Family Medicine & Primary Health Care, Sefako Makgatho Health Sciences University, Pretoria, South Africa
According to the World Health Organisation (WHO), there were 3.3 million deaths globally due to alcohol use in 2012. Establishing patients’ knowledge of safe alcohol use and practices regarding alcohol consumption could reform intervention policies.
The aim of this study was to assess patients’ knowledge of safe alcohol use and practices regarding alcohol consumption among patients attending the Family Practice Clinic at Dr. George Mukhari Academic Hospital (DGMAH) in Pretoria.
The sample consisted of 300 patients (150 males; 150 females). Data relating to patients’ baseline characteristics, knowledge of safe alcohol use and practice were collected by means of a researcher administered questionnaire. The SAS, Release 9.3 was used for data analysis. The statistical level of significance was set at p < 0.05.
Majority of the respondents had lack of knowledge on safe quantities of alcohol use per day, for male and female individuals [268 (89.3%) vs 32 (10.7%); p < 0.0001] and [279 (93.0%) vs 21 (7.0%); p < 0.0001], respectively. Respondents mostly consumed alcohol on special occasions (152; 50.7%), and on weekends (100; 33.3%). Age groups ≥ 38 years consumed more alcohol per day (100; 33.3%). Majority of the respondents (179; 59.7%) were binge drinkers. Relatively less patients with higher levels of education were chronic harmful users of alcohol (p ≤ 0.001).
The finding that majority of the patients lacked knowledge on safe quantities of alcohol use for males and females, and the unsafe use of alcohol, including binge drinking, warrant introduction of safe alcohol use awareness campaigns at primary health care, particularly targeting the middle aged and the elderly.
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According to the report by the WHO in 2015, 3.3 million deaths per annum worldwide were associated with alcohol abuse. Globally, over 200 diseases and injuries were att-ributable to alcohol abuse, which represented 5.1% of the global burden of disease. Furthermore, about 5.9% of all global deaths and almost 25% of all deaths between the ages of 20-39 years were attributable to excessive alcohol consumption [1World Health Organisation. Global status report on alcohol, 2015. [Retrieved 2018 Aug 01]. Available from: http: www. who. int/ mediacentre/ fact sheet/ fs349/en].
The effects of harmful alcohol use, including liver cirr-hosis, pancreatitis, susceptibility to infections, various mali-gnancies and interpersonal violence, have been reported in the literature world-wide [2Centre for Disease Control and Prevention. National centre for chronic disease prevention and health promotion. Alcohol and Public Health, 2016. [Retrieved 2018 February 14]. Available from: https://www. cdc. gov/ alcohol/ faqs.htm-4Rehm J, Anderson P, Kanteres F, et al. Alcohol, Social Development and Infectious disease. BMC Public Health. 2011. [Retrieved 2018 Jul 23] Available from: https://sverigesradio. se/ diverse/ appdata/ isidor/files/83/7020.pdf]. It has also been shown that alcohol is a psychoactive substance with dependence-pro-ducing properties and that it is associated with violence, marital breakup and spouse abuse [5Centre for Disease Control and Prevention. Alcohol and Public Health, 2015. [Retrieved 2018 Aug 25] Available from: http://www.cdc.gov]. It also leads to poor life quality of individuals in general as it leads to poor productivity [5Centre for Disease Control and Prevention. Alcohol and Public Health, 2015. [Retrieved 2018 Aug 25] Available from: http://www.cdc.gov].
It has been reported that the fifth leading cause of death in South Africa is harmful alcohol use and that the country has a high rate of foetal alcohol disorders, affecting at least 500 000 South Africans country-wide [6University of Cape Town. Urbanization and disease: alcoholism in South Africa, 2011. [Retrieved 2018 Jul 15]. Available from: pathology.uct.ac.za [accessed 19 March 2016]]. Furthermore, drunk driving has been found to be responsible for up to half of all road accidents in South Africa [7Online Road Safety Awareness. Drunk driving and road safety, 2016. [Retrieved 2018 March 27] Available from: http:arrivealive.co.za], making this practice one of the biggest threats to road safety in South Africa.
