Staff Reporter
Natalie Johnson, a Fulbright Specialist based in Butha Buthe, is conducting groundbreaking research on the intersection of alcohol use and mental health in the country’s remote districts. With a focus on Butha Buthe and Mokhotlong, Johnson’s work is part of a larger initiative to address mental health issues in underrepresented regions of the world. Her research is linked to the VITAL study, which examines differentiated HIV care and its outcomes in Lesotho. Her interest in alcohol use stems from alarming patterns observed during the VITAL study, where high rates of alcohol consumption were reported among participants.
In this interview with Newsday, she shares details about her research, driven by both professional and deeply personal motivations. Johnson discusses how her background in global mental health and extensive experience in low- and middle-income countries informs her approach to the unique challenges of designing effective interventions that resonate with the local context. Her work in Lesotho aims to uncover the social dynamics that influence alcohol use, with the goal of informing interventions that could reduce alcohol-related harm not only in Lesotho but in similar contexts worldwide.Top of FormBottom of Form
Newsday: Could you elaborate on why you chose Lesotho, specifically the Butha Buthe and Mokhotlong districts, as the focus of your research on alcohol use and mental health?
Natalie Johnson (NJ): Lesotho is underrepresented in global mental health research. Much of the existing research focuses on high-income countries, and within Africa, most studies are concentrated in South Africa and Kenya. Additionally, the director of the division where I am enrolled as a PhD student, Prof. Dr. Niklaus Labhardt, has been working in Lesotho for over 10 years, addressing infectious diseases such as HIV and TB. His work, in collaboration with SolidarMed—a Swiss non-profit organisation—and the Ministry of Health, has primarily concentrated on the remote districts of Mokhotlong and Butha Buthe, which face significant challenges in HIV and TB care. As SolidarMed’s mission is to strengthen health systems, they work very closely with health facilities, which is where my research takes place. My research is part of a larger study called Viral Load Triggered ART care in Lesotho (VITAL), a trial that examines whether differentiated, technology-assisted HIV care based on HIV viral load improves treatment outcomes. The study followed people with HIV who were receiving care at clinics in Butha Buthe and Mokhotlong. Participants in this study reported high rates of alcohol consumption. Additionally, specific conditions in these districts contribute to the prevalence of alcohol use and its associated problems. In Butha Buthe, economic challenges, limited employment opportunities, and the availability of low-cost alcoholic beverages due to cross-border trade have led to widespread alcohol consumption. In Mokhotlong, gender dynamics contribute to high alcohol consumption among men, leading to serious social issues, including gender-based violence. Across both districts, and much of the country, there is a lack of services for individuals seeking help with alcohol use, compounded by stigma, social normalisation, and a lack of awareness of alcohol-related problems.
Newsday: How did you engage with local communities and stakeholders during your research? How important is community involvement in ensuring the success of your study?
NJ: The idea for this study emerged from frequent reports of alcohol consumption among participants in the VITAL study. Recognising this pattern, we conducted a qualitative study to gain a deeper understanding of alcohol use among these participants. We discovered that social drinking and peer pressure were significant factors influencing their habits. This insight led to the current research, which aims to determine whether social network drinking and social support impact alcohol use problems. We engaged closely with local health facilities and community members, successfully recruiting 255 participants for the study. Hospital staff assisted with blood draws and participant recruitment, while clinics and hospitals provided space for us to meet with participants. We also approached individuals in waiting rooms to gauge their interest in the study. Over time, enrolled participants began referring others they knew to be eligible, based on criteria such as regular drinking or significant issues related to alcohol use. To date, we have connected around 20 percent of participants with one another. Community engagement is central to my research approach, a value shaped by my service in the Peace Corps. During my Fulbright fellowship in Lesotho, I consulted 32 community leaders, youth, and experts to gather advice on future research focused on youth mental health. Their input has shaped research to develop a mental health intervention through a two-phased approach. In the first phase, youth across the country will participate in citizen science by submitting photos and explanations via WhatsApp in response to prompts. In the second phase, Basotho youth with lived experience of mental health challenges will take part in workshops to design an intervention, incorporating elements identified by the youth in the first phase.
Newsday: What inspired you to pursue this line of research, particularly focusing on alcohol use and mental health in LMICs like Lesotho?
NJ: My interest in addressing alcohol use problems is deeply personal, as it stems from my family’s experiences. Both my father and sister were profoundly affected by the harmful consequences of alcohol. In 2018, I lost my sister due to alcohol use. My father, who has been sober for over 30 years, credits Alcoholics Anonymous for his recovery. However, I believe there are multiple paths to leading a happy and functional life, even for those who continue to drink. The Global Mental Health group I work with emphasises a harm-reduction approach rather than advocating for total abstinence. Since I began working in low- and middle-income countries (LMICs) in 2010, I have observed that many people are unaware of the dangers associated with heavy alcohol consumption. My commitment to this issue solidified in 2011 during my Peace Corps service in Mongolia, where I collaborated with local stakeholders—including the Ministries of Health and Education and World Vision—to launch alcohol awareness campaigns. In LMICs, mental health care often involves the introduction of interventions developed in high-income settings, which may not be fully applicable or effective in these different contexts. It is crucial to design interventions that are locally relevant and take into account the specific realities and preferences of the populations they are intended to serve.
Newsday: Beyond the scope of this study, how do you see your findings contributing to the broader field of mental health and alcohol use interventions in LMICs?
NJ: If our study concludes that alcohol use is significantly influenced by social networks, it will provide valuable evidence in support of socially driven interventions in Lesotho and similar settings. This could pave the way for targeted interventions focused on peer groups, families, and couples, which are designed to address and mitigate the social factors that contribute to alcohol use.
Newsday: What impact do you hope your research will have on the development of interventions for reducing alcohol use in Lesotho and other similar contexts?
NJ: Research in other settings has shown that alcohol use is closely linked to social networks, and our preliminary work suggests the same may be true in Lesotho. If my study confirms that social networks significantly influence drinking behavior, I hope to see the development of interventions that target not just individuals but also their social circles. By focusing on companions and peer groups, these interventions could be more effective in reducing alcohol use in Lesotho and similar contexts.
Newsday: You mentioned your hypothesis that social networks might offer both supportive factors and pressures related to alcohol use. Can you share more about how you identified and measured these factors in the context of your study?
NJ: To assess social support, I utilized the Multidimensional Scale of Perceived Social Support (MSPSS). Participants were interviewed by a research assistant and self-reported their levels of social support through 12 questions. An example of one such question is, “I have a special person who is a real source of comfort to me.” The MSPSS has demonstrated strong measurement properties in similar settings and allows for the separate examination of support from friends, family, and significant others. To measure social pressures related to drinking, I used a self-report tool called the Important People Instrument. This measure includes report of the drinking habits of three important people in their lives as well as how many days per month they drink with each person.
