INTRODUCTION TO SPECIAL ISSUE GENDER, CULTURE AND ALCOHOL PROBLEMS: A MULTI-NATIONAL STUDY

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1 Alcohol & Alcoholism Vol. 41, Supplemet 1, pp. i3 i7, 2006 doi: /alcalc/agl070, available olie at INTRODUCTION TO SPECIAL ISSUE GENDER, CULTURE AND ALCOHOL PROBLEMS: A MULTI-NATIONAL STUDY KIM BLOOMFIELD 1,2 *, GERHARD GMEL 3,4 ad SHARON WILSNACK 5 1 Uit for Health Promotio Research, Uiversity of Souther Demark, Esbjerg, Demark, 2 Istitute for Biostatistics ad Cliical Epidemiology, Charité Uiversity Medicie Berli, Germay, 3 Swiss Istitute for the Prevetio of Alcohol ad Drug Problems (SIPA), 4 Alcohol Treatmet Ceter, Lausae Uiversity Hospital, Switzerlad ad 5 Uiversity of North Dakota School of Medicie ad Health Scieces, Departmet of Cliical Neurosciece, Grad Forks, North Dakota, USA Abstract: This paper provides a itroductio to a series of articles reportig results from the EU cocerted actio Geder, Culture ad Alcohol Problems: A Multi-atioal Study which examied differeces i drikig amog wome ad me i 13 Europea ad two o-europea coutries. The geder gap i alcohol drikig is oe of the few uiversal geder differeces i huma social behavior. However, the size of these differeces varies greatly from oe society to aother. The papers i this issue examie, across coutries, (1) me s ad wome s drikig patters, (2) the prevalece of me s ad wome s experiece of alcohol-related problems, (3) geder differeces i social iequalities i alcohol use ad abuse, (4) geder differeces i the ifluece of combiatios of social roles o heavy alcohol use, ad (5) how societal-level factors predict wome s ad me s alcohol use ad problems o a regioal ad global level. Coutry surveys were idepedetly coducted ad the cetralized at oe istitutio for further data stadardizatio ad processig. Several results idicated that the greater the societal geder equality i a coutry, the smaller the geder differeces i drikig behavior. I most aalyses the smallest geder differeces i drikig behaviour were foud i Nordic coutries, followed by wester ad cetral Europea coutries, with the largest geder differeces i coutries with developig ecoomies. BACKGROUND The geder gap i alcohol drikig is oe of the few uiversal geder differeces i huma social behaviour. I geeral populatio studies throughout the world, as compared with wome, me are more ofte drikers, cosume more alcohol, ad cause more problems by doig so (e.g. Fillmore et al., 1991; Kebede ad Alem, 1999; McKee et al., 2000; Sieri et al., 2002; Jhiga et al., 2003; Hao et al., 2004; Almeida- Filho et al., 2005). However, the size of these geder differeces varies greatly from oe society to the other. Neither the uiversality or the variability of these geder differeces has bee adequately explaied (Wilsack et al., 2000, 2005). Perceptios of ad resposes to geder-specific drikig ca reveal how societies have differetiated geder roles, for example, by makig drikig behaviour a demostratio of masculiity (Driesse, 1992; MacDoald, 1994; Campbell, 2000; Roberts, 2004) or by the expectatio that wome abstai from alcohol or limit their cosumptio as a symbol of subserviece (Nicolaides, 1996; Willis, 1999; Marti, 2001). Further, geder differeces i alcohol use have iflueced how societies idetify ad attempt to cotrol alcohol-related problems. For example, the associatio of heavy drikig with masculiity or male camaraderie may ecourage male drikers to dey or miimize drikig problems ad to regard druke behaviour as ormal or permissible (Greefield ad Rogers, 1999; Tomse, 1997; Graham ad Wells, 2003). Likewise, assumptios that wome do ot drik heavily may iitially lead to wome s drikig problems beig miimized or igored (Brieza ad Stei, 2002; Svikis ad Reid- Quioes, 2003; Weiser ad Matzger, 2003). *Author to whom correspodece should be addressed at: Uit of Health Promotio Research, Uiversity of Souther Demark, Niels Bohrs Vej 9, 6700 Esbjerg, Demark. Tel: ; Fax: kbl@health.sdu.dk These differeces i ad resposes to geder-specific drikig ca differ substatially across coutries ad cultures. For example, previous research has observed that the degree of geder equality withi a particular society is associated with the way that social demographic characteristics are correlated with heavy drikig amog wome, for example, whether formal