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Jackson K, Baker R, O'Donnell A, Loughran I, Hartrey W, Hulse S. Understanding the challenges of identifying, supporting, and signposting patients with alcohol use disorder in secondary care hospitals, post COVID-19: a qualitative analysis from the North East and North Cumbria, England. BMC Health Serv Res 2024; 24:772. [PMID: 38951799 PMCID: PMC11218181 DOI: 10.1186/s12913-024-11232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context. METHODS Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings. RESULTS Findings were grouped using the NPT domains 'implementation contexts' and 'implementation mechanisms'. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring). CONCLUSIONS COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings.
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Affiliation(s)
| | - Rosie Baker
- North Tees and Hartlepool NHS Hospitals Foundation Trust, Stockton on Tees, UK
| | | | - Iain Loughran
- North East Commissioning Service, Newcastle upon Tyne, UK
| | - William Hartrey
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Sarah Hulse
- North East and North Cumbria Integrated Care Board, Newcastle upon Tyne, UK
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Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician Reluctance to Intervene in Addiction: A Systematic Review. JAMA Netw Open 2024; 7:e2420837. [PMID: 39018077 PMCID: PMC11255913 DOI: 10.1001/jamanetworkopen.2024.20837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/07/2024] [Indexed: 07/18/2024] Open
Abstract
Importance The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low. Objective To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions. Data Sources A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021. Study Selection Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included. Data Extraction and Synthesis Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons. Main Outcomes and Measures The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria. Results A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug. Conclusions and Relevance In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.
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Affiliation(s)
| | - Laura Nolan
- JBS International, Inc, North Bethesda, Maryland
| | - Michelle Corbin
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Lisa Farinelli
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jarratt D. Pytell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Caty Simon
- National Survivors Union, Greensboro, North Carolina
- NC Survivors Union, Greensboro, North Carolina
- Whose Corner Is It Anyway, Holyoke, Massachusetts
| | - Stephanie T. Weiss
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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Lewis H, Parker R, Ul-Haq Z, Lucas A, Cohen C, Vergis N, Thursz M. Healthcare interactions prior to first hospital admission with alcohol-related liver disease. Liver Int 2024. [PMID: 38771187 DOI: 10.1111/liv.15969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/12/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND AND AIMS To examine the healthcare contacts of patients in the year before an index admission to hospital with alcohol-related liver disease (ArLD) to identify where opportunities for earlier identification of alcohol use disorders (AUD) and ArLD and intervention may occur. METHODS A retrospective cohort study using the regional database encompassing NHS organisations across North West London (344 general practitioner [GP] practices, 4 acute hospital trusts and 2 mental health and community health trusts). Patients who had an index admission with ArLD were identified through healthcare coding and compared with a control cohort. Healthcare contacts, blood tests and AUD testing in the year preceding admission were measured. RESULTS The ArLD cohort had 1494 participants with an index hospital admission with ArLD. The control cohort included 4462 participants. In the year preceding an index admission with ArLD, 91% of participants had at least one contact with primary care with an average of 2.97 (SD 2.45) contacts; 80% (n = 1199/1494) attended ED, 68% attended an outpatient clinic, and 42% (n = 628/1494) had at least one inpatient admission. Only 9% of the ArLD (137/1494) had formal testing for AUD. Abnormal bilirubin and platelets were more common in the ArLD than the control cohort 25% (138/560) and 28% (231/837), respectively, v 1% (12/1228) and 1% (20/1784). CONCLUSIONS Prior to an index admission with ArLD patients have numerous interactions with all healthcare settings, indicating missed opportunities for early identification and treatment.
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Affiliation(s)
- Heather Lewis
- Liver Unit, Imperial College NHS Healthcare Trust, St Marys Hospital London, London, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Zia Ul-Haq
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Carole Cohen
- Discover-NOW, Imperial College Health Partners, London, UK
| | - Nikhil Vergis
- Digestive Diseases Division, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Mark Thursz
- Digestive Diseases Division, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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Cai H, Zheng H, Li J, Hao C, Gu J, Liao J, Hao Y. Implementation and evaluation of crowdsourcing in global health education. Glob Health Res Policy 2022; 7:50. [PMID: 36522678 PMCID: PMC9753011 DOI: 10.1186/s41256-022-00279-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Current global health course is most set as elective course taught in traditional teacher-taught model with low credit and short term. Innovate teaching models are required. Crowdsourcing characterized by high flexibility and strong application-orientation holds its potential to enhance global health education. We applied crowdsourcing to global health teaching for undergraduates, aiming to develop and evaluate a new teaching model for global health education. METHODS Crowdsourcing was implemented into traditional course-based teaching via introducing five COVID-19 related global health debates. Undergraduate students majoring in preventative medicine and nursing grouped in teams of 5-8, were asked to resolve these debates in reference to main content of the course and with manner they thought most effective to deliver the messages. Students' experience and teaching effect, were evaluated by questionnaires and teachers' ratings, respectively. McNemar's test was used to compare the difference in students' experience before and after the course, and regression models were used to explore the influencing factors of the teaching effect. RESULTS A total of 172 undergraduates were included, of which 122 (71%) were females. Students' evaluation of the new teaching model improved after the course, but were polarized. Students' self-reported teaching effect averaged 67.53 ± 16.8 and the teachers' rating score averaged 90.84 ± 4.9. Students majoring in preventive medicine, participated in student union, spent more time on revision, and had positive feedback on the new teaching model tended to perform better. CONCLUSION We innovatively implemented crowdsourcing into global health teaching, and found this new teaching model was positively received by undergraduate students with improved teaching effects. More studies are needed to optimize the implementation of crowdsourcing alike new methods into global health education, to enrich global health teaching models.
