Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework

Alcohol misuse is a major risk factor for ill health and death [1], accountable for 5.3% of all deaths worldwide and 5.1% of the global burden of disease and injury [2]. The economic impact of alcohol use and related harm alone can reach as much as 3.3% of the Gross Domestic Product [3]. Even small reductions in alcohol intake can bring about significant health gains [4]. For example, a reduction in the daily average consumption of pure alcohol from 40 to 30 grammes (from 4 to 3 standard drinks) is associated with a 48% decrease in the risk of oral cancer, and a decrease in the risk of hypertension of 13% in men and 66% in women. The World Health Organization recommends the implementation of several high-impact strategies to change drinking behaviour, including the provision of alcohol screening and brief interventions (SBI) in primary health care settings [5].

In the past four decades, randomized controlled trials and meta-analyses have found alcohol SBI in primary care settings to be effective and cost-effective or cost-saving [6‐13]. Alcohol increases the risk of several physical, mental and social conditions that present frequently in primary care [3, 4] and a significant proportion of patients visiting primary care drink least at a hazardous or higher level [14‐16]. However, few at-risk drinkers are identified as such and counselled to cut down [17‐23]. For example, a recent trial found that, prior to intervention, only 5.9% of the consulting patients were screened and, of the screen positives, 73.7% received advice [24]. Therefore, many at-risk drinkers leave their primary care appointment unaware of the risks of their alcohol consumption or how it might be contributing to current ill health. Notwithstanding recent debates questioning SBI effectiveness [25, 26], these represent missed opportunities to increase patients’ awareness of alcohol-related risks, a first step towards enabling them to make a more informed choice on whether or not to cut down [4].

Although there is a growing literature on barriers to and facilitators of the implementation of alcohol SBI in routine clinical practice, this information is scattered and provides an unclear representation of the factors affecting primary care providers’ systematic engagement with at-risk drinkers. A review by Johnson et al. identified the barriers to and facilitators of the delivery of screening and brief intervention for alcohol misuse [27] but prioritized studies judged to best inform UK practice and focused on several different healthcare settings. Lack of training, support from management and resources, as well as workload pressures were identified as the main barriers to implementation; whilst adequate resources, training and the identification of those at risk without stereotyping were the main facilitators. This review updates the Johnson et al. review, employs a more comprehensive search strategy and has an international focus.

Another gap in the evidence base is the lack of theoretical insights in this area [28]. Knowledge of how identified barriers and facilitators fit with the theoretical understandings of behaviour change can help in selecting the implementation interventions that have a higher chance of bringing about the desired change in practitioner behaviour. Our review is informed by the Capability-Opportunity-Motivation-Behaviour (COM-B) system [29] and Theoretical Domains Framework (TDF) [30] system in that the barriers and facilitators were mapped to the TDF domains which, in turn, fit with the COM-B system. The review aims to identify the theoretical concepts underpinning the barriers and facilitators to implementation. Our intention is to provide practical evidence for selecting the best strategies to increase the implementation of alcohol SBI in primary health care.

This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (see Additional file 1) [31]. The protocol was pre-registered on PROSPERO (CRD42016052681) and published elsewhere [32]. No amendments were introduced to the review protocol.

This review identified a range of barriers and facilitators influencing GPs’ and primary care nurses’ routine delivery of alcohol SBI in adults that linked to the capability, opportunity and motivation components of the COM-B system and to all TDF domains.

The analysis linked all the TDF domains within each component of the COM-B system to at least one of the barriers identified. This suggests that increasing all aspects of capability, opportunity and motivation may be needed for successfully implementing alcohol SBI in primary health care. Furthermore, several barriers linked to more than one TDF domain suggesting that multicomponent strategies may be needed to address some barriers. For example, ‘time’ linked to the TDF domains ‘environmental context and resources’ and ‘beliefs about capabilities’. Restructuring the environment (e.g. involving receptionists in the screening process, arranging for more time per consultation) and modelling (e.g. demonstrating that advising at-risk drinkers within the time of the consultation is manageable) are examples of strategies that could be used to address this barrier. These findings highlight the challenges researchers face in studying alcohol SBI implementation in PHC and help to understand why routine delivery of alcohol SBI in PHC has been proven difficult to implement.

The analysis identified the following TDF domains as having the highest number of data units coded: ‘Environmental Context and Resources’; ‘Beliefs about Capabilities’; and ‘Skills’. Comparatively, few data units were linked to ‘Behaviour Control’, ‘Memory, Attention and Decision Processes’ and ‘Optimism’. Caution should be exerted when deciding the domains on which to intervene based on the frequency a particular barrier is reported in the literature. The behaviour change theories most commonly used in research to explain healthcare professionals’ behaviours are based on constructs related to the reflective, rather than the automatic, aspect of behaviour, which could lead to a bias in the frequency of the reported factors to behaviour change [117]. For example, the majority of studies found in this review are survey-based which provided GPs and nurses with a list of potential barriers, potentially inflating the salience of those barriers whilst neglecting others that could explain the variance of the behaviour. Therefore, it is conceivable that significant barriers to implementation linked to TDF domains with fewer data units coded are yet to be identified, which could give the misleading idea that addressing these domains are less likely to influence implementation. Huijg and colleagues developed a TDF-based questionnaire [118] that could be tailored to study these under-explored barriers and assess their importance.

In a previous review, Johnson and colleagues identified barriers and facilitators to implementing alcohol screening and brief interventions [27]. This review included studies from settings other than PHC, reported only on studies published in English, and gave priority to studies judged most likely to inform UK practice. Our review updates the Johnson et al. review concerning the barriers and facilitators to implementation in PHC. Firstly, we provide evidence on barriers and facilitators from several countries that were not limited to inform a particular practice. One recently published survey study conducted in the largest five European Union countries found that the most frequently cited barriers to implementing alcohol screening among patients with hypertension varied substantially from country to country [119]. This shows that the barriers to, and facilitators of, implementation can vary substantially, between countries that are in geographic proximity and even from place to place within countries. Country features such as individually paid vs nationally funded healthcare, educational level and buying power could influence the salience of a particular factor in the implementation efforts. Therefore, the successful implementation of alcohol SBI will be contingent to tailoring the intervention to local needs [120]. By providing a breakdown by country of study, this review could be of use in the selection of the barriers and facilitators that are more meaningful locally. Secondly, this review was informed by a theoretical framework of behaviour change. Most programmes in practice and research have lacked a theoretical rationale for how they would change practitioner behaviour [28, 121, 122]. Understanding how identified barriers and facilitators fit with the theoretical understandings of behaviour change are key to inform intervention design, and may increase the chances of successful implementation. For example, we have used the results of this review to inform the design of a novel practitioner intervention which has been trialed in Portugal [123]. Therefore, this review may also support researchers in the design of novel theory-based interventions.

This study identified a wide range of potential barriers and facilitators to the implementation of alcohol SBI delivery in primary care practices and adds to the scarce body of literature that identifies the barriers and facilitators from a theoretical perspective. Given that alcohol SBI is seldom implemented, this review provides researchers with a tool for designing novel theory-oriented interventions to support the implementation of such activity.