Types and Effectiveness of Community-Based Cardiovascular Disease Preventive Interventions in Reducing Alcohol Consumption: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) poses a global health challenge, with modifiable risk factors, notably alcohol consumption, impacting its onset and progression. This review synthesizes evidence on the types and effectiveness of community-based interventions (CBIs) aimed at reducing alcohol consumption for CVD prevention. Electronic databases were systematically searched until October 31, 2019, with updates until February 28, 2023. Given the heterogeneity in outcome measures, we narratively synthesized the effectiveness of CBIs, adhering to the synthesis without meta-analysis (SWiM) guidelines for transparent reporting. For selected homogenous studies, a random-effects meta-analysis was utilized to estimate the effects of CBIs on alcohol consumption. Twenty-two eligible studies were included, with 16 demonstrating that CBIs reduced alcohol consumption compared to controls. Meta-analysis findings revealed reductions in above moderate-level alcohol consumption (pooled odds ratio (OR)=0.50, 95% confidence interval (CI): 0.37, 0.68), number of alcohol drinks per week (standardized mean difference=-0.08, 95% CI: -0.14, -0.03), and increased odds of low-risk drinking (pooled OR=1.99, 95% CI: 1.04, 3.81) compared to the control groups. Multi-component interventions (particularly those combining health education, awareness, and promotion activities) and those interventions with a duration of 12 months or more were notably effective. The beneficial effects of CBIs focusing on achieving a reduction in alcohol consumption showed promising outcomes. Implementing such interventions, especially multicomponent interventions, could play a significant role in mitigating the increasing burden of CVDs. Future studies should also consider employing standardized and validated tools to measure alcohol consumption outcomes to enhance the consistency and comparability of findings.


Introduction And Background
Cardiovascular diseases (CVDs) impose a huge socio-economic burden on communities and the health system.In the last three decades, the global prevalence of CVDs has nearly doubled from 271 million in 1990 to 523 million in 2019, while CVD-related mortality has increased by more than 50% from 12.1 million in 1990 to 18.6 million in 2019 [1].Over the same period, years lived with disability due to CVDs has doubled from 17.7 million in 1990 to 34.4 million in 2019 [2].Consequently, CVDs have become the largest single contributor for noncommunicable diseases accounting for one-third of the annual deaths across the world [1,3].An increase in age-standardized CVD rate has been observed in countries that were once known to have a declining trend [2].The morbidity and mortality vary between countries and regions due to the influence of culture, globalization, industrialization, epidemiological and demographic transition, and the prevalence of other risk factors [4,5].More precisely, the prevalence of modifiable risk factors, including excessive alcohol use, is known to contribute to the burden of CVDs [2].
Although the link between excessive alcohol consumption and CVD has long been recognized, more recent evidence is challenging the notion of any beneficial effects related to moderate alcohol consumption [3,6,7].A recent World Heart Federation and World Health Organization (WHO) report indicated that even small amounts of alcohol consumption raise the risk of CVDs, including coronary disease, stroke, heart failure, cardiomyopathy, atrial fibrillation, and aneurysm among adults [8,9].In light of this evidence, targeting alcohol consumption through the development, implementation, and evaluation of cost-effective Central, Google Scholar, ClinicalTrials.gov,and the WHO International Clinical Trials Registry Platform were also searched for relevant similar articles.Based on a preliminary keyword search, a systematic search strategy was developed using terms related to population, intervention, and outcomes.Details of the search strategy are available in a previous publication [17], and the search terms in Medline are available in the supplementary materials (Box S1).Citation mining was also done by reviewing the reference list of the included articles.

