Project BISTAIRS. Deliverable 1b (Work Package 4)

Transcription

1 Project BISTAIRS Brief Interventions in the Treatment of Alcohol use disorders in relevant settings Deliverable 1b (Work Package 4) Survey results Dipl. Psych. Christiane Schmidt, Dipl. PH Bernd Schulte, Dr Ingo Schäfer, Dr Peter Degkwitz, Dr Uwe Verthein, Prof Jens Reimer Contact: Christiane Sybille Schmidt Centre for Interdisciplinary Addiction Research, Hamburg University Department of Psychiatry (W37) University Medical Center Hamburg-Eppendorf Martinistr. 5, 04 Hamburg, Germany Tel Fax This work was supported by the health programme of the European Union as part of the BISTAIRS research project (Agreement number 011_104). The sole responsibility lies with the author and the Executive Agency is not responsible for any use that may be made of the information contained therein. For further information, visit the project website at 1

2 Table of contents Abbreviations... 3 Tables... 4 Figures Executive Summary Aims and purpose.... Methods Results Participating countries and regions Alcohol consumption and prevention Implementation and availability of brief interventions in different settings Impact of brief interventions in different settings Prerequisites for a further implementation of brief intervention for alcohol in different settings Conclusive summary... 5 Annex Expert questionnaire... 7

3 Abbreviations AMPHORA BI BISTAIRS EU INEBRIA ODHIN PHC PHEPA SD VINTAGE Alcohol public health research alliance Brief interventions Brief InterventionS in the Treatment of Alcohol use disorders In Relevant Settings European Union International Network on Brief Interventions for Alcohol and other drugs Optimizing delivery of health care interventions (project name) Primary health care Primary Health care European Project on Alcohol Standard deviation Good health into older age (project name) 3

4 Tables Table 1: Participating countries and regions... 7 Table : Mean implementation status per setting Table 3: Implementation status of BI: summary of items C.to C Figures Figure 1: Problem estimates of alcohol use... Figure : Adequacy of current prevention efforts Figure 3: Structures for quality of care Figure 4: Availability and accessibility of help for persons with harmful alcohol consumption Figure 5: Alcohol advice as part of routine clinical practice Figure : Attempts to implement brief interventions Figure 7: Mean implementation status Figure : Implementation status of BI per setting and country Figure 9: Mean estimates (over all settings) of BI implementation per country Figure 10. Guidelines and protocols Figure 11: Education and post-gradual training Figure 1: Specifity of guidelines and education for different settings Figure 13: Estimated impact of different settings to reach risky drinkers Figure 14: Estimated ability of different settings to provide screening, brief interventions and referral to treatment.... Figure 15: Prerequisites for further implementation of BI inmedical and social settings

5 0. Executive Summary Aims and purpose: In this part of the project BISTAIRS (Brief InterventionS in the Treatment of Alcohol use disorders In Relevant Settings), we aimed to provide an overview on the current implementation status of brief interventions (BI) in a range of different settings (primary health care (PHC), workplace health services, emergency care and social services). This was realized by means of a brief expert survey. Methods: An electronic questionnaire was developed to obtain basic information on alcohol prevention and BI implementation efforts, and estimates on the availability and potential impact of BI in the settings. The questionnaire was sent out via to a total of 34 experts from all 7 EU member states. Experts were retreived from several alcohol and BI research networks (e.g. ODHIN, INEBRIA) Results: In general, accessibility of patient help or routine advice regarding alcohol consumption was estimated higher in medical settings (especially general/family practices) than in social services. Although rather modest, also the implementation BI was rated higher in PHC, compared to social, workplace or emergency settings. Over all settings, 10 out of 19 countries report a very low implementation status of BI (below three points on a scale between 0 = not at all and 10 = fully ). The overall mean value over all countries and settings is 3.33 (SD.05). Regarding the ability of each setting to provide screening, brief interventions and referral to treatment, the highest impact was attributed to PHC, and the lowest to accommodation offices and employment agencies. Main prerequesites for further BI implementation comprised nationwide strategies/ supportive policies, allocation of financial resources, provision of education and training, but also an intensification of treatment referral or integrated care networks, and more evidence on BI effectiveness in nonmedical settings. Conclusions: Over a variety of items, the focus on PHC is consistently observable. This concerns the better although still not sufficient - implementation status of BI, and also the expert estimates regarding the potential impact of the various settings (in screening, provision of BI and treatment referral) which are clearly lower for settings beyond PHC. This is also reflected in the prerequisites needed for a better BI implementation, as the need for more evidence of effectiveness was expressed predominately for non-medical settings. 5

