|Year : 2017 | Volume
| Issue : 2 | Page : 105-111
Alcohol consumption, hazardous drinking, and alcohol dependency among the population of Andaman and Nicobar Islands, India
Sathya Prakash Manimunda1, Attayuru Purushottaman Sugunan2, Kandavelu Thennarasu3, Dhanasekara Pandian4, Kasturi S Pesala5, Vivek Benegal6
1 Scientist-D (Medical), National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bengaluru, Karnataka, India
2 Scientist-F, Regional Medical Research Centre (ICMR), Port Blair, Andaman and Nicobar Islands
3 Professor, Departments of Biostatistics, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
4 Additional Professor, Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
5 Assistant Regional Director, Indira Gandhi National Open University, Mumbai, Maharashtra, India
6 Professor, Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
|Date of Web Publication||2-Jun-2017|
Sathya Prakash Manimunda
National Centre for Disease Informatics and Research, Indian Council of Medical Research, Kannamangala Post, Bengaluru - 562 110, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Harmful use of alcohol is one of the globally recognized causes of health hazards. There are no data on alcohol consumption from Andaman and Nicobar Islands. Objective: The objective of the study was to assess the prevalence and pattern of alcohol use among the population of Andaman and Nicobar Islands, India. Methods: A representative sample of 18,018 individuals aged ≥14 years were chosen by multistage random sampling and administered a structured instrument, a modified version of the Gender, Alcohol, and Culture: An International Study (GENACIS) which included sociodemographic details and Alcohol Use Disorders Identification Test (AUDIT). Results: The overall prevalence of alcohol consumption was 35% among males and over 6.0% in females, aged 14 and above. Two out of every five alcohol users fit into a category of hazardous drinkers. One-fourth of the total users (23%) are alcohol dependents. Both the hazardous drinking and dependent use are high among males compared to females. Almost 18.0% of male drinkers and 12.0% of female drinkers reported heavy drinking on typical drinking occasions. The predominant beverages consumed were in the category of homebrews such as toddy and handia. Conclusion: The present study highlights the magnitude of hazardous drinking and alcohol dependence in Andaman and Nicobar Islands, India and the complex sociocultural differences in the pattern of alcohol use. Based on the AUDIT data, among the population of Andaman and Nicobar Islands (aged 14 and above), one out of ten requires active interventions to manage the harmful impact of alcohol misuse.
Keywords: Alcohol, Andaman and Nicobar Islands, consumption, India, pattern, prevalence
|How to cite this article:|
Manimunda SP, Sugunan AP, Thennarasu K, Pandian D, Pesala KS, Benegal V. Alcohol consumption, hazardous drinking, and alcohol dependency among the population of Andaman and Nicobar Islands, India. Indian J Public Health 2017;61:105-11
|How to cite this URL:|
Manimunda SP, Sugunan AP, Thennarasu K, Pandian D, Pesala KS, Benegal V. Alcohol consumption, hazardous drinking, and alcohol dependency among the population of Andaman and Nicobar Islands, India. Indian J Public Health [serial online] 2017 [cited 2020 Sep 30];61:105-11. Available from: http://www.ijph.in/text.asp?2017/61/2/105/207406
| Introduction|| |
The World Health Organization (WHO) estimates that there are about 2 billion people worldwide who consume alcoholic beverages and 76.3 million with diagnosable alcohol use disorders. The 2010 analysis of 67 risk factors and risk factor clusters for death and disability found that alcohol consumption was the third leading risk factor for death and disability accounting for 5.5% of disability-adjusted life years (DALYs) lost globally. This is up from the 4.6% reported in 2004 and 4.0% in 2000., Overall, there is a causal relationship between alcohol consumption and more than sixty types of disease and injury. To name a few, alcohol is estimated to cause about 50% of liver cirrhosis, 30% of cancers of oral cavity and pharynx, 22% of esophageal cancer, 15% of traffic injuries, 12% of tuberculosis, etc., worldwide. In 2012, 5.9% of global deaths (7.6% for men and 4% for women) are estimated to have been caused by alcohol consumption.,
In India, alcohol consumption is one among the top ten risk factors and attributable to nearly 3% of DALYs lost. The National Household Survey on Drug Use in the country, the only systematic effort to document the nationwide prevalence of drug use in India, recorded alcohol use in the past year in about 21% of adult males. Prevalence among adult women has consistently been lower than 5%., Significantly higher use has been recorded among tribal, rural, and lower socioeconomic urban sections. However, the relatively low prevalence of alcohol use (compared to other cultures) is offset by the alarming signature pattern of alcohol use in India, i.e., heavy drinking, typically more than five standard drinks on typical occasions.,, It is documented that prevalence of alcohol use and hazardous use is trending upward in India.,,,
In addition to the health costs, there are indirect costs linked to a wide variety of social costs from alcohol misuse. The social cost attributable to alcohol use, extrapolated to the entire country was estimated at Rs. 244 billion for the year 2003–04. Alcohol-related health care costs can result in catastrophic impoverishment among alcohol-using households.
