Effective alcohol policies and lifetime abstinence: An analysis of the International Alcohol Control policy index.

INTRODUCTION: Alcohol abstinence remains common among adults globally, although low and middle-income countries are experiencing declines in abstention. The effect of alcohol policies on lifetime abstinence is poorly understood. The International Alcohol Control (IAC) policy index was developed to benchmark and monitor the uptake of effective alcohol policies and has shown strong associations with alcohol per capita consumption and drinking patterns. Uniquely, the index incorporates both policy 'stringency' and 'impact', reflecting policy implementation and enforcement, across effective policies. Here we assessed the association of the IAC policy index with lifetime abstinence in a diverse sample of jurisdictions. METHODS: We conducted a cross-sectional analysis of the relationship between the IAC policy index score, and its components, and lifetime abstinence among adults (15+ years) in 13 high and middle-income jurisdictions. We examined the correlations for each component of the index and stringency and impact separately. RESULTS: Overall, the total IAC policy index scores were positively correlated with lifetime abstinence (r = 0.76), as were both the stringency (r = 0.62) and impact (r = 0.82) scores. Marketing restrictions showed higher correlations with lifetime abstinence than other policy domains (r = 0.80), including restrictions on physical availability, pricing policies and drink-driving prevention. DISCUSSION AND CONCLUSION: Our findings suggest that restricting alcohol marketing could be an important policy for the protection of alcohol abstention. The IAC policy index may be a useful tool to benchmark the performance of alcohol policy in supporting alcohol abstention in high and middle-income countries.

Effectiveness of psychological interventions to reduce alcohol consumption among pregnant and postpartum women: a systematic review.

This study aims to synthesise the available evidence on psychological interventions to reduce alcohol consumption among pregnant and postpartum women. Six electronic databases were searched to identify controlled studies targeting pregnant and postpartum women who drink or are at risk of drinking due to previous patterns of alcohol use. Controlled quantitative studies such as randomised controlled trials and quasi-experimental studies were included. The search was limited to peer-reviewed articles in English. The methodological quality of studies was assessed using the Cochrane risk of bias tool. A narrative synthesis of the findings was conducted. In total, 12,610 records were screened, and 11 studies were eligible for inclusion (9 with pregnant women, 2 with postpartum women). All studies were randomised controlled trials. Five studies had positive or partially positive primary outcomes of reductions in drinking or abstinence, and their interventions ranged from multi-session brief interventions to self-help manuals based on cognitive behavioural components. All studies showed considerable methodological limitations. Psychological interventions may be effective in promoting abstinence or reducing alcohol consumption among pregnant and postpartum women. Interventions that demonstrated some efficacy showed higher level of engagement with pregnant women compared to studies which delivered interventions in a single session. Paucity of evidence, inconsistency of outcomes, large heterogeneity in the interventions and methodological weaknesses limit the ability to make final conclusions about the overall effectiveness of these interventions. Findings highlight the need for better quality research on this topic.

Psychological Distress During Pregnancy: Cross-Sectional Prevalence and Associated Risk Factors in a South African Sample.

The prevalence and risk factors associated with peripartum psychological distress-a unifying factor among common mental disorders (CMDs)-are not widely understood in underresourced settings. Cross-sectional data were collected from 664 pregnant women who reported for antenatal care at any of one of the 11 midwife and obstetrics units in Cape Town, South Africa. The prevalence of prepartum psychological distress was 38.6%. Associated factors included low socioeconomic status as measured by asset ownership (odds ratio [OR], 1.45; 95% CI, 1.24-1.68), recent physical abuse and/or rape (OR, 1.94; 95% CI, 1.57-2.40), complications during a previous birth (OR, 1.18; 95% CI, 1.01-1.38), and having given birth before (OR, 1.61; 95% CI, 1.21-2.14). The high prevalence of psychological distress is consistent with those found in other South African studies of peripartum CMDs. If effective context-specific interventions are to be appropriately designed, closer investigation of a broader symptomology associated with peripartum CMDs in these settings is warranted.

South African service users' perceptions of patient-reported outcome and experience measures for adolescent substance use treatment: A qualitative study.

INTRODUCTION AND AIMS: Patient-reported outcome measures (PROM) and experience measures (PREM) for substance use disorder (SUD) treatment exist for adults but have unknown relevance for adolescents. This study aimed to explore adolescents' perceptions of effective SUD treatment and possible barriers to completing PROMs and PREMs to guide efforts to adapt the South African Addiction Treatment Services Assessment (SAATSA) for adolescents. DESIGN AND METHODS: Five focus groups were conducted with 38 adolescent service users recruited from residential and outpatient SUD treatment facilities in South Africa. Group discussions explored perceptions of treatment components necessary for desired SUD treatment outcomes, treatment experiences that support engagement in care, and perceptions of PROM and PREM completion. RESULTS: Participants viewed treatment elements that enhance motivation for change, coping and emotional regulation; provide recreational alternatives to substance use; and improve family relationships and home environments as critical to positive treatment outcomes. They reflected that provider characteristics and developmentally and culturally appropriate services facilitated engagement in treatment. PROM and PREM completion seemed acceptable, with participants suggesting ways to enhance their appeal. DISCUSSION AND CONCLUSION: Findings confirm that adult-oriented PROMs and PREMs require adaptation for adolescents. Service user inputs identified ways to expand the content of the SAATSA to better reflect adolescents' treatment priorities. These inputs have also guided changes to item formulation and administration procedures to enhance the SAATSA's acceptability for adolescents. Ensuring the SAATSA addresses treatment outcomes and experiences that matter to adolescents is vital for generating information to guide improvements to adolescent SUD services.

