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Table 2 TICD domains and concepts linked to Affinity Diagram themes and codes

From: Strategies in primary healthcare to implement early identification of risky alcohol consumption: why do they work or not? A qualitative evaluation of the ODHIN study

TICD Domain

Theory-led TICD concepts

• Empirically-led Affinity Diagram themes

Codes

1. Guideline factors

Cultural appropriateness

• Cultural appropriateness

SBI is not a task for PHCU_referall to specialised care outside the PHCU; no guideline available_SBI too late

Strength of recommendation

• Barriers to adhere to the guideline

Too strict_nr of drinks; SBI does not fit in short time consult; doubts about effectiveness pro-active screening

Compatibility

• Adherence TO guideline

• Routine

• Follow-up of SBI

Return to the habitual system; routine_Application of the screening in all cases; already a routine; routine_preventive activities; SBI part of the nurse’s protocol; SBI part of GP’s protocol/routine; follow-up after SBI suboptimal; policies_screening during initial general interview with every new patient; focus on alcohol addicted patients/co-addicts; focus on chronically ill patients; routine_follow-up of patients; repeat SBI

Observability

• Facilitators to adhere to the guideline

Partly adherence to guideline; adherence to guideline; clear cut-off screening tool stimulates brief intervention; use evidence based knowledge/material; use evidence based knowledge/material – mi; adherence implementation takes a while; adherence_Initial difficulties; adherence_Simple adaptation process; interventions were feasible; feasibility_ of the instrument

Feasibility

• Adherence to guideline

• Facilitators to adhere to the guideline

• Implementation of guidelines

• Feasible guidelines

Example of interventions

2. Individual factors

Agreement with recommendation

• Evaluating own performance

• Implementing new practice

• Role perception

• Screening opportunities

• Barriers

Screen to make patients aware of daily drinking habit; role perception_patient motivated when given BI from a GP; performance perception_effects of SBI; performance perception_no effects of SBI; my role to start the process; role perception SBI; barrier screening_perceived_not relevant in context; role perception_to recognise signs given by a patient; it’s not my role; agreement recommendation; awareness _alcohol is not a medical problem

Expected outcomes

• Personal motivation to participate from societal perspective

• Collaboration from individual perspective

• Evaluating own performance

• Role perception

• Professional’s expectations

• I don’t care

• Barriers

ODHIN outcome expectation_to catch more case positives; role perception_patients like GPs to ask about lifestyle; expectation_patient’s reaction; expectation_conformed to expectations; professional age; motivation to participate ODHIN_curiosity about the outcomes; expected MI intervention outcome_high; expected intervention outcome_low; expectation_With no initial expectations; lack of motivation to change; barriers referral_big step; GP afraid of patient’s reaction

Emotions

• Implementing new practice

• Barriers

E-health_using e-health is a personal weakness; new patient; hard to screen GP’s own friends or acquaintances

Frustration

• Implementing new practice

ODHIN impact_more frustration

Intention and motivation

• Personal motivation to participate from societal perspective

• Training

• Collaboration from individual perspective

• E-health

• Personal motivation individual perspective

• I don’t care

• Barriers

Motivation to participate in ODHIN_to help patients; ODHIN training_positive but not fully attended; Motivation to participate ODHIN_motivation for intervention; motivation to participate ODHIN_the size of alcohol problem; motivation to participate ODHIN_easier with a network; e-health_positive in e-health; e-health_barrier referral; e-health_no time to become familiar with e-health intervention; e-health_not familiair with website content; e-health_negative attitude; motivation to participate ODHIN_consider load and benefit; not motivated by financial incentives; motivation to participate ODHIN_to act pro-socially; motivation to participate ODHIN_personal interest/benefit; motivated by ODHIN financial incentives; motivation to participate ODHIN_negative; motivation to participate ODHIN_Interesting subject; not motivated to improve SBI; low patient awareness_inhibits professional; low motivation to change_inhibits professional; motivation to change_motivates BI; patient reactions_denial inhibits brief intervention;

Learning style

• Training

• Implementing new practice

• Routines

ODHIN training_increases awareness of the problem; ODHIN training_temporary stimulation; ODHIN training_positive; ODHIN presence cause reminders/awareness_temporary; continuous triggers necessary for SBI; routine and practice

Self-efficacy

• Self-efficacy

Self-efficacy in BI_high; high screening self-efficacy; self-efficacy; self-efficacy_frustration; self-efficacy in BI_moderate; performance perception_GP can always do something

