Drinking in the Injury Event: A Comparison of Emergency Room Populations in the United States,...

The International Journal of the Addictions, 28(10), 931-945, 1993

Drinking in the Injury Event: A Comparison of Emergency Room Populations in the United States, Mexico, and Spain

Che I J. Cherpitel, Dr.P.H.: Albert Par&, M.D.? Juan Rodes, M.D., ? and Haydee Rosovsky, ~ I ~ . P . H . ~

' Alcohol Research Group, Medical Research Institute of San Francisco, 2000 Hearst

'Alcohol and Liver Unit, Hospital Clinic y Provincial, University of Barcelona, Barcelona, Avenue, Berkeley, California 94709, USA

Spain

Mexico 22 D.F., Mexico Division of Epidemiological and Social Sciences, Mexican Institute of Psychiatry,

ABSTRACT

Variables related to drinking in the injury event were compared among probability samples of emergency room patients in Contra Costa County, California (N = 1,001), Mexico City (N = 1,688) and Barcelona, Spain (N = 1,684). Drinkmg companions and places of drinking prior to injury, place of injury associated with drinking, amount of alcohol consumed, proximity of drinking with the injury event, perceived drunkenness at the time, and causal attribution of drinking with the event were all found to vary among the samples. The data suggest that the context in which alcohol is involved in the injury event is affected by the context in which alcohol is typically consumed in a culture and is important in analyzing alcohol's role in injury occurrence and situations which may be considered high-risk for alcohol-related injuries.

93 1

Copyright 01993 by Marcel Dekker, Inc.

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932 CHERPITEL ET AL.

Key words. Mexico; Spain

Alcohol; Emergency room; Injuries; Cultural context;

INTRODUCTION

While a large literature, both national and international, exists on the association of alcohol consumption and casualties (reviewed by Roizen, 1982, 1989), and this linkage is well-established, much less in known of the actual role drinking plays in injury occurrence. The majority of studies have focused on the prevalence of alcohol involvement as measured by estimated blood alcohol concentration among emergency room (ER) patients at the time of admission to the ER (Wechsler et al., 1969; Peppiatt et al., 1978; Walsh and MacLeod, 1983; Cherpitel, 1988a; Teplin et al., 1989). However, few studies reported in the literature have examined the context in which drinking occurred prior to injury or other drinking-in-the-event variables such as the amount of alcohol consumed, proximity of drinking to injury occurrence, or perceived drunkenness at the time of injury. Two studies of drinking in the injury event have been carried out in the United States using similar study methodology, but in dissimilar ER populations: San Francisco General Hospital, which is an inner city trauma center (Stephens, 1987), and in an adjacent suburban county (Cherpitel, 1989). In the San Francisco study, injuries were more likely than noninjuries to occur within close proximity to drinking, with 17% of those injured reporting being very drunk at the time of the event, but only 63% of these attributing a causal association of drinking with the event. When injured in this sample were compared to those in the suburban county study, however, the suburban sample was more likely to report fewer drinks prior to injury but a shorter time lapse between the last drink and the event, with only 8% reporting feeling very drunk at the time, but with 93% of these feeling the event would not have happened if they had not been drinking. In both of these studies the place where the injury occurred was predictive of drinking prior to the event.

These two emergency room populations have been found to differ greatly in demographic characteristics and in usual drinking patterns and alcohol- related problems (Cherpitel, 1988b). The relationship of alcohol consumption to injury occurrence is clearly not dose-dependent, and this is particularly evi- dent in cultures in which usual drinking patterns vary greatly. For example, comparative analyses of drinking patterns and problems with injury occurrence in the suburban ER sample discussed above and in a comparable ER sample in Mexico City found infrequent moderate to heavy drinking to be associated with injuries in Mexico but not in the United States (Cherpitel and Rosovsky, 1990). Similar comparative analyses (using the same quantitatively derived drinking categories) between this United States sample and a comparable ER sample in

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DRINKING IN THE INJURY EVENT 933

Barcelona, Spain, found light moderate-frequency drinking to be associated with injuries in that country (Cherpitel et al., 1991).

