Introduction
Methods
Study Design
Content of the eSBI
Introduction
Alcohol Screening Tool
Brief Intervention
eSBI Feedback Questions
Participant Enrollment
Data Collection
Quantitative Component
Qualitative Component
Data Analysis
Quantitative Component
Qualitative Component
Results
Quantitative Results
Katutura Health Centre (n = 373) | Oshakati Hospital (n = 396) | Total (n = 769) | |
---|---|---|---|
Age in years, mean ± SD | 40.2 ± 8.1 | 42.2 ± 10.7 | 41.2 ± 9.6 |
Sex | |||
Female | 193 (52%) | 254 (64%) | 447 (58%) |
Primary language | |||
Afrikaans | 23 (6%) | 0 (0%) | 23 (3%) |
English | 55 (15%) | 5 (1%) | 60 (8%) |
Oshiwambo | 295 (79%) | 391 (99%) | 686 (89%) |
Education | |||
No school | 64 (17%) | 50 (13%) | 114 (15%) |
Primary (grades 1–7) | 120 (32%) | 129 (33%) | 249 (32%) |
Secondary (grades 8–10) | 132 (35%) | 154 (39%) | 286 (37%) |
Secondary (grades 11–12) | 40 (11%) | 50 (13%) | 90 (12%) |
Tertiary or higher | 17 (5%) | 13 (3%) | 30 (4%) |
Marital status | |||
Single | 97 (26%) | 130 (33%) | 227 (30%) |
Relationship (not married) | 122 (33%) | 133 (34%) | 255 (33%) |
Married or living with partner | 138 (37%) | 109 (28%) | 247 (32%) |
Separated or divorced | 10 (3%) | 9 (2%) | 19 (2%) |
Widowed | 6 (2%) | 15 (4%) | 21 (3%) |
Employment status | |||
Employed | 202 (54%) | 116 (29%) | 318 (41%) |
Wages receiveda | |||
Daily | 8 (4%) | 12 (10%) | 20 (6%) |
Weekly | 9 (4%) | 4 (3%) | 13 (4%) |
Monthly | 185 (92%) | 99 (86%) | 284 (90%) |
Monthly household incomeb | |||
0 to 500 NAD | 132 (36%) | 251 (64%) | 383 (50%) |
501 to 1000 NAD | 102 (27%) | 82 (21%) | 184 (24%) |
1001 to 2500 NAD | 86 (23%) | 34 (9%) | 120 (16%) |
2501 to 5000 NAD | 37 (10%) | 18 (5%) | 55 (7%) |
> 5000 NAD | 14 (4%) | 8 (2%) | 22 (3%) |
On ART (past month) | |||
No | 12 (3%) | 6 (2%) | 18 (2%) |
Yes | 361 (97%) | 390 (98%) | 751 (98%) |
Self-reported ART adherence (past month)c | |||
Excellent | 213 (59%) | 272 (70%) | 485 (65%) |
Very good | 111 (31%) | 79 (20%) | 190 (25%) |
Good | 21 (6%) | 32 (8%) | 53 (7%) |
Fair | 13 (4%) | 5 (1%) | 18 (2%) |
Poor | 3 (1%) | 2 (1%) | 5 (1%) |
Classification | Definition | Katutura (n = 373) | Oshakati (n = 396) | Total (n = 769) |
---|---|---|---|---|
A. Risk level based on AUDIT score | ||||
Low risk | Score: 0–7 | 293 (79%) | 362 (91%) | 655 (85%) |
Medium risk | Score: 8–15 | 55 (15%) | 25 (6%) | 80 (10%) |
High risk | Score: 16–19 | 15 (4%) | 5 (1%) | 20 (3%) |
Dependent | Score: 20–40 | 10 (3%) | 4 (1%) | 14 (2%) |
B. Risk level based on specific answers to AUDIT questionsa | ||||
1. Non-drinker, no risk | Not currently drinking; no alcohol related injuries or others concerned about drinking | 145 (39%) | 201 (51%) | 346 (45%) |
2. Non-drinker, past or recent alcohol problem | Not currently drinking; past or recent alcohol related injuries or others concerned about drinking | 29 (8%) | 50 (13%) | 79 (10%) |
3. Low risk drinking | Currently drinking 1 or 2 drinks typically and never ≥ 6 drinks on one occasion | 72 (19%) | 76 (19%) | 148 (19%) |
4. Hazardous drinking | ≥ 3 drinks typically or ≥ 6 drinks on at least one occasion | 127 (34%) | 67 (17%) | 194 (25%) |
a. Alcohol dependence | Impaired control over drinking; increased salience of drinking; morning drinking | 94 (25%) | 44 (11%) | 138 (18%) |
b. Alcohol harm | Guilt after drinking; blackouts; alcohol-related injuries; others concerned about drinking | 90 (24%) | 48 (12%) | 138 (18%) |
Hazardous drinking | OR (95% CI) | |||
---|---|---|---|---|
No (n = 575) | Yes (n = 194) | Unadjusted | Adjusted | |
Age in years (mean ± SD) | 41.3 ± 9.8 | 41.1 ± 8.8 | 0.99 (0.98, 1.01) | – |
Site | ||||
Katutura | 246 (66%) | 127 (34%) | 1.00 | 1.00 |
Oshakati | 329 (83%) | 67 (17%) | 0.39 (0.28, 0.55) | 0.50 (0.35, 0.72) |
Sex | ||||
Male | 209 (65%) | 113 (35%) | 1.00 | 1.00 |
Female | 366 (82%) | 81 (18%) | 0.41 (0.29, 0.57) | 0.48 (0.34, 0.69) |
Education | ||||
No school | 88 (77%) | 26 (23%) | 1.00 | – |
Primary (grades 1–7) | 184 (74%) | 65 (26%) | 1.20 (0.71, 2.01) | – |
Secondary (grades 8–12) | 281 (75%) | 95 (25%) | 1.14 (0.70, 1.88) | – |
Tertiary or higher | 22 (73%) | 8 (27%) | 1.23 (0.49, 3.09) | – |
Marital status | ||||
Single | 179 (79%) | 48 (21%) | 1.00 | 1.00 |
Married/in a relationship | 371 (74%) | 131 (26%) | 1.32 (0.90, 1.92) | 1.04 (0.70, 1.56) |
Separated/divorced/widowed | 25 (63%) | 15 (38%) | 2.24 (1.09, 4.57) | 2.27 (1.04, 4.96) |
