Implementation of a screening, brief intervention and referral to treatment programme for risky substance use in South African emergency centres: A mixed methods evaluation study

Autoři: Claire van der Westhuizen aff001;  Bronwyn Myers aff002;  Megan Malan aff001;  Tracey Naledi aff004;  Marinda Roelofse aff004;  Dan J. Stein aff006;  Sa’ad Lahri aff007;  Katherine Sorsdahl aff001
Působiště autorů: Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa aff001;  Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa aff002;  Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa aff003;  Western Cape Department of Health, Cape Town, South Africa aff004;  School of Public Health Medicine & Family Medicine, University of Cape Town, Cape Town, South Africa aff005;  SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa aff006;  Department of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa aff007;  Khayelitsha Hospital Emergency Services, Cape Town, South Africa aff008
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224951



Screening, brief intervention, and referral to treatment (SBIRT) for risky substance use is infrequently included in routine healthcare in low-resourced settings. A SBIRT programme, adopted by the Western Cape provincial government within an alcohol harm reduction strategy, employed various implementation strategies executed by a diverse team to translate an evidence-based intervention into services at three demonstration sites before broader programme scale-up. This paper evaluates the implementation of this programme delivered by facility-based counsellors in South African emergency centres.


Guided by the Consolidated Framework for Implementation Research, this mixed methods study evaluated the feasibility, acceptability, appropriateness and adoption of this task-shared SBIRT programme. Quantitative data were extracted from routinely collected health information. Qualitative interviews were conducted with 40 stakeholders in the programme’s second year.


In the first year, 13 136 patients were screened and 4 847 (37%) patients met criteria for risky substance use. Of these patients, 83% received the intervention, indicating programme feasibility. The programme was adopted into routine services and found to be acceptable and appropriate, particularly by stakeholders familiar with the emergency environment. These stakeholders highlighted the burden of substance-related harm in emergency centres and favourable patient responses to SBIRT. However, some stakeholders expressed scepticism of the behaviour change approach and programme compatibility with emergency centre operations. Furthermore, adoption was both facilitated and hampered by a top-down directive from provincial leadership to implement SBIRT, while rapid implementation limited effective engagement with a diverse stakeholder group.


This is one of the first studies to address SBIRT implementation in low-resourced settings. The results show that SBIRT implementation and adoption was largely successful, and provide valuable insights that should be considered prior to implementation scale-up. Recommendations include ensuring ongoing monitoring and evaluation, and early stakeholder engagement to improve implementation readiness and programme compatibility in the emergency setting.

Klíčová slova:

Behavioral and social aspects of health – Critical care and emergency medicine – Employment – Global health – Health care policy – Health services administration and management – Randomized controlled trials – Social research


1. World Health Organization. Global Health Observatory (GHO) data: Screening and brief interventions for substance use in primary health care Geneva: World Health Organization; 2018 [cited 2019 29/04/2019]. Available from:

2. World Health Organization. Global status report on alcohol and health 2018. Geneva: World Health Organization, 2018.

3. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR. The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. South African Medical Journal. 2009;99(5 Pt 2):339–44. Epub 2009/07/11. 19588796; PubMed Central PMCID: PMC3191537.

4. Vellios NG, Van Walbeek CP. Self-reported alcohol use and binge drinking in South Africa: Evidence from the National Income Dynamics Study, 2014–2015. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 2017;108(1):33–9. Epub 2017/12/22. doi: 10.7196/SAMJ.2017.v108i1.12615 29262976.

5. Pillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE, Groenewald P, Glass T, et al. Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study. The Lancet Global health. 2016;4(9):e642–53. Epub 2016/08/20. doi: 10.1016/S2214-109X(16)30113-9 27539806.

6. World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP), version 2.0. Geneva: World Health Organization, 2016.

7. Del Boca FK, McRee B, Vendetti J, Damon D. The SBIRT program matrix: a conceptual framework for program implementation and evaluation. Addiction. 2017;112:12–22. doi: 10.1111/add.13656 28074572

8. Elzerbi C, Donoghue K, Drummond C. A comparison of the efficacy of brief interventions to reduce hazardous and harmful alcohol consumption between European and non-European countries: a systematic review and meta-analysis of randomized controlled trials. Addiction. 2015;110(7):1082–91. doi: 10.1111/add.12960 25916993

9. Babor TF, Del Boca F, Bray JW. Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice. Addiction. 2017;112:110–7. doi: 10.1111/add.13675 28074569

10. Janice V, Amanda G, Donna D, Manu S, Bonnie M, Frances DB. Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration. Addiction. 2017;112(S2):23–33. doi: 10.1111/add.13652

11. Nilsen P, Kaner E, Babor TF. Brief intervention, three decades on:An overview of research findings and strategies for more widespread implementation. Nordic Studies on Alcohol and Drugs. 2008;25(6):453–67. doi: 10.1177/145507250802500608

12. Ronzani TM, Mota DCB, Souza ICWd. Prevenção do uso de álcool na atenção primária em municípios do estado de Minas Gerais. Revista de saude publica. 2009;43:51–61.

