epidemiological study on prevalence of alcohol consumption, alcohol drinking patterns and alcohol

54 Pages·2006·0.34 MB·English

MOH WHO CMHN

EPIDEMIOLOGICAL STUDY ON
PREVALENCE OF ALCOHOL
CONSUMPTION, ALCOHOL DRINKING
PATTERNS AND ALCOHOL RELATED
HARMS IN MONGOLIA

Ulaanbaatar - 2006
Mongolia
Acknowledgement

The “EPIDEMIOLOGICAL STUDY ON PREVALENCE OF ALCOHOL CONSUMPTION,
ALCOHOL DRINKING PATTERNS AND ALCOHOL RELATED HARMS IN MONGOLIA”
survey was supported by the World Health Organization special fund and successfully
conducted with the support and participation of the following organization and personnel.

Institutional and personnel acknowledgements

Ministry of Health of Mongolia
World Health Organization
Center of Mental Health and Narcology, Mongolia
Public Health Institute, Mongolia
Health Science University of Mongolia
Bayan Ulgii aimag Health Department
Uvs aimag Health Department
Uvurkhangai aimag Health Department
Bulgan aimag Health Department
Dundgobi aimag Health Department
Dornogobi aimag Health Department
Sukhbaatar aimag Health Department
Dornod aimag Health Department
Chingeltei district Health Center
Bayanzurkh district Health Center
“New era against drug abuse” association
Dr.Hao Wei, professor, Mental Health Insitute, WHO Collaborating Research Center for
Abuse and Health, Changsha, Hunan, China
Dr.Maximilian de Courten WHO consultant Assoc. Prof., Monash University, Australia.

Project coordinator

Dr. G.Tsetsegdary, MD, PhD, senior officer of Health Policy and Coordination Department,
Ministry of Health of Mongolia

Project Team

International consultant

Peter Anderson, MD, PhD, MPH, WHO Public Health Consultant
PhD Medical Sciences, University of Nijmegen, Netherlands

Local Scientific Consultants
G.Tsetsegdary, MD, PhD, Health Policy and Coordination Department, Ministry of Health of
Mongolia
S.Byambasuren, MD, PhD, Professor, Health Science University of Mongolia
Z. Khishigsuren, M.Sc., Health Science University of Mongolia
L.Erdenebayar, MD. Dr.Sc, Prof., Center of Mental Health and Narcology, Mongolia
N.Demidmaa, MD, PhD, Center of Mental Health and Narcology, Mongolia
B.Aushjav, MD, clinical prof., Center of Mental Health and Narcology, Mongolia
Dr. K.Tungalag, MD, epidemiology M.Sc.,Medical Insurance Council secretary

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International contributors

Dr. S.R. Govind, Public Health Specialist, the office of the WHO Representative in Mongolia

Statistical analysis team

Dr. D.Otgontuya, Reseacher, Nutrition Research Center, Public Health Institute
Dr. S.Tsegmid, Reseacher, Nutrition Research Center, Public Health Institute
Nai. Tuya, clinical professor, Center of Mental Health and Narcology
B.Dolgorsuren, statistician, Center of Mental Health and Narcology
O.Soel-Erdene, statistic doctor, Center of Mental Health and Narcology
B.Enkhmaa, Reseacher, Center of Mental Health and Narcology

