Background
Methods
Study design
Framework analysis
Participants and setting
Data collection
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Why?
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Engagement: reasons for subscribing to the ODHIN trial
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How and for whom?
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Description of the SBI implementation process: description of SBI proceedings and expectations
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Under what circumstances?
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Barriers and facilitators to following the guidelines on risky alcohol consumption -
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Facilitators or barriers to implementing SBI, related to the allocation groups -
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Opinions and suggestions for organisational and political barriers and facilitators -
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Other thoughts and suggestions to speed up the implementation process
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Data analysis
Results
Study population
Catalonia | Sweden | Poland | Netherlands | Total | |
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N GPs | 12 | 5 | 12 | 11 | 40 |
N nurses | 10 | 10 | 0 | 8 | 28 |
N high performance | 13 | 9 | 6 | 10 | 38 |
N low performance | 9 | 6 | 6 | 9 | 30 |
N T&S | 11 | 5 | 6 | 9 | 31 |
N no T&S | 11 | 10 | 6 | 10 | 37 |
N FR | 13 | 5 | 7 | 10 | 35 |
N no FR | 9 | 10 | 5 | 9 | 33 |
N e-BI | 9 | 6 | 3 | 11 | 29 |
N no e-BI | 13 | 9 | 9 | 8 | 39 |
Male (%) | 27 | 13 | 16 | 37 | 26 |
Mean age | 47 | 52 | 47 | 44 | 47 |
Total | 22 | 15 | 12 | 19 | 68 |
Barriers and facilitators to implementation
TICD Domain | Theory-led TICD concepts | • Empirically-led Affinity Diagram themes | Codes |
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1. Guideline factors | Cultural appropriateness | • Cultural appropriateness | SBI is not a task for PHCU_referall to specialised care outside the PHCU; no guideline available_SBI too late |
Strength of recommendation | • Barriers to adhere to the guideline | Too strict_nr of drinks; SBI does not fit in short time consult; doubts about effectiveness pro-active screening | |
Compatibility | • Adherence TO guideline • Routine • Follow-up of SBI | Return to the habitual system; routine_Application of the screening in all cases; already a routine; routine_preventive activities; SBI part of the nurse’s protocol; SBI part of GP’s protocol/routine; follow-up after SBI suboptimal; policies_screening during initial general interview with every new patient; focus on alcohol addicted patients/co-addicts; focus on chronically ill patients; routine_follow-up of patients; repeat SBI | |
Observability | • Facilitators to adhere to the guideline | Partly adherence to guideline; adherence to guideline; clear cut-off screening tool stimulates brief intervention; use evidence based knowledge/material; use evidence based knowledge/material – mi; adherence implementation takes a while; adherence_Initial difficulties; adherence_Simple adaptation process; interventions were feasible; feasibility_ of the instrument | |
Feasibility | • Adherence to guideline • Facilitators to adhere to the guideline • Implementation of guidelines • Feasible guidelines | Example of interventions | |
2. Individual factors | Agreement with recommendation | • Evaluating own performance • Implementing new practice • Role perception • Screening opportunities • Barriers | Screen to make patients aware of daily drinking habit; role perception_patient motivated when given BI from a GP; performance perception_effects of SBI; performance perception_no effects of SBI; my role to start the process; role perception SBI; barrier screening_perceived_not relevant in context; role perception_to recognise signs given by a patient; it’s not my role; agreement recommendation; awareness _alcohol is not a medical problem |
Expected outcomes | • Personal motivation to participate from societal perspective • Collaboration from individual perspective • Evaluating own performance • Role perception • Professional’s expectations • I don’t care • Barriers | ODHIN outcome expectation_to catch more case positives; role perception_patients like GPs to ask about lifestyle; expectation_patient’s reaction; expectation_conformed to expectations; professional age; motivation to participate ODHIN_curiosity about the outcomes; expected MI intervention outcome_high; expected intervention outcome_low; expectation_With no initial expectations; lack of motivation to change; barriers referral_big step; GP afraid of patient’s reaction | |
