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Hazardous and Harmful Alcohol Use and Associated Factors in Tuberculosis Public Primary Care Patients in South Africa

Hazardous and Harmful Alcohol Use and Associated Factors in Tuberculosis Public Primary Care Patients in South Africa
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   Int. J. Environ. Res. Public Health 2012 , 9 , 3245-3257; doi:10.3390/ijerph9093245 International Journal of Environmental Research and Public Health   ISSN 1660-4601  Article Hazardous and Harmful Alcohol Use and Associated Factors in Tuberculosis Public Primary Care Patients in South Africa Karl Peltzer 1,2, *, Julia Louw 1 , Gugu Mchunu 1 , Pamela Naidoo 3,4 , Gladys Matseke 1  and Bomkazi Tutshana 1   1  HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; E-Mails: (J.L.); (G.M.); (G.M.); (B.T.) 2  Department of Psychology, University of Limpopo, Turfloop 06854, South Africa 3  Population Health, Health Systems and Innovation, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; E-mail: 4  Department of Psychology, University of the Western Cape, Cape Town 8000, South Africa *  Author to whom correspondence should be addressed; E-mail:; Tel.: +27-12-302-2000; Fax: +27-12-302-2067.  Received: 28 May 2012; in revised form: 14 August 2012 / Accepted: 24 August 2012 / Published: 5 September 2012 Abstract:  The aim of this study was to assess the prevalence of hazardous and harmful alcohol use and associated factors among patients with tuberculosis in South Africa. In a cross-sectional survey new tuberculosis (TB) and TB retreatment patients were consecutively screened using the Alcohol Use Disorder Identification Test (AUDIT) within one month of anti-tuberculosis treatment. The sample included 4,900 (54.5% men and women 45.5%) tuberculosis patients from 42 primary care clinics in three districts. Results indicate that, overall 23.2% of the patients were hazardous or harmful alcohol drinkers, 31.8% of men and 13.0% of women were found to be hazardous drinkers, and 9.3% of men and 3.4% of women meet criteria for probable alcohol dependence (harmful drinking) as defined by the AUDIT. Men had significantly higher AUDIT scores than women. In multivariable analyses it was found that among men poor perceived health status, tobacco use, psychological distress, being a TB retreatment patient and not being on antiretroviral therapy (ART), and among women lower education, tobacco use and being a TB retreatment patient were associated with hazardous or harmful alcohol use. The study found a high prevalence of hazardous or harmful alcohol use among tuberculosis primary OPEN ACCESS    Int. J. Environ. Res. Public Health 2012 , 9  3246 care patients. This calls for screening and brief intervention and a comprehensive alcohol treatment programme as a key component of TB management in South Africa. Keywords:  alcohol misuse; tobacco use; associated factors; tuberculosis patients; public primary care; South Africa 1. Introduction South Africa has 0.7% of the W orld’s  population and 28% of the W orld’s  population of HIV and TB co-infected individuals. It has been estimated that approximately 60% of people with TB are co-infected with HIV [1]. Co-infected patients have almost double the chances of getting multidrug-resistant TB (MDR-TB) as well as extensively drug-resistant TB (XDR-TB). These patients also have a high mortality rate due to co-infection with HIV [2]. In addition to alcohol ’ s role in the onset of TB, there is also strong evidence of a negative influence of heavy drinking/alcohol use disorder (AUD) on the clinical course of TB, higher relapse rates and experiencing the most destructive forms of TB [3,4]. Prevalence of alcohol use disorders among TB patients have ranged from 10% to 50% in studies carried out in Australia, Canada, Russia, Switzerland, and the USA [4]. There is only a few studies which have assessed alcohol use disorders in tuberculosis patients in low and middle income countries: Kazakhstan: 4% alcohol abusers [5]; Russia: 24  –  62% alcohol abuse/dependent [6  –  10]; India: 14.9  –  32% alcohol abusers/alcoholics [11  –  13]; Brazil: 14  –  24% alcohol abusers [14,15] and South Africa: 31  –  62% alcohol misuse [16]. Alcohol use was estimated to have been responsible for 939,000 disability-adjusted life-years lost in South Africa for TB and HIV/AIDS alone in 2004 (253,000 for women, 687,000 for men). This figure corresponds to 4.6% of the overall disease burden in South Africa (2.5% for women, 6.6% for men) [17]. Factors associated with alcohol use in tuberculosis patients include: (male) gender [10,13], older age [13], being married [13], school education [13], middle income [13], treatment category [13] and TB medication non-adherence [5,9  –  11,18,19]. Smoking plus alcohol abuse was found as a probable risk factor for pulmonary tuberculosis in Chengdu, China [20]. Previous studies also found that anxiety or depression and tobacco use were associated with alcohol use disorders in general patients [21  –  24]. There is a lack of information on prevalence of alcohol use and AUD amongst TB patients and its impact on adherence and disease progression, in particular in low and middle income countries [3,4]. Detecting alcohol use disorders, specifically alcohol abuse and dependence, provides a critical opportunity for early intervention efforts to reduce adverse impacts of consumption. It is against this background that the reported study was carried out. The findings from this study will assist the national TB programme in South Africa to develop effective intervention strategies for TB patients with problems related to alcohol use. The aim of the study is to estimate prevalence of recent alcohol use and hazardous or harmful drinking among TB patients attending public primary care clinics in South Africa.   