The available evidence of alcohol consumption and its pattern of consumption are from individual studies in isolated areas based on the specific interests of researchers. However, the wide socioeconomic and cultural variations within the country make it highly unlikely that assessments made in one part of the country, will accurately measure the situation in other parts. Lack of knowledge on alcohol use and alcohol consumption pattern is a barrier for alcohol education and intervention activities. Therefore, the present study was carried out with the objective to determine the prevalence of alcohol use and its pattern including extent of hazardous use and alcohol dependency in the Union Territory (UT) of Andaman and Nicobar Islands in India.
| Materials and Methods|| |
Study settings and population
Andaman and Nicobar Islands is a UT, an archipelago of more than 500 islands and islets (38 inhabited islands), located at longitude of 92°–94° east and latitude of 6°–14° north in the Bay of Bengal, 1200 km away from mainland India. Over 356,000 people live in this area consisting of six aboriginal tribes. A tsunami event devastated these islands in December 2004.
A cross-sectional population-based survey was conducted to assess the prevalence and pattern of alcohol use in the populations of Andaman and Nicobar Islands during 2007–2009. The Institutional Ethics Committee of the Regional Medical Research Centre of the Indian Council of Medical Research, Port Blair, Andaman and Nicobar Islands approved the study. The survey was carried out in the populations of the archipelago which fall into one of five prominent social groupings, namely: (1) the Nicobarese tribal people, who constitute the indigenous population of the archipelago; (2) the resettled Ranchi tribes from the Jharkhand region; (3) people from the mainland who settled in the islands before 1942; (4) later, settlers mainly from Bangladesh, rehabilitated by the Government of India under various rehabilitation schemes; (5) nonsettlers belonging to Tamil, Telugu, and Malayalam native speaking community from the mainland temporarily living in the islands for business and employment.
The study used a multistage random sampling method to survey 18,000 individuals in the age group of 14 years or more. A different sampling was followed in Car Nicobar Island in view of distinct tribal habitat. In rest of Andaman and Nicobar Islands, at first stage, 70 of 204 revenue villages were chosen randomly. In the second stage, every third household in these selected villages was chosen by systematic random sampling, the first household being a random choice. In Car Nicobar Island, all 308 “Tuhets” (extended joint families) were enlisted and 50 Tuhets were chosen by simple random choice. All the members aged 14 and above in these selected “Tuhets” or households were interviewed.
A structured questionnaire was used to survey the family composition, individual sociodemographic details and to assess the prevalence and pattern of alcohol use. The questionnaire used was a modified version of an instrument that was used successfully in several multicountry epidemiological studies of the WHO, i.e., Gender, Alcohol, and Culture: An International Study (GENACIS). Piloting of the instrument was carried out to make adaptations to the culturally and socially complex environment of Andaman and Nicobar Islands.
