The Effectiveness of a Web-Based Self-Help Program to Reduce Alcohol Use Among Adults With Drinking Patterns Considered Harmful, Hazardous, or Suggestive of Dependence in Four Low- and Middle-Income Countries: Randomized Controlled Trial

BACKGROUND

Given the scarcity of alcohol prevention and use disorder treatments in many low- and middle-income countries (LMICs), the World Health Organization has launched an eHealth portal that includes the web-based self-help program "Alcohol e-Health."

OBJECTIVE

We aimed to test the effectiveness of the Alcohol e-Health program in a randomized controlled trial.

METHODS

This was a two-arm, individually randomized, and controlled trial across four LMICs comparing the self-help program and a psychoeducation and internet access as usual waiting list. Participants were broadly recruited from community samples in Belarus, Brazil, India, and Mexico from January 2016 through January 2019. The primary outcome measure was change in the Alcohol Use Disorders Identification Test (AUDIT) score with a time frame of 6 months between baseline and follow-up. Secondary outcomes included self-reported numbers of standard drinks over the previous week and cessation of harmful or hazardous drinking (AUDIT score <8).

RESULTS

For this study, we recruited 1400 predominantly male (n=982, 70.1%) at least harmful or hazardous alcohol drinkers. The mean age was 37.6 years (SD 10.5). The participants were recruited from Brazil (n=587), Mexico (n=509), India (n=212), and Belarus (n=92). Overall, complete case analysis identified higher AUDIT changes in the intervention group (B=-4.18, 95% CI -5.42 to -2.93, P<.001, d=0.56) that were mirrored by changes in weekly standard drinks (B=-9.34, 95% CI -15.90 to -2.77, P=.005, d=0.28) and cessation rates for harmful or hazardous drinking (χ21=14.56, N=561, P<.001). The supplementary intention-to-treat analyses largely confirmed these initial results.

CONCLUSIONS

The expansion of the Alcohol e-Health program to other LMICs with underdeveloped alcohol prevention and treatment systems for alcohol use disorders should be considered after successful replication of the present results.

TRIAL REGISTRATION

ISRCTN ISRCTN14037475; https://www.isrctn.com/ISRCTN14037475.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1111/add.14034.

The global proportion and volume of unrecorded alcohol in 2015

Background

Alcohol consumption is associated with elevated risks of disease and injury, and the best indicator of the level of consumption in a country is total alcohol per capita (APC) consumption among adults which comprises recorded consumption and unrecorded consumption. While recorded consumption can be assessed with small measurement bias via taxation or other governmental records, unrecorded consumption is more difficult to assess. The objectives of this study were to estimate the country-specific proportion and volume of unrecorded APC in 2015, to identify main sources of unrecorded alcohol and to assess to what extent experts perceive unrecorded alcohol as a public health, social, and financial problem.

Methods

Estimates of unrecorded APC were based on a multilevel fractional response regression model using data from World Health Organization’s (WHO) STEPwise approach to surveillance surveys (16 countries, 66 188 participants), estimates from the routine WHO reporting on key indicators of alcohol use (189 countries), and a nominal group expert assessment (42 countries, 129 experts). Expert assessments also included data on the sources of unrecorded alcohol and the perception of unrecorded alcohol as a public health, social, and financial problem.

Results

The volume of global unrecorded APC was 1.6 L pure alcohol, representing 25% of the total APC. The volume of unrecorded APC was highest in Europe (2.1 L per capita), while the proportion of unrecorded APC was highest in the WHO Eastern Mediterranean region (57% of the total alcohol). In countries with available data, homemade alcohol was identified as a major source of unrecorded alcohol. The majority of experts considered unrecorded alcohol to be a public health (62%), social (60%), and financial problem (54%).

Conclusions

High volumes of unrecorded alcohol are consumed globally; however, the volumes consumed and the sources of the unrecorded alcohol exhibit large geographical variation.

The social location of harm from others' drinking in 10 societies

AIMS

Survey data from 10 diverse countries were used to analyse the social location of harms from others' drinking: which segments of the population are more likely to be adversely affected by such harm, and how does this differ between societies?

METHODS

General-population surveys in Australia, Chile, India, Laos, New Zealand, Nigeria, Sri Lanka, Thailand, United States and Vietnam, with a primary focus on the social location of the harmed person by gender, age groups, rural/urban residence and drinking status. Harms from known drinkers were analysed separately from harms from strangers.

