Hazardous Alcohol Consumption and Violence: The importance of evidence for prevention

Hazardous Alcohol Consumption and Violence: The importance of evidence for prevention – Blog

Background

The recreational use of alcohol is usually considered harmless, besides an occasional headache. However, the abuse of substances like alcohol and drugs is associated with many negative outcomes, including an increase in violence. While most alcohol drinkers are not violent, much of the crime and violence that is perpetrated in South Africa, and indeed around the world, is enabled and exacerbated by substance abuse. This makes addressing substance use and abuse, an essential component of any violence prevention initiative.

The Centre for Justice and Crime Prevention (CJCP) is currently running a violence prevention project (the Umhlali project) in Walmer Township, Port Elizabeth. Data from the baseline study conducted prior to the implementation of this project showed that alcohol was by far the most frequently consumed substance in the community (64.6%), compared to marijuana (2.7%) and other drugs which were reported by less than 1% of the sample.[ii] A small study was subsequently conducted to determine how much of the alcohol use was, in fact, hazardous and whether the level substance abuse was likely to impact on the levels of violence in the community.

Relevance of Alcohol Consumption for Violence Prevention

There is a wealth of evidence linking violence and hazardous alcohol consumption. For example, a study in 2012 found that 65% of social contact crimes, such as murder, attempted murder, rape and assault, occur in the context of alcohol abuse, and to a much lesser extent, abuse of other substances. Alcohol abuse has also been found to directly contribute to intentional and unintentional injuries, the spread of infectious diseases, intimate partner violence, as well as child neglect and abuse.  

Alcohol abuse also influences violence indirectly. South Africa has one of the highest Foetal Alcohol Syndrome (FAS) rates in the world, with large numbers of mothers consuming alcohol at a hazardous level during their pregnancies. Children affected by FAS have higher rates of adverse developmental outcomes with far-reaching consequences even into adulthood. These include:

Deficits in cognition and executive functioning strongly associated with early onset and lifelong persistent offending trajectories;

  1. Hyperactivity;
  2. Mental health problems;
  3. Difficulties with educational engagement;
  4. Poor employment prospects;
  5. Inappropriate sexual behaviour;
  6. Increased conflict with the law; and
  7. Addiction to substances.

Thus, it is not surprising to find higher rates of people affected by FAS in the criminal justice system.

The risks of FAS are much higher in communities characterised by low socio-economic status, low educational attainment, high number of pregnancies and heavy alcohol consumption.

The cost of all this to society is immense, from missed potential to injury and even death. Indeed, the total tangible and intangible costs related to harmful alcohol use has been found to represent 10 -12% of South Africa’s 2009 Gross Domestic Product (GDP).

Assessing Alcohol Consumption in Walmer Township

The World Health Organisation’s Alcohol Use Disorder Identification Test (AUDIT) was used to measure hazardous alcohol consumption in Walmer. 

The AUDIT was developed by the WHO as a screening and brief intervention tool for primary health care practitioners so that they can identify people who require support for reducing or ceasing alcohol consumption. The AUDIT produces a score which is used to refer people to appropriate interventions. The AUDIT has been found to provide an accurate measure of risk across gender, age and cultures. 

It showed that high risk (35%) and probable alcohol dependent drinkers (26%) account for more than 60% of the adult population of the township, while low-risk drinkers (20%) and abstainers (19%) account for the remaining 40% of the population. This finding is of vital significance for the project, as it provides evidence that alcohol abuse is a pervasive activity in the community and that if unaddressed, may inhibit the effectiveness of the intervention. 

When exploring the gender differences, the study showed that female participants constituted the majority of abstainers (63.5%).  Low-risk drinking patterns were equally shared between males (50%) and females (50%). In this sample, a higher percentage of females (52.2%) were present in the high-risk drinkers category than males.

This is unusual, and warrants closer attention when developing hazardous alcohol consumption interventions, as women head up 41.2% of all households in South Africa. This has implications for increased risk of child neglect and possible abuse, as well as FAS.  This high score could possibly be attributed to the slightly higher number of females in the sample when compared with the general population of Walmer Township. Males made up the majority of probable alcohol dependence drinkers at 52%.

When analysing the data by age, we found that 82.3% of high-risk drinkers were between the ages of 21 to 40 years. The same age group accounts for 88.3% of probable alcohol dependence drinkers.

From the data, it appears that the at-risk age groups for hazardous alcohol consumption for women are between the ages of 21 to 30. For males, it is 21 to 40 years of age. This means that there is a wider spread of hazardous drinkers amongst males than females. This also means that the planned interventions should be age-appropriate for adults. Counter-intuitively, the youth and young adults 20 years and younger had the least hazardous alcohol consumption for both genders.

