Prevention and Early Intervention

Abstract

This chapter focuses on primary prevention—programs designed to prevent or delay the commencement of harmful alcohol use—and secondary prevention, also called early intervention, namely programs targeting those who are already engaging in harmful alcohol use or considered at risk of doing so. Historically, programs addressing alcohol problems among Aboriginal people have emphasised primary prevention, especially through media campaigns and health promotion initiatives, and residential treatment, at the expense of early intervention. Primary prevention initiatives are reviewed. The evidence base for program effectiveness is sparse, although it is difficult to distinguish the effects of poor program quality from that of poor (or non-existent) evaluations. The limited evidence available suggests that a high level of community involvement, multi-component programs, promotion of cultural connectivity and skills development are all factors conducive to effective primary prevention. Initiatives in screening and early intervention are also reviewed. The chapter describes efforts to embed screening and early interventions in primary healthcare settings, and the barriers encountered in these efforts. The chapter also examines recent initiatives aimed at surmounting these barriers.

3.1 Introduction

Both the National Alcohol Strategy and the National Drug Strategy (NDS) in Australia are based on a policy of harm minimisation, as is the National Aboriginal and Torres Strait Islander Peoples Drug Strategy 2014–2019 (Intergovernmental Committee on Drugs (Australia) 2014). This policy in turn rests on three ‘pillars’: demand reduction, supply reduction and harm reduction (Commonwealth of Australia (Department of Health) 2017; Intergovernmental Committee on Drugs (Australia) 2014; Commonwealth of Australia 2019). Supply reduction measures are designed to reduce availability of alcohol and other drugs; harm reduction measures aim to reduce the harm caused by AOD use both on users themselves and on other people, for example by providing sobering-up shelters for persons intoxicated in public. In this and the following chapters, we focus on the remaining pillar–that is, measures aimed at reducing the demand for alcohol and other drugs.

Demand reduction measures are conventionally categorised according to a three-part prevention typology. In the case of alcohol, this comprises.

• Primary prevention: preventing or delaying uptake of harmful alcohol use among healthy individuals, for example through education and health promotion and provision of alternatives to alcohol and other drug use;

• Secondary prevention, also called early intervention: preventing the onset or continuation of harmful alcohol use among people who are already drinking or at risk of harmful use;

• Tertiary prevention, or treatment and rehabilitation: facilitating recovery from harmful use and/or alcohol dependence and preventing relapse to harmful drinking.¹

This chapter addresses primary and secondary prevention, while the following chapter looks at tertiary prevention, or treatment and rehabilitation.

Ideally, as the National Aboriginal and Torres Strait Islander Peoples Drug Strategy 2014–2019 notes, a range of options will be available to cater to people with different needs and circumstances, including screening and brief interventions, withdrawal management, pharmacotherapies, counselling, social support and relapse prevention (Intergovernmental Committee on Drugs (Australia) 2014: 12). In reality, the options available to Aboriginal Australians have long been limited. A study published in 1998 confirmed what several critics had been arguing for well over a decade: firstly, that prevention programs for Aboriginal people with alcohol issues were concentrated in the first category—primary prevention—in the form of media campaigns and health promotion initiatives—and in the third category—in residential treatment programs for people who were in many cases in the late stages of drinking careers. Missing were early intervention programs targeting at-risk drinkers with evidence-based interventions designed to prevent them from adopting or continuing harmful drinking (Brady et al. 1998). The second finding was that clients of tertiary treatment services were in most instances offered only a very limited range of abstinence-oriented, disease-based treatment options of dubious effectiveness (Brady et al. 1998). In this chapter, we review developments that have occurred since that time in attempts to rectify these problems and gaps. We begin with primary prevention.

3.2 Primary Prevention

Primary prevention programs aim to educate people about the use and misuse of alcohol and other drugs, raise awareness, build resilience and/or enhance community capacity to prevent AOD problems. They are usually grounded in health promotion and/or community development principles. A study of alcohol and other drug intervention projects conducted by or for Aboriginal Australians and operating during 1999–2000 identified 277 projects, of which 57 (20.6%) were prevention projects offering one or more of health promotion, sporting, recreational or other alternatives or diversions from alcohol and other drug use, or community development (Gray et al. 2002). Although these projects accounted for one-fifth of all projects, they received only 10.5% of the total expenditure in that year of $35.4 million (Gray et al. 2002).

At present, the evidence base underpinning primary prevention initiatives in Aboriginal communities is sparse. Many primary prevention projects are not evaluated or, if they are, fail to demonstrate any changes in alcohol use or other behaviours. A study of evaluated interventions addressing Aboriginal alcohol use conducted in 2000 identified five health promotion projects, including a school-based education program implemented by the Queensland Department of Education and a Commonwealth-funded tour of NT Aboriginal communities by the band Yothu Yindi—together with a TV commercial (Gray et al. 2000). The study concluded that none of the evaluations demonstrated ‘impressive’ results, but added that these findings may have owed as much to inappropriate evaluation designs or other methodological flaws as to weaknesses in the programs themselves (Gray et al. 2000). Lee et al. (2013) conducted a systematic review of studies published in peer-reviewed journals between 1990 and 2011 that evaluated programs aimed at reducing substance misuse among young Aboriginal Australians (aged 8–25 years). Eight studies met their inclusion criteria, four of which reported reductions in substance misuse. In two of these, the focus of the interventions was petrol sniffing (Burns et al. 1995; Preuss and Brown 2006). The remaining two targeted alcohol and other drug use, one of them by means of a peer support and skills training program designed to raise self-esteem and reduce drug use (Gray et al. 1998), and the other through a community development-based program of training, recreational and cultural activities (Lee et al. 2008).

On the basis of their review, Lee and her colleagues identified several features common to all of the interventions that appeared to contribute to reductions in substance misuse. These are summarised in the extract in Box 3.1 below.

Box 3.1 Common Elements of Promising Interventions

Extract from Lee et al. (2013: 95)

The four programs that were associated with reductions in substance use shared several common elements: two incorporated cultural activities (Lee et al. 2008; Preuss and Brown 2006), all offered regular rather than one-off initiatives and all involved more than one component. Each was developed with communities to protect young people (and sometimes the whole community) against substance misuse. These broader elements were combined with other elements, such as education on the risks of substance use (Burns et al. 1995; Lee et al. 2008), recreational activities (Lee et al. 2008; Preuss and Brown 2006) or supply control (Burns et al. 1995; Preuss and Brown 2006). Two of these studies reported sustained benefits 20 months (Burns et al. 1995) and 12 years (Preuss and Brown 2006) after implementation, and each included elements of supply control.

