Origin:rl Reseirch
Alcohol misuse in patients attending a defence force
general medical clinic
Ilekket. D. NIllChB. }Il'-anr\'Ie<l l,'at t l'elrlet t D/'j, N{llCtrl}, NIPlax},Ie<l Departnrcnt ol' I.'anrih' \'Ie<li<'ine, I Tuivclsit] ol' StcllcnlxrschConesl.titrlottr.'I)r l) llekker', 3 (lroblel Strcet, Arrxla l)Lrrlxurville, 7.5.50 - l ' e l :
0 2 1 - . i 9 0 2 ( i 3 . i , c - r n a i l : it i 0 0 7 2 1 ) @ r u l e b . c o . z ; r
Airn.: DesigLt: Methods:
To detemritre the prevalence of alcohol misuse in adult patients attencling a <leI'cnce lorce gcner-al practice clinic.
Descriptir,'e cross-sectional sun,ey,.
The setting is a militar-v sickbav situated in the Cape Tolr'rr rnetr<>politan :uea, South Aliica. P;uticipants included all adult patients (>18 I'ear-s) attending the clinir'<luring a thr-ee u'cek periotl rniclvear. 'I-he Alcohol IJse Disor<lers Iclentificatiotr -fest (AlIDIT) questionnair-e was corr)plete<l lrv patients. Tu'<r dilect ;rlcoltol consutnptiou rluestious u'ere adcled deterntining the total drinks per vueek as u'e'll as the nrarimum number of drinks per occasion.
Of the 65tl patients approached, 40 (6%) declined to fill in the rlucstionnairc. 42,/" ol'the 6l U patie nts sun'e1,s6f were fetnzrle :rnd 58% were male with an average age of .l,l vears. -fhe gr-oup c<>nsisted <>f 44% current def'ence lbrce members,257u retired defbnce tirrce rneurbers,22,Vu medical rlepenrlcnts zrnd 7% cir.ilians. The overall rate of alcohol nrisuse according to the AUDlT<pestionuaire lr'as 13,27%. Anr<xrg nt:rle patients, 20,6'/o scored zrs nrisusers of alcoh<>l, cclnryrar-erl vith 2,7V" irrlr()ng f'euralcs. A rrruch higher level of nrisuse u'as also found un<ler ]'olur!{el' age groups. 38,I,X, of nrale :rp1lr-cntices at tlre technic:rl college l:ncl 40,0,/" of male current <lefence force nrenrbers staf inS; on t]rc lt:rse scorerl 8 or nlore on the AtlDIl'. In tlte group scorimg Iess than B on the AlJDl'l'-rluestionnaire a lirrther !) patients t eporled drinking on a\'e rage rrtore thiur I 4 drinks pcr rveek fbr nrales :rncl rnore than {) drinks per w'eek lbr females. In this group (AtJDl'l-score <U) 7(j patients repolte<l maxinlrm nunrber ol-drinks per occasion of more than 4 firr rnen anrl rnore thiur Il lil' uomen. I1'these tu.o rluestions are included the overall mte of alcohol misuse foun<l vlas 26.0:i%.
Results:
Conc']usictn: The high rate of alcohol misuse four<l in this goup of patients is ueed Iirr concem. -l-he or,erall rate ol-alcohol misuse r,rtls not f<rund to be highe r than what rvirs found in other stulies in S<>uth Allica as r,r'cll as ofJrer counft-ies. This studt'supp()rts the implernentation of scleening an<l interlcntiorr str':rtegics in general meclical clinics in the defbnce force.
SA l-iun Prac't 2003;4,1(2):I0-Lf
INTRODUCTION
A l c o h o l m i s u s e m a y c o m e t o b e recognized as one ofthe most significant public health concerns facing South Africa over the next few years. This is a direct result of alcohol's impact on the health services, the economy, and the South African society as a whole.l
Alcohol misuse is common world-wide and in South Africa there is an estimatedprevalence of llYo of alcohol
dependence in the adult population.2 However, relatively few studies have been published on drinking patterns in South Africa. With regards to adults, epidemiological studies in recent years have also focussed almost entirely on the black and coloured population while they are not the only groups who have high levels of risky drinking.t
There has always been a perception that a high prevalence of alcohol misuse exists amidst defence force patients, but
the only study found pertaining to military personnel looked at the pattern of drug-taking of 188 drug-dependent n a t i o n a l s e r v i c e m e n s e e n i n t h e department of psychiatry of 1 Military Hospital in Pretoria in the year 1971. Alcohol were used by only 18% of the subjects.r In our study practice we are not aware of many alcohol dependent patients. According to the social work deparlment, they have detected a high prevalence of alcohol misuse especially
under the younger uniformed members (age 18-25) who are busy with their apprenticeship at the military technical college, but no effort has been rnade in our practice to screen or treat for alcohol misuse as part of an organised health promotion plan.
