Department of Family Medicine, Mercer University School of Medicine, Macon, Georgia, USA
Received 25 April 2001; in revised form 10 August 2001; accepted 15 September 2001
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ABSTRACT |
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INTRODUCTION |
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South American indigenous groups are thought to be ethnically related to North American Native Americans, with anthropologists postulating that all Native American groups entered the Americas through territory that now makes up Alaska (Jennings, 1983; Garbarino and Sasso, 1994
). Little formal alcohol research has been done among South American native groups. Careful scientific study of the characteristics of alcohol problems and their socio-cultural origins among native populations outside the USA has thus far been extremely limited (Heath, 1989
). Literature searches conducted in March, 2001 using both Medline and Lilacs, a database which indexes the Latin American medical literature, found only five studies that examined alcohol use among indigenous Latin American groups, and none which included quantitative evaluation of alcohol use and its consequences.
Venezuela provides some unique opportunities for exploring alcohol problems in indigenous populations. In contrast to Native Americans in North America, indigenous people from this area produced alcoholic beverages prior to European colonization (Carrizales et al., 1986). A number of indigenous groups have retained many of their historical linguistic and cultural patterns. Although occasional contact with Western civilization dates to the 1490s, large-scale daily cultural contact did not occur in some areas until the 1940s, when permanent Catholic missions were built in remote areas (Coppens and Escalante, 1983
). Among several Venezuelan Native American groups, alcohol misuse is reported to be a major problem. The current study was designed to obtain both quantitative and qualitative information on alcohol use patterns and alcohol-related problems in one of these groups.
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SUBJECTS AND METHODS |
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The CAGE screening exam is a four-question alcohol screening instrument designed to elicit signs of alcohol-related problems, including loss of control, annoyance at others' expressed concerns about one's drinking, guilt associated with drinking, and use of alcohol in the morning as an eye-opener. Studies have revealed variability in its sensitivity and specificity, depending on the population surveyed, with sensitivity ranging from 60 to 95% and specificity ranging from 40 to 95% (Beresford et al., 1990). In most studies, patients giving two or more positive answers are considered to have alcohol problems.
The AUDIT is a 10-question alcohol screening instrument developed by the World Health Organization and validated in a six-country sample, from four industrialized and two developing countries (Saunders et al., 1993). Questions included in the instrument showed reliability across a wide range of cultural settings. The AUDIT differs from earlier screening instruments in that its purpose is to identify the early signs of harmful and hazardous drinking as well as dependence. The AUDIT has been shown to be a highly sensitive (80%) and specific (89%) screening instrument in populations containing both daily drinkers and individuals who consume large quantities of alcohol infrequently (Medina-Mora et al., 1998
). The AUDIT has been widely used in alcohol screening in the USA (Fleming et al., 1991
; Isaacson et al., 1994
; Luckie et al., 1995
; Mar et al., 1995
; Rigmaiden et al., 1995
; Schmidt et al., 1995
; Morton et al., 1996
; Matthews, 1997
), Scandinavia (Holmila, 1995
; Seppa et al., 1995
; Gudmundsdottir and Tomasson, 1996
), Western Europe (Sharkey et al., 1996
; Piccinelli et al., 1997
), Australia (Fleming, 1996
) and New Zealand (Poon et al., 1994
; Quarrie et al., 1996
). Application of the AUDIT in developing countries has been more limited (Schoeman et al., 1994
; Guevara-Arnal et al., 1995
).
The first three questions of the AUDIT explore quantity and frequency of alcohol consumption, while the last seven questions explore alcohol-related problems and signs of alcohol dependency. Each question is given a response from 0 to 4 and responses are summed up, giving an alcohol score', for each person, with 40 being the maximum and most severe score. Subjects scoring 8 on the AUDIT are generally agreed to have significant alcohol-related problems (Conigrave et al., 1995
; Medina-Mora et al., 1998
).
