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|Title: ||A medicina geral e familiar e a abordagem do consumo de álcool : detecção e intervenções breves no âmbito dos cuidados de saúde primários|
|Authors: ||Gomes, Cristina Maria Pires Ribeiro, 1960-|
|Advisor: ||Rebelo, Luís Miguel Henriques da Silva, 1954-|
|Keywords: ||Medicina familiar|
Médicos de família
Consumo de bebidas alcoólicas
Cuidados de saúde primários
Teses de doutoramento - 2010
|Issue Date: ||2010|
|Abstract: ||O consumo de bebidas alcoólicas em Portugal tem vindo a aumentar e é uma das principais causas de morbilidade e mortalidade no nosso país. De acordo com os dados do World Drink Trends – 2005, Portugal ocupa o oitavo lugar no mundo no consumo de álcool puro por habitante. Estima-se que existam cerca de setecentos e quarenta mil bebedores excessivos e quinhentos e oitenta mil doentes alcoólicos no nosso país, o que torna o alcoolismo um importante problema de Saúde Pública.
Face aos números, torna-se imperativo implementar uma estratégia preventiva eficaz que permita detectar precocemente os indivíduos com um consumo de álcool de risco antes que as consequências sociais e na saúde se tornem evidentes, uma vez que a maioria dos problemas ligados ao consumo de álcool (PLA) e o respectivo impacto na sociedade são maioritariamente causados por consumidores excessivos.
O European Alcool Action Plan enfatizava o papel dos cuidados de saúde primários na prevenção dos PLA. Os Médicos de Família têm, assim, uma função importante a desempenhar neste contexto, visto haver um contacto mais estreito com a sua população de doentes e prestarem cuidados de saúde em continuidade. Adicionalmente, vários estudos sugerem que intervenções breves, consistindo em aconselhamento sobre o consumo de álcool e o fornecimento de informação no âmbito da prática clínica, são tão eficazes como intervenções especializadas em reduzir o consumo de bebidas alcoólicas. Vários trabalhos foram realizados com o intuito de verificar a efectividade de uma intervenção breve no espaço de consulta feita por Médicos de Família para promover a redução do consumo de álcool numa população de consumidores excessivos. Os resultados publicados nos principais estudos permitem concluir que 5 a 10 minutos de aconselhamento simples conduz a uma redução de 25 a 35% no consumo de álcool em 6 meses a 1 ano e uma diminuição na proporção de bebedores excessivos em 45%.
Em resumo, a evidência acumulada assinala claramente a efectividade das intervenções breves na redução, nos bebedores excessivos, dos níveis de consumo de álcool. Contudo, as populações mediterrânicas com um padrão cultural distinto não estão ainda suficientemente representadas nos estudos referidos, o que poderia diminuir a generalização das conclusões no nosso meio.
Há necessidade de verificar se estas conclusões se podem extrapolar à realidade dos nossos cuidados de saúde primários. Para isso realizou-se um estudo quase experimental, controlado, comparando a redução do consumo de álcool em utentes submetidos a intervenção breve pós detecção com o questionário AUDIT pelo seu médico de família com um grupo de doentes não sujeito a esta intervenção de forma estruturada. Adicionalmente, pretendeu-se caracterizar os doentes com consumos de álcool considerados de risco e nocivo em termos de sexo, idade, estado marital, profissão, padrão e história de consumos de bebidas alcoólicas.
Apesar dos estudos, que demonstram a eficácia das intervenções dos Médicos de Família nos seus utentes com problemas associados ao consumo de álcool, há de facto a percepção de que, na prática e no contexto habitual de consulta, existem vários obstáculos e limitações relativamente às aptidões destes técnicos em abordar esta problemática e promover um bom trabalho preventivo e de educação para a saúde. Um outro objectivo desta investigação é ainda conhecer as atitudes que o médico de família tem sobre a abordagem dos problemas ligados ao alcool junto dos seus utentes.
Utilizou-se para o efeito um questionário de atitudes, validado por Anderson, SAAPPQ (Short Attitudes Alcohol Problems Perception Questionnaire) e fez-se a aferição desse mesmo questionário numa fase pré-estudo propriamente dito.|
Assess SAAPPQ questionnaire on Family Physicians/General Practitioners in a group of Primary Health Care Centers located in the District of Lisbon;
o Check if the Physician’s training on Brief Interventions to approach alcohol consumption related problems contributes to change their attitudes towards hazardous and harmful alcohol consumers;
o Check if Brief Interventions are effective to reduce alcohol consumption of patients detected as risky consumers.
