Title: Advancing Research to Reduce Alcohol Related Harms -Lessons for Policy, Practice and Sustainable Development in India
Funder: Department of Health and Social Care

Abstract: BackgroundHazardous/harmful drinking are major contributors to morbidity, mortality and disability across the world. India, and other low- and middle-income countries (LMICs), are experiencing a steady increase in alcohol consumption and hazardous/harmful drinking. 86% of such individuals in India do not have access to any kind of care for their drinking problems, the highest treatment gap amongst all mental and substance use disorders. There is robust evidence of the effectiveness of psychosocial treatments for drinking problems, there remains a gap in the understanding of (a) integrated interventions that can be used to respond to the whole spectrum of drinking problems, (b) providing care for difficult to engage hazardous/harmful drinking individuals, and (c) effective implementation models to scale up such treatments. Hence, we have been unable to translate to implementation at scale, most commonly due to the lack of contextually relevant interventions and capacity of the health systems to integrate the evidence-based interventions. AimsThe overarching goal of my programme is to guide the translation of research evidence in LMICs informed by evidence generated through a series of studies aimed at (a) developing, and implementing a contextually relevant, scalable and integrated intervention for hazardous and harmful drinking, and (b) identifying and disseminating contextually-relevant health systems strengthening processes to aid implementation in low resource settings. I will leverage the studies described below as exemplars to develop a research translation guidance document suitable for use in low resource settings. MethodsStudy 1 (Development of Alcohol Problems Treatment Plus (APT+)): Using systematic and evidence-based intervention development processes I will integrate interventions developed in the study setting into a single integrated intervention (APT+). The process will include consultations with various stakeholders such as expert clinicians, individuals with drinking problems, and family members; followed by evaluation of acceptability and feasibility through treatment cohorts using process evaluation and in-depth interviews with the various stakeholders.Study 2 (Integrated Care for Alcohol Problems): hybrid effectiveness-implementation RCT with two arms comparing treatment as usual (TAU) with APT+.Study 3 (IMPRESS): hybrid implementation cluster RCT which will compare two task-sharing models for delivering a psychological intervention by non-specialist health workers, i.e. as a stand-alone intervention in public-sector primary care clinics versus being integrated with an evidence-based community intervention delivered by community based agents aimed at increasing demand for care and improving treatment adherence and effectiveness. Study 4 (Bench to Bedside-B2B): I will systematically review lessons learnt from ICAP and IMPRESS and consolidate them into strategies using a systematic process which includes triangulation of data from nested qualitative studies and process data from the two studies, Delphi process with implementation science experts, and semi-structured interviews with key stakeholders, including policymakers. Community engagement/DisseminationA range of community stakeholders will actively contribute to the intervention development and/or implementation and testing as equal partners. Through rapid feedback loops integrated into the study design; and involving participatory research and dissemination through various channels, we will ensure that the study outputs are responsive to inputs and felt needs of the communities in which they will be implemented.

Lay abstract: Problem drinking affects large numbers of individuals and their families across the world. It also leads to social harm through violence, loss of work, and increased direct law enforcement and healthcare costs. As India and other similar countries become more affluent, drinking is becoming more common. Furthermore, the harms related to drinking are disproportionately affecting the poorest in society. Despite this burden of problem drinking, only one out of ten such drinkers has any access to appropriate care in India. This is due to the inability of our health systems to successfully integrate and scale-up effective treatments in a sustainable manner. Through my programme I aim to bridge this gap between 'what works' and 'how to make it work at the population level' by developing contextually-relevant strategies to guide the translation of such research evidence in low resource settings. I will do this by using the lessons learnt in a series of research studies conducted in India. In one study I will first develop and then test a contextually relevant and scalable intervention that caters to the various levels of severity of problem drinking and also engages the families of those with drinking problems to enhance entry into and adherence to the treatment. In the other study I will test how engaging communities in care allows greater engagement in care and consequently better outcomes in those with depression. While investigating if these interventions work in real-world settings, I will also examine the various strategies required to prepare the health-systems for efficiently and sustainably integrating these interventions into routine healthcare delivery.All these studies will include a systematic engagement with a range of community stakeholders including service users, their families, clinicians, community leaders, and policy makers. All these stakeholders will be equal partners in the research and will actively contribute to the design and implementation of the studies. The studies will be designed so that they are responsive to inputs of the stakeholders and felt needs of the communities in which they will be implemented. In parallel with all these studies, I will coordinate a systematic process, involving various stakeholders, through which I will consolidate the lessons learnt from the individual studies to develop a guidance document to aid the efficient scaling-up of psychosocial interventions in low resource settings.The short-term impact of the programme will be the benefits accrued by the study participants receiving the psychosocial interventions, and contextually relevant knowledge generated about 'what works' i.e. psychosocial interventions for problem drinking. The long-term benefits beyond the duration of the programme, and also beyond India, will be through the knowledge generated on how to sustainably scale up effective programmes so that they are easily accessible to those who need them.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE;MENTAL HEALTH