https://orcid.org/0000-0001-7061-5762
Figures
Abstract
Background
Disease and disability from alcohol use disproportionately impact people in low- and middle-income countries (LMICs). While varied interventions have been shown to reduce alcohol use in high-income countries, their efficacy in LMICs has not been assessed. This systematic review describes current published literature on patient-level alcohol interventions in LMICs and specifically describes clinical trials evaluating interventions to reduce alcohol use in LMICs.
Methods and findings
In accordance with PRISMA, we performed a systematic review using an electronic search strategy from January 1, 1995 to December 1, 2020. Title, abstract, as well as full-text screening and extraction were performed in duplicate. A meta-summary was performed on randomized controlled trials (RCTs) that evaluated alcohol-related outcomes. We searched the following electronic databases: PubMed, EMBASE, Scopus, Web of Science, Cochrane, WHO Global Health Library, and PsycINFO. Articles that evaluated patient-level interventions targeting alcohol use and alcohol-related harm in LMICs were eligible for inclusion. No studies were excluded based on language.
After screening 5,036 articles, 117 articles fit our inclusion criteria, 75 of which were RCTs. Of these RCTs, 93% were performed in 13 middle-income countries, while 7% were from 2 low-income countries. These RCTs evaluated brief interventions (24, defined as any intervention ranging from advice to counseling, lasting less than 1 hour per session up to 4 sessions), psychotherapy or counseling (15, defined as an interaction with a counselor longer than a brief intervention or that included a psychotherapeutic component), health promotion and education (20, defined as an intervention encouraged individuals’ agency of taking care of their health), or biologic treatments (19, defined as interventions where the biological function of alcohol use disorder (AUD) as the main nexus of intervention) with 3 mixing categories of intervention types. Due to high heterogeneity of intervention types, outcome measures, and follow-up times, we did not conduct meta-analysis to compare and contrast studies, but created a meta-summary of all 75 RCT studies. The most commonly evaluated intervention with the most consistent positive effect was a brief intervention; similarly, motivational interviewing (MI) techniques were most commonly utilized among the diverse array of interventions evaluated.
Conclusions
Our review demonstrated numerous patient-level interventions that have the potential to be effective in LMICs, but further research to standardize interventions, populations, and outcome measures is necessary to accurately assess their effectiveness. Brief interventions and MI techniques were the most commonly evaluated and had the most consistent positive effect on alcohol-related outcomes.
Author summary
Why was this study done?
- Low- and middle-income countries (LMICs) report high rates of risky alcohol use behavior, a known risk factor for death and disability worldwide.
- In order to investigate the potential for a patient-level intervention to reduce alcohol-related harms in a low-income setting, we sought to identify interventions with adequate efficacy.
What did the researchers do and find?
- We conducted a systematic review of studies from 1995 to 2020 in LMICs evaluating interventions to reduce alcohol use and alcohol-related harms.
- Of the 117 studies included for review, the majority were in middle-income countries and had varied intervention types, outcome measures, and follow-up time.
- The most commonly studied interventions with the most consistently positive results were brief interventions. Similarly, motivational interviewing (MI) techniques were the most commonly described intervention techniques.
What do these findings mean?
- Future research on alcohol use and alcohol harm reduction in LMICs may benefit from consistency of methodologies, studying similar populations, interventions, and alcohol-related harm reduction outcome measures.
- Especially in LMICs, further research on comparative effectiveness or implementation strategies delineating optimal interventions and target populations is needed.
Citation: Staton CA, Vissoci JRN, El-Gabri D, Adewumi K, Concepcion T, Elliott SA, et al. (2022) Patient-level interventions to reduce alcohol-related harms in low- and middle-income countries: A systematic review and meta-summary. PLoS Med 19(4): e1003961. https://doi.org/10.1371/journal.pmed.1003961
Academic Editor: Margarita Alegria, Massachusetts General Hospital, UNITED STATES
Received: June 19, 2019; Accepted: March 9, 2022; Published: April 12, 2022
Copyright: © 2022 Staton et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All related data and metadata for the reported findings are available at doi.org/10.6084/m9.figshare.13836668.
Funding: CAS received salary support funding from the Fogarty International Center under Staton, K01 TW010000-01A1 (URL: https://www.fic.nih.gov/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: AA, Alcoholics Anonymous; ACROBAT-NRS, A Cochrane Risk Of Bias Assessment Tool for Non-Randomized Studies; ASSIST, Alcohol, Smoking and Substance Involvement Screening Test; AUD, alcohol use disorder; AUDIT, Alcohol Use Disorders Identification Test; CBT, cognitive behavioral therapy; DALY, disability-adjusted life year; LMIC, low- and middle-income country; MI, motivational interviewing; NOS, Newcastle–Ottawa scale; PNF, personalized normative feedback; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RAPI, Rutgers Alcohol Problem Index; RCT, randomized controlled trial; SADQ, Severity of Alcohol Dependence Questionnaire; STEP, School-based Teenage Education Program; STROBE, STrengthening the Reporting of OBservational studies in Epidemiology; WHO, World Health Organization
Introduction
Alcohol use is an important cause of chronic disease and injury. It is one of the top 5 risk factors for death and disability in the world [1–3]. The detrimental effects of alcohol use contribute to 3.3 million deaths and 139 million disability-adjusted life years (DALYs) lost globally each year [4]. Alcohol use has also been associated with risky behaviors, including crime, aggressive driving, interpersonal violence, and self-inflicted injury [5]. Such behaviors not only have harmful effects on the individual but also on the greater population [6]. Compared to high-income countries, low- and middle-income countries (LMICs) report higher rates of risky drinking behaviors, such as binge drinking and episodic drinking, as well as an earlier onset of alcohol consumption [4].
