Int J Health Geogr (2007) Baumann
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Associations of social and material deprivation with tobacco, alcohol, and psychotropic drug use, and gender: a population-based study,
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Sommaire
Résumé
- Contexte
- The aim was to assess the relationships between social and material deprivation and the use of tobacco, excessive alcohol and psychotropic drugs by both sexes and in various age groups. Greater knowledge concerning these issues may help public health policy-makers design more effective means of preventing substance abuse.
- Méthode
- The sample comprised 6,216 people aged ≥ 15 years randomly selected from the population in north-eastern France. Subjects completed a post-mailed questionnaire covering socio-demographic characteristics, occupation, employment, income, smoking habit, alcohol abuse and "psychotropic" drug intake (for headache, tiredness, nervousness, anxiety, insomnia). A deprivation score (D) was defined by the cumulative number of: low educational level, manual worker, unemployed, living alone, nationality other than western European, low income, and non-home-ownership. Data were analysed using adjusted odds ratios (ORa) computed with logistic models.
- Résultats
- Deprivation was common: 37.4% of respondents fell into category D = 1, 21.2% into D = 2, and 10.0% into D ≥ 3. More men than women reported tobacco use (30.2% vs. 21.9%) and alcohol abuse (12.5% vs. 3.3%), whereas psychotropic drug use was more common among women (23.8% vs. 41.0%). Increasing levels of deprivation were associated with a greater likelihood of tobacco use (ORa vs. D = 0: 1.16 in D = 1, 1.49 in D = 2, and 1.93 in D ≥ 3), alcohol abuse (1.19 in D = 1, 1.32 in D = 2, and 1.80 in D ≥ 3) and frequent psychotropic drug intake (1.26 in D = 1, 1.51 in D = 2, and 1.91 in D ≥ 3). These patterns were observed in working/other non-retired men and women (except for alcohol abuse in women). Among retired people, deprivation was associated with tobacco and psychotropic drug use only in men.
- Conclusion
- Preventive measures should be designed to improve work conditions, reduce deprivation, and help deprived populations to be more aware of risk and to find remedial measures.
Background
Worldwide, the use of tobacco, alcohol and psychotropic drugs results in substantial morbidity and mortality [1-6]. More than 400,000 people die from cigarette smoking every year, and one in every five deaths in the United States is believed to be smoking-related [7]. The consequences of smoking include respiratory and cardiovascular diseases, cancer, physical disabilities, mental disorders, injury, and death [1-8-14]. Among the effects of alcohol abuse are cirrhosis, cardiovascular disease, cancer, gastrointestinal problems, neurocognitive deficits, bone loss, emotional challenges, depression, deterioration in posture control and mobility, injury, job-loss and premature death [4-15-17]. Psychotropic drug intake is common in Europe [1-2-5-18] and alters health status, increases the risk of cancer, injury, and obesity, and deteriorates quality of life [3-13-19-22]. Substance abuse is associated with poor living conditions [2], and recent research has shown that its aetiology involves genetic, material, social and psychological factors [2]. Use of tobacco, alcohol or psychotropic drugs is widely recognised to be a strong, but controllable, risk factor for poor health and social disparities in health [1-3-5-8-23]. It is therefore necessary, from a pubic health perspective, to identify and help those individuals most at risk. Social and material deprivation affects a large number of people [24-27] and is multidimensional. Factors to consider include low educational level, poor employment status (manual worker, unemployed), living alone, ethnic background (other than western European) low income, and not being a home-owner [28-33]. Findings over recent decades have shown that, taken together, these characteristics result in very difficult living conditions, markedly deteriorated health status, premature death, and unsafe health-related behaviours [8-24-40], notably substance use [1-2-8-23-25-35-36].
Most studies in the literature were focused on one substance, but the patterns of risk may vary from substance to substance due to differences in their social acceptability and other factors. Greater understanding in this area would be expected to lead to improvements in the design of preventive measures. France is a vine growing country where alcohol consumption and psychotropic drug intake are higher than elsewhere, and smoking is prevalent[1-2-5].
Risk patterns may also differ between working and retired people and between the sexes. Many working people, particularly manual workers, use substances in order to cope with work-related difficulties [23-41], and occupations differ between men and women. On the whole, retired people have less good health status and more disability[26-42] than working people due to ageing itself and to having a longer history of working. Risk patterns also vary according to occupational group. Women suffer more from mental disorders than do men[25-42-43], and are more likely to take psychotropic drugs under medical supervision [1-17], to be given them following a medical consultation, to receive longer courses, and to renew the treatment [44].