Local participants

N.Demidmaa, Consultant on narcology, Center of Mental Health and Narcology
G.Bertsetseg, narcologist, Center of Mental Health and Narcology
S.Munkhtuya, narcologist, Center of Mental Health and Narcology
B.Dorjmaa, narcologist, Center of Mental Health and Narcology
D.Ganbat, narcologist, Center of Mental Health and Narcology
B.Purevjargal, narcologist, Center of Mental Health and Narcology
O.Byambasuren, narcologist, Center of Mental Health and Narcology
Z.Tuya, narcologist, Center of Mental Health and Narcology
D.Chuluunbolor, narcologist, Center of Mental Health and Narcology
K.Elena, narcologist, Center of Mental Health and Narcology
B.Tuya, psychiatrists, Center of Mental Health and Narcology
S.Dashpilgee, psychiatrists, Center of Mental Health and Narcology
L.Altantsetseg, psychiatrists, Center of Mental Health and Narcology
Sh.Batpurev, clinical professor, Center of Mental Health and Narcology
G.Narantuya, psychiatrists, Center of Mental Health and Narcology
G.Tsogzolmaa, family doctor, “Khasagt Erdene” family clinic
P.Ichinkhorloo, family doctor, “Khasagt Erdene” family clinic
D.Unursaikhan, family doctor, “Khasagt Erdene” family clinic
Ch. Otgonbayar, family doctor, “Khasagt Erdene” family clinic
B. Tuul, family doctor, “Khasagt Erdene” family clinic
L.Bayarbat, family doctor, “Khasagt Erdene” family clinic
D.Batsuren, family doctor, “Achlakhui” family clinic
S.Bayarmaa, family doctor, “Achlakhui” family clinic
Ts.Enkhtuya, family doctor, “Achlakhui” family clinic
B.Ounchimeg, family doctor, “Achlakhui” family clinic
D.Oundelger, narcologist, Chingeltei district Health Center
N.Tuvshinbayar, family doctor, Chingeltei district Health Center
D.Narantsetseg, family doctor, Chingeltei district Health Center
G.Tugsjargal, family doctor, Chingeltei district Health Center
T.Enkhbold, family doctor, Chingeltei district Health Center
N.Ounchimeg, family doctor, Chingeltei district Health Center
O.Luvsanbud, family doctor, Chingeltei district Health Center
B.Nyamaa, family doctor, Chingeltei district Health Center
B.Budsuren, family doctor, Chingeltei district Health Center
D. Bartsetseg, narcologist, Sukhbaatar aimag Health Department
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S.Unurtsetseg, family doctor, Sukhbaatar aimag Health Department
M. Delkhiitsetseg, family doctor, Sukhbaatar aimag Health Department
D.Erdenetsetseg, family doctor, Sukhbaatar aimag Health Department
U.Ounbat, narcologist, Uvurkhangai aimag Health Department
G.Bundjav, family doctor, Uvurkhangai aimag Health Department
S.Amargargal, family doctor, Uvurkhangai aimag Health Department
N.Ountsetseg, family doctor, Uvurkhangai aimag Health Department
B.Batbold, narcologist, Dornod aimag Health Department
S.Altantuya, family doctor, Dornod aimag Health Department
B.Erdenetsetseg, family doctor, Dornod aimag Health Department
S.Tsetsgee, family doctor, Dornod aimag Health Department
Kh.Nergui, narcologist, Dundgobi aimag Health Department
B.Erdenesuren, family doctor, Dundgobi aimag Health Department
Kh.Tumengargal, family doctor, Dundgobi aimag Health Department
Ts. Saruul, family doctor, Dundgobi aimag Health Department
G.Maira, family doctor, Bayan Ulgii aimag Health Department
N.Mairagul, family doctor, Bayan Ulgii aimag Health Department
A.Zauresh, family doctor, Bayan Ulgii aimag Health Department
A.Erkegul, family doctor, Bayan Ulgii aimag Health Department
Ts.Khandsuren, narcologist, Uvs aimag Health Department
K.Ounchimeg, family doctor, Uvs aimag Health Department
B.Murun, family doctor, Uvs aimag Health Department
S.Orolzodmaa, family doctor, Uvs aimag Health Department
B.Gerelmaa, narcologist, Dornogobi aimag Health Department
Ts.Sainbayar, family doctor, Dornogobi aimag Health Department
P.Dagiimaa, family doctor, Dornogobi aimag Health Department
L.Ariunjargal, family doctor, Dornogobi aimag Health Department
L.Budsuren, narcologist, Bulgan aimag Health Department
L.Oundelger, family doctor, Bulgan aimag Health Department
B.Bayarmaa, family doctor, Bulgan aimag Health Department
B.Batchimeg, family doctor, Bulgan aimag Health Department

Report compiled by

Dr. K.Elena, Center of Mental Health and Narcology, Mongolia

Translators

Dr. K.Tungalag, Medical Insurance Council secretary
Dr. K.Elena, Center of Mental Health and Narcology