6 1. Aims and purpose Brief interventions (BI) show evidence to be effective in the management of alcohol consumption for non treatment-seeking harmful alcohol drinkers, who are at physical and social risk, but not dependent yet. As general objective, the project BISTAIRS (Brief InterventionS in the Treatment of Alcohol use disorders In Relevant Settings) aims to foster the implementation of brief interventions in a range of different settings (primary health care, workplace health services, emergency care and social services) by identifying, systematising and extending good practice of BI across the European Union (EU) member states. Work package I of this project aims to determine the evidence base regarding the effectiveness of BI as well as to provide an overview on their current implementation status in the European Union. In addition to the recently finished systematic literature reviews, we developed a brief electronic expert questionnaire, which we sent out to members of several alcohol research networks. This report displays and summarizes the main survey results.. Methods The electronic questionnaire (see annex) was developed to obtain basic information on alcohol prevention and BI implementation efforts, and estimates on the availability and potential impact of BI in the settings of primary health care (PHC), workplace health services, emergency care and social services. Experts were retreived from several alcohol and brief intervention research networks, namely ODHIN, AMPHORA, INEBRIA, VINTAGE and PHEPA. Further, each recipient was asked to provide names and adresses of further experts, who were contacted consecutively. Finally, a total of 34 experts from all 7 EU member states were contacted. In case of nonresponse, we wrote up to two reminder s. We also distributed questionnaires to be filled out by hand on the 9th INEBRIA conference in Barcelona in september 01. Recepients did not receive any financial reimbursements or other incentives. We finally received 47 responses from 17 countries (Austria, Belgium, Czech Republic, Denmark, Finland, Germany, Greece, Ireland, Italy, Lithuania, Netherlands, Poland, Portugal, Slovakia, Spain, Sweden, UK), whereas 10 countries, mainly from Eastern Europe, did not respond (Bulgaria, Cyprus, Estonia, France, Hungary, Latvia, Luxembourg, Malta, Romania, Slovenia). Among our 47 respondents, the experts from Spain differentiated between Catalonia and other Spanish regions, which is why we also made this difference in our analysis. Same for UK: respondents indicated either England or Scotland (there was no response from Wales), which is why we categorized their answers seperately. This results in a number of 19 countries and regions included in our analysis. In case of missing data, participants were contacted again and asked to indicate a value, if possible. However, few missing values remained, as some participants explicitly stated not to be able to judge some items or aspects.

7 3. Results 3.1 Participating countries and regions Country/Region Austria Belgium Catalonia 3 Czech Republic 3 Denmark England Finland Germany 1 Greece 1 Ireland 3 Italy 5 Lithuania 1 Netherlands 3 Poland 4 Portugal 3 Scotland Slovakia 1 Spain (region Ourense) 1 Sweden Total 47 Table 1: Participating countries and regions Number of experts 3. Alcohol consumption and prevention Item B.1 Alcohol consumption: To what extent on a scale from 0 (not at all) to 10 (fully), would you say that the alcohol consumption in your country is problematic? 1) Amount of alcohol consumption in the population; ) Amount of hazardous /harmful alcohol consumption in the population; 3) Amount of alcohol dependence in the population. Responses on this item are displayed in figure 1, revealing that most experts consider the alcohol consumption levels in their countries as rather problematic (only Austria gave a medium rating of 5). Over all countries, the mean rating for alcohol consumption in the general population was 7.53 (SD 1.3), the problem estimate of hazardous /harmful alcohol consumption was 7.57 (SD 1.95), and alcohol dependence was rated. (SD.0). Ratings were comparable for general alcohol consumption, hazardous/harmful use, and alcohol dependence, although some countries (e.g. Italy, Poland, Belgium) considered the amount of hazardous use more problematic than general drinking or dependence. Respondents from two countries (Netherlands, Slovakia) regarded, in contrast, alcohol consumption in the general population as the larger problem. 7

