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BMC Research Notes

, 12:748 | Cite as

Trauma exposure and alcohol use disorder among prisoners in Jimma Zone correctional institution, Southwest Ethiopia: a cross-sectional study

  • Yimenu YitayihEmail author
  • Matiwos Soboka
  • Elias Tesfaye
  • Mubarek Abera
  • Almaz Mamaru
  • Kristina Adorjan
Open Access
Research note
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Abstract

Objective

Trauma exposure and alcohol use are closely related, and large proportion of trauma-exposed individuals use alcohol. The data presented in this paper were obtained as part of a study on substance use disorder and associated factors among prisoners in the correctional institution in Jimma, Southwest Ethiopia. Therefore, in this study we examined comorbidity of traumatic life experiences and alcohol use disorder in inmates of correctional institution in Jimma, Southwest Ethiopia.

Results

The overall prevalence of lifetime alcohol use disorder was 40.1%, and the prevalence of alcohol use disorder among prisoners with lifetime trauma exposure was 44.0%. Participants with multiple trauma exposures had 2.5-fold higher odds of association for alcohol use disorder than their counterparts (AOR = 2.47 [1.23–4.94]). Living in urban areas (AOR = 4.86 [2.38–9.94]), presence of psychopathy (AOR = 3.33 [1.25–8.86]), khat abuse (AOR = 7.39 [3.99–13.68]), and nicotine dependence (AOR = 2.49 [1.16–5.34]) were also positively associated with alcohol use disorder. The prevalence of alcohol use disorder was higher among prisoners with lifetime trauma exposure. Also, this study indicates that prisoners with multiple trauma exposures had higher odds of association for alcohol use disorder than those with no trauma exposure. A public health intervention targeting survivors of traumatic experiences needs to be designed and implemented.

Keywords

Crime Prisoners Trauma Alcohol use disorder Khat abuse Tobacco dependence 

Abbreviations

AOR

adjusted odds ratio

AUD

alcohol use disorder

AUDIT

alcohol use disorders identification test

COR

crude odds ratio

DAST

drug abuse screening test

FTND

Fagerstrom Test for Nicotine Dependence

MAD

median absolute deviation

Introduction

Traumatic events are extremely prevalent; they are related to adverse mental health and have social and economic consequences [1]. The prevalence of exposure to traumatic events according to DSM-5 criteria is 89.7% [2]. A national trauma comorbidity report found that 60% of men and 50% of women experience trauma in their lifetime [3]. Such events are an almost universal experience among prisoners [1]. One study found trauma exposure rates ranging from 62.4 to 87.0% among incarcerated adult males [4]. Another study showed that 22% to 43% of patients with posttraumatic stress disorder (PTSD) develop a substance use disorder over the course of their lives [5]. Recent research has also identified PTSD to be a risk factor for substance use relapse and worse treatment outcome [6, 7].

Studies have identified several potential mechanisms to explain the relationship between trauma exposure and AUDs. For example, Boys and Marsden defined the self-medication hypothesis as a specific type of functional substance use [8]. In the context of substance use, the self-medication hypothesis suggests that people use alcohol to suppress or reduce the burden of posttraumatic symptoms [9]. In addition, alcoholic patients with a high trauma load often functionally consume alcohol to cope with sleep issues, depression, or intrusive memories [10]. According to the behavioral sensitization paradigm, repeated administration of substances or exposure to stress can cause sensitization of dopamine neurons, resulting in a higher dopamine release in response to subsequent stress and substance abuse [11].

The high-risk hypothesis claims that people with a substance disorder have a higher likelihood of developing PTSD because their risky lifestyle is likely to lead to adverse, stressful, and negative life experiences, which can then lead to PTSD [12, 13]. The vulnerability may be influenced by a lack of coping strategies or neurochemical brain changes caused by substance use [14].

The data presented in this paper were obtained as part of a study on substance use disorder and associated factors among prisoners in the correctional institution in Jimma, Southwest Ethiopia [15]. As noted, previous research has addressed the association between trauma exposure and substance use disorders in general [15]; however, to our knowledge the potential association of traumatic life events with problematic alcohol use has not been examined among prison populations in Ethiopia. Therefore, this study aimed to assess trauma exposure and AUD in prisoners in a correctional institution in Jimma, Southwest Ethiopia.

