Department of Community Medicine, Malmö University Hospital, Lund University, 205 02 Malmö, Sweden
* Author to whom correspondence should be addressed at: Tel.: +46 040 333003; Fax: +46 040 336215; E-mail: martin.lindstrom{at}smi.mas.lu.se
(Received 21 March 2005; first review notified 14 May 2005; accepted in final revised form 12 July 2005)
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The concept miniaturization of community may be described as a theoretical specification within the social capital theory concerning the relationship between social participation and trust. The concept may be seen as a consequence of the empirical observation that social participation and trust do not always enhance and strengthen each other, as would have been expected from the theoretical literature on social capital. In a public health survey in Scania 2000 in southern Sweden 25% of all men and 28% of all women aged 1880 years were found in the miniaturization of community category (Lindström, 2003). High alcohol consumption is a health related behaviour which may be affected by social and contextual circumstances such as social capital and the miniaturization of community. The miniaturization of community represents a combination of social participation that may be hypothesized to increase alcohol consumption among individuals and groups of individuals who are prone to consume such alcohol because of psychological traits associated with low generalized trust. The other theoretically unexpected combination, i.e. low social participation combined with high trust, has in a previous paper been termed traditionalism. This group may include both in different respectsdisabled persons and older persons with high trust who may have had high social participation. Older people are overrepresented in the traditionalist group (Lindström, 2003
). The four different social participation/trust combinations (high/high = high social capital, high/low = the miniaturization of community, low/high = traditionalism, and low/low = low social capital) and their associations with health and health related factors have been analysed previously in the Scania public health survey 2000 data material. These studies have found a positive and significant association between the miniaturization of community and intermittent smoking (Lindström, 2003
), poor psychological health (Lindström, 2004a
), cannabis smoking (Lindström, 2004b
), patient dissatisfaction with treatment in primary health care (Lindström and Axén, 2004
), and the consumption of home made and smuggled liquor (Lindström, 2005a
) in this adult 1880 year population. The study concerning home made and smuggled liquor (Lindström, 2005a
) is of particular interest in the present study, because the results indirectly suggest that the total consumption of alcohol might be higher in the miniaturization of community category than in the high social capital category (which was the reference category throughout the previous studies). In the present study, the hypothesis thus concerns the combinations of the social participation/trust variables and total alcohol consumption (the sum amount of drinking in normal days and binge drinking). The hypothesis of this paper is thus that the miniaturization of community and low social capital are properties associated with a high total consumption of alcohol.
Alcohol is an important cause of a number of diseases. Alcohol was estimated in 1996 to be the cause of 1.5% of all deaths in the world, 2.1% of all premature deaths in the world, 6% all lives lost due to functional disability, and 3.5% of the summary measure of mortality and DALY (disability adjusted life years). Alcohol is positively related to disease in over 60 diagnoses, while, on the other hand, a negative association between alcohol consumption and disease has been observed for ischemic heart disease, cardiovascular disease in the brain, and type II diabetes (Murray and Lopez, 1996). Since 1996 the estimated contribution of alcohol to total mortality in the world has been estimated to having increased to 3.2% and the total disease burden measured by DALY to 4.0% (Rehm, et al., 2004
).
The total per capita consumption of pure (100%) alcohol among all citizens aged 15 years and above has increased in Sweden since the mid-1990s. The registered per capita consumption, i.e. the sales through the Swedish State Monopoly and through the restaurants, increased from 5.8 l 100% alcohol per capita in 1998 to 6.5 l in 2001. However, one part of the total alcohol consumption in Sweden is not registered in the official sales statistics. This unregistered part of the consumption in Sweden seems to have increased dramatically for several years due to less severe restrictions on the amounts of different kinds of alcohol permitted to be brought into the country. In 2001 unregistered alcohol added almost another 3 l of 100% alcohol per capita to the total per capita consumption, which was estimated to be 9.2 l (Centralförbundet för alcohol- och narkotikaupplysning, 2002), and in 2003 the estimated total alcohol consumption in Sweden had increased further to 10.6 l per capita (www.sorad.su.se). In Sweden this increase in alcohol consumption may have even more severe health consequences than in some other countries, e.g. countries in southern Europe, because in Sweden each drinking occasion is 23 times more likely than in southern Europe to lead to harmful intensive consumption (Babor et al., 2003
).
