Centering Patient Voices: Implementing Screening,Brief Intervention,and Referral to Treatment to Address Risky Substance Use in Family Planning Clinics

Abstract

Background:

To describe the contextual factors that affect patients’ acceptability and feasibility of alcohol and substance use-related service implementation in family planning (FP) clinics in Massachusetts.

Materials and Methods:

We conducted a qualitative study of patients at an FP clinic in Massachusetts. Through semistructured interviews (N = 11), we asked participants about their perspectives regarding receiving substance use screening, patient preferences for care and referral, barriers and facilitators to receiving care, and their acceptability of receiving screening, brief intervention, and referral to treatment (SBIRT) implementation within the FP clinic context. Interview data was analyzed through content thematic analysis utilizing Dedoose software.

Results:

Patients shared insightful knowledge about the barriers and facilitators to their acceptance of SBIRT implementation within FP clinics in Massachusetts. Patients emphasized the need for SBIRT implementation efforts to be contextually rooted within FP care while also considering how best to alleviate barriers to accessing care. Facilitators to SBIRT implementation included provider trust, psychological safety, provider congruence, varied care modalities, and selectivity by appointment type. Barriers to SBIRT implementation included stigma, transportation, funding, scheduling, and staffing scarcity.

Conclusions:

Despite persistent structural and systemic barriers, participants expressed broad support for integrating SBIRT into FP settings when delivered in ways that felt affirming, trauma-informed, and individualized to patient needs. Findings revealed critical opportunities for integrating alcohol and/or substance use-related care into FP settings.

Keywords

substance use women reproductive health screening

Introduction

There is a significant need for substance use services for reproductive-aged individuals in the United States.^1,2 In recent years, multiple public health crises have converged. These include rising rates of alcohol and substance use,¹ ongoing impacts of SARS-CoV-2,³ and persistent maternal-infant morbidity and mortality.⁴ Leading public health authorities, including the National Academy of Medicine, have emphasized the urgent need to address these intersecting challenges through the use of evidence-based strategies to identify and prevent risky substance use behaviors.⁵ Such strategies must be designed to effectively engage structurally marginalized, reproductive-aged individuals at elevated risk for alcohol and/or substance use disorders (AUD/SUD).^6–8

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based integrated behavioral health model that uses validated screening questionnaires to identify individuals at risk for harmful alcohol and/or substance use and then engages them in a brief counseling intervention as well as linkage to care if indicated.⁹ SBIRT is effective in emergency and primary care settings, primarily for risky alcohol use.^10–12 More recently, a few studies have examined the utility of SBIRT at the intersection of behavioral health and sexual and reproductive health (SRH) for pregnant people in obstetric settings and those living with HIV receiving care at community and safety-net clinics.^13–18 Despite its promise, the efficacy of SBIRT within family planning (FP) clinics remains largely unexplored, presenting a critical gap in service delivery.¹⁹ FP clinics often serve as the sole source of primary care for many pregnant people,^20–24 and serve as critical access points for those who use alcohol or drugs at risky or more harmful levels. Virtual adaptations of SBIRT have also been successful, indicating further potential in reducing barriers to care in the FP setting.¹⁵

FP providers already possess skills aligned with core SBIRT practices, including a nonjudgmental, motivational style, shared decision-making, and routine screening for related concerns such as mental health and intimate partner violence.²⁵ Yet, challenges remain in implementing SBIRT in clinics.^19,26,27 FP providers may hesitate to initiate conversations about substance use,²⁸ and patients may be reluctant to disclose symptoms of AUD/SUD due to stigma,²⁹ misinformation about treatment options, or concerns about cost and continuity of care.^30–32 Even when risk is identified, patients may decline referrals, limiting access to treatment and support.^33–35 FP providers are also often faced with navigating constant legal and regulatory changes related to their provision of care and may not be able to prioritize additional training for AUD/SUD care.³⁶

To identify potential facilitators and barriers to SBIRT implementation in FP settings, we conducted in-depth qualitative interviews with patients at an urban FP clinic in Massachusetts. Interviews focused on patients’ experiences accessing substance use care, their views on SBIRT within the clinic, and their recommendations for expanding the model to virtual modalities such as telehealth. By examining patient-level factors influencing SBIRT uptake in FP clinics, we aim to identify facilitators and barriers to enhancing patient safety, satisfaction, and acceptability of conversations about substance use, including referrals to AUD/SUD treatment. These efforts aim to inform future implementation of integrated behavioral and FP care for reproductive-aged people.

