Community-based alcohol education intervention (THEATRE) study to reduce harmful effects of alcohol in rural Sri Lanka: design and adaptation of a mixed-methods stepped wedge cluster randomised control trial.

INTRODUCTION: Alcohol consumption is a leading cause of mortality, morbidity and adverse social sequelae in Sri Lanka. Effective community-based, culturally adapted or context-specific interventions are required to minimise these harms. We designed a mixed-methods stepped wedge cluster randomised control trial of a complex alcohol intervention. This paper describes the initial trial protocol and subsequent modifications following COVID-19. METHODS AND ANALYSIS: We aimed to recruit 20 villages (approximately n=4000) in rural Sri Lanka. The proposed intervention consisted of health screening clinics, alcohol brief intervention, participatory drama, film, and public health promotion materials to be delivered over 12 weeks.Following disruptions to the trial resulting from the Easter bombings in 2019, COVID-19 and a national financial crisis, we adapted the study in two main ways. First, the interventions were reconfigured for hybrid delivery. Second, a rolling pre-post study evaluating changes in alcohol use, mental health, social capital and financial stress as the primary outcome and implementation and ex-ante economic analysis as secondary outcomes. ETHICS AND DISSEMINATION: The original study and amendments have been reviewed and granted ethical approval by Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and February 2022) and the University of Sydney (2019/006). Findings will be disseminated locally in collaboration with the community and stakeholders.The new hybrid approach may be more adaptable, scalable and generalisable than the planned intervention. The changes will allow a closer assessment of individual interventions while enabling the evaluation of this discontinuous event through a naturalistic trial design. This may assist other researchers facing similar disruptions to community-based studies. TRIAL REGISTRATION: The trial is registered with the Sri Lanka Clinical Trials Registry; https://slctr.lk/trials/slctr-2018-037.

'The Drug Survey App': a protocol for developing and validating an interactive population survey tool for drug use among Aboriginal and Torres Strait Islander Australians.

BACKGROUND: Disadvantage and transgenerational trauma contribute to Aboriginal and Torres Strait Islander (Indigenous) Australians being more likely to experience adverse health consequences from alcohol and other drug use than non-Indigenous peoples. Addressing these health inequities requires local monitoring of alcohol and other drug use. While culturally appropriate methods for measuring drinking patterns among Indigenous Australians have been established, no similar methods are available for measuring other drug use patterns (amount and frequency of consumption). This paper describes a protocol for creating and validating a tablet-based survey for alcohol and other drugs ("The Drug Survey App"). METHODS: The Drug Survey App will be co-designed with stakeholders including Indigenous Australian health professionals, addiction specialists, community leaders, and researchers. The App will allow participants to describe their drug use flexibly with an interactive, visual interface. The validity of estimated consumption patterns, and risk assessments will be tested against those made in clinical interviews conducted by Indigenous Australian health professionals. We will then trial the App as a population survey tool by using the App to determine the prevalence of substance use in two Indigenous communities. DISCUSSION: The App could empower Indigenous Australian communities to conduct independent research that informs local prevention and treatment efforts.

Effects of service-wide support on regularity of alcohol screening of clients in Australian Aboriginal and Torres Strait Islander Community Controlled Health Services: a cluster randomised trial.

