Table 1: Baseline characteristics of the 23 practitioner who participated in the interviews.
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Control (n=12)
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Intervention (n=11)
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Organization type
|
|
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CHC
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2
|
5
|
FHT
|
9
|
5
|
NPLC
|
1
|
1
|
Organization Performance
|
|
|
Sites that provided the alcohol workbook infrequently (less than 30%),
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4
|
3
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Sites that provided the alcohol workbook some of the time (30%-69%)
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7
|
6
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Sites that provided the alcohol workbook most of the time (at least 70%)
|
1
|
2
|
Participant Gender
|
|
|
Male
|
1
|
1
|
Female
|
11
|
10
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Participant Occupation
|
|
|
Nursea
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6
|
7
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Pharmacist
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2
|
2
|
Otherb
|
4
|
2
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Years in STOP Program
|
|
|
< 2 years
|
2
|
2
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2-5 years
|
3
|
6
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> 5 years
|
7
|
3
|
a Includes registered nurse and registered practical nurse.
b Includes social worker, respiratory therapist, dietician
We organized our findings below using the key domains of the Hexagon Tool (32). First, we present the three components of the Hexagon Tool associated with the COMBAT program (evidence, supports, and usability) followed by the three components of the Hexagon Tool associated with the STOP implementing sites (need, fit, capacity).
(1) Evidence: practitioners’ belief that there is evidence that implementing a brief alcohol intervention to the STOP program will be beneficial.
Most practitioners (17/23) believed there is evidence demonstrating the effectiveness of addressing alcohol in a smoking cessation program.
“it’s not a separate issue. They can address both at the same time and people can be successful at addressing both two addictions.” Interview 18
“When you get into smoking cessation, of course we all know the relevance [of addressing alcohol]” Interview 14
"I really support the fact that you can stop everything at once because everything comes together half the time, anyway. You increase your smoking with your alcohol use. …. You associate these things quite a bit together, so it’s excellent to stop everything at the same time." Interview 16
However some practitioners (n=6) voiced concerns that addressing alcohol may negatively affect participants’ smoking cessation efforts.
“If you [try to] fix everything at once they end up not doing anything. They get discouraged and they get dismayed and they just, fall off wagon. So, you've got to figure out which is the most important and...thing to do right now. Tackle that and get some success and then you can start tackling the others. So, my stance is if...perhaps that is the case with addiction too. So, again, with the alcohol thing, I really don't think it's something to be pursued at that appointment. At that baseline appointment. Yeah. Mention it but other than that, move on and let's stick with your priority because, you've already identified the...that you want to give up smoking.” Interview 10
Even when practitioners believed it was important to address alcohol and smoking at the same time, many participants (n=13) expressed some concerns with using the CCS guidelines to screen for alcohol use:
"I think that, you know, guidelines aren’t black and white. Right? … I think there needs to be some professional judgment." Interview 21
“The average person will go home and have a drink after work right? So, or a couple drinks one day and then you know, maybe a couple another day and then, you know, they’re at their seven. So, some of the providers thought that maybe that number was kind of low.” Interview 9
(2) Supports: practitioners’ perception that there are sufficient resources to support the implementation of COMBAT, including staff, training, staffing, technology supports, data systems and administration.
Practitioners mentioned there were some resources in place at their clinics to support the implementation of COMBAT, but that much more was needed. Organizational limitations were frequently cited as a barrier to providing a brief alcohol intervention. Eighteen practitioners pointed to time as the most prominent barrier for implementing the COMBAT intervention.
“I feel the questions are relevant, the intervention is relevant. It’s just a matter of whether or not we’re able to do it in that given timeframe.” Interview 20
"The actual questions themselves don’t take up very much more time. The only thing is that if you get into discussing them that does take a lot of time. And I think the whole idea is to discuss it, but I don’t always." Interview 13
In order to address the time barrier, some practitioners (n=7) reported that their organization implemented an adaptation to address time constraints, including lengthening the initial appointment, allocating extra time each day for completing documentation and changing scheduling practices. Most of these practitioners (5/7) were from organizations randomized to the control arm of the study.