Main text

Method and materials

Study design and setting

We conducted a cross-sectional study in the correctional institution in Jimma, Southwest Ethiopia over a 4-week period (June–July) in 2017. In total, the facility houses 1460 prisoners (1418 men and 42 women).

Sample size

The sample size (n) was calculated by using the single population proportion formula, (n = \(z2pq/d2\)) and assuming a prevalence (P) of 50%, i.e. 0.5 (because no similar study has been performed among a prison population in Ethiopia), a 95% confidence interval (CI) (Zα/2 = 1.96), a 5% margin of error (D, 0.05), and a non-response rate of 10%. Thus, the final sample size required was 336.

Study procedures

We used a systematic random sampling technique to select study participants. A total of 1460 prisoners were eligible for the study. The sampling interval was 1460/336 = 4. Data were collected by five Master of Science in Psychiatry students. All data collectors were given training on the study. The five students were supervised by two Masters of Science in Public Health students and the principal investigator. A pre-test was conducted on 5% of the sample in the Agaro prison, which is located 45 km away from Jimma; on the basis of the responses in the pre-test, we corrected some ambiguous words on the data collection questionnaire. We assessed the presence of AUDs with the Alcohol Use Disorders Identification Test (AUDIT) which was developed by the World Health Organization (26). An AUDIT score ≥ 8 is considered to indicate an AUD. The sensitivity and specificity of AUDIT for AUD are 0.90 and 0.80 respectively [16] and the reliability of AUDIT in this study was 0.87 (Cronbach’s α). Adverse traumatic life events were assessed with the Life Events Checklist (LEC) (positive score if at least one traumatic event was recorded). The LEC was developed by the National Center for Posttraumatic Stress Disorder to aid in the detection of PTSD; it has been widely used in cross-cultural settings and is predictive of AUD, anxiety, depression, and PTSD [17]. We assessed nicotine dependence by the Fagerstrom Test for Nicotine Dependence (FTND) in which a score ≥ 1 indicates nicotine dependence [18]. The reliability of the FTND in this study was 0.80 (Cronbach’s α). To evaluate khat abuse we used the Drug Abuse Screening Test (DAST) a score ≥ 3 indicates abuse [19]. The reliability of the DAST in this study was 0.88 (Cronbach’s α). In addition, we used a questionnaire to assess the following variables for AUD: socioeconomic factors (age, sex, marital status, ethnicity, religion, educational status, occupation, income); environmental factors and behavioral and mental health factors. We assessed social support with the Oslo 3-item Social Support Scale [20] and psychopathy with the Psychopathy Checklist: Screening Version (PCL: SV; cutoff score ≥ 13) [21]; the sensitivity of the PCL-SV was 0.94, the specificity, 0.85, and the reliability in this study, 0.86 (Cronbach’s α).

Data processing and analysis

After the tests and questionnaires had been checked for completeness, EpiData Version 3.1 was used to enter the data. Then, the data were exported to the Statistical Package for Social Science version 21.0 for further analysis, and binary logistic regression analysis was used for both bivariate and multivariate analysis to explore associations and identify variables independently associated with AUD. Factors associated with the outcome variables that had a P value < 0.25 in the bivariate analysis were included in the multivariable analysis. Statistical significance was set at P < 0.05.

Results

Socio-demographic characteristics

A total of 329 prisoners participated in the study. The response rate was 97.9%; 2.3% (n = 7) did not participate because they were unwilling to be interviewed about their substance use histories. Detailed information on socio-demographic characteristics is provided in Table 1. The median age of the participants was 26 years (median absolute deviation [MAD] 8.9). The majority of the participants had been residing in urban areas before imprisonment and were unmarried. The most common religion was Muslim (see Table 1).
Table 1

Socio-demographic characteristics of prisoners (n = 329) in the correctional institution in Jimma, Southwest Ethiopia

Continuous variables

Median

MAD

Range

Age (years)

