Original Article Journal of Addictions Nursing & Volume 25 & Number 1, 41Y47 & Copyright B 2014 International Nurses Society on Addictions
Harmful Alcohol Use Among Aboriginal People in Southern Taiwan The Prevalence, Correlates, and Adverse Drinking Effects Mei-Hua Wang, RN, MSN m Chien-Hung Lee, PhD m Chien-Yu Lai, RN, PhD m Ke-Hsin Chueh, RN, PhD m Cheng-Fang Yen, MD, PhD m Mei-Sang Yang, RN, PhD
Abstract This cross-sectional study aims to examine the prevalence and correlates of harmful alcohol use among aboriginal people in southern Taiwan and to examine the associations between harmful alcohol use and adverse drinking effects. Four hundred forty-nine aboriginal adults were recruited from two townships in southern Taiwan to complete the questionnaires. Among the aborigines, 59.7% scored an 8 or above on the Alcohol Use Disorders Identification Test, including 26.7% who were found to be hazardous drinkers (AUDIT level II), 18.5% who were harmful drinkers (level III), and 14.5% who were with likely dependence (level IV). Male aborigines who participated less in religious activities, had stressful life events, were cigarette smokers, or were betel quid chewers were more likely to have harmful alcohol use. Harmful alcohol use was also associated with an inability to work and with arguments with other people. Our study suggests that aboriginal people in southern Taiwan experience alcohol-related risks at rates as high as other worldwide populations for which AUDIT results are available. Individuals with AUDIT scores at levels II and III are generally candidates for brief interventions delivered in generalist health settings. Individuals with AUDIT scores at level IV should be referred for an addiction specialty evaluation and possible treatment as well as lower-risk individuals (those with AUDIT levels IIYIII) if they have concurrent physical or psychiatric disorders.
Mei-Hua Wang, RN, MSN, College of Nursing, Kaohsiung Medical University, and Department of Nursing, Meiho University, Taiwan. Chien-Yu Lai, RN, PhD, and Mei-Sang Yang, RN, PhD, College of Nursing, and Chien-Hung Lee, PhD, Department of Public Health, Kaohsiung Medical University, Taiwan. Ke-Hsin Chueh, RN, PhD, Department of Nursing, Fe Jen Catholic University, Taipei, Taiwan. Cheng-Fang Yen, MD, PhD, Department of Psychiatry, Kaohsiung Medical University Hospital, Taiwan. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Mei-Sang Yang, RN, PhD, College of Nursing, Kaohsiung Medical University, No. 100, Shi-Chuan 1st Rd., San Ming Dist., Kaohsiung 80708, Taiwan, ROC. E-mail: [email protected] DOI: 1097/JAN.0000000000000021 Journal of Addictions Nursing
Keywords: aboriginal people, adverse effects, harmful alcohol use, prevalence
INTRODUCTION Excessive alcohol use is a global health concern (Chen & Yin, 2008). Alcohol intake in excess can increase one’s risk for hypertension, coronary heart disease, stroke, liver disease, cancer, the early onset of dementia, and falls (Coulton et al., 2008; Epstein, Fischer-Elber, & Al-Otaiba, 2007; Room, Babor, & Rehm, 2005). Those who drink alcohol in excess exhibit mood imbalances, anxiety, poor relationships, a poor quality of life (Dawson, Grant, Chou, & Stinson, 2007), and self-harm (Li, 2007). In addition, these individuals can be easily victimized by criminals and are more prone to injuries (Room et al., 2005), accidents (Li, Tsai, Hu, & Wang, 2006), and occupational disabilities (Hwu, Yeh, & Yeh, 1989) than those who do not drink excessively. Studies have found that alcohol use can be associated with race, traditional culture, socioeconomic status, religion (Chen & Yin, 2008), chewing betel quid (Liang, Chou, Ho, Shieh, & Yang, 2004; Lin et al., 2006; Wu, Liu, Fang, Hsu, & Sun, 2006), and smoking tobacco products (Aekplakorn et al., 2008; Shah, Bazargan-Hejazi, Lindstrom, & Wolf, 2009; Wu et al., 2006). Stress in daily life (Cheng & Loh, 2007), poor family function, and inadequate social support have also been associated with excessive alcohol use (Lai, 2008). People at risk for excessive alcohol consumption are generally younger (Shah et al., 2009), men (Gomberg, 2003; Liang et al., 2004; Shah et al., 2009; Walitzer & Dearing, 2006), and single (Liang et al., 2004; Shah et al., 2009). Men are three times as likely to be diagnosed with an alcohol problem (Lai, 2008). Drinking behaviors vary greatly among people of different ethnic and cultural backgrounds (Chen & Yin, 2008). In Taiwan, alcohol consumption is a part of the aboriginal culture and occurs regularly during marriages, funerals, entertainment, social contacts, and sacrificial offerings (Huang, 2008). The prevalence of alcohol addiction among aboriginal communities was 1% in 1940, 10% in 1980, and 15%Y25% in 2000 (Yang, 2004). Among the Bunnun tribe, 38% experienced alcoholism, and 19% of the Atayal tribe in central Taiwan were found to be alcoholic people in 2006 (Lai, 2008). During 2003 and 2004, the prevalence of alcohol consumption during pregnancy among the aboriginal women has been found to range from 27.2% to 31.9% in www.journalofaddictionsnursing.com
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southern and eastern Taiwan (Chou, Yang, Kuo, Chan, & Yang, 2009; Yang et al., 2008). In addition, 46% of the aboriginal inpatients in a general teaching hospital in eastern Taiwan were found to have alcohol use disorders (Wu et al., 2006). According to the annual report on aboriginal health statistics from the Council of the Indigenous People of Taiwan, the 10 leading causes of death among the aboriginal people have been strongly correlated with excessive alcohol consumption (Council of Indigenous People, 2009). The life expectancy of the aboriginal people from Taiwan is 9.4 years less than that of all other Taiwanese residents (Ministry of the Interior, 2009) and 16 years less than that of alcohol addiction from other countries (Yang, 2004). Significantly higher body mass index and glutamic oxaloacetic transaminase levels have been found in the aboriginal people who drank excess alcohol than in those who did not (Chao, Fan, Li, & Fan, 2007). In addition, previous studies found that aboriginal women who simultaneously used alcohol, cigarettes, and betel quid during pregnancy were more likely to have female babies, with lower birth weight, and reduced birth length (Yang et al., 2008). Aboriginal women who use alcohol have also been reported to be more likely to have depressive symptoms and suicidal notions (Yang, Yang, Chang, Chen, & Ko, 2006). According to the findings from Yen et al., aboriginal adolescents whose parents drank alcohol were more likely to experience physical abuse (Yen et al., 2008c) and to be problem drinkers themselves (Yen et al., 2008b). The prevalence of alcohol use disorders among the aboriginal people of Taiwan affects health, diminishes family relationships, and increases medical costs. Seventy-three percent of the aboriginal people of southern Taiwan who drank excessively were found to have poor insight into their alcoholrelated problems (Yen et al., 2008a). Thus, the problems of alcohol use should be of great concern to healthcare providers in aboriginal communities. Previous studies have found that brief interventions based on transtheoretical model (TTM) are an effective strategy for alleviating harmful alcohol use (Evers et al., 2012; Tsai, Tsai, Lin, & Chen, 2008). Thus, we conducted this research to provide support for hazardous/ harmful alcohol use screening and for the resources to intervene in problem drinking among the aboriginal communities. Purpose The aim of this study was to examine the prevalence, correlates, and adverse effects of hazardous/harmful alcohol use among the community-dwelling aboriginal people of southern Taiwan. METHODS Design and setting A cross-sectional study was conducted using a sample of individuals from two aboriginal townships in southern Taiwan. The data were collected between January and October 2010. Participants Interval sampling was used in each village based on house numbers. The inclusion criteria included aborigines living 42
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in the target community for 4 days or more per week, age 18Y60 years, able to understand the Chinese language, and without any psychiatric diagnosis. Only two participants were included from each household. Priority recruitment included a married couple of one man and one woman. Exclusion criteria included hospitalization, pregnancy, or an inability to provide data. Measures Demographic Questionnaire The demographic questionnaire