Selection Process
Articles retrieved from electronic databases were exported as a single library using EndNote and were then verified and deduplicated.Subsequently, deduplicated searches were imported into Rayyan.aisoftware (http://rayyan.qcri.org/).Three reviewers (HYH, RN, and NMB) independently screened all articles by reviewing their titles and abstracts, using predefined inclusion criteria to determine whether each article met the requirements for inclusion in the review.Moreover, articles that were included in the full-text screening were assessed by two reviewers (HYH and NMB) for eligibility to be included in the review.When decisional conflicts arose regarding the inclusion or exclusion of an article and a final decision could not be reached through consensus, an arbitrator (RN) was designated to resolve the conflict and make the final decision.For full-text articles with missing or incomplete information, the corresponding author(s) were emailed twice.Justifications for excluding studies during the full-text process were documented and presented in the PRISMA flow chart (Figure 1).

Risk of Bias Assessment
Quality appraisal of evidence for the included randomized controlled trials was assessed following the revised Cochrane tool for Risk of Bias (RoB2) [18].This tool was also used to appraise cluster-randomized controlled trials by evaluating additional domains that account for bias due to clustering.The risk of bias in non-randomized studies was assessed using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool [19].All studies' risk of bias were independently assessed by two reviewers (HYH and NMB).

Data Extraction
Data extraction was performed by two independent reviewers (NMB and HYH), following the development of the data extraction forms.All disagreements between authors were resolved by consensus or arbitrated by a third person, if necessary.Study characteristics, including study population, intervention and its description, comparators, outcomes and outcome measures, intervention duration, study design, study settings, methodological approach (e.g., measurement tools and statistical analysis used), sample size, attrition rate, results, and funding sources, were extracted rigorously.In addition, effect estimates with 95% confidence intervals (CIs) and the direction of effects were extracted and validated after data extraction.In a few studies where results were presented solely using graphs, we utilized WebPlotDigitizer [20] only after a failed attempt to contact the study authors.

Data Synthesis
Due to the heterogeneity in the outcome measures used, evidence for the effectiveness of CBIs for CVD prevention was predominantly narratively synthesized for all the included studies.To enable transparent reporting, the Synthesis Without Meta-analysis (SWiM) guideline was utilized to present our findings [21].The nine-item SWiM checklist is available in the supplementary material (Appendix, Table S5).We grouped studies using study design, target population, and intervention types.Data are presented in tables using information related to the country, year of publication, type of study design, intervention type and duration, target population, setting, measures of alcohol consumption, and risk of bias assessment of included studies.Results are presented and discussed in relation to the income per capita classification of countries (high-income countries (HICs) vs. low-and middle-income countries (LMICs)), target population, risk of bias, measures of alcohol consumption, type of study design, intervention setting, and duration.Mean differences, odds ratios, and adjusted regression coefficients were used to compare study groups and present findings from the included studies.Finally, to synthesize the overall evidence, vote counting based on the direction of effect was used.

Meta-Analysis
Studies that reported similar study populations and measures of alcohol consumption were synthesized using a meta-analysis.For continuous outcome measures, standardized mean differences (SMD) with 95%CIs were presented, while for dichotomous outcomes, the strength of association was expressed in terms of odds ratios (ORs) with 95%CIs to provide the pooled effect estimate.When standard deviations and/or standard errors were not reported in the original studies, these quantities were imputed using other reported parameters based on the Cochrane guideline.For studies that reported multiple intervention or control arms, groups were combined to conduct a single pair-wise comparison [22].This decision was based on the arms being sufficiently similar in terms of delivery methods, outcome measures, participants' characteristics, and the setting and duration of the study.Random effects meta-analyses were used to account for between-study variability across the included studies.Lastly, heterogeneity was assessed using the I 2 statistic, and its significance was tested using the Q statistic [23].

Results
We identified 16,118 titles/abstracts from databases and 64 from manual searches.After screening for duplicates and titles/abstracts, we reviewed 817 full-text articles.Out of these, 128 studies fulfilled the eligibility criteria, with 22 of them reporting on at least one measure of alcohol consumption as an outcome.Among the 22 included studies, eight were considered in the meta-analysis (Figure 1).