A useful but not vigorously validated application of the AUDIT developed by Fleming (1996) allows the classification of problem drinkers into more specific subgroups defined as hazardous, harmful, and dependent drinkers. These three categories are determined as follows. Questions 13 assess the quantity and frequency of drinking, and are used to detect at risk' alcohol consumption. A combined score of 4 classifies drinking as hazardous'. Questions 46 screen for signs and symptoms of alcohol dependence, and a combined score of
4 indicates the existence or emergence of alcohol dependence. Questions 710 enquire about problems caused by alcohol consumption and adverse consequences of drinking. A combined score of
4 indicates the existence of harmful drinking'.
The pilot study involved a convenience sample of 32 adults presenting for clinical attention in primary care outreach clinics conducted by the Zumaque Foundation in three mountain villages of a single sub-tribe. Physicians were asked to interview as many adult patients as possible during a busy outpatient clinic. Patients were selected at the discretion of the physicians, who were likely to select patients in whom alcohol problems were suspected. Episodic binge drinking and alcohol-related problems were reported by both men and women. Alcohol-related problems were significantly more common among men than among women, with men also reporting earlier onset of drinking (mean age 17.5 vs 19.2 years). These findings led to the decision to conduct a prospective population-based household survey.
Because little was known about ideas regarding alcohol use in this indigenous culture, we sought to collect both quantitative and qualitative information regarding alcohol use, its historical and cultural origins, its consequences, and perceptions of individuals regarding the presence or absence or alcohol-related problems. Quantitative data were collected using a revised questionnaire, which included the AUDIT plus the question, Who in your family drinks a lot?' The questionnaire was translated into the tribal language, and two villages accessible by vehicle and to which the non-profit foundation's medical team was well known, were selected for inclusion in the household survey. Permission was obtained from the village chiefs for conducting the study. Inhabitants of these two villages represent two different subtribes. A random sample of half the families in each village was selected by numbering the households and drawing numbers from a hat. House-to-house interviews of all household members 15 years or older were performed by an experienced alcohol investigator (J.P.S.) and two trained high school seniors during April and May of 1997. Investigators worked with local elementary school teachers or nurses, who were fluent in both the tribal language and Spanish. Patients were first questioned in Spanish, and questions were repeated in the tribal language for those who could not understand the Spanish questions. Individuals of other ethnic backgrounds and individuals of mestizo origin (one non-tribal parent or two or more non-tribal grandparents) were excluded from the study. Many individuals who were not a part of the random sample also volunteered to complete the questionnaire, thus information was gathered on additional subjects as well. Results were analysed with 2-tests using SPSS software.
Qualitative data were collected by means of focus groups, which were conducted according to the method described by Varkevisser (1991). In each village, after AUDIT information was obtained, two focus group discussions were held, one involving women and the other involving men. Each group included 1015 participants, who had completed the AUDIT. Based on their answers to the AUDIT, participants were carefully selected to include both the youngest and oldest participants in the study and participants with a wide range of AUDIT scores. One investigator (J.P.S.) directed the discussion in Spanish with the assistance of a community participant fluent in both Spanish and the local language. The oldest participants in each focus group were asked to describe drinking patterns in their villages prior to significant interaction with Venezuelan Creole culture. All participants were asked how their drinking patterns had changed as a result of increasing cultural contact, and whether they perceived that alcohol was causing problems in their communities. Focus groups were tape-recorded. The tapes of all four discussion groups were reviewed by three investigators to determine common answers to the questions asked.
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RESULTS |
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Answers to the AUDIT questions are presented in Table 1. The overall mean AUDIT score was 2.2 for females and 16.2 for males. Using a cut-off score of 8, 7.5% of females and 86.5% of males met overall criteria for problem drinking, resulting in a male:female ratio of 11.5:1 (P < 0.0001).
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Analysis of AUDIT questions 710 revealed that 7.5% of women and 80.8% of men had experienced sufficient consequences from their drinking to be classified as harmful drinkers'. At least one alcohol-associated problem was reported by 75% of past and current female drinkers, and by 100% of male drinkers. Among women, the most frequently reported problems included being advised to cut-down on their drinking (14% of all women) or injury to themselves or others as a result of their drinking (12%). Eighty-three per cent of the males had been advised to cut back on their alcohol consumption, 71% had experienced blackouts, and 65% had felt guilty about their drinking within the past year.