requested for information regarding tribe, gender, age, educational level, marital status, occupation, smoking and betel quid chewing habits, family structure, the initial age of alcohol use, and the reasons for alcohol use and any adverse drinking effects. The General Health Scale of the Taiwanese version SF-36 Questionnaire was used to measure the health status of the participants. The general health scale of the SF-36 questionnaire is a fiveitem instrument that is scored from 1 to 5, with 1 representing ‘‘extremely good’’ and 5 representing ‘‘extremely bad.’’ The scores range from 5 to 25, with higher scores indicating more positive health perceptions. An internal consistency was indicated with an alpha coefficient of 0.82 and an itemYscale correlation between 0.55 and 0.73 in the general Taiwanese population (Rachel Lu, Tseng, & Tsai, 2003; Tseng, Rachel Lu, & Tsai, 2003). The content validity index (CVI) was 1.00, and the alpha coefficient was 0.72 in this study. The five-item Brief Symptom Rating Scale (BSRS-5) was used to measure the mental health status of the participants. The BSRS-5 was developed by Lee et al. (2003) and includes five items that measure the five symptoms of anxiety, depression, hostility, inferiority, and insomnia. The instrument has shown good reliability and validity with multiple Taiwanese populations (Chen, Wu, Lee, Liao, & Lee, 2005; Lee et al., 2003; Lung & Lee, 2008). The respondents were asked how much discomfort they have experienced in each area during the past week. Their responses were rated on a 5-point Likert-type scale from 0 to 4, with 0 representing ‘‘not at all’’ and 4 representing ‘‘extreme.’’ The scores indicate different levels of mood disorder: 0Y5 (normal), 6Y9 (mild), 10Y14 (moderate), and 15 and above (severe). The CVI was 1.00, and the alpha coefficient was 0.85 for this study. The Family APGAR Index was used to measure the family function of the study participants. This index was derived from Smilkstein (1978), translated into Chinese (Chau, Hsiao, Huang, & Liu, 1991; Chen, Hsu, Hsu, & Lin, 1980) and consists of five items that cover the dimensions of adaptability, partnership, growth, affection, and resolve. The 4-point response scale ranges from 0 (never) to 3 (almost always); 0 and 1 are collapsed to 0, 2 is scored as 1, and 3 is scored as 2. Total scores of 0Y3 indicate ‘‘very poor,’’ 4Y6 indicate ‘‘moderately poor,’’ and 7Y10 indicate ‘‘good’’ family functioning. The alpha coefficient was 0.80Y0.85 in Smilkstein’s study and 0.88 in Chen et al.’s study. The CVI was 1.00, and the alpha coefficient was 0.88 in this study. The Chinese Version of the Alcohol Use Disorders Identification Test (AUDIT) was utilized to detect harmful alcohol drinking in the participants. January/March 2014
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The AUDIT, a 10-item scale, was originally developed by the World Health Organization (WHO) to screen for excessive drinking and to identify persons with harmful alcohol use in a primary care medical setting (Babor, De la Fuente, & Saunders, 1989; Sauuders & Aasland, 1987) and was translated into Chinese by Tsai, Tsai, Chen, and Liu (2005). Participants were asked to respond to a set of alcohol-related issues and describe their frequency during the past year. Each response was given a score ranging from 0 to 4 with the total scores ranging from 0 to 40. On the basis of the WHO criteria (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), the total AUDIT score can be used to measure health risks related to alcohol use. The AUDIT scores ranging from 0 to 7 indicate low risk or abstinence, 8 to 15 indicate a moderate risk or hazardous level, 16 to 19 indicate a high risk or harmful level, and scores above 20 indicate the highest risk and probable dependence. In general, a total score of 8 or above is recommended as an indicator of hazardous and harmful alcohol use with likely alcohol dependence at scores of 20 or above. The Chinese version of the AUDIT has shown good reliability and validity (Chen, Chen, & Cheng, 2004). In the current study, the CVI was 0.86, and the alpha coefficient for the scale was 0.74.
ing effects. The chi-square test and multiple logistic regression were used to assess the relationships between the demographic characteristics and harmful alcohol use and between harmful alcohol use and adverse drinking effects. In this study, scores of 8 or higher were defined as harmful alcohol use. The odds ratios (ORs), adjusted ORs (AORs), and 95% confidence intervals (95% CIs) were also calculated. The statistically significant p value was set at .05.
Procedures Before being conducted, this study was approved by the institutional review board of Kaohsiung Medical University (approval number: KMUH-IRB-980354), Taiwan. The purpose of this study, the confidentiality of the information, and the right to withdraw were explained to potential participants. After the participants understood the study process and a written consent was obtained from each, the study could begin. The participants in the study were interviewed in their homes by well-trained interviewers. Each interviewer was given the target home addresses based on interval sampling in each village unit. Forty-three questionnaires were incomplete. Therefore, we collected 449 completed questionnaires with an effective response rate of 91%.
Prevalence and Correlates of Harmful Alcohol Use Using an AUDIT cutoff score of 8 or above indicated that the prevalence of hazardous/harmful alcohol use was 59.7% (95% CI [57.38, 62.00]). The distribution of risk levels defined by AUDIT among the participants was provided in Table 1. Of the participants, 40.3% (181 of 449) were at level I (low-risk use, AUDIT score of 0Y7), 26.7% (120 of 449) were at level II (hazardous use, scores of 8Y15), 18.5% (83 of 449) were at level III (harmful use, scores of 16Y19), and 14.5% (65 of 449) were at level IV (likely dependence, scores at 20 or above). Among the drinkers, 27.5% (33 of 120) of the hazardous users and 38.6% (32 of 83) of the harmful users reported that they have experienced somatic diseases (liver disease and cardiovascular disease) during the preceding year. The relationship between the demographic characteristics and hazardous/harmful alcohol use was provided in Table 2. After adjusting for the covariates in the table, male participants (AOR = 1.72, 95% CI [1.05, 2.86]) who were not active in religious practice (AOR = 1.57, 95% CI [1.001, 2.46]) had
Data Analysis The data were analyzed using the SPSS 18.0 software package (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to examine the demographic data of the participants, their prevalence rates of harmful alcohol use, and any adverse drink-
TABLE 1
RESULTS Four hundred forty-nine adult aboriginal people (95% from the Paiwan tribe and 53% women) completed all questionnaires. Among these, 54% had 9 years of education or less (junior high school), and 33% had 10Y12 years of education (senior high school); 47% were Christian, 69% were married, and 59% were unemployed. The mean age of the participants was 43 T 11 years (range =19Y60 years). Most of the participants reported chewing betel quid (68%) and smoked (36%) daily. The major reasons provided for alcohol use were special festival celebrations, stress relief, and being in a bad mood. Alcohol consumption typically began with an invitation at an early age (22.2 T 7.1 years).
The Prevalence of Risk Levels for Alcohol Use Defined by the AUDIT Scores Among the Aborigines (N = 449) Risk Level Low Risk or Abstainers (AUDIT = 0Y7)
Medium Risk or Hazardous Level (AUDIT = 8Y15)
High Risk or Harmful Level (AUDIT = 16Y19)
Highest Risk and Probable Dependence (AUDIT Q 20)
Participants (n)
181
120
83
65
Prevalence (%)
40.31
18.49
14.48
26.73
Note. AUDIT = Alcohol Use Disorders Identification Test.
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TABLE 2
Relationships Between Demographic Characteristics and Harmful Alcohol Use Among the Aborigines (N = 449) Harmful Alcohol Use (AUDIT Q 8)
Variables
Yes (n)
No (n)
AOR
95% CI
Male
151
60
1.72*
1.05, 2.86
Female
117
121
e9
115
86
1.36
99
113
95
1.0
No
180
90
1.57*
Yes
88
91
1.0
Poor (Q6)
116
54
1.38
Good (G6)
152
127
Poor (scores of 0Y6)
162
87
1.07
Good (scores of 7Y10)
106
94
1.0
Yes
208
101
No
60
80
1.0
Yes
134
29
3.11***
No
134
152
Yes
208
87
2.92***
No
60
94
1.0
Gender
1.0
Education, years 0.87, 2.12
Active religious practice 1.001, 2.46
Mental health (BSRS-5 total score) 0.83, 2.28
1.0
Family function 0.68, 1.68
Serious stress event 2.18**
1.35, 3.52
Cigarette smoking 1.80, 5.37
1.0
Chewing betel quid 1.85, 4.61
Note. Because of missing values, the totals did not equal to 449. OR = odds ratio; AOR = adjusted for covariates in the table; CI = confidence interval. *p G .05. **p G .01. ***p G .001.
experienced serious stressful events (AOR = 2.18, 95% CI [1.35, 3.52]), smoked cigarettes (AOR = 3.11, 95% CI [1.80, 5.37]), or chewed betel quid (AOR = 2.92, 95% CI [1.85, 4.61]) were more likely to have harmful alcohol use. No significant associations were found between the age, marital status, employment status, or the general health status of the participants and their harmful alcohol use.
drinking. Compared with the nonharmful alcohol users, after adjusting for age and gender, the results of the multiple logistic regression indicated that the aboriginal people who were harmful alcohol users were more likely to have experienced an inability to work (AOR = 3.84, 95% CI [1.25, 11.80]) and dispute with others (AOR = 14.73, 95% CI [1.94, 112.08]).
