HIGHLIGHTS

  • To reduce hazardous drinking in Mozambique, this study compares the Screening, Brief Intervention, Referral to Treatment–Conventional Training and Supervision (SBIRT-CTS) approach with a mobile health version of SBIRT (mSBIRT), examining community-level implementation, clinical outcomes, and cost-effectiveness.

  • The use of mSBIRT is envisioned as a cost-effective, sustainable delivery mechanism for evidence-based services in low- and middle-income countries.

  • This study explores a causal model and predictors of SBIRT implementation success by combining psychological theories of behavior change with organizational theories.

Editor’s Note: In partnership with Milton L. Wainberg, M.D., Psychiatric Services is publishing protocols to address the gap between global mental health research and treatment. These protocols present largescale, global mental health implementation studies soon to begin or under way. Taking an implementation science approach, the protocols describe key design and analytic choices for delivery of evidence-based practices to improve global mental health care. This series represents the best of our current science, and we hope these articles inform and inspire.

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Hazardous drinking, that is, alcohol consumption that places individuals at risk for adverse health events, is a major public health challenge, particularly in low- and middle-income countries (LMICs) (13). Alcohol misuse is avoidable, yet results in high morbidity and mortality rates and ranks as the third-leading risk factor for poor health globally (14). Harmful alcohol use contributes to >200 types of diseases and injuries. Alcohol’s impact is worst among people in poor populations and in LMICs where disease burden per liter of alcohol consumed is greater than among individuals in wealthy populations (2, 5, 6).

Mozambique is a low-income country where half of the population lives below the poverty line as set by the World Bank and disease burden is high. Although research on alcohol use in Mozambique is scarce, recent studies have revealed that binge drinking (episodes of excessive drinking, i.e., four or more drinks per episode for women and five or more drinks per episode for men) is frequent among drinkers in Mozambique. Two recent studies with Mozambicans ages 25–64 years found that 24%−29% of women and 49%−58% of men were current drinkers (having consumed at least one drink in the past year) (7, 8). Approximately 60% of current drinkers consumed alcohol at least once or twice a week, and >40% reported binge drinking in the previous week. Three-quarters of drinkers reported consuming home-distilled traditional alcohol beverages with high alcohol content, which was strongly associated with binge drinking. Having depression and experiencing the death of a child were associated with hazardous drinking (a score of >4 on the Alcohol Use Disorders Identification Test [AUDIT]) (9).

Mozambique’s HIV prevalence has increased by 15% since 2009 (10). Alcohol is implicated in behaviors that increase the risk for contracting HIV and in poor HIV care adherence (11). HIV is the second largest category of alcohol-attributable disability-adjusted life years (DALYs); alcohol-attributable disease burden worsens if the impact of alcohol consumption on HIV incidence and course is considered, with alcohol being responsible for 6.4% of all deaths and 4.7% of all DALYs lost in the African region (12). Thus, decreasing hazardous drinking could improve HIV care outcomes.

The World Health Organization’s Mental Health Gap Action Programme (mhGAP) guidelines (13, 14) recommend using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) (15) approach to reduce hazardous drinking. SBIRT is typically integrated into medical care to address substance use disorders (16). However, there are challenges to implementing SBIRT with fidelity, obtaining the effectiveness observed in trials, and sustaining SBIRT (17), particularly in LMICs (18). Hazardous drinking services (HDS) in Mozambique are delivered in specialty clinics by psychiatric technicians trained in SBIRT and other HDS informed by mhGAP evidence. With one specialty clinic per district, each with 50,000–150,000 inhabitants, most individuals who engage in hazardous drinking are not served. Our study aims to address this challenge through work with the Mozambican Ministry of Health to task-shift SBIRT to community health workers (CHWs). We will build on the Ministry of Health’s mhGAP-Epilepsy Program (19) and our community mental health trial, funded recently by the National Institute of Mental Health, which links study data to Mozambique’s electronic medical record system (e-saúde) to track the impact of two SBIRT approaches on comorbid conditions, including HIV and tuberculosis (TB).

Mobile health technologies (mHealth) (20), such as the mobile SBIRT (mSBIRT) application (21), are a promising tool for widespread, cost-effective, and sustainable health service delivery in LMICs (20, 2224). The mSBIRT application was designed for use by health care providers. It assists providers in quickly assessing a patient’s alcohol use risk level and guides providers through a brief intervention that is tailored to the patient’s responses. For LMICs such as Mozambique, identifying the most appropriate strategy to implement SBIRT in community HDS is crucial. Capitalizing on Mozambique’s task-shifting strategies and commitment to inform HDS scale-up with local treatment guidelines (i.e., SBIRT and mhGAP), this study will scale up SBIRT in the community. We will compare mSBIRT with the SBIRT–Conventional Training and Supervision (SBIRT-CTS) strategy to determine the most cost-effective approach for expansion and for overcoming implementation barriers.

Community Implementation of SBIRT using Technology for Alcohol use Reduction in Mozambique (Community I-STAR Mozambique) comprises a 2-year, cluster-randomized, hybrid implementation-effectiveness type-2 trial in 12 districts evaluated by mixed-methods analyses (Table 1). Our first two aims will be accomplished throughout the trial. Aim 1 is to conduct an implementation impact evaluation by using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) model and compare the adapted mSBIRT with SBIRT-CTS in terms of reach (primary outcome), adoption, implementation fidelity, and maintenance over time. Aim 2 is to compare clinical effectiveness and cost-effectiveness of mSBIRT and SBIRT-CTS overall and by patient’s gender, age, and urbanicity (25). Aim 3 will be accomplished throughout the trial and the subsequent scale-up phase (i.e., when the most effective strategy is expanded to other districts) and will identify organizational and clinician-level factors that affect SBIRT implementation and effectiveness. Design solutions that are responsive to key challenges and advantages of the study are detailed in Box 1.

TABLE 1. Time line and milestones of the Community Implementation of SBIRT using Technology for Alcohol use Reduction (I-STAR) in Mozambique trial, by yearly quarter

Year 1 Year 2 Year 3 Year 4 Year 5
Milestone 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Start
Personnel training, IRB approvals, measure finalizationa
Finalizing SBIRT-CTS and mSBIRT training and supervision manuals and pilotingb
Finalizing data collection and management and manual of procedures
Training of trainers and harmonizing training sessions
Effectiveness-implementation type-2 RCT (aim 1 and 2)c
RCT implementation phasec
Training of CHWs and PCPsd
Performing services, consultations, monitoring, feedback
RCT sustainability phasec
Assessing competency
Cost-effectiveness data analysis

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