Health Promotion Advocates Research Articles

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BackgroundAlcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.MethodsWe are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost–benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.ConclusionsProject ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.Clinical Trial Registration: Clinicaltrials.gov identifier: NCT05338151.

Understanding perceived availability and importance of tobacco control interventions to inform European adoption of a UK economic model: a cross-sectional study

BackgroundThe evidence on the extent to which stakeholders in different European countries agree with availability and importance of tobacco-control interventions is limited. This study assessed and compared stakeholders’ views from five European countries and compared the perceived ranking of interventions with evidence-based ranking using cost-effectiveness data.MethodsAn interview survey (face-to-face, by phone or Skype) was conducted between April and July 2014 with five categories of stakeholders - decision makers, service purchasers, service providers, evidence generators and health promotion advocates - from Germany, Hungary, the Netherlands, Spain, and the United Kingdom. A list of potential stakeholders drawn from the research team’s contacts and snowballing served as the sampling frame. An email invitation was sent to all stakeholders in this list and recruitment was based on positive replies. Respondents were asked to rate availability and importance of 30 tobacco control interventions. Kappa coefficients assessed agreement of stakeholders’ views. A mean importance score for each intervention was used to rank the interventions. This ranking was compared with the ranking based on cost-effectiveness data from a published review.ResultsNinety-three stakeholders (55.7% response rate) completed the survey: 18.3% were from Germany, 17.2% from Hungary, 30.1% from the Netherlands, 19.4% from Spain, and 15.1% from the UK. Of those, 31.2% were decision makers, 26.9% evidence generators, 19.4% service providers, 15.1% health-promotion advocates, and 7.5% purchasers of services/pharmaceutical products. Smoking restrictions in public areas were rated as the most important intervention (mean score = 1.89). The agreement on availability of interventions between the stakeholders was very low (kappa = 0.098; 95% CI = [0.085, 0.111] but the agreement on the importance of the interventions was fair (kappa = 0.239; 95% CI = [0.208, 0.253]). A correlation was found between availability and importance rankings for stage-based interventions. The importance ranking was not statistically concordant with the ranking based on published cost-effectiveness data (Kendall rank correlation coefficient = 0.40; p-value = 0.11; 95% CI = [− 0.09, 0.89]).ConclusionsThe intrinsic differences in stakeholder views must be addressed while transferring economic evidence Europe-wide. Strong engagement with stakeholders, focussing on better communication, has a potential to mitigate this challenge.

Reaching Adolescents for Prevention: The Role of Pediatric Emergency Department Health Promotion Advocates.

Almost 200,000 adolescents visit US emergency departments (EDs) yearly for conditions involving underage drinking but receive no follow-up referral. Other health risk behaviors resulting in sexually transmitted infections, car crashes, and assault-related injury are common among adolescents. A pediatric ED (PED) visit presents an opportunity to discuss and promote prevention. We report here on implementation of a new PED navigator/extender role, the Health Promotion Advocate (HPA). Health Promotion Advocates surveyed patients to identify health risks, stresses, and needs. A positive screen triggered a brief conversation containing the following elements: permission to discuss risks/needs; exploration of context (a typical day in your life); brief feedback (information and norms); exploration of benefits and consequences of risk behaviors; assessment of readiness to change; calling up assets, instilling hope; discussing challenges of change; negotiating a menu of options and prescription for change; referrals to primary care, community resources; and treatment services as indicated. During 2009-2013, HPAs screened 2149 PED patients aged 14 to 21 years and referred 834 for an array of services (eg, primary care, mental health, insurance, personal safety, human immunodeficiency virus testing, general education diploma (GED), employment, housing, and food pantries) to address reported health risks; 785 screened positive for at-risk substance use (53% female, 36% without primary care). Among them, 636 received a brief intervention; 546 were referred to specialized substance abuse treatment. Two case studies are presented to illustrate the engagement and referral process. Health Promotion Advocates working as PED team members can extend PED services beyond the scope of the presenting complaint.

Health promotion by stealth: active transportation success in Helsinki, Finland.

