The sample included outpatients of Dr. George Mukhari Hospital. Outpatients were screened for alcohol problems, and those identified as hazardous or harmful drinkers were randomized into an experimental or control group. The experimental group received one brief counselling session on alcohol risk reduction, while the control group received a health education leaflet.
Principles for recruitment
Inclusion criteria Outpatients (males and females) 18 years and above, without mental impairment, who visit the hospital outpatient department and who scored as hazardous or harmful drinkers i.e. 8–19 for men and 7–19 for women on the Alcohol Use Disorder Identification Test (AUDIT) questionnaire  were included in this study.
Exclusion criteria Outpatients with a score of 20 and above on the AUDIT (with possible alcohol dependence). Also, outpatients who score less than 8 for men and less than 7 for women on the AUDIT questionnaire, patients with mental impairment, those who are pregnant, and those who are already under alcohol treatment, were excluded.
Randomization After baseline assessment, each patient was randomized to either a control or a brief intervention group. Patients were randomized using sequentially numbered opaque sealed envelopes prepared according to a computer-generated randomization allocation sequence. Block randomization using randomly varying block sizes (prepared using Stata version 10) ensured equal numbers of patients were recruited into each group.
Blinding Hospital staff members and outpatients were not blind to their intervention. However, to protect against information biases in the reporting of alcohol use behaviour, the data collection team who assessed the outcomes were blind to the client’s status as intervention arm.
Procedure Systematic sampling of all presenting outpatients was used whereby all consecutive clients were recruited from five different out-patient departments, i.e., family practice (10.4%), general out-patient department (48.0%), cardiology (10.5%), diabetes (19.4%) and ear nose and throat department (7.1%) and from a dispensary (4.7%). All out-patients were interviewed using an interviewer-administered questionnaire by four trained research assistants (qualified nursing assistants) in private rooms as they waited for their medical visit or at the dispensary throughout all hours of clinic operation for a period of three months in one tertiary hospital. Research assistant 1 asked for consent from patients attending the hospital outpatient department to participate in the study, i.e. do a baseline assessment using the AUDIT questionnaire. Research assistant 1 was not involved in delivering treatment. Research assistant 2 scored the results of the alcohol section of the questionnaire. Hospital outpatients who scored 8–19 for men and 7–19 for women on the AUDIT questionnaire after the screening were being included in the study. Patients with a score of 20 and above on the AUDIT were referred for further management. Research assistant 2 implemented the randomization to intervention or control arms. Research assistant 2 carried out the intervention for all the participants, after which they were followed up at 6 months and 12 months, and assessments were done by Research assistant 1, who was blinded to the intervention allocation of the participants. In the event of a dropout, at least six individual attempts were made to contact patients by telephone and letter. Even if a contact was not successful at 6 months, further attempts were made at 12 months. Participants received 40 South African Rands for transport for returning to the hospital and completing each of the two follow-up assessments (in total R 80) . Questionnaires were administered in English or Tswana at baseline, 6 and 12 months follow-up visits. We received ethical approval from the Medunsa Research and Ethics Committee (Project number: MREC/H/220/2010:IR). Dr. George Mukhari Hospital also provided approval for this study. The study was conducted from February 2011 to June 2012.
Control arm Participants randomized to this group were provided with a health education leaflet on responsible drinking.
Experimental arm: brief intervention Participants who were randomized onto the brief intervention arm receive personalized feedback on their AUDIT results, a health education leaflet, simple advice plus brief counselling about reducing excessive drinking, during a one session 20 minute intervention. The steps of brief counselling were: 1) To identify any alcohol related problems mentioned in the interview, 2) To introduce the sensible drinking leaflet, emphasize the idea of sensible limits, and make sure that patients realize that they are in the hazardous or harmful risk drinking category, 3) To work through the first 3 sections of the problem solving manual while mentioning the value of reviewing the other sections, 4) To describe drinking diary cards, 5) To identify a helper, and 6) To mention the 6 and 12 months follow-up assessments. The Information-Motivation-Behavioural Skills (IMB) Model was used to guide the alcohol reduction intervention. More details on the theory-based intervention are provided elsewhere .
Counsellor training and intervention quality assurance The intervention assistant nurse counsellor delivered the interventions to men and women patients as per usual clinic services. The assistant nurse counsellors were trained to administer the intervention protocol through role playing and general skills training techniques in a 5 day workshop . Site visits were done bi-weekly by the project manager to offer support and supervision to the trained assistant nurse counsellors. In addition, during implementation, assistant nurse counsellors were observed “in vivo” for adherence to the detailed 15 steps counselling protocol by an external staff .