Community I-STAR Mozambique: Community Implementation of SBIRT using Technology for Alcohol use Reduction in Mozambique

危险饮酒(HD)是世界范围内的主要公共卫生负担，发病率和死亡率都很高。这个 与这一全球负担相关的预防和治疗差距要求采取有效的干预措施 扩大规模，利用现有平台和政策制定者的参与，随时准备应用和维持 随着时间的推移，循证政策。为了减少HD，世卫组织建议使用筛查，简要 干预、转诊至治疗(SBIRT)和精神健康差距行动方案指南(MHGAP)。 随着中低收入国家(LMIC)采用SBIRT和mhGAP提供基于社区的高清服务 (HDS)，扩大规模的主要挑战是确保服务的有效性、保真度和可持续性。移动医疗 技术(MHealth)，如我们团队成员开发的mSBIRT应用程序，是一个很有前途的工具 社区卫生工作者(CHW)广泛以成本效益的方式提供循证HDS，因为其 提高保真度、有效性和可持续性的潜力。拟议的项目，社区i-STAR (使用减少酒精使用技术实施SBIRT)莫桑比克将利用下列资源 现有的莫桑比克卫生部方案：(1)培训精神病患者的任务转移战略 技术人员(心理医生)使用mhGAP；(2)由世界卫生组织资助的由CHWS提供的癫痫社区计划； 以及(3)针对疟疾、肺炎和腹泻的移动健康计划(见SCALE--针对 社区准入和持久影响)。这些目前正在运行的程序为mSBIRT的使用奠定了基础 由社区卫生组织在莫桑比克提供社区HDS，并制定扩大政府资助的政策 社区HDS利用现有的人力资源。莫桑比克i-star社区由三个成员组成 阶段：1)mSBIRT适应，2)集群随机试验，3)最具成本效益的扩大 干预。在使mSBIRT适应莫桑比克的背景/文化的形成阶段之后，我们将进行2- 年，整群随机，混合效果--在12个地区实施第2类试验：6个地区随机 接受mSBIRT和6到SBIRT常规培训和监督战略(SBIRT-CTS)，并同时接受 由CHWS运送的武器。在为期两年的试验中显示出较高成本效益的ARM将扩大到 其他6个地区为期12个月的“跨界”。在整个试验和“交叉”扩展过程中，定性和 流程数据将补充量化评估，以检查实施、可持续性和扩大规模。 我们的方法在不需要新的人力资源的情况下重新定义了工作角色，并且与卫生部的 致力于实施HDS。我们将使用循证实践(SBIRT)来a)建设 完成可持续社区--HDS做法的任务转移；以及b)使用执行工具审查 两个SBIRT交付战略的实施和效果，随后对MOST的扩大进行评估 具有成本效益的战略。社区i-STAR莫桑比克将扩大一个具有成本效益的可持续计划，并 告知适用于莫桑比克和其他小岛屿发展中国家的政策。

Hazardous drinking (HD) is a major public health burden worldwide with significant morbidity and mortality. The prevention and treatment gap associated with this global burden requires that efficacious interventions be scaled-up, leveraging existing platforms and participation of policy makers ready to apply and sustain evidence-informed policies over time. To reduce HD, the WHO recommends using Screening, Brief Intervention, Referral to Treatment (SBIRT) and the mental health Gap Action Programme guidelines (mhGAP). As low- and middle-income countries (LMIC) embrace SBIRT and mhGAP for community-based HD services (HDS), a main scale-up challenge is ensuring effectiveness, fidelity, and sustainability of services. Mobile health technology (mHealth), such as the mSBIRT app developed by members of our team, is a promising tool for widespread cost-effective delivery of evidence-based HDS by community health workers (CHWs) because of its potential to increase fidelity, effectiveness, and sustainability. The proposed project, Community I-STAR (Implementation of SBIRT using Technology for Alcohol use Reduction) Mozambique, will leverage the following existing Mozambique Ministry of Health (MoH) programs: (1) a task-shifting strategy training psychiatric technicians (PsyTs) to use the mhGAP; (2) the WHO-funded epilepsy community program delivered by CHWs; and (3) an mHealth program for malaria, pneumonia, and diarrhea (inSCALE - Innovations at Scale for Community Access and Lasting Effects). These currently operating programs set the stage for the use of mSBIRT by CHWs to deliver community HDS in Mozambique and generate policy for scale-up of government-funded community HDS harnessing existing human resources. Community I-STAR Mozambique comprises three phases: 1) mSBIRT adaptation, 2) a cluster-randomized trial, and 3) scale-up of the most cost-effective intervention. After a formative phase to adapt mSBIRT to Mozambique’s context/culture, we will conduct a 2- year, cluster-randomized, hybrid effectiveness-implementation type 2 trial in 12 districts: 6 districts randomized to receive mSBIRT and 6 to an SBIRT Conventional Training and Supervision strategy (SBIRT-CTS), with both arms delivered by CHWs. The arm showing higher cost-effectiveness in the 2-year trial will be scaled up to the other 6 districts for 12 “cross-over” months. Throughout the trial and the “cross-over” scale-up, qualitative and process data will complement quantitative assessments to examine implementation, sustainability, and scale-up. Our approach redefines work roles without requiring new human resources, and it comports with the MoH’s commitment to implementing HDS. We will use evidence-based practices (SBIRT) to a) build capacity for complete task-shifting of sustainable community-HDS practices; and b) use implementation tools to examine implementation and effectiveness of two SBIRT delivery strategies followed by evaluation of scale-up of the most cost-effective strategy. Community I-STAR Mozambique will scale-up a cost-effective, sustainable program and inform policy applicable to Mozambique and other LMICs.