Background
Methods
Theoretical Framework
First Round
Round 1 | Round 2a
| Round 3 | ||||
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N
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N (%) |
N
|
N
|
N (%) | ||
Invited | Response | Response | Invited | Response | ||
Health professionals | GP | 32 | 13 (40) | 60 | 60 | 37 (62) |
Practice nurse—mental health care | 17 | 11 (64) | 83 | 83 | 63 (76) | |
Practice nurse—somatic care | 5 | 4 (80) | 12 | 12 | 6 (50) | |
Psychologist | 0 | 0 (0) | 1 | 1 | 0 (0) | |
Addiction prevention experts | Addiction prevention worker | 9 | 6 (66) | 50 | 50 | 30 (60) |
Researcher | 2 | 2 (100) | 3 | 3 | 3 (100) | |
Manager prevention department addiction center | 4 | 3 (75) | 5 | 5 | 5 (100) | |
Total | 69 | 39 (57) | 214 | 214 | 144 (70) |
COM-B | Barriers | Questions |
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Capability | Lack of knowledge | 1. What is needed to increase knowledge about symptoms, risk groups and intervention techniques to effectively implement ASBI in routine practice? |
Use of personal reference frames to discuss alcohol | 2. What is needed to discuss alcohol use with patients independent from reference frames formed by own alcohol use? | |
Motivation | Lack of motivation | 3. What is needed to increase motivation to work with problematic alcohol users? |
Lack of incentives | 4. Which incentives are needed to implement ASBI effectively in routine practice? | |
Uncertainty about professional role | 5. What is the role of the GP/practice nurse in screening and brief intervention for patients with problematic alcohol use in GP practices? | |
Opportunity | Difficulty and sensitivity of subject | 6. What is needed to make the subject “alcohol use” easier to discuss for health professionals in general practice? |
Lack of time | 7. What is needed to implement ASBI in routine care despite lack of time? | |
Lack of low-threshold referral options | 8. What is needed to utilize low-threshold referral options in general practice? | |
Lack of collaboration with addiction treatment centers | 9. What is needed to improve collaboration with addiction treatment centers? |
Second Round
Third Round
Results
First-Round Results
Second- and Third-Round Results
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Q.1. What is needed to increase knowledge about symptoms, risk groups and intervention techniques to effectively implement ASBI in routine practice? First, strategies targeting the provider that had achieved consensus and a high rating on applicability included the following: “supportive materials such as Web sites” (enablement), “following expertise-enhancement training” (training), “an educational intervention through E-learning” (education), and “learning through examples and insights into favorable results of ASBI” (education). The following strategy related to general awareness and the GP setting was consensually endorsed: “more publicity and attention in the media and in the general practice setting” (communication/marketing). No consensus was reached about “the applicability of enhancing knowledge by means of using an app” (enablement), “involving an addiction consultant in the general practice setting” (service provision) or “involving addiction centers in the organization of information meetings for GPs and practice nurses” (service provision).
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Q.2. What is needed to discuss alcohol use with patients independent from personal drinking norms and reference frames? Three items were consensually supported on applicability: “standardizing discussing alcohol through clearer guidelines”; “protocols and norms” (guidelines); “peer-to-peer coaching about professional attitude to become more aware of own reference frames, alcohol norms, and behavior” (training); and “destigmatization of problematic alcohol use” (communication/marketing). No consensus was reached on the following items: “giving GPs and practice nurses more information about alcohol usage and alcohol norms of peer health professionals” (education) and “discussing alcohol usage of GPs and practice nurses in training” (training).
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Q.3. What is needed to increase motivation to discuss alcohol use with patients? Consensus was reached on the applicability of a wide variety of strategies to increase motivation to work with problematic alcohol users. Four items at the provider level emphasized the importance of education: “knowledge about how to work with problematic alcohol users,” “clear instructions for treatment,” “more insight into how symptoms are associated with problematic alcohol use,” and “more insight into the effectiveness of ASBI.” Furthermore, there was consensus about the applicability of supportive materials (enablement): “practical tools for patients (e.g., alcohol diary or agenda)” and “distinguishing problematic alcohol users from dependent drinkers” (enablement). At the organizational level, three items about referral options emphasized the importance of low-threshold accessibility and publicity: “more accessible referral options and consultations with experts for support and cooperation” (service provision) and “more publicity about the possibilities of ASBI by means of E-health” (communication/marketing, education). However, there was little consensual support for “financial incentives for ASBI” (incentivization) or “learning to establish trust between health professional and patient” (education) as ways to increase motivation to discuss alcohol use with patients.
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Q.4. Which incentives are needed to effectively implement ASBI in routine practice? Four out of seven items achieved consensus on applicability of incentives: “more insight into the health profits of ASBI for patients” (persuasion), “financial reimbursements from health insurance companies to implement ASBI” (incentivization), “more financial contributions to projects in general practice about problematic alcohol use” (incentivization), and “implementing a practice nurse specialized in addiction problems without extra costs” (service provision). In contrast, no consensus was reached on the following items as incentives to implement ASBI: “more insight into the financial profits of ASBI” (persuasion), “faster referral and treatment in primary care and secondary care” (service provision), and “a monetary fee per screened patient” (incentivization).