In 1984, Ewing devised a tool which he abbreviated “CAGE” to assess chronic harmful alcohol use. Using this tool, respondents are asked four close-ended questions: (1) if s/he has the feeling to cut (C) down on alcohol consumption, (2) has been annoyed (A) by critics for his/her alcohol consumption, (3) ever felt guilty (G) about his/her alcohol consumption and (4) needs a drink to steady the nerves on waking up in the morning (eye-opening), hence E. A “Yes” in any of the questions asked is allocated 1 mark. A score of ≤ 1 indicated “non-harmful alcohol use” while a score ≥ 2 indicates “harmful alcohol use [8Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984; 252(14): 1905-7. [http://dx.doi.org/10.1001/jama.1984.03350140051025] [PMID: 6471 323] ]. In addition to the definition of harmful alcohol use according to the CAGE assessment, binge drinking has been defined as taking above four drinks (alcohol standards) in one occasion regardless of the sex [9Degenhardt L, O’Loughlin C, Swift W, et al. The persistence of adolescent binge drinking into adulthood: Findings from a 15-year prospective cohort study. BMJ Open 2013; 3(8)e003015 [http://dx.doi.org/10.1136/bmjopen-2013-003015] [PMID: 23959750] ].
According to the report by the WHO in 2015, health educators and researchers employ different definitions of a standard drink (a notional drink that contains a specific amount of pure alcohol) because of differences in the typical serving sizes in various countries [5Centre for Disease Control and Prevention. Alcohol and Public Health, 2015. [Retrieved 2018 Aug 25] Available from: http://www.cdc.gov] To this effect, one standard drink in Canada = 13.6 g of pure alcohol, in the UK = 8 g, in the USA = 14 g, in Australia and New Zealand = 10g and in Japan = 19.75 g. However, according to the guidelines provided by Fabor on alcohol use at primary care, the amount of alcohol contained in a standard drink is the conversion factor of ethanol and allows for conversion of any volume of alcohol into grams. For each millilitre of ethanol, there are 0.79 grams of pure ethanol. For example, one can of beer (330ml) at 5% (strength) x 0.79 (conversion factor) = 13 grams of ethanol [10Fabor TF. “The alcohol use disorders identification test: Guideline for use in primary care”. World Health Organization: department of mental health and substance dependence. 2nd edition, 2001. [Retrieved 2018 September 23]. Available from: http://www. who. int/ iris/ handle/ 10665/ 67205]. Using this formula, a glass of wine (140 ml at 12% ethanol) and a shot of spirit (40 ml at 40% ethanol) represent a standard drink of about 13 g of ethanol.
Most studies conducted on knowledge regarding alcohol quantities and use focussed on the general public [11Ipsos MRBI. Alcohol: Public knowledge, attitudes and behaviours (Report, 2012). [Retrieved 2018 Sept 05]. Available from: http://www.drugs.ie/resourcesfiles/reports/Alcohol_Public_Knowledge_Attitudes_and_Behaviours_Report.pdf], health workers and health worker trainees [12Welsh C, Earley K, Delahanty J, et al. Residents’ knowledge of standard drink equivalents: Implications for screening and brief intervention for at-risk alcohol use. Am J Addict 2014; 23(2): 194-6. [http://dx.doi.org/10.1111/j.1521-0391.2013.12080.x] [PMID: 2411 2850] ] and learners [13White AM, Kraus CL, Flom JD, et al. College students lack knowledge of standard drink volumes: Implications for definitions of risky drinking based on survey data. Alcohol Clin Exp Res 2005; 29(4): 631-8. [http://dx.doi.org/10.1097/01.ALC.0000158836.77407.E6] [PMID: 15834229] , 14Mogotsi M, Nel K, Basson W, Tebele C. Alcohol Use by Students at an Emerging University in South Africa. Int J Sociol Anthropol 2017; 5(2): 187-95. [http://dx.doi.org/10.1080/09766634.2014.11885623] ]. However, the study by Sprague and Vinson in the USA on primary health care patients’ knowledge on risky alcohol drinking revealed that 21% screened positive for risky drinking and only 10% correctly estimated daily low risks limits and 9% weekly limits. Patients with a positive screen were twice as likely to say that they knew what a standard drink was, but only 33.3% gave accurate estimates [15Sprague DJ, Vinson DC. Patient perceptions of risky drinking: Knowledge of daily and weekly low-risk guidelines and standard drink sizes. Subst Abus 2017; 38(3): 253-6. [http://dx.doi.org/10.1080/08897077.2015.1048922] [PMID: 26155 748] ].
This study sought to assess patients’ knowledge of safe alcohol use and practices regarding alcohol consumption among patients attending the Family Practice Clinic at DGMAH in Pretoria. The finding that patients at primary health care lacked knowledge on safe alcohol consumption and had unsafe alcohol consumption practices could be used by policy makers as evidence to raise awareness on the various local brands of alcohol at patients’ disposal. The various alcohol types, and the frequency of alcohol use in relation to patients’ demographic characteristics could be used as context on which policies are based. It is hoped that the study findings will assist in curbing unsafe alcohol use among patients.