In Sweden, alcohol consumption is related to individual characteristics such as age, sex, country of origin, education, and economic stress (National Public Health Report, 2001). The current highest recommended levels of alcohol consumption which are not considered to have a damaging effect on health, e.g. an increased risk of liver cirrhosis, are 168.0 g of pure alcohol/week for men but 108.0 g/week for women (British Medical Association, 1995
), which constitute lower levels than the previous recommendations in Sweden 210 g/week for men 120 g/week for women.
The aim of this paper is to investigate the impact of social participation, trust, and the miniaturization of community on the risk of high alcohol consumption above recommended levels. The main hypothesis is that the miniaturization of community, i.e. high social participation combined with low trust, and low social capital, i.e. low social participation/low trust, cause a higher inclination to high alcohol consumption.
![]() |
MATERIAL AND METHODS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Dependent variables
High alcohol consumption (above recommended levels) was defined following current international recommendations (British Medical Association, 1995) as a consumption of 168.0 g or more of pure alcohol per week for men and 108.0 g or more per week for women. Alcohol consumption was assessed with a QF (quantity/frequency) method of alcohol assessment which measures the number of days of alcohol consumption and the amount of alcohol consumed during a typical day of alcohol consumption (beer, wine, liquor) during the past 30 days (reference period), and the number of days during the last year with a daily consumption of five bottles or four cans of beer or more, one bottle of wine or more (75 cl), and 37 cl of strong liquor or more (half of this amount for women) (see Appendix). The dependent alcohol consumption variable is thus dichotomous with 168.0 g/week or more as the limit among men and 108.0 g/week or more as the limit among women. Abstainers (no alcohol consumption) are also included in the male and female categories with an alcohol consumption of <168.0 g/week and <108.0 g/week, respectively, in Tables 1
3.
|
|
|
Country of origin. All persons born in countries other than Sweden were merged into a single category, which yielded the two categories Sweden and other.
All analyses were stratified by sex.
Education was divided by length of education into 9 years or less, 1012 years, and 13 years of education or more.
Economic stress was categorized by the answer to the question How many times during the past year did you not have money enough to afford the food or the clothes you and your family need?. The respondents were classified by the alternatives: (i) (almost) every month, (ii) 6 months a year, (iii) very occasionally, and (iv) never.
Social participation (during the past year) describes how actively the person takes part in the activities of formal and informal groups in society. Respondents were asked whether in the previous 12 months they had been involved in any of the following 13 activities: study circle/course at workplace, other study circle/course, union meeting, meeting of other organizations, theatre/cinema, arts exhibition, church, sports event, writing a letter to the editor of a newspaper/journal, demonstration, night club/entertainment, large gathering of relatives, and private party. It was measured as an index consisting of the 13 items and dichotomized into low social participation (three activities or less) and high social participation (four activities or more). The social participation item has been used by Statistics Sweden in the investigations concerning living conditions since the 1960s and 1970s (National Central Bureau of Statistics, 1980). The reliability of the social participation items have been investigated in Malmö by testing the testretest stability of 200 respondents in the Malmö Shoulder and Neck Study (MSNS), and the test-retest stability of most of the items was reasonably high with a
coefficient 0.70. The internal consistency, i.e. the correlation between the items of an index, was 0.61 for the social participation variable (Hanson et al., 1997
).
Trust is a self-reported variable that reflects the person's perception of generalized trust in other people. It was assessed by the item Generally, you can trust other people that contained four alternative answers: Do not agree at all, Do not agree, Agree, and Completely agree. It was dichotomized with the two first alternatives as low trust.
The combination of social participation and trust results in four alternatives: high social participation/high trust (high social capital), high social participation/low trust (the miniaturization of community), low social participation/high trust (traditionalism), and low social participation/low trust (low social capital).
