Opportunities for intervention for alcohol and other drug use problems for men before prison: A qualitative study.

Research into opportunities for prevention including health promotion information about alcohol and other drugs (AoD) harms for people who go to prison is sparce. This is despite there being ample research reporting how much and how frequently AoD have been used by people who go to prison. This article describes results from a qualitative thematic analysis of interviews with 31 men in a Sydney prison, about where they first received health promotion information about AoD-related harms and their first-ever treatment episode. No participant reported receiving education on AoD harms or treatment support services in primary school or high school. Only one participant received their first treatment episode through a health service (in his case from a doctor) and none reported being screened for AoD use at a health service. Almost all (n = 27) participants had their first session with a trained AoD professional through the criminal justice system. Pro-active screening in health services for AoD use disorders and referral to appropriate health services is needed.

Revision of the Australian guidelines to reduce health risks from drinking alcohol.

INTRODUCTION: The Australian guidelines to reduce health risks from drinking alcohol were released in 2020 by the National Health and Medical Research Council. Based on the latest evidence, the guidelines provide advice on how to keep the risk of harm from alcohol low. They refer to an Australian standard drink (10 g ethanol). RECOMMENDATIONS: •Guideline 1: To reduce the risk of harm from alcohol-related disease or injury, healthy men and women should drink no more than ten standard drinks a week and no more than four standard drinks on any one day. The less you drink, the lower your risk of harm from alcohol. •Guideline 2: To reduce the risk of injury and other harms to health, children and people under 18 years of age should not drink alcohol. •Guideline 3: To prevent harm from alcohol to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol. For women who are breastfeeding, not drinking alcohol is safest for their baby. CHANGES AS RESULT OF THE GUIDELINE: The recommended limit for healthy adults changed from two standard drinks per day (effectively 14 per week) to ten per week. The new guideline states that the less you drink, the lower your risk of harm from alcohol. The recommended maximum on any one day remains four drinks (clarified from previously "per drinking occasion"). Guidance is clearer for pregnancy and breastfeeding, and for people aged less than 18 years, recommending not drinking.

A Context-Specific Instrument to Record Drinking Behaviour: A Pilot Study on Implications of Identifying the Context of Risky Drinking.

A context-specific quantity-frequency (CSQF) questionnaire has been developed to accurately measure alcohol consumption using probing questions on drinking context. The study aimed to describe the drinking context associated with different drinking intensities in a community of southern Thailand using the CSQF. A cross-sectional survey was conducted among adults aged > 15 years in Songkhla Province, Thailand. Among 804 participants, there were 183 current drinkers with 412 drinking events (215 low-, 79 medium-, and 118 high-intensity). More than half of these events occurred in special situations (i.e., holiday, party, and cultural drinking). About half of the drinking events occurred outside the drinker's house and most drinking events occurred among friends. Higher drinking intensity was associated with higher level of education [adjusted odds ratio (aOR) 4.74 for medium- and aOR 5.23 for high-intensity] and with a special drinking situation (aOR 2.46 for medium- and aOR 2.78 for high-intensity).

Acceptability and feasibility of a computer-based application to help Aboriginal and Torres Strait Islander Australians describe their alcohol consumption.

We examined acceptability and feasibility of a tablet application ("App") to record self-reported alcohol consumption among Aboriginal and Torres Strait Islander Australians. Four communities (1 urban; 3 regional/remote) tested the App, with 246 adult participants (132 males, 114 females). The App collected (a) completion time; (b) participant feedback; (c) staff observations. Three research assistants were interviewed. Only six (1.4%) participants reported that the App was "hard" to use. Participants appeared to be engaged and to require minimal assistance; nearly half verbally reflected on their drinking or drinking of others. The App has potential for surveys, screening, or health promotion.

Recruiting a representative sample of urban South Australian Aboriginal adults for a survey on alcohol consumption.

