Abstract
Objective. To estimate the proportion of heavy drinkers among occupational healthcare patients and evaluate their characteristics. Design. Patients visiting their doctor in six occupational health clinics were asked to complete a questionnaire containing the Alcohol Use Disorders Identification Test (AUDIT) and other questions concerning health. Setting. Occupational health services. Subjects. A total of 757 patients participated in the study. Main outcome measure. Heavy drinking was defined as having a score of 10 or more (men) or 8 or more (women) in the AUDIT questionnaire. Results. Of the men 114 (29%) and of the women 48 (13%) were heavy drinkers. Only smoking differentiated both male and female heavy drinkers from moderate drinkers among the clinically relevant characteristics. Conclusion. There are a considerable number of heavy drinkers among occupational healthcare patients. Heavy drinkers do not have any particularly specific characteristics except for the drinking that distinguish them from other patients. Thus, screening is necessary to identify heavy drinkers in occupational healthcare settings.
Heavy drinking is a health risk Citation[1]. It is a well-known risk factor for several medical conditions often encountered in occupational healthcare, e.g. hypertension, high body weight, stomach problems, depression, and insomnia Citation[2]. For employers, heavy drinkers are costly, because of the loss of working capacity and greater numbers of accidents and absences due to sickness Citation[3], Citation[4]. Thus in recent years employed heavy drinkers have been a source of concern in terms of the work environment.
Although brief intervention for heavy drinkers in primary healthcare has yielded convincingly good results, the implementation of this method has not been successful.
The data presented demonstrate a surprisingly high number of heavy drinkers among the occupational healthcare patients.
There were only a few characteristics to distinguish heavy and moderate drinkers, smoking being the most prominent.
Heavy drinkers must be detected systematically because they are not found by the usual patient characteristics.
In Finland it is mandatory for employers to provide occupational healthcare services. In the 1990s, the occupational healthcare system covered over 85% of wage earners and 76% of the employed labour force. In contrast to other countries, employers in Finland may offer their employees medical services in addition to the preventive care required by law, and 84% of them do so. Over four million medical visits are made to occupational healthcare professionals every year, accounting for about half of all the visits to general practitioners in the age group 16 to 65 years. Health check-ups are an essential method in preventive work. About one million health check-ups are done Citation[5]. These health check-ups aim at health promotion and are mostly voluntary. Furthermore, about one million mostly voluntary health check-ups, essential methods in preventive work and health promotion, are conducted annually Citation[5]. Occupational healthcare, as part of primary healthcare, offers a good possibility to tackle heavy drinking as most of those working are yearly met there, and because the prevention of work-related health problems and health promotion in general are regarded as the primary task of occupational healthcare. However, alcohol-related issues are seldom discussed in occupational healthcare Citation[6].
Brief intervention for heavy drinkers in primary healthcare has yielded convincingly good results Citation[7–10]. Typically brief intervention consists of a specific discussion of not more than 15 minutes at a session on alcohol consumption, health risks, and strategies to decrease alcohol intake. If needed, one or two follow-up sessions for reinforcement may be arranged. However, effectiveness of strategies to implement brief interventions in primary care has been rather modest Citation[11]. One of the reasons might be that professionals are not aware of the real prevalence and characteristics of heavy drinkers.
The prevalence of heavy drinking among occupational healthcare patients in Finland has varied in men between 17% and 31% and in women from 6% to 11% Citation[12], Citation[13]. Using the CAGE questionnaire the prevalence of heavy drinking in primary care and the general population was 20% and 16% among men and 9% and 13% among women Citation[12]. In another study the prevalence of heavy drinking was 11% among 30- to 65-year-olds Citation[14]. Heavy drinking was more prevalent among males than females (17% vs. 5%) Citation[14]. According to the WHO Alcohol Report 2004 in Sweden the rate of heavy drinking among drinkers was 4% among males and 3.3% among females in age group 20 to 64 years. Heavy drinking was defined as the average consumption of 40 g or more of pure alcohol a day for males and 20 g or more of pure alcohol a day for females. In Denmark, the rate of heavy drinking was 11% (14% among males and 8% among females) among those aged 16 years and over. Heavy drinking was defined as the consumption of more than 21 drinks a week for men and 14 drinks a week for women.