Emotions | • Implementing new practice • Barriers | E-health_using e-health is a personal weakness; new patient; hard to screen GP’s own friends or acquaintances | |
Frustration | • Implementing new practice | ODHIN impact_more frustration | |
Intention and motivation | • Personal motivation to participate from societal perspective • Training • Collaboration from individual perspective • E-health • Personal motivation individual perspective • I don’t care • Barriers | Motivation to participate in ODHIN_to help patients; ODHIN training_positive but not fully attended; Motivation to participate ODHIN_motivation for intervention; motivation to participate ODHIN_the size of alcohol problem; motivation to participate ODHIN_easier with a network; e-health_positive in e-health; e-health_barrier referral; e-health_no time to become familiar with e-health intervention; e-health_not familiair with website content; e-health_negative attitude; motivation to participate ODHIN_consider load and benefit; not motivated by financial incentives; motivation to participate ODHIN_to act pro-socially; motivation to participate ODHIN_personal interest/benefit; motivated by ODHIN financial incentives; motivation to participate ODHIN_negative; motivation to participate ODHIN_Interesting subject; not motivated to improve SBI; low patient awareness_inhibits professional; low motivation to change_inhibits professional; motivation to change_motivates BI; patient reactions_denial inhibits brief intervention; | |
Learning style | • Training • Implementing new practice • Routines | ODHIN training_increases awareness of the problem; ODHIN training_temporary stimulation; ODHIN training_positive; ODHIN presence cause reminders/awareness_temporary; continuous triggers necessary for SBI; routine and practice | |
Self-efficacy | • Self-efficacy | Self-efficacy in BI_high; high screening self-efficacy; self-efficacy; self-efficacy_frustration; self-efficacy in BI_moderate; performance perception_GP can always do something | |
Awareness and familiarity with the recommendation | • Personal motivation to participate from societal perspective | ODHIN motivates to screen pro-active; awareness of alcohol problems; importance of screening | |
Knowledge | • Training • Implementing new practice • I don’t care • Barriers • Screening opportunities | Skills thank to previous training; ODHIN impact_encouragement to introduce more prevention; previous training_don’t remember; barrier screening_language barrier; barrier screening_information from system not available; barrier BI_skills; Skills_plurimedication; Patient nightlife related with drugs/alcohol; patient known to drink too much; screen because of patient signals; skills_professional knows well patient’s medical history; importance_associated pathology; screened patients suspected of drinking alcohol; patient drunk during the visit; problem reported by family member | |
Knowledge about own practice | • Collaboration from individual perspective • I don’t care • Barriers | Barrier screening_already SBI by colleague; barrier screening_other important health and other topics; barrier screening_sociodemographics; patient religious issues | |
Skills needed to adhere | • Implementing new practice • Personal motivation individual perspective • Professional patient approach • Professional’s expectations • Barriers • Screening opportunities | ODHIN impact_new skills/procedures; motivation to participate ODHIN_need for more knowledge and skills; expectation_increase knowledge/skills about interventions; skills_no judgemental attitude/tolerance; skills_professional keeps motivating the patient; skills_individual approach to patient; alcohol is a sensitive issue/difficult subject; need for more knowledge & skills for SBI; performance perception_screening justified by the research project | |
Capacity to plan change | • Personal motivation to participate from societal perspective • Implementing new practice | Barrier screening_economic crisis situation; ODHIN impact_introduction of new data into patients’ records | |
Nature of the behaviour | • Implementing new practice | ODHIN impact_effort to perform | |
