17th May 2019, Volume 132 Number 1495

Jennifer Lai, Paul Hanton, Angela Jury, Charito Tuason

In New Zealand, one in five adults have potentially hazardous drinking patterns.1 The Health Promotion Agency recommends no more than 15 standard drinks per week among men, and 10 for women, with at least two alcohol-free days per week (see www.alcohol.org.nz). Alcohol is a contributing risk factor for physical and mental health problems,2 problems with work and social relationships,2 and is related to at least one-third of police recorded offences.3 The estimated social costs of hazardous alcohol use in New Zealand was NZD$146 million in 2005/06.4

In 2017, New Zealand’s community alcohol and other drug (AOD) services provided treatment for 2,786 adults where alcohol was recorded as the main substance of concern at treatment start.5 These people represent more than half (56%) of adults accessing community AOD services. AOD services offer a range of treatment approaches for individuals and groups, such as counselling, motivational interviewing, psychosocial education and groupwork. Evidence suggests New Zealand community AOD services are having a moderate-to-large effect on reducing days of alcohol use among people with alcohol as their main substance of concern.5 To further understand the impact of AOD services on people’s lives, the literature suggests wellbeing and quality of life are important factors to consider alongside measures of alcohol use.6,7

Recovery is self-defined by a person and may take into account the overall reduction in alcohol use or alcohol-free days, as well as physical and emotional wellbeing, having a stable and secure place to live, meaningful social relationships and daily activities.8 People who experience alcohol use problems often report lower quality of life, and both issues can significantly improve after AOD treatment.6,7 This relationship between quality of life and alcohol use may depend in part on sociodemographic factors, such as age, gender and socioeconomic status.6,7 To date, the association between reduced days of alcohol consumption and quality of life among people accessing AOD services has not been examined in New Zealand.

Against this background, the study’s aims were to examine the impact of reducing days of alcohol use on lifestyle and wellbeing among adults accessing community AOD services in New Zealand and practice implications. The specific objectives were to examine the (i) correlation between days of alcohol use and weekly lifestyle and wellbeing issues and (ii) variance explained between days of alcohol use and weekly lifestyle and wellbeing issues while adjusting for covariate factors. Based on previous quality of life research, it was hypothesised that reduced days of alcohol use would be associated with an improvement in lifestyle and wellbeing.6,7 This could have potential implications for practice approaches within AOD services and people accessing services.

Methods

Data collection

This study was based on routinely collected Alcohol and Drug Outcome Measure (ADOM) data from New Zealand adult community AOD services for people who completed treatment in 2017. Community AOD services are mandated to submit ADOM outcomes data, service activity and sociodemographic information into the Programme for the Integration of Mental Health Data (PRIMHD, see www.health.govt.nz). This includes Ministry of Health funded non-government organisation (NGO) and district health board (DHB) services.

Data was extracted from PRIMHD on 10 October 2018, and includes information collected from individuals at both treatment start (new episode of care) and treatment end (completion of an episode of care) as reflected in report building rules (see www.tepou.co.nz). The study sample was based on adults accessing AOD services who reported alcohol as their main substance of concern at the start of their treatment, including people not currently consuming alcohol. One DHB was excluded from the analysis as they did not collect ADOM data during this period.

Measures

Days of alcohol use

The ADOM is a self-rated tool comprised of three distinct sections: (i) alcohol and drug use; (ii) lifestyle and wellbeing; and (iii) recovery, which is available at www.tepou.co.nz. Section 1 (alcohol and drug use) has been shown to have good test-retest reliability, concurrent validity and sensitivity of change.9 For example, days and amount of alcohol use have excellent concurrent validity with Degree of Drug use Index (DDI) and Timeline Follow Back (TLFB). Section 2 (lifestyle and wellbeing) has adequate psychometric properties.10 Practitioners facilitate a collaborative process of working through the ADOM with people accessing services.

At treatment start and treatment end people were asked about their days of alcohol use in ADOM Section 1: In the past four weeks how many days did you drink alcohol? Days of alcohol use at treatment end was subtracted from treatment start (T0treatment start–T1treatment end). Positive change scores reflect a reduction in days of alcohol use.

