DECISION

ON PROMULGATION OF GUIDELINES FOR SCREENING AND INTERVENTION TO REDUCE NEGATIVE EFFECTS FOR PERSONS FACING ALCOHOL-RELATED HEALTH RISKS AT PRIMARY HEALTHCARE ESTABLISHMENTS AND IN THE COMMUNITY

MINISTER OF HEALTH

Pursuant to the Law on Prevention and Control of Harmful Effects of Alcoholic Beverages dated June 14, 2019;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017 on functions, duties, powers and organizational structure of the Ministry of Health;

At the request of the Director General of General Department of Preventive Medicine.

HEREBY DECIDES:

Article 1. Promulgated together with this Decision are the guidelines for screening and intervention to reduce negative effects for persons facing alcohol-related health risks at primary healthcare establishments and in the community.

Article 2. The guidelines for screening and intervention to reduce negative effects for persons facing alcohol-related health risks at primary healthcare establishments and in the community are applicable in the community, at primary healthcare establishments and at other relevant healthcare establishments across the country.

Article 3. This Decision takes effect from the date on which it is signed.

Article 4. General Department of Preventive Medicine shall take charge and cooperate with relevant units in providing direction and guidelines on screening and intervention to reduce negative effects for persons facing alcohol-related health risks at primary healthcare establishments and in the community as well as inspecting and supervising compliance therewith.

Article 5. Head of Office of the Ministry of Health, Director General of General Department of Preventive Medicine, Chief Inspector of the Ministry of Health, heads of departments of the Ministry of Health; Directors of Departments of Health; and heads of relevant units shall implement this Decision./.

GUIDELINES

ON SCREENING AND INTERVENTION TO REDUCE NEGATIVE EFFECTS FOR PERSONS FACING ALCOHOL-RELATED HEALTH RISKS AT PRIMARY HEALTHCARE ESTABLISHMENTS AND IN THE COMMUNITY

(Enclosed with Decision No. 4946/QD-BYT dated November 26, 2020 by the Minister of Health)

I. GENERAL INFORMATION

1. Some definitions and terms

a) Definition of food-grade alcohol, spirit and beer

- “food-grade alcohol” refers to an organic compound with the molecular formula C2H5OH and scientific name ethanol, which has impurities removed, meets the requirements for use in food in accordance with the national technical regulation and potentially leads to addiction and acute poisoning.

- “spirit” refers to a food-grade alcoholic beverage obtained from the fermentation of one or a mixture of ingredients mainly including starches of cereals or sugar syrups of plants, flowers, tubers or fruits or beverages obtained from food-grade alcohol.

- “beer” refers to a food-grade alcoholic beverage obtained from the fermentation of a mixture of ingredients mainly including malt, barley, brewer’s yeast, hops and water.

According to the abovementioned definitions, other alcoholic beverages mixed with food-grade alcohol such as cocktails, fruit juices containing food-grade alcohol produced following a spirit production procedure, etc. are also classified as spirits.

b) Definition of unit of alcohol

Unit of alcohol is a unit of measurement used to convert spirits, beer and other alcoholic beverages with different concentrations into quantities of pure alcohol. One unit of alcohol equals 10 grams of pure alcohol (ethanol) in a drink.

Unit of alcohol calculation method:

Unit of alcohol = Volume (ml) x Concentration (%) x 0,79 (conversion factor)

E.g., a 330 ml bottle of beer with a 5% alcohol concentration will have the following grams of alcohol:

330 x 0,05 x 0,79 = 13g, which is equivalent to 1,3 units of alcohol.

Therefore, one unit of alcohol is equivalent to:

- 3/4 of a 330ml bottle or can of beer (5%);

- A 330ml bottle or can of alcoholic fruit juice/cider/strongbow (4,5%);

- A 330ml glass of draught beer (4%);

- A 100ml glass of wine (13,5%);

- Or a 40ml glass of spirit (30%).

2. Alcohol-related diseases and disorders

Excessive use of alcohol has multiple negative effects on human health, the family and the community, disrupts traffic safety, public order and social safety, causes financial damage and leads to other social issues.

