Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: A community based cross-sectional study

Getasew Legas; Sintayehu Asnakew; Amsalu Belete; Getnet Mihretie Beyene; Gashaw Mehiret Wubet; Wubet Alebachew Bayih; Ermias Sisay Chanie; Agimasie Tigabu; Tigabu Dessie

doi:10.1371/journal.pone.0257804

. 2021 Sep 30;16(9):e0257804. doi: 10.1371/journal.pone.0257804

Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: A community based cross-sectional study

Getasew Legas ^1,^*, Sintayehu Asnakew ¹, Amsalu Belete ¹, Getnet Mihretie Beyene ¹, Gashaw Mehiret Wubet ², Wubet Alebachew Bayih ³, Ermias Sisay Chanie ³, Agimasie Tigabu ³, Tigabu Dessie ³

Editor: Markos Tesfaye⁴

PMCID: PMC8483395 PMID: 34591890

Abstract

Background

Alcohol use disorder is the major public health problem in low- and middle-income countries that account for up to 70% of alcohol related premature mortality in the region. Therefore, the aim of this study was to assess the magnitude of alcohol use disorder and its associated factors among adult residents in south Gondar zone, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted among 848 adult residents of the south Gondar zone from January 13 to February 13, 2020. A multistage sampling technique was used to recruit study participants. We assessed alcohol use disorder (AUD) using the alcohol use disorder identification test (AUDIT). A binary logistic regression model was employed to identify factors associated with AUD.

Results

The prevalence of alcohol use disorder over the last 12-months was found to be 23.7% (95% CI: 20.9, 26.7). Being male (AOR = 4.34, 95 CI; 2.800, 6.743), poor social support (AOR = 1.95, 95 CI: 1.098, 3.495), social phobia (AOR = 1.69, 95 CI; 1.117, 2.582), perceived high level of stress (AOR = 2.85, 95 CI; 1.829, 34.469), current cigarette smoking (AOR = 3.06, 95 CI; 1.764, 5.307) and comorbid depression (AOR = 1.81, 95 CI; 1.184, 2.778) were significantly associated with alcohol use disorder.

Conclusion

The prevalence of alcohol use disorder is high among adult residents of the south Gondar zone and associated with many factors. So, it needs public health attention to decrease the magnitude of alcohol use disorder in Ethiopia.

Background

Alcohol use disorder is defined as a persistent pattern of alcohol use characterized by taking a large amount of alcohol drinking, unsuccessful effort to cut down, strong desire to use, increased amount of drinking to achieve the desired effect, and experience of withdrawal symptoms after reduction of drinking occurring within a 12-month period [1].

Alcohol is the most prevalent substance use disorder, up to 99.2 million disability-adjusted life years (DALYs) were attributed to alcohol use disorder [2]. Approximately more than 2 billion adults (48% of the adult population) use alcohol [3, 4]. Globally, 4% of the global burden of disease was contributed by alcohol consumption, which is equivalent to tobacco smoking, but alcohol is more contributes to premature death in young adults than tobacco smoking [5].

In recent years, high-income countries have increased their attention to alcohol-related harm by implementing governmental regulations to reduce alcohol consumption [6, 7]. It contributes to more than 200 alcohol-related preventable diseases. It was also responsible for 7.6% and 4% of alcohol-related deaths in men and women respectively [8, 9]. However, up to 70% of alcohol-related premature mortality occurs in low- and middle-income countries [10, 11].

In sub-Saharan Africa, alcohol consumption was higher than the global consumption rate (7.4% vs 6.2%) and the consumption rate was 42% higher than the global rate per adult drinker [12].

The magnitude of alcohol use disorder is different across the world. In the United States, approximately about 13.9% and 29.1% of persons aged 18 years and older suffer from 12-month and lifetime AUD respectively [13]. A study conducted in rural Brazil reported that 18.4% of subjects had AUD [14]. Another data in Brazil showed, almost half (50%) of participants had AUD [15]. A community-based study done in India showed that the magnitude of alcohol use disorder was 9.4% [16]. In Nepal, a number of researches were conducted in the general population and the magnitude of AUD ranged from 7.3% to 25.8% [16–18].

