The first diagnostic evaluation and validation of the AUDIT for alcohol dependence, alcohol dependence/abuse and hazardous drinking in Nepalese language has been reported here. The feasibility of using the AUDIT in the busy out-patient setting by successfully screening 1068 patients has been demonstrated. The prevalence of alcohol dependence and alcohol abuse/ dependence was 32.2% and 40.5% respectively. The prevalence of alcohol dependence was very high in this study. Several epidemiological studies have estimated a higher prevalence of AUDs in medical settings than in the general population[26, 27]. Namely, lifetime prevalence of alcohol abuse or dependence has been identified in ~10% of the general population and in 16–36% of outpatients. In a previous study using the CAGE questionnaire Jhingan et al. reported the prevalence of alcohol dependence in Nepal to be 25.8%.
AUDIT has demonstrated a high degree of internal consistency over a broad range of diverse settings. In a reliability generalization analysis of studies that appeared in 2000 or before, Shields and Caruso calculated a median reliability coefficient of 0.81, ranging from 0.59 to 0.91. In a more recent review of 18 studies published since 2002, Reinert and Allen found comparable results with a median reliability coefficient of 0.83, ranging from 0.75 to 0.97. The Cronbach’s coefficient of 0.82 found in this study is therefore consistent with previous findings.
Although cultural differences may have significantly influenced the cut-off points, it is confirmed by the current study that the Nepali version of AUDIT can be used as a reliable and valid screening tool for alcohol dependence and alcohol dependence/abuse. However the diagnostic performance for identifying hazardous drinking is weaker. The best diagnostic cut-off score for dependence was ≥11 in both males and females, with high NPV (>95% in both sexes) and moderate PPV (76.3% in males and 72.1% in females). Sensitivity and specificity estimates were comparable to those found in studies done in Switzerland where the diagnostic cut-off scores for dependence ranged from 10 to 13. Tsai et al. reported the same cut-off score (≥11) for diagnosing alcohol dependence among hospitalized Chinese patients. Guo et al. performed an epidemiological survey in a Tibetan population and found AUDIT cut-off scores of 10 and 13 as best diagnostic discriminators for diagnosing alcohol abuse and alcohol dependence, respectively, with sensitivity and specificity estimates >0.84. Gache et al. conducted a cross-sectional study in three French speaking areas and recommended a cut-off score of ≥13 for the detection of alcohol dependence. These findings are in contrast to the recommendations of the developers of AUDIT, who had set cut-off scores >19 for identifying alcohol dependence.
In this study, for alcohol abuse/ dependence the best cut off value was ≥9 for both males and females. Similar values (≥10 for alcohol dependence/abuse) were found by Guo et al. using the Chinese version of the AUDIT in Tibet. However these values are higher than found by Gache et al. in the French version where they found cut-off values of ≥6 for men and ≥5 for women. The sensitivity of the AUDIT was much higher in Nepal (96.7% for males and 94.37% for females) than in France (76.7% for males and 78.7% for females though the specificity was found to be similar.
Diagnostic studies focusing on hazardous drinking are barely comparable because the criteria used to define hazardous drinking vary considerably. For example, the SDU amounts to 8g of pure ethanol in United Kingdom and 14g in the USA. In this study, we used the WHO definition of 10g ethanol per SDU. The diagnostic performance of the AUDIT for hazardous drinking is shown by AUC in Figure3. The best cut-off score was ≥5 for males and ≥4 for females. For AUDIT, the reported cut-off for hazardous drinking has ranged from ≥4 in a family practice center to ≥10 in hospital in-patients and out-patients who volunteered for the study with other values in between these extremes. Other studies recommended cut-off scores below the standard value of 8 to screen for alcohol-problems of lower intensity than alcohol dependence or abuse. Three of these investigations, which were conducted in primary care or general practice settings determined that the best cut-off scores to identify both hazardous and harmful use was 5 in women and 5–7 in men with sensitivity and specificity estimates ranging from 73 to 96% and 88 to 96%, respectively[18, 35, 36]. In a general population sample, Rumpf et al. proposed the use of a cut-off score of 5 as optimal for identifying hazardous drinking (sensitivity: 77%; specificity: 80%). A slightly higher cut-off score of 6 was suggested by Kokotailo et al. for detecting hazardous drinking among U.S. college students (sensitivity: 91%; specificity: 60%).
According to findings of this study the following AUDIT scores can be recommended. For males: 0–4 no problem, 5–10 hazardous drinking, ≥11 alcohol dependence. For females: 0–3 no problem, 4–10 hazardous drinking, ≥11 alcohol dependence.
This study has some limitations. First, the external validity of the findings is limited since our study patients were attending an out-patient department of a university hospital. Secondly, patients may under- or over-report alcohol consumption. Miss-reporting was minimized by including all types of glasses and containers used locally for consumption of alcoholic beverages, and by asking patients several times about the exact frequency and volume consumed., Third, our study population consisted of out-patients attending a tertiary-level care hospital in Nepal, so the results may differ somewhat in other clinical settings like primary care centre and community hospitals. Despite these limitations, this study shows that the use of Nepali version of AUDIT is feasible and can be used reliably in the busy out-patient setting for screening of hazardous drinking and alcohol dependence. Our findings also indicate that commonly used cut-off scores for adults must be lowered when AUDIT is used among the Nepalese population as compared to the cut-off points of ≥19 for alcohol dependence and 8–15 for hazardous drinking recommended by the developers of AUDIT.