Signs of alcohol dependence (questions 46) were rare among women. Six per cent reported loss of control when drinking, 6% reported needing a first drink in the morning, and 2% reported failing to meet responsibilities because of drinking. No women met AUDIT subscale criteria for alcohol dependence. Among the men, however, 63% were unable to stop drinking once they started, 42% had failed to meet normal obligations due to drinking, and 40% sometimes needed a first drink in the morning. Overall, 36.5% of men met subscale criteria for alcohol dependence. Among subjects actively drinking at the time of the survey, 28.6% of current female drinkers and 79.6% of current male drinkers reported one or more signs of dependence within the past year.
Only 9.4% of women and 15.4% of men denied having any family members who were heavy drinkers. Females reported a mean of 2.1 family members, and males reported a mean of 1.8 family members, who drank heavily or had drunk heavily in the past. Although not all participants described their relationship to drinking members mentioned, 70 (66.7%) listed relatives whom they identified as first degree relatives.
Focus group findings
Participants in all four focus groups described significant alcohol consumption in their villages prior to significant contact with Venezuelan Creole culture. Several times each year, especially during the corn harvest season, the trunk of a large tree would be hollowed out and filled with corn mash by an individual specially chosen by the community. The corn mash would be allowed to ferment to create an alcoholic beverage, with a high enough alcoholic content to cause intoxication after consumption of only two glasses or gourdfuls. When the corn liquor was ready, a village festival would be held in which all adults would drink to the point of falling down. Men would typically bring their bows and arrows and fight to settle grudges. Festivals would end after 2 or 3 days, when the corn liquor ran out. None of the participants could recall individuals who consumed alcoholic beverages at times other than festival celebrations.
With increasing contact with Creole culture, several changes occurred which resulted in changes in drinking patterns. Cash incomes were generated through the sale of cash crops, timber, and through day labour on nearby cattle ranches. Men from the villages began to frequent the bars of nearby towns and consume beer and rum. Drinking to the point of intoxication in town, at times accompanied by fighting, became a frequent pattern for men during harvest times or on payday for those working in ranches. Participants in all four focus groups reported alcohol-related problems, which had developed with these changes in drinking patterns. These included lack of food, medicine, or school supplies for their children after spending all or most of their cash incomes on alcohol, individual cases of trauma from falls, fights, or vehicular accidents (usually bicycles or motorcycles), medical illnesses and family problems (most commonly arguments or fights). Disorderly conduct or fighting would frequently result in individuals being put in village jails, especially on holidays, e.g. the period from 24 December to early January. In each community, both men and women expressed their desire for help in decreasing alcohol-related problems in the community.
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DISCUSSION |
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Alcohol consumption patterns among women differed dramatically from those in men in almost every area. Women reported markedly higher levels of abstinence and markedly lower levels of problem drinking. The prevalence of problem drinking is significantly lower than that of North American Indian women, but slightly higher than rates reported in Mexico (Medina-Mora et al., 1998) and in epidemiological studies of Blacks, Whites and Hispanics in the USA (Helzer et al., 1991
). Nonetheless, binge drinking patterns were evident among women drinkers, with 25% of women typically consuming six or more drinks per occasion and 11% of women typically consuming 10 or more drinks per occasion. This consumption was infrequent, however, with most only consuming alcohol once or twice a year. Though women reported negative consequences of drinking in all areas surveyed, their numbers were small. There was no evidence of alcohol dependence in women, who have infrequent access to alcohol, except during cultural celebrations. This is of interest, in the light of recent studies in both Panama and the USA which indicate that lack of access to psychoactive substances may be a key reason for lower levels of substance misuse problems in women (Delva et al., 1999
).
