Pilot of an early intervention programme for low-risk persons who use drugs in the Philippines

Abstract

Objective:

The aim of this study was to pilot and evaluate the feasibility of an early intervention programme for low-risk drug users in the Philippines.

Design:

The early intervention consists of three sessions delivered by paraprofessionals focusing on stress, wellbeing, substance use, family and drug use and communication skills. The study was conducted in two phases. In the pilot phase, a randomised controlled trial design was used. In the second phase, a larger field cohort evaluation study design was implemented.

Setting:

The randomised controlled trial in the first phase was undertaken in four local government units (LGUs). The second phase took place in 13 LGUs in three island clusters in the Philippines.

Methods:

In the first phase, 42 low-risk users from three urban and one rural community were randomly assigned to treatment and wait-control groups. In the second phase, 744 low-risk users undertook the programme. In both phases, the pretest and posttest measured recovery skills, life skills, quality of life, perceived family support, wellbeing and intent to use drugs.

Results:

In the first phase, analysis of variance with repeated measures revealed significant differences in pretest and posttest scores in recovery skills and quality of life of participants compared to those who did not participate in the programmes. In the second phase, paired-sample t-test revealed significant improvements in terms of recovery skills, life skills, quality of life, perceived family support, wellbeing and intent to use drugs. Path analysis provided support for the programme’s theory of change. Facilitators perceived the programme to be effective and easy to implement.

Conclusions:

The study suggests that an early intervention focusing on mental health and substance use delivered by paraprofessionals may be a viable means to reduce drug use and improve mental health in countries such as the Philippines that have little resources and scarce mental health professionals.

Keywords

Drug use mental health Philippines prevention substance use

As understandings of drug use have grown in the past decades, so have approaches to drug treatment. Rather than a one-size-fits all approach, the United Nations Office on Drugs and Crime advocates that treatment should correspond with users’ level of risk (United Nations Office of Drugs and Crime [UNODC] et al., 2016). Low-risk users are those who use drugs occasionally and have not experienced any problems because of use. Moderate-risk users are regular users who experience health, social, legal or financial problems because of drug use. High-risk drug users are those who manifest signs of dependence and experience multiple problems associated with drug use (Humeniuk et al., 2010). Most persons who use drugs (persons who use drugs) are at low to moderate risk for drug dependency, do not require inpatient treatment and can be treated in the community (UNODC et al., 2016).

However, drug use cannot be treated in a vacuum. For example, the gateway theory (Kandel and Kandel, 2014) suggests that drug use is often preceded by the use of other substances such as tobacco (Haug et al., 2014; Reed et al., 2022) and alcohol (Barry et al., 2016). As such, early interventions with these substances are important to preventing escalation to drug use and dependence (Stanis and Andersen, 2014; Stockings et al., 2016).

Early interventions for substance use typically seek to develop life skills (self-regulation and social and emotional learning skills) and resistance skills (knowledge on effects and refusal skills) (Botvin et al., 2015; Hale et al., 2014). Other brief interventions include motivational interviewing and education on the effects of substance use and on promoting healthy behaviours (Burgess et al., 2015; Osilla et al., 2010). A critical review of drug treatment suggests that most successful drug interventions incorporate skills to reduce cravings, manage triggers and prevent relapse (Skewes & Gonzalez, 2013).

Quality of family relationship is a social determinant of drug use especially among adolescents and young adults (van Ryzin et al., 2012). There is evidence that programmes involving parents such as the American Families – Teen Programme that include effective protective parenting practices for caregivers can be effective in lowering the frequency of substance use among teenage young people living at home (Brody et al., 2012). Beyond content, the length and design of interventions are just as important. There is evidence that single lectures and talks are not effective in reducing substance use. However, brief programmes ranging from 11 to 30 hours can be just as effective as more intensive programmes (Strøm et al., 2014). Research also suggests that interventions that involve the facilitation of learning are more effective than lecture-type interventions (do Nascimento and de Micheli, 2015). In addition, the way a programme is structured and implemented is key to the success of prevention (Ennett et al., 2011).

Despite the wealth of published research on prevention interventions for substance use, there are several gaps that need to be addressed. The majority of early interventions for substance use have taken place in rich world contexts, with very few studies from other settings and low- or middle-income economies (UNODC, 2018). In addition, despite the increasing number of studies on substance-use-prevention programmes in schools, families and workplaces, there is a dearth of knowledge about community-based early interventions (Petersen et al., 2016). This study sought to address these gaps by examining the effectiveness of a community-based early intervention for low-risk drug users in the Philippines.