8 Alcohol consumption Hazardous/ harmful use Alcohol dependence Austria Belgium Catalonia Czech Republic Denmark England Finland Germany Ireland Italy Lithuania Netherlands Poland Portugal Scotland Slovakia Spain (Region Ourense) Sweden Figure 1: Problem estimates of alcohol use; 0 = not at all problematic, 10 = fully problematic

9 10 Primary prevention Secondary prevention Tertiary prevention 4 0 Austria Belgium Catalonia Czech Republic Denmark England Finland Germany Greece Ireland Italy Lithuania Netherlands Poland Portugal Scotland Slovakia Spain (Region Ourense) Sweden Figure : Adequacy of current prevention efforts. 0 = not at all adequate, 10 = fully adequate. 9

10 Item B. - Prevention: To what extent on a scale from 0 (not at all) to 10 (fully), would you say that the current implementation status of the following levels of alcohol prevention is adequate? 1) Primary prevention (e.g. education programmes) ) Secondary prevention (e.g. brief interventions) 3) Tertiary prevention (e.g. alcohol treatment options) Overall, ratings for primary prevention were 4.74 (SD 1.4), for seconday prevention 3. (SD.35), and 5.7 (SD 1.77) for tertiary prevention. As shown in figure, estimates vary considerably between countries, and also between prevention types. The majority of countries (1 out of 19) consider tertiary prevention (e.g. alcohol treatment options) as more adequately imlpemented than secondary and primary prevention. Secondary prevention, which is predominately targeting at-risk and hazardous, but not (yet) dependent drinkers, was rated lowest in nearly all countries, except for Catalonia, Finland and Scotland. Item B.3 - Structures for quality of care Is there a formal governmental organization, or organization appointed or contracted by the government that: 1. Has the responsibility of preparing clinical guidelines for managing hazardous and harmful alcohol consumption?. Monitors health outcomes at the population level from managing hazardous and harmful alcohol consumption? 3. Monitors the quality of care provided for managing hazardous and harmful alcohol consumption? 4. Reviews the cost effectiveness of interventions for managing hazardous and harmful alcohol consumption? 5. Reviews the safety of pharmacological treatments for managing alcohol dependence?. Provides information on managing hazardous and harmful alcohol consumption to health care providers? 10

11 Yes No Inconsistent Has responsibility of preparing clinical guidelines Monitors health outcomes at the population level Monitors the quality of care provided Reviews the cost effectiveness of interventions Reviews the safety of pharmacological treatments Provides information to health care providers Figure 3: Structures for quality of care. For each item, the number of countries/regions that indicated yes / no is displayed. The category inconsistent was given if answers from several experts from the same country/region differed. As shown in figure 3, most countries indicate having organisations that review the safety of pharmacological treatments against alcohol dependence, and organisations that provide information on managing hazardous and harmful alcohol consumption to health care providers. In contrast, only a minority of countries indicate having organisations that monitor the quality of health care provided, or that review the cost-effectiveness of interventions. For both these items, and also regarding organisations that have the responsibility of preparing clinical guidelines, and organisations that monitor health outcomes at the population level, there is a considerable number of inconsistencies, i.e. expert from the same countries differed in their responses. 11

12 Item B.4 - Availability and accessibility On a scale from 0 (not at all) to 10 (fully), to what extent do you think that patient help for hazardous and harmful alcohol consumption is accessible (accessible means that patients can get the help) in the following settings? As shown in figure 4, only addiction services (and special clinics, to a lower extent) were considered to provide fairly adequate availability of help (mean rating of.93 and 5.51, respectively). All other settings were given mean ratings below five points. Overall, accessibility of help was estimated being higher in medical settings (especially general/family practices) than in social services. 10,93 4 5,51 4,9 4,5 3,77 3,77 3,57 3,0,53,19 1,7 1,41 0 addiciton services special clinics general/family practise hospital clinics emergency care criminal justice system youth welfare services workplace health schools/universities pharmacies accomodation offices employment agencies Figure 4: Availability and accessibility of help for persons with harmful alcohol consumption. 0 = help is not at all available 10 = fully available. 1

