PRIMARY HEALTH CARE EUROPEAN PROJECT ON ALCOHOL (PHEPA) 2ND PHASE: PROJECT ON DISSEMINATING BRIEF INTERVENTIONS ON ALCOHOL PROBLEMS EUROPE WIDE

Transcription

1 PRIMARY HEALTH CARE EUROPEAN PROJECT ON ALCOHOL (PHEPA) 2ND PHASE: PROJECT ON DISSEMINATING BRIEF INTERVENTIONS ON ALCOHOL PROBLEMS EUROPE WIDE STRATEGY FOR SLOVAKIA Written by: Alojz Nociar 1

2 INTRODUCTION The Slovak Republic, or Slovakia, is a republic which became an independent state on January 1st 1993, when the antecedent state, Czechoslovakia, was divided peacefully by parliamentary decision. According to the Slovak Constitution, we have three main state officials the president, who is the head of state, prime minister, who is the head of the government, and the chairman of the National council, who is the head of the parliament. The president is directly elected for fiveyear term, and 150 deputies of the National council, either coming from political parties, or independent, are also directly elected for four-year term. Now, after 15 years Slovakia is a member of the NATO, and a member country of the EU, using the Euro as national currency since January 1st The Slovak Republic covers an area of 49 thousand km2 and the average population density is 110 inhabitants per km2. The number of inhabitants was 5.4 million at the end of 2008 (2.7 million women). Life expectancy for males was 70.5 years and for females 78,1 years. The mean age of males was 36.4 years and of females 39.5 years. Negative trends in population structure were reflected in younger people (25,1 % of 15 and less years in 1990, and 19.2 % in 2000) and older ones (e.g % over 64 years in 1990). In Slovakia 15.8 % were aged 15 or less and 16.3 % over 64 years in The capital and largest city is Bratislava with 450 thousand inhabitants. More then a half of the Slovak population (58 %) live in urban areas. The Slovak Republic is divided into eight regions, governed by the state administration of higher territorial units and autonomous governments as well. Relatively low life expectancy of Slovak men is caused mainly by cardiovascular diseases, other alcohol and tobacco related diseases, and also by excessive alcohol consumption. The Slovakian population is predominantly of Slovak origin (86%), and it belongs to the family of Slavonic nations. The rest of the citizens are of Hungarian (close to 10%), Roma (2.5%), Czech (0.8%), and Ukraine nationalities (07%). The official language is Slovak. According to 2001 census about 69 % of the Slovak population are Roman Catholics, 7 % are Protestants, 5 % are of Greek Catholic and Orthodox church religion, 13 % are atheists and remaining 6 % are either unknown or of minority religious groups. 2

3 THE USE OF ALCOHOL The tradition of drinking home-made alcohol beverages is strong in Slovakia, including all types of spirits of 40 to 60 % of alcohol by volume. There is also production of home-made wines. Hence it is very difficult to determine real amount of per capita consumption without taking into account an estimation of unrecorded production. Previous sources indicated per capita consumption from 3 to 5 litres of 100 % ethanol before the sixties, with a low proportion of beer and equal proportions of wine and spirits. Drinking alcoholic beverages was for a long time a male privilege, but also women have started to drink more and after 1989 they were drinking in public or in various drinking settings. This was true above all for adolescent girls and young women. Beer and spirits were the most favoured drinks for males, wine for women. Recently there was a shift in the preferences for alcohol beverages, with a decline in wine consumption among both men and women and a clear tendency to drink much more spirits. Per capita consumption in the sixties was quite high in Slovakia, and it nearly doubled during 20 years from 4.7 litres of 100 % spirit in 1960 to 10.7 litres in 1980, with peak of 10.9 litres in Alcohol consumption increase was constant in the period from 1960 to 1980, with small drop from 10.2 to 9.5 litres in , but since 1990 the officially recorded consumption has been gradually decreasing (figure 1). The estimation of average home-made production and unrecorded consumption might be as high as one third of officially recorded numbers on consumption per capita. This amount concerns most of all spirits and wines, i.e. not beer, which has never been produced at home in Slovakia. So, in 1990 instead of the officially registered 13.9 litres per capita among 15+ year olds it would be 18.5 litres per capita; in 2000 instead of 11.0 litres it would be 14.7 litres per capita and in 2004, instead of litres. It is estimated that roughly up to 5 % of the Slovakian population are abstainers, around 60 % are alcohol consumers without problems, 30 % are hazardous, risky or problem drinkers, and the remaining 5 % are alcohol dependent persons. This division corresponds to estimations of problem drinking and alcohol dependence among secondary school students, as signs of problem drinking, measured by the CAGE, were present among over 5 % of students, and signs of dependence were present among nearly 5 % of the secondary school students. Also the ESPAD questions concerning lifetime prevalence of any alcohol among 16 to 18 years old secondary school students showed 4.2 % of abstainers in 1995, but only 3.5 % in 1999 and 2.0 % in

