ALCOHOLISM: LOW STANDING WITH THE PUBLIC? ATTITUDES TOWARDS SPENDING FINANCIAL RESOURCES ON MEDICAL CARE AND RESEARCH ON ALCOHOLISM

Michael Beck, Sandra Dietrich, Herbert Matschinger and Matthias C. Angermeyer*,

Department of Psychiatry, University of Leipzig, Leipzig, Germany

(Received 16 May 2003; first review notified 21 June 2003; in revised form 7 July 2003; accepted 29 July 2003)

* Author to whom correspondence should be addressed at: Department of Psychiatry, University of Leipzig, Johannisallee 20, D-04317 Leipzig, Germany. Fax: +49 3 41 9724 539; E-mail: krausem{at}medizin.uni-leipzig.de


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To assess the extent to which the German public supports the allocation of financial resources to the care of people with alcoholism and to research on alcoholism as compared with other conditions. Methods: 5025 interviews were conducted in the scope of a representative survey in Germany during May and June of 2001, using a personal, fully structured interview. Results: Respondents most frequently selected alcoholism as the disease for which medical care expenditures could be spared and cut down and on which research funds should neither be spent in the first place nor should be spent at all. Conclusion: Our study shows that despite the spread of the concept ‘alcoholism is an illness’, this disease is still treated ‘unfavourably’ compared to other conditions. Health campaigns that increase the public's awareness that alcoholism is not a personal failure but an illness with severe medical and social consequences may help reduce the public acceptance of structural discrimination.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
There are three different levels of discrimination—individual, institutional/structural, and self-stigmatization (Pincus, 1996Go; Link and Phelan, 2001Go). Pincus (1996)Go defines individual discrimination as the behaviour of individual members of one group that is intended to have a differential and/or harmful effect on the members of another group. In research, this form of discrimination is most frequently measured by the desire for social distance (i.e. the amount of distance that individuals of one group would hypothetically place between themselves and the members of another group in certain situations of personal contact) (Bogardus, 1925Go). Applied to mental disorders, it is the willingness to readily engage persons with a mental illness in activities such as hiring them for babysitting, dating them and renting them a room (Corrigan et al., 2001Go). The second form, structural discrimination, refers to institutional practices and policies that work to the disadvantage of minority groups even in the absence of individual prejudice or discrimination (Link and Phelan, 2001Go). It can take place in regard to legal provision as well as in regard to the interpretation and administration of laws (Gutiérrez-Lobos, 2002Go). Another area where structural discrimination can occur is the allocation of financial resources (e.g. when it comes to allocating research disbursements and expenditures for medical care or job creation). Self-stigmatization, on the other hand, occurs when members of a minority group internalize the stigmatizing ideas of their social environment and start to believe that they are of less value and will be rejected by most people.

Most of the studies investigating attitudes towards people with alcoholism have primarily focused on the first of these three forms: individual discrimination. The general tenor of these studies was that significant prejudices exist against those who are alcohol-dependent in comparison to people with other conditions. Westbrook et al. (1993)Go and Tringo (1970)Go showed that alcoholism is far less accepted than other diseases. Coe and Smith (1972)Go found that alcoholics are more often and more strongly rejected than any of those believed to be mentally ill. Blizard (1969Go, 1970)Go came to the conclusion that the alcoholic is rejected to a much greater extent than are people with neurosis or schizophrenia, with very few respondents wanting to accept close and continuous contact with the alcoholic. In the study of Albrecht et al. (1982)Go, respondents expressed greater social distance from alcoholics and drug addicts than from disabled such as paraplegics and the blind. More recent studies by Link et al. (1999)Go and Angermeyer and Matschinger (1997)Go, who compared the social distance respondents desired from people with different mental disorders, found that apart from people with drug dependence, people with alcohol dependence encounter the greatest amount of rejection, with the social distance desired towards them being even greater than that towards people with schizophrenia.

In contrast to the numerous studies on individual discrimination towards people with alcoholism, structural discrimination towards members of this group of society is still a field that researchers have not yet studied. Until now, only Stein (1985)Go has researched attitudes towards financing the treatment of alcoholism. The results are rather negative: despite 78% of the sample agreeing that insurance should cover expenses for the treatment of alcoholism, one-third of the sample expressed that it would be unreasonable for the general public to pay the costs of treatment of people who are alcohol-dependent. However, structural discrimination could be of importance in fighting stigmatization of people with alcoholism. Our study aims to assess the extent to which the German public tends to support the allocation of financial resources to the care of people with alcoholism, and to research on alcoholism, as compared with other conditions (i.e. an indicator for structural discrimination). Apart from investigating whether structural discrimination against people with alcoholism is as marked as the individual discrimination indicated by the above literature, we will examine how public attitudes are influenced by people's value orientations and suggest measures that could help reduce stigmatization of people who are alcohol dependent.


