According to the current global status report on alcohol and health [
19], Uganda is among the top 10 African countries in per capita consumption. Due to a high number of abstainers, especially among women, the average (9.5 l of pure alcohol being consumed per year by Ugandans ≥15 years) seems quite low, while the total alcohol per capita consumption in male drinkers (≥ 15 years) is exceptionally high, with 32.7 l of pure alcohol annually. Worldwide, consumers drink about 15.1 l. The African region ranges more than 20% above this global average (18.4 l). The global status report on alcohol and health [
19] reports alcohol dependence in 4.2% of the Ugandan male population (12-month prevalence estimates), whereas another countrywide survey reports 9.8% using the same timeframe [
33]. In the formerly conflict-affected northern areas, studies found similar levels of dependent drinking at 9.9 and 8.9%, respectively, with both studies reporting 12-month prevalence rates for males estimated by AUDIT scores of 20 and above [
5,
6]. Compared to the global status report on alcohol and health [
19], this may hint at elevated numbers related to the past conflict and its consequences. Taken together, prevalence data suggests that those (predominantly male) Ugandans who drink have especially harmful drinking habits and patterns and this seems to be true for many LMIC [
19].
This study aimed to externally evaluate PACTA’s
Treatment Camp approach. Next to its impact on alcohol-related measures, we also address issues of acceptability, feasibility and safety. Additionally, if available we interviewed participants’ partners and children to get pre-treatment, and follow-up information on relationship quality and violence at home. Studies evaluating potential changes in family violence after mental health interventions with an individual family member, including alcohol-related interventions, are extremely rare. Tol et al. [
36] reviewed the literature for LMIC and found only seven eligible studies. They report that alcohol-focused intervention studies did not show benefits on intimate partner violence (IPV). Our quantitative data collection was complemented by a way of service user involvement unique in this context. We conducted qualitative interviews with participants, which we analyzed using the framework method [
37]. Participants were asked a) which elements they perceived as helpful and which as not helpful during the
Treatment Camp, b) what they perceived as helpful versus not helpful in the time after the
Treatment Camp and c) what factors they perceived as either causing relapse, or successful abstinence, or the successful stable reduction of alcohol intake to harmless levels. Thereby, we tried to shed light on topics and elements of the intervention and later environmental conditions which facilitated healing and which hindered healing in the eyes of the participants. Qualitative outcomes and partner- and children-data can only be addressed in brief here. Details can be found in the supplementary material.
Discussion
This exploratory study evaluated a locally designed and implemented one-week community-based inpatient detoxification treatment complemented by psychosocial interventions aiming at psychoeducation and relapse prevention (cf. Figure
2). The approach is not primarily new concerning its content, but innovative and groundbreaking concerning its mode of service delivery and recruitment, which is highly adapted to the context of LMIC. Firstly, the mobile camp setup is ideally overcoming the lack of secondary and tertiary health facilities by covering large underserved areas consecutively. Secondly, it enables clients, who would neither have the means to travel nor to stay in a specialized rehabilitation center to use the service. Thirdly, the
Treatment Camp is set up in a way to optimally imitate an inpatient setting, where patients can concentrate on recovery without distraction. Fourthly, the inpatient nature of the
Treatment Camp overcomes many of the exclusion criteria that apply to home-detoxification programs or brief interventions that are the common alternative models of alcohol-related service delivery in LMIC [
11,
14,
34,
35]. The combination of the inpatient setting with medical staff overseeing the provision of medication and dealing with physical concerns on the one hand and counselors or lay therapists providing sessions on psychoeducation and relapse prevention on the other hand helps to treat and monitor AUD patients intensively. This allows for the inclusion of individuals with severe AUD, with withdrawal symptoms, and comorbid psychiatric disorders. Lastly, since the program was designed and implemented in collaboration between the local NGO PACTA, local Caritas counselors, and staff of the local regional referral hospital, the risk of choosing culturally or contextually inappropriate or incomprehensible content or interventions was limited.
The recruitment strategy chosen by PACTA is well adapted to the requirements of resource-poor settings, where mobile phone- and TV-based, printed or internet-based information is not yet reaching the majority of people. Radio calls in combination with verbal transmission of information by community leaders eventually lead to word-of-mouth communication among the population, finally reaching most of the target-individuals. A positive side effect of announcing the
Treatment Camp is that individuals and their families, who would not have known where to turn with an alcohol-related problem, learn about treatment options. This recruitment strategy might be more efficient than recruiting at public or private clinics as Nadkarni et al. [
35] did. Primary care facilities as entry point seem pragmatic, yet Nadkarni et al. [
35] reported a low consent rate of 23% next to a high dropout rate, which was not the case for the
Treatment Camp approach with a consent rate of 89% and no dropouts during the
Treatment Camp intervention. The low dropout-rate during treatment in the present study is exceptional for this patient-group [
63].