Alcohol is one of the causes of more than 230 diseases and injuries as mentioned in the ICD-10 Classification of Mental and Behavioral Disorders of the World Health Organization (WHO). Some major diseases and injuries caused by alcohol consumption include:

Cancer: International Agency for Research on Cancer classifies alcohol as a group 1 carcinogen, which means it poses as high a risk of cancer as tobacco, asbestos or ionizing radiation. Alcohol consumption is a direct cause of cancer of the oral cavity, throat, larynx, esophagus, colon - rectum and liver and breast cancer in women.

Cardiovascular diseases: alcohol increases the risk of stroke, heart failure, hypertension and aortic aneurysm.

Digestive diseases: alcohol causes damage to the liver (alcoholic fatty liver disease, acute alcoholic hepatitis, etc.), cirrhosis, worsens damage caused by hepatitis C and B virus, acute and chronic pancreatitis, diseases of the esophagus, stomach, etc.

Mental disorders: alcohol causes memory loss, reduces thinking capacity, induces anxiety, depression, psychosis, aggression, suicide, etc.

Other disorders and diseases: alcohol use can lead to early aging, immunodeficiency, fetal alcohol syndrome and low birth weight.

Injuries: alcohol consumption is the leading cause of traffic accidents and other unintentional and intentional infliction of injuries.

Social issues: alcohol has a negative effect on family relations, causes work capacity reduction or loss, unemployment, violence, unsafe sex, legal issues, etc.

3. Levels of risk posed by alcohol consumption

To adopt interventions in the community, the risk posed by alcohol consumption shall be assessed following the guidelines provided by the AUDIT screening instrument (Alcohol Use Disorder Identification Test) of WHO. The total score of the 10 questions of AUDIT ranges between 0 and 40.

Based on the total score, the subjects shall be classified into the following groups:

a) Low-risk alcohol consumption

This group includes those scoring from 0 to 7 points. For people classified into this group, it is ideal that they do not drink alcohol; or drink no more than 2 units of alcohol per day for men and no more than 1 unit of alcohol per day for women and for no more than 5 days a week. At this level of consumption, the impacts of alcohol on health are usually at the minimum.

b) High-risk alcohol consumption

This group comprises those scoring from 8 to 15 points. Alcohol consumption at this level poses high risk. Despite lack of manifestation of any alcohol-related physical damage or disorder, people belonging to this group face high risk of injury, inflicting violence or committing acts with legal consequences, work capacity reduction or causing social issues due to acute alcohol poisoning; as well as high risk of non-communicable diseases and other chronic diseases due to regular alcohol use.

c) Very high-risk alcohol consumption

This group includes those scoring from 16 to 19 points. People classified into this group already have health issues, which may be physical harm (liver damage, liver dysfunction, cardiovascular diseases, etc.) or mental disorders (depression, psychosis, etc.), and/or have been involved in an accident, inflicted violence, committed a violation against the law, suffered from work capacity reduction and caused other social issues due to regular/excessive alcohol consumption.

d) Risk of alcohol dependence/addiction

People scoring 20 points or more are those at risk of alcohol dependence, which is characterized by craving (intense desire to drink), loss of control (inability to stop drinking despite wanting to), increase alcohol tolerance and physical impacts. They also face high health risks such as brain dysfunction, leading to loss of consciousness and control over their behaviors, gradual memory loss, cognitive impairment, mood disorders, paranoia, hallucinations, etc. in addition to liver damage (cirrhosis, liver failure, liver cancer), esophageal varices, gastrointestinal bleeding, pancreatitis, epilepsy, etc.

II. PURPOSE, SUBJECTS AND LOCATIONS OF SCREENING

1. Purpose

Help healthcare workers evaluate and detect those facing health risks or suffering from disorders and diseases due to alcohol consumption early on so as to give advice, provide instructions and make early interventions for prevention and minimization of risks to and negative effects on health caused by alcohol consumption.

2. Persons in charge of screening and intervention

- Collaborators/participants involved in prevention and control of negative effects of alcohol.

- Healthcare workers and healthcare collaborators of hamlets and villages.

