Innovating Care of Addictions in Low-Resource Settings
The entire range of addictions is increasingly being acknowledged as an area of public health concern. Substance use disorders and behavioral addictions are associated with a range of adverse health, lifestyle, social, and economic outcomes. Despite the availability of evidence-based interventions, low-resource settings are ridden with challenges of demand-side and supply-side barriers to effective health care, including care for addictions. There is a need for a well conceptualized and integrated response to the growing epidemic of a range of addictions, especially in low-resource settings. Some innovative approaches such as task-sharing and technology-based care, which are highlighted as case studies in this chapter, have shown promise for use across low-resource and even high-resource settings. The future calls for strengthening of the evidence base for addictions care in low-resource settings, focus on the less-researched addictions, cross-setting implementation of existing solutions, and further evaluation and development of existing and alternative innovative approaches. These actions need to be supplemented by robust monitoring and evaluation systems, and a concerted focus from key actors in the health care sector.
Mental and substance use disorders are significant contributors to the global burden of disease and are responsible for a higher burden than communicable diseases such as HIV/AIDS and tuberculosis and noncommunicable diseases such as diabetes (Whiteford et al. 2013). A significant proportion of the burden attributable to mental, neurological, and substance use (MNS) disorders is found in low-and-middle-income countries (LMICs) such as China and India (Charlson et al. 2016). This increasing burden is linked to rapid societal changes including socioeconomic conditions, urbanization, globalization, and technological advances, issues to which LMICs have been particularly susceptible over recent years (Prasad et al. 2016). As a result, there have been major shifts in attitudes regarding substance use, changing trends, and patterns of substance use including increase in availability and consumption, lowering of the age of onset of substance use, patterns of harmful substance use, higher levels of substance use-related problems, and emergence of newer addictions, such as those related to technology (Spooner and Hetherington 2004).
Alcohol use disorders (AUDs) consist of a spectrum of conditions related to excessive alcohol consumption with hazardous drinking, harmful drinking, and dependent drinking representing progressively more serious forms of the condition. Alcohol use is one of the leading risk factors for adult chronic disease, with more than 40 disease categories being fully attributable to alcohol (Rehm et al. 2017). In addition to individual-level harms, the large costs of AUDs to societies are not limited only to health-care costs, but also include unmeasured costs related to social harm, loss of productivity, and direct law enforcement costs (Rehm et al. 2009). AUDs are one of the leading risk factors for disabilities and premature deaths in the world (Whiteford et al. 2013). They account for a larger proportion of disability and mortality, in comparison with other MNS disorders, and are ahead of severe mental disorders such as schizophrenia and bipolar disorder (Whiteford et al. 2013). Alcohol use is also one of the highest risk factor for disability and death in LMICs, especially countries in sub-Saharan Africa, South Asia, and Latin America (Lim et al. 2013). Smoking is also one of the leading risk factors for early death and disability worldwide. Although the prevalence of smoking and consequent morbidity and mortality is now falling in most high-income countries, it is projected that future mortality in LMICs is likely to be huge (GBD 2015 Tobacco Collaborators 2017). A large proportion of smokers worldwide live in LMICs, and in many of those, population growth means that the number of smokers, and hence the burden of harm from smoking, continues to rise (GBD 2015 Tobacco Collaborators 2017). The negative effects of smoking extend well beyond individual and population health, and billions of dollars are lost every year due to lost productivity and health-care expenditure related to smoking (Yang et al. 2016). Generally, the prevalence of illicit drug dependence is the highest in high-income countries in Western Europe and North America (Degenhardt and Hall 2012). Among all substance use disorders, the largest contributor to mortality is opioid dependence, with particularly high proportions of opioid use-related deaths occurring in high-income countries and Sub-Saharan Africa (Degenhardt and Hall 2012). There is a great variation in the geographical distribution of disability within illicit drug use disorders, with the lowest disability being in the LMICs of Sub-Saharan Africa and Latin America (Degenhardt and Hall 2012).
Along with addiction to substances, there is a growing concern about the increasing prevalence and impact of hitherto neglected behavioral addictions. In the modern world, internet use is increasingly becoming an ubiquitous part of our daily lives. Excessive internet use is characterized by some of the core symptoms of substance use disorders, such as loss of control over the involvement in the activity, tolerance to the level of activity, and continued use despite adverse effects on the user’s life (Kuss et al. 2014). With the rapid advances in technology and increasing internet penetration rates across the world, there is reason to be concerned, especially due to the increasing dependence of young people on the internet for social interaction and learning. Similar to substance use disorders, internet addiction too has been shown to have deleterious effects on physical (e.g., association with unhealthy lifestyles, including poor diet, and physical inactivity) and mental (e.g., depression and attention-deficit and hyperactivity disorder) health, and is associated with lower life satisfaction (Kuss et al. 2014). Similarly, another behavioral addiction with health and social consequences that concerns many countries across the world is gambling. Although the prevalence of problem gambling varies across the world, high rates have been reported in countries as diverse as Estonia, South Africa, and the USA (Calado and Griffiths 2016). The growth of online gambling is an added concern, as it is not limited by geographical boundaries, difficult to monitor and control, and is especially easily accessible to younger populations. Despite the relatively low prevalence rate, the burden of gambling addiction extends beyond the individual, to the family and social structures. This includes physical health concerns, comorbid mental health problems (such as substance use disorders, mood, anxiety, and personality disorders), difficulties in relationships, and economic opportunities, and emotional, financial, and social strain on family members (Griffiths 2004; Kalischuk et al. 2006).
