The International Journal of Psychosocial Rehabilitation
 
Behavioral Problems Perceived by the Alcoholic and His Family
- A Study among Males in Rural Areas


Ramamurthy Srinath
S.M.O. at World Health Organization (WHO), Calicut, India.
Email: ram_srinath@hotmail.com

 Subramanian Sendilvelan 
 Dr. M.G.R. Educational and Research Institute, University,
Chennai–600095. India.

*Email: sendilvelan.mech@drmgrdu.ac.in

 



Citation:
Srinath R & Sendilvelan  S. (2017)   Behavioral Problems Perceived by the Alcoholic and His Family
 - A Study among Males in Rural Areas. 
International Journal of Psychosocial Rehabilitation. Vol 21 (2) 13-19

Abstract
While alcohol use is deeply embedded in many societies, recent years have seen changes in drinking patterns across the world. Rates of consumption, drinking to excess among the general population and heavy episodic drinking among young people are on the rise in many countries. Health problems associated with alcohol consumption have reached alarming levels, and alcohol use contributes to a wide range of diseases, health conditions and high-risk behaviors, mental disorders, loss of productivity, road traffic injuries, liver diseases and spousal violence. Although the prevalence of alcoholism among rural males in Tamil Nadu, India had been reported, but there is a lack of information regarding the prevalence of various types of alcoholism and problem drinking along with the psychosocial and economic aspects of drinking, especially in this part of the region. To highlight these problems the various types of alcoholism and problem have been extensively analyzed in this study.

Introduction:
The economics of alcohol has a multidimensional approach looking from the consumption patterns both at the national level, the stake-holders level and at the individual level. Mere estimation of the alcoholics in a community in not warranting without assessing the social, psychological menace it creates and measuring the economic burden it gives to the individual, family and in turn the entire nation. This prompts the importance of taking up this study which will be an eye-opener for the public to get the awareness regarding the real burden of the alcoholism and to the policy makers, public health leaders and government agencies regarding the importance of focusing on the intervention and prevention strategies of alcoholism.

PREVALENCE OF ALCOHOLISM
Alcoholism is defined as chronic disabling addictive disorder characterized by dependence on alcohol or repeated excessive use of alcoholic beverages or development of withdrawal symptoms on reducing or ceasing intake or morbidity including cirrhosis or decreased ability to function socially and vocationally (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). WHO regions show wide range of difference in terms of the prevalence. European Union has the highest prevalence of 87.4%, followed by America with 84.4%. SEAR has a prevalence of 31.6% among adult males (Casswell & Thamarangsi, 2009). Prevalence of alcoholism is affected by various factors such as culture, religion, educational status, occupation, economic status and status of living of the people.

Varma et al reported that 41% prevalence of alcoholism among males in northern India, with 49.5% of alcoholics doing unskilled or semi-skilled work (Vijoy K Varma, Malhotra, & Dang, 1985). Sundaram et al reported the prevalence of alcoholism among rural males above 15 years as 36.1% (Sundaram, Mohan, Advani, Sharma, & Bajaj, 1984). The same study also reported the vulnerable group for alcoholism as illiterate married men, in an age group of 20-35, living in a nuclear family and doing unskilled or semi-skilled occupation. Ghulam et al reported a prevalence of alcoholism among urban males above 18 years as 32.9% (Ghulam, Rahman, Naqvi, & Gupta, 1996). Srinivasan et al reported 20.5% prevalence of alcoholism among hospital patients (Srinivasan & Augustine, 2000). Hazarika et al reported the prevalence of alcoholism among rural males in the border area of Assam and Arunachal Pradesh as 39.4%, with 47.4% of the illiterates (Hazarika, Biswas, Phukan, Hazarika, & Mahanta, 2000).

ALCOHOL-RELATED PROBLEMS
The harmful effects of alcohol use on health and the possibility of developing dependence have been recognized as issues of great concern for a long time. Alcohol related problems (Girish, Kavita, Gururaj, & Benegal, 2010)(Casswell & Thamarangsi, 2009) can be classified as, Effects of alcohol on day-to-day functioning and Consequences of alcohol use.

PREVALENCE OF PSYCHO-SOCIAL PROBLEMS
In this study, the alcoholics were assessed for psychosocial problems. The psychosocial problems found out were further grouped into behavioral problems perceived by the drinker himself and his family, social problems, health and psychological problems.

