Development and evaluation of two instruments for assessing screening, brief intervention, and referral to treatment (SBIRT) competency.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is shown to be effective in identifying, intervening with, and making appropriate referrals for patients with unhealthy alcohol use. SBIRT training consists of knowledge-based and skill-based components and has increased the use of screening and intervention skills in clinical settings. This article reports on the development and evaluation of 2 SBIRT proficiency checklists for use across institutions to assess SBIRT skills in both simulated and clinical encounters. METHODS: A national panel of 16 experts identified 137 discrete SBIRT skills items for the checklists. From this final list, 2 proficiency checklists were derived: the SBIRT Proficiency Checklist (SPC), composed of 22 questions for videotaped interviews, and the Clinical SBIRT Proficiency Checklist (CSPC), composed of 13 questions for direct clinical observation. An evaluation was conducted to test the reliability of the SPC and to assess the utility of the CSPC. RESULTS: Two checklists for assessing SBIRT proficiency were developed by a collaborative workgroup. Fleiss' kappa analyses indicated moderate agreement. In addition, faculty recorded satisfaction with the CSPC for assessing residents on their SBIRT performance during clinical encounters. CONCLUSIONS: The SPC and the CSPC are practical tools for assessing competence with SBIRT and are easily integrated as standard instruments in a wide range of training settings. Future advancements to the checklists and their evaluation include modification of the SPC rating scale to be consistent with the CSPC, developing a training program for using the checklists, and further testing to improve interrater reliability.

Reinventing the reel: an innovative approach to resident skill-building in motivational interviewing for brief intervention.

To enhance the skills of primary care residents in addressing substance misuse, residency screening, brief intervention, and referral to treatment (SBIRT) programs increasingly offer motivational interviewing (MI) training, but seldom include feedback and coaching. This innovative 2-round "Virginia Reel" approach, supplementing 3 hours of basic MI instruction, was designed to teach and coach residents to use MI while providing ongoing medical care. SBIRT/MI-competent facilitators served as both trainers and actors at 8 carefully sequenced Objective Structured Clinical Examination (OSCE) stations, providing instruction, role-play practice, and feedback on 17 microskills in 2 successive clinical "visits"/rounds addressing alcohol misuse and diabetes management. Evaluation included OSCE checklists, overall competency assessments, and responses to open-ended questions. Three residents showed improvement between rounds. Resident evaluations were strongly positive, identifying practice of MI skills and receipt of coaching and feedback from MI experts as particularly valuable. Further study is needed to confirm effectiveness of the approach and explore the impact of fewer OSCE stations of longer duration.

Skills-based residency training in alcohol screening and brief intervention: results from the Georgia-Texas "Improving Brief Intervention" Project.

Alcohol screening and brief intervention (SBI) is recommended for all primary care patients but is underutilized. This project trained 111 residents and faculty in 8 family medicine residencies to conduct SBI and implement SBI protocols in residency clinics, then assessed changes in self-reported importance and confidence in performing SBI and brief intervention (BI) rates. Clinicians reported significant increases in role security, confidence, and ability to help drinkers reduce drinking and decreased importance of factors that might dissuade them from performing SBI. Stage of change measures indicated 37% of clinicians progressed toward action or maintenance in performing SBI; however, numbers of reported BIs did not increase. At all time points, 33% to 36% of clinicians reported BIs with ≥10% of the last 50 patients. Future studies should focus on increasing intervention rates using more patient-centered BI approaches, quality improvement approaches, and systems changes that could increase opportunities for performing BIs.

Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison.

BACKGROUND: Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates. METHODS: In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention. RESULTS: Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients. CONCLUSIONS: Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Characteristics of problem drinking in an urban South American indigenous population.

This 2002 Medcen Foundation-funded study explored characteristics of problem drinking among 211 urban Venezuelan Native Americans of Arawak origin. Prevalence of problem drinking using Alcohol Use Disorders Identification Tests was 88.5% among men and 17.3% among women. Periodic binge drinking was marked by loss of control, failure to meet obligations, and alcohol-related trauma. Focus group participants noted that previous occasional binge drinking by men has been replaced by frequent male and female heavy weekend drinking, violence, and death. Limitations and implications are discussed. Awareness of high levels of problem drinking and desire for assistance present compelling mandates for community intervention efforts.

Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum.

BACKGROUND: This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education (December, 2008), presents a model curriculum for Family Medicine residency training in substance abuse. METHODS: The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U.S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models. RESULTS: This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice. CONCLUSIONS: Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training.

A qualitative inquiry into the community and programmatic dimensions associated with successful implementation of church-based diabetes prevention programs.