In Africa, two studies were done in Uganda and Nigeria, the magnitude of alcohol use disorder was 9.8% and 39.5% respectively [19, 20]. A number of factors were found to affect alcohol use disorder. Different kinds of the literature showed that male sex, illiteracy, low level of education, perceived high level of stress, poor social support, stressful life events, cigarette smoking, comorbid depression, and social phobia were significantly associated with alcohol use disorder [21–30].

In Ethiopia, the magnitude of alcohol use disorder in the general population ranges from 12.4% to 21% [31–33]. So, assessing the magnitude of alcohol use disorder at the community level had a great significance to enforce the government and stakeholders to implement mental health services in primary health care settings to manage alcohol use disorder. So, this study is designed to determine the magnitude and factors associated with alcohol use disorder among adult residents of the south Gondar zone, northwest Ethiopia.

Methods and materials

Study settings and populations

A community-based cross-sectional study was conducted from January 13 to February 13, 2020. The study was conducted in the South Gondar zone, northwest Ethiopia. South Gondar zone was divided into fifteen districts/woredas with an estimated population of 2,051,738. From those, 1,041,061 were men and 1,010,677 were women. Debre Tabor town is the capital city of the south Gondar zone. The town is 100 km far from Bahir Dar (the capital city of the Amhara region) and 667 km far from the capital city of Ethiopia. Currently, the south Gondar zone had one referral hospital, seven district hospitals, and 94 health centers but mental health service (outpatient and inpatient treatment) is delivered by only three governmental hospitals.

Study participants

The study was conducted among adult residents whose age was 18 years and above in the south Gondar zone, northwest Ethiopia. Individuals who were seriously ill and unable to communicate were excluded from the study. We determined the sample size by using the single population proportion formula assuming that 21% of adult residents in Ethiopia might have alcohol use disorder at 95% CI, 4% margin of error, and adding a 10% non-response rate. Considering of design effect of 2, the final sample size was 875.

Sampling

A multistage sampling technique was used to select 848 study participants. In a total of 15 districts/woredas, we selected three districts by simple random sampling technique. Then, we selected three sub-districts/kebeles in each of the selected districts of the south Gondar zone. In each of the selected sub-districts, we selected 875 households proportionally. In the case of more than one individual in a household, select one of them by lottery method. The number of households was obtained from health extension workers (Fig 1).

Measurements

Sociodemographic factors age, sex, marital status (never married, married and living together, married and not living together, divorced, or widowed), living circumstance (living with family or alone), educational status (unable to read and write, primary education, middle school or college and above), residence (rural or urban), and occupational status (employed or unemployed) were adopted from different literatures conducted in Ethiopia.

To identify AUD, we used a 10-item alcohol use disorder identification test questionnaire (AUDIT). Each item of AUDIT was rated on a five-point scale, ranges from 0 to 40. A total score of 1–7 considered social drinker, the total of score 8 or more indicates probable alcohol use disorder, the total score of 8–15 indicates hazardous alcohol use, a score of 16–19 indicates harmful alcohol use and a score of 20 or more indicates probable alcohol dependence in the last 12-months [34]. The presence of comorbid depression in the last two weeks was assessed by the patient health questionnaire (PHQ-9). The tool has nine items and each item has rated on a four-point scale, 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day) with the total score ranging from zero to 27. A score of five or more on the PHQ-9 questionnaire considered as having comorbid depression [35]. Individual-level of stress in the last one month was measured using 10 items of perceived stress scale questionnaire (PSS). Each item of PSS has rated on a five-point scale, 0(never), 1(almost never), 2 (sometimes), 3 (fairly often), 4 (very often) with a total score ranging from zero to 40. Scoring of 0–13 considered a low level of stress, scoring of 14–26 considered a medium level of stress, and scoring of 27–40 considered a high level of stress. Previous studies carried out based on this cut-off point [36–39]. The level of social support was measured using a three-item Oslo social support scale which has three items with a range of between three and fourteen.” scoring of 12–14 = Strong support” score of 9–11 = Moderate social support and”, a score of “3–8” Poor social support scale [40]. Social phobia was assessed by a 17-item social phobia inventory scale (SPIN). SPIN has 17- items rates from 0 (not at all) to 4 (extremely) with a total score ranges from 0 to 68. A score of 21 or more is considered as having social anxiety disorder [41]. The tool was validated both for adults and adolescents in different countries [42, 43].

