The framework for the development of Counselling for Alcohol Problems (CAP) was informed by a synthesis of existing evidence for cultural adaption of psychological treatments for mental health conditions, those that could be delivered by lay health workers as well as methodologies used by other Indian research teams for mental health intervention development.
Based on these experiences, our methodology6 involved 3 sequential stages:
- Identifying potential treatment strategies and developing a theoretical framework for the treatment
- Evaluating the acceptability and feasibility of the treatment
- Evaluating the effectiveness and cost-effectiveness of the treatment
Selecting feasible and acceptable strategies and developing a theoretical framework
- Stage 1: A survey was conducted with 2 diverse groups to identify and filter pre-determined strategies deemed feasible and appropriate for delivery by lay counsellors and acceptable by patients within the Indian primary health care context.
- Stage 2: Invited Local and international mental health experts to participate in six treatment development workshops based on the survey. A coherent treatment delivery framework was developed culminating towards a treatment plan of up to four sessions6
Evaluating the acceptability and feasibility of the CAP treatment
- A clinical case series was carried out where treatment was delivered in stages from professionals to lay counsellors (with supervision).
- Lay counselors delivered CAP to patients in PHCs and were supervised in groups by local mental health professionals.
- Participants were identified through screening of PHC attenders, referrals from GPs and psychiatrists or were self‐referred clients.
- CAP was iteratively revised based on observations made continuously through the case series
Evaluating the effectiveness and cost-effectiveness of the CAP treatment
A randomised controlled trial was designed and implemented in 8 PHCs in Goa, India. Participants were screened using the AUDIT and the Patient Health Questionnaire (PHQ- 9) and recruited from PHCs. Trained health assistants, independent of the counsellors, screened patients using AUDIT and administered a baseline questionnaire to trial participants to collect sociodemographic information (eg age and marital status) and data for potential moderators of treatment effect. All outcome interviews were audio-taped (with permission), and the tapes were randomly selected (using a random selection strategy stratified by outcome assessor) for review by the supervisor for quality assurance.
- Treatment Arm: In the CAP group, participants received EUC plus CAP which was delivered in three phases over a maximum of four sessions (each lasting approximately 30–45 min) at weekly to fortnightly intervals.
- Control Arm: In the EUC group, usual care (consultation with the PHC physician) was enhanced by provision of the screening results to the PHC physician and provision of a contextualised version of the WHO Mental Health Gap Action Programme guidelines9 for harmful drinking, including when and where to refer patients for specialist care.