Student thesis: Doctoral thesis


    Alcohol is the most consumed addictive substance with a significant impact on health and society. Implementing early identification and brief intervention (EIBI) for risky alcohol use in health services, especially primary health care (PHC), is one of the five most cost-effective policies for reducing alcohol-related harm according to WHO. In Catalonia we have implemented such strategies continuously since 2001, within the Beveu Menys (Drink Less) program. Program evaluation highlighted fidelity issues in the use of tools for early identification, in recording drinking patterns in the medical record, and in the implementation of brief interventions in primary care consultations. Objective: 1) review the latest advances in the implementation of EIBI in risky alcohol consumption; 2) identify the factors which can improve fidelity in the use of EIBI; 3) evaluate ultra-short tools for EI of risky alcohol consumption; and 4) assess the usefulness of a computerized tool for detecting risky consumption and improving implementation fidelity in BI. Methods: The first study consisted of a narrative review of the recent literature on implementation of EIBI for risky alcohol consumption in primary care. The second was a secondary data analysis of the results of the Optimizing delivery of health care interventions (ODHIN) project, to analyse the impact of different factors such as training and support, incentives, and eBI tools in improving implementation fidelity in EIBI. The third explored the validity and reliability of ultra-short tools based on the Alcohol Use Disorders Identification Test (AUDIT) as screening instruments for risky drinking in PHC. The final study explored the usefulness of a computerised version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in PHC via a multi-centre cross-sectional observational study in a non-randomised convenience sample. Results: Review of the literature supported the evidence for the effectiveness and cost-effectiveness of BI in reducing consumption. It also highlighted knowledge gaps in how to ensure that these strategies have an impact at population level. The secondary analysis showed that professionals do not have difficulties in using AUDIT correctly (errors below 0.5%) and in correctly classifying people according to their level of consumption risk. Nonetheless, there were errors in the provision of BI. The rate of not providing a BI to those who required it was only reduced in those groups receiving incentives (OR = 0.56; 95% CI, 0.31-0.99; P < .05). AUDIT-3 was found to function better than AUDIT-QF and to function best at a cut-off point of 1, with AUROC (0.84) y S (75.8%), E (84.9%), VPN (95.1%) con un VPP de 47.6%. ASSIST was useful in detecting risky and harmful consumption in our context, placing risky tobacco use at 46.1%, alcohol at 17.5%, cannabis at 13%, non-prescribed sedatives at 6.3% and cocaine at 4.2%. Fidelity issues in the application of BI were more pronounced with regard to illegal substances reaching 93.8% for opioids and 71.4% in people with multiple substance use. Conclusions: It is important to monitor the impact of performance incentives for improving implementation fidelity in EIBI; and to promote the use of short tools such as AUDIT-3 for improving EI of risky consumption in time-poor settings, and ASSIST when undertaking integrated screening for the most common psychoactive substances. Monitoring fidelity in the use of EIBI is key to ensuring that they are effective in reducing alcohol consumption and related harms to individuals and society in general.
    Date of Award19 Mar 2021
    Original languageSpanish
    SupervisorGual Solé Antoni (Director), Maria Teresa Gutierrez Rosado (Director) & Maria Soledad Mora Giral (Director)

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