Additional comparisons of the United States, Mexico, and Spain would be particularly informative, especially in relation to the context of drinking and other drinking-in-the-event variables, because these three countries exhibit dis- tinctly different drinking patterns. Mexico reports less frequent usual drinking but more frequent heavy drinking leading to drunkenness than that found in the United States (Medina-Mora et al., 1980; Caetano and Medina-Mora, 1986), while Spain reports more frequent usual drinking but less frequent drunkenness than either the United States or Mexico (Caetano and Martinez, 1987). In the United States, daily light drinking is less common than in Spain and frequency of drinking is related to drinking larger quantities per occasion (Hilton and Clark, 1987). In Mexico, a large portion of alcohol is consumed on special occasions such as fiestas, while in Spain, drinking occurs primarily at meal times and with family members which is typical of wine-drinking cultures (Salamanca, 1984).

Given these distinct differences in usual drinking patterns between the three countries, one might expect the role of alcohol in the injury event to vary accordingly; that is, the context in which alcohol consumption is involved in the injury event may vary according to the context in which alcohol is usually consumed in that culture. Such comparative analyses may contribute to better understanding situations in which alcohol consumption influences injury occurrence and to identifying drinking situations which could be considered high risk for alcohol-related injuries within a given cultural context of drinking. This paper compares the United States suburban ER sample, Mexico sample, and Spain sample discussed above on variables related to drinking prior to the injury event, the context in which drinking occurred, and the perceived role of alcohol in the injury event.

Studies in all three countries used the same questionnaire (translated into Spanish for use in Mexico and Spain) and the same study design and methods to maintain comparability for comparative analyses. The United States study was conducted in the county hospital and three of the six community hospital emergency rooms in Contra Costa County, California. These emergency rooms were selected to achieve a wide geographic and demographic distribution across the county. The Mexico study was carried out in eight emergency room facilities in Mexico City which were representative of the principle kinds of emergency health system services found in Mexico. These included four hospitals which were part of the Ministry of Health system and primarily attended emergency cases, three other hospitals operated by the Red Cross, the Mexican Social Security System and the Social Security Institute for Government Employees, and a privately-operated hospital. In Spain, data were collected at the University Hospital in Barcelona. This is the largest of five emergency ser-

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vices in the city and draws from a cross-section of all of those seeking emergency care in Barcelona.

METHODS Sample Selection

In each of the four hospitals in Contra Costa County, a probability sample of every second patient 18 years and older admitted to the emergency room was taken over a 24-hour period every other day. Sampling over a 3-month period (1985) at each hospital provided a total sample of 3,609 patients. In six of the eight Mexico City hospitals, all emergency room patients 18 years and older were sampled. Because of the large number of ER admission in two hospitals, every other patient was sampled in them. The samples taken from these two hospitals were weighted up to obtain equal representation of all emergency rooms. (The total N was then down-weighted to obtain the actual number sampled from the eight hospitals.) Data were collected in each hospital 24 hours a day for a 1-week period (1986). A total of 2,507 patients were sampled during a 2-month period of data collection. In Barcelona, a sample of every patient 18 years and older was drawn from all patients treated on the medical/surgical/ trauma ward of the emergency department. Sampling one shift every other day during a 1-year period (1987) provided a sample of 2,972 patients. Samples were drawn in each county to assure equal representation of all shifts for each day of the week during the study period. All three studies drew samples from the emergency room admission form which generally reflected consecutive patient arrival in the ER.

A 73% completion rate for interviews was obtained in Contra Costa (N = 2,626), an 88% completion rate in Mexico City (N = 2,197), and an 80% completion rate in Barcelona (N = 2,363). Less than 3% of the Mexico sample refused to be interviewed compared to 9% in Contra Costa and close to 12% in Barcelona. The largest number of noninterviews in Contra Costa was due to the patient’s condition prohibiting the interview (lo%), while in Mexico City and Barcelona only 4% of noninterviews were due to patient condition. The primary reason for noninterviews in Mexico was due to failure to locate the patient and the patient leaving prior to completing the interview (6%). In all three studies, those who were not interviewed were similar to those interviewed on demographic characteristics other than age-the noninterviewed were somewhat older than the interviewed. The noninterviewed were also more likely than the interviewed to be admitted to the emergency room for medical problems than for injuries.

