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Table 5 Contextual factors coded data

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

Reference Cultural adaptations made Capacity building of non-professionals Policy factors discussed Resource factors discussed Sociocultural factors discussed Implementation barriers/facilitators discussed
Almeida do Carmo et al. [87] N/A N/A This program was a direct result of a government launched initiative in 2013
Virtually all RH residents were not working and therefore would not have the right to apply for the government benefit due to local laws
N/A Most of the residents asked for help by seeking health professionals, not family members. Authors mention that family groups may be protective factors, but can also be an important risk factor for crack use, e.g., because of the shame and stigma that affects family relations
The reason most frequently cited for relapses by subjects (89%) was the difficulty of establishing family ties and building a social support network
Assanangkornchai et al. [86] The Thai version of the ASSIST was used to screen patients attending outpatient clinics held at the health centers. As krathom (mitragynine speciosa, Kroth., a traditionally used plant with sedative properties) and krathom cocktail (a mixture of boiled krathom leaf juice and a cola drink with medicines, such as benzodiazepines, antihistamines and ‘cough syrup’) are substances commonly used in the area, they were included in the Thai ASSIST under the ‘other drugs’ category N/A During the study period, the Thai Government launched a new initiative… with the target of reducing the number of users by 400,000 in the first year… Strategies to achieve this included: screening for substance abuse in various settings; various forms of compulsory treatment; and relapse prevention programs. This initiative could have influenced outcomes Most previous similar studies have been carried out in developed countries. Authors claim to have demonstrated that similar studies can be completed in developing countries despite problems in funding, staffing and transport; skepticism; and competing priorities
In general practice and emergency services… the difference between 8 and 4 min… can be the main factor that determines whether or not screening is adopted as a routine procedure
Humeniuk et al. [71] Each country developed their own culturally appropriate brief intervention (no examples given) N/A N/A N/A N/A N/A
Kane et al. [70] N/A A 10-day in-person CETA training was conducted by study authors, followed by weekly small group meetings in which lay counsellors practiced the treatment elements with a local supervisor (before providing CETA to clients). Sixty-three lay counsellors (20 male, 43 female) and seven supervisors were trained in 2016. Supervisors completed one pilot treatment group to strengthen their CETA knowledge and skills and are periodically monitored. Weekly meetings are… held between each local supervisor and a CETA trainer. N/A N/A N/A After the first few weeks of intervention delivery, multiple participants were missing group sessions due to logistical challenges (e.g. work, funerals), which necessitated CETA providers to conduct separate individual sessions for participants that were absent. It became challenging for providers to keep up with the many in-between group sessions they had to conduct, and then also had to repeat material in groups if an individual missed and was not available in-between group sessions. Participants also indicated frustration in that they did want to participate but there was no flexibility for tardiness (in Zambia, this may be defined as an hour or more late) or work/family scheduling within groups. The challenges were substantial enough that the authors would not recommend group CETA in Lusaka, Zambia (urban area), even if it was found to be clinically effective. Therefore, they modified CETA to be individually delivered
Lancaster et al. [76], data also extracted from sister article Miller et al. [77] N/A Trained outreach workers who were knowledgeable about community dynamics, including geographic areas, settings and organizations frequented by PWID, were selected to do the recruitment. Outreach workers were trained on basic methods of rapid assessment procedures to target areas of high drug use
Note: counsellors in this study did have previous counselling experience.
Local government restrictions on MAT access, such as low numbers of MAT clinics (Indonesia, Ukraine) and substantial travel distance (Vietnam), often complicated MAT initiation and retention
In all three countries, the number of available MAT clinics is increasing due to changes in health policy, consequently, uptake of MAT services among the enrolled cohort may have increased throughout study follow-up.