13 Item B.5 - Clinical accountability To what extent do you estimate on a scale from 0 (not at all) to 10 (fully) that the following health care professionals consider advice for hazardous and harmful alcohol consumption as part of their routine clinical practice? Results are displayed in figure 5. The respondents of our survey estimate that, among several groups of health care professionals, predominately addiction specialists and - to a lower extent - also psychiatrists tend to consider advice on alcohol consumption as a part of their routine clinical practice. For most other groups of health care professionals, ratings were rather modest (ranging between four and five), and low estimates were given for pharmacists and dentists. 10,07,50 4 4,91 4,7 4,7 4,1 3,9 3,0 3,74 3,51,31 1,77 0 addiction specialists psychiatrists general practitioners psychologists nurses working in general practise counsellors social workers doctors in hospital obstetricians nurses working in hospitals pharmacists dentists Figure 5: Alcohol advice as part of routine clinical practice. 0 = not at all 10 = fully. 13

14 3.3 Implementation and availability of brief interventions in different settings Item C..1 Implementation attempts Have there been any attempts to implement brief interventions for alcohol in the daily work of professionals working in the one of following settings: 1) Primary health care ) Workplace health 3) Emergency care 4) Social services? As shown in figure, almost all participating countries/regions report implementation attempts in PHC. In emergency care settings, there have bee implementation efforts in at least half of the participating countries, whereas attempts to implement BI in the workplace or in social service settings are less frequent. yes no inconsistent primary health care workplace health emergency care social services Figure : Attempts to implement brief interventions. For each item, the number of countries/regions that indicated yes / no is displayed. The category inconsistent was given if answers from several experts from the same country/region differed. 14

15 Item C.. Implementation status To what extent on a scale from 0 (not at all) to 10 (fully), would you say that brief interventions for alcohol are currently available in [these] settings? In accordance to the responses on item C.1, mean implementation status (over all countries/regions) was rated highest in the PHC setting, although a value of 4.77 is still rather modest (see table and figure 7). Mean SD Primary health care Workplace health.93.5 Emergency care..30 Social services Total Table : Mean implementation status (all respondents; n = 47) per setting. 0 = not at all implemented, 10 = fully implemented 10 4,77 4,93,,7 0 primary health care workplace health emergency care social services Figure 7: Mean implementation status (all respondents; n = 47) per setting. 0 = not at all implemented, 10 = fully implemented Figure reveals marked differences in the estimated BI implementation levels. In accordance with the setting mean values displayed in figure 7, most countries/regions indicate that BI are best (or almost only) implemented in PHC whereas other settings play a less important role. Only Sweden and Finland, and on an overall lower level also Belgium gave comparable or higher implementation ratings for BI in workplace health services. Regarding emergency care, the highest ratings were reported for Finland, Scotland, the Netherlands and England. As to social services, the highest implementation estimates were found as well in the Northern parts of Europe, namely Finland (the only country with a value above 5) and the Netherlands. 15

16 10 primary health care workplace health emergency care social services Austria Belgium Catalonia Czech Republic Denmark England Finland Germany Greece Ireland 4 0 Italy Lithuania Netherlands Poland Portugal Scotland Slovakia Spain (Region Ourense) Sweden Figure : Implementation status of BI per setting and country. 0 = not at all implemented, 10 = fully implemented. 1

17 For a better comparison of the participating countries and regions, regarding their overall implementation status of BI, the mean values over all settings are displayed in figure 9. Based on these, we identified three countries with relatively high implementation estimates (mean values above 5), and six countries with mean values between 3 and 5. For approximately half of the participating countries/regions, implementation status was rather low (mean ratings below 3). 10 7, 5, 5,7 5,0 4, 4 0 Finland Scotland 4,1 3,5 3,4 3,1,9 Netherlands Catalonia Sweden Belgium England Italy Czech Republic,3,0,0 1, 1,5 1,5 1,0 Ireland Portugal Austria Slovakia Spain Germany Poland Denmark 0,5 0,0 Lithuania Greece Figure 9: Mean estimates (over all settings) of BI implementation per country. 0 = not at all implemented, 10 = fully implemented. Item C.3 - Guidelines and standard documents Are there any guidelines or written protocols on brief interventions for alcohol available? As shown in figure 10, most countries indicate having guidelines on brief interventions, whereas answers regarding other written protocols or standard documents are varying. Item C.4 - Education and training Is there any education or training on brief interventions for alcohol available in your country/region? As displayed in figure 11, education and post-gradual training are reported to be available in approximately half of the participating countries and regions. However, there is a relatively high number of inconsistent answers regarding post-gradual training. 17