As outlined below, there is a growing body of evidence that supports the effectiveness of interventions targeted at prevention, reduction and treatment of addictions, especially AUDs (Room et al. 2005). Such interventions include individual-level programs, community-based approaches, and national policies. School-based education and public information campaigns are popular and widely used strategies. They are aimed at prevention of alcohol problems, but the evidence for their effectiveness is largely unfavorable. The large body of work assessing increasingly complex school-based alcohol education programs demonstrates changes in knowledge and attitudes, but this does not necessarily translate into actual and sustained change in drinking behaviors. Similarly, the experiences with public information campaigns too have not been very encouraging. A range of interventions are available for the treatment of alcohol-related problems. These include “Brief Interventions” – delivered before or soon after the onset of alcohol-related problems or for high-risk drinking, and specialized treatments for more severe alcohol-related problems (i.e., on the harmful and dependent end of the spectrum) to manage alcohol withdrawal, prevention of relapse, and rehabilitation, e.g., medically assisted detoxification using benzodiazepines in inpatient and outpatient settings, residential or outpatient rehabilitation programs, psychosocial interventions (e.g., behavior therapy, motivational enhancement therapy, Twelve Step Facilitation, family therapy), and pharmacotherapy (e.g., naltrexone, acamprosate, disulfiram). In terms of policy-level interventions, there is strong evidence which demonstrates that alcohol consumption is responsive to price, and increased taxation on alcohol reduces mortality rates due to liver cirrhosis and drink-driving, as well as rate of violent crime. Besides increasing price, reduction in the availability of alcohol too reduces amount of drinking and alcohol-related problems, e.g., restriction of the hours and days of alcohol sale and the numbers and types of alcohol outlets, and raising of drinking age. Just as preventive measures are focused on reducing drinking, preventive strategies can also be focused on reducing the adverse impacts of drinking, e.g., drink-driving countermeasures such as laws forbidding driving above a stated blood-alcohol concentration, sustained police attention to drink-driving, sustained program of publicized and random breath-testing, and graduated licensing measures. Preventive measures can also be focused on reducing violence and casualties around public drinking, especially in cultures where public drinking is a norm, e.g., server training and enforcement of policies denying alcohol service to those who are already intoxicated or underage lead to lower rates of customer intoxication, reduced drink-driving casualties, and violence.
Many of the principles that underlie the various interventions for AUDs also apply to other substance use disorders and behavioral addictions. Evidence-based tobacco control policies include taxation, advertising bans, smoke-free policies, restrictions on the marketing and promotion of cigarettes, and individual and community-wide smoking cessation interventions (Levy et al. 2004). Similarly, a variety of policy and prevention approaches have been developed to reduce gambling-related harm, although the evidence base is not so strong because of paucity of research (Dickson-Gillespie et al. 2008; Petry et al. 2017). These include regulatory measures to reduce supply such as limiting the number of gambling outlets, reduction of access hours, and imposition of access restrictions based on age. Demand reduction measures include limiting alcohol use while gambling, restricting access to money, building awareness about gambling-related harm, and helplines and face-to-face interventions for problem gamblers and their families. Finally, for management of illicit drug dependence such as opioids, interventions that are found to be effective in reducing the risk of mortality include opioid substitution therapy, and safe needle and syringe programs (Platt et al. 2018).
Despite the availability of evidence-based treatments globally, the “treatment gap” (proportion of people with an illness who need treatment but do not receive it) for addictions is extremely high, e.g., the contact coverage (proportion of affected individuals who seek help with a service provider) of care for AUDs is less than 20% in most countries (Kohn et al. 2004). Moreover, most patients who are in contact with services do not have their addictions recognized or do not receive evidence-based interventions; hence, the “effective coverage gap” (gap in the actual healthcare gains to the population) is likely to be even larger (De Silva et al. 2014). There are several reasons for such a large treatment gap and these include non-acknowledgment of the problem, lack of awareness about the problem, about available treatments, and about effectiveness of the available treatments, low-help seeking rates, stigma, and logistical barriers such as lack of finances, and limited availability, and poor accessibility of available services.