The World Health Organization (WHO) has placed an emphasis on the development and implementation of both policy-level and patient-level interventions to reduce harmful alcohol use in LMICs. While policy-level interventions are a crucial, cost-effective manner of reducing alcohol-related harms, context-appropriate, and effective patient-level interventions are also greatly needed to form multipronged alcohol harm reduction strategies [4]. A broad array of patient-level alcohol harm reduction interventions, such as brief interventions (for this paper, defined as any intervention ranging from advice to counseling, lasting less than 1 hour per session [7] up to 4 sessions [8], psychosocial interventions, and pharmacological treatments) have been found to be effective in high-resource settings [9,10]. Yet, alcohol use disorders (AUDs), characterized by moderate to severe alcohol abuse and dependence, remain a low priority of LMIC health systems [11]. Barriers, such as funding constraints, lack of policy, and low public awareness, often prevent access to psychosocial and pharmacological treatments that target AUDs [11]. Especially in some settings where alcohol use is culturally ingrained, adopting an alcohol harm reduction strategy, as opposed to focusing on abstinence, is crucial given the limited alcohol policy, health system treatments, and social support [12]. As such, WHO and The Lancet have recently issued calls to action to reduce hazardous alcohol use [4,13], yet the full scope of the evidence-based patient-level interventions to reduce harmful alcohol use in LMICs is missing from the literature. While narrative reviews of global alcohol-related harms have been published, we have found no systematic review conducted focusing on alcohol interventions specifically applicable to or evaluated in LMICs [1,11].
In order to address this gap, this paper aims to (1) review and describe the current published literature on patient-level alcohol interventions in LMICs; and (2) conduct a meta-summary of studies evaluating interventions to reduce alcohol use and harms in LMICs.
Methods
Protocol and registration
This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [14] (see S1 Table) and is registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42017055549.
Eligibility criteria
Our primary criterion for article consideration was a patient-level alcohol or alcohol-related harm reduction intervention in a LMIC, as defined by our PICOS framework: LMIC Participants, patient-level Interventions, Compared to a control group, alcohol harm reduction Outcomes, all Study designs but focused on randomized clinical trials if there are enough. To be included, articles had to (1) evaluate a patient-level alcohol-related intervention’s ability to reduce an (2) alcohol-related outcome in a (3) LMIC and be (4) peer-reviewed and published between January 1, 1995 and December 1, 2020. Study locations had to be classified as LMICs according to World Bank criteria at the time of the search [15]. The search strategy was inclusive of multiple study designs (randomized controlled trials [RCTs], prospective/retrospective cohort, quasi-experimental, or secondary data analyses with before and after intervention comparison) in case there was a dearth of literature from LMIC settings. Articles were excluded if they were abstracts only, literature or systematic reviews, meta-analyses, or commentaries. If 2 studies used the same data, then the most recent data were included in the review.
Information sources
We searched electronic databases (PubMed, EMBASE, Scopus, Web of Science, Cochrane, WHO Global Health Library, and PsycINFO) for articles that evaluated patient-level interventions aimed at reducing an alcohol-related outcome in LMICs. No studies were excluded for language. Additionally, we manually searched references and performed a citation analysis of the included articles using Web of Science and Google Scholar. Any citation that met the inclusion criteria based on the title and abstract was added.
Search
The initial search consisted of the MeSH terms “alcohol drinking,” “low or middle income country,” and “intervention.” Search strategy demonstrates the search strategy used in PubMed, Embase, PsycINFO, and WHO Global Health Library databases (S1 Fig).
Study selection
Six pairs of reviewers from the specified individuals (KA, TC, SE, DE, SG, CP, LR, NS, AS, CY, and AP) independently reviewed the titles and abstracts, and any inconsistencies regarding inclusion were resolved by a third reviewer (DG or CS). Abstracts that did not provide enough information to determine eligibility were retrieved for full-text evaluation. Reviewers independently evaluated full-text articles and determined study eligibility. Disagreements were solved by consensus, and if disagreement persisted, a third reviewer’s opinion was sought. After inclusion, we assessed each study for the study design. We reported all study designs in order to summarize the type and quality of study designs in the literature. Based on the large number of RCTs identified, we chose to narrow further analysis to RCTs.
Quality of studies
Since our systematic review included studies of different designs (RCTs, nonrandomized intervention, prospective/retrospective cohort, quasi-experimental, or secondary data/cross-sectional with before and after comparison), we opted to perform a data quality assessment according to study design using the following approaches. STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) indicators were used for reporting observational studies. Two scales were used for nonrandomized studies: the A Cochrane Risk Of Bias Assessment Tool for Non-Randomized Studies (ACROBAT-NRS) [16] and Newcastle–Ottawa scale (NOS) [17]. Cochrane’s revised risk-of-bias tool was used for randomized studies [18]. Finally, the Effective Practice and Organisation of Care (EPOC) suggested risk of bias indicators for interrupted time series studies (EPOC) [19]. We assigned risk of bias (low, moderate, and high risk) as suggested by the Cochrane Handbook [20] by study design. Studies were classified as (a) low risk of bias if all domains had low risk; (b) some concerns if at least 1 domain raised some concerns for bias; and (c) high risk of at least 1 domain was at high risk.
Data extraction
Five pairs of reviewers independently conducted the data extraction, and any disagreements were resolved by a third reviewer. General characteristics of the studies were recorded, such as year of publication, location where the study took place, inclusion and exclusion criteria, and participant characteristics. In addition, information on alcohol-related outcome measures, intervention type, and intervention impact or effectiveness measured as an effect size of outcome measures was extracted. The main outcome measures were Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores, Rutgers Alcohol Problem Index (RAPI), number of drinking days, number of heavy drinking days, number of binge drinking days, drinks per drinking day, percent remaining abstinent from drinking alcohol, and percent relapsed back into drinking alcohol.
