Abstract
Background
Several national and regional epidemiological studies in China have reported increases in the prevalence of alcohol use disorders over the past three decades.
Methods
This cross-sectional study conducted in 2007 identified 11,884 male subjects aged 18 to 60 years using multi-stage randomized cluster sampling methods in two rural communities in China and interviewed 9,866 of them. Current and lifetime alcohol use disorders were assessed with a semi-structured diagnostic interview.
Results
The age-standardized prevalence of current (lifetime) alcohol abuse and alcohol dependence in Hunan were 1.8% (4.8%) and 4.7% (8.6%) respectively, and those in Henan were 7.6% (11.8%) and 8.7% (10.8%). Higher age (55–60) and lower education were risk factors for alcohol dependence in Hunan while middle age (35–44), currently married, and higher education and higher income were risk factors in Henan.
Conclusions
Alcohol abuse and dependence are no longer uncommon disorders among rural men in China. Unlike most western reports, alcohol dependence shows higher prevalence than abuse. There are significant differences in the prevalence of alcohol use disorders and the socio-demographic profile of affected individuals in the two different regions of the country.
Keywords: alcohol abuse, alcohol dependence, epidemiology, risk factors
Introduction
The serious public health and mental health problems associated with alcohol use occur in all countries, including China. Alcohol production and consumption in China has increased rapidly since the start of the economic reform era in 1978: Based on the Chinese National Bureau of Statistics data, from 1978 to 2006 the production of alcoholic beverages in China increased 21-fold (from 2.47 million to 52.04 million tons) (National Bureau of Statistics of China, 1978; 2006). Several national and regional epidemiological studies over the past three decades have reported corresponding increases in the prevalence of alcohol use disorders (Collaborating Research Group on Alcoholism and Related Problems, 1992; Hao et al, 1999a; Hao et al, 2004; Liu et al, 1999; Shen, 1987; Shi et al, 2005; Tao et al, 2002; Zhang et al, 1998; Zhang et al, 2008).
The 1982 psychiatric epidemiological study in 12 sites around the country that used ICD-9 criteria identified only 7 individuals with alcohol-related disorders among 39,135 respondents (0.018%) (Shen, 1987). Two subsequent studies using similar methods carried out in Shandong Province in 1984 and 1994 reported rates of current alcohol dependence of 0.036% (N=88,822) and 0.134% (N=67,901), respectively (Liu et al, 1999). Using DSM-III-R criteria, Hao and colleagues conducted two national surveys in the same locations and reported a prevalence of current alcohol dependence of 3.4% in 1993 (N=23,513) (Hao et al, 1999a), and 3.8% in 2001 (N=24992) (Hao et al, 2004). Using DSM-IV criteria and the Structured Clinical Interview for DSM-IV (SCID), the prevalence of current alcohol use disorder (abuse and dependence) was 2.9% in Zhejiang Province in 2001 (N=14,639) (Shi et al, 2005). Previously reported risk factors of current alcohol dependence in China include male gender, middle age, low educational status, higher income, and occupations that involve manual labor (Hao et al, 1999b; Chen et al; 2005). The reported prevalence among males is 10- to 65-fold that reported in females (0.2%–0.5%) (Hao et al, 1999a; Shi et al, 2005). Anecdotal evidence suggests that people living in northern China have a higher level of alcohol consumption than those living in southern China (Cochrane et al, 2003). Only a few of these studies have used structured interview instruments for diagnosis and none of them reported the lifetime prevalence of alcohol abuse or dependence.
According to the DSM-IV (APA, 1994), alcohol use disorders include alcohol abuse and alcohol dependence. An abuse diagnosis requires at least 1 of 4 persistent or recurrent alcohol-related difficulties (e.g., social or interpersonal problems) but without meeting criteria for alcohol dependence. Alcohol dependence diagnosis requires at least 3 of 7 alcohol-related cognitive, behavioral, and/or physiological symptoms (e.g., larger/longer drinking than intended) with or without co-occurring alcohol abuse. This report considers alcohol abuse, alcohol dependence, and alcohol use disorder defined as either alcohol abuse or dependence. Given the rapid social and economic changes in China, up-to-date epidemiological data on the socio-demographic pattern of alcohol use disorders are needed. The current community-based study assesses the prevalence and socio-demographic risk factors for current and lifetime DSM-IV alcohol use disorders in men in China who live in rural communities of one northern and one southern province. Women were not surveyed because of their very low prevalence of alcohol use disorders in China.
