Methods
Setting and Context
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Feedback (personally relevant)
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Responsibility (helping people realize their need for change and that they have choices related to their substance use and behaviors)
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Advice (provision of clear advice to reduce harm from continued use, delivered in a non-judgmental manner)
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Menu of option (suggesting a range of strategies)
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Empathy
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Self-efficacy (eliciting strengths and capacity to change)
RCT Design and Procedures
RCT Participants’ Recruitment
Statistical Analyses
Qualitative Methods and Analyses
Results
RCT Participants
Public | Private | ||||||
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Variable | Fb + BI | Fb | p | Fb + BI | Fb | p | |
Gender (n (%)) | Male | 311(49.9) | 312(50.1) | 0.814 | 245(49.1) | 254(50.9) | 0.430 |
Female | 29(48.3) | 31(51.7) | 10(58.8) | 7(41.2) | |||
Wealth index quintile (n (%)) | 1 poorest | 86(54.1) | 73(45.9) | 0.042a | 49(47.1) | 55(52.9) | 0.770 |
2 | 117(49.0) | 122(51.0) | 54(53.5) | 47(46.5) | |||
3 | 62(55.9) | 49(44.1) | 51(47.7) | 56(52.3) | |||
4 | 8(26.7) | 22(73.3) | 65(52.0) | 60(48.0) | |||
5 richest | 67(46.5) | 77(53.5) | 36(45.6) | 43(54.4) | |||
Employment status (n (%)) | Self-employed | 97(44.5) | 121(55.5) | 0.166 | 47(46.1) | 55(53.9) | 0.644 |
Casual labor | 116(49.8) | 117(50.2) | 33(45.2) | 40(54.8) | |||
Employed | 69(53.1) | 61(46.9) | 157(51.5) | 148(48.5) | |||
Unemployed | 57(57.0) | 43(43.0) | 16(53.3) | 14(46.7) | |||
Marital status (n (%)) | Ever married | 258(51.1) | 247(48.9) | 0.330 | 219(51.9) | 203(48.1) | 0.020a |
Single (never married) | 80(46.8) | 91(53.2) | 35(38.5) | 56(61.5) | |||
Education level completed (n (%)) | Primary and below | 183(50.4) | 180(49.6) | 0.827 | 54(52.4) | 49(47.6) | 0.799 |
Secondary | 111(47.8) | 121(52.2) | 135(48.6) | 143(51.4) | |||
Tertiary | 27(50.0) | 27(50.0) | 52(49.5) | 53(50.5) | |||
Household size (n; mean ± SD) | 5.3 ± 3.5 | 5.0 ± 3.3 | 0.253 | 4.0 ± 2.4 | 3.7 ± 2.2 | 0.081 | |
Age (years; mean ± SD) | 38.5 ± 13.5 | 37.8 ± 12.4 | 0.455 | 37.8 ± 10.2 | 35.7 ± 9.9 | 0.016a | |
Alcohol intake t0 (g; mean ± SD) | 422.8 ± 609.5 | 406.7 ± 514.0 | 0.709 | 416.2 ± 470.3 | 326.4 ± 413.5 | 0.022a |
Changes in Alcohol Consumption over Time
Treatment allocation | Time | Paired Mean Decrease (g) | t | p | ||
---|---|---|---|---|---|---|
Mean | SE | 95% CI | ||||
Public facilities | ||||||
Fb + BI | Baseline to 1 month | 208.0 | 36.4 | (136.3; 279.7) | 5.7 | < 0.001a |
1 to 3 months | 52.0 | 22.0 | (8.7; 95.3) | 2.4 | 0.019a | |
3 to 6 months | 81.6 | 15.8 | (50.6; 112.7) | 5.2 | < 0.001a | |
Fb | Baseline to 1 month | 160.5 | 31.8 | (98.0; 222.9) | 5.1 | < 0.001a |
1 to 3 months | 30.7 | 28.9 | (− 26.1; 87.6) | 1.1 | 0.289 | |
3 to 6 months | 118.4 | 26.7 | (65.8; 171.0) | 4.4 | < 0.001a | |
Private facilities | ||||||
Fb + BI | Baseline to 1 month | 257.5 | 26.3 | (205.7; 309.4) | 9.8 | < 0.001a |
1 to 3 months | 60.2 | 11.6 | (37.4; 83.0) | 5.2 | < 0.001a | |
3 to 6 months | − 3.6 | 9.2 | (− 21.7; 14.5) | − 0.4 | 0.696 | |
Fb | Baseline to 1 month | 176.3 | 22.1 | (132.7; 219.9) | 8.0 | < 0.001a |
1 to 3 months | 32.2 | 11.8 | (9.0; 55.4) | 2.7 | 0.007a | |
3 to 6 months | 27.9 | 9.0 | (10.2; 45.7) | 3.1 | 0.002a |
Time | Treatment allocation | Mean (g) | SD | t | df | p |
---|---|---|---|---|---|---|
Public facilities | ||||||
Baseline | Fb + BI | 422.8 | 609.5 | 0.37 | 681 | 0.709 |
Fb | 406.7 | 514.0 | ||||
1 month | Fb + BI | 214.8 | 323.4 | -1.29 | 681 | 0.196 |
Fb | 246.2 | 311.4 | ||||
3 months | Fb + BI | 162.7 | 296.5 | -1.64 | 681 | 0.102 |
Fb | 215.4 | 515.7 | ||||
6 months | Fb + BI | 81.1 | 137.6 | -1.32 | 681 | 0.189 |
Fb | 97.0 | 176.2 | ||||
Private facilities | ||||||
Baseline | Fb + BI | 416.2 | 470.3 | 2.306 | 514 | 0.022a |
Fb | 326.4 | 413.5 | ||||
1 month | Fb + BI | 158.7 | 204.2 | 0.490 | 514 | 0.624 |
Fb | 150.1 | 194.0 | ||||
3 months | Fb + BI | 98.5 | 130.0 | -1.702 | 514 | 0.089 |
Fb | 117.9 | 129.2 | ||||
6 months | Fb + BI | 102.1 | 145.1 | 1.076 | 514 | 0.283 |
Fb | 90.0 | 108.2 |
Variable | Category | Public | Private | ||||||||
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β | S.E | 95% confidence interval | p | β | S.E | 95% confidence interval | p | ||||
