# Effectiveness of a brief intervention and text-based booster in the emergency department to reduce harmful and hazardous alcohol use: A pragmatic randomized adaptive clinical trial in Moshi, Tanzania

## TL;DR

A brief counseling session with follow-up text messages reduced binge drinking in hospitalized patients in Tanzania compared to usual care.

## Contribution

The study introduces a culturally adapted brief intervention with text-based boosters for reducing harmful alcohol use in a low-resource setting.

## Key findings

- The intervention group had a 1.2-day reduction in binge drinking days compared to usual care at 3 months.
- The study supports integrating brief alcohol interventions into emergency department care in Tanzania.
- Self-reporting limitations suggest potential bias in outcome interpretation.

## Abstract

Alcohol use contributes to over 3 million deaths annually. In Tanzania, there are no evidence-based culturally adapted interventions to address harmful alcohol use behaviors. Our hypothesis was that “Punguza Pombe Kwa Afya Yako” (PPKAY, Reduce Alcohol for your Health), a culturally adapted brief intervention with text-based boosters, is superior to usual care in reducing binge drinking at 3 months post discharge.

This manuscript reports. Stage 1 of our adaptive clinical trial which seeks to determine the effectiveness of the PPKAY+ booster to usual care; a subsequent stage will compare the PPKAY only to personalized and standard boosters. Adults who sought care for an acute injury at the Kilimanjaro Christian Medical Centre Emergency Department, self-disclosed alcohol use prior to the injury, scored ≥8 on the Alcohol Use Disorder Identification Test, and/or test positive by alcohol breathalyzer were offered enrollment. Participants were randomly assigned to PPKAY+ boosters (personalized or standard) or usual care at 1:1:1 allocation. Primary analyses followed the intention-to-treat principle. The PPKAY is a 15-min nurse delivered brief intervention using motivational interviewing techniques combined with a standardized or personalized text based reminder sent weekly to participants after hospital discharge and until 1 year post enrollment compared to a usual care arm. Follow-up was performed by blinded outcome assessors. Our pooled intervention arms PPKAY+ boosters were compared to usual care to determine the effectiveness of the intervention in reducing the number of binge drinking days, the trial’s primary outcome, in the previous 4 weeks at 3 months after discharge. A total of 1,484 patients were screened for eligibility between October 12th 2020, and on April 14th 2023. 448 patients met inclusion criteria and consented to participate. 148 were randomized to usual care, and 300 to the pooled intervention arm. Reasons for attrition included loss to follow-up (n = 69), withdrawal (n = 6), and deaths (n = 4), with no differences between arms. Most participants were male (94%), from the Chagga tribe (59%) and had an average age of 36.4 years (SD 12.6) at baseline. At the 3-month follow-up, the intervention arm showed a notable reduction in mean predicted binge drinking days by 1.2 days (95% CI: [−2.3, −0.3]; p = 0.002) compared to the usual care group in a difference-in-differences analysis. Importantly, the self-reported nature of our primary outcome introduces the potential for social desirability bias, particularly in the absence of participant blinding, and should be considered a limitation when interpreting the findings.

The reduction in binge drinking behavior at 3-month follow-up compared to usual care suggests our culturally adapted intervention is an effective alcohol intervention for patients acutely injured in Tanzania. According to the adaptive study design, the next phases of the trial will continue to compare the intervention arm with a paired down version without the text messages boosters.

ClinicalTrials.gov NCT04535011

Alcohol use is a significant cause of death and disease worldwide, and Tanzania has a particularly high rate of alcohol-related problems.

Before this study, there were a lack of proven and culturally appropriate ways to help people in Tanzania reduce harmful alcohol use.

Although it was known that many patients injured in Tanzania use alcohol, hospitals do not routinely screen for alcohol problems or offer help.

The researchers conducted a study with 448 adult patients seeking care for an acute injury in Tanzania who were using alcohol.

Patients were randomly assigned to receive either the usual care at the hospital or a brief 15-min counseling session with a nurse about reducing alcohol use and follow-up reminder text messages.

The study found that after three months, the group that received the brief counseling and text messages had a greater decrease in the number of days they engaged in binge drinking compared to usual care; on average, this was a reduction of 1.2 more binge drinking days per month.

The results suggest that a short counseling session delivered by nurses, along with supportive text messages, can be a helpful way to reduce risky drinking behaviors among patients with injury in a low-resource setting like Tanzania.

This study supports the idea of integrating such brief alcohol interventions into routine care in hospital emergency departments to reach people at a time when they might be more open to changing their drinking habits.

Importantly, our primary outcome is self-reported and participants were not blinded, which may introduce social desirability or differential reporting bias; additionally, we enrolled all patients with AUDIT ≥8 (including those with probable dependence), and those with more severe alcohol problems may require more intensive treatment, potentially diluting the observed effect of this brief intervention.

In an adaptive clinical trial in Tanzania, Catherine A. Staton and her colleagues investigate whether a culturally adapted brief intervention with text-based boosters, called Punguza Pombe Kwa Afya Yako, is more effective than usual care at reducing harmful alcohol use behaviors.