A Mixed-Methods Evaluation of the Implementation of a Performance Measurement System for South Africa's Substance Use Treatment Services.

OBJECTIVE: Minimal knowledge exists on the factors that affect implementation of performance measurement systems, particularly in low- and middle-income countries (LMICs). To address this, we describe the implementation of a performance measurement system for South Africa's substance abuse treatment services known as the Service Quality Measures (SQM) initiative. METHOD: We conducted a mixed-methods evaluation of system implementation. We surveyed 81 providers about the extent of system implementation within their agencies and the factors that facilitated implementation. We conducted 26 in-depth interviews of providers' perceived barriers and facilitators to implementation. RESULTS: The overall penetration of this system was high. Almost all providers viewed the system as feasible to implement, acceptable, appropriate for use in their context, and useful for guiding service improvements. However, the extent of implementation varied significantly across sites (p < .05). Leadership support (p < .05) was associated with increased implementation in multivariable analyses. Providers reflected that high rates of patient attrition, variability in willingness to implement the system, and limited capacity for interpreting performance feedback affected the extent of system implementation. CONCLUSIONS: It is feasible to implement a performance measurement system in LMICs if the system is acceptable, appropriate, and useful to providers. To ensure the utility of this system for treatment service strengthening, system implementation must be optimized. Efforts to enhance target population coverage, strengthen leadership support for performance measurement, and build capacity for performance feedback utilization may enhance the implementation of this performance measurement system.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative.

BACKGROUND: Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC. METHOD: We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit. RESULTS: Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit. CONCLUSION: Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

The Alcohol Environment Protocol: A new tool for alcohol policy.

INTRODUCTION AND AIM: To report data on the implementation of alcohol policies regarding availability and marketing, and drink driving, along with ratings of enforcement from two small high-income to three high-middle income countries, and one low-middle income country. METHOD: This study uses the Alcohol Environment Protocol, an International Alcohol Control study research tool, which documents the alcohol policy environment by standardised collection of data from administrative sources, observational studies and interviews with key informants to allow for cross-country comparison and change over time. RESULTS: All countries showed adoption to varying extents of key effective policy approaches outlined in the World Health Organization Global Strategy to Reduce the Harmful Use of Alcohol (2010). High-income countries were more likely to allocate resources to enforcement. However, where enforcement and implementation were high, policy on availability was fairly liberal. Key Informants judged alcohol to be very available in both high- and middle-income countries, reflecting liberal policy in the former and less implementation and enforcement and informal (unlicensed) sale of alcohol in the latter. Marketing was largely unrestricted in all countries and while drink-driving legislation was in place, it was less well enforced in middle-income countries. CONCLUSION: In countries with fewer resources, alcohol policies are less effective because of lack of implementation and enforcement and, in the case of marketing, lack of regulation. This has implications for the increase in consumption taking place as a result of the expanding distribution and marketing of commercial alcohol and consequent increases in alcohol-related harm.

Providers' perceptions of the implementation of a performance measurement system for substance abuse treatment: A process evaluation of the Service Quality Measures initiative.

BACKGROUND: In South Africa, concerns exist about the quality of substance abuse treatment. We developed a performance measurement system, known as the Service Quality Measures (SQM) initiative, to monitor the quality of treatment and assess efforts to improve quality of care. In 2014, the SQM system was implemented at six treatment sites to evaluate how implementation protocols could be improved in preparation for wider roll-out. OBJECTIVE: To describe providers' perceptions of the feasibility and acceptability of implementing the SQM system, including barriers to and facilitators of implementation. METHODS: We conducted 15 in-depth interviews (IDIs) with treatment providers from six treatment sites (two sites in KwaZulu-Natal and four in the Western Cape). Providers were asked about their experiences in implementing the system, the perceived feasibility of the system, and barriers to implementation. All IDIs were audio-recorded and transcribed verbatim. A framework approach was used to analyse the data. RESULTS: Providers reported that the SQM system was feasible to implement and acceptable to patients and providers. Issues identified through the IDIs included a perceived lack of clarity about sequencing of key elements in the implementation of the SQM system, questions on integration of the system into clinical care pathways, difficulties in tracking patients through the system, and concerns about maximising patient participation in the process. CONCLUSION: Findings suggest that the SQM system is feasible to implement and acceptable to providers, but that some refinements to the implementation protocols are needed to maximise patient participation and the likelihood of sustained implementation.