Acceptability, feasibility and safety of the
Treatment Camp approach was good. This is confirmed by quantitative and qualitative data from participants and their relatives. Recruitment reliably reached the targeted population, no participant discontinued the one-week program and no adverse events or emergency referrals occurred. In contrast, the pilot study by Nadkarni et al. [
35] exploring the acceptability of a home-based detoxification and relapse prevention program in India lost 3 out of 11 (27%) participants in the detoxification-phase and 20 out of 27 (74%), who had joined the relapse component only. This vast contrast in dropouts might be partly explained by the differing recruitment strategies of the two exploratory studies. Moreover, PACTA’s
Treatment Camp approach is likely to be safer than other (lay-)counselor-delivered services commonly implemented in LMIC, since complications in the detoxification phase can be directly and professionally handled. In fact, most publications about alcohol-related interventions in LMIC either don’t report on their dealing with withdrawal symptoms or exclude persons that are likely to develop withdrawal symptoms [
11,
14].
However, health service delivery by NGOs or community-based organizations (CBOs) like the Treatment Camp described here, has one major disadvantage: its uncertain sustainability. Usually local nongovernmental service providers rely on funding from private donors or funds from bigger international agencies and development aid organization. Resources are granted for limited implementation periods and funding priorities are changing quickly, often resulting in ad hoc developed programs that can neither be thoroughly evaluated nor implemented permanently. A way forward would be the funding of scientific evaluation and sustainable implementation of verified developments by NGOs. In a subsequent step these could be considered for dissemination to public health service providers. In the case of the Treatment Camp approach eight further Camps followed in each of the eight districts of the Acholi sub-region. Recruitment, management, content and duration of these Treatment Camps followed the model of the one described here, including the participation of a Senior Psychiatric Clinical Officer and a Laboratory Technician from GRRH. Each time PACTA linked up with the main hospitals of the respective region for potential emergency referral.
This case series following
Treatment Camp participants and their families up to one year after treatment found that 67% of the former AUD patients were either abstinent or considered subthreshold consumers at the last follow-up. Those who were drinking and smoking at the same time additionally reduced their cigarette intake by 60%. Alcohol-related symptoms, drinking frequency and amount (measured according to the AUDIT and TLFB) and indicators of craving (OCDS), including craving frequency and intensity, reduced significantly up to one year after treatment with large effect sizes (Hedges’s
g) ranging from 0.89 to 3.49. Nadkarni et al. [
35] found a significant difference between baseline and 3 months post recruitment assessments in daily alcohol consumption and heavy drinking for those participants who received home detoxification and relapse prevention counseling, but not for those who received relapse prevention counseling only. The first finding is in line with the current study that also combined both approaches and found high effect sizes on all alcohol-related measures. A single-arm trial with 185 Italian dependent drinkers, who attended a one-week inpatient detoxification program with a fixed-schedule drug regimen and accompanying non-pharmacological interventions was very similar to the present trial in treatment content and design and reported extremely similar AUDIT trajectories from pre-assessment to the 6- and 12-month follow-ups [
64]. In Zambia, Sheik et al.’s [
8] 7–10 days detoxification treatment combined with a 20-min relapse prevention intervention from the WHO mental health general action plan included the AUD patient and a relative as co-therapist, who was asked to help the patient to remain abstinent, join mutual-help groups and request further appointments in case of relapse. It was similar to the present program concerning its success, but differed concerning the location of service delivery, the type of aftercare, the applied outcome measures and the follow-up period. The treatment was carried out in the only psychiatric hospital of the country (Zambia), i.e. access to care for AUD patients, especially from the periphery of the country was likely to be limited and follow-up assessments were carried out up to 2 months only as opposed to 12 months in the present study.
We did not find any significant additional gain for the 19 participants that attended at least one session of the guided peer support groups (either AA meetings, or Caritas or GRRH open-topic psychosocial groups). The trajectory of first-time lapses after intervention followed results reported by Witkiewitz and Masyn [
65], with a decreasing risk of lapsing over time. All except two participants lapsed at least once during the follow-up period, but still the reduction in drinking frequency, amount and related symptoms was significant and remained stable for more than one year post intervention. This is again in line with Witkiewitz and Masyn [
65], who describe common patterns of post-lapse drinking in a large sample of American participants of a community-based alcohol treatment. They report the vast majority returns to abstinence or infrequent drinking following initial lapse and only few individuals show frequent heavy drinking after lapsing initially. Participants were openly sharing reasons for (re)lapsing in the qualitative interviews (cf. Supplementary Table 7, Additional File
2). Internal (physical or emotional) and external conditions triggering the urge to drink were mentioned prominently, e.g. the wish to overcome negative emotions, boredom, physical pain, or the wish to forget problems or being unable to withstand the former drinking environment. Other reasons were social pressure, e.g. from family, friends and during occasions where drinking is commonly expected.
