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

Abstract

Background and Aims Screening and brief interventions (SBI) in primary health care practices (PHCPs) 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=8,062; 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 SBI following the principles of the Behaviour 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.