Table 1 A brief outline of selected papers
Authors & country | Study aims | Methods & analysis | Strengths | Weaknesses | Findings: facilitators | Findings: barriers |
|---|---|---|---|---|---|---|
M Aalto, P Pekuri and K Seppa [47] Finland | Identification of obstacles for GPsa and nurses in screening and brief intervention for heavy drinkers | Method Focus groups Analysis Content analysis | Innovative approach to looking at heavy drinking among patients | Lack of representativeness due to small numbers (18 GPs, 19 nurses) in one practice setting | Positive views about the need to address alcohol use with heavy drinking patients (and recognition that this extends to youth drinking) | Confusion over terms ‘early phase heavy drinking’, and ‘alcohol dependence’; pessimism about worth of addressing alcohol use; role responsibility ie addiction clinic better suited to address alcohol use; impact on doctor/ patient relationship; lack of guidelines |
A Beich, D Gannik and K Malterud [49] Denmark | Qualitative study to explore GPs views of AUDIT in their daily practice | Method Interviews and focus groups Theory/analysis A ‘modified phenomenological’ approach | Included questions on use of alcohol screening with young people | Did not use transcriptions for coding, but direct from audio tapes, which might have lost some detail despite being used ‘to minimise loss of shades of meaning’ | One doctor said he would try to incorporate the questionnaire into his practice | Doctors said they would not screen their patients for alcohol use, because: difficult to implement in normal flow of work; affected a ‘person-centred’ approach to patient interaction; additional workload |
Broyles et al., (2012) [17] United States | Prospective study to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BIb and RTc for hospital patients | Method Focus groups Theory/ analysis: from grounded theory | Early example of a study looking at professionals’ own alcohol consumption Discomfort identified in discussing alcohol in relation to age and sex of patients | Due to prospective nature of study, features were anticipated, rather than experienced in relation to barriers to implementation of SB and RT | Potential facilitators: development of knowledge, skills, communication and collaboration. Also expansion of roles in provision of care | Lack of alcohol-related knowledge and skills; poor communication across disciplines around alcohol-related care; poor alcohol assessment procedures and integration with e-records; concerns about negative reaction and limited motivation among patients; issues of compatibility in screening, BI and RT and healthcare philosophy and role; structural issues e.g. lack of time |
N Fitzgerald, H Molloy, F MacDonald and J McCambridge [36] United Kingdom | To explore the impact of training for community-based staff in Scotland, in use of ABId | Method Telephone interviews Theory/ analysis Thematic analysis | Wide variety of health and community-based staff were interviewed | Telephone interviews only Lack of clarity in defining the 3 themes related to barriers | Some increase in knowledge, or confidence in using the tool | Three themes identified: majority said they had not encountered appropriate clients with whom to use ABI; tool did not fit with practice or role; clients problems were too severe and therefore use of ABI was considered inappropriate |
AJ Gordon, L Ettaro, KL Rodriguez, J Mocik and DB Clark [19] United States | Examines primary care providers, adolescents and parents attitudes to SBIRT in rural health setting | Method: Mixed methods study, including focus groups Theory/ analysis: Grounded theory, thematic analysis | Comprehensive exploration of professional, adolescent and parents attitudes to SBIRT | Limited to small rural area Limited focus on qualitative analysis of group interviews | All were enthusiastic about computer-based interventions Professionals and parents saw the benefits of SBIRT | Provider’s lacked training, tools and onward referral options; adolescents worried about confidentiality |
Hutchings et al. (2006) [46] United Kingdom | To examine acceptability and feasibility of using SBIe in primary care settings | Method: Focus groups Theory/ analysis: Framework analysis | Explored both patients’ and professionals’ diverse perspectives about who should implement ASBI in primary care setting | Small number of participants | Practice nurses seen as appropriate in addressing alcohol use, especially when ‘lifestyle’ issues needed to be raised | GPs and nurses: lack of awareness of importance of alcohol problems; ‘light’ drinkers considered more likely to benefit from SBI than ‘heavy’ drinkers; SBI should be addressed as ‘lifestyle’ intervention; worried about giving offence; work overload; young people’s alcohol use better addressed through educational institutions, not primary care |
K Johansson, I Akerlind and P Bendtsen [41] Sweden | To identify to what extent nurses are willing to be involved in alcohol prevention | Methods: Focus group interviews Theory/ analysis: None mentioned | Addresses potential solutions from nurse perspective, in relation to screening strategies | Although a qualitative study, paper was written as a short communication and so lacked depth | Nurses felt they had learned new skills and had improved their skills in identifying risky drinking behaviour | Alcohol prevention seen as one among many interventions within role remit; preferred to screen only if a problem was identified first, and if onward referral services existed; worried about damaging relationship with patient; seen as ‘time consuming’; and lack of ‘self-efficacy’ |
