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