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The International Journal of the Addictions, 27(9), 1067- 1077, 1992
Acculturation, Alcohol Consumption, and Casualties among United States Hispanics in the Emergency Room* Cheryl J. Cherpitel, Dr.P.H. Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco, 2000 Hearst Avenue, Berkeley, California 94 709
ABSTRACT The association of alcohol consumption and casualties was analyzed among Hispanic emergency room patients to determine whether level of acculturation and accompanying changes in drinking patterns influence risk of alcohol-related injuries. A sample of patients admitted to a county hospital emergency room during a 1-year period was breathalyzed and interviewed ( N = 1,102). Of these, 112 identified themselves as Hispanic. Hispanic males were more likely than nonHispanics to have positive breathalyzer readings, to report drinking prior to the event, and to attribute a causal association of drinking with the event. These findings were most pronounced among those in the moderate and high acculturation groups.
Key words. Alcohol consumption; Acculturation; Casualties Hispanic; Emergency room
*Prepared for presentation at the Fifth Iberoamerican Congress on Drug Dependencies and Alcoholism, Madrid, Spain, November 15-17, 1989. 1067
Copyright 01992 by Marcel Dekker, Inc.
CHERPITEL
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INTRODUCTION Nonfatal casualties have been found to be positively associated with alcohol consumption (Roizen, 1982; USDHHS, 1990), and these associations vary with drinking characteristics of the particular populations studied, both within the same culture (Cherpitel, 1988a, 1989; Rosovsky and Garcia, 1988) and between different cultures (Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991, in press). Within a given cultural context, however, the association of alcohol consumption with injuries has not been examined in relation to various ethnic groups in the culture. In a comparison of alcohol and casualties between emergency room populations in the United States (Northern California) and Mexico (Mexico City), drinking patterns were found to reflect typical patterns in their respective populations, although higher rates of heavy drinking, drunkenness, and alcohol-related problems were found among both injured and noninjured in the emergency room (Cherpitel and Rosovsky, 1990) than that found on general population surveys for both countries (Clark and Midanik, 1981; Hilton and Clark, 1987; Medina Mora et al., 1980). General population surveys of drinking patterns in Mexico have found higher rates of infrequent but heavy drinking leading to drunkenness among males and higher rates of abstention or infrequent intake among females compared to that found in the United States (Medina Mora et al., 1980; Caetano and Medina Mora, 1986). General population data from Mexico come from a sample of those who live in the state of Michoacan (near Mexico City), and it is from this area that a large number of Mexicans migrating to the United States come. In studies of the effect of acculturation, or cultural adaptation to American society, on drinking patterns among Mexicans migrating to the United States, it has been found that Mexican men adopt quantity and frequency patterns of heavy drinking similar to those found among males in the United States general population, and this occurs within the first 5 years of United States residency (Caetano and Medina Mora, 1988). Among females, rates of frequent heavy drinking were greater among those who migrated, but this was not related to length of residency in the United States. However, an analysis of a general population sample of United States Hispanics (including those who identify themselves as other than Mexican) found females who were highly acculturated to be nine times more likely to be frequent heavy drinkers than those who were less acculturated (Caetano, 1987a). These national survey findings confirm previous findings of Hispanics living in Northern California (Caetano, 1985). If Mexican males and females adopt patterns of more frequent heavy drinking within a relatively short time after migrating to the United States, it is possible that this change in usual drinking patterns may put them at an added risk for alcohol-related casualties. This paper analyzes the association of
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alcohol consumption and acculturation with injury occurrence in a sample of casualty patients admitted to the emergency room (ER) at the county hospital in a Northern California county during a 1-year period. A comparison is made between Hispanics and non-Hispanics, and among Hispanics by level of acculturation, in relation to breathalyzer reading, drinking-in-the-event, and usual drinking patterns. If acculturation is accompanied by changes in drinking patterns which in turn lead to an increase in alcohol-related casualties during the transition period of adapting to the new culture, identification of these individuals carries the potential for prevention of future alcohol-related injuries.
METHODS Sample Selection A one-third probability sample was taken of every casualty patient over the age of 18 admitted to the emergency room (ER) between December 1986 and December 1987. Sampled shifts were rotated so that each shift was equally represented for each day of the week during the 52 weeks of data collection. This sampling scheme provided a total sample of 1,527 patients, of whom 1,102 were interviewed and breathalyzed, for a 72% completion rate. The sample was drawn from the ER triage forms and the ER logbook which generally represented consecutive admission of patients to the ER. Those who were not interviewed were not significantly different from those interviewed on sex or age, although noninterviewed were slightly older than those interviewed. Noninterviews were due to being in police custody (9%), physical condition prohibiting the interview (8%), refusal (7%), and leaving prior to being interviewed (4%).