26

8.9

16–86

Income [Birr/months]

1000

1112.0

0–35,814

Time in prison (months)

9

10.4

1–120

Duration of sentence (months)

39

46.0

0–360

Categorical variables

n

Percent

Sex

 Male

307

93.3

 Female

22

6.7

Place of residence

 Urban

223

67.8

 Rural

106

32.2

Religion

 Muslim

181

55.0

 Orthodox

97

29.5

 Protestant

38

11.6

 Catholic

13

4.0

Marital status

 Single

175

53.2

 Married

124

37.7

 Widowed

23

7.0

 Divorced/separated

7

2.1

Level of education

 Primary education

178

54.1

 Secondary education

94

28.6

 College and above

30

9.1

 No formal education

27

8.2

Occupation

 Employed

134

40.7

 Farmer

99

30.1

 Student

43

13.1

 Unemployed

36

10.9

 Other

(housewife/dressmaker)

17

5.2

Prevalence of lifetime trauma exposure and alcohol use disorder

Of the 329 participants, 209 (63.5%) had lifetime trauma exposure and 132 (40.1%) had AUD. Of the 209 prisoners with lifetime trauma exposure, 92 (44.0%) had AUD in the 12 months before imprisonment: 44 (21.1%) had hazardous drinking, 16 (7.7%) had harmful drinking, and 32 (15.8%) had alcohol dependence; 117 (56%) had no alcohol use problem. The most commonly encountered types of trauma in the whole group and in the prisoners with AUD were transportation accidents (whole group: n = 126, 38.3%; prisoners with AUD: n = 69, 54.8%) and physical assault (whole group: n = 91, 27.7%; prisoners with AUD: n = 64, 70.3%) (see Table 2). In the whole group, 146 (44.4%) participants had experienced two and more traumatic events. Among the prisoners with AUD (n = 119), 27 (22.7%) had no exposure to a traumatic life event, 23 (19.3%) had experienced one traumatic life event, and 69 (58%) had experienced multiple traumatic life events.
Table 2

Lifetime trauma exposure among prisoners (n = 329) in the correctional institution in Jimma, Southwest Ethiopia

Variables

Alcohol use disorder

No, n (%)

Yes, n (%)

Transportation accident (for example, car accident, boat accident, train wreck, plane crash)

 Yes

57 (45.2)

69 (54.8)

 No

153 (75.4)

50 (24.6)

Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)

 Yes

27 (29.7)

64 (70.3)

 No

183 (76.9)

55 (23.1)

Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, or bomb)

 Yes

32 (42.1)

44 (57.9)

 No

178 (70.4)

75 (29.6)

Fire or explosion

 Yes

21 (33.9)

41 (66.1)

 No

189 (70.8)

78 (29.2)

Sudden, unexpected death of someone close to you

 Yes

18 (34.0)

35 (66.0)

 No

192 (69.6)

84 (30.4)

Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)

 Yes

6 (15.0)

34 (85.0)

 No

204 (70.6)

85 (29.4)

Natural disaster (for example, flood, hurricane, tornado, earthquake)

 Yes

7 (17.9)

32 (82.1)

 No

203 (70.0)

87 (30.0)

Severe human suffering

 Yes

15 (35.7)

27 (64.3)

 No

195 (67.9)

92 (32.1)

Sudden, violent death (for example, homicide, suicide)

 Yes

12 (31.6)

26 (68.4)

 No

198 (68.0)

93 (32.0)

Life-threatening illness or injury

 Yes

16 (43.2)

21 (56.8)

 No

194 (66.4)

98 (33.6)

Other unwanted or uncomfortable sexual experience

 Yes

3 (13.0)

20 (87.0)

 No

207 (67.6)

99 (32.4)

Serious injury, harm, or death you caused to someone else

 Yes

12 (40.0)

18 (60.0)

 No

198 (66.2)

101 (33.8)

Combat or exposure to a war zone (in the military or as a civilian)

 Yes

12 (42.9)

16 (57.1)

 No

198 (65.8)

103 (34.2)

Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)

 Yes

8 (44.4)

10 (55.6)

 No

202 (65.0)

109 (35.0)