MATERIALS AND METHODS
Sampling
The survey was carried out from June to September, 2007. The primary sampling sites were Shuangfeng County in Hunan province in central southern China and Weihui City (a rural county although it is administratively classified as a city) in Henan province in northern China. Multi-stage randomized cluster sampling methods were used to identify subjects. In the first stage, three towns in Shuangfeng county and two towns in Weihui city were randomly selected. Then 139 villages were randomly selected from the 5 towns and then 18,187 households were randomly selected from the 139 villages. In each household all the male adults 18–60 years of age who resided in the community for at least six months in the year prior to the interview were identified and one was selected as the target subject using a random numbers table.
No one lived in 2,762 of the 18,187 (15.2%) households and in 3,541 (19.5%) there was either no male adult present or those present had not lived in the community for 6 months in the prior year. Appropriate subjects were identified in 11,884 (65.3%) households: 1,809 (15.2%) could not be located (after 3 visits to the household), 94 (0.8%) refused, 114 (0.9%) only finished part of the interview, and 9,866 (83.0%) completed the interview. Respondents were about 3 years older than non-respondents (44.2±11.1 years vs. 41.3±10.5 years, p<0.001).
The characteristics of subjects who completed the interview are shown in table 1. Older residents were over-represented, particularly in Hunan; this probably occurred because younger rural males were more likely to be transient laborers in urban areas. Compared to respondents from Henan, those from Hunan were older, less educated, more likely to be unmarried, and had higher mean annual per capita family income (all p-values < 0.05).
Table 1.
Socio-demographic characteristics of respondents
| Characteristics | Hunan (n=5351) | Henan (n=4515) | |
|---|---|---|---|
| Age | 18–24 | 91 (1.7%) | 413 (9.1%) |
| 25–34 | 423 (7.9%) | 1163 (25.8%) | |
| 35–44 | 1469 (27.5%) | 1451 (32.1%) | |
| 45–54 | 1599 (29.9%) | 878 (19.4%) | |
| 55–60 | 1769 (33.1%) | 610 (13.5%) | |
| Marital status | Married | 5002 (93.5%) | 4228 (93.6%) |
| Divorced/separated/widowed | 141 (2.6%) | 31 (0.7%) | |
| Never married | 208 (3.9%) | 256 (5.7%) | |
| Years of formal education | <7 | 2495 (46.6%) | 1239 (27.4%) |
| 7–9 | 2046 (38.2%) | 2589 (57.3%) | |
| >9 | 810 (15.1%) | 687 (15.2%) | |
| Mean annual per capital family income ($US) | ≦167 | 1594 (29.8%) | 1695 (37.5%) |
| 168–326 | 1496 (28.0%) | 1912 (42.3%) | |
| ≧327 | 2261 (42.3%) | 908 (20.1%) |
Instruments
Socio-demographic information and drinking behavior
The interview used in this study was developed based on a questionnaire that was employed by Hao and colleagues in two large-scale investigations in China (Hao et al, 1999a; Hao et al, 2004). It assesses a number of socio-demographic variables (e.g. gender, age, ethnicity, education level, occupational status, marital status, average annual income in the last year, self-report of adequacy of income). It also contains detailed questions about drinking behavior that are the focus of another report.
Alcohol-related problems screening test (APST)
This instrument is based on the Diagnostic Interview Schedule (Robins et al, 1981) and was developed by Shen and colleagues and had a reported sensitivity of 0.98–0.99 and specificity of 0.61–0.74 for alcohol use disorders in 3,824 subjects (Shen et al, 1993). APST includes 11 dichotomous items (‘yes’ or ‘no’): the first two questions ask about drinking frequency and amount, and the remaining nine questions assess acute intoxication, physical dependence, withdrawal symptoms, and alcohol-related social dysfunction. The screen is considered positive if one of the first 2 items is positive and a total of 2 or more of the 11 items are positive (Hao et al, 1999a; Hao et al, 2004).
