Francis, JM (2015) Epidemiology of alcohol use and alcohol use disor

178 Pages·2017·6.28 MB·English

LSHTM Research Online
Francis, JM; (2015) Epidemiology of alcohol use and alcohol use disorders (AUD) among young
people in Northern Tanzania. PhD thesis, London School of Hygiene & Tropical Medicine. DOI:
https://doi.org/10.17037/PUBS.02374475
Downloaded from: https://researchonline.lshtm.ac.uk/id/eprint/2374475/
DOI: https://doi.org/10.17037/PUBS.02374475
Usage Guidelines:
Please refer to usage guidelines at https://researchonline.lshtm.ac.uk/policies.html or alternatively
contact [email protected].
Available under license. To note, 3rd party material is not necessarily covered under this li-
cense: http://creativecommons.org/licenses/by-nc-nd/3.0/
honline.lshtm.ac.ukhttps://researc
EPIDEMIOLOGY OF ALCOHOL USE AND ALCOHOL USE DISORDERS
(AUD) AMONG YOUNG PEOPLE IN NORTHERN TANZANIA

Joel Msafiri Francis

Thesis submitted in accordance with the requirements for the degree of
Doctor of Philosophy
University of London
AUGUST 2015

Department of Infectious Disease Epidemiology

Faculty of Epidemiology and Population Health

LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE

Funded by STRIVE RPC, an international research consortium funded by the UK
Department for International Development (DFID) to investigate structural drivers of
HIV.

1
I, Joel Msafiri Francis, confirm that the work presented in this thesis is my own. Where
information has been derived from other sources, I confirm that this has been indicated in the
thesis.

Date: 31st July 2015

2
Acknowledgement

I must admit PhD work involves a lot of sacrifice and commitments, it has been a very
demanding undertaking but extremely useful journey for my research and academic
career. In this engagement, I developed research concepts, designed, implemented,
analyzed the data and prepared reports on the research findings. I have attained this
milestone with support of the Almighty Lord and individuals described below.
I am extremely grateful to my supervisors Professor Heiner Grosskurth and Professor
Helen Weiss for continuous guidance and support in this training. My supervisors made
things look simpler and meaningful even in the moments where I thought it was
impossible.
I extend my sincere thanks to the PhD advisory committee (Dr Saidi Kapiga, Prof David
Ross and Prof Jim McCambridge) for their valuable inputs that shaped PhD research ideas
and Ms Kathy Baisley for her immense support during the data analysis for the cross-
sectional study among young people in Mwanza and Kilimanjaro.
I thank the PhD upgrading examiners (Prof Liam Smeeth and Ms Kathy Baisley) and the
chairperson, Prof Suzanne Filteau for their valuable advice to consider an evaluation of
alcohol screening tools using biomarkers in African young people.
I greatly appreciate support of Mr John Changalucha, director of the National Institute
for Medical research, Mwanza centre and Dr Saidi Kapiga, scientific director of Mwanza
Intervention Trials Unit (MITU) for the opportunity and the resources to pursue this
training through a research consortium funded by the UK Department for International
Development (DFID) to investigate structural drivers of HIV (STRIVE RPC).
3
I am very thankful to the STRIVE RPC teams in Mwanza and London, specifically to Dr
Gerry Mshana, Prof Charlotte Watts and Dr Lori Heise for their support in funding of the
studies and critical comments on the implementation plans. Studies conducted in this
PhD training contributed to the objectives and outputs of the STRIVE RPC.
Lastly but not least, I thank all study participants, heads of local institutions and work
places in Tanzania for their permission to conduct the research. I am also grateful for
the contribution of the fieldworkers who helped me to collect the data, and of the data
management team at MITU/NIMR in Mwanza who entered the data.

4
List of Abbreviations
AUD Alcohol Use Disorders
AUDIT Alcohol Use Disorders Identification Test
AUROC Area Under Receiver Operating Characteristics
Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers -
CAGE
screening test for problem drinking and potential alcohol problems
CDT Carbohydrate-Deficient Transferrin
CI Confidence Interval
DALY Disability-Adjusted Life Year
DFID UK Department for International Development
DSM IV Diagnostic and Statistical Manual of Mental Disorders
GGT Gamma-Glutamyl Transferase
HIV Human Immunodeficiency Virus
IQR Interquartile range
MINI Mini International Neuropsychiatric Interview questionnaire
MITU Mwanza Intervention Trials Unit
NIMR National Institute for Medical Research
PEth Alcohol biomarker Phosphatidylethanol
PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses
QATSO Quality Assessment Tool for Systematic reviews of Observational studies
SSA Sub Saharan Africa
STIs Sexually Transmitted Infections
acronym of a Research Programme Consortium (RPC) to investigate
STRIVE RPC
Structural Drivers of HIV Infection
STROBE Strengthening the Reporting of Observational studies in Epidemiology
TB Tuberculosis
TFLB Time Line Follow Back calendar
WHO World Health Organisation

