Aims To test if training and support of primary health care providers (PHCP), financial reimbursement to PHCP for screening and brief advice, and option for PHCP to refer screen positive patients to an internet-based method of giving advice (eBI) increases PHCP's delivery of screening and advice to heavy drinkers, compared to a control group of PHCPs.Design Cluster randomized factorial trial with 12-week implementation measurement period.Setting Primary health care units (PHCU) in different locations throughout Catalonia, England, Netherlands, Poland and Sweden.Participants 120 PHCU, 24 in each of Catalonia, England, Netherlands, Poland and Sweden.Interventions PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR), and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI.Outcome measures Primary outcome measures is proportion of eligible patients screened during a 12-week implementation period. Secondary outcome measures are proportion of screen positive patients advised; and, proportion of consulting adult patients given an intervention (screening and advice to screen positives) during the same 12-week implementation period.Results During a 4-week baseline measurement period, 5.9 (95% CI 3.4 to 8.4)per 100 adult patients consulting per PHCU were screened for their alcohol consumption. Based on the factorial design, PHCU that received TS had a 1.48 (95% CI 1.13 to 1.95)relatively higher proportion of patients screened during the 12-week implementation period than PHCU that did not receive TS; PHCU that received FR had a 2.00 (95% CI 1.56 to 2.56) relatively higher proportion than no FR. The option of referral to eBI did not have a higher proportion. A combination of TS plus FR had a 2.34 (95% CI 1.77 to 3.10) relatively higher proportion of patients screened than no TS plus FR. A combination of TS plus FR plus eBI had a 1.68 (95% CI 1.11 to 2.53) relatively higher proportion of patients screened than no TS plus FR plus eBI.Conclusions Training and support of PHCP, and financial reimbursement to PHCP for screening and brief advice increase the proportion of adult patients screened for their alcohol consumption, at least in the short term. Trial registration ClinicalTrials.gov. Trial identifier: NCT015015523

The extent of alcohol education and GPs' attitudes towards alcohol were associated with the reported number of patients managed. Thus, it is worth exploring the extent to which improved education, using pharmacotherapy in primary health care and a shift to personalized health care in which individual patients are facilitated to undertake their own assessment and management (individual responsibility) might increase the number of heavy drinkers who receive feedback on their drinking and support to reduce their drinking.

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis Conclusions Strategies should include a combination of patient, professional and organisational oriented implementation approaches and involvement of mid-level professions as well as physicians. Evidence for a new and innovative combination of multiple implementation approaches to increase alcohol focused SBI uptake in PHC, is required.4

The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.