Nadia Minian1,2,3,4, Aliya Noormohamed1, Mathangee Lingam1, Laurie Zawertailo1,3,5, Bernard Le Foll2,3,4,5,6, Jürgen Rehm3,7,8, Norman Giesbrecht7,9, Andriy V Samokhvalov6,10,11,12, Dolly Baliunas1,9,13, Peter Selby14,15,16,17,18. 1. Nicotine Dependence Service, Centre for Addiction and Mental Health, 1025 Queen Street W, Toronto, ON, M6J 1H4, Canada. 2. Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada. 3. Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St, 1st floor Toronto, ON, M6J 1H4, Canada. 4. Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada. 5. Department of Pharmacology and Toxicology, Faculty of Medicine, Medical Sciences Building, University of Toronto, Room 4207, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada. 6. Department of Psychiatry, University of Toronto, 250 College St., Toronto, ON, M5T 1R8, Canada. 7. Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON, M5S 2S1, Canada. 8. Technische Universität Dresden, Klinische Psychologie & Psychotherapie, Chemnitzer Str. 46B, 01187, Dresden, Germany. 9. Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada. 10. Addiction Division, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON, M5S 2S1, Canada. 11. Homewood Health Centre, 150 Delhi St., Guelph, ON, N1E 6K9, Canada. 12. Department of Psychiatry and Behavioural Neurosciences, McMaster University, 100 West 5th Street, Hamilton, ON, L8N 3K7, Canada. 13. School of Public Health, The University of Queensland, Herston, QLD, Australia. 14. Nicotine Dependence Service, Centre for Addiction and Mental Health, 1025 Queen Street W, Toronto, ON, M6J 1H4, Canada. peter.selby@camh.ca. 15. Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON, M5G 1V7, Canada. peter.selby@camh.ca. 16. Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St, 1st floor Toronto, ON, M6J 1H4, Canada. peter.selby@camh.ca. 17. Department of Psychiatry, University of Toronto, 250 College St., Toronto, ON, M5T 1R8, Canada. peter.selby@camh.ca. 18. Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada. peter.selby@camh.ca.
Abstract
BACKGROUND: Randomized trials of complex interventions are increasingly including qualitative components to further understand factors that contribute to their success. In this paper, we explore the experiences of health care practitioners in a province wide smoking cessation program (the Smoking Treatment for Ontario Patients program) who participated in the COMBAT trial. This trial examined if the addition of an electronic prompt embedded in a Clinical Decision Support System (CDSS)-designed to prompt practitioners to Screen, provide a Brief intervention and Referral to Treatment (SBIRT) to patients who drank alcohol above the amounts recommended by the Canadian Cancer Society guidelines-influenced the proportion of practitioners delivering a brief intervention to their eligible patients. We wanted to understand the factors influencing implementation and acceptability of delivering a brief alcohol intervention for treatment-seeking smokers for health care providers who had access to the CDSS (intervention arm) and those who did not (control arm). METHODS: Twenty-three health care practitioners were selected for a qualitative interview using stratified purposeful sampling (12 from the control arm and 11 from the intervention arm). Interviews were 45 to 90 min in length and conducted by phone using an interview guide that was informed by the National Implementation Research Network's Hexagon tool. Interview recordings were transcribed and coded iteratively between three researchers to achieve consensus on emerging themes. The preliminary coding structure was developed using the National Implementation Research Network's Hexagon Tool framework and data was analyzed using the framework analysis approach. RESULTS: Seventy eight percent (18/23) of the health care practitioners interviewed recognized the need to simultaneously address alcohol and tobacco use. Seventy four percent (17/23), were knowledgeable about the evidence of health risks associated with dual alcohol and tobacco use but 57% (13/23) expressed concerns with using the Canadian Cancer Society guidelines to screen for alcohol use. Practitioners acknowledged the value of adding a validated screening tool to the STOP program's baseline questionnaire (19/23); however, following through with a brief intervention and referral to treatment proved challenging due to lack of training, limited time, and fear of stigmatizing patients. Practitioners in the intervention arm (5/11; 45%) might not follow the recommendations from CDSS if these recommendations are not perceived as beneficial to the patients. CONCLUSIONS: The results of the study show that practitioners' beliefs were reflective of the current social norms around alcohol use and this influenced their decision to offer a brief alcohol intervention. Future interventions need to emphasize both organizational and sociocultural factors as part of the design. The results of this study point to the need to change social norms regarding alcohol in order to effectively implement interventions that target both alcohol and tobacco use in primary care clinics. Trial registration ClinicalTrials.gov NCT03108144. Retrospectively registered 11 April 2017, https://www.clinicaltrials.gov/ct2/show/NCT03108144.
BACKGROUND: Randomized trials of complex interventions are increasingly including qualitative components to further understand factors that contribute to their success. In this paper, we explore the experiences of health care practitioners in a province wide smoking cessation program (the Smoking Treatment for Ontario Patients program) who participated in the COMBAT trial. This trial examined if the addition of an electronic prompt embedded in a Clinical Decision Support System (CDSS)-designed to prompt practitioners to Screen, provide a Brief intervention and Referral to Treatment (SBIRT) to patients who drank alcohol above the amounts recommended by the Canadian Cancer Society guidelines-influenced the proportion of practitioners delivering a brief intervention to their eligible patients. We wanted to understand the factors influencing implementation and acceptability of delivering a brief alcohol intervention for treatment-seeking smokers for health care providers who had access to the CDSS (intervention arm) and those who did not (control arm). METHODS: Twenty-three health care practitioners were selected for a qualitative interview using stratified purposeful sampling (12 from the control arm and 11 from the intervention arm). Interviews were 45 to 90 min in length and conducted by phone using an interview guide that was informed by the National Implementation Research Network's Hexagon tool. Interview recordings were transcribed and coded iteratively between three researchers to achieve consensus on emerging themes. The preliminary coding structure was developed using the National Implementation Research Network's Hexagon Tool framework and data was analyzed using the framework analysis approach. RESULTS: Seventy eight percent (18/23) of the health care practitioners interviewed recognized the need to simultaneously address alcohol and tobacco use. Seventy four percent (17/23), were knowledgeable about the evidence of health risks associated with dual alcohol and tobacco use but 57% (13/23) expressed concerns with using the Canadian Cancer Society guidelines to screen for alcohol use. Practitioners acknowledged the value of adding a validated screening tool to the STOP program's baseline questionnaire (19/23); however, following through with a brief intervention and referral to treatment proved challenging due to lack of training, limited time, and fear of stigmatizing patients. Practitioners in the intervention arm (5/11; 45%) might not follow the recommendations from CDSS if these recommendations are not perceived as beneficial to the patients. CONCLUSIONS: The results of the study show that practitioners' beliefs were reflective of the current social norms around alcohol use and this influenced their decision to offer a brief alcohol intervention. Future interventions need to emphasize both organizational and sociocultural factors as part of the design. The results of this study point to the need to change social norms regarding alcohol in order to effectively implement interventions that target both alcohol and tobacco use in primary care clinics. Trial registration ClinicalTrials.gov NCT03108144. Retrospectively registered 11 April 2017, https://www.clinicaltrials.gov/ct2/show/NCT03108144.
Entities:
Keywords:
Alcohol drinking; Clinical Decision Support System; Hexagon Tool; Primary Health Care; Qualitative Interviews; Smoking cessation; Tobacco
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