Drug use in the Philippines

In the Philippines, about 2.05% of the population (1.67 million) are reported to be active drug users (Dangerous Drugs Board [DDB], 2019a). People who use drugs in the Philippines are generally male and between 20 and 30 years of age (Amista and Peters, 2020; Estacio, 2018; Pelegrino, 2022). The majority of drug users come from marginalised sectors of society – being informal workers, construction workers, unemployed individuals or those with no fixed income. In terms of education, most persons who use drugs have finished high school education or less. Studies in the Philippines have also reported that drug use is motivated by the need to stay awake or have more energy to work to support their families (Dio et al., 2019; Pelegrino, 2022). Other drivers of drug use include peer influence, unemployment and problems related to family and personal relationships (Estacio, 2018). In terms of level of risk for drug dependence, the majority of Filipino persons who use drugs are low- to moderate-risk users (Estacio, 2018; Pelegrino, 2022).

In 2016, the Philippine government initiated a war on drugs that involved the aggressive pursuit of drug suppliers and users across the country (Xu, 2016). Supply reduction efforts led to the arrest of 223,780 individuals (DDB, 2019b). Demand-reduction efforts were also implemented including the construction of inpatient mega rehabilitation centres in anticipation of the number of persons who use drugs that would need treatment (Lasco and Yarcia, 2022). However, inpatient treatment for persons who use drugs proved to be expensive, not just in terms of operational costs but also for families, and resulted in under-utilised facilities (Romero, 2017).

Recognising that most users are at low to moderate risk and can be treated in the community, the DDB (2019c) issued guidelines that recommend a continuum of care from outreach to social reintegration. In the prescribed client flow, persons who use drugs are first screened to determine their level of risk using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST, Humeniuk et al., 2010). Low-risk persons who use drugs are recommended to join general programmes or receive brief interventions and/or psychoeducation programmes in the community. Those who are at moderate risk are provided community-based treatment programmes. High-risk persons who use drugs are referred to doctors for drug dependency assessment and, based on their level of dependence, may be referred to community, outpatient or inpatient programmes (DDB, 2019c).

In the Philippines, the drugs of choice are methamphetamine and marijuana. Unlike addiction to opioids or heroin that can be treated medically, there are no medically approved treatments for methamphetamine or marijuana use. Behavioural therapy is more generally used. In addition, even though there are early interventions developed in other countries (Aalborg et al., 2012; Alavijeh et al., 2014; Faggiano et al., 2010; Marsch and Borodovsky, 2016), international guidelines stress the importance of ensuring that interventions are culturally nuanced (UNODC et al., 2016). Studies of community-based drug rehabilitation in the Philippines suggest that a wide variety of programmes may be used, but there are few evidence-based and culturally-nuanced interventions (Hechanova et al., 2018). A community-based intervention that appears to have the most evidence is the Katatagan, Kalusugan at Damayan ng Komunidad (Resilience, Health and Care in the Community) which is based on cognitive behavioural therapy, motivational interviewing and mindfulness. The programmes consist of 15 modules that cover recovery and life skills and family modules. Evaluation studies reported a significant decline in substance use dependence symptoms and increased recovery skills, life skills, wellbeing, perceived family support and family functioning of participants (Calleja et al., 2020; Hechanova et al., 2018) following participation in the intervention. However, the programme was developed specifically for moderate-risk drug users or those with mild dependence. Because of this, there was an expressed need for an appropriate intervention for low-risk users (Hechanova et al., 2019). To address this gap, this study aimed to develop and pilot test an early intervention for low-risk drug users.

Development of the General Intervention on Health and Wellbeing Awareness programme

The General Intervention on Health and Wellbeing Awareness (GINHAWA¹) programme was designed as an early intervention for low-risk persons who use drugs. The design was informed by a needs analysis conducted among 925 clients of community-based drug rehabilitation in four local government units (cities and municipalities) in the Philippines. The results revealed that drug dependence among community-based drug rehabilitation clients was predicted by severity of drug use, cigarette and alcohol use, mental health problems and lack of recovery skills. The study also reported that perceived family support, life skills and psychological wellbeing indirectly predicted the severity of drug use (Hechanova et al., 2023).