BACKGROUND: Population estimates of alcohol consumption vary widely among samples of Aboriginal and Torres Strait Islander (Indigenous) Australians. Some of this difference may relate to non-representative sampling. In some communities, household surveys are not appropriate and phone surveys not feasible. Here we describe activities undertaken to implement a representative sampling strategy in an urban Aboriginal setting. We also assess our likely success. METHODS: We used a quota-based convenience sample, stratified by age, gender and socioeconomic status to recruit Indigenous Australian adults (aged 16+) in an urban location in South Australia. Between July and October 2019, trained research staff (n = 7/10, Aboriginal) recruited community members to complete a tablet computer-based survey on drinking. Recruitment occurred from local services, community events and public spaces. The sampling frame and recruitment approach were documented, including contacts between research staff and services, and then analysed. To assess representativeness of the sample, demographic features were compared to the 2016 Australian Bureau of Statistics Census of Population and Housing. RESULTS: Thirty-two services assisted with data collection. Many contacts (1217) were made by the research team to recruit organisations to the study (emails: n = 610; phone calls: n = 539; texts n = 33; meetings: n = 34, and one Facebook message). Surveys were completed by 706 individuals - equating to more than one third of the local population (37.9%). Of these, half were women (52.5%), and the average age was 37.8 years. Sample characteristics were comparable with the 2016 Census in relation to gender, age, weekly individual income, Indigenous language spoken at home and educational attainment. CONCLUSION: Elements key to recruitment included: 1) stratified sampling with multi-site, service-based recruitment, as well as data collection events in public spaces; 2) local services' involvement in developing and refining the sampling strategy; and 3) expertise and local relationships of local Aboriginal research assistants, including health professionals from the local Aboriginal health and drug and alcohol services. This strategy was able to reach a range of individuals, including those usually excluded from alcohol surveys (i.e. with no fixed address). Carefully pre-planned stratified convenience sampling organised in collaboration with local Aboriginal health staff was central to the approach taken.

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement.

BACKGROUND: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. METHODS: We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. RESULTS: Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements. CONCLUSION: Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).

'That thing in his head': Aboriginal and non-Aboriginal Australian caregiver responses to neurodevelopmental disability diagnoses.

Little is known about the significance of cultural differences to how caregivers receive a diagnosis of neurodevelopmental disability. As part of a Fetal Alcohol Spectrum Disorder prevalence study among sentenced, detained youth, our qualitative study explored the experiences of diagnostic assessment among detained young people and their caregivers. We present findings from the perspectives of caregivers. In conversation with the sociology of diagnosis literature, we present vignettes of three Aboriginal and two non-Aboriginal caregivers' experiences of the diagnostic assessment process. We found that Aboriginal caregivers conceptualised their children's diagnosis and ongoing management in the context of their family networks and community. In contrast, non-Aboriginal caregivers focused on how the diagnosis would affect their child and interactions with various institutions including healthcare systems and schools. Caregivers' engagement with diagnostic reports and resources also followed cultural lines. Reflections on intergenerational drinking were voiced by Aboriginal caregivers, who expressed shame at receiving diagnosis. These findings advance our appreciation of cultural difference in receiving a diagnosis, the examination of which is in its nascent stages. We also suggest ways to mitigate harm from a stigmatising diagnosis and soften the well-established effects of medical dominance over the process of defining a person's capacity and status.

Patterns of drinking in Aboriginal and Torres Strait Islander peoples as self-reported on the Grog Survey App: a stratified sample.