Several studies have shown that doctors fail to detect alcohol misuse in the majority of their patients. They are particularly unlikely to identify misuse in its earlier stages and therefore miss major opportunities for intervening.a r7 Research has established the effective-ness of even brief interventions by primary care physicians on patients with h a z a r d o u s a n d h a r m f u l a l c o h o l consumption.rs-25
New evidence continues to appear appertaining to levels and patterns of alcohol use in relation to health effects, social well-being, and economic costs. Data from several recent large prospec-t i v e s prospec-t u d i e s s u g g e s prospec-t prospec-th a prospec-t a l c o h o l c o n s u m p t i o n i n q u a n t i t i e s c o n s i s t e n l with hazardous and harmful drinking may increase the risk of adverse health events, such as haemorrhagic stroke and breast cancer.26'28
Every effort should thus be made in primary care settings to detect and treat a l c o h o l m i s u s e in i t s e a r l i e r s t a g e s (heavy, hazardous and harmful drinking) because it is more common and pro-bably more responsive to treatment than alcohol abuse or dependence.
By looking at the prevalence and pattern of alcohol misuse in patients a t t e n d i n g o u r c l i n i c w e a i m e d t o determine the size and distribution of the problem to enable us to motivate for and do proper planning towards inter-vention as part of health promotion. METHODS
A descriptive, cross-sectional survey design was used. The study setting was Wingfield Military Sickbay situated at Goodwood, one ofthe northern suburbs of Cape Town. Participants in the study included all adult patients (>18 years) attending the general medical clinic for a period of three weeks (28 June to 18 July 2000). We aimed at a minimum s a m p l e s i z e o f 3 4 0 - 3 5 0 fo r v a l i d i t y purposes. The patient population served by the clinic was estimated at more than
I 1000.
The Alcohol Use Disorders ldentifi-cation Test (AUDIT) questionnaire2eia was given for self-completion to patients during normal clinic hours (07h30
-16h00). Questions additional to those posed in the questionnaire were added with regards to personal information as well as alcohol consumption to deter-mine the prevalence of at-risk drinking. It has been demonstrated that direct q u e s t i o n s a b o u t a v e r a g e d a i l y consumption or frequency of heavy consumption are less sensitive than standard sel f-reporr screen i ng question-n a i r e s iquestion-n d e t e c t i question-n g a l c o h o l m i s u s e . Biochemical markers, especially serum gamma glutamyl transfierase can assisl in identifying problem drinking but are also less valid than self-report measures. In detecting alcohol dependence or abuse, the most widely used instruments are the CAGE2e 3a with 4 items and the Michigan Alcoholism Screening Test (MAST)'+34 with 25 questions. They have proven to be useful screening instruments and have revealed a higher validity compared to laboratory data. T h e y a r e h o w e v e r i n s e n s i t i v e f o r hazardous or heavy drinking. The Alcohol Use Disorder Identification Test (AUDIT) was developed by the W o r l d H e a l t h O r g a n i s a t i o n i n a n international multi-site trial2e in an attempt to also detect earlier stages of drinking which place the patient at risk for suffering eventual severe alcohol related problems. The authors gave particular attention to selecting items generalisable across culture, gender and a g e . M o s t o f t h e A U D I T q u e s t i o n s inquire about the previous year rather t h a n e v e r i n t h e p a t i e n t ' s li f e t i m e , thereby decreasing errors of mislabeling individuals who have already resolved e a r l i e r p r o b l e m s w i t h a l c o h o l . Questions on the AUDIT covers the three domains of consumption, alcohol dependence and adverse consequences of drinking.2era
At a cut-off value of 8 of the possible 40 points on the test, sensitivity and s p e c i f i c i t y c o e f f i c i e n t s a r e h i g h . Saunders et al reported a 92% sensi-tivity and 94o/o specificity for hazardous and harmful drinking and a 100o/o sensitivity for alcohol dependence.re Isaacson et al found sensitivity and specificity of 96oh in the detection of a l c o h o l a b u s e a n d d e p e n d e n c e
compared to the Structured Clinical lnterview for DSM-III-R (used as the "gold standard" for alcohol abuse or dependence).')
Results of the AUDIT have also been associated with more distal indicators of problematic drinking. It was found to be a good predictor ofboth alcohol-related social and medical problems.:t:s-:0 The AUDIT questionnaire is currently the only validated instrument designed to detect hazardous drinking.
