Cost Effectiveness of Community Based and Residential Based treatment of Alcohol Use Disorders : Findings of a study in Kenya

Alcohol Use disorder (AUD) treatment should be effective, available and affordable. The treatment of AUDs in Kenya, which is traditionally residential, based and community based treatment, has not been documented. Objective: to Determine Cost effectiveness of Community based and residential based treatment for AUD. Design: Clinical trial with pre-/post measurements. Method: The WHOASSIST and the CIDI questionnaires were administered to 188 alcohol-dependent persons at intake and after six months for the community based group. A socio demographic questionnaire was also administered at intake. They were then subjected to outpatient detoxification and follow-up within the community. Similar instruments were administered to 88 persons admitted for AUD treatment to 2 residential treatment centres during the study period. They were treated as per the set standards of the treatment centers and discharged after three months. They were contacted after 6 months and their alcohol use determined. Results: After six months, 56.9 % of the community based treatment group and 44.3% of the residential based treatment group were abstinent for the entire six months. Community based treatment was more cost effective and 1.7 times cheaper than the nonsubsidized residential based treatment. Conclusion: Community based treatment for persons with AUD are more cost effective.


INTRODUCTION
Alcohol use disorders are on the increase in Kenya with reported increase in use of both illicit and licit alcoholic brews.The treatment of AUDs is traditionally residential based with no research based evidence of their effectiveness.This residential based treatment is limited to a capacity of less than 700 bed capacities in the 65 residential rehabilitation centers.Only one of the rehabilitation centres is public, and the cost of rehabilitation is high.None of the rehabilitations offer detoxification and patients who require detoxification undergo the same as inpatients in hospitals before joining rehabilitation.This raises the cost of treatment for AUD and makes it unaffordable to the majority of the people in need.There is no evidence -based report on outpatient or community based treatment for AUDs in Kenya.
Excessive alcohol use is fairly new phenomena in Kenya.In the past, the cultural set up prohibited use of alcohol by women and the youth with alcohol being used for ceremonial purposes only.However, with the changes in the social fabric, alcohol use has become wide spread and AUDs are common.In spite of the escalating alcohol use, there is no research that has been conducted to explore on cost effectiveness of existing treatments neither have there been research on other possible interventions.Studies indicate that in order to address new challenges in health delivery it is important to know the interventions that are effective and their cost [Laxminarayan, R.et al. [2006], Eddy D.M. [1990], Weinstein M.C. and Stason, W.B. [1977].Such an Understanding will help in implementation of interventions that are more cost effective, thus benefiting larger populations of persons with AUD.

Cost Effectiveness of Community Based and Residential Based treatment of Alcohol Use
Disorders: Findings of a study in Kenya In treatment of alcohol dependence, it is important to consider three factors, namely, the type, effectiveness and cost of treatment.Cost effectiveness in a health intervention is the quantifiable, significant results obtained from the intervention Jamison, D.T.W. et al. [1993].A cost effective intervention is one that has a relatively low ratio of cost to effectiveness.
In Kenya there are competing health challenges among them_ malaria and HIV/AID, which attracts more attention for funding.However the increasing prevalence of alcohol use calls for a management approach that is both effective and affordable by the majority of those in need.Interventions with a high price should, all things being equal, be used less, whereas those with a low price should be used to a greater extent [Laxminarayan, R.et al. [2006].Community based treatment of drug dependence has been recommended as a good treatment approach_ World Health Organization, United Nations Drug Control Program [2008].There is however no research evidence of its effectiveness in the Kenya settings.
Cost effectiveness analysis helps identify neglected opportunities by highlighting interventions that are relatively inexpensive, yet have the potential to reduce the disease burden substantially and helps identify ways to redirect resources to achieve more Jamison, D.T.W. et al. [1993].It is a method that would guide in choosing among two interventions when resources are limited.Primer on cost-effectiveness analysis [2009].Kenya is among the low and middle income; It is considered to be the most appropriate method for the evaluation of health economics when at least two alternatives are being compared and when outcomes can be expressed in a common unit, such as cost per life years saved Brockhuis B. et al. [2002].More generally, CEA evaluates the relative costs and benefits of different medical technologies, procedures, or clinical strategies Gazelle G.S. et al. [2005].
Typically, a new clinical strategy is compared with the most widely used current practice alternative Chisin R [2009].In the current study for instance, the community based detoxification and rehabilitation of alcohol dependent persons which has not been implemented in Kenya is compared with the traditionally practiced residential based detoxification and rehabilitation of alcohol dependent persons.
In evaluating the economic aspects of a programme cost, all costs directly or indirectly associated with the programme are compared with the positive effects of the programme, both for the individual and in terms of reduced problems for society.This comparison includes cost-benefit evaluation, a comparison of all costs and benefits resulting from treatment with those that would have been incurred without treatment [Laxminarayan, R.et al. [2006].The basic calculation involves dividing the cost of an intervention in monetary units by the expected health gain measured in natural units such as number of lives saved.Some studies calculate cost effectiveness using years of life lost as natural unit for measuring the effect of interventions [Laxminarayan, R.et al. [2006].