Weekly lifestyle and wellbeing problems

The total number of self-reported weekly lifestyle and wellbeing problems experienced were based on responses to seven questions contained in ADOM Section 2. These questions collected information about problems experienced over the past four weeks in relation to physical health, mental health, social relationships, participation in work or other activities, housing, and involvement in criminal activity. For example, people were asked: “How often has your general mental health caused problems in your daily life?”. Engagement in work, study and caregiving activities was also examined and reverse scored. The number of lifestyle and wellbeing issues experienced weekly at treatment end was subtracted from treatment start so positive change scores reflect a reduction in issues.

Covariates

Change in the total number of other substances used between treatment start and end was based on self-reported use of cannabis, amphetamine-type stimulants, opioids, sedatives/tranquilisers and any other drugs, as captured in ADOM Section 1.

The sociodemographic factors examined included age (years), gender (female/male) and ethnicity (Māori/non-Māori).

Statistical methods

The data was screened prior to analysis and six outliers were deleted based on z-scores and residual analysis. This included three people who reportedly consumed alcohol every day at treatment end, but little or none at treatment start.

In the first stage of the analysis, descriptive statistics and bivariate correlations between variables were examined. In the second stage of the analysis, a hierarchical multiple regression analysis was undertaken to examine the independent effect of alcohol consumption on lifestyle and wellbeing. Step 1 of the hierarchical model included the sociodemographic covariates, Step 2 the number of other substances used, and Step 3 days of alcohol use.

Analyses were undertaken using Stata Version 15 (StataCorp, College Station, Texas, US) using all available data. Ethical approval was not required for routinely collected de-identified data.

Results

Descriptive statistics

In total, 598 adults aged 18 years and over who accessed community AOD services with alcohol as their main substance of concern were included in the sample with ADOM collections at both treatment start and treatment end. Three-quarters of participants were seen in NGOs. Two-thirds (66%) were male and the mean age was 40 years (SD=12.82, range 18 to 82 years). Māori people reflected 36% of the sample (Table 1). The average duration between treatment start and treatment end (an episode of care) was 20 weeks (M=139.92 days, SD=130.11, range 28 to 769 days).

Table 1: Sociodemographic characteristics of the sample (N=598).

Variable

Number

Percent (%)

Ethnicity

Māori

218

36.45

Non-Māori

380

63.55

Sex

Male

394

65.89

Female

204

34.11

Age (years)

18–24

71

11.87

25–44

299

50.00

45–64

209

34.95

65+

19

3.18

At treatment end, the proportion of people with zero days of alcohol use more than doubled compared to treatment start (44% and 21% respectively) (Table 2). On average, days of alcohol use reduced by five days (M=5.35, SD=8.56). The number of other substances used also reduced (M=0.13, SD=0.52). These results reflect a reduction in alcohol and drug use during treatment.

Table 2: Days of alcohol use at treatment start and treatment end (N=598).

Days of alcohol use

Treatment start

Treatment end

0 days

21%

44%

1–10 days

45%

47%

11–20 days

19%

6%

21+ days

15%

3%

At treatment start, the most common lifestyle and wellbeing issues related to mental health (39%), physical health (34%) and engagement in work (32%) (Table 3). At treatment end, issues related to mental health, physical health and social relationships showed the most improvement. On average, the number of weekly lifestyle and wellbeing issues experienced during treatment reduced by about one (M=0.85 SD=1.55).

Table 3: Weekly lifestyle and wellbeing issues experienced at treatment start and treatment end (N=598).

Lifestyle and wellbeing issue

Treatment start

Treatment end

Difference (start–end)

Physical health

34%

18%

16%

Mental health

39%

16%

23%

Social relationships

28%

9%

19%

Work or other activities

22%

8%

14%

Not engaged in work (weekly)

32%

27%

5%

Housing

7%

4%

3%

Criminal or illegal activity

7%

2%

5%

Bivariate analyses

Correlations between the change in the number of lifestyle and wellbeing problems experienced and independent variables ranged from -0.01 to 0.44. There was a significant positive relationship between change in both days of alcohol use and lifestyle and wellbeing issues experienced (r=0.44, p<.001). The relationship between changes in the number of other substances used and lifestyle and wellbeing issues experienced was also significant (r=0.18, p<.001).

