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Table 4 Descriptions of the interventions and main findings

From: Community-based psychosocial substance use disorder interventions in low-and-middle-income countries: a narrative literature review

Reference Intervention characteristics Summary of findings
Almeida do Carmo et al. [87] Recovery Housing (RH) program consisting of accommodation in a drug-free environment and a range of structured interventions to address drug and alcohol misuse, including abstinence-oriented interventions such as multi-professional case management, monitoring of drug use, pharmacological and psychotherapeutic treatment (motivational interviewing, daily care assistance, social and interpersonal functioning, relapse prevention, mutual help). A collaboration between the state and private companies provides job opportunities and is monitored by a social worker. Residents are also given the opportunity to return to education. The approach to family reintegration is determined on a case-by-case basis after evaluation of family ties The most common drug use history was use of alcohol and cocaine (72%), followed by alcohol use alone (16%). 51% completed treatment or were reinserted in society (formal jobs and return to the family… and 49% had a recurrence during their stay; of the latter, 47% followed treatment at a rehabilitation or psychiatric clinic, 23.5% continued with outpatient treatment, and 29.5% returned to their families and continued treatment elsewhere. Twenty-nine of the 34 cases of recurrence occurred in the first 45 days of residence in the RH, and five between 150 and 180 days of residence
Assanangkornchai et al. [86] The WHO ASSIST-linked brief interventiondelivered (by a project worker) as per the 10-step WHO procedure including a Feedback Report Card and Self-Help Strategies Manual (part of ASSIST) used to discuss with the patient the meaning of the score and strategies for reducing or stopping their substance use. The focus of intervention was on the substance that resulted in the highest score on the ASSIST or that was of most concern to the participant. The average duration of the BI sessions was 8.8 min and 3.9 min for the control group Significant reductions over time in the specific substance involvement scores (SSIS) and total substance involvement scores (TSIS) for both alcohol and other substance users in the BI and SA groups (non-significant between-group differences). There were similar patterns of reduction in both groups over time and between facility types. There was an earlier reduction of scores in the sub-district health centers than in the district hospitals and participants from sub-district health centers changed from moderate-risk to low-risk faster and in greater proportions than those from district hospitals. At the end of the study 53.3% and 53.4% of the baseline ‘moderate-risk’ users in the BI and SA groups, respectively, had become ‘low-risk’. Between-group comparisons revealed non-significant differences in changes in frequency of use for both alcohol and other substances at three and 6 month
Humeniuk et al. [71] The Brief Intervention (BI) was designed to be relatively short and easily linked to the results of the 7-item ASSIST screening questionnaire score via the use of the ASSIST Feedback Report card comprised a major part of the BI. Participants also took the self-help guide developed as part of the ASSIST package. The intervention incorporated motivational interviewing techniques that have been found to reduce client resistance while facilitating behavior change. Each country developed their own culturally appropriate brief intervention based on these principles. Average ASSIST baseline screening required 7.9 min and the BI 13.8 min. Screening and BI was delivered by trained project staff (treated as clinic staff for the intervention to appear to be routine care) and (in Brazil) by clinicians and researchers There was a significant reduction over time for the pooled sample regardless of group, and a significant group x time interaction effect in which the group receiving the BI at baseline (regardless of substance) had significantly lower mean total illicit substance involvement scores at follow-up than the control group. Participants receiving the BI in Australia, Brazil and India had significantly reduced total illicit substance involvement scores at follow-up compared with control participants. There were also significant differences in interaction effects between the countries. Intervention effects were greatest among Australian participants. India and Brazil had a strong BI effect for cannabis, as did Australia and Brazil for stimulants and India for opioids. Although none of the substance-specific interaction effects were significant for the United States, there were significant reductions in both the experimental and control groups at follow-up for all substances. In general it appeared that severity of use within the moderate-risk range (scores 426) did not influence the success of the BI
Kane et al. [70] CETA is a transdiagnostic mental health intervention developed for delivery by non-professionals in LMIC…based on research of common elements or transdiagnostic treatment approaches used in the USA… but with a focus on being appropriate for training and delivery by non-professionals in lower resource settings. CETA is based on evidence-based treatments for trauma, anxiety, depression, and behavioral problems. The main components of CETA in this trial include: psychoeducation and engagement, anxiety management, behavioral activation, cognitive restructuring, exposure, danger assessment and planning, CBT for SU and relapse prevention and safety planning and violence prevention
CBT for SU component delivered to all men and substance-abusing women: included motivational enhancement and goal setting (particularly those related to SU drivers), and teaching and practicing behavior change and avoidance
The trial was completed in January of 2019 (no results published yet). Results (compared to treatment as usual) will include: change in severity of violence against women scale (SVAWS), change in WHO IPV measures, change in youth victimization scale, change in AUDIT scores, change in ASSIST scores, change in CES-D scores (depression), change in Harvard Trauma Questionnaire scores (PTSD), change in child PTSD symptom scale scores, change in aggression scale, change in GEMS score (gender norms), change in Index of Psychological Abuse (psychological violence), change in hair sample cortisol biomarker
Modifications to the protocol after first weeks of implementation: CETA delivery was changed to individual delivery instead of through group settings due to challenges in maintaining attendance to group sessions. This also led to an increase in the sample size to 248 families.