Structured Clinical Interview for DSM-IV (SCID-I-P)
The study employed DSM-IV criteria (APA, 1994) for current (one-year) and lifetime alcohol abuse and alcohol dependence. Diagnoses were determined based on administration of the alcohol use disorder section of the translated and adapted Chinese version of SCID-I-P (First et al, 2002) which was revised to overcome the potential underestimation of alcohol dependence in persons who do not endorse alcohol abuse criteria (Hasin and Grant, 2004).
Procedures
Subjects who reported any prior alcohol use were administered the screening instrument (APST), those who screened positive were administered the revised version of the alcohol use disorder section of the SCID (which covered both abuse and dependence in all subjects, without skip outs). Diagnoses were determined based on the results of the face-to-face SCID interview. Consistent with DSM-IV, alcohol dependence was diagnosed regardless the diagnosis of alcohol abuse, and alcohol abuse was diagnosed only when the subject did not meet diagnostic criteria of alcohol dependence.
All questions were administered to subjects orally. Interviewers mainly spoke Mandarin during interview, which was adequate in most cases. In the situation when communication was difficult, mutual translation between Mandarin and local dialect were provided by local guide persons. We hired one or two local guide person(s) for each group of interviewers to assist accessing a household. To our experience, local guide person was very important while conducting household-based survey in rural China. This study was approved by the IRB of Xiangya Medical School, Central South University at Changsha City, Hunan Province, China. Oral informed consent was obtained before interview.
Quality control
All 44 interviewers were medical students who were provided standardized training (by the same researchers) for five days. Pilot studies were conducted after training in both sites. Diagnostic inter-rater agreement was 0.896 in Hunan Province and 0.922 in Henan Province by repeated examinations of 30 cases during the pilot phase.
During the main study interviewers were divided into 5 groups of 8–10 interviewers. Each group was supervised by an experienced psychiatrist or epidemiologist. After each interview, the questionnaire was checked by the interviewer, and then after each day of data collection, the supervisors checked the questionnaires completed by their corresponding groups for missing or inconsistent information. Any missed item or inconsistent information was revised or confirmed by re-interviewing the subject.
During the survey, 210 respondents were randomly selected for re-interview by a different medical student. The kappa values for APST and the presence of an alcohol use disorder diagnosis were 0.71 and 0.81 respectively.
Statistical methods
Chi-square tests were used to compare sociodemographic characteristics and drinking behavior between Hunan and Henan. The crude prevalence of alcohol use disorders was standardized to the age distribution of the 2005 male population in China to adjust for the over-representation of older men in the samples (National Bureau of Statistics of China, 2006). Adjusted odds ratios and 95% confidential intervals derived from unconditional multiple logistic regression models were used to assess the relationship between alcohol use disorders and sociodemographic variables. Due to small numbers of individuals with alcohol use disorders in the youngest two age groups, they were combined into an 18–34 category. For the same reason, persons who had never married were combined with those who were separated, divorced, or widowed into a ‘not currently married’ category.
RESULTS
Among the 9,866 respondents 7,670 (77.7%) respondents reported prior alcohol use and 3,053 (30.9%) screened positive with the APST. The latter group were administered the revised alcohol use section of the SCID-I-P.
The crude and age-standardized prevalence of alcohol use disorders for the two provinces are shown in Tables 2 and 3. Age-standardization had a minor effect on crude rates for Henan but a substantial effect on crude rates in Hunan. Overall rates were higher in Henan than in Hunan and the demographic distribution of alcohol disorders is dissimilar in the two provinces. After controlling for the sociodemographic factors in a multiple regression model, the Hunan:Henan odds ratios (95% CI) of current and lifetime alcohol abuse were 0.25 (0.20–0.32) and 0.42 (0.36–0.50), respectively; the odds ratios for current and lifetime alcohol dependence were 0.63 (0.53–0.74) and 0.93(0.81–1.06); and the odds ratios for current and lifetime alcohol use disorders (combining abuse and dependence) were 0.44 (0.38–0.50) and 0.63 (0.56–0.70).