educatio or havig childre have beeficial or detrimetal effects o wome s alcohol use (Gmel et al., 2000). But this lie of iteratioal comparative research has remaied quite sparse (e.g. Wilsack et al., 2000). A step i improvig the uderstadig of how geder ad culture combie to affect alcohol use ad abuse has bee udertake by the cocerted actio Geder, Culture ad Alcohol Problems fuded by the Europea Commissio (cotract QLG4-CT ) which has examied differeces i drikig behaviour amogst me ad wome i 13 Europea ad two o-europea coutries. By examiig geder differeces i alcohol use amogst several Europea coutries, this project provided a uique opportuity to focus o a part of the world which cotais a iterestig spectrum of coutries with regard to geder equality. Several Nordic coutries, which are amog those with a very high degree of geder equality, were icluded i the study. The project attempted to represet most regios of the Europea Uio, ad i additio, icluded two o-europea coutries. This diversity provided additioal coutry-level variatio with respect to the type of drikig culture ad levels of atioal ecoomic developmet. Thus, with variatios i geder equality, drikig culture ad ecoomic developmet across coutries, the study had the potetial to reveal how geder differeces i drikig behaviour may be liked to these societal-level factors cross-atioally. Study coutries i the curret project iclude Austria, the Czech Republic, Filad, Frace, Germay, Hugary, Israel, Italy, The Netherlads, Norway, Swede, Switzerlad, ad the Uited Kigdom. I additio, two coutries outside of Europe, Brazil, ad Mexico, participated (It was origially i3 Ó The Author Published by Oxford Uiversity Press o behalf of the Medical Coucil o Alcohol. All rights reserved

2 i4 plaed that Caada, the Uited States, ad Russia would also participate. However, due to iteratioal juridical ad cotractual hurdles, these coutries had to withdraw.), i the project, as did the World Health Orgaizatio (WHO) i a advisory capacity. Further, the curret project is affiliated with a larger iteratioal research edeavour, etitled GENACIS (Geder, Alcohol, ad Culture: A Iteratioal Study). This larger, ogoig project, led by Sharo Wilsack, is also ivestigatig geder differeces i alcohol use ad misuse across a larger rage of coutries much beyod those i Europe. Aside from the coutries ivolved i the curret EU cocerted actio, the GENACIS study coutries iclude Argetia, Australia, Belize, Caada, Costa Rica, Demark, Icelad, Idia, Irelad, Isle of Ma, Japa, Kazakhsta, Nicaragua, Nigeria, Peru, Russia, Spai, Sri Laka, Switzerlad, Ugada, Uruguay, ad the Uited States. Participatio of these coutries has bee fuded through the US Natioal Istitute o Alcohol Abuse ad Alcoholism (Research Grat No. R21 AA012941) ad the World Health Orgaizatio with fudig earmarked for developig coutries. Where appropriate ad if available at the time of aalysis, it was possible i three of the five papers preseted i this special issue to add some of these o-eu GENACIS coutries to the aalyses. I this collaboratio with a larger, more comprehesive study, a commo core questioaire was developed for implemetatio i those coutries which collected ew survey data i or after 2000, whe the commo questioaire was drafted. It was ecouraged that each survey use as much as possible, if ot all, of this ew questioaire. However, if surveys were fiaced by atioal govermets or health agecies, it was ofte the case that other priorities existed i what kid of health data would be collected, ad i some cases oly a selectio of items from the project s core questioaire could be icluded. Nevertheless the use of a stadardized questioaire represets a sigificat step forward i uifyig alcohol survey data withi Europe. Objectives of the study The origial project pursued a umber of research questios. The papers cotaied i this special issue address a subset of them, amely, the followig. (i) To compare withi ad across coutries me s ad wome s drikig patters. (ii) To compare withi ad across coutries the prevalece of me s ad wome s experiece of alcohol-related problems. This is doe with special referece to the AUDIT (Alcohol Use Disorders Idetificatio Test) questioaire which was icluded i a substatial subset of study coutries. (iii) To compare, withi coutries ad across coutries, geder