The focus groups provided information regarding cultural attitudes toward alcohol-related consequences and historical origins of the drinking patterns observed. Awareness of alcohol-related problems was high. Both men and women clearly acknowledged problems in their communities caused by alcohol, including economic, legal, and medical problems, as well as violence. Heavy alcohol use is characteristic of both past and present tribal life. Current alcohol-related problems appear to have their roots in both earlier cultural patterns of alcohol use (i.e. binge drinking when alcohol was available) and in changes that occurred as a result of contact with Western society. Focus group participants described a long-standing cultural pattern of episodic heavy drinking, followed by fighting, during festival celebrations. This pattern has also been observed by anthropologists who have studied tribal groups of Carib origin (Coppens and Escalante, 1983). Alcohol consumption has apparently escalated as a result of greater contact with Western society. Whereas previously availability was limited to certain occasions and to the amount which could be produced in one tree trunk, it is now available in virtually unlimited quantities in Venezuelan towns and cities. It is of interest that those who report having drunk traditional corn liquor are more likely to manifest alcohol-related problems. Changes appear to parallel those described by Natera (1987) in rural areas of Mexico, in which commercial beverages gradually replaced autochthonous ones, and more frequent consumption replaced occasional ritual or festival use. The result has been a progressive increase in alcohol misuse which has paralleled increases in cash incomes. One interesting area for future study would be to examine in a more systematic way whether increasing levels of acculturation correlate with more advanced alcohol problems.
Another interesting finding of this study is the similarity between the drinking patterns in this South American Indian culture and drinking patterns observed among Native American populations in the USA. Both groups demonstrate periodic, explosive' episodes of group drinking marked by drinking to intoxication, and displays of aggression, with alcohol rapidly consumed until the supply is exhausted or drinkers pass out (Weibel-Orlando, 1989). These similarities are present, despite the marked differences in historical exposure to alcohol in these widely separated regions. Most Native Americans in the USA and Canada, for example, had no exposure to alcoholic beverages prior to the arrival of Europeans (Heath, 1989
). In South America, on the other hand, fermented beverages have been consumed for centuries, with Christopher Columbus reporting sampling of fermented beverages made by the indigenous peoples upon arrival to the coast of Venezuela in the 1490s (Carrizales et al., 1986
). It would be intriguing to study genetic markers, such as those recently described by Long et al. (1998), among Native Americans in both the USA and Venezuela to ascertain whether these similarities in drinking patterns might be associated with genetic factors common to both groups. Further exploration of problem drinking in this tribe could test the hypothesis that individuals who had greater contact with Western society, or came from families with more Western contact, were more likely to have problems. Another area warranting further study involves analysis of factors which may account for differences between this tribal group and a neighbouring tribe, which has remained even more isolated from Western society, has no corn liquor tradition, and has a very low prevalence of alcohol problems.
There are several limitations of this study. One is the small sample size. Though overall numbers are small, our random sample represents ~5% of the adult population of the entire tribe and our combined adult sample (the random sample plus 72 additional adult subjects who completed the questionnaire) represents some 9%. We believe, however, that this percentage is large enough to draw meaningful conclusions. Another limitation is the fact that the study villages could have exaggerated levels of alcohol problems due to greater access to Venezuelan towns than other villages in more remote mountain areas. In an attempt to address this limitation, we analysed non-random data collected during the course of this study from the 72 additional subjects from five other more remote villages. We found the prevalence of alcohol problems in more remote villages to be even higher than that of our population-based sample, although the non-random sample selection may have influenced these results. A third limitation of the study is the possible misinterpretation of focus group findings, due to mistranslation or differences in cultural understanding. We believe this to be unlikely, since translation was performed by educated tribal individuals with a solid understanding of both their tribal culture and the larger Venezuelan society. Another limitation is the possibility of incomplete information because of participants' reluctance to disclose or freely discuss alcohol problems with outsiders. Both the high level of alcohol problems reported and the low refusal rate would seem to indicate that this was not the case.
In conclusion, the use of the AUDIT questionnaire, followed by focus group discussions, revealed a high prevalence of alcohol-related problems in this South American indigenous group, especially among men. Patterns of alcohol consumption, including heavy occasional binge drinking, drinking to intoxication, and frequent fighting while intoxicated, parallel patterns seen among many North American groups, to whom they are believed to be ethnically related. Women showed higher rates of abstinence and lower rates of problem drinking, perhaps due in part to lesser access to alcohol. Focus groups revealed apparent contributing factors in both cultural patterns of alcohol use and the consequences of contact with Western civilization. The high level of awareness of alcohol-related problems and an interest in finding solutions indicate the need to mobilize resources to assist community leaders in promoting local norms to help limit alcohol misuse and in offering assistance to problem-drinkers who wish to reduce their consumption.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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