Training was another issue that was frequently reported as a major barrier for implementing COMBAT. Nineteen practitioners expressed desire for more training; however, the majority (n=15) of these practitioners had not attended any of the online training webinars offered by the study team. Practitioners who viewed the webinar had more favourable attitudes towards implementing the COMBAT initiative, and some credited this directly to watching the webinar:
“The webinar I listened to help reinforce that it’s not a separate issue. They can address both at the same time and people can be successful at addressing both two addictions." Interview 18
Many respondents (n=19) including those who attended the webinar, expressed need for further training on the evidence of addressing alcohol and tobacco simultaneously, as well as techniques and tools that can be used during the intervention.
"I think if people understood that a little bit more, then maybe they might put a little bit more, I can say 'effort', because I think everyone puts effort into it but kind of think about framing. Because if you really understand the relationship and its impact that alcohol has on people’s ability to quit smoking, that I think that if you really understand that, then you’ll frame it in the sense it’ll be better received and try to help people." Interview 4
Practitioners in the intervention group had mixed views about the CDSS, reporting benefits but also questioning some of the algorithms embedded in the CDSS. Most practitioners in the intervention group (n=9) reported they found the CDSS guidance helpful, and that it helped them deliver brief interventions when needed.
“I think as far as the portal goes, it’s easy-peasy. I mean it’s very easy read, it’s very easy fill in the blanks, and I mean to be me it’s got all the options … the reminders to give an [alcohol] intervention are great” Interview 11
However, some practitioners in the intervention group (n=6) also expressed some challenges with using the portal technology, including: questioning the accuracy of the CDSS scoring, experiencing portal slowdowns, or experiencing discomfort when a patient was able to view the practitioner’s screen with CDSS messaging.
"It could be my calculations are off, but I just wondered sometimes if it triggered some of them for being over when they weren't." Interview 17
“Sometimes I’m like, ‘Oh, you know, are the patients seeing this.’ Are they, you know, now going to be on guard that they see this popup that it’s indicating that they have an alcohol addiction problem.” Interview 15
Three practitioners mentioned that due to their lack of training in delivering an alcohol intervention, and/or their focus on smoking cessation, they would ignore the prompts:
“It's asking me to perform a brief intervention … and I'm not going to do that because I'm not trained and because we're going to focus on your smoking.” Interview 10
Other technological barriers to effective implementation outside of the CDSS included the lack of secure email, which prevented practitioners from emailing resources to patients, as well as the lack of access to coloured printing, which many agreed was important for appeal of the educational resource.
(3) Usability: COMBAT has been clearly defined and operationalized in a way that fits with their context
There were mixed reviews regarding the operalization of the COMBAT initiative and its usability. Most practitioners (n=19) found screening for alcohol was useful and they were happy to use validated assessments that could allow patients to reflect on their drinking.
“I think it’s been really good, because there is more of an awareness on the client’s perspective of the fact that if they said that they do drink then the questions are a whole lot more specific, especially when they, when it says, ‘Yesterday was Friday’ and the date and, ‘How many drinks did you have that day?’ And I take them through their week backwards, and I think that is a really good snapshot for them that, ‘Oh, I really did have a lot more than I thought that I did.” Interview 3
“It’s nice to be able to point out some facts about the risks of cancer and alcohol use, and offer support around that. Because people won’t realize if they’re drinking too much until it comes up.” Interview 16
A common concern for practitioners working in clinics randomized to the intervention arm was that the CCS guidelines adopted by COMBAT were restrictive, and did not reflect the social norms. Some practitioners worried that if they intervene as prompted, it might end up stigmatizing patients.