Prevalence of Behavioral Problems Perceived by the Alcoholic and His Family
In this study, 72.8% alcoholics had a false perception that they are a normal drinker and 93.7% of alcoholics were not seeking anyone’s help to bail them out from their drinking problem. Among the alcoholics, 67.4% admit that their wife or parents complaint to them about their drinking habit. Meanwhile, 56.8% of alcoholics were unable to stop with one or two drinks and 35.4% had the habit of hangover drinking.

Prevalence of Social Problems
Among the alcoholics in this study, 45.1% had problem with their wife including violence. Only 1.9% had lost their friends because of their drinking habit. In this study, 28.6% of the alcoholics had trouble in their workplace and 13.1% had lost their job because of their drinking habit. Alarmingly, 10.1% of the alcoholics had been arrested because of their drunken behavior whereas 13.1% had the habit of drunken driving.

Prevalence of Health Problems
In this study, 19.4% of the alcoholics had liver disease or cirrhosis and 51.5% of alcoholics had withdrawal symptoms including tremors, hallucinations, delirium tremens etc. In this study, 21.3% of the alcoholics had been admitted in the hospital due to their drinking habit and 18.9% of them had been admitted to a psychiatric centre.

HEALTH SEEKING PATTERN AMONG CURRENT DRINKERS
The health seeking pattern (place and type of health care services along with the reason for their health care visit) among the current drinkers for their alcohol-related problems were found out.

Place of Health Care
In this study, among the current drinkers, 103 sought health care services for alcohol-related health problems. Among them 59.2% sought treatment for their drinking problems in government hospitals whereas 40.8% went to private hospitals or nursing homes. (Table 1)

Type of Health Service
Among the current users of alcohol who sought health care, 59 (57.2%) went as an out-patient whereas 44 (42.7%) got admitted for their drinking problems. (Table 2)
Reason for Seeking Health Care

In this study, 103 drinkers sought health care services for their alcohol related problems. Among them, 35.9% were due to liver disease or cirrhosis, 23.3% due to road traffic accidents and 20.4% were due to the injury following physical violence. (Table 3)
 
Table 1: Place of Health-care
Place Ever Users Percentage (%)
Government Hospital 61 59.2
Private Hospital 42 40.8
Total 103 100.0
 
Table 2: Type of Health Service
Type of Heath Service Ever Users (N=103) Percentage (%)
Out-patient 59 57.2
In-patient 44 42.7
Total 103 100.0
 
Table 3: Reason for Seeking Health Care
Reason for Seeking Health Care Number of Participants (N=103) Percentage (%)
Liver disease/Cirrhosis 37 35.9
Road Traffic Accidents 24 23.3
Physical Fights 21 20.4
Headache/Gastritis 16 15.6
Withdrawal Symptoms 5 4.8
 
ECONOMIC IMPACT OF ALCOHOLISM
In this study, the economic impact of the alcohol was calculated for all the current drinkers (320). The economic impact of drinking was classified into cost of drinking and the alcohol-impact expenses. Cost of drinking includes the cost of alcohol, refreshments, travel expenses and cost of tobacco. Alcohol-impact expenses include health costs (costs for injuries and hospital admission), work related expenses (loss of pay due to absenteeism and borrowing in work place) and social costs (debts, mortgages, gambling and damage to properties). The cost of drinking including the expenses for alcohol related consequences for a current drinker of alcohol was found to be 21,053 INR (Indian Rupee Rate) during the study period of past 12 months.

A current drinker, on an average had spent 11,498 INR for his drinks and refreshments and 3,273 INR for his health expenses in the past 12 months. On the account of the burden of drinking behavior on a current drinker, the workplace related expenses amounted to 14,046 INR and the social costs amounted to 12,632 INR. But due to the wide range in the spending for various expenses, median values were considered instead of mean values. Hence, a current drinker of alcohol in this study, spent around 8,250 INR for his drinks and refreshments and 15,000 INR for the alcohol-related consequences, which include health cost (1,200 INR), social costs (6,250 INR) and work place related expenses (12,500 INR) in the past 12 months. (Table 4)

Table 4: Monetary Cost of Drinking (12 months)
Expenses Number of Drinkers Mean (INR) Median (INR) Range (INR)
Minimum Maximum
Health Related 99 3,273 1,200 50 24,050
Workplace Related
 