Number of Studies Effect Size (95%CI) I 2 (%)
Proportion of low-risk alcohol consumption 3 1.99 a (1.04, 3.81) 30% Proportion of above moderate level alcohol consumption 3 0.50 a (0.37, 0.68) 0% Drinks per week (continuous) 3 -0.08 b (-0.14, -0.03) 0% a , pooled odds ratio after exposure to intervention; b = pooled standardized mean difference; above moderate level alcohol consumption, more than two drinks per day for men and more than one drink for women; CI, confidence interval; I 2 , describes the percentage of variation across studies due to heterogeneity.

Narrative Analysis
A comprehensive summary of the direction of the effects of community-based interventions on alcohol consumption has been provided in Table 3 and Figure 5.In 16 out of the 22 studies, the observed effects favored the intervention group, showing a greater reduction in alcohol consumption compared to the control group.This includes six CRCTs [27,28,31,38,41,44], seven RCTs [25,29,30,34,37,39,42], and three NRCs [24,35,36].Conversely, in the remaining six studies, comprising one CRCT, one RCT, and four NRCs, the reduction in alcohol consumption was favorable in the control group compared to the intervention group [26,32,33,40,43,45].  3).
Among the 10 studies that demonstrated a significant reduction in alcohol consumption favoring the intervention group over the control group, seven studies reported dichotomous outcome measures [27,28,36,38,39,41,44].Notably, three of these studies employed validated alcohol assessment tools (such as AUDIT, CARET, and CARPS) to assess risky alcohol consumption [27,28,41].Conversely, among the two NRCs that showed significant effects favoring the control group [43,45], one did not specify the measurement unit for alcohol consumption [43].
In contrast, among the 10 studies that showed no statistically significant difference between the control and intervention groups, the majority (n=6) employed single-component interventions [30,[32][33][34]37,40].Two of these studies utilized personalized feedback delivered electronically [30,32], while one each used health education [37], health communication via text messages [34], individual-based counseling [33], and health promotion activities using youth agents of change [40].Of the two NRCs for which the effect favored the control compared to the intervention group, one utilized health communication delivered through traditional media [45] (Figure 4).

Meta-Analysis
CBIs were effective in increasing the proportion of participants classified as "low-risk drinkers" in the intervention group as compared to the control group (OR=1.99,95%CI: 1.04, 3.81).A decrease in the above "moderate level" of alcohol drinking (two drinks per day for men and one drink per day for women) was observed in those who received a CBI as compared to their control counterparts (OR=0.50,95%CI: 0.37, 0.68).Additionally, a decrease was observed in the number of drinks consumed per week in those who received a CBI as compared to those who were in the control group (Table 2, Figure 6).