Key questions in this context concern the relationships between deprivation and tobacco, alcohol and psychotropic drug use. Sex- and age-related differences among active and retired people are also of interest, as are the associations between various dimensions of deprivation and the use of specific substances. Knowledge about these patterns may be of use to professionals directly helping the people concerned, and to those responsible for designing and implementing public health policies intended to reduce social inequalities. Disparities in health are a burgeoning field in which debate is ongoing concerning the models used to explain inequality (particularly whether it is mediated by social, economic and lifestyle-related determinants of health) [29-39-45]. Although social disparities in mortality are greater in France than in other western European countries [34], inequalities in health are poorly documented there [46-48]. Research in recent decades has shed light on the impact of deprivation on health, but most of the work has focused on populations in specific geographic areas defined by neighbourhood deprivation indices [28-30]. Deprivation affects people in most parts of all countries, and epidemiological studies may need to look beyond the so-called "deprived areas" [24-25].
The present study looked at the relationship between social deprivation and substance use among people aged 15+ years in a French population. It investigated (1) the relationships between deprivation and tobacco, excessive alcohol and psychotropic drug use, (2) sex and age differences among working/other non-retired and retired people, and (3) the relationships between various aspects of deprivation, and tobacco, excessive alcohol and psychotropic drug use.
Materials and methods
The initial sample consisted of everyone aged 15 years or more living in 8,000 randomly selected households in the Lorraine region of north-eastern France (2.3 million inhabitants). Only households with a telephone were eligible.
Before the initial survey, a 3-month media campaign (television, print, and radio) was conducted in order to raise awareness. The investigation was approved by the Commission Nationale d'Informatique et Libertés, and written informed consent was obtained from respondents.
The study protocol included: (a) an application to participate that ascertained the number of people in the household, and (b) three standardized self-administered questionnaires with a covering letter and a pre-paid envelope for the reply. Mailings were made at 1-month intervals. When the number of individuals was unknown, two questionnaires were sent first, and another later. Questionnaires were completed by the subjects themselves, but adolescents were free to ask their parents about anything they did not understand. Questions covered: sex, date of birth, educational level, occupation (previous occupation for retired people) coded according to the Insee classification (Paris, 1983), smoking habit, alcohol abuse, nationality, family characteristics, unemployment, home-ownership, perceived income, and psychotropic drug use. Alcohol abuse was defined using the Deta questionnaire (at least two positive responses to four items: (i) consumption considered excessive by the subject; (ii) consumption considered excessive by people around the subject, (iii) subject wishes to reduce consumption, and (iv) consumption on waking)[8-25].With regard to perceived income, subjects were asked whether they considered themselves: comfortable or well off, earning just enough, coping but with difficulties, or getting into debt. Psychotropic drug use was determined by asking whether respondents had frequently taken medication (prescribed and/or non-prescribed) for headache, tiredness, nervousness or anxiety, or insomnia over the previous year (Yes/No)[8-18-43]].Deprivation was defined by the number of positive responses to the following seven criteria: low educational level (primary school), manual worker, unemployed, living alone, nationality other than western European, low income (coping, but with difficulties, or getting into debt), and not being a home-owner [28-30]. Of the 8,000 households included in the sample, mailings to 193 (2%) were lost (due to address error or death). Of 7,807 households contacted, 3,460 (44.3%) participated (all eligible members of the family took part in 86% of those). In total, 6,234 subjects filled in a questionnaire; 18 were of unknown sex or age, leaving 6,216 subjects who were similar in age and sex distribution to the Lorraine population (Table (Table11).
Statistical analyses
The χ2 independence test was used to compare the two sexes for various variables. The deprivation score (D) was defined by the number of the seven criteria considered above and classified into four groups: D = 0, D = 1, D = 2, and D ≥ 3. We also used the principal component analysis in order to define a score as a linear combination of the previous criteria but this was not retained because: (1) the seven eigenvalues found were close enough (1.33, 1.20, 1.06, 0.97, 0.87, 0.84, and 0.73), suggesting that each component contributed almost equally to the D; and (2) the relationships between the deprivation levels defined by the 50th, 75th, and 90th percentile values of the score obtained [49] with tobacco, excessive alcohol, and psychotropic drug use were close to those found with D = 0, D = 1, D = 2, and D ≥ 3. Cronbach's alpha was modest (0.24). To assess the relationships between D and tobacco, excessive alcohol and psychotropic drug use, adjusted odds ratios (ORa) and 95% confidence intervals were calculated using logistic models.