Next, we compared the alcohol consumption patterns to the general Drinkers’ Pyramid. The Drinkers’ Pyramid is a reference tool used in the AUDIT manual, based on general norms, which need to be adjusted to local alcohol consumption patterns. The alcohol consumption patterns of Walmer Township illustrated drinking patterns that exceeded the normative Drinkers’ Pyramid. There are far fewer abstainers and low-risk drinkers in Walmer Township, and far more high risk and probable alcohol dependence drinkers than what is generally considered to be normal.

This data is extremely useful when it comes to developing and implementing a campaign to reduce hazardous alcohol consumption.  When we know which groups are most at risk, we can target interventions accordingly.  The WHO AUDIT also provides guidance as well as educational materials which can be used for interventions. These can be found in the AUDIT guide.

Recommendations for Implementation

The WHO makes the following multi-level recommendations to address problematic alcohol consumption:

To these, we add the following recommendations based on the data which emerged from the Walmer AUDIT. We will be implementing these recommendations within the Umhlali project and will be evaluating the impact of this work in 2018.

A. We will be putting in place a structured intervention with targeting licensed and unlicensed taverns in Walmer Township that focuses on:

  1. Creating distribution points for people to access information on hazardous alcohol consumption;
  2. Education and engagement around the link between violence and hazardous alcohol consumption;
  3. Ethical business practice; and
  4. Creating a self-driven platform where taverns owners and community members can work together to address issues arising from alcohol consumption and crime.

B. We will also be putting in place targeted interventions aimed at the following vulnerable groups:

  1. Females aged 21 to 30 years
  2. Males aged 21 to 40 years

C. Given the high rate of hazardous alcohol consumption in Walmer, the following components will be built into the intervention strategy:

  1. Prevention activities aimed at encouraging and/or maintaining abstinence aimed at children, youth and adults
  2. Develop intervention material based on the WHO Brief Intervention for Hazardous and Harmful Drinking which will form the basis of prevention activities
  3. Use the self-completed screening tool in group settings within the existing Umhlali programme activities, such as life skills and parenting skills development
  4. Develop  appropriate educational leaflets and handouts to leave at local taverns
  5. Implement regular educational workshops on hazardous alcohol consumption
  6. Establish counselling and monitoring intervention within the existing family service
  7. Establish external referral system to specialists who can conduct diagnostic evaluations and prescribe treatment
  8. Establish a partnership with existing alcohol dependence service providers to render monitoring and counselling services.

Through this targeted and evidence-based approach, we hope to prevent violence in the short and long-term by reducing the amount of hazardous alcohol consumption in Walmer. 

Work cited

Boles, S. M., & Miotto, K. 2003. Substance abuse and violence: A review of the literature. Aggression and violent behavior, 8(2), 155-174.

Jules-Macquet, R. & Phyfer, J., 2016. Assessment of Community Needs: Umhlali Household and School Baseline Data, Cape Town: Centre for Justice  & Crime Prevention.

Jacobs, L., Steyn, N. & Labadarios, D., February 2012. ‘Mind The Gap’: Observations In The Absence Of Guidelines For Alcohol Abstinence Among Expectant Women In South Africa, s.l.: HSRC.

World Health Organization, 2014. Global Status Report On Alcohol And Health, Geneva: WHO.

Civilian Secretariat For Police, 2016. White Paper On Safety And Security, Pretoria; Jacobs, et al., February 2012.

Jacobs, L., Steyn, N. & Labadarios, D., February 2012; World Health Organization, 2014. Global Status Report On Alcohol And Health, Geneva.

Hughes, N., Clasby, B., Chitsabesan, P. & Williams, H., 2016. A Systematic Review Of The Prevalence Of Foetal Alcohol Syndrome Disorders Among Young People In The Criminal Justice System. Cogent Psychology, Volume 3.

Brown, J., Mitchell, M., Wartnik, A. & Russell, A., 2015. Fetal Alcohol Spectrum Disorder and the Courts: An Introduction for Legal Professionals. Behavioral Health, 3(1).

Rendall-Mkosi , K. et al., 2008. Fetal Alcohol Spectrum Disorder in South Africa: Situational and Gap Analysis. University of Pretoria, University of Cape Town, Medical Research Council & UNICEF.

Matzopoulos, R. G., Truen, S., Bowman, B. & Corrigall, J., 2014. The Cost Of Harmful Alcohol Use In South Africa. South African Medical Journal, February, Vol. 104(No. 2), pp. 127-132.

Statistics South Africa, 2013. Social profile of South Africa, 2002–2012, s.l.: s.n.

Babor, T. F.; Higgins-Biddle, J. C., 2001. Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care, Geneva: World Health Organisation; Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B. & Monteiro, M. G., 2001. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, Geneva: World Health Organisation.

World Health Organization, 2014; Anderson, P., Chisholm, D. & Fuhr, D. C., 2009. Effectiveness And Cost-Effectiveness Of Policies And Programmes To Reduce The Harm Caused By Alcohol. The Lancet, Volume 373, p. 2234–46.