Alcohol Use Disorders Identification Test (AUDIT) was administered to all those who reported drinking at least once during the past 12 months to assess the frequency and quantity of alcohol consumed, hazardous alcohol use, and alcohol dependency. The test was designed to be used internationally and was validated in a study using patients from six countries.,, Questions 1–3 deal with alcohol consumption, 4–6 relate to alcohol dependence, and 7–10 consider alcohol-related problems. A score of ≥8 out of 40 is indicative of hazardous alcohol use and a score of ≥4 out of 12, in questions 4–6 suggests a possibility of alcohol dependence. Four levels (Zone I to Zone IV) of risk can be derived from the AUDIT scores. Any level above Zone I (AUDIT score of ≥8) requires active and graded intervention in addition to alcohol education.
The quantity of alcohol consumption was categorized into light (<5 standard drinks on typical occasions) and heavy (five or more drinks on typical occasions). The frequency of alcohol consumption was categorized into abstainer (no drinking in the past 12 months or more), infrequent (less frequent than once a weekly), and frequent (drinking once a week or more frequently).
The details about beverage of choice, tobacco use, age of initiation of drinking and regular drinking, and the impact of the tsunami on alcohol consumption were elicited through a structured questionnaire. A drink containing 12 g of ethanol was considered as one standard drink. In each of the locally brewed alcoholic beverages, the strength was measured 3 times. Hence, it was estimated that the concentration of alcohol in “Jungli” (Distilled illicit spirit) is 40% v/v, “Handia” (traditional rice beer) is between 5% and 8% v/v, and “Toddy” (It is derived from the natural fermentation of the sap from the cut ends of the flowering spathe of coconut tree) is between 5% and 8% v/v.
The study instruments were reliably translated into Hindi (using the standard translation-back-translation methodology) before administration and pilot tested in the same community to fine-tune the questions. The interviews were carried out by thirty trained field workers, under the supervision of one of the investigators. A team comprised a psychiatrist, psychiatric social worker, and epidemiologists conducted the training sessions. The data collected were cross-checked by the investigators by random selection of thirty participants every week. The collected data were entered into a computer application by trained data entry operators manually. Data cleaning was done once a week. The detailed methodology is described elsewhere.
A descriptive analysis was carried out. The proportion of people using alcohol and the consumption patterns were described under different sociodemographic heads. The differences in alcohol use, hazardous alcohol use, and alcohol dependency under various sociodemographic heads were subjected to Chi-square test for statistical significance. The data analysis was performed using the Statistical Package for the Social Studies version 17.0 (SPSS Inc., Chicago, IL, USA).
| Results|| |
In total, 18,018 (9130 males; 8888 females) people participated in the survey with a response rate of 97% (18018/18554). This works out to a sex ratio of 1000:970. Mean age of the sampled population was 35.5 (±15.0) years. Females were slightly younger than males (34.3 ± 14.6 years vs. 36.2 ± 15.4 years). While more than one-third (34%) of the population represented the social group “settler,” 42% of the study group represented “nonsettlers.” Nearly one-tenth of the study populations were Ranchi tribes and a similar proportion was Nicobarese. The proportion of Pre-42 social group was very small (2.5%). Mean years of schooling among studied population were 7.2 (±4.8), almost 20% being illiterates. The proportion of the studied population who were widowed/divorced/separated status was 6.1%. Nearly two-third were married or living with a partner (63.7%). Only 40% of the sampled populations were regularly employed.
Prevalence of alcohol use
More than one-fifth (20.7%) of all the respondents (3732 of 18,018) reported drinking alcohol at least once in the past 12 months. The prevalence was higher in males in comparison to females (34.7% vs. 6.3% [P < 0.001]). It was highest among the Nicobarese social group (49.7%), followed by the Ranchi strata (36.6%) and lowest in the pre-42 social group (9.0%) (P < 0.001) [Table 1].
|Table 1: Distribution of sociodemographic characteristics of the study participants in relation to prevalence of alcohol consumption, hazardous alcohol use, and alcohol dependency among them|
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Patterns of drinking
Quantity and frequency
Five percent of the male population and 0.5% of the female population reported frequent (weekly or more) heavy (5 ± standard drinks) drinking. This translates to frequent heavy drinking in 14.6% (461 of 3168) of the male drinkers and 8.3% (47 of 564) of female drinkers. Infrequent but heavy drinking was reported by 3.1% (99 of 3168) of male and 4.0% (23 of 564) of female consumers, respectively. Effectively, 17.7% of male drinkers and 12.3% of female drinkers reported heavy drinking on typical drinking occasions. Heavy drinking is more among the Ranchi social group (19.4%) followed by the Nicobarese (18.6%) and least among the nonsettler social group (13.5%) (P < 0.001) [Table 2].