“There's pushback …, a lot of the counsellors had to do a lot of self-reflection. None of us smoke so, that was never an issue but we...now we bring in different substances and you're dealing with your own, personal...how you feel about it. “ Interview 5
“The average person will go home and have a drink after work right? So, or a couple drinks one day and then you know, maybe a couple another day and then, you know, they’re at their seven. So, some of the providers thought that maybe that number was kind of low.” Interview 9
“It [the STOP Portal] warns you that they're drinking over the limit and all of that and binge drinking. And, they don't see that. And, I think society maybe we don't see that as a problem till three or four or five drinks” Interview 10
“So, I had two incidences yesterday where patient’s may only drink once a week but on those occasions they might have five or more drinks and this triggers a whole line of questioning that I’m not sure is completely appropriate.” Interview 12
“I don't want to set that stigma.” Interview 17
Despite receiving training prior to the initiative launch, practitioners in the control arm did not seem completely aware of the CCS guidelines. When asked how they identified patients drinking above guidelines, most practitioners (n=9) used informal ways to score patients drinking.
“I don’t add it up myself. And I don’t report a specific number or anything in my EMR encounter. I just mention alcohol use.” Interview 13
"I base it on the answers that they’ve given me throughout these questions. And you know, I’ve asked them if they feel alcohol is an issue." Interview 6
The few practitioners who reported using a scoring system (n=3) used the Canada’s Low-Risk Drinking Guidelines.
“So, what I use are the, what’s it called, the ‘rethink your drinking’ or the low risk drinking guidelines. That is what I use. So, if people are above that I tell them they are having too many drinks at a time.” Interview 19
Another issue some (n=5) practitioners voiced was how COMBAT had operationalized the addition of the alcohol intervention to the patient’s first visit. They preferred to move the brief intervention to the follow-up appointment. However, since this concept was un-probed, it is possible that additional respondents also felt this way but did not express it during the interview.
"So, my process has always been when I do my smoking education with patients we get them started and then usually it’s only at the second appointment that I address these issues. So, that’s why I find it really hard with the initial assessment when we’re talking about the alcohol right away, right? Because, typically my second appointment with folks they start talking about triggers. How did it go and where’s your trigger? And that’s where we get into you know, the link with alcohol and smoking. And how much are you drinking and... So, the flow for me to do it when I’ve just met the patient and enrolling them in the STOP, it doesn’t seem quite right…” Interview 18
"It's a question that we'd much rather delve into more deeply with...as far as COMBAT at a follow-up. [Because] we've developed a rapport and they're enrolled in the STOP and hopefully we haven't scared them away and they come back for follow-up. And that's a really good time to talk about other triggers...You're just shifting it. You're just sort of...even at the initial visit you cou...you still saying the connection between the two and the importance of it and you know, when I see you next time or maybe at another time, would it be okay if we talked about that a little bit more and I don...no one would say no. A few people would say no. Yeah, it's just a lot for a first visit." Interview 5
(4) Needs: practitioners’ perception that their patients would benefit from COMBAT.
Practitioners were asked about the need for an alcohol intervention among STOP program participants. Most participants (18) felt an alcohol intervention was needed due to: its connection with smoking behaviours; prevalence of high drinking levels in their patient populations; and the frequent underestimation of drinking risks in primary care.
"I think it’s very relevant. I think it’s an important conversation to have, particularly in primary care just in general." Interview 23
“How important it truly is in its relation specifically to smoking cessation … The two go hand-in-hand, you know what I mean? ... And, often the biggest reason why people, especially young people, don’t quit is because of alcohol. Almost every 20-something that I have that can’t quit smoking, it’s always they do good on the week and then they go on the weekend, they’re out with their friends and then their smoking again.” Interview 4
A few practitioners (5) felt there was no need to address alcohol in the STOP program since their patients were facing more pressing issues:
“There are more important issues right now than alcohol. It’s not that much of a big issue in our centre. You know, there are other you know...diabetes is very important. We do have an increase in diabetes in our community and COPD. So, alcoholism is not a big issue. So, these questions have you know, they’re there. I need to do them but they’re not really helping in any way." Interview 7
Only one practitioner mentioned there is a need for this intervention; in order to reduce cancer risks.
(5) Fit: COMBAT fits with current initiatives in the organization, priorities, structures and supports, and community values
All participants commented that the COMBAT initiative fits well with the priorities of their clinic and with the STOP program.
