CHAPTER TWO: METHODOLOGY

The overall design of the study was a cross-sectional survey of patterns of alcohol abuse in terms of frequency, risk and protective factors and impacts. This necessitates examination of self-reported use and abuse in the general population and among users, as well as examination of their views and those of key stakeholders including users significant others, government officials, civil society, faith based organization, business community among others. The study was conducted through the following methods and tools:

2.1. HOUSEHOLD SURVEY

2.1.1. Survey coverage
The target population for the study was all adults aged 15 – 64 years. The survey covered all the 7 districts (as of 1999 Census) in Central province ; Kiambu, Kirinyaga, Muranga, Nyandarua, Nyeri, Thika and Maragua (as at now Central province is divided into several other districts but there is no complete information, since 2009 census results have not been released)3. The survey disaggregated for rural and urban areas of the province.
2.1.2. Sampling methodology
A two stage cluster sample design was adopted. The first stage involved selection of EAs using Probability Proportional to Size (PPS) and the second was random selection of households.
2.1.3. Sampling Frame
The sampling frame for the study was the EAs from 1999 census and stratified according to district and urban/rural classification.
3 In addition, the new constitution of 2010 has abolished and replaced the districts with counties. The province has now five counties namely Kiambu, Muranga, Nyeri, Kirinyaga, and Nyandarua. However, the specific boundaries have not yet been specified. This implies that although the counties would be suitable context for presentation of the current survey, it is not possible to do so given that the survey was designed in the context of the seven districts existing as of 1999.

2.1.4. Sample Size and Allocation
In computation of the sample size, it was estimated that 30 % of adults in Central province consume alcohol, a coefficient of variation (CV) of 10% is targeted, design effect of 2 and a non-response adjustment of 5%. Based on above assumptions a uniform sample of 500 households per district was expected resulting into an overall sample of 3,500. Given that the Kenyan population distribution is 80% rural and 20% urban, the number of households to be selected from the various districts as in Table 2.
Table 1: Sample Allocation Dist Code District 1999 Census HH Estimated Sample (HH) Estimated EAs Rural EAs Urban EAs Total EAs Final Adjusted Sample (HH)

Table 2: Selection of Households Dist Code District Rural Number of households Urban number of households Total

2.1.5. Sampling of Eligible Respondents
Upon entry into a household the head of that household or in event of his/her absence any responsible member of that household (i.e., aged between 18 – 64 years and mentally aware) was selected to provide general household information. Such information included the identity of household members in terms of age, gender, occupation etc. and the general socioeconomic indicators such as property/assets owned, types of income generating activities, expenditure etc.
Out of all the members of the household, one of them aged 15 - 64 years was selected randomly to provide information on their own alcohol use or abstinence and related risk and/or preventive and impacts. The only exclusion criteria were mental or physical illness that would render such respondent unreliable or distressed from the interview.

2.1.6. Data Collection Methods
Face to face interviews with the aid of questionnaires was conducted among the household level respondents to identify the prevalence of alcohol use and abuse and quantifiable impacts (e.g., deaths) and identify perceptions on risk and protective factors.

2.1.7. Methods of Data Analysis
Quantitative data were summarized, organized and presented through graphics including pie-charts, histograms and frequency tables through SPSS.

2.1.8. Expected Outputs, Outcomes and Impact
The major output of the study is a report detailing:
1. Key evidence in terms of findings, conclusions, recommendations and other relevant information emerging,
2. A review on how alcohol abuse has been mainstreamed in the public policy and make proposals for further mainstreaming,
3. Specific recommendations feasible interventions relevant for internal and external mainstreaming of alcohol abuse which may be translated into programmes.

The major expected outcome is improved policy formulation, planning and programming towards evidence-based alcohol abuse interventions in Central Province and in Kenya. A related outcome is improved networking among various actors involved.
The major expected impact is ensuring that alcohol abuse does not compromise developmental objectives. This will be achieved by ensuring that abuse is mitigated among all but particularly among the youth.

CHAPTER ONE: INTRODUCTION

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

ALCOHOL USE IN CENTRAL PROVINCE OF KENYA

For the next few weeks I will be posting the details of the findings of

A BASELINE SURVEY ON MAGNITUDE, CAUSES AND EFFECTS FROM THE PERSPECTIVE OF COMMUNITY MEMBERS AND INDIVIDUAL USERS

Carried out by NACADA and released in December 2010.

I will post a stage by stage content without any editing for your own scrutiny and awareness. WELCOME:

EXECUTIVE SUMMARY

This baseline survey on alcohol use in Central Province came in the background of public and Government concern over increasing alcohol use in the province. It also came in the background of a previous fact finding mission (NACADA, 2009) that confirmed the existence of an acute alcohol problem. The purpose of this study was to investigate principally through quantitative means the magnitude of alcohol use and the underlying causative factors and effects. The ultimate goal was to gather data and information that would assist in formulation and implementation of effective prevention and control policies and other interventions. The specific objectives were to:

1. Ascertain the magnitude of alcohol abuse with respect to types of alcohol, age, gender, and other social, economic and demographic factors;

2. Identify social environmental risk and protective factors to alcohol abuse;

3. Establish the impact of alcohol abuse on health, security and socioeconomic indicators in the community;

4. Assess the influence of existing alcohol regulations, related policies and other interventions;

5. Make recommendations with regard to appropriate policies and interventions.

The overall design of the study was a cross-sectional survey which gathered views of community members and of individual alcohol users from seven Central Province districts (as at 1999 Census) namely Kiambu, Kirinyaga, Muranga, Nyandarua, Nyeri, Thika and Maragua. The survey also disaggregated for rural and urban areas of the province. The sampling procedure involved selection of Enumeration Areas (EAs) using Probability Proportional to Size (PPS) and random selection of households. In computation of the sample size, it was estimated that 30 % of adults in Central province consume alcohol, a coefficient of variation (CV) of 10% is targeted, design effect of 2 and a non-response adjustment of 5%. Based on above assumptions a uniform sample of 500 households per district was expected resulting into an overall sample of 3,500, which as adjusted to 3,495. The survey managed to capture 3,259 or 93.2%.