Haz.ardous drinking is defined as a quantity or pattern of alcohol consump-tion that places individuals at risk for adverse health events and is recognised b y t h e W o r l d H e a l t h O r g a n i s a t i o n (WHO) as a distinct disorder. The quantity or pattem of alcohol consurrp-tion that constitutes hazardous drinking i s t y p i c a l l y s p e c i f i e d b y s e t t i n g threshold values for an individual's average number of drinks consumed per week or per occasion.26
Heavy drinking is defined as a quantity of alcohol consumption that e x c e e d s a n e s t a b l i s h e d t h r e s h o l d v a l u e . 1 6 T h e A d d i c t i o n R e s e a r c h Foundation of Ontario and Canadian Centre on Substance Abuse adopted threshold levels of more than 14 drinks per week for men and more than 9 drinks per week for women based on cuffent scientific evidence.2T Individuals whose drinking exceeds these guidelines are thought to be at increased risk for adverse health events. The definitions of hazardous and heavy drinking are thus sirnilar. However, the threshold levels set for hazardous drinking in developing the AUDIT were an average daily consumption of 609 per day (6 drinks) for men and 40g (4 drinks) for women.2e If a male were to drink 3 units of alcohol per day for 7 days a week and have no adverse consequences of drinking or signs of dependence, he m a y , d e p e n d i n g o n t h e r e s t o f h i s answers on the AUDIT questionnaire, score only 5 points. Although women suffer from adverse consequences of drinking at lower levels of consumption t h a n m e n , t h e A U D I T l i k e o t h e r validated questionnaires, does not use a separate scoring system based on gender.rT A woman who drinks 2 drinks per day would by definition and current e v i d e n c e o n h i g h r i s k d r i n k i n g b e
( )*gi: :al tr4t't;
;rt
;. 1
:
c o n s i d e r e d a h a z a r d o u s o r h e a v y drinker, but may score only 4 on the AUDIT. It has therefore been decided t o a d d 2 q u e s t i o n s o n c o n s u m p t i o n which follows after the AUDI! deter-mining the total drinks per week as well a s t h e h i g h e s t t o t a l o f d r i n k s p e r occasion, Many studies define heavier drinking episodes as occasions on which more than 4 drinks were consumed. The National Institute ofAlcohol Abuse and Alcoholism ruSA) sets this threshold at >4 drinks for men and >3 drinks for women. However, there is no strong evidence favouring any specific amount as marking a discrete threshold of risk.26,27
To ensure that confidentiality about the identity of the patients were pre-served, questionnaires were completed anonymously and no code were kept of t h e i d e n t i t i e s o f p a t i e n t s . A f t e r c o m p l e t i o n . t h e q u e s t i o n n a i r e w e r e deposited by the patient in a visibly locked wooden box. The scoring system were not indicated on the questionnaire. D u e t o t h e d i v e r s i t y o f h o m e languages in the defence force it was decided to present the questionnaire in English seeing that it is the language mastered by the majority of the patients.
A research assistant was appointed and trained to distribute the question-naires to the patients in the waiting room. This person was available full-time to assist with any problems that m i g h t a r o s e i n c o m p l e t i n g t h e questionnaire.
Before finalisation, the questionnaire was first piloted on 6 patients.
Descriptive statistics were deter-mined. Within the samples comparisons were made with respect to groups formed by gender, race, occupation etc. C o n t i n g e n c y t a b l e s w e r e u s e d t o investigate the influence of discrete classificatory factors. Percentages out of a total less than 20 were calculated only for comparative purposes, but the r e a d e r a r e a d v i s e d t h a t t h e s e percentages are highly variable. RESULTS
Of the 658 people approached, 40 (6%) declined to filI in the questionnaire. The reasons stated were as follows: 2 did not have time. 3 felt too ill^ 4 could not write (due to stroke, Parkinson's disease and
hand injuries) and I I left their reading glasses at home. Of the other 20 people, 3 stated that they did not drink, 1 felt that the questionnaire was not relevant to him, 1 wanted the questionnaire in Afrikaans, I wrote that he felt uncom-fortable, I wrote that it was too personal and t4 gave no reasons.
females. Of the retired defence force members (average age of 58), 5.2% scored positive compared to 24,2o/o of the current defence force members (average age of 29). Higher levels of alcohol misuse was found in lower age groups as demonstrated in Table I. All w o m e n s c o r i n q 8 o r m o r e o n t h e
Of the 6l 8 patients surveyed, 42o/o were female and 58Yo were male. 58olo indicated that they were white, 18olo coloured, 7 o/o black, 2oh Indian and | 4o/o declined to reveal there race. Of this l4yo, 10 (1,6%) stated that their home language were African (Xhosa, Zulu, Tswana, S/Sotho), 49 (7,9%) Afrikaans, 26 (4,2%) English and 4 (0,60/o) Afri-kaans and English. The majority of the sample's home language was Afrikaans (54,7%) followed by English (33,5%), Afrikaans and English (3,4yo), Xhosa (3,4%),Zulu (1,5o/o), Tswana (1,5%), S/ Sotho (1,4%), Tsonga (0,5o/o), Ndebele (0,2o ), N/Sotho (0,2%) and Tsonga/ Swazi (0,2%o).
