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| Journal of the New Zealand Medical Association,
25-September-2009, Vol 122 No 1303
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Alcohol and injury: a survey in primary care settings
Rachael McLean, Jennie Connor
The Law Commission is currently reviewing the 1989 Sale of
Liquor Act, and has heralded the possibility of widespread changes in response
to community wide concern about increasing alcohol-related harm in New
Zealand.1,2
Among the issues up for review are the possibility of
increased regulation of the density of liquor outlets, and types of off-licence
outlet.1 This reflects increased attention on
the role of liquor outlets, both on and off licence, in relation to
alcohol-related harm which is also the focus of the Sale and Supply of Liquor
and Liquor Enforcement Bill currently in select committee. The Bill introduces
the potential for Local Alcohol Plans which are able to restrict supply and sale
of alcohol both in on-licensed and off-licensed
premises.3
Alcohol is New Zealand’s most commonly used
recreational drug. The 2004 New Zealand Health Behaviours Survey (2007)
estimated that overall, 81% of New Zealanders aged between 12 and 65 had
consumed alcohol in the previous 12 months, while young New Zealanders
(18–24 years) consumed alcohol less frequently than older New Zealanders,
but were more likely to consume large amounts of alcohol on a typical drinking
occasion.4
Ethnic differences in alcohol consumption patterns have also
been described, and show that while the proportion of Māori and Pacific
people who drink alcohol is smaller than for non-Māori/non Pacific,
Māori and Pacific drinkers consume larger amounts of alcohol per drinking
occasion than non-Māori /non Pacific
drinkers.5,6
Results of surveys of New Zealand university students have
shown that, compared to their non-student peers, university students are more
likely to drink hazardously.7 Indeed, a survey
of students at the University of Otago showed that the majority (70%) had
consumed alcohol in the week preceding the survey and 87% of this was drunk in
heavy episodes.8 Moreover, surveys of New
Zealand university students have reported a wide range of self-reported harms,
including violence, law breaking, hangover and emotional outbursts, academic
problems, risky sexual behaviour, and sexual
assault.9–11
Several high profile events in Dunedin have focused
attention on alcohol-related harm in the city. Following ‘riots’ in
the North Dunedin student quarter following the 2007 Undie 500 car
rally, Dunedin Police asked the Dunedin City Council to extend the existing
liquor ban area into the north Dunedin residential zone. The local public health
unit (Public Health South) was consulted and recommended the Council conduct a
Health Impact Assessment of the proposed extension of the current liquor ban
area. As part of this process, a lack of local information about the role of
drinking location on alcohol-related harm was identified.
This survey was undertaken in order to investigate the
association between alcohol use, drinking location and injury in Dunedin in
order to better inform initiatives to reduce alcohol-related harm at Public
Health South. In particular we wanted to:
MethodsA cross-sectional survey of first-presentation injury
consultations for patients 16 years and older at three primary care facilities
was undertaken from 10 March 2008 to 30 April 2008 (inclusive) in Dunedin.
Participants included those eligible for Accident Compensation Corporation (ACC)
funded care for their injury, and were excluded if their injury had occurred
more than 3 months prior to presentation. They were also excluded if they were
severely intoxicated at the time of consultation and judged unable to give
consent to participate, or if they presented for gradual process claims.
Participants were identified by health centre staff and
were asked to complete an anonymous survey at the same time as they were
completing their ACC paperwork. The questionnaire contained questions about
sociodemographic factors, type of injury, and asked whether participants had
consumed alcohol in the 6 hours prior to injury. Drinkers were asked to list the
drinks they had in the 6 hours prior to their injury and were asked to name the
specific location where the last drink was consumed.
A description of their injury was self-reported by
participants and later coded using the READ code system. If multiple injuries
were listed, the first in the list was coded. The number of standard drinks
consumed in the 6 hours prior to injury (a timeframe recommended in World Health
Organization guidelines13) was estimated from
the drinks described. The lowest estimate from what was reported was recorded.
Moderate alcohol intake was defined as having 4 or
fewer standard drinks for women and 6 or fewer standard drinks for men, which is
the upper limit of recommended drinks in any one drinking occasion identified by
the Alcohol Advisory Council of New Zealand
(ALAC).14 More than this was classed as
hazardous alcohol intake.