The work environment and drinking habits are changing Citation[15], Citation[16]. Drinking, especially among women, has increased Citation[15]. Little is known of the prevalence of heavy drinking in modern working life. We therefore aimed to evaluate drinking habits and the prevalence of heavy drinkers among occupational healthcare patients and to ascertain possible characteristics of heavy drinkers. The purpose was to identify a potential target group for brief intervention in occupational healthcare.
Material and methods
The study was conducted between February 2003 and April 2004. During the previous year 26 occupational healthcare clinics in Southern Finland were approached and six clinics with nine doctors volunteered to participate. Two of the occupational health care clinics (including four doctors) were municipal primary healthcare centres providing services to small enterprises. Two of the clinics (two doctors) were municipal clinics for their own workers. One clinic (one doctor) was private and owned by a candy factory providing services for its workers. One clinic (two doctors) belonged to a big energy company providing services for its workers. Each of the doctors worked with one or two occupational healthcare nurses. All the clinics provided treatment for common diseases. The clinics are only open in the daytime; for emergencies the patients use municipal healthcare centres.
To collect the study data, each patient visiting the occupational health clinics doctor was asked to complete a health behaviour questionnaire containing the Alcohol Use Disorders Identification Test (AUDIT) Citation[17]. AUDIT consists of 10 questions about alcohol consumption and drinking habits. It is considered the best questionnaire for screening alcohol use disorders, with a median sensitivity of 0.86 and a median specificity of 0.89 Citation[18]. Heavy episodic drinking was defined as the weekly consumption of six drinks or more on one occasion. The study questionnaire also elicited information on age, gender, if they lived with a partner, education, the nature of work, weight, height, smoking, perceived work ability, and attitudes towards changing drinking habits. Chronic illness is diagnosed by a doctor and needs lifelong medical attention (e.g. hypertension, asthma, diabetes). A teetotaller scored zero in AUDIT. The nature of work was either mainly physical (blue collar) or mainly sedentary (white collar) or both. An everyday smoker was a smoker who smoked regularly daily. Heavy episodic drinking meant drinking six or more drinks on occasion.
After providing information about the study, the assistant staff distributed the questionnaire to all patients. Patients with low language proficiency in Finnish, with a terminal illness, or who were pregnant were meant to be excluded from the study. The patients completed the forms before seeing their doctor. According to the Finnish AUDIT recommendations, a male patient was defined as a heavy drinker if he scored 10 or more on AUDIT and a female patient if she scored 8 or more Citation[19]. A standard Finnish drink contains 12 g alcohol, which is a national agreement of outlet service proportions.
The research protocol was reviewed and approved by the Helsinki University Hospital ethical board. The patients gave informed consent to participate.
By the end of April 2004, 757 patients had completed the questionnaire. In one of the study clinics a record was kept of the number of patients declining to participate in the study: 17 (14. 5%) of 117 patients refused to answer. Later, by interviewing the assistant staff, it was estimated that in all the clinics fewer than 20% of the patients refused to complete the questionnaires. The questionnaires were carefully completed, thus there were very few missing data. The question with most incomplete answers was found among women inquiring about chronic illness (n = 15, 4.1%). All participants were Caucasian. The study group comprised 388 men (average age 45.7 years) and 369 women (average age 46.3 years). A wide range of occupations was represented among respondents: 330 of them (44%) were white-collar workers, 169 (22%) blue-collar, and 257(34%) both.
Comparisons were made between heavy drinkers and those not drinking in a heavy way (= moderate drinkers; also including absolute teetotallers) and between male and female heavy drinkers. SPSS 11.5 statistical software was used in the analysis of the data Citation[20]. Chi-squared analysis was used for frequency comparisons. When means were compared, t-test was used. P<0.05 was considered significant.
Results
Of the men 114 (29.4%) and of the women 48 (13.1%) were heavy drinkers according to AUDIT. Of the respondents 42 (5.5%) were teetotallers (AUDIT score 0), 21 (5.7%) women and 20 (5.2%) men. An AUDIT score of 14 or more may indicate alcohol dependency (13) and of all the respondents 66 (8.7%) had this score ()
Table I. Cumulative audit score of the occupational healthcare patients.