METHOD
In the study conducted in Nairobi and it's environ, two groups of participants were included in the study.The first, referred to as the community-based treatment (CBT), group was purposively selected from the Kangemi informal settlement located in the west of Nairobi city.The study area has a high population of people with drug use disorders, particularly alcohol dependence Ndetei, D.M et al. [2007].
After obtaining informed consent participants who scored > or = 15 for male and > or =13 for female on the AUDIT score, were enrolled to the study if they were aged 18 years and above.
All aspects of detoxification and rehabilitation including medication, dosage and side effects, and right to withdraw at any time during study were explained after which consenting individuals signed consent.
Ethical approval was obtained from the Kenyatta hospital/University of Nairobi research and ethical review board.Excluded from the study were those unavailable or unwilling to join the study for the 6 months.Those suffering from severe medical and neuropsychiatric complications (including delirium tremens, active psychosis (hallucinations, delusions), suicidal thoughts and tendencies, and severe memory difficulties) at the time of screening were also excluded.Those with multiple drug use/abuse were included in the study.A total of 20 persons were excluded.
A researcher-designed socio demographic questionnaire (SDQ) was administered at intake to provide necessary information including that which was needed for follow-up of participants.Alcohol Smoking Substance Use Identification Screening Test (ASSIST) Edwards, S.H. et al. [2003] was used to screen for alcohol and other substance use and alcohol-related problems.The PAPI version of the Composite International Diagnostic Interview (CIDI) Kesser, R.C. [2004] instrument was administered to screen for psychiatric co morbidity.Both the ASSIST and the CIDI were administered both at intake and at six months.
The participants were subjected to detoxification for 10 days using a pair of ampoules of high potency vitamin B &C injection daily for 3 consecutive days, Diazepam 5 mg and Carbamazepine 200 mg for 5 and 10 consecutive nights, respectively, on outpatient basis.Although the study participant had a general physical examination done (including blood pressure, temperature, and body weight check), no laboratory or radiological investigations were done in the current study.Low doses of benzodiazepine were given to all participants to avoid heavy sedation that would complicate any existing medical conditions.Similarly, low doses of Carbamazepine were used.
There was documented follow-up at home for each participant by the community health worker (CHW) twice a week, and the principal researcher (P.I) or research assistant (once a week) at Kangemi Heath Centre for a period of 6 months.During each review a structured follow-up questionnaire was used to determine whether the participant was abstaining from alcohol and symptoms experienced.Both the P.I and the CBHW reports on the drinking status of the participants were compiled weekly.There was a bimonthly group therapy conducted in groups of 20 s by the P.I and/or a clinical psychologist.
The second study group referred to as the residential based treatment (RBT) group enrolled from 2 rehabilitation centres.These were the 2 oldest and most established among the 65 registered rehabilitation centres in Kenya.The first residential treatment centre (S) was a mission based with a subsidized cost while the second (NS) was a non-subsidized residential treatment centre.The participants were enrolled to the study on the day of admission to the residential treatment centre, if they were aged 18 years and above, and if the reason for admission was alcohol use disorder (irrespective of whether they had undergone detoxification or not).They were subjected to a socio demographic questionnaire_ the ASSIST, CIDI were administered at intake and the participants followed the residential rehabilitation programs without any form of intervention by the researcher.They were discharged from the residential rehabilitation centres after a period of three months but were informed by the researcher that they would be contacted on phone at the sixth month.A short structured telephone questionnaire was administered at the sixth month to determine abstinence for the last 3 months.

Data Analysis
Data collected was coded, entered, and stored in computer.Only the PI had the name related to the code number.The data was analyzed using STATA version 10 and descriptive and inferential statistics performed.A cost effectiveness analysis was done.This involved four stages or steps: Firstly, the expected impact was identified as the proportion of the alcohol takers who stopped six months after each intervention (CBT and RBT).Secondly, the total resource costs of the two programmes were assessed or determined.Thirdly, the cost per unit output and outcome are assessed, through the simple division of costs by outcomes (number of those stopped drinking).Finally the results were then expressed as $ per life time quitter.