Data analysis
Initial evaluation of the papers indicated that a meta-analytical approach would result in high heterogeneity due to high methodological variability (e.g., outcome measures, study designs, and sample characteristics). Therefore, we conducted a meta-synthesis for all the included manuscripts, which qualitatively aggregated findings by grouping relevant findings into categories that represent the study’s objectives (e.g., effectiveness of alcohol intervention). No manuscripts were excluded based on quality. The process involved summarizing main results of each included paper and performing a thematic analysis. Emerging themes on types of intervention and outcomes were presented. Interventions were grouped by similarity into 4 types: brief interventions, psychotherapy and counseling, health promotion and education, and biomedical treatments.
Using WHO and National Institute on Alcohol Abuse and Alcoholism (NIAAA) descriptions of brief interventions, we defined brief interventions as any intervention ranging from advice to counseling, lasting less than 1 hour per session [7] up to 4 sessions [8] independent of how the original study defined brief intervention. Interventions including a one-on-one interaction with a counselor that lasted longer than a brief intervention or that included a psychotherapeutic component were defined as psychotherapy and counseling. Motivational interviewing (MI) techniques could be included as either a brief intervention or psychotherapy and counseling, depending on how long and over how many sessions the intervention took place. A study was considered health promotion and education, independent of the study’s definition, if an intervention encouraged individuals’ agency of taking care of their health, such as risk reduction skills and health education [21]. Biomedical treatments were used as a taxonomy to group studies that had the biological function of AUD as the main nexus of intervention, including brain stimulation and medicines.
Results
Study selection and description
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].
Biomedical treatments.
The final group of RCTs evaluated biomedical treatments and included 19 RCTs evaluating medications and brain stimulation. The 14 RCTs evaluating medications looked at naltrexone (3) [22,24,32], ondansetron (1) [43], gabapentin (1) [51], disulfiram (5) [46–50], and topiramate (2) [32,62]. Two RCTs evaluated combined behavioral and medication interventions: evaluated acamprosate with Alcoholics Anonymous (AA) [31] and one evaluated baclofen with a brief intervention [52]. One RCT evaluated the efficacy of adding acupuncture to an escitalopram treatment regimen [96].
The RCTs evaluating naltrexone and ondansetron found limited impact on abstinence, number of heavy drinking days or number of abstinent days [22,24,32], and abstinence [43]. Mixed effects were found by RCTs for topiramate, where Baltieri found an increase in abstinence at 4 weeks, although Likhitsathian found no differences in any drinking quantity or frequency measures up to 12 weeks [32,62].
On the other hand, the RCTs evaluating gabapentin, acamprosate, and baclofen exhibit more positive results. Furieri found that gabapentin was associated with a significant decrease in quantity and frequency of drinking and higher mean abstinent days [51]. Baltieri found that acamprosate improved abstinence rates but only for those who participated in AA [31]. Moreover, Gupta found that patients who received baclofen compared to a nutritional supplement, with a brief motivational intervention, were more likely to remain abstinent, have lower heavy drinking days, and fewer alcohol cravings [52].
We identified 4 RCTs that studied transcranial direct current stimulation, and all of them occurred at 2 institutions in Brazil. While 3 of these studies found a decrease in alcohol cravings compared to sham stimulation [36,44,60], one study found a lower relapse rate in the brain stimulation group but with no difference in alcohol cravings at 6-month follow-up [59]. Ultimately, 3 of the 4 studies in this group found more relapses in the intervention group at 4-week, 6-month, and 12-month follow-up [44,59,60].
Discussion
This is the first review, to our knowledge, of alcohol harm reduction interventions evaluated in LMICs. Most studies we found took place in middle-income countries; there was a noticeable gap of studies in the Middle East, North Africa, Europe, Central Asia, and South Asia regions. Overall, we found that there was limited uniformity for interventions, outcomes, and follow-up times across studies, which limited our ability to compare results. The vast majority of evaluations were limited to middle-income settings, leading to feasibility and generalizability concerns for low-income settings. Of all the RCTs, brief interventions were the most commonly studied; similarly, MI techniques were the most prevalent behavior change technique common in both brief and psychotherapy and counseling interventions. Brief interventions and motivational interviewing techniques also had the most consistent positive results in our findings.
Lack of uniformity limits effective comparisons
The studies included in our meta-summary used a wide variety of metrics to measure alcohol-related outcomes of alcohol interventions; these metrics included (i) AUDIT scores; (ii) ASSIST scores; (iii) # of drinking days; (iv) # heavy drinking days; (v) # drinks per drinking day; (vi) # abstinent days; (vii) # drinks per day; (viii) % of patients abstinent; and (ix) % of patients relapsing.
The time period over which these outcomes were measured also varied considerably, from 3 months [41] to 24 months [90]. This lack of uniformity compromised our ability to discern the effectiveness of interventions or to compare results across studies. The diversity of alcohol consumption outcomes measures is due in part to varying recall, reference period, and definition of a “standard drink” [97–99]. Future study studies may benefit from using consistent outcome measures and adopting uniform methods of intervention implementation or study designs.
Uncertain feasibility of implementing interventions in low-income country setting
The vast majority of the studies in this review were conducted in middle-income countries. Thus, the feasibility of implementing these interventions and their effectiveness in low-income settings is uncertain. Low-income countries face greater barriers (such as scarcity of medical facilities, limited training available to medical staff, infrastructural barriers to healthcare access, and effective patient communication/follow-up) to implementing effective healthcare than either high- or middle-income countries. As a clear example, all 4 studies [36,44,59,60] that used brain stimulation as an intervention were conducted in Brazil, an upper middle-income country. In addition to its uncertain effectiveness, brain stimulation requires expensive equipment and specific facilities, and it is not likely to be feasible in some low-income country settings. In another example, although psychotherapy and counseling interventions are demonstrably effective [45,61,73,83,92], none of these studies took place in a low-income country, so the feasibility of implementing this type of intervention is uncertain. Given that infrastructure in low-income settings is even more limited in mental health and substance abuse facilities and professionals, with a greater associated stigma, an alcohol use reduction intervention implementation of this kind is still potentially unfeasible. Similarly, medication shows some evidence of a positive effect on abstinence from alcohol, but reliable availability of medication is essential for this intervention to be effective; thus, medication may not be a feasible intervention in a low-income country [100,101].