Statistics
Prevalences (%) of high alcohol consumption (above recommended levels), demographic, socioeconomic, economic stress, and social capital variables were assessed. Crude odds ratios and 95% confidence intervals (OR, 95% CI) were calculated in order to analyse associations between demographic, sociodemographic and economic stress variables, social capital variables, and high alcohol consumption (above recommended levels). The multivariate analysis was performed using a logistic regression model in order to investigate the potential importance of possible confounders on the differences in high alcohol consumption (above recommended levels) between individuals with high versus low social participation, high versus low trust, and their combination categories. The statistical analysis was performed using the SPSS software package (Norusis, 2000).
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Table 2 shows that the odds ratios of high alcohol consumption above recommended levels were significantly more prevalent among younger persons (among men), persons born in Sweden (compared to persons born in other countries than Sweden), and persons who had experienced economic stress during the past year. No significant educational differences were observed. The odds ratios of high alcohol consumption in the group with low social participation compared to high social participation were not significant. The odds ratios of high alcohol consumption were significantly higher for the low trust compared to the high trust category among men but not among women. The odds ratio of high alcohol consumption was significantly higher for the miniaturization of community category (high social participation/low trust) compared to the high social capital (high/high) category among men but not among women. The low/high (traditionalist) and low/low (low social capital) categories did not significantly differ in high alcohol consumption from the high social capital category.
Table 3 shows that after adjustments for age, country of origin, education, and economic stress in the multiple logistic regression analyses the odds ratios of high alcohol consumption above recommended levels remained significantly higher for the miniaturization of community category compared to the high social capital category among men, and for the low trust category compared to the high trust category among men. No statistically significant odds ratios were observed for women. The number of internally missing on the alcohol outcome variable is 1239 for women and 786 for men. The number of internally missing added by including all the age, country of origin, education, economic stress, and social capital/miniaturization of community variables in the analyses is 83 (total 1322) for women and 683 for men. The problem of adding more internally missing to the multiple regression analyses is thus more substantial for men than for women. However, fixing the number of individuals included in the multiple regression analyses (using blocks function in the regressions in the SPSS) does not yield any results differing from the results already presented in this study.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The validity of alcohol consumption assessment in questionnaires is defined as the extent to which a person's response in a survey approximates actual consumption levels. Previous studies have consistently shown that surveys and questionnaires tend to underestimate alcohol consumption by 4060% when compared with total alcohol consumption measured by sales statistics. However, assessment of alcohol consumption by postal questionnaires sent to respondents is still considered sufficiently valid (Dawson, 2003). The proportions of men and women with high alcohol consumption above recommended levels are thus most likely underestimated in this study as in all other studies on alcohol consumption utilizing this assessment method. However, there is no reason to believe that the results in this article differ from the general pattern and experience concerning validity, because the proportions of high alcohol consumers correspond very well with other data on alcohol consumption from Sweden during the same period (National Public Health Report, 2001
). There is no reason to believe that this study is prone to differential misclassification. The reliability and validity of the social participation index variable has already previously been demonstrated to be reasonably good (Hanson et al., 1997
). Trust is a self-reported and subjective variable which is impossible to directly validate. The patterns of the prevalence of trust agree in a reasonable way with the patterns reported in other studies (Holmberg and Weibull, 1996
; Rothstein, 2003
).
Age, sex, country of origin, education, and economic stress might be confounders of the association between the social capital and miniaturization of community variables and the self-reported home made and smuggled liquor variables. Stratifying for sex and adjusting for the other variables in a multiple analysis, however, only affected the estimates to some extent.
The cross-sectional study design is a weakness because it is theoretically possible that the direction of causality between the social capital variables and the high alcohol consumption above recommended levels variable may go in both directions. However, the direction of causality investigated here is certainly the most plausible. Social capital and trust are often founded in early life, during childhood and adolescence (Putnam, 1995, 2000
), while high alcohol consumption is measured in the age interval 1880 years in this study.
