Journal of the New Zealand Medical Association, 25-September-2009, Vol 122 No 1303
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:
A 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.
A 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
To 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.
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: firstname.lastname@example.org
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