School-based education, which is anecdotally a commonly implemented intervention, was not found to be effective in two studies (Gamarania et al. 1998; Sheehan et al. 1995). Although firm conclusions cannot be made based on these limited data, the findings are consistent with studies of general populations showing that school-based education focused on reducing the risks of substance misuse alone has variable effectiveness (Thomas and Perera 2006). Conversely, a small number of social learning-focused school-based prevention programs in general populations have been reported to be effective in reducing substance use (Teesson et al. 2012).

In the general population, although there is some evidence for the effectiveness of multi-component preventive interventions (Foxcroft and Tsertsvadze 2011), there is little evidence comparing these against single-component initiatives. In an Indigenous setting, a broad approach is compatible with the complexity of health and social issues affecting young people (Ministerial Council on Drug Strategy 2006).

The importance of interventions initiated and guided by the local Indigenous community is aligned with national (Ministerial Council on Drug Strategy 2006) and international (World Health Organization 1978) guidelines. This helps foster community acceptance and ownership of the intervention (Ministerial Council on Drug Strategy 2006). The importance of ongoing ‘whole’ community engagement in the design and delivery of the programs was also emphasised (Ministerial Council on Drug Strategy 2006).

The role of cultural (Ministerial Council on Drug Strategy 2006) and recreational (Cairnduff 2001) activities in reducing substance use is compatible with the current understanding of the risk factors for increased risk of substance use disorders among Indigenous people (Kirmayer et al. 2000). Cultural discontinuity is believed to be a risk factor for poor mental health, suicide, violence and substance misuse (Kirmayer et al. 2000). Sometimes, whole communities (and young people in particular) may feel ‘lost between two cultures’ (Kirmayer et al. 2000). This, and social marginalisation, may contribute to a sense of lack of connectedness. Even in general populations, helping young people feel connected to family and school (Bond et al. 2007), or to community (Hawkins et al. 2009), helps protect them against substance misuse and mental health problems (Bond et al. 2007; Loxley et al. 2004). However, these approaches have not been systematically evaluated in an Indigenous context. Cultural or recreational programs are likely to support a sense of social and cultural connectedness and may also offer attractive alternatives (Ministerial Council on Drug Strategy 2006) to substance use.

More recently, Geia et al. (2018) also conducted a systematic review of studies in peer-reviewed journals of programs targeting substance misuse among Australian Indigenous youth. Only four studies met their inclusion criteria, three of which addressed petrol sniffing or other volatile substance misuse rather than alcohol. The sole study that focused on alcohol was an evaluation of a two-year community-wide intervention designed to reduce high-risk, binge drinking among young people in a far north Queensland Aboriginal community (Jainullabudeen et al. 2015). The program included social events, education, and youth-specific sporting and social activities designed to promote self-empowerment. A survey conducted at baseline and at the end of two years revealed a statistically significant reduction of 10% in the proportion of youths who reported having engaged in one or more episodes of short-term risky drinking, and in the frequency of short-term risky drinking for all beverages except wine. Mean expenditure on alcohol during drinking occasions marked by short-term risky drinking also declined, while participants’ awareness of what constituted binge drinking and standard drinks rose (Jainullabudeen et al. 2015).

International studies corroborate the findings of the Australian studies referred to above. A review of programs aimed at preventing substance misuse among American Indian and Alaskan Native youths conducted in 2004 by Hawkins et al., while noting the paucity of methodologically sound evaluations, concluded that high levels of community involvement in developing and delivering programs, together with a skills development component, offered the most promising approach (Hawkins et al. 2004). More recently, Snijder et al. conducted a systematic review of evidence relating to substance use prevention programs among Indigenous adolescents in Canada, the US, Australia and New Zealand published between 1990 and 2017 (Snijder et al. 2020). Twenty-six papers which evaluated, between them, 27 prevention programs, met their selection criteria—18 conducted in the US, six in Australia and two in Canada. Fourteen programs were found to have had beneficial substance-related outcomes. Among these, the most common components were (1) a high level of community involvement in developing the program; (2) cultural knowledge enhancement through, for example, activities such as ceremonies and storytelling or learning about traditional practices; (3) skills development, for example, in problem solving, resistance strategies and interpersonal skills; and (4) substance use education (Snijder et al. 2020). Snijder et al. also identified two domains in which further attention was warranted: family-based programs and the use of computers and online technology in delivering prevention programs to young people.

The principles underpinning good practice in community-based prevention programs are not new, even if they are not always followed. In 1992, the American sociologist Philip May outlined the need for a comprehensive, public health-based approach to preventing and reducing alcohol-related problems in American Indian communities. May cautioned against relying on single policy options or short-term measures, arguing for a range of measures to address both supply of and demand for alcohol. He also identified eight principles for community-based prevention, together with some ‘don’ts’. These are reproduced below in Box 3.2 in the belief that they are no less applicable to Aboriginal Australian settings.

Box 3.2 Implementing Community-Based Prevention: Guiding Principles

Extract from May (1992: 47–48)

In terms of implementation, there are several suggestions that can be made.

• 1. Define where your community is regarding knowledge, attitudes and opinions on alcohol policy and its readiness to work for change and improvement A survey would be of tremendous value here.

• 2. Develop generalisations that are held by the majority and around which a consensus can be formed.

• 3. Based on the specific areas of consensus, select specific topics, policy options or techniques that can be pursued and accomplished through study, debate and work plans. For example, if fetal alcohol syndrome is an area of concern and consensus, begin with it. Or, if infant car seats are deemed important, do likewise.

• 4. Keep community-specific data and records on

  • a. baseline indicators of mortality, morbidity (sickness and injury), public opinion and arrests related to alcohol;

  • b. the process of intervention on problems; and

  • c. the outcome (both intermediate and final) or outcomes of positive action taken.

• 5. Form explicit and positive ties between all constituencies in the community who play a role in the problem. Included should be the legal community, law enforcement, the media, business, government, schools, churches, service groups, families and others.

• 6. Emphasise positive programs in the media to keep the public informed and invested.

• 7. Fine-tune the programs and policies from time to time, for the effectiveness of events such as DUI crackdown recedes in the long run (12–18 months or longer) if the public perceives a reduction in enforcement effort, a reduced likelihood of being apprehended or less likelihood of being negatively affected by the problem.

