Alcohol and other drug interventions in refugee settings

Principal Investigators: Jeremy Kane and Claire Greene, Columbia University Mailman School of Public Health

What did the study set out to achieve?

Refugees are at risk for unhealthy alcohol and other drug (AOD) use, yet few receive treatment. This research represents the first fully powered trial of an intervention to reduce alcohol-related harms in a humanitarian setting. The study evaluated the effectiveness and implementation of stepped-care AOD services (screening, brief intervention, and referral to evidence-based psychotherapy) for Congolese refugees and host community members in Mantapala, an integrated settlement in northern Zambia.

The study first explored the types, correlates, and patterns of AOD use, validated measures for AOD use, and adapted the intervention and research procedures to be locally relevant and acceptable in the study context. Refugee incentive workers were trained to deliver the intervention to 200 persons reporting unhealthy AOD use. Using a hybrid effectiveness-implementation trial and mixed-methods data collection, the feasibility, cost, barriers and facilitators to implementation of the intervention were evaluated, as well as its effectiveness in reducing unhealthy AOD use and co-occurring mental health problems 12-months after baseline relative to those receiving treatment-as-usual.

The intervention aimed to reduce alcohol and other drug use, improve mental health, and reduce harmful substance-related consequences (e.g., gender-based violence). The study team also anticipated discovering unique considerations for adapting evidence-based interventions to complex humanitarian settings. The research further provided an opportunity to examine the implementation of a public health intervention through an integrated governmental and non-governmental system to both refugees and host community members.

What were the key findings?

• SBIRT was highly effective even among those with very severe symptoms, including those with probable alcohol use disorder.
• Mental health: Improvements in depression/anxiety were evident at 6 months but not sustained at 12 months.
• Feasibility: Uptake and follow-up were strong. 87%completed SBIRT; follow-up remained 76–78% across time points, indicating feasibility in routine services.
• Costs & value for money: Over 28 months, it cost around $84,500 to set up SBIRT and another $136,000 to keep it running, mostly staff costs. SBIRT cost about $158 for each one-point improvement on the AUDIT scale.

What does this mean for policymakers and practitioners?

The findings show that SBIRT is an effective intervention for alcohol use and co-occurring mental health problems in humanitarian settings. The results also suggest that the intervention is effective for individuals with both higher and lower severity problems. Findings also showed it was feasible to train non-specialists to deliver SBIRT while maintaining high quality in a humanitarian setting.

While SBIRT produced meaningful short-term improvements in depression and anxiety, these effects were not sustained at 12months. This may reflect the persistent social and economic stressors facing people in humanitarian contexts, suggesting that psychological interventions alone may be insufficient to maintain gains in mental health over time. For some individuals, additional or ongoing support – such as booster sessions or linkage to livelihood programs – may be needed to address the structural and contextual factors that contribute to poor mental health outcomes.

Although the intervention requires financial investment, it is lower cost than mental health interventions delivered by professional therapists, and there are likely to be downstream positive economic impacts in the community by treating substance use problems, which are highly prevalent in humanitarian contexts.  

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