Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America.

BACKGROUND: Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru. OBJECTIVE: To describe the process of development and cultural adaptation of the clinical intervention and training package. METHODS: We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework. RESULTS: In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway. CONCLUSION: Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Perceived appropriateness of alcohol screening and brief advice programmes in Colombia, Mexico and Peru and barriers to their implementation in primary health care - a cross-sectional survey.

BACKGROUND: Providing alcohol screening and brief advice (SBA) in primary health care (PHC) can be an effective measure to reduce alcohol consumption. To aid successful implementation in an upper middle-income country context, this study investigates the perceived appropriateness of the programme and the perceived barriers to its implementation in PHC settings in three Latin American countries: Colombia, Mexico and Peru, as part of larger implementation study (SCALA). METHODS: An online survey based on the Tailored Implementation for Chronic Diseases (TICD) implementation framework was disseminated in the three countries to key stakeholders with experience in the topic and/or setting (both health professionals and other roles, for example regional health administrators and national experts). In total, 55 respondents participated (66% response rate). For responses to both appropriateness and barriers questions, frequencies were computed, and country comparisons were made using Chi square and Kruskal-Wallis non-parametric tests. RESULTS: Alcohol SBA was seen as an appropriate programme to reduce heavy alcohol use in PHC and a range of providers were considered suitable for its delivery, such as general practitioners, nurses, psychologists and social workers. Contextual factors such as patients' normalised perception of their heavy drinking, lack of on-going support for providers, difficulty of accessing referral services and lenient alcohol control laws were the highest rated barriers. Country differences were found for two barriers: Peruvian respondents rated SBA guidelines as less clear than Mexican (Mann-Whitney U = -18.10, P = 0.001), and more strongly indicated lack of available screening instruments than Colombian (Mann-Whitney U = -12.82, P = 0.035) and Mexican respondents (Mann-Whitney U = -13.56, P = 0.018). CONCLUSIONS: The study shows the need to address contextual factors for successful implementation of SBA in practice. General congruence between the countries suggests that similar approaches can be used to encourage widespread implementation of SBA in all three studied countries, with minor tailoring based on the few country-specific barriers.

Impact of Training and Municipal Support on Primary Health Care-Based Measurement of Alcohol Consumption in Three Latin American Countries: 5-Month Outcome Results of the Quasi-experimental Randomized SCALA Trial.

PURPOSE: We aimed to test the effects of providing municipal support and training to primary health care providers compared to both training alone and to care as usual on the proportion of adult patients having their alcohol consumption measured. METHODS: We undertook a quasi-experimental study reporting on a 5-month implementation period in 58 primary health care centres from municipal areas within Bogotá (Colombia), Mexico City (Mexico), and Lima (Peru). Within the municipal areas, units were randomized to four arms: (1) care as usual (control); (2) training alone; (3) training and municipal support, designed specifically for the study, using a less intensive clinical and training package; and (4) training and municipal support, designed specifically for the study, using a more intense clinical and training package. The primary outcome was the cumulative proportion of consulting adult patients out of the population registered within the centre whose alcohol consumption was measured (coverage). RESULTS: The combination of municipal support and training did not result in higher coverage than training alone (incidence rate ratio (IRR) = 1.0, 95% CI = 0.6 to 0.8). Training alone resulted in higher coverage than no training (IRR = 9.8, 95% CI = 4.1 to 24.7). Coverage did not differ by intensity of the clinical and training package (coefficient = 0.8, 95% CI 0.4 to 1.5). CONCLUSIONS: Training of providers is key to increasing coverage of alcohol measurement amongst primary health care patients. Although municipal support provided no added value, it is too early to conclude this finding, since full implementation was shortened due to COVID-19 restrictions. TRIAL REGISTRATION: Clinical Trials.gov ID: NCT03524599; Registered 15 May 2018; https://clinicaltrials.gov/ct2/show/NCT03524599.

The Social Ecology of Parental Monitoring: Parent-Child Dynamics in a High-Risk Peruvian Neighborhood.

