Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 International Journal of https://doi.org/10.1186/s13033-022-00548-5 Mental Health Systems REVIEW Open Access Brief interventions for alcohol use disorders in low‑ and middle‑income countries: barriers and potential solutions Abhijit Nadkarni1,2*† , Urvita Bhatia2,3†, Andre Bedendo4,5, Tassiane Cristine Santos de Paula4, Joanna Gonçalves de Andrade Tostes6, Lidia Segura‑Garcia7,8, Marcela Tiburcio9 and Sven Andréasson10 Abstract Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low- resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to imple‑ mentation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disor‑ ders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of gen‑ eralisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a grow‑ ing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders. Keywords: Brief interventions, Alcohol use disorders, Low- and middle- income countries, India, Latin America Introduction Alcohol and drug use is the fifth-leading risk factor for poor health in men globally, associated with 6.6% (2% in women) of disease [1]. Alcohol use is ranked as the seventh leading risk factor for premature death and † Abhijit Nadkarni and Urvita Bhatia—Joint first authors and contributed disability [2]. Alcohol use disorders (AUDs) (chronic equally to this work relapsing conditions characterized by an impaired *Correspondence: abhijit.nadkarni@lshtm.ac.uk ability to stop or control alcohol use despite adverse 1 Centre for Global Mental Health (CGMH), Department of Population Health, health, social, or occupational consequences) are the London School of Hygiene & Tropical Medicine, London, UK Full list of author information is available at the end of the article largest contributors to premature mortality amongst © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 2 of 14 all mental and substance use disorders and account for in terms of types of BIs, key content, potential target 9.6% of DALYs and 44.4% of Years of Life Lost caused groups, and settings in which they can be delivered. by these disorders [3]. Overall, alcohol use is associated In general, BIs are grounded in social-cognitive theory with far more health loss for males than for females, and incorporate some or all of the following elements: with the attributable burden for men around three feedback on the person’s alcohol use and any alcohol- times higher than that for women [2]. However, there is related harm; clarification as to what constitutes low-risk growing evidence to indicate the increasing prevalence alcohol consumption; information on the harms associ- of alcohol consumption amongst women, and also ated with risky alcohol use; benefits of reducing alcohol other demographic groups such as adolescents and the intake; advice on how to reduce alcohol intake; motiva- elderly, including in low- and middle-income countries tional enhancement; analysis of high-risk situations for (LMICs) [4–12]. drinking and coping strategies; and the development of Between 1990 and 2017, global adult per-capita alco- a personalised plan to reduce alcohol consumption [16]. hol consumption increased from 5.9 to 6.5 L, and is Although there are several forms of BIs, the more com- expected to reach 7.6 L by 2030 [13]. Importantly, the monly used approaches are brief structured advice and annual growth rate of volume consumption per person motivational interviewing (MI)-based interventions, (1997–2009) was 2.8% in LMICs compared to 1.1% in and also interventions delivered electronically, through high-income countries (HICs) [14]. In such a scenario, mobile phone applications and websites, where advice global goals for reducing the harmful use of alcohol, as may be accessed more conveniently by patients [17]. expressed by the WHO global alcohol strategy to reduce The settings, target groups, and delivery agents the harmful effects of alcohol, are unlikely to be achieved described in studies of BIs vary [16]. When applied in [13]. Given these developments, it becomes critical to primary care and emergency care they are generally ensure that cost-effective intervention measures are delivered by general practitioners, generalist healthcare implemented to reduce alcohol exposure. workers, nurse practitioners or psychologists. The target One such evidence based measure is brief intervention groups are hazardous and harmful drinkers who are not (BI) for alcohol problems, and some of the characteristics specifically seeking help for alcohol problems and the aim of BIs make them a particularly appealing choice of inter- is reduced consumption and alcohol-related harms. ventions in low-resource settings (particularly for hazard- Brief structured advice lasts 5 to 10 min and is used ous and harmful drinking). BIs are a variety of structured when the time is limited and is relatively directive in techniques that aim to motivate behaviour change and nature e.g. providing feedback with information on are utilised to change risky alcohol use [15]. BIs can be drinking risk levels, and encouraging the reduction of adapted to different behaviours, settings and practition- consumption by simple advice, often accompanied by ers’ needs and hence can involve a variety of approaches. educational materials [18, 19]. It aims to evoke change in Table 1 summarises the essential characteristics of BIs drinking behaviour, by providing individuals with infor- mation about their drinking and how they may reduce Table 1 Essential characteristics of BIs Approach Brief (range: between 5 and 40 min), flexible, can be adapted to different behaviour contexts, settings, practitioners Target group Hazardous and harmful drinkers Measures Use of validated screening tools to identify drinking