Lower | Upper | Lower | Upper | ||||||||
Treatment allocation | Fb + BI | 9.54 | 47.51 | − 83.58 | 102.66 | 0.841a | 74.81 | 42.5 | − 8.47 | 158.09 | 0.078 |
Fb | Ref | Ref | |||||||||
Gender | Male | 48.75 | 20.20 | 9.17 | 88.34 | 0.016a | 104.31 | 32.1 | 41.43 | 167.20 | 0.001a |
Female | Ref | Ref | |||||||||
Wealth index quintiles | 1 poorest | − 66.22 | 22.18 | − 109.69 | − 22.74 | 0.003a | 46.49 | 23.4 | 0.64 | 92.34 | 0.047a |
2 | − 28.69 | 23.19 | − 74.15 | 16.77 | 0.216 | 53.21 | 20.1 | 13.82 | 92.60 | 0.008a | |
3 | 22.89 | 28.03 | − 32.04 | 77.83 | 0.414 | 90.02 | 23.5 | 43.92 | 136.13 | 0.000a | |
4 | 78.62 | 84.54 | − 87.08 | 244.33 | 0.352 | 26.55 | 17.5 | − 7.68 | 60.77 | 0.128 | |
5 richest | Ref | Ref | |||||||||
Employment status | Self-employed | 20.71 | 25.15 | − 28.58 | 70.00 | 0.410 | − 54.83 | 53.2 | − 159.06 | 49.40 | 0.303 |
Casual labor | 51.47 | 24.90 | 2.67 | 100.26 | 0.039a | − 28.00 | 58.7 | − 143.00 | 87.00 | 0.633 | |
Employed | 29.88 | 26.52 | − 22.09 | 81.85 | 0.260 | − 96.65 | 51.8 | − 198.20 | 4.90 | 0.062 | |
Unemployed | Ref | Ref | |||||||||
Marital status | Ever married | 16.61 | 22.46 | − 27.40 | 60.63 | 0.459 | 72.37 | 23.5 | 26.38 | 118.35 | 0.002a |
Single | Ref | Ref | |||||||||
Education level completed | Primary or less | 1.47 | 33.28 | − 63.75 | 66.69 | 0.965 | 35.97 | 27.4 | − 17.76 | 89.71 | 0.189 |
Secondary | − 19.54 | 32.91 | − 84.05 | 44.96 | 0.553 | − 8.03 | 18.3 | − 43.95 | 27.90 | 0.661 | |
Tertiary | Ref | Ref | |||||||||
Household size | − 5.73 | 2.08 | − 9.81 | − 1.65 | 0.006a | − 0.77 | 3.5 | − 7.56 | 6.01 | 0.823 | |
Age (years) | − 0.29 | 0.74 | − 1.75 | 1.16 | 0.691 | − 3.30 | 1.0 | − 5.18 | − 1.41 | 0.001a | |
Time | − 97.83 | 9.73 | − 116.90 | − 78.75 | < 0.001a | − 72.04 | 8.4 | − 88.47 | − 55.61 | < 0.001a | |
Fb + BI*Time | − 11.00 | 14.88 | − 40.16 | 18.16 | 0.460 | − 21.31 | 12.2 | − 45.29 | 2.67 | 0.082 | |
Fb*Time | Ref | Ref |
Participating Facilities and Health Workers
Number of participants | |||
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RCT participants | Male | Female | Total |
Public facilities, county 1 | 19 | 20 | 39 |
FGD men, Fb + BI | 9 | ||
FGD men, Fb | 10 | ||
FGD women, Fb + BI | 10 | ||
FGD women, Fb | 11 | ||
Public facilities, county 2 | 23 | 4 | 27 |
FGD men, Fb + BI | 11 | ||
FGD men, Fb | 12 | ||
KIIs woman, Fb + BI | 2 | ||
KIIs woman, Fb | 2 | ||
Private facilities | 19 | ||
FGD men, Fb + BI | 11 | ||
FGD men, Fb | 8 | ||
Total | 49 | 37 | 86 |
Healthcare workers | |||
County 1 (5 facilities) | |||
FGD clinicians | 3 | 5 | |
FGD screeners | 2 | 6 | |
KII clinician | 1 | 1 | |
County 2 (3 facilities) | |||
FGD clinicians (3) and screeners (5) | 2 | 6 | |
Private facilities (2 facilities) | |||
FGD clinicians (2) and screeners (2) | 3 | 1 | |
KII clinician | 1 | ||
Total | 11 | 20 | 31 |
Grand total | 60 | 57 | 117 |
Qualitative Findings
RCT participants |
“…when I met these people, they explained to me, they gave me papers to go and study from home. They also asked me to come after a month. I was asked if I read the papers, and I was asked whether I had reformed, and I told them I will reform with time… With alcohol, I stopped at once… They told me the dangers of alcohol, and I saw it… So, these counselling guys are like pastors who preach the word of God… Even my body, I feel like I am now healthy. Thank you very much.” FGD men, Fb, county 2 “It has changed and now [I] have stopped to drink completely.” FGD women, Fb, county 1 “I have learnt so much because now I can stay the whole day without going to drink. That is why I feel that [I] have improved very much. I also reach home early and find when food is still hot.” FGD men, Fb + BI, county 1 “So, the second time when they called me, I decided to reduce taking alcohol and as time went by, I stopped completely. … I just want this study to reach the whole of Kenya because I have seen its impacts on me.” FGD men, Fb + BI, county 2 “I have completely reduced for almost three months now. I have not even tasted alcohol.” KII women 2 Fb + BI, county 2 “I reduced my consumption of alcohol; I have actually almost dropped it.” FGD men Fb + BI private |
Healthcare workers |