Editors

Mongolian editors

S.Byambasuren, MD, PhD, Professor, Health Science University of Mongolia
Z.Khishigsuren, MD, Lecturer teacher, Health Science University of Mongolia

English editor

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Peter Anderson, WHO Public Health Consultant, MD, PhD MPH

Chapter I. INTRODUCTION

1.1 Geography and population
Mongolia is a very large country with a relatively small population. It faces many difficulties
and challenges in the painful changes of transition from a long-term planned economy to a
market orientated one. Situated in the center of the Asian land mass Mongolia lies between
the Inner Mongolian provinces of China in the south and the Asian part of Russia in the
north, Mongolia covers 1.56 million square kilometres, with an ethnically mixed population
at 2.533.100 people with 49.6 percent living in rural areas, of which about 31% are children
below 15 years of age. Except for the million or so people who live in or near the capital
Ulaanbaatar, the country’s population is sparsely distributed across the vast Mongolian
steppes in nomadic herding communities that are constantly on the move across the vast
plains to find new grazing pastures for their sheep and cattle that form the mainstay of the
food and of economy of Mongolia. The country stretches for about 2500 kilometres from
east to west at its longest and about 1000 kilometres from north to south at its widest. The
Gobi desert covers about a third of the country, and lies to the south along the long border
with the People’s Republic of China.

Mongolia is divided into 18 aimags or provinces and 4 independent municipalities (such as
the capital city of Ulaanbaatar) that are also sometimes called aimags like the larger
provinces. Each aimag is divided into sums. The capital city of Ulaanbaatar has a
population of about 870,000; the other 1.6 million people are distributed in the other 18
provinces, with some provinces having less than 100,000 people. The average life
expectancy in Mongolia on 2004 year was 64.58 years. The main religious is Buddhism
(80% of population), followed by Islam (10%), Christianity (4.7%), and other religions
(5.3%).

1.2 Current situation of alcohol consumption

1.2.1 World situation of alcohol consumption and alcohol related harms

The misuse of alcohol represents one of the leading causes of preventable death, illness
and injury in many societies throughout the world. However, with the rapid development of
economy, urbanization and westernization, alcohol production, consumption, and numbers
of admitted patients with alcohol-related physical and mental diseases have increased
steadily over the past 25 years (Hao et al., 2003). Alcohol consumption is associated with a
variety of adverse health and social consequences. Adverse effects of alcohol have been
demonstrated for many disorders, including liver cirrhosis, mental illness, several types of
cancer, pancreatitis, and damage to the fetus among pregnant women. Alcohol use is also
strongly related to social consequences such as drink driving injuries and fatalities,
aggressive behaviour, family disruptions and reduced industrial productivity (WHO, Int.
Guide…, 2002). Murray and Lopez (1996) estimated that globally in 1990 alcohol
contributed to 773,600 deaths, 19.3 million years of life lost and 47.7 million disability
adjusted life years. Some 82% of this burden of death, illness and injury falls on regions of
the world classified as “developing” (Murray et al., 1997).

Asian areas other than China and India (OAI) (e.g. Indonesia, Vietnam) also indicated
higher than average levels of death caused by alcohol (1.8%) (WHO, Int. Guide…, 2002).
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Adult per capita consumption data are very useful as an indicator of trends in alcohol-
related problems. Of international sources, the Food and Agriculture Organization (FAO)
provide the most reliable data. Studies done primarily in developed countries have found
that per capita consumption is a reliable proxy for the percentage of heavy drinkers in a
population, in the absence of national survey data (Edwards et al., 1994). Per capita alcohol
consumption in pure alcohol for adults is an essential predictor of alcohol related problems,
based on WHO data, the growth rate of per capita alcohol consumption was 402% from
1970 to 1996 (WHO, 1999). The figure for average annual alcohol consumption was still
low compared with that of the developed countries (WHO, 1999), which was about 10.01
yearly. For example, the recorded per capita consumption of pure alcohol per adult 15
years of age and over in 1996 was 11.90 liters in Austria, 11.67 liters in Germany, 11.27
liters in Switzerland, 9.62 liters in Italy, 9.55 liters in Australia, 9.41 liters in the UK and 8.90
liters in the US. The current global trends on alcohol use were that per capita alcohol
consumption in developed countries was decreasing sharply, and increasing steadily in
developing countries. In the countries of the Soviet Union and in many developing
countries, alcohol production for home use or for the informed sector is extremely
important, being as high as 80% of the total alcohol available for consumption.

