Training primary care nurses to conduct alcohol screening and brief interventions in South Africa

Although progress has been made in developing a scientific basis for alcohol screening and brief intervention (SBI), training packages are necessary for its widespread dissemination in primary care settings in developing societies. Using a training package developed by the World Health Organisation 121 nurses from one rural site (29 clinics in Vhembe District) and one urban site (3 clinics and 6 mobile clinics in Polokwane/ Seshego) in South Africa were compared before and after SBI training regarding knowledge and attitudes, and the subsequent practice of SBI in routine clinical practice. Although the training effects were at times moderate, all changes were in a direction more conducive to implementing SBI. Health care providers significantly increased in knowledge, confidence in SBI and higher self-efficacy in implementing SBI at follow-up after 9 months after receiving the training. When delivered in the context of a comprehensive SBI implementation programme, this training is effective in changing providers' knowledge, attitudes, and practice of SBI for at-risk drinking.


Introduction
A dult p er cap ita co n su m p tio n of absolute alcohol in South A frica is between 9 and 10 litres per year, which places the country among the higher alcohol consuming nations.Since 1993 the level of per capita adult absolute alcohol consumption appears to be rising, after a decrease in 1990and 1991(Myers & Parry 2002: 3).Based on the findings of the Department of H ealth's South African Demographic and Health Survey (SADHS) conducted in 1998 by the Medical Research Council (1998:15), just under half of men (45%) and one-fifth of women (17%) 15 years and older report that they currently consume alcohol.Peltzer (1999: 98) found that in primary care rural clinics in the Limpopo Province that past 6 months alcohol use among men was 72.5% and among women 9%, and of those 31% of the men and 9% of the w om en engaged in h azard o u s drinking.Hazardous drinking is a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others (Babor, Campbell, Room & Saunders 1994:22).From this primary care sample of current substance users 61% of the men indicated that their drinking or drug use had caused a family problem, 58% needed to drink or use drugs more and more for effect, 33% of men and 7% of women felt they had a drinking or drug problem now and 15% had a family member with a drinking or drug problem.Only a few had sought help for their substance abuse problem (men: 1 0 %; women: 2 %) from the following sources: friend, pastor, relative, traditional/faith h ealer, and nurse.N one had ever undergone treatment for their substance abuse problem.The White Paper for Transformation of the H ealth System in South A frica (Department of Health 1997: 25) and the National Drug Master Plan (Department of Welfare 1999: 3) in South Africa have prioritised prevention and management of alcohol abuse and the integration of substance abuse management in primary health care.The Department of Health (2001: 34) has included in the service description of clinics the prevention and m an ag em en t o f substance abuse.Standards for primary health care include health-learning materials on alcohol in local languages and competence of health staff in identifying alcohol abuse and provide basic counselling for behaviour ch an g es and re ferral to n o n governmental organisations specializing in substance abuse.Alcohol consumption in amounts that significantly increase the chances of health problems (i.e., at-risk drinking) is common among patients presenting to primary care, and imposes a significant econom ic burden on the health care system (Fleming, Mundt, French, Baier-Manwell, Stauffacher & Lawton-Barry 2000: 7).Primary health care is the first point of contact of individuals, families and com m unities in m ost countries' h ealth system s (K aner, W utzke, Saunders, Powell, Morawski & Bouix 2001: 621).Primary care is therefore a particularly valuable point of delivery for com m unity-based interventions for excessive alcohol consumption due both to its universality and also to the large proportion of the population who access it each year (Department of Health 2001: 35).Moreover, problem drinkers present to primary health care twice as often as o th er p atien ts and co n stitu te approximately 2 0 % of patients on practice lists (Anderson 