PURPOSE: This study explored church members' perspectives regarding implementation of a church-based diabetes prevention program (CBDPP) within African American churches. METHODS: Qualitative exploration of themes associated with planning for program implementation and good program outcomes was conducted using a series of four focus groups in churches located in the southeastern United States. Three of these focus groups were conducted with church leaders during the planning phases of program initiation and one focus group involved program participants who had realized the most weight loss and decrease in fasting glucose. Focus group transcripts were subject to content analysis. Participants discussed their views about how to implement a CBDPP within their church and how both the program and broader church community had helped them succeed. RESULTS: Two broad thematic domains emerged with respect to successful CBDPP implementation. The first domain covered church functions and program integration within the church. This was further divided into three thematic clusters relating to church organization, promotion from the pulpit and program visibility, and church service. The second domain addressed the motivational and relationship factors associated with successful program involvement. This was divided into three clusters relating to individuals' motives and beliefs, learning from others, and the support of others. CONCLUSIONS: Implementation of a CBDPP depends on the endorsement by the church leadership, congregational awareness of the program objectives, and active community and program support of CBDPP participants. These occur through a variety of formal and informal channels within the church community.

Diabetes prevention in a faith-based setting: results of translational research.

AIM: The purpose of this study was to translate the National Institutes of Health (NIH)-Diabetes Prevention Program (DPP) into a church-based setting. METHODS: The lifestyle arm of the NIH-DPP was implemented in an African American Baptist church. Church members 18 years or older completed a risk screen during Sunday service followed by fasting glucose (FG) testing at the church during the week. Persons with prediabetes participated in a 16-session DPP conducted over 4 months. Participation rates, height, weight, blood pressure (BP) and FG were followed for 12 months post-intervention. Fifty participants completed the risk screen, 26 were at risk for diabetes, 16 of 26 received FG testing, and 8 had prediabetes (FG = 100- 125 mg/dL). RESULTS: The mean participation rate was 10.4 (65%) sessions. Following the intervention, weight, systolic and diastolic BP, and FG decreased by 7.5 lb (3.6%), 16 mm Hg (11.7%), 12 mm Hg (14.0%), and 5 mg/dL (4.8%), respectively (P < .05). In comparison with baseline, significant reductions were evident at 6 and 12 months postintervention for all endpoints. CONCLUSIONS: This study demonstrated successful translation of the 16-session NIH-DPP into a church-based setting. Future studies should test this intervention in churches of different sizes and denominations.

Implementing a diabetes prevention program in a rural African-American church.

OBJECTIVES: The purpose of this study was to determine the feasibility of implementing a diabetes prevention program (DPP) in a rural African-American church. METHODS: A six-session DPP, modeled after the successful National Institutes of Health (NIH) DPP, was implemented in a rural African-American church. Adult members of the church identified as high risk for diabetes, based on results of a risk questionnaire, were screened with a fasting glucose. Persons with prediabetes, a fasting glucose of 100-125 mg/dL, participated in the six-session, Lifestyle Balance Church DPP. The primary outcomes were attendance rates and changes in fasting glucose, weight and body mass index measured at baseline, six- and 12-month follow-up. RESULTS: Ninety-nine adult church members were screened for diabetes risk. Eleven had impaired fasting glucose. Ten of 11 participated in the six-session intervention, for an attendance rate of 78%. After the intervention and 12-month follow-up, there was a mean weight loss of 7.9 lbs and 10.6 lbs, respectively. CONCLUSIONS: This pilot project suggests that a modified six-session DPP can be translated to a group format and successfully implemented in a church setting. Further randomized studies are needed to determine the effectiveness of such an intervention.

Developing a church-based diabetes prevention program with African Americans: focus group findings.

PURPOSE: The purpose of this study was to use a community-based participatory research (CBPR) approach to identify resources and barriers to implementing a church-based diabetes prevention program (DPP) in a rural African American church community in Georgia. METHODS: In collaboration with community leaders, researchers conducted 4 focus groups with 22 key informants to discuss their understanding of diabetes and identify key resources and barriers to implementing a DPP in the church. Three researchers analyzed and coded transcripts following a content-driven immersion-crystallization approach. RESULTS: The participants' comments on diabetes and prevention covered 5 research domains: illness perceptions, illness concerns, illness prevention, religion and coping, and program recommendations. Program success was deemed contingent on cultural sensitivities, a focus on high-risk persons, use of church resources, and addressing barriers. Barriers identified included individuals' lack of knowledge of risk and prevention programs, lack of interest, and attendance concerns. Solutions and resources for overcoming barriers were testimonials from persons with illness, using local media to advertise the program, involving the food committee of the church, ministering to the healthy and at risk, and acquiring a support buddy. CONCLUSIONS: A CBPR approach engaged church members as partners in developing a church-based DPP. Focus groups generated enthusiasm among church members and provided valuable insights regarding barriers and resources for program implementation. This methodology may prove useful in other church-based chronic disease prevention efforts with at-risk populations.

