France

World Health Organization Collaborative Project on Identification and Management of Alcohol-related Problems

in Primary Health Care: Phase IV

Development of Country-wide Strategies for Implementing Early Identification and Brief Alcohol Intervention in Primary Health Care.

France

[Customisation] [Communications] [Strategic Alliance] [Demonstration Project]

Final Country Chapter, January 2006

Collaborative Centre:

Paris. Centre Magellan, 10 rue de la Paix, F-92230 Gennevilliers

Tel: + 33 1 41 21 05 63 Fax: + 33 1 47 94 84 39 Email: centre.medical.magellan@wanadoo.fr

Chief Investigators:

Dr Philippe Michaud (Email: philippe.michaud@wanadoo.fr), Pr Francois Paille (Nancy), Dr Elisabeth Kind (Paris), Dr Anne-Violaine Dewost (Paris), Dr Sabrina Levy (Paris) Mme Veronique Dorner (Paris)

Geographical Area in which Implementation Strategy will be Applied:

Île-de-France (Parisian administrative area: 10 million inhabitants)

Starting Date:

16/03/99

Completion Date:

End 2005

Project Strands and Milestones:

1999:

(Strand 1a) French validation of AUDIT
(Strand 1b) Material customisation (focus group: (i) alcohol issues general understanding (ii) adapting screening process and intervention package: GPs, primary health care staff, patients)
Baseline measures (pool)

2000-2

(Strand 2a) Training of three groups of general practitioners out of three separate but similar communities ('villes nouvelles' i.e. recently built suburban communities): Saint-Quentin-en-Yvelines, Evry, Orly, for screening and brief intervention.
(b) RCT (CO): Comparison of two methods of screening AUDIT vs AUDIT in health questionnaire
(c) Final version of the screening and brief intervention material

2003-4

Implementation regional programme
(Strand 3a) Focus groups of general practitioners about the best way for adapting the marketing strategies: group training, tutorial support, mail plus telephone.....
(b) Study: Is money a good way of convincing GPs to intervene in a liberal system?
Comparison of two communities, the first one with economic incentive (by social insurance system), the second one only with motivational information.
(c) Outcome measures at the community level (pool, alcohol-related incidents, emergency consultations, consumption, etc...)
(d) Communication strategies about the results
(e) Final choice for marketing strategies
(f) Training the trainers for implementation

2003-4

Implementation in acts: (Strand 4-a) Screening and brief intervention (SBI) in medical post graduate training
(b) SBI in medical schools
(c) Mass media communication

2004-6

(d) Final outcome measures at region level and economic analysis
(e) Consensus meeting
(f) Mass media communication
(g) Legal action: nation-wide implementation

Proposed funding Sources:

Social security prevention funds
Regional council
'Départements' councils
'Fondation de France'
Ministry of public health and social affairs
Private sponsoring (insurance, pharmaceutics, soft drinks)

Local Support:

Observatoire régional de santé (ORS)
Caisse régionale d'assurance maladie (CRAMIF)
Groupement régional d'alcoologie (GFA)
Direction régionale des affaires sanitaires et sociales (DRASSIF)
Comité régionale d'éducation pour la santé (CRESIF)
Délégation régionale de l'assocation nationale de prévention de l'acoolisme (DRPA/ANPA)
Public health specialists from the following cities: Evry, Orly and from the départment des Yvelines

Support at national level:

Société Française de médecine générale (SFMG)
Société Française d'alcoologie (SFA)
Comité Française d'éducation pour la santé (CFES)
Collége national des généralistes enseignants (CNGE)
Ecole nationale de la santé publique (ENSP)
Ecole de santé publique de la Faculté de médecine de Nancy

CUSTOMIZING MATERIALS AND SERVICES

Focus groups with GPs, receptionists (in Public Health Centres with a primary care section), patients, occupational doctors and nurses on the following themes:

Goals of an intervention for risky drinking
Screening proposition
Screening material (AUDIT included in a health questionnaire)
Intervention package
Financial incentives and others
Barriers to a systematic approach of early detection
What could be a useful pre-screening
Better follow up procedures
The best way of training the doctors about alcohol issues
Quality assurance

Structured questionnaires (postal study, enhanced by telephone., or face-to-face)

Training and motivations to change (and barriers)

Early Identification (Screening):

French (validated) translation of AUDIT questionnaire and AUDIT questions inside a wider health questionnaire. Pre-screening will be discussed (antecedents of accidents, shorter questionnaire, list of opportunities for proposing screening....)

Brief Intervention Package:

The Drink-less programme will be adapted by the focus groups. Mail and/or group training plus phone will be used for dissemination, after adaptation by the focus groups.

Brief Intervention process:

Two (or three) interventions in the course of medical interviews

Training of Primary Health Care Staff:

Basis and continuing training are both necessary. The training of public primary health care centre receptionists will be integrated into public staff continuing education (delivered by a state agency). The contents of the training will be discussed, after customisation, between the medical associations and the Steering Group, with possible relations with other themes (e.g. tobacco, or preventive action against withdrawal syndrome for physically dependent patients) and with other institutions (e.g. medical schools). It must be kept in mind that the programme should be finally integrated into initial medical training.