Of these, some of the biggest barriers to healthcare access in low-resource settings are the shortage of specialist human resources and geographical barriers to access to limited and inequitably distributed healthcare facilities (Knapp et al. 2006). Overcoming such barriers requires disruptive innovations that challenge the status quo and change the way we have been traditionally dealing with the management of addictions. One such disruptive innovation is to deliver psychosocial interventions through task-sharing, i.e., rational redistribution of tasks among health workforce teams. Nonspecialist health workers (NSHWs) are one such human resource with which health care tasks can be shared. NSHWs are first-level providers who have received general rather than specialist mental health training and include professionals (doctors, nurses, and other general para-professionals) as well as nonprofessionals (such as lay providers). Use of NSHWs in frontline healthcare delivery is not a novel concept in other areas of global health, and such use of NSHWs has shown generally encouraging results in the fields of maternal and child health, as well as in communicable diseases such as tuberculosis. Interventions designed to be delivered by NSHWs are an important strategy in reducing the treatment gap for mental health problems in the absence of specialist human resources, especially in LMICs. The estimated total number of mental health care workers needed in LMICs in 2005 was 362,000 (22.3 per 100,000 population in low-income countries and 26.7 per 100,000 in middle-income countries), an overall shortage of 239,052 mental health workers (17.3 per 100,000 population in low-income countries and 14.9 per 100,000 population in middle-income countries) (Kakuma et al. 2011). Extrapolated to all 144 LMICs, there was a shortage of 1.2 million mental health workers; and all low-income countries and about two-thirds of middle-income countries had a shortage of health workers to deliver a core set of mental health interventions (Kakuma et al. 2011). Task-sharing is one way of overcoming this human resource barrier, and NSHWs trained and supervised by specialists have been able to effectively detect and treat mental health problems, refer appropriately, and provide psycho-education and follow-up care; and worked in a range of settings like clinics, halfway homes, and community outreach services, providing services for common mental disorders, severe mental disorders, substance use disorders, epilepsy, learning disabilities, and dementia using complex stepped-care interventions, group interpersonal therapy, cognitive behavioral therapy, behavioral activation, motivational interviewing, and psycho-educational programs. Interventions delivered by NSHWs have been shown to increase recovery from depression and/or anxiety, reduce symptoms in mothers with perinatal depression, reduce the symptoms of post-traumatic stress disorder, improve the behavioral symptoms of people with dementia, improve mental well-being, burden, and distress of carers of people with dementia, and decrease alcohol consumption (van Ginneken et al. 2013). However, when it comes to AUD, there are, at present, very few evidence-based NSHW delivered interventions for any form of AUD in LMICs. This gap is even larger for other types of substance use disorders and behavioral addictions.
A second potential game-changer is the use of a range of technologies which now cover large swathes of the global population and penetrate all walks of life. These technologies offer the potential for revolutionary changes in healthcare delivery by radically restructuring conventional healthcare systems that continue to be largely based on the physical connection between the patient and physician (Naslund et al. 2017). Technology can solve several of the major barriers to healthcare access encountered in LMICs such as geographical distance and a lack of health care workers, and in doing so enable improvements in terms of efficiency and lower health care delivery costs. Technology-enabled services can take several forms and include web-based information resources, web-based self-help interventions, telephone messaging interventions, remote monitoring of patients, remote interpretation of medical reports, videoconferencing, and tele-health, including the remote services of a specialist. All of this can be done through technology platforms such as the internet, computers, mobile phones, smartphones, patient monitoring devices, mobile telemedicine/tele-care devices, and mobile computing. Thus, technology can play a fundamental role at several levels of the care delivery process such as supporting prevention, diagnosis, treatment decision-making, and follow-up by assisting human-executed processes.
The next section describes a few illustrative case examples of innovative healthcare delivery that challenge the existing systems of care for addictions in low-resource settings.
Innovations to Increase Access to Care for Addictions in Low-Resource Settings
Nonspecialist Health Worker-Delivered Interventions
Nonspecialist health workers (NSHW) are first-level providers who have received general rather than specialist mental health training and include professionals (e.g., nurses) as well as nonprofessionals (such as lay providers). NSHWs are also conceptualized based on their background and level of training as lying on a spectrum with the “natural helper” (unpaid community members) at one end and the “para-professional” (paid workers with minimal qualifications, trained and demonstrating acceptable levels of standardized competencies) at the other end (Eng et al. 1997). Use of NSHWs in frontline healthcare delivery in areas of global health has demonstrated effectiveness in increasing access to care, e.g., promoting immunization uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality (Lewin et al. 2010; Swider 2002; Viswanathan et al. 2010). Since the 1990s, the increasing health inequalities within and between countries, resurgence of several infectious diseases and the spread of the AIDS epidemic, and the inability of the existing public health systems to deal with increasing chronic noncommunicable diseases led to an increased interest in NSHW programs, especially in LMICs (Hadley and Maher 2000; Lehmann et al. 2009; Maher et al. 1999). NSHWs trained and supervised by specialists have been able to effectively detect and treat mental disorders, refer appropriately, and provide psycho-education and follow-up care; and worked in a range of settings like clinics, halfway homes, and community outreach services, providing services for common mental disorders, severe mental disorders, epilepsy, learning disabilities, and dementia using complex stepped-care interventions, group interpersonal therapy, cognitive behavioral therapy, and psycho-educational programs for caregivers (Araya et al. 2003; Bolton et al. 2003; Patel et al. 2010; Dias et al. 2008; Rahman et al. 2008; Rojas et al. 2007; Xiang et al. 1994; Ran et al. 2003). However, despite the high treatment gap for substance use disorders, evidence-based NSHW delivered interventions are a rarity (Noknoy et al. 2010; Papas et al. 2011). One such example of a lay counsellor-delivered intervention for harmful drinking in primary care in India is described below.
