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Table 2 Overall results of the findings using Consolidated Framework for Implementation Research

From: Using Consolidated Framework for Implementation Research to investigate facilitators and barriers of implementing alcohol screening and brief intervention among primary care health professionals: a systematic review

Domain/constructs Facilitators of implementation Population and range of sample size among different studies (see the note below this table) Country (see the note below this table) Reference Barriers of implementation Population and range of sample size among different studies (see the note below this table) Country (see the note below this table) Reference
Intervention characteristics
 Intervention source
 Evidence strength and quality Proven efficacy of SBI P(4): 126-282 AU(1) CA(1) DK(1) FR(1) GB(3) HU(1) IT(1) NO(1) NZ(1) PO(1) RU(1) [15, 16, 60, 93] Doubt about the effectiveness of SBI P(4): 75–131
DHP(2): 43–47
FI(2) GB(2) US(2) [21, 23, 26, 46, 56, 90]
 Relative advantage
 Adaptability Targeted rather than universal screening, such as new patient registrations, general health checks, and particular types of consultations DHP(1): 43 GB(1) [26]
Computer-based methods for screening DHP(2): 18-47 US(2) [56, 74]
 Trialability
 Complexity Perceiving SBI as a complex intervention DHP(1): 214 ZA(1) [81]
 Design quality and packaging Simplicity of SBI techniques DHP(1): 79 BR(1) [38]
 Cost Workload or lack of time P(32):13–2377
N(6):19–2549
DPH(4):18–2468
AU(1) BR(1) CA(2) DE(2) DK(1) ES(3) FI(2) FR(2) GB(9) HU(1) IT(2) LK(1) NO(1) NZ(2) PO(2) RU(1) SE(6) SI(2) TR(1) US(5) ZA(1) [15, 16, 1922, 2426, 37, 38, 41, 48, 5055, 5763, 68, 69, 7476, 82, 83, 86, 93]
Causing management or logistic problems P(4): 81–2377
N(1): 196DHP(1): 47
GB(3) LK(1) US(1) [5052, 56, 57]
Considerable resources or too much effort needed P(1): 24
DHP(1): 2468
DE(1) DK(1) ES(1) FR(1) GB(1) IT(1) [42, 58]
Outer setting
 Patient needs and resources Willingness to be asked about their drinking consumption, receive adv, or pay for alcohol counselling P(2): 84–276
N(1): 167
DHP(1): 47
AU(1) FI(1) PO(1) [13, 47, 60] Refusal, unwilling, or low interest to take advice or receive help P(11): 32–853
N(2): 47–141
DHP(2): 32–47
AU(2) CA(1) DK(1) ES(1) FR(1) GB(3) HU(1) IT(1) NZ(1) NO(1) PO(2) RU(1) SE(1) SI(1) TR(1) US(3) ZA(1) [15, 16, 22, 37, 47, 48, 54, 55, 60, 61, 82, 27, 93]
Request for health advice on alcohol consumption or self-motivation for seeking help P(6): 43–2377 AU(1) CA(1) DK(1) FR(1) GB(4) HU(1) IT(1) NZ(1) NO(1) PO(2) RU(1) [15, 16, 51, 60, 83, 93] Denial of alcohol misuse P(5): 35–211 DE(1) FI(1) FR(1) GB(1)US(2) [23, 41, 49, 54, 68]
Showing alcohol-related symptoms P(3):13–1790
N(1): 2549
FI(1) SE(2) [21, 59, 63] Dishonesty of alcohol consumption or unreliable patient alcohol use histories P(2): 19 AU(1) NZ(1) [76, 91]
Clear reason for consultation of patients P(1): 35 FI(1) [21] Neglect of negative consequences caused by excessive alcohol consumption P(1): 60
N(1): 47
ES(1) [48]
Risk status as measured by AUDIT score P(1): 84
N(1): 128
