Alcohol use disorders-Mobile based Brief Intervention Treatment (AMBIT): Technological innovation to bridge the treatment gap for hazardous drinking.

The World Health Organization (WHO) defines three levels of problematic alcohol consumption, namely hazardous drinking (HD) (which puts a person at risk of developing health/social problems), harmful drinking (where health/social problems are already occurring), and alcohol dependence (where serious problems have already occurred). Although HD and harmful drinking affects a larger proportion of the population (and causes many more problems) than alcohol dependence (the 'prevention paradox'), in India health policy focuses mainly on institutional delivery of care for alcohol dependence. Extensive evidence globally demonstrates the effectiveness of Brief Interventions (BIs) in reducing drinking in HD. However, in India, the major barriers to providing such evidence-based psychosocial treatments are the lack/inequitable distribution of trained healthcare professionals and concerns about the cultural generalisability of psychosocial interventions developed in the West. One innovation to overcome the human resource barrier is to use mobile phone technology like SMS (Short Messaging Service) and interactive voice response (IVR) to deliver BIs to large numbers of HDs, quickly and at low cost, as demonstrated in interventions for smoking cessation. Furthermore, a growing body of evidence demonstrates that following a systematic methodology to culturally adapt psychosocial interventions increases acceptability by recipients and delivery agents, and feasibility of delivery.

The overall objective of AMBIT is to develop a contextually appropriate BI for HD that can be delivered using mobile phone technology to overcome barriers to access in low resource settings. The specific aims of AMBIT are to 1) Develop a BI package delivered using mobile phone technology, in partnership with our technology partner; 2) Examine if it is acceptable/feasible to deliver such an intervention in an Indian setting; 3) Conduct preliminary testing to see if the intervention helps in reducing drinking; and 4) Fine-tune procedures for the definitive testing of the effectiveness of the intervention. The aims of the programme will be achieved through a range of processes including identification of the existing evidence; development of the intervention in partnership with our technology partner and utilising feedback from a range of individuals and groups including Hazardous Drinkers; refinement of the intervention; and testing of its preliminary impact. The output of this treatment development process would be a contextually acceptable and feasible mobile-technology-delivered BI package which can then be tested in a larger trial. To summarise, we want to help hazardous drinkers to reduce levels of harm caused to them, their families and society in general, by transforming a way of helping (BIs) which has in the past been delivered face-to-face by healthcare workers into a much more accessible and widely available form, by using mobile phones (widely owned across India and other LMICs) and SMSs (widely used across India and other LMICs). HD is a big and growing problem, both in itself, and also because many people with HD will go on to develop even more problematic versions of AUD. If successfully developed and found to be cost-effective, our intervention can reach millions of people across the world (as mobile phone use has increased exponentially even across the developing world) and could be a real game changer in the field of public health.

Hazardous drinking (HD), harmful drinking and dependent drinking reflecting progressively more serious forms of Alcohol Use Disorders. Despite the high public health burden of HD and harmful drinking in India, policy focuses predominantly on alcohol dependence which affects a much smaller proportion of the population. Extensive evidence demonstrates the effectiveness of Brief Interventions (BIs) in reducing alcohol consumption in HD. In India, the major barrier to making such evidence-based treatments accessible are the lack and inequitable distribution of trained healthcare professionals. One innovation to overcome this barrier is to use mobile phone technology like SMS to deliver BI to large numbers of HDs, quickly and at low cost, as successfully demonstrated for other behavior-change interventions such as those for smoking cessation. AMBIT's aims are to develop a contextually appropriate BI package that can be delivered using mobile phone technology. More specifically the aims include the following: 1) Develop and refine a BI package delivered using mobile phone technology; 2) Examine contextual acceptability/feasibility of the intervention; 3) Conduct preliminary evaluation of its impact on alcohol consumption; and 4) Fine-tune procedures for a RCT of the intervention. These aims will be achieved through identification of the evidence through systematic reviews; development of the intervention package for mobile phone delivery, based on that identified best evidence, and through participatory methods involving multiple stakeholders; iterative refinement of the intervention package and delivery platforms through data obtained from a treatment cohort with a before and after design; and preliminary testing of impact of the intervention and procedures for a definitive RCT through a pilot RCT. The output of this treatment development process would be a contextually acceptable and feasible mobile-technology-delivered BI package, ready for testing in a definitive RCT.

The prevalence of hazardous drinking (HD) varies across India but a conservative estimate of 15% amongst males equates to approximately 94 million men with HD in India. Globally almost 80% of such men do not receive any treatment for their HD. Brief Interventions (BIs) delivered by healthcare workers are effective in reducing HD. However there is a critical shortage of healthcare workers in India: 2.08 per 1000 population, lower than WHO's critical shortage threshold of 2.28. Mobile phones, on the other hand, are almost ubiquitous-81% of the Indian population owns one. If this commonly available technological resource were to be used to deliver BI then we could increase access for HD to evidence based care.

Our project is the first step towards developing such a BI that can be delivered using mobile phone technology and it will make an impact on the following groups, in the following ways:

1)People with HD: The intervention aims to reduce drinking in HD. As users will be primary stakeholders in our project, they will play a role in the design and conduct of our research, in order to make it more relevant and acceptable. Consequently, the intervention will have an impact on health outcomes and quality of life of such drinkers, and an indirect positive impact on their family members by reducing stress, improving family finances etc.

2) Health care professionals and workers: Our intervention will generate findings relevant for clinical practice. One major reason why health workers do not intervene with HD is that they do not know what to do or how to help. If shown to be acceptable, feasible and effective, our intervention will provide health workers with a simple tool to help reduce drinking in HD. This intervention could be utilised in routine primary care as it will not require any training of health workers. In India, HD often come in contact with a range of health care professionals when they access healthcare services for a range of health problems; which would provide a window of opportunity for such professionals to link the drinker to our m-Health intervention.

3) Researchers: Researchers based in academia, government, non-governmental and the charity sector will be academic beneficiaries of our research. On a broader level, our research outputs will expand the evidence base for the use of m-Health interventions to increase access to healthcare in low resource settings, inform similar research efforts, and highlight recommendations for future research. 4) Policy makers and legislators: This group of 'decision makers' will benefit from our research, particularly on findings related to the effectiveness and cost-effectiveness of the psychosocial intervention (this evidence will be gleaned in the long term through a definitive trial).

We will adopt a multi-modal communication and engagement strategy with each of these groups, as relevant. These will include involvement of stakeholders in the research process, research and other publications, and networking in professional groups, and a preliminary policy brief.

In the shorter term, our project will lead to the development of a testable m-Health intervention for hazardous drinking, probably the first of its kind in a low and middle income country. If demonstrated to be cost effective in a definitive randomised controlled trial, our intervention will have several long term impacts. On a broader level it will contribute to the nation's health by dealing with a milder form of AUD and preventing its progression into a more severe form, and to the nation's wealth by increasing productivity in the workforce, a substantial proportion of which has drinking problems, especially in the heavy industrial sector. Finally, it will also increase the capacity of the heavily overstretched public health services in low resource settings by using technology to deliver an intervention which has traditionally been delivered by healthcare professionals.