1; Ladislav Csémy
Authors place of work:
Státní zdravotní ústav, Praha
1; Psychiatrické centrum Praha
Published in the journal:
Čas. Lék. čes. 2011; 150: 394-397
Aim: The aim of this work was to investigate subjective well-being, morbidity and healthcare needs of persons with hazardous, harmful and problematic alcohol consumption.
Methods: Data from a questionnaire-based survey performed on a representative sample of 2,221 persons (of these, 51.4% were men) aged 18 to 39 (average age 29.9, s.d. 5.8) were used for the analysis. The level of risk related to alcohol consumption was assessed through the screening questionnaire (the Alcohol Use Disorders Identification Test [AUDIT]) and categorization into 4 groups with critical scores of 8, 16 and 20 was applied to the analysis. The questionnaire focused on the respondents' drinking habits and health and their demographic, social, and psychological background and circumstances.
Results: The respondents' subjective assessment of their physical and mental health was varied significantly across the different score categories in AUDIT. Over one-quarter of the respondents falling in the category of harmful or problem drinkers rated their physical and/or mental health as poor or very poor. Compared to no-problem alcohol users, problem drinkers sought special help for emotional problems more frequently (3.1% vs. 21.3%; p<0.01); visited their doctors more frequently during the past year (3.1 vs. 4.8; p<0.05); had more episodes of illness (1.4 vs. 6.8; p<0.01), more days of sick leave (10.4 vs. 27.6; p<0.01); and were hospitalized more frequently (6.9% vs. 18.7%; p<0.01).
Discussion and conclusions: The results support/confirm the link between hazardous, harmful and problematic alcohol consumption on the one hand and the drinkers' perception of their health status and use of medical/healthcare services on the other hand. A modification of inappropriate consumption patterns through a short intervention by a general practitioner can lead to health improvement and reduction of the drinkers' healthcare costs, which are borne by the whole of society.
Key words: alcohol consumption, harmful drinking, AUDIT, morbidity, young adults
Based on recent
reviews, studies of the relationship between health and alcohol
consumption has focused on mortality depending on alcohol dose. Rehm
(1) cites 80 papers of this type in his meta-analysis. A
total of 60 diseases/health conditions are reported as being affected
by alcohol to a larger or lesser extent (2,3,4).
Chronic diseases in which alcohol is involved include, in particular,
tumorous diseases (especially cancer of the oral cavity, oesophagus
and liver), cardiovascular diseases (hypertension, coronary heart
diseases, cerebrovascular diseases), neuropsychiatric disorders
(epilepsy, depressions, dependence on alcohol) and gastrointestinal
tract diseases (especially alcoholic cirrhosis of the liver).
Relative mortality risks depending on gender and alcohol dosage have
been identified for the majority of these diseases (4).
the acute effects of alcohol, most attention is apparently paid to
injuries and health impacts of traffic accidents (5).
Studies devoted to
the impact of alcohol drinking on morbidity and on the quality of
life are less numerous. The reasons for this include mainly
methodological issues and the costs of such studies (6).
Murray and Lopez (6)
estimate the overall contribution of alcohol to annual mortality to
be 1.5 per cent. In view of the significant impact of alcohol on
health and mortality, questions arise as to what strategies could
reasonably limit such social and economic losses. Papers by Babor (7)
and by Anderson and Baumberg (8) summarise evidence for their
conclusions that mere raising of public awareness has little effect
and medical treatment of the consequences of alcohol drinking is very
costly and not very effective from the public health aspect. The
authors suggest that brief intervention in the primary health care
setting is an economically feasible and, at the same time, reasonably
efficient alternative. The efficiency and effectiveness of brief
interventions have been documented by several papers, including the
recent review by Bertholet et al. (9). According to the latter, eight
studies confirmed the effect of brief interventions, resulting in
weekly alcohol consumption reduction by 38 grams in average.
Screening and brief interventions are not unknown in the Czech
Republic either. Sovinova and Csémy (10) adapted one of the most
widespread screening instruments to the Czech setting and tested its
properties. As far as brief interventions are concerned, we
translated and published the World Health Organization guidelines
written by Babor and Higgins (11).
The aim of the
present study was to establish the level of risk related to alcohol
consumption, measured in a sample of young Czech adults aged 20 to 39
by using The Alcohol Use Disorders
Identification Test (AUDIT), and to analyse
the relationships between the risk level and the subjects' health
during the past year. This is the first study of this type conceived
and performed in the Czech Republic. We even found no paper in
international literature devoted to the relation between AUDIT
alcohol drinking categories and the individuals' health.
Study group. The
study group included 2,221 subjects aged 18 to 39 (mean age 29.9, STD
5.8). The sample was representative of the Czech population with
regards to gender, age, level of education and geographic
distribution. The parameters of the study group are summarized in
Table 1. The subjects were recruited by a two-step selection process.
The electoral districts were chosen in the first step. The Complex
Samples module was used to perform the stepwise selection, applying a
step calculated on the number of registered voters in each electoral
district (the number of registered voters is the measure of size in
the PPS systematic selection method), whereby the probability of
inclusion was identical for each voter. The stepwise selection was
performed for each administrative region independently (the
administrative region was the stratification variable), whereby
appropriate representation of all regions was assured. The required
number of electoral districts selected in each administrative region
was calculated proportionally with respect to the number of
registered voters in the region. In step two, the random walk
approach was used; interviewers sought respondents based on a quota
system within each electoral district selected. A total of 234
trained field interviewers were involved. Data was collected in
October and November 2009. From among the 2663 persons who were
invited to participate, 442 (16.3%) refused, mostly stating lack of
time as the reason.