Methods

Recruitment

Patients aged 18 or older seeking care at an FP clinic in Eastern Massachusetts were approached while waiting to see their provider. Those who expressed interest in learning more about the study were invited to complete a brief screening survey, which included items from two standardized screening instruments, the Drug Abuse Screening Test (DAST-10)³⁷ and the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C).³⁸ Threshold scores for risky alcohol or drug use for the two screeners were based on the patient’s sex assigned at birth as documented in their medical chart. Participants were enrolled according to a purposive sampling matrix designed to represent diverse perspectives and experiences across various levels of alcohol and substance use risk and clinic appointment types. For these purposes, levels of alcohol and drug use risk were categorized as follows: Risky to Harmful Alcohol Use if the DAST-10 score = 0 and the AUDIT-C score = 4–7 for males or 3–7 for females; Risky to Harmful Drug Use if the DAST-10 score = 1–5 and the AUDIT-C score = 0–7; Severe Alcohol Risk if the DAST-10 score = 0–5 and the AUDIT-C score = 8–12; and Severe Drug Risk if the DAST-10 score ≥6. These categories do not reflect all possible risk levels but represent the most frequent patterns of substance use in this sample. Demographic information, including race/ethnicity, sex assigned at birth, age (categorized by 18–24 and 25 years and older), and appointment type, was collected.

Data collection and analysis

The qualitative interview guide was informed by a comprehensive literature review and prior relevant work by the team and was initially informed by a focus group of 34 FP providers who shared their views on opportunities for SBIRT use in FP clinics.¹⁹ Focus group discussions drew upon the constructs of the Consolidated Framework for Implementation Research (CFIR), which focuses on implementation barriers and facilitators.³⁹ The Patient-Centered Access to Care Framework⁴⁰ was used to supplement CFIR’s implementation focus during the development of the patient interview guide. This framework is rooted in human rights and equity, highlighting both provider- and patient-side factors that influence service utilization.^40,41 Constructs such as approachability, acceptability, and availability informed questions designed to explore patients’ expectations, preferences, and barriers to SBIRT-based care.

Interviews were conducted by a member of the research team either in person following the patient’s appointment or virtually on a separate date, based on their preference. Using the Consolidated Criteria for Reporting Qualitative research guidelines,⁴² all interviews were audio recorded and transcribed verbatim for analysis, followed by the development of a codebook. First, an inductive approach was employed to identify emergent themes from the patient interview transcripts, which formed the basis of the preliminary codebook. This was followed by a deductive phase, during which the codebook structure was refined to align with constructs from CFIR as informed by the Patient-Centered Access Care Framework and existing literature on SBIRT implementation in clinical settings. To ensure analytic rigor and data reliability, all transcripts were double coded by two members of the research team (J.L. and S.I.S.) both with graduate-level education in qualitative data analysis. Coders independently reviewed transcripts and applied initial codes, after which a consensus process was used to reconcile discrepancies, refine code definitions, and ensure consistency and accuracy in code application by two additional independent reviewers (V.J. and A.M.H.), both with graduate-level education in qualitative research.

Content analysis was employed as part of the thematic analysis to better understand and organize key concepts that emerged from patient interviews.⁴³ The analytic process involved a close reading of interview transcripts by two coders, who identified discrete units of meaning reflecting patients’ experiences, attitudes, and perceptions of SBIRT implementation. Codes were then grouped into broader categories based on conceptual similarity and frequency. Codes that appeared more than 10 times across all patient transcripts were considered especially salient and prioritized in thematic synthesis.

