The 15-method: a novel method for addressing alcohol overuse – implementation in general practice

Background
Despite alcohol being a leading preventable public health risk, treatment and intervention rates for alcohol-related problems remain low, especially for mild to moderate cases. Barriers to treatment include stigma, limited provider training, and low intervention sustainability, leaving alcohol with one of the largest treatment gaps of any health condition. The 15-method is an opportunistic, structured Screening, Brief Intervention and Referral to Treatment (SBIRT) tool for healthcare professionals (HCP) in primary care. The 15-method combines motivational interviewing, cognitive behavioral techniques, and pharmacological options to address alcohol use in a steppedcare, patient-centered approach. Implementation science study how interventions like the 15-method can be successfully integrated into routine care. By focusing on context, adaptation, and implementation strategies, implementation research can help close the research-to-practice gap, optimizing the delivery of evidence-based healthcare interventions like the 15-method. 

Aims
The overall aim of this thesis was to evaluate the feasibility of the 15-method in Danish general practice, adapt it to Danish general practice context, and assess its implementation. The objective for each of the studies was to: 1) Evaluate the feasibility of the 15-method in Danish general practice, 2) Identify which aspects of the 15-method HCPs and patients found most important to adapt for a better fit to Danish general practice context, 3) Develop and finalize a Danish adapted version of the 15-method, 4) Identify intervention- and context-specific determinants influencing the implementation of the 15-method in Danish general practice, and 5) Identify and classify adaptations and modification to the 15-method made by healthcare professionals during implementation in general practice. 

Methods
This thesis followed the Medical Research Council (MRC) framework for developing and evaluating complex interventions, encompassing feasibility evaluation (Study I), stakeholder engagement and intervention refinement (Studies II and III), and implementation and adaptation evaluations (Studies IV and V). All studies used qualitative methods, drawing from implementation science, participatory design, and complex intervention research. Study I applied thematic content analysis to interview data. Studies II and III employed the participatory design approach “tell, make, and enact” in iterative cycles of interviews and user workshops. Study IV used the Consolidated Framework for Implementation Research (CFIR) to identify implementation determinants, and Study V applied the Framework for Reporting Adaptation and Modification to Evidence-based interventions (FRAME) to classify intervention adaptations and modifications.

Results
Study I: Implementation of the 15-method in Danish general practice was deemed feasible. Healthcare professionals and patients viewed the 15-method positively, praising its structure and interdisciplinary potential.

Study II: Barriers included misaligned agendas between patients and HCPs, difficulty initiating conversations about alcohol, and workflow challenges. Facilitators included strong interpersonal skills, attentiveness to the patients’ perspective, established routines, and interdisciplinary collaboration. Suggestions for additions included digitalization, visual aids, and a quick guide.

Study III: The 15-method’s structure and materials were shortened. Materials were re-structured to increased flexibility and flyers, posters, and a quick guide were developed. A field test confirmed these changes improved flexibility and interdisciplinary use.

Study IV: Thirty-two implementation determinants were identified: 14 facilitators (e.g., adaptability, compatibility, evidence base), six barriers (e.g., communication challenges, practice organization), two neutral, and ten mixed (e.g., intervention complexity). Findings underscored the complexity of implementing the 15-method across diverse contexts.

Study V: Three modifications were identified and included loosening the method’s structure, condensing the method’s materials, and modifying screening procedures. One adaptation was identified as an integration into clinical procedures. Most occurred on practice level, driven by general practitioners, to improve patient reach and engagement and address organizational constraints (time, staff resources). Training and structured follow-up were highlighted as crucial for building confidence in delivering the method.

Conclusion
The 15-method can be successfully implemented in Danish general practice, providing healthcare professionals with a structured yet flexible tool to address alcohol-related issues. Adaptations to its materials, structure, and workflow facilitated adoption to Danish general practice context. Healthcare professionals and patients found the 15-method meaningful, comprehensible, and with the potential to fill a gap in existing treatment options. The 15- method’s flexibility enabled personalized treatment but also introduced challenges, underscoring the need for ongoing adaptation and implementation planning.