differeces i social iequalities i alcohol use ad abuse. (iv) To compare geder differeces i the ifluece of combiatios of social roles o heavy alcohol use. (v) To aalyse how societal-level factors predict wome s ad me s alcohol use ad alcohol-related problems o a regioal ad global level. Factors of iterest i the preset study are idicators of ecoomic developmet ad moderizatio, alcohol culture, ad geder equality. K. BLOOMFIELD, G. GMEL ad S. WILSNACK METHODS The coutry surveys Oe of the mai stregths of this comparative iteratioal study was the cetralizatio of the survey data files at oe istitutio where further data processig took place to recode variables or to costruct ew variables which were as comparable across the coutries as possible (see ext subsectio). The coutry surveys were idepedetly coducted i the differet coutries ad the cetralized at the Swiss Istitute for the Prevetio of Alcohol ad Drug Problems i Lausae, Switzerlad. The data were collected i all coutries i the past few years of the 1990s or early 2000s, with the exceptio of Austria, where the data were collected i Most samples were atioal, with the exceptios of Brazil (Botucatu), The Netherlads (Limburg), ad Italy (Tuscay). Survey modes ad sample sizes varied across coutries. Respose rates i those coutries for which the data exist (some surveys employed quota samplig) suggest relatively high respose rates i geeral (70%, with exceptios). The mai characteristics of the surveys of the EU project coutries, as well as the two additioal GENACIS coutries (Icelad ad Spai), are displayed i Table 1. The paper by Rahav et al. icludes data from may other coutries from the broader GENACIS project. Due to space limitatios, the reader is asked to refer to the GENACIS project website (www. geacis.org) for characteristics of surveys i these additioal coutries. Data cetralizatio The data cetralizatio ad data maagemet i the preset project come close to fulfillig the criteria of Bethlehem (1997) with regard to the Data Editig Research Project. She proposed the followig priciples: (i) Cocetratio: All data processig activities with respect to a survey should be cocetrated as much as possible i oe departmet; (ii) Stadardizatio of hardware: All data processig activities should be carried out as much as possible o the same type of computer platform; (iii) Stadardizatio of software: All data processig activities should be carried out with stadard software istead of tailor-made software; ad (iv) Itegratio: All software required for data processig must be part of a itegrated system usig machie readable metadata iformatio cotaiig all required iformatio about the survey. This metadata defiitio must be used by all systems ad departmets as the mai source of iformatio about the survey. Bethlehem s criteria were largely applied i the preset project. Data were processed i oe departmet, usig the same computer platform ad stadard software for processig the data, ad a commo set of metadata defiitios was developed. Metadata are data about data (va der Berg et al., 1992) ad cotai iformatio required for collectig, processig ad publishig survey data. The data cetralizatio was coducted i four major steps. The first cosisted of idetifyig variables that were comparable across datasets. This phase cosisted of assigig uique variable ames to the survey variables used i the study, ames that reflected the locatio of idividual questios withi topic domais of the questioaire, scales to measure

3 GENDER, CULTURE AND ALCOHOL PROBLEMS i5 Table 1. Overview of survey characteristics of the EU project coutries plus Icelad ad Spai Samplig frame If regioal, where? Survey mode the same costruct ad multiple respose questios, ad the creatio of a codebook. I the secod phase, datasets were edited to reduce icosistecies, icludig differeces across surveys i skip (or route) istructios (e.g. if questios o alcohol related problems were skipped for those drikig less frequetly tha oce a moth) ad i restrictios o rages of values (e.g. assigig of missig values for codes that are ot valid). The third step cosisted of creatig ew variables. The measuremet of alcohol cosumptio requires combiig differet variables, for example, the multiplicatio of aual frequecies ad usual quatities to yield a volume measure (see paper by Mäkelä et