Table 1 Outline of the intervention programme

GP directed interventions

1

Distribution of the guideline on problematic alcohol consumption issued by the Dutch college of GPs.

2

A reminder-card to display on desk of the GP. This card featured the signs, symptoms and characteristics which should trigger a physician to ask about alcohol consumption. At the back site the Five Shot Test was listed, a five-item questionnaire to designed to estimate the amount of alcohol consumption of a patient, which is recommended in general practice because of its practical advantages and diagnostic properties.

3

Educational training session tailored to professionals’ attitudes. The entire general practice team (including practice assistants and nurses) was invited to participate in the small-scale training sessions (maximum around ten participants). Minimally one and maximally three sessions could be attended, tailored to the wishes, needs, and attitude of the teams. These sessions were offered to the practice teams in the early evening hours together with a light dinner (soup, bread, fruits). The duration of the sessions was between two and three hours. The basic content of the educational trainings was based on the guidelines of the Dutch college of GPs and on recent international guidelines. More in detail, the content was tailored to the attitudes of the GPs. In order to identify the attitudes towards and experiences with alcohol problems the Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ) was used. During the first training session the outcomes of the SAAPPQ were discussed and presumptions towards hazardous and harmful levels of alcohol consumption were addressed. Furthermore, the theoretical basics were discussed. And finally, the local addiction services were invited to participate in this session (see ‘Organisation/practice directed interventions’). The second and third sessions focussed on bringing theory into practice to overcome the barriers that hinder GPs. After a short summary of the theory about how to approach alcohol problems, the participants were able to revert to unfinished matters from the first session of support visit (if attended) or to bring in cases from their daily practice. Next, the GPs practiced motivational interviewing in role plays, a useful method in the treatment of lifestyle problems and disease. The casuistry in the role plays depended on the attitude and experiences of the participating GPs.

Organisation/practice directed interventions

4

Feedback identifying the number of patients who are at risk because of their alcohol consumption. From the AUDIT patient questionnaires, distributed by the practice teams, the amount of alcohol consumption for each responding patient was calculated. The patients were divided into 4 categories: I. Safe to moderate drinker; II. Hazardous drinker; III. Harmful drinker; IV. Possibly dependant drinker. For each practice the proportion of patients in every category were calculated. The practices received this anonymous information together with the total number of returned patient questionnaires.

5

Facilitation of the cooperation with local addiction services for support and referral. The local addiction services were invited to join in the first educational training session. The goals were that the practice teams took cognizance of the experiences of the addiction services, that the GPs knew more precisely when to refer and what subsequently happened to their patients and to come to agreements about communication, accessibility, and cooperation.

6

Outreach visitor support by a trained facilitator tailored to needs of practice. Again, the entire practice team was invited and participation was tailored to the wishes and needs of the teams. Minimally one and maximally three support visits were offered. The visits took place during daytime and lasted around one hour. The content of the support visits was tailored to the barriers of the practice organisation as a whole. First, remaining questions after the educational training sessions were dealt with. Implementation barriers in daily practice were addressed next. Besides practical tips to tackle structural, logistical and communicative issues the facilitator focussed on the attitudes and beliefs of the practice team and discussed individual barriers to act upon alcohol problems.

Patient directed interventions

7

Patient information letters about alcohol issued by the Dutch college of GPs and leaflets and self-help booklets issued by the NIGZ. These patient materials were offered to the general practices in order to be distributed by the GPs.

8

Poster in the waiting room. This gaudy poster drew the attention to alcohol with the advice to contact the GP or look at the websites of the NIGZ (National Institute for Health Promotion and Disease Prevention) or Trimbos (National institute of knowledge about mental healthcare, addiction services and societal care) for further information.

9

Personal feedback based on their alcohol consumption. The patients received a letter which cited the category to which they belonged and the corresponding advices. The advices were to turn to their GP or to look at the websites of the NIGZ or Trimbos. For patients in category I this was not necessary and for patients in category IV we added the advice to inquire at the local addiction service.