• 8. Be creative. Public policy is not a science and cannot be completely fine-tuned so that it can be totally science directed. Seek new approaches that increase the probability of improvement; new, creative policies can be assessed retrospectively as to their effectiveness. Some detailed literature on local programs might be helpful.

There are some special issues or pitfalls in prevention that a community must avoid. These issues are very much at risk in western Indian, Native and bordertown communities. Specifically, a comprehensive program must avoid.

• Blaming any one type of individual or group, for alcohol abuse is everyone's problem.

• Championing one particular therapy, approach or ideology over other possible options, for many approaches must play a role.

• Looking for single case, ‘magic bullet’ approaches.

• Polar arguments such as us versus them; Indian versus non-Indian; or rural versus urban.

• Being coercive with large segments of the non-drinking or light-drinking population by enacting a policy that is radically different from the views of mainstream citizens.

• Focusing narrowly on the treatment, incarceration and processing of chronic alcoholics only.

• Expecting immediate success.

• Expecting ‘someone else’ (e.g. experts, or the federal or state government) to solve the problem for the community.

Instituting a comprehensive prevention/intervention alcohol policy in a community will take a great deal of detailed study, work and deliberation. It is a complex and complicated task and process. It is also a contingent process, that is, one decision will affect many others. Therefore, action in one part of a region will necessitate adjustment of policy in another part. A change in policy in one institution of the region (e.g. legislation) will necessitate an adjustment in other institutions (e.g. law enforcement, media and business).

The full text of the article from which the above extract is taken, together with commentaries on May’s article by others, is available at https://coloradosph.cuanschutz.edu/research-and-practice/centers-programs/caianh/journal/past-volumes/volume4.

May’s article, when originally published, generated several commentaries that can be read today at the URL above. Among these was a cautionary note about an issue likely to confront any group seeking to change drinking behaviour at a community level, not only in American Indian communities:

A further important question needing to be answered is how do individuals or communities respond to policies that are at variance with their personal beliefs and values? Alternately, can policy change lead to changes in individual behaviour if there is no personal motivation to change? At a more philosophical level, how far can or should policy be pushed before there is a backlash based on infringement of individual rights? Underlying these and other similar questions is the search for barriers that prevent adherence to policy. On most reservations today there are very extensive policies regarding alcohol use, yet there is also a clear lack of compliance with these policies. We would do well to understand why past efforts to moderate drinking practices through policy means have been ineffective (Beauvais 1992: 77).

One community-led intervention that literally ‘ticks all the boxes’ in May’s list of principles in Box 3.2 is the comprehensive set of alcohol control measures introduced into the Fitzroy Valley of the Kimberley region in north-western Australia from 2007. The origin and evolution of these measures were described in a report prepared in 2010 by the Aboriginal and Torres Strait Islander Social Justice Commissioner. An edited extract from the Commissioner’s report is reproduced as a case study in Chap. 5 below. As the extract shows, what began as a 12-month trial of restrictions on take-away alcohol sales from a local outlet in response to a crisis of violence and self-harm evolved into an ongoing, comprehensive community program addressing, among other issues, the presence of Fetal Alcohol Spectrum Disorders (FASD) and Early Life Trauma (ELT) in the community.

Not all such preventive interventions, however, are destined to play out over such a long period and with such far-reaching consequences. The second example we have selected describes an initiative more limited in scope than the Fitzroy Valley example, but one that nonetheless displays the same principles of community leadership, strategic partnerships, clearly defined objectives and a pathway to achieving them. The initiative took place in the small town of Elliott, located 700 km north of Alice Springs in the Northern Territory, in 1991 (Walley and Trindall 1994). At the time, Gwen Walley and Darrin Trindall were Aboriginal Health Promotion Officers stationed in Alice Springs and Tennant Creek in the NT, respectively. They were already known in Elliott as a result of having taken part in several health promotion activities indirectly related to alcohol issues, including working with a women’s centre, support for a recreation officer and health education in schools.

At the time of Walley and Trindall’s intervention, Elliott had a population of around 400 Aboriginal and 100 non-Aboriginal people. Employment was provided mainly by pastoral properties and government agencies. Recreational facilities were limited, and many middle-aged and older people—both Aboriginal and non-Aboriginal—pursued a lifestyle that often involved heavy drinking (Walley and Trindall 1994). Many people in the community, including Health Centre staff, recognised alcohol misuse as a major problem, but lacked confidence in addressing it. Aboriginal Health Workers at the Elliott Health Centre asked for help in developing their community development skills to work with the wider community. In collaboration with the local Gurungu Council, the two Aboriginal Health Promotion Officers encouraged community members to voice their concerns and consider possible solutions. The extract below, taken from a paper by Walley and Trindall, begins with the results of this process.

Box 3.3 Strengthening Community Action in the Northern Territory

Extract from Walley and Trindall (1994: 60–61)

Priority was given to short-term strategies that could be put in place almost immediately. These strategies were dependent on support from the Liquor Commission of the Northern Territory. Strategies included.

• limitations on ‘take-aways’

• having only one liquor outlet

• a reduction in trading hours, e.g. no take-away on Sundays

• not allowing children in the public bar

• refusing to sell liquor to those considered intoxicated.

The Gurungu Council requested that the Liquor Commissioner ratify these areas of concern. The Commissioner responded by attending a community meeting to discuss these concerns and to explain the function of the Liquor Commission.

Although community members said they supported these strategies, they did not attend the meeting because of fear of possible repercussions. Therefore, ratification of these strategies did not occur.

As a result, Gurungu Council requested that the Health Promotion Team from Tennant Creek conduct a survey to determine community support of these strategies.

The purpose, process and methodology for the survey and how the results would be used were decided after a group discussion involving the Health Promotion Team and Gurungu Council representatives. Although the community identified five priority areas, it was decided that the survey should focus on three basic issues:

• the limits on take-away alcohol

• children being allowed in the public bar

• whether take-away on Sundays should cease.

As Elliot is only a small town, two members of the Health Promotion Team were able to conduct the survey. They walked around the community, explaining to people what the survey was about. A simple ballot-type paper was used and community members marked appropriate boxes. This was considered to be the simplest method to collect the data. Analysis of the data was undertaken by people elected by the community and included members from all sections of the community.