Results

A total of 29 individuals were approached/screened prior to obtaining verbal consent for participation. Eleven interviews were conducted with patients receiving care for abortion (n = 1), gender-affirming hormone therapy (GAHT) (n = 2), sexually transmitted infections (STI) (n = 2), long-acting reversible contraception (n = 2), other (n = 1) and more than one appointment type (n = 3). Table 1 lists demographic characteristics of the sample. The majority of participants identified as White (n = 7), or mixed race, (Black or African American and White) (n = 2). One individual identified as Black or African American and one as Arab or Middle Eastern.

Table 1.

Demographic Information from Participant Interviews (N = 11)

	n (%) or mean (SD)
Gender
Male	4 (36%)
Female	7 (64%)
Ethnicity
White	7 (64%)
Black or African American	1 (10%)
Arab or Middle Eastern	1 (10%)
Mixed race	2 (18%)
Age
18–24	5 (45%)
25 or older	6 (55%)
Services received
STI/HIV testing	2 (18%)
Abortion care	1 (10%)
Gender affirming care	2 (18%)
Contraception	2 (18%)
Other	1 (10%)
More than one	3 (27%)
Risk category
Risky to harmful alcohol use	3 (27%)
Risky to harmful drug use	6 (55%)
Severe alcohol risk	1 (10%)
Severe drug risk	1 (10%)
Risk scores
Mean AUDIT-C	4.5 (2.8)Range: 1–11
Mean DAST-10	1.2 (1.7)Range: 0–6

AUDIT-C, Alcohol Use Disorder Identification Test-Consumption; DAST-10, Drug Abuse Screening Test; STI, sexually transmitted infections; SD, Standard Deviation.

Three key themes related to SBIRT implementation in FP settings emerged from the patient experience: (1) facilitators to SBIRT receptivity, (2) barriers to SBIRT receptivity, and (3) emotionally responsive approaches to SBIRT implementation to adequately address the needs of the patient population. Table 2 provides a summary of the themes, key components, and illustrative findings based on codes associated with each theme.

Table 2.

Themes, Key Components, and Illustrative Findings Based on Codes from Patient Interviews

Core theme	Key components	Illustrative findings based on codes
Relational facilitators	Provider trust and psychological safety	Patients are more receptive to SBIRT when they feel respected and safe within the clinic environment
Relational facilitators	Cultural responsiveness	Affirming care for sexual, gender, and racially diverse individuals enables more sensitive behavioral health integration and better overall experience
Structural and systemic barriers	Logistical access challenges	Transportation difficulties, insurance coverage, and travel costs remain significant perceived barriers to accessing follow-up care.
Structural and systemic barriers	Resource scarcity	Long wait times and a lack of accessible external providers complicate the referral process
Psychosocial barriers	Anticipated stigma	Concerns of being judged or stereotyped hinder disclosure of substance use. Previous negative interactions in health care settings influence current patient-provider interactions and safety levels
Patient-centered implementation	Emotional responsiveness	Patients advocate for trauma-informed, nonjudgmental approaches that enhance agency and utilize lived experience to navigate conversations
Patient-centered implementation	Flexible and integrated care	Receptivity is higher when SBIRT is tailored to the visit context, offered via multiple modalities (e.g., telehealth), and integrated into existing workflows

SBIRT, screening, brief intervention, and referral to treatment.

Facilitators to SBIRT implementation: Relational

Trust in providers emerged as a critical facilitator in SBIRT acceptability for participants. Participants emphasized the importance of relationship-building before engaging in sensitive conversations and valuing flexibility in how and when these discussions occurred. The clinic from which patients were recruited was consistently associated with psychological safety, which enhanced openness to additional services. This sense of safety was closely tied to provider demeanor and communication style, which could either reinforce or undermine patient dignity.

