|Year : 2017 | Volume
| Issue : 1 | Page : 66-72
Prevalence, pattern, and correlates of alcohol misuse among male patients attending rural primary care in India
Sanghamitra Pati1, Subhashisa Swain2, Sandeep Mahapatra2, Mohammad Akhtar Hussain3, Sandipana Pati4
1 Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar, Odisha, India
2 Indian Institute of Public Health Bhubaneswar, Public Health Foundation of India, Bhubaneswar, Odisha, India
3 School of Public Health, The University of Queensland, Brisbane, Australia
4 Department of Health and Family Welfare, Government of Odisha, Bhubaneswar, India
|Date of Web Publication||15-May-2017|
Regional Medical Research Centre, Indian Council of Medical Research, Chandrasekharpur, Bhubaneswar - 751 023, Odisha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There are limited data available on how the problem of alcohol use is detected in primary care setting in India. Particularly in Odisha, it has not been investigated yet. This study was conducted to determine the prevalence of drinking, drinking patterns, and quitting behavior among the male patients visiting a primary health-care facility in a district of Odisha. Methodology: A cross-sectional study was conducted among patients attending community health center (CHC), Buguda in the state of Odisha, India, from December 1, 2014, to February 31, 2015. Patients above 18 years of age, conscious, and willing to participate in the study were included in the study, while those with cognitive impairment and critically ill were excluded from the study. All eligible consecutive patients attending outpatient department of CHC were invited to participate while they came out after physician's consultation. A pilot study was conducted prior to the study. Informed verbal consent from each patient was obtained before the interview. The study was approved by the Institutional Ethics Committee of Indian Institute of Public Health, Bhubaneswar. Results: A total of 431 patients were interviewed. Our study showed 38% (95% confidence interval [CI]: 33.5%–42.7%) of respondents were alcoholic and of those 60% (95% CI: 51.4%–66.5%) were hazardous drinkers. One in five patients had a history of alcoholics in their family, and a similar proportion of participants were heavy workers. Smokers were eight times (adjusted odds ratio [AOR] =7.56; 4.03–14.52) more likely to be alcoholics as compared to nonsmokers (P < 0.001), whereas the prevalence of alcohol drinking was four times (AOR = 3.94; 2.25–6.92) higher in smokeless tobacco users compared to nonusers. Conclusion: Focusing only on counseling and treatment services will not reduce the piling burden of alcohol use. It is important to target the environment that leads to such habits.
Keywords: Alcohol misuse, hazardous drinking, India, Odisha, primary care
|How to cite this article:|
Pati S, Swain S, Mahapatra S, Hussain MA, Pati S. Prevalence, pattern, and correlates of alcohol misuse among male patients attending rural primary care in India. J Pharm Bioall Sci 2017;9:66-72
|How to cite this URL:|
Pati S, Swain S, Mahapatra S, Hussain MA, Pati S. Prevalence, pattern, and correlates of alcohol misuse among male patients attending rural primary care in India. J Pharm Bioall Sci [serial online] 2017 [cited 2021 Jan 23];9:66-72. Available from: https://www.jpbsonline.org/text.asp?2017/9/1/66/206222
| Introduction|| |
Accompanying the near ubiquity of alcoholic beverages in human history has been a lively appreciation of the social and health problems caused by drinking. The Lancet  found that alcohol was the third leading risk factor for death and disability accounting for 5.5% of disability-adjusted life years lost globally, i.e., 136 million years of life lost through dying early or living with an alcohol-related disability. Based on 2010 data, alcohol is ranked 3rd in terms of risk after high blood pressure and smoking. These findings support the call by the World Health Organization for countries to give greater priority to addressing harmful alcohol through evidenced-based population level intervention strategies. Each year worldwide, approximately 4.6 million alcohol-related cancer cases are diagnosed. In developed countries, approximately 1.9 million alcohol-related cancer cases are estimated; whereas, in less-developed countries, 2.8 million alcohol-related cancer cases are estimated. Overall, alcohol consumption is estimated to account for 5% of all cancer deaths worldwide, with similar proportions in low- and middle-income countries. Alcohol is also an important cause of health inequalities.
