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539NORDIC STUDIES ON ALCOHOL AND DRUGS VO L . 25 . 2008 . 6

IntroductionThe Brazilian Unified Health System (SUS – Sistema Único de Saúde), which is part of the nationwide public health system of Bra-zil, is the result of major health policy changes over the last 20 years. One of the major chang-es in the public health system has been the introduction of Family Medicine concepts as part of the overall Primary Health Care (PHC) reform that began in 2000. Today, almost six thousand municipalities in Brazil are pro-vided with at least one Family Health Team per 2,500 inhabitants, reaching over half of the Brazilian population. Besides the Family Health Program there is an older system of primary health care widely distributed in the country. This system consists of PHC-Clinics that provide basic health care within limited geographical areas of about 20 thousand in-habitants. The clinics are staffed by a team of at least one physician and a variable number of nurse assistants, who are health profession-als with secondary educational level certified to perform basic care, blood sampling, blood pressure monitoring, wound care, vaccina-

ERIKSON FELIPE FURTADO CLARISSA MENDONÇA CORRADI-WEBSTER MILTON ROBERTO LAPREGA

Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil: evaluation of the PAI-PAD training model

E. F. Furtado & C. M. Corradi-Webster

& M. R. Laprega: Implementing brief

interventions for alcohol problems in

the public health system in the region of

Ribeirão Preto, Brazil: evaluation of

the PAI-PAD training model

INTRODUCTION

This paper provides a comprehensive

view of the implementation of alcohol

screening, brief intervention, and referral

to treatment (SBIRT) in the primary health

care system of the region of Ribeirão

Preto, in the State of São Paulo, Brazil,

mostly concerning the evaluation of SBIRT

training.

METHODS

The data were obtained from a

community-based study of 774 public

primary health care professionals

enrolled in an SBIRT training and

implementation program in the

region of Ribeirão Preto, SP, Brazil,

from 2003 to 2008. The majority of

health professionals who attended the

trainings were community health agents

(59%) working in the Family Health

Program. Physicians, psychologists

and nurses also contributed. Data

collection was performed using self-

report questionnaires, direct interviews,

observational methods and focus groups.

RESULTS

There was a statistically significant

decrease in health professionals’ positive

beliefs about alcohol consumption in the

post-training period and a significant

increase in SBIRT knowledge. Among

professional groups, physicians and

nurses showed most improvement in

Research report

A B S T R A C T

540 NORDIC STUDIES ON ALCOHOL AND DRUGS V OL . 25 . 2008 . 6

tions and health education.It is generally believed that in Brazil, as in other countries,

most patients with alcohol-related problems are not detected in primary health care settings, despite their obvious medi-cal and psychiatric complications. Rosa et al. (1998) inves-tigated the ability of Brazilian medical doctors and nurses to detect alcohol misuse among patients in a general hospi-tal. The physicians considered only half of the patients that were assessed as having an alcohol problem with the CAGE assessment instrument as alcohol abusers, while the nurses identified only a third of them. Even medical residents in psychiatry fail to detect alcohol misuse in their patients. Macedo et al. (2002) reported that less than 25% of CAGE-positive psychiatric outpatients had been recognized by psy-chiatrists in residency training.

In Brazil the prevalence rates of risky drinking by some high risk groups could exceed that of developed countries. Fabbri et al. (2007) reported that 22% of 450 pregnant women in the city of Ribeirão Preto were positive cases in a screen-ing study of risky drinking, using the Brazilian version of the T-ACE (a short questionnaire developed by Sokol et al. 1989, the T-ACE acronym refers to Tolerance, Annoyance, Cut-down and Eye-opener).

Ribeirão Preto is probably the most important center of the alcohol industry in Brazil, being the largest producer of sugarcane, sugar, and industrial alcohol in the country. Alcohol in the region is chiefly produced for chemical or energy purposes, not primarily for beverages. However, the region is also known as “the capital of draft beer” because of the high per capita consumption rate and its very popular breweries. This region has a high social tolerance for alcohol consumption. Despite restrictive laws, alcoholic beverages are universally accessible for teenagers. This may account for the observed increase in emergency room admissions of young people diagnosed with alcohol-related problems (Fur-tado 1998).

Brazil as a whole is known as one of the most affected countries in the world because of its share of the burden of disease attributable to alcohol consumption (Rehm & Mon-teiro 2005). The region of Ribeirão Preto has the highest rate of liver disease among males in the State of São Paulo, reach-ing about 75.5 deaths/100,000 inhabitants, with 44.5 attrib-

their perceived feeling of

being “prepared to counsel”

patients about risky alcohol

use. Qualitative analysis

showed an improvement in

the level of awareness of

alcohol problems, adoption

of a disease model, and

an increase in referrals

for alcohol treatment. The

program was disseminated

to a large enough proportion

of the health professionals

in small cities to have a

significant reach into the

general population of heavy

drinkers.

