Family-centred interventions for people with substance use disorders in low-income and middle-income country settings: a scoping review protocol

Abstract

Introduction

Substance use disorder (SUD) and problematic substance use are global public health concerns with significant multifaceted implications for physical health and psychosocial well-being. The impact of SUD extends beyond the individual to their family while imposing financial and social burdens on the community. Though family-centred interventions have shown promise in addressing SUD, their implementation and impact in low-income and middle-income countries (LMICs) remain underexplored.

Methods and analysis

Per Joanna Briggs Institute’s scoping review protocol, a systematic search strategy was employed across OVID Medline, Embase, PsycINFO, Web of Science–Core Collection, Global Health and CINAHL from 22 February 2024 to 26 February 2024, to identify relevant studies focused on family-centred interventions for SUD in LMIC, devoid of publication time and language constraints. Two independent reviewers will screen the titles, abstracts and full texts, with discrepancies resolved through discussion or third-party reviews. The extracted data charted in a structured form will be visualised by diagrams or tables, focusing on the feasibility and impact of family-centred interventions for SUD in LMIC. For qualitative studies, the findings will be synthesised and presented in thematic clusters, and for studies that report quantitative outcomes, specific health, including SUD and psychosocial, outcomes will be synthesised, aligning with the Population, Concept and Context framework.

Ethics and dissemination

These data on substance use, psychosocial outcomes and perspectives of individuals with SUD and their families will be presented in narrative format, highlighting patterns and identifying research gaps. This review aims to synthesise the existing evidence on family-centred interventions for improving substance use and/or psychosocial outcomes in individuals with SUD in LMIC and seeks to inform future policy and practice. Ethics approval is not required for this scoping review, and modifications to the review protocol will be disclosed. Findings will be disseminated through conference proceedings and peer-reviewed publication.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This review fills the gap in the literature, which focuses on evaluating family-centred interventions in high-income countries, by advancing the understanding of the feasibility of implementation and the impact of these interventions in low-income and middle-income countries.

• The review includes diverse evidence sources, such as grey literature, devoid of language and publication time constraints, thus providing a comprehensive view.

• We are intentionally limiting the review to not include subsets of family-centred interventions (eg, behavioural couples therapy) or interventions focused on a caregiver with substance use disorder.

Introduction

Substance use disorder (SUD) encompasses physical, social and mental impairments resulting from the use of a wide range of substances, including nicotine, cannabis, alcohol, sedatives, stimulants, hypnotics, inhalants, opiates and hallucinogens.¹ Per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms of SUD are categorised into four groups: impaired control, physical dependence, social problems and risky use.² Individuals with SUD often find themselves using more of the substance than intended or for extended periods.² Despite their efforts to reduce or quit, they cannot, driven by intense cravings or urges for the substance.² Tolerance develops, necessitating higher doses to achieve the desired effect and withdrawal symptoms emerge when substance use is discontinued.² SUD can consume significant time with individuals devoting substantial effort to obtain, use and recover from substance use.² This condition frequently leads to the neglect of personal and professional responsibilities, straining relationships and causing individuals to withdraw from social activities.² Finally, substance use may extend to risky situations that endanger the individual’s well-being, all the while persisting despite the harm it causes to the individual.² These criteria, based on extensive research, serve as a comprehensive framework for understanding and diagnosing SUD.²

Globally, the prevalence of substance use and SUD surged by 23% and 45%, respectively, during the past decade (between 2011 and 2021) with an estimated 296 million individuals reporting that they use substances and nearly 40 million individuals with SUD in 2021.^{3 4} While available estimates suggest significant global differences in the prevalence of SUD with countries such as the USA, the UK, Russia and Australia reporting the highest rates,⁵ the extent of SUD in low-income and middle-income countries (LMICs) is likely not fully represented given gaps in global data. However, several studies provide insights into the burden of SUD in LMIC. A systematic review by Baranyi et al focusing on incarcerated populations in LMIC aimed to discern the prevalence of mental health disorders and SUD and estimated the 1-year prevalence for SUD to be at 5.1%, roughly six times that of the general population.⁶ Specific to alcohol use disorder, a systematic review on studies from Eastern Africa observed a prevalence of problematic alcohol consumption in youth at 15%, comparable to alcohol consumption prevalence estimates among youth in the USA.^{7 8} The prevalence of SUD has been escalating in LMIC,⁹ compounded by challenges, such as the lack of training among healthcare workers in early problem recognition and concerning gaps in the availability and accessibility of SUD treatment services due to limited public funding.¹⁰ The paucity of services for SUD is particularly exacerbated within rural areas of LMIC, where the treatment gap reaches alarming levels, ranging from 75% to 95%.^{9 11}