Primary care validation of a single screening question for drinkers.

OBJECTIVE: The aim of this study was to conduct a primary care validation study of a single screening question for alcohol misuse ("When was the last time you had more than X drinks in 1 day?," where X was four for women and X was five for men), which was previously validated in a study conducted in emergency departments. METHOD: This cross-sectional study was accomplished by interviewing 625 male and female adult drinkers who presented to five southeastern primary care practices. Patients answered the single question (coded as within 3 months, within 12 months, ever, or never), Alcohol Use Disorders Identification Test (AUDIT), and AUDIT consumption questions (AUDIT-C). Alcohol misuse was defined as either at-risk drinking, identified by a 29-day Timeline Followback interview or a current (past-year) alcohol-use disorder by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria, or both. RESULTS: Among 625 drinkers interviewed, 25.6% were at-risk drinkers, 21.7% had a current alcohol- use disorder, and 35.2% had either or both conditions. Considering "within the last 3 months" as positive, the sensitivity of the single question was 80% and the specificity was 74%. Chi-square analyses revealed similar sensitivity across ethnic and gender groups; however, specificity was higher in women and whites (p = .0187 and .0421, respectively). Considering "within the last 12 months" as positive increased the question's sensitivity, especially for those with alcohol-use disorders. The area under the receiver operating characteristic curve of the single alcohol screening question (0.79) was slightly lower than for the AUDIT and AUDIT-C, but sensitivity and specificity were similar. CONCLUSIONS: A single question about the last episode of heavy drinking is a sensitive, time-efficient screening instrument that shows promise for increasing alcohol screening in primary care practices.

Using children as simulated patients in communication training for residents and medical students: a pilot program.

Medical schools are charged with the challenge of teaching effective communication skills, a core competency for residents and medical students. Especially challenging is the task of developing effective methods for training residents and students to communicate with children with mental health issues. The authors describe a pilot program at Mercer University School of Medicine that used pediatric standardized patients (SPs), ages 9-19, to aid in training residents and medical students in complex interviewing skills addressing mental health issues. New curriculum components for four pediatric problems, anorexia nervosa, depression, separation anxiety, and attention deficit hyperactivity disorder (ADHD), were designed and implemented by the authors in 2002-04. The training sessions were evaluated by the participating SPs as well as the residents and medical students in training. The components of the training were a lecture and subsequent practice using pediatric SPs and adults acting as their mothers. Evaluation included the qualitative analysis of SPs' reactions to participation in the training as described during a posttraining-session focus-group, as well as questionnaire responses by residents and medical students. The children role-playing the scenario of a difficult-to-manage situation and their adult "parent" actors voiced strongly positive reactions to participating in training residents and medical students. The reactions of physicians in training were also positive. The authors thus conclude that child and adolescent actors can be effectively used as SPs to train residents and students in complex interviewing skills, even in cases involving children with challenging mental health issues.

Effects of screening and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- post-intervention assessment.

BACKGROUND: Many hazardous and harmful drinkers do not receive clinician advice to reduce their drinking. Previous studies suggest under-detection and clinician reluctance to intervene despite awareness of problem drinking (PD). The Healthy Habits Project previously reported chart review data documenting increased screening and intervention with hazardous and harmful drinkers after training clinicians and implementing routine screening. This report describes the impact of the Healthy Habits training program on clinicians' rates of identification of PD, level of certainty in identifying PD and the proportion of patients given advice to reduce alcohol use, based on self-report data using clinician exit questionnaires. METHODS: 28 residents and 10 faculty in a family medicine residency clinic completed four cycles of clinician exit interview questionnaires before and after screening and intervention training. Rates of identifying PD, level of diagnostic certainty, and frequency of advice to reduce drinking were compared across intervention status (pre vs. post). Findings were compared with rates of PD and advice to reduce drinking documented on chart review. RESULTS: 1,052 clinician exit questionnaires were collected. There were no significant differences in rates of PD identified before and after intervention (9.8% vs. 7.4%, p = .308). Faculty demonstrated greater certainty in PD diagnoses than residents (p = .028) and gave more advice to reduce drinking (p = .042) throughout the program. Faculty and residents reported higher levels of diagnostic certainty after training (p = .039 and .030, respectively). After training, residents showed greater increases than faculty in the percentage of patients given advice to reduce drinking (p = .038), and patients felt to be problem drinkers were significantly more likely to receive advice to reduce drinking by all clinicians (50% vs. 75%, p = .047). The number of patients receiving advice to reduce drinking after program implementation exceeded the number of patients felt to be problem drinkers. Recognition rates of PD were four to eight times higher than rates documented on chart review (p = .028). CONCLUSION: This program resulted in greater clinician certainty in diagnosing PD and increases in the number of patients with PD who received advice to reduce drinking. Future programs should include booster training sessions and emphasize documentation of PD and brief intervention.