The group consisted of 44% current defence force memberc, 25%o retired defence force members (85% white, 6% coloured, 9%6 race unknown), 22%o medical dependents (95% female) and 7o/o civilians.
AUDIT rcsults
The overall rate of alcohol misuse according to the AUDIT questionnaire was 13,27o/o. Of the 536 people scoring below 8, 70 left out one or more ques-tions. However, 38 of the 70 indicated that they never drink. Of the other 32, 15 could have scored 8 or more if they filled in all the questions. If that would have been the case, it would have brought the total up to 15,670/o.
The average age of the 13,27o/o who scored 8 and higher was 29 years, compared to 43 years in the group s c o r i n g l e s s t h a n 8 . A m o n g m a l e patients, 20,6%o scored as misusers of alcohol, compared with 2,7oh among
AUDlT-questionnaire were below the age of46 years.
In the current defence force group, 69,2%(9 outof only l3) Indians scored as misusers compared to 32,5% (13140) blacks, 25p% (19176) coloureds, 77 ,7%o (17/96) whites and16,7%o (8/48) inthe unknown race group.
Male current defence force members had a positive scorc of 28,9o/o (651225). Wingfield being a naval base, mainly current naval defence force members were seen with 29,2o/o (52/178) males scoring as misusers of alcohol compared to30,0%(9/30) male air force members. The numbers for the army and medical services were too small for comparative p u r p o s e s . 3 8 , l Y o ( 3 2 1 8 4 ) o f m a l e apprentices studying for electrical or mechanical fitters at SAS Wingfield Naval College scored as misusers of alcohol.
40,}Yo (24/60) of male current defence force members staying on the defence force base (average age of 26 years), scored as misusers of alcohol according to the AUDlT-questionnaire.
274 of the 618 people (44,3%o) that took part in the study, stated that they never drink alcohol.
Weekly alcohol consumption compated to the AUDIT questionnairc
In males scoring <8 on the AUDIT questionnaire, only 5 of the 266 rhat answered the question (1,9%) said that they consumed a number of units in excess of the limits set for low-risk d r i n k i n g ( > 1 4 u n i t s p e r w e e k ) . I n females scoring <8 on the AUDIT Total in age group
z__
questionnaire, only 4 of the 224 that answered the question (I,8%) said that they consumed >9 units per week.
Those whose AUDIT score was 8 or more, had a less impressive showing in comparison. All identified alcohol misusers answered this question, with 13 of 74 males (17,3o/o) and 2 of 7 females declaring an intake above the limit.
When compared to the AUDIT, self-reported alcohol consumption per week had a sensitivity of only 18,5o/o and a specificity of 98,2o/o (Table II). When c o m p a r e d to s e l f - r e p o r t e d a l c o h o l consumption per week, the AUDIT questionnaire had a sensitivity of 62,5Yo and a specificity of 87,9o/o.
Maximum number of drinks per occasion compated to the AUDIT questionnaire
In males scoring <8 on the AUDIT, 54 out of 234 (23,1%) who frlled in this question stated that the maximum number of drinks that they drank per occasion was greater than 4. Of these 5 4 p a t i e n t s 7 i n d i c a t e d t h a t t h e i r maximum was greater lhan 12 drinks.
In females scoring <8, only 22 out of 233 who filled in the question (9,4%) stated that the maximum number of drinks that they drank per occasion was greater than 3.
In males whose AUDIT-score was )8, 63 out of 74 (85,1%) stated that their m a x i m u m n u m b e r o f d r i n k s p e r occasion was more than 4. All alcohol misusers filled in this question (male and female). In females whose AUDIT-score was >8,7 out of 7 (100%) stated that their maximum number of drinks per occasion was more than 3.
When compared to the AUDII self-reportedmaximum number of drinks per occasion had a sensitivity of 86,40/o and a specificity of 84,90/0 (Table III). When compared to self-reported maximum number of drinks per occasion, the AUDIT had a sensitivity of 47,9o/o and a specificity of 9l ,5oh.
DISCUSSION Limitations of study
The data was obtained during 3 weeks i n t h e m i d d l e o f t h e y e a r w h i c h coincided with the school holidays.
i ! t',11,t
t a.,t')
1a;:.,t
:1 t'11
However, it was not expected that this would lead to an unrepresentative peak in the results. The AUDlT-question-naire also specifically refers to alcohol experiences in the past year.