GB(2) [66, 71] Private health insurance did not reimburse patients for alcohol counselling P(3): 126–279 AU(1) CA(1) DK(1) FR(1) GB(2) HU(1) IT(1) NZ(1)
NO(1) PO(2) RU(1)
[15, 16, 60]
Materials for patients P(1): 170 AU(1) [80] Discomfort when talking about alcohol issues DHP(1): 32 US(1) [27]
 Cosmopolitanism Referral services were available, such as provision of addiction care, specialized treatment for alcohol problems, access to local community alcohol teams, general support services (e.g. self-help or counselling) P(15): 24–1842
N(2): 193–2549
AU(1) CA(1) GB(5) LK(1) NO(2) PO(1) SE(2) SI(1) US(1) [15, 18, 19, 24, 46, 50, 52, 57, 59, 60, 72, 78, 80, 86, 93] Lack of referral services or difficulty in patients’ referral P(7): 42–853
DHP(4): 32–79
AU(1) BR(1) CA(2) DK(1) FR(1) GB(2) HU(1) IT(1) NL(1) NZ(1) O(1) PO(1) RU(1) US(5) ZA(1) [16, 38, 55, 56, 83, 89, 90, 92, 27]
 Peer pressure
 External policy and incentives Implementation of SBI using a national alcohol strategy; P(1): 32 SI(1) [19] Lack of government policy to support preventive medicine P(5): 32–279 AU(1) BR(1) CA(1) DK(1) FR(1) GB(2) HU(1) IT(1) NZ(1) NO(1) PO(2) RU(1) SI(1) ZA(1) [15, 16, 22, 60, 82]
Public health education campaigns make society more concerned about alcohol; P(5\4): 126–282 AU(1) CA(1) DK(1) FR(1) GB(3) HU(1) IT(1) NZ(1) NO(1) PO(2) RU(1) [15, 16, 60, 93]
Policy making preventive medicine a higher status in the medical profession; P(1): 126 AU(1) CA(1) DK(1) FR(1) GB(3) HU(1)
IT(1) NL(1) NZ(1) NO(1) PO(1) RU(1)
[16]
Professional recognition of early intervention by medical bodies P(1): 126 AU(1), CA(1) DK(1) FR(1) GB(1) HU(1) IT(1) NL(1) NZ(1) NO(1) PO(1) RU(1) [16]
Inner setting
 Structural characteristics Teamwork or interprofessional cooperation in the delivery of SBI P(1): 1790
N(1): 2549
DHP(3): 18–214
BR(1) SE(1) US(1) ZA(1) [38, 59, 74, 81] Lack of staff, specialist support or multidisciplinary team P(3): 41–2377
DHP(1): 43
GB(2) US(1) ZA(1) [26, 41, 51, 92]
 Networks and communications
 Culture Organizational culture about alcohol use DHP(1): 79 BR(1) [38]
 Tension for change
 Compatibility Interruptions of the natural course of consultations P(3): 24–40 DK(1) NO(1) SI(1) [42, 78, 82]
Doubt about the appropriateness of screening all patients P(3): 24–40 CA(1) NO(1) SE(1) [62, 78, 86]
 Relative priority Prioritization of alcohol issues DHP(2): 18–214 US(1) ZA(1) [74, 81] Low rating of importance of alcohol screening, patients with multiple problems or other competing priorities P(1): 43
DHP(2): 79–2468
BR(1) DE(1) ES(1) GB(2) IT(1) [38, 58, 83]
 Organizational incentives and rewards Financial support/ incentives/reimbursements, such as improving salary conditions, health scheme reimbursements P(8): 32–2345 AU(1) CA(1) CZ(1) DK(1) ES(1) FR(1) GB(4) HU(1) IT(2) NL(1) NO(2) NZ(1) PO(3) PT(1) RU(1) SI(2) [1519, 60, 93] Lack of financial support, incentives, reimbursement, funding, such as
Contractual incentives, time spent on treating alcohol patients
P(8): 32–282
DHP(1): 43
AU(1) CA(1) K(1) FR(1) GB(4) HU(1) IT(1) NO(1) NZ(1) PO(2) RU(1) SI(1) US(1) ZA(2) [15, 16, 22, 26, 60, 69, 82, 92, 93]