- Healthcare workers of commune-level healthcare stations and healthcare stations of regulatory bodies, units and organizations.

- Healthcare workers of clinics, grassroots-level hospitals, preventive healthcare establishments and other relevant healthcare establishments.

Persons in charge of screening and intervention to reduce negative effects for persons facing alcohol-related health risks at grassroots-level healthcare establishments and in the community shall receive training and guidance concerning use of the AUDIT screening instrument, screening and intervention procedure, and interventions to reduce negative effects on alcohol users.

3. Subjects of screening and intervention

Persons requiring screening and intervention are alcohol users aged 18 or older, including:

- People in the community.

- Persons visiting healthcare establishments for medical examination, treatment, regular check-ups, occupational disease examination and other healthcare services, especially those with chronic diseases and health disorders related to alcohol.

4. Locations

- In the community

- Commune-level healthcare stations; healthcare stations of regulatory bodies, units and organizations.

- Clinics, medical consultation rooms of grassroots-level healthcare establishments and other relevant healthcare establishments.

Note: alcohol use is private information that many might not be willing to share with a stranger or in the presence of other people, thus, the interviewer should select a suitable interview location and setting.

III. INSTRUMENT AND PROCEDURE FOR SCREENING AND INTERVENTION TO REDUCE NEGATIVE EFFECTS FOR ALCOHOL USERS

1. Risk screening questionnaire

The screening instrument is the predesigned screening questionnaire for alcohol-related health risks (hereinafter referred to as “screening questionnaire”). The questionnaire is developed based on the AUDIT screening instrument (Alcohol Use Disorder Identification Test) of WHO.

The screening questionnaire consists of 10 questions.

Each question scores from 0 to 4 points. The total score ranges between 0 and 40 points. The questionnaire is divided into the 3 following parts:

- Part 1: 3 questions (question 1, question 2, question 3), which collect information on hazardous alcohol consumption.

- Part 2: 3 questions (question 4, question 5, question 6), which collect information on alcohol dependence.

- Part 3: 4 questions (question 7, question 8, question 9, question 10), which collect information on harmful alcohol consumption.

Questions from 1 to 8 collect information on alcohol consumption in the past 12 months.

Questions 9 and 10 collect information on alcohol-related health problems encountered up to date.

Screening questionnaire

As alcohol consumption poses risk to your health and affects your treatment as well as use of medications, I would like to ask you some questions to screen the risk that alcohol consumption poses to your health. Your answers will be kept confidential and the collected information will only be used to provide consultancy and health care for you. I hope to receive your cooperation.

Full name of subject: …………………………; Age:……..; Sex:……………….

Address: ……………………………………………..……; Interview date: ….../…../………

2. Procedure for screening and intervention to reduce negative effects for alcohol users

The procedure comprises of the 4 following steps:

Diagram of screening and intervention procedure

a) Step 1 - Meet screened subject

- The interviewer greets and introduces themselves to the subject, informs the subject of the screening purpose and time, and promises to keep information provided by the subject confidential.

- Before the screening, the interviewer asks: “Have you ever had a drink containing alcohol?”

If the subject answers “never”, end the interview, encourage the subject to maintain healthy behaviors and distribute communication documents (if any).

If the subject answers “yes”, start screening using the screening questionnaire and follow the next steps.

- When conducting the interview, the interviewer should pay attention to the following:

+ Show an open attitude, do not frighten the subject or make the interview feel serious.

+ Only engage with those able to give an interview, do not interview people who are drunk or needing immediate medical care.

+ Only interview people who have agreed to participate.

b) Step 2 - Interview using screening questionnaire

- Explain alcohol, unit of alcohol and unit of alcohol calculation method to the subject.

- Interview the subject using the screening questionnaire (provided for in section III) as follows:

+ Ask the questions one by one and record the selected choice. Each question has 3 or 5 choices (corresponding to 0 - 4 points). After the subject gives their answer, circle the score at the beginning of the choice and write the corresponding score into the adjacent square.

