Individual-level factors made the largest contribution to problematic alcohol use in this study, with those in the combined ‘at-risk group’ (i.e., hazardous and harmful drinking) being more likely to be male, younger in age, never married, to have higher neuroticism and to have experienced more recent adverse life events. While there was a significant univariate association between levels of psychological distress and alcohol use, this association did not hold in the multivariate analysis once individual predispositional characteristics, recent difficulties and social support were accounted for. The multivariate model for at-risk alcohol use provided limited support for the hypothesis regarding the role of rural specific or regional/district-level factors.
We found patterns of association between adverse life events and at-risk alcohol use, and specifically events indicating interpersonal and financial adversity, although the direction of causation could not be determined from this cross-sectional analysis. This association may be indicative of the adverse consequences of excessive alcohol use, such as becoming unemployed, experiencing a major financial crisis, or close relationship problems. However, this association is also consistent with the identified role of financial stress and economic strain, especially among men, in contributing to adverse health outcomes [34
] and supports the evidence concerning the link between psychological distress, alcohol use and interpersonal conflict especially among men. Further examination of this relationship is under investigation in the longitudinal follow-up of this sample, which is currently in progress (NHMRC grant #401241).
In addition to at-risk alcohol use, we also examined the outcomes of high consumption and lifetime consequences as measured by the AUDIT. Male gender was associated with all three outcomes. Individual rural exposure factors (e.g., perceived service and support accessibility, worry about drought) were not associated with the outcome in any model in this population, however, with adjustment for other variables a lower proportion of life spent in the rural district was associated with at-risk alcohol consumption. Younger age, neuroticism and increased adverse events were associated with the outcomes of at-risk consumption and lifetime consequences. Never having married was independently associated with at-risk use and high consumption but not lifetime consequences. The district contextual factor of socioeconomic disadvantage was significantly associated with consumption status, such that those with high consumption were likely to be relatively less disadvantaged, reflecting availability of financial resources.
The AIHW 2007 National Drug Strategy Household survey data indicated that at-risk drinking is most prevalent in the 20–29 years age group [36
], with reference to the 2001 Australian Alcohol guidelines (NMHRC). Levels of at-risk consumption in this rural study were highest in the 18–34 year age group (approximately one in five) and halved with age (8.4%% in those aged 65 years and older). High consumption varied little by age. However, the younger age group was associated with more lifetime consequences of alcohol (see Figure ), whereas this may have been expected to increase with age. This result may reflect several possibilities, including the lower response rate from younger males [10
]. Alternatively, it may support a genuine cohort effect, reflecting actual societal change, such that drinking related behaviours and incidents involving younger people are viewed more negatively now than previously. On the other hand, it probably represents a simple recall effect, with older people being less likely to recollect past alcohol related incidents, concerns or comments.
National survey data suggest that 20% of Australians (24% of males and 17% of females) consume alcohol at at-risk or high risk levels [36
]. Similarly, one in four males in this rural sample reported at-risk alcohol consumption, more than one in three males reported high consumption, and almost one in five males reported at least one adverse lifetime consequence of drinking alcohol. At-risk drinking levels for females in this rural sample were approximately half (8.2%) the rates found in the national data.
With regard to remoteness, at-risk drinking was similar across all remoteness categories in this sample, ranging from 15% in inner and outer regional areas to 14% and 11% in remote and very remote areas respectively. The national data reported that people living in remote or very remote areas were more likely to drink at at-risk or high-risk levels than those living in other areas (32.1% in remote or very remote regions, versus 20.7% in inner regional areas) [36
ARMHS has measured an extensive range of important variables, including a range of regional/locality data to investigate the factors contributing to variability in alcohol use (covering objective ecological data and subjective, individual perceptions of community/locality). However, this paper was unable to address other known major determinants of alcohol consumption, such as price and physical availability, including distance to alcohol outlets and exposure to advertising and promotion. Estimates of at-risk alcohol use are also potentially subject to selective non-response bias.
The findings generally support the validity of the AUDIT as a measure of clinically significant alcohol problems (in this instance, against concurrent WHO-CIDI-3.0 diagnoses). However, the authors acknowledge the limitations of using the AUDIT for measuring alcohol consumption per se. AUDIT response categories allow only crude estimates of consumption, particularly at higher levels, and are sensitive to measuring current problems as opposed to past problems. For the findings from this study, these limitations potentially impact upon the two alternative regression analyses of high consumption and lifetime consequences. Moreover, although 41% of the AUDIT at-risk group reported drinking 6 or more drinks per occasion on a weekly basis (see Table ), which is suggestive of a binge drinking pattern, this could not be confirmed without a more detailed alcohol consumption diary.
The cross-sectional nature of this analysis and the low survey response rate limit interpretation of this data, together with our acknowledgement that some factors such as recent adverse life events may be secondary to alcohol use. ARMHS will have longitudinal follow-up data on alcohol consumption at one, three and five year follow-up, allowing the relationship between alcohol use in rural communities to be further explored. The generalisability of this work to the other diverse rural communities, both across Australia and internationally, is also unclear – and awaits replication and refinement – however, younger, single males appear to be a population subgroup deserving specific attention in many communities. Such an emphasis is also compatible with the 12-month prevalence patterns for any alcohol use disorder reported in the 2007 Australian National Survey of Mental Health and Wellbeing (e.g., males, 5.9% vs.
females, 2.7%; 16–24 year olds, 11.1% vs.
65+, 0.7%; single, 9.2% vs.
married, 1.8%) [37