The role of systems navigator can be fulfilled by peers, social workers, counsellors, or cliniciansthe key feature is that navigators understand the local health-care system and are able to facilitate entry and retention in care. The role did not require a high level of educationsome counsellors in Ukraine and Indonesia did not have bachelor’s degrees. The roles of counsellor and systems navigator are conceptually distinct, but in all three sites, the same people served both roles, reducing the number of personnel necessary to implement the intervention For PWID in Vietnam, low levels of education may serve as a barrier for HIV and substance use treatment… the limited number of females in Indonesia and Vietnam accurately reflects the population of PWID in these countries based on culture and historic precedence. Female PWID often face more stigma and discrimination than their male PWID, which can be an additional barrier for engaging in HIV and substance use treatment. Treatment as prevention interventions, as well as substance use treatment, should address vary education levels and integrate female tailored approaches, where appropriate
Injection network size likely reflects the social norms related to injection behavior in each area… (dense networks are associated with injection practices that increase the risk for HIV transmission)… The larger networks in Ukraine may arise because of the uncertainty of the drug sources and the culture of home-made drug preparation
L’Engle et al. [75] To ensure cultural relevance for FSW in Kenya, focus groups to inform intervention adaptation were held with FSW. Intervention adaptations included incorporating a ladder image to assess motivation and readiness to change because the original ruler image was not understood by less literate FSW and development of visuals depicting real-life situations of FSW such as fighting while intoxicated and not drinking while pregnant. Focus group participants also were asked about drinking patterns of FSW and for suggestions they had to reduce risky drinking before engaging in sexual activity; these ideas were incorporated into the intervention visuals and mentioned by counsellors as examples of methods FSW could use to reduce their drinking Nurse counsellors were trained in motivational interviewing techniques and provided the intervention in one-on-one sessions lasting 20 min on average. Quality assurance of intervention delivery was provided monthly by an alcohol intervention expert through direct observation of counselling sessions, meeting with the nurse counsellors and presentation of cases, and review of data, assessment, and plan notes. N/A N/A N/A Authors found that the AUDIT was not effective enough at detecting drinking behavior changes over time. For example, some items referred to lifetime experiences and thus limited the ability to measure change in alcohol use or could not be easily or consistently answered by participants who had stopped drinking during the study period. Therefore, before unblinding, these end points were replaced with items from the behavioral interview asking about drinking behavior over the last 30 days that were answered by all participants regardless of current drinking status
Nadkarni et al. [82] CAP is entirely a culturally adapted intervention which was developed by (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability, feasibility, and impact of the treatment. Further, data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counsellors of the treatment. Four previously published intervention manuals were evaluated by assessing the adequacy of coverage of selected strategies, their suitability for use by lay counsellors, and the extent of adaptations needed for the local context
CAP employs comprehensive and pictorially dominated psychoeducational materials to engage patients in the treatment since the vast majority of patients with harmful drinking in primary care are not specifically seeking help for their drinking problem and many patients have limited literacy.
128 applicant non-professionals were selected for interview, which involved a structured questionnaire, a brief role play to test for skills such as empathy and questions to evaluate willingness to be part of a team, communication, and interpersonal skills. Following the interview, 31 candidates were invited for and completed the training. Of these, 19 completed the internship and delivered CAP under supervision. During the internship, the lay counsellors delivered CAP to patients in PHC and were supervised in groups by experts drawn from the group of local mental health professionals. CAP was iteratively revised based on observations made continuously through a case series. (See Patel et al., 2014; Singla et al., 2014 for further details) N/A It was challenging for lay counsellors to achieve the standards of competence to deliver MI
The main strength of this study is the structured methodology used to address the challenges inherent to the development, evaluation, and implementation of psychosocial interventions in low resource and culturally diverse contexts, which in turn has led to an intervention which is acceptable to various stakeholders, feasible to deliver, and hence has greater chances of being effective and scalable. If the resulting intervention is found to be cost-effective, then this has major implications for alcohol treatments in low resource settings
Treatment engagement was hindered as primary care attenders rarely seek health care for their harmful drinking, and patients and family members are not accustomed to receiving “talking treatments” and express a desire for medications to treat the drinking problem; MI stance was not an acceptable approach in a setting where patients expect prescriptive advice from health professionals; Although CAP emphasized family involvement, family members sometimes saw counselling as a “waste of time” or patients were unwilling to involve family members A third of the patients screening positive for harmful drinking were alcohol dependent. Patients often did not have time for the first session (45 to 60 min) after screening positive for harmful drinking. Dropout rates were high due to practical barriers such as lack of time to attend counselling because of work commitments and inability to travel to the PHC for financial reasons.
Nadkarni et al. [73] See above See above N/A N/A The low prevalence rate of alcohol dependence in the study might be the result of the stigma associated with alcohol dependence which hinders help-seeking and could promote socially desirable responses to the screening and outcome tools Alcohol dependence (AD) may require a more intensive psychosocial treatment, and a brief treatment such as the CAP might not be sufficient to deal with the complex cognitive and behavioral processes associated with AD
Noknoy et al. [72] N/A Nurses had been trained during a single 6-h session, which included an introduction to the research project, lecture and practice exercises to assess the severity of alcohol problems, the effect of alcohol on the patient’s health and the effect of alcohol on the family and society N/A Motivational interviewing is complex, and extensive practice is required to reach advanced levels. The extent and nature of training provided in this study are clearly sub-optimal by current international standards The overall increase in GGT levels at week 6 may be because baseline data were collected immediately after ‘Kao Pansaa’, a 3-month period of Buddhist retreat during which it is customary for people to avoid wrongdoing, including limiting their alcohol drinking. After this period, normal drinking patterns are usually resumed… the increased mean levels of GGT are in contrast to the reduced alcohol consumption that was self-reported… this suggests that the use of self-reported data is still liable to social desirability bias. Any such problem may be exacerbated in Thailand where there is a cultural desire to please Fidelity to motivational interviewing was not assessed, so it is unknown to what extent the interventionas deliveredrepresents an optimal and valid test of that particular type of brief intervention
Because of the small number of women in the study, the effect of gender on outcomes could not be determined.
