The design of an outpatient harm reduction intervention for the management of alcohol use disorders (AUDs) in South Africa

Abstract

Alcohol Use Disorders (AUDs) pose significant health and social challenges globally, with a rising prevalence in low and middle-income countries, including South Africa (SA). In SA, harmful alcohol use contributes significantly to health and socio-economic burdens, particularly in the Limpopo, Mpumalanga, and Gauteng provinces. Despite global and national efforts in addressing AUDs, the dominance of abstinence-based treatment models in SA has created a gap in accessible alcohol harm reduction approaches tailored to the needs of individuals unwilling or unable to embrace abstinence. This study addresses this gap firstly through insights gathered from service users using qualitative interviews and secondly through quantitative data collected from service providers using a web-based QualtricsXM survey. Lastly, the study bridges this gap by designing an outpatient alcohol harm reduction intervention grounded in the harm reduction approach. Hence, the goal of the study was to develop an outpatient alcohol harm reduction intervention for the management of AUDs in South Africa. In line with the framework of Intervention Research (IR), the study started by performing a scoping review aimed at synthesising the existing literature on alcohol harm reduction interventions within the Global South, specifically for one decade (i.e., January 2013 – June 2023). This was followed by a mixed methods research approach as operationalised through a concurrent mixed methods design within the framework of IR. A total of 89 participants were purposively selected, comprising 60 service providers (social workers, psychologists, nurses and doctors) and twenty-nine service users with AUDs at outpatient treatment centres in three SA provinces. Quantitative data were gathered through a non-standardised web-based QualtricsXM survey with service providers, while qualitative data was gained through semi-structured interviews with service users. The scoping review (i.e., Phase 2 of IR, specifically “Information gathering and synthesis”) highlighted critical gaps in existing interventions, particularly the limited focus on outpatient settings and the lack of targeted strategies for vulnerable populations in the Global South. The triangulated results (i.e., Phase 1 of the intervention research, specifically “Problem analysis and project planning”) highlighted the critical harms associated with AUDs from both the perspectives of service users and service providers, such as social isolation, economic difficulties, and co-morbid physical and mental health challenges. Hence, the developed prototype intervention (i.e., Phase 3 of IR - Design) seeks to address these challenges/harms through ten embedded sessions. The ten sessions of the intervention focus on a structured and client-centred approach to reducing the harms associated with AUDs. The intervention addressed key elements: assessment, motivation, leveraging support systems, managing barriers, understanding health impacts, and developing personalised strategies for harm reduction and responsible drinking. The findings of the study demonstrate that individuals experience alcohol harms (i.e., physical health issues, psychological harms, social harms, and economic challenges) as a result of their harmful alcohol use. The study further found that there is a need for a viable alternative to abstinence-focused models in addressing AUDs in outpatient settings, such as the intervention developed in the present study. It is recommended that the intervention be piloted and refined to ensure flexibility and effectiveness in diverse settings.