Violence and Alcohol: A Study of Injury Presentations to Emergency Departments in Eldoret, Kenya

Transcription

1 Violence and Alcohol: A Study of Injury Presentations to Emergency Departments in Eldoret, Kenya W. Odero 1 School of Public Health, Moi University D. Ayuku Department of Behavioural Sciences, Faculty of Health Sciences, Moi University ABSTRACT The objective of this study was to estimate the extent of alcoholrelatedness in injury patients, with special reference to interpersonal violence. A cross-sectional hospital-based descriptive study was undertaken in Eldoret, Kenya, over a period of six months. Demographic and injury circumstances data were collected on trauma patients consecutively presenting to hospitals. Alcohol consumption was assessed by either blood analysis or breath test, using a Lion Alcolmeter-SD2, in patients aged 16 years and above who arrived within an interval of 10 hours from the time of injury. Of the 778 subjects evaluated for alcohol, 31.1% were positive (BAC >0.05 g/100ml). A greater proportion of assaulted patients (42.5%) tested positive for alcohol than those with road traffic injuries (23.3%) and falls (17.9%). Nearly a third of assaulted patients were intoxicated (BAC=>0.5g/100ml). Males were twice as likely as females to have been drinking prior to injury (OR=1.8; CI, ). Young adults of ages years were three times as likely to be involved in alcohol-related violence than adolescents aged years (OR=3.16, p=0.005). Most alcohol-related injuries occurred at night and over weekends. Alcohol is an important, but poorly documented factor contributing to violence that results in injuries for which patients seek medical treatment in hospitals. Hospitals' emergency departments clearly present opportunities for objective assessments of the role of alcohol, identifying high-risk groups, and for implementing interventions for reducing alcohol abuse. Routine testing of trauma patients for alcohol consumption should be considered for introduction into Kenyan hospitals. INTRODUCTION Violence is a major public health problem worldwide and is the leading cause of death among people aged years, responsible for 14% of deaths in males and 7% in females (World Health Organisation (WHO), 2001). Alcohol plays a major role in violence, and is often involved in homicides, stabbings, fights and domestic violence. The World Health Organisation (WHO, 1996) estimates that over half of all cases of interpersonal violence reported worldwide are associated with alcohol, and many studies have provided evidence of a strong relationship between alcohol consumption and violence (Beech & Mercadel, 1998; Brismar & Bergman, 1998; Haberman & Natarajan, 1986; Parry, Tibbs, van der Spuy & Cummins, 1996; Perkins, Sanson-Fisher, Robertson, Johnson, Boyle, & Hopkins, 1995). Alcohol-related injuries have, in particular, a great impact on medical services. Studies in Cape Town indicate that 77% of patients admitted at the Tygerberg Hospital Trauma Unit with assault and motor vehicle injuries had detectable alcohol in their blood, and 67% had blood alcohol ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ 1 Please direct all correspondence to W Odero, School of Public Health, Moi University, P.O. Box 4606, Eldoret, Kenya; Tel ; Fax ; iphmu@africaonline.co.ke 38