4 (percentages of lifetime drunkenness had grown accordingly from 60.6 % in 1995 through 66.7 % in 1999 to finally 79.4 % in 2003). Officially registered per capita alcohol consumption is displayed in the following figure: ,8 Total Beer Wine Spirits 14,3 14,5 13,9 13, ,5 10,3 11,0 11,5 11,4 11, ,9 3,4 2,0 1,5 4,8 4,7 4,7 4,7 3,0 2,7 5,2 6,6 2,9 3,0 7,1 7,2 4,1 7,6 2,7 2,6 2,4 5,0 3,9 4,4 3,4 1,9 4,9 4,6 4,1 5,9 5,4 4,1 1,7 1,9 1, Picture 1. Recorded adult per capita consumption (age 15+): Slovak Republic from 1960 till 2004 Source: Statistical Office of the Slovak Republic; Processing and graphics: Alojz Nociar 2005 The numbers of non-consumers among Slovak citizens aged 18 to 64 were estimated via biannual population surveys from 1996 till These estimations were counted separately for three types of alcohol beverages (see tables 1,2,3). Table 1. Drinking of beer within a sample of adult Slovak population (data in %) YEAR DAILY DRINKING 2 3 TIMES PER WEEK DRINKING OCCASIONALLY DO NOT DRINK AT ALL

5 Source: Institute for Public Opinion Research. Statistical Office of the Slovak Republic, Bratislava The group of non-consumers of beer consisted of approximately one third of the adult population. Daily consumers were most frequently males, workers, respondents with elementary education and unemployed. On the other hand, non-consumers were predominantly women, people aged 60 and more, and living in places with between 2 to 10 thousand inhabitants. Drinking wine is not so frequent in Slovakia as drinking beer, a fact which is documented by data in the next table from the interval of ten years. Table 2. Drinking of wine within a sample of adult Slovak population (data in %) YEAR DAILY DRINKING 2 3 TIMES PER WEEK DRINKING OCCASIONALLY DO NOT DRINK AT ALL Source: Institute for Public Opinion Research. Statistical Office of the Slovak Republic, Bratislava Non-consumers of wine represented approximately one quarter of the adult population. Daily consumers were most frequently citizens in the category of other nationalities, but other sociodemographic groups did not differ from the whole-slovakian average. Non-consumers were mainly among people aged 60 and more, with elementary education, and among students. Table 3. Drinking of spirits within a sample of adult Slovak population (data in %) YEAR DAILY DRINKING 2 3 TIMES PER WEEK DRINKING ONLY OCCASIONALLY DO NOT DRINK AT ALL

6 Source: Institute for Public Opinion Research. Statistical Office of the Slovak Republic, Bratislava Use of spirits is less frequent compared to wine and beer drinking. The group of non-consumers of spirits consisted of 35% of respondents in This was a little bit more then before, and there were also fewer occasional consumers. Daily consumers and those drinking 2-3 times per week are approximately the same frequency as in previous years. Drinking of spirits 2-3 times per week is typical for males, citizens of Hungarian nationality, workers and the unemployed. Nonconsumers were mostly females, people aged 60 and more, respondents with elementary education, and students. 6