It is critical to note that SUD often occurs concurrently with mental health disorders, as well as other SUD, a phenomenon known as co-occurring disorders (COD).¹²,¹⁴ With regard to the prevalence of COD, one study observed that the population prevalence of COD increased from 15% to 32% from 2009 to 2017.¹⁵ Notably, the prevalence of other mental health disorders tends to be higher among those with opioid and stimulant use disorders compared with alcohol-related issues.¹⁶ Furthermore, research has shown that the prevalence of specific co-occurring SUD varies for adults with opioid use disorder from 10.6% for methamphetamine to 26.4% for alcohol.¹² The prevalence of COD additionally contributes to the public health crisis of SUD.

SUDs affect individuals, families and communities worldwide. The ramifications of substance use extend beyond the afflicted individual, encompassing spouses, caregivers, extended family members and vulnerable children within the family unit.¹⁷,²⁰ However, families can play a pivotal role as staunch allies in the journey towards recovery. Central to this idea is the recognition that bolstering family functioning is a critical protective mechanism, both in the prevention of substance use initiation and the support of sustained recovery efforts.²⁰,²²

Within this context, numerous evidence-based family-centred interventions, which refer to psychosocial interventions that encompass a broader approach that involves the entire family unit, have been developed, such as multidimensional family therapy,²³,³³ multisystemic therapy,³⁴,³⁶ functional family therapy,³⁷,⁴¹ brief strategic family therapy,⁴²,⁴⁶ ecological-based family therapy^{39 47} and behavioural family therapy.⁴⁸ The aim of these interventions is to enhance family dynamics, address the distinctive needs and vulnerabilities of family members grappling with the effects of substance use, and empower them to contribute positively to the recovery of individuals struggling with SUD.^{23 35 40 43 48 49} Furthermore, these interventions enhance the family/social recovery capital of individuals with SUD by leveraging resources available through family relationships⁵⁰ while also promoting family recovery by fostering support and rebuilding healthy relationships.²² These interventions have not only been developed but also subjected to rigorous testing, demonstrating their effectiveness across a wide spectrum of substance use and psychosocial outcomes, such as improved engagement and retention in substance use treatment programmes, reduced substance use among affected individuals, as well as enhanced family resilience.2425 31 36 41,44 48 49 51 52

Prior reviews have provided valuable insights into family-centred interventions for SUD, forming a foundation for understanding their implementation in health services and effectiveness.³⁶⁵³,⁵⁵ However, these reviews primarily focus on high-income countries, as indicated by a search in PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis, leaving a notable gap in our understanding of the feasibility of implementation and the impact of these interventions in LMIC. Specifically, individuals with SUD and their families in LMIC settings encounter distinct barriers to receiving family-centred interventions, including socioeconomic barriers, limited access to trained providers and diverse cultural contexts, thereby necessitating tailored and context-specific approaches for successful intervention implementation.⁵⁶

To address this gap, our scoping review focuses on the key evidence for the use of family-centred interventions to address SUD in LMIC settings. First, we emphasise that individuals with SUD are likely to derive benefits from diverse psychosocial interventions. Second, our scope encompasses family-centred interventions, acknowledging that SUD and resultant health and/or psychosocial outcomes impact not only individuals but also extend their effects to families and social networks. Thus, interventions aimed at addressing family vulnerabilities and enhancing protective factors hold the promise for impacting substance use and psychosocial outcomes for individuals with SUD and their family members. Lastly, we contextualise this scoping review within LMIC, recognising the dearth of literature pertaining to the implementation of family-centred interventions for SUD in these settings.

In this scoping review, we aim to synthesise the available evidence on family-centred interventions aimed at improving substance use and/or psychosocial outcomes among individuals with SUD in LMIC.

Methods/design

Patient and public involvement

Patients and the public were not involved in any way in the development of this study’s protocol.

Our scoping review, which will be carried out from February 2024 to August 2024, will follow the methodological stages outlined here: (1) defining the research question, (2) locating relevant studies, (3) selecting suitable research sources, (4) extracting and organising data and (5) synthesising and presenting the findings.⁵⁷ To facilitate reproducibility, the final output of our review will adhere to the reporting guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews statement.^{58 59}

Identifying the research question

The primary research questions addressed in this scoping review are as follows:

1. What family-centred interventions have been created and/or adapted/modified and put into practice, with or without formal evaluation through studies or trials in LMIC?

