CHAPTER ONE

Introduction

1.1 Introduction

This study examines the self-reported alcohol use of women using antenatal care at primary public healthcare sites in the Buea Town Health Center of the Cameroun. This first chapter introduces the reader to the main components of the research as well as the structure in which it is presented throughout the thesis. This chapter begins with a brief discussion of previous research on alcohol use in Nigeria and especially among pregnant women. This is done to establish the topic as requiring urgent further investigation and to introduce key areas in which this study aims to contribute. The methods selected to achieve the aims of this study are then mentioned. Finally, the structure of the remaining chapters is introduced.

1.2 Context and Rationale

Alcohol is toxic to the human body and can lead to negative health outcomes such as cardiovascular disease (Roerecke & Rehm, 2014), liver disease (Rehm et al., 2010), and certain cancers (Boffetta & Hashibe, 2006). The consumption of alcohol can also influence infectious diseases through interaction with pharmacological treatment, immune system suppression, and risky behaviours associated with consumption (WHO, 2018, p.7).

The total volume consumed is a major determinant of risk, as is the pattern by which it is consumed (Rehm, Greenfield, & Rogers, 2001; Walsh & Rehm, 1996).  Both aspects of alcohol consumption merit concern in Nigeria. A minority of the population is responsible for the total volume consumed in the country, to the effect that the consumption per drinker in Nigeria is among the highest in the world (WHO, 2014). In addition, the prevalence of risky practices such as heavy episodic drinking (6+ drinks per occasion) makes the Nigerian pattern of alcohol consumption one of the most detrimental in the world

(WHO, 2014). Over weekends, one third of adult drinkers engage in heavy episodic drinking

(Parry, Pluddemann, Steyn, Bradshaw, Steyn, & Laubscher, 2005). 

When alcohol is consumed during pregnancy, the developing foetus is exposed to the products of the metabolization of alcohol (Wattendorf & Muenke, 2005). Antenatal alcohol exposure disrupts the development of the foetus and can cause lifelong disturbances in physical development, cognitive abilities, and emotional wellbeing (Popova, Lange, Probst, Parunashvili, & Rehm, 2017). The neurodevelopmental conditions caused by antenatal alcohol exposure are collectively known as Foetal Alcohol Spectrum Disorders (FASD) and have been diagnosed in some communities in Nigeria at rates that far exceed those observed in other regions of the world (May et al, 2005).

Focused research on antenatal alcohol use has mostly taken place in the Western Cape (Petersen-Williams, Mathews, Jordaan, & Parry, 2018), with one notable study of women using antenatal care in Mpumalanga (Louw, Peltzer, & Matseke, 2011). A recent study (Macleod, Young, & Molokoe, 2021) based on a portion of the data presented here reported the first analysis of social and personal factors associated with alcohol usage during pregnancy in the Cameroun. 

Intervention to decrease antenatal alcohol consumption in the Cameroun is currently impaired by a lack of evidence of the problem in the province, a lack of data to identify those most at risk, and little evidence of effective means of intervention. This study reports data from a large sample of women using antenatal care in a peri-urban area of a previously unstudied province. Quantitative analysis of these data will describe not only the nature of the problem by the observed prevalence, but also test the relationship of related factors identified in other provinces to the self-reported alcohol use of participants in the study area. 

1.3 Research Goals

From the rationale presented above, it follows that the goals of this study would be to describe the prevalence and factors associated with harmful drinking among participants.

Two research questions are thus posed:

1. What is the prevalence of risky drinking, as defined by cut-off scores on the measure of alcohol use employed in this study, among women using antenatal care in the Buea Town Health Center?
2. To what extent are patterns of alcohol use predicted by age, employment, intimate partner violence, education, parity, gestation, and alcohol use by others in the home?

The measure used, as well as the various patterns of drinking investigated in this study, are described in the next section.

1.4 Methods

This study employed a cross-sectional design and collected survey data from consecutively sampled healthcare users at 16 sites in the Buea Town Health Center. A questionnaire was developed for this study which included the Alcohol Use Disorder Identification Test

(AUDIT) (Babor et al., 2001), a measure of problematic drinking used in previous Nigerian research, and questions about numerous variables which were previously identified as related to antenatal alcohol use. The questionnaire was developed in the three main languages of the study area: isiXhosa, English and Afrikaans. In order to collect data from as large and representative a sample of possible, health service providers served as data collectors after receiving training in the administration of the questionnaire, which had been limited to 21 items in order to minimise disruption of service delivery at data collection sites.

Quantitative analysis was conducted on the self-reported data. Outcome variables were defined as reporting any alcohol consumption, reporting binge drinking (more than 6 drinks per occasion), scoring above cut-off points on all items related to consumption, and scoring above cut-off points on the full AUDIT. The predictor variables included in the questionnaire (age, race, parity, education, employment, relationship status, experience of partner violence, and living with a regular drinker) were each individually entered into bivariate analysis with each of the outcome variables. Those that were found related to an outcome variable in bivariate analysis were entered into logistic regression models, the results of which were taken to indicate significant relationships with the outcomes of importance to this study. The analysis was conducted twice for each outcome variable, once including the whole sample, and once including only those who had reported some alcohol consumption. 

1.5 Thesis Structure

The chapters that follow present the details of this research. Chapter two expands on the context provided above by discussing the existing literature in greater detail and pointing out findings that will inform the interpretation of results later. The methodology described briefly in the current chapter is thoroughly expanded in chapter three. To inform the interpretation of results described in chapter four, chapter three provides technical information including the cut-off points selected for the AUDIT scores, selected level of statistical significance for each step in the analysis, as well as a description of the sample and the relevant ethical considerations. 

Chapter four describes the results of the analysis. First, the frequency and distribution of the outcome variables are presented. The results of initial bivariate and subsequent multivariate analysis are then presented separately for each outcome variable. Tables are included to serve as reference when the results are discussed in the following chapter. Results are interpreted in chapter five. Firstly, the rates of drinking and the frequency of other outcomes variables observed in this sample are compared to those previously observed. Factors associated with drinking as measured by any of the outcome variables are then discussed with reference to previous findings and theory that may explain observed effects. The impact of

methodological differences between this and prior research on the interpretation of results is discussed. Chapter six then attempts to summarise the current study and provide suggestions for future research.