1.1. Significance of the Study
While working at the Family Practice Clinic at Dr. George Mukhari Academic Hospital (DGMAH) the main researcher observed that during social history taking, patients showed lack of knowledge regarding safe alcohol ingestion according to the individual’s sex, as well as the maximum number of days per week that alcohol can be consumed for, without causing harm to their health. This observation prompted to conduct an assessment on their knowledge and practices regarding alcohol use.
1.2. Ethical Considerations
The study commenced after obtaining ethics clearance from the Sefako Makgatho Health Sciences University Research Ethics Committee (SMUREC) in Pretoria, South Africa (Clearance Certificate number: SMUREC/M/ 203/ 2016:PG). Permission from DGMAH Chief Executive Officer and the Head of Department in charge of the Family Practice Clinic was obtained. Participation was voluntary and written informed consent, in both English and Setswana languages was completed by each consenting respondent.
2. MATERIALS AND METHODOLOGY
2.1. Definition of Safe Alcohol Use
Moderate / non-harmful alcohol consumption is defined as having up to one standard drink per day for women and up to two per day for men. This is the amount to be consumed on any single day [5Centre for Disease Control and Prevention. Alcohol and Public Health, 2015. [Retrieved 2018 Aug 25] Available from: http://www.cdc.gov]. The WHO recommended low-risk alcohol drinking levels as no more than 20 grams of alcohol per day, taken five days a week (hence, recommending two non-drinking days per week of seven days) [10Fabor TF. “The alcohol use disorders identification test: Guideline for use in primary care”. World Health Organization: department of mental health and substance dependence. 2nd edition, 2001. [Retrieved 2018 September 23]. Available from: http://www. who. int/ iris/ handle/ 10665/ 67205].
2.2. Study Aim and Objectives
The study aim was to assess the knowledge and practices of patients using alcohol regarding safe alcohol use at DGMAH. The objectives were to evaluate their knowledge regarding safe alcohol consumption, their alcohol consumption practices and to assess the relationship between their know-ledge and practices of alcohol use and selected demographic characteristics.
2.3. Study Design
This was a cross-sectional study.
2.4. Study Setting
The study was carried out at the Family Practice Clinic of DGMAH, a tertiary hospital in Pretoria, South Africa. At the time of writing of this article, the Family Practice Clinic served as a gateway clinic for the tertiary hospital whereby patients were treated as outpatients, and those requiring secondary and tertiary levels of health care were referred to appropriate disciplines within the hospital. All the patients that attended this clinic were primary health care patients referred from the neighboring Community Health Centres (CHCs) and clinics of GaRankuwa and Soshanguve townships, with the combined population of 750,000.00 [16South African Census. [Retrieved 2018 September]. Available from: http://www.statssa.gov.za/?page_id=3839].
2.5. Study population and Sampling Strategy
The study population were all the patients who attended the Family Practice Clinic of DGMAH. In Sub-Saharan Africa, the prevalence of alcohol drinking has been estimated at 25.1% [17Morojele N, Nkosi S, Kekwaletswe CT, et al. Review alcohol and HIV in Sub- Saharan Africa. South African Medical Research Council and Department of Health 2013. [Retrieved 2018 January 24]. Available from: http://www.mrc.ac.za/sites/default/files/attachments/2016-06-27/AlcoholSubSaharan.pdf]. In South Africa, Peltzer and Ramlagan reported the prevalence of alcohol use in the general population as ranging from 16-40% [18Peltzer K, Ramlagan S. Alcohol use trends in South Africa. J Soc Sci 2009; 18(1): 1-12.]. Given this range (average 28%), the researchers regarded the reported prevalence of 25.1% as a reasonable estimate. According to the clinic register, the monthly average intake of patients who attended the Family Practice Clinic at DGMAH were 1820 patients. Using the prevalence of 25.1%, the estimated number of patients drinking alcohol who attended the clinic was about 455 (1820 x 25.1%) per month. With a sample size of 300 patients, a two-sided 95% confidence interval for the percentage of patients who had knowledge about alcohol use and its harmful effects was within ± 2% of the percentage to be calculated from the sample of 455 patients, assuming that the percentage was 10%. Sample size calculation was done on nQuery Advisor (Statistical Solutions Limited, Cork, Ireland), Release 7.0 and was based on the large sample normal approximation of the binomial distribution adjusted for a finite population of 455. Sampling occurred from 2nd of January to the 31st March 2017. Each patient who admitted to using alcohol and who consented to participate was included in the study. Assuming that the patients presented in a random order, the sample may be considered as a random sample of the target population.
