TECHNICAL REPORT
PATTERN AND CORRELATES OF ALCOHOL USE AMONG OUTDOOR SOCIAL DRINKERS IN PUBLIC DRINKING PLACES IN IBADAN Principal investigator LASEBIKAN VO, PhD, MPH, MSc, FWACP Department of Psychiatry, College of Medicine, University of Ibadan Email:
[email protected] or
[email protected] Phone: +2348060733382 Co-Investigators Ayinde OO MBBS,FWACP, Department of Psychiatry, University College Hospital, Ibadan Ojediran B MBBS, FWACP, Department of Psychiatry, University College Hospital, Ibadan Oladele O MBBS, MWACP, Department of Psychiatry, University College Hospital, Ibadan Adeitan O MBBS, M.Sc MWACP, Department of Psychiatry, University College Hospital, Ibadan
This work was funded from the “Endowment Fund for the Promotion of Mental Health and Neurosciences in Nigeria, Neuropsychiatric Hospital Aro, Abeoukuta, Nigeria”.
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ABSTRACT There are growing research evidence that alcohol consumption is increasing in Nigeria. In this community -based study, 1, 310 subjects were interviewed. They were selected from 22 social joints randomly selected from the 11 local government areas of Ibadan by snowballing. The main aim of the study was to evaluate the pattern and correlates of alcohol use in public drinking places in Ibadan, Nigeria A mixed qualitative and quantitative approach was used to obtain information about their drinking pattern. Results show that of the 1119 respondents, 91.7% were current drinkers. Prevalence of hazardous & harmful drinking was 21.7% and alcohol dependence 1.8% . Social drinkers were predominantly men, those who were married and were in employment. None of them had ever sought treatment for their alcohol use. There was a widespread reluctance by the participants to be followed up for further evaluation. There is a need for further exploration of these research findings.
Keyword: Alcohol consumption, social-joints, hazardous drinking, reluctance for treatment
PROBLEM STATEMENT AND PROJECT RATIONALE Alcohol use and abuse have long been a worldwide public health problem1 affecting different segments of the population with multiple harmful effects in different domains, including physical, mental and social wellbeing.2 Reports have indicated that alcohol use in Nigeria is on the increase for different social and economic reasons. 3 Studies in Nigeria have also indicated that binge drinking, which has been identified as one of the most dangerous pattern of alcohol consumption, 4 is the characteristic pattern of drinking in Nigeria.5 Binge drinking, the consumption of large quantities of alcohol at a single session resulting in intoxication has been defined variously by different authors, but Lasebikan and Adebayo 6 defined binge drinking as “taking 5 or more drinks (for men) or 4 or more drinks (for women) on one occasion”. This pattern of drinking is
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most often seen at commercial motor parks 7,8 and public drinking places popularly known as ‘drinking joints’ in Nigeria. Binge drinking has been associated with increasing road traffic accident rates among commercial drivers and has been a major focus of traffic regulating agencies throughout the world, including the Federal Road safety commission (FRSC), the body charged with the responsibility of providing safety on Nigerian roads. Road traffic acciden ts claim lives and cost enormous amounts in treatment and preventable suffering for families of bread winners who lose their lives. The World Health Organisation has shown over the years to be intensely interested in both alcohol use problems and Road traffic accidents, both epidemics of some sort.9 Other recognised harmful effects of binge drinking include multiple organ damage, violent crimes and poor long term psychosocial outcomes.2,10 A study from Russia 11 found a high correlation between the daily distribution of deaths due to alcohol and homicide. The authors also found that the number of alcohol deaths was significantly higher on Saturdays and Sundays (presumably as a result of drinking on Friday and Saturday nights) and the number of homicide deaths was significantly higher on Fridays and Saturdays. Pattern and type of alcohol use ultimately determines the long and short term effects of the substance, including acute intoxication, which is important in binge drinking and its relationship to increased road traffic accidents. Beverage of choice in Nigeria was palm wine12 but this is gradually being replaced by several local alcoholic herbal mixtures with yet undetermined but suspected to be high alcoholic content, with potential for rapid inebriation.13 Pattern of alcohol consumption has been studied in different settings in Nigeria 14–16 but none has focused on drinkers at public places where drinkers
