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Keywords:

  • Indigenous health services;
  • alcohol;
  • screening;
  • brief intervention

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Introduction and Aims

Aboriginal Community Controlled Health Services (ACCHSs) are often the primary point of contact for Indigenous Australians experiencing alcohol-related harms. Screening and brief intervention (SBI) is a cost-effective treatment for reducing these harms. Factors influencing evidence-based alcohol SBI delivery in ACCHSs have been identified. Evaluations of strategies targeting these factors are required. The aim of this paper is to quantify the effect of training and tailored outreach support on the delivery of alcohol SBI in four Aboriginal Community Controlled Health Services (ACCHSs).

Design and Methods

A pre- post- assessment of alcohol information recorded in computerised patient information systems of four ACCHSs.

Results

For ACCHSs combined there was a statistically significant increase in the proportion of eligible clients with an electronic record of any alcohol information (3.2% to 7.5%, P< 0.0001) and a valid alcohol screen (1.6% to 6.5%, P< 0.0001), and brief intervention (25.75% to 47.7%, P< 0.0001). All four ACCHSs achieved statistically significant increases in the proportion of clients with a complete alcohol screen (10.3%; 7.4%; 2%, P< 0.0001 and 1.3%, P< 0.05), and two in the proportion with a heavy drinking screen (7% and 3.1%, P< 0.0001).

Discussion and Conclusions

Implementing evidence-based alcohol SBI in ACCHSs is likely to require multiple strategies tailored to the characteristics of specific services. Outreach support provided by local drug and alcohol practitioners and a one item heavy drinking screen offer considerable promise for increasing routine alcohol SBI delivery in ACCHSs. Training and outreach support appear to be effective for achieving modest improvements in alcohol SBI delivery in ACCHSs.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The deleterious impact of alcohol misuse on the health and well-being of Indigenous Australians, including the social functioning of their families and communities, is well documented [1-4]. Health-care practitioners in Aboriginal Community Controlled Health Services (ACCHS) are well placed to contribute to reducing the disproportionate burden of alcohol-related harm in Indigenous communities: they are typically the primary point of contact for Indigenous Australians experiencing alcohol-related harms, giving them insight into the social and environmental context in which these harms occur [5-7].

Screening patients to assess their level of alcohol consumption, followed by the provision of brief intervention (brief advice; motivational interviewing, counselling and/or referral to specialist support as required) to those identified as being at risk of alcohol-related harm [8], has been shown to reduce alcohol consumption [9] and be cost-effective [10]. Despite evidence that alcohol screening and brief intervention (SBI) is cost-effective, multiple factors have been shown to influence its routine uptake by health-care practitioners [11-13]. These factors can be broadly categorised into those associated with individual health-care practitioners (e.g. perceived lack of time and expertise), the organisation (e.g. the availability and utilisation of systems and processes for systematic prevention and treatment activities) and the client (e.g. their preferences for clinical care) [14]. The emerging body of evidence from empirical studies to date indicates that there is no single strategy that will successfully address these factors: multiple strategies targeting the needs of individual health-care practitioners and tailored to the environments in which they practise are typically required [14, 15]. While there is considerable research on the effectiveness of strategies for improving alcohol SBI in mainstream health-care settings [16], their effectiveness in Indigenous-specific health-care settings remains unclear [17], despite the substantial promise of alcohol SBI in these settings if barriers to its routine delivery can be overcome [18, 19].

A recent qualitative study exploring factors influencing alcohol SBI in four ACCHSs found that health and management staff in these settings lacked some understanding of what constituted evidence-based alcohol SBI and did not optimally use available clinical systems and processes to reinforce its routine delivery [20]. The aim of this paper is to quantify the effect of an intervention combining training and tailored outreach support on the delivery of alcohol SBI in these four ACCHSs.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Ethics

Ethical approval for this study was provided by the Human Research Ethics Committee, University of New South Wales, the Aboriginal Health and Medical Research, Ethics Committee, New South Wales and Chairpersons of boards of participating ACCHSs.

Settings

The study was set in four ACCHSs previously involved in a qualitative study exploring alcohol SBI delivery in their setting. ACCHS A was located in a metropolitan centre, ACCHS B in a medium rural centre and ACCHS C and D in small rural centres [21]. In each ACCHS, health-care practitioners in the clinical team were the main target group. Clinical teams comprised at least one general practitioner, registered nurse and Aboriginal health worker.