1993:263).Screening procedures (asking patients routinely, e.g. about the amount and frequency of alcohol use) have been developed to identify at-risk drinkers (e.g., Babor, Higgins-Biddle, Saunders, & M onteiro 2001: 2ff.), and significant reductions in drinking and related risks can be achieved by brief interventions (e.g., Moyer, Finney, Swearingen, & Vergun 2001: 279).Screening for alcohol consumption among patients in primary care carries many potential benefits.It provides an opportunity to educate patients about low-risk consumption levels and the risks of excessive alcohol use.Information about the amount and frequency of alcohol consumptions may inform the diagnosis of the patient's presenting condition, and it may alert clinicians to the need to advise patients w hose alco h o l consum ption m ight adversely affect their use of medications and other aspects of their treatment.Screening can also identify persons likely to be alcohol dependent, and referral for diagnostic evaluation may encourage patients to seek treatments that have been shown to be effective (Babor, Higgins-Biddle, Saunders & Monteiro 2001: 6 ).B rie f in terv e n tio n s are characterized by their low intensity and short duration.They typically consist of one to three sessions of counselling and education.They are intended to provide early intervention, before or soon after the onset of alcohol-related problems.M ost program m es are designed to motivate high-risk drinkers to moderate their alcohol consumption, rather than to promote total abstinence with specialized treatment techniques.Brief interventions also provide a valuable framework to facilitate referral of severe cases of alco h o l dependence to specialized treatment (Babor et al. 2003:212).
In tro d u c in g new screening and prevention activities into primary care practices presents significant logistical, attitudinal, and behavioural challenges.Many nurses feel inadequately trained when faced with patients who have alcohol-related problem s (Church & B abor 1995: 278;R endall-M kosi, Siegfried, & Allen, 2003: 31).Barriers to adequate coverage of alcohol-related problems in both nursing schools and co n tin u in g p ro fessio n al education include traditional attitudes about the moral culpability of chronic alcoholics, co n fu sio n as to w hether problem drinking is a m edical or psychiatric concern, lack of faculty role models, lack of training materials, and role ambiguity re g ard in g who is re sp o n sib le for screening and intervention (Bendtsen & Akerlind 1999:795).Another factor could be the relative lack of awareness that Screening and Brief Intervention (SBI) leads to significant reductions in drinking and risk.R esearch on m edical education has shown that training can be effective in improving health providers' knowledge and skills in addressing alcohol issues (Ockene, Wheeler, Adams, Hurley, & H ebert 1997: 2334) but changes in knowledge may be easier to produce than changes in attitudes and behaviour (El-Geubaly, Toews, Lockyer, Armstrong, & Hodgins 2000:949).Kaner et al. (2001: 621) found that greater exposure to alco h o l-related continuing m edical education appears to have resulted in better diagnosis and more appropriate management of alcohol-related problems by general practitioners (GPs).A recent review of the components and outcomes of medical education in substance-related disorders concluded that the selection of a combined didactic and interactive educational strategy may be the most cost-effective learning strategy, but there is little empirical evidence to support this approach (El-Geubaly et al. 2000:949).
Although some progress has been made in the development and dissemination of SBI in industrial countries (Babor & Higgins-Biddle 2000: 677, Kaner et al. 2 0 0 1 : 621), this study evaluates the dissem ination of the development of successful training packages that include programme implementation procedures in a developing country.The WHO SBI program m e was developed to train medical providers to implement SBI in primary care settings.In this article we evaluate the effects of this programme on nurses in South Africa, as part of a World Health Organization Collaborative S tudy on B rief In terv en tio n s for Hazardous and Harmful Alcohol Use in developing countries (Monteiro & Gomel 1998: 5).It describes the effects of the programme on trainees' knowledge and attitudes, and the subsequent practice of SBI in routine clinical practice.