Table 2.
Prevalence of current and lifetime DSM-IV alcohol use disorders by socio-demographic characteristics in Hunan province
| Current (one-year) prevalence N (%) | Lifetime prevalence N (%) | ||||||
|---|---|---|---|---|---|---|---|
| Alcohol abuse | Alcohol dependence | Alcohol use disorder | Alcohol abuse | Alcohol dependence | Alcohol use disorder | ||
| Crude Prevalence | 111 (2.1) | 353 (6.6) | 464 (8.7) | 311 (5.8) | 637 (11.9) | 948 (17.7) | |
| Age-standardized Prevalence* | 1.8% | 4.7% | 6.5% | 4.8% | 8.6% | 13.4% | |
| Age | 18–24 | 1 (1.1) | 1 (1.1) | 2 (2.2) | 2 (2.2) | 2 (2.2) | 4 (4.4) |
| 25–34 | 8 (1.9) | 8 (1.9) | 16 (3.8) | 18 (4.3) | 16 (3.8) | 34 (8.0) | |
| 35–44 | 22 (1.5) | 81 (5.5) | 103 (7.0) | 73 (5.0) | 150 (10.2) | 223 (15.2) | |
| 45–54 | 33 (2.1) | 117 (7.3) | 150 (9.4) | 96 (6.0) | 214 (13.4) | 310 (19.4) | |
| 55–60 | 47 (2.7) | 146 (8.3) | 193 (10.9) | 122 (6.9) | 255 (14.4) | 377 (21.3) | |
| Marital status | Married | 108 (2.2) | 332 (6.6) | 440 (8.8) | 298 (6.0) | 607 (12.1) | 905 (18.1) |
| Divorced/separated/widowed | 2 (1.4) | 7 (5.0) | 9 (6.4) | 7 (5.0) | 14 (9.9) | 21 (14.9) | |
| Never married | 1 (0.5) | 14 (6.7) | 15 (7.2) | 6 (2.9) | 16 (7.7) | 22 (10.6) | |
| Years of formal education | <7 | 59 (2.4) | 206 (8.3) | 265 (10.6) | 158 (6.3) | 346 (13.9) | 504 (20.2) |
| 7–9 | 35 (1.7) | 119 (5.8) | 154 (7.5) | 106 (5.2) | 223 (10.9) | 329 (16.1) | |
| >9 | 17 (2.1) | 28 (3.5) | 45 (5.6) | 47 (5.8) | 68 (8.4) | 115 (14.2) | |
| Mean annual per capita family income | Lowest | 31 (1.9) | 121 (7.6) | 152 (9.5) | 88 (5.5) | 212 (13.3) | 300 (18.8) |
| Medium | 29 (1.9) | 95 (6.4) | 124 (8.3) | 81 (5.4) | 171 (11.4) | 252 (16.8) | |
| Highest | 51 (2.3) | 137 (6.1) | 188 (8.3) | 142 (6.3) | 254 (11.2) | 396 (17.5) | |
standardized to the national age distribution of males in 2005
Table 3.
