Periodic Reporting for period 3 - SCALA (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America)
Período documentado: 2020-12-01 hasta 2021-11-30
SCALA is a quasi-experimental study implemented in primary health care at municipal level in Bogotá, Colombia; Mexico City, Mexico; and, Lima, Peru. SCALA tests the extent to which training of primary health care providers and the provision of community support increase the number of patients who are identified and managed for heavy drinking and comorbid depression.
Heavy drinking is a causal factor for some communicable diseases (including TB and HIV/AIDS), for many non-communicable diseases (NCDs, including cancers, cardiovascular diseases and gastrointestinal diseases) and for many mental and behavioural disorders, including depression, dementias and suicide. World Health Organization’s SAFER initiative includes ‘facilitating access to screening, brief interventions and treatment’ as one of five initiatives that should be implemented by countries to reduce the harm done by alcohol.
Based on its six objectives, SCALA:
1. Delivered a tailored clinical and training package to improve the prevention and management of heavy drinking and comorbid depression.
2. Set-up and implemented the scalable clinical and training package, with stakeholder support in three implementation municipalities from Colombia, Mexico and Peru;
3. Demonstrated that training of primary health care providers increased the number of patients whose alcohol consumption was measured 13-fold, and a combination of training and community support nearly 17-fold. Training increased the number of patients assessed for depression three-fold, with the addition of community support not increasing this further.
4. Identified the main facilitators of success as strong leadership at the centre level, a high level of motivation and strong views of self-efficacy of providers at the outset, simple and easy-to-use clinical packages, and a supportive organisational or broader policy environment. The cost to implement the programme was int$3 per person whose alcohol consumption was measured, with savings in reduced hospital admissions of $5.4 per person whose alcohol consumption was measured.
5. The SCALA Framework for asking and advising about alcohol in primary health care at municipal level was presented to support implementation and scale-up in other municipal areas.
6. Sustainability plans are actioned in each country, with support from the Pan-American Health Organization.
Heavy drinking is a causal factor for some communicable diseases (including TB and HIV/AIDS), for many non-communicable diseases (NCDs, including cancers, cardiovascular diseases and gastrointestinal diseases) and for many mental and behavioural disorders, including depression, dementias and suicide. World Health Organization’s SAFER initiative includes ‘facilitating access to screening, brief interventions and treatment’ as one of five initiatives that should be implemented by countries to reduce the harm done by alcohol.
Based on its six objectives, SCALA:
1. Delivered a tailored clinical and training package to improve the prevention and management of heavy drinking and comorbid depression.
2. Set-up and implemented the scalable clinical and training package, with stakeholder support in three implementation municipalities from Colombia, Mexico and Peru;
3. Demonstrated that training of primary health care providers increased the number of patients whose alcohol consumption was measured 13-fold, and a combination of training and community support nearly 17-fold. Training increased the number of patients assessed for depression three-fold, with the addition of community support not increasing this further.
4. Identified the main facilitators of success as strong leadership at the centre level, a high level of motivation and strong views of self-efficacy of providers at the outset, simple and easy-to-use clinical packages, and a supportive organisational or broader policy environment. The cost to implement the programme was int$3 per person whose alcohol consumption was measured, with savings in reduced hospital admissions of $5.4 per person whose alcohol consumption was measured.
5. The SCALA Framework for asking and advising about alcohol in primary health care at municipal level was presented to support implementation and scale-up in other municipal areas.
6. Sustainability plans are actioned in each country, with support from the Pan-American Health Organization.
Set-up phase
The first 18 months of the project was the set-up phase, with the following undertaken: (i) full adaptation, tailoring and preparation of all clinical and training materials available in English and Spanish languages with variants for Colombia, Mexico and Peru; (ii) recruitment of 58 primary health care centres; (iii) appointments of stakeholder members and meetings of Community Advisory Boards; (iv) full identification and preparation of municipal support mechanisms and community-based communication campaigns; and, (v) finalization and testing of all instruments required for evaluation.
First implementation phase and adaptation due to COVID
The second 18 months of the project was the implementation phase, with the following undertaken: (i) completed the one-month baseline measurement period; (ii) delivered pre-implementation training to providers in Arms 2, 3 and 4; (iii) completed at least five months of full 18-month implementation period in all countries before impact of COVID-19 mitigation measures; (iv) maintained partial implementation during the months of March to November 2020, providing primary health care centres with mental well-being support and resilience training; (vi) tailored and adapted all clinical interventions and protocols, community support mechanisms, communication campaigns and measurement instruments in face of COVID-19 mitigation measures; (vii) developed and delivered online training programme for primary health care providers; and, (viii) developed tele-medicine approaches for measurement and advice giving to continue programme in Peru.
Extended implementation phase and completion of project
The last 12 months of the project was the completion and exploitation phase, with the following main results:
(i) completion and availability on project website of all materials required for implementation and scale-up;
(ii) demonstration that training increases the proportion or patients whose alcohol consumption is measured 13-fold, and the proportion of heavy drinking patients assessed for depression three-fold.
(iii) demonstration that community support increases the proportion or patients whose alcohol consumption is measured by a further 28% over and above training, with no further increase in the proportion of heavy drinking patients assessed for depression.
(iv) estimated the cost to implement the programme at int$3 per person whose alcohol consumption was measured, with a return on investment in saved hospital admission of 1.8.
(v) identified the main facilitators of success as strong leadership at the centre level, a high level of motivation of providers at the outset, strong views of self-efficacy at the outset, simple and easy-to-use clinical packages, and a supportive organisational or broader policy environment.
