014505274 014505274 Liverpool Unlv VTTERl S AND DIFFERENCES IN ALCOHOL DRINKING AMONG THE THREE MAIN RELIGIOUS GROUPS IN INDIA: HINDUS, MUSLIMS AND SIKHS This is a thesis submitted in accordance with the requirements of the University of Liverpool for the degree of Doctor in Medicine in the Faculty of Medicine (Division of Psychiatry) Year of presentation: 2013 Dr Samir Kumar Ghosh Declaration I i declare that, except as indicated in the thesis, this work has been carried out and the thesis has been written by myself. Samir Kumar Ghosh M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page | 2 Declaration II No portion of the work referred to in this thesis has been submitted in support of an application for another degree or qualification of Liverpool or any university or other institution of learning. Samir Kumar Ghosh M.D. Thesis in Psychiatry — Dr. S.K. Ghosh Page | 3 ACKNOWLEDGEMENTS I would like to express my sincere gratitude to Professor K.C.M. Wilson, Department of Psychiatry, University of Liverpool, Merseyside for the supervision, guidance and constant advice throughout my study and preparation of this thesis. I remain ever indebted to Dr. Brian Faragher, Senior Lecturer in Medical Statistics, University Hospital of Tropical Medicine, Liverpool, Merseyside for his constant encouragement, thorough supervision and endless help from the very beginning of my study, advising me on statistical analysis required, and painstakingly checking all results including proof reading of the thesis, always fitting me into his very busy work schedule, being available for advice whenever necessary. My sincere thanks and gratitude for my long time close friend Mr. Edwin Warburton, ex-teacher/instructor, Social Services Department, Manchester for his help and constant encouragement to continue with my study and helping me in every possible way, including conducting primary reading of the draft version of my writing of the thesis. I am fortunate to have been helped by my secretary and friend Mrs. Elaine Parkinson in organising, formatting, structuring and typing some part of the thesis. She has also been available whenever I needed her, with endless patience. I am also thankful and appreciative to Mrs. Linda Whitehouse, secretary at the Stepping Hill Hospital, Stockport, Cheshire, SK2 7JE for helping me by printing a chapter of the thesis at short notice. I have borrowed freely from many authors in the literature review of this thesis and I am indebted to all of them mentioned in the chapter of references. I am grateful to Dr. M.L. Selzer for allowing me to use his screening instrument Michigan Alcohol Screening Test (M.A.S.T.) to detect alcohol dependence (alcoholism), a short version (B.M.A.S.T.) of which was used in this study. M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page | 4 I am grateful to all community and religious leaders, general practitioners and psychiatrists in West Bengal, India, who constantly gave me the benefit of their help, support, advice and co-operation in conducting my community survey of alcohol drinking. Many religious leaders especially of the Hindu, Muslim and Sikh religions constantly advised me to understand the background of respective religions; I am deeply indebted to all of them. The librarian of the medical library, Mrs. Elizabeth Stitt, Calderstones Hospital, Whalley, Blackburn, BB7 9PE has inspired me over many years by her help, but particularly so in this thesis by obtaining for me literature from several sources. Her encouragement and help has played a major part in the completion of the thesis. M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page|5 ABSTRACT For a period of three years a community survey of alcohol drinking was carried out by the author in the West Bengal State of India to inquire into the different drinking patterns of three main religious groups of people in India: The Hindus, Muslims and Sikhs. The survey sample was drawn from the population of the city of Greater Kolkata, West Bengal and altogether 650 respondents were interviewed, of which 622 belonged to the three religious groups. The sample was selected at random from the population of adults over 18 years of age, and of either sex. The subjects were interviewed by the author using a disguised and structured questionnaire, mostly in their homes, after obtaining their consent. The questionnaire was in three parts. The first part had questions on demographic details, occupation, living style etc. also including religious practice. The questions in the second part covered family health etc., drinking and attitude towards drinking alcohol. The third part included questions, embedded among questions on health etc, on drinking alcohol by the subjects, places and types of drinking and Brief Michigan Alcoholism Screening Test (B.M.A.S.T.) questions. The categories of drinkers were occasional, light, moderate and heavy, also alcohol dependents (alcoholics). Questions