Instruments

In all three studies, data were collected using the same 15-20 minute interviewer-administered questionnaire. A cadre of professional interviewers

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DIUNKING IN THE INJURY EVENT 935

especially trained for each study was supervised by the authors in their respec- tive locations. Interviews were obtained (with informed consent in the Contra Costa study) as soon as possible after a patient had been selected for the study. Patients in each sample were told by the interviewer that a study of alcohol’s role in injuries was being carried out in that hospital and that they had been randomly selected to participate. All patients were breathalyzed and interviewed regarding usual drinking patterns and alcohol-related problems, and these results have been reported elsewhere (Cherpitel and Rosovsky , 1990; Cherpitel et al., 1991). Injured patients who reported drinking within 6 hours prior to injury were interviewed regarding drinking companions during this time, all the places where drinking occurred, amount consumed during the 6 hours, length of time between the last drink and the injury, whether they were feeling drunk at the time of injury, and whether they believed the injury would have occurred even if they had not been drinking.

Sample Characteristics

Less than half (42.6%) of the Contra Costa sample was admitted for injuries compared to over three-quarters (76.8%) of the Mexico City sample and 71.3 % of the Barcelona sample. Table 1 shows demographic characteristics for injured in the three samples. In the Contra Costa sample, 117 patients who were in for follow-up of a previously treated injury were excluded from the analysis since the purpose here is to analyze drinking in the original event. (Patients in Mexico City and Barcelona did not use the emergency room for follow-up of previous injuries.)

The proportion of males and females was evenly divided in the Barcelona sample while males were more likely than females to be admitted to the emergency room for injuries in both Contra Costa and Mexico City. In all three samples the largest proportion of patients was under 30 and in both Contra Costa and Barcelona three-quarters of the patients were under 40. Only 10% of the injured were abstainers in the Barcelona sample compared to 19% in Con- tra Costa and 39% in Mexico City. However, 27% of the injured reported drinking in the 6 hours prior to the event in Mexico City compared to 19 and 16% in Contra Costa and Barcelona, respectively.

RESULTS

Injury patients who reported drinking during the 6 hours prior to the injury event were asked who they were drinking with during this time and the places where they were drinking (not shown). Males who reported drinking during this time were most likely to report drinking with friends in all three samples. Among females, those in the Contra Costa and Mexico City samples were also most likely to report drinking with friends while those in Barcelona most often

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Table 1.

Demographics and Drinking Characteristics of Injured

Contra Costa Mexico City Barcelona (1,001) ( 1,688) ( 1,684)

Sex: Male Female

Age: 18-29 30-39 40-49 50-59 60-69 70 +

61 39

71 29

49 51

50 56 39 24 21 18 12 I 1 12 6 I 13 5 3 9 3 2 8

Education: < 8th grade 4 55 High school graduate 51 31 Some college 28 9 College graduate 1 1 6

Marriedharried-like Marital status:

relationship 49 55 Separated 7 2 Divorced 10 I Widowed 4 4 Unmarried 30 38

51 19 8 1

51 4 8 1

37 Unemployed 16 6 8 Drinker:

Male Female

81 70 90 61 81 93 39 41 87

Reported drinking prior to injury: 19 21 16

Males 22 35 24 Females 14 6 7

reported drinking with their spouse. Females in all three samples were most likely to report drinking in their own home, while among males, those in Con- tra Costa were also most likely to report drinking at home, but those in Mexico City most often reported drinking on the street and those in Barcelona were most likely to report drinking in a restaurant or bar.

The place where the injury occurred was asked of both those who did and those who did not report drinking prior to the injury. In all three samples those who reported drinking prior to injury were more likely to report being injured

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in the home of another or in a restaurant or bar compared to those who reported no drinking prior to injury. In Barcelona those who reported drinking were also more likely to be injured in a motor vehicle than those not drinking. Differences in place of injury by drinking status were found between males and females in all three samples, as seen in Table 2.