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have the double disadvantage of driving themselves to these joints and having to drive back home at night under the cover of darkness. It is therefore important to study both the pattern of and preferred drink of choice among this population. This may eventually translate into policy, as it has in some developed climes where the purchase of alcohol is tied to on-the-spot breath alcohol content, and the higher the breath content, the more a consumer pays, up to a certain level where he may not be able to purchase more. This may also lead to legislations mandating beer manufacturer to display educational materials on the harmful effects of unsafe alcohol consumption at public drinking places, first in Nigeria and other countries beyond our shores. The overall aim of the research was to determine the prevalence of alcohol use and alcohol use disorders and their correlates among outdoor public social drinkers in Ibadan, Nigeria
METHODS Setting of study and background information on area The study area is Ibadan, capital of Oyo state, Nigeria. The city is located in the southwestern part of the country. It has a population of about 2.5 million people as at 2009. Ibadan is divided into eleven local government areas. 17 Ethical considerations 1. Ethical approval was obtained from the Ethical Review Committee of the Department of Planning, Research and Statistics, Ministry of Health, Oyo state to ensure adherence to proper ethical standard. 4
2. Informed consent was also obtained from each participant in the study. 3. Participants were also duly informed of the objectives of the study. 4. Anonymity was maintained during the entire study period, from period of data collection to include data entry and analysis. Procedure A mixed methods study design was utilized in two phases: Phase I: Qualitative data collection Phase II: Quantitative data collection Phase I (Qualitative): This consists of a Focus Group Discussions (FGD), Key Informant Interviews (KII) and Direct Observation. Sampling Procedure All drinking joints in all the 11 local governments in Ibadan were listed according to ward in each local government. Thereafter, 1joint was randomly selected from each of the wards in the local government. Since there were 2 wards in each enumeration area, a total of 22 drinking joints spanning the 11 local governments in the state was randomly -selected for the study. Based on the cosmopolitan distributions of the joints, the 22 joints were thereafter grouped into rural joints, semi-urban joints and urban joints. Focus Group Discussions: Five sets of FGDs at randomly selected ‘joints’, with 6-8 participants in each set were carried out with the overall aim of eliciting views on 5
alcohol use patterns among social drinking joints patrons. The exact composition and number in each group was determined by the principle of “pragmatic redundancy” where data collection was stopped when teams were satisfied that core beliefs had been represented and no new information was obtainable (data saturation). The preferred alcohol beverage and reasons for the preference, perceived safe quantity of alcohol, possible harms, alcohol use legislations and reasons for the continued popula rity of social drinking joints were explored. The timing of the focus group was such that it did not interfere with their work or other private issues. The moderator was the PI who is an addiction specialist and also versatile on the topic. Each session commenced by welcoming all participants and appreciating them for participating. This was followed by the introduction of the moderator, the purpose of the FGD and the ground rules. The ground rules were: participants did the talking, there was no yes or no answers, information divulged was kept confidential, and all activities were tape recorded. All the sessions, including other activities, body language and other subtle clues were also recorded. Snacks were served at each session and free blood pressure measurement was also carried out as incentives. Immediately after all participants left, the PI and other coinvestigators had a quick debriefing while the recorder was still running. All tapes and notes were labelled with date, time and name of the group. Key Informant Interviews: Experienced night club owners and drinking joints were also interviewed on the above issues.
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Direct Observation: An observational checklist of alcohol selling activities within and around the social joint was also conducted. Analysis: Data analysis, commenced during the period of data collection in the field. The data were initially collated into broad themes in a matrix by the researcher and thereafter transcribed at the end of each day to identify emerging themes that were explored during further focus groups and with participants. A further thematic analysis was conducted aimed at unitizing the data. This was carried out by two independent analysts. The analysis included categorizing of themes, identification of associations between themes and subthemes, search for outlier examples, intervening variables and triangulation with other data sources. The two analysts thereafter reconciled their data and thereafter came to a consensus opinion on issues of discussion. Quotes were also reported after the data collection.