"I feel that the smoking cessation encompasses their alcohol, their eating, their sleeping, their…everything’s a part of it, so I feel that I’m doing diligence if I offer them, you know, more information about some of the things that might arise because of their smoking cessation or something that’s already a co-addiction" Interview 2
However, some practitioners were concerned that even though the alcohol intervention fit well with their clinics, it did not fit well with some of their patients, in particular men and younger adults. They voiced how both men and younger adults were generally more resistant to the screening questions and less likely to think their drinking is an issue, while women tended to be much more willing to accept resources.
“I would probably say the gender issue is very relevant. Most of my male patients seem to feel that they’ll be just fine. So, they don’t seem to want any additional information around it.” Interview 20
Many respondents (n=11) reported that addressing alcohol with their clients was very difficult because alcohol is so normalized in our society.
"Where my people, most of them are...especially the men obviously more than the women are the heavy smokers of two packs a day. You know, drink a 24 on the weekend kind of thing. Or come home from hunting and drink three or four beer every night kind of thing. So, it’s certainly an excess and they know that but they’re not going to...that’s what they’ve done, that’s what their father did, that’s what their son did; that’s just what they do." Interview 17
Some practitioners (n=7) also described social determinants of health as barriers to the appropriateness or fit of this intervention among their patient populations. Respondents explained that unstable housing, trauma, poor support systems, and other precarious circumstances often meant their patients were less likely to be receptive to the intervention or take-home resources.
“As far as the type of patients who are declining? Again, our demographic here, we do have a lot of people on social assistance, low education, low income who have a lot of other social determinants of health issues that they’re struggling with, and I feel like that’s definitely a barrier. It’s almost like their lives are too overwhelming to take it on.” Interview 9
Practitioners frequently said that patients are often already stressed by the thought/task of quitting smoking, the added alcohol layer often seems irrelevant or overwhelming to them.
“For a lot of them it's already hard enough to come in to talk about their smoking...I just found... you know, if they're coming in, they know they're coming in for smoking, they're open for that. And, I just at first found that when you start asking about the alcohol it starts-...kind of made some people feel uncomfortable or you know, why are you asking me all these questions.” Interview 17
A few practitioners in the control group (3) mentioned that the alcohol abstinence resource did not fit with the harm reduction framework they use in their clinic, so they preferred to offer the alcohol reduction resource whenever intervention was needed. The COMBAT intervention provided the option of two educational resources. The first resource encouraged alcohol reduction for patients drinking above CCS guidelines but not at risk of alcohol dependence. The other resource encouraged alcohol abstinence for patients at risk of alcohol dependence, as determined by the Alcohol Use Disorders Identification Test (AUDIT 10) questionnaire (33).
"We work from a Harm-Reduction perspective here...We do try to work with clients who use alcohol in a way that reduces the harm. Often times, abstinence is not a goal for the client or not realistic at this time so kind of working with the client where they’re at." Interview 1
(6) Capacity to Implement: clinic has the capacity to implement COMBAT as intended and to sustain and improve it over time.
None of the practitioners reported having financial barriers to implement the COMBAT program. However, nine practitioners highlighted the lack of staff in their clinics or supports in the area as a barrier for them to implement the COMBAT initiative:
"We only have one Social Worker; one full-time Social Worker and wait time for people in our area to get mental health counseling can be up to six months. So, you know, that’s the thing we’ve, you know, we’ve ripped off the Band-Aid and we have no way of stopping the bleeding at this point. So, because we have very few mental health resources here in this area, Psychiatry, Mental Health Services in the community. Even in our own clinic, we just don’t have the mental health support." Interview 12
A common phrase that came up when practitioners explained they lacked the capacity to implement COMBAT with fidelity, especially to provide the brief intervention, was they felt that they were ‘opening up a can of worms’.
“Now I've opened a whole can of worms, now what? They came to see me for smoking and now I know about drinking...it's a lot.” Interview 5
"So, if you identify it, then you’ve opened up a full can of worms and then you need to do something with it...because now you own it, for the most part. So, I guess it’s that follow up piece. It’s great to identify the issues but what’s going to be in place to deal with it?" Interview 12
“It's like opening up another can of worms. And, right now we're trying to deal with the smoking cessation, right? Like, one thing at a time.” Interview 9