Self monitoring or feedback | • Personal motivation to participate from societal perspective • evaluating own performance • implementing new practice • screening opportunities • I don’t care • Barriers | ODHIN outcome _catching patients in early stage of disease and follow-up; motivation to participate ODHIN_awareness of trivialising; satisfaction with own performance; lack of satisfaction with own performance; self-monitoring of screening; self monitoring of BI; insight SBI potential afterwards; ODHIN impact_more patient/new groups of patients screened; ODHIN presence cause reminders/awareness_own consumption behaviour; ODHIN presence cause reminders/awareness; ODHIN did not make any difference; ODHIN presence did not cause reflection on own consumption behavior; barrier screening_simply forgotten; has routine; barrier screening_experienced workload; Patient age; patient gender; physical GP’s tiredess; Screened every patient (or tried to screen) | |
3. Patient factors | Patient behaviour | • Patient reactions | Patient reactions; feel suspected of being a drinker; afraid/suspicies; stressed/tense; not honest; honest; frustration; defensive; surprise; relief; no objection/acceptance; negotion/trivialisation |
Patient beliefs and knowledge | • perceived patient awareness • lack of interest in E-BI | Awareness_personal decision of the patients; awareness_self-control of drinking; patient reactions_awareness guidelines; BI_difficult when patients not aware; patient reactions_don’t treat beer as alcohol; self-efficacy in BI_low/doubts if patiens will change anything; patient reactions_lack of interest e-health; patients not interested in e-BI | |
Patient motivation | • Patient trust required • Motivation to change | SBI requires patient’s trust; motivation to change_Serious alcohol problem; motivation to change_Social support | |
Patient preferences | • Patient reactions | Patient reactions_positive | |
4. Professional interactions | Communication and influence | • Decision to participate • General assessment of PHCU routines and engagement | Decision to participate in ODHIN_agreement; decision to participate in ODHIN_GP decided to participate; decision to participate in ODHIN_nurses agreed; decision to participate in ODHIN_practice nurses not involved; motivation to participate ODHIN_order or influence of other professional/supervisor/colleague, etc.; GP takes the lead in ODHIN SBI; engaged other staff in alcohol discussions than those involved in the Odhin project; team (not) on the same line; different routines among the staff |
Referral processes | • Barriers • Task division in the team • Referral | Addiction care disappointing; GP internal referral to specialised professional; nurse referral to other(s); ODHIN initiates referral option specialised nurse; GP referral to addiction care; need for low barrier referral possibilities; conditions in the PHCU_additional support | |
Team processes | • Barriers • Organisation of SBI care • Task division in the team • Learning from each other • Making agreement within the practice | Recent screening; colleagues less practice/experience; organise care multidisciplinary; counseling done by other profession; care requires a specialized practice nurse; team process SBI_SBI only partly by nurse; unknown patient; practice nurses_have more time_for MI; other professionals have more time’; practice SBI in team; share experiences; lack of communication; sufficient communication; nurse not informed about procedures; agree on team objectives; agree on SBI strategy | |
Undefined | • Difference in opinions | ODHIN_waisted money | |
5. Incentives and resources | Availability of necessary resources | • Physical working conditions in the PHCU • Difference in opinions • Tools as facilitators • Screening tool usefulness • Trigger for screening • Importance of time | Conditions in the PHCU_privacy; conditions in the PHCU_disturbances; ODHIN did not lack resources; little bureaucracy; ODHIN provides tool for BI; need for patient information_low barrier patient information; more resources in the treatment of the patient; screening instrument not within reach; advice_use available training and tools; screening tool helps to structure; advice_use screening tool; ODHIN provides screening tool; screening instrument_Suitable instrument; screening tool did not help; screening instrument_too complicated for patients; screening instrument_easy to use; screening instrument_anonymous; visible screening instrument does not stimulate; visible screening instrument stimulates; need for summary card on desk; advice_time is necessary resource; GPs want more time per patient; increase available time for extra practice nurses; time pressure inhibits BI; time pressure inhibits GP’s MI; time pressure inhibits screening; time is no barrier to screen; time is no barrier for advice; addicted patients need more time; time for creating right atmosphere; time pressure forces need for follow-up appointment |