147 14,046 12,500 1,000 62,500
-        Loss of Pay 139 13,809 12,500 1,000 62,500
-          Expenses out of Borrowed Money 56 3,086 2,500 1,000 10,000
Social Expense 60 12,632 6,250 750 1,00,000
Alcohol Impact 180 17,679 15,000 50 1,06,500
Alcohol 320 11,498 8,250 800 58,400
-          Alcohol Alone 320 6,794 3,675 400 47,450
-          Food 318 1,821 1,225 100 7,000
-          Tobacco 206 4,066 5,000 100 10,500
Expenses for Alcohol and Alcohol-impact 320 21,053 13,400 800 1,30,000
 
Comparison of Alcohol-related Expenses between Alcoholics and Normal Drinkers
In this study, the mean amount spent on alcohol related expenses by the alcoholics and the normal drinkers were compared using independent t-test. An alcoholic on an average spent 1,537 INR for his health expenses due to alcohol related problems as compared to a normal drinker who had spent 65 INR. The difference is found to be statistically significant (p < 0.0001). On comparing work expenses, an alcoholic had a work expense (loss of pay due to absenteeism and expense out of borrowed money) of 9,887 INR whereas a normal drinker had an expense of 246 INR. The difference is found to be statistically significant (p < 0.0001). An alcoholic on an average had an alcohol-impact expense of 15,233 INR while the same expense for a normal drinker was found to be 388 INR. The difference is found to be statistically significant (p < 0.0001). (Table 5)

Table 5: Comparison of alcohol-related expenses between Alcoholics and Normal drinkers
Alcohol Related Expenses Alcoholics Normal Drinkers P Value
Health Expenses 1,537 65 0.0001
Work Expenses 9,887 246 0.0001
Social Expenses 3,636 77 0.0003
Alcohol Impact Expenses 15,233 388 0.0001
 
Proportion of Annual Income Spent on Alcohol
Current drinkers spent 13.4% of their annual income for alcohol and alcohol-related expenses. On stratifying them based on their standard of living index, large difference is found on the proportion of annual income spent on alcohol. Current drinkers having high standard of living, spent only 6.3% of their annual income for alcohol and alcohol related expenses whereas those having low standard of living spent 36.2% of their annual income. (Table 6)
   
Table 6. Proportion of Annual Income spent on Alcohol
Particulars Number of subjects Mean Annual Income (INR) Mean Alcohol Expense (INR) Proportion of Annual Income (%)
Low SLI 55 1,02,218 37,039 36.2
Middle SLI 138 1,38,652 22,348 16.1
High SLI 127 2,00,692 12,722 6.3
Current Drinkers 320 1,57,012 21,053 13.4
 
Discussion
This cross-sectional study was done to find out the prevalence of alcoholism and various risk levels of drinking among rural males and its psychosocial and economic impact. Rural males of age 18 years and above were included in the study as it is the legal age for drinking in the state of Tamilnadu. The mean age of the study population was 41.9 15.4 years, with 87.3% literates, 67.2% married and 51% doing unskilled and semi-skilled occupations. The mean monthly per capita income of the study participants was 3072 1697 INR with 50.8% of them having high standard of living.

Behavioral Problems Perceived by the Alcoholic and his Family

In this study, 72.8% of the alcoholics had a false perception that they were just a normal drinker. Ghosh et al had a similar finding were 84% of the alcoholics had this perception (Ghosh et al., 2012). Ironically 93.7% of the alcoholics weren’t seeking help from anyone regarding their drinking problem. Grant et al, Pal et al and Well et al had explained the reason for why these alcoholics weren’t seeking help from others to bail them out from this problem (Grant, 1997)(Pal, H.R. et al., 2003)(Wells, Horwood, & Fergusson, 2007). Main reason behind it was the feeling of shame and disbelief in the benefit of the treatment. Meanwhile most of the alcoholics were not aware of their problem and not concerned about their drinking habit. They weren’t considering their alcoholism as a burden and even do they concern about it, they were not ready to seek the help of others to bail them out of it, thinking that they can deal it with themselves. These false perceptions can indeed keep them deep into the abyss of alcoholism.