Awareness and familiarity with the recommendation

• Personal motivation to participate from societal perspective

ODHIN motivates to screen pro-active; awareness of alcohol problems; importance of screening

Knowledge

• Training

• Implementing new practice

• I don’t care

• Barriers

• Screening opportunities

Skills thank to previous training; ODHIN impact_encouragement to introduce more prevention; previous training_don’t remember; barrier screening_language barrier; barrier screening_information from system not available; barrier BI_skills; Skills_plurimedication; Patient nightlife related with drugs/alcohol; patient known to drink too much; screen because of patient signals; skills_professional knows well patient’s medical history; importance_associated pathology; screened patients suspected of drinking alcohol; patient drunk during the visit; problem reported by family member

Knowledge about own practice

• Collaboration from individual perspective

• I don’t care

• Barriers

Barrier screening_already SBI by colleague; barrier screening_other important health and other topics; barrier screening_sociodemographics; patient religious issues

Skills needed to adhere

• Implementing new practice

• Personal motivation individual perspective

• Professional patient approach

• Professional’s expectations

• Barriers

• Screening opportunities

ODHIN impact_new skills/procedures; motivation to participate ODHIN_need for more knowledge and skills; expectation_increase knowledge/skills about interventions; skills_no judgemental attitude/tolerance; skills_professional keeps motivating the patient; skills_individual approach to patient; alcohol is a sensitive issue/difficult subject; need for more knowledge & skills for SBI; performance perception_screening justified by the research project

Capacity to plan change

• Personal motivation to participate from societal perspective

• Implementing new practice

Barrier screening_economic crisis situation; ODHIN impact_introduction of new data into patients’ records

Nature of the behaviour

• Implementing new practice

ODHIN impact_effort to perform

Self monitoring or feedback

• Personal motivation to participate from societal perspective

• evaluating own performance

• implementing new practice

• screening opportunities

• I don’t care

• Barriers

ODHIN outcome _catching patients in early stage of disease and follow-up; motivation to participate ODHIN_awareness of trivialising; satisfaction with own performance; lack of satisfaction with own performance; self-monitoring of screening; self monitoring of BI; insight SBI potential afterwards; ODHIN impact_more patient/new groups of patients screened; ODHIN presence cause reminders/awareness_own consumption behaviour; ODHIN presence cause reminders/awareness; ODHIN did not make any difference; ODHIN presence did not cause reflection on own consumption behavior; barrier screening_simply forgotten; has routine; barrier screening_experienced workload; Patient age; patient gender; physical GP’s tiredess; Screened every patient (or tried to screen)

3. Patient factors

Patient behaviour

• Patient reactions

Patient reactions; feel suspected of being a drinker; afraid/suspicies; stressed/tense; not honest; honest; frustration; defensive; surprise; relief; no objection/acceptance; negotion/trivialisation

Patient beliefs and knowledge

• perceived patient awareness

• lack of interest in E-BI

Awareness_personal decision of the patients; awareness_self-control of drinking; patient reactions_awareness guidelines; BI_difficult when patients not aware; patient reactions_don’t treat beer as alcohol; self-efficacy in BI_low/doubts if patiens will change anything; patient reactions_lack of interest e-health; patients not interested in e-BI

Patient motivation

• Patient trust required

• Motivation to change

SBI requires patient’s trust; motivation to change_Serious alcohol problem; motivation to change_Social support

Patient preferences

• Patient reactions

Patient reactions_positive

4. Professional interactions

Communication and influence

• Decision to participate

• General assessment of PHCU routines and engagement

Decision to participate in ODHIN_agreement; decision to participate in ODHIN_GP decided to participate; decision to participate in ODHIN_nurses agreed; decision to participate in ODHIN_practice nurses not involved; motivation to participate ODHIN_order or influence of other professional/supervisor/colleague, etc.; GP takes the lead in ODHIN SBI; engaged other staff in alcohol discussions than those involved in the Odhin project; team (not) on the same line; different routines among the staff

Referral processes

• Barriers

• Task division in the team

• Referral

Addiction care disappointing; GP internal referral to specialised professional; nurse referral to other(s); ODHIN initiates referral option specialised nurse; GP referral to addiction care; need for low barrier referral possibilities; conditions in the PHCU_additional support