18 yes no under preparation inconsistent guidelines protocols Figure 10: Guidelines and protocols. For each item, the number of countries/regions that indicated yes / no is displayed. The category inconsistent was given if answers from several experts from the same country/region differed. yes no inconsistent education post-gradual training Figure 11: Education and post-gradual training. For each item, the number of countries/regions that indicated yes / no is displayed. The category inconsistent was given if answers from several experts from the same country/region differed. 1

19 In addition, we asked those who indicated having guidelines/ protocols or education/post-gradual training to provide estimates on their setting specificity: To what extent on a scale from 0 (not at all) to 10 (fully), would you say that 1) guidelines or protocols ) education and training on brief interventions for alcohol are specific for the following settings (PHC, workplace, emergency care, social services)? As shown in figure 1, guidelines and protocols as well as education and training are reported to be most specific for the PHC setting, and appear to have only low specificity on workplace health, emergency care and social service settings. Guidelines and protocols Education and training primary health care workplace health emergency care social services Figure 1: Specificity of guidelines and education for different settings. 0 = not at all specific for this setting ; 1 = fully specific for this setting Table 3 summarizes the previously reported responses on all items related to BI implementation and gives an overview per country. In case of inconsistent responses on implementation attempts or on the availability of guidelines and education, a + was given if the majority of experts per country indicated yes. 19

20 Guidelines Protocols Education Postgradual training Implementation attempts PHC Workplace health Emergency care Social services Rating (mean, range) Implementation attempts Rating (mean, range) Implementation attempts Rating (mean, range) Implementation attempts Rating (mean, range) Austria (1-4) (1-) (1-) -.5 (1-4) Belgium (5-7) +.0 (5-7) +.0 (-) +.5 (-3) Catalonia (7-9) (4-7) (3-4) (-5) Czech Republic (-7) -.3 (0-7) +.0 (-) (-7) Denmark (-3) (0-1) (0-1) (0-1) England (3-) +.0 (1-4) + 4. (3-) -. (1-5) Finland (-9) +.5 (-9) (-9) +.0 (5-7) Germany Greece Ireland (1-10) (1-) (1-3) (0-) Italy (4-7) (0-5) -. (0-4) (-5) Lithuania Netherlands (-) (4-) (5-7) (3-7) Poland (1-4) - 0. (0-1) (1-1) -.3 (0-4) Portugal * (-5) +.0 (0-4) (0-4) +.0 (1-4) Scotland (9-9) -.5 (-3) (7-) (3-5) Slovakia Spain (Region Ourense) Sweden (-) +.0 (7-9) +.5 (1-4) (1-) Table 3: Implementation status of BI: summary of items C.to C.4. + "majority of experts indicated yes; - "not implemented or unclear" * under preparation 0

21 3.4 Impact of brief interventions in different settings Item C.5. - Reachability of persons with hazardous and harmful alcohol consumption To what extent on a scale from 0 (not at all) to 10 (fully), would you say that a further implementation of brief interventions for alcohol in the following settings will have a significant impact to reach persons with hazardous and harmful alcohol consumption? As shown in figure 13, most experts consider the PHC setting having the highest impact to reach this target group. Emergency care, workplace health services, the criminal justice system schools/universities and youth welfare services have comparable, medium ratings, whereas employment agencies and accommodation offices are estimated to have a relatively low impact primary health care workplace health emergency care employment agencies schools/universities criminal justice system youth welfare services accomodation offices Figure 13: Estimated impact of different settings to reach risky drinkers. 0 = no impact at all, 10 = full impact Items C., C.7 and C. - Screening, delivery of BI and referral to treatment To what extent on a scale from 0 (not at all) to 10 (fully), would you say that the following settings and contexts are 1) adequate to screen for persons with hazardous and harmful alcohol consumption (C.) ) adequate to deliver brief interventions for alcohol (C.7) 3) able to refer persons with alcohol problems to a specialised treatment unit (C.)? Figure 14 displays the estimated ability of each setting to provide screening, brief interventions and referral to treatment. Overall, the pattern is similar to figure 13, attribuing the highest potential to the PHC setting, and the lowest to accomodation offices and employment agencies. Comparing the 1

