In relation to Question 2 (Do health workers have adequate knowledge to prevent and manage alcohol use disorders among their patients? What matters to them? How can they be better informed?) I have identified a few interesting papers, some of them written by HIFA members (Abhijit Nadkarni, Richard Velleman, Erica Frank...). Below is a helpful overview paper by Abhijit Nadkarni, a member of our working group on AUD, Richard Velleman and colleagues:
https://www.hifa.org/projects/mental-health-meeting-information-needs-su...
https://www.hifa.org/support/members/abhijit
Closing the treatment gap for alcohol use disorders in low- and middle-income countries
https://www.cambridge.org/core/journals/global-mental-health/article/clo...
Published 09 December 2022
ABSTRACT
The alcohol-attributable disease burden is greater in low- and middle-income countries (LMICs) as compared to high-income countries. Despite the effectiveness of interventions such as health promotion and education, brief interventions, psychological treatments, family-focused interventions, and biomedical treatments, access to evidence-based care for alcohol use disorders (AUDs) in LMICs is limited. This can be explained by poor access to general health and mental health care, limited availability of relevant clinical skills among health care providers, lack of political will and/or financial resources, historical stigma and discrimination against people with AUDs, and poor planning and implementation of policies. Access to care for AUDs in LMICs could be improved through evidence-based strategies such as designing innovative, local and culturally acceptable solutions, health system strengthening by adopting a collaborative stepped care approach, horizontal integration of care into existing models of care (e.g., HIV care), task sharing to optimise limited human resources, working with families of individuals with AUD, and leveraging technology-enabled interventions. Moving ahead, research, policy and practice in LMICs need to focus on evidence-based decision-making, responsiveness to context and culture, working collaboratively with a range of stakeholders to design and implement interventions, identifying upstream social determinants of AUDs, developing and evaluating policy interventions such as increased taxation on alcohol, and developing services for special populations (e.g., adolescents) with AUDs.
SEKECTED EXTRACTS
The evidence about treatment interventions for AUDs in LMICs is limited...
Brief interventions are generally characterised by a few short sessions involving an assessment of individual risk with feedback and advice, followed by provision of structured advice, or brief motivational interviewing that takes a more patient-centred approach, or a combination of both. BIs are the most tested interventions for AUDs in LMICs, most commonly using motivational interviewing techniques delivered by non-specialist health workers or through digital platforms. There is substantial evidence on the effectiveness of BIs on a range of short- and long-term drinking outcomes, in healthcare and community settings, in men as well as women, and when delivered by NSHWs, or digitally. Compared to a range of other public health policies designed to reduce alcohol-related harm (e.g., regulation of alcohol advertising) BIs achieve larger effects as measured by DALYs.
Despite the high burden of AUDs and availability of evidence-based interventions, outlined above, access to appropriate treatment remains low. The pooled treatment rate of AUD from any source of treatment is 17.3%. This effectively means that four out of five individuals with AUD do not have access to appropriate care for their drinking problems. [*see comment below]
Treatment gap refers to the proportion of individuals who require treatment for a particular condition but do not receive it;
The treatment gap may be explained by some combination of (1) limited access to general health and mental health care, (2) poor accessibility of evidence-based treatments, (3) limited availability of and clinical skills among health care providers, (4) lack of political will and/or financial resources, (5) historical stigma and discrimination against people with AUDs, and (6) poor planning and implementation of policies (Connery et al., Reference Connery, McHugh, Reilly, Shin and Greenfield2020).
In summary, in many LMICs, prevention in earlier stages of problem drinking is mostly non-existent and alcohol-related problems are first addressed when they are already severe and difficult to treat.
COMMENT (NPW): The paper defines the treatment gap as 'the proportion of individuals who require treatment for a particular condition but do not receive it'. Does this include all people with an Alcohol Use Disorder, as defined by the DSM-V, whether or not they seek treatment? It would be interesting to have an idea of [number of people with AUD] vs [number of people with AUD who seek medical help but cannot get it] vs [number of people with AUD who seek medical help and receive it]. Clearly, the picture is blurred also by the quality of help provided, and by whom. I expect perhaps that many people bypass the health system in the first instance and seek help from non-medical sources. It would be very interesting to hear some case studies of people with AUD and their experiences of seeking help for their condition.
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org
