Alcohol Problems: A Health Promotion Approach Module Guide

Masters in Public Health

Alcohol Problems: A Health Promotion
Approach
Module Guide

Kirstie Rendall-Mkosi
Lucy Alexander & Nandipha Matshanda (Editors)

School of Public Health
University of the Western Cape

Masters in Public Health

Alcohol Problems: A Health Promotion
Approach
Module Guide


Module Registration Number: 880111
Value of module: 20 credits
Study time required: 200 notional learning hours

Pre-requisites:
Postgraduate Diploma in Public Health or equivalent;
Core modules for the Masters in Public Health

Study Materials for this module:
Module Guide & Module Readings

Module convenor: Kirstie Rendall-Mkosi

Private Bag X17
Bellville
7535

E-mail: ccarolissen@uwc.ac.za
Fax: + 27 21 959-2872
Tel: +27 21 959-2166 or 959-2809

Copyright 2010, by the SOPH, University of the Western Cape. This work is licensed under a
Creative Commons License : Attribution-ShareAlike 3.0.

First published 2004.
This version 2008/2010 (Module Intro)

The vision of the School of Public Health at the University of the Western
Cape is to build the capacity of Public Health workers to transform the health
sector from a predominantly curative, hospital-based service to a high
quality, comprehensive, community-based, participatory and equitable
system. The aim of this module is to enhance the measurement skills required
to achieve these Public Health objectives.

MultiWorks
Design & layout: Cheryl Ontong

CONTENTS

I MODULE INTRODUCTION PAGE
1. LETTER OF WELCOME 1
2 INFORMATION ABOUT THIS MODULE 3
2.1 Module Aims and Rationale 3
2.2 Module Outline 3
2.3 Learning Outcomes 3
2.4 Texts and References 4
2.5 Module Evaluation 5
3 ASSESSMENT 5
3.1 Information about the Assignments 5
3.2 Assignments and assessment criteria for Alcohol 6
Problems: A Health Promotion Approach

II STUDY SESSIONS 8
UNIT 1 INTRODUCTION: ALCOHOL ORIGINS AND USE 8
Session 1 Alcohol: Origins of Use, and Value as a 10
Commodity
Session 2 Patterns of Consumption 17
Session 3 The Theories of Alcohol Use and Addiction 33

UNIT 2 CONSEQUENCES AND APPROACHES TO 41
ALCOHOL PROBLEMS
Session 1 The Consequences of Alcohol Use 43
Session 2 Different Approaches to Alcohol Problems 52
Session 3 The Range of Interventions 58

UNIT 3 POLICY AND ENVIRONMENTAL INTERVENTIONS 63
Session 1 Control through Policy 65
Session 2 Environmental Changes 77
Session 3 Multifaceted Integrated Programmes 84

UNIT 4 ALCOHOL AND THE INDIVIDUAL 96
Session 1 Alcohol Education 98
Session 2 Early Intervention 104
Session 3 Rehabilitation 110

Readings 117
Feedback 121

I MODULE INTRODUCTION

1 LETTER OF WELCOME

School of Public Health (SOPH)
Private Bag X17
Bellville
7535
South Africa

Dear colleague,

Welcome to the ‘Alcohol Problems: A Health Promotion Approach’ module. Since
alcohol abuse can have negative consequences for individuals, families and the
wider society, it constitutes an important public health issue. Unfortunately it is
not as straightforward to deal with on a policy and educational level as other
tobacco, because alcohol can be used with no harmful effect if used responsibly.
In developing countries it is still a neglected problem in terms of prevention and
rehabilitation, with few resources allocated to law enforcement, awareness
raising, and training of service providers and policy makers.

We have purposely introduced the history of the use of alcohol in Southern Africa
at the beginning of the module, as the history has important socio-political,
economic and behavioural influences on current patterns of alcohol use.

The module will help you to develop an understanding of the various
consequences of alcohol abuse and of the research processes used to measure
this. The rest of the module will provide you with approaches to preventing
alcohol problems, ranging from policy and environmental changes to educational
and rehabilitation programmes. Some of the readings were chosen to illustrate
the main concepts of the module using the following themes: youth, women, and
foetal alcohol syndrome.

We hope that you will be equipped to assess alcohol problems in the
communities in which you work and live, and have some realistic ideas on
initiatives involving people in taking control of alcohol sales and consumption.
This is normally demonstrated through the two assignments that are required to
be done for this module.

We hope that you find the module interesting and that you will be an advocate for
putting alcohol problems higher on the public health agenda locally and

SOPH, UWC: Alcohol Problems - A Health Promotion Approach – Mod u le In t rod u ct ion 1

nationally.

We would greatly value your feedback on how you found the experience of
completing the Module. You can let off steam and reflect on what you have
gained from this experience, while letting us know how we could have made the
study experience easier and more useful for you. For your convenience, please
use the Module Evaluation Form located on this site. We suggest you complete
the Evaluation Form soon after you complete the module.

Sincerely

Kirstie Rendall-Mkosi
Module Convenor

2 SOPH, UWC: Alcohol Problems - A Health Promotion Approach – Mod u le In t rod u ct ion

2 INFORMATION ABOUT THIS MODULE

2.1 Module Aims and Rationale

This module is designed to address the following issues:

 The history of the use of alcohol, focusing on developing countries;
 How the burden of disease/injury and social problems relates to alcohol;
 The concepts of responsible drinking, risky drinking, and dependent drinking;
 The different approaches that can inform health promotion strategies to
reduce alcohol related problems;
 Planning interventions on a policy, environmental and individual basis;
 Community based programme planning and development using the Ottawa
Charter as a framework.

2.2 Module Outline

The module consists of four units, each of which is divided into three study
sessions.

Study sessions vary in length, and may take between five and six hours to
complete. The four units are as follows:

Unit 1 - Alcohol Origins and Use.
Unit 2 - Consequences and Approaches to Alcohol Problems.
Unit 3 - Policy and Environmental Interventions.
Unit 4 - Alcohol and the Individual.

2.3 Learning Outcomes

This module is intended to assist you in further developing the following skills and
knowledge.

By the end of this unit, you are expected to be able to:
 Develop tools for planning, monitoring and evaluating alcohol interventions.
 Discuss the shifts in patterns of alcohol use in South Africa, in relation to socio-
political and cultural factors.
 Contrast the benefits and harmful effects of alcohol, particularly in developing
contexts.
 Identify and interrogate measures used in collecting alcohol related data and the


factors which affect them.
 Use these measures critically to identify patterns of use.
 Explain and apply different explanations and theories of alcohol use, addiction
and dependence, and how these theories influence prevention and treatment
approaches.
 Describe and contrast the Harm Reduction and the traditional Preventive
approaches to alcohol problems and their range of relevant strategies.
 Describe the range, requirements and uses of multifaceted integrated
programmes in the control of alcohol problems.
 Show a critical understanding of the role of different agencies (such as
government, media and community involvement) in alcohol intervention.
 Describe ways in which policy can be used to control the use, marketing, cost,
availability and contents of alcohol.
 Describe and assess the concept and technique of the Brief Interventions
strategy to alcohol intervention and assess the requirements for making the
intervention succeed.

2.4 Texts and References

Parry, C.D.H., & Bennetts, A.L. (1998). Alcohol Policy and Public Health in
South Africa. Cape Town: Oxford University Press

You will also be expected to pursue relevant current literature and additional
resource material as required for your assignment tasks. The School of Public
Health provides students with a Reader of just over 400 pages, which contains
the required readings for the module, but not the readings listed under Further
Readings at the end of each session. SOPH pays for copyright for these Readers
per student and therefore cannot offer the Reader as an OER.

Relevant websites

The following websites may be helpful to you in the course of this module:

Web Address Organisation / document
www.mrc.ac.za/adarg/adarg.ht Alcohol and Drug Abuse Research Group –
m Medical Research Council. Can download recent
publications.
http://wn.apc.org/sanca/ South African National Council on Alcohol and
Drug Abuse. Resource centre in Milpark,
Johannesburg.
www.CDA.gov.za Central Drug Authority. Responsible for
implementation of National Drug Master Plan.
www.niaaa.nih.gov/ National Institute on Alcohol Abuse and
Alcoholism – part of the National Institutes of


Health in the USA. Range of resources.
www.adca.org.au/ Alcohol and other Drugs Council of Australia –
NGO representing alcohol and other drugs field.
www.alcohol.org.nz/ Alcohol Advisory Council of New Zealand
www.ccsa.ca Canadian Centre on Substance Abuse
www.ias.org.uk Institute of Alcohol Studies
www.cad.org.za Christian Action for Dependents in South Africa
www.alcoholicsanonymous.org. Alcoholics Anonymous in South Africa
za
www.fasworld.com National Organisation on FAS in Canada

2.5 Module Evaluation

When you come to end of the module, we would be grateful if you could provide
us with feedback on how you found the experience – what was good about it, as
well as things you would like to see changed. A link to the evaluation form is
located on the webpage menu. This feedback will assist us in revising the
module, planning future modules and providing students with appropriate
support.

3 ASSESSMENT

3.1 Information about Assessment

There are TWO compulsory assignments in the module.

The modules are weighted as follows:
Assignment 1: 40%
Assignment 2: 60%

To pass the module:
 You are required to pass both assignments with a minimum of 50%.
 You must have a minimum aggregate of 50% or more for the module.
 If you get below 50% in Assignment 1, you may repeat it once only.
 If you do not pass it second time around, you cannot proceed to Assignment
2 and must repeat the module.
 If you do not achieve 50% in Assignment 2, you repeat the entire module the
following year.

3.2 Assignments for Alcohol Problems: A Health Promotion Approach


ASSIGNMENT 1: A Comparison of Two Approaches to Alcohol Problems
(100 marks; length: 2 500 words) (40% of module result)

Compare “reduction in consumption” and “harm reduction” - the two main
approaches to reducing alcohol related problems at a population level.

Discuss the theoretical origins and main principles of the two approaches.
Describe a concrete example of each approach in action, from the literature.

Then, briefly describe a local setting where drinking takes place and argue for the
use of either one of the two approaches in implementing one specific strategy,
giving reasons for the choice.

Marking Criteria: Assignment 1 Marks
Assignment has a logical structure & is written in an academic style. 10
The approaches and their theoretical origins are clearly distinguished. 30
Appropriate examples are presented. 10
Reasons for choice of approach and strategy are convincingly argued. 30
Insight and creativity is evident. 10
Referencing and Reference List/Bibliography are presented in a recognised
10
academic format.
Total 100

ASSIGNMENT 2: Plan an Intervention for Alcohol Problems
(100 marks; length: 2 500 words) (60% of module result)

Plan a range of appropriate interventions to reduce alcohol related harm for a
specific target group or risky setting in the area where you live or work.

Address the following issues in the discussion of your plan:
a) The community group or setting.
b) Evidence of alcohol related problem/s in terms of patterns of alcohol use, the
social dynamics involved, and the consequences of alcohol abuse.
c) Describe and justify key interventions at a policy, environmental and personal
level that could realistically reduce the risks in this setting.


Marking Criteria: Assignment 2 Marks
Assignment has a logical structure & is written in an academic style. 10
Sound description and analysis of drinking patterns and consequences. 20
Scope, appropriateness to setting and creativity of interventions is evident. 30
Rationale for choices of interventions convincingly argued. 20
Appropriate structures and role players are included in the intervention
10
strategies.
Referencing and Reference List/Bibliography are presented in a recognised
10
academic format.
Total 100


UNIT 1
Introduction:
Alcohol Origins
and Use
Introduction
Welcome to the first unit of this module, which has been designed to present a
contextual background to the topic of alcohol problems in the Southern African
context. The first unit focuses on the history of alcohol in this region, as well as
patterns of consumption and abuse.

Remember that alcohol is no ordinary commodity: so before looking at the
consequences of problematic uses of alcohol, you need to think and read about
its use and meaning to different people. This will lay the foundation for
understanding the difficulties and challenges of designing appropriate legislation
for control of alcohol, and for shifting patterns of alcohol use in different
communities.

There are three Study Sessions in this unit:

Study Session 1: Alcohol: Origins of Use, and Value as a Commodity.

Study Session 2: Patterns of Consumption.

Study Session 3: The Theories of Alcohol Use and Addiction.

In Session 1, we explore the history of alcohol use and production in colonial and
post-colonial Southern Africa, the socio-political and cultural influences on the
use of alcohol in developing countries, and the impact of industrialising alcohol
production in these contexts.

Session 2 provides an overview of the concepts and measures used in
researching alcohol problems, and stresses the importance of understanding
social and cultural patterns of alcohol usage.

8 SOPH, UWC: Alcohol Problems - A Health Promotion Approach – Un it 1

Session 3 focuses on the theories of alcohol use and health behaviour, and
explores how one’s model of understanding alcohol problems influences the
intervention strategies one is likely to choose.

INTENDED LEARNING OUTCOMES OF UNIT 1

By the end of this unit, you should be able to:

 Discuss the origins and shifts in alcohol use in Southern Africa in relation to
socio-political forces.
 Explain the production and consumption of alcohol as an economic activity.
 Identify and interrogate measures used in collecting alcohol related data.
 Identify the patterns of use and other critical factors which promote or limit the
use of alcohol.
 Discuss cultural variables in the measurement of alcohol consumption.
 Explain and apply the different theories of addiction and dependence.
 Describe the influence of these theories on prevention and treatment
approaches.
 Demonstrate insight into possible explanations for alcohol problems.

This unit is important in providing the essential conceptual tools you will need for
addressing alcohol problems using a Health Promotion approach. Commit
yourself to engaging with the tasks, as this is the best way to ensure that you
have internalised new concepts and issues.

SOPH, UWC: Alcohol Problems - A Health Promotion Approach – Un it 1 9

Unit 1 - Session 1
Alcohol: Origins of Use, & Value as
a Commodity
Introduction
This session introduces you to the historical, political and socio-economic issues
surrounding alcohol from the 1800s to the present. We ask you to consider how
alcohol has been used in your own family and to engage in a quick survey of
historical changes in the practices of alcohol production, control and usage in the
colonial and post-colonial contexts.

We look in some detail at the economics of alcohol production in the developing
country context, and who benefits from it, particularly in the Southern African
context. This sets the scene for Sessions 2 and 3, where we consider how
different communities use alcohol today, as well as the patterns of abuse which
have developed from our socio-political past and persist in the present.

A good question to hold in mind while you study this session is:
What political and economic roles has alcohol played, then and now?

Contents

1 Learning outcomes of this session
2 Readings
3 The origins of the use of alcohol
4 Alcohol as a commodity
5 Session summary
6 Further reading

Timing of this session

This session requires you to complete three substantial readings totalling 64
pages and three tasks. It should take you about four hours to complete.


1 LEARNING OUTCOMES OF THIS SESSION

By the end of this session, you should be able to:

 Discuss shifts in alcohol use in Southern Africa in relation to socio-political
forces.
 Explain the production and consumption of alcohol as an economic activity.

2 READINGS
You will be referred to the following readings in the course of this session.

Author/s Publication details Page numbers in
Reader

Room, R., (2002). Ch 2 - Drinking in Developing 339-348
Jernigan, D., Societies: The Economic, Social and
Carlini-Marlatt, B., Cultural Context. In Alcohol in
Gureje, O., Developing Societies: A Public Health
Makela, K., Approach. Helsinki: Finnish Foundation
Marshall, M. for Alcohol Studies in collaboration with
Medina Mora, M., the WHO: 21-36.
Monteiro, M.,
Parry, C.,
Patanen, J.,
Riley, L., Saxena,
S.
Ambler, C. & (1992). Ch 1 - Alcohol in Southern African 1-18
Crush, J. Labor History. In J. Crush & C. Ambler
(eds). Liquor and Labor in Southern
Africa. Pietermaritzburg: University of
Natal Press: 1-35.
Jernigan, D. H. (1999). Ch 9 - Country Profile on Alcohol 167-178
in Zimbabwe. In L. Riley & M. Marshall
(eds.). Alcohol and Public Health in 8
Developing Countries. Geneva: WHO:
157-175.


3 THE ORIGINS OF THE USE OF ALCOHOL

In order to understand the complexities of the meaning and use of alcohol in the
world today, we need to trace its origin and the influences on its use. Alcohol is
no ordinary commodity like milk or bread: because of its psychoactive properties,
i.e. that it affects the brain and influences behaviour, it has been effectively used
and abused across most societies in the world.

Before you start reading, it may be interesting to reflect on your own family’s
values and experience (historical and cultural) of alcohol by doing Task 1.

TASK 1 – Tracing alcohol use in your family

Think of your grandparents or what you know of your great grandparents in the late
1800s and early 1900s.
a) Do you know what norms and values surrounded the use of alcohol in their
time?
b) Were norms (like age, gender, time and place of drinking) influenced by factors
outside of their immediate community, or did they follow their traditions only?
c) What was the drink of choice? Who produced it and how was it distributed?
d) Now think of your current family and answer the same questions for the present
situation, before moving on to question (e).
e) What main factors have resulted in changes in alcohol consumption compared
to 100 years ago?


Now compare your conclusions on the factors that have influenced these
changes with those identified by Room et al (2002). This historical survey
identifies trends in alcohol use which have arisen from our colonial history. As
you read, take note of the economic and social trends which are identified as
significant areas to investigate in a Health Promotion approach to alcohol use.

READING: Room, R. et al. (2002). Ch 2 - Drinking in Developing Societies: The
Economic, Social and Cultural Context. In Alcohol in Developing Societies: A Public
Health Approach. Helsinki: Finnish Foundation for Alcohol Studies in collaboration with the
WHO: 21-36. See pp339-348 in the Reader.

For those of you working in developing contexts, the reading suggests that the
contextual aspects of alcohol usage need to be well understood, and sensitively
handled in the post-colonial era.

Room et al emphasise the historical links between alcohol and political control of
groups of people in colonial Southern Africa. “Alcoholic beverages were …
commonly used as a colonizing force to attract, pay, entertain and control
indigenous labourers” (Room et al, 2002: 24). However, it is also significant that
historically, alcohol followed the same pattern of industrialisation as most other
commodities and that colonies were “… turned into markets for alcoholic
beverages …” (Room et al, 2002: 24).

In South Africa, home-brewed liquor from the rural areas was recognised as a
popular beverage and commodity in the urban areas: it was therefore
commercialised alongside the European-origin malt beer. Although this
challenged the traditional role that women played in brewing the beer, it did not
end their role in brewing and selling liquor in both rural and urban areas. In fact,
many of the shebeens and taverns that serve as important places for socialising,
are owned by women and enable their owners to make an income. Traditional
home-brew is now often sold alongside commercially produced beer, wine and
spirits. Another phenomenon which may arise from contextual factors is the
emergence of different choices of drink being made by different classes of
drinker. Working class people still tend to buy traditional and commercial beer,
and sometimes cheap wine, while those aspiring to a middle class lifestyle
choose only commercial liquor, particularly spirits.

The next reading by Ambler & Crush (1992) traces the use of alcohol in pre-
colonial Africa and Europe, and describes the convergence of the two during the
colonial era in the 19th and 20th centuries. The Temperance Movement which
swept the world in the 1880s, during which authorities and temperance societies
tried to ban the use of alcohol, also had some influence in Southern Africa.

Most striking again is the use of alcohol as a political tool of control by the white
colonialists over the majority black population. The tension facing the authorities
between the potential profits in selling liquor and the need to be in control of


people’s behaviour and movements, is clearly described.

TASK 2 – Consider the impact of the control of alcohol on our society

As you read this chapter, take notes on the effect that past control of access and
sale of liquor has had on Southern African societies today.

In Southern Africa today, it is clear that traditional norms on the use of alcohol
have largely been eroded. This is identified as one of the many reasons for
increased consumption of alcohol, especially in urban areas. In this regard, think
of who produces and sells what alcohol, and the extent of economic gains: in
READING: Ambler, C. & Crush, J. (1992). Ch 1 - Alcohol in Southern African Labor
History. In J. Crush & C. Ambler (eds). Liquor and Labor in Southern Africa.
Pietermaritzburg: University of Natal Press: 4-35. See pp 1-18 in the Reader.

other words, who benefits from the increased use of alcohol today?

Clearly liquor selling and use is an integral part of all communities in Southern
Africa and needs to be accepted as such. Any attempt to regulate harmful
consumption needs to take this history and economic reality into account. In
relation to the economic aspect of the industry, we will discuss the current Liquor
Act in South Africa in Unit 3, and the way in which it attempts to formalise the
production and sale of liquor. In part, this Act attempts to increase the controls on
liquor, while at the same time expanding its economic potential, by increasing the
number of licensed sellers, and relaxing the times of operation.

4 ALCOHOL AS A COMMODITY

The production and sale of alcohol is an important aspect of the economy in
many countries, and developing countries are no different. However, owing to the
transitional nature of their economies, much alcohol production and sale in
developing countries takes place informally, making it difficult for the authorities
to regulate and tax these transactions.