Despite the growing global interest in the problem, less is known about the prevalence of alcohol use in many developing countries. In an alarming revelation, the global status report on alcohol and health 2014 released by the WHO states that the amount of alcohol consumption has raised in India between the periods of 2008 and 2012 years. A similar pattern (frequency of use, drinking to intoxication, binge drinking, and chronic use) of health risks associated with regular use of alcohol as reported in other countries is also being observed in India. A hospital-based study in the emergency department of Indian hospitals by the WHO found that the proportion of injury cases with alcohol involvement was above 20%.
In India, while only 21% of men consume alcohol (for women it has been estimated at <5%); evidence suggests that more than half of those who consume alcohol are heavy drinkers. Moreover, drinking is disproportionately higher among poorer and socially marginalized groups, notably scheduled tribes, India's indigenous populations. Despite being a public health crisis, alcohol misuse has not received adequate attention in India.
Epidemiological research shows that, on a population level, the majority of alcohol-related harm is attributable to excessive or hazardous drinking where consumption exceeds recommended drinking levels. Screening and brief intervention are probably the most thoroughly researched intervention for alcohol problems and have the strongest evidence base. Early identification and secondary prevention of alcohol problems using screening and brief interventions in primary care have increasingly been advocated as the way forward., Primary care is an ideal setting for early detection and secondary prevention of alcohol-related problems due to its high contact and exposure to the population. There is a strong evidence in favor of the use of screening and brief intervention in primary health care worldwide. There are many opportunities for identifying and managing excessive drinking in primary care. Screening and brief interventions in routine primary care would typically occur opportunistically, even though drinking problems may not be the primary reason for the presentation and patients would not actively seeking treatment.
Recent research has focused on implementing brief alcohol interventions in routine primary care across a number of countries. However, this form of preventive care seems to be influenced by both health service providers' and patients' personal and social characteristics. Exploration of perceptions and attitudes toward receiving and providing alcohol intervention at primary care would provide important insights into designing and implementing context-specific alcohol interventions. There are limited data available on how the problem of alcohol use is detected in primary care setting. Particularly in Odisha, it has not been investigated yet. There is a strong need for undertaking studies to address this gap. This study delves around the prevalence of drinking, drinking patterns, and quitting behavior among the male patients visiting a primary health-care facility in a district of Odisha.
| Methodology|| |
We conducted a cross-sectional study among patients attending community health center (CHC), Buguda in the state of Odisha, India. The CHC at Buganda is located in Ganjam District of Odisha State and provide curative and preventive medical services to a population of 80,000–1,00,00. The study was carried out from December 1, 2014, to February 31, 2015. Patients above 18 years of age, conscious, and willing to participate in the study were included in the study, while those with cognitive impairment and critically ill were excluded from the study. All eligible consecutive patients attending outpatient department of CHC were invited to participate while they came out after physician's consultation. A pilot study was conducted prior to the study. The majority of the women patients refused to take part in the study. Hence, the study was conducted only among the male patients. A total of 431 patients were interviewed. The sample size was calculated assuming the prevalence of alcohol use to be 40% among patients attending primary care practices  with 80% power, 5% level of signifcance, and 15% nonresponse rate (considering cultural and social taboos surrounding alcohol).. All interviews were conducted in local language (Odia) using a pretested validated questionnaire. Data collection was carried till we reached the desired sample size.
Informed verbal consent from each patient was obtained before the interview. The study was approved by the Institutional Ethics Committee of Indian Institute of Public Health, Bhubaneswar.
The following data were collected:
Age, gender, education, religion, marital status, caste, total household members, total household income per month, and type of housing.
Job-related questions such as present occupation, their self-reported job stress, i.e. they were asked, whether currently they perceive stress at the current workplace or not? Duration of working hours and level of physical activity involved in their present job (according to their response) categorized as mild/moderate/heavy were recorded.
Tobacco use (both smoke and smokeless) and alcohol habits of patients, age of initiation of alcohol consumption, and alcohol consumption among their family members were asked.
A pictorial tool adopted from AUDIT was used for probing into more details about standard drinking and alcohol habits. The World Health Organizations AUDIT was used to collect data on alcohol use. AUDIT-C has already been validated for screening alcohol use in wide range of countries including India. It entails three questions as follows:
- How often did you have a drink containing alcohol in the past year?
- How many drinks did you have on a typical day when you were drinking in the past year?
- How often did you have six or more drinks on one occasion in the past year?