This work had two distinct phases with two types of underlying studies. One phase of characterization and assessment of the SAAPPQ questionnaire in a random sample of physicians in the District of Lisbon (Phase 1) – a cross-sectional descriptive study. Another phase with two components, the first aiming at examining the perceived attitudes of Family Physicians/General Practitioners towards alcohol consumption of their patients before training and again nine months after training, when they were already using early identification and brief intervention (EIBI) in their clinical practice. The second component ment to determine whether the clinical competences of the Family Physicians/General Practitioners had improved in detecting and intervening next to their patients with hazardous or harmful alcohol consumption, after the training in Brief Interventions. This detection was measured by the AUDIT questionnaire, applied again to the patients nine months after the first time (Phase 2) – analytical quasi-experimental, prospective and longitudinal study. From the sample of 188 physicians who answered the SAAPQQ (in which internal consistency was checked), 72% were female and had an average age of 46 years. It was observed that the main difficulties of the physicians were lack of trainning (66%), lack of time (67%) and the fact that the appointments with patients were frustrating (68%). The physicians felt legitimacy to take action next to the patients (90%), and thought they were able to advice the patients, despite of the difficulty to deal with them (67%). On the other hand, they were poorly motivated (43%) and unsatisfied with the fact that they had to work with excessive alcohol consumers (16%). In relation to the score obtained by physicians in SAAPPQ, there was homogeneity for sex and age.
When comparing the pre-study physicians (n=188) and the physicians of the present study (n=73), similar values were observed in gender proportion (72% and 75% were female, respectively) and average age (46 and 43 years old, respectively). Similarly, close values in the proportion of positive responses on the difficulties found in dealing with patients with alcohol related problems (ARP) were observed (range of proportions between groups of 5% to 14% by type of difficulty). The homogeneity between these two groups concerning the responses of SAAPPQ was also checked.
Physicians in the control group (n=35) had an average age moderately higher (45 years versus 41 years) when compared to physicians in the experimental group (n=38). In the first stage of the study, physicians in the experimental group reported more lack of training (87%) and more difficulty in making the diagnosis (40%) than physicians in the control group (54% and 14% respectively). Lack of time was the difficulty felt by most physicians (80%). Physicians in the experimental group felt more motivated (63%) and satisfied (21%) than the control group (32% and 9% respectively). In the second stage of the study, homogeneity among the groups of physicians concerning difficulties in dealing with patients with alcohol related problems (ARP) was observed, except in the cases where the appointments with patients had been frustrating, with higher proportion of physicians in the control group stating that difficulty (77% versus 45%). Physicians in the experimental group felt more motivated (71%), had higher self-esteem (79%) and were more satisfied (32%) than the control group (29%, 44% and 9%, respectively). There was a positive development of the attitude of physicians from the first stage to the second stage (evolution of 0 points to 1 point), specially in the physicians of the experimental group.
In the sample of 2.010 patients to whom AUDIT was applied, 60% were female, 18% were smokers and the average age was 54 years. The average score obtained by patients on the AUDIT was 3 points and 21% of the patients had some risky alcohol consumption (AUDIT C). About 30% of the patients were abstinent and 34% had an intake of risky hazardous and harmful drinking or had an alcohol dependence, while 15% of the total reported consuming 6 or more drinks on one occasion, once a month or more frequently (binge drinking). Patients of the group with risk consumption showed a higher association with certain health problems, such as lipid metabolism (40% versus 28%), smoking habits (28% versus 15%) and diabetes (17% versus 11%), had a higher proportion of family with history of alcoholism (42% versus 31%) and a lower average age of initiation of consumption than the patients without alcohol risk consumption (17 years old versus 18 years old).
In the sample of patients with risk consumption (n=369), 62% were male, 28% were smokers and the average age was 55 years old. In the first stage of the study, the average score obtained by patients on the AUDIT was 7 points, having homogeneity between the control group and experimental group. In the second instance of the study, the average score obtained by patients on the AUDIT was 6 points, with patients of the experimental group having, in average, less than one point in the AUDIT score than patients in the control group. It was observed that patients followed by a physician of the experimental group (compared to patients followed by a physician of the control group) had an increase of 54% in the success rate in reduction of, at least, one point on the AUDIT, from the first to the second stage of the study. In the first stage of the study, the consumption of alcohol (in grams) was homogeneous between groups and an average of 193 grams of alcohol consumption per week was observed. In the second instance of the study, the average alcohol consumption was 145 grams of alcohol per week. This decrease in consumption was observed mainly on patients followed by physicians of the experimental group.
Results concerning the relationship between physicians and patients (n = 273) demonstrates that a better attitude of physicians in relation to patients with alcohol related problems (ARP) can influence the decrease in alcohol consumption of those patients (from the first to the second stage of the study).
|Description: ||Tese de doutoramento, Medicina (Medicina Geral e Familiar), Universidade de Lisboa, Faculdade de Medicina, 2010|
|Appears in Collections:||FM - Teses de Doutoramento|
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