Factors Influencing Lay and Professional Health Workers’ Self-efficacy in Identification and Intervention for Alcohol, Tobacco, and Other Substance Use Disorders in Kenya

  • Sian Hsiang-Te Tsuei
  • Veronic Clair
  • Victoria Mutiso
  • Abednego Musau
  • Albert Tele
  • Erica Frank
  • David Ndetei
Original Article


The global burden of substance use disorders (SUDs), including alcohol and tobacco, disproportionately affect low- and middle-income countries (LMICs), considering their rising disease burden and low service capacity. Nested within a Kenyan training program, this study explores factors associated with healthcare providers’ self-efficacy to treat SUD. Surveys of 206 healthcare workers were used to perform regression and sensitivity analysis assessing various factors association with self-efficacy. Self-efficacy for SUD was lower in those practicing in public facilities and perceiving a need for alcohol use disorder (AUD) training; while higher self-efficacy correlated with a higher proportion of patients with AUD in one’s setting, access to mental health worker support, cannabis use at a moderate risk level, and belief that AUD is manageable in outpatient settings. Increasing awareness about SUD prevalence, identification, and treatment skills could improve the self-efficacy of LMICs’ health care providers and therefore the willingness to implement more services for patients with SUDs.


Alcohol Tobacco Substance use disorders Self-efficacy Low–middle-income countries 



We would like to thank Verena Rossa-Roccor, MD, and Mary Arakelyan for their editorial assistance.

Compliance with Ethical Standards


This study was supported by the Global Mental Health Grant # 0092-04 from Grand Challenges Canada, the Canada Research Chairs program, the Annenberg Physician Training Program in Addiction Medicine (APTPAM), the IMPART clinician fellowship, the Canadian Addiction Medicine Research Fellowship, and the Michael Smith Foundation for Health Research post-doctoral award program.

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.