Prevalence of current and lifetime DSM-IV alcohol use disorders by socio-demographic characteristics in Henan province
| Current (one-year) prevalence N (%) | Lifetime prevalence N (%) | ||||||
|---|---|---|---|---|---|---|---|
| Alcohol abuse | Alcohol dependence | Alcohol use disorder | Alcohol abuse | Alcohol dependence | Alcohol use disorder | ||
| Crude Prevalence | 346 (7.7) | 396 (8.8) | 742 (16.4) | 543 (12.1) | 495 (11.0) | 1038(23.0) | |
| Age-standardized prevalence | 7.6% | 8.7% | 16.3% | 11.8% | 10.8% | 22.6% | |
| Age | 18–24 | 29 (7.0) | 31 (7.5) | 60 (14.5) | 36 (8.7) | 35 (8.5) | 71 (17.2) |
| 25–34 | 103 (8.9) | 80 (6.9) | 183 (15.7) | 154 (13.2) | 100 (8.6) | 254 (21.8) | |
| 35–44 | 124 (8.5) | 153 (10.5) | 277 (19.1) | 188 (13.0) | 187 (12.9) | 375 (25.8) | |
| 45–54 | 61 (6.9) | 82 (9.3) | 143 (16.3) | 103 (11.7) | 99 (11.3) | 202 (23.0) | |
| 55–60 | 29 (4.8) | 50 (8.2) | 79 (13.0) | 62 (10.2) | 74 (12.1) | 136 (22.3) | |
| Marital status | Married | 327 (7.7) | 383 (9.1) | 710 (16.8) | 523 (12.4) | 478 (11.3) | 1001(23.7) |
| Divorced/separated/widowed | 1 (3.2) | 1 (3.2) | 2 (6.5) | 2 (6.5) | 2 (6.5) | 4 (12.9) | |
| Never married | 18 (7.0) | 12 (4.7) | 30 (11.7) | 18 (7.0) | 15 (5.9) | 33 (12.9) | |
| Years of formal education | <7 | 87 (7.0) | 105 (8.5) | 192 (15.5) | 136 (11.0) | 126 (10.2) | 262 (21.1) |
| 7–9 | 202 (7.8) | 215 (8.3) | 417 (16.1) | 325 (12.6) | 274 (10.6) | 599 (23.1) | |
| >9 | 57 (8.3) | 76 (11.1) | 133 (19.4) | 82 (11.9) | 95 (13.8) | 177 (25.8) | |
| Mean annual per capita family income | Lowest | 128 (7.6) | 128 (7.6) | 256 (15.1) | 178 (10.5) | 157 (9.3) | 335 (19.8) |
| Medium | 134 (7.0) | 171 (8.9) | 305 (16.0) | 233 (12.2) | 225 (11.8) | 458 (24.0) | |
| Highest | 84 (9.3) | 97 (10.7) | 181 (19.9) | 132 (14.5) | 113 (12.4) | 245 (27.0) | |
standardized to the national age distribution of males in 2005
Considering the two sites combined, among the 749 respondents with current alcohol dependence, 179 (24.0%) did not met criteria of current alcohol abuse; and among the 1,132 respondents with lifetime alcohol dependence, 292 (25.8%) did not meet criteria of lifetime alcohol abuse. Given substantive differences in the socio-demographic correlates of alcohol use disorders identified in the two provinces, the remaining analyses were stratified by province.
Table 4 shows the adjusted odds ratios of current episodes of the three alcohol-related conditions (abuse, dependence, alcohol use disorder) versus no current alcohol use disorder for different demographic characteristics of the subjects. There are relatively minor differences in the risk factor profile between alcohol abuse and alcohol dependence within provinces but substantial differences in the risk patterns between the two provinces. In Hunan the risks of alcohol abuse and alcohol use disorder were greatest in the oldest age group (55–60) but in Henan it was lowest in the oldest age group and was highest in the 35–44 year old group. And the risks of alcohol dependence and alcohol use disorders were lowest in more highly educated individuals in Hunan but highest in the best educated and those with higher incomes in Henan. Being currently married was a risk factor for alcohol dependence and any alcohol use disorder in Henan but not in Hunan.
Table 4.