2. How have family-centred interventions in LMIC been adapted or culturally tailored to suit the distinct sociocultural contexts of these regions?

3. What substance use and/or psychosocial outcomes have been evaluated and measured following family-centred interventions?

The subquestions addressed in this scoping review are as follows:

1. What are the perspectives of individuals with SUD regarding these interventions and their impact?

2. What are the perspectives of family members of individuals with SUD regarding these interventions and their impact?

Eligibility criteria

Using the Population, Concept, Context (PCC) framework from the Joanna Briggs Institute, the eligibility criteria for this scoping review (table 1) were determined. The authors do not endorse the terms ‘drug abuse’, ‘substance abuse’, ‘substance dependence’ and ‘problematic substance use’. However, we are including these terms in the inclusion criteria given the potential use of these terms in studies conducted in LMIC, which is the focus of this scoping review.

Table 1. Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Study focus	Studies focusing on a family-centred intervention for SUD, drug use, drug abuse, substance abuse, substance dependence and/or problematic substance use.	Studies not focused on a family-centred intervention for SUD, drug use, drug abuse, substance abuse, substance dependence and/or problematic substance use.
Population	All: children, adolescents, and adults.
Study context	LMIC, under-resourced settings.	HIC, high-resource settings.
Intervention	Family-centred intervention (ie, multidimensional family therapy, multisystemic therapy, functional family therapy, brief strategic family therapy, ecological-based family therapy, strengths-oriented family therapy, behavioural family therapy, culturally informed and flexible family treatment for adolescents, families preparing the new generation, systemic-motivational therapy, psychoeducation, solution-focused brief therapy, community reinforcement and family training, network therapy, adolescent community reinforcement approach, treatment family with elements of family therapy, de novo/ad hoc interventions).Family-centred intervention may be combined with another intervention (eg, medications for opioid use disorder).	Main SUD intervention is not family-centred intervention and does not pertain to the entire family unit (ie, behavioural couples therapy, peer-delivered interventions, and individual and/or group psychotherapy for individuals using substances, etc).
Outcome	Substance use outcomes (change in measure of substance use, change in the frequency of substance use).Substances include tobacco, nicotine, alcohol, opioids, opiates, marijuana, hashish, narcotics, methamphetamines, cannabis, sedatives, hypnotics, anxiolytics, inhalants, hallucinogens, stimulants, etc.Psychosocial outcomes (reduction in substance use stigma, improvement in family communication, improvement in family functioning, improvement in academic/education, improvement in work, reduction in mental health comorbidities (depression, anxiety, suicidality)).	Does not include substance use outcomes or psychosocial outcomes.
Study characteristics	Randomised controlled trialsIntervention studiesCross-sectional studiesObservational studies qualitative data studiesCase reports/nongovernmental organization (NGO) reportsBook chaptersMeta-analysis and/or systematic reviewsAbstractsConference proceedingsDissertations	Expert opinions/reviews
Time frame	No constraints based on publication date
Publication language	No constraints based on publication language	Unable to obtain translation

HIChigh-income countryLMIClow-income and middle-income countrySUDsubstance use disorder

Identifying relevant sources of evidence

Our research encompassed a structured exploration across various electronic databases, including OVID Medline, Embase, PsycINFO, Web of Science–Core Collection, Global Health, and CINAHL from 22 February 2024 to 26 February 2024, to provide relevant evidence. A search for grey (ie, literature difficult to locate in electronic databases) may be necessary. To refine our search strategy, we initially developed it in MEDLINE, using Medical Subject Headings (MeSH) and pertinent keywords specifically tailored to family-centred interventions for SUD, drug use, drug abuse, substance abuse, substance dependence and psychosocial outcomes (table 2). Following a pilot search on PubMed (online supplemental material 1), we evaluated the titles and abstracts of prospective sources for pertinent text and index terms that will be incorporated into the search strategy. To ensure the reliability and comprehensiveness of our search strategy, a health sciences librarian subjected it to rigorous evaluation in alignment with the Peer Review of Electronic Search Strategies statement before adapting it for use in other databases. Furthermore, we will contact authors involved in ongoing or forthcoming studies to obtain full-text articles or any supplementary information, as needed.

Table 2. Pilot Search.

Search strategy	Search date	Electronic database	Number of studies
(Keywords)	XX/XX/2024	PubMed	XXXX

Studies will be chosen without language limitations, acknowledging the importance of research published in other languages, particularly in LMIC. If non-English articles are included, they will be translated by colleagues and associates, who are native speakers of the respective languages. Additionally, articles will be selected regardless of publication date to ensure a comprehensive approach to examining the outcomes of family-centred interventions for SUD in LMIC over the past decades.

