Implementação de intervenções breves para uso problemático de álcool na atenção primária, em um contexto amazônico

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.

Práticas de Atenção Primária à Saúde na área de drogas: revisão integrativa

RESUMO O objetivo deste estudo foi o de identificar e analisar as práticas voltadas ao consumo prejudicial de drogas na Atenção Primária à Saúde. Trata-se de Revisão integrativa que buscou estudos nas fontes Medline e Lilacs utilizando os termos ‘Atenção Primária à Saúde’ e ‘Redução do Dano’. Como resultado, incluiram-se 52 estudos, analisados de acordo com os arcabouços teóricos que orientam as práticas em saúde. Tais estudos foram sintetizados em três categorias empíricas: comportamento de risco, que incluiu intervenção breve, programas para prevenir e diminuir o uso de drogas, entre outros; fatores determinantes, que incluiu visitas domiciliares, práticas grupais e organizacionais; e necessidades em saúde, que incluiu práticas educativas emancipatórias. Conclui-se que, majoritariamente, os estudos abordam o uso de drogas pela categoria risco, com proposição de práticas para adaptação social. As intervenções relativas aos determinantes promovem a saúde, propondo melhorias em ambientes de vida e trabalho. Práticas críticas às relações sociais estabelecidas pelo complexo das drogas são minoritárias e envolvem complexidade operacional.

Perceived appropriateness of alcohol screening and brief advice programmes in Colombia, Mexico and Peru and barriers to their implementation in primary health care - a cross-sectional survey

BACKGROUND

Providing alcohol screening and brief advice (SBA) in primary health care (PHC) can be an effective measure to reduce alcohol consumption. To aid successful implementation in an upper middle-income country context, this study investigates the perceived appropriateness of the programme and the perceived barriers to its implementation in PHC settings in three Latin American countries: Colombia, Mexico and Peru, as part of larger implementation study (SCALA).

METHODS

An online survey based on the Tailored Implementation for Chronic Diseases (TICD) implementation framework was disseminated in the three countries to key stakeholders with experience in the topic and/or setting (both health professionals and other roles, for example regional health administrators and national experts). In total, 55 respondents participated (66% response rate). For responses to both appropriateness and barriers questions, frequencies were computed, and country comparisons were made using Chi square and Kruskal-Wallis non-parametric tests.

RESULTS

Alcohol SBA was seen as an appropriate programme to reduce heavy alcohol use in PHC and a range of providers were considered suitable for its delivery, such as general practitioners, nurses, psychologists and social workers. Contextual factors such as patients' normalised perception of their heavy drinking, lack of on-going support for providers, difficulty of accessing referral services and lenient alcohol control laws were the highest rated barriers. Country differences were found for two barriers: Peruvian respondents rated SBA guidelines as less clear than Mexican (Mann-Whitney U = -18.10, P = 0.001), and more strongly indicated lack of available screening instruments than Colombian (Mann-Whitney U = -12.82, P = 0.035) and Mexican respondents (Mann-Whitney U = -13.56, P = 0.018).

CONCLUSIONS

The study shows the need to address contextual factors for successful implementation of SBA in practice. General congruence between the countries suggests that similar approaches can be used to encourage widespread implementation of SBA in all three studied countries, with minor tailoring based on the few country-specific barriers.

CUIDADO AOS USUÁRIOS DE ÁLCOOL NA ATENÇÃO PRIMÁRIA: MORALISMO, CRIMINALIZAÇÃO E TEORIAS DA ABSTINÊNCIA

Resumo Os danos advindos do uso prejudicial de álcool ganharam destaque a partir do século 18, com a ascensão do capitalismo. Medidas de controle governamentais e sanitárias acompanharam a construção sócio-histórica. No Brasil, a Política de Álcool e Drogas do Ministério da Saúde, instituída nos anos 2000, propôs ações de cuidado em rede, incluindo os serviços da atenção primária. Apesar de esforços para qualificar os profissionais, as ações em saúde se mostram pouco acolhedoras, estigmatizantes e ineficazes diante da complexidade do tema. Objetivando conhecer e analisar as crenças e as práticas de saúde no cuidado ao usuário de álcool na atenção primária à saúde, foi realizado este estudo qualitativo com profissionais de saúde de um serviço de atenção primária, utilizando-se da entrevista semiestruturada e da análise de conteúdo. Os referenciais teóricos relacionados à saúde coletiva e às ciências sociais dão sustentação a esta análise. Os resultados apontaram para atitudes moralizantes e preconceituosas, com uma prática que criminaliza o uso de álcool, principalmente nas classes menos favorecidas, pautada por condutas normatizadas, foco na eliminação dos riscos e na abstinência total, em consonância com o modelo biomédico hegemônico, e distante das necessidades dos sujeitos e da complexidade que envolve a questão.

Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries

BACKGROUND

Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap.

OBJECTIVES

To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review).

DATA COLLECTION AND ANALYSIS

Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect.

MAIN RESULTS

The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care.

AUTHORS' CONCLUSIONS

Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.

Consumo de bebidas alcoólicas entre trabalhadores de uma unidade de Saúde da Família em Vitória, Espírito Santo, Brasil

Objetivo: Descrever o consumo de bebidas alcoólicas por trabalhadores da Atenção Primária à Saúde (APS). Métodos: Em dezembro de 2011 e fevereiro de 2012 realizou-se um levantamento anônimo com trabalhadores da APS numa unidade de Saúde da Família em Vitória (ES), através de questionário autoadministrado, com questões sobre frequência, quantidade usual e consumo em binge extraídas de um levantamento nacional. Foram obtidos ainda dados sociodemográficos e ocupacionais. Resultados: Dentre os 59 trabalhadores elegíveis, 53 (90%) participaram do levantamento. Ninguém relatou consumo muito frequente (5 dias ou mais por semana), mas 60% (32/53) relataram pelo menos um episódio de consumo nos últimos 12 meses. 76% (39/51; porém, 2 não responderam) relataram consumir usualmente 2 doses ou menos por dia de consumo. O consumo em binge foi relatado por 51% (27) de todos os 53 trabalhadores, ou seja, 84% dos 32 que consomem bebidas alcoólicas. Os trabalhadores de nível superior tiveram a menor prevalência de abstinência (19%; 3/16) e a menor proporção de consumo em binge entre os que consomem bebidas alcoólicas (69%; 9/13). Conclusões: Os trabalhadores dessa unidade de Saúde da Família apresentaram um consumo usualmente moderado de bebidas alcoólicas, mas a maioria consumiu em binge alguma vez nos últimos 12 meses. É necessário estudar no Brasil a relação entre o padrão de consumo de bebidas alcoólicas pelo trabalhador da APS e seu papel na detecção do uso problemático de álcool.