CONCLUSION

The training model

combined with concurrent

supervision and support

seem to be effective in the

implementation of SBIRT

in the routine of health

professionals in primary

health care. This model

shows promise as a way to

implement alcohol screening

and brief intervention as

a standard practice in

primary health care in large

population areas of Brazil. It

has been extended to other

parts of Brazil and could

serve as a model for other

Latin-American countries.

KEYWORDS

alcohol screening, brief

intervention, SBIRT,

implementation, early

intervention


541NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6

utable to alcohol abuse (SEADE 2004). Re-cent findings corroborate these data. About 50% of fatal victims of auto accidents had BAC levels above the Brazilian legal limit (Martinis 2006). In a study of health condi-tions among truck drivers, 51% were iden-tified as alcohol abusers according to the AUDIT screening test, which was admin-istered to drivers on the highway routes in the region of Ribeirão Preto (Domingos & Pillon 2007).

According to a recent population based study in urban regions (Laranjeira et al. 2007), 52% of adult Brazilians are current drinkers (65% male, 41% female). Among them 60% of men and 33% of women drank five or more standard drinks if they had a heavy drinking episode. Consider-ing the whole sample of men, 11% drink daily while another 28% drink 1–4 times weekly. Information about the drinking of rural populations in Brazil is scarce. According to the 2000 National Census, 81.2% of Brazilians live in urban areas. In a case-control study (Santos et al. 2003) about risk factors for paracoccidioidomy-cosis in rural workers, it was found that 68.3% answered positively to the question about current drinking.

Since 1999 the University of São PauloSince 1999 the University of São Paulo at Ribeirão Preto has been the home of PAI-PAD (Program of Integrated Action for Prevention of Alcohol and Drug Prob-lems in the Community), which is based at the School of Medicine’s teaching hos-pital. This program was established in 1999 with the purpose of disseminating early identification and intervention pro-cedures to health professionals working at the primary health care level. In 2002, af-ter a meeting in Alicante, Spain, convened by the World Health Organization, PAI-

PAD was invited to join a cross-national initiative to adapt and disseminate brief interventions for alcohol problems. Fol-lowing this meeting, PAI-PAD organized a symposium in 2003 with the participation of representatives of the Federal Ministry of Health, State Health Department and health managers from the public health system at the regional, city and local lev-els. In the same year the Ministry of Health published a policy document where, for the first time, a recommendation was made for the inclusion of brief interventions as part of the officially prescribed health strategies for alcohol and drug users. In 2004, the Ministry of Health published a federal rule establishing that brief coun-seling and brief interventions are compo-nents of the basic services to be provided at general outpatient clinics, the family health program and the program of com-munity health agents (Ministério da Saúde 2004). Brazil’s Family Health Program is the most important government attempt to improve primary health care by providing a comprehensive range of preventive and curative health care services delivered by a team composed of one physician, one nurse, a nurse assistant, and five or more community health workers. The latter group tends to have a low educational level, and no formal education in health sciences. They live in the target commu-nity, perform home visits, conduct screen-ing and monitor the most prevalent health problems, including alcoholism. The team is responsible for the care of all families in a specific geographic area, usually consist-ing of about 3,500 people per team.

The PAI-PAD Training Program for Fam-ily Health Professionals was developed in 2003 (Furtado 2003). Following a pilot

Implementing brief interventions for alcohol problems in the public health system in the region of Ribeirão Preto, Brazil:

evaluation of the PAI-PAD training model

542 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 5. 2 0 0 8 . 6

trial to test the concept and the materials, changes were introduced to emphasize practical aspects related to the typical rou-tine of a Family Health Team, and more emphasis was placed on the confrontation of stigma and negative attitudes about al-cohol use and alcoholics.

This article presents the results of quan-titative and qualitative assessments of the implementation process and trainings con-ducted by PAI-PAD for the dissemination of alcohol screening and brief intervention activities in the region of Ribeirão Preto.