Counselling for Alcohol Problems (CAP) (Nadkarni et al. 2017)
The Counselling for Alcohol Problems (CAP) intervention is targeted at harmful drinking patterns. The intervention has been designed to be delivered by lay counsellors (also called lay health workers or NSHWs), i.e., people with no previous background or qualifications in mental health who are trained intensively over a short period of time to deliver the intervention under supervision. CAP was developed in a program called PREMIUM, based in India, and involved a rigorous process of developing and testing the intervention content and its delivery. The counselling style of the counsellor that forms the spine of CAP and runs across the treatment phases is informed by Motivational Interviewing (MI) and Client-Centered Supportive Counselling. CAP has three phases as follows: “Initial phase” – Step 1: Help the patient understand the problems associated with drinking, through a detailed assessment followed by personalized feedback. Step 2: Facilitate a commitment to change from the patient. Step 3: Generate a “change and action plan” which summarizes what the patient wants to do to change his drinking, what the related problems are, and the actual actions that the patient will take to achieve this goal. “Middle phase” – Help the patient to develop “thinking and behavioral” skills and techniques that will allow him/her to make the changes that he/she desires. These skills include drink refusal, handling drinking urges, problem-solving, and handling difficult emotions. “Ending phase” – Help the patient learn how to manage potential or actual relapses using these “thinking and behavioral” skills and techniques.
CAP involves two to a maximum of four sessions, which are ideally delivered at a weekly to fortnightly frequency, allowing for adequate time between sessions to complete the assigned “homework” and to practice skills learnt during the sessions. Each session lasts 30–50 min and can span one or more “phases” of CAP. The pace at which the patient moves through the “phases” and the number of “phases” that get completed depend broadly on the patient’s readiness to change. For example, if a patient entering treatment is not ready for change, then the complete first session would be focused on the “initial phase,” but if a patient enters treatment ready for change, then the counsellor will quickly move through the “initial phase” in the first session and proceed to the “middle phase” in the same session. Just as CAP has an inbuilt flexibility in what is delivered (i.e., the strategies used), it has flexibility in other aspects such as where it is delivered (i.e., clinic, home, or any other alternative place), how it is delivered (i.e., phasic delivery), and who is involved in the treatment process (i.e., significant others involved or not). The intervention could be delivered in the clinic, patient’s home, or in any other convenient but safe place (e.g., friend’s home). It is recommended that the significant other (e.g., family member, close friend) should be engaged as far as possible in the first session to get a better understanding of the patient’s drinking and its impact, and also to help in developing a change plan. However, subsequent involvement of the significant other may be encouraged based on how helpful the involvement is expected to be, and the patient and the therapist should decide this collaboratively. Finally, the use of the accompanying CAP treatment booklet is strongly recommended as it helps the patient engage with the treatment in between sessions. The booklet has information related to alcohol use (e.g., impact of heavy drinking), skills (e.g., how to handle drinking urges), and worksheets to record the “change and action plan,” all designed to make the booklet interactive, personalized, and usable by the patient between sessions.
Key features: (1) Evidence-based model, (2) manualized treatment for harmful drinking derived from Motivational Interviewing and Client-Centered Counselling, (3) flexible delivery, (4) promotes involvement of family members.
An intervention such as CAP cannot exist in isolation without supportive services, and needs to be embedded within a wider healthcare system which optimizes the limited resources available in LMICs. An example of such a system is the collaborative care model focused on home-based care, which is influenced by the evidence-based MANAS model (developed for management of common mental disorders in low-resource settings).
The MANAS Model (Patel et al. 2010)
Community-based collaborative care model for AUDs
Steps of care
Responsible health worker
Sensitive and specific detection of AUD
NSHW, e.g., GP, nurse, community health worker
Use of screening tool, e.g., Alcohol Use Disorder Identification Test (AUDIT)
Provision of intervention for hazardous drinkers
Provision of intervention for harmful drinkers
Simple advice plus CAP and continued monitoring
Provision of intervention for uncomplicated dependent drinkers
NSHW and psychiatrist
Community detoxification led by NSHW under supervision by psychiatrist, relapse prevention counseling (individual or group), relapse prevention medication prescribed by GP
Provision of intervention for complicated dependent drinkers
Inpatient detoxification led by psychiatrist, relapse prevention counseling (individual or group), relapse prevention medication prescribed by psychiatrist
Management of treatment-resistant cases
or complex patients (e.g., dual diagnosis)
Intervention tailored to the requirements of the complex presentation
Although such a model can have a potentially multiplier effect on access to care, the success of such an effective collaborative care model focused on community-based psychosocial interventions hinges on the willingness of specialists to (a) share healthcare responsibilities with nonspecialists (which could sometimes be associated with fear of losing work, identity and income), (b) reduce the amount of time devoted to individual clinical care and increase the time for training of other personnel, and (c) devote significant time to periodic support and supervision of the nonspecialists.