Data collection

The data was collected by nine psychiatry nurses after three days of training and supervised by three-degree holder psychiatry professionals. The interviewer administered questionnaire was used after translated into Amharic language (local working language).

Data processing and analysis

The collected data were checked for completeness and consistency and entered into Epi-data V.3.1. Then, exported to SPSS window V.21 for analysis. Descriptive, bivariate, and multivariate logistic regression analysis was used to identify factors associated with the outcome variable. A p-value of < 0.05 at 95% CI with adjusted OR is considered as statistically significant.

Ethical consideration

Ethical clearance was obtained from the ethical review committee of Debre Tabor University. Confidentiality was maintained by omitting the name and address of the participants. Written informed consent was taken after explaining the purpose of the study. A formal written permission letter was obtained from the south Gondar zone health department.

Result

Sociodemographic characteristics

A total of 848 participants were interviewed with a response rate of 96.91%. The majority of the respondents, 528(62.3%) were male. 824 (97.2%) of participants were Amhara by ethnicity. Regarding religion, 804 (97.2%) were orthodox Christian followers. 320 (37.7%) were married and living together. 600 (70.8%) were employed. Most of the respondents 520 (61.3%) were from urban areas. 280(33%) were attended primary education and 616(72.6%) were living with family (Table 1).

Table 1. Socio-demographic characteristics of the participants in south Gondar zone, northwest Ethiopia, 2020 (n = 848).

Variable	Category	Frequency	Percentage
Age	18–24	208	24.5%
	25–34	200	23.6%
	35–44	208	24.5%
	45–44	104	12.3%
	> = 55	128	15.1%
Sex	Male	528	62.3%
Sex	Female	320	37.7%
Ethnicity	Amhara	824	97.2%
Ethnicity	other	24	2.8%
Educational status	Unable to read and write	216	25.5%
	1–8 grade	176	20.8%
	9–12 grade	280	33%
	Diploma & above	176	20.8%
Religion	Orthodox Christian	804	94.8%
Religion	Other	44	5.2%
Marital status	Never married	304	35.8%
Marital status	Married & living together	320	37.7%
	Married & not living together	56	6.6%
	Divorced	112	13.2%
	Widowed	56	6.6%
Living circumstance	With family	616	72.6%
Living circumstance	Alone	232	27.4%
Occupational status	Employed	600	70.8%
Occupational status	Non-employed	248	29.2%
Residence	Rural	328	38.7%
Residence	Urban	520	61.3%

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Clinical, psychosocial, and substance use characteristics

Of the total 848 respondents, 312 (36.8%) had a family history of alcohol use, and the majority, 376(44.3%) had poor social support. Two hundred twenty-four (26.4%) had social phobia and 175(20.6%) having co-morbid depression. Regarding substance use, 322(38.4%) of respondents experienced Khat (leaves) chewing in their lifetime and one hundred eight (12.7%) were smoke cigarettes in the last three months (Table 2).

Table 2. Clinical, psychosocial, and substance use characteristics of the participants in south Gondar zone, northwest Ethiopia, 2020 (n = 848).

Variables	Category	Frequency	Percent %
Family history of mental illness	Yes	87	10.3%
Family history of mental illness	No	761	89.7%
Family history of alcohol use	Yes	312	36.8%
Family history of alcohol use	No	536	63.2%
Ever use of Khat	Yes	322	38.4%
Ever use of Khat	No	526	61.6%
Ever use of cigarette smoking	Yes	214	25.2%
Ever use of cigarette smoking	No	634	74.8%
Ever use of cannabis	Yes	153	18%
Ever use of cannabis	No	695	82%
Current use of Khat	Yes	188	22.2%
Current use of Khat	No	660	77.8%
Current use of cigarette smoking	Yes	108	12.7%
Current use of cigarette smoking	No	740	87.3%
Current use of cannabis	Yes	32	96.2%
Current use of cannabis	No	816	3.8%
Depression	Yes	175	20.6%
Depression	No	673	79.4%
Social phobia	Yes	224	26.4%
Social phobia	No	624	73.6%
Social support	Poor	376	44.3%
	Moderate	312	36.8%
	Strong	160	18.9%
Individual level of stress	Low	640	75.5%
	Moderate	160	18.9%
	High	48	5.7%

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Magnitude of alcohol use disorder

The magnitude of alcohol use disorder in adult residents of the south Gondar zone was 23.7% (95% CI: 20.9, 26.7). From these, 140 (16.50%) had hazardous alcohol use, 44 (5.2%) had harmful alcohol use, and 17 (2%) had probable alcohol dependence (Fig 2).

