The World Health Organization Substance Abuse Instrument for mapping services

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1 Thomas F. Babor & Vladimir Poznyak Research report The World Health Organization Substance Abuse Instrument for mapping services Rationale, structure and functions Introduction The development of effective treatment and prevention programs is a crucial part of a public health response to the problems associated with substance use disorders. To promote the orderly planning and dissemination of evidence-based addiction services within national health care and social service systems, the World Health Organization (WHO) Acknowledgements This paper is based on documents commissioned by the World Health Organization (WHO 2006). The authors are grateful to the following individuals for their contributions to the development of the WHO SAIMS: Professor Jacques Besson, Dr. Louisa Degenhardt, Dr. Alexandra Fleischmann, Professor Tarek Gawad, Dr. Steven Gust, Dr. Riaz Khan, Professor Harald Klingemann, Dr. Bronwyn Myers, Dr. Usaneya Perngparn, Dr. Emanuele Scafato, Dr Kerstin Stenius, Dr. Sofia Tomas, Professor Ambros Uchtenhagen, Dr. Jan Walburg, Dr. Daniele Zullino. Both authors were involved in the development of the instrument. Submitted Initial review completed Final version accepted A B S T R A C T T.F. Babor & V. Poznyak: The World Health Organization Substance Abuse Instrument for mapping services: Rationale, structure and functions This paper describes the rationale for and development of the World Health Organization Substance Abuse Instrument for the Mapping of Services (WHO-SAIMS), a new procedure for assessing, monitoring, and evaluating treatment systems for substance use disorders in all UN Member States. The paper begins with a description of the information needed to understand the structure and function of drug and alcohol service systems. A conceptual model is presented to show how service system policies and characteristics impact on population health. Five kinds of research are then reviewed to suggest how the nature and impact of alcohol and drug services can be evaluated: 1) systems mapping studies; 2) assessments of service needs; 3) monitoring system development; 4) analysis of system performance; and 5) comparative studies. Although the WHO-SAIMS has a primarily descriptive function that will allow for gaps in service delivery and areas for system improvement to be identified, it can also be used for monitoring and process evaluation to allow countries to identify changes in the system over time and to assess the extent to which system improvement strategies have been implemented. Key words Substance abuse, treatment systems, monitoring, WHO NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

2 has developed a new procedure for assessing, monitoring, and evaluating treatment systems for substance use disorders (WHO 2006). This development is based on the experience accumulated in the WHO Assessment Instrument for Mental Health Systems (WHO AIMS) that has been used for assessment of mental health systems in many low- and middle income countries (WHO 2004). The purpose of this paper is to describe the rationale for and development of the WHO Substance Abuse Instrument for Mapping Services (WHO- SAIMS), and to consider its potential applications to the understanding of how treatment and prevention services contribute to a comprehensive public health response to substance-related problems in all countries where substance use disorders contribute to the burden of disease and disability. Information needs for understanding treatment and prevention service systems According to the World Drug Report (United Nations Office on Drugs and Crime 2006) and the Global Status Report on Alcohol (WHO 2004), the high prevalence of substance-related problems poses a significant challenge to health care systems and societies. Effective national responses to these problems include the development of prevention and treatment policies and programs. To assist countries in effectively designing and implementing alcohol and drug services, information is required for each level of the health and social service system. At the macro level, information regarding policy frameworks for service provision is needed. For example, the Global Status Report on Alcohol 2004 (WHO 2004) outlines the burden of harm associated with alcohol use disorders and policy responses to these disorders in various countries. At the meso level, information is required on the organization of prevention and treatment systems for substance use disorders. And at the micro level, information concerning client characteristics and how they interact with existing alcohol and drug services is needed. Such information can reflect gaps in service delivery and resource allocation. It can also aid in the strengthening of substance-related programs and policies, and can provide benchmark data for monitoring progress in meeting population needs. Structural components and qualities of service systems To understand the factors that should be included as part of a systems analysis, it is important to discuss the structural components of prevention and treatment services for substance use disorders (Babor et al. 2008). Alcohol and drug services occur along a continuum, ranging from primary prevention activities that ensure a disorder or problem will not occur, to secondary prevention activities, including early identification and management of substance use disorders, and tertiary prevention activities that aim to reduce disability, and health and social consequences of an established disease or a disorder. In many countries, primary, secondary and tertiary prevention services have been developed separately and are rarely integrated into a single system. Yet each of these service components consist of similar core elements: resources (e.g., facilities, personnel and programs), tasks (e.g., prevention, medical care, rehabilita- 704 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

