Country and policy factors influencing the implementation of primary care-based alcohol screening: A comparison of Colombia, Mexico and Peru

Figures & data

Figure 1. Framework for the contextual analyses, adapted from Ysa et al. (2014).

Figure 2. Overview of data collection process.

Table 1. Summary of the country and policy factors at the beginning of the implementation and impact of COVID-19.

	Colombia	Mexico	Peru
Country factors (A1–11)* Country demographics Political system World values survey Corruption perception index GINI Index Human Development Index	population 48,258,494 (2018 data) presidential democratic republic upper middle income high human development values emphasising the importance of religion, parent-child ties, deference to authority and traditional family values, as well as economic and physical security higher inequality higher public sector corruption	population 119,938,473 (2015 data) Unitary semi-residential representative democratic republic upper middle income high human development values emphasising the importance of religion, parent-child ties, deference to authority and traditional family values, as well as economic and physical security higher inequality higher public sector corruption	Population 31,237,385 (2017 data) Federal presidential representative democratic republic upper middle income high human development values emphasising the importance of religion, parent-child ties, deference to authority and traditional family values, as well as economic and physical security higher inequality higher public sector corruption
Policy factors: country profile (A12–18) Alcohol consumption prevalence Existing alcohol screening guidelines and practice	Total alcohol consumption 15+ (in litres of pure alcohol): 5.5 [4.4, 6.6] Males: 8.8 [7.2, 10.9] Females: 2.3 [1.8, 2.8] Alcohol and depression early detection recommendation guidelines exist, but no indication of their use in practice	Total alcohol consumption 15+ (in litres of pure alcohol): 5.0 [4.0, 6.3] Males: 8.1 [6.5, 10.3] Females: 2.2 [1.7, 2.7] Official standards (NOM-028-SSA2-1999) and (NOM-004-SSA3-2012) stipulate inclusion of information on alcohol use in patients’ clinical history, application of AUDIT can count towards productivity for some types of professionals	Total alcohol consumption 15+ (in litres of pure alcohol): 6.8 [5.7, 8.0] Males: 10.4 [8.8, 12.3] Females: 3.2 [2.7, 3.9] No existing guidelines, mental-related health screening can count towards productivity
Policy factors: structures (A19–25) Organisation of health system Organisation of primary care	Sistema General de Seguridad Social en Salud (SGSSS, General System of Social Security in Health). Most people are affiliated with the SGSSS through contributory regime or the subsidised regime. There is also the special benefit regime and private insurance. In 2016, the new Comprehensive Health Care Model (Modelo Integral de Atención en Salud, MIAS) was introduced, with the aim to strengthen primary health care delivery and improve population access to healthcare, through increasing the responsibility and decision-making capacity of health teams.	Mexican health care works by three-tier system: a mix of social insurance schemes, a voluntary public programme for the uninsured, and private insurance. In 2015, a Comprehensive Health Care model (MAI) was introduced in order to standardise health care services, optimise health resources and infrastructure, and promote citizens’ participation, which placed PHC one of the most important strategies for healthcare in Mexico.	The Peruvian health care system consists of four tiers: comprehensive health insurance of the Ministry of Health, social security, armed forces. national police insurance, and private insurance. It is decentralised: the national level sets overall policies and frameworks, with regional and local authorities being responsible for implementation. In 2003, the Ministry of Health formulated and formalised the Comprehensive Health Care Model (Modelo de Atención Integral de Salud, MAIS), but with limited implementation. In 2011, Comprehensive Health Care Model based on Family and Community (Modelo de Atención Integral de Salud basado en Familia y Comunidad, MAIS-BFC) was introduced to further strengthen primary care.
Policy factors: strategies (A26–31) Alcohol and mental health policy National strategies and policy priorities	Both alcohol policy and action plans exist	Both alcohol policy and action plans exist	Only mental health policy and action plan, no standalone alcohol policy Mental health reform: one pillar is strengthening the role of primary health care centres and general hospitals, second pillar is focused on establishments of the Community Mental Health Centres (CMHCs) to aid shift of mental healthcare from psychiatric hospitals to the community level
External shocks (added later) (A32) COVID-19 pandemic	First case on 6 March 2020 4.91 million confirmed cases and 124,883 confirmed deaths as of 30st August 2021 On 17 March 2020 (Decree 417), state of emergency was declared, followed by national lockdown Centres stop regular consultations between March and June 2020, followed by gradual reopening	First case of COVID-19 was confirmed on 28 February 2020 3.34 million cases and 258,491 deaths in Mexico as of 30st August 2021 No nation-wide lockdown, instead relying on public service announcement campaign to promote social distancing and hand washing (Jornada de Sana Distancia). Some restrictions on state level Centres shift focus but do not stop working	First case on 6 March 2020 2.15 million cases and 198,269 deaths in Peru as of 30st August 2021 State emergency announced on March 15 (Supreme Decree N° 044-2020-PCM), strict national lockdown Health services restricted to emergency and COVID-19 care

*References are included in Appendix 1.

Table 2. Overview of the country and policy factors influencing the implementation of alcohol screening.

