Alcohol use is an important public health problem, especially in developing countries like India. There was a marked variation between World Health Organisation sub–regions on average volume of alcohol consumption and patterns of drinking. Average volume of drinking was highest in established market economies in western Europe and the former socialist economies in the eastern part of Europe and in north America and it was lowest in the eastern Mediterranean region and parts of southeast Asia, including India . A recent study highlighted that in India, health loss from alcohol will grow even larger, unless effective interventions and policies are implemented to reduce these habits .
Very few community-based studies have been conducted on the prevalence of alcohol use in India [3–6]. There is a paucity of data on pattern and associated factors of alcohol use, which may be different in different geographical locations. Such studies will be useful for understanding the problem of alcohol use and for taking specific interventional measures at the community level. So, we conducted a cross sectional study to determine the prevalence of alcohol use, its associated factors and pattern of alcohol use in rural Tamil Nadu, southern India.
Material and Methods
Setting and Study Design
This cross sectional study was conducted during August to October 2012 in Vanur village of Vanur Taluk, in the Villupuram district of Tamil Nadu. Vanur village, with a population of 1500, comes under Vanur Commune Panchayat (with a total population of 9000).
Sample Size Estimation
Minimum sample size required was 1000 subjects, based on 10% prevalence rate , a precision of 20% and a non–response rate of 10%. We decided to include residents who were aged 10 years and above, from the selected area, as study subjects .
After obtaining their informed consent, the respondents were interviewed by using a structured questionnaire. Data on socio-demographic details and presence of any chronic morbid conditions were collected. Data on consumption of alcohol and tobacco was also collected. Socio-economic status was assessed, based on the modified BG Prasad classification (year 2004) scale. A history of smoking or tobacco chewing in the preceding month of the survey was considered for presence of smoking or tobacco chewing habits. A subject who consumed alcohol in the past 12 months was taken as the criteria for defining alcohol use. A pre- tested and validated AUDIT (Alcohol Use Disorders Identification Test) questionnaire was used to assess the pattern of alcohol use [8,9]. This was translated to the local language (Tamil) and it was translated back into English to ensure its reliability and validity. Data on hazardous level drinking (items: frequency of drinking, quantity and frequency of heavy drinking), dependence symptoms (items: an impaired control over drinking, an increased salience of drinking and morning drinking) and harmful alcohol use (items: guilt after drinking, blackouts, alcohol–related injuries and others which were concerned with drinking) were assessed, based on the scoring of above items in respective categories. Total scores of 8 or more were recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. A pilot test was conducted before initiation of the study, to look for the feasibility of administration of questionnaire.
Method of Data Collection
Prior permission was obtained from the village president and local leaders for conducting the study. A village leaders meeting was conducted, during which the purpose of the study methods which had to be adopted and the possible implications of the results were discussed. Following the village leaders meeting, village mapping and social mapping of the area was done, in order to know the study area and to plan for data collection. Data was collected by making house to house visits and interviewing the subjects by using the questionnaire. Informed consent was obtained from the study subjects. If the designated house was locked during the visit, household members in the next house were considered as study subjects. This study was done as a part of a community diagnosis posting for medical students, who were given training on administration of questionnaire and data collection process, under the supervision of the investigators.
Data was entered and analysed by using SPSS (Statistical Package for Social Sciences) version 16.0 for Windows. The findings were expressed in terms of proportions and mean, SD. A univariate analysis was carried out to test the association between socio-demographic and other factors and alcohol use. To determine the independent effect of various factors on alcohol use, a multiple logistic regression analysis was performed and their significance was estimated in terms of adjusted Odds Ratio and its 95% confidence interval. P values of less than 0.05 were considered as significant.
A total of 946 subjects who were in the age group of 10 years and above were analysed, with a response rate of 94.6%. Most of the subjects were in the 15–44 year age group (497, 52.5%). Overall, the prevalence of alcohol use was found to be 9.4% and prevalence of hazardous or harmful use of alcohol was 3.7% (based on the cut off value of ≥8 on AUDIT). Mean age at initiation was found to be 25.3 years (SD–9.0). Two thirds of alcohol users belonged to the age group of 15–44 years (59, 66.3%). Around 1/3rd (32.6%) of them had a preference for local arrack [Table/Fig-1].
Characteristics of alcohol use among the subjects (n=89)
|Type of alcohol preference|
|Others (Mixed)||5 (5.6)|
|Risk level scoring|
|Zone 1 (0-7)||54 (60.7)|
|Zone 2 (8-15)||22 (24.7)|
|Zone 3 (16-19)||9 (10.1)|
|Zone 4 (20-40)||4 (4.5)|
Prevalence of alcohol use was more among males (16.8%) as compared to that in females (1.3%). Male gender, lower education and income levels, tobacco use, smoking and presence of chronic diseases were found to be significantly associated with alcohol use on univariate analysis [Table/Fig-2]. A multiple logistic regression analysis revealed that adult age group (15–44 years) (OR=3.56), male gender (OR=11.23), illiteracy (OR=6.16), lower education levels (OR=2.57) and smoking (OR=17.78) were independently associated with alcohol use [Table/Fig-3].