“… you pass by and they are like, ‘he is the one who told us to stop taking alcohol.’ Can you see how we have changed?” FGD screeners, county 1 “They were coming for something else different, but after a few periods and also giving them the materials to go and read, it really helped … Actually like 90% of the patients returned and they used to say like, ‘I have quit.’ Even like today, you meet some of them in the street, they say doctor you helped me.” FGD clinicians, county 1 “At the health center, they appreciate your help for changing our community. The rate of taking alcohol has greatly changed… When we started the program, we had to teach them…Since then, those who appreciate the help have not stopped coming back for advice and help. 50%-60% were positive about the discussion and we are glad.” FGD clinicians and screeners, county 2 “I can say that this project has helped many in that some have reduced the consumption of alcohol while others have completely stopped.” FGD clinicians and screeners, county 2 “… they would say thank you for introducing us to the study, so the attitude changed. They have also reduced taking substances. Some of the patients we met at first, they look different; they are different people after the exercise. I believe it is an exercise that has brought changes even at their families. There are some who now bring their friends for the same thing.” FGD clinicians and screeners, private “So, with the brief intervention, patients were able to stop or reduce substance abuse and we could see an improvement in their health. That is an important issue because people who are living with HIV and using drugs are at a higher risk of dying as compared to those with HIV who are not using alcohol and other substances.” FGD clinicians and screeners, private “And they say [the patients] they really appreciate it, and it has been like two or three months and they have really cut down smoking, drinking. So, for some it really worked.” KII clinician 1, private |
Subtheme 2.A. New confidential, empathic services with decreased stigma, attracting patients |
RCT participants |
“I thank this clinic because it has helped me. When I was called for the first time, I refused, but when I entered to see the doctor, I did not expect the doctor to talk to me the way he did. He asked me questions so well about substances which I answered… So, the doctor talked to me so nicely…so I continued with the doctor’s advice until I stopped completely taking the substances.” FGD men, Fb, county 2 “if you saw the doctor, he was…someone whom you could confide with while talking to him. The whole team was also willing to help us and this encouraged us to feel comfortable.” FGD men, Fb, private “Even the doctors were ignoring me, but the way your team handled me, I decided to change.” FGD Men, Fb + BI, private "And the way they approached us, it didn’t seem like they could disclose that secret outside. So, I accepted, and they proved my gut feelings right.” FGD women, Fb, county 1 “Yes, because I was asked questions in a private room. Even if someone else came into the room, they could wait and pause first until the person left, then we could continue. She even told me that I should be transparent so that we can help each other. I see them as helpful people and they did it very well and my privacy was kept.” FGD men, Fb + BI, county 2 “I believed them, because one, they called me alone, second, they were people who were talking politely and third I found them to be people who would keep secrets.” FGD women, Fb + BI, county 2 |
Healthcare workers |
“I would say there is great attitude change because, am not bragging because I am from M…but you could see patients coming all the way from W and X…when you ask why they have travelled so far to come here…they say that they are well received here, we handle them well and that we understand them. We don’t judge them… We have a big turn up at the hospital, and it is because of mind and attitude change towards the patient.” FGD clinicians, county 1 “Yeah, the stigma is decreasing because, if I take an example of a facility here before this program came into being, whenever we got maybe a patient who is drunk, then you would find that the treatment was not so nice. Maybe most of the people would think he is an intruder within the institution; he is a troublemaker. … so, they are not given equal treatments compared to the other clients who are coming to seek treatment.” KII clinician 1, county 1 “At first, I can say there was stigma, even you could see a client, him just rush away. We don’t want to see mental people but, in the process, they came, they realized we are there to help them. So, we became friends, and the screening was so much easier than at the beginning” FGD screeners, county 1 “To us, it is an added advantage to associate with