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Patient-level interventions to reduce alcohol-related harms in low- and middle-income countries: A systematic review and meta-summary

['Catherine A. Staton', 'Duke Division Of Emergency Medicine', 'Department Of Surgery', 'Duke University Medical Center', 'Duke University', 'Durham', 'North Carolina', 'United States Of America', 'Duke Global Health Institute', 'Health Sciences Graduate Program']

Date: 2022-04

In total, 5,036 abstracts were reviewed. From those, 500 articles were manually reviewed to identify 117 articles matching our inclusion and exclusion criteria ( Fig 1 ). No studies were excluded based on language. Of these 117 studies, 75 were RCTs ( Table 1 ) utilizing a vast array of interventions, which we categorized into 4 main categories of interventions, including brief interventions (24 studies) ( Table 2 ), psychotherapy or counseling (15) ( Table 3 ), health promotion and education (20) ( Table 4 ), and biological treatments (19) ( Table 5 ). One study by Shin and colleagues had one arm in biomedical treatments and another arm in brief intervention [ 22 ]. Two other studies had one arm in psychotherapy or counseling and another arm in health promotion and education [ 23 , 24 ]. These 75 studies were performed in 15 countries, representing 8 upper middle-income countries (60% of studies), 5 lower middle-income countries, and 2 low-income countries (7% of studies) ( S2 Fig ). The majority of the studies came from Brazil (28%) and India (20%). Alcohol-related outcomes found included alcohol quantity or frequency measure, intention to use alcohol, use/abstinence/remission proportion or frequency, alcohol-related scores, alcohol cravings or cravings per day, or alcohol use during pregnancy or before sex.

Meta-summary

Brief interventions. The brief interventions category had the greatest number of RCTs in our study with 24 RCTs, and these interventions were the most similar to each other. The types of interventions included most commonly were WHO-based brief interventions (which utilizes some MI techniques) [28,29,79–82] or MI interventions [22,58,76,88,89,91,93]. Some studies focused more on the intervention delivery, specifically nurse or layperson [67,70,71,75] or computer-based interventions [30,34,35,41]. Outcomes were also varied including harmful alcohol use scores (AUDIT) or alcohol misuse (ASSIST), abstinence or remission (ASSIST), and percent or number of days of drinking or heavy drinking. Overall, the majority of the studies evaluating brief interventions demonstrated evidence of efficacy in one or more of their alcohol-related outcomes, for both short- (up to 3 months) and long-term (6+ months) outcomes, comparing intervention and control [29,34,35,41, 58,67,70,71,75,76,80,88–90,91,93,94]. WHO-based brief interventions were found to be efficacious to reduce average daily alcohol consumption in males at the health setting [29] and AUDIT average scores in university students [81]. With brief interventions delivered from a motivational intervention framework, Signor and colleagues found at 6-month follow-up, 70% of individuals in the helpline-based brief intervention group and 41% in the control/minimal intervention group had remained abstinent [89]. Similarly, this mode of delivery showed evidence of efficacy at the primary care setting to reduce alcohol use [76,91,93] and with university students [58]. Simao found that college students had a significant reduction in the amount of alcohol use per occasion and AUDIT scores up to 24 months after the intervention [90]. Other modes of delivery revealed that lay counselor–delivered interventions had significant differences between intervention and control [67,71,75], and a computerized intervention reduced alcohol use as much as an in-person motivational intervention [41]. One study focused on the efficacy of a women-focused brief intervention demonstrated efficacy of the interventions in reducing heavy drinking behavior and heavy drinking days in women [94]. However, there were some studies that found a similar reduction in alcohol-related outcomes between both the intervention and control groups, thus a null effect [22,28,30,79,80,82,88]. Assangkornchai and Pengpid found brief interventions at the primary care setting addressing alcohol and other substances reduced alcohol use for both intervention and control arms equally [28,80,82]. Similarly, those evaluating a brief intervention in tuberculosis patients in the inpatient or outpatient setting showed limited results [22,79]. Web-based, personalized normative feedback (PNF) interventions showed conflicting results in 2 studies with similar populations [30,34]. Nadkarni and colleagues found a reduction in alcohol consumed and mean AUDIT score for both MI-based interventions but no difference between the groups; however, this feasibility study was not powered to detect such differences [70,72].