Serious accident at work, home, or during recreational activity

 Yes

14 (60.9)

9 (39.1)

 No

196 (64.1)

110 (35.9)

Exposure to toxic substance (for example, dangerous chemicals, radiation)

 Yes

4 (36.4)

7 (63.6)

 No

206 (64.8)

112 (35.2)

Any other very stressful event or experience

 Yes

6 (25.0)

18 (75.0)

 No

204 (66.9)

101 (33.1)

Factors associated with alcohol use disorder

Multivariable logistic regression showed that experiencing multiple traumatic life events was significantly associated with AUD: Prisoners who had experienced multiple traumatic life events were almost three times more likely to develop AUD than prisoners with no exposure to a traumatic life event (adjusted odds ratio 2.47, 95% CI 1.23, 4.94) (see Table 3).
Table 3

Multivariable logistic regression analysis for independent predictors of alcohol use disorder among prisoners (n = 329) in a correctional institution in Jimma, Southwest Ethiopia

Variable

Alcohol use disorder

AOR (95% CI)

No (%)

Yes (%)

Psychopathy

 No

200 (69.4)

88 (30.6)

Reference value

 Yes

10 (24.4)

31 (75.6)

3.33 (1.25– 8.86)

Adverse traumatic life event

 No exposure to traumatic life event

93 (77.5)

27 (22.5)

Reference value

 Exposure to one traumatic life event

40 (63.5)

23 (36.5)

2.04 (0.86–4.88)

 Exposure to multiple traumatic life events

77 (52.7)

69 (47.3)

2.47 (1.23–4.94)

Place of residence

 Rural

89 (84.0)

17 (16.0)

Reference value

 Urban

121 (54.3)

102 (45.7)

4.86 (2.38–9.94)

Khat abuse

 No

159 (83.2)

32 (16.8)

Reference value

 Yes

51 (37.0)

87 (63.0)

7.39 (3.99–13.68)

Nicotine dependence

 No

186 (70.5)

78 (29.5)

Reference value

 Yes

24 (36.9)

41 (63.1)

2.49 (1.16–5.34)

AOR adjusted odds ratio, 95% CI 95% confidence interval

Reference value: In the analysis, this variable indicated a lower likelihood of alcohol use disorder; it was coded as zero in SPSS logistic regression

Discussion

The present study examined the presence of trauma exposure and AUD among prisoners in a correctional institution in Jimma, Southwest Ethiopia. We found that prisoners with trauma exposure were at greater risk for AUD than prisoners with no trauma exposure: 92 (44.0%) of the prisoners with lifetime trauma exposure had an AUD in the 12 months before imprisonment, compared with 27 (22.5%) of the prisoners without lifetime trauma exposure.

Participants who had been exposed to multiple traumatic life events had higher odds of association for AUD than participants with no exposure to traumatic life events. This finding is in agreement with a study performed in Israel, which found that exposure to traumatic events was a factor for alcohol use [22]. People exposed to multiple traumatic life events are hypothesized to use alcohol to cope with negative emotional feelings, such as anger, despair, and emptiness, and to numb themselves from the experience of the traumatic event [23]. People might also use alcohol as a coping strategy to reduce awareness of the traumatic event [23].

Previous research has also provided substantial support for the self-medication hypothesis in the context of alcohol use in PTSD. Boys and Marsden found that drugs are intentionally used to suppress, control or inhibit negative affective states [8]. Furthermore, Jacobsen et al. [5] found evidence of the intentional use of alcohol to suppress typical PTSD symptoms in particular. Additionally, neuropharmacological studies have provided clear evidence that alcohol is effective in self-medicating PTSD and that withdrawal from alcohol can reactivate the symptoms of PTSD (5, 6, and 9). Waldrop et al. [7] showed that use of alcohol can help PTSD patients cope with sleep issues, depression, or intrusive memories and reduce physical hyperarousal. In the present study, the group of people who consumed alcohol was also the group with the highest trauma load. Thus, we can assume that the prevalence of PTSD was very high among these respondents and that they intentionally used substances to better deal with symptoms from the PTSD spectrum.