    SUBJECTS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Sample
During May and June of 2001, a representative survey was conducted among German citizens aged 18 years and over, living in private households. This survey was part of a study on ‘Public conceptions of mental disorders and attitudes towards people with mental disorders’ (M.C.Angermeyer and H.Matschinger, submitted). The sample was drawn using a three-stage random sampling procedure, with electoral wards at the first stage, households at the second, and individuals within the target households at the third stage. Target households within the sample points were determined according to the random-route procedure and target persons were selected according to random digits. In total, 5025 interviews were conducted, which reflects a response rate of 65.1%. The personal interview was fully structured.

Instruments
Attitudes towards allocation of financial resources to medical care and research The respondents were asked the following question: ‘There is an increasing shortage of financial resources. Please choose from the following list those three conditions for which, in your opinion, it would by no means be acceptable to cut down medical care expenditures. Please also name those three conditions where one could best spare money.’ The respondents were then presented with a list of nine disorders: alcoholism, cancer, AIDS, cardiovascular disease, diabetes, Alzheimer's disease, rheumatism, schizophrenia and depression. In addition, the respondents were asked: ‘Please choose from the following list those three conditions for which, in your view, money on research should be spent first. Please also indicate on which three diseases research money should rather not be spent at all.’ The respondents were then presented with a list containing the nine above conditions plus BSE, as this disease was an important public issue in Germany as in other European countries at the time of the survey.

Value orientations Respondents' personal values were assessed with a list of 18 behavioural patterns representing three different value orientations: liberal values, traditional values, and modern values (Maag, 1989Go). Using a seven-point scale, respondents were asked to express their opinion on the social desirability of each behaviour.

Statistical analyses
Apart from descriptive statistics (frequency distributions in percentages), multivariate procedures were used. Because the dependent variables consist of two characteristics (choice of alcoholism yes/no) that is, dichotomous variables, the logistic regression analysis is the most suitable procedure.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Of the nine conditions provided, respondents most frequently selected alcoholism as the condition for which medical care expenditures could be spared and cut down. A similar picture emerges for the allocation of research funds: of the conditions presented, respondents also chose alcoholism as the illness on which research funds should not be spent first nor should be spent at all. An exact opposite relationship is revealed when looking at interviewees' responses in the case of cancer. Here, respondents' opinions were clearly dominated by the notion that financial resources for medical care and research should on no account be reduced or spared. Compared to the other psychiatric disorders presented (i.e. schizophrenia and depression), alcoholism was either less frequently selected (questions 1 and 3) or more frequently selected (questions 2 and 4).

This clearly negative attitude towards alcoholism is hardly influenced, if at all, by differences in sex, age, and educational attainment. A slightly higher acceptance of structural discrimination towards alcohol-dependency is shown with female respondents, with increasing age and with lower educational attainment. However, these differences are statistically marginal and do not influence the overall picture that cutbacks in the medical care of alcohol dependents are—in comparison to the other conditions presented—more likely to be accepted. A similar picture emerged in the case of spending research funds on alcoholism, with a far higher acceptance of structural discrimination against alcoholism as compared to the other conditions given.

Value orientations
The principal component factor analysis of the 18 behavioural patterns of the value orientations yielded three dimensions that are virtually identical with those described by Maag (1989)Go, as follows. Liberal values (eigenvalue 5.8; explained variance 32.0%), including: dealing fairly with everyone (factor loading 0.73), treating everyone equally (0.72), being just (0.71), being tolerant (0.71), removing social differences between individuals (0.61), solving conflicts by compromise (0.59), increasing participation in decision-making processes (0.53). Traditional values (eigenvalue 2.5; explained variance 12.0%) comprising the following: being on time (factor loading 0.72), being conscientious (0.71), trying one's best (0.70), accomplishing one's tasks (0.69), being careful (0.62), valuing wealth (0.54). Modern values (factor loading 1.5; explained variance 8.6%): enjoying life (factor loading 0.75), doing as you please (0.71), being independent (0.65), seeking self-realization (0.63), valuing wealth (0.54), being emotional (0.51).

In a logistic regression we analysed the effects of respondents' value orientations on their attitudes towards the allocation of financial resources to the medical care of alcohol dependents and research on alcoholism. The analysis of the interviewees' responses to the four questions of our study yielded an explained variance of only 2–5%. Liberal and traditional values showed significant effects. Respondents with liberal and traditional value orientations showed a tendency towards thinking that financial resources for medical care should on no account be shortened and that money should be spent on research on alcoholism. Conversely, negative significant effects were observed for liberal and traditional value orientations and ‘sparing money for medical care of alcoholics’ and ‘spending no money on research on alcoholism’. Only modern values showed no significant effect with regard to selecting alcoholism among the conditions presented.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In Germany, alcoholism was first officially recognized as an illness in 1968, defined by the Federal Social Court in terms of ‘permanent, compulsive dependency on the addictive drug’. Consequently, health insurers became legally obligated to pay the costs for the treatment of alcohol addiction. In addition, in 1974, the cost distribution between health insurers and pension scheme providers was regulated by law, with the first financing medical treatment and the latter financing further rehabilitation measures. In this period, self-help groups increasingly propagated the concept of alcoholism as an illness. These developments could indicate that the lay concept of persons who are alcohol-dependent as morally weak and themselves to blame for their misfortune, was superseded by the concept of the alcohol-dependent as a person with a psychiatric disorder. This might have had a positive influence on people's attitudes towards alcohol-dependent persons.