Participation in the survey was by choice, but it did cover a very broad section of the community and included known drinkers as well as non-drinkers. According to the electoral roll, 188 out of a possible 287 adults (65%) participated in the survey. The results are shown in Table 3.1.

Table 3.1 Responses to survey

After the survey data was analysed, another meeting with the Liquor Commissioner was arranged to report the results and discuss the appropriate strategies. With community support, the three strategies were ratified and are now formally in place and apply to all, including people passing through town.

Conclusion

The people of Elliott have set a precedent in the Northern Territory by implementing these strategies, and they are proud of the way they confronted the alcohol issue.

The community members pursued something they believed in and achieved the outcome they desired. The confidence they have gained through this process will place them in a strong position to further address alcohol and other drug issues in the future.

Strengthening community action is dependent on community members identifying the issues and implementing appropriate strategies to achieve their desired outcomes.

In some instances, the community itself may not be the most appropriate level at which to try to bring about change. Brady, in an article published in 1995, criticised prevention programs based on health promotion and the public health model for focusing on entire populations and paying insufficient attention to what she called ‘the routines of everyday settings and activities’ in communities (Brady 1995c). These informal social contexts, she argued, influence behaviours no less than individuals’ decision-making. While they may facilitate heavy drinking or other drug use, they also provide mechanisms for controlling alcohol and other drug use. Initiatives that enhance the capacity for informal social controls in everyday settings, she argued, were more likely to be effective than those focusing on individual drinkers or the community as a whole. While acknowledging that the normalisation of heavy drinking in some communities made it difficult to prevent young people from being drawn into the drinking culture, she argued that communities also harbour ‘sources of resilience’ (Brady 1995c: 19). In the extract below, she identifies some examples of local initiatives.

Box 3.4 The Importance of Informal Social Contexts

Extract from Brady (1995c: 19–20)

Many of these [sources of resilience] are manifest in small grassroots projects, although some have governmental support (such as night patrols). We have to find ways in which governments can be encouraged to support non-government agencies and groups to address these problems; to improve the communication networks between the two; to provide better and faster sources of funding to those who can best use them; and, while encouraging monitoring, evaluation and competence, to give local organisations the freedom to act. Issues of sharing the best information available from a variety of sources, and giving the best possible advice, are significant. Research can have a role here, because actually involving people in research in their own communities acts to motivate people, as can the feedback of information. But research needs to be applied: ‘no research without service’ is a good motto.

Some of the best prevention initiatives in Australia for indigenous people include:

• The widescale use of indigenous media and other organisations for prevention messages aimed at young people: rock songs, rock concerts, alcohol-free discos, cartoons, radio and TV advertisements and ‘soap operas’. These have more promise than handbooks and other written prevention material;

• Locally run drop-in centres which include access to counselling, birth control and health advice for teenagers;

• Community-based ‘night patrols’working in close collaboration with police, as a means of defusing trouble and preventing alcohol importation;

• Community-wide lobbying and presentations to licensing authorities in order to limit supplies of alcohol;

• 'Mentor’ programs for marginalised children such as ‘Big Sister, Little Sister’, where an older Aboriginal person makes a special friend of a young one to help them along;

• The use of wilderness and culture camps for young people as a means of strengthening the security of an identity as Aboriginal. Finding alternatives to substance abuse;

• Involving parents in all programs for young people so as not to further dispossess those adults of their roles;

• The development of counselling techniques such as ‘narrative therapy’ models which let Aboriginal people tell their own stories from the past, and help them to understand the nature of their negative stories of themselves and to re-work those accounts.

3.3 Secondary Prevention/Early Intervention

Early interventions, also called secondary prevention, focus on people who have begun to engage in harmful alcohol use or are considered at risk of doing so, but who have not reached a stage of requiring intensive treatment or rehabilitation. The settings best suited to early interventions are hospitals and—even more so—primary healthcare centres, where signs of harmful effects of drinking among patients are most likely to present healthcare providers with a ‘teachable moment’ (Anderson 1996). The potential value of early intervention was first highlighted by a WHO expert committee in the early 1980s (Saunders 1995). In Australia, the National Campaign Against Drug Abuse (NCADA), which commenced in 1985 and became the forerunner of the National Drug Strategy, included a commitment to developing early intervention programs as part of a range of evidence-based prevention and treatment strategies for licit and illicit drugs (Dillon 1995). However, as Brady observed in a paper published in 1995, emphasis on early intervention did not immediately find its way into Aboriginal primary healthcare settings, for several reasons including remoteness and the immediate demands generated by the presence of serious health problems in these settings (Brady 1995a).

Notwithstanding these barriers, the case for supporting alcohol interventions in Aboriginal primary healthcare settings remains compelling, in part because Aboriginal people with substance misuse problems are more likely to seek out treatment in these settings than to access specialist alcohol and other drug services (Gray et al. 2004; Loxley et al. 2004; Shakeshaft et al. 2010). For example, a supplementary survey conducted as part of the 1994 National Drug Strategy Household Survey found that, among urban Aboriginal and Torres Strait Islander people who reported seeking help in connection with their alcohol or other drug use, 67% had turned to a primary healthcare setting compared with 15% who used a rehabilitation centre (National Drug Strategy 1994). Medical practitioners can also influence drinkers who subsequently stop drinking alcohol without the assistance of residential treatment, counselling or other programs. Brady (1993, 1995b) interviewed 37 people who had given up without formal intervention and been abstinent for at least 12 months. The most commonly advanced reasons for stopping drinking were a serious medical condition and/or a doctor’s warning (17 cases), followed by family relationship reasons (9), accident trauma (4) and adoption of Christianity (3 cases).

A number of attempts and initiatives have been launched with a view to embedding screening and early intervention for problematic alcohol use into clinical practice in Aboriginal primary healthcare settings. In 1999, the Commonwealth Department of Health and Aged Care published National Recommendations for the Clinical Management of Alcohol-Related Problems in Indigenous Primary Care Settings (Hunter et al. 1999). The authors of the recommendations argued that the potential for health practitioners in primary healthcare settings to intervene opportunistically in alcohol and other drug problems being experienced by Aboriginal people was ‘largely untapped’ (Hunter et al. 1999: 8). They identified five major strengths that practitioners brought to such interventions. The first was that health practitioners, unlike many other people, were expected by Aboriginal patients to give advice about health matters. In a study based on interviews with Aboriginal people who had given up heavy drinking of their own accord, Brady (1993, 1995b) found that patients trusted doctors with whom they interacted, and believed that their doctors had acted appropriately in warning them about the dangers of continuing alcohol misuse. The second strength was that the advice offered by health practitioners was personalised rather than general. For Aboriginal and non-Aboriginal people alike, the authors argued, advice linked to a personal health problem had far more persuasive power than general information about the dangers posed by alcohol to the body. Further, as they noted: “Sensitively delivered personal information of this kind also helps to diminish the possibility that a patient will interpret well-meaning advice as personal criticism” (Hunter et al. 1999: 9).