The per capita alcohol consumption in Sweden has been increasing rapidly in recent years. The 1999/2000 public health survey in Scania was conducted during this process of rapidly increasing alcohol consumption. The socioeconomic differences in alcohol consumption have for several decades been inverse compared to many other health related behaviours, i.e. higher consumption levels in higher socioeconomic strata (National Public Health Report, 2001). In this study the differences between different educational groups still remain, because the group with the lowest level of education has a significantly lower proportion of persons with high alcohol consumption compared to the group with the highest level of education. It seems to be too early to draw any conclusions concerning the effects of the increase in per capita consumption on the patterns of socioeconomic differences in alcohol consumption.
The difference between men and women in prevalence of high alcohol consumption is in accordance with results of national surveys (National Public Health Report, 2005). There are also differences between men and women in social participation. A previous study with focus on ethnic differences in the different aspects of social participation included in the social participation index variable shows that men attend meetings in other organisations than unions and sports events to a higher extent than women, and women attend study circles, theatre/cinema, arts exhibition, and church to a higher extent than men (Lindström, 2005b
).
The core components of the social capital concept, social participation, and trust, may be hypothesized to affect alcohol consumption in different ways. Social participation may either increase or decrease the inclination to high consumption of alcohol depending on the nature of the participation. Social participation of individuals may even exacerbate poor health related behaviours such as high alcohol consumption above recommended levels (Putnam, 2000). On the other hand, the effect of trust on alcohol consumption is more likely to increase alcohol consumption for several reasons which include poorer psychological health (which is partly related to low trust) (Lindström, 2004a
), poorer psychosocial conditions, and a higher level of general mistrust in health related information from authorities. The miniaturization of community, i.e. the combination of good access to social participation combined with low trust may be of special importance in this regard. High levels of social participation for people with low trust may provide more effective channels to access and consume alcohol compared with the possibilities for the low social capital category (low social participation/low trust).
The miniaturization of community has been founded as a concept by Fukuyama in the meaning of generalized trust in other people. However, generalized trust in other people has also been demonstrated to be strongly positively associated with political trust and trust in the institutions of society (Brehm and Rahn, 1997), which implies that the results of this study may reflect both the high alcohol consumption above recommended levels in relation to the miniaturization of community and in relation to lack of political and institutional distrust.
Previous work shows that high social capital and the miniaturization of community have significantly higher prevalences of all the 13 activities in the social participation index variable than the two categories that contain low social participation. Comparisons between the high social capital and the miniaturization of community categories show that study circles at work, other study circles, meetings of other organisations, theatre/cinema, arts exhibition, and gathering of relatives are more prevalent in the high social capital category than in the miniaturization of community category. In contrast, having visited a night club/entertainment during the past year is significantly more prevalent in the miniaturization of community category than in the high social capital category (Lindström, 2003).
The results of this study have direct implications for prevention. High alcohol consumption is not significantly associated with social participation, but significantly and positively associated with low trust and the miniaturization of community (the combination of high social participation and low trust) among men. High social participation combined with low trust thus seems to promote high alcohol consumption among men. Norms and values in general and in particular instances, e.g. high alcohol consumption, are formed in the socialization process during childhood and adolescence. Trust in other people is closely associated with the socialization process during adolescence. Putnam (2000) has also convincingly demonstrated that the decrease in trust in the USA is a birth cohort phenomenon rather than a period phenomenon. The importance of both family, school and peer supervision, and the formation of norms and values have been emphazised (Battistich and Hom, 1997
). It is possible that both the formation of norms and values concerning alcohol consumption and the formation of generalized trust in other people which most importantly occur during adolescence should be seen in a life course perspective by targeting adolescents and young adults in the prevention of high alcohol consumption.
The second line of preventive strategies would be measures to restrict alcohol availability in the adult population. Historical data on alcohol consumption in Denmark and Sweden during the course of the twentieth century suggest that consumption levels in both countries clearly correlate with the extent to which alcohol availability was restricted (in Denmark high prices and in Sweden restrictions on amounts) (Lindström, 2005c). The findings in the present study suggest that men with psychological traits such as low trust have high alcohol consumption to a higher extent than other men. This is also particularly observed among low trust men with high social participation, i.e. access to social activities and social networks seems to increase access to alcohol among these low trust men, who for psychological reasons might have the preconditioning for high alcohol consumption. Similar findings have been observed in a previous study concerning cannabis smoking among young men (Lindström, 2004b
).