Psychotherapy or counseling. Overall, 15 RCTs matched our definition of psychotherapy or counseling. Interventions in this group varied in terms of length, population, and framework. Most commonly, interventions used MI techniques [22,23,61,69,72,83] or cognitive behavioral therapy (CBT) [53,64,68,77,78,87]. Some interventions used education and stigma reduction [73] or a combination of methods [45,92]. These studies also had varied populations, including hospitalized patients [45,63,73,74,87,91], emergency department patients [92], outpatient primary care patients [69], and patients visiting clinics specializing in reproductive health [61,83], HIV or tuberculosis [22,77], and substance abuse [23,64]. A number of the studies found a reduction in alcohol-related outcomes. Daengthoen’s intensive inpatient rehabilitation combination therapy intervention had a reduction in alcohol consumption and drink cravings [45]. Nattala found that a significantly higher percentage of dyadic intervention patients (57%) were abstinent compared to individual treatment (27%) or treatment as usual (30%) patients [73]. Sorsdahl and colleagues found a reduction in the ASSIST scale for those who received the MI with problem solving intervention compared to the control, yet there was no difference between the MI alone and the control group [92]. L’Engle, Rendall-Mkosi, and Moraes all had significant findings for their MI interventions reducing binge drinking up to 12 months, reducing the proportion of women at risk for alcohol-exposed pregnancies and increasing the proportion of abstinent patients [23,61,83]. Ng and colleagues used a body–mind–spirit multidimensional intervention and reported significantly less alcohol cravings, drinking days, drinks per drinking day, and relapse in the intervention group compared to treatment as usual at 3 months [74]. Randomization to receive CBT, in different modalities, was found to be associated with a higher reduction in drinking days, drinks per drinking days [77,78], and AUDIT score [63] in comparison to usual care, at 3 months for HIV-infected outpatients reduction in mean AUDIT score [68], and alcohol consumption [53] in participants positive for intimate violence. A few of the studies in this subgroup had null effects or found no difference between the intervention and control arms. Marques and colleagues found a reduction in many of their alcohol-related outcomes for the group and individual intervention arms at 15 months, but the intervention arms were not significantly different from each other [64]. Similarly, Satyanarayan found a reduction in Severity of Alcohol Dependence Questionnaire (SADQ) scores for CBT and usual care arm patients but no significant difference between intervention arms; authors believed that this was because both intervention arms received similar alcohol reduction strategy intervention components [87]. Alternatively, Shin and colleagues found that their intervention, which focused on inpatient tuberculosis patients with severe AUDs, caused no change in alcohol-related outcomes, likely because the study did not include alcohol treatment–seeking patients, but had patients with low readiness to change or poor intervention participation rates combined with relatively low enrollment numbers [22].

Health promotion and education. In total, we found 20 RCTs, which evaluated health promotion and education interventions. Of these, 2 were based in the workplace [26,38], 5 in the community [23,37,43,84], 6 in schools [33,40,65,85,86], and 7 in clinics [39,55–57], of which 1 was focused on women sex workers [95]. The majority of programs addressed alcohol use in the context of HIV/AIDS prevention and risk reduction [38–40,43,56,57,95]. About half (8 of 17) of the health promotion and education interventions were found to have positive results [25,26,38,39,54,56,57,65,66,84]. Some of these studies also had mixed results. For example, Aira and colleagues found a reduction in drinks per day and an improvement in attitudes toward drinking, but not a reduction in the total amount of alcohol consumption [26]. Similarly, Rotheram-Borus found that home visits for pre- and postnatal women were associated with a reduction in the use of alcohol during pregnancy, but this drinking resumed postpartum [84]. Meanwhile, a majority of the studies that found no effect of their interventions either were not adequately powered to detect the alcohol-related outcome [23,43] or were compared to another intervention rather than a control, thus potentially obscuring some potential reduction in harm [95]. Cubbins and colleagues evaluated a community-level intervention in which popular community individuals relayed education through casual conversations and found significant alcohol reduction in both the intervention and control groups, but no difference between the groups [43]. Chhabra and colleagues looked at the effectiveness of a Severity of Alcohol Dependence Questionnaire (STEP) school-based program but found that students, and more specifically girls, had an immediate reduction in their intent to use alcohol, but there was no difference in the intention to use alcohol at the 10-week outcome assessment [40].

[END]

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