Discussion
The increasing burden of CVDs has spurred the exploration of effective prevention strategies, with CBIs emerging as a pivotal avenue.This review assessed the types and effectiveness of CBIs targeting the reduction of alcohol consumption -a strategic approach aimed at alleviating the CVD burden by targeting one of its main risk factors.We assessed 22 eligible studies by exploring varying intervention components, settings, duration, outcome measures, and their impact on the reduction of alcohol consumption.Due to the heterogeneity in outcome measures, only eight studies with similar measures of alcohol consumption measures were integrated into the meta-analysis.Overall, our findings revealed a reduction in different measures of drinking patterns and risky alcohol consumption within the intervention group in comparison to the control group.Furthermore, multicomponent interventions, especially those that combined health education with health promotion activities, demonstrated a more pronounced effect in the intervention group.
Our findings yielded insights into the effectiveness of CBIs in reducing alcohol consumption.Specifically, we observed a substantial reduction in the number of drinks consumed per week in the intervention group compared to the control at 12-month follow-up.Furthermore, a reduction in alcohol consumption was observed in the intervention group, particularly in terms of above-moderate-level and risky alcohol consumption.These findings underscore the potential of community-based strategies to successfully address alcohol consumption as a contributing risk factor for CVDs.
While these results are promising, it is important to acknowledge the substantial heterogeneity observed in the measures of alcohol consumption across the included studies.This variation reflects the diverse and inconsistent approaches employed in assessing alcohol consumption.Previous reviews have similarly highlighted this issue and emphasized the importance of using validated and consistent assessment measures to enable meaningful comparisons and accurate evaluations of intervention effectiveness [16,46].The significance of employing consistent and comprehensive assessment tools was also underscored by our findings.The majority of the studies that employed validated and comprehensive tools, such as AUDIT, CARET, and CARPS, to assess unhealthy alcohol consumption demonstrated a finding favoring the intervention group.This could be attributed to these tools capturing a wide range of recommended factors associated with alcohol consumption, including drinking patterns, alcohol-related problems, and high-risk consumption enabling an accurate and comprehensive evaluation of alcohol consumption [46,47].Therefore, such and other similar assessment tools should be considered for use depending on the aims and context of community-based cardiovascular interventions targeting the reduction of alcohol consumption.
Previous studies have demonstrated the effectiveness of multi-component intervention strategies [15,16], which is consistent with our review.In our review, multi-component interventions that specifically combined health education and awareness creation with health promotion activities exhibited a more pronounced effect in reducing alcohol consumption.Similar results have been reported in previous systematic reviews exploring CBIs targeting alcohol consumption and other major risk factors of CVDs [16,48].This might be attributed to the fact that such strategies intervene at both the individual level and within the surrounding environment, which is essential for facilitating the desired behavior change.Health education serves to dispel the widespread myth of alcohol consumption benefits and foster an accurate understanding of its harmful effects on cardiovascular health [3,48].Coupling this foundational element with health promotion activities may not only aid in reinforcing but may also empower individuals to reduce their alcohol consumption.Therefore, the comprehensive and synergistic nature of multi-component interventions, encompassing health education and health promotion activities, is instrumental in fostering successful reductions in alcohol consumption in the context of CVD prevention and should be considered in future interventions.
Furthermore, intervention duration appeared to play a role in determining their effectiveness in reducing alcohol consumption.Most of the longer-term interventions, lasting 12 months or more, demonstrated a reduction in alcohol consumption.Previous studies have also indicated a longer intervention duration to be positively associated with observing strong evidence for an intervention's effectiveness and better alcoholrelated outcomes [16,49,50].Moreover, a prior study concluded a longer intervention duration (intervention sessions spread over up to 12 months or more) was associated with a higher likelihood of abstaining from consuming alcohol and other drugs after controlling for intensity [51].Changing and sustaining desired behavior, such as reducing alcohol consumption, requires an extended period to reinforce, practice, and adapt to new habits.Achieving relevant behavior change within a short timeframe may be challenging due to the potential for relapse into previous drinking habits [52].Thus, the value of persistent efforts to promote behavior change and the challenges of achieving immediate results in the context of alcohol consumption reduction should not be underestimated.Consequently, prioritizing a longer duration of intervention is imperative, besides the intensity of the intervention, when aiming to accurately assess its effectiveness on alcohol consumption.
Notably, the majority of interventions conducted in LMICs demonstrated effectiveness in reducing alcohol consumption, whereas the majority of studies conducted in HICs exhibited non-significant findings.This discrepancy could be attributed to the potential existence of unobserved influence of other public health policies designed for reducing alcohol consumption in addition to the CVD CBIs [53].This may lead to the underestimation of the intervention's effect in HICs.Despite the heaviest burden of heavy episodic drinking among both males and females being prevalent in LMICs [54], there exists a disproportionate distribution of community-based CVD interventions between HICs and LMICs.This finding aligns with prior reviews that have underscored the limited presence of community-based CVD interventions, particularly in LMICs, especially in Sub-Saharan Africa [16,17,55].Thus, there is a critical need to enhance research capacity in LMICs for the implementation of CBIs targeting CVD risk factors, including alcohol consumption.This emphasis is crucial due to the potential cost-effectiveness and the heightened prevalence of heavy episodic drinking within these regions.

