The European Union (EU) has the highest alcohol consumption of the world: in 2009, the average adult (aged 15+ years) alcohol consumption in the EU was 12.5 litres of pure alcohol . A review showed that consumption above 20 to 30 grams of alcohol a day (two to three glasses of wine) increases an individual’s risks of mortality and morbidity [2, 3]. However, people often overestimate the positive health effects of alcohol; in fact, only small amounts of alcohol have positive effects on health [2, 3].
Alcohol consumption is the third world leading cause of diseases and premature death . The costs related to alcohol are €125bn a year for health, welfare, employment, and criminal justice sectors as a consequence of alcohol-attributable disease, injury, and violence . Therefore, individuals and society would benefit from effective preventive measures with respect to morbidity and mortality and social costs.
There is considerable evidence showing that early identification of hazardous and harmful alcohol consumption result in reduced alcohol consumption and improved health outcomes. Primary healthcare (PHC) is the primary point of contact for many people seeking healthcare. In this setting, screening  and brief intervention programs have proven to be effective in reducing alcohol consumption [6–10], with a mean reduction of 38 grams of alcohol per week (three to four glasses of wine) . Although the evidence is still inconsistent about positive effects of nurse-led interventions [11, 12], generally screening and brief interventions are provided by healthcare workers such as GPs, nurses, or psychologists . The number needed to treat (NNT) in offering screening and brief interventions is eight (for every eight people treated one will change their behaviour) , which is relatively low compared to smoking cessation, which has a NNT of around 35 or higher . Despite the evidence for efficacy and cost-efficacy of screening and brief interventions in PHC, these interventions are rarely implemented in routine practice . Commonly, less than 10% of the population at risk are identified, and less than 5% of those who could benefit are offered screening and brief interventions in PHC settings .
Some of the reasons for this gap are identified and can be categorised in three main domains. First, evidence suggests there is substantial lack of knowledge among general practitioners (GPs) [5, 16]. A survey across 13 countries found that one-third of all GPs reported never receiving alcohol-related education, 23% reported less than four hours, and 37% reported more than seven hours of alcohol-related education ever . A recent update from England has shown that 52% of the United Kingdom’s surveyed GPs indicated that they had received less than four hours of post-graduate training, continuing medical education, or clinical supervision on alcohol and alcohol related problems . Furthermore a lack of role security and therapeutic commitment has been identified .
Secondly, lack of adequate resources and support are identified as important barriers [16, 20]. Financial reimbursement could be important measures to overcome this barrier, but as far as we know, there have been no randomised controlled trials conducted investigating the impact of reimbursement for alcohol screening and brief interventions in the PHC setting.
The third important barrier relates to time constrains in terms of perceived workload and work pressure for screening and brief intervention activities . In PHC, trained nurses are increasingly involved in preventive care activities and in the management of chronic ill patients due to the increased workload of GPs. It has shown that they provide safe and effective care . This study focuses on all healthcare professionals working at primary healthcare units (PHCUs).
Although previous implementation studies [22, 23] have tried to increase screening and brief interventions in primary healthcare, the gap between scientific knowledge and everyday clinical practice remains . With regard to the first category of barriers of knowledge and attitude, earlier studies found that training and support could make GPs even less secure in their work with drinkers, when the training and support does not address prior GP’s attitude in the training and support [15, 19]. In the ODHIN study, we will tailor our implementation strategy to the primary healthcare worker’s prior attitude. With regard to the second category, lack of resources, there are mixed results of evidence of finance systems to change provider behaviour [25, 26]. There is limited evidence that finance systems can change provider behaviour of screening and brief interventions of alcohol . Still, financial incentives for smoking cessation interventions have shown a significant positive outcome on increases in referral to tobacco cessation services , and suggest financial support for alcohol interventions might be effective. In the third category, workload and work pressure, we suggest e-health interventions might be of benefit. E-self help interventions without therapist support are available both in brief and more extended formats and have shown to be effective in reduction of alcohol consumption . Additionally, internet interventions with therapist support focused on depression and anxiety were found to have larger effect sizes compared to internet interventions without therapist support , but has not yet been tested for alcohol internet interventions. These e-health interventions might be helpful to reduce workload of healthcare professionals after identification of patients at risk as well as availability for patients 24 h a day. Therefore, it is of interest to test if primary healthcare workers’ referral to internet-based brief interventions, hereafter termed e-BI, could be time-saving for healthcare professionals and consequently might raise primary care worker’s intervention activity.
It is of significant public health interest to explore, and optimize, effective implementation strategies to improve PHC activities in screening and brief interventions for hazardous and harmful alcohol consumption. In the current study, we evaluate the effect of three strategies, each aimed to tackle one of the above reported barriers, singly or in combination, in order to overcome the gap between knowledge and daily practice.
Aim and objectives
Our aim is to study the effectiveness of training and support (T&S), financial reimbursement, and internet based brief interventions (e-BI), targeted singly or in combination to primary healthcare units, on screening and brief intervention activities, compared to treatment as usual. The following hypotheses will be tested in the study:
Provision of training and support to primary healthcare providers will increase use of preventive screening and brief interventions compared to a care as usual control group.
Financial reimbursement to primary healthcare providers as a pay-for-performance of brief alcohol interventions will increase screening and brief intervention rates compared to care as usual.
Providing resources, i.e., offering referral possibility to an internet-based method of delivering brief intervention, will increase screening and brief intervention rates compared to care as usual.
The combination of training and support, financial reimbursement, and e-BI will be more effective in increasing screening and brief intervention rates compared to single-focused implementation strategies.