Each database search will be systematically documented, encompassing the search date, strategy and the number of records retrieved (online supplemental material 2). We will cross-reference the references within eligible sources to uncover additional relevant evidence. To streamline our research management and screening processes and eliminate duplicates, we will use Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews (www.covidence.org).

Selection of sources of evidence

To mitigate selection bias, a rigorous screening process will be employed involving two independent reviewers who will evaluate all articles retrieved from the database searches. Initially, titles and abstracts of studies and publications will undergo screening in the Covidence platform, aligning with the eligibility criteria outlined in this scoping review protocol. Subsequently, based on the screening of titles and abstracts, a detailed assessment of the full-text articles will be conducted. In instances where discrepancies in evaluations arise, the two reviewers will engage in a thorough re-evaluation to resolve the dispute. In cases where consensus remains elusive, the input of a third reviewer will be sought to render a decision. The entire process of source identification and selection will be comprehensively documented and presented in accordance with the PRISMA flow diagram.⁵⁹

Extracting and organising data

To systematically organise pertinent information from each selected article, a structured data chart will be devised in Excel. This form will encompass the following categories: (1) source title, author(s), publication year and study location; (2) aims and objectives; (3) characteristics of the target population (eg, age and ethnicity); (4) sample size; (5) details of family-centred interventions; (5a) how was the intervention developed (ie, de novo, adapted and/or modified from existing evidence-based interventions)? (5b) who is administering the intervention? (5c) what is the educational qualification of the individual administering the intervention? (5d) what is the duration of the intervention? (5e) what are the components of the intervention? (5f) in what setting is the intervention being delivered/administered (inpatient vs outpatient)? (6) outcomes; (6a) specific substance use outcomes targeted; (6b) substance use outcomes measured; (6c) other outcomes measured (ie, psychosocial impacts on individual with SUD and/or psychosocial impacts on family); (6d) substance use preintervention; (6e) substance use postintervention; (6f) statistical test (p value, etc) and (7) principal results and conclusions drawn from the study.

To ensure the effectiveness of the data-charting form, an initial pilot test will be conducted on a subset of the selected sources of evidence. Subsequent adjustments will be made to the form as needed to facilitate comprehensive data charting. Two independent reviewers will be responsible for charting data from each of the included sources. In cases of disparities in data charting, the two reviewers will engage in collaborative reassessment and discussion to reach a consensus. If consensus proves elusive, a third researcher will be consulted to help resolve any discrepancies. In line with the PRISMA scoping review guidelines, a formal quality assessment of the included evidence sources will not occur.⁵⁹

The outcomes of the data charting process will be visualised through diagrams or tables, aligning with the objectives of this scoping review, which pertain to the feasibility of implementing family-centred interventions and their impact/influence on addressing SUD and/or psychosocial outcomes for both individuals with SUD and their family units. The data mapping process will align with the PCC eligibility criteria, focusing on individuals with SUD, the concept of family-centred interventions and the context of LMIC settings. The breakdown of evidence sources will be presented by publication year, settings and methodological approaches. Qualitative data pertaining to (1) substance use and psychosocial outcomes, (2) perspectives of individuals with SUD on receipt and impact of family-centred interventions and (3) perspectives of family members on receipt and impact of family-centred interventions will be synthesised. In particular, we will conduct a thematic synthesis.⁶⁰ Two researchers will independently conduct a thematic analysis of the findings from all the studies in the data extraction table; specific patterns discerned in the charted data will be highlighted to facilitate the categorisation of results into thematic clusters.⁶⁰ After discussing the themes that emerged from their independent reviews, researchers will organise them into 4–5 distinct categories, with data and themes grouped accordingly within each category.⁶⁰

Ethics and dissemination

These thematically synthesised findings will be presented in a narrative format contextualised within the scope of the review’s objectives and research questions. Furthermore, gaps in the existing literature will be identified, and directions for future research and potential interventions will be outlined accordingly. This review aims to contribute to policy, as well as improvements in public health and healthcare practices for individuals and families affected by SUD in LMIC. As such, given the disproportionate burden of SUD in LMIC, this evidence synthesis will be valuable for practitioners and policymakers globally.

Ethics approval is not needed for this scoping review, and any modifications to the review protocol implemented during the course of this scoping review will be disclosed in the final manuscript. The findings of this scoping review will be disseminated through conference proceedings and publication in a peer-reviewed journal.