Study design

A pre- and post-assessment of alcohol information recorded in the electronic patient information systems of four ACCHSs, 12 months before and 6 months after, implementation of an intervention.

The intervention

The intervention comprised two main strategies: training and tailored outreach support. The selection of strategies was informed by evidence from the research literature [16] and findings of qualitative interviews with staff of participating ACCHSs [20], as outlined in the introduction.

Training included a 3 h workshop delivered to the clinical team in each ACCHS by a drug and alcohol clinician and at least one researcher. The workshop comprised an overview of alcohol treatment guidelines for Indigenous Australians [22]; practical training in how to use the alcohol assessment tool in Medical Director (MD, the electronic patient information system used by the clinical team in each ACCHS); and skills-based training in alcohol brief intervention using FLAGS (Feedback, Listen, Advice, Goals and Strategies), an evidence-based brief intervention framework [23].

Tailored outreach support included 1-day visits to each ACCHS for 6 months after training by a member of the research team and/or a nominated local drug and alcohol clinician. The number of outreach visits to each ACCHS varied because of differences in their support needs and preferences, and included: five visits to ACCHS A, four to ACCHS B and three each to ACCHS C and D. Specific support included additional alcohol SBI training as required; advice and guidance to clinical practice managers to integrate evidence-based alcohol SBI into clinical processes (e.g. client health assessments) and systems (e.g. electronic and manual screening templates); and assistance to resolve barriers to alcohol SBI implementation. Support via phone and email was also available on an as-required basis.

Data sources

The alcohol assessment tool in MD was the source of all outcome data. The assessment tool is comparable to Alcohol Use Disorders Identification Test—alcohol consumption (AUDIT-C), a validated alcohol screening tool [24]. Both tools measure the frequency and quantity of alcohol consumption, and frequency of heavy consumption, with slight variations between each in the number and wording of response categories. The alcohol assessment tool in MD also includes a text box for health-care practitioners to document their advice and actions (i.e. brief intervention). Given evidence for the cost-effectiveness of computerised patient information systems for improving alcohol SBI in primary care [25], researchers and clinical practice managers decided that optimising health-care practitioners’ use of the alcohol assessment tool in MD offered the greatest potential to improve their delivery of evidence-based alcohol SBI.

Outcome measures

In each ACCHS, outcome measures related to differences in the proportion of eligible clients pre- versus post-intervention with a record of alcohol SBI in MD. Eligible clients were those presenting for clinical care pre- and/or post-intervention; ≥18 years of age; and with no record of alcohol screening in MD in the previous 12 months (annual alcohol screening of Indigenous Australians was the national recommendation at the time of the study [22]).

Specifically, outcome measures included the proportion of eligible clients, pre- versus post-intervention, with:

  1. Alcohol screen information—the number with some alcohol screen or information in the alcohol tool in MD divided by the total number.
  2. Complete alcohol screen—the number with a complete alcohol screen in the alcohol tool in MD divided by the total number. A complete alcohol screen was defined as completion of question 1 for all clients, or completion of all three questions for clients identifying as drinkers on question 1.
  3. Heavy drinking screen—the number with question 3 completed in the alcohol tool in MD divided by the total number of eligible clients. Question 3 screens for heavy drinking (six or more drinks on one occasion) and is a valid one-item screener item for detecting active alcohol abuse and dependence in heavy-drinking populations [26, 27].
  4. Valid alcohol screen—the number with a complete alcohol screen or heavy drinking screen in the alcohol tool in MD divided by the total number.
  5. Brief intervention—the number with advice or action documented in the alcohol tool in MD divided by the total number screened at risk of alcohol-related harm. Definitions of at-risk drinking were consistent with Australian alcohol guidelines current in 2008. These included, ‘at risk of chronic harm’: ≥28 standard drinks in 1 week for men and ≥14 drinks in 1 week for women; and ‘at risk of acute harms’: ≥6 drinks on any one occasion for men and ≥4 drinks on any one occasion for women [28].

Data collection

Anonymised client data were extracted retrospectively from the alcohol tool in MD by researchers (AC and CD) using a software extraction program developed by an information technology technician. Outcome variables extracted for clients included: demographics (age and sex); alcohol screening questions (frequency, quantity and frequency of heavy drinking); and actions or advice (brief intervention) recorded for at-risk clients in the text box.