Lancaster et al. [76], data also extracted from sister article Miller et al. [77] Index participants in the standard of care group received referrals to existing HIV and MAT clinics where they were given primarily methadone; a standardized harm-reduction package… and the WHO package of care for PWID… Intervention group received the standard harm-reduction package plus the following interventions: systems navigation to facilitate engagement, retention, and adherence in HIV care and MAT, and to negotiate the logistics and… costs of any required laboratory testing (e.g., tuberculosis testing) and transportation; psychosocial counselling by use of motivational interviewing, problem solving, skills building, and goal setting to facilitate initiation of ART and MAT, and if started, medication adherence; and ART initiation. The primary goal for systems navigation was to address individual-level or systems-level barriers to ART and MAT enrolment… A minimum of two psychosocial counselling sessions (Lasting 16–60 min) focused on ART and MAT adherence… tailored to the participant’s needs. Injection partners in both groups received a standardized harm-reduction package with referral for MAT Demographic and clinical characteristics at baseline were similar across the intervention and standard of care groups (mostly male, median age of 35). 402 (80%) index participants reported being ART naive at baseline. Only 109 (22%) index participants reported current MAT use at enrolment. Group distributions across sites were, on average, 125 to the standard of care group and 42 to intervention group. Findings showed that the intervention was feasible (80% retention at 52 weeks), with good intervention uptake, and led to increased ART use, MAT use, and viral suppression. In Vietnam and Ukraine, the intervention effect was positive for self-reported ART initiation, viral suppression, self-reported MAT initiation, and mortality, whereas in Indonesia the effect of the intervention appeared to be smaller. MAT uptake was lower than for ART but still significantly higher among intervention participants. In Vietnam, 42 (86%) of 49 index participants completed two psychosocial counselling encounters within 4 weeks compared with 30 (64%) of 47 participants in Ukraine and 15 (50%) of 30 participants in Indonesia. More counselling sessions were done with a support person present at the Vietnam and Ukraine
L’Engle et al. [75] Six (approximately 20 min long) counselling sessions that took place monthly for 6 months. Nurse counsellors were trained in motivational interviewing techniques and provided the intervention in one-on-one sessions. Intervention contained elements from stages of change and social cognitive health behavior change theories and motivational interviewing. Specific (example) goals included: identification and discussion of risks and consequences from drinking, soliciting participants’ commitment to reduce drinking, identifying the goal of reduced drinking or abstinence, developing a habit-breaking plan, discussing high-risk situations and coping strategies, and providing feedback and encouragement Nearly 75% of participants completed all 5 post-enrolment counselling sessions: 292 alcohol intervention participants (71.4%) and 296 nutrition control participants (72.5%). More participants in the intervention group than in the control group reported reduced drinking in the last 30 days at 6-month and 12-month follow-up visits (including frequency of drinking alcohol, overall binge drinking, binge drinking with paying clients, and binge drinking with non-paying partners—all statistically significant). Women in the intervention group had less than one third of the odds of reporting higher levels of drinking than women in the control group. No between-group differences on laboratory-confirmed STIs including HIV were detected. The odds of self-reported sexual violence from clients was significantly lower among intervention than control participants at both 6 and 12 months
Nadkarni et al. [82] Motivational Interviewing (MI) techniques were used across all the sessions to help patients develop and maintain their motivation to change. Several intervention manuals were identified in consultation with experts as potential starting points for the development of the CAP manual. CAP was delivered in 3 phases by trained non-professionals:
Phase 1: Problem identification with the counsellor using assessments and personalized feedback. Generating a change and action plan that summarized the patient’s drinking-related problems and behaviors, and what steps he would take to achieve his behavior-change goals
Phase 2: Helping the patient develop thinking and behavioral skills and techniques (e.g. drink refusal among others)
Phase 3: Learning to manage potential or actual relapses using these thinking and behavioral skills and techniques