|Table 2: Severity of drinking pattern by general demographic characteristics|
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Overall, males drink four standard drinks on average (interquartile range [IQR] =2–8) and females, three standard drinks (IQR = 1–6) on a typical drinking occasion. Nicobarese and pre-42 men drink the largest amount on typical occasions (4 drinks) followed by Ranchi, settler, and nonsettler men. Among women, the Ranchi women, on an average drink, four drinks per typical drinking occasion with the rest at around three drinks.
The average number of drinking days is around 80 days in a year for males and around 60 days for females. This is about 140 days/year for pre-42 males, 100 days a year for Nicobarese men, 90 days/year for settlers, 80 days for Ranchi tribals, and around 70 days for nonsettlers. Among women, the settlers have the highest frequency (90 days), followed by the nonsettler, Ranchi, and Nicobarese tribal women (about 60 days).
The mean amount of standard drink consumed by a drinker per year is 252 (males: 270 and females: 154). This translates to 7.6 L of alcohol (40% v/v)/drinker/year (males: 8.1 L and females: 4.6 L). The per capita consumption was 1.6 L (Standard deviation = 0.8) of alcohol (40% v/v) per year for each member aged 14 and above of the population of Andaman and Nicobar Islands.
Beverage of choice in drinkers
Almost 62% of the alcohol consumers prefer locally brewed beverages in Andaman and Nicobar Islands (Handia: 26%, Toddy: 23%, and Jungli: 13%). The remaining (38%) prefer Indian-Made Foreign Liquor (IMFL) such as whiskey (20%), brandy (8.1%), rum (7%), vodka (1.6%), beer (1%), and gin (0.3%). Among Nicobarese men and women, toddy is the preferred drink (87.3% and 98.6%, respectively). In around 12.0% of the Nicobarese men, the preferred beverage is either IMFL or jungli. Among Ranchi men and women, Handia is the drink of first choice (69.6% and 89.4%, respectively). Among the pre-42, settler, and nonsettler men, IMFL is the drink of choice (55%, 61.4%, and 58.7%, respectively) followed by the locally brewed “jungle.” Among pre-42, settler, and nonsettler women, beverage of first choice is “handia” (100%, 45%, and 84.1%, respectively).
In total, 41.6% of alcohol consumers had patterns of use amounting to hazardous drinking (AUDIT ≥ 8). This proportion is significantly higher among males (44.9%) than females. Hazardous drinking pattern is highest among the Ranchi tribals (60.9%), whereas it is lowest in Nicobarese social strata (25.2%). The proportion who engages in hazardous drinking is highest among adolescents (46.6%). The hazardous drinking pattern observed under different sociodemographic particulars is shown in [Table 1].
Nearly one-quarter (23%) of the drinkers is alcohol dependent. It is significantly higher among males (24.6%) in comparison to females (14.0%). Alcohol dependency is highest among the “Ranchi” social group and the least among Nicobarese (13.3%). Likewise, the proportion of alcohol dependents is highest among adolescents (27.6%) [Table 1].
Alcohol and tobacco use
Among those who consume alcohol, 92.7% use some form of tobacco in Andaman and Nicobar Islands (males: 92.7% and females: 92.6%).
Tsunami and alcohol consumption
Almost 12% of the males and 9% of the females who consume alcohol feel that they are drinking more after the tsunami event. Among those who are living in temporary shelters or those who lost their family members (following tsunami), more than three-fourth (76%) reported that they were drinking more after the tsunami.