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Affiliation(s)
- Huanle Cai
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Huiqiong Zheng
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Jinghua Li
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, China
- Center for Health Information Research, Sun Yat-Sen University, Guangzhou, China
| | - Chun Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, China
- Center for Health Information Research, Sun Yat-Sen University, Guangzhou, China
| | - Jing Gu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, China
- Center for Health Information Research, Sun Yat-Sen University, Guangzhou, China
| | - Jing Liao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China.
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, China.
- Center for Health Information Research, Sun Yat-Sen University, Guangzhou, China.
| | - Yuantao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, No.74 Zhongshan 2nd Road, Guangzhou, 510080, China
- Sun Yat-Sen Global Health Institute, Sun Yat-Sen University, Guangzhou, China
- Center for Health Information Research, Sun Yat-Sen University, Guangzhou, China
- Peking University Center for Public Health and Epidemic Preparedness and Response, Peking University, Beijing, China
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5
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Bode K, Whittaker P, Dressler M, Bauer Y, Ali H. Pain Management Program in Cardiology: A Template for Application of Normalization Process Theory and Social Marketing to Implement a Change in Practice Quality Improvement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095251. [PMID: 35564643 PMCID: PMC9104749 DOI: 10.3390/ijerph19095251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/28/2022] [Accepted: 04/24/2022] [Indexed: 12/04/2022]
Abstract
Quality improvement plays a major role in healthcare, and numerous approaches have been developed to implement changes. However, the reasons for success or failure of the methods applied often remains obscure. Normalization process theory, recently developed in sociology, provides a flexible framework upon which to construct quality improvement. We sought to determine if examination of a successful quality improvement project, using normalization process theory and social marketing, provided insight into implementation. We performed a retrospective analysis of the steps taken to implement a pain management program in an electrophysiology clinic. We mapped these steps, and the corresponding social marketing tools used, to elements of normalization process theory. The combination of mapping implementation steps and marketing approaches to the theory provided insight into the quality-improvement process. Specifically, examination of the steps in the context of normalization process theory highlighted barriers to implementation at individual, group, and organizational levels. Importantly, the mapping also highlighted how facilitators were able to overcome the barriers with marketing techniques. Furthermore, integration with social marketing revealed how promotion of tangibility of benefits aided communication and how process co-creation between stakeholders enhanced value. Our implementation of a pain-management program was successful in a challenging environment composed of several stakeholder groups with entrenched initial positions. Therefore, we propose that the behavior change elements of normalization process theory combined with social marketing provide a flexible framework to initiate quality improvement.