Six percent of patients approached declined to participate in the study. This c o m p a r e s w e l l w i t h t h e s t u d y o f Isaacson et al.e where l2oh declined to participate as well as the study of Sharkey et al.6 where 9olo of outpatients declined. These were the only studies found where the AUDlT-questionnaire was used in similar settings. Only 20 ofthe 40 patients did not have a valid reason for not participating and 3 of these said that they did not drink. Ifall of the 17 patients were regarded as misusers of alcohol, the overall rate of alcohol misuse would then be 15,60/o (991635) which is only slightly higher than what was found.
The questionnaire was handed out for self-completion and therefore it can be expected that some questionnaires would not have been completed in full. Fortunately most patients that left questions on the AUDIT unanswered, did so because of the fact that they were teetotallers and therefore felt that the questions were not applicable to them. To try and prevent patients from not completing the questionnaire honestly, i t w a s d e c i d e d o n a n a n o n y m o u s q u e s t i o n n a i r e . T h e q u e s t i o n s w e r e obviously ofa very personal nature and it is to be expected that some patients would be inclined to minimise their alcohol consumption habits, which could lead to an under-estimation of the prevalence. However, the aim of the study was explained on the question-naire as well as by the research assistant, a n d t h e s u b j e c t s w e r e a s s u r e d o f complete confi dentiality.
I\Iotable tesults
The greatest influences on the rate of alcohol misuse found were age and gender. There is by far a greater level of alcohol misuse among males and younger age groups. 28,90 of male current defence force members scored as misusers of alcohol on the AUDIT. Our suspicion was confirmed by finding a high level of misuse (38,1%) under m a l e a p p r e n t i c e s s t u d y i n g a t t h e technical college on the base. 40o/o of male defence force members stavins on AUDlT-questionnaire
Weekly alcohol consumption
Sensitivity : 15/81 : 18,5% Specificity : 481 /490 : 98,2%o
AUDIT-questionnaire Maximum number of
drinks per occasion
Sensitivity -- 70181 = 86,4Yo Specificity : 4271503 -- 84,90
1.. 2: tt:i;:;tl i,4.'. '., :,:; t
t h e b a s e a l s o s c o r e d a s m i s u s e r s according to the AUDlT-questionnaire.
Even though low threshold levels w e r e t a k e n , s e l f - r e p o r t e d a l c o h o l consumption per week had a sensitivity of only 18,5%o compared to the AUDIT-questionnaire confirming what we a l r e a d y k n o w n a m e l y t h a t d i r e c t questions about alcohol consumption a r e l e s s s e n s i t i v e th a n s c r e e n i n g questionnaires in detecting alcohol misuse. It is however interesting to see that self-reported maximum number of drinks per occasion had a much higher sensitivity, namely that of 86,4o/o, compared to the AUDIT even though these thresholds were arbitrarily chosen based on tradition rather than empirical study.
When compared to self-reported alcohol consumption per week, the AUDlT-questionnaire had a sensitivity of 62,5oh and thus missed 9 patients who had an increased risk for adverse health events according to current evidence on arrisk drinking.
When compared to self-reported maximum number of drinks per occa-sion, the AUDlT-questionnaire had a sensitivity of 47,9Yo and so missed 76 patients who misuses alcohol according to threshold levels set by the National I n s t i t u t e o f A l c o h o l A b u s e a n d Alcoholism (USA).
If both these numbers were included, t h e o v e r a l l r a t e o f a l c o h o l m i s u s e detected by the AUDlT-questionnaire c o m b i n e d w i t h t h e s e t w o d i r e c t consumption questions is then 26,05yo ( 1 6 1 / 6 1 8 ) .
Comparative studies
In the USA, about I loh ro 20Vo of patients presenting to general medical clinics are diagnosed as suffering from alcohol abuse or dependence.r0 This is comparable to the 13,27%o of alcohol m i s u s e a c c o r d i n g t o t h e A U D I T -questionnaire that was found in this group, and the 260/o through the combined methodology.
Only one sfudy was found that has u s e d t h e A U D I T q u e s t i o n n a i r e to determine the extent of alcohol misuse in those attending a general medical clinic. Isaacson et al. used the AUDIT-questionnaire among those attending a general medical clinic in inner city
D e t r o i t , U S A . T h e r a t e o f a l c o h o l misuse was higher, with 2loh (261124) identified. The average age of the sample was 45 years with 52Yowomen. However, the patients were of low socio-economic status and predomi-nanlly of African American origin.
One other comparable study was found which looked at the pattern of a l c o h o l c o n s u m p t i o n o f a g e n e r a l hospital population in north Belfast, Ireland (Sharkey et a1.,1996)6. 15V" of o u t p a t i e n t s s c o r e d a s m i s u s e r s o f a l c o h o l a c c o r d i n g t o t h e A U D I T questionnaire of which 7 60/o, however were female. Among male patients,2T%o scored as misusers, compared with 10o% among females which is higher than the 20.6oh andthe2.TV:o found in males and females in our study group. The average age was 45 which is slightly higher than the average age of 4l in this study group.