CAP was delivered in 1 to 4 sessions at the patient’s home or the PHC
Twenty-seven men were assigned to CAP and 26 to EUC. Forty-seven (88.7%) participants completed the outcome assessment and there were no statistically significant baseline characteristic differences between the groups (education, age, occupation, marital status, and AUDIT score). The amount of alcohol consumed in the past 2 weeks, mean AUDIT score, and alcohol-related problems were all lower in the CAP arm compared to the EUC arm, but the between-group adjusted mean differences were not statistically significant. There were nonsignificant reductions in outcomes in participants who completed treatment compared with those who dropped out with regard to mean AUDIT, … mean alcohol consumed in past 2 weeks, and mean SIP (Short Inventory of Problems, a 15-item questionnaire that measures physical, social, intrapersonal, impulsive, and interpersonal consequences of alcohol consumption) score. A number of key barriers were encountered and strategies were modified to address these (see Table 5)
Nadkarni et al. [73]  The CAP intervention was the same one as the one mentioned above and was delivered by 11 of the same lay-counsellors of the trial for harmful drinkers [73]. Referral to the local secondary or tertiary care de-addiction center for medically assisted detoxification consisted of informing the participants about the need for detoxification, providing them with details about de-addiction centers and suggesting that they attend (delivered in out-and in-patient settings in two district hospitals and one tertiary care psychiatry teaching institute, and private sectors) A total of 66 participants were randomized to EUC and 69 to CAP plus EUC. There was no significant difference between the arms for (a) proportion with remission at 3 months and 12 months; (b) proportion of participants reporting no alcohol consumption in the past 14 days at 3 months and 12 months; and (c) consumption among those who reported any drinking in this period at 3 months and 12 months. At 3 months, greater expectation of usefulness of counselling was associated with dropout from the study; and at 12 months, older age and greater readiness to change was associated with dropout from the study (that said, 89.6% of participants were retained at 3 months and 83% at 12 months). The mean number of sessions completed was 2.4 (SD = 1.2) and the mean session duration was 45.9 min (SD 9.6). Fifty-eight percent of participants achieved a planned discharge
There was a 20% chance of CAP being cost-effective at the willingness-to-pay threshold of $415. However, from a societal perspective, there was a 53% chance of CAP being cost-effective
Noknoy et al. [72] Motivational Enhancement Therapy delivered by trained primary care nurses; a brief intervention using the Project MATCH MET protocol (Miller et al. 1992). The intervention was composed of three scheduled sessions, on Day 1, at 2 weeks and at 6 weeks lasting approximately 15 min. Different techniques were used depending on the stage of behavior change of the patient (i.e. pre-contemplation, contemplation, determination, action, and maintenance), such as feedback, self-motivational statements, resolving ambivalence, readiness to change assessments, personalized action plans, goal setting, and relapse prevention Self-reported drinks per drinking day, frequency of daily and weekly hazardous drinking and of binge drinking sessions were reduced in the intervention group more than the control group (P < 0.05 in 9/10 outcomes assessed) at 3 and 6 months. The groups did not differ at 3 or 6 months on self-reported frequency of being drunk. The incidence of alcohol-related consequences in the 6-month period was low in both groups. GGT (a biological marker available for evaluation of the severity of current drinking) levels were higher in both the intervention and control groups at 6-month follow-up than at baseline. However, the mean GGT level… in the intervention group was lower than… in the control group to a statistically significant degree (P= 0.038)
Pan et al. [88] The participants in the CBT group received individual CBT weekly and group CBT monthly in addition to the standard care of MMT treatment for 26 weeks. The CBT was delivered by psychotherapists experienced in providing counselling or psychotherapy services for patients with SUDs and mental health disorders using an adapted intervention manual. The first 6 weeks focused on building treatment relationships and enhance motivation for MMT by helping patients understand their physical, mental health, social function, legal, economic, family, and employment problems associated with their opiate use, and by promoting commitment to treatment through signed ‘treatment goals-agreements’. Weeks 7–14 focused on skills training and… management of triggers for opiate use, as well as developing an individualized treatment protocols and receiving progress feedback to further improve the course of treatment. Weeks 1526 focused on managing psychological stress, building a balanced lifestyle, and maintaining abstinence Participants had a higher (yet non-significant) retention rate in the CBT group than the control group at week 26. The average proportion of opiate-negative urine samples in the CBT group was higher than that in the control group at week 12 (p = 0.02) and week 26 (p = 0.02). The average days stay in MMT and mean dosage (mg/day) of methadone did not differ significantly between two groups