![]() |
CONCLUSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
APPENDIX |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The first question is: When did you drink wine, liquor, or beer at the latest occasion? (If this occurred during the past 30 days, the alcohol consumption of the respondent was calculated.)
The next question is: How many days during the past 30 days have you consumed beer? (The respondent could respond 030 days).
The following question is: If you consumed beer, how much beer did you on average consume on each day you consumed beer? (The number of bottles (33 cl) and cans (45 cl) was recorded.)
The same two questions were asked for wine and liquor/spirits. (Wine: glasses of 12 cl/day, half bottles 37 cl/day, and whole bottles 75 cl/day; liquor/spirits: drinks 46 cl/day, half bottles 37 cl/day, and whole bottles 75 cl/day.)
Binge drinking was assessed by separate questions: How many days during the past 30 days did you consume more than five bottles (33 cl) or four cans (45 cl) of beer? (Respondents were asked to answer 030 days.)
Similar questions were asked concerning the number of days during the past month the respondent consumed more than one bottle of wine and >37 cl of liquor/spirits in one single day.
The alcohol consumption in centilitres pure alcohol per day was then calculated as the average (beer + wine + liquor)/spirits consumption in all normal days (days without binge drinking) and the binge drinking days (separately), then normal days and binge drinking days were added together.
![]() |
ACKNOWLEDGEMENTS |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Battistich, V. and Hom, A. (1997) The relationship between student's sense of their school as a community and their involvement in problem behaviours. American Journal of Public Health 87, 19972001.[Abstract]
Bourdieu, P. (1986) The forms of social capital. In The handbook of theory: research for the sociology of education. Richardson, J. G. ed., pp. 241258. Greenwood Press, New York.
Brehm, J. and Rahn, W. (1997) Individual-level evidence for the causes and consequences of social capital. American Journal of Political Science 41, 9991023.[ISI]
British Medical Association (1995) Alcohol: guidelines on sensible drinking. (1992) National Institute on Alcohol Abuse and Alcoholism. Alcohol alert No. 16 PH 315, London.
Carlsson, F., Merlo, J., Lindström, M. et al. (2005) Representativity of a postal health questionnaire survey in Sweden, with special references to ethnic differences in participation. Scandinavian Journal of Public Health, in press.
Centralförbundet för alkohol- och narkotikaupplysning (The Central association for Alcohol- and Narcotics Information). (2002) Drogutvecklingen i Sverige (Trends in alcohol and other drugs in Sweden). Report 2002. Stockholm.
Coleman, J. (1990) Foundations of social theory. Harvard University Press, Princeton.
Dawson, D. A. (2003) Methodological issues in measuring alcohol use. Alcohol Research and Health 27, 1828.[ISI][Medline]
Fukuyama, F. (1995) Trust. The Social Virtues and the Creation of Prosperity. The Free Press, New York, London, Toronto, Sydney, Tokyo, Singapore.
Fukuyama, F. (1999) The Great Disruption. Human Nature and the Reconstitution of Social Order. Profile Books, London.
Granovetter, M. (1973) The strength of weak ties. American Journal of Sociology 78, 13601380.[CrossRef][ISI]
Hanson, B. S., Östegren, P. O., Elmståhl, S. et al. (1997) Reliability and validity assessments of measures of social network, social support and control-results from the Malmö Shoulder and Neck Study. Scandinavian Journal of Social Medicine 25, 249257.[ISI][Medline]
Holmberg, S. and Weibull, L. (1996) "Förtroendets fall" (The fall in confidence) Ett missnöjt folk (A dissatisfied people). Holmberg S, Weibull L, eds, SOM Rapport no. 18. SOM-institutet, Göteborg.