As data were extracted retrospectively and the extraction tool only had the capacity to extract the most recent information entered, there were some clients in the pre-intervention period with an alcohol assessment in MD dated after the pre-intervention period. These clients were ineligible for inclusion in the pre-intervention period as their alcohol SBI status for this period could not be determined. Ineligible and eligible clients were compared for differences in mean age using the t-test and in proportions of men and women using the two-proportion z-test.

Data analysis

All data were analysed in stata Version 11.2 [29]. The two-proportion z-test was carried out on pooled (ACCHSs combined) and non-pooled (individual ACCHSs) data to determine if there was a statistically significant increase from pre- to post-intervention in the percentage of eligible clients with an alcohol screen (outcome measures 1–4) and brief intervention (outcome measure 4). Fischer's exact test was used when the z-test was inappropriate (n < 5). Statistical significance was set as P < 0.05 at a confidence level of 95%. As analyses were based on the entire population of interest, tests of statistical significance to estimate the probability that the values observed in the sample were those obtained in the population were unnecessary.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Client eligibility

In ACCHS C and D, 100% of clients (≥18 years of age) presenting in the study periods were eligible to have their record of alcohol SBI in MD included in outcome analyses.

In ACCHS A, 10.8% (n = 360/3330) of clients pre-intervention were ineligible to have their data from the alcohol tool in MD included in outcome analyses on the basis that their alcohol screening status could not be determined. In ACCHS B, 1% (15/1575) of clients pre-intervention were ineligible for the same reason.

The only statistically significant difference between eligible and ineligible clients was in the proportion of men and women in ACCHS A for the pre-intervention period (P < 0.05).

Alcohol screening and brief intervention for ACCHSs combined

For ACCHS combined (Table 1), there were statistically significant increases (P < 0.0001) in the proportion of clients with any alcohol screen information (4.3%); a complete alcohol screen (2.7%), heavy drinking screen (1.9%) and valid alcohol screen (4.9%).

Table 1. Proportions and numbers of clients with types of alcohol screen and brief intervention for ACCHSs combined
 PrePost% change
  1. a

    P <0.0001. ACCHS, Aboriginal Community Controlled Health Services.

Clients with any alcohol screen information3.2%7.5%4.3%a
(186/5674)(272/3648)
Clients with complete alcohol screen1.2%3.9%2.7%a
(67/5674)(141/3648)
Clients with heavy drinking screen only0.4%2.3%1.9%a
(22/5674)(84/3648)
Clients with valid alcohol screen1.6%6.5%4.9%a
(89/5674)(225/3648)
At-risk clients with brief intervention25.7%47.7%22%a
(9/35)(41/86)

A total of 314 out of 9322 clients (3.4%) presenting during the study period received a valid alcohol screen, of which 121 (38.5%) were at-risk drinkers. There was a statistically significant increase in the proportion of at-risk drinkers with a record of brief intervention (BI) (22%, P < 0.0001).

Alcohol screening and brief intervention in individual ACCHSs

The proportion of clients screened in each ACCHS by type of alcohol screen (outcome measures 1–3) is shown in Table 2.

Table 2. Proportions and numbers of clients with types of alcohol screen by ACCHS
 Clients with any alcohol screen informationClients with complete alcohol screenClients with heavy drinking screen only
 PrePost% changePrePost% changePrePost% change
  1. a P <0.05; b P <0.0001. c P = 0.64. ACCHS, Aboriginal Community Controlled Health Services. ACCHS A, Aboriginal Community Controlled Health Services located in metropolitan centre; ACCHS B, Aboriginal Community Controlled Health Services in a medium rural centre; ACCHS C and D, Aboriginal Community Controlled Health Services in small rural centres.