Methodological Considerations
Interestingly, the effectiveness of CBIs varied based on the type of study design.Randomized studies demonstrated reductions in alcohol consumption favoring the intervention group compared with nonrandomized studies.Specifically, almost all CRCTs demonstrated reductions in alcohol consumption favoring the intervention group.This disparity in outcomes might be attributed to the inherent design of CRCTs, which account for community-level influences and potentially create a more conducive environment for behavior change through the intervention's spill-over effect, influencing behaviors of participants within the same cluster [56].
However, it is also important to acknowledge the concerns identified in our review regarding the quality of studies assessed using the Cochrane Risk of Bias assessment tool.For the NRCs, biases arising from deviations from intended interventions, confounding, and missing data handling in most studies compromised their quality.Specifically, the two NRC studies that favored the control group in reducing alcohol consumption exhibited issues related to bias due to confounding, selection of participants, classification of intervention, deviation from intended interventions, and missing data handling [43,45].On the other hand, for randomized studies, deviations from intended interventions mainly affected their quality.Therefore, based on these findings, it is recommended that researchers aiming to implement CBIs targeting alcohol consumption reduction prioritize rigorous study designs, such as CRCTs, which can account for community-level influences, and ensure strict adherence to intervention protocols to minimize deviations and enhance the overall quality of the research.
This review presented the effectiveness of various types of CBIs for reducing alcohol consumption in the context of CVD prevention.Specifically, it underscored the effectiveness of multi-component interventions, particularly those that combine health education with promotion activities.Furthermore, it identified essential components of interventions, offering valuable insights for future researchers to consider, including intervention duration and the utilization of validated assessment tools to comprehensively and accurately measure alcohol consumption outcomes.Lastly, this review emphasized the critical need to enhance research capacity and implement context-specific interventions in LMICs.As such, the findings not only contribute additional evidence for policymakers and public health practitioners but also provide actionable recommendations to strengthen CBIs for CVD prevention with a focus on alcohol consumption reduction.

Limitations
Our review has limitations that should be acknowledged and considered when interpreting its findings.Firstly, language bias may have arisen due to the restriction of articles to the English language.This might lead to a biased understanding of the effects of interventions, as valuable findings from non-English sources are overlooked.Consequently, this might result in an overestimation of the interventions' effectiveness in regions primarily publishing in English while potentially ignoring successful strategies documented in other languages.Secondly, the heterogeneity in measurement approaches used across the included studies precluded meta-analysis for certain outcomes, resulting in difficulties in comparing and synthesizing results.This limitation restricts our ability to pool findings and draw robust conclusions about the effectiveness of CBIs in reducing alcohol consumption.Nevertheless, outcomes not included in the metaanalysis were summarized using narrative synthesis.Lastly, the inclusion of only a small number of studies in the meta-analyses led to wide confidence intervals for the effect sizes, indicating less precise estimates.

Conclusions
In summary, this review provided substantial evidence of the effectiveness of CBIs targeting the reduction of alcohol consumption as a strategy to mitigate the burden of CVDs.The review included a diverse range of study designs, intervention components, and settings, revealing reductions in alcohol consumption within the intervention groups.Notably, multi-component interventions, particularly those integrating health education and promotion activities, displayed a more pronounced effect in reducing alcohol consumption.
The findings underscore the potential of community-based strategies in addressing alcohol consumption as a risk factor for CVDs.Therefore, to enhance the effectiveness of community-based CVD preventive interventions in reducing alcohol consumption, integrating multi-component intervention, and extending the duration of these programs is recommended.Future research should employ standardized and validated tools to measure alcohol consumption outcomes, enhancing the consistency and comparability of results.Furthermore, detailed methodologies and assessments included in the main text enhance the transparency of the review process.Relocating these details might give the impression that certain aspects of the review process are being obscured or de-emphasized.

Effect Estimates
Quantitative results from the study, such as mean differences, odds ratios, and other statistical measures.
Outcomes Measures health outcomes measured by the studies, including factors like Alcohol consumption, blood pressure, dietary intake, or physical activity.

Participants
The age range or average age of participants in the study.

Rate
The percentage of participants who dropped out of the study.

Sample Size
The total number of participants in the study.