+ The interviewer should take notice if there is anything that makes the subject hesitate to share information and build trust and help the subject feel as comfortable as possible. If an answer is ambiguous or the subject avoids answering a question, the interviewer should repeat the question and provide the choices for the subject to select the one most appropriate to them.

+ After the subject answers all questions, add up the points and write the total score into the square on the last row of the questionnaire.

c) Step 3 - Classify level of risk

After completing the screening questionnaire, classify the subject into one of the following 4 groups of alcohol-related health risk based on the total score:

Risk group 1 (from 0 to 7 points): low-risk alcohol consumption Risk group 2 (from 8 to 15 points): high-risk alcohol consumption Risk group 3 (from 16 to 19 points): very high-risk alcohol consumption Risk group 4 (20 or more points): risk of alcohol dependence/addiction.

d) Step 4 - Make interventions

Take quick intervention measures suitable for each level of risk (each risk group): raise awareness, give advice or refer persons facing risk of alcohol addiction to specialized establishments for treatment and care.

To be specific:

IV. INTERVENTION TO REDUCE NEGATIVE EFFECTS FOR EACH RISK GROUP

1. Risk group 1: raise awareness

Those scoring 0 point are alcohol non-users.

Encourage them to continue to not consume alcohol.

Those scoring from 1 to 7 points are low-risk alcohol users. However, they can be affected and might consume more alcohol in the future, thus, they need to receive education on the health risks posed by alcohol.

Intervention purpose: raise awareness to help screened subjects understand the harmful effects of alcohol use and the need to avoid or limit alcohol use.

Procedure:

(1) Inform the screening result to the subject

(2) Inform the level of risk: explain to the subject that they are facing low risk of alcohol-related health issues if they continue to drink moderately. However, there is no safe limit for alcohol consumption. Small amounts of alcohol still pose risk of cancer.

(3) Provide knowledge: help the subject understand the harmful effects of alcohol (show illustrations of negative effects of alcohol on health).

(4) Raise awareness:

- To prevent the harmful effects of alcohol, the subject should not consume alcohol as there is no safe limit for consumption. If the subject does use alcohol, they should not drink more than 2 units of alcohol per day for men or 1 unit of alcohol per day for women and not drink for more than 5 days a week (show illustration of unit of alcohol).

- The subject must not consume alcohol in the following cases: the subject operates a motor vehicle or machine, the subject is under 18 years of age, pregnant or breastfeeding, the subject has a history of or is suffering from a mental disorder, the subject has a history of alcohol or narcotic substance addiction, the subject is suffering from a condition worsened by alcohol (cardiovascular diseases, liver diseases, etc.).

- Inform the subject of some prohibited acts and locations where alcohol use is prohibited according to regulations of the Law on Prevention and Control of Harmful Effects of Alcoholic Beverages.

(5) Conclude and give encouragement: assert the necessity of discontinuation or reduction of alcohol use; encourage the subject to persist in avoiding or limiting their drinking to a low-risk amount.

2. Risk group 2: raise awareness and provide instructions

This group includes high-risk alcohol users (scoring from 8 to 15 points). These persons might not be showing signs of any alcohol-related physical damage or disorder but they face high risk of injury, inflicting violence or committing acts with legal consequences, work capacity reduction or causing social issues due to acute alcohol poisoning; as well as high risk of non-communicable diseases and other chronic diseases due to regular alcohol use.

Intervention purpose: help the subject understand the health risks they are facing due to high-risk drinking; encourage the subject to change their drinking behaviors immediately.

Procedure:

(1) Inform the screening result to the subject (inform the family member accompanying them with their permission).

(2) Inform the level of risk: explain to the subject that they are consuming a high-risk amount of alcohol.

(3) Provide knowledge: help the subject understand that they will face the following harmful effects and health risks if they continue to consume a high-risk amount of alcohol (show illustrations of negative effects of alcohol on health):

- High risk of chronic diseases such as cancer, cardiovascular diseases, metabolic disorders, etc. due to regular high-risk drinking.

- High risk of accidents, injury, work capacity reduction or inflicting violence and social issues due to acute alcohol poisoning.

(4) Raise awareness: the subject must stop or reduce their drinking immediately to prevent and minimize health risks:

- The subject should not consume alcohol as there is no safe limit for consumption.

