Mapping key components of community-oriented strategies to facilitate alcohol-related early identification and brief intervention in general practice: a scoping review.

Hazardous alcohol use is one of the leading risk factors for morbidity and mortality in the world. Early identification and brief interventions (EIBIs) delivered in primary care is an effective but underutilized strategy to address this issue. Community-oriented strategies (COS) are suggested to facilitate EIBI delivery. COS are public health activities directed to the general population raising awareness and encouraging behaviour change. Unfortunately, it remains unclear what these COS should comprise and what their added value might be in EIBI delivery. To map the available information on COS aiming to facilitate alcohol-related EIBI delivery in general practice. A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping reviews guidelines, was used to map both grey and peer-reviewed literature. Of the 6586 information sources screened, 8 sources were retained in this review. Three COS are currently described in the literature, all with their different components. They include the use of mass media, self-assessment tools and waiting room actions. Waiting room actions comprising audio recordings or computerized self-assessment tools significantly increase the discussion on alcohol use in primary care. The effect of mass media and community-wide self-assessment tools on EIBI delivery remains to be determined. Currently, the described COS lack empirical justification to motivate their added value in facilitating EIBI delivery. However, a theoretical reflection showed the use of a limited set of behaviour change techniques, which might support the use of COS. There remains a lot of possible strategies to explore. This review highlights the current evidence gap and discusses the next steps.

Implementing alcohol screening and brief interventions in primary health care: study protocol for a pilot cluster randomized controlled trial.

BACKGROUND: Alcohol is one of the most important risk factors contributing to the global burden of disease. Screening and brief interventions in primary care settings are effective in reducing alcohol consumption. However, implementation of such interventions in routine practice has been proven difficult. Most programmes in practice and research have lacked a theoretical rationale for how they would change practitioner behaviour. OBJECTIVE: To determine whether a theory-based behaviour change intervention delivered to primary care practices significantly increases delivery of alcohol screening. METHODS: We will conduct a two-arm, cluster-randomized controlled, parallel, open trial. Twelve primary care practices will be randomized to one of two groups: training and support; and waiting-list control. Family physicians, nurses and receptionists will be eligible to participate. The intervention will be a training and support programme. The intervention will be tailored to the barriers and facilitators for implementing alcohol screening and brief interventions following the principles of the Behaviour Change Wheel approach. The primary outcome will be the proportion of patients screened with the Alcohol Use Disorders Identification Test. CONCLUSION: This study will test whether a theory-driven implementation programme increases alcohol screening rates in primary care. Results from this trial will provide a useful addition to existing evidence by informing implementation researchers what areas of behaviour change are critical to increasing alcohol screening rates. TRIAL REGISTRATION: clinicaltrials.gov NCT02968186.

Development and Validation of Quality Indicators on Continuing Care for Patients With AUD: A Delphi Study.

AIMS: To develop indicators to assess quality of continuing care for persons with alcohol use disorder (AUD). METHODS: A guideline-based RAND-modified Delphi method was used to develop and validate indicators regarding the process and outcome of continuing care. We systematically searched for evidence-based guidelines and existing quality indicators. A multidisciplinary expert panel prioritized recommendations using a written questionnaire followed by a group discussion. Important recommendations were then translated to quality indicators. The panel subsequently selected indicators that were measurable and applicable in Belgium. In a final round the indicators face-validity was assessed. RESULTS: We extracted 69 recommendations from 06 guidelines and 17 relevant quality indicators. Of all, 13 indicators remained after 03 written rounds and 02 group discussions. CONCLUSIONS: This study describes a systematic approach to develop and validate quality indicators for continuing care for AUD. The final set of selected indicators consisted of 10 process and 03 outcome indicators. As the level of evidence of effective continuing care components is very low further development of the indicators is recommended. SHORT SUMMARY: This study describes a systematic approach to develop and validate quality indicators for continuing care for AUD. The proposed set of indicators consisted of 10 process and 03 outcome indicators. As the level of evidence of effective continuing care components is very low further development of the indicators is recommended.

Attitudes toward preventive services and lifestyle: the views of primary care patients in Europe. the EUROPREVIEW patient study.

BACKGROUND: For preventive interventions in general practice to succeed, patients' points of view must be taken into account in addition to those of GPs. OBJECTIVE: To explore patients' views and beliefs about the importance of lifestyle and preventive interventions, to assess their readiness to make changes to their lifestyle and their willingness to receive support from GPs. METHODS: Cross-sectional survey conducted by EUROPREV in primary care practices in 22 European countries. Patients were consecutively selected and interviewed from September 2008 to September 2009. RESULTS: Seven thousand nine hundred and forty-seven participants, 52.2% females. Only 30.5% of risky drinkers think they need to change, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% with lack of physical activity. Risky drinkers reported that GPs initiated a discussion on alcohol consumption less often (42%) than on smoking (63%), eating habits (59%) or physical activity (55%). Seventy-five per cent, 66% and 63% of patients without hypertension, diabetes or hypercholesterolaemia, respectively, think blood pressure, blood sugar and serum cholesterol should be checked yearly. Women (80%) think they should be screened with the cervical smear test and 72.8% of women aged 30-49 years with mammography, yearly or every 2 years. CONCLUSIONS: A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits, and about half the patients reported not having had any discussion on healthy lifestyles with their GPs. Patients overestimate their need to be screened for cardiovascular risk factors and for cancer.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery. DESIGN: Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial. SETTING: PHCPs in Portugal. PARTICIPANTS: Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58. INTERVENTION AND COMPARATOR: PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial. MEASUREMENTS: The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider). FINDINGS: The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices. CONCLUSION: A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.

Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework.

BACKGROUND: Alcohol is a leading risk factor contributing to the global burden of disease. Several national and international agencies recommend that screening and brief interventions (SBI) should be routinely delivered in primary care settings to reducing patients' alcohol consumption. However, evidence shows that such activities are seldom implemented in practice. A review of the barriers and facilitators mediating implementation, and how they fit with theoretical understandings of behaviour change, to inform the design of implementation interventions is lacking. This study aimed to conduct a theory-informed review of the factors influencing general practitioners' and primary care nurses' routine delivery of alcohol SBI in adults. METHODS: A systematic literature search was carried out in four electronic databases (Medline, CINAHL, CENTRAL, PsycINFO) using comprehensive search strategies. Both qualitative and quantitative studies were included. Two authors independently abstracted and thematically grouped the data extracted. The barriers and facilitators identified were mapped to the domains of the Capability-Opportunity-Motivation-Behaviour system/Theoretical Domains Framework (TDF). RESULTS: Eighty-four out of the 258 studies identified met the selection criteria. The majority of the studies reported data on the views of general practitioners (n = 60) and used a quantitative design (n = 49). A total of 660 data items pertaining to barriers and 253 data items pertaining to facilitators were extracted and thematically grouped into 46 themes. The themes mapped to at least one of the 14 domains of the TDF. The three TDF domains with the highest number of data units coded were 'Environmental Context and Resources' (n = 158, e.g. lack of time), 'Beliefs about Capabilities' (n = 134, e.g. beliefs about the ability to deliver screening and brief advice and in helping patients to cut down) and 'Skills' (n = 99, e.g. lack of training). CONCLUSIONS: This study identified a range of potential barriers and facilitators to the implementation of alcohol SBI delivery in primary care and adds to the scarce body of literature that identifies the barriers and facilitators from a theoretical perspective. Given that alcohol SBI is seldom implemented, this review provides researchers with a tool for designing novel theory-oriented interventions to support the implementation of such activity. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016052681.

Factors Influencing the Implementation of Screening and Brief Interventions for Alcohol Use in Primary Care Practices: A Systematic Review Protocol.

INTRODUCTION: Alcohol is a leading risk factor contributing to the global burden of disease. National and international agencies recommend evidence-based screening and brief interventions in primary care settings in order to reduce alcohol consumption. However, the majority of primary care professionals do not routinely deliver such interventions. OBJECTIVE: To identify factors influencing general practitioners/family physicians' and primary care nurses' routine delivery of alcohol screening and brief intervention in adults. MATERIAL AND METHODS: A systematic literature search will be carried out in the following electronic databases: Medline, CINAHL, CENTRAL, and PsycINFO. Two authors will independently abstract data and assess study quality using the NIH National Heart, Lung, and Blood Institute quality assessment tools for quantitative studies, and the CASP checklist for qualitative studies. A narrative synthesis of the findings will be provided, structured around the barriers and facilitators identified. Identified barriers and facilitators will be further analysed using the Behavioural Change Wheel/Theoretical Domains Framework. DISCUSSION: This review will describe the barriers to, and facilitators for, the implementation of alcohol screening and brief interventions by general practitioners/family physicians and nurses at primary care practices. By mapping the barriers and facilitators to the domains of the Behavioural Change Wheel/Theoretical Domains Framework, this review will also provide implementation researchers with a useful tool for selecting promising practitioner-oriented behavioural interventions for improving alcohol screening and brief intervention delivery in primary care. CONCLUSION: This review will provide important information for implementing alcohol screening and brief intervention in primary health care.Systematic Review Registration: PROSPERO CRD42016052681.