7 THE HARM DONE BY ALCOHOL The analysis was based upon the study by G. Hardman from York University "Updating the social costs of alcohol misuse". We estimated average numbers of deaths, caused by excessive drinking or alcoholism. From the overall mortality rate in the period observed, there were 8 % of people who died because of diseases caused very probably by alcohol abuse or alcoholism. Losses caused by or attributable to alcohol were estimated by the Socio-economical Analyses Department of former National Health Promotion Centre. 8% from the overall mortality in the year analysed died because of diseases which were very probably caused by alcohol abuse and/or dependence. Death of fathers and mothers in their young or middle age attributable to diseases caused by alcoholism led to losses in: (a) income of families, with lowering of life standard; (b) economic field: values not created because of short term sickness absence, permanent disablement and premature death; (c) social field: families without a bread-winner and subsequent problems among youth, expenses for widow s allowances and orphans annuities; (d) and in other fields, related to social pathology, like aggressiveness and violent criminality, alcohol caused fatal crashes, expenses for police forces and prisons, etc. The analysis was done in In the course of 230 working days in 1994 the work of workers was lost, as they were absent because of alcohol abuse or alcoholism. In regard to GDP in 1994, and the number of labour power, the amount of Slovak koruna (Sk) was created by one worker. Because of all year absence from work of workers, there was a loss of mil. Sk of non-created GDP. In the case of permanent disablement as well as high unemployment in this category of citizens, loss of the GDP for disabled would be mil. Sk in Furthermore, because of premature death (i. e. in productive age up to 55 years in women, and up to 60 years in men), we must count also loss of non-created values for the rest of active life. Health, Crime and public disorder, losses of productivity, social harms Health indicators, concerning alcohol related morbidity and mortality (from cardiovascular, gastrointestinal, pulmonary, liver diseases to alcohol poisoning etc.) were monitored by the National information system by the National Institute on Health Information (NIHI). Also the Statistical Office was monitoring amount of registered consumption of alcoholic beverages, computed as percentages of absolute alcohol. 7

8 Whole group of indicators was then analysed as follows below: a)increased costs in health care and social sphere; b)loss resulting from not used education and qualification; c)losses of society caused by overall criminality. Selected tables of these NIHI indicators are below: Table 4. Deaths due to chronic liver diseases and cirrhosis in Slovakia: T O T A L M A L E F E M A L E YEAR ABSOLUTE ABSOLUTE ABSOLUTE , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,41 8

9 T O T A L M A L E F E M A L E YEAR ABSOLUTE ABSOLUTE ABSOLUTE , , , , , , , , , , , ,17 Table 5. Number of deaths due to motor vehicle accidents in Slovakia T O T A L M A L E F E M A L E YEAR ABSOLUTE ABSOLUTE ABSOLUTE , ,0 82 4, , ,2 74 3, , ,4 92 4, , ,2 91 4, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,9 9

10 T O T A L M A L E F E M A L E YEAR ABSOLUTE ABSOLUTE ABSOLUTE , , , , , , , , , , , ,8 Because the study from previous decade was not repeated for alcohol, we are using its findings also now, as the only estimate available at national level for alcohol. Alcohol related diseases leading to death at a productive age are lead to non-recoverable income losses in families, to overall economic and social losses, criminality, etc. If they are based on scientific evidence, such facts are used for comparisons of profits from trade and sale of alcohol beverages with expenses-costs for consequences of excessive drinking and alcoholism in advanced countries. A summary of the results in Slovakia is presented below. Criminality, losses of productivity, harm to families and social networks these variables, which have consequences for society as a whole (car accidents, criminality, divorces), and for societal sectors as well, but above all for health care (cirrhosis mortality, alcohol poisoning, alcoholic psychoses, and other alcohol attributable diseases), were included in the analysis and are summarised in Table4. Summary of harms Tab. 4. Summary of the economic consequences of alcoholism Indicator I. Expenses for health care and overall social costs including - Operating costs of hospitals and treatment facilities - payments of insurance companies for sickness absence - disability pensions - widows allowance and orphans annuity II. Loss for not created gross domestic product including - loss caused by sickness absence - by disablement - by premature death III. Other losses and social expenses including - education of those who died prematurely - costs attributable to overall criminality - expenses of the police and judiciary Expenses and losses together : T o t a l c o s t s in mil. Sk /mil. U.S. $ millions Sk 97,1 48,3 14,0 21,8 13,0 412,4 112,4 207,4 92,6 61,9 4,4 20,1 37,4 571,4 millions U.S. $ 10