In South Africa high levels of alcohol dependence according to the CAGE questionnaire were found in very selected groups: 87o/o in coloured farm workers in the Koue Bokkeveld38, 560lo in a coloured rural community in Fraser-burg 500 km from Cape Town3e, 620/o in hospitalised coloured TB patientsa0, 3lo/o inhospitalised black TB patientsao and32"/o in black miners in Welkomar. 2 studies were conducted that targeted t h e a d u l t p o p u l a t i o n i n t h e C a p e Peninsula, but again only the coloured and black groups. Here, GiIles et al. (1973) found a prevalence of 19,6% (male) and 1,2o/o (female) of alcohol m i s u s e u n d e r t h e g e n e r a l c o l o u r e d population of the Cape Peninsula and Lombard and Steyn (1991) found a prevalence of 26,70/o (male) and 5%o (female) of alcohol misuse (>5 drinks per day or communally on weekends) under the black population ofthe Cape P e n i n s u l a . r W i t h t h e n e w n a t i o n a l defence force being more representative of all the race groups and the retired defence force group consisting mainly of white patients, the average age of black and coloured patients in this study were much younger (26 years and 31 years respectively). Therefore you would expect to find a higher rate of alcohol misuse in this study compared to the general population as was the case: 32,4o/o of black males and, l2,5To
(1 out of only 8) black females scored a s m i s u s e r s o f a l c o h o l . 2 4 , 7 Y o o f coloured males and 2.8%o of coloured females scored as misusers according to the AUDlT-questionnaire.
On average, alcohol consumption rates in South Africa appear to be 15-2}o/ohigher for men than for women in all ethnic groups.rThis study also found a substantial difference in rates of a l c o h o l m i s u s e a c c o r d i n g t o t h e AUDIT-questionnaire between men (20,6%) and women (2,7%).
T w o s t u d i e s o v e r 1 0 y e a r s a g o ( R o c h a - S i l v a 1 9 8 9 , 1 9 9 1 ) c o m p a r e d differences among race groups in the general population of South Africa and found the highest level ofrisky drinking among blacks, followed by coloureds, Indians and whites. A fairly substantial
13% difference between white and black m a l e s w a s n o t e d i n t h e 1 9 8 5 s t u d y (Rocha-Silva 1989).' The same trend was found in this study according to the AUDIT except for the Indian group which consisted of only l5 patients in total and the high prevalence ofalcohol misuse found here (60,0oh,9ll5), may t h u s b e d u e t o r a n d o m e r r o r . A difference of l5oh was found between black and white current defence force members where the average age were comparable.
CONCLUSION
In this group of patients attending a defence force general medical clinic the overall rate of alcohol misuse according to the AUDlT-questionnaire was not found to be higher than what was found in other studies in South Africa as well as in other countries. However, a 130% rate of alcohol misuse according to the AUDlT-questionnaire is still need for concern and with much higher levels of misuse found in certain subgroups, it is even more distressing.
With current threshold levels of consumption for hazardous drinking set lower than what was originally defined with the development of the AUDII it is recommended that the two direct questions on consumption determining average number of drinks per week as well as maximum number of drinks per o c c a s i o n b e a d d e d t o t h e A U D I T -questionnaire for routine screening for
at-risk drinking. If findings from these t w o c o n s u m p t r o n q u e s t l o n s w e r e included in this study, the overall rate of alcohol misuse found was 26,05%.
With brief intervention having been s h o w n a s a l o w c o s t , e f f e c t i v e preventive measure for healy drinking in primary care settings, the imple-m e n t a t i o n o f i n t e r v e n t i o n s t r a t e g i e s should be considered in general medical c l i n i c s i n t h e d e f e n c e f o r c e a n d elsewhere.O
Acknowledgements:
The author would like to thank the SANDF for allowing her to conduct and publish this study as well as Theodata for statistical assistance.
Refetences
l. Parry CDH, Bennetts AL. Alcohol policv and public health in South AJrica. Cape Town: Oxford University Press, 1998. 2. Wilson D. Routine scrcening tests for
alco-h o l i s m . "l Ali Med J 1999;89(9):949-51. 3. Levin A. The pattern of drug+aking among
d r u g - d e p e n d a n t S o u t h A f r i c a n n a t i o n a l ser-vicemen. S A/r Med J 1972;46(44):1690-4 .
4. Sri EV, Raguram R, Srivastava M. Alcohol problems in a general hospital - a prevalence study. J Indian Med Assoc 1997;95(9):505-6 .