Some countries have state-run alcohol production, resulting in direct revenue to
the government, such as the beer halls in Zimbabwe. Other countries have a few
large commercial companies producing and selling liquor, which are directly
taxed on their sales. These operate alongside and interact with many
unregulated small outlets, such as in South Africa and Nigeria, where it is difficult
for the government to ensure that tax is paid.

The economics of alcohol production and marketing is critical to understand:
Task 3 offers you a chance to consider the issue in your local context before
reading about it at national and global levels.

TASK 3 – The economic importance of alcohol in your area

Consider the town or city in which you live, and try to list all the different kinds of
producers and sellers of liquor.

a) What proportion are informal sellers and what proportion are formal
sellers?
b) Where do they get their stock? Is it brewed on site or is it bought from a
wholesaler?
c) Do you know who owns the wholesaler and where the various liquors are
produced? If not, try to find out.
d) What are the numbers of people benefiting from the production and sale of
alcohol - ranging from the managing director and shareholders of the
holding company, to the shebeen owner?
e) What is the geographical spread of liquor outlets? Are there more in
working class areas than in middle class areas, or less?
f) What do you conclude about the importance of alcohol as a commodity in
your area?

There is unfortunately a lack of research and ongoing surveillance data to
confidently describe alcohol production, consumption and consequences in
Southern African countries. This includes South Africa which is ranked as a
middle-income country and therefore could be viewed as more able to monitor
and control issues around alcohol. Understandably Zimbabwe, a low-income
country with a legacy of political use of alcohol similar to South Africa, faces
many more serious challenges than the control of alcohol.

The next reading by Jernigan (1999) highlights the dilemmas of Zimbabwe with
regard to alcohol. Liberalisation of the market economy, under pressure from the
International Monetary Fund (IMF) and World Bank, has resulted simultaneously
in increased production and advertising of alcohol, and reduced controls on
sales, especially in the rural areas. The article also describes the monopoly that
exists on traditional and non-traditional alcoholic beverages and the relationship
of these to the government of Zimbabwe, and to the South African monopolies.


READING: Jernigan, D.H. (1999). Ch 9 - Country Profile on Alcohol in Zimbabwe.
In L. Riley & M. Marshall (eds.). Alcohol and Public Health in 8 Developing
Countries. Geneva: WHO: 157-175. See pp167-178 in the Reader.

Jernigan applies his conclusions to developing countries in general, emphasising
the need for “… monitoring, research and exchange of experience regarding
alcohol policies in developing country contexts. … Without this [he concludes],
there is a strong chance that, as in Zimbabwe, alcohol will be left to the market to
regulate” (Jernigan, 1999: 171).

5 SESSION SUMMARY
In this session, you have considered contextual influences on alcohol production
and consumption. Through the readings, you have hopefully gained some insight
into the socio-political history of alcohol and the economics of production and
consumption in Southern Africa. If you consider the numbers of people that
benefit from alcohol production, it is clearly not to be ignored as a commodity in
the market. However, bear in mind that we have not yet discussed alcohol in a
balanced way, by looking at the negative consequences of the use of alcohol and
the costs thereof.

In the next session, we introduce you to the concepts used for measuring
consumption and the importance of understanding the patterns of use in a
community. We also consider the consumers’ perspective on when, how much,
with whom, and where they choose to drink.

6 FURTHER READING

 Mager, A. (1999). The First Decade of “European Beer” in Apartheid South
Africa: The State, the Brewers and the Drinking Public, 1962-72. Journal of
African History, 40: 367-388.
 Haworth, A. & Acuda, S. W. (1998). Sub-Saharan Africa. In M. Grant (ed.).
Alcohol and Emerging Markets. Patterns, Problems and Responses. USA.
International Centre for Alcohol Policies: 19-56.
 Riley, L. & M Marshall. (1999). Country Profile on Alcohol in South Africa. In
Alcohol and Public Health in 8 Developing Countries. Geneva: WHO:
135-156.


Unit 1 - Session 2
Patterns of Consumption
Introduction
In the first session, we introduced the socio-political and economic issues related
to alcohol production and consumption. In this session, the focus is on
consumption and patterns of usage.

As you well know, there is plenty of variation in the consumption of alcohol from
one person to the next. How do we measure and monitor the use of alcohol by
an individual, or in a group, a community or at a societal level? What methods
and indicators can be used by health promoters to measure these different levels
of consumption, and what are some of the factors that promote or limit alcohol
use? Hopefully by the end of this session you will be clearer about these issues,
and the dilemmas we face in measuring alcohol use. There are a lot of tasks in
this session: try to engage with them, to ensure that you grasp the “essential
tools” or concepts you need for working in this field.

Contents
2 Readings
3 Concepts and measures of consumption
4 Identifying patterns of drinking
5 Norms for drinking
6 Session summary
7 References and further reading

This session contains eight fairly short readings totalling 32 pages, and six tasks.
It is a very important session, so you should work through it thoroughly. It could
take you at least four hours to complete.




 Explain some of the key terms used to describe alcohol consumption and
patterns of use.
 Identify and interrogate measures used in collecting alcohol related information.
 Discuss cultural variables in the measurement of alcohol consumption.
 Describe the patterns of use and other critical factors which promote or limit the
use of alcohol.

2 READINGS

Reader

Roche, A. M. & (1998). Ch 13 - The Implications of 315-338
Evans, K. R. Drinking Patterns for Primary Prevention,
Education, and Screening. In M. Grant &
L. Litvak (eds). Drinking Patterns and
Their Consequences. USA: International
Centre for Alcohol Policies: 243-265.
Parry, C.D.H., (2002). Alcohol Use in South Africa: 297-304
Bhana, A., Myers, Findings from the South African
B., Plϋddemann, Community Epidemiology Network on
Flisher, A.J., et al. Drug Use (SACENDU) Project. Journal of
Studies on Alcohol, 63(4): 430-435.
Claasen, J. N. (Sept. 1999). The Benefits of the CAGE 57-62
as a Screening Tool for Alcoholism in a
Closed Rural South African Community.
South African Medical Journal, 89(9):
976-979.
Flisher, A. J. et al. (2001). Substance Use by Students in 121-130
South Africa, Tanzania and Zimbabwe.
African Journal of Drug & Alcohol
Studies, 1(2): 81-97.
London, L., Nell, (1998). Health Status Among Farm 187-194
V., Thompson, M- Workers in the Western Cape – Collateral
L. & Myers, J.E. Evidence from a Study of Occupational
Hazards. South African Medical Journal,
88(9): 1096-1101.


Croxford, J. & (Sept. 1999). Alcohol Consumption by 63-68
Viljoen, D. Pregnant Women in Western Cape.
South African Medical Journal, 89:
962-965.
Bennett, L. A., (1993). Boundaries Between Normal and 39-46
Janca, A., Grant, Pathological Drinking: A Cross-Cultural
B. F. & Sartorius, Comparison. Alcohol Health & Research
N. World, 17(3): 190-195.
Heath, D. B. (2000). Drinking Occasions: Comparative 149-154
Perspectives on Alcohol and Culture.
USA. International Centre for Alcohol
Policies: 191-198.

3 CONCEPTS AND MEASURES OF CONSUMPTION

Measuring the consumption patterns of alcohol at community or countrywide
level is not an easy exercise. As discussed in Session 1, the production and sale
of alcohol ranges from regulated to unregulated, which makes measurement at
the point of sale difficult. In addition, consumption patterns vary considerably
from person to person, as a result of a myriad of influences.

The terminology used in measuring drinking includes the following concepts
amongst others: dependent drinkers, risky drinking, drinking patterns, regular and
harmful use of alcohol, absolute and average alcohol content and drinking
occasions. We will discuss the use of these concepts in the course of this
session.

At this point it may be useful to define what we mean by dependent drinking and
risky drinking:
“Alcohol dependence” refers to a user’s experience of tolerance to alcohol,
withdrawal symptoms such as an acute craving for alcohol and trembling,
relief drinking to take away the withdrawal symptoms, loss of control, and/
or compulsive drinking, which is a compelling need to consume alcohol.”
(American Psychiatric Association, 1994)

Risky drinking refers to a drinking level that (at a particular time) that could
lead to negative consequences., These are often dependent on the
individual, his or her sex, alcohol tolerance and the environment.

Alcohol problems are usually discussed in terms of the quantities of alcohol used.
Setting aside cultural norms of what constitutes problem drinking at this point, we
face the dilemma of how to measure it. This is a conceptual dilemma which must
be resolved at the outset and we will now explore it further.


3.1 Two Models for Measuring Alcohol Usage

It has been found that the total per capita intake of alcohol, or even the weekly or
monthly intake by an individual, is not a particularly useful measure in
addressing alcohol problems. Can you think why?

Faced with an individual’s total consumption or even their weekly or monthly
intake, how can you know whether they are engaging in problem drinking? Do
they drink most of their intake over one continuous occasion as in binge drinking,
or do they drink a little each day? Total consumption is meaningless in this
context. A more meaningful way to measure drinking is to focus on and measure
drinking occasions or events when drinking takes place, rather than measuring
total individual consumption.

Another way to measure alcohol intake is represented by Model A below. How
useful do you think it would be to you in assessing problem drinking in a
community? (Remember that the significance of a model is that it represents the
way we understand something: it therefore influences the interventions we
propose.) Model A is often used to elucidate drinking: it is a continuum stretching
from Non-use to Harmful use. The scale implies little or no intake on the left and
heavy usage on the right.

Model A

A Model of Alcohol Usage

Non-use Experimental use Occasional use Regular use Harmful use

(The Public Health Bush Book, 1999:1.53)

In this model, the continuum is based on the assumption that we can identify
people’s average consumption and locate them on the continuum. The model
also implies that Harmful use is one stage more serious than Regular use,
implying that only very frequent use or dependence are the problem areas.


TASK 1 – Analyse a model of alcohol consumption

Why do you think Model A is problematic as a tool for identifying risky drinking in a
community?

FEEDBACK

This model is questionable, because it equates drinking at the harmful level, (i.e.
drinking which could result in problems) with high consumption or dependent
drinking. In fact many people who use alcohol occasionally or experimentally, do
so in a harmful way, perhaps in a binge fashion. In addition, there are many more
risky drinkers than dependent drinkers, and the dependent drinkers are more
likely to practise harm minimisation strategies.
If this model were to be used in isolation to understand a situation of alcohol
consumption, it is likely that interventions would target the Regular users in
particular, to prevent them from reaching the Harmful use end of the continuum.
This suggests that there would be little or no focus on the broad range of
drinkers, nor on occasional or experimental binge drinkers, nor on the specific
occasions of drinking. Such interventions would only target a small number of
people rather than the occasions when people from across the spectrum indulge
in risky drinking.

Thus far we have noted that neither total nor average consumption are
particularly helpful in identifying problem or harmful drinking, which is what we
are mainly interested in. This model is therefore not that helpful.

Model B

A more recent model discussed by Roche & Evans (1998) in the reading
mentioned below advocates a shift away from a focus on average consumption,
to a focus on drinking patterns and the risks involved in some of them. The
concept of a drinking pattern implies describing the amount, regularity and
context in which alcohol is used, while drinking occasions are those events
during which alcohol is used “in one sitting”. In using this model, our interventions
would aim to reduce the potential harm of drinking occasions, regardless of the
individual’s average or total intake, and to promote the beneficial aspects of low
levels of social drinking in a safe environment.

To assist you in reading the paper with focus, try Task 2. The paper covers more
than we are presently addressing in this session, but you will also find it helpful
when you start your first assignment; so remember to return to it.

Focus on the eight conceptual shifts that have influenced the way alcohol

problems are addressed, as well as on the discussion of “Contextual Issues”.
Take note of Table 13.1 on page 249, in which the authors describe three levels
of perspective on alcohol problems: their model focuses on the meso or middle
level perspective. This perspective implies that one should “[f]ocus on particular
episodes of drinking in which individuals or community are harmed or placed at
risk” (Roche & Evans, 1998: 249). The section on “The Continua of Risk”
presents their model, which is seen as “alternative or complementary” to the
traditional model (Roche & Evans, 1998: 254).

READING: Roche, A. M. & Evans, K. R. (1998). Ch 13 - The Implications of Drinking Patterns
for Primary Prevention, Education, and Screening. In M. Grant & L. Litvak (eds). Drinking
Patterns and Their Consequences. USA: International Centre for Alcohol Policies: 243-265.
See pp 315-338 in the Reader.

Task 2 – Using a complementary model to measure alcohol problems

a) Summarise the conceptual shifts in describing alcohol problems which are
covered in this paper: what does each imply about the data we collect to
describe or measure alcohol problems?
b) What do you believe to be the value of the meso level perspective when
dealing with alcohol related problems?
c) What sort of data must be collected in the “risk level” model presented by the
authors?

FEEDBACK

Here is some selective feedback:
a) We have summarised the conceptual shift termed “Alcohol as an Exception to
Population Health Control Concepts”. Alcohol, because of its nature,
(intoxicating, able to produce dependence in some individuals), does not fit
the usual Public Health approach of advocating reduction at the population-
wide level: instead of gathering data on average or total consumption, this
shift implies that patterns of use and drinking occasions should be described.
b) The meso level perspective focuses on patterns of consumption and drinking
occasions, thereby addressing the specific risks caused by this particular
substance.
c) You will find these data listed at the bottom of page 254.

In order to describe patterns of alcohol use in a community or society, we need to
pose a series of questions relating to the when, where, who, how, what, and why
of alcohol use. The trends in alcohol use that shift over time can also be traced
through answering these questions for different decades. Read the short chapter
by Heath to understand the contribution of qualitative data in the understanding
of alcohol patterns.

READING: Heath, D. B. (2000). Drinking Occasions: Comparative Perspectives on
Alcohol and Culture. USA: International Centre for Alcohol Policies: 191-198. See
pp 149-154 in the Reader.

The dilemma as to which model is more useful or whether they should be used in
combination will be discussed again in Unit 2; but keep it in mind when reading
about the measures currently being used to quantify alcohol use, and their
consequences. The next important concept that we will discuss is the alcohol
content in different drinks.

3.2 Alcohol Content and Risky Drinking

Absolute alcohol content (or pure alcohol) is a quantity measured as a
percentage of a volume of an alcoholic beverage. Different countries use slightly
different measures for a “standard drink”. The amount of alcohol per standard
drink (usually a commonly used size for serving each type of beverage) is
calculated as a percentage, and as an absolute amount in grams (ranging
between 6g and 16g of pure alcohol, but more usually around 11g or 12g). The
range of different alcohol contents is detailed in the table below.

HOW MUCH ALCOHOL IS THERE IN ONE DRINK?
Drink Average alcohol Size of one drink Absolute alcohol
content (%volume) (typical serving) content (g)
Malt beer (lager) 5% 340ml 12
Sorghum beer 3% 500ml 12
Cider 6% 340 ml 16
Cooler / grape 5-10% 340ml 12
Wine 12% 120ml 11
Sherry 17% 50ml 7
Liqueur 30% 25ml 6
Brandy, whisky, 43% 25ml 11
gin, vodka, cane
(Adapted from Parry & Bennetts, 1998: 129)

To quantify the amount of absolute alcohol taken by a person, the type of drink
and the number of standard drinks needs to be recorded. A calculation can then
be done to find the absolute alcohol intake, e.g. two glasses (120ml) of wine
(11g) = 2 x 11g = 22g of alcohol.

When blood alcohol concentration (BAC) is measured, it is expressed in g/ml.
The legal limit for driving in South Africa is 0.05g/100ml or 50mg/100ml. This is
roughly the level after drinking two beers, or two glasses of wine, or a double tot


of spirits.

Risky drinking can be understood as: five (5) or more standard drinks for males
on any one occasion, and three (3) or more standard drinks for females on any
one occasion. However, depending on the safety of the environment and the
tolerance of the individual, negative consequences could arise after even fewer
drinks e.g. A man doing scuba diving could have impaired judgement after only
two drinks, resulting in his drowning.

3.3 Sources of Data

It is necessary to use various sources of data when describing levels and
patterns of consumption of alcohol. These sources may be based on routine data
collection such as police statistics, occasional surveys, or health service records,
treatment centres and mortuaries. Inevitably many of these sources measure the
consequences of alcohol abuse and only indirectly, the amount of alcohol
consumed, e.g. Measuring the blood alcohol level of bodies in a mortuary gives
an indication of the level of alcohol use before death.

While it is possible to gather information on alcoholic beverage sales from the
formal liquor companies and to calculate crude per capita alcohol use over a
specific period of time, this does not, as we have seen, give sufficient information
on the nature of drinking habits, nor on the consequences of harmful drinking.

To get a broader overview of the range of sources of data, read the article by
Parry et al (2002) which presents the findings of a study of alcohol usage in
South Africa over a four year period. Focus on the questions in Task 3 as you
read.

READING: Parry, C. D. H. et al. (2002). Alcohol Use in South Africa: Findings from
the South African Community Epidemiology Network on Drug Use (SACENDU)
Project. Journal of Studies on Alcohol, 63 (4): 430-435. See pp 297-304 in the
Reader.


TASK 3 – Limitations in various methods of describing alcohol use.

As you read the article by Parry et al (2002), try to answer this question:
To what extent is SACENDU able to provide an accurate picture of alcohol
consumption and its effects in South Africa?

Use these sub-questions to do your analysis:
a) Identify all the studies and sources referred to in this paper, the methods used
and the populations which fall into the samples.
b) Which sources have inherent biases in them, and which are less biased?
c) Are there other sources or methods which you think could provide better
information on which to base policies and interventions?

FEEDBACK

Check your responses to questions (a) and (b) here.
a) The main sources of information referred to in this paper are:
1. The South African Demographic and Household Survey.
2. An epidemiological study on foetal alcohol syndrome (FAS).
3. A study of the drinking habits of a group of people in jail.
4. AOD (Alcohol and other drugs) treatment centres’ profile of their
patients.
5. National Violence and Injury Surveillance study.
6. Survey of high school students’ drinking habits.
7. Study of the blood alcohol content in a sample of people arrested.

b) Limitations and possible biases in the studies:
A major issue in any behaviour-related study is the use of self reported
information. Drinking alcohol is a behaviour that is likely to be under
reported, owing to the stigma of drinking too much, or not being in control
of one’s behaviour. It is also difficult to quantify alcohol intake because of:
differing alcohol content in different beverages (ranging from 3% to 49%),
styles of drinking (e.g. passing a vessel around), and the sizes of glasses
or other vessels used. The studies where blood alcohol level is measured,
or a breathalyser is used, give a more accurate picture of the person’s
current alcohol intake but cannot be used to describe the pattern of
drinking of the individual.

The majority of the studies focus on the major cities and therefore exclude
most of the rural population. In some provinces, the rural population is
higher than the urban, and therefore a significant section of the population
is not reflected in the studies, e.g. in the Eastern Cape and Limpopo
Provinces.

Another issue is whether the data on treatment in a particular year is

representative of a population. Although treatment centres report various
trends in the types of drugs used, ages of patients, etc, one needs to
consider critically what part of the population gets admitted to treatment
centres, or uses an outpatient facility. Poorer people, women with
dependents and people in outlying areas are likely to experience problems
in accessing these services. So again, the trends should be viewed with
caution as they do not represent all those who may need treatment, but
only those who have accessed treatment.

What did you conclude about the SACENDU initiative?
In the absence of data that is collected in a systematic and standardised way,
and bearing in mind the limitations of each of the data sources contributed at
SACENDU meetings, the information can be used to understand only some
trends, and inform policy on some specific problems.

3.4 Screening for Alcohol Problems and Alcohol Dependence

By now you will have realised that a person can have problems as a result of
using alcohol without necessarily being dependent on it (or being classified as an
“alcoholic”).

The CAGE screening tool (which stands for Cutting down, Annoyance at
criticism, Guilty feelings and use of Eye-openers) is commonly used in the
screening of people to detect possible alcohol problems or dependence. As can
be seen in the article by Claasen (1999), the tool can also be used as part of a
survey to gather information at the level of alcohol problems in a particular
community.

READING: Claasen, J. N. (Sept. 1999). The Benefits of the CAGE as a Screening Tool
for Alcoholism in a Closed Rural South African Community. South African Medical
Journal, 89 (9): 976-979. See pp 57-62 in the Reader.

When combined with a few other questions, the CAGE screening tool can
provide a clearer picture of the place, time, amount, alcohol of choice and
company in which people drink. These patterns, as well as the extent of
problematic drinking, could be established through this sort of cross sectional
survey, bearing in mind the difficulty of getting honest answers from people.

Other commonly used screening tools are the MAST (Michigan Alcoholism
Screening Test) and the AUDIT (Alcohol Use Disorders Identification Test). Both
of these use responses to a number of questions related to a person’s drinking
patterns. The scoring is designed to give the clinician or researcher a sense of
the level of use of alcohol in terms of potential harm to the individual or others
around them. The MAST is more useful in identifying dependent drinkers while

the AUDIT is used for categorising levels of problem drinking.

4 IDENTIFYING PATTERNS OF DRINKING
A critical part of understanding alcohol use is analysing data based on specific
groups of people who live, work or naturally congregate together. Most such
studies, focusing on individual beliefs and behaviour regarding alcohol, engage
specific age groups or those in particular settings, and involve the surveillance of
alcohol patterns and consequences.