2.6. Data Collection
The research team consisting of the main researcher and two research assistants, collected data using an adapted ques-tionnaire issued in English, IsiZulu and Setswana languages, the latter two being the dominant African languages spoken in the study setting. The researcher administered questionnaire was formulated using questions from WHO on the Alcohol Use Disorders Identification Test (AUDIT) [19World Health Organization. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva, 2001 [Retrieved 2018 May 15]. Available from: http://apps. who. int/ iris/ handle/ 10665/ 67205] and Michigan Alcohol Screening Test (MAST) issued by National Council on Alcoholism of the San Fernando Valley (NCADD) [20The NCADD of the San Fernando Valley. 2018. [Retrieved 2018 July 18]. Available from: https://www.ncadd-sfv.org/]. The AUDIT questions were adapted and used in the four questions relating to the section on “Practices of patients using alcohol”. The Michigan Alcohol Screening Test (MAST) was integrated in the CAGE questions. The questions in the section on “Knowledge of patients using alcohol on harmful alcohol consumption” were developed de novo by the main researcher to address the study aim and objectives. The CAGE tool explained above was used to assess chronic harmful alcohol use for each patient.
2.7. Data Analysis
Descriptive data were presented as frequency tables. The SAS (SAS Institute Inc, Carey, NC, USA), Release 9.3 was used for data analysis. Univariate analyses of the baseline characteristics and bivariate statistical analyses of dependent and independent variables for associations using the Chi-square test were done. The statistical level of significance was set at p-value < 0.05. Data analysis was done through the guidance of a statistician.
3.1. Baseline Characteristics
Table 1 demonstrates that the mean age of the respondents was 49.9 years with a standard deviation of 13.8 years. Respondents above 57 years old (100; 33.3%) constituted the largest age-group, while those 18-27 years constituted the smallest age-group (17; 5.7%). The sex distribution comprised of an equal proportion of male to female patients (150; 50.0%). Regarding marital status, almost half (149; 49.7%) of the respondents were single, followed by the married (128; 42.7%). The dominant highest level of formal education was the secondary school education.
Table 1 Baseline Characteristics (n=300).
Table 2 Respondents’ knowledge about safe quantities of alcohol consumption (n=300).
Table 3 Reported types of alcohol consumption and occasions of consumption (n=300).
3.2. Knowledge about Safe Alcohol Consumption
Table 2 shows that the proportion of respondents who reported to know the maximum number of drinks per day that a male individual can take without causing harm to health (10.7%), was significantly lower than a chance outcome of 50% (z test, p < 0.0001). Likewise, the percentage of patients who knew the maximum number of drinks per day (7.0%) for a female individual, was significantly lower than a chance outcome of 50% (z test p < 0.0001). The respondents who did not know the maximum number of days per week that an individual can take alcohol for without causing harm to their health was also significantly low (13.3%), z test, p < 0.0001. Ninety-five percent Confidence Intervals (CI) were calculated for the percentage knowledge (“Yes”).
3.3. Practices about Harmful Alcohol Consumption
3.3.1. Types of Alcohol and Occasions of Consumption
Table 3 shows that amongst all the alcohol types reported consumed, beer 145 (48.3%) and cider 94 (31.3%) accounted for more than 79%. Regarding the reported occasions of consumption, consumption occurred mostly on special occasions (152; 50.7%), followed by “on weekends” (100; 33.3%). These two occasions accounted for 84.0% of all the occasions of alcohol was consumption. The reported duration of alcohol consumption was almost evenly distributed amongst the three duration categories: ≤ 5 years (99; 33.0%), 6 – 10 years (94; 31.3%) and > 10 years (107; 35.7%).
3.3.2. Alcohol Types and Age Groups versus Number of Alcohol Drinks
Table 4 illustrates that more than two-thirds of the respondents (107; 35.7%) reported consuming an average of 5 – 6 drinks per day followed by those who consumed 3 – 4 drinks per day (89; 29.7%) and more than six drinks per day (72; 24.0%). Beer in both 330ml and 750 ml bottles was consumed the most per day (145; 48.4%).
Regarding age groups versus number of alcohol drinks per day, the age group ≥ 38 years of age displayed high proportions of alcohol consumption (245; 81.7%). On average, the largest quantity of alcohol consumed across all the age groups fell in the category of 5-6 drinks per day (107; 35.7%). The age-groups that demonstrated more binge drinking were ≥ 48 years (104; 34.6%).
Table 4 Alcohol type and age groups versus number of alcohol drinks (n=300).
3.3.3. Types of Alcohol Consumed versus Patient’s Sex
Table 5 shows that the proportions of women using wine (25; 8.3%) and cider (67; 22.3%) were significantly higher compared to those for men; p = 0.032 and p = 0.0001, respectively. There was a significantly higher proportion of beer consumption (330ml and 750ml) by men, (100; 33.3%) compared to women (45; 15.0%), p < 0.05.
