Occupational factors associated with long-term abstinence among persons treated for alcohol dependence: A follow-up study.

Background: Several studies have examined the occupational factors associated with alcohol use and dependence. However, there are very few studies that investigated the role of occupational factors associated with long-term abstinence among persons treated for alcohol dependence in India. Aim: To examine the occupational factors associated with long-term abstinence among persons treated for alcohol dependence.
Methods: Sixty in-patients treated for alcohol dependence were selected using inclusion criteria from the Government-run de-addiction center, tertiary care teaching hospital, Bangalore. All patients were followed up periodically for 1 year. The semi-structured interview schedule was used for collecting data on occupational factors associated with long-term abstinence. Descriptive statistics, Chi-square test, and Fisher exact test were used for data analysis.
Results: There was a positive trend showing self-employed (pf = 1.74, P = 0.45), having skilled work (pf = 1.52, P = 0.72), regular pattern of employment (pf = 1.21, P =.60), monthly mode of income (pf = 1.43, P =.76) were factors associated with abstinence. Among eight occupational variables, employment status (x 2 = 4.0, P =.04) and having well-defined working hours ((pf = 6.18, P =.04) were significantly associated with long-term abstinence among persons treated for alcohol dependence.
Conclusion: Occupational factors seem to influence the outcome in alcohol dependence and appropriate vocational interventions would be effective in promoting long-term abstinence. Copyright:

INTRODUCTION

Occupation is the duty of mankind. Work is the panacea for all ailments. Occupation is an essential component of social functioning and it occupies a central position in human life. It reflects the intellectual, educational, economic, and social status of an individual in a society.[1] Employment plays a vital role in the initiation, maintenance, and recovery from alcohol use disorder. Alcohol intake among employees poses a major public health challenge. Though alcohol intake at the workplace is uniformly low and subtle,[23] however, it incurs a huge loss to the companies through accidents, decreased productivity,[234567] absenteeism,[268] loss of workers and their skill, cost of employing another worker, sickness benefits.[26]

A rapid assessment survey conducted in 12 major enterprises in nine Indian cities revealed that the prevalence of alcohol use among employees was about 23%, and 12% of employees come intoxicated to work, 50% of sick leave taken was related to alcohol use, 8% were adversely affected by colleagues’ alcohol use.[2] It affects 15% of the workforce, 2% drink before work, work under the influence of alcohol, 7% drink during workday, 9% work with a hangover.[49] Information on factors associated with abstinence is crucial for designing effective treatment for alcohol dependence (AD).

Role of occupational factors

Several occupational factors contribute to the onset of alcohol use,[10] dependence, and recovery as well. Occupational dysfunction and disability are more among alcohol users.[11] The highest mortality from alcohol-related diseases and injuries was common among industry workers, cleaners, bar staff, managerial occupations,[1213] caterers, cooks, painters, fishermen, bricklayers, masons.[1415] Farmers, drivers had fewer alcohol-related deaths.[16]

Availability of alcohol at work, social pressure to drink, freedom from supervision, opportunity to obtain relatively inexpensive alcoholic beverages were the factors associated with alcohol use at the workplace.[1] To overcome boredom during non-working days is a common cause for relapse. Individuals who are employed and not employed in a particular occupation reveal a reduction in risk for AD. There is an increased AD risk for those who leave other occupations. Evidence suggests that employment in specific occupations may be protective for AD.[17] At the same time, many studies report certain occupations may be associated with AD.[10]

AD is high among blue-collar workers,[18] construction-workers,[19] transport industry, pensioners,[20] unemployed,[20] and who were laid-off.[17212231] Low and high-risk drinking is more among manual occupations, coal-mining,[23] white-collars, and middle-level managers.[12]