The promotion of active transportation (AT-utilitarian trips including walking, cycling, and public transit use), represents a well-recognized opportunity for increasing physical activity. This study examines the strong AT success achieved in Helsinki, Finland (in 2013, the share of daily trips in Helsinki completed by AT was 77 per cent) from a political perspective. Helsinki represents a noteworthy example of AT success given important challenges including the region's relatively low population density, its difficult winter climate, and Finland's high driving rate. This research applied the advocacy coalition framework (ACF), a formal policy process theory from political science. Interviews were conducted with 23 AT experts in Helsinki. Document review was employed as a secondary method. Overall, the research indicates that Helsinki's success may be attributed to the long-term dominance of municipal transportation policy by a pro-AT advocacy coalition. When viewed from the perspective of health promotion, it is striking that this success is not strongly attributable to health considerations or efforts from health-related fields. Rather, the data suggest that the coalition, comprised of members from a variety of non-health fields, was most strongly motivated by a desire to protect a high degree of livability. Importantly, a number of significant historical events and background-level factors greatly facilitated success. Overall, these results suggest that health promotion advocates may have very useful allies in non-health sectors, and that awareness of the importance of political factors is likely to contribute to stronger health promotion efforts. Finally, several possibilities for related and further research are suggested.

Problematizations in Health Policy

This article directs attention to the significance, for health promotion advocates, of reflecting on how “problems” are constituted, or brought into existence, as particular sorts of problems, within policies and policy proposals. To this end, it introduces a poststructural analytic strategy called “What’s the Problem Represented to be?” (WPR approach), and contrasts this perspective to the ways in which “problems” are commonly conceptualized in health policy analyses (e.g., “a problem stream,” “wicked problems”). Such a perspective offers a significant rethinking of the conventional emphasis on agenda setting and policy-making processes in considering the meaning of success or failure in health policy initiatives. The starting point is a close analysis of items that are “successful,” in the sense that they make the political agenda, to see how representations of “problems” within selected policies limit what is talked about as possible or desirable, or as impossible and undesirable. This form of analysis thus enables critical reflections on the substantive content of policy initiatives in health policy. The article takes a step back from policy process theories, frameworks, and models to offer reflections at the level of paradigms. Highlighting potential dangers and limitations in positivism, interpretivism, and critical realism, it uses international, Australian, and South Australian examples in health policy to explore what poststructural policy analysis contributes to understanding the broad political influences shaping contemporary modes of rule.

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores.

A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30. Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking. At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition. At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not. ClinicalTrials.gov. NCT02056535.

Health wash in Helsinki

In June 2013 the 8th Global Conference on Health Promotion on Health in All Policies was held in Helsinki. The fourth plenary session featured speakers from the World Bank and World Economic Forum (WEF) and immediately reminded us of corporate ‘green wash’ whereby companies grossly exaggerate their environmental sustainability credentials to gain social credibility and consumer comfort. In Helsinki we witnessed a similar ‘health wash’, in which the private sector was portrayed as an essential and beneficent ‘partner’ in promoting health by providing its expertise and much needed resources. Jane-Llopis and Xydia-Charmanta (2013) (Director, WEF) reminded us that 44% of the world’s 100 top economies are corporations rather than countries, and argued that the private sector is flexible, innovative and more attentive to consumer convenience and satisfaction than the public sector. This portrayal of the private sector’s role in health promotion contrasted sharply with that of World Health Organization’s (WHO) Director General Dr Margaret Chan who, in her opening address, condemned the economic power and destructive health impact of large industries, including food, tobacco, soda and alcohol: ‘In the view of WHO, the formulation of health policies must be protected from distortion by commercial or vested interests’, whose tactics ‘include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt’ (Chan, 2013). This theme echoed through the following five days. The Irish Minister for Children and Youth, Frances Fitzgerald, talked of the need to make the lobbying tactics of industry transparent and to ensure that health promotion advocates have the same access to politicians as industry representatives. Ilona Kickbusch spoke of the commercial determinants of health. The twitter wall at the conference was busily rinsing off this corporate ‘health wash’ with comments about the need to deal with industry’s adverse impacts. But the big question confronting the health promotion movement is how best to control corporate interests? The answer to this requires understanding why corporations have and maintain such power. Our global economic regime is structured to meet the needs of rich countries and transnational corporations. This is done through trade agreements that make the world safe for capitalism (Chang, 2008), taxation regimes that enable corporations to pay little tax (Tax Justice Network, 2013) and investment treaties that allow foreign companies to sue governments for new public health regulations that might put a dent in their profits (Khor, 2012). The fall of the Soviet Bloc has meant an ideological domination for capitalism that crowds out ideas for alternative economic regimes in dominant discourse and rich country media. Gramsci’s (1971) hegemonic capitalism has well and truly come to pass. It is this ideological climate that makes a ‘health wash’ so easy for industry to get away with. What reasonable person would oppose a public private partnership to provide more health services or gain more funds for a children’s hospital by having Ronald MacDonald Health Promotion International, Vol. 29 No. 1 doi:10.1093/heapro/dat054 # The Author (2013). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com Advance Access published 8 August, 2013