BACKGROUND: The Grog Survey App is a visual and interactive tablet computer-based survey application. It has been shown to be an accurate and acceptable tool to help Indigenous Australians describe what they drink. METHODS: The Grog Survey App was used to enquire into patterns of drinking in a stratified sample of Indigenous Australians in urban and remote/regional sites during testing of the App. The App asked about the last four drinking occasions in the past 12 months, including preferred alcohol types and containers; and symptoms of alcohol dependence, based on ICD-11 descriptions. Drinking patterns are presented here using medians and interquartile ranges, and the thresholds set out by the Australian National and Health and Medical Research Council guidelines. Patterns of consumption are compared by gender and remoteness, using Wilcoxon rank-sum test to compare medians. Logistic regressions tested whether alcohol types and drinking containers varied by remoteness. RESULTS: In this stratified sample most people either consumed nothing (21.7%), or consumed quantities which placed them at short- (95.6%) or long-term risk (47.8%) of harms. Drinkers in remote areas were more likely to drink beer, but less likely to drink pre-mixed spirits. 'Stubbies' and other beer glasses were popular in urban areas, compared with 'slabs' (cases of beer) in remote/regional areas. The use of improvised containers (i.e. empty juice bottles) did not vary by remoteness. Nearly one in six (15%) current drinkers reported experiencing at least two symptoms of alcohol dependence at least monthly. Average drinks per day was the consumption measure most highly correlated with each dependence symptom (r = 0.34-0.38). CONCLUSIONS: The App was able to capture a wide range of preferred alcohol types and containers, and demonstrate a diversity in how alcohol is consumed. This detail was captured in a relative brief survey delivered using an interactive and appealing tablet computer-based application.

Correction to: Developing a tablet computer-based application ('App') to measure self-reported alcohol consumption in Indigenous Australians.

After publication of the original article [1] it was noted that the name of author, Peter Jack, was erroneously typeset in both the PDF and online formats of the manuscript as Peter Jack GradDipIndigH.

Developing a tablet computer-based application ('App') to measure self-reported alcohol consumption in Indigenous Australians.

BACKGROUND: The challenges of assessing alcohol consumption can be greater in Indigenous communities where there may be culturally distinct approaches to communication, sharing of drinking containers and episodic patterns of drinking. This paper discusses the processes used to develop a tablet computer-based application ('App') to collect a detailed assessment of drinking patterns in Indigenous Australians. The key features of the resulting App are described. METHODS: An iterative consultation process was used (instead of one-off focus groups), with Indigenous cultural experts and clinical experts. Regular (weekly or more) advice was sought over a 12-month period from Indigenous community leaders and from a range of Indigenous and non-Indigenous health professionals and researchers. RESULTS: The underpinning principles, selected survey items, and key technical features of the App are described. Features include culturally appropriate questioning style and gender-specific voice and images; community-recognised events used as reference points to 'anchor' time periods; 'translation' to colloquial English and (for audio) to traditional language; interactive visual approaches to estimate quantity of drinking; images of specific brands of alcohol, rather than abstract description of alcohol type (e.g. 'spirits'); images of make-shift drinking containers; option to estimate consumption based on the individual's share of what the group drank. CONCLUSIONS: With any survey platform, helping participants to accurately reflect on and report their drinking presents a challenge. The availability of interactive, tablet-based technologies enables potential bridging of differences in culture and lifestyle and enhanced reporting.

Ready, set, go: a cross-sectional survey to understand priorities and preferences for multiple health behaviour change in a highly disadvantaged group.

BACKGROUND: Socially disadvantaged groups, such as Aboriginal Australians, tend to have a high prevalence of multiple lifestyle risk factors, increasing the risk of disease and underscoring the need for services to address multiple health behaviours. The aims of this study were to explore, among a socially disadvantaged group of people attending an Aboriginal Community Controlled Health Service (ACCHS): a) readiness to change health behaviours; b) acceptability of addressing multiple risk factors sequentially or simultaneously; and c) preferred types of support services. METHODS: People attending an ACCHS in regional New South Wales (NSW) completed a touchscreen survey while waiting for their appointment. The survey assessed participant health risk status, which health risks they would like to change, whether they preferred multiple health changes to be made together or separately, and the types of support they would use. RESULTS: Of the 211 participants who completed the survey, 94 % reported multiple (two or more) health risks. There was a high willingness to change, with 69 % of current smokers wanting to cut down or quit, 51 % of overweight or obese participants wanting to lose weight and 44 % of those using drugs in the last 12 months wanting to stop or cut down. Of participants who wanted to make more than one health change, over half would be willing to make simultaneous or over-lapping health changes. The most popular types of support were help from a doctor or Health Worker and seeing a specialist, with less than a quarter of participants preferring telephone or electronic (internet or smart phone) forms of assistance. The importance of involving family members was also identified. CONCLUSIONS: Strategies addressing multiple health behaviour changes are likely to be acceptable for people attending an ACCHS, but may need to allow flexibility in the choice of initial target behaviour, timing of changes, and the format of support provided.

