European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
Received 10 January 2000; in revised form 3 May 2000; accepted 21 May 2000
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ABSTRACT |
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INTRODUCTION |
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It has been recognized for many years that the prevalence of problem drinking is especially high among hospitalized patients (Jarman and Kellet, 1979), although reported levels vary widely depending on the population studied and the method of screening used (Pearson, 1962; Green, 1965
; Nolan, 1965
; Barcha et al., 1968
; Moore, 1971
; McCusker et al., 1975; Jariwalla et al., 1979
; Barrison et al., 1982
; Taylor et al., 1986
; Mansoor and Edwards, 1991
; Umbricht-Schneiter et al., 1991
). Outside specific surveys, however, the scale of the problem is often overlooked and many patients with alcohol-related problems are unrecognized by their physicians (Moore et al., 1989
). This is unfortunate, because a hospital admission offers potential to intervene and there is some evidence that brief interventions, including patient assessment and education, counselling, goal setting, and monitoring of liver enzyme levels can be effective in reducing alcohol consumption (Kahan et al., 1995
).
Locally conducted surveys of the frequency of problem drinking among hospitalized patients can be used to draw attention to the scale of the problem and to act as a baseline against which to monitor future trends. Despite the high burden of disease attributable to alcohol, such surveys have not previously been undertaken in Hungary. The present paper addresses these issues.
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METHODS |
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An instrument was designed and piloted that incorporated three sets of questions: demographic characteristics, screening for hazardous and problem drinking, and details on cause of admission and on alcohol consumption in the previous week (or, for those recording no consumption in the previous week, consumption in the previous month). Data were collected by medical students, typically in the day following admission, using interviews with patients and extraction of data from case notes. The medical students underwent two training periods, each lasting half a day. The first session covered the aims of the survey and clarified their understanding of the meaning of each question. The second involved observation of actual interviews with subjects, followed by feedback and discussion. The training emphasized the importance of a consistent administration of the interview.
Survey instruments
Several methods have been used to identify excessive or problem-drinking among hospitalized patients (Chick, 1994). They include questionnaires on consumption, drinking diaries, physical examination, and biological markers, any of which may be used alone or in combination (Centre for Reviews and Dissemination, 1993
). Survey instruments include interviews and self-completed questionnaires. Most are designed to detect alcoholism (ICD-8) or alcohol dependence and alcohol abuse (ICD-9; DSM-IIIR criteria).
LAST (Luebeck Alcoholism Screening Test) is a 7-item questionnaire [two questions derived from CAGE (Ewing, 1984) and five from MAST (Seltzer, 1971
)] that has been shown to have a higher sensitivity than CAGE or MAST among hospitalized patients (Rumpf et al., 1997
). Although LAST is essentially a questionnaire to detect alcohol misuse and dependence, it differs from AUDIT in that it asks about lifetime problems. The cut-off score of
2 has been used in this study.
AUDIT (Alcohol Use Disorders Identification Test) was developed by a World Health Organization working group (Babor et al., 1987) to be a brief, culturally generalizable screening tool for early identification of problem drinking, rather than for identification of alcohol dependence. The original AUDIT instrument consisted of a questionnaire combined with a clinical examination. A subsequent development process produced a 10-item questionnaire. This has been designed specifically to facilitate international comparisons (Saunders et al., 1993a
). The initial validation was undertaken in Australia, Bulgaria, Kenya, Mexico, Norway and the USA (Saunders et al., 1993b
). The threshold for AUDIT above which problem drinking is defined has been the subject of discussion, as there is, inevitably, a trade-off between sensitivity and specificity. However, a score of
8 is now considered to be optimal (Cherpitel, 1995
; Conigrave et al., 1995
) and this was adopted in the present study.
LAST and AUDIT were chosen for their superior performance and international transferability. Both instruments were used because, when seeking information on the relationship between disease and alcohol consumption, it is relevant to consider both current and lifetime problem drinking. LAST asks questions about lifetime drinking, whereas AUDIT asks only about the previous year. The instruments were translated into Hungarian, with translation being checked through blind back translation.
Although it was not possible to undertake a comprehensive validation of the instruments in the Hungarian population, the performance of the two instruments was compared, reliability was examined using Cronbach's alpha test, and the results were compared with both physician and self-reports of alcohol consumption and related problems. Analyses were undertaken using the Statistical Package for Social Sciences.
The sample consisted of 3140 patients: 33.7% were in the University Hospital in Debrecen, 19.7% each in Pécs and Szeged, and 26.8% in Budapest; 52.4% were female; 42% were under the care of specialists in internal medicine; 28% surgery; 11% traumatology; 10% neurology, 5% respiratory medicine; and 4% psychiatry.