- If the subject continues to use alcohol, they should not drink more than 2 units of alcohol per day for men or 1 unit of alcohol per day for women and not drink for more than 5 days a week.

- The subject must not consume alcohol in the following cases: the subject operates a motor vehicle or machine, the subject is under 18 years of age, pregnant or breastfeeding, the subject has a history of or is suffering from a mental disorder, the subject has a history of alcohol or narcotic substance addiction, the subject is suffering from a condition worsened by alcohol (cardiovascular diseases, liver diseases, etc.).

- Inform the subject of some prohibited acts and locations where alcohol use is prohibited according to regulations of the Law on Prevention and Control of Harmful Effects of Alcoholic Beverages.

(5) Conclude and give encouragement: reassert the necessity of immediate discontinuation or reduction of alcohol use; encourage the subject to do this.

(6) Monitor: provide the subject with a healthcare worker's phone number in case the subject needs advice. The subject should be screened and assessed again at least once a year.

3. Risk group 3: give quick advice

This group includes those scoring from 16 to 19 points or scoring from 8 to 15 points and 04 points for either question 9 or question 10 or both.

These persons are drinking a very high-risk amount of alcohol and have suffered from physical and mental health issues and/or been involved in an accident, faced problems related to violence or the law, had their work capacity reduced or had other social issues due to excessive and regular alcohol consumption.

Intervention purpose: give advice to the subject to help them understand the health consequences they are facing due to very high-risk drinking; provide advice and assistance for them to change their drinking behaviors.

Procedure:

(1) Inform the screening result to the subject (inform the family member accompanying them with their permission).

(2) Inform the level of risk: explain to the subject that they are consuming a very high-risk and harmful amount of alcohol. Assert that the subject is facing direct health risks or is already having health issues due to alcohol consumption.

(3) Provide knowledge: help the subject understand that they will face the following harmful effects and health risks if they continue to consume a very high-risk amount of alcohol (show illustrations of negative effects of alcohol on health):

- Acute or long-term damage to physical health (liver damage, liver failure, cirrhosis, cardiovascular diseases, etc.);

- Mental disorders (depression, psychosis, etc.) or other social consequences (accidents, abuse, work capacity loss/reduction, etc.).

Give advice on behavior change:

(4) Raise awareness:

The subject must stop or reduce their drinking immediately to prevent and minimize health risks:

- The subject should not consume alcohol as there is no safe limit for consumption.

- If the subject continues to use alcohol, they should not drink more than 2 units of alcohol per day for men or 1 unit of alcohol per day for women and not drink for more than 5 days a week.

- The subject must not consume alcohol in the following cases: the subject operates a motor vehicle or machine, the subject is under 18 years of age, pregnant or breastfeeding, the subject has a history of or is suffering from a mental disorder, the subject has a history of alcohol or narcotic substance addiction, the subject is suffering from a condition worsened by alcohol (cardiovascular diseases, liver diseases, etc.).

- Inform the subject of some prohibited acts and locations where alcohol use is prohibited according to regulations of the Law on Prevention and Control of Harmful Effects of Alcoholic Beverages.

(5) Assistance with behavior change:

Identify which stage of drinking behavior change the subject is currently at to select the suitable intervention as follows:

(6) Monitor and assist:

Keep in touch, assist and exchange information with the subject after each consultation session, help the subject achieve their objectives of changing drinking behaviors to prevent and minimize health risks.

- If the subject has decided to change their behaviors, healthcare workers shall contact them on a regular basis to monitor and help the subject with maintaining their new behaviors. Monitor the subject at least once a month for the next 2 months. Refer the subject to a healthcare establishment if they fail to change their behaviors or relapse after intervention or have a comorbid condition.

- If the subject is not ready to change their behaviors, the healthcare worker shall emphasize the negative effects of alcohol use on health, show the subject that they are consuming a very high-risk amount of alcohol and give encouragement and instructions for the subject to change their behaviors.

- The subject should be screened and assessed again at least once every six months.

