Women’s alcohol consumption in a Primary Health Care service^*

Consumo de alcohol de mujeres en un servicio de Atención Primaria de Salud

ABSTRACT

Objective:

To identify alcohol consumption patterns in people cared by a Primary Health Care service and verify the association between the patterns and the variables of the sample.

Method:

Our observational study used both the Alcohol Use Disorders Identification Test instrument and a questionnaire with socio-demographic, clinical, and behavioral questions for data collection. We carried out the descriptive and univariate analysis with Kendall and Kruskal-Wallis correlation tests. We introduced variables with p ≤ 0.2 values in the multiple logistic regression – Mann-Whitney test.

Results:

The sample of the study was constituted by 561 women. The analysis results indicated relevant influence for higher patterns of consumption: not having a partner, not having a religion, smoking and drug habits, and having arterial hypertension. Besides that, within each additional year in women’s age, the alcohol consumption decreases.

Conclusion:

We endorsed data that female alcohol consumption is presenting a tendency to increase especially among younger women, this information is essential for the promotion of Primary Health Care.

DESCRIPTORS
Women; Alcoholism; Substance Abuse Detection; Primary Care Nursing; Primary Health Care

RESUMEN

Objetivo:

Identificar el patrón del consumo de alcohol de usuarias de un servicio de Atención Primaria de Salud, examinando la asociación entre los patrones y las variables de la muestra.

Método:

Se trata de un estudio observacional que utilizó el Test de Identificación de Trastornos por Consumo de Alcohol y un cuestionario con preguntas sociodemográficas, clínicas y conductuales para la recogida de los datos. Se realizó un análisis descriptivo y univariado con las pruebas de correlación de Kendall y Kruskal-Wallis. Se introdujeron variables con valores de p≤0,2 en el modelo de regresión logística múltiple – Prueba de Mann-Whitney.

Resultados:

La muestra del estudio estaba formada por 561 mujeres. Los resultados del análisis señalan influencias relevantes en los patrones de consumo más elevados: no tener pareja, no tener religión, consumir tabaco y drogas y padecer hipertensión. Además, con cada año que aumenta la edad de la mujer, su patrón de consumo de alcohol disminuye.

Conclusión:

Se refuerzan los datos de que el consumo de alcohol tiende a aumentar en las mujeres, sobre todo en las más jóvenes, una información fundamental para los cuidados en la Atención Primaria de Salud.

DESCRITORES
Mujeres; Alcoholismo; Detección de Abuso de Substâncias; Enfermería de Atención Primaria; Atención Primaria de Salud

RESUMO

Objetivo:

Identificar o padrão de consumo de álcool de usuárias de um serviço de Atenção Primária à Saúde, verificando a associação entre padrões e variáveis da amostra.

Método:

Estudo observacional que utilizou para coleta de dados o instrumento Alcohol Use Disorders Identification Test e questionário com questões sociodemográficas, clínicas e comportamentais. Realizou-se análise descritiva e univariada – teste de correlação Kendall e Kruskal-Wallis. Variáveis com valores de p≤0,2 foram introduzidas no modelo de regressão logística múltipla – teste de Mann-Whitney.

Resultados:

A amostra do estudo constituiu-se de 561 mulheres. Os resultados da análise apontam influência relevante para maiores padrões de consumo: não ter acompanhante, não ter religião, fazer uso de tabaco e de drogas e ter hipertensão arterial. Além disso, a cada ano acrescido na idade da mulher o seu padrão de consumo de álcool diminui.

Conclusão:

Reforçam-se dados de que o consumo de álcool feminino vem apresentando uma tendência ao crescimento especialmente entre as mais jovens, informação fundamental para a prestação de cuidados na Atenção Primária à Saúde.

DESCRITORES
Mulheres; Alcoolismo; Detecção de Abuso de Substâncias; Enfermagem de Atenção Primária; Atenção Primária à Saúde

INTRODUCTION

The XX century was marked by scientific, technological, educational, and social changes. The female gender had a notable transformation in their social and economic conditions, they have conquested political rights, assured access to education, and gained space in jobs outside their homes. Such changes have caused the redefinition of their social role, which allowed a shift from their status as wife and mother to also workers, increasing the social burden imposed on them(¹).