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RESULTS |
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Performance of survey instruments
Within each instrument, responses were consistent, with Cronbach's alpha scores of 0.76 for LAST and 0.83 for AUDIT (values in excess of 0.70 are generally taken as indicating reliability (Nunally, 1978). Item-to-total correlations were also calculated. Within LAST, the highest correlation was for ever feeling that one should cut down drinking (r = 0.77) and the lowest was for not always being able to stop when wanting to (r = 0.49). For AUDIT, the highest correlation was for frequency of heavy drinking (r = 0.79) and the lowest for someone being injured by one's drinking (r = 0.49).
Quantity and frequency of drinking
The self-reported quantity and frequency of drinking is shown in Table 1, which also shows the percentage of individuals in each quantity/frequency category who were identified by AUDIT as problem drinkers. As shown, 23.5% of men and 53.5% of women reported never drinking alcohol. Of those who did drink, about one in 10 men and less than 1% of women reported drinking 5 or more drinks on a day when they drank.
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Regardless of the instrument used, problem drinking was most common in the age band 3544 years, in which about a third of men were so categorized. Problem drinking was especially common among divorced men and divorced and cohabiting females. There was no obvious association with either employment or education.
A total of 22.5% of men and 5.5% of women had consumed alcohol in the 48 h prior to admission; 8.3% of men and 3% of women reported that they considered alcohol to have contributed to their admission to hospital. Of these, among men, 80.6% thought that this had been due to their own consumption of alcohol, 6.5% to that of others, and 9.7% to both. The corresponding figures for women were 53.8%, 38.5% and 7.7%.
There was, as expected, a large difference in the percentage of patients defined as current or lifetime problem drinkers (subjects meeting criteria on either AUDIT or LAST or both) among those with different diagnoses. Because there were very few women categorized as problem drinkers, data are presented for men only (Table 3). The diagnostic categories used are, inevitably, somewhat arbitrary but have been designed to be clinically meaningful in the context of a study of alcohol use. The other diagnoses was largely made up of patients undergoing elective surgery or with neurological or dermatological disorders. The categories used were derived from the case notes which were coded using ICD-10. Two-thirds of men with chronic liver disease were, or had been, problem drinkers. The prevalence of problem drinking was also high among those with tuberculosis and cardiomyopathy.
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DISCUSSION |
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It is possible that the figures obtained may under-estimate the scale of the drinking in Hungary. First, although the medical students underwent training and the importance of consistency was stressed, they may have under-estimated the extent of problem drinking as their results were not validated against a gold standard. Second, especially among the elderly, there may, as in some other countries, be a tendency by some people claiming to be abstainers to discount consumption that is viewed as medicinal.
There are no directly comparable data on the quantity/frequency of drinking in the general population in Hungary. However, a Health Behaviour Survey undertaken in 1994, which provided a nationally representative sample of the population aged 1564 years, reported frequencies of drinking that are similar to those reported in this hospitalized population (Central Statistical Office, 1996): 22% of men (23.5% in this survey) and 47.1% of women (53.5% in this survey) were abstainers; 24.9% of men (23%) and 3.2% of women (2.9%) drank daily. Unfortunately, only overall figures from this survey have been published, and so it is not possible to adjust for age. The hospitalized population is, however, somewhat older than the general population. In most societies, older age groups consume less alcohol than younger people. Thus, had it been possible to adjust for the different age distributions, the comparable population rates could be expected to be lower. The frequency of drinking thus seems to be higher among the hospitalized than the general population, but it is not possible to say by how much.
This study indicates the importance of using more than one instrument. The two used are intended to identify different things and, importantly, examine different periods of time. AUDIT has been found to be especially good at predicting alcohol-related social problems (Conigrave et al., 1995). LAST is intended to detect alcohol dependence or abuse at some time in the past, and thus to indicate the propensity to alcohol-related health problems that might be missed by AUDIT if problem drinking was in the past. The limited evaluation of the instruments is encouraging and concerning. The results obtained indicate that both instruments display a high level of internal consistency in the Hungarian setting. In addition, they have some apparent validity in that they correlate well with measures of quantity/frequency of drinking.
Comparison with similar studies is fraught with problems. First, the threshold for admission and the pattern of disease treated in hospital is likely to vary considerably within and between countries. Second, many studies have used instruments other than LAST or AUDIT. Third, many report on only a selected group of patients, such as those attending an emergency room (Cherpitel, 1998a).
One of the few almost comparable studies is from Belfast, which used the AUDIT Instrument. This found that 30.8% of male and 7% of female in-patients had AUDIT scores of 8 (Sharkey et al., 1996
). The comparable figures in the present study were 18.9% and 1.9% respectively. These seem improbably low in view of the very high level of alcohol-related mortality in Hungary, although the patients served by the Belfast hospital were drawn from a very deprived inner city area with many social problems, and so may be less representative of the overall hospitalized population in Northern Ireland than is the present sample of the Hungarian population.
This study does establish that a substantial proportion of patients in Hungarian hospitals have alcohol-related problems, with, in some age groups, almost a third of hospitalized men so defined. Importantly, it provides a baseline for future measurement and contributes further support to those advocating a concerted policy on alcohol in Hungary (Varvasovszky and McKee, 1998).
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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