Associated factors of alcohol use among the study subjects (n= 946)
|Associated factors||Total number of subjects||Number of subjects with alcohol use (%)||χ2, p value|
|10-14||211||0 (0)||28.307, <0.001*|
|1st to 10th standard||562||62(11.0)|
|Monthly per capita income (in Rupees)|
|≥2756 (Class1)||60||12(20.0)||15.128, 0.004*|
|1376-2755 (Class 2)||502||34(6.8)|
|826-1375 (Class 3)||198||20(10.1)|
|411-825 (Class 4)||148||20(13.5)|
|≥ 410 (Class 5)||38||3(7.9)|
*P value less than 0.05 is considered as significant.
Correlates of alcohol use: Multiple Logistic Regression analysis
|Variables||Odds Ratio Adjusted (95%CI)||p value|
|1st to 10th standard||2.573 (1.255-5.275)||0.01*|
|Monthly family income (in Rupees)|
|≥2756 (Class 1)||1.954 (0.388-9.831)||0.417|
|1376-2755 (Class 2)||1.784 (0.412-7.714)||0.439|
|826-1375 (Class 3)||2.023 (0.447-9.158)||0.360|
|411-825 (Class 4)||1.287 (0.284-5.846)||0.743|
|≥ 410 (Class 5)||–||–|
* p value less than 0.05 is considered as significant.
It was seen that a majority (60.7%) of the alcohol users belonged to the risk zone level 1, on AUDIT scores. On analysis, as per the domains and item content of AUDIT for severity of alcohol use, it was observed that 56% fell in the pattern of harmful alcohol use. Among the current users of alcohol, around 30% and 33.7% of them had hazardous drinking levels and dependency levels respectively.
Few studies have been conducted in the past, to determine the pattern of alcohol use in general population in India [3–6,10–12]. A recent study which was done in a slum area in Kolkata among men, reported the prevalence of alcohol consumers to be 65.8% , while a Vellore study reported that alcohol use in the past year was 34.8% . A study which was done in Faridabad showed the prevalence of alcohol use to be 24.6% among men, while none of the women had used alcohol . In contrast, our study showed that prevalence of alcohol use was 1.3% among females.
In contrast to our findings, studies in other countries showed higher prevalence rates of alcohol use. A study from Russia found that 75% of the men drank spirits , while a Thailand study which was done among subjects who were aged 12-65 years, showed the prevalence of current drinkers to be 28.6% . A study which was done in Finland showed the prevalence of hazardous drinking to be 5.8% . The difference which was observed in prevalence may be due to difference in the exposure status of associated risk factors in different geographical locations. Definition and instrument which were used to define alcohol use, age group which was studied, methodology which was adopted and urban-rural difference may be the factors which are responsible for this varied observation.
Male gender and adult age group were found to be independently associated with an increased risk of alcohol use in another study . Similarly, it was found that illiteracy and lower educational levels were associated with an increased risk of alcohol use in the general population . Various studies have shown that smoking was one of the important factors which was associated with alcohol use, as was seen in our study also [7, 16, 17]. However, income was not found to be associated with alcohol use, as was found in another study . A study from Vellore reported that hazardous alcohol use in the past year was 14.2% as compared to a 30% use in our study . A study among industrial workers in Goa showed the prevalence of hazardous drinking to be 21% , while another study which was done in the same place among general practice attendees, showed the prevalence of harmful drinkers to be 8.2% . Another study which was done in north India showed that 48.5% of alcohol users had ≥8 AUDIT scoring, which is slightly higher than that in our study . AUDIT is as an epidemiological tool that can be used in surveys of health clinics, health service systems, and general population samples and it was developed as an international instrument. It is one of the best screening instruments for alcohol consumption and for related risks in primary care settings and in community surveys. AUDIT scores between 8 and 15 (zone II – medium level of alcohol problems) are most appropriate for simple advice which is focused on the reduction of hazardous drinking; while scores between 16 and 19 suggest a brief counseling and a continued monitoring. AUDIT scores of 20 or above warrant a further diagnostic evaluation for alcohol dependence. Health education sessions on harmful use of alcohol and referral services were conducted among the village population at the end of the survey. This community based, cross sectional study gives valuable information on alcohol use in the general population with the use of a standard instrument. Such data can be beneficial in formulating strategies for reducing alcohol use in the community and for offering support services. This study has its own limitations. An in depth evaluation of the reasons for initiation of alcoholism was not done and the past drinking profile was not assessed due to feasibility constraints. There was under reporting, which was due to a recall bias. Longitudinal studies will be required to look further into the associated factors of alcohol use and its consequences.
Alcohol use is an important public health problem in this area, especially due to the high prevalence rate and a larger involvement of adult age group. Prevalence of alcohol use is high, especially among males. Health educational interventions and proper treatment may help in reducing the burden of alcohol use in this area.*P value less than 0.05 is considered as significant.* p value less than 0.05 is considered as significant.