The Adverse Effects of Harmful Alcohol Use The top three adverse effects of drinking found in this study are described in Table 3. Among the harmful alcohol users, 41.9% (75 of 179) reported that they had experienced an inability to work, 39.11% (70 of 179) had disputed with others, and 34.6% (62 of 179) had been involved in accidents after
DISCUSSION In this study, we used the AUDIT process to screen for hazardous/ harmful alcohol use among aboriginal communities and found that it provides a convenient and effective measurement tool. Our results indicated that 59.7% of the community-dwelling aboriginal people of southern Taiwan are hazardous/harmful alcohol users (with AUDIT scores of 8 and above), which is
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January/March 2014
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TABLE 3
The Prevalence of Adverse Drinking Effects Among Harmful Alcohol Users Unable to Work
Variable
Disputed With Others
Accidents Occurred
%
AOR
%
AOR
%
AOR
Yes (n = 179)
41.90
3.84*
39.11
14.73**
34.64
2.44
No (n = 26)
15.38
1.0
15.38
1.0
Harmful alcohol use
3.85
1.0
Note. Harmful alcohol use: AUDIT score of Q8. AOR = adjusted odds ratio, adjusted for age and gender. *p G .05. **p G .01.
higher than that found in a Latin American indigenous population (46.7%) using the same alcohol measure tool (Seale, Seale, Alvarado, Vogel, & Terry, 2002). This study provides updated information on the prevalence of hazardous and harmful alcohol use among aboriginal population in Taiwan. To prevent and manage alcohol-related harm, effective interventions for these hazardous/harmful alcohol users are necessary. According to the WHO guidelines (Babor et al., 2001), appropriate interventions should be offered at four different levels of risk based on an individual’s AUDIT scores. In this study, the 40.3% of low-risk drinkers (with AUDIT scores of 0Y7) should receive harm-reduction advice and education. The prevention programs should include education regarding the negative impacts of excessive drinking on physical and psychosocial health. Furthermore, this study identified 26.7% of the participants (with AUDIT scores of 8Y15) as hazardous drinkers and 18.5% of the participants (with AUDIT scores of 16Y19) as harmful drinkers. A previous report found that brief interventions based on TTM could be used to manage harmful drinkers (Babor & Higgins-Biddle, 2001). Alcohol consumption can also be decreased by delivering motivational interventions based on the ‘‘FRAMES’’ method (feedback, responsibility, advice, menu, empathy, and self-efficacy) for hazardous drinkers (Beckham, 2007). As recommended by the WHO, harmful drinkers (AUDITscores of 16Y19) should be further examined for the concurrent risks (Babor & HigginsBiddle, 2001). One third of the hazardous drinkers and harmful drinkers in our study experienced physical harm (liver disease and cardiovascular disease). Therefore, we suggested that these two groups (45.2%) require further physical assessment and should receive brief interventions based on the TTM or based on the ‘‘FRAMES’’ method (Miller, 1996) either in individual sessions or in groups. Moreover, the 14.5% at highest risk of harmful drinking (with AUDIT scores of 20 or higher) meet the criteria for probable alcohol dependency as defined by the AUDIT. These participants should be referred for further diagnosis and treatment by medical or specialist services. The results of this study indicate that aboriginal people who regularly participated in religious activities were less likely to have hazardous/harmful alcohol use. A recent study indicated that an attachment to God was another protective factor for alcohol abuse and was negatively associated with substance abuse (Badr, Taha, & Dee, 2013). Primary healthJournal of Addictions Nursing
care providers could cooperate with the religious institutions in the communities to develop comprehensive alcohol intervention programs for harmful alcohol users. Our study also found that aboriginal people who experienced a serious stress event or had poor mental healthVas measured by the BSRS-5 (Chen et al., 2005; Lee et al., 2003; Lung & Lee, 2008)Vwere more likely to become hazardous/harmful alcohol users (OR = 2.75, 95% CI [1.82, 4.14]; OR = 1.80, 95% CI [1.20, 2.68]). Similar result was found by Cheng and Loh (2007). Thus, we suggest that the healthcare professionals should assess the mental health of alcohol drinkers, providing education for stress management to reduce their alcohol consumption. In addition, our study found that aboriginal men with a lower educational level (OR = 1.52, 95% CI [1.04, 2.21]), who were cigarette smokers (OR = 5.24, 95% CI [3.30, 8.33]), and who chewed betel quid (OR = 3.75, 95% CI [2.49, 5.64]) were at a higher risk for hazardous/harmful alcohol use. These results were similar to those of previous studies (Aekplakorn et al., 2008; Gomberg, 2003; Lai, 2008; Liang et al., 2004; Lin et al., 2006; Shah et al., 2009; Walitzer & Dearing, 2006; Wu et al., 2006). These correlates could be of concern to alcohol intervention programs within the aboriginal communities. Aboriginal people who were hazardous/harmful alcohol users were found to be less able to work (41.9%) and more likely to dispute with others (39.1%) or be involved in accidents (34.6%). These findings are similar to those of other studies that correlated increased mood imbalance and poor relationships with excess alcohol consumption (Dawson et al., 2007; Li, 2007; Li et al., 2006), occupational injuries, disability, and accidents (Hwu et al., 1989; Li et al., 2006; Room et al., 2005). This finding also provided evidence of the adverse effects of drinking that should be of concern in any preventive program. Limitations Two limitations were identified. First, the generalization of the study findings was limited because all hospitalized patients and pregnant women were excluded. In addition, only one aboriginal tribe was included in this study, which also limits any generalizability of the results. Second, the AUDIT provides information about the frequency and quantity patterns of alcohol consumption associated with alcohol risk but does not provide information necessary to establish diagnostic criteria www.journalofaddictionsnursing.com
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for dependence. Therefore, the data are insufficient for drawing conclusions regarding possible dependence, even among individuals with AUDIT scores above 20. CONCLUSIONS This study identified a high prevalence of harmful alcohol use among the community-dwelling aboriginal people of southern Taiwan, with a high proportion of adverse effects including accidental injuries and an erosion of interpersonal relationships and occupational functioning among harmful drinkers. The factors identified in this study should be noted when conducting alcohol intervention programs. The results of our study reinforce the need for alcohol screening in health and social service settings to detect hazardous and harmful alcohol use among aboriginal people in Taiwan. Once identified, these individuals can benefit from brief interventions designed to reduce their alcohol risk behavior and, if necessary, referrals to specialty addiction treatment. Acknowledgments: This study was funded by the Taiwan National Science Council (NSC 98-2314-B-037-054-MY3). We thank all participants and interviewers in this study. We also thank Dr. Berry, at the University North Carolina at Chapel Hill School of Nursing, for editorial suggestions and comments.
