Alcohol-related disorders account for

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1 Original Article Correlated Factors and Prevalence of Alcohol Treatment in Brazil: A National Survey Clarice S. Madruga, MD,*w Patricia De Saibro, MSc,* Cleusa P. Ferri, PhD,*w Raul Caetano, PhD,z Ronaldo Laranjeira, PhD,* and Ilana Pinsky, PhD* 1 Abstract Background: The knowledge of the motivations underlying treatment seeking is essential for the development of campaigns and evidence-based treatment strategies. This study aimed to estimate the rate of alcohol treatment use among Brazilians with alcohol disorders. We also investigated factors associated with willingness to stop drinking and motivation to engage into treatment programs. Method: This is a cross-sectional study using data from the first Brazilian National Alcohol Survey. A subsample of 1590 alcohol users was selected from the original survey, which interviewed 3007 individuals from the Brazilian household population. Prevalence of alcohol disorders and treatment factors were estimated. Mutually adjusted odds ratios with 95% confidence intervals were calculated using the appropriate STA- TA survey commands. These odds ratios estimate the associations between sociodemographic characteristics and selected alcohol-related problems. Results: Alcohol abuse and/or dependence was identified in 19.2% of the subsample of alcohol users. Nearly half of the participants with alcohol problems were not willing tostop drinking. Lessthan 10% of the participants with alcohol abuse/dependence that reported willingness to stop drinking have ever treated their alcohol problem, and AA meetings and specialized clinics were the most common treatment options mentioned. Willingness to quit drinking was positively associated with being male, participants who reported the negative impacts of alcohol and psychological problems caused by alcohol. Being advised to stop drinking by a doctor was also significantly associated with willingness to quit. Engagement into treatment was associated with self-reported physical problems, psychological problems, and with being advised to quit by a doctor. Conclusions: This study found very low rates of treatment engagement among participants with alcohol disorders. Our results should help develop treatment strategies more in tune with patients motivations to change. There is an urgent need to implement alcohol brief interventions in primary care in Brazil. Key Words: Brazil, alcohol, treatment, brief intervention, primary care, abuse, dependence, motivation (Addict Disord Their Treatment 2014;00: ) Alcohol-related disorders account for an enormous burden of disease in low-income and middle-income countries. In 2004, the percentage of all disability-adjusted life years attributable to alcohol among Brazilian men was the second greatest among 10 other populous countries. 1,2 The improvement in social and economic conditions seen in Brazil in recent years is not necessarily leading to an expansion of the health system. There is a chronic lack of specialized treatment in the face of a high prevalence of alcohol abusers. 3 The Brazilian psychiatric system has been through structural reforms since A network of facilities, the Psycho-Social Care Center for Alcohol and Drugs (acronyms CAPS-AD), has been implemented and is in constant change. 5 Brazilians can also count on other public services for alcohol dependents such as Alcoholics Anonymous, religious or nonprofitable organizations running detox farms, and also hospital-based day care and inpatient treatments. However, access to these services by the population is still far from satisfactory. Both socioeconomic barriers and a number of other factors such as disease severity, social support, and previous experience of treatment influence treatment engagement. 6 A recent Brazilian study including 300 hospitalized patients assessed factors associated with engagement in treatment. It demonstrated that patients with higher education were more likely to engage in the Alcoholics Anonymous groups than those less educated. 7 Comorbid psychiatric diseases such as mood and anxiety disorders also play a From the *National Institute of Policies on Alcohol and Drugs (INPAD), Departamento de Psiquiatria, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; wking s College London, Institute of Psychiatry, Health Service and Population Research, London, UK; zuniversity of Texas School of Public Health, El Paso, TX. The authors declare no conflict of interest. Reprints: Patricia De Saibro, MSc, Unidade de Pesquisa em Álcool e outras Drogas (UNIAD), Departamento de Psiquiatria, Universidade Federal de São Paulo, Rua Botucatu, 390 Vila Clementino, , Sao Paulo, SP, Brazil. ( s: saibrop@gmail.com; saibrop@me.com). Copyright r 2014 by Lippincott Williams & Wilkins DOI: /ADT