Inactivity Physiology- Standing up for Making Sitting Less Sedentary at Work

Emergent research suggests that prolonged sitting throughout the day over long periods of time in adults is significantly associated with chronic diseases such as diabetes, heart disease, hypertension and some cancer forms. Singaporean youths and adults respectively, are not sufficiently active during schooling and at work. This pervasive exposure to prolonged sitting in youth and adulthood (e.g. more than four hours daily) expose large segments of the population to health risks and increased all-cause mortality. Some researchers describe ‘prolonged sitting’ as the new ‘smoking’ disease, because of it could be a serious threat to optimal physical and metabolic health. Interventions to fragment sitting time involve the use of standing desks or treadmill workstations but these have produced mixed results since prolonged standing could give rise to other health ailments that are associated with too much standing while expensive desk treadmills would be impractical and are beyond the reach for most people. Moreover, it is inconceivable that these could be used in work group discussions. The use of a seat cycle, to sit and cycle at the same time is an innovative approach at intervening where it makes sense, where its use is not intrusive and could be ‘assimilated’ into the work culture. The use of the seat cycle even challenges the notion and definition that prolonged sitting is sedentary. This case study briefly describes the key concepts and ingredients of an on-going pilot 3-month intervention study that examines the feasibility and utility of making sitting less sedentary at the National Institute of Education in Singapore. Results emanating from the study would provide empirical data for product innovation and development, strong opportunities for interdisciplinary collaborations among product engineers, sensor scientists, medical practitioners and health-promotion advocates at worksites.

The Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act has come under intense scrutiny about its mandate for individual health insurance purchase, yet it has received little praise in the popular press for its prevention measures. Irrespective of the Supreme Court's decision regarding the "individual mandate," it is important for public health professionals to advocate for the preservation of the prevention and wellness provisions in the current law. The article addresses the Supreme Court's hearing for the "individual mandate," the likely impact of the general election in 2012, and specific prevention components of the law that should be championed by health education and health promotion advocates.

A Preliminary Report of Knowledge Translation: Lessons From Taking Screening and Brief Intervention Techniques From the Research Setting Into Regional Systems of Care

This article describes a limited statewide dissemination of an evidence-based technology, screening, brief intervention, and referral to treatment (SBIRT), and evaluation of the effects on emergency department (ED) systems of care, utilizing the knowledge translation framework of reach, effectiveness, adoption, implementation, and maintenance (RE-AIM), using both quantitative and qualitative data sources. Screening and brief intervention (SBI) can detect high-risk and dependent alcohol and drug use in the medical setting, provide early intervention, facilitate access to specialty treatment when appropriate, and improve quality of care. Several meta-analyses demonstrate its effectiveness in primary care, and the federal government has developed a well-funded campaign to promote physician training and adoption of SBI. In the busy environment of the ED, with its competing priorities, researchers have tested a collaborative approach that relies on peer educators, with substance abuse treatment experience and broad community contact, as physician extenders. The ED-SBIRT model of care reflects clinician staff time constraints and resource limitations and is designed for the high rates of prevalence and increased acuity typical of ED patients. This report tracks services provided during dissemination of the ED-SBIRT extender model to seven EDs across a northeastern state, in urban, suburban, and rural community settings. Twelve health promotion advocates (HPAs) were hired, trained, and integrated into seven ED teams. Over an 18-month start-up period, HPAs screened 15,383 patients; of those, 4,899 were positive for high risk or dependent drinking and/or drug use. Among the positive screens, 4,035 (82%) received a brief intervention, and 57% of all positives were referred to the substance abuse treatment system and other community resources. Standardized, confidential interviews were conducted by two interviewers external to the program with 24 informants, including HPAs and their supervisors, clinicians, nurse managers, and ED directors across five sites. A detailed semistructured format was followed, and results were coded for thematic material. Barriers, challenges, and successes are described in the respondents' own words to convey their experience of this demonstration of SBIRT knowledge translation. Five of seven sites were sustained through the second year of the program, despite cutbacks in state funding. The dissemination process provided a number of important lessons for a large rollout. Successful implementation of the ED-SBIRT HPA model depends on 1) external funding for start-up; 2) local ED staff acting as champions to support the HPA role, resolve territorial issues, and promote a cultural shift in the ED treatment of drug and alcohol misuse from "treat and street" to prevention, based on a knowledge of the science of addiction; 3) sustainability planning from the beginning involving administrators, the billing and information technology departments, medical records coders, community service providers, and government agencies; and 4) creation and maintenance of a robust referral network to facilitate patient acceptance and access to substance abuse services.