Instruments Data were collected using the same 15-20 minute intervieweradministered questionnaire which has been used in a number of other ER studies in the United States, Mexico, and Spain (Cherpitel, 1988a, 1988b; Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991). A breath sample was also obtained using the Alco-Sensor I11 breathalyzer which provides estimates of blood alcohol having a high correlation with chemical analysis of blood (Gibb et al., 1984). Interviews were conducted in both English and Spanish, using a cadre of professional interviewers trained and supervised by the University of California, Berkeley, Survey Research Center. Breath samples and interviews were obtained as soon as possible after a patient had been selected for the study. Patients falling into the study sample were approached with an informa-
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tion sheet regarding the purpose of the study and an informed consent to participate. Patients were interviewed regarding the injury which brought them to the ER, alcohol consumption 6 hours prior to the injury, feeling drunk at the time of injury, believing the event was related to drinking, and quantity and frequency of usual consumption during the last year. Drinking-in-the-event questions excluded all patients who were in the ER for follow-up of a problem which had previously been treated ( n = 278). These patients were breathalyzed, however, and asked all questions pertaining to usual drinking patterns. Patients who identified themselves as being of Hispanic racial or ethnic background (Latino, Mexican, Mexican-American, Chicano, or Spanish heritage) were also asked a series of questions regarding preference for Spanish or English in talking with various categories of people, reading, listening to music and the radio, and watching TV ( n = 112).
Quantity-Frequency Typobgy Patients were asked about the quantity and frequency of drinking during the last year. Frequency of usual drinking ranged from daily to no drinking during the last year. Patients were then asked the frequency of drinking between 5 and 11 drinks on an occasion and 12 or more drinks on an occasion during the last year. Frequency of these higher amounts ranged from daily to not in the last year. Quantity and frequency of drinking during the last year were analyzed using the same typology which has been used in prior ER studies in the United States, Mexico, and Spain (Cherpitel et al., 1988b; Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991). This quantity-frequency (Q-F) typology has been found useful in jointly analyzing the association of these two measures with injury status in ER populations and consists of the following six categories: Abstainer (no drinking during the last year), Infrequent Light (drinks less than once a monthhever 5 drinks at one time), Infrequent Moderate-Heavy (drinks less than once a month/5 or more drinks on occasion), Light (drinks more often than once a month/never 5 drinks at one time), Moderate (drinks more often than once a month/5 to 11 drinks on occasion or drinks at least once a month but less than 3 times a week/l2 or more drinks on occasion), Heavy (drinks at least 3 times a weeWl2 or more drinks on occasion).
Acculturation An acculturation scale was developed to measure the degree of adaptation to United States culture among Hispanic respondents and was adapted from that used by Caetano (1987b) in a general population survey of United States
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Hispanics. The reliability of this acculturation scale was assessed with Cronbach's alpha (.91)and the split-half method (.87, Guttman split-half coefficient). This scale is positively correlated with being foreign born and with the number of years living in the United States and negatively correlated with age. This scale was also found to be predictive of drinking patterns and of drinking in various social settings in the general population (Caetano and Medina Mora, 1988). While acculturation is an ongoing, dynamic process, a measure such as this, at one point in time, has proven useful in understanding the effect of exposure to United States culture. Patients who could speak both English and Spanish were asked whether they usually spoke English (scored 3), usually spoke Spanish (scored 1) or spoke both about the same (scored 2), separately for spouse, children, siblings, parents, other relatives, friends, neighbors, and people at work. These items were combined to form a single scale for speaking. Patients who could read both English and Spanish were asked whether they preferred to read in Spanish rather than English on a 3-point scale of most of the time (scored l ) , about the same (scored 2), or almost never (scored 3). Patients were also asked whether they preferred to listen to Hispanic music, to listen to a Hispanic radio station, and to watch a Hispanic TV channel on the same 3-point scale. Responses to all items were summed with speaking given twice the weight as the other variables (range 6-18). If respondents could not answer certain items because the question was not applicable (e.g., not married, don't watch TV, etc.), they were assigned their average score on all other items in the scale. The scale was divided into three groups representing low (scored 6-10), medium (scored 1114), and high (scored 15-18) acculturation.
Sample Characteristics Table 1 shows the sex and age distribution for non-Hispanics ( n = 962) and Hispanics (n = 112) by acculturation. (No ethnic identification was available for 28 patients who were interviewed.) The non-Hispanic group included primarily Anglos (78%),Blacks (13%),and Native American Indians ( 5 % ) .
RESULTS Breathalyzer Readings Table 2 shows breathalyzer readings within 6 hours of arrival in the ER for non-Hispanics and for Hispanics by acculturation. While a larger proportion of non-Hispanics had positive readings compared to Hispanics, at the 0.10 mg% level (legal intoxification) Hispanics as a whole had a greater proportion of positive readings, with those in the highest acculturation group having twice
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Table 1. Sex-Age Distribution for Non-Hispanics and Hispanics by Acculturation (in O/O)
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Hispanics Non-Hispanics
Total'
Law
Medium
High
(962)
(1 12)
(26)
(28)
(57)
Male Female
63 37
80 20
81 19
82
79 21
18-29 30-39 40-49 50-59 60-69 70
51
61 23 7 7 2 0
61 19 8 8 4 0
43 32 II II 3 0
Sex: 18
Age:
+
31 10
4 3 I
69 21 5
5 0 0
One Hispanic patient did not have sufficient data for assigning an acculturation score.