Research setting
The study, conducted between 2003 and 2004, involved the implementation and evaluation of the WHO Screening and Brief Intervention (SBI) programme in one rural and one urban site in the Limpopo Province, South Africa.The sites were chosen purposefully representing one rural and one urban health service area.The rural site was in one o f four municipalities of Vhembe district (which has a population o f 1 097 621), the M akhado local m unicipality w ith a population of 497 077.A section of the Makhado local municipality was chosen, the Elim area with one hospital and 29 primary health care centres that is 2 health centres and 27 clinics.It is predominantly occupied by African speaking Tsivenda and Xitsonga, as well as few Afrikaans speaking white farmers living farming units within the area.The urban site is in one of five municipalities (Polokwane) in the Capricorn district.The latest census reported a population of 832 474 for the District.One portion of the Polokwane municipality with a population figure of 424 976 has been selected to pilot the SBI project, Focusing mainly on two major urban areas, that is Polokwane city and Seshego Township with the two public hospitals, one health center, 3 clinics and 6 mobile clinics.The area comprise of Northern Sotho speaking Africans who are in the majority, followed by A frikaans and English speaking Whites, Coloureds and Indians.The staff in the health centres and clinics consisted of professional and assistant nurses, not doctors.In a representative community survey in the project area, Peltzer, Seoka and Mashego (2004: 705) found using a cut-off score of 8 for the Alcohol Use Disorders Identification Test (AUDIT) that 27% of all men and 6.4% of all women were found to be problem drinkers.

Sample and procedure
The training participants consisted of 121 nurses, 8 6 professional nurses (chief, senior and professional nurses) and 19 enrolled nurses and 1 0 assistant nurses.Eighty-two nurses were trained from 29 clinics in Vhembe District and 45 from 3 clinics and 6 mobile clinics in Polokwane/ Seshego.This was 38.7 % of all the nurses (n=314) of the 35 clinics.First all managers o f all the clinics were trained, and thereafter, additional nurses (at least two) per clinic were trained.Clinic managers selected their staff (one at a time) to attend additional trainings in a central venue.Most trainee nurses were women (90.9%) and 8.3% were men.Their mean age was 39.8 years (SD=8 .6 ), with an age range of 23 to 62 years, and their mean years of professional practice was 14.3 years (SD=9.3).The evaluation of the effects of training and programme implementation were measured prior and by the same health care p ro v id ers 9 m onths afte r the train in g , w ith a self-ad m in istered questionnaire.One of the researchers (PS) administered the questionnaire to the nurses prior to the trainings in a central venue and at follow-up in the clinics.All nurses were contacted at follow-up twice.The response rate was 67%).Informed consent was taken from participants.Nurses were given a consent form to sign after reading the purpose of the study.Ethics approval was obtained from the University of Limpopo Ethics Committee and the Provincial Department of Health and Welfare.

Training curriculum and trainers
It takes a practical, systems approach, aiming to facilitate the implementation of SBI in clinic operations rather than merely educating staff.The training curriculum contains modules addressing practical issues deemed essential to implementing the programme.For early id en tificatio n o f alcohol problems in primary care the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al. 2001: 2ff.) and for the brief intervention the WHO brief intervention package for hazardous and harm ful drinking (Babor & Higgins-Biddle 2001: 2ff.) were used.Both were adapted to the South African context, e.g. in terms of standard unit of alcoholic drink and d rin k in g lim its.The A U D IT was translated and back translated according to scientific standard procedures (Brislin 1980: 392) into four o f the m ajor languages (Tsonga, N orthern Sotho, Venda, and Afrikaans) in the project area.The self-help booklet for patients and a handout on "cutting back" showing the drinking limits and health effects of risky alcohol consumption were also made available in the target languages.The AUDIT manual explains the purpose of screening for alcohol problems in prim ary care, the context o f alcohol screen in g , the developm ent and validation of the AUDIT, administration guidelines, scoring and interpretation.The Brief Intervention manual defines concepts and term s, ro les and responsibilities of Primary Health Care, SBI: a risk management and case finding approach, alcohol education for low-risk drinkers, abstainers and others, simple advice for risk zone II drinkers (AUDIT scores betw een 8 and 15 are m ost appropriate for simple advice focused on the reduction of hazardous drinking), brief counselling for risk zone III drinkers (A U D IT scores betw een 16 and 19 suggest brief counselling and continued monitoring), referral for risk zone IV drinkers (AUDIT scores of 20 or above clea rly w arrant fu rth e r d iag n o stic evaluation for alcohol dependence), patient education, self-help booklet and training sources.Critical administrative activities included ad m in istratio n and scoring o f the screen in g in stru m en ts, assu rin g a v a ila b ility o f p atien t b ro ch u res, seq u en cin g o f in terv e n tio n s w ith treatment of presenting health problems, the essential elements of an intervention, and the management of SBI records.A nurse and a psychologist trainer (PS) delivered all the 14 trainings, with a duration of six hours each.A project site consultant (KP) ensured by periodic supervison of the trainings that the tra in e rs follow ed the stan d ard ise d tra in in g curriculum .F o llo w -u p supervisory and support visits were also provided by one of the trainers (PS).Q u a lity assu ran ce o f train in g was conducted by analysing transcribed tape-recordings of 40 nurses-patient SBI in te ra c tio n s.By co m p arin g the implementation efficacy of SBI with the training curriculum the researchers assessed the quality of the training.