the less fortunate in the society. The name of the hospital becomes raised and kind of famous. More people are now coming to the hospital, and when they leave, they are happy.” FGD clinicians and screeners, county 2 “Men were always open, and after visiting, they could come back with their friends.” FGD clinicians and screeners, county 2 “We also changed our personal attitudes towards SUD patients, unlike the way we looked at them as failures before we were trained.” FGD of clinicians and screeners, private; with the group signifying general agreement afterward “for some, they actually bring their relatives, because you see you actually had that impact in the society, so you see some of the clients actually came back with their relatives” KII clinician, private |
Subtheme 2.B. Provision of other ASSIST-linked BI FRAMES components 2.B.i. Feedback, responsibility and advice elements |
Healthcare workers |
“Like this part where you come to discover so many people are in the drinking team because they have never been told, they don’t have the knowledge at hand. They are not aware…you know it’s like there are no counselors… You find that at least with this knowledge, if everybody else is aware about this, they will involve themselves in other activities like football or some other income-generating projects.” FGD screener, county 1 “They realized that some S.U.D has led them to such grievous deeds and they started thinking about their lives.” FGD clinicians, county 1 “From my understanding, the danger of taking alcohol has been discussed openly and we have shared with the clients positively.” FGD clinicians and screeners, county 2 “…we educated them on the benefits and why they need to go through the system and once they were discovered to have this disorder, we would see what we can do to help them to complete the process.” A screener from the FGD clinicians and screeners, private |
RCT participants |
“When I was told about my score, I felt good because I accepted that state, and got to realize that I needed help. It was not something that I could be happy about, but those results were good because they made me to accept and decide that I needed to change.” FGD men, Fb, county 1 “I understood that the more you continue to drink excessively is the more you continue to spoil things like your liver” FGD women, Fb, county 1 “They told me the dangers of alcohol and I saw it. I even used to insult my wife while drunk, but right now, it is like I got saved. I am peaceful at home.” FGD men, Fb, county 2 “The information was adequate because it helped me a lot… I have learnt that alcohol is not good because it will influence someone to do bad things which might lead to family breakups.” KII Women 1 Fb County 2 “First of all, we were taught on that substance use is not a good thing and the moment you continue using them, they will affect your health.” FGD men, Fb, private “I also felt bad because nobody has been buying these substances for me, I have been buying them for myself and I felt like my money has wasted me. So, that score really hurt me and what I have been doing to myself.” FGD men, Fb, private “What I learnt is that when I am under the influence of drugs, I will not make a good decision. But when I am sober, even if I don’t make a decision, I will still be ok.” FGD men, Fb, private “So, the counseling helped me a lot… This worked out so well. He told me the consequences of alcohol consumption and how it affected me and my family.” FGD men Fb + BI, county 2 “My score is what made me to change…that is when I saw the need to change. For one, I found that I was almost beyond life. I decided to change… Even the doctors were ignoring me, but the way your team handled me, I decided to change.” FGD men, Fb + BI, private “Yes, that was the start of knowing myself. It is like I did not know about myself, but after sitting down with these people and after they gave me my score, that is the time I realized how far the substances I have been using had ruined me. So that was my turning point… the more teachings I got, the more I decided to change.” FGD men, Fb + BI, private |
2.B.ii. Use of the menu of option FRAMES component to decrease harm from alcohol use |
RCT participants |