Age at initiation of drinking
The age of onset of drinking is relatively late among Nicobarese men and women (23.4 years and 25.4 years, respectively). The Ranchi tribal men and Nonsettler men reported the earliest ages at initiation (19.6 years). There is a consistent decrease in the age at initiation of alcohol use in successive birth cohorts.
Proportion of the population requiring intervention
Based on the AUDIT data of studied sample, when extrapolated to entire population aged 14 and above, almost 16.0% of males and 1.5% of females of Andaman and Nicobar Islands require intervention other than alcohol education.
| Discussion|| |
We studied the prevalence and pattern of alcohol consumption in a representative sample of 18,018 individuals aged 14 and above in Andaman and Nicobar Islands in India. The proportions of individuals in our sample population representing the various social groups are similar to the total population proportions of these groups in Andaman and Nicobar Islands. One-third of male and one of every twenty women consume alcohol. Two of five consumers of alcohol fit into a category of hazardous drinking and nearly a quarter of the users are alcohol dependent. Both the hazardous drinking and dependent use are high among males compared to females.
The prevalence of drinking in our study is higher than the national average. For example, only one-fifth (21%) of the study populations use alcohol in the National Household Survey of Drug and Alcohol Abuse 2000–2001. However, previous studies of male drinkers show wide variations in estimates of prevalence between different regions of the country (16.7% in Madras city in southern India to 49.6% in a Punjab village in northwest India). The estimates on the prevalence of alcohol use among women are always <5%.,, The most recent data from the National Family Health Survey-3 indicate that almost one-third of men (32.0%) in India use alcohol, compared with only 2.0% of the women.
The hazardous and dependent use of alcohol observed in Andaman and Nicobar Islands is comparable to data from mainland India. For example, more than half of male (52%) and more than a quarter of female (28%) population in the South Indian state of Karnataka report patterns of use amounting to hazardous drinking in the GENACIS multinational study. The National Household Survey on Drug Use in India reports alcohol dependency among 17.0%–26.0% of alcohol users as per the International Classification of Diseases 10 diagnosis of dependence. However, in the GENACIS study, over 60% of male drinkers and 47% of female drinkers report heavy drinking on a typical drinking occasion. In contrast, the proportion of heavy drinkers in Andaman and Nicobar Islands is very low (17.7% among males and 12.3% among females).
There are wide differences in the prevalence and patterns of alcohol use between different social groups within Andaman and Nicobar Islands. Nicobarese aborigines have lowest rate of hazardous drinking, whereas it is highest among “Ranchi” social group. Further studies from socioanthropological perspective may answer these complex issues.,
In contrast to rest of the country where IMFL and illicit spirits constitute the most popular beverage segments, the predominant beverages consumed are in the category of homebrews such as toddy and handia among the population of Andaman and Nicobar Islands.
The difference between male and female drinking appears to be only in the frequency of drinking. This is consistent with the trend observed in the rest of the country.
The clear trend of decreasing age at initiation of drinking at successive birth cohorts is cause for concern because it indicates a dangerous pattern evolving over a period time.
The AUDIT data of the study suggest that almost 10% of adult population of UT require active interventions to reduce the harmful impact of alcohol misuse. Even the Nicobarese aborigines are not an exception to this in the context of rapid acculturation of this population.
A large cross-sectional survey in a representative sample (n = 18,018) of the target population is the biggest strength of this study. The use of standard study tools enabled both within-country and international comparison. The cross-sectional nature of our study and the self-reported rates of alcohol use and the pattern of use are the two major limitations of our study.
| Conclusion|| |
The present study highlights the magnitude of hazardous drinking and alcohol dependence in Andaman and Nicobar Islands, India and the complex sociocultural differences in the pattern of alcohol use. Among the population of Andaman and Nicobar Islands (aged 14 and above), one out of ten requires active interventions to manage the harmful impact of alcohol misuse.
The authors would like to thank Mr. Mihir Mohanthy, Ms. Monica Singh, and Ms. Sheethal, for their help in executing the study. The authors acknowledge the tremendous help received by the Tribal Council, Car Nicobar Island and by countless Nicobarese volunteers during the study.
Financial support and sponsorship
The study was funded by ActionAid International, India.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]