ACCHS A1.4%4.4%3% b 0.5%2.5%1.9% b 0.03%0.8%0.73%
(42/2970)(94/2143)(16/2970)(54/2143)(1/2970)(17/2143)
ACCHS B4%9.9%5.9% b 1.6%2.9%1.3% a 1%4.1%3.1% b
(63/1,560)(69/968)(25/1560)(28/968)(15/1560)(40/968)
ACCHS C7.7%18.7%14% b 3%13.3%10.3% b 0.8%0.9%0.1% c
(41/532)(42/225)(16/532)(30/225)(4/532)(2/225)
ACCHS D9.7%21.5%11.8% b 1.9%9.3%7.4% b 1%8%7% b
(40/414)(67/312)(8/414)(29/312)(4/414)(25/312)

There were statistically significant increases in the proportion of clients with any alcohol screen information and a complete alcohol screen in ACCHS A (3% and 2%, P < 0.0001) and ACCHS C (14% and 10.3%, P < 0.0001).

ACCHS B and D achieved statistically significant increases in the proportion of clients with any alcohol screen information (5.9% and 11.8%, P < 0.0001), a complete alcohol screen (1.3%, P < 0.05 and 7.4%, P < 0.0001) and a heavy drinking screen (3.1% and 7%, P < 0.0001).

There was a statistically significant increase in the proportion of clients with a valid alcohol screen (complete or heavy drinking screen) in all four ACCHSs: ACCHS A (2.6%, P < 0.0001), ACCHS B (4.4% P < 0.0001), ACCHS C (10.4%, P < 0.0001) and ACCHS D (14.4%, P < 0.0001).

Pre- to post-intervention increases in the proportion of clients with a valid alcohol screen resulted in the detection of a greater number of at-risk drinkers; however, no individual ACCHS achieved statistically significant increases in the proportion of at-risk drinkers with brief intervention (see Table 3).

Table 3. Proportions and numbers of clients with a valid alcohol screen who were at risk, and the proportion of those at risk with a record of brief intervention, by ACCHS
 Clients with valid alcohol screen, at-riskAt-risk clients with brief intervention 
 PrePostPrePost% change
  1. a

    Fishers exact test. ACCHS, Aboriginal Community Controlled Health Services; ACCHS A, Aboriginal Community Controlled Health Services located in metropolitan centre; ACCHS B, Aboriginal Community Controlled Health Services in a medium rural centre; ACCHS C and D, Aboriginal Community Controlled Health Services in small rural centres.

ACCHS A35.3%33.8%50%37.5%−12.5%
(6/17)(24/71)(3/6)(9/24)(P = 0.69)a
ACCHS B42.5%41.3%35.3%31.6%−3.7%
(17/40)(19/46)(6/17)(6/19)(P > 0.99)a
ACCHS C40%46.9%0%13%13%
(8/20)(15/32)(0/8)(2/15)(P = 0.55)a
ACCHS D33%52%0%86%86%
(4/12)(28/54)(0/4)(24/28)(P = 0.13)a

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

For ACCHS combined there were significant increases pre- to post-intervention in the proportion of clients with any alcohol screen information, and a complete and heavy drinking alcohol screen. There were also significant increases in the proportion of clients with a valid alcohol screen (complete or heavy drinking screen) in all four ACCHSs, and with a complete alcohol screen in two ACCHSs. The increases in the proportion of at-risk clients with brief intervention in two ACCHSs were not statistically significant.

The potential of ACCHSs as a setting for the detection of Indigenous Australians with alcohol problems was underscored by the fact that of the 314 eligible clients who received a valid alcohol screen in the pre- and post-intervention periods, 38.5% (n = 121) were at-risk drinkers. This emphasises the potential opportunity lost if health-care practitioners in ACCHSs do not deliver routine and appropriate alcohol screening: 95% of eligible clients (8864/9322) in the pre- and post-intervention periods had no information recorded in the alcohol assessment tool in MD in the previous 12 months.

The overall increase in the percentage of clients with a valid alcohol screen, although a modest 4.9%, was a main positive outcome of this study. The increase, however, was not always straightforward, with indication of a trade-off between types of screening in some ACCHSs. For example, in ACCHS B there was a greater increase in the percentage of clients screened with question 3 only (heavy drinking), than those screened with all three questions (complete alcohol screen). One likely explanation for this is that during outreach visits health-care practitioners identified a lack of time as a main barrier to alcohol screening using all three questions. Following discussions between researchers and clinical practice managers, it was decided that a practical and acceptable way to resolve this barrier was for health-care practitioners to ask clients question 3 (frequency of six or more drinks on at least one occasion) when they did not have enough time to ask them all three questions. This decision was made on the basis that a one-item heavy drinking screen has proven to be effective for detecting active alcohol abuse and alcohol use disorders in men [26] and women [27], and for increasing rates of alcohol screening [30]. Notably, of the 82 clients who were at-risk drinkers, 72% (n = 59) reported consuming six or more standard drinks at least monthly, indicating that a one-item heavy drinking screen is also likely to be effective for identifying a substantial proportion of at-risk Indigenous drinkers in primary care.

