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BRIEF INTERVENTIONS in Preventing Drug and Alcohol Abuse in Rural Areas: a Pilot Study

Annibale Cois
Maria Assumpta Mission, Acornhoek, SA annibalecois@gmail.com
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14th ANNUAL CONFERENCE ON RURAL HEALTH


SWAZILAND 26-28 AUG 2010

widespread abuse of psychoactive substances by adolescents in rural South Africa is reported by all major epidemiological studies published over the past fifteen years [1]. Prevention programs aimed to reduce or delay substance use among adolescents are an important part of global community health strategies: substance abuse is, in fact, strongly related with an increased risk of physical and mental illnesses, HIV infections and other STDs, accidents and injuries [2][3]. In the alcohol and drug abuse field, a broad spectrum of interventions characterized by their shortness and collectively called Brief Interventions (BI), are well established for therapeutic and harm-reduction purposes in high risk adolescents [4][5]. BI involve a limited delivering time, usually up to 3 sessions in individual or in group format. They focus on changing specific behaviours, and typically incorporate a mix of cognitive-behavioural, motivational, personalized feedback techniques, and life skills training. The interest in using this class of interventions as universal prevention tools (and non only for special populations) is increasing, because of the short delivery time that allow implementations in non conventional settings (emergency or primary care units, home care settings, informal meeting places, etc), joining people otherwise excluded, and because of the low cost. Both these characteristics can be really valuable in low- and middle-income countries. Moreover, BI can be easily manualized and delivered by non-specialists, ensuring both spreading in rural areas and correct implementation. There is growing evidence that BI, especially when based on the Motivational Interviewing [6] and/or the Comprehensive Social Influence Model [7], can be effective in reducing risk behaviours related to alcohol and drug use [8][9][10]. Nevertheless, most of the research is done in the USA and in the EU, in school or college settings. There is a lack of knowledge of applicability and effectiveness in different socio-cultural contexts and settings [11][12][13].

The RSTP
The RSTP is a BI originally proposed and validated in the USA to prevent alcohol and drug related risk behaviours in high school [14][15]. It addresses some typical adolescents behaviours and feelings that can foster substance use [16][17]: the fact that most of them do not recognize their substance use as problematic and believe that frequent risk-taking is the norm; the increased wish of autonomy that may prevent adolescents from accepting prevention messages; the influence of peers behaviour. The intervention consists in two parts. In the first one participants are anonymously assessed about their substance-related behaviours, beliefs and perceptions. In the other they are provided with an individualized feedback, and a discussion is carried out in a nonconfrontational approach consistent whit basic motivational techniques. The discussion is aimed to: challenge myths and positive outcome expectancies for substance use; discuss evidence that most youth tend to overestimate peers substance use; discuss consequences of substance use and offer specific strategies to decrease related risks. For the present study, the RSTP was adapted to the different context and setting, retaining the same basic structure and contents, and all materials translated in the local languages. The sessions were lead, according to a detailed procedure, by specifically trained native speakers (Auxiliary Social Workers with previous experience in leading groups).

Cognitive Appraisal of Risky Events Quest. (modified) Risk Behaviours

0 [11-15]

.1

.2

.3

[16-17] Aggressive Illegal Behaviours Heavy Alcohol Use

[18-19] Drug Related Risk Behavours

[20-27]

9 5 6 7 8

MDMQ - Melbourne Decision Making Questionnaire * Decision Making Style

* = our translation in Tsonga / Sepedi, not validated

4 [11-15]

[16-17] Hypervigilance Vigilance

[18-19] Procrastination

[20-27]

BIS11A Barratt Impulsiveness Scale 11A * Impulsivity

65

66

67

68

64

* = our translation in Tsonga / Sepedi, not validated

[11-15]

[16-17] Barratt Impulsiveness Scale 11A

[18-19]

[20-27]