Methods
The statistical methods used to analyze the data.

Sources
The source of funding for the study.State the method(s) used to examine heterogeneity in reported effects when it was not possible to undertake a meta-analysis of effect estimates and its extensions to investigate heterogeneity 6,7 6 Certainty of evidence Describe the methods used to assess certainty of the synthesis findings 6 7 Data presentation methods Describe the graphical and tabular methods used to present the effects (e.g., tables, forest plots, harvest plots).Specify key study characteristics (e.g., study design, risk of bias) used to order the studies, in the text and any tables or graphs, clearly referencing the studies included   ( Interven* OR strateg* OR approach* OR program* OR "health education" OR "health educ*" OR advise OR "raising awareness" OR counsel* OR "health promotion" OR "health campaign" OR "wellness program*" OR "mass media" OR "behaviour* change" OR "behavior* change" OR "lifestyle intervention" OR "lifestyle program*" OR "screening" "motivational interviewing" OR "risk scoring" OR refer* OR training OR "capacity building" OR "peer" OR "peer group" OR "community health worker" OR "CHW" OR "community health volunteer" OR "health worker*" OR "Community Health Extension Worker" OR "Health promoter" OR "Community Health Care Provider" OR "social support" OR "adherence support" OR "coaching" OR "self management" OR self-management OR "outreach" OR "home visit" OR "appointment reminders" ) #3 ( "Cardiovascular disease" OR "CVD" OR "CVD risk" OR "cardiovascular disease prevention" OR "cardiovascular disease control" OR "stroke" OR "coronary heart disease" OR "heart diseas*" OR "heart failure" OR "kidney disease" OR "Cardiovascular risk factor" OR "hypertension" OR "raised blood pressure" OR diabetes OR "raised blood sugar" OR "cholest*" OR triglyceride OR HDL OR LDL OR "lipid profile" OR "metabolic syndrome" OR "body mass index" OR "BMI" OR "Overweight" OR "obesity" OR "obese" OR "waist circumference" OR "life style" OR "lifestyle" OR "alcohol" OR "tobacco" OR "smoking" OR "diet*" OR "nutrition" OR "food habit" OR "junk food" OR "fast food" OR "fruit" OR "vegetables" OR "five a day" OR "salt reduction" OR "physical inactivity" OR "physical activity" OR "exercise" OR "stress") #4 ("randomized controlled trial" OR "randomized" OR "randomised" OR "controlled study" OR trial OR RCT OR cluster OR CRT OR "comparative study" OR "quasi experimental study" OR "quasi-experiment" OR "experimental" OR "control group" OR "follow up" OR "prospective" or "retrospective" OR placebo OR random* OR "follow-up" OR "non-random*" OR "nonrandom*" OR "before after stud*" OR "before and after" or "time series" or "time-series" OR "interrupted time series" OR longitud* OR "controlled before" OR "pre-post" OR pretest OR posttest OR "pre intervention" or "post intervention") #4 #1 AND #2 AND #3 AND #4 #5 Filters: year of publication: (January 2000 to June 2019), Language: English Age: adults (18 and above) population: humans

FIGURE 1 :
FIGURE 1: Illustration of the article selection process using the PRISMA flow chart.CVD, Cardiovascular disease; PRISMA, Preferred Reporting Items for Systematic reviews, and Meta-Analyses

FIGURE 2 :FIGURE 3 :
FIGURE 2: Risk of bias assessment of the included studies for all domains.