Instead, the most studied and potentially most feasible intervention is a brief intervention. In our systematic review, 6 studies evaluated brief interventions in South Africa [67,79–81,93,94]. Brief interventions have been studied to decrease alcohol use and alcohol-related consequences in a variety of settings and countries [102–105]. They have also been suggested to be cost-effective in high-income countries [106]. In low- and middle-income settings, brief interventions are likely to be feasible because they can be delivered by nonprofessionals requiring less training.
Limitations
There are a few limitations to our study. First, our search strategy did not exclude studies due to language, and, yet, we found no manuscripts in other languages. Thus, either there is no non-English language literature on this topic or the data sets we searched have limited non-English language articles. Second, our ability to conduct a thorough meta-analysis was restricted by nonuniform outcome measurements, a wide variety of outcome assessment times, and a wide variety of interventions, making it difficult to compare interventions and their effects. To compensate for this, we summarized results from RCTs qualitatively. Similarly, we conducted our database search for only LMICs at that time. This might limit our findings by excluding articles from countries that have become high income since the study occurred or erroneously including countries that were high income but then reduced their status at the time of the database search; in the former case, we cannot determine the number of potential studies, but for the latter case, we rechecked the World Bank status of all countries and their intervention time periods to ensure this was not occurring. Finally, we tried to group types of interventions based on standard definitions rather than study-specific descriptions that might limit the interpretation of effect size and differ from the original author’s description.
Improving future research
Future alcohol harm reduction intervention studies should use uniform reporting. Studies ranged widely in their intervention type, framework, population, augmentation, or boosters, as well as outcome assessment frequency and timing. Adherence to 1 or 2 sets of standardized outcome reporting measures at a specified time period would greatly improve comparability across time and geographic location, allowing for a meta-analysis of intervention methods. Based on our review, brief interventions using the ASSIST or AUDIT scoring systems are the most widely used and appear to provide the best standardization among outcomes. Overall, future research should include both comparative effectiveness to determine best interventions for LMIC settings but also most effective implementation strategies including target populations.
Conclusions
In conclusion, alcohol harm reduction interventions in LMICs are nonuniform in nature, skewed in geographic regions where applied, and result in uncertain effectiveness over varying time horizons. Feasible options specific to low-income countries are most likely brief interventions and interventions that utilize motivational interviewing techniques. Identifying uniform methods of implementation and assessment of alcohol harm reduction interventions can be a first step toward establishing a set of evidence-based protocols for treatment for low-income settings. Current studies in brief interventions, psychotherapy, and brain stimulation show promise, but have been tested primarily or exclusively in middle-income settings. Feasibility testing in low-income settings, comparative effectiveness testing, and uniform reporting methods are needed to help determine the most effective alcohol harm reduction strategies for low-income settings in order to address this global health crisis.
Supporting information
S2 Fig. Map of study location and intervention type.
Source: Global Administrative Areas (2022). University of California, Berkely. Available online: http://www.gadm.org [11/03/2022]; https://geodata.ucdavis.edu/gadm/gadm4.0/gadm404-shp.zip.
https://doi.org/10.1371/journal.pmed.1003961.s002
(TIF)
S1 Table. PRISMA Checklist.
PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
https://doi.org/10.1371/journal.pmed.1003961.s003
(DOCX)
References
- 1. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009 Jun 27;373(9682):2223–33. pmid:19560604
- 2. Murray CJL, Lopez AD. Measuring global health: motivation and evolution of the Global Burden of Disease Study. Lancet. 2017 Sep 16;390(10100):1460–4. pmid:28919120
- 3. Rehm J, Imtiaz S. A narrative review of alcohol consumption as a risk factor for global burden of disease. Subst Abuse Treat Prev Policy. 2016 Oct 28;11(1):37. pmid:27793173
- 4.
WHO | Global Status Report on Alcohol and Health 2014 [Internet]. [cited 2020 Dec 22]. Available from: https://www.who.int/substance_abuse/publications/alcohol_2014/en/
- 5. Korlakunta A, Reddy CMP. High-risk behavior in patients with alcohol dependence. Indian J Psychiatry. 2019 Apr;61(2):125–30. pmid:30992605
- 6. Moss HB. The impact of alcohol on society: a brief overview. Soc Work Public Health. 2013;28 (3–4):175–7. pmid:23731412
- 7. Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 2004 Oct 15;364(9442):1334–9. pmid:15474136
- 8.
National Insititute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much. A Clinician’s Guide. 2005.
- 9. Chisholm D, Doran C, Shibuya K, Rehm J. Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use. Drug Alcohol Rev. 2006;25 (6):553–65. pmid:17132573
- 10. Chisholm D, Moro D, Bertram M, Pretorius C, Gmel G, Shield K, et al. Are the “Best Buys” for Alcohol Control Still Valid? An Update on the Comparative Cost-Effectiveness of Alcohol Control Strategies at the Global Level. J Stud Alcohol Drugs. 2018 Jul;79(4):514–22. pmid:30079865
- 11. Benegal V, Chand PK, Obot IS. Packages of care for alcohol use disorders in low- and middle-income countries. PLoS Med. 2009 Oct 27;6(10):e1000170. pmid:19859536
- 12. Meier P, Purshouse R, Bain M, Bambra C, Bentall R, Birkin M, et al. The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research. [version 1; peer review: 2 approved]. Wellcome Open Res. 2019;12 (4):174. pmid:31815191
- 13. Beaglehole R, Bonita R. Alcohol: a global health priority. Lancet. 2009 Jun 27;373(9682):2173–4. pmid:19560583
- 14. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009 Jul 21;6(7):e1000097. pmid:19621072
- 15.
