Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

Executive summary
In Nepal, harmful alcohol use is increasing noticeably, and with it, a concomitant rise
in poverty, Non Communicable Diseases (NCDs), Intimate Partner Violence (IPVs)
and non-compliance to HIV treatment. Market policies are also highly favourable for
unregulated alcohol sale. The increasing burden and divergent associations of harmful
alcohol use in Nepal is summarized in this policy report, which aims to identify
strategies policymakers can employ in order to reduce injurious alcohol use, and
propose actionable and scalable interventions for the same. Key recommendations
include: training primary care workers in WHO mhGAP, social behaviour change
communication for coexisting IPV, and mechanisms restricting sale of alcohol to
minors. Due to limited scope of the study, all probable associations of alcohol use
could not be explored. Policymakers and government may deliver appropriate training
and facilitate policy where applicable, in order to effectively disseminate proposed
strategies in the report.

Introduction
Harmful use of alcohol is on the rise globally, with affliction of Alcohol Use Disorder
(AUD) increasingly borne by emerging economies in Asia like India, China, Vietnam,
and Sub Saharan Africa (1). In Nepal too, this trend is perceptible, and presents with
divergent associations like poverty, NCDs, increased noncompliance among HIV
patients undergoing active treatment, and Intimate Partner Violence (IPV) (2,3),
amongst others. According to the Global Burden of Disease 2020 (1), between 1990
and 2016, alcohol deaths in Nepal increased by an alarming 376%, and alcohol
consumption had increased in all age groups with the highest being among males 15
to 39 years. Additionally, alcohol has been implicated in cases involving sexual
abuse, and road traffic accidents (4). Partner alcohol use also directly correlates to
maternal and neonatal outcomes during late pregnancy; this is significant in Nepal as
the national gains in this area are relatively recent and hard-earned (5).

Effective alcohol sale reduction and prohibiting marketing of alcohol products remain
elusive in Nepal. Various aspects of alcohol policies and legislature are dictated by
different Acts, which are governed by different ministries (6), with minimal harmony
among policies. Owing to this alcohol advertising/sale is pervasive and unmonitored,

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Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

and alcohol use amongst youth is on the rise, as is advanced alcohol related disease at
an early age (7). The widespread availability and use of locally produced alcohol,
illicit alcohol and alcohol surrogates further complicates the effectiveness of policies
targeting harmful use of alcohol (8), which only targets registered alcohol sale. On
account of ever increasing prevalence, and aforementioned extended associations of
harmful use of alcohol, systematic, scalable and low-cost responses are urgently
warranted in Nepal.

Rationale
In Nepal, young men and ethnically disadvantaged groups are more likely to be
regular and avid alcohol consumers (9). Not surprisingly then, the median sample age
of a cohort of advanced alcohol disease was young at 43, and likely to hail from an
underprivileged background (7). In economically disadvantaged societies, alcohol use
tended to reinforce poverty while both simultaneously promoted exposure to NCDs
(2). Sizeable number of communities also brew and consume alcohol traditionally,
and also use it as a means to earn their livelihoods (2). For those seeking treatment,
there is a dearth of adequately trained primary care counsellors (10), and almost all
specialty clinics are confined to cities, where rehabilitating attendees are more likely
to belong to a higher socioeconomic group, educated and reside in urban areas (11).
Compounding this, are the facts that no special permit is required to sell alcohol, there
exists no age-limit to purchase, and availability/use of home brewed and counterfeit
alcohol and alcohol-surrogates is widespread (8).