Table 2. Breathalyzer Reading within 6 Hours of ER Arrival" for Non-Hispanics and Hispanics by Acculturation (in Yo) Hispanics
Positive 2.05 2.10
Non-Hispanics (897)
Total (107)
LOW
Medium (26)
High
(24)
13.4 9.2 5.5
11.2
4 0 0
12 8 4
14 13
8.4 6.5
(56)
I1
Excludes 65 Non-Hispanic and 5 Hispanic patients who were not breathalyzed within 6 hours of ER arrival. hPositive is 2.01 (10 mg alcohol per LOO mL blood. The breathalyzer categories are nested: positive includes 2.05 and 2 .lo; 2.05 includes .lo.
A
the proportion of readings at this level than non-Hispanics. When breathalyzer readings were analyzed by sex (not shown), none of the Hispanic females had positive breathalyzer readings, and Hispanic males in the highest acculturation group were almost three times as likely to have readings at .10 and above than non-Hispanic males. (All differences are nonsignificant because of the small
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UNITED STATES HISPANICS IN THE EMERGENCY ROOM
number of Hispanics in the analysis, especially when analyzed by acculturation level .)
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Drinking-in-the-Event Table 3 shows the proportion of those who reported any alcohol consumption within 6 hours prior to the injury event. Among Hispanics a larger proportion reported drinking compared to non-Hispanics, and this was greater in the highest acculturation groups. These differences held for males and females separately. Table 4 shows the proportion of those feeling drunk at the time of injury among those who reported drinking prior to the event. Half of the Hispanics reported feeling drunk compared to 35 % of non-Hispanics, with over twice the proportion of Hispanics reporting feeling very drunk compared to nonHispanics. These numbers were too small to analyze by level of acculturation. Patients who reported feeling drunk at the time were asked whether they believed the event would have happened even if they had not been drinking
Table 3. Self-Reported Alcohol Consumption within 6 Hours Prior to Event for Non-Hispanics and Hispanics by Acculturation a (in YO)
Hispanics Non-Hispanics (7 10)
Total (86)
Low (17)
Medium (19)
High (49)
26
32
24
37
35
a
Excludes the 252 Non-Hispanic and 26 Hispanic follow-up patients.
Table 4. Feeling Drunk at Time of the Event for Non-Hispanicsaand Hispanics by Acculturation (in %)
Drunkenness Not drunk Somewhat drunk Very drunk a
Non-Hispanics ( 180)
Hispanics (28)
65 27 8
50 31 19
Excludes 6 non-Hispanics on whom these data were not obtained.
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(Table 5 ) . Half of the Hispanics attributed a causal association of drinking with the event compared to 37 % of non-Hispanics.
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Quantity and Frequency of Drinking The quantity and frequency of usual consumption was analyzed for Hispanics and non-Hispanics to examine the association of drinking patterns with injuries (Table 6). A quarter of both Hispanics and non-Hispanics reported heavy drinking (drinking at least 3 times a week and having 12 or more drinks on at least one occasion during the last year), and this was highest among those in the highest acculturation group. When quantity-frequency was analyzed by sex, 30% of both Hispanic and non-Hispanic males reported heavy drinking, and this reached 40% among males in the highest acculturation group (not shown). Table 5. Believed Event Would Have Happened Even If I Had Not Been Drinking among Those Feeling Drunk at Time (in oh) ~
Non-Hispanics (63)
Hispanics (14)
59 37 5
43
Yes No Not sure
50 7
Table 6. Quantity and Frequency of Usual Consumption Drinking Last Year for Non-Hispanics" and Hispanics by Acculturation (in oh)
Hispanics Quantity-Frequency
Non-Hispanics (957)
Total (112)
LOW (26)
Medium (28)
High
18
18
(57)
~~
Abstainer InfrequentILight Infrequent/Moderate-Heav y Light Moderate Heavy
14.5 13.0 5. I 13.9 30.5 23.0
17.0 7. I I .8 11.6 36.6 25.9
15 15 0 12 31 27
0
7
3 I1 54 14
2 12 30 32
Excludes 5 Non-Hispanic patients on whom both quantity and frequency data were not obtained.
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DISCUSSION Hispanic males in the highest acculturation group were most likely to have breathalyzer readings at the legally intoxicated level and to report heavy drinking. The data suggest, however, that Hispanics in the moderate acculturation category may have been somewhat more likely to report drinking prior to injury than those in the high acculturation group. If alcohol-related injuries increase as patterns of more frequent heavy drinking of the dominant culture are taken on, then alcohol-related injuries would be expected to be lowest among those in the low acculturation group and highest among those in the moderate acculturation group, with some leveling-off expected in the high acculturation group. The high acculturation group would include those who had been living in the United States for varying lengths of time and who may have developed a tolerance to increased quantity and frequency of usual drinking, putting them at less risk for alcohol-related injuries. It should be noted that years of residency in the United States was not ascertained in this sample, and the high acculturation group most likely also included some who were born in the United States. Regardless of acculturation status, Hispanic males compared to nonHispanic males were also more likely to report being drunk at the time of the event and to attribute a causal association of alcohol with the injury. While the number of patients analyzed is quite small, and the emergency room population is not representative of the larger population in relation to drinking characteristics, and possibly to a number of other variables, these findings suggest that United States Hispanics may, indeed, be at greater risk for alcohol-related injuries. Studies are needed which include a greater number of both male and female Hispanics at all acculturation levels and which also include an analysis of length of residency in the United States, for a further exploration of the acculturation hypothesis of alcohol-related injuries in this group.