Training in early alcohol intervention recognized for continuing medical education credits P(2): 126–279 AU(1), CA(1) DK(1), FR(1) GB(2) HU(1) IT(1) NZ(1) NO(1) PO(1) RU(1) [15, 16]
Providing early alcohol intervention recognized for quality assurance credits P(3): 276–282 GB(2), PO(1) [15, 60, 93]
 Goals and feedback Lack of understanding of the goals of SBI DHP(1): 32 US(1) [27]
 Learning climate More chances to try and observe SBI DHP(1): 214 ZA(1) [81]
 Leadership engagement Variability of the institutional support due to changes in leadership DHP(1): 79 BR(1) [38]
 Available resources Training P(15): 15–2377
N(3): 167–196
DHP(2): 47–214
AU(5) BE(2) BG(1) CA(2) CZ(1) ES(1) FI(1) FR(1) GB(11) U(1) IT(2) LK(1) NL(1) NO(1) NZ(1) PO(3) PT(2) SE(1) SI(1) TH(1) ZA(2) [1315, 17, 22, 24, 45, 47, 5053, 57, 60, 6567, 80, 81, 93] Lack of training in detection in alcohol misuse, counselling in reducing alcohol consumption P(17): 42–2377
N(4): 47–196
DHP(2): 32–47
AU(2) BE(1) BG(1) CA(2) DK(1) ES(1) FI(1) FR(2) GB(7) HU(2) IT(2) LK(1) NZ(2) NO(2) PO(3) PT(1) RU(1) SE(1) TH(1) US(6) ZA(1) [13, 15, 16, 22, 24, 395052, 5457, 60, 65, 69, 79, 27, 93]
Screening and counselling materials were available P(9): 13–2345
N(1): 193
AU(3) CA(1) CZ(1) DK(1) ES(1) FI(1) FR(1) GB(4) HU(1) IT(2) NL(1) NO(1) NZ(1) PO(3) PT(1) RU(1) SE(2) SI(1) [1517, 24, 25, 35, 60, 80, 93] Lack of screening devices or counselling materials P(8): 24–282
N(1): 193
DHP(1): 47
CA(1) FI(2) GB(2) SE(1) PO(1) US(1) ZA(1) [15, 2124, 56, 60, 86, 93]
Lack of space and in-patient facilities P(1): 77
DHP(2): 32–47
GB(1) US(1)
ZA(1)
[26, 92]
 Access to knowledge and information Easy access to clear guidelines or information related to implementing SBI P(2): 84–1790
N(2): 167–2549
DHP(1): 47
AU(1) FI(1) SE(1) [13, 47, 59] Lack of guidelines P(2): 18–32
N(1): 19
FI(1) SI(1) [20, 82]
Support calls responding to questions or problems that arose during SBI P(2): 632–1300 AU(2) BE(2) CA(2) FR(1) GB(2) IT(1) NO(1) NZ(1) PT(1) [14, 40]
Characteristics of individuals  
 Knowledge and beliefs about the intervention Knowledge: knowledge, qualification, or education level of alcohol medicine P(8): 50–2345
DHP(1): 47
AU(2) BE(1) CA(3) CZ(1) DK(1) ES(2) FR(2) GB(5) HU(1) IT(3) NL(1) NZ(2) NO(2) PO(2) PT(2) RU(1) SE(1) SI(1) US(1) [16, 17, 40, 46, 53, 56, 59, 75, 85] Knowledge: confusion regarding the definition of early-phase heavy drinking and problem drinkers, the recommended sensible drinking limits, or what is health drinking P(12): 18–282
N(5): 19–193
AU(1) CA(1) DK(1) FI(2) FR(1) GB(5) HU(1) IT(1) LK(1) NO(2) NZ(1) PO(2) RU(1) SE(1) SI(1) TR(1) ZA(1) [13, 15, 16, 20, 22, 24, 37, 57, 60, 70, 78, 79, 82, 93]
Familiarity with expert guidelines P(1): 853 US(1) [55] Insufficient knowledge of screening tools, intervention techniques, counselling skills P(10): 19–1790
N(3): 32–2549
DHP(2): 18–2468
AU(2) CA(1) DE(2) DK(1) FI(2) ES(1) FR(2) GB(2) HU(1) IT(2) NZ(1) NO(1) PO(1) RU(1) SE(1) SI(1) TR(1) US(2) ZA(1) [13, 16, 22, 37, 41, 58, 59, 64, 68, 74, 82, 91]
knowledge of alcohol screening or brief intervention; P(6): 15–1790
N(2): 28–2549
AU(1) ES(1) NL(1) NO(1) PO(1) SE(3) SI(1) [18, 19, 45, 59, 61] Having their own disease model rather than prevention model of alcohol problems P(4): 50–2345 ES(1) CZ(1) GB(2) IT(1) NL(1) PO(2) PT(1) SI(1) ZA(1) [15, 17, 22, 60]