Results
Data from the self-report questionnaires show a significant alcohol use in last 3 months for both males (71%) and females (32%), mainly during the weekends. Intoxication ( 29%, 12%) and Binge Drinking ( 33%, 5%) is also reported frequently. Other drugs use (excluding tobacco) affects, conversely, a small part of the sample, whit average lifetime use below 10%. Accordingly to other studies, the perception of peers substance use is strongly biased: the estimated peers alcohol use, for example, is more than 6 times the real one. Aggressive behaviours are reported frequently: 39% of the males and 19% of the females declare to have slapped or punched someone al least once in the last three months. An interesting result, coherent with the literature, is that most indicators of risk behaviours, impulsivity traits and dysfunctional decision making styles show a maximum or increase steeply between 16 and 18 years, as displayed in Figure 2. Aggressive Behaviours, Heavy Alcohol Use and Drug Related Behaviours, measured by a modified version of CARE [18], show the maximum increase between 16-17 and 18-19 years, and tend then to level out or to decrease. Hypervigilance and Procrastination (dysfunctional decision making styles measured by the MDMQ [19]) show a similar trend. Conversely, the functional trait of Vigilance increases steadily with age. The same trend is displayed by Impulsiveness, measured by the adolescent version of BIS11 Scale [20]. The exam of post-session reports shows that the groups behaviour in response to the inputs provided by the intervention essentially coincide with the one described in previous implementations of the model [14]. Particularly, the groups reaction to the discussion about peers substance use, Balanced Placebo Design Experiment, and Refusal Skills, agreed completely. The setting, less structured than the school one, engendered some difficulties in the timetable and in ensuring the same participants between the first and second session. An empirical measure of the quality of the data, the error rate in filling the self-report questionnaire, was calculated. The average number of skipped or ambiguous answers was 1.91% (sd= 2.2). Three questionnaire with an error rate above 8% were excluded from the calculations.

Figure 2: Age trends in risk behaviours, decision making styles and impulsivity

Conclusions
Despite the small size of this pilot study and consequent lack of statistical power and generalizability, the collected data support the feasibility of brief, low-cost prevention interventions in rural areas. Results are coherent with the hypothesis that the basic assumptions that support the validity of BI are fulfilled in this particular context, provided some linguistic an cultural adaptations. Particularly, collected data show no difference with previous validated experiences in regard to: (1) typology of risk behaviours, beliefs and expectations about substance use; (2) group response and session participation; (3) comprehension of the questionnaires. Moreover, age trends in risk behaviours and impulsivity measures agree with the international literature about benefits in implementing universal prevention program before the age of 16-18 years: as shown by recent studies in brain development and risk behaviours (and confirmed by our observations) in this age risk-taking attitudes reach their maximum [21], exposing adolescents to the highest risks to develop addictions and other substance-related problems likely to produce harm lasting in the adulthood. Studies with appropriate statistical power and design, allowing the comparison with other published data, should be carried out in order to test effectiveness, long term outcomes, and cost-benefit ratio of Brief Interventions.

Method
A pilot adaptation of the Risk Skills Training Program (RSTP) [14] was realized in the Ehlanzeni district in Mpumalanga Province, SA, in May-June 2010. Participants were recruited in five rural communities among young people of the local Catholic Church, and their friends.

N = 63 subjects = 18 = 42 Age: 17.32 (sd 3.08) Edu: 10.05 (sd 2.3)

5 rural communities (10-15 participants per community)

Figure 1: Sample characteristics


In order to test the feasibility of the intervention, data were collected both about session delivering and participants characteristics. Session delivering was directly supervised by the Author. At the end of each session, supervisor and group leaders wrote a qualitative evaluation of the participation level, specific problems and group behaviors and responses to the proposed activities compared to the standard ones reported from previous implementations of the model. Data about participants' demographic characteristics, drug and alcohol use, risk behaviours, perceived peers substance use, impulsivity, and decision making style were collected translating and adapting RSTP assessment instruments and other widely used self-report questionnaires (BIS11 for adolescents, Melbourne Decision Making Questionnaire).

References
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