ACKNOWLEDGMENTS Supported by a National Alcohol Research Center Grant (AA-05595) from the U.S. Institute on Alcohol Abuse and Alcoholism and from a grant (CCA85 10/040) from the US.-Spain Joint Committee for Scientific and Technological Cooperation.
REFERENCES CAETANO, R. (1985). Hispanic drinking practices in Northern California. Hispanic J . Behav. Sci. 6: 345-364. CAETANO, R. (1987a). Acculturation and drinking patterns among U.S. Hispanics. Br. J . Addirr. 82: 789-799.
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CAETANO, R. (1987b). Acculturation, drinking and social settings among U.S.Hispanics. Drug Alcohol Depend. 19: 215-226. CAETANO. R.. and MEDINA MORA, M. E. (1986). Immigration. Acculturation and Alcohol Use: A Comparison berween People of Mexican Decent in Mexico and the U S . Alcohol Research Group, May. CAETANO, R., and MEDINA MORA, M. E. (1988). Acculturation and drinking among people of Mexican decent in Mexico and the United States. J. Srud. Alcohol 49: 462-47 1. CHERPITEL. C. J. STEPHENS (1988a). Alcohol consumption and casualties: A comparison of two emergency room populations. Br. J . Addict. 83: 1299-1307. CHERPITEL, C . J. STEPHENS (l988b). Drinking patterns and problems associated with injury status in emergency room admissions. Alcoholism: Clin. Erp. Res. 12: 105-1 10. CHERPITEL, C. J. STEPHENS (1989). Prediction of alcohol-related casualties: A comparison of two emergency room populations.,Drug Alcohol Depend. 24: 195-203. CHERPITEL, C. J. STEPHENS. PARES, A,, and RODES, J. (1991). Drinking patterns and problems: A comparison of emergency room populations in the United States and Spain, Drug Alcohol Depend. 29: 5-15. CHERPITEL, C. J. STEPHENS, PARES, A,, and RODES, J. (in press). Prediction of alcoholrelated casualties in the emergency room. J. Stud. Alcohol. CHERPITEL, C. J. STEPHENS, and ROSOVSKY, H. (1990). Alcohol consumption and casualties: A comparison of U.S. and Mexico emergency room populations. J. Stud. Alcohol 51: 319-326. CLARK, W. B., and MIDANIK, L. (1981). Alcohol Use and Alcohol Problems among U.S. Adults: Results of the 1979 survey. Report on the 1979 National Survey. University of California, Berkeley: Social Research Group. GIBB. K., YEE. A,, JOHNSTON, C., MARTIN, S., and NOWAK. R. (1984). Accuracy and usefulness of a breath alcohol analyzer. Ann. Emerg. Med. 13: 516-520. HILTON, M., and CLARK, W. B. (1987). Changes in American drinking patterns and problems, 1967-1984. J. 9 u d . Alcohol 48: 515-522. MEDINA MORA, M. E., DE LA PANA, A,, and TERROBA. G. (1980). The consumption of alcohol in the population of the Federal District. Rev. Salud Publica Mex. 22: 281-288. ROIZEN, R. (1982). Alcohol involvement in serious events. In Alcohol Consumption and Related Problems, Alcohol and Health. Monograph DHHS Pub. (ADM) 82-1 190. Washington, D.C.: US. Government Printing Office, pp. 179-219. ROSOVSKY, H., and GARCIA, G. (1988). Alcohol-Related Casualties in Mexico: A Comparison berween Two Populations. Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Berkeley, California, June 5-1 I . U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: SEVENTH SPECIAL REPORT TO THE U.S. CONGRESS ON ALCOHOL AND HEALTH (1990). NIAAA, DHHS Pub. (ADM) 281-88-0002. Washington, D.C.: Superintendent of Documents, US. Government Printing Office.
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THE AUTHOR Cheryl J. Stephens Cherpitel, R.N., Dr.P.H., received her Dr.P.H. in epidemiology from the University of California, School of Public Health, Berkeley. She is presently a senior scientist at the Alcohol Research Group in Berkeley where she has conducted a number of studies on the epidemiology of alcohol and casualties in emergency room populations. In addition to many publications in this area, Dr. Cherpitel has also published on the validity of self-reported alcohol consumption based on breathalyzer readings, alcohol consumption in primary care populations, and variables associated with drinking during pregnancy and pregnancy outcomes.