3 tion services, social control), and linking elements that allow for the coordination of resources to accomplish tasks (including integration of specialist treatment services with other services such as mental health and criminal justice). In addition to these structural features, system qualities inform the organization of prevention and treatment service systems. These qualities include equity, or the extent to which population subgroups have equal access to services; efficiency, defined as the most appropriate mix of services to address population needs; and economy, or the efficient use of available resources to reduce the prevalence of substance use disorders. Resources and system qualities affect the effectiveness of services, although effectiveness is often moderated by factors such as client characteristics and culturally conditioned patterns of alcohol and drug use. Because of the potential impact of these system features, assessments of prevention and treatment services should include an analysis of both the structural elements and system qualities that define alcohol and drug service systems. A conceptual framework Figure 1 describes how the structural resources and service qualities of prevention and treatment systems interact with macro and micro level factors to influence population health (Babor et al. 2008). In this model, alcohol and drug policies (a macro-level factor) are the main determinants of struc- Resources Facilities Programs Personnel Treatment policies Planning Financing Monitoring Regulation Tasks Medical care Social control Prevention Linking elements Effectiveness Population health System qualities Equilty Efficiency Economy Moderating factors Pattern of characteristics Pattern of substance use Macro level meso level micro level Policies System charasteritics Effectiveness Population impact Figure 1. Conceptual model of population on impact of treatment systems NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 tural resources for prevention and treatment as well as system qualities. In turn, system resources and qualities contribute to service effectiveness (i.e. the extent to which a specific service is responsible for positive changes in substance-related problems). As effective services hold long-term positive benefits in terms of population health, population rates for substance-related deaths, disease, disability, and social problems are convenient indicators of this factor. The availability of country-specific information on these population indicators (and the feasibility of including these indicators as part of an assessment instrument) should make it possible to evaluate the population impact of service systems. The model also allows for the development level of a particular service system to be examined. Service systems can be characterized in terms of their extensiveness, resources, mix of services, and integration. Four development levels are proposed to account for the range of systems that have evolved in different countries: 1) Minimal/fragmentary; 2) Limited, with some specialized services in medical and psychiatric settings and some delivered in primary care settings; 3) Modest, with a variety of services delivered in most settings and some regional coordination and planning; and 4) Mature, with a variety of integrated services and stable financing for these services. The specification of these levels could be useful for suggesting ways in which these systems can be improved and for monitoring changes in system development over time, but this remains as a task for future systems research. Describing, monitoring and evaluating service systems Five kinds of research are useful for describing, monitoring and evaluating alcohol and drug services, and all are likely to be facilitated by a service mapping assessment instrument that conforms to the conceptual model shown in Figure 1. Systems mapping research This involves the description of system structures and qualities. Treatment mapping research can reflect a variety of perspectives as well as interactions between professionally-run and lay service providers (Gossop 1995). This approach allows for cross-country comparisons of treatment systems in various stages of development and is useful for service planning at local and national levels. Treatment mapping research of this type has been conducted in Hungary, Poland, the Russian Federation, France, Switzerland, Germany, the United Kingdom, the United States, Finland, Sweden and a variety of other countries (Gossop 1995; Klingemann & Hunt 1998; Klingemann et al. 1992; Klingemann et al. 1993). Several data collection tools have been developed for treatment mapping purposes, but these instruments do not examine broad treatment systems issues. Service needs assessment The second type of research is needs assessment studies. The need for substance abuse services in the general population can