There is a relationship between job loss and subsequent alcohol use among non-drinkers.[24] Adverse employment consequences were high among rural young adults who use abuse alcohol.[25] Excessive drinking occurs after work-hours among employed.[20] Working more than 40 hours per week[1026] earning irregular compensation,[25] employment status, income, job-stress[2728] working conditions,[20] weak bonds in the workplace, job demand,[29] job anxiety, job insecurity,[10] Job dissatisfaction[30] frustrating experiences and discrimination at the workplace, work-family conflict, working in specific settings (grocery, restaurants), drinking sub-culture at the workplace,[30] drinking as a normative part of work-life, improving social relationships, reducing boredom, expressing solidarity in defiant management rules,[30] and having no interests in social involvements outside the workplace were related to drinking alcohol and AD.[10141516172027] Manual occupations,[1819] and restricted leisure activities,[30] workplace harassment,[12] predicts low and high-risk drinking.[3233] Skills used, workload, irregular work schedule, have no association with increased alcohol use.[1234]

Harmful drinking is high among unemployed younger males.[35] unemployed alcohol dependents have higher family strains, family dysfunction, and family violence.[3637] Unemployment predicts a poor prognosis among alcohol dependents. Reducing unemployment would contribute to reduced alcohol problems. Re-employment showed a reduction in alcohol use severity.[35]

Untreated alcohol dependents had more maladjustment in work, social, and leisure time activities.[38] The individuals with AD who had adjustment problems in the occupational domain,[39] had a higher degree of occupational dysfunction in an industrial setting.[40] Regular employment is the strongest predictor of a good prognosis among alcohol-dependents.[4142] Blue-collar workers had higher remission rates than white-collar workers.[43] More skilled employees were abstinent from AD in an industrial setting, and the reason for maintaining abstinence was the threat of losing the job. One of the supportive measures responsible for abstinence was management and employee-counselor.[44] Several studies have examined occupational factors associated with alcohol use. However, very few studies specifically explored occupational factors related to abstinence from alcohol dependence. Hence, this study examined the occupational factors associated with long-term abstinence among individuals with alcohol dependence.

METHODS

The study was prospective in nature. Sixty individuals, who availed in-patient treatment for alcohol dependence at a Government-run de-addiction center, in a tertiary care teaching hospital, were recruited for the study by consecutive sampling using inclusion and exclusion criteria. The study was conducted in a hospital-based population. At that time, on average 600 people get admitted per year for the treatment of alcohol and other substance use disorders at centre for addiction medicine. The population size of the study was 600, 10% of the study population was considered as the sample size (N = 60). The confidence interval was calculated at the confidence level of 95%. The confidence interval of the study is 2.4% which means the margin error in the study results would be ± 2.4%.

Inclusion criteria: Males aged 25 to 60 years, availing in-patient treatment for alcohol dependence, those who give consent to participate in the study and follow-up, those who have primary caregiver from a family of origin or family of procreation (to involve them in the treatment and to bring the patients for follow-up) and stable place of residence, and no treatment for alcohol dependence syndrome in previous 90 days. Exclusion criteria: People who have a cognitive impairment, major co-morbid psychiatric disorders, those who have current legal problems which are likely to interfere in follow-up, and those who do not have family members (unavailable) at the time of in-patient treatment were excluded from the study. Tools used: Data on socio-demographic, clinical and occupational variables were collected using a semi-structured interview schedule. Alcohol problem questionnaire[45] was used to alcohol-related problems. It has eight domains such as problems with friends (two 2 items, 2-4), finance (five items, 5-9), legal (two items, 10-11), physical health (eight items, 12-19), psychological (nine items, 20-28), marital (eight items, 29-36), children related (five items, 37-41) and work-related problems (eight items, 42-49). Higher scores indicate more alcohol-related problems. There are 46 items in the original version and the modified version has 49 items. Participants were followed up periodically for 1 year after the discharge. Abstinence status was assessed at an interval of 1 month after discharge, 3rd, 6th, 9th, and 12th month. Patients who show no signs of dependence or maintained continuous abstinence for more than 90 days were considered as maintaining long-term abstinence from AD. Informed consent was sought from the participants for the study and telephone follow-up service.