Results
The characteristics of the subjects are shown in Table Table2.2. Deprivation (D) was common: 37.4% of subjects were classified as D = 1, 21.2% D = 2, and 10.0% D ≥ 3. Low educational level, living alone, unemployment, and not being a home-owner were more common among women, whereas men were more likely to be manual workers. Men exhibited a significantly (p < 0.001) higher prevalence than women of tobacco use (30.2% vs. 21.9%) and alcohol abuse (12.5% vs. 3.3%), but women reported more frequent psychotropic drug use (for headache, tiredness, nervousness/anxiety, insomnia, 41.0% vs. 23.8%).
Table Table33 shows that the deprivation patterns differed between various age groups with the exception of "foreign" nationality for both sexes. There were clear differences between generations/ages in educational level, income and home-ownership. Tobacco use was more frequent among younger men and women. Alcohol abuse predominantly affected men aged 40–59 and women aged under 50. No difference between the age groups was found in psychotropic drug use among either men or women.
The results in Tables Tables44 and and55 demonstrate a strong and similar relationship between deprivation and tobacco and psychotropic drug use among both sexes, and with alcohol abuse in men (not women) of all ages combined. However, risk patterns differed between working/other non-retired subjects and retired respondents. Among working/other non-retired men and women, the relationship between deprivation and tobacco and psychotropic drug use persisted, whatever the age group. The risk of alcohol abuse was similar for the D = 1, D = 2 and D ≥ 3 groups in men and non-significant in women. In retired men, there was a proportional relationship between deprivation and psychotropic drug use, but only the D ≥ 3 group had a significant OR for tobacco and alcohol abuse. Among retired women, a higher risk of psychotropic drug use was observed in subjects who were in D ≥ 3 and less than 70 years old.
Tables Tables66 and and77 show that risk patterns varied between working/other non-retired and retired people, the two sexes, and according to the deprivation dimensions and the substance concerned. Among working/other non-retired men, low educational level, manual employment and low income were related to tobacco and psychotropic drug use, whereas low income was associated with the use of all three substances, living alone with alcohol abuse only; and not being a home-owner with alcohol abuse. Among retired men, having been a manual worker was associated with alcohol abuse only, and low income with alcohol abuse and psychotropic drug use. In women, low educational level, being a manual worker and low income were associated with psychotropic drug use, but low income, living alone and unemployment were associated with tobacco use in working/other non-retired and retired subjects. Among retired women a significant association was noted between not being a home-owner and alcohol abuse only.
Discussion
The present study demonstrates that deprivation is common in the population considered, and that it has a strong association with tobacco, excessive alcohol intake, and psychotropic drug use. It highlights that risk patterns vary with the substance concerned, sex, and between active and retired people. The risk of substance use differed between deprivation dimensions. The material and social deprivation index used here was defined from seven criteria (low educational level, manual worker, unemployed, living alone, nationality other than western European, low income, and not being a home-owner) generally used in the literature [28-30] 28,30]. The nationality criterion was included in the deprivation index considered because it may be associated with cultural disadvantages, poor work/living conditions, poor living environment, poor health and access to care. It should be noted that racial composition has been included in deprivation indexes by several authors [30]. The seven eigenvalues found with the principal component analysis were close enough (between 0.73 and 1.33) to suggest that all components contributed almost equally to the D value. Cronbach's alpha was modest. A similar observation was highlighted in the literature after elimination of redundant items in each domain[30]. The deprivation index described here reflects the multidimensional character of community socioeconomic status [30].
These findings indicate that material and social conditions are potential risk factors for harmful health-related behaviours during both working life and retirement, and that the presence of several dimensions of deprivation is associated with a very high risk. This is consistent with the results of other studies, although, to our knowledge, they did not focus on all three substances studied here [19-23-28-30-32].Tobacco, alcohol and psychotropic drugs are strong contributors to social disparities in health [1-3-5-8-23]. Two studies in France showed a strong relationship of the cumulative number of deprivation dimensions with tobacco, cannabis, psychotropic, tranquillizer and antidepressant use, as well as with physical and mental health status, obesity, underweight, diabetes and hypertension [-5-24].
References
- ↑J Alonso ,MC Angermeyer, S Bernert , R Bruffaerts, MC Angermeyer, S Bernert, TS Brugha, H Bryson, de Girolamo G, Graaf R, Demyttenaere K, Gasquet I, et al. Psychotropic drug utilization in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 2004:55–64. [1]
Voir aussi
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