already had their own strategies in asking patients about their alcohol drinking; P(1): 43 GB(1) [73] Low awareness of alcohol problems P(2): 35–170
DHP(1): 43
AU(1) FI(1) GB(1) [21, 26, 80]
practical skills in interviewing or counselling technique P(2): 68–1790
N(2): 193–2549
NO(1) SE(2) [18, 24, 59]     
Beliefs: the belief that having the responsibility to ask about patient's alcohol consumption P(5): 24–1790
N(2): 141–2549
CA(1) FI(1) NO(2) SE(2) [35, 59, 61, 78, 86] Beliefs: the belief that discussion about alcohol issues might harm the patient-physician relationship P(8): 13–901
N(1): 26
DHP(2): 18–43
AU(1) FI(1) GB(1) NO(2) SE(3) SI(1) TR(1) US(1) [18, 21, 25, 26, 37, 62, 63, 74, 78, 82, 91]
The belief that having the right to ask patients about their drinking P(4): 24–1235
N(1): 24
CA(2) GB(3) US(1) [39, 46, 53, 70, 85, 86] The belief that alcohol was not an important risk factor P(2): 35–211 DE(1) FI(1) [23, 68]
Greater therapeutic commitment to working with alcohol problems P(3): 101–1300 AU(2) BE(2) CA(2) FR(2) GB(2) IT(1) NZ(1) NO(1) PT(1) [14, 40, 49] The belief that drinking was a personal rather than a medical responsibility P(5): 50–2345 CZ(1) ES(1) GB(3) IT(1) NL(1) PO(3) PT(1) SI(1) ZA(1) [15, 17, 22, 53, 60]
The belief that health status was influenced by alcohol P(3): 24–67
N(1): 141
DHP(1): 214
CA(2) SE(1) US(1) ZA(1) [61, 81, 86, 89, 27] The belief that alcohol issue was not an important issue in general practice P(3): 135–279 GB(1) PO(1) TR(1) [15, 60, 37]
The belief that it was rewarding to treat patients with alcohol use disorder P(1): 105 LK(1) [57] The belief that general practice was not organized for preventive medicine P(2): 50–279 GB(1) ZA(1) [15, 22]
The belief that it was rewarding to treat patients with alcohol use disorder P(1): 105 LK(1) [57] The belief that it was not rewarding to work with drinkers P(6): 71–2377 CA(1) GB(4) US(1) [39, 46, 5052, 85]
The belief in preventive function of screening P(4): 65–1842
N(1): 141
AU(1) PO(1) SE(1) US(1) [60, 61, 72, 80] The belief that discussing alcohol consumption was unacceptable P(1): 37
N(1): 32
FI(1) [64]
The belief that anyone could develop alcohol problems P(1): 65
N(1): 141
SE(1) [61] The belief that regular screening was unnecessary DHP(1) 2468 DE(1) ES(1) FR(1) GB(1) IT(1) [58]
The belief that general practice was an appropriate setting or alcohol issue was an important issue in general practice P(6): 24–2377
N(3): 32–196
DHP(1): 32
CA(1) FI(2) GB(3) US(1) [13, 5153, 64, 86, 27] The belief that moderate use of alcohol was acceptable or it had social or coping function P(2): 35–276
N(1): 14
FI(1) GB(1) PO(1) [23, 60, 70]
     Doubt about the rationale in screening in young people P(1): 24 DK(1) [42]
     The belief that some people used for traditional purpose DHP(1): 214 ZA(1) [81]
     The belief that asking elderly about their drinking was a sign of disrespect DHP(1): 214 ZA(1) [81]
     Other negative/pessimistic attituded towards alcohol patients such as not feeling proud, unwilling to work with drinkers, more tiring to take care of Patients with alcohol problem than other patients P(4): 50–1235 N(1): 141 CA(1) GB(1) LK(1) SE(1) [53, 57, 61, 85]