In total, 72.5% completed the follow-up interview at week 26 (92 were in the CBT group, 82 were in the control group). The addiction severity index (ASI) scores decreased significantly over time in both groups with non-significant between-group differences. Analyses… revealed that the CBT groups improved more on employment function at 26 weeks, and decreased more on stress level at both week 12 and week 26 compared with the control group
Papas et al. [83], data also extracted from Papas et al. [43] Six weekly 90-minute group sessions conducted in Kiswahili by Kenyan, trained non-professionals. The intervention was culturally adapted to best suit local beliefs, drinking behaviors, communications, stigma, gender differences, and HIV-positive diagnosis (see Table 5) There were 42 CBT and 33 usual care participants. Of those randomized to CBT, participants attended 93% of the 6 sessions offered. Results … showed that… reductions since baseline were significantly larger in the CBT condition compared to the usual care condition for both percentage of drinking days (PDD) and number of drinks per drinking day (DDD). Cohen’s d effect sizes of reductions since baseline compared between conditions at 30-days post-treatment were large and at the 90-day follow-up were moderate. More CBT than control participants reported abstinence at all follow-ups. During the treatment phase, CBT participants reported reducing alcohol use at a faster rate than control participants… During the follow-up phase, CBT participants maintained reductions while control participants continued to report gradual reductions over time. It is not known whether differences between conditions increased or decreased beyond 90 days due to the study design. Independent ratings of CBT integrity among paraprofessionals showed acceptable adherence and skill ratings
Parry et al. [50] Face-to-face baseline questionnaire with participants by peer outreach workers, risk behaviors were recorded and a risk-reduction plan was developed with each drug user which consisted of intravenous drug use and non-intravenous drug use (IDU/NIDU)-related risks, sex-related risks and HIV testing. Thereafter, an intervention session was offered to the clients covering education about HIV, condom demonstration and the provision of referrals as needed. Twenty peer outreach workers were recruited, trained, and paid to deliver the intervention. At follow-up (varying timeframes), both the questionnaire and risk-reduction plan were discussed again to assess behavior change and revise risk-reduction plans. There was monthly and bi-annual monitoring of intervention practices… through observations and performance ratings by the project coordinators. Behavior change and benefits of the intervention were self-reported There were only statistically significant reductions in alcohol use between time 1 and time 2. No significant differences were observed over time for cannabis, cocaine, heroin and Ecstasy use. There was also no significant change in the frequency of substance use. In total, 45.7% of drug users did not report any changes in the number of different substances used, 23.2% increased the number of different substances they used and 31.1% decreased the total number of different substances used over the follow-up period (non-significant). Following the intervention, drug users had significantly fewer sex partners but there were no significant differences with regard to frequency of sex or use of condoms… In total, 39.1% of the drug users did not report any changes in the number of different substances used during sex, 21.7% increased the number of different substances that they used during sex and 39.1% decreased the total number of different substances used during sex (only significant reductions in marijuana use during sex)
