Hazardous Alcohol Drinking and Associated Factors Among Patients with Tuberculosis Attending Public Healthcare Facilities in Gedeo Zone, Southern Ethiopia

Background: Hazardous drinking is a quantity or pattern of alcohol consumption that places individuals at risk for adverse health events. Studies have shown that hazardous alcohol drinking among patients with tuberculosis has been often linked to a decrease in immune system functioning, greater rates of treatment-resistant cases, and death during treatment. However, there are rare studies that assessed the prevalence of hazardous alcohol use and associated factors among patients with tuberculosis in Ethiopia. Therefore, this study was aimed to assess the prevalence of hazardous alcohol drinking and associated factors among patients with tuberculosis attending public healthcare facilities in Gedeo Zone, Southern Ethiopia. Methods: An institution-based, cross-sectional study was conducted among a randomly selected sample of 415 patients with tuberculosis. The study was conducted at the tuberculosis unit of public healthcare facilities in the Gedeo zone, Southern Ethiopia. The Alcohol Use Identication Test (AUDIT) scale was used to measure hazardous alcohol drinking. Data on social support, perceived tuberculosis stigma, and depression were collected using a standard, validated, and structured questionnaire. Results: The prevalence of hazardous alcohol drinking in our study was 20 % (95% CI; 16.1% -24.2%). Medical comorbidity (AOR = 2.44, 95% CI: 1.29–4.62), length of illness (>=12 months) (AOR = 2.88, 95% CI: 1.03–3.04), and being male (AOR = 2.10, 95% CI: 1.17–3.77) were found to be signicant predictors of hazardous alcohol drinking after controlling for potential confounders. Conclusion: A high prevalence of hazardous alcohol drinking was observed among patients with tuberculosis. Therefore, routine screening for alcohol use and a holistic treatment approach for patients with tuberculosis are crucial.


Background
Alcohol is a psychoactive substance with toxic and dependence producing properties, which is widely used across the world. It is a potent drug that causes both acute and chronic changes in almost all neurochemical systems (1).
The World Health Organization (WHO) de nes "hazardous drinking" as "a quantity or pattern of alcohol consumption that places individuals at risk for adverse health events" (2). Hazardous drinking was also de ned as an average consumption of 21 drinks or more per week for men (or ≥7 drinks per occasion at least 3 times a week), and 14 drinks or more per week for women (or ≥5 drinks per occasion at least 3 times a week)." (3).
According to a report from the WHO, globally in 2016, alcohol is the leading cause of premature mortality and disability among those aged 15 to 49 years, accounting for 10% of all deaths in this age group (4).
Worldwide in 2016, the harmful use of alcohol resulted in some 3 million deaths worldwide and 132.6 million disability-adjusted life years (DALYs). Mortality resulting from alcohol consumption is higher than that caused by other communicable and non-communicable diseases (5). Harmful use of alcohol is responsible for 5.1% of the global burden of disease (5).
Tuberculosis (TB) is a potentially serious infectious disease that mainly affects the lungs. The bacteria that cause tuberculosis, Mycobacterium TB are spread from one person to another through tiny droplets released into the air via cough and sneezes (6).
Epidemiological data suggest that a signi cant proportion of patients with tuberculosis had a history of excess alcohol consumption and comorbid alcohol use disorders. A study from the USA revealed that that 15.1% of patients with tuberculosis had reported an excess use of alcohol, with a higher prevalence in males than females (8). Harmful use of alcohol increases the risk of TB threefold and is also a strong risk factor for poor TB treatment adherence (4).
Studies have also shown that alcohol consumption among tuberculosis patients has been often linked to a decrease in immune system functioning, which increases the risk for active tuberculosis (9-11), death during treatment (8) positive smear results (8), higher rates of homelessness (12), and greater rates of treatment resistant cases (13). Thus, early identi cation and management of alcohol use problems among patients with tuberculosis are vital to reduce and possibly prevent the associated negative consequences.
However, there are limited studies that assessed the prevalence of hazardous alcohol drinking and the associated factors among patients with tuberculosis. To the best of our knowledge, there are no previous studies on the prevalence of hazardous alcohol drinking and its associated factors among patients with tuberculosis in Ethiopia. Therefore, this is the rst study to determine the prevalence and associated factors of hazardous alcohol drinking among patients with tuberculosis in Ethiopia.