Our measure of daily impairment in functioning was not restricted to AUD-related difficulties only, but included functioning impairment due to other psychopathologies as well. Self-reports of
Treatment Camp participants indicated a significant improvement in functioning that was documented by a large effect size (Hedges’s
g = 0.84). Perceived stigmatization because of alcohol consumption reduced significantly as well, with a slightly lower, medium effect size (Hedges’s
g = 0.75). This might hint at a change in people’s attitude and behavior towards the former dependent drinkers and could be a sign of regained social status, possibly leading to a re-integration into productive work and community life. Qualitative statements of
Treatment Camp participants back this interpretation (cf. Supplementary Tables 3, 4 and 8, Additional File
2). However, we can’t fully rule out that for some participants only their perception changed and not the actual attitude and behavior of their social environment. We observed a significant reduction in depression symptoms in the medium range (Hedges’s
g = 0.61), yet not for PTSD symptoms. A similar decrease in depression symptoms was reported by Oliva et al. [
64] in their sample of Italian AUD patients attending a one-week inpatient detoxification program. Depression symptoms may have reduced as a function of participants’ reduced alcohol use, although we can’t prove this assumption, since we lacked the power for mediation analyses. The lack of change in symptoms of PTSD is not surprising, since no PTSD-specific treatment components were implemented during the
Treatment Camp. Moreover, only few PTSD symptoms were reported at pre-assessment.
Concerning the trajectories of communication problems within their relationship, relationship satisfaction and quality, the male participants generally report less change than their partners (cf. Supplementary Table 1, Additional File
1). This result is plausible, since the male participants were the ones who were in treatment and possibly changed their behavior within the relationship parallel to their drinking habits. Interestingly large changes in IPV were reported by both partners. This implies that physical and emotional violence reciprocally reduced once the male partner had changed drinking habits. This finding is contrary to what was recently reported by Tol et al. [
36], who found that the reviewed alcohol-focused intervention studies did not show benefits on IPV. In line with the couple-results, the participating guardians and their children report a considerable decrease of harsh parenting and family violence including neglect (cf. Supplementary Table 2, Additional File
1). Interestingly, both parties agree on the decline of physical violence, but not on emotional/psychological maltreatment. Children reported an improvement on emotional maltreatment, whereas the participating guardians reported not having changed their psychological aggression.
In addition to the above mentioned strengths of the
Treatment Camp approach itself, several strengths of the evaluation study stress its uniqueness. This is the first study ever examining the feasibility, acceptability and safety of a mobile, community-based inpatient treatment model for AUD and one of the few dealing with severe AUD in LMIC. The evaluation of this innovative service delivery approach was carried out by an organization different from those who designed and implemented the interventions. This constellation is likely to lead to less bias in the data, since assessors are not feeling a strong commitment towards the program and participants are less likely to answer in socially desirable ways. At each follow-up participants were interviewed by assessors they had not interacted with before. We had hardly any dropouts, with only one participant lost at each follow-up assessment. This is rare in this clientage, especially considering the long follow-up period [
64]. The latter is a strength in itself, since most alcohol-related intervention evaluations commonly use shorter follow up periods of 3 to 6 months [
11,
13,
14]. This study used a mixed method approach and complemented quantitative data with qualitative data, which has not been done for withdrawal treatments in this context before. Qualitative data is especially valuable in this early stage of intervention evaluation in order to learn which and how much content dependent drinkers can grasp during the detoxification phase. The feedback of participants on helpful and not helpful aspects of the
Treatment Camp and the time after will facilitate adjustments to this emerging intervention model and contains valuable information for other intervention endeavors as well (cf. Additional File
2). This study is meeting the call for more service user involvement in LMIC on two different levels [
66]. Firstly, PACTA staff includes former AUD patients who integrate their experiences and know-how from management to intervention planning and implementation. Secondly,
Treatment Camp participants were asked for their feedback on treatment content and processes.
Although their number is small, we included participants’ partners and children and can at least descriptively report their data in the Additional File
1. This longitudinal data from involved family members complements and partly validates the reports of
Treatment Camp participants. In contrast to other studies in the field (e.g. Nadkarni et al. [
35]) we did not solely rely on the AUDIT for the assessment of AUD, but pre-assessments were confirmed by GRRH staff at entry into the
Treatment Camp. Moreover, we did not only assess alcohol-related measures, but also perceived stigmatization, functioning impairment and other pathologies.
This study also has several limitations that should be noted. Since the organizations involved in implementing the
Treatment Camp did not design its realization as a comparative trial, the absence of control arms means that participants’ changes could also be due to spontaneous remission or to a placebo effect of an actually inefficacious intervention that could have also spread to the non-participating family members. We consider spontaneous remission on a large scale unlikely, since participants reported to have realized addiction-related problems at around 29.5 (SD = 10.90) years of age, yet they were on average 40.6 (SD = 10.71) years old at entry into the
Treatment Camp. This implies rather long histories of addiction. Participants were recruited following a radio-call, i.e. they represented a self-selected population which limits generalizability. Participants were almost exclusively males, which limits generalizability to females with AUD. However, this imbalance was to be expected and is reflecting the prevalence of AUD in the given context. AUD is still almost exclusively a male problem in Uganda [
5,
6,
8,
19]. Although the information provided by partners and children validated the participants’ information to a certain extend our findings are relying on self-reports that could have been biased. Social desirability and feelings of shame might have played a role during follow-up assessments, however, studies suggest that self-report on alcohol is quite accurate [
67,
68]. The instruments for craving were implemented for the first time in the given context and still would have to be validated.