	Factor	Colombia		Mexico		Peru
General factors
Country factors	Population	Displaced population in the intervention municipality (population changes often) → less opportunity for the providers to establish longer-term relationships with attending patients that would facilitate conversations about alcohol	(–)			High crime rates in some areas → in one centre, patients responded aggressively to additional questions, impeded providers starting conversations around alcohol	(–)
Country factors	Political factors					General political instability in the country reflected also on the regional level with five regional health authorities’ directors changing over two years → due to constant changes, it is difficult to ensure continuous support from health authorities	–
Policy factors: country profile	Existing practice	Alcohol early detection recommendation guidelines exist, but no indication of their use in practice → some providers familiar with AUDIT and concept of alcohol screening, facilitating its application in practice	(+)	Official standards stipulate inclusion of information on alcohol use in patients’ clinical history → majority of providers familiar with AUDIT and using it in practice at least occasionally, facilitating its application in practice	+	No existing general guidelines, screening considered as a domain of psychologists (as they are trained for it) → majority of providers (who are not psychologists) not familiar with AUDIT or concept of alcohol screening, impeding its introduction in practice	–
Policy factors: strategies	Policy priorities	In policy documents, alcohol framed as public health issue, and there is standalone alcohol policy → population approaches such as alcohol screening better accepted by authorities and providers	+	In policy documents, alcohol framed as public health issue, and there is standalone alcohol policy → population approaches such as alcohol screening better accepted by authorities and providers	+	In policy documents, alcohol is framed as an addiction/medical issue, and there is no standalone alcohol policy → leads to authorities and providers’ perception that alcohol problems should be dealt by specialists on individual level, rather than by primary care providers	–
Policy factors: strategies	Policy priorities	In policy documents, there is emphasis on strengthening of primary care → support for the project from the regional authorities as it fits well with the primary care focus	+	In policy documents, there is emphasis on strengthening of primary care → support for the project from the regional authorities as it fits well with the primary care focus	+	Ongoing mental health reform: focus is on development of community mental health centres (but not on strengthening primary care level) → lack of support for the project from the regional authorities as there are other priorities	–
Policy factors: strategies	Policy priorities	Focus on primary care also means competition of other promotion and prevention projects → primary care institutions can select between several possible preventive activities, alcohol screening not always priority	(–)	Focus on primary care also means competition of other promotion and prevention projects, there are other trainings for providers to attend → providers can select between several possible preventive activities, alcohol screening not always priority	(–)	Tuberculosis screening competition on in primary care → providers have to select between activities (Screening for tuberculosis must be carried out if patients ask for that service), alcohol screening not always priority	(–)
Policy factors: structures	Healthcare system			Higher resistance for participation in additional activities among the unionised providers → unionisation providing protection against additional workload	(–)	Fragmentation of the healthcare system and vertical integration → because the main entry point in the healthcare system (to recruit the centres) was only through the regional health authorities, it was in practice difficult to obtain access to the centres because of the leadership instability within the regional health authorities	–
Time-bound factors
Existing healthcare system		Temporary contracts as part of obligatory ‘año rural’ (rural internship year) → When participating providers contracts expire, generally by the end of the year, they very often have to leave the centre and their position	–	Implementation of new insurance scheme (INSABI) covering larger part of population (starting from January 2020 but with delayed implementation due to COVID-19) → more patients eligible to attend the centres, new providers employed by the centres (and some joining the project)	+
Impact of COVID-19 restrictions		Centres not open for non-urgent consultations between March-August 2020 After August 2020 reorganisation of the centres to accommodate new covid-19 related tasks Higher workload for providers, focus on dealing with COVID-19-related issues → no opportunity for providers to perform alcohol screening in this period	–	Centres continue operating, albeit in restricted manner Refocus of providers work to deal with COVID-19 (testing, later vaccinations), decreased patient attendance Vulnerable providers not coming to work, high workload for remaining providers Medical interns are not allowed to work in the centres anymore → centres are able to choose whether to continue with alcohol screening, 6 centres continue with tally sheet application in period March-August 2020 Loss of trained providers as interns not allowed to work in centres anymore	–	Centres not open for non-urgent consultations March 2020–May 2021 Vulnerable providers not coming to work Healthcare system collapsing under pressure → focusing on healthcare system survival and dealing with COVID-19 more important than alcohol screening, therefore non-urgent matters were not prioritised	–
Interaction of COVID-19 impact with other factors		Regional elections contributing to project champion ending her term on influential position in intervention municipality – but they are able to stay on the influential position longer as mandate extended due to COVID-19-related restrictions (November 2020 instead of April 2020) → during their term, the project champion had influence on setting goals and encouraging applications of screening in the centres	–/+
External shocks		Politically motivated protests across Colombia, including Soacha in April/May 2021 → less patients attending the centre due to traffic disruption and violence on the streets	–	Measles outbreak in Mexico City in February/March 2020 → some providers have to redirect their work on measles outbreak prevention (surveillance, vaccination)	–

Notes: Factor → mechanism by which the factor would impact the outcome. Direction of impact: + : positive impact likely associated with outcome; – negative impact likely associated with outcome (can explain the examined outcomes). (+): positive impact possibly associated with outcome; (–) negative impact possibly associated with outcome (but cannot be ascertained from the examined outcome).

Figure 3. Explanation of country differences in number of alcohol screenings and screening providers.

Figure 4. Month-by-month trajectory of screenings, the screening providers and influential events.

Ysa, T., Colom, J., Albareda, A., Ramon, A., Carrión, M., & Segura, L. (2014). Governance of addictions: European public policies. Oxford University Press.

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