Expenditure incurred toward alcoholic beverages per month by them was recorded in Indian Rupees. Questions probing “intention to quit alcohol” such as,
“Have you ever thought of quitting?”
“Have you ever tried quitting?”
“Have you consulted any physician for quitting advice?” and
“Do you like to have quitting services? If yes, where?” These questions were asked to know their quitting-related behaviors.
The presence of any longstanding chronic illness along with present illness was also elicited. Self-rated health was used to know about self-reported physical and mental health.
- For example, how would you rate your general health these days? Excellent/very good/good/fair/poor
- How would you rate your mental health these days? Excellent/very good/good/fair/poor.
IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp. Patients were categorized into three groups based on AUDIT score ranged from 0 to 12. Patients who scored 4 or more were grouped as “Hazardous drinkers,” patients scoring within 1–4 were categorized as drinkers, rest (score 0) were classified as teetotalers. Binge drinkers were identified by definition “Having more than four drinks in one go within a month.” Simple mean imputation method was adopted to substitute the missing values in household income for 23 individuals. Distribution of sociodemographic characteristics was explored across different drinking categories. Descriptive data on chronic illness, intention to quit, and self-reported health across different drinking categories were described. Univariate analysis (Chi-square test) was performed to identify any association between these variables and drinking habits. Multiple regressions were done to find out the predictors of hazardous drinkers.
| Results|| |
[Table 1] shows the distribution of study participants according to their sociodemographic characteristics. Thirty-eight percent (95% confidence interval [CI]: 33.5%–42.7%) of respondents were alcoholic and of those 60% (95% CI: 51.4%–66.5%) were hazardous drinkers. The mean age of the respondents was 39.9 (±15.1) years, and there was no difference in the mean age among teetotalers and alcoholic drinkers or hazardous drinkers. A quarter of respondents were smokers and more than one-third (36.2%; 31.8%–40.8%) smokeless tobacco users. One in five patients had a history of alcoholics in their family, and a similar proportion of participants were heavy workers.
Smokers were eight (adjusted odds ratio [AOR] =7.56; 4.03–14.52) times more likely to be alcoholic as compared to nonsmokers (P < 0.001); whereas, the prevalence of alcohol drinking was four times (AOR = 3.94; 2.25–6.92) higher in smokeless tobacco users compared to nonusers [Table 2]. Patients with self-reported higher job stress and those in the highest income quintile were twice (AOR = 2.13, 1.21–3.76) and thrice (AOR = 2.89, 1.19–7.04) more likely to be associated with alcoholism as compared to those with low job stress and in the lowest income quintile, respectively. Of those who were alcoholics, three-fourths (75.6%, 68.6–81.7%) of them had a frequency of drinking two or more times per week; and 83% had consumed alcohol within 1 month before the interview [Table 3]. Self-reported general health and mental health were significantly worse in hazardous drinkers as compared to others [Table 4].
|Table 2: Univariate and multivariate analysis for predictor determination (teetotaler vs. drinkers)|
Click here to view
On exploring about the intention to quit smoking, almost two-thirds (68.3%) responded that they had thought of quitting smoking, but only three-fourths of them had ever attempted to do so. Only 4% of alcoholics who had ever attempted quitting alcohol had consulted a physician for their advice [Figure 1].
| Discussion|| |
The burden of alcohol use poses a serious threat to the countries around the world. Globally, harmful use of alcohol causes approximately 3.3 million deaths every year, and 5.1% of the global burden of disease is attributable to alcohol consumption.
Our study delves around the prevalence of drinking, drinking patterns, and quitting behavior among the male patients visiting a primary health-care facility in a district of Odisha. A total of 431 male participants took part in the study. Only male participants were included in the study as the pilot study recorded very few female respondents. This could be because of the questions related to alcohol use and the social taboo associated with the same among women. The mean age of the study participants was about 40 years. The majority of the study participants were married and had education till secondary or higher secondary level.
The prevalence of alcohol consumption was found to be 38% among our study population, out of which about 60% were hazardous drinkers. In a similar study done across various parts of India, the prevalence of alcohol use was found to be between 23% and 73%. The study results also document the prevalence within the similar limits. The proportion of people in different groups of this spectrum of consumption varies considerably among different societies, population groups, and countries, and there are differences even among individuals within a district, state, or country. In the present study, 60% of the reported respondents who consumed alcohol were categorized as hazardous drinkers. This is a staggering number for any geography and poses a serious situation needing immediate attention. The prevalence of hazardous drinking was found to very high in our study even compared to the results of a study in Goa, where drinking is considered to be more prevalent.