Table 5 Types of alcohol consumed by sex and amount of alcohol consumption per sitting versus sex (n=300).
Regarding the number of drinks consumed per sitting there was no significant difference between males and females, p > 0.05. However, when both sexes were combined, 179 (59.7%) took five or more drinks per sitting (binge drinking).
3.3.4. CAGE Score by Age Groups, Sex and Levels of Education
The results of Table 6 indicate that the significant difference between the patients who were non-harmful alcohol users (CAGE score ≤ 1) versus those who were (CAGE score ≥ 2) was observed in the younger age groups (18-37 years), while the older age-groups (38 - >57years) tended to be non-harmful chronic alcohol users (p < 0.01). However, on the whole, there was a higher proportion of non-harmful chronic alcohol users (CAGE ≤ 1) compared to harmful alcohol users (CAGE ≥ 2); [205 (68.3%) versus 95 (31.7%)]. Regarding the CAGE scores by sex, there was no significant difference between the proportion of males and females who indicated a CAGE score ≤ 1 and ≥ 2, respectively.
Table 6 also indicates that using the CAGE score by education level, there was no significant difference between those who were harmful alcohol users versus those who were not among the patients who had no formal education (p = 0.058). However, the higher the level of education, the greater the difference between the proportions of those who had harmful alcohol use (CAGE ≥ 2) and those who did not (CAGE ≤ 1); (p ≤ 0.001). It is also noticeable that the percentages of users increased with education in each category – more among the non-harmful alcohol users compared to their counterparts.
The study demonstrated that there was a larger proportion of respondents who consumed alcohol among the older age-groups and the single. Poor knowledge regarding the quantities of alcohol consumption which do not cause harm to health was also shown. A large proportion of men consumed beer than women who consumed wine and cider more. When comparing harmful and non-harmful alcohol use according to age and academic level progression, there was an inverse relationship in both cases.
Most of the respondents enrolled in the study belonged to the age groups of above 57 years old (33.3%) compared to the other age-groups. There was an increase in alcohol consumption as the participants’ age groups increased toward 57 years and above, in contradistinction with the study by Knott et al. [21Knott CS, Bell S, Britton A. The stability of baseline-defined categories of alcohol consumption during the adult life-course: A 28-year prospective cohort study. Addiction 2018; 113(1): 34-43. [http://dx.doi.org/10.1111/add.13949] [PMID: 28734088] ], where alcohol consumption and related problems were found to decrease as drinkers grew older because of ill-health that set in with age. However, the study by Grant et al. [22Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001–2002 to 2012–2013. JAMA Psychiatry 2017; 74(9): 911-23. [http://dx.doi.org/10.1001/jamapsychiatry.2017.2161] [PMID: 28793 133] ]. tallied with our study in also finding an increase in harmful alcohol use with age. In South Africa, the study by Peltzer et al. found that there was an increase in high risk drinking and alcohol abuse among older adults putting them at risk for increased morbidity and mortality [23Peltzer K, Phaswana-Mafuya N. Problem drinking and associated factors in older adults in South Africa. Afr J Psychiatry (Johannesbg) 2013; 16(2): 104-9. [http://dx.doi.org/10.4314/ajpsy.v16i2.13] [PMID: 23595529] ]. The researchers in the current study are of the view that differences observed in the other studies are ascribable to the differences in sample sizes and the fact that the quoted studies were cohort studies over a period of time, unlike the cross-sectional method used in this study. Nevertheless, the current study suggests that health care professionals need to specifically enquire about alcohol abuse among elderly patients as well and not assume that they are unlikely engage in the harmful use of the substance.
Table 6 CAGE scores by sex, age groups and level of education (n=300).
In this study, the highest age group among the alcohol users were single (49.7%), in keeping with the study by Halme et al., who found an association between “not being married” and alcohol drinking problem [24Halme JT, Seppä K, Alho H, et al. Hazardous drinking: Prevalence and associations in the Finnish general population. Alcohol Clin Exp Res 2008; 32(9): 1615-22. [http://dx.doi.org/10.1111/j.1530-0277.2008.00740.x] [PMID: 18616 689] ] and Dan, who also found binge drinking in men to be associated with those who were divorced, separated or widowed (i.e. living single) [25Dan G. The Epidemiology of At-Risk and Binge Drinking Among Middle-Aged and Elderly Community Adults: National Survey on Drug Use and Health 3rd ed. 2009. [Retrieved 2018 Jul 22] [http://dx.doi.org/10.1176/appi.ajp.2009.09010016] ]. This suggest that being single for whatever reason renders the individual vulnerable to harmful alcohol use.