RESULTS

In all sites, risky or moderate drinkers were more likely than abstainers to report harm from the drinking of known drinkers, with risky drinkers the most likely to report harm. This was also generally true for harm from strangers' drinking, although the patterns were more mixed in Vietnam and Thailand. Harm from strangers' drinking was more often reported by males, while gender disparity in harm from known drinkers varied between sites. Younger adults were more likely to experience harm both from known drinkers and from strangers in some, but not all, societies. Only a few sites showed significant urban/rural differences, with disparities varying in direction. In multivariate analyses, most relationships remained, although some were no longer significant.

CONCLUSION

The social location of harms from others' drinking, whether known or a stranger, varies considerably between societies. One near-commonality among the societies is that those who are themselves risky drinkers are more likely to suffer harm from others' drinking.

The Differential Effects of Exposure to “Youth-Oriented” Magazines on Adolescent Alcohol Use

This study examines the effects of exposure to “youth-oriented” magazines on normative beliefs about teenage drinking, drinking expectancies, and drinking frequency during the past 30 days among a group of 972 seventh- and eighth-grade students from two Western U.S. states. Three magazine categories were considered: music/entertainment, sports, and men's lifestyle. Structural equation modeling was used to test the simultaneous influences (direct and indirect) of magazine exposure, religiosity, parental drinking, and the number of best friends who drink on the three outcome variables (normative beliefs, expectancies, and current drinking). Exposure to each magazine type was tested in a separate model. Men's lifestyle magazine reading frequency was positively associated (both directly and indirectly) with all three outcomes. Music and entertainment magazine reading was positively linked to normative beliefs and drinking expectancies, but was unrelated to drinking frequency in the past 30 days. Sports magazine reading was unrelated to the three outcomes.

Alcohol e-Help: study protocol for a web-based self-help program to reduce alcohol use in adults with drinking patterns considered harmful, hazardous or suggestive of dependence in middle-income countries

BACKGROUND AND AIMS

Given the scarcity of alcohol prevention and alcohol use disorder treatments in many low and middle-income countries, the World Health Organization launched an e-health portal on alcohol and health that includes a Web-based self-help program. This paper presents the protocol for a multicentre randomized controlled trial (RCT) to test the efficacy of the internet-based self-help intervention to reduce alcohol use.

DESIGN

Two-arm randomized controlled trial (RCT) with follow-up 6 months after randomization.

SETTING

Community samples in middle-income countries.

PARTICIPANTS

People aged 18+, with Alcohol Use Disorders Identification Test (AUDIT) scores of 8+ indicating hazardous alcohol consumption.

INTERVENTION AND COMPARATOR

Offer of an internet-based self-help intervention, 'Alcohol e-Health', compared with a 'waiting list' control group. The intervention, adapted from a previous program with evidence of effectiveness in a high-income country, consists of modules to reduce or entirely stop drinking.

MEASUREMENTS

The primary outcome measure is change in the Alcohol Use Disorders Identification Test (AUDIT) score assessed at 6-month follow-up. Secondary outcomes include self-reported the numbers of standard drinks and alcohol-free days in a typical week during the past 6 months, and cessation of harmful or hazardous drinking (AUDIT < 8).

ANALYSIS

Data analysis will be by intention-to-treat, using analysis of covariance to test if program participants will experience a greater reduction in their AUDIT score than controls at follow-up. Secondary outcomes will be analysed by (generalized) linear mixed models. Complier average causal effect and baseline observations carried forward will be used in sensitivity analyses.

COMMENTS

If the Alcohol e-Health program is found to be effective, the potential public health impact of its expansion into countries with underdeveloped alcohol prevention and alcohol use disorder treatment systems world-wide is considerable.

A Multi-Country Study of Harms to Children Because of Others' Drinking

OBJECTIVE

This study aims to ascertain and compare the prevalence and correlates of alcohol-related harms to children cross-nationally.

METHOD

National and regional sample surveys of randomly selected households included 7,848 carers (4,223 women) from eight countries (Australia, Chile, Ireland, Lao People's Democratic Republic [PDR], Nigeria, Sri Lanka, Thailand, and Vietnam). Country response rates ranged from 35% to 99%. Face-to-face or telephone surveys asking about harm from others' drinking to children ages 0-17 years were conducted, including four specific harms: that because of others' drinking in the past year children had been (a) physically hurt, (b) verbally abused, (c) exposed to domestic violence, or (d) left unsupervised.

RESULTS

The prevalence of alcohol-related harms to children varied from a low of 4% in Lao PDR to 14% in Vietnam. Alcohol-related harms to children were reported by a substantial minority of families in most countries, with only Lao PDR and Nigeria reporting significantly lower levels of harm. Alcohol-related harms to children were dispersed sociodemographically and were concentrated in families with heavy drinkers.