A multi-stakeholder panel consisting of policy experts, mental health specialists,

primary care staff, and community members came together in a ‘Theory of Change”
workshop, where, alcohol use was nominated one of four pertinent, prevalent and
feasible to intervene among mhGAP priority conditions in Nepal (12), clearly
indicating perceived urgency. The scale and rolling effects of harmful alcohol use can
perhaps also be gauzed by another study in which nearly half of the participants
reported partner drinking when interviewed for IPV, with associated fall in ANC
(Antenatal Care) visits, lower institutional delivery and diminished use of skilled birth
attendants (5); not to mention the perinatal outcomes which was not measured here. In
addition, partner alcohol use is detrimental to maternal mental health (5), effective

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Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

couple communication, conflict resolution, and also lays strain on household finances
in the Nepalese context (13). Harmful alcohol use is also significantly positively
found to be associated with non-adherence of HIV positive patients to Antiretroviral
therapy (ART) and associated decrease in quality of life (3).

The archaic Narcotics Drugs Act of 1976 forms the basis of laws governing alcohol
sale and has provisions restricting the sale of alcohol and tobacco at 18 years (17);
however, in reality any age-group can easily access both (2). A study also found that
marketing to underage individuals was the most challenging risk factor for underage
drinking (17). The ever tenacious global alcohol industry has strong financial interests
to protect in developing economies, and has already succeeded once in Nepal at
stalling an act that would have seen the drinking age raised to 21, and imposed a total
ban on alcohol advertising, among others (4).

Aims
The objectives of this policy report are to summarize the scope of harmful use of
alcohol, it’s diverse relations, explore available research based actions and then
recommend three key actions that can be taken in efforts to reduce this harmful
alcohol use in the Nepalese context.

Findings
The WHO mhGAP is a low cost, field-proven intervention guidelines for priority
MNS conditions designed to be delivered by lower level health care workers (14). In
primary care setting in Nepal, health workers trained in mhGAP have been shown to
be as effective as counselling by psychosocial consultants, in the treatment of alcohol
use disorder (10), which was a sustained up to 12 months. Similarly, a RCT in
Zimbabwe showed that both WHO mhGAP and Motivational Interviewing/ Cognitive
Behavioural Therapy were effective in reducing AUDIT scores amongst HIV positive
individuals with harmful alcohol use (15). Another promising avenue is proactive
community case finding: for example, using the specifically developed Community
Informant Detection Tool (CIDT), community informants in two Nepali districts were
able to refer almost 50 alcohol-use disorder cases, two thirds of which were correctly
identified by non-medical personnel (16).

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Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

Elsewhere in Nepal, another study demonstrated sustained reduction in partner

alcohol use and IPV, as well as reduced “problematic use of money” hence improving
household finances, by employing couples based social change communication
strategy (13). This included participants listening to a serial drama followed by
listener engagement in the form of separate male and female Listening and Discussion
groups (LDGs), where the content of the radio episode was reflected upon by the
couple through guided group discussions, and included skill development in effective
communication, conflict resolution, and advocacy based on the community (13).

Legislatures governing associated aspects of alcohol use are scattered amongst

multiple acts in Nepal: for example; supply, sale and distribution of alcohol is
overseen by the Hotel Regulations, Sale and Distribution of Alcohol Act (1966),
while advertising falls under the National Broadcasting Act (1993), which does not
ban but only levies a penalty on alcohol advertising (6). Meanwhile, driving-under-
influence legislature, falls under the Vehicle and transport Regulation Act (1993), and
is highly forgiving: a meagre fine of NRs. 1000 for violation (6).

Mechanisms to reduce alcohol sale to minors and their compliance have been
explored in a study Bhutan, and revealed that posting alcohol signage, undercover and
regular police checks for verifying compliance, and fines where necessary, were
deemed possible solutions (17). In Spain, supermarkets that completed alcohol
vendors training program designed to reduce sale of alcohol to minors were found to
be significantly more compliant to underage sale regulations (18). In Nepal however,
alcohol is available in all small and big shops, hence training of all the vendors would
be a herculean task. Like India, because of widespread availability of illicit as well as
locally produced liquor, taxation of registered liquor to discourage purchase may not
work, and instead policies limiting promotion of alcohol products may be more
helpful (19).