Odds ratios of current alcohol use disorders versus no current alcohol use disorders adjusted for all socio-demographic characteristics
| Characteristics | Adjusted Odds Ratios (95% Confidential Intervals) | ||||||
|---|---|---|---|---|---|---|---|
| Hunan | Henan | ||||||
| Alcohol abuse | Alcohol dependence | Alcohol use disorder | Alcohol abuse | Alcohol dependence | Alcohol use disorder | ||
| Age | 18–34 | 0.69 (0.32–1.41) | 0.25 (0.13–0.51) a | 0.37 (0.22–0.62) a | 1.93 (1.24–2.99) a | 0.92 (0.63–1.34) | 1.28 (0.96–1.72) |
| 35–44 | 0.56 (0.32–0.98) a | 0.77 (0.56–1.04) | 0.71 (0.54–0.94) a | 2.03 (1.32–3.13) a | 1.41 (0.99–2.01) | 1.63 (1.23–2.16) a | |
| 45–54 | 0.78 (0.49–1.24) | 0.97 (0.75–1.27) | 0.93 (0.73–1.17) | 1.56 (0.97–2.48) | 1.15 (0.78–1.69) | 1.29 (0.95–1.76) | |
| 55–60 | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | |
| Marital status | currently married | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| not currently married | 0.38 (0.12–1.23) | 1.03 (0.65–1.64) | 0.86 (0.56–1.33) | 0.70 (0.42–1.15) | 0.46 (0.26–0.82)a | 0.57 (0.39–0.85)a | |
| Years of formal education | <7 | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| 7–9 | 0.81 (0.51–1.29) | 0.80 (0.62–1.04) | 0.80 (0.64–1.01) | 0.97 (0.73–1.28) | 0.98 (0.76–1.28) | 0.98 (0.80–1.19) | |
| >9 | 0.97 (0.53–1.75) | 0.50 (0.33–0.77) a | 0.61 (0.43–0.86) a | 1.12 (0.78–1.60) | 1.44 (1.04–2.00) a | 1.29 (1.01–1.66) a | |
| Mean annual per capita family income | Lowest | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Medium | 1.03 (0.62–1.73) | 0.89 (0.67–1.18) | 0.92 (0.72–1.18) | 0.93 (0.72–1.19) | 1.22 (0.96–1.55) | 1.07 (0.89–1.29) | |
| Highest | 1.29 (0.81–2.05) | 0.94 (0.72–1.22) | 1.01 (0.80–1.27) | 1.35 (1.01–1.80) a | 1.59 (1.20–2.11) a | 1.46 (1.18–1.81) a | |
Ref=Reference category
Odds ratio is significant, p<0.05
Assessment of the risk factors for lifetime episodes of the three alcohol-related conditions compared with subjects without lifetime alcohol use disorders after adjusting for all other variables (Table 5) show little difference in the risk profiles for abuse, dependence, and alcohol use disorder within provinces but show differences in some socio-demographic correlates between the two provinces. Higher education and higher income was associated with alcohol dependence in Henan but not in Hunan. Being currently unmarried (vs. married) was protective from all three alcohol-related conditions in Henan and showed a similar pattern at a trend level in Hunan.
Table 5.
Odds ratios of lifetime alcohol use disorders versus no lifetime alcohol use disorders adjusted for all socio-demographic characteristics
| Characteristics | Adjusted Odds Ratios (95% Confidential Intervals) | ||||||
|---|---|---|---|---|---|---|---|
| Hunan | Henan | ||||||
| Alcohol abuse | Alcohol dependence | Alcohol use disorder | Alcohol abuse | Alcohol dependence | Alcohol use disorder | ||
| Age | 18–34 | 0.51 (0.30–0.85) a | 0.24 (0.15–0.40) a | 0.34 (0.28–0.48) a | 1.17 (0.84–1.63) | 0.65 (0.47–0.91) a | 0.89 (0.70–1.14) |
| 35–44 | 0.67 (0.48–0.94) a | 0.72 (0.57–0.91) a | 0.70 (0.58–0.86) a | 1.31 (0.95–1.81) | 1.04 (0.77–1.42) | 1.17 (0.92–1.48) | |
| 45–54 | 0.85 (0.64–1.14) | 0.96 (0.78–1.18) | 0.92 (0.78–1.10) | 1.14 (0.81–1.61) | 0.85 (0.60–1.19) | 0.98 (0.76–1.27) | |
| 55–60 | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | |
| Marital status | currently married | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| not currently married | 0.63 (0.35–1.11) | 0.78 (0.53–1.16) | 0.73 (0.53–1.02) | 0.46 (0.28–0.73) a | 0.47 (0.28–0.78)a | 0.46 (0.32–0.66) a | |
| Years of formal education | <7 | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| 7–9 | 0.89 (0.67–1.17) | 0.89 (0.73–1.08) | 0.89 (0.75–1.05) | 1.13 (0.90–1.42) | 1.15 (0.90–1.47) | 1.14 (0.96–1.36) | |
| >9 | 0.99 (0.69–1.42) | 0.72 (0.54–0.97) a | 0.81 (0.64–1.03) | 1.18 (0.86–1.60) | 1.67 (1.23–2.26) a | 1.39 (1.11–1.75) a | |
| Mean annual per capital family income | Lowest | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) | 1.00 (Ref) |
| Medium | 1.01 (0.73–1.37) | 0.90 (0.72–1.11) | 0.93 (0.77–1.12) | 1.23 (0.99–1.51) | 1.36 (1.10–1.70) a | 1.29 (1.10–1.52) a | |
