Cultural Adaptation of a Brief Intervention to Reduce Alcohol Use Among Injury Patients in Tanzania

Abstract

Background Harmful alcohol use is a leading risk factor for injury-related death and disability in low- and middle-income countries (LMICs). Brief negotiational interventions (BNIs) administered in emergency departments (EDs) to injury patients with alcohol use disorders (AUDs) are effective in reducing post-hospital alcohol intake and re-injury rates. However, most BNIs to date have been developed and implemented in high-income countries. The efficacy of BNIs in LMICs is largely unknown as few studies have undertaken the rigorous task of culturally adapting these interventions to new settings. Given the high prevalence of alcohol-related injury in the Kilimanjaro region of Tanzania, we culturally adapted a BNI to reduce post-injury alcohol use for implementation in this patient population. Methods We used an iterative, multiphase process to culturally adapt a high-income country standard of care BNI to the Tanzanian setting using the Intervention Mapping ADAPT framework. Our team consisted of local healthcare professionals with extensive experience in counseling patients who use alcohol, as well as an international team of academic and clinical professionals. Focus groups were used to inform culturally appropriate changes to the standard of care BNI protocol. Objective assessment of BNI delivery was performed to ensure adherence to the FRAMES model of motivational interviewing. Results We developed the Punguza Pombe Kwa Afya Yako (PPKAY); a one-time, 15-minute nurse-led BNI that encourages safe alcohol use and motivates change in alcohol use behaviors among injury patients in the Kilimanjaro region of Tanzania. Adaptations to the original intervention protocol include changes regarding the interventionist, how a patient is greeted, how the topic of alcohol use is raised, how a patient is informed of their harmful alcohol use, how graphics are visualized within the intervention protocol, how behavior change is motivated, and which behavior changes are encouraged. Conclusions The PPKAY intervention is the first BNI to be culturally adapted for delivery to injury patients in an LMIC population. Our study demonstrates a unique approach to adapting substance use interventions for use in LMICs, and shows that cultural adaptation of alcohol use interventions is feasible even in settings where community knowledge regarding harmful alcohol use is limited. Our study prompts the need for further research and cultural adaptation of BNIs for other low-income communities at increased risk of alcohol-related harm.

Feasibility of a pragmatic randomized adaptive clinical trial to evaluate a brief negotiational interview for harmful and hazardous alcohol use in Moshi, Tanzania

“…Nurses maintained a high rate of PPKAY intervention fidelity. Overall, 76% of the PPKAY interventions delivered had 19 or more of the 22 critical actions as recommended in the BI Assessment Scale [ 37 , 60 ]. Interventions performed after QI discussions were found to be more adherent than earlier ones, suggesting success of our QI processes.…”

“…This is a four-step discussion: 1) raise the subject of alcohol, 2) provide feedback, 3) enhance motivation, 4) negotiate and advise. PPKAY was culturally adapted based on quantitative and qualitative data from the Swahili-speaking KCMC injury population [ 37 ]. Prior to feasibility trial enrollment, PPKAY was iteratively improved and reassessed by Tanzanian nurse counselors who evaluated the cultural appropriateness and the adherence to the tenants of BNI and motivational interviewing.…”

Feasibility of SMS booster for alcohol reduction in injury patients in Tanzania

“…In order to prolong the potential impact of the in-person PPKAY, SMS boosters were created to reinforce the knowledge/awareness of alcohol related harms, and goal-setting and self-efficacy components of the PPKAY. While further details on this multi-step process of the PPKAY and SMS development is described in full elsewhere [29,38], in short, these short standard or personalizable phrases focused awareness, self-efficacy, and goal setting were translated, acculturated and validated through multiple rounds of translations, piloting in our research team, clinicians and the target population.…”

“…PPKAY was designed and adapted using the American College of Emergency Physicians/ NIAAA-recommended standards [28]. The PPKAY was adapted to Swahili and the Tanzanian environment with help from a trained local research team with methods further delineated elsewhere [29]. A Pragmatic Randomized Adaptive Clinical Trial (PRACT) was designed to evaluate 1) whether the PPKAY would lead to a reduction in alcohol related harms at 3-month follow-up when compared to the usual standard of care; 2) whether a standard SMS booster would improve the effectiveness of the PPKAY intervention; and 3) whether a personalized SMS booster would be more effective than PPKAY alone or PPKAY with standard booster.…”

Understanding the Impacts and Perceptions of Alcohol Use in Northern Tanzania: A Mixed-Methods Analysis

“…Previous work from our team has examined stigma (29,33), perceptions of alcohol use (23), the prevalence of alcohol-related injuries upon Emergency Department (ED) arrival (32), and developing and implementing an intervention to reduce alcohol misuse for the ED injury patient population (34,35). Building off of this research, a greater understanding of the specific societal perceptions of alcohol will allow for a clearer picture of its role within the Moshi community.…”