Alcohol use places a considerable burden on health systems, economies and societies across the globe. The 2016 Global Burden of Disease study ranked alcohol use as the seventh leading risk factor for premature death and disability, and the leading risk factor for people aged 15-49 years . Alcohol consumption has been linked to 60 acute and chronic diseases, with the base of evidence suggesting that risk of alcohol-attributable disability and death increases with volume of alcohol consumption and frequency of heavy drinking occasions [1–4]. Beyond immediate health impacts, alcohol misuse can place significant societal and economic burden on countries: studies conducted across twelve countries suggest that the economic burden ranges from 0.45% and 5.44% of gross domestic product (GDP) [5, 6].
Harmful alcohol use has been defined as drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as patterns of drinking that are associated with increased risk of adverse health consequences . Screening, brief interventions and referral to treatment typically seek to identify and prevent harmful alcohol use within the general population . Alcohol use disorders represent a sub-set of harmful alcohol use, characterised by chronic relapsing brain disorder with an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences . Treatment for alcohol use disorders may be psychosocial or pharmacological, with evidence that a combination of both approaches may be most effective [7, 9].
In Thailand, the 2014 Burden of Disease estimated that alcohol addiction was responsible for 3% of the total disease burden, and the leading cause of disability adjusted life years . Prevalence of alcohol use disorders has been estimated at 5.4% . Thailand has a long history in implementing a coordinated alcohol control policy, which follows the five areas of intervention recommended in the WHO SAFER technical package, namely strengthening restrictions on alcohol availability; advancing drink-driving countermeasures; facilitating access to screening, brief interventions and treatment; enforcing restrictions on alcohol advertising, sponsorship and promotion; and raising alcohol prices [12, 13].
Interventions in Thailand are split into three levels . The first level includes campaigns and interventions in the general population to prevent and manage drinking behaviour; the second covers screening and brief interventions for individuals with risky drinking behaviours; and the third is concerned with the treatment and rehabilitation of individuals with alcohol use disorder. This review will examine interventions that could be provided under the latter two levels, to identify whether any effective screening, brief interventions or treatment for harmful alcohol use are currently missing from the benefits package provided under the Thai Universal Coverage Scheme.
Prior systematic reviews and umbrella reviews for prevention and treatment of harmful alcohol use have either focused on specific interventions (e.g. brief interventions [15–18], pharmacotherapy for withdrawal , self-help groups ) or specific populations (e.g. pregnant women [21, 22], youth [23–25]). Moreover, existing reviews include limited analysis of applicability across settings and contexts, especially with regards to health system structures and resourcing . We will therefore conduct an umbrella review as a streamlined approach to identify a set of options for policymakers , with a focus on translatability of findings to low- and middle-income country (LMIC) settings.
This umbrella review aims to identify which interventions are effective in the prevention and treatment of harmful alcohol use. We have two specific research questions (Figure 1):
Research question 1: which screening, brief interventions, and referral to treatment mechanisms are effective at reducing harmful alcohol use in the general population?
Research question 2: which treatment interventions are effective at reducing harmful alcohol use among people diagnosed with alcohol use disorder?
The research questions, considering the effect of interventions on intermediate behavioural outcomes related to harmful alcohol use, are represented by solid blue lines. The dashed line represents the relationship between the intermediate and health outcomes. Although research questions focus on intermediate outcomes, reviews reporting on either intermediate and/or health outcomes will be included.
Interventions will be considered as effective if they significantly improve the outcome of interest compared to placebo or standard care. We will summarise the evidence on the identified interventions in a format that is relevant for policymakers, highlighting applicability to LMIC settings, variation in definitions or practice within the same intervention, and limitations in evidence that are important for policy. Searching the International Prospective Register of Systematic Review (PROSPERO) and the Joanna Briggs Institute Systematic Review Register did not identify any systematic or umbrella review underway for this topic.