New country classifications by income level: 2019–2020 [Internet]. [cited 2020 Dec 22]. Available from: https://blogs.worldbank.org/opendata/new-country-classifications-income-level-2019-2020
- 16.
ACROBAT-NRSi (A Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions) for non-clinical community based studies: a participatory workshop using a worked example from public health | Colloquium Abstracts [Internet]. [cited 2020 Dec 22]. Available from: https://abstracts.cochrane.org/2015-vienna/acrobat-nrsi-cochrane-risk-bias-assessment-tool-non-randomized-studies-interventions-non
- 17.
Ottawa Hospital Research Institute [Internet]. [cited 2020 Dec 22]. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
- 18. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343:d5928. pmid:22008217
- 19.
EPOC Taxonomy | Cochrane Effective Practice and Organisation of Care [Internet]. [cited 2020 Dec 22]. Available from: https://epoc.cochrane.org/epoc-taxonomy
- 20. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions. Wiley; 2019.
- 21. Nutbeam D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int. 2000 Sep 1;15(3):259–67.
- 22. Shin S, Livchits V, Connery HS, Shields A, Yanov S, Yanova G, et al. Effectiveness of alcohol treatment interventions integrated into routine tuberculosis care in Tomsk, Russia Addiction. 2013 Aug;108(8):1387–96. pmid:23490304
- 23. Moraes E, de Campos GM, Figlie NB, Ferraz MB, Laranjeira R. Home visits in the outpatient treatment of individuals dependent on alcohol. Addict Disord Their Treat. 2010 Mar;9(1):18–31.
- 24. Ahmadi J, Babaeebeigi M, Maany I, Porter J, Mohagheghzadeh M, Ahmadi N, et al. Naltrexone for alcohol-dependent patients. Ir J Med Sci. 2004 Mar;173(1):34–7. pmid:15732235
- 25. Ahmadi S, Jamshidimanesh M, Zafarghandi M, Ranjbar H. The effectiveness of peer education interventions on HIV- and HBV-preventive behaviours in women with substance-related disorders: a cluster randomised control trial. HIV AIDS Rev. 2019;18 (3):183–92.
- 26. Aira T, Wang W, Riedel M, Witte SS. Reducing risk behaviors linked to noncommunicable diseases in Mongolia: a randomized controlled trial. Am J Public Health. 2013 Sep;103(9):1666–74. pmid:23865647
- 27. Altintoprak AE, Zorlu N, Coskunol H, Akdeniz F, Kitapcioglu G. Effectiveness and tolerability of mirtazapine and amitriptyline in alcoholic patients with co-morbid depressive disorder: a randomized, double-blind study. Hum Psychopharmacol. 2008 Jun;23(4):313–9. pmid:18327889
- 28. Assanangkornchai S, Nima P, McNeil EB, Edwards JG. Comparative trial of the WHO ASSIST-linked brief intervention and simple advice for substance abuse in primary care. Asian J Psychiatr. 2015 Dec;18:75–80. pmid:26412051
- 29. A cross-national trial of brief interventions with heavy drinkers. WHO Brief Intervention Study Group. Am J Public Health. 1996 Jul;86(7):948–55. pmid:8669518
- 30. Baldin YC, Sanudo A, Sanchez ZM. Effectiveness of a web-based intervention in reducing binge drinking among nightclub patrons. Rev Saude Publica. 2018 Jan 18;52:2. pmid:29364357
- 31. Baltieri DA, de Andrade AG. Efficacy of acamprosate in the treatment of alcohol-dependent outpatients. Rev Bras Psiquiatr. 2003 Sep;25(3):156–9. pmid:12975689
- 32. Baltieri DA, Daró FR, Ribeiro PL, de Andrade AG. Comparing topiramate with naltrexone in the treatment of alcohol dependence. Addiction. 2008 Dec;103(12):2035–44. pmid:18855810
- 33. Barbosa Filho VC, Bandeira A da S, Minatto G, Linard JG, Silva JA da, Costa RM da, et al. Effect of a Multicomponent Intervention on Lifestyle Factors among Brazilian Adolescents from Low Human Development Index Areas: A Cluster-Randomized Controlled Trial. Int J Environ Res Public Health. 2019 Jan 18;16(2). pmid:30669291
- 34. Bedendo A, Ferri CP, de Souza AAL, Andrade ALM, Noto AR. Pragmatic randomized controlled trial of a web-based intervention for alcohol use among Brazilian college students: Motivation as a moderating effect. Drug Alcohol Depend. 2019 Jun 1;199:92–100. pmid:31029880
- 35. Bedendo A, McCambridge J, Gaume J, Souza AAL, Formigoni MLOS, Noto AR. Components evaluation of a web-based personalized normative feedback intervention for alcohol use among college students: a pragmatic randomized controlled trial with a dismantling design. Addiction. 2020 Jun;115(6):1063–74. pmid:31785189
- 36. Boggio PS, Sultani N, Fecteau S, Merabet L, Mecca T, Pascual-Leone A, et al. Prefrontal cortex modulation using transcranial DC stimulation reduces alcohol craving: a double-blind, sham-controlled study. Drug Alcohol Depend. 2008 Jan 1;92(1–3):55–60. pmid:17640830
- 37. Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C, et al. A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PLoS Med. 2014 Nov 11;11(11):e1001757. pmid:25386945
- 38. Burnhams NH, London L, Laubscher R, Nel E, Parry C. Results of a cluster randomised controlled trial to reduce risky use of alcohol, alcohol-related HIV risks and improve help-seeking behaviour among safety and security employees in the Western Cape, South Africa. Subst Abuse Treat Prev Policy. 2015 May 8;10:18. pmid:25951907
- 39. Chaudhury S, Brown FL, Kirk CM, Mukunzi S, Nyirandagijimana B, Mukandanga J, et al. Exploring the potential of a family-based prevention intervention to reduce alcohol use and violence within HIV-affected families in Rwanda. AIDS Care. 2016 Mar;28 Suppl 2:118–29. pmid:27392007
- 40. Chhabra R, Springer C, Leu C-S, Ghosh S, Sharma SK, Rapkin B. Adaptation of an alcohol and HIV school-based prevention program for teens. AIDS Behav. 2010 Aug;14 Suppl 1:S177–84. pmid:20589528
- 41. Christoff A de O, Boerngen-Lacerda R. Reducing substance involvement in college students: a three-arm parallel-group randomized controlled trial of a computer-based intervention. Addict Behav. 2015 Jun;45:164–71. pmid:25679364
- 42. Corrêa Filho JM, Baltieri DA. A pilot study of full-dose ondansetron to treat heavy-drinking men withdrawing from alcohol in Brazil. Addict Behav. 2013 Apr;38(4):2044–51. pmid:23396176
- 43. Cubbins LA, Kasprzyk D, Montano D, Jordan LP, Woelk G. Alcohol use and abuse among rural Zimbabwean adults: a test of a community-level intervention. Drug Alcohol Depend. 2012 Aug 1;124(3):333–9. pmid:22386686
- 44. da Silva MC, Conti CL, Klauss J, Alves LG, do Nascimento Cavalcante HM, Fregni F, et al. Behavioral effects of transcranial direct current stimulation (tDCS) induced dorsolateral prefrontal cortex plasticity in alcohol dependence. J Physiol Paris. 2013 Dec;107(6):493–502. pmid:23891741
- 45. Daengthoen L, Saengcharnchai P, Yingwiwattanapong J, Perngparn U. Effects of the Phramongkutklao model on alcohol-dependent patient: a randomized controlled trial. J Subst Use. 2014 Mar;19(1–2):81–8.
