Preventing Harmful Alcohol Use Among Trauma Patients in Cameroon

**Detailed Description**

Alcohol use is a major contributor to the burden of injury in Cameroon and other low- and middle-income countries (LMICs). Studies conducted in Cameroon have demonstrated high levels of alcohol use among road users and trauma patients, with substantial proportions of injured patients reporting recent alcohol consumption or testing positive for alcohol at the time of injury. Harmful alcohol use is associated with increased risk of injury, injury recurrence, disability, and mortality. Despite this burden, systematic alcohol screening and intervention services are not routinely integrated into trauma care in Cameroon.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach designed to identify individuals with risky alcohol use, provide brief counseling to promote behavior change, and facilitate referral to treatment when indicated. SBIRT has been successfully implemented in emergency departments and trauma centers in high-income countries and has demonstrated effectiveness in reducing harmful alcohol use and alcohol-related consequences. However, little is known about the feasibility, acceptability, and effectiveness of SBIRT in resource-constrained emergency care settings in sub-Saharan Africa.

The purpose of this study is to evaluate a Cameroon-adapted SBIRT program implemented within the Emergency Department of the Limbe Regional Hospital. The intervention was developed through a participatory adaptation process involving emergency department clinicians, mental health providers, trauma researchers, implementation scientists, and other stakeholders to ensure cultural appropriateness and operational feasibility within the Cameroonian healthcare context.

The study has three primary objectives: (1) to train emergency department healthcare providers in delivery of a Cameroon-adapted SBIRT program; (2) to evaluate the feasibility, acceptability, adoption, and fidelity of SBIRT implementation in routine emergency care; and (3) to evaluate the effectiveness of SBIRT in reducing harmful alcohol use among trauma patients.

The study will be conducted in phases. During the preparatory phase, stakeholders will be engaged to refine implementation procedures and pretest the training curriculum. Emergency department healthcare workers, including physicians, nurses, and mental health nurses, will then undergo structured training on alcohol screening, motivational interviewing, brief intervention delivery, and referral procedures. Following training, a transition period will be used to integrate SBIRT into routine emergency department operations and optimize implementation workflows before initiation of full study enrollment.

All eligible adult trauma patients presenting to the Emergency Department will be screened for alcohol use using the Single Alcohol Screening Question (SASQ). Patients reporting alcohol use will complete the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Men with AUDIT-C scores of 4 or greater and women with AUDIT-C scores of 3 or greater will be considered positive for risky alcohol use and eligible for study enrollment. Participants will subsequently complete the full Alcohol Use Disorders Identification Test (AUDIT) for characterization of alcohol use severity. Individuals with AUDIT scores of 8 or greater will be referred for additional evaluation and treatment according to the study referral protocol.

Eligible participants will be randomized to either an intervention arm or a waitlist-control arm. Participants assigned to the intervention arm will receive the Cameroon-adapted SBIRT program delivered by trained healthcare workers during their emergency department visit. The intervention consists of alcohol risk screening, personalized feedback regarding alcohol use, a brief motivational interviewing-based counseling session, and referral to treatment when indicated. Participants assigned to the waitlist-control arm will receive usual care during the study period and will be offered the intervention following completion of study follow-up.

Participants will be followed for six months following enrollment. Follow-up assessments will occur at one month, three months, and six months after enrollment. Alcohol use outcomes will be assessed using both self-reported and biological measures. Self-reported alcohol use will be measured using the AUDIT instrument. Biological alcohol use will be assessed using phosphatidylethanol (PEth), a validated biomarker of recent alcohol consumption. Additional outcomes will include referral uptake, treatment engagement, depression symptoms measured using the Patient Health Questionnaire-9 (PHQ-9), and injury-related outcomes.

Implementation outcomes will be evaluated using implementation science frameworks including the Consolidated Framework for Implementation Research (CFIR), Proctor's Implementation Outcomes Framework, and the FRAMES model. Feasibility, acceptability, fidelity, adoption, and implementation determinants will be assessed through implementation monitoring, provider surveys, direct observation of intervention delivery, and qualitative interviews with healthcare workers and patients.

The primary hypothesis is that the Cameroon-adapted SBIRT program can be feasibly integrated into routine emergency department care and that participants receiving the intervention will demonstrate greater reductions in harmful alcohol use over six months compared with participants receiving usual care. The study will generate evidence regarding implementation strategies, intervention effectiveness, and scalability of alcohol interventions in trauma care settings within LMICs.

Results from this study are expected to inform future implementation and scale-up of SBIRT programs in Cameroon and other resource-limited settings. The findings may also provide implementation insights relevant to underserved trauma systems and emergency care settings globally where access to behavioral health and substance use services remains limited.

Inclusion criteria

• Adult trauma patients aged 18 years and older presenting to the Emergency Department of Limbe Regional Hospital.
• Positive alcohol screening based on the Single Alcohol Screening Question (SASQ).
• AUDIT-C score ≥4 for men or ≥3 for women.
• Able to provide informed consent.
• Resident within the study catchment area and available for follow-up.
• Access to a telephone or another reliable means of contact for follow-up assessments.

Exclusion criteria

• Severe cognitive impairment preventing participation in study procedures or - provision of informed consent.
• Severe traumatic brain injury or other medical condition requiring immediate life-saving intervention that precludes participation.
• Current psychosis or severe psychiatric illness preventing meaningful participation in the intervention.
• In police custody or other circumstances limiting ability to participate in follow-up.
• Planned relocation outside the study catchment area during the study follow-up period.
• Previously enrolled in the study.