Employment status | ||||
Unemployed | 361 (80%) | 90 (20%) | 1.00 | – |
Employed | 214 (67%) | 104 (33%) | 1.94 (1.40, 2.71) | – |
Monthly household incomea | ||||
0 to 500 NADb | 314 (82%) | 69 (18%) | 1.00 | 1.00 |
501 to 1000 NAD | 133 (72%) | 51 (28%) | 1.75 (1.15, 2.64) | 1.38 (0.89, 2.15) |
> 1000 NAD | 123 (62%) | 74 (38%) | 2.74 (1.86, 4.04) | 1.86 (1.21, 2.85) |
Past month ART adherencec | ||||
Excellent | 385 (79%) | 100 (21%) | 1.00 | 1.00 |
Less than excellent | 179 (67%) | 87 (33%) | 1.87 (1.34, 2.62) | 1.70 (1.19, 2.43) |
Timing of eSBI and Feedback Questions
Feedback statement | Mean (SD) |
---|---|
1. “I thought the computer program was easy to use” | 1.27 (0.70) |
2. “I felt comfortable using this computer program” | 1.34 (0.82) |
3. “The computer program was too long” | 2.04 (1.40) |
4. “I found this computer program helpful” | 1.28 (0.69) |
5. “The information I received will help me limit my alcohol use” | 1.33 (0.83) |
6. “I would use this computer program again” | 1.36 (0.81) |
7. “I would rather use this computer program than speak to the doctor or health worker about my drinking” | 1.41 (0.91) |
8. “I answered the questions more honestly than I would have if I had been speaking with a doctor or a health worker” | 1.32 (0.75) |
Qualitative Results
Interviews with Study Participants
Program Usability
“It was difficult in the beginning but the interviewer helped me…the computer sometimes I press but nothing changes”—Katutura, female, 45 years old
most found the eSBI easy to navigate and liked the questions, advice, and pictures:“The second part was difficult because the questions were being repeated a lot”—Oshakati, female, 44 years old
“It was easy to learn”—Katutura, male, 27 years old
“The one speaking in the computer explained it well. She made it very easy to use”—Katutura, female, 42 years old
“I understood the questions and teachings. The explanations were good”—Oshakati, male, 54 years old
“The pictures were very clear and show reality”—Katutura, female, 45 years old
A substantial minority of participants interviewed felt that the eSBI program was too long.“Yes, it was a great joy for me to watch the pictures in the video. I learned a lot”—Oshakati, female, 40 years old
Progam Effects
“It showed me that if I keep drinking, my medicine will not work”—Katutura, male, 46 years old
“It has taught me about the dangers of consuming [alcohol] whilst on ARV treatment”—Katutura, female, 45 years old
Some participants indicated following the advice given to them by the eSBI program:“It touched me a lot. When a person is drinking alcohol you always forget to drink your medicine”—Oshakati, female, 40 years old
Examples of specific advice used by participants included:“I used the advice, mostly because it [drinking] could lead to drug resistance and treatment will fail”.—Katutura, male, 27 years old
“I stopped staying with friends who drink”—Oshakati, female, 40 years old
“I left all my bad friends, yes I learned a lot from the advice I received from the computer”—Oshakati, female, 36 years old
Among those that reported alcohol use, many reported changing their alcohol behavior since participating in the eSBI program.“I keep myself busy with other things, because I want to take better care of myself. I had to reduce [my alcohol intake]”—Katutura, female, 45 years old
“It changed me because I don’t think of alcohol any more…and it’s all because of the program”—Katutura, male, 27 years old
“Yes, alcohol touched my life, but now that I changed I see a difference in my life”—Katutura, female, 36 years old
“I stopped drinking. My life changed and I am grateful”—Oshakati, female, 23 years old
Progam Acceptability
“The first time was very difficult because I was afraid”—Oshakati, female, 48 years old
We only received a few suggestions from patients on how to improve the eSBI program, including making it shorter, providing it to all patients at the ART sites, and using tablets instead of laptop computers.“It was difficult, I was afraid of the questions. I became happy because of the advice it added to what I know already”—Oshakati, female, 40 years old
FGD’s with Providers
Perceived Benefits of the eSBI Program