Exposure to traumatic events was higher among prisoners in the Jimma correctional institution, with almost two-thirds reporting having experienced a traumatic event. Although multiple exposures to traumatic events was a significant risk factor for alcohol use among prisoners, the relationship between multiple exposures to traumatic events and alcohol use is more nuanced. Although we cannot establish causality from our data, mental health professionals should recognize that multiple traumatic exposures among prisoners may be a particular risk factor for AUD. These findings also underscore the need for mental health professionals who work with prisoners who have been exposed to a variety of traumatic experiences to thoroughly assess the prisoners for AUD. Given the many barriers to help-seeking in this population, these findings suggest that treatment should target multiple psychopathologies at once. A primary health physician is thus a critical link to substance use treatment or treatment for trauma exposure for prisoners. Further research on integrated models of treatment should examine the effectiveness of such models in addressing trauma exposure and AUD among prisoners.

In summary, this study has a significant clinical impact in that it will help prison health services meet the complex mental health needs of prisoners. It demonstrates the relevance of integrated and socially acceptable care for treatment of trauma and AUDs in prisons.

Conclusion

This study in an Ethiopian prison found a high prevalence of AUD among prisoners with lifetime trauma exposure. Prisoners with greater trauma exposure had higher odds of association for AUD than those with no trauma exposure. This study highlights that a public health intervention targeting survivors of traumatic experience needs to be designed and implemented to decrease the risk of AUD and that there is a critical need to provide treatment for prisoners with AUD.

Limitations

  • AUD were based on self-reports that the prisoners provided during an interview and therefore the prevalence of AUD may have been underestimated.

  • Participants may have under reported or denied alcohol use because of social desirability bias.

  • AUDIT has not yet been validated in prison populations.

  • Data on mental illness were also based on self-reports, so they may be biased, and we could not verify the validity of the participants’ responses through a psychiatric interview.

Notes

Acknowledgements

We would like to thank Jimma University for granting ethical approval. Our deep thanks go to all study participants who spent their valuable time responding to the questions in this study. We thank also Jacquie Klesing, Board-certified Editor in the Life Sciences (ELS), for editing assistance with the manuscript.

Authors’ contributions

YY wrote the protocol, participated in data collection, analyzed the data and wrote the manuscript. MS, ET, MA, AM, and KA made substantial contributions to revising and approving the protocol, analyzing the data, and revising subsequent drafts of the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for this study.

Ethics approval and consent to participate

The study protocol was approved by the Research Ethics and Approval Committee of the Jimma University Institute of Health (IHRERB/755/2017). Participation in the study was voluntary. If participants decided not to participate, there were no negative consequences. Participants could withdraw from the study at any time without giving a reason and without any negative consequences. Verbal consent was obtained from the prisoners because some of them were illiterate or unfamiliar with the use of forms and to protect the anonymity of participants. The Research Ethics and Approval Committee of the Jimma University Institute of Health allowed us to accept verbal consent from study participants. Even though the information was not provided in paper form, we provided participants with all the necessary information in a verbal consent procedure before obtaining their consent. We explained to the participants that selection for participation in the study was random and that they had the right not to respond to questions that they were not comfortable with and also had the right to ask questions. After data entry was complete, the questionnaires were kept securely locked away. Study participants who did not want to participate in the study but had been exposed to trauma and had AUD were referred to the Jimma University Medical Centre.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Copyright information

© The Author(s) 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Yimenu Yitayih
    • 1
    Email author
  • Matiwos Soboka
    • 1
  • Elias Tesfaye
    • 1
  • Mubarek Abera
    • 1
  • Almaz Mamaru
    • 1
  • Kristina Adorjan
    • 2
    • 3
    • 4
  1. 1.Department of Psychiatry, Faculty of Medical SciencesJimma UniversityJimmaEthiopia
  2. 2.Institute of Psychiatric Phenomics and Genomics (IPPG)Medical Center of the University of MunichMunichGermany
  3. 3.Departments of Psychiatry and PsychotherapyMedical Center of the University of MunichMunichGermany
  4. 4.Center for International HealthLudwig-Maximilians-UniversitätMunichGermany

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