The low proportion of at-risk clients with a record of alcohol BI indicates that health-care practitioners are either not routinely delivering BI or documenting its delivery. There is some evidence that screening can reduce alcohol consumption independent of BI [31, 32]. Therefore an increase in the proportion of patients screened for alcohol, in the absence of an increase in at-risk patients given BI, although not ideal, still offers potential to reduce at-risk alcohol consumption among clients in ACCHSs. Studies also report that health-care practitioners typically do not document their BI delivery [33, 34]. Future studies targeting increases in alcohol BI in ACCHSs might therefore consider using more sensitive measures, such as health-care practitioner or client exit interviews, to assess changes in BI delivery.

Studies implementing alcohol SBI have shown a positive association between the intensity of implementation effort (training and support) and effectiveness (delivery of alcohol SBI) [35, 36]. In this study, however, a positive association between the number of outreach support visits and delivery of alcohol SBI was not clearly evident. For example, ACCHS A achieved the smallest increase in the proportion of clients with a valid alcohol screen, despite receiving one more outreach support visit than ACCHS B and two more than ACCHSs C and D. Notably, ACCHS C and D achieved the greatest increases in the proportion of clients with a complete and valid alcohol screen. At least two factors might explain these apparent anomalies. First, ACCHS C received outreach support from local drug and alcohol practitioners, whereas the other ACCHSs received support from researchers as local drug and alcohol practitioners were unavailable. With evidence that local opinion leaders can promote evidence-based practice [37], drug and alcohol practitioners’ status, clinical expertise and insider knowledge of the community may have meant they were more influential than researchers in promoting routine alcohol SBI. Second, the proportion of clients screened at baseline was the greatest in ACCHS C and D, indicating they were better oriented towards alcohol SBI at the beginning of the study than ACCHS A and B. Evidence-based health care is more likely to be successfully implemented where the practice environment is oriented towards its delivery [38]. There would, therefore, be likely value in examining the cost-effectiveness of outreach support provided by local opinion leaders for implementing evidence-based alcohol SBI in ACCHSs, particularly in those services that are poorly oriented to its delivery.

Limitations

This study has several key limitations. First, a pre- and post-test study design increases the level of uncertainty regarding the extent to which the changes in alcohol SBI delivery are attributable to the intervention or other factors [39]. Second, less than optimal data quality limited the range of analyses could be undertaken. For example, alcohol SBI rates that could not be reliably calculated because of limitations in how clinical activities were entered and captured in MD. This may have reduced or increased outcome effects. ACCHSs did, however, use the same electronic patient information system in a similar manner. Therefore it is reasonable to assume that biases resultant from data quality are spread evenly across ACCHSs and unlikely to considerably account for variation in outcomes. Third, the clinical audit tool may not have extracted all relevant data. The likelihood of this was reduced by testing and refining the tool, including cross-checking a random selection of information it extracted. Finally, this study was undertaken in 18 months, a relatively short time period in view of evidence that the uptake of evidence-based health care is typically a much longer-term process [40].

Conclusion

The findings of this study provide some evidence that training and tailored outreach support can result in modest improvements in evidence-based alcohol screening in ACCHSs. The findings also emphasise the potential opportunity lost to reduce Indigenous Australians’ disproportionately high burden of alcohol-related harm if evidence-based alcohol SBI is not routinely delivered in ACCHS settings.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Thanks to staff from participating ACCHSs for their involvement in this study. We also wish to thank individual drug and alcohol clinicians for delivering training workshops to participating ACCHSs. We gratefully thank the Department of Health and Ageing for funding this research through the National Drug Research Institute, Perth, Australia. Dr Anton Clifford was an National Health and Medical Research Council Postdoctoral Research Fellow in Aboriginal and Torres Strait Islander Health at the time of this research. This research was undertaken while Dr Anton Clifford and Ms Catherine Deans were working at the National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.

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  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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