The scale of the problem

Alcohol and heavy drinking cause a wide range of diseases and injuries; and tackling the many individual and societal harms caused by alcohol use disorder (AUD) and harmful alcohol use is a public health priority. This is especially true in Latin America, where alcohol ranks as high as the fourth leading risk-factor for morbidity and premature death.
AUD is highly comorbid with other mental disorders, and over two-fifths of people presenting with AUD in primary care suffer from depression, itself the most common mental disorder.

The COVID-19 pandemic in 2020 has various impacts on SCALA: It is normal and understandable that people are experiencing increased feelings of fear, worry, and stress in the uncertain context of the COVID-19 pandemic. Although the evidence is still not robust, this could cause some people to adopt unhelpful coping strategies, such as drinking more alcohol or harmful drinking behaviours (e.g. binge drinking, excessive drink around minors, violence associated with drinking) The health service is under strain from coping with the health consequences of the virus; leaving professionals less time to devote to other issues, such as training and screening for harmful alcohol use. Professionals are also under stress, and may find it harder to apply new methods The SCALA study timing and format have had to be adapted to work around these issues and the necessary switch to telemedicine that COVID-19 has brought about

Scaling up the solution

Programmes to prevent and manage heavy drinking in primary health care (PHC) have been shown to be clinically effective and cost-effective, but uptake and implementation in routine practice has remained low, with only modest and short-term public health gains. Studies by the WHO have suggested that this could be improved by embedding PHC activity within broader community and municipal support, as well as training individual health providers.

SCALA sets out to test and build on this hypothesis in Latin America; with an 18-month quasi-experimental study to compare the scaled-up implementation of a tailored PCH-based screening and brief intervention programme which has been embedded within on-going supportive municipal action with practice as usual.

Download the SCALA flyer

The SCALA objectives:

• Tailored intervention packages for improving prevention, early detection and advice for heavy drinking and co-morbid depression in Colombia, Mexico and Peru.
• Implement and test whether the embedded scale-up of implementing tailored packages improves widespread screening and brief intervention in urban municipalities of middle-income countries
• Identify barriers and facilitators to scale-up and document the resource requirements for economic analysis
• Produce a validated scale-up framework and strategy, taking into account stigma and equity, to improve replication of the SCALA tailored packages throughout the world.

Project process and timeline

The process of SCALA is based on the Institute for Healthcare Improvement’s (IHI) 4-phase framework for ‘going to scale’, with the steps adapted to suit the field of prevention and management of alcohol problems and comorbid depression, and the setting of primary healthcare in Latin America.