Given these results, an intervention was designed focusing not only on drugs but also on other substances such as alcohol and cigarettes. The programme’s theory suggested that if the General Intervention for Health and Wellbeing Awareness programme improved recovery and life skills and enhanced perceived family support of participants, it would lead to improved wellbeing and quality of life, reduced intent to use and increased willingness to prevent drug dependence. Given the evidence that group interventions are appropriate in collectivist cultures such as those characteristics of the Philippines (Hechanova et al., 2020), the programme was designed to be delivered to small groups. Because spirituality is an important factor in resilience among Filipinos (Arnado et al., 2022), faith reflections were included as optional ways to end each session. Given the dearth of mental health professionals in the Philippines, the programme was designed to be delivered by trained paraprofessionals such as community health workers, faith-based volunteers and anti-drug abuse focal persons.

The design of the programme was undertaken using an iterative process of consultations between the research team and the national government’s Department of Health (DOH). The framework for the programme was presented to community programme managers and service providers and adjusted based on their feedback. The programme was then reviewed by subject matter experts from the DOH prior to pilot-testing. A facilitator’s manual, slides, videos and flipchart were developed to standardise the content and ease delivery. The resulting programme consists of three modules (see Table 1).

Table 1.

General Intervention for Health and Wellbeing Awareness programme design.

Module	Topic	Contents	Tasks
1	Stress and wellbeing	Aspects of wellbeing, effects of stress on wellbeing, helpful and unhelpful ways to cope with stress, motivations to change to a healthier lifestyle	Answering worksheets, group process discussions
2	Substance use	Effects of smoking, alcohol and drugs, signs of addiction and effects on the body, identifying triggers, managing cravings	Creating a plan to decrease unhelpful behaviours, manage cravings and avoid triggers
3	Substance use and the family, life skills	Clarifying myths about substance use, information on different types of families and the impact of substances on families, effective listening, assertive communication, providing family and social support	Group process discussions, creating a family support plan

Because the needs analysis showed that mental health and wellbeing were significant predictors of substance use, the first module focuses on different aspects of wellbeing, the effects of stress and adaptive ways to cope with stress. Given the needs analysis suggested that smoking and alcohol use and recovery skills predict drug use, the second module focuses on the effects of cigarettes, alcohol and drugs. The modules also covered signs of addiction, triggers for substance use, managing craving and creating a plan to decrease substance use. Given the role of the family on drug use, the third module invited family members to attend the sessions to inform them about the myths of substance use and the role of family in substance use recovery. It also aims to hone participants’ interpersonal skills including effective listening and assertive communication.

Specifically, in this pilot study, we asked:

To what extent can the GINHAWA programme improve recovery skills, perceived family support, perceived quality of life and perceived wellbeing?

To what extent can the GINHAWA programme decrease substance use disorder symptoms and intent to use drugs?

Methodology

This pilot work was conducted in two phases. The first phase took the form of a small randomised controlled trial with a pretest and posttest design. The second phase was a larger cohort field study using a pretest-posttest design.

Participants

Participants in the first phase pilot study comprised persons who use drugs from three urban areas (Caloocan, Malabon and Manila in the National Capital Region) and one rural (Tolosa, Leyte) community in the Philippines. Participants voluntarily agreed to participate in a community-based drug rehabilitation programme and were assessed as low risk for substance users using the ASSIST by the World Health Organisation. Initially, 52 persons who use drugs participated in the pretest, but 10 (20%) were not able to finish the programme. Reasons included conflict with work or livelihood. However, Little’s Missing Completely at Random (MCAR) Test showed the missing data were not at random, p < .05. As a result, only the pretest and posttest data from 42 participants aged 18 (minimum legal age in the Philippines) to 56 years (M = 39.8 years, SD = 11.3 years) were included in the study. The majority (81%, n = 34) of participants were men.

Participants in the second phase initially consisted of 838 participants who were screened using the ASSIST screening tool and identified as low-risk users. Of these, 744 completed the programme, but only 676 completed both the programme and the post-programme survey. Participants came from 13 local government units in three island clusters in the Philippines: Luzon, Visayas and Mindanao. Most were in their late thirties although their ages varied widely from 14 to 75 years. The average age of first drug use was 25 years but ranged from 9 to 60 years. Over 90% of clients were male, and about two-thirds of the participants were married. The majority report being employed although most held contractual and not regular employment. More than 80% of clients had high school education or less.