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From the community views on alcohol use, the findings point at the following key findings:

 Magnitude: There is a very strong consensus in the community that alcohol use is a major problem in the province owing to the high level of usage, increasing trend and ease of availability, affordability and accessibility.

 Level of alcohol consumption: About two thirds of community members reported that alcohol consumption in their areas is high or very high. Across the districts, the level of usage ranged from a low of 51.5 per cent in Nyandarua to a high of 75.4 per cent in Kirinyaga.

 Trends: More than 80 per cent of the respondents felt that the second generation alcohol was increasing, while 58 per cent expressed the view that the first generation alcohol was decreasing. However, a significant proportion of the respondents held the view that traditional liquor and chang’aa usage was more of constant than increasing or decreasing.

 Availability, affordability and accessibility: The findings reveal that the second generation alcohol as the most available, affordable and accessible type of alcohol in the province. Chang’aa and traditional liquor were reported to be the least available and accessible types of alcohol.

 Drinking time: A significant proportion of the respondents (nearly 60%) reported that in their areas there is alcohol consumption before noon, apparently the most productive hours of the day. There was also a clustering of drinking activities between noon and 6 pm.

 Alcohol usage by age and gender: A significant proportion of the respondents rated the consumption of alcohol among people aged less than 18 years as “high”. Further, results point at the concentration of the drinking among the youth, gender notwithstanding. “Very high” usage was reported for ages 25 – 34 years (males, 79%; and females, 15%); and 19 – 24 years (males, 77%; and females, 14%). Alcohol consumption among males aged 35 – 54 years was rated as “very high”. However, alcohol usage declined with reference to ages 55 years or above.

Besides the community perspective on alcohol use, this survey made an inquiry on individual experiences with alcohol. Some of the key highlights include:

 Life time prevalence: The findings show that 29.6 per cent of the community members surveyed had used alcohol on at least one occasion in their lifetimes. However, the lifetime prevalence rate was higher among males than for females with 53 per cent and 8 per cent respectively.

 Current usage (last 30 days): As measured by use in the past 30 days, current usage was estimated at 18 per cent with a male rate of 34 per cent while the female rate stood at 3 per cent.

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 Type of alcohol: Less than 50 per cent of the respondents were using first generation alcohol, while consumption of the second generation alcohol stood at 40 per cent. The others accounted for 10 per cent.

 Frequency of use: As was the case with the community perception, a significant number of people reported using alcohol before noon. Further scrutiny reveals that most of those taking alcohol before noon were clustered around chang’aa and the second generation alcohol

 Alcohol dependency rates: The findings show that dependency was higher for chang’aa, traditional liquor and second generation alcohol compared with the first generation brands. For instance, 75 per cent of chang’aa users regularly felt that they needed it to remove hangover. In addition, alcohol dependency was reported more for male users.

 The findings reveal that some of the risk factors include: idleness; peer pressure; unemployment; work related stress. The risk factors also varied by gender. For instance, while more males used alcohol due to occupational factors (e.g. work related stress, idleness, and unemployment) more of the females used it due to relational issues notably marital problems, problems with parents and peer pressure. Some of the reasons pointed out for taking alcohol include: to feel good or have fun; relaxation; cope with stress; interact with others; and ‘kill time’. These factors also vary with district. Religious values; parental restrictions; positive peer pressure; work and school commitment; fear of stigmatization and peoples bad experience with alcohol were found to be important protective factors.

 The study further found out that alcohol abuse has several adverse effects to the individual, the household and the community. Such effects included: episodes of loss of consciousness; inability to meet financial obligations; having multiple sex partners; threatened and attempted suicides; motor vehicle accidents and domestic violence. Others include community level effects such as: low school enrollment; high school drop-out rates; poor results in national examinations; decreased employability; marital breakdown; and infertility.

 In conclusion, the findings point to a relatively high level of usage of alcohol in Central Province of Kenya. This vindicates the current public and policy makers concern of high alcohol use in the province. However, a more worrying question is the increasing penetration of the second generation brands that are eating into the market of the first generation alcohol. Nevertheless, the fact that many people do not know about the trend of traditional liquor and chang’aa may partly be linked to their illegality. This is because, unlike the first and second generation brands, chang’aa and traditional liquor are processed, marketed and consumed with some secrecy.

 From the community and individual perspective there is strong consensus on the adverse implications of alcohol use in the province in general. In fact the

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findings show an overwhelming disapproval of alcohol use in the community implying that those who abuse alcohol do so against the expectations of the community. Across the seven districts, hard work and education as still highly treasured values. Such solid community disapproval of alcohol use augurs very well for any interventions meant to address the challenge posed by the problem of alcohol abuse in the province.

In view of the study findings, the following recommendations are made:

 Increased community education on the adverse effects of alcohol at the individual, household and community level. This may include the provision of IEC materials, use of theater, mass media and especially the local FM radio stations; games and sports and increased targeting of the youth.

 Enhanced enforcement of the new legal provision on alcohol since it became evident that there was laxity in the enforcement of the old legal regime that governed the production and sale of alcohol in the country.

 Pro-actively engage the community leaders in leading the campaigns against alcohol abuse in Central Kenya.

 Working with relevant government departments to ensure that the youth are positively engaged into productive activities e.g. increased uptake of the devolved funds in a way that is beneficial to the youth.