While parental monitoring is understood to protect adolescents from engaging in risk behaviors, little is known about how the family dynamics involved in parental monitoring differ across sociocultural contexts. We sought to gain an in-depth understanding of parent-child relationship dynamics and parental knowledge of adolescents' activities in an urban Peruvian neighborhood with high levels of crime and adolescent substance use. We conducted 15 in-depth interviews and two focus groups with adolescents and 12 in-depth interviews with mothers sampled from a secondary school in Callao, Peru. Our findings emphasize the importance of parent-child confianza (trust) as a foundation for parental awareness of adolescents' lives and activities. Participants in our sample characterized confianza as encouraging adolescent disclosure and shaping how parental solicitation and rules were interpreted by adolescents. Participants described how confianza was rooted in features of the parent-child relationship, including shared parent-child time, parental affection, adolescent perceptions of parents' ability to give good advice, and awareness of how parents would react to delicate topics. Participants linked these family dynamics, in turn, to economic hardship, parental feelings of sacrifice and stress, perceptions of neighborhood risk, and gender norms limiting fathers' involvement in caregiving. Results have implications for the planning and adaptation of family-based prevention programs for use in high-risk contexts in Latin America.

Si bien existe una comprensión en relación a que la supervisión de los padres protege a los adolescentes de participar en comportamientos de riesgo, se sabe poco acerca de cómo la dinámica familiar involucrada en la supervisión difiere en distintos contextos socioculturales. Se buscó obtener una comprensión profunda de la dinámica de la relación entre padres e hijos y el conocimiento parental acerca de las actividades de los adolescentes en un barrio urbano peruano con altos niveles de delito y de abuso de sustancias por adolescentes. Realizamos 15 entrevistas a profundidad y dos grupos focales con adolescentes, y 12 entrevistas a profundidad con madres, que fueron seleccionadas en una escuela secundaria en Callao, Perú. Nuestros hallazgos enfatizan la importancia de la confianza entre padres e hijos como la base del conocimiento de los padres sobre la vida y actividades de los adolescentes. Los participantes en este estudio caracterizaron a la confianza como alentadora de la revelación por los adolescentes de lo que les pasa, y que da forma a cómo las reglas y las indagaciones que hacen los padres a sus hijos, fueron interpretadas por los adolescentes. Los participantes describieron cómo la confianza se encuentra arraigada en las características de la relación entre padres e hijos, incluyendo el tiempo compartido entre padres e hijos, el afecto de los padres, las percepciones de los adolescentes sobre la capacidad de los padres de dar buenos consejos y el conocimiento de cómo los padres reaccionarían a temas delicados. Los participantes asociaron esta dinámica familiar, a su vez, con la dificultad económica; los sentimientos de sacrificio y el estrés de los padres; las percepciones de riesgo del barrio; y las normas de género que limitan el involucramiento de los padres en el cuidado. Los resultados tienen implicancias para la planificación y adaptación de programas de prevención basados en la familia con el fin de utilizarlos en contextos de alto riesgo en América Latina.

Stigma towards mental illness and substance use issues in primary health care: Challenges and opportunities for Latin America.

Stigma towards mental illness and addictive disorders is a global problem and one of the main obstacles in tackling this issue remains the effective integration of mental health services into primary health care (PHC). In Latin America, information has significantly increased on the existence of stigma; however, little is known about effective interventions to prevent stigma and promote recovery-oriented practices in PHC. The aim of this study is to understand the existing evidence regarding mental health stigma in PHC with a special focus on the Latin American region. A scoping review of the literature related to mental health stigma in PHC was conducted. Two hundred and seventeen articles were evaluated; 74 met inclusion criteria and 14 additional articles were selected from references of search results. Results were subdivided into five different perspectives: users, family members and significant others, health professionals, contextual factors, and potential effective interventions. Only nine studies were based in Latin America, and only one described an intervention to reduce stigma in mental health services, not specifically in PHC. We found an urgent need to develop interventions to understand and reduce stigma in PHC settings, especially in Latin America.

Family Factors and Adolescent Problem Drinking in a High-Risk Urban Peruvian Neighborhood.

BACKGROUND: Family relationships are widely recognized as playing a role in adolescent alcohol use. Although family relationships and parenting vary by culture, limited research has explored these relationships in Latin America. OBJECTIVES: We sought to determine which family factors are associated with adolescent alcohol use in Callao, Peru. METHODS: Data come from a cross-sectional survey conducted in a public secondary school in Callao, Peru in 2007. A total of 180 11th grade students are included in the analysis. Our main outcome measure was problem drinking, defined as self-report of having ever consumed beer, wine, spirits, or hard alcohol to a point of drunkenness. Logistic regression was used to determine if odds of problem drinking varied by level of parental monitoring (knowledge of activities and whereabouts), positive family relationships, or family conflict, while controlling for demographic and peer variables. RESULTS: Low levels of parental monitoring and low levels of positive family relationships were each associated with significantly higher odds of lifetime problem drinking in analyses adjusted for deviant peer affiliation along with sociodemographic variables (odds ratio (OR) = 4.2; 95% confidence interval (CI): 1.3-13.5; OR = 4.4; 95% CI: 1.5-13.0, respectively). Although family conflict was associated with elevated odds of lifetime problem drinking, this did not reach significance (adjusted OR = 2.01; 95% CI: 0.8-5.1). Conclusions/Importance: Interventions designed to prevent adolescent alcohol use in urban Peru may benefit from promoting positive family interactions and parental monitoring skills.