patterns Content Structured techniques focussed on motivating behaviour change including: Feedback on the person’s alcohol use and any alcohol-related harm Clarification as to what constitutes low-risk alcohol consumption; information on the harms associated with risky alcohol use; and benefits of reducing alcohol intake Advice on how to reduce alcohol intake Motivational enhancement Analysis of high-risk situations for drinking and coping strategies Development of a personalised plan to reduce alcohol consumption Referral to further treatments where appropriate Types of BIs Brief structured advice Motivational interviewing based BIs Digital BIs (e.g. app-based) Settings in which BIs may be Primary care delivered Specialist care Emergency care Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 3 of 14 their consumption to sensible drinking levels [20]. On In summary, early identification and care for people with the other hand, MI-based interventions are more flexible AUDs has received much less attention in LMICs than in and take a client-centred approach that avoids explicitly HICs [31–33]. While lessons from HICs are important, directive advice. Such interventions may last between implementation of BIs in LMICs involves a different set 20 and 40 min and often include follow‐up sessions. of contextual challenges [31, 34], and such possible bar- Based on the principles of MI [21], it has been applied riers to BIs in LMICs, and solutions to overcome them, in contexts where there is more time and where trained need further investigation. professionals are available. BIs are usually delivered opportunistically for individuals who are not particu- Methodology larly seeking help for their alcohol use but whose use is We conducted a literature search through Medline, a concern for the practitioner [22]. They are conceived as Google Scholar and SciELO to find and select published public health interventions, with the aim to detect alco- research covering a broad range of aspects on BIs in hol use problems in the early stages and provide advice LMICs. Our inclusion criteria were (1) BIs for alcohol and to reduce adverse consequences at individual and societal drugs, (2) any kind of use ranging from risky/hazardous levels. to substance use disorder, (3) any publication date, and BIs for alcohol use disorders (AUDs) have been exten- (4) in LMIC settings. Our eligibility criteria were inten- sively researched over the last four decades [20, 23, 24], tionally broad as the literature on BIs in LMICs is sparse with a large body of evidence indicating their efficacy and our primary objective was to provide the reader with in primary care and emergency care. However, more the landscape of evidence base related to BIs in resource- recently, questions have been raised about the effec- constrained settings. Many of the identified studies from tiveness of BIs [25, 26], especially the translation of the Latin America did not evaluate effects of BIs, and/or did research evidence into implementation in routine prac- not discuss implementation barriers. Therefore, we also tice, including the referral of more severe alcohol use included additional relevant publications in order to problems from primary care to specialised addiction improve the description of the implementation strate- treatment (e.g. referrals are likely not to be successful gies used in Latin America. Table 3 summarises evidence because most patients are reluctant to seek specialized from studies reporting BI implementation experiences treatment for alcohol problems, and, when referred, are (barriers or effects). lost along the way) [27]. We did not apply any date and language restrictions The current debate regarding the effectiveness of BIs to the studies. JT summarized literature on barriers to is centred around the primary challenge of implemen- implementation in LMICs. AB synthesised literature tation at scale. Based on the efficacy studies of BIs, one from Latin America and UB synthesised literature from can consider them as a highly competitive option for India. Using a narrative synthesis approach [35], we sum- public health interventions to reduce alcohol related marize key examples below to highlight salient character- harm. Along with a range of other public health poli- istics of the content and delivery of BIs in LMICs, with cies designed to reduce alcohol related harm, such as a focus on evidence related to the Latin American and increased taxation of alcohol, regulation of alcohol adver- Indian context as case studies representative of LMICs. tising, and control of opening hours for alcohol retail outlets, BIs stand out as another effective policy measure, Results achieving large effects as measured by disability adjusted Summary of barriers to alcohol BI implementation in LMICs life years (DALYs) [28]. This conclusion however is based There are several barriers to implementation of BIs, the on the efficacy of BIs, and not taking implementation key ones being lack of financial and structural resources. barriers into account. Despite their efficacy, if BIs cannot In this paper, we will discuss these barriers, reflecting on be implemented in practice, other evidence-based poli- specific examples from diverse low-resource settings. We cies should be considered. It is with this perspective that specifically discuss two types of barriers seen in addic- the analysis of barriers to implementation of BIs becomes tions care: demand (related to the felt need for services) crucial. and supply (related to the provision of services) side bar- Thus, although a large number of trials of BIs have been riers. Table 2 provides a brief taxonomy of barriers, sum- conducted, with modest outcomes in HICs, implemen- marizing the evidence