“She made me feel a bit relaxed and comfortable…she made me feel human.” (P7)

In addition, participants praised the clinic’s cultural responsiveness, particularly regarding queer and trans identities, and saw SBIRT as a way to further integrate substance use support within the context of affirming care. For many, culturally congruent care from providers and a strong sense of community helped participants feel more at ease navigating care when compared with other clinical settings.

“Part of why I don’t have a GP is it’s very intimidating for me being trans to go and try and find a doctor’s office…and the people here a lot of them are queer or trans in a way that is nice.” (P3)

Furthermore, participants indicated that the use of digital tools such as electronic medical records (EMRs) and telehealth platforms could be useful for facilitating low-barrier communication and resource sharing. This directly connected to perceived barriers, discussed below, such as access to transportation and time concerns that hinder patients’ access to the clinic.

“I would probably enjoy being able to have the option to have the conversation in person or remotely…to feel out where I would be more comfortable.” (P5)

However, one participant shared that in-person visits may yield better results due to privacy concerns such as the fear of being recorded, which may hinder participants’ openness about discussing substance use with a provider.

“I think talkin’ about substance abuse, I think, can be scary online because there’s always the feeling of being recorded or something. I wouldn’t be as comfortable sharing everything.” (P1)

Barriers to SBIRT implementation: Structural/systemic and psychosocial

Considering the importance of perceived psychological safety in sharing substance use experiences, it is relevant that participants recognized potentially experiencing stigma as a barrier to SBIRT conversations. Anticipated stigma related to substance use, identity, and provider behavior emerged as a recurring barrier to openness. Participants voiced concerns about being judged—particularly as women, parents, and people of color—which shaped their willingness to disclose substance use to a provider.

“We carry our own baggage and cultural expectations…then that can get exacerbated…there’s always this fear of not being taken seriously.” (P14)

Additionally, navigating transportation challenges, especially for participants living outside of urban centers, added further challenges to accessing care and receiving SBIRT.

“Let’s say people don’t live in [city]…it’s not the easiest to get help outside of cities.” (P1)

“Travel, really. Honestly, that really is the only thing ‘cause for so long I didn’t have a car, so I didn’t drive. It’s either I Ubered here to get here in the morning, or I took a train.” (P4)

Difficulty in accessing the clinic because of transportation concerns led some participants to champion the flexibility of telehealth services in accessing care and thus encouraged participants to be more accepting of SBIRT implementation as well.

“Well, if you do have stable internet, it’s super convenient. You don’t have to go anywhere. It can be cheaper ‘cause you don’t have to travel on the [train] or the bus or a car. That’s really nice. You can even do it on a lunchbreak at work or something like that.” (P6)

Participants cited insurance coverage and service cost as a potential barrier to accessing care. While uninsured and underinsured participants appreciated the clinic’s sliding scale, because cost was a barrier to them at other clinics, many were uncertain about whether SBIRT services would also be offered at an affordable rate.

“When I didn’t have health insurance…I was able to be seen at [clinic]…I can still go here.” (P5)

“Well, one thing would be like if insurance covers [an SUD related referral]. That would be a big thing. Like assuring the coverage.” (P1)

For some, long wait times and the emotional burden of navigating external systems further complicated access to care. Participants emphasized the benefit of having a “one-stop shop” for their care needs in increasing their acceptability of SBIRT. When asked about receiving AUD/SUD support within the clinic, several participants emphasized the benefit of an on-site behavioral health provider, citing a general shortage of accessible therapists.

“Every time I would try [to get a PCP]…they would be like, ‘Well, we’re full now’…my next phone call that I have the energy for is in a couple weeks.” (P8)

“Granted, that therapists are so hard to come by, especially in [city], I think it would only be infinitely more helpful to have one here, just so that if someone did come in and that was a topic that came up and you could recommend this therapist that may have more availability because it’s specific to [clinic]…” (P6)

Emotionally responsive approaches to SBIRT implementation: Patient-centered implementation

In addition to concerns about barriers to accessing health care, participants discussed how negative past experiences in health care impacted how they now interact with providers. Concerns about provider attitudes and potential stigma influenced participants’ feelings of safety in discussing sensitive topics with providers, like substance use. Some participants advocated for a more tailored approach, suggesting that the appropriateness of SBIRT should be informed by both visit context and individual risk, whereas others recognized the importance of this information in patient counseling about partner risk.