Phase II (Quantitative): A multistage random sampling technique was employed at this stage.
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Sample size Minimum sample size was obtained from sample standard size table, (Research Advisors).18 Thus, for a total population of 2.5Million people in Ibadan,17 at 95% confidence interval (0.05 error margin), the minimum sample size is 384. 18 However, considering the usual low response rate known among addiction researchers, we proposed to interview all consenting adults encountered at the drinking places between the hours of 5pm and 6pm. We interviewed 1308 participants in all, however, data was complete for only 1,119 among whom analyses were performed. Sampling Procedure The 11 local governments in Ibadan were divided to wards, 2 wards were randomly selected from each local government. The wards were further divided to enumeration areas, one enumeration area was randomly selected from each of the selected ward and a drinking joint, randomly selected from each enumeration area thereby giving a total of 22 drinking joints spanning the 11 local governments in the state.
Participants were
recruited into the study by snowballing. Measures Socio-demographic questionnaire was used to obtain information on sociodemographic characteristics such as age, sex, religion, marital status and occupation
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The Alcohol Use Disorder Identification Test (AUDIT) The AUDIT was developed to provide an accurate measure of risk across gender, age and culture.19 The AUDIT has the advantage of having cross cultural standardization, identifies harmful and hazardous alcohol use and is consistent with ICD 10 harmful alcohol use and dependence syndrome. It is very brief, rapid and flexible. Questions 1 to 3 captures hazardous alcohol use, 4 to 6, dependence and 7 to 10 harmful use. Each question is rated from 0 to 4. A score of 8 or more is indicative of hazardous and harmful alcohol use and possible dependence. Among respondents older than 65 years, a cutoff point of 7 is recommended. Intervention: scores of 0 to 7 are categorized as zone I in terms of health risk, and the intervention required is alcohol education, scores 8-15 are categorized as zone II and the intervention is simple advice, scores 16 to 19 are categorized under zone II health risk and the intervention required is simple advice pus brief counseling and continued monitoring, while a score of 20 and above is categorized under zone IV risk level and the required intervention id referral to specialist hospital for diagnostic evaluation and treatment. Supplementary questions were also generated from the first phase of the project and from extensive review of the literature on the subject matter. These include preferred alcoholic beverage, views on alcohol use legislation and enforcement, etc. Analysis: The data generated were entered, cleaned and thereafter analysed using the Statistical Package for the Social Sciences (SPSS) version 16.0. Further explorations of the data will be conducted using the same statistical package
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In the course of the survey, a brief intervention consisting of five minutes of simple advice was carried out on those with hazardous drinking. Identified subjects with moderate to severe drinking problems (scores 8 and above) were advised to seek medical intervention. Telephone numbers of all participants were collected to ensure follow up. The interviewers had been involved in field surveys. They had received a 2-week training consisting of an initial 3-day training by the principal investigator followed by a further 2 days of debriefing and review after each interviewer had conducted two pilot interviews in the field.