 Self-efficacy Self-efficacy in alcohol history taking; N(1): 196 US (1) [55] Low self-efficacy in inquiring about patients’ alcohol drinking, giving advice, counselling patients P(4): 24–75 CA(1) DK(1) GB(1) ZA(1) [22, 42, 46, 77]
Confident in alcohol management skills or in asking, giving advice, motivating or influencing patients’ drinking P(12): 15–2345
N(1): 167
DHP(1): 746
AU(2) BE(1) CA(2) ES(1) FI(1) FR(1) GB(4) IT(1) LK(1) NL(1) NO(1) NZ(1) PO(2) PT(1) SE(1) US(2) [13, 40, 43, 45, 50, 57, 60, 72, 83, 85, 88] Not confident or discomfort in working in alcohol issues (e.g. Establishing rapport with patients) or in helping patients reduce alcohol consumption P(13): 15–2377
N(3): 19–141
DHP(1): 79
BR(1) CA(1) DK(1) FI(2) GB(3) NO(1) PO(1) SE(3) US(1) ZA(1) [15, 18, 20, 22, 38, 42, 51, 52, 6064, 69, 86]
 Individual stage of change
 Individual identification with the organization
 Other personal attributes Male patients P(3): 58–901
N(1): 128
DE(1) GB(2) NO(1) [18, 44, 66, 71] University educated or old patients (60–69 years old) P(1): 84 GB(1) [66]
Unemployed patients P(1): 84 GB(1) [66] Physicians had alcohol drinking habits or problems P(2): 32–276 PO(1) SI(1) [60, 82]
Younger physician age P(2): 853–901 NO(1) US(1) [18, 55] Some nurses worried more or had lower self-efficacy than physicians P(1): 65
N(1): 141
SI(1) [61]
Female healthcare providers P(4): 58–1842
N(1): 228
DE(1) ES(1) US(2) [44, 55, 72, 84] Lack of motivation of physicians P(1): 312 US(1) [39]
Longer years of practice P(2): 101–3611 FI(1) US(1) [87, 88] Female physicians P(1): 24 CA(1) [86]
Physicians (asking about alcohol use) P(1): 65
N(1): 141
SE(1) [61]
Nurses (provided advice for reducing alcohol use) P(1): 1543
N(1): 228
ES(1) [84]
Smaller number of patients seen by GP in an average week P(1): 276 PO(1) [60]
Longer average practice consultations P(1): 84 GB(1) [66]
Solo practice P(1): 84 GB(1) [66]
Physician’s motivation or interest in alcohol issues P(2): 32–71 GB(1) SI(1) [19, 46]
Having a specialist licence in general practice or occupational health care P(2): 1909–3611 FI(2) [36, 87]
Process  
 Planning
 Engaging
 Executing Lack of a systematic strategy P(1): 24 CA(1) [86]
 Reflecting and evaluating The feedback provided by the SBI trainers during their visits at the clinics DHP(1): 214 ZA(1) [81]
  1. Note:
  2. 1. Abbreviations for populations: P physicians, N nurses, DHP different health professionals
  3. 2. The number in the bracket in Population and Country indicated the number of studies, and the number on the right-hand side in Population indicated the range of numbers of participants
  4. 3. Abbreviations for country names: AU Australia, BE Belgium, BG Bulgaria, BR Brazil, CA Canada, CZ Czech Republic, DE Germany, DK Denmark, ES Spain, FI Finland, FR France, GB United Kingdom of Great Britain and Northern Ireland, HU Hungary, IT Italy, LK Sri Lanka, NL Netherlands, NZ New Zealand, NO Norway, PO Poland, PT Portugal, RU Russia, SE Sweden, SI Slovenia, TH Thailand, TR Turkey, US the United States of America, ZA South Africa