The International Journal of the Addictions, 27(9), 1067- 1077, 1992
Acculturation, Alcohol Consumption, and Casualties among United States Hispanics in the Emergency Room* Cheryl J. Cherpitel, Dr.P.H. Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco, 2000 Hearst Avenue, Berkeley, California 94 709
ABSTRACT The association of alcohol consumption and casualties was analyzed among Hispanic emergency room patients to determine whether level of acculturation and accompanying changes in drinking patterns influence risk of alcohol-related injuries. A sample of patients admitted to a county hospital emergency room during a 1-year period was breathalyzed and interviewed ( N = 1,102). Of these, 112 identified themselves as Hispanic. Hispanic males were more likely than nonHispanics to have positive breathalyzer readings, to report drinking prior to the event, and to attribute a causal association of drinking with the event. These findings were most pronounced among those in the moderate and high acculturation groups.
Key words. Alcohol consumption; Acculturation; Casualties Hispanic; Emergency room
*Prepared for presentation at the Fifth Iberoamerican Congress on Drug Dependencies and Alcoholism, Madrid, Spain, November 15-17, 1989. 1067
Copyright 01992 by Marcel Dekker, Inc.
CHERPITEL
1068
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INTRODUCTION Nonfatal casualties have been found to be positively associated with alcohol consumption (Roizen, 1982; USDHHS, 1990), and these associations vary with drinking characteristics of the particular populations studied, both within the same culture (Cherpitel, 1988a, 1989; Rosovsky and Garcia, 1988) and between different cultures (Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991, in press). Within a given cultural context, however, the association of alcohol consumption with injuries has not been examined in relation to various ethnic groups in the culture. In a comparison of alcohol and casualties between emergency room populations in the United States (Northern California) and Mexico (Mexico City), drinking patterns were found to reflect typical patterns in their respective populations, although higher rates of heavy drinking, drunkenness, and alcohol-related problems were found among both injured and noninjured in the emergency room (Cherpitel and Rosovsky, 1990) than that found on general population surveys for both countries (Clark and Midanik, 1981; Hilton and Clark, 1987; Medina Mora et al., 1980). General population surveys of drinking patterns in Mexico have found higher rates of infrequent but heavy drinking leading to drunkenness among males and higher rates of abstention or infrequent intake among females compared to that found in the United States (Medina Mora et al., 1980; Caetano and Medina Mora, 1986). General population data from Mexico come from a sample of those who live in the state of Michoacan (near Mexico City), and it is from this area that a large number of Mexicans migrating to the United States come. In studies of the effect of acculturation, or cultural adaptation to American society, on drinking patterns among Mexicans migrating to the United States, it has been found that Mexican men adopt quantity and frequency patterns of heavy drinking similar to those found among males in the United States general population, and this occurs within the first 5 years of United States residency (Caetano and Medina Mora, 1988). Among females, rates of frequent heavy drinking were greater among those who migrated, but this was not related to length of residency in the United States. However, an analysis of a general population sample of United States Hispanics (including those who identify themselves as other than Mexican) found females who were highly acculturated to be nine times more likely to be frequent heavy drinkers than those who were less acculturated (Caetano, 1987a). These national survey findings confirm previous findings of Hispanics living in Northern California (Caetano, 1985). If Mexican males and females adopt patterns of more frequent heavy drinking within a relatively short time after migrating to the United States, it is possible that this change in usual drinking patterns may put them at an added risk for alcohol-related casualties. This paper analyzes the association of
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alcohol consumption and acculturation with injury occurrence in a sample of casualty patients admitted to the emergency room (ER) at the county hospital in a Northern California county during a 1-year period. A comparison is made between Hispanics and non-Hispanics, and among Hispanics by level of acculturation, in relation to breathalyzer reading, drinking-in-the-event, and usual drinking patterns. If acculturation is accompanied by changes in drinking patterns which in turn lead to an increase in alcohol-related casualties during the transition period of adapting to the new culture, identification of these individuals carries the potential for prevention of future alcohol-related injuries.
METHODS Sample Selection A one-third probability sample was taken of every casualty patient over the age of 18 admitted to the emergency room (ER) between December 1986 and December 1987. Sampled shifts were rotated so that each shift was equally represented for each day of the week during the 52 weeks of data collection. This sampling scheme provided a total sample of 1,527 patients, of whom 1,102 were interviewed and breathalyzed, for a 72% completion rate. The sample was drawn from the ER triage forms and the ER logbook which generally represented consecutive admission of patients to the ER. Those who were not interviewed were not significantly different from those interviewed on sex or age, although noninterviewed were slightly older than those interviewed. Noninterviews were due to being in police custody (9%), physical condition prohibiting the interview (8%), refusal (7%), and leaving prior to being interviewed (4%).