5. Stein MD, Wilkenson J, Berglas N, O'Sulli-van P Prevalence and detection of illicit drug disorders among hospitalizcd patients. Am.J Drug Alcohol Abuse
1996;22(3):463-5 . Sharkey J, Brennan D, Cunan P. The pattem ofalcohol consumption ofa general hospital p o p u l a t i o n i n n o r t h B e l f a s t . A l c o h o l A I c o h o I | 9 9 6 : 3 | ( 3 ) : 2 7 9 -B 5 .
M e h l e r P S , M c C l e l l a n M D , L e z o t t e D , Casper E, Gabow PA. Improving identifi-cation of and intervention for alcoholism.
I k s t J M e d 1 9 9 5 ; 1 6 3 ( 4 ) : 3 3 5 - 4 0 . S c h m i d t A , B a r r y K L , F l e r - n i n g M F .
Detection ofproblem drinkcrs: the Alcohol Use Disorders Identification Test (AUDIT). S o u t h M e d J 1 9 9 5 ; 8 8 ( l ) : 5 2 - 9 .
Isaacson JH, Butler R, Zacharek M, Tzelepis A. Screening with the Alcohol Use Disorders I d c n t i f i c a t i o n T e s t ( A U D I T ) in an inner-city population. .J Gen Intern Med 1994;9 (10): 5 ) t r - - J .
M c M e n a m i n J P . S c r e e n i n g fo r a l c o h o l disorder in a general practice. N Z Med J 1994; 107 (972):s5-7 .
Moore RD. Screening and assessment of alcohol and other drug abwe. Md Med J
1 9 9 4 ; 4 3 ( l ) : 3 5 - 9 .
Rydon P, Redman S, Sanson-Fisher RW, R e i d A L . D e t e c t i o n o f a l c o h o l - r e l a t e d
7 .
il
problems in general practice. J Stud Alcohol 1 9 9 2 ; s 3 ( 3 ) : 1 9 7 - 2 0 2 .
12. Buchsbaum DG, Buchanan RG, PosesRM, Schnoll SH, Lawton MJ. Pysician detection of drinking problems in patients attending a general medicine practice. J Gen Intern Med 1992;7(5):517-21.
13. Cleary PD, Miller M, Bush BT, Warburg MM. Delbanco TL. Aronson MD. Preva-Ience and rccognition of alcohol abuse in a p r i m a r y c a r e p o p u l a t i o n . A m J M e d 1 9 8 8 ; 8 s ( 4 ) : 4 6 6 - 7 1 .
1 4 . W o o d a l l H E . A l c o h o l i c s r e m a i n i n g a n o n y -mous: resident diagnosis ofalcoholism in a f a m i l y p r a c t i c e c e n t e r . J F a m P r a c t 1 9 8 8 2 6 ( 3 \ : 2 9 3 - 6 .
15. Reid AL, Webb GR, Hennrikus D, Fahey PP, Sanson-Fisher RW. Detection of patients w i t h h i g h a l c o h o l i n t a k e b y g e n e r a l practitioners. Br Med J (Clin Res Ed) 1986; 2 9 3 ( 6 5 4 9 \ : 7 3 5 - 7 .
16. Wallace B Haines A. Use of a questionnaire i n g e n e r a l p r a c t i c e t o i n c r e a s e t h e r e c o g n i t i o n o f p a t i e n t s w i t h e x c e s s i v e alcohol consumption. 8r Med J (Clin Res Ed) t985;290(6486): 1949-53.
17. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Briefphysician- and nurse practitioner-delivered counselling for high-risk drinkers: does it work? Arch Intern Med I 9 9 9 ; I 5 9 ( I 8 ) : 2 I 8 9 - 2 0 5 .
I 8. Fleming MF, Manwell LB, BarryKL, Adams W, Stauffacher EA. Brief physician advice f o r a l c o h o l p r o b l e m s i n o l d e r a d u l t s : a randomized community-based trial. J Fam Pract 1999:48(5):378-84.
19. Smith AJ, Shepherd JP, Hodgson RJ. Brief i n t e r v e n t i o n s f o r p a t i e n t s w i t h a l c o h o l -related trauma. Br J Oral MaxilloJitc Surg I 9 9 8 ; 3 6 ( 6 ) : 4 0 8 - I 5 .
20. Marlatt GA. Baer JS" Kivlahan DR et al. Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment. J Consult Clin Psychol I 998;66(4):604- I 5.
2 l . S e n f t R A , P o l e n M R , F r e e b o m D K , H o l l i s JF. Brief intervention in a primary care setting for hazardous drinkers. Am J Prev Med 1997 ;13(6):464-7 0.
2 2 . F l e m i n g M F , B a r r y K L , M a n w e l l L B , J o h n s o n K , L o n d o n R . B r i e f p h y s i c i a n advice for problem alcohol drinkers. A randomised controlled trial in community-b a s e d p r i m a r y c a r e p r a c t i c e s . J A M A 1 9 9 7 : 2 7 7 ( | 3 ) : 1 0 3 9 - 4 5 .