13. Cruvinel E, Richter KP, Bastos RR, Ronzani TM. Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice. Addiction science & clinical practice. 2013;8:4. Epub 2013/02/13. doi: 10.1186/1940-0640-8-4 23399417; PubMed Central PMCID: PMCPMC3598982.

14. Pengpid S, Peltzer K, Skaal L, Van der Heever H. Screening and brief interventions for hazardous and harmful alcohol use among hospital outpatients in South Africa: results from a randomized controlled trial. BMC public health. 2013;13:644. Epub 2013/07/13. doi: 10.1186/1471-2458-13-644 23844552; PubMed Central PMCID: PMCPmc3849548.

15. Sorsdahl K, Stein DJ, Corrigall J, Cuijpers P, Smits N, Naledi T, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial2015 2015-1-1; 10:[46 p.]. doi: 10.1186/s13011-015-0042-1 26576946

16. Ward CL, Mertens JR, Bresick GF, Little F, Weisner CM. Screening and Brief Intervention for Substance Misuse: Does It Reduce Aggression and HIV-Related Risk Behaviours? Alcohol and Alcoholism. 2015;50(3):302–9. doi: 10.1093/alcalc/agv007 25731180

17. Assanangkornchai S, Balthip Q, Guy Edwards J. Screening and brief intervention for substance misuse in Thailand. Public Health. 2013;127(12):1140–2. doi: 10.1016/j.puhe.2013.08.011 24275032

18. Areesantichai C, Iamsupasit S, Marsden J, Perngparn U, Taneepanichskul S. Effect of "tailored goal oriented community brief intervention model" on AUDIT reduction in Thai communities. J Med Assoc Thai. 2010;93(8):992–7. Epub 2010/08/20. 20718176.

19. Sorsdahl K, Petersen Williams P, Everett-Murphy K, Vythilingum B, de Villiers P, Myers B, et al. Feasibility and Preliminary Responses to a Screening and Brief Intervention Program for Maternal Mental Disorders Within the Context of Primary Care. Community Ment Health J. 2015. Epub 2015/03/07. doi: 10.1007/s10597-015-9853-9 25744699.

20. Peltzer K, Matseke G, Azwihangwisi M. Evaluation of alcohol screening and brief intervention in routine practice of primary care nurses in Vhembe district, South Africa. Croat Med J. 2008;49(3):392–401. Epub 2008/06/27. doi: 10.3325/cmj.2008.3.392 18581618; PubMed Central PMCID: PMCPMC2443624.

21. Peltzer K, Naidoo P, Louw J, Matseke G, Zuma K, McHunu G, et al. Screening and brief interventions for hazardous and harmful alcohol use among patients with active tuberculosis attending primary public care clinics in South Africa: results from a cluster randomized controlled trial. BMC public health. 2013;13:699. Epub 2013/08/02. doi: 10.1186/1471-2458-13-699 23902931; PubMed Central PMCID: PMCPmc3733870.

22. Myers B, Petersen-Williams P, van der Westhuizen C, Lund C, Lombard C, Joska JA, et al. Community health worker-delivered counselling for common mental disorders among chronic disease patients in South Africa: a feasibility study. BMJ open. 2019;9(1):e024277. doi: 10.1136/bmjopen-2018-024277 30647043

23. Parry CD, Morojele NK, Myers BJ, Kekwaletswe CT, Manda SO, Sorsdahl K, et al. Efficacy of an alcohol-focused intervention for improving adherence to antiretroviral therapy (ART) and HIV treatment outcomes—a randomised controlled trial protocol. BMC Infect Dis. 2014;14:500. Epub 2014/09/13. doi: 10.1186/1471-2334-14-500 25212696; PubMed Central PMCID: PMCPMC4174635.

24. Myers B, Lund C, Lombard C, Joska J, Levitt N, Butler C, et al. Comparing dedicated and designated models of integrating mental health into chronic disease care: study protocol for a cluster randomized controlled trial. Trials. 2018;19(1):185. Epub 2018/03/20. doi: 10.1186/s13063-018-2568-9 29548302; PubMed Central PMCID: PMCPMC5857135.

25. Babor TF, Kadden RM. Screening and interventions for alcohol and drug problems in medical settings: what works? Journal of Trauma. 2005;59(3 Suppl):S80–7; discussion S94-100. Epub 2005/12/16. 16355071.

