Melbourne School of Population and Global Health - Theses
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ItemDimensions of alcohol's harm to others and implications for policy and service in low- and middle-income countries, including a case study of Thailand( 2018)This thesis focuses on alcohol’s harm to others (HTO), the negative effects of alcohol consumption on other people around the drinker. Secondary analysis was undertaken using population survey data of five low- and middle-income countries (LMICs), including Thailand, Sri Lanka, India, Laos and Vietnam, which employed the WHO/ThaiHealth Research Protocol, aiming to understand situations of HTO in LMICs. This thesis found that harms from others’ drinking-related aggression, violence and misconduct are prevalent in the population at large of the five LMICs (50-73%); the most commonly reported harms: public disturbance and insult or harassment due to others’ drinking. More serious forms of HTO (assaults and traffic harms) were less commonly reported than public disturbance or harassment, but still stood out as substantial. When compared with high-income countries, these figures were much larger, in particular when calculated by per capita consumption or “harm per litre”. Variations in rates between demographics by harm type and by country are evident. Predominantly, men were more likely than women to experience harm from others’ drinking, especially traffic harm, whereas women were more likely to feel unsafe and afraid because of others’ drinking than men. Generally, young, people with less formal education, and those living in urban areas were most at risk of being harmed by others’ drinking. The analysis of Thai data revealed that people around drinkers also paid a high price for others’ drinking, with 21% of Thais experienced financial harms due to others’ drinking in the last year. The greater part of total costs was incurred as a result of property damaged due to others’ drinking. The poorer the family, the greater the financial burden. The more frequent the drinking pattern, the closer to the drinker, the greater the consequences reported. Those being harmed financially were more likely to perceive that they had been strongly negatively affected compared with those who did not experience any financial harm. Rates of seeking help due to others’ drinking were relatively low (7-20%). Affected people in most countries more commonly sought help from informal sources than from police or health services. There was no consistent pattern across countries for the relationships between demographics and seeking help for HTO. Where there were rural/urban differences, those living in a non-rural area sought help from the police more often than those living in a rural area. In conclusion, this thesis revealed a high prevalence of HTO and relatively low rates of help-seeking due to others’ drinking in the five Asian countries, and considerable costs to others around drinkers. These findings support the need for more efforts to strengthen alcohol policies in LMICs, particularly to address heavy drinking patterns, alongside the need for more available, accessible and improved social response services for those who need help. Alcohol policies should aim not only to reduce harms to drinkers, but also to limit harm to others. Additionally, this thesis points out gaps in knowledge and contributes to the improvement of routine data collection systems and research methodology in the HTO field.
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ItemLocal input in issuing liquor licences: contemporary policy issues in historical context( 2017)Since the 1970s, increased alcohol availability in Victoria has resulted from neoliberal policies and market-oriented reforms, and rates of harms from drinking have risen despite relative stability in level of consumption. Local government roles in planning and licensing decision-making have been regarded as a potential corrective. This thesis examines approaches to issuing new liquor licences in local areas across five empirical chapters. These approaches include 1) involving residents in decisions about new licenses through polls, and 2) empowering local governments to influence the issuing of licences through planning and licensing mechanisms. Both approaches potentially limit the growth in local alcohol availability, and, therefore potentially also reduce alcohol-related harms. The research was guided by a pragmatic epistemology, drawing on historical, documentary, interview, and quantitative methods to assess the potential of local regulatory approaches to limit the local availability of alcohol. The research on the local licensing poll examines the formation and longevity of the poll as well as providing a descriptive analysis of the 57 local polls conducted between 1955 and 2014. The research illustrates the power of local lobby groups and political compromise in maintaining Local Option. This living relic, which was antithetical to politicians’ general inclinations and the dominant free-market ideology of the time, enabled residents to restrict the local availability of alcohol. The research on the role of local government comprises: interviews with 22 local government officers from 11 Victoria municipalities covering regional, rural, suburban and inner-city areas; analysis of local government planning policies; and further interviews and policy document analysis with Melbourne’s four inner-city municipalities. Data was analysed thematically from an applied policy perspective. Interviews with local government officers revealed the challenges involved in using planning policy to restrict growth in alcohol availability. These included accessing and compiling data; constraint in role and powers as defined and devolved by state government; and ambiguity about whether health and wellbeing were relevant considerations within a planning regulatory framework. Overall, these challenges suggest that changes to planning policy alone are unlikely to provide a means of restricting alcohol availability. This thesis demonstrates the significant challenges in implementing local control over alcohol availability. Providing for a greater role for local government and local input in decisions to issue licences requires legislative frameworks which endow voters and local governments with meaningful power to enact their decisions and resist strong commercial interests.
