Alcohol related harm is any problem that comes from misuse of alcohol, which is drinking of alcohol with resultant physical, psychological and social problems. The harm can be on one’s self or on another person or community, and can be immediate or long term harm (1). Frequently, the worse effects are seen in behaviors like binge drinking as seen in adolescents and female sex workers amongst others (2,3). Some of the burdens attributed to alcohol include the detrimental net effect on health which leads to mortality and morbidity. Globally, alcohol contributes to about 3.8% deaths and 4.6% of disability-adjusted life-years (4). High and middle income countries spend more than 1% of their gross national product on alcohol related harm with social problems being the most often associated with this expenditure. Developed nations’ morbidity and mortality of adolescents and young adults’ is attributed to a greater extent to alcohol and other drug use with mortality from acute conditions in young people averaging more than twice that of chronic conditions (4,5).
There is insufficient interventions globally to control alcohol and yet there is evidence that it causes significant burden of disease.u1 This is because of expanding economic players in the production and marketing of alcohol hence a rise in consumption in new markets and young people in developed world. There is also inadequate utilization of interventions and policies to restrict alcohol associated harm because of little will from politicians and producers of alcohol in different countries (6). Alcohol negatively affects adolescents more because of limited experience and lower tolerance for outcome of alcohol. Therefore, even a short term event has a significant negative outcome in this population including unsafe sexual behavior, trouble with community including parents and police, accidents/injuries and other inappropriate behaviors leading to peer problems (1). Among female sex workers, alcohol is prevalent because of a variety of reasons including the use to facilitate work and some are coerced by clients/pimps, which may end up in binge drinking with a negative outcomes such as having unprotected sex and sexually transmitted infection (3).
This paper summarizes interventions done to reduce alcohol related harm on the most vulnerable populations including the adolescents in the United Kingdom (U.K) and female sex workers (FSW) of Mombasa, Kenya.
The first is a Multi-level growth modelling analysis of the differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences. In the UK, many preventive interventions showed evidence of little behavioral change. The intervention study here was a secondary analysis of data from a non-randomized trial of The School Health and Alcohol Harm Reduction Project (SHAHRP), an intervention considered to have good interactive and developmental design for behavioral change in adolescents. SHAHRP is a class room-based alcohol education intervention involving children aged between 13 and 16 years old in the UK. Secondary analysis of Australian SHAHRP data was also done. This study tested differential effects of adapted version of SHAHRP in the UK based on baseline context of drinking categorized as abstainers, supervised drinkers and un-supervised drinkers with the hypothesis that this context would replicate those found in Australia (1).
Results of this study shows that SHAHRP has a significant and positive effect on participants. This is because they demonstrated good knowledge and attitude on alcohol across all the different baseline drinking behavior hence supporting its applicability as a universal intervention. Also noted is the fact that the baseline unsupervised drinkers who received intervention were significantly influenced by SHAHRP more than the abstainers or supervised drinkers according to behavioral effects as hypothesized before. The Australian longitudinal assessment of SHAHRP reported behavioral impact on risky drinking across the study period with baseline abstainers, leading to a deduction that the modification of the original intervention reduced the effects seen in Northern Ireland, UK as compared to the Australian baseline abstainers (1).
The second is the impact of an alcohol harm reduction intervention on interpersonal violence and engagement in sex work among female sex workers in Mombasa, Kenya: Results from a randomized controlled trial. The aim was evaluate whether an alcohol harm reduction intervention was associated with reduced interpersonal violence or engagement in sex work among female sex workers (FSWs) in Mombasa, a randomized control trial. There was 6 session alcohol harm reduction interventions done for the intervention group and 6 sessions of non-alcohol related nutritional interventions were done for the comparison group. This was done from HIV prevention drop in setting in Mombasa (3).
Results showed statistically significant decreases in physical violence and verbal abuse from paying partners at the post intervention times. There was a reduced chances of engaging in sex work in the immediate and 6 months post intervention. Therefore, the Alcohol harm reduction was ass. With reduction in violence and engagement in sex work among female sex workers in Mombasa, Kenya. It is also noted that even the control group reported a reduction in alcohol consumption and its related harm but to a smaller extent as compared to the intervention group (3).
These two interventions registered successes and some of them are discussed here. Notably, the differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences study, the secondary data analysis of the different SHAHRP study had a success in that it compared the same type of interventions from different communities demonstrating similar results for all. This makes this feasible for use in health promotion to reduce alcohol related harm (1).
The intervention in Kenya was a success too because of reduced alcohol consumptions among female sex workers and consequently reduced alcohol related harm because of shift in behavior of this population. The obviously observed effect of this success was reduced interpersonal violence, reduced odds of engagement in sex work and reduced number of sexual partners in both intervention and control groups although much reduction was seen in the intervention group. In addition, there was increased financial saving leading to reduced economic vulnerability, a known factor to increase likelihood of someone becoming a sex worker hence reduced engagement in sex work (1).
In conclusion, these studies opens up doors for further studies especially on the pathway through which alcohol reduction leads to change in knowledge and attitude towards alcohol harm reduction both in adolescents and even the female sex workers. In the case with female sex workers, the study points out the importance of economic empowerment as an intervention to reduce this risky behavior resulting from economic vulnerability (3).
Like every interventions, these two were not free of failures and limitations. The differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences study demonstrate that the SHAHRP intervention was not sustainable in that it did not leave immediate and lasting effect because it is seen that the positive outcome was noted after delivery of both phases and the effect reduced as the intervention reduced (1). Other limitations of this study has been the small number of baseline abstainers, as compared to the other alcohol use related surveys in schools, self-reported questionnaires used which is not the best for this population in terms of obtaining correct information free of response bias. Also noted is that some schools withdrew from the study hence affecting some measures and this study did not obtain information on other alcohol interventions given to this intervention and control populations. The study did not take into account some school policies on alcohol and drugs use which may affect the results in this comparison populations (1).
In the interventions on alcohol reduction among female sex workers in Kenya, a randomized control trial, the magnitude of the effect of the intervention was not measured accurately because similar changes have been seen in the comparison group as well although to a smaller extent compared to the intervention group. This can be because the control group received equal attention interventions, the nutrition information could have reduced their alcohol consumption hence its beneficial effects, there could have been the Hawthorn effect as well in the control group, and the reduction could as well be explained by the contamination from treatment group since the randomization occurred in the same area and with the same social interaction among the intervention and control groups. Other limitations of this study is that all participants visited the HIV drop in zones and this may have influenced their behavior and does not reflect that of the other sex workers. In addition, most data were self-reported and this is a sensitive group that may under report hence leading to a response bias (3).
More work must be done to improve research and interventions in the future. Further studies should be done to take into account the contaminations which has been a limiting factor in these studies. Research is needed to understand the mechanisms through which these alcohol reduction interventions impact on the behavioral change that subsequently lead to reduction in alcohol related harm or any other risky behaviors.
More research is needed to look at other approaches to reduce alcohol consumptions and alcohol related harm and these findings used to formulate evidence based public health policy on alcohol.
There should be collaboration and partnership with other organizations including governments and NGOs, parents, schools and the community involvement in advocacy for research and interventions to control this problem. These forms of interventions should be diverse and look at the entire populations with booster interventions in order to produce a more sustainable effects. Leaders and politicians should be given information through effective communication on evidence based findings to influence political will towards controlling alcohol consumption.
In conclusion, public health professionals demonstrating key competencies must take up this seriously and intervene at all levels in reduction of alcohol related harm.
u1This is a serious comment that needs referencing…. It needs validation.