Continuing education system | • Importance of training | Advice_continuous training; training should be organised in PHCU; more role playing; Providing training tools suitable for professionals | |
Financial incentives and disincentives | • Importance of finances | No financial resources from health Insurance; finances required for practice nurse; financial incentives rewards your effort; financial incentives would create more priorities; more funds needed | |
Information system | • Role in information system | Usual registration in information system; information system obligatory field; no use of information system; register SBI in information system; information system not adapted to SBI; information system not obligatory field | |
6. Capacity for organisational change | Assistance for organisational changes | • PHCU SBI policy • Nurses protocol for SBI | Advice_invite a consulent; practice nurse not skilled |
Monitoring and feedback | • PHCU SBI policy | Need for ongoing evaluations | |
Priority of necessary changes | • PHCU SBI POLICY | Advice_SBI prioritarisation | |
Regulations, rules, policies | • Systematisation of SBI • PHCU SBI policy • Nurses protocol for SBI | Policies_need for a systematic approach to disease prevention; make it part of protocol; make it part of performance indicators; Nurses protocol adapted in line with ODHIN | |
7. Social, political, legal factors | Economic constraints on the healthcare budget | • Increase public awareness | Advice for improving public health_society should be richer |
Influential people | • Importance of regional policy • Increase public awareness • Awareness of prevention task of primary care | The board plays an important role; advice_increase public awareness (media); advice_increase public awareness (media)_broad lifestyle; advice_increase public awareness (media)_involve environment; advice_increase school and parent awareness; little effect public campaigns; synergy effect of advice from multiple people; less ads; change social attitudes; advice_increase primary care awareness outside PHCU; increase awareness in professionals; prevention task of PHCU | |
Legislation | • Need for effective policy actions • More strict legislation | Mandatory trainings for GPs’; advice_increase alcohol taxes_not effective; advice_increase alcohol taxes; advice_legislate higher age buying alcohol; advice_make alcohol less available; fear of bureaucracy | |
Payer or funder policies | • Increase public awareness | Advice for improving public health_don’t waist public money on projects like ODHIN | |
Undefined | • Increase public awareness • need for effective policy actions • awareness of prevention task of primary care | Advice for improving public health_use disulfiram implants; advice for improving public health_state alcohol policy is schizophrenic; raise awareness of screening, BI and available tools; build trust between GPs and patients; advice_organise peer buddy’s; increase knowledge in primary care professionals; Approach general/integral; policies_screening during initial general interview with every new patient; introduce more programs like ODHIN | |
8. Implementation strategy practicalities | Training and support | Caused awareness; MI requires long term practice; MI useful for other lifestyle issues; positive; preference for more factual knowledge; role playing_not favorable; temporary stimulus | |
Financial reimbursement | No effect; extra motivation | ||
E-health | low outcome expectation; low patient motivation inhibits professional; easily accessible intervention; increases awareness; negative attitude; no time to become familiar with e-health; not applicable for elderly; not applicable for low SES; no effect |
Why?
Alcohol problems are really big in this area. I’ve been observing them for years.(GP, FR, low performance, PL)
How and for whom?