Instruments Data were collected using the same 15-20 minute intervieweradministered questionnaire which has been used in a number of other ER studies in the United States, Mexico, and Spain (Cherpitel, 1988a, 1988b; Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991). A breath sample was also obtained using the Alco-Sensor I11 breathalyzer which provides estimates of blood alcohol having a high correlation with chemical analysis of blood (Gibb et al., 1984). Interviews were conducted in both English and Spanish, using a cadre of professional interviewers trained and supervised by the University of California, Berkeley, Survey Research Center. Breath samples and interviews were obtained as soon as possible after a patient had been selected for the study. Patients falling into the study sample were approached with an informa-
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tion sheet regarding the purpose of the study and an informed consent to participate. Patients were interviewed regarding the injury which brought them to the ER, alcohol consumption 6 hours prior to the injury, feeling drunk at the time of injury, believing the event was related to drinking, and quantity and frequency of usual consumption during the last year. Drinking-in-the-event questions excluded all patients who were in the ER for follow-up of a problem which had previously been treated ( n = 278). These patients were breathalyzed, however, and asked all questions pertaining to usual drinking patterns. Patients who identified themselves as being of Hispanic racial or ethnic background (Latino, Mexican, Mexican-American, Chicano, or Spanish heritage) were also asked a series of questions regarding preference for Spanish or English in talking with various categories of people, reading, listening to music and the radio, and watching TV ( n = 112).
Quantity-Frequency Typobgy Patients were asked about the quantity and frequency of drinking during the last year. Frequency of usual drinking ranged from daily to no drinking during the last year. Patients were then asked the frequency of drinking between 5 and 11 drinks on an occasion and 12 or more drinks on an occasion during the last year. Frequency of these higher amounts ranged from daily to not in the last year. Quantity and frequency of drinking during the last year were analyzed using the same typology which has been used in prior ER studies in the United States, Mexico, and Spain (Cherpitel et al., 1988b; Cherpitel and Rosovsky, 1990; Cherpitel et al., 1991). This quantity-frequency (Q-F) typology has been found useful in jointly analyzing the association of these two measures with injury status in ER populations and consists of the following six categories: Abstainer (no drinking during the last year), Infrequent Light (drinks less than once a monthhever 5 drinks at one time), Infrequent Moderate-Heavy (drinks less than once a month/5 or more drinks on occasion), Light (drinks more often than once a month/never 5 drinks at one time), Moderate (drinks more often than once a month/5 to 11 drinks on occasion or drinks at least once a month but less than 3 times a week/l2 or more drinks on occasion), Heavy (drinks at least 3 times a weeWl2 or more drinks on occasion).
Acculturation An acculturation scale was developed to measure the degree of adaptation to United States culture among Hispanic respondents and was adapted from that used by Caetano (1987b) in a general population survey of United States
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Hispanics. The reliability of this acculturation scale was assessed with Cronbach's alpha (.91)and the split-half method (.87, Guttman split-half coefficient). This scale is positively correlated with being foreign born and with the number of years living in the United States and negatively correlated with age. This scale was also found to be predictive of drinking patterns and of drinking in various social settings in the general population (Caetano and Medina Mora, 1988). While acculturation is an ongoing, dynamic process, a measure such as this, at one point in time, has proven useful in understanding the effect of exposure to United States culture. Patients who could speak both English and Spanish were asked whether they usually spoke English (scored 3), usually spoke Spanish (scored 1) or spoke both about the same (scored 2), separately for spouse, children, siblings, parents, other relatives, friends, neighbors, and people at work. These items were combined to form a single scale for speaking. Patients who could read both English and Spanish were asked whether they preferred to read in Spanish rather than English on a 3-point scale of most of the time (scored l ) , about the same (scored 2), or almost never (scored 3). Patients were also asked whether they preferred to listen to Hispanic music, to listen to a Hispanic radio station, and to watch a Hispanic TV channel on the same 3-point scale. Responses to all items were summed with speaking given twice the weight as the other variables (range 6-18). If respondents could not answer certain items because the question was not applicable (e.g., not married, don't watch TV, etc.), they were assigned their average score on all other items in the scale. The scale was divided into three groups representing low (scored 6-10), medium (scored 1114), and high (scored 15-18) acculturation.
Sample Characteristics Table 1 shows the sex and age distribution for non-Hispanics ( n = 962) and Hispanics (n = 112) by acculturation. (No ethnic identification was available for 28 patients who were interviewed.) The non-Hispanic group included primarily Anglos (78%),Blacks (13%),and Native American Indians ( 5 % ) .
RESULTS Breathalyzer Readings Table 2 shows breathalyzer readings within 6 hours of arrival in the ER for non-Hispanics and for Hispanics by acculturation. While a larger proportion of non-Hispanics had positive readings compared to Hispanics, at the 0.10 mg% level (legal intoxification) Hispanics as a whole had a greater proportion of positive readings, with those in the highest acculturation group having twice
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Table 1. Sex-Age Distribution for Non-Hispanics and Hispanics by Acculturation (in O/O)
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Hispanics Non-Hispanics
Total'
Law
Medium
High
(962)
(1 12)
(26)
(28)
(57)
Male Female
63 37
80 20
81 19
82
79 21
18-29 30-39 40-49 50-59 60-69 70
51
61 23 7 7 2 0
61 19 8 8 4 0
43 32 II II 3 0
Sex: 18
Age:
+
31 10
4 3 I
69 21 5
5 0 0
One Hispanic patient did not have sufficient data for assigning an acculturation score.
