Early Intervention for Risky Drinkers at GP Office: An Experience in Florence

2. INEBRIA at Gateshead 8-9 October, 2009 Early Identification and Brief Intervention for risky drinkers at GP office. An experience in Florence Allaman Allamani* Manuele Falcone* Fabio Voller* Vittorio Boscherini** * Agenzia Regionale di Sanità, Regione Toscana **Cooperativa Medici di Medicina Generale Leonardo PRISMA Project national co-ordinator: Higher Institute of Health, Health Ministry, Rome

3. ALCOHOL PREVENTION & PRIMARY HEALTH CARE A few studies in central and northern Italy reported both ambivalence and low identification by GPs of their high -risk drinking clients – about 2-5% instead of the expected 10-20% (see Alberti et al. 1987, Axerio 1994). In the last 20 years it has been shown that clients at risk for excessive drinking may be early identified by both GPs and PHC professionals, who can also deliver a brief educational intervention (Babor & Higgins-Biddl, 2001). Some initiatives targeting at GPs were promoted in Udine (Friuli Venezia Giulia), and Florence (Tuscany), Italy, as part of the European WHO “Phase IV” Study started in 1996, involving many countries including Italy.

4. The Florence EIBI Project • planning the project

5. GP EIBI Project in Florence, 2005-2007Building alliances (Institutions involved)

6. Province of Florence -

7. The Florence EIBI Project • planning the project • a two-session alcohol training program for GPs(2002 and following years) “IDENTIFICATION 0F ALCOHOL-RELATED PROBLEMS and COMMUNICATION SKILLS” • local customization of the WHO EIBI protocol (2000- 2004)

9. Fills in the alcohol card FOLLOW-UP (months 3,6,9,12) Pt drinks <30gms/die if M, <20 if F Pt drinks >30gms/die if M, >20 if F recommends cut down + leaflet Alcohol Dependence NO intervention Refers to Alcohol treatm. service, AA, Club for alcoholics if pathological blood tests recommends stop drinking + leaflet GP/client Protocol

10. The Florence EIBI Project GP Intervention Partecipant GPs 25 GPs Scandicci: 10 (40%) North Chianti: 15 (60%) Clients enrolled at baseline2,869 clients enrolled Scandicci: 1,354 (47.2%) North Chianti: 1,515 (52,8%)

11. The Florence EIBI Project Client frequency distribution according to age classes Mean:53.5 Mean:57.5

12. The Florence EIBI Project GP Intervention RISKY DRINKING (RD) CLIENT IDENTIFICATION & FOLLOW-UPS at baseline: N clients enrolled 2,869 Nclients identified as RD 308 (10.7% of 2,869) N at first follow-up 126 (40.9% of 308) N at 2nd follow-up 38 (30.2% of 126)

13. The Florence EIBI Project Mean daily alcohol consumption at baseline (grams of pure alcohol) according to gender total RD M 23.4 63,6 F 8.242,9 according to geografical area total RD Scandicci 13.0 39.9 North Chianti 16.9 64.1

14. The Florence EIBI Project Frequency of drinking alcoholic beverages among GP clients at baseline 48% 72%

15. The Florence EIBI Project Frequency of binge drinking among GP clients at baseline During the last 12 months on some occasion did you happen to drink 6 or more glasses ( 5 or more if female) of wine/beer/spirit ? total clients6.9% RDs 29.5%

16. The Florence EIBI Project GP intervention Changes in Alcohol Consumption (daily gms of pure Alcohol) at 1st follow-up among RD clients (N=126)

17. The Florence EIBI Project- GP intervention Alcohol consumption (gms/day) changes between baseline (N=308) and 1st follow up of risk drinking clients at GP’s office (N=126) Regression line adjuested according to RTM Regression line

18. The Florence EIBI Project - GP intervention Changes in Alcohol Consumption (daily gms of alcohol) among RDs at baseline (N=308), at first (N=126) and at second (N=38) follow-up , according to gender

19. The Florence EIBI Project GP Intervention RISKY DRINKING (RD) CLIENTS FOLLOW-UPS • problems: • clients came back at follow-ups • irregularly (not according protocol time frame); • risky drinkers >80 gms/die are less likely to come back; • also RDs with no biological harm, • and individuals < 40 yrs tend not to come back.