REFERENCES Aekplakorn, W., Hogan, M. C., Tiptaradol, S., Wibulpolprasert, S., Punyaratabandhu, P., & Lim, S. S. (2008). Tobacco and hazardous or harmful alcohol use in Thailand: Joint prevalence and associations with socioeconomic factors. Addictive Behaviors, 33(4), 503Y514. Babor, T. F., De la Fuente, J. R., & Saunders, J. B. (1989). AUDIT: The Alcohol Use Disorders Identification Test, guidelines for use in primary health care. Geneva, Switzerland: World Health Organization. Babor, T. F., & Higgins-Biddle, J. C. (2001). The brief intervention for hazardous and harmful drinking: A manual for use in primary care. Geneva, Switzerland: World Health Organization. Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The Alcohol Use Disorders Identification Test, guidelines for use in primary care. Geneva, Switzerland: World Health Organization. Badr, L. K., Taha, A., & Dee, V. (2013). Substance abuse in Middle Eastern adolescents living in two different countries: Spiritual, cultural, family and personal factors. Journal of Religion and Health. Retrieved April 1, 2013, from http://www.ncbi.nlm.nih.gov.ezproxy.lib.kmu.edu.tw:2048/ pubmed/23526183 Beckham, N. (2007). Motivational interviewing with hazardous drinkers. Journal of the American Academy of Nurse Practitioners, 19(2), 103Y110. Chao, S. R., Fan, T. S., Li, Y. C., & Fan, H. H. (2007). Aboriginal Taiwanese: Demographic characteristics, health-related behavior and health conditions. The Journal of Health Science, 9(3), 169Y187. Chau, T. T., Hsiao, T. M., Huang, C. T., & Liu, H. W. (1991). A preliminary study of Family Apgar Index in the Chinese. Kaohsiung Journal of Medical Sciences, 7, 27Y31. Chen, C. C., & Yin, S. J. (2008). Alcohol abuse and related factors in Asia. International Review of Psychiatry, 20(5), 425Y433. Chen, C. H., Chen, W. J., & Cheng, A. T. (2004). Prevalence and identification of alcohol use disorders among nonpsychiatric inpatients in one general hospital. General Hospital Psychiatry, 26(3), 219Y225. Chen, H. C., Wu, C. H., Lee, Y. J., Liao, S. C., & Lee, M. B. (2005). Validity of the five-item Brief Symptom Rating Scale among subjects admitted for general health screening. Journal of the Formosan Medical Association, 104(11), 824Y829. 46
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Chen, Y. C., Hsu, C. C., Hsu, S. H., & Lin, C. C. (1980). A preliminary study of Family Apgar Index. Acta Paediatrica Sinica, 21(3), 210Y217. Cheng, A. T. A., & Loh, E. W. (2007). The alcohol addiction is not only heredity. Scientific Americans Chinese Edition, 63, 70Y73 (in Chinese). Chou, F. H., Yang, Y. H., Kuo, S. H., Chan, T. F., & Yang, M. S. (2009). Relationships among smoking, drinking, betel quid chewing and pregnancy-related nausea and vomiting in Taiwanese aboriginal women. The Kaohsiung Journal of Medical Sciences, 25(2), 62Y69. Coulton, S., Watson, J., Bland, M., Drummond, C., Kaner, E., Godfrey, C., I Tober, G. (2008). The effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care (AESOPS): A randomised control trial protocol. BMC Health Services Research, 8, 129. Council of Indigenous People. (2009). Aboriginal population and health statistics annual report in 95 and 96 year. Taipei, Taiwan: Council of Indigenous People. Dawson, D. A., Grant, B. F., Chou, S. P., & Stinson, F. S. (2007). The impact of partner alcohol problems on women’s physical and mental health. The Journal of Studies on Alcohol and Drugs, 68(1), 66Y75. Epstein, E. E., Fischer-Elber, K., & Al-Otaiba, Z. (2007). Women, aging, and alcohol use disorders. Journal of Women & Aging, 19(1Y2), 31Y48. Evers, K. E., Paiva, A. L., Johnson, J. L., Cummins, C. O., Prochaska, J. O., Prochaska, J. M., I Go¨kbayrak, N. S. (2012). Results of a transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools. Addictive Behaviors, 37(9), 1009Y1018. Gomberg, E. S. (2003). Treatment for alcohol-related problems: Special populations: Research opportunities. Recent Developments in Alcoholism, 16, 313Y333. Huang, L. Y. (2008). From the Qing Dynasty Taiwan literature looked that the indigenous people liquor song with drinks wine culture. Journal of National Taiwan College of Arts, (83), 127Y157 (in Chinese). Hwu, H. G., Yeh, E. K., & Yeh, Y. L. (1989). Alcoholism in Chinese and Formosan aborigines: Analysis of risk factors. 8th WAP Congress, 12Y19. Lai, L. H. (2008). Factors associated to alcoholism in aboriginal community: A study on some villages in central Taiwan (master’s thesis). Retrieved from http://ir.cmu.edu.tw/ir/handle/310903500/773 Lee, M. B., Liao, S. C., Lee, Y. J., Wu, C. H., Tseng, M. C., Gau, S. F., & Rau, C. L. (2003). Development and verification of validity and reliability of a short screening instrument to identify psychiatric morbidity. Journal of the Formosan Medical Association, 102, 687Y694. Li, Y. M. (2007). Deliberate self-harm and relationship to alcohol use at an emergency department in eastern Taiwan. The Kaohsiung Journal of Medical Sciences, 23(5), 247Y253. Li, Y. M., Tsai, S. Y., Hu, S. C., & Wang, C. T. (2006). Alcohol-related injuries at an emergency department in eastern Taiwan. Journal of the Formosan Medical Association, 105(6), 481Y488. Liang, C. Y., Chou, T. M., Ho, P. S., Shieh, T. Y., & Yang, Y. H. (2004). Prevalence rates of alcohol drinking in Taiwan. The Taiwan Journal of Oral Medical Sciences, 20(2), 91Y104. Lin, C. F., Wang, J. D., Chen, P. H., Chang, S. J., Yang, Y. H., & Ko, Y. C. (2006). Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines. BMC Public Health, 6, 271. Lung, F. W., & Lee, M. B. (2008). The five-item Brief-Symptom Rating Scale as a suicide ideation screening instrument for psychiatric inpatients and community residents. BMC Psychiatry, 8(1), 824Y829. Miller, W. R. (1996). Motivational interviewing: Research, practice, and puzzles. Addictive Behaviors, 21(6), 835Y842. Ministry of the Interior. (2009). Indigenous people simple life table abstract analysis in 2007. Retrieved from http://www.moi.gov.tw/stat/ life.aspx (in Chinese) Rachel Lu, J. F., Tseng, H. M., & Tsai, Y. J. (2003). Assessment of healthrelated quality of life in Taiwan (I): Development and psychometric testing of SF-36 Taiwan version. Taiwan Journal of Public Health, 22(6), 501Y511. (in Chinese). Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet, 365(9458), 519Y530. Sauuders, J. B., & Aasland, O. G. (1987). WHO collaborative project on identification and treatment of persons with harmful alcohol consumption. Geneva, Switzerland: World Health Organization. January/March 2014
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Seale, J. P., Seale, J. D., Alvarado, M., Vogel, R. L., & Terry, N. E. (2002). Prevalence of problem drinking in a Venezuelan Native American population. Alcohol and Alcoholism, 37(2), 198Y204. Shah, A. A., Bazargan-Hejazi, S., Lindstrom, R. W., & Wolf, K. E. (2009). Prevalence of at-risk drinking among a national sample of medical students. Substance Abuse, 30(2), 141Y149. Smilkstein, G. (1978). The family APGAR: A proposal for a family function test and its use by physicians. Journal of Family Practice, 6(6), 1231Y1239. Tsai, M. C., Tsai, Y. F., Chen, C. Y., & Liu, C. Y. (2005). Alcohol use disorders identification test (AUDIT): Establishment of cut-off scores in a hospitalized Chinese population. Alcoholism: Clinical & Experimental Research, 29(1), 53Y57. Tsai, Y. F., Tsai, M. C., Lin, Y. P., & Chen, C. Y. (2008). Brief Intervention for problem drinkers in a Chinese population: A randomized controlled trial in a hospital setting. Alcoholism Clinical Experimental Research, 33(1), 95Y101. Tseng, H. M., Rachel Lu, J. F., & Tsai, Y. J. (2003). Assessment of healthrelated quality of life in Taiwan (II): Norming and validation of SF-36 Taiwan version. Taiwan Journal of Public Health, 22(6), 512Y518. Walitzer, K. S., & Dearing, R. L. (2006). Gender differences in alcohol and substance use relapse. Clinical Psychology Review, 26(2), 128Y148. Wu, S. I., Liu, S. I., Fang, C. K., Hsu, C. C., & Sun, Y. W. (2006). Prevalence and detection of alcohol use disorders among general hospital inpatients in eastern Taiwan. General hospital psychiatry, 28(1), 48Y54.
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Yang, H. J. (2004). The alcohol addiction patient increase 200 times for 50 years. Retrieved from http://www.tgs.com.tw/news93110802.htm (in Chinese) Yang, M. S., Lee, C. H., Chang, S. J., Chung, T. C., Tsai, E. M., Ko, A. M., & Ko, Y. C. (2008). The effect of maternal betel quid exposure during pregnancy on adverse birth outcomes among aborigines in Taiwan. Drug and Alcohol Dependence, 95(1Y2), 134Y139. Yang, M. S., Yang, M. J., Chang, S. J., Chen, S. C., & Ko, Y. C. (2006). Intimate partner violence and minor psychiatric morbidity of aboriginal Taiwanese women. Public Health Reports, 121(4), 453Y459. Yen, C. F., Hsiao, R. C., Ries, R., Liu, S. C., Huang, C. F., Chang, Y. P., & Yu, M. L. (2008a). Insight into alcohol-related problems and its associations with severity of alcohol consumption, mental health status, race, and level of acculturation in southern Taiwanese indigenous people with alcoholism. The American Journal of Drug and Alcohol Abuse, 34(5), 553Y561. Yen, C. F., Yang, M. S., Chen, C. C., Yang, M. J., Su, Y. C., Wang, M. H., & Lan, C. M. (2008b). Effects of childhood physical abuse on depression, problem drinking and perceived poor health status in adolescents living in rural Taiwan. Psychiatry and Clinical Neurosciences, 62(5), 575Y583. Yen, C. F., Yang, M. S., Yang, M. J., Su, Y. C., Wang, M. H., & Lan, C. M. (2008c). Childhood physical and sexual abuse: Prevalence and correlates among adolescents living in rural Taiwan. Child Abuse & Neglect, 32(3), 429Y438.