be estimated through the use of health and social indicators, such as substancerelated mortality, morbidity, and social problem statistics; population surveys that estimate prevalence rates; measures of treatment service demand; and expert 706 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 opinion on treatment needs. The use of these methods to estimate need has not been internationally standardized. Should a formula be developed for assessing need, it would be possible to identify the gap between existing services and population needs. Unfortunately, the information necessary for estimating treatment needs is often not available in low and middle income countries, particularly prevalence data on substance use disorders in the general population, and health and social indicators of substance-related harms. Systems monitoring This involves monitoring the current configuration of treatment and prevention services. Monitoring can provide a longitudinal assessment of the development of services in terms of quantity and quality. It also provides useful descriptive information for planning and evaluation purposes. When systems are monitored over time, questions regarding how resources should be allocated and organized to meet population needs can be addressed. Unfortunately, the collection of information on systems configuration using comparable indicators is not being done in low and middle income countries, as well as in many high income countries. This is partly due to a fragmented or nonexistent system monitoring capability, and a reluctance on the part of service providers to have their performance evaluated. Performance analysis These analyses are rarely conducted, even though they allow policymakers to examine the extent to which services meet clinical standards and population needs. With proper resources, performance analysis could involve the collection of quantitative and qualitative data on service utilization, continuity of care, attrition, service costs, and the impact of treatment services on health and social indicators. Performance monitoring helps system administrators determine whether the system is serving both clinical and public health interests, and how efficiently the system is operating. Comparative research When standardized research methods are used, data collected at the national or subnational levels can be compared across countries or subregions to answer important policy questions. Several compendiums have been created to highlight the capabilities of comparative cross-national treatment research (Gossop 1995; Klingemann & Hunt 1998; Klingemann et al. 1992). These studies also illustrate some of the difficulties of conducting comparative cross-national research, including funding for international collaborative studies, defining the unit of analysis due to the heterogeneity of treatment systems across country contexts, and variability in the availability and quality of treatmentrelated information. The WHO Substance Abuse Instrument for Mapping Services (WHO-SAIMS) Although progress has been made in the development of methods to monitor and evaluate alcohol and drug treatment systems, treatment system research remains sparse (WHO 2006; Babor et al. 2008). In order to address the need for better descriptive and comparative data, the World Health Organization decided to adapt the NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

6 WHO-AIMS (WHO 2009), an instrument currently used to describe, monitor and evaluate mental health treatment systems, for the assessment of prevention and treatment systems for substance use disorders. To this end, the WHO Substance Abuse Instrument for Mapping Services (WHO- SAIMS) has been developed to provide information on prevention and treatment systems that can be used for policy planning, service design and service improvement. In its present form, the WHO-SAIMS has a primarily descriptive function that will allow gaps in service delivery and areas for system improvement to be identified. It can also be used at the national and sub-national levels for monitoring and process evaluation to identify changes in the system over time and to assess the extent to which system improvement strategies have been implemented. Eventually, the instrument can be used for the five kinds of research described above, as data collected in national treatment mapping exercises becomes available for scientific purposes. The boundaries of the WHO-SAIMS are broad enough to reflect cross-country variations in alcohol and drug service systems and are applicable to systems at all developmental levels. The scope of the WHO- SAIMS was designed to include prevention as well as treatment services. A primary purpose of the WHO-SAIMS is to examine the structure of alcohol and drug service systems in terms of resources, facilities, personnel and programs. The instrument provides a functional assessment of treatment and prevention service systems. Indicators of treatment services include pathways to care, patient flow through the system, continuity of care, and service coordination. To assess how well the system functions, indicators include equity, efficiency, and accessibility as well as system malfunctions such as waiting times for services, underutilization of services, and gatekeepers to access. The instrument is designed to assess the provision of alcohol and drug services in multiple sectors and settings, including specialist inpatient facilities, outpatient