Teferra, Solomon(MD, PHD)Hanlon, Charlotte(MD,PhD)Zewdu, Selamawit(Phd)2021-11-292023-11-052021-11-292023-11-052021-06http://etd.aau.edu.et/handle/123456789/29019Background: Alcohol use disorder (AUD) is disabling yet neglected and frequently left untreated in low- and middle-income countries (LMICs). To increase the treatment rate, AUD services need to be integrated into primary health care (PHC) units as people with the disorder often make contact with PHC due to physical health consequences of AUD. Objectives: 1) To determine the magnitude of AUD and associated disability, co-morbid depression, suicide, internalized stigma and help seeking behavior in Sodo district, Gurage Zone,South-Central Ethiopia. 2) To assess the impact of a brief intervention delivered at PHC on alcohol use after 12 months. 3) To explore the perspectives and experiences of people with AUD, caregivers and service providers about the brief intervention delivered at PHC in Sodo district. Methods: The study was nested within the PRogrammme for Improving Mental health carE(PRIME). Mixed quantitative and qualitative methods were used: 1) Using a cross-sectional house-to-house community survey of 1500 adults (aged 18 years and above) living in Sodo district. The prevalence of AUD help seeking behavior, barriers to care, disability, co-morbid depression, internalized stigma and suicidality were determined. AUD was assessed using a culturally adapted version of the Alcohol Use Disorders Identification Test (AUDIT), A Poisson working model with robust variance was used to determine prevalence ratios. 2) A pilot beforeand-after study was carried out among 49 people attending PHC facilities who had probable alcohol use disorder. Participants received an evidence-based single session brief intervention for AUD which was delivered by trained PHC workers. Follow-up assessment was conducted at 3 and 12 months. This included evaluation of AUD severity, functioning using World health organization disability assessment schedule (WHODAS 2) Score), consequences of drinking using Short Inventory of Problems revised version 2 (SIP-2R) and depression using the patient health questionnaire (PHQ-9). A mixed-effect linear model was used to assess the impact of the intervention at 3 and 12 months. 3) A nested qualitative study was conducted to explore perceptions and experience of service users, caregivers and service providers on the acceptability, impact and implementation of the intervention. Twenty-six in-depth interviews were conducted with 14 people with alcohol use disorder, four caregivers and eight health professionals who were providing the intervention. Framework analysis was used for analysis. Results: The prevalence of alcohol use disorder was 13.9% (25.8% in men and 2.4% in women).Alcohol used disorder was more prevalent among men (adjusted prevalence ratio (aPR) 7.7, 95% confidence interval (CI): 4.4, 13.1; farmers aPR 3.9, 95% CI: 1.0, 14.8), traders (aPR 6.0, 95% CI: 1.5, 23.9) and daily laborers (aPR 6.3, 95% CI: 1.5, 26.1) compared to housewives. A oneyear increase in age was associated with a 1% increase in the prevalence of AUD (aPR 1.01,95% CI: 1.00, 1.02). As the number of stressful events, depressive symptom score and disability score increase by one, the prevalence of AUD increased by 27% (aPR 1.2, 95% CI: (1.1, 1.3), 3.0 % (aPR 1.03, CI: 1.01, 1.03) and 2.0% (aPR 1.02, 95% CI: 1.01, 1.04), respectively. Having suicidal thoughts was also associated with AUD (aPR = 1.5; 95%CI: 1.1, 2.1). Of participants with an AUDIT score ≥16 (indicating harmful drinking), only 13% (n=6) sought help for alcohol problems, and 70.0% reported high internalized stigma. Major barriers to seeking help were: wanting to handle the problem on their own, believing that it would get better by itself, being unsure about where to go, not bothered by the problem, financial barriers, including being concerned about the cost of professional help, concerned about what people might think, and access. Forty-nine people with AUD received the brief intervention, and 92 % completed the assessments. Following the brief intervention, there was a statistically significant reduction in AUD severity, consequences of drinking and depressive symptoms. The adjusted mean difference (AMD) in AUDIT score at 3-months was -2.66 (95% CI -5.21, -0.11) and at 12 months was -4.15 (95% CI -6.76, -1.54). For SIP-2R score, AMD for AUDIT score was -2.52 (95% CI -4.86, -0.18) at 3-months and -3.00 (95% CI -5.87, -0.14) at 12-months. For PHQ-9 score AMD was -2.06 (95% CI -3.35, -0.77) at 3-months and -2.03 (95% CI -3.35, -0.72) at 12months. Although positive effects of the intervention on functioning were not seen in the quantitative analysis, the qualitative study strongly supported the impact of the intervention on improving functioning. People with AUD and caregivers reported improved work capacity,increasing earnings, less money wasted and, consequently, being able to better provide for their family. The brief alcohol intervention was accepted by most service users. Service providers reported low acceptability of their advice by participants, participants’ lack of openness to talk about alcohol, and shortage of space as barriers for implementation. Primary health care workers recommended further training, raising awareness of the community about alcohol use disorder, and working with the community and health extension workers. They also requested a stronger administrative support system for improving management of alcohol use disorder. Conclusions: Although alcohol use disorder was a common problem in the study setting, the unmet need for treatment was substantial. A pilot integration of a single session brief intervention in PHC had a positive impact on the severity of AUD, consequences of drinking,and depressive symptoms over a period of 12 months. The intervention was also feasible,acceptable and perceived to bring benefits. However, there is a need to address such issues as low community awareness about AUD, stigma, inadequate skills of PHC workers and engagement of the community in order to increase help-seeking behavior, and enhance acceptability and the impact of intervention in PHC settings. With more frequent supervision,non-specialized workers at the PHC level have the potential to contribute to the reduction of the burden of AUD through early screening, brief intervention, and referring people with severe AUD for specialist treatment.en-USAlcohol use ,Disorder,Alcohol intervention,help-seeking behaviorThesis