below into two major categories, tation in clinical practice remains elusive, calling for a demand side and supply side barriers. rethinking of the core principles underlying these inter- Although there are not many such studies from LMICs, ventions. Furthermore, there is very limited evidence there is no reason to believe that barriers to BI identified for both efficacy and effectiveness of BIs in LMICs, and in HICs (e.g. lack of trained specialists) would not apply implementation of BIs in LMICs is rare as well [29–31]. to LMICs. Studies from Latin America (and other LMICs Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 4 of 14 Table 2 Barriers to BI implementation Demand side Supply side Stigma associated with alcohol use disorders [29, 40–42] Quality of BI implemented [24] Lack of knowledge about available treatments [38] Primary health care providers are not trained, are overburdened with existing responsibilities [31, 32, 34, 36, 37] Low help-seeking rates for alcohol use disorders [38, 39] Poor structural resources, including training and systems [34, 38] Poor sensitisation among primary health care providers [36, 37] Lack of financial resources and investment in BIs [31, 32, 38] Poor policy planning [48, 49, 66] such as South Africa) observed that factors influencing in LMICs. Additionally, in resource-poor settings such as the implementation of BIs in routine primary care prac- LMICs, where the investment in health is already inad- tice included the percentage of nurses trained in BIs, sup- equate, interventions to reduce stigma and minimize its port visits, clinical workload, competing priorities, team impact on users and family members are even less pri- work, early adoption, compatibility beliefs, perceived oritized. Therefore, the same cultural and structural fac- complexity of innovation, trialability and observability of tors that enhance stigma also threaten development and BIs, social norms relative to substance use and the rela- maintenance of interventions aimed to deal with this tionship between technicians and health professionals problem [42]. [31, 32, 36, 37]. Finally, there is limited willingness among policymak- Specifically, in LMICs, specialized services are lim- ers to invest in implementation of BIs in LMICs. Some ited or non-existent [32] and hence primary care is often of this is a consequence of the mixed evidence about the the only possible alternative to implement BIs. How- effectiveness of BI- some encouraging [30, 43], other less ever, health professionals in such settings generally lack so [24]. Furthermore, despite evidence from HICs, little training to deal with AUDs [36, 37], and often the level is known about the effectiveness and feasibility of BIs in of engagement is slow [38]. This can lead to reluctance LMICs [37]. It is critical to develop the evidence base in to address the problem due to concerns about patients’ LMICs where there are marked socioeconomic inequali- reactions [37]. A great number of patients experiencing ties, and hence it is important to understand which types alcohol problems avoid disclosing such problems with of BIs are appropriate for which target population and for healthcare providers and they usually seek treatment for which contexts. However, although one might acknowl- other conditions that may be related to their alcohol use. edge that such research is necessary, the resources for This is one of the reasons why screening and appropri- conducting such research in LMICs are limited [32]. ate management is crucial to reach this target population [38]. Strategies and new approaches for BIs: perspectives However, for healthcare professionals this is difficult from selected LMICs within the context of intensive work hours, multiple jobs, Latin America low wages, poor working conditions, work overload, and Alcohol consumption represents a major health prob- reduced staff numbers in these settings [34]. One key lem for Latin America. Countries with the most per obstacle that health professionals face is that patients capita consumption are Argentina, Brazil, Chile, Mexico, have low motivation to participate in interventions for Panama, Paraguay, and Uruguay [44]. Several inequities their drinking problems as they prefer to handle these present in Latin America such as living conditions and problems by themselves [38]. Concerns about patient limited access to the health care system reinforce the confidentiality and privacy, and lack of patient coop- impact of alcohol consumption and the related prob- eration are other challenges that professionals describe lems. Among key concerns are a higher mortality rate [39]. These barriers to access add on to the existing large from alcohol‐attributable causes, emerging high-risk health disparities in LMICs where low socioeconomic groups such as youth and women, and the consumption position increases the severity of alcohol problems, of high alcohol content beverages [45]. Although public which are then further aggravated by a lack of access to health policies have a fundamental role in the reduction healthcare and other relevant services [31, 38]. of alcohol-related mortality, there is no consensus among Another barrier is the stigma related to AUDs, leading Latin American countries regarding current legislation to limited acceptability and adherence to treatment [29, on alcohol and public health. 