  1. Alem, A., Kebede, D., & Kullgren, G. (1999). The prevalence and socio-demographic correlates of khat chewing in Butajira, Ethiopia. Acta Psychiatrica Scandinavica, 100(S397), 84–91. doi: 10.1111/j.1600-0447.1999.tb10699.x.CrossRefGoogle Scholar
  2. Bahora, M., Hanafi, S., Chien, V. H., & Compton, M. T. (2008). Preliminary evidence of effects of crisis intervention team training on self-efficacy and social distance. Administration and Policy in Mental Health, 35, 159–167. doi: 10.1007/s10488-007-0153-8.CrossRefPubMedGoogle Scholar
  3. Ballew, P., Castro, S., Claus, J., Kittur, N., Brennan, L., & Brownson, R. C. (2013). Developing web-based training for public health practitioners: what can we learn from a review of five disciplines? Health Education Research, 28, 276–287. doi: 10.1093/her/cys098.CrossRefPubMedGoogle Scholar
  4. Bandura, A., & Cervone, D. (1983). Self-evaluation and self-efficacy mechanisms governing the motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017–1028.CrossRefGoogle Scholar
  5. Battersby, M., Von Korff, M., Schaefer, J., Davis, C., Ludman, E., Greene, S. M., et al. (2010). Twelve evidence-based principles for implementing self-management support in primary care. Joint Commission Journal on Quality & Patient Safety, 36(12), 561–570.CrossRefGoogle Scholar
  6. Bazzano, A. T., Zeldin, A. S., Diab, I. R. S., Garro, N. M., Allevato, N. A., Lehrer, D., & Team, W. R. C. P. O. (2009). The healthy lifestyle change program: a pilot of a community-based health promotion intervention for adults with developmental disabilities. American Journal of Preventive Medicine, 37(6 Suppl 1), S201–S208.CrossRefPubMedGoogle Scholar
  7. Beckman, H., Hawley, S., & Bishop, T. (2006). Application of theory-based health behavior change techniques to the prevention of obesity in children. Journal of Pediatric Nursing, 21(4), 266–275. doi: 10.1016/j.pedn.2006.02.012.CrossRefPubMedGoogle Scholar
  8. Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. (2011). Canada: a land of missed opportunity for addressing the social determinants of health. Health Policy, 101(1), 44–58. doi: 10.1016/j.healthpol.2010.08.022.CrossRefPubMedGoogle Scholar
  9. Buckelew, S. M., Adams, S. H., Irwin Jr., C. E., Gee, S., & Ozer, E. M. (2008). Increasing clinician self-efficacy for screening and counseling adolescents for risky health behaviors: results of an intervention. Journal of Adolescent Health, 43(2), 198–200. doi: 10.1016/j.jadohealth.2008.01.018.CrossRefPubMedGoogle Scholar
  10. Cox, G., & Rampes, H. (2003). Adverse effects of khat: a review. Advances in Psychiatric Treatment, 9, 456–463.CrossRefGoogle Scholar
  11. Crandall, S. J., George, G., Marion, G., & Davis, S. (2003). Applying theory to the design of cultural competency training for medical students: a case study. Academic Medicine, 78(6), 588–594.CrossRefPubMedGoogle Scholar
  12. Davis, D., O’Brien, M. A. T., Freemantle, N., Wolf, F. M., Mazmanian, P., & Taylor-Vasley, A. (1999). Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA, 282(9), 867–874.CrossRefPubMedGoogle Scholar
  13. Delgadillo, J., Moreea, O., Outhwaite-Luke, H., Dace, T., Nicholls, B., Ramseyer, G., & Dale, V. (2014). Confidence in the face of risk: the risk assessment and management self-efficacy study (RAMSES). Psychiatric Bulletin, 38(2), 58–65. doi: 10.1192/pb.bp.112.040394.CrossRefGoogle Scholar
  14. DiClemente, C. C., Fairhurst, S. K., & Piotrowski, N. A. (1995). Self-efficacy and addictive behaviors. In J. E. Maddux (Ed.), Self-efficacy, adaptation, and adjustment: theory, research, and application (pp. 109–141). Boston: Springer US.CrossRefGoogle Scholar
  15. Elder, J. P., Ayala, G. X., & Harris, S. (1999). Theories and intervention approaches to health-behavior change in primary care. American Journal of Preventive Medicine, 17(4), 275–284.CrossRefPubMedGoogle Scholar
  16. Embleton, L., Atwoli, L., Ayuku, D., & Braitstein, P. (2013). The journey of addiction: barriers to and facilitators of drug use cessation among street children and youths in western Kenya. PloS One, 8, e53435. doi: 10.1371/journal.pone.0053435.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Franco, L. M., Bennett, S., & Kanfer, R. (2002). Health sector reform and public sector health worker motivation: a conceptual framework. Social Science & Medicine, 54, 1255–1266.CrossRefGoogle Scholar