School Disconnectedness: Identifying Adolescents at Risk in Ontario, Canada

There is strong theoretical and empirical support for school connectedness as an important element of healthy youth development. The primary objective of this study was to replicate previous research identifying factors differentiating youth who do not feel connected to their schools in a sample of adolescents in Ontario, Canada. A secondary objective was to extend this work by assessing whether physical activity was an additional health behavior that differentiated youth who feel connected to their schools from those who do not. Data for this study were based on questionnaires from 2243 grade 7 to grade 12 students derived from the 2001 cycle of the Ontario Student Drug Use Survey. Logistic regression analysis was used to examine associations between physical activity, other health risk factors, and school disconnectedness. The odds of feeling disconnected from their schools were substantially greater for female students who perceived their health or academic performance to be poor, engaged in no vigorous physical activity, reported 3 or more physician visits during the past year, and had low extracurricular involvement. None of the sociodemographic factors or substance use measures was significantly associated with school disconnectedness for any students. Our results highlight sex differences in how school disconnectedness is related to health-compromising behaviors such as physical inactivity. Further research is required to examine how boys and girls perceive, interpret, and internalize the school climate. Increasing school connectedness should be a consideration for academic administrators and health-promotion advocates.

Intensive Intervention Improves Primary Care Follow-up for Uninsured Emergency Department Patients

To test an intervention designed to improve primary care use and decrease emergency department (ED) utilization for uninsured patients using the ED. Using a randomized design, an intensive case-management intervention was tested with patients identified at a Level 1 urban trauma center from April 2002 through July 2002. Following assessment in the ED, six-month follow-up data were gathered from four primary care sites (two Federally Qualified Health Centers, two hospital outpatient clinics) and two area hospitals. Eligible participants were uninsured, were at least 18 years of age, and did not have a regular primary care provider. Of 281 patients approached, 273 (97.2%) agreed to participate. After 42 patients were eliminated following enrollment due to ineligibility, there were 121 intervention and 109 comparison subjects. Health Promotion Advocates (HPAs) in the ED gathered information from all study participants. On intervention shifts, HPAs assisted patients in choosing a primary care provider and faxed all information to a case worker at the selected site. Case managers attempted to contact patients and schedule appointments. On comparison shifts, patients received care as usual. Primary care contact in 60 days and subsequent ED visits in six months post-ED assessment were the main outcome measures. Intervention subjects were more likely to have a primary care contact (51.2% vs. 13.8%, p < 0.0001). There was no statistically significant difference between groups in either number of inpatient admissions or postintervention ED visits, although postintervention ED visits for the intervention group were less expensive. This project has demonstrated that it is possible to improve primary care follow-up for uninsured ED patients.

Evaluation of a Brief Intervention in an Inner-City Emergency Department

This study tests the effect of a brief intervention with emergency department (ED) patients to reduce at-risk drinking. We enrolled patients aged 18 years or older who screened positive for at-risk drinking in an urban academic ED and used alternative allocation to assign them to control or intervention status. A 20-minute, semiscripted, negotiated interview was conducted with the intervention group in English and Spanish by 3 health promotion advocates (peer educators). The Alcohol Use Identification Test (AUDIT) was administered at baseline and 3 months after enrollment. Among 1,036 patients screened for at-risk drinking, 295 with CAGE questionnaire score greater than 1 and no alcohol treatment in the past year enrolled in the study and were randomly assigned to the control arm (n=151) or the intervention arm (n=144). Follow-up was achieved with 88 patients in the intervention group and 97 patients in the control group (63% of enrollees). Among the 185 patients followed up, 64% of the intervention group versus 80% of the control group scored greater than 7 on the follow-up AUDIT (scored on a scale of 1 to 40; P<.05, odds ratio [OR] 2.35, 95% confidence interval [CI] 1.21 to 4.55). Multinomial logistic regression analysis demonstrates, after controlling for demographic characteristics and other independent variables, that assignment to intervention status decreased the odds of at-risk (moderate) drinking as defined by AUDIT scores of 7 to 18 (OR 0.42, P<.05, 95% CI 0.19 to 0.91) but did not affect patients with AUDIT scores in the 19 to 40 range. Brief motivational intervention administered by peer educators to ED patients appears to reduce moderately risky drinking and associated problems.