A Multisite Initiative to Increase the Use of Alcohol Screening and Brief Intervention Through Resident Training and Clinic Systems Changes.

PURPOSE: Screening and brief intervention (SBI) is a seldom-used evidence-based practice for reducing unhealthy alcohol use among primary care patients. This project assessed the effectiveness of a regional consortium's training efforts in increasing alcohol SBI. METHOD: Investigators combined alcohol SBI residency training efforts with clinic SBI implementation processes and used chart reviews to assess impact on SBI rates in four residency clinics. Data were derived from a random sample of patient charts collected before (2010; n = 662) and after (2011; n = 656) resident training/clinic implementation. Patient charts were examined for evidence that patients were asked about alcohol use by a validated screening instrument, the screening result (positive or negative), evidence that patients received a brief intervention, prescriptions for medications to assist abstinence, and referrals to alcohol treatment. Chi-square analyses identified differences in pre- and posttraining implementation of SBI practices. RESULTS: Following program implementation, screening with validated instruments increased from 151/662 (22.8%) at baseline to 543/656 (82.8%, P < .01), and identification of unhealthy alcohol use increased from 12/662 (1.8%) to 41/656 (6.3%, P < .01). Performance of brief interventions more than doubled (10/662 [1.5%] versus 24/656 [3.7%], P < .01). There were no increases in the use of medications or referrals to treatment. CONCLUSIONS: Resident training combined with clinic implementation efforts can increase the delivery of evidence-based practices such as alcohol SBI in residency clinics.

Impact of a medical student alcohol intervention workshop using recovering alcoholics as simulated patients.

BACKGROUND: Alcohol screening and brief intervention (SBI) reduces drinking among at-risk drinkers. Lack of training and negative attitudes represents a barrier to SBI performance. This study evaluates the impact of a medical student workshop using recovering alcoholics in simulated patient interviews to teach SBI skills. METHODS: Third-year students (n=94) were surveyed before and after a 3-hour alcohol SBI workshop regarding their perceived importance and confidence in performing eleven SBI behaviors. Students were also asked to list factors increasing and decreasing motivation to conduct SBI. Students completing off-campus rotations (n=71) served as controls, completing surveys during the same time period but without attending the workshop. RESULTS: Analysis of variance found a significant interaction effect between the students participating in the workshop and control students on both importance scores [F(2,174)=3.34] and confidence scores [F(2,174)=9.13], indicating higher scores for the workshop students at the follow-up time periods. Commonly listed motivators for performing SBI included clinical experience with alcohol misuse and the impact of alcohol on health and relationships. High relapse rates and patient reactions to questions about alcohol use decreased the motivation to perform SBI. CONCLUSION: SBI workshops that include recovering alcoholics as simulated patients can produce long-term improvements in students' perceived importance and confidence in performing SBI.

Impact of system-level changes and training on alcohol screening and brief intervention in a family medicine residency clinic: a pilot study.

BACKGROUND: Although screening and brief intervention (SBI) are effective in reducing unhealthy alcohol use, major challenges exist in implementing clinician-delivered SBI in primary care settings. This 2006-2007 pilot study describes the impact of systems changes and booster trainings designed to increase SBI rates in a family medicine residency clinic which annually screened adults with a self-administered AUDIT-C questionnaire and used paper prompts to encourage physician interventions for patients with positive screens. METHODS: Investigators added the Single Alcohol Screening Question (SASQ) to nursing vital signs forms, added a checkbox for documenting brief interventions to the clinicians' outpatient encounter form, and conducted one-hour nurse and clinician booster trainings. Impact was measured using chart reviews conducted before implementing systems changes, then six weeks and six months post-implementation. RESULTS: At all three time points screening rates using AUDIT-C plus SASQ exceeded 90%, however AUDIT-C screening decreased to 85% after 6 months (p=.025). Identification of unhealthy alcohol users increased from 4% to 22.9% at six weeks and 18.8% at six months (p=.002) using both screens. Nursing vital signs screening using the SASQ reached 71.4% six weeks after implementation but decreased to 45.5% at six months. Changes in clinician brief intervention rates did not achieve statistical significance. CONCLUSIONS: This is the second study reporting sustained primary care alcohol screening rates of more than 90%. Screening patients with SASQ and/or AUDIT-C identified a higher percentage of patients with unhealthy alcohol use. Dissemination of effective strategies for identifying unhealthy alcohol users should continue, while future research should focus on identifying more effective strategies for increasing intervention rates.