In-patient treatment consists of 21 days of stay. Family members were encouraged to stay with the patient. One attendee must stay with the patient during admission. All participants were exposed to pharmacological and psychosocial treatment. The center has multi-disciplinary team members consisting of psychiatrists, clinical psychologist, psychiatric social workers, and psychiatric nurses, yoga therapist and follow-up counsellors. Psychosocial treatment consists of individual counselling on motivational enhancement and relapse prevention strategies, need-based family intervention to address interpersonal and family issues, group therapy sessions lasting about 45-60 minutes four days in a week, weekly family support group sessions focussing on role of family members in recovery, recreational groups weekly once, nursing interventions, pharmacological interventions consists of diagnosis, treatment of alcohol dependence, withdrawal management by detoxification, craving management by prescribing anti-craving agents, management of co-morbid psychiatric conditions. Patients with other co-morbid medical conditions are managed by referrals to nearby hospitals. Quantitative variables were analysed using ddescriptive statistics, and categorical variables were analysed using Chi-square test, and fisher exact test. Study obtained ethical clearance from Institute Ethics Committee (59th IEC/2008/8.05)

RESULTS

The mean age of the respondents was 41 years (± 6.75), mean years of education was 9 years (± 4.06), the median income of the respondents was Rs. 6000, a majority were Hindus (78.5%), hailing from a nuclear family (72%), were employed (86%), belong to lower socioeconomic status (55%), hailing from urban domicile (82%). Clinical profile during baseline assessment revealed that mean age at initiation of alcohol use was 21.5 years (± 5.25), dependence was 27.5 years (± 5.36), duration of drinking was 20 years (± 8.12), and average intake of alcohol was 19 units (± 7.3), dependence duration was 13 years (± 7.02), Mean score on alcohol problem questionnaire was 34.41 (± 6.53), in sub-domain had more health-related problems 11.6 (± 3.3) work-related problem 5.60 (± 1.25), 54 persons had nicotine dependence, four had diabetes, nine had hypertension. Seven patients stayed for 12-18 days, did not complete psychosocial treatment and required number of days of treatment, 23 persons stayed for 18-21 days. Out of 30 persons who had more than one admission, 17 persons had hospitalization for 21- 42 days, and remaining 13 persons hospitalized for 42-82 days owing to relapse.

Table 1 shows the occupational profile of respondents. Half of the persons treated for alcohol dependence were self-employed (50%), have skilled employment (50%), have a monthly mode of payment (50%), and monotonous nature of the job (75%) and having well-defined working hours (47%).

Table 1

Occupational Profile of the Respondents

Occupational Variables	Categories	Frequency (n=60)	Percentage (%)
Employment Sector	Government sector	14	23
	Private sector	16	27
	Self-employed	30	50
Employment Category	Unskilled	12	20
	Semi-Skilled	05	12
	Skilled	31	5
	Professional	09	18
Pattern of Employment	Regular	41	68
	Seasonal	14	23
	Contract	05	08
Mode of Payment	Daily	11	18
	Weekly	15	25
	Monthly	30	50
	Quarterly	04	07
Nature of Employment	Monotonous job	45	75
	Non-Monotonous job	15	25
Employment Status	Employed	52	87
	Unemployed	08	13
Working hours	Well-defined working hours (9-5)	28	47
	Shift based working hours	14	23
	12 hours	07	12
	ill-defined working hours	11	18

Follow-up assessment at the end of 12 month revealed that follow-up details were available for all 60 subjects. As the centre maintains physical medical record at medical record department and their clinical information details, date of admission, date of discharge are maintained in a separate electronic registry for telephone follow-up purpose. Six follow-up counsellors with post-graduation in social work/psychology do regular telephone follow-up service, send follow-up reminder text messages before the due date (written consent taken at the time of admission for telephone follow-up service). Two follow-up counselors make a home visit along with one psychiatric social worker to find out the general health status of discharged patients who missed three follow-up appointments after reminder telephone calls weekly once for three continuous weeks. As a result, follow-up details were available for all 60 subjects. There were two drop-outs in the study, an average number of follow-ups was 6 for 12 month period. Twenty people had 2-3 follow-up in one year, 18 persons had 5-7 follow-ups, eight persons had 8-12 follow-ups, six persons had more than 12 follow-ups due to relapse, two persons never came for follow-up for 1 year.

