Summary of findings 9. Lay health worker‐led interventions compared to enhanced usual care for adult patients with alcohol dependence in low‐ and middle‐income countries.
| What are the effects of lay health worker‐led interventions vs enhanced usual care for adult patients with alcohol dependence in low‐ and middle‐income countries? | ||||||
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Patient or population: adult patients with alcohol dependence Setting: low‐ and middle‐income countries (India (1 study)) Intervention: lay health worker‐led psychological interventions Comparison: enhanced usual care (screening and referral) | ||||||
| Outcomes | Anticipated absolute effects*(95% CI) | Relative effect (95% CI) | №. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with enhanced usual care | Risk with lay health worker‐led interventions | |||||
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Clinical recovery ‐ harmful or dependent alcohol use (1 to 6 months post intervention) Defined by AUDIT score < 8 (RR > 1 denotes higher likelihood of recovery) |
145 per 1000 participants | 271 per 1000 participants (131 to 566) | RR 1.87 (0.90 to 3.90) | 121 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWb | It is uncertain whether LHW‐delivered interventions for adult patients with dependent use of alcohol have any effect on recovery from dependent alcohol use 1 to 6 months post intervention compared to enhanced usual care |
| Prevalence of alcohol dependence (1 to 6 months post intervention) | No studies that reported on this outcome were identified | |||||
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Clinical symptoms ‐ alcohol use (1 to 6 months post intervention) Assessed with grams of ethanol consumed (lower number = lower amount consumed) |
Mean alcohol use in this LHW intervention is 0.3 grams of ethanol lower (21.6 lower to 21.0 higher) compared to enhanced usual care | MD ‐0.3 (‐21.6 to 21.0) | 121 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWc | It is uncertain whether LHW‐delivered interventions for adult patients with dependent use of alcohol have any effect on alcohol use 1 to 6 months post intervention compared to enhanced usual care | |
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Clinical symptoms ‐ depression (1 to 6 months post intervention) Assessed with PHQ‐9 (higher score = higher depression symptom severity) |
Mean depression score in this LHW intervention is 0.5 points lower (2.68 lower to 1.68 higher) compared to enhanced usual care | MD ‐0.5 (‐2.68 to 1.68) | 121 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWc | It is uncertain whether LHW‐delivered interventions for adult patients with dependent use of alcohol have any effect on depression symptoms 1 to 6 months post intervention compared to enhanced usual care | |
| Quality of life | No studies that reported on this outcome were identified | |||||
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Functional impairment (1 to 6 months post intervention) Assessed with WHODAS II (lower score = less functional impairment) |
Mean functional impairment score in this LHW intervention is 0.9 points lower (3.43 lower to 1.63 higher) compared to enhanced usual care | MD ‐0.9 (‐3.43 to 1.63) | 121 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWc | It is uncertain whether LHW‐delivered interventions for adult patients with dependent use of alcohol have any effect on functional impairment 1 to 6 months post intervention compared to enhanced usual care | |
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Service utilisation ‐ Unplanned hospitalisation in past 12 months (RR > 1 denotes higher risk of hospitalisation) |
148 per 1000 participants | 104 per 1000 participants (39 to 279) | RR 0.70 (0.26 to 1.88) | 112 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWd | It is uncertain whether LHW‐delivered interventions for adult patients with dependent use of alcohol have any effect on unplanned hospitalisations more than 6 months post intervention compared to enhanced usual care |
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Adverse events ‐ death in past 12 months (RR > 1 denotes higher risk of death) |
15 per 1000 participants | 5 per 1000 participants (0 to 117) | RR 0.32 (0.01 to 7.70) | 135 (1 RCT)a | ⨁⊝⊝⊝ VERY LOWd | It is uncertain if LHW‐delivered interventions for adult patients with dependent use have any effect on death more than 6 months post intervention compared to enhanced usual care |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). AUDIT: Alcohol Use Disorder Identification Test; CI: confidence interval; LMIC: low‐ to middle‐income country; LHW: lay health worker; MD: mean difference; PHQ‐9: Patient Health Questionnaire‐9; RCT: randomised controlled trial; RR: risk ratio; WHODAS II: World Health Organization DIsability Assessment Schedule 2.0. | ||||||
| GRADE Working Group grades of evidence. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||||
aNadkarni 2019. Manualised psychological intervention (“Counselling for Alcohol Problems”) vs enhanced usual care (screening and referral).
bDowngraded by one level for indirectness: Nadkarni 2019 was performed in a lower‐middle‐income country, and interventionists underwent 2 weeks of classroom training followed by 6 months of internship. Patients were males only. Training may not be scalable to other populations in LMICs. Single trial in a single setting. Downgraded by two levels for serious imprecision: few events. Confidence interval ranges from no clinical effect to favouring LHW‐led intervention.
cDowngraded by one level for indirectness: Nadkarni 2019 was performed in a lower‐middle‐income country, and interventionists underwent 2 weeks of classroom training followed by 6 months of internship. Patients were males only. Training may not be scalable to other populations in LMICs. Single trial in a single setting. Downgraded by two levels for serious imprecision: Low total numbers. Confidence interval ranges from favouring LHW‐led interventions to enhanced usual care.
dDowngraded by one level for indirectness: Nadkarni 2019 was performed in a lower‐middle‐income country, and interventionists underwent 2 weeks of classroom training followed by 6 months of internship. Patients were males only. Training may not be scalable to other populations in LMICs. Single trial in a single setting. Downgraded by two levels for serious imprecision: Very few events. Confidence interval ranges from favouring LHW‐led intervention to favouring enhanced usual care.