“It made me to limit my things even when I go out. I know that when it reaches eleven, I know that am supposed to go home.” FGD women, Fb, county 1 — changing the timing of the drinking, reducing harm “You know us, we call it “Kitindo” meaning when you stay with drunkards all the time, you will be influenced to go back to drinking. So, I have decided not to keep such companies now.” KII women 1, Fb, county 2 — changing social network “You see, if you are idle, you will go to drinking, but if you are busy, you will not.” FGD men, Fb, county 2 — occupy oneself “again, like my parents were so impressed with this study and when they started seeing the changes in me, they were more than willing to give me transport whenever I wanted to go for follow-ups, they were even wondering if they could rent an apartment for me near the hospital… (all laughing).” FGD men, Fb, private — support from loved ones “I am also too busy with my life which was so messy. I do my general cleaning over the weekend; I can visit my family and parents and I can get to work at the right time.” FGD men, Fb, private — finding activities to occupy oneself “Avoiding bad companies.” FGD men, Fb, private — changing social network “Those things of going to the bar and buy beer for everybody, even spending the money that was supposed to be for the children, have stopped. Like he has said, the best thing is we avoid going to those places.” FGD men, Fb + BI, county 1 — avoiding triggering locations, different use of money “I go home straight, and if am unable to go, I call him and he comes to fetch me.” FGD women, Fb + BI, county 1 — avoiding triggering locations, getting support from loved ones “It means being busy in groups, meetings and work. Not coming from work and then you just sit until you start thinking ‘let me go and do one two with friends. When you come from work, you have your own programs, to maybe do this and that or attend meetings, then come back… keep myself busy because if you stay idle, you can easily fall back there.” FGD women, Fb + BI, county 1 — finding activities to occupy oneself “I have completely stopped. I even meet with my friends who we used to drink together, and they ask me, “so can I buy you one today,” and I say I am saved… The third thing is I dropped all my friends who we used to drink with.” KII women 1, Fb + BI, county 2 — refusing offers to drink, changing social network “Keeping myself busy always, if I am not at the market am at home washing clothes or at the farm digging, as in making sure I am occupied every minute of the day.” KII women 2, Fb + BI, county 2 — finding activities to occupy oneself instead of drinking “So, to me shortly I can say that what I learnt is about…the first day I met with your doctor, he told me a simple term that "bad company collapses good morals". He told me so. He told me that I am very young, and he asked me to put what he had told me in mind. That encouraged me to learn more. Next, I learnt to be soft and giving people who surround me respect.” FGD men, Fb + BI, private — changing social network “Avoiding bad companies.” FGD men, Fb + BI, private — changing social network “Just to keep myself busy, like by watching movies.” FGD men, Fb + BI, private — finding activities to occupy oneself other than drinking |
Subtheme 2.B.iii. Self-efficacy |
RCT participants |
“I used to be so drunk and even used to sleep outside in the marketplace. They also gave me soaps and it helped me because I never used to do washing or even wash my children’s clothes, I used to be so dirty. I also never used to cook for my children. I was so bad. Even my body was unhealthy; I can’t even tell you how I looked like. But right now, I can do everything.” KII women 1, Fb, county 2 “Initially, I could not even educate my children well, but right now, I can see my expectation is getting met because of the counseling I have received. I was advised to stop taking alcohol and I did. I have my projects such as chicken, cows, something that I never used to do before. So, I thank this study.” FGD men, Fb, county 2 “It has helped my family relationship with my wife and children. Also, my body is healthy now. I can say that I thank you so much because now I have a vision with my life.” FGD men, Fb, county 2 “My expectations were that if I go there, at least I can be accountable and responsible in using my money and this is something that I can see has changed and helped me in my life.” FGD men, Fb, private “I was very happy to be interviewed and asked questions about alcohol, cigarettes, and after that, I managed to stay for one week without drinking and also reduced smoking by smoking two cigarettes. That gave me the moral to continue, and I saw that if I continue like that, I can someday be able to stop all these things” FGD