University students' perceived norms of peers and drug use: a multicentric study in five Latin American countries.

This cross-sectional study compared perceived peer drug use and actual drug use in a sample of Latin American university students. Students from nine universities in five countries (Brazil, Chile, Colombia, Honduras and Peru) completed a questionnaire that addressed the use of tobacco, alcohol, marijuana and cocaine. Analysis focused on comparing perceptions to actual drug use. The findings largely, but not completely, confirmed the idea that students overestimate peer drug use. The unexpected findings were those relating to alcohol. While students generally overestimated peer use of tobacco, marijuana and cocaine, they accurately estimated or underestimated peer use of alcohol. Apart from the anomalous findings with regard to alcohol, this study shows that perceived drug use relates to actual drug use in Latin America as it does elsewhere. The results also support the suggestion that interventions using normative feedback would be useful to strengthen drug use prevention programs aimed at youth in Latin America.

[Perceived norms among Peruvian students for drug use among peers]. / Normas percibidas por estudiantes peruanos acerca de sus pares y el uso de drogas.

OBJECTIVE: to evaluate the difference between perceived norms about drug use among peer and actual drug use as reported by the same university students. The students were between 18 and 24 years old and attended health courses. METHOD: cross-sectional study based on a survey, using an anonymous questionnaire filled out by the students. RESULTS: There were 306 participants. Senior students used drugs as follows: 51.3% used tobacco, 90.8% used alcohol, 5.9% used marijuana, and 0.7% used cocaine. Differences were observed between perceived norms and actual drug use for tobacco (70% vs. 51.3%), marijuana (10% vs. 5.9%) and cocaine (8.3% vs. 0.7%). CONCLUSIONS: university students presented an overestimated rate for the use of tobacco, marijuana and cocaine among their peers.

University students' perceived norms of peers and drug use: a multicentric study in five Latin American countries / Normas percibidas por estudiantes universitarios respecto a sus pares y el uso de drogas: estudio multicéntrico en cinco países de América Latina / Normas percebidas por estudantes universitários sobre seus companheiros e uso de drogas: um estudo multicêntrico em cinco países da América Latina

This cross-sectional study compared perceived peer drug use and actual drug use in a sample of Latin American university students. Students from nine universities in five countries (Brazil, Chile, Colombia, Honduras and Peru) completed a questionnaire that addressed the use of tobacco, alcohol, marijuana and cocaine. Analysis focused on comparing perceptions to actual drug use. The findings largely, but not completely, confirmed the idea that students overestimate peer drug use. The unexpected findings were those relating to alcohol. While students generally overestimated peer use of tobacco, marijuana and cocaine, they accurately estimated or underestimated peer use of alcohol. Apart from the anomalous findings with regard to alcohol, this study shows that perceived drug use relates to actual drug use in Latin America as it does elsewhere. The results also support the suggestion that interventions using normative feedback would be useful to strengthen drug use prevention programs aimed at youth in Latin America.

Este estudio transversal se comparó la percepción que se tiene del consumo de los pares con el uso real de drogas, en una muestra de estudiantes universitarios de América Latina. Los estudiantes de nueve universidades en cinco países (Brasil, Chile, Colombia, Honduras y Perú) respondieron a un cuestionario que abordaba el uso de tabaco, alcohol, marihuana y cocaína. El análisis se concentró en la comparación de la percepción y el consumo real de drogas. Los resultados en gran medida, aunque no completamente, confirmaron que los estudiantes sobreestiman el uso de drogas entre sus pares. Los resultados inesperados fueron los relacionados con el alcohol. Mientras que los estudiantes generalmente sobrestimaron el consumo de tabaco, marihuana y cocaína entre sus pares, los mismos estimaron con bastante precisión o subestimaron el uso de alcohol entre sus pares. Además de los resultados inesperados en relación al alcohol, este estudio muestra que la percepción del uso de drogas en América Latina se comporta de manera similar a otros lugares. Los resultados también apoyan la sugerencia respecto a que la retroalimentación normativa sería útil para fortalecer los programas de prevención de drogas dirigidos a jóvenes en América Latina.