In this section, we will explore two studies, one of which focuses on drinking
patterns within a particular age cohort (Flisher et al, 2001), while the other
(London et al, 2001) concentrates on a particular setting, a fruit farm in the
Western Cape.

If the young people in the Flisher study and the farm workers in the London study
had only been asked about their average weekly consumption, it is likely that no
problematic drinking would have been identified. It is the binge nature of drinking
practised by both these groups that results in high levels of risky drinking. It is
therefore necessary to collect information that describes how much is drunk in
one occasion and how frequent these occasions are. The factors encouraging
more risky drinking are also of interest if meaningful preventive interventions are
to be made.

4.1 Measuring Usage by Age Group

In developing countries, we are particularly concerned about the beliefs and
behaviours of young people regarding alcohol. The factors influencing the
experimentation and regular use of alcohol amongst youth are complex and need
to be examined from various angles.

The paper by Flisher et al (2001) demonstrates how classroom based surveys
can be used to gauge the knowledge, beliefs and practices of school-going
youth. If repeated every few years, the trends of age of first use of substances,
frequency, amount consumed and gender differences can then contribute to the
design of educational and life skills programmes. Appropriate policies around
access to and control of the amount of alcohol consumed, and the enforcement
thereof, could also be made more realistic.

Factors such as access to money, religious norms and the stage of societal
development are all used to explain the differences between the rates of use of
substances in the three cities in Flisher et al’s paper, i.e. Cape Town, Harare,
and Dar es Salaam, and the difference of use between the sexes. It must be
noted, however, that since the studies for each city were not identical, and the


analysis for this paper is based on extrapolation, the results are difficult to
generalise beyond these particular cities or urban areas.

READING: Flisher, A. J. et al. (2001). Substance Use by Students in South Africa,
Tanzania and Zimbabwe. African Journal of Drug & Alcohol Studies, 1 (2): 81-97.

TASK 4 – Measures of alcohol consumption

After reading this paper on substance use by students, answer the following
questions:

a) What are the main measures of substance use in the questionnaires?
b) What do the different time periods imply?
c) What are the main conclusions of the study and how would this inform
prevention programmes in those places?

4.2 Measuring Usage in Relation to Setting

Another important way to conduct research on people who drink is through a
focus on the occupational setting. This article by London et al (2001) describes a
study assessing the occupational hazards for a group of male fruit farm workers
in the Western Cape. Alcohol consumption was found to be an important co-
factor in poor nutrition, rate of head injuries and exposure to pesticides. Focus on
Task 5 while you read it.

READING: London, L., Nell, V., Thompson, M-L & Myers, J.E. (1998). Health
Status Among Farm Workers in the Western Cape – Collateral Evidence from a
Study of Occupational Hazards. South African Medical Journal, 88 (9): 1096-1101.


TASK 5 – Assessing further measures of alcohol consumption

While reading this paper, which includes a focus on alcohol use by male farm
workers, answer the following questions:
a) What are the main measures of alcohol use in the study?
b) Are the data collection tools more reliable than the questionnaires used in the
previous study? Why?
c) What does the information about the length of time spent working in the
agricultural setting tell us?
d) What role could the patterns revealed in this study play in guiding a Health
Promotion intervention in this context?

4.3 Measuring Drinking Patterns with Surveys & Self-reported Habits

The article by Croxford & Viljoen introduces you to a survey method of assessing
drinking patterns, based entirely on self-reported data; it also introduces the
phenomenon of foetal alcohol syndrome (FAS).

READING: Croxford, J. & Viljoen, D. (Sept. 1999). Alcohol Consumption by
Pregnant Women in Western Cape. South African Medical Journal, 89: 962-965.

The study reported in the article aimed to assess alcohol use by pregnant women
in three under-resourced areas of the Western Cape – two of them small towns
and one within the Cape Metropole. The sample of 636 women was drawn from
17 antenatal clinics across the three areas, and each woman was interviewed
once only. In this study, the collection of demographic information was important
in order to establish whether, amongst these pregnant women, there are
subgroups (for example based on age, socio-economics or geographical
location) that drink more heavily than others.

The results provide a useful description of women attending clinics in
predominantly coloured areas. The dominant characteristics of the group were:
between 20 - 30 years of age; single (57%); Christian (72.8%); with formal
education between 8-10 years. As high as 42.8% admitted to varying degrees of
alcohol ingestion during pregnancy with beer being the drink of choice (91.5%);
the drinking pattern was of a “binge” nature. Smoking was reported by 45.6%
altogether, and 29.6% admitted to smoking and drinking. This left only 41.2 % of
women using neither alcohol nor cigarettes.


This is important data on which to base interventions to reduce drinking in
pregnancy, and can also serve as a baseline to compare to after a few years. It is
also alarming to realise from the data that up to 9.5% of the women were at risk
of having a child with FAS or a milder version thereof (ARND – alcohol related
neurological defects).

Even though honesty is an issue when it comes to self-reported data relating to
alcohol use and smoking, the authors report that it seemed not to be a concern in
this study.

5 NORMS FOR DRINKING
One of the issues that every researcher should be aware of when measuring
alcohol consumption is the concept of what is regarded as normal drinking in a
particular community. The relationship between alcohol and culture, and
specifically what is viewed as normal and not-normal drinking, differs widely in
different areas of the world. It is also important to recognise that people are
strongly influenced by such norms, e.g. We keep spirits for special occasions like
dances, and people get very drunk.

The reading by Bennett et al (1993) provides an insight into “how people from
different cultures differentiate between normal and pathological drinking”
(Bennett, 1993: 190), which is in itself a major influence on drinking patterns.

READING: Bennett, L. A., Janca, A., Grant, B. F. & Sartorius, N. (1993). Boundaries
Between Normal and Pathological Drinking: A Cross-Cultural Comparison. Alcohol
Health & Research World, 17 (3): 190-195. See pp 39-46 in the reader.

The paper also summarises what we covered in our discussion of patterns of
consumption. Although there are no simple explanations or descriptions of
drinking patterns for any community, the author gives some means to answering
the when, where, who, how, what and why of alcohol use. As you read it, try to
answer the questions in Task 6.


TASK 6 – The effects of alcohol: descriptors used in your community.

After reading this paper, consider the following questions:

a) What are the main questions that have been asked in this paper on the effects of
alcohol?
b) Apply the same questions to members of your own community and write down your
responses in a similar way to the results in tables 2 and 3.
c) Which community in the study is most similar to your community and why do you
think this is so?
d) What are some of the factors which influence drinking patterns?

FEEDBACK

When doing a situational analysis in order to plan any intervention related to
alcohol problems, it is essential to have a sense of the prevailing norms around
drinking alcohol. If people in the community do not view risky drinking in the
same way as you do, you will have difficulty involving them in any prevention or
harm reduction programme. Any interventions need to bear in mind the status of
the drinkers as well as the facilitating and inhibiting factors in relation to who
drinks where and how much on any occasion.

6 SESSION SUMMARY
In this session, we have looked at a range of data sources and methods for
measuring and describing alcohol use, through a number of studies. Hopefully
you have recognised that there are limitations in all the sources of data, but that
together they can provide quantitative and qualitative information to understand
the alcohol problems and possible prevention possibilities.

Hopefully you are convinced that it does not help to just monitor the average
consumption of a population as this tells us nothing about the where, when, how
much and why of individual and group drinking habits. In this regard, remember
that more harm is caused by drinkers who occasionally become intoxicated (risky
drinkers) than dependent drinkers.

You may have concluded that both quantitative measurements and qualitative
descriptions are necessary in order to have a full picture of alcohol use patterns
in any community or target age group. You will possibly also have noted that


some methods are more accurate than others, but that they may carry the
disadvantage of cost or skill required to use them, e.g. Gamma-
glutamyltransferase (GGT) tests.

You have also started to apply some research questions to your own community
and should have begun to build a picture of their patterns of alcohol
consumption. In addition, you should be able to identify the economic forces that
operate in that context, from the information in the previous session.

In the final session of Unit 1, we introduce you to the debates around alcoholism
and the effect that different models of understanding people with alcohol
problems has on our prevention and treatment approaches.

7 REFERENCES AND FURTHER READING

 American Psychiatric Association. (1994). Diagnostic and statistical manual
mental disorders, fourth edition. Washington, DC: American Psychiatric
Association.
 The Public Health Bush Book: A Resource for Working in Community
Settings in the Northern Territory. (1999). Darwin: Northern Territory Health
Services.
 Parry, D. H. C. & Bennetts, A. L. (1998). Alcohol Policy and Public Health in
South Africa. Cape Town: Oxford University Press.
 WHO. (1999). Global Status Report on Alcohol. Geneva: Substance Abuse
Department, Social Change & Mental Health, WHO.


Unit 1 - Session 3
Theories of Alcohol Use and
Addiction
Introduction
Although most of this module focuses on moderate alcohol use consumed in a
risky pattern, it is also important to discuss consumption which occurs as a result
of a dependency relationship between an individual and alcohol.

Much of the emphasis in the past was on “the alcoholic”, while little emphasis
was placed on other consumers. Before you read any further, choose the
description of alcoholism which you believe to be correct:

A person who is addicted to alcohol (an alcoholic):
- has a disease called “alcoholism” or
- has developed a habit that cannot be controlled.

This question remains debatable, so read the interesting articles that follow and
then reflect on your own understanding of alcohol addiction.

While we are focusing on individual alcohol use, we will also apply two of the
well-established theories of Health Behaviour, in order to understand the
interrelationship of various factors in the decision to drink and the level of
drinking.

Contents
2 Readings
3 Models for understanding alcohol problems
4 Theories of Health Behaviour
5 Session summary
6 Further reading



In this session there is only one task, and the task requires you to start
addressing issues in your local context. There are also four fairly long readings
totalling 63 pages. Allow at least four hours to complete the session.



 Explain and apply the different theories of addiction and dependence, i.e. the
medical, psychological and sociocultural theories.
 Describe how these theories influence prevention and treatment approaches.
 Apply selected theories of Health Behaviour to alcohol use.
 Demonstrate insight into possible explanations for alcohol problems.

2 READINGS

the Reader

Fingarette, H. (1988). Ch 3 - What Causes Alcoholism? 95-108
In Heavy Drinking: The Myth of
Alcoholism as a Disease. Berkeley,
California: University of California Press:
48-69.
Edwards, G., (1997). Ch 11 - Drinking Problems and 79-86
Marshall, E. J. & the Life Course. In Treatment of Drinking
Cook, C. C. H. Problems: A Guide for the Helping
Professions. Cambridge, UK: Cambridge
University Press: 175-185.
Tones, B. K. & (2001). Ch 2 - Selecting Indicators of 437-446
Tilford, S. Success: The Importance of Theories of
Change. In Health Promotion:
Effectiveness, Efficiency and Equity.
Cheltenham, UK: Nelson Thornes: 74-93.
Morojele, N. (1997). Ch 12 - Adolescent Alcohol 257-270
Misuse. In C. de la Rey, N. Duncan &
T.Shefer & A. van Niekerk (eds).
Contemporary Issues in Human


Development. A South African Focus.
Johannesburg: International Thomson:
207-232.

3 MODELS FOR UNDERSTANDING ALCOHOL PROBLEMS

Many academic modules on substance abuse would begin with the theory of
alcohol consumption and alcoholism as it applies to individuals. In this module
we have purposely covered the environmental approach (meaning socio-political,
cultural and economic issues) to addressing alcohol problems first. The reasons
for this will become clearer as we proceed through the units. However, the main
reason is that we are taking a Health Promotion approach, focusing on alcohol
use and problems from a risky drinking/harm reduction perspective and
balancing the environmental variables with individual factors.

It is, however, necessary to understand the theories which are applied to alcohol
problems: this will enable you to choose which model you personally accept as
the most useful explanation for alcohol dependence, and to identify the most
likely set of factors influencing this behaviour.

Read the chapter by Fingarette (1988) in which the author questions the various
explanations of alcoholism; then review your answer to the question we asked
when we began this session.

READING: Fingarette, H. (1988). Ch 3 - What Causes Alcoholism? In Heavy
Drinking: The Myth of Alcoholism as a Disease. Berkeley, California: University of
California Press: 48-69. See pp 95-108 in the Reader.

Whether you believe in the concept of an alcoholic, and that it is a disease with
genetic influence and physiological explanations, will directly influence your
approach to prevention and treatment. Many treatment programmes, including
the Alcoholics Anonymous organisation, base their approach on the premise that
if a person has had the problem of alcohol dependence, they will remain an
“alcoholic in recovery” forever. This is what we call the Disease Model: it tends to
focus on the individual and that “pathology” to the exclusion of the culture and
context in which the person drinks.

An alternative perspective is to view alcohol consumption on a continuum, where
anyone may drink at a light, moderate or heavy level, occasionally or regularly.
Authors such as Fingarette prefer to explain drinking patterns from a social and
cultural perspective and reject the notion of a univalent disease. For them there
is no single causal explanation. This is called the Sociocultural Model and
suggests that heavy drinkers, whose drinking is causing problems, need to be
individually understood and not automatically classified as “mentally ill” with

alcoholism.

A combination of the psychological hypothesis and the sociocultural explanation
is most likely to lead to a treatment approach that balances the necessity for
individual counseling with making changes in the norms the people under
treatment accept and the context of their drinking.

The DSM IV Criteria for making a diagnosis of alcohol dependence are stated in
the reading by Morojele (1997: 213). This classification system for mental health
problems attempts to aid clinicians and researchers to diagnose problems in a
standardised way. But as Morojele suggests in the article you will read later in
this session, the classification system is not always applicable to adolescents. It
may also not be applicable to those of other ages in populations outside of
Western developed countries. As you read about the DSM IV Criteria, consider
the example of an unemployed man with no pattern of daily activities: he
probably does not drive and does not own anything substantial. Most of the
criteria are not applicable to him, despite the fact that he spends a lot of time
drinking every day, and is at risk of developing long-term health problems.

READING: Edwards, G., Marshall, E. J. & Cook, C. C. H. (1997). Ch 11 - Drinking
Problems and the Life Course. In Treatment of Drinking Problems: A Guide for the
Helping Professions. Cambridge, UK: Cambridge University Press: 175-185. See
pp 79-86 in the Reader.

Despite there being little consensus between various follow-up studies of people
with alcohol dependence, Edwards proposes some factors which could be used
to indicate potential for recovery in the long term: these include baseline
characteristics, acceptance of a treatment goal, treatment and AA support and
natural processes of recovery. Rather than supporting any intensive treatment,
Edwards proposes that “… it is the nudging of the person towards a more
constructive way of seeing things, the encouragement of self-actualisation and
the enhancement of self-efficacy, help with choice of appropriate goal, and the
alliance between therapeutic intervention and natural processes of change, that
research suggests are in the long-term the most potent contributions which
treatment can make to recovery” (Edwards, 1997: 182). We will revisit this
approach in Unit 4, when we discuss the role of service providers in carrying out
“Brief Interventions” with people with alcohol problems.

4 THEORIES OF HEALTH BEHAVIOUR
Whether your interest in alcohol and health is at the individual level or the
broader population level, it is necessary to be able to describe the factors that
promote and inhibit alcohol use at the individual level. Since alcohol use can vary

so much from one person to the next, one needs to be able to describe these
individuals as part of a sub-group, and have an understanding of what the critical
factors are that influence their drinking pattern, in order to plan appropriate
interventions.

An important stage in the development of a Health Promotion response to
alcohol related problems is to have a theory through which to understand the
underlying factors or determinants. Various health behaviour models were dealt
with in the Health Promotion II module and will not be revised here. However, I
have found the Health Action Model proposed by Tones and Tilford to be useful
when describing the factors influencing alcohol use, and understanding possible
points for intervention.

This chapter by Tones and Tilford (2001) was also included in the Health
Promotion II module, so you may recognise it. Although it is quite densely written,
and is not specific to alcohol issues, the references to drug use can be applied
equally well to alcohol use. After looking at the diagram on page 78, focus your
reading on the “Theory at a micro level” on pages 84-93, and the critique thereof
on page 77 under “Gaining insights into client characteristics”.

READING: Tones, B. K. & Tilford, S. (2001). Ch 2 - Selecting Indicators of
Success: The Importance of Theories of Change. In Health Promotion:
Effectiveness, Efficiency and Equity. Cheltenham, UK: Nelson Thornes: 74-93.

Below is another version of the Health Action Model (HAM) which was presented
at a short course at UWC by Sylvia Tilford in 2002.


Tilford, S. (2002). Health Action Model. Slide from School of Public Health Winter School,UWC.

The next reading has been included because Morojele (1997) gives some
explanation and theoretical argument for substance use by adolescents, and its
potential harmful consequences. In addition to reading the content of what she
writes, take note that this paper provides an example of how to apply theory to a
particular group. You could use it as a model when you conduct your own
research.

Morojele’s focus on adolescents is also important in that the population pyramid
in developing countries indicates that a third or more of the population is under
15 years old. It is partly for this reason that we have included in this unit the
survey of student substance use in Session 2 as well as the reading by Morojele.
While the article by Flisher et al (2001) gave some self-reported rates of use of
various substances, Morojele’s chapter goes further towards theorising in relation
to the determinants of substance usage. Focus your reading primarily on pages
215-224 and consider whether you are convinced by his theoretical application
and proposed intervention strategies.

READING: Morojele, N. (1997). Ch 12 - Adolescent Alcohol Misuse. In C. de la Rey, N.
Duncan & T.Shefer & A. van Niekerk (eds). Contemporary Issues in Human
Development. A South African Focus. Johannesburg: International Thomson: 207-232.

TASK 1 – Apply the Health Action Model to a familiar group.

Select a specific group within your community for consideration, e.g. young men,
adult farm workers, pregnant women or teachers.

a) Refer to the Health Action Model diagram and attempt to explain the factors
that influence the drinking of alcohol among your chosen group. Insert key
words that describe your target group under each of the main sections of the
diagram provided.

FEEDBACK

Your work on this task could be used in your second assignment, so check the
assignment requirements and file your work on this task for future use.

5 SESSION SUMMARY
In this session we have considered different arguments relating to ways of
understanding alcohol problems, and emphasised the influence that this
understanding has on your intervention strategy. We have also introduced
several theories of Health Behaviour which can be applied to the study of alcohol
problems, and you applied one of them to members of a familiar community of
drinkers.

This concludes the first unit of this module, which has hopefully given you a
foundation in three important areas in the study of alcohol problems:

 Contextual aspects of alcohol usage.
 Useful measures and data in researching alcohol usage.
 Key theories of alcohol usage and Health Behaviour and their influence on
intervention strategies.


In the second unit, we focus on the harm and benefits of alcohol use and
consider various Health Promotion approaches to alcohol problems.

6 FURTHER READING
 Edwards, G., Marshall, E. J. & Cook, C. C. H. (1997). Ch 1 - Causes of
Drinking Problems. Treatment of Drinking Problems: A Guide for the Helping
Professions. Cambridge, UK: Cambridge University Press.


UNIT 2 Introduction
Consequences
and Approaches
to Alcohol
Problems

Introduction

Welcome to Unit 2, in which we focus on some of the consequences of alcohol
problems and explore different approaches, strategies, levels and sites of
intervention, and the importance of using integrated strategies.

Study Session 1: The Consequences of Alcohol Use.

Study Session 2: Approaches to Alcohol Problems.

Study Session 3: Types and Levels of Intervention.

In Session 1, we explore the benefits and consequences of alcohol and risky
drinking on the individual, and on particular social groups as well as at a broad
social and economic level.

Session 2 provides an introduction to the conceptual shift which has taken place
from the so-called Preventive to the Harm Reduction or Harm Minimisation
Approach.

Session 3 focuses on the possible levels and types of intervention within a
strategy to address alcohol-related problems.

By the end of the unit you should be in a position to tackle your first assignment.

Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Unit 2 41



 Explain why the harm related to alcohol outweighs the benefit, particularly in
developing contexts.
 Discuss the range of social and health problems caused directly or indirectly by
alcohol use.
 Identify specific high risk contexts, groups or behaviours linked with alcohol
usage.
 Contrast the Harm Reduction approach with the traditional Preventive approach.
 Give a rationale for the Harm Reduction approach.
 List a range of strategies applicable to the two approaches and apply these to a
specific population or setting.
 Summarise a range of policies that can increase control over alcohol and
promote safer usage.
 Identify strategies and interventions at different levels of implementation, e.g. the
meso level.
 Discuss the roles that different agencies can play in interventions, and the value
of integrating strategies.

We hope that you will find the unit stimulating and challenging and that it will
enable you to recognise the important shift in perspective that has taken place in
this field.

42 Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Unit 2

Unit 2 - Session 1
The Consequences of
Alcohol Use
Introduction
In Unit 1, we considered alcohol use in the social context, particularly in the
developing country context. We also introduced the concept of patterns of usage
as well as ways of measuring alcohol consumption, and we explored some of the
theories of use and addiction. As we embark on Unit 2, we are preparing to
explore approaches to addressing alcohol problems. It is therefore important to
consider some of the consequences of alcohol use. This will hopefully also
reinforce your understanding of why it is important to address alcohol use in its
contextual setting, and to identify patterns of usage.