Study Design and period
Institution-based, cross-sectional study design was used in this study. It was conducted from November 1 to December 30, 2018.

Study setting
The study was conducted among adult patients with tuberculosis attending TB clinics in the public health facilities of Yirgacheffe, Wonago, and Dilla Zuriya districts, Gedeo zone, Southern Ethiopia. Gedeo zone is found in South Nation, Nationalities and Peoples' Regional State of Ethiopia, 359 km southeast of Addis Ababa (the capital city of Ethiopia). In the zone, there are about 42 public healthcare facilities (1 referral hospital, two primary hospitals, and 39 health centers).
Sample size determination and sampling procedure Since this study was the part of the study on 'Prevalence of depressive symptoms and associated factors among patients with tuberculosis attending public health institutions in Gede'o zone, South Ethiopia´ the sample size calculated for depression was used for the current study, with the following assumptions of 95% con dence level, a 5% margin of error and 43.3% prevalence of depression in Ethiopia (14) and a non-response rate of 10% was taken to determine a nal sample size of 415. Study participants were proportionally allocated for each health institution, according to patient ow by referring to the previous year annual reports. A systematic sampling technique was used to select the study participants.

Study participants
All patients with TB attending TB clinic were taken as a source population, while those patients with TB who were available during the data collection period were considered as a study population. Patients aged 18 and above years old and patients who were on anti-TB medicine for at least 2 weeks were included in the study. Those patients who were severely ill during the study period were excluded.

Data sources and measurement
Data were collected using a structured, pretested, and standard questionnaires by face-to-face interview technique. Trained nurses and public health professionals working at the TB clinic were collected the data. The questionnaires included socio-demographic data, Patient Health Questionnaire-9 (PHQ-9), Oslo social support Scale-3, and structured questions for assessment of the associated factors.
The dependent variable hazardous alcohol drinking was measured as a dichotomous variable (Yes/No) on 10 items of the AUDIT, with the cutoff point set at greater than or equal to 8, that is, patients with tuberculosis who scored greater than 8 had hazardous alcohol drinking.
The 10-item Alcohol Disorder Identi cation Test (AUDIT) assesses alcohol consumption level, symptoms of alcohol dependence, and problems associated with alcohol use. Responses to items on the AUDIT are rated on a 4-point Likert scale from 0 to 4, with a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk; a score of 8 and above indicates a tendency toward problematic drinking or hazardous or harmful drinking. The AUDIT was translated into Amharic and back to English by two different language expertise and mental health professionals for checking its consistency (15)(16)(17).

Data quality management
The questionnaire was designed in English and was translated to Amharic and back to English, that is, forward and backward translation. The questionnaire was designed and modi ed appropriately to control the quality of the data. The questionnaire was pretested on 5% of the sample. The data collection process was supervised daily by the supervisors and the principal investigator, and the completed questionnaires were checked for completeness and coded.

Statistical Analysis
Data was entered using Epi Data version 3.1 and analyzed using SPSS-20. Means, frequencies, and percentages were used to summarize the data, which was then presented in the form of gures, tables, and text. The strength of the association was presented by crude odds and adjusted odds ratio with their corresponding 95% CI. Statistical signi cance was set at p<0.05.

Results
Socio-demographic and economic characteristics A total of 409 participants were interviewed, of whom 252 (61.6%) were males. More than fty percent of the participants resided in rural areas. Of the participants, 66.5 % were engaged in government work and private business. One-third of the participants were aged below 24 years and more than 50 % were married. Regarding literacy, 22.5% had not attended formal education, 40.3 % had primary education, and more than one-third, 37.2 % had secondary and above education. The majority of the participants had a monthly income of <1539 and 21.8 % had >= 1539 ETB per month (Table 1). In addition to TB, 71 (17.4%) had HIV, and 22 participants reported having other comorbid chronic illnesses: hypertension (n = 6), cardiac illness (n = 10), diabetes mellitus (n = 2), and kidney disease (n = 4). Only 5.1% had a family history of mental illness. Two hundred thirty-six (57.7 %) were interviewed within 6-12 months of their illness. Nearly half of the participants had depressive symptoms (Table 2).  Key: * = p-value less than 0.05; COR crude odds ratio, AOR adjusted odds ratio, CI confidence interval