Key features: (1) Evidence-based model, (2) strengthening of health-systems, (3) collaborative and stepped care, (4) manualized treatment incorporating psychiatric and psychological care.
The treatment of alcohol dependence, the more severe end of the AUD spectrum, requires a range of responses, which includes detoxification and relapse prevention using psychosocial and/or pharmacological interventions. The policy response, especially in LMICs, is focused primarily on funding tertiary care services to provide these interventions. However, such services are scarce, resource-intensive, and often difficult to access because of financial or geographical factors (National Collaborating Centre for Mental Health 2011; Benegal et al. 2009), and certainly not indicated for less severely dependent patients (National Collaborating Centre for Mental Health 2011). Hence, the treatment of alcohol dependence in existing platforms of institutional care in LMICs is both limited by its accessibility, and suboptimal, because community-based care is rarely available despite it being recommended in most cases (National Collaborating Centre for Mental Health 2011) as both a viable and efficient solution (Ibrahim and Gilvarry 2005). An efficient utilization of resources is community-based treatment of people with mild to moderate dependence, through home-based assisted withdrawal programs involving fixed dose medication regimens, a carer overseeing the process with daily monitoring by trained staff, and psychosocial support (National Collaborating Centre for Mental Health 2011). Such a program, based on the principle of collaborative care, has proven strengths such as effectiveness in improving clinical outcomes, cost-effectiveness and acceptability, and overcomes challenges related to accessibility and acceptability of treatment, which are often found in low-resource settings (Fleeman 1997; Heather et al. 2006).
Community-Oriented Non-specialist Treatment of Alcohol Dependence (CONTAD)
A real-world example of such a collaborative care model for treatment of alcohol dependence is CONTAD, a proof-of-concept project implemented in India. CONTAD was a community detoxification program for men with alcohol dependence. The intervention package comprised medically assisted alcohol detoxification and relapse prevention psychosocial intervention, both delivered in the patients’ homes. Consistent with the task-sharing approach, the intervention package was delivered by lay counsellors. The lay counsellors were trained intensively over 10 days by addictions experts to deliver the intervention package and subsequently had weekly supervision to ensure maintenance of competencies.
After a detailed assessment of eligibility for home detoxification first by the lay counsellors (e.g., history of seizures, history of delirium) and then by the GP (e.g., physical examination), blood investigations would need to be done, primarily to evaluate the status of the liver, and to make a decision about a suitable benzodiazepine (i.e., long- or short-acting) for the detoxification. The GP would then prescribe appropriate medications based on a formal detoxification protocol. The medically assisted detoxification would subsequently be conducted in the patients’ homes. The lay counsellor would visit the patient at home once a day through the course of the detoxification, and sometimes twice a day as per need. A family member would be engaged in the intervention process right from the outset to ensure accurate dispensing of medications, to monitor for any adverse events requiring emergency action and to provide any other identified form of support. The lay counsellor would remain available on the phone through the day and the patient and/or the designated family member could contact him/her for advice as needed. The first session of the psychosocial intervention would be delivered by the lay counsellor once the distressing symptoms of alcohol withdrawal had subsided and the patient was able to concentrate on the content of the sessions, usually the last couple of days of the detoxification. The focus of the relapse prevention package was a detailed assessment to identify potential triggers for lapse/relapse and building the patients’ skills to deal with such triggers in the future.
Key features: (1) Based on global evidence, (2) manualized treatment for dependent drinking, (3) home delivery of detoxification, (4) involvement of family members.
It needs to be highlighted that task-sharing solutions are not without their share of challenges. Some of these include the distress experienced by the task-sharing workforce, their perception about their own competence, the resistance to this workforce by other health care professionals, and the nature and quantum of incentives that need to be provided to ensure workforce retention (Padmanathan and De Silva 2013). Considering such challenges, it is imperative that other innovative solutions need to be constantly explored.
In LMICs with fragmented health-care systems and inequitably distributed services, technology-driven platforms of care could help millions of people gain access to mental health care. This could potentially reduce the need to develop expensive mental health facilities by offering technology delivered direct-to-consumer mental health care. This is increasingly becoming a reality as digital technologies become an integral part of societies worldwide. The models of care described above are innovative as they attempt to overcome the shortage of specialist healthcare manpower through rational re-distribution of frontline mental healthcare tasks to nonspecialists. The impact of such task-sharing models could potentially be augmented through the innovative use of technology to support treatment and clinical care, connect patients or community providers with mental health specialists, enable the diagnosis and detection of mental disorders by nonspecialist providers, support the development of skills in mental health care among community health workers or other nonspecialist providers, and facilitate the supervision and mentoring of nonmedical care workers (Naslund et al. 2017). The next sections describe how digital technologies can be used to deliver interventions and to train and supervise NSHWs, and concludes with an example of how task-sharing models can be integrated with technological innovation to enhance outcomes.