Per capita consumption figures should be developed for the major categories of alcoholic
beverages available within a country. Most international sources limit these to beer, distilled
spirits and wine.

Ethanol conversion factors differ by country but generally are about 4-5% for beer, about 12
percent for wine and about 40 percent for distilled spirits. Common alcohol conversion
factors: 1 ml ethanol = 0.79 g.

The most commonly used measure of High Risk drinking for acute problems is the volume
of consumption (WHO, Int. Guide…, 2002).
Low, Medium and high Risk average daily consumption levels for men and women
long-term of serious illness
LEVEL OF RISK
Gender LOW MEDIUM HIGH
Male 1-40g 41-60g 61+g
Female 1-20g 21-40g 41+g

In different countries, health educators tend to employ different definitions of a standard unit
supposedly reflecting typical serving sizes in that country. For example, a unit or standard
drink in Canada is usually defined as 13.6 grams, in the UK it is 8 grams, in the USA it is
between 12 and 14 grams and in both New Zealand and Australia it is thought to be 10
grams of alcohol (WHO, Int. Guide…, 2002). Turner et al., 1990 analyzed the size of these
units in 125 published studies, while these were mostly between 9 and 14 grams they were
also as low as 6 grams, and as high as 28 grams in one Japanese study.

The results of 2001 review in China showed that 6.7% of adults were heavy drinkers, who
consumed 55.3% of the total alcohol consumption.

The review by Shultz (Shultz et al., 1991) estimated that 50% of unspecified liver cirrhosis
cases in the US were due to alcohol. The study by English concluded that 54% of
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unspecified cirrhosis in males and 43% of such cases among females in Australia could be
attributed to alcohol. However, this estimate will not apply to all countries, for example, it
has been estimated that only 7.6% of liver cirrhosis in China is caused by drinking alcohol
(Zhou et al., 1984).

Alcohol is a causal factor in alcoholic psychosis, alcohol dependence syndrome and
harmful alcohol use. For example, of all alcohol – caused deaths in Canada in 1992, 10%
were due to alcohol-related mental disorders. In Russia, officially recorded rates of alcohol
dependence and alcoholic psychosis combined were 1.8% of the population while
epidemiological surveys suggest the higher rate of between 3 and 3.5% (Vroublevsky et al.,
1998).

Alcohol is the prime cause of alcoholic cardiomyopathy. In 1992, about 1.1% of all alcohol-
caused deaths in Canada were recorded as due to alcoholic cardiomyopathy. Alcohol is
also considered a factor in cardiac dysrhythmias and heart failure, causing 1.5% and 0.18%
of all alcohol-caused deaths, respectively, in Canada in 1992 (WHO, Int. Guide…, 2002).

Alcohol consumption is positively related to hypertension (high blood pressure). In
particular, one very recently conducted review (Campbell et all 1999) concluded that
observational studies have almost uniformly found a relationship between heavy alcohol
consumption and increased blood pressure.

Alcohol is the direct cause of a small number of deaths and hospitalizations each year from
gastritis. Alcohol gastritis comprised 1.06% of alcohol-caused deaths for Finland between
1987 and 1993 (Makela et al., 1997). The English et all (1995) review estimates that 24% of
acute pancreatitis and 84% of chronic pancreatitis cases are due to alcohol.

Violence occurs across all kinds of interpersonal relationships including those of relatives,
friends, acquaintances, and strangers. Alcohol is implicated as a factor in assault in two
ways: high alcohol intake represents a risk factor in becoming a victim of assault and
alcohol is also a potential causal factor in committing an assault. Studies in Zambia have
estimated that alcohol is involved in between half and two thirds of all violent deaths
(Haworth et al., 1998). In the Canadian cost study, it was estimated that 160 deaths and
3.175 hospitalizations occurred in Canada in 1992 as the result of alcohol attributable
assault.