were asked about taking addictive drugs. Alcohol related questions were embedded amongst questions on health and leisure pursuits. Statistical analysis of the findings revealed many interesting and significant differences in drinking patterns between the three religious groups; Hindus, Muslims and Sikhs. The Muslims were found to be drinking less than the Hindus and Sikhs. Maie drinkers were found to be more than female in all three religious groups. Among the Sikh religious group both males and females drank consistently. No female drinker M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page [ 6 was found in the Hindu group of subjects. The mean age of initiating alcohol drinking was found to be higher in this study compared with other known studies in other regions of India. The age of starting drinking alcohol was found to be higher compared to several other studies in other parts of India. Many subjects started drinking earlier in their lives but did not continue. BMAST screening tool detected less than 1% of “alcoholics" in this study which is considerably less than other published studies in India, Hindus are found to be drinking more in the religious and other ceremonies than in their homes. Muslim and Sikh subjects denied drinking in any religious ceremonies Country liquors and illicit liquors were found to be used by the lower socio-economic classes of people sustaining many serious and often irreversible, health problems. Many significant differences were also found between the three religious groups regarding the types, places and styles of drinking alcohol, also between their habits of taking addictive drugs. Social drinking, as known in the Western countries, was not found to exist and most alcohol drinkers consumed alcoholic beverages with a desire to get drunk and stay drunk as long as possible. Interesting differences were found among the family drinkers among the three religious groups. The subjects belonging to the higher and lower socio-economic class groups were found to be dinking more alcohol than the middle class groups in all three religions. “Alcoholism” as detected by BMAST screening tool was found to be less in the West Bengal State of India compared to many other States, as shown in the thesis reviewing available published studies. Among the three religious groups more Muslim subjects were found to be “alcoholics”. No female subject was found to be detected as “alcoholic". M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page|7 However, only two previous known published epidemiological studies, one on mental health, including alcohol drinking, and the other was on alcohol drinking in lower socio-economic groups, found in the West Bengal State of India. In conclusion, the author commented that to date there is no known study comparing pattern and pathologies of alcohol use of the three main religious groups in India. Alcohol production and drinking in India is on the rise steadily and findings of this study will encourage researchers to replicate studies on drinking and also harmful use of alcohol in the West Bengal State as well as nationwide and in all other States of India. M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page|8 TABLE OF CONTENTS: ACKNOWLEDGEMENTS 4 ABSTRACT 6 TABLE OF CONTENTS: 9 CHAPTER 1 INTRODUCTION AND BACKGROUND 14 BACKGROUND 17 INDIAN RELIGIONS 18 HINDUISM 18 ISLAM 24 HINDUISM AND ISLAM 29 SIKHISM 31 BUDDHISM AND JAINISM 32 HISTORY OF ALCOHOL DRINKING AMONG THE THREE MAIN RELIGIOUS GROUPS IN INDIA: HINDUS, MUSLIMS AND SIKHS 35 ALCOHOL DRINKING AND HINDU TRADITION 35 SUMMARY AND CONCLUSION 48 CHAPTER 2 ALCOHOL IN MODERN INDIA: AVAILABILITY, ATTITUDES AND CONSUMPTION 50 AVAILABILITY OF ALCOHOL 50 TRENDS IN ALCOHOL PRODUCTION AND SALES 52 ALCOHOL INDUSTRY 52 AVAILABILITY OF ALCOHOLIC BEVERAGES 52 EXCISE ON LIQUOR 53 ADVERTISING OF ALCOHOLIC BEVERAGES 53 ILLICIT LIQUOR 53 COMMUNITY ACTION AGAINST ALCOHOL DRINKING 54 INVOLVEMENT OF NON-GOVERNMENTAL ORGANISATIONS 54 ALCOHOLICS ANONYMOUS GROUPS 55 TYPE OF ALCOHOLIC BEVERAGES COMMONLY CONSUMED AT PRESENT 55 NATIONAL MASTER PLAN 57 M.D. Thesis in Psychiatry - Dr. S.K. Ghosh Page | 9 SOCIAL CHANGES 60 PREVALENCE OF ALCOHOL CONSUMPTION AND ALCOHOLISM 61 DRINKING PATTERNS AND ATTITUDES 69 ROLE OF FAMILY AND EXTENDED FAMILY 71 ROLE OF CASTE AND CLASS 72 PREVALENCE AND PATTERNS OF ALCOHOL USE 72 CONCLUSIONS 74 CHAPTER 3 CROSS-CULTURAL STUDIES ON ALCOHOL DRINKING 77 CHAPTER 4 METHODS 88 STUDY DESIGN 88 SURVEY AREA AND POPULATION 89 QUESTIONNAIRE DESIGN 90 ISSUES 90 THE QUESTIONNAIRE 95 METHODOLOGICAL ISSUES 96 CONDUCTION OF SURVEY 103 SURVEY QUESTIONNAIRES 105 QUESTIONNAIRE: PARTS 1 to 3 105 QUESTIONNAIRE - PART 4 (The Brief Michigan Alcoholism Screening Test) 120 MICHIGAN ALCOHOLISM SCREENING TEST (M.A.S.T.) QUESTIONNAIRE 121 SHORT MICHIGAN ALCOHOLISM SCREENING TEST (S.M.A.S.T.) 123 S.M.A.S.T. QUESTIONNAIRE 123 THE BRIEF M.A.S.T. QUESTIONNAIRE (B.M.A.S.T.) 124 TABLE 1: M.A.S.T.