Methods Training Program

The current 16-hour course format of the PAI-PAD Training Program is divided into four modules. The first module is a general introduction focusing on epidemiological evidence about the impact of risky drink-ing on public health as well as basic in-formation about the AUDIT screening test. The second module is dedicated to the identification of risk zones, as proposed in the WHO Manuals (Babor et al. 2003a; 2003b), and the discussion of safe drinking limits. The third module presents practical aspects of the “Stages of Change: theory”. The fourth module deals with how to use brief interventions in the context of refer-ring severe cases. Each module is divided into two parts with the first section devoted to theory and the second section to a work-shop with exercises and group interaction. The underlying theoretical framework has been published in Brazil in 2004 (Marques & Furtado 2004). The number of partici-pants is generally 20 to 25, and includes all health professions to facilitate discus-sion of practical aspects of the local SBIRT implementation at the Family Health Unit

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level. For the workshop section, partici-pants are asked to organize themselves in small groups. After the small group ac-tivities, participants return to the original group and discuss their questions and con-clusions. The participants receive a kit of educational materials consisting of WHO manuals, AUDIT forms, booklets with in-formation for patients and general infor-mation about the PAI-PAD activities.

Study DesignImplementation of the PAI-PAD SBIRT program was evaluated using both quanti-tative and qualitative methods. Compari-sons of attitudes, knowledge and behav-ioral intentions (Training Outcome Meas-ures) were conducted before and after a series of 35 training workshops for health professionals by means of individual self-report questionnaires. Further analyses were conducted to describe differences between municipalities using secondary data from official statistics on demographic characteristics, health personal and serv-ices distribution. In addition, focus group meetings (Qualitative Assessment) were conducted following implementation of the program to identify themes that would explain the kinds of changes identified af-ter the training.

ParticipantsThese training workshops took place over a five year period between May, 2003 and March, 2008, and were conducted in 14 municipalities. The total sample included 772 health professionals (92.5% female, mean age 35.6, range: 18–62) who agreed to participate in the evaluation study, completed the training and signed the In-formed Consent. There were no refusals.

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About 30% of the initial sample did not participate in the post-training research waves, mostly due to job leaves, job ter-minations or changing employment. For some pre- and post-training comparisons the sample size changed as a function of the completeness of the research data. Concerning educational level, 23% of the training participants had achieved the ba-sic primary school level, 45.8% had ob-tained at least a high school education and 31.2% had a college or university graduate degree.

The distribution of the sample according to major professional categories was 59.2% community health agents, 9.7% nurse as-sistants, 9.6% graduate nurses, 5.6% psy-chologists, 4.7% physicians, 2.6% health managers (mostly physicians and nurses), 2.1% social workers and 2.8% profession-als without direct involvement with the PHC system, including administrative staff and other professionals (dentists, phar-macists, nutritionists, physiotherapists, juvenile counselors, etc.). PHC profession-als composed the majority of the sample (91.4%). The study protocol was reviewed and approved by the Human Research Eth-ics Committee of the Health Center of the School of Medicine of Ribeirão Preto.

Research InstrumentsThe following instruments were used to collect data from the training workshop participants:

Inventory of Alcohol Positive Beliefs and Expectancies (IECPA – Inventário de Expectativas e Crenças Positivas Sobre o Álcool). This is a self-report questionnaireThis is a self-report questionnaire with 61 items rated on a 5-point Likert-type scale (completely disagree to com-pletely agree). The statements describe

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positive aspects of alcohol use with higher scores generally reflecting greater alcohol involvement and positive expectations for its effects. The instrument was developed by Pinto Golveia et al. (1996) in Coimbra, Portugal. The Brazilian version showed good psychometric properties comparable to the original Portuguese version.

SBIRT Knowledge Test (SBIRT-KT): This test has three sections and nine items. The first section contains four multiple choice questions dealing mostly with the defini-tion of a standard drink and related risky drinking behaviors. The second section has three “true-false” questions concern-ing optimal patient interviewing styles, use of screening instruments and whether nurses can be effective when doing brief interventions. The last two questions ask about moderate drinking limits for men and women. This questionnaire is based on factual information communicated in the training program.

Health Professions Study Questionnaire (HPSQ). This structured self-report ques-tionnaire with 50 items was developed by Babor et al. (2005) to measure performance indicators and mediating factors associ-ated with the implementation of SBIRT programs. The first section (14 items) asks about frequency of doing screening for al-cohol problems as well as for other health risk factors such as exercise and diet. It also includes questions about whether the respondent “feels prepared” to perform al-cohol counseling. The additional 36 items, rated on a five-point Likert scale (agree – disagree), make statements about profes-sional attitudes and institutional climate regarding SBIRT implementation.