Introdução: O consumo de álcool é um importante fator de risco a nível mundial. Apesar de serem recomendadas por muitas instâncias nacionais e internacionais, a deteção e intervenção breve no consumo de álcool ainda não está integrada na prática da maioria dos profissionais de saúde dos Cuidados de Saúde Primários. Objetivo: Identificar as barreiras e os facilitadores à implementação da deteção e intervenção breve nos consumos de álcool nos Cuidados de Saúde Primários por parte dos Médicos e Enfermeiros de Família. Material e Métodos: Será realizada uma revisão sistemática da literatura nas seguintes bases de dados: Medline, CINAHL, CENTRAL, e PsycINFO. Dois autores irão, de forma independente, extrair os dados, e avaliar a qualidade dos estudos selecionados. A qualidade dos estudos quantitativos será avaliada através das checklists do NIH National Heart, Lung, and Blood Institute, enquanto a dos estudos qualitativos será avaliada através da checklist CASP. Os resultados serão apresentados numa síntese narrativa, estruturada em torno das barreiras e facilitadores identificados, e analisados à luz dos domínios teóricos da Behavioural Change Wheel/Theoretical Domains Framework. Discussão: Esta revisão sistemática descreverá as barreiras e os facilitadores à implementação da deteção e intervenção breve nos consumos de álcool nos Cuidados de Saúde Primários. Ao estabelecer a ligação entre estes fatores e os diferentes domínios teóricos da Behavioural Change Wheel/Theoretical Domains Framework, esta revisão sistemática vai facilitar o desenho de programas que visem a implementação destas boas práticas neste nível de cuidados. Conclusão: Esta revisão contribuirá com informação importante para a implementação da deteção e intervenção breve nos consumos de álcool nos Cuidados de Saúde Primários. Registo: PROSPERO CRD42016052681.

A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study.

OBJECTIVE: This study examines the impact of marketing strategies on the dissemination of a brief alcohol intervention program to general practitioners (GPs). The marketing strategy was tested to determine the most effective way to promote awareness about and consideration of a brief alcohol intervention program. The study also examines the impact of training and support strategies to promote the program's implementation in routine primary care. METHOD: A pragmatic trial was carried out in Australia, Belgium (Flanders), Denmark, England, New Zealand and Spain (Catalonia) in which GPs were randomly allocated into one of three marketing conditions (direct mail, telemarketing and academic detailing [personal visits]). The GPs who requested a brief intervention program and agreed to use it were stratified by previous marketing condition and randomly allocated into one of three implementation strategy groups: written guidance, outreach training and outreach training plus ongoing telephone support. RESULTS: Acceptance of the brief intervention program was more effective with use of telemarketing (65%) and academic detailing (67%) than with direct mail (32%) for promoting awareness about and consideration of a brief alcohol intervention program. The median proportion of patients screened was higher for trained GPs (6%) and supported GPs (9%) than for control GPs (1%), who received only written guidance on how to conduct brief intervention. Similarly, the median rate for giving advice to at-risk patients was higher for trained GPs (3%) and supported GPs (3%) than for control GPs (0%). CONCLUSIONS: The adoption of more direct approaches for disseminating evidence-based intervention programs to GPs is a necessary first step for changing practice behavior. However, outreach training was required to promote actual use of a new procedure in routine practice.

Continuing care for patients with alcohol use disorders: a systematic review.

BACKGROUND: A chronic care perspective should be adopted in the treatment of patients with alcohol use disorders (AUDs). Initial treatment in a more intense psychiatric care setting should be followed by continuing care. This systematic review aims to identify effective continuing care interventions for patients with AUDs. METHODS: Electronic databases were searched up to February 2013 (MEDLINE, EMBASE, CENTRAL, CINAHL and PsycINFO) to identify RCTs studying continuing care interventions for patients with AUDs. Study selection and quality appraisal was done independently by two reviewers. Drinking and treatment engagement outcomes were considered. Relative risks and mean differences were calculated with 95% confidence intervals. A statistical pooling of results was planned. RESULTS: 20 trials out of 15,235 identified studies met the inclusion criteria. Only six were evaluated as methodologically strong enough and included for further analysis. Interventions ranged from telephone calls and nurse follow-up to various forms of individual or couples counseling. Four trials suggested that supplementing usual continuing care with an active intervention empowering the patient, could be beneficial to drinking outcomes. Effect sizes were limited and not consistent across all outcomes. Because of heterogeneity in the interventions and outcome measures, a meta-analysis could not be performed. CONCLUSION: For the treatment of a disease with such devastating consequences, it is remarkable how few high quality studies are available. Adding an active intervention to usual continuing care seems to improve treatment outcomes. We propose an integrated care program with different elements from the selected studies and discuss implications for further research.

Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study.

AIMS: To determine if GPs' attitudes towards working with drinkers moderated the impact that training and support had on screening and brief intervention activity in routine practice. METHODS: Subjects were 340 GPs from four countries who were part of a World Health Organization randomized controlled trial to evaluate the effectiveness of training and support in increasing screening and brief alcohol intervention. GPs' self-reported attitudes towards working with drinkers were measured with the Shortened Alcohol and Alcohol Problems Perception Questionnaire. RESULTS: Whereas training and support increased GPs' screening and brief intervention rates, it did so only for practitioners who already felt secure and committed in working with drinkers. Training and support did not improve attitudes towards working with drinkers and, moreover, worsened the attitudes of those who were already insecure and uncommitted. CONCLUSIONS: To enhance the involvement of GPs in the management of alcohol problems, interventions that increase both actual experience and address practitioners' attitudes is required. Such support could take the form of on-site support agents and facilitators.