BACKGROUND: We have previously shown that service-wide support can increase the odds of alcohol screening in any 2-month period in a cluster randomized trial of service-wide support to Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHS). Here we report an exploratory analysis on whether the resulting pattern of screening was appropriate. AIM: we assess whether that increase in screening was associated with: (i) increased first-time screening, (ii) increased annual screening, (iii) whether frequently screened clients fell into one of four risk categories as defined by national guidelines. METHODS: Setting and participants: 22 ACCHS; randomized to receive the support model in the treatment ('early-support') arm over 24-months or to the waitlist control arm. INTERVENTION: eight-component support, including training, sharing of experience, audit-and-feedback and resource support. ANALYSIS: records of clients with visits before and after start of implementation were included. Multilevel logistic modelling was used to compare (i) the odds of previously unscreened clients receiving an AUDIT-C screen, (ii) odds of clients being screened with AUDIT-C at least once annually. We describe the characteristics of a sub-cohort of clients who received four or more screens annually, including if they were in a high-risk category. RESULTS: Of the original trial sample, 43,054 met inclusion criteria, accounting for 81.7% of the screening events in the overall trial. The support did not significantly increase the odds of first-time screening (OR = 1.33, 95% CI 0.81-2.18, p = 0.25) or of annual screening (OR = 0.99, 95% CI 0.42-2.37, p = 0.98). Screening more than once annually occurred in 6240 clients. Of the 841 clients with four or more screens annually, over 50% did not fall into a high-risk category. Females were overrepresented. More males than females fell into high-risk categories. CONCLUSION: The significant increase in odds of screening observed in the main trial did not translate to significant improvement in first-time or annual screening following implementation of support. This appeared to be due to some clients being screened more frequently than annually, while more than half remained unscreened. Further strategies to improve alcohol screening should focus on appropriate screening regularity as well as overall rates, to ensure clinically useful information about alcohol consumption. Trial Registration ACTRN12618001892202, retrospectively registered 16 November 2018 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001892202 .

Support for Aboriginal health services in reducing harms from alcohol: 2-year service provision outcomes in a cluster randomized trial.

BACKGROUND AND AIMS: There is a higher prevalence of unhealthy alcohol use among Indigenous populations, but there have been few studies of the effectiveness of screening and treatment in primary health care. Over 24 months, we tested whether a model of service-wide support could increase screening and any alcohol treatment. DESIGN: Cluster-randomized trial with 24-month implementation (12 months active, 12 months maintenance). SETTING: Australian Aboriginal Community Controlled primary care services. PARTICIPANTS: Twenty-two services (83 032 clients) that use Communicare practice software and see at least 1000 clients annually, randomized to the treatment arm or control arm. INTERVENTION AND COMPARATOR: Multi-faceted early support model versus a comparator of waiting-list control (11 services). MEASUREMENTS: A record (presence = 1, absence = 0) of: (i) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening (primary outcome), (ii) any-treatment and (iii) brief intervention. We received routinely collected practice data bimonthly over 3 years (1-year baseline, 1-year implementation, 1-year maintenance). Multi-level logistic modelling was used to compare the odds of each outcome before and after implementation. FINDINGS: The odds of being screened within any 2-month reference period increased in both arms post-implementation, but the increase was nearly eight times greater in early-support services [odds ratio (OR) = 7.95, 95% confidence interval (CI) = 4.04-15.63, P < 0.001]. The change in odds of any treatment in early support was nearly double that of waiting-list controls (OR = 1.89, 95% CI = 1.19-2.98, P = 0.01) but was largely driven by decrease in controls. There was no clear evidence of difference between groups in the change in the odds of provision of brief intervention (OR = 1.95, 95% CI = 0.53-7.17, P = 0.32). CONCLUSIONS: An early support model designed to aid routine implementation of alcohol screening and treatment in Aboriginal health services resulted in improvement of Alcohol Use Disorders Identification Test-Consumption screening rates over 24 months of implementation, but the effect on treatment was less clear.

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement.

BACKGROUND: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. METHODS: We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. RESULTS: Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements. CONCLUSION: Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).

The characteristics of oncology social work in Australia: Implications for workforce planning in integrated cancer care.