  18. Frank, E., McLendon, L., Elon, L. K., Denniston, M., Fitzmaurice, D., & Hertzberg. (2005). Medical students’ self-reported typical counseling practices are similar to those assessed using standardized patients. Medscape General Medicine, 7(1), 2.PubMedPubMedCentralGoogle Scholar
  19. Gottlieb, N. H., Mullen, P. D., & McAlister, A. L. (1987). Patients’ substance abuse and the primary care physician: patterns of practice. Addictive Behaviors, 12(1), 23–32. doi: 10.1016/0306-4603(87)90005-0.CrossRefPubMedGoogle Scholar
  20. Green, M. L., & Ellis, P. J. (1997). Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Medicine, 12, 742. doi: 10.1046/j.1525-1497.1997.07159.x.CrossRefGoogle Scholar
  21. Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients’ care. Lancet, 362(9391), 1225–1230.CrossRefPubMedGoogle Scholar
  22. Grol, R., & Wensing, M. (2016). Barriers to and incentives for achieving evidence-based practice. The Medical Journal of Australia, 180(6 suppl), s57.Google Scholar
  23. Harris, B. R., Shaw, B. A., Sherman, B. R., & Lawson, H. A. (2016). Screening, brief intervention, and referral to treatment for adolescents: attitudes, perceptions, and practice of New York school-based health center providers. Substance Abuse, 37(1), 161–167.CrossRefPubMedGoogle Scholar
  24. Henry-Edwards, S., Humeniuk, R., Ali, R., Monteiro, M., & Poznyak, V. (2003). Brief intervention for substance use: a manual for use in primary care. Retrieved from Geneva.Google Scholar
  25. Hodges, B., Inch, C., & Silver, I. (2001). Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950–2000: a review. The American Journal of Psychiatry, 158(10), 1579–1586.CrossRefPubMedGoogle Scholar
  26. Howe, L. D., Galobardes, B., Matijasevich, A., Gordon, D., Johnston, D., Onwujekwe, O., et al. (2012). Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper. International Journal of Epidemiology, 41(3), 871–886. doi: 10.1093/ije/dys037.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Humeniuk, R., Ali, R., Babor, T. F., Farrell, M., Formigoni, M. L., Jittiwutikarn, J., et al. (2008). Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Addiction, 103(6), 1039–1047.CrossRefPubMedGoogle Scholar
  28. Humeniuk, R., Henry-Edwards, S., Ali, R., Poznyak, V., & Monteiro, M. (2010). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. Retrieved from Geneva, Switzerland.Google Scholar
  29. International Labour Office. (2016). Women at work: trends 2016. In: International Labour Office.Google Scholar
  30. Jenkins, R., Kiima, D., Njenga, F., Okonji, M., Kingora, J., Kathuku, D., & Lock, S. (2010a). Integration of mental health into primary care in Kenya. World Psychiatry, 9(2), 118–120.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Jenkins, R., Kiima, D., Okonji, M., Njenga, F., Kingora, J., & Lock, S. (2010b). Integration of mental health into primary care and community health working in Kenya: Context, rationale, coverage and sustainability. Mental Health in Family Medicine, 7, 37–47.PubMedPubMedCentralGoogle Scholar
  32. Jenkins, R., Othieno, C., Okeyo, S., Aruwa, J., Kingora, J., & Jenkins, B. (2013). Health system challenges to integration of mental health delivery in primary care in Kenya—perspectives of primary care health workers. BMC Health Services Research, 13, 368. doi: 10.1186/1472-6963-13-368.CrossRefPubMedPubMedCentralGoogle Scholar
  33. Johnstone, S. M., & Soares, L. (2014). Principles for developing competency-based education programs. Change: The Magazine of Higher Learning, 46(2), 12–19. doi: 10.1080/00091383.2014.896705.CrossRefGoogle Scholar
  34. Kadden, R. M., & Litt, M. D. (2011). The role of self-efficacy in the treatment of substance use disorders. Addictive Behaviors, 36(12), 1120–1126. doi: 10.1016/j.addbeh.2011.07.032.CrossRefPubMedPubMedCentralGoogle Scholar
  35. Kay, K., & Shipman, C. (2014). The confidence code: the science and art of self-assurance—what women should know (1 ed.): HarperBusiness.Google Scholar