Autonomy Level Assessment of the PHC Clinic Team (ALS-CT). A group of 21 PHC




Clinics received monthly supervision vis-its after completing the training program between 2006 and 2008. At the end of the supervision period each clinic was evalu-ated by two raters independently using a 4-item rating scale (very low, low, medium and high) to assess the autonomy level of the clinic team regarding local SBIRT im-plementation. The following topics were rated: presence of educational material for patients; number of AUDIT screenings; number of engaged health professionals; leadership, formal or informal, for imple-mentation; SBIRT utilization in group ac-tivities for patients; local projects; numer of interventions; solicitation of advice; and specific case discussions.

In order to assess the effectiveness of SBIRT training in changing PHC profes-sionals’ attitudes, motivation and level of knowledge, a post-training assessment was performed within an average time in-terval of 7.1 months for the first phase (N = 167; min. 1.84 – max. 21.45; SD = 2.99) and 6.2 months for the second phase (N = 179; min. 3.42 – max. 17.91; SD = 2.52). Outcome measures for IECPA, RTC and SBIRT-KT are provided only for the first phase participants. The ALS-CT was per-formed only in the second phase, as well the estimates of screening frequency us-ing AUDIT, frequency of counseling and number of families and patients who were reached.

Qualitative AssessmentsFocus group meetings were conducted with four independent groups of health profes-sionals in the post-training period. Each group originated from the same health unit team. The health teams trained in the first phase provided the groups. These meetings

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occurred four to six months after the train-ing. The focus groups were conducted to provide additional qualitative information that expanded upon the quantitative data collected in questionnaires. There were no selection criteria, so these were samples of convenience.

Each group was composed of seven to eight health professionals, with a total of 30 professionals recruited into the quali-tative study sample. All participants had attended the screening and brief interven-tion training workshops. Each group of health professionals belonged to a differ-ent Family Health PHC out-patient com-munity clinic. The School of Medicine of Ribeirão Preto of the University of São Paulo is the owner and manager of these clinics, which are devoted to PHC services as well as education and practical training for medical students, residents, nurses and students of other health professions.

Following recommended focus group techniques (Krueger 1988), two central questions were formulated and presented for open discussion to all groups. The questions covered the benefits of training and the perceived barriers to implement-ing brief interventions at the PHC site level (Rush et al. 1996; Aalto et al. 2003). Each group was moderated by a member of the evaluation research team. All discus-sions were tape recorded and transcribed for these analyses. Three independent judges read the transcripts to establish meaningful categories representing the central ideas expressed by the focus group participants.

Further qualitative data were derived from administrative documents, reports, statistics and communications. Other in-



formation was obtained from direct obser-vations of several hours of meetings and personal interviews and appointments with health managers at all levels.

Results Training Outcome Measures

Figure 1 shows the cumulative number of professionals trained during the two phas-es of the project. The figure documents the general implementation of the program over the three year training period, with a higher rate of implementation during the second phase.

At the pre-training assessment the SBIRT knowledge test (SBIRT-KT) mean score was 3.94 (SD = 1.45; 95% CI 3.72-4.16). At the post-training assessment this score showed an improvement of approximately two points (µ = 5.47; SD = 1.65; 95% CI 5.22-5.72). This increment was statistical-ly significant (N = 172; ∆ = 1.53; SE = 0.17; t = 9.13; p < 0.0001). Better educational level was positively correlated with higher scores on the SBIRT-KT at the post-training

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assessment (r = 0.20; p < 0.01; N = 184), as well with duration of job experience (r = 0.16; p < 0.05; N = 150). No significant dif-ference was found across different job cat-egories in the knowledge scores between pre- and post-training phases.

The measure of positive expectancies for alcohol (IECPA) showed a mean score of 91.2 (SD = 39.85; 95% CI 85.23-97.23) at the pre-training assessment. After the training the mean decreased to 82.5 (SD = 31.04; 95% CI 77.86-87.20). This differ-ence was statistically significant (N = 172; ∆ = - 8.70; SE = 3.85; t = -2.26; p < 0.05). Higher scores in the SBIRT knowledge test correlated positively with larger rates of reduction of alcohol positive expectancies as measured by IECPA at the post-training assessment (r = 0.215; p < 0.005; N = 185). These changes are illustrated in Figure 2.

When using the HPSQ to evaluate the proportion of PHC professionals who de-clared themselves as “prepared” to per-form counseling before and after training, a significant difference was found. At the

Figure 1. Cumulative number of primary health care professionals trained by PAI-PAD.