Research tool. Data
was collected using a questionnaire specifically developed for this
survey. The questionnaire consisted of 61 questions, some of which
were broken down into sub-questions. Each respondent provided 206
pieces of data. The questionnaire as a whole was divided into four
general areas. The first part asked questions regarding the
respondent's relationship to alcohol; the remaining three parts were
concerned with the respondent's health, psycho-social adaptation, and
demographic data including information about the respondent's family
Data collection method.
Information was gathered during a controlled structured interview,
mostly conducted in the respondents' homes. From among the 2228
interviews accomplished, seven were finally eliminated because of a
relatively large number of unanswered questions.
Electronic data file
creation. Information in the questionnaires was rewritten into a
program Statistická analýza sociálních dat. The cleaned data set
was converted to an Statistical Package for Social Sciences (SPSS)
The risk level in relation to alcohol consumption was assessed using
the AUDIT screening questionnaire. Mean yearly alcohol consumption
(in litres of pure ethanol) was calculated based on the typical
frequency and amount for each type of alcoholic beverage. The
following health parameters were considered: subjective assessment of
physical and mental well-being; seeking of professional help due to
physical and mental health problems during the past 12 months; number
of medical examinations, episodes of illness, sick days and days of
inpatient care, all during the past 12 months.
Statistical analysis. Data
was processed by using SPSS ver. 16 software. The chi-square test was
used to examine the difference in the frequency distribution, and
variance analysis was applied to test the differences between the
The recommended critical
levels in the AUDIT screening questionnaire were used to categorise
the risk level as follows: score lower than 8: low risk; score
between 8 and 15: hazardous drinking; score between 16 and 19:
harmful drinking: score 20 or more: problem drinking or addiction.
The distribution of the study sample into those categories is shown
in Graph 1; 71% respondents fall in the low risk drinking category,
20.7% fall in the hazardous drinking category, 4.4% fall in the
harmful drinking category, and 3.6% fall in the high risk (problem)
drinking category. The total average yearly alcohol consumption
matches the risk levels. The average consumption is 4.8 litres of
100% alcohol in the low risk drinkers group and increases rapidly and
linearly up to 38.8 litres in the problem drinkers group.
and mental well-being depending on the risk level differed
statistically significantly (p<0.001) for both genders. It was
particularly problem drinkers who reported impaired somatic and/or
mental well-being with increased frequency. Graph 2 shows clearly
that over one-fifth of the problem drinkers assessed their mental and
physical well-being as poor or very poor.
regarding how the subjects were actively seeking medical or other
professional help is summarised in Table 1. While the categories did
not differ in the extent to which the respondents sought medical help
for physical problems, the need for professional help for mental
problems was considerably different; it was particularly in the
problem drinking group that the respondents sought professional help
to a several times larger extent than in the lower-risk groups.
Table 2 summarises data
regarding the average number of visits to a doctor, average number of
diseases and days of illness during the past 12 months, and inpatient
hospital care. Statistically significant differences among the
different risk groups were identified for all of these variables. The
average number of visits to a doctor was three for the whole sample
and 4.8 in the problem drinkers group. The latter group also
exhibited a larger number of cases of illness during the past 12
months. Problem drinkers were ill 6.8 times on average, as against
the 1.3 times in the whole sample. As regards the days-of-illness
variable, elevated levels were found even in the harmful drinking
group (13.8 days) and were considerably higher in the problem
drinkers group (27.6 days). (The critical level F and the statistical
significance of the difference are included in Table 2.) The number
of hospitalisations was roughly triple in the harmful and problem
drinking groups as compared to the lower-risk groups (15.4% and 18.7%
respectively, against 6.9% and 5.9%; P<0.001).
While the vast majority of
publications in this area are concerned with specific health impacts
(such as mortality for selected diagnoses) particularly depending on
the alcohol dosage (4), it was the aim of this study to find whether
the risk level measured by a screening test whose score includes, in
addition to drinking habits, symptoms of problem drinking and
consequences of drinking, is reflected in the general well-being and
health of young adults. The results of the study show that harmful
and problem drinking does indeed have measurable impacts on the
well-being (health) of young adults. Individuals who drink alcohol
excessively seek medical help more frequently, are ill more
frequently, have a larger number of sick days and are more frequently
admitted to hospital as inpatients.
Health is generally
also affected by other lifestyle factors, such as lack of physical
activity, unsuitable diet, being overweight and, in particular,
smoking. Regarding habitual smoking, interaction with alcohol
consumption should be considered because smoking correlates with
drinking. There were 31% daily smokers in the study sample as a whole
and 22% in the low risk group. This suggests that to some extent,
smoking will affect the health of the subjects in all drinking-risk
groups. Therefore, we also performed analyses controlling for the
smoking factor. The effect of alcohol consumption on health remained
significant even when the effect of smoking was eliminated.
In our opinion, this
study has two important practical implications. Firstly, the results
show that the drinking risk levels measured by a simple screening
questionnaire relate to health, hence, that the screening instrument
can be applied for identification of the risk level. Secondly, brief
advice or brief intervention aimed at reducing hazardous or harmful
drinking can be implemented in the primary care setting and such
advice or interventions are meaningful even in the hazardous drinking
category where the health impacts are still minimal and no severe
impairment is observed (12, 13, 14). Identification of problem
drinking by means of the AUDIT questionnaire can prompt the
practitioner to refer the patient to specialised medical care.
Early identification of
alcohol problems and brief intervention can result in improved health
and cost savings in the specialised treatment of diseases that are
contributed to by excessive drinking.
This work was supported by
Grant # NS 9645-4/2008/ from IGA MZ CR.
Affiliation of the senior
author: Hana Sovinová, MD Státní zdravotní ústav Šrobárova 48 100 42 Praha 10 firstname.lastname@example.org Phone: 267082328
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