The current study demonstrated that only about one-in-ten (10.7%) respondents were aware of the maximum number of drinks per day that a male individual can take without causing harm to health, while nine-in-ten (89.3%) were not. These findings are almost similar to a study conducted by Rosenberg et al., in the UK were the level of awareness on recommended alcohol limits stood at 8% [26Rosenberg G, Bauld L, Hooper L, et al. New national alcohol guidelines in the UK: Public awareness, understanding and behavioral intentions Public Health 2017 (Oxford, England) 1-8. [Retrieved: 2017 Sept 28]. Available from: https://doi.org/10.1093/pubmed/fdx126]. The same trend was displayed in the current study on the level of awareness on the maximum number of drinks per day recommended for a female individual without causing harm to their health – only 7% were aware. Furthermore, on the maximum number of days per week that an individual can take alcohol for, without causing harm to their health, awareness was only found in 13.3%. According to the United States Department of Health and Human services and the United States Department of Agriculture, recom-mendations for moderate drinking has been defined as one alcoholic drink for females and two drinks for males per day [27Department of Health and Human Services and U.S. Department of Agriculture. (2015). Dietary Guidelines for Americans 2015–2020 [Online]. [Retrieved 2017 Sept 19]. Available from: http://health. gov/ dietaryguidelines/ 2015/ guidelines/]. Low risk for developing Alcohol Use Disorder (AUD) was described for males as drinking a maximum of 4 drinks on any day of the week to a maximum of 14 drinks per week, and a maximum of 3 drinks on any day of the week to a maximum of 7 drinks per week for females [19World Health Organization. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva, 2001 [Retrieved 2018 May 15]. Available from: http://apps. who. int/ iris/ handle/ 10665/ 67205]. Lack of awareness by individuals about these recommended alcohol quantities and frequencies of ingestion could be a reflection on the lack of patient education in this regard by health care professionals.
The study demonstrated that beer was considered fav-ourable amongst respondents accounting for almost half of all respondents’ consumption (48.4%) and was followed by ciders with almost a third of the respondents (31.3%) using it. The finding regarding beer consumption was also reported by the WHO [28World Health Organization. Global Status Report on Alcohol and Health 2014. [Retrieved 2018 Jul 22]. Available from: http://apps. who. int/ iris/bitstream / 10665/ 112736/ 1/ 97892 40692 763_eng.pdf?ua=1], in its Global Status Report on alcohol and individual country profiles for South Africa in 2014 where beer was found to constitute 48% of all alcohol consumption. However, unlike in the current study, the beer frequency was followed by wine at 18%. Globally, the most consumed beverage type is spirits (50.1%), followed by beer (34.8%). Wine constituted only 8.0% of the total recorded alcohol consumption (ibid). Given that what matters most is the number of alcohol standards consumed by an individual, health care professionals have the responsibility to educate patients that it is the quantity consumed that matters [8Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984; 252(14): 1905-7. [http://dx.doi.org/10.1001/jama.1984.03350140051025] [PMID: 6471 323] ], and not the alcohol types.
Almost one-in-two respondents reported that they consumed alcohol mostly on special occasions, followed by “on weekends” (33.3%). These two occasions accounted for almost one-in-five (84.0%) of all the occasions during which alcohol was consumed, in keeping with the study by Lau-Barraco et al. [29Lau-Barraco C, Braitman AL, Linden-Carmichael AN, Stamates AL. Differences in weekday versus weekend drinking among nonstudent emerging adults. Exp Clin Psychopharmacol 2016; 24(2): 100-9. [http://dx.doi.org/10.1037/pha0000068] [PMID: 26901592] ]. Weekend drinking was found to be associated with more risks of violence compared to during the week drinking [30Liang W, Chikritzhs T. Weekly and daily cycle of alcohol use among the U.S. general population. Injury 2015; 46(5): 898-901. [http://dx.doi.org/10.1016/j.injury.2015.01.029] [PMID: 25661106] ]. There was no difference in the proportion of patients based on the duration of time they have been ingesting alcohol. However, there is evidence that excessive alcohol drinking for longer duration is associated with a number of diseases, notably liver cirrhosis, some types of cancer and immune system disorders [5Centre for Disease Control and Prevention. Alcohol and Public Health, 2015. [Retrieved 2018 Aug 25] Available from: http://www.cdc.gov]. Health care professionals need to factor in the possibility of binge drinking on weekends and the duration of excessive alcohol intake in their enquiry on the history of alcohol intake by their patients.