Thirty-nine programme facilitators from five local government units were also surveyed to obtain their experiences and challenges implementing the programme. Facilitators were generally female (N = 27) and were community workers or volunteers.

Measures

All scales used were forward translated and back-translated from English to Filipino with a follow-up validation discussion with a team of researchers for accuracy.

Recovery skills

Recovery skills refer to individuals’ understanding of the effects of substances, knowledge of triggers to use, ability to manage cravings and triggers and refusal skills. They were measured using a five-point Likert-type nine-item scale (Hechanova et al., 2018). The internal consistency (Cronbach’s alpha) of the scale was .88 for pretest and .90 for posttest.

Life skills

Life skills refer to an individual’s ability to manage stress and enhance wellbeing. It was measured on a five-point Likert-type scale with eight items including knowing the causes of stress, coping strategies, handling negative emotions and feelings attached to stressful situations (Hechanova et al., 2018). The scale’s internal consistency (Cronbach’s alpha) was .94 at pretest and .96 at posttest.

Perceived family support

This was the extent one feels supported by family members. It was measured using a subscale of the Multidimensional Scale of Perceived Social Support (Zimet et al., 1988). This four-item, five-point Likert-type scale measured the extent of participants’ agreement with statements about their family. The internal consistency (Cronbach’s alpha) of the measure was .86 (pretest) and .89 (posttest).

Perceived wellbeing

This refers to an individual’s feelings of cheerfulness, calmness, activeness, vigour and motivation to pursue things that interest them. It was measured using the WHO-5 wellbeing scale (Topp et al., 2015). Test internal consistency revealed a Cronbach’s alpha of.96 (pretest) and .95 (posttest).

Perceived quality of life

This refers to perceived quality of life. It was measured using Flanagan’s (1982) Quality of Life Scale after it had been subjected to a process of forward translation and back-translation in Filipino. This 16-item scale measured overall quality of life including material needs, health, relationships to family, close friends, helping others, learning, understanding oneself, work, creative expression, socialising, entertainment, recreation and independence. Items were measured using a five-point Likert-type scale, with a higher score indicating greater quality of life. Internal consistency (Cronbach’s alpha) was .96 for both pretest and posttest.

Intent to use

A three-item scale was used to measure the intent to use drugs. The items ask participants how likely they are to use drugs in the next week, month and year using a four-point Likert-type scale. Its internal consistency (Cronbach’s alpha) was .95 for both pretest and posttest.

Facilitator survey

An online survey was sent out to community facilitators who had implemented GINHAWA in their respective communities. The questionnaire consisted of items pertaining to facilitators and barriers in implementing the programme as well as perceived effects of the programme on people who use drugs and participated in the programme.

Procedure

The study received approval from the ethics review board at Ateneo de Manila University. Prior to implementation, community facilitators were trained by the research team in basic facilitation skills and motivational interviewing. The facilitators consisted of personnel or volunteers from different local government units assigned to facilitate community-based treatment in their communities. During the training, participants were asked to simulate the modules and were provided with feedback and coaching to ensure quality and programme fidelity. Facilitators’ were evaluated in terms of competence in facilitation skills, motivational interviewing and fidelity to the module design.

Recruitment of participants was undertaken in partnership with the Anti-Drug Abuse Councils (ADAC) of the four local government units. Written informed consent was obtained from participants prior to entry into the programme. The form assured participants of the confidentiality of their responses and their right to withdraw from participation at any time and/or have their data excluded in the study. For participants who could not read or write, the informed consent form was read and explained to them orally. Once the participants had given their consent, personnel from the local ADAC assisted them in placing their right thumbprint on the document instead of a signature.

The pretest and posttest were administered by the research team and trained community facilitators in groups. The research team and facilitators administered the questionnaires orally when participants expressed difficulty in reading the questionnaires.

Participants were placed in groups of 10–12 individuals and were tasked to attend one module a week for 3 weeks, with each session lasting for an hour and a half to 2 hours. Group confidentiality was established at the beginning of the programme and ensured that assigned programme facilitators conducted the sessions for their cohort from the first to the last module. Participants answered the posttest questionnaire administered at the end of the third module. Members of the research team observed the facilitation of the modules and provided supervision in between sessions when necessary to ensure programme fidelity.