2 2 Madruga et al significant role in determining treatmentseeking behaviors Knowledge of the motivations underlying treatment seeking and adherence is essential for the development of evidence-based treatment strategies. Although there is a large body of data on treatment from high-income countries, the use of this information to support the improvements of health services in Brazil is problematic. Analyses of individuals decision to seek treatment must be cultural sensitive and targeted to a specific population. 16 The objective of this paper is to understand the underlying characteristics associated with willingness to seek treatment for alcohol disorders. More specifically, the paper examines the characteristics of those reporting their desire to stop drinking and of those who have ever been to treatment. The types of alcohol treatment chosen by the participants were also assessed. MATERIALS AND METHODS Sampling and Procedures The Brazilian National Alcohol Survey was conducted between November 2005 and April A multistage cluster sampling procedure was used to select 3007 individuals aged 14 years and above from the Brazilian household population (response rate = 66.4%). The present study was based on the subpopulation of alcohol users (N = 1590). Alcohol use was defined by the question: Have you ever drank an alcoholic beverage? The sampling involved 3 stages: (1) selection of 143 counties using probability proportional to size methods (PPS); (2) selection of 2 census sectors for each county, with the exception of the 14 biggest selected counties, totaling 325 census sectors, also using PPS; and (3) within each census sector 08 households were selected by simple random sampling, followed by the selection of a household member to be interviewed using the the closest future birthday technique. One-hour face-to-face interviews were conducted at the respondents home by trained interviewers using a standardized questionnaire. Measurements The questionnaire used was the Brazilian adaptation of the HABLAS questionnaire. 17 Sociodemographic characteristics such as sex, age, family and personal income, education, and marital status were assessed among alcohol users only (N = 1590). The treatment variables ( Advised to quit by a doctor, Desire to quit, and Ever treated alcohol problem ) were analyzed among the population presenting alcohol abuse and/or dependence only (N = 290). We assessed alcohol consumption in the last 12 months with questions covering frequency and quantity. Alcohol abuse and dependence diagnoses were established according to DSM-IV criteria using the Brazilian version of Composite International Diagnostic Interview (ICD version 2.1). 18 The participants were also asked about whether or not they had ever sought treatment for alcohol problems and to describe what type of treatment they have used in the past. Illegal substance use was defined as self-reporting use of stimulants, ecstasy, crack or cocaine, solvents, opioids, cannabis or hashish, and hallucinogens use in the last 12 months. To assess experience with alcohol problems of other people, 10 questions were asked: (1) family problems; (2) beingapassengerinacarwhenthedriver drank in excess; (3) being in a car accident caused by drink and driving; (4) suffered physical aggression due to someone under the influence of alcohol; (5) had financial problems because of someone else s alcohol problem; (6) had any property destroyed by someone under the influence of alcohol; (7) ever suggested someone to treat an alcohol disorder; (8) ever helped someone to look for alcohol disorder treatment; (9) was insulted verbally by someone under the influence of alcohol; (10) was a victim of sexual harassment or abuse by someone under the influence of alcohol. The assessment of the negative impact of alcohol on life was based on 6 questions: Do you think drinking has ever affected your: (1) friendships and social life?; (2) life projects and perspectives?; (3) family and marriage?; (4) financial status?; (5) job or job opportunities?; (6) health?. r 2014 Lippincott Williams & Wilkins

3 Correlated Factors and Prevalence of Alcohol Treatment Depression was assessed using the Brazilian-validated version of the 20- item Center for Epidemiological Studies Depression Scale, using score 16 as the cutoff point. 19 Alcohol publicity was assessed by the question: In the last 30 days, how often did you see alcohol publicity campaigns on TV, newspaper, magazines, Internet, radio, or in establishments such as bars or restaurants. a, never; b, less than once a month; c, 1 to 3 times in a month; d, 1 to 3 times a week; e, every day; f, more than once a day. Statistical Analysis Statistical analyses were performed using STATA version 10e. Given the multistage-stratified sampling design, all analyses were weighted to take account of differing selection probabilities at each stage and of nonresponse using poststratification. All estimates of prevalence and association were made using the appropriate STATA survey commands to generate robust SEs. Sociodemographic characteristics, substance use, household environment, and mental health were described by sex. Mutually adjusted odds ratios with 95% confidence intervals were calculated for the associations between sociodemographic characteristics and other possible correlates such as physical conditions caused by alcohol consumption, detriments caused by alcohol, problems caused by alcohol use by another person, usage of illegal substances, and depression. We also evaluated the influence of access to alcohol advertisement and campaigns against alcohol use. Ethics All respondents granted their informed consent. This study was approved by the Ethics Committee of the Federal University of Sao Paulo. RESULTS Sociodemographic Characteristics The mean age of the participants was 34.1 years old (SD = 15.7) and the sample was equally distributed between sexes (50.75% men and 29.25% women) (Table 1). The prevalence of alcohol abuse and/or dependence was 19.2% among those who reported alcohol use. Nearly 1 in 10 of those participants reported they had hepatitis due to alcohol consumption (7.5%) and 11.7% reported stomach disorders caused by alcohol consumption; 34.8% of the participants reported at least 1 physical condition caused by alcohol consumption; of those, less than half were advised to quit by a doctor (48.1%). Depression was identified in nearly one third of the alcohol users (23.5%) and it was more prevalent among women (14%). The prevalence of depression rose to 41.3% among the participants with alcohol disorders. Alcohol Treatment Of the participants presenting alcohol abuse and/or dependence, 24.6% were advised to quit by a doctor, 1 in 10 were willing to quit, and only 2.5% had ever treated the problem. Of the participants willing to stop drinking, only 9.41% had ever treated their condition (Table 2). Participants who mentioned having sought alcohol treatment were questioned about what types of treatments they chose. Alcoholics Anonymous (27%), specialized surgeries (24%), and general hospitals (20%) were the most referred treatment types (Fig. 1). Associated Factors Willingness to quit drinking was positively associated with being male 2.65 (1.76 to 3.99), negative impact of alcohol 1.56 (1.37 to 1.78), self-reported psychological problems caused by alcohol 1.79 (1.24 to 2.56), and with being advised by a doctor 4.87 (2.52 to 9.41). Treating alcohol disorders was associated with self-reported physical problems 1.89 (1.13 to 3.15), psychological problems 2.12 (1.42 to 3.18), and with being advised to quit by a doctor 6.02 (1.85 to 19.64) (Table 3). DISCUSSION Thecareofpeoplesufferingfrom alcohol disorders is a growing public 3