al. i this issue for descriptio of drikig variable costructio). A omeclature was developed to costruct uique variable ames for these ewly created variables, ad thus repeated the codig step for this set of variables. Fially, liks to other files, as a importat step of the metadata processig (Bethlehem, 1997), were provided. This icluded the creatio of workdecks across coutries, ad the developmet of a data model that allowed the likig of workdecks. Workdecks are subgroups of variables which are thematically iterrelated (e.g. variables for drikig idicators, socio-demography, or drikig cosequeces). Creatig workdecks meat that researchers did ot have to explore the full data model across all variables ad all coutries, but istead could cocetrate o iterrelatios amog variables that are importat for specific (sub)hypotheses. The creatio of likig variables guarateed that differet survey year respose rate (%) age rage workdecks could be easily coected. Additioal iformatio was collected about the differet surveys ad archived (icludig survey questioaires i the origial survey laguage ad their traslatios) alog with a descriptio of the samplig desig ad the use of weightig variables to adjust for the samplig desig. For additioal details about data cetralizatio the reader is referred to Bloomfield et al. (2005). IMPLICATIONS AND CONSIDERATIONS FOR FUTURE RESEARCH The results reported i the preset papers cofirm the very clear existece of geder differeces i drikig behaviour amogst the study coutries. Although this fidig is ot ew, it has become apparet through our research that there are ideed factors which ifluece the degree ad ature of these geder differeces across societies. Oe of the most otable factors is geder equality: the greater the geder equality i a coutry, the smaller the geder differeces i drikig behaviour. I most of our aalyses the smallest geder differeces i drikig behaviour were foud i the Nordic coutries, followed by wester ad cetral Europea coutries, with the largest geder differeces i coutries with developig ecoomies. At first glace, this fidig may appear baal. But it is a fidig which reoccurs throughout the preset study with differig aalysis techiques ad with varyig groups of me wome Austria Natioal Face-to-face 1993 quota Brazil Regioal Botucatu, all Face-to-face 2001/ quota 18+/ / / /365 urba area residets 2002 Czech Republic Natioal Face-to-face Filad Natioal Face-to-face (AUDIT + drugs: self-admiistratio) Frace Natioal Telephoe Germay Natioal Postal Hugary Natioal Face-to-face (with 2001 quota self-admiistered paper pecil for alcohol questios) Icelad Natioal Mixed (half/half / postal ad telephoe survey) Israel Natioal Face-to-face 2001 < Italy Regioal Tuscay Mixed 2001/ (postal + telephoe) 2002 Mexico Natioal Face-to-face Norway Natioal Face-to-face (with 1999 quota Spai Regioal Galicia, Valecia, Catabria self-admiistratio) Face-to-face (sesitive questios self-admiistered*) 2003 quota Swede Natioal Telephoe Switzerlad Natioal Telephoe The Netherlads Regioal Limburg Postal UK Natioal Face-to-face ad CAPI *Sesitive: sexual ad romatic relatios, violece, illicit drug use quota

4 i6 study coutries. This cosistecy, first, ca cofer a measure of validity ad credibility to the overall patter of fidigs. Secod, to observe that the geder gap i drikig behaviour is related to the geder equality of a society is iterestig i so far that oe may the begi to look for cofirmatio of similarities i other social ad health behaviours (e.g. utritio, smokig, other life style factors). It would ideed be iterestig to kow which behaviours are iflueced by or correlated with geder equality ad which are ot (ad ultimately why ot). Fially, maily because our data are cross-sectioal, our results do ot tell us i ay detail how geder differeces i drikig behaviour decrease. Is it because wome are drikig more i the coutries where the differeces are smaller, or are the differeces smaller because me are drikig less or experiecig fewer problems? Or perhaps both are true. This is ideed a importat questio to aswer sice for policy formulatio it is ecessary to kow who is drikig more or less whe geder differeces coverge. We hope that our study will provide for other Europea alcohol researchers, as well as alcohol researchers i geeral, a iterestig ad provocative poit