22 different aspects of brief alcohol interventions (screening, delivery of BI and referral to treatment), there are only marginal differences within each setting. For example, emergency care and criminal justice settings were considered slightly better in screening and treatment referral, compared to BI delivery, whereas schools/universities have marginally higher estimates for BI delivery, but, in contrast, are estimated having a relatively low ability for treatment referral. Screening Delivery of BI Referral to treatment primary health care workplace health emergency care employment agencies schools/universities criminal justice system youth welfare services accomodation offices Figure 14: Estimated ability of different settings to provide screening, brief interventions and referral to treatment. 0 = not able/adequate at all, 10 = fully able/adequate. In addition to our pre-defined settings, participants had the possibility to indicate up to two further areas where they see an impact of BI. These were predominately pharmacies, but also social inclusion programmes, dentistry, online interventions or the military forces setting.

23 3.5 Prerequisites for a further implementation of brief intervention for alcohol in different settings Item C.9 - Prerequisites To what extent on a scale from 0 (not at all) to 10 (fully) would you say that the following steps are needed for a further implementation of brief interventions for alcohol in medical and social settings? We pre-defined four aspects: - Extensive provision of education/training - Development of specific guidelines/protocols - Allocation of finacial resources/funding - Supportive policy initiatives In addition, respondents had the possibility to make up to five further suggestions to improve further BI implementation. Regarding the four pre-defined aspects, figure 15 reveals that they are considered nearly equally important. The development of specific guidelines or protocols obtained slightly lower rates, especially in medical settings, which might be due to the fact that guidelines and protocols are already available in most of the participating countries. There are only marginal differences between medical and social settings; only the allocation of financial resources seems to be considered slightly more necessary in medical settings. 10 medical settings social service settings 4 0 Extensive provision of education/training Development of specific guidelines/protocols Allocation of financial resources/funding Supportive policy initiatives Figure 15: Prerequisites for further implementation of BI in medical and social settings. 0 = not at all needed ; 10 = fully needed 3

24 Most respondents used the possibility to indicate further suggestions for BI implementation. We identified six main categories (sorted in descending order; first category was most often mentioned) - Networking/ integrated care: local network of appropriate services/ treatment referral networks/ integrated care pathways/ supportive community initiatives/ coordination with other health promotive efforts - Nationwide strategies/policies: nationwide structures to support BI/ national performance targets/ stustainably policy/ financial rewards for performing above basic levels of screening - Education: undergraduate education/ supportive education and training programmes/ adequate system of education on an institutional basis - Evidence of effectiveness: in non-medical settings or pharmacies/ research validation of screening instruments/ evidence on fidelity on intervention delivery - Discussion of feasibility: adressing the issue of trust in staff s possibility to cary out BI/ discuss possibilities of prevention when the work load already is high/ adressing problematic attitudes to alcohol, e.g. not my job, we all drink, etc. - Use of modern technologies (internet, cell phone) Apart from these main issues, other suggestions comprised: Leadership at strategic and ground level, better access to BI, service commisioning in pharmacies, supportive informatic system and monitoring indicators, or sensitizing campaigns in the media. 4

25 4. Conclusive summary The main results of our survey can be summarized as follows: Most experts considered the alcohol use in their countries/ regions as highly problematic, which was equally the case for general consumption, hazardous use and the amount of alcohol dependence. 1 out of 19 countries consider tertiary prevention (e.g. alcohol treatment options) as more adequately imlpemented than primary and especially secondary prevention (e.g. BI), which obtained lower ratings in almost all countries. Patient help and routine advice regarding alcohol consumption were estimated to be fairly available in addiction treatment services or among health care professionals specialized for addiction treatment, but to a much lower extent in other more general structures of care. Overall, accessibility of help was estimated being higher in medical settings (especially general/family practices) than in social services. Current implementation status and previous attempts to implement BI were estimated highest although still not sufficient in the PHC setting. In workplace health care, emergency care or social services, BI implementation plays a minor role. Computing the mean values over all settings, 10 out of 19 countries/regions have a very low implementation status of BI, six countries gave medium to low estimates, and only three countries have mean ratings over 5 points (on a scale from 0 = not at all to 10 = fully ). The overall mean value over all countries and settings is 3.33 (SD.05). Most countries report having guidelines on BI. Education or post-gradual training is less implemented and answers show a higher variability, also between experts from the same countries. Both guidelines and education are reported to be more specific for PHC than for other settings. Regarding (future) impact and the abilities of each setting to provide screening, brief interventions and referral to treatment, the highest potential was attributed to PHC, and the lowest to accommodation offices and employment agencies. Based on pre-defined and open questions, we identified the following main prerequisites for further BI implementation : - Supportive policies/ nationwide strategies - Allocation of financial resources - Extensive provision of education and training (on an institutional basis) - Networking (treatment referral, integrated care pathways) - Evidence of effectiveness in settings beyond PHC - Discussion of feasibility 5