Binge drinking which represents acute alcohol use in the current study was demonstrated in almost 60% of the respondents whereby five or more drinks per sitting were consumed. The deleterious effects of binge drinking on cognition – particularly among adolescents [31Jacobus J, Tapert SF. Neurotoxic effects of alcohol in adolescence. Annu Rev Clin Psychol 2013; 9: 703-21. [http://dx.doi.org/10.1146/annurev-clinpsy-050212-185610] [PMID: 23245341] ], health and safety [32NHTSA. Traffic Safety Facts 2013: Alcohol-Impaired Driving, 2014. [Retrieved 2018 Jul 15] Available online at: http://www- nrd. nhtsa. dot. gov/ Pubs/ 812102.pdf] its contribution towards Alcohol Use Disorders (AUD) [33Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: Age at onset, duration, and severity. Arch Pediatr Adolesc Med 2006; 160(7): 739-46. [http://dx.doi.org/10.1001/archpedi.160.7.739] [PMID: 16818840] ] have already been reported. Beer in both 330ml and 750 ml bottles was consumed the most per day by about half of the respondents. Regarding the types of alcohol consumed, the 2016 report by STATS SA has shown that beer is currently the most popular alcohol type in South Africa and accounts for 2.1% of total household spending [34STATS SA. Beer is more popular than vegetables. [Retrieved 2018 Jul 27]. Available from: www.statssa.gov.za]. The large proportion of men consuming beer compared to women has also been reported by Colen and Swinnen, whose study on the determinants of global beer consumption among beer drinking nations found that men were more likely to drink beer than women and that beer was more popular in the younger ages (18-44 years) [35Colen L. Swinnen JFM. Beer Drinking Nations. The Determinants of Global Beer Consumption., LICOS Discussion Paper, No. 270, LICOS, Leuven S. 2010. [Retrieved 2018 Jul 27]. Available from: https://www.econstor.eu/bitstream/10419/75022/1/dp270.pdf]. However, this has no clinical significance as all types of alcohol are amenable to abuse, depending on the amount consumed [8Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984; 252(14): 1905-7. [http://dx.doi.org/10.1001/jama.1984.03350140051025] [PMID: 6471 323] ].
The current study findings indicated that there was a significant difference between the patients who were non-harmful chronic alcohol users (CAGE score ≤ 1) versus those who were (CAGE score ≥ 2) among those in the age groups ≥ 38 years. There were less respondents in the age group ≥ 38 years who engaged in chronic harmful alcohol consumption (CAGE score ≥ 2) compared to their younger counterparts. This finding suggests an inverse relationship between age and harmful alcohol use. In this study, comparing males and females, the CAGE screening showed no significant difference between them regarding non-harmful and harmful alcohol uses (CAGE score ≤ 1 and ≥ 2). However, a study conducted by Bradley et al., using the Alcohol Use Disorders Identification Test (AUDIT-C) tool illustrated a higher prevalence of alcohol-related problems and disorders in primary care among men compared with women [36Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res 2007; 31(7): 1208-17. [http://dx.doi.org/10.1111/j.1530-0277.2007.00403.x] [PMID: 17451 397] ]. This could be explained by the differences in the parameters used in these two tools, with the AUDIT-C questionnaire looking more at the quantity and frequency of alcohol ingestion, compared to the CAGE questionnaire which looks at the individual’s social behaviour and his/her functionality as a result of alcohol use [8Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984; 252(14): 1905-7. [http://dx.doi.org/10.1001/jama.1984.03350140051025] [PMID: 6471 323] ].
Regarding the use of the CAGE scoring system in relation to the highest level of education, the current study demonstrated that the higher the level of education, the greater the difference between the proportions of those who had harmful alcohol use (CAGE score ≥ 2) versus those who did not (CAGE score ≤ 1). However, the percentages of users increased with education in each category – more among the non-harmful alcohol users compared to their counterparts. This suggests that the higher the education level, the fewer the harmful users of alcohol. This could suggest that education brings about awareness on the dangers associated with harmful alcohol use. However, other studies have shown an increasing harmful alcohol consumption with an increase in academic levels, as a result of the socio-economic status conferring affordability to the individual [37Droomers M, Schrijvers CT, Stronks K, van de Mheen D, Mackenbach JP. Educational differences in excessive alcohol consumption: The role of psychosocial and material stressors. Prev Med 1999; 29(1): 1-10. [http://dx.doi.org/10.1006/pmed.1999.0496] [PMID: 10419792] -39Thørrisen MM, Skogen JC, Aas RW. The associations between employees’ risky drinking and sociodemographics, and implications for intervention needs. BMC Public Health 2018; 18(1): 735. [http://dx.doi.org/10.1186/s12889-018-5660-x] [PMID: 29898703] ]. This studies are multicentre large sample surveys which could explain the different finding in the current study. Furthermore, there was paucity of comparative studies conducted specifically among patients.