The third strength was that health practitioners, more than others, were understood to have a detailed understanding of the internal organs of the body—an attribute that enhanced the credibility of their advice. The fourth strength was that medical advice to stop drinking could be and was used by some Aboriginal people as an excuse to legitimise their changed behaviour with respect to their kin and friends. As the authors noted, drinkers experienced strong social pressures to take part in collective drinking sessions, and attempts to extricate oneself from the drinking group threatened to jeapardise valued relationships. In these circumstances, citing medical advice—especially if backed up with ‘proof’ in the form of test results—provided an external legitimation for an otherwise difficult action.

Finally, the authors noted, consultations with health professionals were conducted in private. While some treatment programs utilised AA meetings and other forms of public disclosure, not everyone liked to air their alcohol-related problems in front of others (Hunter et al. 1999: 8–9).

3.3.1 Screening for Risky Alcohol Use

Early intervention typically involves two steps: screening for problematic alcohol use, and a brief interview with patients identified through screening as being at risk. Several validated questionnaire-type screening instruments exist; however, many of these, such as the Michigan Alcohol Screening Test (MAST) and the CAGE² questionnaire are designed to identify dependent drinkers rather than those at risk of harmful drinking, while others, such as the Indigenous Risk Impact Screen (IRIS), which was developed as a screening instrument for substance misuse and mental health problems among Indigenous Australians, are considered to be too long to embed in general clinical interviews or routine health checks (Islam et al. 2018).

The most widely used screening instruments are derived from the Alcohol Use Disorders Identification Test (AUDIT), a 10-item instrument developed through a six-country collaborative project in the early 1990s (Saunders et al. 1993). The questions in the original full AUDIT are set out below in Box 3.5.

Box 3.5 The Alcohol Use Disorders Identification Test: Self-report Version

From Babor et al. (2001: 31)

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest.

Place an X in one box that best describes your answer to each question.

Questions	0	1	2	3	4
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2–4 times a month	2–3 times a week	4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
3. How often do you have six or more drinks on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or someone else been injured because of your drinking?	No		Yes, but not in the last year		Yes, during the last year
10. Has a relative, friend, doctor or other healthcare worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the last year		Yes, during the last year

The first three questions in AUDIT are designed to identify levels and patterns of consumption; Questions 4–6 focus on indicators of alcohol dependence, and Questions 7–10 address alcohol-related harms. In Australia, some versions of AUDIT replace ‘drinks’ in Questions 2 and/or 3 with ‘standard drinks’—a modification that, as we show below, has posed difficulties for Aboriginal applications. Scores are aggregated. A score of less than 8 indicates low-risk drinking; a score of 8–15 indicates a medium level of alcohol problems, while a score of 16 and above points to a high level (Babor et al. 2001).

In June 2017, the Australian Government introduced a requirement that all Aboriginal Community Controlled Health Services (ACCHSs) in receipt of Australian Government funding must henceforth screen patients for alcohol use, using the first three questions in AUDIT. The shortened version, which focuses on alcohol consumption, is known as AUDIT-C (Islam et al. 2018). Around the same time, Islam et al. reviewed studies that reported on the validity, acceptability and feasibility of alcohol screening tools among Aboriginal Australians (Islam et al. 2018). They found that shortened forms of AUDIT—including AUDIT-C and also including a version consisting only of Question 3 (i.e. the one on binge drinking)—appeared to be suitable and valid for Aboriginal primary healthcare settings, provided that they were delivered in appropriate local languages (Islam et al. 2018). They noted, however, that training may be needed to encourage the implementation of screening. They also identified two continuing barriers to screening. The first was the episodic pattern of drinking by some Aboriginal people, particularly those living in remote areas, which might consist of bouts of heavy drinking followed by long periods of abstinence. What was a ‘typical’ frequency of drinking under these conditions? Second, the need to convert amounts consumed—such as one individual’s share of a cask of wine consumed by a group—to ‘standard drinks’ of alcohol sometimes presented difficulties.

3.3.2 Brief Interventions

Brief interventions typically include some or all of the following:

• Simple advice about drinking safely;

• More personalised advice based on a presenting problem or screening result;

• Referral to a specialist alcohol or other service;

• Initiating a brief motivational interview (described below); and/or

• Discussing relevant, practical ways to reduce or cease drinking alcohol (Hunter et al. 1999: 25).

The value of brief interventions to reduce harmful alcohol use derives from evidence that a discussion of as little as five minutes, delivered at an appropriate time in a primary healthcare setting by a health practitioner, can lead to reductions in the amount and frequency of drinking on the part of at-risk drinkers (Anderson et al. 2017). A systematic review of 69 controlled trials of brief interventions for alcohol use found that the amount of alcohol consumed each week one year after the intervention was reported in 34 trials, involving a combined total of 15,197 participants (Kaner et al. 2018). People who received the intervention drank less than the control group participants. Anderson et al. (2017) summarise the evidence in the extract in Box 3.6.

Box 3.6 Brief Advice in Primary Health Care

Extract from Anderson et al. (2017: 3)

Brief advice delivered in primary health care is commonly 5–10 min in duration and often based on the ‘FRAMES principles’ and the ‘Five As’ (Hester and Miller 1995). FRAMES is an acronym summarising the key components of brief advice: feedback (on the client’s risk of having alcohol problems); responsibility (change is the client’s responsibility); advice (provision of clear advice when requested); menu (what are the options for change?); empathy (an approach that is warm, reflective and understanding); and self-efficacy (optimism about the behaviour change). The five As are (1) assess alcohol consumption with a brief screening tool, followed by clinical assessment as needed; (2) advise patients to reduce alcohol consumption to lower levels; (3) agree on individual goals for reducing alcohol use or abstinence (if indicated); (4) assist patients in acquiring the motivations, self-help skills or support needed for behaviour change; and, (5) arrange follow-up support and repeated counselling, including the referral of dependent drinkers to specialty treatment.

