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https://doi.org/10.1177/00178969231203973
Health Education Journal
2023, Vol. 82(8) 892 –906
© The Author(s) 2023
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sagepub.com/journals-permissions
DOI: 10.1177/00178969231203973
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Pilot of an early intervention
programme for low-risk persons
who use drugs in the Philippines
Jim Rey R Baloloya, Maria Regina Hechanovaa,b ,
Trixia Anne C Coa and Patrick Louis B Angelesa
aUniversity Research Co LLC, Makati City, Philippines
bPsychology Department, Ateneo de Manila University, Quezon City, 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
Corresponding author:
Maria Regina Hechanova, Psychology Department, Ateneo de Manila University, Leong Hall, Loyola Heights, Queson
City 1108, Philippines.
Email: rhechanova@ateneo.edu
1203973HEJ0010.1177/00178969231203973Health Education JournalBaloloy et al.
research-article2023
Original Article
Baloloy et al. 893
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 inter-
ventions 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 educa-
tion 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 incor-
porate 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 prac-
tices 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 inter-
ventions 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 interven-
tions 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 imple-
mented 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 sub-
stance-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
894 Health Education Journal 82(8)
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 relation-
ships (Estacio, 2018). In terms of level of risk for drug dependence, the majority of Filipino per-
sons 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 rein-
tegration. 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 pro-
grammes 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 meth-
amphetamine 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 recov-
ery 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 depend-
ence. 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
Baloloy et al. 895
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 charac-
teristics 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).
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, manag-
ing 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:
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
896 Health Education Journal 82(8)
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 liveli-
hood. 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 pro-
gramme, 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,
Baloloy et al. 897
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 meas-
ured 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 well-
being scale (Topp et al., 2015). Test internal consistency revealed a Cronbach’s alpha of.96 (pre-
test) and .95 (posttest).
Perceived quality of life. This refers to perceived quality of life. It was measured using Flana-
gan’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, under-
standing oneself, work, creative expression, socialising, entertainment, recreation and inde-
pendence. 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 partici-
pants 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 pro-
gramme 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 com-
munities. During the training, participants were asked to simulate the modules and were pro-
vided 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 partici-
pants 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
898 Health Education Journal 82(8)
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 facilita-
tors 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 confidential-
ity was established at the beginning of the programme and ensured that assigned programme facili-
tators 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 treat-
ment 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 para-
metric 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 max-
imisation 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).
Baloloy et al. 899
Table 2. Comparison of pretest and posttest scores by group.
Control Treatment
Pre-mean
(SD)
Post-mean
(SD)
TSig d (CI) Pre-mean
(SD)
Post-mean
(SD)
tSig 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.
900 Health Education Journal 82(8)
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 sub-
stantial 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).
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 2 = .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 coeffi-
cients 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 addic-
tion 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
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.
Baloloy et al. 901
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 partici-
pants 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 communi-
cation. 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
Figure 1. Path analysis.
902 Health Education Journal 82(8)
treatment suggests that effective interventions are those that seek to promote adaptive coping strat-
egies 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 sig-
nificant 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 well-
being 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 conduct-
ing 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, interna-
tional 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 psychoeduca-
tional programme, providing wraparound services related to education, livelihoods and employ-
ment is critical to improving participants’ quality of life.
Overall, the results signal the potential of GINHAWA as a community-based early intervention pro-
gramme 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 solu-
tion 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 imple-
menting community-based drug rehabilitation. Local government units need to ensure adequate budg-
ets, personnel and capacity to implement programmes such as GINHAWA on an ongoing basis.
Aside from implementing early interventions in communities, programmes can also be imple-
mented 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 effective-
ness of GINHAWA in these settings.
Baloloy et al. 903
Despite the fact that the study showed improved outcomes for GINHAWA participants, one limi-
tation 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 ran-
domised controlled trials are necessary to enable more robust conclusions about programme effec-
tiveness. 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 recov-
ery skills, life skills, perceived family support, wellbeing and quality of life among low-risk per-
sons 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.
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 publica-
tion 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 https://orcid.org/0000-0002-3922-1340
Note
1. GINHAWA is a Filipino term for wellbeing.
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