Session contents
2 Readings
3 The benefits and risks of alcohol use
4 Harmful consequences
5 Session summary
6 Further reading


This session includes four readings amounting to about 30 pages. From the May
(1995) reading, you need read only the feedback for Task 3, which is in one of
the tables in the reading (you will be referred to it at the appropriate point). There
are three tasks; the session should take you three to four hours to complete.




 Explain why the harm related to alcohol outweighs the benefit, especially in
developing contexts.
 Discuss the range of problems caused directly or indirectly by alcohol use.
 Identify specific high risk contexts, groups or behaviours linked with alcohol
usage.

2 READINGS

Author/s Reference details Page nos in
Reader
Gureje, O. (Aug, 2000). The Health Claims of 145-148
Alcohol: Contextual Considerations for
Africa and the Developing World.
Proceedings of the Global Alcohol Policy
Advocacy Conference. Syracuse, New
York: The Globe, Special Edition: 33-35.
Parry, C. D. H. & (1998). Ch 3 - The Consequences of 271-282
Bennetts, A. L. Alcohol Misuse. Alcohol Policy and
Public Health in South Africa. Cape
Town: Oxford University Press: 57-76.
May, P. A., (2000). Epidemiology of Fetal Alcohol 223-232
Brooke, L., Syndrome in a South African Community
Gossage, J. P., in the Western Cape Province. American
Croxford, J., Journal of Public Health, 90 (12):
Adnams, C., 1905-1912.
Jones, K. L.,
Robinson, L. &
Viljoen, D.
May, P. A. (1995). A Multiple-level Comprehensive 195-222
Approach to the Prevention of Fetal
Alcohol Syndrome (FAS) and Other
Alcohol-Related Birth Defects (ARBD).
International Journal of the Addictions, 30
(12): 1549-1599.


3 THE BENEFITS AND RISKS OF ALCOHOL USE

Although there is research to support the theory that alcohol has some physical
health benefits, this can only be said to be true when alcohol is taken in low
quantities by people over 40 years of age who have a predisposition to ischaemic
heart disease (ISD).
As Dr Gureje from Nigeria explains in the first reading (2000), the risky effects of
alcohol use in developing countries far exceed the positive effect on ISD. He
points out the main issues in a risk-benefit analysis:
 There are low rates of ischaemic heart disease in developing countries;
therefore there would be a minimal overall reduction effect if low level drinking
in older people was promoted.
 The population distribution and health status is such that the main focus
should be on young people and basic survival needs.
 The drinking pattern in developing countries is generally different to that in
developed countries, with more binge drinking; in addition, the environment in
which people drink is more hazardous.

We should not forget that alcohol can be used safely, and is used safely by many
people. It plays a significant role in celebrations (champagne at various events),
some churches (for communion), as well as in social gatherings. At social
gatherings, it helps people relax, and as long as people drink in moderation, the
risk of negative behaviour is low.

Read the paper by Gureje (2000) and do Task 1 in which you are asked to
decide whether the “contextual considerations” raised by the author apply to the
context in which you work.

READING: Gureje, O. (Aug, 2000). The Health Claims of Alcohol: Contextual
Considerations for Africa and the Developing World. Towards A Global Alcohol
Policy. Proceedings of the Global Alcohol Policy Advocacy Conference. Syracuse,
New York: The Globe, Special Edition: 33-35. See pages 145-148 in the Reader.


TASK 1 – The impact of alcohol consumption on a local community

Read article by Gureje. As you read, note the positive and negative impacts of
alcohol consumption which he discusses.

Record the negative impacts, you will use them in Task 2.

a) To what extent do the negative impacts apply to the community with which
you work?
b) Do you agree with Gureje that “…drinking holds no overall benefit for
Africans today”? (2000: 35).

FEEDBACK

Lack of data may make it difficult to decide whether the so-called health claims of
alcohol are valid in your context; however, it is likely that many of the
consequences noted by Gureje apply to your context. In the next section, we
explore the issue of the harmful consequences of alcohol.

4 HARMFUL CONSEQUENCES
Many of the harmful consequences of alcohol use have already been mentioned
in some of the readings. You will have noted that some of these consequences
are direct, and impact on the individual, their family or others involved with the
individual, through violence or accidents. Others are indirect, resulting in an
economic burden on society through high health service costs or trauma
response, and lost productivity.

Many of the negative consequences of alcohol abuse are associated with
specific groups (age or gender based drinking) while others are associated with
the context of drinking, e.g. work-based drinking resulting in occupational injuries;
drinking while engaging in water sports resulting in drowning, etc.

You could revisit a couple of readings from Unit 1 to reinforce the linkage
between who drinks, where, how much, and the negative consequences that can
follow. There is a useful summary of the consequences of alcohol abuse for
youth in the chapter by Morojele (2000: 214); and the SACENDU paper by Parry
et al (2002: 430 & 431) addresses consequences for adults generally.

4.1 Categories of Harm

It is useful to group the consequences of alcohol abuse into: medical
consequences, e.g. chronic conditions, injuries and accidents; effects on the


family; economic, workforce and social issues, as well as criminal activities.
Obviously, any individual could cause and suffer consequences in more than one
area, but when planning interventions on a population wide basis, it is important
to respond to the kind of data presented by Parry & Bennetts (1998), which
enables you to target areas where problem drinking exercises greatest impact or
damage. As you read this chapter, take notes on the range of consequences of
problem-drinking, particularly for women, using the suggested template in Task
2, which follows.

READING: Parry, C. D. H. & Bennetts, A. L. (1998). Ch 3 - The Consequences of
Alcohol Misuse. Alcohol Policy and Public Health in South Africa. Cape Town:
Oxford University Press: 57-76. See pages 271-282 in the Reader.


TASK 2 – Identify the consequences of problem drinking and consider their
application to a familiar context

Take notes from the article under the section headings, and then consider whether these
consequences apply to the group or setting in which you plan to focus your assignment
and/or work. Take particular note of consequences for women and children, as well as
any which are particular to your context.

Negative consequence Summary of key points in Application to your
reading assignment / work context
Individual (chronic and
injury)
o
o
Individual (social,
economic)
o
o
Family and public
o
o
Economic & social
Development
o
o
Business & work-force
o
o
Criminal justice system
o
o
Other
o
o

FEEDBACK
You may find the summary table you have created a useful reference when you
plan an intervention for Assignment 2. Take note that you have been considering
the consequences of drinking at a social and an economic level, as well as at an
individual medical level; remember that economic consequences are also
conceptualised in terms of family income, losses to private companies and
impact on the national budget in terms of health costs.


4.2 Fetal Alcohol Syndrome

One of the serious consequences of problem drinking is Fetal Alcohol Syndrome
(FAS). This affects up to 5% of people in towns and districts in the Western and
Northern Cape and in other pockets of Southern Africa. A child born with FAS is
permanently affected, and will have lower intellectual functioning than other
children; they will display behavioural problems, and be of smaller stature.

An epidemiological study undertaken in 1999 in the Western Cape confirms the
seriousness of this preventable, yet long term problem: it is a case-control study
and is described in the paper by May et al (2000). Information gathered in this
study provides a starting point for planning FAS prevention programmes and for
identifying women at high risk. Read the article using Task 3 to focus your
reading.

READING: May, P. A., Brooke, L., Gossage, J. P., Croxford, J., Adnams, C.,
Jones, K. L., Robinson, L. & Viljoen, D. (2000). Epidemiology of Fetal Alcohol
Syndrome in a South African Community in the Western Cape Province. American
Journal of Public Health, 90 (12): 1905-1912. See pages 223-232 in the Reader.

TASK 3 - List risk factors for FAS

Read the article by May et al and establish a list of the factors that put some
women at higher risk than others, for producing a FAS baby.

For feedback, you will find most of the key factors listed in the table on page
1562 of the reading by May, P. A. (1995) below. You will read this paper in full
in the next Unit.

READING: May, P. A. (1995). A Multiple-level Comprehensive Approach to the
Prevention of Fetal Alcohol Syndrome (FAS) and Other Alcohol-Related Birth
Defects (ARBD). International Journal of the Addictions, 30 (12): 1549-1599. See
pages 195-222 in the Reader.

5 SESSION SUMMARY

In this session, you have explored the benefits in contrast to the harmful
consequences of drinking. We have focused on a broad range of consequences
of problem drinking, noting the particularly serious impact on women, especially
pregnant women.

The session also aimed to provide you with data similar to that which you may
need when planning interventions. Such data would enable you to understand
more fully the seriousness of the problem within a particular context, and to guide

your strategy for intervention. In Session 2, we consider the Preventive and Harm
Reduction/Minimisation approaches used to intervene in alcohol-related
problems. In the session, we provide a rationale for the latter approach.

6 FURTHER READING

 WHO. (2002). A Summary of Alcohol in Developing Societies: A Public
Health Approach. Management of Substance Abuse Dependence, Non-
Communicable Diseases. Geneva: WHO.


Unit 2 - Session 2
Approaches to Alcohol
Problems
Introduction
This session focuses on the traditional Preventive approach to alcohol problems
and on what is known as a Harm Reduction or Minimisation model, tracing the
shift in perspective in recent years. This change is largely contingent on a shift in
the way we understand alcohol consumption, and refers to a number of the
issues discussed in Unit 1 Session 2 - Patterns of Consumption. The importance
of understanding risky drinking in terms of drinking patterns and drinking
occasions is again raised, suggesting forms of intervention designed to reduce
harm rather than to prevent drinking. This session provides opportunities to do
much of the groundwork for your first assignment.

Session contents
2 Readings
3 The Preventive approach
4 The Harm Reduction approach
5 Session summary


In this session, you are expected to read three texts amounting to about 40
pages, and to undertake three tasks. The tasks constitute useful preparation for
both your assignments. You should already be fairly conversant with the contents
of one of the readings. This session could take you up to four hours to complete.




 Compare the Harm Reduction approach with the traditional Preventive
approach.
 Give a rationale for the Harm Reduction approach.
 List a range of strategies applicable to the two approaches and apply these to a
specific population or setting.

2 READINGS

Reader
Parry, C. D. H. & (1998). Ch 5 - Reducing Per Capita 283-296
Bennetts, A. L. Consumption and High-Risk Behaviours.
Alcohol Policy and Public Health in South
Africa. Cape Town: Oxford University
Press: 103-127.
Grant, M. & (1998). Ch 15 - Shifting the Paradigm: 131-140
Single, E. Reducing Harm and Promoting Beneficial
Patterns. In M. Grant & L. Litvak (eds).
Drinking Patterns and Their
Consequences. USA: International
Roche, A. M. & (1998). Ch 13 - The Implications of 315-338
Evans, K. R. Drinking Patterns for Primary Prevention,
Education, and Screening. In M. Grant &
L. Litvak (eds). Drinking Patterns and
Their Consequences. USA: International

3 THE PREVENTIVE APPROACH

The traditional Preventive approach to alcohol problems is concerned with levels
of consumption and addresses alcohol problems at primary, secondary and
tertiary levels.


 The primary level would include all the general educational strategies aimed
at preventing problems from occurring and encouraging people to consume
low levels of alcohol, or to abstain completely. Primary prevention may be
supported by various policies that restrict access to alcohol.
 The secondary level is aimed at the early detection of problematic alcohol use
by individuals, and the use of counselling to reduce alcohol usage. The
legislation designed to catch drunk drivers is a secpndary level intervention
and could be seen as a punitive approach to reducing consumption by
individuals with occasional or established alcohol abuse.
 Tertiary prevention identifies people who have serious ongoing problems with
alcohol and applies a treatment and rehabilitative approach.
If you refer to the table on pages 106-107 of the next reading by Parry &
Bennetts (1998), you will see a wide range of possible legislative, structural, and
educative strategies, most of them aiming to reduce overall consumption; in
addition there are early intervention strategies at an individual level. Many of
these strategies are in place in South Africa, but have had limited success in
reducing the consequences of alcohol use. This is mainly because many people
do not take the risks seriously and much risky drinking occurs where legislation
cannot be enforced, such as in people’s homes and in unlicensed premises. In
addition, it would require huge resources to implement and enforce these
legislative measures.

Read this chapter, and identify what strategies Parry and Bennetts suggest within
legislation, structural changes, education, and early intervention.

READING: Parry, C. D. H. & Bennetts, A. L. (1998). Ch 5 - Reducing Per Capita
Consumption and High-Risk Behaviours. Alcohol Policy and Public Health in South
Africa. Cape Town: Oxford University Press: 103-127. See pages 283-296 in the
Reader.

Although Parry and Bennetts briefly state that: “ … the two approaches or pillars
of reducing per capita consumption and high-risk behaviours (harm reduction)
are in the end complimentary” (Parry & Bennetts, 1998:107), the strategies they
list are mostly focused on reducing consumption (the Preventive approach)
through population-based control measures. This approach appears to be
predominantly based on research and policies from other countries in the early
1990s, and there is no mention of Harm Reduction strategies. There is also very
little targeting of high risk groups. You will learn about the Harm Reduction
approach in the next section and will be able to compare the strategies
suggested by the Harm Reduction proponents with the ones suggested in the
reading by Parry & Bennetts.


4 THE HARM REDUCTION APPROACH
While some aspects of the traditional Prevention approach continue to be
important, there is growing support for a Harm Reduction approach. This
approach refers to policies and programs that focus on reducing the adverse
consequences of drinking rather than restricting access to alcohol..
The Harm Reduction approach, also known as Harm Minimisation approach,
relies on identifying risky drinking groups and patterns of drinking, and attempts
to mitigate the harm caused by these groups or individuals. The outcomes of this
approach are measured in terms of reduced harm, and not reduced
consumption.

For those who believe that all alcohol use can lead to harm, and that abstention
should be the ultimate goal, a mind-shift towards accepting that people will
continue to use alcohol, is necessary. In addition, one needs to accept that many
people will use high levels of alcohol at times, but that the risks of harm can be
reduced.

Read the chapter by Grant and Single (1998), and identify the Harm Reduction
strategies that they propose.

READING: Grant, M. & Single, E. (1998). Ch 15 - Shifting the Paradigm: Reducing Harm
and Promoting Beneficial Patterns. In M. Grant & L. Litvak. Drinking Patterns and Their
Consequences. USA: International Centre for Alcohol Policies: 287-294. See pages
131-140 in the Reader.

TASK 1 – Identify harm reduction interventions

As you read Grant and Single’s chapter, identify the Harm Reduction strategies
being proposed and consider whether they would be appropriate or possible in a
setting with which you are familiar.

FEEDBACK
Some of the interventions suggested by Grant and Single (1998) are:
 Education on harmful consequences of alcohol.
 Responsible hospitality programmes.
 Measures to encourage quality control of alcoholic beverages.
 Measures designed to ameliorate adverse consequences of intoxication.
 Early identification and simple interventions.
 Controlled drinking programmes as a treatment alternative.

Essentially, Grant and Single are promoting Sensible Drinking guidelines which
go far beyond how many drinks are consumed. They focus, in their words, on “…
the reduction of harmful consequences of reckless drinking rather than on
monitoring individual levels of consumption to avoid dependence” (1998: 297).


You have already read much of the chapter by Roche and Evans (1998) in Unit
1. The authors explore the need for a shift in mind-set from the traditional
Preventive approach (calling it a shift in “gaze” or perspective). They suggest that
those who address alcohol problems need to focus half way between the
population and the individual level at what they term “the meso level”: this would
involve data collection on drinking occasions where harm is caused; identifying
potentially harmful patterns of drinking; and intervention which focusses on
minimising harmful episodes and ensuring environments that facilitate low-risk
drinking. While you revisit this chapter, try Task 2. Note that issues of screening
will be dealt with in Unit 4.

READING: Roche, A. M. & Evans, K. R. (1998). Ch 13 - The Implications of
Drinking Patterns for Primary Prevention, Education, and Screening. In M. Grant &
L. Litvak (eds). Drinking Patterns and Their Consequences. USA: International
Centre for Alcohol Policies: 243-265. See pages 315-338 in the Reader.

TASK 2 – Identifying the points in an argument

As you read the chapter by Roche and Evans, identify the key points in their
argument in favour of the Harm Reduction approach. Take notes as a series of
steps (in the argument) that build upwards to this conclusion. Note the page number
where you found each point in the argument.

FEEDBACK

STEPS IN THE ARGUMENT IN FAVOUR OF A HARM REDUCTION APPROACH

STEP I
Mean levels of drinking and single distribution theory of alcohol consumption have
been abandoned. (p244)

Overall levels of consumption are no longer used to predict risky drinking. (p245)
…and so on.

From the reading by Grant and Single (1998), you identified a set of Harm
Reduction intervention strategies. Roche and Evans (1998) add the following
proposed strategies:

 Appropriate control over access to the product.
 Increased knowledge among consumers and health professionals of the risks
associated with inappropriate use of the product.
 Minimisation of the risk of harms associated with consumption on particular
occasions and under particular circumstances.


TASK 3 – Select appropriate intervention approaches

Return to your analysis of a target group in your community. Consider which
strategies from the Prevention approach and which from the Harm Reduction
approach could usefully apply to this group in order to reduce alcohol related
problems.

Justify your choices in terms of the drinking patterns you have identified and the
potential for these strategies to be realistically implemented in this community.

There is no feedback to this task, but you will find that your work will be helpful in
preparation for your second assignment; so file it safely.

5 SESSION SUMMARY

In this session you have been introduced to the debate concerning the two key
approaches to dealing with alcohol problems – the Preventive approach which
aims to reduce overall consumption, and the Harm Reduction approach, which
aims to reduce harmful consequences of consumption at any level. The authors
who have promoted a “shift in our gaze” provide some interesting food for
thought, and encourage us to consider a less punitive, less “legislative” approach
to alcohol control. Instead, they favour an emphasis on drinking occasions, and
strategies to make the environment less risky, regardless of the level of
consumption. Both approaches incorporate environmental as well as individual
changes to reduce the consequences of alcohol use, but they offer very different
approaches to consumption.

In the third session of this unit, we take up the issue of intervention in more
detail.


Unit 2 - Session 3
Types and Levels of
Intervention
Introduction

Based on what you have covered in Unit 1 and the first two sessions of Unit 2,
you now have some of the necessary insights and skills to investigate and
describe patterns of alcohol consumption, and to access data to understand the
consequences of alcohol use. You have also been introduced to examples of
interventions that are particular to reducing consumption and to minimising
potential harm. We shall now focus on planning interventions, and locating them
at a particular level of society.

In this session, we invite you to consider a broad range of possible interventions
and the different levels at which intervention is possible, i.e. from government
policy to individual counselling. We also encourage you to consider the
importance of an integrated strategy in addressing alcohol-related problems.

Session contents
2 Readings
3 Policies for different levels of intervention
4 Integrated strategies
5 Session summary
6 Further reading


This session requires you study two readings amounting to about 20 pages and
to do two tasks related to those readings; it should take you about two hours to
complete, after which you should be ready to draft your first assignment.




 Summarise a range of policies that can increase control over alcohol, and
promote safer usage.
 Identify strategies and interventions at different levels of implementation, e.g. the
meso level.
 Discuss the roles that different agencies can play in interventions, and the value
of integrating strategies.

2 READINGS

Reader
Room, R., (2002). Ch 9 - Building an Effective 385-398
Jernigan, D., Response to Alcohol Problems. In
Carline-Marlatt, Alcohol in Developing Societies: A Public
B., Gureje, O., Health Approach. Helsinki: Finnish
Makela, K., et al. Foundation for Alcohol Studies in
collaboration with the WHO: 217-228.
Tenth Special (2000). Latest Approaches to Preventing 409-420
Report to the Alcohol Abuse and Alcoholism. Alcohol
United States Research & Health, 24 (1): 42-51.
Congress on
Alcohol and
Health.

3 POLICIES FOR DIFFERENT LEVELS OF INTERVENTION

Across the world, policies have been made and programmes implemented by
both governments and civil society bodies in response to alcohol problems. Part
of the transition from developing to developed country status seems to bring with
it wider use of alcohol and more alcohol related problems. In addition, the
resources to implement policies and programmes that limit these problems are
seldom available (Room et al, 2002: 217). To develop and carry out any strategy,
many different sectors are involved, not just health nor just economic affairs.


Ideally, consistent messages should be developed and co-ordinated with
implementation of educational endeavours and policy formulation. To achieve
this, we need to have an understanding of the spheres of influence exercised by
different levels of government and civil society groupings.

Broadly, national level government can develop policy guidelines, and can assist
with supporting more regional and local initiatives. Where possible, however,
policies and programmes should be adapted to suit the local culture, norms and
values.

In the reading below by Room et al (2002), you will find a useful summary of the
current situation regarding alcohol drinking patterns and problems, and the
economic dynamics involved in most developing countries. Concentrate on the
section that focuses on policy formulation, and the different levels at which
policies are applied.