  36. Kiima, D., & Jenkins, R. (2010). Mental health policy in Kenya—an integrated approach to scaling up equitable care for poor populations. International Journal of Mental Health Systems, 4, 19.CrossRefPubMedPubMedCentralGoogle Scholar
  37. Koller, M. (2011). Opening minds at university: results of a contact-based anti-stigma intervention. In: Mental Health Commission of Canada.Google Scholar
  38. Lemieux, V., Levesque, J. F., & Ehrmann-Feldman, D. (2011). Are primary healthcare organizational attributes associated with patient self-efficacy for managing chronic disease? Healthc Policy, 6(4), e89–e105.PubMedPubMedCentralGoogle Scholar
  39. Lim, S. S., Vos, T., Flaxman, A. D., Danaei, G., Shibuya, K., Adair-Rohani, H., & AlMazroa, M. A. (2012). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2224–2260.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Manghi, R. A., Broers, B., Khan, R., Benguettat, D., Khazaal, Y., & Zullino, D. F. (2009). Khat use: lifestyle or addiction? Journal of Psychoactive Drugs, 41(1), 1–10.CrossRefPubMedGoogle Scholar
  41. Miller Perrin, E., Flower, K. B., Garrett, J., & Ammerman, A. S. (2005). Preventing and treating obesity: pediatricians’ self-efficacy, barriers, resources, and advocacy. Ambulatory Pediatrics, 5(3), 150–156. doi: 10.1367/A04-104R.1.CrossRefGoogle Scholar
  42. Mokaya, A. G., Mutiso, V., Musau, A., Tele, A., Kombe, Y., Ng’ang’a, Z., et al. (2016). Substance use among a sample of healthcare workers in Kenya: a cross-sectional study. Journal of Psychoactive Drugs, 48(4), 310–319. doi: 10.1080/02791072.2016.1211352.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Morgan, J. F., & Killoughery, M. (2003). Hospital doctors’ management of psychological problems—Mayou & Smith revisited. The British Journal of Psychiatry, 182(2), 153–157. doi: 10.1192/bjp.182.2.153.CrossRefPubMedGoogle Scholar
  44. Muga, F. A., & Jenkins, R. (2008). Training, attitudes and practice of district health workers in Kenya. Social Psychiatry and Psychiatric Epidemiology, 43(6), 477–482.CrossRefPubMedGoogle Scholar
  45. National Campaign Against Drug Abuse Authority. (2012). Rapid situation assessment of the status of drug and substance abuse in Kenya, 2012. Retrieved from.Google Scholar
  46. Ndetei, D., Ongetcha, F., Mutiso, V., Kuria, M., Khasakhala, L., & Kokonya, D. (2007). The challenges of human resources in mental health in Kenya. African Journal of Psychiatry, 10(1), 33–36.CrossRefGoogle Scholar
  47. Ndetei, D., Khasakhala, L., & Omolo, J. (2008a). Incentives for health worker retention in Kenya: an assessment of current practice. Retrieved from Kenya.Google Scholar
  48. Ndetei, D., Pizzo, M., Kuria, M., Khasakhala, L., Maru, M., & Mutiso, V. (2008b). Substance abuse and psychiatric co-morbidities: a case study of patients at Mathari Psychiatric Hospital, Nairobi, Kenya. African Journal of Drug and Alcohol Studies, 7, 53–58. doi: 10.4314/ajdas.v7i1.46359.Google Scholar
  49. Ndetei, D., Khasakhala, L., Ongecha-Owuor, F., Kuria, M., Mutiso, V., & Kokonya, D. (2009). Prevalence of substance abuse among patients in general medical facilities in Kenya. Substance Abuse, 30(2), 182–190.CrossRefPubMedGoogle Scholar
  50. Ndetei, D., Mathai, M., Khasakhala, L., Mutiso, V., & Mbway, A. (2010). University medical education in Kenya: the challenge. Medical Teacher, 32, 5.CrossRefGoogle Scholar
  51. Ndetei, D. M., Khasakhala, L. I., Mutiso, V., & Mbwayo, A. W. (2011). Knowledge, attitude and practice (KAP) of mental illness among staff in general medical facilities in Kenya: practice and policy implications. African Journal of Psychiatry, 14, 225–235. doi: 10.4314/ajpsy.v14i3.6.CrossRefPubMedGoogle Scholar
  52. Njenga, A. (2015). Alcohol control and devolution in Kenya.Google Scholar
  53. Nturibi, E. M., Akinsola, A. K., & McCurdy, S. A. (2009). Smoking prevalence and tobacco control measures in Kenya, Uganda, the Gambia and Liberia: a review. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 13(2), 165–170.Google Scholar
  54. O’Campo, P., Kirst, M., Tsamis, C., Chambers, C., & Ahmad, F. (2011). Implementing successful intimate partner violence screening programs in health care settings: evidence generated from a realist-informed systematic review. Social Science & Medicine, 72(6), 855–866.CrossRefGoogle Scholar
