1.1. Background
The World Health Organization (WHO) estimates that there are about 2 billion (33%) people worldwide who consume alcoholic beverages and 76.3 million with diagnosable alcohol use disorders (WHO, 2004) making alcohol the most widely used and abused substance world over (Basangwa et al., 2006). The widespread use of alcohol is fuelled by ease of its production process (i.e., a plain process of fermentation achieved by yeast acting on sugar) and multiple daily usage for recreation, curative and religious purposes (Basangwa et al., 2006). Alcohol use, however, has serious health and social effects making its prevention and control a public health priority. According to WHO (2002, 2004), alcohol causes 1.8 million deaths (3.2% of total) one third (600,000) of which result from unintentional injuries. It also causes a loss of 58.3 million (4% of total) of Disability-Adjusted Life Years (DALY) of which 40% are due to neuro-psychiatric conditions.
Alcohol consumption and abuse is influenced by multiple factors including gender, family history and parental influence. Men are more likely to use alcohol with some estimates indicating a ratio of 5:1 (Emmite and Swierzewski, 2008). Men are also at higher risk of heavy drinking and intoxication (Gmel, Rehm, & Kuntsche, 2003) and developing alcohol use disorders (Jhingan et al., 2003). However, the number of women who drink, abuse, and become dependent on alcohol is rising.
Studies indicate that up to 25% of children with an alcoholic parent will develop alcohol abuse or dependence (Basangwa et al., 2006). The prevalence of alcoholism among individuals with alcoholic parents or siblings is two and half times that of the general population. The major familial risk factors for alcoholism include growing up with parents who are dependent on alcohol, use alcohol to cope with stress, and have coexisting psychological disorder(s). Others are family violence and having several close blood relatives who are alcohol dependent.
Some studies show that regardless of a family history of alcoholism, a lack of parental monitoring, severe and recurrent family conflict, and poor parent-child relationships can contribute to alcohol abuse in adolescents. Children with conduct disorders, poor socialization, and ineffective coping skills as well as those with little connection to parents, other family members, or school may be at an increased risk for alcohol abuse and/or dependence. Peers also influence drinking behavior. Recent studies in the USA reported that lower educational levels and unemployment do not cause higher rates of alcoholism (Emmite and Swierzewski, 2008).
Studies indicate that intoxication is the most common cause of alcohol-related problems, leading to injuries and premature deaths (Basangwa et al., 2006). In Australia alcohol intoxication is responsible for 30% of road accidents, 44% of fire injuries, 34% of falls and drowning, 16% of child abuse cases, 12% of suicides, 10% of industrial accidents and 67% of the years of life lost from drinking (Government of South Australia, 2010) over a 25% of all drug-caused deaths and five (5) per cent of deaths from all causes (Health Department of Western Australia, 1998). Alcohol also leads to criminal behaviour – in Australia over 70% of prisoners convicted of violent assaults have drunk alcohol before committing the offence and more than 40% of domestic violence incidents involve alcohol.
Alcohol contributes to short-term effects including loss of work productivity through absenteeism, lateness or leaving early, feeling sick at work, having problems with job tasks, accidents, and damage to co-worker and customer relations (Blum, Roman and Martin, 1993; Gordis, 1999; Randerson, 2007)1. This further leads to organizational constraints in form of high turn-over and subsequent recruitment, consumption of health benefits, for example, in case of illness or accidents that would result to compensation (Randerson, 2007). In the United States, alcohol and drug abuse by employees is estimated to contribute to company loss of $100 billion a year (Buddy, 2003). Furthermore, alcohol abuse among employees can threaten public safety, for instance, in the case of neglect of essential duty as health/medical care, security or
1 Employee relationships are hampered because colleagues may resent or feel they must ‘cover up’ for someone with a problem.
3 aggression among workers or with clients. Besides alcohol causes enormous psycho-social losses in terms of pain and suffering experienced by the users and their significant others as well as by the employer.
1.2. The Context
WHO normally estimates the scale of alcohol consumption on the basis of recorded alcohol data, which refers to licensed liquor and unrecorded alcohol data that refers to unlicensed liquor. The unrecorded alcohol in Kenya constitutes traditional and illegal beverages (e.g., chang’aa) that are poorly monitored for quality and strength and often contain impurities and adulterants. For instance kumi kumi is illicit liquor made from sorghum, maize or millet but contains methanol and is adulterated with car battery acid and formalin.
In Kenya only 15% of alcohol consumption is recorded and based on this measure Kenyans aged 15 years and above on average consume 1.74 liters of pure alcohol annually (WHO, 2004). This is a moderate level compared to some other African countries like Zimbabwe (5.08 litres) Tanzania (5.29 litres) and Botswana (5.38 litres). On the other hand, based on unrecorded alcohol the per capita consumption (15+) from 1995 was 5.0 litres, which compares with levels found in the high range African countries such as Swaziland (4.1 litres), Rwanda (4.3 litres), Burundi (4.7 litres), Seychelles (5.2 litres), Zimbabwe (9.0 litres) and Uganda (10.7 litres) (WHO, 2004).
