the demonstration project in which the strategy customised by means of focus groups and Delphi studies will be submitted to a local consensus strategy involving one exploration group and a quality circle with GP and Community workers to refine the local outreach strategy to GP and community action strategies.

Completion date of first demonstration project:

Dependant on start.

Starting during 2002 - 2005 according to agreement on study protocol by sponsoring authorities

Project Strands and Milestones:

Strand I: started 1999

Alliance building and communication strategies: February 99- end 2000
The following actions were already accomplished:
• Discussion of project with VAD (started); adaptation of protocol to be continued; This strategy will allow entering support for community related to the regular activities of this organisation
• Discussion within Scientific Society of Flemish general Practitioners. Agreement obtained to enter in normal programming of the society end 1999 a proposal for Flemish recommendations for early detection and brief intervention on alcohol use due end 2001, first version presented December 2000
• A health survey was performed in CENTRUMLOGO in 2000 (formerly LOGO2) to collect baseline data and define feasibility of such a survey
• Presentation of the strategy to selected partners in Flemish Brabant autumn 2001
• Request to the ministry of Social Security for a demonstration project autumn 2001
Planned to be discussed at approval of demonstration project:
• Reframing of public understanding was prepared by a regional survey in CENTRUMLOGO 2000
• Communication strategy should be embedded in VAD strategy and municipality action plans
Materials Customisation and re-framing alcohol issues
• Customisation of early detection strategy
• Focus groups on Drink-less materials and systematic practice approach: performed
• Validation of WHO well-being scale as pre-screening instrument in a philosophy to detect a larger array of psychosocial problems: done 2000, pre-screening tool not retained.
• Stepped care proposal using a mix of ED strategies to be fitted to practice settings to be discussed in local QA groups beginning 2002 as validation procedure for Flemish GP recommendation.
• Customisation of materials. June 1999
• Quality assurance package tested, disseminated experimentally June 99-dec 99 in 13 QA groups by central VHI project team.
• Animators of 30 self-selected local QA groups were trained throughout Flanders to use this package in intervention area’s by VHI (now Department of Research WVVH) beginning 2000
• In October 2000 an additional training in motivational approach was provided to local community and GP prevention workers in CENTRUMLOGO during the ECATOD/WHO Phase IV meeting
• Validation of recommendation to Flemish GP: adapted version 2001 (WVVH)
• A philosophy for Community action has been established in 1998 by VAD called ‘Schakel jezelf in’. The approach is based on central support for multisectorial approach by training facilities, monitoring support, and co-ordination. This approach is put into practice by municipality and other prevention workers in the field dealing with alcohol (and other drugs) co-ordinated in provincial platforms for substance abuse. A Flemish Conference will be held with all intermediate actors in November 2001

Strand II:

From 1999 till 2001 26 regions for health promotion have been created in the Flemish Linguistic Community in Belgium. LOGO’s are planning for their actions on health promotion in negotiation between all possible involved partners and supported by a team consisting of 2,5FTE specially trained personnel.
A demonstration project is being prepared on active local involvement of primary health care associated or not with community action in CENTRUMLOGO with own funds. In case of no approval of further funds this project will result in promotion of EIBI in three municipalities by HOUVOL associated with community action.
As provisional intervention area the municipalities with prevention workers in CENTRUMLOGO (Asse, Overijsse and Vilvoorde, inhabitants) have been selected. In case of sufficient sponsorship at community or federal level a more extensive area will be approached covering CENTRUMLOGO with one or more of the other LOGO’s in Flemish Brabant as control area.

Two possible scenarios:

Intervention	Reduced action	Extended action
GP action	CENTRUMLOGO	CENTRUMLOGO + LOGO1//3/4
Community actions	Municipalities with Prevention workers	CENTRUMLOGO (formerly LOGO2) if approved by Ministry Community otherwise as reduced version
Control	Municipalities without LOGO1/3/4 Flemish Brabant

Proposed Funding Sources:

Strand I:

Early testing of QA package to GP groups was supported by industrial sponsorship (Merck, 1999-2000).
Focus groups: Drink Bewust programme Flemish Community (1998) and Ecatod (partially,1999)
Regional Health Survey: CENTRULOGO (formerly LOGO²)
primary health care support: WVVH: Convention with Ministry of Health of Flemish Community for development of guidelines and QA packages (convention 2000-2001)

Strand II:

to be found but integrated in regular sources except research evaluation part
WIV plans a national survey to be repeated in 2002/3 can be promoted as baseline measurement

Municipality community action support (reduced project version):

PROVINCE, CENTRUMLOGO, MUNICIPALITIES

Larger Community Action:

Ministry of health of Flemish Community

Primary Health Care Demonstration Project and Cost Offset Studies:

Federal Ministry of Social Security: new proposal demonstration project

CUSTOMIZING MATERIALS AND SERVICES

Brief Intervention Package

Joint adaptation by WVVH and VAD to Drink Bewust (Drink-less).