- 46. De Sousa A, De Sousa A. A one-year pragmatic trial of naltrexone vs disulfiram in the treatment of alcohol dependence. Alcohol Alcohol. 2004 Dec;39(6):528–31. pmid:15525790
- 47. de Sousa A, de Sousa A. An open randomized study comparing disulfiram and acamprosate in the treatment of alcohol dependence. Alcohol Alcohol. 2005 Dec;40(6):545–8. pmid:16043433
- 48. De Sousa A, De Sousa A. An open randomized trial comparing disulfiram and naltrexone in adolescents with alcohol dependence. J Subst Use. 2008 Jan;13(6):382–8.
- 49. De Sousa AA, De Sousa J, Kapoor H. An open randomized trial comparing disulfiram and topiramate in the treatment of alcohol dependence. J Subst Abus Treat. 2008 Jun;34(4):460–3. pmid:17629442
- 50. De Sousa A. A comparative study using Disulfiram and Naltrexone in alcohol-dependent adolescents. J Subst Use. 2014 Oct;19(5):341–5.
- 51. Furieri FA, Nakamura-Palacios EM. Gabapentin reduces alcohol consumption and craving: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2007 Nov;68(11):1691–700. pmid:18052562
- 52. Gupta M, Verma P, Rastogi R, Arora S, Elwadhi D. Randomized open-label trial of baclofen for relapse prevention in alcohol dependence. Am J Drug Alcohol Abuse. 2017;43 (3):324–31. pmid:27808555
- 53. Hartmann M, Datta S, Browne EN, Appiah P, Banay R, Caetano V, et al. A combined behavioral economics and cognitive behavioral therapy intervention to reduce alcohol use and intimate partner violence among couples in bengaluru, india: results of a pilot study. J Interpers Violence. 2020 Jan 20; pmid:31959030
- 54. Jirapramukpitak T, Pattanaseri K, Chua K-C, Takizawa P. Home-Based Contingency Management Delivered by Community Health Workers to Improve Alcohol Abstinence: A Randomized Control Trial. Alcohol Alcohol. 2020 Mar 19;55(2):171–8. pmid:31919523
- 55. Jordans MJD, Luitel NP, Garman E, Kohrt BA, Rathod SD, Shrestha P, et al. Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal. Br J Psychiatry. 2019 Jan 25;215(2):485–93. pmid:30678744
- 56. Kalichman SC, Simbayi LC, Vermaak R, Cain D, Smith G, Mthebu J, et al. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med. 2008 Dec;36(3):270–9. pmid:18836789
- 57. Kalichman SC, Simbayi LC, Vermaak R, Cain D, Jooste S, Peltzer K. HIV/AIDS risk reduction counseling for alcohol using sexually transmitted infections clinic patients in Cape Town, South Africa. J Acquir Immune Defic Syndr. 2007 Apr 15;44(5):594–600. pmid:17325606
- 58. Kamal K, Sunita S, Karobi D, Abhishek G. Nurse-Delivered Screening and Brief Intervention Among College Students with Hazardous Alcohol Use: A Double-Blind Randomized Clinical Trial from India. Alcohol Alcohol. 2020 Apr 16;55(3):284–90. pmid:32103254
- 59. Klauss J, Penido Pinheiro LC, Silva Merlo BL, de Almeida Correia Santos G, Fregni F, Nitsche MA, et al. A randomized controlled trial of targeted prefrontal cortex modulation with tDCS in patients with alcohol dependence. Int J Neuropsychopharmacol. 2014 Nov;17(11):1793–803. pmid:25008145
- 60. Klauss J, Anders QS, Felippe LV, Nitsche MA, Nakamura-Palacios EM. Multiple Sessions of Transcranial Direct Current Stimulation (tDCS) Reduced Craving and Relapses for Alcohol Use: A Randomized Placebo-Controlled Trial in Alcohol Use Disorder. Front Pharmacol. 2018 Jul 3;9:716. pmid:30018558
- 61.
LʼEngle KL, Mwarogo P, Kingola N, Sinkele W, Weiner DH. A randomized controlled trial of a brief intervention to reduce alcohol use among female sex workers in Mombasa, Kenya. J Acquir Immune Defic Syndr. 2014 Dec 1;67(4):446–53.