20. The Florence EIBI Project Biological harm among Risky Drinkers at GP’s office Biological harm (> gGT, MCV, transaminases) among RDs according to area and gender Total biological harm= 40.6% of RDs (125/308)

21. The Florence EIBI Project • Qualitative Evaluation Study • in the community • In October- November 2005 and February-May 2007 • in both Scandicci and North Chianti • respectively 1,275 and 1,344 subjects • filled in a self administered questionnaire, among (opportunistic selection): • - 18 years old students • - middle school parents • people attending communityhealth institutions • & community recreational facilities.

22. The Florence EIBI Project Qualitative Evaluation Study COMMUNITY RISK PERCEPTION (Oct-Nov 2005 – N = 1,275) (Feb-May 2007 – N = 1,344) People in SC and NCwho reported no potential health risks if drinking daily › 40 gms (>20 if female) of alcohol SCANDICCI NORTH CHIANTI BOTH AREAS 30.1% 30.5% 39.3% 34.0% 35.3% 32.3%

23. The Florence EIBI Project Qualitative Evaluation Study COMMUNITY RISK PERCEPTION (Oct-Nov 2005 – N = 1,275) (Feb-May 2007 – N = 1,344) People in SC and NC who reported to have been informedby their GP on potential risks of alcohol for their health SCANDICCI NORTH CHIANTI BOTH AREAS 18.2% 18.8% 15.0% 15.5% 16.4% 17.6%

24. The Florence EIBI Project Qualitative Evaluation Study PARENTS’ VIEWPOINT ON THEIR CHILDREN ATTENDING COMMUNITY MIDDLE SCHOOLS (2007, N= 1344) At what age your son/daugher tasted an alcoholic beverage for the first time? 2007 4,9% 1,1% 8,4% Before 3 27,0% Between 3 and 6 28,4% 68,1% 62,1% Between 6 and 11 After 11 North Chianti Scandicci

25. The Florence EIBI Project Qualitative Evaluation Study OPINIONS FROM COMMUNITY RESIDENTS (N=1344, 2007) If during last year you were informed about the potential risk from drinking alcohol (about 47%) , by whom were you informed ? Scandicci North Chianti 14,6 % 16,6 % 18,8 % 15,5 % GP or healtk professional 10,4 % 14,8 % 5,1 % School 6,6 % 11,9 % Friend 82,4 % 74,9 % 12,5 % Parent/relative Newspaper, TV, radio Other 4 students out of 100 are reached by health professionals

26. The Florence EIBI Project GP Intervention BRIEF INTERVENTION DELIVERED TO RD CLIENTS • What happens and howin the consultation room between GP and the RD client? • the time needed for delivering BI • the content of the advice about cutting down or stopping drinking • the non-judgemental way of the interaction • are three aspects of paramount relevance if one wants to see if BI “works”.

27. The Florence EIBI Project GP & Client Communication Study GP & CLIENT COMMUNICATION STUDY

28. The Florence EIBI Project • GP & Client Communication Study • 4 GPs agreed that: • some of their interactions with R-D clients • may be video-taped at their office; • to self-evaluate the effectiveness • of both their communication with client • and B.I. to change risky drinking, • by means of 2 short 5-item questionnaires. • A psychologist in the doctor’s office • was doing a parallel evaluation.

29. at GP’s Office. a GP & her Client: an interaction (1)

30. at GP’s Office. a GP & her Client: an interaction (2)

31. at GP’s Office. a GP & his Client: an interaction (3)

32. at GP’s Office. a GP & his Client: an interaction (4)

33. Self administered BI & TC questionnaires for GP The Florence EIBI Project & Client Communication Studyevaluation 13 interactions between 13 RD clients and 4 GPs Observation with BI & TC questionnaires by researcher Interactions videotaped and independently evaluated

34. The Florence EIBI Project GP & Client Communication Study RESULTS Both GPS and the observer questionnaires, as well as the VT independent evaluation score from moderately positive to definitively positive. The observer tended to give higher scores. GP communication skills and quality of BIimplementation appear positive, more than they themselves admit. (Allamani & al SUM 44:775-793 2009)