40, 41]. As in HICs, stigma remains one of the greatest BIs were first used in Latin America in the late 1980s in hindrances for substance users to access health services Brazil [46] and, since then, substantial efforts have been Table 3 Key characteristics of studies reported in this review Author Year Country Setting Sample N Study design Key findings Latin America Carneiro 2018 Brazil Online survey with com‑ Health professionals or social 2420 complete a online Online survey with course Most of course completers pleters of a distance learning workers, who had completed survey attenders and follow-up of used SBI in their work and felt course a 120-h distance learning 25 of those implemented patients receiving SBI very motivated to do it course on alcohol and drugs, screening and BI Patients receiving SBI shower screening and BI 79 patients followed lower alcohol and cocaine/ 83% were women from the 3 months after receiving BI crack scores in ASSIST South and Southeast (68%) 3 months after follow-up regions Patients with ASSIST scores higher than 11 for alcohol or 4 for other drugs and aged 18 or above Conde 2018 Argentina Public secondary schools Adolescents 167 (150 at follow-up) RCT (two control groups The intervention effectively Age: M = 15.14, SD = 1.46 (screening, screening and reduced alcohol consumption (Screening only: M:15.2; evaluation) and one experi‑ and related problems in about Screening and evaluation: mental group (screening, one out of seven adolescents, Nadkarni et al. International Journal of Mental Health Systems M:15.2; Screening, evaluation assessment and intervention) with a minimal investment in and intervention: M:15) training and implementation. 81% Male (Screening only: However, we did not find sig‑ 75%; Screening and evalua‑ nificant differences in alcohol- tion: 80%; Screening, evalua‑ related problems among the tion and intervention: 90%) groups, which decreased under (2022) 16:36 Abstainers: 9% (Screening all conditions only: 8%; Screening and evaluation: 8%; Screening, evaluation and intervention: 12%) Martínez-Martínez 2018 Mexico 350 Primary Care Units Health professionals 756 Cross-sectional Main barrier were amount of time taken to conduct an evaluation of the problem, that users do not complete the tasks assigned, their low educa‑ tional, the user’s difficulties in going to the centre Poblete 2017 Chile 9 primary care centres Non-treatment-seekers 806 (400 Intervention, 406 Open-label parallel-group No difference between the two (n = 520), eight emergency ASSIST scores higher than Control) trial groups for the ASSIST, alcohol, rooms (n = 195) and five 11 for alcohol or 4 for other cannabis or cocaine police stations (n = 91) drugs 79% Male (Intervention); 78% Male (Control) Age: Mean 28.6 (SD: 7.8) Intervention; Mean 29.7 (SD: 8.3) (Control) Page 5 of 14 Table 3 (continued) Author Year Country Setting Sample N Study design Key findings Reyes-Rodríguez 2017 Colombia Secondary schools Adolescents (11–18 years) 3159 Longitudinal (follow-up Participants of the preventive 52% Females conducted between 1 and program brief intervention 44% last month alcohol use 7 months after first session) based on Motivational Inter‑ prevalence viewing showed a reduction of the frequency and quantity of alcohol consumption Andrade 2016 Brazil 6 weeks web-based interven‑ Mean age 40 years 929 accessed the intervention Longitudinal Heavy users reduced their alco‑ tion to reduce alcohol use 53.6% male 94 with 6-weeks follow-up hol consumption by 30–50% and related problems 80.3% employed data after baseline 68.6% college degree Dependent alcohol users were more adherent to the interven‑ tion than Harmful users Hoffman 2016 Peru People living with HIV/AIDS Tertiary hospital professionals Two focus groups: N = 51 Qualitative interviews and Main barriers to BI implemen‑ attending people living with Follow-up interviews after focus groups tation were: (1) the unknown HIV/AIDS 6-months: N = 6 extent of substance use within PLWHA, (2) space and time limitations hinder completion Nadkarni et al. International Journal of Mental Health Systems of brief interventions during routine visits, and (3) insuf‑ ficient number of services to refer patients to substance use treatment appropriate for HIV patients (2022) 16:36 Martínez Martínez 2016 Mexico Workers from institutions Purposive sample of key 16 Qualitative interviews Main barriers programs imple‑ providing BI informants with experience mentation were bureaucratic with BI 28 to 57 years (Mean: procedures and institutional 40.6, SD = 8.72) policies, lack of knowledge of All Psychologists with the theoretical bases of the 2–10 years of health and clini‑ program, and the diversity of cal experience users demanding the service Moretti-Pires 2011 Brazil Primary health care 136 health care profession‑ 136 health care professionals Mixed methods (focus groups 25% of patients had a AUDIT als (9 doctors, 7 nurses, 120 667 screened patients and epidemiological data) score higher than 8 health community agents) Main challenges to implement trained to use screening BI were the predominance of and BI the biomedical approach, lack of continuity due to high pro‑ fessional rotation levels related to political reasons, difficulties to stabilize policies in places with limited access Natera Rey 2011 Mexico Community health centres Alcohol user relatives 60 Quasi-experimental The group that received the 18–65 years intervention showed a signifi‑ Women only Small communi‑ cant reduction in physical and ties (340 habitants) psychological symptoms and depression Page 6 of 14 Table 3 (continued) Author Year Country Setting Sample N Study design Key findings Martínez Martínez 2010 Mexico Urban and rural adolescents Adolescents (14–18 years) 58 RCT (three groups: brief inter‑ Both interventions groups attending high school Binge drinkers in last vention, brief counselling and showed reductions on alcohol 6 months, reporting at least control group) use compared to control one alcohol-related problem, and no dependence diag‑ nosis Ronzani 2009 Brazil Primary Care Units from two Primary healthcare profes‑ 113 Mixed methods