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Affiliation(s)
- Kerstin Bode
- Department of Electrophysiology, Heart Center Leipzig, Struempellstr. 39, 04289 Leipzig, Germany;
- Department of Cardiology, Asklepios Clinic Weißenfels, Naumburger Str. 76, 06667 Weissenfels, Germany
- Correspondence: ; Tel.: +49-3443-401921
| | - Peter Whittaker
- The University of Edinburgh, Old College, South Bridge, Edinburgh EH8 9YL, UK;
| | - Miriam Dressler
- Medical Faculty, University of Leipzig, Liebigstr. 21, 04109 Leipzig, Germany;
| | - Yvonne Bauer
- Department of Electrophysiology, Heart Center Leipzig, Struempellstr. 39, 04289 Leipzig, Germany;
| | - Haider Ali
- Business School, The Open University, Walton Hall, Milton Keynes MK7 6AA, UK;
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Birch JM, Critchlow N, Calman L, Petty R, Rosenberg G, Rumgay H, Vohra J. The Frequency and Content of Discussions About Alcohol Use in Primary Care and Application of the Chief Medical Officer's Low-Risk Drinking Guidelines: A Cross-Sectional Survey of General Practitioners and Practice Nurses in the UK. Alcohol Alcohol 2021; 56:433-442. [PMID: 33179022 DOI: 10.1093/alcalc/agaa120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS To examine how often general practitioners (GPs) and practice nurses (PNs) working in primary care discuss alcohol with patients, what factors prompt discussions, how they approach patient discussions and whether the Chief Medical Officers' (CMO) revised low-risk drinking guidelines are appropriately advised. METHODS Cross-sectional survey with GPs and PNs working in primary care in the UK, conducted January-March 2017 (n = 2020). A vignette exercise examined what factors would prompt a discussion about alcohol, whether they would discuss before or after a patient reported exceeded the revised CMO guidelines (14 units per week) and whether the CMO drinking guidelines were appropriately advised. For all patients, participants were asked how often they discussed alcohol and how they approached the discussion (e.g. used screening tool). RESULTS The most common prompts to discuss alcohol in the vignette exercise were physical cues (44.7% of participants) or alcohol-related symptoms (23.8%). Most practitioners (70.1%) said they would wait until a patient was exceeding CMO guidelines before instigating discussion. Two-fifths (38.1%) appropriately advised the CMO guidelines in the vignette exercise, with PNs less likely to do so than GPs (odds ratio [OR] = 0.77, P = 0.03). Less than half (44.7%) reportedly asked about alcohol always/often with all patients, with PNs more likely to ask always/often than GPs (OR = 2.22, P < 0.001). Almost three-quarters said they would enquire by asking about units (70.3%), compared to using screening tools. CONCLUSION Further research is required to identify mechanisms to increase the frequency of discussions about alcohol and appropriate recommendation of the CMO drinking guidelines to patients.
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Affiliation(s)
- Jack M Birch
- MRC Epidemiology Unit, University of Cambridge School of Clinical, Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.,Cancer Policy Research Centre, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK.,Macmillan Survivorship Research Group, School of Health Sciences, University of Southampton, Southampton, SO17 1BJ, UK
| | - Nathan Critchlow
- Cancer Policy Research Centre, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK.,Institute for Social Marketing and Health, University of Stirling, Stirling, FK9 4LA, UK
| | - Lynn Calman
- Macmillan Survivorship Research Group, School of Health Sciences, University of Southampton, Southampton, SO17 1BJ, UK
| | - Robert Petty
- Cancer Policy Research Centre, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK
| | - Gillian Rosenberg
- Cancer Policy Research Centre, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK
| | - Harriet Rumgay
- Cancer Intelligence, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK
| | - Jyotsna Vohra
- Cancer Policy Research Centre, Cancer Research UK, 2 Redman Place, London, EC20 1JQ, UK
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Lennox L, Linwood-Amor A, Maher L, Reed J. Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review. Health Res Policy Syst 2020; 18:120. [PMID: 33050921 PMCID: PMC7556957 DOI: 10.1186/s12961-020-00601-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available, choosing the most appropriate one is increasingly difficult for researchers and practitioners. To understand the value of such approaches, evidence warranting their use is needed. However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice. This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings. Methods A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A 5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool. Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches. Results This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies. Approaches have been applied across a range of healthcare settings, including primary, secondary, tertiary and community healthcare. Approaches are used for five main purposes, namely analysis, evaluation, guidance, assessment and planning. Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs and difficulty in application) associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainability outcome variables explored; therefore, the impact of approaches on sustainability remains unclear. Additional sustainability outcome variables reported in retrieved articles are discussed. Conclusions This review provides practitioners and researchers with a consolidated evidence base on sustainability approaches. Findings highlight the remaining gaps in the literature and emphasise the need for improved rigour and reporting of sustainability approaches in research studies. To guide future assessment and study of sustainability in healthcare settings an updated list of sustainability outcome variables is proposed. Trial Registration This review was registered on the PROSPERO database CRD 42016040081 in June 2016.
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Affiliation(s)
- L Lennox
- National Institute for Health Research, Applied Research Collaboration North West London. Imperial College London, 369 Fulham Road, SW10 9NH, London, United Kingdom.
