Alcohol use disorders (AUD) are common and chronic and affect 6.5% of VA patients. While specialty addictions treatment is effective for treating AUD, a majority (~66%) of VA patients with AUD never receive it. Three medications are FDA approved and considered standard care for AUD in the VA, but ~95% of VA patients with diagnosed AUD do not receive them. Primary care may represent an optimal setting in which to increase access to these medications for Veterans with AUD, many of whom only receive care in this setting. However, there are likely to be multiple barriers to provision of medications for AUD in primary care. Social marketing is a theory-based approach to behavior change that employs business marketing techniques, including "segmenting the market" to identify groups that may lead change, and focuses on identifying and changing underlying emotions and attitudes that determine behavior.
This mixed methods study used social marketing theory to: 1) Describe barriers to and facilitators of primary care providers' use of medications to treat AUD in VA primary care, and 2) Develop a survey to assess types of media that could influence prescribing practices, as well as determinants of use of medications to treat AUD among a generalizable sample of VA primary care providers.
This mixed-methods study recruited primary care providers from 5 primary care clinics associated with a single local VA medical facility. All primary care providers with prescribing privileges who practice at least one half day per week in one of 5 clinics were eligible for participation. Top down recruitment methods were used in which we contacted clinical leaders at each site and together identified the best and least disruptive way to recruit primary care providers. Recruitment of individual providers was then arranged via email or through on-site recruitment. Providers gave verbal consent to participate, consistent with the IRB approved protocol. Participating providers were given a brief written survey (a pilot survey for Aim 2), which they completed either during or after meeting with the study team. Participants were then guided through a semi-structured qualitative interview. Semi-structured interviews were developed based on social marketing theory and were thus focused on identifying emotional and attitudinal obstacles to behavior change. All interviews were digitally recorded and transcribed. Data were analyzed in an iterative fashion using both rapid analysis techniques and template analysis (thematic coding). For template analysis, two coders coded all transcripts, discrepancies between coders were reviewed by the study team and resolved with consensus; and content was sorted by domain for reporting. During analysis, a key tenet of social marketing theory was used to "segment the market" in order to identify a segment, or distinct group, of primary care providers who may be most amenable to change. Therefore, qualitative analysis was used to identify and describe themes within segments, and data from self-administered surveys were summarized descriptively both overall and across segments (or distinct subgroups) of participants.
We recruited 24 primary care providers [19 Medical Doctors (MDs), 1 Doctor of Osteopathy (DO), and 4 Nurse Practitioners (NPs)] from 5 primary care clinics associated with a single large VA medical facility. Results of semi-structured interviews suggest that few participating providers had prescribed medications for AUD, and providers reported several concerns including lack of time to adequately address AUD, need for training in prescribing these medications, and need for additional trained staff to support both medication and behavioral follow up for AUD. Three "segments" (distinct groups) were identified: those willing to prescribe ("Willing," n=9), those open to but not comfortable with or interested in prescribing without additional support ("Maybe Willing," n=11), and those unwilling to prescribe ("Unwilling," n=4). Providers who were willing to prescribe were differentiated from the other two groups because they viewed prescribing for AUD as part of their role as a primary care provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing these medications in primary care may catalyze change while reducing stigma and other barriers to specialty addictions treatment. Nineteen participants (79%; 5 Willing, 11 Maybe Willing and 3 Unwilling) completed the written survey. Approximately half were female, most reported being white race, though 3 reported Asian and 1 reported Native Hawaiian/Pacific Islander race. Among respondents, 14 were MDs, 1 was a DO, and 4 were NPs. Participants reported a range of media outlets and resources used to obtain information that influences their medical practice, with no clear differences across segments of providers. However, participants in the Willing group were more likely to be younger age and to be MDs than those in the Maybe Willing or Unwilling groups.
Primary care may be an optimal setting in which to increase access to medications for AUD. This research serves as a first step in understanding and removing barriers to use of AUD medications in a setting in which Veterans with AUD commonly receive care.
- Bensley KM, Sox-Harris AH, Gupta S, Jones-Webb R, Rubinsky AD, Glass J, Williams EC. Racial/ethnic differences in Access to and Engagement with Specialty Addictions Treatment among patients with Alcohol Use Disorder in the Veterans Health Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN.
- Lapham G, Williams EC, Richards J, Ludman E, Lozano P, Caldeiro R, Lee A, Bradley KA. Low reach of four different alcohol screening approaches in the absence of population-based screening: Results from one large integrated health care system. Paper presented at: HMO Research Network Annual Conference; 2015 Mar 13; Long Beach, CA.
- Lapham GT, Williams EC, Richards J, Ludman E, Lozano P, Caldeiro R, Lee A, Bradley KA. Low reach of four different alcohol screening approaches in the absence of population-based screening: Results from one large integrated health care system. Paper presented at: Addiction Health Services Research Conference; 2014 Oct 5; Boston, MA.