1.2.2 Alcohol consumption in Mongolia

Alcohol dependence and the harm done by alcohol have become of major public health and
social concern in Mongolia.

The common alcoholic beverages available in Mongolia are commercially marketed legal
vodka (spirits), beer and wines and homemade milk vodka and fermented horse milk. In
2002, Mongolia produced 4.9 million litres of spirits, 9.4 million litres of vodka, and 3.3
million litres of beer. Fifteen million litres of alcoholic beverages were imported. Per capita
consumption in Mongolia is estimated to be 9.03 litres absolute alcohol per year. According
to 2004 data of the Special Control Division, there are currently 12 spirits factories, 173
vodka factories and 29 beer factories. There are 48 wholesale markets and 3482 shops,
338 restaurants and 1297 bars that sell alcoholic beverages. All aimags (provinces) have
at least one or two factories that produce alcoholic beverages. Traditionally, Mongolians
produce national alcoholic beverages, such as: fermented horse milk (airag) and distilled
milk vodka (nermel).
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The study on alcohol and alcohol dependence, which was conducted by the Dr. L.
Erdenebayar of the Center of the Mental Health and Narcology in 1997, indicated that over
51% of the population used alcohol more than they should do, 8% of these being women.

UN survey on 1998 identified that 12.7% of adults were classified as heavy drinkers.

The Public Health Institute conducted KAP survey in 2001 (Public Health…, 2002) and
indicated that 43.6 percent of respondents consumed 1-3 standard drinkers per week and
47.5 percent consumed more than 3 standard drinks per week, with the frequency of
alcohol use increasing in both high and low-income households.

However, there have been many changes in the country since the survey, and new and
reliable data are urgently needed to give a clearer picture of the problem. We conducted
the national epidemiological survey on alcohol consumption, alcohol drinking patterns and
alcohol related harms, with technical and financial support of the World Health
Organization.

1.3 Survey Goal

The “EPIDEMIOLOGICAL STUDY ON PREVALENCE OF ALCOHOL CONSUMPTION,
ALCOHOL DRINKING PATTERNS AND ALCOHOL RELATED HARMS IN MONGOLIA”
survey was undertaken to determine the prevalence of alcohol consumption, alcohol
drinking patterns and alcohol related harms among the population.

1.4 Survey objectives
1. To determine the prevalence of alcohol consumption
2. To identify the alcohol drinking patterns
3. To determine the prevalence of alcohol dependence
4. To identify health alcohol related harms
5. To identify social alcohol related harms

1.5 Survey rationale

The “EPIDEMIOLOGICAL STUDY ON PREVALENCE OF ALCOHOL CONSUMPTION,
ALCOHOL DRINKING PATTERNS AND ALCOHOL RELATED HARMS IN MONGOLIA”
survey will be used to provide information on the alcohol consumption, alcohol drinking
patterns and alcohol related harms among the population. The survey results will be used
as an evidence based tool for public health alcohol related decision making, will be a main
information source for the rational implementation of the “National program on alcohol
prevention and control” (2003), and will provide important socio-economic, theoretical and
practical information.

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Chapter II. SURVEY METHODOLOGY
2.1 Study sample
The study sample was a quota sample obtained from eight provinces (aimags): Bayan Ulgii
and Uvs aimags in the west, Dornod and Sukhbaatar aimags in the east, Dundgobi and
Dornogobi aimags in the south, Bulgan and Uvurkhangai aimags in the central parts of
Mongolia and in the two districts Chingeltei and Bayanzurkh in Ulaanbaatar city. The
sampling frame used a multistage, area probability design. After the ten sites were
selected, the sampling process continued with the selection of local government areas,
households, and finally, the respondents within the household. For the resident population a
representative sample was used based on households; for the nomadic population a
representative quota sample was used based on households (gers).