Este estudo transversal comparou a percepção dos companheiros de usuários de drogas em uma amostra de estudantes universitários da América Latina. Os estudantes de nove universidades, localizadas em cinco países (Brasil, Chile, Colômbia, Honduras e Peru) responderam questionário que abordou questões sobre o tagagismo, álcool, maconha e cocaína. A análise foi focalizada na comparação da percepção e da realidade dos atuais usuários de drogas. Os resultados confirmaram, de forma geral, a ideia de que os estudantes superestimam o uso de drogas. Resultados inesperados foram identificados em relação ao uso de álcool. Enquanto os estudantes geralmente superestimam o uso de tabaco, maconha e cocaína, entre seus pares, estimaram com bastante precisão ou subestimaram o uso de álcool entre seus pares. Apesar desse resultado inesperado, este estudo mostra que a percepção do uso de drogas entre estudantes universitários da América Latina se comporta de maneira similar ao uso de drogas em outras localidades. Os resultados também apóiam a sugestão de que intervenções, usando retroalimentação normativa, seriam úteis para fortalecer os programas de prevenção ao uso de drogas, dirigidos aos jovens da América Latina.

Normas percibidas por estudiantes peruanos acerca de sus pares y el uso de drogas / Normas percebidas por estudantes peruanos sobre uso de drogas entre seus pares / Perceived norms among peruvian students for drug use among peers

El objetivo de este estudio fue estimar la diferencia entre las normas percibidas sobre el uso de drogas por sus pares y el uso real de drogas entre universitarios, entre 18 y 24 años, de las áreas de salud. Se trata de un estudio transversal, basado en un censo y en un cuestionario anónimo y autoaplicado. Participaron 306 estudiantes (82 por ciento). La proporción del consumo, en el último año, fue de 51,3 por ciento para el tabaco, 90,8 por ciento para el alcohol, 5,9 por ciento para la marihuana y 0,7 por ciento para la cocaína. Se observó una diferencia entre la norma percibida de consumo y la proporción de uso real informado para el tabaco (70 por ciento vs. 51.3 por ciento), marihuana (10 por ciento vs. 5.9 por ciento) y cocaína (8.3 por ciento vs. 0.7 por ciento). Se concluye que los universitarios sobrestiman el consumo de tabaco, marihuana y cocaína de sus pares.

Objective: to evaluate the difference between perceived norms about drug use among peer and actual drug use as reported by the same university students. The students were between 18 and 24 years old and attended health courses. Method: cross-sectional study based on a survey, using an anonymous questionnaire filled out by the students. RESULTS: There were 306 participants. Senior students used drugs as follows: 51.3 percent used tobacco, 90.8 percent used alcohol, 5.9 percent used marijuana, and 0.7 percent used cocaine. Differences were observed between perceived norms and actual drug use for tobacco (70 percent vs. 51.3 percent), marijuana (10 percent vs. 5.9 percent) and cocaine (8.3 percent vs. 0.7 percent). CONCLUSIONS: university students presented an overestimated rate for the use of tobacco, marijuana and cocaine among their peers.

O objetivo deste estudo foi avaliar a diferença entre as normas percebidas pelos estudantes universitários, com idade entre 18 e 24 anos, sobre o uso de drogas pelos seus pares e o uso de drogas relatado pelos próprios estudantes em cursos da área da saúde. Foi usado o método transversal, baseado em censo realizado através de questionário, preenchido pelos próprios estudantes, sem identificação. O número de participantes foi de 306 (82 por cento). Como resultados obteve-se: a proporção de estudantes que utilizou drogas no último ano foi de 51,3 por cento para o tabaco, 90,8 por cento para o álcool, 5,9 por cento para a maconha e 0,7 por cento para a cocaína. Diferença entre as normas percebidas e o uso de drogas foi observada para o tabaco (70 por cento vs 51,3 por cento), maconha (10 por cento vs 5.9 por cento) e cocaína (8,3 por cento vs 0,7 por cento). Conclui-se que os estudantes universitários apresentaram estimativa aumentada sobre o consumo de tabaco, maconha e cocaína entre seus pares.