This search for their own identity and social recognition impacted the family model that caused unfavorable consequences for gender relations. The female double shift brought contradictions and conflicts that probably are involved in their psychogenesis and may be triggers for psychic disorders. The “female freedom” has progressed and also brought with it a higher exposure of women to the risk of consuming alcoholic drinks and drugs in general(¹).

Although the prevalence of disorders related to alcohol consumption (abuse and dependency) is still greater among men (8.6%, nearly 237 million men) than women (1.7%, nearly 46 million women) in the world, these damages may converge in the future(²). In many countries, the convergences of alcohol consumption and related problems were already observed in men and women(²,³,⁴,⁵). We highlight the high rates of abuse and dependence observed in the Americas for both genders: 11.5% among men and 5.1% among women(⁶).

In Brazil, a study investigated the rate of abusive consumption of alcoholic drinks for the periode of 30 days, indicated an 11% prevalence(⁷). A study carried out in the United States(⁸), in a sample of women in their reproductive age, emphasized that 53.6% of the interviewee consumed alcohol and had also episodic heavy use (in 18%) – ingestion of four or more doses of alcoholic drink in a single occasion. Both studies pointed out(⁷–⁸) that younger women tend to drink more, these results are consistent with the estimates that indicate an upward trend to the pattern of women’s alcohol consumption in the last decade, with an emphasis among the youngest(⁹).

Considering the epidemiological data that has been pointing out an increase in the rejuvenation of alcoholic drinks consumption by the female population and the physical and social repercussions of the harmful consumption in the health of that population, it is important that they have access to information regarding the consumption of the substance and that preventive measures are planned to aim to support them, in case they choose to decrease the usage, allowing the expansion of their choices and behavioral changes(¹⁰–¹¹).

Hence, the Primary Health Care (PHC) services are responsible for developing prevention actions in health in Brazil(¹²), constituting itself in a scenario of potentialities for the development of preventive actions of abusive alcoholic consumption in women. Therefore, studies that provide indicators about the pattern of women’s alcohol consumption that search for health care in these spaces are important, mainly when we observe that in Brazil the majority of studies of that nature proposing to investigate this reality(¹³–¹⁴), include people from the male gender in their analysis, making a direct analysis of the female population and its specificities difficult to be performed.

Besides allowing the comprehension of the common characteristics among women that drink, the identification of prevalence of alcohol consumption patterns in the female population offers subsidies for the organization of the Primary Health Care, in order to meet the needs of this population that constitutes the largest portion of users in the services of primary care in Brazil(¹⁵). Therefore, the study aims to identify the patterns of alcohol consumption in women who are attended in a PHC services from São Paulo city, verifying the association between the patterns of the usage and the socio-demographic, clinical, and behavioral variables of the sample.

METHODS

Type of Study

Transversal and observational study.

Setting

The study was carried out in a Primary Care Center (PCC) from the central region of São Paulo city.

Population

An intentional sampling was composed by 561 women that went to PCC for health care participated in the study. The Primary Care Center investigated is located in the central region of São Paulo city and has an area of influence of approximately 40 thousand inhabitants, six teams of family health strategy, and two teams of street consultation(¹⁶).

Selection Criteria

The inclusion criteria in the study were: being 18 years old at the date of the interview or older and accepting participation in the research. The exclusion criteria of the sample were: not being fluent in Portuguese or being pregnant.

We approached the users in different spaces of the health service, such as the reception desk, hallways, and waiting rooms where the woman was invited to participate in the research, and those who accepted were introduced to a reserved space. The interviews lasted 15 minutes on the average.

Data Collection

Five members of the Research and Study Center in Nursing in Additions – Alcohol and Other drugs (NEPEAA in Portuguese) of the Nursing School from the Universidade de São Paulo collected the data in the period from July 2017 to February 2018. These researchers had been previously trained for the interviews and the application of collection instruments aiming the standardization of the procedures. We invited women that attended the PCC in that period, and those who accepted were part of the sample (561).