settings, and community settings. In addition, primary health care, mental health (e.g. psychiatric clinics), social welfare settings, and the criminal justice sector are also covered so as not to exclude country variation in service provision. Treatment is defined broadly in the WHO-SAIMS to include services provided by self-help groups, traditional healers, and other lay service providers. The WHO-SAIMS was designed to describe the linkages between various components of alcohol and drug service systems. It gathers information about the professional substance abuse treatment sector s linkages to (and integration with) services provided by the primary care, mental health, criminal justice and social welfare sectors. It also describes the professional sector s linkages with mutual help organizations and other lay service providers, and examines interactions between different levels of care, such as patient movements from less intensive to more intensive levels of care. The WHO-SAIMS takes into account the limited availability of information relating to system performance and population needs within low and middle-income countries. Based on this recognition, the WHO-SAIMS consists of a core instrument appropriate for use in all countries, irre- 708 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

7 spective of developmental level, and a set of optional supplementary questionnaires. The latter includes data on population needs, especially the prevalence of substance use disorders and related harms in the general population as well as system performance measures, such as outcome indicators of abstinence and relapse. These complimentary modules reflect both the consumer and the service provider s perspectives on the structure and functioning of alcohol and drug service systems. The scope and configuration of the instrument can be summarized in terms of its major domains. 1. The policy and legislative domain includes items about national alcohol and drug policies; legislation governing drug control, prevention and treatment; strategic plans that address substance use disorders, work-force development for substance abuse professionals, and resource allocation to and the financing of alcohol and drug services. 2. The second domain covers the country s substance abuse situation and current alcohol and drug service needs within the population. This overview of population-related alcohol and drug service needs and current services provided is designed to (i) help identify whether current services match needs and (ii) allow for some claims to be made about service coverage. Due to the limited availability of population indicators in low and middle income countries, the use of qualitative indicators or a narrative overview of available information is encouraged where quantitative data are not available. 3. A description of the country s current alcohol and drug treatment system. This domain describes the current substance abuse system s level of development in terms of the type and mix of services provided, service integration, and system complexity. It also includes a description of the functional aspects of alcohol and drug services that reflect how the system operates, such as referral pathways and ideal treatment algorithms as well as linkages between different actors in the substance abuse system. Given the limited availability of quantitative indicators on the functioning of alcohol and drug service systems, the functional aspects of these systems can also be examined using qualitative methods. 4. The alcohol and drug services domain. This section of the instrument covers: 1) other residential services for alcohol and drug problems such as half-way houses and sober living environments; 2) alcohol and drug services provided by other sectors such as mental health facilities, primary health care services and the criminal justice sector; 3) the linkages between these services and the extent to which services in different sectors are integrated with each other; 4) the availability of psychosocial treatments; 5) the availability of psychotropic medications in these facilities; 6) the treatment modalities used in each setting; 7) the availability of substitution therapies and harm reduction services for opioid dependence and needle exchange, respectively; and 8) equity of access to alcohol and drug services. 5. The substance abuse in primary care domain. Items in this category refer to: physician-based alcohol and drug serv- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

8 ices; non-physician-based alcohol and drug services (e.g. nurses, health care workers); the types of interventions used in primary care settings; linkages and integration with services provided in other settings; and capacity to provide alcohol and drug services in primary care settings (e.g. training, skills in the work-force, competing priorities). 6. The human resource domain. This domain includes items relating to the quantity of human resources; human resource development such as training and accreditation of professionals for the substance abuse field and training of lay service providers; and user/consumer and family associations in the alcohol and drug field, including mutual-help organizations and recovering communities such as AA and NA. 7. The public education and links with other services domain. This section includes items relating to public education services on substance use disorders and treatment options, as well as formal links between the specialty substance abuse treatment sector and the mental health, social welfare, and criminal justice sectors. 