Brief alcohol counselling cut harmful drinking in a Zambian refugee settlement

A brief counselling programme delivered by non-specialists reduced harmful drinking in a Zambian refugee settlement, in what its authors describe as the first trial in a humanitarian setting to show a significant, sustained effect on alcohol use. The result, published in The Lancet Global Health on July 24, points to a low-cost way to address a problem that humanitarian health programmes have largely neglected [s1].

A neglected problem

Alcohol and other drug use is a leading cause of preventable death and disability worldwide, and it falls hardest on low-resource settings — yet it remains largely absent from humanitarian health research and programming [s1]. WHO's fact sheet records that around 2.6 million deaths were caused by alcohol consumption in 2019, and that an estimated 400 million people, or 7% of the world's population aged 15 years and older, lived with alcohol use disorders, of whom 209 million lived with alcohol dependence [s2]. Displacement and the conditions of camp life can compound the risk.

The trial

The study was a parallel, individually randomised trial in the Mantapala refugee settlement in Zambia [s1]. Eligible participants were Congolese refugees and Zambian host community members aged 15 years and older who screened positive on the Alcohol Use Disorders Identification Test — a score of 8 or more for men and 4 or more for women [s1].

Participants were allocated 1:1 to one of two arms. The intervention was screening, brief intervention, and referral to treatment, or SBIRT: a screen, a short counselling session, and, where indicated, referral to psychotherapy for alcohol, other drug use, and mental health conditions, all delivered by trained non-specialists [s1]. The comparison arm, treatment as usual, referred people to primary health centre staff trained in basic management of alcohol problems [s1]. The primary outcome was the AUDIT score at 6 months [s1].

What they found

Between April 26, 2023, and February 29, 2024, the team screened 443 people, excluded 43, and enrolled 400 — 199 to SBIRT and 201 to treatment as usual [s1]. Some 299 participants (75%) completed the 6-month assessment and 310 (78%) the 12-month assessment [s1]. The mean age was 36.9 years, 287 (72%) were male, and 232 (58%) were Congolese refugees [s1].

AUDIT scores fell in both arms from baseline to 6 months — by 12.6 points (95% CI -14.3 to -11.0) in the SBIRT group and by 8.1 points (-9.8 to -6.3) in the treatment-as-usual group [s1]. The difference in mean change favoured SBIRT: 4.6 points greater reduction at 6 months (95% CI -6.9 to -2.2; p<0.0001; effect size d=0.56) and 3.5 points at 12 months (-5.8 to -1.1; p=0.0030; d=0.43) [s1]. The incremental cost per unit of improvement in AUDIT at 6 months was US$158, and there were no study-related adverse events [s1].

The persistence of the effect to 12 months matters. Brief interventions often show a first-few-months benefit that fades; here the gap between groups was smaller at a year than at six months but remained statistically significant [s1].

Why the design is notable

Two features stand out. First, the intervention was delivered by trained non-specialists rather than by scarce mental-health professionals — the task-sharing model that most low-resource health systems must rely on if they are to reach people at all [s1]. Second, the comparison was not against nothing but against a genuine alternative: referral to primary care staff with basic training [s1]. Beating an active comparator is a stiffer test than beating a waitlist.

The caveats

The trial was necessarily unmasked at enrolment — participants, counsellors, and research assistants knew the allocation, although the data analysts were masked through dummy coding of the study groups [s1]. The primary outcome was a self-reported questionnaire score, which can be influenced by knowing which arm one is in and by social desirability, particularly for a stigmatised behaviour. Follow-up was incomplete, with a quarter of participants missing the 6-month assessment, though the analysis used multiple imputation and an intention-to-treat approach [s1]. And a single settlement in one country is a starting point, not a general proof.

The trial was funded by Elrha's Research for Health in Humanitarian Crises programme and is registered as NCT05471921 [s1]. Its authors conclude that SBIRT is a feasible and effective strategy to reduce alcohol-related harm in humanitarian and low-resource settings, with potential to be built into national and global health systems [s1].

What to watch

Whether the approach reproduces in other camps and countries, whether the effect holds using measures less vulnerable to reporting bias, and whether humanitarian funders — under acute financial strain — treat alcohol and drug use as part of the core health response rather than an afterthought.

This article is informational and is not medical advice.