Recommendations
Enabling active screening and initial intervention

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Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

In the primary care setting, health care workers should be adequately trained in the
WHO mhGAP guide and deployed to screen for alcohol use disorder and offer initial
psychosocial or medical therapy as indicated. Teams of mhGAP trained health
workers can also conduct screening and awareness camps in traditional alcohol using
communities, where treatment-seeking behaviour is low, and alcohol use disorder
may lie concealed (7), affecting them disproportionately. This training should also
extend to HIV treatment centres, where the opportunity to diagnose and treat patients
undergoing ART with harmful alcohol use should not be missed. In the community,
informants may be equipped with proven tools like CIDT for proactive screening of
alcohol use disorder and refer them to primary care centres, where a mhGAP trained
health worker can further investigate the case. A robust referral mechanism to refer
complicated cases to a specialty centre and improving patients to the community, with
routine follow-up is also vital. A stakeholder monitoring and feedback system to
improve performance, with periodic refresher mhGAP trainings may be helpful in
achieving optimum patient screening and effective health worker outcomes.

Couples based social behaviour change communication

Where harmful use of alcohol is concurrently present with Intimate Partner Violence
or a high-risk thereof, social behaviour change communication strategy may be more
beneficial. This would entail introducing or scaling up the listener engagement in
separate (male and female) LDGs in vulnerable communities, with simultaneous
scaling up of or introducing new language and culture sensitive serial drama content.
Couples may further be trained in critical skills like effective communication and
conflict reduction, and in addition to improving domestic financial savings, this has
the potential to positively affect maternal physical and mental health, not to mention
the cascading effects on perinatal outcomes. Interventions that target multiple health
outcomes may be of additional value in a resource poor setting like Nepal.

Mechanisms to reduce alcohol use by minors

Policies should require stores that sell alcohol to mandatorily display the minimum
age limit to purchase, as well as the trading hours for alcohol sale, in large visible
signage; while vendors at larger centralized stores must be trained on compliance with
regards to alcohol sale to minors. The enforcing of this age limit needs to be verified
with undercover police checks and rigorous fines; and with alcohol license suspension

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Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

for violation. In addition, owing to the fact that youngsters are especially vulnerable
to marketing, a complete ban on the advertising of alcohol products, as well as
informing the harmful effects of alcohol in targeted public messaging by responsible
government institutions will undoubtedly prove beneficial. Surplus school-based
awareness programs to inform adolescents about the harmful effects of alcohol early
in life, may be used to reinforce underage abstinence. The lax drink-driving laws
needs to be made more stringent with higher fines and perhaps adding driving license
suspension to discourage youth drink-driving.

Limitations
Several limitations of this policy report merit mentioning. Numerous studies have
deliberated co-morbidity of various MNS (including suicide), and social and gender
predispositions of alcohol use, here these studies are largely absent on account of the
limited scope. So are studies exploring co-existent substance use prevalence, alcohol
use in pregnancy, and novel approaches like the research in shifting the locus of
control (from external to internal) in alcohol use. The true scale of underage sale and
consumption of alcohol is undocumented, and a paucity of evidence of interventions
that has worked in the Nepali setting can also be felt.

Conclusion
This report explored the rising harmful use of alcohol use in Nepal, and sought to
nominate low cost, easily scalable and demonstrated interventions amongst available
options, to reduce this detrimental use. Three interventions are suggested, which can
be deliberated upon by government and policymakers, who can then empower public
health actors (primary care, HIV centre, and community health workers), couples
(with concurrent IPV), to take action, and protect underage citizens against harmful
exposure to alcohol in early life. Because they are demonstrated in the field, relatively
low-cost and easily scalable strategies, aforementioned approaches are probably best
suited for the Nepalese context. Additional research into underage drinking
prevalence and its correlates are also further warranted. Any policy that infringes on
the alcohol market must also be backed up with robust public health reasoning and
debate, and include all relevant stakeholders, or it risks getting intercepted by the
alcohol lobby, as has already once happened.

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 Policy Report on Alcohol and Substance Use- Strategies to Reduce Harmful Use of Alcohol in Nepal

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