| | - A Linwood-Amor
- Ministry of Health, Environment, Culture and Housing, George Town, Grand Cayman KY1-9000, Cayman Islands
| | - L Maher
- Ko Awatea Health System Innovation and Improvement, Middlemore Hospital, 100 Hospital Road, Otahuhu, New Zealand
| | - J Reed
- Julie Reed Consultancy, 27 Molasses House, London, SW113TN, United Kingdom
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Bell L, Garnett C, Qian T, Perski O, Potts HWW, Williamson E. Notifications to Improve Engagement With an Alcohol Reduction App: Protocol for a Micro-Randomized Trial. JMIR Res Protoc 2020; 9:e18690. [PMID: 32763878 PMCID: PMC7442945 DOI: 10.2196/18690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Drink Less is a behavior change app that aims to help users in the general adult population reduce hazardous and harmful alcohol consumption. The app includes a daily push notification, delivered at 11 am, asking users to "Please complete your mood and drinking diaries." Previous analysis of Drink Less engagement data suggests the current notification strongly influences how users engage with the app in the subsequent hour. To exploit a potential increase of vulnerability of excess drinking and opportunity to engage with the app in the evenings, we changed the delivery time from 11 am to 8 pm. We now aim to further optimise the content and sequence of notifications, testing 30 new evidence-informed notifications targeting the user's perceived usefulness of the app. OBJECTIVE The primary objective is to assess whether sending a notification at 8 pm increases behavioral engagement (opening the app) in the subsequent hour. Secondary objectives include comparing the effect of the new bank of messages with the standard message and effect moderation over time. We also aim to more generally understand the role notifications have on the overall duration, depth, and frequency of engagement with Drink Less over the first 30 days after download. METHODS This is a protocol for a micro-randomized trial with two additional parallel arms. Inclusion criteria are Drink Less users who (1) consent to participate in the trial; (2) self-report a baseline Alcohol Use Disorders Identification Test score of 8 or above; (3) reside in the United Kingdom; (4) age ≥18 years and; (5) report interest in drinking less alcohol. In the micro-randomized trial, participants will be randomized daily at 8 pm to receive no notification, a notification with text from the new message bank, or the standard message. The primary outcome is the time-varying, binary outcome of "Did the user open the app in the hour from 8 pm to 9 pm?". The primary analysis will estimate the marginal relative risk for the notifications using an estimator developed for micro-randomized trials with binary outcomes. Participants randomized to the parallel arms will receive no notifications (Secondary Arm A), or the standard notification delivered daily at 11 am (Secondary Arm B) over 30 days, allowing the comparison of overall engagement between different notification delivery strategies. RESULTS Approval was granted by the University College of London's Departmental Research Ethics Committee (CEHP/2016/556) on October 11, 2019, and The London School of Hygiene and Tropical Medicine Interventions Research Ethics Committee (17929) on November 27, 2019. Recruitment began on January 2, 2020, and is ongoing. CONCLUSIONS Understanding how push notifications may impact engagement with a behavior change app can lead to further improvements in engagement, and ultimately help users reduce their alcohol consumption. This understanding may also be generalizable to other apps that target a variety of behavior changes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18690.
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Affiliation(s)
- Lauren Bell
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Claire Garnett
- Research Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Tianchen Qian
- Department of Statistics, Harvard University, Cambridge, MA, United States
| | - Olga Perski
- Research Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Henry W W Potts
- Institute of Health Informatics, University College London, London, United Kingdom
- Health Data Research UK, London, United Kingdom
| | - Elizabeth Williamson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Health Data Research UK, London, United Kingdom
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9
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Khadjesari Z, Stevenson F, Toner P, Linke S, Milward J, Murray E. 'I'm not a real boozer': a qualitative study of primary care patients' views on drinking and its consequences. J Public Health (Oxf) 2020; 41:e185-e191. [PMID: 29912419 DOI: 10.1093/pubmed/fdy067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/12/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The public health message around alcohol is complex, with benefits versus harms, the confusing concept of risk and drinking guidance changing over time. This provides a difficult context for alcohol screening in primary care, with established barriers from the practitioner perspective, but less is known about the patients' perspective. This study explores patients' views on drinking. METHODS Eligible participants were recorded as drinking above low risk levels in primary care. Six practices in North London participated. Interviews were in-depth, semi-structured, transcribed verbatim and underwent detailed thematic analysis. FINDINGS Interviews were conducted with 8 women and 12 men, aged 26-83 years, mostly educated to undergraduate level and of 'White' ethnicity. UK drinking guidance was viewed as irrelevant for reasons related to life stage, lifestyle and absence of harm. Dependence, loss of functionality and control were perceived as key features of problematic drinking. Healthy lifestyles, in terms of diet, exercise and not smoking, were thought to mitigate potential problems associated with alcohol intake. CONCLUSION The findings suggest that public health messages and brief advice should focus on harm experienced at different life stages, among people with different lifestyles, to challenge the ubiquitous view that 'I'm not a real boozer'.
