Validity and item response theory properties of the Alcohol Use Disorders Identification Test for primary care alcohol use screening in Mozambique (AUDIT-MZ)

Abstract

Background: No validated tools exist to screen for substance use or dependence in Mozambique. The aim of this study was to validate the Alcohol Use Disorder Identification Test (AUDIT) for use in primary care settings in Mozambique.

Methods: The study administered a final adapted Mozambican 10-item AUDIT (AUDIT-10-MZ) to 502 individuals from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary health care clinics in Sofala Province, Mozambique. The study evaluated the AUDIT-10-MZ against the MINI 5.0-MZ as a gold standard diagnostic tool.

Results: Using the MINI 5.0-MZ, 16 (3.2%) of the sample tested positive for alcohol dependence and 3 (0.6%) tested positive for harmful alcohol use. The full AUDIT-10-MZ had acceptable internal consistency (α = 0.74); however, the shorter AUDIT-C-MZ had a higher alpha value than the full AUDIT screener (α = 0.79). The AUDIT-10-MZ performed well for screening in primary care, achieving areas under the receiver operating characteristic curves (AUROCs) of 0.94 (95% CI: 0.91, 0.96) for alcohol dependence. The AUDIT-C-MZ also performed well with an AUROC of 0.88 (95% CI: 0.80, 0.96) for alcohol dependence. Using a cut-off of ≥6, the AUDIT-10-MZ achieved a sensitivity of 68.8% and specificity of 92.0% for screening for alcohol dependence; a cut-off of ≥3 for the AUDIT-C-MZ achieved a sensitivity of 56.3% and specificity of 90.7%.

Conclusions: Both the AUDIT-10-MZ and AUDIT-C-MZ are valid instruments for screening for alcohol dependence in Mozambique. The AUDIT-C-MZ performed particularly well and providers could use it as a brief screener in primary care settings. Optimal cut-points will depend on weighing false positives and false negatives but could be employed at ≥ 6 or ≥ 7 for the AUDIT-10-MZ and at ≥ 2 or ≥ 3 for the AUDIT-C-MZ. Future implementation research is needed to examine how best to integrate screening for substance use or dependence in primary care settings in Mozambique and other similar LMICs.

Keywords: AUDIT; Alcohol misuse screening tool; Alcohol use; Mozambique; Primary health care; Validation.

Figure 1.

Political map of Mozambique including provincial capital cities. Focal area of Beria City and surrounding Dondo highlighted by the red box. Figure sourced from: Fernandes QF, Wagenaar BH, Anselmi L, Pfeiffer J, Gloyd S, Sherr K. Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. Lancet Global Health. 2014; 2

Figure 2.

Item information functions from item response theory graded response model for Alcohol Use Disorders Identification Test (AUDIT) screening tool among 502 primary care patients in Mozambique.

Figure 3.

Test characteristic curve and expected scores for different values of the latent trait (Theta) Mozambican Alcohol Use Disorders Identification Test (AUDIT-10-MZ) screening tool among 502 primary care patients.

Figure 4.

Receiver operating characteristic (ROC) curves for both the Alcohol Use Disorders Identification Test 10-Item (AUDIT-10-MZ) and the Alcohol Use Disorders Identification Test-Concise (AUDIT-C-MZ) to detect alcohol dependence among 502 primary care patients in Mozambique.