- 62. Likhitsathian S, Uttawichai K, Booncharoen H, Wittayanookulluk A, Angkurawaranon C, Srisurapanont M. Topiramate treatment for alcoholic outpatients recently receiving residential treatment programs: a 12-week, randomized, placebo-controlled trial. Drug Alcohol Depend. 2013 Dec 1;133(2):440–6. pmid:23906999
- 63. Madhombiro M, Kidd M, Dube B, Dube M, Mutsvuke W, Muronzie T, et al. Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial. J Int AIDS Soc. 2020 Dec;23(12):e25641. pmid:33314786
- 64. Marques AC, Formigoni ML. Comparison of individual and group cognitive-behavioral therapy for alcohol and/or drug-dependent patients. Addiction. 2001 Jun;96(6):835–46. pmid:11399215
- 65. Marsiglia FF, Kulis SS, Booth JM, Nuño-Gutierrez BL, Robbins DE. Long-term effects of the keepin’ it REAL model program in Mexico: substance use trajectories of Guadalajara middle school students. J Prim Prev. 2015 Apr;36(2):93–104. pmid:25416154
- 66. Mendez-Ruiz MD, Villegas-Pantoja MA, Alarcón-Luna NS, Villegas N, Cianelli R, Peragallo-Montano N. Prevention of alcohol consumption and transmission of human immunodeficiency virus: randomized clinical trial. Rev Lat Am Enfermagem. 2020 May 11;28:e3262. pmid:32401905
- 67. Mertens JR, Ward CL, Bresick GF, Broder T, Weisner CM. Effectiveness of nurse-practitioner-delivered brief motivational intervention for young adult alcohol and drug use in primary care in South Africa: a randomized clinical trial. Alcohol Alcohol. 2014 Aug;49(4):430–8. pmid:24899076
- 68. Murray LK, Kane JC, Glass N, Skavenski van Wyk S, Melendez F, Paul R, et al. Effectiveness of the Common Elements Treatment Approach (CETA) in reducing intimate partner violence and hazardous alcohol use in Zambia (VATU): A randomized controlled trial. PLoS Med. 2020. Apr 17;17(4):e1003056. pmid:32302308
- 69. Nadkarni A, Velleman R, Dabholkar H, Shinde S, Bhat B, McCambridge J, et al. The systematic development and pilot randomized evaluation of counselling for alcohol problems, a lay counselor-delivered psychological treatment for harmful drinking in primary care in India: the PREMIUM study. Alcohol Clin Exp Res. 2015 Mar;39(3):522–31. pmid:25704494
- 70. Nadkarni A, Weobong B, Weiss HA, McCambridge J, Bhat B, Katti B, et al. Counselling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial. Lancet. 2017 Jan 14;389(10065):186–95. pmid:27988144
- 71. Nadkarni A, Weiss HA, Weobong B, McDaid D, Singla DR, Park A-L, et al. Sustained effectiveness and cost-effectiveness of Counselling for Alcohol Problems, a brief psychological treatment for harmful drinking in men, delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial. PLoS Med. 2017 Sep 12;14(9):e1002386. pmid:28898239
- 72. Nadkarni A, Weiss HA, Velleman R, McCambridge J, McDaid D, Park A-L, et al. Feasibility, acceptability and cost-effectiveness of a brief, lay counsellor-delivered psychological treatment for men with alcohol dependence in primary care: an exploratory randomized controlled trial. Addiction. 2019 Jul;114(7):1192–203. pmid:30957341
- 73. Nattala P, Leung KS, Nagarajaiah Murthy P. Family member involvement in relapse prevention improves alcohol dependence outcomes: a prospective study at an addiction treatment facility in India. J Stud Alcohol Drugs. 2010 Jul;71(4):581–7. pmid:20553667
- 74. Ng S-M, Rentala S, Chan CLW, Nayak RB. Nurse-Led Body-Mind-Spirit Based Relapse Prevention Intervention for People With Diagnosis of Alcohol Use Disorder at a Mental Health Care Setting, India: A Pilot Study. J Addict Nurs. 2020;31 (4):276–86. pmid:33264200
- 75. Noknoy S, Rangsin R, Saengcharnchai P, Tantibhaedhyangkul U, McCambridge J. RCT of effectiveness of motivational enhancement therapy delivered by nurses for hazardous drinkers in primary care units in Thailand. Alcohol Alcohol. 2010 Jun;45(3):263–70. pmid:20236990
- 76. Pal HR, Yadav D, Mehta S, Mohan I. A comparison of brief intervention versus simple advice for alcohol use disorders in a North India community-based sample followed for 3 months. Alcohol Alcohol. 2007 Aug;42(4):328–32. pmid:17360720
- 77. Papas RK, Sidle JE, Gakinya BN, Baliddawa JB, Martino S, Mwaniki MM, et al. Treatment outcomes of a stage 1 cognitive-behavioral trial to reduce alcohol use among human immunodeficiency virus-infected out-patients in western Kenya. Addiction. 2011 Dec;106(12):2156–66. pmid:21631622
- 78. Papas RK, Gakinya BN, Mwaniki MM, Lee H, Keter AK, Martino S, et al. A randomized clinical trial of a group cognitive-behavioral therapy to reduce alcohol use among human immunodeficiency virus-infected outpatients in western Kenya. Addiction. 2021 Feb;116(2):305–18. pmid:32422685
- 79. 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 Jul 31;13:699. pmid:23902931
- 80. 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 Jul 11;13:644. pmid:23844552
- 81. Pengpid S, Peltzer K, van der Heever H, Skaal L. Screening and brief interventions for hazardous and harmful alcohol use among university students in South Africa: results from a randomized controlled trial. Int J Environ Res Public Health. 2013 May 21;10(5):2043–57. pmid:23698697