Managers engagement and municipalities sionals and managers from healthcare professionals’ three cities integration were associated Age: Municipality A was M: with greater effectiveness in 37 years; in the other two M: implementing alcohol preven‑ 30 years tion strategies Sex: Municipality A 92.5% were female; in the other two 71.2% were females Martínez Martínez 2008a Mexico High school/College Adolescents (14–18 years), 40 RCT​ BI group showed lower alcohol Binge drinkers in last use compared to a control 6 months, reporting at least group 3- and 6-months post- Nadkarni et al. International Journal of Mental Health Systems one alcohol-related problem, treatment and no dependence diag‑ nosis Martínez Martínez 2008b Mexico High school Adolescents (14–18 years) 25 Longitudinal (single group Results showed a reduction on with alcohol/drug abuse with 1, 3- and 6-months alcohol and cannabis use at (2022) 16:36 76% Male follow-up) follow-up Age: M:16, SD:1.8 17 alcohol users and 8 can‑ nabis users Ronzani 2005 Brazil Primary health care Managers and primary health 45 (5 managers; 40 health Qualitative interviews Participants reported difficul‑ care professionals trained to care professionals) ties in routinely implementing use screening and BI BI; Health care professionals limited BI use to alcohol- dependent patients and demonstrate lack of motivation for preventive work De Micheli 2004 Brazil Outpatient treatment centre Adolescents (10–19 years): 99 RCT (four groups: a control A single BI session with drug COUM = M:15,5 (SD:2); group of users in the last use showed a reduction on CONUM = M:13 (SD:1,5); month (COUM), a control cannabis, alcohol and tobacco BI = M:15 (SD:1,5); group of non-users in the consumption after 6 months PO = M:13,5 (SD:2) last month (CONUM), a Brief CONUM group showed at 50.5% Male Intervention group (BI -in 6-month follow-up a significant Attenders of a outpatient case they were regular users) increase in cannabis, alcohol care unit and a Preventive Orientation and tobacco consumption, group (PO—in case they as well as in the intensity of were non users in the last related-problems month) Page 7 of 14 Table 3 (continued) Author Year Country Setting Sample N Study design Key findings India Jhanjee 2017 India Community Female only sample 100 Pilot randomised controlled BI group were two times more Mean age: 43 (13) trial likely to stop tobacco use Illiterate (61%), homemakers compared to control group (69%), nuclear family (60%), (simple advice) married (79.0%) Nadkarni 2017 India Primary care Male only sample 377 Randomised controlled trial Intervention was associ‑ Mean age: 42.3 (11.8) treat‑ ated with short-term (over ment group and 41.7 (10.9) 3 months) and sustained control group effects (over 12 months) on Married (78%) (treatment drinking outcomes, including group) vs 154 (81%) (control higher remission and 14-day group), employed: 163 (87%) abstinence rates Nadkarni et al. International Journal of Mental Health Systems (treatment group) vs 164 (87%) (control group), and completed at least primary education 147 (78%) (treat‑ ment group) vs 160 (85%) (control group) (2022) 16:36 Humeniuk 2011 India Community health centres Male only sample 731 (total sample) Randomised controlled trial BI group had significantly lower Mean age: 31.4 (9.3) 177 participants from India Alcohol, Smoking and Sub‑ Average years of education: stance Involvement Screening 9.5 (SD = 5.2) Test (ASSIST) total scores for Employed (94%) illicit substance involvement at Married (34%) follow-up compared with the control participants (wait-list control), with stronger effects on cannabis and opioid use scores at the India site Pal 2007 India Community Male only sample 90 Non-randomised controlled Decrease in severity of Mean age: 29.7 years (9.89) trial dependence as measured by Married: (67.7%) alcohol use in the last 30 days, composite alcohol severity index scores and improvement in physical and psychological quality of life, in those in the treatment group (BI) versus those in the control group (simple advice) Page 8 of 14 Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 9 of 14 made to study them in various countries in Latin Amer- Brazil, and Colombia evaluated the use of BI among ado- ica. However, evidence from Cochrane reviews high- lescent populations [56–62], but evidence is mixed and lights a clear need for more evaluative research on BIs in limited in terms of representativeness of the samples. For LMICs [16]. Most studies of BIs in Latin America have instance, the few randomized controlled trials [60, 62] been conducted in primary care settings, with small sam- vary with regard to the number of BI sessions (from one ples, and focused on process evaluation rather than effi- to four) and sample sizes (ranging from 25 to 58). A qual- cacy or effectiveness, a major limitation that undermines itative study assessing the feasibility of using BI for HIV/ the knowledge on the use of BI in this context. SIDA populations in Peru concluded that there are multi- Human resources in mental health in Latin America ple barriers to the implementation of BIs through existing are scarce [47, 48], and there are high levels of profes- healthcare systems, including lack of awareness of sub- sional turnover [49]. To some extent, this lack of human stance use problems, lack of time and space, and shortage resources is also related to a well-documented lack of of specialized centers to refer patients [63]. These stud- training [48, 50, 51]. Thus, several efforts in Latin Amer- ies highlight the need for randomized controlled trials to ica are aimed at training professionals in delivering BIs. examine effectiveness as well as scaling up of BIs. In Brazil, the countrywide distance-learning course Thus, relevant knowledge from Latin America is pre- SUPERA (https://​www.