Early Identification:

Audit:
• Entered in a slightly more comprehensive health behaviour form.
• A pre-screening test was evaluated for use (WHO well-being test) but cannot be retained based on health survey data 2000. We will therefore consider a variety of choices going form simple questions integrated in regular anamnesis to the whole audit questionnaire integrated in a General Health Questionnaire.

Brief Intervention Process

Array of choices presented in QA package going from BI according to Drink-less to more comprehensive motivational approaches for those interested and motivated to apply them applied in a ‘stepped care’ philosophy.
Simple plastic reminder card A4 with essentials promoted in whole region of demonstration project coupled with brief intervention on smoking.
A recommendation on screening and brief intervention is in development but delayed due to new research findings about possibility of lower cut off point and reduced questionnaires till end 2001.

Training of Primary Health Care Staff:

All QA groups of GP received May 99 a letter to test show their interest in the topic.
13 were visited between Sept 99 and January 2000; delegates of 30 others were invited to two training meetings in the use of the package. The package is adapted to their comments and the new recommendation and will be pre-tested again in local QA groups during the validation process of recommendation by WVVH
The package will be promoted to all Flemish speaking GP within a broader offer for training to primary health care groups on alcohol & drugs planned by VAD in 2001 and health behaviour change (planned by WVVH) after acceptance of recommendation in 2002. Associated CME and QA material will be promoted actively by the research team in intervention areas of demonstration project.

Data Analysis:

Data collection:
• Questions for local health survey were pre-tested in may 2000 in LOGO2 Flemish Brabant
• Larger application in other logo’s will be negotiated in 3 other regions failed to be supported
• Development of a sentinel network in CENTRUMLOGO is under consideration in HOUVOL
During the demonstration project as now proposed to the federal Ministry of health a new reimbursement claim can be provisionally be created to allow payment for EI and subsequent BI. Collection of reimbursement forms will be linked to identification of audit score, final diagnosis, registering BI FU visits and consultations for alcohol related harm
• Flemish and national collection of data is proposed:
• Sentinel network of GP practices for 2002 in collaboration with WIV-LP (Scientific Institute Public Health Louis Pasteur)
• National data collection will be proposed to the relevant co-ordinating team in WIV-LP for the national health survey (2002/3)

REFRAMING UNDERSTANDING OF ALCOHOL ISSUES

General Public:

To be planned in conjunction with VAD and LOGO teams in planning strand II in support of local municipalities. Safety on the road will be one of its elements, as will be action towards the adolescents with schools and youth clubs.

Health Professionals:

See above: philosophy to GP
For other health professions: (based on focus groups results)
Nurses: a basic course in changing health behaviour will be given centrally
Training will be provided not only trough local QA groups of GP but also by multidisciplinary training in SITs (approach piloted with successes in Zaventem, in which nurses, pharmacists as well as GP are involved.
Separate training of pharmacists will be considered with CENTRULOGO and BAF (Brabant Association Pharmacist).

Other Stakeholders:

• CENTRUMLOGO
• Provincial Platform substance abuse and Province Vlaams Brabant
• Centres of mental health care

Media Advocacy:

To be planned in conjunction with VAD and CENTRUMLOGO in planning strand II.

Control of Communications Strategy:

No strategy on this subject is planned, at the moment.
To be planned in conjunction with VAD and LOGO teams in planning strand II.

ESTABLISHING LEAD ORGANIZATION(S) AND BUILDING STRATEGIC ALLIANCES

Lead organisation(s):

VHI + VAD

Strategic Alliances:

VIG: Flemish Institute on Health promotion
Negotiation on evaluation strategy. This has been already started. A proposal will be forwarded by VHI to VIG and commonly introduced to Ministry of Health.

WVVH: Scientific Society of Flemish General Practitioners
Agreement has been obtained to formally develop a recommendation to Flemish GP

SSMG: scientific Society of French Speaking GP
Proposed a training programme to the French Ministry of Health. Are waiting results
Co-ordinator is also secretary of newly created Belgian Society of Alcohology

LOGO teams: see above.
We have contacts in May 99 with region Turnhout, city of Antwerp, city of Brussels and 3 other regions in Flemish Brabant. No positive reaction.
We link collection of data in LOGO2 to the action on smoking , action towards companies and work in close collaboration with local network on alcohol and drug use mainly oriented to community action in selected municipalities and schools

Ministry of Health of Flemish Community:
Finances LOGO’s, financed Phase III, will receive request after agreement between VAD and WVVH for funding a demonstration and evaluation project.