26. Schmidt CS, Schulte B, Seo HN, Kuhn S, O'Donnell A, Kriston L, et al. Meta-analysis on the effectiveness of alcohol screening with brief interventions for patients in emergency care settings. Addiction. 2016;111(5):783–94. Epub 2015/12/08. doi: 10.1111/add.13263 26637990.

27. Barata IA, Shandro JR, Montgomery M, Polansky R, Sachs CJ, Duber HC, et al. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. The western journal of emergency medicine. 2017;18(6):1143–52. Epub 2017/11/01. doi: 10.5811/westjem.2017.7.34373 29085549; PubMed Central PMCID: PMCPMC5654886 are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

28. Young MM, Stevens A, Galipeau J, Pirie T, Garritty C, Singh K, et al. Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review. Systematic Reviews. 2014;3(1):50. doi: 10.1186/2046-4053-3-50 24887418

29. O'Donnell A, Anderson P, Newbury-Birch D, Schulte B, Schmidt C, Reimer J, et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol. 2014;49(1):66–78. Epub 2013/11/16. doi: 10.1093/alcalc/agt170 24232177; PubMed Central PMCID: PMCPMC3865817.

30. Nilsen P, Bernhardsson S. Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC health services research. 2019;19(1):189. doi: 10.1186/s12913-019-4015-3 30909897

31. Zatzick D, Donovan DM, Jurkovich G, Gentilello L, Dunn C, Russo J, et al. Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial. Addiction. 2014;109(5):754–65. Epub 2014/01/24. doi: 10.1111/add.12492 24450612; PubMed Central PMCID: PMCPMC4014067.

32. Bernstein E, Bernstein J, Feldman J, Fernandez W, Hagan M, Mitchell P, et al. An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance abuse: official publication of the Association for Medical Education and Research in Substance Abuse. 2007;28(4):79–92. Epub 2007/12/14. doi: 10.1300/J465v28n04_01 18077305; PubMed Central PMCID: PMCPMC3976968.

33. Geerligs L, Rankin NM, Shepherd HL, Butow P. Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes. Implementation Science. 2018;13(1):36. doi: 10.1186/s13012-018-0726-9 29475440

34. Mitchell SG, Schwartz RP, Kirk AS, Dusek K, Oros M, Hosler C, et al. SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers. Journal of Substance Abuse Treatment. 2016;60:81–90. doi: 10.1016/j.jsat.2015.06.011 26297321

35. Vendetti J, Gmyrek A, Damon D, Singh M, McRee B, Del Boca F. Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration. Addiction. 2017;112 Suppl 2:23–33. Epub 2017/01/12. doi: 10.1111/add.13652 28074571.

36. Hargraves D, White C, Frederick R, Cinibulk M, Peters M, Young A, et al. Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. Public health reviews. 2017;38:31. Epub 2018/02/17. doi: 10.1186/s40985-017-0077-0 29450101; PubMed Central PMCID: PMCPMC5809898.

37. Damschroder L, Aron D, Keith R. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;15.

38. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72. Epub 2016/05/18. doi: 10.1186/s13012-016-0437-z 27189233; PubMed Central PMCID: PMCPMC4869309.

39. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76. Epub 2010/10/20. doi: 10.1007/s10488-010-0319-7 20957426; PubMed Central PMCID: PMCPMC3068522.

40. Stetler CB, Mittman BS, Francis J. Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implementation Science. 2008;3(1). doi: 10.1186/1748-5908-3-8 18279503

41. Currie G, Lockett A, El Enany N. From what we know to what we do: lessons learned from the translational CLAHRC initiative in England. J Health Serv Res Policy. 2013;18(3 Suppl):27–39. Epub 2013/10/30. doi: 10.1177/1355819613500484 24127358.

42. Myers B, Stein DJ, Mtukushe B, Sorsdahl K. Feasibility and acceptability of screening and brief interventions to address alcohol and other drug use among patients presenting for emergency services in Cape Town, South Africa. Advances in Preventive Medicine. 2012;2012(569153). Epub 6 November 2012. doi: 10.1155/2012/569153 23198159

43. Western Cape Government: Department of the Premier. Provincial Strategic Plan: 2014–2019. Cape Town: Western Cape Government: Department of the Premier, 2014.

44. World Health Organization. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization, 2010.

45. van der Westhuizen C, Wyatt GE, Williams JK, Stein DJ, Sorsdahl K. Validation of the Alcohol, Smoking and Substance Involvement Screening Test in a low- and middle-income country cross-sectional emergency centre study. Drug Alcohol Rev. 2016. Epub 2016/06/02. doi: 10.1111/dar.12424 27247085.