​supera.​org.​br) has offered more dominantly derived from experiences with BI training than 135,000 training opportunities in screening and programs and some governmental implementation of BI, since 2006. Most professionals who completed the BI as healthcare policy. These studies highlighted some course applied BI in their work, and patients receiving barriers to BI implementation in Latin America. These the intervention had significantly reduced scores on the include lack of engagement of policymakers and health Alcohol, Smoking and Substance Involvement Screening service administrators [31], stigma among professionals Test (ASSIST) [52]. Additionally, the Regional Referral [49, 64], scarcity of human resources [47], high levels of Centers on Drugs have also trained hundreds of health, professional turnover [49], and lack of training [48, 49]. social and justice professionals around the country [53]. Finally, the majority of these studies from Latin America Implementation studies from Brazil show that BI train- are from around 7 out of 33 nations; each one having its ing helped to overcome the stigma and moralistic views own political, sociocultural, economic, and epidemiolog- about alcohol among professionals. Although neither of ical idiosyncrasies that should be considered while imple- the studies evaluated effectiveness or efficacy of BIs, the menting BIs. authors highlighted the lack of integration within and To summarize, the current evidence of BIs in Latin between services and absence of support from policy- America is promising, but the lack of effectiveness stud- makers or health administrators as relevant barriers for ies remains a major limitation. Appropriate evaluation of implementation of BIs [48, 49]. In Mexico, there have BI efficacy and effectiveness in Latin America is under- been advances in training professionals, prevention, and mined by lack of generalizability, and methodological treatment, with over 400 centers offering BI-based ser- limitations; and implementation is hampered by multiple vices across the country; however, the impact of this pro- barriers. gram has not been fully evaluated [27]. The government’s initiative for implementing BI in Chile has helped mul- India tidisciplinary teams to carry out approximately 600,000 Alcohol is the second most common substance used in screenings and BI annually [53]. However, one of the larg- India, after tobacco [65]. Rapid socio-economic changes est pragmatic randomized controlled trial of BIs in Latin in India over the past couple of decades, have resulted America conducted in a range of Chilean settings (health in an increase in alcohol availability and consumption. centers, emergency rooms and police stations) showed Overall, although India has a relatively high abstinence no evidence of the effectiveness of BI [41]. Finally, the rate, many people who do drink, do so problematically use of web-based BI delivery in LA countries might help [66]. Despite this growing public health problem, the offi- to overcome some implementation barriers, such as the cial policy response in India remains primarily focused lack of training, human resources, and financial support. on treatment services for AUDs in specialist settings, In a World Health Organization (WHO) multicenter and within that, on the more severe problems of alcohol randomized controlled trial testing the efficacy of a web- dependence [66]. based BI [54], preliminary findings from Brazil showed Primary care in India offers opportunities for the early reductions of alcohol consumption [55]. detection and management of AUDs. However, with Several studies considered the use of BI among vulner- addictions treatment being primarily situated in tertiary able populations in LA. Studies from Mexico, Argentina, care, there is no routine screening conducted at primary Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 10 of 14 care or in the community; resulting in a large treatment reasons for this, including conflicting priorities between gap. Furthermore, there have been no systematic and sci- a public health and prevention approach versus a clini- entific efforts to explore the implementation and evalua- cal approach in which general practitioners may be more tion of BIs in primary and community platforms of care concerned with identifying and dealing with patients’ in India. existing problems [75]. In one of the first randomized controlled trials of brief The evidence gap for AUDs in India needs urgent motivational interviewing in any LMIC, a brief treat- attention, with future work needing to focus on examin- ment delivered by lay counsellors to harmful drinkers in ing implementation and scale up concerns regarding BIs, India led to positive and sustained effects on remission and how systems can be better planned to integrate care and abstinence, and was also demonstrated to be cost- for alcohol-related problems. First, a move away from the saving from a health systems’ perspective [67, 68]. There focus on tertiary-care for addictions is necessary, as it is is promise in the road ahead for AUD care in India, with not only expensive, but also has limited availability and emerging evidence on the use of innovative solutions access. Second, with most research in India being focused which can potentially revolutionize how treatment of on BIs for tobacco use [76–78], expansion to other areas addictions is conceptualized [69]. Chand and colleagues of addictions research is crucial. Third, there needs to have developed a system for capacity building in the be a move towards adoption and scaling up of contextu- practice of addictions treatment, by linking non-special- ally appropriate