Statistical analysis—Chi-squared
tests were conducted to determine the statistical significance of associations
between having had a drink in the 6 hours prior to injury and employment status
or sex. A t-test was conducted to test the hypothesis that there was no
difference in age between those who had had a drink in the previous 6 hours, and
those who had not. A Chi squared test was used to test the association between
hazardous alcohol intake and ‘attributing your injury to your alcohol
intake’, and hazardous alcohol intake and place of last drink.
The study was approved by the Lower South Regional
Ethics Committee, and the University of Otago Ngāi Tahu Research
Consultation Committee.
ResultsA total of 317 eligible survey responses were obtained. The
overall response rate was 71%. The age range of respondents was 16–84
years, with a mean age of 32 years and median age of 26; 37% of respondents were
female. Survey respondents self-identified predominantly with New Zealand
European ethnicity (88%), 5.5% self-identified as Māori, 2% as Pacific, 2%
as Asian, and 7% as ‘Other’. Participants were able to self identify
with more than one ethnic group. Māori respondents were asked to identify
iwi (tribal) affiliations. No analyses were undertaken by ethnicity due to low
numbers. 54% of respondents reported being in paid employment, 5% were school
students and 29% were tertiary students. Respondents self reported a wide range
of injury types (see Table 1).
Seventeen percent of respondents had had an alcoholic drink
in the 6 hours prior to injury (‘drinkers’). We compared drinkers
with non-drinkers (those who had not had a drink in the previous 6 hours) and
found that a greater proportion of women likely to be drinkers than men
(p=0.005). Tertiary students were significantly more likely to have be drinkers
(p<0.001). The mean age of drinkers was 21 years (95%CI 19.6–22.8
years), and of non-drinkers 35 years(95%CI 32.8–36.6 years). There was a
statistically significant difference between the groups (p<0.0001) with
respect to age (Table 2).
Of the 53 people who had a
drink in the past 6 hours, three specified type of drink but not amount, 4 did
not specify either type or amount of alcohol, and 1 indicated 96 standard
drinks, which was excluded as being unlikely. Of the remaining 45 responses, 16
people had moderate alcohol intake and 28 people had a hazardous intake of
alcohol (Table 3).
The mean number of standard
drinks was 8.9 (median 7.7, standard deviation 6.7). There was a significant
association between hazardous intake and attributing one’s injury to
alcohol with those with hazardous intake more likely to attribute their injury
to their drinking (p=0.002).
The majority of drinkers had
their last drink at a house or flat (62%). While there appeared to be a greater
proportion of those with hazardous intake that had their last drink in a pub,
bar, or nightclub, this association was not statistically significant. (p=0.122)
Only 9 of the 16 people who had their last drink in a pub bar or nightclub named
the premises on their survey form.
* Participants were able to self identify with more than
one ethnic group.
* 95% confidence intervals.
† χ² test of association.
‡ χ² test of association.
Table 3. Comparison of people with moderate
versus hazardous alcohol intake prior to injury
DiscussionTo our knowledge this is the first evidence regarding the
nature of alcohol-related harm presenting to primary care in New Zealand. The
proportion of patients who had had a drink in the 6 hours prior to injury
(drinkers) was 17%. While this proportion is lower than that in an Auckland
Emergency Department survey where 33% of patients presenting with injury had
consumed alcohol prior to injury,15 this was to
be expected for a number of reasons. Firstly, injuries presenting to primary
care come from a wide variety of sources, and are likely to be less severe than
those presenting to Emergency Departments. Secondly, the timing of the Emergency
Department survey in December may have influenced their result as people may
have been drinking more in the pre-Christmas period.
The timing of our survey in March and April did not include
known events likely to increase alcohol consumption in the Dunedin community
such as Orientation week. However the rate of 17% still represents a substantial
proportion of the injuries presenting, and is consistent with international
studies of injury presentations in Emergency Departments in Australia, the USA
and Canada, the United Kingdom, and Finland which report between 10–18% of
attendees where alcohol has been
involved.15
This survey also showed important differences in population
groups with respect to the proportion of patients who had been drinking prior to
injury. More men than women presented with injury, however a greater proportion
of women (24%) were drinkers, compared to of men (11%), which represents a
statistically significant difference. The reasons for this are unclear from this
study, although it may be because men are more exposed to injury from other
environments such as the workplace than women.