AIMS: To describe the demographics, professional characteristics, self-reported professional development needs and research involvement of oncology social workers in Australia and to describe perceived barriers to provision of quality psychosocial care. METHODS: A cross-sectional online survey was administered to social workers working in the oncology field who were contacted through three professional organizations; the Australian Association of Social Workers, Oncology Social Work Australia and the Psycho-oncology Co-operative Research Group, the University of Sydney. A snowball recruitment method was adopted to maximize the sample size. RESULTS: Two thirds of respondents had over 10 years professional practice experience but with lesser experience in oncology settings. Twenty-eight percent had post-graduate qualifications. Professional development needs were reported as moderate or high by 68% of respondents. No association between professional needs and work setting was found. Years of experience in oncology practice and living in an urban area increased the likelihood of involvement in research. Barriers to psychosocial care included poor understandings of the social work role, time constraints and an inadequate number of social work positions. CONCLUSION: In this first Australian study of the social work oncology workforce, the results demonstrated active, well-qualified and experienced social workers providing frontline services to people with cancer and their caregivers in geographically diverse locations across Australia. Inadequate resources and a lack of integrated psychosocial care were identified as barriers to comprehensive cancer care. The need for Aboriginal and Torres Strait Islander social workers was identified as an urgent workforce priority.

Social Work Intervention Research With Adult Cancer Patients: A Literature Review and Reflection on Knowledge-Building for Practice.

The results of a literature review of social work intervention research with adult cancer patients found only a small number of studies conducted by social work researchers. The findings of the review are presented followed by a reflective discussion on the nature of knowledge-building and research knowledge for practice. Knowledge building is considered as a continuous, negotiated process within communities of practice focused on psychosocial perspectives that draw on a range of knowledge sources. Epistemology, worldviews and research orientations are considered along with the values and stance of social work, all of which create the domain of the practice-researcher.

Identifying research priorities and research needs among health and research professionals in psycho-oncology.

AIM: To identify and prioritize the key research questions in psycho-oncology in order to guide the development of large multicenter clinically relevant studies. METHODS: All members of the Psycho-Oncology Co-operative Research Group (n = 295) were invited to participate in an online survey and 180 responded (response rate = 61%). Participants rated eight priority research areas identified from a previous focus group study on a five-point scale, and ranked their top four priority areas. Within the four ranked research areas, participants selected the three most important specific research questions. RESULTS: The highest rated research priority areas were distress identification (23.3%), survivorship (22.7%), and distress management (15.3%), followed by issues relating to health services (9.7%) and carers (8.0%). Interventions were commonly nominated among the most important research questions within each priority area. The single most important research question identified by 44% of the sample was to "Determine the most acceptable, reliable and valid screening tool to be administered routinely at diagnosis and at other key transition points to identify distress and psychosocial needs". CONCLUSION: This is the first Australian study to explore research priorities in psycho-oncology, and the first international study to explore these issues in depth. To ensure that the research effort is strategic, clinically relevant and cost-effective, clear priorities need to be established. The results of this survey will enable limited resources to focus on key research questions of direct clinical benefit.

Mental health and coping in a war situation: the case of Bosnia and Herzegovina.

The latter part of the twentieth century has seen an increased concern for the implications of war for civilian populations, and more attention has been given to psychosocial impacts of uprooting and displacement. 'Loss of place', acute and chronic trauma, family disruption and problems of family reunification have become issues of concern. The war in Bosnia was characterized by massive displacement, disruption and loss of life, relatives and property. Health and psychosocial well-being were affected in a number of ways. There was an overwhelming loss of perceived power and self-esteem. Over 25%, of displaced people, for example, said they no longer felt they were able to play a useful role; even in non-displaced populations approximately 11% of those interviewed said that they had lost a sense of worth. Widespread depression and feelings of fatigue and listlessness were common and may have prevented people from taking steps to improve their situation. Almost a quarter of internally displaced people had a high startle capacity and said they were constantly nervous. Most adverse psychosocial responses increased with age and in a population that includes many elderly people this poses serious problems. The findings point to major challenges with respect to repatriation and reconstruction. They highlight the importance of family reunification and the facilitating of decision-making by affected people themselves. The findings also shed light on potential problems associated with over-dependence on external assistance and hence the need for people to be given the means of using their skills and knowledge to control their day-to-day lives.