Randomized Controlled Trial of Mailed Personalized Feedback for Risky Drinkers in the Emergency Department: The Impact on Alcohol Consumption, Alcohol-Related Injuries, and Repeat Emergency Department Presentations.

BACKGROUND: Due to the difficulty encountered in disseminating resource-intensive emergency department (ED)-based brief alcohol interventions into real-world settings, this study evaluated the effect of a mailed personalized feedback intervention for problem drinking ED patients. At 6-week follow-up, this intervention was associated with a statistically significant reduction in alcohol consumption among patients with alcohol-involved ED presentations. This study aimed to evaluate the effects of this intervention over time. METHODS: A randomized controlled trial was conducted among problem drinking ED patients, defined as those scoring 8 or more on the Alcohol Use Disorders Identification Test. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. Follow-up interviews were conducted over the phone, postal survey, or email survey 6 weeks and 6 months after baseline screening, and repeat ED presentations over 12-month follow-up were ascertained via linked ED records. RESULTS: Six-month follow-up interviews were completed with 210 participants (69%), and linked ED records were obtained for 286 participants (94%). The intervention had no effect on alcohol consumption, while findings regarding alcohol-related injuries and repeat ED presentations remain inconclusive. CONCLUSIONS: Further research in which the receipt of feedback is improved and a booster intervention is provided is recommended.

Does a retrospective seven-day alcohol diary reflect usual alcohol intake for a predominantly disadvantaged Australian Aboriginal population?

BACKGROUND: Alcohol disproportionately affects socially disadvantaged groups including Aboriginal and Torres Strait Islander Australians. METHODs to assess alcohol intake for disadvantaged communities need to be able to capture variable or episodic drinking. The ability of a seven-day diary to capture typical consumption for a predominantly Aboriginal sample has not been assessed. OBJECTIVE: One aim of this paper was to examine agreement between a seven-day retrospective diary and 'usual' drinking assessed by a modified version of the Alcohol Use Disorders Identification Test question 3 (AUDIT-3m; two questions). Other aims were to describe drinking patterns as reported in the seven-day diary. METHOD: In 2012, consecutive adults attending an Aboriginal Community Controlled Health Service completed a cross-sectional health risk survey on a touch screen laptop (n = 188). Alcohol consumption questions included the retrospective diary and AUDIT-3m. Agreement was assessed using weighted kappa analysis. RESULTS: There was good agreement between the two measures of consumption; however, the AUDIT-3m questions identified more current drinkers. Respondents who were drinkers (54%) tended to consume large amounts per drinking occasion: almost half (46%) of diary completers reported nine or more standard drinks on at least one occasion in the last week. CONCLUSIONS: The seven-day diary did not adequately capture variability in alcohol consumption common among this sample. Although the AUDIT-3m appeared acceptable, alternative approaches to assess usual or risky alcohol consumption, such as asking about specific drinking occasions, or allowing participants to respond in non-standard drink sizes, also need to be considered for indigenous and other disadvantaged communities.

A cross-sectional survey assessing the acceptability and feasibility of self-report electronic data collection about health risks from patients attending an Aboriginal Community Controlled Health Service.