“The patients who were interviewed I think they gave feedback to others who were not randomly selected…those not selected would come contacting us to ask when they would be interviewed. I think it was a positive program because if someone is engaged in something and they give positive feedback, then others like the idea of the program and even decided or came to the level of contacting the health workers to ask when am I going to be interviewed, and you have to explain that it’s not done to everyone.”—Oshakati, P5
Also in Oshakati, providers felt that the eSBI program was beneficial to them as providers because it was adding to the alcohol counseling they were already providing to the patients and would help them to identify patients for increased monitoring and TB treatment.“The positive was people asking to also get interviewed on alcohol because maybe there are some good things I can learn from it.”—Oshakati, P3
“We are already screening our patients when they come for consultation, and during the ongoing morning session, alcohol is one of the topics being touched, so I think adding this program… will help reduce the alcohol consumption and that will lead patients to be able to adhere and they will take their medication correctly at the right time.”—Oshakati, P5
“If you are screening a patient and you are getting the results, then maybe you will see… this person is at high risk, so it will be very beneficial not only to them but also for us to identify those who need additional monitoring”—Oshakati, P1
“It will be beneficial, especially when we are giving the isoniazid and preventative therapy. We don’t give if someone is abusing alcohol and the person will be at risk of getting TB. So if this program is effective then we will give that service to more patients, to prevent TB.”—Oshakati, P4
Problems with the eSBI Program
Also in Katutura, one provider believed that the reason why patients did not attend eSBI follow-up visits was because it took too much time or because the information was repetitive.“Like I said, we didn’t get to see the results so we can’t tell if it worked or not. When we talk to them about alcohol in the screening rooms, they know we are against alcohol consumption with treatment, so they will never tell us the truth. But we don’t know the reality, because we didn’t see the [eSBI] reports.”—Katutura, P1
In Oshakati, where providers had access to patients’ eSBI reports, they felt that patients were hesitant to participate in the study because they feared being punished for drinking alcohol.“From what I saw, patients would come in, and they would not come for follow up, they would disappear…because what happens is, we identify them, then we refer them to [the study coordinator], she would get their files and try to get their medication from the pharmacy, but I think the time spent on the study is what makes them run away…and the other thing is it’s almost like a repetition of the same questions. I don’t know, maybe it’s because I went through it [gave patients information on alcohol] so maybe they feel it’s just the same thing…When we are referring them, working at the front table taking their blood pressure and weight, we recognize the eSBI sticker [indicates they are a study participant] and you refer them to that room, they will just say “no, it’s too much” or “I’m in a hurry” they will just say something.”—Katutura, P1
“There are some who said ‘I don’t want to take part in that study, because otherwise if they learn that I’m consuming alcohol, maybe I will be punished or one day be part of something I don’t want to be part of’”—Oshakati, P3
Suggested Improvements for Future Implementation
“The other challenge I think is, the kind of setting we have in this clinic, we had to accommodate two studies in one room, we then had to move [the study] out of that room to create more space for the other clinic functions. The whole thing is ok, its fine with us, but …we will need a lot of support in terms of staffing, we don’t have space any more unless they bring us a [shipping] container.”—Katutura, P1
“It can [be incorporated into routine clinical care], provided that we will add on the staff so that maybe one or two people are responsible for it…we should add people who are screening the people electronically, then have people to counsel them…”—Oshakati, P1