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Affiliation(s)
- Z Khadjesari
- eHealth Unit, Primary Care and Population Health Research Department, University College London, Upper Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK.,Centre for Implementation Science, Health Service and Population Research Department, King's College London, 16 De Crespigny Park, Camberwell, London, UK
| | - F Stevenson
- eHealth Unit, Primary Care and Population Health Research Department, University College London, Upper Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK
| | - P Toner
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, UK
| | - S Linke
- eHealth Unit, Primary Care and Population Health Research Department, University College London, Upper Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK.,Camden and Islington Mental Health Trust, 4 St Pancras Way, Kings Cross, London, UK
| | - J Milward
- Addictions Department, King's College London, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, UK
| | - E Murray
- eHealth Unit, Primary Care and Population Health Research Department, University College London, Upper Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, UK
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10
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O'Donnell A, Hanratty B, Schulte B, Kaner E. Patients' experiences of alcohol screening and advice in primary care: a qualitative study. BMC FAMILY PRACTICE 2020; 21:68. [PMID: 32321440 PMCID: PMC7178930 DOI: 10.1186/s12875-020-01142-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 04/14/2020] [Indexed: 12/16/2022]
Abstract
Background Despite evidence supporting the effectiveness of alcohol screening and brief advice to reduce heavy drinking, implementation in primary healthcare remains limited. The challenges that clinicians experience when delivering such interventions are well-known, but we have little understanding of the patient perspective. We used Normalization Process Theory (NPT) informed interviews to explore patients’ views on alcohol screening and brief advice in routine primary healthcare. Methods Semi-structured qualitative interviews with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice were analysed thematically, informed by Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflexive monitoring). Results We found mixed understanding of the adverse health consequences of heavy drinking, particularly longer-term risks. There was some awareness of current alcohol guidelines but these were viewed flexibly, depending on the individual drinker and drinking context. Most described alcohol screening as routine, with clinicians viewed as trustworthy and objective. Patients enacted a range of self-regulatory techniques to limit their drinking but perceived such strategies as learned through experience rather than based on clinical advice. However, most saw alcohol advice as a valuable component of preventative healthcare, especially those experiencing co-occurring health conditions. Conclusions Despite strong acceptance of the screening role played by primary care clinicians, patients have less confidence in the effectiveness of alcohol advice. Primary care-based alcohol brief advice needs to reflect how individuals actually drink, and harness strategies that patients already commonly employ, such as self-regulation, to boost its relevance.
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Affiliation(s)
- Amy O'Donnell
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Buiding, Richardson Road, Newcastle, NE2 4AX, UK.
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Buiding, Richardson Road, Newcastle, NE2 4AX, UK
| | - Bernd Schulte
- Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eileen Kaner
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Buiding, Richardson Road, Newcastle, NE2 4AX, UK
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11
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Huddlestone L, Turner J, Eborall H, Hudson N, Davies M, Martin G. Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review. BMC FAMILY PRACTICE 2020; 21:52. [PMID: 32178624 PMCID: PMC7075013 DOI: 10.1186/s12875-020-01107-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/05/2020] [Indexed: 01/28/2023]
Abstract
Background Normalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes. Methods A systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach. Results Thirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives. Conclusion NPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting.
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Affiliation(s)
- Lisa Huddlestone
- Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, LE1 7RH, UK.
| | - Jessica Turner
- School of Applied Social Sciences, De Montfort University, Hawthorn Building, The Gateway, Leicester, LE1 9BH, UK
| | - Helen Eborall
- Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, LE1 7RH, UK
| | - Nicky Hudson
- School of Applied Social Sciences, De Montfort University, Hawthorn Building, The Gateway, Leicester, LE1 9BH, UK
| | - Melanie Davies
- Diabetes Research Centre, Affiliated with the Department of Health Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
| | - Graham Martin
- The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
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12
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Carlos S, Rico-Campà A, de la Fuente-Arrillaga C, Echavarri M, Fernandez-Montero A, Gea A, Salazar C, Martínez-González MA. Do healthy doctors deliver better messages of health promotion to their patients?: Data from the SUN cohort study. Eur J Public Health 2020; 30:466-472. [DOI: 10.1093/eurpub/ckaa019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
Healthy lifestyle adherence is associated with lower chronic disease morbidity/mortality. The role of doctors, as counselors and role models, is essential. Among physicians participating in a prospective cohort, we investigated the behavioral counseling on diet and lifestyle provided to their patients in association with their own personal behaviors.
Methods
We assessed 890 doctors aged ≤65 years participating in the ‘Seguimiento Universidad de Navarra’ (SUN) cohort, who replied to an online questionnaire regarding their practices on behavioral counseling and drug prescription to their patients. Data were combined with previous baseline information on their personal healthy habits.