4 4 Madruga et al TABLE 1. Description of Sociodemographic Characteristics According to Sex Among Alcohol Users N(%) Male* 807 (50.75) Female* 783 (49.25) Total, N = 1590 Sociodemographics Age (13.3) 173 (15.5) 352 (14.2) (37.3) 288 (39.7) 116 (38.4) (33.6) 244 (33.5) 483 (33.6) 55 and over 123 (15.7) 79 (11.2) 201 (13.8) Marital status Single 311 (34.4) 307 (35.8) 618 (35.0) Married 436 (59.8) 366 (51.1) 802 (56.1) Widowed 15 (1.5) 49 (5.4) 64 (3.2) Divorced/separated 45 (4.3) 61 (7.5) 106 (5.7) Education Up to primary School 247 (30.1) 184 (22.3) 431 (26.8) Up to secondary School 354 (38.2) 352 (41.1) 706 (39.4) College or above 206 (31.6) 247 (36.6) 453 (33.7) Family income (MV = 190) Up to 1 monthly minimum wage 51 (12.3) 57 (16.2) 108 (14.0) Between 1 and 2 monthly minimum wage 91 (25.6) 83 (27.3) 174 (26.4) 3 monthly minimum wage or more 160 (62.0) 150 (56.5) 310 (59.6) Alcohol consumption Age of onset mean (SD) 19.4 (5.9) 21.3 (7.4) 20.3 (6.7) Binge drinking 49 (6.1) 27 (3.7) 76 (5.3) Abuse/dependence 208 (26.2) 82 (9.8) 290 (19.2) *All prevalence rates calculated by column. MV indicates missing value healthconcerninbrazil.thereisasevere lack of studies on alcohol dependence treatment in middle-income countries such as Brazil. Most services base their treatment programs on evidence coming from high-income countries or do not base it on scientific evidence at all. The efficacy of approaches such as motivational interviewing and brief intervention can be limited in such circumstances as they can be influenced by sociocultural factorsuniquetobrazil,andwhichare not part of the Anglo-Saxon culture where most of the scientific evidence is derived from. 20 In the present study, we found that the proportion of participants with alcohol disorders was nearly 20% among TABLE 2. Alcohol Treatment According to Sex Among Participants With Alcohol Abuse and/ or Dependence N(%) Male 208 (78.3) Female 82 (21.7) Total, N = 290 Alcohol treatment Advised to treat alcohol problem by doctor 57 (25.7) 16 (20.7) 73 (24.6) Willing to quit alcohol 153 (18.6) 50 (4.6) 203 (11.3) Ever treated alcohol problem 29 (3.9) 7 (0.7) 36 (2.5) r 2014 Lippincott Williams & Wilkins