Table 2. Breathalyzer Reading within 6 Hours of ER Arrival" for Non-Hispanics and Hispanics by Acculturation (in Yo) Hispanics
Positive 2.05 2.10
Non-Hispanics (897)
Total (107)
LOW
Medium (26)
High
(24)
13.4 9.2 5.5
11.2
4 0 0
12 8 4
14 13
8.4 6.5
(56)
I1
Excludes 65 Non-Hispanic and 5 Hispanic patients who were not breathalyzed within 6 hours of ER arrival. hPositive is 2.01 (10 mg alcohol per LOO mL blood. The breathalyzer categories are nested: positive includes 2.05 and 2 .lo; 2.05 includes .lo.
A
the proportion of readings at this level than non-Hispanics. When breathalyzer readings were analyzed by sex (not shown), none of the Hispanic females had positive breathalyzer readings, and Hispanic males in the highest acculturation group were almost three times as likely to have readings at .10 and above than non-Hispanic males. (All differences are nonsignificant because of the small
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UNITED STATES HISPANICS IN THE EMERGENCY ROOM
number of Hispanics in the analysis, especially when analyzed by acculturation level .)
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Drinking-in-the-Event Table 3 shows the proportion of those who reported any alcohol consumption within 6 hours prior to the injury event. Among Hispanics a larger proportion reported drinking compared to non-Hispanics, and this was greater in the highest acculturation groups. These differences held for males and females separately. Table 4 shows the proportion of those feeling drunk at the time of injury among those who reported drinking prior to the event. Half of the Hispanics reported feeling drunk compared to 35 % of non-Hispanics, with over twice the proportion of Hispanics reporting feeling very drunk compared to nonHispanics. These numbers were too small to analyze by level of acculturation. Patients who reported feeling drunk at the time were asked whether they believed the event would have happened even if they had not been drinking
Table 3. Self-Reported Alcohol Consumption within 6 Hours Prior to Event for Non-Hispanics and Hispanics by Acculturation a (in YO)
Hispanics Non-Hispanics (7 10)
Total (86)
Low (17)
Medium (19)
High (49)
26
32
24
37
35
a
Excludes the 252 Non-Hispanic and 26 Hispanic follow-up patients.
Table 4. Feeling Drunk at Time of the Event for Non-Hispanicsaand Hispanics by Acculturation (in %)
Drunkenness Not drunk Somewhat drunk Very drunk a
Non-Hispanics ( 180)
Hispanics (28)
65 27 8
50 31 19
Excludes 6 non-Hispanics on whom these data were not obtained.
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(Table 5 ) . Half of the Hispanics attributed a causal association of drinking with the event compared to 37 % of non-Hispanics.
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Quantity and Frequency of Drinking The quantity and frequency of usual consumption was analyzed for Hispanics and non-Hispanics to examine the association of drinking patterns with injuries (Table 6). A quarter of both Hispanics and non-Hispanics reported heavy drinking (drinking at least 3 times a week and having 12 or more drinks on at least one occasion during the last year), and this was highest among those in the highest acculturation group. When quantity-frequency was analyzed by sex, 30% of both Hispanic and non-Hispanic males reported heavy drinking, and this reached 40% among males in the highest acculturation group (not shown). Table 5. Believed Event Would Have Happened Even If I Had Not Been Drinking among Those Feeling Drunk at Time (in oh) ~
Non-Hispanics (63)
Hispanics (14)
59 37 5
43
Yes No Not sure
50 7
Table 6. Quantity and Frequency of Usual Consumption Drinking Last Year for Non-Hispanics" and Hispanics by Acculturation (in oh)
Hispanics Quantity-Frequency
Non-Hispanics (957)
Total (112)
LOW (26)
Medium (28)
High
18
18
(57)
~~
Abstainer InfrequentILight Infrequent/Moderate-Heav y Light Moderate Heavy
14.5 13.0 5. I 13.9 30.5 23.0
17.0 7. I I .8 11.6 36.6 25.9
15 15 0 12 31 27
0
7
3 I1 54 14
2 12 30 32
Excludes 5 Non-Hispanic patients on whom both quantity and frequency data were not obtained.
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DISCUSSION Hispanic males in the highest acculturation group were most likely to have breathalyzer readings at the legally intoxicated level and to report heavy drinking. The data suggest, however, that Hispanics in the moderate acculturation category may have been somewhat more likely to report drinking prior to injury than those in the high acculturation group. If alcohol-related injuries increase as patterns of more frequent heavy drinking of the dominant culture are taken on, then alcohol-related injuries would be expected to be lowest among those in the low acculturation group and highest among those in the moderate acculturation group, with some leveling-off expected in the high acculturation group. The high acculturation group would include those who had been living in the United States for varying lengths of time and who may have developed a tolerance to increased quantity and frequency of usual drinking, putting them at less risk for alcohol-related injuries. It should be noted that years of residency in the United States was not ascertained in this sample, and the high acculturation group most likely also included some who were born in the United States. Regardless of acculturation status, Hispanic males compared to nonHispanic males were also more likely to report being drunk at the time of the event and to attribute a causal association of alcohol with the injury. While the number of patients analyzed is quite small, and the emergency room population is not representative of the larger population in relation to drinking characteristics, and possibly to a number of other variables, these findings suggest that United States Hispanics may, indeed, be at greater risk for alcohol-related injuries. Studies are needed which include a greater number of both male and female Hispanics at all acculturation levels and which also include an analysis of length of residency in the United States, for a further exploration of the acculturation hypothesis of alcohol-related injuries in this group.