Results
Among doctors, 31% reported <10 min per visit; 73% counseled 60–100% of their patients on smoking cessation, 58% on physical activity, 54% on weight control, 51% on healthy nutrition, 44% on alcohol avoidance/reduction and 28% recommended alcohol moderate consumption. The percentage of doctors that counseled 100% of their patients about lifestyle was 43% for smoking cessation, 15% for exercise and 13% for weight control and nutrition. Better doctor’s adherence to the Mediterranean dietary pattern was associated with more frequent and longer nutrition counseling. Higher practice of physical activity was associated with longer time on counseling about exercise to their patients. Among doctors both current and former smoking were inversely associated with the frequency and duration of their smoking cessation/avoidance counseling practices.
Conclusions
Personal behavioral changes among doctors and better training of medical doctors on a personal healthy diet and lifestyle are likely to contribute to improve the behavioral counseling given to patients.
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Affiliation(s)
- Silvia Carlos
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
| | - Anaïs Rico-Campà
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- Centro de Investigación Biomédica en Red Área de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Madrid, Spain
| | - Carmen de la Fuente-Arrillaga
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- Centro de Investigación Biomédica en Red Área de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Madrid, Spain
| | - María Echavarri
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
| | - Alejandro Fernandez-Montero
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- Department of Occupational Medicine, University of Navarra, Pamplona, Spain
| | - Alfredo Gea
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- Centro de Investigación Biomédica en Red Área de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Madrid, Spain
| | - Camino Salazar
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Sanidad de Castilla y Leon (SACYL), Palencia, Spain
| | - Miguel Angel Martínez-González
- Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- Centro de Investigación Biomédica en Red Área de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Madrid, Spain
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13
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Myers B, Carney T, Johnson K, Browne FA, Wechsberg WM. Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 75:102628. [PMID: 31830616 PMCID: PMC7021212 DOI: 10.1016/j.drugpo.2019.102628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/14/2019] [Accepted: 12/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation. METHODS We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach. RESULTS Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation. CONCLUSION Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.
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Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa; Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa; Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Kim Johnson
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, PO Box 19070, Francie van Zyl Drive, Tygerberg 7505, South Africa.
| | - Felicia A Browne
- Substance Use, Gender and Applied Research, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States.
| | - Wendee M Wechsberg
- Substance Use, Gender and Applied Research, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States; Health Policy and Administration, Gillings School of Global Public Health, The University of North Carolina, Chapel Hill, NC, United States; Department of Psychology, North Carolina State University, United States; Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, United States.
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14
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O'Donnell A, Angus C, Hanratty B, Hamilton FL, Petersen I, Kaner E. Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis. Addiction 2020; 115:49-60. [PMID: 31599022 DOI: 10.1111/add.14778] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/24/2019] [Accepted: 08/06/2019] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. DESIGN Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. SETTING England. PARTICIPANTS Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723). MEASUREMENTS The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption. FINDINGS There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month. CONCLUSIONS Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.
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Affiliation(s)
- Amy O'Donnell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Angus
- Sheffield Alcohol Research Group, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona L Hamilton
- Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Primary Care and Population Health, University College London, London, UK
| | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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15
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Minian N, Baliunas D, Noormohamed A, Zawertailo L, Giesbrecht N, Hendershot CS, Le Foll B, Rehm J, Samokhvalov AV, Selby PL. The effect of a clinical decision support system on prompting an intervention for risky alcohol use in a primary care smoking cessation program: a cluster randomized trial. Implement Sci 2019; 14:85. [PMID: 31443663 PMCID: PMC6708174 DOI: 10.1186/s13012-019-0935-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023] Open
Abstract