Major attributes of alcohol drinking
Hazardous drinking has often been linked with psychological problems and violence as well as multimorbid conditions. The alcohol use and abuse is often linked with the age of initiation. Our study also looked into the age of initiation of alcohol use. The age of initiation reported by our study was about 23 years. The findings were similar to a study by Johnson et al. in a tertiary care hospital in Karnataka which reported the age of initiation to be 21 years. A community-based, cross-sectional study in Kolkata reported even lesser age of initiation of 20 years. Even though the age of initiation of alcohol in our study was comparatively higher than few other studies, what is worrying was the mean age of hazardous drinkers in the study which was 40 years. This indicates that the age gap between initiation of alcohol and transforming into a hazardous drinker is not very long. Moreover, studies have shown that hazardous drinkers have higher chances of being alcohol dependents. Our study also reported clustering of risk factors. There was a clear association between drinking and tobacco use. Smokers were eight times more likely to be alcoholics as compared to nonsmokers (P < 0.001); whereas, the prevalence of alcohol drinking was four times higher in smokeless tobacco users compared to nonusers. A study by Mohan et al. 2002 reported that tobacco users in India are more likely to start alcohol consumption over the follow-up period of 1 year. This is an added concern for Odisha where the prevalence of tobacco use is as high as 46%. Job stress and income also seemed to influence alcohol consumption as per the results of our study. Patients with self-reported higher job stress and those in the highest income quintile were twice and thrice more likely to be associated with alcoholism as compared to those with low job stress and in the lowest income quintile, respectively. A study by Roman PM  on work stress and alcohol use also found a similar relationship between job stress and alcohol use. Even though the information on stressors was self-reported, it should be noted that most of the life events considered in our study were objective and left little room for personal interpretation. Considering the relation between job stress and alcohol use, interventions such as counseling by professionals to cope with stress and quit alcohol may be found useful among alcohol users. Targeted prevention interventions could also be devised keeping such group of people in mind to be more effective. The study also tried to understand the pattern alcohol use among the respondents. The study found that majority of the respondents consume alcohol up to two or four times a week. The majority of respondents reported to have consumed alcohol within a month prior to the study. We also tried to understand the health-seeking behavior among the respondents who were reported alcoholics. The results showed that there was a significant association between hazardous drinking and consultation with physicians. This may be because of the fact that the drinkers identify with their drinking problem and want support so they can quit. The results were further supported by the fact that majority of drinkers had attempted to quit drinking. It was interesting to find that only about 4% of all the drinkers who attempted quitting consulted a physician. This opens a window of opportunity for the health-care systems to work toward assisting people in quitting the use of alcohol.
Advantages and policy implications
This study showed that majority of drinkers (68%) in the study had thought of drinking, while only 4% consulted a physician for the same. This could be because the health-care systems in our country currently focus mainly on providing tertiary care services for the treatment of dependence of alcohol. This focus needs to shift toward the cost-effective strategy of providing brief interventions for alcohol users desiring to quit. People should be made aware of the options that they may resort to if they desire to quit the drinking habit. Policy makers need to ensure that alcohol users are offered the most appropriate services such as structured advice/counseling and progress to specialist treatment services for more serious alcohol use disorders.
The present study was done only in one CHC of a district in Odisha; hence, the results may not be extrapolated to the whole population. Another limitation of the study is that the information in the study was self-reported by the participants. Even though the respondents reported life events, there is a chance of bias.
| Conclusion|| |
It is important to remember that focusing only on counseling and treatment services will not reduce the piling burden of alcohol use. Measures that target the drinking environment and the general population also need to be focused on. Integration of counseling for alcohol users should also be integrated into the National Tobacco Control Program where tobacco users are targeted. The frontline health-care workers such as the ASHA and anganwadi workers can also be sensitized to identify alcohol users in the community and assist them to quit the practice as well as refer them to the health-care facility for counseling. Such efforts can be more beneficial and cost-effective. It is important that more such studies are taken up including both male and female inpatient as well as outpatient section of both private and public health facilities including both tribal as well as nontribal communities.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]