Cumulative Frequency (N)

Time Line

May-03

0

100

200

300

400

500

600

700

800

PHASE 2 - N = 473 (14 Cities)

PHASE 1 - N = 301 (04 Cities)

Jan.-04

July-04

Jan.-05

July-05

Jan.-06

Sept.-06

Jan.-07

July-07

Jan.-08

March-08




pre-training assessment 60.1% felt pre-pared to perform counseling while at the post-training assessment this proportion increased to 89.1% (Npre = 286; Npost = 64; ∆ = 29.00%; χ² = 18.18; p < 0.0001). Phy-sicians showed the highest increment in positive scores for the question about “feel prepared to counsel”. Comparing physi-cians and nurses with community health agents and nurse helpers, we found a sta-tistically significant difference in the rat-ings of being prepared to counsel patients (U = 1791; P < 0,05).

Regarding the post-training assessment of the 4-level ALS-CT autonomy measure of the trained PHC teams, the mean score was 2.52 (N = 21 clinics; SD = 0.87; 95% CI 2.13-2.92). Three PHC teams compris-ing 14.3% of the group (3/21) scored at the highest autonomy level, another 33.3% (7/21) at the high level, 42.9% (9/21) scored at the low level and other 9.5% (2/21) at the lowest autonomy level. The PHC teams classified as high or low auton-omy level were found to be distinctively different regarding the average scores on the agreement scale for the question “no

information is provided for the referral of individuals identified as alcohol abusers”. The high autonomy group showed the lowest scores (Nlow = 10; µlow = 1.88; Nhigh = 8; µhigh = 1.40; ∆ = - 0.48; SE = 0.15; t = -3.19; p = 0.006).

Differences between MunicipalitiesAs noted above, 14 different municipali-ties were represented in this sample. The administrative region of Ribeirão Preto comprises 25 municipalities (1,162,794 inhabitants). Thus, the SBIRT training reached 56% (14/25) of the municipali-ties of the region, which represents 74.5% (866,001 inhabitants) of the region’s entire population.

The majority of the health profession-als (50.9%; 393/772) came from Ribeirão Preto, which is the largest city of the re-gion and its capital with approximately 560,000 inhabitants. Despite the large amount of trained health professionals in this sample, the training in Ribeirão Preto reached only 10.2% of the PHC profes-sionals. A small town like Sta. Cruz da Es-perança contributed only 1.7% (13/772) to the training sample, but this small group of PHC professionals represents 40% of the total working in the public health sys-tem of that town.

In order to examine the influence of the city population size on the implementa-tion of training among PHC profession-als, the average population size was com-pared between the cities with up to 15% of trained PHC professionals and the cities with a larger proportion. In this analysis the city of Ribeirão Preto was excluded from the list because it was too large and thus was considered an outlier. The dif-ference was found to be statistically sig-

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Figure 2. SBIRT knowledge scores and alcohol expectancies before and after SBIRT training.

0

1

2

3

4

5

6

78

80

82

84

86

88

90

92

PRE PO ST

KnowledgeTest Score IECPA Scores

KnowledgeTest Scores

Alcohol Positive Expectancies – IECPA



nificant (t = 10.04; p < 0.001; ∆ = 0.20; SE = 0.02; CI 95%: 0.16-0.25). It was easier to reach a larger proportion of the popula-tion in the smaller than the larger cities. In small cities the ability to reach stake-holders and form an alliance is easier than in larger cities, making it easier to sustain the program.

With respect to the number of clinics enrolled in the implementation program, this sample represents a total of 104 PHC clinics (Basic Care units, Family Health teams, Community Health programs), with seven to eight PHC professionals per clinic on average.

Qualitative AssessmentRegarding the qualitative assessments ob-tained by means of the focus groups, the major findings were related to perceived changes in the conceptualization of prob-lematic alcohol use. PHC professionals provided statements suggesting they had moved beyond a stereotyped view of the alcoholic patient and had gained a more nuanced perception of their patients be-cause of the “risk zones” provided by the AUDIT score. They also gave evidence of changing their somewhat moralistic view about the etiology of alcohol problems, adopting more of a disease model.

Focus group participants reported that before the training they would not have thought that a person with a job and a family could have any problems related to drinking. After the training, having learnt that there are risks other than dependence, they emphasized the importance of asking about alcohol consumption.

“Before this training we thought that an alcoholic person was the kind of person that is on the floor. You know, we didn’t

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imagine that the person that drinks one or two cans (of beer) in a day or every day, during the week, we didn’t know that… (we thought) this person is not an alco-holic, he just drinks a can of beer today, tomorrow another one, understand? So, it is interesting because you can look at it differently, you can separate better, “this one is at risk”. So, we had the idea that the alcoholic was the one that had fallen on the floor. Now the look is very different. We manage to look at the people more care-fully and see what risk they are carrying.”

They also admitted changing their some-what moralistic views about alcohol etiol-ogy and adopted a disease model. Before the training they reported having an idea that the person with alcohol dependence did not have good moral values, but after the training they started to see them as people with a disorder.