Patients were asked the number of drinks they consumed during the 6 hours prior to injury (Table 3). In both Contra Costa and Barcelona the largest proportion of injured consumed only one or two drinks during this time. How- ever, in Mexico City the largest proportion among both males and females reported consuming at least 11 drinks during the 6-hour period.

Table 4 shows the length of time between the last drink and the injury. In both Contra Costa and Mexico City the majority of those who reported drinking prior to injury consumed their last drink within an hour of the injury event, while in Barcelona the largest proportion reported between 1 and 2 hours between the last drink and the injury.

About half of those in Mexico City reported feeling drunk at the time of the injury event, compared to 15% in Spain and 29% in Contra Costa (Table 5) ; however, only 60% of those who reported being very drunk at the time in the Mexico City sample believed the event would not have happened if they had not been drinking, compared to 93 % in Contra Costa and all of those in the Barcelona sample (Table 6).

DISCUSSION

The purpose of this paper was to compare the context in which drinking occurred prior to an injury event and related drinking-in-the-event variables in three samples of emergency room patients from countries which exhibit known differences in cultural context and associated patterns of drinking. It was there- fore expected, in this analysis, to also find distinct differences in the context and pattern of drinking prior to injury among these three samples, and the data reported here suggest this to be the case.

In the Mexico City sample, drinking prior to injury was most likely to occur with friends and in the street for males and with friends in their own home for females. Drinking among males was associated with injury occurring in public places or on the street. A third of both males and females reported consuming 11 or more drinks during the 6 hours prior to injury. They were more likely to report a close proximity of drinking to the event and were also more likely to report feeling drunk at the time of the event, but less likely to attribute a causal association of drinking with the event compared to those in either the Contra Costa or Barcelona samples.

In the Barcelona sample, on the other hand, drinking with friends and in a restaurant or bar was most often reported among males while drinking with

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Table 2.

Place of Injury for Those Who Did and Did Not Report Drinking Prior to Event (in percent)"

Total

Contra Costa Mexico City Barcelona

No No No Self-rep self-rep Self-rep self-rep Self-rep self-rep

Place (187) (797) (442) (1,222) (263) (1,385)

Own home 30 26 13 22* 21 34* Home of another 16 8* 6 2* 4 1* Restaurantlbar 6 0.5* 3 0.5* 4 0.6* Workplace 5 33* 6 23 12 10 Motor vehicle 12 12 7 10* 10 5* Stredpublic place 20 13* 60 33 * 42 37 Recreational area 11 7 4 9* 5 8*

Males

Place Self-rep

(131)

No self-rep (467)

Own home Home of another Restaurantlbar Workplace Motor vehicle Street/public place Recreational area

24 17 7 6

15 20 12

19 6* 0.4*

43 * 12 13 7

No No Self-rep self-rep Self-rep self-rep (413) (768) (204) (633)

12 11 17 25* 5 I * 4 2 3 0.5 5 0.6* 7 30* 14 14 7 9 10 7

62 34* 43 35* 4 13* 5 12*

Females

No No No Self-rep self-rep Self-rep self-rep Self-rep self-rep

Place (56) (330) (29) (454) (59) (752)

Own home 45 37 31 41 36 42 Home of another 14 11 17 4 3 1 Restauranubar 4 0.6 6 0 3 1 Workplace 2 18* 3 10* 5 7 Motor vehicle 5 14* 6 I I 12 4 Street/public place 21 12 34 32 41 40 Recreational area 9 7 3 24* 0 4*

"This table excludes 17 Contra Costa, 24 Mexico City, and 36 Barcelona patients on whom these data were not obtained. *p < .05 (comparison of proportions between those who did and those who did not report drinking prior to the injury within each sample). Su

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Table 3.