BACKGROUND: Aboriginal Australians experience significantly worse health and a higher burden of chronic disease than non-Aboriginal Australians. Electronic self-report data collection is a systematic means of collecting data about health risk factors which could help to overcome screening barriers and assist in the provision of preventive health care. Yet this approach has not been tested in an Aboriginal health care setting. Therefore, the aim of this study was to examine the acceptability and feasibility of a health risk questionnaire administered on a touch screen laptop computer for patients attending an Aboriginal Community Controlled Health Service (ACCHS). METHODS: In 2012, consecutive adult patients attending an ACCHS in rural New South Wales, Australia, were asked to complete a health risk survey on a touch screen computer. Health risk factors assessed in the questionnaire included smoking status, body mass index, and level of physical activity. The questionnaire included visual cues to improve accuracy and minimise literacy barriers and was completed while participants were waiting for their appointment. RESULTS: A total of 188 participants completed the questionnaire, with a consent rate of 71%. The mean time taken to complete the questionnaire was less than 12 minutes. Over 90% of participants agreed that: the questionnaire instructions were easy to follow; the touch screen computer was easy to use; they had enough privacy; the questions were easy to understand; they felt comfortable answering all the questions. CONCLUSIONS: Results indicate that the use of a touch screen questionnaire to collect information from patients about health risk factors affecting Aboriginal Australians is feasible and acceptable in the ACCHS setting. This approach has potential to improve identification and management of at-risk individuals, therein providing significant opportunities to reduce the burden of disease among Aboriginal Australians.

Learnings from a prison-based drug treatment program on planning for release: A qualitative study.

INTRODUCTION: Prison-based drug and alcohol group treatment programs operate in all Australian jurisdictions. With more than two-thirds of people in prison having a history of substance use prior to incarceration, such programs are needed. There have been few published papers on the impact of attending group treatment programs in Australian prisons, and the research published to date has been predominately quantitative. We aim to report the experiences of males in prison who completed and those who did not complete a group-based drug and alcohol program, to gain insight into their strategies for reducing harm from drug and alcohol post-release. METHODS: Qualitative thematic analysis of in-depth interviews with 12 males who completed or were about to complete and 10 males who discontinued a prison-based group drug and alcohol treatment program. RESULTS: Program completers were more likely to have well-developed plans to reduce drug and alcohol harms and maintain abstinence upon return to the community, which included creating healthier social networks. They also showed stronger insights into the factors that led to offending. Those who did not complete the drug and alcohol program appeared to rely on self-will as the main way to reduce drug and alcohol harms, with less awareness of options for support services to reduce or stop drug and alcohol use. DISCUSSION AND CONCLUSIONS: Prison-based drug and alcohol program engagement imparted useful information for program completers. Controlled trials are needed to examine whether such differences equate to improved outcomes after release.

Supporting alcohol brief interventions and pharmacotherapy provision in Australian First Nations primary care: exploratory analysis of a cluster randomised trial.

INTRODUCTION: Primary care provides an important opportunity to detect unhealthy alcohol use and offer assistance but many barriers to this exist. In an Australian context, Aboriginal Community Controlled Health Services (ACCHS) are community-led and run health services, which provide holistic primary care to Aboriginal and Torres Strait Islander peoples. A recent cluster randomised trial conducted with ACCHS provided a service support model which showed a small but significant difference in provision of 'any treatment' for unhealthy alcohol use. However, it was not clear which treatment modalities were increased. AIMS: To test the effect of an ACCHS support model for alcohol on: (i) delivery of verbal alcohol intervention (alcohol advice or counselling); (ii) prescription of relapse prevention pharmacotherapies. METHODS: Intervention: 24-month, multi-faceted service support model. DESIGN: cluster randomised trial; equal allocation to early-support ('treatment') and waitlist control arms. PARTICIPANTS: 22 ACCHS. ANALYSIS: Multilevel logistic regression to compare odds of a client receiving treatment in any two-month period as routinely recorded on practice software. RESULTS: Support was associated with a significant increase in the odds of verbal alcohol intervention being recorded (OR = 7.60, [95% CI = 5.54, 10.42], p < 0.001) from a low baseline. The odds of pharmacotherapies being prescribed (OR = 1.61, [95% CI = 0.92, 2.80], p = 0.1) did not increase significantly. There was high heterogeneity in service outcomes. CONCLUSIONS: While a statistically significant increase in verbal alcohol intervention rates was achieved, this was not clinically significant because of the low baseline. Our data likely underestimates rates of treatment provision due to barriers documenting verbal interventions in practice software, and because different software may be used by drug and alcohol teams. The support made little impact on pharmacotherapy prescription. Changes at multiple organisational levels, including within clinical guidelines for primary care, may be needed to meaningfully improve provision of alcohol treatment in ACCHS. TRIAL REGISTRATION: ACTRN12618001892202 (retrospectively registered on 21/11/2018).