“I never thought that a person who drinks, that is an alcoholic, for example, that he was sick, (I thought) he was an immoral person who liked to drink. But then I started to realize that it is not like that.”

Concerning their perceptions of compe-tence in performing SBIRT, they felt more confident as well as competent in con-ducting screening and brief interventions. They reported that before the training they did not know how to advise patients about risky alcohol consumption. The training provided them with information about low risk drinking, the consequences of problematic alcohol use, how to screen for alcohol problems, the different risk zones, and the importance of establishing a goal and doing a follow up.

“I think we changed a bit our way of listening? ‘Do you use alcoholic bever-




ages? I do. How much? I drink a beer on the weekend’. This was what we started to hear in a different way. Because ‘to drink a beer on the weekend’ I drink also, but we started to learn to ask how many drinks, why do you drink, how often in the week… Because the people, for example, they thought that to drink socially was to drink two beers per day and we see that now, now we have learned to ask more and to ask what it is to drink socially ‘ah, I drink socially’. ‘But, how much is that? How many do you drink? Which kinds of beverage do you drink? How many drinks do you have?’ So, we learned to look, to listen to that in a different way because this thing of ‘sometimes I drink’, ok, you make a note (in their medical files) about that ‘drinks socially’ and with AUDIT, with the training, we learned to do that in a dif-ferent way.”

In the same way they felt more compe-tent in approaching patients as well as in giving advice and counseling regarding general education about the limits of low risk drinking.

“To talk about that, I didn’t have cour-age…, how to approach it. I didn’t know how to approach it, when I saw the man of the ‘cachaça’ (a typical Brazilian dis-tilled beverage), I spoke with him. I don’t even know how to tell you how it was (the speech), it was in my way. I think it made it easier for us to approach.”

DiscussionIt is important to note that this was an open-field study, in some aspects very exploratory. Generalization of the find-ings may be limited to the socio-cultural context in which the research was carried out, including the administrative culture

in the public health sector present in the northwest region of the State of São Paulo, Brazil. Nevertheless, the methods and the findings may be useful in planning SBIRT training and implementation programs in countries with PHC systems like Brazil, especially in Latin America.

There was an increase in the level of health professionals’ knowledge concern-ing alcohol screening and brief interven-tion following the PAI-PAD training pro-gram. This change was observed in both the quantitative and qualitative data. Pro-fessionals with higher levels of education seemed to benefit more from the training concerning the limits of low risk use and how to conduct screening. They felt more prepared to conduct interventions after the training than the health workers with lower levels of education.

According to the instruments used, the community health agents had the least accurate information about the contents of the training (such as drink limits, risk zones). Nevertheless, in the qualitative study they reported improvement on the knowledge scale and feeling more confi-dent to carry on interventions after hav-ing acquired this new knowledge. The graduate professionals, having had more contact with the formal education system, were perhaps more familiar with the need to memorize information and answer test questions, and that could have influenced their higher scores on the knowledge test. The community health agents, even though they had difficulties remembering the contents of the training course, nev-ertheless admitted to being more open to talk about the issue (problematic alcohol use), including the way they ask questions about that subject.



The training course also helped the pro-fessionals to reflect on their own personal expectations concerning alcohol consump-tion. Positive expectation scores declined after the training. This may have been due to the information that even occasional at-risk alcohol use can lead to social, emo-tional and physical harms. Before the training many professionals, as showed by the qualitative study, thought only about alcohol leading to dependence. Increasing their knowledge about the risks of exces-sive drinking seems to have decreased their positive expectations about alcohol consumption.

Talking about problematic alcohol use as a health problem rather than a moral problem brought the alcohol issue into their field of action, increasing their sense of responsibility and removing the fear of asking screening questions and talking about this issue with the patient. They re-ported that before the training, they did not know how to approach this issue, but after the training they had new skills and more courage to talk about alcohol. This courage seems to come from the informa-tion received and the feeling that when asking about alcohol, they were not invad-ing their patient’s privacy, but were rather playing an appropriate role as health pro-fessionals.

Alternatively, the reason for the lower alcohol expectancy score could have been due to the changes in the trainees’ per-ceptions of the most socially desirable re-sponses at the six month follow-up. Other evidence supports the first hypothesis, such as the increase in knowledge, which was inversely correlated with their atti-tudes toward alcohol.