Factors associated with alcohol use disorder

To determine the association of independent variables with alcohol use disorder. Bivariate and multivariable logistic analysis was carried out. Poor social support, living alone, having co-morbid depression, social phobia, male sex, current use of khat, current cigarette smoking, current use of cannabis, and high level of stress was associated with alcohol use disorder on bivariate analysis. Poor social support, social phobia, co-morbid depression, high level of stress, male sex, and current cigarette smoking were associated with alcohol use disorder on multivariable analysis.

This study showed that alcohol use disorder was 1.81 times higher among respondents who had depression compared with those who had no depression (AOR = 1.81, 95 CI; 1.184, 2.778). Alcohol use disorder was more common among respondents who had poor social support compared with the respondents who had strong social support (AOR = 1.95, 95 CI: 1.098, 3.495). Regarding the psychosocial factors, alcohol use disorder was 2.85 times higher among respondents who had a high level of stress compared with those who had a low level of stress (AOR = 2.85, 95 CI; 1.829, 4.469). Social phobia was the other factor that was found to be significantly associated with alcohol use disorder (AOR = 1.69, 95 CI; 1.117, 2.582). Current smoking cigarette was also a major factor in the development of alcohol use disorder (AOR = 3.06, 95 CI; 1.764, 5.307). Our study also identified male gender had a statistically significant positive correlation with alcohol use disorder (AOR = 4.34, 95 CI; 2.800, 6.743) (Table 3).

Table 3. Factors associated with Alcohol use disorder among residents of south Gondar zone, northwest Ethiopia, 2020 (N = 848).

Variables	Category	Alcohol use disorder		COR 95% CI	AOR 95% CI	P-value
Variables	Category	Yes	No	COR 95% CI	AOR 95% CI	P-value
Sex	Male	168	360	4.05(2.709–6.080)	4.34(2.80–6.743) ^*	0.000
Sex	Female	33	287	1	1
Perceived stress	Low	114	526	1	1
	Moderate	71	89	2.30(1.225–4.346)	1.76(0.849–3.655)	0.128
	High	16	32	3.68(2.538–5.339)	2.85(1.829–4.469) ^*	0.008
Social phobia	Yes	91	133	3.19(2.283–4.478)	1.69(1.117–2.582) ^*	0.013
Social phobia	No	110	514	1	1
Living circumstance	With family	124	492	1	1
Living circumstance	Alone	77	155	1.97(1.407–2.761)	1.23(0.811–1.871)	0.328
Depression	Yes	70	105	2.75(1.929–3.944)	1.81(1.184–2.778) ^*	0.006
Depression	No	131	542	1	1
Social support	Poor	102	274	2.33(1.410–3.866)	1.95(1.098–3.495) ^*	0.023
	Moderate	77	235	2.05(1.224–3.451)	1.50(0.851–2.671)	0.159
	Strong	22	138	1	1
Current cigarette smoking	Yes	49	59	3.21(2.114–4.883)	3.06(1.764–5.307) ^*	0.000
Current cigarette smoking	No	152	588	1	1
Current use of khat	Yes	59	129	1.66(1.164–2.391)	0.93(0.606–1.426)	0.740
Current use of khat	No	142	518	1	1
Current use of cannabis	Yes	13	19	2.28(1.108–4.715)	0.65(0.249–1.737)	0.397
Current use of cannabis	No	188	628	1	1

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1 (reference group),

* (p<0.05), COR (crude odds ratio), AOR (adjusted odds ratio)

Discussion

The magnitude of alcohol use disorder in adult residents of the south Gondar zone was 23.7% (95% CI: 20.9, 26.7). The finding of this study was in line with a study carried out in Ethiopia, 21% [33], Dharan town, 25.8% [16], and Chitwan District of Nepal 23.8% [18]. However, the finding of the current study was lower than a study conducted in Brazil 50% [15], and Nigeria 39.5% [19].