TASK 1 – Identify different levels of intervention

As you read Room et al (2002), summarise the information in the following
way:

Draw a table in which you list examples of: policies around services, taxing,
alcohol availability, harm reduction and the collection of data. Group these
according to the level(s) that would be most appropriate for the policy to be
developed and implemented: international; national; provincial and local
level.

READING: Room, R. et al. (2002). Ch 9 - Building an Effective Response to
Alcohol Problems. Alcohol in Developing Societies: A Public Health Approach. In
Alcohol in Developing Societies: A Public Health Approach. Helsinki: Finnish
Foundation for Alcohol Studies in collaboration with the WHO: 217-228. See pages

4 INTEGRATED STRATEGIES
In the previous section, we identified the levels at which responsibility could be
taken for various policies and strategies to reduce alcohol related problems. In
this section, we look at examples of particular alcohol related problems e.g.
driving under the influence (DUI), and learn about the necessity for designing a
range of integrated policies and programmes to deal with the same particular
problem.


A tension always exists between factors that facilitate alcohol use, and deterrent
moves on alcohol use. On the one hand, there are the economic benefits of
selling alcohol plus people’s desire to use alcohol. On the other, there is the need
to protect individuals and the broader society from the potential harms arising
from alcohol use. Control measures need to be multi-dimensional and well
coordinated, so that both these factors are taken into account. Essentially, from a
Health Promotion perspective, we aim to reduce the factors promoting harmful
use of alcohol, and to maximise the factors that provide limits, without unduly
affecting individual rights and the economy. These strategies need to be
integrated across different sectors in order to achieve the intended reduction of
harm.

The next reading, the Tenth Special Report to the United States Congress on
Alcohol and Health (2000), looks at a particular problem, i.e. drunk driving. This
reading illustrates why it is necessary to have a variety of strategies, or an
integrated strategy focusing on the same problem. In this instance, a mix of
strategies, consisting of education, restrictions on driving, and improvements to
car safety mechanisms, have all contributed to a reduction in road fatalities
resulting from drunk driving in the USA. Unfortunately, however, many of the
strategies are more difficult to implement in developing countries.

If you are interested in youth and alcohol problems, the community based
interventions mentioned in this reading will also be useful. The effects of on
children and youth of advertising alcohol, is mentioned and will be covered in
more depth in the next unit. Take a look at Task 2 before you start reading.

READING: Tenth Special Report to the United States Congress on Alcohol and Health.
(2000). Latest Approaches to Preventing Alcohol Abuse and Alcoholism. Alcohol
Research & Health, 24 (1): 42-51. See pages 409-420 in the Reader.

TASK 2 – Identify the barriers to integrated strategies

After reading the article, identify the actual strategies used in the USA to reduce
drunk driving and note the effects thereof. Consider each of these strategies and
debate how feasible it would be to implement each in your home province, region
or area.

This sort of exercise could be undertaken in relation to any specific drinking
problem or pattern.


5 SESSION SUMMARY
By this stage, you will be aware of the range of strategies that may be needed to
tackle alcohol-related problems, the importance of an integrated strategy and of
possibility that the responsibility for some parts of these strategies could be
placed at various levels of government or civil society. You have probably also
recognised that any particular problem is best addressed using a variety of
methods that aim for changes in individual awareness and behaviour, as well as
environmental changes.

This is the end of Unit 2: at this point you should be ready to tackle your first
assignment provided that you have worked consistently through the units so far.
Unit 3 tackles the broad level environmental and policy interventions in more
detail, while in Unit 4, we return to strategies for intervention aimed at the
individual.

6 FURTHER READING

 Republic of South Africa. (March 1999). National Drug Master Plan. Drug
Advisory Board. Pretoria: Government Printers.


UNIT 3 Introduction
Policy and
Environmental
Interventions

Introduction

Welcome to Unit 3. This unit focuses on intervention strategies for alcohol
problems targeted at a broad or environmental level. Broad, environmental
approaches are the essence of the role of the Health Promoter or Public Health
practitioner and have great potential for a broad range impact at national,
regional or community level, particularly since alcohol problems derive from a
reciprocally broad range of determinants.

Although Session 1 focuses on policies and Session 2 on environmental
changes, this is really an artificial separation, since many environmental changes
depend on legislation to drive them.

By now, you will be aware that the argument for broad impact strategies also
arises out of the understanding that some of the highest levels of harm are
caused not necessarily by individual dependent drinkers, but also by moderate
drinkers who engage intermittently in high risk drinking practices. In addition, an
environmental approach takes account of the diversity of societies, and places
potential safety nets at different levels for reducing the harm caused by alcohol.

Within this Unit, you will also be reminded of key steps in the planning and
implementation of programmes. Session 1 incorporates community mobilisation
processes, Session 2 includes collection of relevant data on which to base a
prevention programme, and Session 3 includes monitoring and evaluation
activities.


Study Session 1: Control through Policy.
Study Session 2: Environmental Changes.
Study Session 3: Multifaceted Integrated Programmes.

62 Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Un it 3

In Session 1, we focus on alcohol legislation and its enforcement. In dealing with
this, we consider a range of interventions intended to control or limit the coercive
marketing and consumption of alcohol.

Session 2 provides an overview of a range of environmental strategies for harm
reduction and the introduction of alternative activities that can serve to reduce
drinking. Based on these examples, you will consider what would work in your
context.

Session 3 explores the value of multifaceted programmes for addressing alcohol
problems and links this approach to the Health Promotion principles of the
Ottawa Charter. You will again consider the value of this approach to your own
potential target group.



 Describe and assess different countries’ policy interventions to control alcohol
marketing, cost, availability and contents.
 Discuss different approaches to taxing alcohol sales.
 Analyse ways in which alcohol is made attractive to different target groups.
 Demonstrate insight into the process of community involvement in interventions.
 Assess international examples of environmental adaptations to reduce alcohol
intake and alcohol-related harm in local settings.
 Discuss the role of a variety of media in supporting the communication of
alcohol-related policy and environmental changes.
 Discuss the rationale for a multifaceted approach to alcohol problems.
 Apply the Ottawa Charter framework to alcohol interventions.
 Assess the viability of the multifaceted approach to specific contexts of alcohol
use.

Unit 3 provides substantial preparation for your second assignment: while you
work through it, start gathering background information about your target group
and their context, e.g. drinking patterns. This will enable you to engage more
critically and effectively with tasks in the sessions. Many of them refer you to a
range of intervention strategies discussed in the literature and ask you to
consider their applicability in your situation. We hope that you will find some fresh
and challenging ideas in Unit 3 for addressing alcohol problems in your own
Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Un it 3 63

context, as well as an effective way of monitoring and evaluating the impact of
your programme.

Unit 3 - Session 1
Control through Policy
Introduction

One of the key action areas in promoting health is the development of health
promoting policies. We have seen in Session 1 of Unit 2 that there are many
situations in which alcohol abuse can result in harm to the drinker and to others.
How to control alcohol use without totally prohibiting it is one of the dilemmas
faced by governments in trying to limit harm. A balance needs to be struck
between developing and enforcing regulations, and maintaining a free market
and freedom of lifestyle.

In this session you will familiarise yourself with different approaches to alcohol
legislation and control, and analyse the impact of coercive advertising of alcohol,
particularly on young people. You will also consider ways of limiting this impact
and educating drinkers.

Session contents
2 Readings
3 Legislation and enforcement
4 Marketing alcohol
5 Community mobilisation
6 Session summary
7 Further reading


This session contains six readings totalling 93 pages of reading, and four tasks.
You will need to put aside at least six hours to complete this session.




 Describe and assess different countries’ policy interventions to control alcohol
marketing, cost, availability and contents.
 Discuss different approaches to taxing alcohol sales.
 Analyse ways in which alcohol is made attractive to different target groups.
 Demonstrate insight into the process of community involvement in interventions.

2 READINGS

Reader
Parry, C. D. H. & (1998). Ch 5 - Reducing per Capita 283-296
Bennetts, A. L. Consumption and High-Risk Behaviours.
In Alcohol Policy and Public Health in
South Africa. Cape Town: Oxford
Room, R. et al. (2002). Ch 8 - Targeting Environmental 349-384
Change to Reduce Alcohol-Related
Problems. In Alcohol in Developing
Societies: A Public Health Approach.
Helsinki: Finnish Foundation for Alcohol
Studies in collaboration with the WHO:
181-215.
Parry, C. D. H., (June 2003). The Case for an Increased 305-314
Myers, B. & Tax on Alcohol in South Africa. The
Thiede, M. South African Journal of Economics,
71(2): 265-281.
Jackson, M. C., (2000). Marketing Alcohol to Young 155-166
Hastings, G., People: Implications for Industry
Wheeler, C., Regulation and Research Policy.
Eadie, D. & Addiction 95, Supplement 4: S597-S608.
Mackintosh, A. M.
Webster- (2002). Short Report - Alcohol Awareness 463-466
Harrison, P. J., and Unit Labelling. Journal of Public
Barton, A. G., Health Medicine, 24(4): 332-333.
Sanders, H. P.,
Anderson, S. D. &
Dobbs, F.


Treno, J. A. & (1997). Community Mobilization: 447-462
Holder, H. D. Evaluation of an Environmental Approach
to Local Action. Addiction 92, Supplement
2: S173-S187.

3 LEGISLATION AND ENFORCEMENT

All governments face the responsibility of developing policies that act to control
alcohol use in the interests of public safety and health. At the same time, they
face the challenge of ensuring that such policies can be enforced, and are not
too elaborate. Political, economic, religious and cultural factors can all affect the
extent to which a government attempts to regulate the use of alcohol.

You have already come across some international examples of policies related to
controlling access to alcohol and punishing of DUI offenders in the Session 3 of
the previous unit (Room et al, 2002; and the Tenth Special Report, 2000).

In the reading that follows, Parry and Bennetts (1998) provide a useful overview
of the most common legislative measures relating to alcohol use in South Africa.
These measures include reducing drunk driving, generating revenue through
taxes on alcohol, requiring liquor outlets to be licensed and to adhere to certain
hours of operation, and restricting the advertising of alcohol. Take a look at page
106 of the reading which summarises the legislative measures that could be
strengthened in South Africa. Developing a broad knowledge of the kinds of
legislation used in other countries and the impact thereof is an important step to
contributing to such policies in your own context. Use Task 1 to engage
analytically with the reading.

READING: Parry, C. D. H. & Bennetts, A. L. (1998). Ch 5 - Reducing per
Capita Consumption and High-Risk Behaviours. In Alcohol Policy and Public
Health in South Africa. Cape Town: Oxford University Press: 103-127. See pp

TASK 1 – Analyse alcohol legislation strategies

Select two different legislative strategies described in the chapter by Parry and
Bennetts. Decide whether these strategies aim to reduce consumption or
reduce harm. Analyse whether you think cultural, religious, political or economic
factors have informed these policies. Consider what resources it would take to
enforce these strategies, and what limitations may be encountered. Consider
the sorts of reactions enforcement is likely to draw from alcohol users. Then
assess the potential effectiveness of these legislative strategies.


The National Drug Master Plan was prepared by the Drug Advisory Board, at the
request of the then Minister for Welfare and Population Development, and
published in February 1999. This document is informed by the United Nations
Drug Control Programme (UNDCP) and is ‘the single document adopted by the
government outlining all national concerns in drug control’. Although much of the
Plan focuses on illegal drugs, the problem of alcohol abuse is included within the
scope of the focus areas:
 Crime
 Youth
 Community health and welfare
 Research and information dissemination
 International involvement

The implementation is being facilitated and monitored by the Central Drug
Authority (CDA), based in Pretoria. The implementation of the Plan is to be
through provincial forums and drug action committees.

The CDA was brought about through the ‘Prevention and Treatment of Drug
Dependency Act, 1999’, which is an amendment of the Act 20 of 1992. The CDA
has representatives from most government departments and other national
bodies. See website: www.CDA.gov.za

The next reading by Room et al (2002) provides some interesting case studies to
illustrate some of the main strategies used in regulating alcohol sales and
consumption. The authors describe a range of interventions, some of which fall
into the “harm reduction” category, and provide evidence of their effectiveness.
At this stage, refer only to the specific page numbers listed below, and then read
from page 192 - 210. Choose one of the case studies and redo Task 1 with this
example.

READING:
Room, R. et al. (2002). Ch 8 - Targeting Environmental Change to Reduce
Alcohol-Related Problems. In Alcohol in Developing Societies: A Public Health
Approach. Helsinki: Finnish Foundation for Alcohol Studies in collaboration with
the WHO. Focus on the boxed case studies on the following pages:

Page 188: Minimising intoxication at soccer matches in the Netherlands
Page 190-1: Legislating against selling alcohol along state highways in Brazil
Page 198-9: Prohibition of alcoholic beverages from 1996-8 in Haryana state,
India
Page 200: Prohibition of importation of alcoholic beverages in Barrow, Alaska
Page 205-207: Grog-free days in Tennant Creek, Australia
Page 208: Alcohol rationing in Greenland in the 1970s
Page 211-213: The women’s lobby for prohibition in Moen, Chuuk, Micronesia
Page 213-215: The women’s lobby for prohibition of alcohol in Andra Pradesh,
India in the 1990s. 67
Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Un it 3

3.1 Government Taxation of Alcohol Consumption

Decisions on the level of excise duty (tax) imposed on liquor products are not
straightforward. While it can be demonstrated that alcohol abuse is a cause of
many social and health problems, the liquor industry has significant economic
power and influence.

In general, governments would want to generate a pool of revenue from alcohol
taxes to support the services required to deal with the problems it causes.
However, if the taxes are set at too high a level, illegal brewing and cross border
smuggling is likely to increase. In turn, reduced overall consumption and
increased production costs could jeopardise employment in the industry.

In general, liquor products are taxed according to the absolute alcohol content.
This is a strategy which has been successfully used in Australia, where lighter
beer was promoted by reducing the tax on the product.

Read this article by Parry et al (2003) arguing for an increased tax on alcohol in
South Africa. If you live elsewhere than South Africa, see if you can find out the
most recent tax levels on alcohol in your country, and whether the rationale to
increase tax in real terms has been implemented in your context.

READING: Parry, C. D. H., Myers, B. & Thiede, M. (June 2003). The Case for an
Increased Tax on Alcohol in South Africa. The South African Journal of
Economics, 71 (2): 265-281. See pp 305-314 in the Reader.

In the next section, we consider the role of the media in spreading promotional or
educative messages, and the control of alcohol marketing strategies, particularly
amongst young people.
4 MARKETING ALCOHOL

Promoting products in a free market economy is a well established practice, and
sophisticated communication methods are used to appeal to diverse needs in
different segments of the potential market. In the process of marketing, liquor can
be portrayed in a variety of ways and through different media including radio,
television, or printed media such as magazines, newspapers, billboards, branded
clothes and other products. Such messages could be educative, for example a
health discussion on how to drink sensibly, or they may promote the use of
alcohol, as do advertisements of different liquor brands. Norms and values about
the use of liquor can also be conveyed unintentionally by movies and television

dramas, through their portrayal of drinking and the associated image of those
who drink.

It is because of the powerful impact of marketing that many governments have
introduced strict policies to limit the promotion of tobacco and alcohol products.
In South Africa, much effort was made by the Health Promotion Directorate in the
National Health Department to ensure that the Tobacco Control Policy included a
ban on advertising and sports sponsorships, the introduction of packet labeling
with health warnings, and the restriction of smoking in public buildings and
workplaces. Work is currently being done to promulgate appropriate legislation to
further control alcohol availability and marketing, but the issues are unfortunately
not as clear-cut as they are with tobacco.

One segment of the market which is particularly susceptible to advertising is the
youth. The next reading by Jackson et al (2000) provides a detailed analysis of
the marketing of liquor to young people, and makes recommendations about a
range of ways in which the production, marketing and availability could be
controlled. According to this article there have recently been four major changes
in the United Kingdom which impact on the drinking habits of young people:
1. The development of new designer drinks such as “alcopops”, white ciders and
alcoholic energy drinks.
2. An increase in the strength of alcohol products, in direct competition with the
illicit psychoactive substances market.
3. The use of sophisticated advertising and branding techniques, in keeping with
emerging youth culture.
4. The opening of new drinking outlets such as café bars and theme pubs to
attract younger drinkers.

Before you read the article, take a look at Task 2.

READING: Jackson, M. C., Hastings, G., Wheeler, C., Eadie, D. & Mackintosh, A.
M. (2000). Marketing Alcohol to Young People: Implications for Industry Regulation
and Research Policy. Addiction 95, Supplement 4: S597-S608. See pp 155-166 in
the Reader.


TASK 2 - What influences the drinking habits of youth in your area?

Using the four trends listed above for the United Kingdom to guide you, gather
relevant information on the marketing and promotion of alcohol to youth in your local
area. Based on the information you gathered, answer the following questions:

a) What are young people drinking when they get together?
b) What is the alcohol content of these drinks?
c) In what way does current alcohol advertising appeal to young people?
d) Which of the new venues where alcohol is sold, e.g. restaurants, pubs or
cafes, seem to appeal to young people?

Based on your findings, answer this question: Is there enough evidence to say that in
your area there is a similar trend to that in the UK?

4.1 Labeling of alcohol products

Labeling is one of the ways to advertise and promote a product. The packaging
of any product serves both to appeal to the potential buyer, as well as to provide
information on its contents and possible harmful effects. Liquor producers are
only required to reveal the percentage of alcohol content on the package, but
nothing else. There remains a potential to have laws that require standard drinks
to include warnings and information on labels.

Read the requirements of Task 3, then read the article by Webster-Harrison et al
(2002).

READING: Webster-Harrison, P. J., Barton, A. G., Sanders, H. P., Anderson, S. D. &
Dobbs, F. (2002). Short Report - Alcohol Awareness and Unit Labeling. Journal of
Public Health Medicine, 24(4): 332-333. See pp 463-466 in the Reader.


TASK 3 – Analyse marketing of alcohol to the youth in your area and make
recommendations for its regulation

Spend some time in the next few days purposefully collecting liquor advertisements
from magazines and newspapers, and noting down those you see on the television.
Review all the examples you have collected, and analyse their appeal in terms of the
youth market segment, the type of liquor, and the key message being promoted. An
example of a key message is, for example, If you have this drink you will be part of
the trendy set.

Revisit the five recommendations on alcohol regulation made by Jackson et al
(2000) on pages S606-7, and decide which are relevant in your province or area in
relation to the youth.

Control of marketing and labeling is one strategy to increase legislative control of
alcohol, particularly in relation to groups like youth which are vulnerable to peer
and image pressure. In the next section, we discuss the importance of
community mobilisation and promotion of ownership in any broad intervention to
control alcohol use or reduce harm caused by risky drinking.

5 COMMUNITY MOBILISATION

It would not be possible to implement many of the strategies and policies
described in this session at a local level without the participation of community
based organisations.

The next reading by Treno and Holder (1997) emphasises the importance of
community mobilisation in the process of implementing policies and
environmental changes. The authors use the concept community mobilisation to
refer to “… the efforts to involve community members in activities ranging from
defining needs for prevention … to obtaining community support for a pre-
designed prevention program” (Treno & Holder, 1997: S173).

This is a rather dense article; to begin to process it read the abstract carefully
and then focus mainly on the figure and the tables: this will give you a sense of
what the “Community Trials Project” in the USA was all about. The purpose of
the paper is to be found on page S175, in the right column, second paragraph.
Take note of the challenges of bottom-up and top-down approaches to
community mobilisation (under Strengths and limits in both approaches). Below
is a brief introduction to the paper. Read it and then try Task 4 as you read the
paper.

READING: Treno, J. A. & Holder, H. D. (1997). Community Mobilization:
Evaluation of an Environmental Approach to Local Action. Addiction 92, 71
Supplement 2: S173-S187. See pp 447-462 in the Reader.

The programme described by Treno and Holder involved three comparable
communities - Southern California, Northern California and South Carolina. The
main interventions were:
 The Drink/drive reduction
 Responsible beverage service (RBS)
 Controls of access to alcohol
 Youth prevention

In this context, the environmental approach refers to “… implementing policies to
reduce alcohol-related trauma” (Treno & Holder, 1997: S173).

A phased approach was undertaken comprising:
1. Project design: an ideal set of interventions was developed including
objectives and activities.
2. Staff development: local indigenous workers were appointed and trained.
3. Coalition development: community organisations were involved.
4. Task force development: focused action groups were formed from the
coalition and staff.
5. Intervention: implementation was achieved through leader support and
community awareness.
6. Evaluation: the evaluation of the programme focused on the extent to which
policies were adopted and implemented in the main areas of intervention.

TASK 4 – Plan community mobilisation strategies for an intervention
a) Borrowing from the conceptual model used in the paper by Treno and Holder
(1997) and taking the particularities of your own target group, identify which
strategies could be used to mobilise community involvement in an
environmental intervention in your context. Specify what organisations you
would involve and why they would be critical to the success of a programme.
b) What is the importance of community involvement in alcohol-related
interventions?

FEEDBACK

a)
Deciding on community mobilisation strategies cannot easily be done
before your programme development process has begun. Below is an

example of community mobilisation strategies from my experience.
You could look back at Treno & Holder, pages S174 - S175, and the
diagram on page S177, to assess to what extent the Sensible Drinking
Project in Cape Town, described below, matches that of the
Community Trials Project in the reading.