Participants in the waitlist control group responded to the pretest on the same day as the treatment group. They were given brochures about substance use and were asked to come back after 3 weeks to complete the posttest and before attending the GINHAWA programme. All participants who completed the programme were given certificates of completion. No monetary rewards were provided. After facilitating the programme, the facilitators answered an interview questionnaire regarding their feedback on the effectiveness of the programme. The questionnaire asked questions such as, ‘how would you describe the effect of the programme on the person who use drugs you have given the programme to?’ and ‘what do you think are the ways in which the programme can be improved?’

Data analysis

Prior to the analysis of data, researchers examined whether the data met assumptions for parametric analysis. In the first phase of work, paired-sample t-tests were used to analyse for each group. Cohen’s d and confidence intervals were used to examine effect size. In the second phase of the study, Little’s MCAR test was used and suggested that the missing posttest data were completely at random. Given this, multiple imputation was made using expectation maximisation estimation recovery skills, life skills, wellbeing and quality of life. Although the data were still negatively skewed, given the large sample size, paired-sample t-test and Cohen’s d were computed to examine effect sizes. Path analysis using maximum likelihood estimation was performed using JAMOVI 2.3.2 to assess the programme’s theory of change. Thematic analysis was used to analyse the data on facilitators’ feedback on the effectiveness of the programme.

Results

Phase one: randomised control trial

Results of paired-sample t-test showed a significant difference between pretest and posttest scores for recovery skills for the treatment group (t = –2.38, p = .04) but not the control group (t = 1.74, p = .10). The effect size was medium (d = –.50, CI = –.92, –.06).

Paired t-tests also revealed significant improvements in quality of life (t = –2.189, p = .04) among those in the treatment condition but not in the control group (t = .19, p = .85). Effect size was small (d = –.45, CI = –.88, –.02). There were no significant differences between pretest and posttest scores of the control group on quality of life (see Table 2).

Table 2.

Comparison of pretest and posttest scores by group.

	Control					Treatment
	Pre-mean (SD)	Post-mean (SD)	T	Sig	d (CI)	Pre-mean (SD)	Post-mean (SD)	t	Sig	d (CI)
Recovery skills	4.18 (.58)	4.27 (.54)	1.74	.10	−.40 (–.86, .07)	4.24 (.44)	4.39 (.37)	−2.38	.03	−.50 (–.92, –06)
Life skills	4.13 (.64)	4.21 (.61)	−1.21	.24	−.28 (–.73, .18)	4.24 (.45)	4.37 (.40)	−1.88	.07	−.39 (–.81, .04)
Perceived family support	4.17 (.74)	4.32 (.77)	−.82	.42	−.19 (–.64, .27)	4.48 (.42)	4.55 (.42)	−.85	.40	−.18 (–.59, .24)
Wellbeing	3.72 (1.7)	4.3 (1.10)	−1.99	.06	−.46 (–.93, .02)	3.99 (1.23)	4.36 (.87)	−1.83	.08	−.38 (–.80, .05)
Quality of life	3.98 (.71)	4.00 (.77)	−.19	.85	−.04 (–.49, .41)	4.05 (.65)	4.31 (.53)	−2.18	.04	−.45 (–.88, –.02)
Intent to use	.14 (.46)	.26 (.71)	−.61	.55	−.14 (–.56, .30)	.07 (.22)	.07 (.25)	.00	1.00	.00 (–.41, .41)
SUD symptoms	.89 (1.24)	1.26 (2.18)	−.64	.53	−.15 (–.59, 31)	.87 (1.32)	.70 (1.29)	.48	.64	.10 (–31, .51)

SD: standard deviation; CI: confidence interval; SUD: substance use dependence.

Phase two: field cohort evaluation

The second phase involved the field cohort evaluation study. Participants reported significant improvements in their recovery skills, life skills, perceived family support, wellbeing and quality of life. There was also a significant decrease in intent to use drugs. Effect sizes describe how substantial the gain of a programme is expressed in standard deviation units. Cohen (1988) suggests that effect sizes of .20 to .49 are small, .50 to .70 are medium and .80 and above are large. The programme has a large effect size on life skills (.52) and recovery skills (.51) and small effect sizes on quality of life (.40), perceived family support (.28) and wellbeing (.26) (see Table 3).

Table 3.

Pretest and posttest scores across sites (n = 744).