| Highest | 1.23 (0.93–1.64) | 0.96 (0.79–1.18) | 1.04 (0.88–1.23) | 1.61 (1.26–2.06) a | 1.56 (1.20–2.02) a | 1.58 (1.31–1.92) a | |
Ref=Reference category
Odds ratio is significant, p<0.05
DISCUSSION
Limitations need to be considered when interpreting these results. The study used multi-stage stratified randomization methods to identify male subjects 18–60 years of age from rural communities in two provinces of China so the results cannot be considered nationally representative and do not provide information on alcohol use problems in urban subjects, in women or in individuals under 18 or over 60 years of age. The identified sample under-represented young men presumably due to rural-urban migrant worker transmigration (estimated as 130 million individuals in 2006 (National Bureau of Statistics of China, 2006)), so it was necessary to use age-standardization techniques to adjust the estimated prevalences; this makes the unproven assumption that alcohol use patterns among young men who stay in the rural areas are representative of all young rural males (including those who go to cities to work). A limited number of demographic variables have been considered in this analysis. Relationship between occupational status and ethnicity and alcohol use disorder is not examined because most of the subjects enrolled in this study are farmers and are Han ethnicity. The surveys in the two provinces were conducted by different sets of interviewers so it is possible that between-province differences were due to interviewer bias, but the instruments and training methods employed were identical and inter-rater reliability among coders was excellent so we consider this unlikely. The study focuses on men only because of their much higher prevalence of drinking and alcohol use disorders. However, there is some evidence of increased alcohol use among urban Chinese women (Zhang et al., 2008) and, although it is unclear that a similar pattern is observed in rural areas, the study of drinking and alcohol use disorders in women in rural China is an important topic for future studies.
Major differences between Henan and Hunan in the age-adjusted current and lifetime prevalence of alcohol use disorders (16.3% vs. 6.5% and 22.6% vs. 13.4%) and substantial differences in the socio-demographic profile of individuals at risk for alcohol-related conditions highlight the heterogeneity of alcohol use disorders in China and support anecdotal reports of higher prevalence in northern China where Henan province is located. Possible explanations for these major differences may include different drinking patterns, different culture norms of drinking behavior, and different availability of alcoholic beverages between the two provinces. These possible explanations clearly need further examination.
The overall current prevalence of alcohol use disorders among men in the national studies (that combined results from Shandong Province, Jilin Province, Anhui Province, Hunan Province, and Sichuan Province) in 1993 and 2001 (8.8% and 8.6%, respectively) (Hao et al, 1999a; Hao et al, 2004) were similar to the prevalence we obtained in Hunan (6.5%) but lower than the prevalence identified in Henan (16.3%). The 2001 Zhejiang Province study (Shi et al, 2005) reported a prevalence rate among males (5.5%) similar to that obtained in Hunan in the current report. In contrast, a recent study in Tibet (N=3171) reported a much higher current prevalence of alcohol use disorder among male respondents (31.6%) than in either of the current provinces studied (Guo et al, 2008). It is unclear the extent to which time, sampling methods, diagnostic criteria, instruments and other methodological factors contribute to the variation in prevalence across studies, but the current study (conducted at the same time using identical methods) indicates that location is a major determinant. Clearly, combining alcohol use disorder data among men across locations in China will obscure important local characteristics. Prevention and treatment programs for alcohol use disorders in China need to be location-specific and preceded by detailed epidemiological investigations that identify local demographic patterns and risk factors.