Int. J. Environ. Res. Public Health 2012 , 9  3247 2. Methodology 2.1. Sample and Procedure This is a cross-sectional survey with tuberculosis patients in public primary care clinics in South Africa. Three provinces, in South Africa, with the highest TB caseload were selected for inclusion in the study. One district in each of three provinces with the highest TB caseloads were ultimately included. These districts were Siyanda in Northern Cape Province, Nelson Mandela. Metro in the Eastern Cape Province, and EThekwini in KwaZulu-Natal Province. Within each of these three study districts 14 primary health care facilities were selected on the basis of the highest TB caseloads per clinic, in all 42 clinics. The type of health facilities were public primary health care clinic or community health centre. All new TB and retreatment patients were consecutively screened using the Alcohol Use Disorder Identification Test (AUDIT) within one month of anti-tuberculosis treatment. The screening interview was conducted by trained external research assistants for a period of 6 months in all 42 clinics in 2011. A health care provider who identified a new TB treatment or retreatment patient (within one month on treatment) and 18 years and above informed the patient about the study and referred the patient for participation if interested. A research assistant asked for permission/consent from patients attending the primary care facility to participate in the screening interview. Because of the stigma associated with alcohol consumption, individuals may feel defensive when responding to questions about their drinking and answer inaccurately. To increase the reliability of the AUDIT, researchers have suggested putting alcohol consumption in the context of other health-related behaviours [25]. Therefore, the interviewer administered questionnaire included questions on mental and physical health status, tobacco use and chronic diseases. We have received ethical approval from the Human Sciences Research Council Research Ethics Committee (Protocol REC No.1/16/02/11). The Department of Health in South Africa has also provided approval for this study. 2.2. Measures 2.2.1. Socioeconomic Characteristics A researcher-designed questionnaire is used to record information on  participants’  age, gender, educational level, marital status, income, employment status, dwelling characteristics and residential status.  Poverty  was assessed with five items on the availability or non-availability of shelter, fuel or electricity, clean water, food and cash income in the past week. Response options ranged from 1 = ―Not  one day‖  to 4 = ―Every  day of the week‖.  Poverty was defined as higher scores on non-availability of essential items. The total score ranged from 5 to 20, 5 = being low, 6 − 12 = medium and 13 − 20 = high poverty. Cronbach alpha for this poverty index was 0.89 in this sample. 2.2.2. Alcohol Consumption The 10-item Alcohol Disorder Identification Test (AUDIT) [26] assesses alcohol consumption level (three items), symptoms of alcohol dependence (three items), and problems associated with alcohol use   Int. J. Environ. Res. Public Health 2012 , 9  3248 (four items). Heavy episodic drinking is defined as the consumption of six standard drinks (10 g of alcohol) or more on a single occasion [26]. In South Africa a standard drink is 12 g of alcohol. Because AUDIT is reported to be less sensitive at identifying risk drinking in women [27], the cut-off points of binge drinking for women (four units) were reduced by one unit as compared with men (five units), as recommended by Freeborn et al . [27]. Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; a score of 8 indicates a tendency to problematic drinking or hazardous or harmful drinking. The AUDIT was developed by the World Health Organization as an effective screening instrument for alcohol use problems among patients seeking primary care for other medical problems in international settings including African countries (Kenya and Zimbabwe) [25,26] and has been validated in HIV patients in South Africa showing excellent sensitivity and specificity in detecting MINI-defined dependence/abuse (area under the receiver-operating characteristic curve, 0.96) [28] and among TB and HIV patients in primary care in Zambia demonstrating good discriminatory ability in detecting MINI-defined current AUDs (AUDIT = 0.98 for women and 0.75 for men) [29]. Cronbach alpha for the AUDIT in this sample was 0.92, indicating excellent reliability. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g., physical or psychological harm) [30]. 2.2.3. Tobacco Use Two questions were asked about the use of tobacco products: (1) Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc .)? Response options were ―yes‖  or ―no‖ ; (2) In the past month, how often have you used one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc .)? Response options were once or twice, weekly, almost daily and daily. 2.2.4. Kessler Psychological Distress Scale (K-10) The Kessler Psychological Distress Scale (K-10) was used to measure global psychological distress, including significant pathology which does not meet formal criteria for a psychiatric illness [31,32]. This scale measures the following symptoms over the preceding 30 days by asking: ― In the past 30 days, how often did you feel: nervous; so nervous that nothing could calm you down; hopeless; restless or fidgety; so restless that you could not sit still; depressed; that everything was an effort; so sad that nothing could cheer you up; worthless; tired out for no good reason? ‖  The frequency with which each of these items was experienced was recorded using a five-point Likert scale ranging from ― none of the time ‖  to ― all the time ‖ . The total score of the scale is summed with higher scores reflecting a greater degree of psychological distress, range 10  –  40. The K-10 has been shown to capture variability related to non-specific depression, anxiety and substance abuse, but does not measure suicidality or psychoses [33]. This scale serves to identify individuals who are likely to meet formal definitions for anxiety and/or depressive disorders, as well as to identify individuals with sub-clinical illness who may not meet formal definitions for a specific disorder [31].   Int. J. Environ. Res. Public Health 2012 , 9  3249 This scale is increasingly used in population mental health research and has been validated in multiple settings [34] including in a population-based survey in South Africa [35]. The K10 demonstrated moderate discriminating ability in detecting depression and anxiety disorders in the general population in South Africa; evidenced by area under the receiver operating curves of 0.73 and 0.72 respectively, with a cut off of 16 [35]. We examined the K-10 scale using the cut off of 16 indicating psychological distress. The internal reliability coefficient for the K-10 in this study was alpha = 0.92. 2.2.5. Health Status. Perceived General Health Participants were asked, ― In general, would you say your health is: excellent, very good, good, fair or poor? ‖  The measure was categorized based on participant response (very good = excellent/very good, good, and poor = fair/poor). TB treatment status, HIV status and antiretroviral treatment was assessed by self-report and from medical information. Patients were also asked about a list of chronic and other illness conditions they had been diagnosed with such as diabetes. 2.3. Data Management and Analysis Data from the questionnaires were entered manually and verified. The verification process included double data entry of all questionnaires and its fields, doing programmed range checks by computer to identify outlying values, checking for missing values, and checking for inconsistencies in the data. Data were analyzed using Statistical Package for the Social Sciences (SPSS) for Windows software application programme version 19.0. Frequencies, means, standard deviations, were calculated to describe the sample. Data were checked for normality distribution and outliers. For non-normal distribution non-parametric tests were used. Associations of hazardous or harmful alcohol use were identified using logistic regression analyses. Following each univariate regression, multivariable regression models were constructed. Independent variables from the univariate analyses were entered into the multivariable model if significant at P  < 0.05 level. Logistic regression was conducted for men and for women separately. For each model, the R 2  are presented to describe the amount of variance explained by the multivariable model. Probability below 0.05 was regarded as statistically significant. 3. Results and Discussion 3.1. Sample Characteristics From the total sample (N = 4,935) included in the study 35 subjects (0.7%) refused to participate, so the final sample included 4,900, 54.5% men and 45.5% women, with a mean age of 36.2 years (SD = 11.5), range 18 to 93 years. Almost two-thirds of the participants (65.2%) were between 25 to 44 years old, the majority (72.7%) was never married, 27.7% had completed secondary education, and 17% scored high on the poverty index. Regarding the TB treatment status, 76.6% were new TB patients and 23.4% were TB retreatment patients. From those who had tested for HIV, 59.9% were HIV positive, 22% of the HIV positive patients were on antiretroviral therapy, 9.6% had never tested for HIV. One in five patients (20.0%) were daily or almost daily tobacco users, 81.0% indicated having psychological
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