“I don’t think it should be across the board for all appointments… it’s just gonna take time, trial and error and damage control.” (P2)

“Yeah. If’ I’m coming in for an IUD placement, and they’re asking five, six, seven questions about substances, but I didn’t really come for that, perhaps I could see that as a little off track.” (P8)

“Just because somebody’s here for GAHT doesn’t mean that they take intravenous drugs and vice versa. Just because somebody takes intravenous drugs doesn’t mean they share needles, but that is also something that people don’t really talk about. I was asked during my STI screening whether or not I was actively or had a history of using intravenous drugs or if I knew if my partners had a history of using intravenous drugs. That was a casual question, and it wasn’t unusual, but it is a real concern, and it’s something that people may not be transparent about with their partners.”(P2)

Further, participants highlighted the potential importance of lived experience, indicating that providers with previous experience with substance use may help participants feel more comfortable having SBIRT conversations, thus reducing the perceived stigma participants believe providers may have.

“I think if I were to speak with somebody who—and this might be helpful or harmful depending on who you’re speaking to, but somebody who has personal experience with substance abuse ‘cause they may know how to navigate that conversation better.” (P2)

Discussion

This study highlights the potential for FP clinics to serve as trusted sites for SBIRT implementation to address the critical and growing gap in substance use care among individuals of reproductive age, particularly those from structurally marginalized communities.⁴⁴ Participants identified a range of factors related to their receptiveness to SBIRT within an FP setting. Many felt that due to feeling respected, culturally affirmed, and psychologically safe in the FP setting, they were more receptive to implementation of the model in contrast to other health care settings. Psychological safety was often linked to providers’ communication style, trauma-informed care practices, and the clinic’s commitment to serving queer, trans, and racially diverse communities. Because these factors often contributed to a higher level of trust, patients expressed greater willingness to engage in sensitive conversations around substance use in this context.

How SBIRT is delivered mattered to multiple participants as much as whether it was implemented. Participants recommended trauma-informed, nonjudgmental approaches and providing several modalities for engagement with SBIRT, which included options for telehealth, asynchronous screening, and integration of the model into existing workflows. These preferences reflect broader calls for adaptable, patient-centered models of care,⁴¹ and suggest that embedding SBIRT within existing visit flow could increase receptivity without compromising positive relationships with providers. While our findings suggest strong receptivity among transgender and gender-diverse participants, further research should explore how SBIRT models can be more explicitly designed to meet the needs of this demographic. Existing guidance emphasizes the importance of gender-affirming care, continuity, and provider training to address the distinct stigmas and medical mistrust that this population often faces.^45,46

Participants reported concerns surrounding stigma and accessibility of services despite the clinic being described as affirming and supportive. Participants expressed having fears of feeling judged, the impact of fragmented behavioral referral models experienced outside the clinic, and navigating social needs related to funding for care, transportation, and scheduling barriers. Our findings underscore the importance of addressing these barriers directly in implementation efforts, such as training FP staff to recognize and mitigate intersecting stigmas, developing effective referral pathways to address social needs, and designing workflows that allow for meaningful follow-up. To improve referral success, clinics should consider establishing formal partnerships with local treatment agencies to ensure external resources are accessible and insurance coverage is verified. Utilizing warm handoffs, and when possible, staff with lived experience, may help navigate sensitive conversations and serve as a bridge to treatment when indicated. Finally, if resources are available, embedding on-site behavioral health reduces the burden of navigating fragmented systems and logistical hurdles like transportation.