and evidence-based interventions. For ist health professionals with specialists for remote super- instance, several studies have demonstrated the validity vision [70]. In recent times, India’s health system has and utility of brief screening instruments (e.g. the Alco- undergone a paradigm shift in health care delivery. The hol Use Disorders Identification Test) [79], and effective- recently launched “Ayushman Bharat” (Healthy India) ness of lay-counsellor delivered and primary-care based [71] national level initiative (which has envisioned uni- models for treatment of harmful drinking [67, 68]. BIs versal health coverage) covers preventative and therapeu- can play a key role in addressing the burden, harms and tic interventions for non-communicable diseases at the societal costs associated with AUDs in India. However, community level, through Health and Wellness Centres. there is need for developing and evaluating new con- This shift in care offers opportunities for scaling up inno- textually relevant evidence in India, and also testing the vative and feasible options for the prevention and treat- implementation of evidence based BIs in this specific cul- ment of AUDs, which are major risk factors for several tural context. non-communicable diseases (NCDs). Hence, much more needs to be done in terms of Table 3 summarises the main characteristics of the research on BIs, both effectiveness and implementation, studies reported in this review. in LMICs given the uncertainties about their effects. However, the pace of such research in LMICs has been Discussion disappointing, despite clear evidence suggesting a grow- Although there have been some efforts to test and/or ing burden of AUDs and the magnitude of unmet needs implement BIs in LMICs, as described above, much more of people with such disorders. The first step towards needs to be done, specially taking into account that BIs overcoming this research gap is leadership and champi- are part of the five high-impact strategies to reduce alco- oning of these efforts, not just by addictions researchers hol problems included in the SAFER (Strengthen restric- and specialists, but by generalist clinicians and health tions on availability, Advance and enforce drink driving care system managers within the larger NCD arena. In counter measures, Facilitate access to screening, BIs and this context, examples of some promising initiatives treatment, Enforce bans or comprehensive restrictions include the screening and brief intervention programme on alcohol advertising, sponsorship, and promotion, based on the Alcohol, Smoking and Substance Involve- Raise prices of alcohol) initiative promoted by the World ment Screening Test (ASSIST) to help decrease sub- Health Organization (WHO). This is particularly impor- stance misuse in primary care in Thailand [80], and the tant as not much is known about contextual influences, SCALA program in Colombia, Mexico and Peru. such as cross-cultural variability, and health system idi- Innovative strategies need to be deployed to over- osyncrasies, or indeed how existing evidence, primarily come supply side barriers related to specialist work- from HICs, may generalise to other healthcare settings force shortages in LMICs. There is a growing evidence [72, 73]. on the effectiveness of non-specialist health work- Although there are examples of implementation of ers, including lay counsellors, in delivering frontline BI programmes, including those from Latin America psychological interventions for a range of disorders described above, most efforts to implement BIs at scale including AUDs in LMICs [81]. The potential of have been largely unsuccessful [74]. There are several such a non-specialist cadre of workers needs to be Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 11 of 14 Table 4 Summary points Summary points Research in context: The harmful use of alcohol is projected to increase globally, and particularly substantially in LMICs, indicating the need for compre‑ hensive interventions to address the burgeoning burden of alcohol-related harms. An intervention with demonstrated effectiveness and cost-effective‑ ness evidence from diverse settings is the screening and BI approach for alcohol-related problems. Despite positive evidence favouring the use of BIs, a major challenge in the field of addictions has been the effective deployment and evaluation of this approach in routine practice Added value of this study: Our paper aims to synthesise the state of the evidence for the implementation of BIs for alcohol use disorders, particularly hazardous and harmful drinking. We focus on low-resource settings because of challenges related to the uptake, dissemination and implementation of evidence-based BIs in these settings and provide potential solutions with specific examples from two low-resource contexts Implications of existing evidence: To the best of our knowledge, there have been very few efforts to examine bottlenecks and opportunities in BI research in LMIC contexts. There is promise in potential solutions for supply-side barriers in care provision, including the use of the task-sharing model, digital technology-based delivery, remote capacity building efforts, etc. There is also a need for further work to unpack how BIs can be implemented and optimized in low-resource settings appropriately leveraged through training, monitor- conducted—in LMICs as well as in HICs. Table 4 sum- ing and hand-holding of such personnel. Additionally, marises the key findings of our paper, its implications, there is growing evidence about the utility of technol- and the way forward. ogy based interventions for a range of substance use We hope that our paper, a collaborative exercise problems [82]. This is true for LMICs as well, where between early-career and senior researchers from LMIC technology is increasingly providing new possibili- and HICs, in the context of the International Network on ties for delivering a range of interventions [83]. In Brief Interventions for Alcohol and Other Drugs (www.