Conversely, the finding of this study was higher than the findings in the USA 13.9% [13], India, 9.4% [44], Uganda 9.8% [20], Colombia 9% [45], and studies done in other parts of Ethiopia, (12.3%, in southwest Ethiopia and 13.9%, in southern rural, Ethiopia) [31, 32]. One of the possible explanations for the difference in the previous studies carried out in Ethiopia, the majority of the study participants in Jimma town was Muslim and Protestant, compared with the current study sample which was over 97% of the study sample was orthodox Christian followers. In Sodo, Gurage Zone, South Ethiopia, more than half of the sample was females compared to the current study sample, only 37.7% of the study sample was females. However, females are less likely to involve in public place drinking and heavy drinking due to cultural influence. As a result, females are less likely to have alcohol use disorder. The other possible reasons for this discrepancy might be the difference in the number of participants, differences in the assessment tool used, economic differences, and cultural differences that might have a higher contribution to the discrepancy.

We found an association between social phobia and alcohol use disorder (AOR = 1.69, 95 CI; 1.117, 2.582). The result is similar to the findings of studies conducted in the USA [25, 27, 46]. Subjects who had social anxiety disorder could be drink alcohol to control their fears and anxiety [47].

In the current study poor social support was predictive of alcohol use disorder (AOR = 1.95, 95 CI: 1.098, 3.495). The finding of this study was in line with studies carried out in Sweden [28], and previous Ethiopian studies [22, 29, 30]. The possible reason might be due to lack of experience in social relationships, social and psychological support from their neighborhood and relatives can lead to using alcohol.

Our study also identified male gender had a statistically significant positive correlation with alcohol use disorder (AOR = 4.34, 95 CI; 2.800, 6.743). This finding is supported by studies done in India [44], Brazil [14, 15], and other parts of Ethiopia [22, 32]. Heavy drinking is mostly occurred in men compared with women and biological differences among the two genders might be contributing to the discrepancy. Not only biological factors, but females are also less likely to involve in public places drinking due to cultural influence. So, it could be less likely to have alcohol use disorder [19, 48].

In our study, alcohol use disorder was found to be significantly associated with comorbid depression (AOR = 1.81, 95 CI; 1.184, 2.778). The study is also in line with studies done in Nepal [18], Lebanon [23], India [26], Greek [24], and Uganda [49]. The possible reason might be subjects who had depressive symptoms might be using alcohol to relieve their symptoms [50, 51].

This study showed that alcohol use disorder was 2.85 times higher among respondents who had a high level of stress compared with those who had low level of stress (AOR = 2.85, 95 CI; 1.829, 4.469). The current finding was supported by a study carried out in the UK [52], Korea [53], Greek [24], Lebanon [23], Having someone high level of stress can lead to drinking as a coping mechanism of stress [53].

Finally, we found also an association between current cigarette smoking and alcohol use disorder (AOR = 3.06, 95 CI; 1.764, 5.307). The finding of this study was similar to studies conducted in Nepal [18], Brazil [14], Nigeria [19], India [26], Greek [24], and other parts of Ethiopia [22, 30, 32, 54]. The possible reason might be the two substances share a rewarding effect in the activation of the mesolimbic pathway [55].

Limitations of the study

This study was a cross-sectional study we tried to assess different factors that may predict alcohol use disorder. However, the temporal relationship cannot be concluded by this study design. In addition, recall bias might be also the other limitation of this study. Although the alcohol use disorder identification test (AUDIT) was not validated in the general population of Ethiopia. Despite these limitations, this study had strengths, including many factors that were not addressed in previous Ethiopian studies.

Conclusion

Alcohol use disorder in south Gondar zone adult residents was found to be high. Comorbid depression, male gender, perceived high level of stress, poor social support, social phobia, and cigarette smoking were significantly associated with alcohol use disorder. Therefore, the researchers recommend regular screening of alcohol use disorder by trained health professionals at the community level and the referral linkage with mental health services should be strengthened.

Supporting information

S1 File. Data collection tool to assess magnitude and corelates of alcohol use disorder in south Gondar zone, northwest Ethiopia.

(DOCX)

Click here for additional data file.^{(33.8KB, docx)}

Acknowledgments

We would like to acknowledge data collectors and study participants. We would like also to thank Debre Tabor University for ethical clearance.

