Systematic Review of Clinician‐Reported Barriers to Provision of Brief Advice for Alcohol Intake in Hospital Inpatient and Emergency Settings

Abstract

Hospital inpatient and emergency care settings provide frequent opportunities for clinicians to screen and provide brief interventions to patients who engage in the harmful use of alcohol. However, these services are not always provided, with several reasons given in different studies. We aimed to systematically review clinician-reported barriers in the provision of brief alcohol screening, brief advice, and intervention specific to hospital inpatient and emergency department (ED) settings. A systematic literature review was conducted in MEDLINE, PsycINFO, and CINAHL to identify the barriers perceived by healthcare workers in the provision of alcohol screening and brief intervention. These barriers were then categorized according to the capability, opportunity, and motivation (COM-B) model of behavior change theory. Twenty-five articles were included in this study, which involved questionnaires, surveys, interviews, and conference call discussions. The most commonly cited barriers (i.e., greater than half of the studies) were related to capability (lack of knowledge cited in 60% of studies); opportunity (lack of time and resources, 76 and 52% of studies, respectively); and motivation (personal discomfort in 60% of studies). Twenty-two other barriers were reported but with lower frequency. Clinicians cite a multitude of factors that impede their delivery of alcohol screening and brief interventions in the hospital inpatient and ED settings. These barriers were explored further under the framework of the COMB model, which allows for intervention design. As such, changes can be made at the policy, managerial, and educational levels to address these barriers and help improve the self-efficacy and knowledge of clinicians who counsel patients on alcohol use.

Patient and provider factors associated with receipt and delivery of brief interventions for unhealthy alcohol use in primary care

“…In this regard, the potential contributions of systemic racism and implicit bias, also affecting physicians of color (Chandrashekar & Jain, 2020), While the percentage of missing covariate data was within a similar range of other EHR-based studies (Hirschtritt et al, 2019;Lam et al, 2020), unfortunately, reasons for missing data in our study could not be determined. We have no data on important provider factors such as BI outcome expectancies, concerns about intrusiveness, beliefs that SBI is ineffective, negative attitudes about patients with alcohol problems, and self-efficacy; all have been identified as related to delivery of BI (Gargaritano et al, 2020). KPNC has a wellestablished EHR and has a membership that is racially diverse and reflects the U.S. population with access to care, which allows us to study a large population-based sample of patients and providers; it is not known how well the study's findings generalize to other healthcare systems and populations.…”

Impeding and facilitating factors for the implementation of alcohol interventions in hospitals: a qualitative and exploratory study among Dutch healthcare professionals

“…Many factors in the current study are consistent with previous international research within hospitals: improved knowledge and skills, increased motivation and sense of responsibility (e.g., through reminders), patient receptivity, and development of a single clear and user-friendly protocol [ 12 , 13 , 21 – 23 ]. Strikingly, having an environment where physician and patient have sufficient privacy to discuss alcohol use is frequently mentioned in the international literature [ 11 , 13 , 22 , 23 ], but this factor was not specifically mentioned in this study. However, we did find that healthcare professionals found it difficult to initiate the conversation because of the taboo surrounding alcohol problems.…”

“…In addition, in previous international research, the factor “lack of support” frequently comes up, but then this factor only includes (the lack of) support from colleagues within hospital departments [ 11 ]. In this study, the lack of support from hospital management was added as an important impeding factor.…”

“…Moreover, this study also mentioned the importance of collaboration with parties outside the hospital, with parties such as general practitioners, addiction treatment facilities, and social workers. Particularly the collaboration with the general practitioner is new/different from the international literature here [ 11 ]. This is probably because the Dutch healthcare system is organized in such a way that general practitioners act as gate-keepers for the hospital, in contrast to many other countries [ 14 ]..…”

“…To find out why such alcohol interventions 2 are not yet always implemented in hospitals and to inform future implementations, impeding and facilitating factors need to be known of this specific context. For example, previous international research within hospitals found that lack of knowledge, inadequate time and resources and personal discomfort in confronting patients with their alcohol use were important impeding factors for implementing alcohol interventions within hospital settings [ 11 ]. Important facilitating factors included improved electronic health record features (e.g., templates for screening, electronic reminders and assessment-related consultation orders) and improved knowledge and skills of and collaboration between health care professionals [ 12 , 13 ].…”