26 This study has a number of limitations. The main limitation consists in the small sample size: from five countries/regions, we have responses from only one expert (see table 1). Another point, which might not necessarily be a limitation but which should be considered in the interpretation of the data, is the selection of our expert sample. Participants were retrieved via databases from alcohol and BI research networks, and most probably they may have another view on this issue than service providers, practitioners or other professionals. Whereas the responses per countries should not be overestimated for those with only one or two participants, the estimates regarding different settings may allow more valid conclusions. Over several items, it can be observed that in primary health care, implementation status of BI as well as is rated highest, and although still not sufficiently implemented there were clearly more attempts made in this domain than in other settings. Concerning settings beyond PHC, there is a high variability regarding implementation attempts and current availability of BI between countries, and regarding the questions on their estimated potential it seems that most experts are not very confident in the ability of these settings to reach persons, to screen, to provide BI and to refer to treatment. This is also reflected in the prerequisites needed for a better BI implementation, as the need for more evidence of effectiveness was expressed predominately for non-medical settings.

27 Annex Expert questionnaire Brief interventions for alcohol problems Questionnaire on the implementation status in different settings INTRODUCTION The aim of this questionnaire is to describe the current implementation status of brief interventions for alcohol problems in different settings (Primary health care, work-place health services, emergency care and social services) at a member state level in European Union. 7

28 Instructions to complete the questionnaire It is preferable that you complete the questionnaire electronically (as a word document). Text boxes: Just place the cursor in the text box and type. (Pressing the tab key moves you from box to box). You can also cut text from other documents & paste them into the text boxes. There are no limits to the size of the text boxes. Check boxes: Just place the cursor in the check box that you want to mark and left click the mouse. If you want to correct the check box, just left click the mouse again.

29 A. Personal Information 1. Please provide us with your contact details Name Organisation Telephone. For which country you are answering? Country If you are not able to answer for a country as a whole, you have the possibility to complete the questionnaire for a specific region. Please indicate the region: Region Please note: If you are completing the questionnaire for a specific region, please ensure that ALL your answers apply for this region! 9

30 B. Alcohol consumption and alcohol prevention in your country 1. Alcohol consumption in your country To what extent on a scale from 0 to 10, would you say that the alcohol consumption in your country is problematic? Amount of alcohol consumption in the population Amount of hazard/harmful alcohol consumption in the population Amount of alcohol- dependence in the population not at all fully Implementation status of alcohol prevention in your country To what extent on a scale from 0 to 10, would you say that the current implementation status of the following levels of alcohol prevention is adequate? Primary prevention (e.g. education programmes) Secondary prevention (e.g. brief interventions) Tertiary prevention (e.g. alcohol treatment options) not at all fully

31 3. Structures for quality of care For each topic in the table, is there a formal governmental organization, or organization appointed or contracted by the government that: 1. Has the responsibility of preparing clinical guidelines for managing hazardous and harmful alcohol consumption?. Monitors health outcomes at the population level from managing hazardous and harmful alcohol consumption? 3. Monitors the quality of care provided for managing hazardous and harmful alcohol consumption? 4. Reviews the cost effectiveness of interventions for managing hazardous and harmful alcohol consumption? 5. Reviews the safety of pharmacological treatments for managing alcohol dependence?. Provides information on managing hazardous and harmful alcohol consumption to health care providers? No Yes If Yes, please provide filename for organizational reference 4. Availability and accessibility On a scale from 0 to 10, to what extent do you think that patient help for hazardous and harmful alcohol consumption is accessible (accessible means that patients can get the help) in the following settings? not at all Health care settings General/family practice Hospital clinics Pharmacies Specialist clinics (such as a rehabilitation clinic) Addiction services Workplace health Emergency care Social service settings Employment agencies Schools/Universities Criminal justice system Youth welfare services Accommodation offices fully 31