Hierarchical multiple regression analysis

Table 4 presents results from the hierarchical multiple regression model. The R2 for the regression model was significantly different from zero, F(5, 587) = 29.43, p<.001. Change in days of alcohol use significantly contributed to the prediction of change in lifestyle and wellbeing issues experienced, explaining an additional 16% of the variability over and above other covariates in the model. Altogether, 20% (19% adjusted) of the variability of change in lifestyle and wellbeing issues experienced was explained by variables in the model, indicating a good model fit. The change in wellbeing associated with change in days of alcohol use is illustrated in Figure 1.

Table 4: Summary of the hierarchical multiple regression analysis for variables predicting change in the number of weekly lifestyle and wellbeing issues experienced (N=593).

 

Step 1

Step 2

Step 3

 

B

β

B

β

B

β

Māori

-0.03

-0.00

-0.06

-0.02

0.08

0.03

Male/female

-0.14

-0.04

-0.14

-0.04

-0.07

-0.02

Age

0.00

0.03

0.01

0.05

-0.00

-0.00

Change in:

no. other substances

 

 

0.55

0.18***

0.30

0.10**

days of alcohol use

 

 

 

 

0.08

0.42***

R2

 

0.00

 

0.04***

 

0.20***

Adjusted R2

 

 

 

 

 

0.19***

Note. *** = p<.001, ** = p<.01. 

Figure 1: Predicted change in lifestyle and wellbeing based on change in the number of alcohol-free days between treatment start and treatment end among adults accessing community alcohol and other drug services, N=593.

c 

Sensitivity analyses

Sensitivity analyses indicated the results were similar for Māori and non-Māori. Other change measures of alcohol use examined did not significantly alter the pattern of results, including change in the number of standard drinks consumed on a typical drinking day (adjusted R2=0.13), total volume consumed per week (amount x days; adjusted R2=0.17) and categorisation (increased alcohol use, no change in alcohol use, 1–10 days reduction, 11+ days reduction) (adjusted R2=0.18). Figures 2–4 illustrate the predicted change in wellbeing based on the change in these variables. When the 124 people with zero alcohol consumption at treatment start were excluded from the analysis, similar results were found.

Figure 2: Predicted change in lifestyle and wellbeing based on change in standard drinks consumed on a typical drinking day between treatment start and treatment end among adults accessing community alcohol and other drug services, N=577.

c 

Figure 3: Predicted change in lifestyle and wellbeing based on change in total alcohol volume consumed each week (days x amount) between treatment start and treatment end among adults accessing community alcohol and other drug services, N=575. 

c 

Figure 4: Predicted change in lifestyle and wellbeing based on categorised change in alcohol days between treatment start and treatment end among adults accessing community alcohol and other drug services, N=593.

c 

Discussion

This study examined the association between changes in days of alcohol use and changes in the number of weekly lifestyle and wellbeing issues experienced. Findings indicate a reduction in days of alcohol use significantly contributed to the prediction of positive changes in lifestyle and wellbeing issues experienced. Similar results were found when other measures of alcohol use were examined (eg, amount consumed on a typical drinking day and total volume per week). Overall, greater reductions in alcohol use were associated with larger improvements in lifestyle and wellbeing. This relationship remained significant even when sociodemographic factors and the use of other substances were controlled for. Results also suggest the benefits of treatment on lifestyle and wellbeing are similar for Māori and non-Māori, males and females, and different age groups.

The largest improvements in lifestyle and wellbeing were observed for mental health, social relationships and physical health. These findings support the hypothesis and are in line with systematic reviews showing these quality of life domains improve following AOD treatment.11, 12 Moreover, previous research using the Treatment Outcomes Profile, an outcome measure which informed development of the ADOM, reported similar findings.11 While the design of the study cannot determine the direction of the relationship between change in alcohol use and change in wellbeing, evidence suggests the relationship between alcohol and lifestyle and wellbeing is likely to reflect the causal effect of reducing alcohol consumption, rather than vice versa.12

Mental health

People’s self-rated general mental health showed substantial improvements associated with a reduction in days of alcohol use. Despite the large improvement, mental health remained an issue for one in six people (16%) at treatment end. People who have been diagnosed with mental health problems, such as an anxiety disorder or psychosis, may require additional support to improve their quality of life.13 This may partly reflect childhood trauma, which is common among people with substance use disorders.14 Te Rau Hinengaro indicates around 15% of people with substance use disorders utilise mental health specialist services each year.15 Workforce knowledge and skills in co-existing problems, trauma-informed care, making referrals to mental health services, and working in multidisciplinary teams is required to further support people’s long-term wellbeing goals.16

