A Combined Behavioral Economics and Cognitive Behavioral Therapy Intervention to Reduce Alcohol Use and Intimate Partner Violence Among Couples in Bengaluru, India: Results of a Pilot Study

"...adds to the growing evidence that alcohol reduction is a modifiable means of addressing IPV."

Evidence shows that hazardous alcohol use is a contributing factor to intimate partner violence (IPV) occurrence and severity in both developed and developing country settings. Due to factors such as the low numbers of mental health professionals in low- and middle-income country (LMIC) settings, there are concerns about the feasibility and affordability of interventions to reduce alcohol misuse for IPV reduction in LMICs. This pilot intervention study tested a 1-month layperson-led intervention using contingency management (the provision of small financial incentives to promote behaviour change) and cognitive behavioural therapy (CBT) (in the form of behavioural couples therapy, or BCT) to reduce hazardous alcohol use and IPV in Bengaluru, India.

This study was designed as a randomised control pilot study of Beautiful Home, whose theory of change (TOC) is illustrated above. It was conducted in Jaya Nagar slum in Bengaluru, India, where the research team has a history of engaging with a local community-based organisation, Association for Promoting Social Action (APSA), through their self-help groups (SHGs). The area is characterised by low socioeconomic status of residents, high levels of current alcohol use and IPV, social norms that demonstrate perceived acceptability of alcohol use and IPV, and inequitable gender norms. In brief, the intervention was developed with input from community partners for the mitigation of hazardous drinking among males and IPV among couples. Intervention materials, including counseling protocols, were written in English then translated into the local language (Kannada).

Prior to initiating this study, the research team was trained on ethical issues in IPV research; particular care was taken to develop a close referral network of organisations providing alcohol de-addiction and IPV services to which participants could be referred, along with a detailed case management system. Couples were recruited using community-based approaches, including outreach at women's SHG meetings, at community health camps, and via snowball sampling. Eligibility criteria included: (a) female partner is aged between 18 and 40 years; (b) they are married; (c) both partners speak Kannada; (d) female partner reports male partner has a drinking problem; (e) female partner has ever experienced psychological, physical, or sexual violence perpetrated by her male partner; and (f) both partners are willing and able to provide consent.

To assess the effects of the intervention, the study team recruited 60 couples who were randomised into one of 3 arms (1:1:1 ratio):

• Control arm - Men were prompted every other day for 4 weeks via cell phone voice messages to breathe into Soberlink®, a breathalyser using wireless technology to allow for photo capture. They had the option to come into the office once weekly to receive a portion of their participation fee, while the rest was placed in a savings account and transferred into participants' bank accounts at the end of the study.
• Incentives arm - Men received a twice-daily prompt to blow into the breathalyser for 4 weeks and were offered a monetary incentive for each negative breath alcohol concentration (BrAC) score in addition to their participation fee. During the orientation session, couples learned how the incentives were tied to breathalyser scores and were walked through an exercise in which they jointly decided on goals they would like to save for, such as education, individual savings, and business savings. Men came into the office to receive a portion of their participation and breathalyser test rewards weekly. The majority of their earnings were placed in a savings account, which they later allocated to the goals they selected with their female partners during orientation.
• Incentives plus BCT arm - Those couples randomised into this arm participated in all activities described for the incentives arm, as well as 4 weekly 1-hour-long BCT sessions on topics such as alcohol use and communication. Sessions were conducted by lay counselors who had prior social work experience and who had been trained on BCT facilitation. A senior clinical psychologist trained in the provision of BCT supervised the counselors and supported the interpretation of talking points into Kannada. After each session, couples were asked to complete at-home assignments, including a daily trust contract in which the male partner was asked to convey his intent to not drink to his female partner, who would in turn express her support for his effort. The discussion was logged on a daily calendar. In addition, 8 comic strips and graphics were developed by a local artist in collaboration with the research team to reinforce lessons and skills taught through the sessions. These visuals included some text, which was originally developed in English and then translated into Kannada.

Violence experienced by female participants was measured using an adaptation of the Indian Family Violence and Control Scale (IFVCS), a culturally tailored scale for assessing a range of violent behaviours, which has been tested and validated previously in India. A participant was considered sober if all completed BrAC tests from that day were negative.

Results showed that while incentives reduced alcohol use, there was a greater proportion of negative BrAC samples among participants in the counseling arm compared with the control group (0.96 vs. 0.76, p= .03). Furthermore, the "sustained reduction in alcohol use and IPV 3 months after the intervention concluded demonstrates that incentives do not need to occur in an ongoing manner to be effective. This is in line with contingency management approaches successfully used in other settings..."

Violence also decreased in both intervention arms. The estimated mean violence score for the counseling arm was 10.8 points lower than the control arm at 4-month follow-up visit (p= .02). "The largest reductions in violence were attributable to reductions in men's control of their female partner, which may have resulted from improved communication skills combined with greater emotional regulation engendered by alcohol reduction."

One element of this study of note was the use of lay counselors as case managers and counselors for BCT provision to couples. Even where there are trained mental health professionals in LMICs, stigma against mental health and IPV limit the uptake of services. High retention and participant engagement in the intervention suggest acceptability and limited stigmatisation of participation. This may have been supported by the conceptual focus of "creating a beautiful home", rather than emphasising either alcohol or IPV as the primary driver of intervention engagement.

In conclusion: "Given implementation feasibility, acceptability, and safety, as well as a dearth of other high-impact IPV inter-ventions, this study shows value in continuing to explore the mechanisms at play in violence reduction, and testing efficacy in other settings."