Amount Consumed during Six Hours Prior to lnjuty (in percent)'

Total

Number Contra Costa Mexico City Barcelona of drinks (176) (420) (248)

1-2 3 4 5-6 7-10 11+

47 18 15 6

14

18 17 10 20 34

65 21 7 4 2

Males

Contra Costa Mexico City Barcelona (120) (394) (192)

1-2 39 18 60 3-4 19 17 23 5-6 18 10 8 7-10 8 21 5 11+ 17 35 3

Females


1-2 3-4 5-6 7-10 1 1 +

64 16 11 2 7

26 82 26 14 13 4 7 0

30 0

aThis table excludes 14 Contra Costa, 24 Mexico City, and 15 Barcelona patients on whom these data were not obtained.

their spouse at home was most common among females. Drinking among males was associated with injuries sustained in a restaurant or bar or in the street or other public place. Both males and females were most likely to report just one or two drinks prior to injury and to report between 1 and 2 hours between the last drink and the event. They were also less likely to report feeling drunk at the time of the injury but were more likely to attribute a casual association of drinking with the event than those in either the Contra Costa or the Mexico City sample.

The majority of those in the Barcelona sample reported light drinking prior to injury with a small proportion reporting feeling drunk at the time (15%) in a

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940 CHERF'ITEL ET AL.

Table 4.

Length of Time between Last Drink and Injury (in percenVa

Total

Contra Costa Mexico City Barcelona Hours (178) (412) (25%

< I 1 2 3-6

58 15 11 16

63 17 8

12

34 43 9

14

Males

Contra Costa Mexico City Barcelona (122) (386) (20 1 )

< I 63 1 14 2 7 3-6 16

64 17 7

1 1

36 44

8 13

Females


< 1 46 1 16 2 20 3-6 18

50 6

16 28

26 41 13 19

"This table excludes 12 Contra Costa, 32 Mexico City, and 4 Barcelona patients on whom these data were not obtained.

Table 5.

Feeling Drunk at Time of Injury (in percent)a

Reported Contra Costa Mexico City Barcelona drunkenness (183) (444) (258)

Not drunk Somewhat Very

71 21

8

52 85 31 10 11 5

'This table excludes 8 Contra Costa and 5 Barcelona patients on whom these data were not obtained.

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DRINKING IN THE INJURY EVENT 94 1

Table 6.

Believed the Event Would Have Happened by Reported Drunkenness at Time of Injury (in percent)a

Reported drunkenness

Contra Costa Mexico City Barcelona

Somewhat Very Somewhat Very Somewhat Very Would have happened (39) (14) (151) (45) (26) (12)

Yes No Not sure

59 0 36 35 27 0 33 93 5 1 60 42 100

8 I I 6 31 0 ~

a This table excludes 17 Mexico City patients on whom these data were not obtained.

country where daily light drinking, most often with meals, is the norm. In the Mexico City sample, much larger amounts of alcohol were reported in closer proximity to the injury event with almost half of those who reported drinking prior to injury also reporting feeling drunk at the time of the event; this in a country where infrequent but larger amounts per occasion is common. Interest- ingly, all of those who reported being very drunk in the Barcelona sample felt the alcohol contributed to the injury event, but only 60% of those who were very drunk in the Mexico City sample felt this to be the case.

Cross-cultural comparative analyses between countries must take into account cultural differences in definitions of such qualitative concepts as drunkenness or causal attribution. Considering the amount of alcohol consumed during the 6 hours prior to injury in the Mexico City sample and the close proximity of drinking and the event, one might have expected a larger proportion in this sample to have reported feeling very drunk at the time of the event. These data were all obtained from self-reports at the time of the emergency room visit. While it could be argued that data on drinking prior to injury and alcohol’s role in the event may be differentially reported among cultures with varying drinking patterns and contexts of drinking, prior analyses of these three samples found equally high validity for self-reported alcohol consumption prior to injury as measured by breathalyzer reading at the time of ER admission (Cherpitel et al., 1992).