​ many LMICs there has been a technological leap with inebr​ia.​net), stimulates discussions among policy-mak- a ‘mobile-first’-based approach to communications, ers, researchers, and practitioners in LMICs. Increasing and people are more likely to have access to a mobile access to evidence based care for AUDs in LMICs would phone than to have clean water, or a source of electric- need a concerted effort from all these stakeholders, ity [76]. As the market penetration of low-cost mobile especially with regard to the systemic and philosophi- devices increases in such countries it provides another cal changes to research and implementation strategies potentially transformative opportunity for increasing underlying prevention efforts. access to BIs. Finally, in addition to increasing access, it is also crucial to reduce demand side barriers by Conclusion reframing AUDs as a preventable health risk, espe- In conclusion, the evidence on implementation of BIs in cially in LMICs where they are often seen as a charac- LMICs is limited. Despite the global evidence of efficacy, ter flaw or a moral issue. there are several systemic barriers to implementation and One might question the utility of examining the barri- scaling up BIs in such countries. Our paper highlights ers to implementation of BIs in LMICs when these have these barriers and also makes the case for the implemen- not been implemented in regular practice anywhere else tation and rigorous evaluation of innovative strategies to in the world. Presently there is evidence for a modest enable the scaling up of BIs despite the limited resources effect of BIs in efficacy studies in HICs, while their imple- in LMICs. mentation in regular health care remains elusive. The reasons for this are many, the most important being that Abbreviations the concept of screening and brief intervention comes AUD: Alcohol use disorders; BI: Brief interventions; ASSIST: Alcohol, Smoking from public health, but hopes to be applied in clinical and Substance Involvement Screening Test; HIC: High income countries; LMIC: practice. The major problems with this are well known: Low- and middle-income countries; MI: Motivational interviewing; NCD: Non communicable diseases; WHO: World Health Organization. practitioners do not like general screening, because they do not feel they have time for alcohol discussions and Acknowledgements furthermore they lack confidence in their ability to help We would like to acknowledge the International Network on Brief Interven‑ tions for Alcohol and other Drugs (INEBRIA) for supporting the early career problem drinkers. The barriers to implementation dis- researchers who contributed to this paper. cussed in this paper largely apply to high income coun- tries (HICs) as well: lack of time, lack of skills, lack of Author contributions SA and LS-G conceptualised this paper. AN, AB, UB, TCSdP, JGdAT, and MT perceived relevance, etc. These are observations that call contributed sections to the first draft of the manuscript. All authors reviewed for major rethinking of how brief interventions should be all the drafts. All authors read and approved the final manuscript. Nadkarni et al. International Journal of Mental Health Systems (2022) 16:36 Page 12 of 14 Funding 6. Bye EK, Moan IS. Trends in older adults’ alcohol use in Norway 1985–2019. Andre Bedendo is funded through grants #2018/12729-9; #2017/13831-9 Nordic Stud Alcohol Drugs. 2020. https://​doi.​org/​10.​1177/​14550​72520​ by São Paulo Research Foundation (FAPESP). Urvita Bhatia is funded by a 954325. Global Challenges Research Fund studentship grant. Tassiane Paula is funded 7. Raninen J, Agahi N. Country report: trends in older people’s drinking by Grant 142486/2018-3, National Council for Scientific and Technological habits, Sweden 2004–2017. Nordic Stud Alcohol Drugs. 2020. https://​doi.​ Development (CNPQ). Joanna Tostes is funded by Foundation for Research of org/​10.​1177/​14550​72520​954336. the State of Minas Gerais (FAPEMIG). 8. Kaur G, Bansal R, Anand T, Kumar A, Singh J. Morbidity profile of noncom‑ municable diseases among elderly in a city in North India. Clin Epidemiol Availability of data and materials Glob Health. 2019;7(1):29–34. Data sharing not applicable to this article as no datasets were generated or 9. Yadav A, Prasad JB, Shekher C, Vishvakarma M. A study of morbidity analysed during the current study. pattern among elderly population in urban India. J Soc Health Diabetes. 2017;5(02):100–6. 10. Nair UR, Vidhukumar K, Prabhakaran A. Age at onset of alcohol use and Declarations alcohol use disorder: time-trend study in patients seeking de-addiction services in Kerala. Indian J Psychol Med. 2016;38(4):315. Ethics approval and consent to participate 11. Moure-Rodriguez L, Carbia C, Lopez-Caneda E, Corral Varela M, Cadaveira Not applicable. F, Caamaño-Isorna F. Trends in alcohol use among young people accord‑ ing to the pattern of consumption on starting university: a 9-year follow- Consent for publication up study. PLoS ONE. 2018;13(4):e0193741. Not applicable. 12. Ramadass S, Gupta SK, Nongkynrih B. Adolescent health in urban India. J Family Med Prim Care. 2017;6(3):468. Competing interests 13. Manthey J, Shield KD, Rylett M, Hasan OS, Probst C, Rehm J. Global The authors declare that they have no competing interests. alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. Lancet. 2019;393:P2493-2502. Author details 14. 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