Ministry of Social Security:
Cost offset study, collection of claims

Provincial Platform substance abuse: see above

Discussion platform for mental health: to be involved in quality circle and collecting data about mental health care provision

Institute public health: sentinel data collection GP in association with SSMG and WVVH

DEMONSTRATION PROJECT(S)

Location(s):

Dissemination for guidelines and QA package:
whole Flanders 2002/2003

Intervention area for active GP involvement:
Centrumlogo

Community action:
Municipalities with prevention workers (Asse,Vilvoorde, Overijsse)

Control:
other municipalities

If more funding can be obtained action research will be extended as follows:

Intervention	Reduced action	Extended action
GP action	CENTRUMLOGO	CENTRUMLOGO + LOGO1//3/4
Community actions	Municipalities with Prevention workers	CENTRUMLOGO (formerly LOGO2) if approved by Ministry Community otherwise as reduced version
Control 1	Municipalities without LOGO1/3/4 Flemish Brabant
Control 2	Flanders: survey data and sentinel data from rest of Flanders, Brussels and French speaking community

Projected Start Date:

2002-2003

Projected Completion Date:

2005

Design of Project:

Quasi experimental design with pre/post study on GP involvement with health survey data, and regional data collection in area’s under study;
Comparison with main national health survey and sentinel network data.

Following areas will be considered in more detail:

Municipalities level planned concomitant with activation of QA at GP level
CENTRUMLOGO:
Flanders: dissemination of recommendation and QA package

Outcome Measures:

1. Use and consumption pattern of alcoholic beverages according to population survey

2. % of drinking above safe limits advised to cut down and returning to safe limits

3. % drinking above safe limits developing personal alcohol related harm

4. Knowledge of safe drinking limits according to GP and population survey

5. Attitude towards safe limits according to GP and population survey

6. Drink driving offences and accidents: n° retained during particular period in police registration for area

7. Reported family incidents (N° of certificates made in GP practices area and sentinel practices or signalised to community social services)

8. Newly treated people in centres for mental health care

9. Hospital and GP interventions for:
a) Acute alcoholic intoxications
b) Emergencies related to acute intoxication:
- Personnel Injuries
- Offences
- Car accidents
c) Emergencies due to complications of chronic alcohol related disease:
d) Chronic alcohol related disease
- Organic liver disease
- Psychotic consequences
Inclusion of these measures will be dependant area wise if we can convince the professionals involved and authorities for the creation of a regional sentinel registration network. We are actually working on this issue.

Process Measures:

1. N° and % of GP in different area’s at different moments trained for early identification and brief intervention
2. N° and % of GP trained and not trained using specifically promoted strategies for early detection within their practices as measured by survey to GP and controlled by centralised material distribution

a) AUDIT incorporated in GHQ
b) Isolated 5 shot questionnaire
c) Other questions (Frequency quantity mainly) incorporated in general preventive strategy
d) Advise card
e) Waiting room poster
f) Provision of leaflet on safe limits and safe use
g) Provision of leaflet hazardous drinking
h) Provision of leaflet on dependency

3. N° and % of GP in different municipalities at different moments using following strategies for counselling as measured by survey to GP and population:

a) Brief advice as defined by Drink Bewust (Drink Less) (stepped care approach) according to reimbursement claims
b) Providing follow up counselling: number of follow up visits and their duration according to reimbursement claims
c) Newly referred people to centres Mental health / specialist according to mental health care registration

4. Number and % of patients among inscribed patients between 50 and 65 years of age for which alcohol consumption has been recorded explicitly in file system

a) retrospective audit data at start
b) after each year of the study, in particular for those GP joining the regional data collection network planned by HOUVOL. This network will register vaccinations, accidents at home (with and without substance abuse), consultations for alcohol related harm, intentional violence presented to GP in a similar way as

5. Number Reimbursement claims per GP trained for early identification and brief intervention related to total number of patients seen in fixed period (6 month considered)

6. Percentage of people in overall population who talked with GP, pharmacist, dentist about alcohol according to survey
A number of process measures will relate to the description of the community action itself. Assistance for process measurement will be provided to these teams by Department of research (HSR branch) in WVVH. They will be developed in a participatory approach with active feedback strategy as part of the community programme. Collaboration with the municipalities and provincial platform will be important e.g. to get hold of police data on drunk driving and other public offences.

Economic Analysis:

Detailed analytical accounting of project management teams at national and local level. The registration of mayor health service use parameters for alcohol related problems aims to define potential impact on curative services.
Registrations of minimal clinical data will be planned in joint collaboration between GP circle and hospital wards. Collection of data in collaboration with insurance system will be studied. A mayor problem there may be grouping at district level as lowest unit for analysis.