A series of systematic reviews over 15 years, covering a total of 56 unique primary healthcare-based randomised controlled trials, has consistently found that, up to 12-months follow-up, commonly the longest period studied, brief advice is effective in reducing heavy drinking, leading to lower average alcohol consumption, a reduction in alcohol-related problems, and reduced healthcare utilisation and mortality outcomes (O'Donnell et al. 2014).

Delivery by a range of practitioners has beneficial effects, and there is little evidence to suggest that any one profession of provider performs better or worse than another (Platt et al. 2016). Further, there is little evidence to suggest that the content of the advice is important for the outcome, or that longer or more sophisticated advice leads to better outcomes than shorter or less sophisticated advice (Platt et al. 2016). So, it seems that the length, complexity and sophistication of the advice are less important than the actual contact between provider and patient. Further, two systematic reviews that studied outcomes amongst control groups in studies of brief advice (Bernstein et al. 2010; McCambridge and Kypri 2011) found consistent evidence of reduced drinking. Thus, what is termed screening or assessment reactivity may be additional elements of the positive effects of brief advice.

Most of the evidence for brief advice has focused on adults aged between 18 and 65 years, rather than young or older people (O'Donnell et al. 2014). Thus, it is not possible to conclude that brief advice works just as well for the young and elderly as it does for adults.

Another approach widely used in early interventions for risky alcohol use is Motivational Interviewing (MI)—a form of counselling originally developed in the US by two clinical psychologists—William R Miller and Stephen Rollnick—as ‘a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence’ (Rollnick and Miller 1995: 326). ‘Ambivalence’ implies the client’s awareness of both benefits and costs of persisting with, or changing, a particular behaviour such as heavy drinking. MI works by identifying and enhancing clients’ own motivations to change their behaviour, rather than imparting information, advice or persuasion (Berman et al. 2020; Rollnick and Miller 1995). It proceeds through four steps: the first, termed engagement, involves building an open, trusting, client-practitioner relationship; the second, focus, involves identifying a specific behaviour as the target for the intervention; the third, called evoking, seeks to build the client’s motivation to change her or his target behaviour in a healthier direction; and the fourth—planning—identifies the steps to be taken to bring about the change (Berman et al. 2020). From the outset, Miller and Rollnick have insisted that MI involves more than an intervention technique. What they call ‘the spirit of motivational interviewing’, manifested in the relationship between the client and practitioner, is equally important (Rollnick and Miller 1995: 326). This should be one of partnership, rather than one of an expert and client.

Does this make MI particularly suitable for or adaptable to Aboriginal settings? Internationally, few attempts have been made to adapt MI to minority cultural contexts; however, Oh and Lee cite several studies that suggest MI might be both effective and acceptable among American Indian and Alaskan Native American populations (Oh and Lee 2016).

Strictly speaking, brief interventions based on advice-giving do not meet the criteria for MI as defined by its founders. However, the MI approach is often incorporated into brief interventions, as shown, for example, in the outline of a ‘brief motivational interview’ in the National Recommendations for the Clinical Management of Alcohol-Related Problems in Indigenous Primary Care Settings reproduced below in Box 3.7.

Box 3.7 The Steps in a Brief Motivational Interview Can Include the Following

Extract from Hunter et al. (1999: 82)

• 1. Take a drinking history and/or administer a screening test such as the AUDIT.

• 2. Discuss the pros and cons of the patient's drinking with him or her by asking, “What are the good things about drinking, the things you enjoy?” and provide prompts where necessary.

• 3. Discuss the ‘not-so-good things about drinking’ or ask, “What are your worries about drinking?”

• 4. Discuss any health problems the patient has which could be alcohol-related.

• 5. Make the link for the patient between these problems and their alcohol use. Discuss the general health effects of drinking too much. Discuss the problems associated with binge drinking (health/trauma, etc.).

• 6. Explain the standard drinks and the recommended levels for men and women.

• 7. If you have estimated the patient's consumption, show or explain how this fits in with levels in the overall population.

• 8. Ask the patient, “How do you feel about your drinking?” Based on the reply, you should assess whether the patient is ready, unsure or not ready to make a change.

• 9. If the patient is not ready, let him or her know that they can come back and talk any time.

• 10. If the patient is unsure, you could offer to talk again, offer a blood test or explore in more detail the good and not-so-good things about drinking.

• 11. If the patient is ready, you could offer some ideas on strategies for either cutting down or abstaining. Give out any pamphlet available (preferably those written for an Indigenous audience.) Offer to talk again.

One approach that follows MI in working with clients’ own goals and priorities rather than externally imposed goals is Motivational Care Planning as described by Nagel and Thompson (2008). The approach is designed to identify and treat mental illness in Aboriginal communities by combining brief interventions, motivational interviewing, problem-solving therapy and a structured process of goal setting. A study conducted by the Australian Integrated Mental Health Initiative (AIMhi) in two remote Aboriginal communities in the Northern Territory recruited 49 patients with mental illness (most of whom were assessed as being psychologically dependent on alcohol and/or marijuana) and 37 carers. The study reported high levels of retention and goal achievement as assessed by both participants themselves and by clinicians (Nagel and Thompson 2008). Since then, the project and its findings have been used to develop a range of publicly available resources for both primary care and specialist health practitioners. These include a brief assessment form for alcohol and other drug interventions and the AIMhi Stay Strong App, which offers a structured wellbeing intervention for use by therapists in delivering an evidence-based, culturally appropriate intervention to Aboriginal clients. The assessment form is reproduced below in Boxes 3.8a, and 3.8b with permission from the Remote Alcohol and Other Drugs Workforce Program, NT Health, and the Stay Strong Mental Health and Wellbeing Project, Menzies School of Health Research. The resources are available from the Menzies School of Health Research website.³

Box 3.8a Alcohol and Other Drugs Brief Assessment Form, Page 1

Source Menzies School of Health Research, Stay Strong Mental Health and Wellbeing Project.

Box 3.8b Alcohol and Other Drugs Brief Assessment Form, Page 2

Source Menzies School of Health Research, Stay Strong Mental Health and Wellbeing Project.