CASE STUDY – THE SENSIBLE DRINKING PROJECT, CAPE TOWN, PART 1

How did the Sensible Drinking Project start?
This project started in Manenberg and Guguletu, in Cape Town in 2000. Research
done by the Medical Research Council (MRC) had shown the strong association
between alcohol and trauma at the GF Jooste Hospital, which serves these two
communities. The Regional Medical Officer decided that a community based project
was needed to try to reduce the amount of alcohol use that was leading to this harm.

A Task Team consisting of representatives from the Department of Health, Unicity
Officials, UWC School of Public Health, Cape Town Drug Counselling Centre, SANCA,
Arrive Alive, MRC and others came together to plan harm reduction interventions in
the GF Jooste Hospital's main drainage areas of Guguletu and Manenberg.

A workshop was held in each community involving faith based organisations, schools,
crèches, relevant NGO’s, mass media and community safety and security
representatives, e.g. police. The participants supported the idea of promoting a
responsible attitude towards alcohol usage and a stakeholder's group (the SDP
Committee), consisting of interested community members, was formed in each area.

It was decided to appoint a person from each community to co-ordinate the various
community interventions in shebeens, clinics, sports clubs, schools and in the broader
community. Adverts for the position were displayed at libraries, multi-purpose centres
and other public places. Applicants were short-listed, interviewed and eventually one
coordinator from each catchment area was appointed. They attended a short course in
developing community based alcohol prevention programmes at the UWC Winter
School, as well as the Brief Interventions Training offered by the Cape Town Drug
Counselling Centre.

Launch of Project
The Sensible Drinking Project was officially launched on 5 June 2002 at GF Jooste
Hospital. The programme included presentations from the Director of the Unicity
Health Services, UWC Public Health, the MRC and Dr Keith Cloete, coordinator of the
project. Song items were delivered by Sinethemba and Manenberg Schools. Media
liaison resulted in interviews on eight radio stations, and the community and regional
newspapers carried articles.

Lessons Learnt
1. Spend time in selling the idea to all levels within a community, i.e. from
councillors, to teachers, health forums and members of the community. This
process could take many months, but is essential to removing obstacles later.


2. Choose a coordinator from the community to ensure that the project has a
driver who understands local conditions.
3. Ensure that the coordinator has his/her own motor vehicle.
4. Provide adequate orientation and training to enable the coordinator to carry out
the variety of tasks necessary to achieve the project goals.
5. Compile operational plans with each coordinator, so that they are clear as to
what is expected of them, and the activities on which they should report.

Consider which of these strategies may be relevant to the community you work
in, and do not forget the issue of community mobilisation when you come to
design interventions both for your second assignment and in the future.

6 SESSION SUMMARY
In this session, you have analysed policy interventions which have been used to
control alcohol marketing and availability, as well as the necessity of mobilising
communities as part of the development and implementation of policies. You
have also considered the ways in which alcohol is marketed to young people and
made recommendations on how this could be controlled. Hopefully you have
broadened your view of the range of policy-level interventions that are possible,
and analysed some of the challenges that face governments in relation to
reducing alcohol consumption and the harm caused by it. You were also asked to
consider a model of community mobilisation in relation to your target group. Your
notes on how some of these issues relate to drinking amongst young people in
your own area may be useful in completing your second assignment.

In the next session, we build on the range of possible alcohol related
interventions by considering broad environmental changes that can be made in
the drinking context.

7 FURTHER READING
 Dept of Welfare, South Africa. (1999). National Drug Master Plan, RSA, 1999
- 2004.
 WHO. (2002). Prevention of Psychoactive Substance Use. A Selected
Review of What Works in the Area of Prevention. Geneva: WHO, Dept of
Mental Health and Substance Dependence.
 Parry, C. D. H. (2000). Ch 23 - Alcohol and Other Drug Abuse. South African
Health Review 2000. Durban: Health Systems Trust. [Online], Available:
http://www.hstsahr2000chapter23.htm/ 11pages. [2001-7-18]


Unit 3 - Session 2
Environmental Changes
Introduction
As you by now know, a Health Problem approach to drinking would prioritise
broad strategies which could be used to steer people away from excessive
drinking, or to mitigate the harm caused by it. In this session we explore
environmental strategies for harm reduction and providing alternative activities in
order to reduce drinking. You will consider whether such strategies could be
applied in your local context.

Crucial to environmental interventions is the concept of drinking patterns, which
was discussed in Unit 2 Session 2: so you may want to refresh your memory on
this issue as you work through this session.
This session has relevance to your second assignment, which involves designing
appropriate interventions to address alcohol problems. You may find that the
international examples of environmental interventions stimulate new ideas for
your setting; remember also the importance of community mobilisation as
discussed in Session 1. This may be crucial to making your programme
successful. Most importantly, you will be able to consider what baseline
information you may need in order to evaluate any environmental programme
that you may plan.

Session contents
2 Readings
3 Alternatives to drinking
4 Harm reduction
5 Health Promotion using the media
6 Session summary
7 References

This session includes two readings, constituting 15 pages. There are two tasks
which form useful preparation for your second assignment. Allow at least two
hours for the session.




 Assess international examples of environmental adaptations to reduce alcohol
intake and alcohol-related harm in local settings.
 Discuss the role of a variety of media in supporting the communication of
alcohol-related policy and environmental changes.

2 READINGS

Reading Publication details Page nos in reader

Room, R. et al. (2002). Ch 8 - Targeting Environmental 349-384
Change to Reduce Alcohol-Related
Problems. In Alcohol in Developing
Societies: A Public Health Approach.
Helsinki: Finnish Foundation for Alcohol
Studies in collaboration with the WHO:
181-192.
Soul City. (Undated). Alcohol and You. 399-408
Johannesburg: Jacana Education: 16-21.

3 ALTERNATIVES TO DRINKING

It has often been asserted that people drink too much alcohol when they are
unemployed or when they do not undertake any stimulating activities in their free
time; however, probably as many people drink in a risky way although they are
employed and alternatives to drinking are plentiful. Providing activities to replace
drinking is a fairly common strategy, but its success is questionable and difficult
to measure.

In areas of Southern Africa such as on farms where the dop-system operated, or
on the mines where there are numerous shebeens, a general shift in culture
would be required as well as alternative activities, to reduce the time people
spend drinking.

In the previous session, you explored some of the case studies in Room et al’s
Chapter 8 (2002). Now read the first part of the chapter in full (pages 181-185)
after reading through the requirements of Task 1. This task provides good
preparation for your second assignment.

READING: Room, R. et al. (2002). Ch 8 - Targeting Environmental Change to
76 Reduce Alcohol-Related Problems. In Alcohol in Developing Societies: A Public
Health Approach. Helsinki: Finnish Foundation for Alcohol Studies in collaboration
with the WHO: 181-185. See pp 385-398 in the Reader.

TASK 1 – Assess alternative activity strategies and develop baseline
information for evaluation

In this task, you are asked to consider whether alternative activities to drinking
would have any impact on the community that you have described in previous tasks.
Review your description and then:

a) List those alternative activity strategies mentioned by Room et al which would
potentially work in your target group. Critically assess the strategies in terms of
the context and available resources.
b) Before intervening with alternative activities, you would need baseline
information on current patterns of drinking and harm, in order to measure any
change that may be due to the alternative activities. How would you develop
your baseline information? Refer back to Unit 1 Session 2 where some methods
of measuring alcohol consumption and patterns are discussed.

FEEDBACK

As feedback, we have included another piece of the case study introduced in
Session 1 of this unit, as an exemplar of baseline information to make monitoring
and evaluation possible.


Alcohol availability and drinking habits in Nyanga and Manenberg
A study by the Medical Research Council (MRC) in 2001 in two Cape Town hospitals
assessed the association between alcohol and trauma. The study showed that 50% of
patients being treated in the trauma units for injuries had alcohol on their breath when
and more than 30% of these had possible chronic alcohol problems. Injuries were due
to violence (63%), traffic accidents (22%) and other accidents (15%). More cases were
male than female, and the average age was 30 years old.

In late 2000, a researcher from the UWC School of Public Health was asked by the
Sensible Drinking Project (SDP) Task Team to collect some qualitative data on the
drinking patterns in the target communities of the SDP. Over a two week period, Kirstie
Rendall-Mkosi planned the study, recruited and trained two temporary fieldworkers
(one Xhosa and one Afrikaans speaking) to collect the data through about 25
interviews. Ferdinand Bomvana, of the Metro Health Dept, collected data from
interviews with youth. A presentation of the information gathered was made to the


Task Team and to a community meeting in Manenberg, to highlight the nature of
alcohol use in the area.

The main questions asked in interviews with alcohol sellers, drinkers, and to women in
the community were:
What are the main drinks consumed in this area?
When do people drink and how much?
Is food eaten while drinking alcohol?
How available is alcohol – where and at what times?
Is there a difference between men and women’s drinking habits?
What are the main reasons for drinking?
What factors influence drinking habits and the liquor trade?
What are the things that encourage more drinking and less drinking (the
facilitators and deterrents)?
What happens when people have drunk too much?
What are some of the controls used by alcohol sellers?

Similarities were found between Nyanga and Manenberg, but also some differences.
In both areas, people said drinking mainly happens on weekends, but in the late
afternoons and evenings during the week too. Unemployed people can be drinking at
any time, while employed people drink mainly on weekends. Alcohol can be bought 24
hours a day from some outlets, and the sellers range from informal (selling a few
bottles from the back door) to formal licensed taverns. The habit of drinking until very
drunk is common, and generally people drink without eating at the same time.

The reasons given for drinking alcohol were both positive and negative: for enjoyment
and relaxation; to socialise and network; to celebrate special occasions; to escape
from household problems; to counter boredom; and to make it easier to talk about
problems.

There is some difference in what is used and by whom in the two communities: in
Manenberg, people drink beer and wine mostly, and spirits are reserved for special
occasions, while in Nyanga, mainly beer, brandy and umqombothi are used. In
Manenberg, it is acceptable for both men and women to drink alcohol, whereas in
Nyanga it is less accepted for women to drink. In both areas, drinking among young
people is becoming more common.

The factors which promote alcohol use range from its economic profitability, which
results in many outlets, to the need for people to relax and socialise. Some sellers
allow alcohol to be bought on credit.

The factors which influence people to reduce intake or abstain are based on cultural
and religious norms, expectations that families need to be cared for with available
money, the increasing cost of alcohol, and the action taken by some sellers to limit
drunkenness.

Drinking too much is said to cause fights between friends as well as strangers, to
make people too brave and argumentative, to put them in danger of pedestrian
accidents, and also results in domestic violence.


4 HARM REDUCTION

Interesting strategies are being implemented across the world to reduce the
harmful effects from people drinking. Remember these strategies do not
necessarily aim to reduce overall consumption of alcohol, but to put strategies in
place to protect drinkers and others from possible harm. These strategies could
take the form of boosting the nutritional status of drinkers, containing intoxicated
people in overnight shelters or providing lifts home, and equipping servers of
alcohol with skills to deal appropriately with the behavioural problems of drinkers.

READING: Room, R. et al. (2002). Ch 8 - Targeting Environmental Change to
Reduce Alcohol-related Problems. In Alcohol in Developing Societies: A Public
Health Approach. Helsinki: Finnish Foundation for Alcohol Studies in collaboration
with the WHO: 186-192. See pp 349-384 in the Reader.

TASK 2 – Reducing harm or increasing the appeal of shebeens?

In trying to make shebeens safer places for drinking, some projects have promoted
the idea of having games such as pool available in the shebeen. In addition, it has
been suggested that food should be sold on site and water should be made freely
available.

The problem is that those who advocate these alternatives could be accused of
making shebeens more attractive, and in this way increasing the amount of time
and money people spend there.

What is your opinion and how would you respond to people who question this
“sensible drinking” strategy or harm reduction approach?

5 HEALTH PROMOTION USING THE MEDIA
The influence that visual and auditory images and messages have on people can
be considered part of the environmental factors which influence attitudes, values
and habits concerning alcohol. In the same way as the media is used to promote
the sale of alcohol by producers, there is the possibility of using it to promote
responsible drinking, and even to shift the norms of acceptable drinking towards
more cautious drinking or none at all. While the media can have limited impact in
achieving behaviour change, it can:
 Provide knowledge, and increase awareness of a health problem and its
solutions;

 Contribute to changes in knowledge, attitudes and behaviour;
 Demonstrate skills;
 Role model positive health behaviours;
 Link people to resources;
 Set an agenda and bring issues to centre stage in public;
 Contribute to the creation of a social climate that supports both individual and
collective action;
 Generate public support for healthy public policy initiatives.
(Coulson et al, 1998:117)

Although we do not have sufficient space to go into any detail on developing
effective media here, it is worth at least considering the range of media one can
use, and the fact that media can sometimes be used in combination:

 Posters and pamphlets
 Newspapers and magazines
 Newsletters and journals
 Drama, puppets and live media
 Radio and community radio
 Murals in public places, billboards and media on commuter vehicles
 Videos
 Television
 Personal media such as stickers and t-shirts.

Some educational strategies utilise mass media in an attempt to counter or
balance the messages being promoted by companies marketing alcohol.
Sometimes liquor companies will even sponsor the “sensible drinking” message,
to demonstrate that they recognise that alcohol can cause problems.

READING: Soul City. (Undated). Alcohol and You. Johannesburg: Jacana
Education: 16-21. See pp 399-408 in the Reader.

Take a look at the extract in the Reader from a booklet produced by Soul City on
alcohol use. This series of booklets is distributed occasionally in the Sunday
Times newspaper nationally in South Africa, and at petrol stations and other
public outlets. This issue coincided with the Soul City TV show which dealt with
alcohol problems, amongst other issues, at the time. Copies of the booklet can
still be ordered from Viva Books in Johannesburg.

6 SESSION SUMMARY


In this session, you have touched on a number of aspects of environmental
interventions including examples of such interventions, and the issue of using
media to support healthy environmental changes and harm reduction strategies.
You considered and assessed the application of environmental interventions
similar to those described by Room et al (1992) in your own context. In the
course of this session an important programme development issue was raised,
namely developing a baseline understanding of drinking patterns in your target
group, in order to plan and evaluate environmental interventions. In the final
session of this unit, we explore the potential of multifaceted programme
interventions.

7 REFERENCES
 Coulson, N., Goldstein, S. & Ntuli, A. (1998). Promoting Health in South
Africa: An Action Manual. Sandton: Heinemann.


Unit 3 - Session 3
Multifaceted Integrated
Programmes
Introduction
This session explores the value of multifaceted programmes in addressing
alcohol problems, using the example of the Living with Alcohol Programme from
the Northern Territory, Australia. This programme uses a multifaceted approach
which follows the Health Promotion philosophy formalised in the Ottawa Charter.
This provides a useful point to reflect on the importance of those principles in
planning programmes to address alcohol problems.

In the second paper that you will read, May (1995) makes the point that it is the
multiple influences on drinking behaviour that indicate the need for a broadly
targeted response; he puts forward a wide ranging intervention proposal arguing
that, “[E]mbracing a narrow paradigm such as the disease model of alcoholism
will not be productive for either a full understanding of many behaviours (Illich,
1976) or for a truly successful prevention effort” (May, 1995: 1557).

In the course of the session, you are invited to familiarise yourself with
multifaceted programmes and to consider the viability of such interventions in
your own context. Programme monitoring and evaluation is covered briefly
through the example of the Sensible Drinking Project programme matrix.

Session contents
2 Readings
3 Programmes for whole populations
4 Programmes targeting specific risks
5 Programme monitoring and evaluation
6 Session summary



This session contains 76 pages of reading in four readings. You have, however,
been provided with a summary of Crundall’s interventions, and pointers for
reducing the time you take to read the article by May (1995). You are also asked
to refer to a reading by Croxford & Viljoen, which you studied in Unit 1. There are
three tasks in this session and if you do the reading selectively, it is estimated
that it could take you about four hours to complete.



 Discuss the rationale for a multifaceted approach to alcohol problems.
 Assess the viability of the multifaceted approach to specific contexts of alcohol
use.
 Apply the Ottawa Charter framework to alcohol interventions.

2 READINGS

Reading Publication details Page nos in reader

Crundall, I. (Undated). The Northern Territory Living 69-78
with Alcohol Program: Climbing Through
a Window of Opportunity. Australia: 98-
105.
May, P. A. (1995). A Multiple-level Comprehensive 195-222
Approach to the Prevention of Fetal
Alcohol Syndrome (FAS) and Other
Alcohol-related Birth Defects (ARBD).
International Journal of Addiction, 30:
1549-1602.
Medical Research (Oct 2000). Stop the DOP ... and more. 233-236
Council (MRC). MRC News,
31(5): 7-8.
Territory Health (1999). The Public Health Bush Book. 421-436
Services. Darwin, Australia: Government Printer of
the Northern Territory for Territory Health
Services: 4.42 - 4.56.


3 PROGRAMMES FOR WHOLE POPULATIONS

Since a number of factors influence people’s drinking behaviour as well as the
environment in which they drink, it is logical that any programme aiming to
change drinking behaviours or reduce the potential harm from drinking, should
have multiple targets and a variety of components. Evaluations of many health
promotion programmes relating to health behaviours, such as smoking, have
shown that a multifaceted approach is the most successful (Community
Intervention Trial for Smoking Cessation, COMMIT Research Group, 1995).
The Living With Alcohol (LWA) programme in the Northern Territory of Australia
is a well known programme designed to reduce alcohol related harm. Legislative,
educational and treatment components or services were developed to tackle well
established patterns of drinking, and to reduce the harm it causes. This inevitably
involved a number of government departments (justice, education, health social
welfare etc) as well as agencies from different sectors.

In the first reading, Ian Crundall describes the implementation of this multifaceted
programme, discussing its guiding principles and the impact it had. You will note
that a careful balance was maintained between bureaucratic top-down
interventions such as drink-driving legislation, and community oriented
approaches such as community action plans. Below is a summary of the
components of this programme. Study the summarising diagram below and
familiarise yourself with the requirements of Task 1, before reading the paper.

TASK 1 – Consider the Living With Alcohol (LWA) programme in terms of
the Ottawa Charter

Revise your understanding of the action areas of the Ottawa Charter, i.e.
 Healthy public policy
 Supporting community action
 Developing personal skills
 Reorienting the health services
 Creating supportive environments

a) To what extent do you think the LWA programme uses the Ottawa Charter
as a framework?
b) Brainstorm ideas for a programme for your own context which fulfil each of
the five principles of the Ottawa Charter. Put down at least three ideas for
each.


READING: Crundall, I. (Undated). The Northern Territory Living with Alcohol
Program: Climbing Through a Window of Opportunity. Australia: 98-105. See pp

SUMMARY OF THE ACTIVITIES OF THE LIVING WITH ALCOHOL (LWA)
PROGRAMME, NORTHERN TERRITORY, AUSTRALIA

COMMUNITY ACTION PROGRAMME FAMILY VIOLENCE STRATEGY
Facilitators: * Arrest (where enough evidence);
* Information on safe alcohol consumption * Prosecution;
and developing supportive environments for * Perpetrator programmes;
informed choices, e.g. story board. * Services for victims;
* Feedback from community for development * Community based development of
of community action plan (targeting drinkers, culturally appropriate education &
non-drinkers and learners). schemes, e.g. night patrols; safe
homes.

EDUCATION LEGISLATION
“Drink Sense” * Liquor Act: increased penality for
* Media campaigns using slogans; selling to underage or intoxicated;
* NGO funding for awareness work; * Motor Vehicles Act: increased
* Selection of priority areas: youth; workplace; penalties for drink driving;
liquor industry. * Tax: reduced tax on light beers,

increased tax on high % alcohol.

LIVING WITH ALCOHOL PROGRAM (LWA)
Northern Territory, Australia
Targets: Reduce alcohol related road fatalities and accidents by half;
Reduce apparent consumption of alcohol by 40%.

DRINK – DRIVING TRAINING & PROFESSIONAL DEV
* Increased penalties; * Service providers receive training;
* Alcohol training programme; * Hospitality personnel trained in
* “Sober driver’s pubs”; responsible serving of alcohol;
* Breathalysers in pubs; * Certificate in PHC & subs abuse;
* “Home safely” campaigns in schools; * Alcohol handbook & resource kit.
* Media campaign to promote
responsible drinking guidelines.

TREATMENT & REHABILITATION
* Health services and NGOs provide
counselling; day care and residential
programmes.


Research, Monitoring and Evaluation was undertaken throughout all strategies.

FEEDBACK
Although the authors do not mention Health Promotion theory as such, the
components of the LWA seem to correspond closely with the action areas of the
Ottawa Charter.

 Healthy Public Policy: Various laws were promulgated to control drunk
driving, reduce sales of liquor to underage children, and increase tax on
higher alcohol content liquor. There was also local policy to increase arrest
and conviction of perpetrators of family violence.

 Supporting community action: A localised community action plan was
developed.