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ItemGonna drink, get drunk: a history and ethnography of alcohol in Rarotonga, Cook Islands( 2002-11)This thesis describes the place of alcohol in the lives of people from Rarotonga, Cook Islands. It incorporates historical and ethnographic analyses to provide the broad context of drinking by people aged from their teens to late thirties. The historical component of this study describes specific accounts of alcohol consumption, and situates these with regard to changes that occurred in Rarotonga from the early 19th century. Prior to contact with Papa’a (Europeans), people of Rarotonga neither produced nor consumed alcoholic beverages. Thus, the use of alcohol was a phenomenon intimately bound up with global exploration, proselytisation and trade. I trace historical changes in the distribution of power, resources, religious practice, and social discourse, and show how alcohol practice, distribution, and trade was linked to these changes from missionary contact onward. This history informs the ethnography of contemporary drinking practices. Individual and group practices and understandings of alcohol are described. I also describe the contribution of state policy, commercial interests, government institutions, and religious organisations to the place of alcohol in Rarotonga. Alcohol is a transformative substance that changes the comportment of drinkers. But its effect is ambiguous, and recognised as such. ‘Drunken’ behaviours are often explained as originating in concerns and desires that pertain in sobriety. Thus, the status of alcohol consumption as an explanation for specific behaviours is equivocal, and contested. Drinking is a means by which relationships between friends, kin and strangers are initiated and/or maintained. The particular significance of alcohol to the maintenance of (drinking) relationships is not only due to social constructions of meanings and practices associated with drinking; pharmacological effects of alcohol increase the social salience of drinking. Drinking both alters bodies and alters relationships between drinkers. In this sense, it embodies social meanings and understandings of drinking practice. Finally, I suggest that in Rarotonga, the association of drinking with emotional experience and behaviour is also, in part, attributable to the ‘embodied’ experience of alcohol. The form of emotional experience, and the form of embodied experience of alcohol, are similar. These are associated with one another through analogy (and so by the social construction of each) by embodied experience.
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ItemPleasure and poison: the meanings and practices of alcohol use in women's everyday lives( 1997-04)Within Australia, research on women and alcohol has been predominantly focussed on either large scale surveys of women’s consumption or on alcohol problems studies within treatment populations. Such research mainly draws upon the biomedical understandings of the body and the disease model of alcoholism. In contrast, this study examines the meanings and practices of alcohol use within the social contexts of women’s everyday lives. Alcohol is viewed as a part of life rather than as an excess or problem.
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ItemAlcohol and child maltreatment in Australia through the windows of child protection and a national survey( 2013)This thesis describes the adverse effects of others’ drinking on children as viewed through two different windows. The first focuses on children in the Victorian child protection system. It examines how many, and in what ways children have been affected by the drinking of their carers as recorded by child protection workers between 2001 and 2005 in routine electronic databases. In the second window, national survey data are used to estimate the prevalence of households where children have been affected by someone else’s drinking in the last year, using questions that stem from key definitions of types of child maltreatment. This researchi) documents the extent of alcohol involvement in child protection cases in Victoria,ii) explores and defines risk factors for child protection outcomes, including the role of alcohol, comorbidities and socio-economic factors,iii) assesses the number of Australian households where children have been affected by someone else’s drinking, andiv) compares the size and social location of alcohol-related harms to children in the child protection system and the general population Carer alcohol abuse was reported in a third of all substantiated child protection cases across Victoria. Alcohol was implicated in 27% of physical, 12% of sexual, 39% of emotional and 35% of neglect cases. As further intervention was required, the percentage of cases that involved alcohol increased – from 25% of cases that were substantiated but required no further intervention, to 42% of cases that involved court orders. Alcohol abuse and multiple other “risk factors’, including likely other drug abuse, carer mental ill-health, unstable housing, low income levels and single parent family composition, were associated with the greater likelihood of receipt of more serious child protection interventions and repeated experiences of child maltreatment. Alcohol-related harm to children in the general population was also measured. One in five (22%) respondents or Australian families reported that their children had been affected in at least some way by others’ drinking in the past year. One per cent reported a child being physically hurt, 9% reported verbal abuse, 3% reported exposure to domestic violence and 3% reported a child being left alone or unsupervised because of others’ drinking. These alcohol-related harms to children were prevalent across the socio-economic strata examined. A greater proportion of alcohol-related harm to children in the community exists in middle and high income groups, although there was a higher prevalence of more severe community harm to children in the lower income group. The vast majority of cases in the child protection system were from disadvantaged groups. This suggests there is underestimation of the risks of others’ drinking for children in the general population, and that government child protection service responses are driven by closer scrutiny of low income groups as well as greater need. The two windows of the study indicate that alcohol-related harms to children from others’ drinking are prevalent. To prevent and minimise further harm to children from their carers’ and others’ heavy drinking, alcohol and child protection policy responses are required.
