Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Wesley Guild Hospital, ILESA 233001, Osun State, Nigeria
Author to whom correspondence should be addressed at: Tel.: +234 80 55617605; E-mail: biodunwuya{at}yahoo.com
(Received 15 April 2005; first review notified 18 July 2005; in revised form 20 July 2005; accepted 26 July 2005)
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ABSTRACT |
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INTRODUCTION |
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Studies in Nigeria have focussed on lifetime and current prevalence rates of alcohol use (Odejide et al., 1987; Adelekan et al., 1992
) without exploring alcohol-related problems. There is an urgent need to encourage extensive epidemiological and longitudinal studies of alcohol-related problems in Nigeria in order to accurately determine the populations at risk. Early detection of people with hazardous alcohol intake and time bound interventions aimed at decreasing alcohol consumption and thus the likelihood of harm and dependence is warranted. This first step in doing this is to validate an appropriate screening instrument for the detection of alcohol-related problems among the targeted population in Nigeria. Such an instrument is the alcohol use disorders identification test (AUDIT).
The AUDIT (Saunders and Aasland, 1987; Saunders et al., 1993
) was developed as part of the WHO collaborative project on the detection and management of alcohol-related problems in Primary Health Care, to identify hazardous and harmful alcohol use. Several screening instruments have been developed that are fairly short and easily administered, but they tend to detect severe alcohol disorders such as dependence and overlook hazardous drinking. Literature supports the use of AUDIT for less severe alcohol-related problems (Fiellin et al., 2000
).
This study aims to investigate the screening properties of the AUDIT in the detection of alcohol-related problems among Nigerian university students.
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SUBJECTS AND METHODS |
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Sample size and sampling technique
Because some of the halls have more blocks of flats and more rooms than the others, a multistage sampling technique was adopted. In the first phase, the blocks of flats in each hall were mapped out. The flats with even numbers were then selected. After that, even-numbered rooms in each flat were subsequently selected. In the third stage a student was selected at random from each of the even-numbered rooms for the interview. A final sample of 822 was therefore obtained. Out of this number, 12 refused to participate leaving a sample size of 810.
Procedure
The Ethics and Research Committee of the university approved the study protocol and informed consents were obtained from the participants after the aims and objectives of the study had been explained. Previously trained research assistants who are medical students explained the size of a standard drink to those agreeing to participate. A standard drink was defined as equivalent volumes containing an average of 13.5 g ethanol.
The participants then complete the AUDIT questionnaire. The AUDIT is a self-rated 10-item questionnaire with each item scored 04, giving a total score of 40. Several studies have shown its validity and reliability in the detection of hazardous drinking, alcohol misuse, and alcohol dependence. (Bohn et al., 1995; Piccineli et al., 1997
). Depending on the cut-off and the criterion standards used, studies have reported sensitivities between 51 and 97%, and specificities between 78 and 96%. (Fiellin et al., 2000
).
The participants were then divided into two groups based on their AUDIT scores. The first group consists of those scoring 4 (n = 186) and above, and the second group consists of those scoring below 4 (n = 624). A psychiatrist blind to the AUDIT scores then used the Composite International Diagnostic Interview (CIDI) to assess all participants in the first group and a randomly selected 10% (n = 62) of those in the second group (making a total of 248) for alcohol-related problems. There is no significant difference in the age, sex, and AUDIT scores between the randomly selected 10% and the remaining 90% in the groups with scores below 4. The CIDI (Smeets and Dingemans, 1993) is a structured interview developed by the WHO and based on the National Institute of Mental Diagnostic Schedule and the Present State Examination. It was designed for use by trained interviewers who are not clinicians. The CIDI assesses mental disorders according to the ICD-10 (WHO, 1992
). Alcohol dependence and harmful use were diagnosed according to the ICD-10 criteria. All participants whose weekly alcohol consumption was above the WHO recommendation (280 g for men ad 168 g for women) and/or who fulfilled the criteria for hazardous drinking (WHO, 2000
) were diagnosed as having hazardous alcohol intake.
Data analysis
The Statistical package for the Social Sciences 11(SPSS.11) program was used for statistical analysis. Cases were defined according to their ICD-10 diagnosis. Results were calculated as frequencies (%), means, and standard deviations. Screening parameters including sensitivity, specificity, and predictive values were calculated for the AUDIT scores. Spearman correlation was used to establish concurrence between the ICD-10 diagnosis and the AUDIT scores. The psychometric performance of the AUDIT was compared with the ICD-10 diagnosis using the receiver operating characteristic (ROC) curve. The area under the curve (AUC) was also calculated. All tests were 2-tailed, and the level of significance was set at P < 0.05.
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RESULTS |
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DISCUSSION |
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These differences may not be too surprising. Although the current psychiatric classificatory systems commonly provide similar criteria for the identification of disorders relating to the use of alcohol, the cultural views of alcohol use disorders are influenced by prevailing norms in the society. It is likely that there is a cross-cultural difference in the threshold for the identification of disorders relating to the use of alcohol. It has been suggested that even though some similarities exist with respect to the definition of problematic use of alcohol in ethnically diverse societies, very substantial differences also exist. A number of core concepts underpinning diagnosis of disorders relating to the use of alcohol have no equivalents in the local languages of the various cultures, while some others lacked cultural applicability because of their relative distance from cultural and ethnic norms of drinking (Gureje et al., 1996).
This study also showed AUDIT to be useful in screening for harmful use and dependence among Nigerian university students with cut-offs of 7 and 9, respectively. The PPV when using AUDIT to screen for alcohol dependence was however found to be low indicating a high proportion of false positive result. This could have resulted from the 10 items of the questionnaire being given the same weight in computing the total scores. There are, of recent, studies advocating a shorter form of the AUDIT questionnaire (Gual et al., 2002).
The limitations of this study include the fact that a proportion of participants with alcohol-related problems may have under-reported them both on the AUDIT screening questionnaire and the clinical interview. This may have raised the validity co-efficient of the AUDIT questionnaire. It was also noticed that some participants complained about the length of the AUDIT, and an increase in the participant's defensiveness when answering questions 410 dealing with alcohol dependence and alcohol-related problems was noticed during the screening. Suitable short forms of AUDIT may need to be examined and studied for screening properties. This study is also limited by the probability of observer variation, because all the clinical interviews were performed by a psychiatrist. Also, reliability indices of the AUDIT were not assessed because it was only administered once.
This study has shown that AUDIT is a valid and useful instrument in screening for alcohol-related problems among university students in Nigeria. A cut-off score of 5 is recommended when screening for hazardous use. Cut-off scores of 7 and 9 are equally recommended when screening for harmful use and dependence respectively.
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REFERENCES |
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