46. Hoeft TJ, Fortney JC, Patel V, Unutzer J. Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review. J Rural Health. 2018;34(1):48–62. Epub 2017/01/14. doi: 10.1111/jrh.12229 28084667; PubMed Central PMCID: PMCPMC5509535.

47. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Substance Abuse. 2007;28(3):7–30. 18077300. Language: English. Entry Date: 20080307. Revision Date: 20080912. Publication Type: journal article. Journal Subset: Biomedical.

48. van Ginneken N, Tharyan P, Lewin S, Rao Girish N, Meera SM, Pian J, et al. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database of Systematic Reviews [Internet]. 2013; (11). Available from:

49. O'Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. Journal of Health Services Research & Policy. 2008;13(2):92–8. doi: 10.1258/jhsrp.2007.007074 44185562.

50. Hanson WE, Creswell JW, Clark VLP, Petska KS, Creswell JD. Mixed methods research designs in counseling psychology. Journal of Counseling Psychology. 2005;52(2):224–35. doi: 10.1037/0022-0167.52.2.224 2005-03263-012.

51. Proctor E, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation Research in Mental Health Services: an Emerging Science with Conceptual, Methodological, and Training challenges. Adm Policy Ment Health. 2009;36(1):24–34. doi: 10.1007/s10488-008-0197-4 19104929

52. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing Qualitative Research. London: Routledge; 1994. p. 173–94.

53. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health. 2011;38(2):65–76. doi: 10.1007/s10488-010-0319-7 20957426

54. Higgins-Biddle J, Hungerford D, Cates-Wessel K. Screening and Brief Interventions (SBI) for Unhealthy Alcohol Use: A Step-by- Step Implementation Guide for Trauma Centers. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2009.

55. Bernstein SL. The Clinical Impact of Health Behaviors on Emergency Department Visits. Academic Emergency Medicine. 2009;16(11):1054–9. doi: 10.1111/j.1553-2712.2009.00564.x 20053222

56. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Bangkok). 2010;33. doi: 10.1093/pubmed/fdq095

57. Kaiser DJ, Karuntzos G. An Examination of the Workflow Processes of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Program in Health Care Settings. J Subst Abuse Treat. 2016;60:21–6. Epub 2015/09/19. doi: 10.1016/j.jsat.2015.08.001 26381929.

58. Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in Organizational and Community Context: A Framework for Building Evidence on Dissemination and Implementation in Health Services Research. Adm Policy Ment Health. 2008;35(1):21–37. doi: 10.1007/s10488-007-0144-9 17990095

59. Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, et al. A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. Adm Policy Ment Health. 2016;43(6):957–77. doi: 10.1007/s10488-016-0755-0 27474040

60. Birken S, Clary A, Tabriz AA, Turner K, Meza R, Zizzi A, et al. Middle managers’ role in implementing evidence-based practices in healthcare: a systematic review. Implementation Science. 2018;13(1):149. doi: 10.1186/s13012-018-0843-5 30541596

61. Brooke-Sumner C, Petersen-Williams P, Kruger J, Mahomed H, Myers B. 'Doing more with less': a qualitative investigation of perceptions of South African health service managers on implementation of health innovations. Health Policy Plan. 2019;34(2):132–40. Epub 2019/03/14. doi: 10.1093/heapol/czz017 30863845; PubMed Central PMCID: PMCPMC6481285.

62. Li S-A, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Systematic Reviews. 2018;7(1):72. doi: 10.1186/s13643-018-0734-5 29729669

63. World Health Organization. Task shifting: global recommendations and guidelines. Geneva: World Health Organization, 2007.

64. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries–A Systematic Review. PLOS ONE. 2014;9(8):e103754. doi: 10.1371/journal.pone.0103754 25121789

65. Department of Health Republic of South Africa. National Mental Health Policy Framework and Strategic Plan 2013–2020. In: Do Health, editor. Pretoria: Department of Health; 2013.

66. Williams EC, Achtmeyer CE, Young JP, Rittmueller SE, Ludman EJ, Lapham GT, et al. Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff. Journal of Substance Abuse Treatment. 2016;60:27–35. doi: 10.1016/j.jsat.2015.07.011 26297322

67. Derges J, Kidger J, Fox F, Campbell R, Kaner E, Hickman M. Alcohol screening and brief interventions for adults and young people in health and community-based settings: a qualitative systematic literature review. BMC public health. 2017;17(1):562. Epub 2017/06/11. doi: 10.1186/s12889-017-4476-4 28599632; PubMed Central PMCID: PMCPMC5466741.

68. Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation Research in Mental Health Services: an Emerging Science with Conceptual, Methodological, and Training challenges. Administration and policy in mental health. 2009;36(1):10.1007/s10488-008-0197-4. doi: 10.1007/s10488-008-0197-4 PubMed PMID: PMC3808121. 19104929

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