Social relationships

People accessing AOD services self-reported fewer problems or arguments with friends and family associated with reduced alcohol use. Previous research shows a reduction in the prevalence of intimate partner violence after substance use treatment.17 For Māori people accessing services, improvements in social relationships are especially important. Māori people who perceive greater whānau wellbeing are more likely to report higher life satisfaction and a greater ability to cope with everyday stress.18 This finding supports the strong emphasis on family inclusive practice among AOD services.19

Physical health

Improvements in general physical health were associated with reduced days of alcohol use. This may reflect a reduced risk of alcohol-related injuries,20 short-term effects such as fatigue and headaches,21 and improvements in nutritional intake.22 It may also reflect an increased ability to engage in and adhere to treatment for physical health conditions once alcohol consumption has reduced. The physical health of people who experience mental health and addiction issues is increasingly a priority among health services.23 Further improvement in physical health will require greater access to primary care, routine screening and monitoring for health problems, peer support and integration of wellness programmes into AOD services.23

Engagement in employment and education

A small positive change for people’s engagement in work, study or caregiving activities was found to be associated with a reduction in alcohol use. At treatment end, around one in four people continued to experience weekly problems engaging in work, study or caregiving activities. Employment and other meaningful activities provide people with a sense of purpose and motivation.24 Similarly, Best et al (2013) found engagement in meaningful activities, such as education or employment, were associated with better quality of life among people undergoing AOD treatment.25 It is important AOD services are able to support people to “stay at, return to and remain in work” (p. 6).26 Further improving outcomes for people accessing AOD services who want to engage in work or education will require a strengthened focus on integrating evidence-based employment support, such as Individual Placement and Support (IPS) programmes.24,26

Clinical implications

Findings have implications for AOD practitioners and services. As described above, AOD services and people accessing these services would benefit from strengthened workforce knowledge and skills in co-existing problems, and integration of evidence-based wellness programmes and employment support. In addition, having a better understanding of how reducing alcohol use can impact on people’s live will help inform approaches used to support people accessing AOD services. Findings also support the continued use of ADOM to routinely measure people’s outcomes in community AOD services.

Approaches to supporting people in reducing alcohol use

Increasing people’s number of alcohol-free days may be an important part of any treatment approach and should at least be an adjunct to messages about harm reduction or abstinence. Having a better understanding of the exponential change in lifestyle and wellbeing may potentially lead to a modified approach that primarily emphasises the benefits of reducing the days of alcohol use alongside the other key approaches.

At a service level, it is important AOD services ensure people accessing services are aware of the lifestyle and wellbeing benefits of reducing alcohol use. Results indicate that even a one-day reduction in alcohol use can support small improvements in people’s wellbeing. These findings provide a positive message for some people where abstinence or cessation seems too ‘big’ to achieve or their goal is to reduce their overall alcohol consumption. This information will enable people accessing services to make informed choices about their wellbeing goals and preferred approach to reducing alcohol use, such as goals towards reducing days of alcohol use or abstinence.27 Further investigation is required in developing and evaluating pilot treatment or support programmes that focus on therapeutic goals aimed at a reduction in days of alcohol use.

The utilisation of ADOM in AOD services

Providing feedback is an important part of engagement between people accessing services and practitioners, and has been shown to improve treatment effectiveness.28 Feedback about improvements in lifestyle and wellbeing areas shows people the wider benefits of reducing alcohol use, especially for mental health, social relationships and physical health outcomes. Outcomes information reflecting positive changes and recovery strengths can instil hope and optimism about the future. These research findings can instil hope for both people accessing services and practitioners that even small reductions in alcohol use may contribute to positive outcomes. This is important as hope can potentially lead to further improvements in people’s perceived quality of life.29 People entering services would also benefit from these positive messages, which could usefully be disseminated to different groups and reinforced through various media tools. People with lived experience who work in the sector (peer workforce) could also usefully share this message with people accessing services.

For people who are yet to make substantial improvements, individual feedback using outcome tools like the ADOM enables people accessing services and practitioners to review wellbeing goals and care plans together.28 Outcomes information can also usefully inform service delivery and ensures that continuous quality improvement is informed by the needs of people accessing these services.