Abbreviations

AUDIT: alcohol use disorder identification test
DALYs: Disability Adjusted Life Years
PHQ: Patient Health Questionnaire
SPI: Social phobia inventory scale
OSS-3: Oslo-3 Social Support Scale
AUD: alcohol use disorder
PSS: perceived stress scale

Data Availability

All relevant data are within the paper.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0257804.r001

Decision Letter 0

Markos Tesfaye

17 Jun 2021

PONE-D-21-07650

Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: a community based cross-sectional study

PLOS ONE

Dear Dr. Legas,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Markos Tesfaye, M.D., Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The report presents results from a community survey of alcohol use disorder using screening tool AUDIT through interviews of 848 residents in north west Ethiopia. The authors also presented logistic regression analysis to identify factors associated with alcohol use disorder. The study attempts to address an important public health issue globally as well as in Africa. While the work and results may be relevant to wide range of audience, some of the methods and data interpretation is flawed. Therefore, the authors need to consider the following issues to improve the scientific value of the report.

1. The manuscript has many typographical and grammatical errors that interfere with comprehension. The manuscript needs extensive language revision preferably by a native English speaker.

2. The methods section needs to provide more detailed information about the psychometric properties of AUDIT rather than qualitative statement such as "... is the most preferable tool to identify individuals with AUD"

3. The methods section refers to PHQ-9 validation with a suggested cut-off of 5. The reference actually recommended cut-off of 10 and above. Therefore, the data needs to be re-analyzed using an appropriate cut-off.

4. Similarly, the citation made for PSS-10 does not provide any of the cut-offs mentioned in the manuscript. You may provide correct reference or re-analyze the data using stress scores as continuous variable.

5. It is not clear why the interviews were used rather than self-administered data collection. In addition, what was the setting of data collection? What is the potential effect of using health professionals as interviewers of this sensitive issue? The limitation need to address any biases arising from this.

6. The ethics statement need to be included in the manuscript submission system rather than just "human participants". In addition, information on what was done for any participant with suicide risk and alcohol dependence is important ethical issue. Please clarify what was done or why no action was taken.

7. In the abstract, results, and discussion, the authors use terms suggestive of causation which cannot be inferred from this cross-sectional survey. Terms such as 'risk factor', 'predictor', 'odds of developing', 'likely to develop', etc. need to be replaced with 'associated with' or other appropriate terms.

8. The discussion needs to provide in depth interpretation and implications than simple comparisons of prevalence. You may consider to provide if there are local factors known to increase alcohol use or indicators of complications such as road traffic accident data, etc.

Minor comments:

One or two decimal places are enough for the odds ratios.

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks for your invitation to review this study. Since evidences related to substance use disorders like alcohol are scared in low and middle-income countries like ours particularly in Amhara region. Thus, this study added a valuable contribution to the medical field. So, to make this useful for the general public the authors need to incorporate the comments mentioned below

Language

I advise extensive editing/proof-reading of the written English and re-drafting before the paper can be considered suitable for publication, b/se there are many odd phares and language errors.

Introduction

1. You put repeated sentence at your introduction and citing different references (reference number 6&7). For example, in recent years, high-income countries have increased their attention to alcohol-related harm by implementing governmental regulations to reduce alcohol consumption. In recent years, high-income countries have increased their attention to alcohol-related harm by implementing governmental regulations to reduce alcohol consumption.

Methods and materials

1. Better to say "study setting" rather than study settings

Study participants

1. Have you included participants with mental illness?

2. Under study setting and populations, it is good to mention the numbers and the type of health institutions in South Gondar Zone. In addition to this I strongly recommend you to include the type of mental health services delivered in those hospitals

Measurements

1. Why you preferred to measure alcohol used disorder by using CAGE other than AUDIT? More clarification is required.

Data collection

2. How study participants were reached e.g., door to door knocking/ or telephone interview?

Discussion

3. In paragraph 1 and 2 of your discussion were mentions Brazil twice in contradicting sentences " However, the finding of the current study was lower than a study conducted in Brazil 50% (15), and Conversely, the finding of this study was higher than the findings in USA 13.9% (13), India, 9.4% (41), Uganda 9.8% (20), Colombia 9% (42), Brazil, 18.4% (14) ...