Kawachi, I., Colditz, G. A., Ascherio, A. et al. (1996) A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. Journal of Epidemiology and Community Health 50, 245251.[Abstract]
Kawachi, I., Kennedy, B. P., Lochner, K. et al. (1997) Social capital, income inequality, and mortality. American Journal of Public Health 87, 14911498.[Abstract]
Kawachi, I., Kennedy, B. P. and Glass, R. (1999) Social capital and self-rated health: a contextual analysis. American Journal of Public Health 89, 11871193.[Abstract]
Kuo, M., Adlaf, E. M., Lee, H. et al. (2002) More Canadian women students drink but American students drink more: comparing college alcohol use in two countries. Addiction 97, 15831592.[CrossRef][ISI][Medline]
Lindström, M. (2003) Social capital and the miniaturization of community among daily and intermittent smokers: a population-based study. Preventive Medicine 36, 177184.[CrossRef][ISI][Medline]
Lindström, M. (2004a) Social capital, the miniaturization of community and self-reported global and psychological health. Social Science and Medicine 59, 595607.[CrossRef][ISI][Medline]
Lindström, M. (2004b) Social capital, the miniaturization of community and cannabis smoking among young adults. European Journal of Public Health 14, 204208.
Lindström, M. (2005a) Social capital, the miniaturization of community and consumption of home made and smuggled liquor during the past year: a population-based study. European Journal of Public Health, in press.
Lindström, M. (2005b) Ethnic differences in social participation and social capital in Malmö, Sweden: a population-based study. Social Science and Medicine 60, 15271546.[CrossRef][ISI][Medline]
Lindström, M. (2005c) Price restrictions and other restrictions on alcohol availability in Denmark and Sweden: a historical perspective with implications for the current debate. Scandinavian Journal of Public Health 33, 156158.[ISI][Medline]
Lindström, M. and Axén, E. (2004) Social capital, the miniaturization of community and assessment of patient satisfaction in primary health care: a population-based study. Scandinavian Journal of Public Health 32, 243249.[CrossRef][ISI][Medline]
Loury, G. (1992) The economics of discrimination: getting to the core of the problem. Harvard Journal of African American Public Policy I, 91110.
Macinko, J. and Starfield, B. (2001) The utility of social capital in research on health determinants. The Milbank Quarterly 79, 387427.[CrossRef][ISI][Medline]
Murray, C. J. and Lopez, A. (1996) Quantifying the burden of disease and injury attributable to ten major risk factors. In The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020, Murray, C. J. and Lopez, A., eds, pp. 295327. Harvard School of Public Health on behalf of the WHO, Cambridge, MA.
National Central Bureau of Statistics (1980) Living conditions. Isolation and togethernessAn outlook on social participation 1976. Report no. 18. The National Central Bureau of Statistics, Stockholm.
National Public Health Report (2001) The Swedish National Board on Health and Welfare, Stockholm.
National Public Health Report (2005) The Swedish National Board on Health and Welfare, Stockholm.
Norusis, M. J. (2000) SPSS for Windows. Advanced Statistics. Release 10.0. SPSS Inc., Chicago.
Putnam, R. D. (1993) Making Democracy Work. Civic Traditions in Modern Italy. Princeton University Press, Princeton.
Putnam, R. D. (1995) Bowling alone: America's declining social capital. Journal of Democracy 6, 6578.[ISI]
Putnam, R. D. (2000) Bowling Alone. The Collapse and Revival of American Community. Simon and Schuster, New York, London.
Rehm, J., Room, R., Monteiro, M. et al. (2004) Alcohol use. In Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, Vol. 1, Ezzati, M., Lopez, A. D., Rodgers, A. and Murray, C. J. eds, pp. 9591108. WHO, Geneva.
Rothstein, B. (2003) Sociala fällor och tillitens problem (Social traps and the problems with trust). SNS Förlag, Stockholm.
Rueschemeyer, D. and Evans, P. (1985) The state and economic transformation: Toward an analysis of the conditions underlying effective intervention. In Bringing the State Back in, Evans, P., Rueschemeyer, D. and Skocpol, T., eds, pp. 4477. Cambridge University Press, New York, Cambridge.
|