Applying team-based learning in primary care residency programs to increase patient alcohol screenings and brief interventions.

PURPOSE: Educational research demonstrates little evidence of long-term retention from traditional lectures in residency programs. Team-based learning (TBL), an alternative, active learning technique, incites competition and generates discussion. This report presents data evaluating the ability of TBL to reinforce and enhance concepts taught during initial training in a National Institutes of Health-funded alcohol screening and brief intervention (SBI) program conducted in eight residency programs from 2005 to 2007 under the auspices of Mercer University School of Medicine. METHOD: After initial training of three hours, the authors conducted three TBL booster sessions of one and a quarter hours, spaced four months apart at each site. They assessed feasibility through the amount of preparation time for faculty and staff, residents' evaluations of their training, self-reported use of SBI, residents' performance on individual quizzes compared with group quizzes, booster session evaluations, and levels of confidence in conducting SBI. RESULTS: After initial training and three TBL reinforcement sessions, 42 residents (63%) reported that they performed SBI and that their levels of confidence in performing interventions in their current and future practices was moderately high. Participants preferred TBL formats over lectures. Group performance was superior to individual performance on initial assessments. When invited to select a model for conducting SBI in current and future practices, all residents opted for procedures that included clinician involvement. Faculty found TBL to be efficient but labor-intensive for training large groups. CONCLUSIONS: TBL was well received by residents and helped maintain a newly learned clinical skill. Future research should compare TBL to other learning methods.

Alcohol problems in Alaska Natives: lessons from the Inuit.

In this Alaska Native study, cultural "insiders" analyzed problems associated with increased alcohol availability, factors which have reduced alcohol-related problems, and ideas for improving treatment in an Inuit community. Participants described frequent binging, blackouts, family violence, suicide, loss of child custody, and feelings of intergenerational grief. Helpful existing treatment approaches include alcohol ordinances, inpatient treatment programs, twelve-step groups, and religious involvement. Participants urged the development of family treatment approaches which integrate Inuit customs and values.

Implementing alcohol screening and intervention in a family medicine residency clinic.

The purpose of this study was to evaluate the impact of simultaneous systems interventions and clinician training on management of hazardous and harmful drinking in a residency clinic. Systems interventions included forming a multi-disciplinary implementation team, training registration clerks to distribute health risk questionnaires using the AUDIT-C alcohol screen, and training nurses to score the AUDIT-C and administer the AUDIT to screen-positive patients. Clinicians were trained to perform brochure-based interventions on screen-positive patients. Research staff provided compliance feedback. Over 12 months, 8.0% (241/3014) of patients screened positive and 3.8% (115/3014) received brief interventions. For screen-positive patients, comparisons with baseline measurements found increased rates of alcohol assessment (50% vs. 0%, p < .0001) and intervention (48.1% vs. 9.4%, p < .0001). Clinicians intervened more often when prompted with completed AUDITs (72% vs. 23%, p < .0001). Program modifications resulted in progressive increases in numbers of patients screened. This model shows promise for use in other residency programs.

Alcohol use and cultural change in an indigenous population: a case study from Venezuela.

AIMS: To explore the historical and cultural context of problem drinking in a Latin American indigenous population and identify possible areas for intervention. METHODS: Focus group discussions. RESULTS: Participants reported that prior to 1945, binge drinking and fighting were part of cultural festivals held several times each year. Alcohol was brewed in limited quantities by specially qualified individuals. Limited family violence and injuries resulted. Increasing contact with Western civilization resulted in year-round access to large supplies of commercial alcohol and exposure to alcohol-misusing role models. Increased heavy drinking and decreases in subsistence farming resulted in escalation of problems, including hunger, serious injury, family violence, divorce and legal problems. Communities are beginning to regain control by prohibiting sale of alcohol in villages, sponsoring alcohol-free celebrations, and increasing involvement in religious activities. CONCLUSIONS: Though alcohol may cause devastating consequences in cultures in transition, studies of community responses may identify useful strategies for reducing alcohol-related harm.