'Working at the margins' or 'leading from behind'?: a Canadian study of hospital-community collaboration

Collaboration between hospitals and community organisations has been promoted over the past 20 years by various levels of government, hospital associations, health promotion advocates, and others at the state/province, national and international levels as a way to improve the 'efficiency of the system', reduce duplication, enhance effectiveness and service coordination, improve continuity of care, and enhance community capacity to address complex issues. Nevertheless, and despite a growing literature on interagency collaboration, systematic documentation and empirical analysis of hospital-community collaboration (HCC) is almost completely lacking in the literature, particularly as regards collaborations that address the determinants of health beyond the hospital walls. In this paper, we describe the methodology and key findings from a research study of HCC. The Hospital Involvement in Community Action (HICA) study undertook detailed qualitative case studies (in four urban, suburban, rural and northern locations) and a telephone survey (of 139 community organisations in a large urban centre) in order to learn about the range of collaborations and working relationships that exist between hospitals and community agencies in the province of Ontario (Canada), and the factors that influenced (enabled and/or hindered) HCC. Particular attention was paid to barriers and enablers at three nested levels of context (policy, hospital and community) and, drawing primarily on the qualitative case studies, it is this aspect that is the focus of this paper. That such collaborations continue to be widespread despite a generally unfavourable policy environment and hospital institutional culture that poses significant barriers, suggests that the extent to which HCC flourishes (or exists at all) crucially depends on the presence and ongoing enthusiasm/commitment of one or more 'champions' within the hospital, and the commitment of both parties to overcome the marked cultural differences between hospital and community. We conclude with a discussion of implications for policy and practice.

Manufacturing health: Employee perspectives on problematic outcomes in a workplace health promotion initiative

Workplace health promotion (WHP) advocates promote lifestyle campaigns as an inexpensive way to reduce health care costs and improve employee teamwork while pleasing workers through corporate benevolence. This study problematizes those assumptions by examining employee reactions to the development of a health and recreation center at a car manufacturer. The research provides evidence that depending upon how they are implemented, dominant approaches to health initiatives may actually produce resentment among employees towards the company, create divisions among employees, and alienate employees with differing perspectives about health. It is argued that WHP programs initiatives may be more beneficial for employees if they respond to employee needs by inviting participation early in the planning process, attending to issues of inclusion and exclusion that develop among participants, and respecting multiple approaches to health.

Project ASSERT: An ED-Based Intervention to Increase Access to Primary Care, Preventive Services, and the Substance Abuse Treatment System

Study objective: To test the feasibility and effectiveness of Project ASSERT, an innovative program developed by us to facilitate access to the substance abuse treatment system and to primary care and preventive services for emergency department patients with drug- and alcohol-related health problems. Methods: Multicultural health promotion advocates (HPAs) were trained by ED personnel to screen patients using a health needs history, to administer a brief negotiated interview based on readiness-to-change principles, and to use an active referral process to capture the marginal capacity of the substance abuse treatment system. Outcome measures included (1) number of referrals to the substance abuse treatment system, (2) patient self-report of satisfaction with services received from Project ASSERT and utilization of treatment resources, and (3) changes in self-reported frequency of drug and alcohol use and in Drug Abuse Screening Test scores between enrollment and follow-up at 60 to 90 days. Results: Between March 1, 1995, and February 29, 1996, 7,118 adult ED patients were screened. Substance abuse was detected among 2,931 patients (41%), and 1,096 (37% of detected patients) were enrolled. A total of 8,848 referrals were made: 3,189 to primary care, 2,018 to a variety of substance abuse treatment services, 2,253 for smoking cessation, 339 for mammography, and 689 to other support services (eg, psychiatric nurse, social worker, battered women's advocate or shelter). Comparison of enrollment and follow-up scores for the 245 enrollees who kept a follow-up appointment demonstrated significant reductions, including a 45% reduction in severity of drug problem, a 56% reduction in alcohol use, and a 64% reduction in the frequency of drinking six or more drinks at one sitting. At follow-up, patients expressed satisfaction with Project ASSERT: 91% were satisfied with their referrals; 93% thought the HPAs explained things well; and 99% thought the HPAs respected them as individuals. Among the follow-up group, 50% self-reported that they had kept an appointment for treatment. Conclusion: Project ASSERT is an innovative approach to link ED patients with the substance abuse treatment system and with primary care and other preventive services. Its success is further demonstrated by its adoption by Boston Medical Center as a funded ED value-added service. [Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med August 1997;30:181-189.]