Alcohol screening in 22 Australian Aboriginal Community Controlled Health Organisations: Clinical context and who is screened.

INTRODUCTION: Alcohol screening among Indigenous Australians is important to identify individuals needing support to reduce their drinking. Understanding clinical contexts in which clients are screened, and which clients are more or less likely to be screened, could help identify areas of services and communities that might benefit from increased screening. METHODS: We analysed routinely collected data from 22 Aboriginal Community Controlled Health Organisations Australia-wide. Data collected between February 2016 and February 2021 were analysed using R, and aggregated to describe screening activity per client, within 2-monthly extraction periods. Descriptive analyses were performed to identify contexts in which clients received an Alcohol Use Disorders Identification Test consumption (AUDIT-C) screen. Multi-level logistic regression determined demographic factors associated with receiving an AUDIT-C screen. Three models are presented to examine if screening was predicted by: (i) age; (ii) age and gender; (iii) age, gender and service remoteness. RESULTS: We observed 83,931 occasions where AUDIT-C was performed at least once during a 2-monthly extraction period. Most common contexts were adult health check (55.0%), followed by pre-consult examination (18.4%) and standalone item (9.9%). For every 10 years' increase in client age, odds of being screened with AUDIT-C slightly decreased (odds ratio 0.98; 95% confidence interval [CI] 0.98, 0.99). Women were less likely to be screened with AUDIT-C (odds ratio 0.95; 95% CI 0.93, 0.96) than men. DISCUSSION AND CONCLUSIONS: This study identified areas where alcohol screening can be increased (e.g., among women). Increasing AUDIT-C screening across entire communities could help reduce or prevent alcohol-related harms. Future Indigenous-led research could help identify strategies to increase screening rates.

Countering stereotypes: Exploring the characteristics of Aboriginal Australians who do not drink alcohol in a community representative sample.

INTRODUCTION: Contrary to stereotypes, Aboriginal and Torres Strait Islander Australians are more likely to abstain from drinking than other Australians. We explored characteristics and experiences of Aboriginal and Torres Strait Islander Australians who do not drink alcohol. METHOD: We conducted a cross-sectional, representative survey of 775 Aboriginal and Torres Strait Islander Australians (16+ years) in remote and urban South Australia. We explore correlates of not drinking alcohol using multi-level logistic regression. We describe reasons for non-drinking and harms participants experienced in past 12 months from others' drinking. RESULTS: Non-drinking participants were more likely to be older (OR 1.35 [95% CI 1.21, 1.50] per decade) and unemployed (OR 2.72 [95% CI 1.77, 4.20]). Participants who spoke Aboriginal Australian languages at home were three times more likely to be lifetime abstainers from drinking (OR 3.07 [95% CI 1.52, 6.21]). Common reasons for not drinking alcohol were health and family. Most did not report harms from others' alcohol consumption (79.6%, 76.9%, urban and remote respectively). Stress from others' alcohol consumption was the most reported harm by non-drinkers (14.5% and 23.1%, urban and remote, respectively). DISCUSSION AND CONCLUSIONS: Culture such as speaking Aboriginal Australian languages might have protective effects that promote abstaining but was rarely explicitly cited as a reason for not drinking. A greater understanding of local values held by people who do not drink alcohol could help inform health messaging and other interventions to reduce alcohol-related harms. Understanding local reasons for abstaining can help tailor health messaging to suit local contexts.