Heavy drinking among men was also associated with age under 36 (p = 0.021) with being blue-collar workers (p = 0.010), and less often having a partner (p = 0.039). Male heavy drinkers differed from moderate male drinkers most significantly in their smoking habits: almost 40% of heavy drinkers smoked daily versus less than 20% of moderate drinkers ().
Table II. Comparison between male hazardous and moderate drinkers.
Forty-nine (13%) men reported drinking six drinks or more on one occasion weekly; three (0.8%) reported doing so daily. Of all the male heavy drinkers 44 (38.6%) reported drinking six drinks or more on one occasion weekly, meaning that they were inclined to heavy episodic drinking. On the other hand, among all the men who reported drinking six drinks or more at least on one occasion weekly, 50 (96.1%) of them had an AUDIT score of at least 8 and 44 (84.6%) had an AUDIT score of 10 or more.
Of all female respondents eight (1.9%) women reported drinking more than six drinks on one occasion weekly and one of them reported doing so daily. All of them had a total AUDIT score of at least 8. Of all the heavy drinking women, 8 (17%) reported drinking six drinks or more on at least one occasion weekly. Of the female heavy drinkers, almost 50% were daily smokers and among moderate drinkers only 20% ().
Table III. Comparison between female hazardous and moderate drinkers.
Comparisons of the clinically relevant characteristics between genders are presented in . Male heavy drinkers were more often overweight (p = 0.003) and were more often heavy episodic drinkers (p = 0.006) and were less often white-collar workers (p = 0.01) than were female heavy drinkers ().
Table IV. Comparison of some common health characteristics between male and female hazardous drinkers.
Discussion
Our data demonstrate a surprisingly high number of heavy drinkers among the occupational healthcare patients. Not all heavy drinkers were heavy episodic drinkers, but almost all heavy episodic drinkers were heavy drinkers. Heavy episodic drinking was most common among young men. There were only a few characteristics to distinguish heavy and moderate drinkers, smoking being the most prominent.
Our data revealed a difference between the drinking habits of men and women. This finding was not in accordance with statistics from the general population of Finland showing that differences between men and women in drinking habits have diminished: intoxication-oriented drinking has become more prevalent among women Citation[15]. The difference regarding weight between male and female heavy drinkers concurs with previous findings Citation[21]. It is difficult to make any international comparison of heavy episodic drinking because of the different criteria. In the United States two heavy drinking episodes in one month is considered heavy drinking Citation[22]. Moreover, the criteria for heavy drinking are lower in the United States. This means that the difference between the USA and Finland in heavy drinking (11%, 20%) and teetotallers (38%, 5%) is great. To our knowledge there are few data on heavy drinking among occupational healthcare patients; at-risk drinking prevalence was 11% and abstinence 38% in one urban occupational healthcare clinic in the United States Citation[23]. Compared with these findings the prevalence of abstinence (5%) in Finland is very small. Heavy drinking is most common in young workers. This may be because drinkers lose their jobs or because they cut down their drinking as they grow older.
Our study is based on the AUDIT self-report questionnaire. This has potential for bias, because AUDIT misses some heavy drinkers, but may also wrongly diagnose others Citation[16]. Using a higher than internationally recommended cut-off score for men means that heavy drinkers may be under-diagnosed in the present study Citation[24]. Another issue to consider in our study is that we have no information on those patients who declined to participate in the study. Perhaps patients with definite alcohol problems would be less eager to answer questions about alcohol use. This all means that the number of heavy drinkers may be even higher among occupational healthcare patients than was found in the present study. However, our conclusion regarding a large number of heavy drinkers still holds.
A definite strength of our study is that the study population presents a wide range of different occupations and an even mix of men and women of different ages. Thus our respondents are very representative of occupational healthcare patients in Finland. The questionnaires were completed with care and the AUDIT score was complete in all of them.
We conclude that heavy drinkers form a very important section of patients to recognize in primary care, occupational healthcare being part of that. They must be detected systematically because they are not found through the usual patient characteristics. Occupational healthcare has good coverage in Finland with numerous encounters with healthcare specialists. Thus it offers an important opportunity to identify these numerous heavy drinkers. There are effective tools (e.g. AUDIT questionnaire) to screen for heavy alcohol use. In the future it would be important to study the use of these tools in occupational healthcare.
Acknowledgements
The study was funded by the Competitive Research Funding of Pirkanmaa Hospital District.
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