Another research team composed largely of Aboriginal and Torres Strait Islander researchers has been engaged in developing and testing a tablet-based Grog Survey App for monitoring alcohol consumption and feeding results back, both to individual participants as part of a brief intervention, and to communities as part of community-level health promotion activities (Lee et al. 2018). The project has been funded by a 5-year Australian National Health and Medical Research Council (NHMRC) grant. Indigenous cultural experts and clinical experts worked together to produce an app that would incorporate a culturally appropriate questioning style, gender-specific voices and images, widely recognised events such as AFL/NRL grand finals to ‘anchor’ time points, and options for estimating consumption as an individual’s share in a group drinking session rather than the individual’s own consumption (Lee et al. 2019a, 2019b; Lee et al. 2018). For estimating consumption, participants are shown a range of types of alcohol and beverage containers, from which the app itself estimates Standard Drinks consumed.

In order to gauge the acceptability and feasibility of the app, a pilot version was administered in four communities in South Australia and Queensland between August 2016 and May 2017 (Lee et al. 2019c). Two of the communities were remote, one regional and one urban. A total of 246 people took part in the survey, recruited by five Indigenous field research assistants, whose experience and views on the survey were also collated and analysed. Most participants found the survey app easy to complete, in some cases reporting that completing the survey in itself promoted them to reflect on their own drinking.

3.3.3 Implementing Early Interventions in Aboriginal Settings: Barriers and Challenges

Despite the strong evidence that early interventions in primary healthcare settings are effective in reducing and preventing alcohol misuse, international studies show that implementation of early and brief interventions continues to be hampered by barriers (Anderson et al. 2017; Nilsen 2010; Roche and Freeman 2004). These include reluctance by health practitioners to offer brief interventions because they feel ill-equipped to do so or are sceptical about their value, and systemic factors such as competing demands on practitioners’ time and lack of financial incentives to practice brief interventions. Roche and Freeman (2004) noted that many GPs were unwilling to offer brief interventions, preferring instead to refer patients to someone else (Roche and Freeman 2004). In light of GPs’ reluctance, they suggested turning to practice nurses located in GP clinics, but more recent studies suggest that little progress has occurred along this path (Mitchell et al. 2018).

Aboriginal primary healthcare services in Australia have not been immune from these obstacles to the implementation and may face additional challenges. In 1997, a team of researchers collaborated with an urban Aboriginal Medical Service in Adelaide to conduct a randomised control trial (RCT) of a brief intervention for hazardous alcohol use (Sibthorpe et al. 2002). Under the original project design, Aboriginal Health Workers were to screen patients using the 10-item AUDIT, then refer consenting patients classified as drinking at hazardous or harmful levels to GPs for a brief intervention or to a control group. Implementation proved difficult, in part because health workers found extended direct questioning of patients about alcohol use, as required by AUDIT, to be culturally inappropriate, and in part because of difficulties satisfying the methodological requirements of an RCT research project as well as an intervention (Brady et al. 2002; Sibthorpe et al. 2002). In response to these difficulties, the trial was abandoned and replaced by a ‘demonstration project’ designed to test the acceptability and cultural appropriateness of the intervention, and the impact of training on service providers’ willingness and capacity to provide the interventions. The AUDIT screening was replaced by two questions, and over time, health workers became more comfortable in asking them. However, although the six GPs who took part in the demonstration project were supportive of brief intervention, the researchers concluded that time constraints and the severity and complexity of many patients’ presenting problems continued to create challenges to routine interventions (Brady et al. 2002).

Since then, several attempts have been made to adapt both the content and delivery of screening to make it more congenial to Aboriginal primary healthcare settings. Conigrave et al. conducted a pilot study involving screening and early intervention with a series of eight groups of Aboriginal participants in south-west Sydney (Conigrave et al. 2012). They used the full 10-item AUDIT but modified the wording of some questions to make them easier to understand. For example, “have you had a feeling of guilt or remorse after drinking” (Question 7) became “have you felt bad about your drinking”. They reported that participants were interested in their AUDIT scores, but none of the 58 participants in the study took up the opportunity offered for one-to-one counselling (Conigrave et al. 2012).

Clifford et al. have reported on a number of initiatives designed to increase the uptake of screening and brief interventions (SBIs) in Aboriginal Community Controlled Health Services (Clifford et al. 2011; Clifford and Shakeshaft 2011; Clifford et al. 2012, 2013). A study based on semi-structured group interviews with 37 staff members of five ACCHOs in New South Wales (65% of them Aboriginal) identified four factors that shaped their willingness or otherwise to practice SBIs. These are outlined in Box 3.9.

Box 3.9 Key Factors Influencing Alcohol Screening and Brief Interventions (SBI)

Extract from Clifford et al. (2012: 16–17).

Four factors influencing healthcare practitioners’ practices in alcohol SBI were prominent: outcome expectancy; role congruence; utilisation of clinical systems and processes; and perceptions of alcohol referral options.

Outcome expectancy. Healthcare practitioners generally had expectations that routine alcohol SBI would lead to a negative outcome for themselves or their patients.

First, routine alcohol screening could lead to more problems than it could solve. GPs in particular expressed concern that asking a patient about their alcohol use would identify multiple and complex problems they had neither the time nor expertise to treat.

One of the reasons I don’t really ask whether there is um, alcohol-related problems, like mental health problems and things, is so what . . . the patient’s been drinking in a harmful way, so what? I mean, what can I do for him in my surgery? (GP rural ACCHS 2)

Second, nurses and AHWs expressed concerns that alcohol screening could offend patients and damage rapport.

If someone comes in for a cough and we automatically start asking them about drugs and alcohol then they’re going [to] turn around and go back out the door. You’ve sort of got to build up that rapport with them first before you know what you can and can’t get out of them. (RN metro ACCHS)

...

Third, all types of healthcare practitioners expressed scepticism as to the effectiveness of alcohol BI: at-risk drinkers were described as attentive but non-responsive to advice to reduce alcohol consumption. General perceptions were that risky drinkers willing to change would change, while those resistant to change would not.

...

Role congruence. No healthcare practitioner rejected outright that they had a role in alcohol SBI. However, healthcare practitioners’ perceptions of how well alcohol SBI fitted within their role appeared to influence their willingness to deliver it. For example, Indigenous healthcare practitioners with a defined role in drug and alcohol (D&A) prevention (e.g. AOD worker) or engaged in a structured process for its delivery (e.g. delivering health assessments) reported greater involvement in alcohol SBI than those with less defined and structured D&A roles.

...

General perceptions among RNs were that they had a key role in alcohol SBI as part of health assessment processes, but that it was the GP’s role to deliver it opportunistically. GPs, however, said they were usually too busy treating the patient’s presenting health condition to ask them about their drinking.