4. On paragraph 4 of your discussion, References are particularly useful to substantiate statements which could be considered strengthen your justification e.g. "The possible reason might be due to lack of experience in social relationship, social and psychological support from their neighborhood and relatives can lead to use alcohol"

5. How did you manage the participant who are eligible for dependence treatment during the data collection time?

Reviewer #2: The statement of the problem at the last end of the of the background is not convincing because the community is part of the general population.

On the sampling, the authority used in using (21%) in calculating the size has to be indicated in the manuscript.

The authors used sociodemographic data in the analysis, but have not mentioned the instrument used to collect that demographic data under measurements.

Under results on sociodemographic, the author use figures to start sentence, they need to write those figures in words.

Under limitation, the authors failed to indicate the strength of their research and the application of their findings to solving the alcohol disorder in the study district.

**********

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Reviewer #1: Yes: Mengesha Birkie

Reviewer #2: No

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Attachment

Submitted filename: reviewed.docx

Click here for additional data file.^{(16.7KB, docx)}

PLoS One. 2021 Sep 30;16(9):e0257804. doi: 10.1371/journal.pone.0257804.r002

Author response to Decision Letter 0

28 Jul 2021

Response for the editor’s and reviewers’ enquiry

Dear Editor,

Thank you for your valuable comments and recommendations.

If further correction is needed from the editor, we are ready to do the requested enquires again including re-analysis before the decision has made.

1/ For the Editor

1. The manuscript has many typographical and grammatical errors that interfere with comprehension. The manuscript needs extensive language revision preferably by a native English speaker.

Great thanks! We tried to modify the language throughout the paper.

Thank you for your constructive comment. Modified based on the comment. Please see page 6.

Thank you dear editor! Yes, it is validated at a cut-point score of 10 in PHQ 9. We used a cut-off 5 to include mild form depression. However, the majority of literature conducted in Ethiopia used a 5 cut-off point of PHQ 9. So, we add the appropriate reference for this study. Please see page 6

Ok! We provide the correct reference for PSS-10. Please see page-6

Thank you! As you have seen from the socio-demographic part of the result, 25.5% of study participants hadn’t formal education. Due to this reason, we can’t apply self-administered data collection and they were interviewed in a separate secure place. The main reason for using psychiatry nurses as interviewers was to provide appropriate information and psychoeducation for study participants who had comorbid mental illnesses like depression and anxiety.

Thank you, dear editor. For alcohol use disorder, we provide information on the availability of modern treatment for their problem and individuals who were ready (especially individuals who reach the dependency stage) to get the treatment center, send them to a treatment and rehabilitation center. But individuals who weren’t ready to get treatment center, we have informed them, they can be treated after they have prepared themselves to get modern treatment for their problem after we gave psychoeducation. But all individuals who were on hazardous/ harmful alcohol use (based on our screening tool) send to hospital for further diagnosis of alcohol dependency. we asked about suicidal behavior when we assess depression, and we send all participants who had suicidal behavior (ideation, attempt, or plan) to hospital for further diagnosis and treatment.

Dear editor, thank you for your comments /suggestions. We have revised based on your comments.

Thank you for your constructive comment. Modified based on the comment. Please see page-9

9. One or two decimal places are enough for the odds ratios.

The odds ratio decimal also modified.

2/ For Reviewer 1

Dear reviewer, thank you for the valuable comments and recommendations.

Thank you for your comments. Thank you for your comments on language and we tried to modify the language throughout the paper.

Introduction

Thank you for the comments and modify based on your comment. Please, see the introduction part. Please see page-3

Methods and materials

1. Better to say "study setting" rather than study settings

Thank you, and we correct it as “Study setting”. Please, see the method part.

Study participants

1. Have you included participants with mental illness?

Yes! Participants who had mental illness and can be communicated and give appropriate information was included in our study. But Participants who were clinically diagnosis for known severe mental illness (who received a clinical diagnosis from mental health professionals or psychiatrists) who cannot give appropriate information due to their psychosis, low energy, motivation/hyperactivity and also difficult to give an interview due to complaining of any discomfort or pain, instability was excluded from the study.

Thank you! We add the type of mental health services given by each hospital. Please, see at the study setting and populations part.

Measurements

1. Why you preferred to measure alcohol used disorder by using CAGE other than AUDIT? More clarification is required.

Thank you for your question. CAGE questionnaire is only assessed individuals who reached at dependency or abuse stage but it does not assessed individuals who had hazardous/harmful alcohol use disorder. The other reason it is not validated in Ethiopian setting, but AUDIT was validated in neighboring African countries. Additionally, the majority of previous Ethiopian studies were carried out based on AUDIT.