2 concentrations (BAC) of 0.08g/100 ml or higher (Muller & van Rensburg, 1986). A multi-centre sentinel surveillance of alcohol and drug abuse in three cities in South Africa (Cape Town, Durban and Port Elizabeth) further highlights the prevalence and trends of alcohol-related injuries (Peden et al., 2001). In Kenya, the limited literature available indicates that violence is the leading cause of injury, representing between 25% and 40% of all injuries (Mwaura, Katsivo, Amuyunzu & Muniu, 1994; Norberg, Kimani, & Diwan, 2000; Odero & Kibosia, 1995). Other reports indicate high levels of alcohol consumption in Kenya's general population. A survey of 200 heads of households in a rural district reported a high prevalence of alcohol abuse, with 27% of men and 24% of women being classified as alcoholics (Bittah, Owola, & Oduor, 1979). Alcohol abuse has also been shown to be common among patients attending hospitals, with prevalence rates of more than 50% in males and 25% in females (Acuda, 1990; Nielsen, Resnick, & Acuda, 1989). However, no studies have so far been undertaken in health care facilities to specifically examine associations between alcohol consumption and traumatic injuries. The purpose of this study was therefore to document the extent of alcohol-relatedness for different types of injuries among trauma patients presenting to hospitals for treatment, with special reference to interpersonal violence. METHODS The study was undertaken in emergency departments of hospitals in Eldoret, a town with approximately 250,000 inhabitants located in western Kenya, 320 kilometres north-west of Nairobi. Approval of the Institutional Research and Ethics Committee was obtained prior to commencement of the study. Demographic variables (age, sex) and injury circumstances data (cause, time and day of the week), were collected on all injuryaffected patients presenting to all the four hospitals located in Eldoret over a period of six months (December 1995 to May 1996). Patients were enrolled consecutively after obtaining their verbal consent. Severely injured patients who required emergency treatment and those dead on arrival were excluded. Alcohol consumption status was assessed by either analysis of blood samples or breath test measurements using a hand-held breathalyser (Lion Alcolmeter-SD2), which gives direct digital readings of blood alcohol concentration (BAC). Blood samples (2.5 ml in volume) for BAC analysis, by gas chromatography, were taken from patients unable to blow correctly into the breathalyser and from those with serious injuries. Patients were included for alcohol evaluation if they were aged 16 years and above, and presented to the hospital within an interval of 10 hours from the time of injury. The restriction in age was to allow for inclusion of all adolescents and adults who are potential consumers of alcohol. Because trauma patients normally delay in reaching hospitals due to the absence of ambulance services and lack of a reliable public transport system, it was necessary to allow sufficient time to enable casualties to reach the hospitals. A cut-off time interval of 10 hours was considered reasonable, although this may have increased the probability of a patient having a negative BAC test, as alcohol levels in the blood rapidly decline with time owing to metabolism (Gilman, Rall, Nies, & Taylor, 1990). Blood alcohol concentration (BAC) readings, in grams per 100 millilitres (g/100ml), were recorded. BAC levels equal to or greater than 0.05g/100 ml were taken as a positive test. RESULTS Of the total injury-affected patients aged 16 years and above who arrived within 10 hours of sustaining injury (N=778), 31.8% had evidence of having consumed alcohol prior to injury. A third of males and 22.5% of females had a positive breath test for alcohol. Thus, males were almost twice more likely to have been drinking immediately prior to the injury event than females (OR=1.8; 95% CI, ). Among the major causes of injury, interpersonal violence was more frequently associated with alcohol than all other injury events, with 43.2% being BAC positive (Table 1). Table 1: Alcohol Prevalence by Causes of Injury Cause of injury BAC test positive BAC=>0.5 g/100ml Assault (n=405) Road traffic accident (n=189) Fall (n=28) Other (n=157) In comparison to those affected by road traffic injuries (RTIs), with a positive rate of 23.4%, cases of violence were more than twice as likely to have been drinking (OR=2.4; 95% CI, ). In addition, nearly a third (30.9%) of those with injuries from interpersonal violence were found to be intoxicated (BAC 39

3 equal to or greater than 0.5g/100ml). The likelihood of drinking large quantities of alcohol was also found to be three times greater in cases of violence than in those affected by RTIs (OR=3.2; 95%; CI, ). For violence-affected patients, males (47.2%) had a significantly higher positive breath test rate than females (29.7%) [OR=2.12; 95%CI, ] (see Table 2). Men were also more likely to be intoxicated, though the differences by gender were not statistically significant. Distinct age- and sex-specific variations in alcohol prevalence rates were demonstrated. Whereas the mean age of all BAC positive subjects was 31.9 years, drinking males were, on average, slightly older than females (32.5 years vs 29.4 years), but the difference was not statistically significant (p=0.10). Table 2: Alcohol Prevalence in Assaulted Patients by Age, Sex and BAC Level Variable % BAC positive % intoxicated (BAC=>0.5g/100ml) Sex: Male (n=302) Female (n=103) Age (in years): As shown in Table 2, violence-affected patients aged years had the highest positive breath test rate (53.2%), followed by those aged years (48.8%). When compared to younger patients aged years, those aged years were three times as likely to have been drinking prior to their involvement in the violence (OR=3.16, p=0.005). Heavy drinking was however more common in the older people of ages years. In all age groups, the proportion of drinking males with violent injuries was consistently higher than that of females (see Table 3). Table 3: Alcohol Prevalence in Assaulted Patients by Age Group and Sex Age group in years Breath test positive rate (%) by sex Male (n=302) Female (n=103) Overall (p=0.002) Almost half (48.9%) of the violence-affected patients tested during weekends were positive for alcohol compared to 39.7% on weekdays (Monday to Friday). Although this difference was not significant at a p-level of 0.05, it provides some evidence of a higher incidence of alcohol-related violence on weekends. Of all the days of the week, the greatest proportion of patients with alcohol-related violence was on Sundays (55.1%). Diurnal variation in alcohol prevalence rates in the patients examined was also detected. Whereas 34.6% of those assaulted during the day were affected by alcohol, this rose to 50.2% by night time. Consequently, the probability of association of assault-related injury with alcohol was nearly two times greater at night than during the day (OR=1.91; CI, ). Of considerable interest is the finding that a large proportion of injuries resulting from interpersonal violence were of minor severity: mostly cuts and lacerations (52%), swellings (19.2%) and bruises (14.6%). Serious types of injury such as fractures and head injury were relatively few, and accounted for only 4.4% and 1.5%, respectively. In this sample of patients, the level of injury severity was not found to be associated with alcohol consumption. DISCUSSION Alcohol abuse is a well-recognised risk factor for interpersonal violence (Beech & Mercadel, 1998; Brismar & Bergman, 1998). Whereas over half of all cases of violence worldwide are estimated to be associated with alcohol (WHO, 1996), there are considerable variations between countries. For instance, in South Africa up to 65% of interpersonal violence was reported to be alcohol-related (Parry et al., 1996), while in the Western Pacific countries, the proportion ranges from 82% in Fiji, 67% in 40