Background Clinical decision support systems (CDSSs) may promote practitioner adherence to evidence-based guidelines. This study examined if the addition of a CDSS influenced practitioner delivery of a brief intervention with treatment-seeking smokers who were drinking above recommended alcohol consumption guidelines, compared with practitioners who do not receive a CDSS prompt. Methods This was a cluster randomized controlled trial conducted in primary health care clinics across Ontario, Canada, implementing the Smoking Treatment for Ontario Patients (STOP) smoking cessation program. Clinics randomized to the intervention group received a prompt when a patient reported consuming alcohol above the Canadian Cancer Society (CCS) guidelines; the control group did not receive computer alerts. The primary outcome was an offer of an appropriate educational alcohol resource, an alcohol reduction workbook for patients drinking above the CCS guidelines, and an abstinence workbook to patients scoring above 20 points in the AUDIT screening tool; the secondary outcome was patient acceptance of the resource. The tertiary outcome was patient abstinence from smoking, and alcohol consumption within CCS guidelines, at 6-month follow-up. Results were analyzed using a generalized estimation approach for fitting logistic regression using a population-averaged method. Results Two hundred and twenty-one clinics across Ontario were randomized for this study; 110 to the intervention arm and 111 to the control arm. From the 15,222 patients that enrolled in the smoking cessation program, 15,150 (99.6% of patients) were screened for alcohol use and 5715 patients were identified as drinking above the CCS guidelines. No statistically significant difference between groups was seen in practitioner offer of an educational alcohol resource to appropriate patients (OR = 1.19, 95% CI 0.88–1.64, p = 0.261) or in patient abstinence from smoking and drinking within the CCS guidelines at 6-month follow-up (OR = 0.93, 95% CI 0.71–1.22, p = 0.594). However, a significantly greater proportion of patients in the intervention group accepted the alcohol resource offered to them by their practitioner (OR = 1.48, 95% CI 1.01–2.16, p = 0.045). Conclusion A CDSS may not increase the likelihood of practitioners offering an educational alcohol resource, though it may have influenced patients’ acceptance of the resource. Trial registration This trial is registered with ClinicalTrials.gov, number NCT03108144, registered on April 11, 2017, “retrospectively registered”. Electronic supplementary material The online version of this article (10.1186/s13012-019-0935-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadia Minian
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Dolly Baliunas
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada
| | - Aliya Noormohamed
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada
| | - Laurie Zawertailo
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Norman Giesbrecht
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada
| | - Christian S Hendershot
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.,Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Jürgen Rehm
- Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Chemnitzer Str. 46, 01187, Dresden, Germany
| | - Andriy V Samokhvalov
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell St, Toronto, ON, M5S 2S1, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 3K1, Canada
| | - Peter L Selby
- Nicotine Dependence Services, Centre for Addiction and Mental Health, 175 College St, Toronto, ON, M5T1P7, Canada. .,Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada. .,Dalla Lana School of Public Health, University of Toronto, 155 College, Toronto, ON, M5T 3M7, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
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16
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Angus C, Brown J, Beard E, Gillespie D, Buykx P, Kaner EFS, Michie S, Meier P. Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England. BMJ Open 2019; 9:e023448. [PMID: 31048422 PMCID: PMC6501949 DOI: 10.1136/bmjopen-2018-023448] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 01/24/2019] [Accepted: 02/18/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Brief interventions (BI) for smoking and risky drinking are effective and cost-effective policy approaches to reducing alcohol harm currently used in primary care in England; however, little is known about their contribution to health inequalities. This paper aims to investigate whether self-reported receipt of BI is associated with socioeconomic position (SEP) and whether this differs for smoking or alcohol. DESIGN Population survey of 8978 smokers or risky drinkers in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies. MEASURES Survey participants answered questions regarding whether they had received advice and support to cut down their drinking or smoking from a primary healthcare professional in the past 12 months as well as their SEP, demographic details, whether they smoke and their motivation to cut down their smoking and/or drinking. Respondents also completed the Alcohol Use Disorders Identification Test (AUDIT). Smokers were defined as those reporting any smoking in the past year. Risky drinkers were defined as those scoring eight or more on the AUDIT. RESULTS After adjusting for demographic factors and patterns in smoking and drinking, BI delivery was highest in lower socioeconomic groups. Smokers in the lowest social grade had 30% (95% CI 5% to 61%) greater odds of reporting receipt of a BI than those in the highest grade. The relationship for risky drinking appeared stronger, with those in the lowest social grade having 111% (95% CI 27% to 252%) greater odds of reporting BI receipt than the highest grade. Rates of BI delivery were eight times greater among smokers than risky drinkers (48.3% vs 6.1%). CONCLUSIONS Current delivery of BI for smoking and drinking in primary care in England may be contributing to a reduction in socioeconomic inequalities in health. This effect could be increased if intervention rates, particularly for drinking, were raised.