8. The monitoring and research domain. This section describes current efforts to monitor alcohol and drug services in each of the identified sectors (i.e. primary care, mental health, criminal justice, social welfare and specialized alcohol and drug service sector) as well as other relevant research activities that are taking place in the country. The WHO-SAIMS is designed to be completed over the course of several months by government or academic experts familiar with the broad array of treatment and prevention services in a country or region. Questions of data reliability and accuracy are therefore a major concern, but with proper training and supervision, experience with the WHO-AIMS suggests that it is possible to obtain useful data (WHO 2006; Saxena et al. 2007). The involvement of multiple role players including academic institutions, governmental departments, non-governmental organizations, and civil society is necessary for the objectives of the WHO SAIMS to be realized. Eventually, it is hoped that as the instrument achieves widespread dissemination, it may be used to assess the impact of alcohol and drug services on population health, although this may not be feasible due to the lack of populationlevel indicators in many countries. Nevertheless, the instrument may be useful for research on population impact studies in situations where there are clear hypotheses that can be tested and for comparative analyses within regions or countries where data are available to measure treatment system differences at the regional or municipal levels. Conclusion Treatment and prevention services for substance use disorders form a vital part of effective national responses to the burden of disease and disability resulting from substance abuse. While information on the structure and functioning of these systems is needed to guide service development and system modification, this information is often not available in low and middle income countries. In well-resourced countries, there is a relatively integrated body of research that 710 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

9 includes an examination of services in relation to population needs, treatment mapping, and systems monitoring. In less-resourced settings, information on prevention and treatment systems and service needs in the general population is scanty. Regardless of resources, there is a dearth of research relating to system performance and the impact of treatment and prevention systems on population health. Although the WHO-SAIMS will rely heavily on the use of secondary data from key informant surveys (the reliability of which could be challenged in low and middle-income countries), this should not be a deterrent for the use of such a tool. Instead, the development of a user-friendly instrument that collects reasonably reliable information on existing alcohol and drug service systems may provide a basis for future evaluation research and may stimulate system reform in some countries. For these objectives to be realized, the end-users of the WHO-SAIMS need to apply its findings in developing and implementing service plans based on the recommendations of the assessment process. Thomas F. Babor, Ph.D., MPH Department of Community Medicine University of Connecticut School of Medicine Farmington, CT, USA babor@nso.uchc.edu Vladimir Poznyak, M.D., Ph.D. Department of Mental Health and Substance Abuse (MSD) World Health Organization Geneva, Switzerland poznyakv@who.int REFERENCES Babor, T.F. & Stenius, K. & Romelsjö, A. (2008): Alcohol and drug treatment systems in public health perspective: Mediators and moderators of population effects. International Journal of Methods in Psychiatric Research 17: (S1): S50 S59 Gossop, M. (1995): The treatment mapping survey; a descriptive study of drug and alcohol treatment responses in 23 countries. Drug and Alcohol Depend 39: 7 14 Klingemann, H. & Hunt, G. (eds.)(1998): Treatment systems in an international perspective: Drugs, demons and delinquents. Thousand Oaks, London, New Delhi: SAGE Publications Klingemann, H. & Takala, J.P. & Hunt, G. (1992): Cure, Care or Control: Alcoholism Treatment in Sixteen Countries. Albany, New York: State University of New York Press Klingemann, H. & Takala, J.P. & Hunt, G. (1993): The development of alcohol treatment systems: An international perspective. Alcohol Health Res World 3: Saxena, S. & Lora, A. & van Ommeren, M. & Barrett, T. & Morris, J. & Saraceno, B. (2007): WHO s Assessment Instrument for Mental Health Systems: Collecting essential information for policy and service delivery. Psychiatric Services 58: United Nations Office on Drugs and Crime (2006): World Drug Report, volume 1. Vienna, UNODC World Health Organization (2006): WHO Technical Consultation on the Assessment of Prevention and Treatment Systems for Substance Use Disorders December 2006, World Health Organization, Department of Mental Health and Substance Abuse, Geneva, Switzerland World Health Organization (2009): WHO- AIMS Mental health systems in selected low- and middle-income countries: a WHO-AIMS cross-national analysis. WHO, Geneva, Switzerland WHO (2004): Global Status Report on Alcohol Geneva: WHO, Department of Mental Health and Substance Abuse. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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