Evidence for the spread of understanding alcoholism as a psychiatric disorder can be found in a comparison of US studies over a period of 25 years (Mulford and Miller, 1964Go; Orcutt et al., 1980Go; Blum et al., 1989Go). Between 1964 and 1989, a constant increase was observed in the number of people supporting the medical concept of alcoholism as a psychiatric disorder; at the same time, a drop in the number of people preferring the moral, self-inflicted view was observed. The majority, however, held a mix of these positions. Where medical and moral views coexisted, alcohol dependents were defined as ill, but this did not positively influence their reputation as, simultaneously, they were considered to be guilty of causing their condition. In a study by Blum et al. (1989)Go 78% of respondents said that alcohol-dependents were responsible for their situation, despite the fact that 89% of respondents described them as ill people. In this context, the results of a study by Caddy (1976)Go are noteworthy, where the majority of respondents identified alcohol-dependents as mentally ill people. About one-third of the interviewees in the study by Orcutt et al. (1980)Go supported the illness definition. German studies also reflect the spread of the definition of alcoholism as an illness. While in 1973 only 20% of interviewees in the two investigations by Wieser (1973)Go saw dependency as a criterion for alcoholism, more than half of the interviewees in Stein's 1985Go study believed alcoholism to be an illness—resembling the study by Angermeyer et al. (1995)Go, where 55% of the respondents answered in the affirmative that alcoholism is an illness. However, our present report shows that despite the spread of the concept ‘alcoholism is an illness’, alcoholism is still treated ‘unfavourably’ compared to other conditions and also in comparison to other psychiatric disorders.

It must be pointed out that promulgating alcoholism as an illness is not identical to endorsing a biological concept. Rather, we understand it as a multi-factorial concept that combines both biological and psychosocial causes. As lay people show a tendency towards seeing psychosocial factors as the cause of mental disorders (M.C.Angermeyer and H.Matschinger, submitted), promulgating biological causes alone may result in higher individual discrimination. First, this may be so because lay people are more willing to accept a concept that conforms to their beliefs (ibid.). Second, as has been shown by S.Dietrich et al. (submitted, unpublished observations), promulgating biological causes alone results in higher individual discrimination against people with mental disorders. Further studies could investigate whether health campaigns promulgating a multi-factorial illness concept are helpful in reducing structural discrimination.

As has been outlined in the introduction, most of the studies investigating individual discrimination against people with alcoholism found that prejudices exist against alcohol-dependents in comparison to people with other conditions. Similarly, our study reveals significant public prejudices against people who are alcohol-dependent. One possible explanation for respondents' different attitudes to the conditions presented in our survey might also be an indicator of the different presence and representation of these conditions in the media. While disorders such as AIDS, cancer or diabetes receive more attention in public-education campaigns on TV or billboards, and are thus provided as a topic for public discussion, this type of media presence is rare for the prevention and cure of alcoholism. As there have been hardly any studies investigating the influence of media representation of alcoholism on attitudes towards people with alcoholism, there is room for speculation. We therefore recommend exploration of this relationship as a subject of future studies.

Limitations
First, this study only allows conclusions concerning the German population. Research in other countries is necessary for an international comparison. Second, so as not to exceed people's cognitive capacities, we provided a limited list of conditions for selection. Furthermore, respondents were only allowed to select three of these conditions. Alcoholism appears stigmatized in relation to the other conditions that were selected for this study. A comparison with other conditions not on this list might produce different results. Third, it must be pointed out that respondents' attitudes towards the allocation of financial resources to medical care and research on alcoholism only function as an indicator of structural discrimination and do not equate to actual structural discrimination. Therefore, this study could serve as the starting point from which to explore structural discrimination towards alcoholism in relation to other conditions, and by using other indicators for structural discrimination.

Alcoholism is one of the biggest health issues of current times. It not only impairs those who are alcohol-dependent, others also suffer from the effects of alcoholism: family members, co-workers and neighbours. Nevertheless, alcoholism is rarely a topic of public discourse. People should increasingly be made aware of the fact that alcoholism is a disorder that not only causes damage to health but which can also have unforeseeable social consequences.


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Table 1. Percentages of respondents selecting alcoholism as one of the three responses to the questions regarding the allocation of financial resources, in a study on attitudes towards spending financial resources on medical care and research on alcoholism in Germany

 

View this table:
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Table 2. Effects of value orientations, gender, age and educational attainment on selecting alcoholism as one of the three responses to the questions regarding the allocation of financial resources, in a study on attitudes towards spending financial resources on medical care and research on alcoholism in Germany

 

    Acknowledgements
 
This project was supported by the German Research Association (Grant AN 101/5-1).


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