32 5. Clinical accountability To what extent do you estimate on a scale from 0 to 10 that the following health care professionals consider advice for hazardous and harmful alcohol consumption as part of their routine clinical practice? Advice is routine in clinical practice: General practitioners Doctors in hospital Addiction specialists Psychiatrists Nurses working in general practice Nurses working in hospitals Pharmacists Social workers Psychologists Dentists Obstetricians Counsellors not at all fully

33 C. Implementation of brief interventions on alcohol in different settings in your country 1. Introduction and setting definition The following questions are focussing on the implementation of brief interventions for alcohol in the daily work of professionals working in following settings: Setting Primary health care Workplace health Emergency care Social services Examples General practitioners or family physicians, nurses in primary care units Occupational health and safety staff Physicians or nurses of trauma units Probationers, job advisers, teachers, social workers,. Implementation and availability of brief interventions in different settings Have there been any attempts to implement brief interventions for alcohol in the daily work of professionals working in the one of following settings? If YES, please list any documents/references at the end of the questionnaire. Primary health care Workplace health Emergency care Social services Yes No To what extent on a scale from 0 to 10, would you say that brief interventions for alcohol are currently available in the following settings? Primary health care Workplace health not at all fully Emergency care Social services 33

34 3. Guidelines and standard documents Are there any guidelines or written protocols on brief interventions for alcohol available? If YES, please list them at the end of the questionnaire. Guidelines Protocols Other: Yes No No, but under preparation To what extent on a scale from 0 to 10, would you say that guidelines or protocols on brief interventions for alcohol are specific for the following settings? Primary health care Workplace health Emergency care Social services not at all fully Education and training Is there any education or training on brief interventions for alcohol available in your country/region? Education Post-gradual training Yes No No, but under preparation To what extent on a scale from 0 to 10, would you say that education and training on brief interventions for alcohol are specific for the following settings? Primary health care Workplace health Emergency care Social services not at all fully

35 5. Reachability of persons with hazardous and harmful alcohol consumption To what extent on a scale from 0 to 10, would you say that a further implementation of brief interventions for alcohol in the following settings will have a significant impact to reach persons with hazardous and harmful alcohol consumption? not at all Medical settings Primary health care Workplace health Emergency care Social service settings Employment agencies Schools/Universities Criminal justice system Youth welfare services Accommodation offices Other: Other: fully 35

36 . Screening in different settings To what extent on a scale from 0 to 10, would you say that the following settings and contexts are adequate to screen for persons with hazardous and harmful alcohol consumption? not at all Medical settings Primary health care Workplace health Emergency care Social service settings Employment agencies Schools/Universities Criminal justice system Youth welfare services Accommodation offices Other: Other: fully 7. Delivery of brief interventions for alcohol To what extent on a scale from 0 to 10, would you say that the following settings and contexts are adequate to deliver brief interventions for alcohol? not at all Medical settings Primary health care Workplace health Emergency care Social service settings Employment agencies Schools/Universities fully 3

37 Criminal justice system Youth welfare services Accommodation offices Other: Other:. Referral to treatment To what extent on a scale from 0 to 10, would you say that the following settings are able to refer persons with alcohol problems to a specialised treatment unit? not at all Medical settings Primary health care Workplace health Emergency care Social service settings Employment agencies Schools/Universities Criminal justice system Youth welfare services Accommodation offices Other: Other: fully 37

38 9. Prerequisites for a further implementation of brief intervention for alcohol in different settings To what extent on a scale from 0 to 10, would you say that the following steps are needed for a further implementation of brief interventions for alcohol in medical and social settings? not at all Medical settings Extensive provision of education/training Development of specific guidelines/protocols Allocation of financial resources/funding Supportive policy initiatives Other: Other: Other: Other: Other: fully not at all fully Social settings Extensive provision of education/training Development of specific guidelines/protocols Allocation of financial resources/funding Supportive policy initiatives Other: Other: Other: Other: Other: 3

39 Further information resources Please list any publications (scientific paper, reports, guidelines, protocols etc.) on this topic Author Reference Are there further key informants/experts on BI in your country? Name Please add any kind of further information or comments here: 39