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Affiliation(s)
- Colin Angus
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jamie Brown
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Emma Beard
- Department of Clinical, Educational and Health Psychology, UCL, London, UK
| | - Duncan Gillespie
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Penelope Buykx
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Eileen F S Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Susan Michie
- Centre for Outcomes Research and Effectiveness, University College London, London, UK
| | - Petra Meier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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17
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Hall N, Mooney JD, Sattar Z, Ling J. Extending alcohol brief advice into non-clinical community settings: a qualitative study of experiences and perceptions of delivery staff. BMC Health Serv Res 2019; 19:11. [PMID: 30616659 PMCID: PMC6323768 DOI: 10.1186/s12913-018-3796-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022] Open
Abstract
Background At a population level, the majority of alcohol-related harm is attributable to drinkers whose consumption exceeds recommended drinking levels, rather than those with severe alcohol dependency. Identification and Brief Advice (IBA) interventions offer a cost-effective approach for reducing this harm. Traditionally, IBA interventions have been delivered in healthcare settings and therefore contextual influences on their use in non-clinical settings are not well understood. Methods Qualitative face-to-face and telephone interviews with staff responsible for delivering a pilot IBA intervention across community settings in the UK. Interviews were recorded and transcribed verbatim. Inductive thematic analysis was used to identify key issues and the constant comparison method was employed to compare barriers and facilitators to implementation across and within settings. Results A number of facilitators and barriers to delivery and implementation was identified across settings. These included familiarity with the customer base, working within public spaces, and assimilation of the intervention within existing role boundaries. Despite underlying concerns relating to the sensitive nature of the topic, most delivery staff felt their respective settings were appropriate for the delivery of the intervention and had proactively engaged members of the public with varying levels of risky drinking and readiness for behaviour change. Perceptions of actual or potential intervention success were conceptualised in relation to existing day-to-day role boundaries and responsibilities and the contexts in which they took place. Conclusions Findings support the potential value of multi-setting community approaches to facilitate more inclusive engagement with IBA. By comparing experiences and views from staff responsible for delivering the intervention across different community settings, our findings provide insight into how intervention acceptability and success are framed across settings, and how the intervention is assimilated within everyday practice and role boundaries. This study also highlights key areas to be addressed when implementing IBAs in non-clinical community settings by staff with diverse levels of health-related knowledge, skills and support needs. Although essential, the need for adaptable training and delivery approaches across different setting types is likely to result in methodological challenges that need to be addressed when evaluating future interventions and setting-specific influences on behaviour change and health outcomes.
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Affiliation(s)
- Nicola Hall
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sciences Complex, Sunderland, SR1 3SD, UK, England.
| | - John D Mooney
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sciences Complex, Sunderland, SR1 3SD, UK, England
| | - Zeibeda Sattar
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sciences Complex, Sunderland, SR1 3SD, UK, England.,Faculty of Health and Life Sciences, Northumbria University, Newcastle, NE1 8ST, UK, England
| | - Jonathan Ling
- Faculty of Health Sciences and Wellbeing, University of Sunderland, Sciences Complex, Sunderland, SR1 3SD, UK, England
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18
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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O’Donnell A, Abidi L, Brown J, Karlsson N, Nilsen P, Roback K, Skagerström J, Thomas K. Beliefs and attitudes about addressing alcohol consumption in health care: a population survey in England. BMC Public Health 2018; 18:391. [PMID: 29562901 PMCID: PMC5863360 DOI: 10.1186/s12889-018-5275-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/08/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite robust evidence for their effectiveness, it has proven difficult to translate alcohol prevention activities into routine health care practice. Previous research has identified numerous provider-level barriers affecting implementation, but these have been less extensively investigated in the wider population. We sought to: (1) investigate patients' beliefs and attitudes to being asked about alcohol consumption in health care; and (2) identify the characteristics of those who are supportive of addressing alcohol consumption in health care. METHODS Cross-sectional household interviews conducted as part of the national Alcohol Toolkit Study in England between March and April 2017. Data were collected on age, gender, social grade, drinking category, and beliefs and attitudes to being asked about alcohol in routine health care. Unadjusted and multivariate-adjusted logistic regression models were performed to investigate associations between socio-demographic characteristics and drinking category with being "pro-routine" (i.e. 'agree completely' that alcohol consumption should be routinely addressed in health care) or "pro-personal" (i.e. 'agree completely' that alcohol is a personal matter and not something health care providers should ask about). RESULTS Data were collected on 3499 participants, of whom 50% were "pro-routine" and 10% were "pro-personal". Those in social grade C1, C2, D and E were significantly less likely than those in AB of being "pro-routine". Women were less likely than men to be "pro-personal", and those aged 35-44 or 65 years plus more likely to be "pro-personal" compared with participants aged 16-24. Respondents aged 65 plus were twice as likely as those aged 16-24 to agree completely that alcohol consumption is a personal matter and not something health care providers should ask about (OR 2.00, 95% CI 1.34-2.99). CONCLUSIONS Most adults in England agree that health care providers should routinely ask about patients' alcohol consumption. However, older adults and those in lower socio-economic groups are less supportive. Drinking status appears to have limited impact on whether people believe that alcohol is a personal matter and not something health care providers should ask about. REGISTRATION Open Science Framework ( https://osf.io/xn2st/ ).
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Affiliation(s)
- Amy O’Donnell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX UK
| | - Latifa Abidi
- Department of Health Promotion, Maastricht University, Maastricht, Limburg Netherlands
| | - Jamie Brown
- Research Department of Behavioural Science and Health, University College London, London, UK
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nadine Karlsson
- Department of Medical and Health Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Per Nilsen
- Department of Medical and Health Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Kerstin Roback
- Department of Medical and Health Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Janna Skagerström
- Research and Development Unit, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kristin Thomas
- Department of Medical and Health Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
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