We applied a questionnaire with socio-demographic aspects (age; sexual orientation; gender identity; color or race/ethnicity; marital status; religion; occupation, and family income by social class) clinical (hypertension; diabetes; cholesterol, and diagnosed mental disorders), and behavioral aspects (drug consumption (type, frequency, and quantity); smoking habits (frequency and quantity); and the type of alcoholic substance of preference) to characterize the sample.

We used the Alcohol Use Disorders Identification Test (AUDIT)(¹⁷) instrument to identify the alcohol consumption pattern. The AUDIT is an instrument composed of ten questions and, according to the participant’s punctuation, it helps to identify four different patterns of alcohol consumption: low-risk consumption (untill 7 points – zone I); risky consumption (from 8 to 15 points – zone II); harmful consumption (from 16 to 19 points – zone III); and likely to dependence (above 20 points – zone IV). The questions approach participant’s personal consumption habits and the consequences of alcohol consumption in their lives. The AUDIT instrument is validated in the Brazilian version(¹⁸).

Data Collection and Analysis

For the analysis, we inserted the data in the SPSS (Statistical Package for the Social Sciences v. 20 Windows) program database, according to previously determined coding. Through the database, we carried out a descriptive analysis of the participant’s distribution according to their pattern of alcohol consumption, which we presented in absolute numbers and percentages, as well as the average of the continuous variables.

To verify the association of women’s alcohol consumption patterns with their social-demographic, clinical and behavioral characteristics, we carried out a univariate logistic regression, utilizing the Kendall correlation test for numeral variations and the Kruskal-Wallis test for continuous variables. All variables that presented p ≤ 0.20 values we introduced step by step in the multiple logistic regression, utilizing the Mann-Whitney test.

Ethical Aspects

This paper is part of a wider study entitled “Short intervention for women that consume alcohol riskily and harmfully” and that it was carried out according to the recommendations of the Resolution n. 466/2012, from the National Health Council, for research with human beings in Brazil. We submitted the research, and it was approved by the Research Ethics Committee from the Nursing School – USP, under the protocol n. 1,969,800 and by the Research Ethics Committee from the Secretaria Municipal de Saúde de São Paulo, under the protocol n. 2,083,958, both from the year 2017.

RESULTS

The sample of the study is constituted predominantly by women around the age of 43.2 years old (DP = 15.3), heterosexual (n = 529, 94.8%), with brown skin (n = 244, 43.9%), single (n = 210, 49.9%), catholic (n = 247, 44.2%), high school completed (n = 197, 35.1%), formally employed (n = 196, 34.9%), living in a rented or their own house (n = 521, 94.7%), with a familiar income untill a minimum salary¹ (n = 282, 55.4%), as observed in Table 1.

Table 1
Socio-demographic variables description from the sample of this study – São Paulo, SP, Brazil, 2018.

Variables		Interviewees (n)	Percentage (%)	AUDIT average
Sexual orientation	Assexual	6	1.1	2
	Bissexual	11	2	6.09
	Heterossexual	529	94.8	2.93
	Homossexual	12	2.2	12
Color or race/ethnicity	White	202	36.3	3.03
	Brown	244	43.9	3.01
	Black	98	17.6	4.06
	Yellow	9	1.6	2.89
	Indigenous	3	0.5	2
Marital status	Single	210	37.43	3.94
	Married	164	29.23	2.08
	Divorced	60	10.7	3.37
	Widow	48	8.56	1.94
	With a partner	79	14.08	3.96
Religion	Catholic	247	44.03	3.15
	Evangelical	132	23.53	1.5
	None	84	14.97	5.31
	Other	96	17.11	17.65
Family income by social class*	A	1	0.2	17
	B	5	0.98	1
	C	51	10.02	2.61
	D	170	33.4	2.74
	E	282	55.4	3.3

• ^*
  Family income by social class: A: above 20 minimum salaries; B: from 10 to 20 minimum salaries; C: from 4 to 10 minimum salaries; D: from 2 to 4 minimum salaries; and E: till 2 minimum salaries.
Note: (N = 561).