The diversity of patient perspectives across FP visit types illustrates widespread support for SBIRT when implemented in ways that align with patient values. Participants viewed SBIRT as a potentially vital service when offered with empathy, transparency, and attention to context. These perspectives build on prior research suggesting that effective implementation requires collaborative design with patients and alignment with broader principles of both reproductive justice and harm reduction.^41,44 Despite these challenges, participants across gender identities, alcohol/substance risk profiles, and visit types expressed interest in SBIRT implementation when approached with transparency, empathy, and relevance to their care experience. Participant feedback yielded consistent recommendations for patient-centered SBIRT implementation, including the importance of trauma-informed communication, flexible delivery models such as telehealth, and culturally attuned approaches that acknowledge intersecting stigmas tied to substance use and reproductive health.

As trusted access points for SRH services, FP clinics often provide more affirming, inclusive, and responsive care than standard primary care settings.^19,24 Taken together, these findings highlight support for SBIRT implementation in FP clinics and suggest that the intervention should be part of a broader, equity-based model of integrated behavioral health. Embedding SBIRT within SRH services presents an opportunity to close longstanding gaps in substance use care. Staff training, workflow adaptation, and interorganizational coordination are essential. Further research should explore how to best support implementation across diverse clinical contexts, with special focus on the needs of gender-expansive and racially minoritized populations, and with attentiveness to assessing and addressing the need for additional resources to enable clinics to integrate SBIRT in a sustainable fashion.^27,45,47

Limitations

This study has several limitations. First, AUDIT-C scoring was based on sex assigned at birth as documented in the EMR, which may have misclassified risk among transgender and gender-diverse participants. While aligned with current scoring protocols, this method may not reflect accurate biological alcohol-related risks. Second, we did not collect detailed demographic data from participants, which limits our ability to contextualize findings by socioeconomic status or other intersecting factors that could shape SBIRT receptivity. Third, the relatively small sample size and focus on a single urban clinic constrain the generalizability of findings, particularly to rural settings or clinics operating under varied structural conditions. The study also takes place in a clinic that is housed in an abortion and gender-affirming care protective state, which may mean that findings differ vastly from those in different states with limited FP support, as services and support vary based on state and local policy.

Conclusion

In centering patient perspectives, this study offers critical insight into how SBIRT can be meaningfully integrated into FP clinics to expand access to substance use services for individuals of reproductive age. Participants’ feedback highlights the importance of culturally responsive, trauma-informed approaches to honor patient agency and context. Despite persistent structural and systemic barriers, participants expressed strong receptivity across appointment types, which affirms the promise of FP settings as strategic, underutilized platforms for behavioral health care. As efforts to integrate SBIRT into more health care settings continue, codesigning with patients, investing in staff training, and embedding services within trusted care environments is essential.

Authors’ Contributions

A.M.H. participated in the investigation, formal analysis, and writing—original draft. V.J. participated in data curation, formal analysis, project administration, writing—original draft, and writing—review and editing. E.J. participated in conceptualization, methodology, project administration, supervision, and writing—review and editing. J.F. participated in conceptualization, investigation, project administration, supervision, and writing—review and editing. J.L. participated in formal analysis, investigation, methodology, project administration, and writing—review and editing. S.I.S. participated in formal analysis, project administration, writing—review and editing. E.M., M.A.V., and L.W.A. participated in investigation, writing—review and editing. H.J.G. participated in investigation, methodology, formal analysis, supervision, writing—original draft, and writing—review and editing. K.S.H. and J.W.W. participated in investigation, methodology, formal analysis, supervision, writing—original draft, and writing—review and editing.

Ethical Considerations

This study was approved by the Western IRB Research Ethics Committee (approval no. AAAU3394) on August 18, 2022.

Data Availability

All deidentified data will be made available upon reasonable request.

Footnotes

Author Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

This work was supported by the National Institute on Alcohol Abuse and Alcoholism (R01AA030529).

Supplemental Material

Abbreviations Used

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