In countries with limited access to health services, online psychological interventions allow patients to help themselves directly, or with the help of a therapist. Such interventions have the potential to be less costly, more efficient, increase access to mental health care with minimum therapist time, increase treatment coverage, and partly overcome stigma.
San Francisco Stop Smoking Site (Muñoz et al. 2012)
One critical advantage of technology-based innovations is that they transcend geographical boundaries. Although this program was based in the USA, it had participants from more than hundred different countries worldwide and the eight most represented countries included LMICs as diverse as Argentina, Mexico, India, Chile, Colombia, and Venezuela.
After accessing the online portal, the participant has to first complete a baseline questionnaire that assesses his/her demographic characteristics, mood, and details of smoking. The participant is then presented with a menu of nine intervention elements to choose from. These nine elements with brief details are as follows: (1) “Prequit Checklist” – This is a 10-item to-do list with tips on relapse prevention such as removing smoking-related cues from one’s environment, identifying risky situations that might lead to relapses, and how to deal with such risky situations. (2) “Stop Smoking Guide” – This is a National Cancer Institute’s evidence-based behavioral intervention which provides evidence-based information about the adverse effects of smoking cigarettes, and methods for successful cessation. (3) “Nicotine Replacement Therapy (NRT) Guide” – This provides information about NRT such as who should consider NRT, information regarding the range of available nicotine substitutes, and antidepressant medications used to help people stop smoking. (4) “Taking Control of Your Life” – This is a downloadable document to support participants quit smoking by providing them with skills to maintain a healthy mood state. These included strategies such as engaging in pleasurable activities, and maintaining a daily diary to track the number of positive activities, mood, and the number of cigarettes smoked. (5) “Individually Timed Email Messages” – These were sent to the participants and contained brief tips and encouragement to stop smoking, and which were coordinated with the participant’s self-selected quit date. (6) “Mood Management Intervention” – This was an eight-lesson cognitive–behavioral mood management module that focused on the interactions between thoughts, activities, people, and one’s mood, and included tools to track mood, activities, thoughts, and interpersonal contacts, and to visualize how these are related to smoking behaviors. (7) “The Virtual Group” – This was an asynchronous bulletin board which provided an online forum where participants could post messages and respond to other participants’ posts. (8) “The Journal” – This was a text box in which participants could keep personal notes on their progress toward their smoking cessation goals, view previous journal entries, and share them with the virtual group. (9) “The Cigarette Counter” – This allowed participants to record the number of cigarettes they smoked the previous day on a visual scale and this was displayed graphically so that participants could view their smoking patterns over time.
Key features: (1) Overcomes geographical barriers, (2) self-help internet-based intervention, (3) derived from evidence-based Cognitive Behavior Therapy.
Project ECHO (Extension of Community Health Care Outcome) (Chand et al. 2014)
Technological innovations can be harnessed not only for the delivery of interventions but also in training and supervision of relatively easily available nonspecialist health professionals by scarce and inequitably distributed specialist mental health professionals. Project ECHO by the University of New Mexico, USA, is one such innovative technology-enabled model which aims to improve access to specialist care by linking specialist teams with other health professionals using technology. These specialists help nonspecialist health professionals manage their caseload and share their expertise through mentoring, guidance, feedback, and didactic teaching. It is expected that the learners acquire best practices through learning loops and over time this leads to acquisition of deep knowledge, skills, and self-efficacy. This innovation has been used successfully in a range of low-resource settings and, in India, the ECHO program at the National Institute of Mental Health and Neurosciences (NIMHANS) attempted to enhance the competencies of health professionals specifically for the recognition and management of addictions.
A cloud-based secured videoconferencing facility (zoom.us) was used to deliver the online program from the NIMHANS “hub,” or central location, to the end user “spokes.” Existing computer facilities (desktop with broadband connection) were used to run the training sessions from the hub, and spokes could access the training through any internet-enabled device (tablet, smartphones, laptop, or desktop) free of cost. Zoom allowed several simultaneous trainees to participate in extended video conferences. The weekly, live, 2-hour tele-ECHO training sessions had two parts viz case discussion and didactic teaching. Cases to be presented were typically submitted in advance by the trainees using a standard case template modified to protect the anonymity and confidentiality of the patient, and when an interview was recorded for demonstration, it was done so with informed consent. The first half of each session was devoted to the clinical case presentation. The cases were presented in a structured format by the participant who had submitted the case. Clarifying questions were sought from the participants, including the specialists at the hub. This was followed by recommendations and suggestions, and discussion about teaching points raised by the presented case. Finally, recommendations were summarized and communicated to the presenters. Specialist input was provided by a multidisciplinary clinical team consisting of addiction psychiatrists, counsellors, nurses, and public health professionals present at the hub. The case presentation was followed by didactic teaching by the experts about alcohol and tobacco use disorders. The participants were able to ask questions both through the videoconferencing and through online chat.
Key features: (1) Overcomes geographical barriers, (2) cross-setting applicability, (3) capacity building focus, (4) multilevel training and supervision.