5
Abstract
Excessive alcohol use is a significant public health problem globally. Alcohol use typically
begins in adolescence or early adult life, and effective prevention strategies focused on
this age group are needed to avoid initiation of harmful drinking.
The aims of this PhD are to understand the epidemiology of alcohol use and alcohol use
disorders (AUD) in East Africa, to validate self-reported alcohol use among young people
in Tanzania, and to use the findings to recommend strategies for the prevention or
reduction of harmful alcohol use among young people. Specific objectives include (1) to
systematically review the evidence on alcohol use among young people in eastern Africa;
(2) to estimate the prevalence of alcohol use, AUD and associated risk factors among
different groups of young-people in northern Tanzania; (3) to assess the validity of self-
reported alcohol use against the blood biomarker phosphatidylethanol (PEth); and (4) to
assess the validity of the Mini International Neuropsychiatric Interview questionnaire
(MINI) for the diagnosis of alcohol dependence against PEth, in Mwanza (northern
Tanzania).
The main findings are a high prevalence of reported alcohol use among diverse groups of
young people in eastern Africa, especially among university students and sex workers,
but that few studies used standardised alcohol screening questionnaires. In our survey
of almost 2000 young people in northern Tanzania, the prevalence of reported alcohol
use was higher among males (20-45% for current use) than females (12-47% for current
use). Alcohol use was also associated with being in a relationship, greater disposable
income, and a higher number of sexual partners.
6
There were significant positive correlations between reported total alcohol intake and
PEth concentration in males (Spearman correlation (r )=0.65 among college students and
s
r =0.57 among casual labourers; p<0.001). Self-reported alcohol use in the past month
s
was also a sensitive marker of having a positive PEth result (overall sensitivity 89%, 95%CI
81-94%), and was similar in all groups. The MINI dependence criteria (positive responses
to ≥3 questions) were met by 79/202 (39%) casual workers and college students. The high
prevalence was mainly due to two non-specific questions (on tolerance and compulsion
to drink). Both sensitivity and specificity of the MINI were low when compared to PEth,
raising questions about the validity of the tool for this population.
This thesis finds that alcohol use is a significant problem among young people in northern
Tanzania, and the Timeline Followback calendar (TLFB) and Alcohol Use Disorders
Identification Test (AUDIT) are sensitive measures of alcohol use. Most affected groups
are college students and casual labourers. These two groups need urgent interventions
addressing both individual and societal risks to reduce hazardous/harmful alcohol use.

7
Table of Contents
Acknowledgement .......................................................................................................................... 3
List of Abbreviations ....................................................................................................................... 5
Abstract ........................................................................................................................................... 6
Chapter 1. Introduction and background ..................................................................................... 10
Alcohol use as a global health problem .................................................................................... 10
Alcohol use as a public health problem among young people ................................................. 11
Alcohol use among young people in Africa............................................................................... 12
Screening tools for alcohol use disorders ................................................................................. 12
Biomarkers for alcohol intake ................................................................................................... 13
Outline of the thesis.................................................................................................................. 14
References ................................................................................................................................ 15
Chapter 2. Methods ..................................................................................................................... 20
References ................................................................................................................................ 26
Chapter 3. Systematic review and meta-analysis: prevalence of alcohol use among young people
in eastern Africa ............................................................................................................................ 27
Chapter 4. The epidemiology of alcohol use and alcohol use disorders among young people in
northern Tanzania ......................................................................................................................... 43
Abstract ..................................................................................................................................... 46
Introduction .............................................................................................................................. 48
Methods .................................................................................................................................... 50
Results ....................................................................................................................................... 57
Discussion ................................................................................................................................. 61
Acknowledgements................................................................................................................... 64
Author’s contribution ............................................................................................................... 65
References ................................................................................................................................ 66
Supporting information ............................................................................................................ 69
Tables of results ........................................................................................................................ 71
Chapter 5. The validity of self-reported alcohol use compared with the alcohol biomarker
phosphatidylethanol among young people in northern Tanzania ............................................... 86
Abstract ..................................................................................................................................... 89
Introduction .............................................................................................................................. 91
Material and methods .............................................................................................................. 93
Results ....................................................................................................................................... 97
Discussion ................................................................................................................................. 99
Acknowledgements................................................................................................................. 101
8
Author’s contribution ............................................................................................................. 101
Supplementary Information ................................................................................................... 102
Figure legends ......................................................................................................................... 103
References .............................................................................................................................. 106
Tables of results ...................................................................................................................... 109
Chapter 6. Validation of the MINI (DSM IV) tool for the assessment of alcohol dependence
among young people in northern Tanzania using the alcohol biomarker Phosphatidylethanol
(PEth)........................................................................................................................................... 115
Abstract ................................................................................................................................... 118
Introduction ............................................................................................................................ 120
Experimental section .............................................................................................................. 122
Results ..................................................................................................................................... 126
Discussion ............................................................................................................................... 128
Supplementary material ......................................................................................................... 130
Acknowledgements................................................................................................................. 130
Author’s contribution ............................................................................................................. 130
References .............................................................................................................................. 131
Tables of results ...................................................................................................................... 134
Chapter 7. Discussion .................................................................................................................. 138
Epidemiology of alcohol use and AUD among young people ................................................. 138
Alcohol screening tools ........................................................................................................... 139
A need for targeted alcohol interventions ............................................................................. 142
References .............................................................................................................................. 144
Chapter 8. Conclusion and recommendations ........................................................................... 146
Appendix 1. Systematic review and meta-analysis detailed search strategies .......................... 147
Appendix 2. Survey questionnaire and additional information to determine total alcohol intake
in a drinking event ...................................................................................................................... 156
Appendix3. Pictorial display of beers with standard drinks ....................................................... 175
Appendix 4. Additional information to determine total amount of alcohol intake in each drinking
event as identified in the TFLB .................................................................................................... 176
Appendix 5. Mini international neuropsychiatric interview (MINI) ........................................... 177

9