All people present in the household, aged 15 to 65 years old were invited for interview.
Face to face interviews were conducted within households, and households were selected
until the predesignated sample size was achieved (650 for each of the eight aimags and
2500 for each of the two districts in Ulaanbaatar. For the nomadic population, interviewers
went from ger to ger (nomadic household) until the predesignated sample size was
achieved (which differed from aimag to aimag, dependent on the estimated size of the
nomadic population). The questionnaire and the study protocol were approved by the Ethics
Committee of Ministry of Health, Mongolia. All respondents completed the questionnaire
voluntarily.

2.2 Study questionnaire
The questionnaire was developed in English, and then translated into Mongolian. Back
translation was undertaken from Mongolian to English to identify and correct any translation
difficulties. All interviews were conducted in the national Mongolian language. The
questionnaire comprised seven parts. Part 1 collected data about the interviewer and the
composition of the household; Part 2 collected demographic data of the respondent; Part 3
comprised the ten questions of the AUDIT; Part 4 comprised a series of graduated quantity
frequency questions to measure alcohol consumption (WHO); Part 5 measured social
harms and alcohol dependence with a 12 month reference period. The questions on social
harms were derived from a series of articles and reviews from the Journal of Alcohol
Studies published, which resulted from a scientific meeting on measures of social harm, as
well as the AUDADIS questionnaire. The alcohol dependence questions were derived from
the CIDI; Part 6 measured harm from someone else’s drinking, including domestic violence,
with a 12 month reference period. The questions were derived from a series of articles and
reviews from the Journal of Alcohol Studies published in 2000 which resulted from a
scientific meeting on measures of social harm; Part 7 measured physical harm and
experience of help or treatment for harmful drinking or alcohol dependence with a 12 month
reference period, derived from AUDADIS. The questionnaire was pre-tested with a pilot
survey, held in Ulaanbaatar, 7-8 May, 2005.

2.3 Quality control

Interviewers were psychiatrists and family doctors, who were trained in two stages. A group
of 30 key interviewers were trained for 5 days training in Ulaanbaatar city, including two
days piloting the methodology and the questionnaire. The key interviewers trained a wider
group of interviewers on site. Didactic and participatory and skills based training were used
to explain the aims of survey, the variables of the questionnaires, and interview skills.

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Instructions focused on guaranteeing the respondents’ anonymity, public relations with the
community and seeking the help of community leaders and officials from local government.
After each interview, the questionnaire was checked by the key interviewers.

Before of survey implementation an approval was taken from the Ethics Committee of MOH
on 15 of June, 2005

Definition of Mongolian drink A Delphi type technique was used to define a standard
drink, in the absence of empirical research. A group of 20 primary care physicians, 10
narcologists, and 10 scientists of the National Centre of Mental Health and Addictions,
representative of the whole country, met until agreement was reached. It was concluded
that a standard drink was the equivalent of: one 330ml glass, can, or bottle of beer (5%
concentration of absolute alcohol); one 500 ml bowl of fermented horse milk (5%
concentration of absolute alcohol); one 50 ml glass or cup of vodka (40% concentration of
absolute alcohol); one 100 ml glass or cup of milk vodka (15% concentration of absolute
alcohol); or one 100 ml glass of wine (100 ml) (12.5% concentration of absolute alcohol).

2.4 Data collection process
Eight teams each with 5 members collected data in the rural areas. Two teams each with
16 members collected data in Ulaanbaatar city. Each team consisted of a team leader and
4 to 16 interviewers. Data was collected during the period June 15 – July 31, 2005.

2.5 Data entry, cleaning and analysis
The data from the completed questionnaire forms was first entered into the Epidata 3.1
created database, a Microsoft Windows based computer program. Data were double
entered and verified in the same Epidata 3.1 database and transferred into SPSS for
Windows 11.5 and analyzed.

Data entry into Epidata 3.1 was prepared by a team of two people under the kindly support
of WHO consultant Assoc. Prof. Maximilian de Courten, Monash University, Australia.

Data analyses were performed by a team of six people under the guidance of WHO Public
Health Consultant Dr. Peter Anderson.

Chapter III. Survey Results

A total of 10,157 respondents were interviewed, of whom 10,145 (99.8%) provided valid
data.

3.1 Demographic characteristics

The demographic characteristics of the sample for each of the eight aimags and two
districts of Ulaanbaatar are shown in Table 1.

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