In addition, the physical placement of the eSBI program at the ART site was thought to be important for maximizing participation. In Oshakati, participants were taken to another building to complete the eSBI.“I have the same idea, that we just need extra hands to do that, but it [the eSBI program] is really really needed.”—Oshakati, P5
Providers in Oshakati also suggested that the program be offered late in the afternoon (our study stopped seeing participants at 3 pm each day) to capture the heavy drinkers who tend to come to the clinic late in the afternoon.“It will need to be next to the CDC clinic department, because here it is a bit far. If you refer someone here it will be out of their way. They understand they are going to be joining and I’m going to be there [in another building], they will disappear, more especially those ones who are taking alcohol they are more likely to be stubborn not to show up.”—Oshakati, P1
“What we noticed at the CDC clinic is that some patients who really consume alcohol come late afternoon, like to 5. Some you can even see I can’t attend to this patient, if I’m talking to him he won’t understand me, so it’s better to tell him to come back tomorrow when he is sober.”—Oshakati, P5
Another suggestion that providers in Oshakati had for improving participation in the program was to provide more education to patients before introducing the program in the clinic.“In support with her point that, many a time, those that really consume alcohol come in the later hours, they are the trouble makers. It could be the reason why the answers or response of the study is coming out as such, the majority seen in the morning are the normal people, they come, wait until 10, go back to work they are the responsible ones. The majority who were supposed to be captured (screened and enrolled), they are not captured because it was not incorporated into their time frame.”—Oshakati, P1
“One more thing I think needs to improve is maybe to give health education or health talks, before the actual interview takes place, just to educate them on the benefit of the program so that they can understand.”—Oshakati, P3
Some final suggestions by providers were to make the program shorter and to offer it less frequently.“I would like to say that you must educate the person first that there is a certain study with a program that will come about a b c d, and this is how you will benefit and this is how you are expected to contribute”—Oshakati, P5
“If it can be made a bit shorter, and how often, when it was being designed how often was it meant to be done? Once a year for every patient? Or was it at every visit?”—Katutura, P1
Finally, based on comments from providers at both sites, we felt that a potential improvement for increasing truthful reporting would be to not give providers access to patients’ eSBI reports. In Katutura, providers were not given access to patients’ reports and one provider felt strongly that if this were to change, patients would not report the truth about their drinking levels:“I also want to add on that we should have a schedule for how long [often] we screen our people for alcohol, because we cannot be doing it on a monthly basis. Like the person came yesterday and a month later you have again screened, so if we could incorporate it like ok, we will be screening our patients after each and every 6 months or 3 months, then I understand there we could really see the impact for it to our patients.”—Oshakati, P1
In support of this comment, in Oshakati, where providers were given access to patients’ reports, they felt this inhibited patients from telling the truth.“It’s a good tool, to have at a clinic, however once the patients know we have access to their reports, the stories will change, so next visit they will start changing them…What they know is that if they are taking alcohol and they miss their follow up dates or there are any adherence issues with treatment, we usually stop their treatment. So most of the time they will try to change the kind of responses they give when you ask them anything to do with alcohol. So if they discover we have access to reports, it will be a totally different thing.”—Katutura, P1
“No, they were not telling the truth [on the computer], like how many beers do you take? Instead of saying five, they will say just a glass. They were not told what is the real aim for them to give the real answer. [When I asked] Why did you not tell them? [Patient responded] I thought maybe I’m going to be punished” [Oshakati, P3]