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Harmful Alcohol Use Among Aboriginal People in Southern Taiwan The Prevalence, Correlates, and Adverse Drinking Effects Mei-Hua Wang, RN, MSN m Chien-Hung Lee, PhD m Chien-Yu Lai, RN, PhD m Ke-Hsin Chueh, RN, PhD m Cheng-Fang Yen, MD, PhD m Mei-Sang Yang, RN, PhD
Abstract This cross-sectional study aims to examine the prevalence and correlates of harmful alcohol use among aboriginal people in southern Taiwan and to examine the associations between harmful alcohol use and adverse drinking effects. Four hundred forty-nine aboriginal adults were recruited from two townships in southern Taiwan to complete the questionnaires. Among the aborigines, 59.7% scored an 8 or above on the Alcohol Use Disorders Identification Test, including 26.7% who were found to be hazardous drinkers (AUDIT level II), 18.5% who were harmful drinkers (level III), and 14.5% who were with likely dependence (level IV). Male aborigines who participated less in religious activities, had stressful life events, were cigarette smokers, or were betel quid chewers were more likely to have harmful alcohol use. Harmful alcohol use was also associated with an inability to work and with arguments with other people. Our study suggests that aboriginal people in southern Taiwan experience alcohol-related risks at rates as high as other worldwide populations for which AUDIT results are available. Individuals with AUDIT scores at levels II and III are generally candidates for brief interventions delivered in generalist health settings. Individuals with AUDIT scores at level IV should be referred for an addiction specialty evaluation and possible treatment as well as lower-risk individuals (those with AUDIT levels IIYIII) if they have concurrent physical or psychiatric disorders.
Mei-Hua Wang, RN, MSN, College of Nursing, Kaohsiung Medical University, and Department of Nursing, Meiho University, Taiwan. Chien-Yu Lai, RN, PhD, and Mei-Sang Yang, RN, PhD, College of Nursing, and Chien-Hung Lee, PhD, Department of Public Health, Kaohsiung Medical University, Taiwan. Ke-Hsin Chueh, RN, PhD, Department of Nursing, Fe Jen Catholic University, Taipei, Taiwan. Cheng-Fang Yen, MD, PhD, Department of Psychiatry, Kaohsiung Medical University Hospital, Taiwan. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Mei-Sang Yang, RN, PhD, College of Nursing, Kaohsiung Medical University, No. 100, Shi-Chuan 1st Rd., San Ming Dist., Kaohsiung 80708, Taiwan, ROC. E-mail: [email protected] DOI: 1097/JAN.0000000000000021 Journal of Addictions Nursing
Keywords: aboriginal people, adverse effects, harmful alcohol use, prevalence
INTRODUCTION Excessive alcohol use is a global health concern (Chen & Yin, 2008). Alcohol intake in excess can increase one’s risk for hypertension, coronary heart disease, stroke, liver disease, cancer, the early onset of dementia, and falls (Coulton et al., 2008; Epstein, Fischer-Elber, & Al-Otaiba, 2007; Room, Babor, & Rehm, 2005). Those who drink alcohol in excess exhibit mood imbalances, anxiety, poor relationships, a poor quality of life (Dawson, Grant, Chou, & Stinson, 2007), and self-harm (Li, 2007). In addition, these individuals can be easily victimized by criminals and are more prone to injuries (Room et al., 2005), accidents (Li, Tsai, Hu, & Wang, 2006), and occupational disabilities (Hwu, Yeh, & Yeh, 1989) than those who do not drink excessively. Studies have found that alcohol use can be associated with race, traditional culture, socioeconomic status, religion (Chen & Yin, 2008), chewing betel quid (Liang, Chou, Ho, Shieh, & Yang, 2004; Lin et al., 2006; Wu, Liu, Fang, Hsu, & Sun, 2006), and smoking tobacco products (Aekplakorn et al., 2008; Shah, Bazargan-Hejazi, Lindstrom, & Wolf, 2009; Wu et al., 2006). Stress in daily life (Cheng & Loh, 2007), poor family function, and inadequate social support have also been associated with excessive alcohol use (Lai, 2008). People at risk for excessive alcohol consumption are generally younger (Shah et al., 2009), men (Gomberg, 2003; Liang et al., 2004; Shah et al., 2009; Walitzer & Dearing, 2006), and single (Liang et al., 2004; Shah et al., 2009). Men are three times as likely to be diagnosed with an alcohol problem (Lai, 2008). Drinking behaviors vary greatly among people of different ethnic and cultural backgrounds (Chen & Yin, 2008). In Taiwan, alcohol consumption is a part of the aboriginal culture and occurs regularly during marriages, funerals, entertainment, social contacts, and sacrificial offerings (Huang, 2008). The prevalence of alcohol addiction among aboriginal communities was 1% in 1940, 10% in 1980, and 15%Y25% in 2000 (Yang, 2004). Among the Bunnun tribe, 38% experienced alcoholism, and 19% of the Atayal tribe in central Taiwan were found to be alcoholic people in 2006 (Lai, 2008). During 2003 and 2004, the prevalence of alcohol consumption during pregnancy among the aboriginal women has been found to range from 27.2% to 31.9% in www.journalofaddictionsnursing.com
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41
southern and eastern Taiwan (Chou, Yang, Kuo, Chan, & Yang, 2009; Yang et al., 2008). In addition, 46% of the aboriginal inpatients in a general teaching hospital in eastern Taiwan were found to have alcohol use disorders (Wu et al., 2006). According to the annual report on aboriginal health statistics from the Council of the Indigenous People of Taiwan, the 10 leading causes of death among the aboriginal people have been strongly correlated with excessive alcohol consumption (Council of Indigenous People, 2009). The life expectancy of the aboriginal people from Taiwan is 9.4 years less than that of all other Taiwanese residents (Ministry of the Interior, 2009) and 16 years less than that of alcohol addiction from other countries (Yang, 2004). Significantly higher body mass index and glutamic oxaloacetic transaminase levels have been found in the aboriginal people who drank excess alcohol than in those who did not (Chao, Fan, Li, & Fan, 2007). In addition, previous studies found that aboriginal women who simultaneously used alcohol, cigarettes, and betel quid during pregnancy were more likely to have female babies, with lower birth weight, and reduced birth length (Yang et al., 2008). Aboriginal women who use alcohol have also been reported to be more likely to have depressive symptoms and suicidal notions (Yang, Yang, Chang, Chen, & Ko, 2006). According to the findings from Yen et al., aboriginal adolescents whose parents drank alcohol were more likely to experience physical abuse (Yen et al., 2008c) and to be problem drinkers themselves (Yen et al., 2008b). The prevalence of alcohol use disorders among the aboriginal people of Taiwan affects health, diminishes family relationships, and increases medical costs. Seventy-three percent of the aboriginal people of southern Taiwan who drank excessively were found to have poor insight into their alcoholrelated problems (Yen et al., 2008a). Thus, the problems of alcohol use should be of great concern to healthcare providers in aboriginal communities. Previous studies have found that brief interventions based on transtheoretical model (TTM) are an effective strategy for alleviating harmful alcohol use (Evers et al., 2012; Tsai, Tsai, Lin, & Chen, 2008). Thus, we conducted this research to provide support for hazardous/ harmful alcohol use screening and for the resources to intervene in problem drinking among the aboriginal communities. Purpose The aim of this study was to examine the prevalence, correlates, and adverse effects of hazardous/harmful alcohol use among the community-dwelling aboriginal people of southern Taiwan. METHODS Design and setting A cross-sectional study was conducted using a sample of individuals from two aboriginal townships in southern Taiwan. The data were collected between January and October 2010. Participants Interval sampling was used in each village based on house numbers. The inclusion criteria included aborigines living 42
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in the target community for 4 days or more per week, age 18Y60 years, able to understand the Chinese language, and without any psychiatric diagnosis. Only two participants were included from each household. Priority recruitment included a married couple of one man and one woman. Exclusion criteria included hospitalization, pregnancy, or an inability to provide data. Measures Demographic Questionnaire The demographic questionnaire