Recent community studies (NACADAA, 2007, 2009a, b) indicate significant alcohol consumption in Kenya. The NACADAA (2007) countrywide survey indicated a current usage of alcohol (i.e., consumption in the last 30 days) among persons aged 15-65 years (n = 3,356) to be 14.2% with male consumption being 22.9% and female consumption being 5.9%. Other rates of consumption were: rural - 13.0%, urban - 17.7%; legal/packaged alcohol – 9.1%, traditional liquor – 5.5% and chang’aa2 – 3.8%. Disaggregating by province, the lowest use was found in North Eastern (0 %) and Western provinces (6.8%) while the other six provinces were comparable with a range of 13% - 19% (i.e., Rift Valley - 12.5%, Eastern – 14.8%, Nyanza – 17.0%, Central – 17.7%, Coast – 18.6%, Nairobi – 18.6%).
The survey also looked at lifetime usage (i.e., ever used alcohol) with the results showing 39% usage among 15 – 65 year olds (53.2% male and 25.8% female; 38.8% rural and 40.2% urban) and 8% among children aged 10 – 14 years (8.6% males, 7.1% females; 8.6% rural and 5.6% urban). The study further revealed that 2.4% of the children (10- 14 years old) had ever consumed chang’aa while 15% of 15-65 year olds had ever consumed the same highly potent illicit spirit. In terms of impact, the survey showed that 5% of alcohol users had ever sought medical treatment for alcohol related ailments.
Alcohol use has also led to so many deaths in Kenya. In this year (2010) alone, the cases of large number of people dying out of a single episode of drinking poisonous illicit liquor have occurred in Shauri Moyo and Laikipia. Other most conspicuous cases include the use of kumi kimi in November 2000 which resulted in 140 deaths and lose of sight among some users in poor Nairobi neighborhoods (Mukuru kwa Njenga and Mukuru Kaiyaba) (Mureithi, 2002; WHO, 2004). Similar incidents have also been in Muranga (Muthithi and Kabati areas), Naivasha and Machakos. This shows an urgent need to prevent and control alcohol abuse in Kenya, which however, would only be possible if such efforts were backed by scientific evidence.
1.3. Study Rationale and Objectives
The purpose of this study was to conduct a baseline survey on alcohol use in Central Province with a view to influencing prevention and control policies and other interventions. The
2 Chang’aa is an illegal alcoholic drink which is distilled from grains like maize and sorghum and sometimes adulterated with jet fuel battery acid to accelerate fermentation and make it more potent.
proposed study comes in the back of a recent fact finding study (NACADA, 2009) which explored through public forums and secondary data various manifestations of alcohol abuse in the province. The study found out that alcohol use begins early as 10 years of age with the highest use being among those aged between 15-35 years. It also established the key predisposing and protective factors as well as impacts.
The broad objective of the present study is to examine quantitatively the nature, patterns and scale of alcohol abuse in Central Province and identify appropriate prevention and control policies and interventions. The specific objectives were:
1. To ascertain the magnitude of alcohol abuse with respect to types of alcohol, and to age, gender, and other social, economic and demographic factors;
2. To identify social environmental risk and protective factors to alcohol abuse;
3. To establish the impact of alcohol abuse on health, security and socioeconomic indicators in the community;
4. To assess the influence of existing alcohol regulations, related policies and other interventions;
5. To make recommendations with regard to appropriate policies and interventions.
1.4. Scope of the study
The magnitude of alcohol abuse was established through lifetime and current amount used and frequency of abuse disaggregating for age, gender, situational factors like marital status and religion, socioeconomic status and dwelling (rural-urban; slum). Other factors were availability and accessibility of various types of alcohol, consumption hours and frequency of selling points relative to other amenities like schools, hospitals, churches, groceries, money transaction outlets etc.
The risk factors were established through examination of situational factors like unemployment, poverty, family history of alcohol use, beliefs and values, legal and regulatory provisions and enforcement among others. The protective factors were established through examination of individual, family and community resources available including resilience and coping skills, family responsibility and values, religion, legal/regulatory provisions and Enforcement among others.
The impact of alcohol abuse were established through analysis of alcohol related mortality (death by alcohol; by alcohol related suicide, murder and accidents; related morbidity (e.g., sexual disorder, infertility, liver cirrhosis, suicide ideation, attempts and completion; disability adjusted years of life lost (e.g., contrast risk of death among alcohol users and non-using populations), reckless behavior (e.g. drunk driving, fighting, unprotected sex, prostitution). Others were economic consequences including household expenditure (compare alcohol and others including food, clothing, school fees etc), financial management (e.g., improper selling/disposing of property such as land and livestock, betting/gambling), exposure to criminal victimization (e.g., drinking in dark alleys, late at night), family stability, participation in community projects and activities (baraza, kazi kwa vijana), employability, cultural identity etc. The study also reviewed provisions and enforcement of laws and regulations with reference to liquor licensing, control of illegal alcohol etc.
Tomorrow we continue with the third edition - METHODOLOGY
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