Data Analysis:

The baseline data will be of three different sorts:

Qualitative information about alcohol consumption in the demonstration project areas, and its effects on figures like DWI sentences, emergency room consultations.. (official statistics)
Qualitative information about the importance of risky/hazardous drinking and alcohol dependence among primary health care staff
Semi-quantitative and qualitative information about how GPs deal with 'excessive drinking' (questionnaires).

This information could be gathered and analysed by the ORS, with the help of Social Security Bureau of Statistics. A pool among a sample of adults living in the areas could be necessary.

For the Demonstration project, the economic analysis is of prominent importance, and will be held by or with the social security and a public health school (Ecole nationale de santé publique and/or école de santé publique de la faculté de médecine). The other outcome data will be analysed like the baseline data.

REFRAMING UNDERSTANDING OF ALCOHOL ISSUES

General Public:

Focus groups with patients
New communications target, e.g. 'Your physician should ask you about your drinking'
Newspapers could be involved with a journalist as counsellor in the Steering Group
The regional TV network can be very useful in the communications strategy, but using an event to wake the journalists' interest (for instance a WHO meeting.....)
The CFES has communications specialists, and it participation in mass media campaigns, or better, campaigns held in common must be included in the plan.
The doctors responsible for public health at the local (community) level can enhance efficiency of a national campaign with local actions (posters, letters to the citizens, local radio)
Trade unions, occupational doctors, ex-drinkers associations can endorse the aims of a campaign explaining that risky drinking is a good thing to detect.
Internet sites with alcohol implications could be used as vectors of information about the programme, whether they include the complete programme description and explanation or only hyper -text links.

Health Professionals:

Medical press system: articles in daily medical newspapers or illustration file in weekly journals
The communication strategies of the pharmaceutical industry could be useful and carefully used
See section on training above
A consensus meeting about early identification and brief intervention (EIBI) could also be held at the end of the whole process

Other Stakeholders:

Occupational doctors, trade unions, AA and other ex-drinkers associations
The 'Association nationale de prévention de l'alcoolisme' and ' Fédération française de l'alcoologie ambulatoire' both usually lobby for new means to reduce about alcohol consumption and/ or harm (specially towards Ministry of Health and Social Security). Both can also help by naming professionals able to 'train the trainers'
The 'conférences régionales de santé and the 'conférence nationale de santé', held every year, are an efficient way of making an action well known. This is because they address politicians and administrative authorities as much as the press and the general public. The 'programme régional alcool' as a place in these 'conférences'. The public health doctor belonging to both steering group and 'programme régional alcool' will make the link.

Media Advocacy and control of Communications Strategy:

Close contact with the press, the radio and the TV will be one of the constant preoccupation of the Steering Group

ESTABLISHING LEAD ORGANIZATION(S) AND BUILDING STRATEGIC ALLIANCES

Lead Organisation(s):

If possible: Groupement francilien d'acoologie. If not, Délégation régionale de l'Assocation nationale de prévention de l'acoolisme (DRPA)

Fédération française de l'alcoologie ambulatoire & Société Française de médecine générale (SFMG)

Building Strategic Alliances:

The Steering Group is one of the main ways of building alliances. It has been composed to give a wide representation of GPs, but there is also key -persons to install and maintain the project under a positive atmosphere: 'representatives' of the Ministry of Health, regional health authorities.

Many contacts must be continued. the difficulty will be to get funds for co-operation, with maybe a necessity to shift aspects of the programme to allow an effective collaboration (e.g. CFES, which has already developed its own instrument for intervention).

The main allies could be:

Social security regional organisation - Caisse régionale d'assurance maladie
Regional council
Ministry of public health and social affairs
Observatoire régional de santé (ORS)
Direction régionale des affaires sanitaires et sociales (DRASSIF)
Comité régionale d'éducation pour la santé (CRESIF)
Public health specialists of the following cities: Evry, Orly, and of the départment des Yvelines
Société Française d'alcoologie (SFA)

DEMONSTRATION PROJECT(S)

Locations:

Ville nouvelle d'Evry (département de l'Essonne, 50 000 inhabitants) Ville nouvelle de Saint-Quentin-en-Yveline (50 000 inhabitants) Agglomération d'Orly/Choisy-le-Roi (40 000 inhabitants)

Projected Start date:

September 2000

Projected Completion Date:

December 2002

Design of Projects:

a) Randomized control study with crossing-over: Use of AUDIT alone versus AUDIT included in a wider health questionnaire (AUDIT-HQ) in GP practices and in public PHC facilities.

b) Community-based study, comparing two (or four) 'similar' communities where early identification and brief intervention (EIBI) is promoted either (i) with a (low) economic incentive, e.g. 10 FF (1.52 €) per filled AUDIT and 20 FF (3.04 €) per preformed brief intervention; or (ii) without any economic incentive.

Outcome Measure:

a) Number of patients filling AUDIT or AUDIT-HQ/Number of patients screened 'positive' (relevant for BI) and 'dependent' Pool in a sample of GPs and patients about acceptability (analogic scales and/or structured interviews)

b) Number of patients screened/Number of patients screened 'positive' (relevant for BI) and 'dependent' Number of interventions preformed

Process Measures:

The process will be observed during the whole time of the study by a specialist of human and sciences (sociologist, ethnologist and anthropologist), and the description will be submitted regularly to the Steering Group.

Economic Analysis:

The Ecole nationale de santé publique and/or a Ph D student of the Ecole de santé Publique, faculté de médecine de nancy, will do the economic survey with an economist specialised in health issues.

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