Data collection

2. How study participants were reached e.g., door to door knocking/ or telephone interview?

The participants were interviewed by the nocking door-to-door and they were interviewed in a separate secure place.

Discussion

Great thanks! The contradicting information has been modified. Please see the discussion part of page-9

Thank you for constructive comment! You are right, but we believe that if the explanation/justification is represented for the identified problem, a reference is may not be mandatory.

5. How did you manage the participant who are eligible for dependence treatment during the data collection time?

For alcohol use disorder, we provide information on the availability of modern treatment for their problem and individuals who were ready to get treatment center, send them to a treatment and rehabilitation center for further diagnosis and treatment. But individuals who weren’t ready to get treatment center, we have informed them, they can be treated after they have prepared themselves to get modern treatment for their problem.

3/ For reviewer 2

Thank you for your constructive comments.

1. The statement of the problem at the last end of the of the background is not convincing because the community is part of the general population.

Thank you! But if we understand your comment, we attempt to justify the importance of community-based researches to enforce the government than institution-based researches.

2. The authors used sociodemographic data in the analysis, but have not mentioned the instrument used to collect that demographic data under measurements.

Thank you for your constructive comment! There is no standardized tool to assess sociodemographic characteristics. We adopted from different kinds of literature. So, we included based on your comment. Please see on page 5.

3. Under results on sociodemographic, the author uses figures to start sentence, they need to write those figures in words.

Thank you! We put the figures and tables separately. So, the interpretation of all figures is available in the main manuscript pages 5 and 7.

4. Under limitation, the authors failed to indicate the strength of their research and the application of their findings to solving the alcohol disorder in the study district.

Thank you for your constructive comment! Modified based on your comment. Please see page 11.

Attachment

Submitted filename: Response to reviewr.docx

Click here for additional data file.^{(21.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0257804.r003

Decision Letter 1

Markos Tesfaye

13 Sep 2021

Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: a community based cross-sectional study

PONE-D-21-07650R1

Dear Dr. Legas,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Markos Tesfaye, M.D., Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for addressing the comments.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

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PLoS One. doi: 10.1371/journal.pone.0257804.r004

Acceptance letter

Markos Tesfaye

22 Sep 2021

PONE-D-21-07650R1

Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: a community based cross-sectional study

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S1 File. Data collection tool to assess magnitude and corelates of alcohol use disorder in south Gondar zone, northwest Ethiopia.

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PERMALINK

Magnitude and correlates of alcohol use disorder in south Gondar zone, northwest Ethiopia: A community based cross-sectional study

Getasew Legas

Sintayehu Asnakew

Amsalu Belete

Getnet Mihretie Beyene

Gashaw Mehiret Wubet

Wubet Alebachew Bayih

Ermias Sisay Chanie

Agimasie Tigabu

Tigabu Dessie

Roles

Abstract

Background

Methods

Results

Conclusion

Background

Methods and materials

Study settings and populations

Study participants

Sampling

Fig 1. Schematic presentation of sampling procedure in adult residents of south Gondar zone, northwest Ethiopia, 2020.

Measurements

Data collection

Data processing and analysis

Ethical consideration

Result

Sociodemographic characteristics

Table 1. Socio-demographic characteristics of the participants in south Gondar zone, northwest Ethiopia, 2020 (n = 848).

Clinical, psychosocial, and substance use characteristics

Table 2. Clinical, psychosocial, and substance use characteristics of the participants in south Gondar zone, northwest Ethiopia, 2020 (n = 848).

Magnitude of alcohol use disorder

Fig 2. Bar chart showing that the level of alcohol use in adult residents of south Gondar zone, northwest Ethiopia, 2020 (N = 848).

Factors associated with alcohol use disorder

Table 3. Factors associated with Alcohol use disorder among residents of south Gondar zone, northwest Ethiopia, 2020 (N = 848).

Discussion

Limitations of the study

Conclusion

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Markos Tesfaye

Roles

Author response to Decision Letter 0

Decision Letter 1

Markos Tesfaye

Roles

Acceptance letter

Markos Tesfaye

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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