Healthy Online Self-helping Center (HOSC) (Su et al. 2011)
Healthy Online Self-helping Center (HOSC), an evidence-based package, was an internet-based intervention for the treatment of online addiction in college students from China. The intervention was based on the principles of Motivational Interviewing (MI) and Client-Centered Counselling. The online intervention had four modules as follows: (a) “Ready to start” – This introduced the users to the system and allowed them to register for the program using relevant demographic information; (b) “Understanding myself” – This was a detailed assessment of internet use made by asking the user to enter details such as number of hours per week spent online, the single longest period of time spent continuously online, etc. This information was then used to generate personalized pictorial feedback in which the user’s data were compared with the norm of the usage by those of the same age and gender in China. It then asked the users to describe the pros and cons of his/her online activity and then presented personalized feedback through a decisional balance form regarding the user’s online activity; (c) “Goal of change” – This module began by displaying a “readiness to change ruler” on which the user moved a marker to indicate his/her level of readiness to change. The subsequent steps were matched to the users’ level of readiness to change. If the participant was not prepared to change at all, he/she was given the option of exiting the program. If the participant was ambivalent, then the program allowed the user to complete the decisional balance exercise for the second time and then reported his/her level of readiness again. This resulted in a table that contrasted the pros and cons of not changing and used this to facilitate change behavior. After this exercise, if the user was still not sure, the program ended the intervention. If the user was ready to change or had already taken steps toward change, the program proceeded to goal of change negotiation in which the user filled in his/her expected online hours, online activities, and legitimacy ratio, and generated a feasibility report. Once the goal of change had been set, the system calculated the time benefit this change could bring to the user and asked about his/her confidence of making the change; (d) “Methods of change”: In this final module, the system offered a menu of five cognitive-behavioral strategies for the user to study and practice to make the change in behavior: adjusting irrational cognitions, creating an online plan, resisting internet temptation, using reminder cards, and accessing support resources. The system allowed the user to choose his/her next step of change, to learn to evaluate the change, to devise a plan to reward themselves as appropriate, and to learn how to prevent relapse.
Key features: (1) Overcomes geographical barriers, (2) self-help internet intervention, (3) manualized treatment for internet addiction derived from Motivational Interviewing, Client-Centered Counselling, and Cognitive Behavior Therapy.
Most technology platforms for delivery of mental health interventions eliminate visible face-to-face contact and synchronous interaction raising concerns about a therapeutic environment that does not have an important component of face-to-face interactions viz nonverbal communication. On the other hand, technology allows the use of creative approaches, such as virtual environments which give added therapeutic value. Furthermore, considering the stigma associated with substance use disorders, technology platforms provide sufficient anonymity to facilitate more uninhibited “interaction.”
As outlined above, both task-sharing and technology-based models of care have their own set of strengths and limitations. Leveraging the complementarities of these two models into an integrated system (as described below) could potentially be an efficient way forward to generate exponential gains.
A potentially efficient model of care is one which utilizes multiple innovations at different levels to serve varied functions. One such model is described below.
Health and Development Foundation’s Model for Opioid Dependence (Dmitrieva et al. 2012)
This is a health service delivery model for retention and continuity of care for opioid dependence, which was pilot tested in the Russian Federation. The model was developed and implemented with a dual and integrated focus, to promote care for those with opioid dependence and HIV/AIDS. The model consisted of a suite of interventions, including: (1) HIV testing and counselling: The counselling approach was tailored to suit the needs of various types of client groups such as teenagers, pregnant women, commercial sex workers, etc. The testing and counselling component was incorporated into the program by training regional AIDS centers, with a focus on adherence support. (2) HIV/AIDS “Narcology Post-Graduate Curriculum”: The purpose of this curriculum was to train medical practitioners specializing in infectious diseases in detection, management, and prevention of HIV infection in clients who reported drug use. (3) “Peer Support Groups”: These groups, also known as buffer groups, served as a support system for clients undergoing detoxification, and guided clients in reducing risk for HIV, adherence management, and sustained motivation to engage in treatment. (4) “Narcological Follow-Up Phone Monitoring”: Further follow-up support was provided by peer advocates through the use of the phone, with the purpose of providing adherence support, increasing knowledge of risk reduction, and relevant services available. The postdetoxification follow-up sessions consisted of an assessment of health status and planning continued engagement in treatment. (5) “Women’s Narcological Services”: This consisted of targeted programs for HIV positive women and women with opioid dependence. The focus of the program was on risk reduction and supporting psychosocial needs of women and their children. (6) “Short Messaging Services for Injection Drug Users”: This service involved providing around 30 short text messages focussed on prevention and treatment for HIV and drug use.
This model of care innovated on several fronts. It promoted the horizontal integration of a program for opioid dependence onto an existing platform of care for HIV/AIDS. It also used the NSHW model by training peers to deliver support services. Finally, it used technology to enhance care by delivering interventions through phone calls and SMS. This is an excellent example of integrating multiple innovations into a single program in order to increase penetration and coverage of healthcare services for opioid use disorders.
Key features: (1) Multiple innovations in a single model, (2) implementation model, (3) horizontal focus on HIV and drug use, (4) multicomponent intervention strategies.