At the end of 12 months, 14 respondents had continuous abstinence for one year without lapse or relapse, 42 people had relapse then abstinence, and four had lapse then abstinence. After 12 months, three respondents expired due to liver problems. Those who expired had poor medication compliance and follow-up. The average cumulative abstinence days for 60 respondents was 256 days (± 114) for 12 months period. Alcohol problems reduced to a mean score of 12.45 (± 10.44) and, health-related problems 4.4 (± 3.1) work-related problems 2.60 (± 2.13).

Figure 2 shows a line graph, which reveals that after 1 month of discharge 55 people were abstinent, third month 43 peoplewere abstinent, at 6th and 9th month 31 were abstinent and at the end of 1 year, 35 people were abstinent (cross-sectional), showing declining abstinence trend till 6 months and from 6 to 12 months abstinence trend remained same without decline.

Figure 2

1 Line graph showing respondents abstinence status across interval period

Flowchart showing sample recruitment

Figure 3 bar diagram reveals month-wise abstinence. Out of 60 subjects, 24 were abstinent more than one year, 17 people abstinent for 6 month to one year, 4 people did not improve as they were abstinent less than one month after 1e year post-assessment. Eight people showed mild improvement (1-3 month abstinent), seven people have shown short-term abstinence of 3 to 6 month.

Figure 3

Bar Diagram showing No. of persons maintained long-term abstinence

Table 2 reveals occupational factors associated with long-term abstinence. Employment status and the number of working hours have a statistically significant association with long-term abstinence. Respondents in government service (79%) showed long-term abstinence though it was not statistically significant. Respondents with monthly income, having a skilled job, regular employment were abstinent for a longer duration.

Table 2

Occupational Variables and Long-term Abstinence at One year

Occupational Variables	Categories	Abstinence >90 days		Abstinence <90 days		Fishers’s exact test
		n	%	n	%
Employment Sector	Government	03	21	11	79	pf=1.74 P=0.447
	Private sector	07	44	09	56
	Self-employed	21	70	09	30
	Unskilled	04	33	08	67
	Semi-Skilled	02	29	05	71
	Skilled	08	27	22	73
	Professional	05	45	06	55
Pattern of Employment	Regular	12	29	29	71	pf=1.21 P=0.60
	Seasonal	06	43	08	57
	Contract	01	20	04	80
Mode of Payment	Daily	04	36	07	64	pf=1.43 P=0.76
	Weekly	05	33	10	67
	Monthly	08	27	22	73
	Quarterly	02	50	02	50
Nature of Employment	Monotonous job	12	27	33	73	x2=2.08 P=0.202
	Non-Monotonous	07	47	08	53
Employment Status	Employed	14	27	38	73	x2=4.0 P=0.044*
	Unemployed	05	63	03	37
Working hours	8 hours	06	43	08	57	pf=6.18 P=0.049*
	Shift	06	86	01	14
	12 hrs	07	64	04	36
	Not well-defined	22	79	06	21
Socio-economic status	Lower	12	36	21	64	x2=0.748 P=0.419
	Middle	07	26	20	74

DISCUSSION

This study examined the occupational factors associated with long-term abstinence among persons treated for AD and they were followed-up for 1 year. The occupational profile of persons treated for AD revealed that most persons were employed, had a regular, monotonous job, well-defined working hours, receive a monthly payment. These findings were similar to the Tonse study[46] and in contrast to the Ngaitlang study.[47] The Tonse study reported that most persons treated for AD were employed, employed in the private sector, semi-skilled, satisfied with their work, Ngaitlang[47] reported that most persons treated in the community-based camp were unskilled and unemployed.

The present study showed that long-term abstainers were employed, had a regular job, well-defined working hours. This finding was supported by a previous study[48] The present study revealed that employed respondents showed statistically significant improvement over the unemployed. This finding was in concordance with previous studies.[41] Not being employed full time and being unemployed for a long time was associated with a negative outcome (relapse) from alcohol dependence.[49505152] Most people with a stable employment showed a favourable outcome in terms of 1 year abstinence. Abstinent and relapsed individuals significantly differ in terms of occupation, income, except job satisfaction.[53] There was a contrast finding that abstinence and relapsed groups did not differ in terms of occupation and income.[54] Previous studies showed that relapse was more common in the unemployed[414455] industrial employees, businessmen, and professionals.[56] This finding emphasizes the need for finding a suitable job or vocational placement for recovering and treating unemployed alcohol dependents.