CONCLUSIONS

Family-level drinking patterns were consistently identified as correlates of harm to children because of others' drinking, whereas sociodemographic factors showed few obvious correlations.

Television and drinking expectancies: the influence of television viewing on positive drinking expectanc and alcohol use among US and Norwegian adolescents: a comparative analysis

Objective

Exposure to incidental portrayals of drinking on television and cleverly crafted advertisements has been linked to the development of positive alcohol expectancies in children and teenagers. Researchers hoping to demonstrate this connection, however, have difficultly in finding adolescent groups with little or no exposure to alcohol advertising for comparative purposes. One of the cornerstones of Norwegian alcohol policy has been a government-enacted ban on all forms of advertising for alcohol products containing more than 2.5% alcohol by volume. As a consequence, Norwegian youth have almost no experience with alcohol advertising. This study represents a comparative analysis of Norwegian and US teenagers that seeks to improve our understanding of television's and alcohol advertising's potential role in shaping attitudes about alcohol.

Method

Self-report data on television viewing, normative beliefs about teenage drinking, and alcohol expectancies were collected from convenience samples of 972 junior high students in the US and 622 junior high students in Norway.

Results

Although students in both countries watch about the same amount of television and about equal numbers have tried alcohol, the Norwegian students were more likely to see drinking as a normal teenage behavior and to have more positive outcome expectancies. For students from both countries who had no personal experience with alcohol, frequent television viewers were more likely than light viewers to see drinking as a normative behavior with positive outcomes. This was particularly true for Norwegian students who viewed large amount of US and British programs as well as music videos.

Conclusion

The absence of alcohol advertising in Norway may be overshadowed by the general cultural acceptance of adolescent and young adult drinking. For students with no personal experience with alcohol, however, television may be functioning as an important socializing agent, providing them with portrayals of drinking behaviors, cultivating normative beliefs, and presenting opportunities to cognitively model and rehearse the behaviors shown.

Web-based self-help intervention reduces alcohol consumption in both heavy-drinking and dependent alcohol users: A pilot study

As part of a multicenter project supported by the World Health Organization, we developed a web-based intervention to reduce alcohol use and related problems. We evaluated the predictors of adherence to, and the outcomes of the intervention. Success was defined as a reduction in consumption to low risk levels or to <50% of the baseline levels of number of drinks. From the 32,401 people who accessed the site, 3389 registered and 929 completed the full Alcohol Use Disorders Identification Test (AUDIT), a necessary condition to be considered eligible to take part in the intervention. Based on their AUDIT scores, these participants were classified into: low risk users (LRU; n=319) harmful/hazardous users (HHU; n=298) or suggestive of dependence users (SDU; n=312). 29.1% of the registered users (LRU=42; HHU=90; SDU=82) completed the evaluation form at the end of the six-week period, and 63.5% reported low-risk drinking levels. We observed a significant reduction in alcohol consumption in the HHU (62.5%) and SDU (64.5%) groups in relation to baseline. One month after the intervention, in the follow-up, 94 users filled out the evaluation form, and their rate of success was similar to the one observed in the previous evaluation. Logistic regression analyses indicated that HHU participants presented higher adherence than LRU. Despite a relatively low adherence to the program, its good outcomes and low cost, as well as the high number of people that can be reached by a web-based intervention, suggest it has good cost-effectiveness.

Socioeconomic inequalities in risk factors for non communicable diseases in low-income and middle-income countries: results from the World Health Survey

BACKGROUND

Monitoring inequalities in non communicable disease risk factor prevalence can help to inform and target effective interventions. The prevalence of current daily smoking, low fruit and vegetable consumption, physical inactivity, and heavy episodic alcohol drinking were quantified and compared across wealth and education levels in low- and middle-income country groups.

METHODS

This study included self-reported data from 232,056 adult participants in 48 countries, derived from the 2002-2004 World Health Survey. Data were stratified by sex and low- or middle-income country status. The main outcome measurements were risk factor prevalence rates reported by wealth quintile and five levels of educational attainment. Socioeconomic inequalities were measured using the slope index of inequality, reflecting differences in prevalence rates, and the relative index of inequality, reflecting the prevalence ratio between the two extremes of wealth or education accounting for the entire distribution. Data were adjusted for confounding factors: sex, age, marital status, area of residence, and country of residence.