  55. Othieno, C. J., Kathuku, D. M., & Ndetei, D. M. (2000). Substance abuse in outpatients attending rural and urban health centres in Kenya. East African Medical Journal, 77(11), 592–595.PubMedGoogle Scholar
  56. Othieno, C., Jenkins, R., Okeyo, S., Aruwa, J., Wallcraft, J., & Jenkins, B. (2013). Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya. International Journal of Mental Health Systems, 7, 5. doi: 10.1186/1752-4458-7-5.CrossRefPubMedPubMedCentralGoogle Scholar
  57. Ozer, E. M., Adams, S. H., Gardner, L. R., Mailloux, D. E., Wibbelsman, C. J., & Irwin Jr., C. E. (2004). Provider self-efficacy and the screening of adolescents for risky health behaviors. Journal of Adolescent Health, 35(2), 101–107. doi: 10.1016/j.jadohealth.2003.09.016.CrossRefPubMedGoogle Scholar
  58. Patten, S. B., Remillard, A., Phillips, L., Modgill, G., Szeto, A. C., Kassam, A., & Gardner, D. M. (2012). Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students. BMC Medical Education, 12, 120. doi: 10.1186/1472-6920-12-120.CrossRefPubMedPubMedCentralGoogle Scholar
  59. Pinfold, V., Toulmin, H., Thornicroft, G., Huxley, P., Farmer, P., & Graham, T. (2003). Reducing psychiatric stigma. The British Journal of Psychiatry, 182, 342–346.CrossRefPubMedGoogle Scholar
  60. Republic of Kenya. (2013). Health sector strategic and investment plan (KHSSP) July 2013–June 2017: the second medium term plan for health. In: Ministry of Medical Services and Ministry of Public Health & Sanitation.Google Scholar
  61. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370, 878–889. doi: 10.1016/S0140-6736(07)61239-2.CrossRefGoogle Scholar
  62. Schram, P., Harris, S. K., Van Hook, S., Forman, S., Mezzacappa, E., Pavlyuk, R., & Levy, S. (2015). Implementing adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) education in a pediatric residency curriculum. Substance Abuse, 36(3), 332–338. doi: 10.1080/08897077.2014.936576.CrossRefPubMedGoogle Scholar
  63. Schrecker, T., & Labonte, R. (2004). Taming the brain drain: a challenge for public health systems in southern Africa. Internal Journal of Occupational and Environmental Health, 10(4), 409–415.CrossRefGoogle Scholar
  64. Staff of the Global Legal Research, D. (2015). Legal status of Khat in selected jurisdictions. Retrieved from
  65. The Academy of Medical, S. (2008). Challenges and priorities for global mental health research in low- and middle-income countries: symposium report. Retrieved from.Google Scholar
  66. Thompson, S. C., Schwankovsky, L., & Pitts, J. (1993). Counselling patients to make lifestyle changes: the role of physician self-efficacy, training and beliefs about causes. Family Practice, 10(1), 70–75. doi: 10.1093/fampra/10.1.70.CrossRefPubMedGoogle Scholar
  67. Tumwine, J. (2011). Implementation of the framework convention on tobacco control in Africa: current status of legislation. International Journal of Environmental Research and Public Health, 8(11), 4312–4331. doi: 10.3390/ijerph8114312.CrossRefPubMedPubMedCentralGoogle Scholar
  68. WHO. (2008). mhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological, and substance use disorders. In: World Health Organization.Google Scholar
  69. WHO. (2010). ATLAS on substance use (2010)—resources for the prevention and treatment of substance use disorders. In: World Health Organization.Google Scholar
  70. WHO. (2011). Human resources for mental health: workforce shortages in low- and middle-income countries. Retrieved from.Google Scholar
  71. Woddruff, S. I., Candelaria, J. I., & Elder, J. P. (2010). Recruitment, training outcomes, retention, and performance of community health advisors in two tobacco control interventions for Latinos. Journal of Community Health, 35(2), 124–134.CrossRefGoogle Scholar
  72. Zurn, P., Dal Poz, M., Stilwell, B., & Adams, O. (2002). Imbalances in the workforce: briefing paper. In: World Health Organization.Google Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.School of Population and Public HealthUniversity of British ColumbiaVancouverCanada
  2. 2.Africa Mental Health FoundationNairobiKenya
  3. 3.Department of PsychiatryUniversity of NairobiNairobiKenya

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