Is it possible to quantify alcohol-related problems?
During the past half a century, researchers have been grappling with this problem. They have developed a plethora of tools to quantify alcohol-related problems depending on how they define it. One such famous tool to date is the A.U.D.I.T.: (Alcohol Use Disorders Identification Test). This 10-item instrument came to us as a result of a multi-center study executed by the World Health Organization (WHO).
I do not discuss how it was developed. Rather, I describe the test.
AUDIT (Alcohol Use Disorders Identification Test)
The AUDIT – the 10-item questionnaire – screens for alcohol-related problems within 10 minutes fairly accurately.
In 2001, the WHO published the tool as a freely available booklet. You can access it through this link: AUDIT test. Thomas Babor, John Higgins-Biddle, John Sanders, and Maristela Monteiro authored the booklet (Figure 1).
What is this instrument?
The instrument consists of 10 questions and each question owns 5 responses with scores ranging from 0 – 4. The respondent should choose one response out of 5 responses. This means after responding to all ten questions, the respondent’s score may be any value between 0 – 40.
All the questions inquire about the respondent’s alcohol consumption and related problems during the past 12 months from the date of the interview.
The interview version of the AUDIT tool
The instrument consists of 3 domains: hazardous alcohol use, dependence symptoms, and harmful alcohol use. The first three questions deal with the first domain – hazardous alcohol use while the second three questions probe about dependence symptoms. The last four questions seek information about harmful alcohol use. The box 2 summarises these three domains and its related question items succinctly.
Challenges in using the AUDIT instrument
Among several challenges in using this instrument, the most crucial one is assessing the hazardous consumption in terms of the amount of pure ethanol consumed in the 12 months prior to the interview. This is because the percentages of pure ethanol in alcohol beverages vary significantly by the product. For example, beer products contain about 5 percent of pure ethanol while spirits having about 40 percent of pure ethanol. The instrument adopts the standard drink size concept to overcome the challenge.
While I was validating the AUDIT – a tool widely used to quantify alcohol consumption and related problems – to the Sri Lankan context, although researchers and practitioners all over the world have been using it for decades, I faced many difficulties in translating its first three questions: the quantity-frequency questions.
However, I overcame the challenge. Before explaining the method which could be adapted by anyone in any cultural setting, I again will describe the first three AUDIT questions and the challenges of using it.
Keep in mind that these questions refer to the past 12 months from the date of the interview.
How often do you have a drink containing alcohol?
(1) less than monthly
(2) 2-4 times a month
(3) 2-3 times a week
(4) 4 or more times a week
Any respondent might answer the above question relatively easily if they can recall their past 12 months prior to the interview date. Both interviewers and respondents will face a big problem when dealing with the following two questions since both should know what a “drink” is.
How many “drinks” do you have on a typical day when you are drinking?
(0) 1-2 drinks
(1) 2-3 drinks
(2) 4-6 drinks
(3) 7-9 drinks
(4) 10 or more drinks
How often do you have 6 or more drinks on one occasion?
(1) less than monthly
(4) daily or almost daily
According to the original manual, a “drink” refers to an amount of an alcoholic beverage containing 10 grams of pure ethanol (see page 15 of the manual). This definition varies from country to country: It is 13.6 grams in USA and Canada.
The manual (see page 15 in the link) recommends explaining what a “drink” means to respondents. We first need to prepare visuals of drinks of different alcoholic products since drink sizes vary with its alcohol content: For example, a beer bottle equates a “10-grams drink” since its ethanol content is 5%; in contrast, a whisky shot glass equates a “10-grams of drink” whisky since its ethanol content is 40%. It is more challenging in cultures where informal, home-grown, sometimes illicit products, are commoner.
The problem: Accurately estimating the ethanol amount drank is critical for a proper assessment not only among individuals but in the community also.
However, the ethanol content varies significantly by its type;
- 5% in beer;
- 10% – 12% in wine,
- and 40% in spirits.
If someone consumes two glasses of spirits, it is difficult to estimate the amount of ethanol consumed if we do not know the amount of the beverage consumed. Even if we know the amount, we have to do a simple calculation to determine the amount of ethanol.
The solution: Concept of “standard drink” size.
The concept of the “standard drink size”
In order to address the above challenges, researchers created the “standard drink” concept. In Canadian and US contexts, the standard drink refers to the amount of an alcoholic beverage that contains 13.6 grams (or 0.6 ounces of 100%) of pure ethanol. (However, the World Health Organization defines the standard drink as any alcoholic beverage that contains 10 grams of pure ethanol).
Therefore, “standard drink sizes” of beer, wine and spirits vary depending on its pure ethanol contents – beer equivalent to standard drink is larger than the wine equivalent which is larger than the spirits equivalent.
How Alcohol Use Disorders Identification Test (AUDIT) employs this concept
The AUDIT’s first three questions seek the amounts and frequencies of pure ethanol consumed in the 12 months prior to the interview to quantify the hazardous use of alcohol. It does this by asking questions in terms of the number of standard drinks consumed. You can find the complete tool through this link:https://theupstreamboat.com/?s=standard+drink+size.