RESULTS
A total of 188 participants underwent community-based detoxification but only 156 were followed up for the six months.The majority (76.1%) of the participants of the residential based group joined rehabilitation directly without undergoing detoxification.They all completed the 3 months residential rehabilitation.The residential treatment centres had no aftercare for the clients.
Over ninety percent (98.9%) of the community based and of 91.5% of the residential based participants were male.The mean age for the community-based group was 31.9 years and that of institution-based group was 31.1years.The age of onset for alcohol use by the community and residential group was early with no statistically significant differences in the two groups (54.4% of the residential and 43.2% of the community based groups beginning to use alcohol before the age of 18 years).
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 residential based group.The results are shown in table 1a &1b.The mean AUDIT score for the community based group_ male was 28.6 as compared to a mean score of 15.8 for the male in the residential based group.The levels of hazardous drinking and alcohol dependence were significantly higher in the community based group when compared to the residential based group.However there were no statistically significant difference in alcohol related problems and harmful drinking.The results are shown in table 3.  Using the CBT approach, of the 188 drinkers who began therapy, 74 of 130 who were able to be traced after six months (56.9%) had stopped drinking in the 6 months period of follow up.With the RBT(S &NS) approach, 35 (44.3%) of 79 reached after six months had stopped drinking With the CBT approach, about 23 additional patients will stop drinking as compared with the RBT approach; considering intervention, is applied to 188 drinkers assuming the same rate of drinking cessation.The results are shown on table 5.For the 188 patients treated, the RBT (A) approach would initially cost $ 20717.6 less than the CBT approach or on average $ 110.2 less per person and RBT (B) will cost $ 293505.6 more than the CBT approach, or an average of $ 1561.2 per person.However, CBT would save a per drinker average of $ 789.8 to $ 3785.8 as compared to RBT (A) and RBT (B) respectively in stop drinking cases.Comparing RBT (A) and RBT (B), the RBT (B) would initially cost a total of $ 314223.2more than the RBT (A) which is on average $ 1671.4 per person.At institution RBT (A), an average save per drinker is $ 2962.03 for the stop drinking.This implies that community based detoxification and rehabilitation of alcohol dependent persons was more cost effective than the residential based detoxification and rehabilitation but less cost effective than the subsidized residential based treatment.
Polysubstance use was noted, with 50% of the participants using tobacco while 21.3% of them were using cannabis.Less than 1% of the participants used other substances of abuse.

