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.

Bulgaria

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

Final Country Chapter, January 2006

Collaborative Centre:

National Centre for Addictions, Sofia

Chief investigators:

Dr. Alexander Kanchelov, M.D.

Dr. Gueorgi Vassilev, M.D., M.P.H.

Geographical Area in which Implementation Strategy will be Applied:

Bulgaria

Starting Date:

2 January 2001

Completion Date:

30 December 2006

Project Stands and Milestones:

Strand I: Customisation of materials and services and development of Communications Strategy

Strand II: The Demonstration Project

Strand III: The iterative process and formulation of early identification and brief intervention (EIBI) policy for the country

Proposed Funding Sources:

National Health Insurance Fund

National Programme for Psychiatric Reform

Local Support:

Local and communal authorities, Communal Drug Councils

Regional Health Departments

National Health Insurance Fund – Regional Offices

CUSTOMIZING  MATERIAL AND SERVICES

The brief intervention package to be used is The Drink-less Programme. To meet the aim of achieving a widespread implementation of early identification and brief intervention (EIBI) in particular primary health care setting in the country, some adjustment of the package to these particular needs and circumstances related to the primary health care organization and functioning is needed.

Early Identification:

The early identification instrument to be used is the AUDIT, with some minor adjustments. Early identification will be applied to the total adult population of a primary health care  service, it will be done opportunistically, under normal conditions of primary health care service and where the opportunity is taken to identify risky drinkers among those attending primary health care facilities for reasons other than worries about drinking. Personnel responsible for early identification will include GPs and/or practice nurses or receptionists (where available).

Brief Intervention Process:

Patients identified as risky drinkers will be provided with two types of interventions:

  1. Structured advice to all risky drinkers given by the GP (as formulated in the Drink-less Programme).
  2. more extended counselling ( including condensed cognitive-behavioural techniques and brief motivational interviewing ) to patients that are willing to attend for counselling appointments.

Training of Primary Health Care Staff:

An early identification and brief intervention (EIBI) training programme specific to the primary health care requirements in the country will be developed. It will be used to familiarize primary health care staff with the rationale, principles, methods and procedures of EIBI. The training model will be closely related to the customized EIBI package.

Data analysis:

Data from both focus groups and one-to-one interviews will be analysed in accordance with the guidelines for these analyses, provided by the Phase IV Focus Group Centre.

REFRAMING UNDERSTANDING OF ALCOHOL ISSUES

General Public:

A large-scale Mass media campaign will be an essential element of Communications Strategy. Its main objectives will be to communicate the concept of risky drinking, to encourage members of the public to ask their GP about drinking and whether or not they should cut down, to provide and reinforce information on limits for "responsible" drinking, to give confidence to risky drinkers among the public that primary health care are available and effective in assisting them to solve their drinking problems.

Health Professionals:

Primary health care professionals will be provided with education on alcohol issue and the concept of risky drinking and relevant information to modify their understanding of alcoholism.

Clear messages will be communicated to them that include: 1) raising the issue of risky drinking will not alienate patients; 2) risky drinking causes a substantial damage to public health; 3) EIBI for risky drinking are effective, cost-effective and relevant to primary health care practice.

Other Stakeholders:

Key-persons, experts, decision-makers, policy-makers, funders and other influential figures in the health care services, social services, local authorities, NGOs, volunteer groups, and other institutions and organizations with the power to affect the dissemination process, will comprise another target that will be involved to contribute to implementation of early identification and brief intervention in primary health care.

Media Advocacy:

Media advocacy will be used to assist the Communications Strategy by means of creating links with local journalists to increase their interest in alcohol-related issues and establishing a local lobby of journalists to promote the concept of risky drinking.

Control of Communications Strategy:

The Communications Strategy will be under the control of a Steering Group, consisting of the communications specialist associated with the study, representatives of local GP organizations, representatives of other primary health care professional groups, health authority officials, local authority officers, representatives of NGOs, local voluntary groups, and others.

The Steering Group will be sub-committee of the Main Committee, responsible for running the entire PHASE IV for the country. The Steering Group will define the aims of the strategy, activate the communications process and generally guide and monitor the strategy.

ESTABLISHING LEAD ORGANISATION(S) & BUILDING STRATEGIC ALLIANCES:

Lead organisation(s):

A lead organization will be established with the function to take the lead in developing a co-ordinated, country-wide approach to the promotion of early identification and brief intervention (EIBI) in the country. Its major objective will be to bring together individuals and organizations with interest in EIBI in a spirit of co-operation, mutual expected benefit and effective partnership. the lead organisation will be based at the National Centre for Addictions and its network.

Building Strategic Alliances:

The lead organisation will attempt to bring together into effective alliances all organizations in the country that have an essential role to play in the implementation strategy, including the following:

  1. The Ministry of Health
  2. The Ministry of Social Welfare
  3. National Health Insurance Fund
  4. Central and other agencies interested in funding and supporting special initiatives and innovative projects in primary health care.
  5. Central governmental and other agencies interested in funding activities and research into the reduction of alcohol-related harm.
  6. Prominent scientists, academic and practitioners in the areas of primary health care, training of primary health care professionals, treatment and prevention of alcohol problems, etc.
  7. Key educational and research institutions with expertise in the development of intervention and training materials and methods.
  8. Professional associations, e.g. colleges of general practitioners, nurses, medical social workers, psychologists, etc.
  9. NGOs, voluntary organizations, community groups that could contribute to the implementation strategy with particular respect to communicating the concept of risky drinking among the general public. 
  10. Potential funders and sponsors of the implementation strategy, including those from the pharmaceutical industry ( but not the alcohol industry).

DEMONSTRATION PROJECT(S)  

Location(s):

The city of Sliven, having population of approximately 1000. 000 and 50 PHC physicians.

Projected Start Date:

2 January 2002

Projected Completion Date:

30 December 2005

Design of project:

The Demonstration Project will have a single before-after study design. The data collection strategy will include data collection at baseline, completion and follow-up points, as well as careful evaluation of outcomes and economic outcomes.

Outcome Measures:

Since the main outcome objective is achieving widespread, routine and enduring Implementation of early identification and brief intervention in the primary health care setting, the outcome measures will include: 

  • change in number of GPs and other health professionals who screen and intervene for risky drinking, and the extend to which they do so.
  • change in knowledge of relevant alcohol issues
  • changes in attitudes of professionals towards early identification and brief intervention.
  • changes in community-wide indices of alcohol-related harm.

Data collection will be conducted by means of data-base and follow-up interviews and questionnaires.

Process Measure:

Process variables, relating to how and why the early identification and brief intervention package is effective in leading to reduced alcohol consumption, and under which conditions and circumstances, will be measured through: in-depth interviews with a sample of patients, structured questionnaire to collect data on process of change among patients, structured questionnaire implemented to personnel.

Economic Analysis:

The economic analysis will be based on community-wide indices of alcohol-related harm, changes in cost of health care expenditures, impaired productivity, motor vehicle crashes, and cost and benefits of early identification and brief intervention widespread implementation for the country.

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