	Pre (SD)	Post (SD)	t	p	Effect size (d)	CI lower	CI upper
Recovery skills	4.21 (.59)	4.50 (.42)	−14.03	<.001	−.51	−.59	−.44
Life skills	4.21 (.49)	4.54 (.36)	−14.12	<.001	−.52	−.59	−.44
Perceived family support	4.37 (.51)	4.52 (.41)	−7.63	<.001	−.28	−.32	−.21
Wellbeing	79.69 (27.02)	86.46 (16.74)	−7.15	<.001	−.26	−.35	−.21
Quality of life	4.11 (.67)	4.38 (.47)	−11.02	<.001	−.40	−.48	−.33
Intent to use	1.30 (.76)	1.08 (.24)	8.47	<.001	.31	.24	.38

SD: standard deviation; CI: confidence interval.

The programme’s theory of change was tested using path analysis of the posttest data. The results of the path analysis were assessed using the evaluation guidelines suggested by Hooper et al. (2008). Path analysis yielded a significant χ² = .34.2, p < .01, which is likely a product of sample size (see Figure 1). The root mean square error of approximation and standardised root mean square residual indices were below .08, the comparative fit index was above .95 and the goodness of fit index and the adjusted goodness of fit index were above .90. Regression coefficients support the programme’s theory of change, suggesting that recovery skills predict substance use disorder symptoms and wellbeing. Greater life skills and family support predict greater quality of life. Greater wellbeing and quality of life predict intent to use drugs. Overall, the results were supportive of the programme’s theory of change.

Feedback from facilitators

The facilitators perceived GINHAWA as an effective intervention for low-risk drug users. They reported that participants learned about the effects of substances, clarified myths about drug addiction and learned refusal and life skills. One of the facilitators shared, ‘The PWUDs learned a lot from the programme. It changed their perspective about substance use’.

Facilitators also observed how participants appreciated the emotional support provided to them. A number reported that they observed changes in family members’ attitudes and support after attending the programme. According to one facilitator, ‘Many of our participants have problems with their families. The programme helped families identify their roles in the recovery process and how they can provide support to their loved ones’.

Facilitators did not report any difficulties in facilitating the modules and said that having large flip charts, videos and worksheets made it easy for them to implement the programme. One of the facilitators said, ‘The programme is easy to understand because of the facilitator’s manual. It was easy to facilitate because of the handouts and the videos’. However, they reported several instances where participants had to drop out of the programme because of conflict with work schedules, transfer of residency and so on. They also reported some participants had difficulty responding to the pretest and posttest given the low literacy levels.

Discussion

The study sought to examine the effectiveness of an early intervention programme for low-risk drug users in the Philippines. Data from the first-phase randomised controlled trial study showed a significant improvement in the recovery skills of participants in the treatment group compared to those in the control group. Significant improvements in recovery skills were also evident in the field evaluation study. This is a positive outcome given the literature that suggests that the most successful drug interventions incorporate adaptive coping strategies and skills to reduce cravings, manage triggers and prevent relapse (Skewes & Gonzalez, 2013).

Scores on quality of life increased in the treatment group compared to the control group, and this increase was associated with reported improvements in physical health, mood, relaxation and overall life satisfaction. Significant improvements in quality of life were also reported by participants in the field evaluation phase. GINHAWA’s first module begins by asking participants to reflect on and assess their quality of life and how it might be linked to their wellbeing and stress. The fact that the programme had a medium effect size suggests the objective was met. This is a positive development given studies suggesting that poor quality of life is a predictor of drug use (Costenbader et al., 2007).

Results from the field evaluation revealed significant improvement in participants’ life skills, specifically emotion regulation, problem-solving, stress management and interpersonal communication. The medium effect sizes suggest that GINHAWA is a promising early intervention to build adaptive coping and life skills. This is an important contribution because a review of drug treatment suggests that effective interventions are those that seek to promote adaptive coping strategies and life skills (Skewes & Gonzalez, 2013).

Part of the GINHAWA programme’s theory of change was that enhancing awareness of quality of life and improving recovery and life skills will improve wellbeing. Results from the field study showed small albeit significant improvements in the wellbeing of participants. These results are significant for two reasons. The self-medication theory suggests that drug use is a maladaptive response to stress (Smith et al., 2017). As such, it is expected that greater adaptive coping and improved wellbeing will make people less dependent on drug use as a means of coping with stress. In addition, the findings also suggest that GINHAWA has potential as an early intervention for mental health. Given the comorbidity of substance use and mental health problems, an integrated programme that focuses on both would be an important contribution to public mental health in the Philippines.