DISCUSSION
The socio demographic characteristics of the community and the residential based group are a true reflection of their backgrounds.While the community-based group was from a poor socio economic background, the residential based group had a better socio economic status.This was reflected in the results that showed statistically significant differences in the education level, monthly income and the type of occupation.The community based and residential based group participants were generally young with the majority in both groups being below 40 years of age with no statistically significant difference between the ages of the two groups.This finding is consistent with that by other studies, [Cosar, B. (1996), Hasin, D.S. (2007) which found that alcohol dependence was more common in the 16-39 years compared to other age groups.In addition both the participants of the community based and residential based group started using alcohol at an early age with no significant differences between the two groups on this aspect.In spite of the legal age of alcohol use being 18 years, majority of the participants of both study groups started using alcohol before the age of 18 years.The early use of alcohol is a worrisome situation.In Kenya most of the students complete secondary school education at the age of 18 years and many qualify to join the university or colleges, yet cannot due to various factors especially lack of finances.
Underage drinking is associated with alterations in brain cognitive impairment as well as further escalation of drinking and learning impairment that affect academic and occupational achievement Spear, L. [2002].Additional studies have shown that adolescents who began drinking at an earlier age had a proportionally small hippocampus volumes compared with those that began latter.This may explain the poor academic performance especially in the community-based group.[Kuria, M.W. [1996].
In spite of the majority of both the community based and residential based group participants who have used alcohol early, the residential based group had a statistically higher income and better quality of occupation compared to the community based group.This may be explained by possibly a rich background for the residential based group who may have received support from the relatives.The residential based group was selected from a group that was able to afford costly residential based treatment, implying that they were likely to have a better socio economic background.An additional factor that may have contributed to the lower income, education and poorer occupation status is the level of alcohol dependence and hazardous drinking.AUDIT mean score was higher in the community based than residential based male participants.The community-based group had a statistically significant level of hazardous drinking (P< 0.0001) and alcohol dependence (p value 0.0004) than the residential based group.
Study suggests that higher levels of alcohol dependence can be attributed partly to the low socio economic status of the group [Hasin, D.S., et al. [2007].The majority of the participants in the community and residential based groups were men.This finding is consistent with those of other studies that men are more likely to use alcohol and other substances of abuse Ndetei, D.M. et al. [1997], Peltzer, K. [2006], and that alcohol dependence is significantly higher in males than females [Hasin, D.S. et al. [2007] Bottlender, M andSoyka M. [2005], Ndetei, D.M. et al.. [2008].The African society is traditionally more receptive to use of alcohol by males than females, and use of alcohol by women is associated with stigma.Globally, alcohol abstention rates are higher in females than males WHO et al. [2007].Consequently, the set up of residential based treatment centres in Kenya are generally meant to meet the needs of adult men with all the facilities having more male beds than females or being entirely for male admissions.
There was high co morbidity especially with depression and anxiety disorders.The presence of high co morbidity in the current study is consistent with findings by other studies Kushner M.G. et al. [2000], Gosselin P. et al. [2003].Research indicates that anxiety disorder and alcohol disorder can both serve to initiate the other, especially in cases of alcohol dependence versus alcohol abuse alone National Institute on Drug abuse.[1999].The significantly high levels of anxiety levels in the CBT group may be explained by low social economic background.This finding is supported by studies that indicate that in some anxiety disorders are associated with negative life events, poor live satisfaction and familial problems (e.g.conflicts, abuses) Kujimana, M.P. [1995].Concurrent treatment for co morbid disorders is considered to be one of the fundamental principles in the treatment of substance-induced disorders Yifrah, M.D. [2008].In the current study persons in the community based group who were found to have co morbid disorders were referred for treatment at the mental health clinic at the Kangemi Health centre although the outcome of the referrals were not within the scope of the current study, this is likely to explain the better remission rate (at six months) in the community based group compared to institution based group.This has important implications of the treatment of alcohol dependence persons.It is not adequate to just treat the alcohol dependence but the co morbid disorders should be treated in order to obtain sustainable remission after treatment.The cost of non subsidized AUD treatment in Kenya is high at a cost of 3676.1 US$.This was higher than the subsidized cost at the mission based rehabilitation centre.This is because part of the cost at the mission based residential treatment centre is paid by the sponsoring Church.
The cost effective analysis in the current study shows that treatment of alcohol use disorders in a community based treatment program is more cost effective than in a non subsidized residential treatment program.Kujimana, 1995 reports that community outpatient detoxification is a cost effective step in the treatment of alcohol dependent patients.The fact that the residential based treatment though costly was less effective may be explained by the fact that at the time of study the treatment centres lacked an after care program for their clients after discharged.The nature of the aftercare program has been reported to influence the post treatment outcome in AUDs.
The WHO recommends use of Community based treatment and indicates that it has the potential to reach large populations at a lower cost.Additionally, population based interventions are cost effective when effectively targeted to populations in which disease is prevalent Laxminarayan, R. [2006].AUDs are prevalent in the Kangemi informal settlement where the CBT was conducted Ndetei, D.M et al. [2007).The majority of the populations in such informal settlement may not afford expensive AUD treatment and the policy makers may find it profitable to institute community based treatment.This would avail the limited bed space in the rehabilitation centres for the emerging cases of heroine and other hard drugs dependence.
Residential based treatment, although less cost effective, is ideal for those with co morbid psychiatric and medical disorders since adequate laboratory and other facilities to provide for a more intensive care are available.Kenya's health system is far from providing adequate and affordable health care for the majority of persons with AUDs.In addition, resources are scarce and there other more serious competing health needs like malaria infections and HIV/ AIDS.This may require the policy makers' review and utilize the fairly stable community structures to institute community-based intervention in AUD treatment, especially in areas where these disorders are highly prevalent and resources scarce.The advantage of using CBT is that this can be done at the community level utilizing the lower levels of the country's health facility.

CONCLUSION
Community based detoxification and rehabilitation for carefully selected alcohol dependent persons (without severe medical and neuropsychiatric) is a more cost effective treatment than residential based treatment.

Acknowledgement
University of Nairobi who sponsored the PhD program, Professor D. Ndetei and Professor Isodore S. Obot for the supervision, Miriam Wanjiru for assisting in the preparation of the manuscript.

Limitation
A limitation of the study was the lack of randomization of the samples.Since the intention of the researchers was to study the residential treatment group in their normal setup of treatment, the researchers did not attempt to randomize the selection of study subjects.In addition the sample size was smaller for the residential treatment group due to the low admission rates at the time of study.

Table 2 : Levels of alcohol drinking and alcohol related problems in residential as compared to community based group
High level of psychiatric co morbidity was present in both community based and residential based participants with co morbidity with significantly higher levels of anxiety disorders in the community based group.Three participants of the CBT group were referred to the outpatient psychiatric clinic for treatment within the period of the study.The results are shown on table 3.

Table 4 :
The Cost effectiveness for CBT and RBT