Peltzer et al. [84] The intervention consisted of two sessions (approximately 20 min), the first immediately after alcohol screening and the second within a month thereafter… In the control condition the clinic lay counsellor provided an alcohol education leaflet… The goals for brief counselling were as follows: (1) To identify any alcohol-related problems mentioned in the interview, (2) To introduce the sensible drinking leaflet, emphasis the idea of sensible drinking limits, and make sure that patients realize that they are in the risk drinking category, (3) To provide feedback on the relationship between alcohol and TB treatment, (4) To work through the first 3 sections of a problem solving manual, (5) To describe drinking diary cards, ((6) To identify a helper, and (7) To plan a follow-up counselling session… The Information-Motivation-Behavioral Skills (IMB) Model was used in the study to guide the alcohol reduction intervention. The IMB model proposes that information about alcohol misuse and methods of reducing and preventing harmful and/or hazardous drinking is a necessary precursor to risk reduction 1196 were randomized into 20 control and 20 intervention clinics (n=455, n=741, respectively) … In 75% of the intervention sessions, the lay counsellors implemented at least 6 of the 7 requisite intervention steps… In addition, it was found that in 96% of the cases of brief intervention, only one session was conducted despite having scheduled a follow-up session, and in 4% of cases two sessions. There were significant reductions in AUDIT score… over time across treatment groups… however the intervention effect on the AUDIT score was statistically not significant. The intervention effect was also not significant for hazardous or harmful drinkers and alcohol dependent drinkers, alcohol dependent drinkers and heavy episodic drinking, while the control group effect was significant for hazardous drinkers… At 6-month follow-up the intervention group did not significantly differ to the control group in terms of TB treatment cure or completion rate
Rotheram-Borus et al. [74] Home visiting included prenatal and postnatal visits by community health workers (Mentor Mothers) focusing on general maternal and child health, HIV/tuberculosis, alcohol use, and nutrition
The intervention involved mostly education and support covering key health topics: HIV/TB, prevention of mother to child transmission of HIV, alcohol, mental health, breastfeeding, and malnutrition. Moreover, the community health workers (CHWs) were trained to promote skills to facilitate behavior change: goal setting, problem solving, relaxation, assertiveness, and shaping. On average, CHWs made six antenatal visits, five postnatal visits between birth and 2 months post 18 months old. After 18 months, visits only occurred once every birth, and 1.4 visits/month until the children were 6 months. Sessions lasted 31 min each on average
Intervention membership was not significantly associated with any baseline variables except for an unexpected significant association with the intervention mothers reporting more depression… Having used alcohol during pregnancy was most associated with IPV at baseline and again at 36 months, as well as continued alcohol use at 18 and 36 months. Depression at baseline was most associated with concurrent partner violence, continued depression at 18 months, and more partner violence and less positive emotional health at 36 months… Positive emotional health was predicted by less alcohol use, less depression and less IPV at 18 months, less depression at baseline, and by being in the intervention condition… The intervention reduced depression even though initially the mothers in this condition were more depressed than those in the control condition… There also were significant indirect effects of baseline variables on the 36-month outcome variables… In addition to its direct effect, alcohol during pregnancy had an indirect effect on alcohol use at 36 months. Although the intervention reduced alcohol use in pregnancy, drinking resumed post birth
Xiaolu et al. [89] BI used motivational interviewing techniques and incorporated FRAMES (Feedback, Responsibility, Advice, Menu, Empathy and Self-efficacy) skills. The intervention lasts 1530 min and is based on their alcohol use scores from the AUDIT. This approach is targeted toward non-dependent drinkers whose drinking may still be harmful. Intervention was delivered by 60 village hospital staff who were trained in the technique Among the 239 problem drinkers, 47 (19.7%) had high risk drinking (AUDIT scores between 7 and 15), and 192 (80.3%) had harmful drinking (AUDIT were above 15). At follow-up assessment, compared with the control group, BI group demonstrated significant reductions in AUDIT… and self-rating anxiety scale (SAS) scores… and increased in substance abuse knowledge scale (SAKS)… and general well-being schedule (GWS) scores… controlling for age, education and baseline disequilibrium measurements. Results from separate ANOVA tests showed that there was a time effect… on AUDIT and SAKS in the BI group. The control group showed increase in SAS and SDS scores, and reduction in GWS scores (all significant). Compared with the control group, BI group showed greater reduction on AUDIT and increased on SAKS after intervention.
  1. Italicized text are direct quotations extracted from the included studies