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ItemPrimary health care workers’ perspectives on the introduction of an alcohol brief intervention program in Chile( 2013)This is a study of a brief intervention (BI) program addressing risky drinking in Chile, introduced in 2011. It investigates health workers’ attitudes to BI, implementation contexts and training needs. It aims to identify enablers and barriers for BI implementation in Primary Health Care (PHC) settings. This topic has not been examined in Chile. Data collection included responses to an online survey from 374 Chilean PHC workers and telephone interviews with six key informants from Chilean health departments. As a mixed-method research project, survey data were subjected to quantitative descriptive analysis and qualitative inductive content analysis, and the interview transcripts were analysed qualitatively. The study shows that while health workers welcome the program, successful implementation is contingent on organisational support, continuous training, on-site supervision and changes in how alcohol-related harm and population-based interventions are understood. Among the most common enablers identified in the study were the positive attitudes towards and good experiences of BI that health staff have, particularly non-professionals, the linkage of BI with existing PHC programs, the opportunity of specific BI training, and the team approach of BI. Conversely, the most frequently mentioned barriers were time constraints and the need for a supportive environment, mainly from workers’ closest contexts (managers and team of the health centre). The study stresses the need to consider system and organisational support to encourage and ensure both sustainability of individual staff changes and integration of the BI program in PHC clinical practices. It suggests that, in order to promote implementation of BI in PHC settings, both the BI training package for health staff and the BI delivery should consider diversity of health workers' needs, keeping a team approach; and also that health non-professionals require additional alcohol-specific and skill-based training and additional support. The study’s findings will be of particular relevance to the design of implementation of BI programs in other countries of similar characteristics like low and middle income and places where a substantial proportion of the health workforce comprises non-professional technicians.
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ItemThe effects of changes in the availability of alcohol on consumption, health and social problems( 2012)Following a long period of relative stability, the liquor licensing regime in Victoria, Australia underwent two decades of dramatic liberalisation from the late 1980s. This liberalisation of policy resulted in a sharp expansion of the number of alcohol outlets in the state. Given the previous studies that have shown links between the density of alcohol outlets and rates of alcohol-related problems, it could be predicted that this expansion of outlet numbers would have contributed to increases in a range of alcohol-related problems. The empirical work of this thesis examines whether this is the case. Initial analyses of state-level data find sharp increases in rates of a range of health and social problems related to alcohol during the period of industry expansion. However, there was no indication in any of the survey data available for Victoria that patterns of consumption had changed markedly over the same period. To test whether the harm trends were indicative of a relationship between outlet density and alcohol problems, a series of small-area spatial studies were undertaken. These studies used spatial statistical methods that deal with the potential problems of using spatial units to model data at the postcode level. These models assessed whether areas with higher densities of outlets experienced higher rates of harm and whether changes in local-level outlet densities were associated with changes in local-level rates of harm. Cross-sectional findings pointed to higher rates of heavy drinking among young adults and higher rates of violence in areas with higher densities of alcohol outlets. Longitudinally, the density of outlets was significantly and positively associated with rates of general assault, domestic violence, assault-related hospitalisations and alcohol-attributable disease rates. Importantly, different types of outlets were important depending on the types of harm examined and the types of neighbourhood focussed on. Broadly speaking, the density of general licence outlets (pubs/hotels) had the strongest association with assault rates, while packaged licence outlets (bottle shops) were more strongly associated with domestic violence and alcohol-attributable disease. These effects varied based on neighbourhood characteristics with, for example, general outlets most related to assault rates in the inner-city areas, while packaged liquor outlets were more associated with assaults in suburban parts of Melbourne. Overall, the findings of this thesis point to significant impacts of the sharp growth of liquor licences in Victoria on alcohol-related harm. These findings have serious implications for licensing policy both in Australia and internationally, suggesting that liberalised licensing policies bring with them substantial health and social costs.