5 Correlated Factors and Prevalence of Alcohol Treatment TABLE 3. Correlates of Desire to Quit Drinking and to Treat Alcohol Disorders Among Those With Alcohol Abuse/Dependence OR (95% CI) 5 Desire to Quit Treated Sex Female Male 2.65 ( ) 3.62 ( ) Age (y) 0.99 ( ) 1.02 ( ) Income 1.00 ( ) 1.00 ( ) Problems due to someone s alcohol consumption? 1.09 ( ) 0.98 ( ) Negative impact of alcohol 1.56 ( ) 1.05 ( ) Campaigns against alcohol 1.08 ( ) 0.85 ( ) Adverts of alcohol 1.18 ( ) 1.28 ( ) Physical problems 1.29 ( ) 1.89 ( ) Psychological problems 1.79 ( ) 2.12 ( ) Advised to quit by doctor 4.87 ( ) 6.02 ( ) Illegal drug use 0.97 ( ) 1.98 ( ) Depression 0.90 ( ) 1.26 ( ) CI indicates confidence interval; OR, odds ratio. those who drink. Among men, this prevalence was even higher, reaching nearly one third of the drinking population. We also found that among participants with alcohol disorders, only 25% had been advised to stop drinking by a doctor. Most of these participants were not even willing to quit drinking (88.7%) and a remarkable low proportion (2.5%) had never looked for alcohol treatment in their lives. The fact that over one third of the drinkers reported having at least 1 physical condition caused by alcohol consumption indicates that they might have, at some point, seen a doctor after the abusive drinking took place. On the basis of this information, one can speculate that although those participants have probably been to a health care facility due to alcohol-related physical conditions, only half of them were advised to quit by their doctors. Our results also show that a doctor s advice is by far the strongest associated factor influencing willingness to quit drinking and treatment-seeking behavior. A doctor s advice increased the chances of a respondent reporting willingness to stop drinking and treatment-seeking behavior by nearly 5 and 6 times, respectively. There is a large body of evidence showing that brief interventions in primary care can have long-term FIGURE 1. Choices of alcohol treatment.

6 6 Madruga et al beneficial effects on drinking habits. 21 Our findings are in line with the theory indicating that medical counseling plays an important role on helping patients with alcohol-related problems. A systematic review demonstrated that the good-quality, brief, multicontact behavioral counseling interventions by primary care physicians may reduce the average number of drinks per week by 13% to 34% more than controls, with the proportion of participants drinking at moderate or safe levels being 10% to 19% greater than drinker controls. This study reported maintenance of improved drinking patterns for 48 months. 22 The lack of basic interventions in primary care is not limited to low-income and mid-income countries: in the United States, Burman and his team found that only 30% of the patients with alcohol misuse reported receiving alcohol-related advice from their primary care provider during the year of 2004 when the survey was accomplished predominantly those with the most severe problems due to drinking or medical contraindications to consume alcohol beverages. 23 Besides doctor s advice, negative impacts of alcohol and self-reported psychological problems were also associated with willingness to quit drinking, whereas selfreported physical and psychological problems were associated with looking for treatment. It is well established that several predisposing factors shape the likelihood to take the decision to quit drinking and to engage treatment. Our results are in agreement with the literature suggesting that this change is a consequence of an interaction of social pressure, the severity of the illness, and related impairments. It is also thought that access to services and perceived cost and benefits of the treatment are decisive. 14 There are few studies detailing provision of substance misuse treatment in Brazil. The Brazilian Ministry of Health created Community Social Psychiatric Centres (CAPS), having in view the idea of a progressive substitution of psychiatric beds. In 2009, a study reported that there were 1467 CAPS in the country, but only 223 of those specifically treated drug addicts. The World Health Organization recommends that a country should have 1 center per 100,000 citizens. The CAPS covers only 60% of the Brazilian population, which is about million. To comply with the WHO s request, the country would need to have about 2000 CAPS. 24 The lack of adequate substance misuse services is a reality in Brazil: in the state of Espírito Santo, for instance, of the 250 institutions providing treatment, only 17.6% are governmental, 22.8% are nongovernmental, and 59.6% consist of self-help groups nearly one third of those institutions are related to religious organizations. 22 Furthermore, it has been reported that Sao Paulo (Brazil s biggest city) has a treatment gap of 50%, which is the percentage difference between number of people needing treatment for alcohol abuse or dependence and number of people receiving treatment. 25 Once the access to service is accomplished, the challenge of treatment engagement must be faced. It is known that longer substance-abuse treatment episodes and successful completion of treatment are usually related to positive outcomes; however, as many as 50% of patients in drug and alcohol treatment drop out of treatment within the first month. 16 One of the strategies to achieve successful treatment programs is its ability to be well targeted, and thus the importance of understanding the population opting to quit drinking and engage treatment. Understanding the demographic characteristics of individuals seeking treatment for alcohol-related problems is of paramount importance as it can implement more focused and efficient treatment strategies. In addition, the knowledge of which factors are associated with the will to quit and the decision to embrace treatment is an important tool for public health services as it helps to identify which type of population would be targeted for specific interventions. REFERENCES 1. Obot IS. Limits of substance-use interventions in developing countries. Lancet. 2007;369: Rehm J, Mathers C, Popova S, et al. Alcohol and Global Health 1 Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373: Laranjeira R, Pinsky I, Sanches M, et al. Alcohol use patterns among Brazilian adults. Rev Bras Psiquiatr. 2010;32: r 2014 Lippincott Williams & Wilkins

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