 Developing personal skills: Various media and educational programmes were
developed to raise awareness of the problems and increase knowledge to
facilitate behaviour change, e.g., Drink Sense campaign, and interventions
with perpetrators of family violence.

 Reorienting health services: Training and resources were made available for
health service workers, and there was a shift in treatment to an outpatient
model.

 Creating supportive environments: Hospitality server training was provided,
community based family violence strategies were developed and
breathalysers were made available in pubs.

It can also be seen that any one campaign or component, such as the drink-
driving one, has many elements, and each of these could be categorised under
different action areas of the Ottawa Charter framework. Depending on which
aspect of alcohol related harm is being addressed, so the weighting of policy,
skills training and environmental changes will be different.

4 PROGRAMMES TARGETING SPECIFIC RISKS
According to Naidoo & Wills (1998), there are three main ways of using targeting
in the design of Health Promotion programmes. These include targeting: risk
contexts, at-risk groups and risky behaviours. There is, however, a dilemma in
using targeting. Although targeting may ensure better use of resources if directed
at the people or situations where the problem most often occurs, this approach
can lead to victim blaming or culture blaming. For example, the cause of the
problem may arise from the socio-economic context that people find themselves


in, or the inequities between groups; in this case, no amount of focus on the
target group will improve the situation. Some health determinants require a more
universal approach so as not to label and stigmatise people, but rather to deal
with the causes on a broader basis.

In keeping with our themes of youth, women and settings, we will use the paper
by May (1995) to apply the Preventive Model in reducing the prevalence of Fetal
Alcohol Syndrome (FAS) and Alcohol-related Birth Defects (ARBD). While some
of the interventions are aimed at pregnant women who drink, there are many that
are directed more broadly at the population or aimed at changing the
environment.

READING: May, P. A. (1995). A Multiple-level Comprehensive Approach to the
Prevention of Fetal Alcohol Syndrome (FAS) and Other Alcohol-related Birth Defects
(ARBD). International Journal of Addiction, 30: 1549-1602. See pp 195-222 in the
Reader.

This is a long paper, so unless you are very interested in the detail of the
interventions required for reducing the risk of FAS, I suggest that you focus on
Figures 1 and 4, and Tables 4, 5, and 6. Together, these figures and tables will
provide you with a summary of the levels of risk related to alcohol consumption,
the targeting of prevention activities related to this risk, and the variety of
activities required.

In the prevention of FAS, it is problematic to apply a Harm Minimisation Approach,
since there is no way to protect the fetus from alcohol. The transmission of alcohol
to the fetus is so fast and direct that the ideal remains that no alcohol should reach
the fetus at any time during the nine months in utero. If one has to accept that a
woman cannot stop drinking during pregnancy, the only opportunity to reduce
harm is to alter the contents of the liquor, and the frequency and amount
consumed.


TASK 2 – Assess the potential of an intervention programme and consider
viable alternatives

In an earlier reading discussed in Unit 1 (Croxford, J. & Viljoen, D. (1999). Alcohol
Consumption by Pregnant Women in Western Cape. South African Medical
Journal, 89: 962-965), you were given some insight into the main risk factors and
drinking patterns resulting in FAS in a Western Cape town. Many of them concur
with Table 2 in the reading by May (1995).

a) Bearing these factors in mind, and anything else you may know about the
living conditions and level of service provision for women in the rural
Western Cape of South Africa, assess the viability of the interventions
proposed by May (1995). In other words, identify the activities that could be
realistically implemented in such a context, and those that are unlikely to
work. Most importantly, say why you say so. Think of the issues of culture,
norms and conditions, as well as resource constraints and competing
programmes.

b) Can you think of any existing, universally available health and development
programmes or services on which some of the FAS prevention activities
could piggy-back?

FEEDBACK

In question (a) you were asked to choose an example that would work and one
that would not work and to say why. While I support all the elements listed in the
primary, secondary and tertiary prevention plans outlined by May, there are some
that could easily be applied in the areas of Southern Africa where maternal
drinking is a problem, but some would be impossible mainly due to resource
constraints.

The DOPSTOP Association (meaning ‘stop alcohol’ ) which is based in
Stellenbosch in the Western Cape is an example of an organisation working
mainly on a primary prevention basis. We have included a short article by the
Medical Research Council about its activities which you will find in the Reader.

READING: Medical Research Council (MRC). (Oct 2000). Stop the DOP ... and
more. MRC News, 31(5): 7-8. See pp 238 - 236 in the Reader.

Although the changes in drinking culture and policies related to access to alcohol
take a long time to have the desired effect, they are possible to achieve.

However, the aspects of May’s proposed plan that are least likely to ever be

realised are the secondary and tertiary levels of treatment for women. Since so
many women are potentially damaging their children, it is not feasible to offer
intensive rehabilitation for every woman who binge drinks on the weekend. A
different model of long term community based treatment and support for
changing drinking patterns will have to be developed.

b) The kinds of programmes which could serve to piggy back FAS prevention
activities are as follows: There are fairly wide spread antenatal clinics that could
take on a more active role in the screening and counseling of women who drink.
If they coordinated their work better with family planning services, they may
succeed in lowering the rate of unplanned pregnancies amongst women,
especially those who drink. Another programme which is being rapidly expanded,
and where funds are being directed, is the prevention and care for HIV/AIDS.
The link between alcohol problems and HIV could be highlighted and more
screening and counseling related to alcohol use could be incorporated into HIV
testing, support and care initiatives.

5 PROGRAMME MONITORING AND EVALUATION
It is difficult to cover all the intricacies of programme monitoring and evaluation
briefly. We have therefore chosen to refer you to the reading below, by the
Territory Health Services, which you may recognise from the Health Promotion II
module, as well as some examples that appear in readings in this module.

Many policy and environmental interventions take years to effect the desired
reduction of alcohol related harm, and it is difficult to isolate the effects of specific
interventions, when there may be many other influences at the same time.
However, one can monitor the achievement process and impact objectives in the
shorter term, and make adjustments, to ensure that the anticipated longer term
outcome is more likely to occur.

READING: Territory Health Services. (1999). The Public Health Bush Book. Darwin,
Australia: Government Printer of the Northern Territory for Territory Health Services:
4.42 - 4.56. See pp 421-436 in the Reader.

If you refer back to the reading by Treno & Holder (1997) and look at page S177,
the authors discuss the data used for evaluating their community mobilisation
model.

In addition, in the paper by May (1995) which you read earlier, you will find a
brief, but useful section on programme evaluation at the end of page 1587.

Here is another section of the case study on Sensible Drinking which you have
studied in this unit: take a look at Task 3 before studying the evaluation matrix


used by the Sensible Drinking Project (SDP).

In the first setting the Health Promoting Schools approach was advocated since
this is well known and quite widely used in the Western Cape. It places emphasis
on the whole school system, and involves all role players in taking responsibility
for developing a healthy learning environment and curriculum.


MONITORING AND EVALUATION SDP PROJECT WORKSHOP
Objectives Activities Indicator Measures Time
frame
Setting: Sinethemba High School and Silver Stream School

Develop capacity Initiation of HPS Commitment Training report. Jan –
in school to deal focusing on and process July
with alcohol using alcohol. planned. Training report and
HPS Approach. feedback from
Training of Number trained. Coordinator.
teachers and
learners. Number of Baseline questionnaire Feb -
active leaders. compared with 6 August
Selection and months later.
training of peer Number of
leaders. learners Number of incidents of
involved. drunkenness at school
Increased level of Class sessions functions.
understanding of by Coordinator Reduction in
consequences, and SANCA. drinking Focus groups of
risks and behaviour and learners and teachers
associations with attitude towards to assess
alcohol. alcohol. effectiveness of
programme.

Setting: Clinics, Day Hospitals (Health Centres) and GF Jooste Hospital

Improvement in Further training Number trained. Baseline knowledge of Feb –
identification, of health workers CAGE, counseling Nov
counseling and on 3 day course. Positive attitude and resources.
referral of people development in
with alcohol Introduction of staff. Training report.
problems. case and referral
form. Number of Feedback from
Advocate for more clients identified supervisors. March
resources and Audit of and referred – Nov
better networking resources. successfully. Analysis of forms.
in the area related
to alcohol Meeting with Agreement on Documentation of
rehabilitation. role-players and increased meetings.
decide what to resources from
lobby for. authorities and
NGOs.


Compile
document and
present to
relevant funders
and authorities.

Objectives Activities Indicator Measures Time
frame
Setting: Shebeens in Nyanga and Manenberg
Establish Establish a Active groups Minutes of meetings. Feb –
commitment of group of established. March
owners to potentially
implement various committed Plan of action
controls. owners (code of designed by
conduct). participants.
Agree on Monitoring forms April –
To increase food controls and Food intake to analysed monthly. Nov
intake while developments to drink ratio.
people drink. be tried. Try breathalyser.
Drunken
Promote specific incidents.
food to be sold
To increase other on premises. Number of
activities on premises with April –
premises e.g. Monitor the games. Nov
pool, cards. drinking levels,
food intake and Number of
drunk incidents. patrons involved
in games.
Introduce games
and
competitions.

Using this planning, monitoring and evaluation matrix as a model, develop one
for your own planned interventions.

TASK 3 – Plan your interventions and establish monitoring and evaluation tools

Draw a table similar to the one above, and map out the strategies, activities and
indicators that you are considering for your assignment. You may realise that many
interventions are quite difficult to monitor. However, explaining your activities and what
evidence there is of their implementation is essential for managing, as well as
evaluating a project over time.


6 SESSION SUMMARY
In this session you have read three papers which focus on a multifaceted
approach to addressing alcohol related problems. On the basis of these papers,
one may conclude that no matter what the scale of such programmes, they
require a multisectoral approach and components that use different approaches
and strategies.

The process of establishing these types of programmes is as important as the
actual policies, educational messages or changes that are carried out.
Participation by the relevant stakeholders and beneficiaries from the outset is
more likely to result in an understanding of the problems, as well as commitment
to the planning and implementation of the strategies and activities.

This is the end of Unit 3. In Unit 4, we address individual strategies.

 Naidoo, J. & Wills, J. (1998). Ch 5 - Targeting Health Promotion. In Practising
Health Promotion: Dilemmas and Challenges. London: Bailliere Tindall:
92-111.


UNIT 4
Introduction
Alcohol and the
Individual

Introduction

Welcome to the final unit of this module. This module deals with alcohol problem
interventions that focus on individuals. We have intentionally left individual level
interventions to the last unit, because most people think that education, individual
counselling or treatment are the only options. In order to tip the balance towards
the idea of environmental change, the previous units concentrated on the broad
level interventions that can be made to reduce alcohol problems.

There is, however, definitely a place for education and skills development to
prevent alcohol misuse, and for counselling of individuals who are experiencing
alcohol related problems. Formal treatment is also necessary for the few people
who are addicted to alcohol.

Although much is published in developed countries about these topics, very little
literature based on service delivery and research in Southern Africa is available
or accessible.


Study Session 1: Alcohol Education.

Study Session 2: Early Intervention.

Study Session 3: Rehabilitation.

In Session 1, we explore two aspects of awareness raising and skills
development in relation to alcohol, particularly when it comes to young people.
Preventive campaigns through schools and mass media are discussed, and the
dearth of such programmes with regard to alcohol prevention in the developing

world is highlighted.

Session 2 provides an introduction to the strategy of Brief Interventions, with
some evidence and debate on the efficacy of the approach.

Session 3 focuses on rehabilitation issues, concentrating more on the
accessibility of rehabilitation services than on the actual processes.



 Describe possible educational and skills development programmes commonly
used to raise awareness of alcohol problems.
 Understand the role of mass media in raising awareness and promoting policies.
 Assess the application of some of the alcohol education interventions to a local
target group.
 Explain the concept and technique of Brief Interventions.
 Identify key opportunities at a primary care level for alcohol screening,
counseling (motivational interviewing) and referral.
 Describe the requirements for building staff capacity to carry out Brief
Interventions.
 Discuss the potential for people to overcome alcohol dependency, and the
factors that influence the ability to practice “normal drinking”.
 Understand the aspects of western rehabilitation services which need to change
in order to improve access, appropriateness, affordability and availability.

We hope that you will find the unit helpful and that you will become an advocate
for appropriate educational programmes and treatment services in the future.
Hopefully the principles of brief interventions will enhance your ability to counsel
people with alcohol problems, formally or informally.


Unit 4 - Session 1
Alcohol Education
Introduction
The development of Health Education materials and health talks are typical
activities of health promoters and health workers, and can be termed primary
prevention. In the past decade, it was realised that issuing materials or giving
didactic talks may improve knowledge of substances such as alcohol, but it does
little to enhance young people’s motivation and skills to control their own
experimentation, or the habitual use of alcohol by adults. Nowadays these
methods are regarded as too passive and often not in tune with the reality of the
drinking context.

A number of strategies have been shown to be more effective: these include
skills development and interactive methods for improving people’s awareness of
the consequences of alcohol abuse, and how they can manage the pull factors
towards drinking. In addition, multimedia campaigns and edutainment
programmes, with messages about alcohol embedded in the overall portrayal of
lifestyle, are becoming recognised as the most appropriate media for Health
Education.

Session contents
2 Readings
3 Awareness and skills development
4 Mass media initiatives
5 Session summary
6 Further reading


This session requires you to read three short readings totalling 16 pages and
complete two tasks. It should not take you more than an hour and a half.




 Describe possible educational and skills development programmes commonly
used to raise awareness of alcohol problems.
 Understand the role of mass media in raising awareness and promoting policies.
 Assess the application of some of the alcohol education interventions to a local
target group.

2 READINGS

Reader
Botvin, G. J. & (2000). Preventing Alcohol and Tobacco 47-56
Kantor, L. W. Use Through Life Skills Training. Alcohol
Research and Health, 24 (4): 250-257.
WHO. (2002). Prevention of Psychoactive 464-474
Substance Use. A Selected Review of
What Works in the Area of Prevention.
Geneva: WHO, Dept of Mental Health
and Substance Dependence: 22-28.
Soul City. (Undated). Alcohol and You. (33 page 399-408
booklet linked to radio and TV
production). Johannesburg: Jacana
Education: 16-21.

3 AWARENESS AND SKILLS DEVELOPMENT

Health Education message development is generally based on an understanding
of the beliefs, attitudes and values of people regarding a specific behaviour, as
well as the environmental and interpersonal factors influencing the individual’s
decision-making. You could refer back to the different theories of health
behaviour in your Health Promotion II module: decide which are suitable to
explain alcohol use, and which could assist us to plan education that enables
people to take control over the factors influencing their alcohol use or abstinence.
You could also refer to Morojele’s use of the Theory of Planned Behaviour in
Adolescent Alcohol Misuse (1997), in Unit 1. In addition, in the Botvin reading


below, there is a diagram illustrating the factors that commonly play a role in
decision making and behaviour by youth.

Various programmes are run with youth as part of the school curriculum, or within
environments like youth clubs, in areas where capacity and resources are to be
found. Although the contents, methods and leadership may vary, all of the
programmes aim to inform youth of drug and alcohol dangers and
consequences; many also try to equip them with enough insight and skills to
make responsible decisions about using any substances.

The article by Botvin & Kantor (2000) describes a prevention programme which
targeted younger students on the understanding that use of substances
increases with age. We need, however, to bear in mind that the type of
programme described in this article is based in the United States, where many
years of research and programme development has taken place. While there are
some innovative programmes in Southern Africa, these are few and far between.
This is partly due to the capacity and resources required to offer these
programmes, but it is also because alcohol is not yet recognised as a significant
Public Health issue in Southern Africa.

As you read the article, consider whether any aspects of the programme would
be applicable in your context.

READING: Botvin, G. J. & Kantor, L. W. (2000). Preventing Alcohol and
Tobacco Use Through Life Skills Training. Alcohol Research and Health, 24
(4): 250-257. See pp 47-56 in the Reader.

The Health Promoting Schools initiative that is taking root in Southern Africa is a
good vehicle through which alcohol and drug awareness at schools can be
promoted. A strength of the Health Promoting Schools philosophy is that it
involves all stakeholders related to the school – learners, teachers, parents and
the broader community – and aims to increase Health Promotion at the level of
environmental as well as curriculum interventions.

A large scale systematic review of prevention strategies for substance abuse was
recently released by WHO. They have divided these strategies into regulation of
availability, mass media, community based programmes and school based
programmes. The authors were not convinced that the school based
interventions they had literature on demonstrated a positive outcome, but did
say:

“In particular, [this suggests] encouraging programme planners to adopt a
formative phase of development that involves talking to young people and
testing the intervention out with young people; providing interventions at
relevant periods in young people’s development; interventions that are

interactive and based on skill development; interventions that have a goal
that is relevant and inclusive of all young people; appropriate teacher
training for interactive delivery of the intervention; making effective
programmes widely available and adopting marketing strategies that
increase their exposure.” (WHO, 2002: 56)

TASK 1 – Assess awareness-building initiatives

a) Identify the alcohol issues in your local community with regard to youth.
b) Investigate what kind of awareness and skills building programmes are
available to the youth in school and/or through clubs or other groupings such
as the church.
c) If there are some interventions, what is your judgment of the design of these

Building awareness of the risks of alcohol and skills to manage experimentation
with alcohol form important aspects of prevention, particularly amongst young
people.

4 MASS MEDIA INITIATIVES

We have already looked at the role of the media in marketing alcohol and
suggested that some control needs to be exerted in this area. Conversely,
however, the media and multimedia edutainment programmes can serve to
integrate various positive health messages with appealing images or dramas.
Some of the messages being conveyed are intended to influence people’s
behaviour, while others aim to promote understanding of new policies. We
include a section of a WHO review of “what works in the area of prevention”
which is relevant to the issue of using mass media. You could refer to the whole
document if you want more detail. It can also be ordered from WHO on CD.

The authors of this reading emphasise that the use of media is most effective
when it is part of a “health advocacy” approach, and where the overall purpose is
to provide a more supportive environment for healthy behaviour.

Some key ingredients for a successful mass media campaign are highlighted:
having a well defined target group; the undertaking of formative research to
understand the target audience and pre-testing campaign materials; in addition,
using messages that build on an audience’s current knowledge and which satisfy
pre-existing needs and motives is beneficial; addressing knowledge and beliefs
which impede adoption of the desired behaviour is also important, as is a long
term commitment to the campaign (WHO, 2002).

READING: WHO. (2002). Prevention of Psychoactive Substance Use. A Selected
Review of What Works in the Area of Prevention. Geneva: WHO, Dept of Mental
Health and Substance Dependence: 22- 28. See pp 464-474 in the Reader.

You may be familiar with some Southern African examples of educational media.
Soul City, for example, is a South African health and development organisation
based in Johannesburg, which has had a lot of success in using an edutainment
approach. Over approximately the past 10 years, Soul City has produced a TV
drama series on various determinants of health, and the prevention and
treatment of common conditions. The main characters depicted are also used in
radio dramas and print media that accompany the TV series. Soul City has
become a well recognised “brand” of edutainment and is being translated for use
in many different countries.

The Alcohol and You booklet (see Reader) is one example of the print media
produced by Soul City. These can be ordered in bulk and used in various settings
such as clinics, social development offices and schools. The sensible drinking
message is made relevant and realistic to the local context and the typical drinks
available.

READING: Soul City. (Undated). Alcohol and You. (33 page booklet linked to radio
and TV production). Johannesburg. Jacana Education: 16-21. See pp 399-408 in
the Reader.

TASK 2 – Identify mass media strategies relevant to alcohol prevention

Are there any other examples which you have encountered of edutainment or mass
media carrying a strong preventive health message? Would any of these strategies
work for alcohol problems in your area?

Try using the WHO criteria summarised above to evaluate educational media.

5 SESSION SUMMARY

This session provided a brief overview of educational strategies being used to
raise awareness of alcohol problems and to shift behaviour towards sensible, or
low risk use of alcohol. However, in the face of the continuous pressure being
applied by companies marketing alcohol, educational programmes have to work
hard at countering the image of alcohol portrayed in the media. It has therefore
been suggested that education and skills building, through organisations like

schools and the mass media, have a role to play in enabling people, especially
youth, to make responsible decisions about using alcohol.

6 FURTHER READING

 WHO. (2002). Prevention of Psychoactive Substance Use. A Selected
Review of What Works in the Area of Prevention. Geneva: WHO, Dept of
Mental Health and Substance Dependence: 56-57.

 U.S. Dept of Health and Human Services. (June 2000). Ch 5 - Prenatal
Exposure to Alcohol. In: Special Report to US Congress on Alcohol and
Health. Rockville: National Institute on Alcohol Abuse and Alcoholism:
323-338.


Unit 4 - Session 2
Early Intervention
Introduction

In this session, we explore the Brief Intervention approach, which is a strategy for
early intervention in cases of individual alcohol use. Early intervention aims to
identify health problems before any permanent damage is done. Using
prevention terminology, it is referred to as secondary prevention. Although most
of what is written about early identification of alcohol problems comes from the
health sector, the principles should be applied across all service sectors, i.e.
welfare, education, safety and security.