23. Wilk AI, Jensen NM, Havighurst TC. Meta-a n Meta-a l y s i s o f r Meta-a n d o m i s e d c o n t r o l t r i Meta-a l s a d d r e s s i n g b r i e f i n t e r v e n t i o n s in h e a v y alcohol drinkers. J Gen Intern Med 1997:.
t 2 ( s ) : 2 7 4 - 8 3 .
24. WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health
1996l'86(7):948-55.
2 5 . R e i d M C . F i e l l i n D A . O ' C o n n o r P G . H a z a r -dous and harmful alcohol consumption in p r i m a r y c a r e . A r c h I n t e r n M e d I 9 9 9 ; I 5 9 ( I 5 ) : I 6 8 1 - 9 .
1 j z : : , " t : : t i ? ' 1 . t . " 1 ; , ' . t' t .
26. Bondy SJ, Rehm J, Ashley MJ, Walsh G, S i n g l e E , R o o m R . L o w - r i s k d r i n k i n g guidelines: the scientific evidence. Can J P ub I ic H e al r h 1999 ;90(4):264-7 0. 2 7 . P a r s o n s O A , N i x o n S J . C o g n i t i v e f u n c
-tioning in sober social drinkers: a review of the research since 1986. J Stud Alcohol
I 9 9 8 ; s 9 ( 2 ) : 1 8 0 - 9 0 .
28. Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the Alcohol Use Disorders ldentification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Alcohol Consumption-Il. Addiction 1993;88(6): 7 9 1 - 8 0 4 .
29. Allen J, Litten RZ, Lee A. What you need t o k n o w : d e t e c t i n g a l c o h o l p r o b l e m s i n g e n e r a l p r a c t i c e . S i n g a p o r e M e d J I 9 9 8 ; 3 9 ( I ) : 3 8 - 4 1 .
30. Allen JP, Litten RZ, Fertig JB, Babor T. A e v i e w o f r e s e a r c h o n t h e A l c o h o l U s e D i s o r d e r s I d e n t i f i c a t i o n T e s t ( A U D I T ) . Alcohol Clin Exp Res 1997;21(4):613-9. 3 1 . R u m p f H J , H a p k e U , H i l l A , J o h n U . Development of a screening questionnaire f o r t h e g e n e r a l h o s p i t a l a n d g e n e r a l practices. Alcohol Clin Exp Res 1997:'21(5): 8 9 4 - 8 .
32. Bohn MJ. Babor TF. Kranzler HR. The Alcohol Use Disorders Identification Test ( A U D I T ) : v a l i d a t i o n o f a s c r e e n i n g instrument for use in medical settings. J S tu d A I c o h o I 1 9 9 5 ;5 6(4):423 - 3 2 . 33. Moore RD. Screening and assessment of
afcohol and other drug abuse. Md Med J 1 9 9 4 ; 4 3 ( l ) : 3 5 - 9 .
34. Conigrave KM, Hall WD, Saunders JB. The AUDIT questionnaire: choosing a cut-off score. Alcohol Use Disorder Identification TesI. Addiction 1995;90(10):1349-56. 35. Conigrave KM, Saunders JB, Reznik RB.
P r e d i c t i v e c a p a c i t y o f t h e A U D I T q u e s t i o n n a i r e fo r a l c o h o l - r e l a t e d h a r m . A d d i c t i o n 1 9 9 5 ; 9 0 ( l l ) : 1 4 7 9 - 8 5 . 36. Bradley KA, Boyd-Wickizer J, Powell SH,
B u r m a n M L . A l c o h o l s c r e e n i n g questionnaires in women : a critical review. JAMA 1998.'280(2):166-7 t.
3 7 . L o n d o n L , M e y e r s J , N e l l V Taylor T, Thompson ML, Mbuli S. An investigation into the neurological and neurobehavioural effects ol long-term agrochemical exposure among deciduous fruit farm workers in the W e s t e r n C a p e , S o u t h A f r i c a . 1 9 9 5 . University of Cape Town: MD Thesis. 38. Claassen JN. The benefits of the CAGE as
a screening tool for alcoholism in a closed rural South African community. S A/r Med J 1999:89(9\:976-9.
39. Schoerran JH, Parry CDH, Lombard CJ, K l o p p e r H J . A s s e s s m e n t o f a l c o h o l s c r e e n i n g i n s t r u m e n t s in t u b e r c u l o s i s patients. Tuberculosis and Lung Disease 1 9 9 4 ' , 7 5 : 3 7 1 - 6 .
40. Kew G. A descriptive study of alcohol consumption pattems on a South African gold mine. MRC Urbanisation and Health News lette r 1994:.21 :39-42.
l 0