Team processes

• Barriers

• Organisation of SBI care

• Task division in the team

• Learning from each other

• Making agreement within the practice

Recent screening; colleagues less practice/experience; organise care multidisciplinary; counseling done by other profession; care requires a specialized practice nurse; team process SBI_SBI only partly by nurse; unknown patient; practice nurses_have more time_for MI; other professionals have more time’; practice SBI in team; share experiences; lack of communication; sufficient communication; nurse not informed about procedures; agree on team objectives; agree on SBI strategy

Undefined

• Difference in opinions

ODHIN_waisted money

5. Incentives and resources

Availability of necessary resources

• Physical working conditions in the PHCU

• Difference in opinions

• Tools as facilitators

• Screening tool usefulness

• Trigger for screening

• Importance of time

Conditions in the PHCU_privacy; conditions in the PHCU_disturbances; ODHIN did not lack resources; little bureaucracy; ODHIN provides tool for BI; need for patient information_low barrier patient information; more resources in the treatment of the patient; screening instrument not within reach; advice_use available training and tools; screening tool helps to structure; advice_use screening tool; ODHIN provides screening tool; screening instrument_Suitable instrument; screening tool did not help; screening instrument_too complicated for patients; screening instrument_easy to use; screening instrument_anonymous; visible screening instrument does not stimulate; visible screening instrument stimulates; need for summary card on desk; advice_time is necessary resource; GPs want more time per patient; increase available time for extra practice nurses; time pressure inhibits BI; time pressure inhibits GP’s MI; time pressure inhibits screening; time is no barrier to screen; time is no barrier for advice; addicted patients need more time; time for creating right atmosphere; time pressure forces need for follow-up appointment

Continuing education system

• Importance of training

Advice_continuous training; training should be organised in PHCU; more role playing; Providing training tools suitable for professionals

Financial incentives and disincentives

• Importance of finances

No financial resources from health Insurance; finances required for practice nurse; financial incentives rewards your effort; financial incentives would create more priorities; more funds needed

Information system

• Role in information system

Usual registration in information system; information system obligatory field; no use of information system; register SBI in information system; information system not adapted to SBI; information system not obligatory field

6. Capacity for organisational change

Assistance for organisational changes

• PHCU SBI policy

• Nurses protocol for SBI

Advice_invite a consulent; practice nurse not skilled

Monitoring and feedback

• PHCU SBI policy

Need for ongoing evaluations

Priority of necessary changes

• PHCU SBI POLICY

Advice_SBI prioritarisation

Regulations, rules, policies

• Systematisation of SBI

• PHCU SBI policy

• Nurses protocol for SBI

Policies_need for a systematic approach to disease prevention; make it part of protocol; make it part of performance indicators; Nurses protocol adapted in line with ODHIN

7. Social, political, legal factors

Economic constraints on the healthcare budget

• Increase public awareness

Advice for improving public health_society should be richer

Influential people

• Importance of regional policy

• Increase public awareness

• Awareness of prevention task of primary care

The board plays an important role; advice_increase public awareness (media); advice_increase public awareness (media)_broad lifestyle; advice_increase public awareness (media)_involve environment; advice_increase school and parent awareness; little effect public campaigns; synergy effect of advice from multiple people; less ads; change social attitudes; advice_increase primary care awareness outside PHCU; increase awareness in professionals; prevention task of PHCU

Legislation

• Need for effective policy actions

• More strict legislation

Mandatory trainings for GPs’; advice_increase alcohol taxes_not effective; advice_increase alcohol taxes; advice_legislate higher age buying alcohol; advice_make alcohol less available; fear of bureaucracy

Payer or funder policies

• Increase public awareness

Advice for improving public health_don’t waist public money on projects like ODHIN

Undefined

• Increase public awareness

• need for effective policy actions

• awareness of prevention task of primary care

Advice for improving public health_use disulfiram implants; advice for improving public health_state alcohol policy is schizophrenic; raise awareness of screening, BI and available tools; build trust between GPs and patients; advice_organise peer buddy’s; increase knowledge in primary care professionals; Approach general/integral; policies_screening during initial general interview with every new patient; introduce more programs like ODHIN

8. Implementation strategy practicalities

Training and support

 

Caused awareness; MI requires long term practice; MI useful for other lifestyle issues; positive; preference for more factual knowledge; role playing_not favorable; temporary stimulus

Financial reimbursement

 

No effect; extra motivation

E-health

 

low outcome expectation; low patient motivation inhibits professional; easily accessible intervention; increases awareness; negative attitude; no time to become familiar with e-health; not applicable for elderly; not applicable for low SES; no effect