A supervisor was responsible, who ensured that every
questionnaire was returned by those interviewers for completeness and consistency. Field checks were made to ensure the correct implementation of the protocol and full adherence to the interview format. We also collected the GSM telephone numbers of participants RESULTS One thousand, three hundred and ten participants were interviewed, out of which 1, 256 were drinkers, however, data were complete for only 1,119, therefore analyses were performed on these 1,119 men and women. The demographic and clinical data of the participants are in tables 1 to 2 and figures I to V. The results show that drinking in social joints, cuts across all ages, although less reported among the elderly. A higher proportion of drinkers were men and rural/ semi-rural dwellers. Drinking Prevalence of hazardous/harmful use of alcohol was 21.7%, and alcohol dependence 1.8%. Beer was the first choice of beverage in 64.0%, None of the participants had ever sought treatment for their alcohol use in the past. 10
Table 1 Demographic Distribution of Respondents Age group < 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-77 Gender Male Female Education No Formal Elementary Secondary Post- secondary Employment In Employment Unemployed Dwelling Area Rural/Semi-rural Urban Marital Status Married Not Married Religion Islam Christianity Ethnicity Yoruba Igbo Hausa Others
Frequency 127 144 166 180 148 124 100 52 46 32
Percent 11.3 12.9 14.8 16.1 13.2 11.1 8.9 4.6 4.1 2.9
826 293
73.8 26.2
78 286 253 502
7.0 25.6 22.6 44.9
959 162
85.5 14.5
620 499
55.4 44.6
634 484
56.7 43.3
406 713
36.3 63.7
658 235 36 190
58.8 21.0 3.2 17.0
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Table 2: Profile of Drinking Pattern and Hazardous Consumption Frequency Alcohol Use Never No Hazard or Harmful Use Hazardous & Harmful Use Dependence Alcohol Beverage Type Beer Distilled Spirit Wine Palm wine Local brew (Sorghum) Local brew (Sepe)
Percent
93 763 243 20
8.3 68.2 21.7 1.8
716 110 45 106 37 105
64,0 9.8 4.0 9.5 3.3 9.4
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Results at a Glance
Figure I: Gender of Participants
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Figure II: Hazardous Drinking
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Fig III: First Choice of Alcohol Beverage (%)
FIG IV: Dwelling Area (%)
Dwelling Area
44.6 55.4
Rural/Sem-rural
Urban
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Results of Qualitative Analysis Direct Observation Alcohol use was widespread and use of fermented local beverages referred to as ‘sepe’, ‘paraga’, ‘jedi’, ‘ale’, ‘afato’ and bland locally prepared liquor (‘ogogoro’) was also high. Also observed was sorghum and ‘pito’. There appears to be no laws guiding hours of sales of alcohol and drinking according to our survey Focus Group Discussion Bodija (Urban area) A senior police man:- “Alcohol consumption has taken a new dimension in Ibadan, Nigeria. You need to drive round the city, you will discover that by 2 pm I the afternoon, alcohol vendors would have arranged their platform which quite often are open places. The interesting thing is that all forms of drinkers engage in health competition in games such as ludo, “ayo”, chess, etc. and on rare occasions had violence been reported”.
Molete (Semi-rural Joint) As found in other joints, alcohol was used for recreation and to ‘create a feeling of euphoria’ among them. The respondents reported that they are aware that alcohol if used for a prolonged period could cause health problems, and household financial problems.
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Some of the participants reported that, given the context of financial difficulties, local alcohol brewing was an important source of income for many brewers. A brewer: "It is generational for us in our culture to brew local alcohol, and there is always a high demand for it."
Discussion
In this community based study aimed at determining the profile of drinking pattern among social drinkers in drinking joints in Nigeria, our findings briefly stated show that social drinking is cuts across all ages, most especially, in the middle ages. Men were twice more likely to be social drinkers, and two out of every five respondents met criteria for hazardous drinking. Results from the qualitative studies tended to favour the quantitative assessments.
This is a preliminary report on the findings from this study, to the best of our knowledge, the first of its kind in Nigeria. Although the full analysis has been conducted, our findings will soon be published. Nevertheless, the results of our findings have thus far brought a number of suggestions to us. Firstly, the demography of social drinkers in public joints tend to differ from previous studies from in other settings. For example, strikingly, a higher proportion of social drinkers were married and in employment. Secondly, the emergence of new local brews, although not the first beverage of choice is rapidly growing. Thirdly, Less than a quarter
of the respondents were
harmful/hazardous users and only 1.8% had alcohol dependence. By implication, this group of individuals is at risk of further consequences of alcohol consumption. 17
Given the steady growth of such social joints in Nigeria and insensitivity of the government to control hours of sale of alcohol and other effective alcohol control policies, findings from the current study is an “eye-opener” to a growing epidemiology of alcohol misuse in Nigeria.
Conflict of Interest: None Funding: This work was funded from the “Endowment Fund for the Promotion of Mental Health and Neurosciences in Nigeria, Neuropsychiatric Hospital Aro, Abeoukuta”.
Acknowledgements All, participants and our secretarial staff, most especially, Christie Alabi
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