Limitations

While results show the positive impact of reduced alcohol consumption on lifestyle and wellbeing, the findings are based on the small amount of individual data currently available. That is, not all people entering and leaving services currently have ADOM collections recorded. Improved ADOM collection in routine practice is required by both NGO and DHB services, as collections were under-represented based on service access.5

The study’s results were based on people who completed treatment and may not necessarily apply or generalise to others. It is possible outcomes for people who did not complete treatment differ or other factors are important. Except for the greater likelihood of being younger, an analysis of the characteristics of people (eg, substance use, wellbeing and sociodemographic characteristics) at treatment start who did not complete treatment were similar to those included in this study (as well as people with missing treatment start or end data, and those still in treatment).

The study did not intend to examine the optimal type or length of treatment. Different treatments may lead to different outcomes. Future research should also take into account socioeconomic status,7 satisfaction with services11 and the long-term maintenance of wellbeing,10,11 which have been related to alcohol consumption and quality of life in previous studies.

It is likely the impact of reduced alcohol consumption on wellbeing has been underestimated in the current study given the use of the brief ADOM tool which was designed for clinical rather than research purposes. Future research should consider using more comprehensive wellbeing measures.

Finally, while it is assumed that reduced alcohol consumption has impacted on wellbeing, it is also possible that treatment has directly targeted several areas of functioning alongside alcohol use.

Conclusion

Findings indicate a reduction in alcohol use has a positive impact on lifestyle and wellbeing among people accessing New Zealand’s adult community AOD services. This highlights the usefulness of current local initiatives that emphasise the importance of responding to co-existing mental health problems, whānau engagement and improving the physical health for people who experience addiction issues. However, findings indicate a need to improve support for people to gain or stay in employment and education. Results also have implications for approaches and advice provided within AOD services and primary care about reducing alcohol use. The study is also in line with the findings of He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction,30 which emphasises the importance of considering people’s wellbeing and the need for holistic approaches to help restore and maintain this.

Summary

Using established research methods, it has been possible to analyse data collected from people accessing services at the start and end of treatment for their alcohol-related issues. This analysis has shown that reducing alcohol days of use has a positive impact on lifestyle and wellbeing. The sector often discusses reducing harm, this paper shows increased benefits, a paradigm shift in thinking from reduction of a negative to increased positive.

Abstract

Aim

The study examined the impact of alcohol use on lifestyle and wellbeing among adults accessing New Zealand community alcohol and other drug (AOD) services, and practice implications.

Method

Routinely collected Alcohol and Drug Outcome Measure (ADOM) data for individuals at both treatment start and treatment end was analysed. Hierarchical multiple regression analyses examined the independent impact of changes in days of alcohol use on weekly lifestyle and wellbeing issues. Analyses controlled for sociodemographic variables and other substances used.

Results

In total, 598 people reported alcohol as their main substance of concern. The largest improvements in lifestyle and wellbeing were observed for mental health, social relationships and physical health. Change in days of alcohol use significantly contributed to the prediction of change in lifestyle and wellbeing issues experienced (model R2=20%, adjusted R2=19%, p<.001). Results were similar for amount and total volume.

Conclusion

Reduced alcohol use positively impacts on people’s lifestyle and wellbeing. Findings have implications for increasing awareness of the benefits for people’s lives, even small reductions in alcohol use. The need to strengthen routine ADOM collection in AOD services is highlighted, as well as the availability of vocational rehabilitation to support people’s wellbeing.

Author Information

Jennifer Lai, Research Assistant, Te Pou o te Whakaaro Nui, Auckland; 
Paul Hanton, Clinical Project Lead, Te Pou o te Whakaaro Nui, Hamilton; 
Angela Jury, Principal Advisor Research, Te Pou o te Whakaaro Nui, Auckland; 
Charito Tuason, Data Analyst, Te Pou o te Whakaaro Nui, Auckland.

Acknowledgements

The authors would like to acknowledge Professor David Fergusson’s input in the initial stages of this project, and Dr Mark Smith for his early contributions. Thanks also to Sandra Baxendine for the extraction of PRIMHD data, and Will Ward and Ashley Koning for their review of the draft manuscript.

Correspondence

Paul Hanton, Te Pou o te Whakaaro Nui, PO Box 307, Waikato Mail Center, Hamilton 3240.

Correspondence Email

paul.hanton@tepou.co.nz

Competing Interests

Nil.

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