In this study, 73.3% of the alcoholics were unable to limit their drinking to certain places and time while 56.8% of them were unable to stop with one or two drinks. Mohan et al had a similar finding with 58.5% of the alcoholics were unable to stop their drink with few drinks (Mohan, Chopra, Ray, & Sethi, 2001). In this study 35.4% of alcoholics had the habit of hangover drinking and 33.1% were unable to recollect the events in the morning after a heavy drinking on the previous night. Varma et al reported that 15.5% of alcoholics had hangover drinking (V K Varma, Singh, Singh, & Malhotra, 1980). These findings revealed the level of dependence the rural men were reeling under the alcohol. These problems tempt them to do binge drinking, drink at public places and workplace drinking which would lead to social and legal issues.
Health Problems

In this study, 51.5% of the alcoholics had admitted that they have withdrawal symptoms including tremors, hallucinations, delirium tremens etc. Similar finding was reported by Mohan et al with 40.4% (Mohan et al., 2001). This finding is much greater than the one reported by Ghosh (Ghosh et al., 2012). With this huge proportion of alcoholics having withdrawal symptoms, it makes the physicians’ job of managing them cumbersome along with the policy makers’ role of reducing the alcohol menace. In this study, 21.3% of the alcoholics had been admitted in hospital for their drinking problem, in which 19.4% were diagnosed to have liver disease or cirrhosis and 18.9% were admitted in a psychiatric/de-addiction ward. These findings reveal the chronicity of the alcohol menace and its strong roots among the rural men.

Conclusion

Findings from this study reveal the magnitude of the alcohol menace among the rural males in India. With one half of the rural males be drinkers and one-third to be alcoholics, the burden it gives to the family and society is huge. Psychosocial problems along with the health problems faced by the alcoholics not only affect himself but also his family and in turn the society. With one-fifth of the rural males are problem drinkers, the burden it generates is substantial. With majority of rural population having low standard of living, a current drinker by spending a hefty portion of his annual income for alcohol and alcohol related expense, further depletes his economic status. Improved systems for monitoring and surveillance at different levels, and more effective dissemination and application of information for advocacy, policy development and evaluation purposes. For all this to happen, a vital first step is for health planners and other stakeholders to debate and draft an explicit and rational alcohol policy, appropriate for India. The finding of high prevalence of alcoholism and problem drinking among rural males and the magnitude of psychosocial and economic impact on them warrants the need for a cost-effective, community based alcohol policy at the national level.


Role of Funding Sources
Funding for this study was not provided by any organization. No organization had a role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors
Both the authors have participated in the research and/or the manuscript preparation.
Role of Dr.R.Srinath: Analysis and Statistical Analysis, Finding
Role of Dr.S.Sendilvelan: Data collection, Conducted literature searches and Analysis of Samples.

Conflict of Interest
Authors declares that he/she has no conflict of interest not received any fund for this work. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee.
Informed consent: Informed consent was obtained from all individual participants included in the study.



References
Babor, T., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. 2001. "The Alcohol Use Disorders Identification Test: Guidelines for use in primary care" Geneva: World Health Organization, pp.1–40.

Benegal, V., Velayudhan, A., & Jain, S. 2000. "The social cost of alcoholism (Karnataka)," NIMHANS Journal, 18(1–2), pp.67–76.

Casswell, S., & Thamarangsi, T. 2009. "Reducing harm from alcohol: call to action," The Lancet.

Coder, B., Freyer-Adam, J., Bischof, G., Pockrandt, C., Hartmann, B., Rumpf, H. J., Hapke, U. 2008. "Alcohol problem drinking among general hospital inpatients in northeastern Germany," General Hospital Psychiatry, 30(2), pp.147–154.

D’Costa, G., Nazareth, I., Naik, D., Vaidya, R., Levy, G., Patel, V., & King, M. 2007. "Harmful alcohol use in Goa, India, and its associations with violence: A study in primary care," Alcohol and Alcoholism, 42(2), pp.131–137.

Ghosh, S., Samanta, A., & Mukherjee, S. 2012. "Patterns of alcohol consumption among male adults at a slum in Kolkata, India," Journal of Health, Population and Nutrition, 30(1), pp.73–81.

Ghulam, R., Rahman, I., Naqvi, S., & Gupta, S. R. 1996. "An epidemiological study of drug abuse in urban population of madhya pradesh," Indian Journal of Psychiatry, 38(3), pp.160–165.