Utilisation of clinical systems and processes. Healthcare practitioners’ utilisation of clinical systems and processes to deliver alcohol SBI appeared less than optimal.

...

Alcohol information in electronic and paper records was generally poorly linked and inconsistent, primarily because of different methods of recording by healthcare practitioners. Indigenous-specific alcohol SBI guidelines and resources, although available in all ACCHSs, were referred to infrequently.

Alcohol referral options. A lack of appropriate alcohol referral options was identified as a prominent barrier to alcohol SBI in all group interviews. Specifically, healthcare practitioners reported a lack of: adequate follow-up support for patients post-alcohol rehabilitation; appropriate alcohol detoxification services; AOD and counselling staff; and funding to transport patients to remote rehabilitation and detoxification units. Without accessible and appropriate alcohol detoxification and rehabilitation services for patient treatment and referral, healthcare practitioners perceived alcohol SBI to be of little benefit to their patients.

. . . it’s wonderful to have all the latest and greatest resources, up to date information, but unless you have referral pathways that you can refer your patients onto, all the paperwork in the world’s not going to do you any good. (RN rural ACCHS 2).

These obstacles are clearly formidable, though not—at least in principle—unsurmountable. In another paper, the same researchers reported on the results of an intervention designed to increase the use of screening and brief interventions in four NSW Aboriginal community-controlled health services by two supportive measures: (1) training, in the form of a three-hour workshop and (2) follow-up outreach support in the form of three to five one-day visits to the health centres by AOD clinicians and/or researchers (Clifford et al. 2013). Outcomes were assessed by analysing changes in the proportions of eligible clients who received alcohol screening and/or BI as recorded in the computer-based client record system used by the services. The results were mixed: all the ACCHSs recorded modest but statistically significant increases in proportions of eligible clients receiving alcohol screening (e.g. from 1.2% to 3.9% for receiving a complete alcohol screen). The proportion of at-risk clients receiving a BI also rose from 25.7% to 47.7%; however, this was almost entirely accounted for by an increase in one ACCHS; levels in two others actually dropped (Clifford et al. 2013).

More recently, Dzidowska et al. (2021) conducted a clustered, randomised trial involving 22 Aboriginal community-controlled health services across Australia, half of which were assigned a multi-faceted support program over two years, with the other half receiving the same support program after the two-year study period. The support program comprised eight components, including a two-day workshop in screening and BI, nomination of service champions, regular feedback of results, regular teleconferences with service champions, support in modifying practice software when needed and other resources. Outcome measures included the numbers of clients who received screening, BIs, or other treatment for unhealthy alcohol use, including counselling and provision of pharmacotherapies such as naltrexone or acamprosate (Dzidowska et al. 2021).The intervention resulted in a statistically significant increase in clients receiving screening, but the results with respect to BIs and other treatment were inconclusive.

Despite these efforts, implementation of BIs in Aboriginal primary health settings continue to encounter challenges. In a recent systematic review of community-based alcohol and other drug programs for Aboriginal and Torres Strait Islander peoples, the authors concluded that “brief intervention for alcohol was generally not well received by clients and health workers”—largely for reasons canvassed above (Krakouer et al. 2022: 1424).

3.4 Conclusions

We began this chapter by noting a long-standing dearth of evidence-based secondary or early interventions targeting those who were at risk of harmful alcohol use or already engaging in the practice. We also noted that the evidence-base underpinning primary prevention programs—that is, programs designed to educate people about alcohol and other drug use, raise awareness of associated harms, build resilience and/or enhance the capacity of communities to prevent alcohol and other drug problems—was sparse. Historically, many such programs have been poorly evaluated or not evaluated at all. Many of those that have been evaluated have failed to demonstrate significant outcomes.

At the same time, examination of case studies of successful prevention programs points to a number of components that appear to be common to all of them. These include community leadership; strategic partnerships between community organisations and both internal and external agencies; limited, clearly defined and widely supported objectives; collation of data documenting both baseline and post-intervention indicators of the problem being addressed; and a pathway to achieving selected objectives. Accounts of two successful primary prevention initiatives are presented, one in the Fitzroy Valley region of WA, the other in the small town of Elliott in the Northern Territory. We also reproduce eight guiding principles for community-based prevention (Box 3.2) originally put forward for American Indian communities in the US, in the belief that these are no less relevant to Australian Indigenous communities.

We also cite Brady’s observation that communities may not be the most appropriate level at which to initiate prevention programs. Communities are not always able or inclined to act collectively to address an issue as contentious as the prevention of alcohol-related harm. (Non-Aboriginal communities rarely do so.) Brady suggests that, rather than focusing on entire local populations, it may be more productive to concentrate on the informal social settings in which drinking takes place and through which controls over harmful drinking are most likely to be exercised effectively. Preventive interventions from this perspective would aim to strengthen the capacity for informal social controls to be exercised in everyday settings.

Secondary prevention or, as it is more widely known, early intervention aims to raise awareness and stimulate change among people who are at risk of harmful alcohol use or have already begun harmful use without having reached a stage of requiring more intensive treatment. Early intervention typically involves opportunistic screening for risky drinking, usually conducted in hospital or primary healthcare settings, and one or more brief interventions conducted by a health practitioner. There is strong evidence that screening and brief interventions (SBI) delivered in primary healthcare settings are effective in helping to prevent alcohol-related harms. However, evidence also indicates that, in both Aboriginal and other settings, implementation of SBI faces several barriers, including competing demands on health practitioners’ time, reluctance by health providers to question patients about their drinking, and a perceived lack of referral options for patients requiring follow-up treatment.

The most widely used screening instrument in Aboriginal primary healthcare settings is the 10-item Alcohol Use Disorders Identification Test (AUDIT), often in shortened versions with wording modified to make it more culturally appropriate. Since June 2017, the Commonwealth Government has required all Aboriginal Community-Controlled Health Services in receipt of government funding to screen patients using a three-question version of AUDIT known as AUDIT-C.

A number of research and other initiatives have explored options for increasing the uptake of SBI in Aboriginal settings. These include trialling support for Aboriginal primary healthcare practitioners in delivering SBIs; combining BIs with motivational interviews, problem solving and structured goal setting in a program known as Motivational Care Planning for mental health disorders, and developing a tablet-based app for monitoring alcohol consumption, identifying risky patterns and providing brief intervention.