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

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. Trial registration Protocol Registry: PROSPERO CRD42017055549 Catherine Staton and co-workers report on evidence about interventions against harmful alcohol use in low- and middle-income countries. 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.