Most employed people were abstinent at 6, 9, and 12-month follow-up. This finding was in concordance with an earlier study.[55] The present study revealed that self-employed and those who were employed in the government sector were at low risk for relapse. This finding was supported by a prior study.[57] The present study revealed that there was a trend showing more self-employed persons had long-term abstinence. This finding was in contrast to a previous study where individuals working in the government sector had long-term natural recovery from AD.[57]

The present study showed that more than half of them had re-admission owing to relapse. This finding was in contrast to a prior study which reported only 7% required re-admission for relapse.[55]

In the present study, most people who maintained long-term abstinence were skilled employees. There was an interesting finding that the government employees and self-employed respondents abstained for more than 300 days. For self-employed respondents, the reason could be an internal motivation that they were the sole breadwinner of the family. This factor could have led them to long-term abstinence. For government employees, who had regular jobs, job security would have indirectly helped them to maintain long-term abstinence.

In the present study, there were 35 abstainers out of 60 people treated for AD after one year. This finding was similar to an earlier study which reported there were 36 abstainers at 1-year follow-up[55] [Prasad S, Murthy P]. Respondents involved in a non-monotonous job showed a longer duration of abstinence than those who engaged in a monotonous job. From the clinical experience, persons with monotonous jobs such as driving, hairdressers, painters, tailors, lower division clerks, cooks, mortuary technicians, employees from the hospitality industry, and seasonal employees tend to relapse more. There was a contrasting finding reported that employment status was not associated with early recovery from AD.[58]

In this study, several respondents who had long-term abstinence were monthly wage earners. Respondents who had weekly and daily income showed poor outcomes in terms of abstinence. The outcome is better among respondents who have a monthly income, well-defined working hours. The number of working hours stresses the importance of restoring a balance between work, leisure, and rest. Though there was no significant association with other occupational variables and recovery, there was a positive trend in all eight variables showing the association with abstinence.

Results showed that those who are engaged in a monotonous job were maintaining abstinence for a lesser number of days. Literature supports the association between boredom and substance use.[59] There is no significant difference in the occupational status among well-motivated and poorly motivated AD, persons treated for AD at hospitals and community outreach services.[6061]

A social perspective on workplace alcohol use can be summarized in the following context a) mechanism of social control on alcohol use at the workplace, b) organizational norms, policy related to drinking c) working conditions like stress, powerlessness d) Interaction of external cultural factors like ethnicity, cultural values, belief system, cultural behavior, and drinking sub-culture at the workplace.[30]

Vocational interventions in the domain of leisure and social participation produced better outcomes.[62] Work-place well-being programes can address the issues of substance use disorders among the employees. Employee assistance programes can cover the cost of treatment of substance use disorder. MICO, Bangalore, and Karnataka State Road Transport Corporation cover the substance abuse treatment cost of its employees under the Workplace Alcohol Prevention Programme and Activities.[2] Community social workers at the center for addiction medicine, routinely conduct awareness programes about the harmful effects of alcohol and tobacco use and the treatment availability as part of a workplace intervention program for substance use disorders.

Limitations

The study had several limitations. Study results cannot be generalized due to the small sample size. Standardized instruments were not used to measure alcohol dependence. Lab parameters were assessed during admission for treatment, and the same was not used to confirm the abstinence. During follow-up, relapsed individuals have been advised lab tests for treatment. The study relied on the self-report of the patients and family members who accompanied them during follow-up on the abstinent status. Their alcohol use status was cross-examined by the psychiatric social worker and consultant psychiatrist who provided follow-up consultation. Confounding variables were not adjusted in the analysis which could have influenced abstinence. There is the possibility of sampling bias and selection bias in the study as the study did not include people availing out-patient treatment.

CONCLUSION

Employment status and the number of working hours are strongly associated with long-term abstinence among persons treated for alcohol dependence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.