11 Approximate percentage from GDP : 1.25 % As this table shows, the consequences are not concentrated on the health care sector, but are spread out across various social fields, mainly the economic one, where the total costs and expenses for excessive binge, permanent or addictive drinking must be covered by all society members, including non-drinkers. For example in 1994 every Slovakian citizen in productive age had contributed to mitigate consequences of excessive drinking or alcoholism to the sum of Sk (or 114 U.S. $), which was roughly from 1/2 to 2/3 of his or her mean month salary. The author does not compare the overall sum from Table 1, which is over half a billion U.S. $, with the total income to the state budget from excise, VAT and other taxes from alcohol production and sale, for ethical reasons. In her opinion, the same as in the analysis done in response to the tobacco smoking epidemic, there is no amount of money which can compensate missing years of life in many families, and no means to relieve personal and family tragedies. 11

12 MEASURES TO REDUCE THE HARM DONE BY ALCOHOL Within the National Action Plan for Problems with Alcohol (NAPPA) there were 10 strategies defined for implementation, which were derived from the Paris 1995 European Alcohol Charter, and its 10 recommended strategies. This plan remained practically only written on paper, and in spite of its acceptance by the government, no financial resources were explicitly allocated to its strategies and goals. Formally, however, the NAPPA for the years from 2000 to 2005 was formally approved and later on rewritten according to the new Framework for alcohol policy, for continuation after the year No substantial changes were introduced as far as main strategies are concerned, but the stress was laid more on the health care sector, as the main organiser of this new NAPPA. Anyway, the situation is the same as it was with the old version no financial resources were explicitly allocated in the national budget line, hence the fulfilment of strategies and tasks may end in the same stalemate as in the previous case. Therefore measures reduction of harm done by alcohol are still laid on the shoulders of individual sectors, e.g. justice and home affairs are still responsible for taking measure against drunken driving, or violence at home and families, the sector of education is still responsible for prevention, but their resources are allocated to this not as explicit item taken from NAPPA budget line, but from lines of respective sector, which is not a good solution for year to year sustainability of efforts in the field. 12

13 THE EFFECTIVENESS AND COST-EFFECTIVENESS OF SCREENING AND BRIEF INTERVENTIONS FOR HAZARDOUS AND HARMFUL ALCOHOL USE IN PRIMARY HEALTH CARE Effectiveness of SBI We started to consider SBI earlier then the interest was expressed in 2005 but due to other priorities, namely NAPPA, Slovakia did not take part in the Phepa1. Slovakia declared an interest in taking part in the second phase of the Phepa in the Autumn of 2005 and at the beginning of 2006, and re-confirmed this definitively in May 2006 at the Barcelona conference. The Slovakian representative took part in the first meeting of the Phepa II in Vilnius, Estonia, where the preliminary plan of activities was outlined as the dissemination of early identification and brief intervention against hazardous and harmful drinking among upper primary and secondary school students. Cost-effectiveness No studies of SBI cost-effectiveness were implemented in Slovakia. Implementation All activities within the SBI were under the umbrella of the Slovak part of Phepa2. 13

14 CURRENT POLICIES The SBI as an approach and method were included formally in the NAPPA, but without any financial, labour or material support. Therefore all that was done was training and dissemination implemented via the Slovak part of the Phepa2. 14

15 INTEGRATING PREVENTIVE INTERVENTIONS IN PRIMARY HEALTH CARE This nation-wide mapping of the target population was carried out because of the intention to translate and to adapt for practical use the Clinical Guidelines and Training manual, created during Phepa I, in which Slovakia did not take part. In the second half of the eighties and during the nineties the author of this paper adapted and then standardized tools for screening and detection of alcohol problems and dependence, like ADS (Nociar et al. 1991) but also MAST, CAGE and Trauma Scale. Also Audit and MALT were tried in the clinical population, but not standardized, and the same was true for the Stages of Change Questionnaire (SCS) and the Processes of Change Scale (PCQ) original versions, which we were allowed to use for research purposes by their author J.O. Prochaska. Finally two screening scales, adapted and standardized for the clinical population were considered for use along TAD2006 and ESPAD2007. ADS and CAGE items were used as an addendum to the TAD in recent survey in March 2006, and results showed that the level of risk drinking among Slovakian youths is very high. Because of these empirical findings, supported by epidemiological and also clinical data, we decided to act, rather than the usual drawing attention to an alarming situation and doing nothing. Fortunately, the project of participation of Slovakia in the second phase of Phepa was in line with priorities of main funding institution, the Anti-drug Fund in the field of education and prevention, as well as with the EU health policy, hence we applied both for funding in Slovakia, and for the status of cobeneficiary in EU framework. Practice-based guidelines, protocols and aids The main goal during 2007 was to translate and adapt for practical use the Clinical guidelines on Identification and Brief Interventions and related Training Programme. Other sub-goals were as follows: To adapt clinical and training manuals which were created during previous part of the Phepa I with regard to Slovak conditions; To enable psychologists and educators in general to acquire basic skills in screening and brief intervention for detection of risk drinking in students; To prepare these methods and methodical approach for the dissemination throughout their network in Slovakia; To prepare materials for inclusion of this method into the pool of accepted methods for post-gradual education of school and clinical psychologists; 15