From the reports presented by women, 25% (n = 140) were hypertensive, 9.5% (n = 53) presented high cholesterol, and 21.4% (n = 120) presented some type of mental disorder being treated, in which depression was the most common mental disorder among participants (n = 65, 11.6%). As we can see in Table 2.

Table 2
Clinical variables description from the sample of this study – São Paulo, SP, Brazil, 2018.

Variables		Interviewees (n)	Percentage	AUDIT average
Arterial hypertension	Yes	140	24.96	2.94
	No	421	75.04	3.24
Diabetes	Yes	60	10.7	2.22
	No	501	89.3	3.28
Cholesterol	Yes	53	9.48	1.92
	No	506	90.52	3.28
Mental disorder	Yes	120	21.39	4.65
	No	441	78.61	2.76

Note: (N = 561).

Regarding the behavioral characteristics, 34% (n = 191) of the women practiced physical activity, 17.5% (n = 98) smoked, and 3.6% (n = 20) used illicit drugs, as we can observe in Table 3.

Table 3
Behavioral variables description from the sample of this study – São Paulo, SP, Brazil, 2018.

Variables		Interviewees (n)	Percentage	AUDIT average
Drugs consumption	Yes	20	3.57	15.5
	No	540	96.43	2.72
Smoking habit	Yes	98	17.47	7.15
	No	463	82.53	2.32

Note: (N = 561).

The majority of women declared a low-risk alcohol consumption or abstinence – AUDIT’s zone I (n = 486, 86.6%); in zone II, with a pattern of risky consumption, we had 9,6% of the interviewees (n = 54); the compatible consumption to the harmful usage of drinks – AUDIT’s zone III was in 1.2% (n = 7) of the women, and 2.5% (n = 14) consumed with a probability of dependency of the substance – AUDIT’s zone IV, according to the Figure 1. Regarding the preferably alcoholic beverage for consumption, we found beer (n = 172, 69.1%) in the first place, followed by wine (n = 46, 18.5%), and distilled drinks, such as vodka, pinga, or whisky (n = 31, 12.4%).

Figure 1
Percentage and number of women and their alcohol consumption pattern, according to the AUDIT instrument classification (N = 561).

As a result of the univariate logistic regression, we found an association between a higher score in the AUDIT instrument and being homosexual (p < 0.00), not having a partner (p < 0.02), not having a religion (p < 0.00), having smoke habits (p < 0.00), and other drugs (p < 0.00), and not presenting arterial hypertension (p = 0.04).

The multivariate logistic regression model included in its analysis the variables that presented statistical significance, which are: age, marital status, religion, smoking habits, and other drugs consumption, arterial hypertension, which demonstrated association with the different alcohol consumption patterns of women in this study, as demonstrated in Table 4. The results of this analysis pointed out that there was a significant influence between the consumption of alcohol and the variables: not having a partner, not having a religion, having smoke habits, using other drugs, and having hypertension. Besides that, the analysis also demonstrated that with each additional year in women’s age, the AUDIT score decreases by 2%.

Table 4
Relation between the alcohol consumption pattern and the variables: age, marital status, religion, smoking habit, consumption of other drugs, and hypertension – São Paulo, SP, Brazil, 2018.

Variables	RR*	IC 95%**	p
Age	0.97	(0.96–0.99)	< 0.00
Marital status
With a partner	1
Without a partner	1.31	(1–1.72)	0.05
Religion
Catholic	0.9	(0.63–1.29)	0.57
Evangelical	0.5	(0.32–0.78)	< 0.00
Spiritist	0.81	(0.45–1.48)	0.5
Cristian	0.54	(0.28–1.04)	0.06
Other	0.71	(0.38–1.35)	0.29
None	1
Smoking habit
Yes	2.01	(1.50–2.70)	< 0.00
No	1
Drugs usage
Yes	1.76	(1.12–2.77)	0.01
No	1
Hypertension
Yes	1.54	(1.09–2.19)	0.01
No	1
No	1

• ^*
  RR: Relative Risk.
• ^**
  IC: Confidence Interval.
Note: (N = 561).