(vi) presented the SCALA Framework for asking and advising about alcohol in primary health care at municipal level.
(vii) actioned sustainability plans in each country with local and national health authorities, and, more broadly, with the Pan-American Health Organization.
The first 18 months of the project was the set-up phase, with the following undertaken: (i) full adaptation, tailoring and preparation of all clinical and training materials available in English and Spanish languages with variants for Colombia, Mexico and Peru; (ii) recruitment of 58 primary health care centres; (iii) appointments of stakeholder members and meetings of Community Advisory Boards; (iv) full identification and preparation of municipal support mechanisms and community-based communication campaigns; and, (v) finalization and testing of all instruments required for evaluation.
First implementation phase and adaptation due to COVID
The second 18 months of the project was the implementation phase, with the following undertaken: (i) completed the one-month baseline measurement period; (ii) delivered pre-implementation training to providers in Arms 2, 3 and 4; (iii) completed at least five months of full 18-month implementation period in all countries before impact of COVID-19 mitigation measures; (iv) maintained partial implementation during the months of March to November 2020, providing primary health care centres with mental well-being support and resilience training; (vi) tailored and adapted all clinical interventions and protocols, community support mechanisms, communication campaigns and measurement instruments in face of COVID-19 mitigation measures; (vii) developed and delivered online training programme for primary health care providers; and, (viii) developed tele-medicine approaches for measurement and advice giving to continue programme in Peru.
Extended implementation phase and completion of project
The last 12 months of the project was the completion and exploitation phase, with the following main results:
(i) completion and availability on project website of all materials required for implementation and scale-up;
(ii) demonstration that training increases the proportion or patients whose alcohol consumption is measured 13-fold, and the proportion of heavy drinking patients assessed for depression three-fold.
(iii) demonstration that community support increases the proportion or patients whose alcohol consumption is measured by a further 28% over and above training, with no further increase in the proportion of heavy drinking patients assessed for depression.
(iv) estimated the cost to implement the programme at int$3 per person whose alcohol consumption was measured, with a return on investment in saved hospital admission of 1.8.
(v) identified the main facilitators of success as strong leadership at the centre level, a high level of motivation of providers at the outset, strong views of self-efficacy at the outset, simple and easy-to-use clinical packages, and a supportive organisational or broader policy environment.
(vi) presented the SCALA Framework for asking and advising about alcohol in primary health care at municipal level.
(vii) actioned sustainability plans in each country with local and national health authorities, and, more broadly, with the Pan-American Health Organization.
SCALA goes beyond the state of the art in four important ways:
i. It recognizes the importance of comorbid moderately severe and severe depression with heavy drinking, by building in identification and referral mechanisms, either through specialist services, or through additional specialist support to primary health care;
ii. It adopts a novel approach by embedding and scaling-up the primary health care activity within municipalities, supported by a series of municipal-based adoption mechanisms and support systems, and communication campaigns, aiming to assist in building a new knowledge base, on which better policy could be based;
iii. It provides a model of adaptation and response to the implementation and research constraints imposed by COVID-19 illnesses and mitigation measures; and,
iv. It provides programmes of Internet-based training of primary health care providers and tele-medicine approaches to measurement and brief advice delivery and treatment for heavy drinking and co-morbid depression.
SCALA impacts health and societal impacts in the following ways, modified due to COVID-19:
i. At the municipal level, SCALA assessed 29,306 new patients for heavy drinking, identified, and advised and treated 936 new patients for their heavy drinking, assessed 8808 new patients for comorbid depression, and identified and treated 518 new patients for comorbid depression;
ii. SCALA identified a return in investment for savings on reduced hospital admissions of 1.8;
iii. SCALA estimated that were 25% of the adult population to have their alcohol consumption measured in a primary health care setting, population drinking levels could be reduced by 6%.
iv. SCALA delivered a Framework for going to full-scale for asking and advising about alcohol in primary health care at municipal level. The Framework is actionable in at least almost any municipality in low and middle-income countries, as well as municipalities in high-income countries, including European Union member states.
i. It recognizes the importance of comorbid moderately severe and severe depression with heavy drinking, by building in identification and referral mechanisms, either through specialist services, or through additional specialist support to primary health care;
ii. It adopts a novel approach by embedding and scaling-up the primary health care activity within municipalities, supported by a series of municipal-based adoption mechanisms and support systems, and communication campaigns, aiming to assist in building a new knowledge base, on which better policy could be based;
iii. It provides a model of adaptation and response to the implementation and research constraints imposed by COVID-19 illnesses and mitigation measures; and,
iv. It provides programmes of Internet-based training of primary health care providers and tele-medicine approaches to measurement and brief advice delivery and treatment for heavy drinking and co-morbid depression.
SCALA impacts health and societal impacts in the following ways, modified due to COVID-19:
i. At the municipal level, SCALA assessed 29,306 new patients for heavy drinking, identified, and advised and treated 936 new patients for their heavy drinking, assessed 8808 new patients for comorbid depression, and identified and treated 518 new patients for comorbid depression;
ii. SCALA identified a return in investment for savings on reduced hospital admissions of 1.8;
iii. SCALA estimated that were 25% of the adult population to have their alcohol consumption measured in a primary health care setting, population drinking levels could be reduced by 6%.
iv. SCALA delivered a Framework for going to full-scale for asking and advising about alcohol in primary health care at municipal level. The Framework is actionable in at least almost any municipality in low and middle-income countries, as well as municipalities in high-income countries, including European Union member states.