Reduction of the treatment gap for problematic alcohol use in Belgium

1.1 Background
Alcohol consumption is a widespread phenomenon in western societies and it is a significant cause of morbidity and mortality. Problematic alcohol use affects an estimated 3.6% of the population between 15 and 64 years of age worldwide. The Belgian health survey found that 10% of the Belgian population has a problematic alcohol use.
However, only a small proportion of people with a problematic alcohol use seeks or receives treatment. A European study (including Belgium) found that only 8% of persons with an alcohol problem had consulted some form of professional assistance in the past year. A Belgian study found that 12.8% of persons with an alcohol use problem indicated they searched for help in the year after the problem started but 61% did so in later years with a mean delay of 18 years. So, many people who could profit from help/assistance do not seek or receive it and there is a long delay. It may be concluded that there is a large ‘treatment gap’.
1.2 Research aim
To analyse explanations for the treatment gap and to find ways and interventions, including facilitators and barriers in applying these, to improve the treatment rate of people with problematic alcohol use in Belgium.
1.3 Methods
This study applied 3 research approaches:
• Review of the international and Belgian literature
o Medline, EMBASE, Cochrane Library and Psychinfo and grey literature sources were searched in summer 2014 for review studies and for Belgian primary studies with date limit >2000 and written in English, Dutch, French or German
o Literature was categorized into barriers/facilitators for seeking/starting treatment in individuals with problematic alcohol use, in care professionals and in society and into interventions for reducing the treatment in the mentioned three groups
o Only descriptive analyses of the literature were appliedQualitative research by interviews with persons with an alcohol use problem (n=14), and interviews and focus groups with care professionals, and experts in the alcohol field (n=60)
o To identify the factors on a personal, organisational and societal level that impede or facilitate the screening and advice given by professionals, initiation of treatment, and treatment-uptake by individuals with AUP;
o To understand the complex interactions between those factors;
o To identify the interventions/measures the surveyed individuals and professionals would consider effective in reducing the treatment gap from the point of view of the professionals and patients.
• Delphi study with persons with an alcohol use problem, care professionals, policy makers and experts (total across groups n= 35) in the alcohol field to check acceptability and priority of recommendations for improvement of the treatment
o Two rounds by online questionnaire were planned and a face to face meeting afterwards with Delphi-participants to discuss results of previous rounds and to reach final agreement
1.4 Results
In the literature study 85 relevant reviews and 22 Belgian primary studies were included. It was found that individuals with AUP follow a long road before seeking help. Main barriers along the road are denial of the problem, belief that alcohol problems may improve on their own, desire to handle problems on their own, thinking that treatment is ineffective or uncomfortable, dislike of the prevalent group, fear of stigma, lack of financial resources and other. Next it was found that care professionals face also many barriers to initiate a kind of intervention; common mentioned barriers are lack of time and lack of knowledge and confidence. Also it appeared there is a societal/public stigma towards people with a problematic alcohol use, causing a barrier for affected persons to seek help.
Several effective interventions targeted at easing patient barriers and help them to seek treatment or initiate behaviour change were found: Screening-brief interventions-referral to treatment (SBIRT) by health care professionals, internet based screening and awareness programs,stigma reducing interventions.
Also a large amount of research was found to overcome these impediments. Main intervention for patients is making them aware of their problem, e.g. by screening on alcohol use and motivational brief interventions. Main interventions for professionals is to train and to motivate them to screen and give brief interventions; however, all reviews stated as well that there was a lot of diversity in training formats and intensity, making it difficult to synthetize the results and to define the optimum duration and format of such initiatives. Interventions at a societal level are less clear
The qualitative study revealed that several barriers as well as facilitators are experienced by individuals with AUP and professionals. It appears that the treatment gap is a multiple phenomenon. Some elements are related to the individuals with an AUP, some others to the health professionals, and, more globally, in the socioeconomic context. Four main themes could be deduced from the interviews: individuals with AUP go through a long and stepped (however not always a linear) process before becoming aware of and recognising their problem; relatives (at home or in the social network) and colleagues (at work) play an important role along the persons’ trajectory; professionals lack the time, knowledge, skills and proper attitudes and they pass the buck when it comes to tackling the AUP; and the origin and treatment of AUP are largely influenced by societal habits and views. It appeared that more information is needed among the general population about alcohol-related problems and healthcare professionals’ knowledge on the topic, and the skills to manage it properly should be enhanced. In addition contextual and societal barriers have to be tackled.
The Delphi-study resulted in a general consensus on all proposals, based on the literature and the qualitative study. But it was stressed that it is necessary to implement the proposals simultaneously to enhance synergy.
1.5 Conclusion
The three research approaches confirmed each other and showed that the treatment gap for persons with problematic alcohol use is a multi-layered problem (individuals with AUP, their relatives, professionals, care system and general society). There are effective interventions to lower the treatment gap, but to obtain maximal effectiveness measures have to be taken at all levels in simultaneous way.