4.1. Strengths and Weaknesses
This study was a cross-sectional study conducted in one setting, the Family Practice clinic of the DGMAH. These study finding are not necessarily generalizable to the South African population. However, this study can be viewed as a formative research as recommended by Bohren et al. [40Bohren MA, Oladapo OT, Tunçalp Ö, et al. Formative research and development of innovative tools for “Better Outcomes in Labour Difficulty” (BOLD): study protocol. Reprod Health 2015; 12: 50. [http://dx.doi.org/10.1186/s12978-015-0028-5] [PMID: 26006320] ], which can be used as a basis to launch further studies in this area. Furthermore, the fact that the results are based on information as reported by the respondents had the potential to introduce the social desirability bias (the tendency of respondents to give an answer they deem to be more socially acceptable than would be their “true” answer) [41Lavrakas PJ, Ed. Social Desirability.Encyclopedia of Survey Research Methods Encyclopedia On line Publications 2008. [http://dx.doi.org/10.4135/9781412963947.n537] ], especially that harmful alcohol use is associated with stigma [42Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, Angermeyer MC. The stigma of alcohol dependence compared with other mental disorders: A review of population studies. Alcohol Alcohol 2011; 46(2): 105-12. [http://dx.doi.org/10.1093/alcalc/agq089] [PMID: 21169612] ]. The fact that we could not work out the ingredients of home-brew, as well as the measurements of the containers in which it is served made it difficult for the researchers to quantify the amount of alcohol contained in this type of alcoholic beverage.
The finding that there was lack of knowledge on safe alcohol use among the majority of the respondents in this population suggests introduction of alcohol use awareness campaigns targeting especially the middle aged and the elderly. Furthermore, the finding that women consumed more wine and cider, compared to men who consumed more beer offers an opportunity to health care professionals to raise awareness to patients that safe use is determined by the amount rather than necessarily the type of alcohol used. This awareness should include the deleterious effects of binge drinking observed among the younger age groups, with caution for all patients against harmful alcohol use on special occasions and weekends. The finding through the use of the CAGE scoring system that with an increase in the highest level of education there were significantly more patients who did not engage in chronic harmful alcohol use should be leveraged on by health care professionals in educating patients against indulgence in harmful alcohol use.
Patient education is required on the amounts of alcohol constituting harmful use, including binge drinking (regardless of the alcohol type used and the occasion during which alcohol ingestion occurs) so as to prevent diseases associated with the harmful use.
Although education on alcohol use should be for all patients, according to this study, emphasis should be laid on patients 38 years and above who tend to engage in harmful alcohol use.
Further studies with larger samples and in multiple centers should be undertaken to further explore the findings of this study among patients.
K.K.N. conceptualised the research idea. K.K.N. and L.H.M. both drafted the manuscript, approved the final manu-script and agreed to submission it to the Open Public Health Journal for publication.
ETHICS APPROVAL AND CONSENT TO PARTCIPATE
The study commenced after obtaining ethics clearance from the Sefako Makgatho Health Sciences University Research Ethics Committee (SMUREC) in Pretoria, South Africa (Clearance Certificate number: SMUREC/M/203/ 2016:PG). Permission from DGMAH Chief Executive Officer and the Head of Department in charge of the Family Practice Clinic was obtained.
HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.
CONSENT FOR PUBLICATION
The study details were explained to each respondent, and written informed consent to participate was obtained before the study commenced.
AVAILABILITY OF DATA AND MATERIALS
The study is funded by Discovery Foundation, Rural Fellowship Award (Individual Category) with Reference no. 036944.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
This was a study conducted towards the main researcher’s Masters of Family degree. A special word of gratitude to the patients who participated in the study and to Prof. HS Schoeman (statistician) who assisted with data analysis.
Centre for Disease Control and Prevention. National centre for chronic disease prevention and health promotion. Alcohol and Public Health, 2016. [Retrieved 2018 February 14]. Available from: https://www. cdc. gov/ alcohol/ faqs.htm
Fabor TF. “The alcohol use disorders identification test: Guideline for use in primary care”. World Health Organization: department of mental health and substance dependence. 2nd edition, 2001. [Retrieved 2018 September 23]. Available from: http://www. who. int/ iris/ handle/ 10665/ 67205
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Droomers M, Schrijvers CT, Stronks K, van de Mheen D, Mackenbach JP. Educational differences in excessive alcohol consumption: The role of psychosocial and material stressors. Prev Med 1999; 29(1): 1-10. [http://dx.doi.org/10.1006/pmed.1999.0496] [PMID: 10419792]
Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, Angermeyer MC. The stigma of alcohol dependence compared with other mental disorders: A review of population studies. Alcohol Alcohol 2011; 46(2): 105-12. [http://dx.doi.org/10.1093/alcalc/agq089] [PMID: 21169612]