ACKNOWLEDGMENTS Supported by a National Alcohol Research Center Grant (AA-05595) from the U.S. Institute on Alcohol Abuse and Alcoholism and from a grant (CCA85 10/040) from the US.-Spain Joint Committee for Scientific and Technological Cooperation.
REFERENCES CAETANO, R. (1985). Hispanic drinking practices in Northern California. Hispanic J . Behav. Sci. 6: 345-364. CAETANO, R. (1987a). Acculturation and drinking patterns among U.S. Hispanics. Br. J . Addirr. 82: 789-799.
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CAETANO, R. (1987b). Acculturation, drinking and social settings among U.S.Hispanics. Drug Alcohol Depend. 19: 215-226. CAETANO. R.. and MEDINA MORA, M. E. (1986). Immigration. Acculturation and Alcohol Use: A Comparison berween People of Mexican Decent in Mexico and the U S . Alcohol Research Group, May. CAETANO, R., and MEDINA MORA, M. E. (1988). Acculturation and drinking among people of Mexican decent in Mexico and the United States. J. Srud. Alcohol 49: 462-47 1. CHERPITEL. C. J. STEPHENS (1988a). Alcohol consumption and casualties: A comparison of two emergency room populations. Br. J . Addict. 83: 1299-1307. CHERPITEL, C . J. STEPHENS (l988b). Drinking patterns and problems associated with injury status in emergency room admissions. Alcoholism: Clin. Erp. Res. 12: 105-1 10. CHERPITEL, C. J. STEPHENS (1989). Prediction of alcohol-related casualties: A comparison of two emergency room populations.,Drug Alcohol Depend. 24: 195-203. CHERPITEL, C. J. STEPHENS. PARES, A,, and RODES, J. (1991). Drinking patterns and problems: A comparison of emergency room populations in the United States and Spain, Drug Alcohol Depend. 29: 5-15. CHERPITEL, C. J. STEPHENS, PARES, A,, and RODES, J. (in press). Prediction of alcoholrelated casualties in the emergency room. J. Stud. Alcohol. CHERPITEL, C. J. STEPHENS, and ROSOVSKY, H. (1990). Alcohol consumption and casualties: A comparison of U.S. and Mexico emergency room populations. J. Stud. Alcohol 51: 319-326. CLARK, W. B., and MIDANIK, L. (1981). Alcohol Use and Alcohol Problems among U.S. Adults: Results of the 1979 survey. Report on the 1979 National Survey. University of California, Berkeley: Social Research Group. GIBB. K., YEE. A,, JOHNSTON, C., MARTIN, S., and NOWAK. R. (1984). Accuracy and usefulness of a breath alcohol analyzer. Ann. Emerg. Med. 13: 516-520. HILTON, M., and CLARK, W. B. (1987). Changes in American drinking patterns and problems, 1967-1984. J. 9 u d . Alcohol 48: 515-522. MEDINA MORA, M. E., DE LA PANA, A,, and TERROBA. G. (1980). The consumption of alcohol in the population of the Federal District. Rev. Salud Publica Mex. 22: 281-288. ROIZEN, R. (1982). Alcohol involvement in serious events. In Alcohol Consumption and Related Problems, Alcohol and Health. Monograph DHHS Pub. (ADM) 82-1 190. Washington, D.C.: US. Government Printing Office, pp. 179-219. ROSOVSKY, H., and GARCIA, G. (1988). Alcohol-Related Casualties in Mexico: A Comparison berween Two Populations. Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Berkeley, California, June 5-1 I . U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: SEVENTH SPECIAL REPORT TO THE U.S. CONGRESS ON ALCOHOL AND HEALTH (1990). NIAAA, DHHS Pub. (ADM) 281-88-0002. Washington, D.C.: Superintendent of Documents, US. Government Printing Office.
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THE AUTHOR Cheryl J. Stephens Cherpitel, R.N., Dr.P.H., received her Dr.P.H. in epidemiology from the University of California, School of Public Health, Berkeley. She is presently a senior scientist at the Alcohol Research Group in Berkeley where she has conducted a number of studies on the epidemiology of alcohol and casualties in emergency room populations. In addition to many publications in this area, Dr. Cherpitel has also published on the validity of self-reported alcohol consumption based on breathalyzer readings, alcohol consumption in primary care populations, and variables associated with drinking during pregnancy and pregnancy outcomes.