of departure, from which to coduct future studies. These, the, ca further icrease our uderstadig of cultural ad geder-related iflueces o wome s ad me s drikig behaviour. A NOTE ON COLLABORATION With the exceptio of the Kutsche et al. paper, the first author of each article i this special issue was the coordiator of that particular work package i the EU project which cotaied the relevat research objective. Additioal authors of a paper are other colleagues at the coordiator s istitutio, other cosortium colleagues or colleagues of the broader GENACIS project who cotributed substatially to the paper. Study coutry parters whose data were ivolved i a particular aalysis (listed as with i the ackowledgemets sectio) were also ivolved i the preparatio of the relevat paper. At various stages of the project, they gave feedback ad additioal iformatio for the accurate iterpretatio of the data ad aalyses pertaiig to their coutries. Ackowledgemets This project was supported by the Europea Commissio, Research Directorate-Geeral, through its Quality of Life ad Maagemet of Livig Resources research program with cotract umber QLG4-CT ad was coordiated at the Istitute for Biostatistics ad Cliical Epidemiology at Charité Uiversity Medicie Berli (Prof. Dr Peter Martus, Istitute head). Additioal fudig for the coordiatio of the project, as well as for Germa scietific participatio i the study, was provided by a grat from the Germa Federal Miistry of Health ad Social Security. Special thaks are due to Dr Ludwig Kraus of the Istitute of Therapy Research for his geerosity i providig the Germa team with the ecessary atioal survey ( Epidemiological Survey o Substace Abuse ) ad expert advice i aalysig the dataset properly. The data are also part of the project, Geder, Alcohol ad Culture: A Iteratioal Study (GENACIS). GENACIS is a collaborative iteratioal project affiliated with the Kettil Bruu Society for Social ad Epidemiological Research o Alcohol ad coordiated by GENACIS parters from the Uiversity of North Dakota, the Uiversity of Souther Demark, the Charité Uiversity Medicie Berli, the World Health Orgaizatio, ad the Swiss Istitute for the Prevetio of Alcohol ad Drug Problems. Support for aspects of this project also comes from the US Natioal Istitute o Alcohol Abuse ad Alcoholism/Natioal Istitutes of Health (Grat Numbers R01AA04610 ad R21AA12941, Sharo C. Wilsack, pricipal ivestigator) ad the World Health Orgaizatio (Maristela Moteiro ad Isidore Obot, coordiators). Data coordiator for K. BLOOMFIELD, G. GMEL ad S. WILSNACK the GENACIS project is Gerhard Gmel, Swiss Istitute for the Prevetio of Alcohol ad Drug Problems, Lausae, Switzerlad. Support for idividual coutry surveys was provided by govermet agecies ad other atioal sources ad we would like to ackowledge particular fudig sources of some of the idividual study coutry surveys ivolved i this EU project. The participatio of Switzerlad ad the cetralized databak maagemet was fiaced by the Swiss Federal Office for Educatio ad Sciece (Cotract o ) (Dr Gerhard Gmel, study parter). Additioal support for data cetralizatio was provided by the Uiversity of North Dakota (Subcotract o. 254, amedmet o. 2, UND Fud ). The Swiss survey was coducted by the Swiss Federal Statistical Office. The Amsterdam Group, the Uiversity of West Eglad, Bristol, ad the Alcohol Educatio ad Research Coucil provided support for the survey coducted i the Uited Kigdom (Prof. Dr Moira Plat, study parter). For coductig the survey i Brazil, additioal support was provided by Fudação de Amparo à Pesquisa do Estado de São Paulo (Fapesp 00/ ) (Prof. Dr. Florece Kerr- Correa, study parter). The Israeli survey was fuded by the Ati-Drugs Authority of Israel (Prof. Dr Giora Rahav, study parter). The Swedish survey was supported by the Swedish Miistry of Health ad Social Affairs (Dr Kari Helmersso Bergmark, study parter). The Frech survey ( Health Barometer 2000 ) was fuded by the Prevetio ad Health Educatio Natioal Istitute (INPES) with a grat to the Frech Moitorig Ceter o Drugs ad Drug Addictio (OFDT) (Dr Fracois Beck, study parter). A comprehesive list of coutry-specific fudig for the broader GENACIS project may be foud at REFERENCES Almeido-Filho, N., Lessa, I., Magalhaes, L. et al. 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