The field study showed small but significant improvements in the perceived family support of participants. This is a positive outcome given the literature on the importance of the family in drug recovery (Rowe, 2012).

GINHAWA participants in the field study also reported significantly decreased intent to use substances after the programme. Studies suggest that secondary prevention or early interventions can be effective in decreasing substance use (Pilowsky & Wu, 2013). As such, GINHAWA shows promise as an early intervention programme for preventing drug dependence.

Limitations and challenges

Feedback from the programme implementers highlights the limitations and challenges in conducting a field randomised control trial for drug use. The relatively small sample size and attrition was due to several factors. Community-based drug rehabilitation was scheduled on weekdays and within regular working hours, and clients who were unemployed or underemployed dropped out of the programme to prioritise work. In future work, local government units may wish to address the issue of participant attrition by providing incentives for participants to compensate for their absence from work or by making the programme accessible on weekends.

The GINHAWA programme led to slight improvements in quality of life. However, international health promotion principles suggest the importance of adopting a holistic approach when addressing the social determinants of drug use (UNODC et al., 2016). Beyond the psychoeducational programme, providing wraparound services related to education, livelihoods and employment is critical to improving participants’ quality of life.

Overall, the results signal the potential of GINHAWA as a community-based early intervention programme for low-risk drug users. The results are especially promising in the Philippines where the majority of persons who use drugs are at low to moderate risk (Hechanova et al., 2023). A study by the USAID Renewhealth project has reported that community-based drug rehabilitation programmes are 12%–16% the cost of inpatient treatment (Hechanova, 2022). GINHAWA may be a cost-effective solution especially for local government units that have little resources. The same study, however, highlights the importance of continuing financial resources, human resources and capacity building when implementing community-based drug rehabilitation. Local government units need to ensure adequate budgets, personnel and capacity to implement programmes such as GINHAWA on an ongoing basis.

Aside from implementing early interventions in communities, programmes can also be implemented in schools and workplaces. Studies elsewhere have shown that preventive interventions in high schools, colleges and universities can decrease substance use among students (Faggiano et al., 2010; Strøm et al., 2014). Early interventions in workplaces have also been found to be effective (Osilla et al., 2010; Tetrick & Winslow, 2015). Future research may wish to explore the effectiveness of GINHAWA in these settings.

Despite the fact that the study showed improved outcomes for GINHAWA participants, one limitation of it was the small sample in the randomised controlled trial phase. The study was also limited to the collection of immediate post-programme data rather than longer-term data. Moreover, the study was not able to control for demographic variables such as age and sex despite the wide range of ages among the participants. Assumptions for parametric statistical testing were not satisfied, which made analysing potential covariates not possible. More rigorous investigations using randomised controlled trials are necessary to enable more robust conclusions about programme effectiveness. Larger sample sizes could ensure possible covariates can be thoroughly investigated. Longitudinal studies would also be important to examine the long-term effects of the intervention.

Facilitators reported some participants having difficulties in filling out the pretest and posttest surveys. Future studies may consider participants’ literacy as a possible confounder or moderator. Researchers may also instead opt to obtain informed consent and acquire research data verbally by default (e.g. interviews) as the likelihood of having illiterate participants in a study such as this is high (Dio et al., 2019; Pelegrino, 2022). Another limitation of the study was that it only measured psycho-social outcomes. Future studies may wish to examine the effectiveness of the General Intervention for Health and Wellbeing Awareness programme using drug tests.

Conclusion

Notwithstanding the aforementioned limitations, General Intervention for Health and Wellbeing Awareness programme appears to be a promising intervention when it comes to improving recovery skills, life skills, perceived family support, wellbeing and quality of life among low-risk persons who use drugs in the Philippines. Results suggest that participants reported decreased intent to use substances because of their participation in the programme. This suggests the potential of the programme not only to reduce drug demand but also to improve wellbeing and mental health.

Footnotes

Acknowledgements

The authors thank Bienvenido Leabres, Clara Fuderanan and Carol Narra of the Department of Health for their inputs to the design and materials used in the GINHAWA programme. The authors also thank Yolanda Oliveros, Jean Margaritis and Madison Ethridge for their input to this paper.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this programme was designed and evaluated with the generous support of the United States Agency for International Development’s RenewHealth project. The views and opinions expressed in this paper are those of the authors and are not necessarily the views and opinions of the United States Agency for International Development.

ORCID iD

Maria Regina Hechanova

Notes

References

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