Perhaps the most important aspect of

this descriptive study is the extent to which the SBIRT process and training was established within the health care system of a large population area of Brazil. Al-though training does not necessarily guar-antee that screening and brief intervention will be performed regularly and systemati-cally, the results suggest that most health professionals change their attitudes and knowledge in a direction that should be conducive to the use of evidence-based alcohol screening and brief intervention techniques. In addition, the program was disseminated to a large enough proportion of the health professionals in small cities to have a significant reach into the general population of heavy drinkers.

Beginning in 2006 the São Paulo State Health Department became the major spon-sor of the program, with an annual bud-get of about 300,000 Brazilian Reais (ca. 94,000 €) for the total costs of the program, including general maintenance costs and salaries of supervisors and trainers (two psychiatrists, two psychologists, two nurs-es, one social worker) and three adminis-trative staff. The resulting annual indi-vidual cost for each trained health profes-sional is estimated at 1,000 Brazilian Reais (ca. 310 €), or 0.35 Brazilian Real (0.01 €) for each inhabitant of the municipalities reached by the program. More research will be necessary to evaluate the cost-ef-fectiveness of the program. However, even if the program succeeds in changing 1% of the population affected by risky drinking, this could translate into a reduction in the number of deaths due to hepatic alcoholic disease (75 cases / 100,000 inhabitants), and contribute to a reduction in the need for liver transplants (one liver transplant costs about 60,000 Brazilian Reais – the




PAI-PAD program has a budget equivalent to five liver transplants).

In conclusion, the training model and the concurrent supervision and support for implementation seem to be fairly effective in contributing to the implementation of SBIRT in the routine of health profession-als in primary health care. Currently this program has been extended to two other health administrative regions of the State of São Paulo (Franca and Taubaté – with re-sources from the São Paulo State Research Foundation), and to other Brazilian States (Paraná, Minas Gerais – both with resourc-es of the Brazilian Ministry of Health, and Amazon). This model shows promise as a way to implement alcohol screening and brief intervention as a standard practice in primary health care in large population

areas of Brazil. It has been indicated by the Pan American Health Organization as a possible model for other Latin-American countries.

Erikson Felipe Furtado, Professor University of São Paulo, School of Medicine of Ribeirão Preto,Department of Neurology,Psychiatry and Medical Psychology 14.049-900 Ribeirão Preto, SP – Brazil Email: [email protected] Mendonça Corradi-WebsterUniversity of São Paulo,College of Nursing of Ribeirão PretoDep. of Psychiatric Nursing and Human SciencesRibeirão Preto, BrazilMilton Roberto Laprega University of São Paulo, School of Medicine of Ribeirão PretoDepartment of Social MedicineRibeirão Preto, Brazil

REFERENCES

Aalto, M. & Pekuri, P. & Seppa, K. (2003): Obstacles to carrying out brief intervention for heavy drinkers in primary health care: a focus group study. Drug Alcohol 22: 169–73

Babor, T.F. & Higgins-Biddle, J.C. & Saunders, J.B. & Monteiro, M.G. (2003a): AUDIT: teste para identificação de problemas relaciona-dos ao uso de álcool: roteiro para uso em atenção primária (AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for use in primary care). Portuguese translation by Corradi- Webster C. Ribeirão Preto: PAI-PAD (Publisher)

Babor, T.F. & Higgins-Biddle, J.C. (2003b): Intervenções breves para uso de risco e uso nocivo de álcool: manual para uso em atenção primária (Brief Intervention for Harzardous and Harmful Drinking. A Ma-nual for use in primary care). Portuguese translation by Corradi-Webster. Ribeirão Preto: PAI-PAD (Publisher)

Babor, T. F. & Higgins-Biddle, J. & Dauser, D. & Higgins, P. & Burleson, J. (2005): Alcohol(2005): Alcohol

screening and brief intervention in primary care settings: Implementation models and predictors. Journal of Studies on AlcoholJournal of Studies on Alcohol 66 (3): 361–369

Domingos, J. & Pillon, S. (2007): O uso de álcool entre motoristas no interior de São Paulo. (Drivers’ use of alcohol in the interior of São Paulo) Revista Enfermagem (UERJ) 15: 393–399

Fabbri, C. & Furtado, E. & Laprega, M. (2007): Consumo de álcool na gestação: desem-penho da versão brasileira do questionário T-ACE. (The consumption of alcohol during pregnancy: the Brazilian T-ACE questionn-aire) Revista de Saúde Pública/ Journal of Public Health (41): 979–984

Furtado, E. (1998): Dependência química e psiquiatria infanto juvenil: um desafio atual. In: Associação Brasileira de Psiquia-tria. (Juvenile chemical and psychological dependency: a challenge) (Org.): Cidadania e direito à saúde mental. São Paulo: EditoraSão Paulo: Editora Frôntis