Brief Interventions are promoted as a set of quick, yet effective steps, to ensure
that alcohol related problems are identified, that counseling is offered, and follow-
up is planned. The integration of Brief Interventions into the health services does,
however, require some “reorientation of the health services”. This is in line with
one of the action areas of the Ottawa Charter. It is also important to recognise
that any intervention is only as good as the personnel offering it, as well as the
enabling quality of the environment in which the behavioural change needs to
take place.

Session contents
2 Readings
3 Brief Interventions
4 Capacity for Brief Interventions
5 Session summary

This session contains three readings totalling 33 pages, one of which is a
handbook, and there are two tasks. It should not take you more than two hours to
complete.




 Explain the concept and technique of Brief Interventions.
 Identify key opportunities at a primary care level for alcohol screening,
counseling (motivational interviewing) and referral.
 Describe the requirements for building staff capacity to carry out Brief
Interventions.

2 READINGS

Reader
Fleming, M. & (1999). Brief Intervention in Primary Care 109-120
Manwell, L. B. Settings: A Primary Treatment Method for
At-risk, Problem, and Dependent
Drinkers. Alcohol Research and Health,
23 (2): 128-137.
Living with (1998). Living with Alcohol: A Handbook 129-186
Alcohol. for Community Health Teams. Northern
Territory, Australia: Territory Health
Services: 6-13.
Andersen, P. (1996). Alcohol and Primary Health Care. 19-30
Geneva: WHO: 39-56.

3 BRIEF INTERVENTIONS

There is unfortunately a general trend for service providers to approach alcohol
related social and medical problems in a way that tries to deal with the symptoms
of the problem, instead of its root cause. For example, an injured pedestrian
presenting at a trauma unit will have the wound cleaned, stitched and bandaged,
receive pain killers and be sent home. Seldom will a history of the event be taken
to clarify the underlying cause of injury (which could be intoxication). Similarly,
behavioural problems such as domestic violence, absenteeism from work and
neglect of family responsibilities will not necessarily be investigated for their root
cause. In communities with recognised problems of alcohol abuse amongst


adults, service providers often accept that alcohol is potentially the underlying
problem, but they seldom have the confidence or will to deal directly with it.

The following reading by Fleming and Manwell (1999) introduces the rationale
behind Brief Interventions and describes the basic steps in the technique.
Although the literature often refers to “the physician” as the provider, Brief
Interventions can be undertaken by any health and social service provider. Note
that Brief Interventions have “… proved to be effective” (Fleming & Manwell,
1999: 129) and go beyond counselling, to include the assessment, counselling,
referral to support services or specialist services, and a follow-up plan. The
article outlines the essential elements or steps in the process, presents evidence
of the results of its use in primary care settings, and places the approach in
context with regard to alcohol problems and other intervention approaches.
Acquaint yourself with Task 1 before you start reading.

READING: Fleming, M. & Manwell, L. B. (1999). Brief Intervention in Primary Care
Settings: A Primary Treatment Method for At-risk, Problem, and Dependent
Drinkers. Alcohol Research and Health, 23 (2): 128-137. See pp 109-120 in the
Reader.

TASK 1 – Try out a simulated Brief Intervention

a) Ask a colleague or friend to role play a Brief Intervention with you, using the Five
Essential Steps on page 130 of the reading by Fleming and Manwell (1999).
The most important part of this process will be to discuss with your colleague or
friend how they felt during the process and how you came across when asking
the questions. Were you sufficiently respectful, were you empathetic but firm?
This will give you some insights into the experience of an individual who is at
the receiving end of a Brief Intervention.

b) What factors might influence the way the client received the message of the
Brief Intervention?

Many authors, in discussing Brief Interventions, also refer to a Behaviour Change
Model – the Stages of Change Model developed by Jim Prochaska and Carlo Di
Clemente. The point they make is that the impact of the counselling message
may differ according to the client’s level of realisation or recognition of the
problem, and their level of motivation to change. Take a look at the diagram
below (Rollnick et al, 1999: 19) which is adapted from Prochaska and Di
Clemente and identifies six stages of readiness to change.


SIX STAGES OF READINESS TO CHANGE

Contemplation Determination

Precontemplation Action

Relapse Maintenance

Permanent Exit

In the context of Brief Interventions, the actual counselling part is referred to as
motivational interviewing. There are many booklets and charts available to assist
service providers to use this theory to be more effective in their counselling.
Study the example of an alcohol intervention booklet from Australia developed by
a group called Living with Alcohol (1998), and decide to what extent it could be
used in your own context. The booklet presents a range of helpful questions to
prompt you to prepare yourself to conduct an alcohol intervention.

READING: Living with Alcohol. (1998). Living with Alcohol: A Handbook for
Community Health Teams. Northern Territory, Australia: Territory Health Services:
6-13. See pp 179-186 in the Reader.


4 CAPACITY FOR BRIEF INTERVENTIONS

As with so many interventions at a primary care level, there are inevitably
problems with the capacity and facilities to render these effectively. The
consumers also have perceptions and expectations as to what treatment they
should receive when attending a primary level facility. Unfortunately, Brief
Interventions fall easily into the category of “non-essential” services, and may be
seen as requiring too much time per consultation.

The following reading offers insight into some of the barriers to implementing
Brief Interventions, and draws attention to the capacity building strategies
necessary to equip providers to be effective.

READING: Andersen, P. (1996). Alcohol and Primary Health Care. Geneva: WHO:
39-56. See pp 19-30 in the Reader.

TASK 2 – Consider the use of Brief Interventions

Consider your local primary level health service provider, whether public or private,
and answer the following questions:

a) When going for a consultation, is your use of alcohol discussed, no matter what
the presenting problem is?

b) If you told your health professional that you were drinking excessively, what
would his or her approach be and what sort of advice would you expect?

c) Do you think your provider knows about the techniques of Brief Interventions?

d) If you were a health manager in the area where you live, what strategies would
you use to ensure that all public and private health services implement brief
interventions for alcohol related problems?

We have already noted that alcohol is not widely recognised as a significant
Public Health issue in Southern Africa, a factor which is likely to influence the
allocation of resources for capacity building, as well as the importance accorded
to alcohol counseling programmes in health facilities. Think back to the
economics of alcohol production, and the cultures which surround drinking in
your own context. Are these potential factors for under-valuing alcohol problems
in the field of Public Health?


5 SESSION SUMMARY

There is a lot of work to be done within the primary level of health and social
service provision to increase screening and counseling for alcohol related
problems. If more practitioners were to be equipped with Brief Intervention skills,
there would hopefully be fewer people requiring rehabilitation for alcohol
dependence, less violence, fewer accidents and chronic health problems.

The concept of a Brief Intervention can be applied to many health related
problems such as diet, exercise and smoking: this health promoting approach
could therefore be used to impact on a range of conditions. In the final session of
this unit, we discuss rehabilitation.

 Rollnick, S., Mason, P., Butler, C. (1999). Health Behaviour Change: A Guide
for Practitioners. Philadelphia: Churchill Livingstone.


Unit 4 - Session 3
Rehabilitation
Introduction
As alcohol abuse becomes more recognised as a health and lifestyle problem,
there need to be support services to match the demand. The first two readings in
this session contextualise alcohol dependency in the life course and describe the
recovery from alcohol dependency as an individual process, the outcome of
which is difficult to predict. One of the support organisations dealt with in some
detail is Alcoholics Anonymous (AA).

In this session, we focus mainly on the western medical model rehabilitation
services and examine their levels of suitability for the population, using the
example of the Gauteng Province in South Africa. The appropriateness of
rehabilitation services is taken further by exploring the “fit” of traditional western
rehabilitation programmes for women with alcohol problems.

Session contents

2 Readings
3 Treatment for alcohol dependence
4 Accessibility and appropriateness of treatment
5 Session summary


This session includes four readings totalling 42 pages. In addition, there are
two tasks. It should take you about three hours to complete.




 Discuss the potential for people to overcome alcohol dependency, and the
factors that influence the ability to practice “normal drinking”.
 Understand the aspects of western rehabilitation services which need to change
in order to improve access, appropriateness, affordability and availability.

2 READINGS

Reader
Edwards, G., (1997). Ch 11 - Drinking Problems and 79-86
Marshall, E. J. & the Life Course. Treatment of Drinking
Professions. Cambridge: Cambridge
Edwards, G., (1997). Ch 18 - Working Towards Normal 87-92
Marshall, E. J. & Drinking. Treatment of Drinking
Professions. 3rd Edition. Cambridge:
Cambridge University Press: 305-309.
Beckman, L. J. (1994). Treatment Needs of Women with 32-38
Alcohol Problems: Theory, Methods and
Empirical Findings. Alcohol Health and
Research World, 18(3): 206-211.
Myers, B. (2004) Audit of specialist substances 237-256
abuse treatment facilities in Gauteng:
Monitoring substance abuse treatment
service delivery.
Cape Town: Medical Research Council,
Alcohol and Drug Research Group: 7-17
& 95 - 101


3 TREATMENT FOR ALCOHOL DEPENDENCE
Whatever one’s view of alcohol dependence - the extent to which it is seen as a
disease which is genetically linked, or socially acquired - there are people in all
societies who become addicted to alcohol, suffering reduced daily functioning
and long term health problems. For this reason, tertiary or specialised facilities
are necessary, as are community based support groups to assist people to gain
and maintain control over their addiction for as long as possible.

The treatment of alcohol dependence typically can include: short term medical
intervention and management of detoxification over a few days, followed by
residential care of varying duration, or outpatient treatment. We are not going to
discuss the actual rehabilitation programmes typically used in Southern Africa. It
suffices to say that most established and registered rehabilitation centres use the
same approaches and methods as in western countries. However, the majority of
the population either does not have access to these centres, and or makes use
of a different approach, based on traditional medicine or spiritual healing,
directed by their religious affiliation. Little is written about the conceptualisation of
and approach to alcohol addiction in traditional African groupings.

The next readings by Edwards, Marshall & Cook (1997) explore alcohol
dependence and the factors that may indicate the potential for successful
rehabilitation in different individuals. The point is also made that dealing with
alcohol dependence is a long term process and not just a once off rehabilitation
event.

Some people are also more likely to be able to be “normal drinkers” than others.
The factors influencing this are covered in Chapter 18.

READINGS:
Edwards, G., Marshall, E. J. & Cook, C. C. H. (1997). Ch 11 - Drinking Problems
and the Life Course. Treatment of Drinking Problems: A Guide for the Helping
Professions. 3rd Edition. Cambridge: Cambridge University Press: 175-185. See pp

Edwards, G., Marshall, E. J. & Cook, C. C. H. (1997). Ch 18 - Working Towards
Normal Drinking. Treatment of Drinking Problems: A Guide for the Helping
Professions. 3rd Edition. Cambridge: Cambridge University Press: 305-309. See pp

Alcoholics Anonymous (AA) is a well established voluntary network of groups of
people who meet regularly to support each other to maintain their sobriety.
Although some people do not identify with the religiously based 12 Steps that
form the basis of the AA philosophy, there is research evidence to indicate that it
assists many people with strengthening their commitment to sobriety. It also
provides an alternative social setting to the drinking environment, and a buddy
system of support. The organisation originates in the USA and has spread across


the globe. It seems that in Southern Africa, there are branches in some of the
urban areas (Parry & Bennetts, 1998:173).

These are the AA’s “12 steps”:

1. We admit we were powerless over alcohol – that our lives had become
unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we
understand Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of
our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends
to them all.
9. Made direct amends to such people wherever possible, except when to do so
would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly
admitted it.
11. Sought through prayer and meditation to improve our conscious contact with
God as we understand him, praying only for knowledge of His will for us and
the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry
this message to alcoholics and to practice these principles in all our affairs.

4 ACCESSIBILITY AND APPROPRIATENESS OF TREATMENT

There is little research or follow-up done on people who have attended formal
rehabilitation, and even less research on people who have alcohol dependency,
but succeed in gaining control over it through religious conversion or personal will
power. We can therefore only assume that there is some value in these
formalised treatment programmes, based on established western medical model
approach, which are offered in Southern Africa.

From a Public Health point of view it is important that rehabilitation services are,
like any other health service, available, accessible, affordable, and appropriate.
Unfortunately, alcohol rehabilitation services fall short in all these respects. There
is currently an audit process underway in South Africa using these four criteria,
and so far, Cape Town and Gauteng have been covered. The results indicate
much room for improvement in all four of these measures. Gauteng and Cape
Town probably have the most resources and best developed services in


Southern Africa, so if the rehabilitation services in these areas are found to be
inadequate, those in other areas are likely to be almost non-existent.

READING: Myers, B. (2004). Audit of Specialist Substances Abuse Treatment
Facilities in Gauteng: Monitoring Substance Abuse Treatment Service Delivery.
Cape Town: Medical Research Council, Alcohol and Drug Abuse Research Group:
7-17 & 95-101. See pp 237-256 in the Reader.

TASK 1 – Accessibility and appropriateness of rehabilitation services

Find out about the alcohol rehabilitation services nearest to your community –
inpatient and outpatient.

a) Try to establish what the criteria are for admission into these programmes, and
if there are any barriers in terms of cost, language or diagnosis.

b) Are they accessible and appropriate for anyone in the catchment area who may
require the services? If they are not, why is this?

To return to our theme of understanding alcohol use by women, the next article
by Beckman (1994) questions the applicability of the well established in-patient
treatment model, and proposes “women-oriented alcoholism treatment”. Such
treatment requires health practitioners to rethink their attitudes and practices,
taking account of women’s preferred styles of interaction and of the particular
experiences of alcoholic women, such as physical and sexual abuse or
reproductive health problems.

READING: Beckman, L. J. (1994). Treatment Needs of Women with Alcohol
Problems: Theory, Methods and Empirical Findings. Alcohol Health and Research
World, 18(3): 206-211. See pp 31-38 in the Reader.

TASK 2 – Women’s roles and needs with regard to alcohol

a) After reading the article about women oriented alcohol treatment, think
about the gender roles that women in your culture play on a daily basis.
How is “alcoholism” in women viewed in your community?
b) Could a women only treatment programme that takes women’s roles and
needs into account be acceptable and successful if offered in your area?
Why or why not?

5 SESSION SUMMARY
In this session we have concentrated more on the issues of accessibility of
rehabilitation services than on the nature of the services per se. We have also
emphasised the point that some people with alcohol dependency will have to try
to abstain from ever using alcohol, while others may be able to learn to be
“normal drinkers”.

It should be part of any advocacy work around alcohol problems to lobby for
appropriate rehabilitation and counseling services for all people in a given
population who may need the service. This is a challenge when we plan for the
diversity one finds in Southern Africa in terms of belief systems, religion,
language and gender. At present, by screening people for alcohol problems, we
may be raising false hopes that they can be helped to overcome their alcohol
problems, since there is such low capacity in the health and welfare services.

This is the end of the module: we hope that it has been interesting, and
stimulated you to continue to work in this field or to add your capacity to building
this field. We would be most grateful if you would give us some feedback by
filling in the evaluation form over the page, and sending it back with your
assignment. Good luck with your endeavours in the area of alcohol problems!


 Parry, C.D.H. & Bennetts A. (1998) Alcohol Policy and Public Health in South
Africa. Cape Town: Oxford University.
 Morgenstern, J., Labouvie, E., McCrady, B. S., Kahler, C. W. & Frey, R. M.
(1997). Affiliation with Alcoholics Anonymous after Treatment: A Study of its
Therapeutic Effects and Mechanisms of Action. Journal of Consulting and
Clinical Psychology, 65 (5): 768-777.
 Myers, B. & Parry, C. (2003). Report on Audit of Substance Abuse Treatment
Facilities in Cape Town - 2002. Cape Town: Alcohol & Drug Abuse Research
Group, Medical Research Council.


ALCOHOL PROBLEMS: A HEALTH PROMOTION APPROACH

READINGS

Author/s Reference Details
Ambler, C. & (1992). Ch 1 - Alcohol in Southern African Labor History. In J.
Crush, J. Crush & C. Ambler (eds). Liquor and Labor in Southern Africa.
Pietermaritzburg: University of Natal Press: 1-35.
Andersen, P. (1996). Alcohol and Primary Health Care. Geneva: WHO:
39-56.-

Beckman, L. J. (1994). Treatment Needs of Women with Alcohol Problems.
Alcohol Health and Research World, 18(3): 206-211.
Bennett, L. A., (1993). Boundaries Between Normal and Pathological Drinking:
Janca, A., Grant, A Cross-Cultural Comparison. Alcohol Health & Research
B. F. & Sartorius, World, 17 (3): 190-195.
N.
Botvin, G. J. & (2000). Preventing Alcohol and Tobacco Use Through Life Skills
Kantor, L. W. Training. Alcohol Research and Health, 24 (4): 250-257.
Claasen, J. N. (Sept. 1999). The Benefits of the CAGE as a Screening Tool for
Alcoholism in a Closed Rural South African Community. South
African Medical Journal, 89 (9): 976-979.
Croxford, J. & (Sept. 1999). Alcohol Consumption by Pregnant Women in
Viljoen, D. Western Cape. South African Medical Journal, 89: 962-965.
Crundall, I. (undated). The Northern Territory Living with Alcohol Program:
Climbing Through a Window of Opportunity. Australia: 98-105.
Edwards, G., (1997). Ch 11 - Drinking Problems and the Life Course. In
Marshall, E. J. & Treatment of Drinking Problems: A Guide for the Helping
Cook, C. C. H. Professions. Cambridge, UK: Cambridge University Press:
175-185.
Edwards, G., (1997). Ch 18 - Working Towards Normal Drinking. In Treatment
Marshall, E. J. & of Drinking Problems: A Guide for the Helping Professions.
Cook, C. C. H. Cambridge, UK: Cambridge University Press: 305-309.

Fingarette, H. (1988). Ch 3 - What Causes Alcoholism? Heavy Drinking: The
Myth of Alcoholism as a Disease. California: University of
California Press: 48-69.
Fleming, M. & (1999). Brief Intervention in Primary Care Settings: A Primary
Manwell, L. B. Treatment Method for At-risk, Problem, and Dependent Drinkers.
Alcohol Research and Health, 23 (2): 128-137.
Flisher, A. J. et al. (2001). Substance Use by Students in South Africa, Tanzania
and Zimbabwe. African Journal of Drug & Alcohol Studies, 1 (2):
81-97.
Grant, M. & (1998). Ch 15 - Shifting the Paradigm: Reducing Harm and

Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Re a d in g s 113

Single, E. Promoting Beneficial Patterns. In M. Grant & L. Litvak. Drinking
Patterns and Their Consequences. International Centre for
Alcohol Policies: 287-294.
Gureje, O. (Aug, 2000). The Health Claims of Alcohol: Contextual
Considerations for Africa and the Developing World.
Proceedings of the Global Alcohol Policy Advocacy Conference.
Syracuse, New York: The Globe, Special Edition: 33-35.
Heath, D. B. (2000). Ch 7 - Conclusions and Implications. In Drinking
Occasions: Comparative Perspectives on Alcohol and Culture.
USA: International Centre for Alcohol Policies: 191-198.
Jackson, M. C., (2000). Marketing Alcohol to Young People: Implications for
Hastings, G., Industry Regulation and Research Policy. Addiction, 95,
Wheeler, C., Supplement 4: S597-S608.
Eadie, D. &
Mackintosh, A. M.
Jernigan, D. H. (1999). Ch 9 - Country Profile on Alcohol in Zimbabwe. In L.
Riley & M. Marshall (eds.). Alcohol and Public Health in 8
Developing Countries. Geneva: WHO: 157-175.
Living with (1998). Living with Alcohol: A Handbook for Community Health
Alcohol Teams. Northern Territory, Australia: Territory Health Services:
Programme. 6-13.
London, L., Nell, (1998). Health Status Among Farm Workers in the Western
V., Thompson, M- Cape – Collateral Evidence from a Study of Occupational
L. & Myers, J. E. Hazards. South African Medical Journal, 88 (9): 1096-1101.
May, P. A. (1995). A Multiple-level Comprehensive Approach to the
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116 Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Re a d in g s

ALCOHOL PROBLEMS: A HEALTH PROMOTING APPROACH:
EVALUATION QUESTIONS
SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF THE WESTERN CAPE

Please give us some feedback on this module. Thank you.

1. In general, how do you feel about the module?
2. Did any aspects of the module challenge you to think more deeply about a health
promoting approach to alcohol problems?
3. Are there any sections of the module which could be better explained? Be as specific as
possible.
4. Were there any sections or sessions that you felt were unnecessary?
5. Were there any topics that you felt should have been included in the module?
6. Are there any improvements you could suggest to the assignment?
7. Are there any interesting readings which you feel should be added to the module?
8. Do you have any intention to use or adapt any part of the module?

Date:
Place:
Do you play a role in the field of Public Health? If so what?
Your name: [optional]:

Please paste your response into an email to: Ms L Alexander, SOPH, UWC
lalexander@uwc.ac.za

Masters in Public Health: Alcohol Problems - A Health Promotion Approach: Fee d ba ck 117

Alcohol Problems: A Health Promotion Approach Module Guide

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