Discussion
The prevalence of hazardous alcohol drinking among patients with tuberculosis in the current study was found to be 20% (95 % CI = 16.1-24.2). The current estimate is lower than the studies conducted in Botswana, Lesotho, India, and Thailand (24.7%, 35.1%, 29%, 32%, and 24.4% (10,(19)(20)(21)(22). This might be because of the difference in study setting, study design, study year, socio-demographic, and type of screening tools used.
Even though all studies from Botswana, South India, and Lesotho used AUDIT that might make it similar to the current study, the population, year of study and the socio-demographic difference might account for the difference. The estimate of the current study is consistent with studies reported from South Africa, Scotland, and USA (23.3%, 23.2%, 18%, and 17.9%, respectively (23)(24)(25)(26).
On the other hand, the estimate of the current study is by far higher than the one study conducted in USA (15.1%) (27). The tool used for measuring hazardous alcohol drinking, and the cutoff point used to categorize the patients' alcohol use behavior is completely different from the current study. On top of that, the study design, study time, and the setting at which the current data was collected could be considered as a source of variation in estimation between the current and compared studies.
The current study also identi ed different factors that had an association with hazardous alcohol drinking among patients with TB. Sex of the participant was one of the factors that had a signi cant association with hazardous alcohol drinking. The risk of hazardous alcohol drinking for men participants was higher compared to women. This might be due to the biological differences in reactions to alcohol use, and that gender differences in alcohol use behavior may be modi ed by psychosocial and cultural factors (5,(28)(29)(30). The study result is consistent with institution-based cross-sectional studies from Namibia, Lesotho, India, and Scotland (19,22,25,31).
The other factor that had a signi cant association with hazardous alcohol drinking was the duration of illness. The odds value of hazardous alcohol drinking was 2.88 times higher among those who had longer duration of illness compared to those who had less than 6 months of illness duration. A systematic review conducted on the association between alcohol use, alcohol use disorders, and tuberculosis reported a risk of alcohol use for TB treatment outcome and vice versa (32).
Alcohol use has a negative impact on the clinical course of TB (33,34). People drinking alcohol show higher relapse rates, a higher probability of poor clinical outcome, and a higher probability of experiencing Multi-Drug Resistant-TB (35)(36)(37).
The other factor, which increased the odds range of hazardous alcohol drinking was medical comorbidity, HIV/AIDS, and other chronic diseases. Those who had comorbid medical conditions were 2.44 times at higher risk of being a hazardous alcohol user compared to patients without medical comorbidities (30). Thus, the current nding is supported by WHO Global Status Report on Alcohol and Health 2018 (5). This might be because of the fact that having medical comorbidities will increase stress and other psychological problems.
Unlike other studies, the current study did not nd any association between hazardous alcohol drinking and; age of the participant, marital status, depressive symptoms, social support, and category of TB treatment.
The strengths and limitations of the study Our study has two major strengths. First, the study assessed hazardous alcohol drinking, which was not previously studied. Second, validated and standardized tools were used to assess hazardous alcohol drinking and independent variables.
Since the cross-sectional study design could not establish clear risks of hazardous alcohol drinking among patients with tuberculosis, it was di cult to imply the temporal relationship between signi cantly associated factors and hazardous alcohol drinking. In addition to this, the authors did not consider other mental health issues that can confound the study outcomes. For instance, the presence of severe mental illness and tobacco use, which are commonly associated with alcohol use. Therefore, we recommend further studies to focus on tobacco use and comorbid severe mental health disorders.

Conclusion And Recommendation
In this study, we found that a substantial percentage of patients with tuberculosis were hazardous alcohol drinkers (20%). Having medical comorbidity, a longer duration of illness (12 months and above), being male were found to be signi cant predictors of hazardous alcohol drinking. Therefore, routine screening and a holistic treatment approach of alcohol use among patients with tuberculosis are crucial.