men, Fb + BI, county 1 “You also start liking yourself you know if you are an addict it reaches a point that you lose your self-esteem, you hate yourself so, if it is positive after the change you start loving yourself and start seeing yourself like somebody” FGD women, Fb + BI, county 1 “But after these services came and I got the knowledge, I started reducing, especially drinking in the morning. It was difficult, but I just told myself to try my best and do it.” FGD men, Fb + BI, county 1 “Yes, the more teachings I got, the more I decided to change. There is a time I came and my results had improved and this made me feel that I was doing well. So, to me, the attitude went on changing with time.” FGD men, Fb + BI, private “I came to realize that alcohol is not porridge; you don’t just drink just like porridge that is getting finished. Breweries are busy making more alcohol. So, I learnt how to control myself, and even if I consume alcohol, I now know the amount that will not affect my brain or my lifestyle… So, I have learnt that if someone decided not to take something, they can achieve it.” FGD men, Fb, private “I learnt that if someone cannot do anything, it doesn’t mean that myself I cannot as well do anything. Or if someone else cannot stop drinking, that does not mean that I cannot stop drinking.” FGD Men Fb + BI Private “Yes, and if someone decides to stop them, it is not too late. Even if someone is an addict, it is not too late.” FGD men, Fb, private |
Subtheme C: HCWs personal motivation to learn and help those affected by alcohol use |
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“I personally I have a personal motivation. I have a brother who is a drinker or he takes alcohol and I really felt for him and I wanted to assist him with the whole family, so I wanted to learn more about how to go about his thing so that I can apply the knowledge” FGD screeners, county 1 |
“Yeah to me, I wanted to acquire knowledge to help my community because surely in my community, we have many people who are drunk. So, I wanted to acquire that knowledge so that I can go talk about it.” FGD screeners, county 1 |
“Mine like now I have a friend who uses drugs and my interest is like when we are learning about substance abuse, I was interested to apply the knowledge I have acquired in practice support and substance abuse and then I put it into practice to help the family members and the entire community to change their lifestyle.” FGD screeners, county 1 |
“I am very happy about it since I have the knowledge and I can be able to share with the community. Through sharing, which could happen when I attend church meetings, I am able to assist both the young and older people. The other day I was at K. and was talking to around 300 youths and they had a lot of questions, and I am very pleased about the knowledge I have acquired through training and I feel I have a lot of confidence.” KII clinician 2, county 1 |
“Let’s say when we are here in the hospital, they believe in us according to the relationship we have outside the hospital. When in the hospital, we interact with many people and happen to socialize with them. That is an added advantage especially to the screeners because we don ‘t come from far, so those who meet with during the screening are our dear people.” FGD clinicians and screeners, county 2 |
“We appreciate the knowledge because we can now handle the drunkards in a well-known manner.” FGD clinicians and screeners, county 2 |
“Overall, we gained education or knowledge gain, experience with dealing with SUD patients and we were able to intervene on these clients and I think the core objective we achieved.” FGD clinicians and screeners, private |
“Ok, let me start with the community, the patients and the clients for them—they always see you as someone who is helping them, then the most encouraging thing to them is that they see like you are putting more effort in helping. Some actually say you helped my family because now I would be drowning somewhere else, some come with their spouse and they say you really had an impact on him and they are like we have tried this and this at home, but it hadn’t worked but with the knowledge from the hospital and that kind of a thing. Some are really grateful, and they see you as a counsellor or that kind of a thing, so others are really open and they come and share their stories with you.” KII clinician, private |