Measures
The self-adm inistered questionnaire u sed co n sisted o f the fo llo w in g components: K n o w le d g e on a lc o h o l u se a n d problems ( 8 items).For example, trainees were asked to define moderate drinking in terms of the South African upper limit of number of drinks per day for men.Preand post-training knowledge items were scored according to the num ber of correct responses.(response options from l=strongly agree to 5=strongly disagree), P e rc e iv e d o b sta cles to b r ie f intervention with alcohol problems (19 items), for example: "In general, health care providers cannot do much to get p a tien ts to reduce their drinking." (response options from l=strongly agree to 5=strongly disagree); S e lf-e ffic a c y in S B I (5 item s), for example: "I fe e l I can appropriately advise patients about drinking and its e ffe c ts ."(resp o n se o p tio n s from l=strongly agree to 5=strongly disagree, reverse scored) Expectations o f S B I benefit (5 items), for ex am ple: "S ta tin g my m ed ica l concerns about a p a tie n t' s drinking habits and related health risks will result in their cutting back on their d rinking." (resp o n se options from 1 =strongly agree to 5=strongly disagree, reverse scored).
Internal consistency of all scales used here were above .70prior to and at nine months after the training in this sample.F in ally , the self-ad m in istered questionnaire included questions about socio-dem ographic and professional b ac k g ro u n d , screen in g and b rie f intervention practices (e.g. the uptake of SBI and the number of cases managed w ith SB I) as w ell as open-ended questions on perceived barriers and support in implementing SBI.

Data analysis
G roup m eans o f the know ledge, confidence, perceived obstacles, selfefficac y and b en e fits scales w ere compared across time (before and nine months after training) using a Paired Samples T-Test.

Results
Table 1 shows the average scores for the m easures of knowledge, confidence, perceived obstacles, self-efficacy and ex p e ctatio n s before and after nine months of the training exercise.Health care providers significantly increased in knowledge, confidence in screening and brief intervention and higher self-efficacy in implementing SBI at follow-up after 9 m onths after receiving the training.Participants also decreased levels of perceived obstacles for implementing SBI, and raised their level of expectations relative to their respective baseline scores, though not at significant levels.

Uptake of SBI
At follow-up 81 nurses were surveyed regarding the implementation of SBI in their clinics.All indicated to have takenup SBI.Most (82%) had referred a patient with probable alcohol dependence to a hospital, though 18 percent indicated that they did not know where to refer.
Nurses were asked at baseline and followup how many patients they had managed for alcohol problems in the past nine months.At follow-up significantly more cases had been managed as compared to prior to the training (see Table 2). 19

Implementation barriers and support
At follow-up nurses reported as main b arriers to screen in g and b rief intervention: p atient-cau sed (55% ) (disinterested/refused) and shortage of staff/work overload (35%), and some ( 1 0 %) mentioned that patients at risk do not come to the clinic.Regarding barriers to referral 63% of the nurses noted that they "don't use them/ like them (being referred)" and lack of adequate services for the treatment of alcoholic patients (24%).Most (74%) n urses screen patien ts during consultation, whenever they have time (21%) and after consultation (5%).Most (71%) record the screening results on provided log sheets, 14% in the record book, and 5% on the AUDIT sheet.The m ost su p p o rtin g elem ents for helping the programme succeed were cooperation from colleagues (31%), support from facilitators and supervisors (29%), and training (19%).The most hindering elements for the programme's success were rated as patient-caused (w ith h o ld /g iv e w rong inform ation/ refuse) (54%) and work overload (46%).One-third indicated that the programme works okay, one-third that either only specific staff or all staff should be trained and one-third that it should be widely advertised in the community.