4. Risk group 4: refer to healthcare establishment

Those scoring 20 or more points must be referred to a healthcare establishment for specialized diagnosis and treatment of alcohol dependence/addiction as this screening questionnaire is not a diagnostic tool.

In addition, some persons scoring less than 20 points also need to be referred to a healthcare establishment for specialized diagnosis and treatment if they have any of the following problems:

- They score 02 or more points for question 4, question 5 and question 6;

- They have alcohol addiction syndrome;

- They have a history of alcohol addiction or narcotic substance addiction or they have liver damage;

- They have had or are having a mental disorder;

- They fail to achieve their objectives after receiving advice.

Reference procedure:

(1) Inform the screening result to the subject

(2) Raise the subject’s awareness: this is a severe condition, alcohol consumption has caused many health problems and you might have become addicted to alcohol; you must stop or reduce your drinking with professional help; and you should visit a specialist for diagnosis and treatment.

(3) Refer the subject to a healthcare establishment: provide the subject with a list (including name, address, phone number, etc.) of specialized healthcare establishments or medical centers/other facilities capable of diagnosing, treating and managing alcohol dependence/addiction cases in the subject’s locality and refer the subject to these facilities for diagnosis and treatment (list of facilities receiving these cases for diagnosis, treatment and management at all levels shall be decided by the competent local health authority).

Note: if the subject agrees and cooperates, provide full information and encourage them to visit the facility soon. If the subject disagrees, provide the subject with a solution that allows them to have more time to make a decision.

(4) Persons in charge of screening compile and send list of persons classified into this group to the in-charge medical station or facility for it to formulate a plan for management and rehabilitation of these persons in the community according to guidelines of specialized officials.

Note: after screening a subject with any of the following issues, the screening person must inform the result to their family immediately:

- The subject is at risk for suicide.

- The subject has aggressive behaviors.

- The subject is at risk for violence.

V. MANAGEMENT AND SUPPORT FOR PERSONS FACING ALCOHOL-RELATED HEALTH RISKS IN THE COMMUNITY

1. Compilation of lists of at-risk persons for management, monitoring and support

Objectives: manage persons facing alcohol-related health risks; determine whether a subject has changed their behaviors, identify and solve difficulties arising during previous screening and consultation processes.

Commune-level medical stations shall prepare lists of all persons facing alcohol-related health risks and plans for rescreening and reassessment following the guidelines.

Content: the healthcare worker shall prepare a plan for periodic monitoring and support for the subject after the consultation session based on the subject’s risk group and how much the subject’s behaviors have changed. If the subject shows clear progress in changing their behaviors, monitoring time may be reduced. For cases hard to reach their objectives or maintain their behaviors, prepare a suitable schedule and monitor them frequently to reinforce their behaviors and prevent relapse. For cases not ready to change their behaviors, encourage them to change. Cases facing risk of alcohol dependence/addiction should be referred to a specialized healthcare establishment or medical center/other facilities capable of diagnosis, treatment and management. The healthcare worker shall inform the subject’s family to have them support the subject as they play an important role in facilitating change in the subject’s behaviors.

2. Data recording, reporting and management

Record screening data and calculation methods for relevant ratios to measure results of the screening program.

Manage data that provides the basis for measurement of activity outcomes. Information and screening results should be recorded into available medical examination books of commune-level medical stations and clinics. Alcohol-related risk monitoring is only possible with fully recorded results, which is similar to other non-communicable diseases.

Some main monitoring indicators include:

- Number or rate of persons screened (among total people of the same age living in the same area at the same time).

- Number or rate of persons classified according to the abovementioned levels of risk (among total people of the same age living in the same area at the same time screened).

- Number or rate of persons receiving advice and intervention (among total people screened and classified according to levels of risk).

- Number of persons receiving alcohol-related communication documents (among total people screened in the same area at the same time).

- Rate of persons being managed and monitored (among total people screened and receiving intervention).

- In addition to reporting on quantity, hold briefings on a regular basis for people to discuss and resolve issues arising during implementation of these guidelines.

---------------

This document is handled by Vinas Doc. Document reference purposes only. Any comments, please send to email: [email protected]