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Gender, occupational, and socioeconomic correlates of alcohol and drug abuse among U.S. rural, metropolitan, and urban residents

American Journal of Drug and Alcohol Abuse - May 1, 2004

INTRODUCTION

Many studies have investigated alcohol and drug abuse and dependence separately for urban and rural areas (1-6), however, few studies have looked at the association between geographic contexts (i.e., urban, rural, metropolitan area) and alcohol and drug abuse and dependence (2,7-10). Hence the first objective of this study is to analyze separately the associations among rural, urban, and metropolitan residents' use of alcohol and drugs. Secondly, we assess the strength of association between demographic and socioeconomic status variables and alcohol and drug disorders after stratification by geographic context.

Substance abuse and dependence is a public health problem with far-reaching implications (11) and individuals dependent on illicit drugs experience higher rates of comorbid psychiatric syndromes (12). Many studies on drug use and dependence have focused on urban, nonwhite, low-income, adolescent males, excluding other drug-using groups. Examples include studies on prevalence and consequences (13), drug trafficking (14,15), risk factors (3,4), weapon carrying (16), psychosocial predictors (17), and social correlates (2,3). Until now, no study has employed nationally representative data to compare rural, urban, and metropolitan areas, in terms of the associations between sociodemographic (age, gender, race) and social class (education, household income, and wealth) factors. And the National Comorbidity Survey (NCS) is the only nationally representative dataset with proportionate rural representation to examine alcohol and drug-disorders-using psychiatric diagnostic criteria.

Results of studies comparing rural and urban alcohol and drug abuse and dependence are mixed and are often affected by the possibility of bias or limited generalizability by sample selections. For example, Warner and Leukefeld (10) studied incarcerated subjects and found rural drug abusers to have significantly higher rates of lifetime drug use than do abusers in urban areas. Donnermeyer (7) reviewed 65 reports of research on youth alcohol and drug use and found alcohol use to be similar for both rural and urban youth. Roundtree and Clayton (9) analyzed data from a stratified random subsample of the Kentucky Youth Survey Sample and found alcohol use in both urban and rural schools as well as among racially mixed and racially homogenous schools. Early reports found higher rates of alcoholism among African Americans (18,19). Anthony and Helzer (20), found true racial differences in the prevalence of drug abuse and dependence with Kessler et at. (8), reporting that African Americans in the NCS have significantly lower prevalence of substance-use disorders than whites. This is consistent with the Epidemiological Catchment Area (ECA) finding of higher prevalence of drug and alcohol abuse and dependence among young whites, 18-29 years of age, compared with that among young African Americans (20,21).

Following the aims of our analysis, we used the National Comorbidity Survey (NCS) because in addition to providing a representative sample of U.S. residents, it includes geographic area of residence, demographic and socioeconomic variables, and the prevalence of alcohol and drug abuse and dependence-related disorders.

METHODS

Lifetime Risks of Disorders in the NCS

We used the National Comorbidity Survey (NCS) for our study, because it included demographic and socioeconomic variables associated with the risks of mental disorders, which included alcohol and drug abuse and dependence. Access to (alcohol and drug use and dependence) services in rural areas and availability of rural populations to respond to surveys are two technical difficulties that traditionally burdened psychiatric epidemiology studies in rural areas. However, valid screening instruments in the NCS overcame these limitations because the NCS was conducted in 212 countries across the country with balanced rural representation, thus overcoming access barriers for these hard-to-reach populations (22). Structured interviews like the Diagnostic Interview Schedule (DIS) (23) are the preferred method of assessment in psychiatric epidemiology, and the NCS is the only large study of remote rural areas that incorporated structured interviews. In the present analysis, we carry this research one step further by providing data on the socioeconomic and demographic correlates of alcohol and drug abuse and dependence disorders, separately, in U.S. rural, urban, and metropolitan areas.

The NCS was designed to study the distribution, correlates, and consequences of psychiatric disorders in the United States (8) and was collected between 1990 and 1992 by the Institute for Social Research at the University of Michigan. As the first, and thus far only, national sample on which psychiatric disorders have been ascertained, the NCS data remain pertinent to our purposes. The DSM-III-R is the tool used to generate diagnoses for alcohol and substance abuse and dependence (24). The DSMIII-R is a modified version of the Composite International Diagnostic Interview (CIDI) (25), which was designed to be used by trained interviewers who are not clinicians (26). Interviewers went through a 7-day study-specific training in the use of the CIDI and were closely monitored throughout the data collection period. The CIDI, developed by the World Health Organization, is a reliable and valid epidemiological instrument suitable for use in conjunction with different diagnostic systems (25,26).

Lifetime risk of alcohol and drug (cannabis, cocaine, and opiates) abuse and dependence refers to the proportion of respondents who have ever experienced such disorders. The NCS is nationally representative, and focused on a younger age range than previous studies such as the Epidemiological Catchment Area (ECA). The NCS interview was administered in two parts to respondents aged 15-54 years, in the 48 contiguous states. A total of 8098 respondents were included in Part One, which comprised the core diagnostic interview, a brief risk factor battery, and an inventory of sociodemographic information. The NCS selection of respondents as young as 15 years (instead of the normal lower age limit of 18) was to minimize recall bias with regard to lifetime disorders. Kessler et al. (8), reported that the exclusion of respondents older than 54 years was based on evidence from the ECA study that active comorbidity between substance use disorder and nonsubstance psychiatric disorder is much lower among persons older than 54 years. The NCS response rate was 82.4%. Part Two (N = 5877) of the NCS, which served as the basis for this study, included a more detailed risk factor battery and secondary diagnoses. Kessler et al. (8), provides details for respondent selection processes and criteria. A nonresponse adjustment weight was constructed for the main survey data to compensate for systematic nonresponses. Households were selected at random. A second weight was constructed to adjust for probabilities of selection between and within households. The sample was then weighted (Table 1) to approximate the U.S. population distribution for age, sex, race/ethnicity, and education as defined by the 1992 National Health Interview Survey (8).

Geographic areas were used as stratification variables in this study, based on the U.S. Bureau of the Census (27) standard approach for defining "rural" populations as places or towns of less than 2500 inhabitants and in open country outside the closely settled suburbs of metropolitan cities. Several problems surround the definition of rurality (28), as such arbitrariness and many important variables are not taken into account (29). By contrast, urban areas consist of contiguous counties, which contain at least one city of 50,000 inhabitants or more. Metropolitan Statistical Areas (MSA) have at least 100,000 inhabitants, comprise one or more central cities with at least 50,000 inhabitants, and include adjoining areas that are socially and economically related to the central city. The term MSA was devised to account for the social and economic activity patterns of an area's population (27).

Social Stratification Variables

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