Quality of delivery is a critical factor that influences outcomes, and if an intervention is delivered badly, then this may affect the degree to which efficient and effective implementation is realized. One key consideration in quality assurance is ongoing monitoring and feedback to those delivering the intervention. Despite the growing evidence base about task-sharing in mental health, one key challenge is provision of supervision to assure such quality. It is generally accepted that experts trained in specific treatment modalities are gold standard supervisors (Townend et al. 2002). However, we have already established that one of the major challenges for global mental health is the shortage of specialist human resource. One potential alternative in the absence of expert supervision is self-assessment (monitoring one’s own performance), but this modality has its limitations related to over- or underestimation of the quality of one’s own therapy quality (Brosan et al. 2007; McManus et al. 2012). The subsequent section describes a method of quality assurance that overcomes the barriers related to shortage of experts and the limitations associated with self-assessment.
Delivery of health services requires appropriate systems to ensure the quality and integrity of the interventions being delivered. One such supplementary quality assurance process is the supervision of health workers, and this is extremely crucial, specially in task-sharing approaches to healthcare delivery. However, traditional methods of supervision delivered by specialists are not scalable in most resource-constrained environments. One way of overcoming this barrier is to use innovative and scalable processes such as peer supervision for assessment of therapy quality by nonspecialist workers. Peer-led supervision encourages nonspecialist workers to draw upon others’ experiences and take active roles in assisting one another through a format entailing evaluation based on a competency assessment tool and case discussion. Peer-led supervision was implemented in the PREMIUM program which delivered psychosocial interventions for harmful drinking and depression delivered by lay counsellors in primary care in India (Singla et al. 2014). This program was unique in its approach as the same counsellors were trained and supervised to deliver interventions for two disorders viz depression and harmful drinking.
Individual therapy sessions delivered by the lay counsellors were audio recorded with the patients’ consent. Group supervision was conducted on a weekly basis. Typically, groups consisted of three to four peers and the lay counsellor who conducted the session. The supervision lasted up to a maximum of 90 min including feedback and discussion. One peer, chosen in rotation, moderated the supervision and therapy quality assessments in each supervision session. One individual audio-recorded session was listened to in full and then rated, using the therapy quality scales developed in PREMIUM. The ratings were done by each peer and self-rating was completed by the counsellor whose case was being presented. Self-ratings were completed prior to group supervision to reduce bias as a consequence of the supervision feedback. Once the session was listened to and rated, ratings were discussed and feedback was provided by all group members to the lay counsellor whose tape was being rated. Experts who were well-versed in the treatments that were being delivered also independently rated the tapes of therapy sessions. This was done to check empirically if the peers were able to deliver supervision as well as the experts. It was observed that there were increased levels of agreement between peer and expert ratings over time. Such innovative supervision processes enhance the scalability of psychological treatments delivered by lay counsellors in low-resource settings as lay counsellors can be trained to effectively assess each other’s therapy sessions as well as experts, reducing the reliance on specialists who are a scarce resource.
Over the years, healthcare across the world has evolved to keep abreast of changes in diseases, technologies, administrative models, and health systems. This has always been toward achieving the greater good of patients’ and population health in changing circumstances. As nations struggle with modern epidemics of noncommunicable diseases, such adaptation is again called for. Traditional health systems, even those in high income countries, are ill equipped to deal with these emerging and rapidly evolving health challenges. Innovations such as those described above are the first step toward addressing these challenges, but a lot is yet to be done.
First, the evidence gap in LMICs, i.e., disproportionate research output in comparison with high volume of research emerging from high-income countries, needs to be addressed, with research focused on “what” works best for addictions treatments, and “how” can these treatments be best optimized in existing resource-constrained systems. Over the years, there has been a concerted effort to devolve at least some specialist healthcare delivery to primary healthcare systems, but this strategy continues to face many challenges. Hence, it is now crucial to implement community-directed approaches that provide opportunities for formal health systems to work closely with the community to effectively deliver interventions for addictions. Furthermore, within the formal healthcare system, integration of addictions treatment with existing well-resourced programs such as those for TB or HIV might potentially provide a wider geographical coverage than existing programs focusing just on addictions, especially considering the close relationship of addictions such as AUDs with other health conditions. Finally, the use of technology in healthcare operations is one of the most exciting innovations in recent times and has the potential to be a major game changer in the coming years as it is not limited by geographical boundaries. However, as we develop technological innovations, we need to ensure we build appropriate sustainability plans into such initiatives, ensure that the solutions are locally feasible and appropriate, secure buy-in from key stakeholders, align such initiatives with local and national health priorities, and integrate them into existing health systems, structures, and policies, and ensure that monitoring and evaluation is built into the implementation plans.
Despite the huge burden of addictions across the world, there are several challenges to providing access to care, especially in LMICs. In such low-resource settings, disruptive innovations are the way forward to bridge the immense treatment gap for addictions. There are quite a few examples of innovations in task-sharing and technology-facilitated intervention delivery across the developing world and these can serve as templates to replicate such models in other low-resource settings, including the developed world.
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