Discussion
The results of this study demonstrate that even relatively short training of health care providers in screening and brief intervention techniques can result in gains in provider knowledge, selfefficacy, and expectations about the value of SBI.(Babor et al. 2004: 24).The results of this study indicate that the training of nurses is feasible, and it is effective in preparing health care providers to implement an SBI programme in South Africa.There are, however, other pre-requisites that must be met before SBI will find widespread application in prim ary care practice.S tandards o f p ra ctice by n atio n al accred itin g and p ro fessio n al organizations are needed.Purchasers and payers must encourage this preventative health service and provide financial incentives to providers.Linkages to com m unity-based organizations and hospitals must be developed to support referral for treatment in an integrated service delivery system.Communica tions and social marketing must enlist p atien ts in the search for b e tte r preventative health services.And finally, research will be required to develop more efficient ways to train present and future nurses in the implementation of SBI in ways that assure improved performance in practice in South Africa.

References
Further, a 54-item questionnaire informed by the alcohol health services literature including Project NEADA (Church & Babor 1995: 280) and the World Health O rg a n izatio n S tudy o f G en eral Practitioners (Monteiro & Gomel 1998:8) measured a variety of other factors that might affect a clinician's ability to provide SBI to patients, as follows: Confidence in screening o f alcohol use (5 items), for example: "Asking questions to collect information about a patient' s risk fo r alcohol related problem s. " (response options from l=no confidence to 4=quite a lot of confidence), Primary health care nurses' and physicians' attitudes, knowledge and beliefs regarding brief intervention for heavy drinkers.Addiction.96: 305-311.ANDERSON, P 1993: Management of alcohol problems: the role of the general practitioner.Alcohol and Alcoholism.28: 263-272.ANDERSON, P; KANER, E; WUTZKE, S; WENSING, M; GROL, R; HEATHER, N & SAUNDERS, J 2003: Attitudes and m anagem ent of alcohol problem s in general practice: descriptive analysis on findings of a World Health Organization in tern a tio n al c o llab o rativ e survey.lcohol screening and b rief intervention: dissemination strategies for m edical practice and public health.Addiction.95(5): 677-686.BABOR, I F & HIGGINS-BIDDLE, JC 2001: Brief intervention for hazardous and harmful drinking.A manual for use in primary care settings.World Health Organization, Geneva, Department of M ental H ealth and S ub stan ce Dependence.WHO/MSD/MSB/O1.6b.BABOR, TF; CAMPBELL, R; ROOM, R & SAUNDERS, J (Eds.) 1994: Lexicon of alcohol and drug terms.Geneva: World Health Organisation.BABOR, TF; HIGGINS-BIDDLE, JC; SAUNDERS, JB & MONTEIRO, MG 2001: A UD IT: The A lco h o l Use Disorders Identification Test.Guidelines for use in primary care.World Health Organization, Geneva, Department of M ental H ealth and S u b stan ce Dependence.WHO/MSD/MSB/O1.6a. ; HILL, I ^ HOLDER, H;HOMEL,R; ÓSTERBERG,E; REHM, J; ROOM, R & ROSSOW, I 2003: A lcohol: no o rd in ary com m o d ityresearch and public policy.Oxford: Oxford University Press.

Table 1 . Means (standard deviation) of pre-and post training scale scores for knowledge, confidence, perceived obstacles, self-efficacy and expectations/benefits
P e rc e iv e d o b sta cles to s c re e n in g alcohol use (15 items), for example: "I feel it is an invasion o f privacy to ask patients questions about their alcohol consumption."