requested for information regarding tribe, gender, age, educational level, marital status, occupation, smoking and betel quid chewing habits, family structure, the initial age of alcohol use, and the reasons for alcohol use and any adverse drinking effects. The General Health Scale of the Taiwanese version SF-36 Questionnaire was used to measure the health status of the participants. The general health scale of the SF-36 questionnaire is a fiveitem instrument that is scored from 1 to 5, with 1 representing ‘‘extremely good’’ and 5 representing ‘‘extremely bad.’’ The scores range from 5 to 25, with higher scores indicating more positive health perceptions. An internal consistency was indicated with an alpha coefficient of 0.82 and an itemYscale correlation between 0.55 and 0.73 in the general Taiwanese population (Rachel Lu, Tseng, & Tsai, 2003; Tseng, Rachel Lu, & Tsai, 2003). The content validity index (CVI) was 1.00, and the alpha coefficient was 0.72 in this study. The five-item Brief Symptom Rating Scale (BSRS-5) was used to measure the mental health status of the participants. The BSRS-5 was developed by Lee et al. (2003) and includes five items that measure the five symptoms of anxiety, depression, hostility, inferiority, and insomnia. The instrument has shown good reliability and validity with multiple Taiwanese populations (Chen, Wu, Lee, Liao, & Lee, 2005; Lee et al., 2003; Lung & Lee, 2008). The respondents were asked how much discomfort they have experienced in each area during the past week. Their responses were rated on a 5-point Likert-type scale from 0 to 4, with 0 representing ‘‘not at all’’ and 4 representing ‘‘extreme.’’ The scores indicate different levels of mood disorder: 0Y5 (normal), 6Y9 (mild), 10Y14 (moderate), and 15 and above (severe). The CVI was 1.00, and the alpha coefficient was 0.85 for this study. The Family APGAR Index was used to measure the family function of the study participants. This index was derived from Smilkstein (1978), translated into Chinese (Chau, Hsiao, Huang, & Liu, 1991; Chen, Hsu, Hsu, & Lin, 1980) and consists of five items that cover the dimensions of adaptability, partnership, growth, affection, and resolve. The 4-point response scale ranges from 0 (never) to 3 (almost always); 0 and 1 are collapsed to 0, 2 is scored as 1, and 3 is scored as 2. Total scores of 0Y3 indicate ‘‘very poor,’’ 4Y6 indicate ‘‘moderately poor,’’ and 7Y10 indicate ‘‘good’’ family functioning. The alpha coefficient was 0.80Y0.85 in Smilkstein’s study and 0.88 in Chen et al.’s study. The CVI was 1.00, and the alpha coefficient was 0.88 in this study. The Chinese Version of the Alcohol Use Disorders Identification Test (AUDIT) was utilized to detect harmful alcohol drinking in the participants. January/March 2014
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The AUDIT, a 10-item scale, was originally developed by the World Health Organization (WHO) to screen for excessive drinking and to identify persons with harmful alcohol use in a primary care medical setting (Babor, De la Fuente, & Saunders, 1989; Sauuders & Aasland, 1987) and was translated into Chinese by Tsai, Tsai, Chen, and Liu (2005). Participants were asked to respond to a set of alcohol-related issues and describe their frequency during the past year. Each response was given a score ranging from 0 to 4 with the total scores ranging from 0 to 40. On the basis of the WHO criteria (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), the total AUDIT score can be used to measure health risks related to alcohol use. The AUDIT scores ranging from 0 to 7 indicate low risk or abstinence, 8 to 15 indicate a moderate risk or hazardous level, 16 to 19 indicate a high risk or harmful level, and scores above 20 indicate the highest risk and probable dependence. In general, a total score of 8 or above is recommended as an indicator of hazardous and harmful alcohol use with likely alcohol dependence at scores of 20 or above. The Chinese version of the AUDIT has shown good reliability and validity (Chen, Chen, & Cheng, 2004). In the current study, the CVI was 0.86, and the alpha coefficient for the scale was 0.74.
ing effects. The chi-square test and multiple logistic regression were used to assess the relationships between the demographic characteristics and harmful alcohol use and between harmful alcohol use and adverse drinking effects. In this study, scores of 8 or higher were defined as harmful alcohol use. The odds ratios (ORs), adjusted ORs (AORs), and 95% confidence intervals (95% CIs) were also calculated. The statistically significant p value was set at .05.
Procedures Before being conducted, this study was approved by the institutional review board of Kaohsiung Medical University (approval number: KMUH-IRB-980354), Taiwan. The purpose of this study, the confidentiality of the information, and the right to withdraw were explained to potential participants. After the participants understood the study process and a written consent was obtained from each, the study could begin. The participants in the study were interviewed in their homes by well-trained interviewers. Each interviewer was given the target home addresses based on interval sampling in each village unit. Forty-three questionnaires were incomplete. Therefore, we collected 449 completed questionnaires with an effective response rate of 91%.
Prevalence and Correlates of Harmful Alcohol Use Using an AUDIT cutoff score of 8 or above indicated that the prevalence of hazardous/harmful alcohol use was 59.7% (95% CI [57.38, 62.00]). The distribution of risk levels defined by AUDIT among the participants was provided in Table 1. Of the participants, 40.3% (181 of 449) were at level I (low-risk use, AUDIT score of 0Y7), 26.7% (120 of 449) were at level II (hazardous use, scores of 8Y15), 18.5% (83 of 449) were at level III (harmful use, scores of 16Y19), and 14.5% (65 of 449) were at level IV (likely dependence, scores at 20 or above). Among the drinkers, 27.5% (33 of 120) of the hazardous users and 38.6% (32 of 83) of the harmful users reported that they have experienced somatic diseases (liver disease and cardiovascular disease) during the preceding year. The relationship between the demographic characteristics and hazardous/harmful alcohol use was provided in Table 2. After adjusting for the covariates in the table, male participants (AOR = 1.72, 95% CI [1.05, 2.86]) who were not active in religious practice (AOR = 1.57, 95% CI [1.001, 2.46]) had
Data Analysis The data were analyzed using the SPSS 18.0 software package (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to examine the demographic data of the participants, their prevalence rates of harmful alcohol use, and any adverse drink-
TABLE 1
RESULTS Four hundred forty-nine adult aboriginal people (95% from the Paiwan tribe and 53% women) completed all questionnaires. Among these, 54% had 9 years of education or less (junior high school), and 33% had 10Y12 years of education (senior high school); 47% were Christian, 69% were married, and 59% were unemployed. The mean age of the participants was 43 T 11 years (range =19Y60 years). Most of the participants reported chewing betel quid (68%) and smoked (36%) daily. The major reasons provided for alcohol use were special festival celebrations, stress relief, and being in a bad mood. Alcohol consumption typically began with an invitation at an early age (22.2 T 7.1 years).
The Prevalence of Risk Levels for Alcohol Use Defined by the AUDIT Scores Among the Aborigines (N = 449) Risk Level Low Risk or Abstainers (AUDIT = 0Y7)
Medium Risk or Hazardous Level (AUDIT = 8Y15)
High Risk or Harmful Level (AUDIT = 16Y19)
Highest Risk and Probable Dependence (AUDIT Q 20)
Participants (n)
181
120
83
65
Prevalence (%)
40.31
18.49
14.48
26.73
Note. AUDIT = Alcohol Use Disorders Identification Test.
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TABLE 2
Relationships Between Demographic Characteristics and Harmful Alcohol Use Among the Aborigines (N = 449) Harmful Alcohol Use (AUDIT Q 8)
Variables
Yes (n)
No (n)
AOR
95% CI
Male
151
60
1.72*
1.05, 2.86
Female
117
121
e9
115
86
1.36
99
113
95
1.0
No
180
90
1.57*
Yes
88
91
1.0
Poor (Q6)
116
54
1.38
Good (G6)
152
127
Poor (scores of 0Y6)
162
87
1.07
Good (scores of 7Y10)
106
94
1.0
Yes
208
101
No
60
80
1.0
Yes
134
29
3.11***
No
134
152
Yes
208
87
2.92***
No
60
94
1.0
Gender
1.0
Education, years 0.87, 2.12
Active religious practice 1.001, 2.46
Mental health (BSRS-5 total score) 0.83, 2.28
1.0
Family function 0.68, 1.68
Serious stress event 2.18**
1.35, 3.52
Cigarette smoking 1.80, 5.37
1.0
Chewing betel quid 1.85, 4.61
Note. Because of missing values, the totals did not equal to 449. OR = odds ratio; AOR = adjusted for covariates in the table; CI = confidence interval. *p G .05. **p G .01. ***p G .001.
experienced serious stressful events (AOR = 2.18, 95% CI [1.35, 3.52]), smoked cigarettes (AOR = 3.11, 95% CI [1.80, 5.37]), or chewed betel quid (AOR = 2.92, 95% CI [1.85, 4.61]) were more likely to have harmful alcohol use. No significant associations were found between the age, marital status, employment status, or the general health status of the participants and their harmful alcohol use.
drinking. Compared with the nonharmful alcohol users, after adjusting for age and gender, the results of the multiple logistic regression indicated that the aboriginal people who were harmful alcohol users were more likely to have experienced an inability to work (AOR = 3.84, 95% CI [1.25, 11.80]) and dispute with others (AOR = 14.73, 95% CI [1.94, 112.08]).