There are several differences between these findings and those obtained in western reports. For example, the recent National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) in the United States (Hasin et al, 2007) which reported current prevalence of alcohol abuse and alcohol dependence among men of 6.9% and 5.4%, respectively and lifetime prevalence of 24.6% and 17.4% indicate that the current abuse and dependence rates in the US are higher than the corresponding rates in Hunan but lower than the corresponding rates in Henan. The prevalence of current dependence among men was lower than that of current abuse in the US but the opposite was true in China, particularly in Hunan where the prevalence of current dependence was 2.6- times higher than that of current abuse. In Hao’s study in 2001 (Hao et al, 2004), they also found that prevalence of alcohol dependence was higher than that of alcohol abuse in both genders (3.8% vs. 1.1% in full sample). One possible explanation is that the DSM-IV abuse criteria are less relevant to rural China leading to under-diagnosis. For example, using NESARC data, about 84% of the sample that met criteria for alcohol abuse met the hazardous use criterion, and 69.3% of the sample met the drinking/driving criterion of the Alcohol Use Disorder and Associated Disabilities Inter Schedule-DSM-IV Version (AUDADIS-IV) (Kayes and Hasin. 2008). However, in rural China the low accessibility of automobiles, the limited number of police officers, and the infrequent use of alcohol outside of the home environment makes it much less likely that heavy drinkers will meet the hazardous use or legal problems criteria specified in DSM-IV. Lifetime prevalence of alcohol abuse and dependence among men is higher in the U.S. than in both Hunan and Henan, possibly reflecting the more recent onset of high levels of alcohol consumption in China. In the U.S. younger age groups have a higher risk of alcohol abuse and dependence but our study and other studies in China (Hao et al, 1999; Chen et al, 2005) show that young men have a lower risk of alcohol use disorders and are less likely to engage in heavy drinking (Zhang et al, 2008; Zhou et al, 2006). Finally, we found that even after adjusting for age being unmarried is protective from alcohol use disorders in Henan, while the opposite holds in western studies data (Leonard and Rothbard, 1999). The relationship between marriage status and alcohol use disorder in China need further examination.
Our findings support recommendations for changes in the assessment method used by the SCID for alcohol use disorders which currently does not inquire about dependence if the respondent denies abuse. The NESARC found that 33.7% of individuals with current alcohol dependence and 13.9% of with lifetime dependence did not meet criteria of abuse (Hasin and Grant, 2004). By eliminating the ‘skip out’ in the SCID interview we found that 24.0% of individuals with current alcohol dependence and 25.8% of with lifetime dependence did not meet criteria of abuse.
This study confirms that alcohol-related disorders among rural Chinese men are now a major public health issue for China. Lacking treatment resources or infrastructure, a treatment-oriented approach is not viable for rural China at the present time. The development and testing of prevention programs relevant to rural China, as well as the selective adaption and testing of successful programs used in other communities and countries is needed (WHO, 2006).
Acknowledgments
This project was part of the “Small grants program to improve the quality and implementation of research projects about suicide in China” which was supported by the China Medical Board of New York (grant number 05-813) and coordinated by Professor Michael Phillips of the Beijing Hui Long Guan Hospital and Professor Xue Zhang of Peking Union Medical College. This project was also supported by National Institute of Health D43 (grant number 5D43TW005814 to E.D. Caine) and National Institute of Health P20 (grant number 5P20MH071897 to E.D. Caine).
Sources of support: This project was part of the “Small grants program to improve the quality and implementation of research projects about suicide in China” which was supported by the China Medical Board of New York (grant number 05-813) and was also supported by National Institute of Health D43 (grant number 5D43TW005814) and NIH P20 (grant number 5P20MH071897). There is no connection of any authors with tobacco, alcohol, pharmaceutical or gaming industries in this current research.
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