Cost effectiveness of community based and institution based detoxification and rehabilitation of alcohol dependent persons in Kenya
Government and non governmental agencies the world over, have recommended that drug abuse be dealt with, primarily as a community problem. Community based rehabilitation of patients with various conditions has been tried elsewhere and found .to be cost effective. The World Health Organization (WHO) advocates use of community based health services as means of reaching a large number of people at a low cost. However in Kenya and Africa in general the concept of community based treatment and rehabilitation of persons abusing drugs have not been embraced neither has the effectiveness of various types of alcohol dependence treatment been explored in research. There is therefore need for alcohol dependence treatments to be evidence based and to bridge the gap between knowledge and actual practice. The goal of the study was to provide research based evidence on the cost and effectiveness of community based detoxification and rehabilitation of alcohol dependent persons in Kangemi informal settlement located in the west of Nairobi and compare it with that of institution based detoxification and rehabilitation of alcohol dependent persons. One hundred eighty eight alcohol use disorder identification test (AUDIT) positive alcohol dependent persons were purposively selected to represent the community based group. They were then subjected to alcohol detoxification for 10 days using pabrinex 1 & 11 intravenously daily for 3 consecutive days, diazepam Smg and carbamazepine 200mg for S and 10 consecutive nights respectively on outpatient basis. Pabrinex is parenteral high potency Vitamin Band C combination from Phillips pharmaceuticals. A researcher designed socio demographic questionnaire (SDQ) was administered to provide necessary information including that which was needed for follow up of participants. Alcohol Smoking Substance use Identification Screening Test (ASSIST) and Composite International Diagnostic Interview (CIDI) instruments were administered before detoxification and at the end of six months to determine alcohol related problems and co morbidity, respectively. The community based participants were visited twice a week (at home) by the community based health workers and reviewed once a week by the principal investigator and/or a clinical psychologist and a bimonthly group therapy conducted in groups of 20s. The groups were converted to self-help groups after 4 months to generate income for the participants. Eighty-eight participants admitted in 3 rehabilitation centers over the period of study formed the institution-based group and were similarly subjected to AUDIT, SDQ, ASSIST and CIDI. The follow-up for this group was done after six months (three months after discharge) on telephone and the post test ASSIST and CIDI questionnaire could not be administered to the institution based group at six months since the participants had been discharged three months before. The cost of treatment was obtained for both the community based and the institution based detoxification and rehabilitation groups. Fourteen alcohol samples were collected from the community-based field of study and analyzed for the ethanol and methanol levels. Over ninety eight percent (98.9%) of the community based and 91.5% of the institution based group participants were male. The mean AUDIT score for the community based group males was 28.6 as compared to a mean score of 15.8 for the males in the institution-based group. There were statistically significant differences in the education level, type of occupation and income for the two groups with the community-based group being more disadvantaged as compared to the institution based group. Similarly the co morbidity and level of alcohol use was significantly higher in the community based group. The age onset of alcohol use by the community and institution group was early with no statistically significant differences in the two groups (54.4% of the institution and 43.2% of the community based groups beginning to use alcohol before the age of 18 years). The levels of hazardous drinking and alcohol dependence were significantly higher in the community based group when compared to the institution based group. However there were no statistically significant difference in alcohol related problems and harmful drinking. High level of psychiatric co morbidity was present in both community based and institution based participants. One hundred and thirty (130) out of the 188 who had enrolled in the community based study group completed the six months treatment with 56.9% participants remaining abstinent for the entire period. Seventy nine out of the 88 participants of the institution based group were contacted at six months, 44.3% of them were abstinent for the entire six months of study. There was a statistically significant reduction in the levels of co morbidity and alcohol related problems in the community based group after six months of treatment. The analysis of alcohol samples collected from field of study found anomalies between the actual and the Kenya Bureau of standards recommended ethanol content in sdme of the samples Randomization of the community and institution based groups was not possible before intervention because of ethical and logistical reasons. This complicated the comparison of effectiveness of the community based and institution based interventions. This notwithstanding, community based detoxification and rehabilitation was found to be more effective, safe, affordable and therefore feasible.