- 82. Pengpid S, Peltzer K, Puckpinyo A, Viripiromgool S, Thamma-Aphiphol K, Suthisukhon K, et al. Screening and concurrent brief intervention of conjoint hazardous or harmful alcohol and tobacco use in hospital out-patients in Thailand: a randomized controlled trial. Subst Abuse Treat Prev Policy. 2015 May 27;10:22. pmid:26013537
- 83. Rendall-Mkosi K, Morojele N, London L, Moodley S, Singh C, Girdler-Brown B. A randomized controlled trial of motivational interviewing to prevent risk for an alcohol-exposed pregnancy in the Western Cape, South Africa Addiction. 2013 Apr;108(4):725–32. pmid:23216868
- 84. Rotheram-Borus MJ, Tomlinson M, Roux IL, Stein JA. Alcohol use, partner violence, and depression: A cluster randomized controlled trial among urban south african mothers over 3 years. Am J Prev Med. 2015;49 (5):715–25. pmid:26231855
- 85. Sanchez ZM, Valente JY, Sanudo A, Pereira APD, Cruz JI, Schneider D, et al. The #tamojunto drug prevention program in brazilian schools: a randomized controlled trial. Prev Sci. 2017 Oct;18(7):772–82. pmid:28361199
- 86. Sanchez ZM, Valente JY, Sanudo A, Pereira APD, Schneider DR, Andreoni S. Effectiveness evaluation of the school-based drug prevention program #Tamojunto in Brazil: 21-month follow-up of a randomized controlled trial. Int J Drug Policy. 2018 Aug 3;60:10–7. pmid:30081337
- 87. Satyanarayana VA, Nattala P, Selvam S, Pradeep J, Hebbani S, Hegde S, et al. Integrated Cognitive Behavioral Intervention Reduces Intimate Partner Violence Among Alcohol Dependent Men, and Improves Mental Health Outcomes in their Spouses: A Clinic Based Randomized Controlled Trial from South India. J Subst Abus Treat. 2016 May;64:29–34.
- 88. Segatto ML, Andreoni S, de Souza e Silva R, Diehl A, Pinsky I. Brief motivational interview and educational brochure in emergency room settings for adolescents and young adults with alcohol-related problems: a randomized single-blind clinical trial. Rev Bras Psiquiatr. 2011 Sep;33(3):225–33. pmid:21971774
- 89. Signor L, Pierozan PS, Ferigolo M, Fernandes S, Moreira TC de, Mazoni CG, et al. Efficacy of the telephone-based Brief Motivational Intervention for alcohol problems in Brazil. Rev Bras Psiquiatr. 2013 Sep;35(3):254–61. pmid:24142086
- 90. Simão MO, Kerr-Corrêa F, Smaira SI, Trinca LA, Floripes TMF, Dalben I, et al. Prevention of “risky” drinking among students at a Brazilian university. Alcohol Alcohol. 2008 Aug;43(4):470–6. pmid:18364361
- 91. Soares J, Vargas D de Effectiveness of brief group intervention in the harmful alcohol use in primary health care. Rev Saude Publica. 2018 Dec 20;53:04. pmid:30652777
- 92. 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 trial. Subst Abuse Treat Prev Policy. 2015;14 (10):46. pmid:26576946
- 93. 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 Alcohol. 2015 May 1;50(3):302–9. pmid:25731180
- 94. Wechsberg WM, Bonner CP, Zule WA, van der Horst C, Ndirangu J, Browne FA, et al. Addressing the nexus of risk: Biobehavioral outcomes from a cluster randomized trial of the Women’s Health CoOp Plus in Pretoria, South Africa Drug Alcohol Depend. 2019 Feb 1;195:16–26. pmid:30562676
- 95. Witte SS, Altantsetseg B, Aira T, Riedel M, Chen J, Potocnik K, et al. Reducing sexual HIV/STI risk and harmful alcohol use among female sex workers in Mongolia: a randomized clinical trial. AIDS Behav. 2011;15 (8):1785–94. pmid:21739290
- 96. Zhao F, Xu Y, Yue L, Chen F, Zhang Z, Song H, et al. Escitalopram with or without combined electroacupuncture on protracted alcohol withdrawal symptoms (PAWS) among male inpatients with alcohol dependence. World J Acupunctu Moxibustion. 2020 Jun;30(2):90–6.
- 97. Dawson DA. Methodological issues in measuring alcohol use. Alcohol Res Health. 2003;27 (1):18–29. pmid:15301397
- 98. Greenfield TK, Kerr WC. Alcohol measurement methodology in epidemiology: recent advances and opportunities. Addiction. 2008 Jul;103(7):1082–99. pmid:18422826
- 99. Gmel G, Rehm J. Measuring Alcohol Consumption. Contemp Drug Probl. 2004 Sep;31(3):467–540. pmid:15289203
- 100. Schüklenk U, Ashcroft RE. Affordable access to essential medication in developing countries: conflicts between ethical and economic imperatives. J Med Philos. 2002 Apr;27(2):179–95. pmid:11961696
- 101.
WHO | Medicines in Health Systems: Advancing access, affordability and appropriate use [Internet]. [cited 2020 Dec 22]. Available from: https://www.who.int/alliance-hpsr/resources/publications/9789241507622/en/
- 102. Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012 Oct;44(4):307–17. pmid:23210379
- 103. 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 Jul;110(7):1082–91. pmid:25916993
- 104. Kohler S, Hofmann A. Can motivational interviewing in emergency care reduce alcohol consumption in young people? A systematic review and meta-analysis. Alcohol Alcohol. 2015 Mar;50(2):107–17. pmid:25563299
- 105. Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018. Feb 24;2:CD004148. pmid:29476653
- 106. Angus C, Scafato E, Ghirini S, Torbica A, Ferre F, Struzzo P, et al. Cost-effectiveness of a programme of screening and brief interventions for alcohol in primary care in Italy. BMC Fam Pract. 2014 Feb 6;15:26. pmid:24502342