Department of Labour statistics show that males accounted
for approximately three quarters of all work-related injury claims each year
from 2002 and 2006.16 It does suggest however
that alcohol is an important contributor to injury, particularly for women.
Differences were also shown in occupational groups with 38% of tertiary students
drinking prior to injury compared with only 8% in paid employment. Once again,
this may relate partly to exposure to work related and other injury
environments. However these findings are consistent with other studies, which
demonstrate a wide range of harms associated with hazardous drinking in New
Zealand tertiary students.9
In this group of respondents, drinkers were younger than
non-drinkers. This is consistent with other New Zealand findings which show that
young New Zealanders drink more hazardously,4
especially tertiary students.7 We quantified
the amount of alcohol consumed prior to injury, and showed that most drinkers
(64%) had exceeded guidelines about number of standard drinks in a particular
drinking occasion. Many exceeded the recommended limit by a considerable amount.
Drinking location—This survey
provides new information about drinking location with respect to alcohol-related
harm, which is relevant to the current discussion about the role of off-license
premises. The ‘Last drinks survey’ has been used nationally by
police to monitor the role of specific licensed premises in alcohol-related
harm, particularly with respect to road safety initiatives and to fulfil their
obligations under Sale of Liquor Act 1989.12
The Sale of Liquor Act’s requirement not serve
intoxicated patrons can be tested in this way. However, the important role of
drinking in private homes demonstrated by this study requires a more detailed
review of off licences in alcohol-related harm. The 2004 New Zealand Health
Behaviours Survey found that the most common location for drinking large
amounts of alcohol were private homes, although people aged 18-24 years were
more likely than other age groups to have consumed large amounts of alcohol at
pubs, hotels/taverns or nightclubs.4
The home environment is obviously less amenable to
legislative intervention around alcohol drinking than licensed premises.
However, a range of policy interventions to reduce hazardous drinking in homes
are outlined in the recent Law Commission issues paper on the reform of New
Zealand’s liquor laws.17
Study strengths and limitations—There
are a number of limitations to this survey. Firstly, participants do not
comprise a representative sample of the Dunedin population, or of all those
presenting to primary care with injury. There are a number of potential sources
of bias. All information provided relies on the honesty of self report.
Whereas other studies have used breath alcohol levels to
estimate blood alcohol concentrations of
participants,15 we used self-reported
consumption which is likely to be less reliable. Although the response rate was
reasonable at 71%, it is likely that other eligible participants were
‘missed’ if health centre staff did not ask them to participate.
This illustrates the difficulty of conducting a survey in primary care where
there is a need to rely on busy staff to remember to ask potential participants.
Different systems of recruitment were used in different
locations, with reception staff approaching participants in one facility
(Practice A), and health practitioners approaching participants in the other two
practices, which may have biased results. Finally, the majority of responses
were obtained from Practice A, however this group was more representative of the
Dunedin population than the other two practices.
Although there are limits to the generalisability of results
due to this not being a representative sample, this survey does provide
important local data about the role of alcohol in injury. Responses reflected a
range of people of different ages, and occupation, and a wide range of injuries
was reported among both the drinkers and the non-drinkers, which suggests that
participants were reasonably representative of the Dunedin community.
Conclusions
These results provide new information with respect to the
role of drinking location in alcohol-related harm, as well as association
between alcohol and injury in primary care settings in New Zealand. Although
only injury was examined in this survey, we know that hazardous drinking is
associated with a wide range of harms, and so the degree of alcohol-related harm
in the community is likely to be much greater than that described here. A
comprehensive review of the Sale of Liquor Act is timely and should consider
restricting the availability of alcohol in on and off licensed premises in order
to minimise hazardous drinking in a range of drinking locations.
Competing interests: None known.
Author information: Rachael McLean,
Research Fellow, Edgar National Centre for Diabetes Research, Dunedin School of
Medicine, University of Otago, Dunedin; Jennie Connor, Department of Preventive
and Social Medicine, University of Otago, Dunedin.
Acknowledgements: We thank Sheila Williams
for assistance with statistical analysis—as well as Marion Poore, ,Michael
Austin and Linda Hope, Kim Ma’ia’i, Gwen Walker, and Nicki McNoe for
their assistance with the survey.
Correspondence: Rachael McLean, Edgar
National Centre for Diabetes Research Dunedin School of
Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64
(0)3 4747641. Email: rachael.mclean@otago.ac.nz
References:
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