Girish, N., Kavita, R., Gururaj, G., & Benegal, V. 2010. "Alcohol use and implications for public health: patterns of use in four communities," Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine, 35(2), pp.238–44.

Grant, B. F. 1997. "Barriers to alcoholism treatment: reasons for not seeking treatment in a general population sample," Journal of Studies on Alcohol, 58(4), pp.365–371.

Hazarika, N. C., Biswas, D., Phukan, R. K., Hazarika, D., & Mahanta, J. 2000. "Prevalence and pattern of substance abuse at bandardewa, a border area of assam and arunachal pradesh," Indian J Psychiatry, 42(3), pp.262–266.

John, A., Barman, A., Bal, D., Chandy, G., Samuel, J., Thokchom, M., Balraj, V. 2009. "Hazardous alcohol use in rural southern India: nature, prevalence and risk factors," The National Medical Journal of India, 22(3), pp.123–5.

Kavita, R., Gururaj, G., & Benegal, V. 2010. "Alcohol use and implications for public health: patterns of use in four communities," Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine, 35(2), pp.238–244.

Mohan, D., Chopra, A., Ray, R., & Sethi, H. 2001. "Alcohol Consumption in India: A Cross-Sectional Study," In Surveys of Drinking Patterns and Problems in Seven Developing Countries. pp. 103–114.

Nayak, M. B., Bond, J. C., Cherpitel, C., Patel, V., & Greenfield, T. K. 2009. :Detecting alcohol-related problems in developing countries: A comparison of 2 screening measures in India," Alcoholism: Clinical and Experimental Research, 33(12), pp.2057–2066. http://doi.org/10.1111/j.1530-0277.2009.01045.x

Pal, H.R., S., Y., P.S., J., S., M., Pal, H. R., Yadav, S., Ray, R. 2003. "Treatment nonseeking in alcohol users: a community-based study from North India," Journal of Studies on Alcohol, 64(5), pp.631–3.
Pillai, A., Nayak, M. B., Greenfield, T. K., Bond, J. C., Hasin, D. S., & Patel, V. 2014. "Adolescent drinking onset and its adult consequences among men: a population based study from India," Journal of Epidemiology and Community Health, 68(10), pp.922–7.

Pillai, A., Nayak, M. B., Greenfield, T. K., Bond, J. C., Nadkarni, A., & Patel, V. 2013. "Patterns of alcohol use, their correlates, and impact in male drinkers: A population-based survey from Goa, India," Social Psychiatry and Psychiatric Epidemiology, 48(2), pp.275–282. http://doi.org/10.1007/s00127-012-0538-1

Satyanarayana, V. A, Chandra, P. S., Vaddiparti, K., Benegal, V., & Cottler, L. B. 2009. "Factors influencing consent to HIV testing among wives of heavy drinkers in an urban slum in India," AIDS Care, 21(5), pp.615–21.

Srinivasan, K., & Augustine, M. K. 2000. "A study of alcohol related physical diseases in general hospital patients," Indian Journal of Psychiatry, 42(3), pp.247–252.

Sundaram, K. R., Mohan, D., Advani, G. B., Sharma, H. K., & Bajaj, J. S. 1984. "Alcohol abuse in a rural community in India. Part I: Epidemiological study," Drug and Alcohol Dependence, 14(1), pp. 27–36.

Varma, V. K., Malhotra, A., & Dang, R. 1985. "An alcohol and drug dependence clinic in North India: Initial five years experience," Indian Journal of Clinical Psychology, 12(2), pp.51–61.

Varma, V. K., Singh, A., Singh, S., & Malhotra, A. 1980. "Extent and pattern of alcohol use and alcohol-related problems in north India," Indian J Psychiatry, 22(4), pp.331–337.

Wells, J. E., Horwood, L. J., & Fergusson, D. M. 2007. "Reasons why young adults do or do not seek help for alcohol problems," The Australian and New Zealand Journal of Psychiatry, 41(12), pp.1005–12.
WHO. 2009. "Global Health Risks: Mortality and burden of disease attributable to selected major risks," Bulletin of the World Health Organization, 87, pp.646–646.

WHO. 2012. "Indicator Code Book Global Information System on Alcohol and Health," World Health Organization, pp.1–122.

World Health Organisation. 2014. "Global status report on alcohol and health," World Health Organization.



 

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