4 Australia to 22% in Papua New Guinea (Perkins, Sanson-Fisher, Robertson, Johnson, Boyle & Hopkins, 1995). Other studies in the United States examining associations of alcohol with violence have also reported comparable figures: 84% in lifethreatening assaults (Beech & Mercadel, 1998) and 60% in autopsied homicide cases (Clark, 1996). Country-specific data documenting the prevalence of alcohol in violence-related injuries are therefore needed. In this study, 43% of assaulted patients tested positive for alcohol, a figure slightly lower than those previously reported elsewhere. However, this proportion is still twice as great as that found in traffic-involved cases (23.4%), the other major cause of serious injuries, where a clear dose-response relationship has been well established (Borkenstein, Crowther, Shumate, Ziel, & Zylman, 1964; Mclean & Holubowycz, 1981). Since the subjects evaluated included both perpetrators and victims of violence, the actual importance of alcohol as a risk factor may have been underestimated. Nevertheless, these findings are consistent with previous trials reported by Cherpitel (1997) indicating that patients with violence-related injuries are more likely to have a positive breath test than those with injuries from other causes. The findings also indicate some key risk factors associated with alcohol-related violence. For instance, drinking patients were more likely to be male, aged between 30 to 49 years. This is understandable since men who frequently visit drinking places and consume excessive alcohol have a greater probability of being drawn into arguments and conflicts that often result in fights. Since alcohol has inhibitory effects on the central nervous system (Gilman et al., 1990), this results in increased aggression and violent behaviour with a high probability of involvement in fights and other serious forms of interpersonal violence (such as homicides and the infliction of life-threatening injuries). For the victims, diminished self-preservation instincts, inability to avoid blows and impaired judgement are important effects of alcohol that tend to aggravate injury. In Kenya, most domestic violence is often reported by the media to be alcohol-related, although this has not been documented in health service records. Accurate data providing objective measures of alcohol consumption is needed. Evidently, the association of alcohol with violence is greater in victims visiting emergency rooms during the night and on weekends, when approximately half have a positive breath test. Several studies elsewhere (Hall, 1980; Hedeboe, Charles, Nielsen, Grymer, Moller, Moller-Madson, & Jensen, 1985) have reported a high incidence of violence (65%-80%) being committed between 6pm and 6am, suggestive of the importance of alcohol as a contributory factor during the night. Exposure to hazardous circumstances, such as walking alone at night in unlit streets, alleys or footpaths, may also result in muggings, thus partly explaining the increased incidence of night-time assaults. Given the low staff levels in emergency departments at night and the difficulties often experienced in handling intoxicated, injured patients (because of their disruptive and uncooperative behaviour), intoxicated patients place considerable demands on the on-duty medical personnel. As shown in this study, nearly half of the assaulted patients attending hospitals in Eldoret town had consumed some amount of alcohol. This implies that many patients presenting to emergency rooms with injuries leave undiagnosed as alcohol abusers, since tests for alcohol are usually not done routinely (as they are often regarded by physicians as having little clinical importance to patient care). It is desirable that clinicians routinely screen trauma-affected patients for alcohol consumption, using reliable objective measurements. Emergency departments thus provide an opportunity for performing such screening and other necessary diagnostic tests. Regrettably, in the current practice in Kenya, such opportunities are usually missed. PREVENTION IMPLICATIONS Interpersonal violence is frequently a crime, to which alcohol contributes. In order to reduce or eliminate injuries and deaths resulting from alcohol abuse, accurate evaluation and documentation of alcohol-related violence is needed in hospital emergency departments to assist in developing appropriate interventions. Routine testing of trauma patients for alcohol in emergency departments should be introduced in Kenyan hospitals to help in identifying problem drinkers. In addition, broader policies and strategies aimed at regulating alcohol and altering public attitudes to its use would have a significant impact on reducing the related morbidity and mortality as well other psychosocial effects. REFERENCES Acuda, S.W. (1990). Alcohol research in developing countries: Possibilities and limitations. Nordic Council for Alcohol Research (NAD): NAD Publication No. 18, Helsinki,

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