Pan et al. [88] Translation of measurement tools/questionnaires to Chinese Counsellors received training for the study in a 3-day didactic and interactive seminar. The competence of CBT counselling was rated with the validated rating system after training N/A N/A N/A The frequency of collecting urine samples (once every 2 weeks) may not be sufficient to detect all likely incidents of drug use
More time may be needed for MMT patients to incorporate the skills learned in CBT and to make the requisite changes from cognition to behaviors, especially with regard to negative attitude
The protocol of CBT may need to be revised and adapted in the future to address specific characteristics and factors for improving treatment retention for MMT
Papas et al. [83], data also extracted from Papas et al. [43] Gender stratification of the CBT groups was… deemed necessary to avoid reinforcement of the secondary status of women and encourage their open discussion and engagement in treatment…
Another adaptation included an emphasis on financial cost of drinking: participants reported lack of money as both a reason for drinking and a reason for quitting,… therefore, the contradiction between these two lines of thought was addressed by the counsellors… CBT exercises were adapted (through a prior process with a multi-disciplinary panel) to the local setting, for example, addressing peer pressure to drink at chang’aa dens, and addressing drinking refusals and disclosure of HIV status during sexual encounters (condom use etc.)
Visual aids, treatment materials, and culturally relevant metaphors were used to deliver the intervention. The intervention was delivered by Kenyan counsellors to ensure the integration of cultural values, traditions and beliefs
Treatment was delivered by two counsellors with no prior CBT experience… The training of paraprofessionals to deliver group CBT was chosen in an effort to both accommodate local levels of counselling resources as well as increase the potential for rollout should CBT be shown to be effective. The counsellor training was about 175300 h. N/A Participants were reimbursed their transport costs for all appointments and frequent phone and text appointment reminders to enhance retention. Because of low attendance in some pilot groups, staff also began to transport willing participants to the first CBT session only to boost treatment engagement in the randomized trial CBT group sessions were closed and gender-stratified due to issues of stigma and the consecutive building of knowledge across sessions. Moreover, counsellors were initially intended to be HIV positive to increase trust and because of HIV stigma, however, this was not feasible due to the inability to sufficiently train HIV-positive counsellors N/A
Parry, Carney, & Williams [50] The intervention model was based on a local adaptation of the World Health Organization’s Training guide for HIV prevention outreach to injecting drug users… which lessened the focus on injection drug use-related behaviors and increased the focus on substance-related sexual HIV-risk behavior. In addition, the adapted manual emphasized drugs commonly used in South Africa. N/A N/A In South Africa, attempts to bring HIV prevention, treatment and care interventions into services for drug users… have been associated financial, demographic, and awareness barriers… it is feasible and acceptable to promote such… services with substance users, but more intensive interventions might be needed to have a substantial impact on substance use and substance use-related HIV risk behaviors Authors claim that it is likely that their choice of peer outreach workers of similar age and race to most of the drug-using study participants as well as their empathetic communication and perseverance played a role in facilitating some of the behavior changes that were observed. The study did not include a control group so it is not possible to determine if the changes observed were a result of the risk-reduction counselling or other interventions that may have occurred spontaneously. The sample size was also limited due to the intensity of the outreach and follow-up activities and thus it is possible that real changes over time were not detected. Furthermore, drug users themselves self-reported their substance use, and no biological tests were conducted. Although the study aimed to target both IDUs and NIDUs, IDUs were not reached in this study
Peltzer et al. [84] The AUDIT was translated into Tsonga, Northern Sotho, Venda, Afrikaans, Xhosa, Zulu and Tswana All lay counsellors and up to four nurses per study clinic who were suitable to deliver the brief counselling intervention received formal training… and supervision prior to the start of the study
The training… comprised of four elements: orientation to the relevant practice, standardized power point presentation, recorded simulated consultations with trained actors and on-going clinical supervision by experienced HSRC staff. Counsellors were assessed for adherence to the brief counselling protocol in addition to their behavior and skills
Rotheram-Borus et al. [74] N/A Low-income women were recruited, trained, and certified to serve as interviewers (recruitment phase) … Supervisors monitored and gave feedback on the data quality weekly
Community health workers (CHWs) were trained formonth in cognitive-behavioral change strategies, role-playing, and they also watched videotapes of common situations they might face, they also received monthly refresher trainings. In total, CHWs were trained for two months and about half of the trainees were eliminated because they did not obtain certification. CHWs were trained to provide and apply health information about general maternal and child health, HIV/ TB, alcohol use, and nutrition to low-income, urban women’s lives… CHWs were certified and supervised biweekly with random observations of home visits
Xiaolu et al. [89] N/A A total of 60 staff who worked in the intervention village hospitals were invited to attend training to deliver the intervention. The training involved lectures, group activities and role-plays with video feedback aimed to ensure trainees understood how to conduct the BI… N/A The utility of a BI for AUD has been investigated in a variety of settings, including general hospitals, emergency departments and primary healthcare. This study extends that evidence to village hospital settings in remote regions of China with limited medical resources N/A N/A
  1. Italicized text are direct quotations extracted from the included studies