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Q.5. What is the professional role of the GP/practice nurse in ASBI? The GP, the practice nurse mental healthcare, and practice nurse somatic care were all considered to have important roles in the early detection of problematic alcohol use and this item showed consensus around high agreeability. Healthcare providers’ role in brief treatment was, however, less clear-cut: participants agreed and consented on the role of the GP in providing brief advice/monitoring and motivational interviewing, but participants agreed less and failed to reach consensus about the role of the practice nurse somatic care in brief treatment of problematic alcohol use.
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Q.6. What is needed to implement ASBI in routine care despite lack of time? Four items with consensus around high applicability concerned specific time-saving methods of ASBI delivery: “adding a question about alcohol to a frequently used questionnaire, such as the “Four-Dimensional Symptom Questionnaire (4DSQ)” (enablement), “using a short and simple screening instrument such as the AUDIT-C” (enablement), “giving patients a self-report questionnaire” (enablement), and “implementing a short questionnaire in the registration system” (environmental restructuring). Another two items with consensus around high applicability focused on the individual level: “increasing knowledge about the fact that a short intervention costs little time and can be effective” (education) and “if one suspects problematic alcohol use, scheduling a second appointment with the patient” (regulation). Also consensually endorsed was the need for more time per consultation (regulation). No consensus was reached on the following three items which concern more structural changes at the organizational level of the general practice setting: “implementing online programs for diagnosis and treatment plans” (environmental restructuring), “implementing an alcohol consultation” (service provision), “distribution of self-report questionnaires by receptionists in the waiting room before consultation” (enablement), nor was consensus reached for “more financial aid for conducting ASBI” (incentivization).
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Q.7. What is needed to utilize low-threshold referral options in general practice? Seven items received consensual support to enhance utilization of low-threshold referral options: “providing general information and publicity about the implementation of addiction consultants in general practice” (communication/marketing), “sharing of positive experiences” (modeling), “enhancement of knowledge about the referral options” (education), “actively creating and strengthening connections with addiction care centers” (service provision), and “having fixed contact persons” (service provision). Two measures focusing on structural changes achieved consensus around high applicability: “reimbursement of extra time per patient” (reimbursement incentive) and “offering an easily accessible consult where patients can go without appointment for advice and treatment” (service provision). No consensus was reached on the following item: “having more financial aid for low-threshold referral options” (incentivization).
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Q.8. What is needed to improve collaboration with addiction treatment centers? Consensus was achieved on the applicability of eight items to improve collaboration with addiction care centers: “shortening of waiting lists in addiction care centers” (service provision), “faster communication and accessibility to addiction care settings” (service provision), “telephone and online consultations with addiction care settings” (service provision), “financial reimbursements from health insurance companies for better cooperation with addiction care centers” (incentivization), “trainings organized by addiction care centers to improve informal contacts” (service provision), “faster feedback from addiction care centers about patient information” (service provision), and “composing a cooperation protocol with task descriptions” (guideline). No consensus was reached on the following item: “deploying an addiction prevention expert in general practice” (service provision).
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Q.9. What is needed to make the subject “alcohol use” easier to discuss in general practice? “More awareness about attitudes regarding discussing alcohol use with patients” (education), “increasing knowledge and skills” (education), “displaying posters and information in the waiting room about responsible alcohol use” (communication/marketing), “exchanging positive experiences with colleagues about discussing alcohol use with patients” (education/modeling), and “discussing alcohol on the basis of various physical, social, or psychological signs of risky drinking” (regulation) were listed as ways to make the subject easier to discuss. “Supportive materials such as practical tools (e.g., screening instruments or protocols)” (enablement) and “the use of online screening tools” (enablement) were consensually endorsed as well. All items were rated high on applicability, and consensus was reached on all except “asking every patient about alcohol use” (regulation) and “awareness of own alcohol use and not letting this be a reason to avoid discussing alcohol use with patients” (education).
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Q.10. How applicable do you find the following methods of screening? Two out of seven items showed consensus and a high degree of applicability: (1) one item endorsed a screening method where patients are asked about alcohol use when they present specific symptoms, such as high blood pressure or gastrointestinal symptoms which might be related to problem drinking; (2) another item endorsed a screening method in which patient groups such as diabetics or obstructive pulmonary disease patients are all screened during periodic checkups. A low degree of applicability and no consensus was reached on any other screening method such as universal screening, self-screening at home, or screening in waiting rooms of general practices.