“During my education there was some attention paid to motivational interviewing, but this training was very welcome as it cleared things up, such as fine-tuning my patient approach to their phase of behaviour change according to the behaviour change matrix.” (Nurse, T&S, high performance, NL)
“The more often you ask the questions, it will become more of a routine, it takes time to incorporate new procedures and ask the questions, but most of the time you can ask these questions during each visit” (Nurse, T&S, high performance, SWE)“You have to decide beforehand whether you want to reserve time for this. Do we think it’s important enough to spend time on?” (GP, T&S + FR + e-BI, high performance, NL)
“I stated: “We are taking part in a project aimed at people’s wellbeing”” (GP, T&S + FR, high performance, PL)The high performing professionals who attended training and support, reported being stimulated in discussing SBI experiences within their team. This facilitated a team approach in doing SBI:“We could have talked about this without the ODHIN project. But it gave us a reason to sit down and do so.” (GP, T&S, high performance, SWE)
“The emphasis on your work is on what you are currently busy with. It would be the same if I had participated in a study about cardiovascular diseases.” (GP, T&S + FR + e-BI, high performance, NL)
“Because with the cutbacks there are fewer of us and we have to…stand in for people and that’s hard, isn’t it?” (GP, T&S + FR, high performance, CAT)“Getting an incentive is always good. If this is financial or economic, I think it could be good, but I am not completely sure about it. When you get invited to participate in a study they ask you “Do you want to participate?” and you take part voluntarily. In the end, it turns out that someone publishes an article and your name is there, that’s okay. Of course both the financial and professional incentives are important, but with the financial one you feel they treated you well.” (Nurse, T&S + FR, high performance, CAT)
“Now it is the diagnosis that brings in money, nothing out of this really benefits the patients, but that’s something for financially educated managers to calculate and put in charts and to perform some kind of statistics. What is important in healthcare is the patient.” (GP, T&S, low performance, SWE)
“I have to pay my practice nurse. If I can only pay her for other tasks [other than asking for alcohol consumption], I have to pay for it myself when she is going to ask about alcohol consumption.” (GP, T&S + e-BI, low performance, NL)
“Well, I gave them the e-BI tool and asked them to access it. However, it is up to them, you can ask them to do it, but they don’t always do so. It happens very often, your role as a professional is to say ‘look, if you want more information here it is’ but in my opinion this is a challenging thing.” (Nurse, T&S + FR + e-BI, high performance, CAT)“If they didn’t have a computer at home, or if they did not feel comfortable using one – then it was really not any use to recommend it to them. It was meant for those who felt that they wanted it… I don’t know if they visited the website or not.. I have no idea…” (Nurse, e-BI, low performance, SWE)
Under what circumstances?
“I know that before ODHIN I did not pay as much attention to this as after ODHIN. I did not have specific barriers for asking about alcohol consumption, but if you participate in this kind of project it will become more part of your automatism in anamnesis.” (GP, no strategy, high performance, NL)
“Include it in your protocol. Every time you see it [on your screen], you will be reminded.” (Nurse, T&S + FR + e-BI, high performance, NL)
“Yes… it has facilitated our work a lot because we already had it implemented in our computerised medical record (E -CAP)… and … and this is the usual computerised tool that we always use, as a result of this it has been much easier.” (GP, T&S + FR + e-BI, High performance, CAT)“I do register, but it’s a bit difficult as we do not have an appropriate ICPC [declaration] code” (GP, FR + e-BI, low performance, NL)Subsequently, professionals frequently reported high workloads, which caused T&S not to be sufficient to increase performance.There are not enough GPs … more time and more funds should be reserved … e.g. one extra hour per week for preventive visits should be founded by the National Health Fund (GP, T&S, low performance, PL)
“For professionals, you have to notice it more, read about it more, pay more attention to it in the media and literature. (…) The lobby for quitting smoking is much bigger than the lobby for drinking less.” (GP, FR + e-BI, low performance, NL)
Second-order analysis: relations between framework domains
“The state earns most on alcohol and tobacco. So limiting consumption is against its economic interests.” (GP, T&S + FR, high performance, PL)“There is a social acceptance for drinking.” (GP, T&S + FR, high performance, PL)Furthermore, the organisational environment challenges the SBI implementation, even when implementation strategies seem to work at the individual level i.e.:“The system of work should be changed. Besides alcohol interventions, interventions on nicotine, obesity, physical activity should be conducted. And I have 10–15 minutes per patient.”(GP, no strategy, low performance, PL)“I do register [SBI], but it’s a bit difficult as we do not have a good ICPC code [for health insurance declaration].” (GP, T&S + FR + e-BI, high performance, NL)
“When there are analytical alterations or when there’s a sonogram that shows something, when there’s a pathology behind it (…), it’s easier to focus on it.” (nurse, FR, low performance, CAT)