M Keurhorst, M Heinen, J Colom, C Linderoth, U Mussener, K Okulicz-Kozaryn, J Palacio-Vieira, L Segura, F Silfversparre, L Slodownik, et al. [42] Catalonia, Netherlands, Poland, and Sweden | Looked at why screening not taking place with high risk patients ‘Why, how and for whom were interventions not given’ in 4 countries in Europe | Method: Semi-structured interviews Analysis: Thematic analysis | Example of newer method (Realist Evaluation) used to address the ‘how’ and ‘why’ questions regarding implementation process Unique exploration of use of financial re-imbursement of staff using ASBI | Professional backgrounds of participants were different within each country, making any generalisation to other settings difficult | Training and support improved knowledge, skills and prioritisation of alcohol as an issue Continuous provision, sufficient time to learn intervention techniques and tailoring to individual experience were helpful | Implementing electronic BI required more guidance than was available |
CA Lock, E Kaner, S Lamont and S Bond [23] United Kingdom | Exploration nurses attitudes to brief screening and why it is underutilised in primary care | Method: semi-structured interviews Analysis: Grounded theory | Sets out a clear future agenda in terms of nurses involvement in alcohol-related interventions | Small sample size | Acknowledged importance of alcohol use as a health issue; could identify a need; perceived themselves as in best position to address alcohol use | Lack of training and preparation in alcohol intervention use; lack of confidence; lack of institutional support |
C May, T Rapley and E Kaner [57] United Kingdom | To investigate how primary care practitioners were using aspects of brief interventions in their practice | Method Semi-structured interviews conducted in 2 phases Analysis Constant comparison | Useful exploration of context: contrast of experience-led vs protocol-led practices Discussed findings with participants which enhanced overall understanding | In exploring theoretically, the practice-research gap, there was less focus on recommendations for bringing the two components together less specific detail on how this might be promoted or supported for researchers | Practitioners own independent approaches to managing alcohol use amongst clients | Practice-research gap limited the acceptability of alcohol interventions |
P Nygaard and OG Aasland [48] Norway | Qualitative study investigating barriers in implementing alcohol SBI amongst GPs | Method: Focus groups Theory/ analysis: Thematic analysis | Identified issue of prevention versus intervention | Focused on GPs exclusively Focused only on barriers, not facilitators Small numbers used in the study | If issue was about an intervention resulting from a recognized alcohol problem, GPs were more likely to use SBI Work-based health centres more likely to detect alcohol issues and intervene | Raising issue of alcohol due to ‘stigma’; integration into GPs daily practice; prevention vs. treatment conflict; organisational limitations; potentially negative impact on relationships with patients |
AK Rahm, JM Boggs, C Martin, DW Price, A Beck, TE Backer and JW Dearing [2] United States | Evaluation of SAMHSAf and SBIRTg by mixed health-care practitioners | Methods: Focus groups and individual interviews Analysis: Content analysis | Early study eliciting patient views and perspectives of alcohol screening | Not generalisable to other studies where more limited resources might preclude use of clinical psychologists in implementing SBIRT | Psychologists effectively replaced nurses & doctors as screeners of alcohol use | Time limitations and prioritisation of other issues; organisational leadership was limited; training alone was not adequate – support of institution also recommended |
CWM Tam, N Zwar and R Markham [44] Australia | To understand reasons for the low uptake of screening tools including AUDIT-C, among GPs | Method: Semi-structured group interviews Analysis: Grounded theory | Identifies the role of local context and socio-cultural perceptions of alcohol and its use | Small study and findings therefore limited Some barriers identified were specific to the Australian context ie cultural ideas around alcohol consumption, and therefore not generalisable | Detecting ‘at-risk’ drinking seen as important (but difficult) | Social and cultural barriers to asking about alcohol consumption; dynamics of patient-doctor interactions; alcohol screening questionnaires lack practical utility; community stigma and stereotypes of “problem drinking”; GP perceptions of unreliable patient alcohol use histories; and perceived threat to the patient-doctor relationship |
AE Whittle, SM Buckelew, JM Satterfield, PJ Lum and P O’Sullivan [43] United States | To evaluate a curriculum, pre- and post-training, aimed at improving confidence of clinicians working with adolescents, using SBIRT & MIh | Methods: Mixed methods: questionnaire and observational study Analysis: Content analysis | Focus on evaluation of training, using information, workshop, observation of professionals using intervention with immediate feedback, and feedback from professionals after using intervention | Feedback given in writing, not verbally, which means some opportunities lost for further understanding and might have led to overvalued perspective | Improvement in skills; confidence in approaching alcohol use with young people; ability to self-reflect; opportunity to practice using interventions in training sessions | MI more time-consuming as an approach; knowing when to use MI or another approach, which might be more suitable |
Williams, et al. (2016) [51] United States | To understand the process of implementation and ‘factors underlying quality problems’ in ASBI from the perspective of frontline staff in VAi primary health care | Method: Semi-structured interviews Analysis: Template Analysis. Used to analyse qualitative data thematically by applying a coding ‘template’ [58] | Effective use of conceptual analytic framework - [59] and Mitchie (2005) | Site-specific limitations and therefore questionable generalizability to other settings | Staff considered alcohol use an important issue that required intervention within primary care settings | Implementation did not address training and infrastructure needs; lack of standardization; limited understanding of the goals of SBI; alcohol considered ‘specialists’ role; limited availability of treatment resources; negativity regarding patients’ interest in help-seeking |