FIGURE 4 :
FIGURE 4: Hierarchical clustering analysis of 22 community-based interventions based on five intervention strategies.Each slice of the chart represents the study intervention(s).The sectors in each chart indicate what types of domains were included in each study, with the area of each sector corresponding to the proportion of each intervention type within one study.Meanwhile, the blue branches starting from the center of the chart show how the interventions were divided into the three main clusters with nine sub-nodes, indicating that the study in each cluster has a more similar domain profile compared to the study in other clusters.Health communication interventions refer to the use of posters, leaflets, newsletters, booklets, tip sheets, text messages, newspapers, media, and pamphlets, delivered electronically or in print.Individual-based counseling includes motivational interviewing, either face-to-face or by phone.Health promotion activities refer to youth agents of change, workplace wellness initiatives, support groups, housing rent supplements, training healthcare staff, and initiatives to improve free access to healthcare and facilities promoting a healthy lifestyle.Personalized feedback/report, an individualized feedback or report about participants' alcohol consumption, sent electronically or by mail.Health education and awareness creation intervention refers to lectures, sessions, workshops, street dramas, and demonstrations, delivered face-to-face or via phone.

FIGURE 5 :
FIGURE 5: Forest plots for the included studies for studies reporting (A) the (adjusted) odds-ratio after exposure to the intervention and (B) mean difference.AOR, Adjusted odds ratio; MD, Mean difference

FIGURE 6 :
FIGURE 6: Forest plots for studies reporting (A) the odds ratio of lowrisk alcohol consumption measured by validated tools assessing at-risk alcohol consumption and (B) the odds ratio of above moderate-level alcohol consumption, and (C) the mean difference of drinks per week outcome measures at 12 months follow-up.SD, Standard deviation; SMD, Standardized mean difference, OR, Odds ratio; CI, Confidence interval

2024
Berhe et al.Cureus 16(5): e61323.DOI 10.7759/cureus.61323Variables Description Author and Year Reference for the study to ensure proper citation and identification.the participants were followed to assess the outcomes of the intervention.Intervention Duration Length of time the intervention was actively administered.Risk of Bias (RoB) Assessment of potential bias in the study's execution, categorized by levels of concern.Data extracted to assess the risk of bias was based on the Cochrane tool for randomized studies (RoB2) and the Risk of Bias in Non-Randomized Studies -of Interventions (ROBINS-I) tool for non-randomized studies.Context Rural, Urban, or Mixed; specifying the environment in which the study was conducted.Setting Description of the setting such as community-based, primary care, or home-based, specifying where the intervention took place.Target Group Characteristics of the population targeted by the study (e.g., age group, specific patient demographics like hypertensive patients, or risk-related characteristics like smokers).Participants' Sex Participant gender distribution within the study.Outcome Measures Specific outcomes measured in the study, particularly related to alcohol consumption (e.g., units of alcohol per week, AUDIT scores).Design Type of study design utilized, such as RCT (Randomized Controlled Trial), NRCT (Non-Randomized Controlled Trial).

FIGURE 7 : 7 1b) 6 4
FIGURE 7: Harvest plot for all included studies by overall risk of bias, effectiveness of the intervention, and their study designs.

6 8 12 Discussion 9
Reporting resultsFor each comparison and outcome, provide a description of the synthesised findings, and the certainty of the findings.Describe the result in language that is consistent with the question the synthesis addresses, and indicate which studies contribute to the synthesis 10-Limitations of the synthesis Report the limitations of the synthesis methods used and/or the groupings used in the synthesis, and how these affect the conclusions that can be drawn in relation to the original review question 15,16

# 1 (
"Community" OR "community-based intervention" OR "community-based" OR "community based" OR "community intervention" OR "population-based intervention" OR "population based" OR "population intervention" OR "community health" OR "community organisation" OR "community organization" OR "community program*" OR "Community level" OR "Community networks" OR "community health services" OR "home based" OR "community participation" OR "communitybased research") #2

TABLE 1 : Study characteristics of the included articles.
NI, Not indicated; MA, Included in the meta-analysis

TABLE 3 : Summary findings of the effectiveness of community-based interventions in alcohol consumption.
†, Neighborhood health work; Mean difference, compares the change in outcomes from pre-intervention to post-intervention between two groups; Adjusted odds ratio (after intervention); 95%CI, 95% confidence interval (two-sided); %, Percentage; I, demonstrated reduced alcohol consumption in favor of the intervention group; C, demonstrated reduced alcohol consumption in favor of the usual care or attention control group; *, statistically significant with p-