Differences Between Groups
Kruskal–Wallis test | ||||
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Mdn | IQR |
H
|
P value | |
Q.1. What is needed to increase knowledge? | ||||
An app with information about ASBI | 5 | 2 | 21.07 | 0.002* |
Involving an addiction consultant in general practice | 6 | 2 | 21.07 | 0.000* |
Q.2. What is needed to discuss alcohol use independent from personal reference frames? | ||||
Discussing alcohol use of GPs and PNs in training | 5 | 2 | 9.69 | 0.008* |
Information about alcohol use in own profession | 5 | 2 | 3.26 | 0.196 |
Q.3. What is needed to increase motivation to work with problematic alcohol users? | ||||
Financial incentives for ASBI | 5 | 2 | 2.83 | 0.242 |
Trust between health professional and patient | 5 | 2 | 5.18 | 0.075 |
Q.4. Which incentives are needed? | ||||
Insight into financial profits of ASBI | 5 | 1.75 | 4.30 | 0.117 |
Faster referral and treatment—primary/secondary care | 6 | 2 | 3.56 | 0.168 |
A fee of a few euros per patient screened | 5 | 2 | .16 | 0.922 |
Q.5. What is the role of the GP/PN? | ||||
The practice nurse specialized in somatic care has an important role in brief treatment of problematic alcohol use | 5 | 3 | 1.37 | 0.505 |
Q.6. What is needed to implement ASBI despite a lack of time? | ||||
Distribution of self-report questionnaires by receptionists | 4 | 2 | 14.92 | 0.001* |
An online program for diagnosing, monitoring, care indication and treatment plans | 5 | 2 | 2.49 | 0.228 |
An alcohol-consultation with more time to discuss alcohol use with patients | 5 | 2 | 20.94 | 0.000* |
Financial aid for conducting ASBI | 5 | 2 | 2.93 | 0.231 |
Q.7. What is needed to utilize low-threshold referral options? | ||||
Financial aid for low-threshold referral possibilities | 5.5 | 2 | 7.10 | 0.029* |
Q.8. What is needed to improve collaboration? | ||||
Deploying an addiction prevention expert | 6 | 2 | 20.09 | 0.000* |
Q.9. What is needed to make “alcohol use” easier to discuss? | ||||
Asking every patient about alcohol use, routinely | 6 | 2 | 25.60 | 0.000* |
Q.10. How applicable do you find the following methods of screening? | ||||
Screening of all patients | 4 | 3 | 20.56 | 0.000* |
Screening of newly registered patients | 6 | 2 | 3.72 | 0.156 |
Screening of patient risk-groups (e.g., patients above 50 years of age) | 6 | 2 | 8.57 | 0.014* |
Self-screening by patients in waiting room | 4 | 2 | 1.98 | 0.372 |
Self-screening by patients by means of an online program | 5 | 2 | .56 | 0.756 |
GP | PN | APW | GP-PN | GP-APW | PN-APW | |||||||
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Mdn | IQR | Mdn | IQR | Mdn | IQR |
Z
|
P
|
Z
|
P
|
Z
|
P
| |
Q.1. What is needed to increase knowledge? | ||||||||||||
An app with information about ASBI | 5 | 1 | 6 | 1 | 6 | 1.25 | −3.26 | 0.001* | −2.79 | 0.005* | −0.23 | 0.821 |
Involving an addiction consultant in general practice | 5 | 2 | 6 | 1 | 7 | 1 | −0.76 | 0.449 | −3.93 | 0.000* | −4.32 | 0.000* |
Q.2. What is needed to discuss alcohol use independent from personal reference frames? | ||||||||||||
Discussing alcohol use of GPs and PNs in training | 4 | 2 | 5 | 2 | 6 | 1 | −0.56 | 0.577 | −2.77 | 0.006* | −2.80 | 0.005* |
Q.6. What is needed to implement ASBI despite a lack of time? | ||||||||||||
Distribution of self-report questionnaires by receptionists | 3 | 2.5 | 4 | 2 | 5 | 2 | −1.59 | 0.111 | −3.67 | 0.000* | −2.93 | 0.003* |
An alcohol-consultation with more time to discuss alcohol use with patients | 5 | 3 | 5 | 2.5 | 6 | 2 | −0.86 | 0.391 | −4.23 | 0.000* | −3.99 | 0.000* |
Q.7. What is needed to utilize low-threshold referral options? | ||||||||||||
Financial aid for low-threshold referral options | 5 | 2 | 5 | 2 | 6 | 1 | −0.35 | 0.725 | −1.99 | 0.046 | −2.64 | 0.008* |
Q.8. What is needed to improve collaboration? | ||||||||||||
Deploying an addiction prevention expert | 6 | 2 | 5 | 2 | 6.5 | 1 | −1.57 | 0.117 | −2.71 | 0.007* | −4.48 | 0.000* |
Q.9. What is needed to make “alcohol use” easier to discuss? | ||||||||||||
Asking every patient about alcohol use, routinely | 4 | 4 | 6 | 2 | 6 | 2 | −4.76 | 0.000* | −3.91 | 0.000* | −0.10 | 0.920 |
Q.10. How applicable do you find the following methods of screening? | ||||||||||||
Screening of all patients | 2 | 2 | 4 | 3 | 5 | 2 | −2.99 | 0.000* | −4.13 | 0.000* | −2.70 | 0.007* |
Screening of patient risk groups (e.g., patients above 50 years of age) | 6 | 1 | 6 | 1 | 6.5 | 1.25 | −0.64 | 0.522 | −2.15 | 0.032 | −2.85 | 0.004* |