DISCUSSION

The majority of the participants in this study were characterized as being mothers, single, and an average age of 43.2 years old, and with a family income equal or inferior to a minimum salary. These results reflect women’s profile that that are cared for in health services in the center of São Paulo, which may be observed, for example, in the population projection of the city hall(¹⁶), in which the majority of women attended at the national health services in the last years, presented between 35 to 44 years old, which coincide with the average age presented by women in this study.

Still, concerning the descriptive profile of the participating women, the number of interviewees that self-reported depression was 11.6%. In a Brazilian study(¹⁹) that also investigated the depression rate among women through self-report found a similar percentage (10.9%). However, considering only the woman’s report about their diagnosis may present differences when compared to what we would observe when using diagnostic methods. That can be observed in a study carried out in Primary Care(²⁰) that used as a method a questionnaire, it has found a depression rate of 19.7% among the female population, thus, we suppose that the percentage of women in this study that present depression may be higher.

The problematic use of alcohol, in other words, those women that presented a risky, harmful consumption of alcohol or with probable dependency, constituted 15.85% of the sample of this study. We did not find any similar study carried out exclusively with the female population in Brazil, however, in a study(¹³) carried out in 2014 in Bebedouro city – SP, that also had as base the application of the AUDIT test in their sample, has identified that 12.9% of the women consumed the substance problematically. This data sustains the possibility of a tendency to the increase of a harmful alcohol consumption pattern among women attended in the PCC services. Converging with this data, the II Nacional Survey of Alcohol and Drugs – II LENAD(²¹) (in Portuguese) indicates for the increase of the rate of women that drinks 5 or more doses in a regular day of consumption, registering that in the year of 2006 it was 17% and in 2012 they represented 27%.

These data reinforce the suggestion that women’s alcohol consumption pattern has been modified with a tendency to be expanded, which has been pronounced specifically among the youngest population. A study with Brazilian data has shown that, in both genders, binge drinking tends to decrease with the progress of the age and increase with the level of education(⁷). In this present study, among the different analyzed group ages, we found that to each additional year in women’s age it is expected an average decrease of 2% in the AUDIT score, reinforcing the tendency to find a superior consumption pattern between younger women.

We suggest that this factor is related to the cultural changes that have been occurring in the daily life of younger women, with an increase in alcohol consumption by this population. Supporting this information, a survey carried out by SENAD(²²) pointed out that 30.6% of students from 10 to 12 years old reported using alcohol in their life. A study(⁵) also indicated an increase in the prevalence of young adults (21 to 34 years old) that practiced abusive alcohol consumption (binge drinking), which this increase was not found in the male population studied, the factor that confirms the decrease in the difference of the consumption pattern between both sexes, approximating women’s consumption to the men.

When we observe the university culture, we note a scenario inclined to the abusive consumption of alcoholic substances(²³) that may be explained by an important process of stress accumulation carried by the students in that phase. Another possible explanation for the high alcohol consumption in younger women would be the change in the view about women that drink that society had, assuming more freedom of choice for their alcohol consumption.

Add to the considerable rate of problematic consumption of alcohol, the study has also found that the alcoholic drink of preference reported by the majority of women in this study is beer (69.1%). This fact may be associated with the low cost, easy access, and wide dissemination of beer consumption through mediatic advertisement, which allows the propagation of announces of substances with low and medium alcohol content in Nacional communication means.

Regarding women’s sexual orientation, those that reported being homosexuals presented an association with a higher average alcohol consumption pattern (p < 0.00) when compared to heterosexual women. In a meta-analysis study published in 2007(²⁴), the authors analyzed the relation between the use of substances (alcohol, cigarettes, and other drugs) by women from different sexual orientations, and we may observe that LGBT+ (Lesbian, Gay, Bisexual, and Transexual among others) younger women also had significantly higher rates of the substances use when compared to heterosexuals (p < 0.00).