“Some of these people are our family, friends and whenever we meet, someone has a smile on the face, they can shake your hand and tell you oh… I reduced taking the substances actually, that thing was helping and so on. So, there was a general health improvement.” FGD clinicians and screeners, private |
“Yes, a lot, most people see us as the most educated, even with our colleagues here, they see us as people with extra knowledge.” FGD clinicians and screeners, private |
Subtheme 4.A. Repeated assessments by research staff, with some supporting RCT participants |
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RCT participants |
“…and then she forwarded me to the research assistants who talked to me and advised me on drugs.” KII women 2, Fb, county 2 “even when they meet me on the road, they advise me, ask me to read the papers. Up to date, they advise me and even gave me soaps. I thank you so much” FGD men, Fb, county 2 “They were organized in that after the screening, they took us to the research assistant who even showed us the doctors who may help us, and if you saw the doctor, he was a clean person and someone whom you could confide with while talking to him. The whole team were also willing to help us and this encouraged us to feel comfortable.” FGD men, Fb, private “The whole team were also willing to help us and this encouraged us to feel comfortable.” FGD men, Fb, private “No, there were times I would even come without being told to come and I wouldn’t even call them [the research staffs] and I would get them in the office. Then I would knock on the door and get in and say hi and time them I have come for lunch; we joke for a while and then I tell them that there is a question I wanted to ask and that’s why I have come and they would welcome me. So I would ask and they would explain to me well and I would feel satisfied, then they would ask me if I have been satisfied or not and I would tell them I am satisfied and if I am not I should hide it, I should tell them so that they can look for a solution.” KII women, Fb + BI, county 2 Facilitator (F): “So they were giving you advice well, and that’s why you kept coming.” Respondent (R): “Yeah, even when we meet at the roadside, we would talk well.” KII women 2, Fb + BI, county 2 “…there were times I would even come without being told to come, and I wouldn’t even call them [the research staffs], and I would get them in the office. Then I would knock on the door and get in and say hi… we joke for a while, and then I tell them that there is a question I wanted to ask and that’s why I have come, and they would welcome me. So I would ask, and they would explain to me well, and I would feel satisfied, if I am not I shouldn’t hide it, I should tell them so that they can look for a solution.” KII women 2, Fb + BI, county 2 |
Research staffs (field observation, with audio recording) |
“Facilitator (F): And when you were trying to encourage them to drink less, what were you doing to encourage them to drink less?…Or were you just asking them the question about how much they were drinking…? Respondent (R): Encouraging them to drink less to continuously drink less until they stop it.” RS county 1 “The community really accepted us, and people would bring their husbands they would cooperate and we would help them where we could.” RS county 1 “Okay, personally, I, yeah, it was satisfying. It was very satisfying to me when someone comes for follow up and they are very excited to see you to give you the good news how they've improved. Yeah, making friends. We also made friends from the people we recruited. Yeah. So yeah. Socially, my social skills also improved. Yeah.” RS county 2 “F: And did you feel participating in the project, changed your life in any way. R: Participating in the project changed my way in that I can talk to someone who is a drunkard and change him a bit. Yeah.” FGD RS county 2 “F:… and did it help you in any way for yourself to participate in this project? R: Yes, socializing and even talking to people to change their behaviors.” RS county 2 |
Theme 1. Meaningful Impact on Alcohol Use and Other Domains Reported by All Groups
Like before, I would say that I cannot watch a game without drinking, but right now, I can watch without any alcohol. Initially, it is like I cannot see drinks in a bar and just sit but nowadays, I can just sit next to them without touching. I am also too busy with my life which was so messy, I do my general cleaning over the weekend, I can visit my family and parents and I can get to work at the right time. (FGD men, Fb, private facilities)Since I was married, I had never had a child with my husband, that is why am saying it is very bad [alcohol]. We have stayed for long without me getting pregnant. I have been drinking a lot. After I joined this study, I stopped completely taking alcohol and I became pregnant immediately. This child I am holding here is as a result of this study… (FGD women, Fb+BI, county 1