The Adverse Effects of Harmful Alcohol Use The top three adverse effects of drinking found in this study are described in Table 3. Among the harmful alcohol users, 41.9% (75 of 179) reported that they had experienced an inability to work, 39.11% (70 of 179) had disputed with others, and 34.6% (62 of 179) had been involved in accidents after
DISCUSSION In this study, we used the AUDIT process to screen for hazardous/ harmful alcohol use among aboriginal communities and found that it provides a convenient and effective measurement tool. Our results indicated that 59.7% of the community-dwelling aboriginal people of southern Taiwan are hazardous/harmful alcohol users (with AUDIT scores of 8 and above), which is
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TABLE 3
The Prevalence of Adverse Drinking Effects Among Harmful Alcohol Users Unable to Work
Variable
Disputed With Others
Accidents Occurred
%
AOR
%
AOR
%
AOR
Yes (n = 179)
41.90
3.84*
39.11
14.73**
34.64
2.44
No (n = 26)
15.38
1.0
15.38
1.0
Harmful alcohol use
3.85
1.0
Note. Harmful alcohol use: AUDIT score of Q8. AOR = adjusted odds ratio, adjusted for age and gender. *p G .05. **p G .01.
higher than that found in a Latin American indigenous population (46.7%) using the same alcohol measure tool (Seale, Seale, Alvarado, Vogel, & Terry, 2002). This study provides updated information on the prevalence of hazardous and harmful alcohol use among aboriginal population in Taiwan. To prevent and manage alcohol-related harm, effective interventions for these hazardous/harmful alcohol users are necessary. According to the WHO guidelines (Babor et al., 2001), appropriate interventions should be offered at four different levels of risk based on an individual’s AUDIT scores. In this study, the 40.3% of low-risk drinkers (with AUDIT scores of 0Y7) should receive harm-reduction advice and education. The prevention programs should include education regarding the negative impacts of excessive drinking on physical and psychosocial health. Furthermore, this study identified 26.7% of the participants (with AUDIT scores of 8Y15) as hazardous drinkers and 18.5% of the participants (with AUDIT scores of 16Y19) as harmful drinkers. A previous report found that brief interventions based on TTM could be used to manage harmful drinkers (Babor & Higgins-Biddle, 2001). Alcohol consumption can also be decreased by delivering motivational interventions based on the ‘‘FRAMES’’ method (feedback, responsibility, advice, menu, empathy, and self-efficacy) for hazardous drinkers (Beckham, 2007). As recommended by the WHO, harmful drinkers (AUDITscores of 16Y19) should be further examined for the concurrent risks (Babor & HigginsBiddle, 2001). One third of the hazardous drinkers and harmful drinkers in our study experienced physical harm (liver disease and cardiovascular disease). Therefore, we suggested that these two groups (45.2%) require further physical assessment and should receive brief interventions based on the TTM or based on the ‘‘FRAMES’’ method (Miller, 1996) either in individual sessions or in groups. Moreover, the 14.5% at highest risk of harmful drinking (with AUDIT scores of 20 or higher) meet the criteria for probable alcohol dependency as defined by the AUDIT. These participants should be referred for further diagnosis and treatment by medical or specialist services. The results of this study indicate that aboriginal people who regularly participated in religious activities were less likely to have hazardous/harmful alcohol use. A recent study indicated that an attachment to God was another protective factor for alcohol abuse and was negatively associated with substance abuse (Badr, Taha, & Dee, 2013). Primary healthJournal of Addictions Nursing
care providers could cooperate with the religious institutions in the communities to develop comprehensive alcohol intervention programs for harmful alcohol users. Our study also found that aboriginal people who experienced a serious stress event or had poor mental healthVas measured by the BSRS-5 (Chen et al., 2005; Lee et al., 2003; Lung & Lee, 2008)Vwere more likely to become hazardous/harmful alcohol users (OR = 2.75, 95% CI [1.82, 4.14]; OR = 1.80, 95% CI [1.20, 2.68]). Similar result was found by Cheng and Loh (2007). Thus, we suggest that the healthcare professionals should assess the mental health of alcohol drinkers, providing education for stress management to reduce their alcohol consumption. In addition, our study found that aboriginal men with a lower educational level (OR = 1.52, 95% CI [1.04, 2.21]), who were cigarette smokers (OR = 5.24, 95% CI [3.30, 8.33]), and who chewed betel quid (OR = 3.75, 95% CI [2.49, 5.64]) were at a higher risk for hazardous/harmful alcohol use. These results were similar to those of previous studies (Aekplakorn et al., 2008; Gomberg, 2003; Lai, 2008; Liang et al., 2004; Lin et al., 2006; Shah et al., 2009; Walitzer & Dearing, 2006; Wu et al., 2006). These correlates could be of concern to alcohol intervention programs within the aboriginal communities. Aboriginal people who were hazardous/harmful alcohol users were found to be less able to work (41.9%) and more likely to dispute with others (39.1%) or be involved in accidents (34.6%). These findings are similar to those of other studies that correlated increased mood imbalance and poor relationships with excess alcohol consumption (Dawson et al., 2007; Li, 2007; Li et al., 2006), occupational injuries, disability, and accidents (Hwu et al., 1989; Li et al., 2006; Room et al., 2005). This finding also provided evidence of the adverse effects of drinking that should be of concern in any preventive program. Limitations Two limitations were identified. First, the generalization of the study findings was limited because all hospitalized patients and pregnant women were excluded. In addition, only one aboriginal tribe was included in this study, which also limits any generalizability of the results. Second, the AUDIT provides information about the frequency and quantity patterns of alcohol consumption associated with alcohol risk but does not provide information necessary to establish diagnostic criteria www.journalofaddictionsnursing.com
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for dependence. Therefore, the data are insufficient for drawing conclusions regarding possible dependence, even among individuals with AUDIT scores above 20. CONCLUSIONS This study identified a high prevalence of harmful alcohol use among the community-dwelling aboriginal people of southern Taiwan, with a high proportion of adverse effects including accidental injuries and an erosion of interpersonal relationships and occupational functioning among harmful drinkers. The factors identified in this study should be noted when conducting alcohol intervention programs. The results of our study reinforce the need for alcohol screening in health and social service settings to detect hazardous and harmful alcohol use among aboriginal people in Taiwan. Once identified, these individuals can benefit from brief interventions designed to reduce their alcohol risk behavior and, if necessary, referrals to specialty addiction treatment. Acknowledgments: This study was funded by the Taiwan National Science Council (NSC 98-2314-B-037-054-MY3). We thank all participants and interviewers in this study. We also thank Dr. Berry, at the University North Carolina at Chapel Hill School of Nursing, for editorial suggestions and comments.