RESULTS

Smoking and low fruit and vegetable consumption were significantly higher among lower socioeconomic groups. The highest wealth-related absolute inequality was seen in smoking among men of low- income country group (slope index of inequality 23.0 percentage points; 95% confidence interval 19.6, 26.4). The slope index of inequality for low fruit and vegetable consumption across the entire distribution of education was around 8 percentage points in both sexes and both country income groups. Physical inactivity was less prevalent in populations of low socioeconomic status, especially in low-income countries (relative index of inequality: (men) 0.46, 95% confidence interval 0.33, 0.64; (women) 0.52, 95% confidence interval 0.42, 0.65). Mixed patterns were found for heavy drinking.

CONCLUSIONS

Disaggregated analysis of the prevalence of non-communicable disease risk factors demonstrated different patterns and varying degrees of socioeconomic inequalities across low- and middle-income settings. Interventions should aim to reach and achieve sustained benefits for high-risk populations.

Entertainment and music magazine reading and binge drinking among a group of juvenile offenders

This study examines the relative contribution of exposure to entertainment and music magazines on binge drinking among a group of teenagers under the supervision of a juvenile court system in a medium-sized western United States community. Despite having a large proportion of adolescent readers, entertainment and music magazines typically include a substantial number of advertisements for alcoholic beverages in each issue. Data were collected via a self-report questionnaire administered to 342 juvenile offenders (ages 12-18 years). Three-quarters of our respondents reported they have used alcohol and about 37% indicated they were binge drinkers. As anticipated, binge drinkers were more frequent readers of entertainment and music magazines than non-binge drinkers. Binge drinkers also estimated that larger portions of their classmates used alcohol and would be more accepting of regular drinking than non-binge drinkers. Results of a multivariate logistic regression analysis to predict whether our subjects typically consumed five or more drinks during a drinking episode indicated that perceived ease of access, age, gender, the number of best friends who drink, parental drinking (inversely), and entertainment and music magazine reading frequency were significant predictors of binge drinking. We conclude that the predictive influence entertainment and music magazine reading frequency may actually reflect a selectivity bias among a segment of the youth sub-culture already inclined toward alcohol use and abuse. We recommend that entertainment and music magazine reading should be considered only within the constellation of other risk factors when assessing risk for potential alcohol abuse.

The relationship between viewing US-produced television programs and intentions to drink alcohol among a group of Norwegian adolescents

The aim of this study was to examine the influence of exposure to US-produced television programs and family rules prohibiting alcohol use on the development of normative beliefs, expectancies, and intentions to drink alcohol in the next 12 months among a group of Norwegian adolescents who reported that they had not previously consumed alcohol. Data were collected via a survey administered to 622 eighth and ninth graders enrolled at ten junior highs in southeastern Norway. To examine these relationships we tested the fit of a structural equation model which was based on the Theory of Planned Behavior (Ajzen, 1988). Data from the non-drinkers (n= 392, 63% of the respondents) were used. To control for the influence of peer drinking on behavioral intentions, our model was tested under two group conditions: (1) those subjects reporting that they have no friends who drink alcohol and (2) those subjects reporting that they have one or more friends who drink. The findings indicate that the influence of TV exposure was a significant predictor (directly) of normative beliefs, expectancies (indirectly) and intentions to drink (both directly and indirectly) only for those subjects who reported having no friends who drink. For the group with non-drinking friends, family rules constrain intentions only indirectly by influencing normative beliefs. For those with friends who drink, however, family rules have a direct (inverse) effect on intentions. It is concluded that exposure to US-produced television programs functions as a limited knowledge source only for those subjects who had little or no personal experience with alcohol while the presence of family rules have limited impact on behavioral intentions.

Using "Bud World Party" attendance to predict adolescent alcohol use and beliefs about drinking

This study explored the association between attendance at the "Bud World Party," a family entertainment venue created by Anheuser-Busch for the 2002 Winter Olympics, and alcohol-related beliefs and current drinking behaviors for a group of 7th and 8th graders who attend a middle school in close proximity to the downtown Salt Lake City plaza where the exhibit and related events were located. Data were collected via a questionnaire administered to 283 students 30 days after the closing ceremonies.. Logistic regression was used to predict recent alcohol consumption. Significant predictors were race (non-white) (OR = 3.9), religiosity (OR = .72), having a parent who drinks (OR = 4.8), the number of best friends who drink (OR = 2.5), and the interaction for "Bud World Party" attendance and gender (OR = 33.2). Post-hoc analysis of the interaction effect indicated that the relationship between "Bud World Party" attendance and recent alcohol consumption is moderated by gender. Girls who visited "Bud World Party" were more likely than the boys to have consumed alcohol in the past 30 days. In addition, the girls who visited "Bud World Party" were more likely to believe that drinking would increase their chances of popularity at school than the students who did not.