Theme 2: Fundamental Shift in Knowledge, Attitude, and Practice by Health Worker
Subtheme 2.A. New Confidential, Empathic Services with Decreased Stigma, Attracting Patients
…you know that is something that is disturbing you, but you can't stop. So, if you find somebody that is willing to help you and is telling you that he is helping you and that the information is confidential, OK, you will feel uneasy at first, but if you see that it is helping you, then you become relaxed. (FGD men, Fb+BI, county 1)
I have gained knowledge and that knowledge is power… For example, my father used to take a lot of alcohol, and at one point, he happened to divorce my mother. So, I used to despise the people who take alcohol because a lot happened to me. When they come, I never attend to them... They could wait all day until another person comes in the afternoon shift to attend to them… After being mentored at Africa Mental, I discovered that these are people we can still take care of. At first, maybe it's because I didn't know how to approach them, I didn't know what to tell them, etc. Right now, I've learnt a lot and I know how to handle them better. (FGD clinicians and screeners, county 2)
I can say that there is a lot of change in the sense that like for instance, you find that me working in the facility, you find patients or clients coming in even when them they are not [from] around… I have seen it, so you will find that maybe some have been screened, others have heard it from their fellows who had been screened, you know, in the community. So, you find them bringing themselves, you know, to the facility. They want to know more. (FGD screeners, county 1)
Subtheme 2.B Provision of Other ASSIST-Linked BI FRAMES Components
If you realize someone is taking that, it is good to advise them on the consequences. Then you let them make the decision. (FGD screeners, county 1)
So, when I came here, I was just so happy, we talked and if there was anything to be shared, we did and they gave me advice. They told me the disadvantages of drugs and I saw there was not any advantage of taking alcohol. So, I can say they were ok. We talked as sisters and brothers. (KII woman, Fb, county 1 #2)
Like when I came for counselling, I think it was the second time the nurse that was attending to me, we were talking about things like self-esteem, how to stop hating yourself. She even helped me on how to be positive in life, so I started seeing myself as worthy and that I can also be somebody in life. (FGD women, Fb+BI, county 1)
Theme 3: Contributing Factors to Screeners Delivering the FRAMES Components of BIs
Subtheme 3.A. The ASSIST Tool Design
…feedback is the provision of personally relevant information which is pertinent to the client, and is delivered by the health worker in an objective way. ‘Much of the feedback given in an ASSIST-linked BI can be delivered by reading directly from the ASSIST feedback report card.’ (Humeniuk et al., 2010a)
Subtheme 3.B Opportunities for Screeners to Learn and Provide all the FRAMES Components
Also, the screening course trainees and the primary care management trainees frequently completed the training together, advancing through the module as a group in the different facilities. This exposed the trainees of the screening course to some of the primary care management modules. (FGD clinicians, county 1)
Subtheme 3.C. Health Workers Personal Motivation to Learn and Help Those Affected by Alcohol Use
Maybe I like learning new things, adding knowledge on what I have and also like he has said, our family many of them are drunkards, and I really wanted to help them. I have already started talking to some, and they have started dropping, not that they have dropped completely but at least. (FGD screeners, county 1)
Let’s say when we are here in the hospital, they believe in us according to the relationship we have outside the hospital. When in the hospital, we interact with many people and happen to socialize with them. That is an added advantage, especially to the screeners because we don‘t come from far, so those who meet with during the screening are our dear people. (FGD screeners, county 2)