REFERENCES Aekplakorn, W., Hogan, M. C., Tiptaradol, S., Wibulpolprasert, S., Punyaratabandhu, P., & Lim, S. S. (2008). Tobacco and hazardous or harmful alcohol use in Thailand: Joint prevalence and associations with socioeconomic factors. Addictive Behaviors, 33(4), 503Y514. Babor, T. F., De la Fuente, J. R., & Saunders, J. B. (1989). AUDIT: The Alcohol Use Disorders Identification Test, guidelines for use in primary health care. Geneva, Switzerland: World Health Organization. Babor, T. F., & Higgins-Biddle, J. C. (2001). The brief intervention for hazardous and harmful drinking: A manual for use in primary care. Geneva, Switzerland: World Health Organization. Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The Alcohol Use Disorders Identification Test, guidelines for use in primary care. Geneva, Switzerland: World Health Organization. Badr, L. K., Taha, A., & Dee, V. (2013). Substance abuse in Middle Eastern adolescents living in two different countries: Spiritual, cultural, family and personal factors. Journal of Religion and Health. Retrieved April 1, 2013, from http://www.ncbi.nlm.nih.gov.ezproxy.lib.kmu.edu.tw:2048/ pubmed/23526183 Beckham, N. (2007). Motivational interviewing with hazardous drinkers. Journal of the American Academy of Nurse Practitioners, 19(2), 103Y110. Chao, S. R., Fan, T. S., Li, Y. C., & Fan, H. H. (2007). Aboriginal Taiwanese: Demographic characteristics, health-related behavior and health conditions. The Journal of Health Science, 9(3), 169Y187. Chau, T. T., Hsiao, T. M., Huang, C. T., & Liu, H. W. (1991). A preliminary study of Family Apgar Index in the Chinese. Kaohsiung Journal of Medical Sciences, 7, 27Y31. Chen, C. C., & Yin, S. J. (2008). Alcohol abuse and related factors in Asia. International Review of Psychiatry, 20(5), 425Y433. Chen, C. H., Chen, W. J., & Cheng, A. T. (2004). Prevalence and identification of alcohol use disorders among nonpsychiatric inpatients in one general hospital. General Hospital Psychiatry, 26(3), 219Y225. Chen, H. C., Wu, C. H., Lee, Y. J., Liao, S. C., & Lee, M. B. (2005). Validity of the five-item Brief Symptom Rating Scale among subjects admitted for general health screening. Journal of the Formosan Medical Association, 104(11), 824Y829. 46
www.journalofaddictionsnursing.com
Chen, Y. C., Hsu, C. C., Hsu, S. H., & Lin, C. C. (1980). A preliminary study of Family Apgar Index. Acta Paediatrica Sinica, 21(3), 210Y217. Cheng, A. T. A., & Loh, E. W. (2007). The alcohol addiction is not only heredity. Scientific Americans Chinese Edition, 63, 70Y73 (in Chinese). Chou, F. H., Yang, Y. H., Kuo, S. H., Chan, T. F., & Yang, M. S. (2009). Relationships among smoking, drinking, betel quid chewing and pregnancy-related nausea and vomiting in Taiwanese aboriginal women. The Kaohsiung Journal of Medical Sciences, 25(2), 62Y69. Coulton, S., Watson, J., Bland, M., Drummond, C., Kaner, E., Godfrey, C., I Tober, G. (2008). The effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care (AESOPS): A randomised control trial protocol. BMC Health Services Research, 8, 129. Council of Indigenous People. (2009). Aboriginal population and health statistics annual report in 95 and 96 year. Taipei, Taiwan: Council of Indigenous People. Dawson, D. A., Grant, B. F., Chou, S. P., & Stinson, F. S. (2007). The impact of partner alcohol problems on women’s physical and mental health. The Journal of Studies on Alcohol and Drugs, 68(1), 66Y75. Epstein, E. E., Fischer-Elber, K., & Al-Otaiba, Z. (2007). Women, aging, and alcohol use disorders. Journal of Women & Aging, 19(1Y2), 31Y48. Evers, K. E., Paiva, A. L., Johnson, J. L., Cummins, C. O., Prochaska, J. O., Prochaska, J. M., I Go¨kbayrak, N. S. (2012). Results of a transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools. Addictive Behaviors, 37(9), 1009Y1018. Gomberg, E. S. (2003). Treatment for alcohol-related problems: Special populations: Research opportunities. Recent Developments in Alcoholism, 16, 313Y333. Huang, L. Y. (2008). From the Qing Dynasty Taiwan literature looked that the indigenous people liquor song with drinks wine culture. Journal of National Taiwan College of Arts, (83), 127Y157 (in Chinese). Hwu, H. G., Yeh, E. K., & Yeh, Y. L. (1989). Alcoholism in Chinese and Formosan aborigines: Analysis of risk factors. 8th WAP Congress, 12Y19. Lai, L. H. (2008). Factors associated to alcoholism in aboriginal community: A study on some villages in central Taiwan (master’s thesis). Retrieved from http://ir.cmu.edu.tw/ir/handle/310903500/773 Lee, M. B., Liao, S. C., Lee, Y. J., Wu, C. H., Tseng, M. C., Gau, S. F., & Rau, C. L. (2003). Development and verification of validity and reliability of a short screening instrument to identify psychiatric morbidity. Journal of the Formosan Medical Association, 102, 687Y694. Li, Y. M. (2007). Deliberate self-harm and relationship to alcohol use at an emergency department in eastern Taiwan. The Kaohsiung Journal of Medical Sciences, 23(5), 247Y253. Li, Y. M., Tsai, S. Y., Hu, S. C., & Wang, C. T. (2006). Alcohol-related injuries at an emergency department in eastern Taiwan. Journal of the Formosan Medical Association, 105(6), 481Y488. Liang, C. Y., Chou, T. M., Ho, P. S., Shieh, T. Y., & Yang, Y. H. (2004). Prevalence rates of alcohol drinking in Taiwan. The Taiwan Journal of Oral Medical Sciences, 20(2), 91Y104. Lin, C. F., Wang, J. D., Chen, P. H., Chang, S. J., Yang, Y. H., & Ko, Y. C. (2006). Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines. BMC Public Health, 6, 271. Lung, F. W., & Lee, M. B. (2008). The five-item Brief-Symptom Rating Scale as a suicide ideation screening instrument for psychiatric inpatients and community residents. BMC Psychiatry, 8(1), 824Y829. Miller, W. R. (1996). Motivational interviewing: Research, practice, and puzzles. Addictive Behaviors, 21(6), 835Y842. Ministry of the Interior. (2009). Indigenous people simple life table abstract analysis in 2007. Retrieved from http://www.moi.gov.tw/stat/ life.aspx (in Chinese) Rachel Lu, J. F., Tseng, H. M., & Tsai, Y. J. (2003). Assessment of healthrelated quality of life in Taiwan (I): Development and psychometric testing of SF-36 Taiwan version. Taiwan Journal of Public Health, 22(6), 501Y511. (in Chinese). Room, R., Babor, T., & Rehm, J. (2005). Alcohol and public health. Lancet, 365(9458), 519Y530. Sauuders, J. B., & Aasland, O. G. (1987). WHO collaborative project on identification and treatment of persons with harmful alcohol consumption. Geneva, Switzerland: World Health Organization. January/March 2014
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Seale, J. P., Seale, J. D., Alvarado, M., Vogel, R. L., & Terry, N. E. (2002). Prevalence of problem drinking in a Venezuelan Native American population. Alcohol and Alcoholism, 37(2), 198Y204. Shah, A. A., Bazargan-Hejazi, S., Lindstrom, R. W., & Wolf, K. E. (2009). Prevalence of at-risk drinking among a national sample of medical students. Substance Abuse, 30(2), 141Y149. Smilkstein, G. (1978). The family APGAR: A proposal for a family function test and its use by physicians. Journal of Family Practice, 6(6), 1231Y1239. Tsai, M. C., Tsai, Y. F., Chen, C. Y., & Liu, C. Y. (2005). Alcohol use disorders identification test (AUDIT): Establishment of cut-off scores in a hospitalized Chinese population. Alcoholism: Clinical & Experimental Research, 29(1), 53Y57. Tsai, Y. F., Tsai, M. C., Lin, Y. P., & Chen, C. Y. (2008). Brief Intervention for problem drinkers in a Chinese population: A randomized controlled trial in a hospital setting. Alcoholism Clinical Experimental Research, 33(1), 95Y101. Tseng, H. M., Rachel Lu, J. F., & Tsai, Y. J. (2003). Assessment of healthrelated quality of life in Taiwan (II): Norming and validation of SF-36 Taiwan version. Taiwan Journal of Public Health, 22(6), 512Y518. Walitzer, K. S., & Dearing, R. L. (2006). Gender differences in alcohol and substance use relapse. Clinical Psychology Review, 26(2), 128Y148. Wu, S. I., Liu, S. I., Fang, C. K., Hsu, C. C., & Sun, Y. W. (2006). Prevalence and detection of alcohol use disorders among general hospital inpatients in eastern Taiwan. General hospital psychiatry, 28(1), 48Y54.
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Yang, H. J. (2004). The alcohol addiction patient increase 200 times for 50 years. Retrieved from http://www.tgs.com.tw/news93110802.htm (in Chinese) Yang, M. S., Lee, C. H., Chang, S. J., Chung, T. C., Tsai, E. M., Ko, A. M., & Ko, Y. C. (2008). The effect of maternal betel quid exposure during pregnancy on adverse birth outcomes among aborigines in Taiwan. Drug and Alcohol Dependence, 95(1Y2), 134Y139. Yang, M. S., Yang, M. J., Chang, S. J., Chen, S. C., & Ko, Y. C. (2006). Intimate partner violence and minor psychiatric morbidity of aboriginal Taiwanese women. Public Health Reports, 121(4), 453Y459. Yen, C. F., Hsiao, R. C., Ries, R., Liu, S. C., Huang, C. F., Chang, Y. P., & Yu, M. L. (2008a). Insight into alcohol-related problems and its associations with severity of alcohol consumption, mental health status, race, and level of acculturation in southern Taiwanese indigenous people with alcoholism. The American Journal of Drug and Alcohol Abuse, 34(5), 553Y561. Yen, C. F., Yang, M. S., Chen, C. C., Yang, M. J., Su, Y. C., Wang, M. H., & Lan, C. M. (2008b). Effects of childhood physical abuse on depression, problem drinking and perceived poor health status in adolescents living in rural Taiwan. Psychiatry and Clinical Neurosciences, 62(5), 575Y583. Yen, C. F., Yang, M. S., Yang, M. J., Su, Y. C., Wang, M. H., & Lan, C. M. (2008c). Childhood physical and sexual abuse: Prevalence and correlates among adolescents living in rural Taiwan. Child Abuse & Neglect, 32(3), 429Y438.
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