Piloting a strategy to prevent and manage alcohol-related problems in underage population at risk in health services

Introduction: Adolescence represents an important period in the drinking onset, estimated to be on average at 13.9 years old in Catalonia. In the context of the Drink less program –a region scale screening and brief intervention (SBI) program for alcohol in primary healthcare (PHC)- we have piloted a strategy to prevent and manage alcohol-related problems in underage population based in improving attention in adults and paediatric PHC, hospital emergency departments (HES) and emergency medical service (EMS).  The pilot has been deployed in all health centres of a rural region -9 PHC centres, 4 HED and EMS - in Catalonia for seven months. The strategy includes: 1) SBI to population from 12 to 17 years old during PHC visits and 2) BI and referral to PHC for follow up of minors attended in due to alcohol intoxication in HED or EMS. Implementation components include: 1) organizational actions such as inclusion of screening tools in the medical records 2) actions at professional level such as protocols and training and 3) actions at population level such as informational leaflets. 
Methods:  A mixed methods evaluation was performed. Data on the penetration of screening (N = 360 patient visits) were abstracted from the electronic health records for the 7 months pilot.  The impact on professionals was assessed with pre-post online questionnaires, an online focus groups (N=10) and 4 online semi-structured interviews.
Results: 44 PHC professionals engaged with the screening activity from the 55 professionals who were recruited initially. During the pilot 360 patients were screened (3.6% of the eligible population). The majority of patients were abstainers (75.4%) while 24.6% screened positive for some level of risk -3.2% were at low risk, 17% moderate risk and 4.4% high risk. 4 Cases of intoxication were registered but could not be followed up in PHC for several reasons –lack of coordination between services (N=2), participant rejection (N=1) and loss to follow up (N=1). Paediatric services and nurses were more active but almost all professionals (90%) reported considering the intervention important. Improvements suggested focused on organisational aspects such as referral pathways, training and incentives.  
Conclusion: Mobilization of a health region towards the implementation of an integrated strategy to prevent and manage alcohol-related problems in underage population is difficult and organizational aspects such as electronic health records, referral patways and trainings are essential to achieve it.