16 Training The practical-training part of the project started in Autumn The practical-training part of the project was carried out in the network of selected Centres of educational and psychological prevention, as parts of Educational and Psychological counselling centres. The project was implemented by the Research Institute of Child Psychology and Pathopsychology. It has been planned: - To involve in the second phase key experts from Centres of educational and psychological prevention within the Psychological counselling centres, and eventually also to engage one group of school psychologists; - To carry out at minimum four training events with selected groups of experts, who might be trained for trainers; Because money for the Slovak part of Phepa2 was not allocated, the practical-training part of the project had started in the Autumn 2008 only, and with only a limited number of participants, as well as in the limited number of training sessions (three instead of four, with 30 participants instead of 80). Engaging primary health care providers There was originally an intention to consider the possibility of introducing this topic into the curricula for post-graduate education of general practitioners. Funding and reimbursement During the year 2007 this project was oriented mainly at the adaptation and translation of main textbooks, relevant for the target population of secondary school students. The financial source shall be mainly a grant from the Anti-drug Fund, awarded in 2007 (225thousands of Slovak koruna; approximately 6700 Euro, according to current rate). During 2008 only approximately half of the planned funds from the EU were used for the dissemination of two textbooks (Slovak copies of the Clinical guidelines and the Training manual) and for three trainings in the Autumn and Winter. However, as no finances were allocated to this project from the Anti-drug Fund, all activities planned in the field of the primary health care (training of doctors and nurses) were not implemented, and all this was postponed outside the realms of this project. 16

17 Specialist support and knowledge centres First network of participants to the SBI training was introduced after three full 2,5 day trainings, and one brief introduction of the strategy to supervised participants, with overall number of 45 people from all regions of Slovakia. Monitoring the progress of the strategy Monitoring has been tentatively implemented via evaluation of three training events in the Autumn and Winter of These evaluations were concentrated on the participants and policy makers from the Educational sector only. Preparing for the introduction of the strategy The strategy was submitted to the decision makers in the Educational sector. Managing the strategy No steps for broader introduction and implementation were taken during the duration of the project, namely because of shortage of financial resources. Communicating about the strategy Also some results of the project, which were related to other variables, like bullying and violence at schools, were presented at the international conference (Nociar 2008a). Except for direct dissemination of the Clinical guidelines and the Training manual to participants at the end of trainings, overall activities of the project were described in a separate study (Nociar 2008b). Finally, the Slovak part of the project, as one of the research projects of the Research Institute for Child Psychology and Pathopsychology, went successfully through the formal habilitation process at the Institute. 17

18 RESEARCH NEEDS Presently there are no more research intentions in the SBI field. 18

19 BIBLIOGRAPHY Nociar, A. et al.: Škála alkoholovej závislosti ADS [Alcohol Dependence Scale; Test and Manual]. Bratislava, Psychodiagnostické a didaktické testy, š.p., 1990, pp Nociar, A.: Age, gender and substance abuse in relation to violence at primary and secondary schools in Slovakia. 4th World Conference: Violence at School and Public Policies. Lisbon, June Abstracts, p Nociar, A.: Projekt včasnej identifikácie a krátkej intervencie pri rizikovom pití [Project of Early Identification and Brief Intervention in Risk Drinking]. Prevencia 7, 4, 2008, p Nociar, A., Kopányiová, A., Matula, Š.: Včasná identifikácia a krátka intervencia pri rizikovom pití. Záverečná správa [Early Identification and Brief Intervention in Risk Drinkers. Final report from the research project]. Bratislava, VÚDPaP 2008, pp