Drinking companions and places of drinking, places where injury was most likely to occur in relation to drinking, amount consumed, proximity of drinking to injury, perceived drunkenness at the time, and causal attribution of drinking with the injury event were found to vary among these three samples. These data suggest that the context in which alcohol is involved in the injury event is affected by the context in which alcohol is usually consumed in a culture and is important to bear in mind in analyzing alcohol’s role in injury

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occurrence. If situations which may be considered high-risk for alcohol-related injuries vary across cultures in relation to the usual context in which alcohol is consumed in the culture, both alcohol policy and prevention efforts (personal and environmental) aimed at reducing alcohol-related injuries must also vary across cultures in response to cultural contexts of drinking in order to be effective. Similarly, the training of emergency room personnel to identify those patients in the ER who may be at greater risk of alcohol-related injury and other alcohol-related problems must likewise vary across cultures. Finally, alcohol’s role in injury occurrence is known to vary for different kinds of injury, and future research is needed to explore differences in associations of alcohol and casualties for various types and causes of injury in cultures with varying contexts of drinking.

ACKNOWLEDGMENTS

Work in the United States was supported, in part, by a National Alcohol Research Center Grant (AA-05595) from the U.S. Institute on Alcohol Abuse and Alcoholism. Work in Mexico was supported by the Instituto Mexican0 de Psiquiatria and the Consejo Nacional de Ciencia y Technologia. Work in both the United States and Spain was supported by the U.S.-Spain Joint Committee for Scientific and Technological Cooperation Grant (CCA-85 10/040). Collabo- rative support was provided, in part, by the U.S. Institute on Alcohol Abuse and Alcoholism’s International and Intergovernmental Affairs Program.

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THE AUTHORS

Cheryl J. Cherpitel, R.N., Dr.P.H., received her Dr.P.H. in epidemiology from the University of California, School of Public Health, Berkeley. She is presently a senior scientist at the Alcohol Research Group in Berkeley where she has conducted a number of studies on the epidemiology of alcohol and casualties in emergency room populations. In addition to many publications in this area, Dr. Cherpitel has also published on the validity of self-reported alcohol consumption based on breathalyzer readings, alcohol consumption in primary care populations, and variables associated with drinking during pregnancy and pregnancy outcomes.

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Albert Paris, M.D., Ph.D., received his M.D. and Ph.D. in medicine from the University of Barcelona, Spain. He has specialized in Internal Medi- cine, Gastroenterology and Intensive Care Medicine, and is presently a staff member at the Alcohol and Liver Units of the Hospital Clfnic and Pro- vincial, University of Barcelona, where he has carried out epidemiological studies on alcohol consumption and clinical studies on alcoholic liver disease, hepatic fibrosis, and

fibrogenesis. In addition to many publications in these fields, including alcohol consumption in emergency room populations, he has also published clinical research reports on other liver diseases, particularly primary biliary cirrhosis.

Juan Rodis, M.D., is Professor of Medicine in the University of Barcelona and Director of the Liver Unit of Hospital Clinic i Provincial of Barcelona. He has conducted research in several aspects of liver diseases particularly alcohol and the liver, complications of hepatic cirrhosis, chronic hepatitis, and hepato- cellular carcinoma. The number of publications in the field of hepatology in the last 20 years has been approximately 200 original papers published in medical journals, and he has written more than 40 book chapters and has edited more than 15 books in English, Spanish, and French. Dr. Rod& was president of the European Association for the Study of the Liver in 1991 and at present is the president of the International Association for the Study of the Liver.

Haydie Rosovsky, M.P.H., is a psychologist, and she has been a researcher at the Department of Epi- demiological and Social Studies of the Mexican Institute of Psychiatry since 1976. Since 1986 she has also been head of the Information Center on Alcohol at that Institute. She partici- pated in several studies in the alcohol field in Mexico and has frequently been a consultant for WHO and PAHO. Currently she is a member of the International Collaborative Study

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on Alcoholics Anonymous. She is also a member of the coordinating commitee of the Kettil Brunn Society for Social and Epidemiological Studies on Alcohol. She has published results from her studies on alcohol consumption, alcohol policies and alcohol related injuries, and accidents and violence in Mexican populations in Mexican and international journals.

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Drinking in the Injury Event: A Comparison of Emergency Room Populations in the United States,...

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Transcript of Drinking in the Injury Event: A Comparison of Emergency Room Populations in the United States,...