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Table 1 A brief outline of selected papers

From: Alcohol screening and brief interventions for adults and young people in health and community-based settings: a qualitative systematic literature review

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
  1. aGP General Practitioner
  2. bBI Brief intervention
  3. cRT Referral for Treatment
  4. dABI Alcohol Brief Intervention – term used in paper
  5. eSBI is the term used in paper
  6. fSAMHSA Substance Abuse & Mental Health Services Administration
  7. gSBIRT Screening, Brief Intervention and Referral for Treatment
  8. hMI Motivational Interviewing
  9. iVA Veterans Health Administration