This same study(²⁴) entails that although the analyzed articles have the same conclusions about the higher use of substances by the LGBT+ portion of the sample, none of them approached the causes of that phenomenon. A possible explanation for this association is what the author called “minority stress,” also concluded in another research(²⁵) that approaches the stigma experimented by LGBT+ women. Because they suffer prejudices, discrimination, and violence on their sexuality or gender, consequences of a society with a homophobic behavioral pattern, these women carry an increased burden of emotional stress that consequently could result in a higher propensity to alcohol consumption.

The increased burden of emotional stress may also be found in the mother population that does not have a partner. A study indicates that the combination of variables of being single and a mother may be considered causing factors of stress because of the social pressure over the expectation of their role as a woman and as a mother, and the financial and emotional difficulties related to this condition of life(²⁶). Hence, we suppose that this function accumulation may be, again, a factor that induces the abusive consumption of alcoholic drinks, once that the study showed that women that did not have a partner presented an average increase of 37.0% in the AUDIT score when compared with the married one’s or with a partner.

There are other possible explanations for the higher alcohol consumption pattern among single women. We speculate that the recreation activities of single people, in general, involve contexts that propel the use of drinks, being utilized as a factor of socialization, including the search for a company. Or, yet, the fact of not having someone close enough to help to control the consumption of drinks, being possible to end up in a position of higher vulnerability for the abuse of the substance.

Yet on the behavior presented by the women of the study, we observed that when compared to individuals that do not have a religion, evangelicals presented an average decrease of 51% in the AUDIT score. In a Brazilian survey(²¹), religion was indicated as a factor of protection for the improper use of substances among the youngest, and in this study, we identified that protestants presented a decrease even higher in the AUDIT when compared with other religions. This influence on the use of drinks changes according to the beliefs of each religion and the individual’s rigorousness to its principles. We can suggest that for preaching abstinence or the minimum use of alcohol among their followers, protestant religions tend to present low rates of consumption.

Women that have smoking habits presented an average increase of 135% in the AUDIT score when compared to the non-smokers; among the drug users, we observed an average increase of 122% in the score of the questionnaire when compared to individuals that do not use such substances. It is known that the associated use of alcohol, tobacco, and illegal substances cause a higher risk of developing diseases or premature deaths. A study points out that besides the risk of this associated use, we can observe an even more common relation when we analyze the use among people from the same unfavorable social context(²⁷–²⁸), which corresponds to the profile of the women in this study.

On the clinical data of the sample, we realize that individuals that had arterial hypertension presented an average increase of 52% in the AUDIT score when compared with an individual that did not have the disease. Alcohol can be considered a risk factor for the development of arterial hypertension; relating the abusive consumption of the substance with the blood pressure instability, the grievance of the pathology(²⁹), and an important cause of the treatment abandonment(³⁰), suggesting a deficient posture in the self-care of these individuals and the difficulty in changing the habit of consuming alcohol.

The research has a few limits. We collected all the data through the participant’s reports. For the variables collection, we utilized standardized, validated, and translated to Portuguese language instruments, however, some of them, such as the use of drugs, smoking, or presence of depression, were investigated only with the application of questions developed by the author herself, which may have influenced the results.

CONCLUSION

The research reinforces data that suggests that women’s alcohol consumption pattern has been changing throughout the years, with a tendency to increase, especially amongst the youngest. A possible explanation for the high alcohol consumption in younger women would be a change in the view about women that drink that society had, assuming more freedom of choice for their alcohol consumption. Hence, health promotion and preventive actions in primary care services should escort these epidemiological and social transformations.

We associated larger alcohol consumption patterns to women that carry an emotional stress burden, such as prejudices, discrimination, and violence caused by their sexual orientation or accumulation of functions among those who are mothers and single, as the alcohol consumption may be an alternative way of coping with the stress. The PCC health professional team should be aware of these stress factors and, besides attending each case individually, should also reflect upon actions to combat homophobia and support for these women.

• 1
  The minimum wage per month in Brazil corresponds to R$ 1.100,00 reais or U$ 202,68 American dollars according to the Central Bank of Brazil on May 3^rd, 2021.

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Publication Dates

• Publication in this collection
  25 Aug 2021
• Date of issue
  2021

History

• Received
  13 Oct 2020
• Accepted
  16 Mar 2021