Furtado, E. F. (2003): Implementação de estratégias de diagnóstico e intervenções breves para problemas relacionados ao álcool em serviços de atenção primária na região de Ribeirão Preto (Implementation of strategies for brief interventions for alcohol related problems among primary health care services in the region of Ribeirao Preto). Ribeirão Preto: PAI-PAD/FMRP- USP. Technical Report PAI-PAD/OMS-Bra-zil-rp-01/2003

Gouveia, P. & J. Ramalheira, C. & Robalo, M. & Borges, J.& Almeida, J. (1996): Inventário de expectativas e crenças pessoais acerca do álcool (IECPA). (An inventory of per-sonal expectations and beliefs regarding alcohol) São Paulo: Casa do PsicólogoSão Paulo: Casa do Psicólogo

Heather, N. & Rollnick, S. (2000): Readiness to change questionnaire: User’s manual (re-vised version). Newcastle: Centre for Clini-cal Psychology and Healthcare Research, University of Northumbria

Krueger, R. (1988): Focus Groups: a Practical Guide for Applied Research. Newbury Park: Sage Publications

Laranjeira, R. & Pinsky, I. & Zaleski, M. & Ca-etano, R. (2007): I Levantamento Nacional sobre os Padrões de Consumo de Álcool na População Brasileira. (Patterns of alcohol consumption in the Brazilian population – A national survey) Uniad – Unidade de Pesquisa em Álcool e Drogas, Departamen-to de Psiquiatria da Universidade Federal de São Paulo, e Senad – Secretaria Nacio-nal Antidrogas, Presidência da República, Gabinete de Segurança Nacional

Macedo, L. & Corradi-Webster, C. & Furtado, E. (2002): Levantamento sobre Diagnósti-cos Relacionados ao Álcool em Pacientes Psiquiátricos Ambulatoriais. (A survey of diagnostics related to alcohol consump-tion among non-institutional psyhiatric patients) In: Anais XX Congresso Brasileiro de Psiquiatria

Marques, A. C. P. R. & Furtado, E. F. (2004): Intervenções breves para problemas rela-cionados ao álcool. Rev Bras Psiquiatr 26 (Supl 1): 28–32

Martinis, B. & Martin, C. & De Paula, C. & Braga, A. & Moreira, H. (2006): Alcohol

distribution in postmortem body fluids. Human & Experimental Toxicology 25: 625–626

Ministério da Saúde (2004): Portaria n.2197/GM 14. [Ref. 02.10.2008. Online: http://dtr2001.saude.gov.br/sas/PORTARIAS/Port2004/GM/GM-2197.htm]

Pinto Golveia, J. & Ramalheira, C. & Robalo, M. & Borges, J. & Almeida, J. (1996): Inventário de expectativas e crenças pessoais acerca do álcool (IECPA) (Inventory of Alcohol Po-sitive Beliefs and Expectancies – Manual). São Paulo: Casa do Psicólogo (Publisher)

Rehm, J. & Monteiro, M. (2005): Alcohol consumption and burden of disease in the Americas-implications for alcohol policy. Pan American Journal of Public Health 18 (4–5): 241–248

Rosa, A. & Gonçalves, S. & Stefani, S. & Martins, S. & Rosa, D. & Hunsche, A. & Azeredo, R.& Schonell, L. & Ruschel, M. & De Barros, S. (1998): Perception on and registration of alcohol abuse and alcohol-related diseases at a university general hospital. Revista da Associação Médica Brasileira 4 (44): 335–339

Rush, B. & Powell L. & Crowe, T. & Ellis, K. (1995): Early interventions for alcohol use: family physicians’ motivations and percei-ved barriers. CMAJ 152: 863–69

Santos W. A. dos & Silva B. M. & Passos E. D. & Zandonade E. & Falqueto A. (2003):Associação entre tabagismo e paracocci-dioidomicose: um estudo de caso-controle no Estado do Espírito Santo, Brasil. (The relation of smoking and parascocciolido-miscose: a case-control study in the state of Espirito Santo, Brazil) Cad. Saúde PúblicaCad. Saúde Pública 19(1): 245–253 [serial on the Internet]. [cited 2008 Dec 15]

SEADE/ Fundação Sistema Estadual de Análi-se de Dados (2004): Resenha de estatísticas vitais do Estado de São Paulo. (A review of essential statistics of the state of São Paulo). São Paulo Demográfico 9: 1–6

Sokol, R.J. & Martier, S.S. & Ager, J.W. (1989): The T-ACE questions: practical prenatal detection of risk-drinking. American Jour-nal of Obstetrics and Gynecology 160 (4): 863–870.

